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 ^*iifiiiimim!?iIl?,3;^P''*- l^ussmaul and Tenner 
 
 3 1924 011 938 903 
 
Cornell University 
 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/cu31924011938903 
 
THE NEW SYDENHAM 
 
 SOCIETY. 
 
 INSTITUTED MDCCCLVIII. 
 
 YOLUME T. 
 
SELECTED MONOGRAPHS: 
 
 KUSSMAUL AND TENNEE 
 
 ON 
 
 EPILEPTIFOEM CONVULSIONS FROM 
 HEMORRHAGE. 
 
 WAGNEE 
 
 RESECTION OE BONES AND JOINTS. 
 
 GEAEEE'S THEEE MEMOIES 
 
 ON 
 
 IRIDECTOMY IN IRITIS, CHOROIDITIS, 
 AND GLAUCOMA. 
 
 THE NEW SYDENHAM SOCIETY, 
 LONDON. 
 
 MDCCCLIX. 
 
PRINTED BY J. E. ADLAKD. 
 
 BABTHOLOMEW CLOSE. 
 
TABLE OF CONTENTS. 
 
 ENQTJIEIES INTO THE NATUEE AND OEIGIN OF 
 EPILEPTIEOEM CONVULSIONS AEISING FEOM PEO- 
 rUSE BLEEDING, AND ALSO OP THOSE OF TEIJE 
 EPILEPSY. 
 
 CHAPTER I. 
 
 PAGE 
 
 Introduction . . . . . . i 
 
 CHAPTER II. 
 
 An interruption in the conveyance of arterial blood to the head of a rabbit 
 
 produces epileptic fits as surely as haemorrhage does . . 7 
 
 CHAPTER III. 
 
 Some observations on finding and tying the great arteries of the neck in 
 
 the rabbit . . . . . .11 
 
 CHAPTER IV. 
 
 Description of convulsive paroxysms occurring in the rabbit after 
 ligature of the great arteries of the neck, and proof of their 
 correspondence with epileptic attacks . . ■ ^3 
 
 CHAPTER V. 
 
 On the phenomena attending death in the rabbit after ligature of the 
 great arteries of the neck, and on the symptoms manifested during 
 restoration of the cirdulation . . . • '7 
 
 CHAPTER VI. 
 
 Sudden interruption in the flow of arterial blood to the head produces 
 phenomena similar to those of epilepsy in different warm-blooded 
 animals, and even in man . . . .24 
 
CONTENTS. 
 
 CHAPTER VII. 
 
 PAGE 
 
 Interruption of the circulation in the great arteries of the neck causes 
 
 arterial anaemia of the brain, and this anaemia produces convulsions . 39 
 
 CHAPTER VIII. 
 
 On the results of post-mortem examinations after death by haemorrhage 
 
 and application of the ligature to the great arteries of the neck . 45 
 
 CHAPTER IX. 
 
 The starting-point of epileptic convulsions from rapid and profuse 
 
 haemorrhage is not to be traced to the spinal cord . . 53 
 
 CHAPTER X. 
 
 On the mode of procedure for determining the cerebral region from 
 
 whence general convulsions after profuse haemorrhage, arise . 60 
 
 CHAPTER XI. 
 
 On the relative importance of the several parts of the brain in producing 
 . general convulsions upon abstraction of arterial blood . . 69 
 
 CHAPTER XII. 
 
 On the nervous centres to which the symptoms exhibited by epileptic 
 
 attacks are to be referred . . . .81 
 
 CHAPTER XIII. 
 Upon those changes in the substance of the brain which are the proximate 
 
 causes of epileptic attacks and affections . . .85 
 
 CHAPTER XIV. 
 
 Upon the nervous centres from which the alterations of the brain 
 
 resulting in epileptic attacks proceed . . . 102 
 
 CHAPTER XV. 
 Synopsis and General Summary .... 104 
 
 APPENDIX . . . . . .108 
 
CONTENTS. 
 
 VU 
 
 ON THE HEALINa PROCESS AFTEE THE EESECTION OP 
 BONES AND JOINTS. 
 
 Introduction ..... 
 
 • "3 
 
 CHAPTER I. 
 
 
 Anatomical Examinations of the Human Body 
 
 . 120 
 
 I.— Resection of the head of the humerus 
 
 . 120 
 
 of the elbow . . i 
 
 . 121 
 
 of the lower end of ulna 
 
 124 
 
 of the hip-joint 
 
 • 125 
 
 of the lower end of the fibula . 
 
 129 
 
 of the inner half of the os calcis 
 
 130 
 
 II. — Resection in the substance of a bone 
 
 130 
 
 III. — Extirpation of bones 
 
 13s 
 
 CHAPTER II. 
 
 
 Experiments and Anatomical Investigations on Animals 
 
 140 
 
 I. — Resections of the eitremities of bones 
 
 141 
 
 II. — Resections from the substance of bones . 
 
 144 
 
 in long bones 
 
 145 
 
 in flat bones 
 
 149 
 
 from short bones . 
 
 152 
 
 HI. — Extirpation of bones 
 
 IS3 
 
 CHAPTER III. 
 
 
 Okiginal Experiments on Animals . 
 
 157 
 
 I. — Resection of extremities of bones 
 
 162 
 
 II. — Resection from the substance of bones 
 
 i8i 
 
 III. — Extirpation of bones 
 
 185 
 
 CHAPTER IV. 
 
 
 Experiments which have puenished the Pkepakations for thi 
 
 
 Plates ..... 
 
 186 
 
 Experiment I (Pigs, i, 2, and 3) . 
 
 186 
 
 II (Pigs. 4 and 5) 
 
 191 
 
 ni (Figs. 6, 7, and 8) . 
 
 192 
 
 IV (Pigs. 9, 10, II, and 12) 
 
 194 
 
 V (Pigs. 13 and 14) . 
 
 198 
 
 VI (Pigs. 15 and 16) . 
 
 202 
 
 VII (Pigs. 17, 18, 19, and 20) . 
 
 205 
 
 VIII (Pigs. 21, 22, and 23) . . . 
 
 207 
 
 IX (Pigs. 24, 25, 26, and 27) . 
 
 211 
 
CONTENTS. 
 
 Chapter IV- 
 
 Bxperiment 3L (Kg. 28) . 
 
 XI (Kg. 29) . 
 
 XII (Kg. 30) . 
 
 XIII (Kg. 31) . 
 
 XIV (Figs. 32 and 33) 
 XV (Kg. 34) . 
 
 Tbanslator's Appehbix to Chaptbb I 
 I. — Excisions of joints 
 
 A. Excision of the shoulder . 
 
 B. Excision of the elbow 
 
 D. Excision of the hip 
 
 E. Excision of the knee 
 
 p. Excision of the lower end of the fibula 
 
 G. Excision of the wrist 
 II. — Kesection from the substance of bones . 
 III. — Extirpation of bones 
 
 PAGE 
 
 214 
 217 
 219 
 221 
 223 
 226 
 229 
 229 
 229 
 231 
 234 
 234 
 
 • 237 
 . 237 
 . 238 
 
 • 243 
 
 THEEB MliMOItlS ON lElDECTOMT IN CERTAIN FORMS 
 OF IRITIS, CHOROIDITIS, AND GLAUCOMA. 
 
 Translator's Preface ..... 
 
 Krst Memoir— On Ibidectomy as a means or Treatment in Chronic 
 
 Iritis and Ikido-choroiditis .... 
 
 Second Memoir— On Iridectomy in Glaucoma, and on the Glaitco- 
 
 MATOtrs Process 
 
 Preliminary ohseryations on glaucoma 
 
 Acute or inflammatory glaucoma 
 
 Chronic glaucoma 
 
 Amaurosis, with excavation of the optic nerve 
 
 Iridectomy in the premonitory stage- of glaucoma 
 
 in the acute period of inflammatory glaucoma 
 
 in the later period of acute glaucoma 
 
 in chronic glaucoma 
 
 in amaurosis, with excavation of the optic papilla 
 
 Third Memoir — Additional Clinicai Remarks on Glaucoma, Glau- 
 comatous Diseases, and their Treatment by Iridectomy 
 
 249 
 251 
 
 287 
 287 
 297 
 303 
 '305 
 313 
 317 
 336 
 344 
 352 
 
 359 
 
ON 
 
 THE NATURE AND ORIGIN 
 
 OF 
 
 EPILEPTIFORM CONVULSIONS 
 
 CAUSED BY 
 
 PEOrUSE BLEEDING, 
 
 AND ALSO OF THOSE OF 
 
 TRUE EPILEPSY. 
 
 ADOLF KUSSMAUL, M.D., 
 
 E or MEDICINE AT THE UNIVERSITY OF HEU 
 AND BY 
 
 ADOLE TENNER, M.D. 
 
 FEOFESSOS OT MEDICINE AT THE III41VEES1TY OF HEIDELBEKGJ 
 AND BY 
 
 TKANSLATED BY 
 
 EDWARD BEONNEE, M.D., 
 
 MEDICAL OrnCEE TO THE ERADFOED ETE AND EAR IHFIEMART. 
 
 THE NEW SYDENHAM SOCIETY, 
 LONDON. 
 
 MDCCCLIX. 
 
NATURE AND ORIGIN 
 
 THE EPILEPTIC CONVULSIONS 
 
 WHICH FOLLOW 
 
 PROFUSE HEMORRHAGE. 
 
 CHAPTER I. 
 INTRODUCTION. 
 
 In man, and, as it wotild appear, in all warm-blooded animals also, 
 a rapid and sufficiently copious loss of blood will give rise to general 
 convulsions. Even those not in the profession must long ago have 
 become acquainted with this when watching animals in the slaughter- 
 house during death by stabbing of the heart or vessels of the neck. 
 It is well known that such is the fact in fowls, sheep, and swine, 
 and Kohl informs us that it obtains also in the whale. 
 
 Hippocrates ^ taught that convulsions might arise as well from ful- 
 ness as from want of blood. KeUie ^ made erperiments with sheep and 
 dogs, Piorry^ did the same with dogs, and both frequently noticed 
 convulsions after a profuse abstraction of blood ; we have also our- 
 selves observed, without a siagle exception, in many cases of dogs, 
 cats, and rabbits,* the occurrence of violent and general convulsions 
 
 ' * Aphorisms,' sect, vi, 48. S7ra<r/tot y'tvovrai i] viTO wXripiiaiog fi Kivuiawc, 
 ovTOj Sk Kol \vyiioe. 
 
 2 Marshall Hall, ' On Bloodletting.' 
 
 ' 'Archives gdn6rales de Medecine,' January, 1826. 
 
 ■* Frogs, from which we extracted the heart, died after breathing for upwards 
 of an hour, at first making frequent lively motions, then gradually becoming 
 weaker ; but we could discover no signs of convulsions. 
 
2 ON CONVULSIONS AFTliR HEMORRHAGE. 
 
 during death from loss of blood. Most of the best hand-books on 
 pathology and forensic medicine also assert that great loss of blood 
 in men frequently brings on convulsions, and that death during such 
 convulsions often takes place after it.' 
 
 More attention has unquestionably been paid by EngKsh physi- 
 cians than by others to the subject of convulsions arising from loss 
 of blood. The frightful vampyrism prevalent in the British islands 
 may have afforded them greater opportunities of observing such dan- 
 gerous consequences than would be presented elsewhere. Wardrop 
 is of opinion that frequently in inflammations as much as from thirty 
 to fifty ounces may be drawn in the first venesectionj and that 
 sometimes even from loo to aoo ounces may be taken away; and 
 Marshall Hall, from whose work on bloodletting this statement is 
 made, mentions many cases from the practice of himself and others 
 in which from loo to 120 ounces of blood were taken away in a 
 short space of time. It is, therefore, no wonder that we have received 
 from England the first explanations of the hydrencephaloid disease 
 arising from exhaustion, as well as more accurate notions on con- 
 vulsions after great losses of blood ; and as Marshall HaU, that inde- 
 fatigable investigator of the physiology and pathology of the nervous 
 system, has gained very great renown from his elucidations of the 
 theory of bloodletting generally, so has he been the first to 
 characterise the hydrencephaloid disease and to examine more closely 
 than any one before him into the nature of convulsions arising from 
 haemorrhage. 
 
 This accomplished physician, in his celebrated work above referred 
 to, remarks, that convulsions, next to swooning, are the most usual 
 and immediate effects of great losses of blood. If they come on 
 after venesection, the presumption is that the quantity taken away 
 has been too large. In his own practice, as well as in that of others, 
 excessive bleedings often occasioned convulsions, which endangered 
 the patients' lives. Travers ^ even mentions (according to Marshall 
 HaU) an idiosyncrasy averse to loss of blood, which manifests itself 
 by a great disposition to convulsions. Many patients were so utterly 
 unable to bear abstraction of blood that they soon fell into con- 
 
 ' If hsemorrhage takes place slowly, and the vital powers are gradually con- 
 sumed, death appears then to ensue with swooning, drowsiness, delirium, and 
 vascular irritation, without convulsions. Compare M. Hall's experiments on 
 dogs, and the numerous clinical observations published by him. 
 
 ^ ' On Constitutional Irritation,' p. 50. 
 
MARSHALL HALL S VIEWS. 6 
 
 vulsions, whilst the circulation became so feeble that they were 
 often obliged to have stimulants employed for many hours before they 
 recovered. A clergyman, from whom ao ounces of blood were 
 taken, had fits which came on at intervals and resembled most 
 violent puerperal convulsions. It was only by the continual admi- 
 nistration of stimulants for a whole day that danger was averted. 
 Operations in which loss of blood was unavoidable were often followed 
 by a disposition to convulsions, by which children in particular fre- 
 quently died. Marshall Hall knew a case of a child dying of con- 
 vulsions the day after the removal of an ordinary-sized nsevus from 
 the head, without any subsequent hsemorrhage. Travers had pointed 
 cut prior to Marshall HaU the similarity between convulsions after 
 loss of blood and those of eclampsia. As far as we know, however, the 
 latter gentleman was the first to lay a decided stress on their correspon- 
 dence with epileptic attacks in general, and to deduce from it some 
 important practical inferences. He distinguished a special kind of 
 puerperal convulsions, arising from loss of blood, which are not to 
 be confounded with those springing from other causes; and he 
 describes the same cause as producing eclampsia infantum. Lastly, 
 he endeavours to ascertain the seat of these convulsions, and in doing 
 80 very closely approaches the question as to the central cause of 
 epilepsy, thus demonstrating the great importance of the subject. 
 If by means of experiment we succeed in detecting the seat of 
 epileptic convulsions from haemorrhage, the problem seems solved 
 as to the part to which in general the origin of epilepsy is to be re- 
 ferred. Marshall HaU has not always, however, been of the same 
 opinion as to the seat of convulsions after haemorrhage. In his work on 
 bloodletting he considers it to be the brain, though he makes no 
 attempt to prove his assertion. In his later work, on ' Diseases of 
 the Nervous System,' he transfers it to the spinal cord, and endea- 
 vours to support this hypothesis by facts. His arguments are, however, 
 by no means convincing or irrefutable, as a closer investigation will 
 show. His proofs are : 
 
 I. The result of one of his own experiments. 
 
 II. That of an experiment by Sir A. Cooper. 
 
 III. The result of certain physiological experiments which led 
 him to assume the so-called excitable cerebral-promnees. 
 
 I. Butchers, when killing sheep, generally divide the large blood- 
 vessels of the neck, and the animal dies convulsed. 
 
 Marshall Hall had the spinal cord divided first and then the blood- 
 
4 ON CONVULSIONS AFTEE HEMORRHAGE. 
 
 vessels. "Thereupon strong convulsions ensued, a result which 
 could alone depend upon the bloodless condition of the spinal cord, 
 since the action of the brain was entirely removed." This experi- 
 ment is related with such laconic brevity that it is impossible to say 
 whether M. HaU was justified in drawing such conclusions. Who 
 divided the spinal cord ? Was the carrying out of such a difficult 
 operation intrusted to the butcher ? Which part of the cord was 
 divided, and how long a time elapsed between its division and that of 
 the blood-vessels ? All these questions ought most certaiuly to 
 have been answered. We shall, further on in this treatise, describe 
 numerous experiments entirely contradicting that of M. Hall, and 
 trust to demonstrate that an oversight must have occurred in some 
 part of his. 
 
 11. Sir A. Cooper ' tied the carotids of a rabbit, which operation 
 accelerated the breathing and movements of the heart, but had no 
 other effect. He compressed the vertebral arteries with his thumb 
 for five minutes, leaving the trachea freely open. Eespiration 
 ceased almost instantly, convulsions came on, the animal lost con- 
 sciousness, and to all appearance was dead. On discontinuing the 
 compression, it drew a spasmodic inspiration and revived. It 
 then lay on one side, making strong convulsive movements, breath- 
 ing with difficulty, and its heart beating rapidly. After two hours 
 it recovered, but its breathing stiU remained difficult. This 
 compression was repeated five times with the same effect. Prom 
 this experiment Marshall HaU would conclude that a diminution of 
 blood in the medulla oblongata, which he reckons as belonging to the 
 spinal cord, produces convulsions. Even if Sir A. Cooper's experi- 
 ment were faultless, this conclusion could not be justified, for, when 
 both carotids and vertebral arteries are tied or compressed, not only 
 is the blood withheld from the medulla oblongata, but from the 
 entire brain. Marshall Hall was only entitled to draw his conclusion 
 on condition that he first proved the occurrence of convulsions upon 
 tying the vertebral arteries alone ; which, however, is not the case. 
 Sir A. Cooper also mentions in the same place, that in another 
 rabbit, whose vertebral arteries had been tied, convulsions only took 
 place after a ligature had been appHed to the carotids as well ; this 
 appears to have been overlooked by M. HaU. We ourselves, in 
 more than twenty rabbits, tied both subclavians close to their respec- 
 
 ' " Some Experiments and Observations on Tying the Carotid and "Vertebral 
 Arteries," in ' Guy's Hospital Reports,' vol. i, p. 465. London, 1836. 
 
MARSHALL HALl's VIEWS. 
 
 tive origins without observing any convulsions. The first-men- 
 tioned experiment of Sir A. Cooper was not^ however, a fair one, 
 for it is impossible to compress the vertebral arteries of the rabbit 
 with the thumb, without at the same time including in the pressure 
 some important parts adjoining, such as the pneumogastric, sympa- 
 thetic, or phrenic nerves, the jugular veins, &c. In a later 
 treatise^ Marshall Hall considered it as unquestionable that Sir 
 A. Cooper did not compress (as the latter conjectured and the 
 former at first took for granted) the vertebral arteries, but the 
 jugular and vertebral veins. 
 
 III. Physiological experience teaches that injuries done to the 
 brain produce only paralysis, whereas lesions of the medulla oblongata 
 and spinal cord, in proportion to their severity, result in convulsions or 
 paralysis. Marshall Hall includes under the term "medulla oblongata" 
 all those parts of the brain designated "excitable" — a title given to 
 them by Mourens — the irritation of which, whether mechanical, gal- 
 vanic, or chemical, is followed by convulsions or cries of distress. 
 Without wishing to contest this great extension of the spinal cord 
 up to the thalami optici, a supposition intimately connected with 
 Marshall Hall's theory on the excito-motor nervous system, still 
 we must observe that the effects of mechanical, chemical, or galvanic 
 irritation cannot be decisive where we probably have to do with 
 another kind of influence of a purely nutritive character. If iater- 
 ruptions in the course of the nerve-tubes within and before the 
 thalami optici cause paralysis, a source of power must necessarily 
 exist above the point of such interruption capable of producing ' 
 motion, and, as is weU known, there is good ground for supposing 
 that the moving principle of the soul is that source. If, then, the 
 conjecture be allowed that every motor impetus of the soul is trans- 
 ferred to the proper motor tubes and muscles by the material altera- 
 tions of the different nerves of the cerebrum^ the possibility cannot 
 be denied that by certaia physical influences the cerebrum might be 
 excited in such a way as to cause movements and even general con- 
 vulsions. At all events, until definite experimental results have 
 proved the supposition to be erroneous, it cannot be disputed that 
 an influence upon the action of the brain, so pecuKar as a rapid 
 abstraction of blood must be, will produce an exciting effect upon 
 those parts of the cerebrum which effectuate motion. We think we 
 
 ' " Synopsis of the class of Paroxysmal Diseases of the Nervous Centres," 
 1851, p. 43, in ' Memoirs on the Nervous System.' 
 
6 ON CONVULSIONS AFTER H^MOBTIHAGE. 
 
 have now suffidently shown that the assumption that the spinal cord 
 is the starting-point of convulsions after haemorrhage is by no means 
 so fuUy estabhshed by Marshall Hall's reasoning as physiologists, 
 especially in England,^ are disposed to beheve. The question as to 
 where this starting-point is must be much further considered and sub- 
 jected to a more rigid examination. In our subsequent pages we 
 shall communicate the results of numerous inquiries on the subject. 
 The question that &st calls for an answer is, whether convulsionsi 
 proceed from a certain limited tract in the cerebro-spinal axis, or 
 whether all its sources of psychical, automatic, and reflex movements 
 are in action at the same time. Whether, in fact, as there exists a 
 " sensorium commune," where all the bod/s sensations are com- 
 municated to the consciousness, and a " nodus vitse " for the respira- 
 tory movements, so also there may not be a "centrum motorium 
 commune," a "nodus epUepticus," from which during haemorrhage 
 the convulsions of all the variously affected groups of muscles proceed. 
 We have, in the second place, sought to point out the seat of epi- 
 leptic fits generally, and in conclusion have ventured to make some 
 observations on the nature of those alterations of the brain by 
 which epilepsy is produced. 
 
 We cherish the hope that we may have succeeded in essentially 
 advancing the theory of epilepsy, and that abler men vriU soon exa- 
 mine, confirm, and extend our labours. 
 
 ' Compare, for example, Pereira, ' The Elements of Materia Medica,' 3d 
 edition, vol. ii, part ii, p. 1797. 
 
CHAPTER II. 
 
 AN INTERRUPTION IN THE CONVEYANCE OE ARTERIAL BLOOD 
 TO THE HEAD OE A RABBIT PRODUCES EPILEPTIC PITS AS 
 SURELY AS HEMORRHAGE DOES. 
 
 More than twenty rabbits, which we either killed intentionally by 
 rapid bleeding, or which expired while being experimented upon, 
 died under general convulsions Kke those observed in epilepsy, and 
 which we shall afterwards more fuUy describe. Not one of those 
 which we saw die from bleeding was exempt from convulsions. 
 These convulsions did not differ in any respect from those we observed 
 in several dogs and cats that died from bleeding, or from those de- 
 scribed as occurring in men dying from haemorrhage. 
 
 No difference, moreover, could be discerned between the fits 
 observed in death from bleeding and those which occurred in about 
 loo rabbits whose carotid and subclavian arteries were tied or com- 
 pressed (by an appropriately fine instrument) below the origin of the 
 vertebral arteries. 
 
 Lastly, we became convinced, by observation of more than a dozen 
 rabbits, that the fits produced by compression'of the above-mentioned 
 arteries resembled in every way those brought on accidentally or 
 intentionally in the identical animals by profuse haemorrhage after 
 circulation had been restored to the head. 
 
 We have seen epileptic convulsions take place without any excep- 
 tion after compression of the arteries of the head in both male and 
 female animals, in those three to four weeks old as well as in others 
 of as many years, in both albinos and coloured, provided only that 
 the animals were of fair health and strength. 
 
 The rule, that a rapid death l^ bleeding, or the ligatv/re of the 
 great arterial trunks of the neck, jjroduces epileptic convulsions, is 
 falsified in the case of very weaJc rabbits and in such as have been subject 
 to the influence of ether. 
 
8 ON CONVULSIONS AFTER HiEMORRHAGE. 
 
 A very oldj lean, and extremely weak rabbit, after the above-named 
 arteries bad been tied, fell into a swoon and expired in a few minutes, 
 without convulsions. In all our numerous experiments in tying 
 the blood-vessels of the neck, this was the only rabbit subjected to a 
 directly debilitating influence on the nervous system, and not under 
 the influence of ether, that we saw die without convulsions. 
 
 Rabbits, when thoroughly stupifled by ether, cease, as we have often 
 observed, to be liable to convulsions during death from haemorrhage 
 or when the arteries of the neck are compressed; but, on re- 
 covering from their stupor, they again become so. 
 
 We only noticed one healthy and strong rabbit, which, in spite of 
 the arteries of its neck having been tied, although falling into a 
 state of great debility resembling a swoon, did not after ten minutes 
 exhibit symptoms of convulsions, whilst yet it had not been subjected 
 to the influence of ether, nor its braia or spinal cord acted upon in 
 any other way. This animal also died in convulsions when we 
 opened the aorta. We suspected in this exceptional case that the 
 brain received in some unusual manner just sufficient blood to pre- 
 vent the approach of convulsions. Sometimes small vessels in the 
 nape are observed to go off directly from the arch of the aorta, and pos- 
 sibly in the example last referred to some blood reached the brain in 
 this way or through unusually large anastomoses of the inter- 
 costal with the vertebral arteries. 
 
 We found in every instance that the closing of aU the four 
 arteries was necessary to produce rapid convulsions. If but one 
 carotid or one subclavian artery has remained pervious, we have 
 never seen convulsions take place, even when the ligature has 
 remained on the other three for several hours; the animals, 
 however, have generally appeared enfeebled, and more or less 
 paralysed. 
 
 It appears, therefore, probable that the convulsions that take 
 place upon the closing of the great arteries of the neck proceed from 
 the brain and are produced by its bloodless condition. The further 
 progress of our investigations wiU raise this conjecture into a certainty. 
 Before however, advancing any arguments we may be allowed — 
 
 I. To make some preliminary observations on the mode of 
 seeking for the great arteries of the neck in the rabbit, and the 
 method of tying them. 
 
 a. To describe with precision the convulsive fits, and to point 
 out their resemblance to those of epilepsy. 
 
THEIR PREVENTION BY CHLOROFORM. 9 
 
 3. To describe the attacks under which death takes place after 
 the ligature, aud the symptoms following restoration of the circu- 
 lation. 
 
 4. Lastly, to show the probability that the rule holds good in 
 human beings as well as in warm-blooded animals generally, that a 
 sudden interruption in the supply of blood to the head causes epi- 
 leptic convulsions. 
 
 We will conclude this chapter with a few remarks upon the 
 experimental fact before stated, that etherization carried to a 
 great extent prevents the hability of animals to convulsions after 
 hsemorrhage. The administration of ether to patients who have to 
 undergo an operation wiE, under certain circumstances, expose 
 them to the danger of death from hBemorrhage, without any warning' 
 having been given by the occurrence either of dizziness, swooning, 
 or the yet more serious symptom of convulsions. This is a fact of 
 the greatest importance as regards anaemic persons or those who do not 
 generally bear hsemorrhage well, and consequently are easily brought 
 into danger thereby. 
 
 There are good grounds for the conjecture that many who are 
 supposed to have died from chloroform on the operation-table did 
 not die from being poisoned, but from excessive loss of blood. As 
 to the treatment of epileptic attacks with ether, it seems established 
 that inhaling ether or chloroform during the first approaches of an 
 attack may prevent an outbreak of convulsions. This does not, 
 however, prove that the morbid state of the brain originating the 
 attack is removed, since, for example, in our own experiments the 
 anaemic state of the brain continued in spite of the administration 
 of ether, and the condition was only concealed, not removed. Such a 
 method of cure we consider in a general way to be iajurious, 
 and even dangerous, inasmuch as a certain degree of asphyxia 
 accompanies every epileptic fit, acting injuriously upon the nutrition 
 of the brain, upon which also etherization acts very prejudicially. 
 At the end of our treatise we shall demonstrate the probabihty that 
 one and the same influence is the cause of numerous forms of 
 epilepsy, namely, sudden interruption of the nutritive supply to the 
 
 It stands to reason, then, that everything should be scrupulously 
 avoided that assimilates the arterial blood to the condition of venous, 
 and thereby deprives it of the capability of duly nourishing the 
 
19 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 brain. We do not, however, deny the value of etherization in cer- 
 taia cases. By diminishing excessive irritability in some parts of 
 the nervous system it may sometimes arrest the attacks at their 
 source j we only doubt its usefulness when it is expected to act on 
 that central focus, the brain, and should, under such circumstances, 
 be afraid of paralysis of the meduUa oblongata. 
 
CHAPTEE III. 
 
 SOME OBSERVATIONS ON FINDIKG AND TYING THE GREAT 
 ARTERIES OP THE NECK IN THE RABBIT. 
 
 We made some slight deviations from the procedure of which one 
 of us published an accoimt iu the 'Yerhandl. der phys. medicin. 
 Gesellschaft in Wilrzburg/ 1855, vol. vi, part i. After cutting 
 through the skin and muscles, and breaking and removing the 
 superior part of the sternum as there described, we divided, by the 
 aid of forceps and knife, the fascia and surrounding fat (which 
 in well-fed animals cover the great arteries), together with their 
 sheaths. After this we laid the knife entirely aside, and made use 
 of two fine pairs of forceps. "We carefully separated the small 
 fatty lumps from both sides of the innominate trunk, and dividing 
 the cellular tissue surrounding it, passed under the vessel thus 
 laid Dare a strong silken thread, by means of a small ligature- 
 hook specially made for the purpose. The use of the forceps iustead 
 of the knife considerably abridges the operation, and protects 
 the pleura from bleeding and injuries. An assistant then draws the 
 innominate a little to the right and forward, whilst the operator 
 dissects with the two pairs of forceps close to the left edge of the 
 innominate and of the left carotid, and removes or pushes away the 
 fat on either side, dividing the cellular tissue and gradually penetrating 
 deeper towards the arch of the aorta. When the left subclavian 
 appears, it is likewise laid bare and surrounded by a ligature, or 
 immediately tied. Accidents, such as hsemorrhages, lesions of the 
 pleurae, pericardium, thoracic duct, or the left sympathetic nerve, 
 very rarely occurred, owing to the great facility we had from practice 
 acquired in this operation; and we generally accomplished the whole 
 in from ten to fifteen minutes, seldom requiring more than from 
 twenty to thirty. For compressing the blood-vessels we used the 
 small polished forceps described in our treatise ' On the Influence of 
 
12 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 the Mow of Arterial Blood upon the Temperature of the Ear of the 
 Eabbit/ ' 
 
 In more than eighty rabhits the right subclavian and both carotids 
 commenced in a common innominate artery, the length of which 
 considerably varied, and sometimes appeared reduced to nothing, 
 while the left subclavian commenced independently from the arch of 
 the aorta. In two animals the right subclavian did not arise from 
 the innominate, but to its left side, near the left subclavian, and 
 passed to the right side behind the oesophagus. The comparative 
 sizes of the innominate, carotids, subclavian and vertebral arteries, 
 varied considerably in different animals. 
 
 ' Molesohott's ' Untersuohungen zur Naturlelire des Mensehen und der 
 Thiere,' vol. i, p. 104. 
 
CHAPTER IV. 
 
 DESCRIPTION OF CONVULSIVE PAUOXYSMS OCCURRING IN 
 THE RABBIT AFTER LIGATURE OF THE GREAT ARTERIES 
 OF THE NECK, AND PROOF OF THEIR CORRESPONDENCE 
 WITH EPILEPTICAL ATTACKS. 
 
 General convulsions usually followed in from eight to eighteen 
 seconds after complete withdrawal of arterial blood. We killed six 
 rabbits solely for the purpose of determining in what space of time 
 convulsions would come on. After the arteries had been laid bare, 
 -and the ligatures had been passed round, we allowed the animals to 
 rest undisturbed in an erect position for a quarter of an hour, 
 without making any experiments by compression. One of us then, 
 as qtiickly as possible, tied the left subclavian and innominate arteries, 
 while another, watch in hand, observed the time when the symptoms 
 first manifested themselves. In a very strong male rabbit, two years 
 old, general convulsions came on three seconds after the innominate 
 had been tied j and this is the shortest period that we have noticed 
 in any. In two female white rabbits, four weeks old, the convulsions 
 appeared after an interval of twelve seconds; in a female gray 
 rabbit, two or three years old, in ten seconds ; in a male of the same 
 age, in sixteen seconds ; and in an old strong female, from four to 
 five years old, in forty-five seconds. None of these animals lost 
 during the operations any considerable quantity of blood. 
 
 Out of a hundred strong rabbits we met with four oidy in which, 
 after perfect closure of the above-named vessels, convulsions did not 
 appear tiU after four to six minutes, and one only, as already men- 
 tioned, in which they did not appear at all after the lapse of ten 
 minutes and until the aorta had been opened. The extremities of 
 these five animals became speedily paralysed after the operation, so 
 that they were unable to remain any longer on their legs, but fell on 
 the table as though in a swoon. 
 
14 ON CONVULSIONS AFTER HjEMOEEHAGE. 
 
 The occurrence of convulsions is, without exception, preceded by 
 many different movements, most of which have been more fully 
 described in Kussmaul's above-mentioned treatise.' We wiU here 
 only briefly aUude to some of them : — 
 
 I. Immediately after stoppage of the blood the various sphincter 
 muscles of the face contract, especially, and in a very striking manner, 
 those of the iris and eyelids ; then, in the order of their distinct- 
 ness, the conchse of the ears, the nostrils, and the mouth. The 
 jaws, which are generally already closed, become spasmodically 
 locked. Then, usually a httle before but sometimes simultaneously 
 upon the occurrence of general convulsions, the pupils, and the 
 fissures of the eyelids, ears, and nostrils are widened, sometimes 
 the mouth also very distinctly. The adductors of the under jaw seem 
 also for a few moments to become paralysed, but duriag the attack 
 the jaw becomes locked, either uninterruptedly or in broken succes- 
 sion, by the alternate occurrence of spasmodic and more feeble 
 abductions and stronger adductions. 
 
 %. Convulsive efforts are almost invariably made to turn the 
 pupils towards the internal angles of the eyes ; after which, the eye- 
 balls generally roU about, first inwards, forwards and downwards, 
 .then outwards, backwards and upwards, until at length the pupils are 
 turned towards the external angles of the eyes, and are wholly or 
 partially concealed by the upper eyeHds. 
 
 3. The eyeballs are first drawn back into the sockets, and again 
 become prominent as the pupils dilate. 
 
 4. Eespiration is at first accelerated, but shortly afterwards, a 
 little while before the approach of general convulsions, it becomes 
 prolonged and deep. 
 
 5. The muscles of the neck generally become paralysed and unable 
 to bear the weight of the head, which sinks down upon the breast or 
 side, the animals afterwards falling down in a swoon on their fore 
 feet, occasionally on their hind ones. These symptoms of paralysis 
 are the more distinct and constant the greater the time that elapses 
 before general convulsions come on. 
 
 The signal for general convulsions is given by a tonic contraction 
 of the muscles of the neck. Then commences a terrible scene, the 
 more surprising by contrast if preceded by swooning. The head is 
 drawn violently backwards ; the pupil becomes uncommonly enlarged; 
 
 ' Vide ' Zeitscluift des Wiirzburg. Phys. Med. Vereins.' 
 
EXPERIMENTS IN ANIMALS. 15 
 
 violent lock-jaw ensues; and the animal, if strong, is generally 
 flung forwards with great force, to a distance even of from one 
 to two feet, and sometimes over the shoulders of the observer 
 seated before it. The legs are alternately contracted and extended, by 
 clonic convulsions, in the most violent way; the enlarged pupil 
 appears again fixed in the centre of the palpebral fissure, as the 
 eyeball is again roUed somewhat inwards; respiration is scarcely 
 to be perceived, while the heart continues throbbing very vigorously. 
 The clonic convulsions gradually subside, assuming more the 
 appearance of tetanus, and eventually disappear altogether, passing 
 away as they do so from the front to the back. First the muscles of 
 the neck and fore legs become paralysed, whilst the back part of the 
 body is bent backwards and the hind legs are tetanically extended, 
 until these movements also cease. The duration of these attacks 
 was, according to several observations, from eighteen seconds to two 
 minutes. 
 
 Very frequently, after a pause of from fifteen to seventy-five 
 seconds, a second attack comes on, always weaker and shorter than 
 the first, and often limited to the hinder part of the body in the form 
 of tetanic convulsions; sometimes, however, affecting the whole 
 body, under the form of clonic convulsions. We once observed 
 such a second attack to last, in an exceptional case, two minutes. 
 Sometimes, indeed, convulsions, in which the hind legs become 
 tetanically stretched, recur even for a third and fourth time, at 
 intervals of from fifteen to thirty seconds. They returned in the 
 strongest and most regular manner in those animals whose arteries 
 were tied forthwith, and whose strength had not been previously ex- 
 hausted by experiments of compression. Towards the end of the 
 attacks urine and faeces were sometimes voided ; at other times no 
 such voiding took place, even when the bladder was full. 
 
 In rabbits, cats, and dogs, dying from haemorrhage, the convul- 
 sions are of exactly the same character. 
 
 These convulsions present precisely similar features to those of 
 epilepsy in their complete form, as the following enumeration of the 
 most important symptoms wiU show : 
 
 I. The animals fall down before general convulsions come on, 
 and completely lose the spontaneous use of their muscles. 
 
 a. They give the observer the impression of their being per- 
 fectly unconscious. 
 
 3. Not one of the many animals operated upon, cried out, so 
 
16 ON CONVULSIONS AFTER HjBMOBRHAGE. 
 
 long as the circulation was interrupted ; either before or during the 
 spasmodic attack, and two only whilst the latter was abating. Sub- 
 sequently, however, they began to cry piteously, directly arterial 
 blood began to flow again, or, at all events, soon afterwards. Prom 
 the want of power to cry, and from the gradual swelling of the veins 
 of the brain during the attack, to which we shaU. direct attention 
 further on, we infer that spasm of the glottis (laryngismus) took 
 place. 
 
 4. The pupils are dilated during the attacks, and, to judge from 
 several experiments, appear rigid, the eyeballs being motionless. 
 Before and subsequent to the attacks, however, and when at the 
 very last gasp, the pupils being at the same time very much enlarged, 
 the eyes of some animals that we accurately examined appeared 
 sensible to the influence of light. 
 
 5. The attacks commence with a tonic spasm of the muscles of 
 the neck (trachehsmus). 
 
 6. Eespiration ceases, whilst the heart continues beating. 
 
 7. The hmbs are seized with strong clonic convulsions, and 
 become at last spasmodically stretched. 
 
 ' It is generally acknowledged that in a fully developed attack of epilepsy 
 the pupil ceases to be contracted by the influence of light. But Kussmaul 
 recently observed the highly dilatpd pupils of a boy contract strongly by 
 light during a very violent attack of eclampsia, which lasted for two hours. The 
 lad died in a perfectly unconscious state from tuberculosis of the meninges and 
 caries of the lowest dorsal vertebra. 
 
CHAPTER V. 
 
 ON THE PHENOMENA ATTENDING DEATH IN THE RABBIT 
 AETER LIGATDRE OE THE GREAT ARTERIES OF THE NECK, 
 AND ON THE SYMPTOMS MANIFESTED DURING RESTOR- 
 ATION OE THE CIRCULATION. 
 
 iNTEERtrpTiON of the circulation in the great arteries of the neck 
 causes death when continued; but, if the circulation be restored, the 
 animals recover, unless the organs essential to life have been so 
 affected as to be unable to continue their functions. 
 
 If the circulation continues arrested when the epileptic attack is 
 over, the animal does not die immediately, nor is it incapable of 
 prolonged existence. Some extremely deep, sighing respirations 
 still occur at intervals of five, eight, ten, and twelve seconds, but 
 seldom more. 
 
 These are the more vigorous, rapid, and frequent, the less the 
 animal has been subjected to experiments of compression before the 
 application of the permanent ligature. They sometimes even still 
 take place, when fine red bubbhng foam flowing from the nostrils, 
 indicates that an extensive oedema of the lungs has supervened. 
 
 During these deep respirations the animal widely opens its mouth 
 and jaw-bones, and distinct sounds both of inspiration and expiration 
 are heard at the walls of the chest ; whereas in the normal respi- 
 ration of the rabbit, or when its breathing is simply accelerated, 
 only sounds of inspiration are heard. At each deep inspiration the 
 chest is seen to expand enormously, and air penetrates the wound 
 below the sternum. Frequently air passes forward behind the 
 latter and before the heart, between the laminae of the mediastinal 
 connective tissue, and sometimes it even enters into the pleural cavi- 
 ties producing pneumo-thorax. In what manner, and where, the 
 pleurae are lacerated in this process we could not ascertain!. 
 
 The last gasp generally takes place in from three to five minutes 
 
 2 
 
18 ON CONVULSIONS AFTER HAEMORRHAGE. 
 
 after the left artery has been tied, seldom later. In every experi- 
 ment, without an exception, the heart continued to beat vigorously 
 for some time after the last breath. In some instances we could, 
 with the stethoscope at the chest, hear the pulsation of the heart 
 even half an hour afterwards, or through the open cavity of the 
 abdomen see it beating on the other side of the diaphragm. The 
 diaphragm of the rabbit is so transparent, as to allow the situation 
 of the adjacent thoracic viscera to be clearly seen. In this manner 
 it can always be readily ascertained when air has entered the 
 pleural cavity. 
 
 When the thorax was not opened, the heart seldom ceased beating 
 before the tenth minute. If the heart, which had throughout been 
 over-filled with blood, was exposed to the air after pulsation had 
 temporarily ceased, it began to beat again in all its parts even a quarter 
 and half an hour after the last breath. In a full-grown gray rabbit 
 it even continued beating vigorously after the lapse of an hour, not- 
 withstanding the hind legs had become rigid immediately after the 
 last breath. The same phenomenon was observed by Dr. Mayer, of 
 Bonn, who has published, in the 'Act. Phys. Med.-Acad. Cses. 
 Leopold. Carol.,' of the year 1833, t. xvi, a, p. 68, his anatomico- 
 physiological researches on the brain, spinal marrow, and nerves, 
 wherein he gives an account of numerous experiments on the com- 
 pression of the carotids in dogs, rabbits, a horse, a goat, and a dove. 
 After having tied the left subclavian artery and the innominate artery 
 of a rabbit, complete paralysis of the head and fore legs imme- 
 diately took place, followed by strong tetanic (?) shocks of the trunk, 
 dilatation of the pupils, and death itself within a minute. Forty 
 minutes after, the animal having remained in the stjjB&iess of death 
 for ten minutes, the heart stOl beat eleven strokes a minute. 
 
 These cases offer a striking exception to the ordinary rule, accord- 
 ing to which the left heart is usually the " primum moriens." In 
 every instance, however, the left ventricle died before the other parts 
 of the heart, contracting itself, and becoming pale and rigid ; the 
 right auricle was the last to die. 
 
 Urine and faeces were often voided with the last gasps, or even 
 later, while the cadaveric rigidity usually appeared sooner in the 
 hind than m the fore legs. K, after tying the left subclavian artery, 
 the ligature was removed from the carotid before the animal was 
 at the last extremity, the use of its cerebial and muscular powers 
 was almost without exception restored with remarkable rapidity in a 
 
EXPERIMENTS ON ANIMALS. 19 
 
 few seconds. This was sometimes successfully brought about even 
 when the animal was just dying. When deep respirations recurred 
 only at long intervals, the pupils having been already dilated to 
 such a degree that the diameter of the iris was only one to two mil- 
 Kmeters — a state of dilatation which Bouchut (erroneously, it is true, 
 and as these experiments prove) considered to be the sure fore- 
 runner of death. But in such a case it always took longer before 
 respiration was restored and the animal regained power over its 
 muscles. Thirty-six, forty-five, and a hundred and twenty minutes 
 after the application of the ligature (which we succeeded in removing 
 again with the scissors from the trunk of the carotid), and even in 
 a case where these attacks came on five minutes only after the 
 application of the Kgature, we saw, seven minutes afterwards, respi- 
 ration gradually assuming its normal state with a return of conscious- 
 ness, and of power over the muscles of the body. It may be, as 
 before mentioned, that in the latter case, after the great vessels of the 
 neck had been tied, some blood stiU found its way through collateral 
 channels, and the approach of convulsions was thereby retarded for 
 an unusual length of time. We cannot, consequently, from this ex- 
 periment, determine with absolute certainty how long the brain of 
 the rabbit can remain completely deprived of arterial blood ;i but, 
 from the result of our first experiments, the assumption appears well 
 grounded, that the brain of the rabbit can remaiii dep-voed of arte- 
 rial blood for two minutes without losing its ca/pahilAty of again 
 performing its functions upon the renewal of the circulation. 
 
 A singular phenomenon is presented when the ligature is removed 
 at the precise moment that the convulsions are raging in their 
 greatest intensity. As if speR-bound by the wand of a magician, 
 these convulsions generally cease immediately, and the sudden change 
 from the most frightful spasm to complete relaxation of the system 
 offers a most striking contrast. The rigidly contracted muscles of the 
 neck become paralysed, and the head sinks forward, as though drawn 
 by a heavy weight. Sometimes, the moment the blood lows in, the 
 animals move straight forward, as though the quantity of blood rush- 
 ing into the head would throw them down headlong ; and then they 
 fall to the ground paralysed. Upon the cessation of the flow of 
 
 ' We are here obliged to anticipate the course of our researches by taking it 
 for granted that a deficiency of red blood in the brain is caused by the ligature, 
 althouo-h we cannot prove this assumption until afterwards. 
 
20 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 blood to the head they gradually raise themselves up, or jump up as 
 if awakening from a deep unconsciousness, while sometimes they cry 
 out and endeavour to run away. If the sluice be opened before 
 general convulsions come on, just when the muscles of the neck 
 begin to contract, the animals frequently kneel down, and at length 
 lie on the breast and belly, upon the table. > 
 
 Convulsions are never produced by this strong flow of axterial 
 blood into the head, as might be expected according to the physio- 
 logical theories of the present day, not even when both cervical 
 branches of the sympathetic have been divided and the superior cer- 
 vical ganglia destroyed. On the contrary, numerous groups of 
 muscles become paralysed. Thereupon ensues relaxation of the 
 sphincters of all the moveable orifices of the head, of the iris and 
 eyelids ; of the muscles of the conchas, nostrils, and mouth ; of the 
 attractors of the lower jaw ; of the retractors of the eyeballs ; of 
 the muscles of the neck and Hmbs. The pupils are frequently 
 dilated to as great an extent as is observed in the animal when 
 dying, so that the dilator of the iris seems to be actively concerned ; 
 the dilatation of the orifices of the lids and of the conchee is also 
 generally very remarkable, that of the orifices of the nostrils and 
 mouth less striking. 
 
 If the circulation has been restored during a completely developed 
 epileptic attack, respiration does not return immediately. Some 
 seconds elapse before one or more deep, slow, but noiseless inspira- 
 tions take place, during which the nostrils are considerably widened 
 and the month opened. As the rush of blood decreases, deep 
 respiration becomes gradually more rapid and easy, the orifices con- 
 tract again to their usual size, the protruding eyeball recedes into its 
 socket, and power over the neck and limbs is restored to the animal. 
 
 The astonishing power of banishing the most frightful convulsions 
 which, in these experiments, was possessed by the red blood, strongly 
 demonstrates the folly of the injudicious practitioner who resorts to 
 the lancet immediately on the appearance of violent symptoms of 
 irritation proceeding from the brain. The opinions of eminent 
 physicians, from the distant age of Hippocrates and Aretseus (those 
 sound observers, possessed of more correct ideas upon the treatment 
 of epilepsy than the greater part of those amongst us who have since 
 written upon the subject^), up to Marshall Hall's classical researches 
 
 1 Compare Delasiauve, 'Traits de I'Epilepsie,' 2e partie, ch.i, Histoire du 
 Traitement, p. 308. 
 
BLOODLETTING IN EPILEPSY, 21 
 
 upon bloodletting and hydiocephaloid disease, have apparently- 
 fallen unheeded upon the ears of bloodthirsty quacks. Physicians 
 engaged in treating the insane do not grow weary of relating their 
 experience on the prejudicial consequences of bloodletting and of the 
 debilitating treatment so often employed as the chief remedy in 
 epilepsy and mania, in the earHer stages of imbecility attended with 
 progressive paralysis, and in every excitement of lunatics : their 
 warnings die away within the walls of the asylum. To no purpose 
 is it, as regards epilepsy, an established fact that poor-blooded 
 subjects are oftener attacked than full-blooded ones, that debilitating 
 passions, losses of blood and semen, vicious formation or adultera- 
 tion of the blood (as by alcohol, lead, &c.), and finally congenital 
 weakness of the brain (idiotismus congenitus), in most instances 
 bring on the attack. In vaia do numerous experiments on men 
 and animals warrant the correctness of the doctrine that blood- 
 letting and aU treatment of too debilitating a nature increase the 
 number of the attacks and accelerate their final transition into im- 
 becility and consumption. In vain is advice given to examine most 
 conscientiously the degree of strength in the patient, the condition 
 of the brain's circulation, and cautiously to investigate the causes of 
 the disease before adopting any treatment. The number of those 
 who in all kinds of epilepsy thoughtlessly apply debilitating remedies, 
 at least at the beginning of the disease, is still very great, although 
 the profession in the present day acts on better principles than 
 formerly ; an assertion which cannot yet be made of the treatment 
 of lunatics in the state of maniacal excitement. 
 
 The specific remedies especially in vogue for epilepsy have all a 
 but slightly active or reducing effect upon the organism. They are 
 by no means chosen from the class of mercurials, antimonials, or 
 preparations of lead, but from metals of milder action, such as silver 
 and zinc, which have proved particularly useful. Wormwood and 
 valerian root are also very efBcacious remedies ; but good, plain, and 
 weU-regulated diet, and the " traitement moral," stand pre-eminent. 
 To the latter category, however strange it may appear, most surgical 
 modes of treatment appear to belong. Tracheotomy, hgatnre of 
 the carotids, cauterization of the pharynx, and the other surgical 
 operations generally recommended, and adopted with temporary or 
 lasting success, would in most instances prove useful on the same 
 grounds as the appHcation of any new and yet untried remedy. 
 
 Though ligature or compression of the carotid may in some few 
 
22 ON CONVTJLSIONS AFTER HEMORRHAGE. 
 
 instances have been of service, yet it does not necessarily follow that 
 it was the ansemic condition of the brain that in these cases, produced 
 the favorable result. Apart from the influence just now mentioned 
 of such operations upon the mind of the patient, we must not forget 
 that the arrest of circulation in a vessel produces an increased 
 determination of blood to the collateral vessels. In individuals 
 still possessing an adequate or normal quantity of blood, the closing 
 of the carotids will necessarily cause an increased flow through the 
 vertebral arteries. Let us imagine an epileptic seizure in an indi- 
 vidual, originating in an anaemic state of the posterior and excitable 
 parts of the brain — ^the medulla oblongata, for instance — which con- 
 dition affects but sympathetically the rest of the brain. Compres- 
 sion of the carotids may achieve a cure, not because of the resulting 
 anaemia of the cerebrum, but by the induced hypersemia of the pos- 
 terior part of the brain. Moreover, it is also to be remarked, that 
 every compression of the carotids, however brief, is closely followed 
 by cerebral congestion. Prom the short duration of the compression, 
 as usually appHed, it is difiicult to say how much of the remedial effect 
 is to be ascribed to the cerebral anaemia, sHght in itself, or to the 
 hyperaemia, sequential to it. 
 
 We need scarcely remark that we do not mean absolutely to reject 
 venesection or low diet. Cases but too frequently happen where a 
 rapid abstraction of blood, especially from the external jugular vein, 
 becomes imperative, in order to relieve the brain from congestion of 
 venous blood with which it is surcharged, to facilitate the access 
 of arterial blood, and to arrest an attack of apoplexy. "Wliere epi- 
 lepsy occurs in a patient of luxurious habits and addicted to the 
 pleasures of the table, it is always advisable to enjoin a strict and 
 simple regimen. 
 
CHAPTEE VI. 
 
 SUDDEN INTERRUPTION IN THE FLOW OP ARTERIAL BLOOD 
 TO THE HEAD PRODUCES PHENOMENA SIMILAR TO 
 THOSE OP EPILEPSY IN DIPPERENT WARM-BLOODED 
 ANIMALS, EVEN IN MAN HIMSELP. 
 
 As sudden interruption in the passage of red blood to the head 
 causes epileptic convulsions in the rabbit, it is highly probable that 
 such a condition will produce the same effect in all warm-blooded 
 animals, from their general agreement in the two conditions indis- 
 pensable to such a result ; firstly, from their nourishment by warm 
 and red blood; secondly, their liability to epileptic convul- 
 sions. The inference is the stronger, inasmuch (as it has already 
 been shown), that birds, mam m alia, and men are rendered uncon- 
 scious, and prone to general convulsions, by great loss of blood. 
 And, again, experience shows that, after great loss of blood, mam- 
 mifers, including man, are much more readily subject to faintings 
 and convulsions when in an erect than when ia a decumbent pos- 
 ture. This fact can only be explained upon the assumption that 
 the enfeebled power of the heart, when erect, is no longer 
 capable of overcoming the weight of the blood, and of driving 
 it upwards into the brain. Deficiency of red blood in the brain 
 leads, in this instance, to general convulsions, which commonly 
 cease immediately the body is placed in a horizontal position or the 
 head lowered below the level of the trunk.' Marshall Hall's dis- 
 tinguishing merit consists, as is weU known, in his drawing atten- 
 tion to these facts and deducing therefrom an important practical 
 rule for adoption in venesection, viz., to bleed the pAtient in an 
 upright and not in a reclining position, so that the nervous system 
 
 » Compare Marshall Hall, ' On Bloodletting,' p. 58, et seq. ; Burrows, 
 • Observations on Diseases of Cerebral Circulation of the Blood,' Posner's edi . 
 tjon, 1847 ; and Kussmaul's experiments in the ' Verhandl. der phys. med. Ges. 
 zu Wiirzburg,' 1855, p. 37. 
 
24 ON CONVULSIONS AFTER HJiMOKRHAGE. 
 
 may be more speedily influenced, and tlie abstraction of too large a 
 quantity of blood avoided. It is an old estabHshed rule that 
 persons after losing much blood should assume a horizontal position, 
 the head being kept very low. 
 
 We possess, moreover, a number of experiments and observations 
 on animals and men, which clearly prove that stoppage in the circu- 
 lation of the great arteries of the neck produces epileptic convulsions 
 in other animals than the rabbit. 
 
 Mayer^ saw a dove, ia which the carotids and the arteries of the 
 wings had been simultaneously tied, expire ia convulsions and tetanic 
 spasms so violent as to cause the tied vessels to burst. 
 
 Sir A. Cooper's experiment is well known. He tied both the 
 carotid and vertebral arteries of a dog. The animal appeared 
 to lose sensation, as though intoxicated. It breathed with diffi- 
 culty. The pupils became dilated, and the animal fell over on its 
 side and became convulsed. Stupor and general paralysis having 
 been present during two days, the animal completely recovered, 
 and proved a useful house-dog. Nine months afterwards Sir A. 
 Cooper kUled the animal for the purpose of injecting the arteries, 
 and he found extremely large and numerous anastomoses.^ 
 
 Panum' repeated Sir A. Cooper's experiment, and observed a 
 circumstance explanatory of the dog's survival. After tying both 
 the carotid and vertebral arteries, the dog became convulsed and 
 swooned away, the mucous membrane of the mouth appearing pale. 
 In a little time the animal again opened its eyes and lay quiet for 
 four hours, breathing very deeply and slowly, but regularly; and, 
 although extremely weak, able to stand when lifted up. That the 
 brain still contained a plentiful supply of blood was demonstrated 
 by the following fact : Upon opening the carotid above its ligature, 
 some minutes after its application, such a quantity of blood streamed 
 out, that Panum was obliged to apply immediately a fresh ligature 
 higher up. After having killed the animal and injected its arteries, 
 he found that, between the second and third cervical vertebrae of 
 the dog, very considerable branches from the vertebral arteries are 
 given off to the spinal cord, which unite and form a common stem 
 ascending to the brain, and separate again higher up into two 
 
 ' Loc. cit., p. 719. 
 
 ' Loc. cit., with a drawing of the anastomoses, p. 457. 
 3 On Death by Embolia, 'Zeitsohi-. f. Klin. Medizin von Giinsburg,' 1856, 
 vol. yii, p. 409. 
 
EXPERIMENTS ON HOUSES. 25 
 
 branches, whicli contribute to the formation of the basilar artery. 
 If, therefore, both the carotid and vertebral arteries are tied just 
 where they pass from the canal of the epistropheus into that of the 
 atlas (as was probably done by Panum and Sir A. Cooper), the brain 
 of the dog is stiU. able to receive large quantities of blood. 
 
 In the horse the basilar artery is not formed by the junction of 
 the vertebral, but by that of the occipital arteries within the foramen 
 magnum. The vertebral arteries have not therefore much to do 
 with the nutrition of the brain.i When entering the vertebral 
 canal they are of tolerable size, but become thread-like before they 
 reach the cavity of the cranium. Tying the carotids of the horse will 
 consequently be followed by the same results as are brought about by 
 ligature of the carotids and vertebral arteries of the dog and rabbit. 
 Such was the case in a horse whose carotids were tied by Mayer.^ 
 Weakness of sight, dizziness, falling suddenly down as though struck 
 by lightning, foaming at the mouth, convulsions, and ravings suc- 
 ceeded, and death after a short tetanus, fifty-eight minutes after the 
 operation. Jobert de Lamballe seems to have met with a similar 
 result after the same operation. His treatise, quoted by Norman 
 Chevers,3 to my great regret, I have been unable to procure. If, 
 however, the ligatures on the several arteries of the horse are 
 applied at somewhat longer intervals, so that a collateral circulation 
 can take place, the issue is not invariably fatal. Alessandrini* tied 
 both carotids within thirty-six days, the application of each ligature 
 being preceded by copious venesection. On the application of the 
 second ligature the animal fell on its side, and exhibited signs of 
 stupor; but, nevertheless, recovered without faUing into con- 
 vulsions. 
 
 With regard to man, we do not possess, as far as we are aware, 
 any observations upon the simultaneous and sudden stoppage in the 
 circulation of the blood in the four great arteries of the head. 
 
 ' Stannius, 'Lehrb. der vergl. Anat. der Wirbelthiere,' 1846, p. 440. 
 
 ' Loo. cit., p. 691. 
 
 3 Norman Chevers, Remarks on the Effects of Obliteration of the Carotid 
 Arteries upon the Cerebral Circulation, in ' London Med. Gaz. 'Oct. 31, 1845, 
 pp. 1140 — 1151. 
 
 * Schmidt's ' Jahrbiicher,' 1840, vol. xxvi, p. 322. The experiment of tying 
 both carotids in a horse, made by Rossi and Sessona, as related in Canstadt's 
 'Jahresbericht,' 1856, section Yeterinary Medicine, p. 7, is incorrect, and 
 therefore of no avail to our argument in this place, since the right jugular vein 
 was tied simultaneously. 
 
26 ON CONVULSIONS AFTER HAEMORRHAGE. 
 
 Gradual occlusion of these vessels may take place without producing 
 convulsions, as is shown by Davy's' remarkable observation (in an 
 officer of rank, aged fifty-five years), of the closing of both the 
 carotid and subclavian arteries, in consequence of an aneurism of the 
 arch of the aorta. The patient suffered from frequent a,ttacks of 
 fainting and giddiness, occurring subsequently at longer intervals, 
 until the pulse could be no longer felt in the neck, temples, arm- 
 pits and arms. Fifteen months afterwards the patient suddenly 
 expired while on a journey, in consequence of laceration of the aorta 
 at its base. All the large vessels springing from the arch of the 
 aorta were closed at their origins, while the intercostal arteries were 
 enlarged, so that the collateral circulation must have been effected 
 by the latter and the internal mammary artery. 
 
 It is to be regretted that we know nothing of the symptoms 
 manifested during life in a man who was dissected by an American 
 named Darrach. In this case likewise the innominate artery and 
 left carotid were found obliterated by an aneurism.^ 
 
 In man we have merely some few cases recorded of sudden and 
 partial interruption of the circulation in the head, occasioned by 
 compressing or tying the great arteries of the neck, or by the ob- 
 struction of the great cerebral arteries by means of plugs, espe- 
 cially by those brought from other parts. 
 
 Sudden stoppage in the flow of blood through the carotids is 
 attended by the exhibition of more striking phenomena in man than 
 in either the dog or the rabbit, from the greater development of the 
 human brain and the exceptional distribution of vessels to it. This 
 fact has received ample confirmation from experiments both in the 
 compression of the carotids of men and in the tying of the carotids 
 of men and animals, as frequently performed by physiologists and 
 surgeons from the remotest ages. We refer to the careful history 
 of these experiments in Norman Chevers's critical treatise, without in 
 this place entering more fuUy into the subject of tying the carotids 
 of animals.* We may, however, observe that Norman Chevers was 
 
 ' ' Fide N. Chevers,' p. 1144. 
 
 ° Gerson and Julius Magazin, vol. xiv, p. 338, with a drawing of the pre- 
 paration. 
 
 ' The most important experiments have been performed by Bichat, Mayer, 
 Sir A. Cooper, Jobert, and Miller. Those of the latter are to be found in the 
 'Gazette m^dicale, 1843,' p. 107. Compare also the results obtained from the 
 application of the ligature on both carotids in nineteen rabbits by Kussmanl. 
 (loc. oit.) 
 
COMPRESSION OF THE CAROTIDS IN MAN. 27 
 
 unable to reconcile the conflicting statements of physiologists, 
 doubtless because he had himseK never performed the experiments 
 on which they were based. Thus, Mayer observed dangerous con- 
 sequences much more frequently than Bichat, Cooper, Jobert, and 
 MiUer ; which is to be ascribed to the circumstance that Mayer did 
 not distinguish with sufficient exactness between the results of 
 arresting the circulation of the blood on the one hand, and the 
 operation itself on the other. The former, as we can safely assert 
 from numerous experiments, are always very slight in the rabbit, 
 whilst the latter are frequently very considerable, when suppuration 
 of the cellular tissue (pyaemia), inflammation of the vagus, and 
 stoppage of the venous circulation from the inflammatory tumour 
 supervene. When these conditions are present, stupor, weakness, 
 convulsions, and so forth, wiU certainly ensue ; but these symptoms 
 cannot fairly be ascribed to an interruption in the transit of red 
 blood. The results will necessarily vary if at one time the animals 
 are confined in clean and airy hutches, or at another are pent up and 
 crowded together ; if the wound be closed by sutures or not ; and on 
 other circumstances. Sutures, for example, in rabbits wiLL readily, 
 by preventing its escape, cause an accumulation of thick pus under 
 the skia, occasioning thereby such pressure on the nerves and 
 veins as must be highly injurious. 
 
 That compression of the carotids in men produces stupor and 
 collapse, simulatiag apoplexy, was known before the time of Galen. 
 We find, from Chevers's communications, that Eufus of Ephesus 
 maintained that the word carotis owed its origin to this fact. 
 " Arterias per coUum subeuntes carotides, i. e. somniferas^ antiques 
 nominasse, quoniam compressse hominem sopore gravabaut vocemque 
 adimebant." Chevers likewise relates that by these means, Columbus 
 of Pisa, ia the year 1554, before a large assembly, feigning to use 
 magic, and seemingly to his own amusement, caused a young man 
 to fall down suddenly, much to the dismay of all beholders. 
 
 During the present century, compression of the carotids was in- 
 troduced as a remedy by Caleb Parry, and brought into very general 
 use. Por ample details on this subject we are indebted to the 
 
 ' A philologist has kindly furnished us with the following etymological com- 
 bination : ij Kapoirig, the artery to the head ; r6 and o icdpoe (probably not con- 
 nected with icapri), deep sleep ; icapou, dvv to produce, Kapog to stupify : 
 Kapuaie, V, apoplexy; KapotHe, causing apoplexy. 
 
28 ON CONVULSIONS AFTER HAEMORRHAGE. 
 
 distinguished Jacobi of Siegburg.' It occurred to us, however, 
 that neither Jacobi, who assures us that he performed some hundred 
 experiments, nor any of the numerous authors who have investigated 
 the subject of compression, such as Trousseau, Blaud, Dezeimeris, 
 L'Allier, Stroehlin, Romberg, Pleming, and some others whom we 
 have compared, made any mention of the convulsive attacks 
 following these experiments. Jacobi relates the following symptoms 
 as generally observed : dimness of sight, dizziness, stupor, weakness 
 in the legs, staggering, swooning, loss of consciousness, and sudden 
 apoplectic falling-down ; and this agrees with what is described by 
 the above authors. It seemed, however, improbable that the re- 
 sults in every case should be Hmited to these precursory symptoms 
 of epilepsy, and that no convulsions should ensue. Fresh experi- 
 ments were therefore deemed necessary. We communicate the 
 results of some, in which (in the cases of six male adults) com- 
 pression of both arteries completely succeeded. In all, without 
 exception, the face turned pale. First they made convulsive efforts 
 to close the eyelids : in four of them, the pupils at first contracted ; 
 in all of them, without any exception, they became eventually much 
 dilated. The contraction at the commencement was in two cases 
 very considerable. Although the experiments were performed in a 
 moderately darkened room, the window-shutters being haK closed, 
 still the pupils became remarkably contracted, even more so than 
 afterwards, when strong daylight was readmitted. As soon as 
 dilatation of the pupils began to take place the respiration became 
 slow, deep, and, as it were, sighing. Afterwards dizziness, stagger- 
 ing, and unconsciousness ensued ; and the patients would have 
 fallen but for being supported. In two subjects of weak intellect, 
 and moderately anaemic, in whom, notwithstanding the above 
 symptoms, the compression was continued, a choking sensation, 
 attended by vomiting and general convulsions, came on, which, 
 however, did not attain an aggravated form; for, on withholding the 
 compression, they disappeared in a few seconds. In one instance 
 a twitching in the muscles of the cheek was observed previous to 
 the attack of general convulsions. The face became suffused, the 
 eyes moist, and the pupils more and more dilated, as the thumbs 
 were removed from the neck. Consciousness and volition did 
 not return immediately, but after the lapse of a few seconds 
 
 • Vide his famous work : M. Jacobi, ' Die Seelenstorungen in ihren Beziehun- 
 gen zur Heilkunde,' i, pp. 379 — 388. 
 
LIGATURE OF THE CAROTIDS, ETC., IN MAN. 29 
 
 while tlie red appearance of the face gradually subsided. The first 
 inspirations upon the restoration of the circulation were particularly 
 deep. No further prejudicial consequences ensued. 
 
 We consider it then established that compression of both the 
 carotids in men may occasion loss of consciousness, dilatation of the 
 pupils, prolonged breathing, and general convulsions, — ^in short, all 
 the symptoms of a slight epileptic attack. As these experiments 
 were not always successful, it is well to consider that in closing 
 the carotids no complete stoppage in the flow of arterial blood from 
 the brain is occasioned, and that the arrest itself is mainly compensated 
 by the collateral circulation kept up by the vertebral arteries. Still the 
 probability becomes stronger, that the sudden retention of all the 
 blood conveyed to the head will have the same effect in the human 
 being when experiencing the loss of much blood as in other warm- 
 blooded animals ; that is to say, that sudden occlusion of all the 
 arteries of the head will as certainly produce epileptic convulsions 
 in man, as has been proved to be the case in rabbits, provided the 
 strength of the former be not too much exhausted, and the nutrition 
 of the nervous system not too much impaired. 
 
 The operation of tying the common carotid has been frequently 
 performed since the year i8io.^ Abernethy (in 1803),^ Fleming, 
 Lynn, and others, appKed the ligature in some cases where wounds 
 had been inflicted; and Sir A. Cooper (in 1805), for aneurism. 
 Tying both common carotids consecutively,' and hgature of the 
 innominate,* are operations which have been done more rarely, 
 
 ' Hebenstreit relates an earlier instance of the successful ligature of the 
 common carotid which had been wounded by removal of a scirrhous tumour. 
 Compare Hasse, in Eust's 'Handb.' vol. ii, p. 66; and Velpeau, loc. cit., p. 
 230. 
 
 2 Velpeau knew as early as 1832 of sixty cases of ligatures having been 
 applied to the common carotid, forty of which at least had been successful. 
 Compare his ' Elements de M6dec. operatoire.' In the second edition of his 
 work published in 1839, vol. ii, p. 232, he enumerates one hundred and fifty 
 cases, of which eighty were attended with a favorable result. 
 
 ' According to N. Chevers, Mott is said to have tied both carotids simulta- 
 neously, fatal consequences ensuing in twenty -four hours. It is to be regretted 
 that no details are given, and the source not even mentioned whence his 
 authority is derived. Langeubeok, according to Chevers, is likewise stated to 
 have performed the same operation with the same result. Here, however, 
 a confusion exists with some otlier case in which Langenbeck tied only one 
 carotid, of which we shall hereafter speak. 
 
 •• This operation has been performed ten times on living men, but always 
 with fatal consequences. 
 
30 ON CONVULSIONS AFTER HAEMORRHAGE. 
 
 whilst the vertebral has been tied but once (by Maisonneuve, in 
 ^853)' Of tlie numerous cases we have compared, we have found 
 very few, to our great regret, related with even tolerable accuracy ; 
 especially are the records of the post-mortem examinations, in 
 the cases which proved fatal, very faulty, more particularly the 
 descriptions of the anatomical alterations in the brain. We do not 
 pretend to give, in the following pages, a complete enumeration of 
 all the symptoms attending this operation, but merely a general 
 description, for which purpose a number of carefully compared 
 examples (more than a hundred) may probably suffice. 
 
 After applying a ligature to one carotid, to the innominate artery, 
 or to both carotids in succession, in some instances no disturbance 
 whatever in the functions of the brain was observed ; but in the 
 greater number the following symptoms appeared, namely; a difficult, 
 deep, and even rattling respiration (which, moreover, was speedily 
 induced), spasmodic attacks of cough, headache, or a cessation of 
 headache when previously existing, toothache (according to 
 Dupuytren" and Malgaigne'), loss of sight in the eye on the same 
 side as the part operated on, dizziness, stupefaction, insensibility, 
 loss of consciousness, of speech (Horner), and of free play of the 
 muscles in general, difficulty in swallowing, nausea, vomiting (Lam- 
 bert), swooning, and coma. Swooning has sometimes been imme- 
 diately succeeded by death without convulsions appearing. 
 
 Aston Key' tied the right common carotid of a woman sixty- 
 one years of age, suffering from an aneurism of the innominate 
 artery. In about an hour and a half after the operation, the woman 
 appeared to sleep quietly, the breathing was somewhat stertorous, 
 and grew weaker by degrees ; and, four hours after the operation, 
 she expired. On a post-mortem examination, it was found 
 that the aperture of the left carotid at the arch of the aorta 
 was completely closed, and that the vertebral arteries were of un- 
 usually small calibre. The brain was healthy; its blood-vessels 
 exhibited no morbid appearance, and contained the ordinary quantity 
 of blood ; a moderate quantity of serous exudation was found between 
 the membranes. Unfortunately, no information was afforded with re- 
 spect to the condition of the lungs. If death did not take place at the 
 latterorgans by a disturbance and stoppageinthe circulation, resulting 
 
 ' Rust's 'Magazine,' vol. vii. p. 761. 
 
 ' See afterwards. 
 
 " 'Medical Gazette,' vol. vi, p. 703; Burrows, loo. oit., p. 56. 
 
LIGATURE OF THE CAROTIDS IN MAN. 31 
 
 in oedema and suffocation, as is frequently the case in rabbits and 
 sometimes in men (Halli), after the innominate artery has been 
 tied,^ it must have proceeded from the brain ; the quantity of blood 
 conveyed to it through the two contracted vertebral arteries not 
 sufficing for its nutrition. The statement that the vessels of the 
 brain contained the usual quantity of blood should not bias our 
 judgment; for the vessels which, in the dead body, contain the 
 usual quantity of blood are the veins. As a rule, the arteries are 
 entirely empty in the smaller branches, and almost entirely so 
 even in the larger ones ; and dissection will scarcely ever show the 
 quantity which the arteries contained during life. We shall soon 
 examine these facts more closely. It may further be asked, why 
 no convulsions took place, not-withstanding the fatal diminution in 
 the quantity of blood in the brain. An answer to this ioquiry is 
 readily supplied in considering the age * and feeble constitution of 
 the persons operated upon. 
 
 A result similarly fatal took place thirty-four hours after the 
 operation, attended with rales in respiration and stupor, but 
 without convulsions, in a case of bronchocele in which Langenbeck* 
 first tied the right thyroid artery, and the right carotid eleven days 
 later, in consequence of excessive and repeated heemorrhages from 
 the wound. At the post-mortem examination the right lobe of 
 the cerebrum appeared anaemic, and its surface covered with exuda- 
 tions (serum ?), whilst the left lobe was gorged with blood. Some 
 exudation (serum ?) was discovered in the right ventricle, but not 
 
 ' Velpeau, loo. cit. p. 247. In the cases of Mott, Graefe, Blaud, and Lizars, 
 the persons operated upon died from hsemorrhage. 
 
 ' Our numerous experiments on rabbits have convinced us that in tying the 
 innominate artery the danger from hypersemia and oedema of the lungs and 
 from suffocation increases in proportion to the amount of blood in the patient. 
 But if, in Older to avoid tiiis hazardous consequence, venesection be adopted be- 
 fore the operation, and certain limits be transgressed, another danger will ensue 
 from the brain, its nutrition being impaired in a twofold way. Firstly, by 
 the absolute want of blood in the patient ; and secondly by the closing of such 
 important vessels of supply. When, therefore, tlie carotids of men are to be 
 tied, a too copious venesection, as generally performed by English and Trench 
 surgeons, should be avoided. 
 
 ' One of the cases, however, occurring in Wardrop's own practice, that of a 
 woman seventy-eight years of age, whose carotid was tied without any serious 
 results, clearly shows that the ligature on one carotid is sometimes well borne 
 by very old persons. » 
 
 * Langenbeck, ' Neue Bibl.,' vol. iv, st. 3, p. 586. 
 
32 ON CONVULSTONS AFTER HAEMORRHAGE. 
 
 in the left. In this instance the brain was probably brought into 
 such a morbid state from the excessive debility of the patient — ^pro- 
 duced by the previous repeated and violent haemorrhages — ^thal; the 
 Hgatuie of simply one carotid proved fatal.' 
 
 The ligature of one carotid was frequently followed, sooner or 
 later, by paralysis of the opposite side. If death took place, the 
 affected portion of the brain was found softened, when the reten- 
 tion of the blood had lasted sufficiently long. 
 
 Sir A. Cooper's ^ first case had this paralytic issue. Seven days 
 after tying the right carotid of the woman, who was forty-four years 
 old, her left side became paralysed, and death took place on the 
 twenty-first day. A post-mortem examination was not allowed. 
 
 Gundelach MoUer, of Copenhagen,* tied both carotids of a child 
 four years and a half old, suffering from a vascular tumour of the 
 nose, within a period of four months. Soon after the application 
 of the first ligature the opposite side became paralysed ; after tying 
 the other carotid vomiting and coma supervened, probably, how- 
 ever, not in consequence of the operation, but from a simultaneous 
 attack of scarlet fever that was raging in the hospital where the 
 chUd was. Nevertheless, the child recovered, but with only an 
 imperfect use of the paralysed side. 
 
 Dohlhoff * observed two cases attended with fatal results, in which 
 post-mortem examinations were performed. In the fijst the liga- 
 ture was appHed for a medullary fungus of the superior maxiUary 
 bone in a man forty-nine years of age. His bladder and opposite 
 side became paralysed eight days after. The corresponding half 
 of the cerebrum was softened ; the rest of the brain was filled with 
 blood. The other case was that of a woman aged fifty-one years, 
 in whom paralysis of the opposite side with impaired consciousness 
 took place on the fifth, and death itself on the seventh day after the 
 operation. The brain and its integuments were in a highly con- 
 
 1 Dupuytren (Sedillot, Obs.de ligat. de laoarot;., 'Gaz. m^d.,' 1842, p. 567, 
 and Longet, ' Anat. et Phys. du Systeme nerveux,' vol. i) and Velpeau (loe. 
 cit., p. 239) lost patients in whom one carotid was lied (Dupuytren's patient 
 died on tlie sixth day in a state of great debility, probably from pysemia. These 
 cases do not belong to the same category, neither do those numerous ones where 
 death was caused by hsemorrhage, suppuration (Travers), obstinate vomiting 
 (Syme, in ' Archives g^n^r.' 4eme s6rie, i, 481), pleuritis (Maclachlan), &c. 
 
 " ' Med.-Chir. Trans.' vol. i, p. i. 
 
 ' Gers. u. ' Jul. Mag»z.,' vol. li. 1838, part 3. 
 
 •" Rust's ' Magazine,' vol. li, 1838, part 3. 
 
EFFECTS OF TYING THE CAEOTID IN MAN. 33 
 
 gested state, and no difference was observable between the two 
 halves of this organ. 
 
 Herbert Mayo ' tied the right common carotid of a man whose 
 external carotid had been wounded, and as haemorrhage came on, 
 consequent on ulceration at the point of appKcation of the liga- 
 ture, he repeated the operation on a lower part of the artery. 
 Thereupon a sensation of torpor ensued in the left half of the body, 
 ending in paralysis and death. The right half of the cerebrum was 
 found to be softened, and between the arachnoid and pia mater 
 was interposed a thick layer of lymph. 
 
 Textor ^ likewise saw this operation followed by paralysis of the 
 other side, and death. At the post-mortem examination he found 
 the centrum senii-ovale of the side where the carotid was tied, in a 
 state of suppuration. 
 
 SediHot ^ tied the right common carotid of a man suffering from 
 violent haemorrhage. Three hours afterwards the left haK of the 
 body and the right side of the face became paralysed, and the 
 intellect almost destroyed. Death took place on the ninth day. 
 The three lobes of the right haM of the cerebrum were softened. 
 
 Similar cases, according to Norman Chevers, were observed by 
 Pairfax, Girdwood, Macaulay, Vincent, and Barovero.* Telpeau 
 (loc. cit., V. ii, p. 225) likewise saw hemiplegia with fatal conse- 
 quences ensue, and Chapel, softening of the brain, after the applica- 
 tion of a Hgature to the carotid, according to the ' Eeport of the 
 Meeting of the Academie de Medicine,' held on the aSth of October, 
 1851.5 
 
 Here we must mention the numerous instances either of sudden 
 or else of rapidly produced obstruction of the innominate trunk, or 
 • of the common or the internal carotid, but particularly of the ramus 
 sylvianus, by immigrated plugs or those of autochthonous origin, 
 producing symptoms of apoplexy, with subsequent paralysis of the 
 opposite haK of the body and softening of one-haK of the cere- 
 brum in a greater or less degree.^ 
 
 1 ' Gers. u. Jul. Magaz./ new series, vol. viii, p. 82. 
 
 2 ' Chiron.,' vol. ii, p. a ; Langenbeck, ' Nosol. der Chir. Krankh.,' vol. v, 
 
 p. 445- 
 
 = 'Gaz. Med.,' 1842, p. 567. 
 
 * Barovero, however, tied both the carotid and internal jugular. 
 
 5 'Arch. g6ner.,' p. SSS- 
 
 « Compare Norman Chevers, loc. cit., p. 1146, No. i, and p. 1147, No. 2 ; 
 Hasse in 'Henle und Pfeufer,' Zeitsohr., 1848; Virchow, 'Gesammelte 
 
 3 
 
34 ON CONVULSIONS AFTER HjEMORRHAGE. 
 
 Twice, within our own experience, after tying one carotid, 
 have convnlsions been observed on the side of the application 
 of the ligature, attended with paralysis of the opposite side — 
 symptoms often noticed after haemorrhage into either half of the 
 cerebrum. 
 
 A man, set. 48, whose right carotid was tied by Vincent', 
 on account of an aneurism, was seized with convulsions on the 
 same side an hour and a half afterwards; he then fell into a 
 state of torpor and became paralysed on the left side. Sixty-two 
 ounces of blood were taken from him within the first three days. 
 Nevertheless, the convulsions continued, and only ceased two days 
 before death, which followed on the seventh day after the operation. 
 The right hemisphere of the cerebrum was softened to the consist- 
 ence of cream ; its veins were less congested than those of the left 
 hemisphere, which exhibited blood-spots. The ventricles contained 
 more serum than usual, whilst the cerebellum was in a healthy 
 condition, 
 
 A man, set. a8, thrust the mouth-piece of a clay tobacco-pipe 
 through the root of his tongue into the right carotid at its bifurca- 
 tion. It broke and stuck fast, and acting as a complete plug, gave rise 
 to a tumour, and seven days afterwards induced violent haemorrhage. 
 Vincent ^ tied the carotid, and during the operation remarked the 
 presence of convulsions of the right and paralysis of the left side. 
 These symptoms lasted tiU the man^s death, five days afterwards ; 
 only that the convidsions grew gradually weaker. Up to the time of 
 breathing his last, the patient's mouth and nose bled at intervals. 
 The neck was swollen around the bifurcation of the carotid, where 
 an effusion of blood and pus was found, and the jugular vein was 
 closed to a third part of its circiimference. But little blood was 
 
 Abhandl. zur wissensch. Medizin' (Thrombose und Embolie) ; Kirkes, ' Med.- 
 Chir. Transact.,' 1852, vol. xxxv, p. 281 ; RiiMe, ' Arch, fiir path. Anat.,' v, 
 p. 189; Burrows, 'Med. Times,' Feb., 1853; Bierck, 'Du Tlamolissement 
 C&^bral ; Thfese inaug. Strasb.,' 1853; aud Traube, 'Deutsche Klinik,' 1834, 
 4tli quarter. We have compared the seventeen cases of thrombosis related in 
 the above-mentioned works and papers, and have not found one in which simul- 
 taneous convulsions were observed, a doubtful case of Burrows' excepted, 
 relating to a girl eighteen years old (affected with disease of the heart, and still 
 Tinder treatment when her case was published), who suffered from hemiplegia 
 combined with chorea. 
 
 ' 'Medioo-Chirurg. Transact.,' vol. xix. 
 
 " Ibidem. 
 
EFFECTS OF TYING THE CABOTID IN MAN. 35 
 
 contained in the longitudinal sinus. The cerebial veins were only 
 partially filled with blood, the arachnoid appeared dull and 
 watery, and the convolutions of the right haK of the cerebrum were 
 flattened and softened. The latter contained irregular cavities, with 
 ash-coloured effusion and green shreds. One of the cavities was 
 two inches in diameter, and extended to the corpus striatum of the 
 same side. 
 
 We may conclude that in both these cases the lateral convulsions 
 did not proceed from hypersemia of the opposite half of the 
 cerebrum. In the former case the convulsions continued notwith- 
 standing copious venesection, while in the latter they came on and 
 persisted in spite of great loss of blood. The results of the post- 
 mortem examinations Hkewise militate against such an assumption; 
 the great quantity of serum in the ventricles and membranes of the 
 brain but iU accords with the existence of hypersemia ; neither, on 
 the other hand, do they afford any grounds for maintaining the 
 opposite opinion; namely, that these convulsions as well as the 
 paralysis might have been occasioned by oligoemia. We must 
 content ourselves with confessing our inability, in the present state 
 of science, to decide as to the cause of the simultaneous convulsions 
 in these instances, as well as in effusions of blood into one 
 hemisphere of the cerebrum.^ 
 
 General convulsions have been seldom observed after the applica- 
 tion of a ligature to the carotid. They, however, occurred after an 
 operation performed by Abernethy ^ to arrest a profuse haemorrhage 
 from the left carotid, which had undergone extensive laceration from 
 the thrust of a cow's horn. The first two hours after the operation 
 the man was quiet and in the enjoyment of his intellectual powers. 
 Then followed fever, delirium, and repeated attacks of convulsions, 
 stronger on the left than on the right side, whilst afterwards the right 
 side became paralysed, and the left continued convulsed. The 
 patient died in strong convulsions thirty hours after the operation. 
 The pia mater was found injected, and serum had been effused 
 between it and the arachnoid; the brain exhibited traces of 
 inflammation, and its vessels are stated to have been "full, 
 
 1 The attempts of Brown-S6quard ('Experim. and Clinic. Eesearches on the 
 Physiol, and Pathol, of the Spinal Cord,' p. 64) do not appear to us to eluci- 
 date the matter. 
 
 ^ ' Surgical Observations,' p. 193. 
 
36 ON CONVULSIONS AFTER HAEMORRHAGE. 
 
 but not turgid." It is doubtful whether the case of Zeiss ^ belongs 
 to this category. In a child eighteen months old, whose left 
 carotid had been tied for a vascular tumour of the left ear, sudden 
 convulsions came on nine weeks afterwards, during the period of 
 dentition, and the Hmbs of the right side became paralysed. The 
 child grew thin, and a few days before its death, which took place 
 sixteen weeks after the operation, the limbs of the right side became 
 alternately stiff from spasms of the extensor muscles, and bent from 
 contractions of the flexors ; the vascular tumour had disappeared, 
 but the child's emaciated condition was pitiable in the extreme. 
 A post-mortem examination was not allowed. 
 
 In a girl eighteen years of age, whose common carotid was tied 
 by Sykes,^ hysterical convulsions came on the same evening, and 
 on the following day she was attacked by a violent headache, 
 accompanied by depression and restlessness. 
 
 Magendie published in the 'Journal de Physiologic' the case of a 
 girl aged twenty-five years who suffered from attacks of a decidedly 
 epileptiform character.^ Being affected with an enormous tumour 
 of the left antrum, her left carotid was tied, after she had been 
 subjected to a fortnight's previous treatment of low diet and 
 venesection. Directly after the operation the patient felt well, but 
 soon afterwards suffered from toothache, headache, and dyspnoea, 
 to remedy which twenty-four ounces of blood were abstracted. 
 An hour afterwards she swooned away. The faintings returned 
 on the sixth day, attended with complete loss of consciousness. 
 Her right arm became totally paralysed, her left one partially so, 
 and she was unable either to swallow or speak; some hours 
 afterwards an epileptic attack came on, the head being bent 
 backwards, the pupils extremely dilated, saliva flowing from the 
 mouth, and consciousness being entirely suspended. At length she 
 recovered, but her speech only returned gradually, and it was not 
 before the expiration of three months that she was again able to 
 move her right arm even in the slightest degree. 
 
 Wattmann* applied a ligature to the right carotid of a farmer 
 aged fifty-five years, suffering from disease of the submaxillary 
 glands. Directly after the operation spasmodic movements of 
 
 ' 'Hamb. Zeitschr. fiir die ges. Medizin.,' 1836, vol. iii, p. 9. 
 
 ' ' Pror. Notizen,' 1824. 
 
 ' ' Jul. u. Gers. Magazin,' vol. xvi, p. 93. 
 
 * ' Salzb. Med.-Chir. Zeitg.,' 1852, p. 32. 
 
EFFECTS OF TVING THE CAROTID IN MAN. 37 
 
 the whole body took place, which, however, soon ceased. On 
 the following day, he became deUrions and paralysed in the left 
 half of his body, and six ounces of blood were abstracted, at three 
 different times. The patient died, but no mention is made, either 
 of the time of his death or of the results of the post-mortem 
 examination. 
 
 We wiU, in conclusion, mention a case by Kuhl,^ who tied the 
 left common carotid of a powerful man, fifty-three years of age, 
 for an extensive aneurism of the left occipital artery and its branches. 
 The patient was immediately attacked by swooning and convulsions, 
 and had to be carried to bed in a state of insensibility. Porty-one 
 days afterwards, the application of a ligature to the other carotid 
 was rendered necessary, in consequence of violent haemorrhages 
 from the tumour. Paleness of the face and slight convulsions 
 ensued. The patient's sleep was quiet during the night, only once 
 or twice disturbed by spasmodic movements of the right arm. The 
 next day he complained of heaviness in the head, painful spasmodic 
 movements in the right arm, and dimness of sight. His recovery, 
 though protracted by haemorrhages, and suppuration, was eventually 
 complete fifteen weeks after the second operation. 
 
 Hence it follows, that the tying of the common carotid in man 
 may eventuate in paralysis, as well as in convulsions — ^the former of 
 one side only, the latter general. Paralysis of one side affects the 
 limbs of the opposite side and usually the opposite half of the face, 
 though sometimes the same, if SediEot's observation be correct. 
 General paralysis manifests itseK by syncope, coma, or, as in the 
 case related by Magendie, the arm of the opposite side becomes 
 completely, that on the same side only partially, paralysed. 
 
 Paralysis may either precede, accompany, or follow convulsions. 
 Lateral convulsions are synchronous. General ones may altogether 
 put on the character of epileptic attacks, as proved to demonstration 
 by the experiments of Magendie and Kuhl; and may come on 
 directly after the operation (according to Wattmann and Kuhl), or 
 only some hours or even days afterwards (according to Abemethy 
 and Magendie). 
 
 It is consequently a rare occurrence for epileptic convulsions 
 to make their appearance immediately upon the application of 
 a ligature to the carotid, whilst in the majority of instances 
 
 ' N. Chevers, loc. cit., p. 1145. Unfortunately I could not obtain the 
 original. 
 
38 ON CONVULSIONS AFTER HjBMORBHAGE. 
 
 syncope and paralysis of the side opposite to the one operated on 
 will follow. In post-mortem examinations the cause of this 
 paralysis has been traced to anaemia and softening of the cerebral 
 hemisphere to a greater or less extent, on the same side as that 
 on which the carotid had been tied, and in all cases which have 
 come before our notice of thrombosis of the internal carotid, or 
 of the ramus sylvianus, with subsequent softening of the whole 
 or greater part of the cerebral hemisphere, the thalamus opticus 
 and corpus striatum included, paralysis of one side has been 
 observed to come on without convulsions in a similar way to an 
 apoplectic fit. Hence we are fully justified in deducing these corol- 
 laries, viz. : that epileptic convulsions only manifest themselves in 
 man when, together with the cerebrum, some or all of the parts of 
 the encephaKc mass lying behind the thalami optici are suddenly 
 deprived of blood to a sufficient amount ; but that sudden " falling 
 down," announcing the approach of an apoplectic attack, un- 
 consciousness, and insensibility, originate in causes proceeding from 
 the brain proper. 
 
CHAPTEE VII. 
 
 INTERRUPTION OP THE CIRCULATION IN THE GREAT ARTE- 
 RIES OE THE NECK CAUSES ARTERIAL ANJSMIA OF THE 
 BRAIN, AND THIS ANEMIA PRODUCES CONVULSIONS. 
 
 The controversy as to whether the quantity of blood in the 
 brain is susceptible of diminution, or whether the cranium, " as a 
 closed, undilating capsule, having a capacity always the same," 
 contains a certain and constant quantity of blood, may be regarded 
 as finally determined ' by the celebrated experiment of Bonders.* 
 This physiologist closed air-tight, with a piece of glass> an opening 
 made by trephining in the cranium of a rabbit, and clearly 
 demonstrated by this process the possibility of a change in the 
 diameter of the vessels of the membranes of the brain, as well as of 
 those of the brain itseK. 
 
 There is no other method that leads with equal certainty to 
 the knowledge of the processes of the blood's circulation in the 
 cranium. The results of post-mortem examinations afford a great 
 source of errors, as we shall explain in the next paragraph. In 
 order, therefore, to be certain whether the simultaneous appKcation 
 of a ligature on the carotids and vertebral arteries causes an 
 arterial ansemia of the brain, nothing remained for us but to adopt 
 Bonders' procedure. But here an unexpected difficulty arose. 
 The different cements recommended by Bonders for the air-tight 
 insertion of the small glass plate into the wound caused by tre- 
 phining, such as gum arable and collodion, completely failed in our 
 hands, and it appears to us that Bonders was singularly fortunate 
 in the experiment as communicated by him, turning out so 
 successfully. Collodion, or gutta percha dissolved in chloroform, 
 which we employed in the first instance, does not adhere sufficiently 
 
 ' Cdmpare Virchow, ' Handb. der Patliol.,' vol. i, p. iii. 
 ' Fully related in Schmidt's ' Jalirbiicher,' 1851, vol. Ixix. 
 
40 ON CONVULSIONS AMEE HiEMOKBHAGE. 
 
 to the glass and bone, contracts while drying, and gives way here 
 and there, a mishap partly caused (according to Bonders) by the 
 liquid secreted by the membranes of the brain trickling through 
 the pulverized gum into the gaps between- the small plate of 
 glass and the edges of the bones. After having tried various 
 cements, we at last succeeded three times in cementing the glass 
 plate air-tight, by the following method. 
 
 The surface of the frontal part of the cranium of an old and large 
 rabbit is exposed to a sufficient extent, by cutting the skin into 
 four flaps, which are turned backwards, and by completely scraping 
 off the periosteum to a great distance round. A dry surface of the 
 bone is thus obtained, which is of importance as regards a favor- 
 able issue to the experiment. A small piece of glass out of a 
 watch-glass is then cut, eleven millimetres long, becoming propor- 
 tionately narrower from back to front, so that its posterior end 
 is nine millimetres wide, the front part eight. This is pressed on 
 the surface of the bone, its contour marked on the bone by 
 tracing with a pencil round the edges of the glass. Care must be 
 taken that the edges of the glass are as straight as possible, and 
 that those of its upper surface are ground down to the width 
 of one millimetre, which is easily done on a rough sandstone. 
 Then the piece of bone which has been marked is cut out with a 
 small bone-saw, and the edges made as smooth as possible with a 
 pair of bone-nippers, in order to make the piece of glass fit exactly. 
 
 Laying bare the dura mater generally causes a sKght bleeding, 
 whilst its removal is usually followed by more copious venous 
 hsemorrhage, which is best arrested by a piece of tinder, or by 
 the pressure of the glass itself. After the bleeding has stopped, 
 the glass plate, being perfectly clean, is inserted and allowed 
 to remain there. If the brain be somewhat sunk in, a drop 
 of water may, according to Bonders' procedure, be dropped upon 
 it, in order to prevent any air remaining between the brain and the 
 glass plate. Some fijiely powdered gum is then pressed into the 
 gaps, as Bonders hkewise specifies, and rapidly touched with a red- 
 hot iron, in order to dry it. The use of powdered gum has this 
 advantage, that the serum which rapidly oozes out becomes collected, 
 and adheres at the same time, whereby the glass is held until 
 the proper cement can be applied. The surplus of the powdered 
 gum is then blown off from the glass plate and bone. Instead of 
 gum powder, a solution of shell-lac well saturated with spirits 
 
DONDERS' EXPERIMENTS. 41 
 
 of wine may be used to fill up the gaps. Knely powdered shell- 
 lac is now thickly sprinkled on the edges of the bone, and lightly 
 touched with the red-hot iron. The sheU-lac melts, and imme- 
 diately hardens, forming a cover firmly adhering to the glass and 
 bone, completely closing the several gaps. The smaU openings 
 may in this way be completely closed. Whether the closing 
 be air-tight or not is shown by compressing the innominate artery, 
 while the left subclavian artery is closed. If the smallest open- 
 ing be present, the brain will sink in, and an air-bubble appear 
 between the brain and the glass. Upon the compression being 
 removed, the brain presses against the glass plate, and air and 
 serum come forth through the aperture. In this case the fault 
 must be repaired. If the closure be air-tight, no movement of any 
 kind is to be observed in the brain, no air enters when compression 
 is made, neither, upon the cessation of the latter, is any serum 
 pressed out. 
 
 Before we communicate the results of our experiments with 
 compression when a glass plate has been inserted, it wiU be neces- 
 sary, for the sake of a better comparison, to relate the results 
 of compression on an opened cranium after eight experiments made 
 by us for this purpose. It is a matter of indifference whether 
 the dura mater remains entire or is removed ; the brain, sinks in 
 as soon as compression is applied, and retreats from the cranium 
 in the shape of a cup, the dura mater, if preserved, remaining 
 closely adherent. The brain cannot, however, retreat so far, when 
 the dura mater is preserved intact, as when the latter is removed 
 as far as the bone cavity extends. In the latter case the brain 
 sank in one experiment two and a half millimetres in the centre of 
 the opening. As soon as the brain has become completely 
 pale, the smaller veins cease to be visible to the naked eye, the 
 more completely the smaller their diameter; while the larger 
 veins, which pass across the hemisphere of the cerebrum and 
 terminate in the large longitudinal vein over the falx of the brain, 
 become one fourth to one third smaller in diameter, the longi- 
 tudinal vein contracting to a less marked degree. If, in ex- 
 tensive anaemia of the brain, the animal's nostrils be closed, the 
 brain and its vessels immediately commence swelling again. 
 
 Upon convulsions taking place the brain presses more and more 
 into the fissure of the bone, and even fills it up again, but without 
 turning red, although the veins on its surface visibly enlarge. 
 
43 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 With the cessation of the convulsive attack the veins again be- 
 come less swollen ; and yet, even in death, the brain still remains 
 protruding. 
 
 As soon as the blood begins again to flow, the brain becomes of a 
 deep rose colour, a number of small arterial and venous vessels 
 appear, the veins swell beyond their normal size, while the brain, 
 exceeding its ordinary bulk, protrudes, into the hole made by 
 trephining. 
 
 When the glass plate is inserted air-tight, the symptoms ex- 
 hibited in the brain are no longer the same. It is not possible to 
 induce further movements in the brain, even though the compres- 
 sion be continued until death, and the nostrils be closed ; or the 
 compression be removed, and the brain thereby be intensely con- 
 gested. The brain remains, in all cases, immovably fixed to the 
 glass plate. The phenomena exhibited by the vessels remain the 
 same as those which manifest themselves when the brain has been 
 laid bare. On compression being applied, the latter forthwith 
 becomes pallid, the smaller vessels cease to be visible to the eye, 
 the veins which open into the great longitudinal sinus contract 
 with greater or less rapidity to a fourth or even to a third of their 
 normal diameters. Whether the longitudinal sinus itself undergoes 
 any contraction, remains a matter of uncertainty. 
 
 If, during this period, the nostrils be closed, a distinct swelling 
 and an enlargement of the veins ensue. Even when the brain has 
 become very pale, and the veins have undergone considerable con- 
 traction, yet does not the pale colour of the brain sustain any 
 change. 
 
 When convulsions came on, the veins again swelled without the 
 brain changing either its colour or position, and this continued 
 even tiU the cessation of the convulsions by death, and, indeed, for 
 some minutes subsequent to the last act of respiration. 
 
 When the circulation was restored, the brain immediately assumed 
 a pink colour, a great number of the finest vessels became visible, 
 and the veins appeared considerably swoUen. 
 
 These experiments, therefore, bear signal testimony to the sound- 
 ness of the doctrines which reflect so much credit upon Burrows 
 and Bonders, who established them. The doctrine, so highly 
 important in practice in the application of bloodletting in cases 
 of diseases of the brain, t^t the quantity of Mood in the brain and 
 its membranes can be sensibly diminished, cannot be so clearly de- 
 
VIEWS OF BICHAT AND BURROWS. 43 
 
 monstrated by any other experiment as by the one above mentioned. 
 And it is only by that ingenious method, which will for ever 
 render illustrious the name of Bonders, that reliable information 
 can be obtained as to the state of the cerebral circulation in 
 asphyxia, strangulation, after section of the cervical cords of the 
 sympathetic during the anaesthesia from ether, or during inebriation 
 and narcotization by means of morphia, atropine, &c. 
 
 As it regards our special question it is shewn : — that compression 
 of the great arteries causes capillary and venous anaemia of the 
 brain and its membranes, until convulsions ensue, whereby the 
 venous anaemia is at least partially removed, without that of the 
 capillaries simultaneously ceasing. It is just this latter circumstance 
 which leads to the destruction of Hfe, since aU organic activity is 
 dependent on a constant change of matter, an undisturbed nutrition, 
 and the presence of red blood in the capillary vessels. The brain is 
 suddenly deprived of its supply, and the required quantity of nutri- 
 tive matters to permeate its tissues and replace what is constantly 
 being consumed, is no longer afforded. The brain, therefore, under- 
 goes an internal chemical change and injury, which will be mani- 
 fested by disturbance of its functions. 
 
 Burrows maintains that this alteration in the functions of the 
 brain, attendant upon anaemia, is not susceptible of explanation 
 upon the hypothesis of the withdrawal of nutrition, but that the 
 disturbance is to be ascribed to the usual pressure to which the 
 brain was subjected by the heart-pump, and which was necessary 
 for a regular action of the brain, being no longer kept up. He con- 
 sequently adheres to the opinion which Bichat endeavoured to 
 establish in his celebrated work ' Sur la Vie et la Mort.' 
 
 Without altogether denying the importance of this pressure, 
 we consider it as quite secondary in relation to the question under 
 discussion, since these epileptic convulsions occur irrespectively 
 in the rabbit both after the removal of considerable portions of 
 the cranium and when it has been completely closed. We 
 generally found, upon the skull being opened, if the experiments 
 of compression lasted a long time and were frequently repeated, 
 that the convulsions gradually appeared later than when the skuU 
 was closed. The assertion, therefore, seems fully justified, that 
 a stoppage in the supply of Hood {i.e., the interruption of the 
 change of matter), and not a suspension of mechanical pressure on 
 the brain, occasions convulsions. We beg, in conclusion, to mention 
 
44 ON CONVULSIONS AFTER HAEMORRHAGE. 
 
 an experiment which seems clearly to prove our assumption. In a 
 strong black rabbit we first broke off the anterior portion of the 
 cranium covering the cerebrum as far as the edges of the orbit 
 laterally, and backwards as far as the transverse sinus; then, 
 beginning at the divided membrana obturatoria, we also removed 
 the cranium covering the cerebellum laterally as far as possible, 
 and anteriorly to the transverse sinus. When, lastly, we removed 
 the remaining bridge of cranium over the transverse sinus, and 
 the animal was dying from violent hsemorrhage from the latter 
 blood-vessel, then only, and in spite of the fact that the brain, cere- 
 bellum, and meduUa oblongata, were so extensively exposed, did 
 most frightful convulsions ensue, bearing completely the character 
 of an epileptic attack. 
 
CHAPTEE YIII. 
 
 ON THE RESULTS OF POST-MORTEM EXAMINATIONS AFTER 
 DEATH BY HEMORRHAGE AND APPLICATION OF THE 
 LIGATURE TO THE GREAT ARTERIES OF THE NECK. 
 
 Aftee death, taking place from haemorrliage, we have always found 
 the brains of the rabbits experimented upon of a pale colour ; the 
 surfaces obtained by section presented no blood-spots ; the mem- 
 branes of the brain, bones of the cranium, and soft integuments of 
 the head, were pale; the sinuses and larger veins containing a 
 small proportion of blood ; and the great arteries at the base of the 
 brain a stiU smaller quantity. 
 
 To demonstrate clearly the fallacy of the doctrines propounded by 
 KeHie, Abercrombie, and Hammernik, no better plan can be adopted 
 than that of opening two animals simultaneously, one of which 
 shall have died from haemorrhage and the other in the follovring 
 manner : after dividing firstly both cervical branches of the sympa- 
 thetic nerve, then applying a ligature to the veins of the neck, and 
 (after waiting till respiration has considerably diminished, in conse- 
 quence of the hypersemia in the cranial cavity which is invari- 
 ably present) finally strangling the animal with a strong piece of 
 twine. "We delayed the operation of strangling, in one instance, 
 until the number of respirations was gradually reduced in the space 
 of five hours from 140 to a8. In its last throes the animal's ears 
 turned paler, whilst its arteries and veins contracted. 
 
 On examination of the head immediately after death the ears and 
 skin of the head still appeared pale. So excessive a hypersemia, 
 both of the brain and its membranes and of the sinuses and bones of 
 the cranium, had never hitherto come under our observation. The 
 blood issued forth from the cut surfaces in quantities such as 
 would hardly be seen upon dissecting the brains of living and full- 
 blooded rabbits. 
 
 In death from the application of ligatures to the arteries of the 
 
46 ON CONVULSIONS AFTER HAEMORRHAGE. 
 
 head tlie results of the post-mortem examinations present but one 
 uniform feature. "We found, in every instance, the substance of the 
 brain, as well as those of the medulla oblongata and the upper part 
 of the spinal cord, deprived of blood, the cut surfaces without blood- 
 spots, and the arteries of the cranium empty ; some larger arteries 
 at the base of the cranium excepted, which contained a slight 
 quantity of blood. The quantity of blood in the veins, however, 
 varied considerably. 
 
 "We almost invariably opened the cranium after the last respira- 
 tion, or shortly after the last pulsation of the heart. The sinuses, 
 as well as the large veins with rigid walls in the roof of the 
 cranium near the ears, generally contained even considerable 
 quantities of blood. The larger veins and those of medium calibre 
 iQ the pia mater were also frequently scarcely any smaller than in 
 the animal trephined whilst alive ; but the lesser veins appeared 
 to contain very little or no blood. More rarely, perhaps once in 
 ten cases, were all the veins of the neck, vertebral column, and 
 cranial cavity, found distended with blood. Lastly, all the veins, 
 even the sinuses and vertebral veins of the upper third or upper 
 two-thirds of the cervical part of the vertebral column were some- 
 times found to contain very Uttle blood. 
 
 The conclusion, therefore, at which we arrive, is, that, after 
 applying Ugatuies to the arteries of the head, the proportion of 
 blood in the cranial cavity is on the average much greater than 
 after death from hsemorrhage. But it is in the larger veins more 
 especially that we find a more abundant quantity of blood, while 
 the finer ones and the arteries contain very little or none. Consi- 
 derable haemorrhages frequently take place after trephining the 
 animal when dead, particularly if a vein holding blood be cut, and 
 more especially if the heart is stiU beating. The blood may 
 stream out in such an abundance, even if the head be kept 
 erect, that the cranial cavity from which the brain has been 
 removed frequently will be unable to hold it. This fact, as well as 
 the finding of venous hypersemia in the cranial cavity, may be easily 
 explained from the following circumstances. 
 
 The closing of the great arteries of the neck in plethoric animals 
 causes, in the first instance, hypersemia in the left heart, and then 
 in the lungs and right heart. The heart and great blood-vessels 
 are consequently found greatly distended, the lungs containing" 
 much blood and sugiUated, frequently (Edematous, and, after re- 
 
POST-MORTEM EXAMINATIONS. 47 
 
 peated experiments with compression, sometimes hepatized in 
 several places, whereby the flow of venous blood into the right 
 heart is hindered. In those regions of the body whose veins enter 
 the vena cava nearest to the heart, a collection and accumulation 
 of venous blood takes place. To these regions especially belong 
 the inferior part of the neck, and the dorsal part of the vertebral 
 column, the veins of which region, in the rabbit, open directly into 
 the two superior vense cavse. A greater fluid pressure is exerted 
 upon the collected venous blood, and hence tends to flow back again 
 from the greatly distended and gorged vessels of the back and 
 inferior region of the neck to the less filled or empty and valveless 
 veins of the head. 
 
 With this is associated a circumstance of no slight importance, 
 which we may, perhaps, designate as a condition of active pressure, 
 whilst that just mentioned represents a passive one. The total 
 amount of the arterial blood withheld from the reservoirs of four 
 great arteries of the neck is distributed among the remaining 
 regions of the body, but not equally so. The greater proportion 
 must necessarily be conveyed to those arteries situated nearest to 
 the place of ligature, i.e., to those given off from the thoracic aorta. 
 The intercostal arteries convey, upon an increased pressure, a greater 
 quantity of red blood to the dorsal and posterior cervical regions ; 
 for if the heart still continues to beat vigorously after the last 
 breath and when the left ventricle becomes torpid, it becomes 
 thereby contracted, and expels its contents. 
 
 The black blood in the veins of the region last referred to is 
 consequently placed under a stronger "vis a tergo," whilst it 
 experiences greater resistance on its way to the heart. It must, 
 therefore, seek an outlet in the direction of the neck and head. 
 
 A third link is added to the chain of efficient causes in the con- 
 vulsive attack and the last deep respirations previous to death. 
 During the convulsion respiration completely ceases, the glottis 
 is closed, and the cerebral veins swell, as our experiments after 
 Bonders' method prove. It may readily be conjectured that by 
 the last deep respirations the quantity of venous blood in the brain 
 must be diminished, in consequence of the powerful determination 
 towards the heart and lungs. When, however, the heart and 
 lungs, as is generally the case, are already overcharged with blood> 
 and the latter have become (edematous, the effects of inspiration 
 will be but slight, while every expiration will necessarily expel 
 
48 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 considerable quantities of blood from the thorax and dorsal veins 
 and drive them to the head. 
 
 In factj the experiment so frequently repeated by us shows 
 that in dead animals whose crania have been opened, or whose 
 membrana obturatoria have been divided, large quantities of blood 
 can be propelled into the veins of the neck and skull by compres- 
 sing the thoracic walls, or by simple pressure on the diaphragm, even 
 if a cord shall have been tied two or three times roimd and so tightly 
 as to make aU the veins in the integuments of the neck impermea- 
 ble. The blood has therefore of necessity to pass to the head 
 through the dorsal and vertebral veins. This experiment always 
 answers, provided the large vessels of the thorax contain a suffi- 
 cient quantity of blood. 
 
 The question, however, arises, whether this experiment avails for 
 cases of closed cranium. By taking off the upper part of the 
 skull we remove an impediment which acts as a counter-pressure 
 against the influx of blood from the vertebral veins. And this was 
 certainly the cause of the great hsemorrhages which, soon after the 
 cessation of respiration, so frequently took place during the opera- 
 tion, from the wounded veins of the skidl and brain, in the animals 
 which, in the course of our experiments, died of anaemia of the 
 brain. 
 
 We may, however, be justified in afBrming, that venous blood 
 ^ fram the thorax can also enter the closed skull of a dead animal, 
 as has been reduced to a certainty in the case of the living one 
 both by Bonders' experiments and our own. Why should it not be 
 possible, that under favorable circumstances, even in death, the liquid 
 contents of the skull, the proportion of blood and cerebro-spinal 
 fluid, may change ? The possibility of the entire contents of the 
 skull being put out of place by an altered position of the tentorium 
 cerebelH and membrana obturatoria does not cease with life, 
 and the cerebro-spinal fluid can, in a dead animal, be pressed 
 more easily into the spinal cavity, because with increasing putre- 
 faction, the ligaments between the vertebrae and their integuments 
 become softer and more yielding. The conclusion seems irresisti- 
 ble, that in Hving animals, in whom the most vigorous muscular 
 apparatus for pressure is active, such as the organs of respiration, 
 the heart-pump, and muscular coat of the arteries, such a change may 
 take place much more rapidly and easily than in dead ones, espe- 
 cially if we date the approach of death from the last pulsation of 
 
DR. burrows' experiments. 49 
 
 tlie heart, and not from the last respiration. There are, however, 
 also in the dead body some considerable dynamical forces, which 
 drive the blood towards the head. We refer to the contraction 
 and diminution of the heart, first commencing in the left ventricle, 
 consequent upon the rigor mortis; the development of gas in 
 the intestinal canal, whereby the diaphragm is pressed upwards, and 
 the blood of the hepatic veins and of the inferior vena cava is 
 urged towards the right heart and into the superior vena cava, and 
 with a force so much the greater that the rigid abdominal integu- 
 ments at first offer resistance to the pressure of the gases. Lastly, 
 we refer to the decomposition of the blood, and the development 
 of gas in the heart and great vessels themselves. More important, 
 however, than these causes acting from within, appears to us, that 
 external and casual circumstance to which the medical man's atten- 
 tion is always more directed, namely, the position of the corpse, 
 whether it be with the head inclined downwards, or lying on the 
 belly and chest, whereby a pressure is brought to bear upon the 
 contents of these cavities. 
 
 Burrows^ killed two grown-up rabbits with hydrocyanic acid, 
 and, whilst the hearts were stiU beating, suspended one by its 
 ears, and the other by its hind legs. After twenty-four hours 
 cords were tightly fastened round the necks of the animals, 
 which were placed on the table and opened. In the one sus- 
 pended by the ears, all the external parts of the head, the ears, 
 eyeballs, and so forth, were pale and fiabbyj the muscles and 
 bones of the skull contained very little blood. Upon opening the 
 skull, the membranes and substance of the braia appeared pale; 
 the sinuses, and other vessels, free from blood. In the second animal, 
 suspended by its hind legs, the external parts of the head, the 
 muscles, and bones of the skull appeared of a dark colour and full 
 of blood ; the membranes and vessels of the brain gorged with dark 
 liquid blood, the sinuses also filled with dark blood, and the substance 
 of the brain uniformly dark and highly congested. To give these 
 experiments their fuU weight, Burrows should have suspended the 
 animals only when the heart had ceased to beat. StiU they are 
 instructive, and irrefutably demonstrate that the quantity of blood in 
 the brain and its membranes wiU vary according to the position of 
 the body during the last pulsations of the heart. We, ourselves, have 
 
 ' Loo. cit., p. 14. 
 
50 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 on several occasions noticed the ears of plethoric rabbits, in which 
 we commenced the experiment twenty-four hours after death from 
 hgature of the cervical arteries, become of a bluish-red colour 
 and turgid with blood, after the head had been in a lower position 
 for a length of time, although the ears were extremely pale when 
 death took place, and for some time afterwards. The jugular 
 veins and their branches, which after the application of the 
 ligature had contracted and become almost empty, we have 
 found, under these circumstances, gorged with dark blood. The 
 veins of the neck, of the cranial bones, cervical vertebrae, and mem- 
 branes of the brain have been found hypersemic to such a degree, 
 that one ignorant of the real cause of death might have easily drawn 
 the false conclusion that the animals during Hfe had suffered from 
 congestion of the brain, and had, in consequence, died of apoplexy. 
 The brain itself was not hypersemic, but of a bluish tinge, and 
 soft. 
 
 Engel^ declares it to be impossible that cadaverous hypostasis 
 can take place in the brain and its membranes when the skuU re- 
 mains closed, and he refers to experiments performed upon human 
 bodies which he placed for two hours in a vertical position, the 
 head downwards. Extensive hypostasis took place in the skin and 
 muscles of the face and head, but he coidd not observe any altera- 
 tion in the brain and its membranes, other than would have been 
 shown if the bodies had remained in the ordinary posture. 
 
 We do not know whether the experiments performed by Engel 
 were sufficiently numerous to entitle him to give such an unqualified 
 opinion. At all events it certainly results therefrom that one does 
 not so easily and under all circumstances succeed in producing a 
 greater fulness in the veins of the skull by keeping the head in a 
 downward posture, as has been frequently taken for granted. 
 
 As the quantity of blood in the veins of the cranial cavity may 
 undergo alteration, certainly, in the agonies of death, and probably 
 under other favorable conditions, it is evident that it must be very 
 difficult and often, impomlle to form an opinion from the quantity 
 of blood observed in the skull after death as to the amount con- 
 tained during life. The greatest impediment, however, is met with 
 in the state of the arteries, which, during the period of dying (in 
 the ears of the animal, as seen by us even after section of the 
 
 ' 'Darstellung der Lciohenersoh,' p. 17 et seq. 
 
VARYING QUANTITY OP SERUM IN THE BRAIN. 51 
 
 nervi sympatlietici and application of ligatures to the veins, and 
 after strangulation) , contract and drive their contents with some 
 force through the capillaries into the veins. We could never 
 deduce any results from the post-mortem examinations undertaken 
 with a view to determine the state of fulness before death of the 
 most important parts of the vascular system, viz., of the arteries 
 and arterial capillaries ; and even in the most favorable instance, 
 when similar inquiries were directed towards the veins, our 
 results could only be looked upon as approximate. It appears 
 therefore to us to be especially necessary to study carefully the 
 state of the brain's circulation in asphyxia, narcosis, intoxication, 
 etherization, &c., in the living animal, according to Bonders' 
 method. 
 
 We have hitherto intentionally abstained from making any 
 reference to the state of the cerebro-spinal fluid as it appeared 
 in our experiments, for we have not been successful in discovering 
 any method by which the slight quantities of humour contained in 
 the cranial and vertebral cavities of these animals could be even 
 approximately determined. We can only confirm the statement 
 made by Malgaigne, in his ' Surgical Anatomy,' that in very thin 
 rabbits, the exterior part of whose skull was opened during life, 
 we found very great quantities of serum and but little blood, whilst 
 the opposite condition was observed to hold in weU-fed animals. 
 
 In order to determine whether the proportion of serum is in- 
 creased by applying Hgatures to the arteries of the head, we were 
 accustomed, in most of the dead rabbits, before removing the 
 roof of the cranium, to divide the muscles of the neck trans- 
 versely, to lay bare the lig. obturatorium, and to open the 
 fourth ventricle by puncturing through the middle of the latter, 
 the head being kept in an upright position. The quantity of 
 serum we obtained in this manner amounted generally to a few 
 drops, but seldom did a greater quantity issue forth than would 
 fill a teaspoon, while sometimes none at all appeared, or it only 
 flowed out when the head of the animal was lowered and its 
 body placed in a higher posture. The proportion of serum gene- 
 rally remained below what we obtained from a dozen living animals 
 in whom we punctured the membrana obturatoria when in the same 
 position and whilst the blood was stiU in free circulation. But here 
 it must be carefully observed that during active processes of change, 
 even within a few seconds, greater quantities of cerebro-spinal 
 
52 ON CONVULSIONS AFTEE HEMORRHAGE. 
 
 fluid may perhaps be secreted than the cerebral ventricles may be 
 able to hold at any given time ; and also, that whilst respiration 
 still persists, a certain quantity of water is driven out of the verte- 
 bral cavity with every expiration. Estmiating the quantity of 
 water contained in the brain from the mere appearance of its sur- 
 faces, or of cut surfaces in the dead rabbit, does not lead to any 
 more satisfactory results. Both the natural surface of the brain 
 and that obtained by section, repeatedly presented in those animals 
 which died from strangulation, and even in those which died from 
 the appUcation of ligatures to the jugular veins, no more marked 
 appearance of moisture than in those which perished from cerebral 
 ansemia ; at least no striking difference could be perceived. Berlin ^ 
 also obtained the same results, although he paid but little regard 
 to them. Larger dogs wiU probably be better adapted than 
 rabbits for investigation on this subject. 
 
 Lastly, the experiments according to the method of Bonders 
 did not afford any explanation of the increase and diminution 
 of the quantity of serum in the brain and its membranes in arterial 
 anaemia or hypersemia. 
 
 There is certainly every justification theoretically for the assump- 
 tion that the quantity of serum will increase and decrease inversely 
 with the quantity of blood. We were not, however, unfortunately, 
 in a position to estabhsh this doctrine in the rabbit by an instance 
 of rapidly increased circulation. Perhaps we should have succeeded 
 better if we had compared the specific weight of the brains of such 
 animals as had died from haemorrhage with that of those strangled 
 by the apphcation of ligatures to the veins. 
 
 ' Solimidt's ' Jalirbucher,' 1851, vol. Ixix, p. 14; Nedcrl, 'Lancet,' Feb., 
 1850. 
 
CHAPTER IX. 
 
 THE STARTING-POINT OF EPILEPTIC CONVULSIONS EROM 
 RAPID AND PROFUSE HJIMORRHAGE IS NOT TO BE 
 TRACED TO THE SPINAL CORD. 
 
 Feom the experiments comniuiiicatecl in the preceding pages, 
 positive evidence has been obtained that epileptic convulsions are 
 brought about by a rapidly induced ansemia of the nervous centres 
 included in the skull. The next question to be solved will be that 
 of the state of the spinal cord induced by withholding red blood. 
 Mechanical, caustic, and galvanic irritation of the spinal cord may, 
 it is true, produce general and violent convulsions, with persistence 
 of consciousness. Does, then, the general abstraction of arterial 
 blood act as an excitant on the motor ganglia of the brain as weR 
 as on those of the spinal cord, or do the former alone consti- 
 tute the motor centre from which the impetus to general con- 
 vulsions proceeds, whilst the spinal cord acts only as a conductor, 
 simply transferring the irritation of the brain to the muscles ? Our 
 experiments teach that the latter is the case, that the brain and the 
 spinal cord react in remarkably different ways against this influence. 
 In ten rabbits, differing with respect to age (from four weeks to 
 several years), sex,' colour, and species, we tied both subclavian 
 arteries at their origins, so that the blood was conveyed to the brain 
 through the carotids only. Then the arch of the aorta was tied round 
 with a thread (an operation we succeeded in performing without 
 injury to the pleura or any other important parts) drawn a little 
 forward and compressed with a strong instrument especially con- 
 structed for the purpose. It consists of a small pair of forceps, 
 named after Charriere, 8"5 centimeters long, its branches crossed at 
 their posterior ends, and very elastic, the anterior ends, 3"5 centi- 
 meters long, lying closely together, with smooth surfaces, being 
 
 ' The formation of the thorax in the female renders the application of a 
 ligature to the areh of the aorta easier than in the male. 
 
54 ON CONVULSIONS AFTER HiEMOKBHAGE. 
 
 ^•^ millimeters widej and rounded off at the edges. This instru- 
 ment closes the aorta so completely that not a drop of blood can 
 pass through it to the posterior part of the body. 
 
 "We reserve for another time the description of the symptoms 
 caused by compression of the aorta, in respect to the sphincter of the 
 anus, the muscles of the intestines and of the bladder. We wiU 
 here only remark, that the sphincter of the anus is affected in the 
 same way as are the constrictor muscles of the face in compression of 
 the great arteries of the head. It first becomes spasmodically con- 
 tracted ; the terminal part of the rectum is thrown into a state of 
 complete tenesmus, symptoms which undergo modification after 
 some time into those of complete paralysis. The mucous membranes 
 of the rectum and vagina turn pale, the circumference of the 
 belly suddenly becomes smaller, and by degrees very much 
 so (as in death from haemorrhage), while the integuments relax 
 and the belly feels very soft. Eespiration becomes at once 
 slower, and gradually in the direction from back to front weaker 
 and weaker. The hinder part of the body soon becomes com- 
 pletely paralysed, while the fore legs are only partially so. 
 
 In most of the animals paralysis of the hinder part of the body 
 came on without any convulsion. In three of them a short, slight 
 trembling preceded; whilst these trembling movements were, in 
 one case oidy, somewhat more rapid, resembling those occurring in 
 paralysis tremulans, and lasting for some seconds. Within a few 
 seconds, or at the most within from a minute to a minute and a 
 half, the paralysis of the hind legs was complete. 
 
 Peculiar movements, similar to those witnessed in chorea, are re- 
 gularly observed in the fore legs some time after tying the arch of 
 the aorta. One can scarcely at the onset decide whether they are to 
 be regarded as the expression of a voluntary endeavour to go for- 
 ward, that is, as attempts to escape, or as real convulsions. It 
 appears at first sight as if the animals were making efforts to 
 escape, but that the fore legs moved for that purpose could not 
 follow the direction of the will on account of their partial paralysis, 
 and hence the resemblance borne by these movements to those of 
 chorea. After waiting some time one becomes convinced that they 
 are involuntary convulsions. The animal suddenly becomes alarmed, 
 its head, mostly held backwards, is turned forwards, the closed eye- 
 lids open, the fore legs move more or less violently several times at 
 rapid intervals, and step forwards. These movements are frequently 
 
COMPRESSION OF THE AORTA. 55 
 
 repeated and are produced by a reflex act when the legs are 
 touched. Between the stronger attacks affecting both fore legs, 
 slight convulsive symptoms are observed in one or the other leg, 
 which gradually become less strong and frequent, the animals are no 
 longer able to keep on their fore legs, or hold the head upright ; and 
 finally, just as in the quivering movements of the hands of 
 dying persons, a slight convulsive movement is aU that is to be 
 observed; a movement which ceases gradually during the last 
 minutes of their existence. 
 
 Death first seizes the animals in the posterior and then in the 
 anterior parts of the body. First the hind legs become paralysed, 
 then the fore legs, then the muscles of the neck, and lastly those 
 of the jaw and face. So, with respect to respiration, the action of 
 the abdominal muscles is the first to cease ; then the movements of 
 the diaphragm and thorax become more and more imperceptible ; 
 finally the mouth and nose alone but at short intervals make certain 
 violent gasping movements, phenomena as peculiar, as those pre- 
 sented by the respiration of the heads of decapitated new-bom 
 rabbits. 
 
 In a gray rabbit, one year old, the last respiration took place 
 twenty minutes after applying the ligature. Others were subjected 
 to several experiments by compression, and in these respiration ceased, 
 from eight to eighty-one minutes after the last constant compression. 
 Distinct cyanotic symptoms in mouth and nose were observed in 
 most of the animals towards the end of their existence. The 
 temperature not only of the hind part of the body, but also of the 
 head, fell during the entire duration of the interruption in the cir- 
 culation. In one case, at a temperature of i8° C. in the room, 
 within one hour, that of the rectum became ia° C. lower, that of the 
 ear 9° C. The heart stopped beating from eight to twenty minutes 
 after the last breath. Consciousness appeared but little disturbed up 
 to the last moment. The cavities of the lumbar, dorsal, and cervical 
 vertebrae were, in four animals (the subjects of close examination), 
 void of blood, with the exception of a small quantity contained in the 
 venous plexuses of the vertebrae ; and it was only in the middle and 
 upper third of the cervical vertebrse, that the vessels in the mem- 
 branes of the spinal cord appeared somewhat fuller, while the 
 quantity increased more and more in the direction of the medulla 
 oblongata. We never, however, found an abnormal quantity of 
 blood in the cavity of the skull. The substance of the brain 
 
56 ON CONVULSIONS AFTER Hi15M0RRHAGE. 
 
 was always either partially or altogether devoid of blood, and 
 it was only the veins of the cerebral membranes which contained 
 that fluid in greater or less quantity. The heart and lungs presented 
 the same characters as in cases where the great arteries of the 
 head were tied. 
 
 Upon the circulation being restored, it lasted, after an interrup- 
 tion of more than one minute, remarkably long, until paralysis of 
 the hind legs had gone off, and their free use had been restored. We 
 never in any instance observed the capability of moving to return 
 before from five to ten minutes, when the aorta had been closed for 
 from three to five minutes ; and it was never completely restored 
 after an interval^ of from fifteen to twenty minutes. 
 
 The more frequently these experiments with compression were 
 tried, the more difficulty was there experienced in bringing about a 
 recovery. A slight twitching of some of the muscles in two 
 examples announced the return of the power to move. If, there- 
 fore, the spinal cord of the rabbit be suddenly deprived of the supply 
 of red blood nearly up to the meduUa oblongata, the convulsions 
 which ensue are never of the same character and violence as those 
 which present themselves in death from sudden hsemorrhage, or in 
 arterial anaemia of the brain ; and thus complete proof is at the same 
 time afforded that the source of general convulsions in death from 
 hsemorrhage is to be sought, not in the spinal cord, but in the 
 brain. 
 
 It might perhaps be objected, that convulsions do not ensue 
 when the aorta is tied, for the simple reason that the muscles of 
 the limbs are at the same time affected by anaemia, and attain too 
 speedily a condition which prevents them from responding to the 
 impulse given by the spinal cord. That such, however, is not the 
 case is taught by the following experiment : Both the subclavian 
 arteries of a young rabbit, eight weeks old, were tied near their 
 origins and a thread passed round the arch of the aorta. No loss 
 of blood nor the slightest painful convulsion took place during the 
 whole operation. The animal was then set in an upright position 
 and allowed to rest for ten minutes. 
 
 At 1 1 o'clock we closed the carotids. This proceeding was soon 
 followed by a violent epileptic attack, and we removed the com- 
 pressorium, whereupon the animal rapidly recovered. We now com- 
 pressed the arch of the aorta, and suddenly a complete paralysis of 
 the hind legs and a partial paralysis of the fore legs came on. The 
 
COMPRKSSTON OP THE AORTA. 57 
 
 compressorium was removed thirty-six seconds afterwards, when full 
 power of using the legs was restored in forty-five seconds. 
 
 At 1 1 "5 we compressed the arch of the aorta a second time. The 
 operation was ahnost immediately succeeded by complete paralysis 
 of the hind legs and partial paralysis of the fore legs. Without 
 delay we compressed the carotids, whereupon a violent epileptic 
 attack ensued within a few seconds. Free circulation was allowed 
 to return in the carotids and disturbance abated forthwith. 
 The aorta, which ha.d remained closed, was then similarly treated 
 for forty-five seconds. Only after the lapse of a minute and 
 a half did free power of moving the hind legs return. 
 
 ii'io. — Compression is kept up on the arch of the aorta for 
 one minute, and then only do we close the carotids. Only some 
 slight convulsive movements in the fore legs tate place, the head 
 being drawn backwards. The pupils are extremely dilated, the 
 breathing of the animal becomes very slow and deep, and death 
 appears imminent. The circulation in the carotids is restored after 
 their having been closed for thirty-six seconds, that in the aorta some- 
 what later. The head becomes hypersemic, the fundus ocuH of a 
 ruby-red colour ; the pupils remain for several seconds extremely 
 dilated ; no convulsions foUow ; the animal attempts in vain to get 
 up on its fore legs. - , , 
 
 ii'i7;-^-Hind legs and sphincter ani still paralysed. 
 
 ii"i8. — Sphincter ani again closed. 
 
 11T9. — The animal commences drawing up its hind legs 
 again. 
 
 1 1*20. — The hind legs are again drawn up and the animal can now 
 stand upon them. "We now again compress the carotids, permitting 
 free circulation through the aorta for an entire minute. The animal 
 draws near its end without being attacked ly convulsions. The 
 obstruction is removed. Hypersemia of the head with dilatation of 
 the pupils lasts twenty seconds ; no convulsive movement. 
 
 1 1 "30. — We again compress the carotids, and eight seconds 
 afterwards general convulsions appear, although free use of the 
 hind legs is not yet re-established to its original extent. The source 
 of general convulsions in excessive htBmorrhage is therefore, without 
 any doubt, to be sought within the cranium ; and the spinal cord 
 serves only as a conductor of the motor impulse proceeding from 
 the brain. It results at the same time that by the withdrawal of 
 blood the spinal cord is easily damaged in its nutrition to such a 
 
58 ON CONVULSIONS AFTER HJIMORRHAGE. 
 
 degree as to be unable any longer to act the part of a con- 
 ductor. 
 
 We tested the experiment just mentioned by two others. "We 
 first tied both subclavian arteries of an old male rabbit, then the 
 arch of the aorta, and lastly the carotids. The animal expired under 
 ordinary epileptic convulsions. The brain and spinal cord were 
 found anaemic, their membranes and osseous coverings containing 
 but httle blood ; while both lungs were highly oedematous, hyper- 
 semic, and sugillated. The heart, whose cavities and coronary 
 vessels were filled and distended with black blood, continued beat- 
 ing vigorously in all its parts even an hour after the last breath. 
 Another rabbit of the same age died after compression of the aorta 
 had lasted five minutes, the carotids remaining tied, without falling 
 into general convulsions ; the ordinary spasmodic movements in the 
 muscles of the face being alone perceptible, and the head being 
 drawn shghtly backwards. The post-mortem examination gave the 
 same result as in the former case, with the exception that the heart 
 ceased beating sooner. 
 
 These experiments render it probable, in the highest degree, that 
 Dr. Marshall Hall' was in error when, on witnessing convulsions in 
 death from hsemorrhage after division of the spinal cord, he re- 
 ferred them to the haemorrhage. We suspect that Dr. Marshall 
 HaU allowed the haemorrhage to come on directly after he had 
 divided the spinal cord, and that he wrongly ascribed to the loss of 
 blood those convulsions which result from the division and irrita- 
 tion of the spinal cord. We have repeated Dr. Marshall Hall's 
 experiment on two different occasions, and have obtained results 
 strongly corroborating our supposition. 
 
 Experiment i. — In a female rabbit, a year old, of grayish colour, 
 and of very vigorous and lively habits, we laid the innominate artery 
 bare, and then divided the spinal cord above the third cervical 
 vertebra. The animal did not lose more than about two drachms 
 of blood. It was firmly tied by the fore legs, but only very loosely 
 by the hind ones. Whilst the spinal cord was being cut 
 through, and for some seconds afterwards, the hind legs moved in 
 violent clonic spasms, and respiration became simultaneously slow 
 and laboured. As soon' as the spasms subsided we quickly loosened 
 the animal and opened the innominate artery, which had already 
 ' Compare Introduction. 
 
SECTION OF THE SPINAL COBD, ETC. 59 
 
 been laid bare. Black blood issued from the vessels but slowly ; 
 the contracted pupils dilated, and the animal died without falling 
 into convulsions. 
 
 Experiment i. — In a gray, very strong, grown-up female rabbit, 
 we laid bare the innominate artery, and then divided the spinal 
 cord at the height of the fourth dorsal vertebra, by which operation 
 about a drachm of blood was lost. While the spinal cord was 
 being severed the animal shook violently, and the convulsions of 
 the hind legs continued for some seconds afterwards. The animal 
 was then loosened, and the hind part of the body was found com- 
 pletely paralysed. About three minutes after the severance the 
 innominate artery was opened, and red blood issued forth with 
 great violence ; thirteen seconds afterwards violent convulsions of 
 the fore part of the body took place, attended with dilatation of the 
 pupils, which was preceded by great contraction of the iris, and by 
 a drawing of the head backwards. One minute and a half after the 
 vessel had been wounded, the animal died. The hind part of the 
 body preserved the same position in spite of the convulsions of 
 its fore part, and it was only after the last breath that the tail 
 made some slight quivering movements, and the bladder voided 
 some urine. 
 
 The post-mortem examination showed that in both animals the 
 spinal cord had been completely severed. It may be remarked, 
 that in the rabbit the spinal cord enters very far into the sacrum, 
 so that in the second experiment a considerable proportion of the 
 spinal marrow below the section remained untouched. 
 
 The proof just afforded that the source of epileptic convulsions 
 after profuse haemorrhage, or ligature of the great arteries of 
 the neck, is not to be looked for in the spinal cord, appears to 
 us to favour the assumption that these cannot be referred 
 to the so-caUed reflex spasms, otherwise why do they not 
 occur when so extensive a reflective source as the spinal cord 
 is affected. Lastly, we may mention that when the spasms after 
 haemorrhage, or ligature of the arteries of the neck, have ceased, 
 very often extended spasms can be produced in the form of reflex 
 movements, by a mechanical irritation of the internal surface of the 
 rectum, and likewise by direct irritation of the spinal cord. 
 
CHAPTEE X. 
 
 ON THE MODE OF PROCEDURE EOR DETERMINING THE 
 CEREBRAL REGION FROM WHENCE GENERAL CONVUL- 
 SIONS AFTER PROFUSE HEMORRHAGE, ARISE. 
 
 Having succeeded in solving the problem we proposed to our- 
 selves as to whetker the starting-point of general convulsions in 
 haemorrhage was to be found in the brain or in the spinal cord, 
 we have now to discover the means for solving a second and a 
 more difficult one, viz., the determining from what particular parts 
 of the brain these general convidsions arise. 
 
 The closing of some branches only of the internal carotid or of the 
 basilar artery, may be effected by unirritating plugs driven into the 
 current of the respective vessels; but then it will, in the first 
 place, be uncertain whether, by the obstruction of these vessels, the 
 districts supplied by them wiU -always be sufficiently deprived of 
 blood, considering how great is the number of anastomoses ; secondly, 
 the least irritating plug causes a certain degree of inflammation, 
 which is not always confined in the blood-vessel to that part of 
 its walls where the obstruction takes place ; lastly, we cannot at will 
 fix the spot which the embolus has to reach, and it is quite impossible 
 simultaneously to deprive the brain, on both sides and in the same 
 districts, of its red blood, which for our purposes was indispensable. 
 
 "We, therefore, adopted another course. We cut out certain 
 districts of the brain, and compared the effects of compressing the 
 great arteries of the head before and after this operation. Experi- 
 ments were previously made to determine the influence of the 
 different preparatory steps of the operation upon the motor force 
 which produces the general convulsions ; for, before any con- 
 fidence could be placed in the results obtained by these excisions, 
 it was necessary to prove that these preliminary operations do not 
 detract from or even altogether annul the motor force. Only 
 under such circumstances, could it be inferred with certainty 
 
EXCISION OF PARTS OF THK BRAIN. 61 
 
 from the unaltered appearance or non-appearance of the convul- 
 sions after the removal of a part of the brain, that this does or 
 does not contain the starting-point of the convulsions ; and, from a 
 considerable diminution after excision, could it be deduced, with 
 great probability, that the removed district of the brain produces 
 a part of the force that causes the convulsions. 
 
 It is true we did not possess any other means of comparing the 
 force of the convulsions in the different attacks than those afforded 
 by the eye. These, however, were amply sufiicient, as in a somewhat 
 strong animal the convulsions generally appear within a few 
 seconds, and are, even in repeated experiments with compression, if 
 not too protracted and recurring too quickly, of such violence, 
 that a diminution of them from the influence of a weakening agent 
 cannot be mistaken. In any case, however, where suspicions may 
 attach to the results of compression, the experiment may be re- 
 peated on the same animal ; and, when there is any uncertainty 
 as to the results of one excision, the excision may be repeated on 
 several animals, and the results compared. 
 
 In excision of parts of the brain, it is impossible to avoid the fol- 
 lowing complications : 
 
 I. The skull is removed to a greater extent, and thus the brain 
 becomes subject to a different kind of pressure. 
 
 3. Blood is lost. 
 
 3. Some cerebro-spinal fluid escapes. 
 
 4. The temperature of the brain becomes lower. 
 
 "With regard to the removal of the roof of the skull, it is fre- 
 quently not without influence on the motor action. It is true 
 that some animals seem scarcely or not at all weakened by it, but 
 others fall for a shorter or longer time, even when the loss of blood 
 has been inconsiderable, into a state of paralysis resembling faint- 
 ness, or into a cataleptic stiffness, in which the limbs retain the posi- 
 tion assigned to them. Sometimes these conditions pass off rapidly, 
 the animals recovering in a few minutes, whilst at other times 
 they last longer. This influence must, however, be regarded as 
 unimportant in reference to our question, since the violence of the 
 general convulsions after compression of the arteries of the neck, 
 or after haemorrhage, was not affected in more than twelve experi- 
 ments, in which we paid especial attention to this point. We 
 refer also to the results of our experiment previously communicated, 
 in which the entire roof of the skuU was removed, and the hsemor- 
 
62 ON CONVULSIONS AFTEE HAEMORRHAGE. 
 
 rhage was, nevertheless, accompanied by most friglitful convul- 
 sions. 
 
 The same phenomena present themselves when the cerebro-spinal 
 fluid flows away. If an incision be made in the membrana obtu- 
 ratoria, and as much serum as possible be allowed to flow off (an 
 experiment we have performed three several times), the animal be- 
 comes weakened, it is true, but the convulsions produced by the 
 anaemic state of the brain attain their former degree of intensity. 
 
 Excision of parts of the brain is always accompanied by loss of 
 blood. The brain is an organ containing a very great quantity of 
 blood, and what, in the dead subject, we generally call abundance of 
 blood, would in the brain of the living be considered as scarcity of 
 blood. There are, however, several ways of preventing exhausting 
 losses of blood. In the first place the rabbits must not be 
 fed altogether on green food, but for some days previous to the 
 experiment they must have almost exclusively dry nourishment, 
 such as vetches, oats, &c. In this way the easily coagulable 
 blood of the rabbit is rendered much more so. After trephining, 
 which, if carefully performed, rarely causes a great loss of blood 
 (and a small loss is of no consequence whatever), the innominate 
 artery has to be tied on a smaU. piece of soft amadou in order that 
 no more blood may pass through the blood-vessel. The thread 
 can afterwards easily be cut at any time on the amadou with a pair 
 of scissors, the ligature loosened, and the brain thereby thoroughly 
 inundated, without any fear of wounding the artery. From the 
 one vertebral artery the brain of the rabbit continues to re- 
 ceive a sufficient quantity of blood; upon compressing the left 
 subclavian artery convulsions manifest themselves for some time 
 with stiU. greater violence, and now the whole exterior portion 
 of the brain up to the vicinity of the corpora quadrigemina may 
 be removed, if necessary, from the cranial cavity, without large 
 and exhausting losses of blood being sustained. The blood accu- 
 mulated in the cranial cavity is best removed with pieces of 
 prepared amadou fastened to a pair of forceps. Moderate losses of 
 blood, which still take place notwithstanding, are scarcely un- 
 desirable, since they afford a certain security against hypersemia and 
 oedema of the lungs, easily produced by applying a ligature to the 
 innominate artery. In order to determine the effects of copious 
 and exhausting losses of blood on the force of the convulsions 
 
EXPERIMENTS ON ANIMALS. 63 
 
 occasioned by compression of the arteries of the neck (we already 
 knew that smaller losses of from two to three draohms were of no 
 importance), we performed the three following experiments : 
 
 Bxperiment i. — A white, female, well-fed rabbit, ten weeks 
 old, and weighing one pound nine ounces and a quarter. The left 
 subclavian artery is tied, the innominate artery compressed. 
 Violent convulsions take place. The right carotid is then tied and 
 divided above the ligature. The blood first spouts forth and after- 
 wards drops out. In the course of half an hour five drachms of 
 blood are gradually withdrawn. The animal is put in an upright 
 position. Is in a very weak state ; the belly tolerably sunk in ; the 
 pupils very dilated ; the fundus of the eye, however, of a red colour, 
 and the animal still able to sit upright. 
 
 Ten minutes later, forty minutes after the commencement of 
 venesection, the innominate artery is compressed. The animal 
 leaps forward with great force, and falls into violent convulsions. 
 Upon loosening the compressorium, consciousness returns, but 
 slowly. Ten minutes later, the attempt to abstract some blood 
 from the animal is renewed, whereby the left carotid is lacerated 
 below the place where the ligature is applied, and the animal dies 
 from haemorrhage, terribly convulsed. As the animal was tied by 
 its fore legs, we were able to collect all the blood which issued 
 forth. Only a few drops were found in the left heart. The total 
 amount of blood lost by the animal- in aU the haemorrhages was 
 seven drachms and a half. The last attack came on when the 
 animal had altogether lost six. 
 
 In spite, therefore, of a gradual, copious, and debilitating loss of 
 blood taking place within haK an hour, ten minutes afterwards by 
 compressing the arteries of the head, and twenty minutes after- 
 wards by haemorrhage, the most violent convulsions were produced, 
 folly equal to those which had preceded. 
 
 Experiment a. — A white,, female, well-fed rabbit, about ten weeks 
 old, weighing one pound seven ounces and three quarters ; tempera- 
 ture of the rectum 39° C, temperature of the room 15° C. 
 
 The left subclavian artery is tied, and the innominate artery 
 laid bare, by which operation only a few drops of blood are lost. 
 Violent convulsions ensue within twenty-one seconds after com- 
 
64 ON CONVULSIONS AFTER H^MORKHAGE. 
 
 pressing the innominate. Upon removing the compression the 
 animal remains for nineteen seconds in a state resembling paralysis, 
 when it springs up suddenly. 
 
 io"34 o'clock. — ^The right carotid is tied and opened above the 
 ligature, and haK an ounce of blood is voided within forty-two 
 minutes. 
 
 At 1 1 '20 the animal appears very much weakened and ex- 
 hausted, its belly has become perceptibly smaller and softer, and 
 it is only with difficulty that it keeps upon its legs. Placed upon 
 its hind legs for five minutes, and held up by its neck, it does not 
 fall into convulsions. 
 
 1 1 ■30. — Compression of the innominate artery. The convul- 
 sions appear ten seconds afterwards, and are somewhat weaker 
 than before the haemorrhage. The animal raises itself again twenty- 
 seven seconds after the compression has been removed. 
 
 ii'55. — ^Temperature of the rectum 33*4° C, temperature of 
 the room 15° C. 
 
 1 3' 20 and ia"30. — Compression of the innominate artery. The 
 convulsions are considerably weaker than before, and manifest them- 
 selves for the first time after an interval of nine seconds; the second 
 time after an interval of sixteen seconds. The animal rises each 
 time soon after removal of the compression, but still remains for 
 a time in a half paralysed state. 
 
 i2'33. — Temperature of the rectum 3i"6° C, temperature of 
 the room 13° C. 
 
 I '8. — The animal gets restless and trembles occasionally, having 
 up to this time remained very quiet, and as it were stunned. 
 
 ri6. — Compression. The animal is attacked by very violent 
 convulsions, scarcely less severe than those which preceded the 
 hsemorrhage. The animal is now, at intervals of from three to five 
 minutes, repeatedly assailed with attacks of general and vehement 
 shaking, whereby the head is drawn back, the fore legs move 
 spasmodically, and the whole body trembles. 
 
 I "30. — ^Temperature of the rectum 29° C, temperature of the 
 room 13° C. 
 
 I '55. — ^The spasmodic movements have ceased for the past twenty 
 minutes, respiration is deep and slow (fifty-six inspirations a 
 minute) j the animal is quiet, and so exhausted that it can no 
 longer hold up its head. 
 
EFFECTS OF COMPRESSION OP SUBCLAVIAN, ETC. 65 
 
 V^. — ^Temperature of the rectum 37"8° C. ; temperature of the 
 room 13° C. The animal lies on its side. 
 
 a" 8. — Compression brings on such violent convulsionsj that the 
 animal is thrown over, head forwards, and falls off the table. 
 This attack is, moreover, very little weaker than that preceding the 
 loss of blood. Upon restoration of the circulation the animal utters 
 cries, and recovers with great difficulty. 
 
 3" 16. — Eespiration ^6, deep and distressed. Eectum 37° C. 
 The animal is now killed by compression of the innominate, whereby, 
 moreover, it suffers from an attack of slight, but general con- 
 vulsions. 
 
 In this case we observe that, after a copious, gradual, and very 
 weakening loss of blood, sustained during an interval of forty-two 
 minutes, the convulsions were slighter, immediately upon the com- 
 mencement of the haemorrhage, and in an hour after, than they 
 were previous to it; but became very violent three hours after- 
 wards, and even after an interval of three hours and three quarters, 
 the animal, nevertheless, being in a state of great exhaustion. 
 
 Experiment 3. — A white male, very well-fed, and fat rabbit, 
 about ten months old, weighing two pounds seven ounces. Tem- 
 perature of the rectum 40° C. 
 
 ii"i5 o'clock. — Left subclavian artery tied; innomiaate artery 
 laid bare. Compression performed with the usual result. 
 
 II '30. — ^Within six minutes, five and a quarter drachms of 
 blood are taken from the right carotid in the manner repeatedly 
 described by us. The mucous membranes of the animal are pale, 
 but it is still very lively. Eespiration was generally accelerated 
 during venesection. 
 
 1 1 "3 8. —Compression of the innominate causes strong convul- 
 sions, which are, however, weaker than before the loss of blood. 
 When circulation is restored, the animal recovers slowly, remains 
 stiU for some time, lying as in a swoon, and then it jumps 
 suddenly up. It feels very cold. 
 
 la. — ^An experiment with compression induces convulsions as 
 violent as before the loss of blood. 
 
 i2"io. — ^Another drachm of blood is abstracted. Compression 
 now causes very violent convulsions. 
 
 i2"ao' — ^A drachm and a half of red blood is further taken from 
 the carotid. 
 
 5 
 
66 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 I3.a8. — Compression produces very violent convulsions. 
 
 13-38. — One draclim of blood is abstracted. Exhaustion com- 
 plete. Pupils dilated and pale. The animal is unable to sit, and 
 can no longer hold up its head. The beUy has become very small 
 and soft. 
 
 Ta"43 ^^^ ^^'53- — Compression produces each time very strong 
 convulsions, which are preceded by complete opisthotonos. 
 
 Between the experiments the left fore leg sometimes moves spas- 
 modically. 
 
 1-6. — The animal lies on its side, breathing 120 times in a 
 minute. Eectum 31 "6° C. Temperature of the room as before. 
 The animal voids some urine. 
 
 I'lS. — Compression, The animal stiU falls into convulsions, 
 but their violence is much diminished. The compression is removed, 
 but the convulsions still continue ; the animal breathes rarely and 
 distressedly, makes some spasmodic movements, voids urine, and 
 dies. After the last breath the legs once more move convulsively. 
 Quantity of blood abstracted eight drachms and three quarters. 
 
 Despite the repeated and exhausting losses of blood, very 
 Yiolent convulsions appeared after the numerous compressions, and 
 the convulsions were weaker than before the carotid was opened, 
 only after the first loss of blood, and again, when compression was 
 applied for the last time. 
 
 To these experiments we add a fourth one, in which we endea- 
 voured to determine the influence of refrigeration applied simulta- 
 neously with excision of parts of the brain, and which wiU appear 
 to be considerable, resulting, as it did, both from the losses of 
 blood as well as from the laying bare of the brain and the applica- 
 tion of cold water (of which, however, we used as little as possible). 
 
 Experiment 4. — A white, female, weU-fed rabbit, about twelve 
 weeks old, weighing one pound fifteen ounces and a quarter. Tem- 
 perature of the rectum 40° C, temperature of the room. 
 
 lO'io o'clock. — The left subclavian artery is tied, the innominate 
 laid bare. 
 
 lO'iS. — ^Violent convulsions manifest themselves upon compres- 
 sion of the innominate. 
 
 iO"30. — Removal of the roof of the skuU covering the cerebrum, 
 to the greatest possible extent. 
 
EFFECT OF REFRIGERATION OF THE BRAIN. 67 
 
 io"4a to io"47. — ^Two drachms of blood taken from the right 
 carotid. The animal is put on its legs. 
 
 io"57. — Compression causes convulsions as violent as before 
 the stull was opened. 
 
 ii"i5 to ii"30. — One and a quarter drachms of blood abstracted. 
 
 The brain is cooled by applying snow from ii'ia to ii"30. 
 
 ii'30. — Compression. The animal falls into violent convulsionSj 
 commencing with a violent leap. The refrigeration with snow is 
 continued. 
 
 1 1 "3 6. — ^The animal is excessively cold. The veins of the mem- 
 branes of the brain are opened, and about a quarter of a drachm of 
 blood taken away. Snow again applied. 
 
 I a. — Compression causes violent convulsions. Snow again applied. 
 
 I2'i5. — Abstraction of one and a half drachms of red blood from 
 the right carotid, and until convulsions appear. The animal becomes 
 subsequently exceedingly weak (it lost five drachms of blood alto- 
 gether,) and can no longer raise its body. Eespiratiop quick. 
 Snow is again applied. 
 
 I3'30. — Compression brings on convulsions, but of less violence 
 than the previous ones. Temperature of rectum 36° C, tempera- 
 ture of room 15° C. Eenewed application of snow. The animal 
 preserves its lateral position, and breathes slowly. 
 
 I o'clock. — Compression induces an epileptic attack, which is 
 weaker than the former ones, but still tolerably violent. Continua- 
 tion of cooling with snow. 
 
 1-45. — ^The innominate artery is tied. The head is drawn back- 
 wards ; the hind legs are extended ; slight convulsive movements 
 of the Hmbs ensue, and are followed by death. Temperature of 
 the rectum 3i"6°C. 
 
 The brain appeared at the post-mortem examination exceedingly 
 pale, and the cranial cavity remarkably deficient in blood. Nothing 
 abnormal was noticeable in the lungs. 
 
 It is certainly extremely remarkable that the susceptibility to 
 convulsions, and to such violent ones, should have persisted so long 
 a time, notwithstanding that the brain of the animal was constantly 
 exposed to the influences of cold, and that great losses of blood were 
 simultaneously sustained. The attacks still exhibited great violence 
 an hour and a half after the removal of the skuUj and even after 
 two hours, when the exhausted animal could no longer keep upon 
 
68 ON CONVULSIONS AFTER H^MORBHAGE. 
 
 its legs, they broke out again with great though dimiiiished 
 intensity. Only three hours and a quarter afterwards, when the 
 animal was near death, was its motor power completely ex- 
 tinguished. 
 
 Compression of the arteries of the head, in the rabbit, is there- 
 fore capable of causing violent conmlsions even after large and 
 exhausting losses of blood, with or without simultaneous exposure 
 and cooling of the brain. The spasms can be repeatedly induced 
 in the space of from one to two hours, the time required for the 
 experiments by excision. This, however, is not invariably the case. 
 The convulsions are sometimes sHght, though no satisfactory law 
 can be laid down to account for this irregularity. 
 
 To obviate fallacious results, we therefore determined to make 
 use of strong animals only, and to regard such experiments by 
 excision as alone valuable and decisive, where the inevitable haemor- 
 rhage was moderate — ^not exceeding, in young animals of from ten 
 to twenty weeks old, two drachms, in older ones, from three to four 
 drachms, quantities which a slight experience enables one readily to 
 estimate — and where no symptoms of general anaemia (paleness of 
 the mucous membranes, softness and diminution in the size of the 
 belly) appeared. Further, we allowed shorter or more protracted 
 intervals to elapse between the several acts of operation and com- 
 pression, to afford the animals every chance of recovery. Com- 
 pression was many times repeated in the same individual at greater 
 intervals, that the several results might be checked the one by 
 the other ; and, finally, death was often brought on by haemorrhage 
 (wounding the innominate), instead of the application of the liga- 
 ture. As a rule, our first experiments with compression were per- 
 formed on the left subclavian artery, the innominate being uniformly 
 closed; but the latter was afterwards freed, for the purpose of 
 affording more nourishment to the brain. This method generally 
 gave rise to effusions of blood, though rarely of an extensive 
 nature, into the cranial cavity. After some time the left sub- 
 clavian artery was tied, when compression was more conveniently 
 repeated on the innominate. 
 
69 
 
 CHAPTEE XI. 
 
 ON THE RELATIVE IMPORTANCE OE THE SEVERAL PARTS 
 OF THE BRAIN IN PRODUCING GENERAL CONVULSIONS 
 UPON ABSTRACTION OP ARTERIAL BLOOD. 
 
 Out of more than twenty experiments which we performed for 
 the purpose of tracing the source of general convulsions, we were 
 entitled, in accordance with the principles laid down in the last 
 chapter, to consider fifteen as successful and decisive. Their chief 
 result is that general convulsions arising either from profuse ha.mor- 
 rhage or from, closure of the great arteries of the neck, do not proceed 
 from the non-excitable, hut from the excitable parts of the brain. 
 Our experiments on the rabbit lead therefore to the same conclusion 
 which the researches in the sixth chapter have made exceed- 
 ingly probable in the case of human beings. Convulsions in 
 epileptic attacks sequential to the abstraction of red blood, do 
 not proceed from the cerebrum properly so called, but frmn the 
 motor centres situated behind the thalami optici, the excitation being 
 induced by a sudden arrest of nutrition. 
 
 Numerous experiments have taught us that large pieces can be 
 removed from one or from both cerebral hemispheres, without the 
 violence of the convulsions sustaining any diminution. Six parti- 
 cularly successful ones fully assured us — 
 
 (i) That the removal, of one or 
 
 (a) of both cerebral hemispheres, together with the corpus cal- 
 losum ; 
 
 (3) of the fornix and anterior commissure, as well as the 
 
 cornua ammonis ; 
 
 (4) of the corpora striata ; 
 
 (5) of the pituitary gland, with the greater part of the tuber 
 
 cinereum; and 
 
 (6) of the pineal gland. 
 
70 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 does not exercise any inflnence upon either the production, or 
 the violence of general convulsions. The source of the motor 
 force is not to be found in these parts. As regards the thalami 
 optici, we have ascertained, in four very successful experiments, 
 that considerable pieces on both sides may be cut off from their 
 superficial non-excitable parts, from the gray portion turned towards 
 the third ventricle, as well as from the white substance of the 
 external pulvinar and the corpora geniculata, together with the 
 tractus opticus, without the strength of the convulsions per- 
 ceptibly diminishing ; but that such diminution wiU take place as 
 soon as the excitable and deeper-seated portions are wounded, and 
 pieces removed therefrom. 
 
 If the crura cerebri are removed in great slices or almost com- 
 pletely, together with the anterior corpora quadrigemina up to the 
 pons, the liability of the animal to fall into convulsions, when 
 blood is withdrawn, is by no means annulled, but only considerably 
 impaired ; and the spasms are sometimes confined to the hind legs, 
 as we are justified in concluding from four experiments. 
 
 Finally, one experiment appears to be ia favour of the belief 
 that the removal of excitable pieces of the cerebellum likewise 
 decreases the force of the convulsions. "We omit giving full details 
 of aU our experiments, but restrict ourselves, to avoid prolixity, 
 to an accurate description of the most remarkable and decisive 
 ones. 
 
 Experiment i. — Excision of tJie cerebrum up to the thalami 
 optici. The spasms bring on premature labour. — A large, white 
 female rabbit, weighing three and a quarter pounds. 
 
 3'40 o'clock. — The arteries of the neck are laid bare. 
 
 3'5°- — '^^^ isolation of the innominate artery and of the left 
 subclavian artery is completed, and threads are applied around these 
 vessels. No loss of blood. The animal is made to sit up, and is 
 lively. 
 
 3-55. — Compression of the arteries causes general and violent 
 convulsions within a few seconds. 
 
 4. — ^The roof of the skuU in its anterior circumference is removed 
 with moderate loss of blood ; the innominate artery is tied on a 
 small piece of amadou ; and 
 
 At 4-17 the dura mater is removed. The entire quantity of blood 
 lost up to this time amounts to about a drachm and a half. The 
 
EXCISION OF THE CEREBRUM. 71 
 
 animal is but little affectedj nor does it exMbit any symptoms of 
 stupefaction or paralysis^ 
 
 4"aio'clock. — ^The left subclavian artery is compressed; sii 
 seconds afterwards general convulsions occur. 
 
 4" 24. — The removal of the brain by means of a spoon and scissors 
 is commenced; and 
 
 At 4"a8 both hemispheres of the cerebrum, the corpus callosum, 
 the fornix, and both corpora striata, had been entirely removed, as the 
 post-mortem examination afterwards confirms. The tractus opticus 
 and the optic nerves are weU protected on both sides, as well as the 
 tuber cinereum. The incision has been made exactly on the anterior 
 limit of the thalami optici and downwards along the optic nerves. 
 The pineal gland is torn off. During the removal of the brain 
 the animal, although not tied, did not make any convulsive move- 
 ment or attempt to escape, nor show any sign of suffering, but 
 appeared greatly stupefied, and fell down. Put upon its legs, it was 
 still able to stand, though no longer with its former strength ; and, 
 laid down upon the floor, it remained quietly, and " all of a heap,'* 
 without making any effort to escape. The loss of blood during the 
 removal of the brain was extremely small, perhaps half a drachm 
 altogether. Some drops of blood graduaJly collected afterwards in 
 the anterior cavity of the skull. 
 
 4"32. — Compression of the left subclavian artery. Pive seconds 
 afterwards strong convulsive shocks succeed; compression is sus- 
 pended, and the animal sinks again into a fainting state. 
 
 4-37. — Compression of the left subclavian artery. After five 
 seconds a violent attack of spasms commences, in which the animal 
 is seized with premature labour and expels two foetuses, one of 
 which tries to breathe. Upon relaxing the compression it utters 
 slow moans during the act of parturition. 
 
 4'40. — The ligature on the innominate is relaxed in order to 
 supply the brain with more blood. The fundi of the eyes become 
 darker ; very little blood is lost within the skull, but the animal 
 does not recover from its state of faintness. 
 
 4-48 . — ^The innominate is wounded and the animal dies from 
 hsemorrhage. Previous to death, and seventy seconds after the 
 infliction of the wound, general convulsions of the most violent 
 description come on, so that the animal is thrown froni the table, 
 and for fifty seconds struggles convulsed on the fioor. 
 
 4-_5o. — The last respirations take place. Not a drop of blood 
 
7Z ON CONVULSIONS AFTER HEMORRHAGE. 
 
 appears under the pons or in the medulla oblongata. No pneu- 
 mothorax nor oedema of the lungs. Three foetuses are found in 
 the cornua of the uterus. 
 
 Messrs. Payenstecher, M.D., Schiel, Ph.D., and Eeichertj Student 
 of Medicine, were witnesses of this experiment. Jusi as in the 
 human female, eclampsia gravidarum causes jpremature labour, and 
 thus becomes eclampsia parturientium, so in the pregnant animal 
 have we seen premature labour come on under the influence of an 
 epileptic attach produced in the course of an of experiment. 
 
 Eseperiment a. — Hxcision of the cerebrum up to the thalami optici. 
 — A white, male and very strong rabbit, about a year old, weighing 
 two pounds nine ounces. 
 
 io'i5 o'clock. — The great arteries of the neck are laid bare, and 
 threads placed round them. No loss of blood. Compression 
 causes violent convulsions within six seconds. 
 
 io"30. — ^The anterior part of the roof of the skull is broken 
 off to a great extent, and the dura mater removed without any 
 great loss of blood. The animal appears afterwards somewhat 
 stupefied and paralysed. 
 
 io"4o. — Compression brings on violent general convulsions within 
 six seconds. 
 
 io'43. — -^ Hgature is appUed to the innominate on amadou. 
 
 io"45. — The right portion of the cerebrum is completely 
 removed up to the anterior margin of the thalamus opticus. A 
 moderate haemorrhage ensues. The animal appears still more 
 stupefied and weaker than before. 
 
 1 0-50. — Compression of the left subclavian artery. In a few 
 minutes the animal is attacked with such violent convulsions that 
 it is flung to a distance over the table. 
 
 10*54. — ^The left half of the cerebrum is Kkewise removed close 
 up to the thalamus opticus. Moderate haemorrhage. Up to the 
 present time the animal has lost at the most two drachms of blood. 
 The incision is made through the tractus opticus on both sides, 
 through the tuber cinereum downwards, and separates the hypo- 
 physis cerebri. The animal neither moans nor even once stirs ; on 
 the contrary, it is completely paralysed, continues lying on its belly, 
 and makes no attempt at escape. The limbs continue in any position 
 in which they are placed. 
 
EXCISION OF THE CEREBRUM. 73 
 
 1 1 o'clock. — Compression of the left subclavian artery. General 
 violent convulsions ensue. The innominate is freed ; the fundus 
 of the eye turns of a dark-red colour. The animal loses within the 
 next twenty minutes about one drachm of blood. 
 
 I i"io. — The innominate and left subclavian artery are tied. The 
 animal rapidly falls into frightful and general convulsions, which 
 last for a minute and a half, and towards their termination are 
 interrupted by tetanic spasms. At the conclusion of the attack the 
 animal cries out loudly, voids urine, and begins afterwards to 
 breathe quickly, until respiration becomes slower at ii'ao. 
 
 1 1 "21. — A thermometer is introduced into the rectum, where- 
 upon general violent clonic convulsions ensue, and finally the hind 
 legs are seized with tetanic rigidity. 
 
 T-i'2^. — Eespiration ceases. The crura cerebeUi are irritated 
 with a knife, and a violent and general convulsion succeeds. 
 
 In this case also no blood was effused below the pons or medulla 
 oblongata; the lungs appeared in some places hypersemic, but 
 nowhere oedematous. 
 
 Experiment 3. — Excision of ihe cerebrum and thalami optici to 
 the limits of the excitable districts. — A white female rabbit, ten to 
 twelve weeks old, weighing one pound ten ounces and three 
 quarters. 
 
 1 1 '25 o'clock. — ^The arteries of the neck are laid bare without 
 any loss of blood, and surrounded by a thread. 
 
 II '36. — The skull is opened and the dura mater cut away. The 
 animal loses a moderate quantity of blood, and falls into a state of 
 weakness, which lasts for some time. 
 
 I I "45. — The innominate is tied on amadou; the left subclavian 
 artery compressed; violent convulsions ensue. 
 
 13 o'clock. — ^The whole of the cerebrum anterior to the thalami 
 optici is removed, and the latter are then cut off in slices 
 with a pair of scissors from the outside, upwards and forwards 
 to the interior and inferior portions, until the excitable parts 
 are reached, which becomes apparent from a sudden convulsive 
 motion of the animal. Thus are removed on both sides the gray 
 substance covering the thalami optici, the white lateral elevations 
 (pulvinar, &c.), together with the tractus opticus. At the base of 
 the brain the incision is made through the middle of the tuber cine- 
 
74 ON CONVULSIONS AFTER HAEMORRHAGE. 
 
 reum. The loss of blood amounts to from one and a half to two 
 drachms. The animal becomes blind^ the pupils dilate considerably 
 (nn. oculo-motorii and quinti intact, as shown at the post-mortem 
 examination) ; it assumes a strange position, which indicates that 
 the animal has no longer the free use of its limbs. One fore' leg is 
 extended, the other is bent, and the hind legs become drawn very 
 much forward under the beUy. If touched, the animal makes some 
 rapid but unsuccessful movements as though trying to escape. 
 Placed upon its legs, it keeps upright only with difficulty, and soon 
 falls upon its side. Respiration regular, ninety-six per minute. 
 
 I a' 8. — Compression produces very strong general convulsions, 
 scarcely weaker than the previous ones. Upon the cessation of 
 these the animal remains quietly lying on its side. 
 
 ia"ao. — Compression. The convulsions re-appear in full force, 
 and continue for some seconds after the circulation is restored. 
 
 1 3*30. — ^The ligature on the innominate is loosened without any 
 perceptible hsemorrhage occurring in the skull. The background 
 of the eye has a dark-red tinge. After a short time the animal 
 jumps up, but falls down again on its fore legs, while it stiU keeps 
 on its hind legs. Eespiration gets deeper and by degrees very 
 difficult, (probably from the pressure of the extravasated blood, 
 gradually exerted at the base of the skull on the medulla 
 oblongata). 
 
 ia'38. — The arteries are tied; the animal expires in weak and 
 short, but general convulsions. Coagula are found below the 
 pons and medulla oblongata. No pneumothorax. The lungs 
 exhibit some portions about the size of a lentil which are con- 
 densed, dark brown, and several of them hypersemic, but more 
 of them, oedematous. The heart still beats at i'30. 
 
 , Experiment 4. — ^Exactly similar results were obtained from an 
 experiment performed in the same manner on a male rabbit weigh- 
 ing one pound fifteen ounces. 
 
 Experiment 5. — Excision of the cerebrum, of a part of the 
 thalami optici, and slight wounding of the right cms cerebri. — A 
 large, vigorous, female rabbit, which kindled only a fortnight pre- 
 viously, but does not suckle, weighing three pounds two ounces 
 and a half. 
 
 37 o'clock. — The arteries of the neck are laid bare. 
 
EXCISION OF THE CEREBRUM, ETC. 75 
 
 3'30. — ^They are surrouiided with thieads^ and the animal is made 
 to sit up. 
 
 3"34. — Compression of the arteries causes, after nine seconds, 
 moderately strong general convulsions. 
 
 3'59. — ^The anterior part of the skuU is removed. The animal 
 does not appear stupefied in consequence ; the haemorrhage is 
 slight. 
 
 4'6. — The innominate artery is tied, and the dura mater removed. 
 
 4" 16 0^ clock. — Compression of the left subclavian artery gives rise 
 to moderately strong convulsions within ten seconds. The animal 
 is slow in recovering. 
 
 4'ai. — The cerebrum is cut off anterior to the thalami optici. 
 The tractus opticus is removed on both sides, together with 
 the white rounded elevations on the external and posterior parts 
 of the thalami optici, as well as a portion of the gray substance 
 covering the internal part of the thalami. The incision is next 
 carried downwards, through the posterior third of the tuber 
 cinereum, and passes on the right side, (the animal meanwhile 
 suffering violent convulsive movements) near the median Hue, 
 somewhat further back than on the left side. The animal 
 repeatedly turns its head to the right side, and at first keeps its 
 left leg somewhat more extended, but suddenly makes a violent 
 effort to escape, having previously appeared to be in a state of 
 quiet stupefaction. It is then placed on the floor, where it be- 
 comes calmer; but, if scared, straightway springs up, describing 
 greater or smaller curves in a direction to the right. The loss 
 of blood is sHght, amounting on the whole to about two drachms. 
 
 4'36. — The innominate artery is liberated, causing a very trifling 
 bleeding within the skuU. 
 
 4-41. — AppHcation of a ligature to the left subclavian. 
 
 4"4a. — Compression of the innominate, followed almost imme- 
 diately by moderately strong and general convulsions. Upon now 
 again opening the carotid the animal loses about half a drachm of 
 blood from the cranial cavity. 
 
 4*48. — Compression. Tifteen seconds afterwards violent convul- 
 sions. 
 
 4-50. — Placed upon its legs, the animal runs about the room 
 in a curved direction, -endeavouring to escape. 
 
 4-_5_5. — The innominate artery is punctured. General convulsions 
 ensue in thirty seconds. They are of long continuance, and so 
 
76 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 violent, that it cannot be well ascertained whether any considerable 
 part of the source of motor power has been removed with the 
 portions of the brain that have been cut off. Two minutes and ten 
 seconds after the opening of the innominate artery the animal 
 breathes its last. 
 
 No extravasation of blood below the pons and medulla oblongata. 
 No cedema of the lungs or pneumothorax. The right inferior lobe 
 of the lungs is in some places of a bluish-red colour, but contains air. 
 
 Experiment 6. — Smcision of the cerebrum, of the anterior part of 
 the thalami optici, of the hypophysis cerebri, and of a small portion of 
 the right cms cerebri. — ^A white, female and rather attenuated rabbit, 
 twelve weeks old, weighing one and a half pound. 
 
 10*50 o'clock. — ^The operation of laying bare the arteries of the 
 neck is completed, from which the animal has experienced a slight 
 loss of arterial blood. Compression produces active convulsions. 
 
 11-3. — The innominate artery is tied, the skull opened, and the 
 brain exposed, whereby more than the usual quantity of water 
 flows away, but very little blood is lost. The animal appears 
 weakened, and the fundus of the eye on both sides is very pale. 
 The hemispheres of the cerebrum are removed up to the thalami 
 optici without any indication of pain or convulsions. 
 
 1 1-8. — An incision is made through the middle of the right 
 thalamus opticus, in front and in a downward direction, in con- 
 sequence of which the animal, whose fore legs are tied, moves 
 the left hind leg vigorously. An incision is likewise made in the 
 same direction through the left thalamus opticus, but a little 
 more in front, which is quietly borne by the animal. The pulvinar 
 and the posterior part of the tractus opticus remain untouched. 
 At the base the incision completely severs the tuber cinereum 
 just anterior to the corpus albicans. On the right side the incision 
 is carried further backwards than on the left, reaching up to the an- 
 terior part of the crus cerebri. The haemorrhage is slight. 
 
 The animal is loosened. It cannot keep on its legs when set 
 upon them. The left fore leg is extended tetanicaUy ; the three 
 other ones are paralysed, and it is unable to keep its head erect. 
 When touched, it tries to escape with its hind legs and right fore 
 leg, but is unable to move from its place. 
 
 ii*i6. — ^The animal is still more recovered. Its hind legs are 
 drawn towards the beUy, and it sits up. "When touched, it tries 
 
•, EXCISION or THE CEREBEUM, ETC. It 
 
 to run away. It is now able to move forward, but the fore leg 
 which remains outstretched offers considerable impediment. Ees- 
 piration is quiet and even, seventy-five times a minute. 
 
 ifao. — Compression of the left subclavian. Tolerably active 
 convulsions ensue, yet weaker than before the removal of the 
 brain. They are more active in the hind than in the fore legs. 
 Upon the circulation being restored, the tetanicaUy stretched fore 
 leg becomes relaxed for a short time. ^^^ 
 
 ii'33. — ^To supply the brain with nourishment more effectually, 
 the ligature on the innominate artery is removed. Extensive 
 haemorrhage takes place iuto the cavity of the skull, which, how- 
 ever, soon ceases. The animal breathes one hundred times a 
 minute. The total quantity of blood lost since the commencement 
 of the operation amounts to about three drachms. 
 
 II "37. — ^The animal lies quietly on the side. When touched it 
 jumps up, sits upright, and remains in this position. The left 
 fore leg still continues stiff. 
 
 1 1 "30. — ^The left subclavian is tied. 
 
 II '3 1. — Compression of the innominate artery. General and 
 active convulsions manifest themselves in aU the animal^'s legs, 
 stronger than those observed in the preceding experiment, weaker 
 than before the removal of the brain. "When the blood is again 
 allowed to pass through the innominate artery, not only do the 
 clonic convulsions subside, lut the rigidity of the left fore leg also 
 disa^ears, soon, however, to return. The animal loses another 
 drachm of blood, and remains weakened, lying on its right side, 
 breathing very quickly. 
 
 1 1 "36. — SHght convulsive movements repeatedly appear in the 
 left extended fore leg. 
 
 1 1 •41. — ^Death from haemorrhage on opening the innominate 
 artery. The animal dies without convulsions, only a kind of 
 quivering of the skin being noticeable. The quantity of red 
 blood abstracted this last time amounts to three drachms. 
 
 Some coagulated blood is found below the pons and the medulla 
 oblongata. Neither oedema of the lungs nor pneumothorax were 
 observed. 
 
 Experiments 7, 8, 9, and 10. — Excision of the thalami qptici, crura 
 cerebri, and abortion of the anterior corpora quadrigemina. — ^Large 
 pieces of excitable brain-substance were removed from four animals. 
 
78 ON CONVULSIONS AFTER HAEMORRHAGE. • 
 
 after excision of the cerebrum up to the thalami optici, without 
 exhausting losses of blood ensuing : in one, haK a year old, the 
 greatest part of the thalami optici and of the crura cerebri, 
 together with the corpus mammillare; in another, one year old, 
 the thalami optici completely, together with the cms cerebri, up 
 to the neighbourhood of the pons ; in a third and fourth, two to 
 three years old (and these especially lost but little blood), the 
 thalami optici, the anterior part of the testes, and the crura cerebri, 
 close up to the pons. All of them became affected with opistho- 
 tonos, alternating with several attacks of clonic general spasms at 
 irregular intervals, sometimes of ten minutes ; compression of the 
 left subclavian, which we repeatedly applied in each instance, to 
 secure ourselves from error, produced clonic convulsions imme- 
 diately in every case. Upon the blood re-entering the brain, 
 not only the clonic spasms, but also the opisthotonos, ceased for a 
 short time. TMs cessation, of the tetanic state upon removal of com- 
 pression is not to be ascribed to the losses of bhod frequently attendant 
 upon compression, but to arterial congestion, which comes on when 
 no blood whatever has been lost. 
 
 The clonic spasms after compression were not weaker than those 
 appearing spontaneously, but always weaker than those brought 
 on before removal of the brain, and those directly following the 
 separation of the crura cerebri. In one of the animals, in which 
 the incision was made through the testes, up to the pons varolii, 
 very violent general clonic spasms ensued, passing into opistho- 
 tonos, and returning within the fiist ten minutes, though with a 
 gradual diminution of strength. A'Vlien the tetanic state had lasted 
 unchanged for thirteen minutes, the subclavian artery was com- 
 pressed, when weak convulsions only, appeared in the hind legs. 
 Twenty minutes after this experiment the animal was killed by ap- 
 plying a ligature to the subclavian, whereupon it fell into con- 
 vulsions, not only general, but particularly violent. 
 
 Mceperiment ii. — Removal of a great portion of the cerebellum. — 
 A white, male rabbit, about eleven weeks old, weighing one pound 
 ten ounces. 
 
 io"i5 o'clock. — ^The great arteries of the neck are laid bare 
 without loss of blood. Upon compression the animal falls into 
 strong convulsions. 
 
 Ti. — ^The cerebellum is laid bare to a large extent, whereby 
 
EXCISION OF THE CEREBELLUM. 79 
 
 the animal loses much bloody — about two drachms. The inno- 
 minate artery is not tied. Great slices of the hemispheres are 
 now cut off without the animal's stirring, until the vicinity of the 
 crura cerebeUi is reached. The animal then is unable to keep on its 
 legs, and becomes deprived of the free use of its hmbs. The legs 
 exhibit a certain degree of rigidity, and resist all our attempts to 
 move them. The fore legs become more extended, the hind ones 
 bent. When the animal is made to stand on its legs, it falls down, 
 becomes attg-cked by clonic spasms, and relapses into its former 
 state of stiff immoveability. Some minutes having been allowed to 
 elapse, compression is applied to the vessels. The rigidity of the 
 limbs vanishes, and general convulsions of considerable intensity 
 come on. Upon the blood again flowing into the brain^ they persist 
 for some few moments. The body falls into a state of general re- 
 laxation, until after about a minute, the fore legs become again ex- 
 tended, and the hind ones contracted. We now remove the entire 
 covering of the fourth ventricle, with the exception of a small piece 
 which forms a sort of smaU commissure behind the corpora quadri- 
 gemina, and take off the hemispheres up to those lobes wliich he- 
 hidden in the reniotest niches of the occipital bones ; by which 
 operation the animal again loses much blood (about one drachm 
 and a half), and exhibits some strong convulsions when the crura 
 cerebeUi are reached. After this the animal remains lying quietly, 
 with its legs rigidly extended, but is stiU. able to hold its head up. 
 A compression of the arteries causes no more convulsions, but the 
 rigidity subsides and the legs become quite flabby; respiration 
 ceases; the pale pupils become narrow and afterwards dilated. 
 Upon the blood g-gain flowing in, some sHght spasmodic movements 
 come on in the hind legs, and afterwards the legs turn stiff again. 
 
 The animal is left to breathe quietly for twenty minutes. The hairs 
 on the chin, the mouth, and muscles of the nostrils are in almost 
 constant spasmodic agitation ; respiration easy and superficial. 
 
 1 1 '48. — Compression without any subsequent convulsions, but 
 the stiffness gives way and respiration ceases. When the blood 
 flows in again, a sHght spasmodic movement of the liind legs is 
 observed. 
 
 I2"20. — Compression with the same result. If the animal is 
 made to sit up, it endeavours to make certain movements, but with- 
 out success ; consciousness does not appear extinct. 
 
 ia'30. — Unexpectedly, and without any previous compression 
 
80 ON CONVULSIONS AFTER HAEMORRHAGE. 
 
 or irritation, violent clonic convulsions manifest themselves, ac- 
 companied by gnashing of the teeth, and lasting for about a minute 
 and a half, whereupon the Kmbs become again rigid and extended. 
 
 If the mouth or the legs of the animal are mechanically excited, 
 convulsions break out at once. An experiment vrith compression is 
 unsucessful, although continued until respiration ceases. The 
 animal again falls into a state of rigidity. 
 
 i"io. — ^Violent gnashing of the teeth; spasmodic contractions 
 of the muscles of the face and fore legs. Irritation of the mouth 
 induces a violent attack of general convulsions. 
 
 I '15. — Compression of the vessels produces an attack of 
 couTulsions with all the peculiarities observable in those from 
 hsemorrhage. The backward inclination of the head at the com- 
 mencement, and the opisthotonic extension of the hind legs, are 
 peculiarly marked, which was not the case to the same extent in 
 those spasmodic attacks which appeared spontaneously, or were 
 produced by reflexion. 
 
 i"ao. — ^Mechanical irritation of the mouth and legs does not 
 produce any spasmodic movements. 
 
 I'd^. — ^The application of a ligature to the vessels is followed by 
 death, characterised by general convulsions of moderate intensity, 
 and similar to those just described. 
 
 The floor of the fourth ventricle is untouched, and contains some 
 coagulated blood. No oedema of the lungs. 
 
 We give this experiment in detail, as offering many mysterious 
 faots, although its value is but limited in consequence of the great 
 loss of blood (difficult, to be avoided) attending exposure of the 
 cerebellum. "We communicate it because it is the only one we 
 possess on excision of the cerebellum, and, to be candid, because 
 we have been hitherto unable to overcome our repugnance to 
 repeat so cruel an experiment. 
 
CHAPTER XII. 
 
 ON THE NERVOUS CENTRES TO WHICH THE SYMPTOMS 
 EXHIBITED BY EPILEPTIC ATTACKS ARE TO BE REFERRED. 
 
 Unconsciousness, insensibility, and general tonico-clonico 
 spasms are considered to be the essential symptoms of a complete 
 epileptic attack. If the affection from which these attacks pro- 
 ceed is chronic and unaccompanied by fever, it is styled epilepsy ; if 
 otherwise, eclampsia. 
 
 Between the several attacks (and this is especially the case in 
 epilepsy at the commencement of the attack), no interruptions, or 
 at all events only insignificant ones and of short duration, in con- 
 sciousness, sensibility, and motion take place. 
 
 In addition to the perfectly evolved attacks of epilepsy, one is 
 obliged to admit such as are incompletely developed. Whilst in 
 the former, consciousness and sensibility seem to have completely 
 vanished, and spasms seize all the muscles in the manner so well 
 known, in the latter there is only giddiness and staggering (epileptic 
 vertigo), or a falling down, accompanied by a slight and momentary 
 trembling as weU as by a more violent convulsion of the whole body, 
 or by spasms confined to contain groups of muscles only (partial 
 epilepsy). 
 
 Thus much it is necessary to preface before passing on to consider 
 the origin and nature of epilepsy, which will be the subject of 
 this part of our treatise. 
 
 The question so often propounded from the remotest periods in 
 the history of medicine, with reference to the so-called — and im- 
 properly so-called " seat " of epilepsy, comprises, in fact, two dis- 
 tinct questions, each of which necessitates a special examination. 
 Wwstly, we have to determine which are the nervous centres to 
 which the symptoms of the epileptic attach are to he referred. This 
 problem once solved, it then remains to inquire, whether the altera- 
 tions in those nervous centres from which the symptoms of the attack 
 proceed, emanate from another special centre of the nervous system, andj 
 
 6 
 
83 ON CONVULSIONS AFTER HiEMORBHAGE. 
 
 if SO, where this latter is heated. Tlie second part of the ijaqtiiry 
 can only be proceeded with when we shall have acquired some in- 
 formation as to the nature of epilepsy itself, i. e., the alterations in 
 the nervous centres which occasion it. 
 
 The epileptic attack must always be immediately attendant upon 
 alterations which rapidly and simultaneously affect the organ of 
 consciousness, the sensorium commune^ and the central organs of 
 motion. We axe not justified in endeavouring to find the proximate 
 seat of the attacks in a certain part of the brain or spinal cord, so 
 long as we are unable to prove that one of these parts contains the 
 anatomical centre of consciousness, sensation, and motion. But 
 who is there at the present day that believes in the existence of a 
 certain circumscribed spot, a " nodus animse," in the brain, to which 
 all sensations radiate, from which all voluntary movemeiits proceed, 
 and where the unity of consciousness is to be found, or thinks that 
 the spring that keeps up the clockwork of respiration lies concealed 
 in any single "nodus vitse?" The unity of the soul cannot 
 anatomically be referred to this or that monas of ganglionic cells, 
 but is communicated in an unknown way as the ultimate result of 
 the mutual operation of the extremely numerous and complicated 
 structures of the brain. The times of Cartesius are passed, when 
 the soul was believed to reside in the pineal gland, and with those 
 times should cease the ridiculous attempt to explain the epileptic 
 attack — a combination, of symptoms proceeding unitedly from, the 
 three great circles of nervous life-^&s issuing froin this or that 
 spot in the brain or spinal cord.^ 
 
 The comparative anatomy of the brain of vertebrate animals, 
 physiological experiment, and clinical observation, demonstrate with 
 certainty that the higher active movements of the soul proceed 
 from the cerebrum, from the non-excitable nervous structures 
 aggregated in front of the crura cerebri. We may add, that there 
 is a great deal which speaks in favour of the gray cortical substance 
 of the cerebrum in particular as communicating intelligence ; whilst 
 it appears to be the purpose of the ihedullary substance to transfer to 
 the cortical the impressions received by the sensory nerves, and td 
 the motor nerves the impulses proceeding froin the cortical 
 structure: 
 
 In the nervous substances lying behind the thaliimi optici the 
 
 ' Wepfer, as is well known, placed the seat of epilepsy in the pineal gland 
 on the same grounds that Cartesius located the soul in that sabstauce. 
 
DEFICIENCY OF PARTS OF THE BRAIN. 83 
 
 existeace of great excitable districts, central sources of reflective 
 a,nd automatic motion, is proved beyond a doubt ; there are, however, 
 some non-excitable districts (the hemispheres of the cerebellum) ; 
 and experiment as weU as cUnical observation demonstrates, that 
 behind the thalami optici there lie sources of a very obscure con- 
 sciousness and indistinct sensation ; that active motions performed 
 instinctively take their rise in this locality ; that there exist auxiliary 
 organs for carrying out th§ purposes of the "vifiLl, for the correct 
 adjustment of the movements, and for the communication of con- 
 scious sensations. 
 
 We know, moreover, that not only may very large pieces of 
 the cerebrum be lost on one or both sides, but that, according to 
 the celebrated observations of Bell, CruveiLhier, and Lallemand,' 
 even an entire hemisphere of the brain may be wanting, and, indeed, 
 even a corpus striatum, thalamus opticus, and the corpora quadri- 
 gemina, cerebellum, pyramids, and olivary body of one side may be 
 found diminished in size, withput the intellect and senses being 
 necessarily impaired; whUst, however, the opposite sidjs is always 
 found paralysed. 
 
 Paget2 gives a description of the brain of a full-grown girl in 
 which the corpus caUosum was for the most part deficient, from 
 congenital malformation ; yet was she lively, sensible, and in full 
 possession both of her senses, and of the power of co-ordinatipg 
 her movements. 
 
 Combette* relates a case of a child who had no cerebellum or 
 pons, but was sensible ; its intellect was not destroyed, but only 
 limited j its legs were weak. In order that complete unconscious- 
 ness and insensibility m^y ensue, certain alterations must take place 
 simultaneously and suddenly in both hemispheres of the cerebrum, 
 as well as in those districts of the posterior parts of the brain which 
 are connected with consciousness and sensation. Every attack, 
 therefore, of fully developed epilepsy presupposes an alteration in 
 the principal parts of the brain, because consciousness and sensation, 
 which are communicated only by the co-operation of the greatest 
 part of the brain, are in such a case completely destroyed. Our 
 researches, however, still prove, with respect to the general convul- 
 sions which, in epileptic attacks, come on in consequence of a sudden 
 
 ' Longet, ' Anatomie et Physiol, du Systeme nerveux,' vol. ii. 
 ^ ' Med.-Chir. Transactions,' 1846, vol. xxix, p. 55. 
 3 Longet, vol. i. 
 
84 ON CONVULSIONS AFTER HAEMORRHAGE. 
 
 arrest of the flow of blood to the brain, that these spasms proceed 
 from the posterior excitable parts of the brain, and it therefore 
 becomes highly probable that in every attach of complete epilepsy 
 the same material alteration affects at the same time the whole 
 cerebrum, and, in addition, the greatest part of, if not all, the cerebral 
 districts situated behind the thalami optici. It appears to us an 
 established fact that, even from the commencement, the medulla 
 oblongata is drawn into the sphere of action, because, in like 
 manner, at the beginning the respiratory movements suffer, and 
 are entirely arrested in a completely developed attack, when spasm 
 of the glottis is present. This is, we think, the only satisfactory 
 explanation that can be given respecting the coincidence of uncon- 
 sciousness, insensibility, and general convulsions. 
 
 The convulsions, therefore, in epilepsy and eclampsia fully deserve 
 the denomination of brain-convulsions, and it becomes a matter of 
 doubt, from the results of our experiments, whether or not the 
 alteration which is the proximate cause of these attacks extends 
 beyond the boundaries of the skuU. We found that the same cause 
 (sudden stoppage of the supply), if acting upon the brain, 
 produces unconsciousness, insensibiUty, and terrible spasms; if 
 upon the spiaal cord, paralysis, which, when lasting some time, ren- 
 ders the approach of brain-convulsions an impossibility. The spinal 
 cord need not, therefore, perform any other part in the paroxysms 
 than that of a conductiag cord, transferring the irritation of the 
 motor districts of the braia to the motor nerves of the periphery. 
 It is true that hereby the motor tubules of the spinal cord and the 
 peripheric nerves must be excited and drawn within the sphere of 
 the morbid action, but this alteration will be of another kind, and 
 less energetic than that of the motor centres of the braia. This 
 possibility becomes a probability if, as wiU soon be demonstrated, 
 one frequent cause of epileptic seizures is to be found in the sudden 
 arrest of the brain's nutrition. 
 
CHAI'TEfi XIII. 
 
 UPON THOSE CHANGES IN THE SUBSTANCE OP THE BRAIN 
 WHICH ARE THE PROXIMATE CAUSES OE EPILEPTIC 
 ATTACKS AND AEEECTIONS. 
 
 HowEVEE. great the obscurity may be in wbicb the doctrine as to 
 the internal alterations of the brain-substance that produce epileptic 
 attacks and affections is still enveloped, the results of actual obser- 
 vation on the subject justify us in pronouncing some very decided 
 opinions on this important matter. 
 
 In the first place the observations we have just made, with respect 
 to the nervous centres from which the symptoms of the attacks 
 proceed, demonstrate that alterations of the brain proximately 
 causing them can by no means be confined to a small part of this 
 organ, but must affect the whole or at all events the greater portion 
 of it. Hence it follows, that a circumscribed anatomical alteration 
 of the brain, must not be regarded as theproaAmate cause of epileptic 
 attacks. 
 
 Secondly, it may be affirmed that the proximate cause of the 
 attacks cannot be one of long duration, but an alteration merely of a 
 temporary Mnd. It must be quickly developed to its full extent, 
 and pass during the attack through its different phases, and 
 when the latter are over, cease completely or nearly so. How 
 otherwise is it reconcilable, that, after an attack, the patient so 
 .frequently and often for so long a time recovers the full use of the 
 action of the brain? And how could the circumstance be explained, 
 that in chronic organic affections of the brain, spinal cord, or nerves, 
 the attacks frequently, appear for the first time, only when a 
 new influence is added, for example, psychical excitement or irri- 
 tation of the extremities of sensitive nerves ? As for the epileptic- 
 conditions, they, as something constant, must also be based on a 
 constant alteration of the brain, and closer investigation is required. 
 
86 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 to determine whether the latter affects the whole brain or only some 
 parts of it. "We must, therefore, discriminate between the alteration 
 of the brain which causes the epileptic attacle, and that which 
 produces the epileptic affection. 
 
 Thirdly, it can he no visible alteration of the brain, anatomically 
 demonstrable, that can act as the proximate cause of an epileptic 
 attack. This proposition, resulting from the two former ones, is 
 also valid in the case of epileptic affections. Every physician of the 
 present day, who is at all judicious, will relinquish the hope cherished 
 with childhke confidence by certain schools and times, that patho- 
 logical anatomy is destined to give an explanation of the nature 
 and seat of epilepsy,' and he will only expect that result 
 from the progress of the experimental physiology of the nerves. 
 Material alterations in the brain and its memhrandus and osseous 
 coverings are, it is true, most frequently found in those who havb 
 died from epilepsy and eclampsia, and are often enough recog- 
 nised as the cause during life. Often, however, in spite of most 
 careful examinations, no anatomically demonstrable alterations are 
 found in the structure of the brain ;^ and those which do exist must 
 be generally regarded, especially in epilepsy, as produced by inter- 
 ruptions to the cifcnlation and nutrition during the attacks, particu- 
 larly if ihe latter have 'frequently been repeated and for a long time. 
 Most of the patients suffering from this disease for years, afford the 
 usual appearances found in chronic diseases of the brain, viz., 
 thickening and condensation of the skull, thickening, ossification, 
 coalescence, oedema, exudations, extravasations, tubercles, tumours 
 in the membranes of the brain; numerous Pacchionian glands (accord- 
 ing to Wenzel), hyperemia, hardened and shriveUed-up parts of 
 the brain. Not one of aU the anatomical alterations in whose 
 train epilepsy frequently appears, such as cicatrices, tubercles, 
 and atrophy of the brain, or premature coalescence of the sutures 
 of the skull, with lessening of its cavity, leads invariably to 
 this disease. But frequently we have seen it proceed from extra- 
 encephaHc anatomical lesions, particularly from cicatrices of the 
 
 ' See the lucid explanation of the error of looking for the cause of epi- 
 lepsy in some coarse lesion of the brain, and the critical and concise grouping of 
 anatomical facts by Hasse, in Virohow's ' Handbuch der speciellen Pathologic,' 
 vol. iv, ij pp. 262, 267, et seq. 
 
 ' In thirty autopsies of epileptic patients DelasiauVe/(16c. cit., p. 177) 
 obtained seventeen times only negative results. 
 
THE PROXIMATE CAUSE Of EPILEPSY. 87 
 
 spinal cordj^ cicatrices of the skip., neuromas, ^c. ; find cases are 
 related which have been radically cured by .the reinay.al oi carious 
 teeth, foreign bodies in the ear, pieces of necrosed bones, tape- 
 worms^ &c. The same has been observed, ^ is wall knqvn, ia 
 eclampsia. It is almost superfluous to mention how frequently not 
 the slightest alteration in the braia-substance is to be found in 
 children who have died from eclampsia, in pregnant women, i;^ those 
 affected with uraemia, or who have been poi,soned; how pften in 
 children a ^eries of attacks is brought on, simply by temporary 
 irritations of the mucous membranes, the so-caUed irritation from 
 saburra, as well as that from worms; and how, upon removal 
 of the irritation, aU the symptoms of a morbid action of the brain 
 likewise disappear : such , observations every practitioner jwill Jiave 
 made. Lastly, we observe that very frec[uently psyQhical influences 
 (fright, seeing an epileptic, &c.) at once bring on epilepsy, 
 that reflex irritation forthwith leads to eclampsia, and further 
 we have the eificacy of the "traitement moral" in the mitigation, 
 diminution, and even the complete removal of real epilepsy. All 
 these different facts furnish sufficient grounds for asserting that it is 
 only microscopic alterations of the brain that can be the cause of 
 epileptic affections. Tubercle of the braia, cicatrix of the brain, of 
 the spinal cord or of a cutaneous nerve, are therefore in an exactly 
 similar way to be regarded only as remote causes of epilepsy, and 
 should visible alterations occur in the brain or other parts of the 
 body during eclampsia and epilepsy, they must be regarded as 
 nothing else than ^edisposinff iofluences. 
 
 If the visible alteration of any part of the nervous substance is, to 
 be regarded as the predisposing cause of an epileptic affection, ,the 
 question suggests itseK — what wiU be the nature of the disposition 
 with respect to the attack ? The disposition is nothing else but tj^at 
 state of the brain which forms the |basis from which the attacks 
 
 ' Very instructive and remarkable are the experiments of Brown-Slquard 
 ('Gazette M^d. de Parish'. 1856, No. 41), who observed different traumatic 
 injuries of the spinal cord produce epilepsy after some tjme. The_ attacks then 
 appeared either spontaneously or upon irritation of certain parts of the skin. 
 When the injury was done on one side of the, spinal cord, simple irritation of 
 the face and neck on the same side occasioned the attacks. When the injury 
 was done on both sides, they could be called forth from both sides of the neck 
 and face. Lastly, it is the chief branches of the facial and cervical nerves, 
 especially of the fifth, and not their trunks, which thus. become capable of 
 producing the attacks. 
 
88 ON CONVULSIONS AFTER HAEMORRHAGE. 
 
 arise, and can scarcely be conceived of otherwise than as a very- 
 slight alteration of the whole brain, or of a narrowly circumscribed 
 district; whilst the alteration which is the cause of the attacks, 
 must always affect the whole substance of the braiu, or at all events 
 the greatest part of it, and that moreover in an energetic manner. 
 The jpredisposition is not alone sufficient to bring on the attack. 
 An internal or external cause has still to supervene to make the 
 alteration more extensive and deeper ; that finally the ontological 
 characteristic of epilepsy may become conspicuous to us in the 
 form of paroxysms. Thus the image is not manifested on the 
 daguerreotype plate directly after the action of the light, but 
 only upon the plates being exposed to a further influence, 
 when, all at once, the result of the two changes appears before 
 the eyes as one uniform whole. Prom the intimate manner in 
 which the various parts of the nervous system are united in their 
 nutrition, whereby even the remotest districts of the nerves are 
 linked together in one common bond (we here call to mind the 
 crossed and progressive atrophies of the nerves, and the important 
 microscopical researches of Tiirck, Waller, Schiff, and others ; com- 
 pare also Ludwig, 'Physiologic des Menschen,' vol. i, p. 173), the 
 supposition is certainly warranted that these visible anatomical 
 alterations dispose to epilepsy only in the manner of gradual and 
 invisible changes in the nutrition of certain districts. , 
 
 The epileptic affection is not, however, always so slow in developing 
 itself; it often comes on rapidly, as though produced by a stroke. An 
 influence may operate on the brain, and the attack immediately 
 follow, and with it the epileptic affection be manifested simulta- 
 neously. The epilepsy has become fixed, and the whole of the 
 brain or a portion of it has suddenly been affected by that delicate 
 alteration that will henceforth manifest itself in the periodical 
 appearance of the well-known symptoms. 
 
 What is sometimes the case in epilepsy, is the rule in eclampsia. 
 In the latter the epileptic status is always rapidly induced, and 
 leads quickly or immediately to the attacks, ending, contrarUy to 
 epilepsy, either in recovery or death. 
 
 We regard it as the greatest merit of our work, the having inves- 
 tigated more exactly a state which infallibly causes epileptic attacks 
 in the vigorous rabbit and probably in all warm-blooded animals. 
 We allude to that alteration in the brain produced by a rapidly 
 arrested nutrition brought about by a sudden interruption in 
 
THEORIES OF EPILEPSY. 89 
 
 the supply of blood. A dozen or more attacks can be produced 
 in the same animal at short intervals; and if it were possible 
 to apply compression to the four great arteries of the head 
 without endangering life, convulsive attacks might be easily pro- 
 duced from time to time, aA libitum, and for years, just as in real 
 chronic epilepsy. "We do not even consider the supposition 
 hazardous, that, by frequent and long-continued attacks, a disposi- 
 tion, a really epileptic affection, could be finally brought on, as, in 
 general, frequent returns of spasmodic attacks seem to produce, or 
 at aU events to favour, a so-called " convulsibiUty." (Compare also 
 Experiment 2, in Chapter X.) 
 
 We have thus demonstrated by facts that there is a condition of 
 the brain which fulfils all the requirements which we should be 
 compelled to make, if, proceeding on theoretical assumptions, we 
 should endeavour to discover one that would sufficiently explain the 
 appearance of epileptic attacks. 
 
 I. It comes on very rapidly; 
 
 a. It can be rapidly removed ; 
 
 3. It is capable of bringing on the entire group of epileptic 
 
 symptoms ; 
 
 4. When of short duration the attacks appear in an incomplete 
 
 form; when lasting a longer time they are completely 
 developed ; 
 5- The attack directly follows the alteration in the brain ; 
 
 6. And can immediately produce death ; 
 
 7. By a frequent repetition of the attacks, the action of the brain 
 
 would at last be as much impaired, as in epilepsy itself. 
 Although we are of opinion that certain forms of epilepsy and 
 eclampsia should be referred to a sudden interruption in the 
 nutrition of the brain — a supposition which, in the course of this 
 chapter, we shall find sufficiently tenable — stiU. we are far from 
 regarding this in general as the proximate and real cause, either of 
 the attacks thereby occasioned, or of the origin of epilepsy or 
 eclampsia. The sudden arrest of nutrition acts, as it appears to 
 us, only indirectly by producing certain molecular alterations of the 
 brain-substance, which are in necessary connexion with it ; but these 
 alterations may likewise be brought about by chemical and nutritive 
 agencies of another description. Thus, by stoppage in the flow of 
 blood to the muscles (according to Wundt), molecular alterations 
 are produced, which manifest themselves by an altered state of their 
 
90 ON CONVULSIONS AFTKR HEMORRHAGE. 
 
 elasticity, and finally bring on rigidity; but there are other influences 
 in addition, as, for example, injections of substances acting chemi- 
 cally into the arteries of the muscles (according to Kussmaul), which 
 have the same effect, although the muscle is thereby brought into 
 different internal conditions. In Kke manner attacks of various 
 kinds (mechanical, chemical, or produced by inflammatory irritation) 
 on the molecular arrangement of the brain, although ■^he latter is 
 altered in dissimilar ways, may have the same final result in one 
 direction, perhaps to alter the electrical order of the finest particles 
 in the same manner, and* thus give rise to epilepsy. Hydrocyanic 
 acid brings on fits very similar to those of epilepsy. StiU, until 
 definite proof can be offered, it would be very hazardous for this 
 reason to maintain that hydrocyanic acid acts by bringing on 
 anaemia of the brain (according to Pereira), or by rendering the blood 
 unfit for nourishing the brain, as Dr. Harley' has recently asserted 
 with respect to different poisons producing convulsions.^ We do 
 not question, but that at some future tinie, a class of poisons wiU be 
 found possessing the common property of rendering the blood 
 incapable of nourishing the nerves and imuscles; and numerous 
 hypotheses might easily be framed as to the several different ways in 
 which poisons comprised in this class might act. We deem it 
 advisable, however, not to enter upon this subject until we become 
 more thoroughly acquainted with the facts of the case, and here 
 only desire to draw attention to the reniarkable resemblance which 
 exists in the symptoms from large and rapidly fatal doses of rnost 
 poisons, adding this simple question, viz., whether in these cases 
 the cause of the sudden appearance of unconsciousness, insen- 
 sibility, as well as of general clonico-tetanic convulsions in which 
 the pupils are first contracted and then dilated, is not to be mainly 
 sought in the suddenly, interrupted nutrition of the brain? Do 
 we not also observe, that death, when suddenly caused by internal 
 and very different causes, comes on with partial or general con- 
 vulsions attended by unconsciousness and insensibility; and .do not 
 the majority of children succumbing to acute diseases die in so- 
 caUed "%\s," ^i.e., more or less distinctly developed eclamptic 
 attacks ? 
 
 ' 'The Lancet,' 1856. 
 
 ' Coze (' Gaz. M^d. de Paris,' 34, 1849) states the cause of convulsions 
 from poisoning by hydrocyanic acid to lie in the sudden stoppage of the flow of 
 blood to the spinal cord. This theory is completely refuted by our researches. 
 
THEORIES 0¥ EPILEPSY AND ECLAMPSIA. 91 
 
 Scarlatina, measles, and smallpox often commence with general 
 convulsions and loss of consciousness; meningitis, hydrocephalus, 
 ureemia, and oholsemia are frequently accompanied by them. They 
 also occur in dentition, when the teeth are cutting through the 
 gums, as well as in parturition when the head of the child is pro- 
 truding. If, in all these cases, we were to regaTd the suddenly 
 interrupted nutrition of the brain as the cause, it would be difiicult 
 to fiimish sufficient grounds for this hypothesis, and we might make 
 ourselves as ridiculous as those toxicologjsts, who, in their faulty 
 manner of judging, are only able to refer the actions of most of the 
 drugs and poisons acting on the brain to ansemia and hyperEcmia 
 of that organ, making use of the narcotics for producing the former 
 •condition, the excitants the latter. 
 
 The division of epileptic convulsions into two different classes, 
 eclalnptic and epileptic, is manifestly based on the correct assump- 
 tion that, in spite of complete uniformity observed in the external 
 form of the attacks, there will exist an internal difference. In whett 
 this difference consists will certainly be ascertained at some future 
 time, and then only will it be possible to separate the epileptic con- 
 vulsions into various groups according to the character of the 
 cerebral conditions producing them, whilst at the present day 
 eclainpsia and epilepsy do not represent anything else than ontolo- 
 gioal forms of disease, whose boundaries can alone be fixed by 
 subjective dogmatism, or at the best by practical necessity. 
 
 It has been freqiuently asserted that the attack in epilepsy always 
 jiroceieds from sudden h^peramia of the brain. Experience of 
 epilepsy after great losses of blood, together with our own experi- 
 ments, sufficiently refutes the general soundness of this theory. Th« 
 only question now remaining is, therefore, whether in some cases 
 congestiein : of the brain • or hyperaemia is able to produce an 
 attack. 
 
 The majority of the best pathologists have always' been decidedly 
 unfavorable to every theory of congestion ; we need only mention 
 the celebrated names of Georget, Watson, Copland, Romberg, 
 Hasse, &e. Eomberg,' for example, in his clear and decided manlier 
 of expressing himself, says, "The time is; not long passed since con- 
 gestions to the brain were almost exclusively regarded as causing 
 diseases of the nervous system in general as well as epilepsy. At the 
 
 • 'Lelirbuch der Ncrvenkr.,' vol. ii, p. 348. 
 
92 ON CONVULSIONS AFTER HiEMORBHAGE. 
 
 present day such an assertion, to be credited, must be supported by 
 critical arguments, and it must be matter for surprise that in 
 hypertrophy of the left ventricle of the heart' — a morbid condition 
 which more than all others causes an increased determination to the 
 brain and haemorrhages — epilepsy hardly ever ensues, whilst dizziness, 
 apoplexy, and paralysis frequently do. The plethora resulting from 
 suppressed haemorrhage is of undoubted influence, especially that 
 caused by arrest of the catamenia or of epistaxis ; that following the 
 stoppage of hsemorrhoidal loss is less influential, as also that pro- 
 duced by a luxurious Ufe. Attacks of this sort of epilepsy have an 
 apoplectic character ; are accompanied hy weak convulsions ; and leave 
 the patient in a lethargic state of some hours' or even dayi duration, 
 and suffering from paralysis of single parts, especially of the tongue. 
 ^Frequently, however, the opposite condition, anaemia, is their cause, 
 especially in females, whether it arises from an original crasis of the 
 blood or from insufficient food and loss of humours. Maisonneuve 
 relates a case of eighteen sailors, who, after having saved themselves 
 from the enemy by swunming to a rock, remained there for seven 
 days in a state of starvation and exposure to severe cold. All of 
 them, after having been received into the hospital, were four weeks 
 afterwards affected by epileptic attacks, which were preceded and 
 followed by violent pains in the right hypochondxium. In ten 
 months six of them died, and in eighteen months four more, so 
 that only four survived." 
 
 Delasiauve, who has paid great attention to this subject, and 
 is very well acquainted with it, observed anaemia as the cause of 
 epilepsy much more frequently than plethora; and in this most 
 careful observers agree with him. 
 
 Those who advocate the theory of congestion may be divided 
 into two classes : the first considering the attack as produced by 
 an increased congestion of arterial blood ; the other maintaining 
 that the attack is induced by an impeded ebbing of the venous 
 blood. Mr. SoUy may be regarded as the chief representative of the 
 former, and Dr. Marshall Hall of the latter opinion. 
 
 Solly2 considers the cause of the paroxysm to lie in a determina- 
 tion of blood to the head ; in an arterial congestion, the result of an 
 
 ' On a case of epilepsy following stenosis of the mouth of the aorta, see 
 Bamberger, 'Zur Pathol, des Herzens;' Virchow, 'Aroliiv,' ix, 3 and 4, 1856. 
 
 2 S. Solly, 'The Human Brain, its Structure, Physiology, and Diseases,' 
 London, 2d edition, 1847, pp. 590 et seq. 
 
Solly's views on epilepsy. 93 
 
 increased action of the heart, with simultaneous paralysis of the» 
 muscular coats of the arteries of the head; and the principal 
 grounds on which he bases his opinion are the following : 
 
 I. "Increased determination of blood to any organ augments its 
 secretions to an abnormal extent. Sudden determination to the 
 head must rapidly increase the generation of nervous power, which 
 in a healthy state conveys volition to the muscles, and is identical 
 with electricity. This excessive secretion is carried off by the motor 
 nerves, bte a discharge from an electric battery, and from its 
 quantity and excess produces excessive action of the muscles." 
 
 But why, we ask, does not this superabundance, if it produces 
 excessive motion, produce also excitement of the mind and increased 
 sensibility ? Why do general convulsions never attend the violent 
 congestion to the head caused by removal of compression from the 
 arteries of the neck ; but, on the contrary, paralysis, even when 
 both cervical tracts of the sympathetic nerve have been divided, and 
 the superior cervical ganglia extirpated, and thus, at all events, 
 numerous branches of the carotids become paralysed, as we have 
 seen in many experiments on rabbits ? 
 
 a. " The pulse of the carotids is exceedingly strong during the 
 attacks." 
 
 This well-known fact can, however, be quite as weE. explained by 
 supposing an arterial ansemia of the brain from an impediment 
 barring the progress of arterial blood to the brain ; for example, a 
 contraction of the smaller branches of the carotids, which contain 
 more muscular fibres. 
 
 3. "At the post-mortem examination of persons who have died 
 during the attack, the brain has frequently been foujid in a 
 hypersemic state (PovOle)." 
 
 Hyperaemia was, however, almost always found on the part of the 
 venous system, and might, even if the epileptic attacks proceeded 
 from arterial ansemia, have only arisen in consequence of the attack 
 — an opinion which Poville himself shares — or during the act of 
 dying, or even after death, as is made clearly apparent from our 
 previous researches. 
 
 In truth, not one of Mr. Solly's reasons is sufficient to support 
 his theory as to the origin of the epileptic attack. On the contrary, 
 it seems to us highly improbable that arterial congestion can 
 produce such an attack, although it may bring on dizziness, fainting, 
 and paralytic symptoms, similar to those occurring in apoplexy. 
 
94 ON CONVULSIONS AFTKK, HjEMORRHAGK. 
 
 Marshall Hall's theory^ which, he has endeavoured more or less 
 fuUy to establish ia nimaerous works and essays,'^ is substantially as 
 follows : 
 
 The first link in the chain of symptoms ushering in the epileptic 
 attack, is represented by the direct or reflective irritation of the 
 centrum spinale, causing the muscles of the neck and glottis to con- 
 tract, by which latter the second link is obtained. The third is com- 
 pression of the veins of the neck (sphagiasinus), by the contracted 
 muscles of the neck (tracheUsmus), and asphyxia, by spasm of the 
 glottis (laryngismus). In the fourth series, unconsciousness, insen- 
 sibility, and general convulsions break out as the result of venous 
 hypersemia of the brain and of asphyjda. The incomplete attacks 
 {le petit mal of the Trench) proceed principally from trachelismus ; 
 the complete ones {le haut mal) from trachehsmus combined with 
 laryngismus. This ingenious theory contains a combination of 
 correct and incorrect assertions. 
 
 The assertion is especially incorrect, that contraction of the 
 muscles of the neck and glottis always precedes unconsciousness 
 and insensibility ; in the majority of cases, consciousness and sensi- 
 bility vanish fiist, general paralysis of the organs of vohtion fol- 
 lows — ^the patients faU. down, and then only do general convulsions 
 commence, accompanied by spasms of the muscles of the neck, and 
 stoppage of the respiration. The cerebrum is accordingly already 
 placed out of the sphere of action before the motor nervous centres 
 begin to be excited. The undeveloped forms, where cousciousness 
 and sensibility only are disturbed, without any spasm of the muscles 
 of the neck and with no straitening of the glottis, and their 
 insensible transition to developed and general convulsions, prove 
 likewise that the theory of trachelismus and laryngismus is by no 
 means of general validity. 
 
 Marshall HaU is, however, correct in asserting that a sudden 
 closing of the glottis produces epileptic convulsions ; aud it is his 
 merit pre-eminently to have drawn attention to the resemblance be- 
 
 ' We mention only the following : ' Essays on the Theory of Convulsive 
 Diseases, being a Supplement to the Diseases and Derangements of the Nervous 
 System ;' ' On the Neck as a Medical Region,' ia the ' Lancet,' 1 849 ; ' Synopsis 
 of Cerebral and Spinal Seizures of Inorganic Origin and of Paroxysmal Form ;' 
 and ' Synopsis of Apoplexy and Epilepsy, with Observations on Trachelismus, 
 Laryngismus, and Tracheotomy,' 1853. 
 
MARSHALL HALl's THEORY OF EPILEPSY. 95 
 
 tween the effects of strangtlation and those of epilepsy.^ If animals 
 are strangled by a ligature on the trachea, as we have frequently 
 done it, they soon expire in a state of insensibility and with general 
 convulsions; and these spasmodic attacks are exactly similar to 
 those from hsemorrhage, only that in the former case the head 
 swells and turns blue, while in the latter case it shrinks and turns 
 pale. The approach of convulsions in strangulation can be acce- 
 lerated if the arteries are simultaneously compressed. In men 
 dying from hanging or suffocation the same symptoms are observed 
 as in animals. Liability to epilepsy may even remain in persons 
 who, after having been suspended for a considerable time, have 
 been restored to life. In 184a or '3 Kussmaul saw in the 
 clinical wards of the late Professor Puchelt, at Heidelberg, a strong 
 servant girl, who had been cut down and with difeculty restored 
 to Hfe, affected with violent epileptic attacks for many weeks. 
 The conjunctiva of one eye appeared sUgiUated with blood for a 
 longer time in consequence of the strangulation. 
 
 We find the simplest explanation of the appearance of these 
 attacks upon closing the glottis or triachea, in sudden arrest of the 
 nutrition pf the brain. Hsemorrhage, closing of the arteries of 
 the head, and strangulation, cauSe the blood-vessels of the head to 
 be in different states of fulness, and the brain to undergo various 
 gradations of pressure, but they agree exactly in the one point 
 above mentioned. In the one case there is a scarcity of red blood 
 because it is abstracted from the body or kept away from the 
 brain; in the other because it has suffered a transformation into 
 black blood. The correctness of our opinion seems partially 
 proved by the fact that even in profuse haemorrhage the convul- 
 sions do not proceed from an altered pressure ; and partly, by the 
 observation, that in strangulation, convulsions more rapidly ensue 
 when the conveyance of red blood to the brain is at the same time 
 prevented; and finally, by the results of our experiments on the 
 artificial production of stasis of the brain, on which we shall treat 
 further on in these pages. No one will, therefore, contest Marshall 
 HaU's asserticin, that spasm of the glottis (laryngismus) may 
 lead to epileptic convulsions. Direct or indirect (psychical, or 
 caused by reflexion) excitement of the motor nerves that close 
 the glottis can produce them secondarily, and no doubt certain 
 
 ' Comparison of the effects of strangalation and epilepsy, in M. Hall, 
 • Synops. of Cerebr. and Spin. Seizures/ pp. 63, 38, 39, and 40, 
 
96 ON CONVULSIONS AFTER HyEMOKEHAGE. 
 
 epileptic attacks depend upon this cause.^ In particular may cer- 
 tain states of eclampsia in children, and of epilepsy in hysterical 
 persons, be referred to this cause. To construct upon it, however, 
 a theory of epilepsy, which shall admit of universal application, does 
 not seem to us by any means feasible, because in real epilepsy, as 
 already mentioned, laryngismus generally follows, and does not 
 precede, the cessation of the actions of the mind, and "because 
 we sometimes see cases where clonic spasms appear in their full 
 extent before symptoms of laryngismus are noticeable." (Hasse.) 
 
 The assumption seems incorrect that sudden stoppage of the 
 circulation in the cervical veins is a common cause of epileptic 
 attacks, whereby the theory of sphagiasmus becomes as a matter of 
 course valueless. Marshall Hall lays great stress on an experiment 
 of Sir A. Cooper (loc. cit.), who tied both the jugular veins of a 
 rabbit, which after five days appeared in a state of stupefaction, 
 fell on the seventh day into convulsions, lost its sensibility, and 
 died. On the post-mortem examination an extravasation of blood 
 into the left ventricle of the cerebrum was found. Although we 
 have tied the external jugular veins of rabbits (and sometimes the 
 internal ones at the same time) upwards of two dozen times, and 
 have often allowed the animals to live for weeks, even for months, 
 we have never seen a similar result. In fact we have never observed 
 general convulsions at all. In the majority of instances, no symp- 
 toms of brain affection of any importance appeared ; at most the 
 animals seemed to be stupefied during the first twenty-four to thirty 
 hours, and sometimes gnashed their teeth. The most constant 
 symptom upon stoppage of the venous circulation, and one which did 
 not escape the vigilance of Sir A. Cooper, is a retarded respiration. 
 Thus the above-mentioned experiment forms an exception to the 
 rule, and only proves that the retention of venous blood within the 
 cavity of the skuU may, under certain circumstances, produce extra- 
 vasation of blood, apoplexy with convulsions, but no real epileptic 
 attack. In the reticular distribution, especially, of the superficial 
 veins of the anterior and posterior part of the neck, the number of 
 anastomoses is so great that the obstruction of the jugular veins 
 alone cannot so easily give rise to serious cerebral symptoms. 
 For this reason we several times compressed or tied the cervical 
 
 ' Compare, for example, the very remarkable case of epilepsy in a girl, 
 nineteen years of age, in consequence of irritation of the epiglottis by a long 
 uvula, in the 'Wiener Wooheusohr.,' 39, 1836. 
 
EFFECTS OF VENOUS CONGESTION. 97 
 
 and clavicular veins simultaneously for a longer time. In two 
 cases, where the operation succeeded without any haemorrhage, re- 
 peated compression, continued for a quarter of an hour, did not pro- 
 duce any important brain-affections, whilst the other animal, whose 
 veins were tied, died after forty-eight hours under general convul- 
 sions, and the symptoms during life, as well as in the corpse, in- 
 dicated a considerable hyperemia in the head and cranial cavity. 
 After death the veins of the neck, of the membranes of the brain, 
 and the sinuses were found gorged with blood, but the brain was 
 pale. In this experiment, as well as in that of Sir A. Cooper, 
 convulsions appeared only some time after the veins had been closed, 
 whilst M. HaU's theory woiild require them to be immediately 
 sequential.^ 
 
 It is true that, according to the present state of our knowledge, 
 it cannot be denied that in a venous stasis of the brain it is possible 
 for epileptic affections sometimes to come on rapidly. It is, for 
 example possible, that in a sudden and complete retention of 
 venous blood within the cranial cavity, the veins may become so 
 gorged that no more blood can be introduced through the arteries, 
 and consequently the nutrition of the brain wiU be at once 
 impeded. In reality, however, venous congestion seems to be rarely 
 formed with the requisite rapidity and in a sufficient degree. 
 
 In retention of venous blood within the cranial cavity, the heart 
 is, notwithstanding, generally able for a long time to force blood 
 into it, and, in consequence of the increased pressure on the brain, 
 and of the smaller and greater haemorrhages from the bursting 
 vessels of the brain and its membranes, apoplectic attacks come on 
 either vrith or without convulsions, which in the latter case may, it 
 is true, easily assume the appearance of epilepsy. Marshall HaH 
 himself is obliged to derive the epileptic comatose symptoms in 
 epilepsy more from sphagiasmus and trachehsmus, whilst he 
 considers asphyxia and general convulsions as caused by laryn- 
 gismus. Bibliographical research has not furnished us with 
 any cases affording sufficient proof that simple stasis or plethora 
 
 ' Compare Kussmaul, 'Ueber den Einfluss der Blutstromung auf die Bewegung 
 der Iris,' p. 32. We draw attention, however, to the fact that in this experi- 
 ment the surfaces of the wound, and the inflammation were very considerable. 
 Convulsions and death ought perhaps to be attributed to other causes than to 
 hyperjemia within the cranial cavity. At that time we had a bad place wherein 
 to keep the rabbits, they were therefore easily affected by wound-fever. 
 
 7 
 
wo ON CONVULSIONS AFTER HjEMORRHAGE. 
 
 of the brain has produced real, or, at any rate, pure epileptic 
 attacks.^ 
 
 Being anxious to ascertain the influence of plethora of the brain, 
 and likewise of the pressure on that organ which it occasions, in the 
 production of epileptic affections, we divided the cervical branches 
 of the sympathetic nerve of several rabbits, tying the external and 
 internal jugular veins. Directly after we applied the ligature, the 
 eyeballs protruded considerably from their sockets ; the number of 
 respirations gradually diminished, but in no instance suddenly — 
 sometimes, however, to an extraordinary degree (once, within half 
 an hour, from 135 a minute before the operation to 18 after 
 the same) ; the respiration became snoring and rattHng ; the glottis 
 hecame paralysed ; while stupefaction, weakness in the legs, and diffi- 
 culty of breathing became more and more marked, without the 
 animals, however, losing consciousness, or the power of sitting 
 upright J and finally, gnashing of the teeth, and slight transient 
 convidsive movements of the limbs succeeded. These dangerous 
 symptoms, notwithstanding, disappeared in all cases as gradually as 
 they had come on, and the disturbance in the circulation became at 
 
 ' Compare in particular Stannius, ' Ueber die krankhaften Verscliliessungeii 
 grosserer Venenstamme des menschliehen Korpers,' 1839; and M. Hall, 
 ' Synops. on Cerebral and Spinal Seizures,' &c. Of the various cases the fol- 
 lowing appear to us especially important. Gintrac (according to Stannius) ob- 
 served, in a child four years old, attacks consisting of a momentary stoppage 
 of voluntary movement with diminished sensibility, in which the mental 
 faculi.ies are said to have remained active whilst speech was completely gone. The 
 child began to suffer in this way when only a year old. The superior longi- 
 tudinal sinus was transformed into a stiff cord, and the veins emptying into 
 it were gorged with coagulated blood. Prichard (loc. cit.) found in the 
 corpse of an epileptic subject organized plugs in the whole of the lateral sinus. 
 (Were the plugs the cause or effect of epilepsy ?) Tonnel6 (' Proriep's Notizen,' 
 1829, vol. xxiv, p. 142), in a girl nine years old, after obstruction by plugs 
 of the superior longitudinal, the lateral, and the occipital sinuses of the right 
 side, observed dizziness, with tendency to swooning for two days; then deep 
 sleep, attended by slight convulsions of the left side, and finally resulting 
 in death. A child two years old, during the last moments of its existence, 
 became suddenly affected with convulsions, and great rigidity of the body and 
 limbs. Plugs filled the superior longitudinal sinus, both lateral sinuses and 
 the internal jugular veins. In both instances blood was extravasated below 
 the arachnoid of the cerebral hemispheres ; in one it even went so far as to 
 produce softening of a portion of the right hemisphere of the cerebrum. 
 
EFFECTS OF ACTIVE CONGESTION. 99 
 
 least partially balanced, without the animals having fallen into 
 real epileptic convulsions.^ 
 
 These experiments are in remarkable accordance with the above- 
 mentioned observation of Eomberg, that epilepsy in plethoric 
 subjects has an apoplectic character and is attended by feeble con- 
 vulsions. "We feelj therefore, induced to express our doubts as to 
 whether these so-called epileptic affections in plethora are to be at 
 all ascribed to true epilepsy, or whether they are not rather to be set 
 down among the series of apoplectic affections, and those which 
 have in common with each other, unconsciousness, insensibility, and 
 even the appearance of clonic spasmodic movements of. the Hmbs, 
 although in a sHght degree ; but which differ in their symptoms 
 with respect to the state of the respiratory muscles, and are, in par- 
 ticidar, accompanied by paralysis of the glottis, whilst epilepsy is 
 distinguished by spasm of the glottis. 
 
 The results of our researches are accordingly decidedly at variance 
 with any theory which offers sudden congestion of an active, passive, 
 or mixed character, as the cause of an epileptic attack. We have, on 
 the contrary, proved that the sudden appearance of arterial anaemia 
 of the brain gives rise to epileptic attacks ; and we are, therefore, 
 fuUy justified in propounding the question, " What is the value 
 of the theory which explains them by a spasm of the muscular 
 elements of the vessels of the brain, especially of the smaller arte- 
 ries containing many muscular fibres ?" 
 
 If at any time we can observe that fright is capable "of expeUing 
 the blood from the cheeks," it cannot be denied that it is possible 
 for the same cause, one of the most frequent of epileptic attacks 
 and affections as is well known, to contract the smaller branches of 
 the carotids and vertebral arteries. We know that anaemia, the most 
 fruitful source of epilepsy, renders the nervous system veryirritable and 
 very accessible to the influences of fright ; that ansemic and chlorotic 
 persons possess a small and compressible piilse, and readily turn pale 
 and swoon away. Numerous and accurate observers, such as Georget, 
 Watson, Copland, Trousseau (De Tepileps., ' Gaz. des Hopit.,' 1855, 
 No. 49), and others, expressly mention that at the commencement of 
 the attack the face is always pale, and only turns red and blue subse- 
 quently. Nevertheless, the carotids and the heart pulsate strongly ; 
 indicating the existence of an impediment to the circulation in the 
 ' A more detailed account of the results of these experiments, which are not 
 entirely completed, shall be given at some future time. 
 
100 
 
 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 smaller branches. Cases are even known where the aneurismatic 
 aorta has bnrst during the epileptic attack. Finally, Pereira^ 
 relates that Hoist observed an epileptic subject at Christiania whose 
 pulse always disappeared in the left arm during the attack. At the 
 post-mortem examination a deviation in the course of the arteries 
 was found; the left arm receiving its blood from the vertebral 
 arteries, which themselves obtained their supply through the 
 basilar artery from the carotids. The disappearance of the pulse 
 renders it probable that the circulation through the carotids within 
 the cranial cavity was arrested during the attack. If the last-men- 
 tioned facts speak in favour of the theory that the smaller arteries 
 are contracted at the beginning of, and during the attack, they do 
 not prove, nevertheless, that this spasm of the vessels is the cause ; 
 and it may just as correctly be regarded only as one of the phenomena 
 accompanying the general morbid affection. "What has been said 
 about Marshall HaFs theory of spasm of the glottis consequently 
 holds good in this case. But, just as spasm of the glottis will often 
 undoubtedly cause epileptic attacks, it appears to us that the latter 
 can also be produced by spasms confined at the onset to the muscles 
 of the blood-vessels only. We endeavoured experimentally to 
 satisfy ourselves of the correctness of the theory — a task beset 
 with many difBculties. The ascending cervical branches of the 
 sympathetic nerve do not seem to be the only channels by which 
 the carotids and their branches receive nerves. The thickness in 
 the sympathetic branches differs considerably in different rabbits; 
 and the experiments of Schiff, Bonders, and Callenfels render it 
 probable that vaso-motory fibres reach them from other sources. 
 When the subclavian arteries are tied, and the cervical branches 
 subjected to faradisation, certainty is thereby afforded that all the 
 nerves of the branches of the carotid are excited. Acting directly 
 on the superior cervical ganglia would be productive of more satis- 
 factory results, if the sensibility of this part would allow such an 
 operation. Faradisation of the cervical branches of the sympathetic 
 nerve must therefore be performed, leaving to mere chance the 
 finding an animal in which they form the exclusive, or almost 
 exclusive, vaso-motory nerves of the branches of the carotid. In 
 three experiments which we performed, we first convinced our- 
 selves, after having tied the subclavian arteries, that compression of 
 
 ' Pereira, ' The Elements of Materia Medioa,' 3d edit., vol. ii, p. ii, p. 1797. 
 
INFLUENCE OF THE SYMPATHETIC NERVES. 101 
 
 the carotids did produce general convulsions. Both sympathetic 
 nerves were then laid bare to a great extent, divided at the 
 inferior cervical part, and separated upwards from the ceUular 
 tissue, were placed on small leaves of gutta percha. It was 
 unfortunate that in all the three animals (white rabbits) the 
 nerves were uncommonly thin, but the usual symptoms appeared 
 in the blood-vessels of the ear when the nerves were divided, as 
 well as when faradised, though general convulsions did not ensue 
 after the latter operation. We then tied one of the carotids, so 
 that the brain only received its supply of blood by means of 
 the other one, and faradised the nerve on the side where the 
 circulation continued. In two of the animals no effect was as 
 yet obtained, but the pupils were not so dilated nor the background 
 of the eyes so pale as we had noticed in other cases. In the third 
 rabbit, however, the background of the eye turned completely pale, 
 the pupil became dilated to such an extent that the iris could 
 scarcely be seen, the eyeball protruded very much, the neck was 
 drawn backwards, and violent convulsions seized the hind legs, 
 which were not tied. (The fore legs were made fast, the animal 
 was lying on its back.) The electrodes were removed, when the 
 spasms ceased, the pupil contracted, and the background of the eye 
 turned red, but the animal continued in a swooning condition. 
 After some minutes we again succeeded, by the action of electricity 
 upon the sympathetic nerve, in producing the same effects as at first. 
 A third attempt to excite by faradisation did not succeed. We 
 tied the other carotid, which was still free, and the animal died, 
 (probably from exhaustion of the brain) without again becoming 
 convulsed. 
 
 On account of their importance, these experiments deserve to be 
 repeated in a greater number of cases, reducing, thus, perhaps, to a 
 certainty, what at present is only probable ; — tJiat epileptic convul- 
 sions can be brought about by contraction of the blood-vessels induced 
 ly the vaso-motor nerves. 
 
CHAPTER XIV. 
 
 UPON THE NEUVOUS CENTRES EROM WHICH THE ALTERA- 
 TIONS OP THE BRAIN RESULTING IN EPILEPTIC ATTACKS 
 PROCEED. 
 
 Many causes producing epileptic attacks — for example, great 
 losses of blood and strangulation, — affect the whole brain simulta- 
 neously, and this organ undergoes at once the same alteration. These 
 are undoubtedly epileptic affections whose seat is not to be looked 
 for in this or that part of the brain, but which occupy the- whole 
 organ. We conjecture, for example, that this is the case in those 
 frequent forms of epilepsy which appear after great losses of 
 blood and humours ; in those connected with congenital and ac- 
 quired atrophy of the brain ; in those connected with imbecility 
 following madness producing atrophy, and in eclampsia of ansemic 
 and cholsemic subjects, as well as of many who are poisoned. 
 
 But in those epileptic attacks which are produced by spasm of 
 the glottis, the central point of departure is to be transferred to the 
 place where the roots of the nervi vagi and of the nervi accessorii 
 WiUisii originate, probably therefore to the medulla oblongata. 
 It may be assumed that this source, by direct or indirect agencies, 
 may undergo either a temporary functional alteration, so-called 
 excitement, producing epileptic attacks, or be affected by a lasting 
 alteration of a more powerful character, and thereby cause an epilep- 
 tic disposition. 
 
 If it be true that spasms of the cerebral arteries are capable of 
 producing epileptic attacks, the central point from which these 
 arise would consequently lie in the part where the vaso-motory 
 nerves take their origin, and therefore, if the results of Schiff's re- 
 searches be correct, in the medulla oblongata. An excitement of 
 this nervous centre would then be the first link ia the chain of 
 these processes, ansemia of the brain the second, and the epileptic 
 attack the third. 
 
CENTRAL CHANGES IN EPILEPSY. 103 
 
 This is what, relying upon the facts brought forward, we have 
 ventured to pronounce upon this obscure subject. The field of 
 possibilities is, however, not yet exhausted. We, nevertheless, feel 
 but little inclined to wander about in the dark and fanciful paths 
 of mere hypothesis. 
 
 Lastly, it should be borne in mind that pathological anatomy 
 can give but little information as to the origin of epilepsy. It 
 only supports the supposition to which aU. the symptoms of epilepsy 
 already point, that this origin is to be sought in the brain. But, 
 as we have seen in our researches on the nature of epilepsy, this is 
 more vigorously supported by the etiological forces, and the great 
 importance of the traitement moral. Physiological experiment alone 
 fui'nishes reliable information. 
 
CHAPTEE XY. 
 
 SYNOPSIS AND GENEKAL SUMMAKY. 
 
 Synopsis of the ways in vMeh Bpileptic Attacks resulting from a 
 sudden arrest of the Nutrition of the Brain may arise. 
 
 I. Eapid losses of blood. 
 
 II. Sudden stoppage of the flow of arterial blood to the brain. 
 
 1. Mechanical closure of the great arteries of the headj their 
 larger and smaller branches (ligature, compression, plugs, injected 
 air, &c.) 
 
 2. Spasms of the muscles of the blood-vessels. 
 
 a. By direct excitement of the central seat of the vaso- 
 motor nerves (inflammation, local anaemia, poisons, 
 &c.) 
 
 h. By excitement proceeding from the mind (fright). 
 
 c. By excitement from the sensitive nerves. 
 
 d. By excitement from other motor districts which have 
 
 been irritated. 
 
 3. Venous stasis of the brain. 
 
 III. Eapid transformation of the red blood, by which it is ren- 
 dered incapable of nourishing the brain. 
 
 A. Transformation of the red blood into black, by asphyxia. 
 I. Asphyxia by mechanical methods. 
 
 %. Spasm of the glottis (laryngismus). 
 
 a. By direct excitement of the central seat of the motor 
 
 nerves passing to the muscles that close the glottis. 
 h. By indirect excitement of the same (especially by irrita- 
 tion of the sensitive nerves of the mucous membrane 
 of the trachea) . 
 3. Asphyxia by gases. 
 
 B. Alteration of some other kind of the arterial blood (by 
 ferments, poisons, &c.) • 
 
KESUME 0¥ THE WHOLE ESSAY. 105 
 
 General Summary. 
 
 PoE the sake of greater perspicuity we concisely group together 
 the chief results obtained from our researches under the following 
 heads : 
 
 1. The convulsions appearing in profuse hsemorrhage of warm- 
 blooded animals (including man) resemble those observed in 
 epilepsy. 
 
 2. "When the brain is suddenly deprived of its red blood, con- 
 vulsions ensue of the same description as those occurring subsequent 
 to ligature of the great arteries of the neck. 
 
 3. Epileptic convulsions are likewise brought on when the 
 arterial blood rapidly assumes a venous character, as, for example, 
 when a ligature is applied to the trachea. 
 
 4. It is highly probable that in these cases the attack of spasms 
 depends upon the suddenly interrupted nutrition of the brain. It is 
 not caused by the altered pressure which the brain undergoes. 
 
 5. Epileptic convulsions in haemorrhage do not proceed from the 
 spinal cord. 
 
 6. Neither do they proceed from the cerebrum. 
 
 7. Their central seat is to be sought for in the excitable districts 
 of the brain lying behind the thalami optici. 
 
 8. Anaemia of those parts of the brain situated before the crura 
 cerebri produce unconsciousness, insensibility, and paralysis in 
 human beings; if spasms occur with these symptoms, some excitable 
 parts behind the thalami optici must have likewise undergone 
 some change. 
 
 9. Anaemia of the spinal cord produces paralysis of the limbs, of 
 the muscles of the trunk, and of respiration. When the anaemia 
 suddenly attains its greatest intensity, then only and even then but 
 rarely, do slight trembling movements of the bmbs precede paralysis. 
 The sphincter ani acts analogously to the constrictor muscles of the 
 face in anaemia of the brain, that is, it contracts spasmodically 
 before it relaxes. 
 
106 ON CONVULSIONS AFTER HEMORRHAGE. 
 
 10. Convulsions from haemorrhage are neither psychical nor 
 reflective. 
 
 1 1 . Convulsions from haemorrhage do not ensue — 
 
 a. In cold-blooded animals, at least not in the frog. 
 h. When the haemorrhage is slow, so that the vital power is 
 only gradually consumed. 
 
 c. When the animals are very much debilitated. 
 
 d. When the nutrition of the spinal cord has sufl'ered. 
 
 e. When large pieces of the excitable districts of the brain 
 
 have been removed. 
 
 f. In animals subjected to etherization. 
 
 g. Doubtless also when excitable districts of the brain have un- 
 
 dergone certain pathological alterations. 
 
 13. As suffocation brings on convulsions, and etherization averts 
 them, it is evident that etherization and asphyxia are two different 
 conditions. 
 
 \'},. The brain of warm-blooded animals can only be deprived of 
 red blood for a short time ; otherwise it loses its capability of re- 
 suming its functions when again supplied with the nutritive fluid, 
 and the appearance of death becomes a reality. The brain of some 
 rabbits preserved this capability for two minutes. 
 
 14. It is sometimes observed, after the arteries of the neck have 
 been tied, that the muscles of the trunk perish and take on 
 the rigor mortis before the action of the left heart is extinct. 
 Hence the left heart is not always the primum moriens among the 
 muscular organs. 
 
 15. Contraction and subsequent extreme dilatation of the 
 pupils in the agonies of death, is no certain sign of real death and 
 of the incapability of being revived, as maintained by Bouchut. 
 
 16. To cure epileptic attacks caused by ansemia, there is no 
 better method than that of renewing the supply of red blood. 
 
 17. The debilitating method of treating epilepsy, especially by 
 abstracting blood, should almost always be rejected. 
 
 18. The quantity of blood in the cranial cavity can by way of 
 experiment on the living subject be considerably increased or 
 diminished. 
 
 19. Hyperaemia in the cranial cavity is caused by releasing the 
 stoppage of circulation in the cervical arteries (arterial congestion), 
 by tying the cervical veins (venous congestion), especially by simul- 
 taneously dividing the cervical branches of the sympathetic nerve 
 
RESUME OF THE WHOLE ESSAY. 107 
 
 (venous arterial congestion), and lastly by tying the trachea during 
 inspiration (venous congestion by asphyxia). 
 
 20. Ansemia in the cranial cavity is produced by hsemorrhage 
 and by tying the cervical arteries (passive anaemia), as well as 
 by electric excitation of the vaso-motor nerves of the head (active 
 ansemia) . 
 
 2,1. The quantity of blood contained in the cranial cavity after 
 the application of a ligature to the arteries is greater than after 
 hsemorrhage ; the ansemia as regards small arteries, the capillaries, , 
 and the smallest veins being always present to a greater extent. 
 
 ■2%. Prom the quantity of blood contained in the skull after 
 death, it is seldom possible to draw certain conclusions with respect 
 to the quantity contained during life. The death-struggle brings on 
 numerous conditions altering the circulation of the blood in the 
 skull, and even in the corpse the quantity of blood may still undergo 
 alterations. 
 
 33. The phenomena of the incomplete epileptic attack can be 
 explained by alterations occurring in the cerebrum only ; whilst the 
 phenomena of the complete attack presuppose an alteration of the 
 whole brain. Convulsions in epilepsy are justly styled cerebral 
 ones, and the spinal cord probably plays only the part of a con- 
 ductor, transferring the impetuses it receives, from the brain to the 
 muscles. 
 
 34. Circumscribed anatomical alterations of the brain or altera- 
 tions of protracted duration cannot be regarded as the proximate 
 cause of epileptic attacks, but may cause epileptic affections (dispose 
 to epilepsy). 
 
 25. Pathological anatomy cannot give any explanation as to the 
 nature of epilepsy. 
 
 26. Suddenly withheld nutrition is only one of the causes by 
 which the brain is brought into that peculiar internal condition 
 which is manifested in the form of an epileptic attack. 
 
 37. Aiterial congestion of the brain does not seem to be 
 capable of producing any other symptoms than those of paralysis 
 (dizziness and apoplexy). 
 
 38. Venous congestion of the brain, as well as arterio-venous 
 congestion, brings about conditions which belong more to those of 
 apoplexy than to those of epilepsy, and are characterised by paralysis 
 of the glottis, together with a slower respiration and slight spas- 
 modic symptoms. 
 
108 ON CONVULSIONS AFTER HjEMORRIIAGE. 
 
 29. Marshall Hall's sphagiasmus and trachelisnms are not to be 
 regarded as a source of epileptic attacks, but laryngismus will pro- 
 duce them. All theories are false which assert the epilfeptic attack 
 to be derived from a sudden determination of blood, whether active, 
 passive, or mixed. 
 
 30. It is probable that certain forms of epilepsy result from a 
 Spasm of the muscular coats of the cerebral arteries. 
 
 31. The epileptic affection, which disposes to the attacks, 
 occupies either the whole of the brain, or some districts only, and 
 by it the brain is brought into that altered state on which the 
 epileptic attack is based. 
 
 3a. The medulla oblongata, as being the part whence the nerves 
 causing the constriction of the glottis and the vaso-motor nerves 
 take their rise, seems frequently to be the spot from which eclamptic 
 and epileptic attacks proceed. 
 
 APPENDIX. 
 
 Aftee the preceding treatise was finished, we became acquainted 
 with a highly remarkable case of epilepsy strongly supporting the 
 opinion expressed by us that the medulla oblongata sometimes forms 
 the centre from which the epileptic attacks proceed. 
 
 In 1823, died in the Infirmary at Frankenthal, in the Palatinate 
 of the Rhine, an imbecile boy, twelve years old, who had been 
 affected with epilepsy from his birth, and had a remarkable pro- 
 pensity to steal. The attacks frequently recurred, even on the 
 same day. They exhibited this peculiarity, that they especially 
 appeared when the patient made certain strong rotary movements 
 with his head ; were of remarkably short duration, never lasting 
 more than a few minutes ; and consciousness returning very rapidly, 
 much sooner than in other epileptic cases. 
 
 After a violent attack the patient became very iU, and on the 
 following day aU the symptoms of acute phrenitis manifested them- 
 selves, to which the patient succumbed on the seventh or eighth 
 day afterwards. 
 
EPILEPTIC CONVULSIONS. 109 
 
 At the post-mortem examination the skull was found unaltered^ 
 indications of meningitis were present, and serous exudation had 
 taken place into the cavity of the skull and spine, as well as into 
 the ventricles. There was moreover an anomalous and unique 
 formation of the first cervical vertebra. The atlas was not com- 
 pletely ossified, but consisted of two separate lateral halves, united 
 in the middle of the anterior arch by soft cartilage and by strong 
 ligaments, but at the posterior arch only by very thin moveable 
 thread-like ligaments, so that in the latter place the ends of the 
 bones could be moved one over the other, whereby the foramen 
 for the spinal cord could be very much narrowed. Hence there 
 is much reason for conjecturing that in this case the epileptic 
 attacks were caused by the pressure on the medulla oblongata when 
 the head was turned. The vertebra is still preserved in the 
 Infirmary, which possesses a rich and interesting collection, where 
 we lately had occasion to examine it. We are indebted for the 
 above-mentioned observations on the patient's case to the kindness 
 of Dr. JJettinger, the present excellent Director of the institution. 
 They are partly taken from the annual report of 1833, given by the 
 late Dr. Dapping, at that time Director of the Infirmary, who, in 
 1829, laid the vertebra before the meeting of German Naturalists 
 at Heidelberg (compare the report by Tiedemann and Gmelin, 
 p. 73); partly from a letter of Dr. Hepp, of Zurich, dated 31st 
 March, 1857, who likewise had seen the patient. 
 
 We have to mention, in conclusion, that on the left side of the 
 superior surface of the vertebra, behind the massa lateralis, a sort of 
 half canal was seen, through which the vertebral artery probably 
 passed, whilst on the right side no trace of such a groove was to be 
 found. 
 
ON THE 
 
 PROCESS OF REPAIR 
 
 RESECTION AND EXTIRPATION 
 OF BONES. 
 
 DR. ALBEECHT WAGNEE, 
 
 OF BERLIN. 
 
 TllANSLATBD, WITH AN APPENDIX OF CASES, 
 
 T. HOLMES, M.A. Cantab. 
 
 THE NEW SYDENHAM SOCIETY, 
 LONDON. 
 
 MDCCCLIX. 
 
INTRODUCTION. 
 
 The claims which may be asserted in behalf of the practice of 
 resection of bones, over the other operations which used formerly to 
 be adopted in its stead, may be thus stated : I. That it involves less 
 danger to life. II. That it removes only the diseased bones. III. 
 And that thus it becomes the first step in a process of repair by 
 which a part of the body is restored to more or less complete useful- 
 ness, which would otherwise have been sacrificed to the removal of 
 the disease and the preservation of life. The difiiculties in its 
 performance (such, I mean, as the anatomical relations of the part 
 render insuperable), and the length of time after the operation which 
 is required for the cure, ought not to be set against these consi- 
 derations in forming a judgment as to the value of resections, or at 
 least only in a subordinate degree and under peculiar circumstances. 
 But is it really a fact, that resections do possess these advantages ? 
 or, what are their real results, and what place therefore is to be 
 allotted to them ? This is the question — which has, indeed, been 
 answered up to a certain point, but the complete determination of 
 which is stiU a desideratum. 
 
 After resection of bones had been introduced into the list of 
 surgical operations by White and Park, towards the end of the 
 eighteenth century, it reckoned few supporters for a period of 
 many years, and also few opponents — ^in fact, it remained almbst 
 unnoticed. It was reserved for our century to decide whether re- 
 section should be admitted among recognised operations. The 
 number of its advocates increased rapidly in the early part of this 
 century, together with that of its oppoiients. The chief points on 
 which observation was concentrated in deciding this contest were — 
 
 8 
 
114 ON REPAIR AFTER RESECTION OF BONES. 
 
 the relative mortality after resection compared with other opera- 
 tions; the possibility and certaiaty of removing entirely the dis- 
 eased bones ; and especially what assurance there is of preserving 
 the limb, and what is the degree of its usefulness after recovery. 
 "When the balance had gradually inclined in favour of resection, 
 and in consequence of the increasing number of its supporters, the 
 operation had been extended over the whole skeleton, both in the 
 substance of the bones and at their extremities, observation was 
 necessarily directed, besides those general points, to the differences 
 which arose according to the bone on which the operation was 
 practised, according as the piece of bone was removed from the 
 sabstance or the extremity and according to the extent which the 
 resection had embraced. Here also the results spoke loudly in 
 favour of resection. Soon it was no longer a question whether 
 resections should be recognised among the operations of surgery ; 
 they had won this recogijition indubitably, and were greeted as one 
 of the greatest advances of operative surgery ; and it then became 
 rather the question (and this remains our task at present) to mark 
 out the hmits of the applicability of the operation, and to preserve it 
 from the dangers of faUing into disrepute, in consequence of results 
 being demanded from it which it has never entitled us to ex,pect, 
 and which it can never a,ffiord. This ta,sk must necessarily go 
 hand in hand with an endeavour to make the operation perfect in 
 all respects, and to explore as widely and investigate as deeply as 
 possible the region which it may command. 
 
 It is remarkable that, while numerous resources have been ex- 
 pended on. establishing the indications in cases of resection, e.g., 
 i;he lireasures of surgical science and experience for the diagnosis, 
 the study of anatomy for perfectiag the operative proceedings, and 
 clinical observation for the after trea;tment, very little attention 
 has been paid to the heahng process after the operation. And yet 
 it is indubitably from a faithful observation and accurate knowledge 
 of this process, that we may obtaija sure grounds for improving the 
 operation in various direptiojis, and for deciding the question as to 
 its value. 
 
 There are two, ways in which this may be advantageously studied. 
 The first is, that of clinical observajtion of the process of cure ; and 
 this has been, often used, but without earning the fruits which 
 might be obtained from it. The, observations which we find on 
 record as to the course of the syiiiptoms after the operation are for 
 
INTRODUCTION. 115 
 
 the most part 50 inaccurate, that they aflow pf no conclusion Ijeing 
 formed as to the process, of healiug, and in some respects it seems 
 impossible that a more secure conclusion can ever result £rom_ 
 them. We must, however, express still greater surprise at the in- 
 acc,uracj pf the data which relate to the result of the operation and 
 the functional power of the part operated o^. Except the remark, 
 in resections of the extremities of bones, that a perfect, ankylosis, 
 was produced, an|d in resections from their substance that the 
 solidity of the bone was re-established, or a false joint formed, 
 there is hardly anything in these records w^ich cfin be made useful 
 in the investigation of the healing process ; ai;id even when, we %d 
 aja observation p;f this kind, we get hardly anything said abou,t the, 
 other tissues, besides the bone, vbich haye been, inyplyed in the 
 resection— rnpthing about the ex,tent p| the ^gamentous unioiji, bje^ 
 tween the resected extremities of bofle;— riiothing abpixt the cpj^ditiqn 
 of the latter themselves. Perhaps this also wiU not b.^ fpun(J, pogr 
 sible until the, othei; course, that of anatomical investiga,tion of th,e, 
 healing process,, has been more industriously foUo^ed., Thencg, 
 perhaps, a starting poiii,t may. be obtained, for an accurate and ?Xj- 
 haustive iiivesj;igation on the living body ; and in this n;aiiner w?. 
 sjhall succeed in fiading the connecting links oi^ the phaiffi, th,e, 
 opposite ejads pf wh^ich we hold, in our hands a,t the tijne of the 
 operation and at that of the examination of the pati,ejit a|t.er 
 recovery. 
 
 The cpurse of anatomical investigating into the healing process 
 after resection of bones lea,ds in twp, directions. Tb-.e sBiest way ojf 
 arriving at the object is to examine on the dead bpdy, at the most 
 various times possible after the operatipji, the parts pn whi,ph re- 
 ^ectipn has been performe_d. It seems ahnost to affp,];d a presmnp- 
 tion in favour pf resection, that so little, material (and, unfqr-. 
 tjuiately, stiU less profitable material) has been obtaine,d, ^t might 
 be assumed with some confidence, that a, fatal, result ^er resection 
 is uncommon, and that the necessity of subsequent aiqj):utation hg^ 
 still less frequently occurred. An opportunity has very seldom htea. 
 found of exapoining the body of a man who has be§n pured. by red- 
 irection, a^d survived for a considerable time. 
 
 But even in the cases where the opportTjjnity has pcpuiyred of 
 making an examination a short time, sifter the pper%tip9,. thi^ has 
 not often l?een done. When, however, exaniinations have been 
 made, what is- displayed to the investigators is usually the product 
 
116 ON REPAIB, AFTER RESECTION OF BONES. 
 
 of a diseased action, and not the normal condition of the healing 
 process, so that nothing is gained towards the knowledge of the 
 latter. 
 
 The other method consists in experiments on animals. These 
 offer opportmiities for studying the healing process in all stages, 
 and nsnaUy give results which do not diverge from the normal state 
 of that process. We must be cautious, however, not to draw direct 
 conclusions from what we observe in animals as to the phenomena 
 in men. Thus, to speak only of operations on rabbits, the ratio of 
 mortality would be fixed exceedingly unfavorably for resection, 
 inasmuch as nearly half the rabbits which I operated upon died. 
 It would be assumed that in most cases, after resection of the head 
 of the humerus, inflammation of the pleura, pericardium, or lungs, 
 would be set up, as I have found to be the case in rabbits. Others 
 have observed the same thing, and, in fact, SteinHn allowed himself to 
 be thus brought to the general conclusion, that resections of the 
 extremities of bones were not likely to supersede exarticulations 
 and amputations — a view, however, from which he has since re- 
 ceded. Besides, we must not forget how imperfect the treat- 
 ment subsequent to the operation must be in animals, at the best, 
 and, at the same time, how important it is to take the greatest 
 possible care of them, and how much success depends on it. This 
 circumstance causes a much more important difference in resections 
 upon animals than in experiments on the healing of fractures, 
 though there also the difference is not inconsiderable. The errors 
 which have arisen from this source, and which have long prevailed, 
 have been recently exposed by Voetsch.^ 
 
 The errors, however, into which the use of these two means 
 of anatomically investigating the healing process after resection 
 may lead are mutually destructive. By the differences which 
 appear between observations on the dead body and experiments on 
 animals, we shall learn to separate the essential from the non- 
 essential, the normal from the exceptional; while in other cases 
 they will lead us to the causes upon which they depend. In the 
 end we shall gain a clear insight into the process, and besides this 
 shall obtain numerous hints which will teach us how to guide it 
 for the patient's benefit. 
 
 I have endeavoured, in the following pages, to contribute to the 
 
 ' ' Die Heilung der Knockenbriiche per primam intentionem,' Heidelberg, 
 1847. 
 
INTRODUCTION. 117 
 
 illustration of the healing process by as complete a digest as pos- 
 sible of the recorded anatomical examinations of men and animals, 
 and by new experiments on the latter. The longer my investiga- 
 tion has lasted, the more clear it has become to me how far I still 
 am from being able to form a perfect theory of the process; I 
 hope, however, that I have contributed something towards this, 
 and that, by the collection of new materials, I have been of some 
 use towards the construction of a theory which shall be true to 
 fact. 
 
 The greatest differences are observed in the healing process 
 according as the resection is performed at the extremity or in the 
 substance of a bone, i. e., according as the shaft or the epiphysis 
 is resected. This division wiU, therefore, be observed in what fol- 
 lows ; and a chapter will be added about the healing process e^ter 
 extirpation of bones. 
 
ON THE HEALING PROCESS 
 
 EESECTION AND EXTIRPATION OF BONES. 
 
 GHAPTER I. 
 ANATOMICAL EXAMINATIONS OP THE HUMAN BODY. 
 
 I. Resections of the Extremities ^ Bones. 
 
 A. Resection of the head of the humerus. — I find five examples 
 of dissection of the human body after resection of the head of the 
 humerus. Three of these belong to Textor,' and two to Syme.* 
 The operation was performed three times on account of caries, 
 once on account of comminuted fracture, and once on account of 
 fracture complicated with other injuries. The patients had sur- 
 vived the operation six months, six, ten, eleven, and nineteen years, 
 respectively. The usefulness of the arm had been very great in al 
 of them. It is reported in the case of one of them> a woman who 
 was under Syme's care, and who could sew, knit, wash, and with 
 the left arm (the one operated upon) could raise a full pitcher ef 
 water, and also in that of a inan under Texto/s care, and who con- 
 tinued his work as a thateher, that abduction of the arm was very 
 
 ' Hummel, ' Ueber die Resection im Obeiarmgelenk,' Wuerzbm^, 1832 ; 
 Textor, ' Neuer Chiron.,' Thl. i, stck. i, 3 ; Textor, ' Ueber die Wiedererzeu- 
 guug der Knoeken nach Uesection bei Menschen.,' Wuerzburg, 1843, p. 11. 
 
 ' Syme, ' Treatise on the Excision of Diseased Joints,' Edinb., 1831, pp. 51:, 
 58; ' Contributions to the Pathology of Surgery,' Edinb., 1848, p. 97. 
 
120 ON REPAIR AFTER RESECTION OF BONES. 
 
 imperfect, and could only be effected to any considerable extent by 
 the patient making a movement as if to fling the arm away from 
 him. I have seen the same thing in several cases, especially that 
 of an of&cer on whom Professor Langenbeck' removed the head of 
 the left humerus, on account of its having been crushed by a gun- 
 shot wound, and in whom the motion of the arm was so good that 
 he is stiU doing duty in the Prussian army. In the thatcher 
 operated on by Textor the deltoid muscle was found remarkably 
 thin eleven years after the operation, and firmly consolidated to the 
 newly formed articular capsule and to the infra-spinatus muscle. 
 This atrophy of the deltoid muscle, which is usual after resection of 
 the shoulder, is probably occasioned (as Eeid also says) by the 
 division of the nerves and vessels of the muscle at the time of the 
 operation, even if the whole muscle has not been cut across. Syme 
 found in both his patients — who had died, one six months, the 
 other ten years, after the operation — the head of the humerus 
 rounded off and united by a firm ligamentous tissue to the shoulder- 
 blade ; Textor, however, gives expressly two cases, six and eleven years 
 after the operation, of formation of bone, which in the first appeared 
 as a long styloid prominence, resembliag the styloid process of 
 the ulna, directed upwards, and in the second covered the upper 
 end of the humerus, in the form of an uneven tubercular masg, 
 about half an inch long. Of the eminences upon it, one served for 
 the insertion of the long head of the biceps, the tendon of which 
 must therefore have been divided ; a second, of small size, served 
 to articulate with a small depressed portion of the glenoid cavity of 
 the scapula, which was covered with cartilage. In the case of the 
 thatcher, and in that of a patient who died nineteen years after the 
 operation, Textor found a thick fibro-cartilaginous(?)^ meniscus, in 
 one case freely moveable, between the newly formed mass of bone 
 and the glenoid cavity. This disc was in the latter case united by 
 numerous bands with the acromion, the coracoid process, the sub- 
 clavius and pectoral muscles, and the humerus. In the first case, 
 in which alone of the five a new articular capsule appears to have 
 been formed, the meniscus was united to it. The articular capsule 
 was found, united with a peculiar fibroid tissue, along about the 
 upper fourth of the humerus. It embraced the bone firmly, and 
 > Petrusehky, ' Diss, de Eesect. articulor. extremit. sup.,' Berol., 1851, 
 
 ' The notes of interrogation are the author's. — Tbans. 
 
RESKCTION OF THE KLBOW. 121 
 
 was united intimately to all the parts in the neighbourhood of the 
 joint, especially to the inner surface of the deltoid and to the 
 skin at the situation of the cicatrix. The inner surface of this 
 tissue was rough, and difficult to separate from the bone. Imme- 
 diately around the joint the tissue was much harder than in other 
 parts, and resembled fibro-cartilage. The disc consisted of 
 the same tissue, but was more advanced in cartilaginous (?) 
 formation. It appears from this that the so-caUed meniscus can 
 only be regarded as a thick fibrous envelope to the resected end 
 of the bone, and cannot be classed as an iater-articular cartilage. 
 How the tissue connected with it is to be looked upon wiU be 
 shown farther on. Textor considers the circumstance, that the two 
 patients in whom this meniscus existed were obliged to use their 
 arms much more than the third, who, being a tailor, worked more 
 with his forearm, of much importance in the production of this so- 
 called meniscus. Perhaps, also, the fact that the two former 
 patients survived eleven and niaeteen years, and the third only six, 
 should be taken into account. 
 
 Ankylosis after resection of the shoulder-joint has not been 
 observed up to the present time. 
 
 B. Resection of the elbow. — ^The cases where arms, in which the 
 operation of resection has been performed, have been examined a 
 considerable time after the operation, are not more numerous than 
 those above described, but they give a more uniform result. I 
 find six of them, of which two belong to Syme.i In one of these 
 cases, when he examined the patient, who had survived the operation 
 (which was undertaken on account of caries) only thirty-six days, 
 and then died of pleuro-pneumonia, with formation of a large abscess 
 in the lumbar region, he found the wound healed in most of its 
 extent, but the cut ends of the bones were carious ; so that it appears 
 probable that he had not removed the whole of the diseased bone. 
 In the other case, amputation of the arm operated on was rendered 
 necessary, ten months after the resection by caries, which attacked 
 the wrist. Up to the time of the return of the caries, the patient 
 had been able to use her arm almost as well as the sound one, and 
 had occupied herself priacipaUy with knitting. The uhiar nerve 
 had been divided in the operation, and this had occasioned a feeling 
 
 • 'Treatise on the Excision of Diseased Joints,' Edinb., 1831, pp.91, 
 105. 
 
122 ON REPAIR AFTER RESECTION OF BONES. 
 
 of coldness and numbness along the ulnar side of the hand, but it 
 had disappeared entirely after a few weeks. The third case, which 
 is recorded by Heyfelder,' was also examined after consecutive am- 
 putation of the arm. The resection was performed on account of 
 caries, with false ankylosis of the arm at an acute angle. This 
 wound was cicatrized in four weeks, and all movements of the fore- 
 arm and hand were performed with great facility. Pain, however, 
 continued in the joint, and abscesses formed twice in its neighbour- 
 hood anteriorly, and a year and a half after the resection the fore- 
 arm was hanging from the body, without any power of voluntary 
 motion. The fingers could not be moved without pain, followed, 
 after a short time, by convulsive trembling. There was a space of 
 one third of an inch between the bones of the forearm. The resected 
 ends Were enlarged^ and there was pain in them and in the shaft of 
 the humerus. The muscles were flaccid, and the radial pulse was 
 close to the fiiiger. In this condition amputation was performed 
 three years after the resection. 
 
 The three other cases belong to Roiix,^ Thore,' and Textor,* and 
 contain examinations of persons who had survived the operation 
 four and a half months, three and a half years, and six years. 
 
 Textor is the only one who, after " a preliminary" examination of 
 the arm operated upon, expressly asserts that there was new forma- 
 tion of bone, and this to the precise extent necessary to producfe 
 a perfect new articulation of the ends of the bones upon each other. 
 He found " a lengthening of the ulna to the extent of a quarter of 
 an inch, on which the radius moved, as in the natural state, and thfe 
 trochlea of the humerus appeared as perfect as if none of it had been 
 taken away." 
 
 All the others speak only of a rounding off of the bones and a 
 union between them by firm fibrous tissue, which also partially covered 
 the bony extremities. From the drawing which Syme gives, it ife 
 impossible to say whether it is fibrous tissue or a newly formed mass 
 of bone which covers the lower end of the humerus. It almost 
 
 ' Amputation of tin arm three years after resection of the elbow. BaJer, 
 Corresp. Blatt., 1843, No. 45 ; Schhiidt, • Jahrbuecher,' i8'47 •; 5 Suppl. Bd. 
 
 ' ' Diction, des sciences m^dicales, Art. Resection,' torn, xlvii, p. 548. 
 
 ^ Thore, A.M., ' De la Resection du coude et d'un nouveail proc6d^ p'otir Id 
 piratiquer,' Paris, 1843; Schmidt, ' Jahrb.,' 1844, p. 123. 
 , ■* ' Ueber die Wiedererzeugnng,' &c., p. 13. 
 
RESECTION OF THE ELBOW. 123 
 
 seems to be the latter, since separate parts of newly -foKiied bone on 
 the ends of the radius and ukia ?are represented Siniilarly; 
 
 itoux found the loweJ end of the humerus rounded off, smooth, 
 and as it were encrusted (encroutee) by cartilage. The upper end 
 of the ulna was iA the saine condition. In the upper end of ihe 
 radius was a carious spot, corresponding to a fistulous channel in the 
 soft parts. In no case had a new articular capsule been formed. 
 
 The muscles of the arm were d-trbphifed in Heyfelder's case, and 
 a considerable deposit of fat was found in thein, as wfell as in th6 
 subcutaneous ceUular tissUe. AH the other muscles^ except thfe 
 triceps, had their natural points of insertioii. "Whether these had 
 been spared in the resection is left undecided by the statmeni, that 
 'the portion of bone removed " was not large." The triceps was in- 
 serted, in the case described by Syme, into the posterior surface of 
 the newly formed ligamentous tissue, and through tMs was connected 
 with the upper end of the ulna. 
 
 In Textoir's casfe, in which the flexion and extension of the arm 
 had been quite perfect, the triceps was firmly united to the cicatrix 
 in the skin, without any prolongation to the ulna. 
 
 Heyfelder found the median and radi&l nerves iii their natural 
 position. The ttlnar netve made a pecuhar bend at the point wherfe 
 it ruiis behind the inner condyle of the humeriis. Th'6 "nerves were 
 moi*e broken up, and disprbportiohally thicker and softer than in thfe 
 natural condition> almost like strings of cellular tissue. Betweefi 
 the separate nerve -fibres were found numerous fet - vesicles-. 
 Heyfelder bcMcves that this formation of fat niust be considered as 
 the most potent determining cause of the incapacity for motion to 
 which the arm had recently been reduced. 
 
 The ends of the uliiar nerve, in Symei's case, where it had beeA 
 idividedi were encysted iii ah oblong swelling, ah inch and a half 
 long, iand overlapped cme another inside this. The substance of thi^ 
 sweUihg was grayish in dolour, and extraordinarily hard and tough ; 
 it was united to the sheath of the nerve, and stretched inward between 
 the septate hearve-fibres, which were thus spread asuhdei'. Most of 
 them terminated in the sweUing in a free extremity, which appear- 
 ance, however, might have been prodiiced in the dissection. The 
 remainiiig nerve-fibfes became broader, stronger, and whiter in the 
 swelling than they were elsewhere. Their upper and lower ends 
 approached one another in this altered condition, and finally were 
 united by a flaky substance h&,rdly a Hue in width, which, under 
 
124 ON REPAIR AFTER RESECTION OF BONES. 
 
 the microscope, was foimd to consist of numerous fine fibres crossing 
 each other. These fibres turned of a deep yellow colour on the 
 addition of strong nitric acid, and became firmer and less trans- 
 parent. 
 
 The process of regeneration of the nerve is thus seen to have 
 begun. This fortunate event after division of a nerve in resection 
 appears to be rare. 
 
 Eeid 1 believes that the reason of this rarity is to be found in the 
 fact that the cut ends of the nerve are situated in the thickness of 
 the flaps formed in the operation, and thus even by the most careful 
 management can very rarely be brought into exact apposition, but 
 almost always overlap each other. Such, however, was the case in 
 this instance. Thus the impossibility of regeneration, which Eeid 
 believes to be caused by this overlapping, is disproved. 
 
 Besides the cases which result in the formation of a flexible and 
 more or less long and firm material between the resected ends of the 
 bones, we find healing frequently reported with more or less com- 
 plete ankylosis. The incomplete ankylosis may depend on an ex- 
 tremely short and very firm fibrous mass, occupying the space between 
 the resected ends of the bones, or on an intimate union of the 
 muscles which surround the situation of the joint, by which they are 
 hindered from acting freely. But perfect ankylosis can only be 
 caused by bony soldering of the ends of the bones together, and its 
 occurrence speaks decisively of copious production of callus, and an 
 approximation of the resected ends of the bones by muscular action. 
 
 Esmarch* observed perfect and imperfect ankylosis thirteen times 
 among forty cases of resection of the elbow, thirty-three of which 
 were healed. The after treatment has the most important influence on 
 this result of resection. Most of the cases of ankylosis just men- 
 tioned occurred among the patients who had suffered resection of the 
 elbow in the Schleswig lazarettoes, after the battle of Idstedt, and 
 had afterwards been treated in the Danish lazarettoes. The Danish 
 surgeons had never practised the operation, and being apparently ig- 
 norant of the value of timely passive motion, had entirely neglected it. 
 
 c. Besection of the lower end of the ulna. — Blandin^ resected the 
 lower end of the ulna in the extent of five centimetres (nearly two 
 
 ' ' Die Reseotionen der Knoohen.,' Nuernberg,' 1847. 
 ' 'Ueber Resection nach Sohusswanden,' Kiel, 1851. 
 ' 'Journal de M^d.,' par Champion, Avril, 1843, 
 
EXCISION OJ? THE HIP. 125 
 
 inches), in a man thirty-two years of age, a baker. On the death of 
 the patient, seven and a half months afterwards, a fibrous tissue was 
 found in the place of the excised bone, in which several points of 
 ossification had been deposited. The wrist-joint had preserved its 
 niobihty completely. IVom the absence of ankylosis between the 
 separate carpal bones, Blandin deduces the conclusion, that the joint 
 had not been opened in the operation. (?) 
 
 D. Resection of the hip-joint. — Anatomical investigations, which 
 might give any data as to the changes after resection in the hip- 
 joint, are almost entirely wanting. Perhaps I may be allowed to pro- 
 duce here a case observed at the surgical cHnique at Jena, and which 
 is related by Eeid.^ The head and neck of the femur, which had 
 separated spontaneously after an abscess in the joint, in a boy of 
 fifteen, were extracted through an incision. After the death of the 
 patient, which was the result of Bright's disease, a year afterwards, a 
 new joint was found, two rounded processes having been formed on 
 the remains of the neck of the femur, the upper of which was con- 
 nected with a bony prominence above the acetabulum, and the lower 
 (situated immediately in front of the small trochanter) with the 
 original articular cavity, by firm fibrous tissue, in such a way as to 
 admit of motion. The motions of the limb were Hmited. 
 
 Two accounts of dissection after excision of the upper end of the 
 femur are given by Textor'^ and White.^ 
 
 In Textor's case the patient was a man of fifty-four years of age, 
 who suffered from caries of the neck of the femur and the trochanter 
 major. The head and neck of the femur and the trochanter major 
 were removed. The patient died of hectic fever fifty-three days 
 afterwards. The wound was united, except a small part. From the 
 small trochanter outwards new bone was deposited over the upper 
 third of the femur, the cut surface of which had become rounded off. 
 At the upper and inner side of the femur a depression resembHng a 
 neck was formed. The acetabulum, which was partially covered by 
 granulations, was healthy ; at separate points of it there was also 
 found a deposit of new bone, which, however, separated again on 
 
 " Loc. cit., p. 388. 
 
 ^ 'Oppenheim. Ueber die Resection des Hueftgelenks,' Wuerzburg, 1840, 
 -p. 45. 
 
 ' ' Catalogue of the Pathological Specimens contained in the Museum of the 
 Royal College of Surgeons of England,' London, 1847, ^ol- "• P 230. 
 
126 ON REPAIR AFTER REJECTION OF BONES. 
 
 maceration of the pelvis. The upper end of the femui rested against 
 the ischium at the posterior edge of the acetabulum, so that a 
 depression had been formed in this bone one and a half inch long, 
 half' an inch broad, and two lines in depth. 
 
 "White resected the upper end of the femur, just below- tha 
 trochanter minor, on a boy thirteen years old. In one year recovery 
 was so perfect that the boy could execute flexion, extension, and in 
 fact every other motion of the joint, except rotation outwards. He 
 died within fiv« or twelve years' after the operation. The account 
 is not exact on this point. The iliuni and the remains of tha 
 femur were found thin and light. The thigh-bone, rested ■with its 
 upper extremity against the hinder part of the acetabulum, and was 
 united to it and to the neighbouring portion of the os ilu by a firm 
 ligamentous tissue, which appeared to belong psirtly to the remains 
 of the articular capsule which had been left^ between the bones. A 
 muscle was inserted into this tissue and into the upper portion of 
 the femur.. Notiiing more, is adided in the description of- the pre- 
 paxa.tion. 
 
 E. Besecticm of the knee-joint. — ^Amqng- the compara-tively- few 
 cases of resection of the knee there are only two which elucidate 
 the healing process by dissection. Those who have recovered after 
 resection of the. knee have obtained, some a perfect, some an imper- 
 fect ankylosis, and others free movement at the situation, of the 
 joint. The first result seems to be the only favorable; one, sinqe in 
 the two others the, union between the resected sur^ces qf bone does 
 not attain, even after a long period, the degree of firmness aad 
 solidity which is necessary for- voluntary niotiqn of the leg at the 
 knee. The patients in whom these results had occurred, and in 
 whom the immobility of the knee could not be replaced by a 
 machine, either demanded amputation at a kter period, or they 
 went on crutches, dragging the leg after them as a mere, incum- 
 brance. 
 
 In the case examined anatomically by "Wachter^ the resected 
 
 ' The true date appears to be five years. This, at least, is the time men- 
 tioned by Mr. South in liis account of the case (' Chelius' Surgery,' vol. ii, 
 p. 980) ; and the appearance of the bones in the preparation shows that the 
 patient could not have attained the age of twenty-five, as he would have don^ 
 had he survived the operation twelve years. — Trans. 
 
 ' ' Di.ssert. de Artioulis Bxtirpandis,' &c., Groning., 1810. 
 
EXCISION OF THE KNEE. 127 
 
 bones had been soldered together by a mass of callus, but the latter 
 had again undergone partial spftening in the puerperal state. The 
 patient was thirty-four years old, had borne nine children, and had 
 suffered from caries of the knee-joint. Mulder removed on this 
 account the IjOwer end of the femur, about two inches above the 
 condyles, and the end of the tibia close above its junction with the 
 fibula, and took away the patella. Immediately after the operatioii 
 the space between the resected extremities of the bone was dimi- 
 nished by the contraction of the muscles and skin. The limb was 
 kept in a state of extension by an apparatus, and the resected ends 
 approximated as much as possible. The wound was almost entirely 
 closed by suppuration; this was accompanied, by tolerably severe 
 continued fever, and there was present also a train of symptoms, 
 which were probably diependent on the (unrecognised) pregn.ancy of 
 the pa.tient. A month after the operation the ends of the bones 
 were already so firmly united that the patient could raise her Hmb 
 easily without pain, and enjoyed perfect motion of the foot and toes. 
 4bout four weeks afterwards she wa,s unexpectedly brought to bed 
 of twins. Two days a,fter this the sijppuration in the woui^d, whioTj; 
 was then in small quantity and healthy, was replaced by an extra- 
 ordinarily profuse secretion of a wa,tery fiuid mixed with white, 
 flocculi, and this afterwards gradually diminished and gave place 
 again to suppuration in the wound, which was now almost aU broken 
 open afresh. Acute cough, with profuse expectoration and contin- 
 uous diarrhcEa, so exhausted her strength during he^r lying-in that 
 she died about threCj and a half months aftec the operation. Tha 
 extensors of the leg on the Hmb operated on were rather shorter- 
 than natur^ ; the extensor tendons were firmly united to a newly, 
 formed process of bone, which projected above the lower end of the, 
 femur, and had nearly the form of the knee-pan. The flexors of 
 th,e leg had their usual a.ttachments to the tibia,. Benea.th thei 
 newly formed bony process was found, between the endiS of the bones, 
 a small cavity iilled with. pus. IJh^ callus, which surrounded the 
 ends of the bones with a firm covering and soldered them together, 
 appeared to, have been again broken up and dissolved at the lower 
 part of the ne:wly formed process corresponding .to the. patella. The 
 upper end of the- tibia, corresponding to this spot, appealed to boi 
 carious. At each side of this process there was foijnd running, 
 obliquely backwards a cleft of similar appearance, between the ends 
 of the bones and the mass of caUus, and by means of this cleft 
 
128 ON REPAIR AFTER RESECTION OF BONES. 
 
 the bones, which had before been soldered together, were in part 
 separated again. The head of the fibula, to judge by the drawing 
 given by Wachter, was unaltered. The mass of callus extended 
 up to it. In the ankle-joint was found some pus, and there was 
 incipient caries of the contiguous articular surfaces of the tibia and 
 astragalus. Eeid ' describes a second case operated on by Jaeger. 
 The operation was performed on account of caries on a man twenty- 
 eight years of age ; one inch and four lines of the lower end of the 
 femur, the articular end of the tibia, for the extent of nearly an inch, 
 down to the head of the fibula, and the patella, were removed. The 
 section of the tibia sloped rather sharply upwards in its posterior 
 half. The surfaces of the bones were kept constantly in contact, 
 and the limb extended. In the tenth week the first attempt was 
 made to raise the hmb, and in the fifteenth to walk. Five weeks 
 later the patient was in condition to be discharged, with a thoroughly 
 useful Umb. The femur and tibia were firmly united by callus. 
 The lower end of the femur had slipped somewhat forwards and 
 outwards, and its projection could be plainly felt in this situation 
 beneath the cicatrix, which was firmly united to the bones ; while 
 the prominence of the posterior edge of the tibia could be made out 
 in the popHteal space. This displacement had occasioned an incon- 
 siderable curvature outwards in the neighbourhood of the knee. The 
 muscles of the leg and thigh were not much diminished in size, 
 but were flaccid. The shortening of the Umb measured two inches. 
 The patient on recovery was able, after the interval of a year, to walk 
 Securely and for any length of time with a raised heel an inch thick 
 on his boot, could ascend mountains, stairs, or ladders, and could 
 even dance. A few years before his death he fell off a ladder and 
 broke his fibula in the lower third. Thus it seems that the union 
 at the knee was firm enough to resist the force which caused this 
 fracture. Fourteen years after the operation the patient died of 
 pulmonary consumption. Reid found the cicatrix firmly united to 
 the bone, the extensor and flexor muscles of the leg atrophied, and 
 partly converted into fat. The ends of the femur and tibia were 
 firmly united by bony union, with displacement transversely and 
 partial rotation on each other. The joint between the tibia and 
 fibula was unaltered. The traces of the fracture of the fibula were 
 stiU plainly apparent. 
 
 The preparation of a bony ankylosis, which was formed in a 
 
 ' Loo. cit., p. 44. 
 
CLINICAL RESULTS THE FIBULA. 12& 
 
 case of resection of the knee by Crampton, may be found in the 
 Hunterian Museiun at London. I have been unable, however, to 
 find the description of it.' 
 
 p. Resection of the lower end of fibula. — Grist ^ performed this 
 operation on account of caries limited to the external malleolus. 
 The patient was a bricklayer of phthisical constitution, weakened by 
 frequent confinement in prison. The motion of the ankle-joint was 
 unimpeded and the joint unaffected by the carious process. The 
 tendons of the long and short peronsei muscles were cut through in 
 the operation. The deep cavity left by the resection was fiUed with 
 charpie, and the edges of the wound brought together over this with 
 sticking plaster. Violent inflammatory symptoms appeared in the 
 neighbourhood of the wound, but yielded to topical antiphlogistic 
 measures. The wound healed by granulation, and was cicatrized in 
 from forty to fifty days. The patient was discharged on the ninety- 
 sixth day and immediately went to his work. The foot was capable 
 of adduction as in the natural condition; but the power of ab- 
 duction, as weU as the rotatory movements of the foot, was 
 destroyed. Extension and flexion were almost as free as in the 
 natural condition ; they were effected, however, not in the joint 
 between the tibia and astragalus, which appeared to be ankylosed, 
 but in those between the astragalus and the scaphoid and calca- 
 neum. The patient died of consumption nearly three years after 
 the operation. 
 
 The tibia and astragalus were found ankylosed ; the capsular Hga- 
 ment between the astragalus and scaphoid had become very loose and 
 extensive, and allowed of very free movements in the corresponding 
 joint. The fibula was closely approximated to the tibia, and was 
 firmly and intimately united with it. No regeneration of the bone 
 had taken place, but the periosteum was continued directly into a 
 ligamentous substance, which formed a sort of bHnd pouch around 
 the cut end of the fibula, and passed over to the bones of the 
 tarsus. By means of this newly formed Hgamentous tissue, the 
 danger of dislocation, which occurred whenever the sole was not 
 planted quite level on the ground, was obviated ; it also opposed 
 extreme adduction of the foot, and was sufficient, by its structure, 
 
 ' See Appendix. 
 
 ' Resectio fibulse in articulatione tibio-tarsea. ' Baiersch. Corresp.,' Blatt 
 1843, August, No. 33. 
 
130 
 
 ON REPAIR AFTER RESECTIONS 01' BONES. 
 
 strength, and extent, as well as by the nature of its attachment, to 
 protect the joint and to replace the lost maReolns. Nothing is said 
 as to the state of the tendons of the peronsei muscles, which had 
 been divided in the operation. 
 
 G. Resection of the inner half of the as ealcis. — The power of re- 
 generation of the short bones is usually placed far beneath that of 
 the tubular bones. With respect to regeneration after resection 
 of the extremities of the bones, the difference cannot a priori 
 be assumed to be so very considerable. The articular ends of 
 tubular bones are hardly distinguishable in anatomical structure 
 from the short bones ; even the periosteum, which covers the short 
 bones, is wanting in a portion of the others, and the difference can 
 a priori be founded only on this consideration — whether in resection 
 of the long or tubular bones the shaft is more or less involved in the 
 operative proceeding. That this a priori conclusion is correct 
 is shown also by experience. The only account of an anatomical 
 investigation after the resection of a short bone which I have been 
 able to find, gives a result not essentially different from that which 
 we have seen after resection, for example, of the lower end of the 
 ulna or the fibula. Pergusson,^ in the case I allude to, amputated a 
 foot at the tibio-tarsal joint, in which he had seven years before 
 extirpated almost all the inner half of the calcaneum on account of 
 caries. He found the bone partly regenerated, and the place of the 
 lost substance partly occupied by a fibro-cartilaginous material. 
 The utility of the foot had been perfect. 
 
 II. Resection in the substance of a lone. 
 
 Anatomical examinations on the human subject, in cases where the 
 patients have survived for a long time after resection from the substance 
 of bones, are very scanty. They are confined exclusively to resections 
 of the ribs and to trephining. If we call to our assistance the 
 examinations of patients during life, what was said in the Introduc- 
 tion applies to them. They show us, in cases of the removal of 
 pieces embracing the entire thickness of the shaft of a bone, its 
 replacement either by a new, solid, bony union, or by a non-osseous 
 flexible uniting medium, with more or less ■ shortening of the 
 limb. 
 
 ' 'Medical Times,' June 14, iSgi. 
 
CLINICAL RESULTS AFTER NECROSIS. 131 
 
 The cases in which resections have been performed in the 
 substance of bones for the extraction of sequestra in central necrosis, 
 or for the removal of bones affected with peripheral or total necrosis, 
 cannot be made use of unconditionally here, in endeavouring to 
 illustrate the healing process after resection. These operations for 
 necrosis have also not been usually reckoned as resections. The 
 healiQg process in these cases does not take its origiu from the 
 operation only, but the beginning of the process of regeneration, by 
 which the dead bone is to be replaced, is to be dated rather from 
 the commencement of the necrosis ; and its conclusion is accelerated 
 on the removal of the necrosed bone, whether that removal has been 
 accomplished by the powers of nature or by operative means. The 
 regenerative process which was previously in full march, may, how- 
 ever, possibly receive a foesh impetus from the operation and the 
 inflammation consequent upon it. It is therefore no matter of 
 surprise, that most of the resections performed for necrosis have 
 obtained the most favorable result, viz., that of the regeneration 
 of the resected bongs; and that after these operatioiis bony re- 
 storation occurs in those bones in which the loss of substance 
 after resections for other diseases is very rarely indeed replaced 
 by bone. This is the case especially with the lower jaw. 
 After resection of this bone for comminuted fracture, for 
 new formations, and so forth, the piece removed is in most 
 cases replaced either not at all, or by a narrow and strong, 
 but flexible cord; while Lesser' has put together about thirty 
 cases; and more recently Thormann,'^ Virchow,* and Geist,* 
 have communicated others of a similar nature, in which, after 
 partial or entire removal of the lower jaw, when necrosed, bony 
 reproduction has taken place ; and Shulze' has even observed the 
 formation of teeth in the regenerated jaw. Perhaps this difference 
 may be explained also by the circumstance that in resection of 
 the lower jaw for other causes than necrosis, the periosteum is not 
 
 ' Fall einer Zerslorung und Absonderung des Grossten Theils des Man- 
 dibula nebst Regeneration des Knochens, ' Graefe u. Walther Journ.,' Bd. xxii, 
 
 P- 354- 
 
 * ' Graefe u. Walther Journ.,' Bd. xxx, Hft. 2. 
 
 ' Regeneration des Unterkiefers nacli der Phosphor. Nekrose, 'Verhand- 
 lungen der phys. med. Gesellseh. z. Wurzburg,' No. i, 1852. 
 
 ^ ' Die Regeneration des Unterkiefers nach totalen Nekrose durch Phos- 
 phordampfe,' Erlangen, 1852. 
 
 ^ ' Walther. u. Ammon Journ.,' N. F., Bd. ii, St. 4. 
 
132 ON REPAIE AT?TEB RESECTIONS OF BONES, 
 
 preserved; while in resection on account of necrosis, tMs mem-. 
 brane is usually so thickened and separated from the bone, and so 
 closely united to the other soft parts, that it is almost more easy to 
 leave it behind than to take it away. This consideration must be 
 permitted to have its due weight, inasmuch as the periosteum is 
 allowed to be the principal, though not the sole agent, in the repro- 
 duction of bone. Eied on this account advises that, in resection of 
 the lower jaw, the posterior lamella of the periosteum at least 
 should be preserved. I cannot, however, coincide in his opinion, 
 that this preservation of the periosteum is easiest in resection on 
 account of mechanical injury, and that, in caries and inflammation 
 of bone, the periosteum is usually found firmly united to the bone. 
 All the particulars which establish a difference between the healing 
 process after resection in necrosis and the healing process after 
 resection on account of other affections, result from the researches 
 of Troja,^ and the series of experimenters who followed him. Lately, 
 Geist^ has called attention to the " regenerating membrane" which 
 he asserts to be formed in the process of necrosis, and to possess 
 the exclusive property of the new formation of bone. I have not 
 been able to find this in resections upon animals, and must, there- 
 fore, class it among the differences above alluded to between them 
 and men. 
 
 The differences between the heahng process after the operation 
 for necrosis which has been treated by resection or extirpation of 
 the bone, and the healing process after resections performed for other 
 diseases, appeared to me to be most conveniently touched upon in this 
 place, where resection of the substance of a bone is spoken of ; 
 since necrosis most usually attacks the shaft, and seldom the 
 extremities of the bones. What has been said about necrosis 
 is generally true of all the cases in which the separation of the 
 diseased bone from the soft parts which surround it is produced by 
 the natural forces, and the operative proceeding effects only the 
 final removal of the bone. The process of regeneration is a far 
 more productive one than in other cases ; and, especially as relates 
 to the bone, the restoration of the part removed occurs more 
 rapidly and more certainly than in the cases where the separation of 
 
 ' 'Neue Beobachtungen und Versuche iiber die Knocken, iibers: von 
 Sohoenberg,' Brlangen, 1828. 
 ' Loc. cit. 
 
CLINICAL RESULTS THE RIBS. 133 
 
 the part removed is effected by the operation only. The anatomical 
 details which have been described after resection in the substance 
 of a bone support this assertion. 
 
 Karajew' and Textor^ examined the bodies of two men on whom 
 they had resected a carious piece of a rib, respectively eight and 
 four and a half months previously. The length of the piece was 
 twelve and a half lines in the first case, and two inches four Hnes 
 in the second. In both cases the periosteum was left in the opera- 
 tion; in both the piece had not been reproduced in its whole 
 cubical extent, but the two cut surfaces were united together by 
 irregular deposits of bony material. Karajew remarks expressly, 
 that the deposit, especially at the posterior surface, where the 
 periosteum had been preserved, was found to be about a line in 
 thickness ; while on the anterior surface, and between the two ends 
 of the rib, no bony matter was to be seen. In Tester's case, to 
 judge from the drawing, the state of the parts seems to have been 
 somewhat similar. The same may be said as to the various smaller 
 and larger foramina through which the nutritious vessels passed 
 into the interior of the new masses of bone. Only Karajew mentions 
 them expressly ; but Textor figures them, and at the same time the 
 envelope of very much thickened periosteum by which the new mass 
 of bone was covered. 
 
 An examination by Eied^ had an opposite result to this. He 
 resected the sixth rib at its junction with its cartilage. Yiolent 
 compression of the thorax had caused a fracture of the rib at this 
 spot, followed by the formation of abscess; and at the opening of the 
 abscess the bony end of the rib was found carious, and the carti- 
 laginous fragment exposed. At the operation about half an inch of 
 each was removed. Three years afterwards, on post-mortem exa- 
 mination, a narrow fistula was stiU found running in the direction 
 of the costal cartilage, which had by degrees entirely exfoliated. 
 The bone was covered by a cicatrix, and there was no trace of repro- 
 duction either of it or of the cartilage. 
 
 Equally scanty with the cases referred to above, are the notices of 
 dissection of persons who have survived trephining for a long period. 
 In examinations performed a short time after the operation, the 
 
 ' ' Pricke u. Oppenheim Zeitschrift fiir die gesammte Medicin,' Band xvi, 
 Heft 2. 
 ' ' Ueber die Wiedererzeugung der Knochen,' &o., p. 15. 
 ' 'Die Resectionen der Knochen,' Niirnberg, 1847, p. 250. 
 
134 ON BEPAIR AFTER RKSKCTIONS OF BONES. 
 
 pericranium surrounding or covering the loss of substance of the 
 bone has been found swollen and reddened, and a similar alteration 
 has been discovered in the dura mater lying at the bottom of the 
 opening, with occasionally the deposition of a red brawny material 
 on the latter. Later on, the whole opening has been found filled 
 with granulations, proceeding from the skin, dura mater, and sections 
 of the bone ; and then a bevelling off of the sharp margins of bone 
 through partial necrosis and exfoliation has usually been observed. 
 The closure of the opening is finally effected for the greater part by 
 a fibroid mass, intimately united to the dura mater and the 
 pericranium, and in smaller proportion by bony formations pro- 
 ceeding from the edges of the outer and inner tables of the skull. 
 Eokitansky has observed such formations proceeding also from the 
 surface and edges of the wound in the soft parts, and divides them, 
 as in the union of fractures by the first intention, into primary and 
 secondary callus-formations. He leaves unexplained the causes of 
 the scanty production of callus in the cranial bones, a circumstance 
 which is found also in the perforations caused by necrosis. The 
 case is different with resections in which a piece is removed not 
 including the whole thickness of the cranial bones. The loss of 
 substance in these cases, as occurs in similar circumstances after an 
 injury, is usually replaced completely by a newly formed mass of 
 bone. Dubreuil ' does not believe that a defective power of repro- 
 duction peculiar to the bones of the skull is a sufRcient cause, but 
 refers the phenomenon to the injury or destruction of the pericranium 
 and dura mater which generally takes place at the same time. He 
 examined the body of a sailor, who had died of apoplexy eight years 
 after trephining. A fibrous material only closed the opening of the 
 trephine, while on the contrary a bony cicatrix was found on the 
 forehead in the situation of a loss of substance of the outer table. 
 New bony substance covered by pericranium was found in this part. 
 This substance was separated from the vitreous table by a small 
 interval, which became perceptible after maceration, and was filled 
 with irregular bony granulations (?) ^ 
 
 An account of a similar dissection has been communicated by 
 Guensburg.' It is distinguished for accuracy, and therefore worthy 
 of mention. The skull was that of a female who had survived the 
 
 ' 'Presse M6dicale,' 1837 ; 'Proriep Notizen,' 1837, p. 236. 
 ' The note of interrogation is the author's. — Trans. 
 ' 'Deutsche Klinik,' iSgo, No. 8. 
 
CLINICAL RESULTS AFTER TREPHINING. 135 
 
 operation of trephining for seventy-nine years. The loss of sub- 
 stance, which was situated at the junction of the coronal and left 
 squamous sutures, was covered by a membrane which had a tendinous 
 lustre, and was convex towards the cavity of the skuU. This 
 membrane, however, was deficient in several places, and in these 
 was filled up by a deposit on the dura mater to the height of a line. 
 The upper layer of this deposit consisted of irregularly polygonal 
 flakes, or of a mass resembling homy epithelium, while deeper down 
 a firm fibrous structure was found, which consisted of thick bundles 
 of fibres crossing each other in various directions, and was inserted 
 into the thinned edges of the bone. From the sharply-defined and 
 waU-Kke edge of the deposit fine bundles of fibres resembling 
 needles ran out in a radiating manner into the tissue of the dura 
 mater, and corresponded to the grooves between delicate processes 
 of bone, which were deposited on the vitreous tables starting from 
 an inch beyond the opening, and proceeding up to it and in part 
 across its edge. The material first mentioned as having a tendinous 
 lustre consisted of layers of hori^y epitheKum closely packed one 
 over the other. 
 
 Against these facts is to be placed the restoration of the bones of 
 the head after complete loss of both tables, which has been observed 
 in a whole series of cases collected by Klencke, ' to which he has 
 also added a fresh instance. In aU these cases, which relate to loss 
 of substance, partly by necrosis, partly by trephining, the dura mater 
 was preserved. On this account, and from his experiments on 
 animals, Klencke considers tliis membrane the true matrix for the 
 regeneration of the bones of the skull. 
 
 III. Extirpation of hones. 
 
 What has been said about resection from the substance of bones 
 is true also in general of resection of entire bones. It seems in this 
 case also to be a question of saving the periosteum as much as pos- 
 sible, since where this has been found possible the bone has been 
 regenerated more or less perfectly without any considerable short- 
 ening of the limb ; while, where the periosteum has not been pre- 
 served, a fibrous cord firmly united with the cicatrix has usually 
 been found in the place of the extirpated bone. Eied seems to con- 
 
 ' ' Physiologie der Entziindung und Regeneration in organischen Gewben,' 
 Leipzig, 1842, p. 197. 
 
136 ON EEPAIB AKTEB RESECTIONS OF BONES. 
 
 sider even this appearance asj at least frequently, deceptive, and 
 puts down this cord for nothing more than a cicatrix of the 
 soft parts around the extirpated bone matted together. My ex- 
 periments on animals oblige me to assent to this view. When 
 he speaks, further on, of irregular cartilaginous or osseous points, 
 which are occasionally deposited to replace extirpated bones, I do 
 not understand whether he places the seat of the deposit in this 
 cicatrix, or in a veritable fibroid cord which he may have observed 
 in other cases. I am almost led to believe the latter, since he men- 
 tions, as a known fact, the deposit of such points in the liga- 
 mentous uniting medium which, under certain circumstances, is 
 found between the cut ends of bone after resections from their 
 substance. 
 
 Yery few accounts of dissection after extirpation of long bones 
 are on record. Meyer,^. of Zurich, extirpated the clavicle, on 
 account of caries, on a man thirty-one years of age. The wound 
 was cicatrized in seven weeks ; the patient soon obtained perfectly 
 good use of the arm. In the situation of the extirpated bone a 
 mass of new bone, of the form of a normal clavicle, was plainly to 
 be felt. The patient died about five years after the operation. At 
 the dissection there was found, between the facet for the clavicle on 
 the sternum and the acromion, a fibrous, almost cartilaginous (?)2 
 band, on which the lower edge of the newly formed bone was sup- 
 ported, and with which it seemed to be continuous in some places. 
 The length of this band measured four and a half inches, that 
 of the newly formed bone three inches ten lines. The latter was 
 very thin, flattened towards the sternum, but more rounded towards 
 the acromion ; the end towards the manubrium stemi, which was 
 somewhat broader and thicker, articulated with it by a well-marked 
 articular surface. About an inch from the acromion the new bone 
 ended in a thick head, which was united to the acromion by a broad 
 thick band. In the latter a few well-marked granules of bone were 
 deposited. The upper edge of the new clavicle formed towards its 
 sternal end a marked angle pointing upwards, and towards the 
 acromial end an angle pointing downwards ; its lower edge did not 
 correspond, in consequence of a few deposits of bone passing further 
 down into the fibrous band. 
 
 ' Graefe u. Walther Journ.,' Bd. six, p. 71. 
 The query is the author's. — Trans. 
 
CLINICAL RESULTS EXTIRPATION OF BONES. 137 
 
 D'Angerville' relates a similar case, in which Moreau removed 
 the whole clavicle in a young man on account of necrosis. The 
 wound healed quickly, and the arm regained its former usefulness. 
 On dissection a few months later a new clavicle of the normal length 
 and solidity was found in the situation of the extirpated bone, arti- 
 culated in the normal manner to the acromion and sternum. 
 
 A case operated on by Kunst^ is to be added to these, which in- 
 deed has not as yet been the subject of dissection, but where accu- 
 rate examination during life enables us to arrive at a conclusion as 
 to the changes which occur after extirpation of the clavicle. Here 
 no bony reproduction of the clavicle took place, yet the arm was 
 perfectly serviceable for the hardest work, and the shoulder &m 
 enough to carry burdens. The left clavicle had been removed 
 eleven years before the examination, on account of caries. On ex- 
 amination the articular surface on the manubrium, about as large as 
 a walnut, could still be felt empty ; from this point up to a tubercle 
 on the first rib (apparently the elevation for the insertion of the 
 scalenus anticus muscle) the skin was firmly united to the rib. A 
 cord-Kke material stretched outwards from this latter point to the 
 acromion, in firm connexion with the cicatrix of the skin. This 
 cord could be moved a little upwards and downwards, and separated 
 the supra- and infra-clavicular depressions from each other. Tlie 
 clavicular portion of the stemo-mastoid was inserted by a cord-Hke 
 process into the before-mentioned elevation on the first rib, and was 
 tensely stretched from this point to the fourth cervical vertebra, but 
 without affecting the position or mobiUty of the head. The left 
 shoulder had sunk an inch and three quarters below the right; 
 the point of the scapula was directed rather obliquely backwards, 
 and was higher than on the sound side, and at a greater distance 
 from the ribs. If the patient placed the left arm upon the right 
 side of the neck, the head of the humerus approached the cervical 
 vertebrse within two inches and a quarter, while the head of the 
 right humerus in a similar movement remained at a distance of four 
 inches from them. 
 
 Racord ^ has observed a case of regeneration of the whole of the 
 humerus, together with its upper articular end, in a case which, 
 although it does not belong to the class which we are here con- 
 
 1 ' Mem. de TAcad^mie Roy. de Med.,' torn, xiv, p. 56. 
 = ' Deutsche Klinik,' 1850, No. 24. 
 ' ' Gaz. M6d. de Paris,' 1842, p. 639. 
 
138 ON EEPAIR AFTER RESECTIONS OF BONES. 
 
 sidering, yet deserves to be noticed^ because it affords a proof how 
 abundant the reproduction of a bone is, if its separation have been 
 effected principally by the natural forces, and if the periosteum has 
 been left behind. After an amputation of the forearm below the 
 elbow, the stump was attacked by gangrene, which stopped at the 
 upper arm. The separation of the slough was fuUy accomplished by 
 suppuration in a month ; after this the humerus lay perfectly exposed 
 in the lower part. Sis months afterwards the humerus, which had 
 become spontaneously dislocated, was extracted by a long incision. 
 The periosteum was firmly united to the neighbouring muscles, could 
 be clearly recognised, and was left behind. Two months later the 
 stump, thus deprived of its bone, had again acquired considerable 
 solidity ; at the end of another month it became necessary to ampu- 
 tate it at the shoulder-joint. In the centre of the amputated stump 
 a new bone, twenty-two centimetres (eight inches and a half) long, 
 and three to four centimetres in breadth (about one inch and a 
 quarter), was found. At the upper end of this there was an articular 
 surface corresponding perfectly to the glenoid cavity, and closely 
 united to that cavity by a ligament attached all round it. Another 
 process on the inner edge of the new bone was connected firmly to 
 the third rib by a ligamentous structure. 
 
 Anatomical examinations after the extirpation of short bones are 
 almost entirely wanting. The dissection which Textor, jun.,' per- 
 formed on a forearm eighty-four days after extirpation of all the 
 bones of the carpus displayed a large cavity with numerous pouches 
 in the situation of the wrist-joint, the walls of which were covered 
 with a rich crop of granulations, for the most part very fine, red, and 
 healthy ; and these formed in many places projections and folds, or 
 imperfect partitions. The walls of tliis cavity were formed partly by 
 the periosteum of the metacarpal bones, partly by the remains of the 
 Hgaments which united the bones of the metacarpus to those of the 
 carpus, as well as by the tissue of the cicatrix of the healed wounds 
 of the operations, and by the resected ends of the second and third 
 metacarpal bones. Both bones of the forearm were deprived of 
 their cartilaginous covering, and carious. The palm was smooth and 
 flattened. The loss of the carpal bones was not very perceptible 
 externally. All the tendons which pass across the wrist-joint were 
 uninjured. That of the flexor profundus muscle was united over 
 
 ' ' Prager Vierteljahrsohrift,' 1849, Bd. iv. 
 
CLINICAL RESULTS — EXTIRPATION OF BONKS. 139 
 
 the metacarpus with the periosteum of the metacarpal bones, aii5 
 with the cicatrix of the wound of the operation. The ulnar nerve 
 ended in a smaU swelling in the same cicatricial tissue, as did the 
 median nerve and its branches. 
 
 Examinations during life of persons who have recovered after 
 extirpations of short bones, show that the defect has been remedied 
 as far as possible by approximation of the bones which He nearest 
 together. The interval which is left seems to be filled up with a 
 ligamentous material, in which, according to Eied, masses of cartilage 
 or bone are sometimes deposited. 
 
 Eegeneration of flat bones, as for example of the scapula, has as 
 yet been observed only after necrosis. Cases of it are quoted by 
 Chopart, ' Klencke, 2 Rudolphi, » and Kortum, * by the two latter in 
 the horse. Resection was not practised in these cases, therefore the 
 cases are not applicable here. 
 
 After extirpation of the upper jaw, there is formed between the 
 cut ends of the zygoma and those of the nasal and alveolar pro- 
 cesses a fibrous membrane, by which principaEy the falling-in of 
 the cheek is prevented. A membrane of precisely similar character 
 is formed in the situation of the lower wall of the orbit. The large 
 cavity which is left behind is lined by a red covering resembling 
 mucous membrane, and is narrowed considerably by the soft palate 
 being drawn forwards and upwards. Besides this, Eied considers 
 that the approximation of the bones around the cavity is a probable 
 cause of its diminution. No trace is ever observed of regeneration 
 of the bone. 
 
 ' 'De necrosi ossium theses praes. Chopart,' Paris, 1776, p. 7. 
 ' Loc. cit. ' 
 
 ' ' BemerkuDgen ueber Naturgeschichte, Medicin und Arzneikunde,' Berlin, 
 1805, ii, p. 56; 'Edinb. Med. and Surg. Journal,' April, 1823, p. 217, 
 
 figs- I' 2. 3- . -^. , T, , 
 
 ■• ' Experimenta et observaiiones circa regenerationem ossium. Diss., Berol., 
 1834. 
 
CHAPTER II. 
 
 EXPERIMENTS AND ANATOMICAL INVESTIGATIONS ON 
 ANIMALS. 
 
 The second method of investigating anatomically the healing pro- 
 cess after resection of bone, which proceeds by experiments on animals, 
 has led to much richer results, and is also more easily attainable, 
 than dissections of the human body. We should have arrived long 
 ago by this method at a view of the healing process in its various 
 stages, had it not been that aU experimenters have confined them- 
 selves to endeavouring to discover only the final result of the 
 process. The animal was operated on, and the immediate and 
 subsequent results of the operation left unnoticed; and only after a 
 considerable time was an examination undertaken into the changes 
 which had gone forward ia the parts concerned in the operation, at 
 a time when the process had run its full course, the parts had been 
 restored more or less completely to their functions, and no further 
 changes were to be anticipated ia them. In these cases also the 
 description of the appearances on dissection is wanting in that 
 trustworthiness and certainty which can only be obtained by the 
 microscope in the determination of the nature of the tissue which 
 has been substituted for the parts removed, or has united those 
 divided, in the operation. The first observer who undertook the 
 labour of following step by step the healing process after resections 
 of bone was Steinlin.' I have had the opportunity, while endea- 
 vouring to follow the same method, of subjecting the results of his 
 observation to a careful and well-founded criticism. I will therefore 
 , postpone entering upon them, until I come to that part of my subject 
 where I set out in order the particulars which my own observations 
 have taught me. I wiU merely say here, that I can confirm 
 SteinHn's results in their principal points. What former inquirers 
 
 ' 'Ueber den Heilungsprozess naoh Resection der Knoohen/ Dis. Zurich, 
 1849. 
 
EXPERIMENTAL RESEARCHES THE ENDS OF BONES. 141 
 
 have taught us with respect to the final results of resections on 
 animalsj I believe I have succeeded in embraciag fully in the fol- 
 lowing chapter. 
 
 I. Resections of the extremities of bones. 
 
 Yermandois ' was the first who excised the upper part of the 
 femur just below the trochanter minor on a dog. His object was 
 to recommend the excision of the head of the femur in preference to 
 amputation at the hip-joiat. In a few days the end of the resected 
 bone rose up to the level of the acetabulum, and two months 
 afterwards the wound had healed by suppuration. The animal 
 carried the shortened limb pendulous at first ; towards the end of the 
 second month it supported itself a little on the back of that foot. 
 At the dissection, which was performed about the above time, the 
 femur was found to be thicker than on the soimd side, the medullary 
 cavity very large and full of marrow, the compact substance thinner 
 than in the healthy femur. The upper end was studded Adth irre- 
 gular prominences of compact bony substance, which were directed 
 more especially outwards, towards the cicatrix in the soft parts, and 
 were united to the acetabulum by a ligamentous material. The 
 acetabulum was diminished in circumference, and was filled with a 
 soft, very red substance, which Vermandois took for the synovial 
 gland enlarged and injected. 
 
 To this experiment are to be added the observations of Chaussier,^ 
 Korler,^ Wachter,* and in more recent times B. Heiae.^ They all 
 of them operated on dogs. The results are tolerably consistent 
 with the preceding. The wound was ia most cases united by the 
 interrupted suture, and healed by first intention. Chaussier met 
 with this so often, that in order to investigate the influence of 
 suppuration on the healing process he was obKged to use irritants 
 of various kinds. This was followed by numerous collections 
 of pus, which were allowed to open spontaneously. The final 
 result was not essentially different from that of those cases m which 
 
 ' ' Journal- de M^decine,' 1786, torn. Ixvi. 
 
 ' 'Magasin encycloped.' An. V., torn, vi, Ko. 24; 'Hufeland, Harless n. 
 Schreger Journal der auslandischen Med. Litt.,' Bd. i, 1802. 
 ' 'Experimenta circa regenerationem ossium,' Goett., 1786. 
 * ' Dissert, de articnlis extirpandis/ &o., Groningen, 1810. 
 ^ 'Feigel Chirurg. Atlas,' Wurzbg., 1850. 
 
142 ON REPAIR AFTER RESECTIONS OF BONES. 
 
 the ■wound was united immediately. In all cases the animals 
 carried the shortened Hmb pendulous at the commencement ; from 
 the fourth to the sixth week they began to support themselves upon 
 itj and about the tenth week almost all of them began to use the 
 limb quite well in running. In dogs which were kiUed from two 
 months to four years after the operation, the resected end of the 
 femur was found rounded off or swelled out into a club-like form. 
 The mass of new bone was usually uneven and tubercular, more 
 seldom smooth ; its form was quite unlike that of the resected head 
 and trochanter. In a few cases the exposed articular surface is 
 said to have been covered with a cartilaginous (?) ^ substance. 
 Usually the acetabulum was deprived of its cartilage and filled up with 
 firm fibrous tissue or a deposit of recent bone. New formation of 
 bone was found also on the bones in the neighbourhood of the 
 acetabulum. The upper end of the femur was situated usually 
 close to the pelvis, either opposite to the situation of the acetabulum 
 or above or behind it. Its union with the pelvis was effected by 
 ligamentous tissue, which was sometimes attached around the end 
 of the femur in the form of a closed capsule normal in appearance, 
 and only much thickened, extending frequently to some distance 
 from the situation of the acetabulum towards the ischium and 
 pubes ; at others (and especially if the suppuration had been great) 
 ran across between the free end of the femur and the pelvis, in the 
 form of a cord made up of numerous bundles. In a case reported 
 by Koeler a quantity of fat was scattered between the separate 
 bundles of this cord. Within this articular capsule a serous fluid 
 was occasionally found. If the contact between the pelvis and the 
 upper end of the femur had been very close, a shallow depression 
 was formed at the adjacent part of the pelvis to receive the clubbed 
 end of the femur. In a case of Wachter's the femur was supported 
 against the outer part of the foramen ovale, which was filled up 
 with a very solid ligamentous material of almost bony (?)i con- 
 sistence. Heine alone gives any observation on the condition of 
 the muscles and their insertion ; the latter had become almost the 
 same as before the operation. In most cases the limb operated on 
 was somewhat shortened. 
 
 The resections of the head of the humerus, performed on the dog 
 by Chaussier and Wachter, had the same results. 
 
 The resections of the lower end of the femur, of the sternum, the 
 ' Tlie query is the Author's. — Trans. 
 
EXPERIMENTAL RESEARCHES THE ENDS OF BONES. 143 
 
 humerus, and the lower end of the tibia, as well as the excisions of 
 the knee- and elbow-joiats, yielded a very unsatisfactory result in the 
 experiments undertaken by Chaussier. Both the soft parts which 
 had been divided and the bones did indeed cicatrize favorably, but 
 instead of forming a new joint the ends of the bones rode on each 
 other, and were united to each other by ligamentous material, so 
 that the part of the hmb below the joiat was pendulous, and quite 
 useless for motion. 
 
 The results of other observers differ from these. After resection 
 of the lower end of the radius, Heine has observed the medullary 
 cavity at the level of the section become closed by bony substance, 
 and a mass of new bone given off from it to support the tendons 
 and to form a joint with the scaphoid bone. After resection of 
 the lower end of the ulna, the periosteum being preserved as 
 far as possible, he found after the interval of a year perfect bony 
 restoration of the resected part. Similarly, Wachter observed, after 
 resection of the lower end of the radius and ulna, that when the 
 wound had healed, at first a firm union was formed with the carpal 
 bones. But the dog would not bear the spUnt, on which the fore- 
 arm had been secured, and ruptured this firm union again. After 
 the paw had been hanging loosely from the forearm for some time, 
 the articulation became gradually firmer, and at length the original 
 usefulness of the extremity was completely restored. In the dis- 
 section, which was performed three months after the operation, a 
 new joint was found surrounded by thick capsule ; the end of the 
 radius had been reinforced by new bony deposit, so as to be nearly 
 as strong as natural; the tendons of the muscles were adherent to 
 the radius and ulna. 
 
 Heine has- observed after extirpation of entire joints in dogs the 
 reproduction of a kind of new joint ; but the utility of the extremity 
 operated upon, even if greater than Chaussier found it was, neverthe- 
 less always limited. Two complete resections of the shoulder-joint, ia 
 which the parts were dissected nearly a year afterwards, showed, one 
 the resected ends rounded off and united by a strong fibrous substance, 
 the other the end of the humerus rounded off and received into a 
 corresponding depression on the scapula, the two being surrounded 
 by a membrane resembhng a capsule, with a meniscus between the 
 ends of the bones, which were covered by a reddish enveloping sub- 
 stance resembhng cartilage. 
 
 The resection of the upper end of the femur together with the 
 
144 ON REPAIR AFTER RESECTIONS OF BONES. 
 
 acetabulum has been found to lead to similar results. In one case 
 the pyriformis and gluteal muscles were found inserted into the upper 
 end of the femur, which was covered by a mass of new bone. A few 
 bony deposits had formed around the acetabulum, and the sections 
 of the pelvic bones, which were rounded off by means of these 
 deposits, were found united by firm fibrous tissue ; the femur was 
 supported against these bones, and was moveable. A strong capsule, 
 containing a serous fluid, surrounded the upper end of the femur 
 and neighbourhood of the acetabulum; it was in part formed and 
 partly strengthened by the agglutinated muscles, more especially 
 the tendinous extremities of the psoas and ihacus intemus. 
 
 After the extirpation of the elbow the animal has been observed 
 to be unable to step with the extremity, eighty-four days after the 
 operation. On the resected extremities new masses of bone were 
 found laid down in a wreath of ii-regular nodules, one of which on 
 the humerus corresponding to the external condyle gave insertion 
 to the extensor muscles, another on the ulna to the flexors, and a 
 protuberance on the radius to the muscles of the paw. The course of 
 the biceps muscle was essentially changed. It was adherent to the 
 pronator teres muscle, which was shortened, and to the flexors 
 of the paw, and inserted on the posterior aspect of the radius. The 
 union of the ends of the bones was effected partly by the remains 
 of the capsule, partly by the muscles surrounding the situation of 
 the joint, united together. 
 
 The resection of the ascending ramus of the lower jaw with its 
 articular process was performed once by Heine. It was followed 
 merely by a deposit of new bone covering the surface of the 
 section. 
 
 II. Resections from the substance of hones. 
 
 The experiments on the healing powers after resection from the 
 substance of a bone, which have been performed on animals, as 
 weU as those (to be presently detailed) on recovery after extirpation 
 of entire bones, have been dicected principally to elucidate the 
 process of regeneration only in the bones themselves. The most 
 important point in this has been to clear up the question as to the 
 organ, or the system of organs, which furnish the material necessary 
 for reproduction of bone. We shall see how far the investigations 
 
EXPEIUMENTAL RESEARCHES — THE SHAFTS OF BONES. 145 
 
 have accomplislied this aim, how far the question may be con- 
 sidered as settled by experiments on the heahng process after 
 resection. 
 
 A. Eesections in long tones. — Klencke ^ and Heine excised por- 
 tions out of the shaft of one of the tubular bones without carrying 
 the section completely through its whole thickness, the former on 
 birds, the latter on dogs, and found in aU cases complete restora- 
 tion of the loss of substance by new bony material. Klencke 
 beheves that the soft parts surrounding the bone, as well as the 
 periosteum, are capable, either of them by itself, of furnishing the 
 exudation necessary for this restoration. The grounds for this 
 assertion are not, however, satisfactory. Thus, he concludes that 
 the exudation is sometimes furnished by the soft parts from this 
 fact : that he has seen, twelve days after the operation, a gelatinous 
 extravasation connected with the soft parts, which was extended 
 across the loss of substance in the manner of a bridge, and showed 
 a fibrous transformation at its edges. That the periosteum alone 
 may furnish the exudation, he concludes from the fact that in 
 another case the periosteum was very vascular and covered the 
 material of the callus, while the soft parts were hardly at all 
 adherent to the bone. 
 
 Klencke has always found the medullary cavity corresponding to 
 the excised portion of bone completely closed by new bony material, 
 and the hole occasioned by the operation materially altered in its 
 form by the absorption of its bony edges. Heine observed only a 
 hardly perceptible narrowing of the medullary cavity corresponding 
 to the situation of the resection. After an operation on the thigh- 
 bone, he found necrosis of the cut edges of the bone, to which a 
 siaus led through the caUus-material which, although the interval 
 was only twelve days, had been already deposited around the whole 
 of the femur. 
 
 After resection of the whole thickness of portions of long bones 
 Heine has observed, as early as about two months after the opera- 
 tion, complete restoration by bony material in all the cases in 
 which he had been careful to save the periosteum, and in the 
 opposite case rounding off of the resected extremities by new bony 
 material, and in operations on hmbs having two bones, union of them 
 to the neighbouring bone on which callus-material was also de- 
 posited. This was either without any connecting tissue between 
 ' Loc. cit., p. 163. 
 
 10 
 
146 ON REPAIR AFTER RESECTION OF BONES. 
 
 tlie euds, or else a fibrous material with nodules of bone deposited 
 in itj uniting the cut ends, which were rounded off, and, in 
 operations on Umbs with only one bone, forming a false joint. 
 The relation of quantity between the fibrous and the bony material 
 deposited around the ends of the bone varied, so that occa- 
 sionally a considerable piece of new bony matter passed out from 
 the surface of one of the sections, and there was only a small interval 
 filled with fibrous substance ; sometimes there was a considerable 
 piece of new bone in the centre, united by fibrous material with the 
 surface of each section ; sometimes the fibrous tissue was by far the 
 most plentiful. In almost all cases a considerable shortening and 
 curvature of the limb injured by the resection had occurred, and 
 this was especially the case in Hmbs with one bone, equally 
 whether the union of the ends of the bone had been effected 
 by new bony matter or by fibrous tissue. In limbs with two 
 bones, a more or less considerable curvature of the uninjured bone 
 had been produced. In most of the cases in which Heine ^ 
 endeavoured to bring the parts together again over pieces of bone 
 which he had cut out and replaced, as, for example, in the ribs, he 
 found a far greater reproductive power in all the parts interested in 
 the operation, and the portions of new bone produced under such 
 circumstances showed in a far shorter time a higher grade of 
 organization than in those cases where the hole in the bone was not 
 filled up again with the excised piece. In these cases the vessels 
 surrounding the situation of the resection were considerably 
 enlarged. Heine believes correctly that the replaced portion of 
 bone acts as a foreign body, and compares the phenomenon in the 
 main to the treatment of false joints by setons. The replaced 
 piece of bone is gradually thrust aside by new products deposited in 
 its place, and thrown out ; in other cases it is encysted in the soft 
 parts, or it may be absorbed. In a few cases this absorption 
 could not be clearly made out, and in these it was doubtful 
 whether the replaced piece of bone had not really become united. 
 
 The observations and experiments of Mourens^ and Syme,* to 
 which latter an experiment of Heine is to be added, are decisive, to 
 a certain extent, as to the periosteum being the principal agent in 
 
 ' 'Graefe u. Walther Journ.,' Bd. xxiv.p. 527. 
 ' 'Theorie experiraentale dela formation des Os,' Paris, 1847. 
 ' " On the Powers of the Periosteum to form New Bone," in ' Contributions 
 to the Pathology and Practice of Surgery,' Edinb., 1848. 
 
EXPEE.IMKNTAL RESEARCHES — THE SHAFTS OF BONES. 147 
 
 the regeneration of the bones. T'lourens observed, after resections 
 from the substance of the ribs, where the periosteum had been 
 spared, the first trace of formation of new bone occurring on the 
 inner surface of that membrane, and on that precise part of it 
 which lay in the middle between the two cut ends of the bone, 
 whence it gradually extended towards those extremities. This 
 experiment, if it be not allowed to be decisive by itself, gains in 
 value from the fact that it agrees with the cases described by 
 Heine, and elucidates them"; those, I mean, in which a considerable 
 piece of new bone covered with periosteum lay between the cut ends 
 of the old bones, and was united with the cut surfaces by fibrous 
 substance. Still more important is the following well-known 
 experiment of Flourens, to which I will here merely allude. He 
 bored a hole down to the medullary cavity of a bone, and placed a 
 silver tube within it. The periosteum and medullary membrane 
 became tumefied, and projected into the tube, and then a piece of 
 new bone was formed within the latter. 
 
 Syme excised on two occasions a portion of each radius of a dog 
 an inch and three quarters in length. In one leg he took away the 
 periosteum with the bone, in the other he took the greatest care to 
 preserve it. Six weeks later, in the leg in which the periosteum had 
 been removed with the bone, the ends of the bone were conical and 
 pointed, and united by a fibrous cord ; on the other leg, where the 
 periosteum had been preserved, the whole loss of substance had been 
 repaired by a copious and even superabundant deposition of bone. 
 
 Syme has discovered a further proof of the conclusion which 
 follows from this description in two experiments, which do not, 
 indeed, belong to the class of resections, but which must be men- 
 tioned here because they combine with an experiment of Heine, 
 to afford an answer to the question as to the activity of the perios- 
 teum in the regeneration of bones. On a dog the periosteum was 
 carefully separated from the radius, and a metal plate thrust in 
 between the membrane and the bone ; while, in the other experi- 
 ment, the separated periosteum was removed, and the exposed bone 
 merely covered with a plate of metal. Six weeks afterwards there 
 was found in the first case, above the metal, a plate of new bone, 
 which had no connexion with the old bone ; in the second case 
 only a thick, tough capsule, without a trace of bony substance. 
 Heine observed the same things in the femur of a dog as Syme did 
 in the first case. The piece of bone was denuded of periosteum. 
 
148 ON REPAIR AFTER RESECTION OF BONES. 
 
 and a longitudinal incision was made into it down to the medullary 
 cavity ; a piece of linen was then laid between the periosteum and 
 the bone. Twelve days afterwards the whole shaft of the femur had 
 become necrosed, and was surrounded by a capsule of new bony 
 material, which above and below the piece of linen was in connexion 
 with the bone, but in the part occupied by the foreign body was 
 separated by the latter from the surface of the bone, and was 
 covered in every part with highly injected periosteum. On the 
 portion of bone enveloped in the linen no trace of new formation of 
 bone could be detected. If we bring these facts into connexion with 
 the researches of other experimenters on the activity of the peri- 
 osteum in the formation of bone after fractures and in necrosis, we 
 cannot hesitate to decide in favour of the view that the periosteum 
 plays the principal part in the process of the regeneration of bone. 
 We shall see further on whether this principal part is to be held as 
 an exclusive one, or, if not, what limits are to be assigned to it. That 
 it cannot be exclusive, is proved by a single experiment reported by 
 Michaelis Medici.^ After the resection of a piece, an inch in 
 length, out of the &st false rib of a sheep, in which the periosteum 
 and a portion of the intercostal muscles had been removed with the 
 bone, the loss of substance was found fully replaced about four 
 years afterwards. The new piece of bone was thinner, but broader, 
 than in the healthy condition, and was pierced by small openings 
 in three places. Its outer surface was rough, the inner quite 
 smooth. The structure of the new bone was indistinguishable on 
 a section from that of the old. The new portion of bone had been 
 enclosed again in a fibrous membrane. It is a singular fact, that 
 the new piece was two and a half inches in length, while the 
 piece which had been originally removed was only one inch long. 
 The circumstance that the sheep was only fourteen months old at 
 the time of the operation, and afterwards grew very considerably, 
 must be accepted as an explanation of this fact. The consequence 
 must have been either an equal growth of the reproduced portion 
 and the orginal rib, during the growth of the animal, or, perhaps, 
 an excessive growth of the reproduced portion. I have observed in 
 the human subject a case which may be placed by the side of the 
 above. Professor Langenbeck excised, on a boy, a piece out of the 
 substance of the lower part of the shaft of the humerus. The opera- 
 
 ' ' Novi Comment. Bononienses,' torn. ii. 
 
EXPERIMENTAL KESEABCHES — FLAT BONES. 149 
 
 tion resulted in complete regeneration of the bone, with perfect 
 use of the arm, which was shortened three quarters of an inch. 
 About a year and a haK after the operation the boy was attacked 
 by a violent gastric fever. He grew during and after this time very 
 quickly, and when a short time afterwards I repeated my measure- 
 ments, which had been taken on many previous occasions, I could 
 no longer discover any trace of shortening of the arm. 
 
 B. Resection from the svhstance of flat hones. — ^The healing pro- 
 cess after resections from the substance of the cranial bones is what 
 has most interested the various observers on this head. Their views, 
 however, especially on the subject of repair of loss of substance by 
 bony material, and the conditions on which this is dependent, are 
 at variance with each other. Dubreuil' considers that the regenera- 
 tion of the bone is. dependent principally on the integrity of the 
 pericranium and dura mater after the operation. When this in- 
 tegrity was maintained, he found the roand opening made in tre- 
 phining, when not very large, filled up by a bony pad, which was 
 occasionally united by fibrous tissue to the edges of the old bone. 
 Without the preservation of the pericranium or the dura mater the 
 hole in the bone was closed only by a iirm cicatricial tissue. He 
 attributes also to the vessels of the bone a share in its reproduction, 
 but without showing us on what he founds that opinion. Heine's 
 views agree in the main with these, only he attributes a greater 
 influence in the regeneration of the bone to the diploic substance of 
 the cranial bones, after the pericranium and dura mater, than 
 Dubreuil does. According to him, wlien the pericranium and dura 
 mater had been preserved, but the diploe was very scanty, the closure 
 of the hole in the bones by new bony material was only imperfect ; 
 when one only of these two membranes was wanting, while the 
 diploic tissue was abundant, the regeneration of the bone was com- 
 pletely effected; but when both the pericranium and dura mater 
 were wanting, even when the layer of diploe was a thick one, the 
 greater part of the loss of substance was closed by fibrous tissue, in 
 wliich numerous granules of bone were deposited, and new bony 
 material was found deposited only around the edges of the bone, in the 
 form of needles, or as a thin rim around the opening. 
 
 The dura mater appears, according to experiments on animals, to 
 
 ' 'Presse M6dicale,' 1837, No, 57. 
 
150 ON REPAIR AFTER RESECTION OF BONES. 
 
 be of more importance than the pericraninin in the reproduction of 
 bone. This might even have been assumed h priori from its greater 
 vascularity; still the observations on the human subject, which 
 have been mentioned above, ^o not favour this idea and do not 
 agree with the results of experiments on animals. Thus, in animals 
 where only a piece of the external table and diploe has been re- 
 moved, the pericranium being preserved, the restoration of bone in 
 places where the diploe was scanty has been observed to be more 
 sparing than when the same loss of substance has been extended, 
 under the same circumstances, through the whole thickness of the 
 cranial bones. If, in the same trephine-hole, the internal table has 
 been removed in one part and left in another, in the part where the 
 latter has been the case the deposit of new bony material is less con- 
 siderable than in the part of the wound where the vitreous table has 
 been also removed. Simple cuts, too, penetrating through the 
 whole thickness of the skuU, have been observed to heal by bony 
 union, while after cuts involving only the external table and diploe, 
 it has been often found (and especially if the layer of diploe were 
 only thin) that there was nothing except fibrous material between 
 the edges. If the pericranium has been preserved, it unites firmly 
 to the substance which closes the hole in the bone ; if it has been 
 removed in the operation, it is completely regenerated. The newly- 
 formed portion is found in the form of a strong membrane con- 
 tiuuous with the uninjured pericranium at the edges of the section ; 
 it may be separated from the material which fills up the opening in 
 the bone. Deficiencies of the dura mater, on the other hand, are 
 not repaired. The edges of the wound in the dura mater usually 
 unite to the other membranes of the brain, or to the bones. The 
 brain protrudes through the hole in the dura mater into that in the 
 bone, and becomes iiitimately united to the membrane which closes 
 the latter. When the dura mater is preserved at the operation it 
 usually unites iirmly around the opening to the bony edge, and 
 sometimes there is found, in the situation of the loss of substance 
 in the bone, intimate union of the membranes to each other and to 
 the brain. The brain is then much reddened at this part. 
 
 Necrosis and exfoliation of the bony edge has not been frequently 
 observed. When it has, it has usually attacked only one, and 
 generally the outer, table of the bone. If the hole has been closed 
 entirely by new bone, the cut edges of the old bone were not to be 
 distinguished from the new j wliile when the reproduction of bone 
 
EXPERIMENTAL RESEARCHES FLAT IJONES. 151 
 
 has been partial only, the edges of the old bone have usually been 
 foimd rounded off. If one of the cranial sutures has been cut 
 across in the operation, it is not reproduced in the bone which re- 
 places the loss of substance. 
 
 It occurs only ia the rarest cases that the excised piece of bone 
 unites again when replaced. Merrem^ and Klencke^ have seen 
 this. Kleine has never convinced himseK of it. In one case it was 
 doubtful whether this union had taken place, or whether, as it 
 usually happens, the piece replaced had become necrosed and exfo- 
 liated without being perceived, while the hole in the bone had been 
 filled up by bone newly deposited. 
 
 It may be observed further that Heine believes from his experi- 
 ments that the triangular form of the trephine-hole is more favor- 
 able to its complete closure by bony material than the circular 
 
 Koeler^ is the only author who has endeavoured to investigate 
 the healing process after trepliining in. its separate stages. His 
 observations are indeed very imperfect, but they deserve notice as 
 being the only ones on record. He trephined a dog over the 
 sagittal suture, preserving the pericranium, and observed on the 
 fourth day the dura mater and the edges of the opening in the bones 
 covered with a sticky, gelatinous, reddish material, which gradually 
 increased in quantity and became whiter. In the course of the 
 third week the hole was almost closed by new substance, derived as 
 well from the dura mater as from the edges of the bone. A portion 
 of the outer lamella of the parietal bone exfoliated about this time. 
 About the same time the edges of the wound cicatrized firmly 
 together. The dog was killed at the end of the seventh week. The 
 opening was filled with a material which was cartilaginous in the 
 rest of its extent, and bony on the edges only ; this could not be 
 forced out of the opening, but was thicker than the rest of the 
 bone : the pericranium and dura mater were firmly united to it. 
 There was no trace of a suture in it. In the same way, after re- 
 moval of the anterior waU of the frontal sinus, the edges of the 
 opening were covered ia the days immediately following the opera- 
 tion with a glutinous mass, which was shown, by the dryness of the 
 inflamed mucous membrane, not to proceed from that source. It 
 
 ' • Hildebrand Anatomic von Weber,' I. S., 354. 
 ° Loc. cit., p. 199. 
 ' Loc. cit. 
 
152 ON EEPAIE AT'TEB UESECTION OF BONES. 
 
 gradually increased, so that fourteen days after the operation the 
 opening was already sensibly diminished. Its sharp edges also 
 were even at this time rounded off. Prom the twenty-fourth day 
 the union of the skin with the parts lying below it became so inti- 
 mate, that soon it no longer allowed the opening to be inspected. 
 The result was a complete closure of the opening, after the eighth 
 week, by a bony material, still soft and resembhng cartilage in its 
 centre, which was thicker than the normal skull-wall, and was 
 covered on its outer side by not very thick skin, but had no pro- 
 longation of the mucous membrane on its inner surface. 
 
 Eesections in the substance of any other flat bones except those 
 of the cranium have been performed extremely seldom. Murray^ 
 excised a triangular piece from the breast-bone of a pigeon, taking 
 away the periosteum. Several weeks afterwards the loss of sub- 
 stance was almost entirely closed by deposit of bone, which was 
 much thicker than the natural sternum, and overlapped the edges 
 of the section in places. He holds the muscles to be the source of 
 the reproduction, and explains from this their intimate union with 
 the new bony material. 
 
 After resections from the substance of the horizontal ramus of the 
 pubes and of the symphysis, Heine has observed merely rounding off 
 of the edges of the sections by a deposit of new bone, without any 
 union between them having been effected. After an operation on 
 the tuberosity of the ischium and the iHum, a fibrous union was 
 formed between the cut extremities, with deposition of granules of 
 bone. After the resection of the tuberosity of the ischium, new 
 bony material was deposited also on the os pubis in the neighbour- 
 hood ; the pelvis was contracted in the oblique diameter. 
 
 c. Resection from the substance of short lanes. — No resections 
 have been performed in animals on the short bones except on the 
 vertebrae. The result of resections from the vertebrae have been 
 hitherto very discouraging. 
 
 In twenty-four cats and ten dogs, on whom Heiue^ performed 
 this operation, it had uniformly a fatal result. Two dogs only, not 
 
 ' 'Edinb. Med. and Surg. Journal,' October, 1831; 'Archives g^nfir. de 
 M^d.,' xxvii, 1831. 
 
 ^ A. Mayer, " Die Resection der Wirbelknochen bei Knochenbriichen der 
 Wirbelsaiile," 'Walther u. Ammon Journal/ 38 Bd. ; N.T., 8 Bd., 1848. 
 
EXPERIMENTAL RESKARCHES — EXTIRPATION OF BONES. 153 
 
 included in this list, recovered. In one of them, after resection of 
 the arch of the vertebra, when the dura mater was cut through, a 
 portion of the spinal cord protruded. This was cut away, and yet 
 the animal is reported to have recovered without any paralysis re- 
 maining. The hiatus left by the removal of the arch of the ver- 
 tebra was closed by a firm cicatricial tissue, intimately united to the 
 cicatrix of the skin. After resection of a spinous process, the cut 
 end became pointed off, without any formation of new bone having 
 taken place. 
 
 After resection from the substance of the horizontal ramus of the 
 lower jaw, without complete division of its whole thickness, Heine 
 observed, two months and a haK afterwards, perfect reparation of 
 the defect by new bony material. The cut fangs of the teeth were 
 unaltered. 
 
 III. Extirpation of Bones. 
 
 Heine is the only experimenter who has performed extirpation of 
 bones. The operation was performed on dogs. In his operations 
 he generally separated the periosteum in the most careful manner 
 from the bone, and left it behind in the wound. His observations 
 show the possibihty of restoration of the removed bone by bony 
 material, which indeed does not usually resemble the extirpated 
 bone perfectly in form and size, but still has been found sufficient 
 to re-establish the solidity and usefulness of the limb. The irregular 
 processes which frequently form upon new bones, and usually serve 
 for the insertion of muscles, cannot, to judge from the representations 
 which Peigel' gives, be compared without some stretch of fancy 
 with the natural processes and irregularities of the extirpated bone, 
 although a few cases may perhaps be so explained. The joint-ends 
 of the new bones at least had assumed the form of the extirpated 
 articular processes — an observation which applies quite universally, 
 and which Textor also made after resection of the extremities, and by 
 which he refutes the counter-assertion of Caspari. 2 
 
 "WTien the periosteum had been removed with the bone, the 
 reparation by new bone has been found to be extremely scanty, even 
 after a long period. Separate kernels of bone have been found 
 
 ' Loc. cit. 
 
 3 "Ileber die Entsteliung der Knochenkrankheiten," 'Graefe u. Waltlier 
 Journal,' Bd, v. 
 
154 ON REPAIR AFTER RESECTION OF BONES. 
 
 among the soft parts, and the latter have been soldered together into 
 a firm cicatrix. 
 
 The symptoms which followed immediately after the operation 
 have been, considerable swelling and infiltration of the soft parts, with 
 a reddish-brown serous exudation, especially if the inflammation has 
 been raised to a high degree by the replacement of the extirpated 
 bone. Copious suppuration has followed this, and the wounds 
 healed by granulation. If the inflammation have not been very 
 considerable, the periosteum, when examined so soon as the first 
 few days after the operation, is found swoUen, of a lively red colour, 
 penetrated with numerous fine injected vessels, and between its 
 lameUse a brawny, reddish material. Some time later a few bony or 
 cartilaginous nuclei were found deposited on the interior of the 
 periosteum, which gradually enlarged, and in the end united 
 together into a single bony mass, or were joined together by strong 
 fibrous membrane. The new bony material, when examined at a 
 comparatively early period, was entirely solid j later on, traces of a 
 new medullaiy cavity appeared, partly ceUular, and covered over with 
 a dehcate reddish-brown membrane, and with bony tissue in its 
 interior containing marrow. Heine has observed this medullary 
 cavity developed, though to a limited extent only, throughout the 
 whole extent of the bone. Usually, after extirpation of a long bone, 
 the new bone is considerably shorter than the one extirpated. After 
 the extirpation of one bone only, in a limb containing two bones, 
 the one left behind has been frequently found to be covered with 
 new bony material, which might be removed with some force, and 
 showed the surface of the bone smooth below it. In these cases 
 also the limb was generally a good deal shortened, while the bone 
 which was left behind assumed a proportionate curvature. Con- 
 tractions of the neighbouring joints were more remote consequences 
 of these shortenings. After extirpation of both bones of a Umb, 
 reproduction of two bones separated from each other has occurred, 
 and these have been found soldered together at a few points only. 
 
 The periosteum, frequently thickened, clothed the new bone. 
 The muscles were inserted with it into the bone in tolerably natural 
 order ; they were contracted in proportion to the shortening of the 
 limb, and attached as well to the other parts along the whole lengtli, 
 as especially to the irregular prominences of the bone. If perfect 
 bony reproduction had not occurred, the muscles were found inserted 
 also into the fibrous or cartilagiaous parts which were covered by 
 
EXPERIMENTAL RESEARCHES EXTIRPATION OF BONES. 155 
 
 periosteum. The play of the nniscles was hardly prevented by 
 their being adherent to each other. If processes of the extirpated 
 bone had served as supports or pulleys for particular tendons, these 
 were replaced, if not by new bony processes, yet in this way, that 
 fibrous sheaths had been formed on the new bone, in which the 
 tendons enjoyed a certain degree of motion from side to side. Heine 
 observed after an extirpation of the fibula with its periosteum this 
 state of things in the tendons of the peronei muscles, where they 
 pass round the outer malleolus. 
 
 The articular ends of the new bones were found covered on the 
 side turned towards the articular surface of the neighbouring bone 
 with a strong and smooth fibrous or cartilaginous (?)i covering. 
 Lying on the articular cartilage of the adjoining bone were found 
 remains of the old articular capsule, or a thin, cellular tissue, which 
 was continuous with a short, strong, fibrous cord passing to the 
 newly formed bone. In other cases a new articular capsule was 
 formed around the contiguous ends of bone, covered with a smooth 
 synovial membrane, and containing a fluid resembling synovia. In 
 a newly formed joint of this kind, between the lower end of the 
 femur, which had been reproduced after extirpation and the upper end 
 of the tibia, even the crucial ligaments were found again. Sometimes 
 a tolerably large space was found between the newly formed bone 
 and the adjoining normal articular surface. In these cases the bone 
 was prolonged into a very strong, but flexible, cord, which was con- 
 nected by a soft, fibrous tissue to the adjoining articular surface. 
 This was the method also of connexion found between a newly 
 formed rib and the costal cartilage. In rare cases there lay between 
 the articular surfaces of the newly formed and the uninjured bone a 
 meniscus, about aline in thickness, which, however, probably con- 
 sisted of fibrous tissue. 
 
 The above results apply equally to the extirpation of long, flat, 
 and short bones. After the extirpation of the calcaneum, reproduc- 
 tion of bony material took place. This served for the insertion of 
 the tendo AchiUis, and articulated with the adjoining articular 
 surfaces, the Hmb being perfectly useful. 
 
 To sum up shortly the results which have been obtained by 
 the different experimenters on the healing process after resection, in 
 respect to the regeneration of bones, and in respect to the tissues 
 ' The query is the Author's. — Tkans. 
 
156 ON REPAIR AFTER RESECTION OF BONES. 
 
 wMcli take part in this process by means of their blood-vessels, we 
 obtain the following results. 
 
 I. The periosteum plays the principal part in the repair of the 
 deficiency of bone caused by resection, to such an extent that it is 
 sufficient of itself to form new bony material, which may replace the 
 bone removed. In the cranial bones it is probable that the dura 
 mater takes the part of the periosteum. 
 
 3. Nevertheless, reproduction of bone, although only in a sHght 
 degree, may take place even without periosteum. 
 
 3. This reproduction proceeds — r 
 
 {a) Prom the medullary cavity, or from the diploe, in proportion 
 
 to the extent to which they remain uninjured ; 
 {b) From the soft parts which surround the bones. 
 
 4. The substance of the bone itself does not appear to contribute 
 to the reproduction of bone. Klencke is the only author who 
 expresses the opposite view. He also describes that in the process of 
 exudation from the substance of the bone a partial softening of the 
 latter occurs. 
 
 5. The exudation necessary for the regeneration of the bone 
 appears to be furnished by inflammation of the parts above men- 
 tioned. Irritants, which heighten the inflammation, heighten also 
 the process of reproduction. 
 
 6. The exudation is at first reddish, viscid, or gelatinous, and goes 
 through the steps of cartilaginous development before it changes 
 into bone. 
 
 7. The newly formed bony material is at first solid, and it is 
 not tin after the lapse of some time that a medullary cavity may be 
 found formed in it. 
 
 8. It is only in the rarest cases that the deficiency of the bone 
 is repaired entirely, or sometimes even in excess. Still more 
 seldom does the mass of new bone possess the form of that which 
 was removed. If the repair of the deficiency be entirely by bone, 
 still there is a difference in quantity between the new mass and the 
 resected bone, which is compensated only by approximation of the 
 sections of the bone, with corresponding shortening and curvature of 
 the limb. If this approximation has not taken place, or if from 
 other causes the mass of newly formed bone is not sufficient fully to 
 replace the deficiency, either the loss of substance remains per- 
 manently, or a fibrous material is laid down in its place, in which 
 separate bony nuclei are'often deposited. 
 
CHAPTEE III. 
 
 ORIGINAL EXPERIMENTS AND ANATOMICAL INVESTIGATIONS 
 
 ON ANIMALS. 
 
 Befoee passing now to the description of my own experiments and 
 dissections of animals, I must preface the chapter with a few words 
 of explanation and apology. I hesitated for some time as to 
 whether it would be necessaryj or indeed whether it were worth 
 while, to relate each experiment by itseK and give the anatomical 
 details of the dissections belonging to each, and so to make this the 
 preface to my views on the healing process after resection; or 
 whether I should merely set out in order the results derived from 
 these investigations. I have determined on the latter plan ; because, 
 having commenced my work on the former, I found it impossible to 
 avoid continual and extensive repetitions; and, even where the 
 healing process was most various, the description of its leading 
 symptoms became tediously monotonous ; and I found also, when I 
 had written the following chapter, that it contained, in a complete 
 and elaborate form, all the material which was scattered about in 
 the description of the particular experiments, and that thus nothing 
 was gained for the understanding of the healing process from the 
 enumeration of all the experiments on which my conclusions rest 
 beyond what is contained in the sequel. Fearing, therefore, that to 
 expressly describe each individual experiment would have no effect 
 beyond making my work more voluminous, I expunged that section, 
 and have given at the end an account of only those experiments 
 from which the drawings were made, in order to render the latter 
 more intelligible. 
 
 My experiments were performed upon rabbits and pigeons. They 
 relate principally to resections of the extremities and in the substance 
 of bones. Some extirpations of bone are also included in the same 
 experiments. I hoped to discover the chief varieties of the healing 
 
158 ON RISPAIU AFTER RESECTION OF BONES. 
 
 process, keeping in view especially the defects of the after-treatment 
 in animals, by so conducting my operation, as — 
 
 1st, to bring an articular surface covered with cartilage opposite 
 the cut surface of the bone, and for this purpose I resected the head 
 of the humerus only ; or — 
 
 2d, to bring the two cut surfaces of one or two bones opposite 
 to one another. Tor this purpose I resected from the shaft of the 
 radius. 
 
 I selected this bone because, after its division, the ulna offers a 
 firm support, which secures as perfectly as possible the immobility 
 of the resected ends of the radius. In order to secure still further 
 the repose of the extremities on which the operation was performed, 
 I always, in rabbits and pigeons, chose the anterior extremity for the 
 operation, because rabbits make less use of it in running than of 
 the posterior extremities, and because in pigeons we find a firm 
 support for the Hmb operated upon on the trunk, by tying the wings 
 together. It happens also in rabbits that the animals for the most 
 part carry the bone operated upon in a hanging position, and drawn 
 towards the body. 
 
 I made the resections of the head of the humerus for the most 
 part on rabbits. The operation is, in the first place, more easily 
 accomplished in these animals than in pigeons, and the anatomical 
 relations of the shoulder-joint in rabbits are much more similar to 
 those of man than is the case in pigeons. In the latter the articular 
 head of the humerus is wanting, at least in the rounded form j the 
 bone is at its upper and very broad end provided with a small', 
 oblong, articular surface, forming a very shght prominence, which 
 articulates with the very small articular surface formed by the 
 scapula and coracoid bone. Besides this the humerus in pigeons is 
 filled with air, and injury of the air-ceUs which open into it cannot 
 be avoided in the resection of the upper end, a circumstance, 
 however, which produces no morbid change appreciable either 
 during life or on dissection. 
 
 The resections from the shaft of the radius and the extirpations of 
 this bone I performed chiefly in pigeons. The bones of the forearm 
 in rabbits lie so close to one another that it is very diflicult and 
 requires great caution to resect the radius without cutting into the 
 ulna, or even carrying the incision through the whole thickness of 
 that bone. Thus it happened sometimes that I resected a piece 
 from the radius and the ulna at the same time without intending to do 
 
author's experiments on animals. 159 
 
 so. In pigeons the bones of the forearm lie so far from one 
 another that the operation can be performed with greater facility. 
 It was for the same reason that I extirpated the radius in these 
 animals. The great interval between the radius and the ulna in 
 pigeons has, however, this disadvantage, — that after the division 
 of the radius the ulna is no longer able to secure ' completely the 
 immobility of its fragments. I have only once extirpated the 
 radius and the uhia together in a rabbit. The animal died a few 
 days after the operation. 
 
 The resection of the head of the humerus in rabbits I performed 
 in the following manner : After the hairs were shorn off I cut 
 through the stin and the muscles on the anterior part of the joint, 
 near its middle Hne, by an incision about an inch long, running in 
 the axis of the humerus from the edge of the articular surface of the 
 scapula to a point below the articular head. The shining white 
 capsule of the joint thus exposed to view was opened by an incision 
 running transversely across the head of the bone; the head was 
 rotated outwards, and the muscles attached to the smaller tubercle 
 were cut through close to that prominence ; then the head was 
 twisted inwards, and the muscles were separated from the greater 
 tubercle. The luxation of the head and its complete separation from 
 the soft parts were then effected with facility by incisions carried 
 behind the bone. Lastly, the head, being fixed by a vulsellum, was 
 sawn off either alone or with a portion of the shaft. The tendon of 
 the long head of the biceps lies so far inwards and forwards, and 
 slips with such facihty out of the very flat inter-tubercidar furrow, 
 that it often did not come iuto view at aU during the operation, and 
 was never injured. The greater vessels and nerves were hardly ever 
 cut, and the bleeding was almost always quite insignificant. 
 
 Por resection from the shaft of the radius I penetrated, after 
 the skin was shorn or deprived of its feathers, through a muscular 
 interspace to the bone. The muscles were held aside with fine 
 forceps. "When the bone was exposed I either separated the 
 periosteum, after having divided it to the extent of the portion to 
 be excised, taking the greatest care of it, an object which I was 
 able to accomplish pretty well after some practice, or I cut through 
 the periosteum, transversely in the parts of the bone to which the 
 saw was to be applied. By a ribbon pushed under the portion to 
 be removed the soft parts were carefully protected, and the bone was 
 sawn through upon it. Splinters of bone which remained upon 
 
160 ON REPAIR AFTER RESECTION OF BONES. 
 
 the sawn surface were removed by the bone-nippers. Bruising 
 of the soft parts can never be avoided without the protection of 
 the ribbon, but it especially takes place when the space between 
 the ulna and the radius is so narrow as it is in rabbits, in whom it 
 occurs to some extent even when the ribbon has been pushed 
 through. 
 
 The extirpation of the radius I performed in a manner precisely 
 similar. I did not spare the periosteum in this case. The bone 
 being laid bare, I sawed it through in the middle, and then dis- 
 articulated its upper and lower end. 
 
 The great vessels and nerves were hardly ever injured in these 
 operations, and the bleeding was always very inconsiderable. 
 
 At first I always brought the wound together by the interrupted 
 suture. Perceiving, however, that a firm cohesion of the edges of the 
 wound was attained, but that the suppuration underneath was not 
 diminished, and also that the deficient discharge of the exudation, 
 which was at first bloody and serous and very copious, and after- 
 wards purulent, was the cause of large purulent accumulations, and 
 perhaps of the remarkable mortality of the animals after the opera- 
 tion, I no longer brought the wounds together. The resected ends 
 of the bones were pushed as deep as possible under the soft parts, 
 and I then closed the wounds in rabbits by lightly twisting together 
 the hairs, and it was only in a very few cases that I observed pro- 
 trusion of the bones through the wound. The proportion of 
 mortality was thenceforth much more favorable, especially when I 
 at first cleaned the wound daily with water, and procured by incisions 
 an exit for collections of serous fluid or of pus in the remoter 
 parts. 
 
 Except this there was very little to be done in the after-treatment. 
 A firm bandage which I tried to apply in various ways was never 
 tolerated by the animals, and was soon gnawed and torn off. The 
 only form of bandage which I have not tried, because I unfortunately 
 thought of it too late, is enveloping the whole extremity in plaster 
 of Paris. I do not know whether it would have answered better 
 than those which I did try. They were the following : wrapping 
 the limb and the greater part of the trunk in bandages with or 
 without paste, and with or without splints ; applying splints with 
 several roUs of sticking plaster ; or enclosing the extremity in a case 
 of gutta percha, secured by pasted bandages. If the bandage 
 adhered, it was generally so firm that I was obliged to remove 
 
author's experiments on animals. 161 
 
 it on account of oedema and considerable swelling in the parts 
 around it, and from apprehension of gangrene. The animals 
 remained most quiet when I was able to shut them in separate, 
 and as far as possible, darkened rooms. But I was soon obUged to 
 give up this plan, because in these conditions they became more out 
 of health, and died more frequently than ia other cases. 
 
 I have consequently never succeeded in obtaining an immoveable 
 condition of the parts concerned ui the operation, and I do not 
 venture to assert that aU the means tried by me have so far fulfilled 
 their aim as to secure a degree of immobility such as would even 
 approximate to that which is possible after resection in man. 
 
 Pigeons bear resection much better than rabbits. Out of 
 twelve pigedns none died, while, on the other hand, of forty-five 
 rabbits I lost twenty-one. Death occurred sooner or later after the 
 operation, often from six to seven weeks. I found in these cases 
 generally after resection of the head of the humerus, extensive 
 accumulations of pus in. the subcutaneous areolar tissue and the 
 muscular interstices, not only on the Hmb which was operated upon, 
 but also along the infra- and supra-spinous fossa, on the breast, and 
 thence sometimes even along the whole of the upper extremity wliich 
 was not operated upon, but more commonly along the abdomen as 
 far as the parts of generation. Almost always there was more or 
 less of recent adhesion between the layers of the pleura, serous 
 exudation into the pleural cavities, adhesion of the pericardium to 
 the heart (the most beautiful instances of villous heart), and indurar 
 tion and formation of abscesses, or extensive deposition of tubercles, 
 principally in the upper lobes of the lungs, and sometimes in the 
 muscular substance of the heart. The veins on the hmb operated 
 upon, traced as far as the heart, never exhibited morbid changes. 
 The organs of the abdominal cavity were always sound. Only twice 
 I found in the liver the bodies described by Kauffenann,^ and usually 
 considered as itch-sporules ('psoro-spermien'), in small, scattered, 
 white pustules. After resection from the shaft of the radius death 
 followed much more rarely. In these cases the accumulations of 
 pus were absent, but on the other hand we found changes dependent 
 upon inflammation of the thoracic organs. 
 
 When death followed in a shorter time after the operation, no 
 
 ' ' Analecta ad Tuberculorum et Bntozoorum cognit ionem,' Dissert, inaug., 
 Bcrol., 1847. 
 
 11 
 
162 ON RKPAIB AFTER RESECTION OF BONES. 
 
 trace of the regeneration of the loss of substance was discoverable in 
 the parts concerned. A grayish or greenish-white viscid fluid 
 covered uniformly the bone and the soft parts in the vicinity of the 
 wound. The soft parts were sometimes rotten and brittle, and infil- 
 trated by the same viscid fluid. If a longer time had elapsed between 
 the operation and the death of the animal, the products of the 
 healing process were always present in the injured parts, but they 
 were for the most part essentially inferior in their development to 
 those which I found in animals which had remained comparatively 
 healthy and had been killed at the same time after the operation. 
 The healing process in such cases was not remarkably altered by the 
 illness of the animal, but was remarkably retarded. A few pecu- 
 liarities which were found in them do not essentially deviate from 
 the normal phenomena of the healing process, and will be treated 
 of in the sequel as varieties of that process. 
 
 Desceipxion Of THE Healijjg Peocess, from OKIGINA];/ 
 
 KESEAKCHES. 
 
 I, Resection, of the extremities of lones. 
 
 In most cases the inflammatory phenomena after resection of the 
 extremity of a bone attain a very great height. They usually disappear 
 with the commencement of the suppuration, which remains of a lauda- 
 ble character and moderate, if the secretion have free exit ; but, if that 
 is not the ease, the inflammatory symptoms persist, and the suppura- 
 tion becomes very abundant and spreads rapidly. I have never seen 
 union by the flrst intention. I have indeed observed the union of 
 the wound in the soft parts by first intention when brought together 
 by sutures, but I can only look upon this occurrence as unfortunate, 
 since under the united soft parts the inflammation passed on into 
 suppuration, and thus the further progress of the case was less 
 favorable than it would otherwise have been. Steinlin has observed 
 union by first intention in two cases of removal of the head of the 
 tibia and fibula in the knee-joint. The final results in these cases 
 were no better than in those where healing by the second intention 
 occurs with free exit for the secretion. 
 
 In the fiirst few d9,yg after resection of the extremity of a bone, 
 and frequently after the first twelve hours, a considerable swelling 
 
DESCRIPTION OF THE PROCESS. 163 
 
 is observed around the situation of the resection, which fluctuates, 
 and is usually very painful to the touch, and consists partly of the 
 tumefied soft parts surrounding the joint, partly of extravasated blood, 
 but principally of an abundant serous exudation stained with blood. 
 This is especially abundant if the wound of the operation is firmly 
 closed, and quickly subsides if exit is afforded to the fluid. If 
 this is not done, the swelling gradually increases, the exudation 
 infiltrates the subcutaneous cellular tissue, as well as that between 
 the muscles; and a few days after the operation the whole ex- 
 tremity, and often the neighbouring parts also (especially the 
 chest), are found very tense, oedematous, and extremely painful. 
 In rare cases it occurs that during the following days the inflam- 
 mation subsides, and a more or less complete absorption of the 
 exudation occurs ; but usually the latter is converted into pus, and 
 thus gives occasion to the very considerable infiltration of pus 
 which I have before mentioned. The swelling becomes about this 
 time of a doughy consistence, and less painful. Later on, in the 
 case of rabbits, the pus, which is thick from the commencement, 
 acquires continually more consistence at the part where it is collected, 
 and becomes dry and crumbly : the swelling has by this time 
 become hard to the touch and gradually painless. In this case 
 there are found occasionally a series of abscesses lying close together, 
 often communicating with each other, and encysted in a firm 
 fibrous membrane. Occasionally the pus find a way to the exterior j 
 and then the skin in the neighbourhood of the opening is ulcerated 
 to a greater or less extent. 
 
 Another cause of the infiltrations of pus is the extravasation 
 of blood which immediately follows the operation. This comes 
 apparently from the vessels cut through in the operation — ^it is 
 found, however, to an astonishing extent partly in the subcutaneous 
 cellular tissue, partly in the interstices of the muscles. I have 
 found it almost constantly after resection of the head of the 
 humerus, along the humerus, and in the supra- and infra-spinous 
 fossa, and more rarely in the subscapular fossa also. Its conversion 
 into pus occurs gradually. 
 
 In the human subject it seems that the oedematous swelling of 
 the extremities and the infiltration of pus occur much less conunonly 
 after resection of the extremities of bones ; still examples of these 
 are found in the histories of cases. Seutin especially contributes a 
 case of resection of the head of the humerus, in which consider- 
 
J 64 ON REPAIR AFTER RESECTION OF BONES. 
 
 able infiltrations of pus occurred in exactly the same situations 
 in wiicli I have observed them after the same operation in rabbits, 
 and in which death was caused by pleuropneumonia. SteinHn 
 informs me that he has seen the same appearances after resection of 
 the upper extremities of the tibia and fibula in the rabbit, but not 
 frequently, and always confined to the leg and foot. 
 
 The swelling of the soft parts in the neighbourhood of the resected 
 joint gradually disappears. The muscles surrounding the joint, 
 which are partly cut through, partly uninjured, are at first only 
 loosely united together; later, about the sixth or eighth day, they 
 are ihore or less closely incorporated, especially in the parts imme- 
 diately adjoining the cavity of the wound ; and form, by taking an 
 insertion around the articular surface which has not been removed, 
 and into the resected bone below the level of the section, a firm 
 capsule, which, if the wound made in the operation has united, is 
 an entirely closed one. 
 
 Immediately after the operation the cavity, which it has occasioned, 
 is lessened by the contraction of the muscles approximating the 
 resected bone to the uninjured articular surface. It is exceedingly 
 difficult to practise measurements of the shortening thus produced 
 in such a way that they 'shall give an absolutely accurate result. 
 On an average I have found, after resection of the head and a 
 portion of the shaft of the humerus, a piece on the whole six lines 
 long, a shortening of four Hues. After a certain time (usually only 
 two or three hours) the muscular contraction appears to subside ; at 
 least I have found at that time often no shortening at aU, or only a 
 difference of two hues. The cavity, thus increased in size, becomes 
 fiUed with extravasated blood proceeding from the medullary cavity of 
 the divided bone — ^this extravasation having a hemispherical rounded 
 surface above (which is supported against the uninjured articular 
 cartilage) covering the section of the bone below, and penetrating a 
 short distance into the medullary cavity. I have seen remarkable 
 differences in the extent of this clot ; but I have met with the clot 
 itseK in aU cases. Sometimes it was only a hemispherical layer cover- 
 ing the section of the bone, sometimes it attained the size of a 
 cherry. This variation appears to depend on the size of the cavity 
 left after the operation. If the shortening of the extremity had been 
 considerable, or the piece of the humerus which was resected only 
 small, the clot was of small size ; if the contrary were the case, the 
 coagulum was always found of considerable extent. On microscopic 
 
DESCRIPTION OP THE PROCESS, 165 
 
 examination it was found to consist of the stiff fibres peculiar to 
 coagulated fibrin, of shrunken red corpuscles, and a mass of 
 pale ceUs, most nearly resembling lymph-corpuscles, to which ele- 
 ments were added, in the neighbourhood of the medullary cavity^ 
 granular and vesicular fat in considerable quantity. This coagulum 
 slowly shrivels up into a reddish-yellow or brownish solid mass, 
 which gradually disappears, apparently by being washed away piece- 
 meal in the suppuration. 
 
 Granulations then take the place of the clot, shooting up from 
 the inner wall of the capsule formed by the soft parts around the 
 neighbourhood of the joint. The more luxuriant they are the more 
 perfectly do they fill the cavity. From them, or from the exudation 
 which they furnish, cellular tissue is formed, which, if the granula- 
 tions have shot up only in a thin layer, is arranged as a membrane 
 coveriag the inner surface of the capsule formed by the muscles, and 
 thus represents a new articular capsule, on which the muscles are 
 inserted. If the whole cavity have been filled by granulations, they 
 form a firm solid tissue, uniting the cut end of the bone and the 
 articular cartilage, and continuous with the inner surface of the soft 
 parts surrounding the seat of the resection. When the solid tissue ad- 
 heres only to this surface, as I have often observed it to do, the move- 
 able connexion between the resected bone and the uninjured articular 
 cartilage is formed by the muscles, together with the external layer 
 of the newly formed cellular tissue, which Kes nearest to the 
 muscles, while the portion which fills the remainder of the cavity 
 forms, when in large quantity, that which in anatomical examina- 
 tions of the human body has been called a meniscus. This so- 
 called meniscus, however, may be considerably smaller, and is then 
 found in the form of a tolerably smooth solid plate of cellular tissue, 
 which is stretched transversely across the newly formed articular 
 capsule from one of its walls to the other, between the cut surface 
 of the bone and the uninjured articular cartilage. In other cases 
 this solid mass of cellular tissue is united not only with the muscles 
 but also with the section of the bone and with the articular cartilage. 
 How this union takes place wiU be shown in the sequel. 
 
 Through the difference in the quantity of the granulations there 
 arise other forms of manifold variety on their conversion into 
 cellular tissue. One of the most frequent which I have met with 
 was this, that the mass of cellular tissue appeared to fill entirely 
 the space above the upper end of the resected bone, but that there 
 
166 ON REPAIR AFTER RESECTION OF BONES. 
 
 was still a small cavity in its centre, which is to be regarded as a 
 new ajticnlar cavity encroached upon by the thickness of its walls, 
 and which, in regard to its contents, is pretty closely analogous to 
 the perfect newly-formed capsules. 
 
 The newly-formed articular capsule, which extends from the 
 origin of the muscles at the uninjured articular surface to their 
 insertion into the resected bone, sometimes encloses the latter, so 
 that the head, which is reproduced in the way I shaU presently 
 describe, forms a joint within it with the articular surface, or moves 
 upon the latter at a certain distance; sometimes the lower edge of 
 the capsule unites with the upper end of the resected bone. This 
 difference depends in great measure on the method of performing 
 the operation. Thus, if the bone be separated from the muscles a 
 good deal beyond the part at which it is sawn through, and if the 
 periosteum be preserved on the portion denuded of muscles, 
 but not removed, the first state occurs, viz., that the head of the 
 bone is enclosed in a capsule ; if on the contrary the bone is re- 
 moved just at the part down to which the muscles have been 
 separated, or if the piece of bone which has been exposed below the 
 level of the section has been deprived of periosteum, and in conse- 
 quence is attacked with necrosis and exfoKates, the new capsule 
 unites by its lower edge with the upper end of the bone. 
 
 I have never observed what Steinlin has particularly described, 
 viz., that the reiaains of the original articular capsule contribute to 
 the formation of granulations, and of the new articular capsule which 
 is developed from them. I have found the remains of the original 
 aiticular capsule of the shoulder-joint, which are in all cases only 
 inconsiderable, thrust inwards upon the glenoid cavity, at first 
 between the coagulum and the articular cartilage, and later on 
 between the latter and the granulations. At first it is permeated 
 with much fluid, then is found infiltrated with pus, becomes rotten, 
 easily lacerated, and appears to me always to become sloughy, and 
 to be thrown off. The granulations which shoot up from the 
 muscles surrounding the cavity of the joint, consist of nuclei with a 
 dark contour, and of round cells lying close together, with a delicate 
 cell-membrane, nucleus, and nucleolus. The change into cellular 
 tissue is produced by the elongation of the cells into spindle- 
 shaped bodies, which are arranged with their long axes tolerably 
 parallel, and by the union of these bodies into fibres. Between the 
 spindle-shaped cells dark nuclei are found here and there lying in 
 
DESCRIPTION OF THE PROCESS. 167 
 
 longitudinal directions ; I have not been able to trace their develop- 
 ment into fibre-cells. The fibre-cells I have found, on addition of 
 acetic acid, to be in small numbers relatively to the newly formed 
 fibrous tissue. I could never perceive a spiral twisting of the 
 former around a bundle of the latter. Neither in the recent 
 fibrous tissue, nor in the fully developed, have I ever been able 
 to detect cartilage-cells in this situation. Thus it is seen that the 
 so-called menisci abeady described consist exclusively of fibrous 
 tissue. In general, I have observed that the fibres of the fibrous 
 tissue in the parts lying next the muscles, have more of a parallel 
 arrangement, while towards the free surface of the new tissue they 
 are arranged in bundles crossing each other in various direc- 
 tions. The same difference was found in the transverse plates, 
 the so-called menisci, between their free surface and their deeper 
 parts. 
 
 If, after not too great inflammation and not too copious granu- 
 lation, a more or less strong articular capsule is found, the inner 
 wall of this capsule is covered in rare cases with a layer of pave- 
 ment-epithelium, and its cavity is filled with a fiuid which differs 
 from the normal synovia only in having less consistence. I have 
 never found a separate synovial membrane, such as Steinlin describes, 
 which could be dissected off the capsule. Nor have I been more 
 successful in finding the synovial processes (or epithelial processes) 
 which have been found in the bursse mucosae, the sheaths of the 
 tendons, and on the synovial membrane of the joints, and which 
 have also been recognised by Steinlin in the joints of new formation. 
 That the cells which I scraped off the inner smooth wall of the 
 capsule were epithelial, I concluded from their polygonal form, their 
 close approximation to each other, and from the universal paleness 
 of the ceU-wall and strong prominence of the dark nucleus, which 
 occurred on the addition of acetic acid. The nucleus also frequently 
 separated into several parts. This division of the nucleus, which 
 was observed in the young epithelial cells, is indeed also a property 
 of the nucleus of pus-globules, but a confusion with these was 
 impossible, from the size, form, and regular arrangement of the cells. 
 The fluid contained in the capsule is serous, yellowish, slightly 
 turbid, mixed with reddish points, and stringy. It shows under 
 the.microscope, mixed up into a yellowish and rather turbid mass — 
 1, epithelial cells, somewhat shrivelled, obviously separated from 
 the inner wall of the capsule ; a, small brownish granular corpus- 
 
168 ON REPAIR AFTER RESECTION OF BONES. 
 
 cles, which most resemble shrivelled blood-globules; and, lastly, 
 fat-vesicles of various sizes. The origin of these two latter elements 
 I am not in a position to demonstrate. I have observed the 
 occurrence of the pavement epithelium and of the synovia in only 
 three cases, more than four weeks after the operation. Two of these 
 are described in the sequel, and furnished the preparations figured 
 at figs. 6 — 8 and figs. 34 — 27. 
 
 The condition of the tendon of the long head of the biceps muscle, 
 when uninjured in the operation, deserves particular mention. It has 
 been frequently asserted, that the preservation of this tendon, which 
 is attended with some trouble in operations on the human subject, is 
 of no importance for the future usefulness of the extremity, because it 
 will slough and wiU be removed in the process of suppuration. 
 
 I have never seen anything of such sloughing and separation 
 in any case. In examinations soon after the operation, I have found 
 the tendon adherent to the muscles surrounding the situation of the 
 joint, and covered on its anterior surface, which was turned towards 
 the cavity left by the resection, with a thin layer of pus. In these 
 cases it had lost a little of its polish and of its white colour on the 
 surface, and was of a grayish hue. In later examinations, I have 
 found it either covered only on the surface turned towards the cavity 
 by granulations, which were not attached to it, or completely en- 
 closed in them. If the healing process had proceeded almost or 
 completely to its conclusion, I have found the tendon either united 
 with the exterior of the newly formed articular capsule, or of the 
 fibrous cord between the resected end of the humerus and the 
 glenoid cavity ; or else enclosed to a certain extent in this capsule 
 by a sheath or dupUcature of it. Shortly after the operation, the 
 union with the fibrous tissue is found to be very intimate, and thus 
 the mobility of the tendon much impaired ; but later on, the union, 
 probably by the continuous and powerful muscular action which 
 ensues on the recommencement of the use of the limb, becomes much 
 more loose, and the tendon can be moved hither and thither to a 
 greater or less extent. If it is enclosed in the fibrous uniting 
 material, or in a duplicature of the capsule, the inner sui-face of this 
 sheath is sometimes found polished. I have never found epithelium 
 on this surface, or fluid in the sheath. 
 
 From this I am led to speak decidedly in favour of the careful 
 preservation of the tendon of the long head of the biceps muscle in 
 the operation. 
 
DESCRIPTION OF THE PROCESS. 169 
 
 In reference to the changes produced in the bone, they are 
 as follows. Next to the sawn surface a thin strip of the bone 
 is usually found, to the extent of about haK a Hue, smooth, pale, 
 and deprived of its periosteum. The latter is usually detached 
 from the bone at its upper end in small torn shreds ; and further 
 down, where it is no longer detached, it is reddened, oedematous, 
 and plentifully moistened by a somewhat viscid exudation, which is 
 deposited between the bone and the periosteum in the form of a 
 thin yellowish layer, usually of an annular shape, with numerous 
 minute bloody puncta scattered through it. These changes lq the 
 periosteum, which are to be found from the second to the fifth day 
 after the operation, extend to a variable distance along the bone. 
 In most cases they proceed a short way below the point where 
 the muscles are inserted, together with the periosteum, into 
 the bone ; but sometimes, when the general inflammatory symptoms 
 had been considerable, I have observed the injection and exu- 
 dation throughout the periosteum covering the whole bone as far 
 as to the joint lying nearest below the point of excision. 
 
 The yellow gelatinous layer proceeds from the inner surface of 
 the periosteum. It is more closely adherent to the latter than to 
 the bone, so that on detaching the periosteum only a slight trace 
 of this material remains on the bone, and this may be readily 
 detached from it, leaving a smooth unaltered surface. On micro- 
 scopic examination the gelatinous matter consists of a pale-yeUow 
 mass, very finely granular, in which are scattered numerous fat- 
 vesicles and small dark rounded bodies (nuclei), each contaiaing a 
 nucleolus, usually clearly marked. These bodies, which are proved 
 to be nuclei also by their relations to acetic acid, rapidly increase in 
 number, and are soon found deposited in greater quantity in the blas- 
 tema, which has now become clearer and paler, and from which the 
 fat-vesicles have disappeared. Around many of them there is formed 
 a delicate cell-membrane, usually enveloping them pretty closely, the 
 contents of which, generally finely granular, show as a dark border 
 or edging against the blastema, which is now in small quantity 
 relatively to the numbers of the nuclei and cells. At the same 
 period black nuclei, arranged longitudinally, and spindle-shaped cells, 
 occur in the exudation, apparently as the consequence of a second 
 kind of change in the nuclei originally deposited in it. They are 
 found especially numerous in the superficial layers of the exudation 
 nearest to the periosteum; and about this time, viz., after the sixth 
 
170 ON REPAIR Al'TKR RESECTION OF BONES. 
 
 day, the exudation is found to have undergone changes perceptible 
 to the naked eye. Thus, besides an increase of volume, which is most 
 conspicuous in proceeding from the point where the periosteum with 
 the muscles is inserted into the bone towards the section of the 
 latter, there are found two different substances in the deposit. The 
 one, which lies nearest to the bone, is bluish-white, or frequently 
 slightly reddened, and of cartilaginous consistence; the other is 
 yellowish-brown or reddish, and softer than the former. At the 
 part where they are in contact they present the following arrange- 
 ment : the bluish. white deposit is slightly tuberculated on its most 
 superficial layer, while the yellowish -red substance covers these 
 elevations and sinks into the depressions between them. Thus, in 
 the middle layer of the deposit, by making sections parallel to the 
 surface of the bone, an appearance is obtained of a series of 
 rounded bluish-white bodies scattered through a yellowish-red mass. 
 As might indeed have been conjectured from examination with the 
 naked eye, the microscopic characters of these two substances are 
 precisely like what Toetsch has observed in the union of fractures 
 of bone with considerable displacement and long-continued mobility 
 of the fragments, in the union of callus material which had been 
 refractured, and in the healing process after resection from the shaft 
 of the radius in a pigeon. Steinlin has obviously seen some- 
 thing of the same kind, but is short and inaccurate in his description. 
 I have also found the same differences in the organization of the 
 exudation after resections from the substance of bones. 
 
 The bluish-white material consists of the nuclei and cells above 
 described aggregated closely; between which a slightly fibrillated 
 intercellular substance may be seen in very small quantity. Although 
 the cells are remarkably small, not attaining even later on the size of 
 the cartilage-ceUs, and never showing endogenous cell-formation, 
 yet this material must be considered as new cartilage in process of 
 formation; and this view is confirmed also by reference to the 
 futher changes which take place in it. The yellowish-red layer of 
 the exudation, on the contrary, consists of the elements of immature 
 cellular tissue, such as I have observed and described in the forma- 
 tion of the tissue of the new articular capsule. If fine sections out 
 of the central layers of the exudation, where the two materials are 
 continuous, are put under the microscope, rounded discs are seen of 
 the small cartilage-cells and cartilage-nuclei, situated close together 
 in a pale basement substance, surrounded by the yellowish-red mate- 
 
DESCRIPTION OF THE PROCESS. 171 
 
 rial of the immature cellular tissue. While, however, in the other 
 parts of the exudation the elongated dark nuclei, and the closely com- 
 pacted spindle-shaped cells, have a parallel longitudinal course, in 
 the neighbourhood of these discs of growing cartilage, they affect a 
 concentric arrangement, and mingle with the elements of the cartilage 
 in such a manner, that at a greater distance from the mass of car- 
 tilage single cartilage-ceUs are scattered amongst the components of 
 the immature cellular tissue, and nearer to the masses of unmixed 
 cartilage there is found a perfectly gradual passage of the elements 
 of the one tissue into those of the other. This transition of the 
 cartilage into ceUnlar tissue may be observed in any fracture which 
 is examined during the process of union, in passing from the deeper 
 to the superficial layers of the exudation.^ I have observed it 
 especially well marked in frogs, in whom the apparently extremely 
 late occurrence (or perhaps entire absence) of the process of ossifi- 
 cation does not interfere with the perfect development of cartilage- 
 tissue in the repair of fractures. There is only one distinction to 
 be made here. In investigations of the newly formed tissues 
 around the situation of fracture in a bone, I have always observed 
 the transition from the elements of cartilage to those of cellular tissue 
 to be equable throughout the whole mass, and quite gradual ; while 
 in those after resection, with which we have to do at present, I have 
 found the transition always Mmited to that central layer of the exu- 
 dation of which I have before made frequent mention, and so abrupt 
 that it often has appeared at the first glance as if only single car- 
 tilage-cells were strewn about in the immature cellular tissue, and 
 as if the latter were sharply marked off from the rounded cartila- 
 ginous masses. 
 
 The further development of the two materials above described 
 proceeds also in different directions. The immature cellular tissue 
 is gradually developed into perfect cellular tissue, and is soldered 
 into a single mass with the periosteum, which thus is frequently 
 considerably thickened. The newly formed cartilage ossi&es and the 
 bone thus formed is covered by the thickened periosteum. Only at 
 the point of transition from the young cartilage to the immature 
 cellular tissue, transitional formations are also found when the 
 development has proceeded further. 
 
 * This statement, I believe, is meant to apply orilj to fractures in the lower 
 animals. — Tbans. 
 
172 ON REPAIR AFTER RESECTION OF BONES. 
 
 The process of ossification commences very soon. Its commence- 
 ment occurs at about the same time at which the cartilage reaches 
 the above-described stage of development. In consequence of the 
 very defective development of the cartilage and the very rapid pro- 
 gress of the formation of bone, the healing process after resection 
 of bones offers very little that is useful for the study of the process 
 of ossification. All that I have discovered in long-continued in- 
 vestigations of this subject, leads me to support the views developed 
 by Yoetsch. I am not in a position to explain the cause of the very 
 rapid commencement and progress of ossification. I have not seen 
 either the development of blood-vessels, or vessels fully formed, in 
 the cartilage. The layers of cartilage which lie nearest to the bone 
 ossify the soonest ; and then the process goes on to the superficial 
 layers. I have constantly observed that in the process of ossifica- 
 tion, a finely granular dark opacity of the intercellular substance 
 always precedes the deposit of large, dark granules on the internal 
 surface of the cell-walls. At the Emits of the ossification the stiU 
 unaltered cartilage-cells and cartilage-nuclei are constantly found 
 surrounded by narrow bridges of blackened intercellular sub- 
 stance. 
 
 I cannot, however, give an unconditional assent to SteinHn's 
 assertion, that a difference is to be found in this fact between the 
 process of ossification in union by the first intention and that in 
 union by suppuration; since distinguished observers like KoeUiker^ 
 assert, that in the development of bones the ossification of the base- 
 ment substance slightly precedes, as a rule, that of the cartUage-ceUs. 
 I myseK have never undertaken investigations into the bones of 
 quite young animals ; and the fact that in ossification of enchon- 
 droma I have seen the conversion into bone occurring first and 
 markedly in the cartilage-cells, which were highly developed and of 
 large size, does not justify me in regarding this as a phenomenon 
 necessarily belonging to the normal process of ossification. 
 
 I have succeeded in many cases in clearly observing the develop- 
 ment of the bone-corpuscles (lacunae) out of the cartilage-ceUs in the 
 manner described by Voetsch. After the shrivelling and complete 
 disappearance of the nucleus, I have seen the lacunae in the dry bone 
 appearing unmistakably as empty spaces. The disappearance of the 
 cell-membrane I have not seen tiU a remarkably late^ period. I 
 
 ' ' Mikroscopische Anatomie,' Leipzig, i8go, p. 358, 
 
DESCRIPTION OF THE PROCESS. 173 
 
 have often succeeded, even in the perfectly formed bone, in bringing 
 this membrane into sight again by treating the preparation with 
 dilute muriatic acid. Perhaps the very inconsiderable development 
 and extent of the radiating canals which traverse the basement sub- 
 stance going off from the lacunae, which I have always remarked, 
 depends upon this. The nuclei, around which a ceU-membrane is 
 not formed, are at first enclosed by a finely granular dark 
 material which permeates the intercellular substance. After this 
 they appear to shrivel and disappear, as the nuclei do in the ossified 
 cartilage-ceUs. This view of the case is supported by the fact that 
 in a preparation of new bony material, treated with dilute muriatic 
 acid in which the basement substance was sUghtly turbid, and the 
 cartilage-cells had come into sight again in many places, some with 
 shrivelled nuclei, others without any at all, there were no solitary 
 nuclei to be seen, and the close aggregation of the cartilaginous 
 elements had quite disappeared. I believe that I may be permitted 
 to explain the smaUness of the number of lacunse in the developed 
 bone, in proportion to the extraordinarily close aggregation of the 
 cartilaginous elements before ossification, by this disappearance of 
 the free nuclei. 
 
 The fully developed new bony material is very porous in its 
 superficial, but more solid in the deeper layers. Later on it 
 acquires greater solidity on the surface also. In the porous 
 material are found large clear spaces, quite empty in the dried bone, 
 which are surrounded by relatively narrow bridges of bony sub- 
 stance. Thus, the new bony material has the appearance of a 
 wide-meshed net. I consider these spaces as the medullary cavities 
 of the bone, but I have not arrived at any definite view as to their 
 development. I think I am in a position to assert in the most 
 positive manner that these spaces do not possess any previously 
 formed element, in the organization of the exudation up to the com- 
 mencement of ossification, from which they can be developed. The 
 only possible assumption, which could be founded on these premises, 
 would be that they are formed by the coalescence and subsequent 
 disappearance of several cartilage-cells which do not progress to 
 ossification; but for this view I cannot find any support in my 
 observations. I cannot agree to Bidder's^ view, viz., that they 
 are formed from cartilage-cells which enlarge into maternal cells 
 
 ' "Zur Histogenese der Knochen," Mueller's 'Arcliiv,' 1S43. 
 
174 ON REPAIK AFTER RKSECTION OF BONES. 
 
 surrounded by progeny, because I have never been able to find any 
 trace of endogenous cell-formation in the exudation when it has 
 been organized into cartilage. Por the same reason I cannot 
 assume that they are formed from the canals of the cartilage. I 
 have never seen these latter, and from this circumstance I derive a 
 support to the idea that they are altogether absent in that immature 
 cartilage, which attains only so low a grade of organization as 
 that of which we are speaking at present. I am therefore inclined 
 to KoeUiker's' opinion, that the meshes which I take to be medullary 
 cavities are formed by the absorption of previously formed bone. 
 I have found them to possess exactly the properties described 
 by KoeUiker. Their contour is irregular, often presenting an eroded 
 appearance ; they are larger than the cartilage-cells, elongated and 
 oval, or angular, but with a generally oval figure. I have never 
 been able to find bone-ceUs more or less eaten out on their walls, as 
 KoeUiker has described j but, on the other hand, have often seen pro- 
 cesses of the ossifi.ed basement-substance projecting into them. Per- 
 haps, however, some other explanation of the development of these 
 medullary cavities may suggest itself to the reader from the sequel. 
 The immature cellular tissue which lies next to th« cartilaginous 
 material in the central layer of the deposit also takes part in the 
 process of ossification. I have seen in the most indubitable manner, 
 at the places where the above-described transition of the cartilage 
 into the immature cellular tissue occurs, the deposit of the same finely 
 granular dark masses between the elements of the immature cellular 
 tissue as are found in the cartilage; and I beheve that we must regard 
 the elongated nuclei of this tissue as the preliminary elements for 
 the formation of the bone-corpuscles, or lacunae. I have failed to 
 follow step by step their conversion into bone-corpuscles ; but this 
 view is supported by the extraordinary length and narrowness of 
 the bone-corpuscles in general in the bony material which is formed 
 from the cellular tissue ; and further, by the fact that in treating a 
 preparation of this material with dilute muriatic acid, a considerable 
 development of air-bubbles occurs, the field clears, and shows the 
 clear transparent disc of cartilage, altered as above described, and 
 aurrounded by a tolerably clear, very obscurely fibriUated and 
 almost homogeneous material, of a light-yellow colour, in which 
 longitudinal dark nuclei are seen lying in the situation formerly 
 
 ' Loo. cit., p. 363. 
 
DESCRIPTION OF THE PROCESS. 175 
 
 occupied by the bone-corpuscles. Between these are merely seen 
 scattered single cartilage-cells. I have found this ossification of 
 the cellular tissue only in the central layers of the new deposit ; in 
 the superficial layers of the yellowish-red material of the exudation, 
 I have never seen it. When the process of ossification is ter- 
 minated, one is able to see, sometimes very plainly, a difference in the 
 colouring of the different layers of the new bony material. Thus, 
 I have found the most superficial layer, adjoining the thickened 
 periosteum, of a brown colour for a great distance, while the 
 subjacent layers become lighter coloured, till they attain a snowy 
 whiteness. The porosity and softness of the bone were equal 
 throughout the different layers, and the large medullary cavities 
 studded all of them without distinction. 
 
 The ossification of cellular tissue, or the formation of bone 
 without the transitional stage of cartilage, is no new phenomenon. 
 Virchow' has observed it in the formation of osteophytes on the 
 skull, and has lately remarked upon it in a work on the identity of 
 the corpuscles of bone, cartilage, and cellular tissue. I can testify 
 to the general accuracy of the description which he gives of the 
 process ia the work first quoted. I have, however, never seen 
 vessels in the formative material, nor have I seen the spaces till 
 a later period, when the bone was fully formed. Besides, I have 
 always found that the nidus, in which the deposit of the finely granu- 
 lar dark matter occurs, is composed of the elements of the immature 
 cellular tissue, and that it is not till this deposit has made some 
 progress that these elements become obscure and disappear, when 
 the material assumes a homogeneous appearance. PinaUy, I have 
 almost always found it possible to bring the longitudinal dark 
 nuclei iato view again by the addition of acetic or dilute muriatic 
 acid — more clearly by the former than the latter. 
 
 In normal histology, also, we find the ossification of immature 
 cellular tissue. KoeUiker,^ and Sharpey, whom he quotes, have 
 observed that the increase in thickness of the bones which are formed 
 in cartilage takes place by deposits from the periosteum, which after 
 having been organized into half-formed cellular tissue and simple 
 blasterma-ceUs, are converted into lamellated osseous tissue, by the 
 absorption into their fibrous substance of salts of lime and meta- 
 
 ' ■ Archiv fiir pathologische Anatomie,' 1847, Bd. i, p. 135 ; ' Verliandlungea 
 der wiirzburger med. phys. Gesellsohaft,' Bd. ii, p. 158. 
 " Loc. cit., p. 366. 
 
176 ON REPAIR AFTER RESECTION OF BONES. 
 
 morphosis of their cells into lacunae. A peculiarity of these 
 deposits of bone is their arrangenient into reticulated lamellae, 
 interrupted by rounded or elongated spaces. This bony material, 
 which is rendered porous by the presence of these spaces, does 
 not become compact till a later period. If the reader will com- 
 pare the process as described by me with the above ; if he wiU 
 compare the properties of the newly formed bone on the resected 
 extremities, and its subsequent changes, with these lameHse, which 
 occasion the growth of a bone in its thickness ; and finally, if he 
 will remember that at the end of the healing process after resection 
 so considerable a deposit of bone is found around the resected 
 extremity as to stand in no ratio whatever to the deposit found at 
 the commencement ; I think he cannot refuse to admit the analogy 
 between the two processes. I, therefore, believe it possible, that in 
 the reproduction of bone on the stumps of resections, as in the 
 original development of the bone, an exudation is deposited which 
 is converted into cartilage and then ossifies, and that by continual 
 deposits from the periosteum, which are organized into immature 
 cellular tissue and then ossify directly, a further increase of the new 
 bone which was originally formed in cartilage takes place. 
 
 In reference now to the further processes which take place on the 
 resected end of a bone, and from which, perhaps, the views above 
 propounded may derive stiU further support, they are as follows : 
 
 Contemporaneously with the exudation which takes place on the ex- 
 terior of the bone, and with the reproduction of bone in that situa- 
 tion, the same thing takes place in the medullary cavity of the bone. 
 The ossification of the exudation which occurs in this situation 
 proceeds stiU more rapidly than in that which is formed externally; 
 and the part of the exudation which remains stiU unossified, appears 
 to be so intimately united with the medulla, that when the latter is 
 removed it comes away with it. I have, therefore, no observations 
 to make upon the properties of this exudation at the earlier periods. 
 As soon as the sixth day, and afterwards, a thin ring of bone is to be 
 found on the sides of the medullary cavity, which gradually enlarges, 
 and in the end completely closes that cavity with a plate of bone 
 of greater or less thickness. The upper level of this plug is 
 generally the same as that of the external deposit of bone. While, 
 however, the latter constantly commences at the lower edge of a 
 necrosed portion of the upper end of the bone (the necrosis being 
 a consequence, apparently, of injury of the periosteum, or of its 
 
DESCRIPTION OF THE PROCESS. 177 
 
 detachment in sawing througli the bone,) the deposit of new bone 
 in the medullary cavity is often found lining this external necrosed 
 ring. It is then usually situated with its lower edge exactly on 
 the same level as the upper edge of the external bony deposit. 
 This appearance is exactly in union with the processes observed 
 in peripheral necrosis. Later on, the upper ring of bone becomes 
 entirely necrosed and is thrown off, or else its peripheral layers are 
 exfoliated. We get then a club-shaped, or in the latter case a 
 somewhat pointed, , and completely closed end of bone, resembling 
 more or less an articular extremity, but differing from it essentially, 
 besides the difference in shape. 
 
 In more rare cases the plug of the medullary cavity is absent. I 
 observed this in one case where a small dry residuiun of the blood- 
 clot which originally proceeded from the medullary cavity stiU 
 adhered firmly to its interior, and filled up its upper end ; and again, 
 in a case where the upper end of the bone had become necrosed 
 throughout, and lay quite loose in a hemispherical capsule of new 
 bony material open at the upper end. I have failed to find an 
 explanation for this defective closing of the medullary cavity. 
 Perhaps the blood clot, which may be regarded as a foreign body, 
 and the necrosed ring of bone, kept up the suppuration to such an 
 extent, that the new bony material already formed in the medullary 
 cavity was reabsorbed, an event which Steinlin regards as possible. 
 This view is rendered probable by the fact that the internal surface 
 of the bone in the cases above mentioned had a carious appearance 
 for some distance. 
 
 The loss of substance caused by the resection is not restored by 
 new formation of bonej on the contrary, in consequence of the 
 necrosis and exfoliation of the upper section of the bone, the loss of 
 substance is in most cases greater than immediately after the 
 operation. Only occasionally, when the upper section of the 
 bone is necrosed throughout, new bony material encircles this also ; 
 having no connexion with the dead bone. In the greater number 
 of cases the deposit of new bone serves only to round off and close up 
 the upper end of the old; and thus an increase of volume is caused 
 only in the thickness of the bone. i 
 
 The connexion of the new articular extremity of the bone with 
 the parts which surround it is peculiar. The muscles are inserted 
 into the bone only by means of the new articular capsule, or by 
 means. of. the.fibrous uniting. material,. ..The uppey end. of the boiis 
 
 12 
 
178 ON KEPAIR AFTER RESKCTION OF BONES. 
 
 is covered by a layer of fibrous tissue ; either connected at its edges 
 only witb the new capsule, or on its whole surface with the solid 
 cord between the bone and the opposite articular surface. This 
 connexion takes place partly by means of the granulations which 
 spring from the bone in order to the throwing off of the necrotic 
 ring, and which unite with those which proceed from the soft 
 parts; partly, as it appears, by means of the exudation, which 
 originating in the medullary cavity effects its closure by bone, but 
 on its surface is organized into cellular tissue. I believe at least 
 that I may assume this to be the case, since, even in cases where 
 the separation of the necrosed ring has not yet taken place, I have 
 stiU occasionally seen the bony material which closes the medullary 
 cavity already covered with a layer of cellular tissue. I have 
 never discovered a trace of cartilage on the upper surface of the 
 cut end of the bone. 
 
 The newly formed bony material is at first porous, and encloses 
 the walls of the old bone, which are plainly visible on a longi- 
 tudinal section. Later on, it becomes more compact, and at length 
 a process of absorption occurs in it, as well as in the portion of 
 old bone which is enclosed in it, by which the wall of the old 
 bone becomes rough and perforated, and at length disappears, 
 whilst in the place occupied by it and in the entire mass of new 
 compact bone the formation of diploic tissue commences. Thus 
 the end of the bone presents, finally, a very fine reticular tissue 
 covered by a lamella of compact substance ; on a section, it is seen 
 to be of a reddish colour, and occupied by numerous vascular 
 puncta. "Whether the delicate cells contain, normal medulla, as the 
 medullary cavity does which lies beyond the newly formed plug, I 
 have not been able to decide. I have found the new formation of 
 bone (except that in the medullary cavity), as well as the first appear- 
 ances of exudation, always to the extent of the periosteum only ; 
 and, judging from the alterations in this membrane, and from the 
 relations between the exudation and the periosteum, I consider 
 the latter as the source of the exudation, and I consider 
 inflammation of the periosteum as the cause of its existence. In 
 all the cases in which the general symptoms of inflammation have 
 been very considerable and extensive, the injection and tumefaction 
 of the periosteum, the exudation, and finally the new formation of 
 bone, have been found very extensive. Thus I have observed this 
 formation extend over the whole humerus, over the articular surface 
 
DESCRIPTION OF THE PROCESS. 179 
 
 of the scapulaj and along its spine into the supra- and infra-spinous 
 fossa. In the cases in which I have resected only the head of the 
 humerus and left the shaft quite entire, and thus have mechanically 
 isolated the periosteum but little, or not at aU, on the one hand the 
 consequent inflammatory symptoms were, as a rule, very inconsider- 
 able; and on the other, as SteinHn has also observed, the new 
 osseous formation on the external surface of the bone was either 
 quite absent, or was very scanty ; while in these, as in all other 
 eases, the medullary cavity was closed by a bony plug. 
 
 The relation between the articular cartilage and the uninjured 
 joint-surface opposite the resected extremity is also dependent on the 
 degree of the inflammation and of the suppuration consequent upon 
 it. When this was slight, I have always seen the cartilage remain- 
 ing on the articular surface, slightly turbid on its surface, but 
 otherwise quite unaltered. But if, on the other hand, considerable 
 inflammatory symptoms have preceded, I have found that the 
 investing cartilage has either altogether disappeared, or is loosened 
 at the edges, thinned, and very opaque ; and often covered with a 
 thin layer of yellow viscid exudation, and roughened. In particular 
 cases a perforation of the bony wall of the articular surface may 
 follow on this; the consequence of which is the simultaneous 
 gradual enlargement of the compact tissue of the articular process, 
 and the passage of pus into the diploic texture of that bone, by 
 which it is destroyed. 
 
 Granulations begin to shoot up from the surface of the bone 
 thus denuded of its cartilage, even during the process of exfoliation 
 of the latter ; and these unite with those which proceed from the 
 soft parts, and thus either occasion the union of the solid fibrous 
 uniting medium with the articular cavity in its whole extent, or, if a 
 new capsule has been formed embracing the edges of the articular 
 surface, are organized into a covering of ceUular tissue for that 
 surface. 
 
 The separation or gradual disappearance of the cartilage is accom- 
 panied by alterations in its texture, which Redfern^ has particularly 
 described under the designation of "softening" of the cartilages. 
 These alterations proceed from the circumference and the surface 
 towards the centre and the deeper layers. The intercellular sub- 
 stance appears at first yeHowish, finely punctuated, as it were, and 
 
 • 'Abnormal Nutrition in the Articular Cartilages,' Loud., 1850. 
 
180 ON REPAIR AFTER RESECTION OF BONES. 
 
 opaque; gradually fibres make their appearance in it, which are 
 slightly wavy, and resemble the fibres of cellular tissue, but are 
 frequently broader, and have the same relation to acetic acid as 
 the fibres of cellular tissue. In the cells, which are at the 
 same time considerably enlarged and arranged irregularly, a deposit 
 occurs of a quantity of small darkish bodies, which must be regarded 
 as fat-vesicles. These often fill the entire cell, but occasionally lie 
 in smaller quantity, arranged around the nucleus like a necklace. 
 They either remain separate, or coalesce into one large bubble of oil. 
 Besides these, small dark granulated corpuscles make their appear- 
 ance, disappearing with a considerable development of air-bubbles 
 on the addition of acetic acid, and cells provided with a well-marked 
 nucleus and nucleolus. The membrane of the cartilage-cells 
 becomes gradually paler, and disappears. Their contents are found 
 either enclosed by a clear transparent areola in the intercellular 
 substance, which is contrasted against that substance, but without 
 any definite contour ; or else a similar clear space is found without 
 einy such contents ; or else the fibrous basement substance Hes imme- 
 diately around the contents of the cells which are poured out into 
 it. In the end a homogeneous fibrous material is found, in which a 
 large quantity of fat-vesicles are scattered about together with some 
 small and generally granular cells. A few washed-out clear streaks 
 pass through it. 
 
 In examining the material which covers the surface of the carti- 
 lage as a viscid exudation, I have found it homogeneous, dark, and 
 finely granular, without any trace of organization. 
 
 Towards the end of the healing process, the adhesions between 
 the muscles surrounding the joint are usually reabsorbed. The 
 muscles are again easily separable at some distance from their 
 insertion into the new-formed capsule or the fibrous uniting material. 
 I have already made the same observation as to the adhesions 
 between the tendon of the long head of the biceps and the parts 
 which surround it. Perhaps, as a consequence of this liberation of 
 the muscles, at any rate always simultaneously with it, a recurrent 
 shortening of the extremity operated, on takes place, which, however, 
 I have never seen to so great an extent as that which immediately 
 follows the operation. The degree of this depends of course 
 principally upon the size of the portion of bone removed, and 
 the nature of the new joint which is formed. 
 
 The usefulness of the limb operated. upoa became. in. many cases 
 
DESCRIPTION OF THE PROCESS. 181' 
 
 quite perfect again — ^notwithstanding the shortening; in other 
 cases it remained so far imperfect that the animals used the limb 
 operated on only in quiet motion, and in more rapid movements 
 carried it drawn up to the body and pendulous. In a few cases 
 the result was so unfavorable that the animals appeared unable 
 to raise the limb, and dragged it after them on the ground. Exco- 
 riations then formed upon the leg. I have never seen the formation 
 of anchylosis in the shoulder-joint. Contractions in the neighbour- 
 ing joints occurred only in a few cases, and always only in those in 
 which the inflammation in the upper arm had been propagated 
 downwards to the joint lying next below it, and had resulted in 
 suppuration there. I have found in those cases the articular cap- 
 sule considerably thickened, swoUen out like a ball, and containing 
 dry white pus. The cartilages investing the articular ends had 
 disappeared, and the latter were either rough and porous, enlarged, 
 or covered with fibrous tissue, by means of which they were more 
 or less immoveably anchylosed together. Undoubtedly the altera- 
 tion in the insertions of the muscles involved in the operation is 
 capable of producing contraction, as soon as these muscles come 
 into action again ; but I have not succeeded in proving this to be 
 the cause of it in any of the cases which I have observed. 
 
 II. Resection from the substance of hones. 
 
 The healing process after resections from the substance of bones 
 takes place as often by first intention as by suppuration, if the 
 wounds are brought into accurate apposition. I have never seen 
 any essential differences in the results, dependent on one or the 
 other kind of union. If the union has occurred by suppuration, 
 the preceding inflammatory symptoms have never been so considera- 
 ble, or the suppuration so abundant, so extensive, or so persistent 
 as in resection of the ends. In essentials the process of union 
 is the same as that of fractures, as the latter is set forth by Voetsch 
 in the work which has been so often quoted. 
 
 We find the same alterations in the soft parts which surround, the 
 situation of the resection, the same alterations of the periosteum 
 and of the exudation which proceeds from it. In the latter the 
 differences above described are observable from an early period. 
 
 I have not succeeded in following the development of ossification 
 
182 ON EEPAIR AFTER RESECTION OF BONES. 
 
 in that part which is organized into immature cellular tissue ; and 
 do not know whether it furnishes a product of another form in this 
 case also. In the cases where, after the completion of the healing 
 process, the two resected extremities, which are enlarged by the 
 deposition of new bony material and in which the portion of the 
 medullary cavity lying nearest the sectional surface is closed up, 
 are united by a fibrous material (evidently developed out of the 
 immature cellidar tissue,) granules of bone are frequently found 
 deposited in this cord. I have seen such granules also after resec- 
 tion of the extremities of bones in the portion of the exudation 
 which is converted into fibrous tissue, but have deferred their men- 
 tion till this place. Their origin is doubtful. On the one hand it 
 cannot be denied that it is possible that such granules of bone 
 may be portions of the old bone, which are splintered off in the 
 sawing, and become afterwards imbedded in the exudation. "Voetsch 
 inclines to this opinion. He found a granule of bone of this kind 
 on the eighth day after resection of a portion from the substance of 
 the radius of a pigeon, in the yellowish-red part of the exudation. 
 Again, these granules of bone may also be formed by the ossification 
 of rounded agglomerations of lowly developed cartilage-cells ; and 
 such cells I have found scattered through the immature cellular 
 tissue which is formed from the exudation. This opinion appears 
 to me to have at least as much probability in its favour as the 
 one above mentioned. Por the fact that granules of perfectly 
 developed bony substance should be found so soon after the opera- 
 tion cannot militate against it, inasmuch as about the same time a 
 large part of the cartilage formed around the resected ends is abeady 
 fully ossified. I should have assumed unconditionally the develop- 
 ment of these granides of bone out of the discs of cartilage, were it 
 not from an examination of them and of the cellular tissue surround- 
 ing, them, on one occasion, which made me doubtful of this. Thus, 
 when I have subjected the newly formed bony material, not too 
 long after the resection, to the action of dilute muriatic acid, I have 
 usually observed, after a copious extrication of air-bubbles, the 
 structure of the cartilage come into view again, more or less altered, 
 after a tolerably long interval. But on the occasion referred to, on 
 making a fine section of one of the granules of bone of which I am 
 speaking, in the preparation of which numerous particles, mostly of 
 small size, were detached, and examining it with its surrounding 
 cellular tissue under the microscope, I saw, contrary to the result of 
 
DESCRIPTION OF THE PROCESS. 183 
 
 my other observations, the wavy fibres of the cellular tissue running 
 in a perfectly parallel course, and not arranged concentrically around 
 the dark bony material; and I believed that I could also see them, 
 though very obscurely, running through the finely granular masses. 
 In the latter lay small longitudinal corpuscles, with short radiating 
 processes arranged paraRel to the fibres of the cellular tissue. 
 When I added diluted muriatic acid to the preparation, the fibres 
 outside the dark portions became pale, and gradually disappeared* 
 The black corpuscles with their radiating processes also disappeared 
 from the dark spots with a considerable extrication of air-bubbles, 
 and in the clear transparent homogeneous material, which was left, 
 only shghtly clouded in the situation of the former dark spots, were 
 lying single, round, and elongated nuclei. There was no trace to 
 be seen of any structure resembling cartilage. It seems to me 
 therefore possible that the granules of bone imbedded in the cellular 
 tissue may also originate from an ossification of the cellular tissue 
 itself. 
 
 I have never in any case seen perfect bony reparation of the loss 
 of substance occasioned by resection from the substance of a bone. 
 IVor in the preparations which I removed soon after the operation 
 have I found the materials necessary for it. Por the cartilaginous 
 cushions deposited on the cut ends were never united together, but 
 always separated by a layer, however delicate, of the yellow soft 
 exudation. 
 
 The reproduction of the bony material was reduced to a mini- 
 mum in those cases in which I had taken away the periosteum 
 together with the piece of bone. It appeared then only around the 
 ends of the bones, which were rounded off by it or ended in a 
 tubercular point, while the medullary cavities were closed in the 
 immediate neighbourhood of the sections. Occasionally, in these 
 cases, after resection of the radius, the ends were immoveably 
 united to the ulna by a new bony formation extending to a variable 
 distance on that bone. I have never seen any bony deposit in the 
 medullary cavity of the ulna. The space left between the ends of 
 the bone was either filled up by a cord of cellular tissue, or was 
 quite empty. 
 
 Corresponding to the slightness of the inflammatory symptoms 
 which follow resection from the substance of bones> I have found 
 only in a single case new formation of bone at a considerable 
 distance from the cut ends of the bone; in the rest it was 
 
184 
 
 ON REPAIE AFTER RESECTION 01? BONES. 
 
 always limited to the neighbourhood of the sawn snifaces of those 
 ends. 
 
 ThuSj besides the preservation of the periosteum, I have to lay 
 down as a second condition necessary for the bony union of the 
 resected extremities, their perfect immobility. I have not suc- 
 ceeded in determining whether the want of this condition causes 
 only a difference in respect of quantity in the organization of the 
 exudation into cellular tissue and bone, or whether a difference 
 also in quality is connected with it, so that with complete immobility 
 of the resected extremities no organization whatever of the exuda- 
 tion into cellular tissue occurs. In judging, however, from the 
 results obtained by investigations into the healing process after 
 fractures, I consider the former as probable. 
 
 Occasionally, after resection of portions of the shaft, the cut 
 surfaces of the ends of the bone are attacked with necrosis, and 
 this may, even in rare cases, extend beyond them. If the necrosis 
 is peripheral, the medullary cavity becomes completely closed by 
 bony material within the necrotic portion, while new formation 
 of bone goes on gradually on the outer surface of the bone — 
 especially on the side of the bone turned towards the wound — 
 commencing originally below the necrosed portion. If the necrosis 
 is total, the medullary cavity of the healthy bone is closed below 
 the line of demarcation, and the necrosed portion is sometimes in- 
 vaginated by newly formed bone, which originates from the outer 
 surface of the sound bone, and progresses slowly ; while, occasion- 
 ally, the new formation of bone does not overstep the line of 
 demarcation. 
 
 The newly formed bony material on the resected ends is at first 
 porous; whiter when dry than the remains of the original bone, 
 and quite solid. Later on it becomes more compact — the remains 
 of the original bone are absorbed, and diploic tissue and a 
 medullary cavity are formed in it, the latter being closed at the cut 
 ends by a dehcate lamella of bone. 
 
 If the loss of substance left after the completion of the healing 
 process is somewhat considerable (as it was in all the cases in which 
 I operated without preserving the periosteum), there resulted, as 
 Heine has also observed, a bending or a shortening; which, in 
 limbs with two bones, was strongly marked on the uninjured one. 
 
 In rare cases, especially if the inflammation had been propagated 
 to the next joint, and had there resulted in suppuration, con- 
 
DESCRIPTION OF THE PROCESS. 185 
 
 tractions were developed^ which, rapidly increased and much in- 
 terfered with the usefulness of the extremity. In the joints which 
 had suppurated I found the changes mentioned in the former 
 section. 
 
 The muscles surrounding the situation of the resection, which at 
 first are firmly united together for some extent, at a later period can 
 be separated again; they are adherent to each other close to the 
 point of resection, and are attached only to the periosteum, which 
 is somewhat thickened, and to the ends of the bone, but also 
 project into the gap which is to be found between the latter. 
 
 The utility of limbs with only one bone is of course interfered 
 with by the false joints which are formed; in those with two 
 bones, the one which was uninjured often formed a sufficiently firm 
 support to maintain entirely the usefulness of the extremity. 
 
 III. Extirpation of bones. 
 
 I have extirpated the radius in pigeons, without preserving the 
 periosteum, six times only. The wounds were closed by a firmly 
 adherent dried coagulum of blood, and all healed by the first in- 
 tention. No inflammatory symptoms whatever made their appear- 
 ance in the neighbourhood of the wounds. When I unloosed the 
 wings, from three to six weeks afterwards, the birds flew perfectly 
 well. 
 
 In no case could I see a trace of new formation of bone. I felt, 
 through the soft parts, a firm, thin, perfectly flexible cord in the 
 situation of the radius. In the dissection it was often impossible 
 to find even this. The firm cicatrix in the soft parts occupying the 
 position of the radius, which were closely united together, had 
 obviously given the feeling of a cord. In other cases there was 
 found between the soft parts a thin cord-like fibrous material closely 
 united to them, which in one case enclosed the residuum of a 
 yellowish-brown coagulum of blood. The articular surfaces which 
 had been exposed, but not injured, in the operation, were closely 
 surrounded by the consolidated soft parts, and covered with un- 
 altered cartilage. 
 
CHAPTEE IV. 
 
 EXPERIMENTS "WHICH HAVE EURNISHED THE PEEPAEATIONS 
 POR THE PLATES. 
 
 I. Resections of the extremities of bones. 
 Experiment I. (Eigs. i, %, 3.) 
 
 On a full-growii rabbit the bead of the humerus and a part of 
 its shaft was excised in the way above described (p. 159), and a 
 piece seven lines long on the whole was removed. The length of 
 the upper arm before the operation, from the acromion to the point 
 of the olecranon, was two and a half inches, and immediately after 
 the operation two inches two Hnes. Three hours afterwards no 
 shortening could be detected. The animal was cheerful, ran about 
 with the leg hanging and trailing a little, and fed. Gradually the 
 animal drew the extremity so much towards its body that it no 
 longer touched the ground in running. It died on the eighteenth 
 day after the resection. The examination was made immediately 
 after death. I then found the upper arm which had been operated 
 upon three lines shorter than the sound one. At the dissection, a 
 rather hard swelling, the size of a walnut, was found, on the an- 
 terior wall of the thorax between the fore legs, which contained 
 thick yellow pus. The lungs and heart were healthy. 
 
 No particular sweUing was to be seen in the neighbourhood of 
 the joint. The wound was closed, but the soft parts in its immediate 
 neighbourhood were infiltrated with pus. By cutting through the 
 soft parts on the outer side of the joint, a cavity about the size of 
 a pea was exposed, filled with inspissated pus. The resected end 
 of the humerus was situated in this, lying near to the glenoid 
 cavity. The muscles surrounded the bone up to half a liae below 
 the level of the section. In their course up to the glenoid cavity, 
 and around that cavity, they were firmly united together, almost 
 cartilaginous' in consistence, and thus formed a sort of capsule 
 
author's experiments. 187 
 
 around the situation of the joint. They were covered with granula- 
 tions on their inner (free) surface. The surface of the bony section 
 was covered with a white and tolerably firm cap, about two lines in 
 thickness, which separated it from the glenoid cavity. This cap 
 was in intimate connexion with the medullary substance, and lay 
 upon the free edges of the tube of the bone, but without being 
 attached to them. The substance of this cap was found, on 
 microscopic examination, to consist of an amorphous granular mass, 
 of turbid yellowish hue, through which fine fibres ran, crossing 
 each other in various directions. Pus-corpuscles were visible on 
 the edges and in the circumference of the object. 
 
 The bone above the insertions of the muscles was white, dry, 
 smooth, and deprived of periosteum (fig. i b, fig. 2,bb). It was 
 very diflicult to separate the muscles from the hxunerus. In 
 doing so the periosteum covering the bone up to the necrotic ring, 
 and a few of the bodies which will be described directly, lying 
 between the bone and periosteum, were torn away from the bone 
 with that membrane. On the exposure of the upper end of the 
 bone, an annular swelling was observed around it, which began 
 close below the part deprived of periosteum, and descended in a 
 gradually decreasing layer, down to about a quarter of an inch below 
 the surface of the section, where it passed imperceptibly into healthy 
 bone. This deposit consisted in its outer portion of a yellowish- 
 red mass, in which, especially at its upper edge, were found 
 imbedded some pale, firm granules, about the size of a pin's 
 head, arranged hke a necklace. These again contained in their 
 centre a material of snowy whiteness. The deeper layers of the 
 deposit, lying next the bone, were also white, and (especially 
 below) iaseparably united with the bone (fig. i a, fig. 3 aa). 
 At the upper part the whole deposit might be separated from 
 the bone, as was done accidentally in denuding it of the muscles. 
 The bone underneath it, was pale and rather rough. 
 
 On microscopical examination, the yeUowish-red mass was seen 
 to consist of a number of fine parallel fibres, which became paler 
 on the addition of acetic acid, and gradually disappeared, leaving a 
 number of fine blackish elongated nuclei, lying in a direction which 
 corresponded with the axis of the fibre. Close to the rounded 
 granules which were imbedded in them, the fibres assumed a con- 
 centric arrangement around the granules; the number of nuclei 
 increased here to an extraordinary degree ; they became smaller 
 
188 ON RKPAIR AFTER RESECTION OF BONES. 
 
 and round j and the transition to true cartilage, of wMch tHe pale 
 substance of the hard granules consisted, was very gradual. In 
 the cartilage the nuclei were small, rounded, very thickly aggre- 
 gated together, partly with, partly without, nuclei, and surrounded 
 by a cell-membrane, encircHng them for the most part closely, the 
 contents of which were finely granular and rather darker than the 
 intercellular substance, wliich surrounded it in sparing quantity. 
 At the situation of the snow-white material contained in the white 
 granules, the cartilage was foujid to be ossifying. In the inter- 
 cellular substance at this spot a quantity of fine black corpuscles 
 were scattered, which surrounded the still unchanged cartilage-ceUs 
 at the edges of the ossification. At the situation of the ossification 
 the cartilage-ceUs presented, on their inner surface, a ring of fine 
 black angular corpuscles. Between these corpuscles minute canals 
 led, in. radiating directions, outwards into the intercellular sub- 
 stance. In a few sections the cartilage-cells seemed to have dis- 
 appeared out of the intercellular substance, so that the latter was 
 disposed around clear spaces, and assumed a network appearance. 
 The nuclei in the ossified or ossifying cartilage-cells were partly 
 shrivelled, partly gone, and thus the bone-corpuscle (or lacuna) 
 which had been formed out of the cartilage-ceU was clearly shown 
 as a hollow cavity. On addition of acetic acid the black corpuscles 
 disappeared slowly, with a considerable formation of gas-bubbles ; 
 both the finer ones from the intercellular substance and the larger 
 ones from the cartilage-cells. There remained perfectly clear car- 
 tilage, in which the cartilage-cells were merely very finely granular 
 and less transparent than the substance forming the ground on 
 which they lay, and partly contained shrunken nuclei, partly were 
 destitute of nuclei. The clear meshes were surrounded by hyaline 
 intercellular substance. On drying the preparation which had 
 been treated with acetic acid, small crystals were formed, in the 
 form of rhombic plates, partly single, but for the most part in twos 
 or threes, and lying either touching each other in the form of a 
 star or crossing over each other. These disappeared again on 
 addition of distilled water. 
 
 After the separation of the closely adherent cap from the cut 
 surface of the bone, a ring of porous bony substance, about half a 
 line broad, and extending also about half a line downwards, was 
 found on the inner surface of the free edge of the bone (fig. Z c). 
 This was situated higher than the upper edge of the ring of bone 
 
AUTHOR S EXPERIMENTS. 
 
 189 
 
 which was deposited on the outside. The medullary cavity was not 
 yet quite closed by it. On making a longitudinal section of the 
 bone, the medullary substance below the inside bony ring was found 
 quite normal. On the outer surface of the bone ran two fine strips 
 of bony substance, which became somewhat thicker as they were 
 traced upwards, beginning from about a quarter of an inch below 
 the siirface of the section, and ending about half a line below it, 
 exactly at the level at which the bony ring on the inner surface of 
 the bone commenced. 
 
 The glenoid cavity was covered with fat infiltrated with pus. 
 Beneath this lay the cartilage, which was a little roughened and 
 turbid, and thinned over a great part of the joint-surface. On 
 microscopic examination it showed the appearances of softening, 
 which have been before described. At one point, near the centre of 
 the articular surface (fig. 3 a), the cartilage was gone, and the bone 
 was perforated. The pus had passed through the opening into the 
 diploic tissue of the articular process. Around the opening a layer 
 of white, newly formed bony material was deposited (fig. ^ d b 6). 
 
 "Fig. .. 
 
 Fig. 2. 
 
 Kg. 3- 
 
 Explanation or Figs. 1, 2, and 3. 
 
 The humerus of a rabbit, eighteen days after resection of a piece, seven lines in 
 length, from its upper end. 
 
 Fig. I. Lateral view of the humerus. 
 a. New bony material. 
 4. .Free edge of the section of the humerus, in. a state of necrosis. 
 
190 ON REPAIR AFTER RESECTION OF BONES. 
 
 Fig. 2. The humerus seen on a longitudinal section. 
 a a. Section of the new bony material. 
 6 b. The ring of necrosed bone. 
 
 c. A ring of new bone deposited in the medullary cavity, which has not yet 
 quite closed that cavity. 
 
 Fig. 3. The articulating process of the scapula. 
 
 a. The articulating surface, perforated, and deprived of its cartilage. 
 bbb. New deposits of bone. 
 
 ExpEEiMENT II. (Mgs. 4 and 5.) 
 
 In a fall-grown rabbit, the head of the humerus was excised with 
 a portion of the shaft ; a piece nine lines long on the whole. The 
 length from the point of the acromion to the point of the olecranon 
 measured before the operation two and a half inches. Immediately 
 after the operation, when the animial was quiet, the same space 
 measured two and a quarter inches. A few hours later measurement 
 gave the former length of two and a half inches. The animal remained 
 cheerful, and dragged the fore foot of the limb operated on after it, 
 leaning little of its weight upon it. Towards the end of the third 
 week, it used this foot a little in running ; and after this the useful- 
 ness of the foot increased up to its death. Before the animal was 
 killed (fifty-four days after the operation) the upper arm operated on 
 was found to be about a quarter of an inch shorter than the other. 
 
 Dissection. — The wound was healed except a small part, from 
 which on pressure tolerably thick, yellowish pus escaped. There 
 was no swelling noticeable around the shoulder-joint. The upper 
 end of the humerus was felt through the soft parts rounded off like 
 a ball, and freely moveable. After the soft parts were divided, a 
 newly formed articular capsule was exposed, which passed off from 
 the glenoid cavity, embraced the upper end of the humerus, and 
 was inserted below its rounded end. This capsule contained a little 
 pus. Its walls were on their inner surface somewhat rough, floccu- 
 lent, and turbid. The muscles which surrounded the joint were 
 firmly united to the outer surface of the capsule. Even at a con- 
 siderable distance from the capsule, they could not be separated 
 from each other. The tendon of the biceps muscle was only loosely 
 connected to the capsule,, and ran on its posterior surface. The 
 
AUTHOR S EXPERIMENTS. 191 
 
 upper end of the resected humerus was seen as an irregular smooth 
 ring of necrosed hone^ about aline in depth (fig. 4 e, fig. 5/"). 
 Below this the hemispherical swelling was best marked. It extended 
 about an inch and a half down the humeruSj gradually thinning off. 
 It was covered by periosteum, which was prolonged on to the un- 
 altered part of the humerus below the swelling. On the outer side 
 of the bone two kinds of deposit could be distinguished. The one 
 was snow-white, porous, tolerably soft, began as a thin layer, 
 gradually increasing as it was traced upwards, and lay immediately 
 upon the bone. This thin layer stretched up on one side not quite 
 so high as on the other (fig. 466, fig. 5 c c). The second kind 
 of deposit was brownish-yellow (fig. 4 a, fig. 5 a a) ; it was 
 situated over the substance above mentioned, and was in imme- 
 diate connexion with the capsule. It had not the same Kmits as the 
 material which was deposited immediately around the bone, and was 
 strongest on the side on which that material was the weakest. On 
 that side it formed a cavity for a depot of inspissated pus (fig. 5 b). 
 A few roundish white masses of bone, some of them separate, some 
 joined together, were scattered about in this deposit; and these 
 had precisely the same properties as the material which lay upon 
 the bone (fig. 5 d). Beneath the free surface of the section of the 
 humerus the medullary cavity was filled with pus for the space of 
 about a line, and below this was completely closed by a mass of 
 bone about a line in thickness, which was inseparably adherent to 
 the old bone (fig. 5 e). This deposit was continued for a few lines 
 further downwards upon the walls of the medullary cavity. On 
 microscopical examination the yellowish soft deposit and the new 
 articular capsule were seen 'to consist of fibrous tissue; the white 
 masses of normal bone. 
 
 The articular cartilage of the glenoid cavity was turbid, of a 
 yellowish-brown colour, and separated from the edges of the articular 
 surface. On microscopical examination the appearances of soften- 
 ing already described were seen in the superficial layers, and in 
 those lying nearest to its circumference. In the deeper layers of its 
 central substance it was distinguished from healthy cartilage only by 
 a finely granular turbidity of the intercellular substance, by an 
 increase in the size of the cells, and by a copious deposit of vesicles 
 and granules of fat in them. No changes were seen in the 
 scapula. 
 
192 ON RliPAIR AFTKE llESKCTION OF BONES. 
 
 I'iff. , 
 
 rig- 5- 
 
 Explanation or Figs. 4 and 5. 
 
 Humerus of a rabbit, flfty-four days after resection of a piece, nine lines in 
 length, from its upper end. 
 
 Fig. 4. Lateral view of the humerus on which the resection was performed. 
 
 a. Newly formed yellowish mass, composed of fibrous tissue. 
 
 b b. Newly formed bony material, deposited on the old bone, and dissemi- 
 nated through the yellow mass of fibrous tissue in the form of separate 
 granules. 
 
 c. Ring of necrosed bone at the surface of the section of the humerus. 
 
 Fig. 5. The same humerus ; a longitudinal section having been made of its 
 upper end. 
 a a. The section of the yellow mass of fibrous tissue. 
 
 b. Cavity in the latter, which was filled with inspissated pus. 
 
 cc. Bony material deposited on the outer surface of the humerus. 
 
 d. Granules of bone deposited in the yellow fibrous mass. 
 
 e. Newly formed mass of bone within the medullary cavity, entirely closing 
 
 its upper portion. 
 /. The necrosed ring of old bone. 
 
 Experiment III. (Figs. 6, 7, and 8.) 
 
 On a full-grown rabbit, the head of the humerus (fig. 6), three 
 lines in thickness, was. excised. A splinter obliquely broken off, and 
 adhering to the sawn surface, was cut through with the bone-nippers. 
 The muscles were left covering the remainder of the shaft of the 
 
author's experiments. 193 
 
 humerus up to the same surface. No shorteniBg of the limb could 
 be observed^ either iminediately upon the operation or afterwards. 
 The animal remained quite cheerful. Inflammatory swelling in the 
 neighbourhood of the wound was present only for a few days after 
 the operation, and disappeared when the suppuration began, by 
 which the wound, which was closed at first, but opened again after- 
 wards, healed. As early as fourteen days after the operation the 
 animal ran about well, and used the leg operated upon almost as 
 well as the healthy one. It merely trailed it a little. The animal 
 was killed twenty-eight days after the operation. 
 
 Dissection. — The wound was perfectly healed j the cicatrix in 
 the skin was closely united to the soft parts which lay below it. The 
 humerus was firmly attached to the scapula, but freely moveable. 
 A short, thin, newly formed articular capsule (fig. See) had been 
 developed, which proceeded from the edge of the glenoid cavity, and 
 was inserted on to the upper edge of the divided humerus. The 
 muscles surrounding the joint were firmly united with this capsule ; 
 at a short distance from the capsule they could be easily separated 
 from each other; they were firmly united to the edges of the 
 section of the bone through the medium of this capsule. The 
 tendon of the biceps muscle was uninjured, an& ran on the posterior 
 surface of the capsule, loosely united to it, but pretty freely move- 
 able. Inside the capsule was found a serous, somewhat ropy, fluid, 
 which showed under the microscope fat-vesicles of different sizes, 
 small granular bodies, and epithehal cells. The inner surface of 
 the capsule was smooth, and covered by a layer of pavement 
 epitheliiim, which, together with the capsule, also covered the upper 
 end of the humerus. No trace of cartilage could be discovered in 
 this. On the external surface of the humerus (which was entirely 
 covered by periosteum) an extremely thin layer of white, porous, 
 bony substance had been deposited (fig. 7 a, fig. 8 c c), pass- 
 ing downwards on one side for about two lines, on the other for 
 about six, from the surface of the section of the humerus, and 
 covering the free edges of a portion of that section for a short 
 distance. The medullary cavity was closed for the space of half a 
 line by a firm, rather rough, plate of bone, (fig. 8 d d), which was 
 firmly united to the walls of the medullary cavity and to the cover- 
 ing across the latter, derived from the articular capsule. The 
 glenoid cavity was completely covered by healthy cartilage, nor was 
 
 13 
 
194 
 
 ON KEPAIB AFTER RESECTION OF BONES. 
 
 the scapula altered in any other respect. The lungs and heart were 
 healthy. 
 
 Kg. 6. 
 
 Eg. 7. 
 
 Kg. 8. 
 
 ESPIANATION TO TlGS. 6, •}, AND 8. 
 
 Preparations from a rabbit, twenty-eight days after resection of the head of 
 
 the humerus. 
 
 Fig. 6. Keseoted head of the humerus. 
 
 Fig. 7. Side view of the humerus. 
 
 a. Very sparing thin layer of new bone. 
 
 Fig. 8. The new articular capsule, cut open, to which are attached the humerus, 
 which has been sawn through longitudinally, and the glenoid cavity, 
 seen from the front. 
 
 a. The articular surface of the scapula. 
 
 6 b. The sections of the humerus. 
 
 cc. Newly formed bony material on the exterior of the humerus. 
 
 dd. Linear portion of the upper end of the section of the medullary cavity, 
 closed by a newly formed mass of bone. 
 
 ee. New articular capsule. 
 
 Experiment IV. (Kgs. 9, 10, 11, and 13.) 
 
 In a fuU-grown rabbit the caput humeri was excised, with a 
 portion of the shaft. The piece of bone was altogether six lines 
 
author's experiments. 195 
 
 in length. The wound was united merely by twisting the hairs 
 on its opposite sides loosely together. The length of the upper 
 arm before the operation measured two and a half inches from the 
 tip of the acromion to the olecranon ; immediately after the opera- 
 tion a shortening of four lines was discovered, which, however, 
 had almost entirely disappeared four hours afterwards. The animal 
 was at first confined in a small dark place, and did not feed, but 
 sat quite still. On the second day appeared a considerable swell- 
 ing, fluctuating and very painful on pressure, which occupied the 
 neighbourhood of the shoulder, the whole upper arm, and the 
 external and posterior sides of the forearm. The fluctuation was 
 most perceptible at the back of the forearm, and a small incision 
 in this situation gave exit to a quantity of brownish, watery fluid. 
 The wound of the operation was firmly closed. It was opened 
 again, and then fluid of the same appearance flowed out from it 
 also. The animal was now taken into a larger, light room, and 
 soon began to feed and to run about, in doing which it carried the 
 leg which had been operated on drawn up to its body, and pendu- 
 lous. The sweUing of the Hmb soon disappeared completely j the 
 wound of the incision and operation healed by suppuration, the 
 latter leaving a small fistulous opening, from which a little thick 
 pus continued to exude on pressure. At the end of the third 
 week the animal began to put the injured leg to the ground in 
 runniag, but still dragged it very much, and clearly rested very 
 little of its weight upon it. Towards the end of the twelfth week 
 the animal used the leg which had been operated on almost as 
 well as the sound one, and ran so quickly and nimbly that it was 
 difiicult to catch it, even in a small place. The upper arm operated 
 on was two lines shorter than the sound one. The animal was 
 kiUed eighty-four days after the operation. 
 
 Dissection. — The wound of the operation was completely ci- 
 catrized, except a fistulous opening. The cicatrix, as well as the 
 skin on the upper arm, and in the situation of the incision in the 
 forearm, was firmly united to the subjacent fascia. The upper end 
 of the humerus, rounded off into a club-shape (fig. 9 h, fig. 10 a), 
 was united with the enlarged articular extremity of the scapula 
 (fig. 9 a) by an apparently solid and very thick fibrous structure 
 (fig. 9 c), to the outer surface of which the surrounding muscles 
 were firmly united. This consolidation of the muscles was 
 found even at some distance. The tendon of the biceps muscle. 
 
196 ON REPAIR AFTER RESECTION OF BONES. 
 
 which had not been injured in the operation, ran through the 
 posterior portion of this fibrous structure, and was not very move- 
 able in it, being pretty firmly united to that tissue. It had 
 lost its pearly-white colour, and was duU and grayish. The fibrous 
 material was attached to the whole surface of the glenoid cavity, 
 which was entirely deprived of its covering of cartilage, and it 
 ran down, in the form of an oval, compact mass, about four lines 
 broad, to the upper end of the humerus, into the outer surface of 
 which it was inserted about two lines below its upper edge. The 
 upper end of the humerus formed a hemisphere, open above, and 
 lay in contact with the lower end of the fibrous mass, but was not 
 united to it by its upper surface. In the club-shaped end of the 
 humerus, the upper end of which thus formed a cavity, there was 
 lying an irregular ring of necrosed bone, completely loose, and sur- 
 rounded by a mass of new bone (fig. la). The newly deposited 
 mass of compact bone began as a thin layer seven lines below the 
 upper end of the humerus, and rose up along its outer surface, 
 gradually attaining the thickness of one line, and spreading out 
 into a club-lite shape. It was deficient at the anterior side in the 
 neighbourhood of the articulation corresponding to the fistulous 
 opening, so that the necrosed bone was reached with a probe 
 through the latter. 
 
 The surface of the deposit was studded with small tubercles, but 
 was otherwise smooth. On a longitudinal section itwas found to be no 
 longer clearly distinguishable from the old bone, which had assumed 
 a rather darker brownish hue, and gradually passed into the new. 
 The formation of diploic tissue was shown in it by numerous fine 
 foramina of a reddish colour (fig. ii aa). The medullary cavity 
 of the bone, which was not closed, contained unaltered medulla up 
 to about five lines below the upper end of the humerus, and 
 further upwards thick pus, covering the part of the wall of the 
 old bone which was left, and which was of a white colour and 
 appeared to be carious (fig. 1 1 b), and also filling the ring of 
 necrosed bone. 
 
 The articular extremity of the scapid.a was also covered by a 
 tolerably firm mass of new bone, which was a white colour and 
 tuberculated, extending a few lines along the fossa supraspinata 
 (fig. 9 a). 
 
 The viscera of the rabbit were quite healthy. 
 
author's experiments. 
 Fig. 9. 
 
 197 
 
 Explanation to Figs. 9, 10, 11, and 12, 
 
 Preparations from a rabbit, eighty-four days after resection of a piece, six lines 
 in length, from the upper end of the humerus. 
 
 Fig. 9. The scapula and humerus united by means of a newly formed fibrous 
 
 material, which has been cleanly dissected. 
 a. The articular extremity of the scapula, enlarged by deposit of recent 
 
 bone. 
 I. The end of the humerus, swollen out into a club-like form by a mass of 
 
 new bone. 
 c. Newly formed fibrous material. 
 
 Fig. 10. Lateral view of the humerus. 
 
 a. The end of the humerus operated on, enlarged into a club-shape by a 
 mass of new bone. 
 
198 ON REPAIR, AFTER RESECTION OF BONES. 
 
 Eg. II. The humerus, seen on a longitudinal section. 
 
 a a. Newly formed bony material, in which the formation of diploic sub- 
 stance is clearly shown. The medullary cavity is not closed. 
 
 b. Remains of the old bone, in the interior of the mass of new bone, pro- 
 bably carious. 
 
 Pig. 12. Loose ring of necrosed bone, from the upper end of the humerus, 
 which was freely moveable, and lay enclosed in the upper portion of 
 the newly formed mass of bone in the interior of the fibrous sub- 
 stance. 
 
 Experiment Y. (Figs. 13 and 14.) 
 
 In a large, full-grown rabbit the caput humeri was excised with 
 a portion of the shaft, a piece of bone on the whole six lines in 
 length. The wound was not closed in any way, but the bone 
 merely thrust as deeply as possible beneath the soft parts, and 
 covered over by them. Before the operation the distance from the 
 point of the acromion to the olecranon measured two inches nine 
 lines ; immediately after the operation the same distance measured 
 only two inches four lines. On the foUowiag day no shortening 
 could any longer be detected. There was a moderate amount of 
 swelling around the situation of the resection, extending down to 
 the elbow-joint. The animal was not again examined ; it was 
 cheerful, fed, and ran about with the leg hanging and drawn a little 
 to the body. Towards the end of the fifth week after the operation 
 contraction was noticed in the wrist- and elbow-joints, which gradu- 
 ally increased to such a degree that at the end of the seventh week 
 the animal, keeping the extremity adducted, trod on the point of the 
 arm, which was inclined to the forearm at a right angle pointing 
 downwards. It leant little of its weight upon this, and trailed 
 it somewhat. A little before the animal was killed, which was 
 done on the fifty-second day after the operation, it was ascertained 
 that there was no difference in the lengths of the two upper arms. 
 
 Dissection. — Around the shoulder- and elbow-joints there was still 
 to be felt a spherical swelling, of a soft, doughy consistence. The 
 wound of the operation was closed, except a small opening, from which 
 thick pus oozed on pressure. On the side operated on a depression 
 had been formed under the skin extending downwards to the breast, 
 
author's experiments. 199 
 
 and so along the whole belly as far as the pelvis. This was filled 
 with a small quantity of thick, granular pus. In the situation of 
 the shoulder-joint a very firm capsule had been formed, which was 
 bulged out into a rounded form below and behind, was filled with 
 thick, white pus, and stirrounded both the glenoid cavity and the 
 resected end of the bone (fig. 13 e, fig. 14 cc). The muscles 
 surrounding the joint were firmly consolidated with each other and 
 with this capsule, and were inserted into the resected end of the 
 bone on the same level with the capsule. The tendon of the biceps 
 muscle was enclosed in a fold of the posterior part of the capsule, 
 and loosely united to it. The inner surface of the capsule was 
 somewhat rough and flocculent. The pus, which had become in- 
 spissated, was tolerably firmly adherent to it. On microscopical ex- 
 amination, the structure of the capsxde was seen to be composed of 
 fibres running parallel to each other and somewhat wavy, and of 
 fibre-cells. These elements crossed each other in various directions. 
 Between them were scattered small, rounded, and elongated nuclei. 
 The humerus was covered, from its lower end upwards to the inser- 
 tion of the muscles and capsule, with a firmly adherent deposit of 
 bone, which in some places resembled stalactites (fig. i^b bd, 
 fig. 14 i). This was strongest a little above the lower end of the 
 humerus above the capsule of the elbow-joint, which joint was the 
 seat of the swelling above described, and was filled with thick pus. 
 The upper end of the humerus was swollen into a club-like form. 
 This swelling was found principally external to the new articular 
 capsule. Above the sweUing was seen an irregular ring of necrosed 
 bone (fig. 13 c), the breadth of which averaged one Hne. The 
 bony material deposited around the resected end of the humerus 
 was strongest at its anterior side, and surrounded it on aU sides Kke 
 an irregular nodulated capsule. The ossification was perfect, no 
 trace of cartilage being found left anywhere. The new bony ma- 
 terial was covered partly by the periosteum, partly by the capsule, 
 as far as it extended over the end of the humerus ; they were firmly 
 united to it, sinking into all the depressions between the individual 
 nodules. The upper termination of the medullary cavity was filled 
 with pus ; below this was found complete closure of the medullary 
 cavity by a bony material (fig. i^d). This bone, seen on a longi- 
 tudinal section, was about twice as thick in its posterior as in its 
 anterior half, and was situated in the medullary cavity above the 
 level to which the deposit of bone reached on the outside, with its 
 
200 ON REPAIR AFTER RESECTION OF BONES. 
 
 lower edge exactly on the same level as the upper edge of the layer 
 of bone deposited externally, and therefore corresponding to the 
 ring of bone, which, viewed externally, appeared smooth and 
 necrosed. Below this mass of bone the medullary cavity was filled 
 with perfectly normal medulla, and was not encroached upon at any 
 part. The new. bony material was whiter than the old bone, toler- 
 ably porous and soft, and showed under the microscope the normal 
 texture of bone, with peculiarly large cavities. A similar deposit of 
 bone had taken place around the articular process of the scapula 
 and along the spine of the scapula in the upper and lower spinous 
 fossiB (fig. I'l^a a a, fig. 14 a a). It was peculiarly copious at 
 the upper edge of the articular process, which was swollen out into 
 a solid ball almost the size of a small cherry. In the new deposit 
 were seen on section numerous small and large cavities of a round 
 or irregular form, filled with inspissated pus. The meduUary cavity 
 of the anterior extremity of the scapula was quite unaltered. The 
 cartilage covering the articular cavity was thinned and was entirely 
 deficient at its edges ; where it was present, it was pale, tuibid, and 
 covered with a white deposit. 
 
 Its intercellular substance was opaque, finely granular, and of a 
 yellowish tinge; the cartilage-cells were enlarged, and prolonged 
 longitudinally, and arranged with their axes parallel to each other. 
 Their contents were partly fine, round granules, which must be con- 
 sidered as fat-vesicles, partly from three to five blackish nuclei, 
 with tolerably defined angles, often completely filling the cell. 
 They did not change on the addition of diluted muriatic acid, nor 
 did this occasion the evolution of gas-bubbles. Between the articular 
 surface of the scapula and the upper end of the humerus was 
 situated a smooth cushion, about one line in thickness, which was 
 attached to the capsule and divided it into an upper and lower por- 
 tion (fig. 13/). Its surface had the same properties as the inner 
 surface of the capsule, and on microscopical examination the only 
 difference which could be made out between it and the capsule was 
 that the fibrillation was less distinct, and that it contained a deposit 
 of numerous amorphous, coarsely granular, masses between the fibres, 
 and in interspaces formed by the crossing of the fibres. This 
 appeared to have depended on an imbibition of pus, which had be- 
 come gradually inspissated. 
 
 Between the layers of the pleura were adhesions, partly of old, 
 partly of recent, standing. The heart was firmly united to the inner 
 
AUTHOR S EXPERIMENTS. 
 
 201 
 
 surface of the pericardium, by numerous long, thin bands of adhesion. 
 At the upper surface of the lower lobe of the right lung there was 
 found a deposit consisting of four hard nodules, varying in size from 
 a hempseed to a pea, which on section appeared granular and of a 
 whitish-yellow colour, and consisted of inspissated pus. 
 
 Fig- 13- 
 
 Explanation to Pig. 13. 
 
 Preparation from a rabbit, fifty-two days after the resection of a piece, six lines 
 in length, from the upper end of the humerus. 
 
 Fig. 13. LongitudinjJ section of the humerus, the new joint formed after the 
 resection, and the anterior part of the scapula, seen from the front. 
 
 a a a. New bony material deposited around the articular extremity of the 
 scapula. 
 
 bbb. New bony material deposited on the exterior of the humerus. 
 
 e. A ring of the upper end of the bone, necrosed. 
 
 d. A mass of new bone formed in the medullary cavity, and entirely 
 
 closing it. 
 ee. Newly formed articular capsule. 
 
 f. So-called " meniscus" iu the articular capsule. 
 
202 
 
 ON REPAIR AFTER RESECTION OF BONKS. 
 Kg. 14. 
 
 Explanation to Eig. 14. 
 
 rig. 14. The same preparation, seen from behind. 
 
 a a. Deposit of new bone, in the form of stalactites, on the articular 
 
 extremity of the scapula. 
 bh. k. precisely similar deposit along the whole of the humerus. 
 c c. The new articular capsule. 
 
 Experiment YI. (Figs. 15 and 16.) 
 
 In a small rabbity not full-grown, the right caput hnmeri was ex- 
 cised, with a portion of the shaft, a piece on the whole five lines in 
 length. The wound was not united in any way, the resected bone 
 merely thrust under the soft parts. I forgot to take the measure- 
 ments of the extremity. Three days after the operation a very small 
 obscurely fluctuating swelling presented itself near the situation of 
 the resection; the resected end of the humerus had come out 
 between the edges of the wound for a distance of some lines, and 
 was replaced. The animal was cheerful, and ran about with its 
 forearm drawn in towards its body. Three days later the wound 
 was suppurating; the swelling around the neighbourhood of the 
 
AUTHOR S EXPERIMENTS. 203 
 
 joint had diminisliedj and become pulpy in consistence ; the upper 
 end of the humerus again projected between the edges of the 
 wound for about three lines ; it was covered with glutinous exuda- 
 tion, and of a pale-brownish colour; it was not replaced. The 
 animal continued cheerful ; the wound closed in around the pro- 
 jecting end of the bone ; on pressing on the situation of the joint 
 some rather thick pus still appeared by the side of the bone. This 
 was the state of things when the animal was killed, on the fifty-sixth 
 day after the operation. A short time 'before this it was running 
 about nimbly, it supported itself, however, but Httle on the end of the 
 leg operated upon, and carried it for the most part pendulous, drawn 
 up against the trunk. 
 
 Dissection. — The humerus was displaced to a great extent from 
 below and behind, upwards and forwards; between it and the sca- 
 pula, a firm but moveable union had been efiPected. The upper end of 
 the humerus was necrosed to the extent of four lines (fig. 15 5, 
 fig. 16 a); below this, but separated from it by a well-marked 
 line of demarcation, a white and moderately firm mass of bone was 
 formed on the humerus, both on its exterior and in the medullary 
 cavity. The old bone, which had assumed a brownish hue, was 
 lost in this mass of new bone, so as not to be everywhere clearly 
 recognisable (fig. 15 c c). The new bony material did not entirely 
 close the medullary cavity (i^dd). It passed on the posterior 
 surface of the humerus into a process a quarter of an inch in length, 
 curved from behind forwards, Hke a bird's beak, and somewhat 
 nodulated (fig. 15 e, fig. 166), which rested with its point against 
 the articular surface of the scapula. This was surrounded by a 
 layer of strong fibrous tissue (fig. i^/f), intimately united to it. 
 The latter extended from the point of the process over the whole of 
 the glenoid cavity, which had lost its cartilage, and terminated on 
 the edge of that cavity. The muscles surrounding the shoulder- 
 joint were consolidated, not only to each other, but especially, and 
 more firmly, to this fibrous tissue. Their arrangement was the natural 
 one, but they were shortened, and those which ran on the anterior 
 and inner side of the hiunerus were thrust somewhat backwards, 
 corresponding to the displacement of the humerus. The tendon of 
 the biceps muscle had been preserved, and ran (as did the upper end 
 of the muscle) on the hinder surface of the beak-like process. Up 
 to the point where this process came off, the bone was covered by 
 the natural periosteum, but that membrane could not be followed 
 
204 
 
 ON REPAIR AFTER RESECTION OF BONES. 
 
 fiirtlier. Around the articular extremity of the scapula was a 
 deposit of white, nodulated, newly-formed bone (fig. 15 a). 
 The viscera were healthy. 
 
 Fig- IS- 
 
 rig. 16. 
 
 Explanation to Pigs. 15 and 16. 
 
 Preparation from a rabbit, fifty-six days after resection of a piece of the upper 
 end of the humerus, five lines in length. 
 
 Fig. 15. Scapula, with the resected humerus attached to it. A longitudinal 
 section has been made of the latter. 
 
 a. The articular extremity of the scapula, enlarged by the deposit of new 
 
 bone. 
 
 b. A portion of the humerus, which was necrosed and projected out of the 
 
 wound. 
 
 e e. Remains of the old bone, which pass imperceptibly into — 
 
 dd. The newly formed bony material. 
 
 e. A newly formed bony process, which passes off from the posterior side 
 of the humerus, and rests agaiust the articular surface of the scapula. 
 
 ff. Fibrous tissue, surrounding the bony process in a solid mass, at- 
 tached to the articular surface of the scapula, and maintaining a move- 
 able union. 
 
 Fig. 16. The humerus, seen from behind. 
 
 a. Necrosed extremity of the humerus. 
 
 b. Bony process to the articular surface of the scapula. 
 
author's experiments. 205 
 
 ExPEEiMENT YII. (Figs. Y'] , i8j i.<^, and 30.) 
 
 Oa a full-grown pigeon a piece of the upper end of the humerus, 
 nine Unes in breadth and five in length, was resected (fig. 17). At 
 the operation the injury of the air-cavities was accompanied by a 
 well-marked hissing from the wound and the escape from it of 
 frothy blood. The wound was not united, but the wings were tied 
 firmly together. The animal remained cheerful, ran about, and fed. 
 As soon as the second day after the operation the wound was closed 
 by a firmly adherent dry clot of blood. The swelling in its 
 neighbourhood was very inconsiderable. Suppuration was not 
 clearly perceptible after this, but a thin, yellowish secretion poured 
 out in small quantity from under the coagulum on pressure. The 
 coagulum having separated and been removed at the end of the 
 third week, the wound below it was found closed by a fine linear 
 cicatrix. When I threw the bird into the air at about this time 
 it fluttered and moved the wing operated on a little, but soon 
 fell to the ground, and then let the injured wing hang loosely 
 down. It was kiUed on the forty-sixth day after the operation. 
 
 Dissection. — Immediately on opening the cicatrix a thin mem- 
 branous capsule was exposed, which was united with it (fig. 18 a), 
 and which was inserted into the clubbed extremity of the os humeri 
 attaching it to the scapula and coracoid bone. On these bones the 
 capsule covered not only the articular surface, which was completely 
 denuded of cartilage, but also the surrounding muscles to a great 
 distance, so that these muscles were inserted on to the posterior sur- 
 face of the capsule. On the anterior part of the inner surface of the 
 capsule were inserted the ends of the muscles proceeding from the 
 arch of the shoulder (fig. 18 d), which had been cut across in the 
 operation, as well as the upper end of the triceps muscle. The 
 anterior surface of the capsule was not covered by muscles. Tlie 
 interior of the capsule was villous and reddish ; its texture had the 
 characters . of fibrous tissue on microscopical examination. A 
 rather thin fluid filled its cavity. 
 
 The upper end of the humerus showed a deposit of new bone on 
 its exterior (flg. 19, and fig. 20 a), begroning five lines below the 
 upper end of the bone, and becoming gradually thicker towards the 
 upper part. It was of a reddish-brown colour, very firm, and 
 
206 
 
 ON REPAIR AFTER RESECTION 01? BONES. 
 
 ended in a rounded mass of bone of a deep-yellow colour, which 
 lapped over the free surface of the section of the humerus, but 
 did not entirely cover the medullary cavity, and which enclosed a 
 dried, reddish-brown, very hard substance, the remains of a clot of 
 blood connected with the medullary cavity. There was deposit of 
 new bone on the interior of the humerus also, beginning on the 
 same level as that on the exterior (fig. aoii). This did not 
 entirely close the medullary cavity at any point. It ended at the 
 cut edge of the humerus beneath the deep-yellow mass of bone 
 just mentioned, and was of a reddish-brown colour and great 
 solidity. The, two masses of newly-formed bone adhered firmly 
 and inseparably to the humerus, which still was clearly recognisable 
 between them (fig. q,occ). They displayed all the characters of 
 natural bony tissue on microscopical examination. In the deep- 
 yellow mass the ultimate tissue of the bone had a yellow hue, 
 otherwise this swelling was not to be distinguished from the rest of 
 the deposit. The brachialis muscle cut across covered the anterior 
 surface of the clubbed end of the humerus, and was inserted with 
 the capsule on to the upper surface of that bone. There was no 
 alteration in the bones of the arch of the shoulder. The viscera 
 were healthy. 
 
 Fig. i8. 
 
 Fig. 19. 
 
author's experiments. 207 
 
 EXPLANATIOK TO FiGS. 17, 18, I9, AND 20. 
 
 Preparation from a pigeon, forty-six days after resection of a piece of the upper 
 end of the humerus, nine lines in breadth by five in length. 
 
 Fig. 17. The' excised upper end of the humerus, with the openings of the air- 
 cavities. 
 
 Eig. 18. 
 
 a a. The newly formed capsule, slit open and denuded of muscles in front. 
 
 b. The upper end of the humerus, rounded off into a club-shape, to which 
 
 the new articular capsule is inserted. 
 
 c. The triceps muscle. 
 
 d. The brachialis muscle. Both these are inserted by their upper, cut, 
 
 extremities into the new articular capsule. 
 
 e. The cut ends of the muscles proceeding from the scapula and the cora- 
 
 coid bone, which are inserted into the new articular capsule. 
 
 f. Fibrous tissue, constituting a part of the new articular capsule, which 
 
 covers the articular surface, deprived of its cartilage, and the bone in 
 its neighbourhood. 
 
 Fig. 19. A lateral view of the resected humerus, rounded off into a' club-shape. 
 a. The new bony material. 
 
 Fig. 20. A longitudinal section of the same humerus. 
 
 a a. A. mass of new bone, deposited on the exterior of the bone. It laps 
 
 over the level of the section, but does not entirely close the medullary 
 
 cavity. 
 bb. K mass of new bone deposited in the medullary cavity, which also 
 
 does not completely close it. 
 c c. The unaltered old bone. 
 
 ExPEEiMBNT VIII. fPigs. 31, 22, and 23.) 
 
 On a full-grown rabbit the caput bumeri and a portion of the 
 shaft, forming together a piece eleven lines in length, were excised 
 (fig. 23). A few pointed fragments which had been left on the 
 section of the bone were cut off with the bone-nippers. The length 
 of the anterior extremity, from the point of the acromion to the 
 olecranon, measured before the operation two and half inches. 
 After the operation, when the animal was quiet, the same distance 
 measured two inches. The wound was united by the interrupted 
 suture. The animal dragged its leg after it, but was cheerful. 
 
 During the first six weeks it was kept confined in a small, dark 
 room, and sat quiet, feeding well. It was then taken into a large,. 
 
208 ON REPAIR AFTER RESECTION OP BONES. 
 
 light room, and soon became lively, and ran about witb the fore- 
 leg drawn up against the body. As early as the fourth day after 
 the operation a doughy swelling, of very considerable size, was 
 found in the neighbourhood of the' resected parts. As this in- 
 creased in size continuously during the next two days, the sutures 
 were removed, and the adherent edges of the wound partially 
 separated again. A tolerably large quantity of brownish, watery 
 fluid, and a rather thick, yellow pus, flowed out upon this being 
 done. The space between the acromion and the olecranon could 
 not be accurately measured, on account of the size of the swelling. 
 The animal was not again examined immediately after this. At the 
 end of the fourteenth week I felt around the neighbourhood of 
 the shoulder-joint a doughy but solid swelling, composed of several 
 smaller spherical portions. The wound was firmly cicatrized. 
 Passive motion of the shoulder-joint was quite free, and I believed 
 myself able to feel a new caput humeri through the soft parts. 
 The animal ran nimbly, but carried the fore-leg more frequently 
 than it supported itself on it. The latter was the case in quiet 
 running ; but if it were chased, it drew the leg up, and made use 
 only of the three other legs. The rabbit was killed on the hun- 
 dred-and-ninth day after the operation. 
 
 Dissection. — ^The skin in the neighbourhood of the cicatrix and 
 on the whole upper arm was firmly united to the soft parts below it. 
 The muscles also in the neighbourhood of the joint were equally 
 firmly united to each other and to a new and strong articular cap- 
 sule, which was pouched out above into two hard, spherical swellings. 
 One of these (fig. 21 d!) was united firmly to the articular surface of 
 the scapula, which was swoUen up to the size of a cherry, and 
 denuded of its cartilaginous covering. The strong fibrous covering 
 of this swelling was continued into a second swelling, lying further 
 forward (fig. 31 d), and into the articular capsule. The con- 
 tents, composed of inspissated and dried pus, passed through an 
 opening about the size of a pin's head in the articular surface 
 of the scapula into the diploic substance of that bone. The pus 
 contained in it was enclosed ia a tolerably firm bony capsule, com- 
 posed of the compact substance of the bone spread out (fig,. 
 21 a). This bony capsule was again connected with another 
 swelling, surrounded by a thick capsule of fibrous tissue, containing 
 also inspissated pus, on the posterior and upper edge of the 
 scapula (fig. 21 d"). The prominence situated furthest forward 
 
AUTHOR S EXPERIMENTS. 209 
 
 (fig. 2 1 «) was connected with the capsule itself by an opening the 
 size of a millet seed, and this capsule was also full of rather thick, 
 viscid pus. It was firmly inserted into the humerus on the healthy 
 bone below its upper, clubbed extremity (fig. ai hV). The inner 
 surface of the capsule, as well as that of the pouches, was rough, 
 opaque, and covered with pus. Its structure was that of fibrous 
 tissue. The tendon of the biceps muscle arose from the upper 
 and inner border of the glenoid cavity, and ran, in pretty firm 
 adhesion with the fibrous tissue round the joint, at first in the grooves 
 between the spherical pouches (fig. ai A'd?), and then on the edge 
 separating the anterior and posterior aspects of the pouch situated 
 furthest forward (fig. ai d), down to the humerus. The somewhat 
 thickened periosteum which covered the part of the humerus 
 situated beneath the insertion of the capsule was continuous with the 
 capsule, and passed over the club-shaped end of the humerus, which 
 was situated within it (fig. ai c). The latter was covered on its 
 upper surface with a thin, opaque, yellowish layer of cellular tissue, 
 and was freely moveable in the capsule. On the exterior of the 
 bone there was a deposit of newly formed bony material, which was 
 white, porous, and tolerably firm ; it began five lines below the upper 
 end, became a little thicker above, spread out into a club-shape, and 
 closed the medullary cavity above with a thin, irregular lamella 
 (fig. %'2,hV). On a longitudinal section a slight deposit of bone 
 was visible also on the interior of the himierus ; but in this, as in 
 the external deposit, the formation of diploic tissue had made very 
 great progress (fig. aa). The bony material of the humerus which 
 remained was quite rough, and pierced with numerous minute 
 openings. It seemed to be in process of absorption (fig. aa « «). 
 The whole cavity of the bone was filled with healthy medulla, which 
 appeared rather paler at the upper than at the lower part of the 
 medullary cavity. On the articular process of the scapula, along the 
 fossa supraspinata, and close to the spine along the fossa infra- 
 spinata, there was a deposit of white, porous, nodulated new bone 
 (fig. ai a a). 
 
 The pleura costahs was united with the pleura pulmonalis for a 
 great distance, and the pericardium with the heart. Otherwise the 
 viscera were healthy. 
 
 14 
 
210 ON KEPAIR AFTER RESECTION OF BONES. 
 
 Eg. 22. 
 
 Kg. 23. 
 
 EXPIANATION TO llGS. 21, 22, AND 23. 
 
 Preparation from a rabbit, one hundred and nine days after resection of a piece 
 of the upper end of the humerus, eleven lines in length. 
 
 Mg. 21. The scapula, new articular capsule, and humerus, connected together. 
 
 a a. Tlie scapula, through which a section has been carried. It is enlarged 
 by deposit of new bone. The spherical, expanded, articular extremity 
 formed a bony capsule containing inspissated pus. 
 
 b b. New articular capsule, out open and spread out. 
 
 c. Club-shaped upper end of the humerus. 
 
 d d' d". Encysted abscesses in the neighbourhood of the new joint. 
 
AUTHOR S EXPERIMENTS. 211 
 
 Kg. 22. The humerus, seen on longitudinal section. 
 a a a. Remains of the old bone. 
 
 bbb. L mass of newly formed bone deposited in the exterior and interior, 
 a fine lamella of which entirely closes the medullary cavity of the 
 bone. The formation of diploic tissue in it is advanced. 
 
 Fig. 23. Portion of the humerus removed. 
 
 Experiment IX. (Figs. 24, 35, 26, and 37.) 
 
 In a large^ full-grown rabbit, the riglit caput humeri was excised 
 with a portion of the shaft, a piece, on the whole, nine hnes in length 
 (fig. 25). The wonnd was closed by twisting the hairs loosely 
 together, after the bone operated on had been thrust as deeply as 
 possible under the soft parts. The length of the upper arm from 
 the point of the acromion to the tip of the olecranon measured 
 before the operation two inches, nine lines ; and immediately after it, 
 when the animal was quiet, in the sitting posture, two inches three 
 lines. The animal was cheerful ; it dragged the extremity on the 
 ground slightly in running. Pour hours after the operation, the 
 distance between the points named measured two inches seven 
 lines. On the second day a tolerably large and slightly fluctuating 
 swelling showed itself in the neighbourhood of the wound of the 
 resection. Pressure on this caused the discharge of some brown- 
 coloured, watery fluid out of the wound, which was open. This 
 discharge, to judge by the moisture and matting together of the 
 hairs on the leg operated on, was continuous. On the twentieth 
 day after the operation, the length of the upper arm measured two 
 inches seven lines. There was a constant discharge of thick, laud- 
 able pus from the wound. The animal was cheerful. In running, 
 it supported itself a little upon the leg, which still, however, trailed a 
 Little ; if it was chased, it drew the leg up to the body, and ran on 
 three legs. "When I next examined the animal, at the end of the 
 twelfth week, the wound was firmly cicatrized, and no trace of 
 swelling remained around it. I thought that I could feel plainly a 
 new articular head, through the soft parts. This was fijmly united 
 to the scapula, but moved with perfect freedom. The length of the 
 upper arm measured two inches four lines, while the healthy one 
 measured from the acromion to the olecranon two inches nine lines. 
 The animal ran perfectly well, and both in quiet motion and when 
 
213 ON REPAIR AFTER RESECTION OF BONES. 
 
 chased used the fore-leg operated on as iauch as the iminjiired one. 
 This animal was kiUed on the ninety-first day after the operation. 
 
 Dissection. — The cicatrix was united to an articular capsule lying 
 heneath it. This came off from the edges of the glenoid cavity, and 
 was inserted about three lines below the upper extremity of the 
 humerus, which was expanded into a something of a club-shape. 
 The capsule was perfectly closed. The muscles surrounding the 
 situation of the joint were firmly united to the outer surface of the 
 capsule, while at a little distance from it they were readily separable 
 from each other. Over the anterior surface of the capsule the thin 
 remains of the deltoid muscle were to be traced (fig. 34 h), and 
 they had a common insertion, together with the capsule, into the 
 humerus. The anterior and upper part of the triceps muscle, which 
 lay nearest to the bone (fig. 24 g), and the upper end of the short 
 head of the biceps (fig. 34 /«), were firmly inserted into the bone 
 together with the lower and anterior edge of the capsule. The 
 tendon of the long head of the biceps muscle (fig. i/^d) ran in a 
 fold of the capsule, which was smooth on its interior, and situated 
 on the posterior surface of the latter (fig. 34 c), between two 
 tubercles on the clubbed extremity of the humerus, which was 
 enclosed ia the capsule (fig. 34 e). It was quite freely moveable. 
 The interior of the capsule was smooth, and its walls were covered 
 with a layer of pavement epithelium. I failed to discover any 
 epithelium on the fold of capsule for the reception of the long 
 tendon of the biceps. In the capsule was contained a rather thin, 
 ropy, reddish-yeUow fluid, which showed under the microscope epi- 
 thehal cells, fat-vesicles, and dark, granular bodies. (Qy. shrunken 
 blood-corpuscles ?) The cartilaginous covering of the glenoid 
 cavity remained entire, nor was there any other alteration percep- 
 tible on the scapula. The humerus was covered with healthy 
 periosteum, thickened over its upper extremity, which appeared to 
 be connected with the capsule at its insertions, and was continued 
 into the capsule over the portion of the humerus which was 
 enclosed in it. The upper surface of the bone was covered by a 
 thin layer of cellular tissue, which passed over at the edges into the 
 periosteum. This cellular tissue was more opaque and not so smooth 
 as the inner surface of the lateral walls of the capsule, and not 
 covered with epithelium. Underneath the periosteum a layer of new 
 bony material was deposited (fig. 36 a, fig. 37 a a), which was hardly 
 distinguishable from the original bone, and which was thin at its 
 
AUTHOR S EXPERIMENTS. 
 
 213 
 
 commencement, and became tliicker in proceeding from below up- 
 wards. It closed 'the upper end of the medullary cavity per- 
 fectly, with a thin lamella. The walls of the remainder of the old 
 bone, as might be seen on section, passed gradually into this 
 material, and were indistinguishable from it, as was also a deposit 
 of bone on the walls of the meduUary cavity. A thin layer of com- 
 pact tissue surrounded the internal layer of the new bony material, 
 which was developed into fully formed diploe. The whole of the 
 medullary cavity was fiUed up with meduUa, which was perfectly 
 normal. 
 
 The viscera of the animal were healthy. 
 
 Fig. 24. 
 
 Explanation to Piqs. 24, 25, 26, and 27. 
 
 Preparation from a rabbit, ninety-one days after resection of a piece of the 
 upper end of tlie humerus, nine lines in length. 
 
 Fig. 24. Newly formed shoulder-joint, with its muscles. 
 
 a. Scapula. 
 
 b. Newly formed articular capsule, over which pass the remains of the 
 
 deltoid muscle. 
 
314 
 
 ON KEPAIB AFTER RESECTION OF BONES. 
 
 Fig. 24 — continued. 
 
 c. A fold of the capsule cut open, in which runs— 
 
 d. The long tendon of the biceps muscle. 
 
 e. New tubercle on the humerus. 
 /. Humerus. 
 
 ff. The triceps muscle, partly with its natural insertion, partly attached to 
 
 the humerus, together with the new capsule. 
 h. Short head of the biceps muscle, inserted, by its upper divided end, 
 
 together with the new capsule into the humerus. 
 
 Eg- 23- 
 
 Pig. 26. 
 
 Fig. 27. 
 
 Fig. 25. Excised portion of the humerus. 
 
 Fig. 26. Side view of the humerus. 
 a a. New bony material on it. 
 
 Fig. 27. A longitudinal section of the humerus. 
 
 a a. New bony material. The extremity of the old bone has disappeared. 
 The diploic tissue is fully formed. 
 
 II. Resection from the substance of hones. 
 
 EXPEEIMENT X. (Fig. a8.) 
 
 In a fuU-grown pigeon, a piece four Hnes in length was excised 
 from the shaft of the radius, the periosteum being spared as much 
 as possible. The wound was not united, the wings were bound 
 firmly together, and supported by the trunk. The bird remained 
 
author's experiments. 215 
 
 cTieerful, ran about, and fed. On the second day after the opera- 
 tion the wound was closed by a firm dry, blackish-brown coagulum. 
 A slight swelling existed in the neighbourhood of the wound. The 
 animal was killed nine days after the operation. 
 
 Dissection. — The wound was covered by firmly dried blood clot, 
 which could be removed from it with tolerable ease. Under this 
 the wound was found healed, except a small cleft, through which 
 the clot extended down to the deeper parts. Around the situation 
 of the resection was found a swelling of an oval shape, with its long 
 axis in the direction of the limb, and of a tolerably firm consistence. 
 The divided ends of the bones might still be moved a little from 
 side to side. The skin in the neighbourhood of the wound was 
 firmly united to the muscles which lay below it, and these to each 
 other at the situation of the resection, and to the swelling which 
 was situated below them. After they had been dissected off, the cut 
 ends of the bone were seen surrounded by a yellowish-white, flexible 
 material, which united them together. 
 
 On a longitudinal section of the bone the following was observed. 
 About three Hues above the section of the upper end of the bone 
 there began in the medullary cavity, on both sides of it, a very 
 delicate layer of white, bony substance [e e), which in proceeding 
 down to its cut extremity, became gradually somewhat wider, turned 
 round the free edge of the bone, and being rounded off at its 
 anterior end, was continuous with a similar layer of white bone, 
 which, commencing a little nearer the divided end, ran on the 
 exterior of the bone {b b). On the lower end of the bone the 
 state of parts was much the same, except that the new bony 
 material was • deficient on one side of its exterior, while the bony 
 deposit in the medullary cavity closed it completely (e). Almost 
 at the same level with the external deposits of bone there arose on 
 each side of the two ends of the bone four bluish-white swellings 
 (c c), which became thicker in proceeding towards the surfaces of the 
 sections. They overlapped these surfaces considerably, and almost 
 touched each other, two on each side, by their free edges, which 
 were rounded off in front. Enclosed among these swellings lay a 
 yellowish-brown, shrunken coagulum (/'), corresponding in thick- 
 ness to the medullary cavity, and loosely connected to it, as well as 
 to the parts which surrounded it. This blood-clot was continuous 
 with that which covered the wound, through a narrow fissure which 
 passed through the whole swelling around the ends of the bone on 
 
216 
 
 ON REPAIR AFTER RESECTION OF BONES. 
 
 the side looking towards the wound. Again, on the same level 
 with the other deposits there was a capsule composed of yellowish- 
 red and tolerably soft substance {d d), which formed the outer 
 layer of the whole swelling, and in the interval between the free 
 ends of the above-mentioned bluish-white enlargements passed in 
 to touch the clot in the centre. The periosteum over both ends of 
 the bone was finely injected for some distance towards each joint, 
 and passed over on to the swelling around the ends of the bone. On 
 microscopic examination, the white bony deposit showed the pro- 
 perties of fully formed normal bone, and the substance of the 
 bluish-white enlargements those of young cartilage. In the hyaHne 
 intercellular substance of the cartilage, nuclei were found lying very 
 close together, and partly surrounded by a cell- wall. The yeUowish- 
 red substance which enclosed both of these consisted on its surface 
 of newly formed fibrous tissue, with fibres and fibre-cells running in 
 parallel directions ; in the deeper layers, nearer the centre, there 
 were elongated nuclei and spindle-shaped ceUs also arranged chiefly 
 in a parallel direction to the long axis of the bone. Between them 
 cartilage-ceUs were again found scattered, and were present in 
 greater numbers in several places, aggregated into small round 
 masses, surrounded by the new-formed cellular tissue. 
 
 Explanation to 'Em. 28. 
 
 Longitudinal section of the radius of a pigeon, nine days after tlie resection of 
 a piece, four lines in length, from its sliaft. 
 
 aaaa. The remains of the old bone. 
 
 bb b. New bony material deposited on its exterior. 
 
 cc. k. callus of newly formed cartilage. 
 
 dd. Yellow softer mass, consisting of young fibrous 
 
 tissue. 
 eee. Bony material formed in the medullary cavity. 
 /. Diied blood-clot (substantia intermedia). 
 
author's experiments. 217 
 
 EXPEEIMENT XI. (Kg. 29.) 
 
 In a full-grown pigeon, a piece four lines in length was excised 
 out of the substance of the radius, the periosteum being spared as 
 much as possible. The wound was not united. The wings were 
 firmly bound together, and supported by the trunk. The bird 
 remained cheerful, ran about, and fed. On the third day the wound 
 was found closed by a black, dry, and firmly adherent coagulum of 
 blood. In the neighbourhood of the wound I found a weU-marked, 
 club-shaped, soHd swelling. The animal was killed on the 
 thirteenth day after the operation. 
 
 Dissection. — ^The dried blood-clot was pretty firmly adherent to 
 the wound. When this was drawn away there came into sight 
 with it a yellower and softer portion of the clot, which was pro- 
 longed through the wound into the interior of the swelling, and a 
 small quantity of thin, yellow fluid escaped. The wound was healed 
 at its extremities. The spindle-shaped swelling on the bones was 
 almost an inch in length. The cut ends of the bones were slightly 
 moveable from side to side. The skin in the immediate neighbour- 
 hood of the wound was closely united to the muscles below it, and 
 these to each other and to the material which formed the swelling. 
 When they had been removed, the yellow, flexible material which 
 enclosed the ends of the bone came into view. At the place corre- 
 sponding to the wound in the skin this capsule was open, and by 
 pressing the edges of the cleft away from each other the free end 
 of the lower piece of bone {6) could be seen at the bottom. 
 
 The following was observed on a longitudinal section ; On the 
 exterior of the upper piece of bone, and on the surface turned 
 towards the wound (which I shall call the upper surface), about 
 three lines from the surface of the section, and upon the surface 
 turned away from the wound (which I shall call the under), was 
 deposited a bony swelling (c c), commencing thin and gradually 
 becoming thicker as it approached the divided extremity. This 
 extended on the upper surface not quite to the section of the bone, 
 while on the under surface it passed a little beyond it. There were 
 two thin lamellae of bone (ff) in its interior, begianing on a level 
 Tvith the external deposit on the under surface, which completely 
 
218 ON REPAIR AFTER RESECTION OF BONES. 
 
 closed the medullary cavity at the free end of the bone. Dark- 
 coloured, coagulated blood lay between these two in the medullary 
 cavity of the bone. In the same way there were on the lower end 
 of the bone two lamellae of bone (c c), which began at the same 
 level, and were thin at their commencement and became gradually 
 thicker. The one which was situated on the upper surface adhered 
 firmly to the bone, and terminated in a rounded end about two 
 lines from the surface of the section. That which lay upon the 
 under surface adhered firmly to the bone up to a certain level, like 
 the one above described ; it then left it, and ran making a curve out- 
 wards imbedded in a yellow, soft material, to a point rather beyond 
 the level of the cut end of the bone. The medullary cavity was 
 completely closed by a mass of white bone from the commencement 
 of the bony swelling deposited on the outside dovm to about two 
 lines below the free end of the bone (ff). On the bony swellings, 
 which were deposited externally on the upper end of the bone, and 
 on the bony material which lay on the under surface of the lower 
 end of the bone, there were found three bluish-white swellings 
 {d d d), which arose at the same level, and became thicker towards 
 the section of the bone. These terminated in rounded extremities 
 at the same level with the bony deposits. The lower cut end of the 
 radius was deprived of its periosteum for the extent of about two 
 lines, and was smooth and white, and projected into the material 
 which we are just about to describe {b). Its medullary cavity was 
 filled with dried blood-clot, a small remnant of which stretched up 
 to the upper cut end corresponding in breadth to that of the 
 medullary cavity {/). A yellowish-red soft material [e e) origina- 
 ting at the same level with the deposits on the exterior of the bone, 
 formed the whole remaining part of the sweUing, enclosing the 
 parts above described, and insinuating itself between the bony 
 material on the outer and lower side of the lower cut end and its 
 necrosed portion. The periosteum was finely injected on both 
 ends of the bone nearly to the epiphyses, and passed over on to 
 the swelling, but could not be followed far upon it. 
 
 The new bony swellings showed on microscopical examination the 
 structure of normal bone, with very dark, finely granular, basic sub- 
 stance, and few medullary spaces. The bluish-white swellings had 
 the properties of newly formed cartilage. Its nuclei were for the 
 most part nucleolated, some of them partly surrounded by a very 
 
AUTHOR S EXPKKIMENTS. 
 
 219 
 
 delicate cell-membrane, which enclosed them closely, and they lay very 
 closely aggregated in a hyahne intercellular substance, which was 
 relatively to them in very small quantity. The yeUowish-red sub- 
 stance consisted on its surface of dehcate fibres, running in parallel 
 directions, in which longitudinal nuclei were scattered. In the 
 deeper layers the fibres were in smaller quantity, and were replaced 
 by spindle-shaped bodies, rounded cells, and longitudinal darker 
 nuclei. CaxtUage-cells were scattered about in it, partly separate, 
 partly aggregated into small heaps. 
 
 Explanation to Pig. 29. 
 
 Longitudinal section of the radius of a pigeon, on the thirteenth day after the 
 resection of a piece, four lines in length, out of its shaft. 
 
 aaaa. The remains of the hone. 
 
 b, A necrosed portion of it, not cut through in making 
 
 the section. 
 cccc. New bony material, deposited outside. 
 ddd. New cartilaginous deposits. 
 ee. Yellow soft mass, consisting of young cellular 
 
 tissue, passing in between the lower bony deposit 
 
 on the right side and the necrosed bone. 
 /. Dried blood-clot (substantia intermedia). 
 gg. New bony material formed in the medullary 
 
 cavity. 
 
 Eig. 29. 
 
 EXPEEIMENT XII. (Kg. 30.) 
 
 In a full-grown pigeon, a piece four lines in length was excised 
 out of the shaft of the radius, the periosteum being spared as 
 much as possible. The wound was not united, but the wings 
 bound firmly together. The bird remained cheerful. On the 
 tliird day after the operation the wound was found closed by firmly 
 adherent coagulum, of a blackish hue. A few days later a spindle- 
 shaped, hard swelUng could be felt at the situation of the resection. 
 On the twelfth day the bandage which kept the wings together was 
 removed. The bird moved the wing, but did not fly. The swell- 
 
220 ON REPAIR AFfER RESECTION OF BONES. 
 
 ing persisted. The wings were again tied together. On the twenty- 
 first day the swelling had materially diminished^ the ends of 
 the bone were still moveable, but the bird could fly. The wings 
 were again tied together. On the thirty-fourth day after the opera- 
 tion the bird was killed. 
 
 Dissection. — The wound in the skin was closed by a delicate 
 cicatrix ; there was no swelling in the wing. The resected ends of 
 the radius could be felt through the skin, thickened, and slightly 
 tuberculated, with an interval between them. Each end of the 
 bone could be moved pretty freely. The muscles, which in the 
 neighbourhood of the resection were united together, were dis- 
 sected from each other, and removed from the ends of the bone, 
 which were swollen and tuberculated. The latter were then found 
 to be covered up to the surfaces of the sections with periosteum, 
 which towards the ends was somewhat thickened. Between the 
 ends of the bone it passed over into a ligamentous material. Under- 
 neath the periosteum tliere were found numerous irregular, small 
 deposits of new bony material [b b). They were rough on their 
 upper surface, very porous, and vascular ; situated, over the upper 
 end of the bone, only in the immediate neighbourhood of the cut 
 surface ; over the lower end, along the whole length of the bone. 
 Their union with the bone was intimate, and its surface below 
 them was also thinned, rough, and containing numerous vascular 
 puncta. On a longitudinal section of the bone the. medullary cavity 
 at each end was seen to be closed by new bony substance for about 
 a third of its length [b). The latter was porous, of a deep-red colour, 
 which distinguished it from the waU of the old bone and from the 
 external deposit. This external deposit, which was in the greatest 
 quantity nearest the section, and diminished gradually, extended 
 about as far as the bony material in the medullary cavity. It was 
 continued over the wall of the bone and the internal deposit, and 
 thus helped to close the medullary cavity. On its surface the 
 fibrous material was deposited. At the points nearer to the joint 
 ends of the bone, where deposits of bone were found externally, 
 the medullary cavity was not trenched upon. 
 
 In the ligamentous tissue (e) between the ends of the bones, 
 small whitish bodies, about the size of a pin's head, were found. 
 The chief part of the uniting substance consisted of fibres of fibrous 
 tissue, with very pale outline and wavy, parallel course, between 
 
AUTHOR S EXPERIMENTS. 221 
 
 which were scattered spindle-shaped cells and fibre- cells. Corre- 
 sponding to the small white bodies the section of the mass was 
 opaque, and small pieces of those bodies started out on its being cut 
 into. Here a finely granular deposit was found, in an irregular, but 
 tolerably circular extent, between the fibres, which had become very 
 obscurely marked, and small, longitudinal bone-corpuscles, with 
 radiating processes, lay within it. On the addition of dilute muri- 
 atic acid the fibres became very pale, external to the dark spots, 
 and gradually disappeared. At the situation of these dark spots a 
 strong development of air-bubbles occurred; the dark bone-cor- 
 puscles, with their processes, disappeared, the whole mass became 
 homogeneous, and clearly transparent; round and longitudinal 
 nuclei showed themselves in it, arranged longitudinally. In the 
 situation of the former dark spots, which continued somewhat 
 opaque, they were darker than in the rest of the mass. 
 
 Explanation to Fig. 30. 
 
 Longitudinal section of the radius of a pigeon, thirty-four days after the 
 excision of a piece, four lines in length, out of its shaft. 
 
 Fig. 30. 
 
 aaaa. The remains of the bone. 
 
 b b. New bony material, covering the ends of the 
 bone, and completely closing the upper por- 
 tion of the medullary cavity. 
 
 c. Fibrous material, with bony nuclei scattered 
 through it (the latter are shown diagram- 
 matically). 
 
 EXPEEIMENT XIII. (Mg. 31.) 
 
 In a rabbit, which was not quite full grown, a piece seven lines in 
 length was excised out of the shaft of the radius, the periosteum 
 
222 ON REPAIR AFTER RESECTION OF BONES. 
 
 being spared as much as possible. The wotmd was brought together 
 with sutures. The animal ran about after the operation with the leg 
 drawn up^ without supporting itself upon it. On the second day a 
 considerable fluctuating swelling was found along the whole forearm, 
 largest in the neighbourhood of the wound, which was firmly closed. 
 Up to the fourth day the swelling continued to increase. The 
 animal sat stiU, and would not feed. The sutures were removed 
 and the wound reopened, on which a quantity of brownish, serous 
 fluid escaped, and might be pressed out by stroking the hmb. On 
 this the swelling disappeared almost entirely. On the ninth day the 
 animal had become cheerful again, and fed. The wound was sup- 
 purating healthily. At the end of the third week the wound was 
 firmly healed, and there was no swelling in its neighbourhood. A 
 small interval could stiR be felt between the cut ends of the bone. 
 The animal used the leg operated on as well as the other. It was 
 kiUed on the eighty-fourth day after the operation. 
 
 Dissection. — Under the cicatriK a small depression could be felt 
 between the ends of the radius. The latter were somewhat tuber- 
 cular, and immoveable. The cicatrix was firmly united to the sub- 
 jacent fascia, and the latter to the muscles in the neighbourhood of 
 the resection. The muscles were readily separable from each other, 
 they embraced firmly the tuberculated cut ends of the radius, 
 and dipped down into the depression between them. The ends of 
 the radius were pointed by a deposit of new bone, which was white, 
 porous, and irregularly jagged {cc). It replaced the loss of sub- 
 stance almost entirely for the length of about four lines at the 
 lower and about two at the upper end. The medullary cavity was 
 perfectly closed at both sections. The irregular cleft between the 
 ends of the bone {d), which was about a hue in length, extended to 
 the ulna, with which the cut ends of the radius were firmly united 
 by means of a narrow strip of new bony material, of a white colour. 
 "With this exception there was no deposit of new bone on the ulna. 
 The periosteum covered the bone entirely. It was found somewhat 
 thickened in proceeding towards the cut ends, and came off from 
 them together with the muscles inserted into it. 
 
 The viscera were healthy. 
 
AUTHOR S EXPERIMENTS. 
 
 223 
 
 Explanation to Pig. 31. 
 
 Bones of the forearm of a rabbit, after the resection of a piece, seven lines in 
 lengtli, from the shaft of the radius, eiglity-four days after the operation. 
 
 Eg. 31. 
 
 a. Ulna. 
 
 h. Kadius. 
 
 c c. The cut ends of the radius, covered with 
 new bony material, and firmly soldered by 
 means of this material to the ulna. 
 
 d. Space between the out ends of the bone. 
 
 Experiment XIV. (l?igs. 32^ 33.) 
 
 In a rabbit of middle size, I resected a piece nine lines in length 
 from the substance of the radius, without preserving the periosteum, 
 and united the wound by the interrupted suture. The animal re- 
 mained cheerful, and at first carried the leg operated on drawn up 
 to its body, but after only a few days again bore a little of its 
 weight upon it. About this time a tolerably large, doughy swelling, 
 very painful on pressure, had formed along the whole forearm, and 
 especially around the situation of the resection and in the neigh- 
 bourhiood of the elbow-joint. The wound was firmly closed. I did 
 not open it, and found a few days later only a slight increase of the 
 swelling, which had become more solid than before. The sutures 
 had cut out. The wound was for the most part united. Thick pus 
 exuded on pressure from the ununited part. When I again ex- 
 amined the animal, at the end of the fifth week, the wound was 
 firmly' cicatrized, tbere was no longer any swelling on the forearm. 
 
224 ON REPAIR AFTER RESECTION OP- BONES. 
 
 • but about the elbow-joint, which was flexed to a right angle, there 
 was found a spherical, very hard swelling, not painful on pressure, 
 and the size of a small walnut. The joint was moveable only, 
 to a very slight degree. In trying to extend it forcibly I felt a 
 solid resistance, clearly depending on caUus-material in the joint. 
 At the same time a rectangular contraction of the wrist had 
 occurred, so that the animal touched the ground in running only 
 with the extreme point of the leg. Even this only occurred in quiet 
 motion ; if I chased the animal, it drew up the operated limb to a 
 considerable height, and used only the three sound legs. The fore- 
 arm itself was a good deal curved, with the convexity upwards. 
 An interval, the breadth of a finger, was felt between the resected 
 ends of the radius. Its- condition remained about the same up to 
 the end of the eighth week. The contraction of the wrist had made 
 such progress that the animal, when it rested on the limb, trod on 
 the back of the paw. It was killed on the fifty-sixth day after the 
 operation. 
 
 Dissection. — ^The cicatrix of the skin adhered intimately to the 
 soft parts below. The muscles in the neighbourhood of the resec- 
 tion were united together, and dipped into the hiatus between the 
 cut ends of the radius, which was eight lines in length. In the 
 dissection they came off from the ends of the bone, together with the 
 periosteum, which was somewhat thickened. The ulna {a) was con- 
 siderably bent in a curve, with the convexity upwards. The ends of 
 the radius {e c) were rounded off by a small quantity of new bony 
 material, of a white colour, and were firmly united to the ulna by 
 similar deposit (fig. 33 d d d). This covered the outer side of the 
 ubia also in a thin layer, corresponding in extent to the hiatus in 
 the bone (fig. ^i d). The medullary cavity of the radius was 
 closed at both ends, to a greater extent at the lower than the 
 upper (fig. 33 bb, ce); the medullary cavity of the ulna was 
 unaltered (fig. 33 a a). 
 
 The capsule of the elbow-joint was extraordinarily thickened and 
 hard, and was firmly united to the muscles which passed over it. 
 It had the size and shape of a small walnut. In the capsule dry, 
 thick pus was contained, together with the joint ends of the 
 humerus (fig. 3 a/), the ulna (fig. 3 a e, and 33 e), and the radius 
 (fig. 3a g). They were very much enlarged by formation of new 
 bone, and entirely deprived of their cartilaginous covering. The 
 condyloid process of the humerus was firmly united to the sigmoid 
 
AUTHOR S EXPERIMENTS. 
 
 225 
 
 cavity of the ulna, by a short, strong, fibrous union, which covered 
 also the other articular surfaces of the bones. On section, the new 
 formation of bone could be recognised as a deposit on a portion only 
 of the radius. On the articular process of the ulna, there was 
 nothing to be seen of the original bone, but merely a homogenous, 
 tolerably firm, but porous mass of bone (fig. 33 e). 
 
 Fig. 33. 
 
 Explanation to Fig. 32. 
 
 Bones of the forearm of a rabbit, after the resection of a piece, nine lines in 
 length from the substance of the radius ; fifty-six days after the operation. 
 
 a. The ulna, much curved. 
 h. The radius. 
 
 c c. The ends of the bone, covered v^ith new bony material, by means of 
 which they are firmly united to the ulna. 
 
 d. New bony material deposited on the ulna. 
 
 e. The articular extremity of the ulna, considerably enlarged by deposit of 
 
 bone. 
 
 f. Condyloid process of the humerus. 
 
 g. The head of the radius. 
 
 15 
 
326 ON REPAIR AFTER RESECTION OE BONES. 
 
 Explanation to Fig. 33. 
 
 TLs same preparation, sawn across transversely in the centre, and longitudinally 
 by different sections. 
 
 a a. The ulna. 
 
 bb. The radius. 
 
 cc. New bony material, completely closing the medullary canal of the 
 
 radius. 
 ddd. New bony material, firmly uniting the ends of the radius to the 
 
 ulna. 
 ee. New porous bone, which occasions the enlargement of the head of the 
 
 radius and of the olecranon. 
 
 EXPEEIMENT XV. (Fig. 34.) 
 
 In a full-grown rabbit I resected a piece, five lines in length, out 
 of the shaft of the humerus. The length of the humerus before the 
 operation measiiied two inches nine lines. Immediately after it, 
 through displacement of the lower fragment upwards and forwards, 
 a shortening of one inch was occasioned. The displacement was 
 reduced, and an apparatus of gutta percha with paste bandage 
 applied. The animal, however, would not submit to the bandage, 
 and gnawed it, as often as I replaced it, so as soon to get it off. 
 The displacement of the ends of the bones thus recurred. An in- 
 considerable swelling, which had shown itself on the forearm, dis- 
 appeared, as soon as the wound (at first closed by sutures) was 
 reopened. Union took place by suppuration. The animal remained 
 cheerful, carried the injured limb hanging, or trailed its lower part 
 after it. Shortly before the animal was killed (which was done on 
 the fifty-first day after the operation) the usefubiess of the limb was 
 found not to have improved. The two pieces of the humerus, where 
 they had been sawn apart, remained at an obtuse angle pointing back- 
 wards, and were firmly united to each other, but moveable without 
 crepitus. Mrm caUus-material could be felt through the soft parts. 
 A round swelling of the size of a cherry, firm, but not solid, was 
 present at the point of union of the two fragments, stretching back- 
 wards ; it was slightly moveable, and appeared to be connected with 
 the upper fragment of the bone. 
 
 Dissection. — The cicatrix was very delicate and firm. The 
 
author's experiments. 227 
 
 muscles were natural, except that the triceps muscle was thinned, 
 being raised by the swelling, and its fibres spread out to form a 
 covering for it, and diificult to separate from it. On both fragments 
 of the bone there was deposit of new bone, of an irregular tubercu- 
 lated shape. This was united by a ligamentous material between 
 the two fragments. The sweUiag above mentioned was united 
 directly to the upper end of the bone. Its firm fibrous capsule, 
 which was about a line ia thickness, passed over into the thickened 
 periosteum on the upper end of the humerus. The perios- 
 teum on the lower end of the bone was not thickened. On a 
 section being made into the tumour, a quantity of thick yeUow 
 cheesy pus came into view ; which had also been evacuated, though 
 in small quantity, from a fine opening in the bone close below the 
 articular head, in dissecting the muscles off the bone. On a longi- 
 tudinal section of the swelling and of the two fragments of the bone, 
 the following was observed : 
 
 The corresponding ends of both fragments were enlarged by irre- 
 gularly tuberculated new bony material {dddd), the end of the 
 upper fragment much more than that of the lower. The medullary 
 cavities of both were closed at their corresponding extremities {e e). 
 The new bony material was continued as a narrow strip, which ex- 
 tended, for the most part clearly distinguishable from them, on either 
 side of the fragments, towards their articular endsj and accom- 
 panied the upper fragment up to the joint, and the lower to about 
 its middle. In this bony material the formation of diploic tissue 
 had progressed in parts to a great extent, and the remains of the 
 old bone had been in part absorbed. The medullary cavities in both 
 fragments were filled with the same thick cheesy pus as was found 
 in the swelling, and which showed normal pus-cells under the micro- 
 scope. At the lower end of the upper fragment of the bone there 
 was a cavity as large as a hempseed, which communicated with the 
 medullary cavity by a fine opening. The capsule of this cavity 
 exhibited, under the microscope, smooth fibres crossing each other 
 in numerous directions. To this cavity was connected another and 
 larger swelling {/), separated from it by a similar, but stronger, 
 membrane. The corresponding extremities of the humerus, which 
 were covered by new bony material, were partially united together 
 by a short, strong, ligamentous structure {g), which externally was 
 inseparably united with the periosteum. 
 
 The lungs, heart, and hver of the rabbit were quite healthy. 
 
228 ON REPAIR AFTER RESECTION OF BONES. 
 
 Eg. 34. 
 
 Explanation to !Pi&. 34. 
 
 Longitudinal section of the humerus of a rabbit, fifty-one days after resection 
 of a piece, five lines in length, out of its shaft. 
 
 a. The upper end. 
 
 b. The lower end. 
 
 cccc. The remains of the shaft. 
 
 dddd. New bony material deposited on the exterior of the bone. The 
 
 formation of diploic substance has made great progress ; the remains 
 
 of the old bone are in part absorbed. 
 e e. New bony material closing the ends of the medullary cavity after its 
 
 division. In the upper fragment of the bone this is perforated, and 
 
 is connected with — 
 /. A circumscribed encysted abscess, the pus from which also fills the 
 
 medullary cavity. The communication is shown by a fine bristle. 
 o. ribrous material between the ends of the bone. 
 
APPENDIX TO CHAPTER I. 
 
 I HAVE collected all the instances of dissections after successful 
 operations for excision of bones and joints which I could find on 
 record since the date of Wagner's publication in 1853. The great 
 activity of both English and German surgeons in this branch of 
 operative surgery led me to anticipate, before I commenced the 
 searchj a copious collection of authentic cases which would test the 
 truth of our author's theories, and form a valuable addition to 
 surgical literature. The meagre list which I am able to furnish, 
 after a careful search of aU the principal German, French, English, 
 and American periodicals and treatises, shows how completely erro- 
 neous my anticipations were, and how accurately our author's com- 
 plaint of the barrenness of this field of investigation applies even to 
 the present day, when all other points connected with excisions have 
 been so diligently studied. It is possible, however, that sufficient 
 time has not yet elapsed since the general adoption of the operation 
 for many opportunities to have been found of dissecting limbs on 
 which it has succeeded. I believe the foUowiag Kst includes all 
 which have been put on record. In arranging them I have followed 
 the classification adopted ia Chapter I of Wagner's treatise. 
 
 A. Excision of the shoulder. 
 
 The cases of excision of the shoulder-joint which appear to have 
 become the subjects of subsequent dissection are only three ia 
 number. 
 
 The first is to be found in the 'Deutsche TCIiuilc ' for 1856 (vol. 
 viii, p. 21) by Herr Eeid, of Jena. The operation had been performed 
 one year previously, on account of caries of the head of the bone 
 with acute pain in the joint. One long incision had been made. 
 
230 
 
 ON REPAIR AFTER RESECTION OF BONES. 
 
 and the tendon of the biceps was spared. The patient was in a bad 
 state of health, suffering from the effects of empyema, &c. The 
 scapula was found superficially ulcerated. The case went on well 
 for eight months ; the wound healed, except two small fistulee, and 
 the functions of the arm were perfect, except abduction. Then his 
 health failed, pain recurred at the situation of the joint, and the use- 
 fulness of the arm diminished. He died of lumbar abscess, accom- 
 panied by tubercular disease in other parts. Dissection of the 
 shoulder showed the ends of both bones enclosed in a capsule, which 
 was lined by a membrane resembling mucous membrane, and covered 
 by a viscid secretion. This capsule was closed, except at two points, 
 where it communicated with the above-mentioned fistulse. Its walls 
 were formed in part by the remains of the old articular capsule, but 
 principally by the muscles surrounding the joint. The latter were 
 more or less fattily degenerated, and the supra- and infra-spinatus 
 were also infiltrated with pus from the flstulse. The long tendon of 
 the biceps was traced upwards. It was free up to the resected end 
 of the humerus : here it was firmly united to that bone ; and beyond 
 this point a deposit of bone was found in it corresponding to a 
 bony swelling on the inner side of the resected humerus. Above 
 this it was inseparably united to the capsule, and beyond that again 
 could be traced in the form of a band, a quarter of an inch in breadth, 
 bridging over the interval between the capsule and the remains 
 of the glenoid cavity, which was affected with caries. The end of 
 the humerus was a little enlarged and rounded off; on its inner side 
 was a crest of bone, resembling an exostosis. The thicker parts of the 
 scapula, and especially the acromion, were swollen and very porous. 
 Lamellated bony deposits were found in the supra-spinous fossa. 
 
 The second case will be found in the 8th vol. of the 'Pathological 
 Transactions,' p. 346. Mr. Hutchiason excised the head and about a 
 third of the shaft of the humerus on account of a tumour described 
 as of the myeloid variety. The tumour recurred (being then of a 
 distinctly cancerous nature) in the wound and in other parts of the 
 body, and the patient died five months after the operation. 
 
 The shaft of the bone was itself healthy, and was united to the 
 lower edge of the glenoid cavity by a thick ligamentous band, so 
 strong that the bones could not be separated by any moderate force. 
 This union permitted of free motion in all directions. Springing 
 from the periosteum of the humerus at the point of section, and 
 surrounding the bone and the ligament, uniting it to the scapula. 
 
APPENDIX TO CHAPTER 1. 231 
 
 was a large mass of malignant disease. The deltoid muscle had 
 been previously absorbed by the disease for which the resection was 
 performed. 
 
 The specimen is in the Museum of St. Bartholomew's Hospital. 
 
 The third case is by Professor Heyfelder (' Prager Vierteljahrs./ 
 xxi, p. 87). It occurred before the publication of Wagner's treatise, 
 and its omission is noticed by Heyfelder in a review of this volume. 
 The detaUsj however, are very scanty. The operation had been per- 
 formed a year before, on account of caries. Death was the result of 
 tuberculosis. The missing bone had been replaced by a material of 
 new formation ; which, where it lay close upon the bone, was firm, 
 and of bony appearance; but, further away, resembled brawny 
 fibrous tissue. The coracoid process was carious, and two fistulous 
 openings led from it through the soft parts. 
 
 B. Excision of the elbow. 
 
 Of successful cases of excision of the elbow, I have also been 
 able to find only three on record. They are as follows : 
 
 Case i ('Lancet,' 1855, vol. i, p. 331). — ^The patient was 
 a man thirty-eight years of age, who had been operated upon 
 nine years previously by Mr. Syme for diseases of the elbow- 
 joint, and who had made a rapid recovery, and had since been 
 employed as a guard upon the Edinburgh and Glasgow Railway. 
 When questioned as to the use of his arm, he always made the same 
 reply, that he knew no difference between it and the other Kmb, that 
 he could lift an equal weight with them, and that in swinging himself 
 about from one carriage to another, when the train was in motion, 
 and such other dangerous proceedings, he trusted one Umb quite as 
 much as the other. On accurately comparing the mobility of the 
 two joints, it might be observed that the ex'tent of motion was not 
 so great on the side where excision had been performed as on the 
 other ; but flexion, extension, pronation, and supination were as 
 perfect as could be desired for all useful purposes. The external 
 aspect of the joint was wonderfully natural, the most obvious 
 deficiency being the absence of the olecranon. The Kmb was not 
 quite so muscular as that of the opposite side. He died of the 
 effects of an accident. 
 
 The ends of the bones concerned in the elbow were removed after 
 death, and a representation of them may be seen in the 'Lancet,' as 
 
233 ON REPAIR AETiiR RESECTION OF BONES. 
 
 above referred to. The following is Mr. Syme's description, with 
 such verbal alterations as were necessitated by his references to an 
 accompanying engraving : 
 
 " The elbow has a very remarkable appearance ; the ends of the 
 bones concerned, though quite different in shape from the normal 
 condition, being yet so adapted to each other as to form a secure 
 hinge-joint. The ulna is devoid of either olecranon or coronoid pro- 
 cess, and, instead of embracing the end of the humerus, is received, 
 along with the radius, into the forked end of the os humeri. This form 
 of the last-named bone appears to have been produced by the growth 
 downwards of two processes, one from each side of the cut end of 
 the humerus, which appear to be entirely new formations. The 
 ulna is separated a short distance from the humerus, the interval 
 being occupied by a rather lax and vascular ligamentous union ; but 
 the radius forms with the humerus a true articulation, lubricated with 
 synovia ; the surface of the radius, where it touches the humerus, is 
 rounded, the corresponding concave part of the humerus fitting 
 accurately to it; these surfaces are in part covered with fibro- 
 cartilage, and partly bare, and of porcellaneous hardness ; but it is 
 interesting to observe that a bare part of one bone is always opposed 
 by a cushion of fibro-cartilage on the other. The radius and ulna 
 are also adapted to each other ; the tuberosity of the radius, into 
 which the tendon of the biceps is inserted, being received into a 
 concavity in the ulna, formed in part by a growth of the latter bone 
 upwards into a process that curves over the rounded head of the 
 radius, and gives attachment both in front and behind to a strong 
 and distinct orbicular ligament, which is but loosely connected with 
 the radius, and allows of its free play in rotation. To compensate 
 for the loss of the head of the radius, which was removed in the 
 operation, a promiuent lip has grown out around the upper margin 
 of the bone at its outer part, which thus has a purchase on the orbi- 
 cular Kgament, like the natural head. Between the radius and ulna 
 there is partly loose ligamentous union, and partly a true articula- 
 tion, Hned with synovial membrane ; the expanded insertion of the 
 tendon of the biceps serving to cover the articulating part of the 
 radius, while the depression on the ulna is lined with the nearest 
 approach to pure cartilage that is to be found in this elbow. To 
 the naked eye it looks quite like cartilage ; and under the micro- 
 scope differs from it only in the fact that the matrix is obscurely 
 fibrous. Two strong lateral ligaments join the extremities of the 
 
APPENDIX TO CHAPTER I. 233 
 
 processes of the humerus to the orbicular Kgament on the one side 
 and to the ulna on the other, A separate piece of bone (sesamoid) 
 is imbedded in the internal lateral ligament at its juncture with the 
 ulna. The extremity of the prolongation of the ulna upwards is 
 also a separate piece united to the rest by ligament. The anterior 
 ligament of the joint has been cut away ; it was extremely strong, 
 so as to compensate for the absence of the olecranon iu checking 
 backward movement of the forearm beyond the Hmit of complete 
 extension; it was attached above to the anterior surface of the 
 humerus, and below to the upper edge of the orbicular ligament, 
 and the anterior surface of the ulna. There was also a strong 
 posterior ligament." 
 
 Case a. — Mr. Bickerstety exhibited at the Liverpool Medical 
 Society the elbow-joint of a female, set. 42, who died seventy-three 
 days after complete excision had been performed. After the opera- 
 tion she went on well for a week, when symptoms of phthisis set in. 
 The elbow continued to heal as the disease progressed. Sloughs 
 formed on the back, and a small one on the inner side of the elbow. 
 A new joint had been formed, complete in all its parts, except where 
 the slough had formed. All the movements coidd be readily per- 
 formed. The tendon of the biceps had not been disturbed. A por- 
 tion of the brachialis anticus which had been detached had acquired 
 an insertion into a new anterior ligament. The triceps was attached 
 to the cicatrix, to a new posterior ligament, and to the fascia. The 
 interior of the joint was Hned by a distinct synovial membrane, 
 divided into two cavities, the radio-ulnar articulation being separate • 
 from the remainder of the joint. The structure of the ends of the 
 bones was condensed, the cancelli filled up, and the surfaces present- 
 ing an almost porcellaneous appearance. 
 
 Case 3. — ^Dr. Mayer, of Wuerzburg, relates ('Deutsche Klinik,' 
 vol. viii, p. 188) a case of excision of the elbow, in which only the 
 end of the ulna was removed. Nine months after the operation all 
 the movements of the forearm, flexion, extension, pronation, and 
 supination, were perfect. At the above period a bony process 
 resembling the olecranon could be felt given off from the end of the 
 ulna, and connected with the triceps muscle; as could be easily 
 made out in extension of the arm. 
 
 ' 'Association Medical Journal,' 1856, p. 218. 
 
234 ON REPAIR AFTER RESECTION OF BONES. 
 
 D. Excision of the hip. 
 I have only two cases to add to Wagner's. 
 
 Case i ('Deutsche Klinik/ 1851, p. 497). — Heyfelder relates a 
 case in whichj sixteen months after the unsuccessful resection of the 
 hip, the Kmb was removed together with the carious portion of the 
 pelvis. I find no distinct description of the anatomical condition 
 of the parts involved in the resection. The Kmb is said to have been 
 at one time ankylosed to the pelvis, but the union gave way again. 
 The acetabulum was filled with pus and with softened fragments of 
 bone (deposited ?), and surrounded with isolated fragments, which 
 were removed partly with the forceps, partly with the finger. 
 
 Case a ('Glasgow Medical Journal,' vol. i, 1853-4, p. 10). — ; 
 Dr. Buchanan gives a case in which the head of the femur was 
 removed for caries in a man aged forty-one. The patient died three 
 months afterwards of dysentery. The wound was almost entirely healed 
 up ; a small opening admitting a probe alone remaining open. The 
 whole course of the incision underneath was completely consolidated. 
 The cut surface of the neck of the femur and great trochanter were 
 quite sound, being coated with a cartilaginous incrustation. The 
 circumference of the acetabulum, from which the edges had been 
 removed, was studded with spiculse of new bone, showing the pro- 
 gress which nature had already made towards a cure. The acetabu- 
 lum was filled up with granulations, but in some points was still 
 rough, the reparative process having not yet extended over the whole 
 seat of the disease. At the upper part of the cavity there was a 
 small isolated piece of rough and porous bone, loose, and evidently in 
 the course of being discharged piece by piece. Aiound tliis the 
 bone was rough, but not spongy, while other parts were solid and 
 smooth. 
 
 E. Excision of the knee. 
 
 The successful cases which have been dissected since the'publica- 
 tion of our author's treatise appear to be as follows : 
 
 Case i. — A preparation in the collection of St. Thomas's Hospital 
 shows the condition of the limb after successful excision of the knee. 
 
APPENDIX TO CHAPTEK I. 233 
 
 The patient was under the care of Mr. Souths but I have not been 
 able to learn the exact time which had elapsed between the 
 operation and death. A very smaU portion only of each bone 
 had been removed, and the patella left behind. The preparation 
 shows tolerably perfect bony ankylosis between the tibia and femur, 
 there being only a very slight and obscure movement between them. 
 The remainder of the uniting medium (which is of very small 
 extent) consists of fibrous material; there is no cartilage. A good 
 deal of new bone is deposited around the end of the femur. The 
 cancellous tissue is much condensed. There is a considerable amount 
 of periosteal deposit around the patella, by which its extent is much 
 increased. A portion of this deposit is ossified; and the patella 
 is partially united to the femur by bony deposit. There is a small 
 piece of dead bone in the head of the tibia. The front of the 
 internal condyle of the femur is slightly carious, but this is thought 
 to have been a secondary result of prolonged suppuration excited by 
 the dead bone in the tibia. The soft parts have been removed. 
 
 Case 2. — Mr. Henry Smith' exhibited, at the Medical Society of 
 London, the bones which had been removed from the lower extremity 
 of a boy who had, two years previously, undergone excision of the 
 knee-joint by Mr. Jones, of Jersey, had entirely recovered from the 
 operation, and died of disease of the liver. A firm bony ankylosis 
 had taken place at the site of the operation, between the extremity 
 of the femur and tibia, in nearly a straight position. The patella 
 also, which had not been removed in the operation, was united to 
 the anterior part of the femur, and its ligament was still attached 
 to it and to the tibia, so that altogether a very firm compact mass 
 of bony tissue occupied the situation of the knee-joint. 
 
 Case 3.— Mr. Jones, of Jersey,^ amputated the thigh several 
 (apparently about nine) months after excision of the knee for 
 caries of the femur and tibia. 
 
 The patient, a girl aged fifteen, was exhausted by discharge from 
 a large abscess in the back, and this, together with the occurrence of 
 frequent attacks of hysteria, caused sloughing of the parts and fre- 
 quent displacement of the bones. 
 
 » ' Lancet,' Dec. 9th, 1854 ; from ' Bdinb. Med. and Surg. Journ.' for 1855, 
 
 p. 184. 
 ' 'Medical Times and Gazette,' 1855, vol. ii, p. 343. 
 
236 ON REPAIR AFTER RESECTION OF BONES. 
 
 A portion of the lower third of the femur was found in an 
 advanced stage of necrosis. There was strong ligamentous union 
 between the femur and the tibia, and the pateUa was partially 
 attached to the former. 
 
 Case 4.^ — A preparation of bony ankylosis in the College 
 Museum, from a patient of Sir P. Crampton. 
 
 This preparation is not very exactly described in the College 
 Catalogue. From a card, however, which accompanies it, it appears 
 that the patient survived the operation twenty-seven years. The 
 end of the femur appears to have been sawn through close above the 
 condyles, and is ankylosed at a right angle to the tibia, of which a 
 very thin shce only can have been removed. The tibia appears also 
 to have been displaced a little backwards, and somewhat twisted upon 
 its own axis. A large quantity of porous bone is thrown out 
 around the head of the tibia. The uniting medium between the 
 two bones is solid compact tissue, of an ivory hardness, exactly re- 
 sembling the compact tissue of the shaft in its neighbourhood. 
 
 I am not aware that any detailed history of this case exists, but it 
 is referred to in Mr. Pergusson's ' Practical Surgery.' 
 
 Case 5. — The following case, although the patient is stiU. alive, 
 may deserve meiition here as showing that bony ankylosis is not 
 always necessary to the success of excision of the knee, but that 
 some degree of useful motion may occasionally be preserved. The 
 case is reported in the 'British Medical Journal,' 1858, p. looi. 
 
 A healthy-looking girl, a housemaid, occasionally comes to King's 
 College Hospital, whose knee was excised by Mr. Pergusson in the 
 summer of 1856. On making her stand -vrith her heels together, 
 the limbs seem of equal length, but, on measuring, the left is found 
 to be the shorter by nearly half an inch. The knee has very much 
 the contour of its fellow ; the patella exists, and is slightly move- 
 able ; and the patient can flex and extend the knee to a consider- 
 able extent. The joint, however, does not admit of lateral motion. 
 In following her occupation she is constantly on her legs, and has 
 to go up and down stairs several times during the day. There is 
 
 ' This is the case referred to in Chapter I, of which the author says he has 
 not been able to find a description. 
 
APPENDIX TO CHAPTER I. 237 
 
 just a slight limp in her walk. On referring to the case-book, it is 
 found stated that, at the operation, a sUce half an inch thick was 
 removed from the femur, and two portions from the tibia, together 
 about an inch and a quarter in thickness. 
 
 F. Besection of the lower end of the fibula. 
 
 M. HoueP relates a case in which the leg was amputated six 
 months after resection of the lower end of the fibula. 
 
 All the muscles were lardaceous, and almost fused together into a 
 single mass. It was supposed that the anterior tibial nerve had 
 been divided in the operation, but the cohesion of the muscles made 
 it impossible to determine whether this had been the case. 
 
 The superficial layers of the fibula were swelled out and softened 
 to the extent of eight centimetres (three inches nearly) above the 
 point of section. Below this point was found an osteo-fibrous mate- 
 rial of new formation, continuing the fibula downwards to the exter- 
 nal side of the astragalus ; and it articulated with this bone just as the 
 malleolus externus had done, which it represented exactly. Between 
 the superior extremity of this new malleolus and the free surface of 
 the fibula was a false joint offering for examination two cartilaginous 
 surfaces, lubricated by a viscid fluid, and maintained in contact by 
 two thick bundles of vertical fibres. The posterior surface of the 
 new malleolus was in relation with the peronei tendons, as in the 
 normal state ; but these tendons had contracted intimate adhesions 
 with this eminence, so that, if the resection had succeeded, they 
 would no longer have had any action on the foot. The tibia was 
 hypertrophied in its whole lower half, which was covered by thickened 
 and injected periosteum. Between the external surface of the tibia 
 and the newly formed external malleolus, the interosseous Hgament 
 of the inferior tibio-fibular joint was replaced by a fibro-cartdaginous 
 tissue uniting the two parts intimately. Lastly, the articular surface 
 of the lower end of the tibia was solidly soldered to the upper sur- 
 face of the astragalus by bony substance occupying the whole extent 
 of the pulley-like surface. 
 
 G. Wrist-joint. 
 Case i ('Prag. Vierteljahrschrift,' 1858, Bd. lix, p. la). — Pro- 
 
 ' ' Bulletin de la Soci6t6 de Chirnrgie,' vol. iv, p. 400. 
 
238 ON REPAIR AFTER RESECTION OF BONES. 
 
 fessor Adelmann relates a case of resection of the lower extremity 
 of both radius and ulna, for caries. The hand was useless after- 
 wards, from the extremities of the bones having become again 
 carious. The forearm was amputated six. months afterwards. 
 
 The interval which had been left in the resection was found to 
 have been diminished; the lower ends of the two bones had lost 
 the smoothness of their sawn surfaces, which were covered by 
 irregular masses of bone, which, however, did not reach the carpus. 
 Both bones were increased in thickness, and their original figure 
 was quite lost. 
 
 Case a ('Pathological Transactions,' vol. viii, p. 390). — 
 Mr. Fergusson exhibited a dissection of a forearm from a patient in 
 whom he had excised the wrist-joint six months before death. It 
 is described as follows : 
 
 The whole of the bones of the wrist were supposed to have been 
 removed. Dissection, however, showed that the pisiform bone, the 
 trapezium, and a part of the unciform bone had been left. Portions 
 of the radius and ulna were taken away. 
 
 The operation was performed through a wound in the soft parts 
 on the ulnar side of the joint. The dissection showed how little 
 damage to tendons had been inflicted. The hand moved freely at 
 the wrist, and there was free use of the fingers and thumb. A 
 small sinus remained on both the radial and ulnar side of the wrist, 
 and on dissection it was found that both of the sinuses communi- 
 cated with a portion of the end of the radius which was bare. The 
 patient died of phthisis. 
 
 I have not been able to find a more detailed account of this pre- 
 paration, nor the preparation itseK, which, however, prcjbably exists 
 in King's College Museum. 
 
 II. Besections from the substance of bones. 
 
 The following are aU the cases which appear to bear on this sub- 
 ject: 
 
 Case i ('Medical Times and Gazette,' 1857, vol. ii, p. 453). — 
 Excision of the ulna, and dislocation of the upper end of the 
 radius. — This case is reported in the following words : Samuel 
 
APPENDIX TO CHAPTER I. 239 
 
 D — , 8et. 1 8, a liealthy-looking lad, is now under Mr. Cock's 
 carcj on account of an affection not in any way connected with 
 that which forms the main interest of his case. His right arm 
 presents the following conditions : There extends along the inner 
 border of the forearm, almost from the wrist to the elbow, a linear 
 cicatrix, beneath which the parts are fallen in, and the border, 
 instead of being round and fall, is concave. The styloid process of 
 the ulna and its whole articular head may be felt in its place, but 
 between this and the olecranon the bone is entirely deficient. The 
 cicatrix marks, no doubt, the incisions by which the shaft was re- 
 moved, and there would appear to have never been the slightest 
 attempt at reparation. The extremities of both articular ends are 
 irregular, and much in the condition left at the time of separation. 
 The olecranon is about an inch long, the shaft being abruptly defi- 
 cient, with the exception that a very slender spicula, about two inches 
 long, extends forwards from its inner border. The lower head of 
 the bone is about half an inch long, and ends abruptly. The radius 
 is dislocated forwards over the inner condyle of the humerus, and has 
 there very free motion, being restrained only by membranous bands. 
 The arm is thin, and the state of its bones in the respects adverted 
 to is very easily made out. The lad states that he is right-handed, 
 and always uses the aifected arm. He is accustomed, to wheel a 
 barrow, to lift heavy weights, &c. Its defect appears to be of re- 
 markably little inconvenience to him. As to the history of the 
 original disease, it appears that he was treated in St. George's 
 Hospital, at the age of four, for necrosis of the bone, and that four 
 operations for the removal of sequestra were performed. 
 
 Case 2. — Resection of a portion of the shaft of the ulna. — In the 
 ' Deutsche Klinik,' 1 855, p. 145, will be found a case in which Eobert 
 resected a great part of the ulna, leaving the periosteum — a piece 
 five and one third inches in length, through the coracoid and 
 olecranon processes, but not opening the joint, — on account of 
 chronic periostitis, complicated with bleeding from the inter- 
 osseous artery. The movements of the arm, including rotation, 
 were almost perfectly restored. The patient died eight months 
 after, of apoplexy. The whole of the bone had not been re- 
 generated. The cicatricial tissue between the ends of the bone 
 consisted of a membrane which, close to its origin from the upper 
 section, contained a small plate of bone. The hiatus was con- 
 
240 ON REPAIR AFTER RESECTION OF BONES. 
 
 siderably shorter than the portion of bone removed — the latter 
 having measured eight centimetres, while the former measured only 
 five. Thus it was seen that there had been growth of bone from each 
 sawn extremity, as was proved also by their altered form. Thus, the 
 lower fragment of the ulna ran up into a flat-pointed process, 
 twenty-five millimetres in length, seven in breadth, and four in 
 thickness, which appeared to have come off from the medullary 
 cavity of that bone. This lower portion was approximated to the 
 radius at its upper end. The reproduction of bone was more con- 
 siderable at the upper end — a piece five centimetres long having been 
 deposited on the outer, and one two centimetres in length on the inner 
 side. The fragment had changed its position, the new deposit of 
 bone passing down upon the radius ; to which it was intimately 
 united by fibrous tissue, and formed a sort of false joint, which 
 interfered -with, the rotation of the radius. The new deposit on the 
 interior of the bone passed over to the head of the radius, forming a 
 process which supported it, as it were, and was covered with car- 
 tilage so as.to form a perfect joint. 
 
 The articular surfaces both of radius and ulna were united to that 
 of the humerus by false membranes, but not so as to liinder motion. 
 
 Case 3. — Resection of the greater part of the shaft of the tibia. 
 — ^Professor Adelmann ('Prag. Vierteljahrschrift,' 1858, Bd. hx, 
 p. 44) relates a case in which Herr Bechtold resected the whole shaft 
 of the tibia, from three fingers' breadth below the condyles to 
 two fingers' breadth above the malleolus. 
 
 Three quarters of a year afterwards a "cicatrix of regeneration" had 
 formed from one epiphysis to the other ; but in spite of the unin- 
 jured fibula, shortening of more than two inches had occurred, com- 
 pelling the patient to wear a high-heeled shoe. 
 
 Case 4. — Resection of apiece out of the shaft of the tihia. — ^Pro- 
 fessor Adelmann. ('Prag. Vierteljahrschrift, 1858, Bd. Hx, p. 
 45.) The operation was performed on account of a penetrating 
 ulcer of the soft parts involving the bone, with a view of relie\dng the 
 tissues of the parts, removing entirely the diseased bone, and giving 
 the patient a chance of the heaUng of the ulcer. A piece of bone six 
 inches long was excised. The ulcer healed temporarily, but broke out 
 again. The limb remained useless, and the leg was amputated 
 eight months afterwards. There was no trace of formation of callus- 
 
APPENDIX TO CHAPTER I. 241 
 
 The stumps of the tibia had become pointed off at both ends^ but 
 this state was produced^ not by the deposit of callus material on the 
 ends of the bone and subsequent ossification, but by absorption of 
 portions of bone from the upper and lower ends of the tibia. The 
 interspace between the ends of the tibia was filled by a fibrous exu- 
 dation-substancBj attached to the neighbouring muscles, which 
 were partially atrophied, and intimately blended with them. This 
 rendered it difficult to dissect the separate muscles and vessels. 
 
 Case 5 (Busch, ' Chirurgische Beobachtungen,' p. 360). — A 
 man, set. 50, in good health, suffered trephining of the tibia, 
 which was much hypertrophied, close below the tuberosity, on 
 account of necrosis. The soft parts were separated by a crucial 
 incision, and the thickened periosteum rasped away. This separa- 
 tion of the periosteum extended further than the trephine-hole, so 
 that there remained a portion of exposed bone around the latter 
 uncovered by periosteum. In the progress of the case the perios- 
 teum and soft parts around this ring of bone became inflamed 
 and swollen, and on the fourth day after the operation a well- 
 marked development or extension of vessels into this exposed bone 
 could be seen, forihing a finely injected network running towards 
 the trephine-hole. Two days later these vessels were hidden, and the 
 exposed bone covered, by a reddish, gelatinous exudation almost up to 
 the edge of the section, and on the foUowiag day fine granulations had 
 been formed from this exudation. Thus the process was as follows : 
 In the ring of bone, which was connected with the periosteum 
 only by its outer circumference, and was itself uncovered, a well- 
 marked hyperaemia had occurred, furnishing an exudation from 
 which the newly formed granulations were developed. These 
 granulations reached almost to the edge of the section, and where 
 they ceased a small ring of bone became necrosed. Granulations 
 also sprang from the sawn surface apparently unconnected with 
 those which arose from the medullary cavity, and after the exfolia- 
 tion of the above-mentioned necrosed portion and of a few small 
 sequestra from the medullary cavity, the hole was quite filled up by 
 the union of the granulations from these three sources, and in the 
 end a perfectly solid substance was laid down, which filled up the 
 trephine-hole and united it to the skin. 
 
 (He applies this and similar observations to show that granula- 
 tions sprang from the substance of the bone itself, and thus to refute 
 
 16 
 
242 ON RKPAIR AFTER RESECTION OF BONES. 
 
 Wagner's idea that regeneration takes place only through the 
 periosteum or medullary membrane.) 
 
 Case 6. — In the ' Deutsche Klinik/ vol. viii^ p. 201^ is an interest- 
 ing case reported by Mayer, of Wiirzburg, in whioh he removed the 
 arch of the seventh dorsal vertebra, which had been depressed upon the 
 spinal marrow by direct violence six months before, and had become 
 united in its new situation by caUus. Paralysis had not come on 
 tiU some time after the injury. It was relieved, but only slightly, by 
 the operation, and the patient died three weeks afterwards. 
 
 The cord was found broken up at the seat of the injury. The 
 spinous processes of the fifth, seventii, ninth, and eleventh dorsal 
 vertebrae had been fractured ; the process above the seat of the 
 principal fracture was united by callus, but the others, as well as 
 the fracture of the spinous process, showed no trace of formation of 
 callus, while the lateral fragment of the seventh vertebral arch was 
 displaced upwards and inwards, and united with the upper half of 
 the body of the vertebra, which had been fractured across. 
 
 Case 7. — In ' Guy's Hospital Eeports,' i8_57, p. 364, there is an 
 account of the dissection of a man who had been trephined fifteen 
 years previously by Mr. Cock. The operation had been followed by 
 exfoliation of a portion of bone. The case is worthy of perusal on 
 account of its intrinsic interest. In relation to the wound in the 
 bone it is said : " As regarded the original wound, it was not replaced 
 by the growth of any new bone, but the trephine-opening was filled 
 up by a tough membrane, composed of the integument on one side 
 and the dura mater on the other. These were firmly blended 
 together, and formed a sufficiently strong protection to the brain. 
 They were strongly united to the edges of the opening, the latter 
 being rounded, with smooth edges, and little more than an inch in 
 diameter. At its upper part there were two depressions, whence 
 probably the diseased bone 'had proceeded, and there was con- 
 siderable evidence of ostitis having occurred all round the site of 
 the trephining, particularly at its front part. Here, over the left 
 protuberance of the frontal, the bone was more than twice as thick 
 as the corresponding part of the opposite side. Por about two 
 inches around this opening the dura mater was closely adherent, and 
 upon removing it the inner surface of the skull was seen to be 
 covered with a number of bony points or granulations. Immediately 
 
APPENDIX TO CHAPTER I. 243 
 
 in front of the trephine-tole there was a depression in the bone, 
 which extended upwards and downwards for a length pf three 
 inches. It was caused by a ridge of new bone immediately in front 
 of it, and might have been the site of a fracture which took place at 
 the time of injury; from the great change, however, in the struc- 
 ture of the bone, it was impossible to prove this satisfactorily. 
 
 III. Extirpation of hones. 
 
 Case i (' Wiener Wochenschrift,' 18^5, p. 513). — ^Dr. Eolaert, of 
 Coblenz, extirpated the entire fibula, on account of acute inflam- 
 mation, with central necrosis in parts. The case did well. 
 
 He says : "The peculiar resistance felt in resection-wounds at the 
 .commencement of bony reproduction was first perceived fourteen days 
 after the operation at the lower angle of the wound, as a broad, hard 
 mass, gradually becoming thicker and extending further upwards. 
 This new formation of bone had, at the eighth week, when the wound 
 was cicatrized, extended upwards only to the extent of one third of 
 the removed bone, and when I saw the patient last, on the 23d of 
 February, 1849, one year after the operation, the regeneration of 
 bone had proceeded only to half the length of the tibia. The head 
 of the fibula could be plainly felt in the form of a rounded ball, 
 from which a yielding cord extended to the upper point of the 
 regenerated bone." 
 
 Case 3. — In the 'Medical Times and Gazette,' 1 857, vol. ii, p. 453, 
 is the report of a case in which Mr. Savory removed the whole, as it is 
 supposed, of the shaft of the radius on account of necrosis ui a boy, 
 set. 9. An incision having been made over the centre of the diseased 
 bone, it was divided and drawn .out in two pieces. The" periosteum 
 was found to be separated from the bone, and was left behind. The 
 articular extremities remained untouched. The shaft had in all 
 probability separated at the epiphyses, from the extremity of each of 
 which new bone had been thrown out, so as to encase the ends of the 
 necrosed shaft for an inch or more. 
 
 When examined eight months after the operation, the bone could 
 be felt from both ends growing to within about an inch and a haK of 
 each other, the two points being free, moveable under the skin, and ap- 
 parently connected by a fibrous cord. The boy said that they con- 
 tinued to grow towards each other, but not so rapidly as they used 
 
'244 ON REPAIE AFTER RESECTION OP UONES. 
 
 to do. The lower end of the ulna was very prominent, in consequence 
 of the hand having fallen over towards the hollow left by the re- 
 moval of the radius. The movements of the hand were nearly per- 
 iect, pronation and supination being effected by rotating the 
 humerus. When the humerus was grasped above the elbow these 
 movements were stopped. The size of the regenerated bone 
 appeared much less than that of the original radius. It had been 
 hoped at one time that the two portions would have grown into and 
 united with each other, but this prospect was lost,, or at least 
 delayed, from necrosis having attacked a portion of one of the frag- 
 ments. It seemed, therefore, uncertain whether the whole of the 
 bone would be regenerated. 
 
 Case 3 ('New York Journal of Medicine,' new series, vol. x, 
 p. 135). — ^Dr. Compton excised both radius and ulna on account 
 of extensive compound comminuted fracture, followed by slough- 
 ing. The bones were disarticulated at the elbow, and removed 
 entire, except a small portion of the lower end of the radius. A 
 great portion of the periosteum was detached from the bones and 
 left in the wound. The operation was followed by the formation of 
 several abscesses connected with spicula of bone which had been 
 left in the wound. On recovery, the arm was two or three inches 
 shorter than the other, and was " perfectly firm." It remained at a 
 right angle with the humerus and could be flexed or extended, 
 so that the hand moved through eight or ten degrees of the arc 
 of a circle. The patient had entire use of the hand, could 
 both open and shut it, and grasped objects firmly. {From the 'New 
 Orleans Medical Eet/ister.') 
 
 Case 4 ('Moniteur des Hopitaux,' 1856, vol. iv, p. 838). — In a 
 clinical lecture by M. Thierry, reported as above, the following 
 words occur : 
 
 "You saw here the other day a man, about forty-five years of age, 
 who had already submitted to the operation of resection of the oscalcis, 
 necessitated by the necrosis of that bone. The calcaneum was re- 
 produced, but, unfortunately, this bone of new formation was 
 struck with gangrene like that which preceded it, and we were 
 obliged to extirpate it a second time." (Here follow some details of 
 the operation, which is said to have been long and painful.) 
 
APPENDIX TO CHAPTER I. 245 
 
 Case 5. — Maisonneuve ('Comptes rendus de TAcademie/ &c.. 
 May, 1856) resected the whole of the lower jaw on account of 
 fibrous tumour. The wound united by first intention. Soon after 
 the operation (when the case was reported) a firm tissue was 
 deposited in the place of the resected bone, in which, as the perios- 
 teum had been spared, it was hoped that bone would be deposited. 
 
 Case 6. — In the ' Gazette des Hopitaux,' 1856, p. 604, is the ac- 
 count of an operation in which M. Guerin resected the second and 
 third metacarpal bones — ^the former in its whole length, the latter 
 from just below its upper end. M. Guerin says, " There was no repro- 
 duction of bone, nor could there have been any, for the periosteum 
 was not preserved." 
 
 Case 7. — Excision of the entire radius. — In the 'American Jour- 
 nal of Medical Sciences' for April, 1858, p. 363, is the account by 
 Professor Carnochan of an excision of the entire radius, in which the 
 patient recovered entirely the use of his arm and hand. Examina- 
 tion externally, some time after the operation (apparently about five 
 years), seems to have shown no reproduction of bone, a depression 
 existing along the original site of the radius. AU the movements, 
 including pronation and supination, are said to be performed 
 without difficulty. 
 
 Case 8. — In Dr. Williamson's 'Notes on the wounded from the 
 Mutiny in India/ p. 109, will be found the account and representa- 
 tion of a case in which he excised the entire ulna, an inch and a half 
 of the extremity of the humerus, and also the head and neck of the 
 radius, on account of disease following diffuse inflammation. The 
 wound healed by first intention. Pour months after the operation, 
 the man could bend his forearm, raise his hand behind his head, 
 and lift a twenty-eight pound weight from the ground; he could 
 also pronate and supinate the hand ; there was no anchylosis of the 
 wrist-joint, and he could use his fingers well. Nothing is said as to 
 reproduction of the removed bone. 
 
THREE MEMOIRS 
 
 IRIDECTOMY 
 
 IN CERTAIN FORMS OF 
 
 IRITIS, CHOROIDITIS, AND GLAUCOMA. 
 
 BY 
 
 DR. A. VON GRAEFE. 
 
 THANSLATED BY 
 
 THOMAS WINDSOR, Esq., 
 
 ASS 1 STAN T-SUKGEON TO THE MANCHESTER EYE HOSPITAL, ETC. 
 
 THE NEW SYDENHAM SOCIETY, 
 LONDON. 
 
 MDCCCLIX. 
 
TRANSLATOR'S PREFACE. 
 
 It was originally intended to have published the following trans- 
 lations without the addition of any remarkg, trusting that the 
 importance of the subject and the celebrity of the author would 
 sufficiently counterbalance any imperfections in the translation or 
 difficulties in the original. Einding, however, that a former 
 translation of mine^ did not appear to have been generally under- 
 stood, and that even in Germany a Series of Worts had appeared 
 necessary as introductions,* I have thought it advisable to com- 
 mence by calling the reader's attention to a few points. 
 
 German ophthalmology has especially distinguished itself of late, 
 by the attention it has paid to the anatomy and physiology of the 
 organ of vision, and by the frequent, almost constant, application 
 of facts drawn from those branches to practical purposes, and 
 especially to the examination of cases. As examples, we may quote 
 the ophthalmoscope, oblique iUumination, the use of prismatic 
 glasses, &c. &c. Hence the English reader, who is necessarily 
 more or less unacquainted with these recent discoveries, must expect 
 to meet with many and great difficulties. I may perhaps be 
 allowed to mention, that I propose to publish shortly, as some 
 sHght aid in that direction, a work on the ophthalmoscope, that may 
 serve as a guide to its use and as a resum^ of what has been 
 
 ' Dr. A. V. Graefe, "On Unilateral Cataract," in the 'Med, Times and 
 Gazette/ 1857, vol. ii, p. 269. 
 
 ' Such is the ' Klinische Analyse der Motilitatsstorungen des Auges,' von 
 Dr. Alfred Graefe, Berlin, 1858. 
 
250 translator's preface. 
 
 already discovered by its assistance ; in it I shall also include the 
 subject of obhque iUumiuation, &c. 
 
 The difficulties in the present papers do not, however, seem very 
 formidable, and I hope that the explanation of a few points may 
 enable the reader to peruse them with pleasure and profit. 
 
 By exclusion of the pupil, pupillary eosclusion, or synechia pos- 
 terior totalis, is meant adhesion of the whole of the free margin of 
 the iris to the capsule of the lens. 
 
 The eye may be divided geographically into two hemispheres, an 
 anterior and a posterior, an equator, an anterior pole at the centre of 
 the cornea, and a posterior at the macula lutea. Central fixation is 
 when the eye is so directed, that a line drawn from the object 
 through the centre of the cornea would strike the macula lutea ; 
 should it strike elsewhere, it is called excentral fixation. 
 
 The extent of the field of vision is determined by placiBg the 
 patient at a definite distance, say a foot, from a black board, on 
 which a cross is then drawn with white chalk directly opposite his 
 eye ; on this cross the patient must fix his eye steadily throughout 
 the examination ; the chalk is now moved slowly upwards, downwards, 
 &c., so as to determine by repeated trials how far it can be dis- 
 tinguished, and at each of these points a mark is made on the 
 board ; lastly, by connecting these points, we have a drawing of the 
 field of vision as measured at a foot distance. 
 
 As to the operation <f iridecfomy, I need only remark that the 
 eye should be firmly fixed by seizing a fold of conjunctiva with 
 forceps, that the operation should be slowly performed, and that it 
 is often much facilitated by the use of chloroform. 
 
 65, Piccadilly, Manchestub; 
 October, 1859. 
 
ON 
 
 IRIDECTOMY 
 
 AS A 
 
 MEANS OF TREATMENT 
 
 IN 
 
 CHEONIC IEITI8 AND lEIDO-CHOEOIDITIS. 
 By De. a. v. GEAEFE.^ 
 
 The dangers of iritis in general have materially diminished since 
 the introduction of a bold use of mydriatic remedies in the acute 
 form. Treatment "by antiphlogistics, mercury, or by other methods 
 of considerable repute, though insufficient to effect a complete cure 
 of the disease, continue important auxiliaries, and in many cases it 
 is impossible to apply mydriatics without their previous employment. 
 Mydriatics, however, are indispensable to the complete success of 
 our treatment. In most cases it is not the single acute attack of 
 iritis that threatens the power of vision, but the frequent recur- 
 rences, which sometimes produce fresh pupillary exudations, and 
 sometimes exclusion of the pupil (Abschluss der PupiLle) or other 
 injurious consequences. 
 
 The frequency of such recurrences, and the gradual supervention 
 
 ' Translated, with the author's permission, from the ' Archiv fiir Ophtliahn.,' 
 Bd. ii, abt. a, S. 202. Berlin, 1856. 
 
252 GRAErjS ON IRIDECTOMY 
 
 of certain complications (amblyopia amanrotica ex choroiditide 
 chronica, and finally atrophia bnlbi) led to the supposition that 
 most cases of iritis depended on internal dyscratic causes. 
 •We cannot deny such an etiological relation in certain cases, 
 especially the connexion of iritis with syphilis, so firmly esta- 
 blished by experience. But we must maintain, that in most 
 cases of chronic iritis the recurrences depend on no internal causes, 
 but on residua of the first attack. These form the predisposing 
 causes for later inflammations. Colds, congestions, &c., may indeed 
 serve as exciting causes, but the true foundation of the disease lies 
 in the eye itself. I will not attempt to decide in what way the 
 iritic exudations produce their pernicious secondary action; they 
 may operate through obstruction of the circulation by contraction 
 of the cicatricial tissue, or dragging of the iris when it can only 
 imperfectly follow the impulses of contraction. Putting this ques- 
 tion aside, however, I consider the fact firmly settled, that the 
 existence of posterior synechia is in most cases the true cause of the 
 tendency to recurrence. Iritis cured without posterior synechia 
 seldom evinces any tendency to recur. Iritis with slight and ex- 
 tensible adhesions sometimes recurs, but in comparatively few cases. 
 Iritis with many broad adhesions, resisting all artificial mydriasis, 
 will very generally recur, and there is scarcely any exception to this 
 rule when synechia posterior totalis — a perfect exclusion of the 
 pupil by exudation — ^has occurred. 
 
 For a number of years I have thoroughly proved this exceedingly 
 important connexion. Eormerly in cases of double (not syphilitic) 
 iritis, I often treated one eye antiphlogistically and the other either 
 simply by mydriatics or by mydriatics with antiphlogistics. Some- 
 times both sides recovered without posterior synechia, and then no 
 special tendency to recurrence was found in either eye. Sometimes, 
 however, the eye treated antiphlogistically recovered with posterior 
 synechia, and recurrences were frequently observed in it, whilst 
 none occurred in the eye treated by mydriatics. The converse never 
 took place. It is two years since I last tried this experiment, for 
 the advantages of the mydriatic treatment were so obvious that I 
 could not reconcile neglect of it with my sense of duty. But when 
 patients who had suffered from periodical attacks of double iritis 
 came to me with synechia posterior, I stiU applied to but one eye 
 methodical instillations of sulphate of atropia, and by that means 
 
IN RECURRING IRITIS, ETC. 253 
 
 frequently succeeded in teaxing through adhesions which had 
 existed for many years.' 
 
 In the eye treated with the atropine no recurrence took place, 
 but all succeeding returns affected the other eye. When I became 
 fully convinced, this practice also was abandoned, and in such cases 
 I always ordered double instillations of atropine. StiU we often 
 fail in tearing through the synechise, especially in old cases, and 
 only succeed in stretching them to a greater or less degree. Here 
 we invariably find that the eyes in which the broadest, least exten- 
 sible synechiee remain, are also the most liable to recurrence, and we 
 can frequently show that these attacks proceed from the divisions of 
 the iris affected with the broadest synechise. ' Corresponding to these 
 we find the first injection of the subconjunctival vessels, the first 
 hypersemic coloration of the iris, &c. 
 
 Persons who have recovered from iritis are often affected by 
 periodical ciliary neuroses, which in many cases depend on posterior 
 synechia. After instillations of sulphate of atropia the pains cease, 
 
 • This has been unjustly doubted. After the first instillations I have very 
 often delineated the form of the pupil in persons who had suffered from iritis 
 many years previously. I have frequently seen projecting angles vanish one 
 after another, and the edge of the pupil return more and more to its natural 
 roundness. After so long a duration this can only take place in the tongue-like, 
 prolonged adhesions, known as pointed syneohiae. In broad adhesions the sur- 
 face of union is so great that the power of the mydriatic is insufficient. Many 
 patients feel the syneohise tearing. They have sensations of pressure in the 
 frontal and temporal regions, and sometimes below the eye, at the ala nasi. 
 These sensations increase to a certain extent, and are then suddenly alleviated. 
 Sometimes they have occurred in my presence, immediately after the applica- 
 tion, and I could discover that a syneoliia had actually been torn. In two 
 instances patients, who were perfectly ignorant of the nature of their affection, 
 perceived a tearing sensation just before the pain ceased. Besides, when we 
 consider the anatomical relations, it does not appear extraordinary that such 
 synechise can generally be torn, for the tissue is not separated in its continuity, 
 but simply loosened from an extremely slender adhesion. By experiment on the 
 dead, we may further convince ourselves that the slightest stretching with the 
 forceps is sufficient to break through this union, even in broad synechise. When 
 the surface of adhesion is very small, as in the narrow-pointed synechise, exces- 
 sively little resistance is made to the rupture. Besides, it is known to every 
 observer that synechise may spontaneously separate during the movement of the 
 pupil, even months after the iritis. This occurs in the same w&y by separation 
 from the capsule ; the exudations then remain at the edge of the pupil as pointed 
 processes, which do not adhere to the capsule, but freely follow the motions 
 of the pupil. 
 
254 GRAEFE ON IRIDECTOMY 
 
 but return as the pupil contracts. A methodical use of mydriatics, 
 causing extension of the synechia, often permanently cures the 
 disease. 
 
 Here the affection seems to have entirely arisen fi'om the drag- 
 ging of the iris-tissue by the adliesions. CiHary neurosis is seldom, 
 if ever, observed accompanying anterior synechia, where there is an 
 apparent similarity ; the real conditions, however, are so dissimilar 
 that the same causes may easily produce different effects. The differ- 
 ence is especially observable in the circulation, where almost opposite 
 conditions are evinced : in posterior synechia we generally find long- 
 continued hypersemia of the iris ; in the anterior, obHteration of the 
 vessels, atrophy of the tissue, &c., in the dragged portion. My 
 present intention is to determine fundamental principles with regard 
 to the object of my treatise ; and, in the first place, I shall assert, 
 that the principal cause of the recurrence of iritis is the existence of 
 synechia, especially when broad andinextensible. 
 
 I shall not here specially consider the mydriatic treatment j I 
 have no doubt that the opposition it stiU encounters entirely depends 
 on insufficient examination. It is absurd to recommend a fixed 
 dose of the mydriatic in all cases of iritis, and even the best sulphate 
 of atropia ought not to be employed in every case, and in all stages 
 of the disease. The application of Atropirium sulphuricum is gene- 
 rally sufficient in slight iritis, i. e. iritis with not much injection of 
 the subconjunctival vessels, nor much swelling of the subconjunc- 
 tival cellular tissue, nor much lachrymation, and with only slight 
 opacity of the aqueous humour and pupillary space. The severity 
 of the pain is by no means a contra-indication, but rather one of 
 the most decided indications for this treatment ; for the most severe 
 ciliary neurosis often diminishes when the pupil dilates, and in such 
 cases the mydriatic is supported without difficulty. It should 
 be applied daily, six, eight, ten times, or oftener, at intervals of five 
 minutes ; and notwithstanding the irritation, both the pain and the 
 other symptoms are generally alleviated, and, at the same time, the 
 subconjunctival injection diminishes with remarkable rapidity. 
 Even after the fijst application the pupil begins to dilate, although 
 far more slowly than in the healthy eye. The margin of the iris 
 gradually separates from the exudations i in the pupil, and these 
 
 ' This cloudiness, or " plastic exudation," which occurs in the commence- 
 ment of iritis, really forms a distinct .membrane. This is proved by the per- 
 formance of paracentesis. 
 
IN RECURRING IRITIS, ETC. 255 
 
 wither in the most satisfactory maimer, as might naturally be ex- 
 pected, since they are nourished by the iris, and must atrophy when 
 the source of nutrition is withdrawn. Such a result, however^ 
 could not be obtained by the best resolutives and antiplastics. 
 
 Where there is acute iritis, with profuse lachjymation, chemotic 
 swelling, and cloudiness of the aqueous humour, an entirely different 
 treatment is indicated. Atropine (gr. iv to f^j water) must be 
 instilled twenty to thirty times, to produce even a limited action on 
 the pupil ; sometimes it slightly enlarges, but a genuine mydriasis 
 seldom takes place. Sometimes the desired dilatation is obtaiaed 
 by a very bold use of the mydriatic. Erom these cases, however, 
 nn rule can be drawn. 
 
 Prequent applica;tions during the height of the inflammation 
 sometimes so much increase the irritability that no therapeutical 
 effect is produced. In such cases, I am in the habit of employing 
 three methods to diminish the irritation as rapidly as possible. 
 
 I. Bloodletting, by leeches applied to the temples or nose, and in- 
 cisions of the chemosis with Cooper's scissors, sufficiently deep to 
 unload the subconjunctival vessels, which are intimately connected 
 with the iris. 
 
 3. Paracentesis, which must never be neglected when there is 
 much diffuse cloudiness of the aqueous humour. 
 
 3. In very acute cases, and in those attended by excessive exuda- 
 tion, I employ mercurials. The extremities are rubbed every two 
 hours with Ung. Hydr. Oinereum, and every hour I give from a half to 
 one grain of calomel, until the first indications of salivation appear.' 
 When the irritable condition has decidedly diminished, which must 
 ensue in two or three days, I commence the use of mydriatics, and 
 so vigorously as positively to tear synechise which have already 
 formed. This is the period during which the special object of 
 treatment must be unreservedly followed; and in general, the 
 mydriatics act much more readily than before, partly owing to the 
 diminished inflammatory irritation, and partly also to freer absorp- 
 tion by the cornea.^ My usual custom is to apply the atropine 
 
 ' In addition, I apply a suppurating blister behind the ear, and believe that 
 it is of use ; but from having always employed it in combination with more 
 active treatment, I have been unable to gain so clear an insight into its action 
 in these cases as I have in many forms of corneal exudation, &c. 
 
 " The latter cause alone is insuflBcient to explain the more powerful action 
 of mydriatics after depletion. This is proved by a fact I have often witnessed. 
 
256 GUAEFE ON IRIDECTOMY 
 
 from six to fifteen timesj sometimes twenty to thirty times a day. The 
 pupil must be kept dilated some weeks after the inflammation has 
 perfectly ceased. It need scarcely be mentioned that the choice of the 
 mydriatic is of essential importance. It is, in fact, owing to the substi- 
 tution of sulphate of atropia for the extract of belladonna that this 
 method of treatment in acute iritis has come into more general use. 
 It is also very necessary that the preparation should be weU made, 
 since it is to be applied so often, and the eye is already in so 
 irritable a condition. This is of less importance in cases where it 
 is only applied once or twice a day, and its action is not opposed 
 by internal irritability. In such cases the most various preparations 
 may be employed. But, as I have already elsewhere stated, even 
 the best-prepared sulphate of atropia becomes unbearable to the 
 conjunctiva after very long-continued usej and if circumstances 
 should still render its application necessary, the tone of the con- 
 junctiva must be altered. This is best effected by solutions of 
 acetate of lead, or dilute solutions of nitrate of silver. 
 
 Although I can easily understand that some practitioners are not 
 successful in the mydriatic treatment of acute iritis, because they 
 proceed without discrimination, still I cannot understand how any 
 can yet consider it irrational. In inflammation of a muscular 
 tissue, what indication is more urgent than to keep it quiescent, 
 at the same time relaxing its most irritable and most threatened 
 parts — in the present case, the pupillary margin? Is there a 
 method more likely to induce reabsorption of exudations than to 
 deprive them of their source of nourishment ? KnaUy, does not the 
 diminution of intra-ocular pressure, facilitating the choroidal circu- 
 lation, afford an especial safeguard against the complication with 
 choroiditis' which is so much to be dreaded? 
 
 The method itseK is by no means irrational; it is only its im- 
 proper use that can justly incur blame, as when it causes excessive 
 
 Atropine has been applied in eases of iritis or corneal exudation, without 
 inducing any dilatation, but many hours afterwards it has ensued upon the ap- 
 plication of leeches. All remains of atropine had previously been so carefully 
 removed that it was impossible any could have been left in the conjunctival 
 sac, and hence it must have been absorbed before the use of leeches, its action 
 having been temporarily latent, owing to the excessive inflammatory irritation. 
 ' Ophthalmoscopic examination has shown that after iritisopacities are by no 
 means uncommon in the anterior part of the vitreous humour. Evidently these 
 must be ascribed to the anterior division of the choroid having participated in 
 the inflammation. 
 
IN EXCLUSION OF THE PUPIL. 257 
 
 irritation of the external parts in cases of very intense inflammation, 
 or when an improper mydriatic is applied. The empirical success 
 of mydriatics has appeared to me so evident that it has scarcely 
 seemed necessary to dwell any longer on its beneficial action, either 
 in iritis or in corneal affections that are rapidly spreading. On a 
 former occasion (A. f. 0., Bd. i, Abth. i, 8. 2,2,^) I was the first 
 to mention the latter circumstance, and I purpose entering more 
 fully upon it at some better opportunity. 
 
 A second law is connected with the preceding one, namely, that 
 ike eifclusion of the pupil is the point from which the further compli- 
 cations proceed, especially chronic choroiditis (with progressive am- 
 blyopia, and in the end atrophia bulbi). By exclusion of the pupil 
 I understand simply the total adhesion of the pupillary margin 
 with the capsule — synechia posterior totalis. The pupillary space, 
 properly so called, may be almost free from exudation ; or scanty 
 exudations may adhere to the border of the pupU, whilst its 
 middle portion transmits light perfectly. When the pupil is en- 
 tirely obstructed by exudation, we no longer term it exclusion, but 
 closure of the pupil ; thus the latter involves the former, whilst the 
 former may exist independently of the latter. The operation for 
 artificial pupil, since its first introduction, has been employed 
 in cases of closed pupil, simply for the purpose of making an 
 aperture through which the rays of light may freely pass into the 
 eye ; I purpose introducing it in cases of pupillary exclusion also, not 
 in order to afford a new passage for the light, but to prevent secondary 
 mischief, namely, chronic choroiditis. The above-mentioned law is im- 
 portant as the link that connects aU. these considerations, and its proof 
 is to be found in a series of facts, which, that I may avoid as much 
 as possible any systematising tendency, I wiU communicate in the 
 same order in which they presented themselves in my clinical studies. 
 About four years ago, a man came to me whose left eye was per- 
 fectly blind from irido-choroiditis. The eye felt rather soft, and the 
 iris was closely applied to the cornea, whilst its inner margin was 
 drawn backwards so as to form a slight depression. The pupil 
 was much diminished in size, and occupied by a white membrane. 
 The tissue of the iris was much changed, and some distended 
 vessels ran in its fibre-work, which was of a dull, dirty colour. 
 The entire absence of any quantitative sensation of light, and the 
 atrophy of the globe already induced, left no doubt about the pre- 
 sence of internal complications (chronic choroiditis with separation 
 
 17 
 
258 GRAE.FE ON IRIDECTOMY 
 
 of the retina). The sight of the patient's right eye was very weak, 
 so that he conld only recognise large objects, and guided himself 
 with diificulty. An examination showed evident effects of iritis — 
 synechia posterior totalis. The somewhat contracted pupil was to 
 a considerable extent filled with pigmented exudation, but the 
 centre was nearly free from them, so that the deterioration in vision 
 could not be entirely ascribed to the condition of the pupil, but 
 must have proceeded from a complication with commencing chronic 
 choroiditis. The iris itself was of a greenish colour, and the knob- 
 like protuberances visible here and there upon its surface clearly 
 indicated the commencement of a similar projection to the one, that 
 had advanced so far in the left eye. 
 
 The history showed that the disease had begun in both eyes with 
 simple iritis. The patient was first attacked by a severe inflamma- 
 tion, with ciliary neurosis, which had retrograded after an antiphlo- 
 gistic and mercurial treatment; vision indeed was restored, but 
 there stUl remained some redness of the eyes, great sensibility to 
 light, and pain in the forehead and temples. At frequent intervals 
 this condition of irritability became so acute as to pass into a state 
 of inflammation, sometimes through colds, and sometimes without 
 any known cause ; after which the vision gradually diminished in 
 acuteness, and on the left side entirely disappeared. ]?or eight 
 weeks previously the patient had not been affected by any visible 
 inflammation- of the right eye, yet the sight had continued to dete- 
 riorate. I suspect that it was since that period that the iris had 
 gradually arched forwards. Since antiphlogistics had been already 
 employed as far as the patient could bear, and I could not expect 
 any benefit from a longer use of the mercurials, vainly tried for 
 many months, I trusted entirely to the mydriatic treatment. 
 But not the slightest change occurred in the pupil, evidently owing 
 to the adhesions' being too firm and extensive. This form of 
 disease commences with iritis, rapidly leads to synechia pos- 
 terior totalis, gradually induces a projection of the iris towards the 
 cornea, and in the end terminates in chronic choroiditis and atrophy 
 of the globe. It has been freely discussed in literature and in the 
 clinic, under various names, and with the supposition of different 
 dyscratic causes. All observers have agreed that the prognosis must 
 be considered unfavorable from the moment, when the above-men- 
 tioned disorganization and projection of the iris appear ; and many 
 persons, perceiving the unsatisfactory course of the disease, have 
 
IK EXCLUSION or THE PUPIL. 259 
 
 been led to infer some deeper disturbance as its source^ such as tbe 
 tubercular process. 
 
 The failure of all treatment induced me to make an artificial 
 pupil in the patient's right eye, and, though led by very vague 
 ideas to adopt this course, I believed that the relaxation of the 
 tissue of the iris, the escape of exudation situated behind it, and 
 the discharge of blood from its vessels and the choroid, might act 
 favorably: besides, I apprehended no danger from an operation 
 that is so generally harmless. The pupil was formed close to the 
 inner side ; there was only a small amount of aqueous humour in 
 the anterior chamber, and it escaped very imperfectly when the 
 lance-shaped knife was drawn out, and even when the forceps 
 were introduced.' As I seized the iris with the forceps and tore 
 its tissue, — in such cases the adhering pupillary margin gene- 
 rally remains with the mass of exudation, — a quantity of yel- 
 lowish fluid was discharged from the wound ; it was simply the 
 exudation lying behind the periphery of the iris. On opening the 
 eye the following day, I saw with delight that the iris no longer 
 projected, but that it lay in its normal plane, separated from the 
 cornea by a tolerably deep anterior chamber. It was stiU. of a 
 greenish hue, but the fibre-work was already not so dull as before ; 
 some blood in the process of solution lay at the bottom of the 
 anterior chamber. Eight days after the operation a more careful 
 examination was made ; the pupil formed a large coloboma, only 
 separated from the normal pupil by a small bridge of pupillary 
 margin, which had adhered to the exudation ; the adjoining part 
 of the artificial pupil was filled with brownish exudation, or 
 perhaps, to a considerable extent, by remains of the pigment-coat ; 
 the periphery alone seemed free from it. The iris had almost 
 regained its original colour; the only difference that could be 
 detected was a slight tinge of green; it lay in its normal plane. 
 The anterior chamber seemed of considerable depth. The patient 
 could count fingers at the distance of a room, and recognise letters 
 
 ' This generally occurs in synechia posterior totalis, for the iris with the 
 •exudation-membrane forms a complete partition between the cavity of the globe 
 and the anterior chamber, so that the intra-ocular pressure cannot be trans- 
 mitted to the cornea, as normally, but only to the partition just mentioned. 
 Hence the contents of the chamber will either not escape, or only imperfectly ; 
 or, to speak in more exact terms, the escape will cease when the tension of the 
 iris balances the pressure, and when, consequently, all positive pressure ceases 
 in the anterior chamber. 
 
2G0 
 
 GRAEFE ON IKIDECTOMY 
 
 of large print. How was this improvement of the vision to be 
 explained ? It could scarcely proceed from a change in the 
 entrance of light, for although an additional free space had been 
 gained through the peripheral portion of the artificial pupil, stiU 
 the natural pupil was also tolerably transparent in its centre, and 
 obviously must allow a clearer perception than that portion of the 
 periphery. I could not, however, be satisfied with mere reasoning 
 on so important a point. 
 
 I therefore covered the whole artificial pupil as far as the pupil- 
 lary edge, and convinced myself that this scarcely affected the power 
 of recognition, and that when the artificial pupU was entirely unem- 
 ployed, the patient saw through the central one infinitely better than 
 before the operation. The next idea that suggested itself was, that 
 through tearing away the iris-tissue, absorption of the exudation in 
 the pupil was promoted, just as after artificial mydriasis, and that 
 eight days having elapsed since the operation, the central pupil had 
 become clearer than it was before. It is true, that with the naked 
 eye I perceived no difference, but I did not consider that sufficient 
 to justify my forming a conclusion. Possibly some slight cloudi- 
 ness caused by exudation had cleared away, and this, though very 
 slight, might previously have caused much dissipation of the light ; 
 but the addition of a new pupillary space, and the consequent con- 
 ditional comparison as to the degree of blackness, rendered it very 
 difficult to form a decisive opinion ; and I was unable to come to 
 any conclusion by means of ophthalmoscopic investigation, then only 
 in its infancy, because the increased amount of light passing through 
 the larger pupillary space might easily induce error about the relative 
 transparency of particular parts. It was not until subsequently, 
 after I had sufficiently practised oblique illumination, that my views 
 on tins point became clear. As to this case, I shall only add that, 
 without the use of any medicine, the vision of the operated eye 
 continually improved, that the patient learned to read small print 
 (No. 4 of lager's specimens of type), that for the last four years he 
 has never been attacked by iritis, and that he now fills a post requir- 
 ing good eyesight. I have since repeatedly examined him; the 
 exudations that obstructed one division of the artificial pupU have 
 much diminished, and the tissue of the iris has become normal. 
 
 The inefficacy of all other treatment, and the success of this one 
 operation, emboldened me to perform it in many similar cases. I 
 should at an earlier period have published the results, had it not 
 
IN EXCLUSION OF THE PUPIL. 261 
 
 seemed advisable to watch, for a long time the cases which had 
 been operated on, so as to ascertain the permanency of the results. 
 
 Similar cases to the above were at first the only ones so treated. 
 The operation was sometimes performed on both eyes, in cases where 
 the irides were pushed forward, yet without marked amaurosis. The 
 best possible results constantly followed ; the anterior chamber was 
 re-formed, the iris resumed its normal texture and position, the eyes 
 continued free from inflammation, and there was an important 
 increase in visual power. 
 
 Gradually I convinced myself, by oblique illumination, as pre- 
 viously hinted, that the increased power of vision was in no way 
 dependent on reahsorption of the pupillary exudations, but was 
 entirely to he ascribed to an improvement in the choroidal com- 
 plications. I must admit that all cases were not equally decisive, for 
 sometimes the central pupil was so covered with exudation that 
 the artificial pupil served for the principal entrance of Kght; 
 obviously such cases could throw no light on the subject. 
 
 Amongst other cases there were two especially instructive, in 
 which the whole of the artificial pupil was blocked up by the 
 remains of the pigment-coat,^ so as not to allow the transmission of 
 light ; on the other hand, the natxiral pupil showed not the least 
 change three weeks after the operation, although only containing 
 scanty exudations, which I had previously very accurately examined 
 by obUque illumination; and yet the iris recovered its healthy 
 appearance, re-formation of the anterior chamber took place, and an 
 extraordinary improvement of vision. In one of these cases the 
 serous exudation behind the iris was not held back by the pigment- 
 coat, but flowed out through the wound, as usually occurs. I 
 suspect that some minute apertures, visible at the extreme edge of 
 the periphery, though useless for the transmission of Hght, yet had 
 allowed the escape ; whilst in the second case, the pigment-coat at 
 first prevented the discharge of the exudation. This was proved by 
 its surface being pushed forward so as to form small elevations ; 
 probably it had been strengthened by a layer of pigmented exuda- 
 tion. Here for the first week no improvement took place, and 
 
 ' A proof that only the tissue of the iris had been excised. Tliis is most 
 likely to happen in the oases in question of chronic iritis. The greater part, of 
 the serous exudation is indeed situated behind the pigment-coat, between it 
 and the capsule, but there is also a thin layer of exudation between the tissue 
 of the iris and the pigment-coat. 
 
262 GRAIiFE ON IRIDECTOMY 
 
 hence I determined to reopen about half the wound, and seize the 
 periphery of the pigment-coat with fine forceps. At the moment 
 of seizure, yellowish serum escaped from behind it, and I removed 
 my instrument without excising any portion, for I wished to ascer- 
 tain whether the formation of a considerable division was required, 
 or only the escape of the exudation, with a restored communication 
 between the anterior and posterior chambers. The latter proved to 
 be the fact, for the desired action followed; though the tear which. 
 had been made opposite the edge of the lens appeared by obUque 
 illumination very trivial. 
 
 At a later period, constantly becoming bolder, I even performed 
 the operation in cases where, after previous iritis with pupillary 
 exclusion, atrophy of the globe had far advanced, in consequence of 
 secondary choroiditis. Sometimes the periphery of the iris was 
 closely applied to the cornea, so as to present some difficulty during 
 the operation. Various changes often occurred in the pupil after 
 its first formation ; often it was nearly filled with pigmented exuda- 
 tion, at a later period it sometimes even contracted gradually into a 
 small sHt, and almost closed. But I always found some improve- 
 ment in the colour of the iris, and the restoration of an anterior 
 chamber, to a greater or less extent. This excited the hope that a 
 repetition of the operation might ultimately lead to success. Thus, 
 in some cases, by iridectomy repeated three or four times, I have 
 attained results I had previously considered perfectly impossible. 
 Even when the globe has become to some extent atrophied, it 
 recovers its healthy tension, the tissue of the iris being at the same 
 time rendered normal and the anterior chamber restored. I have 
 treated in this manner, at my clinic, a large number of cases in 
 which the globe had become very soft, and much flattened by the 
 action of the recti muscles, and which were ultimately perfectly 
 refilled. A patient stiU visits me, to whom long since I gave, and 
 that from fuU conviction, a certificate of incurable blindness, on 
 account of atrophy of both globes. Now, the operation having 
 been performed six times, his vision weekly improves. He can 
 count fingers at the distance of some feet, and distinguish all large 
 objects and letters of the largest print; whilst formerly he had 
 long been limited to a dull, quantitative sensation of light. The iris, 
 which was very disorganized, now appears almost normal, the 
 anterior chamber has been re-formed, the volume and tension of 
 the globe have much increased, and there is only a slight trace, 
 
IN EXCLUSION OF THE PUPIL. 263 
 
 where the rectus inferior is situated, of the flattenings previously- 
 visible in all four directions. Yet, at the same time, the lens is 
 very opaque, and the natural pupil is closed by a white membrane, 
 so that, in short, his present vision is almost proportional to the con- 
 dition of the refractive media. 
 
 That an atrophied globe could be refilled would indeed appear 
 somewhat enigmatical if, according to former ideas, we were to con- 
 sider it as a positive disease of nutrition ; but, as we have already 
 often urged, it is in such cases simply a symptom of choroidal stasis. 
 The choroid is the secreting organ of the vitreous body, and if its 
 circulation stagnates, the reproduction of the vitreous body will 
 necessarily fail, and its volume will diminish. -In chronic choroiditis, 
 instead of the normal, an abnormal fluid will be given out for the 
 purpose of nourishing the vitreous body, so that the latter will vary- 
 chemically and quantitatively from its healthy condition.' It is 
 evident that, when atrophy has exceeded a certain extent, the eye 
 cannot resume its original form. Then effusions of blood or 
 serum generally proceed from the choroid (probably to restore the 
 balance of pressure), rendering a perfect recovery impossible. 
 But a certain degree of atrophy of the globe from choroidal stasis 
 is curable, as is well known to all attentive observers, and as the 
 present observations abundantly prove. Besides, we know that in 
 actual iritis, for example, the globe is often softer than in the healthy 
 eye, and that this symptom retrogrades as the inflammation disap- 
 pears. It is evident that the diminished resistance is owing to 
 imperfect secretion (connected with choroidal hypersemia) of the 
 fluid of the vitreous body, for in the volume of the aqueous humour 
 there is no change capable of affording an explanation. 
 
 I need scarcely mention that, in regard to the success of our 
 treatment, the prognosis becomes more unfavorable as the atrophy 
 of the globe advances ; indeed, I have repeatedly observed scarcely 
 any result in very advanced atrophy with such antecedents. There 
 is a certain limit beyond which a restoration of the choroidal circu- 
 lation is impossible, because the permanent changes of inflammation, 
 namely, atrophy of tissue and obliteration of the vessels have 
 already proceeded too far. Hence we derive the principle that the 
 operation should be performed as early as possible. 
 
 Other reasons make it advisable. The presence of serous exuda- 
 
 ' We cannot, at present give a more accurate account of these conditions, 
 owing to insufficient knowledge as to tlie reproduction of the vitreous body. 
 
364 GRAEFE ON IRIDKCTOMT 
 
 tion behind the iris causes in time cloudiness of the lens, leading to 
 the development of cataract. This must not be confounded with 
 those circumscribed opacities in the layer of intra-capswlar cells, 
 which follow almost every inflammatory affection of the iris. The 
 latter do not necessarily lead to the formation of cataract, and 
 occasionally disappear at the same time as the exudation in the 
 pupil. From what I have observed in some cases this seems to me 
 extremely probable, and I have most decidedly observed it in experi- 
 menting on animals. It scarcely requires mention, that the prognosis 
 is rendered much more unfavorable when cataract is developed 
 under these conditions, because all methods of treatment are 
 attended with so much risk. Eeclination is out of the question 
 wlien there is chronic choroiditis. Discision is uncertain, for the 
 capsular wounds dilate with great difficulty when iritis has pre- 
 viously occurred,! and any swelling of protruded portions of the 
 lens may re-excite inflammation. • Only extraction remains, and 
 even here the hardly won success may be entirely lost, if the 
 healing process should proceed unfavorably. 
 
 It seems superfluous to strengthen the preceding observations by 
 detailed reports of cases, especially as most of them were observed 
 in my clinic, and in the presence of many competent colleagues, and 
 have also been to some extent published [vide Rothmund, 
 'Beitrage zur kiinstUchen PupiUenbildung,^ Miinchen, 1855). 
 On the other hand, it may facilitate the general introduction of 
 these views, if in a short summary we consider the various diseases 
 to be treated, and the manner in which the operation acts. 
 
 The disease which has been termed irido-choroiditis is one that 
 presents many different aspects, and we must particularly distinguish 
 two opposite groups, in arranging o\ir cases with reference to our 
 present object. 
 
 xst class. — The disease begins with iritis, and without proper 
 treatment pupillary exclusion results, whether with or without a 
 certain amount of exudation into the pupil is of no importance. 
 The existence of pupillary exclusion is partly proved by mydri- 
 atics not producing the least reaction of the pupil, and partly 
 by oblique illumination, which reveals a circular border of pigmented 
 exudation connecting the tissue of the iris on every side with the 
 capsule. If for any reason paracentesis be performed according to 
 the usual method of operating, in which no artificial pressure is 
 
IN Illino-CHOEOIDITIS, ETC. 265 
 
 applied to the cornea, the imperfect escape of the aqueous humour 
 will furnish a further but superfluous proof. Vision remains perfectly 
 good in a few cases even after exclusion of the pupil has occurred; as 
 the rule, however, bulging of the periphery of the iris takes place, at 
 first partially, in the form of knobs, and then by degrees affecting 
 the whole ; an amblyopia being at the same time developed, for 
 which the condition of the papil no longer accounts. Delicate 
 opacities of the vitreous body are sometimes shown by the ophthal- 
 moscope. The globe becomes softer; in short, aU the symptoms 
 prove the supervention of choroiditis. Most authors bring forward 
 the erroneous opinion that the exudation behind the iris, unipres- 
 sing it forward, is solid. It is true, that there are pigmented exuda- 
 tion-membranes behind it, especially near the pupiUary margin, but 
 the bulging is explained by serous exudation behind the periphery, 
 as may be deduced from the preceding communications. Nor does 
 an examination of the cases collected give any support to the 
 opinion that this form of iritis depends on some special condition of 
 the constitution ; it only differs from ordinary iritides, such as occur 
 after colds, or without any apparent cause, in the very rapid 
 formation of synechia posterior totahs, without much exudation in 
 the pupil — a result that is not attributable to any peculiar quahty of 
 the disease, but for the most part to a defective treatment or one 
 commenced too late. The arching forwards of the iris is simply a 
 consequence of the pupiUary exclusion, and of the serous exudation 
 on the posterior surface. Hence it loses its specific character, just 
 as the form of the pupillary distortion previously did. The question 
 naturally arises, why exclusion of the pupil sometimes does not in- 
 duce bulging of the iris ? I cannot answer satisfactorily. Differ- 
 ences in the circulation of the iris itself may partially account 
 for the dissimilarity of cases, for the vessels sometimes are 
 obliterated to a considerable, and sometimes only to a slight extent ; 
 there is occasionally, however, even when the synechia posterior 
 seems to be complete, stiU. a communication between the anterior 
 chamber and the layer of fluid situated behind the periphery of the 
 iris, the fluid passing through the exudation which adheres to the 
 pupillary margin, or through some very small apertures, occasionally 
 formed in the atrophied tissue of the iris. 
 
 Tid class. — Choroidal changes commence the disease, iritis occur- 
 ring as a secondary compHcation. I have already pointed out 
 (A. f, 0., Bd. i, Abth. i, S. 367) that extensive retinal separa-- 
 
266 GRAKFE ON IRIDECTOMY 
 
 tions, arising through haemorrhage or serous effusions from the 
 choroid^ generally excite in their progress a reactionary ioflamma- 
 tion of the internal membranes, and consequent exclusion of the 
 pupil. Cataract often occurs at the same time as the iritis ; it some- 
 times precedes it, and thus we have cataracta accreta in combination 
 with pupillary exclusion. In general, central capsular cataracts are 
 also formed, and extend over the greater part of the pupil — an impor- 
 tant diagnostic sign, as from their presence^ we can conclude with 
 the greatest probability as to the existence of retinal separation. In 
 these cases, also, arching forwards of the iris generally commences 
 - after the occurrence of pupillary exclusion, then atrophy of the globe, 
 and eventually the appearance of the disease may very closely re- 
 semble the one described above. The differential diagnosis of the 
 two forms of the disease is the more important, because their prog- 
 nosis is very different. The history demands especial attention. In 
 the latter form the disease begins with characteristic symptoms of 
 retinal separation ; contraction of the field of vision generally com- 
 mences at the upper part, gradually advances, and eventually leaves 
 but little power of recognition, which is usually in the direction of 
 outwards and downwards, combined throughout with partial, obhque, 
 and distorted vision. Inflammations only appear at a later period, 
 and are, as a rule, attended with little irritation, owing to the pre- 
 vious atrophy of the vitreous body and diminution of the intra- 
 ocular pressure. In the former group, on the contrary, the disease 
 commences with weU-marked inflammations, wliich periodically 
 recur, and are generally accompanied by ciliary neuroses; at the 
 same time the power of vision is at first tolerably good, then gra- 
 dually impeded by a uniform haziness, but without contraction of 
 the field of vision. It is unfortunate that here, as in other cases, 
 the history is often deficient. Its value varies extremely, according 
 to the patient's power of observation and accidental circumstances. 
 Owing to the disease generally commencing on one side, the dis- 
 turbances of vision often completely escape the patient's notice, and 
 
 ' Of course suoli capsular opacities must not be confounded witii pupillary- 
 exudations. Their exact determination is generally impossible where exten- 
 sive iritic deposits have been cotemporaneously formed. Capsular opacities, in 
 the form of separate lines, proceeding from the periphery, and projecting into 
 the region of the pupil, occur in all forms of cataract, especially in very old 
 opacities, and are in no way characteristic ; but large, white, capsular patches, 
 embracing the pupillary space, the lens being at the same time as yet imperfectly 
 clouded, give, with the greatest probability, the diagnostic sign mentioned. 
 
IN IRIDO-CHOROIDITIS, ETC.- 267 
 
 it isj consequently, very important to possess, for still later periods, 
 objective diagnostic signs. These depend in part on the examina- 
 tion of the tissue of the iris, which usually suffers more when the 
 disease begins with iritis, than when with separation of the retina. 
 Examination of the lens, when possible, may assist. Indeed, as 
 already stated, the formation of cataract usually precedes, or at 
 least accompanies, the irido-choroiditis, in cases qf previous retiaal 
 separation ; whilst ia the former group opacity of the substance of 
 the lens is developed only at a very late period, when projection of 
 the iris has far advanced. Practically, however, the patient^s power 
 of perceiving light (Lichtscheia) is the most important sign. An 
 examination, made according to the principles given in the A. f. 
 0., Bd. i, %, S. 257, discloses a very different condition in the two 
 groups ; though the perception of light is much less ia both than 
 would be proportional to the anterior opacities, stiU. it is by far the 
 least in cases of retinal separation. In these cases, also, the Hght is 
 much better perceived by the upper than by the lower portions of the 
 retina. When there is separation of the retina, and the pupil pre- 
 sents a free entrance for the light, the patient wiU be quite unable 
 to perceive the light of a lamp which is placed in the upper part of 
 the field of vision; in the present case, however, owing to the diffu- 
 sion of the hght, the superior portion of the retina will be affected, 
 whatever be the position of the lamp ; and yet there wiU usually be 
 a quantitative difference in accordance with the situation of the ob- 
 ject. This criterion, also, is lost when there is total bhndness. 
 The primary effect of secondary choroiditis is usually exudation into 
 the vitreous body. In these cases of complete loss of vision, retinal 
 separation has occurred as a secondary affection, even though the 
 disease began with iritis ; all treatment is useless. 
 
 To return to the treatment. I have found that iridectomy only 
 effects a radical cure in ^e, first group of cases. I have often tried 
 it also in irido-choroiditis, resulting from retinal separation, and 
 have generally seen any existing irritation reheved. Under certain 
 circumstances, I might even recommend it for these cases (at the 
 same time cautioning the patient with regard to the future result), 
 and should be, especially incHned to advise it when a sympathetic 
 affection of the other eye threatens to break out during the long- 
 continued irritation of the eye first affected [vide infra) . But no 
 real restoration of vision can ever be expected; more true is the 
 principle, that extensive separations of the retina lead to per- 
 
268 
 
 GRAEFE ON IRIDECTOMY 
 
 feet amaurosis, with atrophy of the globe, provided reactionary 
 inflammation of the internal membranes has once been induced. 
 On the contrary, we can depend upon the action of iridectomy in 
 the former cases, and with the greater certainty if the perception of 
 light be good {vide loc. cit.), and the atrophy of the globe not too 
 far advanced. The best and most certain results, however, are ob- 
 tained where there is total adliesion to the capsule, yet no prominence 
 of the iris. It is true that the advantages of the operation under 
 these conditions appear somewhat dubious to the young practitioner, 
 as in general the vision is still moderately acute, and frequently 
 even small print can be recognised ; and besides> it is not absolutely 
 certain that secondary choroiditis wiH be developed. iN^otwithstand- 
 ing this uncertainty, however, I cannot recommend delay if the 
 other eye has become amaurotic through the effects of the disease, 
 for the possibilities of success might be materially lessened by the 
 occurrence of choroidal complications or the formation of cataract. 
 Besides, I can dispel the natural fear that the vision may suffer 
 from the operation. I term this fear natural, because, under the 
 circumstances, certain dioptrical irregularities cannot be avoided. 
 In particular, the pupillary margin, adhering through pigmented 
 exudation, will remain in its former position, and separate the arti- 
 ficial from the central pupil; and when the pupils are excentric 
 there will be imperfect accommodation, which might occasion double 
 vision. Pigmented exudation wiU be deposited on the capsule in 
 the more central part of the artificial pupil, and might in some de- 
 gree dissipate the light ; even the greater size of the pupU, its peri- 
 phery being opposite the edge of the lens, might have some influence 
 by causing dazzKng. But, practically, these doubts are unimpor- 
 tant, assuming that no extraordinary dimension be given to the arti- 
 ficial pupil. We can provide against these contingencies, and any 
 possible disfigurement, by placing the pupil entirely beneath the 
 upper Hd, when the patient wiU still see through the central one. 
 Thus we obtain the desired action on the chronic iritis, without in 
 any way altering the dioptrical relations. I employ this mode of 
 operating when the middle of the central pupil is perfectly clear, 
 but in all other cases I form the pupfl. on the inner or lower side, 
 and have never seen the vision impaired, even in patients able to 
 read the print No. i of- Jager's specimens. 
 
 The question arises, whether patients on whom iridectomy has 
 been performed, on account of synechia posterior totalis, remain 
 
IN IRIDO-CHOKOIDXTIS, ETC. 3G9 
 
 really free from recurrences of iritis ? I must answer affirmatively 
 for by far the majority of cases^ and after what has been already 
 stated, I should not return to this point had there not appeared an 
 apparent contradiction with the priaciple that the recurrences of 
 iritis are usually owing to posterior synechias. Certainly these are 
 by no means entirely separated through iridectomy, for the pupillary 
 margin, not faUing within the reach of the operation, continues to 
 adhere to the capsule. A priori, I myself should scarcely have be- 
 lieved that the formation of an artificial pupil would prevent the 
 injurious action of the remaining adhesions, yet this has been amply 
 proved by experience, and to some extent we are entitled to seek for 
 a sufficient explanation. By excision of a part of the iris, the ten- 
 sion in the muscular structure must be materially altered ; hence the 
 tendency to inflammation is so far diminished, that the adhesions no 
 longer cause disease. But I beheve the change in the circulation is 
 of stiU greater importance. Without referring to the immediate 
 haemorrhage and escape of aqueous humour, the size of the iris is to 
 a certain extent diminished after the operation. Now, if the cham- 
 ber be afterwards refilled, and apparently in a normal manner, the 
 diminished iris must relatively secrete more aqueous humour than 
 before, and thus the vessels of the iris must be constantly relieved to a 
 greater extent. The condition must somewhat resemble that caused 
 by the periodical repetition of paracentesis ; the antiphlogistic influence 
 of the artificial pupil wiU be, however, far greater, for in this case the 
 rehef is continual, whilst in the former the vessels become temporarily 
 congested (ex vacuo) after the sudden escape of the aqueous humour. 
 I have elsewhere stated my views as to the action of both constant and 
 periodical relief of the vessels in inflammations, and my opinions are 
 unchanged in any material point. StiU, I do not imagine that I 
 can give an exact explanation of the action of iridectomy in chronic 
 iritis. I have simply endeavoured to estaUisJi a fact, and shall be 
 perfectly satisfied if my suppositions give an impetus to investiga- 
 tion, and lead to the discovery of a better explanation. So much on 
 iridectomy in total adhesion to the capsule. 
 
 Where there is akeaiy prominence of the iris, there are almost 
 always signs of a commencing choroidal amblyopia, and even when 
 absent they may be confidently expected, so that the operation 
 should never be delayed. On the supposition that a large and soHd 
 mass of exudation was situated behind the iris, some difficulty in ope- 
 rating might be feared, but provided there is still a small anterior 
 
270 
 
 GRAKFE ON IRIDECTOMY 
 
 chamber, tlais is by no means the case, for the iris, which is 
 pressed forward by serum, readily passes between the blades of the 
 forceps. As the effects of iridectomy in such cases have been 
 already fully explained, I shall only add some general observations 
 on the process itself. 
 
 I. What is the real nature of the so-called secondary choroiditis ? 
 As already mentioned, the ophthalmoscope occasionally reveals very 
 delicate diffuse opacities of the vitreous body; sometimes, however, 
 we conclude that it is clouded, only from the uniformly dull ap- 
 pearance of the back of the eye. Where a clear definition is possi- 
 ble, the retina presents no abnormal appearance. In the choroid, 
 especially towards the equator of the globe, the great vascular trunks 
 are extremely large ; yet I consider this less important than the de- 
 velopment of the chorio-capilaris, of which the finely stippled 
 meshes (in the direct image) entirely disappear, so that an uniform 
 redness is spread over the stratum of external vessels. Hence 
 hypersemia of the chorio-capillaris with morbid imbibition of the 
 vitreous body must be regarded as the point of origin of the 
 secondary choroidal affectioij, and indeed I believe that organic 
 changes in the venous layer do not occur until the disease has made 
 considerable progress; otherwise we should find traces after the 
 disease had retrograded, owing to iridectomy. Hence we perceive 
 the possibility of perfect restoration. Of course, at a later time, the 
 effusions, retinal separations, &c., are too extensive ; and thus the 
 prognosis is essentially changed. 
 
 %. It is also a question whether the exclusion of the pupil and 
 the choroidal affection are essentially connected ? It might indeed 
 be maintained, that choroiditis results entirely from extension of 
 the inflanunation, as would naturally ensue, owing to the vasculaa: 
 continuity between the iris and choroid. But how is it that this 
 extension of the inflammation cannot be prevented ? It, I beheve, 
 depends on the exclusion of the pupU, as the recurrences of iritis 
 depend on the presence of posterior synechia. As proofs, we have 
 the action of iridectomy, after which the choroidal affection sponta- 
 neously diminishes, and also our experience that the changes in the 
 choroid seldom occur, when the treatment is otherwise correct, pro- 
 vided we obtain even the slightest dilatation by means of mydriatics, 
 and so break through the posterior adhesions. 
 
 3. We yet require a thorough analysis of pupillary exclusion, 
 considered as a mechanical agent, and though, notwithstanding some 
 
IN IRIUO-CHOROIDITIS, ETC. 271 
 
 previous investigation on tlie subject of intra-ocular pressure, I may 
 yet be unable to give any decided explanation, this much is cer- 
 tain that, when the pupil is excluded, the pressure both in the 
 posterior parts of the eye, and in the anterior chamber must change 
 — an alteration that may materially affect the circulation. On the 
 other hand, it is also possible that, through stoppage of the commu- 
 nication with the anterior chamber, the fluids do not pass to the 
 cornea in a normal manner, and that thus the conditions of secre- 
 tion and diffusion become abnormal. This view seems supported by 
 the fact, that when exclusion of the pupil has been formed, serous 
 fluid collects behind the iris. After the performance of iridectomy in 
 this state I have never exactly seen recurrences of iritis j I have, 
 however, observed some cases of imperfect resolution. In these in- 
 stances, I have noticed a large accumulation of pigmented exudation in 
 the artificial pupil, which has gradually lessened through the contraction 
 of these and stiU more recent effusions. But as there was evidently 
 some improvement in the texture and colour of the iris, it was 
 clearly indicated to repeat the operation on an adjacent spot ; for 
 the result of this proceeding, I refer the reader to my previous 
 remarks. 
 
 The suspicion has been expressed, that the disease may be only 
 intemipted, but not cured. In general, when vision has not been 
 entirely lost, the choroidal complication recedes by degrees. This 
 has been partly proved by ophthalmoscopic investigation, partly 
 by testing the acuteness of vision. The vitreous body continues to 
 clear for many months, and generally becomes completely trans- 
 parent ; it is only occasionally that opacities are left. On the other 
 hand, the formation of cataract is a secondary result, which must 
 not be passed over in silence. I have already mentioned that, 
 where there is serous exudation behind the iris, the substance of the 
 lens generally becomes clouded. If the projection is recent, and 
 but to a small extent, it is not certain we shall find any opacity of 
 the lens when we make an artificial pupil ; but if it has existed for 
 a long time, and has far advanced, we shall rarely find a lens per- 
 fectly unaffected. These opacities, which generally proceed from 
 the central layers^ of the lens, may by oblique illumination be clearly 
 distinguished from those intra-capsular opacities accompanying iritic 
 deposits, to which I have so often alluded. It is surely unneces- 
 sary to mention the possibility of confounding it with an accidental 
 
 ' I have once seen a perfectly typical stratum-cataract (Schichtstaar) deve- 
 loped after exclusion of the pupil {vide A. f. O., Bd. ii, Abth. 1, S. 273). 
 
273 
 
 GRAEFK ON IRIDECTOMY 
 
 cataract — one caused by tlie operation for artificial pupU, for such 
 a case might be distinguished by the wound in the capsule, its 
 rapid development, &c. This opacity of the lens may remain long 
 stationary after its cause, the exudation, has been evacuated, but it 
 may also continue to gradually develope, so that after some years the 
 improvement in vision is again lost. Then extraction of the cataract 
 becomes necessary and to effect this the artificial pupil must gene- 
 rally be enlarged by removing an adjacent piece of the iris, either at 
 the same time as the extraction or some weeks previously. When- 
 ever possible, the centre of the flap-incision should be opposite the 
 middle of the artificial pupH, for then the edge of the lens passes with 
 greater ease through the corneal wound. Even in young persons 
 the hnear incision is seldom indicated in these cases ; for the cata- 
 racts, which occur after iritis, even when they do not contain a hard 
 nucleus, are always viscous, and are enclosed in a firm capsule, pro- 
 bably thickened by deposit, so that they do not readily pass 
 through a linear wound. It is evident that it is not very pleasant 
 to extract under such circumstances, and yet the results are more 
 successful than would, a priori, be expected. I believe that ex- 
 tensive statistics would show results not much inferior to those of 
 extraction under normal conditions — an apparent enigma explained 
 by the presence of the artificial pupil. "We know, that in the. un- 
 fortunate termination of extraction, suppurative inflammation of the 
 portion of the iris bruised during the exit of the lens forms an essential 
 factor, indeed sometimes the point of origin ; and it necessarily follows, 
 that the injury done by the operation will in general be far less 
 when this part of the iris is absent. It is chiefly owing to the 
 occurrence of turbidity of the lens, with which the ulterior forma- 
 tion of cataract is connected, that I advise the immediate employ- 
 ment of iridectomy in pupillary exclusion, but consider it indicated 
 even before serous exudation has collected behind the iris. 
 
 Most difficult is it to determine the indications and prognosis of 
 the operation, when atrophy of the bulb has been already induced. 
 Here, the pupillary space being entirely obstructed, we can only 
 estimate the changes in the deeper parts by examining how light is 
 perceived.^ If the perception of light is very slight, so that the 
 patients can only just perceive a very bright lamp, held close before 
 them, we must not expect from the operation any improvement in 
 
 ' By this means we are even able to recognise improvements in atrophied 
 eyes from the use of internal means. During a treatment by the sublimate I 
 have repeatedly observed an increased quantitative perception of light. 
 
IN IRIDO-CHOROIDITIS, ETC. 273 
 
 the vision of the affected eye. If the perception of light is of 
 moderate range, so that a bright lamp is perceived at the distance 
 perhaps of four to ten feet, and a medium lamp close at hand, the 
 most important point is to ascertain whether aU. parts of the retina 
 are equally sensitive, or whether there are differences indicative of 
 secondary retinal separation. In the latter case the prognosis is 
 always unfavorable ; in the former, on the other hand, the opera- 
 tion, repeated according to circumstances, affords some hope. If 
 the light is better perceived, so that a medium lamp can be recog- 
 nised at the distance of a room, and also the Ught and shadow of a 
 lowered lamp a few feet off, and at the same time the excentric 
 impressions are symmetrical, some improvement may be reasonably 
 expected. It is evident that the degree of atrophy must also be 
 taken into consideration. If it is more concentric, i. e. if the flat- 
 tenings in the direction of the recti muscles are not conspicuous rela- 
 tively to the diminution of the eyeball in size ; if, in a word, the 
 globe is tolerably regular in form, the prognosis is more favorable 
 than in the inverse case. For we may then conclude that the 
 sclerotic has contracted concentrically during the chronic choroiditis 
 and diminished secretion of the vitreous humour, and that after its 
 new position of equilibrium has been estabhshed by corresponding 
 modifications of tissue, the form of the globe has continued, even 
 when improved choroidal circulation allowed a more abundant 
 secretion of vitreous humour. On the contrary, when the flattenings 
 are much marked, the sclerotic itself exercises no pressure on the 
 contents of the globe, and hence the diminished volume must be 
 entirely ascribed to the insufficient action of the choroid. 
 
 The first form of atrophy is especially developed in youth, when 
 the sclerotic is more elastic. We know, that when morbid processes 
 have occurred during the years of childhood, especially soon after 
 birth, the affected globe sometimes remains small, but regular, which 
 is generally expressed in practice by saying that the development 
 of the bulb has been arrested. I have even succeeded in tracing 
 a similar connexion in many cases of microphthabnus congenitus. 
 Certainly this disease more often depends on foetal diseases than 
 on arrests of development. In two cases of microphthalmus con- 
 genitus, lately under observation, I found, by means of the ophthal- 
 moscope, large choroidal deficiencies in the equatorial region, just 
 such as are found (as atrophic patches) after circumscribed choroid- 
 itis has run its course in adults. I performed tenotomy for strabis- 
 
 18 
 
274 
 
 GRAEFE ON IRIDECTOMY 
 
 mus, on one of these eyes, in a child aged two years ; on the second, 
 in a child aged ten mouths, I made an artificial pupil on the inner 
 side, on account of a large central capsular cataract. 80 far as 
 could be ascertained by trials of vision at so tender an age, neither 
 eye seemed very weak-sighted; in the latter, the ophthalmoscopic 
 examination could not be made- previously to the operation for 
 artificial pupil. 
 
 I have once even had occasion to make an artificial pupil in an 
 eye, which was probably affected with the results of irido-choroiditis 
 at birth. I partly suspect this from a medical report extending 
 from the earliest infancy, partly from the history, according to which 
 the patient was always restricted to an inconsiderable perception of 
 light, and partly because the diminution in size was far advanced, 
 yet perfectly regular. The individual, a delicate girl of eighteen, 
 presented symptoms which showed that internal inflammations 
 were still continuing in both eyes. Both globes were very much 
 lessened, but at the same time regularly round, the muscular veins 
 extremely developed, and the aqueous humour muddy. The greater 
 part of the pupil was filled with a shrivelled, calcareous cataract, 
 which adhered to the margin of the iris ; after the use of mydri- 
 atics it presented (as seen through the muddy anterior chamber) 
 a slight, tolerably distinct projection inwards. The mydriatic treat- 
 ment, and various other means, haviag been unsuccessful, vision also 
 having contiaued to diminish during a year, and finally having be- 
 come reduced to a dull, quantitative perception of light, I resolved to 
 form a pupil in the left eye, and was much astonished at the excellent 
 influence gradually exerted over the whole eye. The case appeared to 
 me the more instructive, because in the eye which had not been opera- 
 ted onl had a constant representation of the previous condition. Three 
 months after the operation the subconjunctival veins had almost 
 perfectly retrograded, the anterior chamber was clear, the pupil per- 
 fectly transparent, except that it was covered to a slight extent by 
 the calcified and floating lens, whilst in the right eye all remained 
 in its former condition. The vitreous body, which could now be 
 readily examined through the large pupil, was somewhat muddy for 
 from six to eight weeks, but then perfectly cleared. There were no 
 appearances of disease in the retina, excepting that the vessels were 
 very small ; the papijla nervi optici a little smaller and whiter than 
 usual, and the central artery especially very delicate (symptoms of an 
 imperfect development of the optic nerve and retina). The choroid. 
 
IN IRIDO-CHOEOIDITIS, ETC. 275 
 
 tolerably uniformly deprived of its layer of pigmentj presented no 
 essential changes, except a few places in the equatorial region, where 
 the tissue was atrophied. Only four weeks after the operation the 
 patient could count fingers. Now, she exercises the eye with 
 convex glasses, in recognising figures and letters of large size. The 
 volume of the bulb has not in the least changed. 
 
 Having proved the cmative action of iridectomy in those forms of 
 irido-choroiditis which are preceded by iritis and pupillary exclusion, 
 I tried it in other and very different conditions, which, for the sake 
 of completeness, I shall successively enumerate ; in doing so, how- 
 ever, I shall be obliged somewhat to repeat myself. 
 
 In the first place, I shall mention the cases already adduced, 
 where irido-choroiditis resulted from retinal separation. As already 
 remarked, there was no special improvement in vision, but, on the 
 other hand, the internal irritation was alleviated, a point that was 
 often of importance to the healthy eye. In most cases, the greater 
 part of the artificial pupil was filled by a cataract of previous 
 formation. 
 
 Secondly, I operated on those cases of irido-choroiditis well 
 known to all observers, but very variously named. In this form 
 the symptoms of irritation are not very severe ; there is diffuse hazi- 
 ness of the aqueous humour, with no great amount of pupillary 
 exudation, without contraction, often even with dilatation of the 
 pupil. In this stage of the disease it has been termed descemetitis, 
 hydromeningitis, aquoi-capsulitis, iritis serosa, &c, to which symp- 
 toms, contemporaneously or at a later period, there are added hazi- 
 ness and softening of the vitreous humour, (very fine floating 
 opacities), great tremulousness of the iris and crystalline lens, 
 generally terminating in retin^ separation, cataract, &c. Guided by 
 the anatomy of former days, this species of disease has been supposed 
 to be an inflammation of the serous tract lining the whole interior of 
 the eye, and even if no part of this conception still remains — for the 
 hydromeningitis is an iritis, and the hyaloiditis is a choroiditis — still 
 (by the delicate nature of the commencing exudation, their suspen- 
 sion in the fluids, the absence of firmly adhering exudation, &c.) 
 this form of disease is sufiiciently distinguished from other forms, 
 for it to occupy a distinct place in nosology. The rapid appearance 
 and disappearance of the diffuse opacities are to some extent charac- 
 teristic. I have sometimes seen the aqueous humouj become turbid 
 
276 
 
 GRAEFE ON IRIDECTOMY 
 
 and again clear within an hour; I have, seen it become clear^ both 
 spontaneously, as after sleep, and after treatment such as bleeding, 
 incisions into the layer of subconjunctival vessels, diaphoresis, &c. 
 The opacities of the vitreous body never clear away so rapidly. 
 Since, as the rule, success may be attained by other means in the 
 first stage of this disease, I only performed iridectomy in some old or 
 desperate cases, and as their number merely amounted to six, I have 
 been unable to come to any decision, but am inclined to repeat the 
 trial, from the results in two instances having exceeded all expecta- 
 tion. Oidy I should recommend a very gradual withdrawal of the 
 instrument, as the greatest care should be talcen to prevent too rapid 
 escape of the aqueous humour, because separations of the retina 
 and intra-ocular hsemorrhages are very liable to occur. This pre- 
 caution is equally important in paracentesis. 
 
 Thirdly, I have operated in sclerotico-choroiditis. I mean cases 
 in which sclerotico-choroiditis posterior had gradually extended to 
 the anterior parts, and had induced a total ectasis ' of the bulb 
 (hydrophthalmus), haziness of the vitreous body, and atrophy of the 
 choroid. I have not seen any injurious effect from the formation of 
 an artificial pupil, but neither have I been convinced of any curative 
 action, so that at present I cannot recommend imitation in similar 
 cases. 
 
 Fourthly, I operated for extensive corneal affections, with and 
 without iritis. I was induced by certain cases in which the corneal 
 disease not having run its course, it was evident that an artificial 
 pupil would ultimately be required, and owing to other circumstances 
 the operation could not be delayed tiU the affection of the cornea 
 had ended. Instead of the operation inducing any redevelopment 
 or aggravation of the disease, I almost constantly remarked that after 
 the formation of an artificial pupil, the filling up of the corneal ulcers, 
 and the clearing of the opacities, as far as was possible, proceeded 
 with extreme rapidity and success. Years ago tliis led me to the 
 idea of performing iridectomy, with the design of shortening the 
 duration of corneal affections. Of course this treatment must not 
 be employed in cases where the corneal lesions may be expected to 
 heal without injury to the central pupil ; but only where total 
 
 ' Eotasis, according to Nysten, is a word proposed by Graefe to denote all 
 diseases characterised by a condition of dilatation ; introduced by Breschet into 
 general use under one form — phlebeotasie — it has, I think, so found its way 
 into some English works. — Tbans. 
 
IN IRIDO-CHOROIDITIS, ETC. 277 
 
 destruction of the cornea is to be feared, as in spreading abscesses 
 with infiltration of pus (eitersenkung), or where the recovery which 
 may be expected renders an increased size of the central pupil de- 
 sirable, as when we can foresee the formation of large cicatrices 
 in the centre of the cornea. I disapprove of iridectomy when the 
 corneal disease depends on a blennorrhoic affection of the conjunc- 
 tiva, for by curing the blennorrhoea the corneal process has always 
 a very favorable termination, at least in a relative sense, and at a 
 later period we can better determine the condition in reference to 
 forming an artificial pupil. Besides, owing to the presence of 
 blennorrhoic secretion, the wound might endanger the eye, and it 
 would also interfere with the application of caustics, a point never 
 to be neglected. Por the same reason I am opposed to it when the 
 corneal affection depends on diphtheritis, or an acute granular pro- 
 cess; on the other hand, the operation is advisable in idiopathic 
 diseases of the cornea. In very extensive central abscesses, with 
 infiltration of pus and hypopion, filling haK the anterior chamber, I 
 have often combined iridectomy with evacuation of matter from the 
 anterior chamber, when the only object was to save the eye,and I 
 have been higlily satisfied with the result in this and similar cases. 
 How is this favorable influence of iridectomy to be explained ? Does 
 it arise simply from the puncture of the anterior chamber? It 
 might be so, where the anterior chamber is annulled or diminished 
 for some time after the operation, through the continued escape of the 
 aqueous humour, for only imder these circumstances do we find that 
 paracentesis exercises that curative action on corneal lesions which has 
 been so often praised {vide A. f. 0., Bd. i, i, S. 334). But in the 
 present case this is only a most exceptional occurrence, for the wound, 
 which is placed on a healthy portion of the corneal margin, quickly 
 closes. Excision of a piece of the iris must necessarily influence the 
 secretion of aqueous humour. Though we have abeady attempted 
 to prove that the remainder of the iris relatively secretes more, still 
 a perfect compensation is not probable, and hence a certain diminu- 
 tion of the intra-ocular pressure maybe readily admitted; besides I 
 have sometimes found, weeks after unilateral operations (under the 
 usual indications), that the eye on which I had operated still 
 was softer to the touch than the healthy one. I suspect that this 
 continued diminution of intra-ocular pressure explains the curative 
 action of iridectomy in corneal lesions, and that in this respect it 
 is allied with the mydriatic treatment and paracentesis. Further, 
 
378 GRAEFE ON IRIDECTOMY 
 
 I must not omit to mention that in acute and deeply penetrating 
 corneal lesions iritis is often unnoticed^ and that it is very difBcult 
 of control, owing to the affection of the cornea. Centeal corneal 
 abscesses with hypopion are often accompanied by iritis, a com- 
 plication that, under such circumstances, should always be suspected 
 when the pupU does not yield to an energetic application of mydri- 
 atics, though, at the same time, the eye is not very irritable. I 
 consider this suspicion justified by the fact, that in these very forms 
 of corneal disease atropine is more readily absorbed into the anterior 
 chamber than in others {e.g. diffuse, interstitial, or deep exuda- 
 tions). Besides, after atropine has been applied, the existence of 
 iritis can sometimes be shown by irregularities, little indentations of 
 the pupillary margin, &c. Indeed, I believe that it is precisely the 
 combination of iritis with central corneal abcesses that explains 
 the occasionaUy unsatisfactory termination of the latter. Iridectomy 
 is beneficial in both respects. 
 
 Fifthly, I have operated in cases where the lens had become 
 swollen, with the view of preventing its injurious effect, both 
 after discisions and accidents. Elsewhere I have indeed maintained 
 that the extraction of the swollen lens by the linear operation is the 
 best course to pursue ; but there are exceptional cases, where iridec- 
 tomy must be performed instead, before, or at the same time. 
 After accidents we often find the iris wedged into the cornea, the 
 pupil being Exceedingly distorted and diminished in size, combined 
 with traumatic cataract. I presuppose that the swelling of the lens 
 is moderate in amount, and that it is only threatening to the eye 
 because the pupil is very narrow, and hence the pupillary margin is 
 irritated by the projecting parts of the lens. Under such conditions 
 we meet with the outbreak of iritis, and yet we cannot perform a 
 linear extraction, for, without referring to the impediments possibly 
 presented by the iris, the imbibition of the lens is yet incomplete. In 
 such cases I have often enlarged the pupil by iridectomy a few days 
 after the injury, and then had no further occasion to interfere with 
 the natural process of reabsorption, owing to the swollen lens no 
 longer exercising an injurious influence on the iris. In other cases, 
 where the imbibition of the lens has abeady far advanced, excision 
 of the iris should be combined with linear extraction of the whole, 
 or of its softened portions. These are no theoretical propositions, 
 but methods I have tested in numerous cases. If the lens has 
 become very swollen, and iritis has already commenced, no time 
 
IN IRIDO-CHOROIDITIS, ETC. 279 
 
 must be lost in performing iridectomy, which, according to circum- 
 stances, must be combined or not with the removal of the lens. 
 The degree of inflammation can never be considered a contra-indica- 
 tion. In truth, there is no treatment which, under such conditions, 
 has so decisive an antiphlogistic action as iridectomy. Superficially 
 considered, it might seem absurd to interfere with the iris, and not 
 at the same time with the lens, which acts the part of a foreign 
 body, but the danger is produced through the pressure exercised by 
 the swollen lens on the iris, and hence the chaia of injurious effects 
 will be interrupted by the operation on the iris, even though the 
 original cause remains. It is, of course, far more satisfactory to 
 remove, at the same time, the crystalline lens ; but I cannot too 
 often repeat that no force should ever be used in attempting 
 removal by a linear incision; the softened portions of the lens 
 readily escape when the operation is properly performed ; the 
 removal of portions of the lens, which are not softened, and which 
 adhere with extreme tenacity, by repeated introductions of DavieFs 
 scoop (curette), &c., is dangerous, and also in some respects un- 
 necessary, because these portions do not afterwards affect the eye. 
 The operation for artificial pupil is employed after discisions as 
 after accidents. In young persons a sweUing of the lens, producing 
 iritis, is usually accompanied by a softening of the lens, of such a 
 character that we receive the most assistance from linear extraction 
 {vide A. f. O., Bd. i, i, S. 255). In elderly persons, on the other 
 hand, the tendency to iritis is so great, that loosening of the cortical 
 substance, even to a moderate amount, readily excites chronic iritis. 
 In consequence I have avoided, as far as possible, operations of 
 discision in adults, for I cannot agree with the experience of English 
 authors, especially of Jacob, as to the excellent action of keratonyxis 
 in partially softened cataracts, even of old persons. The occurrence 
 of iritis, even though chronic, operates most powerfully in prevent- 
 ing reabsorption, for the capsule, thickened by deposit, is incapable 
 of expanding or contracting. It matters not what future treatment 
 of the cataract be intended, iridectomy should at once be performed. 
 In some cases we may. form the artificial pupil at the upper part of 
 the iris, as previously mentioned. 
 
 For a similar reason, iridectomy may be indicated in cases 
 where a small foreign body, such as a fine chip of metal, has 
 pierced the cornea, and is firmly fixed in the iris. AH hope of its 
 becoming encysted, &c., must be abandoned, when the irritable con- 
 
280 GUAEFE ON IRIDECTOMY 
 
 dition is of some continuance; we must then excise, at the same 
 time, both the foreign body and the adjacent portion of the iris. 
 This is far safer practice than to attempt to extract simply the 
 foreign body. I advise the latter method only when the foreign 
 body is of considerable size ; in other cases, it is generally impos- 
 sible to remove it alone. In fact, after the escape of the aqueous 
 humour, a fold of the iris invariably falls within the grasp of the 
 forceps, and it is scarcely possible to extract, without seizing the 
 iris, a metallic splinter that can hardly be seen. "When such an 
 improper proceeding is employed, haemorrhage into the anterior 
 chamber generally occurs, the body can no longer be seen, and we 
 entirely fail in our object; even if we eventually succeed in ex- 
 tracting it, after having, in various ways, injured the anterior surface 
 of the iris, inflammation generally ensues. I have already suffi- 
 ciently called attention to the fact, that vision is practically unaffected 
 by the formation of an artificial pupil, and the advantages of pre- 
 venting iritis are most important. With similar curative views, 
 iridectomy may be apphed even to flap-extraction. I do not mean, 
 when posterior synechiae positively require an enlargement of the 
 pupU, but when the conditions are in every respect of an ordinary 
 nature. Excision' of a contused portion of the iris wiU generally 
 be advantageous, for it often excites deleterious inflammations in 
 cases of extraction where the exit of the lens has been attended 
 with great difficulty. Hence after the removal of the lens I make 
 an artificial pupil at the upper part, not only on account of pro- 
 lapsed iris, inaccurate position, &c., but in the not unfrequent 
 cases where the iris has been violently contused during the passage 
 of the lens. Iridectomy must not be delayed until symptoms of 
 inflammation have appeared, for it is most critical to operate on the 
 eye at such a period after previous flap-extraction; it is better to 
 perform it immediately after removal of the lens. Por those who employ 
 the upper section the ultimate change of position of the pupil is of 
 no importance, for by proper manipulation the displacement of it up- 
 wards is only shght, and not as when there is a considerable prolapsus 
 iridis, or when a piece of the iris is excised owing to its shpping 
 before the knife. The natural pupU preserves its central position, 
 being only continued by a small eoloboma in the direction of the 
 corneal incision; this eoloboma too is covered by the upper Hd. 
 The experience of most observers is in favour of the opinion that 
 the cases of operation in which the iris is excised by the fault of the 
 
IN IRIDO-CHOROIDITIS, ETC. 281 
 
 operator do not temdnate more unfavorably than normal cases, 
 although the performance of the operation is much complicated by 
 the haemorrhage, &c. Certain persons have suggested to me the 
 idea of forming a pupil at the upper part some weeks previous to 
 the operation, and I can only oppose it because it would be super- 
 fluous in an infinite majority of cases, and would not be very com- 
 patible with the limited period which the patients could remain, &c. 
 On the other hand, it might be defended on the ground of security 
 and prophylaxis. 
 
 Lastly, I have performed iridectomy even in a perfectly bhnd eye, 
 simply on account of the other one. Chronic iritis, certainly, in 
 the mass of cases, affects both eyes, and I believe the irritation in 
 the iris of the one eye, caused by adhesions of the pupil {vide supra) , 
 is the main cause of the disease of the other eye. Hence we find, 
 that in cases of iritis terminating in extensive pupillary adhesions 
 both eyes are often affected, but that otherwise the disease is 
 generally restricted to one side. And since iridectomy is the best 
 means of stopping the irritation of chronic inflammation in pupillary 
 exclusion, we have also ia it a very important means of preventing 
 sympathetic disease of the other eye. I could, if necessary, adduce 
 many instances in support of this fact, which is not without importance 
 in reference to nosology.- ' I first remarked this action in a case where 
 one eye was affected by pupillary exclusion, bulging of the iris, 
 and choroidal amblyopia, and the other by more recent iritis and 
 by very partial adhesions. Yet three or four attacks of iritis had 
 already recurred. I then made an artificial pupil on the former 
 eye, because I still hoped for some improvement of its vision, and 
 was much delighted to find that from that time the patient^s second 
 eye remained perfectly free from iritis. Since then I have very often 
 performed the operation, even where there was no longer any 
 quantitative perception of hght; and I have, in some cases, been 
 perfectly convinced of the beneficial influence exerted over the 
 other eye, thus conflnning my previous impressions. I designedly 
 say in, some cases, because only particular combinations could 
 afford direct proof. If the second eye is still healthy, the only 
 question can be as to a prophylactic action, which it is impossible 
 fuUy to prove, as it is not absolutely certain that the second eye 
 win also become diseased. If, however, the second eye is also 
 seriously diseased — thus, if there is union of the whole of the iris 
 with the lens — we have an obvious cause for further disease in this 
 
283 
 
 GRAEFE ON IRIDECTOMY 
 
 eye, and one which, as regards iritis, is more directly influential than 
 the sympathetic action of the first, eye. The only decisive cases 
 were those in which iritis periodically attacked the second eye, yet 
 without producing any structural change, or only to so sHght an 
 extent as to be insufficient to account for the further develop- 
 ment of disease. Many practitioners will doubt the prevalence 
 of such sympathetic inflammatiouj and be inclined to attribute 
 its occurrence in both eyes to constitutional causes. I do not 
 deny the frequency of such a connexion, but I would warn 
 my colleagues not to have immediate and unnecessary recourse 
 to this opinion, as it leads to neglect of the local conditions, 
 which are more under our control. No experienced observer of the 
 present time can doubt that irido-choroiditis, resulting from an 
 accident, not unfrequently induces a sympathetic affection of the 
 second eye. And we arrive at a similar conviction as to internal 
 inflammations of spontaneous origin, when we carefully consider the 
 manner in which they spread. Even irido-choroiditis of traumatic 
 origin may be occasionally treated by the formation of an artificial 
 pupil, when a sympathetic affection threatens the second eye. Of 
 course, proper discrimination must be used in such cases ; for, as 
 the rule, it is clearly indicated to extract a swollen lens, or to 
 puncture the vitreous body, or to remove the cornea or the anterior 
 portion of the globe. I should consider it unnecessary to perform 
 total extirpation of the globe for traumatic irido-choroiditis, with 
 the view of preventing a sympathetic affection of the second eye ; 
 and I only mention the proposition, because I hear that it has been 
 introduced by some of our English colleagues. 
 
 Before leaving this subject, I may be permitted to add a few re- 
 marks on the manner of performing the operation under the circum- 
 stances referred to, and on its immediate effects. 
 
 In regard to the method of operating, I have always employed 
 iridectomy, or the method of tearing the iris, claimed by Desmarres as 
 his own discovery, and which does not differ very essentially from it.'' 
 
 Irido-dialysis is falling more and more into disuse — a natural result 
 of its offering no greater advantages than iridectomy, and yet-being 
 
 ' Desmarres, in my opinion, merits our gratitude, not so much for having 
 distinguished tliis method as for having shown that, in regard to the perform- 
 ance and prognosis of the operation, it is of little consequence in cases of 
 synechia whether the free pupillary margin is brought out, or the tissue of the 
 iris is torn in its continuity. 
 
IN IRIDO-CHOUOIDITIS, ETC. 283 
 
 attended with important disadvantages and dangers. This point 
 has been so fully treated by Desmarres^ that it seems unnecessary 
 to add anything further. I may, however, briefly refer to an appa- 
 rent advantage of irido-dialysis, as on this account it has still its 
 advocates ; it afi'ords broader peripherical pupils, such as are wanted 
 where only a small marginal portion of the cornea is available for 
 the transmission of light. But, without considering the very un- 
 certain success of dialysis under these conditions, where we gene- 
 rally find the tissue of the iris atrophied, we can, through iridectomy, 
 readily obtain pupils in the most external part of the corneal mar- 
 gin. Nothing more is required than not to penetrate at the junc- 
 tion of the cornea and sclerotic, but ^at the distance of haM a line 
 from this point, into the sclerotic itself, and to give the lance- 
 shaped knife such a direction that it may pass into the anterior 
 chamber exactly at the point of union. That this is by no means 
 difilcult appears from the fact that the origin of the iris, as Arlt 
 especially has urged, does not he on the posterior wall of Schlemm's 
 canal, but in the very thickness of the tensor choroideae.^ If the 
 knife is thus passed into the sclerotic, no opacity whatever is caused 
 in the adjacent portion of the cornea ; and this is of especial im- 
 portance when the healthy portion of the cornea is extremely small ; 
 the pupil extends, of course, as far as the extreme edge, so that at 
 a later period, by oblique illumination or the ophthalmoscope, the 
 tops of the ciliary processes are seen projecting into the pupil. It 
 is true such pupils wiH be a little less broad than those obtained 
 under favorable conditions by dialysis. But some weeks afterwards 
 they can easily be enlarged to any extent, by similarly excising an 
 adjacent piece of the iris. Besides, it is seldom necessary to enlarge 
 the pupil, provided, in drawing out the knife, we act on the internal 
 wound, and not on the external, already relatively too large. And 
 even the inconvenience of repeating the operation should not in- 
 
 ^ The older surgeons had already remarked that they could puucture the 
 sclerotic tolerably far back, and still introduce the lance-shaped knife into the 
 anterior chamber ; but, according to their accounts, they generally first passed 
 the knife into the posterior chamber, and then transfixed the iris from behind 
 forwards. I am decidedly opposed to such a proceeding, transfixion of the iris 
 from behind forwards being very unsafe, because the iris, being moveable in 
 the aqueous humour, does not offer sufficient resistance ; besides, when instru- 
 ments are introduced into the posterior chamber, all control over them is lost, 
 and the margin of the lens, &c., may be wounded. 
 
284 GRAEFE ON IRIDECTOMY 
 
 duce us to prefer the hazardous irido-dialysis to iridectomy, so 
 certain as to its results, and attended with so little danger. 
 
 We generally find great structural changes in the iris when irido- 
 choroiditis is still active; if its periphery is pushed forward by 
 serous exudation, as already stated, it can readily be seized; the 
 more central portion, however, adhering through pigmented exuda- 
 tion, remains in its former position, and I would dissuade from 
 using any violence in extracting it, because the advantages are not 
 proportional to the danger of wounding the capsule and of thus 
 causiug traumatic cataract. In other cases the iris is so thickened by 
 exudation into its tissue, that it becomes quite stiff, and unadapted 
 to form a fold. I then employ straight, pupillary forceps, with sharp 
 teeth, which, instead of following the ordinary direction, I apply to 
 the iris somewhat perpendicularly ; according to my experience, such 
 an instrument is of very great service under these conditions. 
 
 Whilst in leucoma adheerens the formation of an artificial pupil 
 causes little or no haemorrhage into the anterior chamher, in irido- 
 choroiditis the bleeding is often very severe. This is readily 
 accounted for by the excessive vascularity and by- the pressure. In 
 the former case the free margin of the iris is frequently seized, so 
 that the small quantity of blood fiowing from the incision for the 
 most part escapes externally. The vessels are also not dilated, and 
 the muscular power of the iris is tolerably normal, which must 
 have some influence on the retraction of the cut vessels ; finally, 
 when the globe is filled in a normal manner, the sclerotic continues 
 to exert pressure on the contents after the whole of the aqueous 
 humour has escaped ; this must necessarily have some influence in 
 limiting the extravasation. If, in synechia anterior, instead of the 
 free margin of the iris being seized, it is torn iu its continuity, the 
 blood from the wounded surface does not indeed escape externally ; 
 it is the rule, however, in these cases, for both the vessels and the 
 tissue of the iris to become very much atrophied, through being 
 dragged towards the corneal cicatrix. On the other hand, in irido- 
 choroiditis there is hyperaemia, partly of an inflammatory, partly of 
 a mechanical nature. The muscular action of the iris (and with it 
 the power of retraction in the vessels ?) is impeded by the deposi- 
 tion of lymph ; even the membranes lying behind the iris not un- 
 frequently become vascular, and aU these tissues are torn in their con- 
 tinuity. Besides, in this case haemorrhage is very much promoted 
 by any existing diminution of pressure, which is still further in- 
 
IN IRIUO-CHOROIDITIS, ETC. 285 
 
 creased by the escape of the aqueous humour. This is particularly 
 the case when the eye has become somewhat atrophied ; then the 
 sclerotic ceases to exert any pressure, and after the vessels are 
 openedj a process of suction occurs, so that it is useless to try to 
 remove the blood by the introduction of Anel's stilette, &c., a me- 
 thod which is perfectly successful after haemorrhage in leucomata, 
 &c. To prevent any increase of haemorrhage, I am rather incHned 
 to apply, soon after the operation, a bandage, so as to produce sKght 
 compression, and this, after half an hour or an hour, I gradually loosen, 
 and finally remove ; at a later period the relations of pressure become 
 equalised by transudation, and no longer by extravasa,tion. ' It is 
 generally said that bleeding into the anterior chamber is UQt of much 
 consequence, and, in ordinary circumstances, I perfectly agree with 
 that opinion, as the blood is rapidly absorbed in a healthy aqueous 
 humour, and without causing any reaction ; but the conditions are 
 of quite a different character when there are internal inflammations. 
 Eifused blood often continues long unabsorbed in cases of iritis and 
 irido-choroiditis, especially when the aqueous humour is somewhat 
 clouded J not only are the endosmotic relations between the blood- 
 corpuscles and the surrounding fluid essentially altered by its satu- 
 ration with exudative matters, but even the conditions of reabsorp- 
 tion are no longer the same, and finally the flakes of blood, which 
 remain for a long period, seem to act as mechanical irritants, and to 
 serve as the starting-point for fresh exudations when they pass into 
 the pupU. Hence severe haemorrhages, filling the whole anterior 
 chamber, are very troublesome in some cases of iritis and irido-cho- 
 roiditis, and success will sometimes be frustrated by them. We cannot 
 always succeed in avoiding them, but since for the most part they 
 arise, so to speak, ex vacuo, I consider it very desirable to exercise 
 a httle pressure even during excision, and afterwards to apply the 
 compressing bandage already recommended. I must also mention 
 the severe pain sometimes produced by seizure of the iris ; whilst 
 this is most exceptional under ordinary conditions, here it occurs 
 almost invariably. This pain, which is partly situated in the bulb, 
 partly radiating as ciliary neurosis into the forehead, temples, and 
 nose, occasionally continues for some hours after the operation. 
 
 I have never seen a more violent degree of iritis ensue after the opera- 
 tion; on the other' hand, there sometimes follows, however, especially 
 when severe haemorrhage has occurred into the chambers, by a very 
 marked state of congestion, of which the symptoms are lachrymation. 
 
286 
 
 GRAKFE ON IRIDECTOMY. 
 
 slight chemosis, moderate swelling of the Hds, and hyperaemic 
 coloration of the iris ; this always forms an essential difference from 
 the usual statCj in which the formation of an artificial pupil excites 
 no reaction whatever ; and even here it is only occasional, princi- 
 pally occurring when we are compelled to operate in very acute cases. 
 StiU it seems advisable to allude to it, that those who may hereafter 
 imitate my example may not be astonished if the allaying influence of 
 iridectomy, of which I have spoken so highly, should not in aU cases 
 immediately follow the operation. Fortunately the state of conges- 
 tion is temporary, and even when excessive it yields' to moderate 
 antipKlogistic treatment, and then, in general, the desired curative 
 action on Jhe internal inflammation gradually appears in the course 
 of a few weeks. After the operation for artificial pupil, all other 
 methods of treatment usually act more favorably than before ; so 
 that, when pupillary exclusion has once formed, I seldom begin to 
 employ other remedies, such as mercurials, until after I have 
 operated. 
 
 Lest I should be charged with one-sidedness, I must, in conclu- 
 sion, remind the reader that I have by no means intended fuUy to 
 consider the treatment of iritis and irido-choroiditis. I have never 
 aimed at supplanting, by mydriatics and iridectomy, other methods 
 of treating these diseases ; and every unprejudiced person who has 
 followed my clinical practice and lectures wiU bear witness how 
 much I value an energetic and properly conducted antiphlogosis, 
 especially at the commencement of the disease. Above all, I am 
 far from wisliing to depreciate the importance of mercurials, and I 
 recognise with the fullest conviction their great value in dangerous 
 internal inflammations. My sole object has been to recommend to 
 my colleagues a proceeding which I think I have tried with the 
 necessary scepticism and circumspection, believing that they wiU 
 find in it a source of numerous successes and the curing of many 
 otherwise incurables. 
 
ON 
 
 IRIDECTOMY IN GLAUCOMA, 
 
 AND ON 
 
 THE GLAUCOMATOUS PEOCESS. 
 By De. a. t. GRAEFE.i 
 
 I. — To the report on the curative effects of iridectomy, already 
 pubhshed in the ' Archiv' (B. ii, Abth. a, S. aoa — 257), I am about to 
 add another of a highly gratifying character, for it refers to a com- 
 prehensive category of diseases hitherto incurable. The present 
 communication would much sooner have been issued, had not the 
 insidious nature of the affection demanded extreme care in judging of 
 the results, and long-continued observation. Hence it is perfectly 
 possible that iridectomy, as a remedy in the glaucomatous process, 
 is already vcell known to most readers of the ' Archiv,' the subject 
 having been discussed in my clinic through two sessions, commu- 
 nicated to many of my colleagues both orally and by letter, and 
 very widely imitated. The best amends for my delay will be to 
 specify the indications and prognosis as accurately as possible; 
 otherwise, indeed, I would not give publicity to these observations, 
 lest those who may adopt my views should not prove equally 
 successful, and I should bring into discredit a method which is 
 
 ' Translated, witli the author's permission, from the 'Arcbiv fiir Ophthalm.' 
 Berlin, 1857. 
 
288 
 
 GRAEFE ON GLAUCOMA. 
 
 happily becoming naturalised in practice within its proper 
 limitations. 
 
 II. — ^Wlien we recommend medicines or modes of operation, it is 
 especially necessary to define the disease in reference to which they 
 are recommended. The absence of general agreement constitutes 
 an hereditary evil of therapeutical scieucBj only to be cured by slow 
 degrees, just as a sanguine predilection for medicines gradually 
 yields to an intelligent analysis of the indications of treatment. I 
 feel the necessity of agreement the more acutely, because the affec- 
 tion in question has ever seemed one attended by confusion and 
 misunderstanding. 
 
 The name glaucoma formerly indicated a vague, expressionless 
 symptom — a sea-green, bottle-green, or dirty-green background of 
 the eye, seen through a fixed, dilated pupil. When greater exact- 
 ness was required, efforts were made to discover definite, material 
 changes, suificient to account for this symptom, but they terminated 
 most variously and contradictorily. Whilst some imagined in 
 glaucoma a peculiar degeneration of the refractive media, and espe- 
 cially of the vitreous body, others referred the origin of the disease 
 to the choroid, others again to the retina; and as each of these 
 views was contradicted, some gave up the seemingly futile attempt 
 to localize, and considered glaucoma a disease of the whole globe. 
 The latter hypothesis obviously attests only the incompleteness of 
 our knowledge, for, owing to the great variety of the tissues of the 
 eye, an exact pathology requires as accurate localization as in dis- 
 eases of the abdomen or thorax. No one can doubt that in the 
 course of the glaucomatous process most tissues of the eye become 
 diseased, but it is equally certain that they are attacked at different 
 periods, and that in consequence we have to distinguish the primary 
 from the secondary changes. Of all the opinions brought forward 
 certainly that one had the most numerous and powerful followers, 
 which explained glaucoma as an inflammation of the choroid, with 
 effusion between it and the retina. This view seemed to be favoured 
 by pathologico-anatomical facts first collected by Schroder van der 
 Kolk, and afterwards especially by Arlt. Notwithstanding, it was 
 still open to controversy which of the changes were primary and 
 which secondary or quite accessory. Most of the preparations 
 were taken from far-advanced cases, and hence, at the time of dis- 
 section, did not present the typical appearances of glaucoma ; and 
 
GRAEFE ON GLAUCOMA. 289 
 
 with tlie exception of a few instances brought forward by Arlt, 
 there had been no examination during life, a point which is almost 
 indispensable for fixing the glaucomatous origin. 
 
 Finally, more than five years ago, there appeared Helmholtz's 
 immortal discovery, destined to throw so much light upon many 
 obscure cases, especially upon amaurotic affections. This naturally 
 excited the hope that the question of glaucoma would also be de- 
 cided. But, unfortunately, this expectation was not so speedily to 
 be gratified ; it rather appeared as if glaucoma would remain an in- 
 soluble mystery, even when examined by the new instrument. The 
 immediate results were of a purely negative nature, proving the 
 non-existence of those effusions suspected to He between the retina 
 and the choroid. The diagnosis of such effusions, formerly possi- 
 ble only when they were very extensive, so as to produce the so- 
 called hydrops subretinalis, had been so much aided by the applica- 
 tion of the ophthalmoscope, that they could not possibly be 
 overlooked ; yet they were never seen, provided typically pure cases 
 of glaucoma — and such, of course, were necessary — were employed 
 in the investigation. Such cases were, in general, somewhat ad- 
 vanced, for in the specially acute period of the process, it is seldom 
 possible, owing to the diffuse opacity of the refractive media, to de- 
 termine with certainty the details of the back of the, eye. Hence it 
 could no longer be supposed that subretinal effusions caused the 
 glaucomatous blindness ; either they had no connexion whatever with 
 the disease, or were developed at an advanced period, as a secondary 
 affection. Neither could the diffuse cloudiness of the aqueous and 
 vitreous humours sufficiently account for the blindness caused by 
 glaucoma ; for the opacity is never so great as to explain the entire 
 loss of perception ; besides, at times, if not prevented by the forma- 
 tion of cataract, it may be seen spontaneously to disappear, without 
 any corresponding power of vision being restored. The changes in 
 the internal membranes, apoplexies, and, at a later period, partial 
 atrophies of the choroid and retina, did not by any means con- 
 stantly occur, and were also developed to a far less extent than in 
 chronic retinitis and choroiditis. Hence it must follow that these 
 structural changes did not directly cause the occurrence of the 
 blindness. Since, however, a peculiar alteration in the entrance of 
 the optic nerve was always apparent in weU-marked glaucoma, the 
 attention of all investigators was directed to this point, as the proba- 
 ble source of the disease. 
 
 19 
 
290 
 
 GRAEPB ON GLAUCOMA. 
 
 ni. — Three facts were ascertained as to this peculiar condition 
 of the optic nerve. 
 
 I. A change in form, first brought into notice and delineated by 
 Ed. Jager (see his book on 'Cataract and Cataract-operations/ 
 plate viii, fig. 34). He believed that this appearance was caused 
 by an arching forwards of the papilla. The error had such an ap- 
 pearance of probability, that it was universally believed, till I found 
 an opportunity (see A. f. 0., B. ii, Abth. i, S. 248, 349) of cor- 
 recting it. The mistake was almost certain to be discovered after 
 Dr. A. Weber (A. f. 0., Band ii, Abth. i, S. 141-6) had carefully 
 discussed the origin and solution of an analogous error in the 
 iastance of a rabbit affected with sclerectasia posterior. The con- 
 viction that the glaucomatous optic nerve does not project, but is 
 hollowed out, has since then acquired complete certainty. I refer 
 any one stiU unconvinced to the anatomical description of a glauco- 
 matous optic nerve, promised by Professor H. Miiller for the next 
 number of the 'Archives.' 
 
 3. A peculiar condition of the retiaal vessels within the limits of 
 the papilla. This has been well represented in Jager's first plate, 
 and explained by Liebreich (see A. f. 0., B. i, Abth. i, S. 375) as 
 caused by the form of the optic nerve. Since the concavity has 
 been shown, this explanation certainly requires some slight modifi- 
 cation, yet it remains essentially correct. 
 
 3. Pulsation in the arterial trunks, already mentioned by Ed. 
 Jager in reference to diseased eyes, and adduced by me (loc. cit., 
 p. 376) as pathognomonic of the glaucomatous process. 
 
 IV. — When the changes in the optic nerve were perceived in glau- 
 coma, there naturally ensued the task of connecting them with the 
 symptoms previously known of circulatory and trophic disturbances. 
 The solution of this problem presented the greatest difficulties. 
 Even if the affection of the optic nerve were really the first cause of 
 blindness, stiU the remaining complex group of symptoms could not 
 result from it, as a secondary affection. We see glaucoma, in its most 
 typical variety, sometimes occurring in previously healthy eyes in 
 the form of acute inflammatory attacks. Besides, a causal relation 
 of the lesion of the optic nerve with the other alterations, of the 
 refractive media, &c., could scarcely be imagined. In amaurotic 
 cases we observe the most advanced metamorphoses of the papiQa, 
 extending even to perfect atrophy of the optic nerve and retina. 
 
GRAEIE ON GLAUCOMA. 291 
 
 ■without the other parts of the eye being affected ; even the most 
 exquisite granular exudation processes in the papilla usually only 
 lead to changes of the retina. This may be readily explained by 
 the nutrition of the retina^ which is independent of the other mem- 
 branes of the eye. Indeed^ this opinion is almost disproved by the 
 fact, that the papilla is not convex, but concave. Had the former 
 been the case, we should probably have had to consider the ques- 
 tion of a swelhng caused by exudation, which we all formerly be- 
 lieved to exist, and which might possibly induce further disease of 
 the globe. But since the papilla is concave, we can scarcely imagine 
 any increase in the size of the optic nerve. Eetraction of the sub- 
 stance of the optic nerve after any previous exudative processes 
 might certainly cause a retraction of the papilla, but no such pre- 
 vious condition of swelling can at present be shown which might 
 justify the hypothesis. Hence the degeneration of the optic nerve 
 cannot be justly considered as the source of the remaining symp- 
 toms, and yet the pathogenesis of particular cases seemed to 
 favour this view. Sometimes, during a long period, only the 
 lesion of the optic nerve was observed, whilst the other symp- 
 toms of glaucoma did not occur until a later period. In compa- 
 rison with the former statement, these cases, however, have been con- 
 tinually becoming less frequent, just as we have gained increased 
 familiarity with the methods of observation, and I now venture to 
 maintain that, on a very minute examination, the other glaucoma- 
 tous signs, such as increased intra-ocular pressure, may be perceived 
 even in the earliest periods, but they are less prominent in the in- 
 sidious forms, so that errors in diagnosis may very readily be made. 
 To prevent any misapprehension, I must at once remark, that there 
 is a small but incontestable category of cases, in which the affection 
 of the optic nerve alone exists, and continues unaccompanied by 
 any other symptoms. My previous statement refers entirely to the 
 cases in which the external symptoms of glaucoma are developed at 
 a later period. I am obliged to urge this, because the affection of 
 the optic nerve might otherwise be imagined, as formerly by myself 
 and others, to be a first and original stage of the glaucomatous pro- 
 cess. In general, three different groups of cases require considera- 
 tion. In the first the whole -sequence of glaucomatous symptoms 
 at once arises ; and in due time, but consecutively, as will hereafter 
 appear, the degeneration of the optic nerve is visible by the oph- 
 thalmoscope. In the second the lesion of the optic nerve is at all 
 
292 
 
 GllAEFE ON GLAUCOMA. 
 
 events the first striking material symptom ; the other glancomatons 
 signs, however, can be shown, though at first but little marked, 
 until at a later time they attain their typical development. In the 
 third group there is throughout only the degeneration of the optic 
 nerve. It wiU be one object of the present communication to esti- 
 mate these three groups of disease in their opposite nosological re- 
 lations, and either to unite or separate them. 
 
 At the time of my writing the above-cited essay on glaucoma, the 
 generation of the ophthalmoscopic signs was still completely veiled 
 in obscurity. The identity in the form of degeneration of the optic 
 nerve seemed to justify us in including aU these groups under the 
 head of glaucoma, explaining the differences of development by the 
 unequal action, in different directions, of a common extra-ocular 
 cause — arterial atheroma. Certainly, the first service rendered by 
 the ophthalmoscope towards understanding glaucoma was not of a 
 very gratifying nature; instead of the simple and comprehensive 
 doctrine of glaucomatous choroiditis, the disease was transferred to a 
 part apparently unconnected with the rest of the evolution ; even the 
 term glaucoma showed this influence, for it now acquired a much 
 more extended signification, and was for some time applied to cases 
 not previously known under that name. If it had ever been possible 
 to agree about glaucoma, it was certainly impossible at the time of 
 the first ophthalmoscopic elucidations. 
 
 V. — There were only two ways of discovering the connexion of 
 the lesion of the optic-nerve with the other glaucomatous symptoms; 
 first by pathological anatomy, and secondly by the most exact 
 clinical observation. Since my opportunities were very insufficient 
 for the anatomical examination of fit cases, I was restricted to 
 the latter method of study. I especially watched those cases 
 in which the appearance of glaucoma was developed after re- 
 peated acute internal inflammations (ophthalmia arthritica). For 
 the time I neglected the question as to what internal mem- 
 brane the origin of inflammation should be referred, and adhered 
 to the supposition of a choroiditis, which was especially favored 
 by Ailt's dissections, the whole appearance of the malady, the 
 sympathy of the iris, and the cloudiness of the vitreous body. 
 The ophthalmoscope had only refuted the occurrence of subretinal 
 effusions, but not of choroiditis, a point to which I shall again 
 refer, especially as in my original note on glaucoma, fettered by the 
 
GRAEFK ON GLAUCOMA. 293 
 
 degeneration of the optic nerve, I passed too rapidly over the account 
 of the internal membranes. Now when I compared the general 
 appearance of this glaucomatous inflammation with that of other 
 internal inflammations, for example, of the common irido-choroiditis, 
 it seemed to me that all the characteristic symptoms tended to one 
 point — increase of the intra-ocular pressure. 
 
 The hardness of the glaucomatous globe has been remarked from the 
 earliest periods of ophthalmology. Since no change in the sclerotic, 
 capable of explaining the altered resistance of the globe, can be justly 
 admitted, it must be founded on the more complete filling of the 
 globe with fluid. The dilatation and immobility of the pupil, are, it 
 is known, not caused by the blindness : were this the case, the pupil 
 must contract on the passage of light into the other and healthy 
 eye, as in unilateral anaesthesia of the retina ; the diameter of the 
 pupil must also change in rotations of the globe, in alterations of 
 accommodation, and in closure of the Hds. Besides, not unfre- 
 quently, after the first attack of glaucomatous inflammation, more 
 or less power of vision returns, and yet the pupil preserves its 
 abnormal properties. Evidently we must refer the pupillary affec- 
 tion directly to iridoplegia — paralysis of the nerves passing to the 
 iris. The degree of mydriasis in glaucoma compared with that in 
 paralysis of the oculomotorius, might indeed seem too great for the 
 admission of iridoplegia j but as I have already elsewhere stated, 
 the maximum dilatation, in which sometimes the iris almost peri- 
 pherically vanishes, does not exist from the commencement, but is 
 developed with the progressive atrophy of tissue, and it sometimes 
 also proceeds from other mechanical causes (see the account of dissec- 
 tions in the previous treatise on Sjonpathetic Amaurosis). The 
 increase of the intra-ocular pressure would furnish a further reason 
 for iridoplegia, the power of conduction in the ciliary nerves being 
 thereby annulled. As a phenomenon analogous to iridoplegia, I 
 found corneal anmsthesia ; this is also explained by compression 
 of the nerves passing to it ; in a second note on glaucoma 
 {vide A. f. O., Bd. i, Abth. 2, S. 305) I have already given a 
 direct proof of this, by showing that after the aqueous humour has 
 escaped, the sensibility of the cornea is again restored, provided the 
 operation is performed at a sufficiently early period of the disease. 
 With these symptoms may be classed ^e flattening of the anterior 
 chamber ; which, in my opinion, depends upon two circumstances. 
 First, the convexity of the cornea is diminished; secondly, the 
 
394. GRAEFE ON GLAUCOMA. 
 
 iris is really more arched forwards. The flattening of the cornea, 
 which may be proved by examinations of the reflection from it, 
 compared with that of another and healthy eye, is in itseK an in- 
 valuable argument for the increase of intra-ocular pressure. In an 
 inflammatory affection we could scarcely explain this symptom in 
 any other way ; perhaps, also, we may be able to found on it an 
 accurate method of measuring the amount of increased pressure, for 
 it is subject to mathematical estimate by means of Helmholtz's 
 ophthalmometer. If the radius of corneal curvature approach 
 that of the sclerotic, the receding angle of the cornea will be pushed 
 outwards, and occasion an alteration in the form of the anterior 
 chamber; at the same time, the iris will be pressed backwards. 
 Since, on the contrary, the iris in glaucoma appears more convex 
 anteriorly, there must, with the demonstrable flattening of the 
 cornea, be a compensating, or more correctly an over-compensating 
 momentum, a far greater increase of pressure acting in the space 
 occupied by the vitreous body than in the anterior chamber, so that 
 the iris is actually pressed forward. Again, the drculatorj/ chaniges 
 in the subconjunctival veins favour the idea of an increased pressure. 
 It is well known that, in the inflammatory stage, the whole system of 
 anterior ciliary vessels becomes much injected ; that at a later period, 
 however, the arteries gradually diminish, whilst the great venous 
 trunks twist and expand, anastomose with one another by loops 
 near the corneal periphery, and at length produce those figures for- 
 merly indicated as pathognomonic of the glaucomatous process, 
 under the name of arthritic or abdominal veins. The arteries ulti- 
 mately contract even to less than their normal size, and with this is 
 connected a progressive atrophy of the subconjunctival layer of 
 cellular tissue, which is proved by the white sclerotic shining 
 through it with much more than natural brightness. The veins are 
 then seen as isolated, dark-red strings, ramifying over a background, 
 which is porcelain- white or wax-like, or after the formation of 
 ectasia, bluish-gray or bluish. The older authors have already 
 mentioned, that " the white of the eye between the arthritic vessels 
 presents a peculiar, dead, lifeless appearance." The dilatation of 
 the veins may be reasonably referred to a mechanical obstruction of 
 the internal circulation. If, from increase of the pressure in the 
 space limited by the choroid and the crystalline system, the blood 
 cannot readily escape by the posterior venous canals, especially by 
 the vasa vorticosa, it passes anteriorly through the anterior ciliary 
 
GRAEPE ON GLAUCOMA. 295 
 
 veins, which open into the muscular ones. Then these expand, so 
 as to form a species of collateral circulation. Various views, having, 
 however, no immediate connexion with our subject, may be formed 
 as to the atrophy of the anterior cihary arteries, occurring at a later 
 period, which in some cases is undeniable. At all events it is 
 closely connected with the progressive atrophy of the iris. That 
 the ciliary neurosis is similarly caused by compression, is in 
 agreement with the fact that it is often immediately relieved by 
 paracentesis. 
 
 The arterial pulsation was the first of the ophthalmoscopic signs 
 that suggested the idea of increased pressure. It is true, that in 
 my first note I gave a different explanation of this phenomenon — 
 obstruction of the arteries. Indeed, it is undeniable that arterial 
 pulsation in the retina may be caused by compression of the arteries 
 externally to the eye, or a diminution in their calibre, provided the 
 explanation I have given of the experimental phenomenon, and 
 which has been accepted by Bonders, is correct. But, on the con- 
 trary, the results of experiment more especially favour the view that 
 it is owing to an increase of the intra-ocular pressure. As regards 
 the occurrence of pulsation, it is clearly the same, whether the bulb 
 is compressed by the finger, or by an increased collection of fluid in 
 its interior. Again, the manner in which the patient becomes 
 totally blind, in the acute cases, reminded me very strongly of the 
 deprival of sight by compression. The contraction of the visual 
 field during the temporary obscurations, the occurrence of coloured 
 vision, the nature of the bhndness even, present the greatest analogy 
 with the perceptions obtained by artificially compressing the bulb 
 until the appearance of arterial pulsation (Bonders) . 
 
 When I published my second notice upon glaucoma in the first 
 volume of this journal (Abth. 3), I expressed the opinion that glau- 
 comatous inflammations essentially depend on increased intra-ocular 
 pressure ; this, indeed, induced me to make the trials of paracentesis, 
 there related. The form of the papilla, however, prevented me from 
 coming to a general decision. The supposed convexity continually 
 turned my attention back to a substantial lesion of the optic nerve. 
 When I became convinced of the concavity of the papilla, an ex- 
 planation was immediately sought in another direction; but it 
 required longer observation to become fully satisfied, the cases in 
 which the lesion of the optic nerve apparently pre-existed (see 
 hereafter) still remaining perfectly inexplicable. A case treated by 
 
296 
 
 GRAEFE ON GLAUCOMA. 
 
 paracentesis, first showed me, that the excavation of the optic nerve 
 only becomes developed secondarily in the so-called acute glaucoma. 
 The patient had come to me during a violent attack of glaucomatous 
 choroiditis. I had performed paracentesis three times in a space of 
 eight days. Clearness of the refractive media was as perfectly 
 obtained as could be wished, and continued also during the follow- 
 mg weeks ; at the same time there were all the signs of a glauco- 
 matous affection, visible in the iris and pupil. The ophthalmoscope 
 showed the papUla to be perfectly normal, and only after many 
 months, when fresh obscurations occurred, did the optic nerve pro- 
 gressively degenerate, advancing with the other symptoms of 
 increased pressure. I only attained a more general conviction as to 
 the point in question, after the employment of iridectomy had enabled 
 me to decide more accurately upon the condition in the earliest 
 periods of disease. It was constantly found that the lesion of the 
 optic nerve did not yet exist after the first inflammatory attacks, 
 but was gradually developed at the same time as the other symptoms 
 of increased pressure. Hence, I felt obliged to conclude that the 
 excavation of the papiUa arises in the same way as many of the 
 sclerotic ectasise which appear in the later stages of the glaucomatous 
 process. The entrance of the optic nerve is, in respect to resistance, 
 the weakest part of the envelopes of the bulb, and it may easily be 
 imagined that this part would also be the first to be pressed out- 
 wards when the intra-ocular pressure is increased. 
 
 Whilst occupied with the examination of these views, I re- 
 ceived last winter a letter from Professor Heinrich MiiUer. 
 Without any knowledge of my nosological investigations, he had 
 arrived at the same conviction, through the anatomical examination 
 of an excavated optic nerve. I should forestall H. Miiller's publica- 
 tion, were I more closely to represent the reasons which guided him. 
 But I briefly aUude to the circumstance, because I had long desired 
 the anatomical confirmation, and it was naturally of the highest 
 importance in the continuance of my investigations. 
 
 Admitting that the lesion of the optic nerve is, in certain cases, 
 caused by intra-ocular pressure, stiU I must at once guard against a 
 too generic and over-hasty adoption of this law. The point I have 
 just maintained is limited, at present, to the acutely inflammatory cases. 
 With respect to the insidious form, in which the symptoms of pres- 
 sure become distinct only at a later period, I think that I might also 
 propose this view, as a probable, although not a certain explanation ; 
 
GRAEFE ON GLAUCOMA. 397 
 
 and, finally, in reference to the tHrd group, in which the excavation 
 of the optic nerve generally continues, without the addition of other 
 glaucomatous signs, there can of course be no question about such 
 a derivation. 
 
 TI. — Having advanced thus far in the analysis of our subject, let 
 us pass to a short exposition of the course of the disease. I do 
 not aim at depicting any new form, nor even at giving an exact 
 nosological description, such having been adinirably performed 
 by many authors. I intend to limit the symptomatology of 
 particular morbid series to what is necessary to supply a con- 
 nexion with the more general principles above stated, and to render 
 possible an agreement about glaucoma — ^the ophthalmoscopic re- 
 sults included. As already mentioned, I distinguish three groups, 
 and would indicate them by the names of acute or infiammatory 
 glaucoma, of chronic glaucoma, and of amaurosis witk excavation of 
 the optic nerve. The transitions or separations of these forms wiU 
 be most naturally discussed in the course of this exposition. 
 
 I. Acute or infiammatory glaucoma. 
 (Syn. Glaucomatous Choroiditis, Ophthalmia Arthritica). 
 
 There is generally a precursory stage ; it is absent in only from 
 twenty-five to thirty per cent. In this premonitory stage, any 
 existing presbyopia is increased, coloured spectra emerge from 
 time to time, especially in the form of rainbows around the flame 
 of a candle. There are also, especially as this stage advances, 
 intercurrent obscurations ; then everything appears gray and misty 
 to the patient, and a functional examination during such attacks 
 sometimes shows a sHght contraction of the field of vision, but, as 
 the rule, only great indistinctness of excentric impressions in cer- 
 tain directions. Towards the end of this stage, the intercur- 
 rent obscurations become more frequent, longer, and more intense ; 
 at the same time, the pupil becomes somewhat larger and sluggish, 
 the aqueous humour even abeady seems slightly and uniformly 
 clouded. Pains in the forehead and temples in the form of ciHary 
 neuroses, which are, as is known, symptomatic of internal ophthal- 
 
298 GRAKFR ON GLAUCOMA. 
 
 mise, sometimes occur at a very early period, sometimes only in 
 the later epochs of the premonitory stage, contemporaneously with 
 the obscurations ; only in rare cases are they entirely absent. The 
 premonitory stage has an indefinite duration, generally of many 
 months, sometimes years. If the obscurations occur at intervals of 
 many weeks, the termination of tliis stage is still uncertain ; if the 
 intervals between the attacks are not longer than a few days, the 
 commencement of the second stage is to be expected ; indeed this 
 may ensue even under the former conditions. The premonitory 
 stage is entirely absent in some cases. 
 
 The rapidly increased presbyopia is not without significance ; I 
 think that here it proceeds from an increase of the internal pressure 
 and flattening of the cornea. The coloured spectra have similar 
 characteristics to those occasioned by pressure on the eye ; they do 
 not depend on dififraction, or conditions of accommodation, but must 
 be referred to a morbid innervation of the retina. This is also 
 true of the obscurations. The temporary dilatations of the pupil 
 proceed from commencing iridoplegia. The sensibihty of the 
 cornea is probably correspondingly diminished, but I do not venture 
 positively to assert that it is so, for shght differences in sensibility 
 can with difficulty be proved, and especially in the aged, in whom 
 the corneal sensibility is generally less acute. 
 
 The special outbreak of the disease is generally sudden; some- 
 times it is developed by a gradual increase in the premonitory 
 attacks. The general appearance of an internal ophthalmia is pre- 
 sented : violent, often unbearable pains in the eye, but especially in 
 the forehead, temples, and side of the nose (as far as the extremity 
 of the bone), injection of the subconjunctival vascular network, not 
 unfrequently to the extent of chemotic swelling, with copious lachry- 
 mation, but with very little mucus ; the anterior chamber diffusely 
 hazy, the cornea generally dulled on its posterior surface, the pupil 
 irregularly dilated, occasionally also broad posterior synechise, the 
 iris of a dirty hue and pressed forwards ; the power of vision some- 
 times entirely lost as if by a stroke, sometimes only much diminished ; 
 the field of vision, when it can be measured, either normal or some- 
 what concentrically contracted; at the same time, in the mass of 
 cases, there are weU-marked subjective appearances of light, pho- 
 topsia, chromopsia : as the rule, these violent symptoms arise in a 
 restless night, and generally after much previous suffering from 
 want of sleep. These inflammatory attacks may recede, vision 
 
GRAEFE ON GLAUCOMA. 299 
 
 being partially or almost entirely restored, yet the anterior chamber 
 usually remains somewhat flatter, the pupil a little dilated and 
 more sluggish, the iris spotted, and the visual field often somewhat 
 contracted. Such a temporary restoration may be spontaneous, 
 although it is usually obtained by antiphlogosis, by opium in large 
 doses, and by paracentesis of the anterior chamber. But in many 
 cases the blindness continues from the very first attack, notwith- 
 standing the retrocession of the inflammatory symptoms. The 
 insidious nature of the disease is such, that either these inflamma- 
 tory attacks are occasionally repeated, each time leaving a renewed 
 and greater deterioration of vision ; or no fresh inflammatory symp- 
 toms again appear, yet the visual fleld becomes continually more 
 contracted, finally excentric, the grayish hue of the iris increases, 
 the pupil dilates and entirely loses its mobility, the globe becomes 
 constantly tenser, and the cornea perfectly anaesthetic. During 
 this process the refractive media — the aqueous humour and vitreous 
 body — may again lose their diffuse turbidity, so as perfectly to allow 
 ophthalmoscopic examination of the back of the eye; then we 
 generally find certain changes in the internal membranes, peculiar 
 retinal ecchymoses in the form of round spots, and not unfrpquently 
 larger choroidal extravasations, especially in the equatorial region. 
 I shall presently add a few remarks upon their signification. There 
 are also constantly found, at this later period, a progressively 
 increasing excavation of the optic nerve, and arterial pulsation, 
 appearing either spontaneously or on the slightest compression with 
 the finger, appearances which were entirely absent after the first or 
 the few first attacks. 
 
 Here we have all the appearances previously mentioned as cha- 
 racteristic of increased pressure. The question cannot any longer 
 be passed over, by which one of the internal membranes is the 
 morbid process of secretion efPected ? The changes shown by the 
 ophthalmoscope afford no immediate decision ; even the apparently 
 positive results must be employed with caution in. coming to a con- 
 clusion. In the very frequent occurrence of retinal ecchymoses, 
 we might readily find a support for the view once promulgated by 
 Ph. V. Walther, who accordingly held glaucoma to be a lesion of 
 the retina. The rapidly advancing blindness, the appearance of 
 photopsise, and chromopsiae, would certainly harmonise with such a 
 conception, the more as, on the other hand, we know how little even 
 far-advanced structural changes of the choroid interfere with the 
 
300 
 
 GRAKFE ON GLAUCOMA. 
 
 action of the retina, provided there is no retinal separation. Still, 
 I think that the participation of the retina is quite secondary. 
 Iridectomy has taught me that extensive retinal ecchymoses of the 
 kind referred to do actually diminish, to some extent, the acuteness 
 of vision, yet they do not by any means explain the peculiar blind- 
 ness. Again, I have ascertained, in a number of cases, that most 
 (perhaps all ?) of the retinal ecchymoses do not occur until after 
 iridectomy, and yet that, at the time of observation, there is very 
 great improvement of vision. This refers to those cases in which 
 the ocular background could be critically examined even before the 
 operation, the haziness of the refractive media not being very great. 
 These retinal apoplexies differ essentially in form from the extrava- 
 sations occurring in apoplectic retinitis, which are distinctly striped, 
 and follow the course of the fibres ; in the former we find extremely 
 regular, round spots, which seem to be seated exclusively on the 
 veins, and for the most part where the larger trunks unite. 
 Besides, in the early stages there is not the slightest granular or 
 striped turbidity of the retina. The general appearance of the 
 retinal lesion gives me quite the impression of vascular ruptures, 
 caused by mechanical hypereemia. When the intra-ocular pressure 
 is so much increased that it completely interrupts the passage of 
 the blood through the arteria centralis retinse between the arterial 
 diastoles (arterial pulsation), we may imagine the much greater 
 effect upon the far more yielding vena centralis. This is also 
 shown by the dilatation of the retinal veins, which always occurs in 
 a certain stage of the disease. If paracentesis of the anterior 
 chamber, or iridectomy, be performed, the sudden relaxation of 
 pressure very readily accounts for the occurrence of ruptured vessels, 
 when there is such venous congestion. It is true that an abnormal 
 hsemorrhagic tendency may also be induced by other causes, espe- 
 cially in old persons with rigid arteries. Forms of glaucoma occur, 
 which have been called apoplectic, in which the haemorrhages of 
 the inner membranes attain an unusual extent, and which are even 
 prematurely accompanied by hsemorrhagic separation of the retina; 
 but in deciding nosological questions, we must always adhere to 
 typical forms of disease, and, judging from them, I believe that the 
 retina plays a subordinate and secondary part in acute glaucoma. 
 
 What are the direct proofs of choroidal inflammation in glau- 
 coma ? We know that in the later periods ectasise frequently form, 
 especially in the equatorial region of the globe ; we also know. 
 
GRAEFE ON GLAUCOMA. 301 
 
 chiefly from Arlt's investigations, that in these places inflammatory 
 processes can be positively shown by dissection ; all this, however, 
 refers to a later period of the disease, and, considered with refer- 
 ence to the pathogenesis, wonld also always admit of other expla- 
 nations. Thus, some relatively weak parts might be bulged out 
 when the intra-ocular pressure was increased, without reference to 
 the original cause, and certain textural changes might then occur 
 in those parts, as consequences of the ectasia. Such reasoning 
 would be the more admissible, because the textural changes which 
 have been observed, are for the most part restricted to thinning of 
 the choroid, and its adhesion with the sclerotic. After a single 
 attack of glaucomatous inflammation, the ophthalmoscope seldom 
 shows any change, except irregular distribution of pigment, and 
 occasionally ecchymoses in the choroid, especially in the equatorial 
 region, formerly I had seen the latter only in chronic cases ; but 
 since the introduction of iridectomy has rendered an ophthalmo- 
 scopic examination possible at an earlier period, it has been found 
 with increased frequency in the acute cases, which we are now con- 
 sidering. The choroidal ecchymoses seem to disappear far more 
 rapidly than those of the retina ; the latter usually continue two or 
 three weeks after iridectomy, and sometimes considerably longer 
 (see below). I only discovered choroidal ecchymoses, provided I 
 made the examination before the end of a week and a half after the 
 operation ; it is generally much more difficult to perceive them, be- 
 cause they are less marked, owing to their irregular form, and 
 because, at the same time, we are obliged to look very much to 
 one side or downwards. On the other hand, during the last few 
 months I have become convinced that these choroidal ecchymoses 
 exist before the operation, and perhaps do not occur consecutively, 
 as do the greater part of the retinal ecchymoses. Thus, a condi- 
 tion has been proved which would favour the opinion that the dis- 
 ease proceeds from the choroid. The participation of the iris also 
 forces us to direct our attention to the region of the uvea. In re- 
 gard to this point, I must especially remark that the iris, even 
 though to a very various degree, always becomes aifected with in- 
 flammation in glaucoma. This would only be admitted by most 
 persons in the cases in which posterior synechise are at the same 
 time formed; yet in other cases, in which they do not occur, in- 
 flammation may be proved by examination of the excised iris. This 
 was always found stiff and infiltrated. The muddiness of the 
 
302 GRAEFE ON GLAUCOMA. 
 
 aqueous humour, aad the dulness of the posterior surface of the 
 cornea, with the irregular refraction of light (mydriasis) and the 
 yellow lens (age of the patient), are the chief causes of the glauco- 
 matous hue of the pupil, and yet these opacities must indisputably be 
 referred to inflammatory effusion from the iris. Besides, the degree 
 in which the iris participates essentially influences the appearance 
 of the affection. If far developed, the pressure seems also to mate- 
 rially increase in the anterior chamber, through hypersecretion of 
 turbid aqueous humour, and then the iris is not pressed forward, 
 &c. The chief argument in favour of choroiditis is, in my opinion, 
 the turbidity of the vitreous body. Even if it contributes little or 
 nothing to the so-called glaucomatous habitus (of the pupil), as we 
 have found by experiments made after paracentesis of the anterior 
 chamber, stiU its existence is shown with certainty by the ophthal- 
 moscope, notwithstanding its diffuse nature. Again, examinations 
 immediately after the discharge of the aqueous humour, also prove 
 its existence ; even if the iris appears perfectly clear, and the glau- 
 comatous hue of the pupil has almost disappeared, still there con- 
 stantly remains a mist, rendering the details of the ocular back- 
 ground indistinct. Besides, the opacity is not perfectly uniform, 
 the inferior portion of the vitreous body being generally the more 
 turbid, so that the upper part of the retina is relatively more acces- 
 sible to examination. The opacity cannot, however, be resolved into 
 separate parts. It is obvious, that in these cases it is most natural 
 to refer the cloudiness to a morbid process of secretion by the 
 choroid. At all events, this presents no difficulty when we have 
 once overcome the physiological doubt with respect to the nourish- 
 ment of the vitreous body by the choroid. The objection has some 
 degree of plausibility, that after the glaucomatous attack but little 
 disease can be shown with the ophthalmoscope, especially in the 
 tissue of the choroid, whilst very striking changes are seen in other 
 of its inflammations. This, however, only proves that there are in- 
 flammations of the choroid of a very different kind,i and a glance 
 
 ' On tin's point, H. Miiller, who has during the last few years traced with so 
 mucli penetration the pathologieo-histological changes in internal ophtiialmise, 
 made a statement that much interested tne. He assured me that he often did 
 not find distinct structural changes, even when there were extensive effusions 
 on the inner surface of the choroid and ciliary body. This shows how cautious 
 we should be in denying choroidal affections, when, as in the present case, (he 
 diagnosis is not immediately determined through the scat of the exudation. 
 
GRAEI'E ON GLAUCOMA. 303 
 
 at the diseases of the iris will, I think, assist us in forming an 
 opinion. Diseases occur in this tissue also, which are characterised 
 by great circulatory and textural changes, the aqueous humour 
 being at the same time not much altered ; whilst there are others, of 
 which the opacity of the aqueous humour is pathognomonic. The 
 general appearance of the so-caUed iritis serosa, or hydromeningitis, 
 was very well described by the older authors ; that their account 
 now requires considerable alteration, is only owing to the anatomi- 
 cal ideas that formerly prevailed. Such an inflammation may con- 
 tinue for a very long time, without the occurrence of distinct 
 changes in texture, adhesions, &c. ; at all events, the chief symp- 
 tom continues to be diffuse cloudiness and increased amount of the 
 aqueous humour, probably with increased pressure in the anterior 
 chamber (perhaps to this should be referred the dilatation of the 
 pupil, which occasionally occurs). I hold a similar view of glauco- 
 matous choroiditis — ^that it is a disease of secretion. Serous iritis 
 is also nosologically allied to chronic glaucoma; we not unfre- 
 quently find transitions of the former into the latter, and we find, 
 mutatis mutandis, this fact already pointed out by the older authors. 
 The treatment of both affections is also analogous, with the differ- 
 ence that, in iritis serosa, iridectomy is a last resource, recovery 
 being often obtained by other means. In short, / consider acute 
 glaucoma to he a choroiditis (or irido-choroiditis) with diffuse imbi- 
 bition of the vitreous body (and aqueous humour), and in which in- 
 crease of the intra-ocular pressure, compression of the retina, and the 
 well-known series of secondary symptoms, are produced by the in- 
 creased volume of the vitreow humour. 
 
 a. Chronic Glaucoma. 
 
 The process of development differs in. this form from the cases de- 
 scribed under the first head, by the absence of any distract and 
 periodically returning internal inflammations. The attacks, which 
 were intercurrent in the premonitory stage, continue for a longer 
 time, and at a later period leave no intermissions, but only remis- 
 sions between them; the eye acquires its glaucomatous habitus, 
 nearly as in the previous form after the inflammatory process had 
 
304 GRAEfE ON GLAUCOMA. 
 
 ended; the pupil gradually becomes wider, the anterior chamber 
 flatter, the iris discoloured, although not very strikingly, the globe 
 tenser, the subconjunctival veins more dilated, the visual field con- 
 tracted, and the acuteness of vision diminished — all this occurring 
 without any attack of violent redness, swelling, or symptoms of irri- 
 tation. Ciliary neurosis is rarely quite absent, yet at the same time 
 the attacks are not very violent. Did not the condition of the re- 
 fractive media and of the iris indicate a local process in the eye, the 
 disease up to a certain stage might be confounded with an amaurosis 
 of extra-ocular origin. Since, in addition, the ophthalmoscope shows, 
 at a relatively early period, an excavation of the optic nerve, which 
 is gradually developed, and soon followed by arterial pulsation ; in 
 many of these cases we might easily fall into the error of consider- 
 ing the lesion of the optic nerve as the primary stage. But an exact 
 comparison of both eyes shows that the iris on the diseased side ap- 
 pears somewhat duller, whence we may at once conclude that there 
 is a diffuse turbidity of the aqueous humour. This haziness also 
 changes with extreme rapidity, in comparison with its amount, so as 
 to disappear and reappear many times during a single day. (In 
 some cases this is indisputably connected with the meals, move- 
 ments of the body, sleep, &c.) On ophthalmoscopic examination, 
 the background of the eye always appears somewhat indistinct, yet 
 it is difficult to determine how far this is caused by the aqueous 
 humour, and how far by the vitreous. The pupil is also larger, and 
 somewhat more sluggish, not simply in regard to the entrance of 
 light into the affected eye, but also (relatively) to the passage of 
 light into the other healthy eye, to accommodation-changes and 
 contractions of the recti interni. This feature essentially distin- 
 guishes it from anaesthesia retinae incipiens, where the contraction of 
 the pupil is unaffected under the above conditions. It is clear that 
 the conduction in the ciliary nerves is here directly diminished 
 through increase of the intra-ocular pressure. Upon very careful 
 palpation of the globe (the customary precautions being taken to 
 prevent errors from displacement), increased resistance is generally 
 evident ; and upon touching the cornea with a roll of paper, dimi- 
 nished sensibility. I should not have repeated aU these remarks, 
 had not these very cases at one time induced errors through the 
 subtilty of the symptoms. By means of the ophthalmoscope, I 
 found, though not constantly, choroidal ecchymoses in the equatorial 
 
GRAEFE ON GLAUCOMA. 305 
 
 region. I cannot decide whether retinal ecchymoses are present 
 before operative interference ; they often form to a surprising ex- 
 tent afterwards. If the disease has run its course, it very much 
 resembles the cases described under the first head, except that all 
 the symptoms depending on increase of the intra-ocular pressure 
 are usually less prominent. At the first glance, it appears probable, 
 that there is only a difference of degree between this and the former 
 category of cases, because the first form is very often developed in 
 the one eye, and the second in the other. This is the essential 
 feature of the fact long since noted, according to which there was 
 developed in one eye an exquisite glaucoma (with the symptoms of 
 arthritic ophthalmia or glaucomatous choroiditis), but in the other 
 eye, a blindness, which only in its later course could be distin- 
 guished from a simple amaurosis dependent on extra-ocular causes. 
 Again, the essential identity of both diseases is shown by the same 
 changes of the inner membranes (especially of an ecchymotic 
 nature), and by the same termination. In conclusion, it must be 
 mentioned, that the second form not unfrequently passes into the 
 first ; it then represents to some extent a more violent, and no 
 longer intermitting, but only remitting premonitory stage. The pre- 
 vious statement of the secondary occurrence of excavation of the 
 optic nerve is of course also true, but with a limitation, because at 
 the time of the more acute outbreak, the affection of the optic nerve 
 has been already induced by the pre-existent (chronic) disease. 
 
 Besides, I willingly admit that we are stiU very ignorant as to 
 this form of chronic glaucoma. I think, indeed, that the excava- 
 tion of the optic nerve in these cases is explained also by increased 
 pressure; I am, however, unable to demonstrate it, because the 
 harmony which existed in the first form between the lesion of the 
 optic nerve and the other symptoms of pressure is not here always 
 apparent. 
 
 3. Amaurosis with excavation of the optic nerve. 
 
 In these cases, which have been often called glaucoma, 
 (but only since the introduction of the ophthalmoscope) the 
 glaucomatous habitus is altogether absent in the external parts of 
 the eye, whilst exactly the same form of lesion as ia glaucoma 
 occurs in the optic nerve. This is the only organic change that 
 
 20 
 
306 GRAEFE ON GLAUCOMA. 
 
 can be shown. Owing to the refractive media remaining perfectly 
 clear, the optic nerve may indeed appear of a somewhat different 
 colour than in glaucoma, but no essential distinction can at present 
 be made. As the rule, however, arterial pulsation does not spon- 
 taneously appear; yet I cannot deny that it generally occurs more 
 readily on the appHcation of the finger than in healthy eyes. In 
 this case it is impossible for us to consider the pathogenesis of the 
 lesion of the optic nerve in the manner already described, owing to 
 the absence of all the other symptoms indicative of increased pres- 
 sure. To be clearly understood, it seems to me absolutely neces- 
 sary to exclude these cases from the group of glaucomatous diseases, 
 and to pursue their study under this or some other name. In the 
 functional disturbances they have also the greatest similarity to 
 chronic glaucoma; but their development is more uniform (gene- 
 rally extremely slow), and the intercurrent obscurations are less 
 marked. The chromopsise also are not so prominent. The essen- 
 tial character is a gradual limitation of the field of vision, generally 
 spreading from one side ; sometimes it is exactly concentrical, and 
 the central vision of these cases is often found to be, in a relative 
 sense, extremely good, so that individuals can read the smallest 
 print, and yet no longer guide themselves with safety — an extreme 
 discordance never found in chronic glaucoma. Besides the iden- 
 tity in the appearance of the optic nerve, and the similarity in the 
 functional symptoms, the incorrect classing of this group of diseases 
 with the glaucomatous was furthered by the circumstance, that 
 sometimes a typical glaucoma is developed in the one eye, and in the 
 other an amaurosis of this description, with excavation of the optic 
 nerve. But independently of the fact that these instances are ex- 
 tremely rare, when cases of chronic glaucoma are definitely excluded, 
 and hence should perhaps be referred to an accidental complication ; 
 my former remarks upon sympathetic amaurosis of the second eye 
 (see the previous treatise) might here deserve consideration, pro- 
 vided, on further study, the excavation of the optic nerve should 
 maintain a kind of pathognomonic indication of sympathetic amau- 
 rosis. There might then be found in glaucoma a relation of the 
 disease in the second eye analogous to that we have abeady dis- 
 covered in irido-choroiditis. 
 
 I cannot at present confirm the observation that amauroses of 
 this kind ultimately assume the appearance already depicted of 
 glaucoma. I urge this, because it contradicts the opinion of some 
 
GRAEl'E ON GLAUCOMA. 307 
 
 of my colleagues, and my own earlier suspicions. We should be 
 especially liable to be led into error by the second category of cases, 
 m which the change of the optic nerve is sometimes the most 
 striking symptom, whUst in the earlier periods the other signs re- 
 quire a very careful iavestigation, and only at a later time become 
 prominent, a metamorphosis apparently taking place. The excep- 
 tional occurrence of discordant affections in the two eyes ^priori 
 also favoured the view mentioned. In amaurosis with excavation 
 of the optic nerve, I have seen no other transformations than those 
 of atrophy of the optic nerve and retina ; and if the future should 
 decide otherwise — if a disease of the internal membranes, similar to 
 that of glaucoma, should be actually added to the simple affection 
 of the optic nerve — ;still this would in no way justify us in designa- 
 ting the lesion of the optic nerve ia general as a first stage of the 
 glaucomatous affection, since the very opposite is certainly the fact 
 in the typical and most perspicuous cases j but it would simply fol- 
 low that a common iaternal cause {e. g. in the vessels), according to 
 its kind and degree, may educe two different forms of disease. (See 
 A. f. 0., Bd. i, Abth. i.) 
 
 After I had perceived the necessity of excluding these cases from 
 the glaucomatous group, I was long incHned to combine them with 
 cerebral amaurosis, because, amongst the changes presented by the 
 latter, we not unfrequently discover in the optic nerves a state 
 approaching excavation. But more distinct differences became by 
 degrees apparent. In those cerebral amauroses to which I refer, 
 the optic nerve is indeed excavated, but there is no displacement of 
 the vessels, or it is only slightly marked. Again, the vessels them- 
 selves become more delicate from the very first, and the substance of 
 the nerve white, gKstening like a tendon, and the periphery of the 
 papOla smaller. In our excavation the veins especially are more 
 dilated at fijst ; and only at a very late period does the nerve be- 
 come white, and sometimes a little glistening, the papilla, however, 
 scarcely any smaller. Por the sake of distinction, I no longer term 
 the former state "excavation," but "retraction." It certainly de- 
 notes a species of atrophy of the optic nerve, and is generally 
 accompanied by other symptoms, iadicative of cerebral causes, 
 which are almost constantly absent in the excavation. We must, 
 therefore, for the present consider the excavation as an organic dis- 
 ease of the optic nerve. It is stiU very problematical whether there 
 
308 GRAEFE ON PARACENTESIS 
 
 are contractile exudations, drawing back the surface, for no stage of 
 swelling can be detected ; but there must certainly be a twofold 
 process by which the lesions of the optic nerve take place — ^first, 
 by pressure on the surface of the papilla (glaucoma), and secondly, 
 by traction from within the trunk of the nerve (amaurosis with ex- 
 cavation of the optic nerve). It remains unexplained why the 
 latter, though subordinately, should predispose to the phenomenon 
 of pidsation. 
 
 From my own observations, indeed, it is evident that we yet meet 
 with much uncertainty in this subject, but I cannot too emphati- 
 cally remark, that in tJie present state of our hnowledge, the lesion of 
 the optic nerve alone is no longer' to be considered as defining glau- 
 coma, because in a series of cases it has a pathogenesis guite foreign 
 to glaucoma. 
 
 VII. —According to the results originally presented by the ophthal- 
 moscope, the incurability of glaucoma seemed to be caused by the 
 changes in the eye being only consecutive and arising from an 
 extra- ocular source, either in the optic nerve, or in the vessels of 
 supply. Although I cannot yet entirely abandon the view of the 
 etiological participation of arterial atheroma, as explained in my 
 first note on glaucoma — a point to which I shall hereafter return, — 
 still the question of treatment took another direction so soon as I 
 no longer referred the origin of the blindness to the change of the 
 optic nerve, but to the increase of intra-ocular pressure. The in- 
 flammation even of the choroid, as we know, yields spontaneously, 
 or is, as the rule, overcome by the usual remedies, especially by 
 antiphlogosis ; but the results of increased pressure — in particular 
 the excavation of the optic nerve — are, from their injurious nature, 
 most momentous. Hence my attention was directed to discovering 
 some method of lessening the intra-ocular pressure. 
 
 After aU other means, which have as their object a rapid with- 
 drawal of the ocular fluids — ^in particular, antiphlogosis, diaphoretics, 
 diuretics, purgatives, and a mercurial course carried even to saliva- 
 tion — ^had been fruitless in my hands, as in those of other practi- 
 tioners, I considered that I ought specially to direct my attention 
 to a local treatment. The first means I tried were the mydriatics, 
 the influence of which in diminishing pressure I had long ago en- 
 deavoured to demonstrate, and to render therapeutically serviceable 
 
OF THE EYE IN GLAUCOMA. 309 
 
 in various ways. But in this case there was not the slightest cura- 
 tive effect. Even the accompanying ciliary neuroses, which ia other 
 diseases (keratitis, iritis) generally yield with such rapidity to in- 
 stillations of atropine, were not in the least influenced, probably 
 because, owing to the increase of the intra-ocular pressure, the my- 
 driatic was only very slightly, if at all, absorbed through the 
 cornea. 
 
 With this were connected trials of repeated paracentesis of the 
 anterior chamber, which gave such evident results, that, with the 
 view of promoting further trials of them, I did not hesitate to pub- 
 lish them at the time (A. f. 0., Bd. i, Abth. a). Not only did the 
 discharge of the turbid aqueous humour, and its replacement by a 
 more transparent fluid, improve the vision, but in addition to the 
 immediate action, and clearly distinguishable from it, a secondary 
 curative action was induced in the disease itself. Another and a 
 great advantage of paracentesis was, that it showed the dependence 
 of many glaucomatous symptoms on increased pressure (thus, of 
 the corneal anaesthesia). Finally, it was paracentesis which first 
 enabled me to discover the ecchymotic changes in the ocular back- 
 ground during the earlier period of the disease, because it caused 
 the refractive media to become clear at a relatively early time. 
 But, unfortunately, in by far the majority of cases the curative re- 
 sults were only temporary. Of the many patients whom I thus 
 treated, only two have been permanently cured : a woman, about 
 fifty years of age, in whom both eyes successively presented the 
 symptoms of acute glaucoma, and who now, three years later, yet 
 enjoys perfectly good vision, in spite of an atrophied, discoloured 
 iris, and irregularly dilated pupil : the second case, a man of forty, 
 whose right eye first became affected with glaucoma, and was cured 
 by paracentesis, and whose left eye was attacked half a year later, 
 and has been cured by iridectomy. It was evident that paracen- 
 tesis was insufficient ; and besides, the few really successful cases 
 were of those in which the inflammatory process of exudation, 
 though accompanied by the whole series of symptoms of acute 
 glaucoma, stiU on its first occurrence only moderately diminishes 
 the power of vision. In other patients, after the improvement had 
 lasted days, weeks, or even some months, a deterioration occurred, 
 although generally not in the form of an acute inflammation, but in 
 that of chronic glaucoma. Even where the improvement in the 
 visual acuteness seemed to last more than three months, stiU, even 
 
310 GRAEFE ON IRIDECTOMY 
 
 within this period, a change for the worse might be foreseen, owing 
 to the contraction of the field of vision. At first I thought I could 
 oppose these relapses by a methodical repetition of the paracentesis ; 
 but the duration' of the therapeutical effect became each time less, 
 and finally null (in regard to the visual power). 
 
 Paracentesis having proved insufiicient, my next inquiry was, 
 whether a permanent change of the pressure could be obtained in 
 place of the temporary one ? I already knew the action of iridec- 
 tomy in chronic iritis and various forms of irido-choroiditis. But 
 the conditions in glaucoma are so different from those in the ordi- 
 nary irido-choroiditis, that I scarcely ventured to hope for therapeu- 
 tical analogies with reference to this operation. There I was en- 
 tirely guided by the condition of the iris, and the operation was 
 directed against the exclusion of the pupil as the source of inju- 
 rious consequences ; but it did not appear from the results in irido- 
 choroiditis that the excision of a portion of the iris had a direct 
 action in diminishing pressure, and I was the less reminded of such 
 an action, because the secondary effect is often even the refilhng of 
 atrophied eyes.' 
 
 On the other hand, it was especially the use of iridectomy in 
 ulcerations and infiltrations of the cornea, that directed me to its 
 effect in diminishing pressure. To the results of this treatment 
 adduced in my work (A. f. 0., Bd. ii, Abth. 2), another was soon 
 added, apparently of great importance. It had reference to partial 
 staphyloma of the cornea, and to staphyloma of the sclerotic. In 
 the former, it was generally the custom in former days to combine 
 removal of the staphyloma with the formation of an artificial pupil 
 (provided it was indicated by the natural pupil being unserviceable), 
 the removal being first made, and then the artificial pupil formed. 
 
 ' The objection has been raised in many quarters, that the very increase of 
 tension in atrophied eyes must liave turned my mind from iridectomy in glau- 
 coma. I cannot entirely admit this. I hare never thence drawn the conclu- 
 sion that iridectomy includes the direct action of an increase of pressure, but I 
 have simply considered it as acting against choroiditis, and explained the refilling 
 of the globe as an indirect result. Just as choroiditis, according to its degree 
 and kind, may produce overfilling of the globe or collapse, so also may the same 
 means, which relieve choroiditis, apparently produce opposite effects. The 
 therapeutical effect of the treatment is often diametrically opposed to the phy- 
 siological, and if I now believe that iridectomy has physiologically a pressure- 
 diminishing effect, this is not, in my opinion, opposed to my earlier experience 
 with reference to the refilling of atrophied eyes. 
 
IN GLAUCOMA. 311 
 
 Having for other reasons reversed this practice, T found that after 
 iridectomy the protruded part often entirely receded to the level of 
 the cornea, and that then the second operation became unnecessary. 
 I have even seen cases in which partial staphylomata had been re- 
 peatedly operated on without success, and iu which iridectomy suc- 
 ceeded. Thus, I have many times seen a perfect and permanent 
 sinking back of the protruded parts after iridectomy, at first in 
 blind eyes aifected with many sclerotic staphylomata; and I have 
 since performed the operation with success under similar conditions, 
 when vision was still left. 
 
 The question now occurred, whether iridectomy also causes a 
 diminution of intra-ocular pressure in the healthy eye, or whether 
 this only takes place under certain conditions of disease. I think 
 that I may answer this question aifirmatively, although I cannot at 
 present adduce any more exact investigations. The eyes of animals, 
 from which I had excised large pieces of iris, generally appeared to 
 me a little softer to the touch, and when I carefully introduced the 
 canula of Anel's syringe into the anterior chamber of such eyes, the 
 whole of the aqueous humour did not ascend through the action of 
 the intra-ocular pressure, as is usually the case, but only a part. I 
 think I have also perceived a slight permanent diminution of ten- 
 sion in patients, where an artificial pupil has been made for leucoma 
 adhserens. 
 
 Supported by these facts and considerations, I considered myself 
 perfectly justified in performing iridectomy in glaucoma; for I 
 knew the favorable action of the operation on the condition of the 
 choroid in regard to its circulation ; and everything seemed to favour 
 the opinion that the operation probably possessed a physiological, and 
 certainly, in many cases, a therapeutical pressure-diminishing action. 
 The first trials were extremely uncertain, for I had no fixed princi- 
 ples, either in regard to the choice of cases or the manner of making 
 the trial. I first employed this method in June, 1856, and from that 
 time have continued it, especially in the cases which I have already 
 described as acute glaucoma. The immediate effects appeared from 
 the first very favorable ; but remembering how my hopes had been 
 frustrated in paracentesis, I was extremely mistrustful, and remained 
 so until, in time, distinct differences appeared between the present 
 results and those formerly obtained. A continued improvement 
 was generally apparent exactly in proportion as the observation was 
 prolonged ; the signs of glaucoma retrograded in the manner here- 
 
313 GUAEFE ON IRIDECTOMY 
 
 after to be described^ and nowj having followed some cases more 
 than a year, and a considerable number more than nine months, I 
 think I cannot be mistaken in regarding iridectomy as a true cura- 
 tive treatment of the glaucomatous process. It h^s its natural 
 limits, Kke every therapeutical method ; and in some degree to de- 
 fine these is the object of the following communication. 
 
 VIII. — "Were I to discuss the application of iridectomy to the 
 various stages and groups of glaucoma in the same order in which 
 they were successively presented for trial, I should have to begin with 
 the old, and in part with cases that had completely run their course ; 
 for it is obvious that, owing to the uncertainty of success, a new 
 method will be first tried in cases where as little as possible can be 
 lost. I think, however, that by such an exposition I should lose 
 sight of the indications on which I especially depend ; and there- 
 fore prefer to leave entirely out of (question the historical de- 
 velopment, and to discuss the relative results in accordance with 
 the previous nosological divisions. Accordingly I shall communi- 
 cate my results in regard to iridectomy — 
 
 I . In the premonitory stage of glaucoma. 
 
 3. In the acute period of inflammatory glaucoma. 
 
 3. In the later period of inflammatory glaucoma. 
 
 4. In chronic glaucoma. 
 
 5. In amaurosis with excavation of the optic nerve. 
 
 Perhaps it might have been better to communicate in extenso all 
 the reports of cases at my command, the number of which has 
 become very large ; as by their consideration, the indications would 
 have been spontaneously presented. But I have decided otherwise, 
 partly to avoid so large an expansion of my work, and partly 
 because many of the cases must be considered as not concluded, 
 there being some probability that the condition last noted will not 
 be permanent. The addition of some observations wUl, how- 
 ever, I think, assist in illustrating my previous remarks. 
 
IN GLAUCOMA. 313 
 
 I . Iridectomy in the premonitorf stage of Glaucoma. 
 
 Patients affected with premonitory symptoms of glaucomatous 
 disease in the one eye only, seldom seek medical aid ; the symptoms 
 are overlooked, or thought of little importance ; as is so often the 
 case in visual disturbances of one side. On the other hand, it very 
 often happens, that one eye having been lost by glaucoma, the 
 patients are frightened by the premonitory symptoms in the second 
 eye. The question naturally arises, whether we should wait for the 
 distinct outbreak of glaucomatous disease in the second eye, or 
 proceed to operate even during the premonitory stage. Por a long 
 time I delayed operating, because vision is still acute during the 
 intermissions ; and for the same reason, the whole of the treatment 
 must previously be proved quite safe. At length, having continually 
 become bolder, from repeated successes, I operated on some cases, 
 even in the premonitory stage, and' was perfectly satisfied with the 
 result. The obscurations 'did not in any case recur after iridectomy. 
 The ciliary neuroses and chromopsise also disappeared ; even the 
 periodical cloudiness of the aqueous humour, which in one case 
 regularly accompanied the obscurations to a moderate extent, never 
 reappeared after the operation. Sometimes the anterior chamber 
 appeared less flat than previously ; I cannot at present decide as to 
 whether there is a slight diminution of the presbyopia. I have 
 now watched for some months after the operation, three such cases, 
 in which the obscurations occurred with tolerable frequency ; and 
 think I may conclude that this success will probably be permanent. 
 By the formation of a moderately broad coloboma, the acuteness of 
 vision is no more affected than the accommodation, as is already 
 known ; and if slight differences in regard to the latter points should 
 result, stiR these would be unworthy of consideration, compared 
 with the prevention of perfect blindness. Of course, such an early 
 application of iridectomy has its reasonable limits. If, for example, 
 the premonitory signs are limited to painful sensations in the fore- 
 head and temples, and to iridescent vision, without any obscuration, 
 and if these pains return at intervals of many months ; if in addi- 
 tion the eye does not present the slightest appearance of disease, I 
 should not advise any operative interference; because this state 
 may continue for a period of many years, and because very few of 
 
314. GRAEFE ON IRIDECTOMY 
 
 the patients perceive, indeed, their danger. There is not the least 
 risk in temporising under such conditions, or in the use of proper 
 internal means ; and we should not forget, that an operation, even 
 though attended with so little danger as iridectomy, may exception- 
 ally become the exciting cause of bad results, through the con- 
 currence of accidents, the disobedience of patients, &c. When one 
 eye is blind from glaucoma, and the second is threatened, I am in 
 the habit of recommending the patient to resort to the operation as 
 soon as the premonitory symptoms become tolerably distinct in the 
 second eye, and especially if they are accompanied by increased 
 obscuration. We cannot safely wait for an acute inflammatory 
 attack ; for though I shall also show (sub. a) that iridectomy, even 
 during the acute stage, generally induces perfect restoration, still 
 the transport of the patient becomes more critical, the operation itself 
 more painful, requiring greater care in its performance and in the 
 after-treatment ; there are more extensive retinal ecchymoses, owing 
 to which vision is more slowly restored ; there usually remain changes 
 of the iris, immobility of the pupil, and paresis of accommodation ; 
 and it is much more diificult to define the limits beyond which relief 
 may be only partial. Besides, we must not omit to state that the 
 premonitory stage does not always pass into the acute form, but 
 sometimes, by continual elongations of the exacerbations, into the 
 chronic; and that then the affection either does not assume an 
 inflammatory character, or only at a time when important secondary 
 results prevent a perfect restoration. At aU events, the premoni- 
 tory stage is the most favorable period for the performance of 
 iridectomy. Sometimes, indeed, even in this case, retinal ecchy- 
 moses appear after the operation, yet, as before stated, to a far less 
 extent, and (even without a compressing bandage) 'extensive 
 haemorrhages into the aqueous or vitreous humours never occur. 
 
 Had iridectomy only the power of preserving a second and 
 threatened eye, after the first had become blind from glaucoma, our 
 science would have been deeply indebted to the operation : to a 
 thoughtful practitioner, these cases were of an extremely depressing 
 character, for owing to his complete powerlessness, bUndness appeared 
 an inevitable result. We must indeed deplore that tliis most happy 
 application of iridectomy is limited to the least part of glaucoma- 
 tous cases ; because there is frequently no premonitory stage, and 
 very often medical aid is not sought until the disease has further 
 advanced. 
 
IN GLAUCOMA. 315 
 
 Case i.^ — ^Wilhelm Hoffler, resident in Berlin, set. 71 years, 
 came to me on the 15th February, 1857, on account of almost per- 
 fect blindness of the right eye. It had existed for many months, 
 and presented the signs of an acute glaucoma, in its latter stage. 
 I shall return to the history of this right eye when I consider the 
 morbid group concerned {vide Case 9). Even at the time when 
 the patient was admitted into my clinic for iridectomy on the right 
 side, the visual acuteness of the left was found on trial a little 
 changeable, and a few weeks after the performance of iridectomy on 
 the right side with relatively good effect, very distinct periodical 
 obscurations occurred on the left, which excited the fear of an early 
 outbreak of the glaucomatous process. In the last week in March, 
 scarcely two days passed without such obscurations, to which were 
 added ominous objective appearances, the pupil became somewhat 
 dilated and perfectly immoveable, the cornea a little less sensitive, 
 the aqueous humour diffusely clouded, the subconjunctival vessels 
 injected; rainbows appeared around the flame of a candle, pretty 
 considerable photophobia, vision diminished until large print could 
 scarcely be recognised, and the distinctness of excentrical vision in 
 particular lessened on every side, so that during the attacks the 
 patient could scarcely guide himself. At the same time he had ex- 
 tremely violent pains in the forehead and temples, which, when they 
 occurred at night, completely banished sleep. At first, the attacks 
 lasted some hours ; in the latter days of March, twelve hours and 
 more j an opiate appeared to shorten them, but not to lengthen the 
 interval, and, as usual, other means proved ineffectual. MnaUy, 
 even the intervals threatened to disappear entirely, and the pupil no 
 longer recovered complete mobility, so that I considered the time 
 for an operation had arrived. 
 
 Shortly before the operation the state of the vision was as fol- 
 lows : the patient could count fingers at the distance of six feet, 
 and read No. 16 of Jager's specimens of print with difficulty and 
 with errors. No. 14 not at all; with convex 6 he read No. 14 
 word by word, but tolerably precisely, of No. 11 the shorter 
 words, of No. 8 nothing ; there was no essential contraction of the 
 
 ' In these histories of cases I shall pay little regard to circumstances having 
 reference to the general condition, because, however important such may be in 
 other respects for the comprehension of glaucoma, their consideration would 
 materially increase the length of my essay, and not be of much service with 
 reference to my object. 
 
316 GRA.KFE ON IRIDECTOMY 
 
 visual field, but diminished clearness of the excentrical vision in 
 every direction ; frontal pains moderate. The period of the opera- 
 tion corresponded with an obscuration which had imperfectly 
 ceased ; correspondent with that were the objective signs, which I 
 need not repeat. I performed iridectomy at the inner side on the 
 1st of April. The frontal pains ceased immediately afterwards. 
 On the 5th of April the patient was discharged from the hospital ; 
 no obscurations nor other premonitory symptoms recurred. Vision 
 continually improved, the pupil regained its normal mobility, so 
 far as was compatible with the coloboma; the cornea became 
 normally sensitive. On the 13th of April an examination gave the 
 following results : the patient read with the convex glasses ( + 12, 
 + 10), proper for his presbyopia, print No. 6 at sight. No. 4 
 stiU precisely but rather slowly. No. 3 also precisely but w^ord by 
 word, stopping occasionally, of No. i he recognised only the easier 
 words. The ophthalmoscope showed no retinal ecchymoses nor 
 other changes of the internal coats ; the refractive media were now 
 perfectly clear, and the optic nerve normal. Vision continued to 
 improve, so that in the month of August he could even read print 
 No. I, with the exception of only a few words. At that time he 
 followed his usual occupations, paying not the slightest attention 
 to' the eye — a point to which I cannot draw too great attention, 
 because it is well known, how otherwise, with similar antecedents, 
 accidents are caused by the least injuries. 
 
 Summart/. — Cure, and apparently a permanent one,^ of a glau- 
 coma of the left side after from four to five weeks' premonitory 
 stage, in which the obscurations occurred at intervals of from one 
 to two days, and consequently the outbreak of a subacute glau- 
 coma had to be taken into consideration.^ The cure of the glau- 
 comatous inflammation in the right eye had no influence in respect 
 to the second eye becoming diseased. 
 
 Iridectomy had the same result even when the premonitory stage 
 
 ' If in the future, recurrences should take place in patients, whom I at pre- 
 sent adduce as " apparently permanently cured," I shall consider myself bound 
 to refer to them in later notices. To be able to do so eventually, I give the 
 names of all the cases, which otherwise I should prefer omitting. 
 
 'No exact limits can be drawn between the premonitory stage and chronic 
 glaucoma. I generally consider the former to be ended when the intervals are 
 uo longer distinct. 
 
IN GLAUCOMA. 317 
 
 had lasted a very long time. As an iastance, I mention a patient 
 wlio was under my treatment two years ago, one eye blinded by 
 glaucoma which had run its coursBj and the second in the pre- 
 monitory stage. Since at that time the periodical obscurations 
 were constantly becoming more frequent and intense, and I knew 
 no treatment for the glaucomatous process, I prepared the patient 
 for the worst, and sent him home to his residence elsewhere. In 
 this very case iridectomy was performed with great success three 
 fourths of a year ago, by my assistant-surgeon. Dr. Alfred Graefe. 
 In the intermediate time the obscurations had become more in- 
 tense, but there had always been tolerably long intervals between 
 them. 
 
 a. Iridectomy in the acute period of Inflammatory Glaucoma. 
 
 I have had much more experience in this than in the premoni- 
 tory stage. I have performed the operation on more than twenty 
 eyes soon after the outbreak of the first acute inflammation. In 
 some cases the inflammatory irritation was so great, that, a priori, 
 operative interference appeared critical; the most violent ciliary 
 neuroses, great chemosis, lachrymation, and photophobia were pre- 
 sent ; in short, the type of the most exquisite arthritic ophthalmia. 
 At first, I used to endeavour to alleviate the symptoms by anti- 
 phlogistic treatment, opiates, &c. ; but at a later period, I became 
 convinced that, notvrithstanding the violent inflammation, it was 
 better to perform iridectomy immediately, for it is especially under 
 these circumstances that any delay is dangerous, and that the 
 operation itseK is the most certain treatment of the inflammation. 
 It "was found that, not only did the symptoms of irritation recede 
 after the operation without the use of other means, but that there 
 correspondingly occurred in all cases a very rapid clearing of the 
 refractive media, so that even six or seven days after the operation 
 the posterior regions of the eye could be readily examined by the 
 ophthalmoscope. This enabled me to ascertain various nosological 
 results in regard to the process. The latter have been already 
 mentioned in the course of my earHer communications ; stiU I do 
 not hesitate to briefly repeat them once more, in their natural 
 connexion. 
 
 A. After the first inflammatory attack the optic nerve is per- 
 
318 GUAKl'Ji ON IRIDECTOMY 
 
 fectly normalj and there is no trace of excavation or of displace- 
 ment of the vessels, provided there has been no previous chronic 
 glaucoma, but that the disease has occurred in a healthy eye, or 
 after a premonitory stage of a positively intermittent character. 
 
 B. It is the same with arterial pulsation. 
 
 c. The round spots of retinal ecchymosis are indeed constantly 
 found, but there is no doubt that most of them are formed after 
 the operation. 
 
 D. On a very accurate examination, especially of the equatorial 
 region, choroidal ecchymoses are frequently observed. These, how- 
 ever, disappear with extreme rapidity, so that it has not yet been 
 ascertained whether their inconstant occurrence depends on the 
 disease, or altogether on the time of observation. Certainly, they 
 must not be considered as entirely produced by the operation, for I 
 have many times observed them before its performance. In general, 
 the vision improved immediately after the operation, owing to the 
 escape of the turbid aqueous humour, just as in paracentesis. Its 
 degree is, however, trivial, when compared with the subsequent 
 improvement of which some small part may also be referred 
 to clearing of the ocular fluids ; in my opinion it results from the 
 retina resuming its functions, which had till then been impeded 
 by the intra-ocular pressure. 
 
 The opinion that the restoration is entirely dependent on clear- 
 ing of the refractive media, is easily disproved. For example, I 
 refer to Gause's case (Case a) ; before the operation there was 
 no qualitative perception of Hght, and yet the ophthalmoscope 
 showed to some extent the contour of the optic nerve. In accord- 
 ance with that, the patient ought yet to have been able to re- 
 cognise large objects. T'ive days after the operation there was a 
 tolerably large quantity of blood in the anterior chamber, so that 
 when examined by the ophthalmoscope, the background of the eye 
 seemed stiU more hazy than before the operation ; yet the patient 
 could again count fingers at the distance of three to four feet. 
 
 There is in general no direct proportion whatever between the 
 clearing of the refractive media and the restoration of vision ; an 
 indirect one is produced by the cloudiness being certainly con- 
 nected with increased secretion of fluid, and this again with the 
 continuance of choroiditis and increase of the intra-ocular pressure. 
 The chief effect on the vision is attained in from two to three 
 weeks. The congestive phenomena usually cease at a far earlier 
 
IN GLAUCOMA. 319 
 
 period. In these cases the cornea always regains its sensitiveness, 
 whilst in older cases this no longer takes place, probably because 
 textuxal changes in the nerves passing to the cornea have been 
 formed, which are no longer capable of retrogression. The ciliary 
 neuroses generally cease immediately after the operation ; in a few 
 cases only did slight paroxysms of frontal pain still occur for the 
 first two days ; as the rule there was perfect freedom from pain, 
 or a traumatic sensation of slight pressure in the eye, perfectly 
 different from the former pains. The state of the iris is very 
 various, and clearly dependent on the degree of iritic participation. 
 I have scarcely seen a perfectly mobile and normal iris, after acute 
 inflammations had once occurred. Frequently partial mobihty re- 
 turned, but in most cases the pupil remained perfectly fixed, and 
 moderately dilated, though not so much as it had been previously. 
 Sometimes also, sufficient allowances being always made for the 
 coloboma, the pupil became somewhat more contracted than nor- 
 mally. Irregular form and displacement of the pupil not unfre- 
 quf ntly remained, even when there were no posterior synechiEB ; 
 and, as is usually the case in glaucoma, must be referred to unequal 
 paralytic participation of the ciliary nerves. Hence it is a question, 
 when we seek an explanation why the pupillary lesion continues, 
 whether the cause lie in structural alterations of the iris, or, 
 perhaps, in rapidly occurring changes of the ciliary nerves them- 
 selves. It is difficult to decide this with certainty ; I am, however, 
 more inchned towards the first opinion, for the pupillary affection 
 is generally in an approximative relation with the permanent struc- 
 tural changes of the iris. In all acute cases the latter never 
 recovers its normal appearance, but ash-gray discolorations and 
 some indistinctness of fibrillation remain, in the form of spots, or 
 extending over a larger space, especially towards the periphery. 
 This is at all times a proof of the glaucomatous lesion, and is of 
 importance for the determination of cases at a later period. The 
 tenseness of the globe receded perfectly to its normal amount ; the 
 operated eyes seemed to the touch in some cases even a trifle 
 softer. 
 
 Though the restoration of vision most strikingly advanced within 
 the period of two to three weeks, stUi a continual improvement 
 always occurred from this time onwards ; so that the vision recovered 
 its utmost acuteness only after about six weeks. This improve- 
 ment was, in my opinion, especially connected with the retrogression 
 
320 GRAEFE ON IIUDECTOMY 
 
 of the retinal ecchymoses. Of these, the smaller ones were, indeed, 
 of no great importance when they were excentrical; but, on the 
 other hand, the larger ones caused indistinctness of excentrical 
 vision in certain portions of the visual field, scotomata, &c. The 
 region of the macula lutea was also sometimes affected ; then the 
 central vision, of course, was much impaired. In a case of that 
 kind, the occurrence of excentrical fixation would have excited great 
 fear for the result, had not the ophthalmoscope shown its cause to 
 be a large central retinal ecchymosis ; and experience already proved, 
 that after retrogression of the retinal ecchymosis, the retina again 
 becomes capable of conduction in aU the affected parts. In six to 
 eight weeks, at the latest, the last traces of retinal ecchymosis 
 disappeared. 
 
 This was true of aU cases of glaucoma, except one (Madame 
 M — 1, from Vienna), in whom the retinal lesion took a particular 
 turn, after an artificial pupil had been made for chronic glaucoma. 
 There repeatedly occurred fresh retinal ecchymoses, although the 
 exterior of the eye looked as weU as could be wished, and finqjly 
 white patches formed around the spots of blood, as in albuminuria. 
 In fact, albumen was also found in the urine at a later period. This 
 case must be temporarily excluded from consideration, and is in- 
 teresting, inasmuch as the retinal ecchymoses succeeding iridectomy 
 formed the exciting cause of retinal degeneration, which was pro- 
 bably connected with a renal affection. 
 
 Vision was perfectly restored in all cases in which the operation 
 was performed before the termination of two weeks from the occurrence 
 of inflammation. Some of these cases seemed perfectly desperate ; 
 for every trace of the qualitative perception of Kght had been al- 
 ready extinguished. I need scarcely mention that at first I pro- 
 mised but little to these patients. I frequently undertook the 
 operation (see Case a) altogether on account of the violent ciliary 
 neuroses, and the effect was, in both respects, very surprising. It 
 is only within the last half-year that I have ventured to predict 
 complete restoration, even where the power of distinguishing has 
 been perfectly lost, it being presupposed that less than two weeks 
 have passed since the commencement of the inflammation, and that 
 a moderate quantitative perception of light exists. 
 
 On longer observation, my fears that the results might not be 
 permanent proved unfounded. Very soon there appeared marked 
 distinctions from the other remissions of the glaucomatous process. 
 
IN GLAUCOMA. 321 
 
 The field of vision remained absolutely normal. Excentric vision 
 continued distinct^ after it had once attained a certain degree. Not 
 the slightest premonitory symptom recurred. The congestion of 
 the subconjunctival vessels entirely disappeared; the anterior chamber 
 was no longer contracted; and nothing betrayed an abnormal con- 
 dition of the eye, except the hue of the iris, and the sluggishness 
 or immobility of the pupil. Should the fear of recurrence at a 
 later period still be entertained, it is true that I cannot whoUy 
 allay it, on account of the Hmited duration of my cases ; but this 
 much is certain, that a similar intermission of the glaucomatous process 
 never occurs spontaneously or after any other treatment. Accurate 
 observation in the other states of inflammatory glaucoma, which 
 have been called stationary, always yields essentially different cha- 
 racters, particularly on a functional examination. Many of the 
 cases operated on were exposed to various noxious influences in 
 their utmost extent, and many of them have now been under ob- 
 servation for about a year, without my having to make any restriction 
 in what has been said. Whatever the final result may be, I think 
 that practitioners who are acquainted with the course of acute glau- 
 coma win feel themselves abeady justified by these statements in 
 adopting the treatment. In spite of the surprising results of iri- 
 dectomy soon after the occurrence of inflammation, still a careful 
 survey of the effects will prove the correctness of what has been 
 stated in favour of operating during the premonitory stage. I may 
 point out once more the difference in the danger of the operation. 
 An accident of consequence will rarely occur in the premonitory 
 stage, even when the operation is not quite correctly performed. 
 On the other hand, success may be frustrated in the acute period 
 by internal hsemorrhages, very large retinal ecchymoses, &c., when 
 all precautionary measures are not taken (see IX). These may pos- 
 sibly occur in scattered cases, notwithstanding the greatest caution ; 
 this, however, can only be decided by extensive statistics. 
 
 Where, then, must we draw the limit between the recent and old 
 cases, so as to render ourselves intelligible? It is clear that this 
 question can only lead to a perfectly arbitrary answer, for no dis- 
 tinctive symptom is found ia the further course of the disease. In 
 regard to the prognosis, it would be most proper to call the cases 
 recent in which there are as yet no contraction of the field of vision 
 and no excavation of the optic nerve. Unfortunately, both these 
 signs are difficult to determine in the inflammatory stage of acute 
 
 21 
 
322 GRAEl'E ON IRIDECTOMY 
 
 glaucoma, because the haziness of the refractive media sometimes 
 renders it impossible to determine with accuracy the condition of 
 the papiUa, and because excessive difficulties are occasionally opposed 
 to the limitatioifi of the visual field, when there is no longer any 
 qualitative perception of light. Hence we were forced in our com- 
 munications to fix aa arbitrary limit to the duration ; and we repeat, 
 that the cases mentioned were within a period of fourteen days fromi 
 the fiist outbreak of inflammation. In all these cases no excavation 
 of the opijic nerve occurred at a later period; and I cannot admit 
 any transitory affection of the. optic nerve, so long as no case is 
 " known in which an excavation has clearly disappeared after iridec- 
 tomy. Even in the case iu which only quantitative perception of 
 light existed (Obs. a), it seemed to extend uniformly over the whole 
 field of vision ; and yet this could not be explained by any diffusion 
 of the Hght. Consequently, it appears that both the above condi-. 
 tions aj.e invariably present, when we speak of a duiation of fourteen 
 days. On the other hand, we shall ha-eafter see that, fortunately 
 iai the cure of glaucoma, these very conditions are often found even 
 after far longer periods. 
 
 The observation of cases shows that iridectomy has no consider- 
 able influence over the second eye. It is not unusual for the affec- 
 tion to occur in the one eye soon after a successful operation on the 
 other {vide Obs. 4 and 6), whilst in other cases the second eye has 
 hitherto remained Tinaffe&ljedi Since the latter, however, is often 
 the case for years, when the affection has. followed its own course, it 
 is not conclusively indicative of a favorable influence ; and the former 
 instances prove, that the glaucomatous inflammation of the second 
 eye do.ea not sympathetically depend on the disease of the first eye. 
 
 Case a.— r^Herr Gause, of BerHuj, about 50 years oldj had re- 
 marked, during the years i8go-^^i his vision being good, a very 
 great increase in his presbyopia, so that he was obliged to increase 
 from -It 24 as far as -f- 10. On the 3d of January;, 1855, he was 
 attacked by a violent inflammation of the right eye, without the. 
 occurrence, of any premonitory symptoms, according to hia account, 
 after taking cold; when there ensued lacerating pains in the fore- 
 head and temples, iridescent vision, and a rapid obscuration of the 
 sight on the light side. Some days later he was received into my 
 clinic, the appearance of ^ glaucomatous choroiditis being fully de- 
 veloped. The disease was at that time treated by paracentesis. 
 
IN GLAUCOMA. 323 
 
 which seemed to afford aTsry Satisfactory result; in fact, no fresH 
 inflammation arose, even at a later period. In March, however, sL 
 distinct deterioration of vision aiid gradual contraction of the visual 
 field were already presented ; atrophy of the iris and anaesthesia of 
 the cornea progressively advafflced^ although the refractive media 
 remained clears In August, 1855, the right eye had become per- 
 fectly bUnd. 
 
 The left eye of the patient continued healthy till the 15th of 
 December, 1856; the presbyopia alone had slightly augmented 
 (to + 8). There occurred on the day mentioned iridescent vision 
 and pains in the forehead and temples, and, on the next day, 
 an extremely violent inflammation. I saw the patient on the aoth 
 of December; he was exceedingly exhausted by the very severe' 
 pains of the last few days, And perfectly resigiled to the loss of his 
 sights which had been immediately destroyed on the occurrence of 
 inflammation, and, as he cltesirly pierceived the uniformity of the dis- 
 ease on the left with that of the right side, he believed that permanent 
 blindness was inevitable. It Was simply for the unbearable pains 
 thait he again required my assistance. Examination showed great 
 injection of the anterior cihary vessels, sUght chemosis, the anterior 
 chamber densely and unifornaly clouded and flattened, the cornea 
 insensible and its posterior surface hazy, the pupil much dilated 
 and smoky, the iris' of a dirty hue, the globe tenSe, and no quali- 
 tative perception of UgM wfiatever, so that the patient could not 
 perceive the motion of a hand', even with the strongest light. The 
 quantitative perception of Hght was also very indifferent ; the light' 
 of a lamp, which had burnt low, was not distinguished. On the 
 other hand, that of a lamp which burned brightly was recognised 
 in a darkened chamber at the distance of some feet, and, as it 
 seemed, unifortaly by every part of the visual field. I fropoSed 
 iridectomy, but, owing to the power of distinguishing being per- 
 fectly lost, did not venture to promise any restoration of vision, but 
 only relief of the inflkmmation. I previously madb * careful 
 ophthaknoscopie examination, with the object of determiinn'g- the' 
 influence which the turbidity of the refractive media might have 
 on the blindness ; the background of the eye, of courses Seemed 
 extremely duU, and yet we perceived, to some extent, the contoilr 6f 
 the optic nerve. Evideitly there was in this' an important dis- 
 proportion with the patient's vision. Iridectomy was perforined' 
 on the 2ad of December, by excision at the inner side. AllSiOti^jf, 
 
321 GKAEFE ON IRIDECTOMY 
 
 when the aqueous humour had escaped, the pupil and iris seemed 
 considerably clearer, yet, immediately after the operation, the 
 patient could not perceive the motion of a hand. The ciliary 
 neurosis immediately and for ever ceased, and the patient only 
 slightly felt the pain of the wound in the eye, which, however, did 
 not in the least interfere with sleep. On the next day the injection 
 was already retrograding, but there was still a considerable quantity 
 of blood in the anterior chamber ; yet the quantitative perception 
 of Hght had materially increased, and the light and shadow of a 
 lamp, burning very low, could be distinguished almost at the 
 distance of a foot. A slightly compressing bandage was apphed. 
 On the second day after the operation the blood in the anterior 
 chamber had diminished in amount ; the patient could clearly dis- 
 tinguish the motions of a hand, and this over the whole extent 
 of the region of exeentric vision — a point of special importance, 
 because, the perception of light being dull before the operation, 
 I had not yet been able to come to a satisfactory conclusion about 
 the field of vision. Pour days after the operation the patient was 
 abeady able to count fingers with certainty, and one day later 
 at the distance of three feet. A perfectly exact examination was 
 now made for the first time since the operation, with the following 
 results : the cornea normally sensitive, no injection whatever ; 
 the pupil very much diminished in comparison with its former 
 state ; the globe less tense ; owing to the hsemorrhagic saturation of 
 the aqueous humour having not yet disappeared, the colour of the 
 iris and pupil could not be determined with certainty; for the 
 same reason, the examination with the ophthalmoscope also gave, 
 as yet, no positive result, and the contour of the optic nerve was 
 now seen less distinctly than before the operation — a circumstance 
 which I expressly point out, because it shows how little the previous 
 state of vision can be optically explained. On the aSth of 
 December the patient was discharged from the hospital, and eight 
 days later the state was again noted. The pupil had now a 
 healthy hue, and was of almost normal size, which it has since pre- 
 served ; the outer portion of the iris presented some circumscribed, 
 gray blotches, which were permanent; in other parts its colour 
 and fibrillation were perfectly normal ; the anterior chamber, com- 
 pared with the presbyopia, not very small, and quite clear; the 
 pupil very slightly affected by light. The ophthalmoscope did not as 
 yet show the background so distinctly as in the healthy eye, which I 
 
IN GLAUCOMA. 335 
 
 referred to some of the diifuse turbidity of the vitreous humour 
 still remaining, yet most of the details could be readily determined ; 
 the optic nerve was not in the least excavated; round spots of ecchy- 
 mosis were found in various parts of the retina, and especially where 
 two veins united. Accurate drawings were made of some of them, so 
 that we might determine any changes with certainty. The patient had 
 no difficiilty in counting fingers at the distance of twenty feet, and 
 read, with + 8, No. 14 of Jager's specimens fluently between eight 
 and ten inches; he deciphered No. 1 1 word by word; of No. 8 he re- 
 cognised syllables here and there. Two weeks later, he read with the 
 same glasses No. 6 with ease. No. 4 word by word, and recognised 
 a few words of No. 3 ; the field of vision was quite normal, the 
 background of the eye perfectly clear, a part of the retinal 
 ecchymoses had already disappeared, and those still remaining 
 were smaller. Eight weeks after the operation no trace of retinal 
 ecchymosis could any longer be discovered; the patient read print 
 No. 4 and No. 3 fluently, and recognised most words of No. i ; the 
 pupil acted so slightly as to be scarcely noticeable, and remained so ; 
 the accommodation was yet extremely limited, as has been the general 
 result in a great part of my operations. This probably depends on 
 permanent changes in the iris and tensor choroidese. From that 
 time the patient followed his usual occupation. When I last saw 
 him, eight months had elapsed since the operation, and yet there 
 had not been a trace of suspicious symptoms similar to those of the 
 premonitory stage ; vision had even a little improved since the last 
 examination ; the field of vision was absolutely normal. 
 
 Besume. — Case of acute glaucoma, without premonitory stage. 
 Immediate and perfect loss of the power of distraction. Iridec- 
 tomy after seven days. Cure (eight months ago). Proof that the 
 effect is not explained by the clearing of the refractive media. 
 Parallel of the course in the eye treated by iridectomy, and that by 
 paracentesis. 
 
 Case 3.— Oertel, a confectioner of Berlin, a healthy man, of 
 about 40, had been in good health, till the middle of December, 
 1856. At this time, according to his own account, there suddenly 
 occurred, without premonitory symptoms, on the right side, a 
 feeUng of pressure in the eye, pains in the forehead and temples, 
 photophobia, lachrymation, and some loss of sight. During the days 
 immediately succeeding the outbreak the symptoms again re- 
 
326 GRAEFE ON IllIDECPOMY 
 
 mitted, I'rom the a4th of December, however, they constantly in- 
 creased. I saw the patient on the a6tht — choroiditis glaucomatosa; — 
 just the same appearances as in the left eye of Cause (Case %), the 
 pupil, however, only moderately dilated} the sensibility of the 
 cornea scarcely diminished ; on the other hand, the a,nterior chamber 
 ejftfeniely fla,t, the aqueous hiimoijr very turbid^ the quantitative 
 peifception of light good, the qualitative, alfliost lost, and only with 
 the. best ppssible idumiaation could the patient perceive the motion 
 of ^ hand ; cHiary neurosis very violent. Iridectomy, by excision on 
 the inner side, on the a 7th of December. Some hours after the 
 operation there was a paroxysm of frontal pain, which did not 
 recur ; a, perfectly good, night. ISText day, no blood in the anterior 
 chafliber, which was stiU somewhat clouded j the posterior surface 
 of the cornea dull, the congestion less ; the patient could perceive 
 the motion of a hand at the distance of a foot, Three days after 
 the operation he counted fingers. Discharged from the institution 
 on the sixth day. Ten days after, the first accurate examination 
 showed the following state i little or no congestion j the aqueous 
 humpui not yel; quite clear; the cornea normally sensitive, the 
 clouded appearance pf its posterior surface limited to, a rather small 
 space in the cenljfe ; the tissue of the iris very much changed; large 
 gray spots, in yhich the fibiriU£|,tion was '^■^xj indistiuct; the 
 pigmented margii^ of the piipil here and, there entirely deiicient ; 
 the pupil still cpntinue^ to be rather diluted, almost to the same 
 extent, qs before, the operation, also perfectly fixed,; tl^e anterior 
 chamber stiU very fl^t, the determiijatipn of the. ocular back- 
 ground still dif&eultj retinal ecchymoses,' perfectly resembling 
 those pf Gawse. The, p^^ent counted fingers at the distance of 
 three to four feet, recognised words of print "No. 16; the visual 
 field was normiaL Three weeks after the opera,tion, the refractive 
 media were clear^ the retinal ecchymoses already retrograding ; tha 
 optic nerve perfectly normal ; the iris and pupil stfll in "the same 
 state; the anterior chamber, however, less flattened; the patient 
 read print No-, n fl.uently. No. 8 accurately^ and 'v^ords of 
 No, 4, Six vee^s, e^ftei; the operation the objective condition was 
 
 ' I do not append to these observations the cases in which choroidal ecchy- 
 moses could be clearly shown, because it is only within the last four months 
 that I have succeeded in finding tlR'm in acute glaucoma, and because such 
 recent cases, would be yet too uncertain with regard to the results of treat- 
 ment. 
 
IN GLAUCOMA. S2T 
 
 the same, excepting that the retinal ecchymoses had fentirely dis- 
 appeared. The patient read print No. 4 precisely, and some 
 words of No. 2. Since then he has been in many ways exposed to 
 the most various noxious influenceSj especially night-Watching and 
 exposure to glaring light (as a confectioner), yet no thleaiemng 
 symptom ever appeared in the ttialS) which were repeated at 
 regular intervals of tliree to four weeks. The far-advtaced altera- 
 tions of the iris still remain exactly ia the same state, and would 
 certainly cause alarm had not everything else remained normal ; 
 vision has even continued to improve. The accommodation of the 
 right eye has, in this case, remained extremely limited j the left eye 
 hitherto healthy. 
 
 ^/■s«w«i/-'-^Acute glaucoma, without a premonitory stage.^ Iri- 
 dectomy a week and si half after the outbreak. Perfect restoration 
 of vision (of eight months' duration) ; far advanced alteratioiis of the 
 
 Case 4. — Madame Maas, of Berlin, a kdy of about 50, with rather 
 inactive bowels, otherwise healthy, had remarked, in reference to 
 the right eye, «iace the winter 1855-6 iridescent visioh, increased 
 presbyopia, and occasional obscurations ; had, however, paid little 
 attention to these appearances, so that they were only ascertained 
 by a thorough examination of the case. In February^ 1857, there 
 suddenly occurred on the right side violient frontal pains, photo- 
 phobia, laehrymatioii, and, in a few hours, entire bUndness; I saw 
 the patient three days later; on the right side there were aU the 
 sjfmptoms of glaucomatotis choroiditis, injection very great, 
 chemosis to a moderate extent, the cornea tolerably insensible, 
 mydriasis and flatteiling of the anterior chamber extremely great ; 
 on the other hand, the ac[ueous humour -^as not very turbid, there 
 was quantitative perception of light over the whole of the visual 
 field, and, indeed, to such An extent, that the light and shadow of 
 a lamp, btuning dioderately low, were distinguished to the distance 
 of eight inches; she could perceive the niotion of a hand only 
 when brightly iUttminated, and even then with uncertainty; at the 
 same time she had violent frontal pains. The next day I per- 
 formed iridectomy by excision on the inner side; although the 
 aqueous humour was only slightly turbid, stiU the effect was so 
 
 ' The existence of* the premonitory stage can never be with certainty' denied 
 when one side only is affected, for the symptoms easily escape the patient. 
 
328 GRAEFE ON IBIDECTOMY ' 
 
 immediate, that after the operation she could count fingers with 
 certainty. A slight pain, as of a wound, took the. place of the 
 torturing ciliary neurosis, and allowed a good night's rest. On the 
 morning after the operation the ehemosis had entirely disappeared, 
 the injection of the anterior ciliary vessels had very much diminished. 
 She counted fingers from two to three feet off; owing to the great 
 mental excitahiHty, a more accurate examination was avoided. The 
 improvement continued for the two following days, as well as could 
 be wished. Three days after the operation she was attacked by 
 frontal pains on the left side, which became very acute towards 
 evening ; at the same time the right side continued perfectly un- 
 affected. The next day an outbreak of glaucomatous choroiditis 
 could be clearly perceived in the left eye. The congestive pheno- 
 mena were so severe on the left side that I was almost afraid 
 of operating ; the ehemosis in particular was very great, and even 
 tonchiag the eyelids caused violent pain. The pupil appeared less 
 dilated in this than in the former eye, but very irregularly in- 
 dentated; there were also broad posterior synechiBe on the internal 
 and inferior sides, the aqueous humour very turbid ; yet she could 
 still count fingers at the distance of some feet. It was decided 
 to perform iridectomy on the following day, when a large piece of 
 the iris on the inner side was excised. This was on the iifth day 
 after the operation on the right side. Owing to the large amount 
 of ehemosis a few short incisions were also made in the conjunctiva 
 soon after the operation, so as to allow the escape of the serum. 
 The pains ceased immediately; the day following only a sKght 
 amount of ehemosis had recurred, which, however, soon entirely 
 vanished. In a few days the injection retrograded, and improve- 
 ment took place just in the same way that has been described when 
 speaking of former patients. It was now very instructive to com- 
 pare the two eyes, of which the first was operated on the fifth 
 day of its being diseased, and the second two days after the attack. 
 This comparison soon proved very strikingly to the advantage of 
 the latter eye; in eight days its power of vision had already 
 reached that of the right one ; the patient could now read with 
 either eye No. 14, by means of proper convex glasses, with trouble, 
 and recognise most words of print No. 11. Prom that time the 
 vision of the left eye surpassed that of the right ; three weeks after 
 she could read with the left eye print No. 3 with certainty; on 
 the other hand, with the right, even print No. 6 only with dilfl- 
 
IN GLAUCOMA. 329 
 
 culty. Eetinal ecchymoses existed^ but what relation their retrogres- 
 sion bore to the improvement I cannot determine, for the patient, 
 residing in the city, was exanained only at long intervals. A dis- 
 tinct difference in the vision of the two eyes remained even at a 
 later time. The visual field was on both sides normal ; the optic 
 nerve healthy; the refractive media became clear, the cornea 
 normally sensitive ; the globe lost its tenseness ; the pupil remained 
 on the right side moderately dilated and perfectly fixed ; the iris dis- 
 coloured in spots, but the anterior chamber in relation to the 
 presbyopia not flattened; on the left side the pupil regained a 
 medium size, and was slightly affected by light, notwithstanding a 
 broad posterior synechia ; the tissue of the iris was but little changed, 
 the accommodation indeed limited, but not nearly to the same 
 extent as on the right side. When I saw her for the last time, six 
 months after the operation, her power of vision had considerably 
 augmented since the previous examination, so that she could read 
 print No. 3, with precision when well illuminated, even with the worse 
 eye. Not the least accident had occurred throughout that time. 
 
 Resume. — Acute glaucoma, after a year's premonitory stage. 
 Operation on the fifth day. Some days after,^ glaucomatous 
 choroiditis in the other eye. Operation in the latter eye two days 
 after the attack. Cure on both sides (six months' duration) ; vision, 
 however, more acute in the eye which was operated on last.^ 
 
 Case 5. — General von Pelden, resident in Berlin, aet. 70 years, 
 arthritic, with very rigid arteries, otherwise robust, was attacked 
 in February, 1857, by a very painful inflammation of the right eye. 
 I was consulted five days after the affection had commenced. By 
 
 ' From this, as well as from some other observations of mine, it might seem 
 as if the operation hastened the outbreak in the second eye ; this is possible. 
 It seems to me, however, extremely doubtful, when I compare my statistics of 
 cases operated on with those not operated on. In the acute inflammatory 
 forms the disease very often successively attacked the eyes. (See, for example, 
 Case 5.) 
 
 = I believe, indeed, that the earlier performance of the operation in this case 
 is essentially concerned in the difference of vision on the two sides ; but the 
 difference in time being so little, a safe conclusion caa be the less drawn from 
 this single observation, because I excised on the left side a larger piece of iris, 
 which, according to my later experience, is advantageous. Besides, even in the 
 acutest oases, I have operated a few times during the second week, and seen 
 restoration of a very satisfactory acuteness of vision. 
 
330 GRAEi'E ON IRIDECTOMY 
 
 examination we found : injection of the anterior ciliary vesselsj the 
 corneal sensibility normal^ slight diffuse turbidity of the aqueous 
 humour ; the pupil verticaliy oval^ at the upper part much dilated^ 
 otherwise but moderately so ; at the same time some photophobia, 
 and very violent ciliary neurosis, especially at night ; vision so fai 
 good that the patient could recognise medium print ; he also asserted 
 that he had never seen so well with this eye as with the left one. 
 Owing to the visual field being also normal, there seemed no danger 
 in delay, and I recommended local bloodletting, Ung. Hydr. c. Bellad., 
 and an opiate at night. He was decidedly better on the following 
 day, so that the surgeon-in-ordinary carried out the treatment for 
 some time. A week later I was again consulted; notwithstanding 
 the bloodletting, &e., there had occurred during the last few days 
 violent frontal pains on the right side, and finally an extremely 
 violent inflammation of the left eye, with torturing ciliary neurosis. 
 On seeing the patient, I at once found an essential change in the 
 right eye ; although the injection and the turbidity of the aqueous 
 humour were trifling, the dilatation of the pupil at the upper part had 
 decidedly increased, the sensibility of the cornea was diminished, and 
 the vision was so much deteriorated that he could scarcely recognise 
 large type. The general appearance Was now distinctly that of acute 
 or subacute glaucoma. On the left side I found great injection of 
 the anterior ciliary vessels^ the pupil fixed and uniformly dilated, the 
 aqueous humour difFiisely turbid; fingers could be counted with this 
 eye, though with difficulty, at the distance of some feet. Iridectomy 
 on both sides was agreed on for the following day. On this day a 
 violent exacerbation in the left eye had occurred ; great chemosis, 
 photophobia, anterior chamber much flattened, the patient Could no 
 longer count fingers; some chemotic sweUing had now become 
 developed on the right side, the patient coxdd only with difficulty 
 count fingers at the distance of a foot and a half. The operation 
 was performed in both eyes at the same time, and a piece of equal 
 size was excised in each. The torturing pains immediately ceased, 
 the rest of the symptoms retrograded as in the cases already men- 
 tioned ; the pupil maintained on both sides a trace of mobility ; on the 
 left side there remained far-advanced changes of the iris, on the right 
 side these were unimportant ; the accommodation on both sides was 
 limited. At first it seemed to me that the result woxdd be most 
 favorable in the right eye ; with this he could in eight days read 
 print No. ii word by word, whilst with the left one he scarcely recog- 
 
IN GLAUCOMA. 331 
 
 nised syllables of No. i6. This difference was explained, on ophthalmo- 
 scopic examination, by there being on the left side extensive ecchymoses 
 over the whole extent of the retina, and even in the region of the 
 macula lutea, and scarcely any on the right side. In connexion 
 with one of these central ecchymoses, he had still for a period of 
 four weeks on the left side a misty spot in the centre of the visual 
 field, through which objects looked smoky and somewhat distorted. 
 Wlien all this had disappeared, vision on the left side was somewhat 
 more acute than on the right, which, however, probably depended in 
 part on the difference which bad formerly existed. When I saw him 
 for the last time he could accurately read "with the left eye print 
 No. 3, with the right No. 5 ; the visual field and the appearance of 
 the optic nerve on both sides were normal. Almost six months had 
 passed away, the patient had suffered much mentally through the 
 death of his wife; during the last few months he had even worked in 
 the evening in opposition to my desire; since then he had also, in 
 many ways, suffered from his arthritic affections, but his eyes had 
 never presented the least symptoms of disease. 
 
 Mesume.'^-Su.ccessiYe outbreak of glaucomatous choroiditis in 
 both eyes, first in the right eye, with moderate inflammation ; a week 
 a,nd a half later in the left one, with, very acute inflammation and rapid 
 loss of vision. Contemporaneous iridectomy in both eyes ; the cure 
 delayed in the left one by extensive retinal ecchymoses, but still 
 perfect (duration of six months). 
 
 Case 6, — MinnaDankhof, of Berlin,, set. 4,6 years, presented herseK 
 at) my chniQ on the i6th of October, 1856. She had suffered from 
 her 13th to her aoth year from menstrual disorders and spasms at heri 
 catamenial periods* 5^om her 20th year these irregularities had 
 disappeared; she was, however, troubled by violent cephalalgia, which 
 often lasted for weeks, compelling her to remain ia bed, and which 
 was altogether independent of ik^ occurrence of the menses. The 
 most viqlent attacks were accompanied also by racking pains in the 
 arms and feet, which rendered any motion difficult. All this had 
 continued up to the time when she presented herself, and had not 
 been essentially modified either by seven labours or intercurrent dis- 
 eases (typhus and intermittent fever). Every year she had been 
 many times bled for these affections. In her 34th year the cephalic 
 affections were first accompanied by morbid sensations in the eyes,, a 
 feeling of heat in them, and pains about the eyebrows: To these was 
 
332 GBAEFE ON IRIDECTOMY 
 
 soon added a morbid closure of the lids, so tliat she could not keep 
 them open when exposed to the least Hght. On account of the lat- 
 ter affections, she had abeady, nine years ago (1847), sought assist- 
 ance in the ophthalmic clinic of the Charite of this place, and had 
 found relief (through repeated bloodletting) . From the year 1848 
 she suffered periodically from iridescent vision and obscurations of 
 the left eye. These gradually occurred at shorter intervals, until in 
 the year 1854 inflammations, with very acute ciliary neuroses, 
 appeared, which, after repeatedly recurring, induced perfect blind- 
 ness of this eye. Since the year 1850 there had been also in the 
 right eye iridescent vision and ciliary neuroses, since 1853 obscura- 
 tions at intervals of many months. These premonitory symptoms 
 very much increased in intensity during the summer months of 1856. 
 On admission of the patient' there was found on the left side a 
 glaucoma, which had run its course ; the pupil was Tnuch dilated, the 
 iris discoloured, the cornea insensible and slightly infiltrated, the 
 globe tense, a cataracta glaucomatosa formed, no trace of sensibility 
 to light ; in addition, internal inflammation yet continuing, effusions 
 of blood into the anterior chamber, frontal pains, and subconjunc- 
 tival injection. The right eye was hyperpresbyopic, and seemed to 
 be passing from the premonitory stage into subacute glaucoma. 
 During the intervals, the acnteness of vision was stiU so good that, 
 with + 6, she could recognise words of No. %. But the obscura- 
 tions were repeated very rapidly, and after fourteen days' observation 
 it was found that now some sluggishness of the pupil, slight diffuse 
 cloudiness of the aqueous humour, and disturbance of the visual 
 acnteness continued, even during the intervals. Since it appeared, 
 as if the deteriorations of the right eye were connected with the 
 violent attacks of inflammation in the left eye, iridectomy was first 
 performed on the left side, on the 7th of November, 1856, of course 
 entirely with the view of removing the inflanmiation, and without 
 any hope of vision. In regard to the first point, the result was very 
 favorable : the ciliary neuroses entirely ceased, congestions and effu- 
 sions of blood did not again occur, and the globe lost its tenseness ; on 
 the other hand, the cornea remained insensible, the cataract proceeded, 
 and, as was expected, vision remained entirely abolished. Notwith- 
 standing the disappearance of the inflammation on the left side, the 
 symptoms on the right side rapidly became more threatening, the 
 
 ' This occurred during my absence, and the journal was kept for the first 
 three weeks by my assistant-surgeon, Dr. Alfred Graefe. 
 
IN GLAUCOMA. 333 
 
 obscujations were accompanied by congestive phenomena ; and even 
 in the remissions the patient conld only read print No. 14 word by 
 word. No. 8 not at all. She suffered much from the violent ciHary 
 neurosis on the right side, which now ceased exactly in the middle 
 line. On the 1 6th of November iridectomy was performed on the right 
 side; the ciliary neurosis immediately ceased, and haa not again 
 returned, although the patient has since suffered, just as before, from 
 her other head-affections. Vision continued to improve, so that on 
 the 29th of November she abeady read print No. 4 precisely, and 
 on the 10th of December print No. i. Obscurations have not 
 again occurred ; only twice during the - winter months she has 
 observed, on arising in the morning, a sUght yeUow appearance 
 before the right eye, which, after a few minutes, has disappeared, 
 and did not impede the perception of objects. The retinal ecchy- 
 moses were very inconsiderable in this case ; the optic nerve per- 
 fectly normal, notwithstanding the long premonitory stage; and 
 the pupil also recovered its free action, which is unusual. I have 
 seen her for eight months at regular intervals of fourteen days ; she 
 has sewn by artificial light, and in general employed her eye rather 
 carelessly, yet the vision has remained intact. Although the other 
 affections were, of course, not removed, the patient relates that since 
 the rehef of the ciliary neurosis her head has been infinitely lighter, 
 and not only the forehead, but the whole cranium has been free 
 from the gouty pains ; these now commence at the occiput. This 
 year she has also had no occasion to be bled, which would otherwise 
 have been indispensable. • 
 
 Resume. — Glaucomatous blindness of the left eye, the iaflamma- 
 tion still continuing. The latter cured by iridectomy; negative 
 effect on the vision, negative effect also on the disease in the right 
 eye ; in this one a six years' premonitory stage, the attacks of which 
 have for some weeks no longer entirely remitted, and through gra- 
 dual augmentation have been developed iuto glaucomatous choroi- 
 
 ' I take this opportunity of pointing out the favorable influence which the 
 curing of ciliary neurosis generally exerts on very extensive hyperseathesia. 
 The new nervous pathology has certainly made a great advance in showing how 
 often loeal irritations of particular nervous filaments successively educe morbid 
 appearfinces in constantly multiplying directions. Ciliary neurosis is an in- 
 structive instance. I have not unfrequently found that very extensive pains, 
 spreading over the whole extent of the cranium, of the occiput, and even further, 
 diminished or ceased entirely when the ciliary neurosis had been relieved. 
 
334 GRAEFE ON IRIDECTOMY 
 
 ditis. Iridectomy on the right" side. Resfroration of vision. Dura- 
 tion of the cure (eight months), notwithstanding the continuance of 
 other affections, which were probably originally connected with the 
 disease of the eye. 
 
 Case 7. — Prau von Bottchei', from Curland, about 60 years 
 oldj first presented herself at my clinic in the spring of 1856. On 
 the right side there was bhndness through chronic glaucoma. I 
 employed no treatment, because vision was entirely lost, and al. 
 symptoms of inflammation had disappeared. On the left side there 
 was cataracta provecta ; the vision in this eye perfectly corresponded 
 with the degree of opacity of the lens, and the appearance of the 
 eye gave no reason for suspecting an amblyopic complication. I 
 recommended the patient to be operated on for cataract at some 
 future time, for it was not yet sufficiently mature. When she again 
 presented herself according to my direction, in the autumn of 1856, 
 I found, on examination, the cortical substance, which was formerly 
 transparent, perfectly turbid, the pupil acting well; th>e eye did not 
 present any suspicious objective symptoms. She could perceive 
 the motion of a hand in any direction. The time for the operation 
 seemed to me to have arrived; owingi however, to some accidental 
 derangement of the health, it was postponed for a few weeks. 
 During this period I was suddenly called to the patient, on account 
 of very violent frontal pains on the left side. I was unable to see 
 her till the following day, when I found, to my horror, the distinct 
 signs of glaucomatous choroiditis in the cataractous eye. She had 
 the most violent ciliary neurosis, so that she moaned incessantly ; 
 the eyelids were sensitive to the touch ;• tfliere were lachrymation, 
 photophobia, subconjunctival injection, commencing chemosis ; the 
 pupil was dilated; the iris somewhat discoloured. I prescribed 
 leeches in front of and behind the left ear, Ung. Hydr. c. Bell., 
 mixed with opium, to be applied to the forehead, and a full opiate 
 in the evening. The next day the patient was rather worse ; during 
 the night she had passed only a few hours in a half-dozing condi- 
 tion, without being at all refreshed ; there was less chemosis indeed, 
 but the mydriasis was greater, the aqueous humour diffilsely 
 clouded, the anterior chamber flattened, and the perception of light 
 less, so that she could no longer perceive the motions of a hand, 
 even when well illuminated ; she could, however, distinguish the 
 light and shadow of a low-burning lamp. I ordered leecheS' in 
 
IN GLAUCOMA. 835 
 
 front of the ear, a blister to the neck, the ointment to be continued, 
 and in the evening acetate of morphia. On the fourth day of the 
 disease she was somewhat more free from pain ; the objective symp- 
 toms were much the same. Prescription as before. Soon, how- 
 ever, the symptoms again became more severe. Chemosis returned, 
 the flattening of the anterior chamber and the discoloration of the 
 iris increased. Finally^ on the eighth day of the disease, the my- 
 driasis having considerably augmented, and the perception of light 
 being also so much diminished that the patient could only recognise 
 with uncertainty 'the light and shadow of a lamp burning very low, 
 I proposed iridectomy as an ultimate resource, and on the ninth 
 day it was performed. The patient's nervous system was much ex- 
 hausted through the constant pain and loss of sleep ; the perform- 
 ance of the operation also was difi&cult, owing to the sensitiveness 
 of the Uds, the rather considerable chemosis, the great flattening 
 of the anterior chamber, arid the peripheral retraction of the iris j 
 bgsides, my intention was to remove a large piece of the iris. The 
 excised piece was extremely stiff (infiltraied) . After the operation, 
 there was an immediate remission of the inflammatory symptoms>. 
 and the patient slept for the first time.. So soon as two days after, 
 an improvement could be perceived in the perception of light. The. 
 pupil contracted so as to be only moderately dilated, but remained 
 fixed ; the iris was very discoloured in spots. The retrograde pro- 
 cess of the morbid symptoms then ensued, just as in the cases 
 previously described; the perception of light gradually increased, 
 so that four weeks after the operation she could, when her back was 
 turned to the window, again perceive the motions of a hand, at the 
 distance of one to two feet. It appeared, however, if we may judge; 
 from the relative clearness of the excentrical impressions, as if the 
 external half of the retina were a httle less sensitive than the inner 
 half; yet I shall venture no decided, inference, for when there is 
 only slight difference the cataract may so dissipate the light as easily 
 to induce error: At all events, the patient's acuteness of central 
 vision must now be considered as normal, for she fixied. well, and 
 could bear, comparison with other cases of cataract.. Three months 
 after iridectomy I extracted the cataract by tha superior flap-inci- 
 sion; some corneal collapse took place during Hie escape of the. 
 aqueous humour. Although the cure was accompanied by prolapsus, 
 iridis, a very satisfactory power of vision was obtained ; she couldi 
 not only distinguish all objects, but with -|- ai could recognise 
 
336 GKAEFE ON IRIDECTOMY 
 
 No. 8 precisely, and most words of Nos. 4 and 3. The visual 
 field was of normal extent, the excentric impressions relatively 
 indistinct towards the periphery of the inner half of the visual field; 
 excentrical vision, however, withia an angle of forty-five degrees, 
 even at the inner part, of relatively normal acuteness. The optic 
 nerve showed no trace of excavation. I have watched this case for 
 nearly three months since the extraction, during which time vision 
 has constantly improved. 
 
 Resume. — Acute glaucoma in an eye previously affected with 
 cataract. Kdectomy on the ninth day. The improvement could be 
 shown by the gradual increase in the power of perceiving Hght, 
 the objective symptoms being disregarded ; restoration of vision by 
 extraction of the cataract three months after iridectomy. 
 
 Additional remark. — It must not be supposed from this case that 
 when cataracta glaucomatosa has abeady occurred, a cure could be 
 obtained by the operation. The time, when the formation of se- 
 condary cataract takes place in the glaucomatous process, always 
 lies beyond the limits, within which iridectomy affords relief; the 
 cataract was here pre-existing, thus no cataracta glaucomatosa, and 
 the case only shows that we may successfully extract a pre-existing 
 cataract in an eye which has been glaucomatous and treated by iri- 
 dectomy.' 
 
 3. Iridectomy in the later period of Acute Glaucoma. 
 
 If the curative action of iridectomy is most decisive in fresh cases, 
 still it in no way loses its importance when the disease has existed 
 for a long period. Although my observations are more numerous 
 for this group than for the preceding, still, owiag to the heteroge- 
 neousness of the results, the question has been less nearly brought 
 to a solution, and a far greater extension of study is required in the 
 future. I may temporarily set down the foUowing remarks as the 
 result of my experience. 
 
 A. A duration for many weeks, even for many months, reckoned 
 from the commencement of the first glaucomatous inflammation, 
 does not absolutely exclude complete restoration; this, however, 
 depends on the circumstances of individual cases. Sometimes the first 
 inflammations are indeed intensely acute, but yet so far of a benignant 
 nature, that in the remissions which afterwards occur, there are left 
 
IN ACUTE GLAUCOMA. 337 
 
 for a long time an almost normal power and field of vision, and an 
 unaltered papilla nervi optici, notwithstanding a little iridoplegia 
 and discoloration of the iris. These are the cases in which the 
 exact commencement of the disease cannot be clearly distinguished 
 from the premonitory stage, because the first inflammatory attacks 
 are developed by gradual augmentation of the premonitory attacks 
 of obscuration. In these cases iridectomy can produce perfect resto- 
 ration, even many months after the outbreak ; and this result we may 
 confidently expect when the field of vision and the papilla optici have 
 been normal in the remission preceding the last attack. The acute- 
 ness of central vision may at the same time be already considerably 
 diminished (see e.g. Case 8). The cures also seem to be perma- 
 nent, as in the first period. In per-acute cases the conditions may 
 be very much less favorable, even within a few weeks after the first 
 attack ; and certain terribly acute cases do sometimes occur, in which 
 the faculty of distinguishing is immediately and for ever annihilated, 
 and in which treatment, even within a few weeks, is already too late. 
 B. The prognosis is completely changed as soon as the field of vision 
 is contracted. Yet a moderate concentric contraction is relatively 
 the most favbrable ; this, however, occurs far more rarely than one 
 proceeding principally from one side. The prognosis is rendered the 
 more unfavorable by the latter, in proportion as it approaches the 
 middle line. The condition of the papilla is of equal importance. 
 In the cases where the field of vision was extremely contracted, and 
 yet the papilla was very little excavated, it is true that no perfect 
 restoration took place, but there was always considerable improve- 
 ment, especially in the acuteness of vision, generally also in the 
 visual field, which occasionally (see Case 9) attained a fourfold ex- 
 tension. Such improvements were usually permanent. If, on the 
 other hand, there is weU-marked excavation of the optic nerve, with 
 great contraction of the field of vision — and this is unfortunately 
 the most common case — I cannot sufficiently warn my readers from 
 too sanguine expectations. Whether the lesion of the optic nerve, 
 when once induced, becomes substantially further developed or not, 
 after the cause has been removed, seems to depend on accidental cir- 
 cumstances, which cannot be calculated. The immediate effect of 
 the operation seemed in most cases favorable ; in a great number there 
 was not only improvement in the acuteness of central vision, but also 
 widening of the visual field; but only in some cases did this improve- 
 ment continue, in others the power of vision again diminished. 
 
 22 
 
338 GRAEFE ON IRIDECTOMY 
 
 It requires long-continued observation to decide as to the final 
 result in such cases^ but this much may now be said, that the results, 
 when excavation of the optic nerve has once been induced, are 
 extremely various and temporary. Successes often entirely vanish 
 again. Still some cases remain of a very satisfactory nature, and it 
 must be allowed that iridectomy, even under such circumstances, is 
 more beneficial than any other means, though often also it may 
 only succeed in delaying the blindness. If the field of vision is 
 already very excentric, we should no longer count on any con- 
 siderable improvement, a decision which is more true in regard to 
 the later stage of acute glaucoma than with reference to the chronic 
 form (see Case 13). Eapidly progressive forms were even yet occa- 
 sionally arrested, so as to induce a stationary condition. I suspect, 
 however, that it is never more than temporary. In no case where 
 the quantitative perception of light was abolished, did any trace of 
 a power of distinguishing reappear. 
 
 c. Tenseness of the globe, iridoplegia, ansesthesia of the cornea, 
 and flattening of the anterior chamber, are, cateris paribus, favora- 
 ble, because they prove that the diminished power of vision is yet to 
 some extent to be referred to increased pressure, on which iridec- 
 tomy has always a favorable action. The same thing is almost true 
 of the haziness of the aqueous humour and vitreous body. Even 
 if it is to be considered as a subordinate factor in regard to the 
 blindness, stiU it is a proof that the process of secretion is yet 
 active, and as such it is a favorable sign. 
 
 D. If, when the lesion is of old date, the improvement obtained 
 by iridectomy is not permanent, still the diminution of vision at a 
 later period is not accompanied by the symptoms of a fresh glauco- 
 matous choroiditis, and hence we ought not to speak of it as 
 a relapse of the original lesion. We have rather, then, the 
 general appearance of a progressive amaurosis, with contraction of 
 the visual field. The substance of the optic nerve becomes whiter 
 and less transparent, the arteria centralis smaller, eveif the excava- 
 tion of the optic nerve seems in some cases to increase.^ Since 
 
 ' Of an actual increase in the excavation after the performance of iridec- 
 tomy, I only possess two examples. Perhaps this result may be thought an 
 objection to the theory, which has been formed as to the origin of the excava- 
 tion of the optic nerve ; it may be said, that if the excavation of the optic 
 -nerve is actually produced by the intra-ocnlar pressure, normalising of the latter 
 must also occasionally produce a restoration of the form of the nerve, and at 
 
IN ACUTE GLAUCOMA. 339 
 
 changes in the internal membranes and opacities of the refractive 
 media, and such symptoms as attest increased pressure, are not 
 superadded, the continued development of the lesion of the optic 
 nerve must be considered as the cause of the blindness. I have 
 met "with but one instance in which the ulterior deterioration 
 again took place under symptoms of increased internal pressure. 
 This was in the case of Madame Sack, from Yienna, a lady of about 
 forty years of age, whose eyes had been attacked by glaucoma some 
 months previously. On both sides the optic nerve appeared much 
 excavated; on the left side only, there existed an excentric field of 
 vision ; on the right side the field of vision was a little contracted, 
 yet there stiU was central fixation and moderate power of vision. 
 The symptoms of increased pressure were well marked, and proved 
 very obstinate, for on the left side a coloboma, formed by iridec- 
 tomy, was obliged to be enlarged still further by a second operation, 
 on account of the imperfect immediate result. At first the same 
 efPect as in the other cases appeared to be induced, but after six 
 weeks the subconjunctival veins appeared more prominent, the globe 
 became more tense, the cornea less sensitive, the pupil larger, the 
 retinal veins broader and serpentine, the excavation more marked, 
 the power of vision weaker, the field of vision narrower, and thus 
 again the case presented the symptoms of chronic glaucoma. This 
 is the only case I have met with where subsequent deterioration 
 depended on an actual recrudescence of the glaucomatous process, 
 and have reason to believe that a still more extensive excision of 
 the iris might have had better success. 
 
 E. In all cases of glaucomatous blindness, even where this disease 
 
 all events must prevent an increase of the excavation. Of course it would be 
 still more decisive as to the correctness of my views, if after iridectomy even 
 the excavation of the optic nerve disappeared together with the other symp- 
 toms of pressure. Unfortunately, I have hitherto been unable to convince 
 myself of this in any case ; on the other hand, that the optic papilla ought to 
 recover from the form which it has once obtained cannot be necessarily deduced, 
 either from physical or from anatomical considerations. Neither can the 
 increased excavation of the optic nerve, which sometimes occurs after diminu- 
 tion of the pressure, anymore demonstrate the falsity of the theory than a case 
 of partial staphyloma, which becomes worse in spite of iridectomy, can dis- 
 prove the participation of intra-ocular pressure in the pathogenesis of this 
 disease. It may very well be imagined, that when the substance and resistance 
 of the Optic nerve are once changed in a certain manner, pressure of the ocular 
 fluids, even to a normal amount, is relatively too great. 
 
340 GRAEFE ON IRIDKCTOMY 
 
 has run its course, iridectomy has still the advantage of relieving 
 any existing inflammatory symptoms and ciliary neuroses. He who 
 knows the agony which the patients sometimes suffer for a long 
 period of years through these blind eyes, wiU greet even this action 
 of iridectomy with a hearty welcome ; it renders it superfluous to 
 treat such patients by frequent bloodletting and narcotics, which 
 formerly were often unavoidable, even when they were contra-indi- 
 cated by the general condition, by the age, &c. Mnally, it is known 
 that during the ulterior course of the glaucomatous process, pecu- 
 liar softenings and ulcerations of the cornea are occasionally caused 
 through its anaesthesia. Iridectomy may also act favorably in this 
 respect, partly owing to the restored conduction of the corneal 
 nerves, and partly because the diminution of intra-oculax pressure 
 seems generally advantageous in corneal infiltrations. 
 
 Case 8. — A workman, named Knrz, of Berlin, set. 6i, presented 
 himself, in the middle of September, 1856, for the first time, at my 
 clinic.^ Since the winter months of 1855-6 he had had, from time 
 to time, blue spectra before his eyes, he had seen rainbows around 
 the candle, and when he fixed an object whilst in this state, or 
 exposed the eye to the light, the coloured spectra revolved, like a 
 wheel, in the field of vision, and the sight became so dim that he 
 could no longer recognise even large print. After a night of good 
 sleep vision was always perfectly acute again. These attacks, were 
 gradually repeated at shorter intervals, and were of constant occur- 
 rence when the eye was exposed to any exertion, or a night was 
 passed without sleep. In August, 1856, inflammation first occurred 
 in the left eye, as a consequence of which vision diininished with 
 considerable rapidity. On the right side, according to the account 
 of the patient, the acuteness of vision had also diminished during the 
 intervals between the obscurations ; still an examination showed that 
 this statement had altogether reference to an increase in the pres- 
 byopia. On admission, there was found on the left side an already 
 well-marked, acute glaucoma, and tolerably decided symptoms of 
 pressure ; on the other hand, at that time, only slight turbidity of 
 the refractive media, the papiUa not yet excavated, the power of 
 vision much diminished and a little varying, because the exacerba- 
 tions and remissions were still well marked. On an average, the 
 
 ' As this occurred during my absence, the journal was kept for the first six 
 weeks by my assistant. Dr. Alfred Graefe. 
 
IN ACUTE GLAUCOMA. 341 
 
 patient could count fingers at tlie distance of eight feet, and with 
 + 6 recognise words of 'No. i6. Vision distinctly diminished 
 during the derivative treatment, which was employed for the next 
 two months ; the obscurations on the right side became also more 
 intense, and each time induced some dilatation of the pupil and 
 cloudiness of the aqueous humour. When I saw the patient, in 
 the beginning of November, there were on the left side great mydri- 
 asis, discoloration of the iris, and considerable diffuse cloudiness of 
 the refractive media, so that it was with some difficulty that I satis- 
 fied myself of the normal form of the optic papilla. The patient 
 counted fingers at the distance of six feet, and, provided with + 6, 
 recognised with difficulty words of print No. ao. The field of vision 
 was perfectly normal. After the performance of iridectomy, on the 6th 
 of November, the pupil on the left side contracted to a medium size ; 
 remained, however, perfectly fixed ; the iris was very much altered, 
 the refractive media cleared in the usual manner, and the vision con- 
 tinually improved, so that the patient could already count fingers at 
 the distance of fifteen feet, on the i ath of November, and recognise 
 with -f 6 words of No. 13, and large letters of No. 10. The further 
 recovery was much delayed by an attack of granular conjunctivitis, 
 which was prevalent at that time in Berlin. In February, 1857, 
 the patient, provided with + 6, could read No. 8 precisely, and 
 No. 5 with errors; in March, No. 6 precisely, and words of No. 3. 
 I may remark, that soon after the operation on the left eye 
 acute glaucoma broke out in the threatened right eye, and that in 
 consequence iridectomy was performed within a few days. The cure 
 of this eye ensued, so far as a normal acuteness of vision, just as in 
 the cases previously related (See Part II) . 
 
 The comparison of the two eyes proved decisively in favour 
 of the right one, for it regained greater acuteness of vision, some 
 action of the pupil, and a tolerably extensive accommodation. In 
 the eight months following the operation, during which I examined 
 the patient at regular intervals, there occurred neither premonitory 
 nor any other morbid symptoms, although the patient exposed him- 
 self to various noxious infiuences (especially night-watching). 
 
 Besiime. — Acute glaucoma, which had broken out after a pre- 
 monitory stage of half a year, and existed for two months and a 
 half; the optic nerve and field of vision normal; the power of dis- 
 tinguishing, for two . months already, very much diminished ; resto- 
 ration by iridectomy of a satisfactory, although not perfectly normal 
 
343 GRAEFE ON IRIDECTOMY 
 
 acuteness of vision (duration, eight months). Outbreak of acute 
 glaucoma in the second eye a few weeks after the operation on the 
 first one ; perfect cure by iridectomy, performed shortly after the 
 outbreak (eight months' duration). 
 
 Case 9. — Wilhelm Hoefler, of Berlin, set. 71, whose right eye 
 has been already mentioned {suh I, Case i), came to my clinic on 
 the 15th of February, 1857. Tor a year and a half he had re- 
 marked coloured rings about the flame of a light, and since Decem- 
 ber, 1856, weak vision of the right eye; it is possible that this 
 existed at an earlier period, for it was by violent pains in the right 
 side of the forehead and temple that he was first compelled to test 
 this eye. With the pains, which never passed beyond the middle 
 line, there occurred at the same time photophobia and lachryma- 
 tion ; at first there was some improvement during the remissions, 
 which at that time occurred periodically, but never perfect restora- 
 tion of vision ; in short, it had been continually diminishing during 
 the months of January and Pebruary. The examination showed 
 the general appearances of an acute glaucoma in its later stage — 
 tolerable dilatation of the subconjunctival vessels, corneal sensi- 
 bility here and there almost lost, aqueous humour diffusely turbid, 
 iris discoloured, pupil dilated, anterior chamber flattened, bulb 
 tense — owing to the haziness of the refractive media, the background 
 of the eye could not be examined — violent ciliary neuroses, vision 
 almost extinguished, central fixation abolished ; the patient fixed a 
 hand with uncertainty, the visual axis passing to the inner side, so 
 that he could still count fingers with the inner half of the retina, 
 with good illumination, at the distance of one foot, although occa- 
 sionally he was wrong. An accurate functional examination, which 
 was very troublesome, owing to the slight power of distinction, 
 showed that the inner half of the visual field was altogether defi- 
 cient ; that the (central) point of fixation lay just on the edge of the 
 portion which still possessed the power of vision, but that it only cor- 
 responded to a very dull quantitative perception ; that the region of 
 vision, stretching from here outwards had, measured at the dis- 
 tance of one foot, a breadth of thirteen inches, and a height which, 
 reckoned from within to without, increased from two and a half 
 inches to eighteen. But within this field of vision there was only a 
 little space which yet allowed a tolerable qualitative perception of 
 light, and this space corresponded, as may be deduced from the 
 
IN ACUTE GLAUCOMA. 3i3 
 
 first-mentioned trials of vision, to an excentric portion of the 
 retina, which was situated pretty nauch on the inner side. Iridec- 
 tomy was performed on the 17th of February; the ciliary neuroses 
 were immediately relieved, so that the patient slept well, a result 
 which could not be obtained by opiates during the previous days. 
 The habitus of the eye gradually experienced a favorable change, the 
 symptoms of irritation entirely ceased, the come recovered its normal 
 sensibility, the pupil became somewhat smaller, yet without action, 
 the iris remained moderately discoloured, the refractive media cleared 
 so rapidly that even six days after the operation the background of 
 the eye could be examined. This showed very abundant retinal 
 ecchymoses, and the optic nerve slightly excavated. On the a^th of 
 February the state of vision was accurately examined ; the patient 
 already counted with certainty fingers at the distance of six feet, 
 and indeed he sometimes employed central and sometimes excentral 
 fixation, testing to some extent the advantages of the two. Hence 
 it appeared that a striking change had already occurred in the 
 visual field. I found by mensuration that the point of fixation, cor- 
 responding to the centre of the retina, lay already within the field 
 of vision, and indeed about an inch more externally than the margin ; 
 the breadth was (always measured at the distance of a foot) eighteen 
 inches ; the height, in a vertical line, passing through the point of 
 fixation, twelve inches, at the most external limit twenty inches, 
 fourteen days later the patient counted fingers at th& distance of 
 eighteen feet, and always fixed with the normal line of vision ; the 
 field of vision passed inwards beyond the point of fixation about an 
 inch and a half, and the form, which was now again copied, had 
 essentially changed since the previous examination ; in place of its 
 former similarity to a trapezium running externally in a divergent 
 direction, it had now almost the form of a square. The breadth 
 amounted to twenty-six inches (previously thirteen inches) ; the 
 height, along a vertical line drawn through the point of fixation, 
 twenty-four inches (previously two and a half), which increase re- 
 mained nearly unchanged as far as the external limit (previously 
 eighteen inches) ; in short, the field of vision was four times as large 
 as originally. In the beginning of April the retinal ecchymoses 
 had disappeared; the patient counted fingers at the distance of 
 twenty-five feet or more; read with -l- 6 No. 11 precisely, some 
 words of No. 7, and even of No. 5 ; the field of vision was as in 
 the last examination, except that it was again somewhat broader. 
 
344 6RAEFE OlS IRIDECTOMY 
 
 During the months inunediately following, everything remained 
 much in the same condition, and not the least symptom of glaucoma 
 recurred. On an examination made in July, I found the range for 
 large objects pretty much as in April, but the recognition of print 
 more difficult ; provided with + 6, he could no longer recognise 
 words of No. 5 (without distinct change of accommodation), and even 
 very few words of No. 8. The excavation of the optic nerve had 
 not in the least increased. In the month of August no further de- 
 terioration had occurred in the acuteness of vision ; the visual field 
 had remained at exactly the same degree of improvement, yet it is un- 
 certain whether a further diminution of vision will not ultimately 
 occur. In the mean time the left eye was operated on before the 
 premonitory stage had concluded, and with perfectly satisfactory 
 and permanent success. (See Case i.) 
 
 Eesume. — Acute glaucoma, which had existed at least two 
 months, a premonitory stage of a year and a haK having preceded 
 it. Slight excavation of the optic nerve, very great contraction of 
 the visual field ; the point of fixation was, in fact, on the margin of 
 the field of vision ; there was, however, excentrical fixation ; there 
 only yet remained a slight power of distiuguishing. After iridec- 
 tomy, clearing of the refractive media, retrogression of the symp- 
 toms of pressure, more than fourfold extension of the field of vision, 
 and restoration of central fixation. Pour months later slight dimi- 
 nution of the acuteness of central vision, without deterioration in 
 respect to the visual field; hence the final result cannot yet be 
 definitely stated. 
 
 4. Irideciomy in Chronic Glaucoma. 
 
 Although it was to cases of this group that I first applied iridec- . 
 tomy, I am still unable to make any decided statement as to the 
 manner in which they ultimately end. Finding among my observa- 
 tions some instances where considerable improvement followed the 
 operation, which remained at the same degree for a period of three 
 months, and then again deteriorated (see Case 10), it is obvious 
 that the utmost precaution is required in admitting a permanently 
 curative effect. I can only state this much, as the result of the 
 trials hitherto made — that iridectomy exerts a temporarily favor- 
 able influence, even in chronic glaucoma, and that its degree and 
 
IN CHRONIC GLAUCOMA. 345 
 
 duration depend on individual circumstances. Since this therapeutic 
 action of the operation is at all events superior to the curative effect 
 of any other method of treatment, it is our duty to continue and 
 vary our observations, and we hope to be assisted in the attempt 
 by many of our colleagues. 
 
 In general, the prognosis seems to depend on the same factors in 
 the present case as in the later stages of acute glaucoma. Contrac- 
 tion of the visual field and excavation of the optic nerve render the 
 prognosis worse, but do not unconditionally destroy the hope of a 
 favorable influence, or of the arrest of the affection, which had till 
 then progressed; it even appears, from my cases, that great con- 
 traction of the visual field is of less importance in chronic than in 
 acute glaucoma, so that considerable improvement is sometimes 
 found, even when the field of vision is very excentrical and sht- 
 shaped (see e.g. Case 13). There is generally less hope of a com- 
 plete cure from the circumstance that excavation of the optic nerve 
 is developed in chronic glaucoma at a relatively early period. Hence 
 a very early diagnosis of the affection is of essential importance. 
 This is not so easy as in acute glaucoma, where it is announced by 
 the first inflammatory attack with iridoplegia, whilst in the present 
 case the external symptoms are often limited for a long time to a 
 very slight turbidity of the aqueous humour, inactivity of the pupil, 
 and a little flattening of the anterior chamber ; and yet even in this 
 period the lesion of the optic nerve occurs. The more the symptoms 
 of increased pressure are distinct at the time of the operation, the 
 more may, cateris paribus, be expected from iridectomy. We need 
 not be alarmed at the duration of the affection, for I have occasion- 
 ally seen considerable improvement after a lapse of many years, 
 improvement which has lasted to the present moment. The aspect 
 of the eye also lost its glaucomatous appearance, the refractive media 
 always became again transparent, the globe returned to its normal 
 hardness, any existing cihary neurosis ceased, retinal ecchymoses 
 were generally presented, although to a less extent than in 
 acute glaucoma; the structural changes of the iris were, on the 
 average, less than in the acute form ; the pupil became more con- 
 tracted, and often recovered moderate mobility, effects which prin- 
 cipally depended on the minor participation of the iris. Excavation 
 of the optic nerve, when once well marked, did not again disappear. 
 
 Case 10. — Prau Hoffmann, of Berlin, set. 57 years, presented 
 
346 GRAEFE ON IRIDECTOMY 
 
 herself at my clinic on the 4th of November, 1856. Tor a long 
 series of years she had suffered from pains in the head, especially in 
 the forehead, from " rheumatic twitchings in the limbs," and want of 
 sleep. Por six years she had remarked coloured vision and periodi- 
 cal obscurations of the left eye ; for four years the vision of this eye 
 had gradually diminished, without any inflammatory symptoms 
 having ever occurred. Fear for the right eye, which now also 
 suffered from periodical obscurations, had brought her to me. At 
 the time of her first visit, there were on the left side aU. the symp- 
 toms of chronic glaucoma ; the subconjunctival veins were dilated, 
 the cornea rather insensible, the anterior chamber flattened, 
 the aqueous humour slightly turbid, the pupil dilated and fixed, 
 the iris a little discoloured, the optic nerve much excavated. She 
 counted fingers at the distance of two feet in a seeking manner, but 
 soon became tired ; with convex glasses she recognised nothing of 
 print No. 20 of Jager's specimens ; the visual field was much con- 
 tracted, and on every side ; externally the opening was only about 10°, 
 in other directions decidedly more, yet an accurate hmitation was 
 very difficult, owing to her accounts varying. This visual power, 
 observed for six days, proved perfectly constant. Iridectomy on the 
 joth of November. On the 15th of the same month she counted 
 fingers four feet off with certainty and better fixation, she deciphered 
 with + 6 words of No. 16, and even of No. 14. On the a4th of 
 November she counted fingers at sixteen-feet distance, read No. 1 1 
 word by word, and recognised a few letters of No. 4. The visual 
 field had decidedly a little extended, the opening outwards was 
 now about 20°, but it was stdl very contracted, so that, measured at 
 the distance of a foot, the transverse diameter was fourteen inches, 
 the vertical diameter but little more ; the external morbid symptoms 
 had perfectly retrograded, and the refractive media had cleared and 
 allowed the recognition in detail of very far-advanced excavation of 
 the optic nerve ; the anterior chamber had become distinctly deeper ; 
 the pupil showed a trace of mobility; the subconjunctival veins had 
 perfectly retrograded; scattered retinal ecchymoses were already dis- 
 appearing. The improvement of the visual power kept at the same 
 degree for almost three months. On the 21st of February, 1857, a 
 fresh diminution of the sight was first discovered ; she could no 
 longer recognise any of No. 4, and No. 11 only by syllables 
 and with errors. The visual field also showed a distinct contraction, 
 which proceeded principally along a diagonal, directed downwards 
 
IN CHRONIC GLAUCOMA. 347 
 
 and inwards from above and without. Vision diminished till the 
 end of April ; on the a6th April she could recognise fingers at eight- 
 feet distance only, read No. i6 precisely, most words of No. 14, 
 scattered syllables of No. 11, and nothing of No. 8. The external 
 appearance of the eye had remained the same ; even in the excava- 
 tion of the optic nerve I could find no difference, except that the 
 substance of the nerve seemed to me to have become a little whiter 
 and less transparent, and the trunks of the retinal arteries a httle 
 smaller. I now thought that it would advance progressively to 
 blindness; from that time, however, tiU. August, 1857, the condition 
 has remained exactly the same, so that the patient continues to 
 possess, nine months after the operation, considerably better sight, 
 and a somewhat larger field of vision, than before it was performed. 
 In the mean time, the glaucoma which was already threatening in 
 the right eye broke out in the acute form. Iridectomy was imme- 
 diately performed with the best result, which has lasted so far (seven 
 months) . 
 
 EesiimS. — Chronic glaucoma, of many years' standing, with ad- 
 vanced excavation of the optic nerve, contraction of the visual field, 
 uncertain fixation, and extremely reduced power of vision. Soon 
 after iridectomy, considerable improvement of vision and distinct 
 extension of the visual field. After the improvement had lasted for 
 three months, fresh deterioration, without glaucomatous symptoms ; 
 which, after progressing for four weeks, attained its present degree, 
 and left, nine months after the operation, considerably improved 
 sight in comparison with the original condition. 
 
 Case ii. — I'rau Lichtenstadt, from Breslau, set. about 50 years, 
 first consulted me in the summer of 1855. The left eye had become 
 perfectly blind from acute glaucoma many years ago; there had 
 occurred also on the right side, for a long time, periodical obscu- 
 rations, frontal pains and chromopsise, and for about a year the 
 vision had gradually diminished, without inflammatory symptoms. 
 Examination showed chronic glaucoma, with moderate contraction 
 of the visual field and some diminution of the acuteness of central 
 vision. Since I was not at that time aware of the curative action 
 of iridectomy, other methods of treatment were followed, and the 
 prognosis given to her relations was that the case was almost hope- 
 less. In August, 1 856, the patient came again. In the meantime 
 the disease had considerably advanced, at the sam& time preserving 
 
348 GRAEPE ON IRIDECTOMY 
 
 its former (not inflammatory) character ; the pupil was very much 
 dilated, the iris being at the same time relatively but little changed 
 in structure ; the anterior chamber was flattened, the aqueous humour 
 turbid, the cornea almost insensible, the bulb tense; there were periodi- 
 cal ciliary neuroses ; the papilla optici was considerably excavated. 
 Vision was now almost extinguished; it was with difficulty she could 
 count fingers, and with +12 decipher a few words of No. 16 of 
 Jager's specimens in a seeking manner. The field of vision was 
 only a narrow slit, and, owing to the unstable fixation, could not be 
 exactly limited. Iridectomy having been performed, there at once 
 occurred the favorable change in the external habitus of the eye 
 which has been so many times described ; notwithstanding the long 
 duration of the disease, the cornea recovered its sensibility, and the 
 pupil to some extent its action. The latter also became considerably 
 smaller than it had formerly been, the ciliary neuroses ceased, the 
 refractive media cleared, &c. Vision much improved, so that she 
 could count fingers with certainty at four- to six-feet distance, with 
 -f- la read some hnes of No. 14 precisely; finding objects was of 
 course difficult, owing to the narrow visual field; but when once 
 within the range of sight, they were now fixed more firmly than 
 formerly. Owing to this fortunate change an accurate determina- 
 tion of the visual field became possible. That this had extended, 
 was evident from her being able to find her way about, though yet 
 only with difiiculty. The field of vision for qualitative per- 
 ception described an elliptical figure, the major axis (measured at 
 the distance of a foot) being seven inches, the minor three inches ; 
 around this space there existed in a tolerably broad zone quantitative 
 perception of light. The patient left Berlin a few weeks after the opera- 
 tion, and I received further information through the .kindness of 
 Poerster in Breslau. In December, 1856, the improvement in the 
 objective symptoms had perfectly continued. With -f- 16 she could 
 recognise correctly some lines of No. i^ ; the visual field had not be- 
 come smaller, but had approximated more to a round form, the major 
 diameter having diminished from seven to six inches, the minor, on 
 the other hand, having increased from three to five inches. Cor- 
 respondingly, she continued to have so great difiiculty in find- 
 ing her way, that she was stiU obliged to be led in the streets. 
 She suffered during the winter months much mental aflliction, and 
 repeatedly watched at night by the bed-side of a sick daughter, un- 
 favorable circumstances which had formerly caused immediate 
 
IN CHRONIC GLAUCOMA. 349 
 
 deterioration. Ciliary neuroses did not again occurs and even the 
 occasional pains in the head were usually restricted to the side which 
 had not been operated on.' In the spring of 1857 I again heard of 
 her, much to the same effect. 
 
 Resume. — Chronic glaucoma for many years in one eye, after 
 glaucomatous blindness of the other eye had already ensued. Iri- 
 dectomy shortly before abohtion of vision (to be supposed according 
 to the previous development), the visual field being contracted in 
 the form of a slit, and the excavation of the optic nerve beiQg of 
 moderate degree. Eetrograde process of the glaucomatous symptoms ; 
 slight (and immeasurable, owing to the uncertainty of fixation before 
 iridectomy) enlargement of the visual field, moderate increase of the 
 visual acuteness and continuance of this improvement for niae 
 months. 
 
 Case 13. — Carl Wagner, of Berlin, aet. 58 years, presented him- 
 self on the aoth of April, 1857, at my cUnic. The right eye had 
 been perfectly blind for a year in consequence of a chronic glaucoma, 
 which had broken out seven years ago, and which still continued 
 to induce very troublesome ciliary neuroses. On the left side there 
 occurred, four years ago, periodical cib'ary neuroses, chromopsiee, 
 obscurations, and then, even in the intervals, weak vision. Especi- 
 ally during the last six months had the power of vision distinctly 
 diminished, and even the patient had remarked the contraction of 
 the visual field, passing from the inner side and rapidly progressing. 
 There had been no infiammatory symptoms. On examination, we 
 found on the left side the complete type of chronic glaucoma : the 
 aqueous humour diffusely turbid, the pupil dilated and almost 
 motionless, the iris but little discoloured, the optic nerve much 
 excavated, arterial pulsation, however, only occurring when the finger 
 was gently applied, the central vessels more than usually displaced, 
 and the retinal veins very large. With + 6 the patient could 
 recognise No. 8 tolerably well, words of No. 4, nothing whatever of 
 No. a ; the visual field was contracted from above and outwards 
 
 • Dr. Foerster related, that objects in the street still constantly appeared to 
 the patient as though they were covered with snow. I have often received a 
 similar statement in excavation of the optic nerve, and the symptom, in my 
 opinion, is directly to be referred to the existing lesion of the optic nerve, and 
 to be carefully distinguished from the glaucomatous chromopsise, which favour 
 the view of increased pressure. 
 
350 GRAEFii ON IRIDECTOMY 
 
 almost a fourth. It was accurately copied in my journal. On tjie 
 aytli April I performed iridectomy in both eyes^ only for the ciliary 
 neuroses, of course. On the left side the external symptoms 
 of disease retrograded as in other cases. Since that time there 
 have not occurred either ciliary neuroses or chromopsise and 
 increased obscurations. Fourteen days after the operation the 
 acuteness of vision was still a little less than previously, which was 
 explained by a few retinal ecchymoses. On the ayth May the 
 patient read with + 6 No. 8 with difficulty, yet precisely, and 
 recognised most words of 4 and 3. Hence the visual acuteness had 
 at least recovered its former degree, and the drawing of the visual 
 field agreed exactly with that taken before the operation. Things 
 continued the same tiU the i8th of August, when the last examination 
 took place. On the right side there was of course no influence on 
 vision ; the ciHary neuroses were cured. 
 
 ResumS. — Chronic glaucoma, inclusive of the premonitory stage, 
 which cannot be limited by the history, existing for four years, with 
 some diminution of the visual acuteness, and considerable contrac- 
 tion of the visual field; the disease rapidly progressive for the last 
 few months. After iridectomy, cessation of the periodical deteriora- 
 tions, and preservation of the existing vision (since four months). 
 
 Case 13. — ^Frau Hauptmann Beinlich, from Pless, in her fortieth 
 year, consulted me in March, 1857. The left eye had many years 
 before become very weak, and gradually bHnd, without symptoms of 
 inflammation. On the right side there had occurred, also many years 
 ago, periodical obscurations and, for more than a year, increasing 
 weakness of vision, so as now only to leave slight power of dis- 
 tinguishing. On examination, I found on both sides the weU-marked 
 appearances of chronic glaucoma : the globes tense, the subconjunc- 
 tival veins on the left side enlarged, the cornese on both sides very in- 
 sensible, the aqueous humour slightly turbid, the pupils much dilated, 
 on the left more than the right side, on both sides perfectly fixed, of 
 a greenish appearance; the anterior chamber flattened, the iris in 
 spots very discoloured and atrophied. The ophthalmoscope showed 
 on the left side (atrophic) choroidal changes in the equatorial region ; 
 the back-ground of the eye on both sides was indistinct ; on the left 
 side even some floating opacities of the vitreous body could (against 
 the rule) be distinguished ; the optic nerve was on both sides very 
 much excavated; on the right side, after a longer observation, inter- 
 
IN CHRONIC GLAUCOMA. 351 
 
 current arterial pulsation could be perceived; on the left side the 
 examination of the vessels passing into the papilla was very difficult, 
 owing to the opacity of the vitreous body ; it even seemed as though 
 in the very fossa of the optic nerve there lay a peculiar dull sub- 
 stance, functional examination showed on the left side only a trace of 
 quantitative perception of light; on the right side fingers could yet be 
 counted as far off as three to four feet, and letters of No. ao re- 
 cognised. The field of vision was extremely contracted, and formed 
 a small sHt; it was already very excentrical; measured at a foot, it 
 began at two inches outwards from the point of fixation; the point 
 of relatively most distinct vision was stiU more excentrical, so that 
 the patient during the trials of vision directed the visual axis at a very 
 distinct angle inwards. The horizontal extent of the visual field was 
 (measured at a foot) about six inches ; the vertical, two and a-half to 
 three inches. Iridectomy was immediately performed on the right side, 
 and a slight improvement of vision took place immediately after the 
 operation. The following day there was a slight effusion of blood 
 into the anterior chamber. The compressing bandage was carefully 
 continued tiU reabsorption. Eight days after the operation the 
 following results were apparent: the globe less tense, the cornea, 
 however, yet very insensible ; the aqueous humour clear, the anterior 
 chamber less flat, the pupil less dilated, of tolerably normal hue, 
 fixed however ; the periphery of the iris generally discoloured, the 
 ocular background distinct, the excavation of the optic nerve as 
 before, arterial pulsation extremely seldom and after definite exciting 
 causes. The vision had clearly improved, the patient could count 
 fingers to the distance of ten feet, and recognise words of No. i6, 
 and the comparative readiness with wliich she discovered objects 
 made us suspect an extension of the visual field. Mensuration 
 showed that the field of vision had not indeed extended towards the 
 point aimed at (Visirpunkt), but that in the direction outwards it 
 had nearly a double, and in a vertical direction almost a quadruple 
 opening. Since the case seemed to me of dogmatic importance, the 
 measures were taken before and alter the operation (as a mutual check) 
 at three different distances — one, four, and eight feet. At the distance 
 of eight feet the patient could now survey more than the height of a 
 man, whilst formerly she could scarcely include in her range the head 
 and half the breast at the same time. Although more exact trials 
 showed that in a great part of the visual field which had now been 
 gained there was only an extremely dull perception, still she could find 
 
352 
 
 GRAEFE ON IRIDECTOMY. 
 
 her way (Orientiring) decidedly better, as lias been akeady pointed out. 
 The excentric fixation had remained just the same. Iridectomy was 
 performed on the left side a little later, not with the least idea of resto- 
 ring vision, but simply on account of the other glaucomatous symp- 
 toms; a rather considerable effusion of blood into the anterior 
 chamber having been reabsorbed, we found a little increase of the 
 quantitative perception of light, besides clearing of the vitreous 
 body with the exception of some floating opacities, clearing of the 
 aqueous humour, diminution of the tenseness of the globe and of 
 the pupillary dilatation. According to a report (medical) received 
 three months later, the vision has remained the same. 
 
 Resume. — Chronic glaucoma of more than a year's duration, with 
 advanced excavation of the optic nerve, and a visual field in the 
 form of a sht, excentric outwards. After iridectomy, retrogression 
 of the glaucomatous symptoms, distinct increase in the visual 
 acuteness, considerable extension of the visual field, but continuance 
 of excentric fixation (present duration, three months) . 
 
 5. Iridectomy/ in Amaurosis with excavatioi of the optic nerve. 
 
 Since I have assigned another cause than glaucoma as an expla- 
 nation of the cases belonging to this group, it may appear strange 
 that I have still tried iridectomy also in it. There were two reasons 
 that induced me. In the fijst place, I expected to find in the com- 
 parison of the curative effects, arguments for the correctness or in- 
 correctness of my nosological views, and besides, even the view of a 
 positive lesion of the optic nerve would not prove the powerless- 
 ness of a certain action of iridectomy. Such a striking, direct effect, 
 as, e. g. in acute glaucoma, could, of course, never be expected from 
 a pressure-diminishing process, when the optic nerve is primarily dis- 
 eased. The optic nerve is, however, constantly exposed to the pressure 
 of the contents of the globe, and this pressure might possibly have some 
 influence on the development of a lesion of it, through limiting the 
 change of tissue, or in some other and unknown way ; it might 
 render the disease constantly progressive, &c. It might then, per- 
 haps, be of use to diminish the pressure to less than its normal 
 amount. If we suppose (to remain witliin the bounds of these sup- 
 jiositions) the substance of the optic nerve softened through any in- 
 ternal process, the papiUa will then yield in an abnormal manner 
 
DETAILS OF THE OPERATION. 353 
 
 to the noimal pressure^ and even if the primary affection is in itself 
 susceptible of cure, still the protruded form of the papilla, and the 
 mechanical and trophic alterations which are connected with it, 
 might impede the restoration of its functions. 
 
 I should certainly have left unmentioned these hypotheses, which 
 at the time far surpassed the facts, had they not induced trials of 
 iridectomy in primary excavation of the optic papilla, and that 
 I wish fuUy to explain the motives wliich led to this course. 
 I can comprise the results of my essays in the statement, that 
 I never observed any special curative action of iridectomy in 
 amaurosis with excavation of the optic nerve, and that I never saw 
 an improvement in the visual acuteness or extension of the field of 
 vision, beyond the limits of possible variations and of errors of 
 observation. The separation of this morbid group from glaucoma 
 is in reality favoured by the effects of the treatment, — a point of 
 view not to be disregarded in so dark a branch of nosology. 
 
 Another question is, whether a stationary condition is sometimes 
 induced by iridectomy in cases of progressive amaurosis with ex- 
 cavation, the diminution of intra-ocular pressure allowing the 
 spontaneous or therapeutical arrest of the lesion of the optic nerve. 
 "With reference to this, I am continuing my investigations, but 
 believe it will require some years to arrive at any conclusion, since 
 the spontaneous changes in amaurosis with excavation of the optic 
 nerve are so slow, that there is often scarcely any alteration in 
 periods of three to six months. In these cases, a stationary 
 condition is sometimes apparently induced by other methods of 
 treatment. Though this arrest occurs, indeed, without any prognos- 
 tical certainty, still it forms a distinction from the glaucomatous 
 process, which constantly progresses, either by starts or by a slow 
 advance. Por the same reason the communication of reports of 
 cases taken from this group, would be out of place. 
 
 IX. — I have but few words to add about the operation itself. 
 The object is to excise a piece of the iris by the same proceeding 
 as is customary in forming an artificial pupil by means of iridectomy. 
 The following points must be specially considered : 
 
 I. The incisions must be situated as excentrically as possible, so 
 that the external wound may enter the sclerotic about half a line 
 from the cornea, and the internal one just at the junction of the 
 two. It is possible, in this way, to remove the iris as far as its 
 
 23 
 
d54 GRAEFE ON IRIDECTOMY. 
 
 ciliary attacliment, and this seems to be necessary for success, 
 at all events it renders it more certain. Since also the iris 
 occupies only a small space, owing to the existing mydriasis, any 
 deviation of the inner wound fccm the corneal periphery wiU 
 very considerably diminish the size of the excised piece. 
 
 a. The excised piece must be as large as possible, and hence a 
 broad lance-shaped knife must be employed, or the ordinary one be 
 introduced tolerably far. In this the operation differs from that for 
 the fotoation of an artificial pupil {e. g. in leucoma adhserens), where, 
 as every one knows, excisions of moderate extent are, for optical 
 reasons, preferable to extensive ones. The more intense the symp- 
 toms, the more marked the increase of pressure, the more extensive 
 an excision should I advise. As to the place operated on, it is 
 obvious that, in this case, it is unimportant. I usually make the 
 excision at the inner side. If, with regard to personal appearance, 
 we wish to be especially careful (which is usually unnecessary, 
 owing to the age of the patient), we can excise at the upper part, 
 although I really find the disfigurement produced by a coldboma 
 placed at the inner side trifling, and in dark eyes unnoticeable. 
 Excision above is besides inconvenient, and requires greater 
 rotation of the bulb with the ophthalmostate ; tliis may readily 
 injure the eye when the inflammation is acute. 
 
 3. The aqueous humour must be very cautiously evacuated, 
 because a too sudden relaxation of pressure (in the present affec- 
 tion) may cause extensive hsemorrhage into the internal membranes 
 and cavities of the eye. In comparison with the ordinary irido- 
 choroiditis with atrophy of the globe there is a factor — the 
 relatively greater pressure — opposed, indeed, to such effusion of 
 blood, even after escape of the aqueous humour. In fact, there 
 seldom occur in glaucoma, effusions so extensive and so slowly 
 absorbing, as ia the cases mentioned. On the other hand, 
 there is in the nature of the disease itseK a great tendency 
 to rupture of vessels; whether through direct paiti'cipation of 
 the vascular walls, or entirely through the previous venous 
 strangulation, I leave undecided. I have repeatedly mentioned 
 the occurrence of retinal ecchymosis, and this alone should make 
 us cautious. 
 
 Even during the escape of the aqueous humour, I usually exert 
 slight pressure on the globe with the finger, and soon after the 
 operation apply a compressing bandage, which is cautiously slack- 
 
GENERAL SUMMARY. 355 
 
 ened in a few houis.^ I have not found any other after-treatment 
 necessary. Even when the operation was performed at the time of 
 most acute inflammation, the inflammatory symptoms spontaneously 
 subsided; an antiphlogistic treatment may, however, be exception- 
 ally indicated under such circumstances, to hasten the retrogression 
 of symptoms of irritation. It is obvious that the eyes must be 
 protected from the light for a longer period, and, in general, the 
 ordinary precautions be more carefully observed than after the usual 
 operation for artificial pupil. 
 
 X. — ^The curative effect of a local treatment on the glaucomatous 
 process, and the duration of the cures obtained, at least in certain 
 cases, might directly lead to the conclusion that the whole affection 
 is necessarily a purely local one, and that the supposition of others, 
 and of myself formerly, as to a vascular affection forming the 
 origin, is incorrect. I admit that this supposition is much shaken 
 by the results of iridectomy, yet such an unconditional inference as 
 the above must for the present be avoided. It may be readily 
 imagined that by changes in the vessels, a definite anomaly of the 
 circulation is induced, which, per se, does not abolish the function 
 ef the internal parts of the eye, but only when a local factor is 
 added to it. After the required change of the local circulation, the 
 original cause might possibly continue, without producing the 
 former effect. If we glance at therapeutics, we find that the cure 
 very frequently depends on the removal of certain intermediate 
 links which maintained the causal relation, and not in the removal 
 of the causes. 
 
 If we bring together once more, in regard to general medical 
 practice, all the previous statement as to the action of iridectomy, it 
 appears — 
 
 I. That the most certain result is obtained in those cases where 
 one eye is threatened after the other has become blind. In such 
 cases it will be the duty of the physician to submit the patient as 
 soon as possible to careful medical observation by an oculist, and 
 reciprocally it will be the duty of the latter to direct the careful at- 
 
 ' The best form of compressing bandage at present known to me, is a rather 
 thick layer of lint laid on the closed eyelids, and held on by a frontal bandage 
 of woollen material. The degree of tightness is regulated by a buckle 
 placed at the side of the head, and must, under all circumstances, be agreeable 
 to the patient. 
 
356 GRAEFE ON IRIDECTOMY. 
 
 tentioa of the ordinary medical attendant to those symptoms which 
 appear to show the necessity of operative treatment. 
 
 a. "When the glaucomatous process has once set in, the results 
 are in general the more favorable and permanent, the earlier the 
 operation is performed. In the very acute cases which immediately 
 annihilate vision, iridectomy must, if possible, be performed during 
 the &st few days of the disease. Early performance is of the 
 utmost importance, and since the transport of the patient at this 
 time, even when external means are at hand, is very difficult, it 
 is desirable that every practitioner, especially in the country, and in 
 small towns, where opththalmology is not practised as a specialty, 
 should make himself conversant with the symptomatology of acute 
 glaucoma on the one hand, and with the method of performing 
 iridectomy on the other. I think that the latter is stiU easier than 
 the former, and even good assistance is less requisite in iridectomy 
 than in many surgical operations, e.g. tracheotomy, which every 
 practitioner must perform under the most unfavorable conditions 
 when the indications are urgent. Iridectomy thus differs from other 
 ophthalmic operations, the performance of which has remained in the 
 hands of a relatively small number of practitioners, owing to the 
 indications being so rarely urgent. As science advances, so also 
 must the demands made of practitioners necessarily be correspond- 
 ingly changed. A glaucomatous eye might formerly be considered 
 incurable from the moment when the diagnosis was settled, and pro- 
 vided only that such injurious influences as were known to hasten 
 the process were averted, it was comparatively unimportant whether 
 this or that medical treatment were decided on somewhat earlier or 
 later. A physician had never to reproach himself for such advances 
 of the disease. Unless we are much mistaken, matters have now 
 changed, and an eye which has become bhnd from acute glaucoma 
 will excite the suspicion of neglect, just as much as closure of 
 the pupil after simple iritis, a badly cured fracture, &c. I am 
 obliged expressly to note this, for — 
 
 3. It has appeared that iridectomy is not, perhaps, a fitting treat- 
 ment for aU stages, but that its effects at a later period, at all events 
 in particular cases, are uncertain, or do not ensue. It is painful to 
 see how many of the incurably blind make distant journeys with 
 the idea of their disease being stiU. curable, although the time for 
 assistance has long passed. To spare our medical brethren and 
 ourselves much fruitless regret, we may urge that all glaucomatous 
 
GENERAL SUMMARY. 357 
 
 cases which have long been perfectly blind, should, if possible; 
 receive advice at home, and that only moderate hopes should be 
 given to the long diseased, who have but little sight and a narrow- 
 field of vision. 
 
 However much I have attempted, during the past year, th^ 
 determination of the facts relating to the cure of glaucoma, I am 
 quite aware of the incompleteness of the results, even in a purely 
 empirical point of view. The number of trials cannot be top 
 great, the effects cannot be foUowed for too long a period, th^ 
 observation itself cannot be too exact and conscientious ; the further 
 I advance in my investigations "the more I am convinced how much 
 remains to be done, and how insufficient is the experience of one 
 man. The theory of the treatment is as yet infinitely darker than 
 the empirical facts. The idea of diminishing the intra-ocular 
 pressure led me to adopt it. In this way, and in following out 
 these views, a result seems to have been obtained, but at the same 
 time no positive proof is aiforded of the correctness of the expla- 
 nation. The action of iridectomy may perhaps be highly compound. 
 Diminution of the secreting (iris) surface certainly accounts for a 
 lessening in the quantity of fluid, yet there is no experimental 
 proof as to how much less aqueous humour is secreted, and 
 whether this deficiency in its amount can explain a striking change 
 of the intra-ocular pressure. The muscular co-operation of the iris 
 with the tensor choroideee, to the study of which I have been 
 principally led by the new theory of accommodation, would in some 
 degree explain how the excision of a piece of the iris might produce 
 diminution of intra-ocular pressure by means of the muscles, by a 
 relaxation of the tensor choroidese. The continuance of accom- 
 modation in coloboma does not indeed favour this view; the 
 conditions, however, are here essentially different. Perhaps the 
 interference with the iris acts at first entirely on the choroidal 
 circulation, and the therapeutical diminution of pressure is only 
 secondary. That iridectomy in glaucoma has a powerful influence 
 on the ocular circulation is at once shown by the occurrence of 
 ecchymoses. Were the analysis of all these points more advanced, 
 and a more correct explanation given, perhaps the treatment itseK 
 would be stin better directed and adapted to the cases ; it is very 
 conceivable that, in certain cases, excision in the ordinary way is 
 not suf&cient, but that success may be obtained by the removal of 
 
358 GRAEFE ON IRIDECTOMY IN GLAUCOMA, 
 
 larger pieces of the iris. I have already {suh IX) communicated 
 my experience, that the excised piece of iris should be larger in 
 proportion as the case is worse. 
 
 To conclude, the whole subject of glaucoma is open to the most 
 various investigations. After the great change produced by the first 
 ophthalmoscopic examinations in the views about glaucoma, I con- 
 sidered the necessity for analysis indisputable. The difficulties 
 which I found wiU indeed have become known to any unprejudiced 
 reader of these pages. I hope that I may have assisted somewhat 
 in solving the question, and that some one with greater powers will 
 soon bring the difficult task to a more happy conclusion. 
 
ADDITIONAL CLINICAL EEMAEKS 
 
 ON 
 
 GLAUCOMA, GLAUCOMATOUS DISEASES 
 
 AND THEIR 
 
 TREATMENT BY IRIDECTOMY. 
 By De. a. v. GEAEFE.> 
 
 Anothee year has passed since I wrote my essay on Iridectomy 
 in Glaucoma for the third volume of. the 'Aichiv.' I have had 
 many fresh cases^ and I have operated on them at most different 
 periods of the disease. So far as was possible I have kept in view 
 all the cases on which I had previously operated, for although the 
 immediate improvement was clear enough, there was yet the possi- 
 bility of its not being permanent. To my own observations have 
 also been added those of many of my colleagues. And now, when 
 I have again to consider critically the question of treatment, I can 
 at once and with pleasure declare, that I have not the least to 
 retract of what I formerly advanced in favour of iridectomy. 
 Some of the cases, indeed, have ultimately been more favorable than 
 I had expected. Por the sake of more ready comprehension, I 
 shall append these remarks to the groups of diseases and reports of 
 cases in the same order as they appeared in the previous memoir. 
 
 I. — I cannot too strongly recommend the operation in the pre- 
 > Prom the 'Arch, fiir Ophtlialm.,' B. iv, Abtli. 2, S. 127, Berlin, 1858. 
 
360 GRAEFE ON GLAUCOMA, ETC. 
 
 monitory stage, when the other eye has become bHnd from the 
 same affection. "Wilhelm Hoffler (Case i), the example given of 
 this group in my previous treatise, continues to visit my cHnic at 
 long intervals ; the sight of the left eye, which was operated on in 
 the premonitory stage, is perfectly good ; with it he reads No. i of 
 Jager's specimens of print, though with a little difficulty. No. 3 
 fluently ; the extent of the field of vision is normal, and the excen- 
 tric vision is in every direction satisfactory. The range of accom- 
 modation is very good. Careless of his eyes, he is occupied as a man- 
 milliner, and since the operation has not perceived the least symptom 
 of disease. I have had occasion to operate from ten to twelve times 
 in this stage, after glaucoma had aheady caused bhndness in the 
 other eye ; constantly with the same good result as in Hoffler. Iri- 
 dectomy is obviously most successful during this period; for the 
 ultimate result is still more perfect, than when it is performed 
 in the inflammatory stage, soon after the disease has broken out. 
 Mobility of the pupil and a good range of accommodation have 
 been recovered, and no retinal ecchymoses have been formed. 
 
 The occurrence of these ecchymoses is probably dependent on the 
 distension of the retinal veius and capillaries; and this, again, is 
 caused by the escape of the venous blood being impeded, when the 
 intra-ocular pressure has rapidly augmented. This hypersemia may 
 be clearly shown by the ophthalmoscope in the venous trunks ; as, 
 occurring in the capillaries, it has been especially referred to in the 
 microscopical reports of Bader (' Ophthalmic Hospital Reports,' No. 3, 
 pp. 74 — 87). The so-called haemorrhages em vacuo may be readily 
 imagined to occur, when the pressure is suddenly diminished by the 
 performance of iridectomy, whilst the vessels are in such a condition. 
 
 Now though experience proves that such ecchymoses often retro- 
 grade, and that vision is perfectly restored, yet, on the other hand, 
 I have met with cases of indistinct excentric or peripheral vision 
 when they were very extensive. This, indeed, makes no essential 
 difference in the recovery, and yet they always indicate permanent 
 structural changes in the affected portions of the internal layers of 
 the retina. 
 
 In all the cases on which I operated during \h& first stage of acute 
 glaucoma, the improvement has remained fully at the extent de- 
 scribed, although most of these patients have pursued their previous 
 employments. A review of my list of cases showed most distinctly, 
 thati'.the .ultirAata lacUten^ss/ of 'vibionilv'fel'yi'rlindhiid.iefpfended'on the 
 
FURTHEU CLINICAL REMARKS. 361 
 
 period at which the operation was performed. The most decisive 
 cases were those where the same individual had both eyes affected 
 by similar symptoms and antecedents, and where the operation was 
 performed on both sides, but at different periods, dating from the 
 commencement of the attack. Thus, in two cases, where one eye 
 was operated on the first or second day after the beginning of in- 
 flammation, and the other from the fourth to the seventh day, there 
 was a notable difference in the two eyes a year after the operation. 
 The one, on which the operation had been earliest performed, read 
 No. I, and the excentric vision was normal; the other, operated 
 on at a later period, read from No. 5 to -No. 5 ; and the circle of 
 tolerably distinct excentrical vision was diminished from' a third to 
 one half in diameter. The cases in thy previous essay, in which both 
 eyes were operated upon (Maass, Case 4, and Felden, Case 5), cannot 
 be adduced as proofs ; for although they favbur' this view, yet there 
 was an original difference in the power of the two eyes, forbidding 
 the drawing of any conclusion. The' accommodation generally re- 
 mained defective, especially when there were great and permanent 
 changes in the iris. 
 
 I can now support my former statement, that typical glaucoma of 
 one eye has no sympathetic influence on the other, at least — ^not in 
 a practical sense — by many additional cases, where, after perfect re- 
 covery of one eye from the glaucomatous process, the other and 
 previously healthy one has yet become diseased, and required the 
 use of iridectomy, and by other cases, where the disease was cured 
 in one eye, and yet the other, which had been previously suffering 
 from chronic glaucoma, was attacked by acute glaucomatous inflam- 
 mation. Of the latter class was the case of Prau v. Bottcher (Case 7), 
 which T mentioned in my previous essay. This patient had lost the 
 sight of one eye from chronic glaucoma, and had a cataract in the 
 other ; the latter eye was attacked by acute glaucoma, and cured by 
 iridectomy j vision was again restored by afterwards extracting the 
 cataract. Nine months later, long after her return home, the blind 
 eye was attacked by acute glaucomatous inflammation. Owing to 
 the distance at which she resided, iridectomy was long delayed, and, 
 according to accounts received from the surgeon in attendance, the 
 eye which had been operated on, and which had recovered its power 
 of vision, appeared to be sympathetically affected. Purther observa- 
 tion, however, showed, that this only referred to the external parts 
 (lachrymation — conjunctival irritation); and an examination after 
 
362 GRAEFE ON GLAUCOMA, ETC. 
 
 the termination of the inflammation showed no change whatever of 
 the power of vision. 
 
 The cases on which I operated during the more advanced stage of 
 acute glaucoma ultimately terminated very variously — a fact which 
 has been pointed out in my former essay. I have, however, never 
 seen perfect blindness ensue, provided the operation was performed 
 before the visual field had become notably contracted. Even in the 
 ease of Madame Sack, of Vienna, which I then quoted as a recur- 
 rence, vision seems to have arrived at a stationary condition. (Ac- 
 cording to a medical report lately received, she recognises fingers at 
 fifteen feet distance, with +15 can read print No. 16, and the field of 
 vision, measured at the distance of a foot, has a vertical diameter a foot 
 long and a transverse of eleven inches.) "Whenever the field of vision 
 is much contracted, a cautious prognosis must be given as to the per- 
 manency of the cure ; and, indeed, according to the other symptoms, 
 it must be considered more or less unfavorable. It is always much 
 worse when the visual field is so contracted as to resemble a sHt, and 
 especially if the point of fi[x.ation is already close to the margin. 
 Notwithstanding that temporary improvements and intermissions 
 of considerable duration often occur, I have found that in the mass 
 of such cases vision gradually deteriorates again ; that the termina- 
 tion is sometimes perfect blindness, and often loss of central vision ; 
 in the latter case, the sight is, of course, very indifferent, owing to the 
 fixation being excentric. As an example, I wjU again quote the 
 case of W. Hofiler. In this case, the left eye was operated on 
 during the premonitory stage, and its vision has remained perfectly 
 good. The right eye was operated on at a more advanced period, 
 the field of vision having already contracted so as to resemble a sKt. 
 Now, after the lapse of a year and a quarter, he sees with this eye, 
 at all events, infinitely better than before the operation ; he counts 
 fingers correctly from eight to ten feet distance (previous to the 
 operation, only at a foot distance, and inaccurately); the point of 
 fixation has, however, again become excentric, and the field of 
 vision has contracted towards it ; hence he can only make out words 
 of the largest print. The field of vision has diminished about one 
 fourth, and hence is only three times as large as before the operation. 
 The eye has remained in tliis state for from four to six months ; so 
 that I rather doubt its ever becoming quite blind. Even when the 
 visual field is already much contracted, if the point of fixation be near 
 its centre, the prognosis is relatively favorable. I have now watched 
 
FURTHER CLINICAL REMARKS. 363 
 
 for a year and a half the course of some cases of this kind, and they 
 have not in the least deteriorated. The second example of this 
 group. Case 8, given in the previous treatise, in which the visual 
 field and optic nerve were still normal, continues as much improved 
 as ever. 
 
 To determine the probability of improvement, not only the state 
 of vision and of the optic nerve, but also any existing sjrmptoms of 
 pressure or opacities of the refractive media, must be specially con- 
 sidered. In proportion as the d_eterioration of vision is caused by 
 the latter, the greater improvement may be expected ; inversely, the 
 more the loss of sight depends on changes in the optic nerve and 
 retina, the less improvement can we expect. In the later stage of 
 acute glaucoma the operation is stiU indicated, so long as there is 
 any qualitative perception of hght. I met with the first perfectly 
 negative results of iridectomy five weeks after the commencement of 
 glaucoma; for eight days, however, aU quantitative perception of 
 light had been lost. 
 
 From a longer observation of cases operated on during this later 
 period, I have generally found the excavation become gradually a 
 little flatter. The retinal veins, which were at first gorged with 
 blood, then became smaller than normal; at the same time, they 
 sometimes retained a more tortuous coui-se. The papilla became 
 whiter, and its substance more opaque, although it never acquired the 
 tendinous white appearance of cerebral amaurosis, but rather a dull 
 waxy appearance. Of course, these changes have no connexion 
 with those originally caused by glaucomatous pressure; they are 
 symptoms of progressive secondary atrophy of the optic nerve. In 
 general, I may repeat my former statement, that ulterior deteriora- 
 tion of vision does not arise from recurrence of the glaucomatous 
 process, but from progressive atrophy of the optic nerve, and that 
 this appears inevitable, when the affection of the nerve has once 
 attained a certain extent. 
 
 The uncertainty of the result in the later stages of glaucoma, 
 especially as regards duration, are so directly opposed to its com- 
 pleteness and durabiHty in the acute period, that the advice, to ope- 
 rate immediately and without hesitation, cannot be too urgent. I 
 must most decidedly reject the recommendation to try first para- 
 centesis advice which has been urged from unfounded ideas of 
 
 caution. Three years' extensive experience has taught me, that the 
 results of paracentesis are, in the infinite majority of cases, tern- 
 
364 
 
 GRAEFE ON GLAUCOMA, ETC- 
 
 porary only. It is true that, when methodically employed, it removes 
 the acute character of the disease, and palliates the symptoms ; it does 
 not, however, prevent gradual deterioration of vision. Within from 
 three to four months, this was almost invariably found to be the 
 case, on a careful examination of the field of vision. When with 
 these results we compare those of iridectomy, there can be no rea- 
 sonable cause for hesitation. By such trials of paracentesis, the time 
 is lost for radical treatment ; for the degree of recovery essentially 
 depends on the length of time the eye has been already affected, and 
 not simply on the condition of the symptoms. Besides, we may 
 reasonably fear that the repeated disturbances of the ocular circula- 
 tion — and every change of pressure must be considered as such — 
 may render the case less amenable to a treatment, the value of which 
 has been actually proved. My clinic presents a considerable number 
 of cases where one eye has been treated by paracentesis in former 
 years, the other by iridectomy. In other cases, where the treatment 
 had commenced with paracentesis, iridectomy was ultimately per- 
 formed on the same eye, owing to the deterioration of vision, and to 
 our having become acquainted with its beneficial action. Only a 
 glance at the fate of these different eyes is needed, to induce the 
 abandonment of all other treatment in Glaucoma than that of the 
 immediate performance of Iridectomy. 
 
 As to this treatment in chronic glaucoma, I have nothing parti- 
 cular to add to my former remarks. It is indicated, so long as any 
 considerable amount of vision remains, though in many cases nega- 
 tive results, and in others only temporary ones, will be obtained. 
 On reviewing my notes of cases (in which the accounts as to 
 vision have been continued to as recent <a period as possible, by 
 means of reports from the physician or patient, when I could not 
 myself observe them), I find a series of relatively favorable cases.^ 
 
 ' One of my oldest observations on iridectomy in clironic glaucoma was in a 
 Berlin saddler (Tackmann), 68 years old, on whom I operated in 1853. As at 
 that time I was entirely ignorant of the treatment of glaucoma by iridectomy, 
 I was guided by other indications. Subacute glaucoma had rendered the 
 patient's left eye perfectly blind some years previously ; the right was suffering 
 under clironic glaucoma with great contraction of the field of vision, exceutrio 
 fixation, and so little sight, that he had some difiiculty in counting fingers. 
 After he had been for a length of time in this condition under my care, iritis 
 supervened ; and although tolerable dilatation had been caused by the glaucoma- 
 tous affection, the pupillary margin formed extensive adhesions with the capsule. 
 Treatment by antiphlogistics, so far as the infirm condition of the patient 
 would allow, and by mydriatics, having failed, and ciliary neurosis being very 
 
rURTHER CLINICAL REMARKS. 365 
 
 Some of them ended in perfect blindness, with symptoms of pro- 
 gressive atrophy of the optic nerve; and in others, after some 
 improvement caused by the operation, vision deteriorated to a cer- 
 tain point, at which it again became perfectly stationary. Por 
 example, the left eye of Madame Hoffmann (Case lo), belongs to 
 the last group. In her, as already mentioned, there was a notable 
 change for the worse three months after the operation, from that to 
 the present time exactly the same state ; the ophthalmoscope shows 
 a moderately white optic papilla and contracted vessels. (The 
 improvement in vision caused by the operation has not deteriorated 
 in Cases ii and 13, so far as the medical reports reach. The vision 
 in Case la, Carl Wagner, is constantly diminishing.) I have ob- 
 served some cases of chronic glaucoma in which the vision, as 
 improved by the operation, has remained unchanged, even though 
 fixation has been very excentric. I have nothing fresh to add as 
 to the points on which the prognosis more particularly depends ; 
 indeed I much fear that it will remain to a pretty considerable extent 
 uncertain, for the point on which the decision specially depends, 
 the condition of the optic nerve (and of the retina), cannot in all 
 probability be accurately determined after it has once undergone 
 organic change. 
 
 II. — To the theory, I believe I am now in a condition to make a 
 very important addition, to the effect that in proper cases the 
 papilla of the optic nerve may be shown to become shaRower soon 
 after the operation, or, in other words, that the excavation becomes 
 diminished. As was mentioned in my former work, I had at that 
 time failed in showing such a change, notwithstanding my utmost 
 efforts. Eully to demonstrate it, we must select one particular 
 group of cases, that where acute symptoms have supervened on 
 
 troublesome, I punctured the eye, and ultimately performed iridectomy. Be- 
 sides the removal of the inflammatory symptoms, I was struck by the improve- 
 ment in vision, and this could not be accounted for by the cure of the 
 inflammation, for he saw considerably better than previously to its occurrence ; 
 he now recognised fingers at a distance of two to three feet. At the 
 present moment, after a lapse of five years, the vision remains exactly the 
 same; left to himself he moves about with difficulty; the field of vision, com- 
 pared with that recorded in my notes, has, if anything, increased. Instead of 
 calling it, as formerly, " chronic glaucoma operated on for secondary iritis," I 
 should now simply say, "acute supervening on chronic glaucoma, and hence 
 treated by iridectomy." 
 
366 
 
 GRAEFE ON GLAUCOMA, ETC. 
 
 previous chronic glaucoma. We cannot employ very recent cases 
 of acute glaucoma, for in them the excavation is not yet formed. 
 It is gradually developed in the later stages of acute glaucoma, and 
 is accompanied by displacement and atrophy of the bundles of fibres, 
 as described by H. MUller ; it is obvious, from the material changes, 
 that such a nerve can never again return to its normal form, even 
 when the mechanical causes of the alteration have been removed. 
 The adhesion of the displaced retinal vessels to the sides of the 
 cavity would oppose any such retrograde process. An exca- 
 vation of the optic nerve arises, or an inconsiderable cavity becomes 
 a large one, most rapidly, when the so-called glaucomatous choroi- 
 ditis suddenly attacks an eye, which has been for some time suf- 
 fering under chronic glaucoma attended by deterioration of vision 
 and increase of pressure to a moderate extent. In such a case the 
 papilla presents much less resistance, owing to the previous chronic 
 disease, and hence yields more rapidly and to a greater extent to the 
 increased pressure. If the operation is performed during this 
 period, some days after the occurrence of an acute attack, or some 
 weeks after the fitrst subacute symptoms (dilatation of the pupil and 
 diffuse opacity of the refractive media), we may most distinctly per- 
 ceive the retrogression of the papilla. In this way I saw deep 
 cavities change within a week into flat, basin-like depressions, the 
 ends of vessels which had been much displaced at the edge of the 
 cavity meet at an obtuse angle, and slight bends in them become 
 perfectly straight. I'or the attainment of perfect certainty, the 
 appearance of the papilla and the vessels should be carefully sketched 
 before the operation, and this drawing should be afterwards used 
 occasionally for the sake of comparison. 
 
 The fact that the papilla becomes flatter immediately after 
 iridectomy seems to me of great importance, for it most decidedly 
 proves that the excavation of the optic nerve depends on an 
 increase of pressure. There can be no other connexion than this 
 between the excision of a piece of iris and the form of the papilla. 
 It is very satisfactory to find our theory so confirmed by the dimi- 
 nution of the excavation coinciding with that of the other symptoms 
 of pressure ; the absence of this proof in former days had always 
 caused a feeling of uncertainty {' Comp. Arch, fur OphthaJ,.,' Bd. 
 iii, 3, p. 539)- It is clear that we cannot at all times and in all 
 cases expect the papiUa to re-approach its normal state any more 
 
FURTHER CLINICAL REMARKS. 367 
 
 than, when the changes in the ciliary nerves from pressure have once 
 exceeded a certain degree, we can expect recovery feom the corneal 
 ansesthesia and paralysis of the iris. 
 
 Another proof of my theory is the condition of increased refrac- 
 tion, which may be readily perceived in some cases after the opera- 
 tion. Decisive cases are, however, very rare, for it is difficult to 
 obtain optometrical results previous to the operation, owing to the 
 state of vision. Yet I have many times observed that a difference 
 in this respect, which had previously existed between the glauco- 
 matous and the healthy eye, could no longer be perceived after the 
 performance of iridectomy. I shall not attempt any statistics, only 
 mentioning that two cases, on which I operated during last session, 
 saw with a convex glass {+ 6) large print many inches further off 
 before the operation than after, although the vision had been 
 rendered very much better by the treatment. This can only be 
 explained_by such an approximation of the point of distant vision. 
 It is very probable that the presbyopia, which occurs even in the 
 premonitory stage, and which often rapidly increases during the 
 course of the affection, is caused by flattening of the cornea ; and 
 that its diminution proceeds from an increased curvature of the 
 same part. Dr. Liebreich has found, on measuring some of my 
 glaucomatous cases with the ophthalmometer of Helmholtz, that 
 they favour this view. These experiments will be published so 
 soon as a sufficient number of decisive cases has been collected. 
 
 Finally, I believe that my view has found a firm support in the 
 recent pathologico-anatomical examinations of excavated optic 
 nerves, and especially through the researches of H. MiiUer (see his 
 essay on this subject). The formation of ectasise in the equatorial 
 regions of the bulb in the later stages of the disease is so entirely 
 analogous to excavation of the optic nerve, that any unprejudiced 
 person must perceive that they are both caused by increase of the 
 intra-ocular pressure. I have found from the examination of some 
 extirpated eyes, that it is at this period that the excavation is espe- 
 cially Hable to become increased. 
 
 Dr. Bader ('Ophth. Hosp. Keports,' No. a, p. 74-88) describes, 
 in three cases, which from their symptoms must be considered 
 as decidedly glaucomatous, a peculiar degeneration of the retina, 
 and he seems to infer that it is this retinal degeneration that 
 forms the origin of the disease. The essay is a very excellent one, 
 and no objection can be made to the facts adduced; as to the 
 
368 
 
 GRAEl'B ON GLAUCOMA, ETC. 
 
 pathogenesis of the disease, however, its clinical history is, in 
 my opinion, more favorable to the view that the degeneration 
 (atrophy or transformation of the inner layers of the retina into a 
 gray, amorpho-grannlar substance) is entirely a secondary change, 
 and, in fact, dependent on excavation of the optic nerve. Atrophy 
 of the fibres, which are displaced in the excavation, must have a 
 similar effect on the retina to that caused by division of the optic 
 nerve. The great distension of the retinal capillaries (Bader) is 
 also, in my opinion, caused by the escape of the venous blood being 
 impeded through the increased pressure. Thus may be explained 
 the occurrence of retiaal ecchymoses, when the pressure is dimi- 
 nished (see above). It seems to me improbable that the destruction 
 of the inner retinal layers could be induced by the pressure of the 
 distended capillaries. I think that my opinion is favoured by the 
 fact, that the organic changes cease at the lamina cribrosa, exactly 
 where the intra-ocular pressure can no longer act. \ 
 
 Admitting that increased pressure is sufficient to account for the 
 whole of the symptoms presented by the optic nerve and retina, 
 we meet again with the question, from whence does this pressure 
 proceed? Notwithstanding the apparently negative results fur- 
 nished by examination of the choroid and ciliary body, I adhere 
 to my former view (1. c, p. 477-481), that they are the source of 
 a hyper-secretion of fluid. Hence it is by no means necessary 
 that marked organic changes should occur. We must not forget 
 that the pigment-cells become rounded (Bader), and that in some 
 cases there is an increased growth of stroma-ceUs. In cases of 
 iritis serosa, where the iris was undoubtedly the source of the affec- 
 tion, there was often nothing more found in pieces of the iris which 
 had been excised (Jnnge). Knally, it deserves consideration, that 
 acute glaucoma may occur when the retina is almost entirely de- 
 stroyed.. I have seen some cases where, after the continuance 
 of chronic glaucoma for many years, the retinal vessels had become 
 extremely contracted, the papilla whitish and excavated, perception 
 of light long and entirely lost, and yet acute glaucoma in its 
 typical form, and with enormous increase of intra-ocular pressure, 
 supervened. After the inflammation had terminated, I found the 
 trunks of the retinal veins distended in comparison with their 
 former state, but yet far from equal to their normal condition, the 
 arteries hardly perceptible. I have seen one case, where glaucoma 
 occurred in an eye which had been long blind from cerebral 
 
FURTHER CLINICAL REMARKS. 3G9 
 
 amaurosis^ and where the rdina was much atrophied. Everything 
 seems to me to militate for the view that the retina is originally 
 passive in these inflammatory attacks, that the veins are distended 
 owing to the escape of their blood being impeded, &c. 
 
 III. — I still hold the opinion promulgated in my former essay, that 
 the affection of the optic nerve is by itself insufiicient to characterise 
 glaucoma. It seems to me that the following points require consi- 
 deration. 
 
 I. There are some cases in which the form of the papilla 
 is perfectly identical with that of glaucoma, and yet the symp- 
 toms and course of the disease are extremely different, so that 
 it is necessary to separate them nosologically, and wiU continue 
 to be so, unless future investigations should possibly show them 
 to be more nearly allied. The formation of a nosological class, 
 which I have named " amaurosis with excavation of the optic nerve," 
 is the actual result of this necessity. 
 
 2. Should we be determined to make the diagnosis depend on the 
 existence of excavation of the optic nerve, we should be unable to re- 
 cognise the disease at the time when treatment has the most beneficial 
 effect, it being admitted that there is no excavation in the early stage 
 of glaucoma, but that it is only formed during the course of the 
 disease. It may not be possible to examine the back of the eye, 
 owing to accidental or consecutive diseases, such as iritis with 
 opacity of the pupil, cataract, cloudiness of the vitreous body, 
 &c. : in these cases we require some other point on which our 
 decision may rest, and yet we have no occasion to give up the 
 hope of diagnosing the case. 
 
 3. I consider the only characteristic to be the complex group of 
 pressure-symptoms, of which I gave an analysis in my former 
 essay. If our delineations of disease are to serve any practical pur- 
 pose, we cannot admit excavation of the optic nerve, nor any other 
 single symptom of pressure, paralysis of the iris, insensibility of 
 the cornea, &c., as pathognomonic ; on the contrary, these symptoms 
 must occur sufficiently in combination. It is true that in certain 
 cases we may fail in discovering any particular symptom, and that, 
 in other cases, the perfect development of all the symptoms may be 
 of more value in showing their mutual connexion than in deter- 
 mining the diagnosis. Thus, if the pupil is dilated, the iris 
 atrophied, the cornea insensible, the bulb hard, and cataract formed, 
 we conclude there is also glaucomatous excavation of the optic 
 
 24 
 
370 GRAEFE ON GLAUCOMA, ETC. 
 
 nerve, although we are unable to prove it by means of the ophthal- 
 moscope. The usual symptoms of a paralysed iris cannot occur 
 when fi'om old iritis the pupil is contracted, and adhesions Have 
 been formed with the capsule; yet this wiU not prevent us from 
 considering the disease to be glaucomatous, if the rest of the 
 symptoms are present. 
 
 4. Our present conception of glaucomatous disease, however, 
 extends beyond the limits of the type of what used to be so 
 designated. The expansion of our ideas of a disease is justifiable, 
 in my opinion, when it springs from a careful consideration of 
 nature, and is not opposed to practical agreement. Should the 
 latter be feared, the name of typical glaucoma, or of glaucoma- 
 tous choroiditis, may be retained for the well-known group of 
 symptoms ; all the affections which resemble that form of disease, 
 by being accompanied by increased pressure and reaction on the 
 optic nerve, yet^ which have a different origin, may be denomi- 
 nated, with the addition of the more special name, diseases with a 
 glaucomatous habitus, glaucomatous tendency, glaucomatous termi- 
 nation, or, in short, "glaucomatous diseases." I do not hesitate, 
 even at the danger of appearing to many indefinite, to speak of an 
 iritis, as being " irido-choroiditis of glaucomatous character" — to 
 add to the designation of a traumatic cataract, " with a tendency to 
 glaucomatous bhndness, &c." I do not hesitate at this, because I con- 
 sider a pathogenetic method of view of greater importance, and more 
 pregnant in results, than a diagnostic dogmatism. Transitional 
 forms and intermediate links occur, just as in every other part of 
 a pathology that is true to nature; this should not prevent us 
 from clearly conceiving the type of disease, and from raising our- 
 selves from this fixed point of view to a conception true to nature, 
 and yet as simple as possible. I shall now proceed to explain 
 these views more exactly, as to the relation of glaucoma to other 
 morbid processes, and the passage of other affections into glaucoma. 
 
 IV. — If the essence of glaucomatous disease depend on an increase 
 in the intra-ocular pressure, we may expect that not only internal 
 but also external causes may excite it, and that we may be able 
 experimentally to educe and to cure it. Such is really the case. 
 The reader may imagine that I refer to experiments on animals ; to 
 these, however, it is unnecessary to have recourse. Experiments 
 enough have been already made on man by many an operator, un- 
 
rTJRTHEU CLINICAL REMARKS. 371 
 
 consciously and to his sorrow. These are related in the history of 
 cataract-operations, especially those by discision, and in the whole sub- 
 ject of traumatic cataract. Experience has definitely settled that blind- 
 ness may be induced during the process of absorption^ when accom- 
 panied by excessive imbibition of the lens ; there are, however, many 
 different ways in which this may occur. Sometimes the swoUen 
 lens, by its contact with the iris and the ends of the ciliary pro- 
 cesses, excites iritis or irido-cycHtis, with plastic or purulent exuda- 
 tion. The eye may be perfectly destroyed by this process, exudative 
 membranes behind the iris may completely prevent the passage of 
 light, effusions into the vitreous body may, by their contraction, 
 separate the retina from the choroid — all this happens in a series of 
 cases, where blindness is caused by the progress of an inflammatory 
 affection, with permanent structural changes of the internal mem- 
 branes. And now we meet with another termination, which has 
 not been sufB.ciently noticed, though of frequent occurrence, and 
 which we have every reason for calling traumatic glaucoma. During 
 the sweUing of the lens the globe becomes very hard, any corneal 
 cicatrices from wounds or other causes become prominent, the 
 cornea even insensible, the anterior chamber flatter, the iris dis- 
 coloured, not, however, by inflammatory hyperemia, but by assum- 
 ing a dirty sallow appearance, and we notice a tendency to dilatation 
 of the pupil, especially in places where there are no posterior synechise, 
 so that no one conversant with the subject can fail to recognise a 
 certain degree of paralysis of the iris. If an examination of 
 the fleld of vision is not prevented by the dissipation of the light, it 
 is found to be already laterally contracted, whilst the central vision 
 is stiU, perhaps, satisfactory. If the light is dissipated to a greater 
 extent, though not completely, by the swollen lens, we should 
 always suspect contraction of the visual field, or at any rate indis- 
 tinctness of excentric vision, when a light moved here and there 
 before the eye is not exactly fixed, and its direction is discovered 
 slowly or not at all. If, under these circumstances, we do not 
 interfere, the result will usually be, when the lens is completely 
 absorbed, that the pupil is faultless, and yet there is little or no 
 sight. The symptoms of irritation which previously existed to 
 a greater or less extent retrograde, and the original condition is 
 only betrayed by a certain discoloration and paralysis of the iris, 
 results which are often only slightly developed. It is usually sup- 
 posed that this blindness is caused by the protracted choroidal 
 
372 GRAEFE ON GLAUCOMA, ETC. 
 
 irritation or choroiditis^ effusions into the interior of the eye, 
 separations of the retina, and so on. The ophthalmoscope, how- 
 ever, shows no trace of such affections in these cases. On the 
 other hand, it does show excavation of the optic nsrve. The pro- 
 cess has been this : from the irritation caused by the swollen lens 
 a state of internal congestion was caused, hyper-secretion of fluid into 
 the vitreous body, increase of the intra-ocular pressure, which has 
 continued for some time, and which has caused excavation by its action 
 on the surface of the papiUa of the optic nerve. If, at a certain 
 stage of these phenomena, we employ linear extraction when the 
 swollen lens is sufficiently softened, or iridectomy in the opposite 
 case, we find that the threatening symptoms recede just as in the 
 acute period of glaucoma ; if, however, they have existed for some 
 time, and attained to a moderate degree, there often remain con- 
 traction of the visual field and a certain amount of change in the 
 optic nerve, as in the later stages of glaucoma. I have seen every 
 stage of this process in cases of cataract, to a slight extent in 
 those of discision, to a greater in the traumatic, and hence have 
 deduced my views of treatment for such cases. I perform iridectomy 
 for exactly the same reasons as in glaucoma, and cautiously avoid 
 interfering with the swollen lens when I am not certain that I can 
 entirely remove it, or at all events its nuclear portion. When the 
 lens is so swollen as to educe such symptoms, it is generally 
 in young persons so soft as to allow its escape by a linear incision. 
 In adult or advanced Hfe, however, the case is different ; the cortex 
 may be so much softened as to cause danger at a time when the 
 nucleus is yet hard. The proper treatment of the former is linear 
 incision, of the latter iridectomy. In some cases it is advisable to 
 combine the two. The same symptoms may occur after the operation 
 for reclination. Cases of blindness after this operation depend only to 
 a certain extent on permanent organic changes caused by inflamma- 
 tion, separation of the retina, &c. In a large number of cases the eye 
 assumes a glaucomatous habitus by exactly the same process, that we 
 have just described. Functional examination shows contraction 
 of the field of vision, and ultimately there is only excentrical vision ; 
 the ophthalmoscope shows the characteristic alteration in the optic 
 nerve. Needle-operatorswere well acquainted with this when they said 
 in their way, " Gout has supervened, gouty ophthalmia has been deve- 
 loped," &c. It is not unfrequent for blindness to ensue after reclina- 
 tion with extreme slowness, and this form is also very often caused 
 
FURTHER CLINICAL REMARKS. 373 
 
 by hyper-secretion of the vitreous fluids and increase of the intra- 
 ocular pressure being excited by the irritation of, the depressed 
 lens. The result is an amaurosis, with contraction of the field of 
 vision, similar to that occurring in the very chronic cases of 
 glaucoma, which are attended by few external symptoms. 
 
 The inflammations which are caused by the passage of a foreign 
 body into the interior of the eye, of course, present very various 
 appearances. In these cases, however, we meet with forms which 
 induce bliadness in. the same way as glaucoma. The symptoms of 
 increased pressure are characteristic, and it is by its reaction on the 
 optic nerve, and not by organic changes in the inner membranes, 
 that vision is destroyed. It may be readily conceived how a foreign 
 body may induce, by its presence, hyper-secretion of fluids, and yet 
 not cause any diffuse inflammation. 
 
 Let us now glance at the cases of blindness after iritis. The fact 
 has been sufiiciently pointed out by myself and others, that cases of 
 iritis, which have terminated in exclusion of the pupil, are followed, 
 sooner or later, by constantly progressive amblyopia. On this rests, 
 to a great extent, the necessity of iridectomy in such cases. I have, 
 however, somewhat modified my views as to the explanation of these 
 amblyopise since the time when I wrote my former essay on this 
 subject. Even at that time I believed that the amount of pressure 
 in the posterior portion of the globe was changed through the ex- 
 clusion of the pupil ; I beheved, however, that these changes in the 
 pressure reacted on the choroidal circulation, excited effusions into 
 the vitreous body, separations of the retina, &c., and that the blind- 
 ness was specially caused by the latter changes. This course of the 
 phenomena very possibly occurs in a large number of cases; but 
 that it is not the only one, and perhaps not even the most common, 
 I conclude from my more recent observations. Two years ago, the 
 case of an old woman engaged my attention, where the edge of the 
 iris adhered to the capsule, and yet the pupil was sufficiently clear 
 to allow a minute ophthalmoscopical examination of the background. 
 She became amblyopic whilst under my care ; the visual field con- 
 tracted laterally, and ultimately fixation became excentric. The 
 globe, indeed, became decidedly hard, and the ophthalmoscope showed 
 a moderate degree of excavation of the optic nerve j yet, owing to the 
 refractive media remaining transparent, I could not clearly perceive 
 how these phenomena were connected, and hence I supposed some 
 accidental compUcation of the effects of an iritis, and an amaurosis 
 
374 GRAEfE ON GLAUCOMA, ETC. 
 
 with excavation of the optic nerve. Soon after that case, a man, aged 
 forty, came under my care, who had one eye blind from irido-cho- 
 roiditis and equatorial ectasise, and the other affected with chronic 
 iritis. An examination of the latter showed perfect exclusion of the 
 pupil; the iris was already pushed forwards at various places by 
 fluid exudation, which lay behind it ; there were some pigmented 
 deposits towards the edge of the pupil, and yet the greater part of 
 it was sufficiently free to allow the use of the ophthalmoscope. Por 
 some weeks the acuteness of vision had been rapidly diminishing, 
 without the occurrence of any fresh inflammation, so that now he 
 could only decipher words of No. ao ; excentric vision was some- 
 what contracted in every direction, and the inner third of the visual 
 field entirely wanting. The globe was very hard, and the ophthalmo- 
 scope distinctly showed an excavation of the optic nerve in process 
 of formation ; the vitreous humour was not clouded. The ambly- 
 opia clearly depended on the lesion of the optic nerve. Prom this 
 case I at once perceived that it was very probable that the ambly- 
 opise following exclusion of the pupil are not unfrequently produced 
 in this way, the contraction of the visual field not directly depending 
 on destruction or separation of the retina, but on the disease of the 
 optic nerve. Since that time I have observed a number of cases, and 
 latterly examined some extirpated eyes, that seem to prove that such is 
 the fact. I do not consider that the collection of serous exudation 
 behind the iris is a direct explanation of the increased pressure, 
 though it must assist in producing it; clinical facts render it 
 probable that there must also always be hyper-secretion of vitreous 
 fluid, and that this is the chief cause of the increased pressure. 
 The resistance presented by the sclerotic must certainly play an im- 
 portant part in these processes ; its flrm resistance must favour the 
 occurrence of increased pressure, and its ready yielding render it more 
 difi&cult. This is the reason why we find these secondary affections 
 follow iritis with pupillary exclusion far more rapidly in the old 
 than in the young — a fact which is equally true in respect to the 
 cases already mentioned of discision and traumatic cataract. The 
 eyes which have been extremely tense for a time, generally become 
 atrophied at a later period, and, siace this is a permanent stage, are 
 most often presented to our notice in this condition j this circum- 
 stance renders it difficult to prove, that the amblyopia secondary to 
 iritis is often caused by an afl'ection of the optic nerve. The atrophy 
 is certainly caused in these cases by secondary organic changes, 
 
FURTHER CLIMICAL REMARKS. 375 
 
 progressive atrophy of the choroid, &c. Hence the explanation of 
 how iridectomy acts in cases of exclusion of the pupil requires change 
 in various respects. The restored conununication between the two 
 chambers is, indeed, the immediate effect and cause of benefit; in 
 the cases, however, to which we are now referring, secondary cho- 
 roiditis is not directly allayed, but, as in glaucoma, the pressure 
 is diminished, and the optic nerve (and retiaa) preserved from 
 danger. 
 
 Our utmost attention is demanded by the transition of sderotico- 
 choroiditis posterior into a glaucomatous form of disease. Yision 
 is generally not much affected in this disease, so long as secondary 
 affections, such as opacity of the vitreous body, separation of the 
 retina, cataract, &e., are absent, or so long as the choroidal changes do 
 not extend to the region of the macula lutea. My attention has been 
 lately, however, directed to another perfectly distinct and less fre- 
 quent course. I found that lateral contraction of the field of vision 
 and progressive deterioration of the sight occurred in old persons, 
 who had been affected by sclerectasia posterior for an indefijiite period. 
 On further observation, I found that excavation of the optic nerve, 
 and other symptoms of increased pressure, were developed in such 
 eases. The excavation of the optic nerve is never so strikingly and 
 clearly marked in these cases as where there is no posterior staphy- 
 loma. This may be readily explained by the state of the parts j for 
 the sclerotic around the optic nerve is diseased, and hence its power 
 of resistance approximating to that of the entrance of the optic nerve 
 far more than in the normal eye, there cannot be formed by pressure 
 a deep cavity in the papilla, but oidy a shallow depression, with a 
 little displacement of the vessels at its margin. The principal dif- 
 ference of this depression from a normal, but rather strongly marked 
 concavity of the papilla (Heinr. Miiller) is, that it reaches to the 
 periphery of the nerve, whilst the natural one only occupies the 
 more central portion, near where the vessels emerge. The appear- 
 ances presented by such an optic nerve are very readily noticed, 
 provided our attention has once been called to the subject. In 
 ordinary cases of sclerectasia posterior, the margin of the optic nerve 
 is indistinct; no difference appears between the space occupied by 
 the papiUa and the adjacent sclerotic, so that often we are only able 
 to distinguish them by supplying a continuation to the margin of 
 the optic nerve, which still remains at the inner side, by the appear- 
 
376 GRAEFE ON GLAUCOMA, ETC. 
 
 ance of the vessels, or by recognising over the sclerotic the choroidal 
 tissue in process of atrophy. In the cases just mentioned, however, 
 the disc of the optic nerve again becomes distinct in the centre or 
 at the side of the white figure. This is what first excites suspicion ; 
 a more careful examination shows that the papiUa is superficially 
 excavated. As already mentioned, no considerable change in the 
 vessels can be expected, but only a little displacement ; and for the 
 same reason, the appearance of the papilla, which is characteristic of 
 excavation of the optic nerve, exists here only to a moderate extent. 
 The occurrence of a distinct excavation of the whole papilla in pos- 
 terior staphyloma seems to me of the more pathological importance, 
 because the normal flattening or depression of the papUla 
 around the vessels, whenever it has previously existed, disappears 
 more or less during the expansion of the posterior portion of the 
 globe — a fact which I have often observed on comparing an eye acci- 
 dentally affected by sclerectasia posterior with the other and healthy 
 one. It is probable that this is directly caused by thinning of the 
 adjacent choroid. During the formation of the excavation in sclerec- 
 tasia, posterior, the globe, which had been previously soft, becomes 
 tense, the pupil generally becomes a little dilated and rather slug- 
 gish, though not perfectly motionless ; the cornea also a little less 
 sensitive. The visual field is sometimes concentrically contracted, 
 sometimes laterally, and we occasionally see the disease end in al- 
 most total blindness. Any practitioner may succeed in soon finding 
 for himself examples of this course. The cases in which it should 
 be looked for are those of sclerotico-choroiditis posterior, in persons 
 who are more than fifty years old, with far-advanced amblyopia, but 
 without disease of the vitreous body, separation of the retina, cata- 
 ract, or perhaps even central scotoma, which is caused by the macula 
 lutea becoming affected. It was interesting to me to review my 
 notes of cases taken previously to my becoming aware of this fact. 
 I found many entries of this diagnosis : " stationary sclerotico-choroi- 
 ditis posterior, with excessive loss of vision and lateral contraction 
 of the visual field." The form of superficial excavation of the optic 
 nerve had at that time escaped me. Since this course occurs almost 
 exclusively in the old, and since there are no progressive choroidal 
 changes connected with it, I consider it most probable that it is 
 owing to senile changes in the sclerotic. It is clear that an increase 
 of the intra-ocular pressure, with reaction on the optic nerve, may be 
 induced, if the sclerotic commences to thicken and to lose its elas- 
 
FURTHER CLINICAL REMARKS. 377 
 
 ticity in a case of large staphyloma. What has been asserted of 
 sclerotico-choroiditis posterior equally applies to the whole group of 
 dropsies of the eye. Excavation of the optic nerve occurs also in 
 sclerotico-cAoroiditis anterior, with sclerectasia anterior, in cirsoph- 
 thalmus, kc, of a certain intensity ; entire loss of vision is generally 
 caused by it and by the secondary atrophy of the inner layers of the 
 retina, even when the ectasite would otherwise be compatible with a 
 tolerable activity of the retina. This view is favoured by the exami- 
 nation of extirpated eyes. When we examine the posterior section 
 of a dropsical eye, where quantitative perception had been entirely 
 lost, we generally find, on looking through the vitreous body, as 
 well-marked excavation of the optic papilla as ever occurs in glau- 
 coma. The increased pressure, and its reaction on the optic nerve, 
 are of the utmost importance even in the earher stages, and must be 
 carefully considered in judging as to the condition. 
 
 Finally, we have to mention a tolerably extensive class of diseases 
 which may assume glaucomatous symptoms, the class of jorojecting 
 corneal cicatrices. Leucoma prominens, partial and total staphyloma, 
 are, as is known, often connected with total amaurosis, or such 
 a deterioration of vision as is out of proportion with the optical con- 
 dition; hence, unless a very accurate examination has been made, 
 the vision, after an operation for artificial pupil, does not improve 
 so much as is expected ; and there are found contraction of the field of 
 vision, and even excentric fixation. This used to be attributed to the 
 position, form, excentricity of the pupil — points which were often 
 little or not at all concerned. Many observers (for example, Arlt) have 
 carefully considered the question, what is the cause of weak sight 
 or blindness in cases of prominent corneal cicatrices? Various 
 authors, and especially the one just mentioned, have pointed out the 
 change in pressure that occurs in the interior of the eye in these 
 cases. In confirmation, I myself, by means of the ophthalmoscope, 
 have arrived at the conclusion that this defective vision or blindness 
 depends on excavation of the optic nerve caused by the pressure. I 
 have been able to make out the excavated form of the optic nerve, 
 both in cases left to nature, where pupils had been accidentally 
 formed by rupture of the iris, and in those of iridectomy, so that 
 now I have no hesitation in concluding as to its presence in pro- 
 jecting corneal cicatrices from the other symptoms presented by the 
 eye, even when it is impossible to employ the ophthalmoscope. The 
 
378 GRAEFE ON GLAUCOMA, ETC. 
 
 increasing hardness of the globe, the iris pressed towards the cornea, 
 its discoloration, the insensibility of the cornea, the congestion of 
 the subconjunctival veins, are aU most distinctly marked. Another 
 symptom, very easy to understand, is the prominence of the corneal 
 cicatrix^ after it has abeady become thickened. So long as the 
 texture filling up the cavity of an ulceration is thin and softj it will 
 readily yield to even normal pressure, and hence protrusion at such 
 a time by no means justifies the conclusion that the pressure is 
 increased. But when the new-formed tissue has become thickened, 
 so as to afford the same or even greater resistance than the healthy 
 cornea, we see the previous prominences approximate to the level 
 of the adjacent parts, or even become depressed below them, pro- 
 vided the pressure remains at its normal amount. This is sufficiently 
 apparent from the history of prolapsus iridis after corneal ulcers, 
 operations for cataract, &c. When, however, the pressure is in- 
 creased, the prominence does not diminish as it becomes thickened; 
 on the contrary, the adjacent portion of the cornea, and even the 
 sclerotic, gradually participate in the change of form. Various 
 reasons may be assigned for the increased pressure : ist, inflamma- 
 tion of the iris adherent to the cornea ; this may be caused by the 
 irritation spreading from the portion of iris which is lying in the 
 corneal wound, or prolapsed through it, and which is invariably in- 
 flamed; it seems to be promoted by dragging of the iris, and 
 especially by the existence of a closed pupil. It is well known that 
 a puncture through the accidental tissue and the iris in projecting 
 corneal cicatrices or staphylomata will often aUow the escape of fluid 
 exudation, and cure the inflammation for a time. A second and 
 very common cause of increased pressure is a swollen, cataractous 
 lens, irritating the iris and ends of the ciliary processes. This may 
 excite a hyper-secretion of flmds. Every oculist knows that its 
 removal is often the most important point in the treatment of true 
 staphyloma; the prominence of even partial corneal cicatrices is 
 often kept up in a similar way. Indeed, I believe that simple 
 pressure forwards and oblique position of a perfectly transparent 
 lens may have the same action, even though the capsule is un- 
 ruptured and no cataract is formed. The following case may serve 
 as an example : 
 
 A boy, a3t. ten years, had a partial staphyloma of his left eye ; 
 the part that was especially prominent was situated towards the 
 
FURTHER CLINICAL REMARKS. 379 
 
 temple^ and its diameter was about half that of the cornea ; it was^ 
 however, clear that the curvature of the entire cornea had undergone 
 much change ; the pupil was displaced outwards, its inner margin 
 to a slight extent free. I performed iridectomy at the inner side ; 
 most perfect flattening of the prominence followed, and he became 
 able to read print of moderate size ; yet so soon as fourteen days 
 later symptoms of internal irritation appeared, and the globe again 
 became tense and hard; the staphyloma soon attained its former 
 size. A few weeks later the central portion of the prominence was 
 excised, and there ensued the same transitory cure as after iridectomy. 
 After a few weeks I decided on a freer removal of the staphylomatous 
 projection ; it was excised at its base, and now the perfectly trans- 
 parent lens, lying in its capsule, presented itself, so as to close the 
 loss of substance in the front of the eye; its external edge had 
 probably pressed to some extent against the pseudo-cornea; at all 
 events it was placed obliquely. I decided, though with some hesi- 
 tation, on leaving the lens, partly because I thought its removal 
 attended with danger, and partly because the other eye of my little 
 patient being weak I considered it very important to save the vision 
 of this eye as much as possible. A compressing bandage was applied, 
 • and cicatrization ensued without a single bad symptom ; yet the im- 
 provement was of only a few weeks' duration, for then the projection 
 again occurred, and at the same time the bulb became tense. Hence 
 I was obliged to remove the transparent lens. The projection 
 formed by tissue of new formation was again excised, the capsule 
 opened, and the lens removed. The recovery was now permanent, 
 and the vision relatively good ; from the hardness of the bulb, and 
 from the decided manner in which the surrounding cornea was 
 becoming affected, I am certain that otherwise he would sooner or 
 later have become blind. 
 
 Let the cause be what it may, I believe that the secretion of 
 vitreous fluid is gradually augmented, and thus the pressure becomes 
 greater ; at all events, it is certain that choroiditis and permanent 
 organic changes, separations of the retina, &c., are far more rarely 
 found in the staphylomatous eyes of the blind than was formerly 
 believed, and that the aboKtion of vision is generally caused by ex- 
 cavation of the optic nerve. Atrophy of the globe is by far the most 
 common result of these complications. The glaucomatous appear- 
 ance which such eyes in time assume has besides been long known. 
 
380 GRAEFE ON GLAUCOMA, ETC. 
 
 as well as the fact that prominence of the anterior hemisphere, 
 together with hardness of the globe in projecting corneal cicatrices, 
 is an almost certain indication of amaurosis. Little can be done 
 for such cases in the way of treatment when the affection has run 
 its course. It is, on the other hand, of infinite importance that 
 symptoms of pressure during the formation and thickening of cor- 
 neal cicatrices should be carefully watched. 
 
 We have now pointed out a number of most different conditions, 
 which may ultimately induce glaucomatous symptoms through increase 
 of the iutra-ocular pressure. These were — traumatic cataract, iritis, 
 irido-choroiditis, posterior staphyloma, hydrophthalmise, and pro- 
 jecting corneal cicatrices. When in speaking of these diseases we 
 say that " they become glaucomatous," or " they threaten glauco- 
 matous blindness," we mean, that through increased pressure, re- 
 action on the optic papilla takes place in an analogous manner to 
 what occurs in typical glaucoma. At the same time we mean that 
 the only treatment from which relief can be expected is one that 
 will diminish pressure. Without neglecting other means, such as 
 mydriatics, paracentesis, or the removal of the swollen or displaced 
 lens, we must still leave to iridectomy the first and most important 
 place ; in it we may often put our trust when all other means fail. 
 It is its efficiency in diminishing pressure, and not any special relation 
 to some particular disease, that renders the operation valuable, or 
 determines and justifies its employment. I'or treatment founded 
 on pathogenesis there even yet remains abundant space. 
 
 THE END. 
 
 PlllNTKO BV J. It. AMLAKD, BABTHOLOMKW CI.OSR. 
 
LIST 
 
 OF THE 
 
 OFFICERS AND MEMBERS 
 
 OF THE 
 
 NEW SYDENHAM SOCIETY. 
 
 DECEMBER, 1859. 
 
 President. 
 C. J. B. Williams, M.D., F.R.S., &c. 
 
 Vice-Presidents. 
 
 SiE Henet Holland, Bart., F.R.S. 
 James W. Cusack, M.D., A.M., Dablin 
 
 EOBEET FEKaUSON, M.D. 
 
 H. W. Aoland, M.D., F.R.S., D.C.L., Oxford 
 
 John Macfaelane, M.D., Glasgow 
 
 Thomas Mayo, M.D., F.R.S., President R.C.P. 
 
 J. Y. Simpson, M.D., Edinburgh 
 
 SiE James L. Bakdsley, Manchester 
 
 William Stokes, M.D., Dublin 
 
 Thomas Watson, M.D., F.R.S. 
 
 W. Sands Cox, Esq., F.R.S., Birmingham 
 
 William Fekgusson, Esq., F.R.S. 
 
 SiE OHAaLES Hastings, Worcester 
 
 James Paget, Esq., F.R.S. 
 
 Samuel Solly, Esq., F.R.S. 
 
 T. P. Teale, Esq., F.L.S., Leeds 
 
OPFICEllS. 
 
 Council. 
 
 Egbert Baknes, M.D. 
 William Bkinton, M.D. 
 John S. Bkistowe, M.D. 
 KoBEKT Druitt, M.D. 
 Geokge F. Evans, M.D., Bir- 
 mingham 
 
 J. G. Fleming, M.D., Glasgow 
 
 W. T. Gaikdner, M.D.,' Edin- 
 burgh 
 
 W. W. Gull, M.D. 
 
 Geokge Johnson, M.D. 
 
 W. S. Kikkes, M.D. 
 
 W. M'Etven, M.D., Chester 
 
 J. Moore Neligan, M.D., Dublin 
 
 John W. Ogle, M.D. 
 
 Thomas B. Peacock, M.D. 
 
 RlOHAKD QUAIN, M.D. 
 
 W. Sedgwick Saunders, M.D. 
 Thomas Simpson, M.D., York 
 
 RoBEUT W. Smith, M.D., Dublin 
 William H. Stone, M.D. 
 Thomas H. Tanner, M.D. 
 Thomas Williams, M.D., F.R.S., 
 Swansea 
 
 E. R. BiCKERSTETH, Esq., Liver- 
 pool 
 Charles Brooke, Esq., F.R.S. 
 James Dixon, Esq. 
 John E. Erichsen, Esq. 
 
 Edmund J. Furner, Esq., 
 
 Brighton 
 Peteb liooD, Esq. 
 
 George M. Humphry, M.D., 
 F.R.S., Cambridge 
 
 Jas. S. Millar, Esq., Edinburgh 
 
 H. Spencer Smith, Esq. 
 
 Henry Thompson, Esq. 
 
 T. Spencer Wells, Esq. 
 
 Treasurer. 
 G. HILARO BARLOW, M.D., 5, Union Street, S.E. 
 
 Secretary. 
 JONATHAN HUTCHINSON, Esq., 14, Finsbury Circus, E.C. 
 
 Dep6t for Books. 
 MR. HEYLIN'S, 28, PATERNOSTER ROW. 
 
MEMBERS. 
 
 Abbey Holme, Cumberland 
 Abeefokd, Yobks. . . . 
 Abergavenny .... 
 Abingdon, Bucks . . . 
 
 AccRiNGTON, Lancashire 
 
 Acton, Middlesex . 
 
 Albrighton, Salop 
 
 Alconbury-Weston, 
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 Aldershot, Hants 
 
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 Lancashire . . 
 
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 Ayton, Scaebro', Yoeks. 
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 Ferguson, C. 
 
 Ellerton, John B. 
 
 Steel, S. H., M.D., Loe. Sec. 
 
 Martin, John F., Loc. Sec. 
 Barrett, Ferberd Sessions 
 
 Arkwright, J., Loc. Sec. 
 Roscow, R. (Church Kirk). 
 Beeker, J. L. 
 Hartley, Doctor 
 Lingham, Henry B. 
 Bidwell, Henry, M.D. 
 
 Newton, L. 
 
 The Aldershot Medical Book Club 
 
 West, R. U., M.D. 
 
 Burnett, Charles, M.D. 
 
 Collingwood, William 
 
 EvERSHED, C. L., Loc. Sec. 
 
 Gervis, W. S., M.D. 
 
 Bangham, F. 
 Dicken, Perry, M.D. 
 
 Robinson, M. A. 
 
 Woollam, George, M.D. 
 Wood, Robert 
 Gait, John 
 
 Wiles, C. B. 
 
 Ceely, Robert, Loc. See. 
 
 Hooper, Charles 
 
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 Whitaker, B., M.B., Loc. Sec. 
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 Prince, Thomas 
 
MEMBERS. 
 
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 Barnstaple, Devon 
 
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 Bath 
 
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 Grimbly, Richard, Loc. See. 
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 Cory, William G., M.D. 
 
 Sadler, M. T., Loc. Sec. 
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 Lawrence, J. 
 
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 Stockwell, J. G. 
 
 Baxter, C. S. 
 
 Brace, W. H., Bath Hospital 
 
 Watts, Charles 
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 Crowfoot, W. E., Loc. Sec. 
 
 Stilwell, S., M.D. (per Dr. Bristowe) 
 
 Barker, T. H., M.D., Loc. Sec. 
 Blower, W. 
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 Savile, G. T. 
 Stretton, W. H. 
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 Wallis, Frederic 
 Acland, W. H., Loc. Sea. 
 Stevens, C. P. 
 Growse, J. L. 
 
MEMBERS. 
 
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 BiLLINGSHURST, SussEX . 
 
 BiLSTON, StAEPOED . . 
 
 BiNPiELD, Berks . . 
 
 BiNGLEY, YOEKS. . . . 
 
 Birkenhead, Chester . 
 
 Birmingham . . . . 
 
 Bishop Auckland, Dur- 
 ham 
 
 Blackburn, Lancashire 
 Blackheath . . . . 
 
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 Franks, W. P. 
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 Best, Henry D., Loc. Sec. 
 Harcourt, George F. 
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 Scholfield, Henry D., M.D. 
 Rickette, C. 
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 Keyworth, J. W., M.D., Loc. Sec. 
 
 Cox, W. Sands 
 
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 Gamgee, J. S. 
 
 Fleming, Alex., M.D. 
 
 Johnstone, James, M.D. 
 
 Pemberton, Oliver 
 
 Evans, George T., M.D. 
 
 The Sydenham Book Society 
 
 Baker, Alfred 
 
 Jones, George 
 
 Fletcher, Thomas B. E., M.D. 
 
 Hadley, J. J. 
 
 Marshall, G. H. 
 
 Bindley, S. A. 
 
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 Hawkins^ Thomas 
 
 Day, John 
 
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 Book Society 
 Berry, Samuel 
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 Thwaites, Thomas B., Lee. Sec. 
 
 Hutchinson, V. 
 
 Jobsoi), J. 
 
 Rae, Matthew J., M.D. 
 
 Purvis, P., M.D. 
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 Risk, K. R., M.D., Loc. Sec. 
 Moon, William 
 Harvev, C. T. 
 
MEMBEES. 
 
 Blopield, Norfolk . 
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 borodghbridge, yoeks. 
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 Bowling, Yorks. . . 
 Box, Wilts .... 
 Bradford, Yorks. 
 
 Brampton, Cumberland . 
 Brecon 
 
 Brentwood, Essex . . 
 Bkidgenorth, Salop . . 
 
 Bridgewater, Somerset 
 Bridlington, Yorks. 
 
 Kidd, Robert B. 
 
 West, C. A., Loe. Sec. 
 
 Sedgwick, Leonard W. 
 
 Merger, Adam A., M.U., Loc. Sec. 
 Snaith, F., M.D. 
 Atkinson, John P. 
 Cammack, Richard 
 
 Ellis, Henry- 
 Falls, W. S. 
 Holmes, A. N., M.D. 
 Snow, F. H. 
 
 FiNUCANB, H. P., Loc. Sec. 
 Meade, R. H. 
 Brown, S., M.D. 
 Bell, J. H. 
 Buckley, W. H. G. 
 Smith, G. P. 
 Kay, D., M.D. 
 Terry, J. H. 
 Parkinson, W. 
 Beaumont, Thos. 
 Poppleton, J. 
 McMichan, W. 
 Douglas, J. 
 Taylor, C. W. 
 Field, William 
 Jamieson, Gavin 
 Bronner, Edward, M.D. 
 Brighouse, John 
 
 Graham, J., M.D. 
 Armstrong, William 
 
 Lucas, Prestwood, M.D., Loc. See. 
 Williams, James 
 North, John 
 Davies, John 
 
 Growse, R., M.D., Loc. Sec. 
 Butler, C. 
 
 Ti-iuRSFiELD, W., Loc. Sec. 
 Gwynn, R. H. 
 Matthias, Alfred 
 
 Parsons, J., Loc. See. 
 Haviland, Alfred 
 
 Hutchinson, C. ¥., Loc. Sec. 
 Ramsay, George H. 
 Mann, G. W. 
 
3IEMBET!,S. 
 
 Bridport, Dorset . . . Cory, S. S., Loc. Sec. 
 
 Hay, W. H. 
 Denziloe, Matthew 
 Hounsell, Henry S. 
 
 Brighton, Sussex . . . Beard, Charles I., M.B., Loc. Sec. 
 
 Humphry, F. A. 
 Blaker, H. M. 
 Scott, S. K. 
 Oldham, James 
 Field, A. G. 
 Tuke, J. K. 
 Furner, E. J. 
 Hall, Alfred, M.D. 
 Rowe, W. H. 
 Brown, R., M.D. 
 The Sussex County Hospital 
 Hughes, Richard 
 Richards, David 
 
 Brighouse, Yokks. . . Farrer, Robert, Esq. 
 
 Jessop, J. R. 
 
 Bristol Fox, Edward Long, M.D., Loc. Sec. 
 
 Symonds, John A., M.D. 
 
 Brittain, F., M.D. 
 
 Beddoe, John, M.D. 
 
 Davey, I. G., M.D. 
 
 Henderson, William, M.D. 
 
 Bleeck, Alfred, Esq. 
 
 Clark, Henry, Esq. 
 
 Clark, Mitchell, Esq. 
 
 Coe, R. W. 
 
 Collins, Charles 
 
 Colthurst, John 
 
 Cross, William 
 
 Godfrey, James 
 
 Hainson, John 
 
 Hore, Henry 
 
 Lansdown, Joseph G. 
 
 Melford, J. V. 
 
 Smerdon, Charles 
 
 The Library of the Royal Infirmary 
 
 The Bristol Medical Library 
 
 Pritchard, Augustin 
 
 Green, Thomas 
 
 Fox, Charles Harry 
 
 Mayor, E. S. 
 
 Foxwell, J. J. 
 
 Knill, James 
 
 Cooper, Geoflfrey V. 
 
 Bromle-y, Kent .... Williams, B. A. 
 
MEJIBEUS. 
 
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 BUDLEIGH, SaLTERTON, 
 
 Devon 
 
 BUNTINGFORD, HeBTS . 
 
 buefokt), oxon . . . 
 Burnley, Lancashire . 
 
 Burton-on-Teent, Derbys 
 Bury St. Edmunds . . 
 
 Buxton, Derbyshire . . 
 
 Camborne, Cornwall 
 Cambridge 
 
 Canterbury, Kent . . 
 
 Capel, Surrey . . . 
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 Thursfield, Richard 
 
 Walker, R. G., M.D., Loc. Sec. 
 
 Powell, R. G. 
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 Cooke, W. R., Loe. Sec. 
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 Coultate, W. Miller, Loc. Sec. 
 
 Briggs, Henry, M.D. 
 
 Brown, Thomas, M.D. 
 
 Uttley, Hiram 
 
 Thompson, Spencer, M.D., Loc. Sec. 
 
 Mason, William 
 
 Tome, George 
 
 Newham, Samuel, Loc. Sec. 
 
 Blackett, Edward R. 
 
 Image, William E. 
 
 Smith, Charles C. 
 
 Kilner, John 
 
 Robertson, W. H., M.D., Loc. Sec. 
 Pearson, J. A. 
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 Bennett, Robert, M.D. 
 
 Hutchinson, Thomas 
 Vincent, P. 
 
 Carter, J., Loc. Sec. 
 Humphry, G. M., M.B. 
 Paget, G. E., M.D. 
 Haviland, H. J., M.D. 
 Fisher, W. W., M.D. 
 Drosier, W. H., M.D. 
 Green, Thos. 
 Burapsted, T. Brooks 
 Hall, Francis Eussell 
 
 Reid, James, Esq. 
 Tucker, C. C. 
 
 Jardine, John L. 
 
 Page, W. B., Loc. Sec. 
 Elliott, Thomas 
 The Carlisle Medical Library 
 Arras, William 
 Carlyle, D., M.D. 
 Lockie, Stewart, M.D. 
 Reeves, William 
 Brown, Robert 
 Devereux. Daniel 
 
MEMBEKS. 
 
 9 
 
 Cakmaethen 
 Carnarvon . 
 
 CaSTLBFOED, YOEKSHIEE . 
 
 Caxton, Cambeidgeshiee 
 Ceene Abbas, Dorset 
 Chacewatee, Cornwall . 
 Chapel-en-le-Feith,Derb 
 Chapeltown, Yorkshire 
 Chard, Somerset . . . 
 
 Charlton, Kent 
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 Chelmsfoed, Essex . . 
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 Chepstow, Monmouth 
 
 Chebtsey, Surrey 
 
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 Chestee 
 
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 Lewis, Thomas, M.B. 
 
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 Moyle, John 
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 Stone, Joseph Hutchinson 
 
 Spicee, E. W., Loc. Sec. 
 
 Ware, Samuel 
 
 Spicer, Northcote W. 
 
 Swinroe, G. M. 
 
 Brown, F. J., M.D., Loc. Sec. 
 
 Tribe, Hermann, H. 
 
 The Rochester and Chatham Medical 
 
 Book Society 
 Matthew, T. 
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 Wood, N. S., M.D. 
 Askwith, R. 
 Smith, T., M.D. 
 Comyn, S. B. 
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 Winterbotham, Lauriston 
 King, Thomas, Loc. Sec. 
 Bradford, B. M. 
 
 Harcourt, George, M.D. 
 Shurlock, Manwaring, Esq. 
 
 Stormont, H. J. 
 
 McEwEN, W., M.D., Loc. Sec. 
 
 Dobie, W. M., M.D. 
 
 Waters, Edward, M.D. 
 
 Harrison, John 
 
 Harrison, John, jun. 
 
 The Chester Infirmary Library 
 
 Bury, John, M.D. 
 
 Jephcott, S. J. 
 
 Brushfield, Thomas N. 
 
 Black, C, M.D., Loc. See. 
 
 Smith, William 
 
 Booth, Charles, M.D. 
 
 Mackarsie, William (Clav Cros=1 
 
10 
 
 MEMBEES. 
 
 Chestek-le-st., Durham , 
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 COCKERMOUTH, CUMBEKLD 
 
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 Bennett, J. B. 
 
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 Stewart, "William, M.D. 
 Bell, Henry 
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 Morris, David P., Loc. Sec. 
 
 Partridge, Joseph 
 
 Laver, Henry 
 
 Colchester Medical Society 
 
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 Williams, Edward, M.D. 
 
 Bree, C. R., M.D. 
 
 Marshall, W. G. (The Asylum) 
 
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 Bywater, Robert T. 
 
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 Powell, H., M.D. 
 
 Waters, E. 
 
 Laxon, W., M.D. 
 
 Phillips, E., M.D. 
 
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 Coventry Medical Book Society 
 
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 DuNHiLL, C. H., M.D., Loc. Sec. 
 
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MEM BEES. 
 
 11 
 
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 Derby 
 
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 DODDINGTON, CaMBEIDGES 
 DONCASTBE, YOEKSHIRE . 
 
 Dorchester 
 
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 Dover, Kent 
 
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 Caepentee, Alfred, M.D., Loc. Sec. 
 
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 Strother, A. 
 
 Piper, S. E. 
 
 Fothergill, John R. 
 
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 Soame, C. B. H. 
 
 HuLKE, F. T., Loc. Sec. 
 
 Jones, Gboege T. (The County Asylum), 
 
 Loc. See. 
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 Cregeen, Jonathan N. 
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 Goode, Henry, M.D. 
 
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 Waed, Henry, Loc. Sec. 
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 Curme, George 
 
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 Nason, John J. 
 Morgan, William, M.D, 
 
12 
 
 MEMBEES. 
 
 DowNHAM Mkt., Norfolk 
 
 Droitwich, Wokcesteks. 
 Dronfield, Derby . . 
 DncKiNFiELD, Cheshire . 
 
 Dudley, Worcestershire 
 
 Ealing, Middlesex . . 
 Earl Shilton, Leicesters. 
 
 Eastbourne, Sussex . . 
 
 Eastham, Cheshire . . 
 East Retford, Notts 
 
 Eccleshall, Stafford . 
 
 Eckington, Derby . . 
 Elland, Yorkshire . . 
 
 Ely, Cambridge . . . 
 
 Enfield, Lancashire 
 Enfield, Middlesex . . 
 Epping, Essex .... 
 Epsom, Surrey .... 
 
 Erchfont, Wilts . . . 
 EsHER, Surrey . . , 
 Ewbll, Surrey . . . 
 
 Exeter 
 
 Wales, T. G. 
 Gardner, James 
 Johnson, John F., M.D. 
 
 Roden, S. S., M.D. 
 
 France, Ed. Towndrow 
 
 AsPLAND, Alfred, Loc. Sec. 
 Barnes, G. A. 
 
 Fereday, S. D., Loc. Sec. 
 Houghton, J. H. 
 Timmins, Daniel 
 
 GooDCHiLD, John, Loc. Sec. 
 
 Fulshaw, Ralph 
 Spencer, Thomas, jun. 
 
 Roberts, Bransby, Loc. See. 
 
 Lingard, Alexander R. 
 
 Pritchard, William, Loc. Sec. 
 
 Swift, George, M.D. 
 Hawthorne, A. N. 
 
 Jones, John Thomas 
 
 Hamerton, John 
 Hiley, James 
 
 Muriel, John, Loc. Sec. 
 Pearson, Henry 
 Cockerton, Richard 
 Pilkington, W. H. 
 Godfrey, B., M.D., Loc. Sec. 
 Clegg, Joseph 
 
 Ward, Joseph, Loc. Sec. 
 Jones, Arthur O'Brien, M.D. 
 
 White, F. G. 
 
 Izod, Charles W. 
 
 Barrett, S., M.D. 
 Walters, John 
 
 De la Garde, John L., M.B., Loc. Sec. 
 James, John H. 
 Sliapter, T., M.D. 
 Caird, William 
 Gumming, Arthur 
 Hall, William, M.D. 
 Kempe, A. 
 
 The Library of the Devon and Exeter Hos- 
 pital. 
 Roper, C, H. 
 
MEMBERS. 
 
 13 
 
 ExMODTH, Devon . . . 
 
 Fairfield, Manchester . 
 Falkingham, Lincoln 
 Falmouth, Cornwall 
 Fareham, Hants . 
 Farningham, Kent 
 
 Fawley, Hants 
 Filey, Yorkshire . 
 
 Fleetwood-on-Wyke, 
 
 Lancashire . . 
 
 Folkestone, Kent 
 
 Feome, Somerset . . . 
 
 FuLBECK, Lincolnshire . 
 
 Gainsborough, Lincoln- 
 shire 
 
 Glasbury, Brecon . . 
 Gloucester 
 
 Glyneath, Neath . . 
 GoDALMiNG, Surrey . . 
 
 gomersall, yorkshire . 
 Gosport, Hants . . . 
 
 Grampound, Cornwall . 
 Gratesend, Kent . . , 
 
 Great Ouseburn, Yorks. 
 GreatWitley, Worcester 
 Greenwich, Kent . . . 
 
 Guernsey ..... 
 Guildford, Surrey . . 
 Haddenham, Cambridge 
 
 Land, W. H. 
 
 Laud, W. H. 
 
 Mallalieu, F. C. 
 
 Grewcock, George 
 
 Vigurs, R. C, M.B. 
 
 Case, William 
 
 Adams, James 
 
 Ashurst, W. R., M.D. 
 
 Churchill, S., M.D. 
 
 Pritchard, E.W., M.D., Loc. Sec. 
 
 Lord, James 
 
 Bowles, Robert L., Loc. Sec. 
 Bateman, William 
 Tyson, W. T. 
 
 Bush, Edward, Loc. Sec. 
 Gockey, Edward 
 
 Newman, William 
 
 Mackinder, D., M.D., Loc. Sec. 
 Smallman, J. C. B. 
 
 Bogle, A. L. 
 
 Wood, A. J., Loc. Sec. 
 Graves, R. W. 
 Rhys, Watkin 
 
 Yate, Frederick 
 Chandler, A. T. 
 Carr, William, jun. 
 
 Kealy, J. R., Loc. Sec. 
 Wharton, Henry Samuel 
 
 Stephens, J. 
 
 Armstrong, J., M.D., Loc. Sec. 
 Pinching, Charles J. 
 
 Crosby, John 
 
 Greensill, J. N. 
 
 Bradley, R. Holland, M.D., Loc. Sec. 
 Shute, Gay 
 Palmer, H. R. 
 
 Corbin, M. A. B. 
 Dundas, J. H. 
 
 Sells, T. Jenner, Loc. Sec. 
 Boxall, Henry 
 
 Davie, J. C. 
 
14 
 
 MEMBEES. 
 
 Halifax, Yoekshiee . . 
 
 Hampton, Middlesex 
 
 Hanwell, Middlesex 
 
 Haulow, Essex . . . 
 Harpenden, Herts . . 
 Harrogate, Yorkshire . 
 Hartlepool, Durham 
 Harwell, Berks . . . 
 Harwood, Lancashire . 
 Haslingden, Lancashire 
 Hastings, Sussex . . . 
 
 ■ Oak, 
 
 Hatfield - Broad ■ 
 
 Essex 
 
 Havant, Hants . . . 
 Haverfordwest,Pembek. 
 
 Hawkshead, Lancashire 
 Hay, Brecon .... 
 Headcorn, Kent . . . 
 Helmsley, Yorkshire 
 Helpekby, Yorkshire 
 Helston, Cornwall . . 
 Hems WORTH, Yorkshire . 
 Henley-on-Thames, Oxf. 
 Hinckley, Leicestersh. . 
 Hindekwell, Yorks. . . 
 Hitchin, Herts . . . 
 HoDDESDON, Herts . . 
 
 Holbbach, Lincolnshire 
 HoLLiNGWooD, Lancashire 
 
 Paley, W., M.D., Loc. Sec. 
 
 Bramley, Laurence 
 
 Jubb, Abraham 
 
 Peacock, W. H. 
 
 Crowther, Thomas 
 
 Holberton, V. H. A. 
 
 Jepson, Henry 
 
 Aubin, F. G. 
 
 Haffenden, Dalton Adolphus 
 
 Day, Robert V. 
 
 West, R., M.D. 
 
 Kennion, G., M.D., Loe. Sec. 
 
 Stamp, T. E. 
 
 Lightfoot, William 
 
 Dearden, James 
 
 Stott, W. J. 
 
 Underwood, John, M.D., Luc. Sec. 
 
 Greenbill, W. A., M.D. 
 
 The East Sussex Medical and Chirurgical 
 
 Society 
 Adey, Charles, M.D. 
 Marks, Alexander H., M.D. 
 Wilson, Robert James, M.D. 
 
 Smith, W.Abbotts, M.D., Loc. Sec. 
 
 Davies, Albert, M.D. 
 
 Brown, J. D. 
 
 Phillips, Ed. Picton 
 
 Johnston, Augustus, M.B. 
 
 Trumper, F. R. 
 
 Skinner, Sylvester R. 
 
 Ness, John 
 
 RouJston, John 
 
 Moyle, M. P. 
 
 Leak, Thomas M. 
 
 Brooks, A. D'Oyley 
 
 Garrard, Stamp 
 
 Laverick, J. 0., M.D. 
 
 Shillitoe, R. R., Loc. Sec. 
 
 Hooper, John, M.D. 
 
 Horley, William L. 
 
 Vise, Edward B. 
 
 Kenworthy, John 
 
MEilBEUS. 
 
 15 
 
 Holyhead, Anglesea 
 Holywell, Flints . 
 HoPTON, Suffolk . 
 
 HORNCHUKCH, EsSEX 
 
 HousHAM, Sussex . 
 HowDEN, Yorkshire 
 huddeesfield, yorks 
 
 Hull, Yorkshire . 
 
 Huntingdon 
 
 HURSTGREEN, SuSSEX . . 
 
 Hurworth-on.-Tees . . 
 Hyde, Cheshire . . 
 Hythe, Kent . . . . 
 Ibstock, Leicestershire 
 Ilkley, Yorkshire . . 
 Ipswich 
 
 Isle of Man 
 Jersey . . 
 
 Keighley, Leeds, Yorks. 
 Kenninghall, Norfolk . 
 Kettering, Northampt. . 
 
 Hughes, Thomas, Loc. Sec. 
 Hughes, Evan Thomas 
 
 Davies, Jesse C, M.D. 
 Williams, James 
 
 Morgan, Charles, jun. 
 
 Cooper, W., M.D., 
 
 Gravely, Thomas 
 
 Dunn, Joshua 
 
 TBottomley, T. S., Loc. Sea. 
 Haycock, William 
 Booth, Samuel 
 
 King, Kelbourne, M.D., Loc. Sec. 
 
 Eraser, E. 
 
 Atkin, George, M.D. 
 
 Healey, Edward 
 
 Craven, R. M. 
 
 Boulter, B. 
 
 The Infirmary Library 
 
 Locking, J. A. 
 
 Foster, Michael, Loc. Sec. 
 Foster, Michael, jun. 
 The Huntingdon Medical Book Society 
 Carver, Edmund 
 
 Manley, John, M.D. 
 
 Cossar, T., M.D. 
 
 Payne, George B. 
 
 Wildash, Henry C, M.D. 
 
 Thomas, R. H. 
 
 Mann, D. 
 
 Hammond, C. W., Loc. Sec. 
 
 Chevallier, B. 
 
 The Ipswich Medical Book Society 
 
 Beck, E., M.D. 
 
 Bullen, George J. 
 
 Sampson, George G. 
 
 Gull, Frederic 
 
 Cowell, George 
 
 Kilgour, John S., M.D. 
 
 Vaudin, Charles, Loc. Sec. 
 Blood, Michael, M.D. 
 Dickson, Joseph, M.D. 
 
 Dickson, John 
 
 Sayer, Thomas J. 
 
 Wyman, W. S., Loc. Sec. 
 
16 
 
 MEMBERS. 
 
 Kendal, Westmoeeland 
 Keynsham, Someeset. . 
 
 KiBWOKTH, LeICESTEK. . 
 
 KiDDEEMlNSTEK, WoROES- 
 TERSHIKE 
 
 KiNGSBEIDGE, DeVON . . 
 
 King's Langley, Herts . 
 
 Kingston-on-Thames, 
 
 Surrey 
 
 Kintek, Stappord . . 
 Kirkoswald, Cumbe rland 
 
 Kirton-in-Lindsey, Lin- 
 colnshire .... 
 
 Knottingley, Yorks. 
 
 Knutsford, Cheshire 
 Lancaster 
 
 Langport, Somerset . 
 
 Leamington, Warwick. 
 
 Leatherebad, Surrey 
 
 Lee, Kent . . . 
 Leeds, Yorkshire 
 
 Walker, R., Loc. Sec. 
 Green, T., M.B. 
 Leeming, R. T. 
 Hatchings, William 
 Macaulay, Thomas 
 Marriott', J. 
 
 RoDEN, W., M.D., Loc. Sec. 
 Gardner, Richard 
 Stretton, Samuel 
 Elliot, John, Loc. Sec. 
 Cornish, Francis, S. 
 Wotton, Richard 
 Wotton, W. G. 
 
 Kershaw, W. W., M.D., Loc. Sec. 
 Holyoake, Thomas 
 Gill, George 
 
 George, C. F. 
 
 Waterland, H. J. 
 
 Bywater, John 
 
 Hollingvrorth, John 
 
 Merriman, C. A. 
 
 Irvin, John W. 
 
 Johnson, C. 
 
 Prankerd, John, Loc. See. 
 
 Larcombe, John 
 
 Ebbage, Thomas, Loc. Sec. 
 
 Clark, James F. 
 
 Thomson, Thomas, M.D. 
 
 Machen, John 
 
 Jones, Richard 
 
 Owen, Francis 
 
 Courtney, Sidney 
 
 Burton, John M. 
 
 Teale, T. p., jun., Loc. Sec. 
 
 Teale, T. P. 
 
 Scarth, J. W. 
 
 Scattergood, Thomas 
 
 Bearpark, G. E. 
 
 Braithwaite, W. 
 
 Brooke, H. 
 
 Braraeld, H. E. 
 
 Carter, J. B. 
 
 Chadwick, C, M.D. 
 
 Foster, E., M.D. 
 
 Garlick, J. P. 
 
MEMBERS. 
 
 17 
 
 Leeds, Yorkshike 
 
 Leek, Staffobd 
 Leicestee . . 
 
 Leigh, Manchester . . 
 Leighton Buzzard, Beds 
 Leominster, Hereford . 
 Lewes, Sussex .... 
 
 Lichfield, Stafford 
 Lincoln 
 
 Liverpool 
 
 Hardwick, R. G. 
 Ikin, J. I. 
 
 Mavne, R. G., M.D. 
 Pi-ice, N. W. 
 Ramskill, Josiah 
 Scott, William 
 Smith, Pyemont, M.D. 
 Wheelhouse, C. G. 
 Irvine, J. W. 
 Hey, Samuel 
 Seaton, James 
 Hall, William 
 Haxworth, William 
 Empson, Charles F. 
 Jackson, H. G. 
 Morley, George 
 
 Cooper, Richard 
 
 BARCLAy, J., M.D., Loc. Sec. 
 The Leicester Infirmary 
 The Leicester Medical Book Society 
 May, William H. 
 
 Anderton, Charles 
 
 Lawford, Edward, M.D. 
 
 Barnett,' Samuel, Loc, Sec. 
 
 Rigden, George C. 
 Miirrell, W. H. 
 Morris, John P., M.D. 
 
 Welchman, C. B. E., Loc. Sec. 
 
 Sympson, Thomas, Loc. Sec, 
 Broadbent, Edward Farr 
 O'Neill, William, M.D. 
 Hewson, John 
 
 Grimsdale, Thomas F., Loc. Sec. 
 
 Bickersteth, E. R. 
 
 Dickinson, Joseph, M.D. 
 
 Long, James 
 
 Manifold, William H. 
 
 Drysdale, John James, M.D. 
 
 Stookes, Alexander R., M.D. 
 
 Nevins, John B., M.D. 
 
 Whittle, Ewing, M.D. 
 
 Inman, Thomas, M.D. 
 
 Gilmour, James, M.D, 
 
 Batty, Edward 
 
 Gill, George 
 
 Eden, Thomas 
 
MBMBEIIS. 
 
 LiVEKPOOL Chalmers, David, M.D. 
 
 Imlack, Henry, M.D. 
 
 Jones, Ellis 
 
 Dawson, Thomas 
 
 The Medical Institution 
 
 Smith, J. Brumby 
 
 Taylor, J. Stopford, M.D. 
 
 Gallon, W. J. 
 
 Allen, Joseph 
 
 Parker, Edward 
 
 Hey, John 
 
 Taylor, — , M.D. 
 
 Capper, Jasper 
 
 George, — 
 
 Walker, G. 
 
 Lister, Edward 
 
 Greenwood, H. 
 
 Llandovery, Carmarthen Thomas, David, Loc. Sec. 
 
 Williams, George G. L. 
 
 Llanelly, Carmarthen . Thomas, Richard 
 
 Addison, Dr. Thomas, M.D. 
 
 Adlard, J. E 
 
 Allingham, William 
 
 Andrew, J 
 
 Adams, William . . . 
 Alison, S. Scott, M.D. . . 
 Armitage, Thomas R., M.D. 
 
 Ash ton, T. J 
 
 Arasden, Geo. John, M.D. 
 
 Allston, W. E 
 
 Ablett, Edward .... 
 Bowman, William, F.R.S. 
 Beale, Lionel S., M.D. 
 Barlow, G. H., M.D. 
 Brown, Thomas . 
 Bristowe, J. S., M.D. 
 Barnes, Robert, M.D. 
 Brodhurst, B. E. . 
 Brinton, William, M.D. 
 Barker, Thomas A., M.D. 
 Bryson, Alexander, M.D. . 
 Buchanan, George, M.D. . 
 Babington,B.G,,M.D.,F.R.S, 
 Barwell, Richard . . . 
 Ballard, Edward, M.D. . 
 Ballard, Thomas, M.D. . 
 
 LONDON. 
 
 24, New Street, Spring Gardens, W.C. 
 
 Bartholomew Close 
 
 36, Finsbury Square, E.C. 
 
 66, West Smithfield, E.C. 
 
 5, Henrietta Street, Cavendish Sq., W. 
 
 80, Park Street, Grosvenor Square, W. 
 
 21, Edward Street, Portman Square, W. 
 31, Cavendish Square, W. 
 
 5, Gloucester Terrace, Hoxton, N. 
 
 King's College, Strand, W.C. 
 
 62, Great Russell Street, Bloomsbury 
 
 .5, Clifford Street, Bond Street, W. 
 
 27, Carey Street, Lincoln's Inn, W.C. 
 
 5, Union Street, Southwark, S.E. 
 
 16, Finsbury Circus, E.C. 
 
 3, St. Thomas Street, Southwark, S.E. 
 
 12, Finsbury Square, E.C. 
 
 20, Grosvenor Street, W. 
 
 20, Brook Street, Grosvenor Square, W. 
 
 71, Lower Grosvenor Street, W. 
 
 Somerset House, W.C. 
 
 75, Gower Street, W.C. 
 
 31, George Street, Hanover Square, W. 
 
 22, Old Burlington Street, W. 
 42, Myddleton Square, W.C. 
 
 10, Southwick Place, Hyde Park, W. 
 
MEMBEES. 1 9 
 
 Brooke, Charles, M.A.F.E.S. 29, Keppel Street, Eussell Square, W.C. 
 
 Bennett, Henry, M.D. . . GO, Grosvenor Street, W. 
 
 Budd, Gen., M.D., P.R.S. 20, Dover Street, Piccadilly, W. 
 
 Burrows, Geo.,M.D.,F.R.S. 18, Cavendish Square, W. 
 
 Banner, Samuel . . . . 11, Delamere St., Up.WestbourneTer.,W. 
 
 Barratt, Joseph G., M.D. . 22, Cleveland Gardens, Hyde Park, W. 
 
 Bateraan, Henry . . . 32, Compton Terrace, Islington, N. 
 
 Barnett, Thomas W. . . 72, Ford Street, Limehouse, E. 
 
 Bourjeand, P 11, Davies Street, Berkeley Square, W. 
 
 Birkett, Edmund Lloyd . 48, Russell Square, "W.C. 
 
 Bryant, "Walter J., F.R.G.S. 7, Bathurst Street, Sussex Square, W. 
 
 Browning, Charles ... 20, Dorset Place, Dorset Square, N.W. 
 
 Bartlett, William . . . Ladbiroke Lodge, Ladbroke Square, W. 
 
 Brett, R Stoke Newington Green, N. 
 
 Barker, Alfred J. ... 5, Belle Vue Villas, Upper Holloway, N. 
 
 Barnes, Herbert Sedgwick 182, King's Road, Chelsea, S.W. 
 
 Bright, J. M Dulwich 
 
 Bush, John The Retreat, Clapham 
 
 Bedford, Robert J. . . . ' The Dreadnought 'Hospital Ship 
 Bower, Richard W. . . 14, Doughty St., MecklenburghSq., "W.C. 
 Brixton Medical Book So- 
 ciety (Samuel Osborn) . 19, Manor Terrace, Brixton, S. 
 
 Bruce, S. N 19, Clifton Villas, Maida Hill, W. 
 
 Browning, G., M.D. . . 10, St. Stephen's Crescent, Westbourne 
 
 Park, W. 
 
 Beale, Bernard C. . . . 2, Park Cottages, Victoria Park, N.E. 
 
 Balliere, Messrs. (5 subs.) Regent Street 
 
 Banks, Philip H. . . . Widdicomb Terrace, Barking Road 
 
 Beattie, Henry .... 7, Wandsford Place, Camden Town 
 
 Bryant, Thomas ... 40, Wellington Street 
 
 Batten, R. W., M.D. . . St. Bartholomew's Hospital 
 Bradford, Wm. Jocelin, M.D. 4, York Place, Islington Green 
 
 Brown, J. L., M.D. . . 86, Park Street, Grosvenor Square 
 Baly, William, M.D., F.R.S. 45, Queen Ann Street, Cavendish Square 
 
 Clarke, Vans, M.D. . . The Royal Naval Rendezvous, Tower Hill 
 
 Collins, Francis, M.D. . . (Staflf Assistant-Surgeon) 
 
 Cock, Edward .... 13, St. Thomas Street, Southwark, S.E. 
 
 Clapton, E., M.D. ... 8, Wellington Street, S.E. 
 
 Callender, G. W. . . . 35, Queen Anne Street, W. 
 
 Coote, Holmes .... 26, New Bridge Street, Blackfrlars, E.C. 
 
 Conol'ly, C. T 1 1 1, Aldersgate Street, E.C. 
 
 Crosby, T.B 13, Fenchurch Street, B.C. 
 
 Cooke, R. H Church Street, Stoke Newington, N. 
 
 Croft, John 'TlieDreadnought' Hospital Ship 
 
 Critchett, George ... 46, Finsbury Square, E.G. 
 
 Copland, James, M.D. . . 5, Old Burlington Street, W. 
 
 Clark, Andrew, M.D. . . 23, Montague Place Russell Sq., W.C. 
 
 Curgenven, J. Brendon . 11, Craven Hill Gardens, Bayswater, W. 
 
 Childs, George Borlase . 11, Finsbury Place South, E.C. 
 
 Clifton, Nathaniel H. . . 38, Cross Street, Ishngton, N. 
 
20 
 
 MEMBERS. 
 
 Cholmeley, William, M.D. 
 Chessall, William , . . 
 
 Clover, J. T 
 
 Cleveland, W. F. . . . 
 Choltnondeley, Joseph 
 Cattlin, William A. N. 
 Cooke, W. M., M.D. . . 
 Collins, Adolphus,40thKegt 
 Cockerton, Richard . . 
 
 Coward, Thomas C. . . 
 
 Chance, — , M.D. . . . 
 
 Coote, Charles, M.D. . . 
 
 Chippendale, John . . . 
 Chambers, Thomas 
 
 Carpenter, John . . . 
 
 Christie, Thomas, M.D. . 
 
 Cheyne, R. R., Esq. . . 
 Couper, John, Esq. . . 
 Curran, Wm., Esq. . . 
 Coleman, Alfred .... 
 Chaplin, Thomas, M.D. . 
 Clarke, J. Fernandez . . 
 Cooper, Frank W. . . . 
 Clark, Charles .... 
 D'Olier, Isaac Arthur, M.D. 
 Denny, John .... 
 Duncan, Bartholomew A. . 
 Duncan, Peter C, M.D. . 
 Davis, Francis W., R.N. . 
 Drury, J 
 
 Down, John L. H. . . . 
 Davies, Herbert, M.D. 
 Druitt, Robert .... 
 Dixon, James .... 
 Duncan, James, M.D. . . 
 Daldy, T. M., M.D. . . 
 Denne, Thomas .... 
 
 Dudgeon, R. E., M.D. 
 Davis, John Hall, M.D. . 
 Drury, W. V., M.D. . . 
 
 Dyer, — , M.D 
 
 Dempsey, J. M., M.D. . . 
 Erichsen, John B. . . . 
 Evans, Conway, M.D. . . 
 Edwards, George N. . . 
 Earle, E. S 
 
 40, Russell Square, W.C. 
 
 5, Gloucester Terrace, Hoxton 
 
 44, Mortimer Street, Cavendish Sq., "W. 
 
 23, Beaufoy Terrace, Maida Yale, W. 
 
 3, Nottingham Place, N.W. 
 
 239, Upper Street, Islington, N. 
 
 39, Trinity Square, The Tower, B. 
 
 15, Clarendon Road, Kensington New 
 Town, W. 
 
 6, Stepney Square, E. 
 The Victoria Hotel 
 
 1, (rloucester Place, Hyde Park 
 
 16, Upper Philli more Place, Kensington 
 42, Grove Road, St. John's Wood, N.W. 
 64, Paradise Street, Lambeth 
 Pembroke House, Mare Street, Hackney, 
 
 N.E. 
 27, Nottingham Place, Marylebone, W. 
 9, Finsbury Circus, B.C. 
 (Army Assistant-Surgeon) 
 3, Finsbury Square, E.G. 
 25, Brorapton Crescent 
 23, Gerrard Street, Soho, W. 
 Charing Cross Hospital 
 1, Adelaide Terrace, NottingHill, W. 1860. 
 1, York Place, Mile End Road 
 1, Sumner Terrace, Brorapton 
 32, Francis Street, Torrington Square 
 12, Cambridge Street, Regent Street 
 
 At Dr. Saunders', Queen Street, Cheap- 
 side, E.G. 
 
 23, Finsbury Square, B.C. 
 
 37, Hereford Street, May Fair, "W. 
 
 I, Portman Square 
 
 Henrietta Street, Covent Garden, W.C. 
 
 39, Broad Street Buildings, B.C. 
 
 1, Cottage Green, Southampton Street, 
 
 Camberwell, S. 
 82, Gloucester Place, Portman Sq., W. 
 Harley Street, W. 
 3, The Crescent, Camden Rd. Villas, N.W. 
 
 7, Berkeley Street, Piccadilly 
 27, Charterhouse Square 
 
 48, Welbeck Street, Cavendish Sq., W. 
 
 30, Brook Street, W. 
 
 1, Finsbury Square, E.G. 
 
 St. Bartholomew's Hospital, B.C. 
 
MBMBJillS. ^1 
 
 Engall, Thomas . . . . 15, Euston Square, N.W. 
 
 Edenborough, Alfred . . 3, West Street, Finsbury Circus, E.G. 
 
 Evans, MicoU .... Stoke Newington Common 
 
 Eyans, Owen, M.D. . ■ . 225, Shoreditch, E.G. 
 
 Fergusson, William, F.R.S. 16, George Street, Hanover Square, W. 
 
 Fuller, Henry W., M.D. . 13, Manchester Square, W. 
 
 Forster, John Cooper . . 11, Wellington St., London Bridge, S.E. 
 
 Fish, Robert 239, Upper Street, Islington, N. 
 
 Forbes, John Gregory . . 9, Devonport Street, Hyde Park, W. 
 
 Frodsham, John Mill, M.D. 26, Up. Bedford Place, Russell Sq., W.G. 
 Ferguson, Rrjt.,M.D.,F.R.S. 125, Park Street, Grosvenor Square 
 
 Fisher, Alder .... 15, John Street, Bedford Row, W.C. 
 
 Farr, G. F 171, Union Street, Southwark 
 
 Fitzgerald, Thos. J. . . (Staff Surgeon) Arftiy and Navy Club 
 
 Gowlland, Peter Yeames . 34, Finsbury Square, E.C. 
 
 Goolden, R. H., M.D. . . 41, Sussex Gardens, Hyde Park, W. 
 
 Gibb, Geo. Duncan, M.D. 22, Portman Street, Portman Square 
 
 Greenhalgh, R., M.D. . . 11, Up. Woburn PI., Russell Sq., W.C. 
 
 Gull, William W., M.D. . 8, Finsbury Square, E.C. 
 
 Giles, George Frederick . Clifton Villa, Victoria Park Road, Hack- 
 ney, N.E. 
 
 Gibson, J. R 115, Holborn Hill, E.C. 
 
 Godfrey, John, M.D. . . 33, Finsbury Square, E.C. 
 
 Gairdner, William . . . 12, Bolton Street, W. 
 
 Goodday, Horatio . . . 76, Oxford Terrace, W. 
 
 Garlick, W 33, Great James St., Bedford Row, W.C. 
 
 Griffith, John T. ■ • • High Street, Peckham, S.E. 
 
 Grosvenor Book-Club'. . 31, Wardour Street, Soho, W. 
 
 Giles, Samuel, M.B. . . 13, Norfolk Villas, Bayswater 
 
 Godfrey, Charles V. . . St. Bartholomew's Hospital 
 
 Hillier, Thomas, M.D. . 21, Upper Go wer Street, W.C. 
 
 Habershon, S. 0., M.D. . 22, Wimpole Street, Cavendish Sq., W. 
 
 Hilton, John 10, New Broad Street, E.C. 
 
 Hutchinson, Jonathan , . 14, Finsbury Circus, E.C. 
 
 Hardinge, Henry, M.D. . 24, S.ickville Street, Piccadilly, W. ' 
 
 Hogg, Charles .... 12, Aldersgate Street, E.C. 
 
 Harkness, W. W. . . . 9, Finsburv Circus, E.C. 
 
 Hewitt, Graily, M.D. . . 17, Radnor Place, Hyde Park, W. 
 
 Hare, Charles J., M.D. . 41, Brook Street, W. 
 
 Hulke, J. W Old Burlington Street 
 
 Hawkins, Csesar H., F.R.S. 26, Grosvenor Street, W. 
 
 Henry, Alexander, M.D. . 5lA,Poulton Sq.,King'sRd.,Chelsea,S.W. 
 
 Harley, George, M.D. . . 40, Somerset Street, Portman Square, W. 
 
 Hodgkin, Thorarts, M.D. . 35, Bedford Square, W.C. 
 
 Holland, Sir Henry, Bart., 
 
 F.R.S 25, Brook Street, W. 
 
 Holthouse, Carsten ... 2, Storey's Gate, St. James's Park, S.W. 
 
 Hewett, Prescott G. . . 1, Chesterfield Street, Blay Fair, W. 
 
 Heath, Christopher . . . 31, Sackville Street, W. 
 
 Harvey, William ... 2, Soho Square, W. 
 
MEMBEES. 
 
 Hunterian Society, The 
 Hancorn, James B., M.D 
 Hoodj Peter . . . 
 Holmes, Timothy . 
 Hawkins, James S. 
 Holman, Andrew 
 Hunter, T., M.D. . 
 Harris, Wintour 
 Henderson, Joseph . 
 Horton, James . 
 Holl, Harvey B. 
 Helm, G. F. . . . 
 Johnson, George, M.D 
 Jones, Philip Sydney 
 Jackson, Hughlings J. 
 Jackson, T. C. . 
 James, J. W. W. 
 Jones, Henry D. 
 Jones, R. Price . 
 James, Henry 
 Jorden, W. P. . 
 Jay, Henry . . 
 Jones, John D., M.D 
 Jones, C. Handfield, M 
 
 Jones, Mr 
 
 Joyce, Thomas . . 
 
 Irving, — ... 
 Kirkes, W. Senhouse, M 
 Keele, George Thomas 
 
 Kirby, Edmund S., M.D. 
 King, Thomas K. . 
 King, H. Staveley, M.] 
 Kisch, Joseph . 
 Kernot, G. C, M.D. 
 Kernot, A. B. . . 
 Kitchener, Dr. . . 
 Leared, Arthur, M.D. 
 Lane, S. A. . . . 
 Lloyd, E. A. . . . 
 Lawson; George . . 
 Ley, H. Rooke . . 
 Lobb, Harry William 
 Langmore, J. C, M.B 
 Little, W. J., M.D. . 
 Love, James . 
 Lattey, Parke P. 
 Lloyd, Thomas . . 
 Langley, "W., M.D. . 
 
 D. 
 
 D. 
 
 Blomfield St., Finsbury Circus 
 
 22, White Lion Street, Spital Sq., E.G. 
 15', Lower Seymour St., Portman Sq., W. 
 39, Curzon Street, W. 
 
 36, Colet Place, Commercial Road, E. 
 10, Jolin Street, America Square, E.G. 
 (Staff Surgeon, 1st class) 
 
 16, Dorset Terrace, Clapham Road, S. 
 71, High Street, Marylebone W. 
 
 8, High Street, Stepney 
 
 33, St. George's Square, S.W. 
 
 St. Bartholomew's Hospital 
 
 S, Woburn Square, W.C. 
 
 42, Myddleton Square, W.C. 
 
 Finsburv Circus, B.C. 
 
 8, Hamilton Place, King's Cross, N.W. 
 
 Nelson Terrace, Stoke Newington, N. 
 
 23, Soho Square, W. 
 
 University College Hosp., Gower St., W.C. 
 
 17, Artillery Place, E.G. 
 
 14, Lower Belgrave Street, Eaton Sq.,W. 
 
 50, Sloane Street, S.W. 
 
 1, Queen's Road, Dalston, N.E. 
 
 33, Albion Street, Hyde Park, W. 
 
 Aldersgate Sti'eet, E.G. 
 
 1, Berkeley Gardens, Camden Hill, Ken- 
 sington 
 
 St. Thomas's Hospital 
 
 2, Lower Seymour St., Portman Sq., W. 
 1, Bruce Villas, St. Paul's Road, High- 
 bury, N. 
 
 1, Taviton Street, N.W. 
 
 23, Addington Place, Camberwell, S. 
 
 28, Lower Grosvenor Street, W. 
 
 Circus Place, Finsbury Circus, E.G. 
 
 Chrisp Street, Poplar, E. 
 
 16, Tavistock Street, Covent Garden 
 
 Guy's Hospital 
 
 48, Finsbury Square, E. C. 
 
 I, Grosvenor Place, Hyde Park, S,W. 
 14, Bedford Row, W.C. 
 
 63, Park Street, Grosvenor Square, W. 
 Grove House Lunatic Asylum, Bow 
 63, Gloucester Terrace, Hyde Park, W. 
 20, Oxford Terrace, Hyde Park, W. 
 34, Brook Street, Grosvenor Square, W. 
 
 II, Burton Street, Eaton Square, S.W. 
 53, Cambridge Terrace, Hyde Park, W. 
 Finsbury Circus, E.G. ' 
 20, King Street, Portman SquaVe, W. 
 
MEIIBEUS. 23 
 
 Logan, D. D., M.D. .• . (Staff Surgeon, 1st class) 
 
 Larab, Robert .... 13, Arbour St. W., Commercial Rd. E., E. 
 
 Low, Sampson, & Co. (two subs.) Ludgate Hill 
 
 Langmore, W. B. . . . 4, Christopher Street, Finsburj' 
 
 Langdon, T. C 30, Frederic's Street, Gray's Inn Road 
 
 Loclchart, — , M.D. . . Park Villas, Granville Park, Blackheath 
 
 Martin, Robert, M.D. . . St. Bartholomew's Hospital, E.G. 
 
 Murchison, Charles, M.D. /9, Wimpole Street, W. 
 
 Meric, Victor De . . . 17, Brook Street, Grosvenor Square, W. 
 
 Mackenzie, — .... The London Hospital, Mile End Road, B. 
 
 Marcet, Wilham, M.D. . 36, Cliapel Street, Belgrave Square, S.W. 
 
 Mayo,Thomas,M.D.,F.R.S. 56, Wimpole Street, W. 
 
 Maclean, Samuel . . . 10, Conduit Street, Regent Street, W. 
 
 Morgan, J. E 48, Green Street, Grosvenor Square, W. 
 
 Markwick, Alfred ... 65, Trinity Square, Southwark, S. E. 
 
 Markham.WilliamCM.D. 33, Clarges Street, Piccadilly, W. 
 
 Meryon, Edward, M.D. . 14, Clarges Street, Piccadilly, W. 
 
 Martin, J. Ranald, M.D. . 71a, Grosvenor Street, W. 
 
 Morris, Matthew ... 8, River Terrace North, Islington, N. 
 
 Morris, Edward .... St. Bartholomew's Hospital 
 Medical and Chirurgical Society, The Royal, Berners Street 
 
 Maclennan, John, M.D. . 53, Upper Harley Street, W. 
 
 Marsh, John, M.D. . . 1, Rockingham Row, New Kent Road 
 
 Marshall, J. Brake . . . 21, Princes Street, Hanover Square 
 
 Manook, S. J 5, Norfolk Street, Strand 
 
 Mason, Samuel, M.D. . . 44, Finsbury Circus, E.G. 
 
 Meeres, Edward E. . . 19, King Street, Finsbury Square, E.G. 
 
 Nunn, T. W 8, Stratford Place, Oxford Street, W. 
 
 Nichol, Robert, M.D. . . Denmark Hill, S. 
 
 Nichols, G. W Rotherhithe, S.E. 
 
 Neale, W. M 18, Westbourne Place, Eaton Square, W. 
 
 Nash, Thomas, M.D. . . 33, Bridge Street, Southwark, S.E. 
 
 Newnham, Lewis, M.D. . 10, Addington Place, Camberwell Rd., S. 
 
 Nichols, Robert J. . . . Rotherhithe 
 
 Oldham, Henry, M.D. . . 26, Finsbury Square, E.G. 
 
 Ord, W. M Brixton Hill, S. 
 
 Ogle, John W., M.D. . . 13, Upper Brook St., Grosvenor Sq., W. 
 
 Ogle, William, M.D. . . 7, Lower Belgrave St., Eaton Sq., S.W. 
 
 Obre, Henry 1, Melcombe Place, Dorset Square, N.W. 
 
 Oswald, R. H., M.D. . . (Madras Army) 
 
 Paget, James, F.R.S. . . 1, Harewood Place, Hanover Square, W. 
 
 Peacock, T. B., M.D. . . 20, Finsbury Circus, E.G. 
 
 Pearse.RobertBryant,M.D. 1 2-, Carthusian St., Charterhouse Square. 
 
 E.G. 
 
 Payne, Mr St. Thomas's Hospital, TheBoro', S.E. 
 
 Priestley, William 0., M.D. 16, Somerset Street, Portman Square, W. 
 
 Parfitt, Henry, M.B. . . 26, St. James's Square, S.W. 
 
 Potts William .... 12, North Audley Street, Grosvenor 
 
 Square, W. 
 
 Pitman, Henry A., M.D. . 28, Montague Place, Russell Square,W.C. 
 
24 
 
 MEMBEES. 
 
 Perkins, Houghton . . . 25, Mortimer Stteet, Cavendish Sq., W. 
 
 Partridge, Richard . . . 17, New Street, Spring Gardens, S.W. 
 
 Pocock, William . . . 1, St. John'sVillas, Angel Ter.,Brixton,S. 
 
 Tettigrew, F. W. . , . 9, Belgrave Rd., Eccleston Sq.,Pimlico,W. 
 
 Pick, Thomas P. . . . 1 1, Deiamere St., Up.WestbourneTer.,W. 
 
 Paul, J. H., M.D. . . . Caraberwell House, Peckbam Rye 
 
 Part, James 7, Camden Rd.Villas, Camden Town, N.W. 
 
 1, Eastcot PI., East India Rd., Poplar, E, 
 
 Heath Street, Hampstead, N.W. 
 
 26, Brompton Crescent 
 
 7, Old Palace Terrace, Richmond 
 
 23, Harley Street, Cavendish Square, W, 
 
 5, St. Helen's Place, Bishopsgate St., E.C, 
 
 12, Hinde Street, Manchester Square, W, 
 
 Hinde^Street, Manchester Square . 
 
 St. Tbomas's Hospital, The Boro', S.B. 
 
 Ruttledge, T. B. . . . The London Hospital, Mile End Road, E. 
 
 Robertson.C.A.L., M.B. . 1, Charles Street, Berkeley Square, W. 
 
 Ray, Edward .... Dulwich 
 
 Rogers, Nathaniel, M.D. . Alma Terrace, Dalston 
 
 Eoberts, J. H 10, Finchley Road, N.W. 
 
 Priddle, George L 
 Prance, R. R., M.D. . , 
 Pollard, Charles F. . . , 
 Parkes, E. A., M.D. . 
 Quain, Richard, M.D. . 
 Ramskill, J. Spence, M.D 
 Richardson, B. W., M.D 
 Eichardson, Thos., M.D. 
 Rudall, J. T. ... 
 
 Robinson, Thomas 
 Roth, Matthias, M.D. . . 
 Rice, James, M.D. . . . 
 Ramadge, F. H., M.D. . 
 Riding, Roger, M.D. . . 
 Ree, Henry Paule . . . 
 Ridge, Joseph, M.D. . . 
 Ridsdale, George, M.D. . 
 Rogers, Henry . . . , 
 Eoe, Hamilton, M.D. . , 
 Rutter, Joseph . . . . 
 Salter, S. J. A., M.B. . . 
 Stone, William Henry, M.B 
 Stevens, N. Henry 
 
 50, Southampton Street, Pentonville, N. 
 
 16a, Old Cavendish Square, W. 
 
 19, Langham Street, W. 
 
 40, Clarges Street, W. 
 
 36, Euston Square, N.W. 
 
 Walliara Green, Fulham, S.W. 
 
 39, Dorset Square, N.W. 
 
 1, Euston Square, N.W. 
 
 St. Bartholomew's Hospital 
 
 57, Park Street, W. 
 
 University College Hospital 
 
 17, New Broad Street, E.C. 
 
 13, Vigo Street, Regent Street, W. 
 
 14, Finsbury Circus, E.C. 
 Saunders,W.Sedg'wick,M.D. 13, Queen Street, Cheapside, E.C. 
 Smith, H. Spencer ... 48, Sussex Gardens, Hyde Park, W. 
 Savory, W. S., M.B.,F.R.S. 13, Charterhouse Square, E.C. 
 Sibley, S. W 14, New Burlington Street, W. 
 
 Solly, Samuel, F.R.S. . . 18,St. Helen's Place.Bishopsgate St., E.C. 
 Sewell,CharlesBrodie,M.D. 13, Fenchurch Street, E.C. 
 Summerhayes, — ... The Surrey Dispensary, Gt. Dover Street 
 Sanderson, John Burden,M.D. 9, Gloucester Place, Hyde Park, W. 
 Sercombe, Edwin ". . . 49, Brook Street, W. 
 Siordet, J. L., M.B. . . 6, Holies Street, Cavendish Square, W. 
 Sutherland, A. J., M.D. . 6, Richmond Terrace, Whitehall, S.W. 
 
 Simpson, F. H 34, Fore Street, Cripplegate, E.C. 
 
 Stewart, Alexander . . . 1a, Russell Square, W.C. 
 
 Semple, R. H., M.D. . . 8, Torrington Square, W.C. 
 
 Scannell, Daniel ... 22, Chapel Street, Belgrave Square, S.W. 
 
MEMBEllS. 25 
 
 tstedman, John B. . . . 171, Union Street, Southwark, S. B. 
 
 Schulof, Maurice, M.D. . 14, Brook Street, Grosvenor Square, W. 
 
 Stewart, "William Edward . 8, Weymouth Street, Portland Place, W. 
 
 Shaw, William .... High Street, Hampstead, N.W. 
 
 Stewart, H. G 42, Grove Road, St. John's Wood, N.W. 
 
 Streatfeild, J. F. ... 15, Upper Brook Street, W. 
 Sanndera, Edwin . . . I3a, George Street, Hanover Square, W. 
 Surgeons, The Royal Col- 
 lege of Lincoln's Inn Fields 
 
 Sexton,George, M.A.,M.D. 2, Clarendon Villas, Ravenscourt Square, 
 
 Hammersmith, W. 
 
 Shillitoe, Buxton ... 34, Finsbury Circus, E.G. 
 
 Seaton, Edward C, M.D. , 33,SloaneSt.(forWesternMedicalSociety) 
 Sequard, Brown, M.D. 
 St. George's Hospital Library 
 
 Sibson, Francis, M.D. . . 40, Lower Brook Street, W. 
 
 Seabrook, — .... 4, Grove Road, St. John's Wood, N.W. 
 
 Spencer, George ... 1, Horbury Terrace, Notting Hill 
 Stoke Newington Medical Society (per Dr. Cooke) 
 
 Stewart, A. P., M.D. . . 74, Grosvenor Street, W. 
 
 Tiiompson, Henry, M.B. . 16, Wimpole Street, Cavendish Sq., W. 
 
 Tyrrell, Walter .... 1, St. Helen's Place, Bishopsgate St., E.C. 
 
 Tudor, John ' The Dreadnought ' Hosp. Ship, Greenwich 
 
 Tanner, P. H., M.D. • . 10, Charlotte Street, Bedford Square,W.C. 
 
 Thorn, William, M.D. . . 87, Harrow Road, W. 
 
 Times, Henry G. . . . 4, Thayer Street, Manchester Square, W. 
 
 Toulmin, Francis . . . Lower Clapton, N.E. 
 
 Tamplin, R. W 33, Old Burlington Street, W. 
 
 Truman, W. H 21, Spring Gardens, W.C. 
 
 Thomas, Henry .... 22, Pentonville Road, N. 
 
 Taylor, Charles .... 4, Bethel Place, Camberwell (for South 
 
 London Medical Reading Society) 
 
 Taylor, Herbert .... 42, Hunter Street 
 
 Timothy, P. Vincent . . 38, Barbican, E.C. 
 
 Vade, John Knox, M.D. . 4, Lower Berkeley St., Manchester Sq.,W. 
 
 Varnham, Mr 41, Bedford Street 
 
 Whitley, George, M.D. . 1 1, Trinity Square, Southwark 
 
 Wells, T. Spencer ... 3, Upper Grosvenor Street, W. 
 
 Whitfield, E. G. ... St. Thomas's Hospital, The Boro', S.E. 
 
 Watson, T., M.D., F.R.S. 16, Henrietta Street, Cavendish Sq., W. 
 
 Williams,C.J.B.,M.D.,F.R.S. 49, Upper Brook Street, W. 
 
 Weber, Hermann, M.D. . 40, Finsbury Square, B.C. 
 
 Wordsworth, J. C. . 
 
 Waggett, John, M.D. . . 4, Stanley Terrace, Notting Hill, N. 
 
 Ward, Stephen, M.D. . . Finsbury Circus, E.C. 
 
 Wood, W., M.D. ... 54, Upper Harley Street, W. 
 
 Willing, G. F. Brutton . 1, Rosslyn Terrace, Hampstead, N.W. 
 
 Winslow,Forbes,M.D., F.R.S. 23, Cavendish Square, W. 
 
 Whaley, John C. . • . Prospect Place, Kilburn, W. 
 
 Warren' Henry .... 24, Mornington Cres., Regent's Pk., N.W. 
 
26 
 
 MEArBERS. 
 
 Wood, Frederick . , 
 Wallace, Alexander, M.D. 
 Weber, Frederick, M.D. 
 Woolfryes, J. S., M.D. 
 
 Witten, B. W. . . 
 Wright, W. H. . . 
 Williams, A. Wynn 
 Woods, Henry C. 
 Wilkinson, Joseph C. 
 
 Winkfield, W. B. 
 Ward, S. M. . . 
 Webb, J. C, M.D. 
 Wollaston, T. J. 
 Wolesley, — , Esq. 
 
 Long Sutton, Lincoln . 
 LoNGTOWN, Cumberland . 
 LosTwiTHiEL, Cornwall . 
 Loughborough, Leicester 
 
 Louth, Lincolnshire . . 
 Lowestoft, Suffolk . . 
 LowicK, Northumberland 
 
 LUDGERSHALL, WiLTS . . 
 
 Ludlow, Salop .... 
 
 Luton, Beds 
 
 Lutterworth, Leicester . 
 Lyme Regis, Dorset . . 
 Lymm, Cheshire . . . 
 
 Lyndhurst, Hants . . . 
 Lynn, Norfolk .... 
 
 Madeley, Salop . . 
 Maidenhead, Berks . 
 
 St. Bartholomew's Hospital, B.C. 
 23, Bedford Place, Russell Square.W.C. 
 44, Green Street, Grosvenor Square, W. 
 Care of H. Woolfryes, Club Chambers, 
 
 Regent Street 
 72, St. John Street Road 
 
 1, Clapton Square, Hackney 
 
 20, King Street, Portman Square, W. 
 
 St. George's Hospital 
 
 Western General Dispensary, Mary-le- 
 
 bone New Road 
 14, Kenningford Cottages, Islington 
 The College, St. Bartholomew's 
 
 2, Lower Grosvenor Place, Euston Sq. 
 35, Tavistock Street, Covent Garden 
 Assistant-Surgeon, 8th Depot Battalion 
 
 Pembroke Dock (per Dr. Cnrran) 
 
 Ewen, Henry 
 
 Graham, F. B. 
 
 Row, Charles 
 
 Eddowes, J. H., M.D., Loc. Sec. 
 Palmer, William G. 
 Sowerby, Thomas 
 Barron, J. C. 
 
 Bogg, J., Loc Sec. 
 Tate, S. J. 
 
 Meadows, Daniel, Loc. Sec. 
 Clubbe, W. H. 
 
 Wikon, George 
 
 Smith, Charles, M.D. 
 
 Mason, Thomas 
 
 Woakes, E., Junr. 
 
 Buszard, M., M.D. 
 
 Hingeston, William 
 
 Simpson, Henry 
 Barr, Joseph Henry 
 
 Lyon, F. W., M.D. 
 
 Hawkins, John V., M.D., Loc. Sec. 
 Kendall, T. Masters 
 Black, Walter 
 
 Proctor, John W. 
 
 Playne, Alfred, M.D. 
 
MEMBERS. 
 
 27 
 
 Malvebn, Wobcesteesh. 
 
 Manchester 
 
 Maidstone, Kekt . . . Fry, F., Loc. Sec. 
 
 Joy, Henry W. 
 Woodfall, John Ward, M.D. 
 Keddell, H. 
 AUwork, Charles L. 
 Plomley, F., M.D. 
 Saiikey, G. 
 Prance, J. C. 
 
 West, William C. 
 Weir, Archibald 
 
 Harrison, G. Morley, Loc. Sec. 
 Wilkinson, M. A. Eason, M.D. 
 Walker, Robert, M.D., 
 Radford, Thomas, M.D. 
 Barton, Samuel 
 Molynenx, James 
 Brown, Henry 
 Noble, Daniel, M.D. 
 Walsh, John 
 Dumville, A. W. 
 Bates, J., M.D. 
 Brownbill, Thomas F. 
 Bardsley, Sir James, Bart., M.D. 
 Turner, Thomas 
 Southam, George 
 Ransome, J. A. 
 Whitehead, J., M.D. 
 Wild, Thomas 
 Fletcher, J. S. 
 Midwood, W. B. 
 
 The Library of the Royal Infirmary 
 The Library of the Medical Society 
 The Library of the Royal Dispensary 
 > (Salford) 
 Armstrong, John 
 Windsor, Thomas 
 Coveney, James H. 
 Heathcote, H. 
 Roberts, D. J., M.D. 
 Fletcher, Ogden James, M.D. 
 Greaves, George 
 Westmacott, J. L. 
 Bouchardt, L., M.D. 
 Heathcote, R. H. 
 Bannister, Alfred James 
 Skinner, W., M.D. 
 
 Margate, Kent . . • • Rowe, T. S., M.D., ioc. -Sec. 
 Market Deeping, LiNCOLNS.Deacon, W. B. 
 
28 MEMBEES. 
 
 Mahket Drayton, Salop . Saxton, W. W., M.D. 
 
 Market Hakborough, 
 
 Leicestershire . . . Francis, James 
 
 Market Latington, Wilts Hitchcock, Charles 
 
 Marlborough, Wilts . . Maurice, David P., Loc. Sec. 
 
 Melbourne, Cambridge . Carver, Eustace John 
 
 Melksham, Wilts . . . King, Jasper 
 
 Melton Mowbray, Lei- 
 cestershire .... Parratt, Henry 
 
 Whitchurch, Nathaniel 
 
 Messingham Lindsey, 
 
 Lincolnshire . . . Terrewest, W., M.D. 
 
 Middleham, Yorkshire . Cockcroft, George E. 
 
 Middlesbro'-on-Tees, 
 
 Yorkshire .... Crummey, L. F., Loc. Sec. 
 
 Locke, T. W. S. 
 
 Coates, George 
 
 Richardson, John 
 MiDHURST, Sussex . . . Ingram, W. Loc. Sec. 
 
 MiLBOURNE-PoRT, SOMER- 
 SETSHIRE Parsons, Samuel W. 
 
 Milton Abbas, Dorset . Ewens, John 
 
 MiLTON, Kent .... Ray, E. R. 
 
 MiNCHINHAMPTON, GlOU- 
 
 CESTERSHLRE .... Turner, C. W., M.D. 
 
 MiRFiELD, Yorkshire . . Wade, Thomas 
 
 Mold, Flint Williams, William, M.D. 
 
 Hughes, E. T., M.D. 
 
 Monmouth Prosser, Thomas, Loc. Sec. 
 
 Willis, George, M.D. 
 
 Moreton-in-the-Marsh, 
 
 Gloster Yelf, Leonard R. 
 
 Moore, G. 
 MoTTRAM, Cheshire . . Pomfret, Henry L. 
 Mount Sorrel, Leicester. Wright, Samuel 
 MuNSLOw, Salop . . . Downs, T. R. C. 
 
 Needham Market, 
 
 Suffolk Beck, Henry 
 
 NEWARK-upoN-TRENT,IiroTTS Deamer, William 
 
 Newbury, Berks . . . Bunny, Joseph, M.D., Loc. Sec. 
 
 Palmer, Silas, M.D. 
 Royston, Christopher 
 Bursey, Henry 
 Hemsted, Henry 
 
MEMBBES. 
 
 29 
 
 Newcastle-undbr-Lyne, 
 
 Stafford Kyan 
 
 Newcastle-upon-Tyne, 
 Northumberland . 
 
 Michael, M.D., Loe. Sec. 
 
 M.D., Loc. Sec. 
 
 Newport, Monmouth . 
 
 Robinson, G., 
 Brady, Henry 
 Houseman, John, M.D. 
 Cave, William Thomas 
 Thompson, T. Y. 
 
 Humble, Thomas, M.D. (the Library of the 
 Newcastle-on-Tyne Infirmary) 
 
 WooLLETT, R. F., Loc. Sec. 
 Morgan, W. W. 
 Limbery, T. 
 
 Baddeley, W. E. 
 Holman, Charles Henry 
 
 North Curry, Somerset . 
 
 NORTHFLEET, KeNT . . 
 
 Northleach, Gloucester 
 
 Newport, Salop . . 
 
 Niton, Isle of Wight . 
 
 NoRHAM, Northumberland Paxton, John 
 
 Northampton .... Faircloth, John M. C, M.D. 
 
 Francis, J. T., M.D. 
 Flewitt, M. W. 
 Olive, G. 
 Percival, W. 
 The Infirmary Library (per Mr. Gray) 
 
 Plowman, John 
 
 Crook, J. Evelyn, M.D. 
 Gould, Samuel 
 
 Bedwell, John R. 
 Howard, James H. H. 
 
 North Shields, Northum- 
 berland Fenwick, S., M.D., Loc. Soc. 
 
 Bourne, William, M.D. 
 
 Bates, W. 
 
 Bramwell, John B., M.D. 
 
 Northwold, Norfolk . Joy, William 
 
 Norwich Eade, P., M.D., "Xoc. Sec, 
 
 Green, Frederick R. 
 
 Muriel, Charles E. 
 
 Johnson, John G. 
 
 Copeman, Edward, M.D. 
 
 Arnold, Edward 
 
 Norwich and Norfolk Book Society 
 
 Wells, John, M.D. 
 
 Hutchinson, George Smith 
 
 Crosse, Thomas W. 
 
 Charles, William (The Infirmary) 
 
 Manby, Frederick 
 
30 
 
 MEMBEES. 
 
 Nottingham 
 
 Nuneaton, Warwick . 
 Odiham, Hants . . . 
 
 Oldham, Lancashiue 
 Ormsby, Norfolk . . . 
 Ormskirk, Lancashire . 
 OssET, Yorkshire . . 
 Otley, Yorkshire . . 
 Ottery, St. Mary, Devon 
 Oxford 
 
 Paignton, Devon . . . 
 Pbndleton, Manchester 
 Penistone, Yorkshire . 
 Penrith, Cumberland . 
 Penzance, Cornwall 
 
 Pbtwobth, Sussex 
 Pewsey, Wilts . . 
 
 Ransome, W. H., M.D., Loe. Sec. 
 
 Eddison, Booth, (the late) 
 
 Thompson, Joseph 
 
 White, Joseph 
 
 Tate, W. B., M.D. 
 
 The Library of the General Hospital 
 
 The Library of the Medical and Chirurgi- 
 
 cal Society 
 Bury, George 
 Bury, John 
 
 Wright, Thomas, M.D. 
 Popham, B. F., M.D. 
 Higginbottom, M. H. 
 
 Nason, Richard B. 
 
 McIntyke, J. M., M.D., Loe. Sec. 
 Pound, George 
 
 Sharp, Christopher, Loe. Sec. 
 Woodman, Robert 
 Ashton, T. M., M.D. 
 Greenwood, J. W. 
 Macleod, William, M.D. 
 Whitby, Charles W., M.B. 
 
 Rolleston, G., M.D., Loe. Sec. 
 
 Symonds, F. 
 
 Acland, H. W., M.D. 
 
 Hnssey, E. L. 
 
 Child, G. W., M.D. 
 
 Gray, E. B. 
 
 Freeborn, R. F. 
 
 Giles, Richard, M.D. 
 
 Jackson, R., M.D. 
 
 Owen, Edward R. 
 
 Taunton, G. 
 
 Pridham, C. W., M.D. 
 Ashburner, J. A. J. 
 Ward, John 
 Wickham, Joseph, M.D. 
 
 Montgomery, J. Barclay, M.D., Loe. See. 
 Harvey, William G. 
 Couch, Richard Quiller 
 Booxe, Francis 
 
 Turner, Roger 
 
 Carter, C. H. 
 
MEliBEfiS. 
 
 31 
 
 Plymouth, Devon 
 
 PONTEPBACT, YORKSHIRE 
 PONTYPOOL, MOXMOTJTHS. 
 
 PooLE, Dorset . . . 
 P0RTMA.DOC, Carnarvon 
 Portsmouth, Hants . 
 
 Preston, Lancashire 
 
 pulborough, sussex . 
 Quorndon, Leicesters. 
 
 Rendle, E. M. Russell, Loc. See. 
 
 Cookworthy, J. C, M.D. 
 
 Hingston, Charles, M.D. 
 
 Square, William J. 
 
 Harper, Thomas 
 
 De la Rue, P. 
 
 Swain, P. W. 
 
 Soltau, William F., M.B. 
 
 Derry, R. H. 
 
 MuscROFT, C, M.D., Loc. Sec. 
 Simpson, James H., M.B. 
 Tucker, Edward E. 
 Lacey, B., Zoc. Sec. 
 Roberts, Robert 
 
 Elliott, E., M.D., Loc. Sec. 
 
 Cowan, Michael, M.D., H.M.S. 'Victory' 
 
 Perks, E. R. 
 
 Smart, W. R. E., M.D., R.N. 
 
 Allnutt, Joseph F. 
 
 Bloxsome, George 
 
 Roche,W.S.,M.D.,R.N., Rl.Hos. 'Haslar' 
 
 Simpson, John 
 
 Eustace, Richard 
 
 Andrews, John 
 
 Coogan, John 
 
 Clark, A. Ducket, Esq 
 
 Austin, Josiah, R.N. 
 
 Flanagan, James, R.N. 
 
 Hill, W. G., R.N. 
 
 Rae, John, R.N. 
 
 Whicker, James, M.D. 
 
 Norman, Burford 
 
 Minter, John M., Royal Yacht 
 
 Garrington, Arthur M. 
 
 Burton, Matthew, M.D., R.N. 
 
 Sparrow, R. P., M.D. 
 
 Allen, Richard, Loc. Sec. 
 Spencer, Lawrence 
 Bell, William, M.D. 
 Berry, John 
 Heslop, R. C, M.D. 
 Barnes, Edward 
 Rose, Frederick H. 
 Gilbertson, J. B., M.D. 
 Arminson, John 
 
 Taylor, William Eccles, M.D. 
 
 Harris, Samuel 
 
 ditto 
 
 ditto 
 
 ditto 
 
 ditto 
 
 ditto 
 
 ditto 
 
 ditto 
 
 ditto 
 
 ditto 
 
 ditto 
 
32 
 
 MEMBERS. 
 
 Ramsgate, Kent . . . 
 Rastbick, Yokkshikb 
 Rawtenstall, Manchestek 
 Rayleigh, Essex . . . 
 Reading, Beuks. . . . 
 
 Redboukn, Herts . . 
 Reduuth, Coenwall . 
 
 Reigate, Surrey . . 
 
 Rhayader, Radnorshire 
 Rhyl, North Wales . . 
 Richmond, Surrey . . 
 
 Rickmansworth, Herts . 
 RiPON, Yorkshire . . . 
 
 Romford, Essex . . . 
 Rotherham, Yorkshire . 
 
 Royston, Cambridges. . 
 RoYTON, Lancashire . . 
 Ruabon, Denbighshire . 
 RuGELEY, Staffordshire 
 Ruthin, Denbighshire . 
 
 Rye, Sussex 
 
 Saffron Walden, Essex 
 St. Albans, Herts . . 
 
 Curling, Henry, Loc. Sec. 
 
 Pollard, Tempest 
 
 Wimpenny, Jonas 
 
 Coles, R. 
 
 "Walfoud, T. L., Loc. Sec. 
 
 May, George 
 
 Reading Medical Book Society 
 
 Woodhouse, R. J., M.D. 
 
 Maurice, Thelwall B. 
 
 Ayre, J. B. 
 
 HiCHENs, James S., Loc. Sec. 
 
 Permewaii, John 
 
 Martin, Peter 
 
 Sisson, Andrew 
 
 Steele, John 
 
 Richardson, R. 
 
 Theed, F. 
 
 Bird, S. D., Loc. Sec. 
 Hassall, Richard, M.D. 
 Duncan, Thomas, M.D. 
 Maybury, A. K. 
 Codd, George 
 
 Tutin, Septimus, Loc. Sec. 
 Husband, Charles 
 Clarkson, W. H. 
 
 Shearman, E. J., M.D., Loc. Sec. 
 Robinson, Benjamin, M.D. 
 Saville, William 
 Hardwicke, Junius, M.D. 
 Stone, Erasmus 
 Crowther, James 
 
 Carver, Frederick C. 
 
 Kershaw, William, M.D. 
 
 Roberts, Richard C. 
 
 Tylecote, J. H. 
 
 Jenkins, J. R., M.D,, Loc. Sec. 
 Jones, Thomas C, M.D. 
 Prytheroh, Thomas 
 Jones, Thomas 
 
 Adamson, Johu 
 
 Stear, Henry 
 
 Lipscomb, J. T. Nicholson, M.D., 
 
 Loc. Sec. 
 Russell, W. A. 
 
MEMBEES. 
 
 33 
 
 St. Helens, Lancashire 
 St. Just, Cornwall . . 
 Salisbxihy, Wilts . . . 
 Sawbridgeworth, Herts 
 Scarborough, Yorkshire 
 
 Seacombe, Cheshire 
 Shaftesbury, Dorset 
 
 Sharnbrook, Beds . . 
 Sheepshed, Leicestersh. 
 Sheerness 
 
 Sheffield, Yorkshire 
 
 Shelton, Stafford . . 
 Shepton-Mallett, Somer- 
 setshire 
 
 Shiffnal, Salop . . . 
 Shipley, Yorkshire . . 
 
 Clement, James D., M.D. 
 Searle, R. B. 
 Bushnan, J. S., M.D. 
 Brickwell, J. 
 Cooke, R. B., Loe. Sec. 
 Miller, Andrew, M.D. 
 Taylor, William 
 Dale, George P. 
 
 Byerley, Isaac 
 
 Bennett, W. H. R., Loc. Sec. 
 
 Bennett, H. 
 
 Stedman, R. S. 
 
 Wood, James 
 
 Swales, Edward, Loc. Sec. 
 Reddell, J. S. 
 Hooker, E. M. C. 
 Gunn, — , M.D., R.N. 
 McDonough, — , M.D., R.N. 
 Keenan, — , M.D., R.N. 
 Fasson, — , M.D., R.N. 
 Martin, James, R.N. 
 Grigor, R., M.D., R.N. 
 Brake, —, R.N. 
 Wrixon, — 
 
 Martin-De-Bartolome, M., M.D., 
 
 Loc. Sec. 
 Jackson, Henry 
 Shearman, C. J., M.D. 
 Hall, John Charles, M.D. 
 Skinner, William' 
 Favell, W. F. 
 Aveling, James H. 
 Hart, Graham, C. B. 
 Parker, Samuel 
 Benson, John 
 Smith, Charles, M.D. 
 Gleadall, James 
 Taylor, George A. 
 Wa'erhouse, John H. 
 Taylor, R. A. 
 Thompson, Edward 
 
 Head, Thomas, M.D. 
 
 Wybrants, J., M.D. 
 Lander, Thomas E. 
 Brumfit, W. 
 
34. 
 
 MEMBBES. 
 
 Shiklei, Hants . . . 
 Shrewsbury, Salop . . 
 
 SiDMOUTH, Devon . . . 
 Snaith, Yorkshire . . 
 Snitterfield, Warwick . 
 SoHAM, Cambridgeshire 
 
 Southampton, Hants . . 
 
 SouTHXNU, Essex . . . 
 SouTHPOET, Lancashire . 
 
 South Shields, Durham 
 
 Spalding, Lincolnshire 
 
 Spenny Mooe, Durham 
 SpiLSBY, Lincolnshire 
 
 Mott, William 
 Weston, Philip K. 
 
 Clement, W. J. 
 Oliver, Richard, M.D. 
 
 Miller, G., M.D., Loc. Sec. 
 
 Hodgson, W. J., Loc. Sec. 
 
 Croft. T. W. W. 
 
 Willis, George 
 Addison, William 
 
 Sampson, J. K., Loc. Sec. 
 Wiblin, John, M.D. 
 Bullar, WUliam, M.D. 
 Cheesman, George 
 Ward, Thomas 
 Aldridge, — , M.D. 
 Purdey, C, M.B. 
 Dusautoy, H., M.D. 
 Lawrence, L. A. 
 Clark, H. 
 Osborn, H., M.D. 
 Dayman, Henry 
 Spear, William 
 Schuyler, — , M.D. 
 Griffin, W., M.D. 
 Atkins, Henry 
 Dennely, Charles 
 Hunter, — - 
 
 Warwick, W. R., Loc. Sec. 
 
 Mort, William, M.D. 
 Blumberg, H., M.D. 
 
 Stokoe, G., M.D., Loc. Sec. 
 
 Armstrong, L. 
 
 Young, Thomas 
 
 Legat, A., M.D. 
 
 Coward, W. 
 
 Glover, J. G., M.D. 
 
 Cammack, Thomas, M.D., Loc. Sec. 
 Wilkinson, W. C. 
 Stiles, Henry T. 
 Morris, Edward, M.D. 
 
 Hawks, R. W. 
 
 Walker, John West, M.B. 
 
MEMBEES. 
 
 35 
 
 Staffobd 
 
 Stalybridge, Chester . 
 Stamford, Lincolnshire 
 
 Stand, near Manchester 
 Steeple Langford,Wilts 
 Stevenage, Herts . . 
 Stilton, Huntingdon 
 Stockport, Chester . . 
 
 Stockton-on-Tees, 
 Durham . . . 
 
 Stonehodse, East, Devon 
 Stourbridge, Worcester 
 
 Stourport, near Kidder- 
 minster, Worcester . 
 
 Stowmarket, Suffolk . 
 Stbadbroke,Woodbridge, 
 Suffolk .... 
 Stratford, Essex . . . 
 
 Masfen, W. E., M.B., Loc. Sec. 
 
 Lomax, Henry T. 
 
 Perrin, William J. 
 
 Weston, Edward J. 
 
 The Staffordshire Gen. Infirmary Library 
 
 Hewson, John Dale, M.D. 
 
 Baddeley, E. A. 
 
 Knight, E., M.B. 
 
 Day, Henry, M.D. 
 
 Smith, T. P., M.B. 
 
 Sutcliffe, William 
 Hopwood, Robert 
 
 Pratt, S., M.D., Loe. Sec. 
 Cook, John 
 Heward, J. M. 
 
 Lancashire, James 
 
 Straton, Alexander, M.D. 
 
 Smith, George Hill 
 
 Acton, Walter 
 
 Pitman, Edward H. 
 Ashton, James, M.D. 
 Blackshaw, Joseph 
 Brooke, John 
 
 Richardson, William, Loc. Sec. 
 Foss, William 
 Keenlyside, R. H., M.D. 
 
 Embling, R. E. 
 
 Giles, F., Loc. Sec. 
 Gordon, William, M.D. 
 Freer, Alfred 
 
 Brown, George Gwynn 
 Lamb, Samuel 
 
 Harper, J. W. 
 
 Gooch, James W. 
 
 Mackmeikan, John, Loc. Sec. 
 Mngliston, G. T. W., M.D. 
 Gill, S. Lawrence 
 Hosford, J. S.' 
 Banks, A. J. H. 
 Kennedy, Augustus 
 Clav, Thomas F. 
 Woodforde, M. T. G., M.D. 
 
36 
 
 MEMBEES. 
 
 StkouDj Gloucestekshire 
 SuDBDRY, Derby . . . 
 Sunderland, Durham . 
 
 SuRBiTON, Surrey . . . 
 Swansea, Glamorganshire 
 
 Sydenham, Kent . . . 
 Syston, Leicestershire 
 Tamworth, Stafpordsh. 
 Taevin, Chester . . . 
 Taunton, Somersetshire 
 Teignmouth, Dbton . . 
 
 Temple Cloud, Somersets, 
 Tenteruen, Kent . . . 
 Thame, Oxfordshire 
 Thames Ditton, Surrey 
 Thetford, Norfolk . . 
 Thirsk, Yorkshire . . 
 Thurnby, Leicestersh. . 
 Tickhill, Yorkshire 
 Timsbuey, Somerset . . 
 Tinteen Parva, Mon- 
 mouthshire .... 
 todmorden, lancashire 
 ToFTHiLL, Durham . . 
 ToNBRiDGE, Kent . . . 
 ToNBEiDGE Wells, Kent 
 
 Tooting, Sueeey . . . 
 Torquay, Devon . . . 
 
 Wethered, Charles 
 
 Forbes, David, M.D. 
 
 Parker, T. P., M.D. Loc. Sec. 
 
 Bowman, Henry 0. 
 
 The Medical Society of Sunderland 
 
 Blumer, L. 
 
 Ferguson, W. B. ' 
 
 Johnson, Frederick, H. 
 
 Coleman, M. T. 
 
 Williams, T., M.D., F.R.S., Loc. Sec. 
 
 Thomas, Benjamin 
 
 The Royal Institution of South Wales. 
 
 Stutter, F. A., Loc. Sec. 
 Robinson, J. C. 
 Blake, R. H. 
 Moreton, James E. 
 KinglakCj Hamilton, M.D. 
 
 Forman, G. E. 
 
 Lake, W. C. 
 
 Perrin, L. D. 
 
 Saunders, Edwin 
 
 Noble, William 
 
 Hotham, R. H. 
 
 Bailey, H. W., Loc. Sec. 
 
 Hutton, J., M.D. 
 
 Hunt, John 
 
 Burrell, John 
 
 Crang, J. 
 
 Audland, John 
 Cockcroft, D. M. 
 Al worthy, C. 
 Walker, J. H., M.D. 
 
 Barry, J. Milner, M.D., Loc. Sec. 
 
 Sopwith, Henry L. 
 
 Richardson, William, M.D. 
 
 Meyer, J., M.D. (The Surrey County 
 
 Lunatic Asylum) 
 Hall, C. Radcliffe, M.D., Loc. Sec. 
 Tetlev. J., M.D. 
 Nankivell, C. B., M.D. 
 Pollard, William J. 
 Plowman, William T., M.D. 
 
MEMBERS. 
 
 37 
 
 Tottenham, Middlesex 
 
 Town Malling, Kent 
 
 Tring, Herts . . . 
 Trowbridge, Wilts . 
 Truro, Cornwall . . 
 
 TyddSt. Mary, Lincolnsh 
 
 Tyldesley, near Man- 
 chester 
 
 Ullermiee, Yorkshire . 
 
 UxBRiDGE, Middlesex . 
 
 Upper Deal, Kent . . 
 Ventnor, Isle op Wight 
 
 Wadebridge, Cornwall 
 Wakefield, Yorkshire . 
 
 Wallingfobd, Berks . . 
 Walmer, Kent .... 
 Walsall, Stappordshire 
 Walthamstow, Essex 
 
 Ware, Herts .... 
 
 May, Edward Hooper, Loc. Sec. 
 
 Moon, William. 
 
 Jackson, George H., M.D. 
 
 Sewell, William 
 
 May, Emmanuel 
 
 Furley, Edward, M.D., Loc. Sec. 
 Hayman, Charles C, M.D. 
 
 Lipscomb, Richard N.' 
 
 Tayler, C. 
 
 Patjll, Alexander, Loc. Sec. 
 
 The Library of the Rl. Cornwall Lifirmary 
 
 Leverton, Henry Spry 
 
 Sharp, Edward 
 
 Metcalf, R. L, M.D. 
 
 Manley, W.E. 
 Graham, William 
 
 Macnamara, G. H., Loc. Sec. 
 Stillwell, James 
 James, Thomas 
 Roberts, Charles, M.D. 
 
 Martin, G. A., M.D., Loc. Sec. 
 Tuttiett, Henry B, 
 Gawthorpe, Matthew 
 Gooch, W., M.D. 
 Tickell, T. S. 
 
 Milner, W. R., Loc. Sec. 
 Balmforth, Joseph 
 Walker, Thomas 
 Kemp, William W. 
 Kemp, Benjamin 
 Statter, William 
 Walker, Ebenezer, Jun. 
 Wood, William, M.D. 
 Jennings, F. Cook 
 Cleaton, John D. 
 Wright, Thomas G., M.D. 
 Dawson, William 
 Barrett, Charles A. 
 Davey, R. Staines 
 Blackford, John C. 
 
 Evans, Alfred 
 Pinching, R. L. 
 
 Smith, F. M., Loc. Sec. (Great Ha'lham) 
 
38 
 
 MEMBERS. 
 
 Waukworth, Nokthum- 
 
 BEULAND 
 
 ■Warminstek, Wilts . . 
 Warrington, Lancashire 
 
 Warwick 
 
 Wateringbury, Kent 
 
 Wath-upon-Dbarne, 
 Yorkshire .... 
 
 Watiington, Oxeord 
 Watton, Norfolk . . . 
 Watford, Herts . . . 
 Wednesburt, Stapfordsh, 
 Wellington, Salop . . 
 Wellington, Somersetsh. 
 Wells, Somersetshire . 
 
 Wem, Salop .... 
 
 West Bbomwich, Staf- 
 fordshire .... 
 
 West Lydford, Somer- 
 setshire 
 
 We ston-super-Ma re, 
 Somersetshire . . . 
 
 Weymouth, Dorset . . 
 Whitby, Yorkshire . . 
 
 Whitchurch, Salop . . 
 ■ Whitehaven, Cumberland 
 
 Tiivnbul], G. W., M.D. 
 Bleeck, Charles, Loc. Sec. 
 Vicary, George 
 
 White, Charles, Loc. Sec. 
 
 Davies, I., M.D. 
 
 Sharp, J. 
 
 Robson, John, M.D. 
 
 Blenkinsop, H., Loc. Sec. 
 
 Gould, Henry M. 
 
 Burman, William Maxwell 
 
 Barrett, Henry 
 
 Sprigge, S. 
 
 lies, J. H. W. 
 
 Bailey, Joseph 
 
 Soame, C. H. H. 
 
 Bridge, S. F., M.D., Loc. See. 
 
 Boyd, B,., M.D., Loc. Sec. 
 Macreight, W. W., M.D. 
 Purnell, Thomas 
 
 Gwynn, Samuel B. 
 Wilson, Joseph Green 
 
 Browne, B. S., Loc. Sec. 
 Duncalfe, Henry 
 
 Culling, Robert 
 
 Alford, R., Loc. Sec. 
 Martin, Edward 
 
 Griffin, Richard 
 
 DowsoN, John, M.D., Loe. Sec. 
 
 Clarkson, W. N. 
 
 Yeoman, John, M.D. 
 
 Sherwood, Eleazer, M.D. 
 
 Mead, E. Preston, M.D. 
 
 Wilson, Henry James, Loc. Sec. 
 
 FAnson, T. F., M.D., Loc. Sec. 
 Irwin, John 
 Jackson, Thomas 
 Jones, William 
 Fidler, J. D., M.D. 
 
MEirBEES. 
 
 39 
 
 Whitwell, Heets . . 
 Whitwick, Leicestersh. 
 WiGAN, Lancashire . . 
 
 WiGTON, Cumberland 
 Wilton, Wilts . . . 
 Wimbledon, Surrey . . 
 
 wincanton, someesetsh. 
 Winchelsea, Sussex . . 
 Winchester, Hants . . 
 
 WiNCHMORE Hill, Ed- 
 monton .... 
 
 Windsor, Berks . . 
 
 WiNTERTON, Lincoln . 
 
 WisBEACH, Cambridge 
 
 Witney, Oxford . 
 Woking, Surrey . 
 Wolverhampton . 
 
 WoNERSH, Surrey 
 Woodford, Essex . 
 
 Woolwich, Kent . 
 
 Phillips, George Marshall 
 Clewley, Thomas M. 
 
 Wright, J. K. 
 Winatanley, Robert 
 Mackenzie, Walter F. 
 
 Ferguson, Charles 
 
 Bennett, T. J. 
 
 Love, G-., Loc. Sec. 
 Finch, Richard S. 
 
 Surrage, James, M.D. 
 
 Skinner, Robert V. 
 
 Butler, F. J., Loc. See. 
 Wickham, W. J. 
 Jacob, Edward L. 
 Lacroix, F. 
 Forder, T. 
 
 Cresswell, John 
 
 Harper, James E., M.D. 
 
 Sadler, Joseph 
 
 Rooke, Henry T. L., M.D. 
 Fawssett, Frederic, M.D. 
 
 Batt, Augustus, M.D., Loc. See. 
 -Fletcher, J. T. 
 ToPHAM, J., M.D., Loc, Sec, 
 Cart Wright, Talbot 
 Newnham, Christopher A. 
 Jackson, L Vincent 
 Nesbitt, F. A. 
 Frazer, John, M.D. 
 Collins, Henry 
 Hancox, Henry, M.D. 
 
 Ede, C. 
 
 BuNCE, J. S., Loe. Sec. 
 Groves, William G. 
 
 Mason, Robert, Loc. Sec* 
 
 Butler, J. M., M.D. 
 
 Bossey, F., M.D. 
 
 Fuller, James 
 
 Library of Royal Artillery Hospital 
 
 Evans, A„ M.D. 
 
 Starling,— 
 
40' MEMBERS. 
 
 WoECEaTEE Williams, Philip H,, M.D., Loc. Sec. 
 
 Hastings, Sir Charles, M.D. 
 Garden, H. D., Esq. 
 
 WOEKINGTON, CUMBBE- 
 
 LAND Jackson, Henry, M.D. 
 
 Worthing, Sussex . . . Harris, William 
 Weexham, Denbighshiee, 
 
 Flint Griffith, Thomas T., Loc. Sec. 
 
 Dickinson, John 
 Jones, Thomas Eyton 
 Rowland, William 
 Williams, Edward, M.D. 
 Lewis, J. K. 
 
 Yalding, Kent .... Pout, Henry 
 
 Yarmouth, Noefolk . . Palmer, Charles, Loc. Sec. 
 
 Vores, W., M.D. 
 
 Smyth, S. T., M.D. 
 
 Aldred, C. C. 
 York Swaine, W. E., M.D., Loc. Sec. 
 
 Williams, Caleb, M.D. 
 
 Simpson, Thomas, M.D. 
 
 Shann, G., M.D. 
 
 Husband, William D. 
 
 Eeed, William 
 
 The York Hospital Library 
 
 Hornby, George 
 
 Whiteman, J. 
 
 Proctor, William 
 
 North, Samuel W. 
 
 Whitling, Henry 
 
 Ball, Alfred 
 
 SCOTLAND. 
 
 Abeedben Cheistib, J., M.D., Loc. Sec. 
 
 Williamson, Joseph, M.D. 
 
 Poole, Richard, M.D. 
 
 University and King's College 
 
 Jackson, Henry, M.D. 
 
 The Medical and Chirurgical Society 
 
 Sutherland, George 
 
 Rainy, George, M.D. 
 
 Ogston, Francis, M.D. 
 
 Steel, James, M.D. 
 
 Fiddles, David, M.D. 
 
 Laing, James, M.D. 
 
 Cadenhead, John, M.D. 
 
MEMBERS. 41 
 
 Alloa, Clackmainnan . Brotherston, Peter 
 
 Ansthuthek, Fife . . . Black, T., M.D. 
 
 AucHTEEMTJCHTY, FiPE . Troiip, Francis 
 
 Akbeoath, Foepar . . . Key, Andrew, M.D. 
 
 Ayr Ronald, Hugh 
 
 Weald, — , M.D. 
 Smith, George 
 Maxwell, P. 
 
 Barrhead, near Paisley . MacKinlay, John, M.D. 
 
 Bathgate Kirk, J. B., M.D. 
 
 Beewick-on-Tweed . . Maclagan, Philip W., M.D., Loc. Sec. 
 
 Henderson, George 
 
 Bothwell, Lanark . . Goff, B., M.D. 
 
 Broughty Ferry, FoRFAH. Smith, J. W. F., M.D. 
 
 Rapisay, A. 
 
 Coldstream, Beewick . Turnhull, M. J., M.D. 
 
 CoESTORPHiNE .... Fowler, W. C, M.D. 
 
 Ctjpar, Fipe Mackie, J. R., M.D. 
 
 Dalkeith, Edinburghsh. Thomson, L. R., M.D. 
 
 Dartel, Ayr .... Rose, R. D. 
 
 Denny, Stirling . . . Cuthill, James, M.D. 
 
 Dreghorn, Aye . . . Caldwell, J. 
 
 Dumbarton Gilchrist, R. M., M.D. 
 
 Dumfries Chisholm, J., M.D. 
 
 Gilchrist, James, M.D. 
 Dickson, John, M.D. 
 Stewart, H. G., M.D. 
 Borthwick, Alexander, M.D. 
 Murray, P., M.D. 
 Little, —, M.D. 
 
 Dundee, Forfar . . . Miller, J. W., M.D., Loc. Sec. 
 
 Greig, David, M.D. 
 Crichton, J. T., M.D. 
 Gibson, W. L., M.D. 
 Bell, R., M.D. 
 Christie, J., M.D. 
 Crockatt, W., M.D. 
 Langlands, R., M.D. 
 Wingett, T. T., M.D. (Asylum, Dundee) 
 Pirie, G. C. 
 Park, J. H., M.D. 
 Mmmo, Matthew 
 Saunders, W. C, M.D. 
 
42 
 
 MEMBERS. 
 
 Dunoon, Argyllshire . Hamilton, J. U. M., M.D. 
 Edinburgh Balfour, George, M.D.,Zoc. iSec. 
 
 Begbie, J. Warburton, M.P. 
 
 Laycock, Thomas, M.D. 
 
 Malcolm, R. B., M.B. 
 
 Gairdner, W. T., M.D. 
 
 Duncan, Matthew, M.D. 
 
 Begbie, J., M.D. 
 
 Millar, James S. 
 
 Graham, Andrew, M.D. 
 
 Balfour, Thomas, M.D. 
 
 Fowler, William G., M.D. 
 
 The Library of the University of Edi-nbro' 
 
 Black, J., M.D. 
 
 Dycer, C., M.D. 
 
 Dunsmure, J., M.D. 
 
 Weir, T. G., M.D. 
 
 Combe, J. S., M.D. 
 
 Duncan, James, M.D. 
 
 Inglis, A., M.D. 
 
 The Royal College of Physicians, Edinbro' 
 
 The Royal Medical Society, Edinbro' 
 
 Cuthbert, C. 
 
 Edwards, A. M. 
 
 Haldane, Rutherford 
 
 Traill, Charles 
 
 Lister, Joseph 
 
 Dalzell, Allan, M.D. 
 
 Balfour, John, H.M., I.S. 
 
 Turner, W., M.B. 
 
 Ziegler, W., M.D. 
 
 Alison, W. P., M.D. (the late) 
 
 Dickson, Archibald 
 
 Saunders, W. R., M.D. 
 
 Maolagau, Douglas, M.D. 
 
 Simpson, J. Y., M.D. 
 
 Balfour, Andrew, M.D. 
 
 Pattison, Thomas, M.D. 
 
 Keith, G. S., M.D. 
 
 Hortin, James 
 
 Murray, — , M.D. 
 
 Dunn, T. 
 
 Wilson, John 
 
 Thomson, A., M.D. 
 
 Seabrook, Thomas 
 
 Ogilbie, — , M.D. 
 
 Ogilvie, J. K., M.D. 
 
 Elgin Duff, George, M.D., Loc Sec. 
 
 McKay, Norris, M.D. 
 McKidd, John 
 
MEMBEKS. 43 
 
 Ekiboll Laihg, Suther- 
 land Clarke, John, M.D. 
 
 FoEKES Innis, J. G., M.D. 
 
 Murray, John, M.D. 
 
 FoBTEosE, Ross-SHiKE , McKenzie, A. R., M.D. Loc. Sec. 
 
 Galasheils Macdougall, George 
 
 GirroED, Haddington . Lothian, John 
 
 Glasgow Wilson, James G., M.D., Loc. Sec. 
 
 Fleming, J. G., M.D. 
 
 Weir, W., M.D. 
 
 Macleod, G. H. B., M.D. 
 
 Watson, Ebenezer, M.D. 
 
 Anderson, A. D., M.D. 
 
 Druramond, J., M.D. 
 
 Lawrie, James A., M.D. (the late) 
 
 Dunbar, Henry, M.D. 
 
 Morton, James, M.D. 
 
 Robertson, A., M.D. 
 
 Ritchie, Charles, M.D. 
 
 Lindsay, Alexander, M.D. 
 
 Thompson, F. H., M.D. 
 
 Macfarlane, John, M.D. 
 
 Leishman, William, M.D. 
 
 Robb, Alexander 
 
 Parker, Robert, M.D. 
 
 Wilson, Robert, M.D. 
 
 Dickson, J. R., M.D. 
 
 Reid, Thomas, M.D. 
 
 Irvine, William 
 
 Coats, John, Jun., M.D. 
 
 Newman, James E., M.D. 
 
 SpeirSj Douglas, M.D. 
 
 Gray, James, M.D. 
 
 Dewar, Donald, M.D. 
 
 Buchanan, T. D., M.D. 
 
 Robertson, George, M.D. 
 
 Eadie, William, M.D. 
 
 Renfrew, Robert 
 
 Tannahill, R. D., M.D. 
 
 Hunter, Robert, M.D. 
 
 Pagan, J. M., M.D. 
 
 Allan, J. R. 
 
 McGregor, George, M.D. 
 
 Dick, James, M.D. 
 
 The University Library, Glasgow College 
 
 Taylor, D. K., M.D. 
 
 Mackenzie, William, M.D. 
 
44 
 
 MEMBERS. 
 
 Glasgow 
 
 GouEocK, Renfrew 
 Greenock, Renfrew 
 
 Haddington . . . . 
 
 Hawick ...;.. 
 Helensburgh, Dumbar- 
 
 tonshire 
 
 Innerleithen, Peebles 
 
 Greenlees, William, M.D. 
 
 Howatt, H. R., M.D. 
 
 Young, James A. 
 
 Goldie, James J. 
 
 Yeaman, George, M.D. 
 
 Clark, William, M.D. 
 
 Coats, John, M.D. 
 
 Paterson, Joshua, M.D. 
 
 McGiU, William 
 
 Clarke, Samuel 
 
 Smith, Alexander Macfie, M.D. 
 
 The Library of the Glasgow Faculty of 
 
 Medicine 
 The Library of the Faculty of Physicians 
 
 and Surgeons 
 Perry, Robert, M.D. 
 Hatrick, W. R, M.D. 
 Connell, R. 
 Fergus, A. 
 
 Anderson, George, Surgeon-Major 
 Buchanan, Simson, M.D. 
 Gentle, John, M.D. 
 Dobbie, James 
 Aitken, John 
 Hadden, J. 
 Golder, James 
 Bennie, Andrew 
 Morton, Alexander 
 Prichard, — , M.D. 
 Paterson, James, M.D. 
 Walker, Robert 
 Mackinlay, William, M.D. 
 
 Mackenzie, John, M.D. 
 
 Wallace, James, M.D., Loc. See. 
 Auld, Charles, M.D. . 
 Marshall, William, M.D. 
 Paton, James Frazer, M.D. 
 Mackie, James, M.D. 
 
 HowDEN, T., Jun., M.D., Hon. Loc. Sec. 
 Lorimer, Robert, M.D. 
 Martine, William, M.D. 
 
 Brydon, James, M.D. 
 
 Macdowall, Alexander, M.D., Loc.Sec. 
 
 Skene, John 
 
 Walker, Stephen, M.D. 
 
 Robertson, John, M.D. 
 
MEMBEHS. 
 
 45 
 
 Inverary, Argyle . 
 Inverkeithing, Fife 
 
 Inveknjjss . . . 
 
 Irvine, Ayr 
 
 Jedburgh, Roxburgh 
 Kilmarnock, Ayr . . . 
 Kircudbright .... 
 Kirkcaldy, Fife . . . 
 
 KlRKINTILLOCH,DuMBARTON 
 
 Largs, Ayrshire . . . 
 Leith, Edinburgh . . 
 
 Lerwick, Shetland . . 
 
 Leslie, Fife . . . 
 
 Linlithgow . . . . 
 Mearns, Glasgow . . 
 Melrose, Roxburgh . 
 Midcalder, Edinbro' 
 
 Montrose, Forfar 
 
 New Galloway, Kircudb. 
 Newhaven, Edinburgh . 
 Newton Stewart, Oastle 
 
 Douglas 
 
 Paisley, Renfrew . . . 
 
 Pathhead, Fifeshire 
 
 McDonald, R. F., M.D. 
 Somerville, — , M.D. 
 
 Manford, Robert A., M.D., Loc. See. 
 
 Frazer, R., M.D. 
 
 Shields, William, Esq., Hon. Loe. See. 
 
 Burns, W. McGregor, M.D. 
 
 Moir, G. D. 
 
 Dalby, W. B., M.D. 
 
 Mitchell, J. 
 
 Shand, John, M.D. 
 
 Dewar, James 
 
 Stuart, D. P. 
 
 Campbell, John, M.D. 
 
 Struthers, James, M.D., Loc. Sec. 
 
 Henderson, John, M.D. 
 
 Gillespie, James, M.D. 
 
 Spence, G. W., M.D., Loe. See. 
 
 Scott, Gideon G. 
 
 Soterbagh, Peter D. 
 
 Bell, J. M., M.D. 
 
 Alexander, James 
 
 Baird, George D. 
 
 Pollock, John 
 
 Brown, W. M., M.D., Loc. Sec. 
 
 Dick, John, M.D. 
 
 Watson, Walter, M.D. 
 
 HowDEN, James C, M.D., Loc. Sec. 
 
 Officer, A. M., M.D. 
 
 Johnston, David, M.D. 
 
 Steele, George, M.D. 
 
 Lawrence, Samuel, M.D. 
 
 Simpson, John 
 
 Tettes, James 
 
 Millman, Alfred M'Kinley 
 
 Finlay, William, M.D. 
 
 More, James, M.D. 
 MoKechnie, W., M.D., Loc. 
 McDonald, James T., M.D. 
 Paton, James, M.D. 
 Richmond, Daniel 
 Taylor, David, M.D. 
 McHutcheon, David, M.D, 
 Otto, John 
 Macgregor, Duncan 
 
 Sec. 
 
MEMBEES. 
 
 P££BL£S 
 
 Perth . 
 
 Pitlochry, Pjerth . . . 
 PoLMONT, Stirling . . 
 
 PORTOBELLO, EdINBRO' . 
 
 Queen's Ferry, South, 
 Linlithgow . . . . 
 
 Ratho, Edinburgh . . 
 
 Ken FREW . . . 
 Rothesay . . . 
 St. Andrews, ¥itt 
 
 Selkirk 
 Stirling 
 
 Thurso, Caithness 
 
 JuNOR, John B., Loc. See. 
 Craig, John 
 
 Lindsay, W. L., M.D., Loc. Sec. 
 Bramwell, J. P., M.D. 
 Absolon, G. W., M.D. 
 
 Irvine, W. S. 
 Myrtle, R. S. 
 Balfour, Andrew H. 
 
 6reig, David 
 
 Craig, James 
 Scott, Stephen, M.D. 
 Stobo, George, M.D. 
 Maddever, John Coombes, M.D. 
 
 Day, George E., Loc. Sec. 
 
 TJie Library of the University of St. 
 
 Andrews. 
 Bell, 0. H., M.D. 
 Raid, W., M.D. 
 Archibald, D., M.D. 
 Meekie, — , M.D. 
 Anderson, H. S., M.D. 
 
 Gibson, Charles, M.D.,Hon. Loc. Sec. 
 
 Dade, Robert 
 
 Johnston, William, M.D. 
 
 Beath, Andrew, Esq. 
 
 Eindlay, David, M.D. 
 
 Mill, James, Loc. Set. 
 
 Smith, John G. 
 
 Robelrtson, Alexander 
 
 Smellie, William, M.D. 
 
 Sutherland, David, M.D. 
 
 Tongub-by-Lairg, Suther- 
 landshire .... 
 
 Tranent, Haddington . 
 
 Black, R. W. 
 
 Watson, J. H., M.D. 
 Wilkinson, J., M.D. 
 
 IRELAND. 
 
 Aghaleb, Lurgan . 
 Ahasoragh, Galway 
 Ardee, Louth . , 
 
 Neeson, A., M.D. 
 
 Kehans, L. C, Loc. Sec, 
 
 Moore, Thomas J., M.D., Loc Sec. 
 Mclver, John 
 
MEMBEES. 
 
 47 
 
 Bagnalstowk, Cablow 
 Bailieborough . . . 
 Ballinasloe, Galway 
 
 BallineeNj Cork . . 
 Ballymena, Antkim . 
 Ballymoney, Antrim . 
 
 Ballymotjs, Sligo . . 
 Ballynahinch, Down. 
 Banaghee, King's County 
 
 Banbridge, Down . . 
 Bangor, Down . . , 
 
 Armagh Ctjming, Thomas, M.D., Loc. See. 
 
 Armstrong, James 
 
 Leslie, James 
 
 Moore, C. F., M.D. (Myddton Tynan) 
 
 Trayer, James J., M.B. 
 
 Johnstone, John A. 
 
 Starkey, p. S., M.B., Loc. See. 
 Home, Patrick, M.D. 
 
 Willis, E. N., M.B. 
 Kidd, Abraham, M.D. 
 
 Latham, W. T., M.B., Loc. Sec. 
 Thompson, James R., M.D. 
 
 McMuNN, Samuel, Loc Sec. 
 
 Dickson, James, M.D., Loc. Sec. 
 
 Tarleton, W. B. 
 
 Bell, William Hutchinson 
 
 BROWNiow, Nathaniel, M.D., Loc. Sec. 
 
 KussELL, Philip, M.D., Loc. Sec. 
 
 Belfast Pirrie, J. M., M.D., Loc. Sec. 
 
 Drennan, J, S., M.D. 
 Corry, T. C. J., M.D. 
 Gordon, Alexander, M.D. 
 Murney, H., M.D. 
 Stewart, Robert, M.D. 
 McGee, Mr., M.D. 
 Stronge, C. W., M.D. 
 Belfast Medical Society 
 Reid, Professor 
 Hunter, Samuel, M.D. 
 
 Beltukbet, Cavan . . O'Donovan, Richaid White 
 
 Boyle, Roscommon . . O'Farebll, Harwood, M.D., Loc. Sec. 
 
 Brookeborough, Fer- 
 managh Lightburne, Joseph, M.D., Loc. Sec. 
 
 Bruff, Limerick . . . Bennett, Samuel, M.D. 
 
 Ca»rickonSuib,TipperaryEdmundson, Joseph, M.D., Loc. Sec. 
 
 O'Ryan, Anthony, M.D. 
 Cashel, Tipperaky . . Russell, Robert P., Loc. Sec. 
 
 Graham, James, M.D. 
 Castlebar, Mayo . . . Knott, Edward, M.D., Loc. Sec. 
 Castlebellingham, Louth Trimble, James 
 Castlerea, Roscommon . Cuppaidge, William, M.B. , 
 
 Cavan Malcolmson, William 
 
 Moore, Mark, M.D. 
 
48 MEMBERS. 
 
 Clifden Suffield, W. H., M.D., , 
 
 Clonevan, Gokey . . . Allen, John B. 
 
 Clough-jordan, Tippebary Walsh, Arthur D., M.D. 
 
 Coal Island, Tyrone . Bindon, John Vereker 
 
 CoLERAiNE, Londonderry Macaldin, J., Loc. Sec. 
 
 Smith, — , M.D. 
 
 CooKSTOWN, Tyrone . . Graves, Henry, M.D. 
 
 CooLocK, Dublin . . . Darley, B. G., M.D. 
 
 Cork O'Leary, Purcell, M.D., Loc. Sec. 
 
 Corbett, Richard, M.D. 
 
 Bernard, W. P., M.D. 
 
 Finn, E., M.D. 
 
 Tanner, W. R., M.D. 
 
 Cremen, D., M.D. 
 
 Armstrong, C, M.D." 
 
 The Cork Medical and Surgical Society 
 
 Gregg, — , M.D. 
 
 O'Flynn, D. G., M.D. 
 
 CftAiG, Antrim .... Dunlop, John 
 
 Crossmaglen, Armagh . Donaldson, Richard, Loc. Sec. 
 
 DowNPATRiCK, Down . . White, W. N., M.D. 
 
 Drogheda, Louth . . . Pentland, Robert, Zoc. /S'ec. 
 
 Pogarty, T. T., M.D. 
 
 Drumconrath, Meath . Jones, John, M.D. 
 
 Dublin ....... Moore, W. D., M.B., Loc. Sec. (South 
 
 Anne Street) 
 Stokes, William, M.D. 
 Tufnell, T. J. 
 Montgomery, W. P., M.D. 
 Lees, Cathcart, M.B. 
 Smyly, Josiah 
 
 The Governor of the Apothecaries' Hall 
 Madden, William, M.D. 
 Gorman, William 
 McClintock, Alfred H., M.D. 
 Croker, Charles P., M.D. 
 Hutton, Edward, M.D. 
 Hardy, Samuel L., M.D. 
 Head, Henry, M.D. 
 The Royal College of Surgeons 
 Barker, W. 0., M.D. 
 Banks, J. T., M.D. 
 Byrne, Thomas, M.B. 
 Sinclair, E. B,, M.D. 
 Denham, John, M.D, 
 
MEMBERS. 49 
 
 Dublin Johnston, George, M.D. 
 
 Grimshaw, Wrigley 
 
 Kirkpatrick, Frederick, M.D. 
 
 Wyse, George, M.D. 
 
 Churchill, F., M.D. 
 
 Marsh, Sir Henry, Bart., M.D. 
 
 Guinness, B. G., M.D. 
 
 Le Clerc, Eugene 
 
 Gordon, Samuel, M.B. 
 
 O'Eeilly, Richard P. 
 
 MacSwiney, S. M., M.D. 
 
 Richardson, B. W. 
 
 Corrigan, D. J., M.D. 
 
 Cusack, James W., M.D. 
 
 Duncan, J. F., M.D. 
 
 Hudson, Alfred, M.D. 
 
 Fitzpatrick, Thomas, M.D. 
 
 Benson, Charles, M.D. 
 
 Evans, John, M.D. 
 
 McDonnell, John, M.D. 
 
 Collis, M. H., M.B. 
 
 Freke, Henrv, M.D. 
 
 Dwyer, H. L., M.B. 
 
 Irvine, Hans, M.B. 
 
 Mulock, Robert, M.D. 
 
 Geoghegan, Thomas G. 
 
 Mayne, Robert, M.B. 
 
 Pakenham, Daniel 
 
 Osbrey, Gerald, M.B. 
 
 Nowlan, John P. 
 
 White, John L. 
 
 Bnrke, W. M., M.D. 
 
 Nolan, H. P., M.D. 
 
 Johnson, Charles, M.D. 
 
 Beatty, Thomas B., M.D. 
 
 Lipsett, L. E. 
 
 Cirroll, W. 
 
 Kennv, John B. 
 
 Nicho'lls, Edward C, M.B. 
 
 The King's&Queen's College of Physicians 
 
 Smith, R. W., M.D. 
 
 Brady, James, M.B. 
 
 Shannon, Peter, M.D. 
 
 Newland, Robert 
 
 Mitchell, Arthur, M.D. 
 
 Forrest, John King 
 
 Cryan, Robert, M.D-. 
 
 Hayden, Thomas, M.D. 
 
 Lyons, E. D., M.B. 
 
 4 
 
50 
 
 MEMBERS. 
 
 Dublin . . , 
 
 DuNDALK, Louth . . . 
 
 DUNGANNON, TYiW)NE . . 
 
 Ennis, Co. Clake . . . 
 Enniskillen, Fermanagh 
 
 FiVEMlLETOWN, TyEONE . 
 
 Galway 
 
 Glasslough, Monaghan . 
 Keady, Armagh . . . 
 
 O'Ferrall, J. M. 
 Grant, James F. 
 Johnson, James R. 
 M'Dowel, B. G., M.D. 
 Neligan, J. M., M.D. 
 Sibthorpe, Henry J., M.D. 
 Colles, William, M.B. 
 Wright, E. P., M.B. 
 Owens, G. B., M.D. 
 Bolland, Edward H., M.D. 
 Shaw, Christopher 
 M'Munn, John, M.D. 
 Haughton, E., M.D. 
 Nicholson, G., Esq. 
 Maunsell, D. T. T., M.D. 
 Hamilton, John 
 Fleming, C, M.D. 
 Cusaek, S. A., M.B. 
 Hamilton, Edward, M.B. 
 Byrne, John A., MB. 
 Wharton, J. H., M.D. 
 Moore, Eobert H. 
 Ledwich, Edward 
 M'Dermott, Robert, M.B. 
 Ringland, John, M.D. 
 Warren, William H. 
 Shea, John, M.D. 
 Minchin, Humphrey, M.B. 
 Quinan, E. J., M.D. 
 Whitlev, Alfred W. 
 Kidd, Archibald N. 
 Law, Robert, M.D. 
 Daxon, William 
 
 Beunkeu, E. J., M.D., Loc. Sec. 
 
 Pollock, William 
 
 Browne, John, M.D. 
 
 Callan, Joseph, M.D. 
 
 Bernard, W., Lnc. Sec. 
 
 NeviU, W., M.D. 
 
 O'Bkien, George W., M.D., Loc. Sec. 
 
 CuUinan, P. M., M.D. 
 
 Walsh, Robert P. 
 
 M 'Niece, William 
 
 King, Chaklbs Ceoker, M.D., Loc. Sec. 
 Moran, Patrick, M.D. 
 
 Douglas, Allen E., M.D. 
 
 Leeper, John 
 
J[EMBEE,S. 
 
 Kilkenny . . . 
 
 KlLSHEELAN . . 
 KlLTORMER, GaLWAY 
 
 Kingstown, Dublin 
 KiNSALT!, Cork . . 
 
 KlNVARA, GaLWAY . . . 
 
 Lawrence Town, Galway 
 Letterpraok, Galway . 
 Letterkenny, Donegal . 
 LiFFORD, Donegal . . 
 Limerick 
 
 Listowel, Kerry . . . 
 Londonderry . . . . 
 
 Longford . . . 
 Loughgall, Armagh 
 LucAN, Dublin 
 Lynn, Sligo . . 
 Mallahide, Dublin 
 Mallow, Cork . . 
 
 Manoehamilton, Leitrim 
 Markethill, Aemagh 
 
 MiDDLETOWN, ARMAGH . 
 
 MiLTORD, Donegal . . 
 MoATE, "Westmeath . . 
 MouNTRATH, Queen's Co. 
 MoY, Tyrone .... 
 Naas, Kildare .... 
 Navan, Meath .... 
 
 Potter, John, M.D., Loc. Sec. 
 
 White, T. K., M.D. 
 
 Courtney, David, M.D. 
 
 Adams, W. O'Brien, M.D., Loc. Sec. 
 O'Flahertv, Jerome 
 Mahood, A. E., M.D. 
 
 FuRLONGE, W., Loo. See. 
 Dorman, Edward, M.D. 
 Bishopp, E., M.D. 
 Hornibrook, W. B., M.D. 
 
 HifNEs, Denis J., Loc. Sec. 
 
 Clarke, \V. H. 
 
 Tyner, George St. George, M.D. 
 
 Thorp, Henley, M.D., Loc. Sec. 
 
 Little, Robert, M.B., Loc. See. 
 
 Gelston, R. R., M.D. 
 
 Kane, Thomas, M.D. 
 
 Thorp, Gabriel, M.B., Loc. Sec. 
 
 Babington, T. H., M.D., Loc. Sec. 
 Miller, J. E., M.D. 
 Forsyth, James, M.D. 
 Whit'e, Barnwell, M.D. 
 
 Hyde, Charles H., Loc. Sec. 
 
 Leeper, W. W., M.D. 
 
 Pnrefoy, T., M.D. 
 
 R. K., -M.D. 
 
 Lloyd, Hans 
 
 Galway, William, M.D., Loc. Sec. 
 Berry, Parsons 
 
 Davis, Thomas, M.D., Loc. Sec. 
 
 Pratt, J., M.D. 
 
 Pratt, Thomas, M.D., (Monnt-norris) 
 
 Moore, C. F., M.D. 
 
 Osborne, J. A., M.D., Loc. Sec. 
 
 Matthews, John M., Loc. See. 
 
 Smith, Henry J., Loc. Sec. 
 
 Crothers, Robert, M.D. 
 
 Jackson, Henry 
 
 NicoLLS, P. J., M.D., Loc. Sec. 
 Nicolls, George P., M.D., R.N. 
 Hamilton, Francis D. 
 
52 ME.MBEllS. 
 
 Nenagh, Tippekaky . . Frith, Geoiige, Loc. Sec. 
 Newcastle, Down . . . Clauendon, Samuel, M.B., Loc. Sec. 
 Newcastle, Limerick . Bolster, Geokge, Loc. Sec. 
 
 Peirce, John, M.D. 
 
 Newmarket - on - Fergus, 
 
 Go. Clare Evans, S. P., M.D., Loc. See. 
 
 New Ross, Wexford . . Boyd, John W., M.D. 
 
 Newtown-hamilton, Ar- 
 magh Reed, William, M.D. 
 
 Newtown-Mount-Kennedy 
 
 WiCKLOw M'Clelland, R., M.B. 
 
 OvocA, WicKLOw . . . Nicholson, Joseph J., Loc. Sec. 
 
 Parsonstown, King's Co. Wallace, W. Alexander, M.D., Loc. Sec. 
 
 Woods, Thomas, M.D. 
 
 Portlaw, Waterford , Martin, James, M.D. 
 
 Ramelton, Donegal . . Johnston, Benjamin, M.B. 
 
 Rathdrum, Wicklow . . Clarke, Charles 
 
 Manning, Samuel 
 Sherwood, Eris Brass, M.D. 
 
 Rath GAR, Dublin . . . Hewitt, David 
 
 Roscommon Harrison, J,, M.D., Xoc. Sec. 
 
 ROSCREA, TiPPERARY . . KlNGSLEY, WiLLIAM, M.D., Loc. ScC. 
 
 Woods, Samuel J. 
 
 Saintfield, Down . . . Breeze, C. K., M.D. 
 
 Shillelagh, Wicklow . Bookey, John W., M.B., Loc. Sec. 
 
 Skreen, Sligo .... M'Munn, R., M.D. 
 
 Tarbert, Kerry . . . Hamilton, William, M.D. 
 
 Tralee, Kerry .... Alton, William, M.D., Loc. Sec. 
 
 Fitzmaurice, Robert 
 
 Tullamore, King's Co. . Ridley, John, M.D., Loc. Sec. 
 
 TuLLOW, Carlow . . . Burnett, Robert, Loc. Sec. 
 
 Waterford Mackesy, John, M.D., Loc. Sec. 
 
 Westport, Mayo . . . Peebles, W. B., M.B., Loc. Sec. 
 
 Wexford ...... Boxwell, H. H., M.D., Loc. Sec. 
 
 Cardiff, J. R., M.D. 
 Goodall, Ebenezer, M.D. 
 Ryan, William Charles, M.D. 
 Waddy, P. Swan, M.D. 
 
 Wicklow Hamilton, William, M.D., Loc. Sec. 
 
 Nolan, William 
 
 Banks, Henry 
 
 Boyce, Allen Keating, M.D. 
 
MEMBEES. 
 
 53 
 
 FOREIGN LIST. 
 
 CONTINENTAL. 
 
 Amsterdam Titanus, J. W. R., M.D. 
 
 Boulogne Scott, John, M.D. 
 
 Nice Blest, — , M.D. 
 
 Paris Giraldis, J. 
 
 Naples Sim, J., M.D. 
 
 AMERICA, &c. 
 
 Antigua Nicholson, Thomas, M.D. 
 
 AshfielDjMassachusetts Knowlton, C. L., M.D. 
 
 Bahia, Brazil .... Dennelly, 'Cornelius. 
 
 Patterson, Dr. 
 
 Baltimore, U. S. . . . Walters, J. S. 
 
 Wacheran, Dr. 
 Bangor, Maine . . . Salter, R. H., M.D., Loc. Sec. 
 
 Jones, R. K., M.D. 
 
 Boston, Massachusetts . Buckingham, C. E., M.D. 
 
 Clark, H. G., M.D. 
 Hayward, George, M.D. 
 Homans, John, M.D. 
 Jeffries, John, M.D. 
 Minot, Francis, M.D. 
 Morland, William W., M.D. 
 Perry, M. S., M.D. 
 Shattuck, George C, M.D. 
 Storer, David H., M.D. 
 Ware, Charles E., M.D. 
 Patch, F. F., M.D. 
 Rupparer, Anton, M.D. 
 Parks, Luther, jun., M.D. 
 Gay, George H., M.D. 
 Bowditch, H. J., M.D. (Gen. Hospital) 
 Jewett, Chas. C, (Boston City Library) 
 Poole, Wra. F., (Boston Athenaeum) 
 Hall, Curtis, M.D. 
 
54 MEMBERS. 
 
 Boston, Massachusetts . Dyer, Ezra, M.D. 
 
 Chamberlain, C. N. 
 Alley, John B. 
 
 Brunswick, Maine . . Chadbourne Prof. Paul A. (Bowdoin 
 
 College) 
 
 Buffalo, New Youk . . Sama, James, M.D. (Erie County Medi- 
 cal Society) 
 
 Cambridge, Massa- 
 chusetts Wyman, Prof. Morrill (Harvard Univer- 
 sity) 
 
 Charlestown, S.C. . . Caritier, George, M.D. 
 
 Coenwall, Canada West Pringle, George, M.D. 
 
 Grafton, Massachusetts Bosworth, F. A., M.D. 
 
 Great Falls, New 
 Hampshire .... Ross, J. S., M.D. 
 
 Montreal Fenwick, George E., M.D., Loc. Sec. 
 
 Brown, Dr. 
 
 Jones, Thomas W., M.D. 
 
 Godfrey, Dr. 
 
 Macdouall, Augustus C., M.D. 
 
 Wbeeler, Dr. 
 
 •Wrigbt, Dr. 
 
 M'Garry, Dr. 
 
 Fi'azer, Dr. 
 
 New Haven, Connecticut Hooker, Professor Charles (Sale College) 
 New Ipswich, New Hamp- 
 shire Jones, Frederick, M.D. 
 
 Newton, Massachusetts Teulon, William F., Esq. 
 
 New York Heywood, Charles F., M.D., Loc. Sec. 
 
 Reynolds, J. B., M.D. 
 
 (Sixty-three other members, names not received). 
 Philadelphia .... Costa, A., M.D. 
 
 Lewis, Samuel, M.D. 
 Mitchell, S. W., M.D. 
 Placersville, El Dorado 
 
 County, California . Titvis, Isaac S., M.D. 
 Quebec, Upper Canada . Blanchett, H., M.D. 
 Roxburgh.Massaohusetts Cotting, Benjamin E., M.D. 
 
 Sacramento, Califoknia Logan, Thomas M., M.D. 
 
 Morse, J. F., M.D. 
 
 Salem, Massachusetts . Peirson, E. B., M.D. 
 
 Worcester, Massachu- 
 setts Green, John, M.D. 
 
MEMBERS. 55 
 
 INDIA. 
 
 Calcutta Goodeve, Edward, M.B. 
 
 Macpherson, J., Esq., M.D. 
 Partridge, G. B. 
 O'Brien, Peter, H.M.I.A. 
 
 CoLDMBo, Ceylon . . Twest, Dr. Van 
 
 DiNAPOEE Balfour, John, M.D. 
 
 Madras Aitken, W., H.E.I.C.S. 
 
 Pomona, Bombay . . . Morehead, C. 
 
 Sueat Byramjee Rustomjee. 
 
^'« 
 
 'Wsi^fr: 
 
 I 'f ^ ff 'i Vi)