767about a twelvemonth ago : it had, therefore, shown rapid pro-gress in attaining its present size. There were two lymphaticglands in the neck, below the body of the jaw on the rightside, which had enlarged ; and the submaxillary gland wasindurated.The aspect and history of the disease gave the impression-

in which Mr. Gay’s colleagues and his friend Mr. Coulson, whohad seen the case, concurred-that it was a malignant growthtaking its origin from the cancellated tissue of the bone ; and,with this impression, Mr. Gay advised its extirpation, ratherwith the view of releasing the patient from a growth whichthreatened speedily to occlude the passages to the lungs andstomach, than with that of eradicating the disease from thesystem.Mr. Gay performed the operation on the 7th of August.

After cutting through the integuments from each corner of themouth downwards below the base of the jaw, and reflectingthem, as well as the intermediate portion from the symphysis,back, Mr. Gay sawed the bone through on each side, keepingquite clear of the disease. This was accomplished with con-siderable difficulty. One saw broke in the process; and thiswas not to be wondered at when, on inspecting the bone, itstissues were found to have become exceedingly compact, sothat in density it resembled ivory. As soon as this part of the,operation had been accomplished, Mr. Gay proceeded to dissectaway the growth from beneath the tongue, and from the frontof the larynx, with which it was in contact, and subsequently ’,from its inferior connexions with the parts at the base of themouth. An incision was then carried downwards along theneck from that which began at the right corner of the mouthto the diseased lymphatic glands, by which these were re-moved. The submaxillary, as it was hoped that it had onlybecome sympathetically affected, was not interfered with. A few vessels had to be secured in the deeper parts of this some-what extensive wound ; and the parts were brought together,and secured by silver suture. A ligature, which had been putthrough the tongue for the purpose of controlling it during theoperation, was allowed to remain in the event of its becomingnecessary to overcome any tendency on the part of its dis-arranged muscular apparatus to draw it backwards towardsthe pharynx.The after-history of the case was, in the main, most satis-

factory. The tongue did not manifest any disposition to’become unruly; its tip, however, to the extent of an inch,sloughed. With the help of a spoon, and the constant andassiduous attention of the deaconesses who devote themselvesto the care of the patients at this hospital, the patient wasable early to take abundance of nourishment and the necessary.amount of stimulus, so that healing commenced quickly, and atthe end of ten days had made such progress, and the patient’shealth had so far recovered, that he expressed himself able toleave the hospital in order to make a more agreeable use of hisvisit to London. At the expiration of a further fortnight he returned to Penzance, wbere important duties called him, or atleast required his supervision, which he said he was quite ableto give to them.The last report, about five weeks since, announced his con-

valescence, with very fair and unexpected powers of speechand mastication. An artificial portion of jaw, in lieu of thattaken away, which Mr. Fox, one of the dentists to the hos-pital, says he can supply, will go far to counteract some of theill results of so considerable a mutilation. The operation wasperformed under the influence of chloroform.An examination of the parts removed showed that the dis-

ease originated in the periosteum, and, from the character ofthe cells, which with some areolar stroma constituted the en-,tire growth, that it was unquestionably myeloid.

ST. BARTHOLOMEW’S HOSPITAL.A CASE OF IDIOPATHIC TETANUS.

(Under the care of Mr. HOLMES COOTE.)THE following case, for the notes of which we are indebted

to Mr. Horsfall, house-surgeon, would seem to be an example’of the condition known as idiopathic tetanus. It is the fourthof its kind which has come under Mr. Coote’s observation.William C aged fifty-four, a labourer, a very muscular

man, came to the surgery on Nov. Ilth, complaining of head-- ache and stiffness of the jaws. Trismus and risus sardonicuswere well marked. He had felt the stiffness two days before.Had no headache until this morning.On admission, he could move his jaw very slightly. As he

went from the surgery to the ward he fell, as he said, fromweakness. He recollected no injury, recent or otherwise, andhas had no pain in abdomen or elsewhere until this morning.Has always been a healthy and temperate man. He was ad-mitted at twelve noon. Bowels open yesterday, and not thismorning.-Half-past one P.M.: Cannot move his jaw at all.Pulse 100, very strong and full; trismus more marked ; musclesof abdomen very tense and hard ; opisthotonos very slight, butpersistent; respiration entirely thoracic. - Quarter past twoP.M.: One minim of croton oil was administered. - Five P.M.:Bowels not open. Croton oil repeated. Pulse as before;tongue very red and moist, protruded with difficulty; opistho-tonos more marked ; perspiring freely. - Eight P.M.: Bowelsopen twice since five; perspiration very profuse; pulse 124,slightly irregular in force, and very full ; shows the tip of histongue with great difficulty; respiration thoracic, but notlaboured.-Quarter past ten P.M.: Pulse 110, not so full, morenatural and regular; bowels open twice since eight P.M.Nov. 12th.-Thirty-five minutes past twelve: Bowels open

at half-past ten, slightly; pulse 108, as before. An ounce anda half compound senna draught administered as an enema ;half a grain of morphia injected subcutaneously.-Twentyminutes past two A.M.: Bowels not open again; respirationthoracic and free ; perspiration less ; says he feels better ; noalteration in other respects. - Four A.M.: Pulse 100, feeble ;breathing stertorous and laboured ; has breathed so for thelast fifteen minutes ; opisthotonos increased and persistent ;both arms completely flexed ; hands clenched ; surface of body,where exposed, very cold; evidently moribund. He died abouthalf-past four.Throughout the progress of this case the spasmodic contrac-

tion was persistent and increasing. A careful examination ofthe surface of the body failed to discover any scratch or bruise.The teeth were not more carious than the average at his age.Nothing whatever was discovered in the post-mortem ex-

amination that could be even hypothetically regarded as anirritating cause.There has been quite a cluster, Mr. Horsfall tells us, of cases

with tetanic symptoms in this hospital of late. Besides theabove, there have been three of tetanus proper-two of whichwere of traumatic origin,-and two of poisoning by strychnia.One of these last, the result of a dose of " Battle’s vermin-killer," was fatal; in the other, very alarming symptoms wereproduced by a very minute dose of liquor strychnine. We shall,probably, refer to these on another occasion.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

TUESDAY, DEC. 10TH, 1867.MR. SAMUEL SOLLY, F.R.S., PRESIDENT, IN THE CHAIR.

(1) ON CERTAIN POINTS IN THE ANATOMY AND PATHOLOGY OFBRIGHT’S DISEASE OF THE KIDNEY; AND (2) ON THE

INFLUENCE OF THE MINUTE BLOODVESSELSUPON THE CIRCULATION.

BY GEORGE JOHNSON, M. D.,PHYSICIAN TO KING’S COLLEGE HOSPITAL.

IT is now generally admitted that cases of chronic Bright’s, disease may be arranged in two distinct classes :-1. Cases in

which the kidney is large, pale, and smooth on the surface.2. Cases in which the kidney is small, red, and granular. Inthe forty-second volume of the "Medico-Chirurgical Trans-actions" the author pointed out the chief features by whichthe two classes of cases may be distinguished. There is somedifference of opinion with regard to the anatomy and pathologyof the various forms of Bright’s disease. Some pathologistsmaintain that the small granular kidney is the result of an in-tertubular deposit. The author maintains that there is no

proof of such deposit; while the red colour and the vascularityof these kidneys seen in an advanced stage afford proof thatno such deposit exists. All the essential changes in this dis-ease are intra-tubular.In the 33rd volume of the "Transactions" the author first

noted the fact, that in all the forms of chronic Bright’s diseasethe muscular walls of the minute renal arteries are hyper-trophied. He then supposed that this was the result of aneffort to propel the blood onwards. It is now generally ad-mitted that the minute arteries act as stop-cocks ; that they

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regulate the blood-supply, but they have no propelling power. which take place in the capillaries materially affected the-The explanation of the hypertrophy of the small renal arteries passage of the blood through them. In asphyxia, Dr. Johnsonwhich is most in accordance with the facts is that, in proportion says that the black blood causes contraction of the arteries.to the destruction of the renal gland cells, there is less demand What proof is there of its not being due to stoppage in thefor blood to be acted upon by the gland; the renal arteries con- capillaries, owing to an arrest of the transformations ordinarilysequently contract upon their contents so as to maintain the accomplished there? In reality, however, black blood wouldbalance between the blood supply and the diminished secretory flow through the vessels even in asphyxia, for he had foundaction of the kidney. This continued overaction of the small that a chemical material might thus pass from one side of thearteries in antagonism to the heart results in hypertrophy of heart to the other.their muscular walls. In the advanced stages of some forms Dr. DICKINSON, while acknowledging the value of Dr.of chronic Bright’s disease the walls of the arteries as well as Johnson’s paper, could not agree with him on all points-as,those of the Malpighian capillaries assume a white and wax- for instance, when he denied the existence of disease in thelike appearance-a result probably of infiltration of albuminous intertubular areolar tissue of the kidney. Why should thisor fibrinous materials into the tissues. This appearance of de- tissue be thus insusceptible of disease when elsewhere it wasgeneration is secondary, and not essential. It has long been so liable to it ? The granular form of kidney he believed to-known that the left ventricle of the heart is hypertrophied in be due to a pseudo-inflammatory change. Between two granu-nearly all cases of chronic Bright’s disease. This is believed latons, one could always discover a shred of fibrous tissueto result from the resistance offered by the small arteries still unchanged-not broken-down renal structure. The red

throughout the body to the passage of blood contaminated with colour he held, depended on vascularity of the new formation,urinary excreta. The muscular walls of the arteries have been which, although it thus contracted, never compressed the largerfound hypertrophied in the brain, in the pia mater, and in the arteries. Dr. Johnson maintained that the granular casts wereintestines of those who have died of chronic Bright’s disease, of epithelial origin. He (Dr. Dickinson) thought they wereand it is probable that this anatomical evidence of arterial re- rather disintegrated fibrin; for he had been able to producesistance to the circulation in these cases will soon be much in- the same microscopical appearances by soaking fibrin in water,creased. He had also shown, by passing water through the kidneys,

Reference was then made to the experiments of Hales upon that the obstruction was greater in the small granular kidneyanimals recently killed, as well as to those of Blake upon living than in the large white one.animals, to prove the influence of the minute arteries upon the Dr. SANDERSON, after expressing his admiration of Dr.circulation. The sudden arrest of the circulation through the Johnson’s paper, and his sense of the importance of his con-lungs by the admission of atmospheric air into the veins, and clusions as to the part played by the capillary arteries inthe impediment to the pulmonary circulation in cholera, are disease, adverted to the recent researches of Professor Ludwig:both referred to the same cause-namely, contraction of the and Dr. Cyon, which had for their object to determine whethersmall arteries upon their contents. Again, some of the pheno- the excitation of certain sensory nerves has any influence onmena of apnoea admit of complete explanation only by reference the arterial pressure through the vaso-motor nerves. Severalto the contraction of the small arteries. A dog was killed by sensory nerves were experimented on, but especially thea ligature on the trachea. The chest being opened, imme- cardiac branches of the vagus. In the rabbit, there is a nerve-diately the right heart was distended, the left nearly empty, which, leaving the vagus high up in the neck, passes down-The lungs were pale, nearly bloodless, and extremely collapsed. wards between it and the sympathetic towards the stellateThe minute pulmonary arteries must have arrested the mass of ganglion and ends in the heart. On exciting the peripheralthe blood before it reached the capillaries. end of this nerve after division in the neck, no effect is pro-A comparison of the phenomena of apnoea with those of duced on the circulation ; but if the central end is faradised,

renal disease appears to warrant the conclusion that an im- the arterial pressure sinks. The depression amounts to twopeded circulation, the result of arterial contraction, may occur or three inches of mercury. It is so marked that it can beunder two different conditions : 1. When the respiratory made out independently of the manometer. The arterieschanges in the lungs are impeded, or when the secretory action visibly contract, and if the belly is opened during life the sur-of a gland, such as the kidney, is impaired, the minute arteries face of the kidneys is seen to become brighter. At the sameof the lung or of the kidney, in obedience probably to a time, the pulse becomes slower in consequence of reflex exci-stimulus conveyed to them through the nerves from the capil- tation of the vagus, for this last effect is absent if the vagilaries, restrict and retard the blood-stream. The anaemia of have been previously divided. These experiments were madethe pulmonary capillaries in cases of acute apnoea, and the in animals under various conditions-e.g., before and afterovergrowth of the muscular walls of the renal arteries in cases section of both vagi, after removal of the sternum, under theof chronic Bright’s disease, are results of one and the same influence of woorara, &c. The experiments showed that the-physiological principle. 2. The minute arteries in any part of excitation of this sensory nerve alters the balance of the cir-the body may be excited to contract by their contents becoming culation-increasing the quantity of blood in the veins, de-

abnormal, and therefore more or less noxious to the tissues. creasing that in the arteries. It remained to show whetherWe have an illustration of this in the resistance which the the influence was exercised on the heart or the capillaries.systemic arteries offer to the passage of macerated black blood, This was done (1) by previously destroying the stellate gang-and of blood contaminated with urinary excreta. We have liou, and thus isolating the heart from the nervous centres andanother illustration of it when certain foreign materials are dividing the vagi, when it was found that in animals so treatedeither accidentally in man, or designedly in animals, introduced the effect of stimulating the cardiac branch in the neck wasinto the veins, and then arrest the flow of blood through the unaltered ; and (2) by repeating the experiment after divisionlungs. The late Dr. Alison and many other pathologists have of the splanchnic nerves. In this experiment of division oftaught that the minute bloodvessels have the power to anta- the splanchnic nerve, Ludwig and Cyon found, as had beengonise the heart and to check the circulation. This power of found before, that the arterial pressure was lowered, in conse-resistance has been almost universally believed to reside in the quence of the paralysis of the capillary arteries of the kidneyscapillaries, which have no contractile power; while the stop- and other abdominal viscera. In such an animal, scarcelycock action of the small arteries, with their contractile, mus- any effect was produced by excitation of the central end of thecular walls, has been almost ignored by pathologists. One of cardiac branch of the vagus. Thus it appears that in thethe main objects of this communication has been to direct at- reflex arrangement by which the arterial pressure is governed,tention to this action of the small arteries in various patho- the principal afferent nerves are associated with the vagus, thelogical states of the system, and to adduce anatomical as well chief motor nerve being the splanchnic. But the most inter-as physiological evidence of its reality and its powerful infiu- esting result of all is that the arterial pressure is governed,ence. not by the capillaries of the whole body, but by those of theThe PRESIDENT thanked Dr. Johnson for his admirable paper. abdominal viscera-a discovery which throws much light on

The importance of his investigations into the muscularity of the way in which changes believed by Dr. Johnson to exist inthe minute arteries could not well be over-estimated. Bright’s disease may affect the arterial pressure. With refer-

Dr. PAW was highly pleased with Dr. Johnson’s paper ; ence to the phenomena of apnma, referred to by Dr. Johnsonnevertheless, he must beg leave to dissent from certain state- in illustration, Dr. Sanderson remarked that the extremements contained in it. The gist of the paper was to throw pallor of the lung observed in dogs asphyxiated by occlusionon the minute arteries that function which physiologists are depends in great measure on the quantity of air that happensaccustomed to assign to the capillaries. Dr. Johnson had not to be in the chest at the time the trachea is tied. He had as-proved this to his satisfaction. The entrance of air into the certained by experiment some years ago, that if, at the momentveins caused arrest of blood in the lungs. Was it in the of occlusion, the chest be tilled with air, the lungs are foundminute arteries or in the capillaries? He held that the changes extremely white after death ; in the contrary case, more or

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less hyperasmic. Secondly, he affirmed that it is not the casethat the circulation of unaerated blood increases the arterialtension. In ordinary apnoea, the arterial tension rises duringthe second minute after occlusion, because the animal strug-gles ; it falls the moment the struggle ceases. The fact thatin an animal suffocated under the influence of woorara, whenall muscular action is in abeyance, excepting the contractionof the heart and capillary arteries, the phenomenon is not ob-served, cannot be explained, as suggested by Dr. Johnson, asdependent on the paralysing action of the poison on the capil-lary arteries, for there is evidence that these vessels are asexempt from its influence as the heart itself.

Dr. JOHNSON, in reply, stated that he was under the im-pression that he gave the ordinary view when he stated thatthe minute arteries regulated the flow of the blood, althoughDr. Pavy objected to the statement. As for Dr. Dickinson’s.objections with regard to the intertubular tissue, some heldthat there was no such substance, whilst his experiment of

passing water through the kidney was of doubtful value.speaking of Dr. Burdon Sanderson’s objections, Dr. Johnsonmentioned that his statements were founded on Dr. J. Reid’s

- experiments, whilst certain of Dr. Sanderson’s doctrines were- completely opposed to those of Bernard.

OBSTETRICAL SOCIETY OF LONDON.

WEDNESDAY, DEC. 4TH, 1867.DR. HALL DAVIS, PRESIDENT.

THE following gentlemen were elected Fellows:—Dr. RaynerBatten Gloucester; Mr. Jessop, Cheltenham; Dr. Junker, Mr.Levy, and Mr. Robinson, London.

Dr. Wynn Williams and Mr. T. Chambers were requested to.act as auditors of the financial statement for the current year.

Dr. D. LLOYD ROBERTS, of Manchester, read a paperON A CASE OF CÆSAREAN SECTION.

The patient was a young woman aged twenty-one, a farmservant, who was sent to St. Mary’s Hospital, Manchester, on.June 2nd, 1867, being at the time in labour. On examination,the outlet of the pelvis was found much contracted ; the archof the pubis reduced to a mere slit, just wide enough to admit’the index-finger ; and the distance between the tuberosities ofthe ischia was less than an inch and a half. Under these cir-cumstances it was decided to perform the Cæsarean section. Thiswas done on June 3rd. The child was extracted alive. Themother died on the sixth day. At the post-mortem examina-tion the external wound was found to be nearly united. Therewere evidences of diffused peritonitis. The edges of the uterinewound were everted and flabby. The lower portion of the,cervix was soft and dark-coloured; and the os was patulous,and nearly black, as if gangrenous. The author remarked thatthe diminution of the pelvis was not caused by rickets ormollities ossium. There was complete anchylosis between thesacrum and ilium on the left side, and as nearly as possible onthe right. The sacrum was smaller than natural. The dimi-nution of the pelvis was in its transverse diameters, and theoutlet was much more contracted than the brim. The exactduration of her labour was obscure ; but while the tonic con-tractions of the uterus were strong and continuous to the end,the alternate or labour pains were as nearly as possible sus-pended, showing exhaustion of uterine energy. In the course,of the operation the ether-spray had been used; but the authorstated that he should not again douche the uterus with it, forhe thought it had the effect of hardening the uterine tissueand interfering with the effusion of plastic lymph. The exactdimensions of the pelvis were given, and the case was furtherillustrated by diagrams and a dry preparation of the pelvisitself.

Dr. GRAILY HEwITT had had an opportunity of seeing thepelvis previous to the meeting. It was a most interesting in-stance of the pelvis technically known as "Robert’s pelvis," "and only two or three such he believed had been described.The peculiarity in the shape arose from the occurrence of an-chylosis of the sacrum on both sides to the adjacent bones,differing from Naegelé’s oblique ovate pelvis in the fact thatin Robert’s pelvis the anchylosis was on both sides, in Nae-gele’s on one side only.

Dr. GREENHALGH remarked that he had never seen a pelvissimilarly distorted. He was disposed to attribute the de-formity to arrest of development of the sacrum, to which theossa innominata were firmly anchylosed, and in depth it re-

sembled the male pelvis. In Naegele’s museum Dr. Green-halgh had seen somewhat similar specimens, but confined toone side, constituting the oblique pelvis of that author.

Dr. GREENHALGH exhibited the uterus of a patient uponwhom he performed the Cæsarean Section eighteen monthsago, on account of epithelioma of the cervix. For more thansix months after the operation, the disease, which was ad-vancing rapidly, underwent considerable improvement, the

haemorrhage and pain ceasing, and the local affection dwindlingto an almost inappreciable degree. The disease then againbegan steadily to advance, and ultimately destroyed her. Itwas interesting to observe that the body and fundus of theuterus with appendages were healthy, the neck being occupiedby a large disintegrating epitheliomatous growth. The in-cision in the uterus, originally about six inches in length, nowreduced to one inch, was perfectly healed ; the serous covering,however, appeared not to have been reproduced.

Dr. BARNES exhibited the Uterus of a patient who had diedfrom Puerperal Fever. The patient was twenty-three years ofage. She was delivered after natural labour, child hving, onthe 16th of November. She was seized with severe pain inthe abdomen, shivering, and fever on the 18th; and on the23rd she died. There was nothing to favour the conjecturethat she had contracted any disease of an epidemic character.The case appeared to be one of simple autogenetic origin. Onexamination, the pelvis, peritoneum, and the peritoneal sur-faces of the intestines in relation with the pelvic organs werecovered with soft fibrin, breaking down into pus. The cavityof the uterus was empty ; the placental seat, near the fundus,still prominent; the walls were thick and fairly contracted.There was no appearance of pus or putrilage in the uterinesinuses. The sinuses even in the neighbourhood of the pla-cental seat were clean and healthy. The veins on either sideof the neck of the uterus in the broad ligaments also seemedhealthy. In one of these there was a feebly-contracted freshclot.

Dr. BARNES also showed a Placenta displaying FibrinousDeposits, forwarded by Mr. John Marshall, of Dover. Theplacenta was taken from a patient in good health ; and thechild, born at the full term of gestation, was alive and well.Dr. Barnes observed that these deposits generally take placetowards the end of gestation; and the effused fibrin is com-monly found in greatest quantity around the margin of theplacenta on the fcetal surface, in the neighbourhood of the cir-cular vein. It does not appear to involve change in the properstructure of the placenta, and the child is generally born alive.It occurs in persons quite free from syphilitic taint.Dr. MEADows exhibited a new Uterine Sound, to which was

attached a Metroscope. The chie’ peculiarity of the soundconsisted in having the measuring points on the concavity in-stead of the convexity of the instrument. The metroscopewas formed by means of a glass prism, fixed at an angle to thehandle of the sound, and was so placed that, when usedthrough the speculum, objects could be seen almost at a rightangle to the axis of the speculum, and at a considerable dis-tance from the refracting surface of the prism.

Dr. HEYWOOD SMITH exhibited a child, five days old,affected with what he believed to be encephalocele. Thetumour occupied the posterior aspect of the head, and mea-sured 6i inches in girth at its root, and about 8 inches fromthe superior margin of the root over the tumour to the inferiormargin. Dr. H. Smith also showed the Placenta, which pre-sented the peculiarity of having the funis fused with the mem-branes for the space of six inches.

Dr. EASTLAKE exhibited a Child in whom the PosteriorFontanelle was large and quadrangular.

Dr. GRAILY HEWITT exhibited a specimen of TraumaticAneurism of the Uterine Artery. The subject of this unusualcase was an Irishwoman, a patient of University College Hos-pital, the mother of several children, aged thirty-seven. Shewas delivered by means of the forceps, and for the first fewdays appeared perfectly well. On or about the fourth dayafter labour, her husband came home drunk, and it is statedthat he knelt upon her as she lay in bed. No immediately badeffects followed, but, thirteen days after labour, a slight flood-ing occurred. Inflammatory action on the right side of theabdomen became evident. Twenty days after labour, a secondviolent flooding took place, from which she nearly died.Thirty-one days after labour large quantities of yellowishmatter escaped per vaginam. On the thirty-fourth day athird violent flooding came on; and on the thirty-seventh daythere occurred again a fourth and final violent hæmorrhage,from the effects of which she could not be rallied. The partsexhibited consist of the uterus and neighbouring structures.