with a diminution in their strength, and almost total disappearance on the left side, in the former position. Her breathing is laboured to an extreme degree, accompanied with extraordinary action of the thoracic muscles; rattling in the trachea and thorax, sensible to the ear and touch. She sits propped up in bed, and obtains but short interrupted intervals of sleep; has lost her appetite; passes but a small quantity of urine, and is irregular in her bowels.

Physical Signs of Chest and Heart.-Percussion over and beyond the limits of cardiac region elicits a very dull sound, extending beyond the sternum to the right side; the heart's impulses can be felt in the cardiac region, not violent nor forcible; on the contrary, weak, but tolerably extensive, the shock being communicated to the touch over a less circumscribed space than that observed in health. A strong vibratory thrill is imparted to the palm of the hand, proceeding from the vibration of air and mucus in the bronchial tubes, intermixed with that resulting from the blood's passage through the cavities of the heart. During the act of suspending the respiration, the sounds of this organ, previously inaudible, and altogether obscured by the respiratory phenomena, became so far distinct, that their action was reported to be extensively heard. Beneath the mammæ, and within the precincts of the præcordial region, the first and second sounds, the entire of the heart's rhythm, are so much confused, masked, or replaced by a constant loud whizzing or rasping murmur, that it is impossible to distinguish between them individually, or recognise them collectively with each impulse and ventricular contraction it commences, and progresses with briskness, roughness, harshness; and at the moment it should cease with the diastole of the heart, and the second sound succeed, a repetition of these physical signs takes place: a retroceding, regurgitating, whizzing murmur, less vigorous, less forcible in its intensity, and possessing less of those characteristic features of the former, becomes developed, and is communicated to the ear; at the termination of which the heart's impulse succeeds, the ventricular contraction follows, accompanied by the rushing or whizzing murmur, not unlike the sound produced by the rasping of the crust of bread, occupying the entire of the first sound, masking the second, and obliterating the interval which naturally intervenes. At the upper part of the sternum, and under the clavicles, the second sound is audible, though feeble; not so clear, having lost much of its energy, and not possessing that sharp, well-defined "claquement" so peculiar to it. Each arterial and valvular "clack" is preceded by a bellows murmur, regular in its succession, and constant in its intensity, but less distinct than that heard in the præcordial region; seemingly continuous with, or a prolongation of, these sounds, and gradually diminishing as we approach the fourchette of the sternum. Pulse 96, full and regular, counted in carotids; it cannot be felt at the wrist on account of the cedema; percussion over the posterior part of the right side is dull; the physical signs indicate, in addition to acute bronchitis, extensive congestion and oedema of the pulmonary tissue, with an accumulation of fluid in the left pleural cavity.

The abdomen is swollen, from the quantity of fluid in the peritoneal sac, a sense of fluctuation is afforded on percussion, and the true condition of the abdominal viscera rendered difficult to ascertain. The liver feels hard, enlarged, indurated; its sharp edge thickened and rounded. The intestines are distended with flatus.

History.-For two years she has been subject to a chronic catarrh, and has for many months suffered from pains in the left side, palpitations, flutterings, and other symptoms of deranged circulation; the distress occasioned by the dyspnoea, violent palpitations excited by very trivial causes, agonising pains, and præcordial oppression, has been much increased within the last few months. The swellings appeared for the first time six weeks since, in the feet and legs, spreading upwards towards the thighs and abdomen,

finally extending over the upper extremities, and producing that state of misery in which she was brought into hospital.

Two days after this report was taken she died.

Autopsy. The serous cavities of the abdomen and chest, left pleura in particular, contained light straw-coloured fluid; the quantity in the former exceeding four or five quarts; that in the latter, a pint.

The heart, when exposed by laying open the pericardium, occupied the mesial line, and encroached considerably on the right pleural cavity, in consequence of its enormous dimensions from the increased capacity of the right ventricle and auricle; on its anterior surface is one of those white patches so frequently seen, occupying in its extent the circumference of half a crown. The veins are enormously turgid, those on posterior aspect, traversing from base to apex, particularly so. The heart is very flabby. The exterior of the right ventricle, which is considerably augmented in its transverse and perpendicular diameter, presents a yellowish marbled colour, traversed by turgid blood vessels; whilst the left, comparatively small, affords a specimen of two rare pathological alterations. As the heart lay in the pericardium, two circumscribed purplish or livid patches attracted our notice; one situated about an inch and a half, the other a few lines, from the apex. The superior one larger, in close proximity to the septum, does not exceed the size of a sixpence; whilst the smaller of the two might be covered by a fourpenny piece. The pericardium corresponding to each is more opaque and dense than that covering the rest of the ventricle. Two distinct indentations, similar to those which may be produced by punching in the muscular substance of the ventricle with the knuckle of the forefinger, were visible on the anterior part of the left ventricle; corresponding to which, and the dark-coloured patches, the muscular fibres of this cavity were so thin and attenuated, that the interior of the ventricle could be felt by the introduction of the finger into either of these depressions or indentations. On first inspection, it was supposed a perforation had occurred near the apex; such, however, was not the case. By examining from the interior of the ventricle, it was evident that, from the absorption and attenuation of the muscular fibres of the ventricles interposed between the endo and peri-cardium, two pouches had formed, which, when distended with blood, or protruded by means of the finger, constituted two circumscribed true aneurisms of the ventricle; in one of which was contained a dark-coloured fibrinous coagulum, being entangled between the fleshy columns encircling the sac, and distinct from other coagula in the ventricle.

The pericardium can be detached with the greatest facility, and removed from the surface of both ventricles, by exerting a slight degree of traction. The muscular substance of the ventricle, excepting the two places described, is hypertrophied, but of a pale colour, separable into distinct laminæ by making a transverse section, raising the fibres, and drawing them from apex to base; thus three, four, or even more plates, or layers of fleshy fibres, can be removed, pale and flabby, but increased in thickness.

It seems probable that the cellular tissue separating the muscular fibres had become infiltrated with serum, participating in the oedematous condition of the cellular tissue diffused over the body; such a supposition becomes justified, from the colour of the right ventricle appearing to originate in a sub-pericardiac infiltration into the cellular tissue, scattered amongst and serving to connect the muscular fibres together-from the muscular fibres themselves being flabby and attenuated—the fleshy columns being thin and numerous-and from these not being sufficient to account for the tumefied appearance and obvious augmentation in the volume of this viscus.

The auricles, right and left, more especially the former, are increased in the capacity of their chambers to double or treble their usual size. Venæ cava dilated, gorged with blood; coats somewhat thickened; parietes of auricles hypertrophied; appendices enlarged, and musculi pectinati

lengthened; the endo-cardium of the left is increased in density, opaque, and easily detached from the muscular fibres.

The right auriculo-ventricular aperture is of enormous size, dilated to nearly double its general measurement. The tendinous ring is sufficiently distinct. The tricuspid valves are inadequate to effect the closure of the orifice, two thirds being thickened, in their perpendicular measurements, with fibrous prominences on their surfaces and borders. The left auriculoventricular aperture and mitral valves are similarly affected, but not to the

same amount.

The pulmonary valves are healthy; those of the aorta of a deeper red in their colour, but retaining their transparency; a slight increase in their density was noticed. The calibre of the arch is dilated. Steatomatous depositions pervade the interior of the aorta, and may be seen in greatest number at some distance from the valves. Not far removed from one of these, there has been deposited a quantity of fibrin beneath the serous, between it and the muscular coat. Advancing from the ascending and transverse portions of the aorta, the coats were found more healthy.

The superior parts of the pharynx and larynx are of a deep red, approaching to a purple hue. The epiglottis less elastic than natural; its mucous membrane of a violet colour, thickened, and velvety feel. The rima glottidis

appears narrowed in its antero-posterior diameter; no ulceration could be detected.

Head. From three to four ounces of limpid serum was effused between the arachnoid and dura mater, also between the arachnoid and pia mater; abundant at the base of the brain, at the superior part of the spinal column, and in the vertebral theca.

In the floor of the third ventricle, anterior and inferior to the orifice of the iter a tertio ad quartum ventriculum, a second orifice, distinct, smooth, and circular, attracted my attention in this, as well as on two previous occasions, in brains not affected by disease. Into this orifice the point of an ordinary sized director can be introduced, which, taking the course of the canal, proceeds upwards and backwards, beneath the floor of the aqueduct of Silvius, and that of the fourth ventricle, on the superior surface of the pons varolii. Passing downwards and backwards between the processes a cerebello ad testes, still preserving the mesial line, it gradually contracts in size, and seems to terminate in a species of cul-de-sac, at a short distance above the posterior spinal fissure, with which it was at first supposed to be continuous; but more minute examination did not ratify this supposition, as the continuation of the canal could not be satisfactorily ascertained. On three separate occasions have I been foiled in tracing a direct communication between the two, and establishing an immediate connection of one with the other, but have succeeded in observing that a minute fissure leads from the apparent termination of the canal. This canal, when laid open in its entire extent, from the floor of the third ventricle, posterior to the infundibulum, to its termination behind, describes a curvilinear course, is circular in its calibre, and presents a smooth, polished, glistening internal surface, being lined throughout its entire extent by serous membrane; its parietes, varying from one to two lines in thickness, consist of a layer of cineritious and medullary substance, inclosed between two laminæ of serous membrane.

OBSERVATIONS.—It is unnecessary to remark, that we possess in this case more than an ordinary amount of instruction; but in commenting on some of the leading features during life, and the pathological changes observed in the autopsy, it will be more profitable to inquire in a cursory manner

1st, Into the similarity existing between the symptoms, physical signs, and pathology of this case, and those noticed in others, as illustrative of the

disease under consideration.

2d, Into the probability of those physical signs having originated in, and being produced by, the aneurisms of the ventricle, and the liability of the one being mistaken for, and confounded with, the other, from such coincidence.

3d, Whether the attenuation of the parietes of the ventricle in those two circumscribed spaces, which was conducive to the formation of the aneurismal pouches, resulted from an inflammatory attack of the muscular structures, preceded, was coeval with, or consequent upon the morbid changes, progressing in the valvular structures.

From the combination of two circumstances, permanent patency of the auriculo-ventricular apertures resulted-first, from a dilatation, an increase in the circumferences of the orifices; secondly, from retraction of the valvular tissues, and consequent deficiency in their length; diseases in themselves sufficient to account for the presence of the physical signs-the masking of the entire of the heart's rhythm, heard in the præcordial region, by a loud whizzing murmur or constant buzz. But herein we are enabled to detect a very striking dissimilarity between the auscultatory phenomena and those recorded in the preceding cases; inasmuch as, at no period of the examination, nor by resorting to those manœuvres and experiments, as far as her deplorable condition permitted, were we able to observe a remission or intermission in the vigour, the intensity, the regularity and asperity of those phenomena, so obvious and so constant in the others, as to be considered one of the characteristics of this disease, and deemed almost pathognomonic of its existence.

We have recorded, it is true, a marked difference between the harshness and loudness of the abnormal murmur accompanying the ventricular contraction, and that heard during its diastole. In the description given, it has been noted, that the sound communicated to the ear gave origin to the idea that "the retroceding, regurgitating whizzing murmur, less vigorous, less forcible in its intensity, and possessing less of the characteristic features of the former," (vide report of physical signs, &c. &c.) proceeded from a reflux of blood through the auriculo-ventricular orifices.

That this description, though virtually correct, must be at variance with our physiological knowledge of the succession of phenomena composing the heart's rhythm, and if not commented on, must lead to confusion, requires not a second consideration; instead, therefore, of being led astray by the sounds communicated to the ear, and attributing this train of phenomena to the regurgitated current produced during the ventricular contraction, and in conjunction with the aneurismatic condition of the left ventricle, chiefly instrumental in causing the loud rasping murmur, we must in preference ascribe it to the succeeding column of blood, passing over an uneven, roughened surface, immediately after the subsidence of the muscular contraction; continuing during the diastole of the ventricles; occupying the heart's interval of repose; being propelled forward in part by the action of the auricles, but chiefly by its own unopposed gravity.

Let us now inquire whether these aneurisms were antecedent to, coeval with, consequent on, or subsequent to, the disease of the valves. The two first inquiries may be disposed of by our confessing that, through want of a sufficient number of cases and consequent experience, a perfect silence must be maintained; but in objecting to trace their origin to, and refusing to acquiesce in any opinion which may attribute these aneurisms to a disorganisation of the valves, it is but right to state that this opposition has been grounded on, and the inference drawn from, the extreme rarity of the coexistence of these affections, which, if viewed in the light of cause and effect, ought to retain a greater comparative frequency than has hitherto been recorded.

In searching after the predisposing and determining causes of this disease, pathological examination and ocular demonstration direct our attention to the existence of acute inflammation of the serous and muscular structures of this viscus at some previous period; but in recalling to mind the different divisions of inflammation; the various changes effected by each, in different parts of the animal economy; the hardening and softening; the thickening and thinning; the increase and decrease of volume, in organs whose struc

tures accurately correspond, we must revert to the effects of that slow, insidious, subacute inflammatory process on other parts of this organ, to be enabled to offer a satisfactory explanation.

During the progress of this inflammatory action, we have had frequent opportunities of attesting that the muscular fibres become weakened and flabby; decreased in bulk and energy; yielding during this atrophying process to the force of the circulating current; and dilating the cavities, in thus yielding during each act of propelling the blood into the arterial system. From an excess of innervation; from predominance of this enfeebled, thinned, attenuated condition of the fibres in two or more circumscribed spaces, and their consequent inability to offer further resistance to the circulating column of blood, they either give way, are absorbed, or form on various portions of the heart's surface those aneurismal sacs, into the interior of which, the blood entering as it passes through the cavity of the ventricle, a gradual distention of its walls takes place, until in the course of time it may have attained a size equaling the normal dimensions of the heart.

That these pouches did not originate in rupture, nor ulceration of the fibres, consequent on the formation of an abscess in the substance of the ventricle, may be inferred from the uninterrupted continuity of the fibres after the removing of the lining membrane of the aneurism, the endocardium ventricle, and there being none of the distinguishing marks of a former abscess.

I can well conceive that if this aneurismal affection of the parietes of the ventricle had existed per se, and the auriculo-ventricular valves had remained sound, we should have had symptoms precisely the same, and physical signs differing but slightly from those described, as the attendant phenomena of permanent patency of the apertures, with morbid growths or excrescences on the surface of the valves.'

BIBLIOGRAPHICAL NOTICE.

Rigby's Midwifery.2

The advent of the volume before us was announced in a late number of this Journal. It was published in London as a part of Tweedie's "Library of Medicine," and is certainly equal to any of the volumes that have preceded it. It is written sensibly and clearly, and the author is aware of most that has been done in the important department of medical science embraced by it. We can, consequently, strongly recommend it to the practitioner and student. The general anatomy and physiology of utero-gestation and fœtal existence are ably treated-subjects sadly neglected in many of our obstetrical works. But few of the diseases of the childbed state are touched upon-they are puerperal fevers, phlegmatia dolens, and puerperal mania. The work is divided into five parts:-Part I. Embracing the Anatomy and

1 We have taken the liberty of considerably shortening this paper: if the reader should perceive any want of perspicuity, he will, therefore, please to attribute it to us.

-ED. GAZ.

2 A System of Midwifery, with numerous wood-cuts. By Edward Rigby, M. D., Physician to the General Lying-in-Hospital, Lecturer on Midwifery at St. Bartholo mew's Hospital, &c. &c. With notes and additional illustrations. 8vo. pp. 491. Philad. 1841.