Professor of Pathological Anatomy in University College, London; and of Clinical Medicine in University College Hospital.

Gentlemen,-Although I have, on several occasions, directed your attention to the study of the diseases of the heart, and more especially to their physical signs, the importance of the subject induces me to offer you some additional observations on the cases which we have had an opportunity of observing during the last three months. You will, I am sure, be surprised to learn, that nearly one half of the patients admitted during that period, with various diseases, have presented physical signs of the existence of anormal conditions of the heart. From the 1st of January up to this date (28th March) there have been admitted 30 female and 29 male patients, with various acute and chronic diseases. Of the former there have been 14 cases; of the latter 11 cases, in which physical signs of these anormal conditions of the heart were observed. In order, however, to estimate the nature and extent of the disease observed in these cases, and, consequently, the importance of the physical signs detected by auscultation and percussion, I shall first read to you two tabular views of the cases before entering upon the investigation of the subject.

From these tabular views of the physical signs observed in the 25 recorded bases, it appears that by far the most frequent consisted of morbid

sounds, either single or double, principally heard at the base or apex, or in both regions of the heart at the same time, and accompanying the natural sounds of that organ. In seven or eight of these cases the morbid sounds were accompanied with a greater or less degree of increase of the impulse and sounds of the heart, heard over a greater or less extent of the chest, beyond the natural limits. In three cases only were the morbid sounds absent, the diseased conditions being manifested by the preternatural extent of the sounds and impulse alone of the heart. In one case no physical signs were observed during life, the disease of the heart (concentric hypertrophy) not having been detected till after death.

Of all the cases in which physical signs of the existence of anormal conditions of the heart were observed, six only were entered in the case-book as morbus cordis, the heart being the organ essentially and primarily affected, and its morbid states the cause of the complications, such as general congestion, anasarca, ascites hydrothorax, bronchitis, and emphysema, which had compelled the patients to seek for relief.

Of the 19 remaining cases, three were cases of rheumatism, three of phthisis, and the rest of various diseases.

We shall divide all the cases into two groups; the first group comprehending those entered as disease of the heart; the second including those entered under their respective names; and endeavour to estimate the diagnostic value of the signs appertaining to each.

In the first group, the physical signs referrible to the morbid conditions of the heart, were of such a character as to entitle them to be considered pathognomonic of organic disease of that organ. In the cases of Gibson and Shaw the post-mortem appearances confirmed, in every particular, the accuracy of our diagnosis. In Gibson's case there were marked physical signs of hypertrophy, and a loud morbid sound heard to the left of the apex of the heart; and after death the size of the heart was found greatly increased, and the mitral valve in a state of permanent patentcy. In Shaw's case the impulse of the heart was too strong, and heard too extensively. A slight morbid sound was heard at the base of the heart along with the diastole; and to the left of the apex along with the systole. After death there were found hypertrophy of the walls of the heart, rigidity, shortening, and obliquity of the mitral valve, and perforation of one of the semilunar valves, conditions which sufficiently explained the production, by regurgitation, of the morbid sounds, and the too strong and extended impulse of the heart observed during life.

In the case of Shiraffs, which I have already detailed to you on a former occasion, we have physical signs equally conclusive of the existence of organic disease of the heart and its valves.

In the case of William Tobin, which I have not yet brought under your notice, the physical signs of organic disease of the heart possess the same positive value as those of the preceding case. He has been in the hospital for upwards of three weeks. The impulse of the heart is too strong and too extended; there is extensive dulness over the cardiac region; and a slight morbid sound, heard at the base, accompanies the second sound of the heart. There were, besides, some congestion of the face, lips and tongue; œdema of the feet and ankles towards evening; palpitations, dyspnoea, orthopnoea, and slight bronchitis.

In the fifth case, viz. that of Halliday, the physical signs were those of hypertrophy and dilatation, in which the latter probably predominated. The chief symptoms were referrible to congestion of the lungs, in some degree of the brain, of the digestive organs, and of the extremities. In his case the organic affection of the heart was not considerable, and probably remediable, but it was the obvious cause of the symptoms enumerated; whilst, in those of Shiraffs and Tobin' (who are still under treatment, and

Both patients left the hospital relieved of all the complications, and in their ordinary state of health.

greatly improved), it is extensive, and of such a nature as to prove ultimately fatal.

In the sixth and last of the cases entered as disease of the heart, viz. that of Foreman, we had also uneqivocal signs of organic disease of the heart. Of the history of this patient's case I shall merely state that about a year and a half before his admission into the hospital, which was on the 15th of January, he became subject to a hacking cough, and soon after experienced severe palpitations of the heart on any exertion, as in walking quick, or going up stairs, &c. These symptoms continued up to that time, and became gradually more and more severe. When examined, the impulse of the heart was found too strong and felt over too large a surface. The rhythm was irregular, with occasional intermittence. The first sound of the heart was replaced by a loud, rough, and prolonged morbid sound, most distinctly heard near the apex. The second sound was heard somewhat morbid at the base of the heart. There was also a very strong purring tremor felt over the cardiac region, especially when the patient stooped forward. The dulness on percussion was not too much extended. From these physical signs it was clear that we had organic diseases of the heart of at least a year and a half's duration. We had, in fact, a case of hypertrophy and dilatation of the walls of the heart, and a morbid condition of the mitral valve, and of the semilunar valves of the aorta. This patient left the hospital greatly better at the end of two weeks. The increased action of the heart became gradually less, and the anormal sounds diminished in intensity. He was bled to eight ounces from the arm on his admission, and took the solution of the iodide of potassium and tincture of digitalis, during the period stated.

Of the second group, comprehending 19 cases of disease, in which physical signs existed of anormal conditions of the heart, three of them were cases of rheumatism, three of phthisis, two of erysipelas, two of eczema impetiginodes, one of acne, of peritonitis, &c., of cephalalgia, of dysentery, of poisoning by opium, of abdominal congestion, of dyspepsia, of colica pictonum, and of lichen.

In some of these cases the diagnostic value of the physical signs can be ascertained with equal certainty and facility. In the three first cases, or those of rheumatism, we have the physical signs either of valvular disease alone, or these combined with those of hypertrophy. You will, perhaps, recollect the case of Mary Bye, admitted the 31st of January, with acute rheumatism, the history and treatment of whose case I brought before you formerly, and which was rendered peculiarly interesting from the fact of the anormal sounds of the heart having, after the space of a few days, considerably diminished, under the influence of the treatment employed. She had been twice bled from the arm, and had taken the acetous extract of colchicum three times a day, and a pill of calomel, and compound powder of ipecacuanha morning and evening, until the mouth had become slightly affected. It was at this time that the anormal sounds in the region of the heart diminished in intensity. They consisted of a double bellows-sound, heard with the first and second sounds of the heart.

As I have already given you the history and treatment of this case up to the seventh day, and as it furnishes a most satisfactary example of the cure of endocarditis, or of inflammation of the valves of the heart, I shall now relate its further progress and termination. On the 9th of February the rheumatic inflammation of the hand, elbow, and shoulder had lessened, but it had become worse in the ankles, which were very red, hot, and painful. The patient could get no sleep at night. The morbid sounds of the heart were the same, that is, less marked than when first heard, but still readily distinguished; and as the pulse was full and firm, twelve ounces of blood were again taken from the arm. The acetous extract of colchicum was increased to two grains, three times a day, and twenty-five minims of the tincture of the meconate of morphia ordered to be taken at night. On the

three following days leeches were several times applied to the joints with considerable benefit. The colchicum had been increased to two grains and a half, and was followed by frequent vomiting and purging, and was, therefore, omitted. The mouth continued sore; the inflammation and pain of the joints gradually diminished, by subsequent applications of leeches, and on the 23d were quite gone. On the 26th the morbid sounds of the heart had almost entirely disappeared, and six days after no trace of them could be heard, when the patient was discharged quite well.

That the double bellows-sound in this case indicated the presence of valvular disease, and that the morbid condition in which it originated was rheumatic inflammation, can no longer be matter of doubt to the stethoscopist; and much, if not the greater part, of the accuracy of our diagnosis of the presence of this complication of rheumatism we certainly owe to the researches of M. Bouillaud, on what he has appropriately denominated endocarditis, in contradistinction to inflammation of the pericardium, or pericarditis. After having laid before you the two other cases of rheumatism, accompanied with physical signs of disease of the heart, I shall, if our time will permit, make some remarks on the seat of the morbid sounds heard in each, and on their probable cause and mode of production.

The second case of rheumatism, accompanied with anormal sounds, occurred in a boy, eight years of age, who was admitted the 19th of February. Previously in the enjoyment of good health, he was exposed to cold, and was seized with pain in the ankle and foot of the right side, which afterwards shifted to the knees, and from them to the shoulders, arms, and hands. When admitted, the pain was confined to the left shoulder, unaccompanied by redness or swelling; was increased by cold, relieved by heat, and worse towards evening. His sleep was disturbed; skin hot; pulse 90; bowels regular. On applying the stethoscope a bellows-sound was heard with the first sound of the heart at the apex only, and when respiration was suspended. The second sound was slightly morbid at the base; the rhythm was regular.

This case of rheumatism was altogether mild; neither the local nor general symptoms had been severe, and were, indeed, very slight when the patient entered the hospital. Notwithstanding, it was complicated with endocarditis, as shown by the stethoscopic signs which I have mentioned. Whether these disappeared before the patient left the hospital was not ascertained; he was discharged, cured, a week after admission, the chief means employed being the solution of the iodide of potassium.

The last of the cases of rheumatism, complicated with disease of the heart, is that of James Finnagen, ætat. 33, admitted 19th of February, and still under treatment. He is a tailor by trade, married, of pretty regular habits, has been lately much exposed to cold and wet, and much fatigue. He has always had good health (with the exception of a cough during the winter months of the last five years), until eighteen months ago, when he became subject to a continued pain in the cardiac region, aggravated at times, and great palpitation. This cough became worse, and the expectoration more profuse. He had supra-orbital headach, red clouds and flashings of light before his eyes, defective vision, and sometimes dy plopia; giddiness, and sometimes he fell insensible; tinnitus aurium, and frightful dreams. These symptoms continued until three or four weeks ago, when he got wet through for several days together, and soon experienced pain in his knees, ankles, hips, loins, left shoulder, elbows, and wrists. The pain also in the cardiac region became worse. He had no advice for the rheumatism, but applied at Moorfields on account of the dimness of sight. He was given some ointment of tartarised antimony to rub on the back of his neck, and had some blue pills to take, but his mouth becoming sore he discontinued the use of both. He got gradually worse, and on the 19th of February came to this hospital.

Present symptoms.—Skin hot and dry; tongue white; headach; disturb