idea of one of those affections which usually cause a great number of affections, viz., inflammation. For how can we allow that inflammation is the cause of an acute softening accompanied by a diminution of thickness, paleness of colour, and a kind of dryness of the texture which is the seat of it? Such a supposition would truly imply a contradiction, and, as I remarked in relation to the softening of the liver, if we knew any cause of disease exactly the reverse of inflammation it would be proper to refer this softening to it.

"Other considerations which I have already given in relation to the spleen support these reflections. The walls of the heart, although more or less softened, had never any pus in them, and there was never any inflammation of the pericardium, which would have been the case rather frequently in softening of the heart, had this softening been caused by inflammation. And in opposition to this opinion, we cannot produce cases of pericarditis observed after other acute diseases, inasmuch as softening of the heart was found in two cases out of eight in which there was pericarditis.

"Moreover, the frequency and severity of the softening were much more marked according as the disease was more early fatal. Thus the heart was softened in nearly half of those patients who died between the eighth and twentieth days of disease, in a third of those who died during the following period, and in a somewhat smaller proportion among those who died afterwards. Besides, in seven cases in which the softening was extreme, not one was relative to individuals who died after the thirtieth day of the disease, and I found

4 out of 17 patients of the first and second series,

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third

3,, 20 "Hence we see, that whatever was the degree of softening, the proportion of cases in which it took place in the different series of patients was very nearly the same; and it was like that of the liver and spleen, more serious in those who died early in the disease, than in those who died after the twentieth day, and

we did not find it at its maximum in patients belonging to the fourth series. The rapidity of its development showed the extreme violence of the cause to which it was owing in certain cases, and as other lesions of the same kind, it necessarily contributed much to produce death and hasten its arrival.

"Another fact which seems to me to be not less remarkable than the rapid softening of the heart is this, viz., no similar lesion was found in any other muscular organ; as all the muscles which preside over voluntary motions preserved, amidst the general disorder, the consistence and colour which are natural to them."*

In these extracts I have given all that has been discovered on the subject; no series of observations on the action of the heart in typhous fever has been published; I have commenced this inquiry, and have sought to derive some important indications of treatment from the existence of the phenomena now described. In the present state of the inquiry I wish it to be understood, that my observations are to be taken as referring principally to the epidemic of last year. Further researches must be made to establish how far they may be applicable to typhus in general; but I have little doubt from studying the researches of Louis, and connecting the facts relative to the anatomical state of the heart, with those now observed as to its vital phenomena, that my observations will be found to have a · very extensive application.

The epidemic of last year was marked by all the signs of putridity. Dark coloured and abundant petechiæ; sordes of the mouth, fœtor of the surface, extreme prostration, and stupor, were the prominent features of the disease; and in many cases bronchial and gastro-enteric irritation existed to a great degree.

In many of the cases the bad symptoms were developed at an unusually early period, yet though recovery by crisis was by no means common, the convalescence was generally satis

Louis. Bowditch's translation.

factory, and the ultimate restoration to health complete. In several instances the disease was traceable to contagion.

We may thus arrange the cardiac phenomena obtained in our typhous fever :

1. Impulse and sounds remaining unaltered; the action of the heart corresponding with that of the pulse.

2. Vigorous impulse, with distinct and proportionate sounds, with absence of pulse for many days.

3. Diminution of both sounds of the heart, with absence of great diminution of the impulse, (foetal character).

4. Diminution of the first sound; with cessation or great feebleness of the impulse.

5. Complete extinction of the first sound, the second remaining clear.

6. Predominance of the first sound, the second being extremely feeble.

Of these the fourth and fifth were the most common.

I have before remarked, that in the progress of a single case we may observe first one and then another of these groups of signs. Thus in the second case, (see page 11,) the sounds on the seventh day were proportionate, but so much diminished as to resemble those of the foetal heart. On the eighth day this character was lost, and both sounds were much louder, with returning impulse; while on the eleventh the second greatly preponderated. Nearly the same phenomena were observed in the third case, (see page 15,) and in the sixth, (page 24.) In the case of T. Keefe the second sound was most distinct in the early periods of the case, while the first became predominant towards its close.

In the great majority of cases, however, the phenomena were as follows:

I. Diminished impulse.

II. Diminished first sound, particularly of the left cavities. With respect to the impulse we arrived at some unexpected results. In most cases, considered through the whole progress,

the diminution and return of the first sound were accompanied with the diminution and return of the impulse. So far the phenomena were what we might expect. But in some instances, at particular periods of the case, this accordance between the impulse and sound did not exist. In the second case, (page 9,) the sounds became distinct before the impulse returned. In the third case, (see page 12,) the impulse became distinct on the eleventh day, while the second sound greatly predominated. In the third, (page 15,) we found that on the eighth day the sounds were not in proportion to the impulse; and on the tenth, the impulse continued, but the first sound was totally absent. On the next day no impulse could be felt, yet the first sound was feebly audible. In the fourth case, (page 19,) the impulse on the twelfth day was less perceptible than on the day previous, but the first sound had more strength.

It is difficult, or impossible, in the present stage of the inquiry, to offer any satisfactory explanation of these apparent anomalies; but it seems certain, that under the influence of the typhoid condition, the heart may have sufficient force to give an impulse with little or no sound, on the one hand; and on the other, its contractions may be accompanied by a sound, although the impulse be absent. Whether we are to explain these facts by referring to particular states of innervation of the heart, or to organic alteration in the muscular fibres, or their connecting cellular membrane, is still to be determined.

My friend Mr. Hopper has suggested, that, if there be any anormal liquid secretion between the muscular fibres, the production of sound might be materially interfered with, though the muscle might contract with a certain degree of vigour. In two of our fatal cases, we found that there did exist a liquid tenacious secretion in the fibres of the left ventricle; and it becomes a question, whether the softening of the heart in typhus is dependent on an alteration of the muscle itself, or an infiltration between its fibres. Analogy would lead us to conclude, that in the early stages of the alteration at least, the fibre itself

is but little affected; and the fact of the rapid restoration of the functions of the organ, in the convalescence of fevers, and the occasional excitement of the heart before death, seem to point out, that in such cases the injury of the muscular fibre itself has not proceeded very far.

That the cause of the want of impulse, and feebleness or cessation of the first sound, is a softening of the heart, I have no doubt. The evidences in favour of this opinion may be thus stated:

I. That softening of the heart exists in typhous fever as a local disease, and without any analogous condition of the muscles of voluntary life.

II. That in our dissections in the last epidemic, we met with this softening of the heart, in cases which during life had presented the phenomena in question.

III. That the physical signs indicate a debility of the left ventricle principally, and it is this position of the organ which is most often altered in consistence.

IV. Laennec has stated, that in proportion to the severity of the prutrescent phenomena, is the liability to softening of the heart. And the same observation is found to be true of the physical signs now described.

If this softening of the heart be one of the secondary diseases of typhus, we should, as in the case of other lesions, observe something like periodicity in its phenomena.. It should appear at a certain time, and decline after its proper period had expired. I have analysed my cases with a view to these points, and the result is, that in most instances the signs of diminished impulse and first sound were developed at or about the sixth day, and the heart seemed again healthy at or about the fourteenth day. It is difficult to determine the period of the first development of the signs in many cases, as they existed on the admission of the patient, but still taking in these cases the dates of the disappearance of the signs, we get the following general results :