relieved on blood-letting, and breathed with less difficulty on walking; blood not buffy; the uneasiness is now felt down the sternum; in other respects no amendment, and additional symptoms have appeared; appears very drowsy, which it was said was not a new symptom, and indisposed to get out of bed coughed up some mucous matter tinged with blood; there was no anasarca of the lower extremities; very costive, not being able to retain in the stomach the sulphas magnesiæ; the skin cool; the tongue clean; thirst continues. The pulse at the wrist and heart, after repose in a recumbent posture, were 60; on getting up to walk across the chamber, I found the heart beat 145 during the first minute, and the artery at the wrist 140 in the second minute. The pulse of both parts, on lying in bed, quickly decreased to the former rate; no appetite for food. At this examination four or five young physicians assisted, of whose excellent abilities I have many proofs, who almost daily took notes at the bed-side of the patient. I own I was not able now to say more than that there was probably some organic disease of the heart, or of the large vessels near it. The question quis morbus? was proposed to each, but one only ventured to conjecture the disease to be water in the chest; ignoro was the answer of all the others.

Pilulæ extracti colocynth. comp. iii. quarta quaque horâ

donec solvatur alvus.

Intermittatur pulvis ipecacuanha comp.

27th.-Third visit. Symptoms as before, but aggravated; unable to be in an erect posture on account of vertigo supervening; wished to remain in bed, lying generally on the back, but also on the left side, and never on the right, on account of the great uneasiness of the whole chest in that posture; had been often sick at the stomach, frequently retching, and sometimes vomiting. From this time till death there were spitting and vomiting of mucous fluid, with blood, which appeared this day, but hitherto moderately. The lips began to appear blue, and the countenance bloated. Mr Hamerton, the judicious apothecary, from time to time administered several appropriate palliative medicines.

28th.-Fourth Visit. Very great dyspnoea having come on, with symptoms manifesting congestion of blood in the lungs, namely, frequent discharge of blood by coughing and vomiting, Jivid countenance as well as lips; the pulse becoming very quick; the general uneasiness of the chest occasioning much inquietude, Mr Hamerton took away ten ounces of blood. It coagulated not firmly, and without any buffy coat. The patient said he felt as if something had burst within his chest, Threw

up two large tea-cupfuls at a time of red blood, frequently during the day, unmixed with other matter.

"

31st.-Fifth Visit. The last two days and two nights, a great quantity of blood had been coughed up. The bystanders observed, that they did not conceive so much was contained in the human body, or, to use their own words," they wondered whence it all. came. It was now black, but heretofore red. The livid lips. and countenance still subsisted. The pulse grew extremely quick and feeble. Complained of pain of the sternum. Manifested great inquietude, but was too feeble to make great exertions, and the breathing not at all relieved by being raised in bed, or became more difficult by being placed with the head low. At last turned and lay all day on the right side; was often sick at the stomach, but little else came up but blood. Became more and more feeble; yet retained his senses. On the evening of the 30th, the powers of life seemed nearly exhausted. Very of fensive blood was continually thrown up, and finally flowed from the mouth, being apparently too weak to cough or vomit. Very early in the following morning died without a struggle.

Sectio Cadaveris.-I was not able to be present, but the heart and lungs were reserved for my examination. My friend Mr Wharrie opened the body, and I could depend upon his report alone, if it had not been confirmed by the evidence of a great number of pupils in the dissecting-room.

The lungs did not collapse on admitting air into the chest. The right lung adhered firmly to the pleura costalis, but no adhesion of the left lung.

The trachea and bronchial tubes contained mucus, and mixed with a little blood. The mucous membrane appeared red from vascularity. On the surface of the lungs were seen many broad red irregular-figured spots, like ecchymoses. No thickening of the pleura. The consistence of the lungs was firm, and more like that of the liver or spleen than the usual spongy texture. Being cut into, nothing but congestion was seen; however, there was still air enough to make pieces thrown into water rise to the top, though slowly, after sinking.

The heart.-In the pericardium about one quarter of a pint of liquid.

The heart was larger considerably than usual, but that was from distention of all the cavities with black blood. There was nothing morbid but enlargement of the ventricle of the right heart.

The left ventricle was much dilated. The mitral valves were in a cartilaginous and partially ossified state, narrowing the pas sage to one half the width from the auricle.

The semilunar valves were in a still more diseased state from thickening and ossification.

The large blood vessels of and near the heart were in a sound

state.

No morbid appearances of the viscera of the abdomen.

Remarks.

The light afforded by the dissection, I think, may enable us to give a not unsatisfactory rationale of the phenomena in the case under inquiry; and perhaps this history may serve to assist in distinguishing a similar disease in future, and, of course, direct more efficacious practice.

The diseased state described of the mitral valves must impede the due action of the heart, in transmitting the blood from the left auricle into the ventricle, and from the ventricle into the aorta. A still greater impediment to this transit must be the disease of the semilunar valves of the aorta. In such a state of the heart, while the body is at rest, the circulation may continue for many months without any symptoms in the pulsation of the heart and arteries, or in the respiration, as in the present instance; but, on bodily exertion, as in walking, running, raising heavy substances, &c. the left heart must be unable to produce the regular systoles required for the transmission of blood through the arterial system. Therefore more frequent actions are excited to compensate for less frequent healthy actions, when, by exercise, the heart is required to transmit an increased quantity of blood. If the blood cannot duly flow through the left heart, it must, in this case, be accumulated in it, and also in the lungs. Hence the dyspnoea. The disease of the valves increasing at length, there is impediment to the transmission of blood even in a state of repose; which impediment is augmented by the muscular power of the heart being weakened by perpetual stimulation of accumulated blood. In course, the blood accumulates, and distends the auricle as well as ventricle, and the pulmonary veins. Hence the hemorrhage in the lungs into both the interstitial parts of the cellular membrane, and into the air tubes, occasioning hæinoptoe in this instance, and a dense liver-like state of the lungs, as occasioned also in the case of Allingham, and for the same reason, viz. the diseased state of the valves of the left heart occasioning accumulation of blood in it, and also in the lungs. Finally, the heart becomes unable to transmit blood to support life, and the lungs cannot transmit oxygen duly. Death then must be the consequence. The whole mischief in this instance was produced by the disease of the left heart only; but, in the former, by a similar morbid

state of the right, as well as of the left. Consequently there was a double regurgitation of blood, viz. into the pulmonary veins, and into the venæ cava, manifested by the pulsations in the jugulars.

It is commonly believed that ossifications are very rare in such young persons as Herbott; but I apprehend they are more frequent occurrences than has been represented.

The distinguishing characters of this morbid state seem to be inordinate action of the heart and dyspnoea, upon bodily exertion, subsiding speedily on repose; peculiar distressing sensation of the chest pretty constantly present; lividity of the lips and face; perhaps nausea, and vomiting, and vertigo. These, in concurrence, and the absence of symptoms of hydrothorax, and of known pulmonary diseases, may assist in preventing this affection from being confounded with aneurisms, and other dif ferent organic maladies.

X.

Case of Cynanche Laryngea. By JOHN ABERCROMBIE, M.D. Fellow of the Royal College of Surgeons, Edinburgh.

MRS

RS M, aged about 45, of a spare habit and sallow complexion, began to be affected with soreness of her throat and slight difficulty in swallowing, on Saturday 24th February 1816. For several days she paid little attention to the complaint; but the symptoms having become more severe, I was desired to visit her on Tuesday the 27th. I found her complaining of great uneasiness in the throat, which she said felt as if it was closed, and great difficulty in swallowing. On examining the throat, nothing was to be seen but a slight and general redness, without the least swelling of any of the parts. The pulse was natural.

It immediately occurred to me, that the uneasiness she complained of was greater than was accounted for by the appearances in the fauces; but as the pulse was soft, and of the natural frequency, and no other symptom existed! that could excite alarm, I merely recommended a blister and a purgative. This was about one o'clock, and she continued without any change in the symptoms till between ten and eleven o'clock at night, when the difficulty in swallowing rather increased, and she began to

feel her breathing a little difficult. I was not informed of the occurrence of this symptom, till, in consequence of the rapid increase of it, I was sent for about three o'clock in the morning of the 28th. I found her affected with severe difficulty in breathing, most remarkable during inspiration, which was performed with a great effort, and a sound resembling that in croup, conveying the impression of great constriction of the la rynx. She had a frequent, short, irritating cough, with which she brought up small quantities of a thick, viscid, transparent, yellowish fluid, evidently the production of an inflamed surface. Deglutition had now become nearly impracticable, the attempt Occasioning violent pain, severe cough, efforts to vomit, and increase of the dyspnoea. Her voice was extremely hoarse-the pulse about 96, and rather small. The pain was referred to a spot a little below the root of the tongue, from which she said it extended along both sides of the throat :-" her throat," she said, "felt as if it was closed." She could open her mouth freely; and nothing could be seen, by the most careful examination of the fauces, but a slight and superficial redness, as on the preceding day.

I immediately bled her to at least twenty ounces. A large blister was applied to the neck and breast, the one formerly applied not having taken effect, and a brisk purgative was directed to be given as soon as she should be able to swallow it.

It was now about four o'clock in the morning of the 28th. At eight o'clock, I found that she had been considerably relieved, both in breathing and swallowing, after the bleeding, but that these symptoms had again become more severe. The pulse was 96, and small. I bled her again to fourteen ounces. Early in the forenoon eleven leeches were applied to the neck, and another blister along the sternum. The blood from both bleedings shewed a strong inflammatory crust. The purgative operated strongly.

By these means the breathing was very much relieved, but deglutition continued nearly as difficult as ever, the attempt exciting cough and efforts to vomit, with severe pain. The appearance of the fauces was now perfectly healthy, the slight redness formerly observed having disappeared. Finding her in this state in the evening, with the pulse 96, I bled her again to eleven ounces, making forty-five ounces in the course of the day, besides what was taken by the leeches.

29th. She had passed a quiet night, and her breathing was quite easy. Had some cough, with which she brought up a little matter, which was opaque and friable. Deglutition was still very difficult, exciting cough and efforts to vomit.