evidence of general debility and atony of the digestive apparatus as it is possible to find. The color of the tongue often gives us a fair idea of the degree of anæmia from which a patient may be suffering.

The movements of the tongue have as great significance as the coating, if not even greater. Aside from the slow protrusion of the debilitated and the sudden extrusion of the nervous and excitable, its movement tells us of conditions of the nervous system. Every one is familiar with the slowly protruded, trembling tongue of advanced typhoid, which, when once out of the mouth, is apt to remain there till the physician repeatedly orders its return to the mouth. If the nervous symptoms of enteric fever are marked, the characteristic fine tremor of the tongue is notable, particularly when the effort is made to move the organ. While the order for showing the tongue needs to be repeated frequently in diseases associated with hebetude, it is a curious fact that patients will often obey this command when so deeply comatose as to be incapable of any other form of obedience. In apoplexy the tongue is of course protruded towards the paralyzed side, and in glossolabio-pharyngeal paralysis the tongue affords one of the earliest of the symptoms, in that its clumsy movements call the patient's attention to his condition chiefly through failure of the lingual sounds in speech. Later in this affection the tongue shows marked atrophy, which may be manifested by a fissured shrivelled appearance, or by local areas of marked atrophy along its edges, giving it a crenated appearance. The size of the tongue is also notably decreased to the eye and touch, and on the mouth being well opened the organ is seen to be affected by fibrillary tremors. If the patient be asked to remove a piece of food from between the cheek and the gum by means of the tongue, he will do it clumsily or not at all. Frequently severe bites of the tongue occur, showing the lack of power in the patient to keep it out of the way of the teeth. This loss of power of the tongue is also seen in rare cases of tabes and progressive muscular atrophy.

While the tongue in true paralysis is always protruded towards the paralyzed side, in hysteria it is always protruded towards the well side.

It is of interest to remember that, in multiple foci of cerebral softening, where the lesion occurs in the cortico-muscular tract containing the fibres supplying the tongue, while the tongue may be paralyzed, it does not atrophy, as it does in glosso-labio-laryngeal paralysis.

Sudden loss of power of the tongue indicates acute paralysis due to hemorrhage or embolism or thrombosis of the basilar artery. Again, there may be rapid loss of power in the tongue from acute bulbar inflammation, in which case the loss of power is not so rapid as

in hemorrhage or embolism, but is more rapid than in glosso-labiolaryngeal paralysis. Compression of the medulla from tumors, aneurism, or bone disease may also produce paralysis of the tongue.

I shall not speak of the eruptions of the tongue closely allied to those of the skin, as, for example, herpes, though they have great diagnostic value in regard to other diseases, but shall finally call your attention to the small, wizened, contracted, red, and irritable tongue of acute peritonitis, and to the ulcer of the frænum in children which occurs in some cases of whooping-cough.

In lesions of the nucleus of the hypoglossus the tongue is found to be affected with hemiatrophy, and to be subject to fibrillary tremblings. The appearance of the affected side of the tongue is like that of the entire organ in glosso-labio-laryngeal paralysis. Protrusion of the tongue is fairly well performed through the vicarious action of the normal half.

Sometimes post-apoplectic chorea manifests itself in the tongue, and a tremor of this organ is also seen in general paresis when the patient attempts to speak.

THE CONDITION OF THE HEART IN MITRAL

INSUFFICIENCY AND IN CHLOROSIS.

CLINICAL LECTURE DELIVERED IN THE CHARITÉ HOSPITAI.

BY PROFESSOR CARL VON NOORDEN, M.D.,
Berlin, Germany.

GENTLEMEN,—I bring before you to-day two cases which we will study with the purpose of ascertaining an exact knowledge of the condition of their hearts. You will then be convinced that the symptoms of disease which we find in the hearts and in many other parts of the circulatory systems of both patients bear an extraordinary resemblance to each other, so that a careless examination and a superficial recognition of the accompanying circumstances would lead one to diagnose both cases as the same disease. A closer study of the two cases will show you that they are quite different.

Allow me in the first place to consider a little the previous history of these patients.

CASE I.-Let us first take the case of Fräulein D. The girl is seventeen years old. Her parents are living and healthy, as are, also, her two brothers; one sister suffers from chlorosis. She herself in childhood had measles and whooping-cough, and was then perfectly healthy until her fourteenth year, when menstruation began, which was generally accompanied by pain, so that the patient was confined to her bed during the first two days of her sickness. At fifteen she had articular rheumatism, which was, however, slight, and in three weeks her health was fully regained. Last year, while the patient was a saleswoman, she had influenza; the attack, however, was slight, and was over in three days. It was at that time that I first saw the patient and examined her. Because of her history of former articular rheumatism, I examined her heart with particular attention, and I can affirm that at that time the size of this viscus and the heart-sounds were perfectly normal. A few weeks later, when she had occasion to consult me regarding an acne of the face and neck, I found the condition the

same. I am thus in a position to state that there was not, as a sequela of the articular rheumatism or influenza, a lesion of the heart. About ten weeks ago the usual symptoms of chlorosis began to show themselves in this hitherto apparently healthy girl,--paleness of the hands and of the mucous membranes, weakness, sleepiness, giddiness, twitching of the eyelids, palpitation of the heart, shortness of breath on going up-stairs, and paucity of menstruation. In the first weeks of the trouble she took Blaud's pills; later there was no treatment. At present her condition is anæmic. You see before you a very pale girl, whose external appearance gives you the impression of a chlorotic patient. Her blood is thin. The number of the red corpuscles in a cubic millimetre is three million eight hundred thousand; the amount of hæmoglobin is about 7.70 grammes, or a little more than one-half of the normal amount. The urine is plentiful (eighteen hundred to twenty-two hundred cubic centimetres per diem), free from albumin and sugar, and very pale, as is generally the case in chlorosis. The condition of the circulation will be spoken of later. In general the most careful examination has been unable to detect any disease of the viscera.

CASE II.-Fräulein G. The girl is nineteen years of age. Her father is alive, and is healthy. Her mother died in childbirth. She has no sisters or brothers. As a child, she had measles, scarlet fever, and diphtheria. She has since been well. She was brought up in straitened circumstances. Her menstruation began in her thirteenth year, and was regular. Later, she had articular rheumatism, and was five weeks in the hospital of her native town. At that time she was told that she had a heart-lesion as a result of the articular rheumatism; nevertheless, she has never had subjective symptoms which could in the least be referred to such a condition of the heart. Soon after her recovery from the rheumatism her surroundings became improved, inasmuch as she obtained a situation in a family where her work made few demands upon her bodily strength. She tells us that here she became much stronger, and in fact you see before you a person of healthy appearance of whom you would not suspect that she had had to struggle with hunger and misery. She affirms, further, that she has at present no trouble with palpitation or breathlessness, and that it is only when she climbs a high stair that she feels any difficulty. I emphasize this the more, as the existence of a heart-lesion is well known. I shall speak later of the circulatory system. The other viscera are healthy. The patient was sent to us on account of a slight angina follicularis, which a two-days' treatment entirely relieved.

It will be our purpose to apply ourselves to the study of the circu

latory system of these two girls, and especially the condition of the heart. You will see that the differential diagnosis presupposes a very exact examination and careful consideration. We have now before us a question that is of practical value and often arises. How shall we determine whether the chlorotic girl (Case I.) is an example of heartlesion or not? The second case serves as a comparison.

The Condition of the Circulatory Apparatus in Case II. (Mitral Insufficiency); Condition of the Thorax.-I will next speak to you concerning the symptoms which are found by the objective examination. The thorax is normally formed, of average depth and width. It is necessary to recognize this, as a too wide or a too narrow thorax gives rise to a deviation of the apex-beat and heart-dulness, which must be considered. The apex-beat of the heart is perceptible over the sixth rib, in an area greater than normal; it reaches to the left one and a half centimetres beyond the nipple-line. At the point of the apex-beat a forcible systolic upheaval of the intercostal space is felt. There is, however, no murmur to be detected, even when the patient sits up or lies upon the left side.

The Closure of the Valves of the Pulmonary Arteries.-In other parts of the thorax is discovered a heart's action that does not contradict this opinion. The examination of the second left intercostal space gives a positive murmur. Then there is felt, one centimetre from the left sternal border, a short, sharp, deep-seated and well-defined impulse, which recurs rhythmically and is most clearly heard on full expiration.

The comparison of the time of the impulse with that of the carotid artery shows that the two alternate, and that the impulse is diastolic, and there can be no doubt that it is produced by the recoil of the blood against the pulmonary valves.

Diagnostic Conclusions.-From these inspections and palpations it is possible to draw very correct conclusions. At the same time it is necessary to be certain that the lungs are sound, as they are in this case. The outline of the lungs is normal; they extend in front on the right side to the sixth rib, on the left from over the sternum to the fourth rib. Over all respiration and vesicular murmur are normal. There is nothing abnormal in their position over the heart.

We learn from these conditions, and from the position and condition of the apex-beat, that there is a dilatation of the left ventricle; perhaps, also, an unimportant hypertrophy of the muscular wall. Further, we learn from palpation over the pulmonary orifices that an increased rebound of the blood-current occurs over these valves. We