PROVINCIAL MEDICAL & SURGICAL JOURNAL. TWO CASES OF PERICARDITIS. April 30th. The friction sound over the apex had not BY FERGUSON BRANSON, M.D., Physician to the entirely ceased, though it was much softened in Sheffield General Infirmary. character. On June the 4th, he came to the Infirmary to be prescribed for as an out-patient; his countenance was anxious, there was again considerable anasarca, and a very distinct, though soft, friction sound over the apex. A bellows murmur with the second sound was now heard on the right side of the heart, over the lower third of the sternum, and supposed to depend upon some obstruction to the passage of the blood through the tricuspid valve. As he could not at that time be admitted into the Infirmary, he was seen several times at his own house, a wretched and comfortless abode. No relief was this time obtained from medicine; he the left shoulder. On the 11th of June the friction sound could scarcely be distinguished, though the tricuspid murmur was distinct, and he died rather suddenly on the afternoon of the 13th. Joseph Morland, aged 14, a table-knife cutter, was admitted an in-patient of the Sheffield Infirmary, December 15, 1843. He had been ill six weeks, and during that time had complained of pain in the left side of the chest, shooting to the left shoulder, with palpitation; he had also pain in the limbs, but no swelling around the joints. The only treatment was a blister applied to the chest, by his mother. A week before his admission into the Infirmary his legs began to swell, and he became generally anasarcous. The day before his admission he was seen by a medical practitioner, who applied leeches to the heart, and recom-complained much of pain shooting from the heart to mended his friends to take him at once to the Infirmary. On his admission he was generally anasarcous, the face pale, and very much puffed, and the eyes almost hidden by the tumid integuments; he was restless, and complained of oppressive dyspnea; the impulse of the heart was bounding, quick, and slightly irregular; the pulse at the wrist was full and jerking; over the whole | of the heart, but especially over the base and middle portion, a friction sound, the "to and fro" sound of Dr. Watson, was distinctly heard; in character softer than usual, so much so as to lead to a doubt whether the sound might not to some extent depend on valvular disease; this supposition, however, was refuted by the superficiality of the sound, and the full and bounding character of the pulse. Without tediously detailing the daily history of the case, my object being rather to connect the prominent physical signs with the after-death appear ances, it is enough to state that by the repeated appli-polypous concretion, of a “pale flesh tint” (Hope) and cation of leeches and blisters, and the continued use of mercury, he was so much relieved as to be made an out-patient on the 22d of February. The anasarca had entirely disappeared, the friction sound over the base and middle of the heart had ceased, and there remained only a very slight double murmur, heard most clearly a little higher than the apex of the heart. The impulse of the heart, though considerably reduced in force, remained stronger than natural; the apex might be felt beating two inches below, and a little to the outside of the left nipple, and the dulness on percussion exceeded the normal limits. There was evident hypertrophy. On March the 12th, he was readmitted; there was a return of the anasarca, though to a less extent than before, and the friction sound was now very distinct over the apex, and not heard at all over the base and middle of the heart. After somewhat similar treatment he was again relieved, and made an out-patient on No. 16, July 17, 1814, At the post-mortem examination on the following morning, the pericardium was found to be universally adherent, with the exception of a small patch on the posterior surface of the heart; the adhesions, however, differed in character; they were much less firm, and apparently more recent over the apex than over the middle and base of the heart. The heart itself was nearly double its natural size, and the walls of the left ventricle much thickened. There was slight thickening of the aortic valves; no disease whatever of the mitral valve; very slight thickening and opacity of the tricuspid valve, and behind the tricuspid valve, and interlaced with the columnæ carnea was a semi-organized adhering to the lining membrane of the heart by delicate filamentous bands of lymph, and clearly formed before death. The valves of the pulmonary artery were healthy; there was no disease of the lungs; the liver was large,with some hypertrophy of the white substance; the kidneys were much enlarged and presented a beautiful specimen of granular degeneration. Unfortunately the attention had been directed too exclusively to the heart, and no search for albuminous urine had been instituted during life. The post-mortem exami. nation of the heart bore out exactly the symptoms observed during life. The firm adhesions over the base and middle of the heart corresponded with the first attack of pericarditis, the less firm adhesions over the apex corresponded with the last attack of pericarditis, and the semi-organised polypous concretion presented an obstruction to the passage of the blood from the right auricle to the right ventricle, suffi R ciently great to cause the murmur with the second jerking; tenderness on pressure in the intercostal sound over the tricuspid valve. William Riddle, aged 45, a comb-maker, and an inveterate spirit-drinker,called on me February 28, 1843. His complexion was sallow and anæmic, and he com. plained much of palpitation, dyspnea, and cough. He said his health had been tolerable till five years ago, when he first remarked the palpitation, and observed that it was easily excited by ascending a hill or going upstairs. Twenty years before this he suffered from an attack of acute rheumatism. On listening to the heart, a remarkably loud musical murmur was found to accompany the first sound and was heard very extensively over the chest. He could only lie on his back, and his pulse had a peculiar thrilling character. I saw the man only once at this time, and made a very brief note of his case. On March 30, 1844, he brought an out-patient's recommendation to the infirmary. His countenance then was bloodless and anxious; there was the same remarkably loud deep-toned and extensively heard musical murmur, loud enough to be distinguished by the unaided ear at a distance of several inches from the chest, and superadded to this older symptom was a friction sound, heard only over the apex of the heart, and at this point only was there tenderness on pressure between the ribs. He was with some diffi. culty persuaded to become an in-patient. On examining him in bed, the intensity of the musical sound was found to be greatest over the upper third of the sternum, and over the cartilages of the adjacent ribs on the right side. The musical sound could not be heard in the femoral arteries, nor in the abdominal aorta, but it was easily detected in the lower part of the carotids. There was no jugular pulsation. The dulness on percussion over the heart extended beyond the normal limits, and the apex of the heart was felt beating an inch below, and to the outside of the left nipple. There was general throbbing of the arteries. The recent attack of partial pericarditis, indicated by the limited extent of the friction sound, was combatted with leeches, blisters, and calomel; he soon, however, became tired of medicine, and was made an outpatient at his own request on the 11th of April. The friction sound had nearly disappeared when he left the infirmary, and ten days afterwards it had ceased entirely. I lost sight of him till the 4th of June, when his wife called at the infirmary to tell me he was much worse. I found him altered in appearance, and much thinner; he was greatly harassed by the cough, and expectorated with difficulty a quantity of frothy mucus. He was unable to lie down, and passed the night in a chair; mucous râles were heard extensively over both lungs, and the musical sound was as loud as ever. spaces over the heart; cough very distressing and followed by urgent paroxysms of dyspnea, which was much increased by the supine position. The urine was scanty and high-coloured, and did not coagulate on the application of heat; there was dulness on percussion over the lower part of the right lung, the respiration being indistinctly heard in that situation and over the whole of the left lung, and over the remaining portions of the right lung there was large mucous crepitation. Leeches were applied and three grains of calomel were given every two hours. On the 17th, the friction sound was rather less distinct, and the heart's action irregular and fluttering. On the 18th, the friction sound was less loud and distinct than on the 17th; the breathing, however, had become even more hurried and laboured; he was no longer able to expectorate, the pulse was rapid, the counte. nance expressed extreme suffering, and he died in the afternoon after a prolonged paroxysm of dyspnea. On opening the chest on the following day a considerable quantity of serum was found in the right pleura, and the surface of the pleura pulmonalis on the right side was to some extent coated with recently effused lymph. The pericardium contained at least a pint of serum. The surfaces of the pericardium were throughout nonadherent, and on both surfaces were found extensive patches of firm, rough, granulated lymph; and which, when rubbed with the finger, gave out a friction sound precisely similar to that heard during life. The heart itself was double the natural size, from dilatation with hypertrophy. The endocardium was throughout considerably injected. The tricuspid valve was perfect, as were also the semilunar valves of the pulmonary artery; and the only lesion, if lesion it could be called, met with on the right side of the heart, was a somewhat friable state of the chorda tendineæ. The pulmonary artery was also softer than natural, and easily broken through by the finger. The mitral valve was healthyperhaps a little thickened. In the aorta immediately above the valves was a considerable atheromatous and bony deposit, the probable cause of the musical murmur; and a similar deposit was found on the aortic valves, but to a much less extent. The bony deposit was confined to an inch and a half of the aorta immediately above the valves, whilst the atheromatous deposit extended along the aorta as far as the finger could be passed into the vessel, but it was felt to diminish in quantity as the distance from the heart increased. The liver had the nutmeg character, and the kidneys were healthy. Sheffield, July 3, 1844. CASE OF IMPERFORATE VAGINA. By W. J. SQUARE, Esq., Surgeon to the Hospital, Plymouth. themselves to the surgeon requiring operation, for the Irregular forms of disease occasionally present performance of which no exact rules are laid down in the systems of operative surgery. In these instances the surgeon is obliged to shape out for himself that course of operative proceeding which appears best calculated to fulfil the end required. The case which I am about to relate is of this nature, ON PUS-GLOBULES. and is so uncommon as to render it improbable that many instances of like disease can ever fall under the care of one individual. Hence, I conclude that a record of the case is important, as it may form one of a series of similar cases scattered over the pages of medical literature, from the investigation of which the surgeon may deduce useful hints for his guidance. Mrs. Tremeer, aged 34 years, admitted into the South Devon and East Cornwall Hospital, on the 1st of March, 1843. She is well-formed and of healthy aspect. Three months since she was delivered by the forceps of her first child, after a very protracted and painful labour. Although she suffered from a considerable purulent discharge from the vagina, no suspicion of injury to that canal was entertained until she slept with her husband about six weeks after her accouchement. On examination of the vagina it is found to be quite closed by firm cicatrization, at about an inch from its orifice. The surface of the cicatrization is puckered up like the end of a purse, and about the centre of it is a dimple or depression. The finger in the rectum does not recognize any extensive tract of induration in the vagina. From this examination, in which I was assisted by my colleagues, Messrs. Derry and Whipple, I concluded that the vagina was not cicatrized from the orifice to the os uteri, but that there must be a cavity, consisting of the upper portion of the vagina beyond the cicatrix. Strongly impresssed with this idea, I pushed a blunt probe against the dimpled part of the cicatrix, and penetrated it, the septum appearing to be about half or three quarters of an inch in thickness. March 3rd. A wax bougie (urethral) No. 6, passed through the opening made by the probe. No menstrual fluid above the obstruction. 5th. No. 8 urethral bougie passed. 10th to 30th. For the last three weeks I have endeavoured to dilate the cicatrix by bougies and sponge tents; but the attempt has been so painful and inefficacious, that I have given up further attempts at dilatation, and determined to wait for the departure of the next catamenial discharge, and then perform an operation for her relief. April 20th. A few days since she had pain in her back for some hours, but menstruation has not taken place. Having introduced a female catheter through the opening previously made, no discharge either followed its removal, or was entangled in the eyes of the instrument. April 22nd. With the advice and concurrence of my colleagues I performed the following operation:The patient tied as for lithotomy. 233 introduced within the vagina, and the patient removed to her bed. Vespere. The plug forced out by ineffectual efforts at micturition. Bladder distended; considerable fever; urine drawn off. Ordered : ५ Calomel, four grains; opium, one grain and a half; at bed-time. Poultice to the belly. Saline mixture, with tincture of henbane. Plug of lint not re-introduced. 23rd. More comfortable-urine again drawn offplug re-introduced. 24th. A wooden plug introduced within the vagina and retained by a bandage. May 20th. From time to time there has been some febrile excitement, with hysteric combination. The wooden plug excites a good deal of purulent discharge. Ordered: Compound-alum enema three times daily. 1 scruple. 2 drachms. . 12 ounces. Two table spoonfuls to be taken three times a day. June 4th. Discharge much less. Wound red and vascular, not granulated. A gum elastic rectum bougie substituted for the wooden plug, and retained four hours every morning. Walks out of doors. July 20th. The same treatment has been steadily pursued. The vagina does not contract. There is scarcely any discharge. Health and spirits good. No catamenial discharge appeared. August 20th. Treatment continued to this date. Has had sexual intercourse without much pain; catamenia absent. Discontinue the injection and quinine; continue the use of the bougie. September 21st. Has had frequent sexual intercourse, and there is now little or no pain. No discharge; no menstruation. November 1st. The vagina has no tendency to contract. Catamenia absent. Continue the bougie. Feb. 10, 1844. I heard from a friend of hers that she is quite well, but could obtain no particulars as to menstruation, &c. ON PUS-GLOBULES; IN REPLY TO AN AR- By W. ADDISON, Esq., Malvern. TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SIR, The author of the articles in the British and Foreign The fore finger of the left hand was introduced Medical Review, (April and July,) referring to my within the rectum so as to depress it towards the Experimental Researches, is, I am aware, considered, sacrum. A straight bistoire cachée, set at an inch, was and very justly so, as an authority upon matters relating passed through the opening in the cicatrized vagina, to microscopical investigation, and, therefore, while the and the blade being directed as in the lateral opera- | subject of nutrition may be still fresh in the recoltion of lithotomy, sprung and withdrawn. An immenselection of your readers, I am anxious to notice a very gush of dark grumous liquid followed this proceeding. The finger now discovered the upper part of the vagina to be dilated into a large oval sac, with a healthy os uteri at its upper part. The cicatrix was now divided on the right side in the same direction, by a probepointed knife. A large cylinder of oiled lint was important point upon which we are at issue, leaving your readers and the members of our Association to judge between us, after having heard my statement in reply. I am the more anxious to do this now, because the reviewer says that "my mode of reasoning, if followed out in other directions, would lead to the utter subversion of all philosophy." A very sweeping assertion, entirely unsupported by any example adduced, and I am left to conjecture whether or not it refers to the point I am now going to notice. The reviewer says "that there is something too specific in the character, if not in the appearance of pusglobules, for him to adopt the conclusion that they are altered colourless blood corpuscles." I ask what this specific character is, and the reviewer refers me to a series of objects which have specific vital properties, and experience specific vital transformations, leaving his readers to infer that the specific character which he means as distinctive between pus-globules and the colourless blood-cells is a specific vital character. Now this is exceedingly improper and very unfair, because any one reading my researches must have known that the whole of my reasoning is based upon the fact that the colourless blood-corpuscles are alive, and in the page but one preceding that from which the reviewer has taken his extract, (p. xvii), I very clearly state my belief that pus-globules are dead; that is, the former have specific vital properties, and undergo specific vital changes, while the latter (from having lost these properties) do not experience these changes. But I also believe, (and have so stated,*) that these dead cells are mingled with a great many others, which have been hurried through the stages of nutrition, and thrown out of the sphere of their specific transformations, and therefore that the fluid called pus contains a mingled variety of dead and dying cells. Again, the reviewer says that pus-globules have a specific character. I ask what it is; and am referred to the living cells of a zoophyte, an oyster and an insect; to epithelium and cancer cells. Now all these microscopic cells have without doubt a specific character (a principle of life) which cannot be seen by the microscope, and therefore perfectly distinct from an appearance. But, (and this is the point to which I ask the reader's attention,) pus-globules are usually allowed to have degenerated from this character. (So stated indeed by the reviewer himself, p. 105, of the article. July.) I will now put the argument in a form more in accordance perhaps with the philosophical taste of the reviewer, syllogistically, and I shall frame.it so as to embrace those extraneous matters concerning living cells which have really nothing whatever to do with the original question, but which he has chosen to complicate it with. Major Proposition:-All bodies that are invisible to the unassisted eye, and which never do become visible by growth or vital transformation, cannot present a sensible character except through the medium of the microscope. forms, (and they are various,) assumed by living colourless blood-cells, (that is the point at issue,) then why not tell us what it is, shortly and succinctly, rather than enter into an argument upon other things which have no relation to the question; an argument on points I never for a moment doubted. Future investigation and experiment, and a careful observance of the phenomena of vicarious secretions and metastasis, (important subjects having an intimate relation to my theory of nutrition, but entirely excluded from the review of my researches,) will ere long determine the remaining points of difference between me and those who differ from me. Whether the colourless blood-cells are or are not individually and bodily incorporated with the tissues: whether the secreting cells are or are not ulterior transformations of the colourless blood-cells; and whether pus-cells or pus-globules are or are not dead and dying colourless blood-cells, arrested in the process of transformation, are all questions of fact, and the web of the living frog, and the tongue of the same useful creature are the parts in which these questions may in some degree be determined. By B. DANIEL, Esq., Kirby Moorside. Hannah Collier, aged 26, a maid servant, residing in Farndale, a perfectly healthy agricultural district, as evinced by the general robust appearance of its inhabitants, came under the care of Mr. Richard Chapman, on the 30th of November, 1843. She is of small stature, spare form, and of anæmiac appearance. Her father, who had been a soldier, and was of intemperate habits, died of phthisis at the age of fifty. At the present time, the patient complains of a slight cough, which she has had for some months, accompanied latterly with the expectoration of a rather tenacious mucus. For the last two years she has occasionally hawked up mucus streaked with blood. There is frequent pain just above the spine of the right scapula, and a little dyspnoea. Her menstruation is scanty, and at long intervals. Her appetite is, on the whole, good. There is a very mild form of hectic, and the pulse is small and stands at 120. The physical signs are very apparent. On inspecting the comparative mobility of both sides of the thorax, that of the right is observed to be materially impeded; there is a very evident falling-in of the right infraclavicular region, and throughout the whole of this space, and along the clavicle, percussion gives an exceedingly dull sound; on the contrary, on the left Minor Proposition:-A pus-globule is a body in-side, the corresponding part appears abnormally promivisible to the unassisted eye; it never does become visible by growth or vital transformation. Conclusion:-Therefore "it is impossible to separate as regards these minute objects a character from an appearance.” If the reviewer still contends that a pus-globule has a sensible character distinguishing it from all the * Vide Provincial Medical Journal, of March 9, 1844. nent, the sound on percussion is unusually clear, and the respiration puerile. On applying the stethoscope to the right supra-scapular, supra-clavicular, and infraclavicular regions, the respiratory murmur cannot be distinguished. There is a loud bellows sound, and a strong pulsation synchronous with the heart's action in the right infra-clavicular region, which is not present in the left; and we cannot positively say whether the BRANCH ASSOCIATIONS. vesicular murmur is really absent, or whether it is obscured by the loudness of the bellows sound. The voice is unusually resonant over the affected side. Over the right inter-scapular space, the sound of both inspiration and expiration may be distinctly heard; the latter being as clear and as continuous as the former, in this respect differing from the opposite corresponding space where it is hardly distinguishable. April 30, 1844. Five months have elapsed since the last report, and the patient has been gradually merging into the second and third stages. She is not so weak as the progress of the disease in the lung would lead us to expect, being yet able to sit up nearly the whole of the day. Neither the heat of the skin nor the night sweats are excessive. The pulse ranges from 120 to 130. Her tongue is redder than natural, there is no epigastric tenderness; she, however, frequently vomits, which she attributes to the violence of the cough, and the nauseous character of the expectoration. She is much distressed with tenesmus and hæmorrhoids, and has occasionally had a severe attack of diarrhoea, which so far has always been relieved by a dose of 235 to the egress of the air, from any cause, will occasion these particular changes in its character. The fact of the existence of an evident bellows-sound and pulsation under the right clavicle, synchronous with the impulse of the heart, and its non-existence on the left, together with the immobility of the affected side, the depression under the clavicle, and the concomitant dulness, leave no doubt of its being the vascular bruit of the subclavian artery, caused and transmitted by the apex of the lung consolidated by tubercle. This symptom was first noticed and explained by Dr. Stokes, who also describes the same local pulsation to arise from sympathetic irritation, without any disease of the lung. When this symptom is dependant upon a consolidated state of the lung, it must in all cases, as in the present instance, depart, when the density of the lung is diminished by the process of softening. In this case, an exceedingly fluid state of the blood may have been a predisposing cause of the production of the murmur, as the patient had been long suffering from the amechalk and morphia. Her cough is materially aggra- right clavicle, must have been the local impediment to norrhoea, but the cause of its presence, only under the vated, and attended with a copious muco-purulent expectoration. An affection of the larynx has just supervened, which prevents her speaking in anything more than a loud whisper. On applying the stethoscope to the right infraclavicular region, we find that the pulsation and bellows the circulation. Kirby Moorside, July 1, 1844, PROVINCIAL sound have entirely disappeared, and are replaced by Medical & Surgical Journal. the humid, crackling, or clicking sounds. Bronchophony is very loud over the same space. The respiratory murmur is very obscure in the right mammary region, and a pulsation is communicated to it from the heart. June 16th. This morning, which is now near seven months since our attendance upon this case commenced, the patient arose, as usual, about 11 o'clock, without any alarming symptom. She had had a bad night, her cough had harassed her very much. Two or three times in the night she had noticed small dark clots of blood in the expectoration. She ate her dinner as usual, but about 4 p.m., being seated on a stool by the fire, she suddenly sprang to her feet in great alarm, and blood flowed from her mouth and nostrils, probably to the extent of eight or ten ounces; she would have fallen, but was immediately carried to bed, where she expired in a quarter of an hour. In the preceeding case there are two points deserving of notice :-the first, the distinctness of the expiratory sound in the inter-scapular space; the second, the sound of the subclavian artery heard in the right infra-clavicular region during the period of consolidation, and its disappearance in the stage of softening. The expiratory murmur was noticed by Laennec, but its variation in intensity, duration, and special character, was more particularly investigated by Dr. Jackson, of Boston, who states this abnormal alteration of sound to be one of the earliest symptoms of tubercles. His views are supported by Louis, Cowan, Fournet, &c. Professor Walshe considers that its utility as a diagnostic mark of tubercle has been exaggerated, for the following reasons:-1st, that in a state of health, it is louder and more prolonged in some individuals than in others; 2nd, that consolidation or obstruction WEDNESDAY, JULY 17, 1844. In another column will be found a letter from a Member of the Provincial Medical and Surgical Association proposing the formation of a Branch Association, to include Gloucester, Cheltenham, and Worcester. The proposition is one which well deserves the consideration of the members residing in those towns, and the neighbouring and intervening country, as well for the sake of the friendly intercourse to which the establishment of such a branch would lead, as from the mutual benefit to be derived from the interchange of communications and ideas. Man is a gregarious and social animal. He is not destined to depend upon self alone, but thrives best both in his physical and intellectual relations when brought into close contact with his fellows. We will not say he needs the stimulus of example and the assistthat he is essentially an imitative being, but ance of others, engaged in like pursuits, to induce and enable him to employ his powers with steadi ness and effect. To apply these remarks to our present purpose, we may point to the formation and progress of the Provincial Association, and observe how, from a small beginning ten or twelve years back, it has grown to its present prosperous condition; how a small number of individuals banded together for the attainment of a few plain, intelligible and useful objects, have not only effected |