3
413 Mr. I. B. BROWN read a paper ON RUPTURED PERINIEUAT. He stated that his object in bringing before the Society this his third paper on the subject, was still further to establish the truth of the four propositions laid down in his second paper- viz., 1. That the oldest and worst forms of ruptured perinseum can be cured by the operation already described. 2. That the worst forms can be cured by operation imme- diately after the lesion. 3. That the new perinseum is not torn by, or prejudicial to, subsequent parturition. 4. That those forms of rupture where the sphincter is not torn through, should be cured, to prevent prolapsus uteri &c. To these he now added a fifth-viz., That the operation may even be performed three or four days after the accident, although the parts may be in a sloughy condition. He adduced instances illustrating all five, and related seven severe cases upon which he had operated, all of which terminated success- fully. He then proceeded to offer a tabular statement of all the cases he had yet published, including those read before the Society, tabulating the statement as to age, duration of rupture, nature of rupture, character of operation, and result, with summary remarks. From this statement it was seen that twenty-eight of the cases were completely successful, two were partially so, and one died. Of the two partially successful, the first was entirely attributable to the entire unmanageableness of the patient after the operation, refusing the absolute quiet so essential to success ; and further, to the patient leaving the hospital before anything could be done to remedy the recto- vaginal opening, which might easilv have been done had the ’, patient submitted to treatment. The second was the most serious case he had seen, with a greater loss of the recto-vaginal septum, and yet so satisfactory was the result, that the patient left the hospital with control over the bowels, and with every prospect of having a permanent and sound perinaJum ; but, as she refused to remain sufficiently long in the hospital for the united surfaces to gain sufficient strength, and as, on her return home, contrary to Mr. Brown’s injunctions to remain quiet, in a recumbent posture, she got up every day and took violent walking exercise, a gradual giving way of a great portion of the united surfaces resulted. The case of death was inte- resting from the fact that the subsequent history (which he, Mr. Brown, had ascertained from his friend and col- league, Mr. Coulson) proved that a slight wound, even from cutting her finger, in one instance, took three or four months to heal, assisted by a residence at the sea-side; and that was, of course, unknown to him at the time of the operation. Of the twenty-eight successful cases, he observed, that in twenty-one cases there was complete rupture of the perinasum, with the loss of the sphincter ani; and in the remaining seven there was either prolapsus of the uterus, bladder, or rectum, all of which affections were completely cured by the operation. He remarked also, that five of these patients had been delivered subsequently to the operation, and with no injury to the perinseum but what was easily remedied by suture; and that of the thirty-one cases, in thirteen of them the cause of rupture was the use of instru- ments. He (Mr. Brown) then proceeded to place before the Society a tabular statement of the operations performed by the late M. Roux, of Paris-tabulated in the same way as he (Mr. Brown) had done his own. M. Roux’s cases were fifteen in number: of these he returned twelve as successful, two as un- successful, and one death. But of the twelve returned as suc- cessful, he (Mr. Brown) observed, that in six of them M. Roux stated that a recto-vaginal fistula remained. It could not, there- fore, be said that the operation was successful; and if those six were added to the three confessedly unsuccessful, it would give nine out of fifteen, or nearly two-thirds cf the whole as un-’ successful. He observed that M. Roux used the quill-suture in all those; but there was no mention of a division of the sphincter ani in any one of them, a fact to which he (Mr. Brown) attri- buted the large number of failures. The author briefly summed up by recapitulating the points to be observed, in the following few word :-quill-suture, division of sphincter, free use of opium, generous diet, and frequent catheterism. Dr. MURPHY was opposed to the performance of this opera- tion immediately or in a very short time after delivery, because, 1, it required some time after labour for the perinseum to contract to its natural size, so that one might determine the real extent of the injury; 2, because of the liability to inflammation after this injury; and, 3, because it was not necessary, the delay of the operation only involving a certain amount of inconvenience to the patient. He believed that cases would be frequently unsuccessful if performed immediately after labour; and he protested against the operation when the parts were sloughing. He had no objection to the proceeding if performed at the proper time. Dr. WINN agreed in the main with Dr. Murphy, but said there were exceptions, and related a case in which the perinseum was ruptured through its entire extent, which was united im- mediately by sutures, and the patient got well. One advan- tage of immediate operation consisted in the fact, that the edges of the wound were recent, and did not require freshening. Mr. HENRY LEE regarded Mr. Brown’s plan as an improve- ment on former operations. He related a case in which he had performed it with success. Dr. BARNES said that when Mr. Brown first brought forward his method of operating, he was much more inclined to differ from some of his propositions than now. But although disposed to agree much more closely than formerly, there were still cer- tain propositions concerning which he must at least reserve his judgment. He could not assent to the propriety of opera- ting when inflammation and sloughing were going on. Upon the question of early operation he entertained no doubt. In the first case of perineoraphy which he had witnessed, one by Mr. Brooke, the bead-suture being employed, the operation was performed within a week of delivery. This case went through to a perfectly successful issue, notwithstanding many most trying complications. The lady had subsequently borne two children, the new perineum remaining perfectly intact. This case had occurred about seven years ago, before the date, he believed, of Mr. Brown’s earliest recorded operation. He believed he was expressing the opinion of Mr. Brooke as well as his own, that, if possible, the stitures should be inserted within a day or two after the injury, as, in that case, there would be no necessity for refreshing the wound ; and if that could not be done, then that the necessary operation should be performed within a week. It was of the utmost importance to the health and peace of mind of the patient, that she should not be permitted to rise from the puerperal bed with an injury of this kind unhealed. Dr. Barnes also reserved his opinion as to the necessity of making such free double divisions of the sphincter as Mr. Broivn recommended. At the time of the first discussion of this question, Dr. B. had suggested that a subcutaneous division of the sphincter might answer the pur- pose. He feared that free open incisions in a situation so abound- ing in loose cellular tissue were not without danger : inflamma- tion, suppuration, and pyaemia might result. The subcuta- neous incision suggested by Dr. Barnes had been recently adopted by an American physician. Dr. Barnes, however, stated that, influenced by Mr. Brown’s advice, he had, in ope- rating for the repair of a ruptured perinseum, at the Metropo- litan Free Hospital, divided the sphincter on Mr. B.’s plan. This woman had for many years suffered from complete pro- lapsus of the womb. In this case he had used Mr. Brooke’s suture. She had made a perfect recovery, and was quite re- lieved from the prolapsus. Dr. B. als04uestioned the expedi- ency of giving such large and repeated doses of opium. In reading the account of Mr. Brown’s cases he could not help concluding that the fever, vomiting, and other distressing spmptoms which followed, were owing to the opium. Nor had he himself seen any necessity for the practice. Dr. B. ex- pressed his opinion that Mr. Brown had rendered a solid and important contribution to surgery ; but he thought also, that in the history of this operation the name of Mr. Brooke ought not to be omitted. Mr. HIRD thought that statistics proved the superiority of Mr. Brown’s plan of dividing the sphincter in these cases, over other operations. He thought that the operation could be re- sorted to directly after the injury in ordinary cases; but the presence of sloughing and inflammation prohibited the perform- ance of any surgical operation. Mr. BROWN hctving replied, the Society adjourned. PATHOLOGICAL SOCIETY OF LONDON. TUESDAY, OCTOBER, 16TH, 1855. MR. ARNOTT, PRESIDENT, IN THE CHAIR. MR. ERICHSEN exhibited a specimen of TUBERCULOUS DISEASE OF THE TIBIA, removed from a man, twenty-one years of age, a banker’s clerk. He first felt pain in the right leg, below the knee, eighteen months ago. In this situation an abscess gradually formed,

PATHOLOGICAL SOCIETY OF LONDON. TUESDAY, OCTOBER, 16TH, 1855

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Mr. I. B. BROWN read a paperON RUPTURED PERINIEUAT.

He stated that his object in bringing before the Society thishis third paper on the subject, was still further to establish thetruth of the four propositions laid down in his second paper-viz.,

1. That the oldest and worst forms of ruptured perinseumcan be cured by the operation already described.

2. That the worst forms can be cured by operation imme-diately after the lesion.

3. That the new perinseum is not torn by, or prejudicial to,subsequent parturition.

4. That those forms of rupture where the sphincter is nottorn through, should be cured, to prevent prolapsus uteri &c.To these he now added a fifth-viz., That the operation may

even be performed three or four days after the accident,although the parts may be in a sloughy condition. He adducedinstances illustrating all five, and related seven severe casesupon which he had operated, all of which terminated success-fully. He then proceeded to offer a tabular statement of all thecases he had yet published, including those read before theSociety, tabulating the statement as to age, duration of rupture,nature of rupture, character of operation, and result, withsummary remarks. From this statement it was seen that

twenty-eight of the cases were completely successful, two werepartially so, and one died. Of the two partially successful, thefirst was entirely attributable to the entire unmanageablenessof the patient after the operation, refusing the absolute quietso essential to success ; and further, to the patient leaving thehospital before anything could be done to remedy the recto-vaginal opening, which might easilv have been done had the ’,patient submitted to treatment. The second was the mostserious case he had seen, with a greater loss of the recto-vaginalseptum, and yet so satisfactory was the result, that the patientleft the hospital with control over the bowels, and with everyprospect of having a permanent and sound perinaJum ; but, asshe refused to remain sufficiently long in the hospital for theunited surfaces to gain sufficient strength, and as, on her returnhome, contrary to Mr. Brown’s injunctions to remain quiet, ina recumbent posture, she got up every day and took violentwalking exercise, a gradual giving way of a great portion ofthe united surfaces resulted. The case of death was inte-

resting from the fact that the subsequent history (whichhe, Mr. Brown, had ascertained from his friend and col-

league, Mr. Coulson) proved that a slight wound, even

from cutting her finger, in one instance, took three or

four months to heal, assisted by a residence at the sea-side;and that was, of course, unknown to him at the time of the

operation. Of the twenty-eight successful cases, he observed,that in twenty-one cases there was complete rupture of theperinasum, with the loss of the sphincter ani; and in the

remaining seven there was either prolapsus of the uterus,bladder, or rectum, all of which affections were completelycured by the operation. He remarked also, that five of thesepatients had been delivered subsequently to the operation,and with no injury to the perinseum but what was easilyremedied by suture; and that of the thirty-one cases, inthirteen of them the cause of rupture was the use of instru-ments. He (Mr. Brown) then proceeded to place before theSociety a tabular statement of the operations performed by thelate M. Roux, of Paris-tabulated in the same way as he (Mr.Brown) had done his own. M. Roux’s cases were fifteen innumber: of these he returned twelve as successful, two as un-successful, and one death. But of the twelve returned as suc-cessful, he (Mr. Brown) observed, that in six of them M. Rouxstated that a recto-vaginal fistula remained. It could not, there-fore, be said that the operation was successful; and if thosesix were added to the three confessedly unsuccessful, it wouldgive nine out of fifteen, or nearly two-thirds cf the whole as un-’successful. He observed that M. Roux used the quill-suture inall those; but there was no mention of a division of the sphincterani in any one of them, a fact to which he (Mr. Brown) attri-buted the large number of failures. The author briefly summedup by recapitulating the points to be observed, in the followingfew word :-quill-suture, division of sphincter, free use of

opium, generous diet, and frequent catheterism.Dr. MURPHY was opposed to the performance of this opera-

tion immediately or in a very short time after delivery, because,1, it required some time after labour for the perinseum to contractto its natural size, so that one might determine the real extentof the injury; 2, because of the liability to inflammation afterthis injury; and, 3, because it was not necessary, the delay ofthe operation only involving a certain amount of inconvenience

to the patient. He believed that cases would be frequentlyunsuccessful if performed immediately after labour; and heprotested against the operation when the parts were sloughing.He had no objection to the proceeding if performed at theproper time.

Dr. WINN agreed in the main with Dr. Murphy, but saidthere were exceptions, and related a case in which the perinseumwas ruptured through its entire extent, which was united im-mediately by sutures, and the patient got well. One advan-tage of immediate operation consisted in the fact, that the edgesof the wound were recent, and did not require freshening.Mr. HENRY LEE regarded Mr. Brown’s plan as an improve-

ment on former operations. He related a case in which he hadperformed it with success.

Dr. BARNES said that when Mr. Brown first brought forwardhis method of operating, he was much more inclined to differfrom some of his propositions than now. But although disposedto agree much more closely than formerly, there were still cer-tain propositions concerning which he must at least reservehis judgment. He could not assent to the propriety of opera-ting when inflammation and sloughing were going on. Uponthe question of early operation he entertained no doubt. Inthe first case of perineoraphy which he had witnessed, one byMr. Brooke, the bead-suture being employed, the operation wasperformed within a week of delivery. This case went throughto a perfectly successful issue, notwithstanding many mosttrying complications. The lady had subsequently bornetwo children, the new perineum remaining perfectly intact.This case had occurred about seven years ago, before the date,he believed, of Mr. Brown’s earliest recorded operation. Hebelieved he was expressing the opinion of Mr. Brooke as wellas his own, that, if possible, the stitures should be insertedwithin a day or two after the injury, as, in that case, therewould be no necessity for refreshing the wound ; and if thatcould not be done, then that the necessary operation should beperformed within a week. It was of the utmost importance tothe health and peace of mind of the patient, that she shouldnot be permitted to rise from the puerperal bed with an injuryof this kind unhealed. Dr. Barnes also reserved his opinion asto the necessity of making such free double divisions of thesphincter as Mr. Broivn recommended. At the time of thefirst discussion of this question, Dr. B. had suggested that asubcutaneous division of the sphincter might answer the pur-pose. He feared that free open incisions in a situation so abound-ing in loose cellular tissue were not without danger : inflamma-tion, suppuration, and pyaemia might result. The subcuta-neous incision suggested by Dr. Barnes had been recentlyadopted by an American physician. Dr. Barnes, however,stated that, influenced by Mr. Brown’s advice, he had, in ope-rating for the repair of a ruptured perinseum, at the Metropo-litan Free Hospital, divided the sphincter on Mr. B.’s plan.This woman had for many years suffered from complete pro-lapsus of the womb. In this case he had used Mr. Brooke’ssuture. She had made a perfect recovery, and was quite re-lieved from the prolapsus. Dr. B. als04uestioned the expedi-ency of giving such large and repeated doses of opium. Inreading the account of Mr. Brown’s cases he could not helpconcluding that the fever, vomiting, and other distressingspmptoms which followed, were owing to the opium. Nor hadhe himself seen any necessity for the practice. Dr. B. ex-

pressed his opinion that Mr. Brown had rendered a solid andimportant contribution to surgery ; but he thought also, thatin the history of this operation the name of Mr. Brooke oughtnot to be omitted.

Mr. HIRD thought that statistics proved the superiority ofMr. Brown’s plan of dividing the sphincter in these cases, overother operations. He thought that the operation could be re-sorted to directly after the injury in ordinary cases; but thepresence of sloughing and inflammation prohibited the perform-ance of any surgical operation.Mr. BROWN hctving replied, the Society adjourned.

PATHOLOGICAL SOCIETY OF LONDON.TUESDAY, OCTOBER, 16TH, 1855.

MR. ARNOTT, PRESIDENT, IN THE CHAIR.

MR. ERICHSEN exhibited a specimen ofTUBERCULOUS DISEASE OF THE TIBIA,

removed from a man, twenty-one years of age, a banker’s clerk.He first felt pain in the right leg, below the knee, eighteenmonths ago. In this situation an abscess gradually formed,

414

which was opened about four months after the first occurrenceof pain. Since this time the leg has not been used. Swellingof the knee-joint now took place, but there was no positivesign of articular disease. The discharge from the abscess con-tinued uninterruptedly. Startings of the limb at night werenow complained of, and about seven months ago bare andsoftened bone was first detected by the probes through theopening below the knee. Abscesses next formed in the lowerpart of the thigh, which were opened, and discharged freely,but no bone came away. The general health becoming dis-turbed, amputation of the thigh was performed on the 10th ofOctober. On examination of the bone and joint, the cancelloustissue of the upper part of the tibia was found to be infiltratedwith tubercle, a small trace of which runs through the head ofthe bone, till it reaches the spine. The tuberculous depositwas found more abundant in the upper part of the shaft thanin the head of the bone. There is one large patch distinctlycircumscribed, nearly two inches in length at the junction ofthe shaft with the epiphysis. Through the cancellous tissue ofthe head of the bone isolated masses, about the size of pins’heads, are freely scattered, chiefly in the external tuberosity.The cartilage covering the inner tuberosity of the tibia is nearlysound; that encircling the external tuberosity is softened andpulpy towards the middle; at the edge it is detached from thesubjacent bone; the spine of the tibia is bare and rough. Thefemur and patella are healthy, and the soft structures aroundthe joint are very much thickened and infiltrated with a largequantity of plastic matter. Under the microscope the affectedbone was of a light yellowish colour, contrasting strongly withthe deep pink of the surrounding congested bone; it was soft,and from the interstices of the cancellous structures, tuber-culous masses could be picked out, which, when examinedunder the microscope, presented-1st, The débris of cells; 2nd,Multitudes of small cells of about half the diameter of free

corpuscles, their outline varying much-some polyhedral, othersnearly triangular, others oblong; none are perfectly round, manyhave a well-marked outline on the greater part of their circum-ference, but appear broken in the rest. The perfect cells havea clear well-defined outline. Their contents are granules, somefatty. This case is interesting-1st, from the large mass ofcircumscribed tubercle; 2nd, from its greater extent in theshaft than in the epiphysis; 3rd, from the illustration it affordsof the large class of joint-affections in which the disease beginsin the ends of the bones rather than in the joint itself; 4th, theabsence of caries, or that molecular disintegration of bone whichso commonly accompanies tubercle.

Dr. PEACOCK exhibited two specimens ofHEART DISEASE.

The first was one of very aggravated disease of the aorticvalves, removed from a man forty-five years of age, a gardener,who had been an out-patient of Dr. Peacock’s at the Hospitalfor Diseases of the Chest, Victoria-park. He had never sufferedfrom rheumatic fever or inflammation of the chest, and hadnever sustained any serious injury, and stated when first seenthat he had only been ill two months. He complained ofdyspnœa, palpitation, and cough, with slight expectoration.He stated that he had never had haemoptysis, or oedema of theankles, or other dropsical symptoms. The pulse was full andjarring, and disappeared under the fingers, displaying some-what the character of regurgitation. The dull space, on per-cussion, on the region of the heart was extended beyond itsnatural limits, and a systolic murmur was heard over thewhole præcordia, but most distinctly at the base and in thecourse of the aorta. The second sound was everywhere im-perfect, and a feeble diastolic murmur audible. He did not

improve while under treatment, and died about a month afterhis first application. The post-mortem examination displayedno material disease, except that of the heart, which weighedtwenty ounces avoirdupois. The aortic orifice admitted onlyof the passage of a ball measuring twenty-four lines in circum-ference, thus indicating a diminution of capacity to the extentof one-third or more. The contraction was due to the existenceof extensive disease of the aortic valves, which were blendedtogether at two of the angles, so as to form a contracted ringcomplete all round except at one side. The valves were muchthickened and ossified, presenting hard projecting nodules ofbone not denuded of the endocardium. At the ununited partthe valves were not in contact, and doubtless allowed of someregurgitation. The left ventricle was of very large size, butthe walls had not increased in thickness; the right ventricleand auricles were also dilated. This case afforded an exampleof aggravated disease, superinduced upon an original malforma-tion of the valves, which consisted in the fusion of the contiguous

angles and curtains of the valves; but it was remarkable inthat two of the angles were united, instead of only one, as isgenerally the case. The disease had evidently been of verylong duration-a slow transformation, probably at no timeconnected with any active symptoms, which was the moreworthy of notice as the patient dated the commencementof his illness only to a period of about three months before hisdeath.

The second specimen was a heart removed from a girl abouttwelve years of age, an out-patient of Dr. Peacock’s, at St.Thomas’s Hospital, who had presented symptoms of mitralvalvular disease. It displayed an example of the entire de-struction of the chordæ tendinæ of one of the fleshy columnsof the left ventricle, so that the curtain of the mitral valvemust have been allowed to fall back towards the left auricleduring the systole of the heart, and could have offered littleresistance to the free regurgitation of the blood from the leftventricle into the auricle.

Mr. SHAW exhibited a specimen ofA NECROSED PART OF THE PETROSAL PORTION OF THE

TEMPORAL BONE,from a boy, aged seven years, who was admitted into theMiddlesex Hospital on the 31st of July, 1855, under Mr. Shaw,for otorrhoea affecting both ears. The disease preceded anattack of scarlet fever, which he had two years and a half ago.The discharge of pus from the right ear was not great. Theleft external ear projected extensively beyond its proper levelfrom the side of the head, and in the concha an irregular pieceof bone, surrounded with fungous granulations and pus pro-truded so as to be visible. He had paralysis of the muscles ofthe left side of the face; for a year he had been completelydeaf in both ears. On the 3rd of August he was put underthe influence of chloroform, when Mr. Shaw removed the pro-jecting portion of the bone; after which another piece wasobserved rolling freely in the cavity of the ear, which was alsoextracted by the dressing forceps by a little force; for a fewseconds dark venous blood flowed freely. He was kept in bedfor a week; the discharge gradually lessened, and the ulcer ofthe tube healed. He left the hospital soon afterwards quitewell. Mr. Shaw looked upon it as a rare form of disease.

Mr. TOYNBEE said the disease was not so rare as Mr. Shawimagined. Mr. Wilde, of Dublin, mentions a similar case inhis work; and Mr. Toynbee has one of a similar description inhis collection.

Dr. QUAIN presented a specimen ofFALSE ANEURISM OF THE HEART, COMMUNICATING WITH THE

AORTA, PROBABLY ALSO WITH THE RIGHT AURICLE AND THECAVITY OF THE PERICARDIUM; DISEASE OF THE AORTICVALVES;

for which he was indebted to Dr. Rae, of Greenwich Hospital.There was disease of the aortic valves, with chronic inflamma-tion of the adjoining portion of the heart’s substance. Soften-ing had here occurred, and haemorrhage, which made its wayinto the aorta. A clot had been formed on the aortic valvenext the seat of disease, and here it presented the appearanceof a mass of vegetation. The pericardium was filled withbloody serum. The liver was cirrhosed, and the kidneys weregranular. Dr. Quain indicated the present as a mass of for-midable disease, which had commenced, gone on, and termi-nated without any special symptom. The man was sixty-fiveyears of age; he had died after a fortnight’s illness of diarrhoea,and there was no history of symptoms referrible to heart orchest disease.

Dr. HILLIER exhibited a specimen ofHYDATIDS OF THE LIVER, ATTENDED WITH HÆMORRHAGE

INTO THE STOMACH AND BOWELS,removed from a woman, aged twenty-nine years, who had leda very irregular life, suffering from want and dissipation toexcess, and who was admitted to University College Hospital,under Dr. Garrod, in July, 1855, for jaundice. Her illnesscommenced a week before her admission, with retching, fol-lowed in two days by jaundice. On examination, the liver wasfound enlarged, and the epigastric region tense and tender.Under the use of an emetic, mercurial treatment, with taraxa-cum, she was nearly relieved of the jaundice. She expectoratedsome blood, and about a month after her admission, was seizedwith some pains in the epigastric region, lasting for four or fivehours. She was very ansemic, suffering often from nausea. Atthe end of another month she was again suddenly seized withspasmodic pains in the stomach, which were now accompaniedwith vomiting of blood; blood was also passed by stool. She

415

became blanched, restless, cold, and clammy, and died in about Itwelve hours, with symptoms of internal haemorrhage. On

opening the body, the liver was found to be enlarged, weighing If,ninety-one ounces. There was a distinct feeling of fluctuationin the right lobe, from which a quantity of dark-red fluidescaped on being cut into. In the cavity was found a largelayer of decolorized fibrine, which, on being detached, wasfound to be stained with bile, and it was rough and irregularlylaminated. From the cavity there was a large opening into abiliary duct, accompanied by many smaller openings into otherducts. The hepatic duct was much dilated in circumferencenear its junction with the cystic duct. The weight of the liverafter emptying the large cyst, was fifty-four ounces; its con-tents weighed thirty-seven ounces. There were two other andsmaller cysts, containing thick ochre-coloured matter, of a

creamy consistence, and with a cartilaginiform wall. The

cheesy matter in one of the cysts was, on examination underthe microscope, found to be partly granular, and to containmany plates of cholesterine. Ecchinococci, or at any rate theteeth, or characteristic hooks of them, could be found in abun-dance. The upper portion of the large intestine was filled withfluid blood, and the lower two-thirds of the ileum was empty.The liver was, no doubt, the seat of three hydatid cysts; thelarger of these communicated freely with the biliary duct;haemorrhage had occurred into the cyst, probably from a branchof the hepatic artery; this blood had in part passed into theintestines, along the hepatic, or common bile ducts, so as tocause haematemesis and melasna, and fill half the small intes-tines.

Mr. PARTRIDGE exhibited a specimen ofFRACTURED SPINE,

removed from a boy, thirteen years of age, who had fallen froma scaffolding at Somerset House, and was admitted into King’sCollege Hospital. On his arrival there he was sensible, pulseslow, and he was inclined to be drowsy. On examination atthe upper part of the spine at the dorsal portion a fracture wasdiscovered. Crepitus was distinct, and he complained of painin the part; the only other injury was a graze on the chin andthe lower part of the back. He complained of sickness that Ievening; there was general paralysis; there was no loss of sen-sation, but he could grasp less firmly with the left hand; there wasno reflex action of the lower extremities; there was no actionof the intercostal muscles; the breathing was purely with thediaphragm. After three or four days there was a little reflexaction by tickling the lower extremities; subsequently the legswere flexed on the thighs. After rallying from the shock, thebreathing was easier and the pulse regular. His ordinarymode of lying in bed was with his hands grasped over his head;the breathing was easier when lying down, and more difficultwhen in the erect posture. The abdomen was tympanitic, andthere was no power over the sphincters; he passed dark fasces.The bladder was emptied three or four times a day, and some-times washed out ; the urine was sometimes ammoniacal.There were bed-sores, for which he was put on a water bed.The bladder was contracted, and contained only four or fiveounces of urine. There was priapism. This state continuedwithout variation until three weeks before his death, when lowfever came on, and he sank. Though the fracture was in thesixth dorsal vertebra, the symptoms were those of injury aboutthe phrenic nerve. On a post-mortem examination some ofthe spinous processes were found fractured; the spinal mar-row was disintegrated, and in a fluid condition. Probablysome of the symptoms were caused by the effusion of fluidblood into the spinal canal. The lungs and liver were healthy.There was slight ulceration in some portions of the intestines.The kidneys were healthy. A small calculus was found in oneof the ureters, and a small calculus was also found in thebladder. The mucous coat of the bladder was healthy. Thecalculus was not examined as to its composition.

Dr. SIBSON wished to know if the movements of the sterno-cleido and the scalenic muscles were noticed in the case re-lated by Mr. Partridge. Dr. Hodgkin had shown him a caseof a young man who fell down some area steps in which therewas fracture of the cervical vertebra, and the sterno-cleido andscalenic muscles acted strongly. The respiration was abnormal.In another patient, a woman, under his own care in St. 1’Iary’sHospital, there was intercostal respiration where fracture ofthe last dorsal and first cervical vertebra existed; there wasno action of the abdominal muscles, and pus was found en-circling the spine at the place corresponding to the fractures.Mr. PARTRIDGE said that he had frequently examined the

patient, and did not notice the action of the muscles referredto. The hands appeared to be kept in the position over the

head before noticed to aid the action of the great pectorals,for when they were removed the patient put them back again.

Mr. BRODH1JRST exhibited casts of

CONTRACTIONS OF THE SECOND TOE OF BOTH FEET.

The patient, aged twenty-five, had suffered for seven yearsfrom this distortion, which was first induced by wearing tightFrench boots; both feet were nearly equally affected and pain.ful. Walking was most painful, and could only be attemptedwith the aid of sticks. The third phalanx was doubled flatunder the toe, and the dorsum rested on the ground; the nailwas destroyed, and the skin over the articulation ulcerated;there was slight motion in the joint. After dividing thetendon, complete extension was gradually effected, and in twomonths the patient was able to walk with ease.

Mr. BRODHURST, in answer to a question by Mr. Partridge,said that the tendon on the plantar surface of the foot, theextensor tendon of the toe, was divided, and of course thesheath cut through.

Mr. ASHTON said he had a similar case under his care whichhe cured by mechanical extension, by means of a piece of corkplaced under the toe at its whole length.The PRESIDENT reminded Mr. Partridge that cases of that

description are common withth ose who wear small-pointed boots.Mr. HUTCHINSON exhibited a specimen ofINVAGINATION OF THE CAECUM AND ASCENDING COLON,

which existed three months, and was removed from a man whocame under his care three weeks before his death for supposedphthisis. There was great loss of flesh; no disease in the chest;the tongue was red; the pulse was quick; and he had frequentsickness after meals. He complained of uneasiness in his rightside, which he relieved by suspending himself from a ladder.During the last fortnight of his illness he complained of severepain in his right side; and the night before his death, whilstat ten, he was seized with severe pain, which caused him to rollon the ground in great agony.

Dr. CRISP wished to know why Mr. Hutchinson supposedthat invagination had existed three months. He doubted itsexistence for so long a period.Mr. HuTCHiNSON.—All the symptoms being more or less in

existence for that time, and there was great sickness.Dr. HARE agreed with Dr. Crisp, and doubted the existence

of invagination for so long a time. If it were so, there musthave been great pain, and the invagination must be discoveredby ordinary examination. In such cases as that now beforethe Society it was almost impossible to afford relief by opera-tion, the adhesion of the invaginated portions was so firm.

Mr. HUTCHINSON. - There was no examination of theabdomen, for there was no symptom to arrest attention duringlife. He believed that an operation might have been beneficial,for the intestine could be easily divided at the post-mortem,but it was now hardened by the alum, in which it was kept.

Mr. EpiCHSEN.—Dr. Hare stated correctly that, looking atthe intestine from above, an operation could be of no avail in.this case. He saw a case, with Dr. Watson and Dr. West, inwhich there was decided evidence of invagination in a child,and where an operation was not admissible, but relief wasafforded by inflating the intestine from below.

Dr. PEACOCK could not agree with Dr. Hare, that great painalways existed in these cases. In a case of obstruction in thelower bowel, which he saw with Mr. Shilletoe, it had existedfor seven years.

Dr. BARCLAY wished to know the state of the evacuations.If invagination existed so long, it was impossible to have anyevacuations. There must have been complete constipation.Mr. HuTCHINSON did not examine the faeces; they were

always passed in the closet.Dr. HARE, in reply to Dr. Peacock, said that his observa-

tions did not apply to obstructions, but to invagination of theintestines.

Dr. CRISP said the plan had recourse to by Mr. Erichsen wasnot at all new.

WESTERN MEDICAL AND SURGICAL SOCIETYOF LONDON.

FRIDAY, OCTOBER 19TH, 1855.DR. JAMES ARTHUR WILSON, PRESIDENT, IN THE CHAIR.

AFTER the transaction of the usual business, the Presidenttook the opportunity of addressing a few remarks to themembers present. He observed that it was the duty of indi-