adherent pericardium, simply because cardiac symptoms are rarely present, except in cases complicated with valvular disease. This view of the case would effectually reconcile all the conflicting evidence on this subject, as a somewhat similar explanation will in all probability apply to the cases and opinions of most of the older authors, and especially of Corvisart. Indeed, all morbid anatomists are welĺ aware of the tendency of post-mortem examinations, when pursued with a view merely to the elucidation of particular symptoms, to lead the observer into a vicious circle of error. The symptoms being predetermined, the problem is to find a morbid appearance which will account for them, and when this has been discovered, or imagined, the inquiry is not pursued further. Thus, the whole class of lesions which are negative as regards symptoms, but which more than any others illustrate the healing powers of nature and art, habitually escape observation.

As a further proof that Dr Hope had not given to the evidence on this subject that impartial consideration which the high reputation of his work, and the confident expression of his own opinion, demanded, I may mention that he has fallen into two very grave errors in stating the doctrine of his predecessors in the inquiry. In the first place, he claims the opinion of "Lancisi, Vieussens, Meckel, Senac, Corvisart, and, more strongly than all, Morgagni," as favourable to the view of the incompatibility of health with pericardial adhesion; whereas we have seen that Morgagni's very careful induction from the facts before him, though by no means decisive, or expressed with undue confidence, has evidently led to a precisely opposite bias in his own mind. In the second place, Dr Hope takes a most inexcusably erroneous view of the statements of Laennec, when he attacks him as founding his opinion solely on "the absence of complaint on the part of the patient." We have seen that Laennec expressly mentions, and puts prominently forward as one of the grounds of his opinion, the absence of signs (i. e., physical signs) of disturbed cardiac function in the fatal illness; and as if to guard this observation from being lightly passed over as a random assertion, he adds the only qualification of it which his experience suggested, in the form of a remark on the contraction of the auricles. Yet this very precise and guarded statement is entirely omitted by Dr Hope, to be superseded by his own counter-assertion, equally unsupported by details of evidence, and in all probability founded on far less exact observation.1

The opinion of Dr Latham, as to the ultimate consequences of

1 The consideration of these inaccuracies, and of the facts to be hereafter adduced, will tend to diminish the mortification of those who, having attempted to apply Dr Hope's "pathognomonic signs" of adherent pericardium in practice, have had their faith in their own powers of observation shaken, by not finding themselves able to detect the affection "with much ease," "in the great majority of cases."-Op. cit., p. 183.

adhesion of the pericardium, is given in a single passage in his "Lectures on Clinical Medicine." "It is a question with me after all, what are the consequences which naturally result to the functions and structure of the heart from simple adhesion of the pericardium? For I have not facts enough to appeal to of the sort which are required to settle it." This free admission of an "open question," in reference to this subject, will not, in all probability, be regarded by the readers of the preceding pages as unduly guarded, or as anything else but the true and honest expression of the sum of our present information. It is well, however, to remark, that Dr Latham's personal experience has revealed to him "a few cases" in which, as in those of Laennec and Louis, complete adhesion of the pericardium was unattended, during the fatal illness, by symptoms referable to the heart; and in which, morever, there was neither hypertrophy nor dilatation of that organ.2 He has also not failed to observe the termination of acute pericarditis in apparently perfect recovery, and has seen such cases at the date of several months after the attack, with unimpaired general health and local function; but he admits the doubt as to whether these were actually cases of adherent pericardium; and considers that the want of the evidence of dissection in this class of cases, and of a sufficient history in the other, together with the casual character of both, preclude the formation of a decided judgment from them. On the other hand, the evidence, from examination after death, of the dependence of hypertrophy of the heart upon adherent pericardium, is vitiated, according to his experience, by the almost constant concurrence of valvular lesions with pericardial adhesions attended by hypertrophy. In this respect the experience of Dr Latham concurs with that of Bouillaud, and with the recorded cases, at least, of Dr Hope.

The great importance of this subject, in reference to the prognosis in cases of recovery from pericarditis, and the manifest deficiency of facts calculated to contribute to the formation of a definite opinion upon it, have led me to believe that a not unacceptable contribution to the natural history of pericarditis might be framed by collecting the entire experience as to the permanent results of adherent pericardium, from the records of upwards of 500 post-mortem examinations, performed by myself, or by others under my superintendence, during the last two years. With this view, I have prepared the following abstract, in which appear, to the best of my knowledge, all the cases of considerably adherent pericardium which have been examined in the Royal Infirmary during the period referred to. Though some of these cases unavoidably, and others through unfortunate neglect on my own part, are deficient in certain particulars bearing on the question, and few of them have any pretensions to completeness as individual histories of disease, they will be found to have a collective

1 Vol. ii., p. 111, Lecture 23d.

3 Op. cit., pp. 101, 102.

2 Op. cit., p. 101.
4 Op. cit., p. 111.

value, arising from the circumstance of their being drawn indiscriminately from the examination of cases of mixed disease, occurring in the wards of a large hospital. And if their actual number be considered too small to warrant the formation of a very decided and definite opinion, they may at least direct the attention of others, similarly situated with myself, to the subject, in such a way as will elicit, ere long, more precise and numerous data.

The cases which I have to adduce are fifteen in number. Many of these are instances of complete and close adhesion, entirely obliterating the cavity; in others, the adhesions were partial, but always so situated as that they may be conceived to have restrained, to a considerable degree, the motion of the heart within its serous cavity. On the other hand, all instances of adhesion near the base, even though firm and close, and of very lax and mobile adhesions, wherever situated, have been omitted as open to objection.

As the cases appear to add comparatively little to our knowledge of the clinical department of the subject, and as the negative evidence which they afford would not be a satisfactory ground of classification, they are here arranged chiefly with a view to bring out prominently the existence or non-existence of hypertrophy of the heart, the presence of which condition may, I think, justly be considered as a sure and delicate test of disturbance or impediment to the function of the organ. In proof of this, I may refer to the almost invariable occurrence of hypertrophy, or hypertrophy with dilatation of the cavities, in conjunction with valvular disease, as well as to the hypertrophy of the right ventricle, which usually supervenes in emphysema of the lungs, and that of the left side in aortic aneurism. Indeed, there is no fact in cardiac pathology more clearly established than the relation of hypertrophy of the heart to mechanical impediment of its function. I shall, therefore, arrange the cases in three groups, the first comprising those in which there was not hypertrophy of the heart to any appreciable degree; the remaining two, those in which hypertrophy existed, with or without other collateral lesions.

FIRST SERIES.-Cases of Adherent Pericardium, in which the Heart was not enlarged or otherwise diseased.

CASE I.-(P. R., Vol. xii., 11).-A female, æt. 46, died exhausted and much emaciated, with symptoms of scirrhus of the pylorus. There were no symptoms referable to the heart, which does not appear to have been examined.

There was a cancerous ulcer of the pyloric end of the stomach, and cancer of the lumbar glands. The pericardium contained about four ounces of clear serum; and there was an old adhesion between the anterior part of the left ventricle and the mediastinal pericardium. The heart was very small, and all its apertures small, but not diseased. Aorta relatively large. No disease of the other thoracic viscera.

1 The references in brackets are to the Pathological Register of the Royal Infirmary. The figure indicates the number of the case in the volume indicated.

NEW SERIES.-NO. XIV. FEBRUARY 1851.

P

CASE II.—(P. R., Vol. xii., 2).—A male, æt. 37, died of diabetes mellitus. No symptoms referable to the heart, though he was long under observation. Pericardium adherent in several places over the left ventricle. Several chronic thickenings of the membrane on the surface of the right ventricle. Heart and lungs normal.

CASE III.-(P. R., Vol. xii., 49).—A male, æt. 30, had the ordinary symptoms of incipient pulmonary phthisis, succeeded by obstinate diarrhoea. The chest was physically examined, but no note is made of any cardiac affection. The urine was albuminous, and of specific gravity 1005. He died exhausted. The dissection revealed miliary and opaque tubercle of the lung, with tubercle of the ileum, and ulceration of the colon. The kidneys were in an advanced state of granular disease. The pericardium was adherent by firm fibrous bands (admitting, however, of some motion) everywhere, except at the apex of the heart, and on the anterior surface of the aorta. No abnormal condition of the heart mentioned.

CASE IV.-(P. R., Vol. xii., 132).—A male, æt. 45, said to have enjoyed good health till the supervention of hepatic symptoms, two months before his admission into hospital. He suffered from ascites. There is in the account of his case a single note, of a murmur with the first sound of the heart, heard at the apex. [As there do not appear to have been any cardiac symptoms, and as the post-mortem examination does not bear out this statement, it is very probable that this is an error. The murmur may have been anemic, or possibly a roughness connected with some slight motion in the adhesions.]

On dissection there was cirrhosis of the liver, accompanied by enlarged spleen. The peritoneum full of fluid. The pericardium firmly and closely adherent. The heart not enlarged.

CASE V.-(P. R., vol. xii., 255.)—An adult male, age not stated. Was admitted for pneumonia, from which he recovered; but during the convalescence took cholera, and died.

The body was emaciated and anemic; there were sloughs on the nates. The lungs presented scattered traces of disease. The pericardium universally and firmly adherent. Heart healthy.

CASE VI.-(P. R., vol. xii., 291.)-An adult male, age not stated. No case. The principal disease found, on examination, was in the urinary organs. There were abscesses in the kidneys, with dilatation of the ureters and bladder, from enlargement of the prostate gland. The pericardium was firmly and closely adherent.

CASE VII.-(P. R.., vol. xii., 335.)-A female, æt. 63. No history. The lungs were tubercular, and there was also tubercular disease of the peritoneum. The pericardium was firmly adherent.

CASE VIII. (P. R., vol. xii., 337.)-A male, aged 45. Died exhausted from malignant disease. Dissection showed cancer of the liver and stomach, and also of the cervical and anterior mediastinal lymphatic glands. The pericardium was closely, firmly, and universally adherent.

CASE IX.-(P. R., vol. xii., 376.)-A male, aged 30, affected with chronic phthisis. Heart's sounds stated to be natural. Died exhausted.

On dissection, the lungs were found tuberculous, and the intestines ulcerated. The heart, firmly adherent all round to the pericardium, weighed, together with the adherent membrane, and the great vessels cut outside the pericardium, only eight and a-half ounces.

CASE X.-(P. R., vol. xii., 385.)-A female, aged 19, affected with syphilitic rupia, died in a state of extreme exhaustion and emaciation. Was long under observation, but presented no symptom referable to the heart.

The liver, kidneys, and lungs were more or less diseased. The whole body extremely emaciated. There was a firm, though rather lax, adhesion between the pericardium and the heart on the right side near the apex. Heart healthy.

The critical reader will possibly object to this series of cases, that in some of them the condition of the heart as to hypertrophy is not specially reported; and that details of weight and measurement are not given in the greater number. But to weigh a heart with the pericardium adherent to it, and two inches of the great vessels attached, would have been to furnish a datum of no practical value, as it could not have been compared with any standard; and to separate the heart from the fibrous pericardium and the adherent cellular tissue for the purpose of weighing it, would not only have been an unduly troublesome and uncertain process, but would have destroyed several preparations which it was desirable to preserve. I can state, however, positively with reference to these cases, that they were all rather under than above the usual average of size (considered with reference to the individual), with the exception of one, which I have preserved as the largest of the series, and in reference to which, perhaps, some degree of hypertrophy may be admitted. This heart, with its adherent pericardium (which is somewhat thickened), and the additional length of great vessels, weighs at present (being preserved in chloride of zinc solution) sixteen and a-half ounces. I have found that the healthy pericardium of a heart weighing nine and a-half ounces, when separated along with the additional length of great vessels, amounted to about four and a-half ounces in weight; so that, making due allowance for the thickening of the membrane in the present instance, we can scarcely suppose this heart to weigh much more than eleven or eleven and a-half ounces-an amount which may have been large relatively to the individual, but can scarcely be considered to constitute at all a marked specimen of hypertrophy. The organ appears, however, to the eye increased in size. I regret that, owing to a note being mislaid, I am unable to state which of the above cases furnishes this doubtful example. On the other hand, several of the cases presented decidedly small hearts, particularly Cases I. and IX. In the latter the organ was preserved as the smallest of the series. It weighed, when recent, as stated in the report, only eight and a-half ounces, with the adherent pericardium, &c.; and, allowing not more than two and a-half ounces for these appendages, the reduction of size must be considered, for an adult, as falling within the limits of atrophy.

These cases appear amply sufficient to destroy the force of Dr Hope's assertion, as to the invariable connection of hypertrophy with adherent pericardium; while, on the other hand, in so far as they are accompanied by clinical details, they bear out Laennec's statement of his own experience. I reserve for the sequel the question, whether they justify his view of the innocuous character of this lesion?

1 Since the above was put in type, I find that this statement must be modified, as the loss of weight from preservation in chloride of zinc is more considerable than I had supposed. It is probable, therefore, that this heart was in the early stage of hypertrophy.