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was complicated with hysteria, it was hoped that thesesymptoms were not indicative of any serious mischief. Ablister was applied to the back of the neck, morphia given atnight, and on the 20th, when the restlessness, moaniug, &c.,had rather increased, the compound mixture of valerian wasordered. The head symptoms, however, became more decided,the eyes did not act consentaneously, the left pupil was dilatedand insensible, the other natural; the features were drawn tothe right side, and the tongue pointed to the left; pulsequick and weak. On the 22nd, six days after the cerebralattack, the urine had to be drawn off, the features were some-what sunken, the pupils remained as before, and the strabis-mus continued.

Dr. Page, who saw her that day, prescribed stimulants andwine-and-water occasionally. The symptoms were nevermitigated in the slightest degree, except that she became attimes more quiet. She was partly sensible, almost up to thelast, and could be roused to answer questions. On the day ofher death, great difficulty in swallowing came on, and thereseemed also to be some dyspnoea; the breathing was loud andstertorous, but the pulse remained regular.The post-mortem examination was conducted by Dr. Ogle

conservator of the museum, and is recorded as follows:-Thebody is in excellent condition and well made; towards theleft glutseal region was the indication of a seton, and of ablister behind the neck. A bursa over the trochanter of theleft femur was full of thick curdy matter, and had a very vas-cular lining. The hip-joint contained healthy synovia, andall the parts entering into the formation of the articulationwere in a pe1:fectly sound state. On opening the cranium themeningeal veins were observed to be much congested; butthe membranes themselves on the upper surface of thebrain, were healthy. At the base of the cerebrum, however,the arachnoid covering the medulla oblongata, the under sur-face of the cerebellum, and the pons Varolii, was muchthickened, and even opaque. Under this part of the mem-brane, recent fibrinous exudations existed. The entire cere-bral mass was somewhat soft, its vessels full, and formingpuncta on section. The ventricles were filled with clearfluid, and in the meshes of the choroid plexus, smalldeposits of yellow, miliary-Iooking, scrofulous matter wasfound. In the centre of the middle lobe of the brain, on theleft side, there was a small rounded mass of yellow tuberculardeposit, about the size of half a pea. The lungs contained agreat number ef miliary tubercles, and in the small intestinesseveral of the solitary glands presented small yellow specksof fibrinous- exudation. The liver was coarse, and of nutmegcolour, and yellow tubercular matter was found in the kidneys.The uterus was healthy in all respects, but the extremities ofthe Fallopian tubes were adherent to the ovaries, and con-tained much- thick, curdy, scrofulous matter.Here was then a perfectly sound joint, which must either

have been the seat of simple neuralgia, or, as is much morelikely, merely hysterically affected. And we may repeat,that it is but seldom that positive proof of the soundness ofthe joint can, in such instances, be obtained. This will showthat physicians are far from being wrong when they ascribe,in cases of this description, the whole ailment to an hystericalaffection, and treat the patient according to this opinion.

Medical Societies.

ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

TUESDAY, MAY 25, 1852.—MR. HODGSON, PRESIDENT.

ON SOME OF THE PRINCIPAL EEFECTS RESULTING FROM THE

DETACHMENT OF FIBRINOUS DEPOSITS FROM THE INTERIOROF THE HEART, AND THEIR MIXTURE WITH THE CIRCULATINGBLOOD. By WILLIAM SENHOUSE KIRKES, M.D.

(Communicated by DR. BURROWS, F.R.S.)As an introduction to the subject, the author observed that

it was a clearly established fact, that the fibrinous principle ofthe blood might,under certain circumstances, separate from thecirculating fluid, and be deposited within the vascular system,especially on the valves of the heart. The forms of fibrinousconcretions to which the following observations especially ap-plied, were, first, the masses usually described as Laennec’sglobular excrescences; and secondly, the granular or wartygrowths adhering to the valves, and presenting innumerablevarieties, from mere granules to large irregular fnngous orcauliflower excrescences, projecting into the cavities of theheart. These growths, when once formed, whatever might be

their origin, were full of peril, and would often remain so, longafter the circumstances which gave rise to them had passedaway. When of large size, or loosely adherent, they might atany time be detached from the valves, and conveyed with thecirculating blood, until arrested within some arterial canal,which might thus become completely plugged up, and thesupply of blood to an important part be suddenly cut off, fromwhich serious if not fatal results would ensue; or, smallermasses might be detached, and pass on into arteries of muchless size, or even into the capillaries, whence congestion, fol-lowed by stagnation and coagulation of the blood, and all theconsequent changes such coagulated blood is liable to undergoin the living body, would necessarily follow. Many singularmorbid appearances observed in internal organs, and not wellaccounted for, were probably brought about in this manner.Again, the masses of fibrine might soften, break up, and dis-charge the finely granular material resulting from their disin-tegration into the circulating blood, and, contaminating thisfluid, might excite symptoms very similar to those observed inphlebitis, typhus, and other analogous blood diseases. Thusthe fibrinous material detached from the valves, or any otherpart of the interior of the heart, might be the cause of serioussecondary mischief. The parts of the vascular system inwhich these transmitted masses of fibrine might be found,would in great measure depend upon whether they were de-tached from the right or left cavities of the heart. Thus, iffrom the left, they would pass into the aorta and its subdivi-sions, and would be arrested in any of the systemic arteriesor their ramifications, and especially into those organs whichreceive large quantities of blood direct from the left sideof the heart, as the brain, spleen, and kidneys: on thecontrary, if escaping from the right cavities, the lungs wouldnecessarily become the primary, if not the exclusive, seat oftheir ultimate deposition. A division of the subject beingthus naturally formed, the author proposed to consider thesubject, first, as to the remote effects resulting from the sepa-ration of fibrinous deposits from the valves or cavities of theleft side; and secondly, as to the corresponding effects pro-duced by the detachment of like deposits from the valves orcavities of the right side of the heart. The author then pro.ceeded to elucidate the first branch of the subject, in whichmasses of some magnitude were detached from the left side,and arrested in an arterial channel of notable size. Thispathological fact was illustrated by three cases, in manyrespects identical; for, in each, death appeared to ensue fromsoftening of the brain consequent on obstruction in one ofthe principal cerebral arteries by a mass of fibrinous material,apparently detached from growths on the left valves. Thefirst case was that of a female, aged thirty-four, of pale anddelicate aspect. She had suffered from rheumatic pains, andthere was a loud systolic murmur heard over the entirecardiac region. While under treatment for these symptomsshe suddenly fell back as if fainting. She was found speech-less, with partial hemiplegia of the left side, but there wasno loss of consciousness; the hemiplegia increased, involvedthe face and limbs, and gradually became complete in regardto motion; but sensation remained unimpaired. These symp-toms lasted five days, when she quietly died. The postmortem examination developed much congestion of the piamater, amounting, in some places, to ecchymosis. The rightcorpus striatum was softened to an extreme degree-beingreduced to a dirty, greyish-white pulp. In the posterior lobeof the right cerebral hemisphere was a similar po of palesoftening. The right middle cerebral artery, jus; at itscommencement, was plugged up by a small nodule of firm,whitish, fibrinous-looking substance, not adherent to the wall,but rendering the canal almost impervious. The vessels ofthe brain were generally healthy, except a yellow spot ortwo in the coats of those at the base of the brain. Theheart was enlarged; several broad white patches externally.The right valves were healthy, so also were the aorta; butthe mitral valve was much diseased, the auricular surfacebeing beset with large warty excrescences of adherent blood-stained fibrine. The right common iliac artery, about an inchabove the origin of its internal branch, was blocked up by afirm, pale, laminated coagulum, which extended into theinternal iliac. The pleurse were adherent in places; liver andintestinal canal healthy; spleen large, pale, and soft, and con-tained a yellowish-white, cheesy substance. The kidneyswere pale, rough, and granular; within the cortex of theright were several large masses of yellow deposit, surroundedby patches of redness. Death had resulted in this case fromthe softening of a large portion of the right side of the brain,which the author considered to have arisen from an imperfectsupply of blood, consequent on the middle cerebral artery of

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the same side being obstructed by a plug of fibrine. The Iauthor then discussed the sufficiency of such an obstruc-tion to produce the effects ascribed to it, and he broughtforward many examples showing that atrophy and dis- Iorganization usually resulted from any circumstance whichmaterially impeded, or entirely cut off, the supply ofblood to a part. The author then directed attention to theprobable source of the fibrinous plug found in the middle cere-bral artery. The suddenness of the cerebral symptoms ren-dered it probable that the blocking up of the artery wasequally sudden, and not the result of gradual coagulation ofthe blood within the vessel. The absence of all local mischiefin the coats of the artery at the point of obstruction, as wellas elsewhere, pointed to some other than local origin for theclot; and the author, at the time of the examination, formedthe opinion, that a part of the fibrinous deposit on the mitralvalve had become detached, and carried by the stream ofblood, until arrested at the angle whence the middle cerebral Iproceeded. This explanation suited equally for the plug foundin the common iliac; for it was quite conceivable that portions Iof the loosely adherent fibrine might be easily detached bythe stream of blood washing over the mitral valve, and when Ionce admitted into the circulating current, they would onlybe arrested by arriving at a vessel too small to allow theirtransit along its canal. Two other cases were described bythe author, possessing many interesting points of resemblance: ’,one, a female, aged twenty-four; the other, a male of the sameage. Both were admitted into the hospital with hemiplegiaof the left side; each had heart-disease, indicated by a loudsystolic murmur. The post-mortem examinations revealedthe following morbid appearances common to bothSoftening of a limited portion of the brain, producingdeath by hemiplegia; obliteration of the cerebral arterysupplying the softened part; coagula in one of the iliacarteries; fibrinous deposits in the kidneys and spleen; andthe presence of fibrinous warty excrescences on the valvesof the left side of the heart. So many and such rare

features of resemblance could not fail to demonstrate a veryclose connexion between the several morbid appearances soexactly reproduced in each case. The author believed thatthese three cases satisfactorily established the two followingconclusions-lst, that softening of a portion of the brain, withattendant loss of function, might result from obstruction of amain cerebral artery by the lodgment of a plug of fibrinewithin its canal; 2ndly, that the foreign substance thus ob-structing the vessel was probably not formed there, but wasderived directly from warty growths situated on the leftvalves of the heart. The author thought it not improbable,although in the absence of direct proof it was but supposition,till further investigation confirmed these facts, that manycases of partial and temporary paralysis suddenly ensuing inone or more limbs of young persons, especially if accompaniedwith signs of cardiac disease, might be due to interruption ofa proper supply of nutriment to the brain by the temporaryplugging up of a principal cerebral artery by fibrine, detachedfrom a diseased valve on the left side of the heart. Otherarterial branches, besides those of the base of the brain, mightarrest these fibrinous deposits derived from the valves of theheart. In Cases 1 and 2, coagula were found in the iliacand femoral arteries; and in Case 3, in the renal. Theauthor thought that many specimens found in museums, andsupposed to illustrate the spontaneous coagulation of theblood, or the deposition of fibrine within a limited portionof an arterial trunk, were probably to be referred to the samecardiac origin, and he illustrated the point by reference to apreparation in the museum of St. Bartholomew’s Hospital.The second subject of inquiry consisted of an examinationinto the effects produced by smaller portions of fibrine de-tached in a similar manner, but arrested in the minutearterial branches, or even in the capillaries. The authorthought that the singular masses of yellow fibrinous substancefound in the spleen and kidneys, and other organs, andhitherto described as "capillary phlebitis," "metastasis," 01’fibrinous deposits," were derived from this cause. Out ojtwenty-one cases in which the author had observed thesedeposits in the spleen and kidneys, or other parts derivingblood directly from the left side of the heart, in nineteenthere was disease of the valves, or of the interior of the leflside of the heart. In fourteen of these there were nbrinouigrowths on the surface of the left valves; in the remainingfive there was simple mention of valvular disease. The autho]thought that the mere fact of so large a number of cases o:so-called capillary phlebitis" being associated with the pre.sence of fibrinous deposit on the valves of the heart, suggested a very close relation between the two morbid states

The author then entered upon the third branch of this partof the subject, concerning the series of effects which mightresult from the introduction of fibrinous particles into thecirculating blood, manifesting phenomena indicative of theexistence of a morbid poison in that fluid. A case was re-lated of a youth, aged fourteen, admitted into the hospitalwith obscure typhoid symptoms, the surface of the body beingcovered with petechiae. Delirium, with much febrile pros-tration, followed; he became subsequently comatose, and died.Upon examination of the body, the surface was found coveredwith petechias. The pia mater was infiltrated with whatseemed recently effused blood. The surface of the brainthus presented a blotchy appearance, and amid thesespots were yellow-coloured patches of various size; somewere of a greenish-yellow hue, and had the appearanceof being smeared over with pus. The brain was unduly con-gested, and some ecchymosis near the surface; the cerebralarteries and sinuses healthy; several petechial spots on thesurface of the heart, as well as in the cavities; and on the auri-cular surface of the mitral valve some white fibrinous vegeta-tions, very soft and friable; a like deposit on the aortic valves,with evidence uf ulceration ; several yellow masses offibrinous deposit on surface of spleen; cortical part of thekidney covered with minute petechial spots, in the centre ofwhich was a bufcoloured dot; several large yellowish blotchesextended deep into the substance of the cortex. The intes-tinal mucous surface was covered with petechial spots, whichwere apparent also on the mucous membrane of the bladder,pharynx, oesophagus, stomach, larynx, and trachea. Theauthor considered the mystery of this case cleared up by thepost-mortl m examination. The attack had been ushered inby a severe pain in the right groin, which was rheumatic;then ensued rheumatic inflarnmation of the mitral and aorticvalves, with ulceration of the latter, and deposition of fibrine.From these deposits portions had probably separated duringlife, and were transmitted with the blood to all parts of thebody, and being arrested in the capillary networks and smallerarteries, produced the various petechial and buff-colouredspots above described.The second pai of the paper related to the effects which

might result from the detachment of fibrinous deposits fromthe right valves of the heart. Reference was made by theauthor to a paper on the Formation of Coagula in thePulmonary Artery, by Mr. Paget, published in the Trans-actions of the ociety, as well as to a specimen in the museumof St. Bartholomew’s Hospital, in which there was depositionof fibrine on each of the pulmonary valves, with old coagulafilling many of the branches of the pulmonary artery. In thiscase several large, solid, fibrinous masses were found in thesubstance of the lungs, presenting appearances not unlike por-tions of old pulmonary apoplexy. Lastly, the author recapi<tulated the principal points which he was desirous of esta-blishing, viz.,-lst. That fibrinous concretions in the valvesof the heart admit of being readily detached during life.2ndly. That if detached and transmitted in large masses, theymay suddenly block up a large artery, and thus cut off thesupply of blood to an important part; if in smaller masses,they might be arrested by vessels of smaller size, and giverise to various morbid appearances in internal organs; or theparticles mingled with the blood might be but the d&eacute;bris ofsoftened fibrine, yet with power to produce a poisoned state ofthe blood, and bring on typhoid or phlebitic symptoms.3rdly. That the effects produced and the organs affectedwould be in great measure determined by the side of theheart from which the fibrinous material had been detached:if from the right side, the lungs would bear the brunt of thesecondary mischief; but if, as was most commonly the case,the left valves were the source, the mischief would be more

widely spread, and might fall on any part, but especially on. those organs which were largely and directly supplied with bloodfrom the left side of the heart, as the brain, spleen, or kidneys..

In the discussion which ensued on Dr. Kirkes’ paper, and. which was prolonged far beyond the usual hour of adjourn-ment, several gentlemen addressed the Society. The unusuali ) length of our abstract prevents our giving a detailed reportof the various speeches in this week’s LANCET. All thei speakers, however, eulogized the paper as a very able and

masterly production; but several of them took exception tothe conclusions arrived at by the author respecting the last

two series of cases. It was admitted by all that the researchesof Dr. Kirkes opened a wide field of observation; and with

reference to the first class of cases, that they threw light on. the cause of many obscure instances of softening of the brain,- respecting which we had hitherto been unable to form anything, better than a conjecture.