[Pg 113]

THE
LONDON MEDICAL GAZETTE,

BEING A
WEEKLY JOURNAL
OF
Medicine and the Collateral Sciences.

SATURDAY, DECEMBER 27, 1828.

PATHOLOGICAL ESSAYS
ON SOME
DISEASES OF THE HEART;

Being the Substance of Lectures delivered before
the College of Physicians,

By P. Mere Latham, M.D.

Physician to St. Bartholomew’s Hospital.

[Continued from p. 7.]

ESSAY II.

Morbid Anatomy of the Internal Lining
Membrane of the Heart.

The membrane which lines the cavities
of the heart is very liable to disease,
but not equally so in every part. Where
it is thin and transparent, and admits
the colour and character of the muscular
structure upon which it is spread
to be seen through it, it is seldom found
diseased; but where it is of a denser
texture, either in itself or from an admixture
of other structures, whether
cellular or fibrous, with its own, it is
frequently, and often exclusively diseased.
This latter character of a denser
texture belongs to it where it forms
the tough white circles which surround
the apertures of communication between
the auricles and ventricles; also
where it is reflected upon itself, and
forms the loose duplicatures of membrane,
which are given off, as it were,
from the internal surface of the heart,
either at the fibrous circles intermediate
between the auricles and ventricles,
constituting the tricuspid and the mitral
valves, or at the commencement of the
pulmonary artery and aorta, constituting
the semilunar valves.

It is remarkable how curiously disease
is apt to limit itself to the spaces
just pointed out. Of the fibrous circle
between the auricle and ventricle, of
the valves which originate from it, and
of the tendinous cords which connect
the valves with the carneæ columnæ,
there will not be the smallest space free
from disease; but the disease will
abruptly stop where the tendinous
cords cease and the carneæ columnæ
begin[1].

The membrane, however, where it
covers the fleshy columns of the heart,
is not exempt from the possibility of
disease: but when disease actually
affects it, it has seldom originated there,
but has generally spread from other
parts of the same membrane, although
(as we have just remarked) it is apt to
stop short before it reaches this.

Of the two sides of the heart, the
membrane which lines the left is unquestionably
the more liable to disease.
But my own observation would never
have led me to conclude that the membrane
of the right side was so far exempt
as it is commonly thought to be.
Speaking from the best recollection I
have of the specimens which have fallen
under my examination, I should say
that, in one-third of the cases where
disease has been found on the left side,
it has existed on the right side also,
and been essentially of the same character.
But there has been a remarkable
difference in the extent to which it
has proceeded on each side respectively:
while on the left it has gone so far as to
be the undoubted cause of death, on
the right, although essentially of the
same character, it has been only just
beginning.

[114]

It very seldom happens that disease
appertains to the lining of the right cavities
of the heart exclusively; and,
where it affects both, the disease in the
right cavities is very seldom found in
advance of that in the left.

It should seem, indeed, according to
the ordinary course of things, that disease
does not begin in the lining of the
right cavities of the heart, until it has
already advanced to an extreme degree
in the left.

The internal lining of the heart, as well
as of the arteries, is often found to have
become of a red colour. This redness,
so well known to all who are accustomed
to examine dead bodies, used to be
regarded as a mere stain imparted to it
by the colouring matter of the blood
after death. Yet a due consideration of
various circumstances connected with
it will hardly warrant this conclusion.

It has been found whether the heart
or artery be full or empty of blood;
and if blood be present it has been
found, whether it is liquid or clotted;
and if it be clotted, whether it does or
does not retain its colouring matter.
External temperature, and length of
time between the death of the patient
and the dissection of his body, have not
made any difference in the frequency
with which this peculiar appearance occurs.
Lastly, no artificial methods,
such as washing of any kind, can get
rid of it; nor will inclosing blood within
an artery for any period produce it[2].
This simple redness is sometimes seen
universally in both sides of the heart
and throughout the whole arterial system,
and sometimes in patches only, of
greater or less extent, whether in the
arteries or in the heart.

Now, when all these circumstances
are considered, although in some instances
it may be a mere stain imparted
by the colouring matter of the blood
after death, it is plainly impossible that
it should be of that nature in any large
proportion of the numerous instances
in which it is found.

But if the appearance in question implies
(as I believe it generally does) a
morbid condition, of what kind is that
condition? There are the same objections
to considering mere redness as
equivalent to inflammation here as in
the pericardium, or in any other part of
the body: here, as elsewhere, in one
case it may be the condition out of
which inflammation is to spring;
while in another it may not be destined
to give origin to any change in the
structure of the part beyond itself, and
may itself constitute the whole disease.

It appears to me, that this mere redness
of the internal lining of the heart
and arteries has become a matter of
undue perplexity to pathologists, because
they have laboured to infer from
it more than the simple fact itself will
authorize. All I wish to establish concerning
it is, first, that it is not always
(probably very seldom) a mere stain
imparted by the colouring matter of the
blood after death; secondly, that it
alone does not constitute inflammation.

It may not be improper to mention
the circumstances under which it has
occurred to myself to find it. I have
met with it most frequently, and to
the largest extent, in subjects whose
previous disease has produced a constant
and habitual impediment to the transmission
of blood through the heart and
through the lungs, and that impediment
has gone on increasing to the hour of
their death; also in those, whatever
might have been the nature of their disease,
whose dissolution (I mean the actual
process of dying) has been tardy and
agonizing, and marked by great labour
of respiration; in the apoplectic, for
example, in whom, after sense and
consciousness were extinct, life had
been protracted, with stertorous breathing,
for many days.

In such subjects the countenance,
the lips, and the whole skin, give
evidence during life of blood pushed
beyond the natural sphere of the circulation,
and detained in the extreme
blood-vessels. Hence it is obvious
that the causes which have loaded and
distended the capillaries in every part
of the body have had a like influence
upon the vasa vasorum.

I do not mean to say that I never met
with this peculiar condition of the heart
and arteries under other circumstances,
or that other causes may not produce it;
but that I am not acquainted with it
under any other with which, from frequent
coincidence, it has seemed to have
a natural connexion, or which have
afforded a reasonable explanation of the
phenomenon.

This condition of the heart and arteries,
considered as inflammation, has
been assigned by some as the cause of
[115]
fevers of the more malignant kind.
The frequency with which it has been
found in some particular epidemic,
must have led to the conclusion. But,
however this may be, from my own observation,
not restricting myself to the
fever of any particular season, but taking
into account all complaints called
febrile, and belonging to all seasons,
also from the result of inquiry among
medical men who have had large acquaintance
with morbid dissections,
and from the experience of those who
have made this particular point a subject
of investigation (Laënnec and Andral)
I venture to conclude that it has
no essential connexion with fevers of
any kind, either as cause or as effect.

On some occasions the internal membrane
of the heart and arteries, wherever
it exhibits the appearance described,
will allow itself to be peeled off from
the subjacent structure with the least
possible force; this facility of separation
ceasing entirely beyond the boundary
of the red tinge.

Here unquestionably is further evidence
of a diseased condition: but of
what nature? Most pathologists would
consider this to be of the nature of inflammation—and
I believe justly.

There is indeed much difficulty in pronouncing
upon the nature of minuter
changes of structure detected in the internal
parts of the body after death. We
are obliged to arrive at conclusions by
help of analogies drawn from morbid
processes, which we have watched in
their progress during life, upon the external
surfaces; for during life we have
the functions and sensibilities of the part
to aid us in forming a right judgment
concerning its disease. When, during
life, one tissue is separated from another,
as the periosteum from the bone,
or the cuticle from the skin, or the mutual
cohesion between different tissues
is sensibly weakened, we find it to be
owing to the intervention of serous fluid
which does not belong to their healthy
state; and this, together with increased
vascularity, or redness and heat, and
pain, is enough to bespeak the presence
of inflammation. All these conditions
cannot remain after death. Hence, if
we desire to form positive opinions concerning
much which is unfolded by dissection,
we must supply the defect by
analogy. Thus, whenever, in any part
of the heart or arteries, the cohesion between
the internal membrane and the
subjacent structure is manifestly lessened,
and the membrane is unusually red
at that part, we may regard these appearances
as the vestiges of inflammation,
without thinking that we go too far
in so regarding them.

The internal lining of the heart and
arteries is often found red solely in the
neighbourhood of ulcerated spaces,
when there can be no doubt concerning
the existence of inflammatory action.

But the internal lining of the heart
and arteries gives the most unequivocal
evidence of its inflammation when it is
found of a deep red colour, with coagulable
lymph adhering to its surface.
This condition is represented, as it was
found in the aorta, in one of the beautiful
plates, illustrative of the diseases of
arteries, by Mr. Hodgson[3]. And the
same condition, in the heart, I
have seen in a preparation of Dr.
Farre’s, where lymph is deposited,
upon the circular zone, which forms the
aperture of communication between the
left auricle and ventricle. These appearances
denote the most acute inflammation:
they are, I suspect, very rarely
met with. In the few instances in which
I have heard of them, they have been
found where death has taken place
after short and severe suffering, and with
symptoms which characterize inflammation.

But the specimens of disease most
frequently met with in the internal lining
of the heart, consist in an entire
change of its natural structure, and in
the formation of new products upon it
or within it. Many of these, from the
analogy of morbid actions in other parts
of the body, must be considered to result
from chronic inflammation.

In any of those situations which have
been stated as especially liable to disease,
the membrane will become thick,
tough, inelastic, puckered and shrivelled;
and cartilage or gristle, and bone, will
enter into its structure; excrescences
will sprout out from it, resembling warts
and fungus; and it will become ruptured
and ulcerated.

Cartilaginous depositions are often
found beneath the membrane where it is
single; or between its folds where it is
double, in the situation of the valves;
and thus they seem rather to belong to
some structure contiguous to the membrane
than to the membrane itself.
[116]
Such depositions will proceed to a considerable
extent, while the membrane
still remains free from disease. From
a valve, which has been thick, opaque,
and cartilaginous, I have seen the membrane
separated on both sides, and
transparent; the opaque and cartilaginous
matter being left behind. Where, in
cartilaginous depositions, the lining of the
heart has become puckered and uneven
on its surface, and the valves shortened
and altered in their shape, the membrane
itself participates in the disease,
and is generally incapable of being separated
from the subjacent structure.
But great thickening may take place in
the situation of the valves, from deposition
of cartilage, without any unevenness
of their surface or alteration of their
shape; and under these circumstances
the membrane itself you may expect to
find hitherto exempt from disease[4].

Osseous depositions are always, I
believe, originally formed beneath, or
exterior to, the membrane, both in the
heart and in the arteries. There are two
circumstances especially worthy of remark
in this process of ossification:
sometimes it is a pure and unmixed process:
bone is formed, and nothing else.
It is deposited in minute granules, or
little brittle scales, or in plates of a
larger size; and the intermediate spaces,
whether in the heart or arteries, preserve
their natural and healthy appearance.
At first, these granules or scales,
or plates of pure bone, are covered by a
delicate pellicle, which is in fact the internal
membrane of the heart or artery,
separating them from the immediate
contact of the circulating blood. But
in process of time, as they increase in
size, and become rough and unequal on
their surface, they cause a rupture of the
internal membrane, and have now nothing
to separate them from the immediate
contact of the blood[5].

Sometimes ossification is a mixed
process, or rather, I suspect, the result
of another morbid process preceding it.
With the cartilaginous depositions already
described there is an admixture of
bone. The quantity of bone generally
bears a very small proportion to the cartilage
when they both occur together, as
if the bone proceeded from the cartilage,
and not the cartilage from the bone. It
is sometimes seen growing from the surface
of the cartilage, and is sometimes
deposited in its substance, and only detected
by the knife.

Simple ossification, as it occurs
in the heart and arteries, has been
classed among the natural changes
which the parts in question are liable to
undergo after a certain period of life.
Of persons above the age of sixty years
the proportion is that of seven in ten
according to Bichât, in which ossification
is discovered in some part of the
arterial system. It very rarely happens
that simple ossification is found before
the period of old age: still it is difficult
not to regard it as a morbid process.

But ossification, when it is a mixed
process, is unquestionably the result of
disease. It is met with at all periods of
life; and probably constitutes one of
the terminations of inflammation. The
kind of morbid structures with which
the bone is united leads to this belief.

Fungous, and wart-like excrescences,
are found in all those parts of the internal
lining of the heart, which have been
already mentioned as most subject
to disease. They seem to be the result
of a new morbid action set up in parts
already disorganized; for I have not
met with them where the membrane has
been otherwise healthy, but only where
it has been thickened or cartilaginous,
or ossified, ruptured, or ulcerated.
They grow either from the surface of the
membrane, or from its ruptured or ulcerated
edges, and are always in immediate
contact with the circulating
blood[6].

According to my observation, when a
fungous or warty excrescence has
grown from the ruptured edges of the
membrane, it has been from them exclusively,
[117]
and from no other part of the
lining of the same heart. And as rupture
of the membrane seldom occurs in
more than one situation at a time, the
heart of the same individual seldom presents
more than one excrescence of this
kind: and as the aortic valves are the
parts most liable to rupture, it is there
that this single excrescence is most frequently
found; not that rupture may
not take place elsewhere. I once saw a
single chorda tendinea ruptured; and a
single fungous excrescence of considerable
size hanging from it into the cavity
of the left ventricle.

Now, this morbid growth is evidently
connected with the lacerated state of the
membrane in the conditions of its production,
whereby it is limited to a small
space.

It is probable that the membrane is
first ruptured; that its lacerated edges
inflame, and then throw out unhealthy
lymph, or unhealthy granulations, in the
shape of these fungous or wart-like excrescences.
When they have sprung
from a ruptured membrane, they
have, in the specimens which I have
examined, been larger than when
they have arisen under other conditions.

But when such excrescences grow
from the surface of the membrane which
is thickened and cartilaginous only, but
not lacerated, they are more apt to
occur in many parts of it at the same
time. I have seen the valvular apparatus
between the auricles and ventricles
on both sides, as well as the aortic
valves of the same heart, studded with
them. They were all about the size of
hemp seeds: they adhered to the membrane
with different degrees of tenacity,
and wherever they were capable of
being detached, they left a rough surface.
The lining of the arteries has
been known to give origin to morbid
growths of the same kind, which have
obstructed the passage of blood, and
given occasion to the formation of a
coagulum, which has obliterated the
pulse.

The internal lining of the heart is
liable to ulceration, not as a common
consequence of simple inflammation,
but as an occasional consequence of
some of those diseased conditions which
have been described.

It is most commonly found around
scales and spiculæ of bone, and under
such circumstances as to leave no doubt
that the bone itself has furnished the
source of irritation from which it springs.
The ulceration commences from the
very border of the bony scale, as if it
was a process of nature for detaching it,
and to a considerable distance around
the ulceration the membrane is reddened,
and easily detached from the subjacent
structure. Where there are several
distinct scales of bone, it is not uncommon
to find a circle of ulceration
around each of them.

Ulceration is also met with where
there is a thickened and cartilaginous
state of the membrane without ossification.
Under these circumstances, as
far as I know, it affects no definite form.
It is often a very destructive process of
disease, obliterating large portions of
the valvular structure, and penetrating
deep into the muscular substance of the
heart.

Rupture of the internal lining of the
heart is not easily distinguished from
ulceration. In collections of morbid
anatomy, many unquestionable specimens
of ulceration are described as specimens
of rupture. Rupture must
always be looked for in the valvular
apparatus of the heart, i. e. in the
valves themselves, or in the chordæ
tendineæ which are their appendages.
It is probably incapable of taking place
elsewhere, except as a part of a rupture,
which involves the whole organ.

That solution of continuity which is
evidently without loss of substance;
that of which the separated edges when
they are brought together are completely
adapted to each other; also that
which is unaccompanied by any thickening
or other morbid condition of the
valve; the solution of continuity which
is found under these circumstances, may
safely be considered to proceed from
rupture, and not from ulceration[7].

But it is probable that these characteristic
conditions do not long remain
after the occurrence of the rupture.
Complete specimens of them are very
rare; but specimens are numerous
where the solution of continuity, by its
form and direction, bespeaks rupture,
while its rounded edges and the general
thickening of the valve denote ulceration.
These, it may be fairly conjectured,
do in fact exhibit a compound of
both. The membrane was originally
ruptured, but disease has subsequently
arisen and obscured the character of
the mechanical injury.

The greater number of those concretions,
[118]
which were regarded by the
older anatomists as polypi of the heart,
were unquestionably portions of mere
blood, which had undergone coagulation
after death. The blood remaining
in the heart after death discharges itself
of its colouring matter as it coagulates,
and, giving off processes between
the muscular fasciculi, assumes a shape
which has suggested the name of
polypus[8].

I have often found (I presume, therefore,
that it is not an uncommon occurrence)
coagula of an irregularly
laminated texture having their colouring
matter not entirely discharged,
but unequally distributed through
them, which have been most intimately
adherent to some part of the lining
of the heart. Of these some have admitted
of separation, while the surface
of the membrane and the surface of the
clot were left rough at the place of contact,
and others were incapable of being
detached without the membrane being
detached along with them. The appendix
of the left auricle is a situation in
which they are apt to occur, and they
are generally accompanied by an extensively
diseased condition of the lining
membrane. These coagula, from their
laminated texture, and from the intimacy
of their union with the internal
lining, seem to be essentially different
from polypi of the heart. They appear
to be connected with a process
of disease in the membrane, and to
have obtained their union with it long
before the death of the patient.

I once saw two separate tumors, entirely
resembling what are called polypi, between
the carneæ columnæ of the left
ventricle, and firmly adherent to the
heart; and in the centre of each a distinct
formation of pus. The heart was
otherwise healthy[9].

There are three preparations in the
museum of the College of Surgeons,
put up by Mr. Hunter himself, and
noted by him as exhibiting “Tumors
on the inner surface of the right
ventricle, seemingly composed of layers
of coagulable lymph one upon another,
the central part having the appearance
of glary mucus.” This last appearance
(the mucus) no longer remains
in any of the three, but in its stead
there is a cavity. The tumors
which I have mentioned as originally
containing in their centre a distinct
formation of pus, also now present
in its stead a cavity. The preparation
preserved at St. Bartholomew’s,
and those at the College of Surgeons,
are probably specimens of the same
disease.

Here what in the recent parts seemed
to be pus or glary mucus, and the cavities
still remaining in the preparations,
must suggest the suspicion, that these
tumors, whether they grew from the
surface or were deposited from the
blood, had become organized, and afterwards
inflamed; and that the inflammation
had terminated in the formation of
an abscess.

ESSAY III.

Morbid Anatomy of the Muscular Substance
of the Heart.

Dr. Baillie, speaking of inflammation
of the substance of the heart,
says, “When the pericardium covering
its surface is inflamed, the inflammation
sometimes passes a little way into
the substance of the heart:” and then
he gives these as the characteristic
marks of such inflammation—that “it
(the substance of the heart) becomes
much more crowded with small vessels
than in its natural state, and there are
sometimes to be seen a few spots of
extravasated blood.” Now, this undue
vascularity, and these few extravasated
spots, where inflammation unquestionably
belongs to a contiguous structure,
may be deemed sufficient evidence of
the muscular substance of the heart
participating, or beginning to participate,
in the same disease; but, absolutely
and exclusively, it may be doubted
whether more is not required to give
a certain assurance of its inflammation.
Here, as elsewhere, we must look for
some of the proper products of inflammation;
or for some of the permanent
changes of texture which naturally result
from it, according to its several
modes of disorganizing.

It is a very rare event to find pus
among the products of inflammation
of the substance of the heart: yet this
event has occurred twice to my observation.
In one instance the whole
heart was deeply tinged with dark-coloured
[119]
blood, and its substance
softened; and here and there, upon the
section of both ventricles, innumerable
small points of pus oozed from among
the muscular fibres. This was the result
of a most rapid and acute inflammation,
in which death took place after
an illness of only two days. In another
instance, after death, which terminated
an illness of long duration and
characterized by symptoms referable to
the heart, a distinct abscess was found
in the substance of the left ventricle,
closed externally by a portion of adherent
pericardium, and connected internally
with an ossified portion of the
lining membrane.

This diffusion of pus, or rather its
formation in innumerable separate
points, throughout the muscular structure
of the heart, by a rapid and acute
inflammation, is a singular occurrence.
No such case has ever fallen within the
knowledge of the most experienced in
morbid anatomy, of whom I have made
inquiry; neither has any such (as far
as I can learn) been recorded in books[10].

A single collection of pus[11], constituting
an ulcer or abscess of the heart,
and resulting from chronic inflammation,
is also a rare occurrence, yet not
so rare but that a specimen of it may
be found in most collections of morbid
anatomy[12].

But independent of the formation of
pus, softening and attenuation, as well
as induration and thickening of the
muscular substance of the heart, do,
in different cases, according to the circumstances
under which they are found,
both bespeak inflammation.

Together with the unequivocal evidence
of inflammation in other parts of
the heart, the muscular fibres have at
the same time been found very soft and
loose, and easily torn; and with this
looseness of texture the heart has sometimes
presented a dark and almost black
appearance, and sometimes it has been
almost blanched and colourless. The
deep dark tinge shews that the muscular
substance is unnaturally loaded with
blood; whereas the absence of colour
shews that it is destitute of its natural
quantity. These different appearances
do, in fact, belong to different stages of
the same disease. The first indicates
inflammation of the muscular substance
in its present state of activity; the
second, an irreparable disorganization
of the muscular substance left by inflammation,
when it has been unarrested
in its earliest stages. The first is
found when death takes place in a
few days after the accession of the disease;
the second, when the patient survives
the first attack, and dies at a remoter
period.

The inflammation, which produces
softening and attenuation of the muscular
structure, is, I believe, always of
an acute kind.

But induration and thickening of
the muscular substance of the heart is
also the result of inflammation. This
must be distinguished from hypertrophy,
or mere augmentation of bulk, of
which we shall speak hereafter. In this
induration, which proceeds from inflammation,
there is, besides increase
of bulk and firmness, a manifest alteration
of texture. A substance[13] is produced
offering a peculiar resistance to
the knife. This condition unquestionably
must result from an interstitial deposition
of new matter among the muscular
fibres. From concomitant circumstances,
as well as from its own
character, I presume that it proceeds
from chronic, not from acute inflammation.
I confess that I never saw a
specimen of what I now allude to. It
is described with some minuteness by
Corvisart; but it may be presumed to
be very rare, since Laënnec admits that
it never fell under his observation.

These opposite states of softening
and attenuation in one case, and induration
and thickening in another, are
known to those conversant with morbid
dissection as the evidences of inflammation
in other parts of the body besides
the muscular substance of the heart.

But there are changes of structure
incident to the muscular substance of
the heart which are independent upon
inflammation, or, perhaps, upon
any process which can properly be
called morbid. They consist of simple
augmentation and simple diminution of
bulk and consistence. This simple
augmentation of bulk and consistence is
owing exclusively to a more ample development
of natural structure. The
muscular substance is more red than
[120]
natural, its carneæ columnæ are increased
in thickness, and its proper fibrous
texture is every where more strikingly
manifest; but there is no interstitial
deposition of matter new in its
kind. It has been called hypertrophia
of the heart, and the name conveys a
tolerably just idea of its actual condition.

The simple diminution of bulk and
consistence is a condition the exact opposite
of the former. The muscular
substance is less red than natural; its
proper fibrous texture less distinguishable;
but there is still the appearance
of muscle shrunk and withered, as if
from an insufficient supply of nourishment.
It may be called atrophia of
the heart.

Conjoined with augmentation, as well
as with diminution of strength and bulk
in the walls of the heart, there is almost
always an increase in the capacity of its
cavities; and in whichsoever part of
the heart the walls are thus augmented
or diminished, it is the cavity appertaining
to the same part which undergoes
the increase of capacity. Hence
it appears either that one of these conditions
is the immediate and necessary
consequence of the other, or that both
are the simultaneous effects of the
same causes.

Dilatation of any cavity of the heart,
with thickening of its walls, is called
active dilatation; and dilatation of any
cavity, with attenuation, is called passive[14].

Active dilatation may appertain to
every cavity of the heart simultaneously;
and so may passive dilatation. But
such occurrences are very rare: for
one cavity being naturally more liable
to this species of dilatation, and another
to that, it most frequently happens that
specimens of both conditions are found
in the different cavities of the same
heart.

The left ventricle is much more
liable to active dilatation than the
right; and the right ventricle more so
than either of the auricles; and of the
auricles unquestionably the left. Upon
the whole, perhaps, the fact may be
truly stated thus—that the left ventricle
commonly gains an increase of bulk
and strength, with an increase of capacity;
and that all the other cavities, at
the time that they expand, are rather
apt to become attenuated.

It sometimes (though rarely) happens,
that, with an increase of strength
and bulk in its muscular structure, the
left ventricle suffers a diminution of
capacity in its cavity. In a case reported
by Laënnec, the left ventricle
was an inch and a half thick at its
broadest, and an inch thick at its
thinnest part; and yet its cavity was
only capable of containing an unblanched
almond. I have seen the same condition
in a less degree.—(Laënnec,
vol. ii. 698.)

The circumstances under which these
opposite conditions, this hypertrophy
and atrophy of the heart, with the enlargement
or diminution of its cavities,
arise, must be explained hereafter.
At present I would only remark that
they are often found conjoined with
actual disease in other structures of the
heart, such as osseous or cartilaginous
thickening of internal lining, adhesion
of the pericardium, and ossification
of the coronary arteries, to which they
owe their origin; and, moreover, that
they are often found where the heart is
otherwise perfectly sound in texture,
and where their cause must be sought
in other parts of the body.

The heart is liable to undergo a simple
dilatation of its cavities without either
thickening or attenuation of its muscular
substance. This simple dilatation
is sometimes of the whole organ, sometimes
of one side, and sometimes only
of one auricle or ventricle. When it is
of one cavity only, it may be complicated
with active or passive dilatation of
another, or of all the rest.

There is reason to believe that the
heart sometimes undergoes a temporary
dilatation, and again returns to its natural
capacity; but that the dilatation
can only subsist for a short time without
becoming permanent.

The power of thus enlarging its cavities,
and restoring them to their natural
condition, belongs more especially to
the right side of the heart.

A large accumulation of fat is sometimes
met with about the heart.

The healthy heart is always more or
[121]
less marked upon its external surface
with streaks of white, and this appearance
results from the deposition of fat in
the cellular texture, which unites the
serous covering with the subjacent muscular
structure. It is found principally
where the venæ cavæ unite to form the
right auricle; also at the base of the
ventricles, and along the line which
marks the boundary between the two,
and around the origin of the great blood-vessels
as they emerge from the heart.
But when fat is deposited in more than
these situations, and in more than the
natural quantity, it is not so much
added to the healthy substance of the
heart, as existing at its expense and detriment,
and the muscular structure is
that which especially suffers. The fibre
of the fat heart is pale and wasted,
like that of a paralytic limb.—Mus. of
the Coll. of Surg. 327.

A rupture of the heart is sometimes
met with; but all the cases of reputed
rupture are not such in reality. An
aperture in the walls of the heart,
through which blood escapes into the
cavity of the pericardium, may result
from ulceration as well as from rupture,
or from a mixed process of one and
the other; but whatever be the precise
nature of the process by which this
perforation of the heart is effected, it is
undoubtedly of rare occurrence.

Where it has been found, there has
generally been at the same time some
peculiar condition of the organ, which
might be presumed favourable to its
production. Its muscular substance
has been so soft and loose of texture,
that it could be pierced through by the
weight of a probe[15]; or it has been converted
into, or greatly intermixed with
fat[16]; or its muscular fibres have been
absolutely defective, leaving a certain
transparent space, where the internal
lining and the pericardium have been
in contact, and served to maintain the
completeness of the cavity, until the
rupture has taken place[17].

Not that a rupture has not been
found where the texture of the parts has
seemed to offer no natural facilities to
its occurrence—as in the case related
by Harvey himself, who found a lacerated
aperture in the left ventricle, capable
of admitting his finger, through
which blood had escaped into the pericardium,
the walls of the ventricle being
increased in thickness and strength,
while an obstacle existed at the entrance
of the aorta[18]. Here the heart must
have torn itself asunder by the simple
violence of its contraction, in contending
against the impediment to the egress
of blood from its cavity. This is an
effect which would hardly be thought
capable of being thus produced; but
I can well believe it possible after having
seen one of the recti muscles of the
abdomen literally torn in twain, in a
man who died of tetanus[19].

[To be continued.]

DILATED ŒSOPHAGUS.

To the Editor of the London Medical
Gazette.

Sir,

Permit me to send the following case
to you for insertion in the Gazette.

Mary Blores, æt. 33, was admitted
into the Middlesex Hospital on the 16th
of November. She was in a state of
extreme feebleness and emaciation.
Those who brought her said that during
the preceding month she had appeared
to swallow nothing: what she took
as food seemed to her to stop in the
gullet, and after a few minutes returned.
I found, however, that a
large œsophagus-bougie passed readily
into the stomach, meeting with no obstruction
beyond a spasmodic resistance
in the pharynx. A draught of
milk and water was given her—she
swallowed it without much effort, but
it quickly returned. In the course of the
[122]
afternoon a pint of beef tea was injected
through an elastic tube into the stomach—it
was thrown up directly.

I now learnt from her that she could
swallow liquids much more readily than
solid food; that when she took a small
quantity, it seemed to her not to reach
the stomach, and in three or four
minutes was invariably thrown up; that
on taking a large draught she had an
impression that it reached the stomach—in
this case vomiting did not follow so
soon, and some part of the draught was
permanently retained; that she craved
food and drink, and was literally dying
of hunger and thirst; that the vomiting
which took place was not preceded by
nausea, although in its progress it had
all the appearance of ordinary retching;
that the matter vomited was not
thrown up at once, but by successive
efforts; it consisted of the food she had
last taken, mixed with colourless
mucus. The belly was so shrunk that
the umbilicus was not more than an
inch distant from the spine, upon
which the pulsations of the aorta were
readily felt: there was no enlargement
or hardness about the stomach,
no particular tenderness on pressing
the epigastrium, no sensation of pain or
heat now or formerly.

The complaint had began ten years
ago, during pregnancy, since when she
had never been free from it, although
at times her sufferings had been less,
and she had been able to retain some
portion of her meals. She had borne
in this period three children; the vomiting
had lasted during the whole
period of her pregnancies, and during
her confinement. The principal remedies
which had been used for her relief
were a succession of blisters on the pit
of the stomach—but they had produced
no benefit. Latterly her symptoms had
been greatly aggravated.

This patient was attended by Dr.
Watson and myself. But the means
which we tried to enable her to retain
her food, and to support her expiring
strength, had scarcely a temporary
effect. She died on the 2d Dec. sixteen
days after her admission. The body
was carefully examined, at the expressed
wish of her relatives.

The unusual appearances found in the
abdomen were—1. the smallness of
the first part of the duodenum, which
was but half the ordinary size of
the ileum; 2. the capaciousness and
fulness of the gall bladder,—from
which, however, on compressing it,
the bile flowed readily into the intestine;
3. a contraction of the middle of the
stomach of the length of two inches,
for which extent the peritoneal coat
was thickened and opaque, and the inner
membranes folded in deep longitudinal
rugæ, the mucous surface of which was
partially suffused with circular spots of
red. The breadth of the contracted
part of the stomach, as it lay collapsed,
was an inch and a half.

But it was in the chest that the most
remarkable circumstance presented itself.
The œsophagus gradually enlarged
from the pharynx, which was
perhaps rather narrower than usual,
to an extraordinary degree of dilatation;
the greatest breadth which it
attained was situated about four inches
above the cardia: the tube then contracted
more abruptly, so as to render
the termination of the œsophagus, like
its commencement, of nearly the usual
dimensions. The structure likewise of
the cardiac extremity for about an
inch, and of the pharyngeal end for
about half an inch, was healthy. The
intermediate part presented, when inverted,
the following curious appearance:—The
inner membrane was thickened
and opaque, and had the appearance
of having partially yielded from dilatation;
at the upper part the furrows or
thinner parts of the membrane followed
in some degree a longitudinal direction;
at the lower part the surface was pitted
with shallow depressions of various
figures. I have represented in the adjoined
sketches these appearances, which on
the middle of the œsophagus passed
from one into the other; at the furrows
[123]
or depressions the membrane seemed of
the natural thickness and colour; the
intermediate raised and thickened part
was opaque and whitish. The muscular
fibres of the œsophagus were of the
natural colour and thickness.

I remain, Mr. Editor,
Your obedient servant,
Herbert Mayo.

19, George-street, Hanover-square,
Dec. 6, 1828.

HYDROPHOBIA.

To the Editor of the London Medical Gazette.

Sir,

As the following case may throw some
additional light on the pathology of
hydrophobia, I have sent it you for
publication.

I am, Sir,
Your obedient servant,
F. Godrich.

Grove House, Little Chelsea,
Nov. 29, 1828.

On Thursday morning, the 25th ult.
I was called up about seven o’clock to
see a man who I understood was exceedingly
ill, and waiting in the surgery
very impatiently for my arrival. I
found my patient (Mr. Barham), a fine
looking old man, about 60, labouring
at intervals of about five minutes under
strong spasmodic paroxysms, affecting
the muscles concerned in breathing
and deglutition. There was a wildness
and an impatience depicted in his
countenance, totally different from any
thing I had ever observed in other spasmodic
affections. His bowels were open,
tongue clean, skin moist, pulse full and
a little accelerated. I took away twenty
ounces of blood, and prescribed a mixture
containing
ʒss.ss.
of laudanum for a
dose every hour until I should see him
again. He walked home half a mile
from my house (Gloucester Road, Old
Brompton), and left me ruminating on
the possible cause of so much mischief
occurring suddenly in a fine healthy
subject. At ten a message was sent,
saying that he was much worse, and
requesting me to call as soon as possible.
He received me tranquilly, and
said he was very glad that I had come
to see him, for he was very ill. His
symptoms were now more distressing
than when I first saw him: he looked
wildly and suspiciously at every one entering
his apartment, and his breathing
was accompanied by a short convulsive
sobbing. On looking at his medicine
I perceived he had taken none, and expressing
my surprise, he assured me it
was impossible for him to swallow a
single drop, as the attempt had been
followed by violent spasms, and produced
so much distress, that he had desisted.
At this period no one had the
slightest idea of the origin of his
malady. I poured out some medicine
into a tea-cup, the very act of which
produced much excitement and alarm.
My first impression as to the true nature
of his disease arose at this period, from
the circumstance of his requiring a tea-spoon,
with which he endeavoured to
take some of the medicine. The attempt
produced much excitement and
alarm, and after two or three painful
efforts at deglutition, with one desperate
effort he swallowed a tea-spoonful, threw
away the spoon, and begged, unless I
wished to destroy him, that he might
have nothing more to swallow. I now
left his room, and inquired of a bystander
whether any thing particular
had occurred to him within the last
few weeks. On recollection she said,
“About a month since, late at night, a
strange dog came into the premises and
fought with his own dog; he got out of
bed to separate them, and the strange
dog bit him in two places, on the left
arm and hand; and bit a puppy, which
died about a fortnight after in a strange
[124]
way, which was thought to be some
kind of a fit.” To ascertain if this occurrence
had produced any effect on his
mind, while again bleeding him I said,
“You have been in the wars, Sir, and
had your hand and arm torn; how did
it occur?”—”Oh!” said he, carelessly,
“that was done by a dog a long time
ago, but it healed.” The circumstance
was never again mentioned to him, and
he died in total ignorance of the cause
of his malady. The wounds were perfectly
cicatrised, and there was not the
least action going on indicative of recent
absorption. He bore the bleeding
pretty quietly:
40℥.40.
were removed,
which on cooling presented strong
marks of inflammation.

Ordered
ℳiv.iv.
Acid. Hydrocyan. omni horâ, in a little water.

Twelve o’clock.—With much difficulty
he has taken two doses of the
acid; pulse full and hard, 110.
30℥.30.
more blood were removed.

Three o’clock.—Has taken two more
doses; complains of a dreadful sense
of suffocation, and implores that nothing
more may be given him. Pulse full, and
beating at 120 to 130. Continue the
acid.

Eight o’clock.—Pulse full and hard.
Has taken in all
24ℳ.24.
of the acid, but
so painfully distressing has the deglutition
now become, that all attempts at
repeating his medicine are discontinued.

V. S. ad
℥xxx.xxx.

During the bleeding he looked wildly
at the basin, and begged that no more
might be spilt (a drop or two had fallen),
repeating frequently, in great
agitation, as the blood was running,
“Take care! take care!”

Between two and three o’clock next
morning my assistant (Mr. Davies) visited
him. He found him tolerably
passive, but observing every movement
with intense anxiety. Pulse full and
hard, face flushed, eyes denoting cerebral
irritation. He had been at times
outrageous. On its being intimated
that bleeding was again necessary, a
paroxysm came on more intense than
any preceding,—and with great effort he
submitted. As the blood flowed he became
more and more alarmed, till at
length he got quite unmanageable; he
raged violently at his nephew, who was
holding the basin, and ordered it peremptorily
to be removed. 30 or
40℥.40.
were taken away. It was found necessary
to put on the straight waistcoat.
About four o’clock Mr. Davies wished
him to take some more of his medicine.
He said, “I can take no more,” and on
reaching the bottle to put out a few drops,
he became violently agitated, threw himself
from side to side, and, as well as
the incessant spasmodic sobbings would
allow, he begged that not one more drop
of any thing might be offered him, and
that the bottle might be taken from his
sight. He did not become tranquillized
until its removal. He lingered on till
ten A.M. in the same state, a few minutes
before which he insisted on getting
up, and walked a short way down
his garden, returned, laid down on his
bed, and died.

Mr. Frederick Salmon, of Old Broad
Street, and Mr. Wilson, of Chelsea,
were kind enough to assist me in conducting
the post mortem examination.
On opening the chest, the heart was free
from disease, with rather more water in
the pericardium than natural; the lungs
were completely gorged with grumous
blood, and the pleura adherent on the
right side. On removing the cranium,
which was remarkably thin, and cutting
the substance of the brain, numerous
red spots presented themselves in the
medullary portion; about a table-spoonful
of water in each ventricle; the
plexus choroides was turgid; the corpora,
striata, thalami, and basis of the
brain every where preternaturally injected;
the cerebellum, crura cerebri,
and cerebelli, in a high state of inflammation.
On removing the spinous process
of the vertebra, the whole cord
was considerably inflamed; and opposite
the two last cervical and dorsal
vertebræ the cellular substance was
studded with dark patches of coagulated
blood, the theca vertebralis thickened,
and the cord in an active state of inflammation.
The larynx and pharynx
bore not the slightest vestige of disease.
The preparation of the cord is deposited
in the museum of the London
University.

The post mortem examination of this
case tends to prove the correctness of
Professor Thompson’s theory of the
proximate cause and seat of this afflicting
malady; and the plate accompanying
a case recorded by him, in the
13th volume of the Med. Chir. Society,
gives a faithful delineation of the state
in which the spinal cord was found in
this case.

[125]

CASE OF LONG PROTRACTED CONSTIPATION.

To the Editors of the London Medical
Gazette.

Gentlemen,

Perhaps the following case may interest
some of your readers, and if you
think so, its insertion in your Journal
will oblige

Your obedient and
humble servant,
S. D. Broughton.

12, Great Marlborough Street,
Dec. 3, 1828.

On Tuesday, Nov. 25, I was called
upon at the St. George’s and St. James’s
Dispensary to advise for an infant at
the breast, of five months and fourteen
days of age, that had not passed
any fæces during six weeks up to the
day before I saw it. After its birth it
had no passage till the fifth day, and
this had apparently been effected by the
introduction of a bougie, and which
was subsequently continued at intervals
for a short time. The infant was otherwise
healthy and strong at its birth, and remained
so until it had gone about three
weeks without any evacuation, when it
was observed to be weak in the lower
extremities; and at the period of my
seeing it the legs were much fallen
away in flesh, hanging flaccid and inert.
Many aperient enemas and medicines
had been given, and, as a last resource,
one drop of the croton oil had been
prescribed the preceding evening. The
infant appeared to suffer from distention,
and to be disposed to coma, and
the croton oil had distressed it much
some hours after it was given. The
fæces could be felt blocking up the intestine,
but the irritation of the finger
produced no attempt at evacuation;
very small pieces only having been
brought away. Hot baths also had
frequently been used some time ago.

Considering the case as one of paralysis
in the parts naturally employed to
relieve the bowels, I recommended
the suspension of all purgative remedies
by the mouth, and a table-spoonful
of the following injection to be substituted,
and to be thrown up with three
table-spoonfuls of thin gruel occasionally
during the day, by means of a
syringe.

℞ Spir. Terebenth. ʒiij.
Træ Zinzib. ʒj.
Aquæ, ℥iss. M.

Spir. Terebenth.
iij.
Træ Zinzib. j.
Aquæ, iss. M.

The following liniment was also directed
to be rubbed in frequently along
the course of the spine.

℞ Linimenti Saponis, ℥iss.
Liquor. Ammon. Comp. ℥ss. M.

Linimenti Saponis,
iss.
Liquor. Ammon. Comp. ss. M.

The result justified my expectations;
for, during the night after this prescription,
two injections having been
given, some large and hard ash-coloured
lumps came away, and these were
shortly followed by a forcible spouting
out of a continued stream of feculent
dark liquid; a brisk diarrhœa having
been kept up till the Saturday following.
The infant’s appetite is become
voracious, its appearance lively and
healthy, and its legs as firm and strong
as is usual at such an age. Cold water
is recommended to be dashed upon the
loins, the liniment to be continued
occasionally, moderate doses of magnesia
and rhubarb to be given when
required, and the turpentine injection
to be used if any return of the complaint
should be threatened.

DISLOCATION OF THE PATELLA.

To the Editor of the London Medical
Gazette.

Sir,

Having seen a case of dislocation of the
patella, reported by Mr. Mayo, in your
Journal a few weeks since, in which
there was experienced some difficulty in
the reduction of the bone, I beg leave
to send you the following, in case you
may think it worth insertion.

On Saturday last, I was called to a
young woman who had dislocated the
patella of the left knee joint outwards;
the inner edge rested upon the outer
surface of the external condyle, and was
immoveably fixed, and caused great pain
when touched. She says it was occasioned
by her foot slipping backwards
from one stair to another, and she immediately
fell down.

I commenced the reduction, as stated
by Mr. Mayo, but I could only produce
semiflexion, and that gave her great
pain; insomuch that I was obliged to
desist, and the patella remained in statu
quo. But when the knee was thus semiflexed,
I desired my assistant to extend
the leg suddenly; and having my fingers
on the patella at the time, and pressing
[126]
it inwards, it immediately returned to
its natural position.

I must confess, sir, that I should
have been afraid to have continued the
flexion as described in Mr. Mayo’s case,
“by bending the knee to the utmost,”
fearing that the remedy might be worse
than the disease, and the result proved
that in this case it was not necessary.

I remain, Sir,
Your obedient servant,
P. M. Hoskings.

168, Fleet-Street,
Dec. 3d, 1828.

VACCINATION.

To the Editor of the London Medical
Gazette.

Sir,

The mistake of the printer in substituting
the word “every” for “even,”
in the paper on Vaccination (p. 40), so
materially affects the sense of the passage,
that I must request the favour of
the following insertion:—

“3d. That while the vaccine cicatrix
retains even one distinct fovea or depression,
the individual continues unsusceptible
both of small pox and of re-vaccination;
but that,” &c.

I am, Sir,
Your obedient servant,
Thos. H. Burder.

2, Brunswick Square, Dec. 15, 1828.

SINGULAR BICEPS MUSCLE.

To the Editor of the London Medical
Gazette.

Sir,
The valuable paper communicated to
your Journal, by Mr. Stanley, last
week, has brought to my recollection a
singular appearance of the parts in front
of the shoulder-joint which I dissected
about two years ago. It is a fact
worth recording; and perhaps you will
be kind enough to insert it in your next
number.

The circumstance was this—that in
the right arm, instead of there being
a biceps muscle having two origins, the
one the shorter from the corocoid process,
the other the longer from the
upper part of the glenoid cavity of the
scapula, there was simply a one-headed
muscle arising from the corocoid process.
I could find no tendon passing
through the joint answering to the long
head of the biceps, neither was there
any appearance of a biceptical groove;
the capsular ligament was, perhaps,
thicker than it is found in ordinary
cases.

I knew nothing of this man during
life, and am therefore unable to give
any account of the use which he made
of this arm.

I am, your obedient servant,
C. M. Burnett.

House Surgeon’s Apartments,
St. Bartholomew’s Hospital, Dec. 8th.

STETHOSCOPE.

To the Editors of the London Medical
Gazette.

Gentlemen,

As you did me the honour, on a former
occasion, to publish some remarks in
defence of auscultation, against its
enemies and detractors, I trust you will
permit me to say a few words in reference
to a communication in a late
number, from a gentleman who appears
to be a friend of that method of diagnosis,
but whose ignorance of the subject
is likely to be more injurious to the
cause than either open enmity or secret
detraction. The case in question (page
780, vol. ii.) appears, from the dissection,
to have been clearly emphysema of the
lungs, as there stated; but I appeal to
every one practically acquainted with
the physical signs of diseases of the
lungs, whether the results of the exploration
with the stethoscope, as narrated
in the case, were those pathognomonic
of that disease? I say they were
not only not pathognomonic of this
affection, but they were actually incompatible
with its existence. The same
ignorance of the subject is shewn in relation
to the disease of the heart, which,
I boldly maintain, no one was justified
in pronouncing to be hypertrophy of the
left ventricle from the stethoscopic indications
stated in the case.

It is just possible that the writer of
the case may have made further explorations
on which his diagnosis was founded;
but if he had such in his case-book,
it is equally unfortunate for the credit
of the stethoscope and his own, that he
suppressed them in his printed case.

I have the honour to be,
Gentlemen,
Your obedient servant,
A Stethoscoper.

Nov. 25, 1828.

[127]

MECHANISM OF VOMITING.

To the Editor of the London Medical
Gazette.

Glasgow University, Nov. 26, 1828.

Sir,

Having lately perused, in the 35th
Number of the Medical Gazette, some
observations “on the mechanism of
the act of vomiting,” by Dr. Marshall
Hall, in which, after controverting the
different opinions which have been entertained
by physiologists on this
question, he endeavours to prove that
vomiting is an effort, not of inspiration,
but of expiration, and advances this
opinion as having originated in himself,
I beg, through the medium of your
Journal, to refer that gentleman to
Richerand’s Physiology, where, on the
subject of vomiting, page 70, he says,
“Sometimes the action of the muscular
fibres of the stomach is quite inverted;
they contract from the pylorus towards
the cardia; and this antiperistaltic motion,
in which the contractions act
with more force and rapidity, and in a
manner decidedly convulsive, produces
vomiting. The action of the abdominal
muscles then connects itself with that
of the stomach; the viscera are propelled
upwards and backwards, by the
contraction of the large muscles of the
abdomen; the diaphragm ascends towards
the chest; if it descended, in contracting,
the œsophagus that passes between
its two crura would be compressed,
and the expulsion of food
through the cardia could not be effected.
It is also observed, that during expiration
only, any thing can pass from the
stomach into the œsophagus.” Again, on
respiration, page 147—”In every effort
of expiration, as coughing and vomiting,”
&c. Here, then, we see that Dr.
Hall’s views, as far as regards vomiting
being an effort of expiration, have
long since been advanced by Richerand.

The profession are certainly much
indebted to Dr. Hall for his corroboration
of these views; at the same time
he should not have taken to himself the
merit of having first suggested them.

Sir,
Your most obedient servant,
A Subscriber.

CHARACTER OF THE LANCET.

To the Editor of the London Medical
Gazette.

Dec. 19, 1828.

Sir,

The events disclosed during the late
trial in the Court of King’s Bench, must
fill every well-disposed mind with astonishment
and horror. The moral aspect
of the case is marked by every feature
capable of exciting a sense of shame
for our profession, and of sorrow for
our kind. Can it be that a publication
conducted in the spirit of the extracts
produced at the late trial of Cooper
against Wakley should be fostered and
encouraged by a large proportion of the
medical public? Is it indeed true that
no feeling of loathing and disgust
should have induced the purchasers of
the Lancet to protest against its glaring
injustice, its undisguised ferocity and
malignity?

I am not a reader of that work myself,
and but for the disclosures recently
made in our courts of justice, together
with what I have learned from your
own pages, I should know little about
it. Some of its early numbers convinced
me that it was a production not
deserving of support, whatever ability
there might be connected with it; subsequent
events have amply justified this
decision, and I now address these few
hasty lines to you, to express my humble
hope that all the respectable medical
men throughout the kingdom will arise,
and with one voice oppose this moral
pestilence, which at once corrupts and
degrades their profession.

The odium medicum, bitter and vindictive
as it unfortunately has been,
never, I believe, appeared in a form so
repulsive. Are we living in the nineteenth
century? Have arts and sciences,
which are asserted of old to soften the
manners and temper the violence of our
nature, produced no such fruits amongst
us? Is serious, and perhaps irremediable
injury, to be inflicted on reputation;
and is the sufferer thereafter to be
dared to mortal combat, and this too by
the wrong-doer? Is it thus that professional
justice is to be awarded? Is
it thus that knowledge is to be advanced,
the dignity of our profession
to be maintained, its benefits enlarged,
and its usefulness transmitted? Is it
thus that the young men are to be
taught how to acquire an unworthy and
discreditable notoriety; to disregard all
[128]
the decencies, charities, and higher
virtues of life; and to bring into the
exercise of our art the insidious cunning
of the knave, the vulgar dishonesty of
the pilferer, and the audacious bearing
of the bravo?

I know not how others may feel on
the present occasion: I am entirely unacquainted
with the parties who have
been at issue in the late suit—I have no
bias of any kind, but what must arise in
the mind of every man who has any regard
for the profession to which he
belongs, or who loves truth and fair
dealing—I am sure that it is not less for
the interests of society at large than for
the advancement of medical science,
that just principles should regulate all
our dealings, both with the public and
with each other. It is manifest that of
late we have signally and woefully departed
from them; and it is most distressing
to know that this departure has
been sanctioned by so many members of
the profession. I now entertain a confident
hope that all who reflect on the
character of the late libel will feel that
their own character is at stake if they
do not mark their disapprobation of it
in every possible way. Sure I am that,
if the principles which guide the Lancet
become generally acceptable, it will
mark an æra of moral degradation
which no surgical dexterity, no medical
acquirements, however eminent, could
possibly redeem.

Veritas.

DURATION OF HUMAN LIFE IN RUSSIA.

Cases of longevity are not only
much more common, but also more extraordinary
in respect to a greater duration,
in Russia than in any other part of
Europe; thus, from the report of the
holy synod, published in 1827, it appears
that there were living in 1825,
among those who professed the Greco-Russian
religion throughout the empire,
not fewer than 848 males who
were 100 and more years old; among
whom, 32 had passed the age of 120, 4
were between 125 and 130, and 4 others
between 130 and 135 years of age. Out
of 606,881 males who died in 1826,
2785 had passed the age of 90 years;
1432 that of 95; and 818 that of 100.
Among the latter, 38 were more than
115 years of age; 24 more than 120;
7 more than 125; and one was 160
years old at his death.

MEDICAL GAZETTE.

Saturday, December 27, 1828.

“Licet omnibus, licet etiam mihi, dignitatem Artis
Medicæ tueri; potestas modo veniendi in publicum
sit, dicendi periculum non recuso.”—Cicero.

ANALYSIS OF WAKLEY’S DEFENCE ON THE LATE TRIAL.

We last week presented our readers
with a full[20] and, we trust, accurate
account of the trial for libel, which
has recently excited so much interest;
and we offered some remarks of a general
nature upon its result and tendency.
We had purposed at the same time to
subject Mr. Wakley’s mode of conducting
his cause to a critical investigation,
but this we were prevented from doing
by want of time and space. We thought
it likely, too, that the Editor of the
Lancet would have fairly met the question
in his next publication, and himself
put the facts of the case, at least,
on record: instead of this, however,
he has devoted his pages to compliments
to himself, and scurrilous and
absurd abuse of Sir James Scarlett, in
which he informs us that in his opinion
that gentleman is “prodigiously overrated
even as a lawyer,” and says many
other things, which serve only to shew
how dreadfully Wakley himself had
smarted under his lash.

We find the general opinion to correspond
with that which we expressed
last week—that the defendant had managed
his cause in a very bungling
manner; and the estimation in which
he and his witnesses were held by Judge
and Jury is apparent from the charge
of the one, and decision of the other.
[129]
Both, indeed, regarded the asseverations
of his whole family party as dust in the
balance against the testimony of one
single competent and honourable man—Mr.
Callaway; for on his evidence the
result obviously hinged. Our contemporary
affects to look upon the verdict
as a triumph on his part—so he would
if the damages had been five hundred
or a thousand pounds, for in truth he
has nothing else for it; and with all
our hearts we wish him many such
victories.

With regard to the amount of damages,
we certainly should have been
better pleased had it been larger; but
we did not expect that it would—nay a
reference to our number which was
published while the trial was going on,
will shew that we were even doubtful of
the verdict, because we know how extremely
difficult it is for a jury to comprehend
such a complicated question—how
easy for a knave to impose upon
their ignorance by misrepresentation
and falsehood. It is quite obvious
that if the jury had believed one syllable
of the evidence of Wakley’s witnesses,
they must have given the verdict
in his favour. In a case like this,
where one individual only, and he the
plaintiff, can be fully aware of the difficulties
which had to be overcome, it is
almost impossible to bring evidence
into a court of justice capable of satisfying
the minds of twelve unprofessional
men. From this circumstance alone it
was that we expressed a doubtful
opinion of the result. But besides all
this, it is well known to all—that one
talesman might go determined to starve
out the rest—that ten special jurymen
might wish to give 500l. and yet that, by
the absurd constitution of the English
law, their verdict might be thus controlled
by one individual friendly to the
defendant.

Most fortunately for the cause of truth,
Wakley had the vanity and folly to conduct
the defence himself, and, judging of
other men’s estimation of moral character
by his own, he did not hesitate
to place in the box witnesses whom no
counsel would have suffered to go there,
and who, being unable to stand the cross-examination,
led to what must have
been to Wakley a most humiliating
exposure. Next to this, the most
beneficial effect produced was that of
the defendant’s cross-examination of
his opponent’s witnesses: it was
amusingly absurd, and shewed a lamentable
want of tact, always eliciting
something which he ought to have
avoided. Lastly came the reply, of
which he tells us he is himself ashamed—”We
may state most unfeignedly,”
says he, “that we look back with regret
to our errors in point of omission.”
Nor is this the only part of it for which
he has cause to blush, for any thing more
miserably deficient we never heard: it
was a mass of confusion throughout—a
repetition of the same ideas and expressions—and
a most injudicious betrayal of
rancorous feeling, at the very moment
he was profanely invoking heaven to
witness that he bore enmity to no man.
In speaking of his reply in our last
number, we declared it to be “false
in statement—sophistical in argument—coarse
in language—and diabolical in
tendency;” and we now proceed to
illustrate these several qualifications, in
doing which little more will be necessary
than to select a few passages, and
arrange them under their appropriate
heads.

False in Statement.—One of Wakley’s
principal objects was to impress
upon the Jury a belief that he had
not in any way attempted to influence
his witnesses, nor even spoken to most
of them, anterior to the trial. “Out
of nine witnesses I have placed in the
box, (says he) I never saw five of them,
nor even spoke to five of them till yesterday.”
We appeal to any man of
[130]
common sense, whether it be probable
that this is true. It is possible indeed,
and only just possible, that he was contented
with employing others to question
his witnesses, and ascertain what
evidence they would give; but even if it
were so, the assertion was not the less
false in a moral point of view, because
his intention was to convey the belief that
he had inquired no farther than merely
whether or not the witnesses had been
present at the operation. But incredible
and absurd as this was, he ventured a
step farther, and assigned a reason for the
choice made of one witness—(Lee the
potatoe-merchant.) “I had heard
(said Wakley) he was present at the
operation—an honest man, and that he
was a friend of Mr. Bransby Cooper,
under the highest obligation to the
Cooper family. Without asking him a
single question I put him into the box,
as I was most anxious you should hear
all the evidence that could be adduced,
and from unsuspected and untainted
quarters.” This lie carried with it its
own refutation; for Lee swore that he
had never even spoken to Mr. Cooper;
and we are therefore amazed that Wakley
should have hazarded so gross an assertion,
as it could only have been effective
on the supposition of his addressing
a jury of absolute simpletons. But
again—”Who were my witnesses? not
men whom I had trained and lectured
on models, and sketches, and drawings.
Has it been shewn to you that I
was closeted with any person or set of
persons?” Yes, Mr. Thomas Wakley,
it has been shewn, and by no less an
authority than that of your fidus Achates,
Mr. James Lambert. “The defendant
(says the worthy author of the libel), the
defendant was there whilst I was explaining
the parts to persons who were
to be witnesses—the defendant also explained
them to the same persons.” And
again, “I have heard explanations given
to persons who were to be witnesses in
this cause FOUR OR FIVE TIMES within
the last six weeks.” So also that excellent
thorough-going witness, Mr. Jeffry
Pearl: “a gentleman of the name of
Lambert introduced me to the defendant;
THE DEFENDANT and Mr. Lambert
endeavoured to shew that the forceps
had passed between the bladder and the
rectum.” So much for placing men in
the box because they are friends of Mr.
Cooper—so much for procuring evidence
from “untainted quarters!”

This is only to be matched in effrontery
by the statement of some wise-acre
at the radical meeting on Tuesday
night. Being asked why no notice had
been taken in the Lancet of a successful
operation of lithotomy performed by
Mr. B. Cooper, soon after the publication
of the libel, he assigned as the
reason that Mr. Wakley thought it
might increase the damages, and otherwise
injure Mr. Cooper! What a
noodle the man must be to expect any
one to believe him[21]!

Mr. Wakley asserted that the evidence
of his witnesses remained “untouched—wholly
uncontradicted;”—whereas
there was scarcely a single
point in their statements which was not
contradicted either by Mr. Callaway,
who was present at the operation, or
Mr. Key and Dr. Hodgkin, who examined
the parts after death. But what
is more remarkable, there was scarcely
a circumstance on which his own witnesses
agreed—for example, they differed
with regard to the nature and direction
of the incisions; with regard
to the manner and frequency of introducing
the forceps; with regard to the
number of instruments used, and the
mode of applying them; with regard
to the size of the wound; with regard
to the degree of force employed, and
with regard to the appearances after
death. Yet, in the face of all this, Wakley
[131]
had the impudence to tell the jury
that his evidence remained “uncontradicted.”
We have no hesitation in asserting
that his own witnesses (putting
Mr. Cooper’s out of the question) advanced
no charge of which they did not
also furnish the refutation.

Mr. Wakley asserted that Mr. Cooper
was incapable of telling why he could
not extract the stone, even “while he
had his finger in the bladder.” This is
false: neither Mr. Cooper nor Mr.
Callaway were able to reach the bladder
with the finger at all, owing to the
depth of the perineum.

Mr. Wakley told the jury that the
plaintiff did not like the bladder to be
exposed, “because to surgeons there is
indisputable proof that Bransby Cooper
did not perform that operation as he
ought,” and that “Mr. Key and Mr. Callaway
knew it.” This is false: Mr. Key,
Mr. Callaway, and Dr. Hodgkin, who
had examined the parts, all deposed that
there was nothing in them indicative of
the operation having been improperly
performed. Indeed, had it been as
Wakley asserted, the plaintiff would
not have been so foolish as to have had
the parts preserved at all.

Sophistical in argument.—One of the
pieces of sophistry on which Wakley
seems chiefly to have depended, inasmuch
as he went over it six times in the
course of his speech, was, that if his
account of the operation had been incorrect
more of those who were present
would have been brought forward
to prove it so. But, as we stated in
our last Number, to have objected to
Wakley bringing forward pupils, on the
ground of their being incompetent, and
then to have done the same thing, would
have been grossly inconsistent. Lord
Tenterden, in his charge, said, “he did
not see whom he (Mr. Cooper) could,
with propriety, have called besides Mr.
Callaway; the others were all young
men, only pupils, and probably too
young and inexperienced to form any
judgment on the case that could be relied
on.” There is also another person
who has objected to these witnesses
whom we may mention—not, indeed,
one for whose authority we have the
highest possible respect, but of whom
the defendant in this case probably
thinks more favourably—we mean Mr.
Thomas Wakley, who, speaking of the
Letter formerly published by Mr.
Cooper’s pupils on the subject of this
operation, says, “their united opinion of
the skill, dexterity, and self-possession
exhibited by Mr. Bransby Cooper on
this occasion, is not likely to influence
the judgment of the profession, whatever
it may effect with the public.”

The use made by Wakley of Sir Astley
Cooper’s expression, “give him
time,” is another specimen of sophistry.
Sir Astley evidently meant merely to
say that, ceteris paribus, a man who had
been twenty years surgeon to an Hospital
would be more experienced than
one who had held the situation but one-fourth
of that period. This we believe
to have been his sentiment, though nothing
was ever less happily expressed.
Accordingly it was not lost upon the
defendant, who exclaimed, “Is that the
way in which our hospitals are to be conducted?
Is that the mode in which your
poor patients are to be treated?—that
young and inexperienced men are to be
placed there to learn their profession—not
to know it before they get there, but
are to go there to learn it—and learn it
upon whom?—upon individuals who
are as much entitled to the best and
most scientific practice of surgery as
any nobleman in this land.” All very
fine—but we should be glad to know
how or where a practical acquaintance
with surgery is to be acquired but
in public hospitals—and if no man
is to be appointed till after he has
gained experience, where are such
men to come from? Where are ready-made
[132]
surgeons to be found fit to
operate even before Lambert, without
his being able to make a hole in their
reputation?

One of the most knavish attempts in
the whole speech, to take advantage of
the jury, was exhibited in his description
of the operation. How different
from the clear, perspicuous, and candid
narrative of Sir James Scarlett. You
are told, says Wakley, that the stone
was shelved above the pubes and behind
the pubes; but, continued he, (placing
a pelvis in the position in which it is
during the operation,) a stone cannot
be lodged above the pubes, because,
you see, the pubes is above the bladder!
This was, indeed, calculated to
confuse men unaccustomed to the subject,
and who did not probably reflect
that above and below are merely relative
terms, which must change with
every change of position, and that it
was not meant that the stone was between
the pubes and external integuments,
which, in the position for lithotomy,
would be the literal meaning of
above the pubes, but that it was in such
a situation as, in the ordinary position
of the body, was above the pubes.
But Wakley assured the jury that it was
impossible for any stone to be above
the pubes, for there was a tendon to
prevent it which no force could overcome;
and he affected to ridicule the
idea of there being anything unusual,
any extraordinary shelf behind the
pubes, in which the stone could have
been lodged. “Had there been
a shelf here,” said he,—”had
there been a crooked passage—had
there been a cavity, or any place for
the deposition of the stone, do you
suppose that shelf would not have been
produced? Had there been any thing
particular in the formation of the
pubes, would they not have cut out
the man’s bone as well as the bladder?”
It is probably impossible for any but
medical men to appreciate fully the impudent
imposition—the fraud of this
statement,—this knavish artifice to mislead
the jury. No attempt was made
in any part of Mr. Cooper’s case to
show that there was such malformation,
or that the stone was in the position
which Mr. Wakley demonstrated
it could not occupy—thus answering
an argument which had never been advanced.

The following is a good specimen of
sophistry and stupidity. Finding it
proved that there was no opening between
the bladder and rectum, Wakley
wanted to make out that he never had
said otherwise, having stated the cellular
membrane to be lacerable, and therefore
not lacerated. And then, forgetting
the nature of his argument, immediately
added, “remember this; the
gorget is not as wide as the finger, and
that it is not an uncommon thing for
an unskilful operator to drive the gorget
in between the bladder and rectum.”
Thus insinuating what had been
proved to be false, and what he had
just argued, from the words of the libel,
he could not have meant.

Coarse in language.—This scarcely
requires illustration. But as specimens,
on the present occasion, of vulgar slang
and miserable attempts at wit, we may
mention his talking of “hole and corner”
proceedings,—his comparing Sir
James Scarlett to sour milk, and which
happy thought he has, in hand-bills pasted
about the town, converted into
“Knight and Professor of Sour Milk,”—his
explanation of the term bat as applied
to surgeons, “because they live in
the dark, they suckle their young, and
live in creaks and crevices of old walls,
hospitals, and dungeons, thriving and fattening
on their own species,”—his address
to the “gang” of hospital surgeons,
whom he represented as wading “through
blood up to the neck,”—and lastly, his
exclamations, several times repeated,
[133]
perhaps with prophetic phrenzy, that he
“would die in a dungeon and expire in
a ditch.”

Diabolical in tendency.—The general
tendency of Wakley’s writings, and especially
of his address to the Jury on this
occasion, so far as such ravings can
have any influence, is to sow distrust
between men in every class of society
and their medical attendants; to poison
the sources of public charity, and arrest
the hand of benevolence; to contract
the relief afforded to human suffering,
leading the poor and uninformed to
suppose themselves the objects of cruel
and wanton experiment, thus encouraging
them rather to suffer disease
to run its course than seek relief in such
abodes of blood and horror as he most
falsely represents our public hospitals
to be.

One of the first ebullitions of this demoniacal
effort consisted in representing
to the Jury, which he did in two different
parts of his address, that the patient had
been kept bound during the operation,
as if some unusual degree of coercion
had been employed. “Yet, in opposition
to the patient’s cries—in opposition
to his repeated entreaties to be
unbound, still the operator kept him
upon the table.”—”Gentlemen,” continued
he, “I should like to know
upon what principle it was that the
man was kept bound upon the table
when he implored to be loosened. Was
he not a free agent?” And then he
goes on to put into Mr. Cooper’s mouth
not only words, but a sentiment he never
uttered.—”No, no, (says the operator,)
my reputation is concerned. You were
brought here to have the stone extracted,
and extracted it shall and must be—if
you were to die upon the table.” Unless
Wakley was intoxicated we cannot in
any other manner account for an argument
at once so absurd, so unprofessional,
and so malignant. It evidently
excited no feeling but that of disgust in
the minds either of the Judge or the Jury.

The next paragraph to which we
shall allude is a masterpiece of hypocrisy—”Let
me ask you (said he) what
you have heard respecting the miseries
of the individual on whom the operation
was performed? Not one word
has escaped the lips of the counsel on
that subject—not one word from the
mouth of one of the witnesses. No,
gentlemen, they are hospital surgeons
themselves, and they know too well
what the practices of our hospitals are,
and the sufferings patients are in the
habit of enduring at their hands, to
feel for this man, or for any other man
placed in a similar situation!” Canting
hypocrite! this from the man who
in the very case before us published his
account of the patient’s sufferings in the
form of a drama, mingled with low and
scurrilous gibes. Mark also the following—”Give
such a verdict as shall
satisfy the poor—as will shew that men
are not to go into offices of this sort
where the poor are to be killed, and
that they shall not be at liberty to wade
and ride through blood up to their
necks to eminence in their profession.
Ah! gentlemen, give such a verdict as
shall satisfy the poor!”

There is in the various paragraphs
we have quoted, more deep-rooted
malice—more abandoned violation of
the truth—more hypocrisy—and more
open outrage of common sense, decency,
and feeling, than we ever remember
to have met with, even in the
pages of the Lancet. It is now quite
obvious that Wakley, alarmed at the
change which has taken place in the
estimation of his work within the last
few months, finds it necessary to adopt
a new system; he therefore throws off
the mask, and openly declares himself
the champion of the ignorant and
illiterate[22]—conjuring up to their imaginations
evils which do not exist—denouncing
[134]
the medical profession as
one of blood and murder—medical
men as “thriving and fattening on
their fellow-creatures”—and calling
upon the “humane contributors to our
hospitals and infirmaries” to support
him.

Why really now, if the times of political
turbulence were to return, and
radical reform again to come into vogue,
Cobbett and Hunt would have a most
valuable coadjutor; but as it is, we almost
think the sphere he has chosen is
too limited for such a genius. Humbug,
to be successful, ought not to be
very open to detection; alleged abuses
ought not to be of a kind which every
man can satisfy himself are entirely
without foundation; and he who professes
disinterested motives ought not
to begin by raising a subscription for
himself. We offer these few hints to
Wakley, in hopes they may be of use to
him in his new career; above all, we
advise him to be sparing in protestations:
there are some already who look
upon his sincerity with a suspicious
eye; for although it is no doubt true,
that he would “rather die in a dungeon,
and expire in a ditch,” than injure
any man, yet somehow an idea has got
abroad, that his constant habits of lying
and slandering are not quite in keeping
with these assertions. Nay, we have
heard of some even of the “humane
contributors” to our charitable institutions,
who have been so unreasonable
as to disbelieve all Wakley’s stories
about the cannibalism of hospital surgeons,
and to look upon the whole system
of the Lancet as one of knavery
and imposition.

WAKLEY’S SUBSCRIPTION MEETING.

A most amusing scene took place at the
Freemasons’ Tavern on Tuesday evening,
of which we subjoin an account. The
object of the meeting was, “to present
Mr. Wakley with some decided mark of
their approval of his spirited conduct in
his late trial;” or, in other words, if
possible, to raise a little money, and bolster
up the Lancet a little longer. The
persons present were small in number,
but great in zeal; and as much noise, hissing,
laughter, and shouting, took place
as would have done credit to a much
larger assembly. As this is a merry
season, and it may amuse our readers,
we subjoin the speeches of the principal
orators on either side: it will be perceived
that both the Gazette and Lancet
had some handsome compliments paid
them; and that Wakley got thoroughly
abused even by some of those who went to
the meeting as the champions of reform.
There was not a single individual present
of any weight in the profession,
and the chair was occupied by a young
man wholly unknown, except as secretary
to the meetings held two years ago
on the subject of surgical reform.
Could no one whose name might sound
familiar in the public ear be prevailed
upon to go?—could none be found but
Pateys, Wallers, Mills, Elliots, Childs,
and the Lord knows who? Where was
he, the idol of the Lancet, who on
other occasions graced the chair—where
he who first ycleped that Journal the
“invaluable”? Alas! poor Wakley,
what an exposure of a sinking cause!
even thy former friends tremble for
their reputations, and desert thee.

SURGICAL REFORM.

[138]

HOSPITAL REPORTS.

GLASGOW ROYAL INFIRMARY.

Injuries of the Head.

D. M’Millan, æt. 40, seaman;—while
he was employed in the hold of a vessel,
a heavy iron block, of a round form, fell
from the rigging, a height of 20
feet, and struck him on the head.
He was knocked down and stunned,
but was able to rise and to walk with
a little support. He was brought about
a mile and a half in a hackney-coach to
the hospital, and admitted by Mr.
Cowan at one o’clock P.M., half an hour
after the accident. At this time he had
a stupified look, but was quite collected,
and was able to walk across the
ward; breathing and pupils both natural;
pulse 75, of moderate strength.
There was a wound in the scalp, commencing
nearly over the centre of the
sagittal suture, and running about
three inches backwards and towards the
left; along this a portion of skull, corresponding
to the wound in size, was
felt fractured, detached, and irregularly
depressed. His right arm was benumbed
and nearly powerless, but no
mark of injury was observed on it.

It was determined to remove the detached
piece of bone, and the original
wound being extended lengthwise in
both directions, an incision was made
through the scalp at right angles to it
over the left parietal bone, thus bringing
the fractured portion into view. This
was found to be broken down into several
fragments, some of which were
firmly impacted under the surrounding
cranium, and one spiculum, driven
through the dura mater, had penetrated
the brain. The trephine was applied a
little to the left of the fracture, and
the intermediate part removed with
Hey’s saw; the detached pieces of
bone, ten in number, of various sizes
and irregular shapes, were removed
with the forceps, the scalp replaced
and retained in position by a stripe of
adhesive plaister and very light dressings.
During the operation one artery
required ligature, and about
℥v.v.
of blood were lost: he had lost perhaps as
much before. He remained quite sensible,
bore it well, and shortly afterwards
had half a glass of port wine in
warm water.

Ten P.M.—Has been tolerably easy;
complains of pain of fore-part of head;
pulse 82, firm.

Fiat V. S. ad
℥xviii.xviii.

Sumat statim Submur. Hydr. gr. viii.
Pulv. Antimon. gr. vi.

Applic. Capiti Lotio ex Alcohol. et aq.
calcis.

Second day.—After bleeding, thought
feeling of numbness of right arm somewhat
lessened, and to-day has rather
more power of it. Passed a tolerable
night; a little head-ache; countenance
pretty natural; tongue slightly loaded;
thirst; no stool.

Sum. stat. Sulph. Magnesiæ
℥j.j.
et rep. vesp. si opus.

Third day.—From an aversion to use
the bed pan, he rose to stool last night,
and fell forwards on the floor, seemingly
from having entangled himself in
the bed clothes; he got into bed without
assistance; had a shivering fit
shortly after, but has had a pretty good
night; bowels freely opened; head-ache
slight; pulse 84, soft; tongue
dry in middle. Towards the evening of
this day he appeared drowsy; and on
the fourth day he is reported as seeming
confused and uneasy; countenance
anxious; articulation difficult; the
right arm was more paralysed, and indeed
the whole right side seemed now
to partake in the paralysis; a small
part of the wound had adhered, the remaining
part was flabby, discharging
thin serum. In the evening the difficulty
of articulation and drowsiness
had increased. Twelve leeches were
applied to each temple, and in a short
time he seemed a little livelier.

Fifth day.—Much in the same state;
took a little beef tea.

Sixth day.—Paralytic symptoms increased;
breathing laborious. Blister
to the neck. It may be worthy of remark,
that in the few words he now
spoke he never made use of the English
language, but of the Gaelic, which was
his native tongue; and even when told
that he was not understood, he persisted
in repeating the Gaelic phrase.

Seventh day.—A small fungus was
observed in upper part of wound, to
which lint dipped in lime water was
applied, and moderate pressure. The
fungus continued to increase.

On the eleventh and twelfth days he
had slight bleedings from the scalp,
[139]
which stopped spontaneously. Stupor,
&c. greatly increased, but he still recognised
his friends; took a very little
chicken soup or beef tea daily, with
lemonade, &c. for drink.

On the evening of the thirteenth day
bleeding to the extent of
℥iv.iv.
or v. took place from fungus: it was checked by
application of saturated solution of
alum, but he sunk rapidly, and died
that night.

Inspection 36 hours after death.—The
fungus protruded considerably beyond
the scalp, and was rather larger
than a hen’s egg, of a dirty brown
colour, and a soft spongy consistence;
it completely filled up the opening
made in the skull by the trephine and
removal of detached bone. The pericranium
to the inferior side of this
opening was found detached from the
bone, to the extent of a crown piece,
and beneath it the bone was rough, and
covered with thin purulent matter.
The dura mater, for two inches around
the fungus, was covered with pus; this
membrane, by sloughing, had allowed
the fungus to protrude, and its edges
adjacent to the aperture were thickened.
On removing the dura mater, the
fungus was observed to arise, partly
from the middle, but chiefly from the
posterior lobe of the left cerebral hemisphere:
it occupied a space about
three inches in length, and an inch and
a half in breadth, extending to within
a line or two of the roof of the ventricle;
at its anterior part was an abscess,
containing
℥ss.ss.
of pus. The fungus
seemed to be a degeneration of the
cerebral substance; sections of it showed
the cerebral matter first dotted with
an unusual number of bloody points,
then assuming a greyish colour, which
gradually passed into a dirty brown.
With the exception of these bloody
points, the brain presented no unusual
vascularity: it was quite firm, except
in the immediate neighbourhood of the
fungus, where it gradually became
softer as the colour of the cerebral substance
became deeper, till in the centre
of the fungus it was nearly of a broken
down consistence. A quantity of serum
was found in each ventricle.

Another man who had been struck by
the piece of iron which fractured M’Millan’s
skull was brought up to the hospital
at the same time. He had received the
blow on the vertex of his head. On admission
he was in a state of fury, requiring
the efforts of several men to hold him.
His head was bruised out of all shape,
quite depressed behind, and a fracture
also of the frontal bone; there were
evident symptoms too of fracture of the
base of the skull. The case was hopeless.
Several large depressed and detached
pieces of bone were removed,
but he died a few minutes after the
operation.

During the same week an old woman
was brought up to the infirmary, who,
the day previously, had fallen headlong
down a stone staircase. She laboured
under the severest symptoms of concussion,
and besides had a comminuted
fracture of the humerus into the elbow
joint, and of the radius into the wrist
joint of left arm. She was past all treatment,
and died on the second day. The
case is mentioned chiefly to remark,
that although no external injury of the
head could be observed, on inspection a
fracture was found extending completely
across the anterior part of base of
cranium.

There are no dispensaries in Glasgow,
but such of the poor as are unable to
obtain admission into the Royal Infirmary,
and those who are not so ill as to
submit to the confinement of an hospital,
or for other reasons prefer remaining
in their own houses, are prescribed
for, and, if necessary, visited at the
public expense. For this purpose the
city is divided into districts, and a surgeon
appointed to each. The “district
shop” thus resembles a dispensary,
where the surgeon prescribes in the presence
of his pupils, who indeed, under
his superintendance, have the management
of many of the cases, both among
the patients who receive advice at the
“shop,” and those who are visited at
home. Although under the care of a
surgeon, the diseases treated are both
medical and surgical, for there is little
distinction made between the two
branches of the profession here.

The following case occurred under
the care of Mr. Stirling:—

W. M. æt. 28, while returning home
during the night in a state of intoxication,
fell from a height of ten feet, into
a court paved with stone. He was rendered
insensible for some time, but on recovering
was able to crawl to the nearest
door, and was conveyed home. Medical
assistance was immediately procured.
[140]
On the forehead, about an inch above
the nasal process of the frontal bone, was
a cut an inch and a half in length, extending
obliquely downwards from the
right side; through this a triangular
fracture was felt, the base of which was
in the direction of the external wound,
and the apex pointing downwards; the
fractured portion of the bone was slightly
depressed; the bones of the nose were
also fractured, and there was great discharge
of blood from the nostrils. One
third, or nearly, of the upper lip was
cut off, and a good deal of blood had
been lost from the labial artery; the
lower jaw at the symphysis was fractured
and comminuted, and several
pieces were perceived to be loose. Was
quite sensible, remembering every thing
up to the period of the accident. Pulse
80; has vomited frequently. Wound of
forehead was dressed with adhesive
plaister; the loose pieces of bone were
removed from the lower jaw, and it was
afterwards retained in juxta-position by
a chin bandage.

Early next morning he was bled to
℥xii.xii.
and had a purge of jalap and calomel,
by which his bowels were freely
opened. That night he felt considerable
pain of head; pulse 90, full, and
strong. He was bled again to
℥xxv.xxv.
Blood first drawn had the buffy coat.
After the bleeding the pain of head
diminished, and he continued to do
well. When the swelling and tenderness
of face had subsided, it was observed
that the fracture communicated
with the frontal sinus. On holding his
nose and attempting to blow it, matter
and air escaped by the fracture. The
man was anxious for a speedy cure, and
for this purpose an operation to remove
the depressed piece of bone was at one
time thought of; there was no constitutional
disturbance, however, and the
case was left to nature. The discharge
gradually diminished, and the wound
healed up in about a month. The bones
of the nose retained their position, and
the broken ends of the jaw, after the
swelling had subsided, were kept in
their proper situation by a pasteboard
splint till re-union took place. The lip
also healed easily, and no deformity is
now observable.

GUY’S HOSPITAL.

Inflammation of Hernial Sac.

The previous report of this case (Gazette,
No. 51) conducted it to Nov.
18th, the tenth day from the operation,
and the third on which fæces had been
discharged from the wound; that discharge
continued on the 19th, but on
the 20th pus only was seen.

Nov. 22.—Yesterday the dresser, Mr.
King, observed a portion of solid fæces
make its escape, and to-day a similar
discharge, in the fluid form, is manifest.

Nov. 26.—Since the 22d, nothing
but healthy pus has been seen; the
wound is rapidly healing, and the patient’s
general condition as good as can
be desired.

Dec. 4.—He has begun to wear a
truss, and is to-day allowed to leave
his bed.

Dec. 8.—As regards his original complaint,
the man is perfectly convalescent,
but he now discloses a small abscess in
the scrotum, which has been gradually
forming, and will detain him in the
house some time longer.

If it be a sound surgical maxim that,
in strangulated hernia, the patient’s
safety depends upon an early operation,
it is also a maxim no less sound, that
where the evidence and symptoms of
strangulation are imperfect, or dubious,
the benefit of the doubt should be
given to the operation, and it should
be performed: for it is better that buboes
should be laid open, or inflamed
sacs cut into, twenty, aye, fifty times
in succession, than that in one case a
man should be suffered to die with
strangulation of the intestine unrelieved.

These remarks apply strikingly to
this case of Mr. Key’s, in which, although
no hernia was found, they perfectly
justify the operation. No case of
strangulation could be more distinctly
marked, or more clearly call for the
knife, than did this; and had Mr. Key
refused to use it, he would have deserved
the scoff which, by a contemporary,
has so preposterously been
thrown on the “no hernia case.” But,
more than this, the operation was not
only justifiable, but beyond a doubt
beneficial—beneficial inasmuch as it at
once relieved the distress of the patient,
secured him from more extensive suppuration,
from farther sloughing of intestine,
and probably from extravasation
of fæces into the abdomen; rendering
also the process of reparation
more easy and rapid.

[141]

Hereditary Hare-Lip.

Dec. 4th, Mr. Key performed the
operation for hare-lip on a child a few
months old, whose case was remarkable
only as it afforded an instance of hereditary
malformation. The father of
the child had congenital hare-lip, for
which no operation had been performed,
and of his six children two were born
with the same malformation.

Queries.—1. If the father’s lip had,
in his infancy, been restored to the natural
form, would the malformation
in that case have descended to his children?

2. Is the casualty in these cases to
be traced directly from the father to the
incipient embryo, or indirectly, through
the medium of the mother’s imagination—It
has been said that paternal resemblances
are produced in the latter
mode.

G.

PARIS HOSPITALS.

Hôtel Dieu.

Cases of Gangrene of the Lungs.

Some interesting cases of gangrenous
suppuration of the lungs were published
by Dr. Chambers, about eighteen
months ago, in which he particularly
pointed out the horrible fœtor
of the breath as a diagnostic mark
of the disease. The following cases
which recently occurred at the Hôtel
Dieu are good illustrations of more
extensive destruction of the lung by a
similar disease.

Case I.—A man, aged 32, of good
constitution, laboured under bronchitis
for some weeks, to which he paid little
attention, when he was suddenly seized
with pain in left side, dyspnœa, considerable
cough, and a rigor, followed
by fever. He was admitted into the
Hôtel Dieu next day. Crepitation was
perceptible over the whole extent of the
left lung, posteriorly, and reaching to
the site of the pain in the side, which
was increased by percussion; great oppression,
with frequent cough, and expectoration
of violet-red colour, mixed
with mucus; pulse frequent and small;
constant chilliness; cheeks flushed.

Next day the symptoms remained unabated,
and fœtor of the breath was
observed. Two days after it is stated
that the expectoration maintained the
same appearance, but was now fœtid;
the breath was, however, still more
offensive, and during the fits of coughing
particularly so. In the evening the
breath is said to have become gangrenous.

21.—The cough was small, difficult,
and painful, producing an expectoration
of violet-coloured matter, approaching
to chocolate, with a characteristic
odour.

22 to 25.—Expectoration and breath
emit an intolerable stench. On the latter
day the patient died.

Examination.—The body not emaciated.
Strong adhesions of the left
lung to pleura costalis. At its posterior
part a large gangrenous layer, occupying
the two superior thirds of the
lung, covered at some points by a false
membrane. The lower third, and the
parts round the gangrenous portion, in
different degrees of inflammation, and
hepatised; the putrid mass was in great
part black or violet-coloured, containing
fragments of the pulmonary texture;
the smell gangrenous, but less
so than that of the breath during life;
pus might be squeezed from the adjacent
part of the lung.

Case II.—A man, aged 55, enjoyed
good health till the beginning of May,
at which time he experienced pain in
the left side of the thorax after exposure
to cold. During the next few
days the cough was frequent, and the
expectoration tinged with blood. A
rigor now came on, followed by a distinct
exacerbation of fever, and he
came to the Hôtel Dieu. At this time
he presented symptoms of inflammation
of the lungs, and was bled with
relief; he left the hospital in twelve
days, being sufficiently well to resume
his occupation. Scarcely had he done
this, however, when he had a relapse,
accompanied by great lassitude, oppression
of breathing, and frequent cough.
At the end of a week he returned. He
was now at the twenty-first day of the
attack. His skin was yellowish; face
pale or of leaden hue, and greatly altered;
his cough frequent, with abundant
expectoration of matter like chocolate,
with small specks resembling
pus, and little bodies about the size of
peas, which appeared to be portions of
the lung. This putrid mass exhaled a
gangrenous odour, and the expired air
was impregnated in a high degree with
an equally disgusting smell, which surrounded
the patient’s bed with a contaminated
[142]
atmosphere. Percussion gave
a clear sound over the whole extent of
the chest; auscultation did not discover
the pulmonary expansion on the right
side. The pulse was weak, but not
frequent; the patient was in a state of
extreme prostration. Next day the
odour of the breath and expectoration
was, if possible, more dreadful. He lingered
two days longer, during which time
the fœtid smell somewhat diminished,
and the proportion of pus in the expectoration
increased.

Examination.—The left lung had
contracted firm adhesions, particularly
above and behind. It was torn in attempting
to remove it, and there issued
from the middle and posterior part a
large quantity of dark-coloured matter,
similar to what had been expectorated.
An incision was made along the back
part of the lung, and laid open a large
cavity, occupying all the extent of the
pulmonary organ, and still in part filled
with the same kind of dark putrid matter.
On washing out the cavity it was
perceived that it was lined with a
smooth and white membrane, to which
were still adherent, at some points, dark
filamentous shreds; these were removed
by the least touch, and left the surface
smooth beneath. The boundary was
formed by a false membrane, about a
line in thickness, which separated the
mortified from the sound parts. The
lung was reduced to a kind of bag, the
parietes of which were on an average
about an inch thick. In the upper part
of the lung, which was hepatized, an
incision discovered a number of smaller
tubercles, which in the centre were in
a crude state; and at one point several
had suppurated, forming a cavity large
enough to contain a nut.

[The Editors of the Journal Hebdomadaire,
from which these cases are abridged,
add, in a note, that although the fœtor
of the expectoration, such as above
described, is usually dependent on gangrene
of the lungs, yet that this is not
invariably the case. In confirmation of
this assertion they refer to three instances
of fœtid expectoration—in the
first, the patient is still alive; in the
second, there was chronic bronchitis,
with considerable dilatation of numerous
bronchi; and in the third, bronchitis
with some appearances of chronic
pneumonia. Laënnec gives a case of
dilatation of the bronchi, with remarkably
fœtid expectoration. The argument
derived from the first patient
having survived we consider to be altogether
erroneous, as patients more
frequently recover from this than other
forms of purulent expectoration.—Ed.]

PROCEEDINGS OF SOCIETIES.

WESTMINSTER MEDICAL SOCIETY.

December 6th, 1828.

James Arnott, Esq. in the Chair.

Pursuant to announcement, Mr. MacKelcan
introduced the subject of concussion of the
brain. After remarking on the several
symptoms, and mentioning the other affections
of the head with which concussion is
apt to be confounded, Mr. M. directed the
attention of the society more particularly to
the treatment in the stage of collapse, adopted
by Professor Andrini of Florence.

Dr. Duffin stated, that having been in
Florence, he had witnessed the employment
of three, four, or six ounce bleedings employed
by the Professor in the stage above-mentioned.
The principle on which they
were used was that of their acting as a
stimulus to the brain; and really the plan
was not apparently attended with any bad
effects. When re-action has ensued, the
practice of M. Andrini is the same as that
resorted to in this country.

The discussion then wavered between
apoplexy and concussion, and ended by some
good-humoured sparring between Dr. Addison
and Mr. Gilbert Burnett, on the capability
of the brain containing more blood at
one time than another.

The President announced from the chair
that a special meeting would take place on
Friday evening, December 12, at 7 P.M.

December 20th, 1828.

Cæsar Hawkins, Esq. in the Chair.

After some business had been dispatched,
to which we shall allude in another place,
Mr. Jewel related the particulars of a case of
“supposed extra-uterine fœtation.” The
case, which is one of much interest, is as
follows:—

Mrs. F. a robust, healthy woman, ætatis
27, had been married one year, and aborted
once; when, in the month of September
1827, she quitted her husband in London,
and accepted a situation in the country.
After the expiration of a few weeks she
received permission to come to London for
a day; and, naturally enough, passed that
night, (November 8th), with her husband,
returning again to the country next morning.
Soon afterwards, the morning-sickness,
heart-burn, and other sympathetic affections
[143]
of pregnancy, appeared; but the catamenia
still returned at the regular periods, though
scanty and paler in colour than natural.
She now quitted her situation, returned to
her husband, and engaged a midwife to attend
her in her expected confinement. The
circumstance of quickening occurred in the
latter part of February, and was accompanied
by a severe paroxysm of fainting, whilst the
abdomen gradually enlarged, and the motions
of the child (as was imagined) could
not only be easily detected with the hand,
but were visible to the eye. On the 9th of
August, making a period of 274 days, she
was seized with the usual premonitory symptoms
of labour; the midwife arrived; found
her walking her chamber, and concluded that
the process had considerably advanced.
Three distinct uterine contractions took
place subsequent to the midwife’s arrival,
the last of which was so severe as to compel
the patient to grasp firmly the back of a
chair, and induce, after its subsidence, excessive
faintness. From this time no further
parturient effort was made; no examination
per vaginam was instituted; neither was
there noticed any sanguineous vaginal discharge.
When Mr. Jewel saw her, examination
detected nothing unusual in the os
uteri, and the symptoms she presents are
these. The abdomen is about the size of a
woman’s in the sixth or seventh month of
pregnancy, the enlargement being general.
Her general health is much disturbed: she
complains of pain in the left hypogastric
region, particularly when the abdomen is
compressed by the hand or stays—and she
also complains of weight in the abdomen,
especially on leaning forwards. The woman
herself has a strong prepossession that
“something is to come away,” or that she
might be relieved by an operation. The
woman believes that she still feels the motions
of the child, though feebly.

Having read this case, Mr. Jewel concluded
by offering some observations on the
subject of extra-uterine fœtation. He considered
this as probably an instance of “graviditus
abdominalis,” and remarked that the
uterus not having expelled its dezidua, was
no conclusive proof to the contrary, Dr.
Blundell and Mr. Langstaff having examined
cases where this was wanting.

Dr. Locock never saw a case where laceration
occurred in the early months of pregnancy.
Dr. L. remembered the particulars
of a case where the uterus was lacerated in
the fourth month, and the ovum escaped into
the cavity of the abdomen, and the symptoms
of pregnancy were exceedingly strong.
Dr. Locock almost doubted whether Mr.
Jewel’s was an instance of pregnancy at all,
for frequently women enjoying sexual intercourse
have enlarged abdomens, and many
of the other symptoms of pregnancy, which
a few doses of purgative medicine will
remove.

Two remarkable instances of extra-uterine
fœtation were related by Mr. Burnett and
Mr. Cæsar Hawkins; and towards the conclusion
of the evening the discussion turned
on the powers of the ergot of rye. Dr.
Locock had frequently tried it in amenorrhœa,
and, on the whole, without any very good
effects. In one remarkable case, where the
lady particularly wished to have children,
Dr. Locock having boiled an ounce of the
ergot in a pint of water down to half a pint,
gave an ounce and a half of this decoction
three times a day. After the young lady
had taken about half a pint, the most violent
convulsions succeeded, which placed her life
in imminent hazard, and from which it was
long before she completely recovered. She
menstruated twice after that, but then the
discharge again was arrested, and has never
since returned, nor has she become pregnant.

The practice of “bougieing the uterus”
in cases of dysmenorrhœa was brought upon
the tapis, and excited a good deal of laughter,
the members appearing to consider the
proposal ridiculous in the extreme.

MR. LAMBERT.

At the last meeting of this Society it
was proposed, on the recommendation of the
Committee, that Mr. James Lambert should
be expelled; and after some discussion it
was agreed that the sense of the members
should be taken by ballot at the next
meeting, Saturday, January 3, 1829. It
was thought that proceeding at once to his
expulsion might give the appearance of the
measure originating with a party, and that
the delay would enable the deliberate judgment
of the whole Society to be passed upon
his conduct.

HUNTERIAN SOCIETY.

Dec. 10, 1828.

Dr. Billing, President, in the Chair.

Mr. Leese, Jun. exhibited to the meeting a
specimen of medullary sarcoma, taken from
the forehead of a man after death, with a
portion of the os frontis. The man was
fifty-eight years of age, long asthmatic, and
appeared to die of hydrothorax. He never
suffered any pain in the tumor, but expressed
a sense of distention. It was immoveable
at the base, and there were some fissures in
the os frontis, from caries. The dura mater
at the corresponding part adhered firmly to
cranium, and on its being removed some
spiculæ from the carius inner table remained
adhered to it. There had never
been any symptoms of cerebral affection.
A tumor of the same nature had formed on
the scapular extremity of the clavicle, and
had occasioned anasarca of the limb.

Mr. Key supposed that the tumor had
originated from the diplöe, and believed
that the only chance of relief in such a case
would be trephining; but he acknowledged
[144]
that there was little encouragement to operate
in these cases, owing to the tendency
of the disease to return in some other part.
He related an instance of the true medullary
fungus taking its origin from the cancellous
structure of the os femoris. The limb was
removed, but the patient died. A circle of
fungoid glands was observed at the base of
the heart, and some of the bronchial glands
were in the same condition.

Dr. Conquest expressed his belief that
carcinoma was always a constitutional affection,
and stated that at least in nine cases
of cancer uteri out of ten, there was carcinomatous
affection of the pylorus, mesenteric
glands, or liver.

Mr. Key and Dr. F. Ramsbotham had
not observed, in their examinations, the
coincidence noticed by Dr. Conquest.

The remainder of the evening was occupied
by a discussion on the different kinds
of ulceration that occur about the os and
cervix uteri, and the circumstances under
which the removal of the uterus, or the amputation
of the cervix, may be warrantable.

Dr. Babington adverted to the occasional
existence of a family disposition to carcinoma.
He had known three sisters successively
die of cancer in the breast.

MEDICAL SOCIETY OF LONDON.

Dec. 13th and 20th, 1828.

Dr. Haslam in the Chair.

The subject of discussion, at the first of
these meetings, was stricture of the rectum,
when the diagnosis and treatment of carcinoma
of that part came under consideration.
There was a remarkable discrepancy in the
opinions of Messrs. Lloyd and Salmon as to
the symptoms and management of carcinomatous
affections of the rectum. Mr. Lloyd
maintained that these affections of the intestine
were sometimes attended with pain
and sometimes not, and that the patients
were often materially benefited by the use
of bougies; while Mr. Salmon affirmed,
that the disease was always painful, and not
to be mitigated by the employment of these
means.

A variety of subjects came before the
society at the next meeting. The president
read a letter from Mr. Wansborough, of
Fulham, describing the “original stomach-pump,”
a specimen of which accompanied
the letter: the instrument Mr. W. stated to
be of 25 years’ standing.

Mr. Shearly exhibited, among other morbid
specimens, a uterus, on the external
surface of which the disease termed the
“white tubercle” was in progress: there
was also a small polypus near the os uteri.
Mr. Pereira exhibited to the society a fine
specimen of medullary sarcoma of the liver.
The organ was so enlarged as to have occupied
two-thirds of the abdomen. The other
viscera were not involved in the disease.
The progress of the disease, as far as it
could be ascertained, was excellently detailed
by Mr. Smith, a visitor. The symptoms
were obscure.

Mr. Armstrong read an extract of a letter
from Mr. Morgan, of the Bristol Infirmary, a
corresponding member of the Society, describing
a curious conformation of the œsophagus
in a child, which lived 106 hours
only, during which period every attempt to
swallow food produced considerable distress.
The œsophagus was found to be divided into
two portions; the upper or pharyngæal extremity
terminating in a cul de sac behind
the bifurcation of the trachea; and the lower
or ventricular extremity arising from the
trachea at this point, between the bronchi,
proceeding down the spine, and terminating,
as usual, at the cardiac orifice of the stomach.
Mr. Drysdale mentioned a somewhat
similar malformation occurring in two
children in one family. Mr. Callaway related
a case of concussion of the brain, which terminated
fatally, after the restoration of the
intellectual functions. The whole of the anterior
lobes of each hemisphere of the brain
was broken down, and mixed with effused
blood. The remarkable feature of the case
was, the return of consciousness, and the
possession of this power for six days, under
the disorganization of the brain described;
and the questions particularly agitated were,
Did this extent of mischief exist immediately
after the concussion? What was the
degree of laceration of the brain at that period?
and, How could the recovery of the
intellectual faculty be reconciled with so
much injury of the brain?

The Society then adjourned to the 12th of
January, 1829.

COOPER v. WAKLEY.

Notes of the Cause, Cooper v. Wakley—We
understand that Mr. Cooper is about to
publish a verbatim account of the above
trial, from Mr. Gurney’s short-hand notes.

ERRATA.

The Advertisement of Mr. B. Cooper’s,
in our last Number, ought to have been
dated “December 15,” instead of “Oct. 15.”
Also, for “Mr. Elton,” the name of one of
Mr. Cooper’s witnesses, read “Mr. Hilton.”

In our last leading article, for “can no
friend of Wakley be named?” read “can
the name of no friend of Wakley be mentioned?”
The alteration is necessary, to connect
it with the conclusion of the paragraph.

W. Wilson, Printer, 57, Skinner-Street, London.