. Diseases of the heart and arterial system : designed to be a practical presentation of the subject for the use of students and practitioners of medicine . , anorexia, flatu-lence, constipation, scanty non-albuminous urine, pain in thehepatic region, and lungs were negative,but on examining the heartthe apex-beat was found to bea weak tap in the fifth left in-terspace on the nipple-line andto be followed by a distinctdiastolic rebound or shock,while there was in addition anunmistakable systolic reces-sion of the fifth interspace,from the border of the ster-num to a point outside
. Diseases of the heart and arterial system : designed to be a practical presentation of the subject for the use of students and practitioners of medicine . , anorexia, flatu-lence, constipation, scanty non-albuminous urine, pain in thehepatic region, and lungs were negative,but on examining the heartthe apex-beat was found to bea weak tap in the fifth left in-terspace on the nipple-line andto be followed by a distinctdiastolic rebound or shock,while there was in addition anunmistakable systolic reces-sion of the fifth interspace,from the border of the ster-num to a point outside of theapex-impulse. Cardiac dul-ness extended from the right sternal border to -| an inch outsidethe left nipple, and in the mitral area was a harsh systolic mur-mur that was transmitted to mid-axillary line (Fig. 22). Bothheart-sounds were audible, and the second at the apex was followedby a short diastolic murmur. The inferior hepatic border waspalpable 2 inches below the costal arch, and was thin, hard, andsomewhat irregular. The pulse was slow, tense, and regular, andthere was no icterus. The diagnosis was plainly that of mitral regurgitation and. 22.—bHows Cardiac Dulness andLocation of Border of Liver. CHRONIC PERICARDITIS L09 adherent pericardium with secondary cirrhosis of the liver andascites. The chronicity of such a case is attested by the fact that afterrepeated tappings and prolonged confinement to the house thispatient again appeared in public, and was accidentally encoun-tered by me in the fall of 1S95. He admitted that he was not verywell, and that he still had his ascites. He died a few months sub-sequently. In this interesting case cardiac symptoms did not as-sert themselves, and the clinical history was essentially that ofatrophic cirrhosis of the liver, and would ordinarily pass for such. The following case is narrated because of its interesting clini-cal course and instructive pathological findings: Mrs. M., agedforty-five, consulted me in February, 1893,
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