fæces, a tendency towards which had certainly been established by the other means employed, when the case was suddenly and accidentally terminated. Meanwhile, the inflammatory state of the intestines might have gradually yielded to the exhibition of calomel and opium.

As an accident appeared immediately to determine the event of the last case, so a very accidental circumstance apparently removed that obstruction on which stercoraceous vomiting depended, in the following case of ileus. I regret that I possess but slight memoranda of it.

I saw a lady in consultation with Dr. Watson, Dr. Ashburner, and Mr. Arnott, who had laboured under acute symptoms of ileus, including fæcal vomiting, for several days. She was justly considered by these gentlemen in great danger. She was aged, ber visage was contracted and sunken, her tongue brown and dry, pulse feeble: her general appearance indicated restlessness and distress, and the curative means employed, calomel and active aperients, had been ineffectual, though applied earnestly and skilfully. A complete examination was now again made of the abdomen, with much pressure of it in various parts, and a plan for the prosecution of the case laid down. In the evening of the same day Dr. Ashburner called upon me, and informed me that the pressure made had moved something, which had, as it were, descended through the bowels: in fact, she had, in the course of a short time, expelled an oval calculous concretion, about two inches

Ꭰ

long, with entire, and, as it proved, permanent relief of all her symptoms.

In a fatal case of ileus, which occurred to Dr. Abercrombie, he gives the following post-mortem phenomena :-"The upper half of the small intestines was distended and inflamed, with considerable exudation. The lower half was collapsed, empty, and of a healthy appearance. At the place where the distension ceased there was found a large biliary calculus, four inches in its largest circumference, and three and a half in its smaller. The common duct was enlarged, so as easily to admit a finger.

CHAPTER V.

CYANOSIS.

It has been well remarked by Dr. R. Willis, in an Essay on Malformation of the Heart,* relatively to cyanosis, that "the only explanation which could be given of the absence of cyanosis in certain cases in which imperfections of the auricular and ventricular septa have been discovered, would be grounded upon the accurate maintenance of the proportion between the powers of the heart and the resistance which it has to overcome." The following case is one in which this conservative principle had acted, probably under greater disadvantages, for a longer term of years than has usually been adduced in the records of such cases.

Mary Thackeray, a stout, tall woman, came into the St. Marylebone Infirmary, on the 3rd of December, 1841. She described herself as labouring under an habitual winter cough; and said that about a year ago she had an acutely painful swelling of the great toe. She is subject to sudden difficulty of breathing, obliging her to jump up, when prone at the time of their occurrence. The pulse was small and quick. Examining the thorax I found considerable cardiac impulse and thumping, dulness over a large space in

* Medical Gazette, vol, xxxii. p. 127.

the cardiac region, and loud systolic bruit at the apex. In repeated examinations I found some crepitus with deficient vesicular penetration about the base of the right lung. The sputa, on her coming into the Infirmary, were mucous and rather tenacious; they became rouillées and mucopurulent, and then lost their tenaciousness, and improved again. A slight attack of pneumonia was occurring at the time, which was obviated by leeches, a blister, and the following prescription.

B M. Tragacanth Co. 3iss; Potassæ Nitrat. 9j; Tr. Camphora Co. 3ss; Tr. Scilla, mxv. 6tis horis.

B Pil. Scillæ c. Hydrarg. bis quotidie.

On the 23rd of December, I find it noted by me, that the dyspnoea was then trifling, but that cough came on irritably, when the patient was recumbent, and her head low. On the night of the 24th, she underwent a severe fright from the violence of another patient in the same ward. Much fluttering of the heart ensued on this, and then first the visage took a purple hue. It was observed also by herself, that her urine, always deficient, became more so. The above mixture was now changed for,

B Mist. Ether Co. 3iss. ;Vin. Ipecacuan. mx; Træ. Humuli, 3ss. 8vis.

And she became on this plan more easy and composed, but the cyanosis remained unaltered. On the 28th she had taken

Mist. Camphoræ, 3jss.; Liq. Op. Sedativ. mxxv.

and had settled comfortably to sleep. At four o'clock the next morning she died suddenly.

A perusal of the autopsy of this case may suggest a doubt whether this woman's circulation was in a fit state for opium, whether its sedative effects may not have been too great.

The contents of the cranium were normal.

The heart weighed eighteen and a half ounces. The right auricle was large its muscular substance well developed. The right auriculo-ventricular opening was also large, but tolerably proportioned to the tricuspid valves. These valves were white, and thickened, particularly near the free edges; their columnæ carnea were remarkably developed. The right ventricle was extraordinarily large, and its walls from three to four-eighths of an inch thick; the columnæ carneæ well marked; the semilunar valves of the pulmonary artery perfect. Its coats, as well as those of the pulmonary veins, greatly distended and thickened, and less supple than usual. The left auricle was large and fleshy, thicker than the right; there was an open communication between it and the right auricle in the situation of the foramen ovale, extending an inch and a quarter from below backwards, and half an inch in the opposite direction. Two membranous bands, extending from the upper to the lower portion of the auricle, divided this opening into three unequal parts. The left auriculo-ventricular opening was normal; the valves ill formed. The under mitral valve almost atrophied; the upper enormously large, about an inch and a half long, and broad in proportion. The left ventricle was greatly hypertrophied; the columnæ carnea large. The aorta normal.

The lungs exhibited a few points of semicartilaginous