418

healthy, or only slightly studded, while others were fatty toen extreme degree. There was also in them a remarkabletrittleness, or tendency to break up into small fragments,which noated about in large numbers in the field of the micro-scope. This was not noticed in the muscular tissue of otherparts of the heart. and is interesting as bearing on the ca.use ofthe rupture. The aorta presented a considerable amount ofatheromatous and earthy deposit throughout. In the pleuraewere old adhesions. The lungs were congested, but healthythroughout.—Abdomen: The walls of the abdomen and thegreat omentum were very much loaded with fat; the liver andspleen rather increased in size, but otherwise healthy; the

kidneys were congested, and the right one at its lower partpresented a cyst as large as a walnut, filled with a clear limpidfluid. In other respects these organs appeared healthy.

ST. GEORGE’S HOSPITAL.

Disease of the Heart; Extensive Sloughing over the Hip.(Under the care of Dr. WILSON.)

WE published last week a case treated by Dr. Todd atKing’s College Hospital, which illustrated in a very instructivemanner how thoroughly obscure and embarrassing certaingroups of symptoms may be, and how difficult it sometimes isto class the case in hand in one or other of the nosological sub-divisions. It is particularly with reference to certain sensationsof pain en the part of patients that the nature of the case maybecome doubtful, this applying especially to women. Thelatter often experience, or think they experience, severe agonyin a given region; and when it is supposed that some localmischief has taken place, the pain suddenly passes to theopposite side, and the observer is forced to conclude that someimportant change is taking place in the circulating fluid, whichchange is sufficiently considerable to influence the nervoussystem in a high degree.Such a state of things seemed to obtain in a case some time

ago under the care of Dr. Wilson at this hospital; but, besidesthese strangely shifting sensations, the case presents one pecu-liar feature-viz., a state of great debility of vital or nervouspower, influencing the circulation and the faculty of resistanceto such an extent as to cause a complete disorganization ofthe tegumentary surface and cellular tissue, exposed to pres-sure ; and very often, the damaging of several organs ofmuch importance to the economy. When this kind of dyscrasiaexists, it may be doubted whether an affection of the heartand pericardium then springing up is cause or effect of the

general vitiation of the solids and fluids of the economy. Dowe not now-a-days fix our eye too exclusively on local lesionsand organic or functional changes, to the exclusion of con-siderations of a more general nature? Causes which maybe called vital are much concerned when the whole frameseems to sink under a noxious influence, which chemistrycannot analyze. We have seen cases in our hospitals wherethe whole fabric gave way without any antecedent fever orany distinct organic disease : witness the patient who died atMiddlesex Hospital—the whole back a mass of sloughs. Suchwas also the case with the patient whose case follows; and ifany supposition may be allowed as to the cause of this exhaus-tion, we would suggest that over-work, combined with badliving, may produce the effect alluded to; and it is very likelythat much distress, disease, and inconvenience, are experiencedby the baneful habit of sending very young people into service,where they mostly are bowed down with a very heavy descrip-tion of work. But let us turn to the case in question:-

Susannah F aged eleven years, was admitted October 6,.1852, under the care of Dr. Wilson. The little patient waslabouring under a febrile attack, associated with symptoms ofa rheumatic character, which had not, however, the aspect ofacute rheumatism. She had been sent out to service, butreturned home a fortnight before she was admitted here, feelingill all over. The poor girl had kept her bed since, and hadespecially had pain in the back and the left side; within thelast few days, however, she had suffered from pain in the ab-domen, which latter was tense and tender to the touch. Thebowels were said to be relaxed; skin hot; pulse quick; andnot firm; tongue very much coated.The patient was directed to have a saline draught every six

hours, the abdomen to be well fomented with decoction ofpoppies, and seven grains of Dover’s powder to be taken atnight.

It was found, the next day, that she had slept a little, butthe bowels had acted only once. The tenderness of the abdo-men was not so great as on the previous day, and she laychiefly on her right side. The heart’s sounds were observed to

be excited and shrill, but there was no abnormal bruit of anykind. In other respects she was much the same as on LdDiia-sion, and fever spots were looked for in vain.

In a couple of days, the pain seemed to pass from the iliacregion in front, round to the side and back, and a distinctfulness and puffiness, with considerable tenderness, was tracedalong the crest of the ilium, on the right side, but no fluctua-tion was detected. The face was much flushed ; the pulsecontinued quick; the tongue was patchy and brownish ; andthere was pain referred to the elbows, ankles, &c.The patient was placed on a water-bed, from which she seemed

to derive great comfort. The heart hal not been examinedfor one or two days, when unexpectedly fully developed frictionsound was clearly heard, with some extension of præcordialdulness, but these pathological changes were unaccompanied bypain or distress.A few leeches were applied, followed by fomentations, but

the patient was too much depressed to bear active n2easuresfand only a little grey powder at night Nv.%s ordered. The red-ness, swelling, and puffiness about the ilium disappeared, butthe back and hips soon began to show a tendency to inflame.The skin first gave way under the left hip, and when thepatient had lain some two or three days on the right side, torelieve pressure, that part of the body also became inflamed.Meanwhile (about fourteen days after admission) very largeeffusion took place into the pericardium, almost annulling thefriction sound with very distinct audulatory movement overthe præcordium. Pulse 156, and excessively iveak; respira-tion 48.

Attacks of dyspnœa now came on, which were relieved bysinapisms, but the face continued much flushed. When theseverity of the pericarditis seemed in some degree abated, thegirl was directed, on the twenty-first day, to have sarsaparilla.,.bottled stout, and nutritious food, as well as morphia at night.The sloughing surface, however, became more extensive and

deeper, and showed no tendency to assume a healthy action.Jelly was given on the twenty-seventh day, with the idea ofsupplying the gelatinous structures, which were so evidentlywasting. Chlorate of potash was added to the mixture, butthe patient’s strength was evidently declining, and the appetitebegan to fail. Nothing worthy of note further occurred,except that, on examination of the heart at a late period—viz.,on the thirty-eighth day, a loud and distinct systolic murmurwas heard over the region of the mitral valves. She sank from

day to day under the exhaustion caused by the immensesloughing, the head of each femur having at last become entirelydenuded. This patient lingered on, and died on the sixtiethday after admission.

Post-mortem Examination.—The body greatly emaciatedand large sloughy sores existed at almost every prominentpart of the body. The whole of the cutaneous surface coveringboth hips was destroyed, and the bone exposed and carious;all the ligamentous structure was gone, so that the head of thebone was on each side dislocated on the dorsum ilii. Th&acetabula were also much diseased on both sides. Thorax:

Except some old adhesions, the lungs were natural; the twolayers of the pericardium were almost entirely adherent, butnot with any great firmness. The heart itself was normal, andweighed seven ounces ; small dark clots were found in the leftcavities. Liver pale and very fatty. Other organs natural.Here the succession of symptoms might lead the observer to

consider this case as one of acute articular rheumatism; butthe pain in the joints was not sufficiently fixed: there was noactual fever, and the uneasiness along the iliac regions and inthe abdomen can hardly be reconciled with acute rheumatism.Then comes a decided attack of pericarditis, and soon after-wards a breaking up of the system, in consequence of whichthe parts pressed upon lost their vitality, and to such anextent that both hips were thrown into the state mentionedabove. Such a case is well calculated to excite reflection, andmake us look, in our eetiological researches, for causes nncon-nected with organic lesions.

ST. BARTHOLOMEW’S HOSPITAL.

Hydrocele; Tapping; Sudden Inflammation of the TunicaVaginalis.

(Under the care of Mr. STANLEY.)WHEN a hydrocele has been tapped once and refills, is it

time to have recourse to the radical cure by exciting inflam-mation in the tunica vaginalis with injections of iodine or portwine? Or should we go on tapping without attempting tofree the patient from a very inconvenient affection ? The mostsatisfactory practice is, very probably, to induce patients to

419

get rid of the renewed accumulations by obliterating the cavityof the tunica vaginalis. But, besides iodine and port wine,there is a way of obtaining the required inflammation,—viz.,by a deep incision. This is seldom practised in this country,but pretty frequently in some Continental hospitals. In the

following case the inflammation was excited by the puncturemade for evacuating the fluid.David H-, a book-keeper, aged forty-nine years, and

married, was admitted March 15th, 1854, into Darker ward.The patient, who is a very intelligent man, had had hydrocelefor the last three years, without any known cause. He hadbeen tapped three times at eight or nine months’ interval; butthis time he allowed the tunica vaginalis to fill for eighteenmonths, when the swelling became much larger than it everhad been before; the patient delaying the operation from thefear of losing good employment.He came, however, to the surgery of St. Bartholomew’s, and

was tapped by Mr. Callender, Mr. Stanley’s house-surgeon, on ’,the 12th of March, when a large bowlful of citron-colouredfluid was evacuated. The same operation had been performedupon him by Mr. Lawrence, and Mr. Archer, late house-surgeon to Mr. Lawrence. On former occasions the patientwant home, and though after the previous tappings he hadnever had but about two hours’ uneasiness, in this instance,on the next morning, he could not get up for pain in the loinsand in the testicle; and by Monday the scrotum was largerthan on the last tapping, the shape different, and the agonyexcruciating.The man passed the Sunday in great distress, and came to

this hospital on the Tuesday. The colour of the scrotum wasa dark mahogany, very tender to the touch, and the size the.same as before the tapping. Poultices were applied, and onthe Thursday the patient was tapped again by Mr. Stanley,when the discharge consisted of clear fluid, mixed with theproduct of inflammation—fibrinous shreds and a little pus.On Friday it had again swollen up to about half the size,

when Mr. Stanley made a large incision, and pus escaped in’pretty large quantity. Poultices were now again applied, andopium with a little calomel, along with Mindererus’ spirit, wereprescribed.From the time the free incision was made, and the pus which

had formed was afforded an exit, matters proceeded veryfavourably, and the man was discharged about a fortnightafter admission, the wound being almost healed, and the in-flammatory action altogether subdued. Now it is very unlikelythat the cavity of the tunica vaginalis will again become dis-tended in this patient, for it is extremely probable that the in-flammation and suppuration which took place have been followedby the gluing together of the two surfaces of the serous sac.The circumstance which will no doubt be looked upon as

worthy of remark, is the rapid filling up of the sac of the tunicavaginalis. By what means was the serous surface so highlyexcited? Was it from the operation, or from a peculiar stateof health of the patient? The latter supposition looks themore likely of the two, for had the trocar inflicted any woundor injury, the patient would have become affected with hæma-tocele, whsreas the principal symptoms were acute pain and aTapid effusion. It is very probable that the tunica vaginaliswas soon after the operation in a state of high inflammation,which state accounts for the pain, the serous effusion, and thesubsequent formation of pus.

Medical Societies.MEDICAL SOCIETY OF LONDON.

SATURDAY, APRIL 8, 1854.—MR. HEADLAND, PRESIDENT.

POISONING OF AN INFANT BY ONE-TWENTIETH: OF A GRAIN OF

OPIUM.

Dr. E. SMITH related a case of poisoning of the child of anItalian lady whom he had attended in her accouchement onMonday, March 27. The child was well developed, and ingood health. During the succeeding nights the infant criedmuch, and to relieve this he was requested to prescribe a com-posing remedy; he declined to do so, but directed them to.give an occasional dose of castor oil. On the Saturday following,that K, on the fifth day of its birth, the French nurse requesteda French pharmacien with whom she was acquainted to giveher medicine to prevent the cries, stating at the same time the- age of the infant. He gave her some syrup, and directed herto give half a teaspoonful every two or three hours ; he put nolabel upon the bottles. The nurse gave half a teaspoonful at I

half-past ten P.M. whilst the infant was crying. In half anhour the cries ceased, the respiration was interrupted, the jawfell, and coma was established. This continued with someintermissions during the whole night, and at half-past nine thefollowing morning he (Dr. Smith) saw the little patient. Hefound it perfectly comatose; insensible to pinching or tickling;the conjunctiva insensible to the touch, and the pupil contractedand insensible to the influence of light. The mouth was open;the eyelids closed; the face pale; and the features undisturbed.When the eyelids were raised by the finger, they remained so;but on one or two occasions the infant raised them herself, asif from convulsive action. The muscles of the limbs were re-laxed, but occasionally there was slight spasmodic movement.There were one or two slight and ineffectual attempts to cry.The function of deglutition ivas almost if not entirely lost.The breathing was very irregular, alternating between periodsof rapid and suspended respiration-the former were not

catching, and were accompanied by a shrill, stridular noise- the latter were prolonged during two or more minutes, whenthe pulsation of the heart ceased, and the child appeared tobe dead. The suspension was terminated by a deep sigh orgasp, which, on being renewed, excited the action of the heart,so that the vessels were seen heavily pulsating at the base ofthe neck. The respiration again failed, and the heart’s actiongradually declined. This state of things was continued untilfive P.M., that is, eighteen hours after having taken the poison,when she died. The syrup was of a light straw colour, and astested by the taste and smell, evidently contained opium. Atthe inquest the pharmacien stated that the syrup was theordinary French syrup of opium-containing five centigrams ofopium to the ounce; so that, assuming that the infant hadtaken half a drachm, or half a teaspoonful as stated, the dosewas about one-twentieth part of a grain of opium, or thequantity contained in one drop of laudanum. The post-mortemexamination gave but little information. The heart was dis-tended in all its cavities with thick, black, non-coagulatedblood; the pericardium contained much coloured fluid; thelungs were collapsed and non-congested; the brain was con-gested, but without any effusion into the ventricles or on thesurface. All other organs were healthy. The foramen ovalewas still quite patent, and also the umbilical arteries and ductusvenosus.

Mr. DENDY related a case in which imminent danger ofpoisoning arose from an eighth of a grain of opium, which hadbeen administered to a child two years of age.

Mr. RICHARDSON related the particulars of a case of

ASCITES, WITH ADHERENT PERICARDIUM, GROWTH IN THE

HEART, AND DILATATION OF THE BRONCHIAL TUBES.

The patient was a lady who had been under his care nearlyfour years, and had been seen by Dr. Snow, Dr. Willis, andseveral other medical friends. The symptoms for the greaterportion of that time had been referable to the heart, and con-sisted in great difficulty of breathing, inability to lie down, andsharp cooing sound with the expiratory murmur, with little orno expectoration. These symptoms had often been met withantimony, cupping, and leeches, and for more than two yearswere generally relieved by this treatment. In the course oflast summer, after one of these attacks, ascites commenced,and some degTee of enlargement of the liver was detected.For this the gums were slightly touched with mercury, withwhich squill was combined; acetate of potash was also given,with occasional purgatives. By these means recovery so fartook place that the patient’s household duties were resumed.Six months ago, however, the dropsical symptoms returnedwith great rapidity, and the body soon assumed a large size.The treatment before adopted having now failed, an elateriumpurge was administered, and repeated twice, with markedbenefit to the dropsical condition, but with so much prostra-tion that it was not continued. It was replaced by occasionalliberal doses of jalap and bitartrate of potash. So long as thepurgations could be borne, the effusion was kept in check; buttheir suspension being rendered necessary by the depressionwhich began to follow their use, and every form of diuretichaving failed, tapping was had recourse to, and two gallons offluid were drawn off. Great relief was experienced, and theeffusion seemed to be kept greatly in check by the careful andsteady application of abdominal bandages. About six weeksbefore death there was detected for the first time a pretty dis-tinct bruit de souffle, which was supposed to be connected withthe mitral valve ; while at the position of the base of the heart,and on its right side, a very peculiar sound, which the stetho-scope could cover, was detected. This sound, which was evi-dently external to the heart, was not a friction sound, but a

I kind of crackle, connected distinctly with every pulsation, as