669

anatomical peculiarity, or you may be ledto draw very false inferences. Here, for

example, we have a sonorous body, justlike a drum, interposed between the heartand sternum, and the consequence is, theproduction of a very peculiar bruit. It is

easy enough to show that the membranecontaining the heart has nothing to dowith the sounds which we hear; for, asyou see, I now open the pericardium, liftthe heart and irritate it with the point ofmy knife; the organ beats with the ut-most vivacity, but still there is no sound

produced; indeed, there could not, be-cause there is no shock of one body againstthe other, and, consequently, no possibilityof developing a noise. To those who attri-bute the bruits of the heart to the actionof the blood on its valves, I may simplyobserve, that if this were the case weshould observe the bruits in the presentinstance, but the closest attention does notenable me to distinguish a single sound.We shall follow up this subject, Gentle-men, in our next lecture.

CLINICAL MEDICINE.

LECTURES

DELIVERED AT THE

NORTH LONDON HOSPITAL,BY

A. T. THOMSON, M.D.,

Physician to the Hospital, and Professor of MateriaMedica in the University of London.

LECTURE IX.

HYPERTROPHY OF THE HEART, WITHVALVULAR DISEASE;- Influence of

Hydrocyanic Acid as a Palliative.

GENTLEMEN,-The only case of much in-terest that has been admitted since our last

meeting is one of hypertrophy, apparentlycombined with valvular disease of the heart.The name of the patient is John Schaaf, apaper-stainer, aged 21, of a thin, sparehabit of body, and a melancholic tempera-ment. He states that he has never enjoyedvery good health ; that he has alwaysbeen of a spare habit of body ; but neverexperienced any palpitations or uneasyfeelillgs about the heart until three yearsago, when he was much frightened ; andon the night of that day was attacked withviolent palpitations as he lay in bed. Theyhave returned, at intervals, ever since; andespecially on making the slightest exertion;and as they have increased in violence and

prevented him from following his trade, hehas come into the hospital. The palpita-tions now recrrr whenever he lies down,especially when he rests upon his rightside; and often when he has settled forsleep, and has dozed for a few minutes,he awakes, and is forced to start up, inorder to relieve a sensation of suffocation.The respiration becomes also hurried,and the palpitations are peculiarly dis-tressing, when he attempts to ascend a.

stair ; and there is always a catching sen-sation in the breathing when he makesthe slightest exertion. He has lately ex-perienced a feeling of constriction at thethroat, and a fulness on each side of thehead, which is relieved, for a time, bypressure of the hands on the temples. His

mind is occasionally confused; his coun-tenance, however, is not expressive ofmuch anxiety, when he is at rest. Hisskin is dry, and his bowels are confined;his urine varies both in its appearanceand in its quantity, being sometimes high-coloured, sometimes pale; but althoughit is not often very copious, yet it is ge-nerally rather so than otherwise. His

appetite is good, but never voracious,-acircumstance which is not uncommon in

hypertrophy of the heart.Such is the account which our patient

gave of himself at his admission into the

hospital. On the examination of theheart by the stethoscope, the irregularityof its action was obvious; some of the

beats were strong, others weak; and thisinequality was perceptible in the pulse.That this probably depends on ossificationof the valves, is obvious from the gratingor rasping sound which the instrumentrenders to the ear when the blood is pass-ing through the diseased valves. Some-

times, instead of this rasping sound, thetone, if I may so speak, is more likethat of sawing, less harsh but in a higherkey. These sounds are truly pathogno-monic of diseased valves ; they are heardwhen the heart is in a state of comparativecalm, which neverhappens when the soundsare connected with other causes, namely,a nervous excitability of habit, or simplehypertrophy with dilatation. Another proofof the valvular character of the disease illour patient, is that the sound is not uni-versal over the heart, but nearly over theregion of the mitral valves, approximatingthe margin of the sternum, on the left side,about the fourth rib. Besides this con-dition of the valve, there is evident hyper-

’ trophy of the heart, without dilatation. Inthe description of the symptoms, whichyou must have observed to simulate someof those which accompany dry asthma,ve find that something like a paroxysm is

apt to supervene after a meal, especially

670

in the evening; and it is at this time

chiefly that that uneasy state of the headwhich has been described occurs; andwhich indicates such an impeded circu-lation within the cranium, that it mightterminate in apoplexy, were the patient aplethoric person.One feature, however, in this case, is at

variance with the ordinary symptoms ofvalvular disease, namely, the slight nature,of the cough, and the defect of expectora-tion. This is generally the character of thecough in simple hypertrophy, when thepulmonary congestion is only temporary;and it usually subsides the moment theheart and large vessels are relieved. Onthe contrary, when the valves are affected,the cough, like that of spasmodic asthma,commonly recurs in violent paroxysms,threatening suffocation, and terminatingin a free, frothy, expectoration, which issometimes streaked with blood. But Ihave seen this anomaly before ; and I hadan opportunity of verifying my opinion ofvalvular disease being nevertheless pre-sent in such cases, by a post-mortem exami-nation of the heart. The person to whomI allude was of a full plethoric habit, andhad suffered under hypertrophy of theheart for many years. He at length poi-soned himself with opium; and, on theexamination of the body, both the mitraland the semilunar valves were found to beossified.The prognosis in every case of organic

disease of the heart, whether valvular orotherwise, should be delivered with ex-treme caution. If the person can remainat rest, and maintain, at the same time,great equanimity of mind, life may beprotracted for many years, even when thebody is emaciated, and much debility ex-ists ; but, long before the constitutionsuffers in this severe degree, the smallestextraordinary bodily exertion, or even

violent mental emotion, may cause instantdeath. Sometimes apoplexy supervenes,and is the consequence of either sangui-neous or serous effusion; but, when thisoccurs, coma is always present for severaldays before the fatal event.With respect to the treatment in this

instance, as our patient was costive, hewas ordered to take five grains of calomelat bed-time, and to follow this with a briskpurgative on the following morning. In

every case of hypertrophy, it is of im-

portance to prescribe an occasional pur-gative to remove any excess of bile, orcrude, undigested food, or acrid mattersretained in the intestinal canal, as nothingis more likely to induce the palpitationsthan intestinal irritation. At the sametime frequent purging, inasmuch as italways more or less reduces the system,

is to be avoided, whenever hypertrophyand valvular disease are conjoined; unlessin very plethoric individuals, or when

dropsy is present. On the 21st our pa-tient was ordered the following draughtto be taken every fourth hour :-

R. Hydrocyanici Acidi tlj, ij ;Conii Tincturae m x ;Aquae Distillatœ f.iss. M.

He was also directed to take gr. v of thecommon aloetic pill every night at bed-time.

The object of the hydrocyanic acid was totranquillize the nervous sytem, and to pro-mote the power of the digestive function. Ihave generally found that, when acidity, fla-tulence, and other symptoms of indigestion,are present, not only the palpitations, butheadach and dyspnoea are augmented;and under such circumstances, the hy-drocyanic acid operates more beneficiallythan chemical antacids or tonics; thelatter, indeed, are only admissible whenhypertrophy with dilatation actually ex-ists ; but in hypertrophy with valvular

disease they are undoubtedly injurious.The hydrocyanic acid, by its sedative in-fluence, calms the irritability of the st04

mach, enabling the gastric juice to bemore slowly and perfectly secreted, andthus it relieves the dyspeptic symptoms,at the same time that it abates spasm.On the 23rd, as the palpitation was in-creased, and the pulse firmer than it had

been for some days previously, gviij ofblood were ordered to be taken from thearm, and the dose of the hydrocyanic acidto be increased one minim. He felt con-

siderably relieved by the bleeding, but thegeneral symptoms remain unabated. Itis my intention to repeat the blood-lettingoccasionally, according as circumstancesshall indicate, and the strength of the pa-tient permit. You will find, Gentlemen,if we for a moment reflect what in-dication is to be fulfilled by bleeding,that this is a much safer method of pro-ceeding than that recommended by AL-BERTINI and others—namely, to abstractmuch blood by frequent large bleedings.

Assuredly, we cannot expect to removethe valvular disease, or the hypertrophy,by large bleedings ; and they can only beregarded as the means of resolving conges-L tion, relieving the dvspnoea, and diminish-. ing the impulse of the heart, whenever thatbecomes inordinately strong. Notbingmore- can be effected by blood-letting; and this

indication is completely answered by ab-;! stracting seven or eight ounces ; and by; I confining the bleeding to this quantity, we; avoid the risk of reducing the strength of the; ’ patient to a point which would only impede, ‘ the respiration still more than usual, and

671

hurry ou the fatal termination of the dis- Iease. Were there any evidence of dilata-tion in this case, I would not order blood- ’Iletting ; but, on the contrary, after clear-ing the stomach by a direct emetic-forexample sulphate of zinc, which would opeiate without much agitation of the

system, I should administer nitrate of sil-ver in combination with minute doses of

ipecacuanha, which, in conjunction withthe use of the shower-bath, I have ob-served to be most serviceable in recruit-

ing the strength, and removing the lan-guor and atony of the system, which arealways to be dreaded, when valvular dis-ease is connected with hypertrophy of thedilated kind. I have not observed that anybenefit has been derived from antispas-modics. I may venture, however, to affirmthat little advantage can be anticipatedfrom any plan of treatment in the casenow before us. An occasional bleeding torelieve the urgency of the symptoms, thehydrocyanic acid and alkalies to regulatethe digestive function, rest, and a calmresigned mind, are the only rational meansof palliating the distress of the patient, andprotracting life for a short space.

PHTHISIS.—Tonics and Emetics.

The treatment which I proposed to pur.sue in the case of Sidney Jarvis has beenrigidly followed up to the present time.He was last cupped between the shoulders’

‘

on Saturday ; he continues the use of thesolution of the hydriodate of iron ; em-ploys the tepid sponging every morning,and takes his narcotic at bed-time. Icannot affirm that he has gained muchbenefit under this plan of management;but he certainly has not lost any ground ;his cough is not increased either in fre-quency or in force, and he is totally freefrom morning perspirations. He says,however, that he still feels weak; but someallowance must be made for the depres-sion of his spirits, from contemplating theprospect before him. His eldest brotheris dead, and the second is fast approach-ing the same crisis. I have observed noinjurious effects to result from the joint’:,employment of the lancet and the hydri-odate of iron ; it is, therefore, my inten-tion to continue them ; but to give, at thesame time, an emetic every second morn-ing. The treatment of phthisis, by fre-quently repeated eimetics, was formerlymuch in vogue ; and if we cannot avoid

crediting the accounts of their beneficialeffects by blorton, Simmons, Bryan Robin-son, Marryat, and others, it is surprisingthat their employment has been so muchneglected of late years. In an admirable

Essay on Tubercular Phthisis, published

in the Encyclopedia of Practical Medi-cine, Dr. CLARK quotes the practice ofDr. GIOVANNI DE VITTIS, the militaryphysician in chief to the military hospi-tals of the Neapolitan army. It appearsthat Dr. DE VITTIS ordered emetics inevery case of pulmonary disease in theMilitary Hospital of Padua. From thelst of May 1828 to the 18th of January1832, 47 cases of phthisis in the first

stage, 102 in the second, and 27 in thethird, were discharged perfectly cured.He administered to each patient, everymorning and evening, a tablespoonful ofa solution of gr. iij of tartar emetic in

f’:3V of infusion of elder flowers, and f.jof simple sirup; and a second spoon-ful if vomiting did not take place at theend of a quarter of an hour. Now with-out wishing to throw discredit on thestatement of Dr. DE Vims, whose diag-nosis might, nevertheless, be doubted insome instances, as it does not appear that itwas aided by the stethoscope; and withoutwishing to lessen the laudatory encomiumsof the older physicians in favour of emetics,I may be allowed to remark, that the prac-tice was, perhaps, carried too far; butthat, if the views of their mode of actionpointed out by Dr. CARSWELL be admit-ted, the practice, modified as regards thefrequency of the repetition of the emetics,might be again advantageously resortedto. Dr. CARSwELL supposes that thetuberculous deposits in the lungs are notmore frequent there than on all mucoussurfaces; but that on some, as, for in-stance, the mucous membrane of thebowels, they are again brushed off by theconstant action kept up on them by thepassage of foreign substances. Now, inthe lungs, this can only be promoted byemetics, which augment the bronchial

secretion and eject it from the lungs;and, therefore, it is reasonable to sup-

pose, that the frequent repetition ofemetics may prevent the deposition, or

at least the accumulation, of tuberculousmatter. This view of the subject is not onlyingenious but feasible, provided the opinionrespecting the deposition of tuberculousmatter on mucous surfaces be admitted, onwhich point I confess, that much as I re-spect my learned colleague’s researches, myopinion is not settled. If, however, weadmit the propriety and importance ofemetics, and that they operate by theagitation which they excite im the lungs,it is by no means necessary to employthose substances that maintain nausea, orexcite perspiration after their emetic

operation is over; and, therefore, I wouldprefer the direct emetics to all others.

With respect to the repetition of the

emetic,—once or twice a week appears to

672

me to be frequent enough ; but whether the necessity for the repetition be increasedafter tuberculous matter is actually pre-sent in the lungs, I am not prepared tosay. In the intervals, the propriety ofattempting to restore the tone and vigourof the habit is evident, when we reflectupon the causes which are usually regard-ed as giving origin to tuberculous depo-sits. We shall have an opportunity of see-ing the value of both classes of medicines,namely, tonics and emetics, as far as wecan form an opinion upon the subject fromthe result of the practice in a solitary case.

HEPATIC ABSCESS WITHOUT JAUNDICE.

On the female side, a case of some in- terest has presented itself in the personof Maria Burgin, 49 years of age, a dailygoverness, a woman who has seen betterdays ; and whose disease and present suf-ferings may, in part, be attributed to thatpressure of mental affliction which she hasextensively experienced, and which is toofrequent in society. She was admitted onthe 22nd, and gave the following accountof her disease. She had suffered muchdistress of mind from the derangement of Iher pecuniary affairs, yet she had enjoyedpretty good health until about three lemonths since, when she was attackedwith a severe rigor, which lasted twohours, and was followed by sound sleep,which continued for three hours. On

awaking, however, she was almost im-mediatelv attacked with a violent stabbingpain in the left side, in the hepatic region,attended with vomiting and purging of

bloody matters; and this continued at in-tervals, more or less distant, for nearlysix weeks; it then ceased, but the painhas recurred at intervals up to the presenttime. On questioning her closely, sheadmitted that, prior to the attack whichhas been described, she had experienceda dull pain of the left side, accompaniedwith uneasiness of the shoulder and armof the same side; but, owing to the ur-gency of her occupations, she had not at-tended much to the symptoms of disease. At the time of her admission the pain ofthe side recurred, at intervals, twice orthrice a day, and at all times she nowfeels pain in the loins; there is, also,some degree of tenderness on pressingover the sacrum. The catamenia left herabout eighteen months ago. Her presentcomplaints refer chiefly to the pains of thehepatic and lumbar regions, to cough,some difficulty of breathing, with tightnessacross the chest on attempting a deep in-spiration. She expectorates freely, andthe sputa are, occasionally, streaked withblood. The tongue is furred; and a little

brown on the edges; the bowels are cos.tive, and the pulse is 76, weak, and com-pressible. The countenance is perfectlyfree from jaundice. On examining thehepatic region, exquisite tenderness is

felt, and I feel, or perhaps imagine that Ican feel, an excavation towards the lowerand posterior part of the left lobe of theliver. The ribs are a little fallen in overthe hepatic region.The history of this case, and the coii-

dition of the hepatic organ, afforded meevery assistance that could be desired informing my diagnosis; and I have no hesi-tation in pronouncing the disease to beabscess of the liver; a disease common inIndia, but rare in this and other Europeancountries. In this instance, I should i-e-

gard the abscess as the result of chronicinflammation; and I am confirmed in thisopinion by the apparent existence of thecyst which I think can be felt; a state ofparts which does not frelluently accom-pany acute inflammation of the liver.The only objection to this opinion is thebloody discharges, for it seldom happens,that in chronic inflammation, terminatingin the ulcerative process, that the vesselsare obliterated in the same manner as inthe cavities that occur in the lungs : andas the process is slow, and the con-

sequent surrounding pressure must be

long continued, the chance of obliterationbefore the ulcerative process even com-

mences, is most probable; whereas, inacute inflammation, nature has scarcelytime to take means to secure the safety ofthe general system by this method ofguarding against hemorrhage.In the case before us, the abscess ap-

pears to have opened into the duodenum,which accounts for the regurgitation ofthe bloody matter into the stomach, andits ejectment by vomiting. This would nothave been the case had the adhesion taken

place with the ascending colon. 1t is, also,probable that there is perforation of thediaphragm and a communication with thelungs ; unless we can describe the streaksof blood, in the expectorated matter, tothe disturbance of the pulmonary circula-tion likely to result from the irregularity inthe portal system, which cannot fail toattend so much mischief as exists in theliver. The expectoration of the contents ofthe abscess is by no means an unfrequentcircumstance in hepatic abscess ; and theready exit of the purulent matter, when its

; first, entrance into the bronchial tubes is, not in such quantity as to cause suftoca-tion, is regarded as one reason of the

frequent favourable termination of theI disease.i With respect to the duodenal opening,e I infer its existence from the double result

673

namely, the vomiting and the diarrhoea; for’ had the abscess opened into the stomach, vomiting alone would have followed ; and had it occurred in any of the other intes-’ itines we should have had sudden diar- Srhoea, but no vomiting, unless of a sym- pathetic kind, in which case bloody mat-ter would not have been ejected from the istomach. Such are the data upon which SI have founded my opinion of this case, Iand I throw out of view altogether the !slight premonitory symptoms, as there aremany cases on record in which patientshave displayed no appearance of jaun-dice, nor suffered from pain of the hy-pochondrium to a degree sufficient to

produce marked attention to it. ANDRALrelates a case in which every characteristicsymptom of hepatic disease was absent,yet gangrene of the liver was discovered after death. You will find in the Anato-mical Museum of the University, a prepa-ration of very extensive disease of the

liver, in a man who was my private pa-tient, whose symptoms were, through-out his disease, merely those of low con-tinued fever. Such is a sketch of this in-

teresting case, to which. Gentlemen, Iam-anxious to direct your attention, thatyou may go along with me in the futuretreatment of it.

CLINICAL SURGERY.

LECTURES

DELIVERED AT THE

NORTH LONDON HOSPITAL.

BY

ROBERT LISTON, Esq.,Surgeon to the Hospital, and Professor of Clinical

Surgery in the University of London.

LECTURE VI.

DISEASES OF THE RECTUM.

GENTLEMEN,—I stated in my last lec-ture, that very considerable differences ofopinion existed amongst writers on the dis-eases we have had under consideration, asto their nature and anatomical characters. ISome of these gentlemen have apparentlybeen at little trouble to satisfythemselves asto facts. They have taken much for granted;they have used their oculi iuterni insteadof the externi; they have imagined andnot observed. A great difference of opinionexists as to the form of operative procedurewhich is most safe and effectual for the cureof the maladies in question. If you were to

follow one set, you would remove by liga-ture all of the swellings and growths;if you put faith in another, you would cutthem off; and a third, more heroic still,would have you combine the cutting andcauterizing systems. ° Igne, ferro, sana-bat," was che motto of old PONTEAU, andhis example does not seem to have beenlost on some of his successors in theFrench hospitals. First, as to tumours aboutthe verge of the anus, and exterior to it.These may always be removed, after allother means have failed, with the most perfectsafety, and without much pain, by the useof cutting instruments. There can in suchcases never arise a necessity for resorting tothe tedious, and, under the circumstances,unnecessary and painful mode by ligature.The tumours may not all be in such a con-

dition as to require removal. One trou-blesome knob mav be uroductive of all thesuffering, and of a great deal of swellingin its neighbourhood. This has been well

pointed out by the late Mr. WARE. Theevulsion of this offending part may alonebe necessary. It is seized, raised from itsbed by the vulsella, which I have alreadyshown you the use of, and cut off by onestroke of the bistoury or curved scissars.When the verge is surrounded by folds ofskin, permanently swelled by warty ex-crescences, cristae, &c., these should beat once taken away in the same fashion,-every thing, in point of fact, made smoothand neat. No vessels of importance are in-volved in this proceeding, and if hemor-rhage should arise, ligature can be applied,or pressure made in such a way as to

prove at once, and without fail, effectual.In dealing with internal tumours, muchmore caution is required ot you. ’I’here

you have not the means of arresting thehemorrhage readily. If bleeding do arise,it is apt to go on rapidly, and withoutexciting alarm (excepting in the mindof one experienced in those matters), till,perhaps, it is too late to render effectualassistance. The bowel gets filled withclot : an attempt maybe made to expel it;from the state of parts this attempt provesineffectual ; the clot acts as a warm wetsponge would do upon a surface exposedand inclined to bleed : the bowels getfilled, the patient feels uneasy, complainsof pain in his loins and hypogastrium, and

be is faintish, becomes pale, attempts toempty his stomach; the breathing be-. comes embarrassed ; the pulse frequent,

. small, and intermittent; the features ap-pear sunk, and the surface is bedewedl with cold perspiration ; the patient ex-

presses great anxiety and alarm, convul-: ‘sive motions supervene, and a very rapidly: ‘fatal termination to cases so managed hasnot unfrequently crowned the work. It