and she afterwards progressed steadily to recovery. Prevention is, however, better than cure, and we cannot leave this subject without dropping a hint that, in relation to the prevention of such diseases as those under consideration, the predisposing causes of which are well known and removable, the conservators of the public health have very important duties to perform.-Med. Times and Gazette, Aug. 13, 1853, p. 167.

26.-Chloroform in Delirium Tremens. By DR. PRATT.-Dr. Pratt has administered chloroform internally, with success, in two cases of delirium tremens. The first patient took four grammes in water, repeated every four hours; the second patient took a tea-spoonful of chloroform in water, followed, in an hour, by eight grammes of spirit, æther, sulph. co., tinct. valerianæ, and four grammes of chloroform. A quarter of an hour afterwards the patient fell asleep, and awoke in three hours and a half with his reason. Small doses of chloroform were subsequently administered from time to time.-Med. Times and Gazette, Aug. 6, 1853, p. 148.

27.-CASE OF SEVERE CHOREA.

By DR. BARCLAY, Medical Registrar to St. George's Hospital, &c.

[In this very violent case, it was for some time doubtful whether a fatal termination would not result. The remedies which seemed to incline the issue favourably, were the administration of chloroform and quinine suppositories. If chloroform, in cases of violent mental excitement, as mania, delirium tremens, chorea, &c., does not produce natural sleep after its effect passes off, the probability is that much more harm will result from its administration than good. It may, however, from its transient effect, be administered in some cases of cerebral excitement where the too persistent narcotics, as opium or morphia, cannot be given. The quinine was resorted to, to sustain the system, and restore its exhausted energies as a tonic. With these preliminary remarks, we proceed to relate the case.]

Susan H, aged 16, was admitted into St. George's Hospital, under the care of Dr. Wilson, on February 23, 1853. She had been in service, and had been much worried by illness in the house, and overwork. No other cause was known for the occurrence of the symptoms of chorea, which had been gradually supervening during a fortnight or three weeks before her admission. She had had no rheumatism, and the heart was healthy. When received into the hospital, the spasmodic movements were not by any means violent, nor very constant; but there was great distortion of features, especially when she attempted to speak. She was ordered a strong purgative, and then directed to have six minims of Fowler's solution in pimento water, three times a day. The bowels were rather loaded, and much inclined to be costive, and the purgative was repeated on two or three occasions. She continued taking the arsenical solution until the 11th of March, and seemed, under its influence, to be gradually becoming quieter and steadier. She was rather out of sorts that day, and the arsenic was left off for a'day or two.

The spasmodic movements now began to be more frequent and severe, and she was obliged to lie in bed. The sesquioxide of iron was given in doses of two scruples three times a day without benefit. Her nights became disturbed, and she used to scream out a good deal during the day. Seclusion had rather a calming effect upon her; and the bed was screened off from the rest of the ward, during which she used to have occasional short slumbers, but, for the most part, she was very restless; the expression of her face was rather wild, and the spasmodic movements constant and severe.

On the 17th, the bowels having been well purged, she was ordered to have a third of a grain of tartar emetic every three hours, and half a grain of acetate of morphia at night. This produced no sickness, and seemed partially to calm her; it was continued a second day, at intervals of four hours. She had had no sleep that night, and was evidently no better; without being very violently tossed about, there was excessive restlessness and desire of movement; her face was much distorted, and

the expression wild, and almost maniacal; and, as she sat upon her bed, with her legs drawn up under her, and her hair in wild confusion about her face, she looked much more like a proper inmate for Bedlam, than a person suffering simply from chorea, and the more so, because of her constant cries; but the nurse satisfied herself that she was free from delirium, and perfectly conscious on all occasions.

She had now passed the catamenial period, with no return of the menstrual flux. Her nights were sleepless, and a quarter of a grain of morphia was given every three hours to six times, but without benefit. She seemed to be gradually becoming exhausted by the constant jactitation and want of sleep. Wine had been given; yet the tongue was becoming dry and brown, the lips covered with sordes, and the pulse quick and feeble. Her aspect was distressed, and she was tossed about very violently by the spasmodic movements of the disorder.

On the 21st she was directed to inhale chloroform, and to have a suppository, with two grains of opium at once, and a draught of four grains of camphor, and some chloric ether every two hours. The first inhalation quieted her, but she awoke almost immediately after the first effects had passed off; it was not repeated till night, and, in the mean time, eight grains of quinine in suppository were ordered every hour for six times. She had some sleep after the second inhalation, and it was repeated the following forenoon. She was decidedly quieter, and the draughts and the suppositories, which had not been all given with perfect exactness, although very frequently during the night, were continued at intervals of four hours. The chloroform inhalation was again repeated on the evening of the 22nd. She slept pretty well after it through the night, and fell asleep naturally next morning, waking up to have her dinner, and almost immediately going to sleep again, and continuing to doze all day. From this time she continued to improve rapidly. She was still a little odd-looking in the face, and restless jactitations lasted for some time; but she gradually became steadier. On the 4th April she was ordered Griffith's mixture, and on the 15th was discharged recovered.—Med. Times and Gazette, May 28, 1853, p. 548.

DISEASES OF THE ORGANS OF CIRCULATION.

28.-ON SOME OF THE PRINCIPAL EFFECTS RESULTING FROM THE DETACHMENT OF FIBRINOUS DEPOSITS FROM THE INTERIOR OF THE HEART AND THEIR MIXTURE WITH THE CIRCULATING BLOOD.

By DR. W. SENHOUSE KIRKES.
Communicated by DR. GEORGE BURROWS, F.R.S.

[That the blood may, in certain cases, deposit its fibrinous constituent upon some portions of the circulatory apparatus, seems now to be an established truth. These may either be the globular excrescences of Laennec, or the many varieties of warty growths adhering to the valves. That these masses may be dislodged during life is easily proved by a very slight force being, in many instances, necessary for their removal after death. Such being the case, it is also easily understood that the first vessel too narrow for their transmission must oppose an obstacle to their further progress; if from the left side of the heart, they will be arrested in any of the systemtic ramifications, especially in those organs receiving a large supply of blood, as the brain, spleen, and kidneys; if from the right, they must necessarily be arrested by the minuter vessels of the lungs. First, on the effects of such an accident in the systemic circulation. The three following cases will show that softening of the brain was consequent on the blocking up of the main cerebral arteries by fibrinous masses, apparently derived from the left side of the heart:]

Case 1.-Margaret Shaw, aged 34, a pale weakly-looking woman; admitted into St. Bartholomew's Hospital, under Dr. Roupell, about the middle of July, 1850, on account of pains in her lower limbs, and general debility. A loud systolic murmur was heard all over the cardiac region. No material change ensued in her condition until August 7th, when, while sitting up in bed eating her dinner, she suddenly fell back as if fainting, vomited a little, and when attended to was found speechless, though not unconscious, and partially hemiplegic on the left side. The hemiplegia

increased, involving the left side of the face as well as the limbs, and gradually became complete in regard to motion, while sensation seemed to remain unimpaired. She continued speechless and hemiplegic, but without loss of consciousness, for five days, when she quietly died.

On examining the body, six hours after death, the skull and dura mater were found natural; but the small vessels of the pia mater were much congested, the congestion amounting, in some places, almost to ecchymoses. The right corpus striatum was softened to an extreme degree, being reduced to a complete pulp of a dirty grayish-white tint, and without any remains of its characteristic striated structure. The corresponding optic thalamus was healthy; but a condition of pale softening, similar to that affecting the corpus striatum, existed also to a considerable extent in the posterior lobe of the right cerebral hemisphere. The rest of the cerebral substance of this hemisphere was softer than natural, and appeared to contain less blood than ordinary. All other parts of the brain were healthy. The right middle cerebral artery just at its commencement was plugged up by a small nodule of firm, whitish, fibrinous-looking substance, which, although not adherent to the walls of the vessel, must have rendered its canal almost, if not quite, impervious. With the exception of a speck or two of yellow deposit in their coats, the rest of the vessels at the base of the brain were healthy and filled with dark blood.

The heart was enlarged; on its exterior were several broad white patches of false membrane. The right cavities and left auricle contained recent separated coagula; the fibrin firm and whitish. The right valves were healthy; so also were the aortic, with the exception of slight increase of thickness. The mitral valve was much diseased, the auricular surface of its large cusp being beset with large warty excrescences of adherent blood-stained fibrin. There were a few scattered deposits in the coats of the aorta. The right common iliac artery, about an inch above the origin of its internal branch, was blocked up by a firm, pale, laminated coagulum, which extended into the internal iliac, and for about a quarter of an inch down the external iliac, where it terminated rather abruptly. The lower portion of the coagulum was colourless, and softer and more crumbling than the upper, which was also more blood-stained and laminated. There was no adh sion of the coagulum to the walls of the vessels. No similar clot existed in the iliac vessels on the opposite side. The pleura were adherent in places; the lungs oedematous, and in places solidified by compact grayish-white masses, such as might result from uncured pneumonia. The pulmonary vessels were free from old coagula.

The liver and intestinal canal were healthy. The spleen was large, pale, and soft. One large portion, about a fourth of the organ, was converted iuto a mass of firm, yellowish-white, cheesy substance. The kidneys were pale, rough, and granular. Within the cortex of the right were several large masses of yellow deposit, surrounded by patches of redness. The portions of medullary structure passing to these deposits were compact, dryish, and yellow.

In the case just narrated, death evidently resulted from softening of a large portion of the right side of the brain; and the cause of this softening appeared to be an imperfect supply of blood, consequent on the middle cerebral artery of the same side being obstructed by a plug of fibrin within its canal. I am not aware that there has yet been recorded a case in which fatal softening of the brain resulted from a cause like this; therefore in itself this case is one of value. That the existence of the fibrinous coagulum within the cerebral artery was the real cause of the changes in the brain, can, I think, scarcely admit of question. The sufficiency of such an obstruction to produce the effects ascribed to it is fully established by the many instances in which disturbance, or complete arrest of function in a part, with subsequent atrophy or disorganization of its tissue, results from any circumstance which materially impedes or entirely cuts off its supply of blood. Examples of this kind at once suggest themselves;-such as the weakened and subsequently degenerated heart, when the coronary vessels are diseased by deposits in their coats; the feebleness, atrophy, or even gangrene, ensuing in the whole or part of a limb whose arteries are similarly diseased, or obstructed from any other cause; also the impairment of cerebral function and subsequent softening of the tissue of the brain when the cerebral vessels are much diseased. But perhaps the best illustration bearing on the case in question is afforded by the results sometimes observed after ligature of one of the common carotid arteries. Such an operation is not un

frequently followed, almost immediately, by giddiness, loss of speech, and unconsciousness, which may pass on even to fatal coma. When not thus speedily fatal, hemiplegia of the side opposite to that of the ligatured artery may ensue, and death may occur from that cause at a more remote period, while examination after death discloses a greater or less amount of disorganization, amounting sometimes to gangrene, in the cerebral substance, especially on that side on which the operation was performed.

[In this case the fibrinous material had evidently been arrested at the angle whence the middle cerebral proceeds from the carotid. In the second case related, the results were so similar that it is scarcely necessary to relate the case. In the third case, the patient, William Purdy, aged 24, was admitted into St. Bartholomew's Hospital on January 22, 1852. His legs and feet were much swollen, and a harsh systolic murmur was heard at the apex of the heart, fading towards the base, where the second sound was clear. He had previously had rheumatic pain in the joints. About a fortnight after the cardiac symptoms had manifested themselves, he was seized with an apoplectic attack, and on admission into the hospital, there was loss of motion over the whole of the left side, though sensation was not much impaired. Nutritious diet and wine were administered, under which he seemed to rally for a short time, but he died ten days afterwards.]

An examination of the body was made twenty-eight hours after death. The emaciation was considerable. The lower limbs remained œdematous, especially the left, the foot of which was of a dark, livid colour. The tissues generally were very pale, especially about the scalp. The skull was pale and light. The membranes of the brain were healthy, but pale, while there was a considerable excess of clear fluid in the cavity of the arachnoid and the tissue of the pia mater. The vessels of the pia mater were unusually deficient in blood, almost empty. The substance of the brain was remarkably pale, soft, and watery in every part; there was no trace of a clot, or any manifest product of inflammation. Impacted within the right middle cerebral artery, just at its origin, was a firm plug of pale fibrinous substance, about the size of a hemp seed, completely blocking up the canal of the vessel, while the branches immediately beyond the obstruction were narrow, but filled with dark stagnant-looking blood, which had quite a different character to that in the other cerebral vessels. There was no trace of any disease in the coats of the cerebral arteries, and no obstruction in the left middle cerebral. Within the left lateral sinus was a large mass of old dryish colourless fibrin, somewhat adherent to the lining membrane, which was spotted red. A piece of similar fibrin existed also in the left internal jugular, but not connected with the mass in the lateral sinus. The other cerebral sinuses and right internal jugular were free from old coagula. The pericardium was healthy within, but externally it adhered to the left pleura. The heart was about natural in size, but much diseased in its interior, the tricuspid, mitral, and aortic valves being encrusted over with large, firm, warty vegetations. On the tricuspid valve these growths were attached along the auricular surface, just above its free border. They varied considerably in size and number at different parts of the valve; many of the masses consisted of small compact roundish or oval bodies about the size of hemp seeds or bigger, attached singly or in clusters to the edge of the valve and to the tendinous cords to which they more or less tightly adhered. In structure they were firm and solid throughout, of a yellowish-white colour, aud evidently composed of a dense fibrinõus substance. The free border of the mitral valve was thickly studded with a continuous ridge of rough cauliflower-like masses of firm white fibrin, which formed warty excrescences of various sizes and shapes. One mass was nearly as big as a hazel-nut, firm, elastic, and solid throughout, and of a mottled yellow and red colour on section.

The aortic valves were studded by a similar crop of smaller warty vegetations. Lying loose in the cavity of the ventricle were several small brownish nodules of old blood-stained fibrin. The muscular tissue of the heart was generally healthy; but just beneath the lining membrane of the left ventricle, and occasionally deep within its substance, were numerous pale yellow or buff-coloured blotches and streaks surrounded by red borders, and having the general appearance of the changes described under the term of capillary phlebitis. The coronary arteries were healthy; so also was the general arterial system, though the aorta and its main branches were very narrow. The principal venous trunks contained recent coagula, but the

two internal and external iliac veins, and both femoral veins, were blocked up by old variously-discoloured masses of firm, friable fibrin. These old coagula were very large, and produced great distension of the veins in which they occurred. There appeared to be no disease of the coats of the veins, and the coagula were nowhere adherent to them; and the arteries leading to the lower extremities were free from old coagula.

There was nothing peculiar in the blood generally. The coagula in the right cavities of the heart presented quite ordinary characters. There were a few scattered pleural adhesions. The lungs were generally very edematous; both lower lobes were consolidated by masses of fibrinous deposit, consisting principally of reddish-brown pulpy material, surrounded by darker portions composed of recently extravasated or stagnant blood. In some parts of the right lower lobe were several collections of greenish thick pus, the majority being about the size of peas, a few as large as a walnut. All the branches of the pulmonary artery leading to the lower lobes were completely plugged up by old, firm, variously-coloured laminated coagula. The branches going to the upper lobes also contained old coagula, though these were softer, apparently of more recent date, and did not so completely block up the canals of the vessels. The pulmonary veins contained recent coagula. The liver appeared healthy, though pale; and there were no old coagula in any of the portal or hepatic vessels. The spleen was enlarged to about three times its natural size, and very dark from extreme sanguineous engorgement; its tissue was soft and pulpy, while within its substance were several variously sized circumscribed masses of fibrinous deposit. These masses varied in colour from dirty brown, spotted with red, to bright yellow; and in consistence from that of a firm, friable cheesy substance, to that of a semi-fluid pulp. One of the collections of pulpy substance was contained in a kind of cyst bounded by the capsule of the spleen; at one point the capsule had given way, and a considerable quantity of the pulpy fluid was found in the peritoneal cavity, and smeared over the intestines. The absence of any signs of peritonitis makes it probable that the escape of this material had taken place either just previous or subsequent to death. There was nothing deserving particular notice in the state of the intestinal canal. The kidneys, though healthy in general structure, were the seat of numerous, large, yellow, fibrinous masses, similar to those in the spleen. In the left, these masses were so abundant and large as almost to replace the entire structure of the gland. All the masses were firm and compact; many of them were surrounded by zones of redness. The main artery of this kidney, from the point of its entrance and along all its traceable subdivisions, was filled up by pale, firm, old fibrin. Similar, though redder, old coagula existed in the renal vein. There were no old coagula in the artery or vein of the right kidney, which, moreover, was much less diseased than the left.

In all essential respects this case closely resembles the two previously narrated. In each there was pale softening of the brain; a plug of fibrin obliterating the canal of one of the main cerebral arteries; masses of fibrinous deposit in the kidneys and spleen; and, which seemed to be the source of the mischief elsewhere, large, warty, fibrinous excrescences on the left valve of the heart.

So many, and yet such rare features of resemblance, cannot fail in demonstrating a very close connection between the several morbid appearances so exactly reproduced in each case.

Although in the autopsy of the last case it was not particularly noted that the right side of the brain, or any portion of it, was softer than the rest, yet the existence of hemiplegia on the left side, and the softening in each of the former cases being most marked at the parts supplied by the obstructed arteries, leave little room to doubt that in this case also, those portions of brain supplied by the right cerebral artery were more atrophied, though perhaps not manifestly much softer than other parts whose vessels were not thus obstructed.

Besides the existence of fibrinous vegetations on the valves of the left side of the heart, and the formation of fibrinous deposits in other parts freely supplied with blood by the left ventricle, it is worthy of particular attention that in this case there were also warty growths on the tricuspid valve, together with coagula in the pulmonary arteries, and masses of fibrinous deposit in the substance of the lungs. The importance of this fact, in support of the close and direct connection between deposits on the valves of the heart, coagula in the arteries, and fibrinous deposits