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OEGANICALLY DISEASED HEARTS 
 
THE MECHANISM 
 
 OF THE 
 
 CIRCULATION OF THE BLOOD 
 
 THROUGH 
 
 ORGANICALLY DISEASED HEAETS 
 
 BY 
 
 HERBERT DAVIES, M.D., F.R.C.P. 
 
 LATE CONSULTING PHYSICIAN TO THE LONDON HOSPITAL, AND FORMERLY 
 FELLOW OF queen's COLLEGE, CAMBRIDGE. 
 
 EDITED BY 
 
 ARTHUR TEMPLER DA VIES 
 
 B.A. (Nat. Science Honours), M.B. (Cantab.), M.R.C.P. 
 
 PHYSICIAN to the ROYAL HOSPITAL FOR DISEASES OF THE CHEST; 
 examining PHYSICIAN TO THE ROYAL NATIONAL HOSPITAL FOR 
 CONSUMPTION, VENTNOR; ASSISTANT PHYSICIAN TO THE 
 METROPOLITAN HOSPITAL; LATE CASUALTY PHY- 
 SICIAN TO ST. BARTHOLOMEW'S HOSPITAL ^ 
 
 LONDON 
 H. K. LEWIS, 136 GOWER STREET, W.C. 
 
 1889 
 

 06^ meB^ 
 
 DtC 
 
 4 1917 
 
 PRINTED BY 
 
 Y 
 
 H. K.N^EWIS, 136 GOWER STREET, 
 
 1 
 
EDITOR'S PREFACE. 
 
 In editing these papers by my Father, the late 
 Dr. Herbert Davies, a sad and melancholy plea- 
 sure falls to my lot. It was his earnest wish and 
 intention to have published them himself during 
 his life-time, but such unfortunately was not to be 
 the case, and shortly before his death, he in- 
 structed me to edit them on his behalf. They are 
 the result of many years careful study and matured 
 thought on a subject in which he took the most 
 profound and deep interest. Only those who were 
 intimately acquainted with my Father are aware 
 of the infinite care and trouble which he bestowed 
 on his writings. He never drew any conclusions 
 without most carefully and assiduously verifying 
 the absolute correctness and soundness of his 
 facts. It will be seen that these papers contain 
 several original and new ideas on a subject the 
 mechanical aspect of which was by no means 
 exhausted, and which has important bearings on 
 
vi PREFACE, 
 
 physiological and pathological problems; but I 
 feel it would be out of place to dwell any further 
 upon the merits of these papers, as they are fully 
 able to speak for themselves. 
 
 Through the courtesy and kindness of the Rev. S. 
 Haughton, M.D., F.R.S., Trinity College, Dublin, I 
 am enabled to publish his important mathematical 
 paper on Aortic Regurgitation, which he under- 
 took at my Father's request. I cannot better 
 conclude this preface than in the following lines, 
 which admirably express my own feelings towards 
 the Author of this work. 
 
 " For in my mind 
 
 Is fixed, and now strikes full upon my heart, 
 
 The dear, benign, paternal image, such 
 
 As thine was, when so lately thou didst teach me. 
 
 « « * * * 
 
 And how I prized the lesson, it behoves 
 
 That long as life endures, my tongue should speak."* 
 
 ARTHUR T. DAVIES. 
 
 23 Finsbury Square. 
 May^ 1889. 
 
 Dante, Inferno, Canto xv. Gary's Translation. 
 
CONTENTS. 
 
 Introduction 
 
 Mitral Regurgitation .."... 
 Mitral Obstruction without Regurgitation 
 Regurgitant Aortic Disease — Section I. . 
 Regurgitant Aortic Disease — Section II. . 
 Contraction of the Aortic Orifice without Regurgitation 
 On the four chief Orifices of the Heart 
 
 PAGE 
 I 
 
 15 
 30 
 
 38 
 
 47 
 51 
 61 
 
-'^ < 
 
 DEC 4 1917 
 
 THE 
 
 MECHANISM OF THE CIECULATION 
 
 THROUGH 
 
 ORGANICALLY DISEASED HEARTS. 
 
 It must, no doubt, have often occurred to the minds 
 of many practitioners, when examining a patient, 
 the subject of organic disease of the heart, to have 
 been surprised at the almost unembarrased manner 
 with which the circulation is maintained, in an or- 
 gan manifestly injured. Perhaps no more striking 
 example of this fact could be found, than in a case 
 recorded by Niemeyer in his "Text-book of Practi- 
 cal Medicine," vol. i., p. 347. A huntsman, in 
 Greifswald, who suffered from extensive stenosis, 
 and insufficiency of the aortic valves, and had 
 immense eccentric hypertrophy of the left ventricle, 
 performed all the manoeuvres and forced marches 
 of the army without difficulty. Cases such as this 
 and others come frequently before us, of severe 
 cardiac lesions of long standing, in which no dropsy 
 has ever supervened, and where even the functions 
 
2 CIRCULATION THROUGH 
 
 of life appear to be carried on with but little incon- 
 venience to the individual. The records of Patho- 
 logy will furnish very many instances of death, 
 revealing- the presence of lesions of the heart, the 
 amount, and even the existence of which, had been 
 unsuspected during life. It will therefore be not 
 only interesting, but practically useful to consider 
 the nature of such cases, and to discuss the mode 
 in which the circulation of the blood is carried on in 
 hearts, which are undoubtedly structurally unsound. 
 
 At the commencement of this enquiry, I think it 
 would be advisable to dwell for a short time upon 
 -the mechanism of the circulation in its healthy 
 state. I need scarcely say, that in reality we have 
 two hearts, each perfect in itself, each adminis- 
 tering to its own share of the circulation, each 
 discharging completely its own proper function, but 
 both intimately and inextricably associated with 
 each other, structurally and functionally by muscu- 
 lar fibres, and inter-communicating nerve ganglia. 
 Two functionally distinct and perfect muscular 
 organs, provided with their respective valvular 
 appliances, and performing very unequal physical 
 tasks, are compelled by co-operative association, to 
 beat and act in unison, and as a necessary conse- 
 quence of such association to obey the two follow- 
 ing fundamental laws : — 
 
 I. The corresponding chambers of the right 
 and left hearts receive and expel their contents 
 exactly synchronously, respectively — the two 
 
ORGANICALLY DISEASED HEARTS. 3 
 
 auricles contracting in unison, and dilating- in 
 unison, and the two ventricles exhibiting, respec- 
 tively, synchronous action in their systole, as well 
 as diastole, and — 
 
 2. Equal volumes of blood pass, in equal and 
 the same times, through any two corresponding 
 orifices of the heart. 
 
 I will not detail at length the proofs of the truth 
 of th^se laws, as I have discussed this part of our 
 subject elsewhere, in a paper published in Proceed- 
 ings of the Royal Society r I will here briefly glance 
 at them. 
 
 That the ventricles act synchronously is shewn 
 
 by:- 
 
 1. The sphygmographic tracings obtained by 
 M. Marey in his experiments upon the horse. 
 Instruments inserted simultaneously into the right 
 and left chambers, and connected with the record- 
 ing apparatus, exhibited a complete uniformity in 
 the action of the ventricles, during systole and 
 diastole respectively. 
 
 2. Grasping in the hand the exposed heart of a liv- 
 ing animal, whether auricles or ventricles, confirms 
 the fact, that the smallest appreciable period of 
 time does not exist, between the respective contrac- 
 tions and dilatations of the corresponding cavities. 
 
 • " On the Law which regulates the Relative Magnitude of 
 the Areas of the four Orifices of the Heart," Proc. Roy. Soc, 
 1870. 
 
 B2 
 
CIRCULATION THROUGH 
 
 3. The auscultator, in listening to the heart, 
 detects only two sounds, although each ventricle 
 produces its first and second sound. The corres- 
 ponding- sounds of each ventricle are exactly 
 blended, and fused into one another, and the four, 
 are, by the synchronous action of the two cham- 
 bers, reduced to two sounds. 
 
 4. Bands of muscular fibres pass from auricle to 
 auricle, and from ventricle to ventricle, compelling 
 thereby the synchronous action of the correspond- 
 ing chambers. 
 
 That equal volumes of blood must traverse, in 
 the same time, the corresponding orifices and cham- 
 bers of the heart, is shewn by the following con- 
 siderations. 
 
 I. Should the left heart receive, continuously, at 
 every beat from the right heart, more blood (how- 
 ever small the excess) than it sends forth, pulmon- 
 ary congestion and stagnation must eventually 
 ensue, and the circulation through the entire organ 
 become inevitably arrested, and the supposition of 
 the left heart receiving, at every beat, less blood 
 (however small the deficiency) than it expels sub- 
 sequently in systole, involves a contradiction, which 
 requires no comment. " There are reasons for be- 
 lieving," say Quain and Sharpey,^'' "that during life, 
 £iny difference in the capacities of the ventricles 
 is very slight, if it exists at all," and I think we may 
 * Quain's Anatomy^ vol. ii., p. 501. 
 
ORGANICALLY DISEASED HEARTS. S 
 
 proceed even further and agree with Valentin*-^' in his 
 statement, that all the four cavities of the heart, 
 probably contain the same quantity of blood during" 
 life. " For as the synchronously acting ventricles, 
 expel during their complete systole, the equal 
 volumes of blood, w^hich they had respectively 
 previously received, during their diastole from the 
 auricles, it follows, that the capacities of the 
 auricles must closely equal the capacities of the 
 ventricles, and that all four chambers of the heart 
 must within certain limits, (to be subsequently con- 
 sidered) contain during life, the same quantity of 
 blood." Having established the existence of these 
 two laws, viz., synchroneity of action and equality 
 of received and discharged volumes of blood, and 
 knowing, that the two hearts associated into one 
 organ have very unequal tasks to perform, we 
 may sum up the mechanism of the circulation of 
 the blood, in the healthy heart, in the following 
 propositions : — 
 
 The two ventricles, acting with unequal forces, 
 send forth equal quantities of blood, synchronously^ 
 into the Pulmonic and Systemic circulations re- 
 spectively, and whatever may be the velocities of 
 the issuing currents, it is evident from the volumes 
 being equal, and their times of flow being the 
 same, that the areas of the pulmonic and aortic 
 
 Valentin's Physiology^ p. 117. 
 
6 CIRCULATION THROUGH 
 
 orifices must be inversely, as the velocities of the 
 currents, which traverse them. 
 
 2. The two ventricles must receive equal volumes 
 of blood in diastole, but in such a manner, that the 
 momentum of pressure of each in-coming- current, 
 is proportional to the inertia of the ventricle, which 
 it has to overcome. By the time, the ventricles are 
 completely filled, all blood movement within them 
 is momentarily suspended, previous to their con- 
 tents being launched forth into the pulmonary 
 artery and aorta, in directions very different from 
 those, in which the molecules of blood entered the 
 chambers. The areas of the tricuspid and mitral 
 orifices are also, of course, inversely as the veloci- 
 ties of the in-coming currents. 
 
 3. The force of each ventricle is such, that the 
 currents through the lungs and general system 
 must be completely, and thoroughly maintained. 
 
 These objects must be secured within certain 
 limits of deviation, the large veins and the right 
 auricle on the venous side, and the vessels of the 
 lungs and left auricle on the arterial side becom- 
 ing compensatory receptacula, for the heart is 
 not a rigid instrument, and although of course 
 always full, does not at all times contain the same 
 quantity of blood, but accommodates itself to the 
 ever varying conditions of the circulation, which 
 arise from muscular pressure and other causes. 
 
 Lastly, from the measurements made by Dr. 
 
ORGANICALLY DISEASED HEARTS. 7 
 
 Peacock and others, the important law^*'* is deduced, 
 that the areas of the four chief apertures of the heart 
 are in proportion, so that whatever ratio the area 
 of the tricuspid bears to that of the mitral, the 
 same ratio does the area of the pulmonic bear to 
 that of the aortic orifice, and as a corollary from this 
 law, and also as the result of actual inspection of 
 the measurement of the orifices, we find that — 
 The area of the tricuspid 
 
 The area of the mitral" ^ ^' 
 
 The area of the pulmonic 
 
 The area of the aortic ~ ^ ^' 
 
 whence the area of any orifice, in either side 
 of the heart, can be determined, when the area 
 of the corresponding orifice on the other side is 
 known. 
 
 I have said, that the heart is not a rigid instru- 
 ment, but allows of deviation in its action, within 
 due limits, according to the circumstances to which 
 it is exposed. The mechanism of the circulation 
 in a person " out of breath " from excessive exer- 
 tion, will afford the simplest illustration of what I 
 mean. As long as the right and left ventricle are 
 synchronously sending forth equal quantities of 
 blood, into the pulmonic and aortic systems respec- 
 tively, so long evidently is the left heart — beat per 
 beat — withdrawing from the lungs the same 
 
 * Proceedings of the Royal Society , No. 118, 1870, Herbert 
 Davies, M.D. 
 
8 CIRCULATION THROUGH 
 
 amount of blood, which has been forced into them 
 — beat by beat — by the right heart, and so long- 
 manifestly is the quantity of air supplied by the 
 act of respiration, exactly equal to the demand for 
 it. The cardiac and respiratory functions exactly 
 respond to each other — the blood is completely 
 aerated. The two hearts ' work smoothly and 
 uniformly in unison, and although the movements 
 of the heart and respiratory muscles may be ac- 
 celerated by the exercise, " dyspnoea," the cry of 
 unaerated blood, does not occur. This co-ordina- 
 tion of the three muscular forces of the right 
 ventricle, respiratory muscles and left ventricle, is 
 an admirable example of the manner, in which, the 
 animal machine adapts itself irrespective, and even 
 in spite of the volition of the individual, to the vary- 
 ing circumstances of the moment. Increased exer- 
 cise will cause the venous blood to move onwards 
 with greater velocity and momentum to the right 
 heart, the right auricle and ventricle will be suc- 
 cessively more rapidly filled, and more forcibly 
 distended, and therefore stimulated to contract 
 more rapidly per minute, but the correlation of the 
 three forces will at once cause a correspondingly 
 increased rapidity, and more complete develop- 
 ment of the respiratory efforts, and a correspond- 
 ingly quicker filling and emptying of the left 
 heart, and thus, and within due limits, will this 
 increased activity of the cardiac and pulmonic cir- 
 
ORGANICALLY DISEASED HEARTS, 9 
 
 culation be maintained without distress of breath- 
 ing-, "dyspnoea/' taking place. 
 
 If, however, by reason of unduly prolonged ex- 
 ertion on the part of the individual, the heart be 
 stimulated to contract at a speed, which the respi- 
 ratory muscles cannot correspondingly maintain, 
 the period of time allowed for the introduction of 
 air into the bronchial channels and air vesicles, 
 and also for the proper chemical change of each 
 charge of blood, being also insufficient, a portion 
 of each charge from the right ventricle will re- 
 main for a time unaerated, and retained in the 
 pulmonary vessels, and possibly in the right 
 ventricle itself. 
 
 The quantity of blood thus retained may be in the 
 first instance very small — a few drops or a drachm 
 perhaps — and the two volumes of blood flowing 
 synchronously from the two ventricles will be nearly 
 equal; but if the extreme muscular efforts of the in- 
 dividual be continued, the residue excess of venous 
 blood in the pulmonary vessels will increase at 
 every beat, to such an amount by reason of the ex- 
 cessive functional energy of the right heart, as to 
 produce painful dyspnoea, compelling the individual 
 to moderate or even to arrest at once his bodily 
 exertions. (There is, I suppose, in health an 
 amount of oxygen present in the blood, more than 
 requisite for the immediate wants of the system 
 a reserve amount upon which the individual may 
 
lo CIRCULATION THROUGH 
 
 draw, when the body is brought into more power- 
 ful action. The reserve amount probably varies 
 in individuals, and accounts for the varying times* 
 in which they can maintain muscular efforts). At 
 this period of breathlessness, the effluxes from the 
 two ventricles are unequal. Anyone, who has 
 watched the countenance of the runners, in a long 
 and distressing foot-race, cannot have failed to 
 observe the pale and bluish tinge of the face, indi- 
 cating the small amount of arterial blood leaving 
 the left heart, and the gorged conditions of the 
 right heart. The following case exemplifies the 
 dangers to which professional trainers are liable. 
 The Report of it is found in the Lancet of May 
 22nd, 1869. R. M., set. 50, was admitted into the 
 Sheffield Public Hospital, under the care of Dr. J. 
 C. Hall on February 3rd, 1869 with the symptoms 
 of urgent dyspnoea. He stated, that he had for 
 many years been a trainer, and a professional 
 man, and had on one occasion walked a thousand 
 miles in a thousand consecutive hours (nearly 
 forty-three days and nights). He was a short 
 muscular man, and complained of great pain in the 
 prsecordia, and great difficulty of breathing, in- 
 creased by the slightest exertion. There was 
 slight prominence of the cardiac region, and the 
 heart's rhythm was irregular. The first sound 
 was unnaturally clear at the apex, and the second 
 sound immediately followed by a slight murmur 
 
ORGANICALLY DISEASED HEARTS, ii 
 
 heard over the course of the aorta. There was 
 some oedema of the lungs. On February 28th he 
 coug-hed up about three pints of blood, and died in 
 a few minutes. P. M., right side of the heart 
 much dilated and the fibres apparently softened, the left 
 ventricle slightly hypertrophied. At the back and 
 upper part of the arch of the aorta, and pressing 
 on the trachea, was an aneurysmal tumour of the 
 size of a hen's Qg%, Everything else was healthy. 
 The frequent and excessive pressure and over- 
 filling, to which the right heart had been exposed, 
 had led to a great dilatation and degeneration of 
 that organ. The aneurysm had had but little or no 
 share in the production of the dilatation, as was 
 shewn in the very slight deviation, from the normal 
 of the cavity of the left ventricle, but its origin lay, 
 no doubt, in the over-strain of the aortic walls, 
 which the life of a professional runner inevitably 
 necessitated. In the above account, I have re- 
 ferred the sense of breathlessness to the presence 
 of an excess of venous blood in the lungs — to a 
 degree of venous stasis in those organs. It would, 
 however, have been much more correct to have 
 ascribed the dyspnoea to a deficiency of oxygen in 
 the system, the feeling of distress being implanted 
 by nature in the chest, in order that the defective 
 supply of oxygen to the tissues, and organs of the 
 body, might be remedied by the act of inspiration, 
 just as the want of food and fluid are felt in the 
 
12 CIRCULATION THROUGH 
 
 stomach and fauces respectively, as hunger and 
 thirst, for the purpose of pointing out instinctively 
 the paths, by which those necessities are to be 
 supplied. Physiologists tell us, that about twenty 
 cubic inches of air enter the chest at every ordinary 
 inspiration, and that five per cent, of this volume 
 of air, or one cubic inch of oxygen is absorbed and 
 conveyed into the general circulation. If then we 
 consider, that the heart fills and empties itself, 
 about four times during each respiratory act, it is 
 clear that about one-fourth of a cubic inch of oxygen 
 passes through the aortic orifice at each ventricu- 
 lar systole, and we may say, that, during the 
 ordinary condition of the body, the general system 
 breathes oxygen through the aortic opening, at the 
 rate of about one-fourth of a cubic inch per beat. 
 The necessity of such a constant supply is evident, 
 when we learn from Bernard's experiment, that 
 the blood of an animal contains as much as ten per 
 cent, of oxygen during fasting,* and from eighteen 
 to twenty per cent, during full digestion, an amount 
 of gas in the arteries, which almost justifies the 
 origin of their name as " air-carrying " vessels. 
 
 As the oxygen appears to be mainly conveyed in 
 the blood stream by means of the red corpuscles, and 
 to be incorporated with them of course in a concrete 
 state, it follows, that the perfection of the circulation 
 will essentially depend, upon these multitudinous 
 * Bernard. Lectures given at the College of France, 1861. 
 
ORGANICALLY DISEASED HEARTS. 13 
 
 bodies being normal in their amount, and sound in 
 their structure. Should these bodies then become 
 markedly deficient in number, or impaired in their 
 structure or function, dyspnoea must result in 
 consequence of an abnormal supply of oxygen 
 carriers. Hence, breathlessness is a characteristic 
 feature in the pale, chlorotic, anaemic girl, in the 
 sufferer from chronic albuminuria, and in all 
 individuals, whose blood presents deficient means 
 of conveying oxygen into the recesses of the body. 
 In all such cases, the aorta breathes too small an 
 amount of oxygen, and dyspnoea of course super- 
 venes on the most ordinary exertion. These ob- 
 servations point therefore, to the practical import- 
 ance of maintaining in all cases, the healthy standard 
 of the blood, and will explain, how many individuals 
 pass through many years of their life, exhibiting 
 but little distress from undoubted cardiac mischief, 
 while others, with the same or even a smaller 
 amount of valvular lesion will rapidly sink under 
 their malady. The former individuals, having 
 good assimilating organs, possess an ample 
 amount of red corpuscles ready to supply the 
 tissues with oxygen, even under the difficulties 
 caused by heart disease, while the latter class 
 wanting their due proportion of blood discs, 
 these essentials to existence, rapidly exhaust in the 
 smallest bodily efforts the supply present in the 
 blood, and speedily becoming bankrupt of oxygen, 
 
14 CIRCULATION THROUGH 
 
 pass into distressing" dyspnoea. The causes of 
 dyspnoea are of course very many, but they all 
 ultimately lead to the want of circulating oxygen, 
 and our aim in practice therefore is, whilst remov- 
 ing-, if possible, the causes which mechanically ob- 
 struct the course of the blood stream, to maintain 
 the normal condition of the liquor sanguinis and 
 blood corpuscles, which play such an important 
 part in the aeration of the body. With normal 
 blood, the compensatory hypertrophy can be devel- 
 oped, and the due amount of oxygen carriers can 
 be maintained, and either failing-, the patient 
 succumbs under his malady. 
 
 It is clear, therefore, that the gravity of any case 
 of heart disease cannot be measured by the physi- 
 cal signs, alone, which mark its existence, without 
 at the same time taking into full consideration, the 
 state and working of the other functions of the 
 body, the most important element for considera- 
 tion being the activity and completeness of the 
 blood-making organs, and the perfect action of 
 every portion of the respiratory system. The heart 
 itself has, we shall see, great powers of self- 
 adjustment, which enable it by various degrees of 
 dilatation and hypertrophy, to overcome to a great 
 extent the injurious effects, which would otherwise 
 result from organic changes in its valves and 
 orifices, and no greater mistake can be made in 
 practice, than to decide upon the gravity of a case, 
 
ORGANICALLY DISEASED HEARTS, 15 
 
 in which heart disease exists, upon the examination 
 alone of the organ itself. 
 
 MITRAL REGURGITATION. 
 
 The mode in which the circulation of the blood 
 is maintained, in the case of structurally diseased 
 openings, is well shewn by the mechanism ex- 
 hibited in this instance. Examples are sufficiently 
 numerous, and readily occur to the mind of the 
 practitioner, where mitral regurgitation has ex- 
 isted for many years, without any marked impair- 
 ment of the function of the heart ; here, as in other 
 instances already quoted of diseased hearts, the 
 compensatory powers of nature overcome for a 
 time the injurious effects, which the morbid lesions 
 produce, and cause the blood to flow evenly as in 
 health, from the right and left ventricle. In other 
 words, the conditions which we have insisted upon 
 so frequently are satisfied namely : — 
 
 (a) The synchroneity of action of the two ven- 
 tricles. 
 
 (h) The equality of effluxes from the right and 
 left ventricle respectively. 
 
 In the healthy heart, the left ventricle sends out 
 at each contraction three ounces of blood through 
 the aortic opening. Let us, however, suppose that 
 by reason of imperfect action of the mitral valves, 
 a small quantity (say one drachm) finds its way, 
 
1 6 CIRCULATION THROUGH 
 
 in consequence of the ventricular contraction, 
 into the left auricle, meeting- the blood, which is 
 already flowing into that chamber; the amount of 
 blood, which is therefore present in the auricle at 
 the close of the ventricular contraction, must be 
 equal to three ounces plus the drachm above men- 
 tioned. Ventricular dilatation now takes place, 
 admitting- into that chamber the whole of the con- 
 tents of the auricle, by reason of the natural dila- 
 tability within certain limits, of the walls of the 
 ventricle. As the ventricle must now contract 
 upon a larg-er mass of blood, its functional activity 
 must be increased, in order, that it may completely 
 empty itself, and by this contraction the normal 
 amount (three ounces) is expelled through the 
 aorta, and the drachm regurgitated, as in the 
 previous beat of the heart, into the auricular 
 cavity ; this process is continually repeated in ex- 
 actly similar manner — beat by beat — with the ulti- 
 mate result of the walls of the ventricle becoming 
 hypertrophied to an amount, corresponding to the 
 increased functional activity, and thus the individual 
 may live for years, exhibiting in his heart a marked 
 mitral regurgitant murmur, but in his daily life, 
 little or no functional disturbance of its action. The 
 compensation is complete, and the diseased heart 
 acts in all respects as a healthy one. It must be 
 borne in mind, that the left auricle becomes also 
 strengthened by the hypertrophy of its walls, as it 
 
ORGANICALLY DISEASED HEARTS, 17 
 
 has to contract each time, after emptying- its con- 
 tents, upon three ounces and a drachm of blood, in 
 place of the normal three ounces; the increased 
 functional energ-y necessitated, develops the in- 
 creased muscularity of its parietes. Let us suppose, 
 that the insufficiency of the mitral curtains increases, 
 allowing- two drachms of blood to regurgitate into 
 the auricle ; as already explained, the three ounces 
 plus two drachms, or the three and a quarter 
 ounces of blood contained in the auricle must 
 dilate the left ventricle to a capacity sufficient to 
 hold it. The ventricle may have sufficient power 
 to expel the whole of its contents, the quarter of 
 an ounce into the auricle, and the three ounces 
 into the aorta, and by the frequent repetition of 
 this process, at every beat, hypertrophy of the 
 ventricle, corresponding to the functional activity 
 required, takes place, and the chamber of the 
 ventricle having become abnormally increased in 
 capacity, by the amount of blood regurgitated, 
 namely, quarter of an ounce, is therefore per- 
 manently dilated. Enlargement of the ventricular 
 cavity to hold the extra amount regurgitated, plus 
 the normal amount received from the right side of 
 the heart, is the first part of the process, whilst 
 hypertrophy lends its aid to enable the ventricle 
 to expel its contents in two opposite directions. 
 In the process of time, further enlarg-ement of the 
 abnormal opening- may occur ; greater dilatation 
 
 c 
 
i8 CIRCULATION THROUGH 
 
 of the ventricular wall will ensue, increased hy- 
 pertrophy will be developed, and the circulation 
 will be maintained, the contents of the right 
 heart will be evenly conveyed into the systemic 
 circulation, provided that the nutrition of the nerve 
 ganglia and muscular tissue of the heart are main- 
 tained. Dilatation of the ventricle and enlarge- 
 ment of the left chamber are not to be considered 
 as a diseased condition, but as being absolutely 
 essential to the circulation of the blood, as without 
 them there would be a stoppage in the passage of 
 the blood from the right to the left side of the 
 heart, and ultimately in the whole venous system. 
 Let us suppose, for example, the left ventricle to 
 be undilatable, beyond the amount of holding the 
 normal three ounces of blood, and the mitral in- 
 sufficiency to allow of the regurgitation of a 
 quarter of an ounce of that fluid. The ventricular 
 contraction would cause the accumulation of three 
 and a quarter ounces of blood in the auricle, but 
 as in our supposition, the left ventricle can only 
 hold three ounces, a quarter of an ounce must 
 remain behind in the auricle, as the result of that 
 beat. At the next beat the process is repeated, a 
 quarter of an ounce being again regurgitated, and 
 therefore added to the previous quarter of an 
 ounce, and thus in a dozen beats, three ounces of 
 blood will have failed to find its way into the 
 systemic circulation. 
 
ORGANICALLY DISEASED HEARTS. 19 
 
 Although the pulmonary capillaries act for a 
 time as reservoirs, to hold some of the regurgitant 
 blood, it is clear that such a process could not 
 continue for any length of time, but that the result 
 must inevitably be stagnation of the venous por- 
 tion of the blood, and death. This reducHo ad 
 absurdum%hov^s, therefore, that ventricular dilatation 
 must occur to allow of the due mechanism of the 
 circulation, and that it and also its associated hy- 
 pertrophy are not examples of disease, but on the 
 contrary, are instances of the instinctive conserva- 
 tive power of nature to neutralise the injurious 
 consequences of diseased apertures. It is evident, 
 from what has been stated above, that we may 
 draw the following conclusions, as to the condition 
 of the heart. 
 
 1. Le/i aun'ck.—Temporanly dilated to hold 
 
 three and a quarter ounces of blood. 
 Permanently hypertrophied to expel three 
 and a quarter ounces of blood, instead of 
 three ounces. 
 
 2. Le/H ven^ncIe.—Temporanly dilated to hold 
 
 three and a quarter ounces of blood. 
 Permanently hypertrophied to act upon three 
 and a quarter ounces. 
 
 3. If (i) and (2) are true, then it also follows, 
 
 that so long as the left auricle and 
 ventricle completely empty themselves 
 that— * 
 
 c 2 
 
20 CIRCULATION THROUGH 
 
 (a) The dilatation and hypertrophy of the left 
 auricle and ventricle, increase pari passu with the 
 gradual enlargement of the diseased opening, or, 
 in other words, that each chamber is temporarily 
 dilated, and permanently hypertrophied by exactly 
 the amount regurgitated. 
 
 (h) That the blood regurgitated is practically 
 a certain amount subtracted from the normal 
 quantity, which passes into the aorta, and there- 
 fore by supposing more and more to regurgitate, 
 we subtract more and more from that, which 
 otherwise would have passed into the aorta, and 
 add it to the auricular contents. 
 
 It must be also borne in mind, that as the on- 
 ward movement of the blood from the left auricle, 
 mainly depends on the contractile energy of the 
 right ventricle, the increased volume resulting 
 from the regurgitation of the left ventricle, must 
 call forth increased power from the right ventricle 
 and hypertrophy of the wall of that chamber, and 
 at this stage there will be no dilation of that 
 chamber. 
 
 We have thus far considered the case, in which 
 the left ventricle completely empties itself at each 
 systole, the force of the ventricular walls being 
 completely sufficient to the task of emptying the 
 chamber. This task consists — 
 
 I. In overcoming at the aortic orifice, the strong 
 resistance of the aortic tension, and the forcible 
 
ORGANICALLY DISEASED HEARTS. 21 
 
 expulsion of three ounces of blood into that vessel. 
 
 2. The expulsion of regurgitant blood through 
 the abnormal mitral opening, in face of the pres- 
 sure of blood contained in the auricle. 
 
 Now the resistance to be overcome at the aortic 
 orifice may be represented by the pressure of a 
 column of blood ninety inches in height, and the 
 resistance at the mitral opening by the pressure of 
 a column of blood say six inches in height. If 
 therefore the ventricular wall fails in vigour, either 
 from general constitutional weakness, or from 
 some incipient degenerative changes in it, its 
 diminished action will be probably most palpable 
 at the aortic orifice, and consequently a smaller 
 amount of blood than usual will find its way for a 
 time into the systemic circulation; at the same 
 time, the amount of regurgitant blood will be but 
 little altered, as the resistance at this opening is 
 comparatively insignificant. Let us suppose, for 
 example, that at the first beat, when feebleness 
 beofins to show itself in the action of the heart, 
 that a quarter of an ounce regurgitates as before 
 into the auricle, and that three ounces, minus one- 
 eighth, pass into the aorta. Now we know, that 
 the auricle at this time contains three ounces plus 
 a quarter of an ounce (the latter being the amount 
 regurgitated) which are ready to be poured into 
 the left ventricle, and when that chamber is perfectly 
 dilated, it must contain three and a quarter ounces 
 
22 CIRCULATION THROUGH 
 
 plus one-eig-hth of an ounce, which is retained. 
 The total amount therefore is equal altogether 
 to three and three-eighths ounces of blood; its 
 capacity is therefore increased beyond the normal 
 amount, by a volume, equal to three- eighths of an 
 ounce. The heart is now stimulated to increased 
 functional energy, expels the quarter of an ounce 
 backward into the auricle, the three ounces into 
 the aorta, and retains one-eighth of an ounce, and 
 thus the three ounces of blood, which came from 
 the right side of the heart, finds its way into the 
 systemic circulation, and the equality of effluxes, 
 which is absolutely essential to the maintenance of 
 the circulation, is established. At the next and 
 succeeding- beats, indefinite in number, the same 
 process is repeated, one-eighth of an ounce being 
 retained at the closure of the systole, quarter of 
 an ounce being discharged into the auricle, and 
 three ounces being driven into the aorta, and in 
 the process of time therefore, the functional energy 
 develops sufficient muscular hypertrophy, to enable 
 the heart to send on into the aorta, the exact 
 quantity of blood, which the right ventricle sends 
 into the lungs. The dilatation of the left ventricle 
 is as absolutely essential for the production of this 
 result, as the hypertrophy, and although looked 
 upon by many writers as an evidence of failing of 
 the heart, it is as important and conservative as the 
 hypertrophy. This condition of affairs may re- 
 
ORGANICALLY DISEASED HEARTS. 23 
 
 main, for an indefinite period of time, the abnormal 
 opening- not increasing- in area, and the hygienic 
 conditions of the patient being well maintained, 
 and the nutrition of the muscular wall being con- 
 sequently undiminished; but as such a fortunate 
 state of things cannot continue indefinitely, the 
 morbid opening will probably increase in area, 
 and a larger amount of blood will regurgitate. 
 The left ventricle becomes more and more dilated, 
 and therefore more hypertrophied, in order to 
 carry on the circulation. The ventricular walls 
 may also, after a time, tend to become more feeble 
 in their action, and therefore will expel a smaller 
 quantity of blood, than previously into the aorta, 
 thereby causing- a larger quantity to be retained, 
 at the close of the systole, in the ventricular 
 chamber, and therefore eliciting a further increase 
 of functional energy, and subsequently of further 
 hypertrophy of the ventricle. Thus, when the 
 mischief resulting from the diseased orifice is met 
 by the necessary dilatation and hypertrophy of the 
 ventricle, the circulation through the diseased 
 heart will fairly represent that of the healthy 
 heart. The same amount will flow simultaneously 
 from both sides, and pulmonary congestion will 
 be entirely prevented. We also see, that in the 
 case where the left ventricle fails to completely 
 empty itself, it is dilated by the amount regurgi- 
 tated, plus the amount retained. 
 
24 CIRCULATION THROUGH 
 
 Now, in course of time, however, it is clear that 
 increased failure of the heart's action will occur, 
 leading- to further dilatation and hypertrophy, the 
 battle of life being fought out, step by step, until 
 the ventricle is found to contain a large amount of 
 residual blood, which appears for a time to be out 
 of the pale of the circulation. The hypertrophied 
 ventricle is able to forward into the systemic cir- 
 culation whatever blood it receives from the right 
 side of the heart. We ought not to forget, in the 
 above consideration, the importance of the as- 
 pirating- power''' of the ventricle in carrying on 
 the circulation through the cardiac chambers, in 
 their healthy and diseased states, for it would 
 seem, that as the left ventricle can only drive the 
 blood to the proximity of the right auricle, where 
 the pressure of the fluid is found to be almost 
 negative, the blood must be drawn into the right 
 side of the heart by the aspiration of the right 
 ventricle, and again, as the power of the right 
 ventricle must be mainly consumed in overcoming 
 the resistance in the pulmonary vessels, which must 
 be considerable in amount, we may conclude, 
 that the blood enters the left auricle, with little or 
 no pressure, and that it owes its capability of 
 flowing into the left ventricle to the aspirating- 
 power of that chamber. This power of aspiration, 
 
 * Goltz and Gaule. Pfliiger's Archiv., xvii,, 1878, p. 100. 
 
ORGANICALLY DISEASED HEARTS. 25 
 
 possessed by the chambers of the heart, and by 
 virtue of which this organ acts as a suction pump, 
 as well as a force pump, plays evidently an im- 
 portant part in the circulation, and it has hitherto 
 been too little studied in relation to diseased 
 function. It is evident, that a diminution of it will 
 lead to retardation in the flow of blood through its 
 chambers. 
 
 We now come to another class of cases, in which 
 the left auricle becomes weaker, and loses its 
 elasticity to a certain extent, so as to permanently 
 retain a quantity of blood, say a quarter of an ounce 
 of the half ounce regurgitated. The auricle there- 
 fore will send into the ventricle three and a quarter 
 ounces. At the next systole of the ventricle, two 
 and three quarters ounces will pass into the aorta, 
 and half an ounce will regurgitate as before. 
 The auricle now contains three ounces from the 
 right heart, half an ounce regurgitated, and quarter 
 of an ounce which it permanently retains ; it is 
 therefore dilated by three and three quarters 
 ounces. It now energises, so as to expel three and 
 a half ounces into the ventricle, and so on. We 
 therefore see, that although the auricle is now 
 dilated, so as to hold three and three quarters 
 ounces, the ventricle as before is only dilated by 
 the amount regurgitated, namely, half an ounce. 
 Suppose now, that the auricle again weakens and 
 loses its elasticity, so as to retain permanently half 
 
26 CIRCULATION THROUGH 
 
 an ounce, at the next systole of the auricle, it will 
 expel three ounces only into the ventricle, but 
 at the next ventricular systole, half an ounce will 
 regurgitate as before, and two and a half ounces 
 will pass into the aorta. The auricle will now 
 hold three ounces from the right heart, half an 
 ounce regurgitated and half an ounce permanently 
 retained, which is equal altogether to four ounces. 
 The auricle is therefore dilated to hold four ounces, 
 but it now energises as in the case above, and 
 drives into the ventricle the same amount as be- 
 fore, namely, three and a half ounces, of which, at 
 the next systole of the ventricle, three ounces will 
 pass into the aorta, and half an ounce v/ill regurgi- 
 tate into the auricle. We see, therefore, that 
 although the auricle is dilated to hold four ounces, 
 that the ventricle is still only dilated by the amount 
 regurgitated, and so on. 
 
 Thus, if the above reasoning be correct, two 
 main facts are shown. 
 
 1. That in this class of cases, however much the 
 auricle is dilated to hold, the ventricle is not 
 correspondingly dilated. 
 
 2. That by each successive weakening of the 
 auricular wall, a certain quantity ot blood is sub- 
 tracted from the ventricular contents, and added 
 to the amount permanently retained in the auricle. 
 
 The anatomical conditions, which one would 
 expect to find present, are : — 
 
ORGANICALLY DISEASED HEARTS. 27 
 
 1. Great dilatation of the left auricle and some 
 hypertrophy of its walls, the former being per- 
 manent. 
 
 2. Some dilatation of the left ventricle with 
 hypertrophy. 
 
 3. Hypertrophy of the right heart to supplement 
 deficient power of the left auricle. 
 
 4. A greater tendency, than in the first class of 
 cases, to dropsy and congestion of the lungs. It 
 would appear, from the statements in (i) and (2) 
 that those cases, in which there is found to be 
 scarcely any dilatation and hypertrophy of the left 
 ventricle, may be thus explained ; for the auricle, 
 by its gradual dilatation, prevents, as it were, the 
 ventricle from dilating, and allows it to maintain 
 its normal size. 
 
 Another variety of cases suggests itself. For 
 let us suppose that the auricle, although it has 
 been permanently dilated to hold three and three 
 quarter ounces, gradually hypertrophies to such 
 an extent, that it expels, not only three and a half 
 ounces into the ventricle, but three and three 
 quarter ounces, or, in other words, that it drives 
 the whole of its contents into the ventricle. Then 
 the ventricle will be dilated to hold three and 
 three quarters ounces, instead of three and a half 
 ounces. As it exerts the same force as before 
 it sends at its next systole three ounces into the 
 aorta, half an ounce into the left auricle, and 
 
28 CIRCULATION THROUGH 
 
 retains now a quarter of an ounce. The left ven- 
 tricle is therefore dilated in this case, as shown by 
 the following considerations : — 
 
 1. By the amount regurgitated, namely, half an 
 ounce. 
 
 2. By the amount retained, namely, quarter of 
 an ounce. 
 
 This condition of affairs may also be brought 
 about in another way. Let us again suppose, that 
 the auricle retains for a time half an ounce, so that 
 it is dilated to hold four ounces, three ounces from 
 the right heart, half an ounce from left heart, and 
 half an ounce retained. The auricle now gradu- 
 ally hypertrophies, and drives into the ventricle 
 three and three quarters of an ounce, instead of 
 three and a half ounces; the ventricle is therefore 
 dilated to hold three and three quarters ounces, 
 as in the case stated above, and as before it 
 sends out three ounces into the aorta, half an ounce 
 into the auricle, and retains quarter of an ounce 
 permanently. Now suppose, again, that the auricle 
 further weakens, and retains for a time three 
 quarters of an ounce instead of half an ounce, it 
 will now contain three ounces from the right 
 heart, half an ounce regurgitated from the left 
 ventricle, and three quarters of an ounce retained, 
 amounting altogether to four and a quarter ounces, 
 it is therefore now dilated by four and a quarter 
 ounces, but let us suppose that it again gradually 
 
ORGANICALLY DISEASED HEARTS. 29 
 
 hypertrophies, so as to expel four ounces into the 
 ventricle. The latter is therefore dilated to hold 
 four ounces plus quarter of an ounce, which it 
 permanently retains. 
 
 Two conclusions may be drawn from the above 
 cases : — 
 
 I. However much the auricle is dilated beyond 
 its normal size, that as soon as it hypertrophies 
 to a sufficient extent, so as to drive almost the 
 whole of its contents into the ventricle, leaving- a 
 small quantity behind (in the above case it is a 
 quarter of an ounce) the ventricle is dilated to 
 exactly the same amount as the auricle ; in fact, 
 the auricle by its hypertrophy is able to send 
 back into the ventricle almost the whole amount 
 of blood, which, through the weakening of its wall, 
 it had subtracted for a time from the ventricular 
 contents. 
 
 The anatomical conditions, which, if the above 
 reasoning is true, we should expect to find, are: — 
 
 1. Great dilatation and corresponding hyper- 
 trophy of the left auricle, both of which are 
 permanent. 
 
 2. Dilatation of the left ventricle, to an almost 
 corresponding extent, and also hypertrophy, both 
 of which are permanent. 
 
 3. Chronic congestion of the lungs. 
 
 4. Hypertrophy of the right ventricle. 
 
30 CIRCULATION THROUGH 
 
 MITRAL OBSTRUCTION WITHOUT REGURGITATION. 
 
 In considering the mechanism of the circulation in 
 this form of heart disease, we will start by esti- 
 mating- the forces, which serve to fill the left 
 ventricle, bearing- in mind the two fundamental 
 laws of the mechanism of the circulation in the 
 healthy heart, namely ; — 
 
 (a) Synchroneity of action. 
 
 (3) Equality of effluxes. 
 
 Now the muscular forces, which serve to fill the 
 left ventricle during- its diastole, are : — 
 
 1. The contractile energy of the right ventricle. 
 
 2. The contractile energy of the left auricle. 
 
 3. The elastic contraction of the coats of the 
 pulmonary artery, which materially assists also 
 the flow of blood along this vessel and its 
 branches. This force owes its existence to the 
 muscular power of the right ventricle, and comes 
 only into play as soon as the contraction of that 
 vessel has ceased. 
 
 4. The suction power of the left ventricle. 
 
 I think, that we need not take into consideration 
 **the interaction between blood and tissue" in the 
 capillary system of the lungs, as we have no 
 evidence of this power, if any, which it exerts in 
 forwarding the circulation. There can be no 
 
ORGANICALLY DISEASED HEARTS. 31 
 
 doubt that the main force, which fills the left 
 ventricle with blood, is derived from the muscular 
 contraction of the right ventricle, the assistance 
 from the left auricle being comparatively slight, 
 as evidenced by the thinness of its walls, and by 
 the very small period of time, during which the 
 auricular contraction is called into operation. 
 The wave, which marks the auricular contraction, 
 starts from the immediate proximity of the vessels, 
 which supply that chamber with blood, and passing 
 rapidly over its walls, becomes apparently con- 
 tinuous with the wave of the ventricular contraction, 
 and the succession of the two waves is so rapid, 
 that no appreciable interval of time can be ob- 
 served between the termination of the auricular 
 and the commencement of the ventricular wave. 
 "These two motions," says the illustrious Harvey,* 
 *' the one of the ears (auricles) and the other of the 
 ventricles, are so done in a continued motion, as 
 it were, keeping a certain harmony and number, 
 that they are both done at the same time, and 
 only one motion appears, especially in the hotter 
 creatures, whilst they move with a sudden motion. 
 Nor is this otherwise done, than when in engines, 
 one wheel moving another, they all seem to move 
 together ; and in the lock of a piece, by the draw- 
 
 - * " The Anatomical Exercises of Dr. William Harvey, 
 concerning the Motion of the Heart and Blood," 1673. 
 
32 CIRCULATION THROUGH 
 
 ing- of a spring-, the flint falls, strikes the steel, 
 fires the powder, enters the touch-hole, discharges, 
 the ball flies out, pierces the mark, and all these 
 motions, by reason of the swiftness of them, 
 appear in the twinkling" of an eye." Physiologists 
 have calculated the time occupied by the auricular 
 systole to be nearly one-eighth of the time be- 
 tween two consecutive pulses. If we take the 
 pulse to beat at the rate of seventy-five per 
 minute, the duration of the systole of the auricle 
 would be equal to one-eig^hth of one-seventy-fifth 
 of sixty seconds, or one-tenth of a second exactly. 
 However small this interval may appear, it is 
 evident that the auricular systole must be com- 
 menced and completed very rapidly, inasmuch as 
 the vessels which supply the auricles are closed 
 during" the emptying" of these chambers, by the 
 contraction of the muscular fibres which surround 
 their orifices. It would appear then, that the 
 interior of the auricles may be shut off from 
 communication with the pulmonic and venous 
 systems respectively, for the small interval of 
 time (one-tenth of a second) without injuriously 
 affecting the circulation, and that these systems 
 are thus protected from the reflux of blood re- 
 gurgitating from the auricle, by the momentary 
 closure of the vessels, in the manner described. 
 Any undue prolongation of the auricular systole, 
 by increasing the time, during which the vessels 
 
ORGANICALLY DISEASED HEARTS, 33 
 
 are closed, must necessarily tend to a vascular 
 congestion more or less dangerous to life. 
 
 From these remarks, it is evident that the left 
 auricle performs a very inferior part in filling the 
 left ventricle, partly from the thinness of its walls, 
 and partly from the very limited time, during 
 which its force can be allowed to act, and as its 
 energy only comes into play when the left ven- 
 tricle is already nearly filled with blood, it is plain 
 that its power is subsidiary to, and insignificant 
 compared with the force exhibited by the right ven- 
 tricle. There can be no doubt, however, that its 
 muscularity aids in the complete distension of the 
 left ventricle, as we find such marked hypertrophy 
 of its walls, when the free flow of blood from its 
 chamber, and the great vessels which supply it, is 
 impeded as in mitral obstruction. In the normal 
 state the auricle is never less than two-thirds full, 
 therefore its capacity varies only by one ounce. 
 Now as the ventricle receives three ounces during 
 its diastole from the auricle, and at the end of its 
 diastole, two ounces are present in the auricle, it 
 follows, that while three ounces are passing from 
 the auricle into the ventricle, two ounces are flow- 
 ing into the auricle from the vena cava. Hence 
 the auricular systole takes place, when two ounces 
 of blood have passed into the ventricle, and its 
 action is therefore to drive an additional ouncQ 
 into that chamber. 
 
 D 
 
34 CIRCULATION THROUGH 
 
 Now from our knowledge of the existence of 
 the two fundamental laws, 
 
 1. Synchroneity of action, 
 
 2. Equality of effluxes, 
 
 we can readily predicate what must be the me- 
 chanical (physical) result, which must follow upon 
 simple contraction of the mitral orifice without 
 regurgitation. Let us suppose the area of the 
 mitral opening to be -25 square inches, in place 
 of the mean normal area 1*25 square inches, the 
 available opening being thus one-fourth of the 
 normal. The force which would be required to 
 drive a quantity of blood equal to the normal charge 
 from the right ventricle and left auricle through the 
 narrowed opening in the normal time, must be 
 increased at least fourfold. Such a force is 
 developed in healthy constitutions by the walls 
 of the right ventricle augmenting in thickness, 
 pari passu with the increased work required from 
 them, aided by an augmented thickness of the left 
 auricular walls. When the compensatory (simple) 
 hypertrophy is established, the right ventricle 
 sends forth its charge of three ounces into the 
 lungs, and at the next opening of the left heart, 
 this full charge is received into the left ventricle, 
 which in its turn expels the three ounces, so that 
 the ventricles are thus enabled to send out equal 
 quantities in systole, into the pulmonic and sys- 
 temic circulations respectively. There is no doubt 
 
ORGANICALLY DISEASED HEARTS. 35 
 
 that this result is noi Qh\.dXx\^di per saltam ; but at 
 the earliest formation of the obstruction at the 
 mitral orifice, the right ventricle for a time, 
 by the instinctive power the heart possesses of 
 measuring- the work it has to perform, increases 
 its muscular energy, which continues until the 
 growth of muscle, hypertrophy, permanently sup- 
 plies the power, which converts the diseased 
 heart into a normally acting organ. This stage, 
 which consists, as has been seen, in increase of 
 energy of the right ventricle in the first place, 
 leading eventually to its hypertrophy, may be 
 sufficient for a long time, provided that the patient 
 leads a quiet life. The circulation will be evenly 
 maintained, the left ventricle receiving its usual 
 supply, but not that of full distension, as is evi- 
 denced by the comparative smallness of the pulse. 
 We have thus far considered the case in which 
 the right ventricle, aided by the left auricle, is 
 able to overcome the obstruction at the mitral 
 orifice, so as to send its charge into the left ven- 
 tricle. In course of time, however, owing to the 
 increasing contraction at the mitral orifice, further 
 obstruction to the circulation is developed, so that 
 the right ventricle even, when aided by the left 
 auricle, is unequal to the task of sending its usual 
 supply through the obstructed orifice into the left 
 ventricular chamber. It is clear, that if the force 
 of the right ventricle and left auricle remain the 
 
 D2 
 
36 CIRCULATION THROUGH 
 
 same, but the obstruction, which they have to 
 overcome, increases, that less blood will pass 
 through the narrowed orifice, and hence a few 
 minims will remain behind in the left auricle. 
 Let us suppose that sixty minims or one drachm 
 is thus retained. At the next systole of the right 
 ventricle, it will send its usual supply of three 
 ounces into the left auricle, which meeting the one 
 drachm already there, will cause the contents of 
 that chamber to be three and one-eighths of an 
 ounce. This chamber will therefore be dilated by 
 this amount. But the left auricle is stimulated to 
 increased functional energy, so that it is enabled 
 to send into the left ventricle the exact amount 
 which it receives from the right heart. It there- 
 fore becomes hypertrophied, as well as dilated, 
 the former process being permanent, and the 
 latter at first temporary. In the course of time, 
 however, this hypertrophy will enable the left 
 auricle to send on the whole of its contents into 
 the left ventricle, which being naturally dilatable 
 within certain limits, is able to receive it, and for 
 a hrief interval of time, therefore, more blood will 
 enter the systemic circulation than usual. We 
 have so far considered the case, in which although 
 the left auricle for a time retains a certain amount 
 of blood, it is enabled, by its hypertrophy, to 
 overcome the obstruction, so as to send on the 
 wliole of its contents into the left ventricle. 
 
ORGANICALLY DISEASED HEARTS. 37 
 
 We now pass on to consider the condition which 
 arises, when, owing- to the increasing obstruction at 
 the mitral orifice, the left auricle is unable at any 
 time to send on the whole of its contents ; this will 
 lead, as shown above, to the retention of some of 
 the charg-e of the right ventricle, causing further 
 dilatation, and eventually further hypertrophy 
 (which is now eccentric in character) of the left 
 auricle. In progress of time, this process is fre- 
 quently repeated, until the dilatation becomes so 
 great, that the cavity of the auricle has been found 
 capable of holding an adult fist.*' 
 
 The hypertrophy of the left auricle is, however, 
 always sufficient to send on into the left ventricle 
 the same amount which it receives from the right 
 ventricle, and thus is the law of the equality of 
 effluxes maintained. Finally, we see how neces- 
 sary and essential is the dilatation of the left 
 auricle,, in order to prevent pulmonary congestion 
 and oedema taking place, for it is obvious that so 
 long as this process, together with that of hyper- 
 trophy, are sufficiently developed, so long will the 
 circulation be evenly maintained, and so long will 
 the patient lead an unembarassed existence. 
 
 * Case recorded by Dr. Bristowe, *' Pathological Society's, 
 Transactions," vol. xi., p. 66. 
 
38 CIRCULATION THROUGH 
 
 REGURGITANT AORTIC DISEASE. SECTION I. 
 
 The mechanism, by which the structurally dis- 
 eased heart in such cases, is able to maintain an 
 almost unembarassed circulation, and without the 
 production of dropsy, is not so simple in character 
 as the one already described. The conditions, 
 however, which are absolutely requisite to secure 
 this result, are the same as those, which are satis- 
 fied by the healthy heart, viz. : — 
 
 1. The synchronous action. 
 
 2. The equality of issues of the two sides of the 
 organ. 
 
 In this, as in every other form of valvular 
 disease, the conservative efforts of the system are 
 powerfully directed to obtain as close an observ- 
 ance as possible of these fundamental laws of the 
 circulation. The anatomical relations of the two 
 ventricles must under all circumstances maintain 
 the integrity of the first condition, but should the 
 second condition fail to be secured for a certain 
 period, the occurrence of pulmonic congestion or 
 systemic dropsy must inevitably ensue. It is 
 interesting to observe to what a degree insuffi- 
 ciency of the aortic valves may exist, and how its 
 injurious effects may be obviated by the conserva- 
 
ORGANICALLY DISEASED HEARTS, 39 
 
 tive development of the ventricle, to v^hat an 
 extent in fact, eccentric hypertrophy must be 
 established in extreme cases to enable the blood to 
 flow evenly through every part of the circulation. 
 Let us suppose now a pure case of aortic regurgi- 
 tation without obstruction of any moment at that 
 orifice, such as for instance when rupture of a 
 semilunar valve has been the result of excessive 
 muscular exertion on the part of the individual. 
 Previously to the accident, the heart had been 
 discharging equal quantities of blood synchron- 
 ously from its two ventricles, and maintaining 
 thereby an even circulation through the lungs and 
 body generally. The immediate effect, however, 
 of the injury to the valve will be a reflux of blood 
 during diastole of a portion of the charge, which 
 had left the ventricle in systole. For the sake of 
 example, let us suppose three ounces of blood to 
 have been expelled by the ventricular contraction, 
 and a quarter of an ounce to flow back into that 
 chamber during the period of its relaxation, the 
 systemic circulation receiving for that beat two 
 and three quarter ounces in place of the mean 
 normal amount, three ounces. The left ventricle, 
 which has a certain amount of dilatability within 
 normal limits, is compelled by the pressure of the 
 aortic column of blood, acting through the abnor- 
 mal opening of the valves, to enlarge its capacity 
 sufficiently to contain the quarter of an ounce of 
 
40 CIRCULATION THROUGH 
 
 reflux blood, plus the mean charge derived from 
 the right ventricle. It contains therefore, when 
 filled, three and a quarter ounces of blood, and its 
 cavity is dilated consequently for the time, in 
 excess of the mean capacity by a space equivalent 
 to the volume of a quarter of an ounce of blood. 
 Having- now an increased quantity of blood to 
 contract upon in systole, the energy of the left 
 ventricle must be correspondingly increased, to 
 enable it to expel its contents of three and a 
 quarter ounces in the same time, in which the right 
 ventricle sends forth its three ounces into the pul- 
 monic circulation, for as I have frequently stated, 
 the inter-connected muscular arrangements of the 
 two hearts necessitate their simultaneous action. 
 The required energy is elicited, and the ventricles 
 are completely emptied. But as soon as the left ven- 
 tricle reopens in diastole, the same process recurs. 
 Again does it fill as before to the extent of three 
 and a quarter ounces, and again does the renewed 
 energy rid it of its entire contents, and this process, 
 as I would term it, is repeated beat after beat, 
 until actual development and growth of the mus- 
 cular tissue follows upon persistently increased 
 functional activity, and an amount of hypertrophy 
 of the left ventricle is produced, sufficient to ensure 
 the complete emptying of the chamber in systole, 
 and thus is every charge of blood, derived from 
 the right ventricle practically forwarded without 
 
ORGANICALLY DISEASED HEARTS, ^l 
 
 dimin.ution of volume, and in regular succession to 
 the systemic circulation, and thus is the law of the 
 equality of issues strictly satisfied. The left ven- 
 tricle, when full, is of course increased in its 
 internal capacity by the volume of a quarter of an 
 ounce of fluid, its walls are correspondingly 
 thickened, and the case is one of eccentric hyper- 
 trophy. The dilatation is a necessary and essen- 
 tial result of the reflux of the blood in diastole, for 
 without its production, the left ventricle could not 
 contain the normal charge sent into it from the 
 right ventricle, plus the amount regurgitated, but 
 by this increase in its capacity, the two chambers 
 are enabled practically to send out equal volumes 
 of blood into their respective circulations, and the 
 injurious results from the incompetency of the 
 valves are thus, for a time at least, completely 
 obviated. I have used the ^nox^ practically^ meaning 
 thereby that though three and a quarter ounces are 
 in the case supposed, actually sent out by the left 
 ventricle in systole, three ounces only are virtually 
 added to the systemic circulation at each beat of 
 the heart, being the same quantity, which the right 
 ventricle urges at every stroke into the vessels of 
 the lungs. The left heart therefore, pari passu, 
 drains off" from the pulmonary circulation the same 
 quantity of blood per beat, which the right heart is 
 pressing into its vessels, and thus is congestion 
 prevented and dyspnoea undeveloped. 
 
42 CIRCULATION THROUGH 
 
 The eccentric hypertrophy of the left ventricle is 
 developed to an amount, which is exactly adapted 
 to completely empty the left ventricle, and to 
 maintain an unembarrassed circulation. 
 
 The steps of this conservative effort upon the 
 part of the ventricle are : — 
 
 1. Dilatation of the chamber to a deg"ree suffi- 
 cient to contain the reflux blood plus the charge 
 sent from the right ventricle. 
 
 2. Increased functional energy of the muscular 
 walls of the ventricle to enable it to completely 
 expel its contents into the aorta. 
 
 3. Gradual development and growth of the ven- 
 tricular wall to an amount sufficient to maintain 
 the full power of the chamber. 
 
 The dilatation of the ventricle is therefore 
 clearly at this stage of the aff"ection in no way a 
 morbid process, but is as essential to the due circu- 
 lation of the blood, as the hypertrophy, which 
 quickly follows upon it. It is evident, that the 
 safety of the individual depends upon the due and 
 speedy production of the hypertrophy, in fact 
 upon the ventricle growing in muscle to meet the 
 additional work thrown upon it. When the 
 balance between the resistance to be overcome 
 and the power to meet it, is established, the dan- 
 gerous effects of the injured valve will be for the 
 time counteracted, and unless the individual be 
 exposed to undue muscular efforts, he may pro- 
 
ORGANICALLY DISEASED HEARTS. 43 
 
 ceed with the ordinary duties of life *'on the even 
 tenor of his way" with but little knowledge from 
 his feeling's, of the serious lesion, which exists in 
 his heart. How long, how many weeks or months, 
 this quiescent condition may continue, it is impos- 
 sible to conjecture, but it will continue no doubt as 
 long as : — 
 
 1. The valvular imperfection continues unal- 
 tered. 
 
 2. The ventricular walls remain correspondingly 
 hypertrophied, and therefore, as long as the 
 general health is well maintained and no excessive 
 exercise at any time attempted. 
 
 Any deviation from these conditions will lead to 
 secondary changes, which are somewhat more 
 complex, but of the same character as those, which 
 lead to dilatation of the left ventricle in cases of 
 aortic obstruction. 
 
 Should the abnormal aperture increase in area, a 
 larger amount of blood will regurgitate into the 
 left ventricle, and lead on the principle already 
 explained, to the necessity of increased dilatation 
 of the chamber, and to further augmentation in 
 the thickness of its walls. There is no doubt, that 
 the valvular lesion in many cases gradually 
 increases, by reason of the centrifugal pressure of 
 the regurgitating column of blood dilating the 
 orifice, and thus leads consequently to a gradual 
 and increased development of the *' active dilata- 
 
r 
 
 44 CIRCULATION THROUGH 
 
 tion " of the chamber in the manner described. But 
 the disease progresses, I believe, usually in another 
 manner, associated more or less with an increase 
 in the amount of the valvular lesion. The hyper- 
 trophied left ventricle, from causes affecting" the 
 general health, becomes somewhat insufficient for 
 its task and fails to empty itself completely at each 
 contraction. A few minims or a drachm or more 
 of blood remains in the cavity at the close of sys- 
 tole. At the next diastole, the chamber must hold 
 the usual amount of regurgitating blood in addi- 
 tion to the supply sent into it from the right heart, 
 and, although already dilated, must therefore be 
 still further enlarged to the extent of a few minims 
 or drachms. Increased functional energy is im- 
 peratively demanded, and perhaps the whole con- 
 tents of the chamber may be sent on into the aorta, 
 thus, for a time, preventing the development of the 
 secondary changes. But supposing the result to 
 be not so favourable, and that a residue of blood 
 occurs at each systole, and that in time further 
 hypertrophy is developed, and the already enlarged 
 chamber is further permanently dilated to an 
 excess of capacity equal to the volume of the 
 minims or drachms of blood, which are so unex- 
 pelled in systole; so long as this is the case, so 
 long is the charge of blood from the lungs sent on 
 into the aorta, and so long is the congestion of these 
 organs prevented and dyspnoea undeveloped. The 
 
ORGANICALLY DISEASED HEARTS, 45 
 
 extra dilatation and hypertrophy generated are 
 now sufficient to the occasion, and while a certain 
 amount of blood always remains in the ventricle 
 (as if out of the pale of the circulation), all the 
 blood, which the right heart sends on into the pul- 
 monary circulation is withdrawn from W., pari passu, 
 and forwarded on to the systemic circulation, and 
 thus though the left ventricle is increased in capa- 
 city and bulk, the equality of issues from each 
 ventricle is practically maintained. Thus, from 
 time to time, failure of the left ventricle and the 
 corresponding efforts on the part of the system 
 to obviate the effects may continue for years, the 
 amount of the residue gradually augmenting till 
 the active dilatation leads to those enormous 
 hearts, in which the left ventricle has been found 
 to hold as much as a pint of blood. 
 
 A remarkable illustration of what I have just 
 stated will be found in a case published by Dr. Stokes, 
 in his work on Diseases of the Heart and Aorta, p. 2 18. 
 In this instance where extensive disease of 
 the aortic valves had lasted for ten years, there 
 had never been at any time dyspnoea, cough, or 
 the least evidence of congestion or interrupted cir- 
 culation. The post-mortem examination revealed 
 hypertrophy and dilatation of the left ventricle to 
 an extraordinary degree, the weight of the emptied 
 heart being forty-four and a half ounces, and the 
 sinuses of the aortic valves were almost filled by 
 
46 CIRCULATION THROUGH 
 
 rugged calcareous deposits. Such developments as 
 I have described may exist, as the above case 
 shews, for years without the production of the 
 slightest dropsy, such a result depending upon the 
 fact that, however great be the mass of blood 
 always present in the left ventricle, whatever 
 amount enters it in diastole from the lungs, the 
 same amount leaves it in systole to pass into the 
 aorta. But as soon as this exact balance is de- 
 stroyed, as soon as the issues from the left ventricle 
 become persistently less than the issue from the 
 right ventricle, so soon will pulmonary congestion 
 commence to be developed, the right ventricle is 
 rendered unequal to send out its full charge into 
 the pulmonary vessels, diminution of flow of 
 venous blood into the right auricle, and diminution 
 of rapidity of current in the vessels occur, exos- 
 mosis and dropsy ensue, and all this results from 
 the great law being unsatisfied, that equal volumes 
 of blood must leave the right and left hearts in 
 exactly equal and the same time. 
 
ORGANICALLY DISEASED HEARTS. 47 
 
 REGURGITANT AORTIC DISEASE. — SECTION II. 
 
 In this form of cardiac mischief, the left ventricle is 
 filled during- its diastole from two sources, normally 
 by the current, which enters through the mitral 
 opening-, and abnormally by 'the reflux stream, 
 which the recoil of the aorta forces downwards 
 into the chamber through the imperfectly closed 
 orifice. The forces, which urge these simul- 
 taneously flowing- currents are unequal in energ-y, 
 and the openings through which the streams pass, 
 differ from each other considerably in area. Hence, 
 the quantities passed through each orifice, to fill 
 the ventricle, are unequal in amount. It will be 
 not only instructive, but interesting, to attempt to 
 discover, in any given case, in what proportion 
 the normal mitral and the abnormal aortic 
 sources respectively contribute to form the ven- 
 tricular charge, in fact, the quantity of blood, 
 which occupies the chamber at the end of its 
 diastole. The problem is by no means easy of 
 solution, but I am indebted to the kindness of my 
 friend, the profound mathematician, and able 
 physiologist, Dr. Haughton, of Trinity College, 
 Dublin, for a clear answer to the question. 
 
48 CIRCULATION THROUGH 
 
 I will illustrate by a rough sketch the facts of 
 the problem to be solved. 
 
 Let the area of M (mitral orifice) = 1-25 square 
 inches, and the area of the abnormal opening of 
 A (aortic orifice) = -25 square inches, and sup- 
 
 The accompanying figure, which is purely diagrammatic, 
 illustrates the two sources, from which the left ventricle is 
 supplied in aortic regurgitation. Area of normal mitral orifice 
 = i"25 square inches. Area of abnormal aortic orifice = '25 
 square inches. V = left ventricle. M. Mitral orifice. A. 
 Aortic orifice. 
 
 pose the pressure of the haemostatic column upon 
 the floor of the aortic valves = v^eight of a column 
 of blood ninety inches in height, and suppose the 
 blood to enter through M under a pressure = 
 six inches column of blood, and also that the left 
 
ORGANICALLF DISEASED HEARTS. 49 
 
 ventricle offers no resistance to the two incoming 
 currents. Let the pulse = seventy-five beats per 
 minute, and let the left ventricle contain three 
 ounces of blood at diastole. What are the re- 
 spective quantities of blood delivered through M 
 and A, which together make up the three ounces, 
 friction being neglected. The quantity of water 
 discharged by a circular pipe in a given time is 
 (including friction) determined by the following 
 formula: — 
 
 Q = ^^j X d\ where 
 
 A = constant. 
 
 h = charge or head of water. 
 / = length of pipe. 
 d = diameter of pipe. 
 Let Q = quantity due to mitral orifice. 
 Q'= quantity due to aortic orifice. 
 
 Q'- V ^' ^ 7 "^ 75 
 
 We may neglect the difference between / and /* 
 in the present problem. 
 
 Hence| = VJxJ 
 
 k = 6 inches and k' = 90 inches. 
 
 (P 1-25 
 Now ^2 ^^~~^r "^ S> as the area varies as the 
 
 square of the diameter. 
 
50 CIRCULATION THROUGH 
 
 .'. -^ = 55*902, and therefore 
 
 Hence the quantity of blood, which enters the 
 ventricle through the mitral orifice, is r930 times 
 as much as the quantity regurgitated through the 
 aortic opening. The three ounces will therefore 
 be divided in the following proportion : — 
 
 Q + Q' • Q' — 3 • quantity regurgitated. 
 
 # + ' 
 
 Aortic supply = 1*024 
 Mitral supply = i '976 
 
 3*000 ounces. 
 
 In the above case, the openings, normal and 
 abnormal, have been supposed to be circular in 
 form. The mitral orifice in action is, I think, 
 always circular, but the diseased aortic opening 
 is rarely of this form, being usually irregular in 
 outline. The problem, which I have proposed, 
 and which Professor Haughton has so ably solved, 
 does not aim of course at being of any especial 
 practical value, but simply enables us to form a 
 clear estimate of how the ventricle Would be filled, 
 should certain Ciin4itois,.as to pressure and area, 
 be given. /^^%S^ tScJ^^the data of this 
 
ORGANICALLY DISEASED HEARTS, 51 
 
 particular case, the aortic column supplies rather 
 more than one-third, and the direct mitral rather 
 less than two-thirds of the whole ventricular 
 contents, which are to be discharged into the 
 aorta at the next systole of that chamber. The 
 pressure of six inches at the mitral orifice is simply 
 hypothetical, but that this pressure is small, is 
 clear from the experiments, which have been made 
 upon the pressure of the blood entering- ttie right 
 ventricle in animals, a pressure which cannot be 
 very much augmented by the contraction of the 
 auricular chambers, which are so thin in their 
 muscular walls, and which act only during a very 
 small portion of the time, from pulse to pulse, 
 being, as calculated above, one-tenth of a second. 
 
 CONTRACTION OF THE AORTIC ORIFICE WITHOUT 
 REGURGITATION. 
 
 The mechanism of the circulation in this case is 
 very simple. In the healthy human heart, the 
 velocities of the streams, which issue simultaneously 
 from the right and left ventricles, are nearly in the 
 ratio of three to four, inasmuch as the two chambers 
 have to send out equal volumes of blood synchro- 
 nously through the pulmonic and aortic apertures, 
 whose mean areas are nearly one square inch, 
 and three-fourths of a square inch respectively — 
 neglecting friction, A contracted aortic orifice 
 
 £ 2 
 
52 CIRCULATION THROUGH 
 
 usually presents a very irregular form, but sup- 
 posing, for the sake of example, its effective open- 
 ing to be circular in shape, and its diameter one 
 half of that of the normal outlet, the force of the 
 ventricle must be increased at least fourfold to 
 enable the contents of the ventricle to be dis- 
 charged in the usual period of systole ; further, 
 the greatly increased friction due to the roughened . 
 orifice must also increase the necessary force of the 
 ventricle. Should this power be developed and 
 maintained permanently by an hypertrophy of the 
 muscular walls of the ventricle, the two fundamental 
 conditions of synchronism of action, and equality 
 of issues from the two ventricles, will be satisfied, 
 and the circulation enabled to proceed with but 
 little embarassment to the individual. Both ven- 
 tricles will be synchronously completely emptied 
 of their contents, and all pulmonic congestion 
 avoided, unless by undue muscular exertion on 
 the part of the individual, an excess of blood be 
 poured into the left chamber. In such a case, the 
 ventricle will become for a time abnormally dis- 
 tended, and unable to free itself entirely, at each 
 systole, of its contained blood, until cessation from 
 bodily exertion enables the right and left hearts 
 to regain the equilibrium, which had been dis- 
 turbed. It is also evident, that a passing dilatation 
 of the ventricle will occur. I have supposed the 
 left ventricle to have exactly adapted itself, by the 
 
ORGANICALLY DISEASED HEARTS. 53 
 
 simple hypertrophy of its walls, to the obstruction, 
 which it has to overcome at the aortic orifice, and 
 that no permanent distension has taken place. 
 The contraction has so far had no marked effect 
 on the cardiac circulation, beyond rendering- the 
 period of systole somewhat prolonged, in com- 
 parison with the period of diastole. This is 
 clearly proved by the sphygmographic tracing of 
 the radial pulse, where the unusually oblique and 
 curved line of the ascent indicates the difficulty,, 
 which the blood had experienced in forcing its 
 way through the abnormally contracted opening-. 
 Let us suppose, however, that the hypertrophied 
 wall of the ventricle becomes diminished in energy, 
 from functional or organic causes, and unequal to 
 the task, which it has hitherto been able to accom- 
 plish, viz., the complete emptying of the chamber,. 
 A small quantity of blood, it may be at the outset 
 a few minims only, or a drachm or two, remain in- 
 the ventricle at the close of its systole. As the- 
 right side of the heart, aided by the left auricle,, 
 continues to propel the usual quantity of blood into 
 the left ventricle, that chamber is compelled to 
 yield to the pressure of the current through the 
 mitral orifice, and becomes consequently sufficiently 
 dilated to contain the normal charge, from the 
 auricle, plus the quantity which had been left in 
 it from the previously incomplete systole. There 
 are now, we may say, three and a quarter in place 
 
S4 CIRCULATION THROUGH 
 
 of three ounces of blood in the left ventricle, and 
 the capacity of the cavity is increased by a quarter 
 of an ounce of fluid. The ventricle, which had 
 become already unequal to its normal task, has 
 now to act with increased force upon a larger 
 volume of blood, and must become further hyper- 
 trophied, in order that the three ounces, which it 
 had received from the auricle, may be forwarded, 
 without hindrance, through the aortic orifice. 
 Eccentric hypertrophy now commences, and should 
 a sufficiently compensatory thickening of the walls 
 be established, three ounces of blood will be syn- 
 chronously discharged from the two sides of the 
 heart, and a quarter of an ounce will remain in 
 the left ventricle, at the close of each systole, 
 while the amount of permanent dilatation of the 
 chamber will equal the volume of a quarter of an 
 ounce of fluid, and thus will the laws of synchronism 
 of action, and equality of issues, be satisfied. This 
 amount (quarter of an ounce) is of course merely 
 hypothetical, and cited as a means of illustrating 
 the manner in which the struggle between the 
 obstruction and the compensatory hypertrophy 
 can be so balanced, that the circulation (pulmonic 
 and systemic) may, for the time, be efficiently 
 maintained, although a portion of the blood (as 
 if out of the pale of the circulation) is constantly 
 retained in the ventricle, behind the contracted 
 aortic orifice. It is evidently impossible to specu- 
 
ORGANICALLY DISEASED HEARTS, 55 
 
 late, even upon the length of the period, during" 
 which this armistice between the two antagonising 
 powers can be prolonged, and further dilatation 
 of the ventricle prevented. A heart moderately 
 dilated, as the result of this affection, may remain 
 unaltered in its internal capacity for months, and 
 even years, provided that no excessive quantity 
 of blood be too frequently forced into its right 
 chamber by undue muscular exercise, and that the 
 nutritive and contractile energy of the muscular 
 walls be maintained, and provided also, that no 
 increase takes place in the amount of the ob- 
 struction at the diseased outlet. If, however, one 
 of these conditions is imperfectly fulfilled, the 
 left ventricle (which, as already stated, failed to 
 empty itself completely) will again discharge a 
 still smaller proportion of its contents into the 
 aorta. Let us suppose a quarter of an ounce to 
 be retained in the ventricle, in addition to the 
 quantity, which had already been persistently left 
 in that chamber after its systole. Half an ounce 
 of blood will therefore remain in the ventricle at 
 the close of its contraction, producing a corres- 
 ponding permanent increase in its capacity, and 
 further dilatation of its cavity can only be pre- 
 vented by an increased hypertrophy of its walls. 
 At this point, therefore, when a balance has been 
 once more established between the obstruction and 
 the hypertrophy, the quantity (say three ounces) of 
 
S6 CIRCULATION THROUGH 
 
 blood, which has entered the left ventricle from 
 the auricle, is enabled to be completely discharged 
 through the narrowed outlet of the aorta, and in 
 this way the two sides of the heart expel synchro- 
 nously equal quantities of blood, and half an 
 ounce of blood remains in the left ventricle, pro- 
 ducing a corresponding amount of permanent 
 dilatation of that cavity. The mechanism by which 
 the eccentric hypertrophy is produced, is very 
 gradual in its action, and slow in effecting its 
 result, and does not lead to the enlargement of the 
 heart per saltam, as might be inferred from the 
 account just given. I merely described these 
 stages as periods in the development of "actual 
 dilatation," where the obstruction and the counter- 
 acting hypertrophy actually balance each other, 
 a sa mode of illustrating generally the nature of the 
 process in operation. The force, which dilates the 
 left ventricle, is entirely derived from the contraction 
 of the right ventricle and left auricle (as I consider 
 the *' pulmonary interaction force " to be of but little 
 avail as a power of the circulation) aided by the 
 suction power of the ventricle itself, due to the 
 elasticity of its fibres, by means of which the walls 
 spring apart in diastole. Now even under the most 
 favourable circumstances, this force is of compara- 
 tively feeble energy. We must remember, however, 
 that it acts upon the internal surface of the ven- 
 tricle, during the period of its muscular relaxation, 
 
ORGANICALLY DISEASED HEARTS. 57 
 
 and will be of course more effectual in producing- 
 enlarg-ement, when the walls of that chamber are 
 deficient in power, from functional or organic 
 causes. There can be no doubt then, that the 
 production of the eccentric hypertrophy of the left 
 ventricle is the result of a series of stages, occur- 
 ring- at very unequal intervals of time, and that 
 the parts of each stage are as follows : — 
 
 1. Retention of a small quantity of blood at the 
 close of the systole, from inability of the ventricle 
 to overcome completely the resistance at the con- 
 tracted aortic orifice. 
 
 2. Over-distension of the ventricle, from the 
 presence within it of the above residue in addition 
 to the usual volume of blood received by it in 
 diastole from the rig-ht side of the heart. 
 
 3. Increased, but insufficient effort on the part 
 of the ventricle to expel its entire contents, a quan- 
 tity of blood remaining at the end of each systole, 
 equal to or less than the residue from the previous 
 systole. In other words, the increased energy of 
 the ventricle being- sufficient to prevent any further 
 over-distension of the chamber, and to carry for- 
 ward into the aorta the entire charge received by 
 it in diastole from the auricle. 
 
 4. Persistence of the ventricle in this increased 
 functional energ-y, until sufficient hypertrophy of 
 the ventricular wall shall have been developed to 
 maintain permanently the increased demand on its 
 contracting power. 
 
58 CIRCULATION THROUGH 
 
 5. And as a consequence of 4, the force of the 
 ventricle will then exactly counteract the resistance 
 at the aortic orifice, and the circulation through 
 the heart be thoroughly established, although a 
 certain amount of dilatation remains constant. 
 
 The production of the hypertrophy is, I need 
 scarcely say, an example of the familiar physio- 
 logical law, that the increased use of a muscle or 
 set of muscles leads to their increased volume and 
 power, provided that their tissue is healthy and 
 sound. An increase, from time to time, in the ob- 
 struction at the aortic orifice will of course lead to 
 a corresponding repetition of the process just 
 described, and produce further dilatation and com- 
 pensatory hypertrophy, and thus will the constant 
 struggle between the resistance at the outlet and 
 the contractile energy of the ventricle give rise to 
 marked eccentric hypertrophy of the left side of the 
 heart. I have dwelt at some length upon this point, 
 as I find that Niemeyer in his excellent Text-hook 
 of Practical Medicine has failed to see the mechanism 
 of the circulation in this class of cases. He says : 
 — '' In simple stricture of the aortic valve, the left 
 ventricle has no increase of pressure to support 
 •during diastole, and hence does not become dilated ; 
 it has, however, to propel the blood through a 
 contracted orifice, and becomes hypertrophied on 
 account of the greater amount of effort thus re- 
 quired from it. In contradistinction, then, to what 
 
ORGANICALLY DISEASED HEARTS. 59 
 
 we meet with in insufficiency of the valves, we find 
 a simple hypertrophy instead of eccentric hyper- 
 trophy of the left ventricle, when the aortic valves 
 are contracted."^** Cases of simple aortic obstruc- 
 tion are rarely met with, as the affection which 
 causes it usually produces also reg^urgitation 
 through the orifice. But the following instance nar- 
 rated in the "Pathological Society's Transactions" 
 of the year 1870, is one in point. The patient was 
 under the care of Dr. Goodfellow in the Middlesex 
 Hospital, and died December 29, 1869. " I have 
 here a specimen" says Dr. John Murray, "shewing 
 the extent to which aortic valvular narrowing 
 may reach, and yet be compatible with life. The 
 orifice of the valve is reduced to a mere chink, and 
 this appeared even still smaller in the recent state ; 
 in fact it was only on stretching the valve, that any 
 opening whatever could be observed looking from 
 above downward. The free edges of the valves 
 are in a state of ulceration, and on them is some 
 fibrinous deposit, which from its firmness does not 
 give one the idea of being of very recent origin ; 
 but without this deposit, the aortic orifice from the 
 rigidity of the valves is greatly narrowed. There 
 was marked hypertrophy of the heart, especially 
 of the walls of the left ventricle, this cavity was also 
 much dilated.'' A similar case to this is related by 
 Dr. Robert King in the " Pathological Society's 
 * English Edition, page 346. 
 
6o CIRCULATION THROUGH 
 
 Transactions," 1873, vol. xxiv. He states, ''on 
 passing- the finger into the aorta, a nodulated mass 
 of calcareous hardness could be felt in the situation 
 of the aortic valves, but no opening- into the ven- 
 tricle could be detected by the touch. On slitting- 
 open the aorta down to the level of the valves, the 
 aortic opening- was found to be almost completely 
 occluded by the hard mass above mentioned, 
 which was merely perforated near its centre by an 
 opening, which would barely admit a number six 
 catheter, and which was so effectually overgrown 
 by vegetations, that water would not pass either 
 from the aorta into the ventricle, or from the ven- 
 tricle into the aorta without considerable pressure. 
 The left ventricle itself was much dilated and its 
 walls greatly hypertrophied. The mitral and 
 and tricuspid valves were slightly thickened and 
 opaque, but apparently competent." These cases 
 clearly exemplify the error of Niemeyer's state- 
 ment. Although the organic lesion had evidently 
 lasted for years in both cases, the oedematous 
 swelling of the legs in the first one was only slight ; 
 nor was it apparently well marked in the second, 
 and in both, the present illness had only com- 
 menced about two months before the fatal termin- 
 ation. Again in the first case, an attack of 
 inflammation of the upper part of the left lung, 
 shewn post-mortem, by the presence of red hepa- 
 tisation, interfered no doubt with the action of the 
 
ORGANICALLY DISEASED HEARTS. 6i 
 
 right ventricle, and impeded the flow of blood from 
 that chamber to the left side of the heart. Hence 
 followed the rapid (136 beats per minute) irregular 
 and unequal pulse, quick respirations and imperfect 
 supply of blood to the nervous centres, and death. 
 The production of eccentric hypertrophy in the 
 manner, which I have described, is, I believe, the 
 necessary consequence of prolonged aortic ob- 
 struction, but the amount to which it may become 
 developed, even in the most serious cases, con- 
 trasts strongly with the enormous dilatation and 
 thickening of the walls of the left ventricle usually 
 found in cases of aortic regurgitation. The differ- 
 ence in the result of the two forms of aortic 
 disease depends mainly upon the great disparity in 
 the pressure power of the mitral direct and aortic 
 reflux currents, which tend to dilate the left ven- 
 tricle during the period of its relaxation. 
 
 ON THE FOUR CHIEF ORIFICES OF THE HEART. 
 
 In the foregoing account, I have taken for granted 
 that the four openings are circular during func- 
 tion, and I may for a few moments dwell upon 
 the proofs. All writers agree in describing the 
 aortic and pulmonic orifices to be circular in 
 shape, we have, therefore, only to shew, that the 
 mitral and tricuspid are circular, although usually 
 
62 CIRCULATION THROUGH 
 
 described as elliptic in form. At the outset I may 
 state that the canals of the body and all the outlets 
 through which fluid has to pass, are, with a few 
 -exceptions, circular in form, and as the largest 
 quantity of fluid can pass with the least amount of 
 friction through a circular opening, it is clear 
 therefore why this form is adopted. If a square 
 and an ellipse and a circle each contain one 
 square inch, their respective perimeters are 4, 
 3*85, 3*54 inches. An elliptic mitral orifice would 
 have a perimeter one third larger than the peri- 
 meter of a mitral opening containing exactly the 
 same area, but of a circular form. 
 
 The elliptic would therefore expose a much 
 larger frictional surface, and would therefore be 
 less favourable to the transit of blood than an 
 opening of exactly circular form enclosing the 
 same area. If the aortic and pulmonic openings 
 are circular, as admitted by all observers, why 
 should the mitral and tricuspid openings be less 
 favourably formed for the passage of the currents, 
 which traverse them. Post-mortem, the mitral 
 and tricuspid openings present any shape but the 
 purely circular as the heart is lax and empty, but 
 when during life the currents of blood are flowing, 
 the centrifugal pressure exerted by the inflowing 
 blood must necessarily tend to throw the openings 
 into a circular shape. By filling the heart with 
 fluid plaster of Paris, the circularity of the open- 
 
ORGANICALLY DISEASED HEARTS. 63 
 
 ings is easily shewn. In the Bison Europseus the 
 walls of the tricuspid and mitral orifices are so 
 thick, that the circular shape of the opening" is 
 readily observed post-mortem. Lastly, Dr. Peacock 
 employed spherical balls for the measurements of 
 the openings, and found them well adapted for that 
 shape. It is equally an interesting fact, upon 
 which no stress has been laid that each of the four 
 openings is unaltered and unalterable in its area 
 during systole or diastole, as is shewn by the fol- 
 lowing reasons : — 
 
 {a) The rings, which surround the openings are 
 formed of white, fibrous, inelastic tissue. 
 
 (3) The muscular fibres around these openings 
 are not arranged in the form of a sphincter, their 
 ultimate insertion being at right angles to the 
 plane of the orifices. The dissections of Dr. 
 Pettigrew^'"' amply prove this statement. 
 
 {c) Mr. Savory f has shewn, that no arrange- 
 ments of circular fibres exist, capable of altering 
 in any way the areas of the tricuspid and mitral 
 orifices; therefore, since neither of the openings 
 are capable of being affected by muscular action, 
 their areas must always be constant. The neces- 
 sity for this condition is shewn by the following 
 reasons : — 
 
 I. The incoming currents have a minimum 
 
 * J. Pettigrew, "Philosophical Transactions," 1864. 
 -f W. Savory, *' Royal Society's Transactions," 1851. 
 
64 ORGANICALLY DISEASED HEARTS. 
 
 amount of friction to overcome, for if the openings 
 are closed by sphincter action, a considerable 
 amount of auricular force would have been re- 
 quired to ensure the passage of the blood stream 
 through them. 
 
 2. Could the openings be closed by the muscular 
 contractions, the arrangement of the tricuspid and 
 mitral curtains would not only be completely 
 unnecessary, but prove an obstacle to the circula- 
 tion. In fact, where sphincters exist, no valves are 
 present, as shewn in the case of the pylorus, anus, 
 orifice of the bladder in man and the right auri- 
 culo-ventricular orifice in birds. 
 
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 JUKES DE STYRAP, M.K.Q.C.P. 
 
 Physician-Extraordinary, late Physician in Ordinary to the Salop Infirmary; 
 
 Consulting Physician to the vSouth Salop and Montgomeryshire 
 
 Infirmaries, etc. 
 
 I. 
 
 TiHE YOUNG PRACTITIONER: With practical hints 
 ■^ and instructive suggestions, as subsidiary aids, for his guid- 
 
 ance on entering into private practice. Demy 8vo, 7s. 6d. nett. 
 
 II. 
 A CODE OF MEDICAL ETHICS: With general and 
 ■"• special rules for the guidance of the faculty and the public 
 in the complex relations of professional life. Third edition, 
 demy 8vo, 3s. nett. 
 
 III. 
 jyTEDICO-CHIRURGICAL TARIFFS. Fourth edition, 
 revised and enlarged, fcap. 4to, 2s. nett. 
 
 IV. 
 
 TIRE YOUNG PRACTITIONER: HIS CODE AND 
 -*• TARIFF. Being the above three works in one volume. 
 
 Demy Svo, los. 6d. nett. 
 
 C. W. SUCKLING, M.D. LOND., M.R.C.P. 
 
 Professor of Materia Medicaand Therapeutics at the Queen's College, 
 Physician to the Queen's Hospital, Birmingham, etc. 
 
 ON THE DIAGNOSIS OF DISEASES OF THE 
 BRAIN, SPINAL CORD, AND NERVES. With Illus- 
 trations, crown Svo, 8s. 6d. 
 
 JOHN BLAND SUTTON, F.R.C.S. 
 
 Lecturer on Comparative Anatomy, and Assistant Surgeon to the Middlesex 
 
 Hospital. 
 
 TIGAMENTS: THEIR NATURE AND MORPHO- 
 '^ LOGY. Wood engravings, post Svo, 4s. 6d. 
 
 EUGENE S. TALBOT, M.D., D.D.S. 
 
 Professor of Dental Surgery in the Women's Medical College. 
 
 IRREGULARITIES OF THE TEETH AND THEIR 
 ^ TREATMENT. With 152 Illustrations, royal Svo, los. 6d. 
 
H. K. Lewis, 136 Gower Street, London. 15 
 E. G. WHITTLE, M.D. LOND., F.R.C.S. ENG. 
 
 Senior Surgeon to the Royal Alexandra Hospital, for Sick Children, Brighton. 
 fONGESTIVE NEURASTHENIA, OR INSOMNIA 
 ^ AND NERVE DEPRESSION. Crown 8vo, 3s. 6d. 
 
 JOHN WILLIAMS, M.D., F.R.G.P. 
 
 Professor of Midwifery in University College, London ; Obstetric Physician to 
 University College Hospital 
 
 PANCER OF THE UTERUS: BEING THE HAR- 
 ^ VEIAN LECTURES FOR 1886. Illustrated with Litho- 
 graphic Plates, royal 8vo, los. 6d. 
 
 BERTRAM C. A. WINDLE, M.A., M.D. DUBL. 
 
 Professor of Anatomy in the Queen's College, Birmingham ; Examiner in 
 Anatomy in the Universities of Cambridge and Durham. 
 
 A HANDBOOK OF SURFACE ANATOMY AND 
 "■ LANDMARKS. Illustrations, post 8vo, 3s. 6d. 
 
 [^nst published. 
 
 EDWARD WOAKES, M.D. 
 
 Senior Aural Surgeon and Lecturer .on Aural Surgery at the London Hospital, 
 Surgeon to the London Throat Hospital. 
 
 I. 
 pOST-NASAL CATARRH AND DISEASES OF THE 
 
 ■*^ NOSE CAUSING DEAFNESS. With Illustrations, 
 crown 8vo, 6s. 6d. 
 
 II. 
 
 NASAL POLYPUS: WITH NEURALGIA, HAY- 
 FEVER, AND ASTHMA, IN RELATION TO ETH- 
 MOIDITIS. With Illustrations, crown 8vo, 4s. 6d. 
 
 DAVID YOUNG, M.C., M.B., M.D. 
 
 Fellow of, and late Examiner in Midwifery to, the University of Bombay, etc. 
 
 ROME IN WINTER AND THE TUSCAN HILLS 
 IN SUMMER. A Contribution to the Climate of Italy. 
 Small 8vo, 6s. 
 
 CLINICAL CHARTS FOR TEMPERATURE OBSERVATIONS, ETC. 
 Arranged by W. Rigden, M.R.C.S. Price is. per doz., 
 7s. per 100, 15s. per 250, 28s. per 500, 50s. per 1000. 
 Each Chart is arranged for four weeks, and is ruled at the back for making 
 
 notes of cases; they are convenient in size, and are suitable both for hospital 
 
 and private practice 
 
16 Periodical Works. 
 
 PERIODICAL WORKS PUBLISHED BY H. K. LEWIS. 
 
 THE NEW SYDENHAM SOCIETTS PUBLI- 
 CATIONS. Annual Subscription, One Guinea. 
 
 Report of the Soclet}-, with Complete List of Works and other information, 
 gratis on application. 
 
 THE. BRITISH JOURNAL OF DERMATOLOGY. Edited by Malcolm 
 Morris and H. G. Brooke. Published monthly, is. per no. Annual 
 Subscription, 12s., post free. 
 
 THE NEW YORK MEDICAL JOURNAL. A Weekly Review of Medi- 
 cine. Annual Subscription, One Guinea, post free. 
 
 THE THERAPEUTIC GAZETTE. A Monthly Journal, devoted to the 
 Science of Pharmacology, and to the introduction of New Therapeutic 
 Agents. Edited by Dr.s. H. C. Wood and R. M. Smith. Annual Sub- 
 scription, ios., post free. 
 
 THE GLASGOW MEDICAL JOURNAL. Published Monthly, Annual 
 Subscription, 20s., post free. Single numbers, 2S. each. 
 
 LIVERPOOL MEDICO-CHIRURGICAL JOURNAL, including the Pro- 
 ceedings of the Liverpool Medical Institution. Published twice yearly, 
 3s. 5d. each number. 
 
 MIDDLESEX HOSPITAL. Reports of the Medical, Surgical, and Patholo- 
 • gical Registrars for 1883 to 1888. Demy 8vo, 2s. 6d. nett each volume. 
 
 TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF PHILA- 
 DELPHIA. Volumes I. to VL, 8vo, los. 6d. each. 
 
 *^* Mr. Lewis is in constant communication with the leading 
 publishing firms in America and has transactions with them for 
 the sale of his publications in that country. Advantageous 
 arrangements are made in the interests of Authors for the 
 publishing of their works in the United States. 
 
 Mr. Lewis's publications can be procured of any Bookseller in 
 any part of the world. 
 
 Complete Catalogue of Publications post free on application. 
 
 Printed by H K. Lewis, Uower Street, London, W.C. 
 
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