253HOSPITAL REPORTS—DR. TAYLOR ON PERICARDITIS.

sense of the speaker’s conduct by leaving the room in a body. IThis would have been marking their sense of the matter Iat once. It will not, however, be any the less severe thatthe matter is rankling in their minds as an unpunished attack,which took them by surprise.

Universal is the condemnation bestowed on Mr. LAWRENCE.

Two opinions respecting his conduct cannot be found. It is

certain he can never again hope to regain his position. He

has begun and ended his professional career by two bad andbold mistakes. We say, ended, for it may, with more truth,be said of him, that he is morally and professionally defunct,than it could be said that there was an end of the apothecaries.His bitter revilings of the general practitioner, his cowardicein attacking the profession on an occasion properly sacred tothe amenities of science, and the bad taste of doing this whena number of eminent lay persons were assembled, each andall have sunk deeply into the professional mind, and will neverbe forgotten. The conduct of the audience in abstaining fromretaliation shows that all who went there were well disposed.Not one went away but felt himself and the profession scan-dalized or insulted. ’ j

HOSPITAL REPORTS.

UNIVERSITY COLLEGE HOSPITAL.ON PERICARDITIS.—By JOHN TAYLOR, M.D., Professor of

Clinical Medicine in University College, and Physician toUniversity College Hospital, London.

CASE 26.-An elderly female, attacked with bilious vomiting andhcematemesis, follozved by melcena and discharge of red bloodper’ anum; pain in left side; little cough; no dyspncea; coma;dilated pupils heares impulse increased; dulness over lowerpart of left lung, with absence of respiratory sound; deat7a.-Post-mm’tem examination: Eight ounces of pus in left pleuraand old adhesions superiorly engorgenie2g and cedenza of bothlungs; pneumonia in left? old and recent adhesions oj peri-cardium; cirrhosis (?) of liver; stonzach healthy; ulceration ofascending colon; granular disease of one lcidney; brain healthy.--Remarks: Pericarditis latent; causes of absence of friction-sound; hypertrophy of the left ventricle stimulated by pleuriticefusion; grounds of diagnosis ; pleurisy latent; signs of effusioninto the pleura; pneumarcia? cirrhosis of the liver; its form pe-culiar; sequelce; hœmatemesis, but no ascites ; the reason sug-gested; Bright’s disease of one kidney only; sequelce; pleuritisand pericai-ditis; coma? another cause of the conaa; absence ofanasarca and of hypertrophy of the heart in renal disease; ul-ceration of colon; its causes and symptoms; causes of the renaland hepatic disease, and of the pericarditis and pleuritis.D. H-, aged fifty-six, admitted March 6th, 1840; a widow;

monthly nurse; of regular habits. She could give no accountof herself on admission. The following particulars were ob-tained from other sources:-A fortnight ago, whilst employedin washing, she was suddenly attacked with violent retching,and vomited large quantities of bilious matter; she had alsogreat pain in the left side. A surgeon saw her, and orderedleeches and a blister to the side, and gave her some purgativemedicines. A day or two afterwards she vomited some clottedblood, on account of which she was bled from the arm. Bloodafterwards passed from the rectum, mixed with the evacua-tions, and likewise alone, in a fluid state, and of a red colour.The bowels were at first constipated, but afterwards therewere frequent, loose, very dark, and exceedingly offensivemotions; was very thirsty, but did not refuse her food. Whenbrought to the hospital, she was lying on her back in a semi-comatose condition, and returned only monosyllabic and irre-levant answers to questions put to her; the pupils were ratherlarge, but contracile; pressure on the abdomen appeared togive pain; the knees were drawn up towards the abdomen;tongue covered with a white moist fur; stools dark-colouredand fœtid; pulse quick and sharp; urine high-coloured andsedimentary; little or no cough; no apparent embarrassmentof the respiration; dull sound on percussion over the lowerhalf of the left side of the chest; respiratory murmur distinctin the upper part of the left lung, but inaudible below; slight

crepitation below the axilla, and about the middle of the backof the left lung; heart’s sounds natural ; impulse too strongand too extended. Ordered venesection to ten ounces; mer-cury with chalk, four grains; Dover’s powder, three grains;and antimonial powder, one grain; to be taken every sixhours. Also, tartrate of potash, half a drachm ; carbonate ofsoda, ten grains; nitrate of potash, three grains; water, anounce; in a draught three times a day. A blister to the leftside.

8th.—Increased torpor; she is unable to answer questions;pupils widely dilated; urine passed involuntarily; bowels notopen; pulse small and feeble. Died at twelve o’clock.

Inspection of the body twenty-seven hours after death.—A considerable quantity of a dark semi-fluid substance, containingblood, had escaped from the intestines after death.-Chest: .’Upper half of the left pleura adherent; lower half filled withgreenish-yellow pus of the consistence of very thick cream,being, in fact, only semi-fluid. There were about eight ounces.A layer of recent lymph covered the surface of the pleura, incontact with the pus, and beneath the lymph the serous mem-brane was exceedingly vascular. In the fissure between thelobes of the lung, the pleura was smeared over with blood.The upper lobe of the left lung was of a very dark red colour,dense, scarcely crepitating at all; contained much spumousserum, and broke down readily on pressure : a portion cut offsank slowly to the bottom of a vessel of water. Lower lobedark-coloured and dense, but containing less serum. No ad-hesions of the right pleura. The whole of the right lungwas in the same condition as the upper lobe of the left,but was affected in a less degree, and the lower lobe wasless affected than the upper. Portions of this were not putinto water. Weight of left lung, twelve ounces and a quarter,avoirdupois; right lung, twelve ounces and three-quarters-Heart: Pericardium adherent almost everywhere; anteriorly,by old false membranes, and behind, by rather soft coagulablelymph. This portion was extremely red, and had an almosthaemorrhagic appearance; it was in contact with the infamedleft pleura.—Left ventricle: Walls not too thick; muscularsubstance flabby and rather pale; cavity not too large; endo-cardium transparent to near the aortic valves, which alsowere scarcely, if at all, thickened; a few small yellow spots inthe commencement of the ascending aorta; mitral valve

healthy; orifice admits two fingers.—Right ventricde Wallsrather thin; cavity of the ordinary size; endocardium andvalves healthy; both auricles healthy; foramen ovale closed,-Blood : No coagula except in the right auricle, and but littlethere; weight, nine ounces, avoirdupoise.—Liver: Its bulkmuch diminished; peritoneal coat thickened; external surfacepaler than usual, and covered with elevations, which in formwere small sections of a sphere, most of them about half aninch in diameter, some smaller, others larger, and separatedfrom each other by shallow sulci only. On cutting into theorgan, the cut surface appeared divided into portions correspond-ing in size and form with the external elevations, and separatedfrom each other by cellular or fibrous tissue. The colour wasuniform, paler than natural, and the substance firmer. Weight,thirty ounces and a half, avoirdupoise; no serous effusion intothe peritonæum.—Splpen: Full sized; weight, six ounces and ahalf, avoirdupoise.—Kidneys." Right one rather small; the cap-sule was readily removed, carrying with it portions of thesubstance of the kidney; external surface pale, mottled, andexhibited a few granular elevations; interior rather pale, witha few small yellowish spots in it. The left was larger thanthe right, and had no appearance of granulation. Weight ofleft, five ounces and a half; right, four ounces and a half.-Pancreas not examined.—Stocmach healthy; all the tunics quitepale; the small intestines were pale externally, but were notlaid open; ascending colon dark.coloured externally, and con-tained a dark-brown slimy-looking substance; the coats of agreat part of the ascending colon were much thickened; mu-cous membrane thick, of a slate-blue colour, and almostcovered with small ulcers; the long diameter of the greaternumber was transverse to the axis of the gut, their edges un-even, and many were exceedingly small; the rest of the colonwas healthy. Rectum was not examined.-Head: Brain

rather pale; no subarachnoid serous effusion, nor any in theventricles ; consistence everywhere healthy; basilar arterydilated, and its coats thin; middle cerebral still more so; thecoats of aU the arteries marked with atheromatous spots.Weight of cerebrum, cerebellum, and medulla oblongata, forty-one ounces, avoirdupoise.

SUMMARY OF THE CASE, WITH REMARKS.

SymptoJi1..s and diagnosis.—Heart." 1. The pericarditis wasnot suspected during life, although the heart was examined.

254

There had been pain in the left side in the early part of the Iillness, which might have been connected either with thepleurisy or the cardiac inflammation. On admission, however,the patient was too torpid to be sensible of pain, even if theother conditions for producing it were present.

2. There was no physical evidence of the disease; .the soundsof the heart were healthy. Two causes may be assigned forthe absence of friction sound, either or both of which mayhave led to this result. The recent adhesions which werefound may have been formed before the patient was admitted,which was only two days before death; or as the attrition ofthe serous surfaces must have been confined to the posteriorsurface of the heart, and also limited in amount, (in conse-quence of old adhesions anteriorly,) the consequent frictionsound may have been too feeble to be heard on the fore partof the chest. It is probable that there was no friction soundbehind, for the chest was examined carefully for other pur-poses, and none was heard.

3. The impulse of the heart was too strong, and was feltover too large a space, so as to lead to the belief that therewas some hypertrophy of the organ. The heart, however,was found to be rather below than above the natural size.The modification of the impulse had been produced by thepus effused into the left pleura. This had pushed the heartinto closer and more extensive contact with the walls of thechest in the mammary region, and the effect of the fluidpressure must have been further increased by the adhesionsof the pleura over the upper lobe of the left lung. The cha-racter of the impulse in such cases is not to be distinguishedfrom that of actual hypertrophy. Perhaps the increased loud-ness of the healthy second sound over the commencement ofthe aorta, which often occurs in hypertrophy, might serve asa ground of diagnosis, especially taken in connexion with thediscovery of effusion into the pleura, or of an aneurismal orother tumour, capable of pushing the heart forwards. Asmight be expected, the heart’s sounds in the present casewere healthy.

Lungs: The dull sound on percussion, and the absence ofrespiratory murmurs, over the lower part of the left side,corresponded with the extent of the pus found in the pleura.There had been pain, but it existed no longer; there wasscarcely any cough, and no apparent dyspnoea, and the blooddrawn from the arm was not buffy. There was engorgement,with consequent oedema of the lungs. There might, in addi-tion, be some pneumonia on the left side, for portions of asimply engorged lung do not usually sink in water. This mayhave been the source of the crepitation mentioned as heardon the left side only.

Liver.—The aspect of the liver was peculiar.* Dr. Carswellstated that he had never before met with similar appearances.It seems probable from the history of the case, viewed inconnexion with the anatomical appearances, that the diseasewas a variety of cirrhosis. Contrary to the statement in thereport of the case, I learnt from a lady who had long knownthe patient, that she had been accustomed to take spiritsfreely. We know that haematemesis is an occasional resultof cirrhosis, and there was nothing but the condition of theliver to which that haemorrhage could be referred in this case.The mucous membrane of the stomach was healthy and pale.There was, however, no ascites, which is a much more common.consequence of the obstruction’ to the portal circulation, towhich the exudation of blood into the stomach, in such cases,is believed to be due. Perhaps the haemorrhage from thecolon so tar emptied the intestinal branches of the portal veinas to prevent the occurrence of ascites. The liver, as a whole,was considerably atrophied, for it was hardly two-thirds theaverage weight of the organ in health. The morbidly densecellular element seems to have been less abundant than incommon cases of cirrhosis, and to have inclosed within eachof its meshes, and thereby subjected to compression, massesof lobules rather than one or two lobules only. Hence thedifference in the appearance of the surface of the organ in thetwo cases.

Kidneys.—1. The appearances in the kidneys are notminutely described, yet sufficiently so to prove, I think, thatthe right one, at least, was affected with Bright’s diseaseThe urine, unfortunately, was not tested.

2. This view is further in complete harmony with thehistory of the case; for (a) the patient had been exposed to acommon cause of the disease, intemperance; (b) it explainsthe occurrence of the thoracic inflammations; (c) it may havebeen connected with the coma which preceded death. Th(brain was found to be healthy and pale: there was no in.

* A model of the liver has been placed in the museum of UniversityCollege.

ordinate serous effusion. These are the common appearancesfound after fatal coma from Bright’s disease. If the head

symptoms, however, were due to the renal disease, it is remark-able that one kidney should have been found healthy, as faras we can judge from the description. There is another causewhich may have produced the coma, or which may have cooperated with the renal disease in producing it,-viz., theexhaustion consequent on repeated losses of blood, especiallyby the bowels.

3. In case twenty-four, I had occasion to make some remarkson the relation between hypertrophy of the heart, anasarca,and Bright’s disease, and in connexion with those remarks Imay notice, the absence of both the complications referred toin the present case. The absence of dropsy is sufficiently ex-plained by the want of any marked dyspnoea, and by the con-siderable diminution of the total mass of circulating fluid.

Intestines.—1. The blood passed per anum in the form ofpitch-coloured evacuations, may have been poured out eitherin the stomach or colon. It is probable that the colon wasthe source of it, because the same kind of matter was found inthat part of the bowel; and, judging by the external aspect,was not present in the small intestine.

2. The only other symptom of the extensive disease in thecolon was, a degree of tenderness of the abdomen, and theposition of the patient on her back with the knees drawn up.I ascertained that the woman’s bowels were habitually con-stipated.

3. The appearances in the colon are those of dysentery-but, perhaps, owing to the necessarily imperfect history, nomore of the common symptoms of dysentery are mentioned.For the same reason, perhaps, there is no mention of any ofthe ordinary causes of dysentery. Was the inflammation ofthe colon another of the consequences of the renal disease?

4. If the report be correct that pure red blood was alsodischarged per anum, it must have come from the rectum-perhaps from haemorrhoids. The rectum, however, was notexamined.

Causes.-l. The renal and hepatic disease might both becaused by the patient’s habit of spirit drinking.

2. The pleuritis may have been of older date than the peri-carditis-if so, the inflammation in the pleura may have ex-tended to the pericardium through the contiguity of the tissues.

3. It is, however, equally likely, that these two inflammationsarose at or about the same time and from the same cause, viz.,impurity of the blood itself, induced by the imperfect action ofthe kidney or liver, or both. The same cause as has beenstated, may have been wholly or partially concerned in pro-ducing the coma, dilated pupils, and involuntary evacuations.We might have expected, that as one kidney appeared to behealthy, it would have been sufficient to eliminate the in-jurious matters which must have been retained in ,the blood.But with so imperfect a description of the appearances beforeus-with manifest granulary disease in the other kidney-andin the absence of a microscopic examination of its structure,it would be a hasty conclusion to affirm that even one kidneywas healthy.

WESTMINSTER HOSPITAL.CASE OF DELIRIUM TREMENS FROM OPIUM EATING—IMPROVED

GENERAL HEALTH, BUT TERMINATING IN DEMENTIA, WITH

CLINICAL REMARKS BY DR. BASHAM.

T. F-, aged 42, a clerk in mercantile employment, was ad-mitted into Burdett ward under Dr. Basham, September 3rd,1845. Has been habituated to the use of opium during the lastseven years, taking from twenty to thirty grains daily. Onadmission, there was great physical prostration ; face flushed;eyes inexpressive, glazed, and suffused ; temperature of thescalp not increased, that of the surface of the body and the ex-tremities much below the natural standard; hands and feetcold and damp; tongue very foul, coated with a white slimyfur; pulse scarcely perceptible, very small, easily compressed.The bowels habitually costive; for some time past has seldomhad more than one evacuation in the week. The stomachwas very irritable; no desire for food; there was deafness ofthirteen years’ duration. The mental perceptions were dulland adumbrated, comprehending faintly the purport of ques-tions, and making wandering and imperfect answers. Therewas much mental aberration, and muttering delirium duringthe night, but there was not any distinct hallucination in his

wanderings. There was continued insomnolency. What-ever mental emotions or expression exhibited during the day

were allied to depression ; frequent crying, sobbing, andgushes of tears. {Similar attacks to these have pre-viously