was

0

2

8

8
7

The total average expense per annu mof a

Paralytic....... 87 curable patient to the charity, in 1836,

Sick and weak 59
£41 5 4
Idiotic

28 Ditto, ditto, to his friends......... 0 14 11

Epileptic..

24

Apoplectic
Total average expense per ann. £42 0 3

Pregnant.
Fits

2 Average expense of an incurable patient to

Venereal.

2 the charity in the same year...£210 10

Aged and infirin. 1 To his friends 20 19 6

210 Total....... £42 0 4

The causes of death during the same six Average cost, per annum, of a criminal la. years were,

Exhaustion ....

23 natic, about ..... ....£36 0 0 Average payment, per annum,

Apoplexy

7 for each to the hospital... 45

Epilepsy
Diarrhoea.

6 Gradual decay

4 Average gain to the hospital.... £9 0 0

Bronchitis The following table of the patients in the

Abscess of lungs

2 hospital in 1836, may probably be taken as

Hydrothorax

Suicide an average:

Effusion of serum, syncope, con-
Duration of Insanity pre-

sumption, chorea, peritonitis, Admitted. vious to admission.

Cured.

debility, paralysis, and unknown 1 Not exceeding 18 months.

cause, each one 2

12
10

63 ] 9

The report is concluded by drawing 7

comparisons between several parts of the 9

system of management of the patients in 14

6

2

Bethlem, with that adopted at other luna. 7

5

1 tic asylums, and especially those of Han. 14

well, St. Luke's, Lincoln, Glasgow, Not28

18 tingham, and Wakefield; and in all cases 37

17 to the disadvantage of Bethlem. It is

submitted, that though to a casual visitor 5

its perfect cleanliness, and the neatness of 44

appearance and absence of all apparent 24

15 restraint of the patients, might lead him 39

24 to conclude that the management of luna

tics bas here attained perfection, yet there

is still room for considerable improvement. 253

134 Some of the defects in the present arrange. The average duration of insanity in the the construction of the building, which

ment are, no doubt, to be attributed to patients who were discharged cured was 56 days.

appears to have been erected partly on the An abstract of the physician's annual with a view to the continuance of the co

plan of the old hospital in Moorfields, reports, from 1820 to 1836, shows, that ercive system there pursued, and is by no there were admitted in that period :

means well adapted to the present im. Curables. Incur. Criin. proved method of treatment. The aspect, 3090 97 67

it is said, is not good, the gallery windows of whom were dis

facing to the north : the windows are 100 charged cured 1-180 22 32

high from the floor, formerly more than Uncured

six feet; the lower galleries ought not to

829 By request of friends 75

be on a level with the earth, nor 23 0

there Improper objects.... 483 6 o any necessity for stone foors in them. No reports received of 14 0 0

The centre of the building is obscured and Escaped.

made gloomy by a heavy useless portico,

0 3 Died

8

4 3

3

10.

3

0

OF

compared with great disadvantage with physician, with suitable assistants and a those in the lunatic asylums at Lincoln remunerating salary, or of making an in. and at Nottingham, which are like com- crease in the number of physicians, and, mon windows to external appearance, but perhaps, an addition of one or two ordi. are secured from being opened more than nary practitioners to those who devote a certain distance. It is considered as much themselves chiefly to the cure of insanity; to be regretted, that the governors should the necessity of a greater portion of statishare consented to the erection of the tical information being afforded by the wings for criminal patients, by which the annual reports ; the propriety of re. patients were deprived of the space now laxing some of the restrictions by which devoted to the use of objects who could certain classes are at present disqualified not have been in the contemplation of the from admission, as those against persons citizens wben the existing lease was with venereal disease or itch ; and ihe imgranted. The criminals now enjoy a portance of shortening the period between larger quantity of ground in proportion to the consideration of the petition and the their numbers than the ordinary patients. admission of the patient. The remaining The whole of the land held by the hospital strictures upon the hospital relate to the appears no more than sufficient for the financial department both of itself and wants of the patients, but a very small Bridewell, (with which it is urged its portion only is devoted to their use. The union is no longer reasonable), and they kiteben gardens and the two lawns might are made with a degree of severity which is be at once used or made fit for use as airing entirely absent in the corresponding regrounds, and the present airing grounds, marks on the other hospitals. which are mere bare cheerless inclosures, might be planted and rendered far more agreeable than at present.

FATAL CASES Within the house the most striking feature is the want of occupation for the men, the greater number of whom may be OBSTRUCTION AND ENORMOUS ssen sauntering about the galleries in list- DISTENSION OF THE BELLY, less and hopeless indifference. Some, indeed, play in the airing grounds, and a Arising from a peculiar Conformation of the

Colon. few are occasionally employed in the lawns and gardens, or in knitting; but BY ANDREW BUCHANAN, M.D. the only general occupation is that of Professor of the Institutes of Medicine in the pumping at the crank and capstan. At

University of Glasgow. Wakefield, Nottingham, Hanwell, Glas- (IVith 12 Figures in illustration.) gow, and many other places, on the con

[Concluded from p. 105.] trary, the occupations are of the most Faried kinds, and the patients are even tangbt trades with which they were before The three cases which I have just narubacquanted, and are employed as black- rated exbibit many striking points of suniths, weavers, shoe-makers, carpenters, resemblance. In all of them ihe most tailors, &c. The intellectual employment remarkable symptom was the extreme also of the patients at Bethlem appears distension of the abdomen. capable of great improvement: only a very was this distension, as to communicate, small portion of them occupy themselves both to the unhappy sufferers themin reading, and it was stated by the ma. trun that the women do not in fact enjoy hension of the actual bursting of the

selves and to the bystanders, an apprethe use of the library. Personal restraint also, though so much less than formerly, belly. On opening the cavity after is still considerably greater and more fre death, the inflated bowels were proquently employed than in many other pelled with such force through the asylums.

wound, as rendered extreme caution neOther suggestions for improvement re. cessary to avoid injuring them; and on late to the too great caution which is evi- puncturing the bowels themselves, the dently displayed before the patients, in imprisoned gases rushed forth like the every thing around them being distinctly winds from the cave of Æolus, or, to speak adapted to prevent them from harming

a little more plainly, with a violence that themselves or others; the absence of any would have extinguished a candle beld medical school or system of pupillage, by shich medical science might be advanced, at some distance from the aperture. To at the same time that it would (as it does those who have not seen this complaint, in the general hospitals) afford a constant I cannot convey a more accurate idea of stimulus to the exertions of the medical it than by comparing it to the disease officers; the propriety of having a resident which occurs in cattle after cating too

So great

a

much wet clover or othersucculent herba. bad obviously been going on in one of ceous food. I have seen several cows the cases mentioned above, it must bave affected with this complaint, and in none been a mere accessory, since there was of them was the swelling greater than no inflammation in the other two cases. in the cases described above.

Can the elevation and immobility of the The next most remarkable circum- diaphragm, and the encroachment of the stance attending these cases was the abdominal viscera upon the cavity of total obstruction of the bowels; to over. the heart and lungs, be regarded as the come which the most powerful purga- cause of death? It may probably be tive medicines introduced into the sto- an accessory cause; but I am disposed mach, and all clysters and suppositories, to think that the principal cause of were quite ineffectual. At the same the patient's death is the excessive distime, the facility with which clysters tension of the belly, which produces the could be injected into the rectum, as most excruciating and unremitting pain, well as the examination of that intestine and thus gradually exbausts the powers with the finger, showed the cause of the of life. In the analogous disease of obstruction to be at some distance from cattle, already mentioned, death seems the external orifice.

to proceed from the same cause ; but it Anotber circumstance worthy of re- takes place in them much more rapidly mark is, that in all these cases, pre--generally in the course of a few vivus to the occurrence of complete ob- bours—owing to the distension being struction, the bowels bad been long much more sudden, and acting upon affected with constipation. This was tissues not previously habituated to that rendered obvious, independently of the kind of irritation. report of the patients, by the accumula- The symptoms enumerated abovetion of fæces in the bowels, which was the enormons tympanitic swelling of the so very large, that it must have been a belly, the complete obstruction of the long time in collecting. The same bowels, the emptiness and large size of point was still further evinced by the the rectum, and the acute course wbich extreme dilatation of the colon, which the disease observes—appear to me to be shewed clearly the existence of a dilat- sufficiently characteristic to enable us ing cause, which had been in operation to distinguish this disease from all other most probably for years before the kinds of tympanitic swelling and con death of the patient. Tbe fully inflated stipation. colon, in its normal state, I have found With respect to the appearances on to be about two and a half inches in dissection, in all the cases ibe colon was diameter: now in the case above men- the organ principally, and, as was unitioned, it was from five to six inches in versally thought, primarily affected. It diameter; that is, it contained at least was much longer than usual, and occufour times as much fæces as when quite pied an unwonted situation, lying in full in its ordinary state. It was the front of the small bowels; it was also large intestine alone that was thus di- much enlarged, having an area four Jated; for the small intestines, although times larger than when fully distended fully inflated, were not wider than in its ordinary condition. natural.

pearances are partly to be referred to Death took place in about twelve or primordial confirmation, and partly to fourteen days from the occurrence of the the long-continued action of a distendtotal obstruction of the bowels. The ing cause. That the great length and disease must therefore be regarded as an unusual disposition of the sigmoid acute one; and this enables us to dis- flexure must be referred to primordial tinguish it from certain chronic affec- conformation cannot, I think, be doubt. tions, attended with swelling of the ed. On the other hand, the great width belly and obstruction of the bowels. To of the intestine must have been gradowhat cause is death to be ascribed in ally produced, and could not proceed such cases ? The mere obstruction of from original formation, as was obvious the bowels cannot be considered as an from the attenuation of its coats and adequate cause, since men bave been other appearances. Before I was aware known to live for more than a quarter that the length of the intestine varied of a year without any alvine evacuation. from original confirmation, I laboured Neither was the cause inflammation of to persuade myself that the elongation the bowels; for although inflammation of the colon, as well as its dilatation,

These ap

a

might be the effect of long.continued tion of the existence of an adequate tension. How easily we impose upon force, I believe the effect to be physi. ourselves by such reasoning will be cally impossible without rupture of the seen from a case quoted below, in which mesocolon. Still further, any twist dethe colon, from original formation, was pending upon irregular action of the shorter than usual; and the narrator, to

muscular fibres could not, as appears to explain the difficulty, argues that an me, be maintained for so long a period increase of width must be necessarily as twelve or fourteen days, and still less attended with a diminution of length. for whole months. Now I have shown

In the two cases last narrated, a twist that, in the preceding cases, the bowels of the colon was supposed to be the cause bore marks of having been for a long of the obstruction of the bowels; and time in a state of obstruction, although this opinion accords with that enter: it was only when that obstruction be. tained of all the other cases of this dis. came complete that the disease bere ease which I bave found on record. under consideration was developed. Nevertheless, I much doubt the accu- In the history of the case first narracy of this opinion. When we remove rated, I bave described in what way the the intestines, to examine them out of proximal convolution of the sigmoid the body, we find them very apt to be. Rexure passed in front of and comcome twisted, knotted, and otherwise pressed ihe extremity of the colon, a variously entangled. Nothing so well little above where it terminates in the illustrates the wisdom of the provision rectum. Now when we consider the by which such accidents are prevented great length and unusual position of the from taking place within the body. By colon in the other two cases, and in sia twist of the intestine may either be milar cases upon record, it appears to meant, that a single ply of the intestine me not improbable that the same, or a is twisted round its own axis, or that an similar cause of obstruction, may have angle of the intestine is twisted--that is, existed in them also. There is one cir: that two conterminous plies are twisted cumstance with respect to the course of round each other. This last kind of the colon in case first, wbich may twist will be adverted to in reference to either be explained as proceeding from a case quoted below. It is certainly original confirmation, or from subsepossible, but we cannot easily conceive quent displacement ; I mean the sweep a force acting within the body capable to the right which the intestine took of producing it, and maintaining it after leaving the left ileum, and before when produced. The other kind of ascending to the epigastrium. That twist is that supposed to have existed in this disposition was not the effect of all the other cases. I cannot, however, primordial conformation, it is impossible see how it is possible, without an open- to say ; but we might oppose to that ing in the mesocolon large enough to opinion the analogy of two cases deadmit of the intestine revolving on its scribed above-tbat of Dr. Hunter, and axis, to produce such a twist as would that observed by myself at the Cholera cause obstruction of the bowels. I can Hospital—in which the intestine, imconceive it possible that a violent and mediately after leaving the ileum, irregular action of the muscular fibres passed obliquely to the upper region of could produce a twist, half round, of n ihe belly. "If such was also the oriparticular portion of the intestine ; by ginal conformation in case first, we must which I mean, such an oblique folding suppose that when the fæces began to of that part of the intestive, that a given accumulate in the oblique portion of the point of its circumference would be car- colon, they carried it downward by their ried from the side on wbich it naturally weight towards the pelvis, as appears lay to the side diametrically oposite; to me would naturally take place. but I cannot conceive the production of In describing the iwo cases referred a complete twist of the intestine, by to at the beginning of this essay, I which I mean, a point of the circumfe. mentioned as a circumstance worthy rence being carried first to the opposite of remark, that in both of them the coside, and then completely round to the lon entered the pelvis on the right side, situation from which it originally set instead of descending in the usual way out. I can conceive no force, acting over the promontory of the sacrum, and within the body, capable of producing entering it in the centre. The end of such an effect; and, waiving the ques. the colon was thus removed as far as