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ing, however, were rather increased than otherwise. The pulse was fuller, and resisting—sixteen ounces of blood, taken from the arm, produced some relief. The breathing became more free. This treatment was directed, not only with the view of improving the secretions of the liver, but of relieving any congested state of that viscus.
The alteration for the better was of short duration. The pain of liver, the difficult and painful respiration, returned with increased violence, while paroxysms of cough followed each other in rapid succession. Pulse 98, of large volume, but readily yielding to pressure; a thick brown coating on the tongue; heat of surface moderate ; bowels acting freely ; motions fætid, of a dark colour; urine plentiful and light. He continued to refer the pain to the liver. Pressing that organ against the diaphragm, caused more acute pain than pressure exercised in any other direction.
The fætor of breath increased. This, though so distressing to him, is not perceptible by myself. The horizontal posture is now attended by a sense of suffocation.
Blood was again drawn from the arm, and as the difficulty of breathing was thereby but little relieved, 24 leeches were applied over the right hypochondrium. The quantity of blood lost by this mode was so trifling, that a further abstraction of blood by cupping was thought advisable. He could now bear much greater pressure, but the cough and dyspnea remained unaltered.
Calomel, squills and the tartrate of antimony were given in small but repeated doses, and a blister was placed over the region of the liver.
The cough and dyspnea continued increasing in severity, and the only position in which he could remain with anything like ease, was leaning forwards, holding both knees.
In consequence of the alarming state of the patient, I requested Dr. Peile, deputy inspectorgeneral, to see him, who, from the nature of the symptoms, suspected that effusion had taken place, causing, by the gravitation of the fluid, that distressing sense of suffocation which invariably occurred in lying down.
Percussion elicited no morbid sound, and auscultation proved the lungs on both sides to be in a healthy condition, as also the heart.
The patient on this occasion stated, that about three weeks prior to his illness he had partaken of a pear, and while part of it was passing down the cesophagus, he experienced a sense of soreness, and thought it remained in his chest.
He pointed to a spot, a short distance below the clavicle, and a little to the left of the sternum. He added, that from that day up to the present, whatever he has swallowed, liquid or solid, appears to him not to pass beyond that spot.
It was soon after the above event that he first noticed the fætor of his breath, which he represents, at times, as most intolerable.
The active treatment which had been pursued
failed in alleviating the symptoms. The cough not only became more frequent, but the paroxysms of longer duration ; the dyspnea, on resuming the recumbent posture, more alarming, added to which, the patient now complained, at intervals, of a sense of syncope.
The system was, at this time, under the influence of mercury. At this period of the case, (October 8th,) Dr. Wm. Stokes was called in, and this gentleman, after a most careful examination of the chest, pronounced the lungs and heart to be healthy.
He considered the disease as depending chiefly upon nervous and spasmodic irritation of the respiratory organs, and advised expectorants and sedatives. Up to this period the cough had been hard and almost unattended by expectoration, which, however, became shortly afterwards abundant, and consisted chiefly of glairy viscid mucus.
Soon after the first interview with Dr. Stokes, the breathing became stridulous, the cough laryngeal, succeeding, in paroxysms, each full inspiration. The patient was unable to remain, even for the shortest time, in the horizontal position, without a most distressing sense of choking.
There was the same, or even increased fotor of the breath. Notwithstanding these urgent symptoms, there was but little acceleration in the pulse or alteration in the temperature of the body. The urine was copious and natural, and the bowels free. Between the thyroid and cricoid cartilages the air passed as if over a roughened surface. The sound
on percussion over the larynx was remarkably dull. The voice at intervals was somewhat hoarse. No indication of disease existed in the lungs, or morbid appearances on inspecting the pharynx. On the 11th October it was suspected that laryngitis had set in. The treatment now consisted in the external application of leeches and extract of belladonna, also calomel, tartar emetic and sedatives taken internally.
No relief followed. On the contrary, the symptoms augmented in violence. Having passed a most distressing night, he was seized on the morning of the 18th October with a severe fit of coughing, which was at length subdued by help of an anodyne mixture ; soon after taking which, he fell into a disturbed sleep.
At this period I was summoned to see the patient.
I found the stridulous breathing replaced by mucous rále ; a total absence of vesicular expansion in the right side, and so obscured in the left, as scarcely to be heard. He was comatose, and in about half an hour after my arrival, after a deep inspiration, he suddenly expired.
Six weeks had elapsed since the commencement of the illness.
Post-mortem Examination thirty hours after death. -Little or no rigidity of the limbs ; the muscles well developed and adipose tissue very abundant.
A small inguinal hernia of the left side, which first became apparent about four years ago.
The removal of the sternum was difficult, in consequence of the ossification of the cartilages of the ribs. The right lung was a little gorged with blood and rather dark-coloured, but it was free from adhesions, and in other respects perfectly healthy. On raising it and dividing its attachments, the knife suddenly entered a cavity, of the size of a pullet's egg, from which a most offensive odour was emitted. This cavity was formed by an abscess in a mass of enlarged bronchial glands, situated at the bifurcation of the trachea. It opened into the right bronchus, ulceration having destroyed a large portion of that tube. The inferior margin of the ulcerated opening was thickened and elevated: on the other side, the abscess communicated with the left bronchus, by an aperture of about half an inch in diameter, having inverted and thickened edges. Posteriorly, the abscess had made its way into the oesophagus by ulceration. The opening into that canal was capable of admitting a large-sized bougie. The abscess contained a quantity of calcareous matter, some very hard, some of a soft consistence. The whole, when first examined, was of a dark melanotic aspect. A triangular portion of the hard calculous matter had firmly wedged itself into the aperture communicating with the right bronchus.
The mucous membrane in both tubes (above the ulceration) was marked by a deep blush, which extended nearly as high as the thyroid cartilage. A small ulcer was discovered towards the inner edge