ST. THOMAS'S HOSPITAL.

4
141 attention has been paid to this subject. Many efforts have been made to discover the secret of nature in this process ; but bi- therto those efforts have been unsuccessful. All we can say is, that inflammation is increased exertion of the circulating sys- tem of the affected part, but in what that augmented activity consists, we cannot determine. It is an increased exertion, with an alteration in the mode of action, but we cannot point out in what that altera- tion consists. Boerhaave was of opinion, that the particles of blood, stopped up the calibre of the minute vessels ; Cullen thought there was a spasm in them ; others bare supposed them to be in a state of atony or paral) sis ; all these are mere visionary notions. A great many have employed them- selves with microscopic investigations, ob- ten’ing the circulation in the transparent parts of certain animals, and then attempting to ex- cite inflammation, These experimentalists have come to the most opposite conclusions. Some have supposed there is an increased activity; others that there is an obstruction. Now as these have been deduced from direct microscopic inquiries, we can place but very little confidence in them ; and, indeed, such investigations have not at all contributed towards giving us any real information on the subject of inflammation. We can decide that the seat of inflammation is in the capil- lary vessels; and that it is seated in the same vessels which carry on the healthy prucebses of nutrition, secretion, and ex- cretion. We cannot yet tell what the differences are in the structure or action of the minute vessel, which produce the various results of their exertions in the healthy state, and we need not be surprised therefore at not being able to determine what is the difference in them which constitutes inflammation. I shall not now go into this subject, as I should only be commencing what it would not be easy to conclude. I shall, however, occupy the few remdiniug minutes of the hour iu making some observations on one or two cases that are either now or have lately bee.ttn the hospital. ( he learned lecturer then adverted to a ca:r- at that moment in the hospital) of a punc- tured lung, the wound having been inflicted bt a knife, and the patient recovered ; the treatment was simply depletion to a great extent, und quietude. Mr. Lawrence next am’erted to some cases of amputation, and gave it as liis opinion, that in all instances in wh)c’i serious injuries are sustained ren- dering it eviden that amputation was neces- aarr, tJ.e performance of the operation im- or within ten hours from the time of the accident, was wiser than delaying it for a longer period.] ST. THOMAS’S HOSPITAL. ABSTRACT or A CLINICAL LECTURE BY Dr. ELLIOTSON. [Delivered on Thursday, Oct. 15, being the First for the Season.] HYPERTROPHY OF THE HEART. DR. ELLIOTSON rejoiced at the opportu- nity of giving clinical instruction, as he de- livered the general lectures on the prac- tice of medicine, because it was impossible to teach the symptoms and history of diseases, with accuracy and minuteness, without the aid of living illustrations,-and to point out the minutiæ of practice, but by actual treat- ment. He was particularly gratified, at having so large a field of observation for pu- pils. Tiue it is, that much greater benefit may be derived from a small number ,of, cases well observed, than from a larger number noticed superficially ; but the advan- tage of an establishment like this, contain- ing several hundreds of beds, is, that there is such great room for selection of particular cases for study ; and, in the course of the year, examples of all the most rare dis- eases are almost certain to occur. He was glad, also, of the opportunities afforded him, of proving the truth of what he taught. It is very easy, continued Dr. Elliotson, to describe diseases in a plausible and inte- resting manner, and yet with great inaccu- racy ; and to lay down rules for diagnosis and prognosis, and to speak with confidence or contempt of particular remedies. But the lecturer, whose practice is witnessed by his pupils, is continually checked, if dis- posed to exaggerate the facility of dis- criminating between the different diseases, and of foreseeing their termination, or to extol remedies and methods of cure beyond the truth. You may rely upon my most perfect good faitli ; you may depend upon my never preaching one mode of treatment, and practising another; and on my Rever making a statement which you will not see verified at the bed-side of my patients, either as to the history of diseases, their diagnosis, prognosis, or the method of cure. As 1 endeavour to make each visit in the wards a clinical lecture, by explaining every thing I can at the bed-side, J shall devote these lectures principally to morbid anatomy, to a detail of the appearances found after death, whenever an inspection shall have taken place during the week, as morbid anatomy is best taught by recent specimens,

Transcript of ST. THOMAS'S HOSPITAL.

Page 1: ST. THOMAS'S HOSPITAL.

141

attention has been paid to this subject.Many efforts have been made to discoverthe secret of nature in this process ; but bi-therto those efforts have been unsuccessful.All we can say is, that inflammation isincreased exertion of the circulating sys-tem of the affected part, but in what thataugmented activity consists, we cannot

determine. It is an increased exertion,with an alteration in the mode of action,but we cannot point out in what that altera-tion consists. Boerhaave was of opinion,that the particles of blood, stopped up thecalibre of the minute vessels ; Cullenthought there was a spasm in them ; othersbare supposed them to be in a state of atonyor paral) sis ; all these are mere visionarynotions. A great many have employed them-selves with microscopic investigations, ob-ten’ing the circulation in the transparent partsof certain animals, and then attempting to ex-cite inflammation, These experimentalistshave come to the most opposite conclusions.Some have supposed there is an increasedactivity; others that there is an obstruction.Now as these have been deduced from directmicroscopic inquiries, we can place but verylittle confidence in them ; and, indeed, suchinvestigations have not at all contributedtowards giving us any real information onthe subject of inflammation. We can decidethat the seat of inflammation is in the capil-lary vessels; and that it is seated in thesame vessels which carry on the healthyprucebses of nutrition, secretion, and ex-

cretion.We cannot yet tell what the differences

are in the structure or action of the minutevessel, which produce the various resultsof their exertions in the healthy state, and weneed not be surprised therefore at not beingable to determine what is the differencein them which constitutes inflammation. Ishall not now go into this subject, as Ishould only be commencing what it wouldnot be easy to conclude. I shall, however,occupy the few remdiniug minutes of thehour iu making some observations on one ortwo cases that are either now or have latelybee.ttn the hospital.

( he learned lecturer then adverted to a

ca:r- at that moment in the hospital) of a punc-tured lung, the wound having been inflictedbt a knife, and the patient recovered ; thetreatment was simply depletion to a greatextent, und quietude. Mr. Lawrence nextam’erted to some cases of amputation, andgave it as liis opinion, that in all instancesin wh)c’i serious injuries are sustained ren-dering it eviden that amputation was neces-aarr, tJ.e performance of the operation im- or within ten hours from the timeof the accident, was wiser than delaying itfor a longer period.]

ST. THOMAS’S HOSPITAL.

ABSTRACT or A CLINICAL LECTUREBY

Dr. ELLIOTSON.

[Delivered on Thursday, Oct. 15, being theFirst for the Season.]

HYPERTROPHY OF THE HEART.

DR. ELLIOTSON rejoiced at the opportu-nity of giving clinical instruction, as he de-livered the general lectures on the prac-tice of medicine, because it was impossible toteach the symptoms and history of diseases,with accuracy and minuteness, without theaid of living illustrations,-and to point outthe minutiæ of practice, but by actual treat-ment. He was particularly gratified, at

having so large a field of observation for pu-pils. Tiue it is, that much greater benefitmay be derived from a small number ,of,cases well observed, than from a largernumber noticed superficially ; but the advan-tage of an establishment like this, contain-ing several hundreds of beds, is, that thereis such great room for selection of particularcases for study ; and, in the course of theyear, examples of all the most rare dis-eases are almost certain to occur. He wasglad, also, of the opportunities afforded him,of proving the truth of what he taught.

It is very easy, continued Dr. Elliotson,to describe diseases in a plausible and inte-resting manner, and yet with great inaccu-racy ; and to lay down rules for diagnosisand prognosis, and to speak with confidenceor contempt of particular remedies. Butthe lecturer, whose practice is witnessed byhis pupils, is continually checked, if dis-posed to exaggerate the facility of dis-

criminating between the different diseases,and of foreseeing their termination, or to

extol remedies and methods of cure beyondthe truth. You may rely upon my mostperfect good faitli ; you may depend uponmy never preaching one mode of treatment,and practising another; and on my Rever

making a statement which you will not seeverified at the bed-side of my patients,either as to the history of diseases, their

diagnosis, prognosis, or the method of cure.As 1 endeavour to make each visit in the

wards a clinical lecture, by explaining everything I can at the bed-side, J shall devotethese lectures principally to morbid anatomy,to a detail of the appearances found afterdeath, whenever an inspection shall havetaken place during the week, as morbid

anatomy is best taught by recent specimens,

Page 2: ST. THOMAS'S HOSPITAL.

142

especially if those specimens be taken fromcases observed during life by the bearersthemselves, and as there is little opportu-nity for minute instruction of this kind inthe dead house.The subject to which I now call your at-

tention, is a very interesting one ; namely,hypertrophy of 6e heart. The word hyper-trophy is derived from two Greek words, sig-nifying excessive nourishment. Most parts ofthe body are liable to tI,is morbid condition.When a part is hypertrophic, it may haveacquired inor2 than the usual hardness or

softness, or its consistence may be natural ;it may likewise be of the natural colour, orthere may be increased redness or paleness.If the heart should be the part affected, itscavities may be of the natural size, and it isthen denominated simple hypertrophy. Ifthe cavities be enlarged, it ia termed eccen-tric ; and when diminished, concentric hy-pertrophy.The natural size of the heart is about that

of the individual’s fist; of course there willbe slight deviations, even in the healthy icondition ; but, as a general rule, its bulk Iwill be found about equal to that of the fist.The parietes of the left ventricle are, natu-rally, twice the thickness of the right, andmeasure about half an inch, but the propor-tions vary with age. In infancy, for in- (stauce, it is three or four times thicker thanthe right, and proportionally thicker also inthe aged; and without this knowledge; a

healthy heart, especially of an infant, mightbe supposed hypertrophied. When cut, theleft ought to remain open, but the parietesof the right should fall together, and effacethe cavity. The cavities of the two ventri-cles are naturally about equal in size. Hy-pertrophy is most frequent in the left ven-tiicle, and is generally greatest at the base;but in concenttic, where the increasedthickness occurs from deposition inwards,and the cavity is conspquentty lessened,there is as much thickening of the walls atthe apex, as at the base. The septum isoften enlarged in hypertrophy of the leftventricle, as are also the carne:e columnae.We must bear in mind, however, that theseare naturally larger in the right ventriclebut are more numerous, and their networkmore intricate and delicate, in the left. Ifthere be dilatation also, aud of both ventri-cles, the heart may acquire an enormoussize, as in this instance. [There weretwo hearts on the table, one of Mhichhad been procured (from the dissecting-room) to how the natural size of that!!

organ. ’1 he other, on which Dr. Elliot-son was lecturing, must have been nearlythree e times the size of the former.] Then i

the heart assumes a round form, for hy-pertrophy increases the length more par-titularly, and diiatatioa the breadth. Hy- )

1 pertrophy may occur without adding to thes density, for if the heart be dilated, and notthinner than natural, it must have additionalt matter to maintain its former degree of

thickness, otherwise it would become thin*ner by dilatation. This fact is often over-, looked in post-mortem examinations, and,consequently, hypertrophy pronounced to

be absent when it really does exist. Thisfconsideration shows how enormous must be. the addition, when the parietes are thicker

than usual, and yet dilated. The present’ heart is an instance of extreme thickening; and dilatation combined, and therefore of’ intense hypettrophy. There is hypertrophy, of both ventricles, but chiefly the left. The. septum is enormously thickened, and thecarneæ columnæ of the right ventricle ore, larger than I ever remember to have seen

them. The following are the symptona

ofhypertrophy of the heart : violent action ofthe heart; if both vertricles 1,.e implicated,the impulse is violent at the left cartilages

and sternum ; if the left only, then tbeaction will be strongest at the lefteartilagesiif the right alone, at the sternum ; if dilata-tion exist also, this action is far strongerand more extensive, reaching to the sternum,and even to the right cartilages, though onlythe left ventricle is affected, for the left mayextend to the region of the right, and pushthis ventricle behind it; also a dull sound isheard, more extensively than in health, onstriking on and around the cardiac region.There is olr5o some anasarca, and great dif-

ficulty of breathing on any sliglat exertion.When the left ventricle is hypertrophied,there will be a strong, large, full, pulse,

particularly if it is dilated also, aud thenthere may be violent pain in the head, andthe pulsation of the carotid and temporalarteries very distressing. In one case ofhypertrophy, 1lOwever, the pulse will basmall, though hard, like acord often, viz. iaconcentric, where the cavity is lessened,from the deposition taking place inwards,because little blood can be projected at eachcoatraction into the arteries; yet here alsothere will be strong action found in the

region of the heart, by the ear or hand. la

every other case the pulse will be alwaysvery full, unless the mouth of the aorta bemuch diminished. The symptoms of hyper-trophy were duly observed in this instance.as I find in the following account taken byDr. Roots, who attended the case duringmy absence., A. B., aged 55, says that about January!last, after leaving off a waistcoat, he wasattacked with pain at the epigastrium, ex-tending afterwards over the whole abèo:nen.for which he says he was largely bled andblistered, but has never been well sincethat time. Has now pain in the region ofthe liver on pressure, and the liver appears

Page 3: ST. THOMAS'S HOSPITAL.

143

enlarged, and hard under the hand. Is.

slightly jaundiced, and has the red nose of.an hnbrtsial drunkard. For the last two orthree mouths, has had great dyspnœa onmoving quickly, with palpitation of theheart; lies best on the right side, cannotsleep on the left. Sleeps badly, unless bend.ing his cliest forward on a table or back of ac!nir, and often awakes suddenly in a fright.1 he legs have been anasarcous the last threemonths ; urine scanty and high coloured ;respiration audible over the whole chest,but sonorous, and with mucous rattle; actionof heart irregular ; impulse of left ventriclestronger than right ; pulse 72, irregular,full, and strong; tongue clean ; bowels

open. Has thick expectoration.But the hypertrophy is not all, for the aorta

is extremely diseased, and rendered quiterugged by a deposition of a peculiar yellowsubstance, under the internal coat. Theaortic valves much thickened, and such car.tjjaginous deposite at one part, that the pas-sa;e of blood there must have been imped-ed. This was ascertained during life ; foron applying my ear, I found a bellows sound,in the region of the left ventricle, synchro.nous with the arterial pulse ; that is, at theaction of the left ventricle, Now the leastimpediment to the course of the blood inthis part, will cause bruit de soufflet, an im-pediment far too little to be noticed by oneunaccustomed to minute examination of theorgan. The impediment may be, pressurefrom without, there being no disease of thesubstance, or lining membrane of the heart;for instance, I once heard a bellows soundfrom the existence of a piece of bone, be-tween the aorta and pulmonary artery.* Itis sometimes caused by a contraction at thebeginning of the aorta, without thickening,and may then be discovered; as the leastobstruction will be sufficient to cause thispeculiar sound, which is often produced byan obstruction insufficient to occasion di.minution of the pulse. A great contractionof the left auriculo-ventricular opening, orthe mouth of the aorta, will cause smallnessof the pulse, for the same reason that di-minution of the left ventricle does, viz. thatso little blood can be propelled into theacrta. But a contraction far too little tocause tbis effect, will produce the bellows-sound. Even no contraction, but relativesmaliness, will do the same ; I meati if a ca-vity be greatly enlarged, and the openingfrom the cavity remain of its usual dimen-tions. Sometimes, too, the contraction maybe spasmodic, like that of the urethra, whengreatly irritated. But when the bruit desoufflet is constant, and there are signs ofdisiaaed heart, we may conclude with a to-

For a history of this case, see LANCET,No, 228, p. 223. A. D. 1828—9.—R. L.

ferablia degree of certainty, that the openingis diminished. A bellows-sound at the ven-tricular action, shows smallness of the arte-rial opening ; if loudest at the left cartilages,this is of the left ventricle ; if loudest underthe sternum, it is of the right ventricle.But when in the right ventricle, I have seenit occasionally produced by the tricuspidvalve not being efficient, so that the bloodregurgitated from the right ventricle (at itscontraction) into the right auricle.The violent action of the ventricles, espe-

cially the left, and full pulse, showed thehypertrophy of the ventricles, and the leftparticularly. The bellows-sound at the ven-tricular action, at the left cartilages, showedcontraction of the aortic opening ; everything that we found was known before death.The symptoms, independent of ausculta-

tion, were purely those of hydrothorax, andthose who despise the use of the stethoscope,would have mistaken it for such:—Dyspnœa,starting up from sleep with fear of suffoca-tion, pale cheeks, blue lips, coldness of theextremities, swelling of feet, paucity ofurine, palpitation of heart, quick and irregu-lar pulse. Auscultation alone made knownthe state of the heart, and it also showedthat there was no water in the pleura, forrespiration was heard all over the chest.The man could not lie on his left side ;

this is a common symptom of hypertrophy ofthe heart, and of all violent action of it, forit then strikes the left ribs so violently, thatgreat suffering is induced. He died sud-denly ; and this is frequently the case, indisease of the heart. The over-excited ordiseased organ intermits its action, a state

of syncope is induced, and only terminatesin death.This case illustrates also the general fact,

that the left side of the heart is more liableto disease than the right; for while the’, valves of the left ventricle are so diseasedand the aorta presents such a rough surface,the pulmonary artery is smooth and healthy,and its valves translucent and thin, thoughthe semilunar base of each is certainly in-durated. The hypertrophy, too, is muchgreater in the left ventiiele than in the right.The cause of hypertrophy is, generally, in-flammation of the pericardium, violent ac-tion from exercise, or impediment; or a pe-culiar disposition, not understood, but quiteindependent of disease of the valves, fre-quently brought on by drinking.

In this man, the obstruction was not suffi-

cient :to explain it, and he had made no vio-lent exertion, it was probably the effect ofdrink, for he had drunk freely, and his ap-pearance was that of the caricatures ofSheridan and Sir William . Curtis, a big

belly, pale cheeks, and red nose. He was aBardolph, and had- only to walk fast, on re-turning from a party, and he would spare his

Page 4: ST. THOMAS'S HOSPITAL.

144

friends the expense of a lanthern. Drunk.enness does not affect the liver only, as i!often supposed, but most parts of the body :the nose also most unquestionably : but itthickens the serous membranea, peritoneum,and pleura, and without any affection of theliver, will cause dropsy of those membranes.It indurates the liver, thickens the mucousmembrane of the stomach and intestines,and commonly thickens the pericardium andheart. Many persons die with dropsy aftera life of drinking, wh(re no disease of theheart is suspected. The acute symptomswhich this man had laboured under, were,probably, inflammation of the pleura, peri-cardium, and liver, predisposed to by hisregular labits of drinking. Lymph stillexists in some parts of the pericardium ;whether the pericarditis caused the hyper-trophy, or whether this existed before, can-not be decided with any certainty. I shouldthink that the hypertrophy existed, first, be-cause it is almost too considerable to haveexisted so short a time. The posterior pul-monary pleura was covered with lymph -,the liver hard, presenting that appearancewhich is designated a nutmeg liver; a state

considered by Andral, as hypertrophy of thesecreting portion of the organ. The treat-ment of hypertrophy is to be by venesectionand cathartics, colchicum, digitalis, and

mercury. Low diet, rest, and avoidingall excitement ; you must, however, becautious not to carry the bleeding too

far, as the strong, full, and sharp pulse,may continue till the day of dpatli, fromthe great substance of the heart, whilethe rest of the system is exhausted. Ifthe pulse alone is regarded, and not the Igeneral powers of the patient also, vene.section may be pushed to a dangerous ex-treme, as too copious evacuation may onlyrender the heart morbidlv irritable, and thus ’quicken the pulse and increase the distressand mischief. ’the case was treated on theseprinciples by Dr. 1,oots until my return, afew days before the man’s sudden death : ;but the case was, 1 am convinced, totallyirremediable at the time of his admission.When a person has been steadily undermin-ing his constitution every day for a series of,years, it is absurd f r him to hope that the’mischief can be remedied by ri little medi-cine. Living and dead, the fate of this man Iwas a sermon against drinking.

HE- WITtt A HUMAN FACE.

C l VIE relates in his "Animal King-dom," that he saw a hen vvitli a humanface, that was exhibited by a Polish Jew, iu18002.

ST. BARTHOLOMEW’S HOSPITAL

CLINICAL LECTUREBY

MR. EARLE.

FRACTURES OF TIIE LOWER EXTREMITIES.e TnE lecturer commenced by stating, thats the circumstance most worthy of Dote,, which had occurred during his taking-iuweek, was the admission of an immense num-ber ot fractures, particularly of the lower,1 extremities. As fracture of’ the lower ex-

; tremity was very frequent, as the treot-

- ment was very difficult, and as all the cir.- cumstances attending it were calculated torender it of great importance, he should con-. fine his present observations to this subject.Want of proper attention on the part ofmedi-cal men, was often not only productive of the; most serious mischief to the patient, but ofirreparable injury to the practitioner him.self. He knew a gentleman in the countrywho had succeeded to an excellent practice,and who, in consequence of mistaking orneglecting a fractured thigh, was obliged toabandon that practice, and remove from thepart of the country in which he bad lived.

Fractures might, for the sake of conveni-ence, be arranged into four classes, viz. thesimple, where there was merely a breach ofthe continuity of the bone; the comminuted,where the bone was broken into manypieces; the compound, where there was an

external wound communicating with the

fractured parts of the bone ; and the cont-

plicated fracture, or that in which other

tissues, or parts of importance, were injured,(and which, frequently, was of the first im- portance in the treatment, particularly in the; neighbourhood of a joint,) or where large! blood-vessels were ruptured or seriouly inj ured.

After fracture had taken place, displace-ment might occur either with reference to

the diameter, or with reference to the lengthof the limb. In a transverse fracture, thelimb might not be actually shortened, thoughthe fractured ends were not exactly in situ.The direction might be affected, according tothe circumference of the limb ; more particu-larlv this was the case in fractures of the

upper part of the thigh. The proper direc-tion of the limb might likewise be consider.ablv varied from its natural axis. Thesede;iations might be produced by the conti-nued application of the force causing thefracture-the superincumbent weight of thebody—the injudicious wav in which patientswere removed an er the accident had hap-pened-a sudden and violent exertion of the