1313 with oxygen, owing to swelling, exudation, or other abnormality in or around the alveolar walls, preventing the diffusion of oxygen inwards quickly enough to saturate the blood in the limited time during which it passes through the alveolar capillaries. The swelling or shedding of the lining cells of the alveoli ' and the widespread interalveolar and interstitial heemorrhage seem quite sufficient to bring this about, and the capillary bleeding in the brain and other organs would further

more »

... vent the tissues from obtaining their requisite amount of oxygen from the already anoxsemic blood. The same process taking place in the kidneys, acting in the same way, would be a sufficient cause of the anuria or albuminuria described in many cases and attributed to the direct toxic action of the arsenic. The forced breathing, rapid, deep, and stertorous, which occurs in these patients would also tend to increase the degree of anoxEemia.5 ConCltfSion. . The conclusion arrived at is that the widespread capillary haemorrhages, demonstrated by microscopic sections, afford a clear anatomical basis for the hypothesis put forward by Surgeon Commander Dudley that the symptoms are due to anoxaemia, that this anoxaemic condition is mainly produced by interalveolar haemorrhage into the lungs, and to a less extent by interstitial capillary bleeding into other organs, and that the continuo2cs administration of oxygen as carried out by Surgeon Lieutenant Commander Parnell offers the best hope of recovery in these unfortunate cases. These appearances would also seem to explain in part the rapid development of the symptoms and the comparatively slow recovery, as instanced by Surgeon Lieutenant Commander Parnell's case, resulting from the continuous administration of oxygen. I wish to express my thanks to Surgeon Commander E. L. Atkinson for his kind assistance, especially in preparing the accompanying photomicrograph. TRAUMATIC rupture of the heart is generally due either to gunshot or to stab wounds. These being commonly received in front, one or other of the right chambers of the heart is the usual site of the rupture. Such ruptures, where not immediately fatal, offer a prognosis distinctly better than do spontaneous ruptures. The wound in the pericardium permits the escape of blood from that sac and so diminishes the risk of rapidly fatal embarrassment of the heart's action; the circumstances of the case, the site, and direction of the wound in the body wall make diagnosis less difficult and so facilitate treatment, and the patient and his heart tissue are often healthy. That such ruptures of the heart have been recovered from, with and without operative treatment, is familiar enough. The following case is of interest for two reasonsbecause of the nearly complete absence of skeletal and superficial injury following upon extreme violence and because of the unusual nature and circumstances of the heart's rupture. ' A well-built, healthy shipwright, aged 23 years, sustained a clean, unbroken fall of 45 feet, alighting on a wooden plank and some steel plates lying on the ground. The precise position of his body at the end of the fall was not known. He was not killed outright, but was dead on his arrival at hospital some 20 minutes later. On post-mortem examination of the body about six and a half hours after death rigor mortis had not begun. Preliminary inspection revealed no damage beyond a few scratches and bruising at the right elbow. A deliberate examination by inspection and palpation showed no further evidence of bruising, laceration, fracture, or dislocation. The peritoneal cavity contained about 2 to 3 pints of fluid blood, of which the source appeared to be five transverse lacerations of the right lobe of the liver-four on its upper, one on its under surface immediately to the right of the transverse fissure. There was a considerable quantity of blood effused into the retroperitoneal tissue. There were two transverse tears about half an inch apart on the front of the right kidney near its middle, one through little more than the capsule, and one about inch in depth through practically the entire width of the kidney. No other source of retroperitoneal haemorrhage was found. No other abdominal injury was discovered. ° I failed to identify the source of a moderate extravasation of blood into the cellular tissue of the posterior mediastinum. This blood extended to the back of the root of each lung underneath the pleura, but not into the substance of either lung, which, indeed, appeared to be normal throughout. The pericardium was intact and contained about a pint and a half of fluid blood. After considerable search a slit-like opening into the cavity of the left auricle was found, about a quarter of a centimetre in length, and situated exactly in the length of the free edge of the left auricular appendage. Professor S. G. Shattock kindly made a microscopical examination of the appendage wall, and reports that there is no trace of any form of disease. Remarks on the Case. The height above the ground of the planks from which deceased fell was 45 ft., and the fall was unbroken. The injuries were thus caused by the violent impact of the body against the plank and plates on the ground. The visceral injuries, and particularly the fact that the ruptures in the liver and right kidney were transverse in direction, suggest antero-posterior compression of the trunk, and the complete absence of bruising of the body wall is remarkable. It would seem on first thought almost incredible that such a fall should occasion no injuries other than visceral. It is probable, however, that such cases are not so very uncommon, and it is therefore important that they should be recorded, as the question is one of considerable legal importance. In this case the nature and accompanying conditions of the cardiac rupture raise questions as to the mode of its production. Cases of cardiac rupture are commonly divided into two classes, spontaneous and traumatic. The former occur from within because a local weakness of the heart's wall renders it there unable to withstand the pressure of the contained blood. Such local weakness is most commonly the result of disease, and its favourite seat is the left ventricle.