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the tube. There was no fluid of any kind in the trachea, until opening its primitive branches; these were found filled with the same ropy mucus which the patient had occasionally discharged in former attacks. The mucus found in the bronchial tubes was of brownish colour. The posterior part of the tra chea, opposite the thyroid cartilages, was of almost cartilaginous firmness, and more than an eighth of an inch in thickness. The interior capacity of the trachea between the thyroid cartilages was very much contracted, leaving a triangular chink scarcely sufficient for the passage of a straw. The space of the larynx above the thyroid cartilages was also greatly narrowed, by thickening of the lining membrane, and more particularly of the reflection forming the rima, (the borders of which were hard and chord-like,) and the covering of the ventricular portion or appendages of the larynx.

"The lungs appeared sound. They were throughout expansible and crepitous, but heavy and dark-coloured, shewing great venous congestion. The patient died, probably rather of suffocation from the loaded state of the bronchial tubes and cells, complicated with strong spasmodic irritation of the larynx, than from any acute derangement or lesion. The mucus with which the bronchial passages were all filled, up to the great division, was so viscid that none of it would flow out by gravitation, and only small portions could be extracted mechanically."

The anatomical description of our author is not particularly clear, but still we think we gather enough to conclude that the organic lesion was not great. We regret that no mention is made of the state of the heart and large vessels, for if they were sound, we see no reason, on the face of the account of the dissection, why tracheotomy should not have been effectual in bringing relief to the breathing. The application of the stethoscope and employment of percussion is of much value in such cases, from the assistance they convey to us in ascertaining the condition of the lungs.

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CASE 1. Chronic Carditis-Hypertrophy with Condensation. Ann Lee, æt. 26, tall and rather pale, admitted June, 1827.

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Temperature of the surface natural; skin soft; pulse 85, very small, not sensibly irregular or unequal; no fever or rigors; countenance pale; complexion a little sallow; eyes clear. Encephalon. No head-ache or vertigo;

senses perfect; mind calm. Gastric system. Tongue clean; slightly lymphatic in the centre; no decided cha. racter of irritation; stomach not deranged in sensation; no morbid sensitiveness about the epigastrium; appetite commonly good; bowels regular; dejections scanty. Thorax. No cough; respiration small, but easy in general, the same when lying, sitting, or standing, but quicker after walking or any effort, and checked suddenly, but not painfully, on attempting full inspiration; no pain in the region of the heart, or the muscles of the chest or arm, and the patient could lie on either side, but preferred the left. Abdomen. Belly rather full, too prominent or rounded at the sides, slightly tense, not generally tender; sensibility greatest in the left hypochondrium, as if from a degree of splenitis, or of morbid tenderness in the left portion of the transverse colon; no defined hardness or volume in the part. This was the only acknowledged seat of soreness or pain about the body, and uneasiness, sometimes amounting to pain, was generally felt here, and frequently referred to by the patient. The region of the liver bore pressure well, which did not betray any unusual evolvement of that viscus. Pelvis. Menstruation suspended; no pain in that seat; urine scanty and high coloured, but voided without pain or irri tation."

Dated the origin of her complaints to the preceding April, when her menses failed to appear, and since which time her health had declined. The patient was put upon an alterative course of calomel with squill, rhubarb, and canella— her mouth was slightly sore at the end of a week-the urine became free-and

the oedema of the lower limbs nearly disappeared. The mercury was now discontinued, the bowels kept open with a bitter cathartic infusion, and after some time a pill composed of myrrh, assafœtida, turpentine, &c. exhibited with a view to excite the catamenial secretion. At the end of eight weeks she was so well as to walk about the wards and engage in her occupation of sewing, but after having been out of the hospital for some days she was attacked one evening by rigor, succeeded by fever, dyspnoea, acute pain in the upper part of the thorax, and cough. The pulse was very thick and thready, the patient much agitated, the orthopnoa distressing. Calomel and antimony with Dover's powder were exhibited, and the solution of tartarized antimony in barley-water. The patient passed a bad night, and on the next day was very weak with puffy face, quick thready pulse, inclination to stupor, cough less frequent, no expectoration. A large blister was ordered to the chest, calomel, camphor and ammonia every four hours, and wine whey drink prescribed. No improvement took place during the day, the orthopnoea increased to the utmost degree in the night, and after a few paroxysms of dyspnoea the poor creature sank down and expired suddenly.

"Dissection. The head was not examined. Thorax. Immediately under the upper third of the sternum appeared a considerable mass of recent gelatinous, or lympho-gelatinous deposit, of pale yellowish colour; the surface of the mediastinum and pleura, and for some space around, exhibited the appearances of recent inflammation; the serous membranes of the chest, (except the inflammatory patch described,) as well as the pulmonary surfaces, in their common state; the right lung much shorter than natural; the heart, with its envelope, presented very full in front, occupying the middle region of the thorax, rather than the left side, and appeared, (from the volume and seeming fullness of the pericardium,) to be larger than common; the front border or margin of each lung, was tied to the sides of the pericardium by

No. XXV. FASCIC. I.

three or four distinct, strong slips or bands, of fibro-ligament, of evidently ancient formation; the bottom of the left lung cohered extensively, by old adhesion, to the diaphragm, and in a partial degree to the pleura costalis; the parenchyma of both lungs was sound, soft, and crepitous; both pulmopleural sacs contained a few ounces of water; the heart, enclosed in its sac, being raised up, felt particularly firm and heavy, and retained its cordiform shape, as if its chambers were filled by some solid matter, while its exterior surface was closely embraced by the pericardium. On making a longitudinal section, to divide the pericardium and expose the heart, nothing of the common distinctness of parts could be found. The pericardium not only cohered to the heart, but was consolidated, or identified with its substance. This union was complete and universal up to the roots of the great vessels. The heart was weightier than natural, and fully equal to the medium size of the bullock's heart. The left ventricle was empty, and remarkably circumscribed, not capable, by conjecture, of containing more than half an ounce of fluid. Its thickness was rather more than an inch, its internal surface of natural appearance; the root of the aorta not sensibly hypertrophied; the semilunar valves soft and natural. The left auricle was of natural size, darker coloured than usual, firmer in its wall than common, but retaining a good deal its soft sacciform character; the mitral valve healthy. The right ventricle was smaller than common, less collapsed than in its natural empty state, no coagula in its cavity, its parietes very firm and thick, like the mass around the left ventricle; the root of the pulmonary artery and its valves sound. The right auricle was uncommonly prominent and rounded, and of particularly purplishred colour, much darker than the rest of the heart. Its wall was half an inch thick in every part, its cavity did not collapse when cut open, and its whole interior was black and ragged, with short flocculent masses hanging from all the inner surface. The inside of the auricle represented a rough ulcerous

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cavern smeared and blackened with grumous blood. There were no traces of purulent or sanio-purulent fluid in the cavity, and only a few flakes of dark fibrinous matter. When the auricle was cleaned out, its interior surface still exhibited a perfectly ragged, (for want of a better term,) ulcer-like appearance. The tricuspid valve was found entire, but was undergoing calcareous degeneration. On being handled, its chorda tendinæ cracked and broke to pieces between the fingers.

"Stomach healthy; remarkably small size, not more capacious than an equal extent of the colon. Spleen somewhat enlarged. The intestines and peritoneum natural, except a very blanched and bloodless appearance; some water in the peritoneal cavity, the abdominal aorta preternaturally small. The liver did not occupy more abdominal space than is common, but was twice its natural bulk; and from some cause not apparent, had ascended in the direction of the left thoracic cavity, pressing the diaphragm before it, and occupied fully half the space of that cavity; hence the compressed and shortened appearance of the left lung, before noticed. The liver, though hypertrophied, bore no particular mark of disease; the gallbladder was small and contained a thin pale green fluid. The kidneys, uterus and bladder natural, the latter of very small size. The ovaries on both sides were converted into a mass of tuberculations, imperfectly suppurated. There were some remains of chronic ulceration in the vagina, the clitoris morbidly enlarged, and part of the labia interna demolished by former ulcerations. Both groins exhibited scars from ancient buboes."

Dr. Wright considers it remarkable that the carditis in the present case should have gone to such an extent without having caused fatal disturbance in the organ and general economy. Now to those who have seen much of these diseases there is nothing remarkable in the matter, on the contrary, it is an every-day occurrence. But we do not hesitate to say, and we speak it advisedly and from experience, that there were characteristic symptoms present,

nay more, that the disease ought to have been discovered. The sallow puffy face, disposition to oedema, dyspnoea on exertion, pain on full inspiration, preference of one side on lying and tendency to orthopnoea, the small pulse and scanty urine are general symptoms that speak an intelligible language to those much accustomed to these cases. No mention is made of the chest having been stripped, or even of the hand having been applied to the region of the heart, We can say most conscientiously that we have not seen an instance of hypertrophy of the heart and adherent pericardium, in which the action of the organ was not seen and felt more extensively than natural. The stethoscope was not applied in the present instance, and yet we venture to predict that it would have indicated the exist ence of the hypertrophy with unerring certainty. We never examined such a case in which there was not powerful impulsion and the bruit de soufflet or the bruit de rape, and we have no doubt whatever that such would have been found in this instance, had they been looked for. No mention is made of the patient having suffered from rheumatism, but adhesions of the pericar dium are very rare without it. Dr. Wright revives the exploded notion of Corvisart, that the végétations in the auricle were caused by the ancient syphilitic affection. We thought that the idea was long since abandoned by all sound pathologists. We might make many more remarks upon the case, but our limits compel us to forbear.

CASE 2. Aortic Aneurism; Rupture into the Trachea and Esophagus.— Henry M'Claskey, æt. 54, very muscular, admitted December 1827.

"The leading symptoms, at the time of admission, were cough, and a constant sense of weight in the chest, increased on exercise, and causing labour of breathing after any considerable effort. The cough was hoarse and dry, without expectoration, not very frequent, not commonly excited or increased by deep breathing, the sense of weight in the chest constant, rather disagreeable than distressing, and not

at all impeding lying down or walking about moderately. The patient represented his present symptoms to have come on about three weeks before, previous to which time he was, or believed himself to have been in good health, had been seldom sick, led an active life, and was free of any aptitude to cough, or other disorder.

"There was no fever, nor feverous temperature of the skin. Examined for many days together, the pulse betrayed no sensible fluctuation; it was sixtyfive to seven; soft without volume, requiring pressure to distinguish it well, and not resisting with any energy of stroke; it was both a weak and sluggish pulse, though the latter is usually characterised by some force. The general state of the system corresponded with the torpor of the circulation; the man kept his bed, was silent, and seemed indifferent to every thing about him, his usual position supine, countenance dull and drowsy; when asked respecting his state of feeling, complained of annoyance by his cough, and of the sense of weight in his breast, spoke little, rather abruptly, and always in terms implying despondence of getting better."

The stethoscope was not applied, no diagnosis beyond "chronic pulmonary embarrassment" formed, and a palliative course of treatment, i. e. a negative one employed. Diarrhoea was prevalent in the infirmary, and the man became affected with it to the increase apparently of his cough. One morning he came out of the privy coughing very hard, violent vomiting was heard immediately afterwards, those present ran to the bed, where they found him eject ing blood in torrents, and in ten seconds' time he was lifeless.

"Examination: -No extravasated blood in the general cavity of the thorax. The right lung extremely dilated, filling the whole right cavity of the chest, of a deep purple hue, and engorged to the utmost possible degree, not from vascular congestion, but complete injection with blood, of all the bronchial passages and cells, to their minutest divisions; no artificial inflation of the lung could possibly have

caused a more perfect display of its expansive capacity. The left lung was. not at all dilated, and exhibited no unusual colour.

"The heart viewed in situ, gave but a very partial representation of the nature of lesion, some appearance of a pouch only presenting just beyond the arch of the aorta. The trachea and œsophagus were divided above and brought down, the membranous connexions around the thorax and to the spine separated, and the heart and lungs taken out together. Being now inverted, the state of the parts was readily traceable. At the deepest posterior part of the arch of the aorta, an inch and a half below the root of the left subclavian, was an aneurismal sac, the size of an egg, its parietes soft and apparently very thin. This was plainly the source of the hæmorrhage, and to trace its communications, the sac was slit open through its greatest length. The coats of the artery, (within the limits of the sac,) were very thin and tender, and tore rather than cut when laid open; the sac was empty, except a few delicate layers of soft coagulable lymph. Passing the finger into the sac, it encountered three or four hard, rough, pointed bodies, on each side, within the aneurismal cavity, which were the extremities of three broken rings of the trachea; the points were thin and sharp, as if wasted, and had a roughness, hardness, and brittleness, more of bone than cartilage. The communication with the trachea, and the cause of bloody insufflation of the right lung, were thus explained; it remained to ascertain why the fatal hæmorrhage had occurred in the form of a violent and repeated gush by vomiting. When the œsophagus was now detached from the trachea behind down to the borders of the aneurismal sac, it was found to be united by adhesions both with the diseased portion of the trachea and a part of the aneurismal bag; a farther separation of the oesophagus from the trachea, disclosed an oval opening, in the former, large enough to admit the point of a finger, by which the oesophagus communicated with the trachea, just behind where the rings of the latter had given

way, which was pretty low on the left side of the trachea. The coats of the œsophagus were very much attenuated over the whole extent of its adhesion to the trachea and sac, and the rent described communicating directly with the current flowing into the trachea after rupture of the rings; the blood seems to have passed freely also, by the route to the stomach; hence its discharge by distinct acts of full vomiting. The stomach contained after death about a pound of coagulated blood.

"It has been mentioned that the left lung was not dilated, or changed in colour, &c. The cause of this difference in the two lungs, was explained while removing the parts from the cavity of the chest. The left lung was found to adhere with great firmness throughout its whole anterior, lateral, and posterior surface, to its own pleura, and by that to the serous membrane of the ribs. The lung was enlarged very much, firm and heavy, and in its whole substance hepatized to so great a degree, that every trace of bronchial tubes and cells was wholly obliterated up to the point where the left bronchus penetrates the lung by its primary branches. From this point there was no channel by which air could enter the lung, and for that cause, the extravasated blood was totally excluded."

This interesting case adds another to the many already upon record, that stamp the insidious character of aneurismal dilatations of the aorta. As Dr. Wright very properly observes, no dependence can be placed upon the statements of previous good health which patients very generally give, for it is obvious in the present instance that the hepatization of the whole of the left lung must have been an alteration of considerable date. It may be asked if the stethoscope would have pointed out the real nature of the disease. It would have shewn the hepatization of the lung beyond a doubt, and we think that in all probability it would have indicated something wrong about the aorta. dilatations of the arch with any degree of hypertrophy of the left ventricle, we almost invariably have a louder sound, or even a decided bruit, above the right

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clavicle, and in all the cases of aneurism of the aorta that we have examined there has been this indication in the situation of the tumour. On this point, however, we would be understood to speak with some diffidence as we have not examined a sufficient number of cases of aortic aneurism to justify us in forming a sweeping conclusion. With the succeeding case we must conclude.

CASE 3. Gangrene of the left upper extremity peculiar affection of the arteries.-Margaret Cash, æt. 56, admitted Oct. 20th, 1827, with aggravated diarrhoea, but no symptoms betraying urgent danger. The left hand was more powerless than the right, and the pulse in the former was barely perceptible. The diarrhoea was much moder. ated by judicious remedies, but a new train of phenomena now presented themselves.

"Ever since the patient's admission into the infirmary, she had complained of pain in the inner side of the left arm, a little below the insertion of the tendon of the teres major. Nothing appeared at the place indicated, to explain the cause of pain there; the part was sore to the touch, but neither swelled nor inflamed; the soreness extended an inch or two up and down the arm, in the track of the brachial artery. At the end of a week from her entering the ward, the pain of the arm, and soreness to handling, had almost entirely disappeared, but the patient was then sensible of total loss both of power of movement and sensation in the left hand. That hand was quite cold, and on the tenth day a faint bluish tinge was discovered over all the fingers, the colour permanent, and not varying by pressure. The discoloration of the fingers became deeper every day, spread slowly, first up the back of the hand, then through the palm, and by the sixth day from its appearance, had reached the carpal articulation all round. The fingers, up to the metacarpal junction, were now evidently lifeless; they were cold, black, and unpliant, yet not at all sphacelated, nor showing any vesiculation, or other marks of putrescent decay; nothing like separation of parts

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