New York State College of Agriculture At Cornell University Ithaca, N. Y. Library The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924003514233 CLINICAL LECTURES AND REPORTS, BY THE MEDICAL AND 8UEGICAL STAIT OS THE LONDON HOSPITAL WITH AN' APPENDIX ON THE EECENT EPIDEMIC OP CHOLERA. VOL. III.— 1866. LOI^DOK : JOHN CHUECHILL & SONS, NEW BUELINGTON STEEET, TABLE OF CONTENTS. *age A case of ligature of the external iliac artery for femoral aneurism, with clinical remarks. — By Mr. Adams - - 1 On spectrum analysis, in relation to chemistry, pathology, and medical jurisprudence. — By Dr. Letheby • ' . - - 6 A lectilre, with cases, on diabetes. — By Dr. I^raser - - 49 A clinical lecture on unilateral herpes,. — By Mr. Hutchinson 68 Three clinical lectures. — By Mr. Maunder - - - 97 I. Organic stricture; retention and extravasation of nrine; bowels obstructed by distended bladder - - 97 II. Retention of urine ; puncture per rectum - - 106 III. Betained testis ; bubonociele ; gangrenous gut * - 118 Notes of unsuccessful and successful cases of saline alcholic injections into the veins for relief of collapse of malignant cholera, treated during the epidemic of 1848-9.— By Dr. Little - - 132 Case of poisoning by the external use of belladonna. — By Dr. Brown 169 Case of poisoning by the external use of belladonna.^ — By Dr. Fraaer 171 Two cases of acute suppuration in the knee-joint, in which recovery with free motion ensued, — Mr. Carter - 175 V CONTENTS. Case in whicli the symptoms of a large abdominal aneurism were pre- sent, and cure resulted. — By Dr. Daly - - 179 Gold Medal Reports ... - 183 Case of morbus Addisonii — (Dr. Parker) — Reported by Mr. Le Rossignol - - - - - 183 Case of aneurism of abdominal aorta — (Dr. Parker) — Reported by Mr. Walker ■ - - 185 Case of repeated attacks of acute rliematism.-.-.(Dr. Davies) — Reported by 'Mr. Walker - - 187- Case of paraplegia of motion. — -(Dr. Parker) — Reported by Mr. Le Rossignol . - . . . 190 Case of extensive phlebitis with plugging of the superficial veins of both lower extremities — (Dr. Davies) — Reported by Mr. Le Rossignol - - - - 192 Notes (abridged) of three cases of obstruction of the bowels — Drs, Fraser, Davies, and Parker — Reported by Mr. Colqu- houn - - - - - - 193 - Case of incised throat (suicidal) —(Mr. Curling) — Reported by Mr. Mackenzie - - - - 196 Case of incised throat (attempted murder)— Mr. Curling) — Re- ported by Mr. Mackenzie - - 198 Case of recovery after probable fracture of the base of the skulL— (Mr. Hutchinson)— Reported by Mr. 'Mackenzie - 200 Case illustrating the value of the operation of puncture of the bladder for retention of urine. — :(Mir. Hutchinson) — -Reported by Mr. Mackenzie - - : - 203 Case of fractured ribs amd ruptured heart in a child — ^Reported by Mr. Mackenzie - - - .''.). 205 Case of large and rapidly spreading epithelial -ca:neer' of the cheek. — (Mr. Curling)— Reported by Mr. Mackenzie 205 Three cases of dislocation of the femur. — Reported by Mr. , Mackenzie .... 206 Case of extensive burn of rectum, etc., operation. — (Mr. Adams) — Reported bj; Mr. Colqixhoun - . . 207 Case of acute necrosis of palate — (Mr. Curling) — Reported by Mr. Colquhoun - 209 Case of leuoocythffimia — (Dr., Davies) — Reported by Mf- ; Colquhoun - - - 210 Case of fracture of the right parietal bone— (Mr. Little) — Re- ported by Mr. Colquhoun - _ - - ^11 CONTENTS. V Page Case of amputation at the hip-joint for disease — (Mr. Curling) — ^Reported by Mr. Colquhoun - - - 214 Lithotrity Syringe. — By Mr. Maunder - - - - 216 A case in which gastrotomy was performed for stricture of the oeso- phagus.— Under the care of Mr. Curling - - - 218 On marriages of consanguinity in relation to degeneration of race. — Bj' Dr. Down ..... 224 A lecture on cases of cerebral haemorrhage. — By Dr. Jackson 237 Observations on an ethnic classification of idiots. — By Dr. Down 259 Cases of delirium tremens, with clinical remarks. — By Dr. Fraser 263 A statistical report of the deaths occurring during the year 1865, amongst Mr. Hutchinson's patients. — Compiled by Mr. Hutchinson and Mr. Tay ... - 284 Case of operation for removal of an extraruterine foetus. — Communi- cated by Mr. McCarthy .... 301 Case of acute sjTnmetrical carcinoma. — By Dr. Fraser - . 303 Observations on the results which follow the section of nerve-trunks, as observed in surgical practice. — By Mr. Hutchinson - - 305 Clinical and pathological facts in reference to injuries to the spinal column and its contents . ' . . . . 320 On dislocations and fractures of the spine. — By Mr. Hutchinson 357 Note on the functions of the optic thalamus. — By Dr. Jackson 373 Notes on Syphilis. — Mr. Hutchinson - - - 37H Detached notes on symptoms, definitions and diagnosis — By Mr. Hutchinson - - - - - -387 b VI CONTENTS. Page Descriptive list of the more important specimens, casts, etc., added to the Museum during 1 865.— By Mr. Little - ' - 400 Hospital Statistics. — Mr. Adams and Mr. Maunder - - 414 Appendix on the eecent epidemic of cholera. - 443 Keport on the cases treated at the London Hospital— By Dr. James, Jackson - - - - - - 436 General remarks on the epidemic. — By Dr. Fraser - - 439 Report on Dr. Clark's cases, with remarks. — By Mr. M'Carthy and Mr. ' Dove - - - - - 443 Remarks on various points in connection with the cholera cases (tem- perature, cholera-rashes, etc.) — By Mr. P. M. Mackenzie - - 453 Notes of cases in which nurses, etc., were attacked. — By Mr. Dove 460 Report on cases treated by the introduction of fluids into the veins - —By Mr. L. S. Little - - - - 462 Report on the cases treated at the Wapping Cholera Hospital. — By Dr. Woodman and Mr. Heckford - - -471 Review of facts as regards the spread of the present epidemic. — By Dr. Letheby - - - - ' . ' -485 LIST OF ILLUSTRATIONS. Condition of Hand after Section of Median and Ulnar Nerves, Litho- graph (Mr. Hutchinson) .... To face l Kirchoff and Bunsen's Speetrosoope (Dr. Lethebt), Woodcut . 11 Browning's Spectroscope (Dr. Letheby), "Woodcut . • .12 Spectra of Alkalies, ete., compared with the Solar Spectrum (Dr. Lethebt), Woodcut . . . . . .14 Lines, in Green of Solar Spectrum, on larger scale (Dr. Letheby), Woodcut ........ 23 Microscope and Spectroscope for examination of Blood (Dr. Letheby), Woodcut ........ 34 Spectroscope in place of Eye-piece of Microscope (Dr. Letheby), Woodcut ........ 36 Spectrum of Blood (Dr. Letheby), Woodcut . . . .37 Syringe for Injection of Saline Fluids, etc. (Dr. Little), Woodcut . 137 Lithotrity Syringe (Mr. Maunder), Woodcut . . . .217 Right Bronchus plugged by a Bean (Mr. Little), Woodcut . . 400 Occipital Encephalocele (of cerebellum) (Mr. Hutchinson), Woodcut 402 Dwarfing of Ulna after Injury in Childhood (Mr. Hutchinson), Wood- cut 403 Vlll LIST OF ILLUSTRATIONS. Calculi removed from Bulbous Tract of Urethra (Mr. Adams), Wood- cut ..... . . . 407 United Bxtra-capsular Fracture of Neck of Femur (Mr. Hutchinson), Woodcut . . . . . . . .410 Dwarfed Kadius after Injury to Epiphysis (Mr. Hutchinson), Wood- cut . . . . . . . .410 Fracture of Tibia, United with Displacement (Mr. Hutchinson), Woo'dcut . . . . . . . .412 Comminuted Fracture of Tibia, United with great Displacement (Mr. Hutchinson), Woodcut ...... 413 Apparatus for Injecting Saline Fluids {Mx. Little), Woodcut . 464 A CASE OF LIGATURE OF THE EXTEENAL ILIAC ARTEET FOE FEMOEAL ANETJEISM, WITH CLINICAL EEMAEKS, By JOHN ADAMS, F.R.C.S. (Notes of the Case by 0. B; Sweeting.) Haeeiet J. aged 53, was admitted in consequence of a large pulsating swelling in the upper femoral region of the left side. She stated that three y6ars ago she received a kick in the left groin, and that shortly after she perceived a swelling, of the size of a hazel- nut, in the situation correspdncKng to that of the femoral artery below Poupart's ligament. The swelling remained statiouary, until thiee months ago, when it enlarged suddenly, and she experienced great pain in it, the pain extending do'^n her leg : her leg became (Edematous and discoloiired by distension of the minute veins. She gradually lost her appetitie, and became very unwell. On examination, an aneurism of the femoral artery was distinctly felt. The sac was circumscribed below Poupart^'s ligameHt, fcut it extended upwards beneath the abdominal walls in the course of the external iliac artery, where it became more diffused, but could still be felt pulsating. The pulsation could be seen and felt in all parts of the swelling, and the diagnosis was as clear as possible. Mr. Adams and his colleagues urged the immediate application of the ligature on the external iliac artery, but she objected; she was, therefore, sent to bed ; her limb was placed on an inclined plane with her heel raised, and a gently supporting bandage was applied from the foot to the groin. After two days' rest the artery was tied. It was requisite to make a very long incision, as the tnfaour extended B 2 MR. ADAMS' CASE OP upwards a great distance, and the woman was excessively fat. The incision was begun about an inch to the left of the umbilicus, and was carried down about five inches so as to impinge opposite the middle of Poupart's ligament ; it had a slight concavity towards the middle line : the layers of the diverse structures, which are met with in this operation, were cautiously divided ; the fascia transversalis was separated from the peritonseum, and the latter was carefully drawn upwards and inwards, and the ligature was placed around the external ihac artery with the usual precaution of opening the sheath with left fore-finger nail, and passing the aneurismal needle from within outwards, so as to avoid the vein. All pulsation ceased at once in the tumour, a few silk ligatures through the skin were employed to retain the edges of the wound together, and the more complete adjustment of the parts was accomplishment by strips of plaster. The whole limb was enveloped in carded wool, and was placed in a completely horizontal position. Thirty drops of laudanum were given, and she took four ounces of wine. The pulse after the operation was 120 in the minute : the temperature of the foot was very low, and immediately after the operation a perceptible diminution took place in the swellitig of the entire limb. The operation was performed on the 17 th of November, and on the 18th, there was fever and great pain in the abdomen; the pulse was now 116, but towards evening these symptoms remitted. On the 19th the oedema had much diminished ; the temperature of the foot had increased, and the general condition was good. Her pulse had sunk to 96. The diet was sustaining without stimulus. On the escape of a large quantity of pus, with a strong gaseous smell, from the wound, a poultice was applied, and a more stimulating diet was given. There was nothing of essential moment to record in her progress, which continued almost uninterruptedly good : she had retention of urine, for which the catheter was used. Slight attempts were made to remove, the ligature from time to time, but it came away spon- taneously, and was found loose in the discharge on the 16th of December, one month from the time of the operation. The wound healed very slowly, but pulsation in the tumour LIGATURE OP THE EXTERNAL ILIAC ARTERY. 3 never returned, so long as she was under observation in the Hos- pital. She went home home, on the 10 th of January, at her own request, the wound being almost closed : but her subsequent history is this : the tumour began to be painful and soft, fluctuation could be distinguished, and she died after two or three attacks of arterial haemorrhage which appeared to come from the lower part of the artery — no examination of the body was obtained. It was well known that the woman was a free and irregular liver and habituated to ardent spirits. Gentlemen, — I do not say that there is anything of especial im- portance in this case demanding a lengthened discussion, but there are some points of interest requiring a few observations. Let us first consider what the nature of the case isj in other words, where did the aneurism begin, and what is its real character ? The history of the case leads us to the conclusion that the aneurismal swelling began in the femoral artery, just where the vessel passes under Poupart's ligament, and where, from being the external iliac, it assumes the name of femoral. Although the line of distinction is arbitrary, still it is requisite that these anatomical landmarks should always be retained, especially where they concern the large arteries of the body. The further history is, that the disease originated from a kick ; and here we may object that this poor woman's account of her case cannot be depended on; and the reason why we may demur to the truth of the history is, that the disease remained three years in abeyance, a mere swelling existing at the seat of injury. But I should be sorry to exclude all evidence of this descripti&n in study- ing this case, for the effect of a severe blow or kick would be very likely to damage the coats of an artery, especially where the inner and middle coats are rendered brittle by age and the changes result- ing from age and irregular living. I dare say you are well aware, that if you take even an healthy artery and roll it between your finger and thumb, you at once form an aneurism ; at least this is the case in animals. Presuming, therefore, that the aneurism did begin in consequence of a blow, shall we call it a traumatic aneurism ? Certainly not; for the term traumatic is only given to aneurisms B 2 4 ME. ADAMS CASE OF where the coats of an artery have been divided, and where the aneu- rism is the consequence of that remarkable distension of the organ- ized material which glues up the o|)ening in the artery, or where the bursting of the sac occurs after a wound, and the blood becomes diffused into the adjacent parts. These two cases come under one pecuHaf category, and demand appropriate treatment, and such as was not pursued in the case before us. The disease was obviously making very rapid progress, but the aneurism was still circumscribed, and the operation was decided, on, but delayed at the wish of the patient. No harm, fortunately, resulted from this delay, and, although no time is to be wasted by the vain endeavours to cure by pressure, or other means^ such cases as the present, yet in an Hospital like this, where a patient can be watched from hour to hour, we can pause a little, as I did in this very case, and, as in this instance, not only no inconvenience, but actual benefit may result. A case occurred here some years ago to our consulting surgeon, Mr. Luke, bearing on this point. Mr. Luke was contemplating the application of a ligature in a case of femoral aneurism, but he ordered a bandage to be applied somewhat compressively to the swelling. On the following day all pulsation ceased in the tumour, and the patient was cured without operation. It is highly probable that a clot of blood was detached here, which filled the artery at the seat of the aneurism, and thus effected a cure. In cases parallel to the present, where the swelling extends into the abdomen, you cannot well apply pressure sufficiently long as to induce those changes which are essential to cure — I mean the coagu- tion of the blood in the sac, &c. It is true that the aorta may be compressed, as it passes over the lumbar vertebrae, either by the fin- gers or by a tourniquet, as has been lately advised by Mr. Syme, and Mr. Lister. Indeed it is well-known that Baudelocque did this in a case of uterine haemorrhage, and saved a patient's life by this means ; and you will find a case recorded in the Medical Gazette, October 31st, 1835, where this plan was successfully followed by a student, in a case of wounded femoral artery j yet here it would have been obviously improper to attempt any other plan than the simple application of the hgature, as the disease was making such rapid advances as to threaten the supply of blood to the entire limb. If you are interested about the application of pressure to the abdominal LIGATURE OF THE EXTERNAL ILIAC ARTERY. 5 aorta, you had better consult a paper on this subject by M. Oliailly Honor^j in ^e, Bulletin de I'Aoademie xvi., p. 731. " It may be a little interesting to us to know that the operation. of tying the external iliac artery was first performed by a student of this Hospital, the late Mr. Abernethy, of 8t. Bartholomew's Hos- pital, who studied surgery here under Sir William Blizard. His first and second operations were unsuccessful, but the third case was cured by the operation, and it became an established operation ;in surgery. Very trifling modifications have been made in the opera- tion since Mr. Abemethy first tied the artery in 1796, and usually it is one of comparative facility. In this case there was a very large quantity of fat under the skin, and between the muscles, but that important structure, the fascia transversalis, was easily made out, and was carefully divided on a director; the peritonaeum was pushed; aside, and the artery was readily secured. " ' The subsequent advance of this case after the patient left the Hospital, should make us pause, ere we congratulate ourselves oil the success of our operations ; and it becomes me to consider the case further, and to point out to you what practice should be followed in parallel instances, where hsemott;hage occurs after the ligatures have ' come away. I may say that the source of hsfemorrhage under such' circumstances is always that part of the artery below the ligature, and where it is most likely that the repair by cohesion of the arte- rial tunics does not progress satisfactorily. If this be true therefore, it is at once clear that kny further use of the ligature to the artery above is futile. What then is to be done? Pressure and ice may be employed over the aneurism, internal stiptics are useless^ but' sponge, soaked 'with a solution of perfchloride of iron, may be stuffed into the wound, and then pressure and ice 'may be used; but fail-' ing these, as is Very likely to be the cage, ydu must adopt the bold and decisive practice of laying 6pen the tumour ;' turning ' out the clots, and haviilg found the lower orifice of the 'artery; insert ybui-' finger into the opening, and direct your assistant to' pass an armed aneurismal needle ' arottnd the blood- vefesel' beloW your finger, and' tlie case is as safe as you can make it.' ON SPECTRUM ANALYSIS, m KEIiATION TO CHEMISTEY, PATHOLOGY, A^D MEDICAL JTJEISPEUDENOB, By H. LETHEBY, M.B., M.A., Ph. D., &c. LECTURER ON CHEMISTRY AT THE LONDON HOSPITAI COLLEGE.* The subject of Spectrum analysis, with its numerous applications to practical science, has lately assumed so much importance, because of its strikingly characteristic results, that it deserves something more than a passing notice ; and seeing how large a function it may yet perform in unravelling some of the mysterious phenomena of life, and in determining the nature, if not the cause, of many pathological changes, it is surely worthy of the closest attention of the medical practitioner. And in order that the leading facts and principles of the inquiry may be clearly understood, and followed throughout their vaiious details, I shall mate no apology for entering more fully into it, than the mere question of medical science would at first sight seem to re- quire. In tracing back the history of the subject, we find that the first experiment relating to it was made in the year 1701, by Sir Isaac Newton — ^then Mr. Newton. He allowed a beam of sun-hght to enter a dark room through a circular hole in a shutter, and by passing it through a triangular glass prism, somewhat Kke a pendant of a chandelier, which he placed near to the hole, he found that the beam, of light was not only turned out of its course by the refractive power - This paper is an abstract of a lecture given by Dr. Letbeby at the Medical CoUege, with such addition? to the subject as have been made since its delivery during the Winter Session. DK. LETHEBY ON SPBCTEUM ANALYSIS. 7 of the glass, but was also broken up into colours, for it presented the magniicent image of a rainbow with its seven prismatic tints. This he called the solar speetrwm ; and he noticed that the colours, as in the rainbow, succeeded each other in regular order, although blended by insensible gradations. Mrst in the series, and nearest to the proper direction of the, solar ray, was a brilhant red, then followed orange, yellow, green, blue, indigo, and violet — the last being the most disturbed from the right course of the beam, and therefore the most refracted. For more than a hundred years this experiment was repeated without variation, and nothing was added to the discovery of Newton, until "WoUaston, in 1802, altered the form of the hole in the shutter, by using a narrow slit instead of a circular aperture. This produced a far more perfect spectrum ; and he was able to see that the colours were intersected by dark bands or lines, which had not before been observed. He also examined the spectra of different kinds of light, as the flame of a candle, and the electric spark, and he noticed that the spectra differed very much from each other — that from the electric spark being singularly im- perfect, for it was composed of only a few of the prismatic colours. We shall see hereafter that this, in reality, is the starting-point of spectrum analysis. In the year 1815, the remarkable lines of WoUaston were carefully examined by a German optician named Praunhofer, who, by fixing the prism before the object-glass of a telescope, was able to magnify the spectrum, and thus to see the dark lines much more distinctly than WoUaston had done. By this means he recognised and mapped out the position of more than six hundred lines, distinguishing the- most important of them by capital letters of the alphabet, and the least important by small letters. He likewise ascertained that the lines were not affected by the material of which the prism was formed — for they appeared the same with all kinds of transparent media, but they were much affected by the Ught made use of. Twenty years later, namely, in the year 1835, Mr. Wheatstone gave an account of the spectra which are produced by the prismatic decomposition of the electric, voltaic, and electro-magnetic sparks ; and he described the singular and characteristic appearances of dif- ferent spectra when the sparks were taken from different metals. 8 DE. LETHEBY ON SPECTETTM ANALYSIS. That fropi mercury, for example, he said consists of seven definite rays only, separated from each other by dark intervals — thus, there are first, two orange rays close together, then a bright green Une, then two bluish-green lines near to each other, then a very bright purple line, ^.nd lasjtly a violet line. The sparks taken in the same manner from zinc, cadmium, tin, bismuth, and lepid in the melted state, were found to give similar appearances ; although the number, position, and colojars of the lines were in each ease diflferent. The appearances, he says, are so characteristic, that ly this mode of examination the metals may he readily dtstinguished from each other. He ascertained, moreover, that the results were not due to the com- bustion of the paet^ls, for )the same appearances were observed when the spar]s;s were t^ken in the vacuum of an air-pump, and in carbonic acid gas. In this way, therefore, another advance was made in the progress of spectrum analysis ; ^nd from th^t time to the present it has been carried still farther by the experimental researches of Fou- cault in 1849, Masson in 1851-55, Angstrom in 1853, Alter ip 1854.-55, Secchi jn 1855, Pliieker in 1858-59, and Willigen in 1869 — all of whom studied and described tjie appearances of the spectfa obtained by the prismp,tic decomposition of the electric spark when taken from different metals and jp different gases and vapours-^ their results being almost demonstrative of the fact, that the charac- teristic differences of the spectra are due to differences in the quality of the light emitted from the different vapours and gases when heated to incandescence by the high temperature of the spark, Bpt this conclusion was not reached at,tliat time, although it was often nearly appro.aehed. If indeed, this true explanatipp of the pheiiOr mena had been fully recognised, and the general fact, a? above described, had been perceived in all its importance, ij; would no doubt have been the nieans of apticipating thp brilliant specpktions which have lately distinguished thp names of Bunsen apd Kirchhoff,-*^ And while these researphes were in progress, appther and very different set of observations were fast leading |;o the same conolusiop. Long ago iti was known tliat when .pertain saline substances are put into a flame it acquires a characteripl^c tint — the salts of sQ(3a, for ex- ample, give it a deep yellpv colopr, potasli a violet, baryta and boraqic * I am indfihted to the lecture of Dr. W. A. Miller, in the Pharmaceutical Journal for February, 1862, for thi^ resume of historical fq,pts. DR. LBTHEBY ON SPECTRUM ANALYSIS. 9 acid a greea, copper a greenish bluBj strontia and lithia a red, and so on. This indeed was the secret of pyrotechnic chemistry, and the delicacy and speciality of the reactions were such that they were often made available in qualitative mineral analysis; but no one thought of examining these coloured flames with a glass prism until the year 1822, when their spectra were first described by Sir David Brewster. Sir John Herschell also, in the same year, gave an account of the spectra of flames tinted by muriate of strontia, muriate of lime, chloride and nitrate of copper, and boracic acid ; . and a little later he added those of lithia, baryta, and iron^ — saying that the muriates succeeded best, because of their volatility ; and that the colour could be easily exhibited by putting the salts in question upon the wick of a spirit-lamp. He also stated that tAe colours thus communicated iy the different bases to fiame, afford, in many cases, a ready and neat way of detecting extremely minute quantities of them ; and he eoncluded, from experiments made in various ways, that the ti/ivt arose from the molecules of the saline matter reduced to vapour, and held in a state of violent ignition. A year or two later, the subject was stUl farther pursued by Mr. Fox Talbot, who, in 1826, when describing the results of his experiments, said, that " a glance at the prismatic spectrum of a fla^e may show it to contain substances which it wotil4 otherwise regime a laborious chemical analysis to effect." He proved also, that notwithstanding the great similarity in the red tint given to flame by strontia and lithia, yet the prismatic spectra exposed at once the differences of the two ; for the strontia flame produces a great number of red rays well separated from each other by dark intervals, not to mention aij orange, and a vejy definite bright l?llie, ray, while hthia exhibited only one single red ray. " -H^^^ce " to use his words, I hesitate net to say that optical analysis can d4stin^ish the minutest portions of these two substances from each other with ; and if the flame is very hot, there are also two or three orange-coloured bands, y, near to the solar line D, Stromtium {Sr^ produces a broad orange»coloured band, a, close to Praunhofer's line, I)., and five or six red bands, between ^. and J)., two of which, |3 and y, are always well marked. There ig also a faint blue line, S, about midway between F. and G. Calcium (C«.) shows a bright and rather' broad orange-coloured band, a, in the middle of the space between the solar lines, C, D. ; and there is also a faint reddish b^nd on the red side of it, and three or four pale yellowish-green bands on the ypllow side of it; besides which there is a rather broad and bright green band, j3, in the space between D. and F. ; and when the temperature of the flame ia high, there is also a blue line on thp indigo side of G. Barium {Ba.) presents the most complicated appearance of all the alkaline spectra, for it exhibits five or six green bands of different widths in the green part of the spectrum. These lines are marked afiySri in the diagram, and the letters represent the order of brilliancy. In addition to these lines there is an orange band, e, and three or four yellow bands near to I'raunhofer's solar line, D., and a few very faint red bands at C. The delicacy of this method of research is most remarkable. Swan found by actual experiment that he could discover the presence of the jsoj™*^ °^ ^ grain of sodium by its characteristic yellow line; in fact, the reaction of this metal is so delicate, and the presence of common salt in air and water is so universal, that it is very difficult to get a flame free from the sodium line. Bunsen and Kirchhoff have rudely estimated the delicacy of the spectrum test by deflagrating known quantities of different substances in a room, and then noting the prismatic effects. Tn this way they -have calculated from the area of the room, and the quantity of matter diffused through it, that it is possible to recognise the iaj,m,),ouo ^h of a grain of soda, the si;o^th of a grain of lithia, the ii^th of a grain of lime or 16 DE. LETHEBY ON SPECTRUM ANALYSIS. strontia, and the jji^tli of a grain of potassa or baryta. Csesia may be discovered when the quantity of chloride used does not exceed the „-g^th of a grain, but it requires about jjl^tli of ^ S™'^ of rubidia to produce its characteristic spectrum. The speciality of these reactions is still observed when the salts of the several metals are mixed together; for as the compounds are yolatalized at different temperatures, the several spectra follow each other in the order of volatality: in fact, if the .chlorides of potassium, sodium, lithiutn, calcium, strontium, and barium, are mixed together in no larger quantity than the ^th. of a grain of each, and the mixture is put upon a platinum wirey and held in the flame of a Bunsen's burner, the spec- trum of each salt is clearly discoverable— first, there appears the bright yellow line of "sodium {Na. a, Kg. 3), with a pale and nearly continuous spectrum of potassium in the background. As the sodium line fades away, the bright red hue of lithium {Li. a.) comes into view, and beyond it is the faint red potassium line {Ka. a.) ; then there appear the two green baiium lines {Sa. a, j3.) with their peculiar shadings ; and as all these fade away, the orange, and the green lines of calcium, {Ca. a, /3.), and the red lines of strontium {Sr. a, |3, y, S.), gradually come into view, and then pass away like the figures of a dissolving view. Other examples of the delicacy of the test may be given, to show how certainly and easily the minutest portion of these alkaline metals may be discovered. If a little of the ash of a cigar is put upon a platinum wire, moistened with muriatic acid, and then heated in the flame, it shows the characteristic lines of sodium, potassiunl, lithium, and calcium ; and the residue of a single drop of sea- water, treated in the same manner, exhibits the spectra of sodium and calcium. A drop also of the mother-liquor of almost any mineral spring, will show the coloured lines of nearly all the alkalies and alkaline earths. - It is, therefore, easy to understand, how, by this method of research, traces of substances have been found, where they were not suspected to exist, and where, but for this process, they might have remained for ever undiscovered. The alkali lithia, for example, once thought to be so rare, is now known to be widely distributed. It has been recognised in a large number of mineral waters, in the ashes of tobacco, in vine leaves, grapes, the tartar of wine, the potashes of commerce, and indeed, in the ashes of all plants which grow upon cer- tain- granitic soils. It has also been found in the milk of animals DE. LETHEBY ON SPECTRUM ANALYSIS. 1? feeding upon those pastures, in human blood, and in muscular tissue. Strontia also, instead of being a comparatively scarce substance, exists nearly everywhere in the mineral kingdom : it is present in sea-water, in the incrustations upon-the boilers of sea-going vessels, in chalt, in certain marbles, and in a great variety of limestones. The new metal, thallium, has likewise been found in many pyritic minerals, associated with copper and iron ; and it has been recognised in the ashes of the grape, tobacco, and chicory; and in treacle and wine.- The extent to which these researches may be applied in gaining infor- mation of the mineral constituents of animal and vegetable tissues is almost unlimited ,- and the influence of them on the future of physio- logy is hardly to be conceived. In all cases, the proper rrieans for developing the spectra of the metals is to convert them into volatile salts ; and of all salts, the chlo- rides are best suited for the re-action ; recourse must, therefore, be had to certain contrivances for effecting this. In most instances, it is suiEcient merely to moisten the substance wilh muriatic acid, and then to put it upon platinum wire, and hold it in the flame of a Bunsen's burner, or, better still, in that of hydrogen ; and when the spectrum disappears, to moisten it again and again with the acid, before heating it. Professor Kirchhoff and Bunsen have given fall directions for the treatment of mineral substances, when they are not acted on by muriatic acid * ; and Mr. Reynolds has contrived a very simple plan whereby nearly all minerals are made to show the spectra of their constituents. He uses the double blow-pipe jet of Mr. Herapath; and by supplying it with hydrogen, and blowing steam charged with muriatic acid through the inner jet, he is able to get a flame which decomposes the fragment of ainy mineral held in it ; and the chlorides so formed, produce the spectra of the constituents. In this way, he has discovered thallium in many Irish pyrites. Another and better means of observing the spectra of the less vol- atile metals, is by examiuing the electric spark as it passes between fine wires of the metals. The spark is best obtained by using the induc- tion coil of M. Euhmkorff, — the light being strengthened by having the wires in communication with tie coatings of a Leyden-jar. By this means the characteristic tint of the metal is seen in the spark, in * On CheTnical Analysis by Spectrum Obaervations, Journal of the Chem- ical Soeiety, Vol. xiii., p. 270. 18 DE. LETHEBT ON SPECTKUM ANALYSIS. consequence of a very minute quantity of it being volatalized by the heat and the disruptive power of the electrical discharge ; and when examined by the prism, the spark gives the spectra of the several metals in even greater splendour than the flame. The spectra of the non-metallic bodies are best seen by passing the spark from Euhmkorff's coil through a narrow tube containing a mere trace of them, either alone or in combination, and, in a rarefied condition. The spark is very brilliant, and from the high tempera- ture, — it gives a magnificent spectrum. In fact, it should be noted that the spectra of all substances vary with the temperature, becoming more and more brilliant, and even more and more complex, as the temperature rises. The lowest heat is that of Bunsen's bur- ner; then follow the spirit-lamp, the hydrogen flame, the oxy- hydrogen flame, the voltaic arc, and the electric discharge. Bunsen and Kirchhoff are of opinion that the spectra are the same in aU cases, but that with a higher temperature, and therefore a stronger light, the duller parts are made more evident, and thus the spectrum is more fully developed. Pliicker and Hittorf, however, have shown that the spectra of many of the elements are altogether different at different temperatures, and that the passage from one spectrum to another, is not gradual as the temperature rises, but sudden, show- ing that there is a corresponding molecular change, and that the body suddenly assumes a new allotropic condition. Nitrogen exhibits three of these changes at diff'erent temperatures; and sulphur is affected in the same way, although not to the same extent. Chloride of lithium also, at the comparatively low temperature of a Bunsen's burner, shows only the crimson' line [Li. a, Fig. 3), bat with the hydrogen flame, it exhibits the orange line {Li. j3), and with the great heat of the oxyhydrogen jet, or the voltaic arc it produces a blue line. The same is true of iron, and many other metals, their spectra being much more complicated at high temperatures than at low. The rationale of the action is the same in all cases; the spectra being due to the peculiar light emitted by the element in its ignited gaseous or vapourous condition; for if a solid or liquid substance is heated, so as to be luminous, it invariably produces a continuous spectrum with all the tints of the rainbow. It may be that the yellow or red rays predominate on account of the body being yellow or red-hot and uol white-hot ; but for all this the spectrum is invariably con- DE. LETHEBY ON SPECTRUM ANALYSIS. 19 tinuous. Not so, however, with a gaseous flame, or with an electric spark ; for then the temperature is so high as to decompose com- pounds, and set free the elements — keeping them for awhile in a gaseous condition intensely heated ; and it is this incandescent gaseous or vapourous matter which produces the characteristic non-con- tinuous spectrum. Hence the necessity for using those salts of the metals which are most volatile, and which are most easily decom- posed by flame. Eemarkable, however, as these discoveries of Bunsen and Kirch- hoff are, with respect to the prismatic properties of incandescent elementary gaseous matter, it is very probable that they would not have commanded much attention if the same observers had not also discovered, or rather proved, that all elementary gaseous matter is endowed with the power of absorbing and destroying the very same beams of light which it emits, Long ago, this fact was suspected, although its importance was not perceived. In 1845, Dr. W. A. Miller observed that when solar light was transmitted through a coloured flame, and examined with a prism, the dark absorptive bauds appeared in the compound spectrum, provided the solar light was not too strong for them ; and he concluded that such flames or luminous atmospheres had a positive absorptive influence on certain colours of other lights. Later still, in 1849, whenM. Poucault was examining solar light by passing it through the voltaic arc, and so producing by means of a prism, spectra of the two lights, he noticed not only that the dark solar line {B) corresponded exactly with the bright yeUow sodium line of the arc, but also that the yellow line darkened still more the solar line ; for when the two spectra were made to overlap each other exactly, the dark solar line was consider- ably strengthened ; but when, on the contrary, they only partially overlapped each other exactly, the line {B) was darker than usual in the solar spectrum, while it stood out brightly in the electric. He even did more than this, to show that the luminous matter, emitting the yellow line, had the power of absorbing yellow Hght j for he projected upon the arc, the reflected image of one of the incandes- cent points of carbon, which, like all ignited solids, gives a continuous spectrum with no lines ; and then he found that the black line {D) appeared as in the solar light, — showing that the incandescent matter, of the voltaic arc, which was emitting yellow lights absorbed the c2 20 DK. LETHEBY ON SPECTRUM ANALYSIS. . corresponding light from the incandescent point of charcoal, and so produced a blafck line. This, as Dr. Miller observes, was the germ of Kirchhoff's important generalization, although its ingenious author was far from perceiving its fuU importance. In 1855, Angstrom carried the inquiry still further, and after speaking of the close cor- respondence of some of the dark lines in the solar spectrum, with the bright lines of certain electrical spectra, he says, " they produce the impression that one spectrum is a reversion of the other,'''' and he adds that he is therefore convinced that the explanation of the dark lines in the solar spectrum embraces that of the luminous lines in the electric spectrum. It was Kirchhoff who furnished that explanation,' by showing that the rays, which a body emits, are the very rays which it absorbs. The real value of this fact can hardly be over-estimated ; and it is surprising that Poucault, Miller, and Ang- strom, who were so near to its discovery, did not perceive it ; and that it was left for Kirchhoff in 1859, to prove it, by experiment, by shewing that when any saline substance is rendered luminous, it emits rays of certain and definite refrangibility, and that the same substance has also the power of absorbing rays of identically the same refrangibility. Sodium, for example, when ignited, emits an intensely brilliant yellow hght, which shows itself in the spectrum as too closely contiguous bands of yellow, close to Praunhofer's hne {D) ; but if through the flame of sodium, the more powerful beams of the electric, or the oxyhydrogen light are transmitted, the con- tinuous spectrum of the stronger light is interrupted by the black lines coincident with the sodium hnes, or the dark band (D) of the solar spectrum. Kirchhoff also ascertained that certain of the bright bands in the spectra of potassium, lithium, barium, and strontium, may, in like manner, be reversed; and Dr. Miller found that some of the strongest of the blue lines in the copper spectrum might also be reversed in the same way. The explanation of this is very simple, and it applies to the cor- responding phenomena of radiant heat, as well as to those of actinic or chemical action. "Atoms,'' says Professor Tyndall, "which swing at a certain rate, intercept waves which swing at the same rate. The atoms which vibrate red light, will stop red light ; the atoms that vibrate yellow, will stop yellow ; those that vibrate green, will stop green, and so on. Absorption is a transference of DR. LETHBBY ON SPECTRUM ANALYSIS. 21 motion from the sether to the molecules immersed in it, and the absorption of any atom is exerted chiefly upon those which arrive in periods cranciding- with its own rate of oscil- lation."* This is true of every variety of vibration, and in the case before us the vapour of a metal put in the tract of a beam of light, wiU stop its own peculiar vibrations, and therefore, w ill produce dark bands in those very places in the spectrum, where its own characteristic coloured bands would have appeared. Or if the bands are obtained from the incandescent vapour, of a metal, and the light thereof is made to pass through a similar vapour, the course of the light is stopped, and there are no bands at all. The reason, therefore, why incandescent solids and Kquids exhibit a white light, and produce a continuous spectrum, consisting of aU the prismatic colours, is that their atoms or molecules swing in every variety of vibration from the red to the violet ; whereas the vapour of an element swings only in certaiu vibrations, and thus produces a coloured flame which gives only the few bands of the spectrum which are characteristic of that flame. The application of these facts to the interpretation of the lumi- nous phenomena of the universe, and more especially to the analysis of coelestial objects, is most interesting ; for as the results are not influenced by distance, it follows that whenever there is Kght enough from any planetary body to produce a spectrum, it afl'ords the means of ascertaining its nature, and of determining its eonditipn. If, for example, it is found that the light emitted by any star or far-off luminous object gives a spectrum with the characteristic bands of ignited terrestrial matter, it is proof that such matter exists therein ; and if the spectrum is continuous, it is manifest that the light comes from an incandescent sohd or liquid ; whereas if the spectrum is not continuous, but consists of only a few bands of colour, it shows that the light is emitted by matter in a state of gas or vapour. And if, in addition to the continuous spectrum, there are dark hues in it, it proves that there is a central mass of ignited solid or hquid matter, with an atmosphere or envelope of vapour through which the hght passes, and by which certain rays are absorbed on darkened. This is the interpretation of the dark hues of Fraunhofer, in the solar spectrum, which have been for so long a time the puzzle to philo- sophers. According to the hypothesis of Kirchhoff, the sun consists * Heat considered as a Mode of Motion, p. 468. 22 DR. LETHEBY ON SPECTEXJM ANALYSIS. of a central orb of molten or solid matter intensely heated, and as this emits rays of all kinds of refrangibility, it would give a con- tinuous spectrum, without a break or bar in it, were it not that it is surrounded by a vapourous envelope through which the rays must pass J and in so doing they are partly absorbed ; for each element of the gaseous envelope strikes down the very rays which it does itself emit, and thus produces its own black lines. If we could see the spectrum of the envelope alone, without the luminous orb behind it, we should see the very bands, which are now dark, lighted up with then: characteristic tints. It would be, in fact, the complex spectrum of all the elementary gases and vapours existing in it. Examined, therefore, from this point of view, we have in the black lines, the dark or reversed spectrum of every element in the solar atmosphere ; and we have but to compare them with the spectra of terrestrial vapourous matter to determine their nature. In this way the labours of Kirchhoff and Bunsen have been directed to the spectral analysis of the sun. The position of every line has been compared with the spectral Hnes of terrestrial matter ; and although much has been done in determining the chief constituents of the solar atmosphere, yet as each line must be accurately compared in every particular, it will take many years before the whole of them can be properly studied. Already about 2000 of them have been thus mapped out; and they indicate the presence in the suu's atmosphere of sodium, calcium, barium, and magnesium; with iron, nickel, cobalt, chromium, copper, and zinc. There may also be potassium and strontium ; but there are no traces of lithium, caesium, rubidium, aluminium, arsenicum, mercury, silver, gold, cadmium, tin, lead, silicium, or antimony. The coincidences of a few of these lines are seen in Pig. 4, which represents only a very small piece of the solar spectrum from Uto 6 in the green of Fig. '6. The recognition of these lines requires a special apparatus, with a series of prisms of great dispersive power, whereby the spectrum is much elongated, and the lines and colours spread out so as to be widely separated from each other. Instruments have been constructed with as many as eleven prisms in series ; and for the purpose of obtaining the highest degree of dispersive power, the prisms have been made boUow, and filled with bisulphide of carbon, which is a liquid of great refractive power. In this way the sodium line (D) which looks single in the common spectroscope, and only double in the — Wf = JRs DR. LETHEBY ON SPECTEUM ANALYSIS. 23 better kinds of instruments, is found ' Fio- *• to be made up of eigM lines, and ""~^j^ thus also tlie positions of other lines, '^^'~~~^~~~~ have been accurately determined. - — ^^^— — ^— It would be out of place to follow ~ x^ the subject much further in this direction, although it is evident that if the interpretation of the pheno- mena of the spectra of planetary bodies is correct, it affords a means of unravelling the structure of the whole visible universe; and there are not wanting observers who are pursuing the inquiry with uncom- mon dihgence — Cooke in America, Donati in Italy, Miller and Hug- gins in this country, and Bunsen and Kirchhoiff in Germany, have already done much for the founda- tions of ccelestial chemistry, and ■- ■ ' • r_j^';j:a±! x^ their results are most interesting. . — ::::::::——?■« Looking at the spectral phenomena of the nearer planetary bodies, — the . cr- members of the solar system, — they '^_ are able to say, not only that the light received from them is the same as that emitted by the sun, and is, therefore, entirely reflected light, but also that some of them have atmospheres, while others have not. The light of the moon, for example, gives a spectrum so exactly _-— -=:^^==: like the solar spectrum, and so ^^^^^^_^,^___= entirely foee from aerial Knes, that it j i..iM'P'MM -■ • '■'"^ :.~ — %« affords conclusive proof of its not — ^S .., having an atmosphere. Not so, ~ however, with Venus, Mars, Jupiter, and Saturn, for they all show, certain additional dark lines, which are in all i-JIfy -re 24 DK. LETHEBY ON SPECTRUM ANALYSIS. probability due to the absorptive power of an atmospbere. In fact these lines correspond so nearly with the lines which are seen in the solar spectrum when the sun is just sinking below the horizon, and when its light is passing through a. great length of atmospheric air, that we may fairly assume they are due to the same cause. But, besides the near planetary bodies, about fifty of the very distant fixed stars have been examined; and, as tbey all give con- tinuous spectra, with the same sort of dark lines, though not quite in the same position, as those of the solar spectrum, it is reasonable to conclude that they are all centres of light — self-luminous, and having precisely the same structure as our own sun. Two of these, namely, Aldebaran and Betelgeuas Ononis have been most carefully studied by Dr. Miller and Mr. Huggins ; and they have ascertained that the former sbows a great number of dark lines in every part of the spectrum except the red, while the latter exhibits a preponder- ance of lines in the red, green, and blue. This, as Dr. Miller and Mr. Huggins suggest, is no doubt the cause of the peculiar colours of these stars, for the one looks red and the other orange— r-these being the rays which are least obscured in the two cases. It is, : indeed, very probable, that the different tints of the fixed stars, are always due to the same cause, namely, the existence of a larger number of black bands in one part of the spectrum than in another — certain rays being thus obscured, while others pass freely. The position of these dark lines, however, is not the same as in the solar spectrum, and, therefore, it is evident that the vapourous matter which produces them is not the same ; although certain metallic elements are nearly always present in the fixed stars, as sodium, magnesium, cal- cium, iron, bismuth, and tellurium. These, indeed, are the leading constituents of the stellar universe. Hydrogen, also, is very gene- rally (Tistributed, though it is absent in a Ononis and /3 Pegasi. As a very striking example of the remarkable information afforded by this method of inquiry, the following may be cited : — On the 16th of May last a new star was discovered in the constella-: tion of the Northern Crown {Corona Borealis) ; when Dr. Miller and Mr. Huggins examined it with the prism, they observed that it gave three spectra superposed upon each other — one of these was a con- tinuous spectrum analogous to that of the sun, the other was a spec- trum of dark lines, and over this was a third spectrum of a few very bright lines. It was evident, therefore, that the star was not only com- BK LETHEBY ON SPECTRUM ANALYSIS. 25 posed like the sun and other fixed starsj of a central orb of incandescent matter, with its outer atmosphere of cooler vapours, but it also possessed another and a still more luminous atmosphere, which had all the characters of ignited hydrogen. This, together with the sudden outburst of brilliancy in the star, and its subsequent rapid decline in brightness, suggested the rather bold speculation, " that in consequence of some vast convulsion taking place in the star, large quantities of gas have been evolved from it ; and that the hydrogen present is burning by combination with some other element, and furnishes the light represented by the bright lines; also, that the flaming gas has heated to vivid incandescence the solid matter of the photosphere. As the hydrogen becomes exhausted, all the pheno- mena diminish in intensity, and the star rapidly wanes."* Encouraged by the success which has followed the examination of the fixed stars, Mr. Huggins has extended the inquiry to those mysterious' bodies, the unresolved nebula, which some astronomers think are clusters of minute stars' — so distant that the present powers of the telescope fail to magnify them into distinct points, while others consider them to be masses of glowing vapours. Now, in all those cases, where the telescope had resolved the nebulae into groups of stars, the prism showed a continuous spectrum — and thus, therefore, the two sets of observations are coincident ; but in eight cases where no magnifying power was able to discover distinct points, the spectra were not continuous, but merely two or three lines like an ignited gas. From which it may be concluded, that although these nebulae are com- paratively bright objects, they will never be resolved into groups of stars, for they are only masses of luminous gas. In all cases the spectra are very nearly alike, consisting of three bright bands, one of which corresponds to hydrogen, another to nitrogen, and the third to an unknown substance. It is not probable, therefore, that these nebute will ever be condensed into solid or Kquid orbs. An examination of the spectrum of the comet of 1866 (Tempel's), showed a broad but faint series of colours ; and the minute nucleus, which was apparently self-luminous, consisted of nitrogen, but the chief light from the comet, giving a faint continuous spectrum, was evidently reflected, probably from the sun. Astronomers will wait with some impatience for an opportunity of examining the spectra of other comets, and of so determining their nature. " Proceedings of the Boyal Society, Vol. xv. p. 149. 26 DK. LETHEBY ON SPECTRUM ANALYSIS. All these illustrations are but proof of the extreme sensibility, as weU as extensive applicability of spectrum analysis ; for they show that the visible chromatic spectrum of any luminous object, vrhether it be an ignited solid or liquid, an incandescent gas or vapour, an electric discharge, or a distant planetary body, affords evidence not merely of the chemical composition of the body, but of its physical structure. And if the inquiry is carried still further, it is found that every visible spectrum is associated with two other spectra which are not visible, but whose manifestations, when properly interrogated, are equally characteristic,- and may yet become equally important aids to analysis. One of these is situated at the red end of the luminous spectrum, and consists of rays of heat which are less refrangible than those of light. The other is found at the opposite, or violet end of the coloured spectrum, and is produced by the highly refrangible actinic or chemical rays. Long ago, the experimental researches of Melloni exposed the peculiar properties of the first of these rays, by showing that in many respects they are similar in their modes of action to the rays of light ; for they are refracted, dispersed, absorbed, and transmitted by different substances. Unlike the rays of light, however, they do not always pass with the same facility, through the same media ; for substances which freely transmit the one, will often arrest the other — alum, water, glass, &c., which are so perfectly transparent to light, are more or less opaque to heat j while a solution of iodine in bisul- phide of carbon, which is quite dark to light, is yet freely transparent to heat ; a few other substances as rock-salt, and bisulphide of carbon, are transparent to both. At present we know but little of the spectra from these rays, although recently the investigations of Professor Tyndall have added something to our knowledge of them ; for he has not only proved the existence of a thermotic spectrum, composed like the luminous spectrum of rays of different degrees of refrangibility, but he has also demonstrated a difference in the thermotic spectra when the rays of heat are passed through different substances, and has proved that, as with light, each substance will arrest or absorb its own peculiar rays. The apphcation, however, of these facts to analysis, is not yet so easy as in the case of light, chiefly because we have no instrument for discovering the differences in the quality of the thermotic rays ; DR. LETHEBY ON SPECTRUM ANALYSIS. 27 and yet it would seem that the delicacy of their manifestations is singularly great; for the merest trace of certain volatile substances, as the hydrocarbons, ammonia, boracic aether, and the perfumes of flowers, when present in the air, is sufficient to arrest the passage of radiant heat, and so to discover their presence. No process of chemical analysis is at all equal to it in the delicacy of its manifestations ; for, to use the words of Professor Tyndall, " it would be idle to speculate on the quantities of matter implicated in the results.* Nor is this all; for the absorptive power of different substances gives us an insight into their molecular constitution. As a rule, the elementary gases and vapours permit a free passage to radiant heat, whereas compounds, which are always groups of atoms, arrest it. " Por every ray struck down by air, oxygen, hydrogen, or nitrogen, — ammonia strikes down a brigade of 7,260 rays; defiant gas a brigade of 7,950 ; while sulphurous acid* destroys 8,800 ; " t and boracic aether 180,000. Even when the molecules of a scent are difl'used through atmospheric air, so as to be hardly perceptible, and when the atoms of the latter are almost infinite in number as com- pared with the molecules of the, former, yet the particles of , scent absorb the rays of heat in a notable manner; for in such an atmosphere, thinly scattered as they are, the molecules of the volatile oil of patchouli will do thirty times the execution of all the air; otto of roses |does thirty-six times the execution of the air ; thyme seventy-four times; spikenard three hundred and fifty-five; and aniseed three hundred and seventy-two times. The conclusion from this, is that the complex molecules, or groups of atoms of compound substances, swing more freely, and take on more easily the thermotic motion of the aether in which they are bathed ; and that they thus absorb the rays of radiant heat. Is the hope, therefore, unwarranted that the phenomena of radiant heat may visualize the atoms and molecules of matter to the eye of intellect; and may show their mechanism and physical structure, — to take an instance or two, there is the element oxygen and its allotropic modification ozone. In their ultimate chemical nature these bodies are the same, and yet how different are their activities ; but on what does this difference depend ? Examined by means of radiant heat, the former is found to give free passage to it, whereas the latter arrests its motion; and so ener- * Heat a Mode of Motion. Second Edition, p. 367. t Ibid, p. 354. 28 DR. LETHEBY ON SPECTBUM ANALYSIS. getically, that it stands beside the hydrocarbons as an absorber of heat. The conclusion, therefore, is, that its structure is the same; and that it consists of atoms of oxygen packed together into groups, or molecules, which swing freely in the circumambient aether. It may be that the same is true of other allotropic forms of elementary matter — as charcoal, plumbago, and the diamond; and the like con- ditions of phosphorus, sulphur, silicon, &c. How far these researches may extend to the comprehension of the molecular structure of organic groups, and even to that of organized matter is yet to be determined ; but the prospect before us is certainly hopeful. With regard to the other invisible spectrum, which is composed of actinic or chemical rays, and is found at the violet end of the luminous spectrum, there are many ways of exhibiting its presence. Professor Stokes has taught us how to make it visible by letting it fall upon a piece of paper moistened with a solution of sulphate of quinine, when it instantly appears as a dim blue phosphorescent light extending beyond the luminous spectrum. Other fluorescent substances, like sulphate of quinine, have the same power of changing the highly-refracted invisible chemical rays into visible rays of lower degrees of refrangibility of a blue colour; and by this means it is found that the actinic or chemical spectrum often extends to six or eight times the length of the coloured or visible spectrum. These rays, like the rays of light and heat, are intercepted by some substances, and transmitted by others. It is found, indeed, that glass, mica, bisulphide of carbon, and many other things which are transparent to hght, are opaque to the chemical rays. This is so marked in the case of the alkaloids, and glucosides, or neutral active principles of vegetables, when they exist in solution, that it may be made the means of discovering their presence, even in very minute quantity. It often happens, in fact, as in the case of the luminous spectrum, that a band of absorption or maximum opacity appears ; and the position of this band affords a highly distinctive character of the substance producing it.* On the other hand, rock-crystal (quartz), white fluor-spar, and water, are very permeable to the chemical rays. Dr. W. A. Miller has obtained a photographic image of the chemical spectrum by receiving it upon a prepared film of collodion in a camera; and after exposure for five minutes to its action,. he has developed the image in the usual way, and fixed it with cyanide * Proceedings of the Royal Society, Vol. xii. p. 168. DR. LETHEBY ON SPECTRUM ANALYSIS. 29 of potassium. It was, of course, necessary that the lenses, as well as the prism should be made of rock-crystal, as glass and other sub- stance are more or less opaque to these rays. In this manner he has obtained photographic* self-made pictures of the actinic spectra of various substances ; and the great facts deducible from them are,— first : that the light from different luminous objects produces very different spectra : — secondly, that there is no relation between the transparency of a substance and its diactinic power : and thirdly, that bodies which are either diactinic or opaque in the solid form, are the same in the liquid state; and in solution in water. Sparks were taken from different metals by means of Ruhmkorff's induction coil, and the photographic pictures of the spectra showed a marked difference in the results. Silver gives the longest spectrum ; and next in order are cadmium, zinc, nickel, cobalt, copper and tin ; while the shortest are gold, chromium, manganese, naagnesium, alumi- nium, lithium, potassium, and sodium. "In many cases" says Dr. Miller, " metals which are allied in chemical properties, exhibit a cer- tain similarity in their spectra. This occurs, for example, with the magnetic , metals — ^iron, cobalt, and nickel, and with the group embracing bismuth, antimony, and arsenic. The more volatile metals exhibit generally the most , strongly-marked lines. Cadmium, for instance, gives two intense groups, zinc, two very strong lines near the less refrangible extremity, three near the middle, and four nearly equidistant lines towards the termination of the more refrangible portion, whilst in the spectrum of magnesium, the chemical action is almost suddenly terminated near the middle by a triple group of very broad and strong lines."* When the spark of the different metals is taken, in air and other gases, it is found that there is the combined effect of the metallic and the aerial spectra. An elevation of temperature also increases the length of the spectrum ; magnesium, for example, at the comparatively low temperature of the oxyhydrogen flame, (15006° Fahr.) gives a short spectrum, whereas, at the high temperature of the electric spark, it produces a long one. And as the chemical spectrum of the sun is rather short, it indicates that the temperature of its gaseous atmosphere is not above that of the oxy- hydrogen flame. Again, the permeabiHty of different substances to the chemical • Proceedings of the Royal Society, Vol. xii. p. 165. See also The Jour- nal of the Chemical Society, Vol. xvii. p. 59, for figures of the spectra. 30 DR. LETHEBY ON SPECTRUM ANALYSIS. rays is very different; for, of solid substances, rock-crystal, white, topaz, white fluor-spar, ice, and pure rock-salt, are the most permeable. Of all liquids, water is the most diactinic; next to this is alcohol and the mineral acids j while the volatile oUs, sether, and bisulphide of car- bon are very opaque to the chemical rays. Dr. Miller has examined the diactinio power of many saline solutions, and the results indicate the possibility of using the chemical spectrum as an agent of analysis ; for, " amongst the various compounds submitted to examination, the fluoricie^ rank first in diactinic power ; then follow the chlorides of the metals of the alkaline earths ; the bromides of the same metals appear to be less diactinic than the fluorides and chlorides, and this decline in power in still more marked in the case of the iodides. Sulphuric, carbonic, and boraoic acids furnish salts with the alkalies and alkaline earths, which are also largely diactinic ; the phosphates seem to be less so, and the arseniates still less. It is remarkable, that although the sulphates are so diactinic, the sulphites are considerably less so, and the hyposulphites are more opaque than the sulphites.* But the group which is most remarkable for its absorptive power is the nitrates, all of which, as well as nitric acid, have a specific power in arresting the chemical rayS, while the chlorates, which are other- wise so analogous, are strongly diactinic. Gases and vapours also oppose the progress of the chemical rays although, contrary to what is observed with the thermotic rays, the elementary gases are among the most opaque of all substances ; in fact, the diactinic power of oxygen, hydrogen, and nitrogen, is greater than that of any solid or liquid ; while ammonia, olefiant gas, and some other gaseous hydrocarbons are far from being powerfully opaque. All these results indicate a power of research, which is especially interesting to the physiologist, and which appear to be full of pro- mise for the future. Already, indeed, the investigations of Professor Tyndall, with regard to the radiating and absorbing powers of cer- tain gases, and vapours for heat, have been accepted by meteoro- logists as a means of explaining the peculiarities of climate, &c. ; and the phenomena of actinic spectrum analysis, when applied to the examination of organic hquids, may yet be most fruitful of results. That, however, which is especially interesting to us is the application of chromatic spectrum analysis to the " recognition of » Journal of the Chemical Society, Vol. ii. New Series, p. 69. DR. LETHEBY ON SPECTRUM ANALYSIS. 31 organic and other colouring-matters, and to the discovery of their chemical and physiological nature. The blood, for example, when examined for its spectrum under the action of different reagents, shows that the colouring-matter is principally concerned in the phe- nomena of respiration ; and the appearances of the spectra are so remarkable, that they become the means pf discovering the presence of blood in very minute quantity. Professor Hoppe was the first to notice this;* and he became acquainted with it by passing a ray of light through a weak solution pf blood, and examining it with a prism : he then observed that the blue end of the spectrum was cut off, and that two dark bands appeared in the green. The same effect was produced with the red blood of all animals, and he, therefore, proposed to use it as a means of medico-legal research. Later still, in 1864, Professor Stokes continued the inquiry ;t and he ascertained that the colouring-matter of the blood, when fresh, was very different from the hsematin of Lecanu ; for it was soluble in water, and had the power of absorbing oxygen, and giving it out with great facility, and that the spectra in the two states of oxida- tion were very different. He, therefore, named the substance cntorin, distinguishing the bright red arterial or oxidized cruorin by the name of scarlet cruorin, and the purple or v-enous coloured deoxi- dized cruorin by the name of purple cruorin. His method of research was very simple, for he merely placed a weak solution of blood behind a slit, and looked at it with a prism. It is, however, better examined by putting it into a test tube, and holding it before the slit of Browning's spectroscope (Fig. 3). When the blood is fresh, and the solution not too strong, the blue end of the spectrum is cut off, and two dark bands appear in the green, one close to Fraunhofer's line (D), and the other, which is a little broader, but not so well defined, is nearer to the blue. This appearance is not affected by adding ammouia, or the carbonated alkalies to the blood; but it is more or less quickly changed, by the caustic fixed alkalies, by acids, heat,- alcohol, &c. ; and then the two bands iu the green either disappear entirely, or they move lower down into the blue, which becomes much more discernible : besides which, there is a dark band in the red. This he found was the * Firchow'g ArcMv. Vol. xxiii. p. 446 (1862). t Proceedings of the Boyal Society, Vol. xiii. p. 355. 32 DR. LETHEBY ON SPECTEUM ANALYSIS. spfectrum of Lecanu's htzmatin, which had been formed by the action of acids, &c., on the cruorin of fresh blood. Both of these colouring- matters are, however, susceptible of oxi- dation, and deoxidation, giving in each case a characteristic, but very different spectrum. Fresh blood, dissolved in water, and made alkaline with ammonia, gives the spectrum of scarlet or oxidized cruorin, with its two well-defined absorptive bands in the green ; but if to this alkaline solution of the blood there is added a little protosulphate of iron, to which enough tartaric or citric acid has been added to prevent its precipitation by the ammonia, the colouring-matter is reduced, or deoxidised by the protosulphate of iron, and the spectrum is changed to one with a single dark band in the green — the band being broader than either of the preceding, and occupying the place which was be- tween them, as if the two bands had come together. This is the spectrum of purple or reduced cruorin ; for, on blowing the solution to stand exposed to the air, it quickly absorbs fresh oxygen, and again becomes scarlet cruorin with its two absorptive bands. An additional quantity of the protosulphate will again reduce it, and so on for many times. Professor Stokes has ascertained, beyond all question, that this change is not due to. the spectral properties of the iron, but to changes in the colouring-matter itself; for, by using other deoxidiz- ing agents, as protochloride of tin, hydrosnlphate of ammonia, &c., the effects are the same, although they take place more slowly. Even blood itself, when it has been corked up, or otherwise placed, so as to be excluded from the air, and has become slightly putrid, ex- hibits the same single dark band of deoxidation ; but on exposure to the air it quickly absorbs oxygen, and shows the spectrum of scarlet cruorin. Professor Stokes infers from this that " the colourr mg-matter of blood, like indigo, is capable of 'existing in two states of oxidation, distinguishable by a difference of colour, and a funda^ mental difference in the action on the spectrum,. It may be made to pass from the more to the less oxidized state by the action of suitable reducing agents, and recover its oxygen by absorption from the air" The importance of these reactions, and of this conclusion, will be best seen when we apply them physiologically. When a little acid, as acetic, tartaric, or citric, which does not DR. LETHEBY ON SPECTRUM ANALYSIS. 33 give a precipitate with the colouring-raatter of the blood is added to it, the solution quickly changes from a red to a brownish red colour, and the spectrum is no longer like that of fresh blood ; for the two bands in the green gradually disappear, or pass downwards into the blue, and there is a distinct band in the red. The change is evidently of a chemical nature, for nothing will restore the colouring-matter to its original condition. The cruorin, in fact, is permanently changed into another substance — the hsematin of Lacanu. But this also, like cruorin, can exist in two states of oxidation, and give two characteristic spectra. The spectrum of oxidised hamatin is that already described ; it exhibits a faint absorption-band in the red, and two in the green, or rather one in the green, about the position of the lowermost black band of scarlet cruorin, and another in the blue. By candle- or lamp-hght, the last band is obscured in conse- quence of the comparatively small amount of blue in the light ; but, by daylight it is very distinct; and if the strength of the solution is gradually increased until the red rays alone pass through it, the band in the blue is the last to go, whereas, with scarlet cruorin, the last colour to fade is the green between its two dark bands. In order to see the spectrum of reduced hamatin, it is neces- sary to obtain -the colouring-matter in . a somewhat pure condition, because the addition of ammonia to the impure acid- solution will render it turbid, and so obscure the field of view. The process to effect this is to acidulate a strong solution of blood, or blood-clots, with a little glacial ^cetic acid, and then to add about two or three times its bulk of sether, and gently move about in a test tube until the sether dissolves the acid colouring-matter, and floats without frothing. This is to be poured off; and if it be at once examined, it will give the characteristic spectrum of oxidised hamatin in a very marked manner. But for deoxidation, it must be washed with a little water to remove the excess of acid, when the colouring-matter separates, and forms a film or layer between the sether and water. The latter is to be drawn ofP with a pipette or syphon, and. the sether with the colouring-matter is to be treated with a slight excess of ammonia, in which the hsmatin dissolves. This gives a spectrum, with a black band, obscurely divided into two at the line (D) of Praunhofer. If to this is added a small quantity of the solution of protorsulphate of iron with tartaric acid, it exhibits a spectrum with two dark and 1) 34 DB. LBTHEBY ON SPECTRUM ANALYSIS. well-defined bands in the green, not much unlike the two bands of scarlet cruorin, but placed lower down, and their relative widths are different from those of fresh blood, for the uppermost is the widest and best defined, instead of the lowermost. On exposing the reduced hsematin to air, it again absorbs oxygen and becomes the oxidized hsematin. Professor Stokes names these also from their colour — hrown hamatin and red hmmatin. These reactions are so delicate, and withal are so characteristic, that they may be used as the means of discovering the presence of a very minute quantity of blood ; but to this end it is necessary that they should be used with microscopic appliances. This was first Fig. 5. done by Mr. Sorby, who put the solution of blood into very small cells or tubes, made out of barometer tubing, of one-eighth of an inch bore, cut into half-inch lengths, and cemented upon a slip of glass. The apparatus and the arrangement of it are shewn in Pig. 5, The solution of blood is contained in the barometer tube (a), which is fastened upon the glass (3), and held in its place by the DR. LBTHEBY ON SPECTRUM ANALYSIS. 35 spring (c), in front of a narrow slit {d). All these are supported on a moveable stand. In front of the tube (») there is a lamp so placed that its light, when condensed by a properly placed condenser, passes through the solution of blood to the glass prism {e), and thence by the acromatic condenser (/), to the object-glass of the microscope {Ji), and so on to the eye ; or if more convenient, the object jnay be placed upon the stage of the microscope at g, and examined by the light which has passed the prism. In both cases, however, the spectrum of the object is seen in the microscope, and the appearances are so well marked, that as little as the i^th part of a grain of blood may, according to Mr, Sorby, be discovered by this. means.* But it was soon found by Mr. Sorby that it would be more con- venient to have the prism in the eye-piece of the microscope, with such an arrangement that the object might be examined in the usual way by direct light j and although the difficulties of effecting this were very great, yet he overcame them at last ; and with the assistance of the practical skill of Mr. Browning, the well-known optician of the Minories, he constructed a spectroscope that can be used in the same way as the eye-piece of a microscope. Its form and arrangements are seen in Kg. 6, and it consists of prisms for direct vision, so arranged that the spectra of two objects can be seen in the field of view at the same time, one of the objects being placed upon the stage of the microscope, while the other is placed upon the stage of the spectroscope. In this way the spectra of an unknown object can be compared with that of a known, and the position of its absorption-bands accurately determined. There is also an adjust- ment for altering the width of the slit, so as to obtain in every case the maximum effect ; and when the slit is fully open, and the prisms are removed, the eye-piece may be used in the usual manner for find- ing and examining the substance. By this means the highest power of the microscope may be employed ; and it is said that the charac- teristic spectrum of a single blood-disc may thus be obtained. One of the principal facts elucidated by Mr. Sorby is that blood in drying and keeping in common atmospheres undergoes change. It acquires, as everyone knows, a brown colour; and this he finds is due to the presence of acid matter in the atmosphere, which converts scarlet cruorin into a brown variety — having a * Journal of Science, April, 1865, p. 211. D 2 36 DR. LETHEB'y ON SPECTRUM ANALYSIS. characteristic spectrum. If recent blood, for example, is dissolved Fig. 6. in water, it gives the spectrum No. 2, Pig. 7, which is the spectrum of scarlet cruorin, with the blue end darkened, and the two dark absorption bands just below Fraunhofer's line (D) ; but if. the spot of blood has been exposed to the air, so as to become brown, its solution furnishes a spectrum like No. 3, in which the two bands in the green are much weakened, and another band appears in the red. If the exposure -has been for a longer • time, it looks .like No. 4, when the red band is still stronger, and the two green ones still paler. A larger quantity of blood is also required- to show these spectra; and if the solution is very strong it only gives a dirty brown spectrum with a dark band in its centre. The time necessary for these changes varies with the locality, and the circumstances under which the blood-spots have been kept. Exposed to the air at Burbage Moor, six miles from Sheffield, and ER, LETHEBY ON SPECTKtJM ANALYSIS. 37 one or two miles from any houses/he found that it took a week to Fig. 7. .1 2 3 1 5 6 7 8 produce any appreciable change ; whereas, in the centre of the town of Sheffield, it occupied only a few hours. He further observed that when the blood-spots were kept in his own house the rapidity of change was tnuch affected by the combustion of gas ; and hence he concluded that it was due to the formation of some acid compound, probably sulphurous acid by the burning gas. He then found that, when the blood-spots upon a piece of linen were sealed up in a glass tube, in a perfectly dry state, it required two or three months to pro- duce a change that would show the spectrum No. 3 ; but if it was sealed up wet it did not undergo any change. It would seem, therefore, that there are three forms of crnorin, namely the scarlet, the purple, and the brown, each of which gives its characteristic spectrum. In all cases of medico-legal inquiry, the method of proceeding with the. examination of blood-spots should be as follows: — If the blood- stain permits of the removal of the blood without admixture with the tissue or fabric upon which it rests, it is proper to detach a portion of it in this manner, and dissolve it in a single drop of water in a watch- glass, and then to transfer it by means of a glass-tube. drawn out to a fine point, to the cell made in the way already described, from a piece' of barometer tube.* After which it is to be covered with a piece * These cells should be made of tubes of various sizes and lengths to suit different circumstances, as of tube from one-tenth to a quarter of an inch 38 DR. LETHEBT ON SPECTRUM ANALYSIS. of tMn microscope glass^ and allowed to stand in a horizontal position, for ten minutes or a quarter of an hour, until the suspended insoluble matter subsides/and leaves the solution clear, and fit for observation. It is then placed upon the stage of the microscope, and examined ■with a magnifying power of from half-an-inch to a-quarter, taking care that the top of the liquid is brought into focus. When this is done the prism of the spectroscope is to be put on, and the slit narrowed until the bands in the spectrum become distinct. If the blood is moderately fresh, it wiU show the spectrum No. 2, Kg. 7 ; but if it is not so fresh, it will look Hke No. 3 or No. 4, according to its age. On adding a little ammonia to the solution, the band in the red of No. 3, or No. 4, immediately disappears, and those in the green become strengthened, as in No. 5. A minute fragment of citric acid is now to be added, and stirr6d into the solution with a fine platinum wire. This will weaken the dark bands in the green, or even make them disappear altogether, if the acid has been added ia excess. Should this be the case a little more ammonia must be used, and then a very small particle of the crystal of green protosulphate of iron, the cell being immediately covered with a piece of thia glass, and secured with gold size, so as to exclude the aii-. On turning the cell over and over for a few minutes, the protosulphate of iron will dissolve and deoxydize or reduce the scarlet cruorin to the purple — forming a pale red Uquid, which will give the spectrum No. 6, with a single dark band in the green. The specimen may be thus preserved for many months. A little of the solution of the blood may .also be dried upon a piece of glass, when it will give the spectrum No. 2, No. 3, or No. 4, according to its freshness and hygroscopicity. If it be very fresh and dry, it will look like No. 2 ; but if it be changed into brown cruorin the two bands in the green wiU be much paler, and when it is breathed on, so as to make it a little damp, it wiU show the band in the red Hke No. 3, or No. 4 ; the dty spot may be thus preserved upon the glass for months without change, provided it is covered with a piece of thin glass, and secured with gold size, or Canada balsam. If the blood be very old and has become changed into hsematin, it will not dissolve in water without the assistance of a vegetable acid ; bore, and from one-ialf to three-quarters of an inch in length, ground flat at the ends, and cemented upon slips of glass. DE. LETHEBY ON SPECTRUM ANALYSIS. 39 it is, therefore, to be treated with a drop of water acidulated with citric acid, and the solution transferred to the cell, and examined as before. Under this treatment whether the blood be new or old, it will be changed into haematin, and will give the spectrum No. 7, with its characteristic band in the red, another in the green, and if seen by daylight there will be one in the blue. On adding a little ammonia, so as to make it distinctly alkaUne, and then a very small particle of proto-sulphate of iron, it will be reduced, and will give the spectrum No. 8, with its two bands in the green ; as in the former case, the cell must be covered with a piece of thin glass, and secured with gold-size, to exclude the air, when it will keep for months un- changed It thus appears that a very minute particle of blood may be made to furnish its characteristic spectra; and when, in a medico-legal inquiry, these spectra are compared with the known spectra of blood, treated ia exactly the same way as the suspected matter, the results are very conclusive. In fact there are no real fallacies to the tests ; for although many red solutions may produce stains upon clothing like blood-stains, and may give spectra, which at first sight appear like one or other of the blood spectra, yet there are none which show all the characteristic appearances of blood under the action of different reagents. Eew indeed, if ^ny, will stand the test of ammonia, which only brightens the absorption bands of blood, while it alters the appearance. of other colours; and if there be any doubt in the matter, a little sulphite of potash will remove it, for this bleaches every colour which is likely to be confounded with blood. Among the reds which cut off the blue end of the spectrum, and exhibit black bands in the green, that are more or less like those of blood, are cochineal, lac-dye, alkanet, madder-red, and munjeet dissolved in each case, in a solution of alum ; but on comparing the spectra, side by side,, with those of blood, it will be at once seen that the bands are not the same, either in their position or character. In the case of cochineal in alum, for example, which is so very like blood, that it might almost be mistaken- for it, the two bands are nearly of the same width, whereas, in blood, the lower band is always the widest; and the reverse in the case with alkanet in alum. Besides which, none of these coloui-s will stand the action of ammonia. Even the gravy of roasted meat^ if it be not from underdone meat, which is 40 DR.. LETHBBY ON SPECTRUM ANALYSIS. more or less modified cruorin, does not give the same spectra as blood ; for although it sometimes shows a dark and sharply defined absorption-band, a little below the line (D), like that of reduced cruorin, yet ammonia weakens it, and citric acid, with proto-sulphate of iron, produces ho change in it, as it does with hsematin. In fact, if the gravy is very dark coloured, and has been strongly heated, it gives a spectrum, like No. 1, Fig. 7, without any absorption-bands. There is, therefore, no colour, as yet examined, which can, with proper care, be confounded with blood. A few precautions, however, are always necessary to guard against possible sources of error, and to obtain the most satisfactory results. In the first place, the solution of blood should not be too strong, for, if it is, it cuts off too much of the light, and the absorbtion-bands merge into each other, and are not seen. On the other hand, if the solution is too weak, the bands are faint and are therefore not well marked. This, however, may be remedied by using a very, narrow tubular cell, and thus increasing the depth of the liquid. Secondly/, the reagents, especially the citric acid and proto-sulphate of iron, should be employed in very minute quantity, as the hsematin produced by the action of the acid on blood is not very soluble in a strong solution of citrate of ammonia, and will, therefore, be precipitated when the acid solution is neutralized, or rather supersaturated with ammonia ; and the precipitate obtained by adding too much proto- sulphate of iron to the alkaline solution of blood, will obscure the field, and thus mask the absorption-bands. Thirdly, it is necessary to throw the object a little out of focus, or there will be lines in the spectrum which are not due to the colouring-matter. FourtMy, the width of -the slit should be adjusted during the examination, so as to obtain the best effect, for, by narrowing the sHt, the absorption-bands become more defined, and therefore more distinct. Fifthly. — It is well to note the differences in the spectra with day- light, and artificial light ; for, as the latter contains more yellow rays than the former, there is a comparative feebleness of the blue end of the spectrum, and it is consequently shorter. In my opinion, the results are most satisfactory with artificial light, as the flame of a parafftu lamp, or of gas, and the Drawing, ' Fig. 7, represents the appearance under these circumstances. DE. LETHEBY ON SPECTEUM ANALYSIS. 41 The delicacy of the spectrum-test is very remarkable. Mr. Sorby says, in a communication to me^ that the Troth of a grain of liquid blood may readily be made to exhibit all the characteristic spectra, — even so small a quantity as the jroth or the jmth. of a grain of blood, may be discovered after a little practice, by using a tubular cell, the TOth of an inch in diameter, and an inch in length. When the blood- stain is upon white linen, a piece, not larger than the I of an inch square, is generally sufficient for the inquiry, but all the spectra are not equally well seen with the same amount of material. If, for example, one part of blood will give the spectrum No. 8 (Pig. 7), it requires two parts to produce the spectrum No. 2, and about ten parts for the spectra Nos. 4>, 5, 6, and 7. It follows, therefore, that the most satisfactory results are always obtained by dissolving the blood in a little water, acidulated witb citric acid, and then supersat- urating with ammonia, and reducing with a very little proto-sulphate of iron. As examples of the delicacy of the test, and also of the time which may elapse after the blood has been drawn, before it loses its properties, the following may be quoted : — In the year 1849 I had occasion to make a medico-legal investigation of some blood-stains upon linen, and the specimens which have been kept from that time to the present, have been recently examined, both by Mr. Sorby and myself. The stains were of a brown colour, and were quite insolu- ble in. water, — showing that the cruorin of the blood had been com- pletely changed into hsematin ; but on treating a piece of the stained linen, not larger than a quarter of an inch in diameter, with a weak solution of citric acid, the colour was completely dissolved, and there was obtained a pale yellow solution, which, in its acid condition, hardly showed a trace of the characteristic blood-spectrum of oxi- dised hsematin. When, however, it vjras m^de alkaline with ammo- nia, it exhibited the two faint bands in the green, which are charac- teristic of alkaline hsematin ; and on adding a minute fragment of proto-sulphate of iron, the spectrum of deoxidised haematin, with its double band in the green, was well seen. A like result was obtained with another medico-legal specimen of blood, dated J 851, and with some more recent specimens of blood which I have had to examine, as in the case of the Ilford murder, in September, 1865, and of Mr. Briggs in July following, and the Plaistow murder in 42 DR. LETHEBY ON SPECTRUM ANALYSIS. November of the same year, — in all of wMch cases tlie spectra are still very characteristic, although the blood, in every instance, is changed into the insoluble form of hsematin. It thus appears, that the characteristic properties of blood are not lost after a lapse of seventeen years, but that the spectra are still as distinct, and as well marked, as with blood of only a few months old. Mr. Sorby has carefuUy inquired into the impediments to the action of the test, and he finds that some dyes, especially those which have been mordanted with alum^ and certain astringent substances, as the tannin of leather, and many hard woods, as well as soap, alcohol, acids, heat, and time, change the colouring-matter of blood into hsematin, and so make it insoluble in water. It is possible, therefore, that these may offer impediments to the recognition of blood, especially if it be examined in a recent condition; but the difBculty is easily overcome by dissolving the blood in a little water, acidulated with citric acid, and then looking for the spectra of alka- line and reduced hsematin. An experiment should also be made by putting a little blood upon the questionable fabric, and after it has become thoroughly dry, examining it for its spectra, and thus determining what are the real effects of the dye or astringent matter upon it. In this way all possible sources of fallacy and impediment are removed; and if to these are added the microscopic and chemi- cal characters of blood, — as the presence of blood-corpuscles or their fragments, the forming a red-coloured solution, which is not easily bleached by chlorine or sulphurous acid, but is coagulated by heat or nitric acid, the results are conclusive. In a physiologrcal point of view, these reactions of cruorin, as studied by its different spectra, — showing how greedily it absorbs oxygen, when exposed to the air, and how readily it gives it out again, under the influence of reducing agents, are especially interest- ing, for they throw a light on the probable function of the colouring- matter of the blood. They prove also that the peculiar red pigment of the blood-corpuscle has not yet been studied, except in the form of Lecanu's hsematin, which is undoubtedly an altered condition of it. Grave doubts have, for a long time, been entertained of the identity of this substance with the colouring-matter of the blood as it exists in the red corpuscles. Lehmann expresses himself very strongly on this point, when he says, that, unfortunately, it is by no DR. LETHEBY ON SPECTRUM ANALYSIS. 43 means certain whether it is a product of metamorphosis of the true colouring-matter of the blood, or whether the hsematiuj prepared by us, only bears the same sort of relation to that which exists in the blood-corpuscles as coagulated albumen bears to that principle in its fluid state. We cannot isolate it in its soluble state from the globu- lin of the blood-corpuscles ; hence we are only acquainted with it in its coagulated (and essentially modified) condition.* In that condi- tion it is a dark brown substance, insoluble in water, but soluble in weak vegetable acids and in alcohol acidulated with suphuric or muriatic acid. These are the properties of the substance which gives the spectra of brown haematin, and it differs essentially from the cruorin of fresh blood. All our notions, therefore, of the physio- logical functions of the colouring-matter of the blood as deduced , from the properties of haematin, are manifestly uncertain, if they are not actually founded in error. It is true that the constant occurrence of red pigment in the blood-corpuscles, and the change of it from purple to red under the influence of atmospheric oxygen, and of red to purple in the systemic capillaries, where the blood parts with oxygen and takes in carbonic acid, are strong proofs of its taking an important part in the function of respiration, and in the metamor- phosis of the tissues; but the precise way in which that change is effected could never be determined so long as there was any doubt of the exact relations of hsematin to the true colouring-matter of the blood. The uncertainty, in fact, which pervaded the subject, is well expressed by Lehmann, when he says, that all sorts of conjectures have been hazarded respecting it, and that it is unnecessary to con- sider any hypothesis until it has been satisfactorily ascertained whether the hsematin in question actually stands in the same relation to the true pigment of blood as coagulated and uncoagulated albumen ; or whether a,rtificially prepared haematin is altogether a product of decomposition of the actual pigment. If hsematin has the same composition, as that we prepare artificially, and if the only difference be that it exists in a soluble form in the blood-corpuscles, there is at once an end to all those very imaginative hyyotheses which assume that the iron takes a great share in the process of respiration, and that it is the conveyer of oxygen to the blood. In further proof of the uncertainty of the subject, he says, "the * Lehman's Physiohgical Chemistry, Vol. i., p. 299. 44 DR. LETHEBY ON SPECTRUM ANALYSIS. experiments of Bruch on the action of gases on tlie colour of the bloodj and the observations of Earless regarding the gradual destruc- tion of the corpuscles of frogs' blood, certainly indicate that there is a chemical action between the blood-corpuscles and their contents on the one hand, and the inspired oxygen on the other, in which action the hsematin doubtless participates. But the observations of Han- nover, which show that persons whose blood is very deficient in red corpuscles (chlorotic persons) exhale as much carbonic acid as healthy persons, seem on the other hand to contra-indicate a direct relation between the blood- corpuscles or blood-pigment an oxidation in the blood. We must, therefore, give up, for the present, all attempts at understanding the function of the blood-pigment." * Now, it is at this very point that the inquiries of Professor Stokes and Mr. Sorby are so valuable, for they not only prove that the hsematin of Lecanu is not the same as the true colouring-matter of the blood, but they also demonstrate the fact that this colouring- matter is endowed with the remarkable property of freely absorbing oxygen, and of as freely parting with it to reducing agents. They show, therefore, that we have in the colouring-matter of the blood a substance which is especially well-suited for the purposes of respira- tion. Nor is this aU — the passage of the colouring-matter of fresh blood, from the state of oxidised or red cruorin, to that of reduced or purple, is accompanied with the precise changes of colour which mark the passage of arterial to venous blood j and as the spectra in the two cases of red and purple cruorin are so diflFerent from each other, it was hoped that they might be the means of discovering the real difference of venous and arterial blood. With the view of solving this question. Professor Stokes, assisted by Dr. Sharpey and Dr. Harley, obtained venous blood from a living animal and examined its spectral properties. Every precaution was taken to prevent the access of atmospheric oxygen, because of the greediness with which it is absorbed. A pipette was adapted to a- syringe filled with water, that had been carefully deprived of its free oxygen by previous boiling and cooling without exposure to the air. The point of it was introduced into the jugular vein of a live dog, and a little blood was drawn therefrom. This was immediately examined for its spectrum, but it showed the bands of scarlet cruorin : indeed, * Ihid, p. 307. DR. LETHEBY ON SPECTEUM ANALYSIS. 45 the solution itself looked more like arterial than venous blood ; and so far it was inconclusive : but, as Professor Stokes remark's, it does not by any means prove the absence of purple cruorin ; it merely . -shows that the colouring-matter present, was chiefly scarlet cruorin. Indeed, the relative proportions of the two present, in the mixture of them with one another, and with colourless substances, can be better judged of by the tint than by the use of the prism ) for, with the prism, the extreme sharpness of the bands of scarlet cruorin is apt to mislead, and to induce the observer greatly to exaggerate the relative proportions of that substance.* Besides which, it is very probable that the recently-boiled vrater absorbed the carbonic acid of the purple cruorin, and so destroyed or altered its characteristic spectrum. Seeing then, that the change of colour from arterial to venous blood as far as it goes, is in the direction of the change from scarlet to purple cruorin, that scarlet cruorin is capable of reduction, even in the cold, by substances present in the blood, and that the action of reducing agents upon it, is greatly assisted by warmth, we have every reason to believe that a portion of the cruorin present in venous blood, exists in the state of purple cruorin, and is re-oxidised in passing through the lungs. That it is only a rather small proportion of cruorin present in venous blood, which exists in the state of purple cruorin, under normal conditions of life and health, may be inferred, not only from the colour, but directly from the results of the most recent experi- ments.t Were it otherwise, any extensive haemorrhage could hardly fail to be fatal, if, as there is reason to believe, cruorin be the substance on which the fuuctions of respiration mainly depends ; nor could chlorotic persons exhale as much carbonic acid as healthy subjects, as is found to be the case.J Additional light is thrown on this subject by the investigations of Magnus, which prove that both arterial and venous blood contain oxygen and carbonic acid, but the proportions in the two cases are different; for while, in arterial blood the proportion of oxygen to carbonic acid is as six to sixteen, in venous blood, it is only as four to sixteen. Other experiments have also proved that venous * Proceedings of the Royal Society, Vol. xiii. p. .361. t FimKsLehrhuch der Physiologie, 1863, Vol. i. p. 108. X Op. cit. p. 361. 46 DR. LETHEBY ON SPECTRUM ANALYSIS. blood will absorb more oxygen than arterial, and arterial blood than serum. Lehmann, in fact, found that a given volume of clot would take up twice as much oxygen as the same volume of serum. It would, therefore, seem not only that the colouring-matter of the blood is the real agent of respiration, but also, that both arterial and venous blood contain cruorin, in its two states, of purple and scarlet. The tint of the blood is no doubt affected, to some extent, by other circumstances than the relative proportions of scarlet and purple cruorin ; for the experimental researches of Nasse, Scherer, Harless, Lehmann, and others, have demonstrated that the form of the blood-corpuscle has something to do with the colour of the blood. When it is flattened, the blood looks brighter, and more arterial, than when it is swollen. Oxygen and many saKne substances have the power of effecting this ; while carbonic acid water and some other agents swell it. All these reactions, however, are very different from the specific changes of scarlet and purple cruorin. Another important question is that which relates to the condition of the oxygen in scarlet cruorin ; is it common oxygen combined chemically, or is it allotropic, or somewhat active oxygen, held to it by adhesion ? The latter seems to be the true ponditions of it ; for if it is combined by a chemical power it is a marvellously weak one — something like that which fixes gases in water, or which holds the second molecule of carbonic acid in bicarbonate of soda, all of which are easily displaced. Profesgor Stokes took two portions of defibrinated blood, and, to one, he added a little of the reducing iron solution, while into the other he passed carbonic acid. The effects in the two cases were the same; the blood lost oxygen, became purple, and showed the spectra of reduced cruorin. Magnus also, has removed as much as from ten to twelve per cent., by volume of oxygen from arterialized blood by merely shaking it with carbonic acid. These experiments illustrate the weak affinity of oxygen for the colouring-matter of the blood, and they show, moreover, that the changes of colour, as well as the differences of the spectra, are not due to the presence of carbonic acid; but to the absence of oxygen. It is on this account that the blood of animals asphixiated by drowning, by carbonic acid, by nitrogen, or by the exclusion of air from their lungs is always dark coloured — the oxygen having been consumed in the circulation, and not renewed. In the dead body also the blood becomes darker and darker, by a process of re- DR. LETHEBY ON CHEMICAL ANALYSIS. 47 duction which goes on as long as there is any free oxygen in the blood to consume. ■ And this continued process of oxidation is further proof, that the oxygen exists in a semi-active condition, and not in the state of common oxygen. Yon Maack, indeed, found that even a solution of hsematin would absorb oxygen and form carbonic acid ; and the more recent experiments of Schmidt have demonstrated that the oxygen of arterial blood has the power of turning guiacum blue. This is a property of active oxygen, and he has, therefore, concluded that ozone exists in the blood.* " But/' as Professor Stokes re- marks, " if by ozone he merely means oxygen in any such state of combination or otherwise, as to be capable of producing certain oxydizing efifeots, such as turning guaicum blue, the experiments of Schmidt have completely established its existence, and have con- nected it with the colouring-matter of the blood,'^t although they do not prove it to be that peculiar aUotropic form of oxygen called ozone. " Now in cruorin we have a substance admitting of easy oxida- tion and reduction ; and connecting this with Schmidt's results, we may infer that scarlet cruorin is not merely a greedy absorber and carrier of oxygen, but also an oaiidizing agent, and that it is by its means that the substances which enter the blood from the food, set- ting aside those which are either assimilated or excreted by the kidneys, are reduced to the ultimate forms of carbonic acid and water, as if they had been burnt in oxygen." This is the conclu- sion arrived at by Professor Stokes, and it is fully borne out by the results of spectral analysis. Moreover, it would seem that the semi- active state of oxygen is acquired in the same way, as we see it mani- fested in powdered charcoal, in sand, in the soil, and in all kinds of finely divided matter. As to the change which the colouring-matter of blood undergoes, when it passes from cruorin to hsematin, we have but little know- ledge, except that it occurs spontaneously, and under the influence of very slight causes. How far this may be concerned in the development of pathological phenomena is hardly to be surmised. The different appearances of the blood, in certain diseases, not only when it flows fresh from the vein, but also when it is seen in the * TJeher Ozon im Blute. Dorpat, 1852. t Op. cit.-p. 363, 48 DE. LETHEBY ON SPECTRUM ANALYSIS. dead body, may, perhaps, be due to abnormal differences in the pro- portions of scarlet and purple cruorin, or even to the presence of their altered products— hsematin. Already the observations of Engel and Rokitansky have discovered a more than possible connexion between the colour and consistence of the blood in the dead body, and its tendency to soak or diffuse into the tissues, and accumulate in certain organs , and they have even classified these physical pro- perties of the blood into six kinds — each characteristic of a special group of diseases. And if to these observations, which are purely pathological and anatomical, there are added the exact investigations of the chemist, and the careful results of a searching spectrum analysis, we may hope for a rich accession of scientific facts. The dark colour of the blood, in nearly all cases of acute poisoning, may also, perhaps, be due to the same cause, and be elucidated by the same methods of research. Dr. Harley found, in his experiments on blood, that different poisonous agents operated very differently in promoting or checking the absorption of oxygen and the evolution of carbonic acid,* and it would be very interesting to determine by means of the prism the altered condition of the blood in all such cases. And then, again, the peculiar changes to which the colouring-matter of the blood is subject, when it passes from its natural colloidal, or amorphous conditions to a crystalline, have yet to be investigated. It is very probable that there are many varieties of these changes — four, at least, have been observed, all characterized by their special crystalline forms. Nor are these methods of investigation confined to the pathology of the blood, they are equally applicable to the elucidation of every kind of organic colouring-matter, as bile, the pigment of urine, and the chlorophyll of leaves. Already much has been done in this direction by Professor. Stokes,t and Mr. Sorby is now occupied in examining the spectra of the colours of flowers j while my own attention is being directed to the spectra of substances used in the falsification of wines, &c. ; and we may look, therefore, to the prosecution of these inquiries for a rich accession of facts to chemistry, physiology, and pathology as well as to the more practical purposes of therapeutics and legal-medicine. * Proceedings of the Royal Society, Vol. xiii. p. 158. f Proceedings of the Royal Society, Vol. xiii. p. 144. A LECTURE, WITH CASES, ON DIABETES, By Dr. FRASER. Gentlimen, — I shall not follow the usual line of clinical teaching, but give first a summary of the disease, as to its causes, diagnosis, and prognosis, and direct your particular attention to its treatment. You will be surprised and puzzled upon reading the literature of the sub- ject, to learn how vague and undefined the views are now held upon points which were considered for many years fixed and certain. It is surprising, that a disease which must have been constantly under the observation of physicians, should have been first described by Dr. Willis, so lately as 1684, for it was he who drew attention to the presence of sugar in the urine, the pathognomonic symptom. Writers divide diabetes into two species, viz. : diabetes meUitus, and diabetes insipidus. Of the former, the case before us. No. I., is an example, and No. VII., is an example of the latter. Many of the symptoms in both are nearly alike, but the characteristic difference is, that in the former the urine contains sugar, and in the latter it is absent ; hence, diabetes insipidus, should not be considered under the head of diabetes, but more properly be looked upon as a diuresis. In the advanced stage of true diabetes, we can rarely, if ever, hope for a cure ; but, by our remedies and advice as to diet and habits, we can alleviate the symptoms, and prolong life, and the earlier the disease is detected, so will our success be measured. What, thererefore, are the early ordinary symptoms ? Slight febriculse, a loaded tongue, intense thirst, pains in the back, and loins, skin dry and harsh, costive bowels, the passage of a large quantity of clear, or yellowish-tinted urine, generally of high specific gravity, and stated to have the odour of violets, or new-mown hay ; all this coupled with a great increase of appetite, E 50 DR. FRASEE ON DIABETES. nevertheless, a progressive emaciation. The quantity of urine passed in some cases is enormous, in one case 12 pints per day; and the solid contents of the urine excreted, often exceeds the weight of both solid and fluid ingesta. In a case in the Hospital, 60 ounces of urine, in excess of the flaid drank, viz. : 145 to 205 in twenty-four hours : this polydipsia arises from the rapid transformation of starchy foods. Now, as all the foregoing symptoms, except the great appetite sometimes approaching to bulimia, may accompany various diseases, they, except the bulimia, lose value as positive points of diagnosis in the early stage ; and, therefore, whenever you meet with a case con- joining more or less the foregoing symptoms, do not delay to inquire as to the quantity of urine passed in the twenty-four hours, and if you find that the quantity ranges more than 40 ounces daily, and the spe- cific gravity above 1"030, although in true cases of the disease, it is sometimes, but very raTely, so low as I'OIO, and albuminous, you must therefore guard against the latter possibility ; your suspicions will now be more raised, and you will proceed to verify or dismiss them, by examining with the usual tests for sugar, all of which you wiU find in the different test-books. You must, however, remember that the mere presence of sugar in the urine; does not constitute diabetes, unless it is persistent, and in large quantities. As much as one ounce of sugar has been extracted from one pound weight of urine. Our late resident medical ofBcer, Dr. Woodman has shown, but previously demonstrated by Briicke, that traces of sugar exist in the urine of many cases of other diseases ; more than "5 per cent, of sugar in the blood will give rise to diabetes. Tou will remember that the two - symptdms, viz. : great thirst, and great appetite, are rarely, if ever, conjoined in other diseases, therefore they are to arrest your attention. The other symptoms attending the advanced stage are : heat, and uneasiness in the epigastric region ; despondency ; depressed energy of mind and body, a permanently quickened pulse ; and now, other organs of the body become diseased, most frequently the lungs, — in- deed a large proportion of all cases of this disease die from pulmonary affections. Of the remote causes of this remarkable disease, we are stiU profoundly ignorant ; in books we are told that : — " It is owing to the conversion of fsecula iiito sugar." — Bour- pMrdai. " It is pretty clearly traced to changes in the action of assimilation, DR. FRASER ON DIABETES. 51 and in the constitution of the blood, not strictly speaking, to morbid action of the kidneys/' — Alison. "A. large quantity of hydrated starch (glycogen) is coatinuaUy formed in the liver, which, on contact with the blood, is transformed into sugar, and is removed as carbonic acid by the lungs : but if the glycogen be in excess, or if the action of the lungs be defective, it passes off as sugar by kidneys, and constitutes diabetes/' — Bernard. " It depends on the sugar normally existing in the blood being undestroyed, and unappropriated/' — Von Buroh. "* It arises from the arfested metamorphosis of the sugar formed in the liver/' — French. " It appears very probable that the sugar is formed, not in any single organ, but that it is produced by a diseased condition of the ■whole system/' — Simon. " It is nothing more than a form of dyspepsia consisting in a difii- culty of assimilation of the saccharine alimentary principle/' — Vrmt. Others have alleged that it is a disease of the lacteal Vessels, disease of the kidneys, a change in the animal electricity of the kidneys, and so on. There is scarcely an organ or function of the body which has not been called upon to explain the predisposing, exciting, and proxi- mate causes of this disease. Light or reddish-haired persons, are said to be more liable. It is less frequent in women* There must be some concomitant circumstances required before this disease arises, altogether apart from the effects of diet or any ordinary external conditions ; otherwise, how are we to explain the comparative rarity of the disease among so large a number of similar circumstanced persons? The highly interesting experiments by Drs. Pavy and Bernard bear upon this point, as also does Dr. Brown- Sequard's very curious fact, that by pricking the mesial line of the fourth ventricle of rabbits, a saccharine condition of the bile and urine may be induced. Schiff has also shown that the introduction of needles into the livei* in rabbits may produce diabetes, and it is known that certain nerve injuries may have the like effect. All these , facts prove that there is an undiscovered cause for this disease. The saccharine condition of the urine induced by these nerve or organic injuries, never induce true persistent diabetes, which shows that the true disease has a deeper-seated cause than a mere saccharins E 2 52 DE. FKASER ON DIABETES. diathesis, which may be after all a mere symptom. In the diabetic stomach every starch material is greedily seized, and quickly converted into sugar, whereas no such thing occurs in a healthy stomach : Bernard thinks that the process is completed in the liver during life, but Pavy dissents from this opinion, and considers it an after-death effect. That special circumstances must be present, is also proved by diabetes not being produced, while a saccharine diet is employed, as shown at p. 53, also by Case 3, p. 50. This question is still undetermined, but our time permits only an allusion to the difficulties, only observing that there is ample inducement to any one of you to pursue this important inquiry. In the supposed causes of this disease the humoral patho- logy is called upon to play a prominent part, and a change in the composition of the blood unfitting it for the supply of new and healthy tissues, is said to be the chief cause of the disease. The prognosis is always unfavourable ; the disappearance of the symptoms, and the appearance of uric-acid in the urine are the favourable signs. The disease may endure for weeks to six months, and even to several years. Morbid appearances. — Every organ of the body has been found in different cases more or less diseased ; but most frequently the lungs (said to be of a non-tabercular character), and kidneys : the liver is said to be firm, and tough to the touch. Nearly a half of diabetic patients die of lang-disease. Whether these morbid appearances are effects or causes, the present state of our knowledge does not enable us to determine. The kidneys are quite as frequently healthy as diseased. If the presence of sugar in the blood were the cause of the organic affec- tions, some of these ought always to be found, which is not the case. To explain the absence in many cases of all morbid appearances, many persons think that the cause of the disease is merely functional; but if this be so, how is it that the disease is so obstinate, and too often incurable ? However, if hepatic congestion, consequent on muscular action, will induce diabetis, it would show that saccharine urine may proceed from mere functional disorder. Treatment. — When we consider that we know little or nothing of either the predisposing, remote, or proximate causes of the disease, it will be manifest that our treatment with drugs must be more or DB. FEASER ON DIABETES. 53 less empirical : also^ when we consider how many different opinions have been offered as to the causes of the disease, you will expect to find an equally discordant array of drugs which have been recom- mended. All the preparations of iron, but the tincture of the sesqui-chloride, the phosphate, the ioduret, have been the most kuded : the latter has been given froin twenty to thirty grains thrice a-day. Carbonate of ammonia during the day, and opium at night, has been very successful in the hands of Bourchardat; Citric acid, saturated with chloride of sodium, is said by Wright to be a specific; Elaterium has been much recommended by Dr. Bright; the tartrate of antimony by Dr. Barlow; fresh rennet by Gray and Bennet; a mixture of lime-water, and liquor ammonia by Dr. Collis ; sodse-potassio-tartras, up to an ounce per day, by Dr. Pavy ; Dover's powder, cod-liver oil, the permanganate of potash, the peroxide of hydrogen, glycerine, the chloride of arsenic, all the alkalies, and all the acids ; bleeding also, has had its chance, especially by Drs. Watt and Satterley ; and even sugar itself has been recommended, and tried; and although, upon one occasion, my Case, No. 3., I employed it, I have no explanation to give as to the expected " modus operandi." The non-effect does not meet the view of Griesinger, who has stated that the continued administra- tion of sugar will lead to permanent diabetes : nor did any of the symptoms described by this writer occur, such as dreams, depression, and a general feeling of illness. It struck me that if sugar as a food was so injurious that some evidence of its evil action should be obtained among the negroes on sugar-plantations, and upon making inquiry of Dr. Campbell, whose quality for observation is undoubted, I received the following reply in writing, " My experience as to the occurrence of diabetes among the negroes of Jamaica while engaged in the manu- facture of sugar, is that the disease is extremely rare j in fact, I have met with it in two negroes only, and only once in a European during the course of a residence of twenty years. During the crop-time, the negro is permitted to eat sugar to any extent, and he increases in fat, and the skin assumes a peculiarly sleek and glossy appearance. The same thing is observed in certain districts during the mango season, when the negro almost entirely subsists on that fruit, which 54 DR. FEASER ON DIABETES. contains a very large amount of sugar." All this goes to show that the sugar is derived ah intra, and that the system in the diabetic is, so to speak, saturated with sugar, and no more can be taken up, and consequently the amount taken by the ingesta, is thrown off by the intestinal excretion, where it may possibly be found unchanged. If this be a fact, the conclusion is inevitable, that our endeavours to reduce by a non-saccharine diet the amount of saccharine secretion are valueless, and that we must seek for a remedy for this disease which will arrest the sugar-forming process going on within. Most of, if not all, the remedies for this disease have been given under the view of acting chemically upon the supposed morbid material, and if we could always apply our remedies upon this principle correctly, our success in cure would often be great, but unfortunately it is not so, and we cannot always give a reason for employing one drug, more than another, although let us strive to follow this rule. However, as an inducement to you to pursue the highly-interesting study of the physiological action of drugs, I will give you a few illustrations, as to their supposed action in the disease. The permanganate of potass, and the peroxide of hydrogen are each supposed to cause a large evolution of oxygen gas, by which the farinaceous foods are oxidised in a higher degree than sugar, con- sequently no sugar is formed. Creosote acts by arresting or delay- ing the saccharine fermentation, consequently "digestion is finished, and the materials removed before sugar can be formed. Opium acts by arresting the secretion of urine, as it does all the secretions, except that 0/ the skin. Hydrochloric acid would seem to act simply by improving the digestion. Antimony, and all diaphoretics act by lessening the labour of the kidneys, and consequently a less amount of material passes through the kidneys, and proportionately a less quantity of sugar is passed. This theory infers that the sugar is formed in the kidneys; which late observations have disproved. Ammonia. — The theory of its action, supposes that both in healthy and diabetic persons the starch is equally converted into sugar, and that in health it is metamorphosed and burnt off by the alkalies; but that in diabetes, there being a deficiency of alkali in the blood, the sugar is passed off unburnt by the kidneys. Phos- DE. LEASER ON DIABETES. 55 phoric acid is supposed to supply the deficiency of the animal salts ; on the other band, this acid has been -found by some to increase the quantity of sugar. If we believe, with Prout, that no known, remedy exists in which there is a specific action for improving the qualities of the urine, and indeed that more injury than good has resulted from the too ready application of specific remedies to supposed diseases or functional derangements of the kidneys, we must turn our atten- tion to something else ; but we do not altogether agree with Dr. Prout, inasmuch as we believe that most, if not all, of those remedies have a more or less beneficial effect, whether by acting directly on the organ which is most at fault, or as tending to the improvement of the assimilative function, and consequent depu- ration of the blood. Whatever may have been our reliance upon drugs in the treatment of this disease, we were always cheered by the hope that we could hold the disease in check by a rigid rule of diet, excluding all amylaceous and farinaceous substances, and substituting a diet con- sisting exclusively of animal food, and avoiding all drinks containing saccharine matter, if the patient would only submit to it ; and if it failed, the feilure was attributed to a clandestine departure from the rules on the part of the patient, or to an imperfection ia the mojie of preparing the gluten bread especially, «nd Dr. Hassall has shown how true the latter danger is, as in the ordinary gluten bread there is 16'33 per cent, of starch; and in bran bread, as usually prepared, there is also a large proportion of starch, but our notions as to the utility of an appropriate diet has, the other day only, received a very rude shock from Dr. Owen Eees, who seeks to show that the exclusion of amylaceous and farinaceous foods, from the diet of the diabetic, is not only riiselessj but dan- gerous. I have myself often had misgivings as to the necessity of inculcating the absolute negation of all starch-carrying food, and the imperative necessity for a large use of animal foods, generally to the extreme disgust of the patient after a time ; but that this strict diet is useless, I am not prepared to admit — indeed, my experience leads me to have good faith in a diet treatment. May we not hope that the failures spoken of by Dr. Eees have arisen from the im- perfect elimination of starch from thefoods, and that we Jjany not be 56 DK. FEASEB ON DIABETES. compelled to ask : What are we now to do ? and be enabled to avoid exclaiming : Hino illm laehrymee. This application of diet will depend very much on the aptitude for certain foods of each individual case, as weU as upon our peculiar opinions as to the cause and origin of the disease. If we believe that the cause consists in a too ready change of the fseculent portion of our food into sugar, then we ought . to replace this by a food containing less fsecula, i.e., bread made from gluten ; bran, or as lately recommended by Pavy, almonds; on the contrary, if we believe that the chief cause of the disease lies in disordered assimila- tion, or, in other words, indigestion, then the indication is to restore the general health by ordinary diet, air, and exercise. The best diet is considered an excess of butchers' -meat; and it does not seem material which is employed, and, therefore, the taste of the patient, as much as possible, is to be consulted. Mutton- chops and beef-steaks, under -done, have been most recommended. The following is an extreme example of this style of diet :— - Por a man, aged 40 : One pound of gluten bread ; two pounds of beef made into beef-tea; quarter of a pound of ordinary beef; four ounces of roast-veal ; six eggs ; two quarts of coffee. Malt-liquors, are inadmissible, spirits are less injurious, and the best wine is dry claret. In conclusion, the following points may be noted as still open for observation, partly suggested by Prout : — Ist.^Is the correspondence of the absolute diminution of the urea with the absolute increase of the sugar an invariable rule? It is now generally thought that ■ the absolute amount of. urea is increased. 2ndly. — May not the nitrogen be removed from the system in some other way, probably in the form of ammonia compounds ? 3rdly. — Do the other secretions undergo a change, especially the bile? 4tlily. — Does the air, which is exhaled from the lungs, differ in composition from that expired by healthy persons ? 5thly. — ^Do the kidneys, liver, or lungs undergo any changes ? and if so, what is their nature ? 6thly. — ^Does the increased secretion of sugar depend upon an absolute increase of activity in the process by which the sugar is DE. PRASER ON DIABETES. 57 formed ; or from a cessation in the action of those causes which, in health, prevent the formation of the sugar ? Case No. 1.— M. W., aged 62, admitted the 9th of October, 1861, states that she has gradually wasted for the past six months, having been previously in good health. She has a great appetite, and suffers from an intolerable thirst, and passes an unusual quantity of water. There are no other very marked symptoms, and there is an absence of the usual roughness of skin. Weight five stone twelve pounds. Specific gravity of urine before fermentation 1'026°; after fermentation 1-003''; loss 2B° ; equal to twenty-three grains of sugar per ounce of urine ; equal to 5"29 per cent, of acid re-action. Muids taken six pints; , passed six pints. Under treatment for 126 days. For thirty-five days she had the peroxide of hydrogen three times a-day, beginning with two drachms. Ordered diet of chops, milk, rice-pudding, and sherry. No manifest change of any one other symptoms. For thirty-one days all medi- cine was intermitted. A rigid meat diet was then enforced, with glaten bread, water- cresses, spinage, and claret wine, and as an extra drink, equal parts of lime-water and milk. At the expiration of thirty -five days, she states that she feels better, and is more lively. Specific gravity of urine 1'024!°; after fermentation 1'007°; loss 17°; equal to 17 grains of sugar per ounce, equal to 8'91 per cent, of acid re- action. Fluids taken, four-and-a-half pints; passed five pints. All medicine and restriction on diet abated for three days. On the 1st of January, 1862, the iodine of iron was given, but it caused great nausea, and seemed to increase the thirst, and was consequently discontinued after four days' trial, a restriction of diet having been enforced during its use. In six days after, viz., the 10th of January, all restriction on diet was removed, and she was allowed the full diet of the Hospital, namely : — 5:8 DE. FBASEE ON DIABETES. Sunday . . 12 8 1 oz. Bread, oz. Potatoes pint Porter. Monday . J)itto. Tuesday . Ditto. Wednesday Ditto. Thursday Ditto. Friday . . Ditto. Saturday Ditto. Gruel. 6 oz. baked Beef. 1 pint Broth. Ditto. 6 oz. boiled Mutton Ditto. Ditto. 6 oz. baked Beef. ' Ditto. Ditto. 6 oz. boiled Beef. Ditto. Ditto. 6 oz. baked Mutton Ditto. Ditto. 6 Qz. boiled Beef. Ditto. Ditto. 6 oz. boiled Mutton Ditto. The iodide of iron was recommenced and continued for .twenty- eight days, during wMcli period she took 227 grains of the salt. At tTie expiration of the twenty-eight days the specific gravity of the urine was 1-027 j after fermeutaticin, 1-007. Weight five stone nine and a-half pounds. A restricted diet was again reimposedj viz. : a mutton-chop ; half- a-pound of boiled beef; a pint of strong beef tea; plenty of greens; and gluten bread, and soda-water for a drink. On the 8th pf Eebruary, fluids taken, five pints, passed fiye pints. Specific gravity of urine 1-023, thirst much diminished : says she is much hetier, and was discharged at her own request. Case No. 2. — George E — ., age 45, bootcloser, was admitted November 3nd, 1861. This patient has led an extremely sedeptary life, often remaining at his work for fourteen consecutive hours, most of the time sitting and stooping. Has had occasional attack pf dyspepsia. About nine months ago he began to suffer fropi extreine thirst, accompanied by general weakness, and loss of -flesh; he also expe- rienced a frec|.uent desire to void his urine (not being able to retain it more than an hour and a-half at a time), which became very Kght in colour. Shortly after this his sight became affected, and this dim- .ness of vision increasing, he was obliged to give up his work, and then he became an in-patient at the Hospital. He is of short stature j slightly deformed (from continual stoop- ing), rather emaciated, with dark hair, and sallow complexion. Skin dry and rough. Pulse about 70 ; appetite very good ; complains of thirst ; is not particularly costive. Urine light in colour, of specific DE. FEASER ON DIABETES. 59 gravity 1"032, shewing distinct evidence of the presence of sugar, which upon further examination, was found in a proportion of rather more than twenty grains in the ounce. Under treatment for 215 days. At the commencement of the treatment on the 3nd of November, 1861, the specific gravity of the mrine was 1'033. Fluids taken, five pints, passed five pints. For sixty-seven days took the peroxide of hydrogen, beginning at 5j. up to jiv. ter die, with a diet restricted to gluten bread, chops, eggs, cresses, and spinage, with claret wine ; at the expiration of the period, the specific , gravity of the urine was 1'030, loss by fermentation, twenty-eight grains, 5"06 per cent, of acidity. Fluids taken, ten pints, passed ten and a-half pints. Per nineteen days he took the iodide of iron, with the full diet of the Hospital; at the expiration, the specific gravity of the urine was 1-029, after fermentatioji, 1'004, loss 25°. The thirst was increased. I'or forty-eight days he h&d the potassio- tartrate of soda, under a restricted diet; at the expiration, the specific gravity of the urine was 1-029, and equal to twenty-one grains of sugar per ounce. Fluids drank, five pints, passed six pints. For forty-five days he took the hydroclorate of ammonia in the day, and opium at night ; at the expiration, the specific gravity of the urine was 1'030. equal to twenty-five grains of sugar to the ounce of urine. Weight, on admission, seven stone one pound ; on dismissal, seven stone eight pounds. When discharged, he expressed himself as feeling very much better. Case No. 3. — C. M — ., age 10. This girl was admitted on the 15th of January, 1861. Her complexion florid, hair fair, eyes blue, skin dry and moist- less; is very emaciated, listless in her look, and lazy in her habits. Four years ago had an attack of scarlatina, and during convale- scence, enuresis was noticed, and general anasarca followed. These symptoms gradually disappeared, and she enjoyed a fair state of health, until six months ago, when she began to droop, and has gradtiially weakened. At present her appetite is very great, iand:thirst inordinate. She 60 DK. FEASEB ON DIABETES. drinks about eight pints of fluid per day, and passes a larger quantity. She weighs three stone six pounds. Under treatment for 157 days, which is consecutively given. Por seven days the tincture of the sesqui-ehloride of iron, aijd the tincture of opium, two and a-half minims of each three times a-day ; diet unrestricted; no change took place; the density of the urine being 1'040. For twenty-four days the peroxide of hydrogen was given, beginning with two drachms three times a-day, and increasing the dose up to six drachms three times a-day. The diet restricted to butchers''-meat, watercresses, milk, and the best gluten bread. During this period the average specific gravity of the urine was 1"040° before fermentation, and 1"007° after fermentation, showing an average loss by urinometer of thirty-three grains. The residue per ounce of urine, after evaporation, fifty-three grains. The average fluid drank, six and three-quarter pints; passed, six and three- quarter pints. For four days all medicine intermitted, but the restricted diet rigidly enforced. Specific gravity 1 • 040, loss thirty-five grains. The residue fifty-five grains after evaporation. Fluids drank, nine pints ; passed nine pints. For twenty-one days the peroxide of hydrogen was recommenced, her weight being three stone seven pounds, nearly the same as upon her admission. Specific gravity of urine 1'040, loss thirty-six grains. The residue after evaporation forty-eight grains ; fluids drank, eleven pints; passed, eleven pints. For twenty-eight days all medicine intermitted, but a rigid diet enforced, six ounces of Claret wine allowed. Specific gravity of urine 1'042, loss forty-two grains, residue after evaporation fifty-five grains. Fluids drank, seven pints ; passed, seven pints. For twenty-eight days all medicine intermitted; diet enforced, but, in addition, she was allowed white crystallized sugar ad lihitum, in any way she chose to eat it. During the twenty-eight days she swallowed twenty-four pounds of sugar. Average specific gravity 1'041°, loss 41°; residue after evaporation, forty-seven grains to the ounce of urine. For three days she had ten grains of pepsine three times a-day. Specific gravity 1'040 ; residue after evaporation, fifty- two grains per ounce. Fluids taken, five and a- quarter pints; passed, six and a-half pints. DR. ERASER ON DIABETES. 61 For forty-one days she took half-drachm doses of the syrup of the iodide of iron three times a-day. Average specific gravity of urine 1'039, loss thirty-eight grains; residue after evaporation, fifty grains per ounce of urine. By this time she had become a mere living skeleton, and died exhausted on the 5th of March. Post-mortem exdmvnation 6tk of March, 1862. — Body much emaciated ; cadaveric rigidity persistent. Thorax. — Right hmg slightly congested at the base, and deficient in elasticity. Left hing in a similar condition, and at the base of latter was a small round cretaceoas mass, about the size of a pea, and of extreme hardness. Heart healthy. Abdomen. — Liver weighed two pounds and a-half, and on the surface of the organ were a number of greyish-yellow spots and patches. Capsule extremely adherent. The surface shows both portal and hepatic venous congestion. On making a section the cut- surfaces were unctuous to thp touch, and a number of patches of a yellowish- grey colour (fatty degeneration) were apparent. The walls of the bladder were found to be enormously thickened, and the muscular fibres could be seen in a highly-developed state through the mucous membrane : in some parts the walls oi this viscus were a-quarter of an inch in thickness. The right kidney was healthy, although rather soft ; the capsule was non-adherent ; the left kidney was in a similar condition ; the spleen was extremely small and exsanguine; mucous membrane of stomach soft and congested. Cranium. — Sinuses of the dura mater were loaded, and the super- ficial vessels of brain much congested, and considerable sub-arachnoid efi'usion. The brain was firm, no evidence of disease in any of the ventricles. Case- No. 4. — William B., aged 30, labourer, unmarried, was admitted June 6th, 1863. Preivous to his present illness, has been healthy, strong, and always capable of doing his day's work. His father and mother are both alive. The former has always been, and is now in good health. The latter has been consumptive for the last fourteen years, but, nevertheless, is not wholly incapacitated for work. The rest of his family has never suffered from any exhausting disease, nor has any of them, to his knowledge, presented symptoms similar to his own. 62 DR. FEASEE ON DIAlBETES. He first became ill about tbree months ago with symptoms of common cold, which, however, was shortly afterwards followed by swelling of the glands of the neck ; pains, and a sense of lassitude in all the limbs ; loss of appetite ; and he gradually became thinner and weaker ; and about a fortnight ago he began to suffer much from thirst, often drinking two gallons of water a-day ; his appetite now became increased, so that (to use his own expression), ." he could eat every thing that came in his Way." On admission he was much emaciated, the skin was hot, dry, and scurfy, had inordinittei appetite and thirst. Tongue red, but not fissured. Urine of a pale-yellow straw-colour, having an odour resembling new hay, and which answered to the tests for sugar. At the expiration of two months he left the Hospital at his own desire, as he considered himself quite recovered, although the great appetite and thirst, and the presence of sugar in the itrine, gave evidence that the disease was not cured. In Hospital sixty-five days. On admission, specific gravity of urine 1*035° ; on dismissal, spe- cific gravity of urine 1'030°. At first no drugs were given ,• but a rigid diet, as under, ordered. The full diet of the Hospital, viz., as at page 58, and in addition a chop, two pints of porter, and two pints of milk. This was continued for thirteen days with no important variation in the symptoms. Upon one occasion the specific gravity of urine fell to I'OSO, and upon that day the patient drank, and passed twenty-one pints ; and on another occasion the specific gravity rose to 1"038, and upon that day the patient drank twenty-four and-a-- balf pints, and passed twenty4wo pints, fot forty-seven days the diet was a chop, half-a-pound of boiled mutton, beef-tea one pint^ lettuce, and oat-cake for bread. At one period an extra pint of beef-tea was allowed, the lettuce changed to cabbage, and an occa- sional bottle of bitter ale. No drugs during these forty-seven days. The result was, that during the period the highest specific gravity was 1-034; the lowest was 1-027. It is to be noticed that when the diet was changed at the commencement of the forty-seven days, the thirst was very great, fifteen pints being taken, and seventeen pints passed, and that immediately on the change the thirst decreased, and the quantity of fluid drank was restored to seven and-a-half pints, and passed four pints. At the commencement of the treat- ment, there was thirteen grains of sugar to the ounce of urine, and DR. FEASEE ON DIABETES. 63 on going out there were five grains of sugar to the ounce of urine. It is a curious fact that oatmeal-and-water assuages the thirst more than any other thing when workmen are exposed to very high artifi- cial temperature ; so much so, that oatmeal is supplied in gas-works, &c,, by the employers, and the men have found the advantage of using it from experience. This was stated to me by Dr. Eamskill. Case No. 5.— Eobert A., aged 38, rigger, admitted the 25th of February, 1864, died 14th of June. The patient is a thin, spare man, with red hair, pallid face, and blue irides. He states that up to about five months ago he had always enjoyed good health, and had been a teetotaller for the last seven years. About this time he noticed that he was losing flesh, becoming weak, occasionally having night-sweats. He soon began to suffer intense thirst, which caused him to drink large quantities of cold water, and he soon observed that he was passing a great deal of urine, according to his estima- tion about twenty-four pints in twenty-four hours. During this time his appetite varied much; sometimes he would eat voraciously, and at others had almost complete anorexia. All sexual desire had left him a;t the comrflencement of the disease. ' On admission he was pale and debilitated, with a perfectly dry skin, confined bowels, no appetite, and tongue' dry, and coated down the middle. "Weight eight stone ten poilnds. There was also dul- ness on percussion at both apices, with a prolonged expiratory murmur. He was passing large quantities of urine of specific gravity 10"40, and containing about twenty grains of sugar per ounce. He was ordered Mist. Sal. t d., his bowels kept open by gentle purges, and ordered a diet of gluten bread, green vegetables, chop, and a small quantity of stimulant. He seemed at first to improve, but he soon began to feel weaker, and the signs of phthisis became more marked. ■ April Znd. — He was much about the same, and wasordered Ammon. Sesqui-carbon. gr. x., Decoc. Cinchon. gj. IQi^, — He is considerably improved, says he feels stronger, and his appetite is better. IStk — ^Not so well, passing seven and eight pints of urine, of specific gravity 10.35 to — 40. At this time crepitation was distinct at both apices. From this time, up to May the 9th, he improved considerably, 64 DR. TRASEE ON DIABETES. and at this time he only passed about five pints of urine, but the specific gravity and quantity of sugar was increased. May 16a.— Not so well, the ammonia was left off, and ol. jecoris aselli given in its place. He now had a sore throat, the tonsils were inflamed, and the uvula being pendulous, and interfering with degluti- tion was cut off. 19^.— Throat quite well, and he expressed himself altogether better passing only three pints and- a-half of urine with fifteen grains of sugar per ounce. June lltL — He remained in much the same condition up to this time as regards his urine, but the disease of his lungs, had made great progress, and he was getting weaker, and unable to eat his diet ; he was allowed ordinary bread, and anything he could eat. Jiine ISiL — He was evidently getting weaker, and at two a.m. on the 14.th, he died without any altered symptoms. 'So post-mortem examination. Remarks. — I consider that this man was very much benefited by the restricted diet, and also that the ammonia treatment was useful. This is another instance of the patient dying of pulmonary disease, and not of the diabetes. Case No. 6. — Stewart P., aged 40, has been in two hospitals, without benefit; ill two years, early symptoms, weakness^ thirst, parched lips, anaphrodisia, increased quantity of water, cramps in legs, emaciation. Was in Hospital from the 24th of April to the 1st of September, 1851, during which time he ordinarily drank 70 ounces per diem, and voided, when first admitted, 120 ounces, specific gravity 1047. Solid matter in 120 ounces evaporated eleven ounces and a- half, weight 114 lbs. ; during his residence, the highest specific gravity was 10'50, the lowest 10'25, just before his death ; but still plenty of sugar. At one time he gained two pounds and a-half in weight. On " one occasion fifteen ounces of solid matter was passed in 120 ounces of water. He took gluten bread for two months without apparent benefit. He had a variety of treatment — steel, creasote ; the former caused diarrhoea, the latter seemed to agree. Before death he had several abscesses, and the fore-finger of right hand required amputa- tion, having become gangrenous. DE. FEASER ON DIABETES. 65 Fod-rnortem examination.- — Kead. — Brain rather soft, otherwise healthy. Thorax.— ^n the upper margin of lower lobe of left lung was a cavitjj and a few tubercles were studded throughout the lung, in right lung was a cavity, and a few tubercles. Heart. — Healthy and firm ; small, weight six ounces and a-half. lAver arid Spleen. — Healthy. Kidneys. — Right kidney, weight seven ounces, gorged with blood, papillae enlarged ; left kidney, weight six ounces and a-haK, healthy as regards colour and appearance ; inner surface of both renal capsules presented an ulqerated appearance. Sugar very perceptible in the urine which was drawn from the ,bladder after death. 1st of August, 1866. — The case of A. M., a woman aged 30, has been in the Hospital only a few days, and, therefore, no definite observations can yet be drawn, except that the intolerable thirst has been much relieved by the potassio-tartrate of soda in two drachm doses three times ardiay ; beyond this quantity it purged. To relieve symptoms in this disease is a great boon to the patient, and we may congratulate ourselves that our mission is thereby not fruitless. Case No. 7. — Diabetes ins,ipidus. — This case ought not to be considered a variety of the real disease j it ought to be called " Biv/resis." July hti, 1863.^-M. A., a girl of 12 years of age, had been observed, for the previous six months to pass a large quantity of water ; there was not much emaciation, no increase of ajipetite, but inordinate thirst. She remained in the Hospital until the 11th of August ; during the whole period the specific gravity of the urine continued persistently at from 1-000 to 1-002. On admission, she drank from five to seven pints of fluid, and passed an equal quantity. The treatment adopted was the phosphate of iron, from ten to twenty grains three times a-day : during its use the thirst diminished, and the quantity of water passed proportionately diminished. Por a time the diet was restricted to meat, eggs, and milk, but this system had no influence on the symptoms. On the 21st of July she drank three pints of fluid, and passed five pints of urine, and the estimated quantity of urea was 336 grains. This quantity varied, for, upon the 19th of the same month, she drank two pints and a-half, and passed five pints. 66 DR. PEASER ON DIABETES. the urea beiag 240 grains ; and upon the 22nd she drank three pints/ and passed six pints, the urea being 148 grains. The general opinion is that this afPection is never idiopathic, but this case shows the contrary, as no special organic cause was here suspected. A SHORT SUMMARY OF CASES. Nos. 1, 2 3, AND 4. Before Treatment. 1^ After Treatment- ,, 'oi *3 f S« 's ^S "i rigid diet. ' e? 1-030 28 10 10 Iodide of iron; freediet. 19 1-029 S5 2 ( Potassio - tartrate ot soda ; rigid diet. 48 1-029 21 5 5 Hydro- chloyate of am- \ monia in the day, .-''*■: and opium at night. 45 1-030 25 ' 1-040 Tincture of the sesqui-' chloride of iron and; laudanum; freecliet. Peroxide of hydrogen; 7 1-040 33 rigid diet. i 24 1-040 33 6| 6| 3< Nomedipine; rigid diet.; 4 1-040 35 4 9 9 Peroxide of hydrpgen; ' rigid diet. 21 1-040 36 11 11 Nomedicine; rigid diet. 28 1-042 42 7 7 No medicine ; rigid diet, and, sugar ad libitum. 28 1-041 41 Pepaiwe ; free diet. 3 1-040 40 5i 6Jt \ Syrup of the iodide of iron ; free diet. 41 1-039 38 ( 1-035 13 No medicine ; free diet. 13 1-034 13 15 17 ' No medicine ; a rigid diet of meat, with I « oatmeal bread, 47 1-027 5 n 4 DR. ERASER ON DIABETES. 67 The general result of these four cases shows little or no change from the employment of any one of the drugs. The most marked change was in No. 1., when a rigid diet was imposed for thirty-one days, the sugar falling from twenty-three to seventeen grains in the ounce, and the quantity of fluid drank and passed sensibly lessened ; and in Case No. 4., during the imposition of a rigid meat diet and oatmeal bread for forty-seven days, the quantity of urine thirteen grains in the ounce fell to five grains, and the quantity of fluid drank and passed from fifteen to sev£nteen pints, fell respectively to seven and a-half and four pints : a manifest improvement which warrants a further trial of the means. I much desire that I could send you away with more practical ideas as to the causes, and, consequently, as to the successful treat- ment, of so serious a disease ; hut it would be a betrayal of my trust if I were even to attempt to show that to he certavk, which is uncer- tain. Let this very micertaiMty, however, be a stimulus to you rising members of the profession, to pursue, with ardour, the inquiry, remembering that a satisfactory solution may be arrived at, ty the union of a certain amount of cheiriical, physiological, and patholo- gical knowledge, anpl a careful observance of symptoms at the bed- side. 2p A CLINICAL LECTUEE ON UNILATEEAL HEEPES. Bv JONATHAN HUTCHINSON, F.R.C.S. Gentlemen, — The disease known as Herpes .Zoster, or common shingles, possesses features of interest which are peculiar to itself, and which far transcend those referring merely to diagnosis and .treatment. It is an instance of an inflammation of the skin pro- duced directly by nervous influence. ;A.^though, as I shall have to suggest, there are probably many other forms of inflammation, both of the internal organs and of the surface of the body which are thus produced, yet shingles is by far the best instance that we have. It is, indeed, so characteristic, that it almost constitutes a class of itself. I need not stop to explain that shingles is not a " disease of the skin" in any correct sense. It is a symptom, displayed by the skin, of disturbance beginning at some part of a nerve-trunk, or possibly, in the very centres themselves. The so-called dermatologists have no claim to it whatever. As an instance, in proof of what the nerves can effect in disturbing the nutrition of the part to which they are supplied, and producing that modification of nutrition known as inflammation, herpes zoster must ever claim a large share of attention from the student of patho- logical causes. It has, however, still other and greater claims on our curiosity and wonder. The phenomena of herpes zoster are familiar to all. A person begins to feel a certain belt of skin, on one side, tender and pa,inful. He strips, -but there is nothing to be seen, the skin is not even red. MR. HUTCHINSON ON HERPES ZOSTER. 69 Next day, however, or it may iii a rather shorter or rather longer time, he finds red points arranged in long oval groups on the painful parts, and very quickly each point shows a small clear vesicle. The vesicles at first are beautifully pellucid, and very often a number are heaped together, not positively confluent, for divisions between them may still be seen, but much in the manner that a number of hills con- stituting one range are piled together. At a later stage, the vesicles may contain a blood-stained serum, and, later still, opaque pus. You will find the groups on one side of the body only. If the fifth nerve is affected, then on one side of the forehead, if one of the intercostals, then on one side of the chest or abdomen, and so of the two extremities. Commencing from behind at the spinous processes, the groups will arrange themselves in a curved line, passing downwards and forwards on the trunk, and approaching the middle line in front. Now and then a few may transgress the middle liile, before or behind, a little, say an inch or soy but scarcely evei" more than that. The affected parts continue very painful during the eruptidn, and often even for a considerable time Mterwards, but the patient complains but little of other symptoms. After the eruption has -lasted a few days it begins to fade, and in a week or ten days' it will have wholly disap- peared, leaving, however, possibly some troublesorae ulcers. It dis- appears at a stated timei just as certainly as does' measles, and like that exanthem, it leaves the patieht free of all' liability to another attack. At any rate, second~'attacks of shingles &'re as rare as are those of measles. The eruJ)tion itself never relapses. You know how almost all skin diseases, except the exanthtos, tend to relapse even in spite of treatment. In shingles, however, it matters not what treat- ment is pursued, you may give your prognosis most confidently, you may assure your patient that it will in a short time disappear, and that it will never return. You may also tell him that there is no risk of giving it to others, for it is neither contagious nor infec- tious. Lastly, I may just add, that when the inflammation has sub- sided, the skin remains for some time rather tender, and, after that, numb, and that it presents numerous little scars in proof that the deep tissues of the true skin were involved. The constitutional disturbance which attends an attack of shingles is rarely more than the pain, &c., will account for, and is generally proportionate to the severity of the eruption. Now and then the patient has a shght rigor before the outbreak, but more usually he 70 ME. HUTCHINSON ON HERPES ZOSTEE. feels quite well It affects all classes and all ages, both sexes, and either side of the body, without apparent preference. That the efuptipn follows the course of distribution of certain sensitive nerves, is usually clear at a glance to any anatomist. When it affects the ophthalmic division of the fifth, the groups of vesicles will be limited most accurately to the forehead, upper lid, side of nose, and side of temple. Not a spot will transgress the middle line, either on nose or scalp, and there will not be a ^ngle vesicle on the lower eyelid or the cheekj Observe the two portraits which I show you. When the second intercostal is the nerve affected, you will often find vesicles down the inner aspect of the arm along its humeral branch. In a few cases, and especially when the lower part of the body is affected or the upper parts of the thighs, it may not be so easy to specify the particular nerve involved. In reference, however, to these oases We must bear in mind that the nerve-trunks near the spine, interlace in a very coliiplex manner, until it results that the trunks which have received names from the anatomist, may very possibly receive filaments from several different sources. As regards the extremities, I think we may note that you will but rarely see shingles on the forearm or hand, and never on the lower extremity below the knee. We are now in a position to state the terms of our riddle, Is ■hefpes zoster an exdnthem or a neurosis ? If an exanthem, why, then, is it not symmetrical, not attended by constitutional disturbance, not hable to spread by contagion ? If a neurosis, why should it not relapse, why should it have stages, and how can it protect the individual against a second attack? There is no other neurosis which can be mentioned (neuralgia for instance), which is not very hable to relapse or to return again after cure. My own suspicion is that it belongs to neither of these classes, but that it constitutes a new group by itself, and further, I feel convinced that whoever may succeed in unravelling the mysteTy ilphich at present surrounds it, must, at the same time, make a discovery in physiologyy Such, then, being the interest and importance of this remarkable disease, I shall need no apology for introducing at some length the clinical evidence which I have collected regarding it. We will, if you please, discuss seriatim, the several points on which I have already made assertions. GENEBAL STATEMENTS. 71 That heroes zoster may occur at almost any age, and if we esccept early infancy, is equally frequent at all periods of life. My own series contains cases in wliicli infants of the ages of 8|, 2 years and 9 months, and 7 months respectively were the patients. In one the subject of it was an old man of 79. {8ee Tahle^ p. 81.) This statement applies only to herpes zoster of the trunk. In that form which affects the first division of the fifth nerve {herpes frontalis), we find a considerable majority of our patients advanced in years. At least, such has been my experience hitherto, but the number is too small for a trustworthy conclusion. In seven cases out of fourteen, the patients were above 60, and in three of the others above 40. See Table p. 94. That the two sexes are equally liable to its attacks. In my own series the number of males is somewhat greater than that of females (37 to 26.). That it is not possible to denote any special condition of general health which predisposes to its attacks. I have carefully inquiredi in all cases, on this point, and in a large proportiop, have not been able to discover any symptoms, either of humoral or visceral derangement* In many cases of zoster on the thorax, the patients are the subjects of spasmodic asthma, but in many others they are not so. In some cases the patients have been out of health for some time before the disease occurred, but in many others not the slightest previous illness had been observed. In further proof that general dyscrasia does not predispose to it, the fact that it does not occur in members of the same family may be mentioned. It .has never occurred to me to have a patient state that any relative had suffered, from similar disease. Herpes zoster is not contagiom. I have never known even the coincidence of two cases occurring in the same house, and I am not aware that one single instance of such occurrence is on record. As a general rule herpes zoster does not occur twice in the same I have myself only one instance in which a patient suffered twice from it. A very few others are on Record. In all such the interval between the two attacks has been very long (from 2(!l to 30 years). Probably these instances of second attacks are not more frequent 72 MB. HUTCHINSON ON HERPES ZOSTEE. relatively to the actual frequency of the several diseases^ than are second attacks of any of the exanthems, and they appear to occur under precisely similar circumstances, i.e., with long intervals. In my own case (see Case VI., p. 82) there are two exceptional features, the occurrence twice and the asserted symmetry of the disease in the first attack. Whether it is probable that the diagnosis in the first instance, was incorrect or not, I must leave in some doubt. In true herpes zoster the eruption is {with the very rarest excep- tions) never symmetrical. I have seen but one case in which the eruption occurred on both sides. In one other case which came under my observation, in a man, the rash was on the right side of his chest, and at the same time on the left frontal region. Several writers on skin- diseases, assert that they have met with symmetrical herpes. There is a rare form of syphilitic rash, so closely similar in all its features to the true zoster, that it is very possible that mistakes may have occurred. Of this remarkable affection, hitherto undescribed, and which I may call " SyphiUtic shingles," I have seen three or four examples. In the last I was able to bring the patient before you. The points of diagnosis are, that the syphilitic form is always symmetrical, seldom limited to the chest, and does not disappear nearly so quickly as the true shingles. A large majority of writers on skin-diseases have never themselves seen the shingles symmetrical, though most incline to the opinion that it may occasionally be so, and quote instances from the older writers.* My own case, in which it occurred on the frontal region of one side, and the thoracic of the other, is, I believe, without a parallel on record, and it seems to be so important, that I shall read its details. Joseph Bond, aged 56, the subject of severe chronic bronchitis and asthma. I had operated on him for the radical cure of hernia * Two physicians, both of them trained observers in skin-diseases, once sent to me a supposed example of symmetrical zoster. Neither of them felt any doubt as to the diagnosis, and detailed notes had been taken for publica- tion. At first sight I was inclined to concur in their opinion, but further examination enabled me to convince both myself and them that the rash was syphilitic. The subsequent progress of the ease left not the slightest room for doubt as to its nature. Had this case been recorded, we should have been compelled to admit it as a well-authenticated example of sym- metrical herpes zoster. GENEEAL STATEMENTS. 73 about two months before, after which he had considerable constitu- tional disturbance. This, however, had wholly subsided, and he was now in usual health. On July 17th, he came to me with a commencing half-zone of shingles on the right chest, extending from the spinous processes behind to the middle of the sternum, and taking the course of the fourth dorsal nerve. Gfreat pain had preceded the'- appearance of the eruption. On the following day ai similar eruption shewed itself on the left forehead. It cohered the left- upper eyelid, the eyebrow, and extended backwards: Over the anterior two-thfrds of the scalp. The conjunctiva was congested and eye irritable. Both on the chest and the scalp the characters of 'the rash were subsequently developed in fuH perfection. ' - ' I have no note of his progress later than the seventh day ; when the rash was fading. , :' ■ i'-' ,:■ .' In a second case I have- seen herpes over- one scapula and a single group on the back of the arm," whilst, at the same time, a few scattered vesicles were present on the opposite side of the chest, but I am doubtful whether the latter were those of true zoster. Mr. Bryant, of Guy's Hospital, has published a case of symmetrical zoster. The only-case which I have myself seem, was that of an old man, kindly sent to me by Dr. Hughlings Jackson. Herpes zoster occurs with equal frequency^ on the two sides. An interesting instance of the fallacy of individual opinions when formed without careful statistical inquiry, may be mentioned in the fact, that Reil says that herpes " always occurs on the left side ; " and Biett, that " in nineteen cases out of twenty it is on the right." The two assertors are almost equally in error. Sir Thomas Watson, in fifteen cases, found it on the right in ten, and the left in five. Eayer, in fifty-three cases, right, thirty-seven, left, sixteen. Mehlis, of twenty-five cases, right, nine, left, sixteen. The total of these observers gives ninety-three cases, and fifty-six on right side to thirty-seven on the left. In my own experience, I have in sixty-two cases, seen it on the right in thirty-two, and on the left in thirty. We may, therefore, conclude that it manifests no very appreciable preference for one side over the other. That herpes zoster generally observes closely the recognised anatom- ical distribution of some nerve. 74 ME. HUTCHINSON ON HERPES ZOSTER. " [Eor proof of this I must refer to -the cases given in the appended Table?, and to Professor Barenspruag's paper mentioned at page 77.] That the nerve affected is usually a cutaneous one, hut that this is not invariahly nor exchisiveh/ the fact. The chief phenomenon of shingles is the development of a crop of vesicles on the skin> denoting an inflammatory disturbance of nutrition in the part of skin affected. That this disturbance of nutrition may take place in other and deeper structures, is rendered probable by the circumstances that not very unfrequently its subjects complain miltoh of severe deep-seated pain ; muscular stitches in the side are not uncommon ; in some cases, especially on the forehead, the amount of swelHng is such as to prove that the subcutaneous cellular tissue is extensively affected. I have, however, in addition to these facts as presumptive evidence, the great good fortune of being able to produce some positive faqtsj The eye (so invaluable to observers of the inflammatory process on account of the transparency of part of its covering) is again the organ which supplies me with the positive evidence referred to* In the case of a man who came under my care at the Ophthalmic Hospital on account of herpes ffontahs, there appeared reason to believe that the vphole ophthalmic division of the fifth nerve was implicated, and the nutrition of the eye itself suffered disturbance. This case is so important that I shall read it in detail. (See Case I., p. 76). This case was the first in which I witnessed undoubted iritis, and, I ibeheve, the first on record. Since then I have seen three or four others, and feel no hesitation in asserting that the inflammation of the iris stands in precisely the same relation to the nerve distur- bance as does the eruption in the skin. Usually the cornea becomes e;s.tensively ulcerated (superficially) at the same time as the iritis occurs, biit in one instance we had had iritis whilst the cornea remained quite clear. The iris in these cases will not respond to the influence of atropine. In severe cases the eye is usually much damaged. That there is no reason for supposing that herpes zoster can be pro- duced by artificial irritation of nerve-trunks. In a case, about ten years ago, in which I had occasion to remove a large exostosis from the inner side of the upper part of the humerus, the patient, a little girl, had, about two months after- wards, an eruption of herpes zoster on the arm and forearm. A GENERAL STATEMENTS. 75 the time I was much inclined to refer it to irritation of the nerve- trunks, as, during the operation, we had been obliged to hold the nerves aside with spatulas. Subsequent consideration has, however, led me to doubt whether such is really probable. In operatioas for the removal of cancerous glands, in those for the ligature of arteries, in neurotomy for neuralgia, in certain wounds and contusions, trunks of nerves must frequently be subjected to mechanical irritation, yet there is no proof that zoster ever follows these. A fact of lesser value, but still of some, is found in the circumstances that physiolo- gical experimenters, in the lower animals, have never noticed this eruption as a sequence to nerve-irritation. , ; ■ , Can unilateroil herpes be ^rodmoed hy internal medication ? I have repeatedly seen herpes zoster occur in patients, whom I had been treating for other skin-affections by means of arsenic. This has happened so frequently, that I have been inclined to sus- pect that it was more than a coincidence. , That the disease runs a def/nite cov/rse. Bateman wrote : — " The shingles commonly follow the regular course of fever, eruption, maturation, and decline, within a limited period like the eruptive- fevers, or exanthemata of nosologists.'' All subsequent observers have confirmed the accuracy of this state- ment. I have nothing novel to add respecting it, but I wish empha- tically to endorse it. No single case has ever come under my notice in which there was any great deviation from the usual course of the eruption. In most instances, for about two or three days, the patient has complained of premonitory symptoms, i.e., slight feverishness and malaise, and more or less severe burning pain in the part about to be affected. Then the eruption comes out, and remains in a cha- racteristic, but changing, state for a week, when steady decline follows. During this week fresh groups of vesicles may often be observed to appear, but npt later. The stage of healing may be in- definitely prolonged, its length depending upon the depth of the ulcers. During this stage, however, there is never any relapse— no fresh vesicles ever appear. Certain other very important questions arise in the investigation of this disease. Why- are the dorsal nerves, and espebially the third or fourth dorsal, so much more frequently affected than any others ? 76 ME. HUTCHINSON ON HERPES ZOSTEE. Why does the eruption so frequently occur in manifest connexion with the distribution of certain branches of the first division ef the fifth nerve, whilst we have so few instances in which the second or third divisions of the same nerve are similarly affected ? "Why are the forearms and the legs so rarely affected ? Does the nerve-irritation, which every one will admit constitutes at any rate one stage in the disease, begin centrally, or at some part of the nerve- trunk external to the centres ? What share has the vaso-motor nerve in the production of the symptoms? ' - ' In concluding this lecture, I must, beg you to' pardon its frag- mentary and inconclusive chaiaoter. ■! have brought forward only doubts and difficulties. My eiid is gained, however, if I have suc- ceeded in convincing: any that there is a special mystery enveloping the origin of .this disease ; that its chnical study offers an almost un- worked, and very hopeful field for scientific investigation; and that whoever shall succeed in finding the right chie as' to the mode of production 'of herpes zoster, will, in ail pirobabihty, make, at the same time, a valuable discovery. in physiology. ' I leave, for investigation in a future lectuf e, what we may conve- niently call " Symptomatic Herpes," a disease scarcely less interest- ing than the one we have just discussed. Symptomatic herpes usually occMs on the lips ; but it may be seen also on the nose, and sometimes on the cheeks ; it is not unfrequent on the prepuce. It is very often symmetrical, though rudely so. It goes through stages exactly like herpes zoster ; but it may occur over and over again in the same individual, and it also differs from unilateral herpes, in that it rarely, or never, leaves scars. It may be observed in any illness in which a rigor has occurred (spasm of arteries, epilepsy of arteries), and is, thus, often seen : — 1. After introduction of catheters. 2. In erysipelas. 3. In ague. 4. In pneumonia. 5. In fever. 6. Any inflammation of a shut sac, pleura, peritoneum, tunica vaginalis, &c. It is a common occurrence in association with ordinary catarrh. That it too, like Herpes unilateralis, is produced through the agency of the nervous system, there can be no doubt. APPENDED CASES. The following cases have appeared to me worthy of record in more detail than I could conveniently give them in the tabular state. APPENDED CASES, 11 ment. Their features of pecularity are, I think, sufficiently denoted in their narration. Some of them are given, because in describing them, I had paid especial attention to accuracy as to the parts of skin involved. Two tabular statements are also appended. The 'first comprises brief facts as to sixty-three cases of unilateral herpes affecting some part of the neck, trunk, or limbs, and i H O H w H < CO Pi m g- In- O !- s. ^ 1—" "5 W3 >, M a p. 82 TABITLAR STATEMENT OF SIXTY-:THEBB "eS (1) & >, •i-i ■n s .^d 1 b(),C| H "^ l=L,--C( 2 » S ° d* S-3 ,J3 iT3'" «"«.-( E « K S . ^ O n CQ 00 6 13 .a « ^ q w .9 S SD'in aj a oja,a 00 ■+J 4^ 4J 0) •§. 0) o 1.: 1^1 o-ffi "3 2 -a "t3 s P*Q ee (U '^ (O OJ -I- d g 03 o S f ° « " .§ ^41 a^ OJ rt ^^ Orrt tT a T3 .3 -^ s o -B £ .a S a ■ o\3 BT3 „ o a.S of M) S ^ S a ., p 8 " .. a,.a a S 5 r— a ^ a> <4 d " 5 •^ o T3 OT IN apLi ph ■a o' a °^ n dol u ^ O to , . « !>. «D 00 0) U3 -JJ 00 u i§s- d . S « n y ^ u IN Jog @ CASES OF HEEPES ZOSTEE, 83 62 84 TABULAR STATEMENT OF SIXTY-THREE s g ■ 1 J3 ^ c3 Q g 1 00 i . « '* m 'a F-H -a m ta 1 1 > ■% 1 1 V i .' Pq Pm u fH H ^ c; (D lu q; 03 1 "1 1 i 1 . i o 15 new « ° tM *^ 111 1 ■ES.2 §■5-3:35 «s a^ fH rt 00 ^ ^^ J J o <-} ►J ^ 1 "a g ►a o .s si o _ to .a- U Oh .. a 4i P< ill 03 03 ^ 3 boa 0) a 'U 1 4 •si 1" .a 1 8 S Si a ■3 " 1l- o S u ^ a 10 1 00 05 T-t cS* 1— ( 1— 1 , , J>. t^ «) 8 g ■ . 9 »- »o , iO "^ «5 fl" .i is M » '-' 1.S (O CO CO ,i_| pq" a 1 1 i 5 BO a p li? 1 - 4 5 1— ( 1-1 IM O t- 00 05 o 1— t IN W N CASES OF HERPES ZOSTBR. 85 ■s 03.3 s 2 a ra 0) 03 « n 03"^ -B S to .ta H rj =! 3 Sfc S . SS >» •S53 O< sa- a js -c W Th eck. 1858. J3 00 00 Ph 00 . rt f^j>: - P S 00 rH S«5 r - « 03 00 i2 03 -i-> *^ IN P< te ■ 03 ;aiJ-^ >, ^ ■CiJm S 1 S s '1 l-H « CO t- 3 OH ^9 ^^ ■13 m 4S sH teT3 S III £ 01 g ID < 1^ V ^ 03 ^ > s Pi ^ (D •^ K o "J, P.J3 03 - K 0,03 -^ •^ 05 .X ■♦J '^ H ■« a o o IS H 0) 03 ", •a *^ S — ! ^1 -t^ ■• t3 0) « S o Pa * o ^4 0) OS a -3 "ta ** .a P, fc != h QD 03 03 o M u 03 ^ 03 CO 03 -*^ '^ 2p.^ S MK ^ -S £ ® 03 U -fJ 03 ►< ja 03 S ^ -WCm 03 *^ &; o OJ Ph O d d d^ cd bo oj d i-H ^ 03 « a •J3,H 5 f j^ 03 tn O 03 ■" 03 m eg ^^ g P4 u 03M H 03 03 ^ ■o,a S 'a. a a £ ■^ a '^ -tJ TS f^ 03 •- 0) a,a CO CO a u) U>03 S. 611 03^ fe 1J o o 60 -a 03 O 03 ^1 O O rTl «-2^ ■ aW g 1^.3 S 050 u &t to 3 V C3 S ■jS 03 "I P,-S 00 00 h7 ^H fO "^ CO a 03 • a>-3 (► a o . O 02 s . 03 eAS,ES OF HERPES ZOSTER. 87 ^ (6 lU '2 3 J5 «j'g O .:3 6 CD a .1 <» OT O ^ bo V J, e i) a "^^ e8 Q) J. OJ 1 03-**-* J. •-S-SiS ■S"3s£^.S'^ §-3:2 « I i^ ^-^-.^ ■^ ■S d M a> (U .aria ^ o °^J- d S "3 rt ?„ * S ft'S ^• "2 q 2 a ■« fl SP-^ o 2ft ^fe'S-i^'S g'^gS •^2 "^SC-S" S'^i>.g a s I u I -a'd^^'S 2'^'a « g 13 0.4'd ^ C3^ 3. CO I I I I O • S - O • CD • CD J2S DQco«n« -oo-g rtSs .3 2 S '^ S -! ^ (S 88 TABULAE STATEMENT OF SIXTY-THEEB (3 a. ■g ^ S &< m s cube s d s u 03 '2 '3. to «M w. OJ h o S e u V 7 u o OJ fl Ji a; Cm 3 0? fl 4J « O tcHS £ a aj o o 'mis S aj +3 na -J-3 o g O CO C O ■- 3 S a. !3 3 m o! _^ o to -^ 03 oe ,. t! ^ ^ = 03 03 O lo > to 9 "^ 2 ? i Cw S IJ - n -H -" — Q O (U c t- .2- O : ■9g|i o "^ &- ' tS O OJ 03 fl^ u o >o ■S a a o N:a ■c^ o S -^ a m a a a "t5 t! "^ SS -J' 03 13 O ,a -y di ^ cd ^^4=0,2 *'M-^:Scu o g.S gK-3 ; - <1 (3 p •s .J b ■ o . _ s m- . a, ^- rt S>o s vjt^ pq^^ «^. W i— 1 .2 00 .a «> •^ .-1 •Q 00 bert Co I. 270. tfarch. am Ha I. 276. April, o - '■S J g » F « « •* * ■<*i j_;^ " ^i2 ai-H S o 2 ^•"•^ '^ " s O ei-i ^ S * o ■^ aa . m S e3 09 *3 « „ C :g o^ a H s-a 2 « J OS QJ Q ■^&| ■tea 1?^ fi s« B O O '^ ■S -5 td gu « « h P 4J -^J -W fl S| " ^ fi U 0! "^ 2 *" 00 M -, C - 03 ;■ SM~ 0}^ 03 g « fe on -3 03 oj _r ^^ 2 « -w a H O J, (U p eS O 2 3 a, o • r-H +3 o s CD is" .J 3.rt +i' o ^^ X] V 0) ; OQ h •a a o o V 00 e a a OS "s ® K H S ■" ce S3 " I .-a Mg ^ u 3 El a ■ o I I" a ■33 ce 03 g .s bus -u o S* CO CO V OS aw| o O o S oo 03 « I si £» CASES OF HEEPES ZOSTER. 91 CO bo °s.a 4J to 9 => CO S ™ » .3 g'i >" n -JS g « S S o ^ % S ■= S a s o ,£* w -, o )^ »< m « «,^ i> n u S O.S9 _Q id .in 'a * Ot3 BO 43 d S 09 (U OJ U (U ^ •-2 8^ ij a V S a^M 0,-2 .a o o S-, S S ° ^ -^ h o e o M „ " g m H aS r3 ^ S -s .t; 5 * » y 4. J5 ' % bo S a I 4 .a bD I «3 •a to n^ o . IP . - o O 00 - • *"^ i-s n 'fl'* .a'^g I ^ HH o a p,H^ ID- o ^ _. ea '^ to o « • b ■s 92 TABULAE STATEMENT OF SISTT-fHBEE 0) a " ft g a !i > »^ hear T 3=^ U "^ O M H S *H m o 03 (» 0) n rt a) S +^ PI » +3 S S J t •a Si 0-73 o o en u s °* a t3T3 §1 0< o aj'o P. . ni S S a B P- o fa -a g I s ^ O !* ^ S3 « on ^^■|^ .. o « "^ OJ "^ ■S .3 .t3 bl O 13 g t.§ 2 *^ 23 2I s . a t3 C ■?: ^ o S 0) 53 w X o *i J= PH U g O •fa "1° ^%'%> "Ta ra O ij ■1 s * s qj o3 rt H o p rt o 15 q; O o _, g s «j o a e3 03 u g 03 0> fa 1^ . a 00 a . g^ •WW «,-S CASES OF HERPES ZOSTER. 93 h ^ g«? W fl r^ OJ O 03 03 ^ CO 03 03 .S % a +3 ^H J '^ C3 03 ea " 1 ■|| ^■5 & s « «:: -g-a s « ■ > ^ be 111 11^ §^ -a a « .1 ° o 1-1 d a -e 1 III « S S3 § 1 CO ,^ > 6- ^03 ° f.g a g s 04 CO ij H 1 P. ■S«- S '« . 1 rfil O O 03 ^ O 03 5° ^ tl ,4 *S r 44 p 1 _« 3 _fi 73 O i s> £? J +^ *:> m ^ O 03 £■03 J aj« U H 1 ^ ^ ?■ N t~ (M « Ci 60 rH 1—1 ^H en ,« t >^-w O .3 S3 " g T3 1^ - a 1 § -g fl 1 3.1 M.^ .„-a IS S g a . S S.9^ a of iS CO SS' <^^^ b^& sssg^s^s 1 CO "IS i^ .a grt 6 03 " 5 g „ £ »3 a « ^ « a P 03 O ja t- 03 '-' „ g cd i-s S tj -§ »■ S t «) '^% p2§ 03 " 33 a a -§ g o 05 o I— 1 cq =2 00 +3 p. . 'A >o S 50 CD «D 94 TABULAR STATEMENT OF FOtTBTEEN rait of this boy is pub- d in the New Sydenham ty's Atlas of Skin Dis- Eye not inflamed. "a -+3 case, ed at have CO • « - 1^ 1 =3 -J -a 0} 0) o> --SI* 1 « « a in 0} >» .a o,a-S CO U -M o o « ? . I ^=2 -SS =3 3 ad ■=• ce o SO (U g-'5 « 2 .a OT3 ■art E o sa S o' * ■"§#■2.5 Soa 1-3 kj &L I H s -t^ •=' M S o ij B o V Oi cdvo) V <1 .a' ."S o-S W LSS^ 1^ «l § i-M^^ I" p I e3 Pi .2« 96 TABULAR STATEMENT OF FOURTEEN was See 866. ten- iris lary hole t be 2 H- 1 cs o) a g ,a MS 3 left f the U in thout 1866. g ". S^U^S S ^t;^i '3 ♦: e -ail §1) w 5^&|3 .Ti oj-sis 2 i-sj It .s i » ir- © 31 S oo*'* iif »^ i 1 i^ g^-S 8 IS S g >=• a °^ ^ "•I ^=^-3 ■3 1 a .9 § « ° S 1 S " »i-S H H a o a5 111 u J OJ >» «S a Micu hJ (ri .-5 ij g g§.d3i 1 •a ti P-a 1'" i ce S ■s < ua 9 ^ ^'^ £>- ev. s^ •Ill-Si 111! i § X5 to CD 1 0) "a (3 ■§JJH to -F^ _- CD -go ^ . -a _~ a.t; fl S ffi CO •all i 1-< IM 1— 1 m >* .sll5 THEEE CLINICAL LECTURES ^tUbtttii Itrttifi-Hjj t^t Sittisiati, 1865-66. By C. F. maunder, F.R.C.S. LECTUEE I. Organic stricture ; retention and exi/ravasation of wine ; bowels obstructed by distended bladder. Gentlemen, — I purpose to day to draw your attention to a case of complicated stricture of the male urethra, which is now in the Hospital, and with which many of you are acquainted. I thiok I shall best fulfil what is intended by the term clinical if I adhere pretty closely to my text (the case itself), and endeavour to explain in words to you the train of thought which arose on my hearing the patient's history of his malady, on seeing his actual condition, and after a physical examination instituted by myself. Thus, by a care- ful analysis of the history and symptoms, a diagnosis was made and treatment adopted, for reasons which I shall explain. I win read an account of the case up to to-day, reported by Mr. Horder. G. B., aged 51, was admitted iato Glo'ster Ward, November 13th, 1865, suffering from almost complete retention of urine. The patient's history of the case is as follows. He has had a stricture of the urethra three years, during which time he has not required any surgical interference. Has had gonorrhoea, but how long before the -appearance of stricture, cannot be distinctly ascertained. On Friday, the 10th November, he found he could not pass water as usual ; he therefore sought the advice of a medical man who pre- scribed for him : next morning he was able, on rising, to pass a small H 98 CLINICAL LECTURE, BY MB. MAUNDER, quantity of urine. On the same day (Saturday), while trucking some bales of jute in the London Docks, he felt something give way in his inside. He became faint, and was unable to continue his employment, and presently, though he felt easier, the scrotum began to swell. He was walking about the rest of Saturday, and on the following day also. On Monday he sought admission into the Hospital, and his condition was as follows : bladder distended, reaching as high as the umbilicus, painful on pressure ; penis swollen, red and oedematous ; scrotum very much distended, of a dusky-red appearance, and exceedingly painfcd ; no fluctuation could be detected in the perinaeum. The patient had an anxious look, a brown tongue, and a quick pulse. The house-surgeon tried to pass catheters of various sizes, but failed to get the smallest into the bladder. Mr. Maunder saw him in the afternoon and laid open the scrotum by free incisions, a considerable quantity of urine passing from the in- cisions. A linseed-meal poultice to be applied, and he is to take two grains of opium at once, and two ounces of house-medicine in- four hours' time. Milk and beef-tea diet, and four ouuces of brandy. litA. — He feels much easier. A considerable quantity of urine passed from the wounds daring the night ; bowels unopened ; tongue brown. To have a simple enema and eight ounces of brandy. l^iL — To-day, the right groin above Poupart's ligament being more red and tender was incised, and urine and pus evacuated. Bowels still confined. Ordered, five grains of calomel at bedtime, and two ounces of house-medicine in the morning, if necessary. 16tA. Bowels still confined. The house-surgeon ordered half an ounce of castor-oil directly, to be repeated if necessary. Mr. Maunder saw him in the afternoon and passed a No. 5 catheter. It was tied into the bladder, but accidentally, slipped out during the night. Hiccup troubles him. mk — Feels much easier. Bowels were very freely opened soon after the bladder was emptied. Pulse very fair. 18^/5.^-Altogether better J moderate quantity of urine flows per urethram. X was introduced to the patient by the house-surgeon, who in- formed me that he had attempted to pass a catheter, but had failed ON A CASE OF COMPLICATED STRICTURE. 99 to do so. On turning down the clothes, the patient being on his back, the abdomen appeared to be somewhat distended below the umbilicus ; the integument, to a less extent,, was reddened, oedematous and tender on pressure; the right inguinal region, above Poupart's ligament, being especially swollen and sensitive to touch. On per- cussion over the abdomen resonance was elicited, except over the hypogastric region where there was marked dulness, and the hand could detect a circumscribed swelling in this region, though the attempt to define this gave pain, and was not persisted in. The attempt to obtain fluctuation by palpation was not made on that account also. The scrotum — this organ was much swollen, dusky red, with a patch of gangrene at its most dependent part ; the peri- nseum — this region was unusually sound towards the anus, but its tissues were indurated and agglutinated just behind the root of the scrotum. The water-bottle was being used as a little urine was dribbling from the urethra. The first question that occurred to one's mind to answer was, what is the cause of this inflammatory condition of the scrotum, is it simple inflammatory oedema associated accidentally with retention of urine, or is the swelling and redness due to extravasation of urine ? In the first place, this condition of the perinseum, scrotum and abdomen is commonly met with in cases of extravasation, while simple inflam- matory oedema is rarely seen ; and secondly, a simple or erysipelatous inflammation is not of necessity limited by the attachments of the deep fascia, whUe this latter membrane determines the direction of an extravasation. Thus, aided by the history, a diagnosis was soon made. Extravasation then having occurred, it was very desirable to aflbrd an outlet to the urine so situated as quickly as possible> for if this be neglected the most acute inflammation, with sloughing of areolar tissue and large tracts of skin soon results, speedily asso- ciated with irritative fever, typhoid symptoms and death. I at once, therefore, incised the scrotum freely on either side of the raph^, and a good quantity of urine gushed out, the incisions being commenced at the root of the scrotum and carried forward through the' most depending and sloughy part, so as to favour the rapid filtration of the extravasated fluid and prevent bagging posteriorly. The scrotum began at once to collapse> and I ordered a .hip-bath and poultice as soon as bleeding had ceased ; two grains of opium at once, and a dose h2 100 CLINICAL LECTURE, BY ME. MAUNDER, of house-medicine four hours after ; good diet ; brandy. Why does the scrotum slough quickly in these cases ? Probably from two causes ; one, by reason of the excessive inflammation caused by the presence of a highly irritating fluid '; the other, an insufficient supply of blood to maintain the Hfe of the tissues, induced by the presence of this urine and inflammatory deposit obstructing the blood-vessels by mechanical pressure, for in this organ there is no cellular tissue to form a bed and protection for the vessels to lie in. I must now leave the consideration of the case for a moment in order to explain the principles upon which the above treatment was employed, and in doing so, must refer to the pathological changes which occur in stricture leading to the condition in which we found our patient. Some part of the urethra, generally the spongy portion near the bulb, becomes the seat of chronic inflammation, attended by a deposit which gradually encroaches upon the canal and narrows it. This process may extend over a period of many years, the stream of urine becoming slowly smaller than normal and the patient finding it necessary to strain in order to accomplish micturition. Now this straining to force the urine through the narrowed channel leads to a dilatation of that portion of the urethra behind the obstacle, and in severe cases the sphincter vesicae even, by reason of the stretching to which it has been subjected by the straining to make water in order to overcome the obstacle, is no longer able to close the orifice of the bladder, and an involuntary dribbling results. But short of this dribbling, a great evil may result. As a consequence of constant pressure upon the urethra behind the stricture this part becomes dilated, and thus allowing a drop or two of urine to rest here after each act of micturi- tion, the mucous lining becomes inflamed, and a small abscess forms in the perinseum (or just behind the stricture wherever that may be), and probably communicates sooner or later by " progressive absorption," with the urethra. Now, supposing this abscess to exist with a very tight stricture in front of it, and the patient suddenly to find that he cannot pass water at aU, the condition of retention is established. Now this retention is believed to be due either to temporary spasm of the muscular wall of the urethra, or to an accession of inflamma- tion, or perhaps to a plug of mucus obstructing the narrow channel, but whatever the cause, if it persist sufficiently long, will lead to the condition in which we find the patient now under treatment. Finding ON A CASE OF COMPLICATED STRICTURE. 101 that he cannot micturate, the patient strains violently with the hope of relieving himself, and in so doing, aU the muscular power that can be brought to bear upon the bladder is called into requisition, and the weakest part of the urinary passages yields to this force if the stricture does not give way. Now the weak point is the urethra immediately behind the stricture, and supposing a communication to exist between the circumscribed perinseal abscess, to which. I have alluded, and the urethra, the only obstacle to extravasation is the abscess wall. This, unable to resist the straining efforts of the patient forcing the urine upon it, gives way at some point, and extravasation is established, and a condition, such as we have witnessed, results. To revert to the patient. In a case of retention the most satisfactory mode of evacuating the bladder is by the urethra with a catheter and you will perhaps ask why I did not attempt to introduce one ; and perhaps also it has not occurred to you that I have already established a communication between the external world and the bladder : but a little reflection will show you that I have done so. In the first place, water dribbled from the meatus urmarites, showing that the stricture was not impermeable and that retention was not absolute, and it was therefore possible, provided the del/rusor urince were not paralyzed by over-distension, that nature was equal to the emergency. But, let us suppose that the stricture had been at the time impermeable, the incisions into the scrotum at once- established an indirect communication through the cellular tissue of the part with the opening in the urethra behind the stricture and thence directly with the bladder. Bearing that fact in mind, I was satisfied to await the result of the above treatment as long as no untoward symptoms called for further surgical interference. Another reason for not meddling with the urethra was this, the adjacent soft parts were infiltrated with urine and with inflammatory effusion, and these would, of course, tend to narrow the urinaiy passage stiU more, but by waiting some hours and giving time for these effusions to subside and for the use of remedies the chances were in favour of any existing spasm becoming relaxed and that temporary pressure on the urethra would be removed. The comparative ease with which a catheter was passed on Thursday, or about seventy hours after the incisions had been made, is a good argument in favour of the line of practice adopted. 102 CLINICAL LECTURE, BY MB. MAUNDER, The fact to be remembered, and upon -which the mode of treatment hinges, in a case of extravasation with retention is this — ^that literally the physical condition understood by the term retention, as applied to the bladder, no longer exists, inasmuch as the urine can flow out into the areolar tissue of certain regions. By free incisions into the infiltrated tissue, and especially the perinseum if involved, or as near to the opening into the urethra as circumstances will permit, retention, so called, is relieved, and the catheter may with advantage be dispensed with for a time. Having done so much, we found on the following day that urine had freely escaped through the incisions, but the swelling and redness had increased in degree but not in extent over the abdominal wall. To relieve this state of inflammation caused, doubtless, by the presence of urine, an incision was made in the groin above Poupart^s Hgament down to the aponeurosis of the external oblique muscle; — mind, the incision must include the deep fascia, because under this, the source of irritation, the urine, will be found for reasons already explained. Still, although a fair quantity of urine flowed by the urethra, the hypogastric tumour was only slightly diminished in size, but as this" symptom was not urgent, I left the case to time and a repetition of the aperient and hip-bath for the second day. On the third day (Wednesday), the bowels being still unopened, I ordered five grains of calomel, and a repetition of the house-medicine, but without the desired effect. On the fourth day (Thursday) the hypogastric tumour remained and hiccup had super- vened, and I now thought the time had arrived for further surgical interference. I presumed that constipation was caused by pressure upon the rectum of the distended bladder, and that the indication was, therefore, to empty the bladder thoroughly by some means or other. How was this to be effected? Common-sense, and a good surgical rule replied— by the urethra, if possible, and I do not hesitate to say, knowing that the urethra had had seventy hours of rest and means had been employed to dispose of the swelling around, that I had great hopes that I should succeed in introducing a catheter. As you saw, I made the attempt first with elastic catheters, but failed ; then with a No. 4 metallic instru- ment, and succeeded in reaching the bladder with tolerable facility and in drawing off two pints of urine, slightly tinged with blood, ON A CASE OF COMPLICATED STHICTURE. 103 tolerably clear and only slightly ammoniacal. I tied the catheter in to prevent refilling of the viscus. As regards the substance of size of a catheter, I may say in every case of supposed stricture of the degree of which you are ignorant, no matter whether you select a soft or a metal instrument, begin with either No. 7 or 8, if neither of these will pass, you may be sure of the nature of the case, and have only to descend the scale until you find that which will effect your object. But, especially where others have stepped in before you and have drawn blood, and you still deem it right to try catheterism, always select a large instrument because it is just possible that Fortune may favour you. The previous escape of Mood may have opened up the stricture, and your large instrument gliding over the existing lacerations, may -pass the stricture and relieve the patient. Then again, as to the instrument, is it to be soft or hard ? In the majority of cases of stricture I use the soft, because less mischief is done with it, and when well softened it readily traverses a tortuous canal; but in the case before us our grand object was to get into the bladder by the urethra if possible, and not to give up the attempt without an effort. I, therefore, gave the preference as you are aware (commencing with the soft in deference to the suggestion of a senior colleague) to a metallic instrument. Now it was of vital importance to empty the bladder, and I d&termifled in this instance to act apparently contrary to my custom in the treatment of stricture, and to use some force, if need bei, in order to traverse the obstruction, rather than without it to resort to some other and more severe operative procedure. The term force is a dangerous one to use in reference to stricture, perhaps steady pressure better conveys my meaning, exercised in the direction of the urethra, and if the end of the instrument has entered the track of the stricture little mischief will be done by a careful operator. Thell again the curve, if one will not pass, try a different one, both larger and smaller. Fowth Bay.—Vsss, bowels were freely moved soon after the bladder was emptied, proving the correctness of the opinion that consti- pation was due to the pressure of that distended viscus upon the rectum. Mfth i)«y.— The catheter slipped out of the bladder and the 104 CLINICAL LECTURE, BY MB. MAUNDER, urine was re-accumulating probably on account of the weakened condition or exhausted irritability of its muscular coat by prolonged distension. But you will probably ask, supposing I had been un- able to pass a catheter, what I should have done to empty the blad- der. Two methods of operation were open to me to choose from, either tapping per rectum or a free incision into the perinseum with the hope of laying open the urethra behind the stricture. I should have selected tapping per rectum, because by this method I was sure of emptying the bladder completely and at once, whereas, had I simply laid open the urethra in the perinseum, or rather attempted to do so, for I could not be sure of success without a guide, and no director could be introduced, the urine very probably would not have escaped more readily than it was doing by reason of the inability of the detrusor urina to contract upon the distended bladder, and I should probably have been obliged to resort to tapping after all. In this case, the urine, which did dribble away, was simply the overflow, that is to say, the bladder becoming distended beyond a certain extent the neck was stretched and the mouth opened, favour- ing the escape of a certain quantity, quite independently of the will of the patient. Prom observation of this case up to the present time, certain practical deductions may be made. 1. That a bladder shall be greatly distended, and yet a fair quan- tity of urine shall be passed daily without emptying that viscus — overflow not incontinence. 2. That in retention with extravasation, free incisions are abso- lutely necessary, while catheterism may be deferred with advantage. 3. That constipation may be caused by a distended bladder. Sequel to Case. — From the date of the above lecture to the begin- ning of March, 1866, the patient passed slowly from a state of danger to comparative good health. The scrotum sloughed to a considerable extent, especially on the right of the raphe, completely laying bare the testicle of the same side. When granulation had set in I attempted to cover the testis by bringing the edges of the wound together anteriorly, and maintained them so by means of sutures, leaving an aperture posteriorly for the escape of urine, The sutures, however, soon gave way, and the wound gaped as ON A CASE OP COMPLICATED STRICTURE. 105 before. Slowly, the wound closed over the testicle, which ascended towards the external ring, and when the man became an out-patient a small fistulous aperture, through which a very little urine flowed on micturition, alone remained. Jime Stk. — The fistula has been closed some time, and the stric- ture allows a No. 5 catheter to pass into the bladder. On examining the perinseum, a depressed cicatrix leads to the suspicion that the opening into the urethra which preceded the extravasation is closed by the cicatrised integuments. The patient will remain under care for some time longer, and will be taught to pass a catheter for him- self periodically. LECTUfiE II. Retention of urine ; puncture per rectum. Gentlemen,— By the courtesy of Mr. Curling, I have lately had a number of interesting cases of disease of the urinary organs under my care. A few weeks ago I made some observations upon a case of retention of urine with extravasation, and to-day I shall allude to three instances of a similar class of disease (complicated stricture). I will take them in the order of their simplicity. Case I. — B. H., aged 47, was the subject of gonorrhoea thirty years ago. During the last eighteen months the stream of urine has gradually become smaller and smaller, and during the last fortnight there has been a gradual accumulation of urine, and to-day, on admission, Eebruary 3rd, 1866, the bladder is as high as the umbilicus and a small quantity only of urine passes. The house-surgeon ordered a drop of croton-oil, and a hot bath after the catheter had failed. February Mh. — The bowels acted freely, and the bladder is rather less distended. To take two grains of opium at once. ^th. — Hypogastric tumour much as yesterday; the urine is ammoniacal and a fair quantity is passed. &th. — The bladder is more distended than ever ; the urine passed is highly ammoniacal, and deposits mucus ; tongue dry and brown, with thirst ; skin hot and dry ; pulse quick and weak ; a catheter cannot be passed ; the bladder is tapped per rectum. Tth. — ^The patient expresses himself as being very well indeed compared with yesterday ; the tongue has cleaned, and the character of the skin and pulse is totally changed for the better. %tL — The urine flowing through the canula is highly tinged with blood. \Qth. — The urine has acquired its uormal colour. There is a slight blush of erysipelas about the left face, consequent the patient MR. MAUNDER ON CASES OF COMPLICATED STRICTURE. 107 thinks on his having scratched off the head of a pimple existing on the temple. Warm fomentation. Tinct. Perri Sesqui-chl. gss. ter die. Brandy gvj. Ylth. — ^The erysipelas spread over the upper part of the entire face leading to abscess of the left upper eyelid, but the patient is convalescent. No urine has flowed per urethram, now eleven days since the operation. The first point that strikes you on reviewing the history of this case is the length of time (thirty years) which has elapsed since the attack of gonorrhoea, which is supposed to have originated the existing stricture. Now the diversify as regards time which is observed in patients the subject of stricture subsequent to gonorrhoea, depends greatly, no doubt, on the mode of life of the individual ; the healthy, and careful, and regular liver escaping the after-effects of gonorrhoea much more surely or, at any rate, for a longer period than the careless and irregular liver. The state of the urine in a person susceptible of stricture is a matter of great importance, and if by any excesses oi* exposure the functions of the digestive organs be deranged, or the excretive power of the skin be checked, this secretion becomes altered in character, a source of irritation to the diseased urethra, 'and, in time, marked stricture results. Here the urine had been accumulating a fortnight at least, a state due probably both to the severity of the organic obstruction, and, as the distension of the bladder continued, to a corresponding loss of contractile power in the muscular coat of that viscus. Even on the day of operation absolute retention did not exist ; why then was an operation per- formed? The constitution was showing signs of sympathy and suffering from the local malady, and the urine passed indicated the effect upon the bladder of certain chemical changes which if allowed to continue, would lead to a fatal result. How was the retention to be relieved ? In all cases of retention the grand desideratum, no matter what operation be resorted to, is to open the urinary track behind the obstacle to micturition, and in this instance the use of the catheter informed us that the obstruction was in the spongy portion of the urethra, and consequently various methods of opera- tion were open to us. By the time that operative interference be- 108 CLINICAL LECTURE, BY MR. MAUNDER, comes necessary the patient^s vital powers, or powers of resisting the effects of an operation, superimposed upon his then condition, are diminished in a great measure, and it may be absolutely necessary to select a method which, while it affords immediate relief, may in the estimation of some surgeons, be less advantageous to the future treatment. In the case before us puncture of the bladder was re- sorted to, not only for the sate of giving instant relief, but also because I believe it to be the best under such local circumstances, by such circumstances I mean, retention consequent on organic stricture, without either perinaeal abscess or extravasation.* The salutary effect of the operation was quickly, made manifest, as is recorded in the history. But there are two other recognised modes of operation, either of which I might have selected — puncture above or through the symphysis pubis, or perinaeal section, without a director. Of these the former is nearly allied to puncture per rectum, but is less advantageous, because the urine must flow contrary to the attraction of gravitation, and unless great care be observed at the outset, the areolar tissue, between the bladder and symphysis pubis will become infiltrated with urine. Still, it must be borne in mind that the instrument in the majority of cases is only to be worn a few days, but were it otherwise the suprapubic operation would probably be preferred. The latter, which consists in plunging a knife into the perinseum with the intention of opening the urethra behind the stricture, and so relieving retention, and then carrying it from behind forwards along the raphe with the hope of cutting through the indurated tissues and opening up the narrow channel, in no way commends itself to me. If successfully performed, benefit both present and future is, secured, because a catheter can be at once passed into the bladder, but success is so remote, that the urgency of the case and the extra risk which such a cutting operation entails, scarcely justify its employment. The object of the operation, whether it be performed above the pubis or per rectum, is two-fold ; first, to relieve retention, and secondly, by retaining the canula in the bladder, to insure the escape of urine from that viscus as fast as it is poured into it, and thus to relieve the urethra of the exercise of its function, as a conduit, for a time, and so to allow existing in- flammation and its products to subside and be absorbed. Thus far, * For treatment in case of extravasation, see p. 99. ON CASES OF COMPLICATED STRICTUEE. 109 then, the case has progressed tolerably favourably, with the exception of an unusual quantity of blood passing, mixed with the urine, for a day or so, and a smart attack of erysipelas of the face which is now on the decline, consequent on scratching a pimple on the forehead. But no urine has as yet flowed by the urethra, although the patient . has experienced a forcing sensation in the perinseum, as if the urine were endeavouring tO' find its right charmel, neither have I used a catheter. The fact that the water has not found its way by the meatus after the lapse of eleven days from the operation, I regard as an indication of the severity of the stricture, and my reason for delay in the use of the catheter is, to afford nature an opportunity by keeping the patient recumbent, and securing local rest to the part affected, of relieving congestion and dispersing some of the inflam- matory deposit, which, encroaching upon the canal, is the cause of stricture. As a rule, in these cases, the urine begins to flow by the natural channel after the lapse of three or four days from the opera- tion, and when it does so, the time for catheterism has arrived and wfll probably be successful, and if so, the canula may be removed from the rectum, while the catheter passed by the urethra is either tied in for a few hours, if difficulty in the introduction has been ex- perienced or is withdrawn, and the case treated on general principles. To-day I shall attempt to introduce a catheter. Sequel to Case I. — On the eleventh day subsequent to the operation I attempted, but in vain, to traverse the stricture, the attempt causing unusual pain to the patient, and much more than average bleeding. Prom time to time, allowing several days to elapse between each trial, a futile attempt was made to reach the bladder with instruments, both solid and elastic, of various shapes and sizes. The stricture was not even entered and the suffering was severe. It was not until the seventeenth day from the operation that urine flowed per urethram. On. Aj3rintA, two months from the date of operation, the excessive sensibility of the urethra persisting, I passed a piece of nitrate of silver, of the size of a pin's-head, down to the stricture, and allowed it to remain and be dissolved there. The application of this caused severe pain -for a few minutes, but by its sedative influence I was enabled on the sixth day subsequent to introduce an instrument with no CLINICAL LECTURE, BY MR. MAUNDER, less pain to tte patient. Finding also that the application of the nitrate had not impeded the passage of urine per urethram, I removed the canula from the bladder just nine weeks from the date of operation. Daring the whole of this time the presence of the instrument in the bladder caused no vesical annoyance whatever, although, latterly, the urine was loaded with muco-pus, and had a strong ammoniacal odour. This odour gradually vanished under the influence of a scruple of Benzoic acid administered on the average five times in the twenty-four hours during the space of about ten days. It thus appears that a silver tube may be retained in a bladder many weeks with comparative impunity, and perhaps with great benefit as regards the stricture, but from another point of view such detention is undesirable; it may engender stone in the bladder. The presence of the canula for a long period is a local source of irritation, and by inducing an extra secretion of mucus from the coat of the vesica, the urine at length becomes ammoniacal and a phosphatic concretion is likely to be deposited about the tube. Under the circumstances the canula cannot be renewed every few days so as to prevent this deposition, and supposing such to have occurred, a fragment of this may be detached, when the tube is withdrawn, and remaining in the bladder, becomes the nucleus of a calculus. In the case before us, having removed the canula with ease, I was gratified to fiud that a very small quantity indeed of earthy matter adhered to it, and as this was bevelled off at its borders none had been detached and left in the bladder. I was certainly surprised to find so small a quantity of calcareous matter upon the canula, and on reflection, am inclined to attribute this fact to the effects of the Benzoic acid, which, by keeping the urine in a state of acidity, either prevented a deposition, or dissolved any that had taken place. Under circum- stances then necessitating the • retention of an instrument in the bladder for a long and uncertain period, the administration of an appropriate acid is indicated, . partly to prevent the reaction of alkaline products of inflammation upon the lining membrane of the bladder, and partly to prevent and dissolve phosphatic deposist. For a similar reason a highly- polished silver instrument is to be preferred to one of softer material, as the latter becoming softened and corroded upon the surface by the action of urine, affords a ON CASES or COMPLICATED STRICTURE. Ill favourable vesting-place for deposits. (To illustrate the latter remarks, T may tell you, that some years ago, a boy was under my observation in a provincial Hospital, the subject of laceration of the urethra. An elastic catheter was retained in his bladder about three weeks, and on its removal was found to be much coated with calcareous matter. Soon, symptoms of "stone" appeared, and he was cut successfully for that malady.) After a second application of nitrate of silver the catheter could be borne with less discomfort by the patient, but it was not until the 12th of May, that a small instrument entered the bladder. The stricture was a long one, occupying about two inches of the posterior part of the spongy urethra. B. H. became an out-patient at the end of May, and No. 7 catheter could be passed. Case II. — Organic Strietitre—Permeml Abscess — Perinceal Section. J. H., aged 36, experienced an attack of gonorrhcea eighteen years ago, and two years subsequently observed his stream of urine becom- ing small, a year later he had retention, again in a twelvemonth's time, again after an interval of four years, and then again after the lapse of five years, when he entered and remained in Bartholomew's Hospital four months, and No. 5 catheter could be introduced. During the three months prior to admission here the catheter was employed, but never passed the stricture. On admission, July 25th, 1865, the urine flowed guttatim, and a small abscess, but how long it had existed the patient could not tell, was found in the periuBeum, this I laid open immediately, and the next day the patient passed water both through the abscess and the urethra. After some days rest in bed, and the usual medicinal treatment, I attempted to pass a bougie through the stricture, but failed, and failed repeat- edly afterwards, while the local condition became aggravated ; the perinseum instead of improving, growing more and more indurated, the wound becoming a mere fistula, and a second had opened. Such being the condition of parts, early in October I laid open the peri- nseum very freely in the mesian line, cutting through a mass of inflam- matory products almost as hard as potato. ¥ot a few weeks subse- quently the local condition improved,, the induration subsided in great measure, and the wound closed rapidly ; stiU no instrument would pass the stricture, and indeed at no time would the posterior two- 112 CLINICAL LECTURE, BY MB. MAUNDER, thirds of the spongy urethra admit of a size higher than No. 6. On December 20th, the perinseum being still induratedj and the scrotum having been for many days in a state of subacute inflam- matory oedema, I determined to make an attempt to reach the blad- der by operation. The patient was placed in the lithotomy position, and a 6 catheter passed along the urethra down to the stricture and there held. By a free incision in the mesian line of the perinseum, the urethra was opened, and the point of the catheter exposed. I now, with a probe, endeavoured to discover the anterior aperture of the strictured portion of the urethra, but failed. Waiting a little for the hsemorrhage to cease, and having dried the part thoroughly, I detected a narrow glistening channel to the right side of the point of the catheter, and believing that to be the urethra, I laid it open with a buttoned bistoury, in a direction from before backwards to the extent of perhaps three-quarters of an inch, and was rewarded by being able to carry the catheter on into the bladder, in which viscus it was retained thirty-six hours, when, on its withdrawal, the urine flowed entirely through the wound. From this date the case progressed favourably, the wound gradually closing and the urine flowing partially by the meatus urinarius, and when made an out- patient on the 12th of February, 1866, the greater part of the urine was passed by the urethra, and No. 6 catheter could be carried into the bladder. Compared with the previous case, how different is the history of this under consideration ; the one patient was free from symptoms of stricture during twenty-eight years subsequent to the attack of gonorrhoea, the other was seized with retention three years after he had been the subject of venereal disease. He has the aspect of an immoderate beer-drinker, and has led a very irregular Hfe. This patient was admitted passing water guttatim, as was not un- common to him, a condition which might result either from a very tight stricture, or from the abscess found in the perinseum. Assuming that the latter might be the cause, I laid it open at once, for two reasons : firstly, to favour more free micturition, and secondly, with the hope that the urethra might not be opened by it. In this latter ON CASES OF COMPLICATED STRICTURE. 113 hope I was disappointed ; on the following day urine flowed through the wound. It is a rule of practice with me, in aU cases of perinseal abscess, associated with very diificult micturition, to open the abscess before using a catheter ; by so doing, the instrument may not be requisite, and the risk of making a communication between the urinary passage and the abscess cavity is avoided. I make, how- ever, one exception to this rule — when the abscess has already opened into the urethra, as is known by the discharge of pus at the meatus independently of micturition, a catheter can often be passed, as in a case of uncomplicated stricture, and if so, the bladder should be evacuated periodically, say twice or thrice in the twenty-four hours, by means of the instrument, with the hope that the abscess cavity will contract and close as soon as the urine can no longer enter it, as it would do if allowed to traverse the urethra as in a state of health. For many weeks the case was treated on general principles without avail. No catheter or bougie traversed the, stricture and a second fistu- lous opening formed in the perinseum with increased induration. This second fistula and augmented induration indicated the tendency to abscess and subacute inflammation, consequent, I thought, on the closing up of the original wound, while the stricture remained im- permeable to instruments, preventing the free egress of urine at the perinseum, and causing it to burrow in the soft parts of that region in order to find a vent. Acting upon that supposition I cut freely through this indurated tissue, and again for some weeks, attempted, but failed, with the catheter even while the urine had a ready means of escape through the wound. All this time the patient was kept in bed on a nutritious but unstimulating diet, and attention paid to the state of his urine. It now became necessary to use more potent means of reaching the bladder through the stricture, and I had a choice of methods more or less applicable. Escharotics and urethrotomes were scarcely considered, on account of the contracted state of a great portion of the spongy urethra ; I had already laid open the perinseum, with the bare possibility of striking the urethra, without success, and I selected as a dernier ressort the operation above described. It succeeded, and the patient has been recently made an out-patient, still passing some of his water through the perinseum. I 114 CLINICAL LECTURE, BY MR. MAUNDER, You will ask if the perinseal fistula is likely to close soon, and what means will be taken to further such closure ? I expect a very long time will elapse before the fistula closes, by reason of the con- tracted state of a long tract of urethra anterior to it forming an obstacle to the onward flow of urine on account of its inability to dilate beyond the dimensions of No. 6 catheter. As regards the means to be employed to assist Nature in her work of repair, the patient will be taught to pass a catheter for himself and never to micturate except through it. By this method, the fistulous communication, being no longer necessary as a safety-valve against retention, may be closed. Sequel to Case II. — J. H. has presented himself occasionally among the out-patients, and I. have usually succeeded in introducing No. 6 catheter. The patient himself passes an instrument now and then, but not with sufficient regularity to insure closure of the fistula, which is still open. His general condition is such as to lead me to suspect that he has organic disease of the kidney. Case III. — Urinary fistulee at the hip ; communicating with the hlo/dder ? R. D., aged 16, was admitted January 25th, 1866, with several openi&gs about the right hip through which urine flowed during micturition. Some of these apertures resulted from disease of the hip-joint many years ago, but had all been closed five years previous to the commencement of his present malady. Twenty months since he fell down a trap and struck the body of the right pubic bone, and although carried home, he went to work as usual on the next day. Three weeks from the date of the accident he experienced pain in the hypogastric region, followed, in a day or two, by gradual and then complete retention of urine for forty- eight hours, relieved at last by the catheter which was introduced with difiiculty and was accordingly retained for a space of forty hours. On the day subsequent to the removal of the instrument, the catheter was again requisite, but during a sojourn of three weeks in Hospital he passed water voluntarily. During ten months following the accident the boy went to work as usual, but at this period a swelling arose ON CASES OF COMPLICATED STRICTURE. 115 near the right antero-superior spine of the ilium, in which there was a smarting burning pain on micturition. This was opened artificially and gave exit to pus and urine ; and other sinuses, about the upper part of the thigh and hip, which formerly discharged pus when he was labouring under hip-disease, reopened, and urine flowed from them during micturition. Soon after the attack of retention the urine was observed to contain pus, but there has never been a urethral discharge. Some half dozen apertures about the right hip give exit to urine when the patient urinates. The first point of interest in this case is the origin of these urinary fistulse ; are they the result of an abscess in the pelvis as a sequel of old hip-disease, or had the faU upon the pubis any share in their production? I am inclined to accept the former proposition, because, had the blow been sufficient to give rise to suppuration within the pelvis, I should have expected evidence of earUer symptoms than those which arose three weeks after the accident ; nothing short of fracture of the pubis would, I presume, have sufficed for the result in question, but the history of the case leads us to no suoh conclusion-^-there was no haemorrhage from the urethra, the urinary organs performed their functions as usual, and the boy went to work the next day. On the other hand, there are several cicatrices about the hip and upper part of the thigh, relics of old hip-disease, most of which have at one time or another given exit to urine ; and as the head of the femur is not in the acetabulum, but upon the dorsum ilii, there is no mechanical obstacle to the passage of fluid through that cavity, supposing it to be perforated. I am of opinion that the urine has made its way out of the pelvis chiefly through the acetabulum because, until lately, no fistulous opening has been established above Poupart's ligament. Now as to the point at which the sinus communicates with the urinary passages, whether within or without ;the pelvis? The external organs of generation and the perineeum are perfectly healthy, therefore the communication must be within, and the finger in the rectum can detect no abnormality through the walls of this viscus, either in the prostate or other 12 116 CLINICAL LECTUEE, BY MR. MAUNDER, locality, and one is, therefore, conducted to the bladder as the seat of communication. If this be the correct view of the case I should not be surprised if a fragment of bone found its way into the bladder as a consequence of cario-necrosis of the acetabulum. Also, I found on inquiry, that at one time there was a discharge of matter by the urethra, but this was always mingled with urine and was only seen at the time of micturition, a clear proof that its source was not anterior to the bladder. Treatment. — The case before us is peculiar, from the fact that the fistulse communicate with the urinary passages within the pelvis, and if the assumption be correct — that the commuincation is with the bladder — the principle of treatment for perinseal fistulse will not be applicable. Our first object will be to pass an instrument into the bladder, and having done so, the next step will be to keep that viscus always empty by means of the catheter retained for the purpose ; in fact, to convert the reservoir into a simple channel of communication between the vesical end of the ureter and of the urethra itself. To allow urine to accumulate in the bladder, and to empty this viscus periodically with a catheter, would I fear be insufficient, because I can imagine, that as the bladder dilates by the accumulation of urine, some of this fluid (in accordance with gravity) finds its way into the sinus which feeds the fistulse, and prevents its closing, independently of the possible presence of a piece of dead bone. At present the sinus is not allowed to close by the action of the detrusor urmce muscle, which, when called into play, forces a portion of the urine along the urethra and a portion along the false passage. I shall also desire the patient to lie as much as possible on his left side in order that urine may be as far removed as possible from the right side on which the sinus is situated. Sequerio Case. — On February 20th. After two or three trails,a short silver catheter was passed along a tortuous urethra into the bladder and retained for three days, the urine flowing away through an India-rubber tube adjusted to the instrument. At the end of this period the boy complained of hypogastric pain, loss of appetite and of rest, and of other symptoms of constitutional disturbance necessitating the removal of the instrument. Still this attempt was not without local benefit, for with one exception the fistulse closed. ON CASES OF COMPLICATED STRICTURE. 117 For some three or four weeks nothing was done locally, and the patient gained flesh. Having recovered the effects of the retained catheter, and this plan being impracticable, it was thought that periodical evacuation with a catheter was the next best method, on the principle already explained, the patient being cautioned against exercising volition and assisting to expel the urine when the catheter was in the bladder. Gentlemen, resident m the Hospital, undertook the task, but were unable to introduce the catheter, and I must say, in justice to them, that the case was a difficult one to manage, the urethra being tortu- ous, and a kind of bar existing at the neck of the bladder. This plan was therefore abandoned. After the lapse of a few days, to allow the urethra to recover from the effects of the recent catheter- ism, I determined to try retention of an elastic catheter in the blad- der as the last and probably only chance of cure. A.bout the 15th of April I fastened a No. 5 elastic catheter in the bladder, and having attached a piecg of India-rubber tubing to the former, the urine was allowed to flow from the bladder as fast as it entered that cavity. On the eighth day the catheter was replaced by a new one in order to avoid accumulation of calcareous matter upon it, but on the tenth day this instrument accidently slipped out and was not replaced during twelve hours, and in this interval the patient micturated twice voluntarily. The catheter was re-introduced, but becoming obstructed was removed. During the flrst ten days in which the instrument was kept in the bladder, not a drop of urine appeared at the fistulous aperture in the groin, and the urine was always normal ; but during the few hours when the catheter was not in the bladder, and also, when after its re-introduction its channel became obstructed, a few drops of urine passed from the groin. These accidents occur- ring late in the course of this method of treatment, doubtless inter- fered with the successful issue of the case for the time, and as the urine was likewise becoming a little cloudy, I deemed it prudent to omit treatment altogether, with a view to re-adopt the same method after giving an interval of repose to the bladder. LECTUEI] III. Retained testis ; bubonocele ; gangrenous gut. Case I. — J. M., aged 20, came under Mr. Maunder's care March 4t]i, 1866. He had been more or less ill, vomiting being one of the chief symptoms, during six- days prior to the operation, and it appeared that his case had been regarded as one of inflamed retained testis. His bowels had responded to aperients up to Friday evening, forty hailrs previous to operation. Since then vomiting had per- sisted, thfe ejecta being yellow, and then decidedly stercoraceous. On examination, he was foiind to be the subject of an ovoid tumour in the inguinal canal projecting through the external ring ; it was firm and liibderately tense, and when compressed, gurglings were felt as when a portion of bowel containing air and fluid is present, and these contents could be slowly prdssed to and fro. At 4 p.m. the patient was seen by Mf . Maunder who, supposing the case to be one of retained testis associated with strangulated congenital hernia, operated at once. He foiind a hernial sac containing a knuckle of small intestine, adherent by fecellt lymph throughout, of a dark red colour, relieved at two points on the convexity of the gut by an ashy spot ; an inch and a-half of sound bowel intervened these spots. He now nicked the stricture seated in the nfeek of the sac so as to establish a com- munication between the cavity of the boWel within, and the bowel without the abdomen, and left the diseased knuckle in the sac. Opium was freely adcdinisteried, and on the day subsequent to the operation the bowel gave way at the points which were of an ashy hue, and an artificial anus was established. Faeces of a brown tint flowed at the wound ; vomiting recurred, and the patient died on March 10th, the sixth day from the operation. At a post-mortem examination the intestine which formed the ON CASES OF STRANGULATED HEBNIA. 119 hernia was found to be perforated at two points, corresponding with, the ash-coloured spots alluded to, and this knuckle of bowel formed a haK twist upon itself. It was adherent to the sac, and recent lymph effused witliin the ring also maintained the hernia m situ. The whole intestinal canal exhibited a dark purple colour (venous congestion). The testis, smaller than natural, was lying upon the inner border of the psoas muscle below the level of the internal ring. Gentlemen, — The first point to determine in cases of vomiting associated with a tumour in a favourite hernial region, is the con- nection between the swelling and. the above symptom, and in all cases in which the physical examination does not allow you to come to a positive conclusion, the nature pf tlie tumour must be determined by an exploratory operation. This is a rule in practice never to be forgotten and always to be actpd upon on Ijhe grpund that it is more desirable to submit a patient to a comparatively trivial operation, than to permit him to succumb to an unrelieved strangulated hernia. But the case before us was even more complicated than the a^ove remarks would lead us to suppose ; not only was there a tumour in the inguinal region, but there was an absence of the testicle of the same side. It therefore becomes necessary in such a case to determine whether or not the swelling in the groin be the testicle or not, and if not, what is its nature ? Now I shall not trouble you here witji a differential diagnosis of the various tumours met with in tlie inguinal region, but refer only to the probable presence of a strangulated hernia. It happens that an undescended testicle is equally liable to diseajse as when it has reached the scrotum, and supposing it to become th^ seat of acute inflammation wbile confined in a comparatively unyield- ing passage, stich as th6 iiigiiinal canal is, you can readily uuflerstanpl that the patipiit's sufferings vyill be severe,, and strangulated hernia may be simulated. Yomiting, a countenfince expressive of paip, with more or less local tpnderuess will be present. I have, never witnesse4 a case of inflamed retained testis, but should supppsp, judging froni the pain pf orchitis when seated in the scrotum, that the exquisitely tender state of the organ would distinguish it fj-om hernia, Bujt, gentlemen, in a question of so great import, it would be wrong to form a diagnosis upon one symptom (pain) which, supposing the disease equally severe in all, would be so differently expressed by 120 CLINICAL LECTURE, BY ME. MAUNDEE, individuals on account of their varying nervous sensibility, and there is still a means of determining the diagnosis which, in a case where delay is dangerous, must be resorted to-^an aperient must be ad- ministered, and its effects be awaited a few hours, when, if the con- tinuity of the alimentary canal be proved by a copious alvine evacua- tion, no operation will be necessary, because a strangulated hernia does not exist, and our chief anxiety will be set at rest. In this instance I performed herniotomy as soon as I had examined the patient, and having seen the condition of the gut, the question arose, what was to be done with it ? There are three methods of dealing with the viscus in its then condition, each of which has its advocates — to leave it in the sac — to lay it open and leave it, or to stitch its margin to the wound when so laid open — to return it into the abdominal cavity. I selected the first method, in preference to either of the others for two reasons ; first, because although I bcKeved that the tissue of the viscus was beyond restoration at the ashy spots alluded to, yet it is impossible to be absolutely certain that the cavity of the gut vrill be eventually opened by the morbid process at work, and no gain could accrue by anticipating nature after I had nicked the stricture and established a continuity between the interior of the bowel above and below the constriction. Secondly, I did not return the bowel into the abdomen, because the gangrenous points were about one inch and a-half apart, and as it would be impossible to place both of these just within and opposite the ring, so that, should the gut give way, its contents might have A direct mode of exit, I left it. I feared the possibility of extravasation of faeces before nature would have time to form a barrier about the injured portion of the viscus. Had only one suspicious spot existed, I should have returned the hernia whence it came, on the principle that the ab- dominal cavity is the most desirable situation for a portion of bowel. There is one circumstance in this case well worthy of note, and that is, the presence of an acquired hernial sac in a man of twenty, asso- ciated with an undescended testis. The more usual arrangement is that which was erroneously thought to exist here — a partially de- scended testis associated with a congenital hernia. ON CASES OF STRANGULATED HERNIA. '121 Case II. —Strangulated femoral hernia ; opium dangerous before, but very valuable after, -reduction ; exceptions to this statement. C. A., a feeble-looking woman, aged 56, has been the subject of a reducible hernia during five years. Pelt something crack in her groin, when over-reaching, and a month after this found a lump in that region. To-night, March 13th, 1866, she states that the lump has re- mained down for the' last forty-eight hours, during which her bowels have been confined and she has vomited repeatedly. There is a small globular tumour in the left groin, not very tense (the taxis had been applied at home just previously with the effect of diminishing the size of the tumour) ; tongue furred, pulse feeble, surface rather cold, but the night is excessively cold also. Chloroform was administered, and the hernia returned without open- ing the sac, the incision being made at the inner side of the neck of the tumour. A compress and bandage were applied, and one grain of opium administered ; milk and beef-tea diet. March Uth, 3 p.m. — Was very comfortable during eight hours subsequent to the operation, when a cup of tea was returned from the stomach, and vomiting attended by hiccup persisted till she was seen by Mr. Maunder at 3 p.m. Now there is also tympanitis without abdominal tenderness, and a very feeble quick pulse. To have two ounces of brandy cautiously administered. Eive P.M. No sickness since she partook of some brandy. 15th. No more sickness ; abdominal distension has sub- sided, > and flatus has escaped per anum. 20th. Bowels opened spontaneously on fifth-day. Patient is convalescent. Many cases of hernia have symptoms common to aU, but most are characterized by some peculiar features. I wish to draw yoar attention to the condition of this patient a few hours subsequent to the operation, and also to the use of opium, in cases of stran- gulated hernia, both before and after operation. You will have re- marked that during the first hours after operation there had been 122 CLINICAL LECTURE, BY Mil. MAUNDER, no return of vomiting, but then sickness set in and the patient was unable to keep anything on her stomach ; there was also occa- sional hiccup associated with a good deal of tympanitis (no flatus having passed per anum) and a very weak pulse when I saw her at 3 P.M., fifteen hours after operation. Altogether she was in a very unpromising condition. What was the cause of these symptoms ? I examined the groin and found that the hernia had not redescended; with the exception of tympanitis there was no other evidence of peritonitis, and I believed this disease was not present ; but I came to the conclusion that my patient was suffering from asthenia (ex- treme debility). She was a weakly-looking woman, and her feeble- ness had been greatly increased by vomiting and want of nourish- ment during some fifty hours. Acting on this belief, I ordered her two ounces of brandy, with the most satisfactory result. She was not sick after taking a portion of it, a large quantity of flatus was gradually passed per anum, and on the following day when I saw her, the tympanitis had subsided and the belly was flat. The vomiting was no doubt due to pressure upon the stomach by the distended intestines, the distension arising from general debility, and persisting from an inability on the part of the muscular coat of the bowel, to contract upon its contents. A stimulant was indicated, and I have no doubt the two ounces of brandy saved the patient's life. Vomiting persisting for some hours after the exhibition of chloroform, is not infrequent, but in this instance the stomach was quiet for several hours after the operation. The above symptom therefore cannot be ascribed to the anaesthetic. Now, as to the use of opium in strangulated hernia. Speaking generally, I may say that this drug is a dangerons remedy hefore reduction, either with or without operation, but a, valuable agent after reduction. There are exceptions lo both statements. In a case of strangulated hernia, I never order a dose of ojnum unless I have previously determined to effect reduction in the course of a certain space of time by operation, when the taxis assisted also by chloroform or^warm bath fails to do so. I adopt this plan when strangulation has existed a few hours only and I have reason to expect that the constriction is not unusually tight. Under such circumstances, aided by ice to the tumour, a hernia wiU sometimea reduce itself, or be readily replaced, either by the ON CASES OF STRANGULATED HERNIA. 123 patient himself or by his surgeon. But supposing the principle upon which opium is to be employed is not understoodj the conse- quences may be most disastrous. The drug checks vomiting, alleviates pain, and has a grateful influence upon the patient gene- rally. But under these apparently happy effects, a morbid process is steadily at work, and the necessary operation is perhaps only per- formed when the pathological condition of the hernia renders it no longer capable of performing its function. An untimely dose of opium, besides blinding the unwary medical practitioner to the actual condition of his patient, may have a very unfavourable influence upon the mind of the suflerer himself. To illustrate this statement, I wiU call to your recollection a case of strangulated hernia, in the person of J. W — b., a patient, under my care, in Devonshire Wardi about three months ago. This man had been the subject of hernia for some years and usually kept it reduced, but once or twice previously it had redescended for a few hours, but had occasioned no serious consequences. This time, however, the sym- ptoms had been sufiiciently urgent, and before I saw him, a dose of opium had been administered with the effect of relieving all pain, and of checking that functional derangement of the stomach (vomit- ing) upon which we place much reliance as an evidence of strangula- tion. He was so comfortable that he at first refused my aid altogether, and at length gave an unwilling consent that if the taxis under chloroform failed, I might use the knife. The operation dis- closed a very tight stricture at the neck of the sac. The man recovered. So much for and against the administration of opium previous to the reduction of a hernia. I will now draw your attention to the use of this drug after reduction. The extent of the injury inflicted by strangulation upon a portioii of intestine will vary, from a variety of circumstances, to which I need not allude. Granted that the bowel has been strangulated, its tissues will be diseased from, in one case, simple congestion toy in another instance, actual mortification ; in all, rest for the injured viscus will be beneficial, in the last it is essen- tial to the patient's already poor chance of recovery. The principle upon which opium is' to be administered after the reduction of a hernia, is that of procuring repose to the damaged bowel, and it operates probably in two ways — it checks secretion and 124 CLINICAL LECTDKE, BY MR. MAUNDER, exhalation in the various glands and canal forming the chylo-poietic viscera, and thus by depriving the alimentary canal of its natural stimulus to contraction, peristalsis is in abeyance — through its influ- ence upon the nervous system also the muscular system is weakened, and irritability of bowel-surface is diminished, tending also to pre- vent peristalsis. Thus, under the influence of opium, time is afforded for Nature to repair the injured gut in order to render it fit to per- form its function, as forming part of a tube along which certain substances have to pass, and which, should they arrive too soon, might either lead to perforation or to dangerous inflammation. Again, should perforation be inevitable from the first, time is afforded for Nature to step in, and by the effusion of lymph, to prevent fatal extravasation into the peritoneal cavity. But, Gentlemen, notwith- standing the incalculable value of opium at this stage, I am of opinion that there is one condition in which its use may well be dispensed with, if it be not indeed fraught with danger. The case before us will illustrate my meaning. It is usual (and ninety-nine times out of a hundred the custom will be advantageously followed) to give a dose of opium, one or two grains, after reduction of a hernia of many hours strangulation. Por reasons already mentioned, I pur- sued the usual practice in this patient, a feeble little woman, in whom you will recollect alarming symptoms recurred after an interval of con- valescence, and I am inclined to think that the grain of opium might have had an injurious effect. Opium diminishes the power of contrac- tion in muscle, and as the muscular coat of the bowels in this patient was already scarcely capable of resisting distension by the gases accu- mulating in their cavity by reason of her feebleness, the drug probably rendered it still less able to do so and helped much to bring about the symptoms. You will ask how are you to determine when to withhold the opium ? If I reply, — From the feeble subject, you will say that is very indefinite, and so it is. I think therefore the best advice I can give you is that by which you will do right in the great majority of instances — give a dose of opium in all cases to insure rest to the in- jured bowel, but watch your patient closely, and directly you observe symptoms of failing power, as indicated by a gradual and painless rising of the belly (tympanitis) and by the pulse, resort to stimulants, and of these brandy is very .valuable. With regard to the operation itself, although in this case and one ON CASES OF STRANGULATED HERNIA. 125 other performed in the same week, the steps were simple enough, yet you must understand that in no case of herniotomy can you foretell what difficulties may arise in the course of its progress. The two cases alluded to occurred in spare subjects, almost devoid of subcutaneous fat, and as you witnessed Gimbernat's ligament, which was the seat of stricture in both instances, was readily reached, the cut- ting part of the operation being completed probably in the space of a minute. In thin subjects I usually make my incision on the inner side of the neck of the sac, in order that, should the patient recover, the cicatrix may be as far removed as possible from the pressure of the truss pad. In fat subjects, or when the tumour is large, and the wound must necessarily be deep, rendering the seat of stricture more difficult to attain, I select the centre of the neck of the tumour for incision. Whatever spot you choose for incision, take care, in deepening your wound, to divide the different layers of tissue in the same line with the first incision, and don't allow an assistant to drag upon one edge of the cut only, lest you loose the relation between the incision in the skin and the situation in which you had intended to sever the deeper structures. You will divide the various structures on a director, and in inserting this instrument take care to keep the point of it well up against the structure to be divided, lest otherwise you open the sac with it unintentionally and possibly wound the contents thereof. For my own part, having had a fair amount of experience in herniotomy, I rarely use a director, except for the passage of the knife which is to nick the stricture, and only occasionally to open the sac do I employ the forceps. By manipulating the parts as httle as possible, I can sometimes insure primary union of the wound even in Hospital. The after-treatment has been alluded to, and should be conducted on general principles. The patient should not assume the erect posture antil a truss can be worn. Strangulated inguinal hernia ; partial redmction ; treatment of irreducible portion. Case III. — E. E. G., male adult, aged 50, has been ruptured five years, and dixring this period has worn a truss, which, except on one occasion, kept the hernia up. The rupture is on the left side and of the inguinal variety, and has been irreducible for about five 126 CLINICAL LECTURE, BY MR. MAUNDER, hours. The scrotal swelling is very firm and tense and no irapnlse is communicated on coughing ; vomiting has occurred twice. Chlo- roform was administered at once^ but the taxis failed to efifect reduc- tioUj and he was ordered to take two grains of opium, to support the scrotum with a crutch pad and to have ice constantlj applied to the tumour. This was at 9 p.m. on the 18th of March, 1866, and Mr. Maunder arranged to see the case again in three hours' time. At midnight the tumour was much as before, and the patient, though he had not slept, felt very comfortable and dozy. Ghlqroform was re-administered, and at least' half the tumour was reduced with the rapid ascent of a portion of it. The remainder resisted a. prolonged taxis, but Mr. Maunder was satisfied with the result, , and sent the patient to bed, leaving instructions that he should be sent for in the morning if symptoms persisted. No opium. March IQtL — The patient is as well as usual, and now he admits that he has had a lump in his scrotum along time, although he ignored the fact yesterday. Ordered to remain constantly recumbent, to have middle diet, and take as little fluid as possible ; to take three grains of grey-powder every night and a dose of house-medicine occasioually, the scrotum to be supported by a crutch-pad, and a bag of ice to be worn night and day upon the tumour. April 1th. — The tumour is decidedly smaller. The gums are slightly tender. Omit the grey-powder, but continue the ice, &c. About one and a-half pints of fluid have been taken during each' twenty-four hours, and he uses a urinal and bed-pan. On one occa- sion he was found sitting up, resting on one elbow, drinking his tea, and it cannot of course be^said to what extent the patient has broken the rules enjoined upon him. After six weeks^ trial, the tumour uot having perceptibly diminished rin size during the latter half, chloro- form was administered and the taxis perseveringly applied in, vain. A hollow truss was ordered and the patient discharged. He presented himself among Mr. Maunder's out-patients on the 18th of May, apd expressed himself well-pleased with the truss. On visiting a patient with strangulated hernia, I makq it a point to endeavour to discover whether or not up to the, period of strangu- lation the tumour was altogether reducible. If your patient be an adult you will probably be able to appeal to himself alone concern- ON CASES OF STKANGULATED HERNIA. 127 ing this fact, and must be prepared to be often incorrectly informed^ not wilfully,, but from carelessness or ignorance of the trath. You are of course aware that many persons are the subject of an irredu- cible hernia, which probably has not for years given them serious inconvenience, but at length a further descent of bowel takes place, and strangulation is the consequence. The advantage which the knowledge of the existence of an irreducible hernia, in such a case as I have mentioned, is two-fold. First, it often allows the surgeon to relieve his patient by what may be termed an incomplete opera- tion. Secondly, the patient is exposed to less risk by the incomplete operation which is alone necessary to his relief. The case before us will illustrate my meaning. On interrogating my patient, before commencing treatment, about the history of the tumour, he stated positively, that except once during the last five years, there had been no unnatural swelling in his groin. But you will recollect, that when we were attempting reduction -by the taxis, only a part of the solid portion of the tumour went up, and I con- tinued my attempts for some time longer, with the hope of reducing the wholew I did not succeed, and for a sufiicient reason. Gn the following day the patient admitted that there had been " something of a lump " in his groin for many years, but did not think it was of consequence that I should know, although, as you remember, I questioned him about it. The first disadvantage which incorrect information on this point led to, was the prolonged use of the taxis ; complete reduc- tion was impossible, either from old adhesions or the size of the rupture. Finding that only a portion of the tumour eould be reduced, I presumed to set aside the statement of my patient and acted on the hypothesis, that I had to deal with an irreducible hernia, capable, under its usual condition, of performing its functions, and that the symptoms (vomiting being the chief) had been caused by the recent descent of a piece of bowel. Thus, we had in the sac, old irreduci- ble hernia, and recent knuckle of gut, and as the tissues around the mouth of the hernial sac did not yield in proportion to the dimen- sions of the new protrusion, strangulation resulted. Suppose now that I had accepted the patient's statement as infal- lible, observe what might have happened. Had I not thought it 128 CLINICAL LECTURE, BY MB. MAUNDER, safe to send the patient bact to bed with the tumour only partially reduced, I should have resorted to the knife, and having severed the tissues external to the sac and again applied the taxis in vain, I should have opened the peritoneal investment to discover that I had operated unnecessarily and exposed my patient to great danger. I need scarcely say, that to do what I have pictured to you as possible — to use the knife at once when the tumour has acquired the physical character referred to combined with absence of tension, would be bad practice indeed. The method of treatment adopted should be your guide in similar instances. The patient is to be put to bed, and to be carefully watched; no anodyne is to be administered, for reasons already stated, and should sickness recur and persist longer than you think may be ascribed to the effects of chloroform only, herniotomy must be performed and the contents of the sac be examined. In the case be- fore us, the patient's bowels were moved on the following day, and he was restored to his usual state of health. I must now return to an earlier period of the treatment. We found on inquiring into the history of the rupture, that it had existed some five years, and symptoms of strangulation set in five hours previous to my seeing him. The tumour was very tense, and chloroform having been administered, the taxis was employed, but in vain. Having failed with the taxis aided by chloroform, some of you might think an operation immediately necessary, but I did not resort to the knife for certain reasons. The rupture was not recent (five years' duration), and therefore I did not expect the mouth of it to be so small as to endanger the integrity of the bowel by the additional three hours of strangulation to which I allowed it to be subjected while I tried certain remedies to favour reduction. These remedies were ice and opium, the former to prevent the ingress of arterial blood, was appUed in an India- rubber bag to the tumour ; and of the latter, tw6 grains were admin- istered by the mouth, to allay pain, to procure muscular relaxation and favour sleep. This treatment was adopted at 9 p.m., and I arranged to see the patient again at midnight. I have elsewhere stated that, as a rule, opium is a dangerous remedy in strangulated hernia lefore reduction is effected, but the case before us is an excep- tion to the rule, because the principle upon which the drug was ON STRANGULATED HERNIA. 129 employed was understood. I had determined, prior to administenng the narcotic, to perform herniotomy after the lapse of three hours (making eight or nine altogether in which strangulation existed) provided the taxis, thus aided, failed to effect reduction. The result of the treatment was very satisfactory. Chloroform was agaiu administered, and partial reduction of the tumour was accompUshed by the taxis, and the patient was restored to his usual condition. In a similar case I should be disposed to employ subcutaneous injection of morphia, in order to save time. I may say that I expect much more good from all the aids to the taxis which we pos- sess, in a case of inguinal than in an instance of strangulated femo- ral hernia, on account of their different anatomical relations. The former, passing among muscles, is likely to rouse their irritability and excite spasm by its mere presence, to say nothing of the stretching to which the lower fibres of the internal obhque and transverse muscles are subjected as they cross from without inwards the neck of an obUqiie hernia. So, in a less degree, would the mus- cular fibres of the external oblique muscle be excited to action by a hernial protrusion stretching or separating one from the other the pillars of the external ring, and these would constrict a hernia. The latter, (femoral) passing through a ring bounded by tissues scarcely affected by muscular action, is little influenced directly by agents favouring muscular relaxation. But besides the direct action of chloroform, opium &c., the iudirect effect of these agents is a great help to the taxis, equally both in inguinal and femoral hernia. When the patient is thoroughly under the influence of chloroform (a physiological state highly conducive to successful taxis) volition is in abeyance and the muscular walls of the abdomen cannot be then employed by the patient in diminishing the capacity of that cavity nor in pushing the viscera down upon the ring by which the hernia has to return into the belly, and so offer an obstacle thereto. I have spoken of the taxis as a means of reducing a hernia, and that this should be successfully employed the principle of its action must be well understood. It is not sufficient to seize the tumour and force it against the structures upon which it is lying. Such pro- ceeding would very generally frustrate your object. The tumour is to be taken into the hands, or between the fingers of both hands, and be gradually and continuously compressed tbpon itself, the pres- 130 CLINICAL LEOTUEE, BY MR. MAUNDEE, sure being slowly augmented and maintained for a space of time varying from five to fifteen minutes and while compression is em- ployed a direction is to be given to the tumour the reverse of that by which it made exit from the abdomen. Thus, you wiU see that it is essential to the success of the taxis that the variety of hernia to be operated upon be recognised. Having then by compression dimin- ished the bulk of the tumour — ^by preventing the influx of arterial blood, by expressing venous blood, serum that may have been in the sac, or any excrementitious contents of intestine, the tumour is to be kneaded in the direction of the mouth of the sac, and reduction, if not impossible from physical causes which we cannot influence by this means, wfll be efiiected. See the different effect of the two kinds of pressure referred to, upon this India-rubber bottle. Let the mouth of a hernial sac be represented by the ring formed by apposi- tion of my finger and thumb and the bottle. the contents of the sac. If I push it thus bodily against the ring it spreads out around that aperture, but when I compress it upon itself gradually and force the air out of it, the long axis of the bottle is in a direct line with the ring formed by my fingers, and the possibility of reduction is in- creased manifold. So is it with a hernia. The following day found our patient in his usual condition, the bowels had been moved spontaneously and there was a diminished sweUing along the cord. Was the patient to be discharged in that state ? You can readily understand how great a discomfort must be the existence of an irreducible hernia, not to mention the constant danger of strangulation by extra descent of bowel to which the sub- ject of it is exposed. A truss, often inadequate to the purpose, is adapted with difliculty and worn with more or less pain, and to rid the patient of such annoyance is desirable. I determined to make the attempt in this instance, and adopted a mode of treatment recom- mended by Mr. Hilton. The more frequent physical causes of irre- duction are — a growth of the hernia, such as a deposit of fat in omentum ; adhesions of the contents of the sac to the surface of the latter and contraction of the mouth of the sac. This latter often has the effect of inducing atrophy in the tissue which it transmits to a surprising extent. I have seen an omental hernia connected with the mass of omentum in the cavity of the abdomen by a mere thread of membrane, a condition induced no doubt by constant pressure. ON STRANGULATED HEENIA. 131 To determine the precise nature of the impediment or impediments to reduction during life is probably absolutely impossible, but know- ing the chief causes which usually exist we must act accordingly. The chief objects to be obtained by treatment are a diminution in the size of the tumour, and a breaking up of the adhesions. The size of the tumour depends partly on the solid and partly on the fluid constituents; the former being principally represented by fat and the latter by Mood, both vefioiis and arteiiaL To' favour the absorption of .fat the patient should be kept on a spare diet, and to lessen the quantity of blood circulating in the rupture as little fluid as possible should be tdkeH by the mouth,' a hydrc^bgue cathartic should be adffliiiistereid twide or thrice a-Week ts unload the portal system, while the recumbent posture is to be constantly maintained by the patient. Locally, the tumour is to be supported by a crutch- pad to favour the return of venous blood, and ice is to.be constantly applied to prevent the entrance of arterial blood. Besides this, Mr. Hilton advises three grains of Hyd. c. Greta every night, with a view to absorption of adhesions. Whethei* or not much can be effected by this latter remedy upon old adhesions, I am unable to say. To bring about the desired result this treatment must be continued for some time, and in order that it may have a fair chance of success you must explain to yout patient that improvement in his local doni- dition will be slo*, and the method irksome, ahd unless he be pre- pared to follow your advice strictly, yoU had better not attempt to relieve him. k2 NOTES OF TrNSUCCESSFUL AND SUCCESSFUL CASES OF SALINE ALCOHOLIC INJECTIONS INTO THE VEINS FOR REUEF OF COLLAPSE OF MALIGNANT CHOLERA, TEEATED DUBING THE EPIDEMIC OE 1848-9. Bt Dr. little, LATE SENIOB. PHYSICIAN TO THE LONDON HOSPITAL. Contents : — PreKminary observations — ^Nature of injecting apparatus — Cases — Report of Dr. Letheby on the analysis of the urine passed by a patient after yenous injection — Some conclusions as to venous injec- tions in general. The subject of Malignant or Asiatic Cholera is, in Great Britain, at the present moment happily of no great threatening importance, I am, however, induced to lay before my professional brethren in some detail, the following cases of unsuccessful and successful instances of therapeutic injection into the veins of salts, water and alcohol, during the epidemic visitation of 18-18-9, because the successful cases are unique, the practice of such injections not having been resorted to elsewhere than at the London Hospital during that epidemic. The fact of recovery, without peculiar accidents after such injections, has an important physiological and pathological as well as therapeutical bearing. In the event of the occurrence of future epidemics in this country, they may also serve as a sign- post to some physician placed in a favourable position for making tentative experiments in therapeutics, or they may even aid the physician in combating the last stage of this frightful malady, in the various parts of the globe, stiU too frequently visited by it. These cases confirm the abihty of the economy to bear the direct infusion into the circulating fluid of considerable quantities of not DE. LITTLE ON THE TREATMENT OF CHOLERA. 133 inert ingredients, and whether or no recovery in the successful cases be generally believed to have been in any degree attributable to the injections, the cases will, I believe, be admitted, to show that during their after-progress, no unfavourable phenomena occurred which are not natural to persons recovering from cholera-coUapse.' The notes of the cases here presented, are printed exactly as they were written out at the time of treatment. They may, perhaps, be curtailed with advantage to the general medical reader, but I prefer to let them appear in their original form, that being, in my opinion, the form in which they would be most useful to any Physician purposing to make studious trial of the method. I have witnessed too much of the appalling incompetency of Art during the cholera visitation of 1832, and 1848-9, to effect more when severe coUapse of malignant cholera has taken place, than snatch a bare majority from death, and that when the extreme stage has been reached, the Physician will be compelled to look on power- lessly until some heroic mode of resuscitation more permanently effective than venous injections as hitherto practised, has commonly been, to be induced to seek by the detailed publication of these cases to establish the mode as a remedy for cholera-collapse. But I have faith that the means capable of even temporarily reviving most of the worst moribund cases, may, by study, by repetition and careful obser- vation, and improvement as to apparatus used — ingredients and mode of operation — be made effectual in a greater proportion of instances. A very brief mention of these cases was made by the author in an oration before the Hunterian Society in 1852, and similar mention was made to the Cholera Committee of the Royal College of Physi- cians about that time. But no detailed notes of Alcoholic Saline injections have hitherto been published ; such notes, as may enable the experienced physician, accustomed to weigh evidence, to judge whether death in the unsuccessful cases was hastened by the injec- tions, and whether recovery in the successful cases was aided by, or essentially modified by them. Although originally induced in 1832, to try venous injections through the theoretic suggestions of Dr. O'Shaughnessy, and the practice of Dr. Latta, which was reported in the periodicals of that date to have been followed by marvellously successful results, my experience at that period was attended with unfavourable results. 134 BE. LITTLE ON THE TREATMENT 0¥ CHOLERA, Dr. O'Shaugnessy, after analysis of the blood in cholera, pro- posed to re-oxygenate the dark blood by venous injection of a solution of chlorate of potash, — a salt combining a large proportion of atoms of oxygen. He also recommended trial of weak alcholic solutions. ' Dr. Latta, of Edinburgh, took the initiative in the practical recog- nition of Dr. O'Shaugnessy's recommendation of venous injection in cholera. Dr. Latta injected into a vein in the elbow, pint after pint of a solution of common salt and carbonate of soda, salts of which the blood had been deprived during the vomiting and purging of this disease. The restorative influence of the injected fluid was so strikingly apparent, and the expressions of relief by the sufi'erer so much surpassed expectations, that he was encouraged to persevere, hundreds of ounces having been thrown into a single patient in the course of a few hqurs. In nearly every case the same extraordinary relief was obtained, although, in the majority, it was only temporary. The journals of the period show that of fifteen pases of cholera-collapse, operated by him, one-third recovered. I will here quote Dr. Latta' s description of the phenomena observed during the injections :■ — '^ There is at first but little felt by the patient, and the symptoms continue unaltered until the blood mingled with the injected Kquid becomes warm and fluid. The improvement in the pulse and coun- tenance is almost simultaneous ; the cadaverous expression gradually gives place to appearances of returning animation j the horrid op- pression at the praecordia goes off; the sunken, turnedrup eye, half covered by the palpebra, becomes gradually fuller, till it sparkles with the brilliancy of health ; the livid hue disappears j the warmth of the body returns, and it acquired its natural colour ; words are no more uttered in whispers ; the voice first acquires its true choleraic tone, and ultimately its wonted energy ; and the poor patient, who but a few minutes before was oppressed with sickness, vomiting, and burning thirst, is suddenly relieved from all distressing symptoms." Every observer of venous injection in cholera, will admit that this forms no exaggerated picture of the primary effect of the process upon many apparently hopeless cases of collapse. Many practitioners followed Dr. Latta's example. Dr. Tweedie may be mentioned, in whose hands one case in four is reported to have recovered. Dr. Craigie, of, Edinbiu'gh, who had one recovery and one death ; Dr. Murphy, two recoveries and one death ; Dr. BY THE INJECTION OF SALINE FLUIDS, ETC. 135 Girdwoodj four recoveries and three deaths, and Mr. Arthur, of Shadwell, thirteen recoveries and five deaths. In 1833, 1 was induced to add alcohol to the solution injected, in consequence of the small and transient reaction, I had once or twice observed after the injection of common salt, carbonate of soda, and chlorate of potash. The reaction after injection of a mixture of hot water, salines and alcohol, was more lasting than after injection of water and salines only. I have notes of six cases injected at this period, aU of which suc- cumbed. These attempts were made upon the most unpromising cases of collapse j they were usually done with all the haste, imperfections of injecting apparatus, insufiiciency of assistance and other disadvan- tages attaching to the treatment of malignant cholera-coUapse, at that time amongst the poor at their own inconvenient abodes. When we take into consideration the difiB.culty of determining with any approach to accuracy, the proper density of the fluid to be intro- duced into the altered blood of cholera patients, without risk of the injury to blood-corpuscles^ and possibly to other elepients of the blood ; the paucity of reliable analyses of the blood of cholera pa- tients ;■ the difSculty in making arrangements in private houses and temporary cholera hospitals, for due preparation of materials ; the imperfection of the injecting apparatus employed, we may justly ex- perience surprise at the number of recoveries which rewarded some operators, rather than at the number of deaths which sometimes succeeded the operation. Notwithstanding the unfavourable results^ of my own injections in 1832, 1 retained a vivid impression of their temporally beneficial effects, and could not avoid the conviction that an agency, capable of beneficially modifying the hunjan organism, even for a short time only, would, after due investigation, be found to possess a thera- peutic value. On the re-appearance of the epidemic in 1848-9, I did not anticipate being enabled to cure cholera by venous injections, but that we might be able to save some lives that were inadequately struggling into reaction. Observation of large numbers of cases of the collapse of malignant or Asiatic cholera shows that, whatever plan of treatment may be adopted, about one half of those who reach this stage do not recover. It may be said, of malignant cholera, as of malignant scarlet-fever, or malignant small-pox, that of each hundred cases, whatever be the 136 DE. LITTLE ON THE TREATMENT OF CHOLEEA, plan of treatment resorted tOj a given proportion will sink under the disease, a given proportion will recover, and a third proportion will consist of those cases in which the termination in recovery or in death wUl depend npon the remedial measures employed by the physician. It is humiliating to think, that . in the collapse of cholera, until a specific antidotal treatment shall be discovered, the proportion of cases, which the art of medicine can claim to be capable of essentially modifying so as to incline the balance of life in the right direction, appears to be very small. There is a powerful incentive to inquiry, and experiments in the fact that about 50 per cent, succumb, in spite of any treatment hitherto applied. The greater number of physicians who have resorted to venous injections in cholera, have recommended their employment at a com- paratively early staged before the coUapse of this terrible disease, had become most intense; and, probably, the larger proportion of re- coveries, sometimes witnessed, has followed this practice. When we compare the results obtained by different observers from performance of an heroic operation, whether it be paracentesis — thoracis, tracheotomy, venous injection, or others, we require to take fuUy into account the difference in the state of the patient, according as the operation is undertaken at an early or advanced stage of the disorder. These operations are inapphcable before the danger of prompt death from asphyxia, asthenia, paralysis of lungs and heart is imminent. It is probable that whatever of good is realizable from the operation is more readily obtainable before the secondary distur- bance of those important organs, which are apt to be involved as the disease progresses, has occurred, and that whatever of ill the opera- tion itself induces, if any, is more readily withstood and overcome when the powers of life are not too far exhausted. These considerations, doubtless, have often prompted to the per- formance of operations which are of uncertain permanent benefit, and not themselves exempt from risk to the economy. Until expe- rience has confidently determined whether, and when, in any early stage of disease, any of these operations should be performed ; the sole justification, in my opinion, for their employment, is, that prompt death is imminent, that great relief to the patient's sufferings can be afforded, and that life may at least be prolonged with comfort and advantage to the patient and bis friends. BY THE INJECTION OF SALINE FLUIDS, ETC. 137 At the London Hospital, in 1848-9, owing to the means placed by the executive at the disposal of the medical staff, the zealous co-opera- tion of the then resident officer, Mr. Burch, and the gentlemen, stu- dents of the Hospital, some of whose names are attached to the cases, I was enabled, during the progress of the epidemic, to make arrange- ments for trial of venous injection under favourable circumstances for testing its value, and, in some of the instances^ of personally superintending the case throughout all the stages. My first mea- sures, accordingly taken, were to ensure perfect purity of the water employed, such as those of distillation and filtration, and perfect cleanliness of all the vessels employed. The materials,* in solution, were kept, after filtration, in sufficient quantities ready to hand in glass-stopped bottles ; the thermometer employed to indicate tempera- ture of the fluid, during the operation, was applied in the method hereafter described so as to enable the operator, during the whole process of injection, to watch that a proper unvarying temperature was, as far as possible, preserved in the reservoir which supplied the injecting syringe, and lastly, this reservoir was brought as close to the syringe as possible to prevent loss of heat, and, in fact, so attached to the syringe, and above it, as to cause the fluid to find its way into the syringe more by gravity than by suction, and thus diminish the risk of air being drawn into the syringe whilst filling it. For the same reason, instead of employing a syringe furnished with valves as in the ordinary stomach-pump or enema syringes, to direct the fluid out of the reservoir into the syringe, or out of it into the vein, I employed a syringe with a single common cock (a, see diagrams), but with two apertures, one (b) leading to the reservoir, * See page 145. 138 DR. LITTLE ON THE TREATMENT OF CHOLERA, and one (e) leading to the vein. A finger-piece or tap was within reach of one hand of the operator, or could be turned by an asiistantj which when turned as required, enabled the fluid to pass from ^the reservoir into syringe, and thence into vein, as required. The tube (d), introduced into the vein, was attached immeckatel^ to the cock. Thus, as the accompanying woodcut shows, all connecting tubing, and unnecessary junctions were dispensed with. The body of the syringe (e) was formed by an ordinary thick- walled brass anatomical syringe, capacity of, about two ounces, well tinned inside. The conical reservoir (f) was made of brass, silvered within, and thickly coated outside with caoutchouc to render it a non-conductor of heat. I found the thickness of the metal, of which a good anatomical syringe is made, was not easily cooled down. I should have covered this also with caoutchouc, but that I preferred the operator, holding the syringe, should be able to feel any acci- dental considerable change in temperature of contents. Lastly, (g) represents a small mercurial thermometer, the frame constructed of ivory only, placed in the reservoir, and, consequently, always under the eye of oper^or and assistants. I may mention the fact, that in all the successful cases, the improved apparatus, with the precau- tionary measures described, were employed. Some of the unsuc- cessful cases were injected before I made the improvement described. I am here writing from memory only, so let the statement stand for what it may be worth. I may mention, that in 1832, 1 employed the same anatomical syringe, but with two one-foot lengths of elastic wire- wove varnished tubing, the use of which preceded the introduc- tion of caoutchouc tubing, to connect the syringe with the vein, on the one hand, and with the common basin containing the fluid to be injected, on the other hand. In anticipation of the epidemic of 1848, 1 provided myself with an apparatus siioilar to BlundeU's Gravitator for passing blood into a vein (see Lancet ci/rca 1828), but discarded it in favour of that which I constructed as above re- presented. I had a sufficient hint in 1833 of the importance of taking extra precautions against injecting air into the vein, in finding in one post-mortem a larger quantity of air in the heatt than was satisfactorily explicable as an orthodox necroscopic phenomenon, one at least said to be sometimes met with in death from cholera when venous injection has not been resorted to. BY THE INJECTION OF SALINE FLUIDS, ETC. 139 In passing, I may recommend my venous injection apparatus to obstetricians called upon to inject blood into the veins. It would require to be of much smaller dimensions than for cholera salino- alcohoUc injections. It will be observed that the construction of the above injecting apparatus necessitates employment of time in turning successively the tap, in watching that it ia correctly turned in order that the stream be not drawn out of the vein instead of from the reservoir, and in noting the temperature of the fluid, and in watching the effect of the introduction of the first ounce, and succeeding ounces of the fluid. This occupation of time is highly important and bene- ficial, as it ensures a slower and more gradual injection of the fluid. I am persuaded that great errors have been committed in too rapid in- jection, and also in the injection of much too large a quantity of fluid. It was at first difiicult to resist introduction of too large a quantity j the primary beneficial influence of one or two pints was so surpris- ing, and so promptly perceived, that the physician was, I believe, often tempted, under the influence of a well-known physiological fascination, to pour in pint after pint, to a dangerous and fatal extent. Medio tutissimus ibis is true in this as it is in the apphca- tion of many ordinary therapeutic agents, It will be observed that in two of the successful cases, comparatively moderate quantities, were injected. Case I. — Malignant cholera.-— August 15th. Seized 11, a.m. with diarrhoea, vomit, cramps, absence of urine. Three p.M.-^A-dnjitted in coUapse. Six P.M. — 'Injection, ^'s.^. Second injection attempted. Death witho\it temporary rallyiijg. C. F. C, aged 40, coppersmith, MUe End New Town, admitted at 3 o'clock P.M., August 15th. Extremities cold and livid, sMn corro- gated ; pulse at wrist barely perceptible; tongue cold; temperature about 85°; voice husky; features shrunk; eyes sunken. States that he was suddenly seized at 11 a.m., with purging and vomiting, attended with some cramps; since the seizure had not passed any urine, complains of pain, and a sense of constriction over the chest and prsBCordium. The remedies immediately exhibited were : Ammon. sesqui.^carb. 140 DE. LITTLE ON THE TREATMENT OE CHOLERA, gr. iij. Murray's solution of Camphor |j. eyery half-tour. Cataplasms of mustard with turpentine and vinegar over the chest and abdomen. Epithem of turpentine and vinegar to the lower extremities, which were at the same time freely rubbed with a coarse cloth. Iced drinks were given to allay the insatiable thirst. At six o'clock he was seen by Drs. Cobb and Little, when he appeared to be fast sinking into a state of hopeless collapse. Under their super- intendence the mid-basilic vein was injected with the saline solution to about seventy ounces. A second injection was soon after attempted, but he rapidly sank. Case II. — Malignant cholera. Saline injection with alcohol Jcclxv. Death. August VltA, 8 a.m. Attacked in abdomen by pains and cramps. Noon. — ^Admitted into Hospital in collapse. One P.M. — Injection into veins^ ^Ixxx. Half-past four p.m. — Re-injection, Jlxxiv. Pive P.M. — Small quantity of urine passed, about Jiss. Eight P.M. — Ee-injection, |cx. Quarter past eleven, p.m. — Death. Joseph Wood, aged 26 years, a clerk, was bought to the London Hospital on August 17th, 1849, and there left without friend or relation to give any account of the attack. States that about 8 a.m. he was suddenly seized with violent pains, chiefly in the abdomen and legs, though occasionally the cramps extended to the arms ; constant vomiting and purging, quite unable to attend his duties, and when so discovered by his master, was brought to the Hospital about 12 o'clock. He was cold, both surface and tongue ; pulse scarcely perceptible, severe cramps in the legs and arms ; violent pain of body ; nausea, but no vomiting ; hands shrivelled, of a dusky blue colour; face of an ashy paleness; voice a mere whisper; intellect perfect; ordered Murray's solution of Camphor, with Ammon. sesqui.-carb. g. v. About one p.m., when quite pulseless, an injection of eighty oxmces of warm water, temperature 115°, Fahrenheit, was thrown into the median cephahc vein ; the water con- tained the usual quantity of salts and alcohol. The skin directly became warm, the pulse regular, 120 per minute, the patient to speak distinctly ; lips became red, instead of livid ; the temperature under the tongue 90° Fahrenheit, instead of 85°, at which it was previously. Three p.m. — Passed an immense rice-water dejection to the amount of BY THE INJECTION OF SALINE PLUIDS, ETC. 141- fifty ounces ; the pulse rapidly diminished in strength ; but increased in freqeuncy up 160 beats per minute. Half-past Four. — Vomited for several minutes ; pulse imperceptible at the wrist, scarcely perceptible in the arm ; had ^Ixxir. of fluid in- jected, when he again improved in every respect, and a few minutes past five P.M. he passed a small quantity of water, about three table- spoonfuls. Eight P.M. — Rapidly sinking, quite unconscious, and apparently with- out pain ; was again injected to the amount of 110 ounces which par- tially revived him. He spoke French fluently, and muttered about the pleasures of VauxhaU, but never recovered his consciousness. Ten P.M. — Pulse very small and very quick ; surface cold, and bathed in cold sweats ; countenance ghastly. Eleven p.m. — Pulse a mere flutter. Quarter past Eleven. Died without a struggle. We have since learned that he was a man of very intemperate habits. Case III. — Augmt, 1849. — Malignant cholera, preceded by con- stipation, provoked by a calomel and colocynth piL. Two injec- tions of saline alcoholic fluid ; the first of gxl, the second of gxxx. Death within twenty-four hours after seizure. Miss J., aged 21, previously chlorotic, living in a house almost sur- rounded by one of the numerous streams at Stratford, Essex, which leaves at every tide mud-banks largely exposed, attended the funeral of her aunt who died of cholera. At bedtime the same evening, the bowels having been for some days confined, such being her habit, she took a calomel and colocynth pill. On the following morning she was disturbed by the action of the pUl ; the looseness, however, did not subside after the ordinary action of the aperient pUl, but, on the contrary, at 9 a.m. the purging and depression of strength were so violent, accompanied with occasional sickness, as to cause apprehension of cholera. I visited her at noon when I found her prostrate, cold, almost pulseless, without much discoloration of surface, indifferent to sur- rounding objects, but capable, when aroused, of giving the above history of the commencement of her illness ; occasionally cramped. The pill had been administered by her father, a manufacturing chemist. The plan of treatment, the particulars of which I am unable to re- member, consisting, I believe, of small doses of calomel and opium, with 142 DR. LITTLE ON THE TREATMENT OF CHOLERA, draughts of camphor, sether and ammonia, which had been commenced by the gentleman already in attendance, was recommended to be continued. I revisited her at six p.m., collapse was then complete ; pulselessness ; livid pallor of face ; deeper discoloration of extremities ; extreme cold- ness of surface and tongue ; greater difficulty of arousing her ; respira- tion, heaving unfrequent ; death apparently near at hand. Between seven and eight, p.m., she was injected with usual Saline alcoholic fluid, ad ^xl. The pulse returned at each wrist, the face and surface generally became warmer ; she expressed herself better, especially that she was relieved from the oppression of breathing, and from the epigastric pain. She also vomited ' once shortly after injection. She was advised to take diluted wine, milk-and-water. External application of warmth to be continued. Before eleven, p.m., she had relapsed into collapse. Looseness of bowels returned. I ordered immediate re-injection, and regretted that it had not been earher repeated. The obstacles to resort to venous in- jections in a private house were apparent ; notwithstanding the patient was in the house and near the factory of a manufacturing chemist (a presumably favourable circumstance), difBculty was experienced in obtaining a proper supply of hoi filtered water. Thirty ounces of fluid W6re, howeVer, thrown in ; agaim benefit was expressed, the rally was however less marked than at first operation. Amelioration continued during an hour or more, until after one a.m. ; the gentleman in charge of the patient endeavoured to inject for the third time, she sank, however, before completion of the process. The assistants at the operations, and the parents, were convinced that fife had been protracted, and relief, with an additional chance of life, afforded by the injections. Case IV. — Cholera-collapse ; venous injection ^xxv. Aggrava- tion; death. A poor Irishwoman,, age about 45, fruiterer, name unknown, admitted into London Hospital about noon ; she had been to market the same morning. Admitted in extreme collapse ; indifferent, restless, very cold, pulse- less and inky ; much cramped, skin having the soddened feel peculiar to sudden collapse. The alarmingly rapid progress of the case, and the probability of very prompt dissolution — ^the whole of the cases admitted into the Hospital about this time having presented extraordinary malig- nancy — led to attempt to procure reaction by venous injection. BY THE INJECTION OF SALINE FLUIDS, ETC. 143 At two P.M. operation commenced ; she complained, however, of so great pain in the right side of, chest, about the seventh or eighth rib, that I caused the operator to desist. Pulse returned feebly to wrists, and some warmth was communicated, but the respiration became more diffi- cult ; she became insensible, and died about two hours afterwards. The only case of injection witnessed by me in which the condition of patient was aggravated by the process. Her Irish relatives prohibited post-mortem examination. Case V.— Malignant cholera. Saline injection |xl. Death. August %Mh. Seized with diarrhoea, and vomiting since midnight. No premonitory diarrhoea. Quarter past six, a.m. Admitted into Hospital. Most rapid collapse. Half-past six, a.m. Saline injection with alcohol, 5x1. No rallying. Death about one hbur after completion of injection. August 24:th, 1849, half-past ten o'clock, a.m., J. W., mariner. No relaxation of bowels yesterday, taken seriously ill at four a.m. (had been drinkiag spirits and beer until midnight ; nose bruised as if during drunken brawl). Admitted into London Hospital at quarter-past six, fair pulse at that time ; very Copiously purged ; no sickness at any time. Jactitation extreme ever since admission until last half-hour. At present, colour very dark everywhere ; coldness universal ; hiccup ; pain in left side (sinapism) ; slight tremor of pulse in left wrist ; tem- perature under tongue 78°. Respiration 44; moaning; eyes partly open ; no motion since quarter-past eight a.m. ; condition aggravated every minute ; pulsation at brachial and carotid just perceptible ; opera- tion of injection by Mr. Eeynolds ; injection of Jxl. completed at eleven A.M. Copious perspiration of face and neck ; lies easier; colour of lips shade better ; temperature of tongue 86° ; face less Hvid. Hands mottled, deep red and mulberry; slightly stupid ten minutes later; pupils sluggish. Previously to operation one drop of thick black blood oozed from the arm ; at the conclusion of operation half-an-ounce of dark but thinner blood escaped. Death about an hour afterwards.* * A case of cholera unsuccessfully injected at London Hospital, in October, 1848, is reported, with the post-mortem examination, in the Lancet, Sep- tember 8th, 1849. The author ventures to refer the reader to the notes attached to that case. 144 DR. LITTLE ON THE TREATMENT OF CHOLERA. Case VI. — Malignant cholera. Saline injections with alcohol, 350 ounces. Recovery. August \1th, 1849. — Diarrhoea and vomiting. Admitted into Hospital 13th in complete collapse. Urine absent before noon on August 13th j secretion restored, August 15 — 16. \Mh. — ^Five, p.m. ; saline injection with alcohol |lxxx. Eight, P.M.; re-injection ^Iv. Midnight; re-injection about |lxx. 15^^. — Eight, P.M. ; re-injection about Jxlv. %%nd,. — Quite convalescent. Bemaiued in Hospital under observation a month. Cured. August, 1849. — B. P., aged 22, seaman, recently arrived in packet ship Victoria from New York, where at his departure, cholera pre- vailed, since resident near the river, was attacked with diarrhoea on 12th, succeeded by urgent vomiting, increased purging, and prostration. On Monday 13th, at midday, he was admitted into London Hospital under the care of Dr. Little, on Monday at five o'clock, cold and pulse- less, urine reported absent since the morning. A single draught on admission containing a few drops of laudanum and aether, and one five grain dose of calomel, succeeded by smaller doses, were the' internal remedies resorted to, his condition nevertheless became aggravated ; and on afternoon of Tuesday 14th, report was made to the effect that no pulse had been distinguishable in radial or brachial arteries, and no urine passed since admission ; the inky blueness of face, hands, and feet greater than in many fatal cases of Asiatic cholera, presenting with the sunken eyes, feeble, almost inaudible voice, and indifference to surround- ing objects, with the cold, damp surface ; the tongue at 82° F., and the sluggish, rare, thoracic heavings, as profound* a case of collapse as ever * The intense symptoms of collapse which rapidly succeed the onset of cholera, should he distinguished from that profomid collapse, observed a few hours later, when death is thus postponed, The accession of symptoms of collapse is often followed by transient returns of pulse and warmth, even in the cases ultimately fatal. ' A disproportionate degree of danger is some- times attached to first symptoms of collapse. The suddenness of invasion and rapid development of the symptoms temporarily overwhelm the system, reminding the observer of the phenomena exhibited on sudden profuse fatal hasmorrhage, viz. : rapid syncope, sometimes immediately fatal ; at other times, partial rally, return of syncope, the condition of the patient fluctuat- ing so long as life remains. The points of analogy between cholerarcollapse and that from hsemorrhage may be carried farther than the dissimilarity in the external appearance of the suffferers from these conditions would indi- cate. At the outset of collapse we should never despair of saving the patient BY THE INJECTION OF SALINE J'LUIDS, ETC. 145 witnessed. Some hours previously voinutiDg and purging had ceased. Distressed and humiliated, as must be every physidan who is doomed daily to witness the inefficiency of art to rescue from death a cholera patient in the prime of life, apparently of naturally robust constitution (with the aged or previously diseased subjects of cholera thp medical practitioner rday become reconciled to succumb in the contest with death), I resolved, after my colleague Dr. Eraser, and Mr. Burch, the resident medical officer, had agreed in pronoundng the case hopeless, to afford an additional chance of life by resorting to injection into the veins of a mixture of saline fluid with alcohoL The ingredients used were, Sodae Hydroohloratis, 5iij . ; Sodse Sesqiai- carb., 9ij. Aquae distill., f cxx., carefully filtered, and subsequently heated. To each imperial pint (f xx.), immediately before injection, at temperature of 110° to 115° P., two drachms of alcohol were intimately mixed by stirring. The injecting tube was introduced by the right median cephalic into cephalic vein (the patient taking no notice of the incision of the integuments, and the early steps of the operation), and the fluid gradually impelled onwards. After introduction of about f xx. the respiratory movements were observed to be more frequent. After a longer pause than that observed after each syringeful of about ^ij. was propelled, by the employment of difiiisible stimuli, external warmth, internal warmth by enemata, maintenance of recumbent position as far as practical, sinap- isms to chest and abdomen, and energetic frictions to the general surface, not forg'etting to comply with the natural craving for diluent Cold bever- ages. .But profoimd collapse, of hours' duration, although oooasionally re- covered from, probably owing to previous integrity of the more important organs, and consequent inherent vigour of constitution, has been justly re- garded as intractable to medical skill. What can rationally be expected in profound collapse, from calomel or other medicines applied to the tissue of the stomach, already almost as inanimate as marble, or as a dead animal- membrane in which porosity remains, but in which capillary circulation and absorption are impossible ? Opium is objectionable in large or fre- quently-repeated doses, when not rejected hy vomiting, as in the event of reaction it compUcates and aggravates the subsequent stage of the disorder. Post-mortem investigations of cholera show no deficiency of bile in the gall-bladder, so that non-secretion of bile cannot be regarded as cause of collapse, and on this account it is difficult to acknowledge the necessity for calomel during collapse. On the other hand, in the diarrhoea believed to be premonitory of cholera, but which we cannot assert, will, or wiU. not, if unchecked, pass into malignant cholera, the ordinary treatment consisting of calomel with opium is, upon all rational ideas of pathology of diarrhoea, advisable ; moreover, it may be prudent to use it even if superfluous, since so large a number of observers speak favourably of it. I. 146 DR. LITTLE ON THE TEEATMENT OF CHOLERA other Jjcx. were thrown in — still no rapidly perc^tible change in patient's condition. On inquiry whether the process was painful, he said, " it felt warm," that "it gave him no pain." Once he mentioned that it felt ".hot, "and applying left hand to chest said that he felt " better." After about Jxxx. were thrown in, the pulse was perceived comparatively full at the wrists and temples ; it was now evident that the stream had not, merely reached the right side of the heart and the pulmonic circula- tion,, but that it had permeated the lungs, and had attained the left side of the heart and the systemic circulation. The effect of the continued injection was carefully watched; after about ^Ixxx., containing one ounce of alcohol, had been introduced, the expired breath was believed to be warmer ; patient, when asked, contiaued to express himself relieved, and a few fine drops of perspiration were noticed on the lower part of the forehead. The process of injection was now discontinued. Shortly the colour of the slrin above the eyebrows improved, a dingy red taking the place' of the inky blueness, the cloud of darkness disappearing up- wards, the redder hue superseding it, sjlcceeded in a short time by dis- tinct return of warmth in the forehead. The pulse beat softly and fuU at 88 ; respiratory movements more complete ; expression of face im- proved, although colour of this part was still dingy; eyes less depressed ; voice clearer. Ordered weak wine-and-water or milk-and-water, cold or tepid at pleasure ; warm bottles to feet and legs. At half-past six p.m., it was evident from the . steady character of pulse, the gradual increase and persistence of warmth, the improved colour of surfsiee, and general expression of improvement', that the injected materials had not merely, by their chemical composition, affected the colour of the circulating fluid, or raised the temperature by imparting the contained caloric, as the quantity of disengageble caloric in eighty ounces of injected fluid, was clearly insufl&cient to maintain, during the time that had elapsed since commencement of injecting process, the augmented temperature now observed in the body that previously pre- sented an almost cadaverous doldness. It could not be doubted that the injected materials had resuscitated the capillary system, and the power of generating animal heat. At eight P.M. other fifty-five ounces ; and at midnight about seventy ounces were thrown in. During the night he occasionally vomited, and purged a black-greenish fluid. On the loth, it was reported that he twice vomited, and purged the same black-green fluid ; the pulse, colour, and temperature, being maintained nearly the same as throughout the previ- ous evening. Towards night the pulse was again observed to flag, the tern- BY THE INJECTION OF SALINE FLUIDS, ETC. 147 perature and colour of the face and extremities to be less favourable ; the injection was, therefore, repeated to the amount of about forty-five ounces. August 16iA.— Half-past nine a.m. Is quite sensible, but little sleep during night ; complains only of tenderness when epigastrium is pressed; no headache. Is heavy-eyed, incipient injection of conjunctivae, colour of surface almost natural, being only slightly purplish ; hands cool, feet warm (hot bottles are apphed to the feet). Observed thafr veins of lower extremities present the natural fulness contrasting with : the indistinctness of these vessels in the stage of collapse. Temperature of mouth 93° F. Tongue moist, coated, slaty-brown, cleaner at edges, no vomiting ; two very dark copious fluid motions since yesterday ; hiccup after swallowing any article whatsoever. States, that he voided urine yesterday and this morning with the dejections. Has had no lumbar pain since the injections into the veins. Pulse 96, moderate." Was removed last evening whilst bed was made. Has taken two pints of milk with half-a-pint of sherry during twenty-four hours. Half-past seven p.m. — Feels " very well considering." Hiccup con- tiaues ; colour good ; temperature moderate ; tongue feels cooler ; oc- casionally vomits and purges, the former greenish, the latter more yellow. Vlth. — Half-past nine a.m. Evidently takes an interest in his his recovery (unlike cholera patients when severely affected) says, " I do not feel so well as I did yesterday ; " aspect nevertheless more favourable than last night ; slept occasionally ; colour and temperature good ; fore- head warm and soft ; no sweat ; veins moderately distended ; vomited matters stringy ; expulsion of matters from stomach and- rectum twice, usually simultaneous. Pulse 72, weak ; mouth 92° P. ; tongue rather dry, improved in colour. Has no pain, except at front of elbow-joints, where injections were effected ; continues barley-water, iced-water and beef-tea ad libitum; medicine recently taken consists of Ammon. Sesqui- carb. gr. iij., ex Mist. Camph. f ss. alt. quaque horS,. MUk, one pint ; wine, |iv. in twenty-four hours. Half-past four p.m. Half-pint urine voided apart from faeces. ISith. — Appears lower, but states that he feels better ; sleeps much ; lies quiet, principally on left side with left arm extended ; aspect that of convalescent from severe cholera ; pain in bowels ; colour and tempera- ture of surface good ; mouth 93° F. ; no hiccup ; pulse 72, moderate ; tongue .brown in middle, clean and moist at sides ; anorexia; motion and urine twice. A purulent discharge has trickled for an hour from right ear. Capiat. Ammon. ex Inf. Cinchonae ter die. Enema consisting of six ounces of Beef-tea every six hours. . 12 148 DR. LITTM ON THE TREATMENT OF CHOLERA, 20th^ — Gradually improved since 18tli. Dozes quietly, a large part ofday and niglit. Intellect quite clear; "feels recovering fast ;" lies ST^ime ; knees drawn up ; offensive sero-purulent discharge from both ears, frincipally from right, quantity diminished. Is rather deaf, colour and temperature perfect. Pulse 84, fuller and stronger; tongue as before ; slight sordeS about teeth ; no sickness ; one motion ; urine twenty-four ounces ; elbows Still tender ; one drop of pus from one of the incisions in left arm (there were two incisions in each arm, each iajectioii having been effected by a different vein) ; no inflammation. 21«t — " Well, I feel a little better to-day," he dozes much ; pulse 88, strong ; tongue and eyes as before ; readily takes fluid nourishment ; bowels unrelieved ; urine more copious ; wine intermitted until action of bowels. Haustus Magnesia c. Eheo. si opus fuerit hora-somni. 22nd. — Slept soundly ; • feels " better than yesterday " complains of right arm, which he bares for inspection ; no inflammation ; cicatrization slow. Remarked that eyes still appear touch sunken; colour of iaoe reddish-brown, probably heightened by former exposure to sun and air. Eyes bright, much less red ; pulse 78, full, quick ; bowels reheved three times without laxative draught. Ordered to be removed into a large airy ward on groundfloor, where other cholera patients are received. It should be remarked' that until this period he had remained in one of a series of small attic wards, originally set apart for cholera patients, where he had been exposed to injurious fluctuation of temperature during the night tad day, the thermometer during part of the twenty-four hours exceeding 90° F. 23rd. — Aspect much improved, " feels much better." Less active reaction than that observed in many cholera patients, who have recovered after having taken large doses of opium, or Murray's concentrated solu- tion of camphor. Pul^ 78, full ; tongue clean, moist, morbidly red and smooth ; motions fiefeulent, three since yesterday ; urine free. 2ith. — Sitting up in bed, " quite well, except weakness ; " says he has enjoyed a good baSin of bread-and-milk since 22nd. Pulse 80, full, soft ; respiratory movem < in the laat^ stage ^ fever, for example, sometimes in tetanus also, life appearg to be saved through the use of . stimulants in considerable quantities ; the apparent mode of operation of the stimulus beiiig to ^nourish? and exdte the heart, capillary system, and jiervous system, tp continue their functions, to prolong the struggle,: during which the,pQiso;n is thrown off by nature herself, or the morbid action exhausts itself, Salino-alcoholic venous injections may rank as. the most powerful stimulus to the heart, capillaries, and nervous , system we possess. During the extreme cold stage of chol^a,,:^edieinal agent;? are in vain introduced into the stomach, absorption is suspended; even the most powerful emetics, fail to excite vomiting when it feas i^ontaneously ceased. i Associated with the deprivation undergone in malignaijt cholera by the general system in. the loss of water, salt and albiuipiflous matter, from the blood, and probable deterioration of con- M 2 164 DE. LITTLE ON THE TREATMENT OF CHOLEEA, stituents of the blood in other ways which our present knowledge of the pathology of cholera does not enable us to specify, we need to remember as a cause of the fatality of cholera the non-renewal of the blood by cessation of ingestion, ab'terption, and assimilation of materials afforded by food. Nothing is more remarkable in cholera than the utter anorexia of the cold stage and the first stages of reaction. If the patient sink in the cold stage, before any signs of reaction have set in, the alimentary canal, from my own observation, in not fewer than twenty posi-moriems, is throughout utterly free from traces of food materials and faeculent matters, and as far as can be judged by the absence of colouring-matter of the bile, the contents of the intestines are free from any of the ordinary secretions of the canal. There is absolutely nothing in the alimentary canal, except a transparent watery fluid, or a slighily lactescent fluid, either holding in suspension small white flakes (albumen ?) the so- called lice,- water fluid, or the contents are a perfectly white pultaceous mass, almost as thick as " hasty-pudding," probably composed of a vast quantity of flakes in a small quantity of fluid. The full state of the gall-bladder replete with apparently normal bile-^attributed hypothetically by many to spasm of the gallrduct, simply because no bUe finds its way into the duodenum, and there happen to be spasms of the voluntary muscles caused by the sudden purging and sudden inanition resulting from it — is an indication that no food particles have reached the duodenum from, the stomach owing to aversion of the patient to imbibition of everything but cold water, and the incessant vomiting. As soon as vomiting remits and reaction commences, and the patient reluctantly takes any nutrient matter into the stomach, some food particles probably find their way into the duodenum, for at this stage bile is apt to appear in the secretions of stomach and bowels, and the facts I have before mentioned suggest that these change from an alkaline to an acid reaction upon test paper. The sudden copious vomiting and purging which, often after a few hours or days previous looseness of the bowels, js incident to, or ushers in the cold stage, offers in its rapidly prostrating effect an analogy with great sudden loss of blood. A large amount of looseness of bowels or even of vomiting, like large repeated haemorrhages from any part of the body, is better borne by the BY THE INJECTION OF SALINE FLUIDS. 165 economy when spread over a long period of time, than the same evacuations or loss of blood concentrated into hours or minutes. In like manner, during protracted states of disease — chronic affections of the stomach for example, arid severe fever — it is remarkable for how long a time life continues without risk of immediate sinking, although a Very small amount of nutriment is introduced into the system ; whereas a person struck down in the apparent plenitude of health,- as is commonly the case in patients affected with malignant cholera,- the sudden deprivation of assimilated materials derived from food to supply the waste of the blood, doubtless tends much to increase the mortality iri coUapse, as also when the patient in- effectually struggles several times into inaction before fintcUy sinking. Now, however useful injections of water-Salts and alcohol into the blood may some day be proved to be, they afford but a poor pabuluni on which the economy is to subsist during the exhausted attenuated condition of severe cholera* 1 regard one value of such injection as Analogous to the value of diluted brandy in fever and many states of exhaustion, of the highest impiortance at the time, to rouse the heart and nervous system into action ; but ultimately powerlessj unless it can be followed by articles of food and their digestion and assimilation. It has been proposed to supply this presumed need of nutrient matter in the blood of cholera patients, by injecting albumen (white of egg) dissolved in the saline fluid. - I am not aware of any recoveries from this method. When cir- cumstances permit^ I would advise trial of the serum of the blood of animals ffesh drawn for the purpose, and mixed with the ordinary saline injection. In conclusion, I may add that, although I regard various injec- tions as useless when the patient is actually moribund, as indicated, for instance, by tracheal r^le, it is in the present state of science only justifiable, when, in addition to the ordinary severe symptoms of severe collapse, jactitation, disturbance of breathing, denote the interruption of function, even at the centres of the circulation, and the heart itself. When determined to resort to it, the physician or surgeon should be prepared to take close charge of the patient, and. not quit him, as may be safely done after many operations, when nature once re- Ueved, will, if unmolested, take care of herself. The quantity of 166 DB. LITTLE ON THE TREATMENT OF CHOLERA, fluid injected should be moderatej although the cases n^rated in this paper, show recovery took place ia one case, where at the first oper- ation eighty ounces were thrown in ; in another case forty ounces ; in a third thirty ounces. I regard forty ounces as a moderate quantity. If the patient be at first greatly relieved, but again col- lapses in two or thi'ee hours, or after four or five hours the opera- tion should be repeated. Sometimes, when before the venous injection, the patient has passed with difiiculty, now and then, a few tablespoonfuls of fluid and a small drain only from the bowels has been going on, it happens that a feW minutes or half-an-hour aftet the venous injection, a copious rush of charactieristic cholera vomit" occurs, perhaps almost equalling in quantity to fluids injected. It has sometimes seemed as if the energetic vomiting coincident with return of pulse, and better temperaiture and colour, and the patient's statement of improvement from the operation might be attributable to the patient beihg already lifted by, the operation from his extreme stage of collapse, in which the was immediately before .the operation> to the state in which he was sometime before he became so much collapsed as to have warranted the operation. I would advise repe-i tition of the injection after this re-appearance of' copious cholera discharges, and, indeed, as often as collapse may return, and tempo- rary improvement from the operation, reward our exertions. In most disfeases, in malignant cholera especially, I am convinced,- despite the great mortality which attends severe collapse, under any plati of treatment, that recovery, other things being equal, is in pro* portion to the attention paid to the patient by his fliedical adviser, by the patient's friends, and by the subordinate attendantsJ ■ Much may be done in the cold stage by the constant supply of cold water, by administering it to him, instead of allowing him to ex- haust himself by rising into semi-erect position to take it> or by attempts to leave his couch to go to stbol^ by warm cataplasms and sinapisms to the suffering prsecordia, by stimulating, assiduous fric-« tions to extremities and trunk, sometimes by hot-ait bath and warm bath, when the patient will tolerate heat, and can be placed in the bath without exertion on his own part ; by wo/rm gruel or thin beef- tea injections per anum^ ktept uj> by the hand of the nurse. Whilst the patient is struggling into reaction, much may be ac- complished by preventing the dissipation df animal heat, by admin- BY THE INJECTION OP SALINE FLUIDS. 167 istration of diluted liquid- nutriment in very sinaU quantities at a time, by injections of beef-tea per aniim, by very diluted alcoboHc beverages, perfect constant recumbency, very cautious augmentation of diet, and by a gentle and considerate medicina sytnptomatorum. Happily the violence of reaction is much diminished since there has been less resort to opium, brandy, camphory and ammonia, than was formerly recommended during the earlier stages. In many cases the rapidity of convalescence appears temarkable When the violence of the attack is considered. I have not designed in this paper to enter fully into the treatment of cholera, or aUude in detail to the indirect methods of treatment recommended at various times iminediately befote, and sincfe the first invasion of malignant cholera in 1832. One of the cases related in this paper well illustrates a danger which springs from the administration of active purgatives during "cholera epidemic." It is that of the young lady whose attack was determined apparently; by an active ^perieit pill. I have also witnessed a rapidly fatal case of cholera determined in an eldetly .gentleman by an aperient pill taken at bedtiine. Such facts do not encourage the' hope that, the in- direct treatment of cholera by purgatives, a plan advisable sometimes in ordinary English summer cholera, is , safely, applicable to the treatment of malignant cholera. My experience, on the contrary, leads me to warn my medical friends against the castorroil plan recently recommended. , The . saline treatment of Dr. Stevens is borne well, and is .grateful, to the patient. Borne conclusions as to venous injections m general, derived from the study of the above cases, and from, the history of the opera- tion {see note at end!). , , The surgical part of the operation of infusion into the veiiis> and transfusion, if performed with due precautions, is not of itself dangerous. Ca:tain substances in solution, and certain fluids, may be injected into the veins with impunity. In certain disordered states, in which in the balance of life and death, the scale greatly inclines in an unfavourable direction, certain 168 DR. LITTLE ON THE TEEATMENT OF CHOLERA. elements of the blood, deficient in quantity, such as water and salts, may, by means of venous injection, be introduced with advantage directly into the circulating system. Injection of alcohohc fiuids into the circulating system, is a powerful means of exciting the action of the heart, the general capil- lary and nervous systems under circumstances of great depression of these actions. Under circumstances of great exhaustion, such as that offered by collapse of malignant cholera, by profuse hsemor- rhage, — fevers? when advanced structural alterations of important internal organs do not exist, life may be temporarily maintained by venous injections, or by transfusion of human bloodj until other remedies act, or the disease subside. In certain cases where medicinal agents caiinot be adequately introduced by mouth or anus, or when the mucous membrane is insensible to their action, or absorption is arfested, their fullest effort may be obtained by injection into the veins. Venous injections may operate, not only dirfectly through the changes effected by it in the blood, and by directly stimulating the venous, cardiac^ pulmonary and cerebro-'spinal tissues, but indirectly by the reaction they sometimes excite in the economyj such as vomit- ing, purging, perspiration. As a promptly beneficial result in cholera collapsej venous injec- tions certainly remove the remarkable congestion of the disease, and when the relief is more than temporary^ they are followed by a return of an important secretion, that of the urine. Every advance in our knowledge of the intimate pathological com- position of the blood, will facilitate the determination of the states of disease in which venous injection may advantageously be employed.* • For an epitome of the history of Venous Injections, since shortly after the time of Harvey to the present day, consult the author's paper read before the Hunterian Society in 1852, and afterwards printed for private circula- tion.. CASE OT* POISONING BY THE EXTERNAL USE OF BELLADONNA. BY R. GOSSET BROWN, M.Dj On December ilih, 186S, I received a note ii6m a lioble lord staying at one of our colossal hotels, — written partly in ink, pattly in pencil aiid diagonally over the paper,-^aSkin^ ine to visit him, as all objects appeared iiidistin6t oi: doUblfed. On the day btit one before I had presfcribed aU embrdcatidn containing two diachms of the Liquor Belladonna in two ounces of- gba|J liniment for Whooping cough, for which he had Come td tdwn to consult die; Oii my arrival I found well-marked symptom^ of the imbibition of Belladoniia ; the pupils dilated to thfeir fullest exteht. He had placed some lettets at the extremes end of the room because he could read nothing except at this remote distance, his countenance w&S anxious, and he spoke etcitedly. His pulse Was 126, small and cdmpressible. I at once explained that these symptoms were due to the Belladonna, and wrote a prescription for another embrocation, leaving out that ingredient. Next day (28th), a partneir in his solicitor's firm summoned me very hurriedly, and on reaching the hotel I foiind the manager and one of the directors aWaiting my ilrrival. In the meantime his lord- ship had been seen by a physician, learned in psychology, who had duly signed a certificate of insanity. Another medical friend, hap- pily unable to attend, had been requested to fill up the second form, and three keepers were present to perform their duties. Unfor- tunately the embrocation containing Belladonna, the use of which I had strictly forbidden, had been again applied on the evening of the 27th. In the course of that night the patient fancied he saw a 170 POISONING BY EXTERNAL USE OF BELLADONNA. woman lying on the sofa in his room, an old woman covered with vermin in the corner, and some one else inside his wardrobe, which he had carefully locked to prevent the possibility of escape. In order to discover how these visitants had found access to his room, the door of which was fastened, he had chmbed to the top of the ward- robe, and in this position was found by his valet on going to call him. Before visiting the patient I explained to those present that the effects which had so much alarmed them and had induced them to send for the learned psychologist, were due to the Belladonna, and would vanish immediately on the disappearance of the charac- teristic symptoms of that drug. On seeing my patient, I found the symptoms of the previous day much augmented. I at once dismissed the three attendants, but after a consultation with the physician who had given the certificate, resolved to leave one man with our patient for the night. Next morning I found all the symptoms of poisoning gone, and my patient quite disposed to talk freely upon the incidents of the preceding days; upon one point, however, he was certain, viz., that there had reaUy been an old woman covered with vermin in the corner of the room, for he had placed a vessel over one of the insects crawling upon the ground. I challenged him to produce the animal, when (upon his very cautiously raising the basin) to the amusement of both, a small piece of down which had escaped from the pillow appeared. The whooping-cough soon disappeared, and a visit to the Continent restored him to health very rapidly. Although I have constantly prescribed Belladonna externally as au embrocation, or in the form of ointment- with which to dress blisters, in sciatica or crural neuralgia, I have never before witnessed results such as here described. The case is instructive, first of all as illustrating the small quan- tity of this drug from either the external or internal use of which symptoms of poisoning may arise : in the next, to actas a danger- signal, to warn us from incarcerating upon a single interview, a patient of whose history and previous treatment we know nothing* Hampstfad, June, 1866. CASE OF POISONING BY THE EXTEKNAL USE OF BELLADONNA. Under the Care of DR. FRASER. Although the following case has already' been noticed in print, the Editors consider it worthy of mention in this place in juxtaposition with the preceding one. Poisoning by the external use of Bella- donna is an exceedingly rare event. In ophthalmic practice especially, the use of this drug and its active salt is at the present day very liberal indeed. It is not by any means uncommon to use a solution of atropinei, four grains to the ounce, and to have it put into both eyes every quarter of an hour for several hours. Belladdnna cataplasms around the eye are frequently employed. As a means of larresting the secretion of milk, the external emplojment of Belladonna has also of late years beeii frequently and freely reported to. Yet we hear of no instances of poisoning by it, and ophthalmic surgeons especially assure us, that beyond irritation to the nasal passages and throat, they never encounter any ill-comequences. There can, however, be no doubt that the two cases now recorded are bond fide examples of the event referred to. In one, the physician consulted, knew beforehand what remedy had been prescribed, and at once recognised its effects, but in the second the diagnosis of Bella- donna poisoning was made in reliance on the symptoms only, and without any knowledge as to the preceding treatment. In this case inquiries afterwards fully confirmed the conjecture. To explain the rarity of these cases we must resort to the theory of idiosyncrasy. It seems clear that some peculiar susceptibility must exist in those who suffer, when we find that out of many equally exposed, almost all escape, and only a very small minority are 172 DE. FEASER's case OE POISONING , injuriously affected. It seems probable tbat the quantity employed bas but little to do witb the result. The following are the facts of the case alluded to, copied chiefly (with some additions) from the notes taken by Mr. Eossigilol the clinical clerk in charge of the patient. On the evening of October ISth, 1865, a yourig womarl, aged 18< a servant^ was brought to the' Hospital by her mistress, who said she had been much alarmed by the girl's strange manner since the morning. She was afitaid she was " going out of her mind.'' It looked very much like it at first ; for, one moment she would appear quite rational and look one in the face, then she would laugh childishly and stare about her, pick at her clothes, stand first on one foot then on the other, then wander round the room, and on being left alone to see what she would Ad, she mcninied up ori the window^seat and attempted to open the window, apparently with the intention of getting outy but without any violence of manner; She seemed simply restless as if she could not be still. When spoken to she at once became attentive and quiet for a short time; and answered any qufestion plit to her, but with evident effort, and ended with a giggle, often breaking off in the middle of an answer, as if sh6 had forgotten what she had to say. It was at once' noticed that her pupils were widely -dilated, and on examination they were found to be perfectly fixed; Her face was pale,- though not extremely so, and even when she was comparatively quiet and atteMive she had a somewhat childish, restless, eager expres- sion, as if she were just going to start off somewhere ; her pulse was quick (above a hundred) and small, her skin was warm but not hot ; her tongue was dry and coated wth fur, and her mouth was ^ery dry. All the history we could get was that she had had pain in her breasts for some days, and had gone to a chemist who gave her some lotion in a bottle labelled "Poison,'' to be apphed to them with cotton- wool covered over with oiled silk; The mistress said she thought the lotion was laudanum. Some of this lotion was apphed to the breasts on the evening before, and some again on the morning of the day of her admission, after which the girl said she felt very ill j her legs felt weak, she tried to get up to bed, but stopped short on the stahs. Her mistress said that in the afternoon the girl became restless and wandered about, and as this seemed to increase, she became alarmed, and thought it best to bring her to the Hospital. BY EXTERNAL USB OE BELLADONNA. 173 The case so far was decidedly puzzling, for though one might have been inclined to take refuge in hysteria, the widely- dilated fixed pupils militated against that hypothesis, as they did also against the idea of commencing feyer, and her skin was not hot. A student who was present — Shaving regard to the fixed, dilated pupils, quick pulse, dry tongue, comparatively cool skin, restless manner, and the history of a lotion having been applied to the breasts — suggested that the case might be one of Belladonna poisoning. On examining the dressing, which was still applied to the breasts, it was found to have a strong odoiir and not unlike that of Belladonna. The girl was then questioned as to her having swallowed some of the lotion in mistake, but she would not admit it, and the mistress didnH think she coald have done so^ or she would have told her. The ophthalmoscope was used, but afforded np information, except- ing that there Tf^s neither marked pallor npr hyperqenjia of the optic discSj Half-a-grain of njorphia was ordered every four liours till she slept, and a saljne draught three times arday, The next day (X4th), her pulsp was 114 in the minute, her tongue was dry in the middle, moigt at the tjp and edges. She got to sleep for a short time during the night (about ten o'clpck) but after- wards was delirioifs, and become very trqublesome, She had been sick once. Her pfl-pils were still dilated, Though §he wandered at times, she w^s ^ble tp tell us that her limbs felt numbed, and that objects appe^re4 a long way off^ and as if double, This was proba- bly simply from indistinctness of vision, and not thgit she really had diplopia. She cannot read ordinary type, but can spell out a few large letters. During the night her temperature in the axilla was 98. Qn the 15th it' is noted that she has voniited several times, and that her pupils contract very sluggishly, and not to the nor- mal size on exposure to strong light. During the afternoon the patient's mpther brought a bottle labelled "Lotion,'-" "Poison," and on the margin was written " Ext. Bellad, 3SS. aquse gj ; " thereby set- ting at rest the question that Belladonna had been used. On asking the girl again what she remembered, she stated, that on Thursday evening, October 12th, her breasts were dressed with this lotion, and that on removing the cotton wool which covered them, she tore the skin, making it bleed. On the following morning she again 174 POISONING BY EXTEENAIi USE OF BELLADONNA. applied the lotion and cotton-wool, covering up with oil-,glk. She remembered being unable to walk upstairs, " she crawled up on her hands and knees,* and was helped into bed about eleven in the morning, but she has no clear recollection of anything since, till the morning of Saturday the 14th. On the 20th she had quite recovered, The symptoms in the above case may fairly be attributed to Bellas donna poisoning, bat whether the drug were imbibed through the skin, or whether the girl drank some of the lotion, cannot posi- tively be settled. We^have only her statement, repeated most definitely, that she did not do so. There was certainly very little abrasion ,of the skin, but she gave a clear account, as ^bove noted, ,pf having torn the skin in taking oif the dressing. TWO CASES OF ACUTE SFPPUEATION IN THE KNEE-JOINT, IN WHICH EECOVERT WITH FEJEE MOTION ENSUED. BY ROBERT B. CARTER, F.R.C.S. I AM desirous to place on record, a short account of two cases of acute suppuration within the knee-joint, one of them occurring in a patient most unfavourably situated, and both terminating in perfect recovery of aU the functions of the articulation. The result was probably due, in some measure at least, to the success of the contri- vance used, to afford rest to the affected part, and support to the limb ; and, it is to the details of this contrivance, that I seek to direct attention. H. G., a coal-miner, in the prime of life, and remarkable among his fellow-workmen for his great strength and endurance, received a severe blow upon his left knee, by thefalhng of some masses of stone, from the roof of the stall in which he worked. Notwithstanding severe pain, he continued to labour until his usual hour ; and then walked a mile and a-half to his home. On arriving there, he went to bed, and enveloped . the injured joint in mustard poultices. The next day I was asked to see him. It is not remarkable that a joint thus injured, and thus ingeniously maltreated after the injury, became. the seat of acute inflammation; nor that, when the inflammation had somewhat subsided, the articu- lar cavity was left much distended by fluid. In due time, an explora- tory puncture showed the contained fluid to be pus ; and it was evacu- ated by a free incision into the joint, in the direction of the axis of the limb, and just external to the outer border of the patella. The pressure of the cdstended joint upon the veins, had produced 176 ME. CARTER ON SUPPURATION IN KNEE-JOINT. considerable oedema of the leg; and, on this account, it seemed desirable to obtain firm and accurate mechanical support for the leg, as well as immobility of the articulation, Tor these purposes, the following contrivance was employed i — A splint, as light and thin as was consistent with the possession of the necessary strength, was cut from a flat piece of deal. This splint was long enough to reach from the tuber ischii to the os calcis. At the upper end it was about three iijches in w^dth, and it gradually tapered to an inch and a-half at the lower end ; so that, when in position, it was everywhere overlapped by the limb. It was padded by two or three ptrips of blanketing, ^nd by a li^itle cushion to fill the ham j and it was secured upon the centre-piece of a many-tailed bandage. This centre-piece was somewhat longer than the sphnt, so as to turn round the heel, and reach along the sole of the foot to the roots of the toes. The tails were rqlled up and tacked to two pieces of tape, and the whole apparatus so fastened together, that it could be put into' its place by once elevating the limb. The heel and malleoli were then protected by strips of xsoft leather, spread with lead plaster ; the splint vpas placed in position, and the leg gently lowered down tq rest upon it, The pad under the ham was accu- rately adjusted, a little cottqn-wool placed to fill up any hollows, and then the tails of the bandage, were laid down firmly and closely, from the toes upwards, and thoroughly secured by starch. Opposite the knee-joint, two tails on each side were left unstarched ; but the starch wa,s again applied above. The unstarched tails were pinned, so that they could be opened to renew some charpie, placed over the wound to absorb the discharge. As soon as the starch had hardened the limb was slung by tapes from a common cradle, so as to move freely from the apetabulum, and to allow the patient to lie in almost any position. After a few days, the subsidence of oedema loosened the bandage. It was then carefully cut through on both sides of the limb, and the whole dressing removed and reapplied, with the smallest possible movement or disturbance. The discharge from the joint, at first purulent and profuse, gradu- ally became serous and scanty. After a time it formed a scab, by which the wound was completely sealed. I expected no better result than anchylosis ; and, when the scab AND RECOVERY WITHOUT ANCHYLOSIS. 177 fell and disclosed a firm cicatrix, I removed the splint and bandage, and left the patient in bed. On visiting him the next day, he was up and dressed, sitting in a chair, with both knees bent in the ordinary manner. He said that a stiff leg would cripple him as a miner, that he determined to try and bend his knee, and that the attempt succeeded. No bad symptoms followed ; and he soon returned to his work. He remained under my observation for more than two years ; and the joint that had suppurated was in every respect as strong, as flexible, and as useful as the other. With the preceding case fresh in my recollection, I was asked by the late Mr. Fox, of Nottingham, to visit for him a pauper patient, who lived near my own house. I found a young woman, the daughter of parents in easy circumstances, but who had been seduced, and had left her home in consequence. She had earned a scanty subsistence by needlework ; and, when I saw her, she had been three weeks delivered of a puny infant, that died shortly afterwards. A few days after her confinement, her right knee-joint became inflamed. I found her with the joint much distended and pointing, with a high degree of irritative fever, half-starved, and thoroughly miserable. Mr. Fox was kind enough to'surrender her entirely to my care j and to furnish me with orders to the relieving of&oer, for everything that her case required. A free incision into the joint gave exit to a quantity of pus, and to masses of pus-clot, some of which were so large, that they required to be eased through the wound. After the incision, the splint and bandage already described were carefully applied. On account of the unfavourable condition of the patient, it was manifest that a good result could only be obtained by extreme care j and, living near, I availed myself of the proximity to superintend the nursing. • For many weeks I took charge of the affected limb, during every change of bedding, clothing, or position. The case was much more protracted than the former one; but its course was in all essentials the same. The purulent discharge became serous, and the wound was sealed, after a time, by a scab, under which, it united firmly. When this scab fell, gentle passive motion was carefully employed. It was followed by increased heat of the joint ; and this heat was subdued by irrigation with cold water. By slow degrees, free movement was obtained ; but, for many months, increased heat 178 ME. CAUTER ON SUPPURATION IN, KNEE-JOINT. was prqdttced by any undue exertion, and sometimes by atmospheric changes. Cold water was always effectual as a remedy, strength M/as gradually gaiued ; and, after the lapse of a year, the patient was able to say that nothing remained, save the cicatrix of the incision, by which she could distinguish the joint that had been inflamed from its fellow. I saw her at intervals for nearly three years, and her condition underwent no change. The great value of firm mechanical support, of strapping and bandaging, in all congested conditions of the lower extremity, has long been recognised and taught at the London Hospital. The cases above described, seem to be illustrations of the same principle, and to show that mechanical support promotes the process of repair, under even the most unfavourable circumstances. It has been the sole object of the writer to bring this fact into prominence; and, hence Space has not been occupied by unimportant details about the general or dietetic treatment bS the patients. The point of most importance Seems to be the narrowness vf the splint ; which, ■nshile securing the necessary immobility of the articulation, was nowhere wide enough to throw off the grasp of the bandage, or to diminish its compressive action upon the hmb. Next in importance was the slinging froiri the cradle, which, by allowing changes of position of the body, greatly promoted sleep, and prevented the occurrence of bedsores. The dressing was so light that the patient could turn the affected limb in its slings at pleasuje, and could lie on tiie side opposite to it as easily as upon the back. Stkoub, G-ioirCESiEESHiEE, July, 1866. CASE IN WHICH THE SYMPTOMS OF A LAEGE ABDOMINAL ANETJEISM WERE PRESENT, AND CURE RESULTED. BY FEEDEEICK H, DALY, M.D. The following case of supposed aneurism of tlie abdoBoinal aorta, cured by treatment, will, I trust, prove interesting to the profession. It presents several most important features. It was a case iw which the diagnosis seemed clear and positiye, aiid, in which, ther^ fore, we (Mr. Hutehiason, who saw the case with me, and myself), gave a most unfavourable opinion, yet, happily, by. loBgrCojntipufid care and treatment, the patient is now restored to health. Mr. F — ., aged 38 years, first became my patient in July, X;863, suffering from an attack of acute dysentery. He bad .always been, previous to this, a healthy man^ — never had any illness. Under treat- ment the acute dysentery subsided into chronic, which for a long time resisted all treatment; but, however, eventuaHy left him com- pletely, in the early part of October. The patient then resumed hig accustomed employment, that of forewan ajt a cabinet-mEiker's, and regained his former health. In March, 1866, 1 was again summoned ito attend Mm ; I found him with a rather anjdous countenance, complaining of some pain at the pit of the stomach, and troublesome vomiting. Being rather pressed for time, I did not examine the ease very- carefully, and attributing the symptoms to gastric disturbance, I prescribed accord- ingly. On the following day I again saw him ; the "vprnilang }iad somewhat a:bated, but he now called my attention to a " strstnge beating at the pit of the stomach.'^ I carefuUy examined him, and * n2 180 DK. Daly's case of cure of found, about two inches below the ensiform cartilage, a large tumour, nearly the size of the two fists doubled, visibly pulsating. I applied the stethoscope to it, and there was a loud distinct bruit, immedi- ately following the systole of the heart. I was able by firm pressure to empty the tumour somewhat of its contents, but it filled again directly. The pulsation was of that expansive nature, so character- istic of an aneurism. The heart's-sounds were normal, and there was no perceptible difference in the femorals on either side. The patient informed me, that some days previously, as he was lifting a heavy piece of furniture in the warehouse, he thought he " felt something give way in his inside.'' Kegarding the whole case, I had no doubt that it was an aneurism of the abdominal aorta, and therefore, expressed a most unfavourable opinion as to the result, but said, that I should much like Mr. Hutchinson to see him with me. On the following day, therefore, that gentleman and I met at his house, and Mr.' Hutchinson, having most carefully examined him, expressed a positive opinion, that he was labouring under an ab^ dominal aneurism, and added that we could scarcely entertain any hope of a favourable issue. We determined, however, to keep the patient in a state pf absolute rest in bed, and, indeed, that he should scarcely be allowed to speakj and that all excitement should be avoided. We recommendedj alsOj that he should have a nourishing, unstimulating diet, with as little fluid as possible, that ice should be kept constantly applied to the tumour, and that he should take the diacetate of lead internally. This plan of treatment I carefully carried out. I gave him three grains of the diacetate of lead, with a quarter of a grain of opium, three times a-day, which he continued to take regularly for fifteen days, — until there was a distinct blue line along the edge of the gums. The lead caused no colic, although he took 135 grains, but he lost flesh, and his appetite almost completely failed him. It also caused much constipation, requiring enemata. I now discontinued the lead for about a fortnight, still keeping the patient perfectly quiet, and the ice constantly appKed. During this period I made but little examination of the tumour, believing handling injurious. At the end of the fortnight, I applied the stethoscope to the tumour, and was astonished but pleased to find, that there AN ABDOMINAL ANEURISM. 181 was no longer a bruit audible, althougb tbere was still pulsation. The tumour was also much smaller and firmer. J then immediately again commenced the lead, giving the same dose as before, three grains three times a-day, and continued it for twelve days (the patient this time taking 108 grains) when I was obliged to discontinue its use, as he was seized with abdominal pain and distention, vomiting and constipation. I ordered turpentine fomentations to the ab- domen, large enemata, and effervescing, medicine. The following day all the symptoms of obstruction were worse, nothing had passed from the bowels. I again called in Mr. Hutch- inson, and he advised a continuance of the enemata, and small doses of sulphate of magnesia internally. He considered the obstruc- tion probably due to a collection of scybalse, caused by the lead. On the following morning there was still no motion from the bowels, and the abdominal distention was greater. I ordered him a little brandy atid soda-water, every half-hour, and a large turpentine enema, fre- quently repeated. I again saw him at five in the afternoon ; the bowels had acted, the vomiting had ceased, and he had passed a large quantity a£ scybalse. The next day he was much better, his countenance had lost its anxious expression, the distention had nearly subsided, and his bowels had acted twice naturally. At the' end of a week he had quite recovered from the attack of obstruction, and I once more examined the aneurism ; but now I could neither hear a bruit nor feel pulsation ; when, however, I pressed my fingers well back towards the vertebral column, I could feel a certain amount of thickening in front of the artery, in the site of the aneurism. In about ten days from this — nearly three months from the date of his first visit — I again requested Mr. Hutchinson to see him, and he was also of opinion that the aneurism was cured. In a few days we allowed him to get up, and he is now (June 19th) about to start for the sea-sidfe. Bemarh. — The question then suggests itself, To what are we to attribute the cure ?, whether to the rest and diet, together with the constant application of the ice so long and feteadily persevered in, or to the lead? No one, of course, will question the necessity of 182 DB. DALY S CASE OV ANEURISM. tlae former, but I cannot help thinking that this man owes his hfe* In a great measure, to the action of the lead^ and that it is well worthy of further trials in such cases, In conclusion, I may remark, that although I kept the ice con- stantly applied night and day for more than two months, the patient suffered neither pain, nor any tendency to sloughing of the skin, from its lengthened application, nor other inconvenience. It is only fair, to our patient to add, that throughout the treatment he exercised the most praiseworthy patience, observing tlffi recumbent position most literally during the whole of the two months. As the diagnosis of abdominal aneurism is beset with difBculties, I have been careful in giving a title to this paper to avoid too great positiveness. That a large tumour was present just below the epigastrium there could be no doubt, nor any that it had an expanding impulse, and a very distinct bruit. The expansive character of the impulse was most decided. Haying stated the symptoms and their gradual disappear- ance under the regime adopted, I must leave the reader to form his own opinion as to whether the diagnosis was probably correct. 101, Queen's Koad, Dalston, P. S. — ^August 14th, 1866. — At the present date the subject of the above case is in good health and has returned to his usual pur- STiits. No tumour can be discovered in the abdomen. CASES SELECTED PEOM THOSE BENT IN BT STTTOENTS IN GOMPETITION POB THE HOSPITAL GOLD MEDALS OP. 1865. [Two Grold Medals are awarded by the Hospital Committee annually for general proficiency in practical medicine and surgery. In addi^ tion to an estimate of the relative amount and quality of the work done by the several candidates in the Hospital Wards, during the year, as dressers, &c., it is required that they shall undergo a com- petitive examination on clinicial subjects, and that each shall ^o furnish the notes of not fewer than six cases. The gold medal for medicine was awarded this year to Mr. Alfred Walker. Two candidates for the surgical gold medal, Mr. P. S. Colquhoun and Mr. P. M. Mackenzie, were considered to be so equally and so highly meritorious, that the Surgical Staff recommended the award of two medali* To this proposal the Hospital Committee kindly assented. The following cases are from the notes supplied by the different competitors. In some instances the notes are sdmost in full, but in most cases they have been greatly abbreviated, and are in fact only abstracts of the original reports. It is due to Mr. Colquhoun to state, that this remark especially applies to liis cases, which were recorded in great detail]. Case I. — Morbus Addisonii. — Death.— Post-mortem. (TJnder the care of Dr. Parker.) {Reported by Mr. A. Le Roasigtiol.) Catherine S,, aged 15, unmarried, a gervaait living at Poplar, was 184 GOLD MEDAL REPOETS. admitted on the 15tli of November with bronzing of the skin associated with general anaemia. The fahiily history afforded no evidence of tubercular or other hereditary diseases. The girl was of a sallow complexion ; her hair brown, and her eyes blue, and she was still moderately well-nourished. She had had measles^ scarlatina, and scarlatinal dropsy ; the latter when eight years old. Por two months before her admittance she had been generally aihng. About this time she first noticed the darkening hue, of the skin. Sickness then came on; at first only in the morning; then it increased to seven or eight times a-day. At last she became so weak that the day she left her situation (three weeks before her application at the Hospital) she fell down while at work and could hardly raise herself. Her mistress then sent her home. A few days after her return home she menstruated freely. The sickness continued and was easily excited by motion. Pains in the loins and stomach then supervened. She would sometimes go a day and a night without passing urine. Condition on Admission. — There is a general duskiness of the skin; a distinct pigmentary deposit of a circular form on the middle of the forehead, and on the right cheek, about the eighth of an inch in size, within the mouth. There are dark areoloe around the nipples, which are normal in size. Dark Knes are to seen above the nia where the clothes hang on the hips, and just below the knees where the garters press the legs. The darkest pigmentary deposits are those above the iha, which are of a chocolate-brown. The whitest portions of skin are those covering the mammas. The tongue is thick and coated, the bowels are not confined; there is pain at the lower portion of the abdomen. Breath-sounds normal; no dulness on percussion. Pulse 120, quick and small. The insides of the lips and the tongue have a very anaemic appearance. The skin is very dry and does not appear to excrete. The urine is normal in quantity, sp. gr. 1015 ; no albumen ; excess of phosphates ; no sugar. The patient is very weak and listless ; so much so, that her intellect might be thought defective. November 27th.— This morning when the nurse put her near the fire, while ' her bed was being made, she fainted, and would MORBUS ADDISONII. — ABDOMINAL ANBUEISM, 185 have fallen, had she not been supported. Pulse very weak and small. She lingered, in a semi-comatose state, from the 4th of December to the 6tli, when she died. Post-mortem. Body tolerably well-nourished. Muscles flabby, general anaemia. Bronzed skin. Darkening of skin on the centre of the forehead, round the nipples, in the folds of the groin and axillae, over the hips, and in the flexures generally. Dark spots on the right cheek, inside of the left;, on the vulva, and on the labia minora. There was an inch of fat on the abdomen. The thoracic organs were normal in position and in external appearance. The pericardium contained an ounce of pale serum. There was a large, firm, pale clot, on the right side of the heart, extending into the pulmonary artery, also another on the left side, extending into the pulmonary veins. The mitral valves were slightly thickened. The apices of both lungs contained a very small patch of tubercle. The bases of both lungs were collapsed and shghtly congested, some portions were emphysematous. The left lung weighed eight ounces and a-half, the right ten ounces. The liver, rather waxy in appearance, weighed two pounds four ounces and a-half. Both supra-renal capsules were fully two inches long by one broad, very hard. On section, some portions had the appearance of a yellow putty-like matter ; others were hard and translucent, and in a few places there was a gritty material, easily felt with the fingers. The capsules were wholly disorganized. Misroscopic examination of the capsules showed malformed cells and molecules resembling tubercle and cretaceous grannies. Case II. — Aneurism of abdominal aorta, — Death from ru§tv/re mto (Under the care of Dr. Parker.) (Reported by Mr. Walker.) Benjamin E., aged 37, was a short, stOutly-built man, well- formed, but pale and slightly emaciated. He had been for many 186 GOLD MEDAL EEPOBTS. years a sailor ; but latterly had been a laboujresr in the Docks, where he had been accustomed to lift heavy weights. About three months ago he noticed a lump in the epigastrium, which " throbbed/' but which gave him but little inconvenience, and he was able to continue his work up to about three weeks ago, when he began to fed great pain after taking food. On admission, the prominent symptom was pain, and occasional sick-^- ness after taking food. There was a hard nodulating swelling in the epigastrium, about the size of a china orange, it rose considerably with each pulsation of the aorta, and transmitted a bruit with the systole, but it was doubtful whether this bruit was conducted from the aorta, or was in the tumour itself ; there was no perceptible lateral ex- pansion. He was cheerful, did not complain of any particular pain, except after eating, and there was no pain in the back, February \st. — Early this morning he became suddenly collapsed, with all the symptoms of internal haemorrhage,. quite blanched ; cc^d extremities ; almost pulseless ; severe burning pain in epigastrium. '2,nd. — ^Has rallifid very much, and seems easy ; Las been attempt- ing to sit Tip in bed. ^th. — ^Expresses himself quite comfortable j eats with good ap- petite, 1th, — This afternoon he had been reading, and on sitting up to reach the book again, he fell back in the bed, and died in a few minutes. Seetio cadcmeris. — ^Body rather emaciated. On opening the abdominal cavity a very large quantity of bloody serum and clots escaped, equal to four or five pints. The ascending portion of the arch of the aorta was dilated, and a saccular weurism was found on the posterior part of the descending arch. On tracing the aorta downwards through the diaphragm, an aneurism was found about the size of a large fist, apparently a dilatation of the artery all round j but principally on the right side, The csehac axis fend the superior mesenteric arteries took their origin from the left side of it, rather at the posterior part, and were not at all dilated ; it was op- posite the eleventh and twelfth dorsal vertebrae, which bones it had much eroded, having destroyed almost the whole of the body of the eleventh. The sac was filled with layers of soft fibrin, especially in front, where it was almost solid. ' EHEUMATISM, PUBPUEA, AND (EDEMA. 187 There were two rents in its walls,, one rather to the right upper side, a small one, and which was dosed by a plug of fibrin, and another quite at the lower left surface, large and irregular, about the size of a half-crown piece. Kidneys small and much contracted in parts, the right one being almost in two pieces ; other organs fairly healthy. The diagnosis was at first rather doubtful in this case. There was a tumour iu the epigastrium, which rose and fell with the pulsa- tions of the aorta, but which had no lateral expansion, and caused the patient no pain in the back ; the heart's-sounds also were nearly healthy, These symptoms were hardly sufBcient to characterize aneurism, while the pain, after eating, the vomiting and position of the tumour seemed rather to point to cancer of the pylorus or. pan- creas ; but the sudden collapse on the 1st of February, with all the sym- ptoms of internal haemorrhage, settled the question pretty conclusively. This aneurism must have commenced as a fusiform true aneurism, and, as it increased in size, the right side happening to be the weaker, yielded most. The pain, after taking food, was , probably produced mechanically by the pressure of the tumour on the stomach, whUe the layers of firm, dense fibrin in jts anterior part quite accounted for the absence of lateral pulsation. The collapse, on the 1st, was most likely produced by haemorrhage from the small aperture in the upper part of the tumour, which was accidentally stopped by a plug of fibrin getting into it, while the enormous rent in the lower part, was the evident cause of the man's sudden death six days after. It is singular that, with so much disease in the vertebrae, no pain should have been felt in the back ; also, that the valves of the heart were healthy, and that no patches of atheroma were found in the coats of the arteries examined. Case III. — Repeated attacks of acute RhetMuatism. — Pwrpmra.-^— Effusim into acroiwm.—Recaoery. (Under the care of Dr. Davies.) {fieported by Mr. Walker.) Thomas I"., aged 38, was a;dmitted January SOth, 1866. Two years ago had been admitted into Hospital for acute rheumatism, 188 GOLD MEDAL REPORTS. having been twice before in " Guy's " for similar attacks. He was placed under the care of Dr. Davies, by whose orders blisters were applied to all the affected joints, he was relieved of all pain in twenty-four hours by this treatment, and left the Hospital cured six weeks after. He is a man with a taste for scientific pursuits, to follow which, he has been in the habit of spending most of his wages in books, inathematical instruments, &c., and in order to do so has lived on a very low diet, consisting chiefly of bread and coffee or tea. Ten days before admission he had another attack of rheumatism, and remembering the effects of the former treatment, purchased, and himself applied, eight blisters to the affected joints. This treatment again relieved him ; but during this time he had been unable to eat the coarse diet he had provided for himself, and conse- quently had taken little -or no food. Three days before admission he noticed large purple spots appearing at the inside of his ankles and knees ; he thought very little of this however, but applied to be taken in on account of his rheumatism. There had been no bleed- ing from any mucous membrane. On admission, he complained of some pain in his joints, but the symptoms were not very acute. On the inner sides of his ankles, on his insteps, and on his arms were large purplish blotches. He was ordered decoction of bark with lemon-juice every four hours; to take milk diet and half-a-bottle of claret daily. Urine sp. gr. 1025 ; very acid. No albumen. Slst. — Mouth sore, gums very tender ; to apply tannin ; and as his bowels were not open, he was ordered a purge. February 2nd. — The scrotum and penis have suddenly become much distended and dark coloured ; the extravasation extends on each side as far as Poupart's ligament, and into the perinseum, which is much distended ; a full-sized catheter can be passed into the bladder ; but there is undoubted history of stricture ; there is, however, very little general fever ; the patient passes his urine and takes his diet. 3rd. — He was seen to-day by Mr. Maunder, who gave his opinion that the effusion into the scrotum was not uriae j advised acupunc- ture of the distended parts, but declined further operative interfe- rence. 5 ^^-T- Acupuncture gave considerable relief, swelling has some- what decreased ; very little pain felt j the purplish blotches are increas- ing in number, a few appearing on the upper part of the trunk; his EHEUMATISM, PURPURA, AND (EDEMA. 189 joints are painful. Ordered tincture of iron and chlorate of potash. 1th. — Swelling rapidly subsiding, and the skin regaining its natural colour ; wishes for more to eat ; ordered boiled mutton. Bth. — A spot on the inner side of the left arm, which was painful yesterday, has to-day taken on violent inflammatory action. Ordered an ounce of turpentine mixture every four hours, a linseed poultice to the arm, and the diet to be changed to fish. ' ' 9th. — The inflammation has proceeded to gangrene of the skin ; a portion about the size of a crown-piece, being quite livid and dead, \Zth. — Slough has separated, and the wound underneath looks healthy ; to return to the mixture of iron and chlorate of potash. \hth. — ^Wound looks very well; the oedema and discoloration have nearly disappeared from the scrotum, &c., and most of the spots have gone from the legs. Ordered oysters, also water-cresses and green vegetables. l&th. — Wound in arm is very healthy, but rather slow in healing ; the whole arm to be lightly bandaged with a flannel roller. Patient asks for more to eat ; ordered four ounces of extra bread. Urine ex- amined to-day, and traces of sugar found with a sp. gr. of 1020. March \sL — Since the last note he has been steadily improving ; the wound in the arm is rather slow in closing up, but looks quite healthy ; there ^re no spots anywhere on the skin, and the pain has quite left his joints ; he gets up and sits by the fire, but is still very weak. 10^^. — In bed again with a slight return of the rheumatism; the arm is still bandaged, as the wound is not quite healed. \Zth. — This evening several raised patches of a parplish colour have appeared about him, which appear to be a mixture of the purpuric rash with urticaria ; there is very little irritation, a,nd he does not seem to suffer much constitutionally. \Qth. — He is now convalescent and expects soon to leave the Hospital : the day before yesterday he had some slight rheumatic pains in his knees, but these were gone in the morning ; he has no spot anywhere ; the wound in the arm is healed ; he eats well and sleeps well. This case was one of considerable interest, on account of the peculiar effusion into the scrotum and adjacent parts. It resem- bled in almost every particular, an ordinary extravasation of urine. 190 GOLD MEDAL EEPOETS. Agdnst this diagnosis we had — ^the absence of any tiglit stricture for some time past, — the fact that a large catheter (No. 8.) passed i^sily into the bladder, — the pecidiar state of the maa^s blood at the time, many small extravasations occurring elsewhere,-^-and th® absence of any serious amount of symptomatic fever, and also of that extreme pain and tenderness on pressure, which usually is present when urine is permeating the cellular tissue. Case IV. — Case of paraplegia of motion,, and, to slight extent, of sensation also. — Recovery undgr treatment by Iodides. (Under the care of Sr. Parker.) (^Reported by Mr. A. Le Bossignol.) ■ Henry M., aged 40, clothier's cutter, of intemperate habits, was admitted into the Hospital with pateJysis of the lower extremities on the 10th of October, 1865. He stated that he had been accustomed to consume five ounces of cut-Cavendish tobacco per week ; smoking and chewing. He had had chancres twice ; the first when about seventeen, when it was followed by a bubo. The. second time was four or five - months before his admission. He had also had gonorrhoea four or five times. Never had any other disease. The disease from which he was now sufering came on with a pain in the lumbar region, extending round the loins.. Turpentine and ammonia were used topically, but with no good result. A day or two after the first accession of pain, while standing, he felt his left knee bend under him ; subsequently, in getting out of bed, his legs would feel quite stiff for sometime. His right leg became affected on the. 4th of October, but previous to this he had left off work for three weeks. When admitted, he could not use either of his Legs. There was no tender spot on the lujmbar, sacral, or dorsal region of the spine. Hot water and ice produced only the usual effects ; no reflex action. There is numbness, but the touch of the fiaiger or the point of a needle are easily felt. The sphincter ani, and sphincter vesicBB are completely paralyzed; Urine, alkaliae and phosphatic. No evidence of cardiac or pulmonary disease. Pulse a little sharper, but not quicker than usual. A large bed-sore just above the nates. Ordered three grains of iodide of potassium three times daily. RECOVERY FROM PAEu^LEGIA. 191 October \itA. — ^Tke left knee can be flexed slightly, bat very slowly. The patient says he can feel better on the left 1^ than on the right. 13^^.— Has not as much power over the left leg as yesterday. Painful spot near second lumbar vertebra. \5th. — About the same. Small ulceration round the orifice of the urethra, due to the irritation produced by the strongly ammoniaicai urine. The patient complains of a tightness above the navel. Urine sp. gr. 1020. Excess of phosphates. No albumen. 16^^.— The bowels are confined. To take decoction of cinchona with nitric acid. nth. — ^The bed-sore is looking much better. Collodion to be applied round it, and wet cotton-wool over it. The patient can move his left leg, and turn the foot aidewaya. %lst. — A small sore over the right trochanter. Bowels do not act without aperient medicine. 26M. — Can flex the left hip-joiiiL Bed-sores looking healthy j collodion to be applied around them. The ulcer on the glans penis to be rubbed over with sulphate of copper. ^Qt&. — To discontinue the nitric acid mixture, and take instead decoction of bark with five grains of iodide of potassium. November %nd. — Appetite improving. The patient can now flcK his right hip and knee. 6^.— Both legs are now easily moved ; but the patient cannoit stand. The urine is not yet retained, it causes great annoyance to the patient when sitting up, by constantly dribbling away. He is im- proving in all other respects very satisi£actorily. Qth.; — rThe urine dribbUng on to the right thigh has produced some excoriations. Zlst. — The patient can stand for a few seconds at a time. December isth. — Cratches were ordered. The iodide of potassium to be increased to seven and a-half grains. Wth. — ^The patient can now, with the aid of crutches, walk round the ward. \4ith. — ^The crutches are put aside, and the patient can walk with the help of two sticks. From ijhis datq, up to the day of his discharge^ the patient continued improving in health, and when he was discharged on the 26th. of 192 GOLD MEDAL REPORTS. January, he had perfect power over the lower extremities, and could walk without any support whatever. He has since attended as an out-patient. I have lately learnt that a month ago he had a fit, and that his mouth is now drawn to one side. ■ Case V. — Extensive phlebitis with plugging of the superficial veins of both lower extremities. — Albuminuria. — Recovery. (Under the care of Dr. Davies.) {Reported by Mr. Le Rossignol.) James E., aged 26, a watchman, rather sallow, but mpderately well nourished, was admitted into the Hospital on the 26th of October, 1865, with a swelling in the left thigh. A few years ago he had jaundice, and within the last two months a chancre, but no bubo. Has lost flesh lately. His present illness began a month ago with rheumatic pains in the joints : the ankles, and knees, were swollen and hot. The urine was thick, and deposited a pink sediment. For three weeks he remained away from work, and during this time attended the Metropolitan Pree Hospital for about a week ; at the end of which he returned to his employment for a few days, but was soon obliged to apply to the Hospital for admittance. When admitted (October 26th, 1865), the right long saphena, the left long saphena, and the right short saphena veins were indurated throughout the whole of their lengths. The left superficial circumfiex ilii, and superficial external pudic were similarly affected. There was great tenderness, redness, and swelling of the skin over the upper portion of the left saphena vein. The heart's action was weak, and a soft systolic murmur was heard at the base of the heart, and ia the supra-clavicular regions. The bowels had been confined for three days. The tongue was furred and moist. The quantity of urine passed was slightly in excess of the normal quantity; sp. gr. 1012 ; albumen about one tenth. Headache was a constant symptom. October 27th. — The pain in the left thigh was so great that the patient could not sleep. Six leeches were applied along the course of the left long saphena vein. An ounce of house-medicine was ordered to be given. CASES OF HJTESTINAL OBSTETJCTION. 193 28^^. — The swelling* is nest so painful. SpoBgio-pilioei is kept constantly on the thigh. The appetite is impctving. Bawds open. Nevemier lai. — The legs were bandaged, from the. toes up as- far as thei groins. Albumen still present in the iirine. 4iii. — The patient compliained. of paiui in the knees and shoulders. A quarter "of a grain of morphia was ordered ta be given at bedtime. 7i&. — Tie pain in the joints had suibsided. There was no swelling now in the left thigh, but the veins of both the lower extremitiea were still indurated. IZiA. — Iodide of potassium in five grain (Joses wa» ordered, ZOth. — The lower portion erf the long saphena ■?euis were not so hard and. CQrd-Hke as at first. Albumen still present its the uiine. December ^nd. — ^Tka patient, was dkeharged.; When, he left tbei Hospital the ^eans were still hardened,, but tiere .was no< activtt disease going on. Cases YI., YII., _and VIII. — IVotes {abridged) of thfee oases ef oil- struetion of the bowels, extending over periods of fifteen, five, and four days, produced by the impagtian of hardened faeces in the rec- tum, amd colon, J — treatment cMefiy by large enemaCa, with cure in all. {Reported by Mt. F. S. Col^houn.) (Case I. Under the care of Dr. Fiaser.). John B.J aged' 35, barmani, was' admitted in the London Hospital on Pebruarj 13th, 1S66, stating that he had had no action of the bowels for fiVe days. His face wa* anxious and' pallid, of a dirty hue; skin clammy; pulse rapid' and feebl'c;^ Hps and m'outh dry tongue loaded with dirty yellowish fur; and rather dry ; breatft . hot and foetid. When examined m bed, there was considerable fulness of flhe abdiomen, especially at the left flexure and descending pari! of colon, the abd'bmen was tympanitic, and' pressure on it ga'vei Mm' pa-m. He had almost eonstant vomiting' for the last fiVe days with complete- anorexia, urine scanty, loaded! with lithates. Has always suffered from constipated bowels^ but never had a similar attack before. Bor- borygmi and eructations constant. Ordered a turpentine enema and put on a milk and bee&tea^ diet. In the evening haid* two or three o 194 GOLD MEDAL EEPQiElTS. evacuations of hard, dark, lumpy fseculent matter, coated with mucus, and passed a quantity of flatus, and. felt much easier. February lUh. — Better ; passed a fair night, as bowels were still painful and loaded. He was ordered two ounces of house-medicine with thirty drops of laudanum. Meat diet with milk. He had . several very copious evacuations during the -day, and sickness ceased. Thirty drops of laudanum at bedtime. Ihth. — Better; bowels still unloading themselves, but very much confined with great accumulations of flatus. Enema to be re- peated. l^th. — Up to the 18th, his bowels continued to unload them- selves, great masses of hard, dark, faseulent matter coming away. On this date they again showed a tendency to become sluggish, and he was ordered an ounce of castorroil, with two drops of laudanum. He had a very copious evacuation after this, and in the afternoon left the Hospital quite well. He was ordered some quinine mixture with chloric aether to take with him as well as some five gr. aloes and myrrh pills, (Case II. Under the care of Dr. Daviea.) Louisa W.J aged 20, shoemaker's wife, was admitted on January 30th, 1866, stating that the bowels had not been relieved for fifteen days past. She was exceedingly thin and weak ; could scarcely stand. Pulse 120, very feeble. Hair black, and surface generally dark, conjunctivae jaundiced. Tongue 'thickly furred and dry ; foetid breath. Eectum jammed with fseces, and lumps can be felt through abdominal walls all along the colon. She said that she had been living very badly lately ; had one child eighteen months ago ; weaned it at thirteen months ; has always been subject to constipated bowels, but never had a similar attack before. She was ordered a warm-bath, after which to take an aperient, with twenty drops of laudanum, and to have five pints of warm water steadily injected, the tube to be passed as high as possible. Soon after she began to pass masses of scybalse, and continued to do so through the day. January %\st. — Almost free from pain ; bowels still unloading themselves. Ordered half-an-ounce of castor-oil, with ten drops of laudanum. February 1st. — Yomiting and all uneasiness ceased, and she feels CASES OP INTESTINAL OBSTRUCTION. ' 195 quite well, but very weak. Tongue clean, and she would like something more to eat. Urine nearly clear ; bowels still unloading. Ordered ■ an ounce of quinine mixture, with chloric aether, and to have, chop and a pint of porter instead of milk diet. She went on per- fectly well, getting up, eating all her diet. Bowels acting once — sometimes twice daily. Urine got quite clear till February 5th, when she again became very sick, but without pain, and abdomen felt quite soft ; this was supposed to be due to pregnancy, though the uterus was not perceptibly larger, still venation with darkening of the areolae of the nipples, and enlargement of follicles were pre- sent. She was ordered an effervescent draught every four hours, with the addition, on the 6th, of three drops of dilute hydrocyanic acid to each ; however, this did not stop the vomiting, whilst, in other respects, she was quite well. On the 7th, she was ordered three grains of the oxalate of cerium when the vomiting came on ; she only took three doses of it, and was perfectly cured, and whilst in the Hospital had no return of it. She continued steadily to im- prove in health and appearance ; the bowels resumed their function acting once, sometimes twice daily, without medicine, and she left the Hospital on February 17th, perfectly cured. (Case III. Under the care of Dr. Parker.) "William B., aged 49, labourer, well- developed, muscular man, was admitted January 20th, 1866, stating that his bowels had not been relieved for four days. His face was anxious, skin and conjunctivae muddy. Skin hot and dry ,• breathing rather hurried ; lips and mouth dry ; tongue loaded with fur, breath foetid and hot; felt very sick, but had not vomited j habitual constipation. Abdomen tym- panitic, with retention of urine and decided fulness at left flexure of colon where abdomen was . most tender. He seemed to suffer a great deal of pain. Pulse rapid and feeble. No action of bowels for four days, but bad been confined for fourteen or twenty days be- fore admission. Partial retention and suppression of urine. Ordered thirty drops of laudanum at once. A long flexible O'Beime's tube was passed up the bowel until quite five feet had gone up, and then five pints of warm water were .slowly and carefully injected, the bowel being fully distended by it ; in fifteen minutes some of the fluid returned coloured, and in eight hours he had six very copious 02 196 GOLD MEDAL KEPOBTS. stods, aH of. tiheia har4 dark, and lumpy. The relief to all his sjunptoms was most nuarked ; the tympanitie fulnessj aad tender- ness disappeared. He passed a quantiity of urine, and perspired slightly. Liasee^-meal poultices were ordered to be applied to the abdomen,, and he; was. put on milk diet and beef-tea. Jauuceiy 2l3i. — ^He slept well, and is., almost free^ from pain; bowels still unloading themselves ; urine high-coloured and turbid. Tongue cleaner and] moister ; pulse quieter. 2Znd. — Bowels still continuing to. act; skin much clearer; face not so anxious. Ordered a mixture containing nitro-nwriatLc acid, and laudanum. Continue poultices and diet. ZSrd. — Bowels stiU acting, faeculent njatter softer; and not quite as dark. Appetite returningi Ordtered Hght pudding, two eggs, mUk, ami beef-tea, Z5tA. — ^Bowels only acted once a day. He is now getting fast well. Urine, clear, of rather low specific gravity— aUiaJine, Pulse quiet, and gaining strength. Tonguei iatsi cleaning. Ordered more beef-teai. 27f Pehruary, full diet. Aperient uepeatedi On the 5th of February he left the H.ospital cured, his bowels having acted daily, and he had not the slightest pain or uneasiness about, the abdoni&n ; urine passed freely without pain, and noraial., Case lK.-^€!asg- of incised throat [suicidal) in which a latrgs (XJnder the care of Mr. Curling.) {Reported hy Mr. F. M. Mackenzie.) Erancis: M,, aa Italian, age 20, a confectioner by trade, was admitted into the London Hospital, under Mr. Curling, at half- past seven a.m,. May 9th, 1865, with an incised wound of the throat. CASE OF INCISED THEOAT, 197 When first seen he was 'apparently insensible, with face and ex- tremities cold, and pulse hardly perceptible at the wrist. There was a large wound across the throat, measuriag five incheis in length, which gaped widely, owing to the position of his head; It was then seen that he had cut through the thyrot-hyoid membrane, open- ing extensivdy into the pharynx. No large vessels, however, were wounded. The left carotid artery was visible, and a part of the pneumo-gastric nerve of same side. An enema of brandy was •admimisteredj and all the usual measures for collapse resorted to. He rallied in about an hour, and Uiough in a very low condition gradaally got better by the eveniteg. It was then ascertained, that Jealousy hajd pron!f)it!ed him on that morning to attempt, fiest his wife's, and then his own Itfe; but in neither attempt had he been coimpletely suocessM. About seven o'clock P.M., he attempted to swallow some liquaid, but it all escaped through the wound. Nor was he more fortunate with solid food. A tube was therefore introduced through the wound, as he refused to allow it through the mouth, into the stomach, and a pint of beef- tea with brandy, and laudanum administered. . Mfa^ 10(A. — He was much better, but still unable to speak or swallow. It was deemed inadvisable to do more to the wound than to bring the edges of itsj extremities together with sutures. He was propped up in bed, and his head brought well forward so as to prevent any gaping of the wound. It was necessary to feed him throtigh a tube four times a-day, and his diet for the first twenty days was as follows : — Nine a.m. — A pint of milk, with two eggs beaten up in it. One P.M. — A pint of strong beef-tea, with wine or brandy ^iv. in it. Six P.M. — The same. Ten p.M^-^— The same as in the morning. The introduction of food -into the stomach was always attended or followed by a profuse discharge of clear saliva, sometimes as much , as four ounces, from his mouth. lltA. — More eheerful, and in eyety respect better. Troubled with a cough which distresseid him somewhat. As his bowlels were con- fined he was ordered an aperient. IZiA. — :The wound looked healthy, and had lliegun to oiose a little, but the frequent introduction of the feeding-tube inter- 198 GOLD MEDAL REPORTS. fered with the healing process. He could articulate a little, but not plainly. 16tA. — The tube was now introduced through the mouth. His general condition good. 20tL — The wound has considerably decreased in size. He was now able to speak tolerably plainly, and to swallow food of himself, but not in sufficient quantity to support life. 25(k. — ^Progressing favourably. Z9(A. — The wound much smaller. He was now fed only twice a- day through the tube, being able to swallow soft food. June 8i&. — No longer fed through tube. His diet was chop, eggs, light pudding, brandy 5ijv porter Oij. The wound is about one inch and a-half in length. 13iA. — He was now allowed up, and seemed in tolerable health. He was, of course, unable to speak distinctly. ZOfL — The wound was three-quarters of an inch long, and the edges seemed to be attaching themselves to the hyoid bone. He was discharged in tolerably good health. He was subsequently brought to trial for the attempt on his wife's life. A verdict of temporary insanity having been returned, he was committed to a lunatic asylum, where he soon afterwards died, but the particulars of his death have not been ascertained. Case X. — Incised throat {attempted murder) ; complete division of the trachea ; recovery with membranous stricture of the trachea ; subsequent death from contraction of the fistula. (Under the care of Mr. Curling.) (^Reported hy Mr. F. M. Mackenzie.) May 9fh. — Elizabeth M. (wife of the last patient), set. 21, was admitted at the same time as her husband, with an incised wound of throat, opposite the third tracheal-ring, about three inches and a- half long, and extending completely through the trachea. She was suflfering much from dyspnoea, and was unable to speak. She was placed in a warm room, and the edges of the wound brought together with sutures. IQth. — ^The dyspnoea had abated ; in other respects she was much the same. COMPLETE DIVISION OE TRACHEA. 199 llik. — On this day the fluids taken at breakfast, were observed to escape through the wound ; this continued for two or three idays, and then ceased, the glottis having recovered sensibility. 16 1 A. — Going on well; occasional dyspnoea; wound closing. 19 tk — Extreme dyspncea; the patient almost asphyxiated; the introduction of a tracheotomy tube soon gave relief; it was kept in. 2Srd. — An attempt to dispense with the tube (as the wound was closing) caused such extreme dyspnoea that it had to be abandoned. June 6(k. — The wound had now closed, excepting where the tube was introduced. ZOiL — On this day she was made out-patient, having quite re- covered, excepting the necessary continuance of the tube. In order to obviate this, Mr. Curling had previously had a tracheal tube with an opening in the upper surface, introduced. The outer end of this was plugged, but the patient could not- then breathe. Mr. Curling thought this might be due to spasm of the glottis, in part depending on the will of the patient, as she was evi- dently afraid of any experiment being made. He accordingly directed that she should be placed under the influence of chloroform, and the attempt renewed. However, the direct inhalation of the chloroform through the tube, produced such violent paroxysms of coughing, that this had to be abandoned. She was therefore dis- missed, wearing an ordinary double tracheal tube, and suffering no inconvenience, excepting the loss of voice. Prom this time nothing was heard about her, until on Priday, March 30th, 1866, when, late in the evening, she came to the Hospital, suffering from extreme dyspnoea. It was understood from her, that of late, she had had occasional difficulty of breathing, but never so severely as to alarm her. She was admitted into a medical ward, and after being in the ward for a short time, recovered somewhat, and passed an easy night. Next day {March. Slst) she still continued better, but about three o'clock the dyspnoea suddenly returned without any apparent cause, and rapidly became worse. The medical officer, on being summoned, found her already dead. The tracheal tube was removed, and the feather of a pen inserted for some distance without encountering any obstruction. Artificial respiration was tried, but ineffectually, as she never breathed again. 200 aOLD MEDAL KEPORTS. April Sind.'^-On this daj a. jiosf -mortem was madcj and tte ftoijicic vjscsra witli tke trachea removed en. masse. The lungs and heart were healthy, except some slight congestion «£ the former. The trachea and bronchi were opened posteriorly. The mueons membrane was foiund throughout congested and thickened, particularly at the seat of the wound, so as even to materially lessen the calibre of the iube. At the lower border of the thyroid cartilage, the larynx was found to be obstjpuctigd by a. membrane reaching across from sidie to side, and directly continuous with the mucous membrane lining iibe part of the larynx above it. In this examination, nothing was found to account for the paroxysms ,of extreme dyspnoea during life or for her sudden death. The occlusion of the larynx may have been due to the union ia the middle lijje «f the divided edges of the mucous membrane, above the wound. Owing to the loose connection of this membrajje to the walls of the trachea, these would be easily separated from them, by the efforts of expiration, causing the ,air in its upward course to force itself between ; and, as inspiration in this case took place through the artificial opening in the 'fcrachea, thpre would be nothing to cause them to return to their natural position. If this was the cause of the occliusion, it would be advisable, m any similar case, to endeavour to secure the divided edges of the mucous membrane to the inargins of the wound, and so leave a fistulous opening which might afterwards he closed by a plastic operation. Case ^1.— Recovery after jprolplfle fracture of lose of skull. — Temporary paralysis of several cranial nerves. (0n4eT the care of Mr. Hutchinaon.) {Reported hy Mr. F. M. Macketizie.) "Walter p., aged ^4, draymau, was admitted ou the 9th of August, 1865, in the following condition. He could nyalkj but with a staggering gait, was apparently very stupid, aud answered any questions put to him in an indistinct and wandering manner. There was blood upon his face and left ear, which could be traced quite into the tympanum, from which blood actually flowed during examination. He had also internal strabismus RECOVERY AFTER FRACTURE OF BASE OF SKULL. 20] of the left eye which his friends declared he had not had before the accident. His pupils were equal and sensitive. He stated that while carrying a nine-gallon cask on his should^ down-some steep steps, he had slipped and fallai, the cask striking his head at the same time that his head came in contact with the ground. He was insensible for half-an-hour, and on his attempting to rise, blood was seen to come from his left ear, while there was eechymosis of the right oonjuncti'va and the surrouiiding skin of the orbit extending backwards. He felt great pain in his head and vomited once or twice. He had, nevertheless, managed to get home after some time, but his strange manner, unsteady gait, and the bleeding from the ear still CDatinuing, induced his friends to bring him to the Hospital. - He was ordered to bed, and ice applied above the left ear. August lOM.— He had passed a tolerably quiet night : still com- plained of headache. He had a distiact jeooUection of the accident, and did not seem in any degree confused. 12^ji.— Headache still continued. There was a copious serous discharge from the left ear, and he was completely deaf on that side. He also complained that every thing he ilooked at now appeared double. A blister was ordered to the nape of lie neck. 13^/^ — Rather better. It was noticed that paralysis of the seventh nerve on the right side was coming on, evidenced by in- ability to close the right eye or use the right levator labii superioris abeque nasi muscle, by the mouth being drawn to the left side, and by his being unable to whistle or keep his lips closed while attempt- ing to fill his cheeks with air. There was no want of symmetry in the soft palate, nor aaiaestbesia of the face. There was now internal strabismus of the right side also, as well as of the left, whidi had existed from the first. There was slight drooping of the left eyelid. Ordered— a purgative draught. August IbfL — Much the same. The discharge still continued. Paralysis more marked. l8fL — Eather better. Headache still continued. A blister behind the left ear was ordered. 'ZOtA. — Still the same. The blister was repeated. 21*^. — ^Was relieved by this and slept better. He could now lopen the left eye better, but his hearing was not improved. 202 GOLD MEDAL REPOBTS. Ordered a blister to the nape of neck. Z2nd. — Much better. Paralysis had decreased. He could whistle, . though feebly, and shut both eyes well. Mouth still slightly drawn to the left side, and left eyelid still drooped, but he could open both eyes widely when desired. He said that he could see better with the right than with the left eye. Z6iL — Always has some headache on waking. Stffl some dis- charge from the left ear. Paralysis of the right sixth and seventh nerves almost gone. Internal strabismus of left eye remained. He could not hear the ticking of a watch on left side. September biL — Some pain in head, darting at times inward from left temporal region. Still some discharge from left ear, and total deafness on that side. Paralysis of the -right sixth and seventh nerves barely apparent, and distinct strabismus of left eye. On this day he was made out-patient. He afterwards attended as an out-patient under Mr. Hutchinson's care at the Ophthalmic Hospital, Moorfields ; and for the folio sring additional notes I am indebted to to the courtesy of Mr. Waren Tay. " October Z^th. — 'Walter D. comes to the Ophthalmic Hospital, Moorfields. He has still slight but evident convergence of the left eye, due to weakness of external rectus. He cannot 'turn the left eye outwards as far as he can the right. When looking straight before him at an obgect at a considerable distance (20 feet) he sees two. "On putting a coloured glass before his right eye, the right image which is in the proper position is coloured. " On putting the same glass before the left eye, the left image is coloured. There is no doubt about this, and it bears out the slight convergent squint of the left eye, the images not being crossed as is the case in divergent squint. " Objects near him he sees singly, as he can converge his eyes well enough. " He hears a watch placed at an inch from the left ear, and at three inches from the right. " I can detect no difference between the two sides of his face. He shuts both eyes equally well, and frowns equally on both sides. Sensation is good. " He sees well with either eye. He complains of pains in PUNCTURE OF BLADDER PER RECTUM. 203 the back of his head, and says that any slight jarring makes it worse. " November '2,1 th. — He has now quite lost the symptoms mentioned in previous note." The chief peculiarity in the above case is the occurrence of para- lysis, gradually commencing, and more gradually subsiding, of the sixth-and seventh cranial nerves of right side. A very similar case of suspected fracture of base of skull was admitted into Cambridge ward, under Mr. Curling, December 24th, 1865. In that case there were some slight tokens of paralysis on the left side, observed immediately after his admission, on which side there was also a serous discharge from the ear, but after the lapse of a few days, marked paralysis of sixth and seventh cranial nerves of right side appeared, and very gradually decreased; not having altogether vanished at the period of the man's discharge from the Hospital. These symptoms, so similar in both cases, suggest the probability of lymph having been effased and subsequen^tly absorbed. Case XII. — Case ilhtstrati/ng the value qf the operation of puncture of the bladder for retention of Urine, with large perinmal abscess consequent on old-standing traumatic stricture, 'Recovery with permeable urethra. (Under fhe care of Mr. Hutchinson.) (Tieported by Mr. F. M. Mackenzie.) Eobert C, aged 64, was admitted June 3rd, 1865, suffering from retention of urine. He was exceedingly ill, and had a large abscess in the perinseum. The following history was obtained subsequently. He stated that twenty-five years before, he, being in the Police Force, had, while in pursuit of a thief, fallen over a post, and received a wound in the perinseum, from which there was considerable hsemor- rhage. He was then taken to Guy's Hospital, faint from loss of blood, and was told that the wound was " connected with the passage." A catheter was passed and tied in ; some abscesses, which afterwards formed, were opened, and the wound healed. From that time he suffered no inconvenience, until about three years ago (1862) when he noticed that he could only pass a small stream, and that at times 204 GOLD MEDAL REPORTS. his water dribbled from him. Por this he went to the Metropolitan Pree Hospital. Mr. Hutchinson there passed a No. 2 catheter, ami as the incontinence was in a short time greatly lessened, he ceased to attend. It again returned, but he neglected it, and so continued for about tw«lve months, when he " felt a sort of gathering," which by pressing on the urethra, had now caused complete retention. Such was the account he gave of himself. The House-.Surgeon attempted to pass a No. 6 silver catheter, but, about two inches from the meatus, a stricture was encountered, wMdi prevented its further progress. No. 2 was then introduced and was with some difficulty got through the stricture, when a small quantity of purulent urine escaped. As a second stricture prevented the introduction of the instrument into the bladder, he was ordeted to have a warm bath, and to take croton-oil. June Mh. — He had not passed any urine, but was in intense pain. There was a large swelling in the hypogastric region, very tense and dull on percussion. Mr. Hutchinson tried to pass a catheter, but to no purpose. He then, with some difficulty succeeded in introducing a Syme's perinseal staff through the first stricture, up to the shoulder^ cut down in the middle line, and opened an ahsftess containing purulent urine, in which the staff lay bare fox about two inches in extent. As the urethra could not be traced beyond this, Mr. Hutchinson decided upon puncturing per rectum, by which method about three pints of urine were withdrawn. The canula was tied in, and he was ordered a Jose of laudanum. June hth. — He had been completely relieved by the operation. Urine passed both through the perinseal wound and the, canula. \Mh. — Urine passed,, on this day, through the meatus, as well as through the wounds, and slightly by the side of the canula. \^th. — Canula removed. 16tt. — ^Tbe wound in periaaeum has nearly healed, the urine pass- ing chiefly through the urethra. \%th. — Mr. Hutchinson tried to pass No. % catheter, but ex- periencing some difficulty at the second .stricture, did not persevere. The urine still partly escaped per rectum, and the patient was unable to retain it for more than an hour. He continued in this way with but little change, except the gradual increase of urine passed through the urethra until — RDI^UEE OF TBE HEABT. 205 July 1 ^tk. — Wb.eiij Mr. Hutchinson succeeded ia passing Noa. 3r and 5. I3i{^, — ^Nq. T was passed ipith some difficulty. He was noiw able, to retain his uriue for about three; hours., \1th. — On this day he asked for permission to go out, and did not return. He was then able to retain his urine for about five hours. Very little escaped through the perineeal wound, and none per rectum. Case XHI. — Fracture of several rihs^, and rtiptnre of the heart in a child. {Reported hy Mr.. F. M. Mackenzie.) The following case is of interest, partly as an instance of rupturei of the heart, and partly on account of the rarity of fractures of the ribs in children : — Sar;ah H., aged 6„ was brought into the London Hospital dead. She was supposed to have been run over. A,t the post-mortem examination, some ecchymosis was found,, corresponding in. situation to the sixth and seventh ribs of left side.. Ob opening the thorax, the fifth,, sixth, and seventh ribs on that side were found to have been fractured near their anterior extremities. The pleural cavities, lungs and pericardium, were uninjured;, but this latter, when, opened, was- full of blood ;, the right ventricle pi the heart having been ruptured, jSI o other injury hadi been sustained,. Case XIV. — Large- and rabidly- spreading- epithelial' ctmcer of the cheeh. — Excision. — Recovery. (Under the care of Mr. Curling.) (Beport'edby- M epilepsy, or imbecility in the family of one or both progenitors, jeaching to the large amount of sixty per cent. In two cases the fathers were habitual drunkards. In one instance the mother was very deaf, and the same case furnished the solitary example of cancer. There were only four cases in which there did not exist either a history of insanity or phthisis in the family. In the first of these the father's mother stammered when young, the mother stated that she was nervous during her pregnancy, during which she was fright- ened by an idiotic man. The boy had four brothers and sisters, all of whom were healthy, and he was one of the cases delivered by forceps. In the second case there was no history of hereditary taint. There was, however, disparity in the ages of the parents, father was 41 and the mother 29. The labour was very lingering, and it was the one case in which ergot of rye was administered.* * Dr. Ramsbotham has shown that the ergot of rye influences un- favourably the viability of the child. OF MAEBIAGES OP CONSANGUINITY. 235 In the third case, the father i^as suffering from Bright's-disease at the time of procreation, from which disease he, died. The fourth case is the only one in which the consanguinity stands as an isolated cause, and even in this instance there are three sisters perfectly sound, and it is the only example of degeiieraijy in the family, while the mother asserts that she was frightened hy. seeing her mother with paralysis at the age of 73. It is worthy of remark that the father's mother also died, from paralysis at the age of 70. The hoy is a microcephale and the last born, the father, about the time of the procreation, grew thriftless, ran away to Australia, and has not been heard of. It is also noteworthy that these four exceptional examples are all males. Reviewing the whole of these cases, there is only one, and that the one just mentioned, in which there is not quite sufficient to account for the idiocy apart from consanguineous influences. Since writing the foregoing, my attention has been called to a paper of Dr. Mitchell's, read before the Medico-Chirurgical Sopiety of Edinburgh,* in which, making observations from a similar point of view to myself, on a different field, he has arrived at very opposite conclusions. He found in Scotland that more than every sixth idiot born in wedlock was the child of cousins. I am unable to account for such a wide disparity, and in the face of it, can only re- iterate the care with which my information has been collected and the impartiality with which my results are here presented. My own researches conclasively show that in England, at least, every fourteenth idiot only is the child of cousins. But can it be as certainly shown that the relationship joer se is the cause of the idiocy? I think not, and the analysis I have made clearly shows, that in the vast majority of such, so great in fact that it may almost be said to be universal, other causes were operating which were merely intensified by the relationship. Had the same care been exercised in the selection of relations, as is displayed by the breeder of race-horses, vastly different results might have ensued; or were the practice of the coloured races of North America in force, of destroying all the weak, rachitic, and diseased children, the inter- marriage of cousins would not have displayed the facts which I have furnished. Consanguinity has doubtless the power of aggra- * Edin. Med. Jour. Vol. viii., p. 872. 236 DR. DOWN ON MARRIAGES OF CONSANGTJINITY. vating any morbid tendency, as I believe it has, of perfecting any good quality. Any statistics on the results of the marriage of relations are of doubtful value, unless they give the life^histoiy of the progenitors. "What a different aspect the whole matter assumes when this plan is adopted, will be' apparent to the readers of this paper. Whenever a similar investigation is made, I believe it will be found, as in the subjects of my own inquiry, that consanguinity is only one of the factors; and not the most important one, in the pro- duction of deterioration. ' If our advice bescrnght> it wiU be our duty to inquire into other elements which are less on the surface, but which have equal or even greater potentiality for. evil, - Alhances, such as I hive exhibited, \lrith hereditary disease on both sides, should be discountenanded even where there is no element of consanguinity. It would only be a part of a true philosophy to render more forcible our bppiosition where blood-relationship would have a well-determined tendency to aggravate the wrong. A LECTURE* ON PASES OF CEEEBEAL H^MOEEHAGE. By J. HUGHLINGS JACKSON, M.D. Gentlemen, — I show you to-day a patient whose case is a good illiistrStioii ofa common 'feoilditioh,io!f ill'-health, a conditiOh Which leads to, or is associated with, many named diseases. The disease, or rather the symptom, for which the patient came to mej was Heiliiplegia. ' ■ s : ; . • .^ ,• ■. • • The' paralysis came on suddenly, and was beyond doubt due to Apoplexy. But the uge'of the woM apoplexy in the sense of efiSision of blood is liable to lead uS wrong. * * * . . * I shall, therefore, in future,' use the term Cerebral Hssmorrhage. I have littlfe doubt that the efflisi'on occurred in the thalamus' Opticus. I do not now, h&wever, s^eak of the physiological symptom's of the patient's case, but of that general condition of his system which led to the giving way of a blood-vessel in his brain. In previous lectures I have discussed the qudstioti of the position of the disease as regards particular forms of hemiplegia ("Lectures' on Hemiplegia, YoiiL). ■ . : Those lectures were on the physiology—- the Medical Physiology — • This is not a lecture on the general subject of Cerebral Hsemorrhage, but on particular instances of Cerebral Haemorrhage. Yet, in considering a few cases, I have spoken widely on collateral topics, as I wish to describe single cases as illustrating general pathology, rather than to point out how, and where, the nervous system is most often damaged by effusions of blood. Moreover, I have not hesitated before printing to alter, or add to, what I orally delivered, although this involves a little anachronism in the intro- duction of more cases for illustration. 238 DR. HUGHLINGS JACKSON ON of Hemiplegia. Clots are most often found where the brain is most vascular. Therefore, they generally involvei the corpus striatum, and thus cerebral hemoirhage often produces paralysis. But it is scarcely precise to call hermplegii a. s^mptonioi cerfebfal hsemorrhage. The pathology vould be the sarhe if th6 clot were in the hemisphere, in the pons, or in the cerebeMumj although the physiology would be different. So then,' althonglt; the amount. of blood effused, and the sea*t of rupture are! all-important to the patient, yet in the line of thought we are now tafeing^ lip, a point of more importance is — how comes he to have effusion of blood in his nervous-tissue at all ? First of all I beg you to observe that the degree' and persistence of paralysis, in a case of hemiplegia, cannot safely be taken as an index of our patient's chancps of' life. Por the amount of paralysis depends (1) on the position, and (^) on the size of the clot. If it i^ere in the mass ^of the heinisphere, above tke ventricle, there need be no paralysis' at all. There might , be general weatnegs, but no localized paralysis.* Tf the motor tract were irijiired — as the corpus striatum, thalmiis opticus, crus' cerebri, &C.7— there would certainly, be some 'paralysis, however small the clot, at aU events at first, and the degree a.nd permanence of the palsy would depend on the size of the clot thus placed. It might vary. from a little weakness of the limbs, of which the patient only might be aware, to complete loss of, power in them. When the damage to the motor tract — at least to the corpus striatum — is very smaU, the pai-alysis may pass off alto- gether, even when the whole of the damage is iiot repaired .f * It is, in my experience, however, rare to find clots, or cells of clots, larger than a pea, at a great distance from the motor trapt. It is impor- tant to bear this in mind when , we are trying to fix the seats of certain faculties. Some parts of the brain, for instance the posterior" lobes, are rarely the seats of hsemorrhagic effusions, whilst others, as the region of the corpus striatum, are often damaged by clots. ' The vascularity of the region of the corpus striatum is, I think, a fact of great significance in the study of the relations of nutritive life and func- tional activity. On this point I have already written. — " Physiology and Pathology of Language," Med. Times and Gazette, June 23, 1866. t It will be observed that disease of the corpus striatum produces partial paralysis of the arm, and not paralysis of part of the arm. The whole of the arm ia, I believe, represented in every part of the corpus striatum, and so, if the damage to this organ be great, there is complete paralysis of the limb, and if slight, the whole of^ it is weakened. I do not say that every part of the arm sufiers exactly the same. It would be difiicult to prove this, CASES OF CEREBRAL HEMORRHAGE. 239 The better a patient's general health is the more likelj, of course, is he to get over the effects of the injury to the brain which caused his paralysis. And when the damagfe is too extensive to be repaired, and when he in consequence continues paralyzed, there is more hope that he may paste a long time, perhaps years, without any further damage to his nervous ■ system. Although I hold^ as I urged in a former lecture,* that we should jn every case ftry to find the Function Disordered (here the paralysis, &c.), the Organ Damaged (here the thalamus opticus), and the Tissue Affected (effusion of blood from rupture of a vessel), the last is most important. Indeed, I think it would- be far better to ignore the paralysis altogether, than to omit to consider the condition of the urine, arteries, heart, &c. The paralysis' (the disorder of function) in our patient shows that the motor aiid sensory tract, and perhaps the adjoining hemisphere, are (the organs or parts) damaged, but an examination of him generally shows that his tissues are nearly everywhere diseased. So, in making z. post-mortem, examination on a case of cerebral hemorrhage, it is almost as bad td omit to examine the kidneys' ais it ij-ould be not to examine the brain. We are often consulted for more or less sudden disorder of function, consequent on damage of organs ; rarely for as some groups of muscles are stronger than otters. When then one small part of the corpus striatum is damaged, the rest inay be cultivated so as to make up for the want of the part damaged.: This is Important as i-egards the views we should hold as to what we call " centres." The centre for the arm is, I hold, the whole nerVous system of the arm (from the corpus stria- tum to the termination of nerves in muscles, and their origin in skin and other parts) and I think we may find by a consideration of the whole of its nervous system, a gradual ascent from grouping of muscles for simple move- ments like flexion or extension, to completer and more complex actions In doing this we must consider Hilton's law of the distribution of nerves to skin, mussle, &c., and Brown-Sequard's researches on the arrangement of fibres in the spinal cord. In such a view of the matter the brachial plexus is a centre as well as is a collection of grey matter. Its complexity must mean something, and no doubt this arrangement of fibres is a help, probably by induction, to combine movements. Quadrupedal- walking, I think, shows that the crossing of the motor and sensory fibres in the cord has a similar duty. Of course much of this must be speculative, as no one knows the effects of section of any one of the various cords which enter the brachial flexus ; but this is a kind of knowledge which it is most desirable to obtain, and to encourage the search for it I put these speculations on record. * See " Lecture on the Study of Diseases of the Nervous System," Vol. i., p. 146. 240 DB. HUGHLINGS JACKSON ON disease of tissues, so lopg as tjiey will hold together,- J think our jjatient i^ in\a yerj tad cotiditidn; ngt from hi's Physiology, hut from his Pathology, if I may use these- terms 'thus. He has jdready had several • effusions of blood, and is very liable to more attacks of the sfime kind. Besides this), ipe know froip experience that such a patient is ready to give way ait almost auy .ppint, and it is very doubtful, to say the. leagt, under which heading, in the ;Eegistrar-General's list, the final medical record .qt his pase will be made.' i J repeat, that you may^ get very far wrong if you conclude that, bpeause a^patient recovers quicklyi hp is necessarily in a bettej- con- dition than one who remains paralyzed. Of course h6 is to be con- gjratulated that he has got rid of bis paralysis, or of any other trouble ; but yoii ceriaiplyuoiight -uot, I think, to tell him that he is well when- the symptom, he constilted you for, has disappeared. We should know no more than our patient if we 'judged n^erely by the superficial ^vent of recovery from a symptom. ■ It would be to en- dorsie ^n idea, the public not unnaturally ^hasre, that their diseases are accidents, and. are to be cured' by some specific. - • There is, doubtless, an accidental element in the bringing about of hemiplegia. • 4-iid.. sometime? ■ it: seems to be altogether an acci- dent, though, perhaps, in the strictest sense, no event is accidental. A person may tp in rabugt health when the function of his corpus striatum is .quite lost, exdepting, of course, for the paralysis, of his limbs due to the loss of that function. This is so when this part of the brain is' softened from plugging of the artery^— the middle cere- bral — the branches of which Si^pply it .with blood. I have, now under my care in the out-patients' room, a woman, 21 years of age, who had an attack of hemiplegia of -the left side (by-the-way, without affection of speech) one' week 'before her confinement. Under the care of my colleague, Dr. Jraser, she got nearly rid of her paralysis ; but when it was most marked; there was nothing whatever about her condition to indicate general ill-health, and the physiological distur- bance of child-bearing had not affected her much. Of course, I can- not demonstrate it, but I have little doubt that embolism of the right middle cerebral artery was the cause of the hemiplegia in this instance. If so, the hemiplegia was as nearly an accident as it could well be.* • This patient has recently had a " partial fit '' affecting the limbs CASES OF CEREBBAI, HEMORRHAGE. 241 When, however, hemiplegia occurs from hsemorrhage into the cor- pus striatum, we have quite different conditions — the hemiplegia here is really a diiferent disease. In a previous lecture (Vol. i., p. 136), I insisted on this point, and gave four instances of hemiplegia, each of the same physiological kind, but depeiiding on a different pathological condition J and in that lectuTe I begged of you not to mistake Medical Physiology for a complete knowledge of your patient's case. Besides, not only are the damages to the corpus striatum different> •but that they occur in a different kinds of people. In cerebral haemor- rha,ge the Vessel breaks in the corpus striatum ; but, as I have said, patients Kable to it are often ready to give way at many points on slight provocation. The orgaq is more seriously damaged, and the organ damaged has very bad associates. Indeed, so generally unsound is the patient, the text of this lecture, that whilst I give his case to you as an instance of the kind of constitution which patients with cere- bral hsemorrhage have, I must tell you that it is an exaggeration in degree of what is common. The patient I shall show you, at the close of this lecture, has, no doubt, for years been getting into a condition in which the vessels of his brain would readily give way. Erequently, however, our. patients know nothing, or they think little, of the serious changes which render them liable to such accidents. Their tissues become so uni- versally, and yet so slowly, lower in vitality, that there are no parti- cular failures to obtrude themselves until somethiiig gives way, or until some part becomes inflamed. And when a patient comes to us for "winter cough," I fancy even we may think too much of his temporary bronchitis, as h.e is sure to do, and too little of his per- manent emphysema. If he consult us for pneumonia or pleuritis, we must not think we have got to the bottom of the matter by say- ing he has taken cold. A patient's pleura is not a thing apart from him, but a piece of his body ; and when we hear a friction murmur, we must not treat *^— if I may say anything so grotesque — but the inflamed pleura, and the man of whom it is a part. It, doubtless^ simplifies matters, in a superficial sense of the word simple, to know which, have nearly recovered from the paralysis, and I think, as I have already suggested (Vol. i., p. 431, 444, 467), that after partial or apparently complete recovery from the paralysis due to hlocking of the middle cerehral artery or some of its branches, sometimes the patient is liable to unilateral epileptiform seizures affecting the side previously paralyzed. B 242 DR. HUGHLINGS JACKSON ON that there is lymph effused, and to thint of mercury, and to try to get the lymph taken up. Just so, it is very loose talk, talking of treat- ing hemiplegia, for hemiplegia is not a constant quantity. Yet, the man who thinks of hemiplegia as ^n entity, and gives what he has found " good for hemiplegia," w,ill have a certain kind of satisfac- tion. But it makes one less confident in the treatment of diseases of the nervous system to define severely when we can, the internal changes oh which the outward symptoms depend. When we can, as it were, see a great brutal clot, or a large, irregular, yellow- stained cavity, in the motor tract, we are less hopeful. The following case illustrates the false confidence I have spoken of, and also what I have been saying about recovery from paralysis, being no safe sign that the patient is likely to continue in health. This patient died, and I am able to give you particulars of the autopsy we made. After reciting his history, I shall return to the case, the chief text of this lecture. Early in 1865, in Harrison's ward, there were two* patients, who were hemiplegic, and each had albuminous urine. One, aged 47, did not improve at all ; the other (W. K.), aged 40, recovered quickly. The first patient had degenerated arteries as well as renal disease ; but although he was thus evidently in a bad enough condi- tion, I thought the other (W. K.) was in a much worse one. The latter had extensive retinal degeneration, such as we know to be characteristic of chronic Bright's-disease, which the former had not. The existence of marked retinal degeneration, leads me to think very unfavourably of cases in which it is present, however little the sym- ptom, for which the patient consults me, may incapacitate him. The following is a very instructive history to those who wish to think a little beyond single striking symptoms: — W. K., 40 years of age, a brewer's servant, was transferred to my care by my senior colleague. Dr. Parker. He was admitted February 20th, 1865, having been attacked three hours before with apoplexy, which produced complete hemiplegia of the left side. He was, * I have spoken of these two cases, and also of that of a third patient, in the ward at the same time, in a paper in the Royal London Ophthalmic Hospital Reports, Vol. iv., Part 4. I have not hesitated to hreak the narrative whenever I have thought a symptom required a larger illustration than one case could give it. CASES OF CEREBEAL HAEMORRHAGE. 243 when admitted^ only partly sensible; and when he came to himself, he talked badly, as many hemiplegics do at first, whether they be affected on the right side or on the left. Next day, however, he was intelligible ; and when I first saw him, a few days later, he talked quite well. He had the common form of hemiplegia, in which we find, after death, disease, either of the corpus striatum, or of the thalamus opticus, or of both. On the diagnosis of the position of disease, I wish to say little now ; and I particularly beg you to ob- serve, tiiat the following investigations ought to have been made, if the effusion of blood had been in the retina only, or if the case had been so sifnple a thing as epistaxis. W. K. had, he said, been " amongst beer all his life." Yet, for a brewer's servant, he had been temperate. He had drunk only five pints of beer a-day, and " a chance drop of spirits now and then." It may seem odd to call this great excess "temperance;" but I speak comparatively. I liave now, under my care for epilepsy, a young man, also a brewer's servant, who says he has been in the habit of drinking twelve pints of beer daily. A gallon a day is not a very uncommon allowance. He got his beer for nothing, and it rarely occurs to patients in this rank of life, or in one a little higher, that now and then fluids, which cost much, had better be poured down a drain than down their own throats. It must be admitted that some of our patients bear ihis continued excess for a very long time without being incapacitated by disease. I have now under my care, a man 55 years of age, who has had, as I pointed out to you in a former lecture, hemiplegia from hijemorrhage into the left side of the pons Varolii. This patient tells me that he has not once gone to bed sober for twenty years. For all this he has no albumen in his urine, although I have very often looked for it. His arteries are only very slightly moveable, and he seems generally vigorous. Moreover, he rapidly recovered from the attack of paralysis. (See London, Hospital Reports, Vol. ii., p. 323.) Do not, however, misunderstand me to mean that drink is the sole cause of degeneration of tissue. We meet with granular kidney, with retinal disease, and with cerebral hsemorrhage, now and then, in young and temperate women. Eecently 1 had, under my care, in Charlotte ward, a woman only 19 years of age, who died of cerebral hsemorrhage. She had ex- B,2 244 DR. HTJGHLINGS JACKSON ON treme granular disease of the kidney ; and during life we saw that the retinse were degenerated, and there were patches of blood scattered in various parts of them. We saw these little clots again after death. Mr. Frederick Mackenzie removed the posterior halves of the globes without interfering with the fronts of the eyes, and, therefore, without disfiguring the patient. The cerebral arteries were much diseased, and there was a large clot in the left hemisphere. W. K. was a stout, flabby, greasy-looking man. His arteries were large and prominent, and were easily seen to move, and felt large and tough to the finger. When he flexed the elbow-joint, we saw that the brachial artery did not accommodate itself to the new position, but arranged itself in several large curves. The apex of the heart was felt to beat on a line with the nipple, and there was a general heaving over the ventricle. At the apex was heard a slight systohc murmur. There was no evidence of aortic regurgitation to account for the mobility of the arteries. There was very trifling oedema of the feet, but a year before he had had swelling of the legs, and he was then away from work five weeks. It is a mistake to think that the complete absence of dropsy nfegatives kidney disease. You must not use the expression, " there is no evidence of kidney disease " when you have not examined the urine. Indeed, you will observe that patients the subjects of retinal or cerebral hemorrhage, rarely have dropsy beyond a little oedema of the feet or back, but I have scarcely ever made a post-nMrtem examination of the body of a patient who had died after cerebral hffimorrhage without finding decided evidence of granular disease of the kidney. In a former lecture (Vol. ii., p. 314), I told you that I had never made an autopsy on a case of cerebral haemorrhage without finding disease of the kidney, but I have recently seen two cases in which I could not say there was anything wrong with this viscus. One of these patients, whose brain Mr. Llewellyn brought to me, however, had instead, if I may say so, cirrhosis of the liver. Of course I exclude cases of hsemorrhage from rupture of aneurisms of the cerebral blood-vessels, in which cases there is no reason to expect an association with disease of the, kidney. Neither must you conclude, that because a patient's urine contains no albumen at one or two examinations, that his kidneys are healthy. Eelieve your minds by stating the facts, that the urine contains no CASES OF CEEEBBAL HiEMOBBHAGE. 245 albumen and no casts, and not by the inference that there is no disease of the kidneys. A few weeks ago, we had in the Hospital, under Dr. Fraser's care, a middle-aged patient who died, after a succession of severe convul- sions. Mr. George Mackenzie tells me that there was no albumen in the urine during life, but the patient^s kidneys were found, at the autopsy, to be very much diseased ; the brain appeared to be healthy. Probably the man died of disease of the kidney, although there was no albumen found in his urine after a few examinations.* To resume W. K^s. case. I dilated his pupils with atropine, and several of us examined his eyes with the ophthalmoscope. We found in each eye changes which are characteristic of Bright' s-disease. The optic discs were nearly lost in a general reddish-white haze, and the veins, seemed here and there, to be partly buried in it. In some parts of the fundus, especially about the yellow spots, there were white patches of various sizes like droppings of melted tallow. The ophthalmoscope was used here for the sake of observing tissue changes, and not in order to learn if the eye, as an apparatus, was normal (See Lecture on the Study of Disease of the Nervous System, Yol. i., p. 147). Indeed the man said that he had always had good eyes, and seemed to wonder why I examined them. He could, however, only read large newspaper print,, although, if he had had convex glasses, he would probably have read smaller type. An ophthalmologist would tell you that test types ought to he used, and that degrees of myopia and presbyopia ought to be estimated carefully. I agree with this, and whilst excusing myself on the ground of want of time, I regret that I did not investigate the state of this patient's sight more precisely. I generally carry with me a few convex and concave glasses, in order to tell readily whether a patient's imperfect vision be due merely to presbyopia or to myopia. Many people of this patient's age require convex glasses to see to read well. Of course the loss of accommodation which constitutes * How he died from disease of the kidney, however, I do not know. All I know of serous apoplexy is that it seems to he a form of ursemia, hut in this patient's hrain there was no excess of serum. It is then almost gratuitous to say that he died from disease of the kidney, as I am quite sure patients die in a similar way who have healthy kidneys, and whose hrains appear to he normal. 246 DB. HUGHLINGS JACKSON ON presbyopia is due to slight degenerative changes, and therefore means something, but it does not mean much. I wish here to impress on you, that we are not justified in saying there is nothing wrong with our patient's eyes, when he tells us that he can see well. This apphes especially to Optic Neuritis. Slow changes are probably overlooked by the patient until they actually incapacitate. At all events, you will not unfrequently find very striking abnormal changes in the fundus when the patient can read very small print. I beg of you to use the ophthalmoscope, in cases of cerebral disease, at all events, in all acute cases. I am quite sure that you will sometimes form an imperfect idea of your patient's caSe, unless you do. Of course record that the patient can see to read small print, but also record the. abnormal appearances in his visual apparatus. W. K. not only thought his sight was good, ,but he thought his general health had been good too. He insisted that he had always been well, except for the short illness of the previous year, and, he had kept at his work. Indeed^ he had felt quite well, until one unlucky morning when, on entering a stable, he found that one foot lagged, and soon after he became insensible. The arteries of his brain, how- ever, had, no doubt, been for a long time slowly getting less elastic and more brittle. Yet his bad tissues answered indifferently well in general, untU one part, perhaps worse than another, suddenly gave way, and then this universally unsound man was brought to us for an actual disease. It is wonderful how long bad materials wiU sometimes keep to- gether. It may be, that although the patients are unsound, their general unsoundness is conservative. There is no healthy organ left to overwork the unhealthy ones. These patients descend into a lower sphere of vitality altogether-^-one which will do for routine work, for fair weather and for easy circumstances. The healthy human body, as Mr. Paget says, is fitted for the storms as well as for the calm of life. But patients like W. K. have no spare vitality, and, as I have said, are ready to give way under unusually unfavourable circumstances. They are ready to die at any point. A man with chronic Bright's-disease may die of apoplexy, of bronchitis, of ursemia, of pericarditis, &c., &c., but to look on the pericarditis, apoplexy, &c., in such cases as idiopathic, as essentially different things, rather than CASES O? CEREBRAL HEMORRHAGE. 247 as different events, depending on one general condition, would be to think, as those historians seem to think, who write history from the reigns of kings, from battles and other striking events. It would be as reasonable to consider the outbreak of the French Revolution as idiopathic, as it would be to consider W. K.'s attack of cerebral haemorrhage as idiopathic. Moreover, and this brings me back to his case, such a patient may be attacked with one of the above diseases, and when recovering may die of another. W. K. was con- gratiilating himself on getting rid of his paralysis when, on April ISth, he took to his bed, became gradually more and more stupid, his skin became hot, he had occasional delirium but no convulsions, and in a few days he died. At the post-mortem examination, kindly made for me in my absence, by Dr. Woodman and Mr. James Adams, a very large, dirty reddish clot was found in the right hemisphere. It occupied nearly the whole length of the hemisphere to the outside of the lateral ventricle, but had not broken into the ventricle. A good deal of serum was also found beneath the arachnoid, and "there was some purulent lymph on the layer of dura mater on the posterior part of the foramen magnum.^'' The kidneys were granular; the left ventricle of the heart was hypertrophied, aad there was atheroma on the valves. The lungs were emphysematous, and were congested, especially at their bases. Whether this patient's death be attributable to arachnitis, due to the kidney disease, and whether indirectly lo general cerebral disorder, being excited by the clot acting in the brain as a foreign body, I can- not tell. It is believed that there is no such thing as" idiopathic arachnitis, but we occasionally meet with cases of arachnitis in which we can discover no local exciting cause, such as injury, diseased bone, &c. In a case of arachnitis, occurring with kidney disease, I have heard Dr. Barlow suggest that the arachnitis may have arisen, as we know pericarditis does, from or with disease of the kidney. Although this, of course, does not explain its occurrence, it puts the question on a particular basis for a possible explanation. We now see that W. K's, recovery from his paralysis wa^ a very small fact to the credit side of health. It did not even point to a small clot, but was owing to the fact, that a large one was placed outside the lateral ventricle. 248 DR. HUGHLINGS JACKSON ON I think, much less, paralysis is produced by damage to the extra- ventricular part of the corpus striatum, than by damage of the part which is in the lateral ventricle. Of course, I do not include cases in which the bodies in the floor of the ventricle are undermined, as they not unfrequently are. I will now relate another instance of rapid recovery from hemiplegia, due to hsemorrhage : a case in which the clot was a very small one. A year ago, I had under my care a patient who was suffering from locomotor ataxy. He had an attack of hemiplegia, and then, by the courteous consent of Mr. Lammiman, I saw the' patient at home. The paralysis was on the right side, and for about twenty-four hours speech was lost. Now, although in this patient the paralysis passed off even more quickly than in W. K's. case, — indeed, in' two or three days, — J thought very unfavourably of the case, as the man had Bright's-disease, as well as the symptoms of locomotor ataxy; At ih& post-mortem examination, some weeks later,, we found the remains of several small clots in his brain, one the size of a pea (and this no doubt caused the paralysis), involving the ventricular part of the left corpus striatum, where it becomes narrow, and the hemisphere near it. One pleural cavity contained a good' deal of fluid. The kidneys were gran'iilar, and the left ventricle of the heart was much hyper- trophied. I shewed you all these parts in a former lecture. The paralysis was so transitory, in this case, that the hemiplegia might have been considered, during life, to have been due to those very slight changes which we call functional. The rapidity of recovery was doubtless due to the fact that the clot was a very small one, and that it involved very little of the motor tract. This case, and that of W. K., shew that we might get far wrong if we were trying to find out what would " cure" hemiplegia — if we thought the drug we gave a patient had cured him, simply because the paralysis passed off after he had taken it. Such an inquiry would be a very hopeless one. It might be intelligible conduct to try to find out what drugs would cure cerebral hsemorrhage ; it would be, at all events, getting nearer to a thing to be done. In neither of' these cases was any drug treatment relied on. And, indeed, I know of no rational plan of curing cerebral hsemorrhage except so far as treating the patient goes. Upon the whole, the best thing you can do, in cases of slight cerebral hammorhage, is to keep the patient CASES OF CEREBEAL HJEMOERHAGE. 249 quiet, remembering that lie has got an injured brain, and that it chiefly requires rest. There is empirical evidence to shew that purgation does good, but we must not add an artificial diarrhcea to the troubles of the system, without a full consideration of what the system can bear. I am not speaking of those severe cases generally called Apoplexy. As to curing, we may " cure j)aralysis " in which there are small clots near the corpus striatum by charms, or globules, but if the motor tract be largely ploughed up, we shall do very little to restore the patient's power. Let us then, turn to what we can do, or rather let us look in the direction in which something may be hopefully expected. Towards this end, besides considering what local damage has been inflicted, let us see what more is likely to happen to the patient when the effects of that local damage have disappeared or diminished as much as they are likely to do. As we cannot treat the local disease with much satisfaction, we must do what we can for the general health. We examine all the important organs, study the conditions of the tissues by examination and inference. But the General Health of many of our patients, as you will have gathered, is not unfrequently General Disease, and unfortunately it often remains so after the eager use of our feeble remedies. The more we know of pathology, the less we can believe in treatment. Had I lived a thousand years ago, I might have cured a case like that of Mr. Lammiman's patient, by charms ; a hundred years ago by some rare drug, but I am glad I live to-day when it is known that such patients recover when let alone. If the haemorrhage had been into the retina only, in the case of W. K., the prognosis would also have been very unfavourable. I do not say quite as unfavourable ; for we must bear in mind that after an attack of cerebral haemorrhage, especially when the effusion has been considerable, the patient has a foreign body in his brain, and this may "excite" general changes — a sort of cerebral fever. The thermometer ought to be used in such cases. I say general changes, but I have not a very clear idea what they are. Hence it is very important to keep a patient quiet who has a clot lying in his nervous tissues. Again, if the clot breaks into the ventricle the seizure is, I believe, nearly always fatal. However, commonly, haemorrhages in nervous tissue have, independently of the importance of the symptoms due to their size and positions, one general bad significance.. The following case is another illustration : — 250 DR. HUGHLINGS JACKSON ON Last winter a patient, sent to me by Mr. P. M. Corner, came' to the out-patients'" room, for slight defect of sight, and giddiness. The former was due to effusion of blood, for we saw it in the retina, and very possibly the giddiness was due to small clots in the hemisphere, of which, of course, we had no means of being quite certain. It may have been due to bad blood from failing work of the kidney. As, besides the effusion of blood, we found the degeneration of the retina of which I have spoken, albumen in the urine, and rigidity of the arteries, we thought very ill of our patient's case, notwithstanding the comparative slightness of his physiological symptoms. A few weeks later this patient died under Mr. Corner's care, of pericarditis. The following case is more stiiking still : — ■ Some years ago I saw, when clinical assistant at Moorfields, a patient under the care of Mr. Wordsworth, who had, first, effusion of blood in each retina and considerable defect of sight, and next, hemiplegia. He, however, recovered his sight to so great an extent, that he thought he saw as well as ever he did, and he got into what he considered to be perfect health. Yet I found that his urine con- tained albumen when he left the Hospital, and about niae months from the first attack of haemorrhage (that is the retinal),* I heard that he died of, it was believed, cerebral hemorrhage. If a patient of middle age were to consult you for a slight epistaxis, you ought; I think, to examine his urine, and if it were albuminous, if his arteries were rigid, and, above all, if his retinae shewed signs of degeneration, you would have to think seriously of his case, however careless he might be of so apparently trivial a thing as the loss of blood by the nose. Epistaxis, giddiness, and all such symptoms, are not so interesting as loss of speech, but their significance is very great, and ought always to lead us take stock of our patient's state of health. I fear there is a risk that you may let your minds dwell too much on symptoms of great physiological interest and under-rate the general condition of the patient. Again, some cases have a sort of dramatic interest which gives them undue importance. If a clergyman begins to talk badly all at once in the pulpit, the alarm is greater, but in reality the epis- * I would here refer the reader to the Medical Times and Gazette, Nov. 18th, 1865, for cases and remarks by Hnlke, Ernest Hart, Hutchinson, Fuller and Gull on retinal disease with disease of kidney. CASES OF CEKEBRAL HEMORRHAGE. 251 taxis in ray patients' case was, I think, quite as significant. The former would be more important, as the nervous system would be damaged in a more important part ; but, when it had passed off, it need frighten us no more, and no less than epistaxis would do if the patient were generally unsound. I hope I need scarcely tell you, that I hold as strongly as any of you, that the position of disease should be ascertained wherever it can be, but I think it a very gross mistake to direct most of our efforts to finding where the disease is, instead of trying to ascertain how it happened, and what is likely to become of the patient who has it. So then, whether the symptoms be aristocratic or plebeian, you must think from them, as evidence of your patient's general conditions, and not on them as individual diseases. Sometimes epistaxis precedes retinal apoplexy as it does the more serious apoplexy of the brain. I have now under my care in the out-patients' room, a patient whose case illustrates this relation. A man, 49 years of agCj had two years ago bleeding from the nose to the extent of " a basinful and a-half." Five months before I saw him he had hemiplegia of the right side and loss of speech. He came to me for the two latter symptoms having, however, nearly re- covered from them. He had then, and since, albuminous urine, and subsequently haemorrhage in the retina of the left eye. For the defect of sight he afterwards consulted Mr. Hulke, but soon returned for a slight attack of hemiplegia of the left side, which is rapidly passing off. This man's case is a very interesting instance of a succession of similiar pathological changes producing very dissimilar results. Un- fortunately it is not very probable that I shall get to know what becomes of this out-patient. I fear it is scarcely likely that he will live long, and it is very doubtful of what diseased organ he will die. Slight effusions of blood in the eye are more frequent than is sup- posed. In some positions they affect the sight so little, that the patient may not consult an ophthalmologist, and the physician may not use the ophthalmoscope. When a patient complains of the slightest dimness, the eye should be examined by tiie ophthalmoscope, or we shall lose facts of great significance. A woman, who was at- tending at the Hospital for epilepsy and paralysis for unilateral epi- leptiform seizures, complained that one day there came a dimness 252 DE. HUGHLINGS JACKSON ON over her eye like a " corkscrew." I found a small clot on the optic dise. Her urine contained albumen. It is not very long since I should have put down such defects of sight in cases of disease of the nervous system to central damage, and I might, perhaps, have relieved my mind by some formula, such as "congestion," "thickening of membranes," "effusion of serum," " disordered circulation," or " irritation." Much of our progress, if I may use an Irishism, is going back, and the great ad- vantage of the ophthalmoscope is, that it has driven away many of the presuming technicalities which pretended to settle large ques- tions, and yet which contained very little real truth. We can come closer to things. The ophthalmoscope has stripped our ignorance of some eye-diseases nearly naked, and w-e rarely now hear people talk of "curing" amaurosis. I do not deny the temporary value of such terms. For, whilst they give body and form to masses of error, we feel that they contain a certain amount of truth which we cannot define, and which we cannot afford to lose. We all of us use many such words — e.g.. Hysteria, — and but little harm wOl happen from their use, if we re- member that they are definitions of our ignorance, as well as state- ments containing something that we know. If we destroyed all words of which this might be said, we should, I fear, destroy language altogether, and render thought itself impossible. Retinal apoplexy does not, however, always, I think, indicate wide degenerative changes, although, I believe, it generally does. There is now in the Hospital, under the care of Dr. Davies, a woman who had, as Mr. F. Mackenzie pointed out to me, a small haemorrhage near a vessel in the apparent lower half of the left fundus. It did not impair her sight much, and it soon disappeared. She had dropsy from heart-disease ; but no evidence of kidney- disease. The patient, whom I shall show you at the close of this lecture, and of whom I spoke at the beginning, has had epistaxis. I now relate his case : — This patient also came under my care, November 17th, 1865, hav- ing been admitted by Dr. Parker, who was good enough to transfer him to me. He is 53 years of age ; he has had, I think, several effusions of blood. For a fortnight before Easter Monday, 1865, he had every night attacks of vomiting. He had violent retchings, but he brought up OASES OF CEEEBRAL HEMORRHAGE. 253 nothing yellow or green. It was not the bilious vomiting of what we hear so much in cases of brain-diseasCj although it had, doubt- less, the same meaning. It may be said that, as this patient has renal disease, the vomiting was due to the more general effect of poisoned blood, rather than to a local lesion of the brain. It is not possible to be quite sure ; but I think it was just as hkely that the vomiting was a symptom caused by injury to a part of the hemi- sphere by a clot. One thing is quite certain, that disease of the hemisphere does produce symptoms such as this patient had, and I shewed you a good instance the other day in a case of cancer, affect- ing the middle lobe of the cerebrum, in a patient who had had optic neuritis and severe vomiting. The attack* was not enough to keep my patient from work, but he was not fit for much, and he suffered from headache. I have often told you that there are three symptoms, which very fre- quently come together, optic neuritis, vomiting, and severe headache. As a rule, these symptoms are produced by tumours, but now and then they come from effusion of blood. Sometimes they occur directly after the haemorrhage, and not unfrequently after awhile, perhaps when the patient thinks he is well from the secondary effects. This, however, is too wide a subject for this lecture. I merely say, in passing, do not hastily conclude that vomiting is due to something wrong with the stomach, or that nervous symptoms with stomach symptoms, are due to derangement of the digestive organs, nor, if you find, albuminous urine, to kidney-disease. Vomiting is a s;^m- ptom which very often attends general disturbance of the brain, whether that be a shock . from sudden pouring out of blood, or the changes (encephalitis) which are " excited " about " foreign bodies." And these foreign bodies may be haemorrhages, as well as tumours. Amaurosis (optic neuritis) is often part of these changes. When the changes are slower, or when the acuteness is over, epileptiform seizures may follow. These facts show how wide the relations are which the symptom vomiting has. Again, when vomiting occurs with • As will be seen by the antopsy, I was probably wrong in this opinion, but I am not wron" in saying that haemorrhage into the hemisphere may produce little more than what for brevity I may call stomach symptoms. A case recorded by "Mr. Gregory Forbes, Path. Soc. Vol. xiii., p. 7, shews this. 254 DR. HUGHLINGS JACKSON ON apoplexy do not take it as certain evidence tliat the clot affects the medulla oblongata, or the cerebellum.' The second haemorrhage occurred during the first fortnight. Although this was only epistaxis, it ig, as I have already urged, a symptom to be carefully noted. We must not, however, forget that it is held by many, that bleeding at thg. hose is salutary as relieving the circulation of the head. It may be so, and, indeed, I think there are reasons for believing that cerebral hsemorrhage may be, sometimes, due to nipture of veins, rather than qf arteries. If so, bleeding at the nose might relieve the venous system generally. Still I think the general evil significance is' pretty much the same, whether blood be effused in the retina, or in the nose, and in each of these cases it is not so much a question of the symptoms as of the state of the tissues of the patient who suffers. The third effusion of blood produced the prominent symptom for which the patient consulted me, namely, the hemiplegia of the left side, which came on on Easter Monday, 1865. To the quasi-acci- .dental circumstance, that this effusion was in the motor tract, I owe it that he became my' patient. Had the first large effusion been in the retina, he would have gone to an Ophthalmic Hospital. Had it been at the nucleus of the ninth nerve, he might have gone to a Laryngoscopist. If bronchitis had been the most urgent sym- ptom, he might have gone to Victoria Park. If the hsemorrhage had occurred in the labyrinth, to some Aural Surgeon. Einally, I introduce the Special Hospital with which I am connected. The patient had been under the care of one of my coUeagties at, the Hospital for Epilepsy and Paralysis. The geographical dis- tribution of disease in London is a curious and interesting subject for study. It would, perhaps, be better if cases were distributed — if there is to be a division of labour' — according to disease of tissues, rather than according to damage of organs. Yet, to suggest this is very likely to suggest one impracticability in the place of another. The attack of hemiplegia came on suddenly, but the patient was not insensible. He said that in the morning, about eight o'clock, as he was preparing to go out with his family, he " began to heave," but did not actually vomit. His left knee gave way ; his left fingers felt stiff, and he fell down. He was at first completely paralyzed, and kept his bed fourteen days, and could, not get out of bed by CASES OF CEKEBRAL HAEMORRHAGE. 255 himself fqr a month. During this fortnight he had gout affecting the non-paralyzed hand, leg, and elbow. I have very little doubt that this attack was owing to a clot. It might be held that as therp was no insensibility, the paralysis was due to the giving way of a few softened fibres ; yet the presence of chronic kidney-disease, in adults, would generally lead to the diagnosis of effusion of blood, when the brain symptoms are one-sided, and come on in the midst of usual health. The more I see of the pathology of the brain, the less do I.believe iii limited sbftening as a cause of decided and continuing local paralysis. In nearly all the cases of hemiplegia, I have examined juos^rmo»-^e/w — putting on one side such obviously different causes as embolism, tumours, &c,. — I have found clots or their remains. Of course, I keep in mind the obvious fact that T do not get post-mortem , examinations on those who get well and keep well. In some cases where the paralysis has been transient, the clot has been a very sma:ll one, or has been near to, or has broken up little of the motor tract (see Case p. 248), I introduce these remarks, as I know thkt some distinguished "men, for whose opinions I havea very^reat and an increasiiig teispect, apcribe transitory attacks of hemiplegia— I do not inean epileptic hemiplegia, hor ought I per- haps to say, in cases in which thfcre is such evidence of degeneration as my patient presents— to those slight changes, which are called functional. I hesitate myself td ^dopt such' a qdnclusion, but I ask you to bear this view in mind as a possible explanation of transient liemiplegia when it occurs in jiatients whose tissues appear to be healthy, or rather not to be in a bad enough condition to justify us in diagnosing rupture of a blood-vessel. I am myself confident that quick .recovery is no certain evidence that there is not obvious, although of course hmited, disease in the brain. And you must clearly understand that cases of hemiplegia are met with, in which there is not sufficient evidence on which to come to a diagnosis of the cause of the damage which produces the paralysis. There are many cases of disease of the nervous system in which, as a first step towards discovery, a definition of our ignorance is urgently required. It is a sign of an uncultivated mind to deter- mine to come to a conclusion whether there is precise evidence or not. It is not possible sometimes to say whether hemiplegia is the result of softening from emboUsm, or of tearing from haemorrhage. 256 DE. HUGHLINGS JACKSON ON Our patient had a fit in August, He had regained enough power in his arm and leg to go about, and was on a short railway journey when it happened. Here let me mention that we must not think our hemiplegic patient is deceiving us as to the degree of his paralysis, because he can manage to get over a good deal of ground in a day. One of my patients, who was formerly, as most of you know, a servant at this Hospital until he was disabled by an attack of hemiplegia, tells me, and I have no reason to doubt his statement, that he has lately walked fifteen miles in one day. Yet he is 'still hemiplegic, and swings his leg in a very marked manner at every step. Were he suing some Company for damages, we might wonder how so much power for walking could remain with such decided paralysis. He got into the train at the Caledonian Eoad station, on the North London Kailway, and then remembered nothing more until he found people washing his f^ce at Bow Station. He soon got well and went home. Unfortunately there is no evidence as to the kind of attack this patient had. I think it very likely that he had had some con- vulsive seizure. The paralysis was not increased. Now I am quite safe in telling you that such a patient is liable to convulsive seizures from effusion of blood in the brain, but whether this convulsive seizure, if it were one, was so caused or not, I cannot say. If it were, it was the third effusion of blood. The fifth was an effusion of blood in the retina, and this you will see for yourselves. Now let us examine the patient who has suffered from these four attacks. His condition is pretty much like that of the patient (W. K.) who died, but it is not, I think, so far advanced. He has moveable rigid arteries. You see that the temporal - artery is much curved, and, as in W. K.'s case, the brachial artery does not accommodate itself to the change produced by bending the arm. I do not wish to deny that such evidence of degeneration af arteries is at all uncommon in persons 53 years of age, but I hope it is far from niarmal, since we frequently find very much softer radial arteries, than this patient has, in people considerably older. For instance, yesterday, I had, amongst my out-patients, a man 85 years of age, also a woman 82, and another woman 76, whose arteries were very much better, I CASES OF CEBEBRAL HEMORRHAGE. 257 cannot but think that it is a libel on old age to class these premature changes with the orderly decline of age. He had a small but decided arcus senilis. The first sound of the heart was indistinct^ and the heart's impulse was diffused^ and there was a general heaving over the cardiac region. He had then hypertrophy of the left ventricle of the heart. His thorax was everywhere far' too resonant. It was barrel-shaped, and the respiratory murmur was diminished. He has also suffered repeatedly from gout, &e. ; indeed, for twenty years he "had had more pain than ease.'-; His father had never had it, bat three of Ms brothers had. The pupils were ;very small,i but are now dijated by atropine. Although this patient' reads the newspapei;- and appears to see weU, the changes in the retinae are very striking. The dptio disc is scarcely to be distiu'guishedi' except by the convergence of its vessels. Its colour is a sdrt of' reddish- white, and this whiteness extends beyond the edge of the digc, whicli it obscures, and gradually fades away with- out any margin. • The veins are much larger than the arteries. There are a few very small efiiisions of blood near the yellow spot. [I then spoke shortly of the :paialysis. ■ There was considerable loss of sensation on the paralyzed side. Eor further remarks on this part of the case which is purely physiological^ and involves questions of extreme importance, see .the paper on the Functions of the Thalamus Opticus.] ' ***** The patient left the Hospital towards the end of December. As I was very anxious to know how he went on, I called on him on December 80th, and was told that he had had a second fit. He fell, became insensible, and foamed at the mbuth, and after the fit it was found that he had knocked a tooth out in the fall. But the things he chiefly complained of were dif&culty of breathing and headache. He had had another attack of gout. It is needless to give in detail the further progress of the patient, although, thanks to the permission of Dr. John Richardson, I had good opportunities of observing it. I have to thank this gen- tleman for many acts of kindness in connexion with the case, and for much valuable help towards the correct observation, of the sym- ptoms. In about the middle of January the patient suffered much 258 DE. JACKSON ON CEEEBEAL H^MOEEHAGE. from attacks of sickness, in wMch he brought up nothing but a little mucus. Towards the end of January his sight failed rapidly, and in about a fortnight he was practically bhnd. The margin of the disc was lost, and the whole background of the eye presented a mealy-white appearance. The arteries were only here and there to be seen, and the- veins were partly obscured too. Near the yeUow spot were several recent linear streaks of blood, and there was one also near a vein in the optic disc. I again admitted him into the Hospital, but on February the 24th, his friends took him out. He was much worse ; he had considerable pain in his head ; had lost his appetite j was in low spirits. He was exceedingly exhausted when he got home, and next morning about seven he had six fits. He died February 27th. Until his death he had frequent fits, and was in the intervals of the seizures, comatose. I saw one of these attacks, and in that the left — ^the paralyzed — side was the one convulsed. The right side was quite lax in this fit. At the autopsy — made by Dr. Eichardson, Mr. Powdl, Mr. W. H. AnseU, and myself — we found disease of the optic thalamus, — the remains of an old haemorrhage — extensive granular disease of the kidneys, and hypertrophy of the left ventricle of the heart, &c. For further details of the case, I refer to my next paper. OBSEEYATIONS 0^ AN ETHNIC CLASSIFICATION OF IDIOTS. By J. LANGDON H. DOWN, M.D., Lond. Those who have given any attention to congenital mental lesions, must have been frequently puzzled how to arrange, in any satisfactory way, the different classes of this defect which may have come under their observation. Nor will the difficulty be lessened by an appeal to what has been written on the subject. The systems of classifica- tion are generally so vague and artificial, that, not only do they assist but feebly, in any mental arrangement of the phenomena which are presented, but they completely fail in exerting any practical influence on the subject. The medical practitioner who may be consulted in any given case, has, perhaps in a very early condition of the child's life, to give an opinion on points of vital importance as to the present condition and probable future of the little one. Moreover, he may be pressed as to the question, whether the supposed defect dates from any cause subsequent to the birth or not. Has the nurse dosed the child with opium ? Has the little one met with any accident ? Has the instru- mental interference which maternal safety demanded, been the cause of what seems to the anxious parents, a vacant futare ? Can it be that when away from the family attendant the calomel powders were judiciously prescribed? Can, in fact, the strange anomalies which the child presents, be attributed to the numerous causes which maternal solicitude conjures to the imagination," in order to account for a condition, for which any cause is sought, rather than hereditary s2 260 DE. DOWN ON AN ETHNIC taint or parental influence. Will the systems of classification, either all together, or any one of them, assist the medical adviser in the opinion he is to present, or the suggestions which he is to tender to the anxious parent ? I think, that they will entirely fail him in the matter, and that he will have in many cases to make a guarded diagnosis and prognosis, so guarded, in fact, as to be almost value- less, or to venture an authoritative assertion which the future may perhaps confirm, I have for some time had my attention directed tp the possibility of making a classification of the feeble-minded, by arranging them around various ethnic standards, — in other words, framing a natural system to supplement, the information to be derived by an inquiry into the history of the case. I have been able to find among the large number of idiots and imbeciles which come under my observation, both at Earlswood and the out-patient department of the Hospital, ■•.that a considerable por- tion can be fairly referred to one of the gre^t divisions of the human family other than the class from which they have sprung. Of course, there are are numerous repregentativjes of the great Caucasian family. Several well-marked e;samples of the Ethiopian variety have come under my notice, presenting the characteristic malar bones, the prominent eyes, the puffy lips, and retreating chin. The woolly hair has also been present, although not alyays black, nor has the skin acquired pigmentary deposit. They have been specimens of white negroes, although of European descent. Some arrange themselves around the Malay variety, and present in their soft, black, curly hair, their prominent upper jaws and capacious mouths, types, of the family which people the South Sea Islands. Nor have there been wanting the analogues of the people who with shortened foreheads, prominent cheeks, deep-set eyes, and slightly apish nose, originally inhabited the American Continent. The great Mongolian family has numerous representatives, and it is to this division, I wish, in this paper, to call special attention. A very large number of congenital idiots are typical Mongols. So marked is this, that when placed side by side, it is difficult to beheve that the specimens compared are not children of the same parents. The number of idiots who arrange themselves aiound the Mongohan CLASSIFICATION OP IDIOTS. 261 type is so great, and tbey present such a close resemblance to one another in mental power, that I shall describe an idiot member of this racial division, selected from the large number that have fallen under my observation. The hair is not black, as in the real Mongol, but of a brownish colour, straight and scanty. The face is flat and broad, and destitute of prominence. The cheeks are roundish, and extended laterally. The eyes a^e obliquely placed, and the internal canthi more than normally distant |from one another: The palpebral fissure is very narrow: The forehead is Wrinkled transversely, from the constant assistance which the levatores palpebrarum derive from the oecipito- frontalis muscle in the opening of the eyes. The lips are large and thick with transverse fissures. The tongue is long, thicJk, and is much roughened. The nose is small. The Skin has a slight dirty yellowish tinge, and is deficient in elasticity, giving the appearance of being too large for the body. The boy^'s aspect is snob that it is difficult to realize that he is the child of Europeans, but so frequently are these characters presented, that there can be no doubt that these ethnic features are the result of degeneration. The Mongolian type of idiocy occurs in more than ten per cent, of the cases tirhich are presented to me. They are always congenital idiots, and never result from accidents after uterine life, . They are, for the most party instances of degeneracy arising ffoin tuberculosis in the parents. They are cases which very much repay judicious treat- ment. They require highly azotised food with a cotisiderable amount of oleaginous material. They have considerable power of imitation, even bordering on being mimics. They are humorous, and a lively sense of the ridiculous often colours their mimicry. This faculty of imita- tion may be cultivated to a very great extent, and a practical direc- tion given to the results obtained. They are usually able to speak ; the speech is thick and indistinct, but may be improved very greatly by a weU-direcled scheme of tongue gymnastics. The co-ordinating faculty is abnormal, but not so defective that it cannot be greatly strengthened. By systematic training, considerable manipulative power may be obtained. The circulation is feeble, and whatever advance is made intellectu- ally in the summer, some amount of retrogression may be expected 262 DE. DOWN ON CLASSIFICATION OF IDIOTS. in the winter. Their mental and physical capabilities are, in fact, directly as the temperature. The improvement which training effects in them is greatly in excess of what would be predicated if one did not know the characteristics of the type. The life expectancy, however, is far below the average, and the tendency is to the tuberculosis, which I beheve to be the hereditary origin of 1;he degeneracy. Apart from the practical bearing of this attempt at an ethnic classification, considerable philosophical interest attaches to it. The tendency in the present day is to reject the opinion that the various races are merely varieties of the human family having a common origin, aad to insist that climatic, or otheir influences, are insufficirait to account for the different types of man. Here, however, we have examples of retrogression, or at ail events, of departiire from one type and the assumption of the characteristics of another. K these great racial divisions are fixed and definite, how comes it that disease is able to break down the barrier, and to simulate so closely the features of the members of another division. I cannot but thiak that the observations which I have recorded, aie indications that the differences in the races are not specific but variable. These examples of the result of degeneracy among mankind, appear to me to furnish some arguments in favour of the unity of the human species. CASES OP DELIEIUM TREMENS, WITH CLINICAL REMARKS. By dr. FRASER. These cases have been made the subject of fomaer clinical observa- tions, and npon the present occasion I may make repetitions, but alaa further remarks. Judging from the of&cial list of diseases kept in the Hospital, one might infer that the influence of the total abstainers was being sbewp in the small number of cases of dehrium tremens in 1865, viz.., seven, and only one death; but this hope is blighted, because for the first half of the present year there are already seven cases, and one death. Firstly, as to, the cause of the disease. It would be well if we were always equally certain as to the remote cause of all other diseases, as we are of delirium tremens : for, although there may be doubts as to the proximate action of alcohol in the production of all the sym- ptoms, there is no doubt that without the action of alcohol there can be no true delirium tremens. The poison is imlabed, and the effect follows as plainly as the shock follows the release of the electric fluid from the battery. The comparison may be further pushed, for, in both, individual immunities will be observed; but sooner or later all, more or less, succumb to the cumulative power of the agent. In some, the effect follows rajpidly on an excessive debauch,, even in persons not habitual drunkards, and them we have the "delirium e potu " of writers. In others, the effect may be slower of develop- ment, and follow the total abstraction of an accustomed stimulus, then we have the " delirium ebriosoram " of writers : edthough both Drs. Layeock, and Peddie, deny that mere abstinence ■•will produce 264 DE. FRASEB's CLINICAL EEMARKS the disease. This nosological distinction reads very well on paper, but when we come to the bedside, the line of demarcation becomes invisible : for example, a non-habitnal drunkard, who after a debauch, is seized with " delirium tremens," i.e., " delirium e potu," is in a similar condition to an habitual drunkard, who from necessity or choice has been deprived of alcohol, and delirium tremens supervenes, i.e.," delirium ebriosorum," fbr both are suffering from the effects of alcohol, merely differing in degree ; the one we may call acute, the other chroiiici The doubt. However, is,iiqt, Whether klcohol is the remote cause of the peculiar disorder, for no one thinks other- wise; but the point is whether 'the pToiimate cause is an excess of alcohol circulating in the blood, and acting lethally in the nerve centres ; or from the deprivation of an accustomed stimulus, by which the tone of the nerve centres is morbidly lowered. This question is not one of theory merely ; but also of treatmelit, as to whether stimu- lants are to be giveU, or withheld ; for it is clear, that if an excess of alcohol is in the blood, instead of adding, We ought to fcliminate; and, on the other hand; if the Symptoms arise from a diminution of power in the nerve Ceritresy owing to the absence of an accustomed stimulus, then alcohol will be the remedy. So far as this point is concerned, the sevfen app'ended cases stand thus : — Nos. 1, 3, 5, 7, would appear to have been of the fortner class, viz., the system saturated with alcohol. No. 1. Treated with alcohol / fatal.' „ 5. Treated with alcohol ; recovery: „ 8; Treated without alcohol ,' fatal. „ 7. Treated without al6ohol ; recovery.' Showing an equal number undet each kind of treatment. Nos. 2, 4, 6, of the second class— the system deprived of alcohol. No- 2 without alcohol ; fatali „ 4 without alcohol; fatal, „ 6 with alcohol ; recovery. Prom the result of No. 6 it would appear that Nos. 2 and 4 might have recovered if alcohol had been given, and this agrees with the theory above stated. Let us now inquire succinctly into the physio- logical action of alcohol on the human body. It is certain that alcohol is absorbed, for it has been detected in the blood, the brain, the Hver, the bile, the urine, and in the secre- ON DELIEIUM TREMENS. 265 tions of all the serous membranes. It has been affirmed that it has a peculiar elective affinity for brain^matter; and Mourens has said especially for the cerebellum. It is a non-iiitrogenize,d substance, and cannot form organized tissues, and its. chief use is in thri evolu- tion of heat, : although Liebig, says that it is oxidised in the body, and serves &s ^oodi Whence, therefore; arises its evil influence on the animal economy ?: The revived humeral pathology leads to the opinion Of.adepravted condition^ or, in other *ordl, a poisoning of the blood from alcohol. - . ' ' Alcohol is said, to take the oXygeii of the blood, (which would otherwise .have gone to the normal oxygenatioii of the Tarioils tissues of the body), and thus to stop the ordinary waste of material} while its carbon and hydrogen are given off as carbouic acid, and \ . i . Qpium, the salts of morphia, camphor, tartar emetic, ammonia, digitalis, chloroform j. the calabar bean, capsicum, iced-bath, &c., &c'. No. 1. — Delirmm ehriosorum, with fits. — Treated yjith opiates and , . ' J, '/ stimulants. • , ■ . ,- Charles Chase, aged 56, a labourer, was brougjit to the HospitaJ on the 23rd of September, 1862, at mid-day. This history was obtained. Kye years ago, had delirium, tremens ; has been drinking largely of latej and the present symptoimsj with occasional fits, haye, existed for about a week. The face is congested,, tongue coated, bowels con- fined, loss of appetite, iskin profusely, perspiring, general tremor, no delirium. He is disinclined to answer questions,' and when told to walk across .the room, did ^so, after some h^itatioi>, whistling at the same time. Shortly afterwairdg he suddenly jumped up and cried out as if in fear. This was followed by an epileptic seizure, after which he remained in a soinnoieot state for a quarter of an hour. At two :o'clDck P.M., had another well-marked fit,; with rigidity of the muscles,' foaming at the.moutb, &c. ' Two drops of croton-oil were placed on Ahe. tdngue, and spirit .lotion, applied to the head; to have milk and beef-tea for diet, with four ounces of brandy^ The purge took good effect; in the;evpniug vo;niting' commenced. Mist* Ammon. effervesc. was now prescribed ; pulse feeble, 120. "^o opium was given on account of ithe epileptic complication, .Though he did not sleep during the night, yet he. remained- comparatively quiet. 24jf/J._Has no .appetite, is very;thi,rsty;' brandy to be discontinued. Passed the day without a return of fits, delirium very slight. Nine P.M., pulse 92 ; no opium to be given, but tg have a scruple of calomel and jalap, with a saline draught- in the morning. However, at three A.M (25th), he became unmanageable, frequently attempting to get out of bed ; persuasion, with a little coercion, sufiiced to keep him in check, but once he ^^'ent so far as to strike his attendant. Ten a.m.^ he proceeded to strip himself, alleging that the room was full of water. ON DELIRIUM TREMENS. 273 aud could with difficulty be restrained, in fact, his vagaries were most extraordinary. The strait-jacket was not applied; at noon had four ounces of brandy, and also a grain of morphia, the latter to be repeated every four hours. Eight p.m., perspiring very freely, pulse 110. Ten P.M., can with difficulty be kept in bed, and refuses his medicine, so it was necessary to conceal it in brandy ; twelve p.m., no signs -of sleep ; pulse 120 ; morphia repeated for the fourth time. Half-past one a.m. (26th), pupils contracted, but as he showed some signs of sleep it was thought advisable to push the remedy, and accordingly a drachm of tincture of opium was given. Half-past two A.M., in sleep, which continued till about half-past eight a.m., when his breathing was remarked to be very feeble, lips blue, pulse 120, and exceedingly small. He Was immediately roused, and had some brandy ~given him, but was kept awake with difficulty. Cold effusion was applied to the head, and strong coffee ordered. After the lapse of two hours he perfectly rallied, and took a proper quantity of food J he was now allowed to doze. Eight p.m., has no delirium. Sili/i. — There is now considerable bronchitis on both sides. To have Mist. Cascarillse co. 4 tis hor., with counter irritation to the chest, the stimulus to be continued, as he wa-s much exhausted. Eight P.M., debility more marked,' with constant cough and much expectoration ; brandy mixture now ordered. 2Stk. — Signs of approaching coma, which gradually increased, and he died on the following morning. Post-mortem examination for- bidden. Remmrlts. — In this case we have an illustration of -the error of inferring a universal from a particular case. Some persons may allege that the opium had a baneful effect, and if it had been given after the supervention of the bronchitis, there would have been grounds for the opinion. On referring to case No. 3, we observe similar symptoms and results, when a comparatively small quantity of opium was given. Neither had the mechanical restraint any thing to do with the fatal result, as it was not employed. The probability is that this man would have recovered if the bronchitis had not supervened. It has been argued that opium kills in delirium tremens by acting as a depressant on the action of the heart, but I think, that the exhaustion consequent on prolonged ^citement, will T 2?4 DR. FBASEr's clinical REMARKS be quite as^ if not more, injurious. Although opium sometimes fails m inducing sleep, or quiet, this is no argument against its legitimate use. No. 2. — BeUrium ehriosorum, with fits. — Treated with laudanum and mechanical restraint. Benjamin Stripling, aged 27, waterman, admitted September I5th, 1862, at four p.m. This patient, a robust, healthy-looking man, entered the receiving-room, expressing a desire that the doctors should examine the contents of two bottles of medicine which he fetched, as "he strongly suspected his medical attendant was poisoning him (at the instigation of his wife). He also begged for an immediate anti- dote ; his manner was restless and excited, the face flushed, hands tremulous, tongue furred, skin bathed in perspiration, and pupils dilated. He gladly consented to come into the Hospital, then suddenly changed his mind, as he wished to give his wife into custody, but was easily prevailed on to remain. He walked to this ward with hasty steps, incessantly talking of his wrongs. It was ascertained that he was in the habit of drinking largely, and that he had been delirious for about a week. • To have a drachm of tincture of opium, in brandy, at once. Later in the evening he became more unmanageable, and was therefore removed to a separate room, and confined by a strait- waistcoat, from which he made desperate attempts to relieve himself. A drachm of laudanum was now re- peated, but with no effect; pupils not contracted. About two a.m., on the 16th, he had a violent convulsive attack, on the subsidence of which he seemed more quiet; a drachm of laudanum again repeated. From his manner, his attendant thought that he would now sleep, but at five a.m. he had become quite comatose, stimu- lants were ordered, but without avail, as death took place in an hour. Pupils uncontracted. The post-mortem appearances, were as follow : — Body well- nourished; face and neck very much congested. On removing the calvaria a large quantity of blood escaped ; veins of the brain highly congested. Serum between the pia mater, and the arachnoid, with small portions of recent lymph between the convolutions of the cerebrum: left ventricle contained some fluid, but the right was perfectly empty. A considerable ammount of reddish serum was ON DELIRIUM TREMENS. 275 erased at tlie base of the brain. Heart-substance somewhat pale and soft, having undergone fatty degeneration, but otherwise healthy. Liver in a state of fatty degeneration. Kidneys congested. Remarks. — This case was viewed as one of arachnitis, and the origin of the inflammatory action cannot be entirely pressed upon alcoholism : although an alcoholic condition of the system would render the morbid action more virulent, whether arising from, or merely coincident with, an alcoholic saturation. In this case deple- tion would have befen injurious. The question is, had the three drachms of laudanum, taken in twelve hours, anything to do with the death ? I think not, for we know the enormous quantities of this drug, which may be swallowed with impunity in all cases of nervous excitement; besides, a similar sudden demise took place in No. 3, in which opium could have had no evil action. It is more probable that the mechanical restraint was injurious, and I wish strenuously to advise against its use in all cases of delirium tremens. No. 3. — Delirium elriosorwm, without fits. — Treated with .digitalis. (Reported by Mr. Adams, jun.) William Page, aet. 38, a potman, admitted into the London Hospital, on the evening of Saturday the 1st of July, 1863 ;' with delirium tremens. He had been long addicted to intemperance, but this was the first attack of " the horrors.'" The heart-sounds were normal, the pulse was 80, and inclined to be full. There being no signs of organic disease, it was determined ,to try lir. Jones's treatment of digitalis ; accordingly, at seven o'clock,, p.m., half-an- ounce of the tincture of digitalis was given ; at eight o'clock the pulse was 60, full and regular, the heart was acting as usixal. At ten o'clock 'P'M., the dose was repeated, the patient passed a quiet and comfortable night, but did not sleep much. In the morning he did not seem so fearful, but was in a highly tremulous condition. At ten o'clock a.m., of the 2nd of July, the same dose was repeated; half-an-hour after he vomited some bilious matter. He was put on a plain nutritious meat diet, and no stimiilanits ; after the vomiting, he seemed quite eiasy. At three o'clock, p.m., a dose of half-an-ounce of the tincture of digitalis was aga;n given, ^i ^four o'clock the circ.Tilation was unaffected, the pillge was 68, and T 2 276 DB. eraser's clinical remarks regular; he vomited again ajfter taking the last dose of digitalis. Towards the evening he became much excited, wishing to go about the wards, pulling his bed-clothes about. At nine o'clock, p.m., two drachms of digitalis were given, but did not produce any obvious efiFect ; he became more violent, and at eleven o'clock he tried to escape from the Hospital. It was found necessary to restrain him by quietly holding him in bed ; he at first shewed some muscular power in endeavouring to free himself, but gradually the muscular exertions became objectless, and convulsiform, and he sank after loudly and repeatedly screaming murder. In thirty hours he took, two ounces, t^o drachms of the tincture of .digitalis. The largest quantity given by Dr. Jones, in ten hours is, one ounce and a-half. Post-mortem examination, fifteen hours after death. — Eigidity of right inferior and upper extremities, pupils dilated, body spare, but muscular. Dura mater adherent to skull throughout the whole of the occipital and parietal regions. Arachnoid apparently free from disease, vessels of pia mater, and chiefly between the sulci, moderately injected with blood, where a little serous fluid was lodged. About six drachms of fluid were found in the lateral ventricles : about an ounce and-half of bloody serum escaped from the spinal canal. Eight side of heart much dilated, and the wills thinned : mucous membrane of stomach softened. Remarks. — Was the effect of the digitalis too depressing upon an already weakened and dilated heart ? I have always believed that the action of digitalis on the heart was depressant, but lately the contrary view has been held : viz., that it stimulates and augments the contractility of the organ, and, I must say, that I have lately seen cases of heart-disease, the result of which, bore out the latter opinion ; for, under the use of digitalis the rhythm of the heaTt becomes healthy, and the contraction more normal. It is, however, to be observed, that all the cases treated with digitalis, which I have witnessed, have been unsuccessful. No. 4 — DeUrivM ebriosorum, without fiis. — Treated with laudanum, James Hutchinson, set. 26, admitted the 20th of September, 1862, a tall robust drayman, habits, of late, most intemperate. The delirium ON DELIRIUM TREMENS. 277 commenced some days prior to admission ; on the second and third day before admission, had attacks of convulsion; his delusions have been of a varied, and occasionally, of a violent character. On admission, he was calm, the face flushed, the eyes brilliant, tongue furred, skin perspiring very freely, hands tremulous. To take thirty drops of tincture of opium, in saUne mixture, every four hours, also to hayfe ten ounces of sherry during the night. About eight P.M., the delusion occurred that a stream of water was continually drenching him, and every few minutes he got out of bed, dragging his sheets on to the floor, having rearranged them to his satisfaction, he returned to bed, but only to arise and repeat the movement. Reasoning was useless, so it became necessary to remove him to a separate room, and a strait-jacket was applied; this caused great annoyance, and he occasionally used vast eflbrts for release. To take thirty drops of laudanum immediately. This excited state continued for some hours, after which he gradually became more tranquil; in reality, however, he was becoming comatose, for, at two a.m., on the 21st he, who, a few hours before seemed a model of muscular development, was a corpse. At the last the pupils were dilated, and the head and neck appeared gorged' with blood, "^o post-mortem examination was allowed. Remarks. — The sudden and fatal termination, in this and similar cases, naturally creates a sensation among the observers ; a few hours previous to the death, none, but those familiar with the character of the disease, would have anticipated the fatal event. In this case, the first impulse would be bleeding, to calm the frantic , excitement ; but, it has been found that general depletion is not well borne, if not actually injurious. It is a serious question, whether the reistraint by the strait-jacket was not injurious, by its depressing moral, and physical effect. It would be better to place the patient in a padded-room, in quietness and darkness. The quantity of laudanum adminstered was only equal to two grains of solid opium. As no examination was afforded, the condition of the brain and its membranes, can only be conjectured ; probably there would have been no pathological appearances at all, or possibly only a^ shght congestion of the pia mater ; or, on the contrary, there may have been indication of meningitis, with patches of recent lymph on and between the convolutions. 278 DR. FRASEEi's CLINICAL REMARKS No. 5. — DeUrimm ebriosorum, without fits. — Treated with digitalis laudanum, and chloroform. Henry Nash, butcher, set. 45, admitted the 24th of October, 1864, under the care of Dr. Praser. Keported by Mr. Adams, jun. States that he has been accustomed to drink spirits^ and beer to excess;, has had two attacks of delirium tremens, within the last twelve months. Had not been drinking much till four days before admission. He was quite rational, hands and tongue tremulous. In the evening he became noisy and delirious. Thirty drops of laadantim -were given with no effect, and, after three hours, 3j. was given, after which he became quieter ; a similar dose was to be given every third hour, if necessary. 25^/5. — Has passed a restless night. Nine p.m., has taken three drachms during the day, and now to have nt- xxx. 26M. — At five A.M., had one drachm of laudanum ; but becoming very troublesome, as the day advanced, he was ordered at eleven o'clock half-an-ounce of tincture of digitalis. Before taking the - draught, the pulse was ninety, small and vreak ; at noon, the pulse was 70, small, but regular. Tlie senses were much clearer, and he said he felt very sleepy ; the tremor was somewhat less ; at three P.M., the pulse was ninety, soft and regular ; half-an-ounce of digitalis was repeated. Twenty-five minutes past three, p.m., pulse 65, soft and conipressible, the tremor had diminished, and he dozed a good deal. Pive p.m., talked rationally; pulse 65, smaller and weaker. Nine p.m., again very delirious ; pulse 75, weakj The digitalis was repeated, in a pint of porter; an hour after taking the draught he 'became very violent ; pulse 90 : was removed to a private ward, a strait-waistcoat applied, and a drachm of laudanum given, with brandy. At midnight was still violent, chloroform was used. %Tth. — At half-past one a.m., the dose of laudanum was repeated; and again at five a.m. ; at eleven a.m., the pupils rather contracted; at one P.M., took forty drops of laudanum. Three p.m., was quite quiet, slept, soon aftei, for four hours, and awoke collected. 28^^ — Passed a good night, and is quite sensible. Took his food ; laudanum repeated at bedtime. Z'dth. — Improving, rejjeated laudanum at night, with porteri ON DELIRIUM TREMENS. 279 November the InA. — Slept without the draught, took some brandy. ^th. — Convalescent. Bemarks.^—It is difficult to say to which, if to any one, of the remedies employed in this case, we are to attribute the recovery ; for, although the digitalis acted beneficially, it seemed to lose its calming effect ;* and the laudanum, useless at the outset, had a most excellent effect at a later period, when givefl after the administration of chloroform. In sixteen successive hours, he took one ounce and a-half of digitalis. When we remember the cautious manner in which this drug is usually employed, this appears a large quantity ; but it is nothing to what some practitioners give ; one ounce for a dose is not uncommon. Dr. Sloane, in a successful case, gave seven drachms in thirty-six hours. In a case where ten grains of opium had been given within twelve hours without effect, a half-ounce dose of digitalis acted magically in inducing quiet.f We may fairly inquire, before putting all the good down to the digitalis, whether the effects of the opium had passed away ? No.6. — Delirium edriosortim, without fits, — Treated with opium and stimulants. Charles Bishop, aged 4<0, lamp-lighter, was admitted at mid-day, on October 17th, 1862, with a severe attack of erysipelas of the face, of five days' duration. Has been in the habit of drinking large quantities of spirits (chiefly gin), but for the last week he had de- prived himself of his accustomed stimulus. Soon after admission his manner was remarked to be restless and excited, he talked in- cessantly, and when he closed his eyes he declared that objects ap- peared around him. The point to which -attention was drawn was, whether this delirium was due to the extension of the eyrsipelatous inflammation to the meninges of the brain, or the sign of approach- ' ing delirium tremens ? The history of the patient, and the sameness of the treatment, point to delirium tremens. The delirium was not of a violent character, on the contrary, of a peculiar busy and lo- quacious description; if questioned, his answers were pertinent, * See former experience "of this drug, in the Lancet of March 8th, 1862, p. 261. f For the effect of digitalis, in delirium tremens, see cases by Dr. Jones of Jersey. 280 DR. eraser's clinical remarks when suddenly his mind would wander to other subjects. His hands were tremulous, and he was constantly picking at the bed- clothes. The tongue was thickly furred ; bowels confined ; the skin bathed in a profuse sweat. He did not complain of any pain, nor did light or sounds annoy him. Was ordered forty drops of laudanum, liquor cinchonse and saline mixture, every four hours, with a light nourishing diet, and four ounces of brandy. After this he slept for some time, but passed an uneasy night. October, 18th. — In the morning he bad an idea that we intended to perform some opera- tion on him, and earnestly begged that we would not carry out our intention, he usually warned us by saying, " Mind what you are at, I am ruptured." To take two scruples of calomel and jalap as the bowels had not been relieved for some time. At four p.m., he took fifty minims of tincture of opium, which produced a little sleep. At eight P.M., having secretly armed himself with a boot, he got out of bed and demanded his clothes, saying he was resolved to quit the Hospital, as we intended to murder him. He did not offer any violence, but acted strictly on the defensive ; argument proving of no avail, he was removed by force to a separate room, but the strait- jacket was not used. Nine p.m., to have twelve ounces of gin during the night, and a drachm of tincture of opium at once. This produced no sleep, although he became less violent. Twelve p.m., the dose of opium was repeated, pulse 110. 19th. — Half-past two a.m., no sleep as yet, he having had five and a-half drachms of opium in thirty-six hours. As the pupils were very contracted the laudanum was stopped. His apprehensions somewhat calmed, but still suspicious. Eleven a.m., no sleep ; to take a drachm of calomel and jalap, the previous purge having had no effect. Two p.m., bowels thoroughly relieved, he now admits his former fears were groundless. Still per- spires very freely; tongue furred, but appetite good, pulse 98. Eight P.M., to take liquor opii, sed. tn,. xl. During the night he dozed hah- an-hour; had occasional delusions, but was perfectly manageable. 2QiA. — Appetite good ; to have meat ; is quite rational, but still has an uneasy fidgety manner. Eight p.m., pulse 86 ; a grain of morphia was ordered,- and repeated in three hours, soon after which the pupils became contracted ; and at three a.m. (21st), a third grain was given, as he showed signs of returning restlessness. He now slept for an hour and a-half, Eleven a.m., erysipelas fast disappearing, still con- ON DELIRIUM TREMENS. 281 tinues to take twelve ounces of gin daily, appetite very good. Is now quite sane. Nine p.m., pulse, 78 ; to have a grain of morphia every three hours, after the second dose he slept soundly for five hours. ZZnd. — Feels much refreshed, and has tost his former nervous manner; pulse, 68. Had eight hours' sleep during night, though he had but one dose of morphia. 23rd, returned to his ward, and in a few days, after gradually diminishing his stimulus, he was discharged. There can be no doubt of the benefit in this from the conjoint use of opium and stimuli. No. 7 — Delirium ehriosorum, without fits. — Treated with stimulants. George Docker, aged 31, a gun-maker, of very intemperate habits, and who had been drinking to great excess for the last three weeks, was admitted with delirium tremens, in a mild form, on January 9th, 1863. Sixteen months ago he had a very severe attack, and since then frequent shght attacks. On the morning of the 7th he awoke with the idea that persons were conversing with him ; on the follow- ing day he applied here as an out-patient. He pleaded very hard for admission, saying, that he knew by experience he would assuredly become worse. An opiate was prescribed, but without benefit, for he returned on the 9th, having run all the way from his home in the fear of an imaginary enemy. On admission he had a peculiar anxious expression, with delusions, and compMned of sleeplessness ; there was slight tremor of the hands, a perspiring skin, costiveness, furred tongue, but good appe- tite. Was ordered tinct. opii, "l xl., but no sleep resulted. Half- past eleven a.m., judging by the foul state of the tongue, that the bowels were in a disordered condition, a scruple of calomel and jalap, followed by a saline draught, were prescribed, these produced only a moderate action. He passed the night in quiet. \^th. — In the morning slept for two hours after taking half a drachm of tinct. opii. Towards night, however, he had become more excited; the dose of opium was now repeated, but this time with no result ; to have six ounces of brandy and three pints of porter, per diem. 11th. — Is decidedly worse, delirium more marked ; face flushed;, pulse quick and small. Three p.m., to have a drachm of laudanum immediately, and forty minims of the same ; to be repeated every two hours. \%th. — ^Three a.m., ptill unmanageable, and for a time refused to 282 DE. PRASEr's clinical REMARKS take his medicine ; he showed great terror when left alone, as he fancied men and animals were about him. He continued all day in the same state. Nine p.m., to take liquor opii, ni xl. et sether, chlor. nx X. om : hori. „ Eleven p.m., pupils very contracted, skin perspiring freely, but he is more calm and rational. IBtA. — ^Appears greatly exhausted, was ordered beef-steaks, and a quart of stout daily, in addition to his former allowance, viz., six ounces of brandy, and three pints of porter, and the opium and sether to be taken every three hours ; from this date to the 19th he remained in the same condition. His answers were generally quite coherent, occasionally he became irrational, but never violent ; he described with great accuracy his sensations, was aware that sleep was necessary to his recovery, but that it was prevented by the constant action of his busy brain. His previous good appetite failed, his countenance became anxious, and exhaustion greater, bowels inclined to be costive, ordered 01. Tiglii nj, i. ZQtk. — Laudanum and aether changed to a grain of morphia, every four hours j ice applied to the head; on the night of the 23nd, a return of delirium, so much so, that it was found necessary to have recourse to the strait-jacket; at five a.m., on the 23rd, he fell into a sound sleep of six hours' duration, and afterwards at intervals during the remainder of the day. 24:ik. — He is perfectly rational and greatly refreshed; In the course of a few days, after gradually diminishing the amount of stimuli, he was discharged cured. Semaris, — This case is remarkable for the time which clasped before sleep was obtained ; for ten days* this man had only four hours' repose. Will the most violent advocate for abstinence point to anything but alcohol ? to prevent the waste of tissue, and vital or heat-producing power, during this long period ? No. 8. — Belirivm, tremens. — Death.-~-i James T., rag-merchant, set. 42, admitted July 6th, 1864, at five P.M., died at two a.m., on July 7th ; had been ill, out of Hospital, * Dr. Laycook gives s, case of one month.. ON DELIRIUM TREMENS. 283 about seven days ; no further history. At the posi-mortem examina- tion^ there was found as follows : — Brain. — Firm down to level o,f corpus callosum, soft below that portion. Eight half of the cerebellum and lateral ventricles full of rosy serum. Heart. — Empty, pale, flabby and thin-T*'alled (brown-paper-like thickness) . Lungs. — Gorged, and bases hepatized. Stomach. — Coroded and ecchymosed. Liver. — Large, but beginning to pucker. Spleen. — Gorged with blood. Kidneys.-^^(j;Y&mA2is, and rotten. No. 9. — Post'mortem examination ofB. U., a woman aged 47, died in Lod^.—Yeij fat. Skull-cap very thick, arachnoid opaque. Brain. — Very soft, full of seium. Heart. — Adherent to pericardium. Eight cavities full, walls very tender (rotten in fact, althougli only dead three days) and pale. Limgs. — Gorged . Liver. — Large and soft. Kidneys. — Were waxy ; cut firm and smooth, and could be dented by finger ; hardly any distinction of substance ; contained some amyloid bodies. A STATISTICAL REPORT ON THE DEATHS OCCUREING DURING THE YEAR 1865, AMONGST MR. HUTCHINSON'S PATIENTS. COMPILED BY MR. HUTCHINSON AND MR. WAREN TAY. On the 1st of January, 1865, ninety-eight patients were in the Hospital under Mr. Hutchinson's care. During the year, 1,114 were admitted, making a total of 1,212. During the year eighty-one deaths occurred, a ratio of one in fifteen, or 6f per cent. In the following Kst (Table I.) the cases which ended fatally, are arranged according to date of death. We shall afterwards consider in groups some of the special causes to which the fatal event was due. We have included all the cases which were nominally under Mr. Hutchinson's care (being placed in his beds), and a few occur which were really treated by his colleagues, chiefly by Mr. Little. In these where the treatment involved any important operation, the name of the operator is given. The report, therefore, includes one- third of the surgical, in-patient, practice of the Hospital. If we could get them, correct and detailed mortality records would be amongst the most valuable information which an Hospital can afford. We regret that on the present occasion our report is much less complete in many respects than we could have wished it, and we hope in future years to" improve on our present plan. We have in- troduced a certain amount of information at several parts as regards cases which recovered, especially in connection with the important subject of hernia. During the year we have been almost free from what may be called " Hospital-diseases," with the single exception of pyaemia. We have had no true Hospital gangrene, very little erysipelas, and only three cases of tetanus. Of the fatal cases of pyaemia and erysipelas, a very considerable proportion were admitted as such, and did not originate in the Hospital. MB. HUTCHINSON S MORTALITY REPORT. 2,85 TABLE I. List op deaths arranged according to date of occurrence. 9 10 11 12 13 14 Id 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Age. Mary Miller George Peel Noah Nichols Henrj^ Sharp Louisa Smith John Trouve Charles Flaok John Cobbin Elias Bruce William Kyte Phoebe Brown ^ James Abbott James Herbert Charles Dyne William Ives Peter Gibson Sophia Wilkins John Adams John Jones Elias Levi Frederick SurreU James Gerraud George Burdite John Fhipps Elizabeth Robinson Edward Lees William Hunter Sarah Antony Jeremiah Cochlan Michael Quiulan Sarah Annstrong Thomas Sime James Winter 24 28 40 70' 28 42 1 |63 11m 24 39 66 25 19 9 2 39 6 58 34 60 15 3 17 5 44 29 11 Date of Death. How many days in Hospital. Jan, 6. Jan. 8, Jan. 12. Jan. 15. Jan. 16. Jan. 17. Jan. 18. Jan. 21 . Jan. 21. Feb. 3. Feb. 14. Feb. 23. Feb. 23. Feb. 25. Feb. 25. Feb. 26. Feb. 27. March 2. March 14. March 14. March 20. March 21. March 22. March 25. April 2. April 6. April 9. April 11. April 12. April 16. April 18. April 28. May 2. Cause of Deatb. 12 Acute tetanus after a severe bum. 13 Epistaxis. Sudden and unexplain- ed death with dyspnoea. 38 Crushed toes. Amputation of toes Pyaemia. Tetanus. 68 Abscesses in connection with disease of the iliac bone. 5 Erysipelas and pneumonia after ex- • cision of breast for cancer. Shock of a bum. 50 Diseased knee. Excision. Pyse- mia, amputation. 6 Inflamed legs. Erysipelas. Bron- chitis. 6 Severe scald. Exhaustion. 10 Broncho-pneumonia after fractured ribs and wound of lung. 11 Exhaustion after a scald. 20 Renal anasarca and tertiary sy- philis. 29 Pyaemia, &c., &c., after compound fracture of tibia. 4 Renal disorganization from stricture and calculus. 3 Peritonitis irom rupture of intestine from a blow. 1 Peritonitis from rupture of intestine from injury. 1 Shock from a severe scald. 3 ■ Cancrum oris. 19 Compound fracture of skull and smash of brain. 18 Exhaustion after a bum. 3| hours Renal disease. Apoplexy mistaken for injury to head. 3 Traumatic delirium after compound fracture of ulna. 2 Pysemia after injury to finger. 26 Pyaemia after primary amputation of leg. 13 Exhaustion consequent on a bum. 1 Exhaustion after phlegmonous ery. sipelas of leg. 24 Pyaemia after primary amputation of thigh. 6 Pneumonia after incised throat, (suicide). 4 Traumatic gfingrene after slight in- jury to arm. 19 Peritonitis after lithotomy. Large stone, 11 Exhaustion consequent on a bum. Enteritis. 2 Erysipelas of head and face from lacerated scalp. 33 Pneumonia, with renal disease, oys' titis, and stricture. 286 MR. HUTCHINSON S MORTALITY REPORT. No. Name. Age. Date of Death; How many days in Hospital. Cause of Death. 34 William Gale 29 Mav2. 4 hours Contusion of brain from a fall. 35, Eli?;a Marshall 56 Mays. 24 hours Peritonitis after operation for femo- ral hernia. 36 Japhet Page 60 May 12. 71 Pyaemia after amputation of leg for 37 Emily Bisiier 9 May 16. 48 cancer. Pysemia after excision of cystic tu- mour in neck.— Mr. Little. 38 George Linnell 36 May 20. 20 Pneumonia after fracture of dorsal spiije. See p. 341. 39 Eliza Harvey 9 May 21. 65 Pyasmia after resection of elbow- joint for disease. — Mr. Little. 40 Willltem Turner 41 May 21. 20 Pygernia after secondary amputation for traumatic gangrene of leg. 41 Henry Fitch 26 May 26. 25 Pyaemia after amputation for dis- - eased knee. 42 William Smy 66 June 7. 9 Disease pf shoulder-joint (acute with osteitis). 43 William Whitmore 40 June 12. 3 Arachnitis after compound fracture of the skull. 44 William Dale 68 June 14. 49 Erysipelas of leg (of five days' dura- tion) from old ulcers. 45 Mary Lynch 56 June 15. 5 Exhaustion after burn. 46 Frederick Parson 15 June 28. 18 Acute osteitis of ilium. Pyaemia. 47 John Moore 12 June 29. 20 Acute osteitis of ilium. Pyasmia. 48 James DrisooU 20 June 29. 14 Popliteal aneurism. Disease of heart. 49 Mary Jane Bralard 8 July 1. 13 hours Hydrophobia. See Lancet, p. 611. 50 Julia O'Marao 65 July 18. 42 Acute inflammation of shoulde>jnt. 51 Thomas Charlton 33 July 28. 27 Paralysis of bladder and cystitis after fever. Exhaustion from advanced disease 52 James Mack 12 July 29. 95 of vertebrae. 53 Anne Halpin 1 July 30. 9 Gangrene of vulva and thigh after severe injury. 54 David Nicholls 53 August 9. 12 hours Elenal disease. Calculus : extravasa- tion of urine. — Mr. Little. 55 Richard Morland 61 Sep. 3. 41 Pyaemia after secondary amputation of thigh for compound fracture. 56 Robert Mallett ■70 Sep. 3. 6 Enlarged prostate and vesical and renal disease. Epithelial cancer of penis. Ampu- 67 John Bacon 30 Sep. 18. 19 tation. Pyaemia. 68 William Adams 56 Sep. 18. 16 Pyaemia after compound fracture of tibia. Secondary amputation. - 59 James Smith 55 Sep. 19. 14 Peritonitis after herniotomy. — Mr. Hivington. Compound fracture of skull. 60 John Garratt 45 Sep. 26. 6 61 Henry Newton 47 Sep. 29. 4 Tmumatio gangrene after compound fracture into elbow-joint. 62 Colman Symmonds 93 Oct. 11. 19 Cystitis and abscess in enlarged prostate. 63 James Garrett 25 Oct. 13. 5i hours Shock from compound fracture of pelvis. 64 Ellen Lee 2 Oct. 26. 10 Exhaustion after bum. 65 Mary Franks 38 Nov. 2. 86 Disease of hip-joint and ihac bone 66 Mary Davis Anne Fisher 70 Nov. 2. 8 hours Laceration of brain from injury. 67 53 Nov. 7. 15 hours Tertiary Syphilis. Renal disease. .Pleurisy. 6S Henry Aymes Mary Pooar 35 Nov. 7. 6 Typhus fever. (Attempted suicide.) Congenital syphilis. Convulsions. 69 ^ Nov. 13. 13 70 William May si Nov. 21. 19 Pyaemia after primary amputation of thigh. DEATHS FROM SHOCK. 287 No. Name. Age. Date of Death. How man? days in Hospital. Cause of Death. 71 72 73 74 75 76 77 78 79 80' 81 George Wells EHzabeth Frioe Thomas Hubbard Joseph Eanderson William Griffin William Little Joseph MoCall Hemy Richards Emite Cohne Michael WaU Mary Simpson 26 30 30 37 35 12 41 27 35 ■70^ 3 Nov. 28. Deo, 3. Deo. 6. Deo. 10. Deo. 13. Dec. 15. Dec. 18. Dec. 19. Dec. 20. Deo. '21. Deo. 25. 91 7 7 76 2 hours 36 hours 5 20 hours 24 hours 3 11 Phthisis. Ulcers on stemirm. Peritonitis after herniotomy. — Mr. Dove. Fracture of skull. Pyaemia. Aneurism of arch of aorta. Shock from extensive injuries. Fracture of pelvis, Sec. Fracture of BkuU and compression of brain. Broncho-pneumonia after fractured ribs. Rupture of gall duct from a blow. Shook fiijm severe bum in an explo- sion. Bronchitis after fractured ribs. Exhaustion after a bum. The first group wEicli we shall take is that in which death occurred from the direct influence of the shock of the accident. But very few really die from this cause ; in nearly all time is allowed for the supervention of some secondary form of disease, or, at any rate, for such an amount of reaction as to take the case out of the category of shock. TABLE II. DEATHS FROM THE IMMEDIATE SHOCK OF ACCIDENTS. (Six Cases.) The mmibers in the first colv/mn refer to those in Table I. Age. Sex. Nature of Accident. Duration of Life. Scald. Extensive injuries to pelvis, femora, &o. - Severe burn in an explo- sion. Laceration of brain. Twelve hours. Two hours. Twenty-four hrs. Eight hours. Complete insensibility without truestertor, respirations twen- ty in thfi minute, chiefly tho- racic. Pulse regular, 100, of fair power. When admitted respirations so feeble that artificial , respiration was tried. 63 Compound fracture of pel- vis. Bum. Five and a-half hours. A few hours. 288 ME. Hutchinson's mortality report. Burns and Scalds. The total number of burns and scalds admitted was sixty, of these twenty-five were burns, and thirty-five were scalds. The gross mortality was twelve, or one in five, and, as indicative of the much more serious nature of the cases which came under the denomination of burns, we have the fact that nine of the twelve deaths were after burns; and only three after , scalds. "We have, therefore, a i:atio of mortality of more than one in three for the burn cases, and of less than one in eleven, for the scalds. Many circumstances probably conspire to this result, but by far the chief is, that in burns a very large extent of surface is usually involved, whereas scalds are much more local and limited. TABLE III. BURNS AND SCALDS. (12 BeatllS.) No. of case. Aje Sex. Nature of Injury. Duration of tife. Cause of Death. Bemarks. 1 32 F Severe bum 12 days Acute Tetanus 9 IM Severe scald 5 days Exhaustion 6 70 M Burn ■ Shock He died on the day of admis- sion. U UmF Scald 11 days Exhaustion 20 5M Burn- 18 days Exhaustion 17 9F Serere scald Iday Shock 25 3F Bum 13 days Exhaustion 45 66 F Bum 6 days Exhaustion 64 2F Burn, 10 days Exhaustion 79 35 M Bum, severe, in an explosion 24 hours Shock 81 3F Bum 11 days Exhaustion 31 8F Bum W days Exhaustion Enteritis A post-mortem was made in this case. As regards the precise cause of death; in most of these cases, we regret to be able to state but little. The term " exhaustion " is applied to those cases in which the patient appeared to sink chiefly in connection with the debility produced, in part by pain, and in part by profuse suppuration. In almost all these, congestion of the lun'gs supervenes in the later stages, and in many it is the immediate cause of death. But few autopsies were obtained in these cases. Of the cases which recovered, three were so severe that the patients re.- mained in the Hospital more than one hundred days. In oase No. 849, a boy of thirteen, had his trousers set on fire by a red-hot rivet, and was most seriously burnt in his thighs and perinaeum ; he was made out-patient after 1 39 days treatment. In Case ITo. 973, a boy again had his trousers set on DISEASES or JOINTS, ETC. 289 fire ; one thigh was most seriously burnt, and around the knee all the sMn was destroyed. It was feared that amputation would be needed, but, after 1 22 days careful treatment, he was made out-patient with good reason to hope that the sore would heal without material contraction. In case 201, a feeble man subject to fits, scalded himself so severely by pulling oter a kettle of boiling water, that he was 105 days in the Hospital. In no case was amputation found necessary for the effects of these injuries. Two children were admitted with scalds of the throat from attempting to drink boiling water, both boys of three years of age. In each case tracheotomy was abstained from, and both patients recovered well. TABLE IV. DEATHS IN CONNECTION WITH DISEASES OP JOINTS, SPINE, ETC. Nature of Disease. Duration. Cause of Death. Remarks. 39 41 42 47 M Abscesses in con- nection with disease of iliac bone Morbus Coxae ? Chronic disease of knee, with great displacement Chronic disease of elbow. The girl was in very fair health at the time of the operation Chronic disease of knee. Synovial membrane in a gelatinous con- dition Acute disease of shoulder- joint with osteitis of humerus Acute osteitis of ilium, involving the hip-joint 6 months 3 months 6 months 2 weeks Exhaustion from profuse suppu- ration Excision of knee, Pyaemia Amputation Resection of el bow. PyEemia Amputation, 14 days Pyaemia Exhaustion Pyaemia 68 days in Hospital. The death was irom osteo- myelitis and pyaemia con- sequent on ^e excision. Excision, December 7th; Amputation, Dec. 22nd Death, January 18th. Mr. Little's patient. In this case there could be no doubt that the pyasmia was the direct result of the opera- tion. Death! month after the excision. A fortnight after disease com- menced he was obliged to take to his bed. He. had refused amputation until the very last. Absorption of inner part of head of humerus. When admitted he was too ill to permit of resection. This case, and the following, were instances of acute osteitis of one iliac bone, following a slight injury, and attended by all the symptoms of pyaemia. U 290 MR. HUTCHINSON'S MORTALITY REPORT. Age. Sex. At*. Nature of Disease. Duration. Cause of Deatb. Remai'ks. 46 IS M A:GtLte osteitis of ilium involving the hip-joint 2 weeks Fysenlia See preceding case. 50 65 Old dislocation of 4yeat3 Acute inflamma- She was admitted quite F shoulder tion of shoulder driink. A dislocation was Attempt at rediifc' joint, -with found, and an attempt at tion absorption of reduction made. It failed. lidftiaihatiDfi 6f head of bone A Second attempt was joint made under chloroform. Acute suppuration of the joint followed, and she sank exhausted 42 days afterwards. See London Hospital Reports, vol. ii, p. 349. 52 12 Caries of Vertebra) "Since he Exhaustion Sensation was good ; he M Faraiplegia was a could just move both legs. Angular curva- child" He wasted to a mere ture skeleton. Abscess above and behind anterior superior spinous process of ilium . 65 38 Disease of hip- 4 riionths Exhaustion from Sro history of injtiry. The F joint and iliac most profuse least movement gave in- bone suppuration & tense pain. She was admitted in a state uf severe pain extreme illness. Dutlngf the year excisions of the larger joints have been avoided as much as possible, from fear of pyaemia. In no case was the head of the femur excised. None"of the fatal cases of hip-joint disease were, however, in the least suitable for relief by that operation. In each there was extensive impKcation of the adjacent iliac bone, and the patient's state of health from the time of admission forbad any serious operation. The favourite treatment for hip-joint disease hais been by immobilisation, effected usually by the plaster of Paris bandage. In this way very satis- factory results were often obtained. Several cases were under care, in which excision might by some have been thought desu-able, but it is not our im- pression that any suffered by the avoidance of this measure. The old man who died of disease of the shoulder-joint, was also too ill when admitted to allow of the performance either of excision or amputa- tion. The fatal case of excision of the knee-joint, was the only one in which, during the year, that operation was performed. Two other oases of resection of the elbow -joint occurred, and in both the result was good. DISEASES OF UEINARY ORGANS. ' 291 TABLE V. DEATHS FROM DISEASES OF THE URINARY ORGANS. {Nine Cases.) Age. Nature of Disease- 12 14 31 33 51 72 33 Syphilitic ulcers on leg Anasarca Suppression of urine , Refusal to take food Melancholia Obstinate vomiting Stricture (30 or 40 years) Calculus (many years) Eztrayasation of urine Renal disorganisation 68 Bright's disease of kidney Apoplexy Disease of retina Coma Breathing stertorous and almost wholly thoracic Heart's action continued for five minutes after cessation of respiration - Stricture, 30 years Perineal fistula, many years Renal disease Cystitis Pneumonia, 1 week Paralysis of bladder. Reten tion. Cystitis after fever, 7 An autopsy was refused. A pale flabby man. His first serious sym- ptom wa^ almost total suppression of urine, and at the same time he became melan- cholic, and refused to eat. A few days later vomiting set in. He came in^in almost a dying state from ex- travasation of urine and sloughing of scro tum. Incisions were made in the perineum. A large calculus was detected in the bladder and removed at once. The result of the removal of the calculus under these despe^ rate conditions was to give very decided relief. For. a day or two it seemed quite possible that the man might rally- At the post-morteri}, examination the kidneys were found disorganized and wasted. Admitted 730 p.m. History of having fal len great height. Not accustomed to "fits." Slight laceration over left eyebrow, upper lip lacerated. Pupils contracted to " pin's points." Pulse fall and compres- sible, 50-75 per minute. Breathing sterto- rous, limbs rigid, but he could feel better with legs than arms. 8-35. pupUs widely dilated and fixed. - lO'SO, breathmg wholly by chest, movements of abdomen not syn- chronous with those of chest. 11, breath- ing ceased, pulse continued for full five minutes. Ophthalmoscopic examination. — Apoplectic extravasations, one in parti- cular on right optic disc. Left optic disc not well seen. Disease of retina. Autopsy. — .An immense blood-clot distended the lateral, thirdand fourth ventricles- Kid- neys, granular, and heart hypertrophied. A poor, decrepit, old man, exceedingly ill- He had been treated at St. Bartholomew's Hospital twenty-nine years ago for stric- ture. Many years ago Mr. Simon, at St. Thomas's Hospital, punctured his urethra in the perinseum, and ever since almost all his urine had pass through the fistula. Urine escaped freely by the fistula, and a instrument coxild be passed through it into the bladder, but not through the stricture. His legs were cede- matous. He improved for a time, but at lengthhad pneumonia and died. There was no post-mortem examination. Seven weeks before admission he had ' ' fever-" His urine " dribbled away." . Onedaylefl. leg swelled, abdomen examined, bladder full, two quarts of urine drtiwn off by surgeon atteuding him. Phymosis, pre- puce slit up. No. 8 passed easily. He gradually sank, and died exhausted. U2 292 MR. HUTCHINSON S MORTALITY REPORT. No, 5i Age. Nature of Disease. Remarks. 63 Stricture, 20 years Admitted with extravasation into penis and Calculus ? scrotum. Scrotum immensely swollen. Kidney disease Catheter. could not be passed. Incisions. Extravasation of urine His face was puffy, legs oedematous, looked albuminuric. In the evening a catheter was passed by Mr. little, who thought he felt a stone. He died early next day. Autopsy forbidden. ' 56 70 Enlari^ed prostate After use of instruments, before admission. Hsematuria after use of instru- he had hsematuria, and became very ill, ments almost unconscious. There is no difficulty Pouch in front of bladder in passing a catheter a certain distance Vesical and renal disease apparently into the bladder, but on with- drawing and pushing in again it goes further. Large quantity of blood drawn off. The probability is that a catheter had only entered a pouch in front of the blad- der before, and the retention had not been relieved. He became comatose, and died. 62 93 Abscess in enlarged prostate tie was so deaf that it was impossible to get Large pouch in front of prostate Cystitis any history. 67 53 Ulcers on leg with oedema She was admitted in the afternoon, and died Syphilitic disease of spleen early next day. At the autopsy cicatrices Kidney and liver were found in capsules of kidneys, spleen, and liver. There was one lardaceous Pleuritis Hydro thorax deposit in spleen as large as a horse-bean. Collapse of lung There was a large quantity of fluid in the pleural cavity, chiefly on the right side, and a few flakes'of recent lymph on pleura. The right lung was coUapsed and pneu- monic. Most of the above cases are in sufficient detail to explain themselves. Two of them were in every sense medical patients, the urinary element con- cerning the kidney only. One of these was (Case 21) put into the surgical accident ward in the hehef that he had received an injury to the head, as he had been picked up in a wood-yard quite insensible with a cut on the forehead. The ophthalmoscope used while he was dying, shewed albu- mennrio retinitis, and led to the conjecture that he was suffering from apo- plexy. In the second (Case 67), the patient had previously been under Mr. Hutchinson's care, six months before, for tertiary syphilis, and came back dying with hydrothorax, the result in all probability of renal disease. Of the other strictly surgical cases, two of them are instances of old men , dying from that form of cystitis whioh so often occurs in the termination of long-existing enlargment of the prostate, and is the result partly of the retention, and in part of the instruments used for its relief. They were aged respectively 70 and 93. In Case No. 72, an old man had been for many years placed in a condi- tion of comparative comfort by the establishment (by Mr. Simon), of a direct perinjeal fistula. Through this the whole of his urine had esqaped, and he had never since suffered either from retention or from abscess. He DEATHS FROM MEDICAL DISEASE. 293 was admitted partly on account of deep corneal ulcerations. His death was from pneumonia, probably in connection with renal mischief. In Case 33, paralysis of the bladder and cystitis had come on in connec- tion with typhus fever. The remaining cases are examples of neglected stricture, and illustrate instructively the usual terminations of such. One of them is mentioned also in the lithotomy Table for this year, and goes to shew how fallacious statistics are unless duly explained. It is true that a calculus was removed from this man, but the whole of his perinseum was in a condition of gangrenous suppuration at the time, and the man was so ill, that it was not thought wise to take him from his bed to the Theatre. As the mem- branous urethra was already laid bare, and a large stone in the bladder dis- covered, it was deemed best to enlarge the wound and remove the concre- tion. Excepting in the fact that this was done, the case has no relation to " Median Lithotomy." Cases in which death was due to medical disease. The following cases ought not properly to have been in the surgi- cal wards. In some there was no surgical ailment whatever, the diagnosis having at first been mistaken, and in others the surgical complication, although most prominently attracting attention, was really of inferior importance to the medical one. In all death was certainly due to. a medical cause : — Case 21. — This patient died of apoplexy ; hut as the fit had occurred when he;was alone, and as he had cut his head in falling,- it was at first supposed to be an injury to the head. Case 61. — The only surgical element in this case was retention of urine ; hut this had followed a severe attack of fever, and was possibly in con- nection with disease of the spinal cord. Case 67. — The woman, who had formerly been in the surgical wai'd with tertiary syphilitic ulcers, was re-admitted with general anasarca and efiu- sion into one pleural sac. She died during the night after her admis- sion. Case 68. — A young man attempted suicide by cutting his throat during the stage of mental disturbance preceding typhus fever. The injury to the throat was trivial, and he died of the fever (under the care of the phy- sician, but not " transferred"). Case 69. — A Uttle puny child, under treatment for congenital syphilis, with rash, of which she was nearly well, had repeated attacks of convul- sions, and died probably from cerebral disease. Case 71. — A man with strumous ulcers in the, sternum, had also phthisis, and after three months stay in Hospital, died of the latter. 294 MR. Hutchinson's MORTALixr report. Cases in which death was directly due to Surgical Operations, It is most imperative tliat surgeons should keep clear accounts as regards the deaths coming into this category. We include in it only those cases in which death followed in such a relation to the operatioDj that there was every reason to believe that had the opera- tion been avoided, the patient would have lived much longer. We do not include those in which it is probable that the operation, although it did not prevent, did not hasten, the event, nor those in which the risk of death from the disease, was as great and as immi- nent as that from the operation. Our list, then, comprises all in which the operation either directly caused or materially hastened the patient's death : — Case 5. — A fairly healthy lady, a governess, had the right hreast, and some axillary glands, removed on account of rapidly growing cancer. Erysipelas attacked the edges of the wound and spread widely. She had acute pleuro-pneumonia, and died on the fifth day after the operation. Case 7. — A man was admitted who had partially recovered from an acute attack of destructive synovitis of the right knee-joint. The tihia was dis- plaeed outwards and backwards, and the limb quite useless. There ap- peared some probability that he might recover from the disease with a stiff and dislocated knee. To avoid this event resection was performed. Osteo-myelitis followed, and, in spite of amputation a fortnight later, he died of pysemia. Case 30. — A healthy lad, of 11, died, after lithotomy, on the ^9th day. The stone was a very large one, but no difficulty occurred in the operation. He had symptoms of peritonitis on the third day. The tube for the wound had not been used. Case 36. — A man, aged 50, died of erysipelas and pysemia, after amputa- tion below the knee for epithelial cancer of the leg. The cancer was very extensive and painful ; but he had had it for some years,"and might, per- haps, have lived another year if the operation had not been done. Case 37. — A girl, aged 9, under Mr. Little's care. She was in good health, but had a deep-seated cystic tumour in the root of the neck; after several attempts to cure it by injections, &o., it was dissected out, the dissec- tion passing deeply towards the first rib. Death from well-marked pyaemia followed. Case 39. — A girl, aged 9, xinder Mr. Little's care. She was in good health, but had chronic strumous disease of the left elbow-joint. Resection was performed, and death from pyaemia followed it. Case 50. — This case has already been published. (See London Hospital JReporis, vol. i.) The patient died of destructive inflammation of the shoulder-joint after an attempt to reduce an old dislocation. CERTAIN SPECIAL CAUSES OF DEAT^. 295 Case 57. — A man, aged 30, was admitted with rapidly-spreading epithe- lial cancer of the penis, which had already implicated the glands of the groin. Although in fair health he had a rapid pulse, and the day before the operation a severe rigor occurred (ague ?). The penis was amputated, and the glands dissected out. After the operation he had repeated and ■violent rigors, and several fcee hsemorrhages from the wound in the groiii. He died of pyaemia. This poor fellow could not have lived many montljs had the operation been avoided, as the disease was rapidly spreading, and his death woidd have been a most painful one. We ^Q pot include any of the fatal hernia cases in this category j since in none was the operation resorted to, until it was urgently demanded. Nor do we include cases in which osteitis and pyaemia followed prinjary or secondary amputations, since these events were just as likely to have resulted from the original injury, as froii) the amputation. Indeed in sonie, if not most of the secondary apiputa- tions indications of pysejnia, were already present. Nor do we include Case li, in which lithotomy was performed, for the man was admitted in an almost dying state with sloughing of scrotum, &p. Looking at the converse side, there does not appear to be any ope case respecting which it might be the thought that a timely* opera- tion would have prevented the fatal event. Perhaps, we ought to except Gase 41, in which a man died after amputation for disease of knee-joint, who had for two weeks refused the operation, and only submitted when he found himself rapidly sinking. It is possible, also, that excision of the head of the humerus, in case 50, might have been advantageous. Eemarh on certain speeial causes of death. Tetanus. ■^-Ilwo patients died of traumatic tetanus'— one man and one woman. In the latter the disease was very acute and welU marked j in the other it was less so, and was in conjunction with pyaemia. Both originated in the Hospital j one after a severe burn, the other after severe crush of the toes, which had necessitated am- putation of several. Both cases occurred in January, and the patients died in the same week. A third case of traumatic tetanus occurred during the year, but it was not a very severe one, and the patient recovered. * We use the word " timely," of course, only in reference to the period that the patient was under care in the Hospital. 296 ME. Hutchinson's mortality report. Erysipelas. — Five patients died of erysipelas. In one, an old man, wlio had been several weeks under care for ulcerated legs, and was in good general health, had erysipelas attack his leg, spread rapidly to the thigh and trunk, and cause, death within a week. Erysipelas had occurred in other patients in the ward, and near his , bed. In a second, the patient died of erysipelas with pneumonia, after excision of the breast. The three other patients all came into the Hospital with erysipelas ; one of them was admitted in a very bad condition, and died the next day ; another died on the second day aft_er admission, and the third on the fifth day. Several other very severe cases of erysipelas were admitted as such, and recovered. In one of these the whole of one lower extremity was involved in cellato-cutaneous inflammations, and free incisions were required (at intervals) from the great trochanter to the toes. Pymmia ranks as a cause of death in seventeen cases. "We have, however, used this term rather liberally, and have made it include all cases in which symptoms of blood-poisoning, attended with rigors, followed wounds or injuries. Most of the cases were, however, weU marked. In case 23, an old man was admitted with symptoms of acute and advanced pysemia, which had followed an injury to the finger resulting in necrosis. He lived only two days after admission. On .Tune 10th and 11th, two boys were admitted, with almost pre- cisely similar symptoms in each, acute inflammation of one iliac bone having resulted as the consequence of a slight contusion. Both were pyeemic and died. AU the cases of pyaemia occurred in connection with injuries to bone, excepting two — cases 37 and 57. We defer a more detailed examination of this fruitful source of surgical mortality to a future report. Traumatic gangrene. — Three patients died of traumatic gangrene. An adult man, of intemperate habits, in whom gangrene of the whole upper extremity followed a contusion with slight wound. A child, aged 1 year, who had gangrene of thigh, vulva, &c., after hav- ing been run over, and a man, aged 47, in whom gangrene followed a compound fracture into the elbow-joint. In a fourth case, ampu- tation was performed for traumatic gangrene of the leg, after com- pound fracture of the tibia. The man, who was in a desperate STATISTICS OF HEENIA CASES. 297 state at the time, rallied, and did well for a wliile, but ultimately died of pyaemia. Peritonitis from rupture of viscera. — Two patients died of rupture of intestines from blows. One had been kicked, the other had re- received the pole of a car into his abdomen. These two young men died on the same day. In a third case a man died of acute peri- tonitis after a blow on the abdomen, and at- the autopsy bile was found in the peritoneum, and there was rupture of the gall-duct. STATISTICS OP THE YEAH's HEENIA CASES. We have reported in the following list all the cases of strangulated hernia, in which the symptoms were sufficiently severe to require admission into the wards. The statistics of hernia operations may mislead greatly if we do not consider together with them the other instances of strangulation in which milder measures succeeded. It is obvious that if a surgeon is accustomed to operate early, he will operate on many mild cases, and will have proportionately good results, whilst a surgeon who is very presevering in efforts at taxis, will probably operate only on the more severe cases, and will have worse herniotomy statistics. These fallacies must be allowed their due weight in aU attempts to determine the relative value of the different modifications of operation. Most of the cases in the iollowing list will explain themselves. None are included but those in which the strangulation was really severe, and, in most, several attempts at reduction had failed. It will be seen that but few cases of inguinal hernia were operated on during the year. In this form, for reasons explained by Mr. Hutchinson in last year's volume of Reports, special pains were taken to obtain reduction by taxis, and it was sometimes considered justifiable to wait longer than in cases of femoral hernia. One case (26) operated on was peculiar on account of its large size, and the fact that although it had been down only eight hours, the man had already passed into collapse. The tumour was as large as an adult head, and was, therefore, very difficult to manipulate in the efforts at taxis. The man's condition did not admit of any delay, he being cold and almost pulseless, otherwise the cautious use of ice might very probably have led to success. Chloroform was given, and taxis being again found impracticfible, the constricting bands 298 MR. HUTCHINSON S MORTALITY REPORT. were divided external to thesacj and reduction without opening, the latter effected. Tlie old man recovered well. In most of the cases of femoral hernia, in which operation? were performed, the "precautionary" use of mercury was resorted to. Calomel, in grain-doses every three hours, was ordered immediately after the operation, and without regard to any symptoms which might be absent or present. If, on the second day the abdomen was soft and painless, the mercury was suspended, but if there were any signs of commencing peritonitis, it was continued, and in larger doses. Thus, by not waiting for symptoms, it was hoped to be beforehand with the inflammation. The results seem to justify a further trial of the plan. In all cases of operation it was endeavoured to avoid opening the sac, but in several this became necessary during its performance. When irreducible omentum was encountered, it was left in sit4. In one instance (Cjase 17.) the intestine gave way a few days after the operation, a fsecal fistula formed, and a large portion of sloughy omentum came away. This patient did remarkably well, as such cases often do. She never had any indications of general peritonitis. Calomel and opium had been given from the firat. The discharge of fseces ceased in about three weeks from its commencement, aud the fistula closed. TABLE VI. THE YEAK's cases of STRANGULATED HERNIA. No. 1 39 53 56 Form of Hernia. Femoral (left) large ; some years ; straJigU' iation 14 hours Femoral j three months ; more than 24 hours' strangulation ; about size of an Femoral ; right size of small os- trich's egg; 5-6 years; strangula- tion 2 days Ti-eatmenc. Operation ; sac opened; adherent omentum left in the sac Operation without opening sac Operation ; calo- mel treatment afterwards Recovered Abscess in ab- dominal wall, No peritooitis Death in 24 hours 40 days in Hospital. Discharged, cured, on 37th Sao opened, bowel reduced, old omentum left in sac. At post-mortem, perito- nitis. See London Hos- pital Beports, Vol. ii. p. 405. STATISTICS OF HERNIA CASES. 299 Age. Form of Hernia. Eesult. 63 63 Femoral; size of large walnut ; 20 years ; strangU' latiou S^ hours Operation ■without opeuing the sao M -6 30 Left femoral ; size of an egg; parall- el with Poupart' s ligament ; as large as a walnut for 20 years ; rather more than 24 hours' stran- gulation Femoral, left rather more than 48 hours' stran gulation ; sym- ptoms severe 7 42 24 10 11 70 44 Operation without opening the sao An abscess in cellular tissue. Discharged cured, on 35th day On 4th day effu- sion into sac. 10th day effu- sion diminish- ing. 27th, effa- sion gone, only omentum left Vomited matter not ster- coraoeous. 'M M M 55 M 12 13 36 55 M M Operation ; the sac was opened, but the intestine was not seen (Mr. Dove) Feritonitisoame on. Calomel ord^rsd.' She died on 8th day At the time of the opera- tion he was in a parox- ysm of spasmodic asthma. Femoral, right 10 years; small egg ; 53 hours' strangulation Inguinal Inguinal (right) : size of fist; 14- 16 years Inguinal Inguinal (right) ; 4 ' years with truss. Ascites arid distension of hernial sao simu- lating ihydrocele Operation ; sac not opened ; calomel treatment after- wards Taxis Taxis ; warm bath Taxis under chlo reform (Mr. Little) Operation ; sw opened (Mr. Kivington) Inguinal right ; 10 years. Inguinal (right) ; 2 fists ; 14 years; 30 hours' stran- gulation There was no symptom of peritonitis before the operation. Post-mortem. — General peritonitis. No perfora- tion of intestine what- ever. 6th day quite comfortable. Discharged, cured, on the 38th day Sent out cured in 4 days Reduotionwith- out chloroform Reduction, cured 8th day Death on 15th day Peritonitis. Disease of liver Operatiouwithout opening the sac (Mr. Rivington) Warm bath ; taxis Supposed three days' stan- gulation. Came down 9 days ago, He was sick next day, buf continued at work till 3 days ago. He went to out-patients' room; was tsipped and a quantity of fluid drained off. He was sick in the night. Tu- mour as large as two fists He was jaundiced before the operation. Sent out, cured, 13 hours' strangulation, on 22nd day Sent out, cured; on 7th day The taxis had been tried repeatedly ; there was some little impulse. 300 HERNIA STATISTICS. No. Age. Sex. FOTm of Hernia. Treatment. Kesnlt Hemarks. 14 31 M Inguinal (right) Ice for 2 hours ; taxis Reduction after some perseve- rance Avery tight stricture could be telt about an inch be- low ext. abd. ring; im- pulse above this, but not below it. It had been down about 24 hrs., and he had been very sick. 15 61 F Femoral, right Operation ; sao opened (Mr. Little) Cured 41st day Doubtful history of stran- gulation for four days. Neck of sac instead of being on inner side, was pushed in front or almost between the vein and the artery. — Pee London Hospital Reports, vol. ii., p. 293. 16 53 F Femoral Taxis Left at own re- quest 12th day 17 53 F Femoral, right ; 6 years' duration; 5 days' strangu- lation Operation ; sao opened ; omen- tum and gut both returned ; mer- curial treatment afterwards On 69th day discharged The hernia was the size of a fist. There was a ster- coraceous odour of the breath. A faecal fistula formed afterwards, and the omentum sloughed. It healed well. 18 57 F Femoral Ice. Taxis She said she had not been ruptured till the day be- fore; probably omental. Out-patient on 7th day. 19 18 M Inguinal Tfl.xis Reduced 20 64 F Small femoral Taxis Reduced Went out on 15th day. 21 49 M Inguinal, left Taxis Reduced Went out on the 7th day. 22 32 M Inguinal, right loe. Taxis Reduced on 3rd day Went out on 8th day; No ** impulse" "on admission. 23 If M Inguinal Taxis Reduced Taken out next day. 24 40 M Inguinal, small Ice.' Taxis Irreducible Complicated with hydro- cele, probably only imen- tum. Patient avowed he had only had it a few days. ' 25 78 M Inguinal (right) , very large ; 14- 15 years Ice. Taxis Partial reduc- tion He went out on tliS 53rd day. 26 70 M Immense scrotal Operation without opening the sao Cured on the 60th day. Par- tially reduced He had had a hernia for 20 years ; strangulated for 8 hours. He was in great collapse- at the time of the operation. A FATAL CASE OP OPEEATION FOR REMOYAL OF AN EXTEA-UTERINE F(ETUS, Communicated bt Mr. McCarthy. E. R., set. 32, residing at Hackney, mother o£ four children, all living, menstruated for the last time in July, 1865, having always previously been regular. She considered herself preg- nant, and reckoned her time from that date. She never had felt any movement of the child in any of her previous preg- nancies, nor did she in this. She described her sensations as being very different from any she had formerly felt : but, no doubt, the latei" events influenced her recollections. Nothing unusual was surmised until the following June, when, becoming alarmed, she consulted her medical attendant, Mr. Clark, who diagnosed extra-uterine fcetation, the child lying between the uterus and epigastrium. On July 3rd, Dr. Hewitt of Kingsland, from whom these particulars bad been obtained, saw her. She was then suffering from violent vomiting and intense pain over the abdomen. A vaginal examination revealed nothing except that the relative position of the parts was abnormal ; but it occasioned so much pain as to prevent a complete investigation. She obstinately refused to take chloroform. The previous diagnosis having been confirmed, an operation was suggested, but this she firmly rejected. A grain of opium three times a-day was ordered : soon afterwards it was increased two grains, and afforded great relief. 302 CASE OF EXTRA-UTEEINE ECETATION. Towards the end of July, violent watery purging set in. This continued for two or three days, and then ceased. She became much reduced in size, and the severity of the symptoms abated. It was hoped that Nature might effect a cure. She went on in the same way, with occasional attacks of purging, until the 26th of August, when she suddenly felt intense pain ; and afterwards became faint and collapsed. She was ordered a grain of morphia and brandy mixture. On the 27th she ral- lied, and as the pain was still excessive, the morphia was con- tinued in grain doses, night and morning. Under this treatment she became easier, and continued so until the 30th of August. She then appeared to be sinking rapidly. Dr. Palfrey now saw her, and pointed out that there were two courses, either to allow the woman to remain as she was, which would be certain death, or to give her a last chance, slight as that must be, con- sidering her condition, and to operate. The consent of her friends having been obtained, chloroform was cautiously admin- istered. An incision was then made by Dr. Hewitt through the abdominal wall, a little to the left of the median line from the umbilicus to within two inches of the pubes. By this the cys^ was exposed, which was found to be firmly adherent on all sides. An opening was made into it, when a quantity of foetid gas escaped, together with some purulent matter. The foetus was now extracted. It measured about ten inches in length, and was much decomposed. The integuments of the head had been wasted away, so as to allow the saggittal border of one of the parietal bones to protrude. The placenta had been alto- gether absorbed. It was then found that at the lower part of the cyst a communication existed with the rectum, too high to have been ascertained by any digital exploration of the latter. It was not considered advisable to attempt the removal of the cyst, which was returned in such a manner as to prevent any risk of strangulation of the bowel. The wound in the adominal wall was closed with sutures, and the woman replaced in bed. Brandy was administered, but she never rallied, and died within an hour after the operation, l^o post-mortem was al- lowed. A CASE OF ACtJT^ SYMMETRICAL CARCINOMA. UNDER THE CARE OF DR. ERASER. The following case is recorded from the notes taken by Mr. A. Le Eossignol. It is an interesting example of a very rare form of disease. The patient,. a servant-girl, aged 20, was admitted on October 3rd, 1865, with a swelling in front of the sternum, induration of both breasts, and a large hard mass in the lower part of the abdomen. She was of dark complexion, fairly nourished, but of hectic aspect. Her illness had commenced about six weeks before her admission. The swelling on the sternum was the first perceived, then followed pain in the abdomen, and soon afterwards swelling of the breasts. "Whilst in the Hospital the symptoms very rapidly increased ; ascites came on, there were signs of pneumonia, and on October 21st the patient died. The whole course of her illness had thus extended o\et not more than two months. The following description applies to her condition about ten days before her death. She was then exceedingly pale, emaciated, and feeble. Her abdomen was distended with ascitic fluid, but large growths could be felt deeply placed in the pelvis. There was a firm swelling in front of the sternum, as large as a child's fist, and firmly attached to the bone. The two mammae were exactly alike, enlarged and indurated in all parts, and of the shape which might have been produced by moulding ia a shallow basin. They were not so hard as true scirrhus, but still very firm. The nipples were fixed, but not materially retracted. The glands were movable on the chest. She .304 CASE or ACUTE SYMMETRICAL CAECINOMA. had had much pain in the breasts. There was no inflammation about either. In addition to these tumours^ almost all the lymphatic glands in her body were enlarged. Everywhere their enlargements presented the same features — smooth, hard, movable kernels, without any adjacent inflammation. The sub-inaxillary, cervical, axillary and inguinal, were thus affected, varying in size from beans to chestnuts. The base of the left lung was now dull on percussion. The post-mortem examination confirmed the diagnosis of acute general cancer. The following are Mr Le Eossignol's notes respect- ing it : — Body emaciated, legs oedematous, abdomen distended with fluid, mammary glands uniformly hardened, the left weighing six ounces and a-half, and the right six ounces. On section they pre- sented a hard, white, translucent structure, involving the whole of the gland. On opening the thorax, a quantity of serous fluid escaped. The right lung was adherent to the parietes at the lower and pos- terior part. An incision being made, it was found congested pos- teriorly ; weight, one pound. The left lung weighed fourteen ounces, and presented the appear- ance of pneumonic solidification, except at its anterior part. The heart weighed seven ounces. Several nodules of encephaloid cancer were present at the apex, and extended from thence along the wall of the right ventricle. A few deposits of a similar nature were found in the other parts of the heart. The liver, normal in size, had numerous deposits of encephaloid cancer. The kidneys were much larger than usual, and were masses of cancer. The mesenteric glands, the appendicse epiploicse, and the omentum were infiltrated with the same morbid material. Both ovaries were cancerous, and much larger than normal, being about the size of large kidneys. The sub-maxillary, sub-lingual, and other glands were indurated, and resembled the mammary glands in their peculiarities of structure. Dr. Andrew Clark made a careful microscopic examination of the different deposits, and found them to consist of the cell elements of rapidly-growing cancer. OBSERVATIONS ON THE RESULTS WHICH FOLLOW THE SECTION OF NERYE-TEUNKS, AS OBSEEYED IN SUEGICAL PEACTICE. By JONATHAN HUTCHINSON, F.R.C.S. The not infrequent cases in which, in wounds of the forearm, one or other of the chief nerves are cut across, supply us with opportunities for observing the results which follow, as regards the the nutrition of the part and the maintenance of animal heat. I was myself scarcely prepared to expect that these results would be so definite, and, in some respects so curious, and believing that to many others they may also have a degree of novelty, I am induced to group together the following cases. From such definite and simple facts — experiments as it were tried for us in the human subject — we seem to obtain information which ought to be allowed its due weight in explaining the phenomema of other much more complicated conditions of disease or sequences of injury. It is quite possible that not a few ill-understood local maladies — some forms of senile gangrene and many skin-diseases — may in future be proved to depend rather upon pathological changes in nerve- trunks than upon defects in blood-supply or morbid states of the fluids. Case I. — Severe injury to the hand necessitating ampuitation of all, excepting the forefinger and thumb. — Section of the median nerve to the forefinger. — State of the nutrition of the finger two years after- wards. — Ten degrees of difference of tenvperatv/re between it and X 306 MR. HUTCHINSON ON THE RESULTS WHICH FOLLOW the adjacent thumb, — History that inflammation of the flmger had been an, immediate consequence of the injury. George K. S., aged 48, was admitted in December, 1863, in con- sequence of a recent accident, but the chief interest of his case belongs to a former injury. Two years before, Mr. Luke had am- putated the little, ring, and middle fingers of his right hand. The injury Tiad been ca;used by a circular "saw, Which had passed deeply in the palm on a level with the annular ligament, almost to the meta- carpal bone of the thumb. The metacarpal bones of the three fingers mentioned were all removed at their carpal joints. Whien he came before me in the out-patienVs room for another injury, I congratulated him on having saved a useful finger and thumb. He replied that the fore-finger was of no use to him, inasmuch as he could not feel in it. He " could put it in the fire without feeling." I then noticed that its skin, below the second joint especially, looked too smooth and shiny, and on touching it found that it was much colder thata the thumib. He complained very much of its aching and coldness. It had never become inflamed of late. The small muscles on the outer side of the thumb were wasted, but its adductor and 1;he abductor of 'the ifldex-finger were in good case. The parts were soundly healed, and the scar ■ across the palm would riot have been noticed without looking for; it was, however, very deeply attached. The long flexdr tendons were free, and he could bend the thumb well, anil the finger to a moderate extent. On careful trials with the thermometer, 1 found thfe tem- perature of the pulp of the finger ten degrees lower than that of the thumb. This djjservation I confirmed by repeated trials (76° and 86°). With regard to the influence upon the nutritidn df tlie finger soon after the accident, the man told me that he was long under care for " swelling and blistering of the whole finger." The thnmb did not inflame. On careful examination of sensation, I found that he could feel on the back of the finger up to, and a little beydnd, 'the joint between first and second phalanx (radial nerve). In all other parts he had no feeling whatever. Case II. — Dvisidn'of the ulnar nerve jmt above the diow-joiiit j Compute and permanent mmsthesia of the integument svppUed hy INJTJEIiES TO NEEVE-TKUNKS. 307 iii — Infiammation rf part of the hand ending in resolution — Painless ungual whitlow of little finger with exfoliation of the sikin and nail.— Perfeoi reprodtcction cfthe nail. — Contraction of three finders (unexplamed). Particulars of the state of the arm as io nutrition, ammal heat, 8fc., twenty months &fter the accident. For an opportunity of examining the case recorded in the follow- ing notes I was indebted to the kindness of Dr. Powell, at that time the Resident Medical Ofiicer of the Hospita;!. ■ Rose M. a rather delicate girl, aged 14, was brought to me on the 28th of May, 1863. In October, 1861 (twenty months ago), she sustained a very severe lacerated cut across the back of her right elbow by pushing it backwards through a pane of glass. The cut was very deep, and a part of the skin was taken quite away. She was admitted into the London Hospital under Mr. Critchett's care. It was three months before the wound was perfectly closed. With regard to immediate symptoms, she describes most accurately the parts which " were quite numb from the very minute she did it " — they are those supphed by the ulnar nerve. She states also that there was great swelling of the back of the hand, and that an abcess was feared, but it went away. She had great pain in the middle and ring fingers. There does not appear to have been any reason to suspect injury to the joint itself. Present condition.' — ^There is a large ^supple scar, just above the back of the elbow-joint. The whole arm is thinner than the other, the difference being most -marked in the lower half of forearm. The hand is very much thinner, and, about the little finger, the muscles are wholly wasted. The metacarpal bone of the forefinger is left bare of muscle. The middle, ring, and little fingers are curved into the palm, the ring finger more than the middle one and the little finger most of all. She cannot straighten them, nor can they by force be bent back into a perfectly straight position. The attempt to do so gives'her no pain, but she says it " drags something at her elbow." This flexion of the fingers is not due to paralysis of the extensor, for aU the tendons of this muscle start up when she tries to extend them, and the first phalanges are bent back on the metacarpal bones but the other joints remain much curved. The triceps is much X 2 308 ME. HUTCHINSON ON THE RESULTS "WHICH FOLLOW wasted and its tendon has probably been partly cut through in the inner side. The spot where the nlnar nerve has been cut is easily felt. It is a little above the internal condyle. There is a separation of the cut ends for the space of about a quarter of an inch. Both ends are somewhat bulbous, but the lower much the more so, being enlarged to three times the natural size of the nerve. Pressure on the swollen ends does not cause much pain but she complains of " pins and needles" if either of them are much pressed, more espe- cially if it is the upper -one. Temperature, sensation, and nutrition^ — I could not distinguish any positive difference of heat in the parts supplied by the ulnar nerve in the two forearms and hands. With the thermometer apphed be- tween the little and ring fingers, it appeared that there was about a degree minus on the paralyzed side, but this observation was not very positive. There was not the slightest sensation in the little finger or ulnar side of ring finger, nor in the integment of the ulnar border of the hand. Sensation was defective, but not wholly absent in the palmar and dorsal aspects of the hand, over the metacarpal bones of the ring and little fingers, and also along the ulnar border of lower third of forearm. The integument of the affected fingers looked a little redder than that of the opposite hand, but presented no other peculiarity. The end of the little finger looted smaller than the other, and its nail was not more than half the size of that of the other hand. She told me in explanation of this, that some two months after the accident, the nail of this finger came off, together with the skin " like the end of a glove." She pulled it off one morning, and a new nail afterwards formed. The whole progi-ess of the whit- low had been entirely without pain. I must ask attention to the fact that the new nail, thus formed in a part whoUy deprived of nerve- influence (at least of cerebro-spinal) was perfect in form, although not of normal size. The girl also stated that in consequence of having no feeling in the little finger, she had several times burnt it, and that the sores had always healed well. The day on which I tested the temperature was very warm. Both the girl and her mother assured me that in winter the paralyzed parts were usually much colder than the others. i*^^ I do not at present know how to explain the flexion of the fingers into the palm which so commonly follows section of the ulnar nerve. INJURIES TO NERVE-TBUNKS. 309 In most of my cases the tendons of the forearm have been injured in the accident^ and to their injury I have been inclined to attribute the contraction. Here, however, we have a case in which the nerve was cut, secundum, artem, and without injury to any other structure, and in which the contraction was most marked. It is interesting also to note that it did not exist at first, but had, according to the patient's statement, gradually come on and increased during the last six months. She considered that it was still increasing. Case III. — Section of ulnar and median nerves of the right forearm. — Ulceration of the paralyzed fingers. — Contraction of the fingers. Mrs. S., aged 30, one day, in the end of August, 1 864, thrust her right hand through a pane of glass, and inflicted a very severe laceration of the wrist. She was at once admitted under .my care at the London Hospital, where both ends of the ulnar artery were tied. She was insensible for some hours, owing to the loss of blood. I did not see her myself till the next day, when, in testing her sensation, I found that she had entirely lost feeling in the parts supplied by the ulnar and median nerves. The hand was kept enveloped in cotton- wool and the wrist well flexed on the forearm. I regret much that I have kept no notes as to the variations of temperature at this time. She left the Hospital in about a fortnight, at her own wish, the wound being in a healthy state, but not nearly healed. Soon after she left, the little finger inflamed (without pain) and ulcerated at its tip and ulnar side. At a later period she had much pain in the ring finger, but still none in the little finger. Januan-y 1st, 1865 — (four months after the accident). Her hand is in the condition represented in the sketch. AH the fingers and the thumb also are bent towards the palm, and she cannot straighten them. The hand everywhere looks thin and skinny, owing to the atrophy of the lesser muscles. This wasting is especially to be noticed in the ulnar border of the hand. The nafl. of the little finger is wanting, and an ulcer occupies its place. A second superficial ulcer is seen on the border of the hand, over the metacarpal bone of the Httle finger. The skin of, all the fingers looks glossy and smooth, the wrinkles, &c., being wanting, although the fingers are thin. The nails are stumpy and broken, and uneven on their surfaces. The fingers are more deeply coloured than those of the other hand. 310 ME. HUTCHINSON ON THE RESULTS WHICH FOLLOW On pressurej their colour is easily removed and returns slowly. The lingers are to the touch much colder than those of the other hand. The scar two inches above the wrist is quite sound. The tronk of the ulnar nerve, behind the inner condyle, is easily felt in each arm. It is decidedly smaller in the injured arm than in the other. Slight pressure gives more annoyance on the right (iajured), than on the left side. Letting the nerve roll under one^s finger, she described as painful at the spot touched on the right side, and as cfausing no sen- sation on the other. . I now pressed the finger very firmly on each nerve-trunk, and asked her what she felt. " I felt nothing in the right side, but, on the left, the little finger is numb and aches.^' This was repeated several times with like results. She never felt any pain below the part pressed upon on the injured side, and firm pressure did not give her more pain at the part itself, than did a light touch. The following are my notes as to temperature : — ■Front of wrist (right) 89° (left) .. .. .. .. 90" Back of middle finger (right) 72 (left) .. .. .. Cleft between httle and ring fingers (right) . . 89 , „ „ (left) ..93° Cleft between middle and ring fingers (right) 88° ' „ „ • .. (left) .. 94° I also made a memorandum of the following points :— " She says that ' her hand never gets hot.' It never feels cold sub- jectively. Sometimes she has cramp in it, sometimes pins and needles ; both these sensations being chiefly felt in the palm. On the front of tlae hand and fingers she cannot feel anywhere, excepting in the radial border of the thumb, and a little in front of it. AU the fingers are absolutely without sensation. On the back of the hand she has no sensation in the ulnar border, nor in the little or riilg fingers. The proximal inch of the middle finger has sensation, and the whole of the fore-finger and thumb, to their naUs, the sensation being how- ever, less acute towards their ends. Behind the wrist she has sen- sation only in the radial half of the surface." Case IV. — Section of the ulaar and median nerve of the right hand. o o INJUEIES TO NEEVE-TRDNKS. 311 — That of (he median not quite complete. -^-T^araly sis still existing fowr months after the mjwry. — St%ll in statu quo tnpenty-two months after the injury, r^-Much pfiin in the iujtf,red limb. — Reflex pain in the other; hand. Caroliue P. aged 15, of feeble circiiilation. On, the lOtli of November, 1864, sbefemndtBjfust her hand thiougb a pane of glass. There was very profuse bleeding, wliicl;i lasted for tii^o hours. She was taken to the London, Hospit^, where her wound ^as dressed, aiiid the ulnar artery secured., ^ the parts of tj;ie. hand supplied by the ulnar ^nd median neryes were paralyzed. I did not see her until January 23rd, 1865 (fourteen weeks, after the accident), when the following notes were taken. " Just above the Tight wrist, is a l9.rge thick scar, crossing from the ulna to the middle pf the forearm- It is soundly healed. She tells me that it was quite healed within three weeks of the injury. The fingers are very slightly flexed, and she can bend and straighten them to a certain extent. The flexor tendons adhere to the scar, and the latter is dragged on, when they are moved. The hand is flabby, red, and mottled. The , metacarpal bones of the thumb and little finger are rendered visible by the wasting of the muscles . which clothe them. The pulps of the finger-ends are soft and not nearly so thick as those of the other hand. On the parts supplied by the ulnar nerve, the loss of sensation is absolute, and it is also very nearly so in those supphed by the median. In the palm of the hand, however, she can just perceive irritation. She says th9.t it causes a little tingling. Back of hand. — Op the thumb she feels easily up to the nail. On the forefinger she feels up %o the joint between the first and the second phalanx, but not in the least beyond itj and on the middle finger up \ja the same joint, hut not acutely enough to bg able to tell which finger is touched. Eing finger, on the back ^nd radial border, as far as the same joint, but not on the ulnar border, Over the wrist and hand itself, she feels well on the radial half, and not at all on the ulnar border. The skin between these parts enjoys imp.erfpct sensation, which diminishes gradually as we approach the ulnar border. Palm of hand. — Thinks she feels sliglitly up to the very tips of the fingers when pricked deeply, not at all on light touching. Over the 312 ME. HUTCHINSON ON THE RESULTS WHICH FOLLOW radial two-thirds of the ^palni, also, she feels when deep pressure is made, and not in the least on light pricking. In front of the fore- finger, she also feels pricting, but not unless it is made forcibly. On the middle finger she does not feel the deepest pricking. Suijective sensations. — She complains that the fingers often burn very much, and that " the ends swell up at night,'' and often keep her awake. She dreams much, and often wakes and finds the hand so hot that she cannot bear it. She says that the nails often turn quite blue, and that " water (perspiration) often runs out of the end of the middle-finger.^' Often the thumb, and across the knuckles, ache with cold. The little finger never either aches or feels hot. When she came into my room (a cold frosty morning), both hands were very cold and mottled and I could distinguish no difference in temperature. After she had sat in the warm room (63°) for half-an- hour, I made the following observations with the thermometer. Cleft between little and ring fingers, left 83° ; right (paralyzed) 64°. This remarkable difference I verified by two careful trials, and there was not the least room for mistake. Both hands were now put into water at 108°; Whilst in it the ■ back of left hand not covered, by water, registered 76° ; The back of the right 68°. Both hands in water at 118°, and the backs of hands not covered, registered; right 78°; left 88°. I pressed very firmly on the right ulnar nerve behind the internal condyle and she felt " pins and needles" in the ulnar border of fore- arm, but not lower than the wrist, not in the least in the little finger. It did not seem to cause pain. The ulnar nerve on this side is not more than half the size of that of the other arm. The loss of temperature occurs in the whole forearm, not only in those parts of the hand below the section of the nerves. Thus we notice the skin to be mottled, and a little livid, and find the ten degrees of difference in its heat in the two arms. Back of right arm a little below elbow 71° ; left 81°. The right arm is very much thinner than the other, and the integument in the state of cutis anserina. About a quarter of an hour after both had been in warm water, the difi'erence was only 4° ; the right being 73°, the left 77°. Thus the left was much cooler than it had been during the first stage of reaction after coming from the cold into a warm room. INJURIES TO NERVE-TRUNKS. 313 The effect of warm water is at first to make the paralyzed hand livid, and the other of a bright red, but on a second trial, and with water of higher temperature the paralyzed hand became deeply coloured of a bright salmon tint or like the spots on a plaice. Wherever pressure had been made red spots appeared, which were abruptly defined. It, would have been easy to write letters on the skin as we can do in urticarious patients. August Wth, 1866. — She has very little use of the hand. Its general condition being much as it was at date of last note. The hand is very much thinner 'than the other. Girth round knuckles three- quarters of an inch less than the other, The scar is quite soft and loose. There is very little evidence of repair of the nerves. The ulnar nerve appears to be still absolutely paralyzed, and she has still but very indistinct sensation in the parts supplied by the median. Thus a pin may be thrust into the pulp of the middle finger, and she does not feel it tiU it is quite through the skin. Even at that depth she cannot tell which finger is pricked. The nails are all quite perfect. The hand is a Uttle mottled. The little finger' especially so. Temperature of room 68° The hands had been placed side by side on a table for about ten minutes before the thermometer was used. Cleft between Httle finger and ring finger, right hand . . . 80° fore „ middle „ right. „ ... 89° J, „ J, lett „ ... y4j It is curious that she now avers, that the tracts of skin supplied by the radial nerve in the injured limb, are much less sensitive than natural. This appeared quite definite. Whenever we touched any part of the radial territory, she said she could " feel a little, but not much." That the whole of the forearm is cooler, as high as the elbow, than the other, there can be no doubt. After both had been equally exposed for some minutes the right forearm, in the middle of the dorsal aspect, registered 83°. The left 86°. She says that the injured forearm often aches very much, more especially in rainy or cold weather. She is then obliged to wrap it up in flannel, because it becomes so cold and discoloured. The nails, she says, get quite black. When the pain in the arm is very bad, it is a confused 314 ME. HUTCHINSON ON THE RESULTS WHICH FOLLOW aching in the whole of the upper extremity. When at the worst, she says that it makes the other hand aohe, and makes it weak,, so that she cannot use it. As regards the use pf the hand, she can scarcely do anything with it. She can just manage to hold a pen ax pencil by pressing it deeply into the cleft between the thumb and fore-finger; if it gets nearer to the ends of the thumb or finger, she cannot feel its presence, and it drops from her hold. So long a period as twenty-one months having passed, it is, per- haps, scarcejy to be hoped that the nerves implicated wijl ever be restored. Case V. — Sx^ovsJS-^Bivisioa of the ulnar nerve anA ves^ej^ a%d of the median nerve. — Anaesthesia of the parts supplied.— Inflammation of the tips of th-ee fingers, unattended hy sensation. — 'Tfmiwidion of animal heat in all the parts pa/ralyzeA.-^nerease of heat during inflammation^ but still not up to the normal standards A healthy girl,, aged 22,, cut the ulnar side of her right forearm very deeply on a broken window. The wound was- at the upper part of the lower third, and passed across the ulnar vessels and nerve deeply into the mid-structure, probably dividing the median nerve. It bled very freely indeed. She was taken to the Hospital where the haemorrhage was arrested, and the wound dressed. She came under my notice three weeks afterwards ; the wound being then just healed. The scar was then puckered in. She stated, as regards pain, that she had had very little in the wound, but much aching in the palm. The haixd of the wounded arm looked a httle thinner and a little paler than the other, but there was no other difference to the eye. All the fingers were kept bent slightly in the palm, and she was unable to straighten them, owing, as she believed, to the effort to extend dragging on the scar. In the attempt to extend, the scar was moved. She was able to flex the fingers fairly, but could not contract her palm, or bring the thumb into apposition with any of the fingers. The muscular mass between the thumb and fore-finger was thin and flabby. The beat of the ulnar artery could be de- tected below the scar. Sensation. — Immediately below the scar she could feel "the prick of a pin, but not acutely ; an inch or two lower, she could scarcely INJURIES TO NEKVE-TRUNKS. 315 feel it. To the radial side, and at all parts above the scar, she coidd feel well. At the level of the wrist^ in front, all sensation was lost, excepting over the ball of the thumb, where it was retained in aa imperfect degree. The little finger had no^ sensation on either side, nor had the ring, middle, or fore-fingers. There was no sensation at the backs of the little, ring, and middle fingers ; very little at the back of the fore-finger, but somewhat more behind the thumb. Over the back of the hand, sensation was imperfect, being more so as the ulnar border was approached. The extremity of her ring- finger was inflamed, and presented an open sore, on the face of which, however, the prick of a pin was not felt in the least. The ends of the middle and little fingers were also inflamed. She had had no pain during the formation of these whitlows, but a continued aching in the palm of the hand. The palm, it should be observed> was not in the least swollen, nor was it tender to pressure. Mutrition. — About ten days after the accident, the tips of the little, ring, and middle fingers inflamed. In each the exact tip was affected, and serum was effused beneath the skin over the entire ex- tremity ; the finger-ends were slightly swollen, reddened, and, in the case of the ring-fiager somewhat tense. No pain was felt. Tile effusion in the Kttle finger was absorbed. The skin at the end of the ring-finger died over a space of the size of a sixpence, and theie is now an open sore at that part. On the middle finger the subcu- taneous bulla still exists. The cuticle is elevated by effused serum (subcuticular whitlow) and there is an areola of reddened skin aboat it. Temj^erature. — On cursory examination, no difference from nor- mal heat would have been observed in the affected hand. (The weather being sultry.) On comparison with the other hand, a differ- ence is, however, very perceptible, the nails of the affected hand fed indeed, slightly cold. By the thermometer, a difference of about nine degrees is shown between corresponding parts of the two hands. On the finger most inflamed, the heat is greater than on the others, but still does not rise quite to that of the same finger of the other hand. Right fore-finger (paralyzed) side 79° front 78° Left „ (sound) .. .. 90°' „ 87° 316 ME. HUTCHINSON ON THE RESULTS WHICH FOLLOW Right little finger (paralyzed) radial side . . 80° ulnar side 79° Left „ (sound) .... 89° „ *89° Right ring finger (paralyzed, but inflamed) front . . 89° Left ,„ (sound) 91° Right middle inger (paralyzed, but slightly inflamed) . . 87^° Left „ (sound) .. .. ' 91° . Case VI. — The following case very closely resembles, in most points, the preceding one. In both, a great loss in temperature was the most marked feature. In both, the influence of the nervous force, in preserving a normal state of nutrition, was illustrated by the occur- rence of whitlows at the ends of the fingers from which it had been cut off. In the former case, thfee fingers were so affected ; in the latter, only one. In all, the position of 'the inflamed part was pre- cisely the same — the very end of the finger. It is an interesting fact, in the present case, that there was very decided loss of tem- perature in the integument, even abovethe position of the wound. The details given will, however, tell their own story. Analysis. — Section of the ulnar nerve, with, prolaih/, wound of the median also.-^Siate of the hand three months afterwards. — Loss of temperature m. the whole hand, and also in the fore-arm above the sear. — Dilated and atonic condition of capillaries. — Whitlow at the end of the ring-finger —Atrophy of the muscles supplied hy the ulnar nerve. — Recovery of a slight degree of sensation in the parts. Emma R., aged 15, on October 19, thrust her right hand through a pane of glass, and received a deep cut on the inner part of the fore-arm, about an inch above the wrist-joint. The radial end of the incision passed as far as the middle line of the fore-arm, but possibly it passed deeply still further. It crossed the ulnar vessels and nerve. There was very free bleeding, which was stopped by compress and tight bandage. She was taken to the London Hospital an hour afterwards. No further bleeding occurred. The wound healed slowly, and with suppuration. She was discharged five weeks after her admission. Examimation. — February 1st, 1863, rather more than three months after the accident. She is in good health, but has not been able to * Two sides exactly alike. INJURIES TO NEEVE-TRUNKS. 317 make any use of her hand. The hand is chilly and bluish-red, like that of a person suffering from chilblains ; the capillaries fill slowly when emptied by pressure; all the finger-nails are somewhat clubbed, and decidedly more curved than those of the other hand. The scar has been quite sound for six weeks, and is free from tenderness. It moves when the fingers are straightened, the tendons being adherent to it. Sensation is good above the scar, and exceed- ingly imperfect below it — over the ulnar side of the hand, the little and ring fingers. No discoverable difference between the two sides of the ring-finger. The middle and fore fingers have only imperfect sensation ; in the thumb it is tolerably good. It appears to improve gradually as we go from the little finger to the thumb. Even over the little finger she has a shght degree of sensation, and can tell sometimes when lightly pricked, A.11 the fingers are bent forward to the palm, but do not touch it, To straighten them causes pain at the scar. The muscles clothing the metacarpal bone of the thumb are much wasted. The qarpo-metacarpal joint is too visible, and the outline of the metacarpal bone is exposed. On the back there is a remarkable hollow between the thumb and fore-finger, and the metacarpal bone of the latter is immediately under the skin, the abductor indicis being quite wasted. When told to draw her thumb across the palm, to make it and the little finger meet, she bends the thumb by the long flexor, and is quite unable to adduct it whilst extended. She cannot bring the thumb and the little finger together by any effort, partly because she cannot move the little finger at all. The structures in the palm are a little thickened, and she has slight tenderness on pressure there. She says that she has not had much annoyance from sensation of cold or aching in the hand, but she is quite aware that it is colder than the other ; she has also noticed tha.t when the hand is put into hot water she does not feel the heat well. At the very end of her ring-finger (injured hand) is a small whit- low j it looks as if a few drops of pus had been effused beneath the skin, and were now nearly absorbed. The skin over it is dry and homy ; there is a little red areola around it. She has had no pain in it, and it is not tender. It began to form nine days ago. The following is a statement of the temperature, as determined by 318 ME. HUTCHINSON ON THE RESULTS WHICH FOLLOW tie thermameter applied to different parts. The experiments were made after the girl had sat in a warm room for half-an-hour, with the two hands eqnally exposed : — . Lefit. Bight. Difference. Ulnar borders of the two hands . . . . 66° 61° 5° Between little and ring fingers (in the ■cleft).. .. „ 65° :bQ° 6° Between Aumb and fore finger (in the •deft) 66 J° Between fore and middle fingers (in cleft) 65° Pulp ;of thumb-end 62^° Ball of thumb (palmar aspect) . . . . :65° Front of fore-arm four inches above wrist (ithree above the scar) . . . . 78° Case YIL-^Section of ulnar nerve, and of part of median nerve. — No return ^sensation two mmths later.— ^Gontr action of fingers. — Evi- dence at fo the distribidion nfthe radial nerve on the back of the 62° 4^ 60° 5° 60i° 2° 61° 4° 74° 4° Edwin N., aged 15, had a deep cut an inch above the wrist-joint across tlie course of the ulnar vessels and nerve. ISio iartery was tied, but it bled at first very much, It was about May ;the 11th that he had the accident, by thrusting His hand through a pane of glass. I saw him a month later (the wound then scarcely healed), and ascertained thathe had at first all the symptoms of section of ithe ulnar nerve, and of notphing of the ulnar edge of the median nerve also. Julff ZQth. He has lost sensation in the little, ring, and middle fingers, both sides of each. Pa;lmar aspect of hand, no sensation till we cross the space between metacarpalbones of middle and index- finger. On the outer side of hand on ulnar border i.e outside the metacarpal bone of little finger he can feel ifairly. He can use his thumb and index, but the middle, ring, and little fingers are all contracted on the palm, and these he cannot nse. He cannot bring the thumb across the palm towards the little finger. When he tries to do so, he merely flexes the thumb. He has no pain. The weather is ihot, and !his paralyzed fingers are warm, nearly as much so as the others. The scar is dragged upwards when he tries i;by aid of .the other INJURIES TO NERVE- TRrrNKS. 319 hand, to extend the contracted fingers. On the back of thfe hand he has good sensation on the hand itself, and on the whole of the thumb and index-finger, but on the little, ring, and middle fingers sensation ends gradually bstween the' knuckle and the next joint. The paralyzed fingers are red and the capillaries when emptied by pressure refill slowly. They have never inflamed. It gives him no pain to extend forcibly the contracted fingers. The middle finger is more ccftitracted than the others. COMMENTS ON THE SEEIES. Anatomical observafions.-^The ulnar and median nerves are from their position those most likely to be divided in injuries to the fore- arm, and the ulnar is much more frequently injured than the median. The ulnar is also usually cut completely through, whereas the median is often only notched on its ulnar side, and not wholly divided. I have never had an opportunity of examining a case in which the tadial had been divided alone, and in almost all my cases this nerve remained intact. » They, therefore, afford us good opportuni- ties for determining how much of the integument of the fingers is supplied by this nerve. My conclusions on this point differ in toto from those of such anatomists as affirm that the radial nerve supplies the *hole of the dorsal aspect of the thumb, fore and middle fingers, and the radial side of the ring finger. It is quite certain that those are right who, with Swan, affirm that it does not pass nearly to the ends of the fingers, On the thumb it passes as high as tl^e root of the nail ; on the fore finger, as high as the middle of the second "phalanx ; on the middle finger, and on the ring finger not higher than the first phalangeal joint. The distal parts of these fingers are sup- plied liehind as well as in front by twigs from the median which curve backwards, and encircle the fingers. When the median is cut these parts lose all sensation, and the border territory between that supplied by the median, and that by the radial, is also decidedly defi- cient in sensation, although not absolutely numb. ■When the ulnar nerve is cut at the wrist, there is complete loss of sensaition in the whole of the little finger, and in the ulnar side of the ring finger, both back and front. The ulnar border of the hand, and the skin overlying the metacarpal bone of the little finger, and part of the next one, are also involved in anaesthesia. 320 MR. HUTCHINSON ON THE RESULTS WHICH FOLLOW One of the most characteristic symptoms of paralysis of the ulnar nerve is a hoUow between the fore-finger and thumb, especially to be noticed close to the metacarpal bone of the fore-finger, and due to the atrophy of the abductor indicis.* This hollow is seen at a glance. The muscles, which depend upon the ulnar nerve for their excite- ment, are all the short muscles of the little finger, the palmaris brevis, the inner part of the short muscles of the thumb, all the in- terossei> and the two internal lumbricales. Amongst the interossei is included the abductor which I have above mentioned. Before we investigate the question as to the influence of the nerves on nutrition, we must answer any objectors who might incline to attribute the lost of heat, &g., which exists, to defects in blood- supply. This is easily done. It is quite true that, wherever the ulnar nerve is cut thrpugh above the wrist, the ulnar artery usually goes with it. Severe hsemorrhage attends the accident, and ligature of the two ends of the cut artery is generally required. This cir- cumstance may interfere with the results for the short time, but not , \ for long ; and there is not the least reason-fcJr believing that ligature ; of the ulnar artery, would have any permanent effect on the nntri- \tion of the parts sijpplied. The inosculations are too free, and the \ * My attentijon was first directed to tliis symptom some years ago by my colleague, Mr. Co]iper. It has been of great use to me several times sinee. Ii have repeatedly, by its aid, recognised paralysis of the ulnar nerve, in ciises of which I had no previous knowledge. I believe that it is not very in- frequent for paralysis of this one nerve to occur without any history»of in- jui-y, and without any other symptom of cerebro-spinal mischief. At any rate, I have had several such cases under care. In these the mortor fanc- tion fails before the sensory, although both are ultimately involved, and the waking of the muscle mentioned may be very apparent before the patient is aware that he has lost sensation in any part. About two years ago,^my friend, Mr. Colman, requested my opinion in the case of Mr. B., a gentle- man; of middle age, and in robust health, but suffering from abnormal sen- sations in the fore-arm. A glance at his hand told me that his ulnar nerve was jiaralysed, and on examination I found that sensation in the little fingeA &c., was almost wholly lost. A few months later I saw a similar case, alnd in neither could we trace the paralysis to any very definite cause. An ingenious and distinguished author has referred this wasting of the muscles between the fore-finger and the thumb, after injury to the ulnar, to reflex aisturbance of nutrition. It is, however, not reflex, but direct, since the muscles in question are supplied by the deep palmar branch from the ulnar trunk itself. INJURIES TO NERVE-TRUNKS. 321 collateral circulation too easily established for such a result to be possible. We have plenty of facts as to the tying of the ulnar artery without injury to the nerve, and in none do any ill-conseT quences result. We may, therefore, feel quite certain that the sym- ptoms met with a few weeks after the accident, or at longer periods, are due to the nerve, and not to the artery. Physwlogical Results. — Next to the loss of sensation, respecting which we need say nothing, we have as the chief result of nerve sec- tion, a diminution of temperature. It is to be noted that none" of my cases were accurately observed soon after the accident, most of them not until the wound was healed. Many conditions make trials of temperature at early periods after the injury liable to mislead, such, for instance, as the fact that the vessels as well as nerves are usually cut, that inflammation is in progress at the wound, and that the part is protected by dressings. Eespecting the state of things some weeks afterwards, I find no exception to the assertion that there is always a remarkable loss of heat in the part which has lost sensation. The amount of comparative loss will vary with the external conditions, for it is a remarkable feature as regards the heat of paralyzed parts that it is so much at the mercy of external influences. All my patients agreed in the statement that in cold weather the anaesthetic fingers became very blue and cold, and in many I was able to demonstrate this fact. In the warmest temperature, however, their heat could never be raised up to that of adjacent, unparalyzed parts. Nor does even the existence of active inflammation raise the part to the normal standard, although it much increases it. In case Y. there was ten degrees of difference between the little finger in the hand from which the nerve-supply had been cut off, and that of the other. The ring finger was paralyzed and inflamed, and its temperature was increased by inflammation, until it came within two degrees of that of the other hand, but still it did not quite reach it. In Case lY. we put the tvvo hands into hot water (118°) and the result was that both hands gained in temperature about ten degrees, and that the difference be- tween them remained as great as at first. It would appear, there- fore, that while a paralyzed part can be cooled to almost any extent, it cannot be raised by artificial heat beyond a certain point, and that point much below the maximum of its uninjured counter part. Y 322 ME. HUTCHINSON ON THE RESULTS WHICH FOLLOW In oae case only it occurred* to me not to find mucli difference between the paralyzed and healthy parts. My general experience has been that a difference of from six to ten degrees will be apparent.t To what are we to attribute this remarkable loss of power to sustain the normal temperature, and to guard against the depressing effects of external cold ? To say that it is the result of mere disuse is un- satisfactory, for we find it just as marked where one finger is contrasted with the others on the same hand, as when the whole hand is affected. One of my cases (Case I.) is almost crucial in this re- spect, for the man had but a finger and thumb, and used neither of them, yet the finger deprived of nerve influence registered ten degrees lower temperature than the thumb which yet enjoyed it. To allege that it is due to " dilatation of the smaller arteries and consequent slowness of the circulation " is scarcely more satisfactory, since para- lysis of the vaso-motor nerve, and consequent dilatation of the vessels, is well known to lead to inerease of temperature. Yet it is quite cer- tain that the capillary circulation is in some way greatly disturbed. If you chill the part it becomes not merely pale, but livid ; if you warm it, it becomes not of a bright, pink, flesh tint, but of a peculiar duU brickrred colour. The most plausible conjecture seems to be, not that the nerve-control over the vessels is at fault, but that the vis afronte is itself much diminished. One way in which this must be reduced would no doubt be by the atrophy of these parts of the skin which endow it as an organ of tactile sensibility. No doubt but that after a nerve of sensation has been long cut you will find the papillse of the skin wasted and shrunken. The nerves themselves will also no longer maintain their own nutrition, and thus a much diminished demand for blood will result. I cannot but think it probable, however, that there is something more than this, and that the endowments of every single cell in a part no longer connected by nerves with the great centres, undergo an alteration. * This was on a hot day ; the patient stated that in cold weather the fingers were very cold. t Mr. Erichsen has recorded an interesting case in which, twenty-one weeks after section of the ulnar nerve, tlie fourth cleft was 9° less than the corresponding part of the other hand. — Art and Science of Swgery, p. 207. INJURIES TO NEEVE-TEUNKS. 323 If we may suppose that the cells of the part no longer possess the same energy of growth and nutrition, no longer attract the blood, take from it what is needed and transmit it forwards, then we can at one and the same time account for the loss of heat, the manifest slowness of » the capillary circulation and the occasional changes n structure to which I must next advert. Whether such an hypothesis is admissible I must leave with physiologists to say. If it be we may perhaps be permitted to speak of paralysis of the vis afronte of the circulation as the real cause of the loss of temperature after division of nerves. Lesions of Nutrition. — It has been the subject of some debate whether the inflammations which often follow in paralyzed parts— as of the eye, in paralysis of the fifth ; the formation of bedsores and the occurrence of cystitis, in paraplegia— -are in direct or indirect connection with the nerve-lesion. It is said that the eye does not inflame if it be covered, and that the bedsores will not form if the patient be protected from pressure (water-bed). There can be no doubt that accidental influences have a large share in the production of the inflarnmation, which follow under the circumstances suggested. The state of nutrition which results from the section of nerves is one which permits rather than causes inflammations. That it may, however, now and then suffice to originate it without any accidental cause super- added, is, I think, highly probable. Some of the facts in my present series seem to strongly support this view. In five, out of the seven, cases, it is stated that the fingers involved in paralysis became inflamed soon after the accident. The kind of inflammation was so similar in all, and so remarkable in some, that it is impossible to believe that it was the result of accident. It is possible that a patient having the fingers wholly without sensation, might allow one of them to press too long against the table, bed, &cr, and thus a sort of bedsore be produced. But, when we find the tips of four fingers inflaming at the same time, when we find that the parts attacked are never those most likely to be exposed to pressure, but always those at the greatest distance from the centres, it is impossible to entertain such an hypothesis. The kind of whitlow which forms in these cases is very pecuhar. It involves the very tip of the finger, and usually the skin t2 324 ME. HUTCHINSON ON INJURIES TO NERVES. and part of tlie subcutaneous tissues with which, perhaps, the nail is exfoHated. In other cases the inflammation recedes, and its products are dried up.* Several of my cases give illustrations of the fact, that although paralyzed parts are liable to inflame, yet they are capable of good repair.t In one case, a perfect nail was reproduced. In no single instance did the tendency to inflammation persist for long. Repair of nerve-trunks. — None of my cases lend any material support to the commonly-received doctrine that nerve-trunks, which have been cut, are rapidly repaired. I have followed several of the patients over long periods of time, and, as yet, there-is no evidence of tendency to restoration. It is true, that in aU, the wounds were open, and several very large, but, on the other hand, in most of them the healing was rapid. It may be, however, that yet longer periods are required. At a late meeting of the Pathological Society, Mr. T^unn brought forward a very interesting and important case, in which, after the lapse of several years, a nerve-trunk was ultimately repaired. To certain other interesting features, in the cases I have recorded, I can but invite attention without discussing thein in detail. Amongst these may be mentioned : — 1. The observation that the loss Of temperature extends even to a considerable distance above the site of the nerve-lesion. 2. The siibjective phenomena of nerve-section, i.e., the aching during cold, burning pain when warm, diffused pain in the whole member (Case IV). 3. The contraction of paralyzed muscles, as seen in Case II. 4. Reflex pain, &c., in the opposite limb. Case IV., p. 310. * The close resemblance between these inflammations and the early- stages of some forms of senile gangrene, is most striking. I have recently had under care an old woman with senile gangrene of the ends of three fingers, in which at first the fingers looked just as I have seen them do after section of a nerve. I am strongly suspicions that many cases of senile gangrene begin from defective nerve-supply. t I have twice operated on the eye in cases in which the fifth nerve was totally paralyzed, and in both the wound healed well. CLINICAL AND PATHOLOGICAL FACTS m REPERENGE TO INJUEIES TO THE SPINAL COLUMN AND ITS CONTENTS. The foUowiug series comprises the more interesting examples of injury to the spinal column, which have been under observation during the last two or three years, with one of more remote date. It . does not; by any means, include all the cases, but only those which seemed to illustrate important points, either as regards treat- ment, diagnosis, or physiological inference. The cases of recovery have especially been collected, with the view of illustrating the important fact, that even in severe cases, with permanent local displacement, and with paraplegia lasting for some weeks, complete recovery may ensue. See Cases I., II., VIII., and XVII. The fact that paralytic symptoms may increase, a few days after the injury, is illustrated in Cases II. and XI. Many of the cases give important information as to the kind of displacement which is mo§t common, and its usual effects upon the cord, and illustrate clearly the inapplicability of operative inter- ference. In no single case has any operation (other than attempts at reduction by extension) been performed at this Hospital. To the report of cases, is added a list of all the specimens in our museum, which illustrate these injuries. A majority of these have been obtained recently, and all such have been put up in jars which can be opened, so as to allow the preparation to be removed, and carefully inspected.* These can, on special application to the Curator, be examined by any surgeon who may wish it. * This statement will explain the term " in open bottle,'' which occurs after the description of some of the specimens. 326 CLINICAL FACTS AS TO INJDRIES The occurrence of paralytic myosis, or inability on the part, of the pupil to dilate, finds examples in several cases, whilst increased heat of the surface depending upon paralysis (partial) of the vaso-motor nerve, is also illustrated (paralytic pyrexia). Fracture of the sternum, in connexion with a bend forwards, oc- curred in cases XIV. and XYI., and in connexion with a bend back- wards, is illustrated by specimens described at pages 351, 348, &c. Cases III. and XVI. afford information as the frequent and remarkable changes in temperature which occur in paralyzed limbs. Case I. — Fracture of the spine in lower lumbar region, with dis- placement. — Paraplegia with paralysis of the sphincters. — Gradual improvement. — Recovery in four months, (Under the care of Mr. Adams.) {^Reported by Mr. W..B. Ditchett.) On June 20th, W. Asher, a labourer in the London Docks, was brought to the Hospital, with the statement that he had fallen from a height of thirty-eight feet into a ship's hold, and struck against an iron plate. He was entirely insensible. There was a considerable prominence of the spine in the lumbar region. His right ankle was also much bruised. There was no priapism. The genitals were completely paralyzed as regards sensation. Eetention of urine, and great flatulence. June %\st. — He is now perfectly sensible. He cannot now move either of his legs. Urine clear, somewhat scanty. Complete paralysis of bladder and consequent retention of urine. He did not feel the introduction of a catheter until the point of the instrument touched the coat of the bladder, when he cried out with pain. 2?)th. — General health better; bowels somewhat constipated. He passes his motions quite involuntarily. Has perfect sensation along the fronts of thighs. Can draw up his left leg, and also the right, but with more difficulty. He says that his right ankle is very painful. Urine more copious, thick, and ammoniacal. Appetite good. Full diet. July 3«c^.— General health good ; bowels are less confined, and he is not so troubled with flatus ; faeces pass involuntarily ; his urine is much increased in quantity ; it is very thick and ammoniacal. Mr. TO THE SPINAL COLUMN AND ITS CONTENTS. 327 Adams orders his bladder to be washed out twice a week with tepid water. ZQf'A. — Since July 2iid, the patient has heeii progressing favour- ably ; his urine is much clearer. The first few times the injection was performed, he complained of much pain. This was, doubtless, owing to inflammation of the mucous lining of the bladder (from deposition of phosphates), for as the urine became clearer the pain has diminished,' and the operation is now quite painless. His bowels are regular ; motions still involuntary. Slight orchitis on right side. He has perfect sensation along the fronts of his thighs and legs, in the hypogastric region, and in the parts supplied by the ilio-hypo- gastric nerve, and in the scrotum; has good sensation in the first and second toes, and very partial feeling in the others ; has not the least feeling along the back and inner sides of the thighs. He ex- periences a desire to make water, but cannot pass it. August lliA. — His appetite is very good, and he states, "that he is gaining flesh.'" During the last day or two he has sat up for a short time. He says "that when he sits up, he has very little pain in the back; but that if he tries to stand, his legs seem to give way under him.'' The paralysis has much diminished. All parts of his legs are now more or less sensitive ; the greatest amount of feeling being along the front, and the least on the insides of the thighs. It is less perfect in the right that in the left leg. Bladder still paralyzed; urine much clearer, and less ammoniacal ; motions regular, but involun- tary. From the situation of the prominence in the spine, and from the fact that sensation is perfect in the parts supplied by the first five lumbar nerves, it is probable that the seat of fracture is about the fourth or fifth lumbar vertebra. After the date of the last note, Asher continued to improve. He became able to walk, and left the Hospital "cured" on Oct. 11th. Case II. — Fracture of the first lumbar vertebra, with slight displacr- ment. — Incotnplete paraplegia at first, becoming more complete two or three days afterwards. — Nearly complete paraplegia for a fortnight. — Gradual improvement. — Perfect recovery. (Under the care of Mr. Hutolimson.) The following case is a valuable one on account of the perfect character of the recovery : — 328 CLINICAL TACTS AS TO INJURIES Samuel Moore, aged 32, a carman, was admitted on January 14 and there can probably be but little doubt that a partial displacement in the lower cervical region had occurred. Bartholomew B., aged 45, was admitted on the 29th of December, 1864, having two days previouslyj while in a state of intoxication, ■ fallen down two flights of stairs and struck his back violently. He was taken to bed, and was reported to have been quite insensible tiU his admission. Shortly after admission he recovered his senses, but was partially paralyzed in all his limbs, the lower extremities being most affected. About three pints of urine were drawn off. January 1st. — He complained of the sensation of "pins and needles " in his arms and legs, and it gave him pain to move his head from side to side, though his neck was not painful on pressure. H e was quite unable to stand, and could scarcely move in bed. No irregularity of the vertebrEe could be detected. 5th. — He appeared relieved by a blister which was applied to the upper part of the spine, and could move his hands better. 10th. — The blister was repeated. His bowels only acted after a purgative, and his urine had to be drawn off regulai-ly with a catheter, which at this date caused a good deal of irritation. 12)th. — He could sit up, and even walk a few steps without assistance. %fith. — He began to have some power over his bladder. 31*^. — It is noted that he no longer required the catheter, and that galvanism was ordered to be applied to the upper and lower limbs every other day. Februa/ry Tth. — Mr. Walker states that the" patient had derived great benefit from the galvanism, and said that " his lower limbs felt warm for the first time since the accident." lUh. — He left for the Convalescent Asylum at Walton. He could walk easily about the ward, but still had some difficulty in TO THE SPINAL COLUMN AND ITS CONTENTS. 335 moving his arms, and especially Ms fingers. His fingers had, however, become much stronger, but he could still only move them slowly. A month later he came up again, and had much improved, but stiU was uot active with his fingers. He could walk for about three miles. A month later (April 18th) he walked from the Waterloo Bridge Station down to the Hospital quite well. He complained of numbness in his extremities, and he was still so slow with his fingers that he could hardly feed Irimself. Ten days afterwards Mr. Walker went to see him at his own house. He could then walk four or five miles, could throw a quoit about twenty feet, and could lift a quarter of a hundred weight. He had perfect control over his bladder and his bowels were opened regularly. After the accident he had lost all sexual desire, but had now quite regained it. Case X. — Fracture of vertebra, with displacement in upper lumbar region.' — Paralysis of motion and sensafiion in the lower extremities. -^-Retention of urine OAid faces. — No priapism. — Recovery in six months. (Under the care of Mr. Adams.) {Reported from Notes by Mr. Sees Llewellyn.) Thomas I., aged 40, was admitted on the 28th of June, 1864. He had fallen a distance of about forty feet on to the ground. He said that he was not stunned at all, but found that he could not use his legs. There was considerable ecchymosis and swelling across the lumbar region, and the spinous process of the ninth dorsal vertebra appeared to have been broken off and depressed. He had lost sensation from the level of the crest of the ilium downwards on both sides : excepting in front of the patella, and over a small area at the upper part of the popliteal space. He could not lift up his legs, but it was noticed that when he tried to do so his sartorius and adductor muscles acted somewhat. When his feet were pricked, no reflex action followed. There was no priapism. His urine had to be drawn off, and his faeces passed involuntarily after a purge had been administered. . Juhi Znd. — His urine was ammoniacal and offensive. 6th. — It is noted that a little sensation was returning in the soles of his feet. 336 CLINICAL FACTS AS TO INJURIES Z9tA. — He complained of pain in his thighs " as if in the bone." He had had a rigor followed by a cold perspiration the day before. August 20^A. — He still had the pain in his thighs^ and he also had frequent spasmodic action of the muscles. September \%tli,. — His urine began to run away from him, his bladder having somewhat regained power. October 16 1 A. — ^He could not separate his thighs, but if they were separated he could draw them together again. He could flex both knees slightly and raise his feet from the bed. He could feel almost as well as ever. Novemier 2?»(?.— He passed his urine voluntarily for. first time. Stated that he had lost all sexual desire until that morning. December 2w<^^-He was made an out-patient. He could then micturate easily and could walk very fairly with the aid of crutches.. As regards treatment, he was put on a water-bed till the 5th of Octobei*, when this was changed for a mattress and a water- pillow. A grain of calomel twice a-day was ordered, on the second day, but it was continued only for a few days. The cystitis was treated by syringing the bladder out with warm water, and by the adminis'tration of dilute nitric acid. Later on, quinine and iron were ordered. Galvanism also was resorted to. Case XI. — Injury to the spine, followed on the second day by motor paraplegia, involving first the legs, and afterwards the arms also. Recovery in five months. — Benefit from the use of galvanism. (Under the care of Mr. Curling.) {Reported from detailed notes .by Mr. F. B. Ryott.) 'I : In the following case there is no proof of fracture or displacement. The diagnosis, as to the nature of the injury or its local conse- quences, is suiiiciently obscure : — Patrick W., set. 30, was admitted May 20th, 1854. He was reported to have fallen oh to his feet from a .height of sixty feet, his back and head coming in contact with an iron funnel as he fell. He seemed stunned by the fall, but answered questions, and com- plained of great pain in the nape of his neck. There was a small scalp wound in the occipital region ; but upon the most careful TO THE SPINAL COLUMN AND ITS CONTENTS. 337 examination, no fracture, either of the skull or spine, could be de- tected, and he could move his arms and legs. As he did not pass any water, a catheter was introduced in the evening. During the night he annoyed the patients and nurse by tumbling out of bed, and lying on the floor. He said he could not lie in bed. He could not stand. The next day he had almost en- tirely lost the power of moving his lower extremities, but the func- tion of sensation was unimpaired. May 29^^. — His skin was very hot, and the paralysis had so much extended, that he could only move his arms by a " wriggling motion." The lower limbs were quite helpless ; still the function of sensation was unimpaired. He had much pain in the region of the bladder, and in the nape of the neck when he moved his head, and he could not sleep at night. Jime \st. — He was very thirsty and much weaker, his pulse was more feeble, and his countenance heavy. His arms were almost completely paralyzed. The passage of the catheter hurt him ex- ceedingly. ^th. — He had had sleepless nights, and had been very much troubled with hiccup. A number of aphthous spots appeared on his tongue and fauces, and his lower extremities were quite cold from the knees downwards. His urine had dribbled away for a week past, and his penis was becoming excoriated. At this time it was not expected that he would recover ; he was in such an exhausted condition, but on the 8tb he was better. He had had some sleep, and complained of being hungry. \^tli. — He could again "wriggle his arms about." The pain in the bladder was less, his coun,tenance looked much .brighter, but the hiccup was still troublesome. His penis was in a very unsatisfactory condition, pulpy in parts, indurated in others, so that it was difficult to pass a catheter. To remedy this the " bottle " was removed, and the urine allowed to dribble on to some sawdust, sprinkled with dilute sulphuric acid. This removed the smell, but irritated his thighs. %\st. — Was better on the whole, but wandered at night, and had a bed-sore added to his other misfortunes. A slough had come from the penis, and the surface underneath looked fairly healthy. July \st. — The passing of the catheter seemed to be such a z 338 CLINICAL FACTS AS TO INJURIES source of irritation that it was determined to discontinue its use. He still could not sleep at night, wandering at times, and eating very httle. 30^^.— He had so much improved, that he was ordered full diet. August l^th. — He complained of pains in his legs and knees. His spirits were good, his face more cheerful, and his mind con- tented. He could push his legs dowa, after thej had been drawn up for him, for the first time since the paralysis came on, 17^-5. — He could draw his legs up himself, and was allowed to sit up in a chair. October 1st. — He has lecsvered the use of bis arms, and the partial use of his legs, but he cannot walk. On the 6th, he went out of the Hospital. He soon afterwards was admitted into another Hospital, where he was blistered, but with no good effect. Afterwards he became an ins-patient of St. Bartho- lomew's, where he was galvanized twice a-week; from which he received the greatest possible benefit. Five months later " he pre- sented himself, much to my astonishment," says Mr. Eyott, "at this' Hospital in perfect health, able to walk well without a stick, and no defect of gait could be detected." Case XII. — Pa/rtietl displacement in the lower cervical region, fol- lowed by immediate paralysis of the right arm.— ^Imperfect re- covery. — -Injury probably to the nerm-roots rather than to the cord (Under the caie of Mr. Hutchinson.) The following is a good instance of a partial displaceinent of vertebrae. The patient only came under care for the results of the injury some weeks after its occurrence: — James G., aged 42, was admitted February 13th, 1866. Five weeks ago, while carrying a sack of coals on his back, he fell down some stairs. He fell with his head jammed in a corner. After he fell he says he could not get up himself, and he was carried to bed. " He had no use whatever in his right arm, and no feehng in it." At the end of the week he tried to get up, but found that he could not do so. He could not even sit in a chair, he felt so weak. At the end of three weeks he could walk across the room, and from that time he has steadily improved. He can now walk well. Present condition. — ^The left hand is cooler to the touch than the TO THE SPINAL COLUMN AND ITS CONTENTS. 339 right one is, this was evident to three different observers ; but we found afterwards that it had been exposed, while the other was eovered. There is decidedly a twist of the neck ; the spinous pro- eesses just above the seventh cervical vertebra, being bent towards the right side. He cannot use the right hand, though he can lift the right arm. He cannot grasp with the fingers. He says that his sensation is as good in one hand as in the other, and we cannot make out any difference with the compasses. Both seem defective. His complaint is, that he is weak from the elbow downwards, espe- cially at the wrist and hand: The right forearm, at its thickest part, measures eight and a-half inches. The left measures fully nine inches. He complains that,, on the ulnar aspect of the left arm, he has a burning sensation. The muscles, both of the upper and fore- arm, are decidedly a little more flabby than those of the left. The capillary cireulktion in both hands is feeble^ and' the hands are mot- tled; he exerts the left great pectoral muscle much better than he does the right one; he cannot grasp with the right hand, nor use the knife with it ; he can- grasp with the left hand almost as well as ever. There is no difference of the pulse on the two sides, nor any real difference of temperatore-. Case XHI. — M-actiir,eofiAe spine in Ipwer dvraalreffienwitk cnshing, of the spintd' cord. — Wcmaplegki,, ^ith para-h/sis of bladder and intestines. — Recovery of the viscera, them sphimcters still remai/ning. pa/rahjzed. — Paralysis of the right third nerve {unexplained)'. — Beath in six weeks.. — Post-mmiem exammation. — PractW-e of last dorsdl vertebra. — Inflammation of the bone where injured. (Under the care of Mr. Hutchinsoiu) James Adams, aged 54, was admitted on the 14th of May, 1866. He had fallen from a ship's-quarter into the dock, quite " flat on. his back." The bottom of the dock was level. Malf-past tieo p.m. (seven hours after adinission).. — He is in collapse, his pulse only just perceptible, his fe.ce pale, his lips dusky, his hands cool ; the lower part of the dorsal' region appears to project, and is much swollen. He is believed not to feel in the least in bis feet. He cannot move his legs at all. There is no priapism. He has not passed any water. May 15th — His pulse is 120, his tongue white and- furred. His z2 340 CLINICAL FACTS AS TO INJURIES right eyelid now droops considerably, and he cannot raise it, the pupil is widely dilated and fixed, and the eyeball is everted. His wife said that she noticed this yesterday morning before our visit. He complains that he cannot feel in his legs. He does not seem to feel when the catheter is passed. His feet are rather hot, and he has no sensation whatever in them, nor in the skin of the penis. He has slight sensation in the skin of the pabes. There does not appear to be any hypersesthesia of the boundary line. There is no sensation in the skin of' the thigh till we come to within an inch of Poupart's ligament on the right side. On the left side he has obscure sensation for six inches below Poupart's ligament. 2lsi. — He is gradually recovering power in his right internal rectus. ZiitL — His pulse is 136. He still has complete ptosis. He cannot raise his right eyelid in the least. The eyelid falls so as to leave a chink of about a quarter of an inch. The pupil acts quite well, and is quite as small as the other. He cannot get the eye into the inner canthus, but can carry it considerably beyond the middle line. He uses the superior and inferior rectus, but imperfectly. He has no pain in his head. His tongue is much cleaner. His countenance is dusky. He complains much of inability to sleep at night, and has some difficulty of breathing. There does not seem to be any difference in the power of the two hands. For the first time he had a free loose motion this morning. It passed from him without his knowledge. Slst. — There is now no dilatation of pupil and very little squint. He feels when the catheter is passed. The urine runs away freely, his bladder having recovered its tone, while the sphincter remains still paralyzed. All this time he has been lying on a water-bed, and has no bed-sore, a fact which favours the practice of placing fractured- spine cases on water-beds from the very first. June UtA.—ln the left limb he can feel indistinctly a little below the knee. At the knee, he says he feels equally well (that is, very shghtly), at the inner and outer sides. On the right side he cannot feel below the hip. He frequently complains of much pain m his left thigh. [It is somewhat unusual to find loss of sensation in the urethra, with a paralyzed sphincter, whilst yet the bladder re- tains such good muscular power.] TO THE SPINAL COLUMN AND ITS CONTENTS. 341 He remained in mucli the same state — his countenance becoming more dusky, his pulse becoming quicker and feebler- — till he died, quite quietly, on July 2nd. The post-mortem examination was performed somewhat imperfectly. It was ascertained, however, that the body of the last dorsal vetebra was crushed, and that at the site of fracture the cancellous tissue was discoloured and green. The cord was crushed. There was no blood in the theca. The adjacent laminae were irregularly fractured, but all displacement had been spontaneously rectified, and the cord was not compressed. The brain was examined, and nothing conclusive discovered to account for the symptoms of paralysis of the right third nerve, which had been present. The nerve-trunk was torn at its origin, but it was impossible to feel sure that this had not been done during the examination. Case XIV. — Fracture of the first and second Itimha/r vertebrce, with partial crushing of the extremity of the cord. — Imperfect paralysis i of lower extremities. — Suppuration at seat of fracture, and death on twenty-first day — Post-mortem examination. (Under the care of Mr. Hutchinson.) J. Linnell, aged 36, was admitted on the 30th of April, 1865. • He had fallen into a dry pit, forty-five feet deep, but no account could be obtained of the. exact way in which he struck the bottom. He was reported to have been insensible on admission. The next morning he had regained consciousness, but did not know in the least what had happened to h!m. He could then move the left leg slightly, but he could not move the right at all. He could move the toes of both feet a little. He did not appear to feel above the knee on the right side, but he could more or less all over the left leg and thigh. His left pupil was smaller than the right and did not act ; it was not,. however, materially contracted. As he lay in a rather dark corner of the ward, his right pupil was freely dilated. During the first few days he had extreme difiiculty of breathing in connexion with the fractured ribs and sternum. After a while, however, he became more comfortable. Death took place on May ZOth. 342 CLINICAL FACTS AS TO INJURIES Wotes of post-mortem examkiutian. — About ,fcalfrian-inch from 'the sternum there is a very visible irregularifcy, the lower end of the upper fragment being depressed almost half-an-inch. On cutting the skin, bruising of the pectoral muscle was found above and below the irregularity, but more extensively below. There was none in the deeper parts of the muscle nor beneath it. The skin showed no evidence of contusion before it was cut. On removing the soft parts we find that the prominence is just above the level of the second rib. (See specimens described at p. 352.) On the right side also in the lateral region there are numerous extravasations.. There was no rigor mortis in "the left arm, and not nearly so much as lusual in the right. There was also less than usual in the lower extremities, but equal on the two sides. The cartilage of the first rib was broken through about its middle. The outer fragment was depressed (behind the inner one, and was still quite moveable. The sternum was fixed at the seat of fracture. On removing the sternum eoohyimosis was observed in the ceUtdar tissue, between the bone and the pericardium. There were no pleuritic adhesions whatever. The lungs were pale and crepitant throughout, and there was scaa'cely any congestion of the posterior lobes. There were a few patches of emphysema here and there. On removing all the viscera a fracture of the eighth rib on the right side, near its angle was found, and there was also nn appearance of rupture of the pleura for an inch and a-half, but which was now cicatrised. The lung' showfed no trace of injury. There was eochymosis into the psoas muscles on both sides of spine. On the right side the parts were very much braised and discoloured, and pus escaped from a small cavity, in the froint of the muscle, and close to the right side of the body of the third lumbar vertebra. The abscess passed obliquely upwards, and iwas .connected with a fracture of the second lumbar vertebra. There was moveBaent at the chief seat of fracture in the body of the first lumbar vertebra. The body of this vertebra was completely crushed, but the spinal column was perfectly straight, there being no permanent displaceme'nt. On the left side there was comparatively little ecchymosis, but on the rigW •side the upper roots of the lumbar plexus were surrounded "with effused blood, and the muscular substance in which they were ernnedded was softened and almost in a state of suppuration. The extremity of the spinal cord was crushed, but the nerves consti- tuting the Cauda equina did not show traces of much injury. TO THE SPINAL COLUMN AND ITS CONTENTS. 343 Case XV. — fracture, with .permanent displacement, in the Hmhar region. — Inaomplete pa/rah/sis of lower exi/remities. — Temporary par ah/sis of coats of bladder, and intestines, and permament para- lysis of thei/r sphmcters. — Death from pyaemia. — Tost-mortem examination. — Partial crushing of the camda equina. (Under the care of Mr, Curling.) In the following case the back was touch col^«Se(d, but no iwegu- larity of the bones could be detected, Doubt was felt by some as to whether it was mere concussion of the spinfe or a case of fracture. William C„ aged 42^ was admitted Tebruary 86thj 1866, into the London Hospital, under the care of Mr. Curling. He said that while stooping beneath the tail-end of a cart loaded with straw, by some means or other, perhaps by the violence of the wind the cart was tilted up^ and he received a violent blow across his back. He declares that his back was doubled up by the violent blow. Im- mediately after the accident, he said that "his back was broken," and he could not lift his legs. March 1st. — When the writer first saw him, about three days after the injury, he could use all the muscles on the fronts, but not those on the backs of his thighs nor those of his legs. Thus he could draw up his knees, but could not put them down again ; he could not feel in the soles of his feet at all ; he could feel down the fronts of his legs, and both on the inner and outer sides, but better on the former. The margins of failure of sensation in the legs were not at all definitely marked ; he had some slight sensation in all parts, excepting the soles of his feet. From this date, until that of the next note, no details were recorded. In the toeantime he had become pysemie, aud was very ill. 2Sth. — At first he had retention requiring the use of the catheter. Now his urine dribbles avay ; he could feel the catheter sometimes ; he has been twice purged after taking medicine, and each time his motions have passed away without his knowledge. Masses of fseces can now easily be felt in his colon through the abdominal wall. He has had during the last week or ten days a succession of rigors ; he has a large bed-sore; his tongue is almost clean, but dry ; his pulse is 100, and his skin is cool. He is too ill to permit of accurate trials as regards sensation, but the state of his lower ex- tremities appears to be much as at first note. 344 CLINICAL FACTS AS TO INJURIES Death followed a few days after the last note, with all the sym- ptoms of advanced pyaemia. The pysemia was probably in connec- tion with the bed-sore, and had nothing directly to do with the fracture or injury to the cord. The autopsy shewed a dislocation forwards of the second lumbar, vertebra with fracture of the body. The cauda equina was hfted on a bridge of displaced bone. The specimen, an exceedingly interest- ing one, has been kept. See description at p. 355. Case XVI. — Fractwe, with displacement, and crushing of the cord at thefowrth dorsal vertebra. — Friwpism. — Paralysis of lower ex- tremities and greater pa/ri of trunk, — Far ah/sis of vaso-motor nerve of upper extremities {?). — Diaphragmatic respiration. — Death from engorgement of the hmgs, 8(e., on the fourth day. — Post-mortem (Under the care of Mr. HutohinBon.) Wiiham Duggan, aged 35, was admitted Peb. 20th, 1866 ; he had fallen a distance of thirty-five feet from some scaffolding ; he was carried into the Hospital in collapse, being very pale ; he complained much of pain in his neck and chest ; the paralytic symptoms were well marked. February %\st. — (The next day.) He says he does not know how he struck the ground, as he lost his senses before he got half way. His pulse is now full, almost bounding, 84 in the minute, and his skin is hot ; his breathing is diaphragmatic ; the- chest " thumps up " in expiration, and he seems to have complete loss of sensation from the nipples downwards. Crepitus can be felt as he breathes, below the right sterno- clavicular articulation, and somewhat to the outer side. Moist crepitation is heard all over the chest, and there is a doubtful friction sound on the left side. He is very much troubled with mucous collecting in his throat ; he cannot cough it up, owing to the paralysis of his chest. Lower extremities completely paralyzed in every respect, upper ones not involved. He can use his great pectoral muscles, but no action of the latissimus dorsi muscles can be detected. Both his feet and hands are hot to the touch, his hands feeling hotter than his feet; his posterior tibial arteries are throbbing; his pupils in the shade are of equal and moderate .size, and equally TO THE SPINAL COLUMN AND ITS CONTENTS, 345 and fairly active. The temperature of both iimer ankles is 101°, that of the palms of the hands 104.° There is a moderate degree of priapism. ZZnd. — Much as yesterday. He can feel in the tract of skin supplied by the inter-costo-humeral nerve, therefore the fracture is below the second dorsal vertebra. His face is dusky, and his hands and feet and legs, although so hot to the touch, are quite pale. [This fact, that the hot Umbs were still pale, would appear to favour the view that increase of temperature depends upon some other influence beyond the mere fulness of the cutaneous capillaries, consequent on vaso-motor paralysis.] After this he remained in much the same condition, his face get- ting more dusky, but without any great distress of breathing. He was delirious at times. He died quietly about one o'clock on the morning of the 23rd. At ike post-mortem examination, we found a fracture of the body of the fourth dorsal vertebra, with fractures extending in various directions through the adjacent laminse, and permitting of free mo- tion. Neither the anterior nor posterior common Hgaments were torn. After the broken laminse had been taken away the theca was exposed. There was no blood in the canal external to the theca, and the theca itself showed no signs of injury. It was clear that the displacement had been of the upper part forwards.- On laying open the theca no blood was found within it, and the surface- of the cord, both before and behind, shewed no signs of contusion. On cutting into the cord, however, it was found to have been com- pletely crushed internally at the seat of injury, and for the length of an inch was in a state of blood-stained pulp. Above, and below this, it was healthy. The spinous processes of all the dorsal vertebrae, excepting the fifth and twelfth, were broken off. On the right side, the fourth and fifth ribs were broken close to their articulations, and the fourth was broken on the left side. There was a considera- ble amount of effused blood in the cellular tissue about the vertebrae, both before and behind, in the whole of the dorsal region. The manubrium of the sternum was separated from the body, but without rupture of the periostpum, either before or behind. It was loose enough to permit of considerable motion. A disc of cartilage, two lines in thickness, was attached to the body of the bone. The fourth 346 CLINICAL FACTS AS TO INJURIES and fifth ribs, on the left side had their cartilages .broken through, close to the sternum. Both lungs were in a state of almost univer- sal hepatization, only small portions in front, and especially at theirfree edges, containing any air -whatever. The lung-tissue, where hepa- tized, was quite solid, black, firm and leathery; It readily sank in water. There was a red margin of abrupt distinction between the crepitant and the solidified portions. The whole of the left lung was placed in water, and it sank with the exception of a very small por- tion in front. The heart was large and flabby. Its right chambers contained a softish fibrinous coagulum, and little or no fluid blood or coloured blood-clot. The left chaim|)ers, although the walls were flaccid, and the cavities large, contained absolutdy nothing. In the abdomen there were evidences of contusion at many parts. Thus the mesentery was ecchymosed, and there was blood in the cellular tissue around each kidney. There were three or four superficial lines of laceration in the cortical substance of the right kidney, posteriorly* The spleen was large, and very soft. The bladder was flaccid and contained about a pint of urine. AU the intestines, especially the lower tracts, were distended with flatus. The rigor mortis was well marked, especially in the lower extremities.. H seemed to involve all the muscles, excepting those connecting the arms to the chest, and those of the neck. The penis was in a con- dition of semi-priapism. (See specimens, p. 851.) Case XVII. — Fracture, with displacement in the mid-Vwmla/r region. — Symptoms of spinal injury not recognised at first. — Incomplete paralysis of lower extremities. — Recovery. (Under the care of Mr, Hutchinson.) 'WiUiamMoore,aged23,was admitted on the 19th of August, 1865, having received injuries in a fall from a house. Both ankles were severely sprained, and attention was at first directed only to these. He had no bladder- or intestinal-symptoms, and it was only when, after five weeks in bed, he was allowed to get up, that he found one lower extremity much weaker than the other. On examination, both proved to be wasted — partially paralyzed. From the symptoms then . present, and the discovery of irregularity in the lumbar region there could be no doubt that fracture had occurred. Probably the cauda equina had been partially crushed at or about the fourth lumbar TO THE SPINAL COLUMN AND ITS CONTENTS. 347 vertebra. Mr. Hutchinson had not himself examined the patient, until the date of the note, when the following particulars were dictated : — September \Sth. — There is a decided irregularity in the situation of the second lumbar vertebra, or thereabouts. He feels every- where and tolerably acutely in the right lower extremity. In the left limb sensation begins to be dull at the knee, and is least in the middle of the leg. He can lift the right leg from the bed, but he does it feebly and slowly. He cannot lift the left leg from the bed at all. The muscles of the left are everywhere thinner and more flabby than those of the right, and on both sides they are more flabby than natural. He can feel on the inner side of the left great toe (long saphena), but not on its dorsum. The numbest pait is on the outer side of the middle of the leg. Sensation is not absolutely lost at any part, but he often does not feel a light prick with a pin. The inner aspect of the leg (supplied by the long saphena) appears to be as numb as the other parts. After this electricity was used, and with gradual benefit. The man became able to move about with crutches, and being very desirous to return home, he was allowed to do so on the 26th of September. Present state. — (August 16th, 1866) we learn from his brother, (not having been able to see the man himself), that after he left the Hospital he 'continued to use crutches until Christmas. Since that time he has been able to walk without assistance, but still does not walk well. He is not able to do a day's work. Case 'X^Yil.—Fractwe in the eewical region, with displacement, iut without cmshing of the cord. — Recovery with pa/rahfsis of the right arm. In this case the patient was a woman of middle age, who came under Mr. Hutchinson's care four months after her accident, on account of partial paralysis of her right arm. She was in good health, and had quite recovered in all other respects. Her accident had consisted in a fall from the top to the bottom of a flight of stairs, and she fell with the neck doubled under her. She was at once carried to St. Bartholomew's Hospital, where she remained for six weeks, during the first part of which time she was very ill. She assured 348 PATHOLOGICAL FACTS AS TO INJURIES Mr. Hutchinson that the House-Surgeon at St. Bartholomew's, throughout her illnesSj was very positive that her spine was broken, but that Mr. the surgeon under whose care she was, would not accept the diagnosis.' When this patient came under care at the London Hospital, there could be no doubt as to a fracture, with displacement, having occurred in the lower part of the cervical region. There was very considerable irregularity of the bones. Her right arm was still paralyzed to a considerable extent. Case XIX. — Fracture in the cervical region, with displacement, hut without crushing of the cord. — Recovery with partial paralysis of the right arm. This case is almost the counterpart of the preceding one. The patient, an Irishman, aged 34, was, whilst drunk, thrown down stairs, and was taken up insensible. His comrades concealed what had happened, and kept him at home without medical advice for some weeks. During this time he was in bed, had almost complete paralysis of his right arm, and very imperfect use of his other limbs. At the end of six weeks, he consulted Mr. Hutchinson at the Hos- pital. In the lower part of the cervical region, there was marked and considerable irregularity, so that there could be no doubt what- ever that a fracture, with displacement, had occurred. The man could run and walk well, but some of the muscles in his right arm were quite paralyzed, and the whole arm was much weakened. These two cases may be compared with Case XII. In none did the injury involve a crush of the spinal cord. Probably the vertebrae were fractured and twisted laterally, so that the nerve-roots, or their trunks were damaged, rather than the cord itself. A DESCRIPTIVE LIST OF THE SPECIMENS RELATING TO INJURIES TO THE SPINE IN THE MUSEUM OF THE LONDON HOSPITAL. Dislocation of lumbar vertebra forwards. (G. 6. b. I.) The last dorsal and three upper lumbar vertebrae, showing disloca- tion forwards of the first lumbar vertebra. The body of this vertebra has slipped forwards for about half-an-iuch on the surface of the second, crushing the latter as well as the intervertebral substance. TO THE SPINAL COLUMN AND ITS CONTENTS. 349 It remained tlius displaced up to the time of the patient's death, and the wire which now retains them in position was introduced before the specimen was cleaned. On the right side the lower articular process of the first lumbar has completely left its fellow of the second, but neither of them are fractured. On the left side, however, the lower articular process of the first is broken off, and that of the second is fissured. The laminae and spinous processes are wanting. The cord must have been crushed by the laminae of the first lumbar against the upper edge of the body of the second, and owing to the permanent displacement it must have been permanently bent at an angle. Note. — It is worth remark, as regards the possibility of reduction during life of such a dislocation, that the articular processes might very possibly greatly impede it. If these were broken, reduction would be much more easy, and possibly the cause why the displace- ment was permanent in this instance is to be found in the integrity of the articular processes on the left side. Obtained and presented by Mr. Little. Dry specimen. Fraclm/re of sternum on anterior aspect, (G. b. e. 3.) A sternum, showing transverse fracture just below the third ribs. The ligamentous structures behind the bone are entire. Those in front are torn completely through, allowing the fracture to gape widely in front. This fracture has clearly been caused by a bending of the bone with the convexity forwards. Obtained and presented by Mr. Little. (No. 68, in open jar.) Dislocation of fourth cervical vertebra forwards. (G. b. b. 3.) The cervical vertebrae with the cord exposed m situ. The laminae and spinous processes have been removed, and the theca laid open. The cord is seen beautifully clear and free from lymph or blood-clot. It does not reveal externally any trace of injury. Very probably, however, if cut into, it would be found to have been crushed. ■ Anteriorly, the anterior common ligament is seen to be partially torn between the fifth and sixth vertebrae, and the body of the fourth is displaced slightly forwards on the body of the fifth. The displace- ment at present is very slight indeed. The notes state " that the 350 PATHOLOGICAL FACTS AS TO INJURIES specimen was removed from a man, aged 60', who had fallen down some stairs at Wapping, and who was admitted with all the symptoms of fractured spine. His lower extremities were completely paralyzed, and the upper ones partially so. He died twenty -four hours after his admission. The theca and medulla appeared little injured. The sternum was fractured. Jffo injury to the thoraicic viscera was discovered." This specimeii is an excellent instance in proof of how slight maybe the external evidence of injury to the cord. No doubt the fracture of the sternum was caused by the man's chin. Dislocation of fifth cervical vertebra. (G, I. h. 4.) The cervical vertebrae showing displacement of the fifth forwards on the sixj;h. The spinal canal has not been opened. At present the vertebrse are almost restored to position. The body of the fifth is still slightly forwards, the intervertebral substance, and probably the vertebrae also has been crushed. The ligaments connecting the articular processes of the vertebrae have been torn, and' from the mobility, at the site of the displacement, it may be gathered that a complete dislocation forwards Occurred. The laminae are not fractured, but there appears to be a fracture across the bone of the transverse process of the sixth on the right side. No history has been pre- served with this specimen. ■ ' Dislocation of lowe.n dorsal vertehm. (G. h. b. 5.) The lower dorsal vertebra. The spinal canal laid open from behind and the cord exposed, No' history has been preserved with this specimen, but probably' the patient lived for some little titne after the accident. The cord is completely disorganized for about an inch in length, the lower part of the disorganized" tract being about half-ani-inch above its' termination in the cauda equina. It would appear that the tenth dorsal vertebra has been displaced forwaids on the eleventh. The displaced at present existing in the specimen is very considerable. The upper edge of the body of the eleventh pro- jecting backwards into the canal, and constituting a bridge half-an-^ inch in height on which the extremity of the cord is lifted. The body of the eleventh vertebra would appear to have been crushed, and from the discoloration in front of the bone it may be inferred that inflammation followed at the seat of injury i TO THE SPINAL COLUMN AND ITS CONTENTS. 351 Dis^lacetiient of lowest dorml vertebra. (Gr. h. I. 6.) The lower dorsal and first lumbar vertebrse, showing displacement forwards of the last dorsal on the first lumbar. The intervertebral substance between these bones would appear to have been crushed. The cord is m situ, and in the specimen as it at present exists, there is no material displafiement, Cr-usAed cervical cord. (Cr. b. b. 7.) Portion t)f the cervicai: spin9,l cord, shewing the effects of crush- ing in dislocation of vertebrae. In about three qaiarters of an inch th& co;?d is completely disorganized and infiltrated with blood-clot. Above and below this part it is quite healthy. The theca was un- injured, and there was uq bljDod in the arachnoid sac. Obtained and presented by Mr. Hutchinson. Crushed cervical cord. (G. b. b. 8.) A precisely simUat specimen. The cord is laid open by a vertical incision, and' although there was but little external evidence of injury, it is seen to be disorganized for upwards of, an inch. Obtained and presented by Mr. Hutchinson^ (These two speci- mens are in the same bottle, open;) Practv/re and displttcemeni of fourth dorsal vertebra. (G. b. b. 9i) Part of the spinal column of W. Diiggan. The anterior common ligament is entire. Eree ihotion is permitted between the fourth and fifth vertebrae, the fourth having been displaced half-an-inch forwards on the fifth, and its body crushed. The posterior common ligament, although stretched, is not torn through, excepting at some parts. The laminae of the fourth and. fifth are irregularly fractured, and the fourth and fifth ribs on the left side are broken close to. their articula- tions. The spinous processes of all the dorsal vei?tebrse, as low- as the tenth, are broken off. With this specimen is preserved the left half of the sternum and portions of the ribs. The manubrium has been separated from the body of the sternum. . It is quite loose, but the periosteum is not torn, and there is no displacement. The disc of cartilage remains in apposition with the lower fragment. (No. 6 i in open bottle.) Obtained and presented by Mr. Hutchinson. 352 PATHOLOGICAL FACTS AS TO INJURIES Dislocation backwards of the fifth cervical vertebra. (G. b. b. 10.) Six cervical and two upper dorsal vertebrse, from a case of disloca- tion backwards, at the fifth cervical. Considerable displacement backwards is permitted, and the structures in front having been completely torn gaping to the extent of half-an-inch may be caused. Posteriorly, the ligaments connecting the articular processes on the right side had been completely torn, so that it would appear that the head and neck had been bent backwards and twisted over with the face to the right shoulder, and the occiput over the left scapula. The intervertebral substance, between the fifth and sixth, has been torn up. There does not appear to have been any material fracture. The inter-spinous ligaments are much stretched, but only partially lacerated. The nerves constituting the brachial plexus have been left in con- nection with this specimen. No. 84, in open bottle. See sternum 84. Obtained and presenied by Mr. Hutchinson. Fracture and displacement of first lumbar vertebra. (G. b. b. 11.) Four lumbar and one dorsal vertebrae, shewing crushing of the body of the first, and displacement of the first forwards upon the second. The body of the vertebra has been completely smashed.. The posterior common ligament has been almost completely torn, and a sharp strong ridge of bone, constituting the lower half of the body, projects upwards into the spinal canal, and must have com- pressed the Cauda equina. (Case of J. Linnell, p. 341.) (No. 40, in open bottle.) Presented by Mr. Hutchinson. Crush of the lower extremity of spinal cord. (G. b. b. 21.) A spinal cord, showing the extremity of the spinal cord crushed, close to the lowest filaments of the cauda equina. (See case XIV. J. Linnell.) Double fracture of sternum, with displacement and overlapping. , (G. b.e. 5.) There is separation at the junction of the manubrium with the body, and the manubrium is displaced behind the body with half-an- inch of overlapping. There is a second fracture through the body of TO THE SPINAL COLUMN AND ITS CONTENTS. 353 tbe bone, about half-an-incb lower down, which would appear to have been produced by pressure of the lower part of the manubrium against it.- The ligamentous structures are entire, both in front and behind, the fractures being wholly intra-periosteal. The extremities, both of upper and lower fragment, are capped with cartilage. Ossification is in progress, a strong bridge of new bone having been developed in connection with the periosteum, which has been detached behind the bone. (See Case XIV., J. Linnell.) Dislocation of aeventh cervical vertebra with fracture. { G. b. b. 12.) Two lower cervical and four upper dorsal vertebrEO, showing dis- placement forwards of the last cervical on the first dorsal vertebra. Neither anterior nor posterior common ligaments have been torn. The displacement in the specimen is to about a quarter of an inch, and there is no very material intrusion into the calibre of the vertebral canal. The body of the vertebra has been somewhat crushed. (No. 47, in open jar. See case III., Thomas Green). Obtained and presented by Mr. Hutchinson. Fracture of fifth cervical, with duplacement. (G. b. i5. 13.) The cervical vertebrae, showing complete crashing of the body of the fifth, and dislocation of the fourth, forwards on it. The displace- ment has been considerable, and there is a longitudinal rent an inch long in the posterior common ligament, caused by a sharp edge of bone. The laminae of -the foijrth and fifth are fractured on the right side. The movement permitted is very free, and consequently the displacement was not permanent. (No 34, in open bottle.) Obtained and presented by Mr. Hutchinson. Dislocation forwards of sixth cervical oertebta. (G. b. b. 14.) Dislocation of the sixth cervical vertebra forwards on the seventh. The displacement has occurred at the intervertebral substance, and there does not appear to have been any fracture whatever, excepting of the edges of the articular facets. The articular ligaments, liga- menta subflava, and the inter-spinous ligaments have all been torn completely through. Free motion is permitted, and there is no per- manent displacement. (The spinal canal has not been opened.) A A 354 CLINICAL FACTS AS TO INJURIES (No. 83, in open bottle). Obtained and presented by Mr. Hutchinson. Separation of odontoid process and false joint. (G. I. I. 16.) This specimen is fully described in Yol. I. of London Hospital Reports, p. 142. Obtained and presented by Mr. Curling. Fracture of sixth cervical vertebra with, displacement. (G. l. h. 15.) The cervical vertebrse and first two dorsal, showing complete sepa- ration between the fifth and sixth. The body of the sixth and its intervertebral substance are crushed. There would appear to have been great displacement at the time of the accident, and the anterior common ligament is torn completely through. The posterior common ligament is considerably injured. The laminse and cord have been removed. Wound of spinal cord by a stab. (G. b. b. 17.)' A spinal cord almost cut across by a puncture in the mid-dorsal region. The patient had been stabbed- in the back by a narrow knife, and was admitted with incomplete paralysis of the lower extremities. She died about a fortnight afterwards. The knife had entered obUquely beneath the laminae of one of the dorsal vertebrse, and had crossed the spinal canal from the left to the right, severing the greater part of the spinal cord. The vertebra is preserved, and a piece of wood introduced shows the direction of the puncture. Obtained and presented by Mr. Maunder. Anchylosis of dorsal vertebra and subsequent fracture, (G. b. b. 18.) This specimen is probably unique. It consists of the sixth, seventh, eighth, ninth, tenth, eleventh and twelfth dorsal vertebrae. On the right side, the bodies of the ninth, tenth, eleventh and twelfth are firmly welded together by a'depositof dense new bone, external to them, and continuous across the intervertebral substance. This deposit ends below, in the middle of the body of the twelfth, but above, it is -continued as high as the specimen permits of examination, and possibly passed considerably higher. It is much thinner and weaker in front of the upper than of the lower vertebrse, and has been broken across in the hne of the intervertebral substance, between the TO THE SPINAL COL-tTMN AND ITS CONTENTS. 355 sixth and seventh,, seventh and eighth, and eighth amd ninith. The body of the ninth is crossed by a vertical fractare, which passes obUquely from the left to the right side. During life there was no displacement, and no symptoms of injury to the spinal cord. The patient, a middle-aged man,* walked into the Hospital. The ffacture of the spine was only discovered at the posi-morfem. Obtained and presented by Dr. John Dawson. Dislocation oftKe third lumhar vertebra from the fourth. (Gr. h. b. 19.) The displacement has occurred by crushing of the intervertebral substance ; there is very slight splintering of the edges of the bones themselves at one or two spots. The third vertebra is nearly half- an-inch in front of the fourth, and the cauda equina is elevated on a sort of bridge formed by the projection backwards of the latter. There was no laceration of the theca, nor any extravasation of blood. The Cauda was not crushed,' but only somewhat contused and stretched, and the paraplegia, which the man presented, was at first incomplete. He died of pyaemia. At the back of the spine the injury was a dislocation without fracture, the articular processes of the two vertebrae having been completely displaced from one another. Presented by Mr. Curling. Dislocation of third lumbar vertebra, (G. b. b. 20.) The laminae, etc., of the lumbar vertebroe from the same case as the preceding specimen,) shewing a clieaB dislocation forwards without fracture* The articular processes of the third lumbar vertebra have completelyleft those of the' fourth, and passed forwards, a. third of an inch. The Ugament^ous structures connecting the l&minse and spinous processes have been) verj; much stcetched and elongated, hut. not materially torn. There is no imporlSant fracture. The edges of the articular processes have been a little chipped by pressure against each • The Museum contains a specimen of anchylosis of the vertebrae of a horse, which is almost the precise counterpart of the one above described. In each instance the anchylosis is by a long" belt of bone in front of the bodies, and in each only one side is involved. In neither are the interver- tebral substances involved. See Mr. Rivington's description of it in Lon- don Hospital Reports, Vol. ii., p. 371. A A 2 356 PATHOLOGICAL FACTS AS TO INJURIES, ETC. other, and there is an incomplete fracture, without displacement, through the spinous process of the fifth. Presented by Mr. Curling. , ' Incomplete fracture in anterior aspect of sternum. (G. h. c. 4.) The upper portion of a sternum, showing an incomplete fracture just above the second rib, and about the junction of the manubrium. The bone is not broken behind, there is merely a fissure in its anterior wall. There is consequently no displacement ■whatever. By firm pressure, the line of fracture may be made to gap a little. Clearly the bone has been bent with its convexity forwards. (See specimen 84, in open jar). Obtained and presented by Mr. Hutchinson. Fractwre of sternum on posterior aspect. (G. I. c. 2.) A sternum, showing transverse fracture'just above the level of the third ribs. The ligamentous structures in front of the bone are entire. Those behind it are torn completely through, allowing the fracture to gape widely towards the mediastinum. The fracture was no doubt caused by the patient's chin. (No. '25, in open jar.) Postscript. — Fractures of the sternum have been mentioned in the above list, whenever such fracture had occurred in connection with injury to the spinal column. Since the sheet containing Case I. was printed off, additional in- formation has been obtained, respecting the subject of it. Mr. Ditchett reports that he met the man (W. Asher) in the street a few months after he had left the Hospital, and that he was then able to walk well, still, however, using a stick. He had not regained control over his bladder, and habitually employed a catheter which he carried in his pocket, in order, by frequent use, to prevent the in- convenience of overflow. ON DISLOCATIONS AND FRACTTJRES OF THE SPINE. By JONATHAN HUTCHINSON, f!r.C.S. Gentlemen, — I wish to give you a summary of the clinical experience we have obtained recently in reference to displacements occurring at one or other part of the spinal column. Interesting examples of these injuries are almost constantly under our observa- tion, and they supply us with very important illustrations of many physiological and anatomical facts, and they also call for a sound knowledge of their requirements in reference to treatment. I shall enter at some length into the consideration of certain special symptoms, and also into the examination as to what are the conditions usually met with in the injured parts. One object which I have in view, is to furnish conclusive arguments in support of the usual practice at this Hospital of abstaining from operative interference. I have taken part in not a few consultations where the question of operation was entertained, and have always dis- suaded from it as strongly as I could. Until a very different body of facts are collected from those to which I shall allude, and some of which are illustrated by specimens contained in these jars, I shall continue to do so. My assertion is, that a good many cases recover, if put under favourable circumstances and let alone, and that of those which'end in death, very rarely indeed, can it be asserted, after joos^- mortem examination, that an operation could by the barest possibility have done any good. In the great majority, then, since it could have done no good, its effect would have been to increase the patient's sufferings, and aggravate his danger. 358 ME. HUTCHINSON ON FRACTURES OF THE SPINE, ETC. I purpose to deal only with those injuries to the spinal column in which its contents are implicated. Fractures of external parts of the vertebrae, the spinous processes, etc., are frequent^ but they present no features of special interest. I shall not attempt any abrupt dis- tinction between a " fracture of the spine " and a " dislocation of the spine." In nearly all cases there is more or less of fracture and more or less of displacement. It is quite possible, especially in the cervical region, that the fracture may be very trifling, and the injury an almost pure dislocation. Lower down, where the bodies are larger, if much displacement has occurred, the body is almost certain to be fractured. The question of the degree of displacement is that which concerns us as practical surgeons, not whether this has been afiected with or without severe fracture of the implicated bones. I must, first by way of introduction, ask your attention to a few details of anatomy. In the cervical region we have eight nerves and only seven vertebrae, and, with ttie exception pf the la?t, the nerves are named from the vertebrae, above which they come out. Thus the fourth cervical nerve, the one of most importance as regards the diaphragm, comes out above the fourth cervical vertebra, and would escape if the cord were crushed on a level with the latter, The eighth cervical nerve, however, comes out below the seventh cervical vertebra, ?,nd would of course be implicated in fracture of the body of the latter. So on, through the dorsal and lumbar regions, the nerves take their numerical designation from the vertebra below which they come. Certain other anatomical considerations must, however, be kept in view before we can hope to give a satisfactory conjecture from the nerves involved in paralysis as to the vertebra which is fracturg^* When the body pf a vertebra is loosened so that movement is permitted, the movement always takes place between it and the one below it, The cord is consequently crushed a little below the dis- placed bone. If the injury involve two v^tebrae, I believe this rule will stUl usually hold good, the chief lesion of the cord will be at the lowest part of the fracture. Thus, supposing the neck to be violently bent forwards tiU the body of the fourth cervical vertebra gives way, this latter will slide forwards on the body of the fifth, the cord will be crushed by the lower edge of the laminae of the fourth against the upper edge of the body of the fifth. Not only will the fourth cervical ANATOMICAL CONSIDERATIONS. 359 nerv« escape injury, but, very possibly, the fifth also, as the latter occupies the large intervertebral foramen, and may easily escape crushing. We must also bear in mind that the filaments which constitute the nerve-roots come off obliquely, and all of them slant downwards. Even within the vertebral canal this obUquity is considerable, and the practical result is, that a nerve comes off from the cord in reality considerably higher up than its name might imply. All these considerations tend to one general rule, which is this, that when we hear of fracture of any given vertebra, we must make an allowance, and understand that the nerve-supply will be cut off considerably lower than the name of the vertebra would seem to imply. On the contrary, when we are examining a patient during life, and find complete paralysis of certain nerves, we may feel sure that the fracture is really one or two vertebrae higher up than those nerves are said to come out from the spine. The statements made above, apply only in a general way, for many accidental circumstances interfere with their applicability in aU cases. Thus not only may the cord be crushed by the movement of one vertebra .on another, but the nerve-roots may be crushed or torn, or the nerve-trunks may be stretched or contused, or ecchymosed, even at some little distance from the foramen, and thus irregular paralytic symptoms will result. Thus, for instance, if the cauda equina have been crushed by displacement of the bones at tbe fourth lumbar, in aU probability the chief part of the anterior crural nerve will escape, and with its escape we shall have the curious symptoms of retained sensation on the inner aspect of the ankle and foot, and at no other parts (long saphenous). It is very possible, however, that the trunk of third lumbar nerve may have also received a separate injury, either from fractured lamina, or from stretching, or from contusion. I am convinced that lesions of nerve-trunks from violence are more common than they are supposed, and feel sure that, in the diagnosis of injuries to the cord, we must not infrequently make allowance for the possibility of their presence as complications of the principal mischief. With regard to the lesions usually met with in the post-mortem- room, I may venture the following assertions. I think that they are based on the examination of, at least, twenty cases : — First. — Permanent compression of the cord, or of any part of it, is 360 MR. HUTCHINSON ON FRACTURES OF THE SPINE, ETC, a very rare event. The cord has usually had a sudden crush during the violence, and when the latter was remitted, the bones sprang back by their own elasticity, and that of the intervertebral substance, and the column was restored almost to its original position. Remember that the vertebral canal is large, and that slight irregularities of the bones and projections of parts of them inwards, may easily be permitted without any pressure upon the cord. You will often, indeed, usually, find some permanent irregularity in the vertebral canal, but it will not be sufficient to influence the cord in any way. In one case I found the trunks composing the cauda equina lifted a third of an inch on a bridge'of bone formed by the displacement of a fractured lumbar vertebra, but they were in no degree compressed, and, excepting a little ecchymosis in their pia mater, showed scarcely any trace of injttry. Mr; Little obtained for our Museum a few months ago the specimen which I now show, and in which the permanent displace- ment is very considerable ; still, however, short of actual compression. Prom my own experience I should not think that permanent dis- placement to any material degree is met with once in ten cases. Second. — As might be expected from the fact that almost all the more serious injuries to the spinal column are due to indirect violence (bends) ; the fractures of the laminae are of little consequence, and never cause compression of the cord. If the fracture were caused by a direct blow on the part, then it is quite possible thai a lamina liiight be driven into the vertebral canal and there remain, 'but against such an injury these bones are exceedingly well protected, and such are, indeed, very rare. In almost all our cases the laminse, spinous pro- cesses, etc., are more or less fractured, but I have never yet seen a case in which any of the fragments were in contact with the cord. ' ' TMrd.^-HsiVmg thus denied that the cord is permcmenthj com- pressed, either by the bodies or the laminse, I now extend my statement to extravasations of blood. You will hear much talk about effusions of blood into the vertebral canal, indeed, this lesion is constantly invoked to explain ■ the existence of paralysis vrhere it is fancied th^t the bones are not fractured. Large eifusions of blood, whether in connection with fractures or contusions of the spine are, I believe, amongst the very rarest occurrences. I have never myself seen any effusion to the extent of possible compression, and in the majority of cases there is little or none. The injury is a crush, and is not one REDUCTION OF DISPLACEMENTS. 361 at all likely to cause much bleediug. There are no large arteries to be injured. When you examine a specimen of fractured spine, you will find the muscles and soft parts externally much ecchymosed, there will be also a few small blood-clots adhering to the edges of the broken bones, but there will be little or no blood between the, bone and the, theca, and none at all in the thecal cavity. I speak of what is usual, and am well aware that exceptions may occur. The theca (dura mater) is very rarely torn, and often, on exposing it,. you might imagine that the cord was not injured. Nay, even further than this, you find the pia mater of the cord entire and without ecchymosis, and only on slicing the cord through do you discover that its sub- stance has been utterly smashed. I show you a sketch of a cord thus injured. You will see that the cord-substance, for nearly an inch and a-half, is reddened by efiused blood, and its substance broken into,a diflluent pulp. Yet, in this instance, the pia mater was stUl entire. Fourth. — Instances of great displacement of one vertebra do some- times occur. They are exceptional, however, and very rarely of a kind which we could rectify by force or by operation. I have no doubt that many displacements of the vertebrae are reduced by the by-standers who pick up the man. To straighten his neck and trunk is the first thing which common-sense dictates, and in doing so, reduction is usually effected, as far as reduction is practicable. In the cervical region, from the shape and position of the articulating processes, replacement into almost normal position is usually easy, ^s we pass downwards it is likely to become more difficult, and in the lower dorsal and lumbar regions, if once the articular processes have com- pletely escaped from each other, I do not believe that replacement would be possible. After you have cleaned the bones, and have them in your hands and es^posed to sight, you can only, by considerable force, put them again into position. Fifth. — The cases in which, during life, there is evidence of con- siderable displacement are not by any means always the most serious ones. The irregularity, perceived externally, concerns rather the spinous and transverse processes than the bodies, and it is very possible that they may have been fractured without any crush of the cord ; and, on the other hand, that the bodies may have been displaced for a moment allowing complete crushing of the cord, and yet no 362 ME. HUTCHINSON ON FBACTUEES OF THE SPINE, ETC. permanent irregularity remain. I kave repeatedly conducted a dis-r section until every portion of muscle was cleared away from the bones before I could discover any proof of fracture. During the life of your patient inability to discover irregularity must go for nothing, as a symptom ; it is common enough., even when the cord has been most severely injured. We will now proceed to examine the various symptoms of damagt to the nervous system which follow injuries to the spinal cord. , . I wLl take first a nerve, hitherto too much overlooked, the vaso-motor nerve. Chief amongst the many discoveries ior which surgeons, stand indebted to physiological experimenters, are those which hav« ex- plained the function and the origin of the sympathetic nerve. That this nerve arises really from the brain and spinal cord, that its integrity is damaged when those centres are injured, and that certain special symptoms foUow such injuries, are facts which we owe to the researches of Claude-Bernard, Brown.pable of active contraction, liable to paralysis and subject to spasm, and that they are supplied by this same nerve, which we now call vaso-motor. Thus the blood-vessels may contract, and diminish the supply of blood to a part ; they may dilate, and allow the part to be flooded. This dilatation or contraction, may be either general or quite local, in due relation to its special cause. Not only, however, does the vaso-motor nerve regulate the size of the blood- vessels, it supplies also the coats of the intestines and bladder, the radiating fibres of the iris, in some degree the substance of the heart, and it probably influences the functional activity of most glands. Paralytic pyrexia, or alterations of ternperatnre in the paralysed parts. I have used the term " paralytic pyrexia " to denote the state of feverishness, which is so marked a feature in the stage of reaction after severe injuries to the head. Throbbing, relaxed arteries, and great heat of skin, are its chief features ; but in greater or less degree the other constitutional symptoms, usually included in the VASO-MOTOB PABAtYSlS. 363 term " pyrexia/' are present ; a furred tongue and dryish mouth, dis- taste for food, with thirst, and scanty urine. Disturbance of the circulation and enlarged calibre of blood-vessels are, howevesr, its chief symptoms; and these we explain by supposing that the shock to the cerebral centres, has caused a temporary aiad partial paralysis of the v-aso-motor nerve. In cases of concussion of the brain the whole of the system of blood-vessels is implicated. In cases of injury to the spinal cord, however, we haye a similar state of things as far as the vessels are concerned ;, but it is only local, and involves of course, only the parts below the seat of injury. After injury in the lower dorsal-or lumbar region, you will usually find the lower extremities pungently hot, and the skin feeling dry and harsh. The tibial arteries are felt with unusual ease, since they are large and throbbing. The temperature of the feet is liable to vary most remarkably with any slight changes of external condition ; tims you iijfili often find one foot much hotter than the other, or both may be hot at one time, and quite cool at another. These differences depend upon how the feet have been placed, whether onje has been more protected than the other, and they are liable to iimrease, from ihe fact, that the patient not feeling his foot cold, and being further quite unable to move it if he did, is prevented from adopting any measures for its comfort. The temperature of the extremities is liable to grteit variations in health. The best data, as regards *hat of the feet that I am ac- quainted with, is given by Dr. Woodman, in a table published in the first volume of our Hospital Reports. Dr. Woodman examined the feet of twenty persons, putting the bulb in the cleft of the great toe, and his results show an average temperature of 81"5°. The highest that he met with was 94°, and the lowest 70°. It must be observed that he has recorded but a single obsHrvation on each individual, and we have, therefore, no information as to the usual range of difference in the same person at different times. I have but few -definite state- ments to make, further than what I have given above. In the case of William Duggan, with fracture in the dorsal region, on the second day, the inner ankles of both feet registered 101". In this man the skin felt very hot^but it was not florid, on the contrary, it was pale. , , In the case of W. Driscoll, a boy with fracture in the lumbar region, 364 MR. HUTCHINSON ON FRACTURES OF THE SPINE, ETC. we found the cleft of the toes 100°, on a single occasion, in the fourth week after the accident. On the day before that observation the same foot had registered 78°. The other foot of this patient had varied in almost equal degree. In the case of the boy Scruby, with fracture in the lumbar region, the highest temperature ever reached by both feet, was 96°. This was in the sixth week. The lowest was registered a week later, and was 75°- In both these boys the observations were made, as I have here stated, long after the accident ; and when the muscles of the limbs were already much wasted. Should the paraplegia persist, and the patient live on, no doubt the ultimate result would be a remarkable failure of temperature, as we find it in cases of division of nerves, and in paralysis generally. We have not recently had any such 'case under observation. All our patients, who have lived, have also recovered from the paraplegia. Paralytic myosis. — Glosely connected with the paralysis of the blood-vessels is that of the dilating fibres of the iris, resulting in im- inobility of the pupil. This is a very important and valuable sym- ptom. It occurs only when the injury is either in the cervical and upper dorsal region. The pupil is neither dilated, nor much con- tracted, it is simply unable to dilate. • Unless carefully examined, the myosis being so slight in degree,' may easily be overlooked. The plan is to examine the eyes in shade, and you will then find that the pupils remain just of the same size as they were when exposed to light. Sometimes one pupil is more definitely contracted than the other. If the pupil is much contracted, then it is quite certain that the circular fibres of the iris are in a state of spasm, and this is pro- bably in connection with some irritation transmitted through the fibres of the third. I, have observed this in injuries to the head, but never after injuries to the spine, although we may suppose it possible, in injuries high up in the cervical region.* Priapism. — Another very interesting symptom, which occurs in connection chiefly with the vaso-motor nerve, after injuries to the spine, is turgescence of the penis, or priapism. Clearly we must re- gard this as chiefly paralytic and passive in its nature. The erectile * For further details concerning these forms of myosis, paralytic and spas- modic, the reader is referred to a paper hy the writer in the Moorflelds' Ophthalmic Journal, April, 1866. PRIAPISM. 365 tissue of the penis consists of blood ckambers, in the walls of wbicli are muscular fibres under the control of the nervous system. If the nerves, distributed to these fibres, are paralyzed, then supposing the heart to continue vigorous, one must expect that blood will be pumped into the cells, and that turgescence will be the result. It is a symptom of precisely the same character as the hot feet, and the throbbing tibial arteries. Bearing out this explanation of its cause, we have the fact that the turgescence is never extreme. The member, although much enlarged, usually remains flaccid ; quite a different state of things from what we find in the very rare examples of idio- pathic priapisin. The degree of turgescence varies at different times in the same patient, as does the temperature of his feet, &c. In some cases> priapism is present, in a slight degree, on the first day or two, and then disappears. Now and then, although aU other reflex functions are completely in abeyance, and although the penis is ab- solutely without sensation, a slight amount of reflex increase of the distension may be produced. In the boy Hyde, in whom this symptom was very characteristically present, we always found that introducing the catheter increased it. This is curious> but it is in keeping with what you must have often noticed in the operating theatre, where, very frequentlyj after full anaesthesia by chloroform (and consequent paralysis of all other reflex functions), the introduction of the sound for hthotomy, or other steps of the operation, may induce a state of strong priapism. Curiously enough, I have never seen this, occur in an adult, whilst it may happen in very young boys. Our patient, Hyde, was only 14, and in our spine cases I think I have never, in adults, known the catheter increase it. Priapism occurs only when certain parts of the spinal cord are injured. I do not know that I have ever seen it after injuries to the head, however weU-marked the vaso-motor paresis might be. I do not think that it is usually present after injuries high up in the cervical region and it is never met with after those to the lower lumbar regions. The upper and mid-dorsal region is that, after injury to which it is constantly met with and usually in a marked degree, and to this part we must, therefore, refer as the probable seat of origin of the vaso-motor nerves of the penis. Effects of injuries to the cord vjpon the heart itself. — Unless the injuries be in the cervical region, no influence upon the heart's action 366 MR. HUTCHINSON OS PK^ACKTEBS OF THE SPINE, ETC. is obseiveS. When high up a very peculiar couiition results. The pulsations are diminished ia frequency, and, the pulse (from the paralysis of the artery)i is remarkably full amd large. Your first impression is that it is much slower than you find it to be om count- ing, at feast, this has generally been my experience,, It feels remarkably^ deliberate. The manner in which the heart, seems exempted from aU share in the patient's general excitement is some- times very curious. I recollect well going to the. bedside of a poor fellow who had been admitted a few hours before, with a fraoture ©f the fifth cervical. It was one of those cases in which the boundary tract of skin between that quite paralyzed and that enjoying perfect sensaticm, was excessively tender. He^ was screaming with pain, and his coimtenanee expressive- of the utmost suffering amd anxiety,, yet his pulse which we might have expected- to be quick and excited,, was slow, full, andi deliberate, about 48 in the minute. Altho.ugtk the pulsei after mjuries to^ the^ cervical cord becomes slow, it does not intermit. After injumesi to the brain, on the contrary^ as I have shown elsewhere,* it becomes, slow*^ and frequently intermittajmlr, especially if the patient be a^ child. It is of course only in the. early stages that we can, estimate:the effects of the injury on the heart, without great risk of fallacy. At a later period the lungs- become congested, or perhaps, cystitis; or bed- sores may occur, and, by these the state of the circulation is in- fluenced. Faralym of mUsimes. — Constipation is* a symptom commoa to almost aU- forms of disease of the cerebro'spinal sgrstem. We con*- stantly meet with it after injuries to. the head^ aind as constantly after injuries to the upper or middle part of the spimali cord. It is customary to speak of incontinence of fseces as a symptom of fracbuned spine, but in reality retention of faeces isithe first occurrenee. As a rule, it is only after the lapse of some days, amd; usually only after the exhibition of a purgative, thai? incontinence follows;, The sphinct^r^ it is true is always paralyzed (however low down theiCond may be crushed), and it offers' no impediment to the escape of the. c.onteBiliSfof the bowel, but then there isno force to exipeL them. If the fiafitwe be in the lumbar region, the bow«ls, and the bladder also,, will probably within a few days- or a week, regain sufficient tone to be able to expel their contente> but in other cases paralytic constipation * The " Astley Cooper Prize Essay " on Injuries to the Head. PABALYSIS OF THE BLADDER. 367 will often be a marked symptom throughout. Id such cases the colon may be distinguished through the abdominal parietes and large faecal masses felt in it. If the intestinal paralysis be complete or nearly so, %mpanitis will be a troublesome symptom ; but it would appear that much less muscular tone is requisite to make gas travel downwards than is needed for solid matters. Eeflex susceptibility is rarely wholly lost by the intestines, and although repeated doses of purgatives may be requisite, sooner or later, action of the bowels may almost always be induced. I have noticed above that reflex vaso- motor function is sometimes demonstrable in the penis in cases in which there is none whatever in the more strictly spinal nerves. In all cases in which the sphincter ani and the mucous membrane about it are paralyzed, defecation is involuntary, and is effected solely by the peristaltic action of the intestines themselves. We need not trouble ourselves to take into account the abdominal muscles, which assist in the act when vobintaryi since these — whether paralyzed' or not — are not called into action. Paralysis ofihe Bladder. — However low down the injury may bej if it crushes any part of the cord, the sphincter of the urethra will be paralyzed, and there will consequently be no impediment to the escape of urine, excepting those offered by the position of ' the trunk as regards gravity, the length of the canal and its curves, etc; In almost all cases, however, the muscular walls of the bladder are them- selves much reduced in efficiency, if not wholly paralyzed. Like those of the intestines, they usually recover tone in the course of a few days or weeks, according to the position of the injury. Our first symptom is, then, retention of urine, and when the bladder is fuUj over- flow takes place. The degree of distension permitted' in different cases differs very much, and by it we measure the severity of the lesion to the vaso-motor system. Often, in injuries to the canda- equina, the bladder will within a week regain suificient tone to keep~ itself almost empty, and to cause constant overflow into the bed. We have no convenient vesical purgative, and custom^ in cases of fracture of the spine, indicates resort to mechanical modes of relief. There is, I think, room for much' doubt as to whether the usual practice of relieving the bladder by- the catheter is judicious. In a few cases where the fracture is in a certain part of the lumbar region the bladder is involved in hypersesthesia, and the pain caused by its distension, necessitates interference. These, however, are very rare. 368 MR. HUTCHINSON ON FRACTURES OF THE SPINE, ETC. and, in almost all cases, tlie bladder fills without causing any dis- comfort whatever, and when full runs over. After a few days it regains a certain amount of tone, and empties itself very frequently. At this stage we have troublesome incontinence, and but little reten- tion. Now, if the catheter be used from the first, inflammation of the urethra and bladder is, I think, almost certain to occur, and the urine will become loaded with pus and mucus. I suspect that cystitis is, ia some cases, one of the influences which brings about the patient's death by exhaustion. Not unfrequently ulcerations of the mucous membrane of the bladder occur. There is a specimen in the Museum of a bladder and rectum from a fractured spine case, in which a fistula passes from the membranous urethra into the rectum, no doubt, in connection with the use of catheters. Why should cystitis thus constantly foUow the use of catheters ? Seeing that there is no impediment to the introduction of instruments, that they give the patient no pain, and are used vidth the greatest ease, why should they produce so much more irritation than we usually observe when they are employed for other reasons ? I think we must admit, that it is probable that the mucous membrane of the bladder when par4yzed, is in a state specially prone to inflame, just as the eye is, after paralysis of the fifth nerve. The practical question before us is, whether to permit the retention to continue until overflow takes place, is less likely to cause this cystitis than is the use of instruments. My own experience has been in favour of non-interference, and I quite intend, in the future, to make a full trial of this plan. The prevention of bed-sores. — The same argument which I have used in reference to the cystitis, — that it is induced in part by the paralysis of the trophic nerves — applies to those inflammations of the skin of the paralyzed regions which result in pressure- or bed-sbres. These occur so quickly after the injury and so certainly, that we are obliged to suspect something altered in the nutrition of the part to explain it. Bed-sores are a frequent cause of death after fractures of the spine, and they sometimes form, in spite of every precaution. Not only do they occur over the sacrum, their most frequent situation, but on any part of the limbs, over the heels, the malleoli, the great trochanters, etc., wherever pressure may chance to have occurred. The sore over the sacrum often forms within a few days of the accident. The rule of practice, which we deduce from this, is that the water-bed PARAPLEGIA. 369 Ought to be had recourse to from the very first. Even with its. aidj we shall not always be successful in preventing them. Paraplegia. — With regard to the loss of sensation and of power of motion I shall, on the present occasion, be very brief. Their degree will depend upon the degree of completeness with which the spinal cord may have been crushed. If displacement of the vertebrae have occurred in any part of the cervical or dorsal regions, it is usual for the cord to be completely crushed, and then the paraplegia of both functions is complete. In the lumbar resrion, however, partly because the vertebral bodies are larger, and partly becaaise it is more difficult to crush, the filaments which compose the cauda equina, than the soft solid mass of which the cord itself consists, the paraplegia is often imperfect. If paraplegia be imperfect you will always find that the patient retains more sensation than motor power. Sometimes he will appear to have lost motion utterly, and to retain sensation almost- perfectly. This difficulty, in extinguishing sensation, is observed, I believe, in all diseases and injuries, whether of the brain or the cord. To a considerable extent it is, perhaps, apparent rather than real. Sensation is merely passive, motion is active, and the latter probably requires a far more efficient condition of the nerve-apparatus than the former. "With a partially crushed spinal cord we may easily suppose a patient unable to transmit the orders of his will through the damaged portion, whilst still a certain degree of passive- sensation (requiring no" exertion of his will) may remain. Another source of fallacy is the difficulty of accurate observations. A man tells you, " I cannot move my legs," and you are "unable to prove the contrary, though it is still possible that a very vigorous exertion of the will inight be able to set certain muscles in action ; in other words, that voluntary motion, although seemingly in abeyance,- is not absolutely lost. The same patient tells you that he "can feel well," yet very probably) if you try accurate tests, such as the compasses,* or drawing a hair or a feather over the surface, you will find that his sensory function is very far from perfect. On account of our frequent neglect of such tests we are compelled to receive with much qualiti cation, recorded statements as to " perfect sensation " being retained after these accidents. In making a diagnosis, in the first instance, loss of sensation is of * The aesthesiometer, devised, I believe, by Ur. Sieveking. B B 370 MR. HUTCHINSON ON FRACTURES OF THE SPINE, ETC. much more value than loss of motion, for the obvious reason that the latter may he only apparent. I will venture one hint as regards; the diagnosis of fracture from cases of concussion of the spine. It is this, examine the lower extremities carefully as regards sensation, and; if you find that at any parts sensation is utterly lost, so that you can thrust pins into the skin, rest assured that there is more than mere concussiort It may be laceration of nerve-trunks, or it may be a crush of the cord, or of part of it, but there is certainly some struc- tural lesion. I am not much of a believer in severe symptoms re- sulting from mere concussion of the spine, but I feel sure that it never produces absolute paralysis of any part, however small., You will find every now and then that the paraplegic symptoms, incomplete at first, increase during the few days immediately foUosmng the accident. This occurred in a man (S. Moore) under care about a year ago. I do hot know ixoro. post-mortem examination, what the change is which causes this increase of symptoms, but judging from clinical evidence, I should infer that it is not of a serious nature. I have several cases in memory, in which, after injuries either to the cord or the brain, motor paralysis, which either did not exist atiirst or only imperfectly, increased and became complete, soon afterwards) and all of them recovered perfectly. The prognosis is certainly veiy much better than when the paralysis is present from the first. The presence of a hypef-sesthetic boundary tract, between the parar lyzed and non-paralyzed . tracts of integument, is often a marked symptom. On this boundary -tract any slight irritation produces not normal sensation, but intense pain. The explanation no doubt is that the sensory nerves, supplying this .portion, run into portions of the cord which are not absolutely disorganized, but only contused, and irritated by the damage sustained. I must leave the subject of the pecuUaiities of respiration, etc., which ensue after fracture in the cervical region, for another time. After a few words on prognosis and on treatment, I must hasten to conclude. It is obvious that the prognosis will depend upon your estimate of two factor-s. Erst, the position of the injury, and, secondly, the extent to which the cord has been damaged. First, then, are- the cases in which the existence of complete paraplegia, below the seat of injury, PROGNOST* Airr) TRTCATMTjNT. 371 indicates that tbe oord has feeeai aioSt Sie\^«rdly damaged. In thesfe the danger to life increases in proportion as w« aicetid towards the medaUa. Many, perhaps most, of-lbhefrackires in the Inmbar aftifi lower dorsal regions, mirfit recover if it weriS pQsable to avoid eyfetitis and hed^sores. Thete is nbthifflg necesBartiy fatal in eomplete and per- manent paralysis 'of tkeiower extremities and of tbe^epMuisters. But, in these cases, yoa uiay hojie foif a 'liettef *esw;lii tiaan.l&ie* In not a few cases the paraplegia will disappfairj (and 'Ae:|)gltient'maiie a eotti' plete recovery. You haTe bat Ito see to the his easeful attimg, place' him on a water-bed, and abstain Horn -serione iiiteffeffenee.' If the fracture be high enough to implicate the respiratory muscles, a new element of danger from pulmonary congestion, &c., is added, and if it be so high as to paralyze all the thoracic muscles, the prog- nosis becomes exceedingly grave. But very few such patients recover or even survive many days. I have been speaking of cases in which one vertebra has been com- pletely displaced from another, and the cord crushed between them, much in the same way that a finger might be crushed by shutting a drawer. There are, however, other cases in which no such complete displacement has occurred, and these will generally be known by the imperfect character of the paralysis. These are, I think, more likely to happen in the cervical region than elsewhere, since they generally result from direct violence, and the neck is more exposed to violence of this kind than other regions. After such an injury, one arm may be paralyzed and the other not, and the muscles of respiration on one side only, and perhaps only imperfectly on that. These cases often recover, in spite of the importance of the region injured, but usually some degree of permanent local paralysis persists. In justification of the strong opinion which I have already ex- pressed against operations with the intention to elevate depressed portions of bone, T must say a few words more. My chief reason is that by doing so, you convert a simple into a compound fracture, and add the risks of pyaeinia, together with those of spinal meningitis. Then, I urge that depressions of bone very rarely exist, perhaps not once in twenty cases, and that it is utterly impossible to select the case. The amount of displacement apparent externally will not help you much, for this may be very great, and may be due to such a twist of an B B 2 372 MR. HUTCHINSON ON FRACTURES OF THE SPINE, ETC. entire vertebra as it will be quite impossible for you to replace. The irregular form of these bones makes it exceedingly difBcult to effect the rectification of a displacement. I must insist that operations for injuries to the spinal column are not to be fairly compared with those on the stuU, In the latter region, you have to deal with large smooth superficial surfaces of bone, you can easily appreciate irregu- larities and easily gain access to them. In the former, the opposite is the fact. Nor, I believe, do clinical results as yet hold out any encouragement to those operations. This latter part ofthe subject I shall, however, leave for the present. NOTE ON THE FUNCTIONS OF THE OPTIC THALAMUS. By J. HUGHLINGS JACKSON, M.D. ErEEY physician must have been struck with the far greater number of cases of loss of motioUj he meets with, in comparison with cases of loss of sensation, from disease of the nervous system. Dr. Handfield Jones, in his recent Lumleian Lectures, says — (I put some of his words in italics) — " The much greater tendency to impairment of motor than of sensory power, in almost all hinds of nervous diseases, organic, as well as inorganic, is a remarkable and unexplained fact." Hemiplegic paralysis especially, is common, but henliplegic ansesthesia is very rare. Both, however, occur together from disease of the same centre of the brain, viz., the optic thalamus, as in the case I am about to mention. The case is, by no means, a common one. Effusion of blood in the thalamus is not at all uncommon, but effusion, nearly limited to the thalamus, is, in my experience, rare. In many of '(h& post-mortem examinations I have made, in cases of chronic hemiplegia, the clot has affected both the corpus striatum, and the thalamus opticus. The case I relate is the only one I can call to mind, in which I have had an autopsy on a patient who has died some months after an attack of hemiplegia, in which the post-mortem changes have been confined, or nearly confined, to the thalamus opticus. In this instance, disease has made a fairly accurate experiment, to shew some points in the physiology of this important centre. The case has an interest to me from a narrower point of view, as regards the question of the condition of sensation in 7the common form of hemiplegia. 374 DR. HUGHLINGS JACKSON ON THE In a lecture {London Hospital Reports, Vol. ii., p. 303), I con- sidered hemiplegia from disease of the corpus striatum^ and hemiplegia from disease of the optic thalamus, as one 'symptom. These two ganglia are often affected together, and lesion of either of them alone seems to produce pretty much the same form of hemiplegia. Dr. Todd -says : " It is remarkable that lesion of the optic thalamus should produce, nearly or precisely, the same effects as lesion of the corpus striatum,'" Por fear of being misunderstood, it may be well to say that' hemiplegia, from disease of the pons Taroliij is not here in question. Considering the common form of hemiplegia then^ from its clinical point of view, as an affection of either the -corpus striatum, or thala- mus, or of both, I was led to conclude that sensation generally escaped in this form of paralysis. I wrote, " There is usually no loss of either common or special s^ns^j;ion. Sometimes, however, sensa- tion is a little-^b it very little^-T^impaired." But I was careful to add, " on tiiese points I take my knowledge chiefly from eAromi^ easgi," and to state further tha<^ "many physicians cansideK that there is decided loss of sensation in this form of hemiplegia." I still th,ink th^ facts are pretty inuch a^ I then stated them, but I now admit that my knowledge was too much " taken from chronic cases," ftnd, wag therefore oneTsided. I think sensation is more often, and more considerably affected in hemiplegia than I used to think it to be. During the last few years I have seen, at the Hospital iox JSpilepsy and Paralysis, several hundred pa.tie]j,ts with hemiplegia, but nearly all of them were chronic cases. In the majority -of the hemiplegics at this JJospital, the cause of the paralysis is, doubtless, cerebral hsemorrhage, and we see chiefly those patients who havq gone through ijhe immediate effects of so serious an accident, and who come for the reHca of a, disease. The cases of recent hemiplegia I have seen at the London Hospital, ^nd especially, when I delivered the lectui;es ' referred toi aie, in comparison, few. I Isnew that, a^ccording to piiysiplogists, there ought to be loss of sensation in disease of the optic thalamus, but as I had very rarely found ansesthesia with hemiplegia, I thought medical physiology, did not strictly harmonize with the conclusions of pure physiologists. Dr. Broadbent has, in a very remarkable and most important paper on FUNCTIONS OP THE OPTIC THALAMUS. 375 Hemiplegia* {Med.~Chir. ^ww, April, 1866), offered an explanation of this apparent discrepancy. Besides this, Dr.|Broadbent has added much to the observations which have been made on the symptoms, both motor and sensory, of hemiplegia. In cases of hemiplegia, loss of sensation is known to be more rapidly recovered from than paralysis of motion. Por instance) Dr. Todd, in the general consideration of paralysis of motion and sensa- tion, writes, "Sometimes at the commencement of an attack they ■ will be conjoined, but the paralysis of sensation usually disappears speedily, leaving Only the paralysis of motion." The absence of ansesthesia, in chronic cases of hemiplegia, ought not, therefore, to be taken as proof that the centre diseased is not sensory as well as motor. Dr. Mexander Robertson has published a very valuable paper on " Brain Disease," in the Glasgow Medical Journal, August, 1866, from which I make the following extract. The observations of this p!hysieian are, I think, worthy of the most careful consideration. " During the last year I carefully noted the symptoms in forty cases of hemiplegia due to organic changes in the brain, mostly of ■ a hsemorrhagic kind ; and many of the patients are still resident in' the Town's- Hospital. In these cases the duration of the paralysis ranged from a few days to many years. On referring to my note- book, I find that at the time of the examiaation, sensibility was defective on the affected side of the face in no less than fourteen instances; two were hyper-sensitive, one had been overlooked, and in the remaining twenty-three its condition was normal, although not iinprobably, from the fact to which I have referred, viz., the frequent rapid restoration of the sensory function, an impairment may have existed in some instances when the pal?y occurred." " With the view," Dr. Robertson adds in a footnote, "of corroborat- ing my opinion on this point, my friend. Dr. Ettssell, physician to the special Fever Hospital of this city, who is Well known td be a careful * I may also mention that this paper contains a most valuable hypothesis to explain the escape of the muscles of the trunk, in cases of the common form of hemiplegia. I know of no facts which seem to contradict Dr. Broadbent's views on this subject, and! beheve I can shew, by the pheno- mena of some cases of epilepsy, that they are correct. I suppose, however, that nearly all who are interested in the study of the Nervous System will, have read Dr. Broadbent's paper. If any of my readers have not, they will thank me for drawing their attention to it. 376 mi. HUGHLINGS JACKSON ON THE and accurate observer of disease, was good enoughj at my request, to test the sensibility of the face in two cases of ordinary hemiplegia of some years' standing, at present under treatment. After a careful examination, he expressed himself as quite satisfied of the correctness of the observation, that the sensory function was distinctly impaired." Dr. Broadbent thinks that just as after an experimental injury, a bridge of grey matter in the cord will conduct sensitive impressions, so, in injury by disease, to the higher part of the motor and sensory tract — the optic thalamus — lateral conduction may become sufficient, even when part of the structure of this centre is actually destroyed. When a great deal is broken up, of course restoration of sensation can only be partial. I now speak, in illustration of the above, of a case I have related at the end of my lecture on " Cerebral Haemorrhage. The symptoms were very like those in the case Dr. Broadbent related in his paper at the Medical Society of London, December, 1865 (since published in the Med.-Chir. Review), and the degree- of loss of sensation -was so unusually great, according to my experience of chronic cases of hemiplegia, and I diagnosed 'disease limited to the optic thalamus with much confidence. I had carefully ascertained during the patient's life that — as Dr. Broadbent said was the case with his patient — sensation was impaired in the region of all the sensory branches of the fifth nerve, which supply the skin, and also in one- half of the trunk as well as in the arm and leg. Sensation was not lost, nor was it so much impaired, but that pinching was painful. There was, moreover, a slight, but decided, wasting of the muscles of the paralyzed arm, chiefly of thq extensors. The disease was not strictly limited to the thalamus. At the autopsy I cut through it from within outwards, beginning at about the line of the posterior commissure. This incision went through the remains of a clot. The diseased part did not extend to within a quarter of an inch of the commissure, nor to within about that distance of the geniculate bodies. In front of the incision, the quantity of the centre disorganized would be equal to a small hazel-nut. Outwards the disease extended through the small tongue of corpus striatum, which curves round the outside of the thalamus, and thence up to the grey matter of the convolutions of the Sylvian fissure. FUNCTIONS OF THE OPTIC THALAMUS. 377 In making the autopsy I had the advantage of the assistance of Dr. EichardsoHj of the Caledonian Eoad, Mr. Powell, of Amwell Street, and Mr. Ansell. Now as regards the patient^s sight it was not much impaired, when, some mouths after the attack of hemiplegia, I first saw him. It failed gradually. I found, however, the retinal degeneration attend- ing Bright's-diseaee, so that the condition of his sight would -have no direct bearing; it could not be precise evidence at least, on an investiga^ tion of the functions of the optic thalamus. With the failure of sight, were corresponding appearances in the retina. The case shews, how- ever, that without an ophthmalmoscopic examination, false conclu- sions might be arrived at as regards the cause of defect of vision ; when, after death, we find disease of the optic thalamus. On these points I have already spoken in the OpMhalmio Review, April, 1866. The clinical history and the autopsy contain points' of greater medical- interest even than those relating to the physiological questions of the functions of the thalamus, but I have already entered into their consideration. I may briefly note one other point. It is well-known, that in disease of the higher parts of the motor tract, the nerve-fibres waste below. Thus I have the medulla oblongata of a woman, who had died two years after hemorrhage into the corpus striatum and thalamus opticus. The corresponding anterior pyramid is much wastfed. It seems to consist of little else than connective-tissue. I have, unfortunately, not got that patient's spinal cord. In the case I have just related, I think it possible that I may trace degenerative changes in the cord, which may give us some hints as to the course and relation of those sensory nerve-fibres which go from the limbs, &c., to the thalamus. NOTES ON SYPHILIS. By JONATHAN HUTCHINSON, JF.R.C.S. Relapsing indurated chwAcre. I AM sure that it is not a very infrequent occurrence for indurated chancres to relapse without any fresh contagion. Thus year -after year the soft scar of a former induration may suddenly again inflame, become liard, and even ulcerated. I have seeuj I think, at least a dozen remarkable examples of this. Often the relapsed induration is so like that of a prinjary chancre, that it is impossible to distinguish it excepting by the patient^s history. Several of my patients have been young medical men^ who were able, therefore, to give a very reliable and accurate account of the course of their symptoms. In one case, I had the same man three times under care at the Hospital with a relapsed induration, and, in another, a man came four times in as many years with the same. In each instance the fresh sore was in the scar of the former ones. A few weeks ago, I saw in consultation with Mr. W. Allingham, a lady who suffered from a ter- tiary affection, and in whom, Mr. Allingham told aie, this relapse of the original chancre had 'repeatedly occured, always exactly in the site of the first one. In many instances sexixal intercourse (without inoculation) appears to be the exciting cause of the relapse. Eelapses are more common within a year or two of the original sore, but I am convinced that they occur even many years after it. Eelapse, long after a sore has soundly healed, may become of much importance in practice. Mr. W. D. Michell brought to me a gentle- man, in whom the relapse had occurred under very painful circum- stances. Having been treated for a soft sore in July, 1864, he married fifteen months later, and within three weeks, the sore re- NOTES ON SYPHILIS. 379 opened and became hard. When I saw him, he had a disc of decided induration in the prepuce, "close to the corona. He said that it was exactly in the site of the former sore. In this instance, it was believed that the original sore had never indurated, nor had it been followed by any marked constitutional symptoms. He had also had a chancre six years previously. On each occasion the chancre was attended by enlarged glands, which did not suppurate. He had never taken mercury. A long course (^iodide of potassmm. Mr. W-, whom I have repeatedly seen during the last three years in consultation with a^vra'y able surgecan, whose, patient he is, has taken iodide of potassium during the whole period. He suffers from tertiary syphiKs, and has lost large portions of bone from the nose. He was first brought to me more than three years ago, with profuse foetid ozoena. We ordered the iodide in seven-grain doses three times daily. He found great benefit from it, and improved not only in the local condi- tion, but in general health. Whenever he left off the remedy he relapsed. At the present time he assures me that he has for nearly three years taken the dose mentioned quite regularly. Mr. W. is married, and the father of a family of healthy children, the youngest now a few months old. He is florid, stout, vigoroHs, and in excellent health. His ozoena is now . well with the exception of a slight discharge when he takes cold, and I think that all the diseased bone has been got away. He is decidedly unwilling to leave off the medicine. I have often given the iodide in very long courses, but, I think rarely with such steady perseverance as in the above case. When once a. patient gets used to it, we never, I think, witness any iU re- sults. It very often disagrees in the oiiset, and not at all afterwards. Syphilitia ^nlwirgenii.&»A^ of hone sinmlcttimff eancer. Very large nodes of long bones — of the femur, or humerus, especially — not unfeequently simulate the characters of malignant disease. A remarkable instance of this was under my care at the MetropoUtan IVee Hospital eight or nine years ago, A married and very respectable-looking woman of middle age, had a general enlargment of the lower third of the left femur. The soft parts were 380 MK. HUTCHINSOK's NOTES ON SYPHILIS. thickened and the whole constituted a very large tumour, the limb measuring several inches more in girth than its fellow. There had been great pain in the swelling, and the patient was sallow and cachectic. She had no other syphilitic symptoms ; but at a sub- sequent visit when, having by the administration of iodide of potas- sium confirmed my suspicions, I put the question, she admitted that fifteen years ago she had contracted the .disease. This was before her marriage, and whilst she was living at an hotel. We admitted this summer a woman with a tumour on the middle of her right femur, which, I believe, everyone who examined it at first took for cancer. My own diagnosis in the admission-room was in that direction. The woman was aged 34, of a yellow faded-leaf complexion, very much emaciated. The middle third of her femur was involved in a general ovoid enlargement, and at the thickest part, was as thick as a fist. When I examined her more carefully in bed, my suspicions were aroused by its even surface, and by the history of nocturnal exacerbations of pain. On pursuing this train, and asking direct questions, we could not obtain any history of syphilis. There were, however, some very suspicious scars of former ulcerations on the leg. She was an American, and had married at the age of 15. The sores on her leg showed themselves within a few years of her marriage. She never had any children. Still it was very possible that cancer might have occurred in a, syphilitic patient. We used the iodide of potassium freely and with the best results. Her pain ceased, the swelling diminishing in size, and after two months' treatment she left the Hospital at her own request, considering herself cured. Nodes ofthefemw. I believe there is a general impression entertained, that the femur is rarely affected by syphilitic periostitis. It happens, however, that' we have a remarkably good series of specimens of nodes of the femur in our Museum. Most of them are without any life-history, but from the character of the sub-periosteal dejiosifc, there can, I think, be no doubt that they are the results of syphilis. . I have not myself seen many examples of nodes of the femur in patients who were the subjects of tertiary taint from acquired disease ; but I have repeatedly seen such from the inherited form. Very probably some of our Museum specimens are from heredito-syphilitic subjects. SPONTANEOUS PBACTUEE THBOTJGH A NODE. 381 Spontaneous fracture in a node of the humerus. — Union, after several months. At the time that the woman, whose case I have mentioned ahove, was under care, we had in Talbot ward a yet more remarkable and puzzling case. This patient, a sailor, of about 30, was transferred to me by Dr. Parker, having been admitted on the medical side with dysentery and rheumatism. He had but just landed from a voyage. There was a large irregular tumour, evidently bony in parts, about the middle and lower third of his right humerus, and in the middle of this spontaneous fracture had occurred. The fragments of bone were quite loose, and grated on each other very freely. Although we had a clear history ot syphilis, yet I could feel but Uttle doubt that this tumour was a malignant one. On the inner sides of both femurs, just above the knee-joints, were large periosteal indurations, smooth on their surfaces, and very like iiodes. At first I treated this man by iodide of potassium ; but his dy- sentery was so urgent that I was obliged to suspend this, and after trial of "Various remedies we eventually cured the latter by full doses (a scruple) of the tris-nitrate of bismuth with opium. When his diarrhoea ceased he began to improve in health. He had no pain in the arm, and in spite of the free movement at the fracture, he used to employ his hand. At length, we found that the swelling was getting a little less, and the movement not quite so free. The final result was that the fracture united firmly, and that a large part of the new deposit about it was absorbed. The man left the Hospital in greatly improved health. The nodes on his femurs were much as at first. We can scarcely, with the result before us, entertain any doubt that this was a case of syphilitic disease of bone, and not of carcinoma. Yet I never before knew spontaneous fracture at the seat of a node occur, excepting in a young infant. Nor have I ever known a case of node with so much of irregular outgrowth about it as was present here. Sa certain did I feel that it was cancer when I first saw the man, aiid for some weeks afterwards, that, had it not been for the existence of the .disease of the femurs also, and for the bad state of the man's health, I should certainly have advised amputation. It should be added that he had not had scurvy. 382 MB. HXJTCHINSOJSr's NOTES ON SYPHILIS. Death from my 0-carditis m the course (f secondary syphilis^ In April last my friend. Dr. Wilkinson, of Old Broad Street, sent to me a young man who had been for some months under Ms care, and who, in consequence of family affiairs, was now anxious to come into the Hospital. I admitted him, but saw him only once, and then hurriedly. Observing that he had several syphilitic ulcerai- tions abput his legs, and was very cachectic, I ordered him iodide of potassium and ammonia, and did not. investigate, his case so thoroughly as I ought to have done. At the time of my visit he was sitting up in bed looking much distressed and very pal^. He answered my questions in a peevi^ manner, and seemed very rest- less, and thinking that something had annoyed him, I did not press my examination. I learnt afterwards that his peculiarity of majiner had struck others who saw hitp, and led to a suspicion that he was going insane. On the second night after I saw him, the House-sur- geon was hastily called to him by the nursej and found him dead. The nurse and patients reported that he had appeared to be very restless until within a very short time of his death. '^'i post-mortem examination was" made by Dr. Hughlings Jackson the next day. No evidence of disease was detected, excepting in the heart. On the surface of this organ, beneath the pericardium, were numerous patches of ecchymosis, ^nd on making section of the muscular subptance it was found to be extensively inflamed. The patches involved were large, and included, indeed, the greater part; of both ventricles, especially of the left. These patches were toler- ably well-defined, and much paler in colour than the rest, being of a yellowish-grey colour. They were not materially softened, but here and there ecchymoses werp seen. Under the .nucroscope, cells, closely resembling those of pus, were found between the muscular, fibres, and there were also numerous oU-globuleg. , There was no lymph in the pericardium, nor any disease of the valves. I ascertained afterwards from Dr. Wilkinson the following details, as to this man's illness; — He had contracted primary syphilis about a year before, and had been irregularly under treatment.. In November he had a severe attack of erysipelas, and was delirious. During January, February,. and March, Dr. Wilkinson treated him at different times by mercurial inunction for a relapsing syphilifip MUSCULAR NODES. • 383 rash. Of this a few unhealed ulcers about the legs were all that remained, but he had latterly lost flesh and became very feeble. For a few days before his admission into the Hospital he had been very restless and rarely able to sleep. He had throughout never been salivated. Anti-mercurialists will probably incline to attribute the myo- oarditis which caused death to the drug rather than to the syphilis. Whether it had or not any relation to either, must remain for the present uncertain. Nodes in miiscld resembling cancerous grotoths, I have had recently several remarkable cases illustrating the im- portance, and, at the same time, the difficulty of diagnosis between syphilitic muscular nodes and mialignant growths. Mrs. P. was sent to me by my friend Dr. H. Weber, on account of a large, ill- defined, growing mass in the substance of the left cheek. We both liought that it was malignant, and the propriety of an operation was discussed. Fiiading, however, that it seemed tO' be in connection with the maseeter muscle a suspicion crossed our minds,, and we determined at any rate, in the first instance, to try iodide of potassium ; I should say that the lady appeared to be in good health, and that she had a grown-up and healthy family. There did not seem the slightest reason for suspecting that she had suffered from syphilis, anid there were manifest ones against asking any direct questions. The ques- tions we did ask, however, aroused her suspicions, and on her third visit to me she, with expressions of great distress, told me voluntarily her story. Fifteen years ago, ahd after the birth of her living family, she contracted syphilis from her husband and suffered severely. Several children bom after this died. Having obtained this clear history, we increased the dose pf iodide to. fifteen grains^ and the tumour, which had at first been as large as t child's fist, melted away as if by magic. In about a month all trace of it had disappeared. A few weeks after the case just recorded, Mr. J... F. Streat- field sent to me a cachectic woman who had a large .nodulated tumour in the right cheek. It was firm in parts, doughy in others, and attached at its base to the masseter. There was no inflammation about it, and the general suspicion was that it was cancerous. I admitted her at the London Hospital, and' finding that she had lost 384 MR. Hutchinson's notes on syphilis. one eye by iritis^ inj suspicion that it was a syphilitio node became almost a certainty. I remarked to the students that they should now have a demonstration of what iodide of potassium could do. "We ordered ten grains, with half a drachm of sal volatile, three times a day. In a few days the tumour was much smaller, and in the course of a month it was gone. The woman had also greatly improved in general health. A few months later she again came under my care for a small induration in tlie site of the former one, which again yielded to the iodide. At present she is for a third time under care, on account of a lamp in her tongue of precisely the same character as those which I shall describe in the following case, and which will, I have no doubt, again yield to the specific. Mrs. L., aged 63, a pallid cachectic-looking woman, applied on January Ist^ 1860, on account of two hard lumps in her tongue. One of the lumps was about the size of a cherry, and was near the tip on the right side, involving the entire thickness of the organ. The other was situated in the under part on the same side, and was as large as two almond kernels inerged together. Both were well- defined and isolated, the adjacent and intervening tissues being soft and quite healthy. There was no ulceration whatever on^the surface of either, but on the upper aspect of the smaller was a white appear- ance, as if the mucous membrane were on the point of giving way. Both adhered to the mucous membrane, beneath which they lay. My first thought was, judging from their hardness, their isolation, their position, the woman's age and appearance, that they must be carcinomatous. Against such a diagnosis, however, was the fact that there were two, and that they were quite distinct from each othej. The woman told me, on questioning, that they had been forming for about a month, and that excepting a little heat and pricking, they had caused no pain. About four years ago she had, she said, been under Mr. Critchett's care at the London Hospital for a similar state of things. At that time there was no lump under the tongue, but the hardness, etc., of the swelling in the upper part was, she felt certain, quite equal to what was now present. She took medicine for many months before the lump " melted away," but at length she got quite rid of it. This history pointed- to syphilis, but then we usually see syphilitic tongues fissured and corrugated, and displaying white markings, etc., whereas, in this instance, with the excep- CANCER FOLLOWING SYPHILIS. 385 tion of the lumps, the whole texture of the organ was soft and perfectly free from morbid alteration. On putting to her the question as to specific disease, she told me that she had been a widow sixteen years, and that, four years before his death, her husband had brought her home " the disease,^' from which she " suffered fearfully, and, indeed, almost died/' She stated that the sores of the genitals were followed by rash, and severe -inflam- mation of both eyes. She was salivated several times. After that, until the time of her tongue being affected, four years ago, she had remained without any special symptoms, although never regaining her former health. At present, she had no other symptom except- ing the lumps in the tongue. All her children had been born before she contracted syphilis, and all were Hving and healthy. With this history I could no longer feel any doubt as to the nature of the disease, and prescribed accordingly full doses of iodide of potassium with the usual most satisfactory result. Cancer of the tongue following syphilitic sores. It is in the case of the tongue that the most diificult cases as to diagnosis occur. I have recently seen several, in consultation, in which it was impossible to feel certain, previous to the trial of the iodide, with which disease we had to deal, or whether with both together. In the case of the tongue, the clear diagnosis of syphi- lis by no means removes the suspicion as to cancer, for it is not un- frequent for syphilitic sores to pass into cancer. In a patient under the care of Dr. Eose, of Mile End, whom I am at present see- ing occasionally, this difiiculty occurred. The man was undoubt- edly syphilitic, and had numerous syphilitic fissures in his tongue, but there was one hard-based ulcer which I thought had become carcinomatous. It did not yield to the iodide, and I advised him accordingly to lose no time, but, at once to have it removed by ligature, which was accordingly done. A few years ago, a gentleman was sent to me by Dr. Peacock for a cancerous sore in his tongue. There was no doubt that the original disease of the tongue was syphilitic, for he had for ten years been, at different times, under the treatment of Mr. Startin, Mr. Coulson, and Dr. Peacock, all of whom had given the same opinion. There was equally little doubt that the final disease was cancer, for although he made an excel- c c 386 ME. HUTCHINSON S NOTES ON SYPHILIS. lent recovery after extirpation of two-thirds of the organ^ and the scar remained sound, yet he died a year or fifteen months later from can- cer of the glands of the neck. When indurated ulcers in the tongue resist the influence of full doses of iodide of potassium, they should be viewed with the utmost suspicion, no matter how clear the diagnosis of syphilis may be. If cancerous action has commenced, there is no time to be lost. DETACHED NOTES ON SYMPTOMS, DEFINITIONS AND DIAGNOSIS. By JONATHAN HUTCHINSON, F.R.C.S. But few of the following detached notes have much claim to originality. They have been penned solely in the hope of putting certain somewhat difficult points in a clearer light, and they have been written chiefly for students. Some of them are directed against what I beheve to be errors in doctrine, or in the definition of terms, which are to be found in some of our best systematic works. In the latter instance I have carefully avoided mentioning names. That the notes may be found useful, is my only ambition in publishing them : — The phenomenon of rigor is probably dependent directly upon spasm of the arteries (excited, of course, through the yaso-mortor nerve).* By this spasm the due supply of arterial blood to the sur- face, to the muscles, and to the brain, is prevented. It is quite pos- sible to have partial rigors as well as complete ones. II. During a rigor as, for instance, a pysemic rigor, the pupfls become widely dilated, just as they do during epilepsy. III. A widely dilated pupil is indicative of spasm of the radiating * See Dr. Brown-Sequard's Lectures. c c2 388 ME. Hutchinson's detached notes on fibres of the iris ; these fibres being under the control of the vaso- motor nerve. Very often there is also paralysis of the circular fibres (third nerve) . In the cold stage of cholera the pupils are not dilated^ but of noroaal size. I therefore infer that there is no arterial or vaso- motor spasm in this stage, and that the hypothesis of those who consider it analogous to the cold stage of ague, is not well founded. IV. A motionless pupil, of rather less than usual size, and quite unable to dilate when shaded, is characteristic of paralysis of the radiating fibres of the iris. It is met with in connection with aneurisms and other tumours in the neck, and with direct injuries to the cervical cord, or to the trunk of the sympathetic ; now and then, but very rarely, it occurs as the only symptom present, and without apparent cause.* In hydrophobia the patient is very -pale, the skin cool, and the pupils widely dilated, or, at any rate, this condition occurs in one stage. These conditions indicate general spasm of the vaso-motor nerve. Such spasm would account for the sleeplessness and terrible TI. Erysipelas is .clearly not an exanthem.f It is not symmetrical in its manifestations ; one attack does not prevent another ; it does not observe stages ; and, lastly, the constitutional disturbance is pro- duced by the local inflammation, and is proportionate to its extent. To call such a disease an exanthem, because it is attended by redness of the skin, is to be guilty of a generalisation almost as hasty as that of the man who saw a donkey for the first time, and exclaimed that he had " found the father of all the rabbits." Tin. We are not as yet in a position to classify skin-diseases j but we * See Ophthalmic EospitalJournal, April, 1866, p. 136. t See an able paper by Mr. Higginbotbam of Nottingham, asserting the same doctrine which I advocate, British Med. Journal, Jan. 7th, 1865. SYMPTOMS, DEFINITIONS, AND DIAGNOSIS. 389 can group theruj or rather we can group some of them, and with much convenience to the learner, and to the prescriber. One natural group of skin-diseases should comprise those which are constitutional, and as a result symtaetrical, and which are liable to relapse. This group should include psoriasis, pemphigus, some forms of lichen, and many of eczema. I should exclude those forms of lichen and eczema, which are in connection with local causes, and take only those which are constitutional. All in this group agree in the circumstance, that they are rema;rkably under the curative in- fluence of arsenic ; which fact proves their mutual relationship yet more closely. IX. Another natural group of skin-diseases would comprise those caused by vegetable growths — the true Tinese. This group, in English practice, would take in Favus, Tinea tonsurans (true ring- worm), whether on the scalp or on a bare surface j pityriasis versi- color, and possibly alopoecia areata. All are contagious, and all are curable more or less readily by local treatment alone. None of them are altered by constitutional measures, however long persevered in. None of them begin in old persons, and several of them occur only in the young. X. It is probable, though not yet proved, that the fungus, which produces the parasitic diseases of the skin, is the same in all, though developed in very different forms. XI. Sycosis, as met with in English practice, is, I believe, not crypto- gamic in origin, but an inflammation of the hair-foUicles more or less allied to acne, and to some forms of lupus. Its cause may differ in different cases. Its cure should be by local and constitutional measures combined. Will some one of the several British dermato- logists, who advocate its cryptogamic origin prove the fact by a demonstration before the Pathological Society ? XII. The contagious element in skin-diseases may be introduced from 390 MR. Hutchinson's detached notes on several different sources. We have contagion by animal parasites, by vegetable parasites, next, and most important, by pus itself, and, lastly, infection or aerial contagion. Infection produces a blood- disease, and an exanthem as the result, — all the others produce local inflammations. The doctrine of contagion by pus I hold to be most important ; it is not only that specific pus is capable of com- munication by contagion, as gonorrhoeal or syphilitic, biife. all pus, under certain conditions favouring inoculation, may produce its like — may originate a suppurative inflammation of the surface to which it is applied. XIII. Common pustular acne is almost always symptomatic of other dis- order. In 50 per cent. I should suppose that it is in connection with the generative functions, and in the rest with disorder of digestion. It is extraordinary how very sUght may be the disturbance of the sexual function, which may induce inflammation of the folUcles of the face. I have known a lady in whom a few acne pustules appeared regularly at each menstrual period. In men, I have been made ac- quainted with the facts of several cases in which a crop of fresh acne would often occur in connection either with unusual sexual indulgence, or with a succession of nocturnal emissions. I was assured by one gentleman that fresh pustules would often foUow within twenty-four or forty-eight hours of the latter occurrence. In such cases it is clear that the inflammation of the foUicles of the face is caused through the nervous system by reflected influence. It is impossible that any blood change could occur to account for it. It is, however, only in some skins that acne' can be produced by sexual causes, and when it does occur in such connection, it by no means implies a state of extreme debility. I have repeatedly seen, instances of extreme exhaustion produced by sexual abuses, in which no acne had occurred. On the other hand, many celibates who have suffered from " sexual acne," lose it entirely on marriage, and at the same time much improve in general health. XIV. The commonest skin-disease which we have to treat in children, is what, following Mr. Startin's nosology, I am accustomed to call SYMPTOMS, DEFINITIONS, AND DIAGNOSIS. 391 "Porrigo." By most authors it is considered to be a form of eczema. I prefer, however, to distinguish it from the latter for the convenience of practice, fully admitting that there is no definite boundary-line between the two. Porrigo is very contagious ; eczema, but rarely so. Eczema is usually constitutional, and to be cured only by internal remedies. Porrigo may be cured in a week, whilst eczema takes months. The cases, which at the Skin Hospital we call porrigo, are charac- terized by the large amount of crust which is effused ; a thick, heaped- up, purulent scab, often of a greenish aspect, or like honey. The crust covers the inflamed area,- and there is little or no thickening of the skin ; the effusion is quite superficial, Its commonest seat is the occiput, but it may affect any part of the scalp, or the face, or the skin generally ; the lymphatic glands almost always enlarge, but they very rarely suppurate. The secreted matter is very contagious, and fresh spots come out wherever, by scratching, inoculation is effected. It is contagious to other parts of the patient^s skin or to other persons, whether young pr old. It often causes whitlows about the nails of those who attend to the child. It may occur in those who are in excellent health, and no internal medication that I am acquainted with will cure it. On the contrary, it may be quickly cured by local means. The nurse must be instructed to clean away every portion of scab, and then to apply to the sores an ointment containing some preparation of mercury or lead. One which I usually employ is fifteen grains of the ammonio-chloride to an ounce of lard, or another, nearly equally efficient, is a drachm of carbonate of lead to the same. A week or ten days ought to suffice for the cure, and if it does not the fault usually rests with the nurse. I think • that we should greatly facilitate the successful study of dermatology if it were agreed to call this disease " common contagi- ons porrigo " instead of associating it with eczema. XV. In cases of fracture of the spine and resulting paraplegia, the patient should, from the very first, be put on a water-bed. There is no fear of redisplacement; The catheter should be avoided if the urine will run away. 392 ME. Hutchinson's detached notes on XVI. I have not chanced to meet with any correct description of all that occurs in diaphragmatic respiration. When all the respiratory mus- cles, excepting the diaphragm, are paralyzed, the thorax, instead of being merely hors de combat, actually counteracts the efforts of the diaphragm. In normal breathing, of course the thorax expands, when the diaphragm sinks, and thus, by co-ordinated effort, the capacity of the chest is increased in all diameters. When the thoracic muscles are paralyzed, the walls of the chest do not remain motionless, but they sink and rise under atmospheric pressure at precisely the wrong times. When the diaphragm contracts and the chest-wall ought to be hfted, it sinks, and when the diaphragm relaxes, the chest-waU. is driven up with a sort of thud, very sudden and very peculiar. This kind of breathing is so remarkable, that I have sometimes recog- nised it immediately in going to a patient's bedside, and before his chest was exposed. Diaphragmatic breathing is rarely quite regular, and often it is very uneven. I thought at one time that it might be well to fix the chest-wall mechanically, but in practice- it did not succeed. XVII. Thoracic respiration, in paralysis of the diaphragm, is also very peculiar. The diaphragm does not remain motionless, but moves up and down, counteracting the efforts of the chest-wall to draw air in through the throat. The belly sinks when the chest rises, and rises when the chest sinks. I have seen but one good example of paralysis of the diaphragm, but in it we watched the breathing carefully for upwards of half-an-hour, and I demonstrated its peculiarities to those present. The man was dying of hsemorrhage into the ventricles ; and at the autopsy we found both lateral ventricles, and also the third and fourth, stuffed full of blood-clots. The clot in the fourth was nearly as large as one's thumb, and no doubt this was the cause of the phre- nic-paralysis. XVIII. One-sided fur on the tongue is, I believe, caused simply by the circumstance, that its subject is accustomed to eat on only one side SYMPTOMS, DEFINITIONS, AND DIAGNOSIS. 393 of his mouth. It is a common symptom, and I have often astonished- patients by remarking, " I see yoji-eat only on the left (or right) side of your mouth." The reply invariably confirms the inference. It is often present where there is mere loss of teeth, no toothache, or source of irritation. I therefore cannot agree with the hypothesis, which supposes it to depend upon reflex disturbance of nutrition through the lower branch of the fifth. It is quite -true that it occurs in its most exaggerated form when there is toothache, but this is precisely the condition in which mastication on the affected side would be most sedulously avoided. XIX. Intolerance of light has in many, if not most, instances, nothing to do with the retina or the optic nerve. It is not met with in retinitis or optic neuritis, and it is met with, in its most intense form, in inflammations of the superficial parts. Its most common cause is ulceration of the cornea. The fifth nerve is the one chiefly concerned in its production. XX. A patient who had been for more than a year quite blind, owing to white atrophy of the optic nerves, consequent on syphilitic disease, became the subject of acute corneal inflammation. Before the latter occurrence he could look at the sun without the least annoyance, having no perception of light whatever. During the inflammation of the cornea he had the most intense intolerance of light, XXI. In many patients suffering from photophobia, if you lift the lids forcibly, violent seeezing will occur: another proof that the fifth nerve is the one concerned. xxn. Tear by year we shall come to believe more and more in reflex inflammations and reflex causes of inflammation. What is called " sympathetic ophthalmitis," furnishes us with the most unquestion- able example of this occurrence. In these cases, a wound involving the ciliary region of one eye, sets up inflammation in the other. 394 MR. HUTCHINSON'S DETACHED NOTES ON Often the reflex inflammation is very rapidly destructive. The influence is probably conveyed tfeQUgh the fifth nerve. Injuries to the retina, or injuries to the optic nerve, or to any part of the eye-ball at a distance from the ciliary region, very rarely cause it. XXIII. We have, during the past year, had one rather remarkable instance of primary union of a deep and large wound. It was, after an operation for inguinal hernia, reduced en massed in which an unusu- ally free dissection was required. The whole of the wound stuck together. There was not a trace of redness at its edges, nor was a drop of pus formed. In this instance the man was put under the influence of mercury, and an ice-bladder was kept over the part, some layers of dry lint intervening. XXIV. Although " sympathetic" ophthalmitis is perhaps the best instance of a reflected disturbance of nutrition, that we can cite, yet, no doubt, we have thousands of examples of the same process, though under less definite circumstances. Wet feet may cause sore-throat; a draught of cold air on the back may induce pleurisy or pneumonia ; the introduction of a catheter into the urethra may cause herpes on the hps ; a nocturnal emission may produce inflammation of the fol- licles of the face (acne) . XXV. The curative power of blisters is probably due far more to reflex influence, than to any effect on the blood. The quantity of serum drawn off is often trivial in proportion to the benefit produced, and many forms of counter-irritation do immense good without abstract- ing anything whatever. Must we not believe that it is through the vaso-motor and trophic nerves that these results are induced ? XXVI. It may easily be the fact, that there are correlated parts in refer- ence to reflex disturbances of nutrition and reflex cures. Thus the two eyes appear to be correlated. It may be that behind the ear is * " Reductio ad absurdum,'' as one of the students called it. SYMPTOMS, DEFINITIONS, AND DIAGNOSIS. 395 the very best position at whicli to apply a blister for the relief of inflammation of the cornea, and that for every local inflammation there is some special tract of skin where a blister would produce a better effect than at any other part.* XXTII. Inguinal hernia in a young female child. — Mrs. S. brought me her child, a girl two years old, on account of a swelling on the right side of the groin. It was about the size of a large filbert, move- able, and feeling much like an undescended testis. It was difficult to reduce, but on two occasions I completely returned it, thus mak- ing the diagnosis of hernia conclusive. It was clearly inguinal. It had been noticed for two months. The child had been observed, after running about the room, to put her hand to the groin, as if in pain there. XXVIII. It is absurd to speak of "concussion" and " compression" as con- trasted, aud wholly difl^erent lesions, since, in almost all cases of trau- matic compression^ concussion must also exist. A man, who has had his head battered till the bones have broken, is likely to have had his brain shaken also. The practical question, is in each case, whether in addition to evidences of general shake of the nervous centres, there is also reason to suspect injury to some special part. The in- dications of injury to special parts, for the most part, are unsymmet- rical symptoms. These unsymmetrical symptoms may be due either to squeeze of some part, or to laceration or contusion of some part ; in the later stages, they may also be due to inflammation. XXIX. The terms " trophic nerves " and " trophic nervous influence " are used by physiologists in reference to the power which the nervous system exerts upon nutrition. Whether there is any such power, is the first question, and if that is answered in the affirmative, then comes the second, as to which nerves regulate it. Some physiologists * I owe maay invaluable hints, on this and on other subjects, in reference to the nervous system and its pathology, to my friend and colleague Dr. Hughlings Jackson. 396 ME. Hutchinson's detached notes on hold that a sensory nerve can do nothing but simply transmit a sen- sation from the surface to a centre^ and that a motor nerve can do nothing but transmit an order of the will or other excitement from the centre to a muscle, and that neither one nor the other exert any influence on the nutrition of the parts which they connect. As regards the vaso-motor nerve {nee " sympathetic ") some hold that it exerts a direct influence on nutrition, others that it only regulates the size of blood-vessels, and thus indirectly controls nutrition by in- fluencing the supply of pabulum. XXX. Many clinical facts seem to me to concur in pointing to the sensory nerves as those of most importance in reference to trophic disturbance. At any rate, if it be not the sensory nerve-fibres themselves, it must be some others which travel in close company with them which are the important ones. Paralysis of the cervical vaso-motor nerve, although followed by increased supply of blood, is not productive of inflamma- tion. Nor have we any facts in support of the idea that injuries to motor nerves cause inflammation. On the other hand we find, In reference to senspry nerves, the following facts : — 1st. The crop of vesicles, characteristic of herpes zoster, is usually mapped out most accurately by the area of distribution of some sensory nerve.* 2nd. That when a sensory nerve, such as the first division of the fifth, is paralyzed, inflammation often follows (of the eye in the case of the fifth). 3rd. That when certain sensory nerves are irritated (not paralyzed) reflex inflammations often ensue. 4th. That after section of mixed nerves, or of the spinal cord, the parts left without sensa- tion often inflame. XXXI. The paralysis of a sensory nerve certainly does not necessarily cause inflammation, but it appears to permit it. The irritation of a sensory nerve may, however, I think, cause inflammation, e.g., her- petic inflammation of the skin. XXXII. A little girl, who was attending at the Ophthalmic Hospital, had * Never by a motor nerve, never by an arterial branch, nor, as far as anatomy yet takes us, by the distribution of the vaso-motor filaments. SYMPTOMS, DEFINITIONS, AND DIAGNOSIS. 397 an ulcer in each cornea and intense photophobia. Her mother assured me that for a fortnight she had never seen her open her eyes- She kept the lids screwed up and her face held down. One day she was out walking with her sister, and keeping her eyes closed, fell into a hole, and was much frightened. Por six hours after the fright she kept her eyes wide open, then the photophobia returned with the^ same intensity as before. XXXIII. It is proved that there is such a disease as inflammation of a tract of skin, induced by some peculiar state of the nerve which supplies it with sensation — herpes zoster. It is proved that inflammation of the iris may be induced by the same kind of irritation to a nerve as that just referred to; Now if the iris may thus be made' to inflame, probably the choroid and other structures of the eye may also be aifected. Further, we may assert, that although as yet we only know herpetic inflammations as skin-diseases, it is quite possible that there may be such diseases as herpetic iritis, herpetic choroiditis, etc., with- out any eruption in the skin. I use the term herpetic as designating the chief peculiarities of herpes zostet ; that it is induced by a nerve ; is unilateral, and tends, to disappear spontaneously. It is possible that what we call herpes zoster, when we see its efi^cts in the skin, may not unfrequently attack internal organs, pleura, lung, liver, arach- noid. "We must suppose that any structure receiving nerves is liable to this form of nerve-induced inflammation. The term herpes, in skin-diseases, ougbt, in future, to be strictly kept to that group of which herpes zoster and herpes labialis are the types. To continue to apply it to eruptions on the scalp, and to cryptogamic diseases, such as herpes iris, herpes tondens, etc., etc., is to perpetuate confusiou. xxxiv. We might perhaps define herpes as an eruption, usually vesicular, which is induced and localized by nerves, which observes accurate stages ; and is essentially transitory. It has, as far as we yet know, two chief varieties, herpes zoster, which is almost always unilateral, and almost never occurs twice in the same patient, and herpes sym- ptomatica, which is rarely quite unilateral, which occurs over and 398 MR. HUTCHINSON S DETACHED NOTES ON over again in the same patient, and has the peculiarity that it almost always shews itself near to the middle line of the body, and at one of the outlets (mouth, nose, penis). XXXV. It is a very curious fact, but possibly owing to imperfect observa- tion, that whilst herpes about the mouth, and nose, and about the prepuce is common, we have no form of anal herpes. XXXVI. Dry or senile gangrene is slow gangrene j moist gangrene is rapid gangrene. Thus, from the same cause, the plugging or occlusion of an artery, either one on the other may follow ; or, in the same case, some parts may shrivel and dry up, and others may become moist. Dry gangrene may occur in young persons as well as in old ones, moist gangrene may, of course, occur in the old as well as the young. All depends upon the rate of death, whether the part dies with its juices in it, or whether death takes place slowly enough to allow of aU the fluid elements being removed. The gangrene of old people is not by any means always dry. I have had three cases during the past few years, in which very old people were attacked by gangrene of the toes, and the gangrene being rapid, was moist and fcetid. XXXVII. It is sometimes needful to be very precise in the directions given to patients. I vouch for the literal truthfulness of the following ; aU being occurred quite recently to myself :-^ A little boy had lost one eye from an injury. It was painful, and, I had reason to believe that a piece of metal was still in it. As its fellow was irritable, I advised removal of the lost eye-ball, and his father consented. A week later the father came to me in a state of great excitement and annoyance, because I had " taken the child's eye out." " Did I not tell you that I intended to do so, and did you not give your consent?" " Yes, but I never thought but what you would put it back again ! " A poor woman brought her child for ulcer of the cornea. I ordered,' amongst other things, that the eye should be covered by a SYMPTOMS, DEFINITIONS, AND DIAGNOSIS. 399 compress of oiled cotton-wool. She apologized at her next visit, that she had been unable to follow out my instructions, " for the child had struggled so, that she really couldn't get the wool well into its eye." A lady brought me her first-born for a trifling ophthalmia. I prescribed a lotion, and " to touch the lids 'at bedtime with cold- cream.'' She told me, when she next came, that she could not get any cold-cream, the London milk was really so poor, she had taken a quart, and set it to stand, but there was no cream worth mentioning. Yet, this lady paid her fees regulerly.* • The limits of human stupidity are. sometimes quite indefinite. An old man came a few weeks ago to my senior colleague, Mr. Dixon, at the Ophthalmic Hospital, and complained that he was losing his sight, and could not see to read. " At first," he added, " I thought it might he my glasses; but I rubbed 'em up with a bit of sand paper, and I'm no better ! " He produced them in a state of ground-glass. DESCRIPTIVE LIST OF THE MORE IMPORTANT SPECIMENS, CASTS, ETC., ADDED TO THE MUSEUM DUEING THE PAST TEAR. By L. S. little, Curator of the Museum. Right bronchus jilugged by a bean. . - .. «. The bean is firmly fixed near tlie commencement of tlie right bronchus, having, by its swelling, considerably dilated, and entirely occluded the tube. The calibre of the left bronchus is diminished one-third, as its inner wall is pressed on by the dilatea right air-tubes. LIST OF SPECIMENS ADDED TO THE MUSEUM. 401 This specimen was removed from the body of a boy, aged 14, who, when sucking some beans, suddenly became nearly suffocated. He arrived at the Hospital an hour after the accident, with urgent dyspnoea. Inversion was tried, and his breathing ceased. After tracheotomy and artificial respiration, his breathing was re-estab- lished, but the dyspnoea remained. In an hour's time there was a great amount of emphysema over the chest and abdomen, so much so that the chest was covered with a layer of air three inches thick, and no aid to the diagnosis could be obtained from auscultatio.n or percussion. Mr. Little now arrived, and passed an elastic catheter, as he thought, into each bronchus, without dif&culty. Six hours later the boy was bled, but without relief, and he died twelve hours after the accident. After death both lungs were found to contain air, and were apparently healthy. Detachment of epiphysis of radius, and fracture of shaft of ulna. The radius and ulna of a young subject, (left arm), removed by primary amputation. The carpal epiphysis of the radius has been detached. Almost the whole of the epiphysal cartilage has gone with the epiphysis, but two small patches remain on the extremity of the shafts The end of the shaft at its margins is a little splintered, but there is no material fracture. On the palmar aspect, about a quarter of an inch from the''outer border, there is a linear fracture, about an inch long. The upper end shows the mark of a tooth of a machine, which had entered the bone. This linear fracture does not involve the whole thickness of the bone, and consequently does not permit of motion, possibly it is only a scratch, and if so, the epiphysis was probably pulled off by the teeth which inflicted it. Unfortunately the carpal end of the bone has not been kept. The ulna presents a den ta ted, almost tranverse,fracture,aninchand a-quarter from the extremity of its styloid process. Obtained and presented by Mr. Dove, (G. h.j. 7.) Dislocation, traumatic, of the tibia at knee-joint. A cast, taken an hour after the accident, of a dislocation, at the knee-joint, of the tibia forwards. The artery was obliterated, and D D 402 LIST OF SPECIMENS the nerve also injured. Eeduction was easy. The condyles x)f the femur were one inch below the level of the surface of the tibia. The patella was loose and unsupported. The cast shows well the increased depth of the joint from before backwards, the prominence of the tibia in front, and of the con- dyles' of the femur backwards. For details of case, see Mr. Hutchinson's lecture in the Medical Times and Gazette, 1865. A sketch of the knee by Mr. F. M. Mackenzie has also been preserved. Occipital encephalocele {of cerebellum) . Cast of the head of an infant, aged two weeks, the subject of encephalocele through the middle of the occipital bone. The tumour is seen to be pedunculated, and is as large as a man's fist, and about half the size of the rest of the child's head. The tumour contained the cerebellum distended into an irregular cyst. See Transactions of Pathological Society, for 1865-6. Presented by Mr. Hutchinson. Talipes calcaneus, from case of encephalocele. A cast of the foot and leg from the same child (encephalocele of cerebellum), showing talipes calcaneus. All the muscles were small, but there was no proof of special atrophy of the gas- trocnemius, as compared with the extensors. ADDED TO THE MUSEUM. 403 Dwarfed radius, after separation of epiphysis in childhood. Cast of the fore-arm and hand of Mrs. , showing a dwarfed condition of both ulna and radius, the radius being much the shorter of the two. There was a history of supposed dislocation at the wrist in childhood, but probably a separation of the epiphysis of the radius. The styloid process of the ulna projects, and the hand is pushed over to the radial side. The woman died in consequence of a severe burn. The bones are preserved. presented by Mr. Hutchinson. (See p. 410.) Intra-capsular fracture of nech of femur. The upper third of a right femur removed a few days after . the accident. The fracture is irregularly transverse, and about the middle of the cervix. It was wholly intra-capsular, and no portion of it could be exposed till the capsule was opened. In the anterior half of the line of fracture, the periosteal fibres, are completely torn through ; in the posterior half, however, they are entire. Thus the only displacement permitted is eversion of the shaft. It is not possible to produce any perceptible shortening- The accident was caused by a wheel passing over the man's" pelvis, no doubt crushing the great trochanter outwards. The ilium, on the opposite side, was displaced at the sacro-iliac sy«- chrondrosis. Obtained and presented by Mr. McCarthy. Dwarjmg of the ulna after injury in childhood. A stereoscopic photograph of the arm of a gentleman, in whom the ulna is much shortened, in consequence of an injury in child- s £ 2 404 LIST OF SPECIMENS hood. The subject of the case was sent to Mr. Hutchinson by Dr. Warwick of Southend. The ulna is very slender at its lower part, as well as much shortened. The hand is pushed over to the ulnar border by the radius. The radius is convex on its outer border, the convexity being probably due to a fracture of the shaft at junction of middle with lower third. It is probable that at the time of the accident, there was fracture of the shaft of the radius above the epiphysis, and separation of the extremity of the ulna at its epiphysal line. Hence the difference, that one bone has continued to grow, and that the growth of the other has been arrested. Presented by Mr. Hutchinson. Recent fracture of the carpal end of the radim. The symptoms during life had been those of an ordinary CoUes' fracture, with the addition, that the shaft of the ulna was broken stbout two inches and a-half from the wrist. The radius is broken across transversely, but with very irregular dentations, about a third of an inch from its carpal surface, and the carpal fragment thus detached is splintered into seven or eight por- tions. The tip of the styloid process of the ulna is broken off, and with it goes part of the intra-articular ligament. The frac- ture of the ulna is a dentated transverse one, with a longitudinal split of the proximal portion. Supra-renal bodies, from a case of morbus Addisonii. These bodies are about three times their normal size, and consist of a homogeneous material, resembling tubercular deposit ; from a young woman admitted into the Hospital with bronzed skin. She had frequent fainting fits, and died exhausted. The other organs were healthy. (See p. 183.) Portions of muscle crammed with encysted iricAincs spirales. The cysts are large ; exceedingly hard and calcareous. On breaking them up, the worms can be turned out entire and healthy ; none showed signs of vitality under the microscope. Larffe salivary calculus. A salivary calculus of conoidal shape, the size of the top ADDED TO THE MUSEUM. 405 of a man's thumb, which came away by ulceration from Wharton's duct. It had been preceded, two years ago, by another. Presented by Dr. Goes. Cholera discharges. Microscopic specimens of choleraic discharges, and "first urines." Tongue excised for cancer. A tongue removed entire, for epithelial cancer, by Mr. Oouper. The excision was performed by making a section through the lower jaw, at its symphysis, and then dissecting backwards, and tying the vessels as they were cut. The patient did well, for the first week, but ultimately died of erysipelas, Ac. Presented by Mr. Couper. Heart and aneurismal sac ; showing a peculiar form of dissecting aneurism of first part of aorta. This specimen was removed from the body of a man aged 70-80, who was brought to the Hospital dead. About five-eighths of an inch, above the junction of the right and middle aortic valves, is an oval opening in the posterior wall of aorta ; about one and three-eighths of an inch long, and five- eighths of an inch wide; directed obliquely from below, up- wards, and from left to right. The right margin of this is smooth and rounded; the upper and left margin is sharp, and looted as though punched out ; a small fragment of membrane ad- hered to it, but could be easily stripped off. This opening leads into a sac, which, when traced, is found to open again into the aorta, by a similar aperture, half-an-inch long, on the left side of left subclavian artery. The sac is rudely hemispherical,' and, when flattened, measures four inches and a-half in diameter, both ways. The anterior wall of the sac is formed by the septum dividing the aorta into two. The lining membrane of the sac is very irregular in character and appearance ; immediately behind the aorta, it is tolerably smooth and glistening; on each side of this, it is 406 ' LIST OF SPECIMENS obliquely ribbed, and appeared like fine cordiitoy ; the ribbings t are berp and tbere interrupted by irregular, flat, smooth patches, slightly raised above the surface, and pinkish or yellowish- . white coloured. Further back, the liniiig membrane, still smooth, appears to be made up of compressed granulations. Quite posteriorly, the membrane is again smooth and flat, but here and there broken through by projecting laminae of calcareous matter. On the left side of the sac, near the top, are two transverse columnar bands, connected at their extremities, and free in the middle. The wall of the sac is tolerably uniform in thickness (about one-eighth of an inch thick), elastic, and obviously composed of three layers ; a thin, semi-transparent lining mem- brane, a tolerably thick, muscular-looking, middle layer, forming the bulk of the thickness ; and. itself divisible into two layers : and, lastly, an outer, thin layer, of condensed areolar tissue. About an inch above the left coronary artery, a minute opening is found, leading into a small cavity between the middle and outer walls: of the aorta, and the middle and outer walls of the sac. In this cavity was a soft clot of Wpod, similar in character to that found in .the cavity of the pericardium. About a quarter of an inch above the left flap of the aortic valves, there is a minute triangular opening, like a leech-bite, which leads into the cavity, containing, the alsoye-mentioned clot. Another opening was found in the walls of the sac, leading directly from the cavity of the pericardium, into the left coronary artery ; a third opening, a quarter of an inch above, and a little to the left side of the left coronary artery, also led directly into the cavity of the pericardium. No other opening was discovered. On tracing the aorta upwards, the lining membrane is seen to : be flaky and studded at intervals with patches of atheromatous deposit. The innominate is apparently double, or rather divided into two, by a septum : one half communicated in a direct line with the aorta: the other communicated independentl^jr with the , aneurismal sac. Presented by Dr. Andrew Clark. ADDED TO THE MUSEUM. 407 Calculi removed from the bulbous tract of the urethra. The following is Mr. Adams's account of this case : — A. man aged 40, came to the Hospital complaining of diffi- culty in making water. This he had experienced for 26 years. Whilst preparing to pass a catheter, I felt a hard oval lump in the urethra when I grasped the penis, and on further examina- tion I found another lump lower down. I also found that they rubbed together and gave the impression of stone. This was confirmed by passing a catheter ; and I, therefore, cut down upon them just in front of the scrotum, and removed the stones shewn below : — I afterwards introduced an elastic catheter into the bladder, and carefully brought, first, the urethral edges into apposition, with three small silk sutures, and afterwards, the skin, with four sutures. The plug of the catheter was left out, and the urine was allowed to dribble away into a porringer. The patient died of pyaemia more than a month after the operation. Presented by Mr. Adams. Syphilitic growths in the larynx of a child. Catherine T., aged 2i, the child of a prostitute, was ad- mitted with dyspncea, the right chest was dull, the respiration was laryngeal ; there was no lividity. The child was still suckled ; not emaciated, but extremely blanched. She was very precocious, and had the characteristic broad sunken nose. After death, the right lung was found col- lapsed, dense, firm, airless and bloodless. Nearly the whole surface of the interior of the larynx is covered with cauliflower vegetations which are largest poste- riorly, and extend upwards on the aryteno-epiglottidean fold. 408 LIST OF SPECIMENS No vocal cords are apparent. The air-passage is very consider- ably diminished in capacity. Atrophied kidney with calculus in ureter. From a lad of 18, who died suddenly frdm an injury. The left kidney is nothing more than an oval sac, two inches long by an inch wide. There is no gland tissue. The interior of the sac resembles the dilated pelvis of a kidney. In the ureter^ close to its commencement, is a uric acid calculus, the size of a large bean, firmly impacted. The ureter is obliterated beyond. The right kidney was larger than normal. The other organs were healthy. Encephaloid tumour springing from the choroid coat of the eye at the yellore spot. The tumour is the shape of a large cherry-stone, seated on a larger base, it has a smooth uniform surface, is of a rather soft and friable nature, and consists almost entirely of small cells. It has pushed the retina before it ; a considerable quantity of yellow serum intervening between it and the ooarcted retina. It was removed from a patient whose right eye was disorganizedj apparently by acute glaucoma. The humours were so muddy, that the fundus could not be examined by the ophthalmoscope. There had been intense ciliaralgia for ten days. The disease dated three or four months back, the eye having become rapidly dim, but without neurosis. The eye was re- moved, to relieve the patient of a useless and painful organ, and to guard the remaining eye from already threatening sympa- thetic disease. The left eye continues sound, after three months. Presented by Mr. Couper. Hydrocele of the tunica vaginalis testis, with deposit of lymph, and much thickening. The tunica vaginalis is dilated to the size of a large orange, its walls are much thickened, and the deposit, internally, of layers of firm lymph, which partially embeds the testicle, seated at the back part, It contained a sero-purulent fluid, with large ADDED TO THE MUSEUM. 409 flakes of recent lymph. From a man aged 38, who had died , suddenly from other disease. Presented by Mr. F. M. Mackenzie. Perforating ulcer of the stomach. Near the small curvature of the stomach, about an inch and a-half from the pylorus, is an opening the size of a three- penny piece, its edges are smooth from eversion of the mucous membrane. The opening in the serous membrane is smaller, with sharp edges. The preparation is interesting from the history. The patient when admitted into the Hospital, had no constitutional symptoms whatever ; he complained of pain in the epigastrium, but not on pressure. The second day peritonitis set' in, and he died on the third, the ulcer having given way, and the contents of the stomach having passed into the peritoneal cavity. Mammary gland, remdved;bg e^harotics. The entire right breast of a woman, which was removed by escharotics for scirrhus disease. The treatment was conducted by a professed cancer-curer, and the paste used was probably the chloride of zinc. The sore never healed, and the disease ha,s now extended widely. Presented by Dr. Kibbler. United, eiotra-capsular fracture of neck of femur. The- patient died of pyseraia seven months after his injuries. At the time of his admission a fracture of the cervix femoris on the right side was detected, the limb being shortened, everted, and freely movable. It'was quite certain from the free movement, that there was no impaction. The straight splint was used, and good union followed; The man's death had no connection with this injury. At the post-mortem the fracture was found to present all the features, which are usually held to indicate impaction. These are well shown in the appended "Woodcut. The great trochanter had been split into two fragments, and between these the cervix had penetrated, and in this position it had become firmly united. The specimen is valuable 410 LIST OF SPECIMENS as showing the risk of error, if we infer impaction from the examina- tion of a specimen after repair has taken place. Obtained and presented by Mr. Hutchinson. See p. 413. Dtcarfed radius after injury to epiphysis. The bones from the case above referred to, p. 403. (See also the London Hospital Reports, Vol. ii., p. 351, for details of the case.) Woodcut showing a vertical section of the carpal end of the radius and of carpal hones ; the latter resting on a projecting ledge, as dcscrihed in the text. The carpal extremity of the radius is mucli altered in form, the chief peculiarity consisting in a projecting lip of bone on its palmar aspect, ADDED TO THE MUSEUM. 411 upon which the carpus rests. There is no evidence of fracture now apparent. United fracture of femur, with displacement. The right femur of a child, showing a united fracture in the upper part of the middle third. Considerable difficulty had been encountered in keeping the child quiet. Plaster of Paris had been applied, but the foot becoming mottled and cool, was of necessity removed in fear of gangrene. After this a gutta-percha splint had been used. The fracture occurred on June 23rd, and the child died of cholera on July 31st. The specimen shows over-lapping to the extent of an inch, the lower fragment behind the upper one, and the upper one slanting forwards. The upper fragment is not abducted, the direc- tion of the shaft being straight, with the exception of the bend forwards. The condition of the bone suggests that the displacement was caused wholly by the upper end of the lower fragment pressing against and displacing the lower end of the upper one. Obtained and presented by Mr. Frederick Mackenzie. Vnited fracture of fibula, with some displacement. United fracture of the fibula in its lower third, with slight dis- placement of the tibia forwards. The patient was a young man who died of cholera in July, 1866. Deformity about his ankle was noticed, and, on inquiry, he stated that he had been treated in the Hospital two years ago for "broken leg." The deformity most noticeable consisted in prominence of the tibia on the instep, as if it had been partially displaced forwards. The specimen consists of the lower third of the tibia and fibula, with the astragalus and os calcis. The fibula shows firm union of an obHque fracture, about three inches above the tip of the outer malleolus. The lower fragment slants backwards. At the seat of unioH the end of the lower fragment is external to that of the upper one. The anterior edge of the tibia projects forwards over the articular surface of the astragalus. The lower part of the tibia posteriorly appear-s somewhat thickened, especially on its outer part. Possibly the periosteum may have been pulled off here, or a thin lamella of bone detached. This specimen probably illustrates a frequent condition after " Pott's " fracture. Obtained and presented by Mr. Frederick Mackenzie. 412 LIST OF SPECIMENS Fracture of the tibia, united, with displacement. Cast of a left tibia, showing the results of fracture, a little above the commencement of the lower third. The fracture has an obliquity of nearly three inches. The displacement is the usual one, the lower fragment having been drawn upwards behind and to the outer side The woodcut shows the displacement as seen from the inner side. of the upper one. The lower extremity of the upper one projects on the inner side. From a specimen in the possession of Mr. Bathurst Dove. Recent fracture of the femur. (G. h. p. 51.) A fracture of the femur at the commencement of its lower third, slightly comminuted and oblique from within out- wards and downwards. During life the lower fragment was displaced behind the upper one, and, from tne shortening, the fracture was sup- posed to be much nearer to the knee-joint tlian it really is. On the post-mortem table the effect of bending the knee was tried, and it was found quite impossible to effect reduction with the limb in this position, as the lower fragment pressed against the upper and tilted it forwards. The more the knee was bent the greater was the diffi- culty in counteracting the tendency to shortening, probably owing to the quadriceps extensor. Obtained and presented by Mr. Hutchinson. Compound fracture of femur with incomplete union. (G. b. p. 19.) The left femur of J. Crisp, set., 24, showing a partially united fracture at the middle of the bone. The lower frag- ment has been drawn upwards on the inner side and behind the upper one. The limb would have been shortened to the extent of at least ADDED TO THE MUSEUM. 413 two inches. The fracture was compound and comminuted. The ends of the bones are separated by a detached fragment, which is in process of exfohatioDj and are at a distance of three-quarters of an inch from each other at the nearest place. Union is eifected by long bridges of bone arching between the two. The cpiantity of new bone produced is very considerable, but it occurs only near to the site of the injury. In this case, but little treatment could be adopted, owing to the severity of the injuries which the man had received. He had a fracture of the neck of the opposite femur. Death from pyaemia six months after the injury. Length of obliquity two inches. Obtained and presented by Mr. Hutchinson. (See p. 409.) Exfoliation of part of ischium. A portion of the tuberosity and ramus of the right ischium ex- foliated, after a severe burn of the nates. (See case, Gold Medal Eeports, p. 207). Presented by Mr. F. S. Colquhoun. Comminuted fracture of the tibia, united, u-ith great displacement. A cast of part of a right* tibia, showing a united fracture in the lower third. The displacement is great, the lower fragment riding Woodcut showing displacement of the lower fraginent in front of the upper one ; seen from the outer side. in the front of the upper one. There is overlapping to the ex- tent of about an inch. There is a short detached fragment behind the end of the lower one, and the three are welded together by strong bridges of porous bone. From a preparation in the possession of Mr. Bathurst Dove. * Owing to the neglect of the wood engraver, to allow for reversal in printing, this woodcut appeal's to represent a left instead of a right tihia. EEPORT ON THE MEDICAL CASES UNDER TEEATMENT IN THE LONDON HOSPITAL, DUEING THE YEAR 1865, By JAMES EDWARD ADAMS. MBDIGAL KEGISTRAR. The total number of cases under treatment in the medical wards during the year 1865 was 1288, arranged as follows : — Remaining in the House, Jan. 1st. Afirriitted since * . . • ■ MALES. FEMALES. TOTAL. 56 658 65 56 518 45 112 1176 110 Remaining on Dec. 1st The average stay of each patient in the Hospital was, for men, 32-8 days ; for women, 33-29. Of the whole, 164 died, making a gross mortality of 12"732 per cent. HOSPITAL STATISTICS FOR 1865. 415 TABLE I. LONDON HOSPITAL STATISTICAL RETURN OP IN-PATIBNTS' DISEASES. Cases Tabulated. as BB'» 31 4 e-5 -a .a a ■ .S3; o is S i» u S OQ (Zymotic Diseases.) Class I. — Order 1. Varicella Croup S,carlatina Quinsy Erysipelas Pyaemia Carbuncle Dysentery Diarrhoea ....... Typhoid Fever (typhia) . Typhus Febricula Ague Rheumatism { Sub-Acute Others Order 11 Gonorrhcea . . Primary Syphilis Secondary syphilis Tertiary syphilis Others .... Order III Purpura ... Delirium Tremens Alcoholismus . Scabies Psoriasis Order IV (Constitutional Diseases.) Class IT.— Order I. Gout Anasarca (from Morb. Cord.) Cancer ..._.... Mortification .... Polysarcia Order II. Bronchocele Phthisis Haemoptysis , . , . . Debilitas ..'.... Melancholia 1 1 2 3 1 22 1 2 2 6 9 13 1 6 13 19 S 3 4 121 28 13 22 3 5 143 89 3 41 8 12 4 416 HOSPITAL STATISTICS FOE 1865. Cases Tabulated. ° 2 ^1 O.S St '3 p. w ( Local Diseases.) Class III.— Order I. Meningitis Paralysis Chorea Mania . Epilepsy Hysteria Neuralgia Hemiplegia Paraplegia Keralt|tis ...... Neuritis Sciatica Vertigo Lumbago Locomotive Ataxis . . Order II. Pericarditis(adraitted as such) Morbus cordis .... Aneurism of aorta, &c. . Agina Pectoris .... Fainting Phlebitis Order III. Broncho-pneumonia . . Laryngitis(CEdema of glottis) Bronchitis Pleurisy Pneumonia Haemoptysis Pleuro-pneumonia . . ' . Dyspnoea (from Tumours of Larynx). . . . • Order IV. Gastritis Enteritis Peritonitis Metritis Constipation. . . • Menorrhagia .... Colic Typhlitis Gastric Ulcer .... Plumbismus Mercurialismus . . . Dyspepsia Urtijcaria ...... Abdominal Tumour (uncer- tain) Hsematemesis .... 26 12 30 15 29 9 16 1 2 2 2 2 I 7 6 1 4 12 1 I 1 14 2 2 5 10 1 1 1 2 1 3 4 1 1 4 HOSPITAL STATISTICS FOR 1865. 417 Cases Tabniated. ■9i • I OS II Mo II ■9g. 11°" CI. III.— Ordet IV. continued. Apoplexy Melsena Heemorrhoids Morbus Addisonii .... Spleen Disease Hepatitis Jaundice Anasarca, post Scarlatina . Cirrhosis (without ascites) . Ascites ' . Order V. Nephritis . Nephria (Bright's disease, Albuminuria) Diabetes Malingering Haematuria Cystitis Suppression Order VI. Ovarian Dropsy .... Ovaritis Order VII. Synovitis . Ostitis (including periostitis and endostitis) .... Herpes zoster Internal haemorrhage . . Hydrarthrosis Arthritis (Rheum.) . . . Inanitio <' Peri-uterine haematocele Uterine Polypus .... Displacement Fibroid Tumour. .... Dysmenorrhoea Uterine diseases (eases not specified) (DEVEr,0PMI8NTAL DISEASES.) Class IV.-^Order I. Bedsores (admitted as such) Phlegmasia ..;... Order II. Chlorosis Amenorrhoea Childbirth ...... .Pelvic Cellulitis .... 2 1 1 1 4 2 2 6 7 9 34 17 1 1 10 4l8 HOSPITAL StATISTICS FOB 1865. Cases Tabulated. 1/ ■at" II 1 1^ St 11 i a a . ■a 3" Vioi-ENT Deaths aKd Diseases. (Accident.) Class v.— Order I. Poisoning by Laudanum . 2 2 1 J „ „ Burnett's Fluid 2 2 2 1) ,} Ammonia . 1 1 1 „ „ Oxalic Acid 1 3 4 3 1 „ „ Sugar of Lead 1 1 1 „ „ Potass Binoxal. 2 2 2 „ „ Sulphuric Acid 3 3 2 1 „ „ Nitric, . . . 1 ] 1- „ „ Chloroform . . 1 1 1 „ „ Naphtha . . 2 2 1 „ „ Belladonna . . 1 1 1 „ „ Hyd. Ammon. Chlor . . . 1 1 1 „ „ Tra. Camph.Co. 1 1 1 1 „ „ Phosphorus 1 1 „ „ InternalHaemor- rhage (source unknown) 1 1 1 The same cause which made the death rate so high last year, has influenced our mortality for the past twelve months ; viz. : the inade- quate accommodation in proportion to the number of applicants, and consequently, the, severity of the cases admitted. No fewer than seventeen cases are noted in the register as being " moribund when admitted}" and it has not unfrequently happened that cases of phthisis, anasarca, &c., have been taken in, lest they should did during the return home. The Hospital has been quite free fr6m anything like an epidemic of zymotic or other infectious diseases. Most of the cases of this class were admitted for surgical injuries, and in no case was the disease transmitted to attendants or students. Of all the cases of typhoid fever, in one case only were the symptoms developed after more than a week from the time of admis- sion. In this case, the patient was a girl, aged 19, admitted on August 6th, for pleurodynia, and the first manifestations of fever were not shown until September 2nd. The disease ran a very severe ■HOSPITAli STATISTICS FOR 1865. 419 course, and although she did not suffer any relapse, her convalescence was very gradual, and she was in the Hospital altogether for seventy- seven days. This patient, when first admitted, occupied, for three Weeks, a bed not far from a water-closet, the drain of which was afterwards found to have been out of order at the time. Of the six cases of typhoid which proved fatal, three were examined and found to have well-marked intestinal lesion ; and one case ia particular, was of much interest, as showing that the amount of diarrhcea is not necessarily an exponent of the amount of ulceration of the bowels ; for in this case there had been diarrhoea for one day only, and yet numerous ulcerations, some as large as a five-shilling piece, were found in the ileum, in some parts almost perforating its coats. In one case the rash was of a mixed character, and, in one other, quite absent ; the remaining cases were well-marked. No specific plan of treatment was adopted, they were all placed under the most favourable hygienic conditions, with carefully regulated diet and stimulants when necessary. There were three cases of typhus. One of them was admitted in a dying state ; and another was admitted for a self-inflicted incised wound of throat (probably an example of typho-mania) followed by a characteristic rashj and death in two days. Excluding cases still under treatment, there were 112 cases of acute rheumatism, four of which died, three from pericarditis, and one from albuminuria and pleuritic effusion. They were all treated with blisters or alkalies, with the following comparative results : — Total. Cured. Relieved. Died. Mean residence in days. Blisters . . Alkalies . . 46 55 35 22 10 34 2 2 3710 36-87 Of the cases which recovered, five had pericarditis, in three of which the symptoms were manifest at the time of admission ; of the re- maining two, one was treated by blisters, and the other by alkalies. Forty 4hree out of the 112 cases had valvular disease at the time of admission, in two only was it acquired during the treatment ; in one of these, peri-caxiial mischief was recognised at the time of admission, and in the other a friction sound became audible on the third day. B E 2 420 HOSPITAL STATISTICS FOR 1865. Morbus Cordis. Of the cases of morbis cordis I have selected forty, which were admitted as such (and not for anasarca, as many were), and find that nearly sixty per cent, of the valvular diseases are traceable to rheumatism. In one case, the patient, a child of eight, had recently suffered from scarlatina, and ague was the only constitutional disease that another patient admitted. They may be tabulated as follows : — Disease of mitral valve . » . .23 „ aortic „ . . . .6 „ aortic and mitral valve . . 6 „ tricuspid „ . , . 3 Hypertrophy ..... 3 Of course, in some cases of valvular diseases there was hypertrophy as well, but in the three cases, tabulated, it formed the chief feature in the case. There were besides many other cases of heart-disease, but -the majority were so intimately associated with albuminuria and anasarca, that one disease could hardly be said to take precedence of the other. The two together form one of the most fatal of the maladies admitted into our wards, and, next to rheumatism, the most frequent. Hemipkffia. Of forty-six cases of hemiplegia, eighteen were of the right side, and twenty-eight of the left. In eight cases there was loss of speech, in all of which the paralysis was on the right side. All these were recent cases. There were eight fatal cases (including those registered as apoplexy), in seven of which the symptoms were owing to intra-cranial hsemor- rhage, as seen in the following Table : — HEMIPLEGIA. 421 Symptoms. Left hemiplegia. Right hemiplegia. Left hemiplegia. Left hemiplegia. Complete coma. No Paralysis. Coma. Left hemiplegia. Left hemiplegia. Post-mortem Appearances. Old clot in right corpus striatum, and optic- thalamus, andlymph ontheposterior margin of the foramen magnum on the under sur- face of dura mater. Hypertrophy of left ventricle. AU the valves atheromatous ; kidneys white and friable. A large recent clot in substance of left hemi- sphere,optic thalamus, corpus striatum. Kid- neys cystic. Great hypertrophy of left ventricle. Aortic valves calcareous. White softening between the anterior pillars of the fornix. Slight atheroma of aorta. Calcareous deposits in the circle of Willis. Left kidney waxy. Pale yellow clot in substance of right hemi- sphere. Other particulars not noted. Recent extravasation in third and fourth ven- tricles. Atheroma of aorta and circle of Willis. Kidneys waxy. Large quantity of blood effused into the mesh- es of pia mater. This patient had epileptic convulsions ; had been trephined eight years previously for fracture. Other organs not examined. Large clot in right hemisphere and ventricle involving the corpus striatum. Left ventri- cle hypertrophied. Kidneys healthy. A large recent clot in right hemisphere, com- pressing the corpus striatum >and optic tha- lamus. Atheroma of the Widdle cerebral arteries. Hypertrophy of left venticle, valves atheromatous. Kidneys granular. The ages and sexes for the whole number were as follow :- Ages .. Males . . Females. 20 25 30 35 40 45 50 65 60 65 3 1 ,0 2 6 2 2 1 4 1 4 1 5 4 1 1 2 4 -2 Total males 33, and females 13. Total 46. 422 HOSPITAL BEPOBTS FOB 1865. Parojplegia. There were eleven cases of paraplegia admitted during the year, of which four were still under treatment on December 81st. There were two fatal cases ; ohe a male of 46, in whom the symptoms came on sudden!^ three days before admission, accompanied by lumbar paiii ; i^oR^oit-mMen, showed white softening of the cord just above the cauda equina. In the other fatal cascj the symptom^ had been preceded for some time by lutobar paitis. The paralysis was complete, and there was a large bedsore over the sacrum at the time "of admission; The lumbar portion of the cord was found to be in a state of red softening, and surrounded by purulent lymph. Kidneys waxy. (Urine albuminous during life.) Of the cases remaining, one was supposed to be hysterical, occur, ring in a girl, aged 20. There was no affection of bladder nor of the tecluin, nor any loss of sensation; she could move her legs in bed> but could not stand. In another case, the onset was sudden, accbtupahifed by lilmbar pains, followed by almost complete re- bovery. General Paresis ; Paralysis of Special Nerves, etc. There were five cases of this disease, one of which proved fatal^ In this there was also albuminuria, with coarsely granular casts and uraemia. They were aU spirit drinkers. Two out of three cases of facial paralysis were fatal ; one was found to be dependent on syphilitic disease of the base of the skull, (Jennings' case), and in the other there was a cicatrix and induration over the parotid glandj and, after death, lyinph was found at the base of the brain, and in the fissure of Sylvius. There were two oases of paralysis of the third nerve, both patients were syphilitic, and were materially benefited by iodide of potassium. There was one case of paralysis of the sixth in a patient who had locomotive ataxia ; and one case of paralysis agitatls in a man aged 33. Chotea. There were thirty»seven cases of* chorea, tW majority Ireiug in ill- nourished children. All made good recoveries, with the exception CHOREA. — ^RESPIRATGEY ORGANS. 423^ of one child, aged 6, who was exceedingly emaciated. Most of them were treated with FoWler's solution ; but some «ases, in which mal- nutrition appeared to be the chief cause, were treated with good diet^ and Vinuum Ferri ; and made satisfactory progress. Of these, fifteen (40^ per cent.) had valvular disease of the heart. One case, in which the tapper extremities were chiefly pffeOted, occurred in a girl of 18, seven months advanced in pregnancy. This patient Was subsequently delivered at full time pf a female child. Ages . . Males . . Females . 5 and under. 10 15 20 23 30 35 TOTAL. 2 3 13 4 U 3 1 8 29 The average duration of treatment was 38'6 4ays. Respiratory Organs. There were twenty-nine cases registered as rancomplicated pneu- monia, ten of which were fatal (34"48 per cent.). In at least twelve cases both lungs were affected, and in those, in which the disease was limited to one side, the majority were of the right ; they were nearly all in the second or third stage when admitted. The others (broncho- and pleuro-pneumonia) were, for the most part, chronic with physical signs obscure, and frequently associated with albumen in the urine. Of fifteen cases of pleurisy, six had large effusion at the time of admission. They all made good recoveries, with the exception of one patient, who, when admitted, had his right chest full of fluid, subsequently had pneumonia of both lungs and two attacks of erysipelas. He was, notwithstanding, fairly convalescent when he discharged himself, having been in the House for ninety -four days. In nine, the disease was on the right side, three on the left, and three were not noted (being slight cases) . The mortality for the cases of morbus cordis was 30'6 per cent. There were also two fatal cases of aneurism, of which I have appended a brief account. The cases of Bright's-disease presented no particular features of interest. Of the fatal eases, one had ursemic convulsions, the others dying from serous effusions, bronchitis, and oedema pulmonum. Mortality 26-56 per cent. 424 HOSPITAL EEPOETS FOE 1865. A TABLE OF THIRTEEN CASES or ■ CANCER. No. Variety. Age. 3ex. Organ Affected. Occupation. Besnlt. 1 Colloid. 49 M. Stomach, pan- creas, and lumbar gins. Ironfonuder. Died. 2 Soiirbus. 30 F. Bladder and rectum. Married, Do. 3 Do. 50 F. Uterus. Out-patient. 4 Do. 28 F. Do. Do. Do. 6 Medullary. 65 M. Liver, and pan- creas. General dealer. Died. 6 CoUdidr 43 M. Intestinal canal. Labourer. Out-patient. 7 Medullary and scirrhus. 20 F, Mammae, ova- ries, kidneys. Servant. Died. 8 Epithelial. ' 67 F. Vagina. Widow. Out-patient. 9 Do. 37 F. Uterus. Married. Do. 10 Do. Excised. 30 F. Os uteri. Do. 11 Scirrhus. 40 M. Liver. Tavern waiter. Died. 12 Epithelial. 38 F. Vagina. Married. Out-patient. 13 Do. 35 F. Epiglottis. Do. Do. STATISTICS OF THE MAJOR OPERATIONS PERFORMED IN THE LONDON HOSPITAL- DURING THE YEAR 1865. Compiled by C. F. MAUNDER, F.R.C.S. SUMMAEY OF OPEKATIONS. .Amputations of Thigh. Becovered Died. Primary . . 3 Secondary . 7 Disease . .10 Total number 20 1 2 4 . 7 2 5 6 13 Amputations of Leg. Recovered Died. Primary . . 5 Secondary . . 2 Disease . . 3 Total number 10 1 1 2 4 2 2 8 Pirogoff 's amputation of foot (primary), one case which recovered. Amputations of Arm. Recovered Died. Primary . . 5 Secondary . Disease . . Total number 5 3 3 2 , 2 Shoulder-joint, amputation' at (primary), one case which recovered. „ „ „ (secondary), one case which recovered. Operations foif Strangulated Hernia. Species. Total No. Sac opened. Not. . Re- covered. Died. M. E. Fern. lug. Fem. Ing. 1 18 10 . 29 20 9 18 11 426 HOSPITAL STATISTICS FOE 1865. There were three cases of excision of the elbow (primary), which re- covered. There was one „ „ (secondary), which recovered. „ were two „ „ (disease), which recovered. „ was one „. . „ . ^ (disease), which died. There were five cases of trephining (primary) which died. „ three „ „ „ which recovered. There were seven cases of tumour of breast, which recovered. There was. OJ10 case . „ which, died. The tumours removed were twenty in number ; of which sixteen re- covered and four died. There were six cases of lithotomy ; four of which recovered and two died. There was one case of extraction of calculus from the female (through a "vesico-vaginal. fistula), which recovered. There were two cases of removal of testis "which recovered. There were two eases Of un-uflited fracturCj one of the femur in an adult male, one of the tibia and fibula in a female child; both were "pegged," but union did not take place. There was one case of fisity of lower jaw from tonfjraction' of cicatrix following cancrum-oris in a child aged six. Esmarch's operation was performed by Mr. Couper with fair result. There were four cases of ligatures of arteties, of which ihree recovered and one died. AMPUTATIONS OF AEM. M If I'i t' t ■d ' Cause of t CO Operator. Causa. If ■■ir 1 ■B .i Deatli. Semarka. 6M Mr. Hutohiiison Com. torn, fract. 2t. 1 Amp. by circular with Ifbceratiou method, middle of arm 18 M Mr. Maunder Comp. com. frao. with, laceration 2h. 1 Amp. by long post. and short ant. flaps, mid. of arm 22 M Mr. JNIa-undfir Com. frao. of ra- dius aud ulua and humerus ; .6h. 27 1* Erysipelas, and ex- haustion Amp.ofleftarmby internal and ex- ternal flaps at upper third also, coffl. com. fraot. of, right fibula,witb con- tusions 66 M Mr. Maunder Com. frao. Of hu- metttsi opento^ elbow-joint, ex- tensive liaoera- tion of fore-aim 8h. 84 1 Exhaustion Very feeble subject 30 M Mr. Couper Comp. com. frac. ,€ore-ann, frao, of humerus 4h. 3 m. 1 3 D 2 Ainp.lbelow simple fracture * Also, amputation of thigh secondarily, HOSPITAL STATISTICS FOE 1865. A2l OPEEATIONS FOR STRANGULATED HERNIA. 1 i Species. ■sl 1^. ■s 1 1 dpei^ator. CkuBe of Death, knd Remarks. 20 CO en «l « M R. Ing. 30 h. Yes 40 I Mr. Curling 70 M Ri lug. 8h. Not 47 1 Mr. Hutchinson 63 M L. Fern. sot. Not 24 1 Mr. Hutchinson 63 F R< Fern. 5d. Yes 68 1 Mr. Hutchinson Gut 'protected by omentum 42 F R. Fern. 48 K Not 28 1 Mr. Hutchinson Blood in first Stool 63, F Fem. 12 h. Not 35 1 Mr. Hutchinson* 6Z F R. Fem. 48 h. Not 26 1 Mr. Hutchinson 30 F L. Fem. 48 h. Yes 7 1 Mr. Hutchinson Exhaustion 56 F R. Fem. 56 h. Yes 1 1 Mr. Hutchinson Peritonitis 43 M R. Ing. 10 b. Not 23 1 Mr. Maundet 17 M R. Ingi 4h. Yes 26 1 Mr. Maunder Great collapse ; tehse and exqui- sitely tender tu- mour; stricture at neck of sac, very tight. Slight pefitoni-l tis subsequent : to operation 28 M L. Ing. 26 h. Yes 18 1 Mr. Maunder 48 M R. Ing. 12 h. Yes 6 w. 1 Mr. Maunder Removed great mass of omen- tuta 68 F R. Fem. 48 h. Not 42 1 Mr. Maunder 69 F R. Fem. 4d., Yes 2 in. 1 Mr. Maunder i Sac slougbed; ne- ; crosis of pittbes. Exhaustion 54 M R. Ing. 5 d. Yes 12h. 1 Rtr. Maunder 1 Cbllapse 5 bowel gahgtsnbus at time of opera- tion, made arti- ficial anus . 21 L. Ing. 12 h. Yes 6 1 Mr. Maunder Peritonitis ; tight stricture ; per- foration at seat ' of stricture after twelve hours' strangulation only be M R. Fem. Yes 142 1 Mr. Couper -J "Lump appeared •suddenly three days ago." Con- stipation islnce, bti'tKovonlitii^. Incision exposed mass of highly 428 HOSPITAL STATISTICS FOR 1865. HERNIA OPERATIONS. {Continued.) i S 5/S - II Species. "S-l =1 If li 1 •s§, li S i a Operator. Cause of Death and Remarks. - congested fibro- cellalar tissue size -of walnut outside sac-r^ac small and empty Sero - sanguineous t ilM Rj Ing. 16 d. Yes 38 1 Mr. Conper fluid in sac, ' which crepitated under the hand t SIV Fem. 108 h. Yes 1 1 Mr. Couper Bowel gangrenous made artificial anus J OM R. Ing. 20 h. yes 1 1 Mr, Couper Bowel perforated at three points ; made artificial anus 6 1J<' R. Fem. 4d. Not 39 1 Mr. Little 2 7M R. Ing. 24 h.- Yes S3 1 Mr. Little Cut away omen- tum 7 6M R. Ing. 4d. Yes 2 1 Mr. Little ' Reduction en masse by patient himself 6 5M L. Ing. 3d. Yes 4 1 Mr. Little 3ut away omen- tum 3 6M R. Ing. 13 h. Not 21 1 Mr. Rivington 3 9F Fem. 4d. Yes 17 1 Mr. Rivington Cut away omen- tum 2 IM l.Ing. 4d. Yes 2 1 Mr. Rivington Peritonitis 4 6M R. Ing. 24 h. Yes 14 1 Mr. Rivington Jaundice & ascites Large quantity of fluid flowed at the wound 17 12 EEMOVAL OF TESTIS. Daration Days in Re- Age. Nature. of Disease. Eos. aiter operation. perator. covered. 29 Strumous 18 m. 30 Mr. Ci irling 1 35 Strumous ^ 6 m. 27 Mr. Hi ntchinson 1 2 HOSPITAL STATISTICS FOR 1865. 429 KEMOVAL OF TUMOUES. Age. Sex. Nature Bate of Com- mence' Seat. Operator. Dys.in Hosp. after i> i a Jl ment. tlon. n F Cancer 3 m. Hip Mr. Curling 1 58' M Cystic , 30 y. Scalp Mr. Couper 21 1 ■30 M Cancer 14 ra. Mr. Hutchinson 19 1 47,: M Epithelioma 14 m. Great toe and ing. glands Mr. Maunder 51 1* 42 F Lipoma 2y. Left costal reg. Mr. Little 10 1 30 F FibroHielliilar 2V. Vulva Mr. Curling 28 1 30 M Pibro-nuclea- ted Melanosis 8y. Scalp Mr. Hutchinson ^t 30 F 16 m. Dorsum of Mr. Maunder 30 It foot 35 M. Epithelioma 3 m. Cheek Mr. Curling 18 1 31 F Cystic Con- genital 18 V. Scalp Mr. Adams 3 1§ 35 F Fibro-cart. Groin Mr. Couper 30 1 37 F Fibro-cellular 12 y. Tongue Mr. Little 20 1 25 F Cystic 4 w. Vulva Mr. Couper 27 1 63 M Rodent ulcer 2v. Lovrer eye-lid Mr. Hutchinson 67 1 15 M Exostosis 1 y. Femur ' Mr. Hutchinson 31 1 63 F Recur-fibroid 2y. Fore-arm Mr. Little 24 1 12 F Cystic years Root of neck Mr. Little 47 HI ' 40 F Fibroicellular 8y. Bursa patellae Mr. Maunder 46 1 57 M Epithelioma 2 m. Lower lip Mr. Maunder 26 1 46 F Scirrhus 5 m. Axilla Mr. Curling 2V 1 16 4 * Both toe and corresponding glands were removed. t This patient died of pysemia after removal from the Hospital. J Originated in a congenital mole. Since operation the corresponding inguinal glands have greatly enlarged. § Ulcerating before removal. Died of hemorrhage. ' II Large serous cyst m posterior inferior triangle of neck— removed portion of cyst-wall. Death from pyaemia. AMPUTATION 0*F FOOT. Opcraitor. 22 5 '»« = Caute of death. 18 Mr. Little. Comp. fract. of metatarsus ; lacerations. 4 h. 53 Pirogoff 's^ leaving epiphysis to re present the por- tion of OS calcis. 430 HOSPITAL STATISTICS FOK 1865. , AMPUTATIONS OF LEG. ■< 1 Operator. Cause. 1= i II 1 g Obhw of 3 Seatb. ItSmarka. 62 53 SO S6 15 69 22 37 50 65 F M M M M M M M M M Mr, Adams Mr. Adams Mr. Hutchinson Mr. Hutchinson Mr. Hutchinson Mr. Maunder Mr. Couper Mr. Couper Mr. Couper Mr. Little Diseased ankle- joint. Chronic ulper — useless limb Epithelioma of integumrait Com.frac, of tibia and fibula. Sup- puration Comp. com, fraot. of (oqt Com. com, frac. of leg. Severe contusion Com. com. frac. of leg, opening ankle-joint OoDi. com. frac. of leg Com. com, frac. of leg\ Com, frac, of leg, with lacerations 12 y, 14 y. 20 y, 13 d, 3 h. 7 h, 2 }i. 2 h, 13 h. 18 d. 39 ao 70 5 29 4 73 6 1 27 1 ■ ] 1 1 I 1 1 1 1 Secpndarjr hssmor- rhage Secondary haimorr- hage Pysemja Exhaustion Exhaustion Exhaustion Exhaustion Amp, at lower third by ant, post, flaps Arteries difficult to secttre. No enlarged glands Amp. mid. of leg by 4nt, post flaps. Amp, at lower third by ant, post, skin flap3. Traumatic gan- grene & hemor- rhage. Amp, by ant, post Haps, boldw mid, of Ipg. Emphysematous flaps,tertiary scars TUMOURS OF THE BREAST. Age. Naluro. Date of commence- ment. ■-!l Operator. i i s 54 66 60 70 40 41 37 Scirrhus Scirrhus Scirrhus Scirrhus Scirrhus Adenocele Adenocele 18 m. 5 m. 2y- 12 m, 9 m, 7 m, ■ Years. 38 39 80 58 6 38 11 Mr, Curling Mr, Curling Mr, Maunder Mr, Little Mr. Hutchinson Mr. Couper Mr. Hutchinson 1 1 1 1 1 1 1 6 1 R 1865. 431 EXCISION OF JOINTS. / |°J'5 II i < 1 ' Operator. (^auae. Period AccMen commenc of Dise .9| 1 •1 Calise of Death. 7 F Mr. Hutchiuson Strumous disease of elbow^joint 2y- 37 10 M Mr. Hutchinson Com. frac. of humerus, opening elbow-joint; severe contusion 1* 17 51 Wtr, Maunder Acute abscess, opening elbow-joint 10 w. 3m 24 M. Mr. Maunder Com. fracture opening elbow-joint 3w. 60 45 F Mr. Maunder Com. dig. of elbow 2h. UOd 1 + 60 M Mr. Couper Gun-shot wound of elbow 3i. 9 F Mr. Little Strumous disease of elbow , 4y. 25 1 Pyaemia 6 1 * Soft parts sloughed uecessitating removal of two inches of the shaft of the humerus ; good result. t Dislocation was produced by forcible extension of the fore-arm across the knee of another person, as one would break a stick. T REPHINING OF THE SKULL. 66 1-10 i 3 23 16 20 16 12 6 6 22 14 13 H 4 1 65 18 6 12 11—20 3 5 2 6 4 8 19 3 9 5 10 8 3 1 39 8 4 8 2 3 2 36 2 1 4 1 2 "2 6 3 4 1 1 22 3 ~8 4 5 2 3 32 1 2 84 106 40 56 44 50 21-30 20 10 2 1 6 3 31—40 5 16 13 8 ~3 10 9 6 3 6 4 2 27 16 6 5 U 8 4 4 53 8 14 6 93 56 28 20 609 52 39 20 18 281 41 17 8 2 228 41-50 2 1 2 1 3 2 1 40 7 2 2 70 4 1 2 31 3 1 2 12 2 1 1 20 51—60 Upwards Totals for the several weeks. 20 17 3 96 57 39 162 97 No cases of diarrhoea, however severe, are included in the above Table. It will be seen that, of the total number, 509 (of which 47 per cent, were females), 54-9 per cent. died. The mortaKty decreased week by week, that of the first week being 85 per cent., of the last 37 per cent., as will be observed by reference to the Table. 438 APPENDIX. It is also noticeable that the largest number of cases, in any decennial period, occurred in that between the ages of one and ten inclusive, as 22 per cent, of the whole number admitted were under ten years of age. The mortality increased pretty regularly with the age. The high mor- tality was, no dojibt, influenced by the poverty and previous habits of those attacked. Of those under ten years of age 44 per cent, died ; of those over sixty years of age, 90 per cent. died. The age of the youngest was sik months ' that of the oldest ninety-nine. The gradual decrease in the mortality is accounted for by the difference in the severity of cases. Thus, at the beginning of the epidemic,' most of the patients were brought into the Hospital in a state of extreme coUapse, and either died shortly after, or at the commencement of reaction. The consecutive fever, which, in many respects, resembled typhus, proved fatal in a large number of cases j and, even in those who recovered from it, the convalescence was very protracted. The cases which occurred during this epidemic differed from those of former ones in the severity of the cramps, which constituted a marked feature in the large majority of cases. The muscles of the calves were those chiefly affected, and the suffering thus produced was extreme, and distress- ing to witness. A walk through the cholera wards at night, in the earlier part of the epidemic, was really heart-rending, from the shrieks and groans of the patients, who were incessantly begging the nurses to rub, and rub hard, thus contrasting very much with what was observed here in the epidemic of 1849, in which the patients lay motionless, and ap- parently careless of the fate, which awaited them. This difference is probably owing to the free use of opium hitherto, and its almost complete exclusion from the list of medicines during the recent visitation. Cases occurred in which any one of the usual symptoms of cholera was absent, Thus, in some cases, collapse was the chief feature, piirging, or vomiting, or both being absent. In others the sickness was most severe and inces- sant, often proving fatal, especially during the consecutive fever. Great care has been taken in the diagnosis, to discriminate between cases of diarrhoea and cholera. Some few fatal cases of diarrhoea at this Hospital have been recorded by the medical papers in their weekly reports. These reports were based on the supposition that the patients had died of the disease for which they were admitted, whereas, in fact, a more careful examination in the wards, and the further progress of the case had revealed its true nature. No fatal case of diarrhoea occurred in the Hospital. Much importance attaches to the question, whether diarrhoea is, or is not, a premonitory sym- ptom of cholera? There is no doubt that diarrhoea existed in the majority of cases previous to the advent of cholera, but I think it desirable to state the fact, that, judging from the histories, where they were truthfully obtained from the patients or their friends, on admission, this symptom was, in a very large number of cases, absent. It was no uncommon thing for a man to go to APPENDIX. 439 bed perfectly -well, -wake up at three o'clock in the morning, -with purging and vomiting, and be brought to the Hospital in a state of extreme collapse at ten, seven hours after seizure. Up to the 'end of August, nearly ten thousand cases of diarrhoea had been treated as out-patients. The treatment varied g,cGording to circum- stances. Where the diarrhoea had existed for any length of time, with watery discharges, astringents were used, and, judging from the compara- tively small number who were subsequently admitted as in-patients, with good results. Where there was much abdomina,! pain with slight diarrhoea, or offensiiVe evacuations, castor-oil, with a few minims of the tincture of opium was given, to be followed by astringents, if necessary. Some facts may be stated bearing/on the question of contajgion. At the height of the epidemic, upwards of one hundred persons were employed in the cholera wards ; seven medical officers, five volunteer nurses, five sisters, eighty nurses, and five porters. None of the medical officers, volunteer nurses, or sisters, were attacked, and the porters enjoyed a like imii^unity. Of the. UTirses five contracted the disease, ?jid of these four died. Three of those who died slept outside the Hospital. In, the laundry eleven women were employed in washing the linen, etc., from the cholera wards, and of this number one was attacked and died. She was also a non-resident. As the mortality among laundresses is usually very large in a cholera epidemic, it would seem that the preventive measures adopted were not altogether ineffeqtual. Further details, bearing on this poinj, vfill be fouijd in another part of this report. No case of cholera, occurredin the general, wards of the Hospital, although during the whole period of the epidegiic, they contained their full number of cases, most of whom came from cholera localities. One child, who was suffering from acute periostitis, and had been transferred to the west attic (where the first case of cholera was received) in consequence of the superyention of measles, contracted the disease, and died during the first week of the epidemic. I cannot conclude this brief report without thanking those ladies who volunteered their services in the wards, and who were invaluable, both in their general superintendence of the nursing, and their personal attendance on the sick. The same office was admirably filled by the Sisters of All Saints', Margaret Street, during the nights. The regular Hospital nurses, many of whom volunteered for service in the cholera wards, at the out- break of the epidemic, did their duties thoroughly well. GENEKAL REMARKS ON THE CHOLERA EPIDEMIC. BY DR. FKASER. It has fallen within my duty to have been engaged in four previous epidemics of cholera. I am, therefore, qualified to ofier an opinion as re- 440 APPEm)IX. gards its cause and symptoms. It appears to me that, to constitute a trae case of cholera-collapse, the nose, tongue, and breath must be cold, the urinary secretion arrested, and the voice reduced to a whisper ; when these conditions are present, the patient rarely recovers. When they are absent the following may be more or less present, and yet recovery may take place: inaudible heart's action, absence of pulse, shrivelled skin, the washerwoman's hand, skin bedewed vrith a cold, and death-Kke moistiire, vomiting, purging, cramps, etc. I consider that this epidemic began suddenly, raged fiercely, culminated sharply, and declined rapidly, as cholera has hitherto generally done, fitly represented by an ascending angle of 45°, and descending by one of 95°. No new symptoms were observed, but a greater variety, in difierent cases, were noticed ; for instance, some had purging and no vomiting, some vomiting and no purging, to each cramps were sometimes added, and in some cramps were the chief symptom.* In this, as in previous epidemics, it is a melancholy fact to report that, whatever be the reason, the ill-clad, and ill-fed poor, those especially re- siding in unwholesome dwellings, were the chief and early victims ; just as if they, although unwittingly, unwillingly, and so far as they are con- cerned, unavoidably, having outraged the organic laws, are the first to fall before the slayer. If the statistics of this epidemic were worked out, it would be found, as it was in Paris in 1854, in the healthy quarters of the Tuileries, the sick were only as 1 in 110, and the deaths 1 in 193 ; whereas in the Veiidome quarter, unhealthy, and inhabited by the poor, the sick were as 1 in 29, and the deaths as 1 in 115. The first case was reported to me on the 4th of July by Dr. Jackson, the resident medical officer, who told me that a woman had been brought to the Hospital the preVious night, and had died with symptoms which he believed indicated cholera. I was unable to attend the post-mortem exami- nation, but remarked, apart from all other pathological appearances, if you find the bladder contracted to the size of a walnut, and empty, you may be assured that you are dealing with a case of cholera ; and you may forthwith bestir yourself and prepare for an epidemic invasion of the disease. That my vyarning was given not a day too soon, will be shown by the dates given by Dr. Jackson. Immediate preparations were made, a ward was prepared, nurses were told off for special duties, and, in fact, the " decks were cleared for action." There was considerable alarm at first among the nurses, and the illness of Eliza Joyce, assistant-nurse, in Wellington ward, tended to increase the feeling of dismay, as at the first blush the attack of this woman bore considerable resemblance to the effects of contagion, and from this case and one or two others, an attempt may be made to prove the contagion * The very important point as to the presence or absence of premonitory diarrhoja is again, in my opinion, left undetermined. Many of the patients denied having had it, but we all know how careful we must be in believing such evidence, and my own belief is that it had been oftener present than absent. APPENDIX. 441 of the disease ; but I am satisfied that when duly examined, the attacks of these persons may be shown to have had no origin from contagion. In pursuing this inquiry as to the persons attacked, the date and place of attack, and the localities visited by them lately, must be carefully settled. No general statements should be admitted, and no evidence employed, ■which has not been clearly verified. I am satisfied that many of the contradictory opinions in matters medical arises from a kind of evidence being admitted, which would not be listened to for a moment in a court of law. Nevertheless, as a matter of precaution, every means were adopted as if contagion was a reality. The following disinfectants were employed : — The first two or three days — Condy's fluid diluted, and chloride of lime. Then Calvert's disinfecting powder, introduced by Mr. Little, was exten- sively employed for five weeks. Afterwards, carbolic acid, largely diluted (1 to 40) mixed with sawdust, in quantities sufficient to wet the sawdust, and sprinkled about the passages, wards, and closets, etc., etc. j in fact, supplied the place of Calvert's powder heretofore employed. None of the excreta from patients was allowed to be emptied into the sewers — kistead, a portion of dilute carbolic acid fluid, about half-a-pint, was put into each chamber-pail and buried in the garden (the pails have water- tight lids). Bird's disinfecting powder, and also Lewis and Ash's powder, sent as presents, were used. Burnett's fluid was sprinkled in the cabs that brought the patients. The straw from the beds was burnt in each case of death, or when much soiled by excreta. The linen from the cholera wards was washed sepa- rately in the laundry of the Hospital with McDougall's disinfecting soap. Hot coffee, beef-tea, &c., were recommended to be taken by the nurses at early dawn, and every one was advised to avoid going on duty vrith an empty stomach, or in' a depressed condition; an extra allowance of wine and pay was made to the nurses. In a very few days the wards were in full working order, and for many days this Hospital was the only place where cholera patients could be taken. The real merits of the various modes of treatment adopted, can only be correctly weighed after a. careful estimate of the results of all the cases, and this will require a close exami- nation of the report of each case. I may just say, that whilst I am a disbeliever in any one specific re- medy, my impressions are in favour of calomel, administered in doses, vary- ing according to the urgency of the symptoms, from five to ten and twenty grains every quarter, half, one hour, two, four, etc., etc. In no case was severe salivation produced; and whenever the gums became tender, or a bilious stool passed, the patient recovered. It may be however, with calomel, as it is with bleeding ; where blood can be made to 442 APPENDIX. flow, in my experience, the case is not severe ; so'with calomel, if the patient live long' enough to admit the gums becoming touched, the case is not severe. But who shall say that those very cases would not have become severe and.fatal, if the treatment had not been put into effect. St External heat, frictions, and turpentine stupes, were much employed, apd often with good effect. I have reiterated in the wards, that with the aid of six powerful rubbers and calomel, many have been saved. Having in re- membrance the wonderful effects of venous injectipns, of which I had had previous experience, I readily recommended this to be tried; and Mr. Little undertook the duty. As he will furnish a special report on that subjedt, I shall only say, that my confidence in the means has been raised by my late experience. Courage, skill, and time are however all required j and it can be only with a large and efficient staff that such a means could be properly and successfully conducted on a large number. I am strongly impressed with the feeling, that by injection through the veins lies the true means of saying life during the paroxysm of real algide cholera ; for, in this stage, all medicines passed into the stomach Ke inert, as if in an inorganic bag, bping unabsorbed, but the material passed into the veins, be it a saline fluid, the serum of animal blood, or human blood, or simple warm water, restores life and consciousness. It may be only for a time, but a renewal of the stimulus produces again a restoration, and it becomes a question whether the poison will destroy life before the stimulus saves it. A natural feeling of doubt will arise in certain minds, whether death may not, in some oases, have been hastened by venous injec- tions ; but even this contingency is strongly overbalanced by the obvious and marvellous reviviiig effects produced by the means ; showing, that if it does not always save, it at least prolongs life. And this is not the least important part of our mission. It will not do on this occasion to launch on the " mare magnum " of the qtiestion of contagion or non-contagion. The more so, as it is quite as easy to declaim against one doctrine as to support another, seeing that logical proof of our facts is, if not impossible, at least difficult on both sides. I have, however, an array of facts, pro and con, and, so far as number is to be considered, a mode of proof, the noncontagionists will be victorious. In conclusion, it will not be amiss here to allude to the first of the three questions put forth by the Council of the Epidemiological Society. In- formation was asked, whether cholera patients could be admitted into the ordinary wards, or special wards set apart for the disease, of General Hospitals, " without undue risk of the extension of the malady to the other inmates of the Institution, and their ordinary attendants ? " My I'eply was, that cholera patients, so far as contagion was concerned, might be ad- mitted with perfect safety into the ordinary wards, and, of course, into special wards of a general Hospital. It is gratifying to find that I was perfectly justified in giving such reply. APPENDIX. 443 ABSTRACT OF NOTES * OP THE CHOLERA CASES UNDER THE CAEE OF DR. A. CLARK, WITH REMARKS. BY ME. J. M'CAETHY AND ME. DOVE. With a view to contrasting more fairly the mortality and recoveries at different periods of the epidemic, in the suhjoined Table, are stated the number of admissions on each of Dr. Clark's days : t the number of the deaths and of the recoveries : whether the death took place in collapse or in reaction ; and the treatment adopted in each case xmtil reaction was established. TABLE I. SHOWING THE ADMISSIONS, MOETAIITY, ETC, THROUGH THE EPIDEMIC?. Abbreviations Msed .'—A.M.— Astringent Mixture; L.P. — Lead Pill; CO. — Castor Oil; S.L. — Saline Lemonade; M.A.T.— Mist. Antimonii Tartarizati; R. — Patient brought in in Reaction; O.— No treatment; M.Q. & F.— Mist. Qninffi. 0. Ferro; CM. — A saturated Solution of Camplior. Date. :i 1 1 1 f Medicinal Treatment. 1 Treatment a July 15 1 1 1 A.M. „ 18 1 1 1 J» „ 19 4 3 3 )> 1 L.P. „ 21,22,23 19 15 7 8 )) 4 A.M. „ 25,36 24 13 9 4 11 AM, 1 E.., 1 10 9A.M.,1R. 1 „ 28,*29, 30 40 20 14 6 17 0., 1L.P., ICM., lA.M, 20 17 0., 1 A.M., 2R. Aug. 1, 2 17 9 5 4 8 0., 1 A.M. 8 6 0., 2 A.M. „ i, 6, 6 24 17 10 7 4 0., 12 CO., 1 R.O. 7 3 0., 4 CO. „ 8,9 13 3 1 2 Sal. Lem. 8 Sal. Lem. 2 „ 11,12,13 30 8 6 3 1 L.P., 3 0., 4 Sal. Lem. 8 4L.P.,3C0.,1S.L. 4 „ 15,16 6 1 1 Sal. Lem. 4 3 0., IS.L. 1 „ 18,19,20 9 2 1 1 1 0., 1 M.A.T. S! IR., 10.,1S.L. lA.M.,lM.Qu.&F. 4 „ 22,23 3 1 1 ICO. 2 „ 25,26,27 9 3 3 1 CO., 1 M.A.T., 1 M. Q. &F. 1 1 M.Qu. & F. 5 „ 29,30 2 76 2 19 I Total . . 192 97 57 40 * The notes of the cases were taken by Mr. GeorgeMaokenzie and Mr. M'Carthy from July 15th to August 9th, and by Mr. Dove and Mr. M'Carthy from that date to August 31st. t The regulation, with respect to adinission of extra medical cases into the London Hospital is, that all taken in after the visit of the physician of the day, are placed under the care of the physician of the next day. I All these have, since this report was drawn up, been discharged cured. 444 APPENDIX. Mistura Astringena. Deooot. Hsematoxyli, half aa .ounce J5tlier. Sulphur. 10 minims' Acid. Sulph. Arom. IS minims CamphorsB, 2 grains Pulv. Capsici. half a grain Every fourth hour. Mist, Antimon Tartar, Pulv. Antimon. Tart. 2 grains Magn. Sulph. half an ounce Aq. half a pint Half'an-ouiice every half-hour. Lead Pill, Plumbi, Acet,, 2 grains CamphorsB, a grain and a-half Ext. Opii, one-sixth grain Creasoti, one-sixth minim Dose : One pill every hour. The mortaKty in Table I., requires correction, as many eases were brought here in a moribund condition, as will be shown by Table II. TABLE II. SHOWINO THK TIME PKOM ADMISSION TO DBATH. In this Table the upper line shews the number of cases in which death occurred at the periods indicated in the middle one. In the lowest the letter m stands for minutes, h for hours, and d for days. Creasote Pill. Creasoti', 1 minim Farinse Tritici, q. e. One pill every hour. Mistura Quina c. Ferro, Quinae Sulph. 1 grain Tr. Ferri Mur. 15 minims ' Aq. 1 ounce. » Every two hours. Grey Powder, Hyd. 0. Greta, 2 grains Pulv. Ipecac, half a grain Pulv. Doveri, two and a-half grains Kight and morning. No. of Deaths. Interval between admis. and death. 4 15 m 1|2 ' 4 2 4 5| 2 1 1 1516 hlh ^i 1 19 h 13|14| 9 ll 2 3 d'd d g 4 d 3 5 d 9 6 d 2 7 d 3 8 d 1 1 11 16 d 2 h 3 h 4 h 6 h 7 h 8 h 1012 hlh 10 d 11 d From this it will be seen that four cases died within a few minutes of admission, and ten more within six hours ; most of these might almost be regarded as virtually dead when admitted. Again the influence of time is seen in the fact that] the number of deaths diminished as the number of days' duration in Hospital increased. There was, however, an increase in the number of deaths of those who had been six days in Hospital, about which period of high reaction there appears to have been great mortality. TABLE III. MEDIGINAl TREATMENT. Treatment. Numtier of Cases. Died. LlTing. Mistura Astringena - Mistura Rubra (.Water and Sugar) Castor Oil - - - Saline Lemonade ... Mist. Antimon. Tart. Mist. QuinsB o. Ferro Lead Pill 48 56 21 20 2 3 9 31 28 14 6 I 4 17 28 7 14 a 6 appendix:. 445 This account of the treatment refers merely to the stage of collapse ; when reaction began the treatment was modified according to individual peculiarities. The unenviable position which the Mistura Astringens occupies in the list, may be in part, if not altogether, due to the fact that all the cases at the commencement of the epidemic, when the type of the disease was unquestionably worse, were placed on that treatment {vide Table I.). This explanation seems the more probable, as at the Wapping Temporary Cholera Hospital this mixture was more successful. In very bad cases the mistura astringens and castor-oil, after a few doses, produced such loathing, that the use of them had to be discontinued. In the list of recoveries are included several mild cases of true cholera • and two patients, who were removed by their friends, of whom one was ascertained to have afterwards died ; but at least between fifty and sixty were extremely bad cases, in-which, either in collapse, or in reaction, the prognosis had been very unfavourable. Baths, at a temperature of from 98° to 104° Fahr., were given, with most marked efieet, in about 130 of the worst cases. In almost all the cases there was commonly, for a few seconds, difliculty of respiration ; and in many, for about the same period, an unpleasant sensation of heat. In chil- dren, fright also contributed in causing some difficulty; but generally, in less than a minute, the good effects of the bath became manifest. Cramps ceased, ansiety of mind vanished, pulse returned, or, if originally to be felt, increased in volume and frequency. Many who had before moaned or ghouted incessantly vsdth pain, began to converse upon indiflferent subjects, or in many cases sank into a tranquil slumber. Often recovery appeared to be the direct consequence of the bath, the improvement being permanent ; but in many more, removal from the bath became the signal for the return, more or less rapidly, of the former symptoms. The testimony of all who had a fair opportunfty of judging, is unanimous as to the relief afibrded by the warm baths, the most convincing being that of the patients, who, in some cases, craved incessantly for them, and remained in, at their own request, for nearly an hour at a time. In a very few cases no relief was derived, but those were cases of great collapse, where their employment had been dictated by despair, rather than by any hope of benefit. Incessant vomiting was one of the most distressing symptoms, continuing sometimes long after reaction had set in. All sorts of remedies were tried, among others, nutrient enemata, so as not to provoke any action of the stomach, but not with much success. In three cases the creasote pill proved of use; in one bismuth and hydrocyanic -acid; sucking ice in many; and one cMld, aged 12, who vomited all fluids as soon as she had swallowed them, begged for bread-and-butter, which she ate with eagerness and retained. The Mistura ftuinse c. Ferro was not used until'a late period of the epi- demic, but many of the cases, still in the Hospital, were treated with it, and 446 APPENDIX. are doing remarkably well. Although it shares the fate of all other medi- cines, in being apparently all vomited up as soon as swallowed, yet some is retaiaed and absorbed, as is proved by iron being fouad in the urine, and by the colour of the discharge from the bowels. The Mist. Ant. Tart, was tried in two cases, one an old woman, aged 70, the other, a man, aged 66, but in fuU vigour of body. He was brought in in extreme collapse ; his temperature, on admission, having been the lowest observed in any of Dr. Clark's cases, 32'9o C, 91 ■22° Pahr. In neither case was there any sign of reaction before death, which took place in both instances on the second day after admission. The saline lemonade was a considerable improvement on the Mistura Subra treatment, and was much liked by the patients. In the reaction stage, when the tongue had become dry and hard. Dr. Clark's grey powder was invariably used, with, in numerous cases, an almost magical effect in restoring the natural condition. In cases of relapse, when the tongue assumed the same appearance, the powder had similar success. The free use of the Chlorate of Potash drink, and of the Saline Lemonade, and attention to the state of the bowels and to diet, was the general treat- ment pursued during this stage. When patients passed into the sleepy state, with flushed face, congested conjunctivBB, and hebetude of mind, sinapisms or blisters to the nape of the neck were often very efficacious — the improvement being generally coinci- dent with return of the excretion of urine. Where severe headache was a prominent symptom from the first, cold irrigation was tried with some success. TABLE IV. AGE, SEX, STATE AT DEATH — (iN COLLAPSE OR HE ACTION). ■6 jj , Age. < DBA.D. Male. t -1 Female. S 1 IiIYIHG. Male. Female. 1-10 45 19 11 2 9 8 S 26 11 16 10-20 35 16 8 4 4 8 7 1 19 14 6 20-30 39 SI 11 6 6 10 4 6 18 12 6 30-40 24 18 11 6 6 7 4 3 6 3 3 40-50 17 12 5 2 3 7 6 1 6 4 1 60-60 6 4 3 2 1 1 1 1 1 60-70 6 6 2 2 3 2 1 1 1 70-80 1 1 1 1 80-90, 1 1 1 1 173 97 62 85 27 45 33 12 76 45 31 In this Table " coUapse " and " reaction " are used relatively, there being no well-defined limit to mark off the two states which, in many cases, merge insensibly the one into the other. Strong reaction was characterized by sharply-defined patches of dusky APPENDIX. 447 redness in the cheeks ; highly congested conjunctivse j a heavy sleepy aspect, with the vacant look of fever; eyes half-closed, with pupils turned upwards and inwards ; dry, hard tongue, denuded of epitheKum ; sordes about the lips and teeth ; very laboured respiration ; and, especially in young lads and children, a preference for the prone position. Hebetude of mind, from which the patient could not be roused, and, in some cases, violent delirium accompanied this state, which usually proved fatal. The local variations of temperature in this state were very remarkable, and would well repay the trouble of registering them, if thermometers could be contrived for the purpose. In one case, a child of 3 years, a space bounded by the superciUum, zygoma, inferior maxiUa from the condyle to the symphysis, and the median line, conveyed to the touch the sensation of burning pungent heat, above and below those limits the surface being, apparently, below normal temperature. This variation was symmetrical on both sides. Such local elevations of temperature were observed in many cases. Dr. Clark suggests that they may have been caused by some cor- responding affection of the vaso-motor nerve. During the epidemic, the temperature in axilla, the rate of pulse, and the rate of respiration were registerefd, and with especial care "for the last five weeks, when the diminished number of patients afforded the opportunity of more accurate and frequent observations. Some curious facts have been observed. There is no evidence to support the theory, that death in cholera is the result of the body having been cooled below a certain temperature. On the contrary, in one case of rapid death, within eleven hours from the first attack, notwithstanding that there was extreme collapse, the ther- mometer in axilla registered 36" C. = 96*8° Fahr. Again the thermometer proved that the temperature cannot be estimated with any degree of certainty by touch. In the case above referred to, the surface of the body felt very cold. And in another case, a young lad, the pimgent sensation, on touching his hand, suggested the idea that he was very feverish, while at the same time the Thermoineter in axilla registered 35° C. = 95" Fahr. The extremes of temperature noted were 32-9" C. = 91"-2 Fahr., and 40-9" C. = 105"6. Fahr. During the state known by us as " reaction " the temperature was often below normal throughout, sometimes even lower than it had been at an earlier period of the attack. In some few cases it was taken per vaginam or per rectum. In one case there was a difference of 3° C. between the temperature in axilla and per va.ginam, registered by two observers at two different periods. As the case progressed, the internal temperature fell, and the external rose until they both almost coincided in convalescence. Similar results, varying only in degree, were met with in all cases where the internal temperature was registered. During favourable reaction there was frequently observed a remarkable 448 APPENDIX. slowness of pulse, 54 per minute being a very general rate. In one lad, 9 years old, who was apparently doing very well, the pulse most carefully reckoned was 45 per minute. In bad cases, of reaction it often became intermittent ; in one case, the seventh beat being invariably wanting. Nothing was found post-mortem to account for this. As to respiration, nothing remarkable was recorded; the extremes observed were 12 and 44. OBSERVATIONS ON COMPLICATIONS, ETC., ETC. Roseolar rash. — In four cases during reaction a pecuHar roseolar rash was observed. In the first, a lad of 17, it appeared on the hands after he had been allowed to sit up, and was considered convalescent. It consisted of smaU circular patches slightly elevated, disappearing on pressure, and again returning when the pressure was removed. It vanished from his hands in a few hours, then came out on his thighs and legs, and finally disappeared altogether within thirty-six hours from the first notice of it. In the second case, that of a German sugar-baker, on the seventh day of his illness the temperature of the hands was observed by Mr. Dove to be 1''4. Fahr. higher than in axilla. On the next day a rash, -similar in appearance to the above-described, came out on the hands and arms. Both these cases recovered. The next two were children, who suffered from extremely violent reaction. In one, a boy, the rash appeared on the eighth day after his admission, and the tenth of his illness ; and in the other, a girl, on the tenth day of her illness. In both cases the rash was preceded by a sudden increase of temperature, which fell again to the normal standard as the rash disappeared. In both it came out on the hands and arms first, then on the body and legs. In the girl it became confluent. In both it disappeared on the third day. After it had disappeared, considerable oedema of the feet ensued in the case of the boy. Spasms of the hands and feet. — The two cases, just alluded to, were ex- tremely interesting, as they both became subject, after the rash disappeared to a peculiar continuous spasm of the hands and feet. On the twelfth day, in the boy, and on the thirteenth day, in the girl, it was observed that the thumbs and fingers, which were themselves straight and rigid were at the metacarpo-phalangeal articulations flexed upon the palms, and the hands upon the fore-arms. There was an analogous afiection of the feet. The spasms were similar in both cases, and no other part of the muscular system was affected. The boy seemed altogether ignorant of it : the girl complained of coldness in the hands, and of pain along the sides of the fingers ; but as she never made any remark about her feet, it is not improbable that sight had some infiuence upon her sensations. In the boy the spasm continued until death ; in the girl, who recovered, it disappeared on the sixth day from the hands, and on the next day from the feet. MR. m'CARTHY's report. 449 Glandular affections. — In one of the first cases admitted, -which proved fatal, the suh-lingual gland of the left side hecame painful, and enlarged to the size of a pigeon's egg on the third day, continuing so until death. In another fatal case, on the second day, the tonsils hecame enlarged and very painful, so as to materially interfere -with deglutition. Both these cases had had small doses of mercury after reaction had commenced, hut not sufficient to afiect the salivary glands. Another fatal- case sufiered much from painful enlargement of the parotid and suh-maxillary glands of the left side. In another, the hoy referred to in the description of the spasm of the hands, both parotids became inflamed and suppurated. In another the glandulae conoatenatse became hard and painful. This case recovered. In the last three instances no mercury was given. All experienced great relief from warm fomentations. Pregnancy. — Several cases were admitted with this complication. All in the early months of pregnancy aborted, and of those about full time three died undelivered, and one was delivered jiormally and recovered. Csesarian section was performed immediately after death on the three cases at full time ; but the children were all dead, as was also the one born at full time. No case, where abortion had taken place, recovered. Secretion of milk. — In four cases attacked with cholera while suckling, the secretion of milk continued undiminished, and proved very trouble- some. No history of the baby becoming attacked was obtained in any case. Of course, mother and child were separated on the admission of the former into Hospital. Noises in the head. — This was often one of the earliest symptoms. In one case it was actually the very first. A nurse, residing wholly in Hos- pital, who, for a fortnight, had been employed by day in the cholera wards, rose one morning in good health, and performed her customary duties until near mid-day, when she got " singing in her ears," soon followed by nausea. She lay down for an hour expecting that it would pass off. Vomiting then ensued, with purging, and soon after cramps. She rapidly passed into a state of extreme collapse, from which she never rallied, and so died within twenty- four hours. This woman had been particularly noted among her fellows for the nicety of her habits with respect to food, and for her personal cleanliness. Another case, a young lad, complained much of the noise in his head, adding, moreover, that the sound of his own voice pained him. This symptom was observed in many more instances, and was most severe in a Dutch Jew, who was nearly driven mad by it. He could not rest, and shifted his head from the top to the bottom of his bed every few minutes for about two days, apparently trying thus to escape from the ever-pursuing noise. Affections of the eye. — In a large proportion of cases, when collapse or & G 450 APPENDIX. reaction had been at all severe or prolonged, the following affection of the eye was observed. The vessels of the conjunctiva covering- the sclerotic became congested, and the cornea dull. By no means the whole of the front • of the eye was thus affected, only a.patch elliptical in shape-, the angles being directed towards the oanthi. It usually included the lower third, at least, of the cornea. As the disease went on, there was a free se- cretion of mucopurulent matter froiji the conjunctival membrane, and the cornea became quite opaque, and in several cases ulcerated. The pal- pebral conjunctivBB were but slightly affected, and in no case was there any considerable swelling of the lids. This affection seems to have been caused by the patients lying with their eyes open in sleep, or during the stupor so frequent in reaction. The lower lid appeared to be drawn in by the shrinking of the tissues of the orbit, so that it required an effort to make the lids meet. Hence when volition was withdrawn, the eyes re- mained open, and the globe being turned upwards, the lower portion of the cornea came to be the part affected by exposure. Of course, the weakened condition of the patient increased the misehiefj consequent on the want of protection. The only treatment required was a vreak alum lotion, and, in some severe cases, closure of the lids secured by the application of a pad of oiled cotton- wool. In only one case of recovery, that of a female child, aged two years, did this complication prove at aU serious. Here both cornese sloughed rapidly, at a late period of the ^disease, and total blindness has resulted. Coryza. — The complication occurred frequently during reaction, especially in children. Menstruation. — This continued unchecked in cases where it had com- menced before the attack of cholera. In one case it came on during cholera, at the regular period, before reaction was established. In all females there was a muco-purulent discharge from the vulva, which in adults was stained with blood, even though it was not the menstrual period. In one case the quantity of blood in it was considerable. jjrine. — The following is a brief outline of the results of the examina- tion of the urine of reaction and of recovery : — Density. — The extremes were from 1005 sp. gr. to 1017, the average of all the observations being 1006. Even in cases where the suppression had continued for several days, and where afterwards the urine had to be drawn off, the density was remarkably low. We may here incidentally observe that frequently the secretion returned before the patient had regained the power of voiding it. Acidify. — The urine was almost invariably acid. The acidity was greatest in that first passed in reaction. To this there were only two exceptions, of which one was urine contaminated by profuse discharge from the vagina. Albumen. — In almost half the cases examined, albumen was present in varying quantities. Except in cases where there was reason to suspect old renal disease, this soon disappeared. MR. M'CAETHY's report. 451 With nitric acid the urine, in many cases, gave a brilliant ruby colour, resembling that often seen under the same reaction in nervous disease. Deposits. — Organic and crystalline. In about one-third of the cases uric acid crystals and urates were found in considerable quantities. No oxalates were observed. Organized deposits. — There was found, in most cases, epithelium from kidney, ureter, and bladder ; and in the female, from the vagina, as if a - general desquamation set in with reaction. Besides, there were found cells in various stages of disintegration, occurritig separately, and often iilled with granules like the " granule cell." There were also casts which were of the following kinds, enumerated in their order of frequency : — Granular, hyaline, and rarely true epithelial. There was, in all the specimens of urine, a remarkable proneness to de- composition at an early period, and to become full of the minutest forms of animal and vegetable life. Discharges from the bowels. — The appearance of cholera stools, as they came from the patient, can be most fitly described as like " rice-water." This, on standing, separated into supernatant fluid, and flaky sediment. The former was like milky water, with a slight tinge of grey, semi- transparent, and, in some cases, contained albumen. The sediment consisted of flakes of coagulated mucus, having embedded in it numerous molecules and granules — ^many of them in active motion — and cells of various sizes, and in various stages of development or decay. Some resembled the colourless corpuscles of the blood ; others were twice as large, and exhibited nuclei without the help of reagents ; and some, filled with refractive granules, were undistinguishable from the well-known granule cell. In addition to these were usually found well-defined cylindrical masses of granular matter, probably casts of follicles. In these nothing like a limiting membrane could be distinguished. * What is especially worthy of remark is, the almost uniform absence from the discharges during life "of the normal epithelium of the bowel. In several cases, as the disease progressed, the stools became tinged with blood, and this more and more deeply, until, in some instances, the discharge appeared to consist of pure blood. Such cases were always fatal. Vomit, — This usually contained a good deal of buccal and pharyngeal epithelium, granular matter, arid various vegetable cells from food. It was intended to have added to this abstract an account of the number of cholera patients who had had premonitory diarrhoea, but this proved impossible. The question was asked with respect to each patient admitted, and the answer recorded ; but later experience proved such answers to have been unreliable, as it was found that most opposite ideas were, in some cases, intended by the words used. One man complained of excessive purging, who was found, on inquiry, to mean that he had had no motion for two days. Again, numbers of labourers altogether disregard slight diarrhcBa, & G 2 452 APPENDIX. and seem to consider it as the acme of good health. Many cases, undoubt- edly, were in good health until the very first onset of the attack of cholera. Two cases died in Hospital wha had not been purged at all. Another had a fseculent motion, caused by castor-oil three hours before death, which took place eleven hours after the first attack. At the beginning of the epidemic, special inquiry was made on each ad- mission as to the water-supply, and the state of the drains, closet, and dust- bin of the house from which the patient had been brought. In two cases only was the answer unfavourable. In one of these the drains and closet were described as being in bad repair. In the other the water-butt was placed beneath the water-closet, and the contents of the former were con- tamiratei by leakage from the latter. Such statements, however, are not very trustworthy. Of all Dr. Clark's patients, twenty-seven had near relatives residing in the same house, either ill with, or dead from, cholera. From one family, five were admitted at the same time ; from two other families, three each ; from two others, two each ; and in two cases mother and infant were admitted at the same time. These infants had pre'^'ipusly been weaned. One individual only from each of these families is counted in the above list of twenty-seven, In these cases the mortality was not great. Of the five, four recovered, and one died. Of the next three families, all recovered. Of the next, one died J of the next, both died ; and of the next, the infant died and the mother recovered. The subject of contagion will be referred to in a separate paper. The arrangement of the cholera wards was such, that even at the time of the greatest demand upon the Hospital space. Dr. Clark's patients had each above 1000 cubic feet of air. Besides this, there were two lobbies communicating with the wards, which ought fairly to be included in the calculation, and would give nearly 12000 cubic feet more among the patients. A list has been kept from the very commencement of the epidemic of all Dr. Clark's cholera patients, and most scrupulous care- taken to exclude therefrom all cases of diarrhoea, choleraic or simple. Hence, all observations recorded in this abstract, were taken from genuine undoubted cases of cholera. This may perhaps, in some measure, account for the high rate of mortality, as compared with that recorded iu previous outbreaks of the disease. MR. MACKENZIE S REPORT. 453 NOTES ON VARIOUS SUBJECTS CONNECTED WITH CHOLERA, AS OBSERVED IN THE LONDON HOSPITAL. BY F. M. MACKENZIE, ASSISTANT RESIDENT MEDICAL OFFICER. I. Thermometrical Observations. On this subject I may venture to make the following general statements : — 1st. — The temperature of the body wlien taken by the thermometer in the axilla, rectum or vagina, will shew to some extent the degree of severity of the attack. 2nd. — The temperature cannot be estimated by the hand at all correctly ; this applies to the stage of reaction especially, and a great deal of care and time is necessary to get anything like careful and reliable observations. 3rd. — The temperature in the axilla will rise 2° Pahr. after a severe attack of cramps ; this may be caused by the muscular exertion and conseiiuent acceleration of the respiration at the same time. 4th. — The number of respirations, in a, minute, and the temperature taken in rectum or vagina seem to have some relation to each other, the more hurried the respiration, the higher the internal temperature will be. 5th. — Cases in which the respirations are more than forty in a minute, and the internal temperature is higher than 101° Fahr., rarely recover. 6th. — The temperature of the body in roseola cholerica is raised in pro- portion to the severity of the eruption. The following Table will give some idea of the temperature in a weU- marked case of cholera : — First Stage. Pulse 110, weak. Pulseless. Pulseless. Pulse 90, bounding and compressible. Respirations 20. Second Stage Respirations 38, laboured. Third StagL Respirations 44, laboured. Fourth Respirations 16, laboured. Temp. Temp. Temp. Temp. I in axilla in rectum ^ or vagina in axilla in rectum i or vagina in axilla in rectum ^ or vagina 95° '98° [94° [100° '97° I 103° in axilla ! 96' in rectum or vagina 97° 454 APPENDIX. During the First Stage, that is, at the commencement of the attack, the temperature externally begins to decrease, lividity shows itself, and the internal temperature is about the normal degree, the pulse is generally weak, and cramps, vomiting, and purging are marked symptoms. In the Second Stage, lividity is increased, the cramps are less, vomiting and purging continue of a rice water kind, there is no pulse at the wrist, respirations are quick and laboured ; the external temperature is rather lower than in the first stage, while the internal is higher than normal by about 2°. Collapse is now extreme j a large number of patients, especially those over fifty years, die in this stage. The Third Stage is, I think, by far the most fatal. The lividity is not of the same tint in all ; in florid persons it becomes a dusky-red colour, and in pale persons, it is a dusky-grey or stone-colour. The patient is comatose, while in the former stage he was wakeful and restless, a profuse perspiration covers the surface of the body, but is best seen on the face ; the skin is hot and clammy; the eye-lids are semi-closed, and the conjunctiva thus exposed, is injected ; the axis of the eye-baU looks upwards, the pupil is more or less con- tracted, unless the patient is roused ; the pulse is not countable, or only just perceptible ; the respirations are very quick and laboured ; the external temperatifre rises to 97°, and the internal is 101°, or more. This stage does not last long ; if well-marked the patient generally dies or passes into the fourth stage ; the vomiting and purging are less, the purging is involuntary , if any. Frequently during this stage the motions are a pink blood colour, and when this symptom is seen the patient rarely if ever recovers. The Fourth Stage is that of well-marked reaction, all the symptoms change, the patient assumes a too natural colour, with dry lips of a bright pink tint. There is vomiting and purging of an emerald- green colour, the stools gradually assuming a typhoid character ; the skin is hot, harsh, and dry, with a glazed surface ; the face flushed ; respirations are slower, but still laboured, and the pulse is full, soft, and compressible. The external temperature is not so high as might be expected, it is, as^a rule, below the normal 1° or 2°, this is so when the patient has a bright flush ; the internal temperature is also lower than natural, about 1°. Patients in this stage frequently pass into delirium and die. Swellings of the glands in the neck may appear. Those who become convalescent, look very pale and ansemic. The temperature, after death, depends on the length and severity of the attack. Patients who die during the second stage, and have a low external temperature during life, have a sort of reaction while dying, and after death the external and internal temperature rises to what it might have been, had they lived a few hours longer. The highest temperatiire, I have taken after death, was in a little boy ; externally, it rose to 101-8 ; internally, to 106'2 ; this boy died in imperfect reaction. It is rare to find it as high as this ; usually it will rise to 99 in axilla, and 102, in rectum. I cannot help thinking, that it depends on the duration of the illness alone, and not on ME. MACKENZIE S REPORT. 455 alteration of tissue or decomposition having commenced. If a patient has got fairly into the third, or critical stage, and then dies after living in it for a few hours, the temperature vcill not be found to rise, but, on the con- trary, to fall a little after death. Spasmodic movements, after death, also depend on the stage at -which death takes place. They occur in severe cases which die in the second stage ; the limb that is cramped, during life, is found to be the one affected with spasm after death. They rarely, if ever, last more than thirty minutes. The greatest extent of motion that I have seen, has been the elevation of the elbow to about three inches above the surface of the chest, while the arm had been lying across it. I have not seen them in children at all. TABLE I. THBRMOMBTBIOAL OBSERVATIONS TAKEN IN THE AXILLA IN CASES OP EXTEEMB COLLAPSE. No. 1 Age. Pulse. il Temp.in AxiUa. Subsequent Eeaction. llBBUlt. 1 M 25 None 36 94-2 Marked Death. 2 F 63 44 94-4 Imperfect — 3 F 32 32 94-4 Marked — 4 F 40 40 95 None .^_ 5 F 24 40 93-6 Imperfect — 6 M 5 ^ 36 95'2 None 7 F 28 30 92 None — 8 M 16 32 94-4 None 9 M 11 30 93 None — 10 M 9 32 94-6 None — 11 F 26 — 36 92 Imperfect — 12 F 20 — 30 93 Imperfect - — 13 F 30 40 96-4 None — 14 M 24 32 93-8 None — 15 F 25 42 94-2 None — 16 F 35 — 40 90-2 Imperfect ■ — 17 M 32 32 94-6 None — 18 F 26 32 96-2 None — , 19 F 50 40 94 Imperfect — 20 M 38 32 93 None ^ 21 M 58 50 94-4 None — 22 F 20 — . 32 94 Imperfect — 23 M .17 40 95-4 Imperfect — 24 F 30 — 42 94-2 None — 25 M 30 30 93 None — 26 M 35 — 40 94-2 None — 27 F 32 30 93 None — 28 F 20 — 60' 97-3 None — 29 M 40 40 94 None — 30 F 36 40 91-6 None — 31 F 50 — 30 93 Imperfect — 32 M 40 — 36 94 Imperfect ' — 33 F 25 — 34 91-8 None — 34 F 39 40 92-2 None — 35 M 2 36 94 Imperfect — 36 F 60 44 93' 2 None — 37 M 69 — 40 94-2 None — 38 M 30 38 93-4 Imperfect —^ 39 M 68 48 93-6 None — 40 F 40 — 30 94-2 Imperfect — 456 APPENDIX. TABLE II. THBRMOMETRIOAL OBSERVATIONS IN THE AXILLA AND BEOTUM, OR VAQINA, IN CASES OE EXTREME COLLAPSE. Bespi- Tation. Temperature in * 1 No. Sex. Age. Pulse. Rectum or Reaction. Result. Asllla. Vagina. 1 F 35 None 40 90-2 102-4 Imperfect Death. 2 F 26 None 38 93-4 101 Imperfect Death. 3 F 20 ■Weak 30 95-6 99 Fair Recovery. 4 M 32 None 32 94-6 100-6 None Death. 6 M 21 120 (weak) 32 95-4 100 Fair Recovery. 6 F 13 Very weak 33 95-6 99-2 Good Recovery. 7 F 26 None 30 95-4 101-8 None Death. 8 F 85 Weak 28 92-2 99-2 Fair Recovery. 9 F 43 None 29 95-4 99-2 Fair Recovery. 10 M 24 Weak 30 94-2 100 Fair Recovery. 11 M 17 None 48 95-4 101-4 None Death. 12 M 35 — 40 94 101 None — 13 F 32 30 93 102-8 None 14 F 24 — 60 97-2 102-4 None — 15 M 60 — 30 95 99 Imperfect — ' 16 F 61 — 36 95-2 99-6 None — 17 F 40 — 30 94-2 100 Imperfect — 18 F 60 — 44 93-2 100-4 None — 19 M 8 — 32 95 100-6 Imperfect — 20 M 40 — 48 97-2 104-4 Imperfect — 21 M 6 120 (weak) None 36 96 100-4 Fair Recovery. 22 M 51 38 91-4 100-6 None Death, 23 M 12 None 48 94-6 100-2 None Death. 24 M 30 None 42 96-4 99-8 Imperfect Death. 25 F 5 130 (weak) 28 96 100 Fair Recovery. 26 M 8 None 32 95 100-4 Imperfect Death. 27 F 41 52 97-2 101-8 Imperfect — 28 M 30 40 94-6 100 Imperfect — 29 M 68 48 93-6 100-8 None — 30 M 42 — 42 95 101-6 Imperfect — 31 M 14 — 52 96-4 102-4 Imperfect — 32 F 49 — 60 98 101-8 Imperfect • Fair — 33 F 33 108 (weak) 112 24 94-2 100 Recovery. 34 M 13 30 95-2 101 Fair Recovery. 35 F 12 132 28 96 99-2 Fair Recovery. 86 F 40 None 36 94 100-2 Imperfect Death. 37 M 19 115 28 96-4 99 Fair Recovery. 38 F 5 98 26 96 99 Fair Recovery. 39 M 29 132 (weak) 38 95-2 101 Imperfect Death. 40 F 48 40 94 101-6 Imperfect Death. With reference to the Tables, I may state that the first dates from the commencement of the epidemic, till about the middle of it. It is in- tended to show the greatest decrease of the external temperature, and the increase of the respirations, during that period, in severe cases. It -w^as thought at that time that a certain decrease of the external temperature ■would prognosticate a fatal result. The cases in Table 11. -were taken during the collapse, -vdth a low external temperature, an elevated internal temperature, quick respirations, and with little or no pulse. In both Tables, a great many who died, and are marked ME. MACKENZIE S REPOET. 457 with, no reaction,"had an" elevation of temperature externally, as weU as internally, whUe dying, and after death. II. Changes in the state of the skin. Eruptions, etc. Some interesting and important changes take place in the skin and mucous membranes during reaction. The skin, after losing its lividity in col- lapse, becomes, at first, natural in colour, then more red ; the surface is dry and has a glazed appearance, the wjhole body is of a brick- dust colour, and the face is flushed. The skin is also, at the end of reaction, liable to eruptions. I have seen, during the epidemic, nine cases of roseola ; only twice has urticaria been noticed, and herpes twice. Roseola cholerica appears to occur at all ages, but rarely in old persons ; it is generally best marked in children. The rash is usually noticed in the morning by the patient on the wrists and arms; it then takes the following order : — wrists, fronts and backs of arms, hands, (in the palms and backs in children, face, eyelids, chest, buttocks, back, abdomen , thighs, legs, and feet. It is found to make its appearance between the seventh and tenth day after the first symptoms of cholera ; it lasts three days generally, but it may exceed this. . It may be either in large irregular patches, or discrete. It is generally well marked on face, arms, buttocks,, and -thighs, but less so on the back and chest ; in the latter regions it is dotted here and there,' and less bright in tint; it has an elevated base, and when it first appears in young children, often resembles urticaria. In one case this was especially noticed that the patches were like those that might have been produced by the stinging- nettle ; a white halo surrounded each, and in the centra, of the then pink patch, was a white spot ; the child rubbed it a good deal, and was very restless. After twelve hours had elapsed, the patches were less elevated, of a bright scarlet colour, no white spot in the centre, but a white halo still occupied the spaces which were not covered by the rash ; it had altered to a pure case of roseola. The rash itched a good deal, but on no patients were there any marks of scratching seen after the rash had disappeared. It is generally accompanied by feverish symptoms, thirst, hot skin, quick pulse ; plenty of urine, of low specific gravity, without albumen, and of acid reaction. The external and internal temperature are always raised whilst the rash is out. In a girl, in whom the rash was profuse, the external temperature was ]01°-6, and the internal was 102°-4. As the rash fades, the skin on prominent parts of the body, begins to desquamate ; in this [respect it is very similar to the epitheKal desquama- tion of scarlatina. This eruption frequently came out during delirium, and was attended by swelling of the glands of the neck. The delirium was generally milder as the rash began to fade, and patients expressed themselves as being much better at this period, in every 458 APPENDIX. case. In no case had opium been given internally. Three had the tur- pentine mixture, two the calomel treatment, one castor-oil, and three had no internal remedies. Urticaria makes its appearance at about the same period that roseola does. It is not so profuse, but in larger and solitary patches. It itches considerably, and fades, but may re-appear. Roseola also ap- parently faded for some hours in the day, and burst out strongly towards the latter part of the evening. Urticaria did not last more than two days, and only appeared occasionally during that time. Herpes was noticed on the face twice in cholera patients, and once severely in a case of severe diarrhoea. In one cholera patient it appeared on the tenth day ; the upper lip was a little svf oUen the day previous. The patch of vesicles was three-quarters of an inch distant from the mucous membrane of the lip, above the left angle of the mouth. The patient re- covered ; there was no history of a rigor having been observed. A man about 45 years of age, who had " acne rosacea'' of the nose, died with gangrene of that organ. m. Affections of the mucous membrane. The skin and mucous membranes are inclined to suppurate or inflame (especially where there are abrasions or sores), in the stage of reaction. The mucous membrane of the eye, i.e., that part which is exposed by ina- bility of the patient to close the lids, becomes, at an early stage, in reaction, injected, and a secretion of mucus is found on the surface of the cornea, and sclerotic, or in the inner angle of the eye. This secretion often is a trouble to children, in whom it is excessive. The mucous membrane of the mouth and lips often becomes sore, and the gums look spongy. There are small vesicles on the mucous membrane of the lips and tongue, about the size of a pea, or smaller. Patients also complain of sore-throat when swallowing. This apthous condition of the mouth was noticed in almost all the cases of roseola cholerica. A severe pain in the epigastric region is a very prominent symptom at the period of reaction. Bronchitis is not very uncommon ; it occurs towards the end of the re- action stage, and some patients die with it. It has been noticed also, by Dr. H. G. Sutton, in a certain number of post-mortem cases, that the patients have died with capillary bronchitis. On examining the lungs, the larger tubes are not found much affected, and on opening the bronchial tubes with a fine pair of scissors, it is noticed that there is little, but not much, pus ; but by making a section of a piece of lung, and squeezing it, a thick creamy pus, apparently airless, oozes out of the minute bronchial tubes. This is known to be one of the most fatal forms of bronchitis. In one case it was especially noticed that the patient was expectorating a matter like pus totally free from air-bubbles, and, on inquiry, the patient had no marked cough, and did not complain of shortness of breath. Air was heard^ to ME. MACKENZIE S EEPOET. 459 enter freely into his chest, and no crepitation, but the rapidity of the breathing was increased, being 32. It is also not uncommon to notice a muoo-purulent fluid in the larger tubes of patients who have died in re- action. The mucous membrane of the labia becomes also inflamed. This is noticed in girls ; the labia are red and swollen, and their mucous sur- face is covered with a pus-like discharge. In women, a pink discharge, similar to that of the menstrual period, has been found ; it lasted three days or more, and ceased without treatment. It has been noticed, in post-mortems on these cases, that the mucoug membrane of the uterus is con- gested as if in the process' of menstruation. IV. Ulceration of the cornea. Ulceration of the cornea is very rare. I have seen only three cases ; it occurs in the very young only. It was noticed in an infant three months old, and from that age to three years. At the very end of collapse, and commencement of reaction, the patient lies in a comatose state, with the eyelids semi-closed ; a quantity of mucus secreted on the conjunctiva, or collected at the inner angle of the eye. The eyelids may remain open for three or more days, without once cover- ing the eye ; the axis of the eye-ball looks upward, leaving the lower third of the cornea exposed to the air, dust, etc. Previous to the ulceration commencing for three or four days, there is, apparently, a layer of opaque lymph covering the exposed surface, more or less. On attempting, in one case, to remove it with the corner of a sponge, I failed, and found it quite adherent, especially over the cornea. On the next day the part of the cornea covered was commencing to ulcerate. The film had separated, leaving a shallow ulcer. The ulcer is, generally crescentic in shape ; the outer convex border being nearly at the margin of the lower edge of the cornea ; the upper ■ one, or concave edge, corresponding to the margin of the upper lid. The ulcer may perforate, and follow the same course that ulceration of the cornea does in small-pox, etc. In one case the right eye only was affected. It will be interesting to see if cataract foUows these cases, as it fre- quently does in those from small-pox. The infant of three months old died ; the other two children lived. The ulcer healed in a month's time after its first appearance. The pupil, in cholera, varies a good deal ; but it is certain that, in adults, during collapse, it is not widely dilated as in the cold stage of ague. During the comatose stage, at the end of the collapse, and commencement of reaction, the eye-balls are turned upwards, the eye-lids are semi-closed, the pupils are then contracted more or less, though not minutely. In this state they do not act ; but on rousing the patient the pupils return to their normal size, but are not sufficiently active. 460 APPENDIX. Atropine and calabar bean have tbe same effect on the pupils during col- lapse, that they would have in a normal condition. The fundus has been examined with the ophthalmoscope, by Dr. H. Jackson and myself, but nothing very important was seen. The retinal veins appeared much distended, and were of a deeper colour than normal, and the artery did not look unnaturally small. Nothing definite could be determined on, as to tension of the eye-balls. NOTES OF SIX CASES OF CHOLERA WHICH OCCURRED IN NURSES OR INMATES OF THE HOSPITAL. BY ME. BATHURST DOVE. It is thought best to give the cases, bearing on this subject of contagion, as fully as possible ; facts regarding such a difficult topic being more valuable than theories or conjectures. Out of somewhat under 130 persons engaged in attending the cholera patients and washing the sheeting, etc., from the cholera wards, seven were attacked by cholera ; of these five died. In addition, one patient, a child occupying a room adjoining one in which there were cholera cases, died of it. Three others had tolerably severe diarrhoea, and one had an attack of pain in the abdomen, with cramps in the legs, without diarrhoea. This calculation makes the deaths amount to 4-6 per cent, of those engaged in the wards, etc. During the five weeks ending August 11th, the period during which all these cases occurred, there were (counting the fatal cases in the London Hospital, many of which were brought from other districts), 510 deaths from cholera inWhiteohapel, the population being ■ in round numbers, 7600. Thus, deaths from cholera in Whitechapel were 6-7 in the thousand. Those amongst attendants on cholera patients in the Hospital (including one patient under nearly the same condition as to contagion), were forty-six in the thousand. It wDl be observed, however, in the reports, that many of the nurses resided out of the Hospital. The following are the notes of the cases above referred to : — Case I. — McC, set. 27, a widow, had attended as assistant-nurse on cholera cases from the 12th of July to the time of her seizure. She lodged at a house in Samuel Street, St. George's, East. On July ISth, she was attending on a fatal case of cholera in which there were foetid emanations from the body before death. Not feeling well, she took, of her own accord, a dose of salts and senna. This purged her severely. On the 19th she was admitted as a severe case of cholera. She became livid, had cramps in the limbs, excessive pui'ging, of the characteristic stools> MR. DOVE S REPORT. 461 and violent vomiting. She died on the 25tli July of pneumonia during reaction. The house she lived in appears a tolerably healthy one. No other case has arisen there, or in the immediately surrounding houses. In the same house two children have since had slight diarrhoea. Case II. — B., set. 28, only recently hired, lodged at 12, Newcastle Place, Mile-end-Boad. She was in the fourth month of pregnanoy^ — a fact which she had concealed when she was engaged as night-nurse. It is thought she had been in want for some time past. Oh the 27th of July, after having been about three nights on duty in the cholera wards, she had an attack of vomiting and purging ; but got better, and remained so up to the 29th. On that day the symptoms returned with the addition Of cramp in the limbs. She rapidly passed into a state of collapse, aborted on the night of the 1st of August, and died the next day. Case III. — P., set. 41, widow, only taken on, within a few days, as assist- ant night-nurse in the cholera wards. She stated that she had been a nurse of cholera patients in a Dublin Hospital during the epidemics of 1848 and 1854. She had lodged two days at 13, Lisbon Street, Cambridge- heath Road, a street in which there were afterwards many bad cases ; but as far as can be ascertained, this was the first which arose there. Her previous residence is unknown. She had been out of employ for some time, and is thought to have been living hard. She was on duty du7.'ing the night of the 27th of July, and left the Hospital about 9 a.m. of the 28th. At 11 A.M. she was seized with purging, followed by vomiting, and cramps, and at 7.30 P.M. was brought in livid, cold, vrith pinched features, no pulse, and whispering voice. She died next day in collapse, Case IV. — C, set. 40, laundry-woman, had been employed here nineteen days. She lived out of the Hospital, and was one of ten women employed in washiftg the sheets, etc., from the cholera wards. Before this she had got chance work at various laundries. She is said to have been very particular in washing her hands before eating, etc. In Dr. James Jackson's report will be found an account of the precautions taken for the disinfection of the linen. On Friday, the 27th of July, C. got an attack of diarrhoea, and left work for part of the day. On Saturday and Monday she was better, and did her work as usual. Tuesday morning, 31st of July, the diarrhoea re- turned, and in the afternoon she got cramps in the limbs. She was admitted into the ward at 6 p.m., with all the symptoms of cholera, and died next day in collapse. Case V.— H., aet. 40, came here from Rochester, and slept in the Hospital from the first. She had been an assistant-nurse in the cholera wards since the 23rd of July, and is known to have had no friends near enough for her to visit during her "hour out" each day, and she only went out for that 462 APPENDIX. time. She was taken at twelve at noon, on August 5th, with purging and vomiting, having before complained of singing in the ears. Cramps, lividity, and purging soon became extreme, and she died next day in collapse. The cases of diarrhoea require no further mention. It will be noticed that all these cases were rather sudden in their acces- sion, and very rapid in their course. The patients were all so ill when admitted, that few questions could, with propriety, be asked them, and, therefore, many interesting facts are unascertained. Case VI. — In the case referred to, in which cholera attacked a patient in the Hospital, the subject of it was a chUd, set. 2, who had been sent to the medical attic, because it had measles whilst in the surgical wards of the Hospital. The first cholera cases were placed in the next room. Within three days the child was attacked by cholera, and _died in a few hours in collapse. He had a convulsion before death. Case VII. — E. J., an assistant-nurse, volunteered for the cholera ward, on July 21st, She concealed the fact that she had had a slight diarrhoea for several days, but on July 25th, passed into well-marked cholera. She had slept in the Hospital, but had once during the time been out to visit a friend in a cholera district. After a severe attack she eventually recovered. These facts are abridged from Mr. F. Mackenzie's notes. The above cases suggest, amongst other things, that it would be well for the nurses employed in cholera wards to be seen and questioned, by a medi- cal man, as to their health every time they went on duty. And, should additional facts show that those attending cholera cases are more subject to the disease than others, it would be well that, as far as possible, they shotild live in some place where precautions could be taken to prevent the spread of the malady amongst the surrounding population, if any of them should take it. REPORT OF CASES TREATED BY THE INTRODUCION OF FLUIDS INTO THE VEINS. BY ME. LITTLE, Onlt patients with no apparent chance of recovery have been injected, eases of extremecoUapse, all of them pulseless at the wrist ; livid, with low external temperature, and having lost quantities of fluid, either by pnrgingor vomit- ing, generally by both. The fluids used were deflbrinated blood, serum, salines, and salines with alcohol. The blood used was sheep's, kept warm by placing the vessel containing it in hot water, deflbrinated by whipping, and strained. I used deflbrinated blood, at the request of Dr. H, Jackson, but only in two MR. LITTLE ON INJECTION TREATMENT. 463 extremely bad cases. It had no favourable influence even temporarily, and seemed to embarrass and hurry the respiration. The oases were such, that no conclusion, either way, can be drawn as to the use of blood. The serum used was also from sheep. The blood was left to separate, and the serum poured off after four or six hours. 1 injected it with the idea that it would be more permanent in its effect than the saline fluid, as it contains the salts and water, with nutritive material in addition. It was only used in two cases, from the difficulty in having it ready at the right moment. In the first case, the serum was mixed with saline fluid, as there was not enough of it. Seventy ounces were injected, with no effect : the patient was, however, moribund at the time. In the second case, forty ounces of pure serum were injected, with good effect, so much so, that I thought on the day after, the patient might recover ; his age, 64, was probably fatal to him. (See Table, Case 12.) The saline fluid used, consisted of, — Chloride of sodium, 60 grains. Chloride of potassium, 6 grains. Phosphate of soda, 3 grains. . Carbonate of soda, 20 grains. Distilled water, 20 ounces. In most of the cases, and in all the successful ones, two drachms of pure alcohol to the pint of water were added, the proportion used successfully by Dr. Little in 1849. It was injected at a temperature of 110°, or very nearly 60, as it cooled somewhat whilst passing through the apparatus. In the earlier cases the syringe, depicted, p. 137 of this volume, was used. Subse- quently, I attached an india-rubber tube, with a nozzle at one end, to a funnel, and allowed the fluid to flow in by gravity. The apparatus figured, has been employed in the last few cases ; with it the whole operation can be easily performed by one person, and in it the fluid can be kept at the right temperature. It consists simply of a vessel holding forty ounces, with a lamp underneath, a thermometer hanging within, and a tap near the bottom, from which proceeds, four feet of thick india-rubber tube, with a silver nozzle at the end. It was found that when this instru- ment was placed at the bedside, about on a level with the patient's head, and the nozzle inserted into a vein at the bend of the elbow, its contents flowed into the vein in about ten minutes.- With it the operator is free to take' , observations, and has only to watch the temperature of the fluid. I think the apparatus might conveniently be larger, so as to contain enough for each operation. In the more successful cases eighty ounces were introduced at a time, generally in between twenty minutes and half-an-hour. The bend of the elbow was the site selected ; there was generally little ■ difficulty in finding a vein, but sometimes none was visible through the skin. I foundit best to expose the vein, and pass a probe under it, before opening it. The fluid from the apparatus being now turned on washes away any 464 APPENDIX. blood issuing from the opening, wliioh tie operator can then dearly see, and c. Nozzle. D. Spii-it lamp. E. Fiistcmng to Led-post. F. Tlieruiometer. runs little risk of pushing the nozzle into the cellular tissue, or up the sheath of the vein. The immediate consequences of the operation were to restore the pulse and voice, improve the colour, relieve the epigastric suffering, and lessen the frequency and diihculty of respiration. The secondary consequences were a rise of temperature in the axilla, and generallj' a fit of shivering, profuse perspiration, and cessation of thirst, cramps, and vomiting. After a period varying from an hour to ten, in the more successful cases, the collapse returned, and the patient was reinjected, but before he became as bad as at first. The operation sometimes required to be again repeated. The patients had little or no reactionary fever, were at once in a state of convalescence, and were fed up with eggs and brandy, beef-tea and arrow-root. The symptoms taken as indications for injection and reinjection, the consequences and treatment are better seen from the detailed cases which follow : — MR. LITTLE ON INJECTION INTO VEINS 465 TABLE 01 c ASES TREATED BY THE INTRODUCTION OF PLTJIDS INTO THE VEINS. Ko. Age. Sex, a E Before Ii^ectlou. |l Pluid. After Injection. .a . 1 1 49 F 8 Tem. in asiUa 92-2 Tem. per rect. 1 ■ag MS 5 wl« g^aj o) S d -a- a ^ p. at. r. 1_ a i' ^1 o 'tf ■3 C3„ ■3=0 ii OT3 rQ «■« § 'icT'S . fl3 a> 00 (B 2 o ^ gg-g 1 "I 6ID« 5 a p-a S, ^ faD a § *^ Mi's! sir [it DE. WOODMAN S REPORT. 483 to S sJ 9 g N £'3 <0 H ^ S|-i rM to O) o CD o fr) i± >qa o : §'"■2 - ^ . S'Si' S' "S S3 JS'ES 'ffB " 3 am II g^. o P ® aj 3 a -s £? a f •a r a t H rj O ® :i3 0= Qi S m m §111 N-J 03 Ti •& .'ff ^11 -a a 6D ..9 o g ^-g ,£3 o ,^ d ^ SIS -5 g jj 1 1 2 484 APPENDIX. d _; d « • c3.a §.9 ri PI P c; o 'is till a" -el! 3. 3-Pil w-S a S «> g ffl S O t» ^^ '"J I -*5 fri ftf (h to ! ^. .^"K m £ S i h t>^ C 03 HI p cS 0? J3 OS- &>•§ o H O H fi 05 CO < o O !z; o E^ '"is 5 "1 H O g. H CO O P-i 60 -I FQcS -^ -11 tH ^ g ra £* (D H ft ™ o CO eg 03 ft to •Si "J 9 2 2 . 6- a "3 ga-g. s-s •- ^^-! D3 h -42 'o rf o 3 rt a g S t*" o d ■P o a p t 1^ .g ■s "g*. Is ^TS I .2'C ^.g.l his I O ^3 .o a. - ■ qaOij S .. S-S fa F* a>a.2-sB . ■s a So' DR. LETHEBy's report. 485 REVIEW OF FACTS AS REGARDS THE SPREAD OP THE PRESENT EPIDEMIC OF CHOLERA. BY DR. lETHBBT. The history of the present epidemic of cholera, as far as it is yet known, is, in many respects, remarkable; the rise and progress of the disease, as well as its habits and duration having been very different from what was observed of it at either of its former visitations ; for, excepting the third great European outbreak of the epidemic in 1853-54, which did not advance into Europe from the East, but was developed from foci already existing in several parts of the Continent; the preceding epidemics of 1831-32, and 1848-49, were characterized in each case by the same methods of invasion, and by almost identically the same lines of route, neither of which have been followed in the present occasion. For example, there was first a severe out- break of the disease in India, where it lasted for a year or two before its migration in Europe. It then passed in a north-westerly direction through Persia to the foot of the Caucasus, where its progress was, for a time, arrested. Its course was also there diverted ;' for it passed westerly by the Black Sea and the Danube, into Southern Europe, and more northerly by the Caspian Sea, and the Volga, into the north of Russia ; and thence by the Baltic through Russia and Holland, to the Eastern ports of England. At the time of its invasion also, there was everywhere observed an unusual amount of sickness, especially of a zymotic character. But the present epidemic has not been characterized by any of these peculiarities ; for, in the first place, there has been no serious outbreak of cholera in Inclia, since the terrible epidemic of 1861. Not that the disease is ever absent from the Indian Peninsula, for it yearly causes a large morta- lity of our troops, as well as of the native populations ; and last year it was somewhat severe at Bombay and Poonah : but for allthis, there has been no serious epidemic like that which preceded the former invasions of the disease. And instead of coming to us through the North-'Western provinces of India, and by Persia, to the shores of the Black Sea and the Caspian Sea, it has reached us from Arabia, and the South-Eastern coast of the Mediter- ranean. The time also of its journey has been remarkably short. In the epidemics of 1831-32, and 1848-49, years were occupied in their movements — the outbreak of the disease in India lasted for a year or more before it crossed the Peninsula ; then there was the journeying of it through Persia and Georgia to the Caucasus, where it halted for a winter, and although it moved forward, in the following spring, along the Western shore of the Caspian Sea, to the Volga, and by the Southern shore of the Black Sea to the Don, and by both of these rivers into Russia, yet it went no farther than 486 APPENDIX, Moscow during that year, for there it again rested for a winter. Even, in the following year, its progress northward was not rapid, for it did not reach St. Petersburg until the months of June and July, and even not in England until the third winter of its journey. But the present epidemic has come to us within five months of its appear- ance on the Eastern shores of the Mediterranean, and its invasion has not been from the Worth, but through Southern Europe. Early in the spring of 1865 two English vessels from Singapore, laden with pilgrims, chiefly Javanese, on their voyage to Mecca, touched at a port named Makalla, on the south coast of Arabia, where cholera was prevailing. Here the crew and passengers became infected with the disease, for, a few days afterwards, while the ships were on their voyage to Jedda, they suffered severely from it, and the mortality was excessive. As soon, however, as the ships entered the Red Sea, and encountered the strong north wind which prevails there at that season of the year, the epidemic ceased, and by the time they had reached Jedda, which is the port at which they landed for Mecca, there was no evidence of the disease among them. They, therefore, journeyed onwards to Mecca, and on the second of May the Mussulman festival of Eourban-Bairam, or the Festival of Sacrifices commenced. Under ordinary circumstances it lasts for twenty days, and it brings together from 70,000 to 80,000 persons, but as this was a jubilee year, the number of pilgrims was unusually large — amounting, perhaps, to about 100,000. They had come from all parts of Asia and Africa, and consisted mostly of the very lowest classes of Mahometans, who had undergone the greatest priva- tions and fatigues during their pilgrimage ; and in addition to this, the very rites of the festival created a condition of things which soon begat disease.; for, crowded as they were together, feeding on the poorest diet, drinking water polluted with corruption, scattering about them the remains of their i animal sacrifices, and living in the utter violation of all the rules of hygenie, it is not surprising that there should have been, as usual, a large amountof sick- ness among them : and this year there also appeared the severest manifesta- tion of cholera. In the official reports of the place it was merely mentioned as cholerina ; but the.disease, must have been very severe, or it would not have broken up the festival, for soon the panic-stricken pilgrims were found upon their road homewards. On the 10th of May a large number of them returned to Jedda, and on the 19th the first ship-load of them arrived at Suez, whence they were hurried on by the railroad to Alexandria. Everywhere along the line of route the cholera appeared. It showed itself at Jedda on the 12th of May, at Suez on the 22nd, at Alexandria on the 2nd of June, and thence it spread by the lines of commerce in all directions. On the 1 7th of June it had moved inwards by the river to Cairo, and directly after it was at Damietta, Rosetta, Tantah, and nearly all the towns and villages on the Delta of the hill. From Alexandria it was traced to Malta, Smyrna, Constantinople, Jaffa, Behrout, Valencia, Ancona, and Marseilles, and each DR. LETHEBY S EEPORT. 487 of these places also became foci of infections. From Malta, where it appeared on the 20th of June, it was carried to the neighbouring island of Grozo and to Gibraltar. From Constantinople, where it showed itself on the 28th of June, it was taken to Odessa, and Salina, and from Anoona in Italy, where it was first seen on the 8th of July, it spread to other parts of the Adriatic, and passed inland to Bologna, Madeira, and other Italian cities. From Marseilles, where it is reported to have appeared on the 23rd of July, it was conveyed to Paris and Havre; and from Alexandria it came to Southamp- ton about the middle of September. Before the first week of December it appeared at New York, where it was carried by infected passengers from Havre or Southampton. In all, therefore, hardly six months had expired from the outbreak of the disease at Mecca to its appearance on the Western hemisphere. The contrast of this with the slow progress of the malady in 1831-32 and 1848-49, is remarkable. In the epidemic of 1829-32 Astrachan was attacked on the 26th of July, 1830, Hamburg in September, 1830, Sunderland on the 26th of October the same year, and New York in June, 1832. The epidemic, therefore, occupied nearly fourteen months from the time of its entrance into Europe, in traversing the Continent ; fifteen months in reaching Great Britain, and two years, less one month, in arriving on the North American coast. In the epidemic of 1845-48 the diseased reached Astrachan in June, 1847, Hamburg in September, 1848 (crossing the Con- tinent of Europe in nearly the same period of time as in the former epide- mic), England in the same month, (Horselydo*n, 22nd September, 1848), and New Orleans on the 2nd of December of the same year — nineteen months after the appearance of the epidemic on the eastern borders of Europe." * This rapid progress of the disease does not appear to have been caused by any peculiar virulence of it, but by the quick movements of commerce. Another peculiarity of the present epidemic has been its disinclination to spread inland, notwithstanding that its extension along the coast line has been so rapid, for, excepting the capitals of England and France, and a few isolated places on the Continent, the disease has not shown itself in a viru- lent form at any large distance from the sea-coast. And lastly, the epidemic has not been preceded by any remarkable amount of zymotic disease. It is difficult to speak of the general condition of the public health at the time of the visitation of the disease in 1831-32, but, in the epidemics of 1848-49 and 1853-54, there were an unusual amount of zymotic disease. " At Moscow, and St. Petersburg, and in other Russian towns, the outbreak of 1848 was preceded by a general prevalence of in- fluenza and of intermittent fever ; the latter disease, in many continental cities, taking the place of typhus in this country. Diarrhoea also, in the European cities first attacked, waS generally prevalent before the actual outburst of the disease. At Berlin, intermittent fever, diarrhoea, dysentery, * Mr. Radcliffe in Eighth Eeport of Medical OiBoer of the Privy Council, p. 366. 488 APPENDIX. but especially diarrhcea, were epidemic. The same disease, but particularly iutermittent fever, scarlet-fever, and influenza, were prevalent at Hamburg . In London there had. been, during the preceding five years, a progressive increase in the whole class of zymotic diseases, amounting to an excess above the average of 31 per cent., while the mortality from typhus, which in 1846 considerably preponderated over that of 1845, was still higher in 1847, and exceeded in 1848, by several hundred deaths, the mortality of any preceding year. The deaths from scarlet-fever were also greatly above the average , and such was the mortality from influenza, that in 1847 and 1848, almost as many at the earKer periods of life perished by this disease, or by the more terrible epidemic that followed it; but the malady, which all along continued its course with Ihe most steady progress, was that which was most nearly allied in nature to the approaching epidemic — namely, diarrhoea ; the deaths from this disease in the five years ending with 1848, amounting to 7,580 ; whereas in the preceding five years they were only 2,828 ; while, taking separate years in the tojes, the deaths in 1848 were more than seven times greater than in 1839, and nearly five times greater than in 1841.* A like increase of certain zymotic maladies, as typhus, scarlatina, whooping- cough, and diarrhoea, preceded the epidemic of 1854, as if the condition of the public health was below the standard, or there was an increase of certain forms of the zymotic force. The deaths in England from scarlatina for example, rose from an aggregate of 13,634 in 1851, to 18,887 in 1852; typhus from 17,121, to rather more than 18,000 in 1853 ; whooping-cough from 7,905 to 11,200 ; and even diarrhoea did not discontinue its ravages after the epidemic of 1849, for the deaths in the three following years were 11,468, 14,728, and 17,617 ; thus showing a gradual increase in the mortality from diarrhoea to the very advent of the cholera year (1853). Not so, however, with the coming of the present epidemic, when the condition of the public health, in BO far as it would be judged of by the mortality returns, was above the average. And then, again, the sudden appearance of the disease in the Eastern districts of the Metropolis, and its rapid increase in severity, are also remarkable. Up to the end of the first week in July there was no evidence of the disease in London ; but on Sunday, the 8th of July, a man aged 29, the mate of a ship which had just arrived with fruit from Rotterdam, where cholera prevailed, died in Bermondsey, from Asiatic cholera, after an illness of eleven hours. The next day there was another case at Hoxton ; and on the 11th of July there were three deaths from cholera in the Eastern districts of London ; one of these occurred at the London Hospital, another at Limehouse, and the third at Poplar — all in the port of London. At the close of the week (July 14th) thirty-two deaths from cholera were recorded ; and of these twenty were in the neighbourhood of the Hospital. Erom that time the disease rapidly increased, so that by the end of the first week in August, 2,335 deaths from cholera, and 1,074 from diarrhoea, were returned * Report of the General Board of Bealth'on the Epidemic of Cholera 0/1848-49, p. 9. dr; letheby s report. 489 upon the registers of London ; of these numbers, 2,062 of the cholera deaths, and 345 of the diarrhcea deaths oooarred in the Eastern districts, imme- diately around the London Hospital. But after that the force»of the epidemic gradually abated, although, week by week, its violence has been most felt in the districts which belong to the port of London, where the Hospital is situated.* - It would be premature to enter at present on the probable cause of this apparent selection of districts ; or, although the history of the previous epidemics tells us of the inflaence of certain conditions of water-supply on the force of the disease, yet it also informs us of the like influence of filth, and poverty, and overcrowding ; as well as of defective drainage, and low- lying situations. If, therefore, it be a remarkable fact that the force of cholera has been exerted in the very districts supplied by a certain water- company, it is also a fact that those are likewise the districts best suited for the manifestation of the disease, on account of other imperfect sanitary conditions : and it is worthy of note that certain places npt supplied with water by the company, but situated within the cholera-field, have been severely visited by the disease ; while other places, using the suspected water but not within the confines of the infected area, have not been touched by it. This is so with two of the workhouses of the Gity Unions. One of these workhouses is in the parish of Bromley, not far from the London Hospital ; it does not use the water of the East London Company, and yet it has lost tweftty-seven persons from cholera, out of a population of less than 800. On the other hand, the workhouse at Hackney, which is supplied by the East London Water Company, but is situated among the Northern districts of London, has not had a single death from the disease. It is manifest) therefore, that the laws of these epidemic visitations are not known * Deaths from Cholera and 'Diarrhoea in the several Districts of London, from July 7th to September 22nd, 1866. Week ending. [ Deatlis ftom Cliolera. Deaths from DiaTxlicea. Districts. Total. 32 346 904 1063 781 455 265 198 157 182 Distrlcta. Total. i d 1 4 6 20 46 38 15 12 15 20 27 203 1 3 1 15 33 23 16 13 9 12 20 145 1 20 308 818 916 673 369 198 122 74 77 1 3 20 39 47 39 48 39 46 39 48 i ■S S ■ o 1' ■Ji 18 37 48 46 31 28 15 ; 12 18 14 37 64 78 79 51 40 21 24 19 11 28 31 44 42 31 22 13 18 14 15 37 60 123 125 lOl 63 41 43 44 35 30 39 56 62 60 41 39 31 37 35 160 221 349 354 264 194 129 128 132 110 July 14th 21st 28th August 4th 11th 18th 25th Sept. 1st 8th 15th 22nd 2 U 12 12 8 7 3 6 12 10 Total in 11 weeks 83 3575 368 4373 267 1 414 258 672 420 2031 490 APPENDIX. to us. " Partly we have learnt the conditions which augment their local spoil; but nothing of what evokes their slumbering powers, nothing of what governs their world-wide spread, nothing of what determines their eventual decline, nothing of what permits their fitful mildness. . In this domain of unknown, perhaps unoonjeetured influences, science would count it irreverence and temerity to dogmatise on a single instance of apparent correlation, or to speak of the obscure impulses of that wandering plague, as though they were strokes of some machine, subject to the guidance of one's human will." * Another circumstance, of singular importance in the history of the pre- sent epidemic, is the comparatively large mortality from the disease on the Tuesday of every week. Classifying the daily . returns, which have been published by the Registrar-General since the 4th of August, the number of deaths, for every day in the week, stands thus : — Daily Returns of Deaths f rom Cholera and Diarrhcea i/n London. Weeks ending. Deaths from Oliolera. Deaths f^om Biarrhosa. E? ^ 1=1 "-a 1 i f 1 1 1 to 1 1 1 1 1 & August 11th. 240 130 109 114 85 94 66 43 39 47 38 31 18tli 139 77 61 64 60 51 46 28 32 40 26 23 25tli 70 51 35 38 36 36 29 27 14 17 19 22 September 1st S3 31 29 29 21 35 28 23 22 16 17 22 8tli 30 31 25 28 19 24 34 21 20 14 20 23 lath 38 26 32 28 32 26 32 16 20 14 9 19 22nd Total. . 570 346 291 301 252 266 235 168 147 148 128 140 So that for every 100 deaths from cholera that have occurred on the daily average of Sunday and Monday, 122 have occurred on Tuesday, 102 on "Wednesday, 105 on Thursday, 88 on Friday, and 93 on Saturday ; and so also of diarrhoea, the proportional numbers being 100, 134, 125, 126, 109, and HI : as if the dissipation of Saturday rendered individuals more sus- ceptible of the disease, which attacked them on Sunday or Monday, and killed them on Tuesday, after which the force of the malady again declined until the following Tuesday. As to the mortality from the disease, in proportion to the number at- tacked, it would seem, from the records of the London Hospital, that the violence of the epidemic, in this respect, has been much the same as in former visitations. The proportion of deaths to attacks, so far as the num- bers have been collected to the present time, are as follows : — Brahilow, 470 per cent.; Odessa, 504; Paris (Hospitals), 51-6; Gibraltar, 54-0; * Report on the Cholera Epidemic of 1854, as it prevailed in the City of London, by J. Simon, F.RiS., etc., p, 14, DR. LETHEBY S REPORT. .491 Aneona (city and environs), 57-1, and Malta, 60-3 ;* while that of the London Hospital has been 54-1 per cent. In the epidemic of 1853-4, the range of mortality in England was from 41 to 51 per pent., the average being 45-2; and in the severe epidemic, in Northern India in 1861, the mortality among the European troops was 63'8 per cent, of all who were at- tacked. It is difficult, however, to obtain precise information of the actual force of this disease among all classes of the community in London ; for^it is more than probable that the cases which are brought to the Hospital, not only represent the severest forms of the disease, but also the poorest classes of people. Lastly, it would seem, that the duration of the fatal oases has been nearly the same as in former visitations, about half of them having terminated fatally within the first twenty-four hours of the appearance of decisive symptoms — whereas, half of the cases of common cholera terminate in about three days, and half of those of diarrhoea extend over a week. The further particulars of the present epidemic, and the points of differ- ence and resemblance to those of former visitations of cholera, have yet to be determined ; and the records of this experience of the disease in the wards of the London Hospital will form no small or unimportant part of both the medical and social history of the epidemic. * Mr. Ratoliff on the Present Diffusion of Cliolera inBarope, in Eighth Report of Medical Officer of the Privy Council, p. 369. INDEX. Acne, symptomatic - - 390 Adams (Mr.), cases under care of, 207, 326; 335 „ ligature of external iliac for aneurism of femoral - 1 „ on case of calculi in urethra - 407 „ (Mr. James), cases by - 275,. 278 „ bospital statistics, medical (1866) - - - 414—424 Addison's disease, case of - 183 „ „ supra-renal bodies in (specimen) 404 Albuminuria, case of - 192 Amputation, at hip-joint, case of - 214 „ statistics of (1866) - -425 „ of arm - - 426 „ at shoulder-joint - - 433 „ of foot - - 429 „ leg - - - 430 „ thigh - - - - 432 Anaesthesia, after division of nerves 306 Aneurism, abdominal, cured - 179 „ femoral - 1 „ of abdominal aorta - 185 „ rupture of, into abdomen - 185 Aorta, abdominal, aneurism of, 179, 186 „ aneurism of (Specimen) - 405 Apoplexy, serous, form of ursemia 245 Appendix, on cholera - 435 Arteries, Ugature of, statistics of - 433 Artery, external iliac, ligature of- 1 Barium, spectrum of - - 16 Bed sores, prevention of 368 Belladonna, cases of poisoning by external use of - - 169, 171 Bladder, distended, obstructing bowels - - - 97 „ fistula, communicating with - 114 „ paralysis of . - - 367 „ value of puncture of - - 203 Blisters, curative influence of - 394 Blood, colour of, cause of - - 45 „ colouring-matter of - 32 „ spectrum, analysis of - - 31 „ „ medico-legal - - 37 Bone, sjrphilis of, simulating cancer ' 379, 381 Breast, cancer of, case of - - S03 „ tumours of, removal of - 430 Brewsteb (Sir David), on spectra of metals - - - . 9 Buoadeent (Dr.), on hemiplegia - 374 Bronchus, plugged by a bean (specimen) - - 400 Brown (Dr.), case of poisoning by external use of belladonna - 169 BKOWNmo'g (Mr.), spectroscope - II Brushpield, report of case of . cholera - - - 157 Bryant (Mr.), case of symmetrical zoster - — - 73 Bubonocele, case of - - 118 Bums, statistics of - - 288 Csesium, discovery of - 13 ,, spectrum of - -' 15 Calcium, spectrum of - 16 Calculi, from urethra, specimen - 407 Calculus in ureter, specimen 408 „ salivary, specimen - 404 Calomel, and primary union - 394 Cancer, acute, symmetrical, case of 303 „ epithelial, of cheek - 206 „ following syphilis - - 385 „ of choroid, specimen - - 408 „ of oesophagus, gastrotomy - 218 „ tongue, specimen - - 405 „ table of cases of - - 424 Capsules, supra-renaJ, disease of 183 Carter (Mr.), on cases of suppura- tion of knee-joint without an- chylosis - - 175 Cerebellum, encephalooeleof, speci- men - - - 402 Cerebral hsemorrhage, on 237 Chancre, relapsing, indurated - 378 Child (Dr.), on marriages of con-- sanguinity - - 224 Cholera, see Appendix - 435 „ acid secretions in, a case of - 160 „ calomel in - - - 145 „ discharges in, specimens 405 „ ex'amiuation of urine in - 149 „ opium in - - 146 „ provoked by a purgative - 141 „ pupils in - 388 ,, saline injections in - - 132 „' state of gall-bladder in - 164 Chorea, statistics of (1865) - 412 494 INDEX. CSioroid, tumour of, specimen - 408 CoLauHOUN (Mr.), cases ty, 193, 207, 209, 210, 211, 214, 218 Compression and concussion - 395 Consanguinity, marriages of - 224 CoRNEE. (Mr.), case by ■ - 250 CowTBK (Mr.), on symptoms of division of ulna nerve 320 Critghett (Mr.), case under - 307 Curling (Mi:.), oases under care of, 196, 198, 203, 205, 209, 214, 218, 334, 336, 343 Dalt (Dr.), a case of recovery after symptoms of abdominal aneur- ism - - 179 Davies (Dr.), cases under care of, 187, 192, 194, 210 Deaths, statistics of -284 Definitions, notes on - - 387 Delirium tremens, cases of 263, 272 Diabetes, cases of, lecture on Diagnosis, notes on Dislocation of femur, cases of ,, ,, manipulation in „ of tibia, specimen „ of spine, on DiTGHETT (Mr.), case by Down (Dr.), on an ethnic classifi- cation of idiots „ on results of marriages of con- sanguinity Dropsy, absence of, ■with kidney 49 387 2U6 206 401 357 326 259 214 244 DuvAT on consanguinity - - 224 Dwarfing, after iujury to epiphy- sis - - - 403, 410 Encephalocele, specimen of - 402 Epiphysis, dwarfing after injury to 410 „ separation of, of radius, speci- men - - 401 ,, „ dwarfing after, specimen - 403 Epistaxis, examination of urine, in 250 Erysipelas, not an exauthem - 388 Fbaunhojer's lines 7,21 Eemur, dislocation of, cases of 206 „ — manipulation in 206 „ fracture of, specimen 403, 409, 411, 412 „ nodes of - - 380 Fibula, fracture of, specimen - 411 JTistulaj, urinary, case of 114 Jfracture of femur, specimens 403, 409, 411, 412 „ of fibula, specimen 411 „ of radius, specimen - 404 „ of spine, on - 357 „ „ specimens of - 348 „ of tibia, specimen 412 413 „ of ulna, specimen - 400 401 „ spontaneous 381 Foetus, extra-uterine, removal of an 301 Eraser (Dr.), eases under care of 171, 193, 240, 245, 303 „ on cases of dehrium tremens 263 „ on diabetes, ■with cases - 49 Gall bladder, state of, in cholera - 164 Galvanism in fractures of spine 334, 336, 346 Gangrene, senile, and section of nerves 324 Gastrotomy, casfe of 218 Gold Medal reports - - 183 Headache, severe, a symptom - 253 HaBmorrhage, cerebral, and cir- rhosis of Hver - 244 „ „ and kidney degeneration - 244 „ „ dependent on general tis- sue change 239 „ „ on cases of - - 237 „ „ ophthalmoscope in cases of - 245 „ „ treatment of 249 „ „ -without dropsy - - 244 „ into corpus striatum - 241, 248 „ into hemisphere 247 „ into optic thalamus 237 „ into pons Varolii - 243 Heart, diseases of, statistics, (1865) 420 „ effects of injuries to spine 365 „ on mpture of, in a child 205 Hemiplegia and epistaxis - 251 „ epilepsy after - - 241 „ from hsemorrhage into corpus striatum - - - 241 „ from haemorrhage into thala- mus opticus - - 237 „ from plugging of middle cere- bral artery- 240 „ in case of meningitis 213 „ in disease of optic thalamus - 374 „ often accidental - - 240 „ rapid recovery from 247, 248 „ „ „ „ deceptive 240, 255 „ statistics of, (1865) - 420 „ with albuminuria 242, 250 „ without albuminuria - - 243 ,, with degeneration of retina 242, 244, 246, 248 Hernia, cases of,' statistics of. .- 297" „ inguinal, in female child 395 „ irreducible, treatment of 126, 130, 131^ „ strangulated, cases of 118, 121,125, 297 „ opium in - - 121 „ „ taxis in - 129 Herniotomy, primary union after 394 „ statistics of, (1865) - 425, 427 Herpes ani - - 398 „ cases of - - 77 „ from nerve irritation - 396 „ frontalis, and iritis - 74 INDEX. 495 Herpes frontalis, tatles of cases of 94-96 „ labialis, a symptom - 76 „ limitation of term - 397 „ symptomatica - 76, 397 „ sypMitioa - - 72 „ mulateral ■ - 68 „ zoster, frequency at different ages - - - 71 „ and artificial irritation of nerves - - 74 „ condition of health with - 7 1 „ course of - 75 „ does not recur - - 71 ,; either side indifferently ^ 73 „ follows nerve distribution 73 „ from medication - 75 „ important questions respect- ing - -. 75 „ iu course of cutaneous nerve - "H „ in the two sexes - 71 „ nature of - - 70 „ not contagious - 71 „ not disease of skin - - 68 „ symmetrical, cases of - 73 „ twice in same person 80 „ unsymmetrical - - 72 „ zoster, tables of cases 81-83 Hilton (Mr.), treatment of irredu- cible hernia - - 130,131 Hip-joint, amputation for disease of 214 HoLMAN (Mr.), case of cholera - 154 HoBDER (Mr.), case by - 97 Hospital statistics, (1865) ' 414 Howe (Dr.), statistics of idiocy 231 HiGGiNS (Mr.), on spectrum from stars - - 24 Hutchinson (Mr.), cases under care of, 200, 203, 327, 329, 331, 332, 338, 339, 341, 344, 346 „ notes on syphilis - 378 „ on diaphragmatic respiration 392 „ on dislocations and fractures of spine - - - 357 „ on herpes zoster - 68, 397 „ on paralytic myosis - 364 „ on paralytic pyrexia - 362 „ on symptoms, definitions, and diagnosis - - 387 „ on " syphilitic shingles " - 72 „ on " trophic nerves " 395 „ on statistics of deaths 284 Hydrocecle, specimen of - 408 Hydrophobia, dilated pupils in - 388 „ spasm of sympathetic in - 388 Hyperaesthesia after fracture of spmS 330 Idiocy and ■ consanguineous mar- niiges 224, 225 „ difficult labour, a cause of - 233 „ ergot, use of, a cause of 234 „ forceps, use of, a cause of 233 Idiots, ethnic classification of 259 „ often flrst-bom - 233 ,, progenitors of, insanity in 234 „ — phthisis in - 234 „ proportion in two sexes - 225 Infiammation after section of nerves - 305 „ and sensory nerves 396 ,, reflex - - 393 Injections, saline, in cholera 132 „ conclusions as to 167 „ syringe for - 137 Intestinal obstruction, oa^o 3 of - 193 Intestines, paralysis of - - 366 Ischium, exfoliation of piii-t of, pe- cimen - - 413 Jackson (Dr. H.) case of symme- trical zoster - 73 „ on cases of cerebral haemorrhage - - 237 on functions of optic thalamus - 373 Joints, excision of, statistics of 431 Jones (Dr. Handfield), frequency of motor, and sensory paraly- ■ sis - - - 373 Kidney, atrophied, specimen - 408 „ degeneration and cerebral hasmorrhage - 244 „ without dropsy - - 244 Knee-joint, dislocation at, speci- men - - . - 401 „ two cases of acute suppuration of, with- out anchylosis - 175 Kirchoff and Bunsen's spectro- scope - - - 11 Larynx, syphilitic growths in, specimen - - 407 Latta (Dr.), on saline injections - 134 Llewellyn (Mr.), case by - 335 Lethbey (Dr.), examination of urine in cholera 149 „ (Dr.), on spectrum ana- lysis - 6 Leucocytheemia, case of - 210 Lithium, spectrum of 14 Lithotomy, statistics of - 434 Lithotrity syringe (Mr. Maun- der' s) - - 216 Little (Dr.), on saline injections in cholera eases - - 132 Little (Mr.), case under care of - 211 „ list of specimens added to Museum - 400 Liver, cirrhosis of, and cerebral haemorrhage - - 244 M'Cabtiiy (Mr.), on case of extra- uterine foetation - - 301 Mackenzie, (Mr.), cases by, 196, 198, 200,. 203, 205, 206 496 INDEX. Mamma, removed by eBcharotics 409 Marriages of consanguinity, re- siats of - - 224 Matjniiee (Mr.), cases rmder care of, 97, 106, 111, 114, 118, 121, 125 „ clinical lectures by 97 „ on complicated stricture - 97 „ on case of perineal section 111 „ on cases of strangulated bemia - - 118 „ on a Hthotrity syringe 216 „ on operations for reten- tion _ - - 108 „ on opium in strangulated hernia - - 122 „ on treatment of irreduci- ble bemia - 126 ,, on treatment of extrava- sation of urine - 99 „ on urinary iistiila - 114 „ . statistics of major opera- tions (1866) - 425, 434 Medico-legal spectrum analysis , 37 Meningitis, traumatic, cases of 211 Metals, spectra of 13 MiLLEE. (Dr. W. A.) on spectrum analysis - - 9 Mitchell (Dr.), on marriages of consang-uinity - 235 Morbus Addisonii, case of - 183 Muscle, abductor indicis, after section of ulnar nerve - 320 „ atrophy of, after section of nerves " - 305 „ nodes in, like cancer 383 „ with trichinae, specimen - 404 Museum, list -of specimens added to - - - - 400 Myo-oaxditis, in syphilis ■ 382 Myosis, paralytic, case of, 329, 331, 341, 364, 388 Nerve, median, section of, cases of 305, 309, 310, 314, 316, 318 „ radial, distribution of, on back of hand ■ 318, 319 „ roots, cervical, injury to - 338 „ supply to back of hand 319 ,„ sympathetic, remarks on - 362 „ third, paralysis of - - 339 „ ulnar, section of, atrophy of abductor indicis, after - 320 „ — cases of, 306, 309, 310, 314, 316, 318 Nerves, cranial, paralysis of 200, 203 „ section of, and gangrene - 324 „ — cases of - 305, 319 „ • — comments on - - 319 „ • — influence on nutrition, 305, 323 „ — pain after - - 311 „ — repair after - - 324 Nerves, section of, sensation after - - - - - 305 „ — temperature after - 305 „ sensory, and nutrition 396 „ spinal, paralysis of 422 „ tJophio - - - 396 Newton's (Sir Isaac), solar spec- trum - - 6 Nodes, spontaneous fracture, through - - - 381 „ in muscle, simulating cancer 383 Nutrition, after section of nerves 305, 323 „ reflex disturbance of - 394 Obstruction, abdominal, cases of 193 „ from bum of rectum, etc. 207 „ by distended bladder - 97 CEsophagus, cancer of.(gastrotomy) 218 Operations, summeury of, (1866) , 426 Ophthahmtis, sympathetic - 394 Opium, in strangulated hernia 118, 122 Optic disc, clot on 252 „ neuritis, a symptom - 253 „ thalamus, disease of, sym- ptoms of - - 374 „ — functions of - 373 O'Shaugnesst (Dr.), on saline in- jections - - 134 Ovaries, cancer of, case of - 303 Ozoena, syphilitic, case of 379 Pain, after section of nerves - 311 Palate, acute necrosis of - - 209 Paralysis of one arm, with injury to spine - 347, 348, 338 „ of third nerve - - 339 ,, ofvaso-motor - 363 Paraplegia after fracture of spine 326 „ case of recovery from 190 „ iodides in - 190 „ statistics of, (1865) - 422 „ traumatic, on - - 369 Paresis, general, statistics of (1866) - - - 422 Pakkee (Dr.), cases under care of - 183, 185, 190, 195, 242 Patients, mistakes by - - 399 Perinaeai abscess, cases of 111, 203 „ section - - 111 Phlebitis, cases of - 192, 210 Photophobia, cause of 393 ,; overcome by fright - 397 Poisoning, by external use of bel- ladonna, cases of 169, 171 Porrigo, on - 390 Potassium, iodide of, long course of - " - 379 „ spectrum of - 13 Priapism, on - - 364 „ after fracture of spine - 330, 331, 344 Purpui-a, case of - - 187 INDEX. 497 Pyaemia after fracture of spine - 330, 343 Pyrexia, paralytic, cases of, 329, 344, 362 duinine, phosphorescence of - 28 Eadins, detachment of epiphysis of, specimen - - - 401 „ fracture of, Colles', specimen - 404 „ dwarfed, specimen - 403, 410 Eamsbotham (Dr.), influence of ergot on foetiu - 235 Eayer,frectuency6f zoster on each side - - - - 73 Rectum, destruction of part of, case of - - - 207 „ puncture, per - - 106 Bespiration, ahdominal, case of - 329 „ diaphragmatic - 330, 331, 344, 392 „. thoracic ... 392 Retina, degeneration of - - 377 Ribs, fracture of,' in a child - 206 Rigor, depends on spasm - - 387 „ dilated pwUs in - ' - 388 Robertson. Ipi. Alexander), on hrain-diseaae - - - 375 RossiGNOL (Mr.), cases by, 172, 183, 190, 192 Rubidium, discovery of - - 13 „ spectrum of - - - 14 Etott (Mr.), case by - - 336 Scalds, statistics of - 288 Sensation, after section of nerves - 305 „ in disease of optic thalamus - 374 Shingles, syphilitic - - 72 SMn-diseases, classification of, on 388 Skull, fracture of base of- -200 „ fracture of, case of - - 211 „ trephining of, statistics of - 431. Spine, trephining of - - 367, 371 Sodium, spectrum of - - 13 SoBBY (Mr.), instrument for spec- trum analysis - 34 Specimen of aneurism of aorta 405 „ of atrophied kidney - 407 „ of bronchus, plugged - - 400 ,, of cholera discharges - - 405 „ of crushed cervical cord - 351 „ of crush of lower spioal cord - 352 „ of detachment of epiphysis of radius - - 401 „ of dislocation of cervical ver- tebra ■ 349, 360, 352, 353 „ — of dorsal vertebrae - 350 „ — of lumbar vertebrae - 348, 366 „ — of tibia -401 „ of displaced dorsal vertebrSB - 351 „ of dwarfed radius 403, 410 „ of dwarfed ulna - - 403 „ of encephalooele - - 402 „ of ^ exfoliation of part of is- chium - " ^12 Specimen of fracture of anchylosed dorsal vertebrae - - 364 — of cervical vertebra 363, 354 — of dorsal vertebrae - 351 — of femur - 409, 411, 412 — of fibula - - - 411 — of lumbar vertebrae - 362 — of radius - - - 404 — of sternum 349, 362, 366 — of tibia - - 412, 413 — of ulna - - 400, 401 of hydrocele - - - 408 of mamma, removed by escha- rotics - - 409 of salivary calculus - - 404 of separation of odontoid pro- cess and false joint - - 364 of supra-renal bodies, diseased 404 of syphiUtic growths of larynx 407 of tafipes calcaneus - - 402 of tongue, removed for cancer 406 of trichinae, in muscle - 404 of tumour of choroid - - 408 of ulcer of stomach - 409 of wound of spinal cord - 364 Specimens, list of, added to Museum (1866) - - - 400 Spectroscopes - - - 11, 34 Spectrum, actinic rays of - 28 „ coloured bands in - 12 „ continuous, explained - - 21 „ from planets - - - 23 „ from stars - - -24 „ solar - - 6, 7, 21 „ voltaic, &o. - - 7 „ analysis - - 6 „ — delicacy of- - - 15 „ — instruments for 11, 34 „ — of blood - - 31 „ medico-legal - - 37 „ — of metals - - 13 „ — of non-metalUo bodies 18 Spine, dislocations and fractures of, on - - - 357 „ fracture of, and hyperaesthesia 330 „ — and sugar in urine - 330 „ — catheter in - - 391 ,, _ galvanism in - 334, 336, 346 „ — myosis after - 329, 331, 341 „ — priapism in - ■ 330, 344 „ — pyaemia after - - 330, 343. „ — recovery after - 326, 327, 332, 334, 336, 336, 346, 347 „ — respiration in - 330, 331, 344 „ — temperature in - 330^ 362 ,, — water-bed in - 391 „ — with paralysis of one arm 347, 348 „ injuries of, list of specimens of, etc. - - - - 348 „ injuries to, cases of - 326 KK Am IBtDEX. Spinet imui^.to^ displacement in 3i6j: „ — effects on heart' -. 365 ,, — r fects as to -. - 325 „ — hsemoirhag^in -. - 36,Q ,y — r permaneiit compreseion in - 3&Q „ — prognosis in - - 37,0 ,', — trephining. in- -. 36 7, 37.1 Spleen, hypertrophy of, case, ofi - 210 StaMs&s of bums and scaMsi - 2S.8 •y of deaths -■ - 284 „' of' hernia cases- - - 297 ,',' of idiocy - - - 231 ,, Hospital (1/866), medipal 414-r,42.4 '■,'," — of cancer - 424 ,, — of ch specimen of 402 TAtt (Mt.j, case by " 202 .„ sl^tistics of deaths 284 Temperaturej after seotien of nerves 305 „ increased^ aftei^fEaetur^ of spine 330, 344 Testis, removal of -. 4^^ „ retained, ease of - 118 Throat, incised, cases of 196, Tibia, dislocation of, specimen „ frajsture, of , specimen - 4;12j TojjD (Dr.), on lesions of optic thalamus „ on patalysis, motoi a^d. sen- . sory - - - Tongue, cancer of, following 8y- philis „ one-sided fur on „ removal of, for cancev Trachea, complete diyiwa 0^ „, stricture of - Trephining, of skuU-, statistics of 198 401 413 374 -375 386 392 405 1,98 198 of spme - T 36,7, TriohinsB, in muscle, spBoiinen - Tumour, of ohoroidv specimen Tumours, removal of Tyn.dale, on spectrum analysis - Ulna, dwarfed, specimen of „ fracture of ahaf^ of, specimen - „ injury to, foUowadjby dwarfing Uraemia, serous apoplexy a form. of - - - Ureter, calculus in, sppciiRen Uretljra, calculi in, case of „ — from, specimen. -. -: Urine, examination of, in. cholera, „ extravasation of, cafle o^ „ — pathology of t „ retention of, case of - 9,7, „ — puncture, per reetwm, for - „ sugar in, after fracture of spine Yaso-jnotor paralysis - ■ . Teins, of lower estremity, plug- ging of .saline injections intft - Vert^hraB, cervical, dislocation of, specimen- - 349, 350, 352, — fifth, displaced, case of ; — fiAh, fracture of, case of - — fourth, displaced, case. Q% - — fourth, fraotmft of, case pf — fracture o&, apeojmeus. 3§3i — fracture of, with (^spli^c^- ment, cases of t 347, ^- leiat, displaced, oaassA — : lowieii, cUsplaeed, cases 3?.4, !^ — sixth, fracture- of, case dorsal, anohylogefli, fractiire of, sp,eoimpn - - -, — dislocatioB of, speeimgn - -^ displacement of, apecimen - dorsal, displacement of last, case of . - dorsal, displacement of sixlili, case of - T dorsal, displacemeut of sb^tli, specimen 431 371 40* 408 429 20 4i03 m 40,3 245 407 m 149 9t lOtt ;o6 106 330 363; 192 132 ^63. 3J(0. 332 330 ?32 364 348 329 338 - 33'6 364 350 351 339 33.9 361 INDEX. 499 Vertebrae, lumbar, dislocation of, cases - . - 344, 348 „ — specimen - - 356 „ lumbar, fracture of, cases 326, 327, 332, 335, 341, 343, 346 „ -^ specimen - - ■ 352 Vomiting a symptom - - 253 Walker (Mr.), cases by 185, 187, 334 "Water-bed, in fracture of spine - 391 Watson (Sir Thomas), frequency of zoster on each, side - 73 Wheatstonb's spectra - - 7 Wollaston's solar spectrum - 7 KK 2 THE MILE END, 1865-67. The next Winter Session will commence on Monday, October 1st, 1866, when The Introductory Lecture 'will be delivered by Dr. Head, at 3, p.m. Lectures on Anatomy, Physiology, and General and Morbid Anatomy, Chemistry, Medicine and Surgery, will be given. The next Summer Session will commence on the 1st of May, 1867. Lectures on Midwifery, Materia Medica, Ophthalmic Surgery, Botany, Forensic Medicine, Com- parative Anatomy, Practical Chemistry, and Practical Histology, will be given. ■WINTER SESSION, 1866-67. JKelftCCne— By Herbert Davies, M.D., F.R.C.P., Physician to the Hospital, Anprevt Clark, M.D., F.R.C.P., Physician to the Hospital, and J. S. Ramskill, M.D,, Lond,, Assistant-Physician' to the Hospital. ■Wednesday and Thursday at 9, a.m., and on Friday at 4, p.m. ^urBftg— By Jonathan Hutchinson, Surgeon to the Hospital, Assistant- Surgeon to the Royal London Ophthalmic Hospital, and Surgeon to the Hospital for Skin Diseases, Tuesday, Friday, and Saturday, at 9, a,m, In connexion with these Lectures, three short special Courses will be given, during the Summer months, on Ophthalmic Diseases, on Syphilis, and on Diseases of the SMn. P?Sn:tatt6e avitS fii«rg;tcaX ^natOniB— By John Apams, Surgeon to the Hospital j Snd Walter Sivington, M.S., Lond., Assistant-Surgeon to the Hospital, Monday, Tuesday, Thursday, and Friday, at 3, p.m. The Class will be examined at the termination of each Session, ^l)^gis>tass RltS f^metiA antt plortiili ^natornj— By j.Hughlings Jackson, M.D., Assistant-Physician to the Hospital, and to the Hospital for Epilepsy and Paralysis; and Morell Mackenzie, M.D.^ Lond., Assistant-Physician to the hospital, and Physician to the Hospital for Diseases of the Throat. Monday, ■Wednesday, and Thursday, at 4, p.m, Supplementary Demonstrations during the Summer. Prattttal SlnatOmB— By Walter Rivinoton, M.S„ Lond., Assistant-Surgeon t» the Hospital, Jambs Adams, and Warbn Tay. Attendance in the Dissectmg Room daily from 10 to 3, excepting Wednesday and Saturday Afternoons. A Demonstration or Examination either in the Anatomical Theatre or Disseotinq P.O0M, on Monday, Tuesday, Thursday, and Friday, at 12.30, p,m. C^emtSto— By Henry Lbtheby, M.B,, Lond., Monday, 'Wednesday, and Friday, at 10.30, a.m. The subjects of this Coiu:se are Physios in their relation to Chemistry and Chemistry proper. These are alternately made the chief subjects of the course, so that Pupils who are studying for the Universities may, in the period of two Winter Sessions, obtain a full course of Lgctures on each subject. ' <&mtaniyi nviis i3at50lafli3 0f tt)z mett), at* JBental ^urg«rs-By fl. J. Barkbtt, M.R.C.S.E. This Course consists of Twelve Lectures, and will be delivered at 5, p.m. A Fee of £2 2s. will be required from gentlemen desiring a Cettifloate of Attendance on this Course. SITMMER session, 1867. ^attoitoK anW &gmStg a( WSamm aitS eiittrreu— By F. H. Ramsbotham, M.D., Fellow of the Royal College of Physicians. Daily (except Saturday), at 3 p.m. Gentlemen when qualified have opportunities of attending an unlimited number of cases of labour in the neighbourhood of the Hospital. ^axenSk Me'^itint—By F. H. ramsbotham, M.D., and J. E. D. RODGERB, M.R.C.S.E., L.S.A. Daily (except Saturday), at 10.15, A.jt. Ptaterta iWelitca antt (Seneral tfljerapeuticji— By j. Lanqdon h. Down, M.D., Assistant-Physician to the Hospital. Tuesday, Thursday, and Friday, at 4, p.m. A Cabinet of Materia Medioa is open to Students. 0]p^t1^atint( ^l^tXSei — By Jonathan Hutchinson, Surg;eon to the Hospital, and Assistant-Surgeon to the Royal London Ophthalmic Hospital. Tuesday, Wkdnesday, and Friday, at 9, a.m., during the month of June. This Course will comprise all Diseases of the Eye and its appendages, with their medicinal and operative treatment. Special instruction will be given in the perform-' ance of Operations ; the use of the Ophthalmoscope ; the employment of Spec- tacles, &o. ^tatttcat C^^cmtettra— By Henry LeTheby, M.B., Lond. In this Course the operations are conducted by the Students, under the Superintend- ence of Dr. Letheby, during May, June, and July, on Monday, Thursday, and Saturday, at 9, a.m. JSotan^ — By Christopher Dresser, Ph. D., F.L.S., Professor of Botany in the Department of Science and Art, South Kensington Museum. Monday, Wednesday, and Friday, at 10, a.m. Practical ^iitalasSt »•"! tl^e Use of the Microscope in Diagnosis— By J. Hugh- lings Jackson, M.D., and Mobell Mackenzib; M.D. This Course embraces, 1st, the methods of investigating and preserving the tissues and organs of the body in health and disease ; and, 2nd, the clinical examination of the blood, urine, sputum, faeces, and other excretions and discharges. A Cabinet of Microscopic Preparations is open to the Students. This Course is free to past and present Pupils. ComparattilC ^natOmS— By ■Walter RivinGTon, M.S., Assistant-Surgeon to the Hospital. This Course will oousist of from 18 to 20 Lectures, several of which wiU be devoted to the consideration of the Parasites afflicting Man and Animals. Tuesday and Thursday, 11.30, a.m. One Course £3 3s. Free to Students Who have paid the General Fee. Special Sn;SttUCti0ll in &»tVStibe 0Utsetyi, in accordance with the Army, Navy, and India Board Regulations, under the superintendence of C. F. Maunder, Assistant-Surgeon to the Hospital. EnStntction in iWeliical «ClaSjSicS, &c., Sft.—Bi. Bughkeim Will attend at the College, on Wednesday, at 7, p.m., to superintend the Studies of Gentlemen preparing for the Preliminary Examination. Fee for the Course £i 2b, Hospital Practice.— The London Hospital contains 445 beds, of which 135 are allotted to Medical, and 310 to Surgical oases. Of these 310 beds, about 190 are exclu- sively appropriated to cases of accident. In the year 1865 the Hospital received 32,640 patients, including 4,317 In-patients and 28,313 Out-patients. Wards are specially appropriated to oases of TTterine Disease and to a limited number of cases of Syphilis. Maternity "Department. — About 500 poor women were delivered at their own residences during the past year. MEDICAL AND SURGICAL STAFF OF THE LONDON HOSPITAL. ConSuItillfl ^urflMfn— Mr. Luke. iSJsSittanS— Dr. Frasbr, Dr. Davies, and Dr. A. Clark. ^urB:e0nS— Mr. Adams, Mr. Cdrling, and Mr. Hutchinson. aS;SiStant49l)8^'ttanS— Dr. Ramskill, Dr. Down, andHuoHLiNGS Ja:ok80k, and Dr. Mokbll Mackenzie. @[SjttStant=^urBe0llS— Mr. Maunder, Mr. Coupbr, Mr. Little, and Mr. RiVINQTON. Obstetric 'pl&a«tcfan— Dr. Head. aSSilitaiTt ©SStEtrtC PI)BB"tttan— Dr. Palfrey. Jiurgenn JBetttt^t— Mr. Barrett. One of the Physicians and one of the Surgeons attend daily ; the former at 8, a.m., or 1^ P.M. : the latter at 1, p.m. : and one of the Assistaiit-TPhysioians and one of the Assistant- Surgeons daily at 1, p.m. Casulties are admitted at all hours by {he House S^rgediis and Dressers. Surgical Operations, except in oases of emergency, are performed on WbdnesDAT, at 2, P.M. Dr. Head attends on Wednesday and Saturday, at 1.30, p.m., to visit the Obstetric In-patients, and Dr. Palfrey on Wednesday and Saturday, at 1 p.m., for the Out-patient department. Mr. Barrett gives practical instruction in Dental Operations on Tuesday, at 10, A.M. CItnual ILettUted — Clinical Lectures are given by the Physicians and Surgeons, and by the Obstetric Physician. Practical Glasses on Auscultation and Percussion. Iltacttcal JWOrbtit ^natOmg— The Post-mortem Examinations take place at 2.30, P.M., and are superintended by Dr. HuGHLiNQS Jackson, Dr. Sutton and Mr. Little. dWuSeum anlf iLftrarj— The Anatomical Museum is open daily to the Students from 11, A.M., to 2, P.M. Curator— Mr. Little. The Reading Room is open daily from 10, a.m., to 4, p.m. The gentlemen who have entered to the Medical or Surgical Practice, or two or more Courses of Lectures are admitted without any fee to the Reading Room. The subscrip- tion to the Library is £1 Is., and is perpetual. Prizes and Appointjnents. — The following Prizes and Appointments are conferred as Rewards of Merit on qualified Pupils of the Hospital and School : — 1. Two Scholarships Will be awarded during the next Winter Session. The com- petition will be restricted to first year's Sti;idents. .The first, value iG20, will be awarded to the Student who shall pass in December, 1866, the test examination in Human Osteology. The second, value £25, will be awarded to , the, Student who shall pass, at the end of the Winter Session, the best examination in Anatomy, Physiology and Chemistry. 2. The Duckworth-Nelson Prize, value £10 10s. , is awarded by competition once in two years, and is open to all iStudents who have not completed their education. The subjects of examination in 1868 will be Practical Medicine and Surgery. 3. Two Gold Medalsnre annually awarded bythe Governors to Students attending the Medical and Surgical Practice, who shall have most distinguished themselves in the performance of their duties at the Hospital. 4 4. A Resident Medical Officer, who resides and boards in the Hospital, and receives- £75, is appointed for twelve months by the Committee of the Hospital. The Kesident Medical Officer is eligible for re-election for the farther period of twelve months, and then receives £100. In the absence of the Physicians and Assistant-Physicians, the Resident Medical Officer has the general superintendence of the Patients in th6 Medical Wards. 5. A Medical and Surgical Registrar is appointed by the Committee of the Hospital, and receives £25 a year. 6. Three House Surgeons are elected every six months, without any additional expense ; they reside in the Hospital, and are provided in part with commons. The House Surgeons are eligible for re-election for a further period of three months. In the, absence of the Surgeons and Assistant-Surgeons, the House Surgeons have the general superintendence of the Sutgical department of the Hospital. 7. A Resident Accoucheur is appointed for six. months, free of SU expense, and is provided with residence and partial board. He is the Clinical Assistailt to the .Obstetric Physician, and the Assistant Obstetric Physician, and under their superintendence assists in the care of the In and Out 'Obstetric Patients, 'and in the conduct of the Maternity Dep ui:mcnt and the Vaccination Bep'artment. 8. An Assistant-Medical OSfioer is chosen froiti among the Medical Pupils. He re- njains in the Hospital day and night, and is provided in part with board. 9. Two Surgical Dressing Put)ils, in rotation, remain in the Hospital day and night for a week, and are provided in part with bpard. 10. Additional Sresserships are, under certain conditions, given to Pupils of the School who have obtained certificates for Dressing the Oat-patients. 11. An Assistant-Dentist is elected for three months, wittout any additional expense. 11. Post-mortem Clerks are selected from among the Students according to merit. 13. Special Certificates are given to those gentlemen who have faithfully performed their various duties. 14. In the selection of candidate^, preference is given to those Pupils who are most distinguished by general good conduct, Tby ability, and by industiy. FEES FOR A'TTENDANCE ON THE HOSPITAL PRACTICE. On the Mbdical Practice, — For six months, six guineas ; iot period required by Apothecaries' Hall, twelve guineas ; unlimited, twenty guineas. On THE SuBGicAL Practice and Dbessing. — ^For .six months, including three months' Dressership, eight guineas ; for twelve months, including six months' Dresser- ship, twelve guineas; for eighteen months, including twelve months' Dressership, eighteen guineas ; for three years, including twelve months' Dressership, twenty-five guineas ; for twelve months' additional Dressership, during the above three years, five guineas ; 'for twelve months' Dressership after the eipirfttion of the above three ^ears, eight guineas. The Fee for Instruction in Vaccination and the Certificate is One Guinea. The Pupils enter and dress under aU the Surgeons. A Medical and Surgical Tutor is appointed to assist the Junior Students. Fee to the Class, Two Guineas. Several of the Lecturers receive resident Pupils. Further information may be obtained from Mr. AD.s!i«s, 10, Finsbury Circus, Mr. Hutchinson, 4, FinsbUry Circus, or on apjiltcation at the College. WORKS II lEDICIlJE km SUE&ERY BY THE DR. FBASER, Senior Physician to the Hospital, A TREATISE ON PENETRATING WOUNDS OF THE CHEST, Founded on Personal Observation in the Field. 148 pp. 8vo., cloth, price 5s. DR. RAMSBOTHAM, LeotTuer on Midwifery, and late Obstetric Physician to the Hlospltal, THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- CINE AND SUEGERY. Elustrated with One Hundred and Twenty Plates on Steel and Wood ; forming one thick handsome volume. Fourth Edition, 8vo., cloth, 22s. LONDON : JOHN CHURCHILL AND SONS, DR HERBERT DA VIES, Physician to the Hospital, and Consulting Physician to the fioyal Infirmary for Diseases of the Chest, ON THE PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNGS AND HBAET. Second Edition. Post 8vo., cloth, 8s, LONDON : JOHN CHURCHILL AND SONS. DR. MORELL MACKENZIE, Assistant-Physician to the Hospital, and Physician to the Hospital for Diseases of the Throat, THE LARYNGOSCOPE: ITS USE IN DISEASES OF THE THEOAT, with an Appendix on Ehinoscopy. Fully Elustrated, cloth, 5s. New Edition, October 1st. LONDON : ROBERT HARDWICKE. JOHN ADAMS, P.R.CS., Senior Surgeon to the Hospital, ac, ON DISEASES OF THE PROSTATE GLAND. Svc, Second Edition, price 5s. LONDON : LONGMAN, AND CO. ADVERTISEMENTS. T. B. CURLING, P.R.S., Surgeon to tbe Hospital, &c., A TREATISE ON TETANUS. OBSERYATIONS ON DISEASES OF THE RECTUM. Second Edition. 8to., cloth, 5s. LONDON: JOHN CHURCHILL AND SONS. A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPEEMATIC CORD, AND SCROTUM. Third Edition, with Additions. 8vo., cloth, 16s. LONDON: JOHN CHURCHILL AND SONS. THE ADYANTAGES OF ETHER AND CHLOROFORM IN OPERATIVE SURGERY. J. HUTCHIIfSON, P.B.C.S., Surgeon to the Hospital, Assistant-Surgeon to tlie Boyal London Ophthalmic Hospital, and Surgeon to the Hospital for SMn Diseases, ON DISEASES OF THE EYE AND EAR IN CONNECTION WITH INHERITED SYPHILIS, with an Appended Chapter of Commentaries on the Transmission of SypWlis from Parent to Offspring, and its more Remote Consequences. With Woodcuts and Coloured Lithograph, pp. 253, Ss. LONDON: JOHN CHURCHILL AND SONS. C. P. MAUNDEB, P.B.C.S., Senior Assistant-Surgeon to the Hospital, Consulting-Surgeon to Queen Ade- larde-s Dispensary. Contrihutor of Article, "Intestinal Ohstruotions," in New Edition of •'Cooper's Surgical Dictionary.' RICORD'S LECTURES ON CHANCRE (On the Duality of the chancrous virus, but the Unity of the syphilitic poison,) edited and translated, with Remarks on the Perineal Section of Stricture of the Urethra,' hy the Translator. iE*rice 4s. LONDON: RBNSHAW, STRAND. OPERATIYE SURGERY ADAPTED TO THE LIYING AND DEAD SUBJECT. 168 Woodcuts. Price 6s. PRIMARY YENEREAL SORES: The possible sources of error in diagnosis, and the evU consequences of such error. LONDON : JOHN CHURCHILL AND SONS. ADVERTISEMENTS. On October 1, 1864, waa Pubilislied, CLINICAL LECTUEES & KEP0RT8 );?Jt»x^I ^, ^Mr|[iml; Staff LONDON HOSPITAL. EDITED BY Dr. ANDKEW CLARK, Dr. DOWN, Mr. HUTCHINSON, a^d Mr. maunder. VOL. I. WITH THREE LITHOGRAPHS AND SEVERAL WOODCUTS, 8vo., toimd; in clotli, pp. 520. CONTENTS. Aoem^i^m. of Iimojnijifltie, &o. (liUipgrapli) by Dr. Davie^. On Leuoodenua (coloured Kthograph) Mr. Hutclimsoii. On Tnie Leprosy i\ . . . v ........_,.. Mr. HatcliinBon. On Cerebral Amaurosis .'. Mr. Hutchinson. On the Treatment of Polysarcia . ; IJr. DoTfn. On Hospital Gangrene „ Mr. Maunder. On Treatment of Stricture Mr. Maunder. Cases of Ligature of Arteries i Mr. Maunder. Rare cases of Fracture of the Vertebrse Mr. Curling. On the Study of Diseases of the Nervous System ^ Dr. Hughlings Jackson. Op the Treatment of Scflrlet Eeyer ' Dr. Do^n. Oil Relapsing Pemphigus „ Mr. Hutchinson. On a casfe oiHeruia .......'..' Mr. Coiiper. ■ Surgical Gold Medal Cases (Various.) Gleanings in Medicine. ..'....;,' : Dr. Andrew Clark. OnStm-birth .fS-.ISrr The Statistics of the Maternity Department | ^ j," H^Sord'^ Miscellaneous Cases ; .... Dr. Woodman. Surgical Notes on the Schlpswig Campaign , Mr. Little. Dislocation of Lower Jaw of four rnonths' duration ..i. Mr. Couper. On the Blister Treatment of Rheumatic Fever, &c., &c. . . Dr. Davies. On Hemiple'gia on flie right side with Loss of Speech'. . . . .' . Dr. Hughlings Jackson. Clinical Illustrations of Diseases of the Nervous Systein. .'.'. Dr. Hughlings Jackson. Extracts from Clinical Lectures' ' ;...'......;.. Mr. Hutchinson. Cases of Disease of the Heart, &c '. Dr. RamskiU. Qasee, of Algeria and Hyp^?esthe^ia Dr. Ramskill. Statistics of me Hospital fbr 1863 Dr. {"owell'. Price to Suliiscribers, 6s. ; to non-subscribers, 7s. 6d. LONDON : JOHN CHURCHILL & SONS. -ADVERTISEMENTS. On October 1, 1805, was pntolished, GLINICAL LECTURES & REPORTS Izhknk mh %ms^kd ^tal LONDON HOSPITAL. EDITED BY. Dr. ANDREW CLABiK, Dr. p,OWN, ^r. HUTCHINSON, and Mr. MAUNDER. VOL, II. WITH FIVE LITHOGRAPHS AiUD NUMEROUS WOODCUTS, 8vo., bound in cloth, pp. 420. CONTENTS. Case of Occlusion of Femoral Artery, &o. ; by Mr. AdMns. Report on Colotomy for Cancer of the Beotum Mr. Curhng. Liquid Diffusion as an Aid in Practical Toxicology Dr. i-e^eby. On the Poisonous Properties of Nitro-Benzole Dr. Letheby. On Circumcision in the Treatment of Epilepsy, &o Mr. Hecktord. On the Treatment of Hy'drothorax • • . • Dr. * raser. Stimulation versus Depletion ^- %i™^r-. „._ On the chief Cause of Death after Operations for Hemia .. ^r. Hute^son, The Diagnosis and Treatment of Lupus and alhed Diseases Mr. Hutchmson. New fS and Opinions as to Inherited Syphilis ., ^I' 5™I?Son Fibro-plastic Tumour of the Scalp ■,•■•. M^- ^'i^^'"'- -On the Blister Treatment of Rheumatism Dr. ^^vie^ Pistol-shot Wound 6f the Tliorax . . .,.,,.,■■ ■ ■ ■ • ■ • ■ Mr. Maunoer. Compound Fractures into the Elbow, &c., &o Mr. Madder. The Differential Diagnosis of Gtanore. . ....... ... ■ Mr. Madder. On Secondary Enlargements of^Lymphatio Glands Mr. Ma^4«>-. Perforating. Fracture of Base of Skull Mr. Coup^. Case of llemia without a Sao ■ •• ^ Woodman. Keport on Fifty Oases of Hernia ■ '••• (y^jious ) Surgical Gold Medal Cases .■"■"■■.■.■ Dr. Hughiings Jackson. Clinical Lectures on Hemiplegia ^^ Hutchinson. Extracts from Clinical Lectures .••■'■•"•;• t., Davies. Case of Prolo^ed Obstruction of the Bowels . .... . . • "^vD^Wnson. Why did not .Kiagedaena occur m Gloucester wara ^^^^^ Report on Additions to the Museum Mr Maunder. Description of a " Spray-producer ■ • j^ Woodman. On Simulated Diseases ■ fVarious). Miscellaneous Cases of Interest |,^ Wojdjn^m and Rt»«=t,Va of the HoSDital for 1S64 (Mr. Maunder; Statistics of t^he I^wi*;^'' *("^ ^*^ Price to subscriberJ^lsTtonon^scribers, 7s. 6d. LONDON : JOHN CHURCHILL & SONS. ADVERTISEMENTS. This Day is Published, CLINICAL LECTUEES & REP0ET8 BY THE P^biml Ettir 3nxQM Staff OP THE LONDON HOSPITAL. EDITED BY Dr. ANDEEW CLAEK, Dk. DOWN, Me. HUTCHINSON,, and Me. MAUNDEE. VOL. III. WITH LITHOGRAPH AND SEVERAL WOODCUTS. 8vo., bound in cloth, pp. 616. CONTENTS. Case of Ligature of External Iliac Mr. Adams. On Spectrum Analysis Dr. Letheby. On Cases of Diabetes Dr. Fraeer. Notes on Symptoms, &c Mr. Hutchinson, On Injection Treatment of Cholera Dr. Little. On Extravasation of Urine Mr. Maunder. On some Hernia Cases Mr. Maunder. On Cases of Stricture , Mr. Maunder. Cases of Acute Synovitis * Mr. Carter. Cure of Abdominal Aneurism Dr. Italy. Poisoning by Endermic Use of Belladonna Dr. G. Brown. Poisoning by Endermic Use of Belladonna Dr. Fraser. On Herpes Zoster and Symptomatic Herpes Mr. Hutchinson. On the Tear's Mortality | Mr. T^y?'^""' """^ Case of Acute Symmetrical Cancer Dr. Fraser A Case of GasUotomy Mr. Curling. A Lithotrity Syringe Mr, Maunder. On Marriages of Consanguinity Dr. Down. Ethnic Classification of Idiots Dr. Down. ' On the Effects of Cerebral Haemorrhage Dr. Hughlings Jackson. Gold Medal Keports t Yarious. Beport on Additions to the Museum Mr. Little. iMr. Adams, Mr. Curling, and Mr. Hutchinson. On Fractures of the Spine Mr. Hutchinson. On Injuries to Nerve-Trunks Mr. Hutchinson. Notes on Syphilis Mr. Hutchinson. Statistics of the Hospital for 1865 f}^^- Maunder, ( Mr. James Adams. Appendix on Cholera Various. Price to . subscribers, 6s. ; to non-subscribers, 7s^6d. LONDON : JOHN CHURCHILL AND SONS.