DISEASE OF THE MITRAL VALVE. 369 



uterine veins occasions menstrual derangement. Finally, should any 

 considerable congestion of the kidneys set in, there is derangement of 

 the secretion of urine, such as may be produced by ligation of the 

 emulgent veins. The urine is scanty, and contains albumen, blood- 

 corpuscles, and the so-called fibrinous or exudation cylinders, that is, 

 microscopic casts of the urinary tubules, the diagnostic importance of 

 wliich is to be considered more in detail when we come to study dis- 

 eases of the kidney. 



Venous engorgement, moreover, leads to one of the most impor- 

 tant, and, in long-standing cases, one of the most constant symptoms 

 of mitral disease, namely, dropsy. As before observed, an impoverish- 

 ment of the blood, particularly a diminution of its albumen, contributes 

 essentially to the establishment of transudation of serum. This im- 

 poverishment is easily traceable to engorgement. Embarrassment to 

 the outflow from the veins extends itself to the thoracic duct, and ob- 

 struction of this duct, of course, impedes the supply of nutritive mate- 

 rial to the blood. The dropsy almost always begins in the extremi- 

 ties, generally in the region of the ankles ; thence it gradually extends 

 over the thighs, the external genitals, the integuments of the abdomen, 

 and so to the rest of the body. The serous sacs also become the seat 

 of dropsical effusions, producing ascites, hydrothorax, and hydroperi- 

 cardium. Years may elapse after the first appearance of oedema about 

 the ankles, the patient alternately improving and growing worse ; his 

 feet now swelling and now growing smaller again, ere the general 

 dropsy is established, of which he, in most cases, ultimately dies. In 

 other cases, he rapidly declines as soon as the first signs of serous effu- 

 sion show themselves. In many cases an erythema is set up about 

 the genitals, the groins, etc., which is very distressing to the patient, 

 and which, not uncommonly, terminates in diffuse gangrene of the 

 skin. When hydrothorax and hydropericardium develop, his condition 

 grows desperate. The dyspnoea becomes extreme ; he can no longer 

 lie down. The serum finally so fills up the air-cells of the lungs, that 

 the blood becomes surcharged with carbonic acid, and his last hours, 

 at least, are relieved by a merciful stupefaction. While the majority 

 of cases thus terminate by dropsy and final oedema of the lung, death 

 takes place, in a smaller number, in consequence of metastases, haemor- 

 rhagic infarction of the lung, or of intercurrent maladies. How much 

 Blight's disease contributes in producing a speedy death is difficult to 

 decide ; at all events, whether due to it . or not, albuminuria certainly 

 promotes the tendency to dropsy. 



Physical signs of insufficience of the mitral Inspection and 

 Palpation. We often see and feel a strong shock, or even a rise and 

 fall of the thoracic wall over all the region which is in contact with 

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