No. 959.

LONDON, SATURDAY, JANUARY 15, 1842. [1841-42.

CLINICAL LECTURE,DELIVERED AT

UNIVERSITY COLLEGE HOSPITAL,BY

DR. TAYLOR,Physician to the Hospital, and Professor ofClinical Medicine in University College.

MORBUS CORDIS. Chronic bronchitis; aedema z

of the legs; cirrosis of the liver, with as- ,

cites; death, and post-mortem appearances.-CLINICAL REMARKS. Diagnosis of theeirrosis ; disease of the heart, and two kindsof dropsy.-CAUsEs of the heart-disease ;its insidious mode of attack; importance ofhaving recourse to auscultation in all cases;causes of the bronchitis and dropsy.-TREATMENT. Comparative effects of diure-tics and hydragogue cathartics.-MoRBIDAPPEARANCES. Mode of development of theseveral morbid changes in the heart wantof correspondence between the extent of dis-ease and the signs during life; explanationof this anatomical characters of bronchitis;carnification of the lung, its character andmode of production; disease of the stomach;mechanical congestion in the intestines ;g ranutar disease of the kidneys ; urine gene-rally fl’ee from albumen serous effusion inhead, and paleness of b7,ain consequentupon it.

EDWARD DiKGLEY, aged 53, was admittedAugust 10, 1841, under Dr. Taylor; mar-

ried, a coachman, of intemperate habits upto within the last few years, during which’he says that he has been temperate. He hashad several attacks of rheumatism ; has acough generally during the winter; neverhad jaundice, or has been subject to biliousattacks. He has suffered from palpitationand shortness of breath on any exertion forthree or four years, and has frequently hadsevere pain at the lower part of the sternum;shooting towards the scapula on each side,and as far as the upper part of humerus onthe left side, but it never extended fartherdown the arm ; he has occasionally hadpains in both hypochondria; can lie on either

side, but not so well on the right as on theleft, on account of a pricking pain in the leftside, about the lower margin of the ribs,when he lies on the right. He never feltpain or a dragging sensation in the right sidewhen lying on the left. He has been latelya good deal exposed to the weather duringthe night, but has not been drinking. Aboutthree weeks ago he began to feel very poorlyall over him, and had great increase of thedyspnoea and palpitation ; he coughed a gooddeal, and expectorated moderately, and hisfeet and ankles began to swell. Four orfive days after this he found that his abdo-men was getting large also, and the dyspnoeasoon afterwards almost amounted to orthop-noea ; he never had had dropsy before.

Present Symptoms.-He complains of greatweakness, of palpitation and dyspnoea onthe least exertion ; lie has no constant painin the chest, but occasionally pain at thelower part of the sternum shooting throughto the shoulders ; he has little cough, andscarcely any expectoration ; he complains ofpain and tenderness over the abdomen, whichis tumid, and presents a distinct fluctuation ;both legs are oedematous, and pit on pres-sure nearly as far as the knees, but the thighsand scrotum are unaffected ; his feet are

cold, but the temperature of the rest of thebody is natural; his tongue is slightly furred,appetite good, bowels regular; the urine,which is slightly coagulated by heat andnitric acid, is passed freely, and in sufficientquantity ; he has no pain in the loins. To becupped between the shoulders to ten ounces :take three grains of calomel directly, and insix hours an aperient draught. To be placedon middle dipt-

12. Dyspnoea better since the cupping, buthe is still obliged to be supported in the semi-erect position in bed ; bowels freely opened.His urine was again tested this morning ;not coagulable by heat or nitric acid.

Physical Signs.-There is abundance ofsonorous and sibilant rhonchi heard all overthe chest, more especially on the right side,but no mucous or crepitant rhonchus, nordulness on percussion. The heart’s action isvery irregular, the impulse is rather too

strong, and felt over too large a surface ; andthere is a prolonged, but not very loud, nwr-

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mur, with the first sound, heard distinctly at murmur with the first sound of the heart isthe apex, also at the base. To have twelve still heard at the apex and base ; tongue stillminims of tincture of foxglove, two scruples furred ; and he complains of distention andof acetate of potash, three grains of iodide of flatulence after his meals. The pills still

potassium, and an ounce and a half of mint- cause nausea, anorexia, and frequent co-water, every six hours. The next day, twenty pious watery evacuations.minims of tincture of henbane were added to 28. The pills do not purge him quite soeach dose. violently as before, but still cause great

14. Sleeps badly during the night, being nausea. The oedema has quite disappeared,much troubled by the palpitation and dys- and the remains of the ascites are daily di-pnoea ; the cough is also more troublesome ; minishing. Take the elaterium twice a-dayhe has great oppression and a feeling of ex- only.treme distention of the stomach after meals. 31. Dropsical symptoms gradually dimi-He has still considerable tenderness over the nishing. The pills still cause from six to

abdomen, but not more in the hepatic region twelve watery stools per diem.than elsewhere. The margin of the liver can Sept. 2. Has headach, but no feeling ofbe felt below the ribs, and is indurated ; but tension after his meals. Let the pill be takenthe extent of dulness on percussion in the only every other day.hepatic region is rather less than usual. He 6. Somewhat improved.passes rather more urine since he commenced 8. Some little increase of the ascites ;the diuretic mixture. Bowels open, stools some oedema of the ankles. Take, the pillnatural in colour. There does not appear to again every day.be any diminution of the ascites or oedema of 10. The pills puyge him briskly; heart’sthe limbs as yet. Pulse 90, intermittent oc- action still irregular, but the murmur is notcasionally, and irregular in force and fre- heard more distinctly ; pulse intermittent,andquency. Let a blister be applied to the irregular in force and frequency.sternum. 13. Ascites diminishing ; oedema gone.

17. His urine was tested to-day, but no 20. There is still tension and enlargementtraces of albumen were obtained by heat or of the abdomen ; no perceptible fluctuation,nitric acid. Palpitations and dyspnoea still nor dulness on percussion at the lower part;very troublesome ; his abdomen is larger some shortness of breathing, little cough,than at last report, and presents a distinct and no expectoration; free from oedema offluctuation, with extensive dulness on per- the legs during the day ; at night there iscussion ; feet and legs are much swollen, and some return of it. He has frequent palpita-pit strongly on pressure; his thighs are not tions, and complains of throbbing of the arte-at all affected; he complains much of pain ries in the neck, which may be distinctlyand a feeling of tension in the abdomen ; a seen to pulsate. Sleeps well at night, ex-turgescence of the veins at the lower part of cept when the palpitation and dyspnoeathe neck is observed during expiration ; come on severely; he is then unable tobowels regular. Omit the diuretic mixture. breathe, unless he sits up in bed ; he occa-To take one-eighth of a grain of elaterium, sionally complains of a dull heavy pain inthree times a-day, in a pill. the fore and upper parts of his head, of

19. The elaterium has caused frequent weight and distention in the region of thecopious, watery stools, and the pain and stomach after his meals ; there is a frequenttension of the abdomen are already much pricking pain in the right hypochondrium;relieved. there is also tenderness on pressure in the

20. Feels very sick during the action of region of the liver, especially at one spot,the elaterium, which still causes frequent three or four inches to the right of the centrewatery evacuations. The oedema of the legs of the epigastrium ; pulse 90, very irregular;and the ascites are diminishing, tongue clean; bowels opened four or five

23. The pills cause great nausea and ano- times a-day by the pills, which frequentlyrexia; he is much and frequently purged; cause a great deal of twisting about the um-stools light coloured, and very watery ; bilicus, and more or less nausea. His stoolsoedema and ascites much diminished ; he are now, and frequently have been, of a palehas much less dyspnoea, but still complains drab colour; makes water freely; heart’svery much of the palpitation ; heart’s action action still irregular; murmur with the firststill very irregular; tongue still much furred. sound still heard both at the base and apex,

26. Complains very much of the action of but more distinctly at the latter. There is athe pills, which still produce frequent pur- degree of roughness in the respiratoryging and vomiting. The oedema has almost sounds heard over the chest, both in frontentirely disappeared, and the ascites is very and behind, which is probably the remainsmuch diminished; he has less dyspnoea, and of the sonorous rhonchus previously heard ;much less of the sonorous and sibilant less dulness on percussion in the hepaticrhonchi are heard in the chest ; he still has region than natural; dulness in region ofa little cough, but scarcely any expectora- spleen rather too extended.tion ; he sleeps much better during the 24. There is much increase of the dys.night ; still suffers from palpitation, and the pnoea and palpitation; more sibilant and

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sonorous rhonchi, particularly on the rightside of the chest; no increase of cough;expectoration brownish-yellow, scanty, semi-transparent, and very glutinous. To be

cupped on the right side to ten ounces.27. A little easier from the cupping; I

still complains of cough, palpitation, anddyspnoea.

30. Bronchitis increased. There is nowa loud, rough, sonorous rhonchus heard andfelt extensively over the chest, especially onthe left side. One-fourth of a grain oftartar-emetic in an ounce and a half of cam-

phor mixture three times a-day. To be

cupped between the shoulders to ten ounces.Oct. 1. Altogether better.8. Has improved since last report. He

has now less cough ; sputa scanty, semi-transparent, viscid, and brownish ; slightsonorous rhonchus at the posterior part of theleft lung ; some sonorous and sibilant rhonchiat the posterior part of the right lung ; sono-rous rhonchus in front on the left side ; vesi-cular murmur slightly impaired on both

sides ; heart’s action very irregular, impulsetoo strong, slight murmur with the firstsound. Omit the tartar-emetic, and take

one-eighth of a gran of elaterium everyday.

15. Considerably improved ; very littleoedema of the legs ; abdominal swellingnearly gone; no distinct fluctuation.

18. Feels difficulty in breathing to-day;no increase in bronchitis ; heart’s actionquick and irregular. To take the followingdraught every six hours :-Twelve minimsof tincture of foxglove, twenty minims oftincture of squills, two scruples of the acetateof potash, a drachm of spirits of nitre, andan ounce and a half of camphor mixture.

20. Breathing better in the day, but as

bad as usual at night.22. Abdomen larger; distinct fluctuation.

To have the elaterium twice a-day. 13y ythis he was much purged ; the fluctuationand swelling became less ; and he was dis-charged relieved on the 9th of November.

This patient was readmitted on the 15thof November, having been out of the hos-pital only a week. He remained well forthree or four days, but on Friday last hewent out of doors, and caught cold. Diffi-culty of breathing supervened; his le·ga be-came oedematous, and his abdomen againincreased in size. He was seen on his ad-mission on Monday by Mr. Quain, whoordered him a blister to the back of the chest,and to take the following medicine:-Oneounce of the decoction of senega and half adrachm of ipecacuanha every six hours, andeight grains of compound extract of colo-cynth and four of calomel directly.

17. Difliculty of breathing still continues ;the external ugiitar vein is very much en-larged ; the arteries of the neck pulsatestrongly, but there is no marked murmur inthe neck. Omit the mixture, and give him

half a grain of tartar-emetic in an ounce anda half of camphor mixture every six hours.To be cupped beneath the scapula to tenounces.

19. He complains that the medicine makeshim sick ; fluctuation very perceptible in theabdomen; cough less; there is abundantsonorous rhonchus in the front of the chest,and sonorous and mucous rhonchi behind ;pulse small and weak; countenance livid ;he had a little sleep in the night; the expres-sion of his countenance is rather stupid andunmeaning; he has vomited five or six timesthis morning; there is a loud murmur in theneck, the impulse more distinct there thanat the base of the heart; there is a murmurwith the first sound at the apex ; the jugularvein is greatly distended. Diminish the doseof antimony to a quarter of a grain. He gotworse, and died in the evening.

After-death Appearances.The body was examined seventeen hours

after death.

External Appearances.-Lips very livid ;external jugular vein much distended; gene-ral venous congestion of the back parts ofthe body; abdomen a little tumid; liver

projects beyond the ribs from two to three

inches, but the dull sound which it yieldson percussion ceases three inches below thenipple, the anterior border of it feels harderthan usual; no oedema of the thighs or legs.

Chest.-Lungs did not collapse on raisingthe sternum and ribs, and they were of a! dark-grey colour.

Right Lunb .-No adhesions of the pleura;the anterior edges emphysematous, as wellas the summit ; bronchial tubes contain agood deal of frothy mucus tinged with blood.The mucous membrane in the large divisions

is redder than usual, and than the subjacenttissue. but its thickness and consistence seem

unchanged ; in the small branches its colouris pale, and not otherwise altered; no dila-tation of the tubes in any part ; the substanceof the back part of the lung, especially inthe lower lobe, denser than usual, and insome parts not at all crepitant; its colour

deep red ; its consistence firm, but alsorather tough, the finger being pushed intoit with considerable difficulty, except in oneor two points, it seems to pit a little on

moderately firm pressure; portions cut offseveral parts which seemed most densefloated in water, some, however, less per-fectly than others. A moderate quantity offrothy serum exuded from the cut surfaces.The cut surfaces presented a number of blackspots, about a line in diameter, and resem-bling points of haemorrhage ; they were seenin all parts of the lung, but in much greaterabundance in the posterior than the anteriorparts ; the external surface of the lung wasmottled with the dark spots often seenthere.

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Left Lung.-No adhesion of the pleura ;much less density of the posterior portions ;no emphysema observed ; bronchial tubessame as in right lung; the biack spots abovealluded to more numerous, and larger in thisthan in the right lung; more abundant inthe back parts than towards the front, andmost in the lower lobe where they stronglyresemble spots of haemorrhage.Heart.-No effusion into the pericardium ;

heart much enlarged. Left ventricle. Cavitymuch enlarged ; endocardium opake, andthickened to a considerable extent in the

body of the ventricle next the aortic valves ;aortic valves tested by water before opening ,,

the ventricle; they admitted the fluid to

pass gradually, but not suddenly, into theventricle; aortic valves much thickened;their adjacent margins adherent by old falsemembranes ; their volume contracted both indepth and breadth. Mitral valve. Laminaemuch thickened, and somewhat Duckered. aswell as the cordae tendinse ; orifice contracted Bso as to admit (from the auricle) one finger Ifreely, or the points of two ; the margin of itindurated ; left auricle very much dilated,perhaps to nearly double its natural size ;walls fully as thick as in health ; foramenovale closed. Right ventricle. Walls thick-ened ; cavity dilated; sigmoid and tricuspidvalves healthy, except that the opening ofthe latter was considerably dilated, so as toadmit four fingers readily side by side ;right auricle much dilated, and walls thick-ened.

Blood.-Auricles contained a large quan-tity of imperfectly coagulated blood; rightventricle, a small coagulum, its upper partfibrinous, its lower black ; thoracic aortafilled with black fluid blood.Abdomen.-Peritoneum contained several

pints of clear yellow serum. Liver. Itsbulk appeared distinctly diminished, but itwas not much altered in shape ; its surfacefelt generally uneven to the finger as it was

passed over it, and small granulations or pro-jections were readily seen, more in some iparts than in others ; the peritoneal coat,principally over the upper surface of theright lobe, was thickened and opake, but inspots, and not uniformly ; substance of theliver much denser than usual, its cut surfaceis paler than in health, the paleness arisingfrom the greater abundance of the pale yel-low portion, and the diminished quantity ofthe proper substance of the liver; gall-bladder of full size; its peritoneal coat

thick ; it seemed to be pretty well filled withbile, but it was not opened.

Spleen somewhat larger than usual, itstissue firmer and rather paler, its coat thick-ened and opake, in spots like that of the liver,but to a greater degree.

Kidneys.-Left, its upper extremity muchenlarged. On cutting it a large cavity waslaid open, capable of holding a very smallurange; its walls lined by a membrane re-

sembling mucous membrane; it was filledwith a substance composed partly of pus,partly of coagulated blood, and partly of asoft semi-fluid grey, and somewhat curdy,matter, having the appearance of partiallysoftened fibrine ; the same appearances ofgranulations as in right kidney. Right.Its lower half diminished in bulk. On "re-moving the proper coat the surface wasseen to be studded with minute granulations,and mottled slightly of a pale yellow andred colour ; the substance was much denserthan usual, and the cones less visible in thelower half.

OEsophagus.-The epithelium, especiallyin the lower part, did not cover the mucouscoat uniformly, but in detached, ash-colouredfragments.

Stomach.—Capacity rather large; mucouscoat mamillated in a very marked degree,and in every part, except the great cul de sac; ;it was most so in the small curvature andnear the cardia ; the mucous coat seemedthicker than usual ; its consistence not

changed, its colour rather dark-grey.Intestines.—Calibre generally small, uni-

formly of a redder colour externally thanusual ; the mucous coat of the duodenum,jejunum, and ileum, of a redder colour thanusual, but uniformly and obviously from theaccumulation of blood in the larger branchesand subdivisions of the veins ; this was lessmarked in the lower half of the ileum ; thepatches of Peyer’s glands were very unusu-ally distinct (apparently from the alterationof the mucous coat around them) ; they werepale and smooth, and apparently healthy ;demressed below the level of the mucousmembrane adjacent; portions of the colonwere of a very deep-red colour, with spots ofecchymosis, but the redness was uniform,and apparently from congestion.

Head.—A considerable quantity of serumbeneath the arachnoid covering the upperpart of the hemispheres, especially towardstheir upper and back part ; a considerablequantity of clear serum in the lateral ventri-cles, parhaps about four or six drachms ineach ; plexus choroides paler than usual;substance of brain decidedly much paler thannatural, both the grey and white matter ; itwas moist, as if from the presence of moreserum than natural; its consistence rather

soft ; veins between convolutions on the sur-face of the brain less visible than is common.

Weight of the Organs.Heart—Twenty-one ounces avoirdupois.Right lung—Two pounds and half an

ounce.

Left lung—One pound, four ounces.Liver—Three pounds, two ounces.Spleen-Seven and a half ounces.Stomach-Eight and three-quarter ounces.Clinical remarks from Dr. Taylor’s lec-

ture.

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Diagnosis.—The first symptom which at-tracted attention was the dropsy, and it wasat once obvious that the patient was suffer-ing from two kinds of it: there was oedemaof the feet and legs, and there was also

ascites, but no dropsy of the intermediate

parts-the thighs. The ascites, therefore,was not the result of the extension of thedropsy from the legs upwards, but musthave a distinct source in the abdomen. Theliver being the organ most commonly dis-eased in such cases, it was next examined,and found to project two or three inches be-

yond the margins of the ribs, as was shownby the dull sound on percussion ; the marginof the liver could also be felt by the fingers,and appeared indurated. It required a littlemanagement to feel the projecting liver incases in which much ascites coexisted. Ifthe hand were placed flat on the abdomen,and pressure were made, the liver was

pressed backwards, and the interposed fluidprevented it being felt. By placing the ex-tremities only of the fingers against thewalls of the abdomen, at the point where thedull sound of the liver ceased, and by de-pressing them quickly, the interposed fluidwas displaced before the liver was, and themargin of this organ could generally be felt.Although the liver projected lower thanusual, it did not appear enlarged, for thedulness on percussion did not extend so highas usual, and was perceived over a smallerrather than a larger extent of surface than inhealth. It was thus ascertained that theliver was rather small, and its margin indu-rated ; the man had ascites, and had been adrinker, hence it was inferred that eirros-is ofthe liver existed. The causes of the generaldropsy might be in the kidneys or in the

chest, or both. The urine when tested thefirst day by heat and nitric acid, yielded atrifling curdy precipitate ; but it was fre-

quently examined afterwards, without everagain leading to the same result. That dis-ease existed in the chest,was sufficiently ob-vious from the great dyspnoea and some

lividity of the countenance. The patientcomplained of palpitations and of pain shoot-ing from the bottom of the sternum throughto the left shoulder, and a little down thearm. The pulse was very irregular, andfrequently intermittent; these were gene-ral symptoms of disease of the heart.Hypertrophy of the left ventricle was in-dicated by the somewhat increased force ofthe impulse ; dilatation by the increasedsurface over which it was felt, and valvulardisease by- the murmur which accompaniedthe first sound of the heart. It was difficultat first to determine whether the aortic ormitral valves, or both, were affected, for themurmur was feeble, and heard in the situa-tion of both valves : afterwards it appearedprobable that both were diseased, for thecharacters peculiar to each were noticed atdifferent times. UJhPri thp respiration was

suspended, a distinct murmur could beheard at the apex of the heart, without anyat the base, indicating regurgitation throughthe mitral orifice. At other times a murmurwas heard in addition at the base and in thecarotid arteries, proving the existence ofsome aortic-valve disease. The presence ofbronchitis was shown by abundant sonorousand sibilant rhonchi in most parts of thechest, but it was worth remarking that therewas, at the same time, very little cough orexpectoration.

Causes.-The patient had had rheuma-tism several times, and this was, probably,the cause of the morbus cordis. The latterdisease, however, could not be distinctlytraced to the former, and this was very oftenthe case.

Disease of the heart supervening on

the progress of rheumatism, might be at-tended with severe and well-marked symp-toms, but in a large number of cases it cameon very insidiously, and without either painor any symptoms calculated to attract muchattention. This was the case with many in-flammations of the lining membrane of theheart limited to a portion of its extent ; com-monly that part forming one or more of thevalves. The pulse might, perhaps, becomesomewhat accelerated, but there was nothingto draw the practitioner’s attention to it, or, ifnoticed, it was ascribed to the accompany-ing rheumatism. There was, probably, al-ways more or less murmur in the region ofthe valves, but this was sought for only by afew practitioners, and generally, therefore,escaped observation. The inflammation wasthus left to produce its usual consequences,viz., structural disease of the valves, andcommonly, also, of the substance of theheart. There was no chance of our beingable to combat the first disease, or to avertthese consequences, except by having re-

course to auscultation, and that not when theheart was complained of only, but in allcases. The bronchitis might have arisen partlyfrom the habitual preternatural accumulationof blood in the lungs consequent upon thedisease of the heart, and partly from the pa-tient’s occupation, that of a coachman, andkeeping late hours, exposing him frequentlyto cold. Although he had suffered from palpi-tation and dyspnoea for a long time, he neverhad dropsy before three or four weeks ago.The patient then took fresh cold, the dys-pnoea increased, and dropsy appeared.This was the usual history of such cases ;and after the dropsy and other urgent symp-toms had been removed, there was nothingwhich the patient ought socarefully to avoidas exposure to cold. On the first subsequentattack of bronchitis the pulmonary obstruc-tion was increased : this added to the labourrequired of the heart, and further embar-rassed its action; and this embarrassed actionof the heart again reacted upon the pulmo-nary circulation, and further diminished its

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freedom. The general venous accumulationthus occasioned induced dropsy, and in oneof these attacks the patient usually died atlast. This was the case with Dingley. Hisurgent symptoms were relieved, and he wasdischarged, with a strict caution to avoidtaking cold. He continued better till thefirst time he ventured out of doors, when thecough and urgent dyspnoea returned. Hewas readmitted with a pretty sharp attackof bronchitis, and a consequent aggravationof all the other symptoms, and within a dayor two he died.

Treatment.-The diseases of the heart andof the liver were, of course, incurable. Theobject of the treatment was first to remove thebronchitis, and next to get rid of the dropsy.The first object was attempted, and, to aconsiderable extent, accomplished, by cup-ping and blistering the chest. The cuppingwas frequently repeated in the course of thetreatment, and generally with temporary re-lief. On one or two occasions the tartar-emetic was prescribed with the same view.To remove the dropsy, he was at first ordereddiuretics. When these were sufficient, theywere preferable in such cases to hydrogoguecathartics, because they accomplished thesame object with less injury to the patient’sstrength. In this case, however, they pro-duced little effect; they scarcely increasedthe quantity of urine, and the tension of theabdomen so far from diminishing increasedconsiderably. Under these circumstances theelaterium was prescribed, and with speedy anddecided relief. It produced numerous copiousand watery stools, and within two or threedays the tension of the abdomen, which hadoccasioned considerable suffering, hadceased, and the swelling had considerablydiminished. Its use was persevered in untilthe ascites was nearly gone; the dose wasthen given at longer intervals, and the ascitesincreased again. Ultimately, however, adose every day, or every alternate day,proved sufficient to keep down the dropsy.The remedy produced some griping pain andoccasional sickness.

In such cases the elaterium was by farthe most powerful remedy we possessed, aswell as the most certain and most speedy inits operation. It required, however, to begiven with some caution, since it occasionallyproduced a serious amount of depression. iThe bronchitis diminished, as well as thedropsy and the dyspnoea also, but not in pro-portion. The patient was discharged threemonths after his admission, having been forsome time previously as well as when hewent out. In a week after he was read-mitted in the condition previously men-

tioned, and he died in about four days.Morbid Appearances in connexion with the

Symptoms.All the cavities of the. heart were much

hypertrophied and dilated; there was great

disease of the mitral, and considerable dis-ease in the aortic valves. It was interestingto trace the mode of development of themorbid changes in the heart. The first stepin the series of changes was, probably, in-flammation of the endocardium, about one orboth sets of valves in the left ventricle. Thisled to structural changes in them ; to thick-ening, rigidity, and permanent patency of themitral valve. The regurgitation of bloodinto the left auricle, by preventing that por-tion of the heart from emptying itself in theusual way, would occasion an unnaturalaccumulation of blood in it and in the lungs ;hence would follow hypertrophy and dilata-tion of this auricle. The obstruction in the

lungs just noticed would occasion a corre-sponding accumulation in the right auricleand right ventricle, and consequent dilatationand hypertrophy of both these cavities. The

tricuspid orifice would become dilated at thesame time and in the same way with theright ventricle and auricle ; these two

changes being always found to accompanyeach other, except when the tricuspid valvewas rendered unyielding by disease. Thedilatation and hypertrophy of the left ventri-cle were not so readily explained, for therewas no obstruction adequate to account forit. The obstruction at the mouth of the aortawas very trifling; and, moreover, the lec-tnrer had often observed the same changes inthe ventricle, when no disease of the aorticvalves existed. The regurgitation throughthe mitral orifice would rather lessen thanincrease the efforts required of the left ventri-cle to get rid of its contents. It might beproduced, perhaps, partly in two ways ; first,the inflammation formerly existing in theendocardium might have led to increasednutrition of the ventricular substance, inthis way enlargement of the heart was

sometimes produced by pericarditis ; and,secondly, the right ventricle being stimulatedto increased action to get rid of its contents,the left, which was so intimately connectedwith it, might be excited sympathetically.It was worth remarking, that there was nosort of proportion between the amount ofdisease in the heart and the physical pheno-mena which it presented during life. Theheart was enlarged to about two and a halftimes its healthy bulk, and there was veryextensive disease of the valves ; yet the im-pulse was by no means remarkably strong,certainly much less than in many cases inwhich the heart was not more than half thesize it was here. Again, the murmur in theregion of the valves was sometimes so faint,that it could not be heard without suspendingthe respiration. This apparent want of cor-respondence between the extent of the dis-ease and its symptoms was not peculiar tothe present case, but occurred generally insimilar circumstances, and the following ap-

peared to be the explanation of it.Whenever the heart became too much

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loaded, its freedom of action was diminished, paler than natural, the blood being squeezedand the impulse and sounds which depended out of it, in this case its colour was deeperupon its action diminished in the same pro- than in health. The lecturer thought thatthisportion. In Dr. Hope’s experiments on the appearance was probably due to a slow modi-motions and sounds of the heart, he found fication in the nutrition of the lungs, occa-

that when the artificial respiration which he sioned by long-continued and habitual con-was carrying on was suspended, the blood gestion of blood in them.accumulated in the heart so as to distend it The Liver presented the usual charactersto double its usual size ; its contractions of cirrosis, but in an early stage, so thatbecame less forcible, less free, and more irre- without a careful inspection they might havegular ; and the sounds experienced a corre- been readily passed over.sponding diminution. This overloaded state Stomach.—The mucous coat was mamil-of the heart would exist habitually in this lated, thickened, and of a grey colour : thecase to a greater or less extent. Again, to whole organ was hypertrophied. These ap-produce a considerable murmur, it was ne- pearances were probably the consequencecessary not only that an obstruction should of chronic inflammation, which might haveexist to the current of the blood, but also been produced by drinking. They mightthat afree current should be forced against also, in part, have resulted from the chronicthe obstruction. In the present case the sanguineous congestion produced by thisformer of these conditions only was fully disease in the heart and liver. The enlarge-present. A very slight obstruction, with a ment of the spleen which was indicated dur-free action of the heart, would produce a very ing life, by an increased extent of dulnessloud murmur. Thus, in experiments made on percussion, might also have been the effectby Dr. Williams, the loudest murmurs were of this latter cause, and was another examplefound to be occasioned by a thread passed of the tendency to hypertrophy, induced inacross the current of fluid. We knew that most organs by disease of the heart.whatever increased temporarily, the actionof the heart increased at the same time any Intestines.—The mucous membrane of theexisting murmurs from valvular disease; and intestines was, to a great extent, of a deepsuch murmurs were also often diminished by red colour, but the redness was uniform, andsubduing the heart’s action by bleeding, or the blood was accumulated more in the largeother remedies. than in the small vessels ; it was, therefore,Lungs.-Several of the appearances in the congestion, and not inflammation, and was

lungs were worth noticing. Signs of inflam- another consequence of the great venous ob-mation were observed in the large bronchi, struction.

but not in the small subdivisions. In these, The Kidneys were distinctly granular, yetthe membrane was not thickened nor sof- the urine repeatedly tested during life yieldedtened, and it was quite pale ; yet the no traces of albumen except once, and thensigns of bronchitis were present in the only in a very trifling degree.lower lobes as well as in the upper. The Brain.—There was some effusion of serumlecturer had very generally observed the within the head ; this probably occurred be-same appearances of the mucous membrane fore death, and might correspond with thein the small tubes when there had been stupid, unmeaning, staring look exhibited bysevere and long-continued bronchitis before the patient the last day of his life. This serousdeath. He suspected that, in detailing the effusion was a further effect of the generalappearances of the mucous membrane in venous engorgement. The extreme palenesssuch cases, writers had much more fre- of the substance of the brain was worthy ofquently drawn upon their imaginations than notice. The skull always containing the samedescribed what had actually fallen under quantity of matter-solid and fluid togethertheir senses. There was a great number of -the effusion of serum in this case hadblack spots in both lungs, resembling points occasioned a diminution in the quantity ofof hæmorrhage; they were, probably, due blood in the head ; and hence the paleness,to the great accumulation of blood in the instead of the appearances of congestionlungs during life. In such cases haemor- which the veins of the brain would otherwiserhage was of frequent occurrence. This have presented.patient had never had haemoptysis. A goodportion of the right lung was denser and ————————————————————————————

tougher than usual, and contained a very LEEGHI:S IN THE ALIiVIENTAFt.Y GANAL.small portion of air, still it did not sink inwater. It was not hepatisation, for the AT a late meeting of the Academy ofcohesion was increased instead of dimi- Sciences, M. Guyon announced that he hadnished. It was a species of carnification. introduced leeches (hemopsis vorax) into theA similar state of the lung was produced by alimentary canal of fowls and rabbits. Thethemechanical compression of it in pleurisywith considerable effusion. There was this animals subjected to these experiments dieddifference, however, between the two, that in the course of a few weeks in a remarkablewhilst in pleurisy the lung was commonly state of emaciation.