1847.]

Paget's Case of imperfect Corpus Callosum,

317

MEDICO-CHIRURGICAL TRANSACTIONS. Published by the Royal Medical and Chirurgical Society of London. Twenty-ninth Volume. Volume the Eleventh of the Second Series, 1846.

[Continued from No. IX., p. 233.]

VII. AN ACCOUNT OF A CASE IN WHICH THE CORPUS CALLOSUM, FORNIX, AND SEPTUM LUCIDUM WERE IMPERFECTLY FORMED. By James Paget, F.R.C.S., Warden of the College, and Lecturer on Physiology at St. Bartholomew's Hospital.

The brain described in this paper was found in a girl 21 years old, who died in St. Bartholomew's Hospital with pericarditis, and who had presented, while under observation there, nothing remarkable in the condition of her mind. The appearances presented by the brain are carefully and minutely described by Mr. Paget. In the hope of obtaining some guidance in the obscure physiology of the corpus callosum, he made careful enquiries into all that concerned this patient's mind. He could "not find otherwise than that this girl's mind was one of the least remarkable kind. Her only peculiarity was vivacity, and a want of caution, showing themselves in an habitual rapidity of action and want of forethought, deliberation and attention. Certainly she could not be regarded as unusually deficient in either moral goodness or intellectual power."

Instances in which the corpus callosum is deficient without any other serious wrong condition of the brain are rare. Mr. Paget states the chief facts of three other recorded cases: one related by Reil, a second by Mr. Solly, and the third by Mr. Chatto. These cases suggest some interesting observations on the anatomy, development, and functions of the corpus callosum. We have only space for the following remarks:

"On the whole, these cases force us to think that the corpus callosum has its office as an organ for the highest operations of the mind. But of what part of the mind it is one of the ministers, and how its function is discharged, we have no evidence whatever. Its structure indicates that it is not a nervous centre, neither a source of nervous power, nor a first recipient of the influence of the mind; for it is composed wholly of nervous filaments, such as, elsewhere, have no higher office than that of conducting impressions, and are incapable of either originating, controlling, or diverting them. If, therefore, as a reasonable hypothesis, we adopt the general expression of the office of this and other commissures, that they serve to ensure unity or harmony of action between those parts of the brain between which they are placed,' we must use it as meaning, for the corpus callosum, not that it is a centre of action from which similar, and therefore, harmonious influences proceed to each side; but that it is formed of conductors, by which a part on one side of the brain is informed (as it were) of the state of some part on the other side, and, probably, is induced into the same state. But, whatever may be meant by this and any similar forms of expression, they must be held as only hypothetical; there is no substantial evidence for their truth."

-P. 73.

Mr. Paget states, in conclusion, that many of the facts adduced in this paper afford support to the doctrine of the brain being a double organ, No. 108

21

a subject to which attention has lately been directed by the vigorous writings of Dr. Wigan.

VIII. CASE OF ANEURISM PRESENTING SOME PECULIARITIES; WITH REMARKS. By Prescott Hewett, Esq., Lecturer on Anatomy at St. George's Hospital School.

G. B., æt. 31, was admitted into St. George's Hospital, in May, 1839, with a pulsating tumour, of the size of a pullet's egg, in the left groin, about an inch below Poupart's ligament, and apparently connected with the common femoral artery. Sir B. Brodie applied, on the 30th of the month, a ligature to the external iliac artery, and all pulsation in the tumour ceased immediately. Peritonitis followed, but he recovered from it. The ligature separated on the 25th day; the tumour in the groin became solid and decreased in size, and the patient was discharged cured August 14th. At the latter end of November he was re-admitted on account of a return of slight pulsation, and a whirring sound in the tumour, which had slightly increased in size. By pressure with graduated compresses all pulsation and sound disappeared and the patient was once more discharged. In Nov., 1841, there was a slight recurrence of pulsation without increase in size, and no plan of treatment was adopted. In January, 1842, the tumour was observed to have increased in size, but no pulsation whatever could be detected in it. "From this period the tumour gradually but steadily increased in size for the ensuing twelve months, during which time it grew to the size of the egg of an ostrich; its surface was somewhat irregular, and softer in some parts than in others, although the tumour itself was perfectly solid. During the whole of the time neither pulsation nor sound of any kind could be detected in the tumour." January, 1843, the tumour became stationary, and some time afterwards it began to diminish; the decrease in size continued until July of the same year, when the patient died of phthisis.

In

At the examination of the body, the tumour, when separated from the neighbouring parts, was of the size of a full-grown foetus, slightly irregular on its surface, but perfectly solid throughout. Upon being cut into it presented the characteristic layers of coagulated blood observed in aneurisms which have been cured.

"The portion of the superficial femoral artery, about two inches, with which this aneurism was connected, was flattened, completely obliterated, and identified with the tumour, below which the cavity of the artery was filled with a coagulum, about an inch in length, somewhat smaller than the vessel, and adherent to it at its upper part only; the remaining part of this vessel presented a natural appearance. The whole of the common femoral was dilated to the size of the common iliac, and irregular on its surface, the irregularity depending upon some smaller dilatations superadded to the general dilatation, which extended up to the external iliac, at the point of the giving off of the epigastric and circumflex arteries. The internal surface of this dilated vessel was covered by thin layers of coagulated fibrine, which, beginning a little below the origin of the epigastric, were continued downwards into the upper parts of the superficial and deep femoral arteries. In the superficial femoral, these coagula completely blocked up the cavity of the artery; but in the deep and in the common femoral, they merely

1847.]

Spitta's Case of Cyanosis.

319

formed a lining to these vessels, a large and distinct channel being still left for the passage of the blood. This channel was, for the greater part, perfectly smooth and lined by a membrane, of new formation, presenting all the characters of the serous coat of the artery, for which it might easily have been mistaken. Both the membrane and the coagula were, however, with a little care, detached from the internal coat of the artery, which did not appear to be diseased. These coagula did not pass further than half an inch down the deep femoral; below this, the coats of the artery presented a perfectly healthy aspect.

"The external iliac artery, from a little above the origin of the epigastric and circumflex to within a quarter of an inch of the common iliac, was completely obliterated and reduced to the size of a small quill; the point at which the ligature had been applied was marked by a constriction, situated about an inch above the origin of the epigastric. The various branches given off from the external iliac, and from the common and deep femoral arteries, were much larger than natural."-P. 78.

Mr. Hewett notices, as remarkable in this case, the long intervals which elapsed between the two periods, when the pulsation recurred; intervals during which the tumour presented all the appearances of being cured. He observes :

"No abnormal distribution of the arteries having been found, the re-appearance of the pulsation is to be explained by the situation of the aneurismal tumour, which, when once the collateral branches were sufficiently dilated, became affected by the large current of blood brought into its immediate neighbourhood-a current of blood sufficient to overcome, for a time, the efforts made by Nature to establish a cure, which she ultimately accomplished.

"The great increase in size which this aneurism presented, even after all pulsation and all sound had ceased in it, is a fact worthy of the attention of all practical surgeons. By this increase in size, and the other circumstances accompanying this aneurism, several experienced surgeons were led to the supposition that the tumour was of a malignant character, and supplied with large arteries, the growth of which had been checked for a time by the obliteration of the external iliac artery."-P. 79.

Lastly, attention is called to two points of pathological interest, viz. the formation of the thin delicate membrane lining the common femoral from the blood, and the liability, should blood pass between the membrane and the internal coats of the dilated vessel, of the appearances being mistaken for what is termed a dissecting aneurism. This is a case of interest, and well related.

IX. CASE OF CYANOSIS OF FORTY YEARS' STANDING, DEPENDING UPON CONGENITAL OBSTRUCTION IN THE PULMONARY ARTERY, AND PATULOUS FORAMEN OVALE. By Robert Spitta, M.B., Lond., HouseSurgeon to St. George's Hospital.

The patient, a female æt. 40, of diminutive stature, pigeon-breasted and affected with cyanosis from birth, was suddenly seized with dyspnoea and partial syncope, accompanied at first with convulsions, and afterwards with intense pain referred to the epigastrium, loins, and hypochondria. This condition continued 24 hours, when, after a slight struggle, she expired. On examination of the body, the principal change in the heart was hypertrophy of the right side, the right ventricle being as thick as the

left ventricle, and the right auricle three times as thick as the left auricle. The foramen ovale was patulous.

"The pulmonary artery was so malformed at its root as to render an accurate description of it extremely difficult. Besides the three semilunar valves usually found there, it presented an adventitious membrane situated immediately above them, and stretched completely across the artery, like the diaphragm across the body. This membrane was a line in thickness, and perforated in its centre, not by a circular foramen, but by a mere slit two lines in length and a line in breadth, with margins of a red colour, and fringed with fibrine of the blood. The three semilunar valves were thrown up as they are naturally in a healthy pulmonary artery during the systole of the heart, and fixed in that position by the adhesion of (what would have been) their free borders to the adventitious membrane."-P. 83.

Mr. Spitta infers, no doubt correctly, that the membrane which obstructed the pulmonary artery was a congenital malformation. He is of opinion that the circulation of imperfectly oxygenated blood impaired no function so much as the formation of animal heat, of which, it appears, the patient was remarkably deficient.

X. ON THE GANGLIONIC CHARACTER OF THE ARACHNOID MEMBRANE OF THE BRAIN AND SPINAL MARROW. By George Rainey, M.R.C.S. Mr. Rainey observes, at the commencement of this paper

"As I believe it has never been supposed by physiologists that there exists within the cavity of the cranium an especial provision of organic nerves for the supply of the cerebral vessels, corresponding to those which, in the abdomen, go from the cæliac ganglia to the vessels of the viscera-the arachnoid serving as a membranous plexus in which they ramify-the announcement of this view can scarcely fail to be received by anatomists and physiologists with extreme doubt. Under this impression I have considered it admissible, at the commencement of this paper, to state, that the views herein set forth are based entirely upon anatomical facts, which I have endeavoured to describe in such a manner as will most facilitate the verification of their accuracy: for this purpose, also, I have detailed these facts and discussed their physiological application nearly in the order they occurred, whilst occupied in their examination."--P. 85.

It is plain, from the preceding statement, that it would be fruitless to attempt giving a condensed account of the facts and inferences drawn from them, which are detailed in this paper. It must be carefully examined with the assistance of the plates to be appreciated. The views of the author are novel and interesting, and cannot fail to attract attention. But it must be recollected that, in the microscopic examination of nerves, there are many sources of error; and of this no more striking example need be given than the recent controversy respecting the nerves of the uterus. It is, however, due to Mr. Rainey to say that he narrates his facts truthfully and faithfully. He states what he has really seen, and not what he wishes to see in order to support a preconceived theory, and he moreover fairly invites enquiry. It is a pleasure to meet with so honest and zealous an enquirer as Mr. Rainey, considering the little encouragement which is given in this country to the pursuit of microscopic anatomy and physiology.

1847.]

Acton's Case of partial Double Monstrosity.

321

XI. AN ACCOUNT OF A CASE OF PARTIAL DOUBLE MONSTROSITY. (Ischiopage Symelien of Geoffroy Saint-Hilaire, Heteradelphia of Vrolik.) By William Acton, Esq., Surgeon to the Islington Dispensary.

The subject of this curious case was a Portuguese child, six months old, exhibited in London during last Spring, and rendered sufficiently notorious by a placard not remarkable for its decency, in which the infant is characterized as "the Human Tripod, or three-legged child, and first Bipenis ever seen or heard of." The monstrosity is thus described by Mr. Acton.

"Below the umbilicus, and to the right and left of the mesial line, are two distinct penes, each as large as the penis of a child of six months old: their direction is normal. I may mention that water passed from both organs at the same moment, during the time that Dr. Cursham and Mr. Perry were examining the infant with me. Each penis is provided with a scrotum, the outer half of each scrotum containing one testicle, the inner half of the scrotum is far removed from the outer, and the two inner halves appear like another scrotum between the two penes. Between and behind the legs of the child, we see another limb, or rather two lower extremities united together in their whole length. The upper part of this compound limb is connected to the rami of the pubis by a short narrow stem half an inch in length, and as large as the little finger, apparently consisting of separate bones or cartilage, for, on moving the compound limb, at the same moment the finger is kept on the stem, crepitation is felt, but I could not detect any pulsation. Immediately beyond this stem, and concealing it, the compound limb assumes a size as large as the compound natural thighs of the child, and within the upper part irregular portions of bone may be felt (probably a portion of a pelvis and the heads of the thigh bones), which may be traced down, united together into one mass, to a leg of comparative small size, though still larger than either of the healthy legs, and terminating by a double foot in the position of talipes, with the sole turned forwards, and furnished with ten toes, the two great toes being in the centre of the others: the two outer toes on each side are webbed.

"When the child is placed on its belly, the spine and back present a perfectly normal appearance; the anus is in its usual situation; the functions of the bowels are duly performed. Viewed in this position, the compound limb assumes a roundness and fulness equal to the buttocks of a young child, and a slight depression is observed, as if for the anus. Tracing the limb downwards, we find only one patella, which is on the same aspect of the limb as the anus, the joint bends freely, and the compound extremity terminates as above described. This compound limb is quite motionless, the upper portion alone appears endowed with sensibility, its vitality seems low, as the toes have a bluish appearance; the upper portion, however, is of the same temperature as the body of the child." P. 105.

and

Mr. Acton has not been able to meet with any recorded case analogous to this. He discusses the question of removal of this compound limb, and is of an opinion that every circumstance is in favour of an operation. He particularly notices the low vitality of the limb, observing that, with every precaution that can be taken, the toes have now a bluish appearance, the history of partial double monstrosities shows, that any, however slight, scratch or contusion heals slowly, and generally ends, at first, in the death of the part, and subsequently of the child. "If the infant escapes this source of danger, its system is found incapable of supporting this additional limb, and the child perishes from debility. There can then, I think,