II.

Case of the late Mr.Knox, Surgeon, of Great Russel Street, with the Appearances on Dissection. By J. Johnson,M.D. Ir may seem a paradox, but I think the following dissection will prove it to be an incontestible fact, that the magnitude of an organic disease will sometimes render it incognizable by the physician and anatomist, during the life of the patient.

The late Mr. Knox, Surgeon, in Great Russel Street, had been for several years in an infirm state of health, owing, as he imagined, to a liver complaint. The prominent features of his disorder were, indigestion, sickness at stomach, and an irregular state of the bowels, attended with loss of flesh and strength. Latterly, and when obliged to confine himself to the house, gastric irritability, uneasiness in the region of the stomach, and a dysenteric affection of the bowels were the predominant sources of complaint. At this time, viz. in January and the beginning of February 1820, Mr. Knox was visited by several of the most eminent physicians, and also anatomists of this metropolis--and they unanimously declared that there were no evidences whatever of any enlargement or organic disease of the liver. I did not see the patient till the day before his death, and the surface of the abdomen being raw from the effects of a blister, I made no manual examination, and hazarded no opinion on the nature of the case. To the eye there was no appearance of an enlarged liver. He died the next day, and I had permission to examine him. The following minutes I sent to some of the medical gentlemen who had seen Mr. Knox before his death, but who were not present at the examination.

Minutes of Dissection.-Present, Dr. Armstrong, Mr. Ogle, Mr. Plumbe, Mr. Dickenson, and Dr. Johnson. 14th Feb. 1820. Considerable emaciation-sallowness and slight yellowness of the skin. On laying open the abdominal cavity, a quantity of yellowish serum ran out. The liver was enormously enlarged, filling both hypochondria, the epigastric region, and stretching from the ribs of one side to the ribs of the other. It also extended downwards to near the umbilicus. It was studded, both on the convex and concave surface with irregular-sized white tubercles, not very prominent, except at one part of the concave surface. The substance of the liver being cut into, presented a structure almost totally morbid. The tubercular masses were in various stages: some of them pretty firm, white, and homogeneous; others soft, and almost gelatinous, while considerable masses of them were broken down into a fluid resembling pus or cream. From one of these depôts a continued stream of this purulent-looking fluid issued, on being cut into by the knife.

There were very few traces of the original parenchymatous structure of this organ remaining, and these portions were pale, flabby, and thinly distributed among the disorganized portions. There was some thin watery bile in the gall-bladder. On the under surface of the diaphragm, and exactly opposite to a rather prominent and irregular tuberculated mass, was an elevated morbid structure, very hard, irregular, and precisely corresponding in size, with the projecting tubercular mass on the liver. It appeared to be caused by the irritation of the latter.

The stomach appeared sound externally, but the villous coat was as smooth and pale as a sheet of writing paper. It could be easily peeled off from the subjacent muscular coat. The pyloric orifice was little, if at all, contracted; but its parietes were enlarged and indurated into a solid and irregular scirrhous mass. It is curious that exactly opposite the pylorus, and in contact with it, was a ruggid, hard, and irregular tubercular projection of the liver, and which may be considered as having long kept up a degree of irritation upon that part of the stomach which was in contact with it. This idea is strengthened by what was seen on the diaphragm, as above stated. There was no ulceration of the pylorus. The pancreas was somewhat enlarged, and appeared to partake a little of the morbid structure of the liver. The first order of mesenteric glands were enlarged and intensely indurated, appearing like a thick-set row of white beads strung all along the interior curvatures of the small intestines. The other mesenteric glands were not much affected. The large intestines were irregularly contracted and dilated in several places. There were ulcerations in several parts of the mucous membrane of the large intestines. The thoracic viscera were sound."

It is almost needless to remark that the uniform expansion of the biliary organ over the epigastric and hypochondriac regions, its thin edge losing itself among the intestines in the umbilical region, was the cause why no enlargement of the liver could be detected by the hands of physicians, surgeons, and teachers of anatomy, during the life of the patient. This statement, therefore, is not meant to insinuate any want of discrimination on the part of the medical attendants, but to show what sources of fallacy we have to contend with, in the investigation of diseases, and how cautious we should be of giving hasty and decided opinions on the nature of internal lesions. It is remarkable, but it is reasonable enough, that the confidence of our decisions, on these occasions, is generally in an inverse ratio to our years and experience. The perusal of the above case may teach the juniors of the profession humility, which is an attribute of wisdom, and

induce them to be not only cautious themselves, but merciful and charitable to their brethren.

I think an attentive consideration of the above appearances would lead us to trace the origin of the disease to a tuberculated state of the liver, and to view the other lesions, functional and organic, as consequences of this state. It may, however, admit of doubt whether or not the induration of the mesenteric glands was coeval with the disorganization in the liver. The disease was evidently incurable from the beginning; and it is sufficiently obvious that any very active mercurial treatment would be more likely to do harm than good. I may be permitted to make one more remark. The size of the abdomen, during life, could not have been in proportion to the great emaciation of the body generally :-and although this, of itself, would not lead us to suspect enlargement of the liver, it was a strong indication of disease of structure in some part or parts of the abdomen.

Spring Gardens, 1822.

JAMES JOHNSON.

III.

Lincoln, Sept. 13th, 1822.

SIR, I have taken the liberty of sending you the following case, as it appears to me to confirm the statement of M. Richerand which is noticed in the 427th page of your excellent Review. J. SWAN.

Joseph Ashton, ætat. 48, was admitted into the County Hospital in October 1821, with a cancerous disease, which occupied the right angle of the mouth, and extended over the whole of the lower lip. It was evident the disease must soon prove fatal; and it was the desire of the patient that 1 should try to relieve him. I began my incision at the upper lip, as near to the angle of the mouth as the disease would allow; and continued it very near to the masseter muscle. I then made another incision obliquely towards the chin, and removed the whole of the lower lip, nearly as low as the chin. I separated the small remaining part from which I removed the lip with the scalpel, from the jaw, to allow of its being drawn towards the upper lip. I brought the parts together with sutures, but nearly the whole wound flew open; nevertheless it healed very well, and the part supplying the place of the lower lip was drawn considerably towards the upper one, so that the mouth performed all its functions. well, and had a much better appearance than could possibly have been expected. Had the removal of the lower lip occasioned much inconvenience, it was my intention to have made a new one from a portion of the skin under the chin.

XIII.

CORRESPONDENCE, INTELLIGENCE, &c.

We have again to call the attention of our foreign, and more especially our American brethren, to the thoughtless custom of transmitting packets to us by post. Two parcels (we imagine of journals) lately were presented to us by the postman, one having 31. 68. and the other four pounds sterling, marked as postage. We were obliged, of course, to refuse them. We request those gentlemen who honor us by the transmission of journals or books, to take opportunities of sending them by private hands, and thus prevent the disagreeable necessity we are under of returning them to the post-office.

Some of our friends are alarmed lest we should introduce new changes in our journal. They need not be alarmed. We will make no change. The regular limits of the Review (224 pages) shall never be encroached upon, or devoted to any other purpose than that of reviews:-but if we choose to give Extra-limites papers at the private expense of ourselves or our contributors, surely the public have no reason to quarrel with us for such conduct. If the Extra Limites are not good, the subscriber pays nothing for them, and he is not forced to read them-if they contain valuable matters, we think we are entitled to thanks rather than censures for introducing them free of expense.

The Medical Intelligencer has misunderstood us when we alluded to the coincidence of opinion between Drs. Curry and Armstrong respecting typhus fever. That coincidence only referred to the etiology, and not to the name or abstract nature of the disease. Both the distinguished physicians in question have attributed the fevers, usually denominated typhus, of late years, to a terrestroaerial cause, or, in other words, to malaria, rather than to contagion. This is the coincidence to which we alluded, and we adhere to the statement which we then made.

Mr. Godfry's letter respecting a quack calling himself "Dr. Bloomfield," has been received; but it would be useless to pourtray the tricks of such wretches to our professional brethren, and beyond the faculty a medical journal is very little known.

We have it in contemplation to adopt Mr. Kingsley's suggested improvement in respect to the index, at the end of the volume. We thank him for the hint.

QUIDNUNC's letter (the postage of which, by the way, ought to have been paid by him, for it was not worth 1s. 1 d. to us) has been received. He informs us, among other things, that most of our reviews are anticipated by our cotemporaries. The remedy he proposes would be infinitely worse than the disease. We neither did nor do pretend to give the earliest account of books, or to be the first to pronounce sentence on their authors. Our object and Vol. III. No. 11.

4 U

698

Correspondence, Intelligence, &c.

[Dec.

end is to give the fullest account of publications—and that cannot be done, in a quarterly journal, unless we are granted time to do so. Be it remembered that our vessel is large, heavy laden, and a slow sailer, making only four instead of twelve voyages in the year. And yet we could shew our friend QUID some sturdy proofs that there are many customers for these stale commodities; for notwithstanding the multiplicity and velocity of medical journals, it happens occasionally even yet, that, "news much older than our ale goes round." Be that as it may, we are sorry we cannot comply with Quidnunc's proposed changes in the constitution of our Journal. Our present maxim is "nolumus leges operis mutari," lest there should, at no distant period, be written on the tombstone of the Journal, an epitaph that might probably apply to some of Dr. QUID's patients"we were doing well-took further advice-and here we are."

P. S. You advise us, dear QUID, to change the title and envelope of the Journal. Pray set the example by enveloping your next epistle in a frank. Nothing is so vulgar as those long drawling figures of the postman on the cover of a letter. Besides a man of your mutable politics must have many patients in Parliament.

The epistle of ANTI-EMPIRICUS came to hand, but in it we clearly discern the QUACK. No virgin can look more demure (at a marriage or a sermon) than the courtezan;—and none thunder fourth such loud anethemas against irregulars, as those whose conduct is guided solely by chacanery and disingenuity-which are more dangerous and disgusting than open undisguised Charlatanism.

Who can think one thing, and another tell,
Our soul detests him as the gates of hell.

In reply to O. P. we beg to say that we are in opposition.to_no man, and much less in hostility with any of our cotemporaries. The day, we can confidently predict, is past, when the editors of medical journals shall disgrace themselves and insult their readers by venting their private feelings in personal abuse of their competitors. Urbanity has how superseded illiberality in the medical periodical press.

NOVELTY.

Our readers will have perceived that Messrs. Jukes and Bush have invented an apparatus for extracting poisons from the stomach. The same apparatus was proposed by Boerhaave, and brought to perfection by Dupuytren and Renault in France. The whole apparatus, exactly as described by Mr. Jukes, may be seen in Orfila's toxiocology, vol. I. Sect. 84. So much for the novelty of the thing.

Obituary.

DR. MARCET.

This distinguished physician has paid the debt of Nature rather suddenly. The immediate cause of death was arthritic inflammation transferred to the stomach. On dissection the heart was also found in a diseased state.