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attack. It is difficult to believe that the whole of thEcoagulum found blocking the pulmonary vessels could bavebeen carried there from the femoral vein, for had suchthorough plugging of the arteries as post-mortem examina-tion disclosed suddenly taken place, death must have en-sued almost instantaneously. Probably only a small portionof clot was originally lodged at the bifurcations of the largepulmonary branches, which, by obstructing the circulation,and interrupting the heart’s impulse upon the mass of bloodwithin the lungs, caused stasis and ultimately coagulationin the vessels-a condition known to occur during life inother affections.On thinking over the case, it appears to me that the in-

temperate habits of the man had so vitiated his conditionof health as to prevent the usual curative processes takingplace at the seat of injury, and must therefore be held prima-rily responsible for his unexpected death. It is well knownthat wounds, whether the result of accident or operation,are more often followed by erysipelas, or some other form ofblood-poisoning, in those who are accustomed to take largequantities of liquor than in persons who are more abstemious.Whether this be due to the constant over-stimulation of,and consequent injury to, the nervous system, or to themorbid changes wrought in the viscera generally, or tosome unhealthy condition of the blood itself induced by thelarge ingestion of alcohol, may be subject of dispute, but ofthe fact itself there is no doubt. In this case a most trivialaccident was followed by phlebitis and blood-poisoning, andalthough the man recovered from his attack of jaundice,the phlebitis persisted and brought about such a series ofchanges in the limb that it is most improbable he couldbave recovered from them. Had not the embolus cut shortthe patient’s life, I cannot but believe that he must soonhave succumbed to the morbid changes which had evidentlytaken place in his blood at the time of death; for the au-topsy disclosed precisely the same conditions that are so fre-quently met with in cases of blood-poisoning after injury-viz., clot rigidly limited to the veins in the neighbourhoodof the wound, with general fluidity of the blood elsewhere,great congestion of the viscera, and rapid decomposition ofthe body. Had this man, who was apparently in a goodstate of health, been operated upon, or had he received anopen wound from accident, there is strong presumption thathe would have become the subject of pysemia or of one ofthe blood diseases so closely allied to it; and he would haveadded another example to that most interesting series ofcases brought before the Clinical Society by Mr. PrescottHewett, in which patients who had not in any way beenexposed to them died from diseases which by some are sup-posed to depend solely upon hospital influences, but which,I think, in not a few instances, have their origin in someorganic vice existing within the patient rather than in somedeleterious agent introduced from without.Queen Anne-street, Cavendish-square, W.

NOTES AND REMARKSUPON A

CASE OF GRANULAR CONTRACTED KIDNEY(CIRRHOSIS OF KIDNEY),

IN A CHILD OF FIVE YEARS AND ELEVEN MONTHS.

BY WILLIAM H. BARLOW, M.D.,HONORARY MEDICAL OFFICER, GENERAL HOSPITAL AND DISPENSARY

FOR SICK CHILDREN, MANCHESTER.

(Concluded from p. 153.)

THE hypertrophy of the left ventricle (which was in thi!case also accompanied by dilatation) is one of the most fre.quent concurrents of this condition of kidney, and its pre.sence leads at once to the consideration of the vexed question!as to the essential nature of the disease and the real caUSEof its accompanying organic derangements.

Dickinson, from an analysis of 250 cases, gives 48 pe1cent. as the proportion of cardiac enlargement. Dr. W,

Roberts, in his table (2nd edit., p. 406), finds it recorded in125 out of 406 autopsies collated from various sources; andall writers upon the subject agree as to the frequency withwhich the two conditions are coexistent.

As to the cause of this condition of the left heart, opinionsas yet differ; but the balance of authority would seem tobe in favour of the old opinion of Bright, somewhat modifiedby the results of modern research. Bright says that 11 themost ready explanation appears to be that the quality of theblood is altered by kidney disease. The blood in conse-

quence affects the minute and capillary circulation, so as torender greater action necessary to force it through the vas-cular system." Dr. George Johnson also explains this in asimilar way. He alludes to the experiments of the lateProfessor John Reid upon asphyxiated cocks, showing howthe contamination of the blood consequent upon deprivationof air leads to obstruction of capillary circulation. His wordsare : "In consequence of the degeneration of the kidney theblood is morbidly changed. It contains urinary excreta,and it is deficient in some of its own normal constituents.It is therefore more or less unsuited to nourish the tissues,more or less noxious to them. The minute arteries through-out the body resist the passage of this abnormal blood. Theleft ventricle therefore makes an increased effort to driveon the blood. The result of this antagonism of forces isthat the muscular walls of the arteries and those of the leftventricle of the heart become simultaneously and in an equaldegree hypertrophied." Dickinson also attributes it to thealtered condition of the blood, and he says of Bright’s theory," There can be no doubt that this explanation is founded onsound principles." Traube,* however, attributes this to adifferent cause, and says that the contraction of the kidney,and consequent obstruction of its capillaries, causes a

diminution of the quantity of blood passing from the arterialto the venous system, and less fluid is withdrawn from thearterial system for the formation of urine. The fulness ofthe arterial system is therefore increased, and the enlarge-ment of the left ventricle is compensatory and forces a largerquantity of fluid through the kidney. Now it has been

proved by Dickinson by actual experiment, "that, withgranular degeneration the kidney could not, on an average,transmit one quarter as much water as passed through ahealthy kidney under the same circumstances."t Niemeyer4,says: 11 This theory (Traube’s) is disputed by Bambergerand others, who reply that the hypertrophy develops in astage of the disease when no obstruction of any importanceto the circulation of the kidney exists. A more extensivecollection of facts will be necessary to decide this disputedpoint; but, at all events, enormous hypertrophy of the heartsometimes occurs, even in the second stage of Bright’s dis-ease, and assuredly the circulatory disturbance of the kidneyis not the sole cause of it." Sir Wm. Gull and Dr. Sutton,in their paper,§ offer another and a different explanation ofthe causation of this cardiac hypertrophy. They say that,inasmuch as in many cases of large white kidney (the sequelof acute tubal nephritis) the heart has been found freefrom hypertrophy (Wilks), and as Dickinson acknowledgesthat " simple hypertrophy of the left ventricle is rarelyassociated with any form of renal disease excepting granulardegeneration," therefore "we must look for a third andmore general morbid condition, antecedent to both thecardiac hypertrophy and the renal disease." They thenquote Grainger Stewart, who in lardaceous disease of thekidney found the heart hypertrophied in only 4 per cent. ofthe cases, and state that of 17 cases of " large white kidney"under their own observation, post-mortem examinationshowed that 11 in 12 of them the heart was healthy," and in4 cases of scrofulous pyelitis they "found the heart healthy."They also state that they have found 11 9 cases in which thekidneys were very contracted and the heart was free fromhypertrophy." These cases they regard as proving thatthe obstruction to the circulation is due neither to the dis-ease of the kidney causing a mechanical impediment to thepassage of the blood through that organ, nor to the produc-tion of a state of blood which can per se cause delay in itspassage through the capillary system; and after describ-ing a certain change in the coats of the vessels, not ofthe kidney only but of the whole body, they say: " Weattribute the hypertrophy to the vascular change." Ina pamphlet just published, Dr. A. L. Galabin holds, onthe other hand, that hypertrophy of the left ventricle

* Ueber den Zusammenhang von Herz und Nierenkrankheiten, p. 58.t Op. cit., p. 105.: Vol. ii., p. 30; translated by Humphreys and Hackley.§ Medico-Chirurgical Transactions, vol. Iv.11 On the Connexion of Bright’s Disease with Changes in the Vascular

System.

191

"belongs especially to a granular kidney, but also in some statement. He further observed "that the thickening in-degree to tubal nephritis of long standing; and this is a volved both the adventitious and the muscular coat, andstrong argument that it results from chronic Bright’s dis- that the latter was both thickened and changed in structure,ease as a disease of the kidney, and not as a common result so that the change was not a simple hypertrophy. The mus-of some third condition." The altered and thickened con- cular nuclei became attenuated or extinct, while the strise,dition of the arteries in Bright’s disease was pointed out both circular and longitudinal, were exaggerated. Thelong ago by Clendinning, and many others have noticed the altered muscular coat was almost unaffected by carmine,concurrence of thick fibrous hypertrophied vessels with while the healthy artery absorbed it abundantly. The thick-fibrous degeneration of other organs.* But it was reserved ened muscular coat was spotted sometimes closely with oil,for Dr. George Johnsont to point out the widespread hyper- and often gave evidence of calcareous change." After Dr.trophy of the muscular coat of the small arteries in chronic Bastian and many other speakers had borne testimony toBright’s disease, not in the kidney only, but in the skin, the reality of the change described by Sir W. Gull and Dr.muscles, pia mater, and intestines. His explanation of its Sutton, Dr. Dickinson observed "that the hypertrophy ofproduction has been already given in speaking of the cardiac the heart was satisfactorily accounted for by the narrowinghypertrophy; but of late this interpretation of the appear- and obstruction of the diseased arteries." *

ances seen in microscopic examination has been called in Dr. Galabin, in his recent thesis already quoted, noticesquestion, as in the before-mentioned paper by Sir Wm. Gull these statements, and doubts the existence of any opposingand Dr. Sutton. These gentlemen have made a series of contraction in the muscular coats of the smaller arteries;investigations into the condition of the smaller arteries and he acknowledges the thickened appearance of the smallercapillaries in this disease, and their observations extend to arteries, but denies that there is any reduction of calibre,the skin, the pia mater, the heart, lungs, spleen, stomach, and says that though a reduction of elasticity in the largerand retina, in all of which they find a thickening of the vessels might be a cause of hypertrophy, yet if it affectedminute arteries (arterioles) and capillary vessels; but they the capillary vessels only it could have no such effect. Hediffer from other observers in their interpretation of the notices the frequency of atheroma in these cases, and isnature of the thickening, which Dr. Johnson ascribes to inclined to look upon that disease, not simply as a degenera-hypertrophy of the muscular coat, and Drs. Wilks and tive change, but rather as a result of inflammation, andDickinson seem to ascribe to atheromatous changes. They states that in the early stage, "there is an active prolifera-assert, on the contrary, that this thickening is due to the tion of cells, such as occurs in inflimmation. We have

deposit of a " hyalin-fibroid" substance in the coats of these thus," he proceeds, " not a mere thickening or fibroid dege-vessels ; that the change occurs ehieny "outside the mus- neration of arteries, but an arteritis, which may be com-cular layer, but also in the tunica intima of some arterioles"; parable to the other inflammations common in the course ofthat the degree in which the affected vessels are altered, Bright’s disease." He mentions 23 cases of atheroma ofand the extent to which the morbid change is diffused over arteries, in which both the kidneys and the valves of thethe vasnutar system of different organs, vary much ; and heart were healthy, and in which there was no otherthat tb... "muscular layer of the affected vessels is often apparent cause for cardiac hypertrophy, and he finds theatrophied in a variable degree." In explanation of this last heart hypertrophied in 13, and its average weight to bestatement they observe that the thickening of the walls of 12? oz., while in granular kidney the average weight of thethe vessels is not from an increased development of the heart was 15 oz., and he concludes from this that, thoughmuscular coat, but from a deposition outside that coat of atheroma of the larger arteries may cause hypertrophy, yetthe before-mentioned hyalin-fibroid substance, and accom- it is " not sufficient to account for the whole of the effect

panied in many cases by atrophy of the true muscular coat produced in Bright’s disease." In order to account for the

(see sketch of section of thickened arteries). This condition whole of this change he believes we must go back to thethey propose to call 11 arterio-c-,ipillary fibrosis," and they opinion of Bright and Johnson as to the obstruction causedsay, " our inquiries show that these changes are, or may be, by the altered condition of the blood, and the consequentindependent of renal disease, and that the renal change, in changes produced by the greater cardiac action required tochronic Bright’s disease, with contracted kidney when pre- keep up the circulation. He then proceeds to give thesent, is but part of a general morbid condition." The result of observations with the sphygmograph, the summarycardiac hypertrophy they explain in the following words:- of which is briefly this: that in a healthy pulse, with a"The hyalin-fibroid material in the walls of the arterioles Mahomed’s sphygmograph, and a pressure of 12 oz. to 3 oz.,must be an impediment to elasticity, and it can be experi- the pulse tracing approaches very nearly to the ideal or truementally shown that greater force is reeluired to propel a pulse-wave. In the case of rigid arteries from causes otherfluid continuously through a non-elastic than through an than Bright’s disease the pressure required is from 3 oz. toelastic tube. The left ventricle therefore, owing to this 4 oz , and the "tidal" or "first secondary wave" is large,diminished elasticity of the arterial walls, has of necessity but in cases of granular kidney a pressure of 4 oz. to 6 oz. isto contract with greater force to carry on the circulation." required, and the tidal wave is very large, in some casesThese views were vigorously opposed by Dr. Geo. Johnson even reaching higher than the primary or percussion wave,

in a paper read at a meeting of the Medico-Chirurgical and similar conditions are found in acute nephritis. He

Society, held Dec. 10th, 1872, in which he maintained that then proceeds to say that 11 this increase in the tidal wavethe hyalin-fibroid" appearance was "a post-mortem pby- indicates a prolongation of the heart’s contraction, such assical result of the distension of the fibrous tissue of the results from atheromatous arteries or aortic obstruction.arteries, by the mixture of glycerine and camphor in which It is obvious that a similar effect would be produced if thereall the specimens had been mounted." And with regard to were an impediment to the capillary circulation. Hencethe theory of the causation of hypertrophy of the heart, he my interpretation of the tracings is that even in the earlystated that, "in this explanation, the elasticity of the larger stage of acute nephritis such an impediment to the circula-arteries, which acts in aid of the heart as a propelling force, tion may occur from altered quality of the blood, that theis confounded with the muscularity of the smaller arteries, arterial pressure is increased, and the heart’s contractionwhich antagonises the heart." And he attributed the hyper- made more laborious. If this be true, it is easy to under-

trophy to senile changes and to the emphysematous condi- stand that this state of things, if continued long enough,tion of the lungs in many of the cases mentioned by the will cause the muscular walls both of heart and arteries tobefore-named authors. Dr. Sutton having replied, showing hypertrophy."that these appearances were visible in specimens mounted The same author, also, makes some remarks upon renalin salt and water, spirit and water, iodised serum, and dropsy, which seem to be worthy of notice. He points outalbumen and water, Dr. Dickinson stated that the appear- that there are two mechanical conditions which would causeances described by Sir W. Gull and Dr. Sutton were, "in his increased exosmosis- viz., increased pressure within theopinion, undoubtedly the result of disease, and not of post- vessels, or diminished specific gravity of the contained fluid.mortem action of any kind." This substance 11 was seen The effect of increased pressure of blood within the vesselsexceedingly well in vessels which had never been touched would be to cause effusion in dependent parts, and this iswith glycerine, but had been hardened in chromic acid, and what occurs in cardiac dropsy ; but if the effusion be thepreserved in Canada balsam or some similar material," and result of a diminished specific gravity of the contents of thethe specimens which illustrate this case fully support this vessels, then it would be equally diffused over the body, and

would be most manifest where the tissues are loosest, and

t Brit. Med. Journ., April lg, 1870, this LjuarczT, Dec. 21st, 1872.

192

this is the case in renal dropsy. That this should be causecby the drain of albumen is an old opinion; and the write]proceeds to quote Christison, who found the specific gravit3of the serum in the early stages of Bright’s disease to b(1020 to 1022, while that of healthy serum ranged between1029 and 1031. But in the later stages (by which we musibear in mind Christison meant chronic cases, and thereforeprobably, mostly cases of granular kidney) it was found 1<be normal. This deficiency of solids affected, not the albu.men merely, but all the salts equally; and our author attri.butes these variations, in the case of tubular or acute ne.phritis, to a failure of the kidney so affected to excretEwater, while in granular kidney or interstitial nephritiethere is no defect in the excretion of water, and conse-quently no dropsy until late in the disease. But, on theother hand, there is retention of the solids, producing verygradually and slowly those changes before referred to inthe structure, not only of the kidney, but of the heart,arteries, and other organs.When we inquire into the probable causes of this condi-

tion of kidney, we find that many of those to which theorigin of this disease is generally attributed are at once dis-proved by the mere age of the patient: thus intemperance,pregnancy, and senile changes are at once excluded (exceptwith regard to the latter, so far as those changes are notnecessarily and inevitably the results of old age). Valvulardisease of the heart is disproved by post-mortem examina-tions ; scarlatina or any form of acute desquamative ne-phritis by the history and the absence of dropsy. There wasno trace of lead-poisoning in the gums, nor was any leadfound in the water used in the house.As to gout, Grainger Stewart says: "It" (granular kidney)

"is more common in the gouty than in any other constitu-tion ; but it is met with in all forms of the arthritic dia-thesis, and in many cases is unsuspected until secondarydiseases manifest themselves." So frequent is the coexist-ence of this condition of the kidney with gouty diathesisthat it was called by Dr. Todd par excellence 11 the goutykidney." There is no doubt, however, that granular con-tracted kidneys are frequently found where there is no traceof gout either in the symptoms or the history of the patient,none either present to our observation, or, so far as our

knowledge can show, latent in the system, and therefore theterm "gouty kidney" ought to be restricted to that varietyof this condition described by Dr. Garrod ("Gout and Rheu-matic Gout"), where deposits of urate of soda were found instreaks or spots in the fibrous tissue of the organ, and oftenvisible to the naked eye. In all these cases described byGarrod (with one exception, and that a very doubtful one,being the first case he noticed, and in which a considerablequantity of uric acid was found in the blood, but the manwas only seen a few days before death, and the fact was notascertained) there had been previous attacks of gout.The evidence seems to show that the "arthritic diathesis,"

though not a constant, is a frequent concomitant of thisaffection; and even where we have as yet had no externalmanifestation of the existence of this condition of the blood,it is quite possible that subtle changes of constitution inthe nutritive fluids may have exerted their deleterious in-fluence upon the structure of the kidney, as well as otherorgans and tissues, although as yet the peculiar depositswhich form the pathological features, or the febrile exacer-bations which are the diagnostic indications of these con-dition!’1, may not have made themselves manifest. Of themode in which the poison of gout may act in causing thiscondition of the kidney, Dr. Todd remarks that it "may beeasily produced by a tainted nutrition. The blood chargedwith the morbid matter of gout furnishes to the kidneysan unhealthy pabulum, which, while it undergoes changesanalogous to those which occur in health, does so in an im-perfect way, insufficient to maintain the nutrition of thehealthy tissues of the gland."The frequent connexion of lead-poisoning with the gouty

(or arthritic) diathesis, and the frequent coexistence of con-tracted kidney in both conditions, first pointed out byGarrod,* has been amply corroborated since ; and this leadsto the consideration that in all the supposed primary causes- intemperance, gout, the arthritic diathesis, lead-poisoning,ague, old age, syphilis, struma, or tuberculosis-we find onecommon factor, a disturbance of the balance and healthy

’ Med.-Chir. Trans., vol. xxxv.. 1854.

condition of the blood. Paget* quotes Treviranust as fol.lows : "Each single part of the body, in respect of it!nutrition, stands to the whole body in the relation of anexcreted substance." Not only, therefore, does the healthystructure take away what nourishes itself, but in so doingrenders the remaining blood more suited to the nutrition oiall the other structures. "The hair, for example, in itsconstant growth, serves not only local purposes, but for theadvantage of the whole body, in that, as it grows, it removesfrom the blood the various constituents of its substance,which are thus excreted from the body";:t and the sameremarks will apply with even greater force to visceralorgans and their various secretions. Further, he goes onto say :

" The right state of the blood-a state not to bedescribed merely as purity, but as one of exact adaptationto the peculiar structure and composition of the individual;an adaptation so exact that it may be disturbed by the im.perfect nutrition of a single organ; and that for the main-tenance of it, against all the disturbing forces of the outerlife of the body, nothing can suffice except continual re-adjustment by the assimilative power of the blood itself." &sect;Now, this balance once destroyed, the very efforts of the

blood to free itself from the noxious or superabundant con-stituents will, unless these be thrown entirely outside thebody, tend to further change, and actually, by the growthof organisable substance so deposited, to further and per-manent changes in the constitution of the blood itself; andin this way we must account for those subtle and all-pervading changes which characterise dyscratic diseases,and which cause their most formidable and remote results.And in this way it may be that changes in the constitutionof the ancestors may affect the descendants, in probablya similar manner as regards the actual blood changes,though the consequent structural alterations may differ asto locality and consequent manifest symptoms.To quote the same author again :&mdash;"In all these things,

as in the phenomena of symmetrical disease, we have proofsof the surpassing precision of the formative process-a pre-cision so exact that, as we may say, a mark once made upona particle of blood or tissue is not for years effaced from itssuccessors." II I And I am myself inclined to look upon thiscase as owing its origin to congenital and inherited pecu-

liarities of constitution. Thus the child inheriting a pecu-liar dyscratic condition of the blood, be that from arthriticor other predisposition, the normal relation between theblood and the capillary vessels is altered, its progress is re-tarded, organisable substances are effused, not in one onlybut in many organs-notably the spleen, liver, kidney, andcoats of the bloodvessels. In the kidney, this structureproduces the symptoms and appearances known as granularkidney, and by its interference with the true secreting powerof that organ tends to a constant aggravation of its owncondition, and a constantly increasing obstruction to thecapillary circulation. This substance, also, is itself liableto be the seat of still further change, as by the deposit ofurate of soda in gouty cases, of calcareous or fatty matterin atheroma; and thus we have the varying morbid appear-ances which have made the study of this disease a subject ofsuch interest and difficulty.In conclusion, I need scarcely point out how strongly this

case tells against the theory prevalent upon the Continent,that granular kidney is the further stage of acute desqua-mative nephritis-a sequence, in short, of the large whitekidney. Frerichs, who is the great supporter of this theory,11 brings forward no case where, with a small contractedkidney, there has been a history of acute inflammation ofthe organ denoted by the ordinary symptoms of acutedropsy, and occurring in a healthy person."

Dr. Geo. Johnson says upon this point: 11 If all the con-tracted Bright’s kidneys have passed through a previousstate of enlargement, it is difficult to understand how itcan happen that the majority of those patients who havereached the final stage of renal degeneration should escapethe dropsy, which, in a greater or less degree, troublesnearly all those who die in what is assumed to be an earlierstage of the same disease." And Wilks’ says: "The in-stance which Frerichs should have brought forward to showthat his small kidney is but the second stage of the acutely

* Surgical Pathology, p. 17.t Die Erochein. und Gesetze des organischen Lebens.

Paget, op. cit. &sect; Op. cit., p. 24.II Op. cit., p. 40, T Op. cit., p. 239.

193

inflamed, should be that of a young person in whom we maypresume healthy organs exist, who has had an inflammationof the kidney, as evidenced by an acute dropsy, and whohas died in the course of two or three years afterwards anda small contracted kidney has been found."To all these points this case is a direct contradiction ; yet

it must be acknowledged that cases do occur in which thelarge white kidney of acute desquamative nephritis doesundergo atrophic changes ; and this, I think, is capable ofexplanation on the supposition that the previous alterationsof structure have so interfered with the secretive power ofthe kidney as to leave the blood loaded with products which,as they cannot be cast out of the body, are deposited asorganisable and contractile structure in this and other

organs; producing, in fact, as a sequel, much the same.condition as we suppose in this case to exist from the first.

Archer’s Lodge, Harpurhey, Manchester.

ON GASTROTOMY.

BY HENRY BARNES, M.D.,PHYSICIAN TO THE CUMBERLAND INFIRMARY.

IN a paper on gastrotomy by Mr. Reoch, of Newcastle, published in THE LANCET of July llth, 1874, a statementis made that 11 about fifty years ago a juggler in Carlisleswallowed a carving-knife with the handle downwards. Onedoctor proposed to give him large quantities of dilute acids,and another suggested to hold him head downwards, andextract the knife if possible by the point; and this is allthat medical art could say or do to alleviate the patient’ssufforings, for in a short time he died a miserable death."This statement contains several inaccuracies. The casewas fully reported in the Edinburgh Philosophical Journal,and also in the London llIedical and Physical Journal, vol. lii.,p. 397, 1824, by my uncle, the late Dr. Barnes, of this city.The patient was a young man, aged twenty-eight years, andthe knife which he swallowed was a bone-handled table-knife, nine inches long. Medical aid was immediately calledto him, and attempts at extraction having failed, the diluteacid treatment was tried for two or three weeks, but dis-continued on account of its increasing the pain in thestomach.

All the professional men in Carlisle were consulted re-- specting him, and various plans of treatment suggested,but no mention is made of the heroic plan of 11 holding thepatient head downward and extracting the knife if possibleby the point." The surgeons of the Carlisle Dispensaryproposed-and their proposal is mentioned as having therecommendation and sanction of one of the first surgeons in

Europe-that an incision shon Ll be made into the patient’sstomach, and the knife extrac’d. They were unanimouslyagreed that nothing but an OpP1’>ttion could save the patient’slife, but he could not be persuaded to submit to it. He con-tinued in Carlisle for some weeks, and left it for London,contrary to the advice of the professional gentlemen inattendance upon him. He died at Middlewicb, in Cheshire,from inflammation and gangrene of the stomach, producedby the irritation of the knife.*

It may also be mentioned, that in order that nothingshould be left undone which could afford the patient anychance of recovery, his case was submitted to Sir AstleyCooper, Mr. George Bell, of Edinburgh, and other dis-tinguished surgeons. These references are sufficient toshow that medical art was more advanced in Carlisle fiftyyears ago than Mr. Reoch tries to make out; and it is diffi-cult to see what better plan of treatment could now be re-commendpd than was suggested in this case.In Dr. Barnes’s paper reference is made to a similar well-

authenticated case which occurred in Prussia in 1635, was re-ported by Dr. Daniel Beckher, of Dantzie, and published inLatin at Leyden in 1636. The patient was a young peasant,who, in endeavouring to excite sickness by irritating thefauces with the handle of a knife, lost hold of it, and itgradually descended into the stomach. Many physiciansand surgeons of great celebrity were consulted respectinghim, and at a meeting of the Fa.culty, held on the 25th June,A post-mortem was made, and the specimen is now in the museum of

the Royal College of Surgeons, London.

it was decided that an incision should be made into thestomach, and the knife extracted. The operation was suc-cessfully performed on the 9th July, and by the 23rd thewound was quite healed. He was restored to the best ofhealth, gradually returned to his usual diet and employment,and lived to become the father of a family. The knife waskept in a velvet bag in the King of Prussia’s library atKoningsberg, where it was seen in 1685 by Dr. W. Oliver,who states that it measured six and a half inches long,English measure.

Six other successful cases of gastrotomy are on record.I will mention two or three. The first is published in theBulletin de la Facult&eacute; de M&eacute;decine de Paris, No. 8, 1819. Thepatient, while attempting to excite vomiting, accidentallyswallowed a silver fork eight and a half inches long, and afterit had remained in the stomach several months, it was suc-cessfully removed by M. Cayroche, of Mendes. The woundhealed in three weeks, and the patient afterwards regainedthe most perfect health. Another case is mentioned in the11 Tablettes Universelles" for October, 1821, in which gas-trotomy was successfully performed by M. Renaud upon ayoung man who had accidentally swallowed a silver fork.A third case will be found in the Boston Journal, vol. Ixi.,in which a bar of lead, 103 in. long, and weighing 9 oz.,was removed from the stomach by Dr. Bell, of Iowa, andthe patient recovered. In all these cases the operation wasfor the removal of a foreign body from the stomach. Theyare sufficient to show the feasibility of the operation, and,in my opinion, form a better justification of it than Mr.Reoch’s experiments on animals, which yielded a mortalityof 50 per cent. It may also be stated that there are fifteencases recorded in which an artificial opening was made inthe stomach for the relief of starvation caused by impass-able stricture of eesophagus; but the operation seems tohave been too long deferred.

Carlisle.

TRANSMISSION THROUGH THREE GENE-RATIONS OF MICROPHTHALMOS,IRIDEREMIA, & NYSTAGMUS.

BY HERBERT PAGE, M.A., M.C.CANTAB.,FORMERLY SURGEON TO THE CUMBERLAND INFIRMARY.

IN the spring of last year I had under observation in theCumberland Infirmary a girl, Agnes T-, aged fifteen,who presented the following condition of her eyes :-Onexamination, there was seen to be almost total absence ofthe irides, smallness of the globes and cornese, and constantnystagmus. In the left eye there was some trace of iris

throughout the whole circumference, more definite, however,in the lower than in the upper half. In the right eye theiris was absent in the upper half, and only just visible inthe lower; and in this eye there was also some displacementof the lens, the lower margin of it being tilted forwards.Nystagmus was constant, the movements being in generalrotatory, and only occasionally horizontal, the latter havingthe appearance of being caused by short, sharp tugs of theexternal recti muscles. The nystagmus was aggravated byspeaking to the girl, who was extremely nervous. Ophthal-moscopic examination was very difficult, owing to the in-cessant movements, and I could catch only a casual glimpseof the fundus. As far as could be made out, the vesselswere smaller than normal, and here and there were patchesof atrophy of the choroid. The girl knew the letters, andspelled out with diBLjutty those of Jaeger Nj. 20.The following members of her family have exactly the

same deformity : her mother, her eldest sister, and this sister’sdaughter. I much wished to have examined these also, al-though the girl herself was so intelligent, and so clear as tothe capabilities of sight of thee relations, that her state-ment might be relied upon. Her mother had had childrenin this order:-1. Daughter. with defect; and mother ofdaughter with like defect. 2. Son, died of " water in thehead." 3. Son. 4. Daughter. 5. The daughter, Agnes T-. .

I have since made inquiries about the cases, and Dr.Fergus Armstrong, of Appleby, where the family lives,

kindly tells me that the girl’s story is correct, and that thecondition described is even more marked in those members