Infund. in aq. bullient. Ib. j. Agitentur in vase clauso per horas duas, colaturæ, adde Æther sulph. 3 j. Syr. amom. zingib. 3ss. Capt. cyath. bis in hora, 24th. Is in a remarkably languid state; requires to be fed. His limbs are almost cataleptic, lying in whatever posture is given to them. Some singultus this morning; is very distinct when spoken to. Pulse 122. Int. med. App. vesicat. nucha. B. Vin. rub. Lus. 3vj. Tinct. opii gtt. xl. M. C. 3ss. om. semihor. et sæpius si op. sit. Let him have a bit of steak. 27th.-Died this morning at seven o'clock, Sectio Cadaveris.-The contents of the cranium, thorax, and abdomen, were carefully examined. About an ounce of a transparent and colourless fluid was found accumulated between the dura mater and arachnoid coat, about the lower surface of the cerebellum, and the origin of the spinal chord, obviously collected here in consequence of the position of the head after death, and in all probability partly derived from the spinal canal. Within the lateral and middle ventricles, there was also from half an ounce to an ounce of a serous fluid. The brain and its membranes presented no appearance of disease. The lungs adhered very extensively on both sides to the parietes of the chest, but chiefly on the right. The adhesions were close and strong. The substance of the lungs had undergone no morbid alteration of structure. The pericardium contained from six to eight ounces of a greyish muddy serum, with flakes of a curdy matter. The heart had suffered a change of texture, not less singular than extensive. The whole parietes. of the right auricle, and the anterior side of the corresponding ventricle, were found converted into a greyish-coloured substance of a very uniform texture, and having the consistence nearly of the prostate gland. There was not the slightest vestige of any of the natural tunics of the heart in this substance. The parietes of the left ventricle had undergone a similar change for about an inch all around its auricular orifice, and there was fully a third of the septum between the ventricles, towards the base of the heart, converted into the same substance. Between the arterial orifices too, the septum was a little thicker than usual. The inner surface of the right auricle was covered with a sort of efflorescence, not unlike that which is often exhibited by hydatid cysts. The left auricle exhibited no morbid appearance. The valves, tricuspid, mitral, and semilunar, were of their natural structure, as also the roots of the pulmonary artery and aorta. Within the cavity of the abdomen, there was most extensive disease. The whole mesenteric glands were enlarged, so as to form one irregular mass. When divided, they exhibited an appearance like that already described, as having been found in the sides of the heart. The whole of the colon had its coats thickened and rendered exceedingly tender. At various points of it, there was a vascularity accompanying this thickening, which indicated inflammation. At other parts, the sides of the intestines had become considerably thinner, and projected in the form of little pouches, which adhered to the parts with which they happened to be in contact. The whole of the jejunum, and a great part of the ileum, were in the same state. In the angle formed by the junction of the transverse part of the colon with the large curvature of the stomach, which were found closely applied to each other, there was a stratum of half an inch broad, and a quarter thick, of the same sort of substance as was found in the heart. Towards the surface of the liver, in its right lobe, and at its upper convex part, there was a knot of the same kind of matter, of the diameter of a shilling; but, in other respects, this organ had a healthy appearance. There were two or three nodules of a similar matter, in the substance of the pancreas. The spleen presented nothing remarkable. There was about a pint of serum effused into the cavity of the abdomen, which, except where it had touched the gall-bladder, and in consequence acquired the colour of bile, was of the usual yellowish tint, and quite transparent. This case appears interesting, 1st, From its rapid and unforeseen event. 2d, From the appearances discovered on dissection. When admitted, it was supposed to be a case of hysteria in a male,—a rare occurrence, yet not unobserved. Some consider hysteria and hypochondriasis as the same state of disease, modified by sex; the former being peculiar to women, the latter to men. This is in general true, but exceptions do occur; and it is not sufficient to reject all the testimonies adduced in proof o this, because we ourselves have not scen it. Unequivocal case of hysteria in men have been seen by Dr Trotter and others. Hypochondriasis certainly oftener affects females. The difference between them depends much on temperament. Hysteria is peculiar to the sanguine, and hypochondriasis to the melancholic temperament. In hysteria, the affections of the mind are characterized by fickleness and mobility; in hypochondriasis, by the obstinacy with which the mind broods over a single subject. In hysteria, the patient is violently affected by every circumstance external to herself, and is agitated by every sudden impression; but the paroxysm is no sooner over, than she laughs at her own folly, thinks no more of it, and resumes her wonted spirits. In hypochondriasis, on the contrary, external circumstances make little impression on the patient; and if a sudden and violent impression rouse him for a moment, he speedily returns to brood over his loss of health, or finds in what has just passed fresh cause for despondency. The symptom in Baxter giving rise to the idea that his disease was hysteria, was the accurate description he gave of the globus hystericus. But after he came under our care the symptom did not recur. I was then led to consider his complaint as hypochondriasis, from the pain of stomach, increased on taking food; the irregular state of his urine; the costive belly; flatulence; interrupted sleep; bad appetite; foul tongue, and bad taste in his mouth; and still more by his constant complaints. I therefore left him a day or two to observe the symptoms. On the 23d it is reported that the pulsation of his heart is distinctly felt, even when lying on or towards the right side; and it is remarkable, that, except the weakness of the pulse, and its occasional frequency, this is the only symptom connected with the state of the circulation noticed in the reports. It indicated a labouring action of the heart; but I did not perceive any irregularity in its action; and as it is a common symptom in hypochondriasis, from sympathy with the state of the stomach and bowels, it did not further attract my attention. Another symptom was noticed the same day, that he had repeatedly fallen from his chair when sitting by the fire. This might either proceed from syncope, or a nervous paroxysm, or from falling asleep; and I was positively assured that it proceeded from the last cause, which, in his debilitated state, was very probable. This day his complaints first appeared to me to be serious, and I resolved to try with him Kaempf's method of treating hypochondriac affections. I therefore ordered him to get two of his visceral injections daily. But, in this case, they did no good whatever, and the treatment was disagreeable both to the pa tient and the nurses. On the 25th, his appearance was strikingly worse, and he was reported extremely weak both in body and mind. He was now evidently sinking. He was lying almost without sense, or the power of motion. Not having seen him for many days except in bed, it was not easy for me to judge of any gradual decrease of strength, but it was now too great to escape notice; and although I did not report it, I had observed that, for some days past, he spoke in an inarticulate mumbling manner; but after it attracted my notice, I could not ascertain whether it was his natural mode of speech, or the effect of disease. On the 26th, he was still much worse; he seemed to have lost all muscular power; he required to be fed as a child; he sunk down to the bottom of his bed, and his limbs, which were perfectly supple, lay lifeless in whatever situation was given to them. He had also some hiccup, but seemed to retain his senses, or at least answered when spoken to. My idea of his present complaints was, that effusion had taken place in the brain or upon the spinal marrow, oppressing the powers of life. The debility was evidently not the effect of fever, and it was too great and too quick in its progress, as I conceived, to be the effect of inanition or natural wasting. I therefore ordered a blister to the nape of the neck, and a stimu lant cordial, with full diet. But these remedies were of no use, for he died next morning at eight, having been seized the evening before, at eleven, with very difficult and laborious breathing, amounting almost to convulsions. The body was opened next day by my friend Dr Gordon, to whom I am indebted for the very accurate and excellent account of the appearances observed. It discovered causes of the man's complaint, totally different from what I had conjectured; some of which corresponded with some of the symptoms which had affected him, but others had not been indicated by any thing observed. The heart was found to be most extensively diseased, indeed to an extent which, from the importance of the organ, seemed impossible; and what is still more singular, it had not been accompanied by symptoms of any disease whatever of that organ, which shows how very difficult is the diagnosis of the diseases, even of the most important internal organ. The pericardium did not seem in any way diseased, but it ⚫ contained from six to eight ounces of a greyish muddy serum, VOL. XII, NO. 45. D with flocks of a curdy matter.' Besides the increased quantity of fluid, its appearance indicated a considerable degree of preceding disease in the membranes which furnish it, although no signs manifested its existence during the life of the patient. The muddiness of the fluid, and the flocks of curdy matter contained in it, are effects which we would naturally expect to have been preceded by inflammation of the pericardium; yet neither did any symptom occur before death, nor did the uniformly smooth surface and natural structure of that membrane, after death, afford any proof that inflammation of that membrane had previously existed; on the contrary, it was almost certain that it had not recently existed. * Corvisart describes three species of pericarditis,-the acute, sub-acute, and chronic. The last he admits to be a disease of a very obscure nature, chiefly from the various complications natural to it; so much so, that he considers it as being generally the consequence of some preceding disease. He says he has frequently met with it, and always found the diagnosis difficult, and very obscure; and that he does not wonder that it should embarrass practitioners at the bedside of the patient. In the instance which he gives of it, he considered the chronic inflam mation of the pericardium proved, by its being thickened and containing a turbid liquid; but, during life, there were manifest symptoms of deranged circulation and respiration, although they did not indicate precisely the nature of the affection. There was great variation in the action of the heart and arteries. The pulse, always quick, was alternately regular and irregular in every possible way, and the respiration was short, embarrassed, frequent, and accompanied by a sense of weight at the ensiform cartilage. In Baxter, the pulse was uniform, not very quick, ranging from 100 to 110, and always weak; the action of his beart, indeed, seemed to be inordinate, but his respiration was perfectly natural. And as there was no thickening of the pericardium, the proof of inflammation rests entirely upon the fluid being turbid, and containing flocculi of a curdy matter. Other authors have also noticed a similar change in the liquor pericardii. Morgagni found more than the usual quantity of somewhat turbid fluid in a negro who died suddenly without any previous disease; but here he ascribes the death to the vessels of the brain containing air.-(Ep.v. Art. 17.) In another case (Ep. x. Art. 13), it was connected with an immense exostosis of A Treatise on the diseases and organic lesions of the Heart and Great Vessels, by J. N. Corvisart, M. D. translated by C. H. Hcbb, pp. 404. 8vo. London, 1813. |