pathology of the cases thus referred to be correct, the origin of the symptoms is connected with obstruction on the right side of the heart, in the majority of instances. The obstruction may be on the left side; but the occurrence is comparatively rare, and the symptoms themselves are modified in detail by the difference in the point of obstruction.

Taken generally; the symptoms of fibrinous obstruction on the right side are those which might be anticipated on a priori physiological reasoning, as necessarily incident to obstruction of blood-making towards the pulmonic circuit. They are the symptoms of arrest in the nutrition and life of the body. They are characterised primarily by a peculiar and distressing dyspnoea. This occurs, not because the respiration is checked, for the respiratory murmur may be audible enough, but because the current of blood to the lungs is in part cut off. As an addendum, emphysema of the lungs, especially in children, results, and the physical signs of this lesion are often a valuable corroboration of the presence of concretion on the right side. The dyspnoea depends on the deficiency in the supply of blood to the lungs and the nervous centres. The left side of the heart being imperfectly supplied with blood, the arterial circulation is weakened; the pulse is small and intermittent; the surface of the body is cold, and generally white as marble; but, as there is stagnation of blood in the venous circuit, the more vascular parts, as the lips and centre of the cheeks, are often of a leaden hue. There is general muscular prostration; and, as the brain is not supplied normally with blood, the muscles are not under the control of the will, but are in a continued restless motion. The mind loses its power; the acts of excretion are per

formed involuntarily; and death sets in, the gasping respiration outliving the paralysed and obstructed heart.

The symptoms thus pourtrayed are applicable to cases in which they last for several hours: in such examples the concretion is either lodged in the right auricle, or is being laid down as a tube in the infundibulum and pulmonary artery, or is commencing at the extremities of the pulmonary circulation.

But other cases occur, where the course of the symptoms is suddenly cut short. There may have been some slight premonitory symptoms, but the suddenness of the end is the great fact. The patient, previously exhausted, is rising in bed or making some muscular movement or strain, when suddenly he reclines or falls, breathless, faint, feebly convulsed, dead.

I have met with two illustrations of this last event. The cause in both cases was the same, and the cause is ordinarily the same; the pulmonary artery is suddenly blocked up with a fibrin cylinder. In each of the cases observed by myself, this cylinder had been hollow, and had conveyed a stream of blood like a tube. Its base had commenced in the infundibulum; its apex had ascended into the pulmonary artery. The concretion had suddenly been torn from its attachments, and carried up into the artery. In its centre was a column of red clotted blood; externally it was encased in a thin layer of blood, the result of a rush of blood past the concretion after its detachment.

Once more there are instances where the symptoms are unusually prolonged. In one instance which I observed, the symptoms of dyspnoea extended over many days, and anasarca supervened as a result of the obstruc

tion. The concretion, in this instance, commenced in the auricula, where it had a firm attachment, and sent a prolongation downwards into the ventricle. In the case supplied by Dr. Sayer, and described at page 89, the symptoms of dyspnoea extended over many months; and Mr. H. Lee has recorded an instance in which a similar extension of symptoms occurred.

When the concretion is deposited on the left side of the heart, the ventricle, the infundibulum, and the ascending portion of the aorta, are the most common positions. The symptoms which characterise the presence of concretion here situated are different in many respects from the preceding. There is tumultuous action of the heart, a symptom which is strikingly indicative that the deposit is on the left side. There is congestion of the lungs, and suffocative dyspnoea, with expectoration sometimes mixed with blood. The surface of the body is of a leaden colour, and the body is cold. The muscular perturbation lapses into powerful convulsions, and coma precedes dissolution. These symptoms may extend over many hours.

But, as in the preceding class of cases, the symptoms may also occur in a sudden manner. The patient, in moving or making a straining effort, suddenly falls back, is seized with a violent convulsive fit, and so expires.

I once saw these symptoms and this sudden form of death in an old lady, who had previously suffered from no other symptoms than a slight attack of cold. In rising from bed she fell, as I have described, and died before medical assistance could be obtained. In this case, the concretion had formed as a hollow cylinder in the infundibulum of the left ventricle, had become dis

lodged, and had been carried into the aorta, which it entirely occluded.

Again; the symptoms of the concretion may extend over a long period. The concretion may, as I have shown, become organised. In such case the symptoms are those of valvular obstruction on the left side. Such cases often end suddenly at last.

Cases may be met with in which concretions exist on both sides of the heart at the same time. In such instances, unless the concretion on the right side be small, or placed out of the direct course of the circulation, the symptoms partake of the characters which belong to deposition in the right cavities.

The pre-existence of disease of the heart, either acute or chronic, favours materially the deposition of fibrin. We have seen in acute endocarditis how this obtains; it is easy to see, and cases abundant are on record for illustration, to what extent dilatation of the heart, feebleness of its walls, or induration of its valves, favour the formation of concretion.

I have often been asked, whether there are no reliable physical diagnostic signs of concretion? I think not. There are sometimes abnormal sounds, but it is difficult to distinguish these from murmurs, the results of valvular lesion. The tumultuous action of the heart, taken with the general symptoms, is always a valuable diagnostic mark of concretion of the left side; but this is compatible with other diseased conditions. The weak irregular action is, with the general symptoms, a valuable diagnostic sign on concretion of the right side; but it is equally compatible with other causes. In some cases, where the concretion interferes with the action of either the auriculo-ventricular or semilunar valves, there

is a muffled character with the sounds, dependent on the obstacle to the play of the valves, by the tension of which the sound is produced. But, as it is scarcely ever the fact, that both sets of auriculo-ventricular valves, or both sets of semilunars, are affected simultaneously by concretion, loss of either sound is of rare occurrence. In short, the only physical signs of moment are, feebleness of action, tumultuous action, or occasionally a peculiar rumbling, fidgety, jog-trot motion, with which the two sounds are heard in natural sequence as regards each other, but irregularly and lispingly.

The diagnosis must therefore rest on the general symptoms, rather than on the physical. The nature of the case must first be considered. All acute sthenic inflammations form favourable pre-existing conditions; pneumonia foremost of all. The puerperal state, before and immediately after parturition, stands in the same category, and this without the absolute necessity of acute inflammatory disorder. The puerperal state is second to none in this particular, and the symptoms of concretion are often as insidious as they are sudden. do not speak here of puerperal phlebitis, and of deposits in the veins, but of cases where there has been no untoward sign, either during pregnancy or after parturition, and where the woman suddenly succumbs, without any preliminary indication of acute disease.

I

I have met with but one example of this kind, and my notes of it are defective. My friend, Mr. Edenborough, has, however, given me a note of an unpublished case which occurred in his practice, in May 1849, which illustrates the argument too painfully. The patient was delivered of her sixth child, after an easy labour of three hours, on May 1st. On the following day, lactation was