1847.] Case of Tumour in the Substance of the Fifth Nerve. 327 mistook the case- -that it was not one of such great and immediate danger as he supposed, or as the history and symptoms led him to infer that no operation or decisive step was really required-that no particular risk would have been incurred in placing a ligature upon the wounded vessel -and, we may add, that there is no authority whatever for applying a ligature to the external iliac for a wound of a superficial branch of the femoral. To say that there was any actual danger of a fatal termination, through a sudden escape of arterial blood from a vessel of the size of that wounded, is too absurd to require serious refutation-the expected fatal termination was part of the erroneous diagnosis which led to the performance of a severe, dangerous, and unnecessary operation.

Mr. Liston, by the publication of this case and the elaborate manner in which he has endeavoured to justify his treatment of it, has fairly challenged the comments which have been made upon this paper. In the imperfect and uncertain state of our art, ample allowance must be made for errors, too often unavoidable, in diagnosis and treatment. But what we feel bound to censure is the attempt to gloss over the mistakes of practice, and, after the post-mortem examination has exposed the error and revealed the true nature of the case, to maintain the necessity for a proceeding erroneously adopted. If the example were followed, much evil might result, and it is a poor compliment to the intelligent race of medical men of the present day to presume that they cannot penetrate the veil of bad pathology and special pleading by which the necessity for the operation is defended. We sincerely regret that so eminent an operating surgeon should by such means mar the reputation he evinces so anxious a desire to support.

XIII. A CASE IN WHICH A LARGE TUMOUR WAS DEVELOPED IN THE SUBSTANCE OF THE FIFTH NERVE AND ITS GANGLION. By James Dixon, Esq.

This paper may be considered as a supplement to one published in the preceding number of the Transactions (vide our Number for April, 1846, p. 438), consisting of an account of the morbid changes in the brain of the patient, a woman aged 59, who had paralysis of the fifth nerve on the left side and had lost the left eye. The parts supplied by the facial nerve on the same side became paralysed, there was total deafness of the left ear and, after attacks of giddiness and loss of memory, she died. The temporal muscle on the right side was of a natural appearance, whilst the left one was so wasted as hardly to be recognised. Every thing was healthy in the brain and nerves on the right side. To the left of the pons varolii was an oval mass, slightly attached to the encephalon at the junction of the pons and crus cerebelli, and extending forwards, beneath the dura mater as far as the foramen lacerum orbitale. This tumour, from which the three divisions of the fifth nerve emerged, had hollowed out for itself an irregular pit in the concavity of the great wing of the sphenoid bone. The morbid growth proved to be a degeneration of the trunk of the 5th nerve and Casserian ganglion. The chief alteration in the eye was adhesion

of the iris to the lens, which was of a pale yellow and opaque at the centre. Mr. Dixon remarks:

"It would be absurd, from a single case like the present, to generalize upon the influence of different nerves in nutrition; but it will be observed that there was here no atrophy of the eye-ball, although the Casserian ganglion, and the whole trunk of the fifth nerve between that body and the brain had been replaced by an adventitious growth."-P. 134.

XIV. ON THE CAPACITY OF THE LUNGS, AND ON THE RESPIRATORY FUNCTIONS, WITH A VIEW OF ESTABLISHING A PRECISE AND EASY METHOD OF DETECTING DISEASE BY THE SPIROMETER. By John Hutchinson, Surgeon.

Mr. Hutchinson commences by reviewing the speculations and opinions of those who have preceded him in treating of the mechanism and functions of the lungs. He begins with Hippocrates, who reckoned air one of the elements of life; attributes to Galen a recognition of the fact that the thorax distending draws in the air, and that the lungs follow the dilatations of the chest, and sums up the opinions which, during 1500 years, from Galen to Robert Boyle, were received by different naturalists and philosophers, under the three following heads:

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First, That by the dilatations of the chest, the contiguous air is thrust away, and that, pressing upon the next air to it, and so onwards, the propulsion is continued till the air is driven into the lungs and so dilates them."

"Second, That the chest is like to a pair of common bellows,' which becomes to be filled because it is dilated.'

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Third, That they are like a bladder, which is therefore dilated because it is filled.""-P. 139.

Torricelli, the pupil of Galileo, discovered in 1643 the law of atmospheric pressure, and explained why air enters the lungs in inspiration. Fabricius described the action and properties of the diaphragm, Malpighi and John Templer, the structure of the lungs. Borelli, Juvin, and Dr. James Keill in succession made admeasurements of the quantity of air expired from the lungs ; and in 1757, Black, Rutherford, Lavoisier, Priestley and Scheele, by discovering the composition of the atmosphere and of the respired air, threw much light upon the chemistry of respiration.

The author, having adverted to the propriety of considering respiration under two grand heads, as chemical, and mechanical; directs our attention to the latter of these.

He recognises in the varying capacities of the chest-" first, extreme expansion or enlargement; second, extreme contraction or diminution; and third, an intermediate condition, an ordinary state."

We proceed to an explanation of the terms Residual, Reserve, Breathing, Complemental Air and Vital Capacity, to each of which he has affixed a specific meaning, likely henceforth to be always associated with it.

Residual air then is that air which remains in the lungs after the most complete expiration that it is in the power of the individual to make. Reserve air is the difference between the quantity remaining after easy or ordinary expiration, and the residual air.

1847.]

Hutchinson on the Respiratory Functions.

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Breathing air is that quantity which enters and leaves the chest in ordinary respiration.

Complemental air is the difference between the quantity of air contained in the chest after the most forced, and that contained after ordinary inspiration.

The vital capacity is made up of the reserve, breathing, and complemental airs together, or, which is the same thing, it is the difference between the aerial contents of the chest during extreme expansion, and during the most forcible contraction. In all cases the air is measured at 60° Fahr.

The residual air is independent of the will, and always present in the chest. The reserve air, to use a simile, is a tenant at will. The breathing air is constantly passing in and out. The complemental air is seldom in the chest and never is so long.

We pass over the details of particular measurements of these several quantities of air and give only the general results with Mr. Hutchinson's pertinent remark upon them.

Vital capacity

Breathing air
Complemental air

"This forms the basis of our present knowledge, from which I can only gather that observers differ. It is possible that all these experiments may be correct; but allowing this, we cannot thence definitively solve the problem respecting the different quantities of air passing through the lungs.-P. 150.

It is subsequently stated that these apparent discrepancies arise from the absence of all correction for temperature and for difference of sex, height, weight, or age of the individuals examined.

The object of Mr. Hutchinson's researches being, by means of his instrument called the Spirometer, to ascertain the vital capacity of different individuals, in order to derive indications with respect to their health; it is necessary, in the first instance, to determine all the circumstances affecting its quantity, or the laws to which it is subject. Now this vital capacity is disturbed directly, or modified by the height, weight, and age of the person examined, as well as by disease.

In reference to the influence of the first of these, Mr. Hutchinson, from experiments made on nearly 2000 individuals, has deduced the law, that the vital capacity increases by 8 cubic inches for every additional inch of height for all statures between five and six feet; the average vital capacity for men of five feet being 174 cubic inches; or the bulk of air which at 60° has that measurement.

be con

The effect of a considerable excess of weight beyond what may sidered to correspond to the stature of the individual is to diminish the vital capacity which is normal for that stature. Now the weights of 2600 men having been taken, it was found that 120 lbs. being the average of those who were 5 feet 1 inch high, 174 lbs. was that of men of 5 feet 11 inches. A near approximation then to the average normal weight for any intermediate height may be obtained by adding 5.4 lbs. to the former of these weights for each additional inch of height. It does not appear that

a reduction of weight below this normal standard produces any alteration in the vital capacity; and it seems that we may have an addition of weight to the extent of about seven per cent. beyond these averages without affecting it. But beyond this, the vital capacity will diminish at the rate of one cubic inch per lb. up to 35 lbs. weight of increase as a consequence of the impediments to respiration occasioned by corpulency. And for still greater weights a greater decrement of vital capacity per lb. of weight must probably be allowed.

As regards the effect of age, we find that vital capacity is increased from 15 to 35 years of age, and from 35 to 65 years of age it is decreased in the progression of 19, 11, and 13 cubic inches for the several successive decades.

"To conclude this portion of the enquiry, it may be added, that the healthy vital capacity is chiefly affected by three circumstances-height, weight, and age.

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By height, an increase of 8 cubic inches at 60° for every inch of height.

By weight (at the height of 5 feet 6 inches), the vital capacity is not affected under 161 lbs., or 11 stone; but above this point it diminishes the vital capacity in the relation of 1 cubic inch per lb. up to 196 lbs., or 14 stone. And at other heights, between 5 feet 1 inch and 5 feet 11 inches, ten per cent. may be added to the mean height, before we allow the weight to affect the vital capacity in the relation of 1 cubic inch per lb.

"By age (from 35 to 65), a decrease of rather more than 1 cubic inch per year."-P. 174.

It is a curious and interesting result of numerous experiments, made by means of plaster casts of the thoracic cavity after death and subsequent to the removal of the heart and lungs, that the absolute capacity of the chest bears no fixed relation to the vital capacity. The conclusion that universal adhesions of the opposed surfaces of the pleuræ, do not diminish the vital capacity, is, if it be safe to trust to a single observation, an important step in knowledge, contrary as it is to all preconceived ideas on the subject.

A study of the phenomena attendant on respiration leads our author to the belief that the ordinary breathing movement is abdominal, caused by the descent of the diaphragm pushing out the abdominal viscera; that the deep inspiratory movement is not so, but quite the contrary; in this the sternum advances while the abdomen recedes; the chief enlargement of the thoracic cavity in deep inspiration being made by the ribs and not by the diaphragm.

case,

In females, however, the ordinary breathing is thoracic, very little abdominal movement being perceptible.

The following paragraphs embody the chief inferences drawn from observations too numerous for us even to sketch in detail.

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Having now given a brief outline of the respiratory movements, I must recall the attention to the vital capacity.

"We have seen that this corresponds with the height, and not with the absolute capacity of the thorax: why is this the case? I confess myself as much at a loss to explain it as I was the first day I commenced the research. I believe the vital capacity is mathematically commensurate with the range of mobility or thoracic movement; but why the mobility increases in arithmetical progression with height, which it appears is chiefly dependent on the length of the limbs, and not on the length of the trunk of the body, I am incapable of explaining. So

1847.]

Hutchinson on the Respiratory Functions.

331

completely is mobility, and consequently the vital capacity, affected by nature, that a man will breathe in different positions different quantities of air: thus, standing, I blow 260 cubic inches; sitting, 255; and when recumbent, (supine) 230, (prone) 220; position making a difference of 40 cubic inches."-P. 197.

The question of the relative force of the inspiration and expiration has received the attention of Mr. Hutchinson, and by means of an instrument fitted to the nose, and so contrived that he could measure by a column of mercury the suction power of the former, and the forcing power of the latter, he has shown that the opinion previously entertained is entirely erroneous. He remarks upon his results set forth in a tabular form: "It will be observed that the figures on each side of the same word differ in their value, the expiratory side ranging about one-third higher, because the power manifested (I do not mean power exerted) by these muscular efforts varies in this relation. Thus, a man capable of elevating by his inspiratory muscles 3.5 inches of mercury, may be expected to raise by his expiratory muscles 4.5 inches." He says, further on, "I am inclined to look for the first intimation of debility from disease in the inspiratory effort, and not in the expiratory; the expiratory muscular effort may, however, be taken as a test of health when it exceeds the inspiratory." The excess of the force of expiration over that of inspiration is attributed to the elasticity of the ribs and lungs co-operating with the former but opposing the latter power. Experiments were made to determine the amount of this force of elasticity, but our space prohibits our entering into a detail of them: they seem to show that it is very considerable.

There are some observations regarding the effects of decussating, diametric and oblique power which are in the main erroneous, as is the inference deduced from them to the effect that, every external intercostal muscular lamella can raise a rib independently of the lamella next above it. This matter, however, has little bearing on the general object of the paper, and like some others subsequently touched upon may be deemed episodical, and might perhaps have been reserved with advantage for a separate essay. Mr. Hutchinson has, as we have seen, given guides for the determination of the healthy vital capacity in any individual as influenced by height, weight, and age; we are thus furnished with a standard of comparison, so that when, by means of the Spirometer, the actual vital capacity is ascertained, we can at once recognise the existence and the amount of any deficiency. In a table, in which are given the results of an examination of many phthisical patients, it is shown that, even in an early stage, the indications of the instrument are very decided, and important. It must be remarked, however, that the deficiency of vital capacity indicated by the instrument, depending as Mr. Hutchinson has shown upon diminished mobility of the thoracic walls, will not point out the specific disease. far from this that his method has been found available by the author for the detection of ailments which might be supposed to be little capable of affecting the respiration, as for instance hernia, and ruptured tympanum. It was, however, the mercurial instrument before spoken of for measuring the force of inspiration that led to the discovery of these affections. The Spirometer consists essentially of a cylinder closed at one extremity, inverted in another similarly formed, but of somewhat larger diameter and filled with water. Air is blown, by means of a pipe or tube, through the

So