to me in the case of Mrs. K., that a portion of the left lung, at the point where it partially envelopes the left side of the heart, had been drawn downwards by pleuritic adhesion, and bound to the thoracic wall immediately over the heart; that the piece of lung thus placed was subjected to the impulse of the heart during systole; and that, when the lung was inflated on inspiration, the sudden compression, produced by the impulse, elicited the crepitation by forcible expulsion of air from the air-vesicles. I explained this view to Dr. Snow, who concurred with me entirely. In the succeeding two cases the same explanation presented itself; in the last case a like exposition was suggested, except that in this example the aorta, instead of the heart, was the pulsating body. Let me now show how far this diagnosis was proved correct.

Post mortem Facts. The first two cases above recorded ended fatally, and both, curiously enough, exactly six weeks after the occurrence of the pulsatile crepitation. I look upon this circumstance, of course, only as coincidental. The first patient died slowly, from exhaustion. The second died while he was sitting up in bed, laughing at some passing

event.

The post mortem examination, in the first case, revealed no disease of the segments of the mitral valve itself; but in the left ventricle, immediately below the valve, and to the left side, there was firmly attached to the endocardial membrane a rounded concretion, the base of which was of the size of a shilling, and the projection of which into the ventricle

extended for at least half an inch. The concretion was partly organised. The heart was hypertrophied. The pericardium was adherent to the lung, and over the base of the left ventricle, to the left side, in the exact position over which the pulsatile crepitation had been heard during life, there extended a corner or tongue of lung. This structure, bound down to the pericardium by the under surface, was attached to the thoracic wall above by a band of adhesion an inch broad, which was inserted, almost like a fine tendon, into the thoracic wall close to the sternum. This band pulled the lung quite over the heart in an oblique direction. On its under surface the piece of lung was compressed into a concavity, into which the rounded surface of the heart fitted; the appearance of the lung indicated that the structure had been subjected to compression at this overlapping point. The parts as thus presented were shown at the Medical Society of London in 1854.

In the second case, extensive disease was found on the left side of the heart. The segments of the mitral valve were thickened and indurated; on the aortic valves were atheromatous deposits; and there was an extension of atheroma into the aorta. The heart was unusually large from dilatation, with parietal hypertrophy.

At the base of the heart externally there was the same condition as was observed in the preceding example, except that there was no adhesion of the lung to the pericardium; but a piece of the left lung, at its lower anterior margin, two inches in length and

tongue-shaped, was dragged obliquely from above downwards over the heart by a membranous band. The band was firmly attached to the sternum by its extreme end. The portion of lung passing over the heart was compressed on the under surface into a concavity, and its structure was condensed. The centre of the compressed spot corresponded above with the centre of the ring which I had marked on the thorax externally by the iodine line.

To make the fact of causation more evident still, I performed, in this inspection, the following experiment. I placed a piece of tubing in the trachea, the lungs and heart being still in situ, and made my assistant inflate the lungs with air, whilst I, seizing the extreme point of the tongue of lung, extended it in the line in which it had been bound; then, when the whole lung was full of air, I forcibly compressed the tongue of lung between the fingers and thumb of free hand, and, holding the stethoscope between the back of the compressing hand and my ear, I elicited, with each compression of the hand, the same sound precisely as I had heard during the life of the patient.

my

OBSERVATIONS BY DR. WOILLEZ.

At the time when I first described the case of Mrs. K., in 1854, the sound which is here designated as "pulsatile pulmonic crepitation" had not, I believe, been noticed by any other observer; and, indeed, the same remark applies to the paper published in the Medical Times and Gazette in February, 1860. But I

observe in L'Union Médicale for June 16th, 1860, that Dr. Woillez has reported to the Société Médicale des Hôpitaux the particulars of a case in which the same sound was detected. Dr. Woillez's case occurred in the person of a young man, aged 22, a medical student at Vienna, who had a peculiar thoracic deformity. This patient, though delicate, had experienced no inconvenience in breathing, nor pulmonary disease. There was also in him no hereditary predisposition to thoracic disorder. In the anterior part of his chest there was an irregularly oval depression, funnel-shaped, nearly ten inches long, in the vertical direction, i. e. from the commencement of the cleft of the sternum and internal portion of the clavicles as far down as the level of the epigastrium; seven inches in the transverse direction; and two inches and three quarters deep. Apart from this deformity, the general conformation was satisfactory; there was no lateral deviation of the vertebral column. In a word, there was simply extreme depression of the sternum.

The physical signs presented by Dr. Woillez's patient were peculiar. On percussion, there was a slightly dull sound at the level of the centre of the heart. On auscultation, the maximum of the impulse and of the sounds of the heart was distinctly perceptible at the level of the cartilage of the third left rib, and these sounds were normal. At the apex the sounds were obscured by a portion of lung, the vesicular murmur being here discernible. The respiratory movements were mainly by the upper ribs. The

respiratory sounds were weak in the two sides of the thorax, but tolerably strong in the axillary region on the right side. On the left side of the thorax posteriorly, the beatings of the aorta were distinct. These beatings were heard in the upper part of the back, immediately to the left of the spine; but diverged from it in proceeding downwards to a distance of about two inches and a half, opposite to the deepest point of the sternal depression. At this point a sound was distinguishable, very different from the simple arterial sounds perceptible above. The arterial sound heard at the level stated, was not uniform nor well defined: if the patient were told to hold his breath, an intermitting vascular sound was heard, regular and synchronous with the pulse, and which was neither a blowing sound, nor a rasping sound, nor a simple arterial bruissement, but a sound manifestly granulous in character, beginning and ceasing with the beating of the artery, but without an analogue in the anomalous vascular sounds which have been described. Moreover, when the patient was made to resume his breathing, immediately the normal vesicular murmur and the aortic sound were heard again. Each new examination, often repeated, produced identical results.

Apropos of the aorta, Dr. Woillez explains the cause of the "granulous murmur" as follows: "The aorta, being several centimètres distant on the outside of the vertebral column, was necessarily surrounded on all parts except behind by pulmonary tissue; for the respiratory murmur was heard to the inner as well as to the outer side of the aorta. At the level of the maximum of the anterior sternal depression there