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of blood.

An Account of a Bullet which lodged near the Gullet for almost a Year. By
George Lord Carpenter, F. R. S. &c. N° 449, P- 3l6.

The late Lord Carpenter was wounded in the mouth, at the defence of the
breach of Brihuega in Spain, by a small Spanish musket-ball, which having
taken away part of his upper lip, beat out all his teeth, except 2, on one side,
broke and splintered part of his upper jaw-bone, went through his tongue, and
lodged itself near his gullet, where it remained i>J weeks and 3 days, before it
was extracted, the surgeons thinking it had been spit out with some of his
teeth soon after his being wounded.

The ledge which was made on the bullet by the 2 fore teeth, lying almost by
the gullet, and continually grating on it, occasioned an intolerable pain, and
preventing him from swallowing any thing but liquids, it brought him so low,
that his life being despaired of, to make a final trial, his tongue was drawn out
as far as it could be, and one of the surgeons feeling the ball with his probe,
which he then took to be a piece of a tooth, several pieces of teeth having

6 G 2



228 PHILOSOPHICAL TRANSACTIONS. [aNNO 1 738.

been beaten into his tongue by the bullet, and- endeavouring to extract it, he
took hold of the ledge with his forceps, and drew the ball out; after which he
recovered in a few weeks.

The marks of the fore teeth are to be seen on the bullet, and where it flatted
upon the jaw-bone.*

An Obstruction of the Biliary Ducts, and an Imposthumation of the Gail-
Bladder, discharging upwards of 16 Quarts of bilious Matter in 25 Days,
without any apparent Defect in the Animal Fu7ictions. By Claud. Amyand,
Esq. F.R.S. N" 449, p. 317.

Mr. La Grange, about 50 y6ars of age, of a sallow bilious complexion, died
of an abscess in the vesica fellis.

Dr. Vatas, his physician in ordinary, reports, that about 14 years before,
this gentleman was afflicted with a tertian ague, which was cured by the bark,
and from that time had complained of a sense of weight, and some uneasiness
and hardness in the region of the liver and borborygmi, which were relieved by
frequent purgations; notwithstanding which, he had enjoyed all the appearances
of health, till about 4 months before his death, when some symptoms of the
jaundice first began to appear on him, which had greatly increased 5 or 6
weeks before he died, when he began to complain of shooting pains on the
right hypochondrium ; which was soon followed with a hard inflammatory
tumour there, tending to suppuration.

May 4, Mr. A. met Dr. Vatas, and Mr. Fiquel, his surgeon, in order to
open a large abscess pointing below the cartilages of the 2d and 3d spurious
ribs on the right side. It was determined to open it immediately with a lancet,
upon which a pint of a purulent fetid matter was discharged. The aperture
being large, and the dressings easy, by the next day a very large quantity of
sanies, and some pus left in the bag, had found a vent ; and this was so great,
that it was thought proper to renew the dressings twice a day.

This had the desired effect so far, that from this time the matter daily de-
creased, till the 12th of May, when during the night the wound had discharged
near 2 quarts of matter of a saffron colour, intermixed with large flakes and
thick lumps of a coagulated lymph or jelly, tinged of a deep yellow; and it
was surprising that on dressing they made way for the discharge of about a
quart more of the same, as they enlarged the orifice of the bursted bag, to

♦ A very extraordinary narrative of a gun-shot wound, is to be seen in N" 320, of the Philos.
Trans. It is the case of one Dr. Feilding, who was shot in near the eye, and after 29 years the
bullet was cut out near the pomum adarai.— Orig.



TOL. XL.] PHILOSOPHICAL TRANSACTIONS. 22Q

favour the coming out of the large flakes and lumps of jelly, obturating at
times this orifice. During this day the discharge was very great, and at night
about a pint more of the same matter was emptied.

From this time a short and thick, canula was left in the opening of the
bursted bag, this causing a more easy and constant discharge, and a vulnerary
injection, strongly saturated with spirit of wine, had the good effect to diminish
it very considerably; but yet it continued so very great, that they apprehended
the patient would soon sink under so great a flux of this bilious matter, and
the rather that his stomach and his rest failed him; but the discharge daily
lessening, and his appetite and rest returning in proportion, he recovered
strength enough to be able to walk.

All this while the appearances of the jaundice were wearing off, the urine
was returned to its natural colour, and the patient had regularly a natural stool
every day, till about 8 days before his death, when his body becoming costive,
the physician found it necessary to discharge the faeces, by clysters and lenient
purges. Whilst Mr. A. attended him, his belly was always free from fulness
or tension, being soft and lank, and he was less troubled with wind, than he
had been for many years before. Two days before he died, he went to air
himself in another room, and caught cold: this is presumed to have occasioned
a fever, followed with a lethargy, in which he continued till the 29th of May,
when he died.

On dissection, it was observed, that the patient was not near so extenuated
as might have been expected, after so great a discharge of bile and lymph
during 25 days ; for much fat was yet observed under the skin and elsewhere,
and his flesh not much sunk from the natural state, but the blood-vessels were
found extremely empty. In the abdomen, the caul or omentum was shrivelled
up, and adhered to a large bag or cystis, affixed to the inside of the great lobe
of the liver, and stretching from thence along the right flank, over one half of
the kidney on that side. The left lobe of the liver was removed from the left
side to the right, not reaching farther than the right edge of the cartilago
ensiformis, and the pylorus : the ligamentum latum suspensorium hepatis, was
drawn backwards into the right hypochondrium. The liver was of a natural
colour, but very small, and more decayed and wasted in proportion than the
other viscera, but as free as they from any preternatural adhesion, obstruction,
or induration, and the bag or cystis, arising from it, strongly adhering by its
outside only, to the peritoneum, down to the right kidney.

On passing a finger through the wound in the integuments, it entered first
into a cavity made between the peritoneum and the outside of the cystis, in
which the matter of the abscess had been lodged, and then through a hole in



^do



PHILOSOPHICAL TRANSACTIONS.



[anno 1738.



the cystis, or grand bag, through which the great collection of bile in this
saccus had afterwards made its way ; and it was observed, that the strong coali-
tion of this bag to the peritoneum, round that part where the pus had been
collected, had shut up all communication with the cavity of the belly, and so
prevented any extravasation into the abdomen

Now the bag or cystis being separated from the peritoneum, and this and the
liver spread on a board, it was observed that the matter had been collected in
the gall-bladder, without affecting the liver itself. The vesica fellis was become
a very large bladder, and extended so as then to appear capable of containing 3
pints, or more ; it was nearly as broad as long : it arose very broad from the
surface of the right lobe of the liver, which it occupied about 10 inches in cir-
cumference, or more: its bulk had removed the stomach and pylorus from their
natural situations, and pressed them far under the left hypochondrium, and that
part of the colon placed naturally on the right kidney, forwards on the spine :
its surfaces were rugged and unequal, as that of a potatoe, and its coats thick
and horny, forming several tumours, elongations or expansions, of different
sizes and figures ; one of which, as large as a hen's egg, was full of a cretaceous
matter, intermixed with hard white stones. This cretaceous bag was made in
the duplicature of the vesica fellis, but had no communication with nor open-
ing into it, which several other tumours, appearing of the same kind had ;
whence it was presumed that some very small pieces of creta, found in the great
bag, might have dropped from them into it ; but it is more likely they had
dropped them there, because nothing like them had been discharged through
the wound. The outer opening in this bag answered in the cavity of the
abscess, where incision had been made, as this latter was formed between it
and the peritoneum. In the bag were found about 2 oz, of the same bilious
matter which had all along been discharged ; which being computed, must be
equal to, if not exceed, the quantity of 18 or 20 quarts, during the 25 days
the patient lived, from and after the opening of the tumour.

It has been observed, that the liver was in a natural state, and that the matter
collected in the vesica fellis, had not in the least wounded or affected the liver
itself; so that the great quantity of bile and lymph daily discharged through
the incision, must have proceeded from the internal surface of the distended
gall-bladder. This put them on inquiring for the radices cysticae and hepatico-
cyslic ducts ; i. e. for those very ducts which Giovanni Caldesi so carefully
traced in several animals, and delineated in his Observ. Anatomiche al illustr.
Sig. Francisco Redi 1687, and which Verheyen discovered in the bullock
kind, but could not trace in man ; these ducts, by which so great a quantity of
gall had been deposited in the vesica fellis^ for as much that the cystic duct was



VOL. XL.] PHILOSOPHICAL TRANSACTIONS. 231

obturated, by which some anatomists have supposed the gall to flow back from
the hepatic ducts; and on dissection, Mr. A. traced a trunk, like to that which
Bidloo and Winslow observed in man; and resembling that formed by several
branches in the liver, and discharging itself into the vesica. He would gladly
have traced this further, but the time allowed for dissection did not permit him
to pursue this inquiry.

The ductus communis choledochus was found empty, and opening, as usual,
into the cavity of the duodenum ; but the cystic duct was so compressed by the
bag, that nothing could pass through it. The spleen, pancreas, and all the
other viscera, were in a natural state, except that some of them had changed
and altered their natural situations.

On the whole it appears, 1st, That the animal functions have been in nowise
vitiated by some of the viscera having been displaced; and notwithstanding that
for 25 days, the discharge of the bile through the wound had been so great,
that little was left to pass into the duodenum, yet he digested his food well.
The stools continued regular, till within a few days before death, and even to
the last the faeces all along retained theii* natural colour. 2dly, It may be ob-
served, that the jaundice was not occasioned by the obstruction of the cystic
duct, though that is apprehended as a common cause of this malady; for this
obstruction must have been of many years standing, and this patient's jaundice
was of a very late date. Nor was his jaundice owing to any retention of the
bile in the porus biliarius, from the tumour continually pressing that duct, and
so obstructing the free discharge of the bile, from the glands of the liver into
the duodenum and gall-bladder ; nor even to the strong compression and total
obstruction of some, and almost all the biliary ducts, viz. the porii biliarii, the
ductus hepaticus, the hepatico-cystic, and the ductus-cysticus, and communis
choledochus, the principal of which are seated in the concavity of the great
lobe of the liver, under the pressure of this great and hard tumour, and under
its increase for near 14 years together, obstructions and compressions generally
accounted as primary and idiopathic causes of the jaundice, because no distemper
like the jaundice had appeared in this patient, till within a few months before his
death, and no true jaundice till within a few weeks, and only then as the ab-
scess formed in the neighbourhood of the liver had brought an inflammation
there; but as all the symptoms of his jaundice began to wear off, soon after the
pus had got a vent, viz. as the inflammation of the liver brought on occasionally
by a suppuration in the neighbourhood wore off, and some days before the
bursting of the vesica fellis, it does not appear unlikely, that this inflammation
of the liver was the pathognomonic cause of the jaundice here; which inflam-
mation of the liver, as it was accidental, so the jaundice occasioned by it, was



232 PHILOSOPHICAL TRANSACTIONS. [aNNO 1738.

actually removed soon after a vent was made for the purulent matter, which
had occasioned this inflammation.

Some Observations on the foregoing Case of Mr. Le Grange. By Alexander
Stuart, M. D. F. R. S. &c. N° 449, p. 325.

Dr. Stuart points out what appears to be the mechanical and necessary con-
nexion between these apparent causes and their effects, in this uncommon
case.

], As to the original or prime cause of all the symptoms, viz. the distention
of the gall bladder, now become a morbid cystis of an enormous extent.

If we consider the size and figure of the liver, and the situation of the gall-
bladder, with the course or direction of the biliary vessels, from various places
of the liver, towards that narrow space where the pori biliarii open into the
cystis, it will appear, that in almost every position of the body, at least in an
erect, supine and lateral position, some of these biliary ducts terminating in the
gall-bladder, are perpendicular, or nearly perpendicular, to the Horizon and to
the cystis : therefore, as far as gravity takes place in the animal economy, the
bile descending by these ducts, will press on the contents of the full cystis and
its sides, as a cylinder of that fluid, of the length of the secretory ducts or
pipes, and of the diameter of the cystis.

Besides this, the extremity of every one of these small ducts, conveys its
fluid into the full cystis, as a wedge acted on by the repeated strokes, impulses,
or pressures of the circulating blood of the vena porta, where it supplies the
gland at the origin of each secretory duct. Therefore, by the known laws of
hydrostatics and mechanics, it is apparent, that the force of this secretion of
the bile, into the gall-bladder, is very great, and the quantity copious; suffici-
ent at least to distend the cystis to an enormous pitch, where the discharge by
the ductus cysticus, is not equal to the secretion by the pori biliarii and the
ductus hepatico- cysticus.

These powers sufficiently account for the distention of the abdomen in an
ascites, of the womb in gestation, of the bladder in a morbid or voluntary
retention of urine ; also of morbid imposthumes or tumours, and of the gall-
bladder in the case before us.

But this distention could never have happened, without a total or partial ob-
struction of the excretory duct, the ductus cysticus. Had this obstruction been
at once total, as when a calculus is thrown suddenly out of the cystis into the
duct, and stops it totally, he must have had the jaundice immediately, or very
soon after : for, notwithstanding the strong powers abovementioned, it would



VOL. XL.] PHILOSOPHICAL TRANSACTIONS. 233

have been impossible for the sides of the cystis to have yielded to such a sudden
dilatation, no more than the womb in the first week, of gestation, can be dilated
to the pitch it is brought to in the Qth month, without a rupture : so that the
dilatation here must have been very slow and gradual, and therefore the ob-
struction must have been at first, and probably for many years, only partial ;
and the gall-bladder thus slowly distended, gradually yielded and gave way, only
for the reception of the excess of the secretion beyond the excretion, and so
prevented the jaundice, or regurgitation of the bile into the blood.

This partial obstruction of the cystic duct may probably have been occasioned
by one of those small soft incysted tumours, lodged between the membranes of
the cystis fellea, near the origin of its excretory duct, containing a soft white
pultaceous matter, with calculi, or chalky concretions, in its centre. If this
was the case, it is conceivable that while the contents of this small incysted
tumour were fluid or soft, they might not be capable to obstruct totally the current
of the bile through the excretory duct : but as the matter of it grew thicker,
and its bulk, increased, by pressing gradually more and more on the duct, the
obstruction must increase ; and the formation of calculi, by their pressure,
must at last make the obstruction total. But as the cystic duct was, at opening
of the body, entirely coalesced and obliterated, its vicinity and situation, with
respect to these small incysted pultaceous and cretaceous tumours, cannot be
precisely determined ; and therefore this is offered only as a probable con-
jecture.

The bulk, contents, and adherences of the gall-bladder to the right side,
were doubtless to him a very sensible, and to us a visible cause of his first
symptom, the increasing weight he had felt in the region of the liver, for 14
years before his death.

The current of moving humours in the animal body, is always determined
most strongly to the place of least resistance : therefore, by the partial ob-
struction of the cystic duct, a greater quantity of bile than usual will be forced
on the biliary ducts, leading directly from the liver into the great hepatic duct,
to discharge itself by the choledochus communis into the duodenum, suflicient
for the moderate uses of the animal economy ; though not so perfectly suflicient,
but that the peristaltic motion, in this case, felt the want of the cystic bile, or
at least the defect of it so far, as to become weak and imperfect, too weak to
propel the excrements, or keep the elastic air within due bounds; and therefore
the patient must be subject to flatulent distentions, and some degree of costivc-
ness, only to be relieved by supplying the want of a suflicient natural stimulus
of the gall, by the artificial stimulus of purgatives and clysters, to assist from

VOL. vnr. H h



234 PHILOSOPHICAL TRANSACTIONS. [aNNO 1738.

time to time the expulsion both of the excrements and also of the flatuses, for
the ease of the patient, as was practised in this case.

As to the jaundice, which began to show itself 4 months before his death,
and continued increasing, till the external purulent tumour in his side was
opened, when it began to decline, and quite disappeared soon after the gall-
bladder burst : it is easy to conceive, that so long as the gall, descending from
the pori biliarii, could make its way into the cystis fellea, and dilate it, there
could be no regurgitation of the bile into the blood, and therefore no jaundice:
but as soon as the purulent imposthume began to form itself in the neighbourhood
and contact of the distended gall-bladder, it encroached or pressed on the cystis
fellea, by the force of a multitude of vessels, pouring pus into the cavity of the
imposthume, urged on by the circulation of the blood, which is more forcible in
these vessels than in those of the liver: and therefore this purulent tumour in-
creasing, will very forcibly encroach on the cystis fellea in contact with it, and
not only hinder its further distention, but even force the gall it contains to re-
gurgitate, or return again by the pori biliarii upwards, and from thence, by the
capillaries of the vena cava, into the blood, and so produce the jaundice ; with-
out raising an inflammation or obstruction in the liver itself, whose vessels and
passages remain open, though the bile take a retrograde course in its biliary
secretory ducts.

But as soon as this accessory pressure is taken off^ from the cystis fellea, by
opening and emptying the purulent tumour or imposthume in its neighbourhood,
adjoining and adhering to it, the bile begins again to flow freely into the cystis
fellea, and to dilate it as before; therefore the regurgitation of the bile into
the blood ceases, and the jaundice begins to decline.

Then, as soon as the rupture or bursting of the gall-bladder happened, and
it began to be emptied, all degrees of resistance being now totally taken off
from the pori biliarii, they spew out their contents so copiously, that the hepatic
ducts are gradually frustrated by such a strong revulsion ; the bile begins to
flow all to the wounded and almost emptied cystis biliaria, and either very little
or none to be carried by the ductus hepaticus to the choledochus communis,
whose diameter and passage into the duodenum was found larger than usual, but
empty. In this state, which was the last stage of his distemper, the peristaltic
motion begins ta fail, the expulsion of the excrements to be very tardy, or not
at all to succeed without the assistance of purging medicines or clysters, which
also had but a very slender effect; the patient ceases to be nourished, though
he takes a competent quantity of food, and dies in a week after this costiveness
began.

The degree of perfection of the natural, vital and animal functions in this



VOL. XL.] PHILOSOPHICAL TRANSACTIONS. 235

person, during 14 years indisposition, was certainly owing to the soundness of
all the viscera, and an almost sufficient secretion and excretion of bile by the
ductus hepaticus, into the choledochus communis, whose cavity and passage
into the duodenum was large and open, which could not have been and have
continued, without a continual and proportional flux of bile through it : for it
is well known, that as soon as the fluids cease to flow through their natural
ducts, their sides soon collapse, coalesce, and at last totally shut up. Thus the
uraclius, and canalis arteriosus Botalli in the foetus, shut up totally soon after
the birth ; and Mr. Amyand and Dr. S. have seen one of the ureters totally
coalesced and shut up, for want of a fluid from the kidney, which had secreted
no urine for some time, having become a cystis, filled with a thick white pulta-
ceous matter, nearly of a cretaceous consistence.

Therefore, as the cystic duct was found obliterated, and the choledochus
communis large and open, it is plain that no bile had for some time flowed
through the former, and that there was a constant supply from the hepatic duct
to the latter, for the uses of the animal economy ; until the wound or rupture
of the gall-bladder, gradually abating its current by that channel, at last stopped
it quite, and put an end to life in a few days after.

The apparent Times of the Immersions and Emersions of the four Satellites of
Jupiter, for the Year 1 740, computed to the Meridian of the Royal Observa-
tory at Greenwich. By James Hodgson, F. R. S. In all 374. N° 449,
p. 332.

This is another repetition of Mr. Hodgson's usual calculation of these
eclipses.

A Continuation of an Account of an Essay towards a Natural History of Caro-
lina, and the Bahama Islands; by Mark Catesby, F, R. S. with some Extracts
out of the Qth Set, by Dr. Mortimer, Seer. R. S. N° 44g, p. 343.

The extracts and account of the 8th set are inserted in N°441 of the Phil.
Trans. This Qth set begins with pi. 6l, of the 2d vol, and as the foregoing
treated chiefly of serpents, this contains the figures and descriptions of several
quadrupeds, intermixed with plants.



HH 2



2SG PHILOSOPHICAL TRANSACTIONS. [aNNO 1738.

MatthicE Belli, Pannonii, R. S. Lond. S. &c. Observatio Historico-Physica de
^4quis Neosoliensium JEratis, vulgo Cement- Wasser dictis, Ferrum jEre
permutantibus, in Epistold ad illustr. Dm. Hans Sloane Bart. &c. scripid,
co7nmu7iicata. N° 450, p. 351.

This pnper gives an account of tiie copper waters (cement-wasser) in the
copper-mines near the town of Neusol in Hungary. The rain, or spring water,
as it percolates through the sides of the excavations worked in these mines, be-
comes impregnated (from its action on the copper-pyrites) with vitriol of cop-
per, and is conveyed by numerous channels into large wooden cisterns, or re-
servoirs, placed in various parts of the mines. When pieces of iron are thrown
into the water collected in these reservoirs, and are suffered to remain therein
for a sufficient length of time, they are, according to the belief of the vulgar,
turned into copper ; i. e. the copper is precipitated upon the surface of the iron
in its metallic state.* It is afterwards scraped ofFfrom the iron, and melted and



Online LibraryRoyal Society (Great Britain)The Philosophical transactions of the Royal society of London, from their commencement in 1665, in the year 1800 (Volume 8) → online text (page 28 of 85)