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or otherwise disturbing its action. lIenee we ought ratherto be surprised (as Corvisart remarks) that the heart is notmore frequently diseased than it is." (Part 1., p. 242.)Among the many cases of heart disease seen in hospitals, it
may perhaps be said that the " extrinsic" class forms themajority-viz.: first, acute or chronic inflammation of certaintextures of the organ connected with rheumatism; secondly,the same resulting from intemperance, long-continued or
occasional muscular exertions, or from powerful mentalemotion, whether of an exciting or depressing nature. Wehave this day to bring before our readers a case of thekind alluded to, which seems to be clearly connected withhabits of intemperance, but in which the pathological altera-tions appear to have taken place in a very short time, thesebeing no less than acute ulceration of portions of the aorticvalves, and enormous hypertrophy. It should, however, bementioned that cases of this sort are by no means frequentlyseen in hospitals, the chronic form of disease being the morefrequently met with. In the present instance the affectionproved quickly fatal, and this will be easily understood whenthe amount of valvular destruction, consequent embarrassment tin heart and lungs, and the broken-down constitution of thepatient are considered. The details of the case were notedby Mr. Nesbitt, one of Dr. Burrows’ clinical clerks.John M———, aged twenty-four years, was admitted July
7th, 1853. The patient is a strong, well-built, muscular man,with brown liair, blue eyes, and fair complexion; his counte-nance is rather languid and anxious, his face pale, skin warmand moist, and the eyes surrounded by a slightly dark areola.Pulse 112, sharp, full, and soft; respirations forty in a minute,but a deep breath can be taken without exciting pain. The
patient has a hollow cough, and expectorates phlegm mixed withblood. Tongue fissured, with a dry red stripe down the centre,and a rough, yellowish fur laterally. The man is very thirsty;he has no appetite, and his bowels have been moved from sixto seven times a day for a fortnight up to his admission; themotions are reported slimy; there was but one evacuationwith much griping pain on the day previous to his coming intothe house. The urine passes freely, but is of deep colour.The patient complains of a sinking pain about the sternum’after coughing, and frontal headache produced by the samecause. The ankles are cedematous, and the legs swollen andvaricose; on the right leg are several scars, some produced byinjury, others by ulcers ; the cough prevents the patient fromsleeping at night; the abdomen is full, soft, resonant, andtolerant of pressure.-Auscultation of the Heart: Diffusedrubbing sound at the apex over the left ventricle, and also asystolic murmur; no increased dulness On the anterior partof the chest the resonance is good, and the respiratory mur-mur natural, both anteriorly and posteriorly.History.-The patient is a steward of a river steam-boat,
and of very intemperate habits. His illness commenced threeweeks before admission, when he awoke, while sleeping ondeck, with a feeling of severe stabbing pain across the chestextending to the arms, sickness, shivering, and pain in thelimb. Cough came on five days before admission, and therigors continued up to the time of his coming to the hospital.He applied as an out-patient to one of the hospitals of themetropolis, where lie was so severely purged that he wasafraid of returning. He was subsequently treated at thishospital as an out-patient by Dr. Jeaffreson for a few days,until he was admitted into John’s ward, under the care of Dr.Burrows. The patient had never had rheumatism or syphilis,and the health had generally been pretty good. He was-ordered a blister to the epigastrium, one grain of opium im-mediately, and another at bed-time; beef-tea, and six ouncesof wine.Second day.-The patient slept very little in the night,
’t)eing kept awake by the pain, and by his being unable to liedown; the blister rose well; countenance somewhat haggard;face blanched and a.nsemic; conjunctivae pale and bloodless; lipsand gums in the same state; respiration hurried and panting,56 per minute. When the patient attempts to lie down the
pain shoots from the chest to his right scapula, and down thearm on the same side; he coughs a great deal, and expectoratesa quantity of viscid, frothy, bloody mucus; the latter lookedas if some blood had been intimately mixed with it, air havingbeen freely admitted.; pulse 102, of moderate volume, sharp,and very weak; tongue cleaning and moist; great thirst; hetakes his nourishment well, and the bowels have been openedonce freely; urine evacuated without uneasiness, specificgravity 1005, clear, amber-coloured, unaffected by heat ornitric acid; the stabbing pain across the front of the chest isworse, and does not allow him to lie down.--Auscultation ofthe heart: Loud, harsh, double murmur, clearly endocardial,
as the action is too tranquil for it to be a friction-sound. Chestposteriorly: Clear, good respiration throughout the right lung;on the left side loud, coarse breathing above, abundant crepi-tation limited in extent below, and dull on percussion at thebase. It is supposed that the expectoration, though resemblingthat of pneumonia, is not bonr1.fide such, but that its characteris dependent on engorgement, as a result of aortic regurgita-tion, and perhaps the commencement of pulmonary apoplexy.The regurgitation is not supposed to be mitral because thepulse is of moderate volume, and not small, thready, and in-termittent.-Three P.M.: The poor man is very restless; he istossing himself about, demanding more air; respirationsheaving, 60 per minute; cough rather loud and ringing; paindiminished. He died at seven o’clock on the same evening,being sensible to the last; he had no convulsions, and got upto go to the closet a few minutes before lie expired.’ Post-mortem Exagniiiation, eighteen hours after death.-General condition of the body: Not much oedema; face pale;vessels of the head and neck not congested; rigidity general;scalp tough; skull heavy and thick; adhesions between duramater and bone, the latter looking as if worm-eaten.-Mem-branes of the brain: Arachnoid rather milky and spotted;excess of fluid in the subarachnoid tissue. The cerebralventricles contained about twenty ounces of fluid. Vesselsof the brain healthy; brain pale and soft; ventricles granular.-Chest: The pericardium contained from four to six ouncesof turbid fluid; a white patch of lymph, evidently of oldformation, was observed on its anterior and inner surface.Heart twice its natural size; fatty degeneration of its tissue;aorta much diminished in calibre; all the valves healthy, withthe exception of the aortic, which were attacked by destructiveulceration, the outer half of the middle valve, and the innerhalf of the outer, being destroyed. The other valves were
healthy, but vascular, and the ulceration extended throughthe coats of the aorta as far as the endocardium. Some wartymasses of fibrine were deposited on the ulcerated surface.
(See the annexed engraving.) Each pleura contained about a
pint of fluid, there being here and there scattered adhesions.Lungs cedematous; lower lobe of the right lung congested;bronchi very vascular. Liver large, and gorged with blood.Both kidneys were enlarged and nodular, but not lobulated;the nodules were pale and bloodless, and the capsule waseasily stripped off. There was only a rim of cortical substance,the medullary extending to the parietes.The question might now be raised, whether the amount of
hypertrophy observed in this case had taken place in thethree weeks which followed the acute seizure. This is notprobable; but it is likely that some hypertrophy alreadyexisted in consequence of warty excrescences upon thevalves, which excrescences were attacked with the acute in-flammation, which led to ulceration, and to considerableinefficiency of the valvular apparatus. Another reason fornot supposing the changes to have been so sudden is the factof fatty degeneration of the substance of the heart. On thislatter subject (adipose transformation) we would fain dilate,but must postpone our remarks to a future occasion, when weshall have to report another case of degeneration of theorgan. -
KING’S COLLEGE HOSPITAL.
Chronic Rheumatism; Cardiac complication; Albuminuria;Anasarca and Ascites; Good effects of Elaterium.
(Under the care of Dr. TODD.)
IT would be well if physicians, and all engaged in the practice of the medical art, were to turn their earnest attentionto incurable diseases, and use their best efforts to relieve thesymptoms (both slight and distressing) of the patients affectedwith such maladies. Sufficient importance is, perhaps, notattached to this point, and a wide door is thus opened to theimpositions of quackery. It is unfortunately but too true thatwe meet in practice with a great number of affections, of theincurability of which we are deeply and painfully convinced;but although we cannot cure, we have at our command meanswhich will afford the sufferers considerable relief, cheer themon in the sad struggle between the vis conservalriae of the
organism and the inroads of disease, and, in fact, render the fluid, and, if possible, the prevention of large accumula.-path to a ff0aMt<Ttet as smooth as is consistent with circum- tions. This end, when the kidneys have undergone changes
stances, hardly of a serious import, has generally been sought by actingIt need hardly be mentioned that, besides therapeutical upon the skin and the intestinal mucous membrane more than
agents, we possess,the moral influence necessary to act. upon upon the secreting apparatus of the kidneys. For the skin,the mind of the patient, and this should be used to its fullest the most effectual means is the vapour-bath, and for the in-extent to keep up the spirits of those who place confidence in testines, elaterium. Now, from our experience of the medicalour skill, thus rendering our presence and encouraging words wards of hospitals, we would be inclined to think thatas indispensable as the medicines we prescribe. Those who these means are hardly enough appreciated, for we do not seesee a great deal of practice are fully aware of this, and they physicians employ them as often as it might. comparatively bealso know that indifference, want of gentleness and kindness, expected. And yet what more effectual diaphoretic have weon the part of the medical attendant, will cause the patient to than the vapour-bath what more certain hydrogogue do weplace himself at the mercy of impostors, who, full of promises possess than elaterium It may no doubt here and there happenand with an assurance which a conscientious man cannot that the patient’s strength does not allow these powerful agentsassume, recal hope into the invalid’s heart, and comfort him to be had recourse to, but it remains nevertheless true, thatto the last. they are extremely valuable in appropriate cases. There doesThese remarks apply both to those diseases whose progress not seem to be any objection that both should be concurrently
is very rapid, and hurry the patient to the grave, and to the used in moderation, but we desire this day to lay before ourchronic affections which are fatal only after years of lingering. readers an instance in which one of these means was employedIt is, however, principally with the latter description of com- with as satisfactory results as could be expected, and we doplaints that we are this day concerned, as we wish to direct so the more willingly as cases similar to the one about to beattention to the manner in which Dr. Todd treated a patient related are not at all unfrequently met with in practice. Weaffected with the different maladies to be found in the above are indebted for the notes to Mr. Charles Macnamara, one ofheading. The thought often rises in the student’s mind, when Dr. Todd’s clinical clerks.he has been pointed out the pathological meaning of certain M. p aged forty-four, was admitted into King’s Collegeabnormal sounds of the heart and lungs-when he has been Hospital on the 14th of May, 1853. She states that she is a.
made aware that such sounds are almost certain proofs that native of London, and has twelve children, the youngest ofthese organs are considerably and irreparably damaged- whom is now eighteen months old. Her father died at sixty-What is to be done in such a case? Can the production of eight years of age of "gout and dropsy." She lost her mothertubercles- be stopped ? Can the valves be made to regain when young, and does not know from what disease. Thetheir pristine integrity ? Can the fatty changes going on patient complains of great debility, and says that she hasin the heart be arrested ? His teacher is constrained to answer been losing flesh for the last six months. She has been laidin the negative, and can only say-We must endeavour to up with an attack of rheumatic fever every year since shemake the patient avoid all causes which might render the was twenty years of age. She does not remember herabnormal changes more rapid; we must use the therapeutic chest ever having been attacked; but for some time pastmeans at our command to stay or render these alterations very has been troubled with shortness of breath, which was in.’-slow, and relieve the symptoms to which they give rise. As creased by the slightest exertion. The patient has calcareousto heart disease we should never despair; let us quote the deposits on several of the joints of her fingers and toes.opinion of some authors on this subject. [ This woman’s illness came on about five weeks before ad-
" Since the discovery of auscultation, however, our means mission, when, as in her former attacks, she had swelling ofof diagnosis have been considerably improved; the distinction the ankles, which also became very painful; but, unlike anybetween the several forms of cardiac disease has been laid other seizure, the swelling did not go down in a few days, butdown with much greater precision, and it does not admit of it gradually extended up the legs to the knees and thighs, anddoubt, that many morbid conditions of this organ have not then the abdomen also became swollen. She also noticedthe tendency to run on to a fatal termination, that was formerly that at this time she passed much less urine than usual.supposed, and many of them likewise may be kept in check.by State on admission.-The legs are much swollen andappropriate remedial measures:"-(Bellingham on the Heart, oedematous, and there is distinct fluctuation of thep.245.) abdomen, which measures thirty-four inches in circum-
Dr. Chevers (treatise on Diseases of the Heart) speaks still ference. The superficial jugular veins are much distended;more encouragingly:—" Confirmed organic heart-disease, ab- they do not empty themselves when compressed below thesolutely insusceptible of cure as it is, carries with it the re- point of compression ; and there is an indistinct systolicdeeming point, that, in its ordinary forms, the victim’s life is bellows-sound to be heard. She passes in forty-eight hoursallowed a more lengthened respite than is the case in any about three pints of uriue, which is loaded with albumen, andother description of destructive chronic disease with which contains a number of epithelial casts and crystals of thewe are acquainted-a respite which, it is true, is fraught with triple phosphate of ammonia and magnesia. The patient hassome amount of suffering, great need of self-denial, and many a constant cough, which troubles her very much, and pre-perils ; but during which, if the self-denial be rigorously main- vents her from getting any sleep at night. She expectoratestained, while the sources of peril are carefully avoided, the a large quantity of mucus; and over the whole of the front ofsuffering may be in a great measure mitigated, and the term the chest loud rhonchus is to be heard. Dr. Todd orderedof existence be prolonged to a degree, the full limits of which decoction of scaporium, one ounce and a half; carbonate ofare probably far more extended than we are at present aware ammonia, five grains; benzoic acid, five grains, to be takenof. We know that the most ordinary forms of exocardial and every sixth hour; and ten grains of Dover’s powder everyendocardial disease, adherent pericardium and valvular con- night.traction, certainly do not generally and of necessity destroy She continued this plan of treatment for sixteen days,life by their own advances, and by the influence which they without any diminution of the dropsy, but rather an increaseexert in gradually impairing other organs, in less than from of it, as she was passing less water than when she came in-ten to fifteen years, and the duration of their progress is viz., about one pint and a half in the day.found to be occasionally longer even than this." On the 1st of June, seventeen days after admission, sheAmong the symptoms to which heart disease may give rise, complained of convulsive movements of the limbs; and during
anasarca and ascites stand prominent, when lungs, heart, or the same night she was suddenly seized with epileptic fits,kidneys are affected; and physicians have from the remotest the whole body being convulsed; she foamed at the mouth,times used their best energies to remove or palliate dropsical and bit her tongue. She remained unconscious after the fitscomplications. Modern practitioners have doubtless the great till just before another one was coming on, when she used toadvantage of mostly being, able to detect the cause of the rise up iu bed. She complained of no paiu; the pupils weredropsy, and they are thus enabled to make a judicious choice dilated during the fit, but became contracted in the intervals-among the evacuants and diuretics to be employed. Care is She had had eight of these fits by three o’clock the followingthen taken to prescribe those only which will not directly day. Dr. Todd then saw the patient, and ordered her todistress the organs affected, whilst favouring the evacuation take a quarter of a grain of extract of elaterium, made into aof fluid from the economy; and we may add, that the know- pill, every three hours. At six o’clock she began to be-ledge of those causes leads in cases wherein the organs are purged, and in the course of the twenty-four hours her-not irremediably damaged, to the administration of medicines bowels had been opened as many as twenty times, and she:which may procure permanent benefit. passed a considerable quantity of water with each motion-In the case which Dr. Todd had to treat, it was self- There had been no symptoms of another fit.
evident that palliatives only could be thought of, the Twenty-first day.-She was ordered to take the pills onlyprincipal end held in view being the removal of the every six hours, as they purged her a great deal; and she
continued them in this way for ten days. She became veryweak, but that was all she complained of. She could liedown in bed without her cough troubling her. The legswere not at all oedematous, and there was only a smallquantity of fluid in the abdomen. The urine contained amuch less quantity of albumen than on admission, and shewas at this period passing about two quarts in the day. Thewoman was now ordered to take forty grains of compoundjalap powder every morning.
Fifteen days after this, notwithstanding the bowels werefreely opened by the powder, the quantity of urine diminishedconsiderably, and the legs and abdomen began to swell also.The patient was therefore ordered to take a drachm ofbitartrate of potash, and one drachm of spirit of nitrousether, every four hours. The diuretics, however, did not have the desired effect ; she
passed only about a pint and a half of urine in the day; thedropsy had increased more than ever, and after continuingthis treatment for a week, she complained of convulsive move-ments of the limbs. Do. Todcl now resumed the hydragoguemedicine, and she was ordered to take a quarter of a grain ofextract of elaterium every third hour. This was continuedfor two days; she had no more symptoms of a fit, but wasviolently purged. Dr. Todd therefore ordered her to take thepills only twice a day.
This treatment was persevered in for a fortnight, at the endof which time the patient was much better; she slept com-fortably at night, had lost her cough, and the dropsy hadagain diminished. The pills were now taken once a day, thebowels being thereby opened three or four times per diem.At the end of another week this patient was discharged at
her own request. She was able to get up and go about thewards; her appetite was good, and she slept well; the urinecontained a slight amount of albumen, but no casts, and shepassed about two quarts in the day. The dropsy had alto-gether disappeared, but she was very weak, and it was judgedthat a change of air would do her good.
It is remarkable how the epileptic fits (probably dependingon the circulation of poisoned blood in the brain) were stayedby the numerous aqueous evacuations procured by the ela-terium ; and it might almost be supposed that some of themateries morbi was carried off by the stools. Some prac-titioners will, perhaps, think the doses given in this case largeand pretty frequently repeated; but it is evident that any ’lesser doses would have failed to afford the relief which washere obtained, and we consider the case valuable as showing ]
how much of the hydragogue can be given, and how far it can 1safely be pushed. -
Reviews and Notices of Books.
&psgr;&ggr;XH: a Discourse on the Birth and Pilgrimage of Thought.By WALTER COOPER DENDY, Honorary Fellow, and for-merly President, of the Medical Society of London, &c. &c.London, 1853. Square 8vo. pp. 144.
WHEN lately drawing the attention of our readers to thenew issue of the Philosophical Dissertations in the " Encyclo-pmdia Britannica," we remarked upon the extent to whichthe science of mind has been indebted in this country to thelabours of mon who have been more or less associated withthe study or practice of medicine. We instanced the namesof Locke, Brown, Mackintosh, Hartley, Abercrombie, &c., as
illustrative of the fact, and we expressed our satisfaction atthe fresh impetus which has of late years sprung up amongstus to prosecute inquiries in the wide and interesting field ofpsychological investigation. Besides those who, having enteredupon the study or practice of medicine, have afterwardsabandoned them, and become philosophers by profession, orhave devoted their intellectual energies to the elucidation ofthe higher metaphysics, there are others we could name that,still maintaining an intimate relationship with practicalmedicine, liive displayed no little ability in illustrating thatcommon ground where physiology and psychology meet andinfluence each other. Without venturing within the limitsof formal logic, on the one hand, or the domains of speculativethinking or of the pure reason, on the other, (or which latter,when ventured on, is, as in the work before us, trodden ratherwith the spirit of the poet than with the analytic temper of
the metaphysician,) but regarding human nature, in prefer.’ ence, with the eye of the physiologist and natural historian,
they have done much to elucidate the character and varietiesof habits and instinctive emotions. They have helped to exhibitunder more experimental aspects those phases and manifesta-tions of our mental life in which what may be termed the
organic conditions of thought are more directly hinted at, orthrough which they may be more directly sought out andestablished; they have abundantly, nay, often profusely,illustrated the reciprocal and relative influences of mind andbody upon each other, and have ably portrayed those specialand often very peculiar mental and moral manifestationswhich supervene upon, or are modified by, particular somaticcauses, or physiologic stimuli. From amongst those who havethus cultivated an inquiry into the interweaving elements ofthe psychical and somatic portions of our existence, there arefew whom we could name that have brought a more poeticfancy, elegant pen, discursive knowledge, refined taste, toge-ther with extensive practical professional information, tobear upon a favourite subject than the highly-accomplishedand well-known author of the "Philosophy of Mystery," andof our present" YuXn." To those acquainted with the formerwork, or the other writings of its author, to assure them ofthe refined elegance and suggestive thoughts characterisingthe present " Discourse" will be unnecessary. We have readit with much pleasure, and although some fundamental
principles of our philosophy are not those of our author, andvice versd yet we are sure that any of our professionalbrethren who, after a day’s occupancy with the more materialand often melancholy duties connected with the sufferingbody of our humanity, would wish to touch upon some loftierand brighter region of light and life, as exemplified in thehistory of the mind, will thank us for directing them to thepages of the little work before us, where they may makeacquaintanceship with the views of one of no mean intellectualqualifications as to what Is the fountain of that thought ? what that mysteriouslight that has so richly illumined the framework of humannature,-that inspired Shakspeare to create new worlds offancy; Milton to presume an earthly guest, into Paradise andPandemonium; Herschel, Davey, Wollaston, and Faraday, toplay their splendid tricks with gases and metals; Smeaton,Telford, and Stephenson to subjugate the stubborn laws ofmechanics to their will; and Newton to demonstrate theruling principle of the universe ?"-p. 2.
The Journal of Psychological Medicine and Mental Pathology.Edited by FORBES WINSLOw, M.D. No. XXIII. July,1853.
Pharmaceutical Journal and Transactions. London, August,1853.THE present is a very interesting and instructive number of
Dr. Winslow’s Review, containing in particular, amongstother matter, an extended analysis of Mr. Morell’s new workon Psychology, Feuchterslebeu’s 11 Dietetics of the Soul," andan interesting essay by Dr. Symonds, of Bristol, upon " Habit,physiologically considered." Will the learned editor excuseus the remark, however, in connexion with the paragraphheaded " Our Library Table," that an atmosphere couleur derose seems to rather indiscriminately surround all contribu-tions which have the fortune to be brought to it.The present number of the P7tarmaceutical Journal contains
an interesting article upon the manufacture of ammonia andammoniacal salts, and, moreover, furnishes fresh proof, in theremarks made upon the adulteration of citric acid and of
pulvis aeacim, of the urgent necessity there has existed forthe investigations undertaken by our own Analytical SanitaryCommission.
ROYAL FREE HOSPITAL COLLEGE.-On the 1st ofOctober a College in connexion with the Royal FreeHospital will be opened. The new buildings are progressing.There will be attached to the College a very extensivemuseum.