610 REPORT— 1878. 



edges of the other segments, and • turning downwards towards the cavity of the 

 ventricle. Its edge was puckered and folded, as if an effort had been made to fold 

 it downwards. The whole of the segments were somewhat rigid and thickened, 

 free, however, from atheroma and vegetations. 



The mitral valve was healthy, and acted well. 



The aorta was not materially diseased. 



All the other organs were healthy. 



From the injury to the day of death, 147 days, or exactly 21 weeks, had 

 elapsed. 



Case 2. — A dock-labourer, set. 36, also in St. Thomas's Hospital, had been sud- 

 denly attacked when pulling at a sugar hogshead. His hands slipped, struck him a 

 severe blow on the left side of the chest, and he fell backwards. He immediately 

 felt severe pain in the region of the heart, and in the evening his breathing became 

 difficult. He died 3£ months from the injury. 



The heart was found to be greatly enlarged, weighing 23 ounces. The left 

 angle of the posterior semilunar segment at the aortic orifice was found to be torn 

 from its attachment, so that it was quite loose, and readily admitted of retroversion, 

 allowing free regurgitation from the artery into the ventricle. 



Case 3. — A French waiter, set. 20, came into St. Thomas's for acute rheumatism. 

 On January 12, 1878, he had a sudden attack of pericarditis, from which he had 

 been perfectly free before. This proceeded to total adhesion, and after leaving the 

 hospital for a time he returned and died on July 7, exactly 176 days, or twenty- 

 weeks and a day, from the commencement of the disease. 



All the valves of the heart and all other organs in the body were substantially 

 healthy. The pericardium was, however, firmly and universally adherent. The heart 

 itself weighed 1$H ounces. 



Case 4. — A boy, 14 years of age, was admitted into St. Thomas's on August 22, 

 1876, suffering from obvious hypertrophy of the heart, but without evidence of val- 

 vular disease. I considered the case to be, like the last, one of adherent pericardium. 

 It was difficult to obtain any distinct history from so young a person but, from 

 information tendered by his relations, the following facts were established : 



He had been quite well until three months before admission. He then " caught 

 a severe cold," accompanied by cough, pain in the chest, short breath, and prostration. 

 When first seen he was pale, oedematous in the face, suffering much from spasmodic 

 cough. The heart was obviously enlarged, as was also the liver. The temperature 

 was 98° - 4. The urine of sp. gr. 1016, containing much albumen. This, however, 

 disappeared after a fortnight's rest, and never returned to any appreciable extent. 



A sphygmographic tracing of the pidse at the wrist, taken two months after his 

 admission, showed the remarkable fact that the heart's pulsation was entirely under 

 the command of respiration, so that when he held his breath, the tracing was 

 reduced to a faintly undulated line. On the other hand, when he coughed, a wave 

 of great force and extent was sent through the artery, somewhat resembling the 

 healthy pulse tracing. He had occasional slight haemoptysis and increased dyspnoea, 

 under which symptoms he sank on November 20, 1876. The pericardium was found 

 entirely free from adhesions, the heart weighing 19£ ounces, greatly hypertrophied, 

 but without any valvular lesion. 



The aorta and great vessels of the neck were extremely atheromatous, much 

 thickened in places, but quite pervious. 



The left kidney was atrophied, flattened, and of triangular shape, somewhat re- 

 sembling the suprarenal capsule. Its vessels and the ureter were normal and per- 

 vious, but the vessels were only about half the size of those on the right side. 



The arteries at the base of the brain were extremely atheromatous ; the atheroma 

 extending throughout their branches as far as the small vessels spreading over the 

 convexity of the hemispheres. 



On comparing the above cases, we obviously have three different causes, all of a 

 physical character, but producing one and the same result — namely, hypertrophy. 

 In the first two the permanent obstacle between the heart and the arterial system 

 was broken down, and the momentum of the blood column was thus permitted to 

 fall back upon the muscular structure itself, instead of being warded off by the re- 



