We know not whether this may be fairly stiled a case of fungus hæmatodes of the breast, for, in fact, nothing is so difficult as to assign a name and classification to each tumour we come across. Whether it was or was not fungus hæmatodes, Mr. Morgan acted very rightly in removing it, for it bade fair to go on to the destruction of the patient, if let alone. Was the disease originally malignant, or was the "small lump" observed in the breast for ten years previously, a mere chronic enlargement, which, under particular or accidental circumstances, was converted and ripened, in so short a time as fourteen weeks, into a large and formidable tumour ? The question is more easily asked than answered.

3. CASES OF INTERNAL STRANGULATION.

[La Charité. M. Louis.]

These cases are uncommon, but they are probably not so much so as is imagined. Modern pathological investigations are daily placing such instances on record.

Case 1. A female, aged 34 years, of moderate embonpoint, was admitted into LA CHARITE, on the 15th December, 1824. Her menstrual discharge had been suppressed from the age of 18, and she suffered pains in her loins, and other inconvenience, at stated periods ever since. She had been six days ill before she came to the hospital. The complaint commenced with thirst, loss of appetite, nausea after taking food, shiverings, perspirations at night. Still she had regular, though scanty evacuations from the bowels. On the fifth morning she had numerous bilious vomitings, with pains in the hypogastrium, which pains became more and more considerable, accompanied by a burning heat there, augmented by pressure. Sixth day. The vomiting still continued, and there was obstinate constipation, with an indescribable pain about the anus.

At this period she was bled from the arm, by a private practitioner, without any relief. On coming into hospital, she presented the following symptoms:-Countenance yellow, and exhibiting signs of prostration-malaise-anxiety-constant restlessness-white but moist tongue-ardent thirst-epigastrium soft, and void of pain-nauseaabdomen rather distended and painful below the umbilicus-constipation-retention of urine-pulse small, quick, and feeble-temperature of skin little elevated. The bladder was emptied by the catheter, and 30 leeches were applied round the umbilicus, to which succeeded fomentations and lavements, but the latter could not be thrown up. 16th. No relief; indeed, the symptoms were rather aggravated, and the abdomen more enlarged. Another relay of leeches-warm bath-castor oil by the mouth. Lavements could not be made to pass up. 17th. The skin was generally yellow, and the features shrunk, while the abdomen was still more distended, and the constipation as obstinate as ever. M. Chomel examined the rectum with his finger, and found it spasmodically contracted. 18th. She died.

VOL. VIII. No. 15.

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Dissection. We pass over the appearances in the head and chest, as presenting nothing particular. On laying open the abdomen, the small intestines rushed out, and were greatly distended. In several places, they were glued together by coagulable lymph of recent secretion. The strangulation was found in the ileum, 22 inches from the cæcum, and the portion of strangulated gut was two feet in length. The strangulation was effected by means of a ligamentous cord, 21 lines long, and one line broad, which bound the ileum to the sigmoid flexure of the colon. This cord, which was probably slack in a natural state, had formed a kind of noose, through which the knuckle of intestine had unfortunately passed, and thus became strangulated. The more the ileum was distended, the tighter the stricture became. It is difficult to conceive how a band or cord, only 21 lines in length, could thus form a noose, through which so large a portion of bowel had descended; but such was the fact, and, therefore, all the symptoms antecedent to death were easily explained.

Case 2. A female, aged 31 years, was admitted into LA CHARITE, on the 30th April, 1827, having been ailing for three months previously. The complaint had commenced with pain of a wandering kind in the abdomen, nausea, bilious vomitings, thirst and occasional chills, followed by increased heat. These symptoms continued, with more or less intensity, for ten weeks, during which she could not procure alvine evacuations without the aid of lavements. Her appetite had entirely failed, and she lived solely on small quantities of milk. More than a hundred leeches had been applied to the abdomen, without any benefit. For a fortnight before entering the hospital, the constipation had been obstinate, the lavements returning unchanged, and the vomitings were frequent. May 1st. Great anxiety-expression of suffering in the countenance-constant change of position-plaintive moanings-the intellectual faculties unaffected. Her tongue was red and dry--thirst urgent-occasional nausea-abdomen voluminous, and, while in pain, the convolutions of the intestines could be plainly distinguished. Leeches were applied to the abdomen. 2d. The pains were rather mitigated; but no other alteration in the symptoms was perceptible. Purgative lavements were thrown up, and eight grains of calomel were given by the mouth. The patient was in great pain during the remainder of the day, and had two very small motions. She died the next day.

Dissection. There was no extravasation in the abdomen, which was principally occupied with the distended convolutions of the small intestines not adherent to each other. A portion of ileum, not far from its termination in the cæcum, was found intimately adherent to the side of the uterus in the pelvis, and there a kind of zig-zag twist or knot had formed, which completely strangled the intestine. The small intestines were, of course, greatly distended with matters above the obstruction, and their mucous membrane was ulcerated in several points. It was observed that the coats of the distended ileum, above the obstruction, were prodigiously thickened, especially the muscular coat-doubtless from the constant efforts which the tube

was making to force the obstruction below. This teaches us how the parietes of the heart may acquire a state of hypertrophy, where an obstacle is presented to the flow of blood through the vessel.-Archives Générales.

These two cases are the only ones of the kind which M. Louis has observed, during a period of six years, in LA CHARITE, where he examined, in that period, 530 dead bodies. In eight years, we have met with two cases of this kind, in private practice-one of which was that of the late Mr. Belzoni's servant, of which case we stated the particulars in a former number of this Journal.

4. EMPYEMA AND PNEUMO-THORAX.

BY DR. DUNCAN.

[Royal Infirmary of Edinburgh.]

In the October number of our northern cotemporary, Dr. Duncan has stated some cases of the above diseases, partly from an interest which he felt "in tracing the progress of his own knowledge," and partly with the hope that they may prove instructive to others. Empyema and pneumo-thorax, Dr. D. observes," are recognized, during the life-time of the patients, by the common symptoms-or, by the more recent methods of investigating pulmonary diseases, by percussion and the stethoscope. It is after their presence has been suggested by the FORMER, that we have recourse to the LATTER, for the purpose of acquiring CERTAINTY. These never leave the diagnosis doubtful when they are employed." Dr. D. asserts that he was among the first-if not the very first, who made use of the stethoscope and percussion in this country-that he persevered, "notwithstanding the ridicule and sneers of the ignorant and prejudiced." "I have now," says he, "the satisfaction to see that they (auscultation and percussion) are duly appreciated by the whole profession-even by those who at first opposed them." Softly, friend Duncan! These means are very far from being duly appreciated by the whole profession, or by one half of the profession; but they are becoming more and more so every day. What will Dr. Duncan say, when we inform him that, on the day we received his Journal, (2d of October) a professor of physic, and a public lecturer in this metropolis-one, too, who is not more than 40 years of age, and, consequently, not past the period of improvement-publicly denounced the stethoscope as a French bauble, or piece of quackery, which he would never countenance! There are many of the most eminent physicians and surgeons in this metropolis who entertain the same sentiments as the professor above-mentioned; but they are beginning to be less clamorous against the study of auscultation, because they have just discrimination enough to see which way the cat jumps. Nay, there are many who pretend to a knowledge of an instrument which they deeply hate and secretly curse, because the study of it interrupts the placid course of their routine practice. We saw one of these worthies the other day put on a look of great wisdom-apply the wrong end of the stethoscope to his ear-hold the other end about two inches from

the patient's chest-and sagely remark, that he heard, very distinctly, the respiratory murmur! This respiratory murmur was no other than the murmur of a hackney coach, passing over a piece of newly macadamized street, opposite to the patient's house! Were it not that the subject is very serious, we could relate some anecdotes of great physicians, which would be very likely to create a smile in the most saturnine countenance. We shall venture to state one instance which occurred to us this very day-2d of October, in the year 1827.

Mr. Charters, an eminent coach-builder in this metropolis, who has consulted almost every physician and surgeon, of any reputation, both in this country and the Continent, presented himself to us-observing, with a significant and intelligent smile, that he came more from curiosity, than with any hope of advantage. We were determined to return the compliment, though we took care that he should not see the drift of our particular inquiries. By a little management we induced the patient to return home, and collect the prescriptions and written opinions which he had received from the lions of physic and surgery. These he submitted to us-not without an air which sufficiently indicated the degree of respect in which he held medical opinions generally. God forbid that we should be so base as to turn any of the documents which were placed in our hands to the detriment of any individual. But we will say, that a statement of this gentleman's case, and a detail of the opinions and prescriptions which he had received, would form an appendix to " WADD'S MEMS. MAXIMS, and MEMOIRS," which might rival the whole collection which that indefatigable surgeon has compiled! The venerable PORTAL, now on the verge of 80, is in no danger of suffering from, or even knowing, any criticism which we make on his opinion. This opinion occupies nearly two foolscap pages, and sets out with stating that Mr. C.'s liver is so enlarged as to reach nearly to the pubes, on the right side. It then descants on the physiological effects of this enormous liver on the organs and functions of the thorax and abdomen, concluding with very minute directions as to diet and medicines, with the view of counteracting these derangements of function in the contiguous vis

cera.

After a most accurate examination of the patient, in the horizontal and vertical positions, we declare that no part or portion of the liver descends below the ribs, or can at all be felt, even when Mr. C. holds in his breath and strains downwards! The patient is so thin, that the aorta can be distinctly traced, from the origin of the cœliac artery to its bifurcation-and in such a person, it is needless to say that an enlarged liver could not possibly be overlooked. Now it appears quite evident, that M. Portal fell into some long reverie or dream of early life, and unconsciously portrayed, on his large foolscap pages, the case of some patient who had passed under his hands half a century previously! If any thing could induce men, when entering their dotage, to reflect on the lot of humanity, and retire before their loss of intellect becomes conspicuous to the world, the above instance might prove a useful hint. We shall draw a veil over the incongruous opinions and wild plans of treatment which are scattered on the record preserved by Mr. C. To our apprehension, the opinion of

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Magendie came the nearest to truth:—namely, that there was dilatation of the right chambers of the heart, and some degree of hepatization of the lungs. As there is scarcely a medical man of fame in this metropolis who must not recollect the case of Mr. C. the above anecdotes may be interesting to them.

We shall now notice one or two of the many cases which Dr. Duncan has put on record in the last Ed. Journal.

Case 1. Mark Young, aged 33, had been under Dr. Home, in the clinical ward, when Dr. D. took charge of it, on the 1st Feb. 1815. Dr. H. treated the patient for hydro-thorax. For some time he had laboured under such painful micturition as to mask the thoracic affection. His whole complaint was of the pain in the urethra, before and after making water, to which the calls were very frequent. He had also difficulty of breathing in going up an ascent-fluttering at the region of the heart-pain on pressure at the epigastrium, and also in the hypogastrium. The difficulty of breathing came on five years previously, after an inflammatory attack. Dr. Duncan's whole attention was directed to the disease of the urinary organs, but entirely failed in affording the patient any relief. It is stated, however, that he had cough and difficult expectoration, with a pulse at 146, small and sharp. In this condition the poor fellow expired, being completely worn out. The dissection was performed by the late Dr. Gordon.

Autopsia. The pleura costalis of the right side was observed to be much thickened, and, in that side, there were 130 ounces of opake fluid, resembling the serum of the blood, but which, on being agitated, looked like cream. There were flakes of coagulable lymph in various parts of this side. The lung was compressed to about one eighth of its natural size, but seemed otherwise healthy. There was a small abscess in its upper part, and numerous small abscesses were dispersed through the substance of the other lung. There were three ounces of clear fluid in the pericardium, but the heart itself was healthy. The left kidney and ureter were free from disease; but the projecting papillæ of the right kidney were in an ulcerated state, and their membranous coverings, the infundibula, nearly destroyed. The pelvis of this kidney was enlarged, and filled with a granular matter, resembling particles of inspissated pus. The ureter was much dilated. The inner coat of the bladder was inflamed throughout, and, in many places, ulcerated. The prostate gland and urethra appeared free from disease.

Dr. Duncan has little doubt that this man's death is to be ascribed solely to the disease of the urinary organs-and "that his fever and emaciation proceeded entirely from irritation and want of sleep." We cannot agree with the learned Professor on this point. Such a collection of purulent matter in the right side of the chest, with a diminution of that lung to one eighth its natural size, while the other lung was universally studded with small abscesses, and the bronchia filled with pus, were circumstances quite sufficient to destroy lifeand cannot be left out of the cause of death, notwithstanding the inflammation and ulceration of the bladder.

We were a little surprised to find that Dr. Duncan, who takes the