Two Remarkable Cases in Surgery, by Mr. Francis Geach, Surgeon in Plymouth. Communicated by John Huxham, M. D. F. R. S.

XXXVI. Two remarkable Cases in Surgery, by Mr. Francis Geach, Surgeon in Plymouth. Communicated by John Huxham, M.D. F.R.S. Extract of a Letter from John Huxham, M.D. F.R.S. to W. Watson, M.D. F.R.S. dated at Plymouth, the 10th of May, 1763. I have herewith sent you two extraordinary cases, which Mr. Francis Geach, one of our surgeons, put into my hands some time ago. I think there are some things remarkable in them. I have sent also three of the concretions found in the gall-bladder of the icteric person. The three others I reserve for making some experiments on them. They are all nearly of the same shape and size. The person, wounded in the eye, is now considerably stronger and better. The observation, that wounds of the brain often cause a paralysis on the opposite side of the body, is as old as Hippocrates, and is taken notice of also by Aretæus. I am very well assured that the facts are exactly related; and I choose to send them in the words, nay even in the hand writing of Mr. Geach. CASE I. SIR, Read June 23, 1763. A Man aged forty-two years, not much addicted to spirituous liquors, nor too rigidly abstemious, seven months ago received a violent blow on the right hypochondrium: soon after he was seized with the colic, and had a yellow suffusion over his skin: himself dated the æra of his misfortune from the blow. At first he had a diarrhoea, but at last became so costive as to have no regular intestinal discharge, but by the help of lenitives. He was much emaciated towards the end of life, his skin was astonishingly yellow, and dry as parchment, or leather shrivelled by the fire. Many medical processes were employed ineffectually. He had no considerable pain anywhere. A week before his death the left arm turned quite black. He had frequent hemorrhages from his nose. On dissection, the liver was found considerably enlarged, externally of a pale lead colour, harder and more solid than in a sound state, but not schirrous; internally, more porous and spungy. The inner substance not deviating from its natural colour, seemed to be made up of distinct fibres intersecting one another, with vacuities between them equal in size to the small cells of honeycombs. The ductus cysticus, and hepaticus, as well as the pori bilarii were perfectly ligamentous. The gall-bladder had changed its pyriform figure, and affected that of a cylinder, the fibres of which were were hard, white, and compacted. The pylorus, and the duodenum were in a similar state. The circular fibres of the pylorus were rigid beyond conjecture. The concretions, six in number, each weighing half a drachm, and specifically heavier than water, a circumstance unusual, were all ranged in a parallel line, and tallying pretty exactly with one another, so completely filled up the tube (for it might be called with more propriety so than bladder) as to allow but little intermediate space. The passage into the duodenum was almost closed up. Scarce any sincere gall issued forth on incision; but a small quantity of a turbid, saponaceous fluid, not unlike chocolate in colour, came out, or rather was expressed out, gradually.—The bile, not finding a ready exit through the ductus choledocus, stagnated probably in its repository, became diseased, and, acquiring the consistence of soapy dregs, proved the constituents of those concretions, which on experiment are found combustible as wax, and as no fermentation arises from pouring acids upon them, it may be concluded the bile is no alkali. The omentum was almost destroyed, the little that remained of it, was hard and black, and afforded no ill emblem of sea weed, when dried. The glands of the mesentery were in some parts schirrous; in others, they represented small and distinct steatomas. It may be needless to observe what is common to other dead bodies, that the distension of the stomach and intestines was in the greatest extremity. CASE II. Read June 23, 1763, Mr. James L——d, midshipman of his majesty's ship Liverpool, in a riot, December 10, 1762, was wounded in the left eye: a small sword entered in at the external angle, and passing quite through the eye, towards the basis, struck against the inner part of the orbit. He fell down instantaneously senseless, with loss of speech, and an hemiplegia of the opposite side: blood was immediately drawn, the texture of which was not strongly cohering: the next morning he was found lying upon his back, with the right eye widely opened, and the pupil (though in a light room) considerably dilated. This eye was incapable of discerning objects, never winking at the waving of the hand, or the close application of the finger; though sometimes it was convulsed. The left eye was extruded from its orbit, and enlarged to the size of a pullet's egg, though destitute of all its humours: his pulse beat at long intervals, with a lazy motion, and stopped upon gentle pressure: the body was not feverish, but preserved a natural heat, the paralytic side, arm, and thigh excepted, which were livid, cold, and rigid; the lancet was employed without exciting any sensation, and blisters lay on several days without raising any vesications; these benumbed parts were constantly bedewed with clammy sweat. He was devoid of anxiety, or quietude, the powers of nature seemed to be almost suspended, and life to be carried on, only through the large organs and vessels. The functions of the lower lower belly were debilitated, lenient and strong purgatives producing no irritation in the stomach and intestines; and clysters, though repeatedly injected, were never repelled. The urine was emitted by drops only, and sometimes it would run off suddenly in a deluge: his hearing, though not quite lost, was considerably impaired; he lay lethargic and dead almost to every thing, though by pulling the arms and shaking the body, by loud and frequent calling, by desiring him to extend his tongue, he would gape widely; and forgetting seemingly what had been said to him, keep his mouth wide open, when the tongue might be seen quivering and retracted. Five weeks elapsed in this state of insensibility, every thing he took was with voracity, but without relish and without distinction. About this time a new and dreadful symptom began to threaten, the jaw seemed to be moved with difficulty, and liquids only could be poured down; the hypocondria were hard and distended, and every effort to procure an intestinal discharge proved ineffectual, when very large eruptions of the miliary kind were suddenly diffused over the sound parts. From that critical moment he perspired freely, and had an easy motion of the jaw; his urine was rendered in a due quantity, and purgatives of the lenient kind easily operated, the hypochondria were soft, and equal; the discharge from the eye, which hitherto had been acrid, was now copious and laudable, the sound eye had its motion, he could see distinctly, and seemed in other respects sensible, when roused from his stupefaction: soon after he could bear to be moved from the bed to a chair without fatigue, the paralytic parts were rubbed with vinegar and mustard, and he took the following medicines. Pulv valerian Θfs — Caft. Ruf. gr. 4. Spec. Diambræ gr. iiij. Syrup. Croci q. f. m. f. Bolus ter die sumend. ex haustu feri sinapini. A cataplasm of bread and milk had been daily applied to asswage the inflammation and swelling of the eye, and a decoction of thyme and mustard was employed as a gargarism to help the suppression of voice. Soon as he began visibly to mend, he had sometimes loud and sudden bursts of laughter, and sometimes only a long continued silent simpering, a species of convulsion not unlike that called by the Greek physicians Κυνικὸς ἀπασμός, save only that this was not attended with a fever. When he attempted to walk, he had such gestures as accompany the St. Vitus's dance; and seemed a perfect idiot, throwing eagerly forward one leg, and dragging the other trembling after. His appetite is now naturally moderate, his sleep sound and refreshing, his hearing acute, he speaks, but drawls out his words rather indistinctly than articulately, the paralytic arm and thigh are again animated, and recover but slowly their flexibility and extension. He tells me that he remembered nothing from the moment he received the injury, to the time he recovered and sat up; there was a temporary privation of the intellectual faculties. It may be worth while to observe, that though several large floughs were thrown off from from the Eye, though the suppuration was in a large quantity; yet the bulk of the parts did not diminish, nor the inflammation lessen, till an astringent fustus of red rose-leaves and port wine was applied, which so effectually braced up the relaxed parts, that the lids now cover the deformity. Though it may be difficult to account satisfactorily for the paralysis of the opposite side, yet monsieur de la Faye * has something pertinent to the matter; the passage is not long, and may be worth transcribing. La Moëlle Allongée n’est que le prolongement de la substance médullaire du cerveau, &c du cervelet. Les fibres qui la composent, se croisent, de sorte que celles du côté gauche passent au côté droit, &c celles du côté droit au côté gauche; c’est de cette Moëlle Allongée que partent immédiatement les dix paires de nerfs qui sortent du crane. Comme les fibres de la substance medullaire se croisent, les nerfs se croisent aussi, c’est à dire, que ceux qui viennent du côté droit, passent au côté gauche, &c que ceux qui viennent du côté gauche, passent au côté droit. Delà vient, à ce qu’on pretend que la paralysie, lorsqu’elle est la suite de la compression de quelque endroit du cerveau, se trouve pour l’ordinaire au côté opposé à celui de l’endroit comprimé. * Principes de Chirurgie, premiere partie. Francis Geach.