hardness at their summits; they were congested with blood and somewhat oedematous, but everywhere crepitant. The liver large, of the nutmeg character, its weight 64 ounces. The kidneys were small. The other abdominal viscera were normal, as was the brain.

One

In this monstrous case of perforate foramen ovale, the patient had attained her 57th year, a strongly made and not unhealthy woman, entirely free from the purple hue which belongs to a circulation thus rendered imperfect. In what way, or by what immediate agency, that arrangement was destroyed which had so long given for the most part a right direction to the respective columns of blood, when the sudden fright incurred by the patient occasioned an unfavourable turn to her symptoms, and what was the immediate cause of death, are questions of equal difficulty and interest. important practical consideration suggests itself in relation peculiarly to this case, and also to many others of less degree which have been collected,-that structural lesions, or diseases of a fatal nature, are not incompatible with prolonged duration of life. This consideration acquires increasing importance in proportion as medical science increases the catalogue of physical symptoms by which such lesions or diseases may be recognized. A disregard of it will produce a feeble and despondent use of medical measures when abnormal states of a fatal tendency have been discovered; and thus the march of pathology may, in their absence, interfere with, instead of promoting, that of therapeutics.

The following case strengthens this argument, by presenting also a long duration of cardiac mischief,

though of another kind, which was at last apparently rendered fatal rather by the intemperance of the patient, than the disorder itself.

Joseph Smith, aged 32, a brewer's drayman, was admitted into the Infirmary, September 26th, 1842. He was a stout, fair, sanguine person, and was throughout of a very placid, tranquil, enduring manner; he confessed that he had been intemperate. Came in under intense dyspnoea; visage purple, dilated; sharp and strong impulse of a struggling kind at the apex of the heart; its diastolic sound scarcely perceptible. His tongue dry and very foul; urine scanty, not passed without catheter, very high coloured; abdomen distended, legs oedematous; coffee-ground vomiting; very low pulse, the effective beats of which were about twenty in the minute. Conjunctiva and visage generally yellow. The urine was instantly set free in this case, and the dyspnoea sensibly relieved by

B Acid. Hydrocyan. Dilut. mv. ex haust. effervescent. 8vis horis.

which draught was equally effectual in the first of these points ever afterwards. I should observe, that I gained but little history with this man, except that he had had rheumatism severely many years before; but had since been actively employed up to the last few weeks. His state from his admission to his death was as follows.

The yellowness of conjunctiva, and foulness of tongue, gradually relieved, with much improvement of dyspnoea, principally noticed while he was under salivation from mercury. After some time, a mitigated recurrence of

symptoms, gradually terminating in sleepiness, coma, and death, in about four months from the time of admission. Capability at all times of lying prone; coffee-ground vomiting recurring whenever his urine was suspended or materially diminished; the urine highly acid; no albumen.

PHYSICAL SYMPTOMS.-The breathing generally vesicular, but often with large crepitus. Dulness over a large cardiac space. Heart's action heard distinctly over every part of the thorax, but remarkably strong pulsation and impulse, as if immediately under the ear, at a defined point under the right clavicle; this, however, varying much in relation to the application of leeches, by which it was also mitigated. Second sound of heart always inaudible. Alvine excretions generally healthy. Mind at all times perfectly collected, until coma supervened.

With respect to treatment, active purgatives, particularly Pulv. Jalapæ c. Hydrarg. Chlorid., were frequently given, and always with great relief. Olei Crotonis, mj. often profited much during the latter part of the case. Calomel was carried to salivation with great relief of dyspnoea. As diuretics, the hydrocyanic acid in an effervescing mixture, and next to this, the Mistura Etheris c. Scilla of the Marylebone Pharmacopoeia, profited greatly.

He did not wake distressed after taking, hora somni, Morphiæ Muriat. gr., which was often thus given. Leeches occasional.

AUTOPSY.-Brain normal, except that it was rather

exsanguine. Heart everywhere adherent to pericardium, but adhesions in many points soft: weight twenty-two ounces. Right ventricle normal, right hypertrophied; valves normal, except that the edges of the aortic valves were thickened. Brachiocephalic artery much narrowed in its calibre just before its bifurcation, and at the very point at which the heart's impulse was heard so loudly; lungs gorged, oedematous, not hepatised or tuberculated; liver very large, but healthy, as were the other abdominal viscera.

I could not ascertain the existence of any rheumatic symptoms immediately previous to the illness which occasioned his coming to the Infirmary. It is probable, therefore, that the cardiac change occurred at the remote period of life at which he said that " he had rheumatism severely."

CHAPTER VI.

ERYSIPELAS.

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THERE is no disorder in which the principles of treatment have been more broadly and positively stated, and at the same time in which less care has been taken to reconcile the differences which they involve, than erysipelas. It is not pretended in this censure, that remedies of contrary kinds may not be (even simultaneously) efficient towards a given object; since the large incisions of Mr. Lawrence, and the bark of Dr. George Fordyce, may both tend to relieve an oppressed circulation but it may fairly be alleged, that the cases, or the precise periods of a given case, in which the one or the other of these principles is most appropriate in the treatment of erysipelas, have not been brought out with clearness or precision. Accordingly, a certain "metus audax, et fiducia pallens" seems to overhang the practitioner, whenever he avails himself forcibly of either class of agents in this disease. Here, then, according to the views submitted in my first chapter, an inquiry is wanted, which may separate from each other, and individualise in relation to treatment, cases of the same kind.

The distinctive phenomena of erysipelas may present themselves either in an erythematic form, with a partial and well-defined flush upon the face or other parts of