Studies from the Institute of Pathology

THE. patient was a boy of sixteen years. On admission to hospital he gave a history of "heart trouble" since birth. This was chiefly manifested by breathlessness on exertion. He had always been of a blue colour. He had been twice in hospital in the last year with swelling of ankles and face. Four weeks ago he took a sudden severe "crushing feeling" in his chest which was accornpanied by abdominal pain. When the pain passed off he felt very weak and vomited frequently. Since this episode he had been breathless without exertion and had transient attacks of vertigo, and a few days before admission his ankles began to swell. There was nothing relevant in the family history. His bowels were regular, but he ate and slept pporly. The amount of urine passed had diminished. On examination he was very cyanosed and a little breathless. There was marked cedema of the feet, ankles, and sacral region. His fingers showed clubbing. The pulse-rate was 120, was regular, and its volume and tension fair. The apex-beat of the heart was forceful and diffuse, and was palpable in the fifth intercostal space five inches from the middle line. By percussion the heart was found to be enlarged to the right of the sternum. Oin auscultation there were presystolic and systolic murmurs at the apex, and a systolic murmur in the pulmonary area. The blood-pressure was 110 systolic, 50 diastolic. In the chest there was dulness at both bases, with diminished breath-sounds and vocal resonance. A fluid thrill was felt in the abdomen. The spleen and liver were easily palpable. No signs of disease were found in the other systems. The day following admission one and a half pints of. clear fluid was aspirated from the right pleural sac. A radiograph showed bilateral pleural effusions and transverse enlargement.of the heart to the right. A blood-count showed 5,310,000 red cells and 11,100 white cells per cubic millimetre. Spectroscopic examination of the blood revealed no abnormal pigments such as methaemoglobin. The urine contained a trace of albumen throughout the illness, and the temperature ranged between 970 and 99°F. After the first week in bed the oedema cleared up slightly, but in the next three weeks it grew steadily worse. The cyanosis was persistent. During this time a notable feature was the changing character of the murmurs in the heart. A systolic thrill became palpable at the …