fered from rheumatic fever; but had recovered, as he thought, completely. In March, 1851, he had a second attack of rheumatism, for which he would allow no treatment to be adopted, and after which he was never well. On the 16th of June, when I first saw him, he was sitting in a chair, his face presenting extreme anxiety; his gait was feeble and tremulous; his limbs restless; and his mind irritable. On examining the chest, the lungs were found free from any disease. The heart was enormously enlarged, and, as it seemed, pushed downwards, so as to displace the liver; the point of visible pulsation was an inch and a half above the umbilicus, but during a deep inspiration the pulsation was observable immediately over the umbilicus. The action of the heart was irregular, the sounds indistinct. On listening to this heart, it conveyed the idea of a large, soft, Indiarubber bag filled with fluid, on which the walls of the bag were irregularly contracting. The pulse was small and irregular; the veins were turgid; and there was regurgative pulsation of the jugulars. The skin was of yellow paleness; but there was no indication of enlargement of the liver, nor of dropsy. The secretions were natural.

The marked subjective feature of this case, again, was cardiac apnoea. But it occurred somewhat otherwise than in the other cases. The man himself was conscious of the want of air, and the anxiety for air during acute paroxysms was as great in his case as in the others; but throughout the respiration did not, to the observer, appear so laboured. Whenever

the patient was asked to take a long inspiration, he could do it, and the transmission of the air into the lungs was, to the ear, freely accomplished. The pain which attended the paroxysms was referred rather to the back and abdomen than to the sternum.

The man continued under our observation without evincing much change of symptom until August, when he was almost altogether prevented from sleep by the recurrence of the attacks whenever he resigned himself to repose. On the 6th of August, during one of the paroxysms of breathlessness, he threw up some blood, bright, red, and frothy. This did not cause an increase of the paroxysms, but rather lightened them. By this time the breathing had become distinctly oppressed; the chest was fixed; and the pain. in the back and abdomen during a paroxysm was greatly increased. On the morning of the 10th, he felt slightly relieved; his breathing was free, and he could hold his breath as long as I could hold mine. But the relief was only transient. At nine in the evening, his oppression from want of air, and his efforts. to bring the contracted chest into play, were terrible: withal, he was collected. I detected now that there was some effusion taking place in the right pleural cavity. At eleven o'clock, he died while I was present. He rose up in bed, and, saying that another fit was coming on, fixed himself to meet it, with his clenched hands buried in a pillow on each side of him he opened his mouth widely, as if to inspire, and there he sat fixed as a statue, as I had often seen him before. But this time was the last. I waited,

and found there was no pulsation going on at the wrist; yet the features, drawn firmly in expression of inscrutable agony, continued so fixed, that I did not know whether he was living or not. We put pillows behind him, and gradually he relaxed upon them, unmistakably a dead man.

The diagnosis I had formed in this case was, that there was a source of obstruction to the circulation through the right side of the heart; but I thought that obstruction was in the cavity of the ventricle, consisting, perhaps, of an organised fibrinous concretion. The latter part of the diagnosis was incorrect; for the post mortem examination revealed a heart enormously enlarged from dilatation; the pericardium adherent over the whole surface; a firm adhesion between a large surface of the pericardium and the diaphragm; and a girdle of ossific matter, two lines thick and half an inch broad, surrounding the heart almost completely. The bony ring was imperfect only for a short distance over the left ventricle. The right ventricle was large enough to enclose a full sized orange, and its walls were hypertrophied. It had evidently been doing its work as a fixed ventricle.

There was some effusion into the right pleural cavity; but the lungs were normal. The mouths of all the great vessels were much dilated. There were no separated fibrinous concretions; but the enlarged right auricle was filled with red coagulated blood. All the other viscera of the body were healthy.

In this illustrative case, the cardiac apnoea was due

to pericardial adhesion and ossification, by which the right side of the heart was disabled.

On November 26th, 1850, a female child, 10 years old, came under my care for debility. She had suffered from a febrile attack; her friends thought from scarlet fever, as there had been a rash on the skin, and as scarlet fever had been present in a house near by. I ordered the child a saline, and afterwards a tonic; and continued to look in upon her daily until the 26th of August. On the morning of that day she seemed so well that I stated the visit to be the last: she was, when I called, actively at play, and had no complaint except of slight stiffness of the neck, which had been present from the first, but was so trifling that in my mind it passed as a little affectation on the part of the child, rather than as a fact. On the evening of the 26th, I was summoned hastily to this child. She had been well all day, but towards the close of the evening had once or twice coughed. At half-past ten she went to bed with her sister, and got into bed making great merriment. As she was sitting down, she gave a scream, and cried for breath. Her sister turning round, saw her face turn bloodlessly pale, her head being drawn back, and her chest heaving: she gave an alarm, and within six minutes I was by the bedside. The patient was reclining on two pillows, with her head drawn back, and the trunk of her body as rigid as marble. She was conscious; and, when I asked her whether she was in pain, she tried to make an affirmative move

ment with her head, and pointed to the sternum. I rushed home to fetch some sulphuric ether: when I returned, she was in the same position as I had left her, but dead. She remained rigid for some hours.

I opened the body next day. There was a little thin fluid in the pleural cavities, but no adhesions. The lungs were inflated with air, and were not in the least congested; there was a slight frothy mucus in the larger bronchi, but no obstruction in any part of the respiratory channels. The heart was so con

tracted, that it had the appearance of a walnut, and it felt to the grasp as hard as a walnut. When it was laid open, its rigid contraction was still evident, but on immersion in warm water it relaxed. Its endocardial surface, prior to the relaxation, was approximated, so that really no cavities existed, so firm was the contraction. There was not a trace of blood in the organ; but the large veins leading into the auricle were full to distension. All other parts of the patient's body were normal except the kidneys, which were slightly marbled in appearance. The whole of the soft tissues were pale, from absence of blood.

In this illustration, the cardiac apnoea was due to tonic spasm of the heart.

In the year 1847, a boy, 12 years of age, residing in Saffron Walden, Essex, was induced by his comrades to take a lesson in smoking tobacco. He smoked two or three pipes, and then, to crown the mischief, put a portion of the weed into his mouth and