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cleansed, and occasionally removed for the purpose. Owing tothis, in the afternoon an attempt was made by the house-surgeon to introduce a new tube; but some difficulty beingexperienced, as well as on account of the difficulty of breathing,the opening was slightly enlarged. There was a good deal ofbleeding, and some of the blood must have trickled into thetrachea. The child soon afterwards died.The incision had divided the crico-thyroid membrane, the

cricoid cartilage, the two upper rings of the trachea, and theisthmus of the thyroid. The soft palate and tonsils were foundulcerated, and the latter covered with a thick layer of recentlymph. The mucous lining of the epiglottis and of the larynxwas throughout covered with a similarly very thick layer offalse membrane, and the aryteno-epiglottidean folds were quitecedematous. The lining membrane of the trachea was coveredwith a thin layer of false membrane, mixed up with muchtenacious mucus and blood, which stained the membrane of ared colour; and in the larger bronchial tubes a similar appear-ance was found, but this existed to a much less extent. The

lungs were very congested, and the smaller bronchial tubescontained much blood mixed with thick tenacious mucus. Theheart was healthy.SYPHILITIC ULCERATION OF THE LARYNX, PRODUCING URGENT

DYSPNŒA AND THREATENING SUFFOCATION, THE PATIENTBEING AT THE FULL PERIOD OF PREGNANCY; TRACHEOTOMY;DELIVERY THE SAME NIGHT WITHOUT INCONVENIENCE; COM-PLETE RECOVERY.

(Under the care of Mr. POLLOCK.)This case forms a, striking contrast to the preceding one, in

that the difficulty of breathing depended upon a totally differentcause, in the person of an elderly female.The interesting points worthy of mention are, the syphilitic

origin of the obstruction to respiration, the temporary relief ofthe opening in the larynx, the radical improvement during itsexistence from the treatment constitutionally, also the fact ofthe mother being taken in labour, and wearing the tube duringthe progress of the birth. The undoubtable syphilitic condi-tion of the mother not giving evidence of disease in the childuntil some weeks after its birth, might open the questionwhether the milk of the mother did not influence the conditionof the infant already infected by the poisoned blood of themother.The first case is interesting as a contrast to the present, as

the operation, though highly beneficial at the time, and cer-tainly having prolonged life, is not by any means so uniformlyor generally effective as when had recourse to in the morechronic affections of the trachea and larynx.

Elizabeth M-, aged thirty-six, was admitted on January21st, 1856, with cough, huskiness of voice, and much expec-toration. Under treatment she did not improve, but the huski-ness of voice increased, and with it some increasing obstructionto respiration was evidently taking place. On the morning ofthe 23rd of February this difficulty was almost complete; ahecould not lie or sit down, and was struggling for breath,standing up and supported on each side by a nurse, her facebeing very dusky, and her distress of countenance most acute.Mr. Pollock was requested to see her, and immediately pro-ceeded to open the larynx. This was only effected after muchtrouble, in consequence of the bleeding from some large andmuch congested veins and the restlessness of the patient.Great relief was afforded immediately the opening was madeinto the larynx, and the countenance soon recovered a com-posed and natural aspect. The patient was near the period ofher confinement, and in the evening labour came on, and shewas delivered safely the same night, without any inconveniencefrom the presence of the tube in the trachea.The cause of the difficulty in respiration appeared to be from

old syphilitic affection of the larynx, a rupial sore being ob-served on the left arm, which she stated had lately made itsappearance. She was placed under treatment with sarsaparillaand iodide of potassium, and gradually improved without anybad symptoms. After wearing the tube over seven weeks, shefound she could breathe without its being any longer kept in,and the opening in the larynx was allowed to heal by the tubebeing withdrawn. She has quite recovered her health, and,though her voice is still rather husky, she speaks withoutdifficulty, and her respiration is quite free at this date, the 7thof June.The infant, though not born with any appearance of secon-

dary eruption, some few weeks after birth was found affectedwith an unequivocal eruption of a syphilitic character, and hasbeen under treatment since for this.

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CHARING-CROSS HOSPITAL.ALBUMINURIA AND PURPURA; AMMONIACAL ODOUR OF THE

BREATH, AND DETECTION OF THE CARBONATE OF AMMONIA.

(Under the care of Dr. WILLSHIRE.)THE attention of the students and ourselves has been drawn

by Dr. Willshire to some points of interest in a case transferredto* him by Mr. Hancock, under whose care the girl had pre.viously been for an affection of the eyes. We prefix the fol.lowing history of the patient by Mr. Dickin, clinical clerk :-Martha G-, fourteen years old, states that six months

ago she had a violent cold, attended with rheumatism and in-flammation of her eyes. The latter left her blind. She wentto the Ophthalmic Hospital, where she has been under treat.ment. A fortnight hack she had an attack of acute rheumatismin her left knee, which confined her in bed for a week, but atpresent she has no pain there. A week after she had severedarting pains in her feet and legs, which became so tender andswollen that she could not bear her stockings on. Last Sundaymorning she observed that her feet and legs were covered withred spots, and felt and continue to feel very cold and painfulabout the ankles when moved or touched. Almost as long asshe can remember she has been subject to bleeding from thenose, scarcely a week passing but that she so bled, and withinthe last fortnight she has lost blood nearly every day. Thebleeding comes on without any particular excitement, oftenwhen she is sitting quiet; the blood comes drop by drop, con-tinues for about ten minutes, and then leaves off, though noremedy is resorted to. She has never bled from any otherpart, though she has heard her mother say she bled very muchwhen she had a tooth out, and once or twice lately her urinehas been "terrible red." She has never been "regular," norhas she had scarlet-fever. She has been taking turpentinelately by order of Mr. Hancock. The bowels are rather con-fined. On examining the patient, it is seen that both legs andfeet have a purple, leaden look, are very cedematous, (parti-cularly the left;) the purpuratic spots extend all up her legs,and are very thick here and there. She has some on the trunk,but more on her arms. Some of the spots are very minute,others as large as a "sixpence." Her gums are not spongy,nor is there bleeding nor exudation from the lining membraneof the mouth. The tongue is furred. On Dr. Willshire re-marking that her breath had a peculiar odour, something likean urinous or ammoniacal one, she replied that her breathseemed like pepper" to her. On holding a glass rod dippedin strong hydrochloric acid before her mouth as she breathed,cloudy fumes of hydrochlorate of ammonia became distinctlyvisible; reddened litmus-paper held in the same way had itsblue colour restored, which was again reddened when held tothe fire, proving the alkaline reaction to have been due toammonia. The urine is 1 ’020 specific gravity, and in quantityabout a pint in twenty-four hours; it has a marked acid reac-tion, and affords a copious deposit from heat and nitric acid.There appear no blood-globules in it, but some waxy or grann-lated moulds of the "tubuli" are believed to be seen. The

general aspect of the patient is pale and anaemic, and there isvery slight cedema of the face. The pulse is 100. There is adistinct systolic bruit at the base of the heart, somewhat modi-fied half way (along the course of the heart’s long axis) betweenthe base and apex. At the latter the cardiac sounds are clearand distinct, but a doubtfuL systolic bruit is also heard there.There is much opacity of the corneae, the result of the inflam-mation before alluded to. Ordered to have full diet, withbeer, and as much fresh vegetable matter as she chooses, andthe following medicine three times a day:-Muriated tinctureof iron, fifteen minims; dilute hydrochloric acid, ten minims;infusion of cinchona, an ounce and a half; besides a scruple ofthe bitartrate of potass every night. Cathartic house medicinewhen required.

In some clinical observations to the students, Dr. Willshireremarked that this case presented some points worthy of muchconsideration. In the first place, it confirmed an observationof Huxham and other old writers, since denied by others, thatin what they called " a dissolved and putrid condition of theblood," the breath had a nasty or urinous odour. Secondly, itcorroborated the far more recent assertion of Frerichs, that incertain forms and stages of albuminuria, carbonate of ammonia,a resultant of the decomposition of urea, is contained in theexpired breath of the patient. Latterly, too, Drs. M’Doweland Lees had brought forward the idea that u2-ect, or themuriate or carbonate of ammonia, is eliminated by the gastj.Ú;mucous membrane, giving rise to the vomiting in Bright’sdisease and in cholera. An important question, also, was thatof the connexion of cause and effect between the phenomena,