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month, appeared to have called all her symptoms into activity. I found her at the end of this time labouring under generally diffused bronchitis, her face flushed, her respiration hurried and irregular, varying from 60 to 80 in the minute; her heart beating at the rate of 130; and its pulsations attended with a loud systolic bruit at the apex. Her condition deteriorated, the cough grew harder and more distressing, and the respiration rose habitually to between 80 and 90; while the child took a posture on her face, in which she remained almost habitually, and never obtained any sleep except in that attitude. I saw her for the first time on April 1; she died on the morning of the 5th; quite quietly, having had an anodyne of four minims of laudanum the previous night, which procured her some rest, but no profound sleep.

There were three patches of pulmonary apoplexy, each of about the size of a walnut, in the right lung; and one in the left, somewhat smaller; the languette of the left upper lobe was in a state of collapse, the air-tubes much congested, and containing a good deal of tenacious mucus. The pericardium contained an ounce of transparent serum. The heart was almost as large as two fists, and of a rounded form, its increase of size being due apparently rather to enlargement of the right than of the left half of the organ; though the left cavities of the heart also were unusually large. Both the left auricle and ventricle contained a good deal of black coagulum. The enormously dilated right auricle was filled with firm parti-coloured coagulum; and there was a good deal of black coagulum in the right ventricle. The whole of the right ventricle was enormously dilated; but the dilatation was most remarkable at that part from which the pulmonary artery springs; and which formed behind the pillars of the tricuspid valve almost a second ventricle, so large was it. All the valves were carefully examined, and presented no trace of disease; and the foramen ovale was closed.

A boy, 10 years old, came into the Children's Hospital about a year ago, to die. No history of his previous illness was obtained; but he was very anasarcous, and had a large quantity of fluid in his abdomen, though his urine was found to be free from albumen. The pericardium was found universally adherent, and the endocardium throughout presented a remarkable degree of opacity, though there was no thickening of any of the valves. The heart was very much enlarged owing to dilatation of both its sides; though the left was the more affected. The left ventricle alone was as large as the whole heart of a child 91 years old, whose body

OF THE HEART IN PRODUCTION OF SYMPTOMS.

525

was in the dead-house at the same time, though its walls were scarcely thicker, nor was the aortic orifice larger.

A little girl, when six years old, had an attack of rheumatism, not very severe, since she was scarcely confined to bed at all by it. A month afterwards she first complained of pain in her heart, which for some weeks beat very much. Six months afterwards she began to swell about her face; the limbs afterwards became anasarcous, but the degree of the anasarca had varied much. Nine months after the rheumatic attack she was admitted into the hospital; being then 74 years old. There was some adema of the legs and of the lower part of back, as well as of the abdominal integuments; no ascites, but considerable enlargement of the liver. There was obvious bulging of the left side of the chest. The heart's impulse was visible in the 4th, 5th, and 6th interspaces. Apex beat in 6th interspace; 1 inch outside nipple line, and 1 inch in oblique line below nipple. Impulse somewhat heaving; thrill and impulse in left costal angle.

passed upwards, though still No second sound heard.

At apex a prolonged systolic murmur was heard, which diminished rapidly in loudness as one audible over whole heart's region. Rest and treatment relieved the child, who, having been admitted on February 26, was able to return home on April 16. Her health, however, soon failed again, when she lost the care and comforts of the hospital. She was readmitted on May 6, complaining of constant præcordial pain, probably connected with the supervention of pericarditis, for a friction sound was now for a time audible. Once more she improved, and left the hospital The able and unwearied registrar of the hospital, Mr. Gee, whose notes I have already quoted, found that the Upper dulness limit had now extended to the second rib.

on August 13.

Right

two inches to right of sternum, and half an inch to left of right nipple.

It had, however, already reached this limit on May 22. The heart's impulse was less extensive than in February; the friction sound had completely disappeared, but a systolic murmur was audible over the whole præcordial region; and scarcely any second sound was to be heard.

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IMPORTANCE OF DILATATION OF HEART.

Since she left the hospital I have not seen this little one; but there can be no doubt but that if she has not already found a resting-place and a grave within the walls of some other institution, she will come again to seek such small mitigation of her sufferings as is all that medicine has to offer her. I have related her case not because I assume that it is an instance of dilatation of the heart, independent of valvular disease, but because it is the dilatation which is the cause of her suffering and the source of her danger; and because I have now seen many instances which seem to show that in early life the occurrence of this condition is the one great danger to guard against, since, when it has occurred to any considerable extent, nature seems unable to exert that power of repair and readjustment which, in other cases, she sometimes puts forth so beneficially.*

One more caution may not be out of place with reference to cardiac disease in early life, namely, that the presence of a bruit with the heart's sounds in the child depends more invariably on organic disease than in the adult; inasmuch as those endocardial, arterial, or venous murmurs which are produced by an impoverished state of the blood are very rarely indeed heard in children under seven years old, and are by no means common until that age is attained at which the changes that take place as puberty approaches have commenced, or are on the eve of beginning. I think that I can speak with confidence as to the rarity of such murmurs in childhood, though I cannot venture to assign a reason for it; since the very slight difference between the composition of the blood in early life and in after years can scarcely be alleged as affording an adequate explanation of the fact.

At the same time, however, that we should be most keenly alive to the importance of every sign of heart disease in early life, we should bear in mind that the friends of our patients not infrequently take causeless alarm at the occurrence of occasional palpitation and dyspnoea on exertion, especially if accompanied with irregularity of the pulse. Mere deranged action of the heart, however, is by no means uncommon in children of all ages,

* I have not entered on the question of the mode of production of dilatation of the heart in the young subject. I have no doubt but that muscular weakness has a large share in its production, as the observance of extreme quiet after any attack of endocardial inflammation or of exhausting disease has in its prevention. Dr. Bristowe, in his able paper on Mitral Regurgitation, independently of Organic Disease of the Heart, published in British and Foreign Medico-Chirurgical Review for July 1861, discusses the subject most fully, and with thorough mastery of all the questions involved in its elucidation.

GENERAL CONCLUSIONS.

527

though rarer before seven years old than subsequently. It is most frequently observed in fragile, excitable children, and is not readily amenable to direct treatment, though it subsides in the course of time under a system of general management calculated to improve the health, and of exercise judiciously regulated, and always kept within such limits as not to occasion fatigue.

In conclusion, let me sum up in a few sentences the most important facts concerning disease of the heart in childhood, which I have endeavoured to bring before your notice :—

1st. While disease of the heart is less common in childhood than in the adult, there is no absolute immunity in early life from any of those affections to which the organ in after years is liable.

2nd. Of all the causes of heart affection, inflammation is the most frequent; and while all blood diseases predispose to its occurrence, none exert so powerful an influence in exciting it as rheumatism.

3rd. While inflammation is by far the most frequent cause of valvular disease, there is, nevertheless, reason to believe that it is not the sole cause, but that the valves may become disorganised quite independently of previous endocarditis; and a knowledge of this fact ought to govern our treatment in all cases where the history of the commencement of the affection is at all obscure.

4th. The disposition of valvular disease to increase is not only liable to more frequent exceptions in the child than in the adult, but there is also in early life a special power of repair and of selfadjustment in the heart which warrants our expressing a more cheerful prognosis than would be justifiable in cases of cardiac disease occurring in the grown person.

5th. At the same time, however, the feebleness of the heart in early life, the liability of the child to cachectic conditions and exhausting diseases, the rapidity of the circulation, and the facility with which it may be excited by very slight causes, all tend to favour the occurrence of dilatation of the heart whenever a slight amount of valvular obstruction exists, or even altogether independent of it. Hence it becomes of even more importance in the child than in the adult to insist on long-continued rest, and on the avoidance of all causes which could tend to excite the circulation, not only after attacks of rheumatism, but also after typhoid or scarlet fever, or of any of those more chronic diseases,such, for instance, as chorea,-which are not only associated with disturbance of the circulation, but also with disorder of the circulating fluid itself.

LECTURE XXXI.

DISEASES OF THE ORGANS OF DIGESTION AND ASSIMILATION.-Peculiarities of the digestive organs they require a peculiar kind of food, the milk-composition of that fluid, its adaptation for the nutriment of the infant changes in the digestive organs as the child grows older-these changes take place more slowly in the human subject than in animals.

Evils of giving other food than the mother's milk until the infant is old enough to bear it-shown by the increased mortality it produces-different modes in which sud food acts injuriously--appearances found in bodies of children who have died from imperfect nutrition.

Great importance of infants being suckled, even for a short time-difficulty of analysis of the milk-suggestions for determining fitness of a person for duties of a wetnurse-rules for management of children who are brought up without the breast -substitutes for mother's milk-caution with reference to occasional unhealthy condition of cow's milk.

WE prefaced our investigation of the diseases of the nervous and respiratory systems with an enquiry into the peculiarities of structure and of function which characterise those organs in early life. A similar enquiry will not be out of place now, as preliminary to the study of the diseases of the organs of digestion and assimilation, and their dependencies.

Man, when he has attained to maturity, is able to support his life, and to preserve his health, upon food of various kinds; and the structure of his organs is such as to enable him to live upon an exclusively animal diet, or upon food furnished entirely by the vegetable kingdom. We know that in either case the ultimate elements from which the body is nourished are the same; but that while in the former instance they are furnished as it were ready to hand, they have in the latter to be eliminated by nature's chemistry, through a process which occupies much time, and which requires considerable complexity in the apparatus that effects it.

Those powers, however, of which the adult is possessed, belong in but comparatively small measure to the infant. The growing animal, indeed, needs proportionally more food than the adult; for not merely is the daily waste to be repaired, and that constant reproduction of the tissues to be provided for which is essential to the maintenance of vitality in all parts of the body, but each day is to bring with it an increase in size and stature. But though in