observed, the spaces between the fourth and fifth and the fifth and sixth ribs being retracted at every diastole. Between the fifth and sixth ribs lies the lowest point of cardiac pulsation to be seen or felt, the ribs beneath this closing up, and almost overlapping each other, and extending down into the pelvis; but this is no apex beat, but a broad impulse diffused over a space of two inches and a half. The large arteries of the neck pulsate visibly with great force, and some thrill is felt at each pulsation. On laying the hand over the upper part of the thorax, a considerable amount of thrill is felt, chiefly towards the right edge of the sternum and along its upper border. On putting the finger into the tracheal fossa, the aorta is felt pulsating within half an inch of the upper edge of the sternum. Between the second and third ribs, on the right side, a pulsating tumour is to be felt, extending for about an inch to the right.

On percussing on the left side, one inch from the edge of the sternum, the percussion note is found to be clear down to the upper edge of the fourth rib; dulness extends from that to the upper edge of the sixth rib, and beneath this nothing is perceptible on percussion but the tympanitic note of the stomach. Dulness in the nipple line begins about an inch to the right of the sternum, and extends across for a distance of four inches and three-quarters. Along the right edge of the sternum, from the upper edge of the second rib down to the liver dulness, for a listance of one inch to the right, the percussion note is dull.

On auscultating over the lowest part of the cardiac impulse, the first sound is heard somewhat muffled, and the second is replaced by a murmur. Between the second and third ribs, at the right edge of the sternum, a loud, rough murmur replaces the first sound completely, and the second sound is also wholly replaced by a softer blowing murmur; both of these sounds are louder and harsher over the pulsating tumour already mentioned, and become softer in character, though remaining equally distinct, on auscultating over the sternum. These bruits are propagated upwards into the vessels of the neck, and across the sternum to the left. The pulmonary second sound is distinctly audible just over the left edge of the sternum close to the second interspace, within which it is only faintly to be heard close to the sternum. The pulse is 86, full, and jerking, and is also delayed, the radial pulse coming just between two cardiac impulses, and as nearly as possible equidistant from both. At present his cough is nearly gone, but he still has a slight amount of purely catarrhal expectoration. Other phenomena unimportant, either natural, or without bearing on the

case.

In this case the whole of the urgent symptoms and signs were those of incompetence of the aortic valves, phenomena which are always rare when the disease is mainly of the nature of a sacculated aneurism just above the valves, in which, according to my experience, the symptoms are never cardiac, even though some of the

signs are those of aortic incompetence; and I refer mainly to the murmurs-for where the disease has originally been a sacculated aneurism of the aorta, the heart is rarely much implicated, even after the signs of aortic valvular incompetence have been superadded. Further, the signs present-especially the comparatively slight amount of dulness to the left of the sternum, and the greater amount of dulness to the right, and especially the fact that the pulmonic second sound was scarcely audible at all to the left of the sternum, and only became so after we had placed the stethoscope upon that bone-all pointed to the great probability that the heart had been slightly dislocated to the right,—a fact which, if correct, would of itself sufficiently explain the appearance of a pulsating tumour between the second and third ribs on the right side, and extending not more than one inch from its right margin, as this is just the situation in which the aorta might be expected to appear in such a case. The probability that this was the source of the pulsating tumour was further increased by discovering from the augmented dulness across the upper part of the sternum, and the feeling of pulsation in the tracheal fossa, that the transverse portion of the aorta was dilated; because all experience teaches us that in a case of aortic incompetence with a dilatation of the transverse portion of the aorta, dilatation of the ascending portion is almost certain to exist. But an dislocation of the heart to the right would suffice to push even a normal aorta from under cover of the sternum, and still more, therefore, one which is dilated. Besides, the slight increase in loudness of the abnormal murmur in this case was no greater than what might be expected from the closer approximation to the ear of the pulsating tumour in the second intercostal space, as compared with an artery lying beneath the sternum, and wanted the considerable accentuation of such murmurs as heard over an aneurism. Moreover, all pressure symptoms were entirely absent. The lung on both sides was evidently displaced, and to its absence was unquestionably due the diastolic dimpling of the fourth and fifth interspaces on the left side, while the proximity of the aorta to the walls of the chest was undoubtedly the cause of the greater loudness and roughness of the bruit over the tumour than over the sternum. The slight displacement of the heart was probably caused by the deformed condition of the chest due to rickets, the base of the heart being more displaced than the apex, as if the enlarged heart resting on the diaphragm in this deformed and stunted body leaned somewhat forwards and to the right into the bulging right half of the thorax; and this I have no doubt it did.

This patient died on 1st January 1871, from sudden oedema of the lungs; and though a proper examination of the body was refused by the friends, I was enabled satisfactorily to ascertain that, though the aorta was dilated and projected in the direction indicated, there was no saccular aneurism connected with it.

There can be no reasonable doubt that in this case the cardiac disease was primarily due to the obstruction opposed to the circulation by the sinuosity of the arterial trunks produced by the distortion of the skeleton, which, as Barkow has pointed out, has an unmistakable influence in promoting dilatation and hypertrophy of the heart. The increased energy of the heart in such cases has also a special influence in producing dilatation of the aorta, especially of its ascending portion,2 an influence which we can readily understand may be modified very considerably by the structural condition of the aorta itself. When once dilatation of the ascending aorta is produced, the secondary development of incompetence of the aortic valves is merely a question of time.

The next case was repeatedly under observation, and was always an object of great interest.

CASE II.-M. P., a milliner, unmarried, aged 46, admitted to Ward XIII. on 26th January 1871, complaining of cough, feeling of oppression over the trachea, and of general debility. She had been a milliner for thirty-three years, working during the busy season from 6 A.M. of one morning to 1 A.M. of the next. As the result of this overwork she was never strong, and never free from headache; still, she could take her food well, and was able to continue her work. About sixteen years before admission, she first perceived that her right shoulder was somewhat distorted. Since that time this, as well as the distortion of her body, which she also then first noticed, has gradually increased. But the change has been gradual, and she suffered from no illness more severe than a mere casual and temporary catarrh, till seven years before admission, when she suddenly found herself affected with a cough, which has never since entirely left her. She was not ill or feverish at that time, and was unconscious of having caught cold. Two years subsequently, however, this persistent cough was aggravated by an attack of bronchitis, which lasted for five weeks, and broke down her health very much. Since that time her bodily distortion has steadily increased; and about a year after this her bodily distortion and debility became so great, that she was compelled to give up her occupation. Since then she has been constantly subject to a dull aching pain, referred to the right shoulder-blade, the intensity of which has gradually increased. Since then she has also been subject to pain in the legion of the stomach, more or less constant, but worse when the stomach is empty, and somewhat relieved by taking food.

For some years she has been aware of a pulsation in the front of her neck, but her attention was not particularly directed to it till the morning of the 23d of January 1871, when, after a severe fit of coughing, she accidentally observed that where this simple pulsation formerly existed there was now a throbbing swelling 1 Die Verkrummungen der Gefässe, s. xv. 2 Op. cit., s. xxxv. 3 Op. cit., s. xv.

equal in size to a hen's egg. A feeling of tightness and choking over the chest and lower part of the throat, which subsisted after the cessation of the paroxysm of coughing, induced her to look at her throat, and so to discover this pulsating tumour. On admission, the patient was seen to be much emaciated and etiolated; there was considerable scoliosis of the spinal column in the dorsal region, with right side convexity, some protrusion backwards, and compensatory lumbar curve to the left; the thorax on the right side was thrown outwards and backwards, and flattened laterally; on the left side the ribs were indented and compressed together.

On palpation, the only pulsation to be felt on the left side is between the third and fourth ribs, about half an inch to the left of the sternum. To the right of the sternum, pulsation is felt in the first, second, and third interspaces. This pulsation was most forcible and distinct in the second interspace, where it extended a couple of inches to the right of the sternum, and in this situation a considerable thrill was to be felt. In the lower part of the neck, just over the suprasternal notch, a pulsating tumour, evidently a dilated artery, was felt crossing the trachea and dipping beneath the sterno-cleido-mastoid muscle, being apparently continuous with the right subclavian artery, which, as well as the brachial, was also large and dilated. The left subclavian was also dilated. The aorta was not felt on passing the finger deep into the tracheal fossa. All the arteries at the root of the neck pulsate strongly.

On percussion, the cardiac dulness on the left side was found, at one inch from the sternum on the left side, to commence at the upper border of the second rib, whence it extended down to the liver dulness. From the upper border of the second rib, dulness across the sternum gradually rose to the lower border of the first rib, and at the right edge of the sternum this dulness passed outwards between the first and second ribs to a distance of two inches from that bone, passing downwards to the liver dulness in the same parasternal line. At the level of the fourth rib the transverse dulness is four inches and a half. On auscultating over the cardiac pulsation to be felt between the third and fourth ribs, half an inch to the left of the sternum, both sounds are to be heard, neither very pure. Over the fifth rib, one inch from the left edge of the sternum, these sounds are to be heard with greater distinctness and purity, but no pulsation is to be felt. In the second interspace to the left, distinct but impure first and second sounds are both to be heard. In the second interspace to the right of the sternum, the first sound is impure, and the second is obscured and almost entirely replaced by a diastolic murmur. Over the pulsating tumour already referred to as chiefly lying between the first and second ribs to the right of the sternum, where the pulsation is most fluid and most forcible, we have a loud systolic murmur, followed by a less distinct diastolic murmur. These murmurs obviously have their position of maximum in

tensity in this situation, and from it both radiate outwards in all directions, the systolic murmur extending upwards with most distinctness, the diastolic murmur being propagated with more distinctness downwards, but pari passu less distinctly, being more faint ab origine. The pulmonary percussion was equal on both sides, and the respiration also equal, though neither could be held to represent an average normal, the one being slightly higher in pitch, the other slightly rougher in character. No other signs or symptoms of any importance could be elicited, except that over the pulsating tumour already referred to considerable systolic thrill could be perceived.

Obviously the diagnosis in this case was not far to seek; the absence of the slightest sign of any abnormal pressure, in spite of the existence of an abnormal pulsating dulness in the first interspace to the right of the sternum, was quite conclusive as to the non-// existence of any sacculated aneurism, or even of any considerable arterial bulging of a cirsoid character in that region, and equally conclusive as to the pulsation being simply arterial in character; this being further confirmed by the strict limitation of the dulness to the pulsation. But a pulsating arterial tumour in the region referred to could only be aortic in its origin; and, if only a simple dilatation, must be of unprecedented dimensions to present so large a superficial area of dulness. The position of the cardiac pulsation, however, as well as the situation and form of the area of cardiac dulness, assured us that the heart was tilted upwards as well as thrown over more to the right of the sternum than usual; hence we had the ascending portion of the aorta passing more directly outwards to the right; and, as the transverse portion of the arch did not rise much higher, nor take a wider sweep than ordinary, it must necessarily have made, with the ascending part, a more than usually acute angle. Hence, of course, compression of the lumen of the vessel at this acute angle, and hence, also, a complete explanation of the systolic thrill and the loud systolic murmur, necessarily due to the formation of fluid veins where the blood passed through the constricted part of the artery into another portion, which possibly enough might be more dilated than usual, although that was by no means essential. As for the diastolic murmur, in the absence of any saccular aneurism, which we believed not to exist, its only possible cause must have been regurgitation through the aortic valves, the result of the increased pressure due to accumulation of blood in a dilated ascending aorta, the effect of which in every case must certainly be ultimate rupture of the valve from hydraulic pressure, an inevitable physical result which might possibly enough be complicated and hastened by the certainly less inevitable physiological results of pressure-local endocarditis, thickening and shrivelling of the valve.

This patient died suddenly from syncope, in Ward XIII., on 7th November 1872. At the autopsy the lungs were found con

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