STRAIN AND OVER-ACTION OF THE HEART. 25 



percussion dulness extended from beyond the right edge of 

 the sternum to the axillary line. A systolic murmur was heard 

 all over the cardiac region — and, in truth, over the whole of the 

 left chest. Its point of intensity was at the apex, where it 

 was distinctly musical. The second sound at the aortic carti- 

 lage was somewhat obscure ; that at the pulmonary cartilage 

 well pronounced — indeed, accentuated. The veins of the neck 

 were swollen, but did not pulsate. A considerable effusion 

 existed in the right pleural sac ; the urine was scanty, of high 

 specific gravit}', but not albuminous. 



Under treatment, chiefly by digitalis, scoparius, and iron, 

 the boy was for a time greatly relieved, and the watery swell- 

 ing almost disappeared. But the improvement was not perma- 

 nent ; the dropsy became very general, and he died exhausted, 

 March 27. There was no 'difference to record in the ph3"sical 

 signs excepting that, late in the case, the murmur lost a good 

 deal of its musical character. 



The autopsy, made five hours after death, showed considera- 

 ble effusion in the abdomen and in the pleural sacs, an enlarged, 

 nutmeg liver, a spleen firm, small in size, and very black, and 

 the left lung adherent to the pericardium. This, with the in- 

 closed heart, was found to occupy the whole of the lower part of 

 the mediastinum, and to prevent either lung from being visible. 

 The layers of the sac were tightly adherent, especiallj^ around 

 the base, where the false membrane was very thick. The heart 

 was enormously increased in size, the cavities were all dilated, 

 especially those on the right side. The walls of the right 

 ventricle were thin, in some places not more than a line or 

 two in thickness; the walls of the left ventricle thickened. 

 The valves of the aorta and pulmonary artery were found to 

 be sound ; those of the tricuspid valve, thin, flexible, and with- 

 out roughening, still appeared competent to close the dilated 

 tricuspid orifice. Not so with the mitral; they too were 

 healthy, though not quite as thin and yielding as the tricuspid, 



