Well knowing the difficulties which beset the practitioner-the prejudices he has to encounter--and the necessity which he is often under, of balancing between a conscientious discharge of his duty and the risk of unmerited obloquy for so discharging it, we are not apt to examine, with a very critical eye, the judgment which is formed before the event has removed all doubt. Yet, in the foregoing case, we cannot see how doubt could exist as to the propriety of opening a passage that had been closed for so many weeks, and on the opening of which, the only chance of life remained. The fold of membrane acted completely as a valve in blocking up a scirrho-contracted rectum, and the puncture of this obstruction presented neither difficulty nor danger that ought, for a moment, to have weighed in the balance against the dreadful sufferings and miserable end of this unfortunate female! We know a gentleman in this metropolis, who is afflicted with an obstruction of this kind; but, fortunately, he is able, with his own finger, to push up the valvular fold of relaxed mucous membrane, force it on one side, and thus permit the fæces to pass. We hope the foregoing case and dissection will be the means of saving some unhappy wretch from the horrors of a death such as is depicted by our transatlantic cotemporary.

XXXIII.

APOPLEXY CAUSED (AS WAS SUPPOSED) BY GYMNASTIC EXERCISES.

In the first number of Dr. Farre's halfyearly Journal, there is reported a case of the above description. A young man, aged 20 years, of muscular frame, short neck, and middle size, had habituated himself to considerable gymnastic exercises, and never required the assistance of a medical man. On rising from his bed, on the 19th of October, 1826, he fell down insensible, and expired in the course of an hour. The head was examined the same day. On separating the skull-cap from the dura mater, three or four ounces of blood escaped. The vessels of the pia mater were turgid--the convolutions of the brain

had a flattened appearance. In the right hemisphere of the brain there was a clot of blood, and also an effusion of fluid blood to the amount of five or six ounces. The lateral ventricles were also found filled with blood. The texture of the brain was, of course, completely broken up in the part where the blood was extravasated.

We wonder that so grave and accurate a reasoner as Dr. Farre, should set down the above extravasation of blood, as "consequent on habitual gymnastic exercises." This is an exquisite specimen of the "post hoc, ergo propter hoc" ratiocination. The narrator might just as well infer, that the death of every old Greenwich pensioner is the consequence of sea-life-the said sea-life having, in every instance, preceded the death of the individual! Or, going to Chelsea, and examining the necrological records there, he might deplore the dreadful effects which result from carrying a musket-all the men who die at Chelsea having "habitually" borne arms.

If the reader will turn (in the same Journal) to the case which immediately precedes the one we have been commenting on, he will find an instance of sanguineous effusion in the brain of another young man-"tall, muscular, and accustomed to drink spirits." He died suddenly, and besides six ounces of water and some blood in the ventricles, there were four ounces of coagulated blood at the base of the brain, which blood had escaped "from a small aneurism of the left vertebral artery." Both vertebral arteries were in a diseased state, being, in some places, cartilaginous, though the individual was only 24 years of age. The communicator of this case has not, though he ought to have drawn the conclusion, that the aneurism of the vertebral artery was "consequent on dram-drinking." We are ashamed to see such hasty and unsupported inferences drawn in medicine.

years, of strong constitution, bilious temperament, and who had enjoyed good health, having led a sober and active life, was the subject of severe misfortunes and moral afflictions in the year 1825, which made a great impression on body as well as mind. He became affected with bad digestion, experiencing pain and weight in his stomach, after eating. On the 11th of April, 1828, M. Bricheteau was consulted. The patient then complained of rather severe pain in the umbilical region, which was tense and somewhat shininghis appetite was gone-his bowels obstinately confined; but he had neither fever nor heat of skin. Twenty leeches were applied to the anus-emollient fomentations to the abdomen-tepid bath-diluent drinks-lavements, &c. These means having relieved the pain, the bowels were opened by means of castor oil, and the patient was soon able to take solid food. On the 19th of the same month, late at night, M. Bricheteau was again summoned to the patient, who, for six hours previously, had been in racking pain, in the abdomen, which was now so tense and tender, that no examination could be made. The cries of the patient were most distressing, though he was naturally courageous and placable. Yet there was no febrile heat nor acceleration of pulse. Warm opiate frictions, and an opiate internally, quieted the intensity of the symptoms; but it was thought advisable, next day, to apply 20 leeches to the right hypochondrium, and renew the fomentations, &c. The abdomen being rendered softer, M. Bricheteau made an examination, and felt distinctly an oblong tumour or hardness in the region of the pylorus. There was still some pain in the part, and there was now some febrile action in the pulse. The most rigorous diet was prescribed, and cataplasms, with Jaudanum, were kept to the epigastrium. The pain became more and more obtuse, but the patient emaciated-his strength declined he had eructations-obstinate constipation-no sleep-and finally, after a few days of great malaise about the region of the stomach, he vomited up a quantity of black stuff resembling coffeegrounds. The patient felt relieved by this evacuation, but was not improved in other respects. In eight days he had a repetition of the black-vomiting, and now got so low that he made his will, and considered himself a dying man. So did his physician. Nevertheless the Doc

tor recommended repeated frictions, with the antimoniated ointment over the umbilical and epigastric regions. It

required eight days to bring out a plentiful crop of pustules, so dry and harsh was the skin. The vomiting ceased, but the oval tumour could still be felt, and was painful on pressure. The constipation also continued. After ten days immunity from sickness, the vomiting of black matters was renewed by the attempt to take some asparagus. From this time he kept on a system of the most rigid abstinence, with Seltzer-water for drink, and the tumour gradually lessened till it entirely disappeared. Ultimately he was able to resume light animal and vegetable foodhis bowels became more free, and his health was restablished.

Dr. Bricheteau apprehended, for a considerable time, that the disease was an organic affection of the pylorus. The result has convinced him, that it must have been an inflammatory engorgement of that part, not a scirrhous induration. He attaches great importance to the Seltzerwater, antimoniated ointment, and abstinence. To the two last we give full credit, but how far the Seltzer-water contributed to the cure, we will not pretend to say. The case is interesting, as shewing that we should not too hastily pronounce a disease to be scirrhus of the pylorus, though attended with all the usual symptoms of that dreadful disease.-Journ. Comp.

XXXV.

NEURALGIA.

Dr. Wilson, the talented author of a work on West India Fevers, reviewed in a former Number of this Journal, has transmitted to us some observations on the dreadful case of Neuralgia lately published for consultation, in No. XVIII. of this Journal, page 435. We shall take the liberty of quoting a passage from Dr. Wilson's letter, as it contains some practical facts of interest and utility.

"In three cases of neuralgic disease lately under my care, a cure was effected,

by the combination of calomel, opium, and oil of turpentine. In my Memoirs of West India Fever, I there stated my belief that the oil of turpentine not only accelerated the action of mercury, but, also, in certain cases, increased its curative effects. In the neuralgic cases to which I allude, I gave the turpentine chiefly with the view of speedily inducing the specific action of the mercury. I am, now, however, inclined to believe that the turpentine operated beneficially in itself. The following is the mode of administration which I have employed in the three neuralgic cases above-mentioned.

A pill, containing from two to four grains of calomel, and one or two grains of opium, was given each night at bedtime, and, next morning, one or two drachms of oil of turpentine, mixed with a little honey. In each of the three cases, a complete and permanent cure has been effected by this plan, and in a moderate space of time."

XXXVI.

MEDICAL JURISPRUDENCE.

INSURANCE OF LIVES-MEDICAL CERTIFI

CATES-MEDICAL EVIDEnce.

There is a branch of medical jurisprudence which is every day increasing in extent, from the general extent of insurances on lives, and in which, we are sorry to say, the medical character is daily exposed to obloquy, and suspicion of its integritynot so much, perhaps, from want of principle in individuals, as want of reflection on the duty they are called upon to perform. A policy of insurance cannot be effected without a medical certificate, as to the constitution and state of health of the individual, and the ordinary medical attendant is, of course, referred to by the party proposing to insure. We acknowledge that the physician or surgeon thus appealed to is placed in an awkward situation, If he reveals any defect in the constitution, he risks the rejection of the proposal at the insurance office, and, perhaps, some umbrage on the part of his former

patient;-but if, on the other hand, he conceals any flaw in the said life, he not only deviates from the right line of moral rectitude, and thus exposes himself to the loss of character for veracity-but he exposes the surviving family of the party insured, to disastrous law-suits and forfeiture of the policy! All concealments of disorders or tendencies to disease-all misrepresentations of sound constitution, vitiate the policy, according to law and justice, and shake the foundations of those reciprocal advantages which the insuring and insured parties confer and receive. We have daily opportunities of witnessing the unenvied situation in which medical men place themselves by inconsiderate (to give it the mildest term) attestations of sound health, when a minute's exami nation detects an unsound constitutiontoo often, actual disease of some important organ! These instances of loose and improper certificates from medical men

are

now hourly coming before whole companies of respectable and influential members of society, who must, and do form, in consequence, a low estimate of the medical character, thus injuring the whole profession. The evil is still farther increased by the litigations which naturally ensue, as effects of these unjustifiable certificates, and the wide range which the exposure of the medical character takes through the medium of the press. We need only refer to a recent trial between Baron Von Lindenau and the ATLAS INSURANCE COMPANY, where a system of medical misrepresentation came out that is quite sickening to peruse. The late Duke of Saxe Gotha was insured in the above office for three or four thousand pounds, in the year 1824, on the faith of medical attestations, though it turned out that the Duke was even then reduced to a state of idiocy, mutism, and cecity, by an organic disease-a large tumour in the skull, pressing on the brain! Yet the Duke's physicians, Drs. Dorl and Zeigler (shame on such physicians!) certified that they had known the Duke for many years -that his general health was good-that he was merely "hindered in the faculty of speech"-and had an affection of the left eye! The evidence of the Duke's physicians and servants went to matters of fact and we have no hesitation in saying, that these facts were concealed or misrepresented. The evidence of Mr. Green touched matters of opinion-and these matters of opinion we shall quote.

"Mr. Green examined.-I am a surgeon in London, and lecturer at St. Thomas's hospital. I have attended to the evidence concerning the Duke's health. I am of opinion that the tumour in the skull must, during life, have been in a passive state. I think, from the appearance in the skull, that it must have been formed in very early life. Little change could have taken place after ossification, and the base of the skull is one of the parts earliest ossified. It is the nature of organic conformations like that to produce ailments which continue to increase When such tumours exist in a state that may be termed morbid, the ailments increase. Sup. posing the dissection had not taken place, and knowing only what I have heard today of the state of the duke's health before he went to Italy, I should say there was no symptom of an organic disease. The spasms which followed the tertian tever, and even spasms more violent, might have arisen from causes quite unconnected with the brain. The attacks, gradually diminishing and ultimately ceasing, would confirm me in my opinion that they did not proceed from the brain. From the cure of the derangement of his digestive organs at the baths of Marienbad, I should still conclude the brain was healthy. After the dissection, supposing a knowledge of the tumours discovered in the brain, knowing the whole course of his illness, and taking into account the care taken of the duke, I should say, that the probability before his death was that he would have lived five years longer. With respect to what has been said of the duke's difficulty of speech, I hardly know what cause to ascribe it to, from the imperfect manner in which it has been described; but I think it was in the mind rather than in the tongue. I am inclined to ascribe it to a want of volition. I do not think that it is to be ascribed to the tumours in the brain. I should not consider that the catarrhal attacks he had passed through would render it less probable that he would live. I have heard the state of the duke's mind described, but do not think it amounts to idiocy, imbecility, or derangement-quite the reverse.

"Cross-examined by Sir J. Scarlett.Do you not consider vigour of mind to be the reverse of imbecility, and intelligence, of idiocy?—Yes.

duced in this case as showing Duke Frederic to have possessed an intelligent and I have not said so. vigorous mind!

"No, but you say his state was the reverse of imbecile and idiotic; and you allow that vigour of mind and intelligence constitute the reverse of these conditions. When you hear that the duke was controlled in his intellect'-that he was watched like a child-that he was so lethargic that he did not move unless desired to do so, and that he, a prince, suffered himself, at his parties, to be turned round and round for the amusement of his guests-do you, I ask, consider these facts as evincing a vigorous intellect ?--I have beard the evidence imperfectly, if all these things appear. I heard that he had perception, memory and other mental qualities; that he was fond of music, and of hearing reading.

"Do you think that the symptoms pointed out the existence of disease in the brain ?—I do not think so.

"If a patient had had occasional attacks of spasms--if he had been unable to speak for two years--if he had been so indolent as never to move about except when asked to do so--if he was imbecile in his mind-and if, after he became speechless, he was in the habit of frequently putting his hand to his forehead-would you regard these circumstances as indicating any disease of the head?-These symptoms would lead to a suspicion of disease there.

"If the patient had an attack, with redness about the face--became affected with

paralysis, and died; and if, on opening the head, you found a tumour of the brain, and ten ounces of water effused, would these appearances confirm you in your suspicion, and prove that it had been wellfounded?-I cannot give a direct answer to that question. Pressure on the brain, causing loss of speech, would also have produced other symptoms.

"But suppose a case such as I have described?—It is a case I cannot suppose.

"Might not the copious discharge during the catarrhal fever have relieved the brain ?-Possibly it might, but these are cases not frequently falling under my observation.

"Might the sudden suppression of

-Perhaps it might, by a kind of metastasis.

"What do you mean by that?-That an effusion of a different fluid might have taken place upon the brain from the suppression of the catarrhal discharge.

"Do you think the effusion found on the brain had taken place gradually or suddenly?-Suddenly.

By Lord Tenterden.-"If I as a medical man, was asked by an insurance company concerning the state of a man's health who was unwilling to move, who was subject to control upon his intellect, and who had lost his speech, I should not consider myself at liberty to forbear mentioning these circumstances.

"Lord Terterden.-Then there is an end of the cause, for that is the state of the duke described by Dr. Dorl, who signs the certificate sent to the assurance-office.

66

Plaintiff non-suited."

We know not what to say to the foregoing evidence. Heaven forbid that we should find fault with a man on account of his opinions, merely because those opinions may differ from our own; yet we think there will be but one opinion throughout the profession respecting the majority of Mr. Green's conclusions-namely, that they were erroneous. Mr. Green's statements shew, in a clear point of view, the bad effects of directing too exclusively (as surgeons often do) their talents and attention to operations, anatomy, and purely surgical diseases, to the neglect (comparatively speaking) of internal pathology—or, in plainer language, the nature, effects, and phenomena of diseases. We hope this short article will awaken our professional brethren to the necessity of guarding the character of themselves, and the faculty at large, from the reproaches which are gathering like a cloud, and threatening to cast a shade on their integrity, as far as regards the granting of medical certificates for the insurance of lives.

XXXVII.

AMPUTATION AND EXTIRPATION OF THE UTERUS.

In various numbers of this Journal we have given accounts of the above very for

midable operation, which has not, till of late years, been performed in this country. We fear that British experience has now decided against the repetition of the operation, by any man who has reputation to lose; or, who conscientiously weighs the uncertainty of diagnosis, and the sufferings of the patient against the prospect of success. The operation has now been performed five times in this country-thrice by Dr. Blundell-once by Mr. Banner-and once by Mr. Lizars. Of the operations performed by Dr. Blundell, one only has been publish ed-and that the successful one. It is stated in the Medical Gazette, that in the first case, the patient died-and if so, we call upon Dr. Blundell, in the name of humanity and science, to publish that case--and we hope Dr. Blundell will also give satisfactory reasons why the unsuccessful case was not published before this time? We have heard many of our brethren inquire, whether Dr. Blundell has preserved (but how can this be doubted?) the uterus which was removed in the case where the patient survived; and whether he will favour the inquisitive pathologist with a sight of the preparation? It is of great importance to know, whether, in these successful cases, the uterus was really cancerous-and we cannot, for a moment, doubt that Dr. Blundell will be happy to exhibit the diseased organ to any of his professional brethren who may be curious to examine it. In the third case, operated on by Dr. Blundell, we understand the patient expired in nine hours after the operation.

In Mr. Banner's case, the operation was performed on the second of September, in the presence of several medical gentlemen, at Liverpool, and appears to have been dexterously managed; nevertheless the patient died on the fourth day. Mr. B. states, that the uterus was much larger than natural, and that "several tubercles of various sizes were loosely attached to the body and fundus." When we consider how very rarely carcinoma and tubercles are found in the same organ, we cannot but doubt the existence of real cancer of the womb, in the foregoing case, though "ulceration had taken place on the os uteri," and "a section of the uterus exhibited the common appearances of a scirrhus."