540

incongruity and disagreement of the practice of the law inthese cases, for the rule, if good for one, must apply to both:the laws of nature cannot be abrogated to suit legal f/)H(M,and unreal and artificial distinctions, when the high interestsof moral and physical death are involved in the decision. Alittle madness deprives the lunatic of civil rights-of dominionover property, and its disposition-and annuls wills; whereas,to exempt from responsibility for crime, and cancel socialobligations, the mind must be quite clouded-completeignorance of the knowledge of right and wrong, good and evil,must exist; neither partial insanity nor delusions are ad-

mitted ; the last, not even when traced to the act, if lucid in-tervals happen at the same time. Lord Hale says, there mustbe " total alienation of mind, or total madness, de quibus infra;this is that which, in my Lord Coke’s’ Pleas of the Crown,’ iscalled by him absolute madness and total deprivation ofmemory; .... if there be lucida inter/lalla, the madness, inthat case, will not relieve from responsibility of felony ortreason, if they be committed during that state."

This is illogical, and totally inconsistent with modernauthorities, especially with Lord Lyndhurst’s, since it makesinsanity amenable to punishment and accountable for crime,in one instance, and, in the other, where much less insanityexists, removes the power to execute civil contracts, and theresponsibility to perform civil offices: thus, insanity blendedwith crime (unless the insanity be of the most aggravatedand sesthetical character) is punished with the severest andvindictive penalties of the law; and all other lunatics areabsolved from liability to legal awards, and from right oflegal appeal, carrying out Sir William Blackstone’s doctrine," furiosus furore solum punitur."* Sir Edward Coke says," the execution of an offender is for example, ut pcena adpaucos, metus ad onnes perveniat;" yet surely there can

be no example and no warning given from the gibbetof an executed madman-a folly which was perpetratedin the case of Bellingham, and only narrowly avoidedin the case of Hadfield. If Bellingham had been respitedand placed under surveillance for a time, all doubts mighthave been solved, and all suspicion of a vengeful execu-tion avoided-the more deplorable, connected as it was withthe memory of a most gentle and amiable character, the lateMr. Percival. Lord Erskine, who was the first to advocate amilder code of insanity, says,-" I think, as a doctrine of law,the delusion and the act should be connected; .... incases of atrocity, the disease and the act should be apparent."And again, - The dominion of insanity .... annuls aman’s dominion over property, dissolves his contracts, andother acts which otherwise would be binding in a civil sense;and it takes away his1-esponsibility for crimes."t Haslam says,-"Incapability to the management of affairs is sufficientmanifestation of unsoundness."t Lord Thurlow says, inreference to civil contracts,-the making of ivills, and thedisposition of property-" the burthen of proof attaches to theparty alleging such lucid intervals, who must show sanity andcompetence when the act was done, and to which the lucidinterval refers; .... and the evidence .... should be asstrong and demonstrative of such fact, as where the object ofproof is to establish derangement," and should not berestricted or limited to individual and particular acts, such asmaking a will, but comprehend all acts and conditions. Incriminal cases of lunacy, its construction is limited and narrowed,and without any such rigid inquiry or investigation, and withoutany palliation, the lunatic is held responsible for a criminalact during a lucid interval. The man who makes a will may,grounded upon its inconsistencies, be found mad, and com-paratively slight evidence of error will make him mad, and in-validate the will; but if he commits murder, the crime is notinvalidated, but he is made responsible, and hung for it, makinghim more accountable and more rational at the moment ofcommitting murder than during the act of devising property:one act essentially requiring the exercise of thought, attention,will, memory, and understanding, and the other their absence,and the presence of an excited, turbulent, and disturbed mind,in which there may exist neither memory, will, nor under-standing.

Again, in civil cases, for example in the making of a will,if folly and wisdom be mingled, yet the folly invalidates theinstrument, and stamps the incapacity and insanity of themaker; but if he commits homicide, to invalidate hig responsi-bility he must not possess a glimmering of concioness,memory, or understanding, any knowledge of right or wpoag,or any particle of reason, however small: thus says the Law.

* Sir William Blackstone’s Commentaries, v. iv. p. 24 and 395. Windell’s ed† Erskine’s Speeches. Defence of Hadfield, p. 120.‡ Haslam’s Jurisprudence of Insanity.

However partial may be the insanity, or few and small thedelusions, if the case be carefully observed and comprehended,the ingredients of insanity, even if they be diluted and obscure,may nevertheless be demonstrated by the physiological test8above suggested. °

May, 1852.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, tum aliorum proprias, collectas habere et inter secomparare.—MORGAGNI. De Sed, et Caus. Morb., lib. 14. Proœmium.

GUY’S HOSPITAL.

Aneurism of the Aorta, encroaching both on the Chest andAbdomen; Death; Autopsy.

(Under the care of Dr. BARLOW.)WHEN we have fully and satisfactorily diagnosed an incurable

disease, we feel certain that the patient is labouring under anaffection for the removal of which medicine is powerless; andour task then becomes painful and difficult. The physicianmust, in such melancholy circumstances, consult both his

judgment and his feelings, and act towards his patient or thefriends of the latter with due circumspection. But before

giving the fearful verdict, he should be quite sure of thecorrectness of his diagnosis; and hence the great importanceof studying the symptoms of diseases reputed incurable-bothas to the necessity of giving the information anxiously sought,and in order not to subject patients to various kinds of treat-ment, which may be very irksome, and unnecessarily add totheir misery. Nor is this all; for by timely advice and cautionwe may succeed in prolonging life for an indefinite period, inenforcing certain rules, and cautioning patients againstindulgences which might considerably hasten the fatal issue.Thus it will be seen that our services are ever useful, as, tothe above warnings, we may add the administration of pallia-tives, which, combined with a proper mental treatment, willaccomplish all that human beings are permitted to effect undersuch trying circumstances.We dwell the more willingly on this subject, as we often

hear from students, and even practitioners, " Where is the useof taking so much trouble to discover organic changes uponwhich our most potent therapeutical means have no influencewhatever t Chemistry teaches me how to discover sugar oralbumen in the urine; by the aid of the stethoscope I find outthat the lungs or heart are irretrievably spoilt; the microscopeallows me to see plainly and distinctly the malignancy andheterogeneous character of a tumour or growth. But whatavails all this refinement if I cannot cure my patient ?" Thisquestion is answered above, and we may add that, howeverintractable the disease, and however difficult it may be to rootit out, considerable relief may sometimes be afforded. Take aheart whose valves are damaged: may not the further fibrinousor ossific deposit be, if not arrested, at least rendered muchslower ? May not a milder climate and cod-liver oil impedeor retard the further formation of tubercular matter ? Maynot an animalized diet prevent the transformation into sugarof certain principles so necessary to healthy nutrition ? Maynot the surgeon in malignant disease give years of comfort byextirpating unsightly tumours; or the physician strengthen.his patient so as to resist for a long time the baneful influenceof cancerous growths within any of the three cavities ?Examples might be multiplied; but we must for the present

rest here, and turn to the case in hand, which will show howmany years aneurism of the abdominal aorta may exist withoutdestroying life, how very obscure the symptoms are at theoutset, and what an extraordinary course the tumour maysometimes take. We need not say a word about the sourcesof fallacy in ww4 cases: they are well known. Malignant orinnocent tumours Qr the abdomen have been taken for aneur-isms, and vice ve2)5 These mistakes should render us verycautious; and practititH1êr should well recollect that the pre-

541

sence or absence of a bruit is a symptom not to be reliedupon, and which acquires value only in so far as it is combinedwith other signs, the grouping of which forms a tolerablygood evidence. For instance, Dr. Barlow had some time ago,in the clinical wards, a patient, who will probably live formauy years, and whose abdomen presented an extensivetumour, the nature of which could not be ascertained, thoughthe disease was suspected to be aneurism of the abdominalaorta. There was no bruit whatever; but by the case whichwe are going to relate (from the notes of Mr. J. M. Rooke) itwill be seen that an enormous aneurism of the abdominalaorta may exist without yielding any abnormal sound to theear.

J. S-, aged thirty-five, by occupation a painter, residingat Walworth, was admitted March 20, 1852, under the care ofDr. Barlow. The patient is of a sallow complexion, lookingvery cachectic, and states that he has been ill for the last sixyears. The first symptom he experienced was a pain at theepigastrium, extending round to the spine; this sensationsubsequently passed down the anterior portion of the left

thigh, and was accompanied by retraction of the testicle. Thepain had set in rather suddenly at first, and the patientascribed it to the nature of his business, as he is obliged,while whitewashing ceilings with his right arm, to lean hisbody to the left side, in order to preserve his balance, andretain this constrained position for some time. (Had this con-strained position, so often assumed, any influence on the for-mation of aortic aneurism ? had it the same effect as

the riding on horseback on the development of poplitealaneurism in postboys and others ?) In spite of the above-mentioned pain the patient continued at his work for severalyears; and about sixteen months ago he was admitted intoGuy’s Hospital, where he remained nine weeks, and left some-what relieved. His complaint was then diagnosed to beaortic aneurism; but positive proofs could be obtained neitherat that period nor at the time of his re-admission, which tookplace in March, 1852, as stated above.On this second examination there is now found a con-

siderable projection of the tenth, eleventh, and twelfthdorsal vertebrae, which projection did not exist at the time ofthe patient’s first admission. In the epigastric region, an in-distinct fulness and enlargement are felt, the spot yielding adull sound on percussion. The man is conscious of a throbbingsensation in that locality, as well as in the lumbar region, butno bruit is to be heard at either part, or elsewhere. Pos-teriorly, the systolic sound of the heart is perceived more loudlythan usual, and the whole of the left side of the chest is verydull on percussion, with a complete absence of tactile vibra-tion and respiratory murmur. The general symptoms arethose of depression; the pulse is small, thready, and com-pressible, but there is no heat of skin, and all the secretionsare normal.In consequence of the patient’s great debility, a more com-

plete examination was not made, the latter being postponedto the next day; but at nine in the following morning, hedied suddenly. It appears that he had expressed himselfbetter a short time before his death, had eaten his breakfast,and been out of bed an hour prior to his sudden decease.The body was examined six hours after death; the account

of the appearances is as follows:-Body generally blanched;heart pushed to the right side, small, but otherwise healthy,as well as the great vessels immediately springing from theorgan; left pleura filled with blood, partly fluid, partly coagu-lated, and lung compressed against the spine. On clearing outthe chest, a large tumour was found on the diaphragm, theformer being covered by the serous membrane. Whilst thistumour was in situ, it was considered to be in the abdomen,but by pushing the diaphragm upwards, this muscle was seento have given way towards the chest, the aperture beingalmost circular, and about the size of a five-shilling piece.This rupture had given rise to the hsemorrhage of which thepatient had suddenly died. Below the diaphragm, universaladhesions were found, caused by chronic peritonitis, and frombehind and beneath the liver and stomach an enormousaneurismal tumour, about the size of three fists, was discoveredpushing forwards and upwards. On removing the liver andstomach, as well as the intestines, the position of the aneurismwas more clearly made out. It was now found to have takenits origin at the posterior part of the aorta, just above thecseliao axis; the opening of communication between the arteryand the sac was about an inch and a half in length and threequarters of an inch in breadth, of an oval form, with its longaxis in the course of the artery, its edges rounded, thoughroughened by ossific deposit. The bodies of the eleventh andtwelfth dorsal vertebrae were almost entirely absorbed, the

finger easily impinging upon the membranes of the cord, butthe intervertebral substances had escaped.

This aneurism had taken a somewhat curious course; it hadmade its way beneath the pleura covering the diaphragm onthe left side, having arisen just between the crura of thatmuscle, the tumour being thus placed more in the thoracicthan in the abdominal cavity. It had then dissected its waylaterally, between the muscular coat of the diaphragm andthe pleura, having the former for its lower, and the latter forits upper, boundary. Thus the aneurism could not be said tobe either above or below the diaphragm, being actuallysituated between its distended layers. The upper or serousboundary had, in the end, ruptured. It is very probable thatthe solution of continuity attained its large size somewhatgradually, the effusion having taken place co-relatively, andin a similar ratio. The pouch itself was lined by old fibrinousclots, but no proper coat was perceptible, the sac beingformed by the diaphragm and pleura, as above described; thespine and neighbouring muscular structures forming theposterior limits. The large size of the opening into the sacafforded a satisfactory explanation of the absence of any bruit,though the lattt;r ll1:1Y have existed at an earlier stage of thedisease, when the aperture was smaller. It is but seldom, asfar as we have seen, that patients suspected to suffer fromaortic aneurism are examined in the lumbar region. It isevident, by the foregoing case, that very important informa.tion can be derived by such an investigation; it should, infact, never be omitted. -

ST. GEORGE’S HOSPITAL.

Supposed Disease of the Hip-joint. Death from Meningitis.Autopsy.

(Under the care of Dr. PAGE and Mr. CUTLER.)

SoME authors reject altogether the term coxalgia, as notbeing sufficiently definite; but there may certainly be pain inthe hip-joint independently of any rheumatic or other inflam-mation. The pain may be purely neuralgic, or else sympa-thetic, as we find it in the knee-joint when the hip is actuallyaffected. There may likewise exist a morbid state of thecerebro-spinal axis, giving rise to hysterical phenomena, whichlatter make the patient fancy that there is pain in the coxo-femoral articulation. The word coxalgia, though certainlynot very precise, may, perhaps, be used when our know-ledge of the nature of the affection is so vague, that we have,in some degree, a right to use a vague term. However thismay be, we regard the case which we shall presently relate asone in a thousand, since it has afforded an opportunity ofjudging of the perfect soundness of a joint in which the patienthad experienced more or less painfor eight months. Seldomdoes an hysterical case stand out so patent as this, and we hastento lay the details before our readers, as noted by Mr. Holmes,surgical registrar to the hospital.The patient was a wo:nan, twenty-five years of age, of dark

complexion, and of bilious habit, who was admitted August27th, 1851. under the care of Dr. Page, complaining of pain inthe hip, which was thought to be the result of chronic rheu-matism. There were also some symptoms of phthisis, the apexof the right lung being especially consolidated. The treat-ment adopted was principally of a soothing nature, (hyoscyamusand paregoric at night, &c.,) and it was supposed at first thatno serious disease existed in the hip; but as the pain was notrelieved, she was transferred, on the 22nd of the followingmonth, to Mr. Cutler’s care.The symptoms at that time were those of acute inflamma-

tion of the hip-joint: some pain on moving, startings of thelimb, especially at night, &c. Mr. Cutler ordered four grainsof iodide of potassium, with ten of liquor potassoo, to be takenthree times a day in camphor mixture, and a blister to beapplied and repeated. The symptoms, however, increasing inseverity, an issue was put in over the trochanter, and keptopen. Opium was given at night, which produced sleep, andunder this treatment she slowly improved.

As, however, there was still a great deal of pain on motion,the patient was kept in bed, and compound steel pill given fora short time. But this was soon omitted, as was valerianmixture, which was subsequently ordered, neither of theseagreeing with her.

In the month of February, 1852, the patient became muchbetter, so that it was thought advisable to heal the issue; butas she still was unable to move without pain, she had not lefther bed on the 16th of March, when the attack set in whichproved fatal to her.

This began with pain in the head, low delirium, and wake-fulness. As there had always been a suspicion that the case