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Provincial Hospital Reports.QUEEN’S HOSPITAL, BIRMINGHAM.

CASE OF CEREBRAL RHEUMATISM ; HIGH TEMPERATURE;COMA ; DEATH ; POST-MORTEM APPEARANCES.

(Under the care of Dr. FOSTER.)FOR the report of the following case we are indebted to Dr.

James Sawyer, resident physician :-Rebecca E-, aged twenty-three, cook, was admitted into

the hospital on the 26th of February, 1868. She stated that· four days before admission her knees and ankles became pain-

ful. A day or two previously she was exposed to cold, butdid not get wet; and to this exposure she attributed her ill-ness. Other joints soon were implicated. She had never hadrheumatic fever before; and there was no family history ofrheumatism. On admission her face was flushed, and her skinwas hot and freely perspiring. She was a well-built and well-nourished woman, but of a nervous and excitable tempera-ment. The tongue was covered with a thick, white, creamyfur. All the large joints, together with the joints of the

fingers, were red, hot, swollen, and intensely tender and pain-ful. The heart’s action was regular, percussion showed thecardiac dulness to be normal in extent, and no murmur waspresent. The respiratory sounds were healthy. The tem-perature in the axilla was 1032 pulse 126 ; respirations 26.The joints were wrapped in cotton-wool. She was ordered totake a mixture containing fifteen grains of bicarbonate ofpotash every four hours, together with ten grains of Dover’spowder at bedtime. At night the temperature was 103°;the pulse 126 ; and the respirations were 36.

Feb. 27th.-During the past twenty-four hours she hadvoided thirty-six ounces of urine, and the bowels bad beenopen three times. The urine had a strong acid reaction,sp. gr. 1040, and was loaded with urates, but contained noalbumen. In the morning the temperature was 104§°; pulse,120; respirations, 32 ; while the evening observations gavetemperature 104°, pulse 110, and respirations 35. The gene-ral condition had undergone but slight alteration.28th.-Thirty-six ounces of acid urine, sp. gr. 1034, were

excreted during the preceding twenty-four hours ; the bowelsacting freely. In the morning the temperature was 104%0,pulse 120, respirations 29. A very feeble pericardial soundcould be detected, and a little tightness of the chest was com-plained of. Poultices of linseed meal were applied to thechest. The temperature in the evening was 105°, the pulsewas 120, and the respirations were 26.29th.-The patient’s general condition was worse. She was

depressed, and haunted by the idea of approaching dissolution.She wandered a little. Forty ounces of urine were voidedduring the past day and night. This had a specific gravity of1034, and was faintly alkaline in its reaction. The tempera-ture was 106°, the pulse 128, and the respirations 30. In the

evening the wandering was still present, and the observa-tions gave temperature 105°, pulse 126, and respirations 29.Taking milk and beef-tea pretty freely. No sickness; tonguerather drier.March lst.-In the morning the temperature was 105%0, the

pulse 120, and the respirations 32. She had had a bad night,but was quieter in the morning. Thirty-two ounces of urine,of specific gravity 1033, and having a faintly alkaline reaction,had been voided during the past twenty-four hours. Dating thepreceding day and night the bowels had not been opened. Thejoints were still hot, red, swollen, and painful. She was or-dered to continue the medicine, ice was applied to the head,and a saline purge was given. There was no vomiting. Tonguebrownish. Towards evening she became restless, and therewere marked delusions of the senses. The evening observa-tions gave a temperature of 105°; the pulse was 138, quickerthan it had ever been before; and the respirations 30. Hercondition gradually became worse : the delirium became fiercer;she tore her hair; her face was flushed, eyes suffused, tonguebrown and dry; sordes on teeth; and faeces and urine werepassed involuntarily. Towards midnight she had twitchingsof the limbs; coma supervened; and she died rather suddenlyat 2 A.M.

Åutopsy, thirty-eight hours after death.-The parietal andvisceral layers ot the pericardium were hypersemic. Over theapex of the heart there were some lymphy encrustations. Therewere a few purpuric spots on the parietal pericardium. The

valves of the heart, as well as the great vessels, were healthy.Both lungs were bound to the parietal pleuras by slender andlengthened but apparently old adhesions. The lungs werehealthy; hypostatic congestion was well marked. The vesselsof the meninges of the brain were gorged with blood. Therewas a subarachnoid collection of opalescent fluid covering thesurface of the cerebral hemispheres. Lymph in spots was alsoobserved. The puncta cruenta were numerous and abnormallydistinct. There was no preternatural collection of fluid in theventricles of the brain. The walls of the fourth ventricle werecongested. The other viscera were examined, and foundhealthy.

Rviews and Notices of Books.Tenth Annual Report of the General Board of Commissioners

in Lunacy for Scotland.Seventeenth Report on the Di.çtrict, Crinzinal, and Private

Lunatic Asylums in Ireland.Tj3E opportune issue of the Irish Lunacy Report enables us

to give an epitome of the general progress of insanity through-out the United Kingdom, down to the latest date.The main features of interest in the English Report were

noticed in our columns last week. In dealing now with theReport of the Scotch Commissioners, we observe that its sta-tistics show comparatively little variation from those of previousyears. The number and distribution of the insane in Scotlandon lst January, 1867 (exclusive of unreported lunatics main-tained in private dwellings from private resources), were asfollows: 3519 in royal and district asylums; 672 in privateasylums; 998 in parochial asylums and lunatic wards of poor-houses ; 45 in the lunatic department of the Central Prison;and 1573 in private dwellings-in the aggregate, 6807 lunatics.The corresponding number on 1st January, 1858, was 5774.The numbers placed in private asylums and dwellings decreasedby 284 in the interval, while the inmates of public establish-ments increased by 1317; hence the total increase was 1033,which is equivalent to an annual ratio of 2 per cent., or aboutfour times greater than the ratio of increase of the generalpopulation. In reference to the classes suffering most frommental disease, inch the reasons thereof, the Commissionerssay that " the increase of lunacy is found chiefly among thelower classes of the population, which neither in town norcountry display much mental activity, but which are moreexposed in urban and manufacturing than in pastoral andagricultural communities, to overcrowding, impure air, ex-

hausting labour, insufficient diet, abuse of stimu1a.nts, andcontagious diseases." They add that, among the pauper class,the cases which arise from " over-excitement of the intellector feelings" are few in comparison with those which are dueto physical deterioration-a fact which they commend to thenotice of the Legislature as showing the necessity for such animprovement in the education of the people as will enablethem to understand the laws of health and to appreciate themotives for obeying them. A comparison of the mortality inScotch and English asylums shows that, on a five years’ average,the rate in the former was 8’24 per cent., against 10’39 inthe latter ; both these rates, however, comparing favourablywith an average of 14 per cent. in the French asylums.A point of some importance, which has for some time been

in doubt, has now been decided-namely, the validity of Eng-lish or Irish certificates of lunacy as an authority for the re-ception and detention of lunatic patients in Scotch establish-ments. The question has been referred for decision to the lawofficers of the Crown, who have given it as their opinion thatsuch certificates are invalid. Certificates by Scotch practi-tioners are, consequently, now requisite in the case of patientssent from Eugland or Ireland to Scotch asylums.The Reports of the Deputy Commissioners, Dr. Mitchell

and Dr. Paterson, on the condition of single patients visitedby them last year, show that their condition is undergoing a