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Title: The London Medical Gazette; December 27, 1828

Author: Various

Release date: November 5, 2016 [eBook #53450]

Language: English

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  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.

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 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. 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, 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, 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 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 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 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 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.

[Illustration]

[Illustration]

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 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.
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 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℥. were removed, which on cooling
presented strong marks of inflammation.

    Ordered ℳiv. 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℥. 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. 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.

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℥. 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.




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.

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.

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 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.




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 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. 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 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 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 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, 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 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.

A meeting was held yesterday evening at the Freemasons' Tavern, in
pursuance of an advertisement calling on the "Friends of Surgical
Reform, the Supporters of a free Medical Press, and the humane
Contributors to our Hospitals and Infirmaries," to meet there,
in order to adopt measures for presenting Mr. Wakley, the Editor
of the Lancet, with some decided mark of their approval of his
spirited conduct, in his late trial in the Court of King's Bench,
at the suit of Mr. Bransby Cooper, and of the principles which he
so powerfully advocated on that occasion.

[Mr. Patey, who was called to the chair, stated the object of the
meeting; but as his speech was rather long, and contained nothing
of the least interest, we omit it.]

_Mr. Waller_, in proposing the first resolution, adverted to the
terms of the advertisement, and remarked that the question for
them was not whether they would support Cooper against Wakley, or
Wakley against Cooper; but whether they would have a free medical
press or not--(cheers). Every body must admit that there was
only one medical publication that was entitled to be considered
free--only one that dared to tell the truth. Another had been
attempted to be set up against it, but this wretched rival was
gagged and manacled, and its reports were only a medium which
distorted truth, and were almost unintelligible. It was not,
however, to support any particular man, or publication, that he
came to that meeting, but to support the general cause in which
they were all interested. He concluded by moving, as the first
resolution, that "the best interests of the medical profession and
of the public are identified with the cause of medical and surgical
reform; and that Mr. Wakley, as Editor of the Lancet, having given
the first impulse to that cause, and having subsequently advocated
it with undeviating firmness and fidelity, is entitled to the
cordial thanks and support of this meeting."

_Mr. Mills_ seconded the resolution.

_Dr. Shiel_ said this was an important meeting, in his opinion;
for, if this resolution were passed, it would identify the medical
profession with the Editor of the Lancet. If the principle
embodied in that resolution went forth to the world, it would be
attended with consequences deeply injurious to the profession.
He knew neither Mr. Bransby Cooper nor Sir Astley, and therefore
he was perfectly impartial. The first question was, how far the
medical press was conducted with advantage to medical science and
the members of the profession. Now he contended, but with great
respect, and disclaiming all personal hostility, that the Lancet
had nowise contributed to the progress of medical science or the
improvement of the profession--(loud hissing, and some cheers).
He trusted that the meeting had not been got up by a few of the
friends of Mr. Wakley, and he was sure that that gentleman was
too respectable and too dignified in his proper person to need
any such attempt--(applause). He trusted that the meeting was
before the British public to ascertain how far the Lancet was
useful or advantageous to medical science; and he hoped that,
however partial the gentlemen present might be to Mr. Wakley, they
would be governed in what they should do by the real interests of
science--(hear, hear). The question was one of great interest; for
it was one that embraced not only the freedom of the press but the
advancement of medical science. With respect to the freedom of the
press, they lived in a country where the law always maintained
that principle. When Mr. Abernethy had applied for an injunction
against the Lancet, Lord Eldon said that there could be no doubt
that the Lancet was a most useful publication--(applause). He did
not know whether that observation had been brought forward at the
late trial; but taking the case--what was it? It appeared that the
operation was one of peculiar difficulty, as stated upon oath by
some of the most experienced surgeons of the day. This operation
was laid hold of by the Lancet, and published not as a medical but
as a tragical performance, in which all persons without science
or knowledge were appealed to, and no opportunity afforded to Mr.
Cooper to vindicate himself. Here, then, was a low and pitiful
attempt made through the medium of malice and calumny (loud hisses
and uproar). Here was a rude and pitiful attempt by malice and
calumny (renewed signs of disapprobation). And yet it was contended
that this had advanced the medical profession. The evidence on the
trial went to shew that the dangers by which the operator had been
surrounded were not small, and that there was no just reason to
accuse him of unskilfulness in what he did; and was it then to be
said, in the face of the British public, that a Meeting had been
held at the Freemasons' Tavern to offer praise and reward to the
individual whose conduct had, by the verdict of the Jury, been
stamped with the accusation of untruth (hear, hear! and hisses)?
He would not deny that there was a degree of talent displayed in
the Lancet; but neither could it be denied that it was a public
depredator by means of reports surreptitiously obtained; and the
title of "literary raven," which had been applied by Sir James
Scarlett, appeared to him to truly depict its character (great
hisses and uproar). Was it to be contended that any one had a right
to come into a private lecture-room, and catch up all he could
hear, and then to publish what he had thus surreptitiously and
fraudulently obtained (immense uproar and hisses)? As far as the
medical interest was concerned, he looked upon the Lancet as one of
the most injurious publications that had ever appeared (hisses).
All the best writers on the subject had dwelt with peculiar
emphasis on the necessity of secrecy among the members of the
profession, but the Lancet broke through this good rule, and made
public whatever came within its notice; and he had no doubt that
if it could get at the cases that occurred in private practice, it
would give them without any scruple (uproar).

The _Chairman_ begged to remind the speaker that at all events Mr.
Wakley had not as yet done so.

_Dr. Shiel._--I am arguing on the principle which appears to
actuate Mr. Wakley.

_Mr. John Elliot_ rose to order. He could not allow Dr. Shiel to be
going upon suppositions; the thing that he supposed had never been
done.

_Dr. Shiel_ was sure that whatever turn might be given to the
subject in England, that at all events the conclusions that the
Meeting appeared to be coming to would be resisted abroad. The
weight of Sir Astley Cooper's name abroad would overpower any
such attempt, and, in fact, would render it contemptible; so that
any attempt to prop up so low, pitiful, and mean an attack, must
inevitably be attended with disgraceful failure (hisses).

A gentleman observed, that he was much surprised at what had fallen
from Dr. Shiel. He had been induced to suppose that the Lancet
possessed talent, as he had heard it praised in so many directions,
and he certainly had never heard till that evening that it was
only to be found in the hands of the illiterate (hear, hear! and
a laugh). He had always understood that it was only destined for
the use of students and other members of the profession, and that
it was likely to be of great use in reforming the abuses of the
medical practice (hear, hear! and cries of "So it will!"). For his
own part, he was glad that medical men were occasionally cut up,
because when they did what was wrong it was proper that they should
be told of it; and when they did what was right, it added a fresh
stimulus to their exertions (applause).

_Mr. Thomas_ observed, that he had not intended to say any thing at
the present meeting; but as Dr. Shiel, in the course of his speech,
had thought proper to make some remarks tending to calumniate Mr.
Wakley's witnesses on the trial, of which he was one, he felt
called upon to say a few words (hear, hear!). Dr. Shiel seemed to
consider them all as the mere scum of the earth--as a miserable
band, collected together to support Mr. Wakley, whatever might
be the consequence; as though he was desirous of going the whole
length of the Medical Gazette, which stigmatised them for what it
called "their deep-laid contrivances--their rankling enmities, and
their bitter revenge." For himself he could say, that it was not
till the evening previous to the trial that he had been supœnaed,
and that he had previous to that time never seen Mr. Wakley.

_Dr. Shiel_ said that he could not have alluded to the gentleman
who was speaking, as he did not even know his name.

_Mr. Thomas_ then went on to observe, that as Dr. Shiel appeared
to be the advocate of the opposite party, he also supposed that he
was a contributor to the aristocratical (Medical) Gazette ("No,
no!" from Dr. Shiel). If he were not, at all events he had put
forward ideas that were quite consonant to the sentiments expressed
in that Journal. In giving his testimony, he had not spoken of the
instruments employed in the operation, but of his own impression
on the subject, having been present thirty-five minutes; and that
impression certainly was, that the operation had been performed in
a bungling and unscientific manner (loud applause, mingled with
hisses). Was he then, because he happened to be a witness on the
occasion, to be put down, pell-mell, by the unfounded imputations
of any one? The highly-principled, honourable-minded Medical
Gazette, that had determined never to admit any personalities, had
loaded Mr. Wakley and Mr. Lambert with all sorts of abuse. Was
this what they intended to call acting on principle (applause,
and cries of "No, no!")? He certainly had heard that Mr. B.
Cooper was an amiable man in private life; but what had that
to do with the question at issue? What had they to do with the
private character of a man in a public office (cheers)? Surely the
witnesses of Mr. Wakley were as competent to speak of the manner
in which the operation was performed as those who had not been
present (applause); and as he had seen many operations performed
he conceived that he was a competent judge of the skill of the
operator (applause).

A gentleman, who appeared to be a student, thought that the
introduction of any attack upon the witnesses, or indeed of
anything that occurred at the trial, was irrelevant (hear,
hear!). The way to answer a speaker was not by hisses, but by
disproving his arguments and rebutting his facts (applause). If
questions were to be settled merely by strength of lungs, he
was afraid that instead of the right side prevailing, success
would uniformly attend those whose physical powers probably much
exceeded their mental (laughter and applause). He could not agree
with the gentleman who had stated that the law of England was
the protector of the freedom of the Press; for it was well known
that the Judges had decided, over and over again, that truth was
a libel (applause). It was only the vehicle that conveyed public
sentiment, and not the force that impelled it forward. He was
convinced that any attempt to connect medical reform with Mr.
Wakley should be studiously avoided and disclaimed. As a friend of
free discussion in every case, and anxious to uphold the principle,
whatever he might think of the instrument, he intended to propose,
as an Amendment, "That the latter part of the Resolution, relating
to Mr. Wakley, should be omitted." This would save the cause of
medical reform from being identified with Mr. Wakley, of whose
impartiality he would give a specimen. In the last number of the
Lancet, the report of the late trial was given from the Times, but
with a remarkable omission. The Lord Chief Justice had rebuked
one of the defendant's witnesses for not answering the questions
in a straightforward manner, and this passage was omitted. If Mr.
Wakley would do this on such an occasion, would he be more candid
when the public eye was less upon him? He, therefore, wished to
have the question of medical reform kept separate from Mr. Wakley
individually. The first part of the Resolution would be carried
without a dissenting voice, as on that principle they were all
agreed, whatever they might think of the conduct of individuals.

[One or two persons then made speeches for or against the
amendment; which was negatived, and the original motion carried.]

_Mr. Hensley_ then, after observing that Mr. Wakley's conduct
was highly praiseworthy, because it tended in every way to the
benefit of humanity, moved the second Resolution, which was to the
following effect:--

"That the purposes for which the Hospitals and Infirmaries of
the Metropolis were founded, and that the views of the humane
contributors to their funds, are materially promoted by the
weekly publication of reports detailing the medical and surgical
treatment of the unfortunate patients; and that Mr. Wakley having
originated the practice of publishing Hospital Reports, has
conferred important benefits on Medical Science, and on the cause
of humanity."

The resolution was then carried unanimously.

_Mr. John Elliott_, on moving the third resolution, said that he
did not come there to interfere in the quarrels of Wakley and
Cooper. They had acknowledged that Mr. Wakley's exertions had been
very conducive to medical reform, by the last resolution they
had passed. Indeed, there could be no doubt that he had greatly
served the cause of humanity, by preventing idleness on the part of
medical persons, and compelling attention to the poor placed under
their care. It was his opinion that the editor of the Lancet ought
to be indemnified for the whole expense entailed on him by the
late trial, including the damages awarded against him. This would
not be a private subscription, like Brodie's, but one open to the
world, and not to be questioned in a court of justice. He would not
support Mr. Wakley if he had attacked private character; but he
would, as the editor of the Lancet and the representative of the
medical free press. He concluded by moving--

"That the independent and impartial principles on which the Lancet
was first established, have been preserved by Mr. Wakley at all
risks; and as it was acknowledged at the late trial, that the
legal expenses of his opponents on another occasion have been
defrayed by certain hospital physicians and surgeons[23], it is
farther resolved, that a subscription be opened for the purpose of
defraying the expenses of the late action."

[Dr. Shiel here spoke very strongly against entering into a
subscription--while some spoke in its favour.]

A discussion then arose about the question of whether an account
of a second operation for lithotomy by Mr. Cooper (in which he had
been successful) had been sent to Mr. Wakley? It was stated that
such was the case, but as the action for the present libel was then
commenced, _Mr. Wakley thought that he perceived something in that
second report that might tend to aggravate the damages, and which,
at the same time, would be farther injurious to Mr. B. Cooper_.

The third resolution was then carried by an immense majority, only
five hands being held up against it.

_Mr. Evans_ moved, "That the statement of professional facts in an
unprofessional form, such as the dramatic instead of the narrative,
is highly reprehensible in the individual, and detrimental to the
best interests of science."

This resolution, after some turbulent discussion, was withdrawn.

_Mr. J. L. Stevens_ then moved, as the fourth resolution, that "In
accordance with the feelings this meeting has expressed, Mr. Wakley
be invited to attend a Public Dinner, and that a Committee be
forthwith nominated to arrange the same."

_Mr. Rogers_ seconded the resolution, and it was carried
unanimously.

The members of the committee were then named, and power given to
them to add to their number.--The chairman then vacated his office,
and the meeting separated.--_Morning Chronicle, Wednesday._


In the course of the evening, the conduct of one of the speakers
gave for a short time an amusing turn to the discussion, which for
a great part had appeared to many extremely dry and tedious. The
gentleman in question, (not a medical man), in order to show the
opinion he had entertained of the object of the meeting, proposed
to read for the audience a letter which he himself had written to
the chairman of the committee, asking permission to attend. He
began, but he had scarcely got through a few words when he declared
he was not able to make out his own writing, and requested the
chairman to assist him. The chairman made the attempt, but was not
more successful. Another gentleman then undertook the task, but
with no better effect. The audience received each unsuccessful
effort with loud laughter, which so much annoyed the writer that he
took back the letter, and again tried to go through with it, but
not being able to make it out, he proposed to read for the meeting
two letters which he wrote on the same subject to the editor of a
Sunday paper. (Loud laughter followed this proposition, which was
increased, when, on an attempt to read one of them, he had no more
success than before.) The gentleman, after complaining of the want
of courtesy in the meeting, resumed his seat, declaring that he
would give the letters to the reporters.--_Times, Wednesday._




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. 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.

    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. 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, 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. 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. 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. 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. 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. 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.


_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 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
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 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.


FOOTNOTES:

[1] General thickening of all the valvular apparatus on both sides
of the heart. (St. B. 33.)

[2] Andral, vol. iii. p. 411.

[3] Pl. 1, fig. 5.

[4] Opacity and thickening of the lining membrane on both sides of
the heart, without unevenness or alteration of form. (St. B. 33).

Opacity and thickening in the valvular apparatus between the left
auricle and ventricle, with shortening of the chordæ tendinæ, and
such alteration of structure and form as to produce a considerable
contraction of the aperture. (St. B. 26).

Such thickening of the whole valvular apparatus as to narrow the
aperture of communication between the left auricle and ventricle to
a mere slit. (St. B. 19).

Shrivelled and contracted state of the semilunar valves, in which a
cartilaginous substance has entirely taken the place of the natural
structure. (Hodgson, pl. 1, fig. 6).

[5] Osteum aortæ almost closed by ossified valves. (St. B. 15);
(Hodgson, pl. 1, fig. 2).

[6] Fungus growing from the aortic valves, which are thickened and
shortened. (St. B. 6, 20).

Fungus form the aortic valves, which are ulcerated. (St. B. 21).

Larger specimens of fungus, growing from the ulcerated edges of two
of the valves of the aorta. (Hodgson, pl. 1, fig. 7).

[7] Dr. Baillie's plate.

[8] Polypous coagulum in the ventricle. (Coll. of Phys. 4, A. 16).

Coagulum firmly attached to the lining of the left auricle, with
enlargement of its capacity. (St. B. 19).

[9] (St. B. 13).

[10] It occurs sometimes in the uterus.

[11] Memoir. de l'Acad. des Sciences. Morand, 1732. Morgagni,
Epist. 27.

[12] Andral, v. 3, 466; Hodgson, plate 1, figure 7; St. B. 14.

[13] Corvisart, cap. 4. sect. 1.

[14] Active dilatation of the left ventricle. (College of Phys. 4,
c. 10.)

The thickened walls of the left strikingly contrasted with the
attenuated walls of the right ventricle. (St. B. 9).

Active dilatation of the left ventricle. Its capacity is strikingly
contrasted with that of the right. (College of Phys. 4, c. 11.)

Passive dilatation of both ventricles, especially of the right.
(St. B. 10).

[15] Morgagni, Epist. xxvii. 7.

[16] Ibid. 2.

[17] Ibid. 3.

Rupture of the left ventricle, with attenuation of its muscular
structure. (St. B. 18).

Rupture, without attenuation, but with softening and looseness of
texture in the muscular substance. (St. B. 22).

[18] Harvey, Exercit. altera.

[19] Rupture of the left ventricle without change in its structure.
Bone deposited at the commencement of the aorta. (St. B. 27).

In turning over the Memoirs of the Royal Academy of Sciences, I
find two cases of rupture of the heart, reported by M. Morand. They
both occurred in the year 1730; and, strange to say, one was that
of a Duchess of Brunswick, who was of the same family as George II.
who also died of a ruptured heart. In the one, that of the Duchess,
there was a manifest ulceration through the walls of the right
ventricle, its structure being otherwise unimpaired; in the other,
where the aperture was in the left ventricle, there was probably
a simple rupture, for the flesh of the heart was so soft that the
point of a probe would pass through it wherever it was rested.
(Mem. de l'Acad. Roy. des Sciences, Ann. 1732).

[20] The trial as published in the Lancet occupied less than 21
pages--in the Gazette it extended, in the same type, to 33 pages
and a half. In the Lancet, those parts, both of the evidence and
speeches, which told most against Wakley, were omitted.

[21] See passage in Italics, page 137.

[22] The defendant, on leaving the court, was cheered by the
populace in Palace Yard.--Lancet, Dec. 20.

[23] This we believe is false; nothing of the kind either occurred,
or was stated at the trial.--E. G.




  TRANSCRIBER'S NOTE

  Obvious typographical errors and punctuation errors have been
  corrected after careful comparison with other occurrences within
  the text and consultation of external sources.

  Except for those changes noted below, all misspellings in the text,
  and inconsistent or archaic usage, have been retained.

  Pg 116, 'immedate contact' replaced by 'immediate contact'.
  Pg 119, 'and attennuation in' replaced by 'and attenuation in'.
  Pg 126, 'Tue valuable paper' replaced by 'The valuable paper'.
  Pg 132, 'probably impossibly' replaced by 'probably impossible'.







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