vehement. After a few hours, the chest-wall was raised, and indications of emphysema were presented. At 2 P.M. death closed the struggle. After death I found, as I had suspected, a large fibrinous deposit filling the right auricle of the heart, extending into the ventricle, and so into the pulmonary artery. The deposit had shut off the blood from the lungs, slowly but effectually. The lungs were blanched, emphysematous, and full of air. The windpipe and larynx were sufficiently free: there was no other seat of disease in this child.*

Mr. Duncan McNab, of Epping, has favoured me with the particulars of the following remarkable case of cardiac apnoea.

A labouring man, who had been suddenly seized in the night with a sense of suffocation, came before Mr. McNab. After struggling awhile for breath, he partially recovered, and lived on for weeks, breathing with great difficulty; the only relief he could obtain was by placing himself in one position, viz., by lying with his face downwards and resting on his elbows. In one of his agonising struggles for breath, he died; and after death it was found that a fibrinous band, having its hold in the ventricle, extended into the pulmonary artery. The point of attachment of this band was on the anterior inner surface of the ventricle, so that, when the body was placed with the face downwards, the band was laid parallel with the inner surface of the wall of the vessel, and of

* See also an analogous case in my work "On Fibrinous Depositions in the Heart", p. 18.

fered little obstruction; but when the body was reclining on the back, the band stretched obliquely across the artery and obstructed the blood-stream. The lungs were of milk-white colour, and bloodless. The man had consulted Mr. McNab about strange sensations in his heart, a year or two before; but his complaints were then regarded as due to profuse smoking and consequent hypochondriasis.

In these two cases there was mechanical obstruction of blood on the right side, due to deposition of fibrine.

In the year 1854 a medical friend, living close to me, summoned me late at night to see a relative, also a medical man, who had been suddenly seized with spasmodic breathing and pallor. I obeyed at once, and found a powerfully built man sitting, or rather partly sitting and partly lying, in an easy chair, with every muscle in his body fixed. His arms were as rigid as in tetanus; his head was drawn back, his face was deadly pale, and the surface of his skin covered with a cold sweat. The agony of expression exhibited by the sufferer was appalling, and his efforts to breathe were desperate. I listened over the chest rapidly, and found that, whenever a little air could be drawn, it found its way readily enough into the lungs. The heart was beating with great irregularity, and with such vermicular action that neither the systolic nor the diastolic sound could be clearly distinguished, but sometimes one faint sound, probably diastolic, was audible. The muscles were so rigid that it was with extreme difficulty we got him to take a stimulant;

but having succeeded, the action of the heart became more decisive, and the attack for this time passed away. When the patient was composed, he told me that he had had several such seizures, but none so severe. When he had his first attack, he said, he thought he must have been seized with tetanus. The pain usually commenced in the neck, seemed to creep down the anterior part of the chest, and then shot, like a lightning flash, through the chest, fixing the muscles immovably; thence it extended down the limbs, first as a tingling tremor, afterwards as a continuous cramp. Micturition sometimes took place involuntarily during such attacks. He had lived freely. He had been an army surgeon, and had seen active service. He was not himself suspicious of being a sufferer from heart-disease: and, like many medical men, he did not like to think of his own case.

On the following morning, I made a careful exploration of his chest. I detected a spot on the left lateral aspect of the chest, where the two sounds of the heart were feebly to be heard, the second most distinctly, and both without murmur. But, turning to the anterior aspect, at all points midway between the base and apex of the heart, there was entire absence of distinct rhythm: here the cardiac action was what I should designate vermicular in character. There were three or four quick, confused contractions, followed by a gap or pause. When he held his breath by an effort, this pause was much prolonged, and the symptoms of oppression were elicited. I diagnosed disease of the right ventricular wall; and to the

friends and advisers of my patient I intimated the hopelessness of his case. In the way of treatment, I ordered tonics, and forbade violent exercise and over-anxiety. It was the fortune of this patient to consult, on the same day, another member of our profession, but his misfortune that he intentionally held back the fact that any previous opinion of his case had been arrived at. The physician consulted was in the midst of morning engagements, and seeing a strong looking man before him, complaining of nothing but an occasional irregularity of pulse, did not examine the chest at all; but, thinking that the irregularity was purely functional, that the spasmodic attacks were due to flatulency, gave an opinion that there was no reason for any change in life, and that the symptoms would all pass away under digitalis and alteratives, which were forthwith prescribed.

The sufferer went home satisfied, and made no provision for danger. A few months later, he attended a near relative in labour, concluded the delivery, retired to another room, and, with a scream, fell in one of his old spasmodic attacks. There was relaxation of the spasm, and recurrence; but this time there was no escape: he died in the midst of one of the seizures.

I saw another illustration of this kind, also in a medical man, who had lived very freely, and had undergone much exposure to the night air. In this case, signs of hepatic enlargement, for a time, drew attention away from the heart, the true seat of the disease. Ultimately the exact nature of the malady

became only too apparent. The cardiac dyspnoea in this case was, however, never so intense as in the case preceding; but the attacks were much more frequent, and sufficiently distressing. I went down to the country one evening to see this gentleman, and slept in his house. In the night I was awakened suddenly, to find him in his dressing-gown by my bedside, imploring me to do something that should enable him to sleep, or to lie for one hour at rest, or to make one deep inspiration.

In this patient, the lungs gave no indication of obstruction: in him, too, by careful auscultation of the left side, the systolic and diastolic sounds could be made out; but on the right aspect all was confusion-vermicular action. I made the same diagnosis here as in the preceding case; and that diagnosis was correct. The patient died in one of the attacks of cardiac apnoea; and the right side of the heart was found, after death, utterly disorganised; the structure in parts translucent, and tearing like wet paper. The walls on the left side were pale, but of ordinary thickness; the valvular machinery was normal; and the lungs were free from disease. The liver had undergone but little morbid change.

In these cases the cardiac apnoea depended on disorganisation of the right muscular wall of the heart.

I attended, in concert with Dr. Willis, in the year 1851, a man, 45 years of age, who in June of that year was suddenly seized with great languor, and inability to move. Twelve years before, he had suf