erately filled, and compressible. The pulse averages 80 to 90 per minute when the patient is at rest; but it mounts to 112 on her rising from bed, and the respirations increase from 22 to 36, accompanied with marked vertigo.

The finger and toe nails are bluish and tranversely curved. The subjective symptoms, already detailed, led to an examination of the thorax, and on inspection of the cardiac area the left ventricle was seen to tilt up in a perpendicular direction, the part of the mamma overlying the third and fourth ribs, and slightly to the right of the left nipple. Above this diffuse apex-beat, the pulsation of the pulmonary artery between the cartilages of the second and third ribs was recognized by its rhythm, its superficial character, and the snap of its valves. On a deep inspiration the pulmonary artery was covered, and an impulse existing under the left clavicle also disappeared, disproving the existence of much retraction of the left lung.

Underneath the left clavicle, over the sternal ends of the first and second ribs, there is a third impulse, which is mainly seen during expiration, is weaker than the ventricular systole, and occurs after it. This region is rather depressed than prominent, and on palpation a thrill, which is exceedingly intense and superficial, is felt spreading from the left border of the sternum towards the left shoulder. Dulness on percussion is made out over this thrill for 3 inches transversely, and 2 perpendicularly; then opposite the second intercostal spaces it only measures 12 inches, but over the fourth rib the cardiac dulness expands to 4 inches, and nowhere exceeds 4 inches. (See diagram).

When auscultating over any part of the chest anteriorly, and at the back especially above the upper border of the left scapula and down the left side of the spine, a loud blowing murmur is audible, occupying and following the first cardiac sound, and having its maximum intensity over the seat of the thrill-viz., the first left intercostal space, where also a reduplication of the second sound is distinguished; the latter (pulmonic) being more "clicking" than the former (aortic); moreover, the murmur appears to be influenced by the respiratory act, becoming more prolonged, louder, and higher pitched on inspiration, and the reverse on expiration.

This bruit, although well heard in the mitral area, has not the distribution of a murmur of this origin, but rather that of one arising from aortic obstruction, and it can be traced into the carotids, &c.; and is even heard very distinctly over the tip of the left olecranon.

On examining the heart, the left apex-beat is distinctly felt between the third and fourth ribs, slightly to the right of the nipple, and percussion corroborates that the left ventricle does not descend much below the fourth rib. The right ventricle appears to be the larger of the two, but its systole does not yield any definite impulse. The second sound in the cardiac area cannot be said to be accentuated. There is very marked pulsation in the episternal notch and in the carotids, and an upward wave is discernible in the external jugular veins.

Diagram (outlines reduced from the frontispiece in Dr. Balfour's work), showing the relative positions in the thorax of the aneurism, the heart, and the liver.

T-Corresponds to area of thrill, maximum intensity of ventricularsystolic murmur, and a pulsation only seen on expiration. D-Upper seat of dulness.

P-Pulmonic pulsation, and where the snap is felt from closure of the valves.

A-Diffusion of impulse from left ventricle.

L-Exact position of the liver.

The respiratory sounds are obscured by the cardiac, and beyond slight tubularity anteriorly over the left apex, and faint crepitus on inspiration (not constant) posteriorly above the scapula, nothing abnormal is noted. She has a frequent tendency to cough, with little expectoration, and the mere act causes a good deal of pain over the heart, and great exhaustion. The patient states she has had two or three slight attacks of hæmoptysis. No laryngeal symptoms exist. Swallowing is not interfered with, but the presence of much food in the stomach causes angina-like symptoms, and, consequently, she restricts the amount of her diet. Defæcation is regular, and an examination of the urine pointed only to a hysterical temperament.

The determination of the upper border of the liver strengthens my opinion that the heart is situated in the thorax above its ordinary position. Thus, in the line of the right nipple, the hepatic dulness reaches to the middle of the fourth rib, and its lower border descends to the eighth (see diagram), measuring fully 4 inches perpendicularly.

Menstruation is regular, but too continued and profuse, necessitating the giving of ergot. I never examined the uterus, as any preparation for such an inquiry brought on an hysterical seizure.

Remarks. The diagnosis in this case-viz., that the pulmonary artery is implicated and communicates with the aorta through the ductus arteriosus, must be inferential, and based partly on negative signs. The age and sex of the patient; the position and size of the left ventricle; the fact of the murmur having the distribution of one of aortic origin (obstruction), and also being so markedly influenced when the blood rushes to fill the branches of the pulmonary artery; all lead me to attribute the lesion to a congenital defect, and if so, then primarily pulmonary, rather than aortic; and likewise militate against the supposition that the aorta is alone enlarged. Still, if the symptoms are dependent on a congenital condition, why have they been so long in abeyance, and how is cyanosis absent? The ductus arteriosus may have been patent always to a slight extent, but made more so by the sudden strain thrown on the pulmonary artery when the patient was submerged, to which occurrence she ascribes her present sufferings. We have seen lately how a segment of the aortic valves was apparently torn during muscular exertion and intense excitement (Heart, &c., shown by Dr. Finlayson at the Glasgow Pathological and Clinical Society. See this Journal for July, p. 63). Cyanosis is not always present when congenital

defects exist, and must depend upon the direction, &c., of the blood currents.

This patient has been known to Dr. George W. Balfour, of Edinburgh, for some time, and he wrote to me that a careful examination of all the facts led me (Dr. B.) to conclude that there was in her case an aneurism of the ductus arteriosus. I had no sooner arrived at this conclusion than, after finding very little to confirm me in the older literature, I fell upon a case with very similar symptoins with p. m. and pictures of the parts in a German Journal." Dr. Balfour had also a corresponding case, in which the late Dr. Begbie and himself arrived independently at the same conclusion.

A FATAL CASE OF RHEUMATIC FEVER.

By JAMES J. B. TAYLOR, M.B., Ulverston, Lancashire. It is often as instructive to detail the history of a case which we have failed to cure, as to report one in which we flatter ourselves that by our superior skill a recovery has been wrought.

To the list of uncured cases, I beg to add the following:

January 18th, 1879.-Was called to see Mrs. M., aged 37, mother of five children, in comfortable circumstances. She has always been healthy, and the family history is free from hereditary disease. A week ago she walked 4 miles in the snow, and got very wet and chilled about the lower extremities. I found her suffering from a smart attack of rheumatic feverthe right shoulder, elbow and wrist joints, both knee joints, and both ankle joints being acutely inflamed. Temp. 103°. Pulse 120. Heart normal.

Ordered full doses of salicine, warm applications to joints, milk and beef-tea diet.

19th. About same as yesterday.

20th. The other elbow joint affected; fever higher; very restless and fretful.

21st. Much the same as yesterday. Medicine still continued.

22nd, Morning-Has had a bad night; frequently wanders in her talk; all joints still inflamed as ever; very excitable and fearful of coming danger. Examined her chest very completely, but found nothing wrong. To have a dose of castor oil, and continue medicine.

Evening.-Much worse; temp. 104°, pulse 130; wild delirium; great pain in back of head; some sickness; pupils contracted and sluggish; twitching of facial muscles, and starting of limbs (meningitis diagnosed); heart sounds and respiration normal. Ordered 12 leeches to temples, blister to nape of neck, and to take full doses of iodide of potassium and tr. digitalis.

23rd, Morning.-During first part of night had much improved, but at hour of my visit was very bad again. I was surprised to find that the articular affection had almost subsided: all the affected joints could be moved and touched without much pain, and there was but little redness or swelling left. Delirium not so wild, nor twitching of face and limbs so bad. Temp. 104. Pulse 130. Respiration 50. Observing the hurried respiration, which was shallow and accompanied by a short dry purposeless cough, I again examined her chest and found a distinct friction rub over left side (pleurisy diagnosed.) Heart sounds natural. Ordered blister over left side, followed by warm poultice, and to continue medicine.

Evening. No better; respiration 50; friction sound extended; delirium still persisting; bowels acted slightly; joints nearly free of inflammation; patient very restless. To have half drachm dose of bromide of potassium with each dose of medicine.

24th, Morning-Has had a very bad night, but more tranquil this morning. Joints apparently well; delirium of a low muttering kind; twitching of face more marked; a tendency to drowsiness. Friction sound over left pleura extended, and a well marked see saw cardiac murmur can now be heard (pericarditis diagnosed.) Temp. 105°. Pulse 140. Respiration 60. Ordered blister over heart, to be followed by hot poultices.

Noon. Her mother said she fell asleep soon after my morning visit and they had not dared to wake her. I found she was in a semi-comatose state, out of which we could rouse her when she would swallow whatever was given to her and immediately relapse into the same state; pupils still sensitive to light. Ordered 2 drops of croton oil.

4 P.M.-Croton oil acted well; coma more profound; pupils hardly sensitive to light; temperature and pulse rising.

10 P.M.-Temp. 107°. Friction sound over heart very loud and distinct; coma profound; cannot rouse her; pupils fixed; urine passed involuntarily; evidently sinking.

25th.-Died at noon to-day.

Remarks.-1. It is not at all uncommon to have a meningeal,