., ;^!:>;U';^ :;:>.:-. \\CtoS\ Ctd5 COLUMBIA UNIVERSITY EDWARD G. JANEWAY MEMORIAL LIBRARY 'ju.. ackuuwledgiueiits are cordially rendered lor the mou' than generous manner in which- he at all times encouraged me to utilise the oppor- tunities afforded Ijy his wards during the years w^e were associated in the Eoyal Infirmary. By Professor Cunningham, Dr. XoLd Paton, Professor Muir, and Professor Stockman the greatest assistance has been given me in writing those portions of the vohiuu' which deal witli the special depart- ments they severally cultivate, and my warm thanks are now returned for their unwearied kindness. In the verification of the references invalualjle services have been rendered by Mr. J. Matheson Shaw and Mr. J. Y. AV. MacAlister, Librarians to the Royal College of Physicians of Edinburgh, and to the Eoyal Medical and Chirurgical Society of London respectively ; to these gentle- men my obligations are heartily acknowledged for their un"\'arying courtesy. The illustrations, with the exception of a few taken from previous works of my own, have been entirely oljtained for this volume. Those which deal with objects seen witli the naked eye are mostly due to Mr. Hume Paterson, of the Laboratory of the Eoyal College of Physicians of Edinburgh, while the reproductions of microscopic appearances have all been drawn by Mr. Eichard Muir, of the Pathological Laboratory of the I'niversity of Edinburgh, to Itoth of whom my thanks are cordially given. 17 Ai.v.v Stueet, Edixbukgh, •lUh Sejitembcr 1898. CONTENTS, CHAPTER I. MORPHOLOGICAL PAGE. luti'orluctoiy — ^ Embryological Considerations — The Heart and Great Vessels — The Blood Vessels — The Fcetal Circulation — Anatomical Considerations — Pericardium — Exterior of the Heart — Interior of the Heart — Orifices and Valves — • Blood Supply — Innervation of the Heart — Dimensions of the Heart — Position and Relations of the Heart — Surface Relations — Structui'e of the Heart — Structure of the Blood'and Lymph Vessels ...... 1 CHAPTER n. PHYSIOLOGICAL. Cardiac Movements and Sounds — Electromotive Changes — Forces which fill the Heart in Diastole — TTutrition of the Heart — Work done by the Heart — The Arteries — Flow in the Arteries — The Blood Pressure — Velocity of the Blood — The Capillaries — The Veins — The Pulmon- ary Circulation — The Duration of the Blood Circuit — The Lj-mph Circulation — Innervation of the Heart and Blood Vessels . . 46 CHAPTER m. PATHOLOGICAL. Etiology— Intrinsic Causes — Extrinsic Causes — Disease Processes — De- generative Changes — Hyaline Degeneration — Cardiac Atrophy — Calcareous Infiltration — Pigmentary Degeneration — Reaction Processes — Comj)ensation — Repair — Eff'ects of Lesions — Causes of Disturbance connected with the Heart — Compensation for Dis- turbances — Causes dependent on the Condition of the Blood Vessels — Causes connected with the State of the Blood . . .88 X COXTENTS. CHAPTEK IV. SEMEIOLOGICAL. PAOE. Symptoms connected with tlie Heart — Inspection — Palpation — Per- cussion—Auscultation — Tlie Arteries — The Pulse — The Sphygmo- grajili — Blood Pressure in the Arteries — Auscultation of the Arteries — The Capillaries — The ^'eins — Symptoms connected with the Digestive System — With the Htemopoietic System — With the Resjjiratory System — With the Integumentary System — With the Urinary System — With the Reproductive System — With the Nervous System ....... 121 CHAPTER V. THERAPEUTICAL. Different Classes of Disorders requiring Treatment — Indications for Treatment — Provisions for meeting Disturbances — Means of relieving Difiturbances — The Alcohol Group — • The Ammonia Group — The Camphor Group — The Caffeine Group — The Morphine Group — The Atropine Group — The Aconite Grouji — The Veratrine Group — The Digitalis Group — Acute Diseases — Dynamic Diseases — Toxic Conditions ........ 255 CHAPTER VI. CONGENITAL HEART DISEASE. Etiology — Morbid Anatomy — Symptomatology — Diagnosis — Prognosis — Treatment — Illustrative Cases ..... 284 CHAPTER VII. DISEASES OF THE PERICARDIUM. Pericarditis — Frequency — Etiology — Exciting Causes — Predisposing Causes — Morbid Anatomy — Diagnosis — Prognosis — Treatment — Illustrative Cases — Adherent Pericardium — Etiology — Morbid Anatomy — Symptomatology — Diagnosis — Prognosis — Treatment — Illustrative Cases — Mediastino - Pericarditis — Etiology — Morbid Anatomy — Symptoms — ■ Diagnosis — Prognosis — Treatment — Pneu- mopericardium — • Etiology — Morbid Anatomy — Symptoms — Diag- nosis — Prognosis — Treatment — Pericardial Tuberculosis — Etiology — CONTENTS. xi rAOK. Morbid Anatomy — -Symptoms — Diagnosis — Prognosis — Treatment — Pericardial Syphilis — Pericardial Neoplasms — Hydropericardium — Etiology — Morbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment — Hsemopericardium . . . . . .313 CHAPTER VIII. DISEASES OF THE ENDOCARDIUM. Endocarditis — Etiology — Infective Endocarditis preceded by old Cardiac Disease — -Without pre-existing Cardiac Disease — With Infective Lesions — Morbid Anatomy — Symptomatology — Diagnosis — Prog- nosis — Treatment — Illustrative Cases .... -390 CHAPTER IX. CHRONIC AFFECTIONS OP THE ORIFICES AND VALVES. Frequency — Etiology — Morbid Anatomy — Endocarditic Changes — De- generative Lesions — Neoplasms — Traumatic Lesions — Effects — Symptoms — Diagnosis — Prognosis — Treatment . . . 436 CHAPTER X. AFFECTIONS OF THE AORTIC ORIFICE. Aortic Obstruction — Etiology — Morbid Anatomy — Symptoms — Diagnosis • — Prognosis — ^Treatment — Illustrative Cases — Aortic Incompetence — Etiology — Morbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment — Illustrative Cases — Combined Aortic Lesions — Illustra- tive Cases ........ 472 CHAPTER XI. AFFECTIONS OF THE SUTRAL ORIFICE. Mitral Obstruction — Etiology — Morbid Anatomy — Symptoms — Diagnosis —Prognosis — Treatment — Illustrative Cases — Mitral Incompetence — Etiology — Morbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment — Illustrative Cases — Mitral Obstruction and Regurgita- tion — Etiology and Morbid Anatomy — Symptoms and Diagnosis — Prognosis and Treatment — Illustrative Cases . . . .519 xii COXTEXTS. CHAPTER XII. AFl'^lXTIUNs OF THK ITI.iloNAUY ORIFICP: I'AOE. ruliuonaiy Obstruction— Etiology— Jlorliid Anatomy— Syinptoniatology — Diagnosis — Prognosis — Treatment — Pulmonary Incompetence — j\Iorliiil Anatomy— Symptoms — Diagnosis — Prognosis — Treatment — Illustrative Cases ....... 561 CHAPTER XIII. .\FFKCTIUNS OF THK TRKTSPID ORIFICE. Tricusiiiil Obstruction — Etiology — ]Morbiil Anatomy— Symptoms— Diag- nosis — Prognosis — Treatment — Illustrative Cases — Tricuspid In- competence — Etiology — Morbid Anatomy — Diagnosis — Prognosis — Treatment— Illustrative Cases ..... 588 CHAPTER XIV. AFFECTIONS OF THE MYOCARDIUM. Cardiac Weakness — Etiology — Morbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment — Illustrative Cases — Cardiac Atrophy — Etiology — Morbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment — Degeneration — The Fatty Heart — Fatty Infiltration — Fatty Degeneration — Etiology — Morbid Anatomy — Symptoms — Diagnosis — Progno-sis — Treatment — Illustrative Cases — Myocarditis — Acute ]\Iyocarditis — Etiology — Morbid Anatomy — Diagnosis — Prognosis — Treatment — Chronic Myocarditis — Etiology — Morbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment — Illus- trative Cases — Dilatation — Etiology — -Morbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment — Illustrative Cases — Cardiac Aneurysm — Etiology — Morbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment — Spontaneous Kupture — Hypertrophy — Etiology — ^lorbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment — Chronic Infective Processes — Tubercle — Syphilis — New Formations — Wounds of the Heart ..... 624 CHAPTER XV. COMPLEX SEN80UY AND MOTOR AFFECTIONS. Angina Pectoris — Etiology — Morbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment— Illustrative Cases — Recurrent Tachj'cardia — Etiology — Morbid Anatomy— Symptoms — Diagnosis — Prognosis — CONTENTS. xiii I'AfiE. Treatment — Illustrative Cases — Recurrent Brai.lycardia — Etiolo;^y — Morbid Anatomy- — Symptoms — Uiairnosis— I'rognosis — Treatment — Illustrative Cases ....... 756 CHAPTER XVI. DISEASES OF THE AORTA. Acute Aortitis — Etiology — Morbid Anatomy — ■Symjitoms — Diagnosis — Prognosis — Treatment — Chronic Aortitis — Etiology — Morbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment — Aneur- ysm of the Aorta — Etiology — Morbid Anatomy — Symptoms — Diag- nosis — Prognosis — Treatment — Illustrative Cases . . . 81-3 Appendix I. — Radiography ...... 887 Appendix II. — Bibliography . . . . . . 889 General Index . . . . . . . .917 Index of Authors ....... 925 LIST OF ILLUSTRATIONS. FIG. PAGE. 1. Longitudinal section of heart seen from riglit . . . .14 2. Longitudinal section of heart seen from left . . . .15 3. Transverse section of heart looking towards apex . . .17 4. Diagram of the connections of the cardiac nerves . . .25 5. Sagittal section through the thorax of a male adult . . .29 6. Sagittal section through the thorax of a male adult . . .30 7. Sagittal section through the thorax of a male adult . . .31 8. Transverse section through the thorax of a male adult . . 32 9. Transverse section through the thorax of a male adult . . 33 10. Transverse section through the thorax of a male adult . . 33 11. Heart in thorax seen from right side . . . . .35 12. Heart in thorax seen from front . . . . • .35 13. Heart in thorax seen from left side . . . . .35 14. Tracing from conus arteriosus in sternal fissure . . .52 15. Simultaneous tracing from conus arteriosus and carotid artery . 52 16. Tracing from conus arteriosus with curve of tuning-fork . . 53 17. Upward displacement of thoracic organs in ascites . . . 125 18. Upward displacement of the heart in scoliosis .... 125 19. Displacement of the heart to the right in pleurisy of the left side . 126 20. Displacement of the heart in left pneumothorax . . .126 21. Displacement of the heart to the right from old fibroid changes in the right lung . . . . . ... . 127 22. Complete transposition of the viscera . . ' . . . 127 23. Cardiogram from a case of adlierent pericardium . . .129 24. Tracing from the apex beat of a case of mitral obstruction with marked thrill ........ 135 25. Diagrammatic representation of the cardiac cycle . . . 140 26. Normal heart sounds ....... 141 27. Accentuation of aortic second sound ..... 142 28. Accentuation of pulmonary second sound .... 143 29. Diminution of aortic second sound ..... 143 30. Diminution of pulmonary second sound .... 144 31. Accentuation of mitral first sound ..... 145 LIST OF ILLUSTRATIOXS. FIG. 32. 33. 34. 35. 36. 87. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 69. 70. 71. 72. 73. 74. Diminution of mitral first sound Accentuation of tricusj>id first sound Diminution of tricus})id first sound Tracing from conns arteriosus .... Double second sound ..... Double first sound ..... Tracing of chest in jicricarditis witli mitral incompetence Presystolic murmur ..... Presystolic murmur ..... Systolic murmur ..... Sj'stolic murmur following first sound . Systolic murmur following first sound . Systolic murmur accompanying first sound Systolic murmur replacing first sound . Diastolic murmur ..... Diastolic murmur following the second sound . Diastolic murmur accompanying the second sound Diastolic murmur rephicing the second sound . Late diastolic murmur ..... Continuous .systolic and diastolic murmur in patent ductus arteriosus Presystolic and .systolic murmurs Systolic and diastolic murmurs .... Presystolic, systolic, and diastolic murmurs Systolic and diastolic murmurs .... Presystolic, .systolic, and diastolic murmurs Presystolic and diastolic murmurs Aortic systolic murmur ..... Aortic diastolic murmur .... Aortic systolic and diastolic murmurs . Systolic jiropagated more widely than presystolic murmur Presystolic propagated more widely than systolic murmur Presystolic propagated more widely than systolic murmur S3-stolic propagated more widely than presystolic murmur Presystolic propagated more widely than diastolic murmur Diastolic propagated more widely than presystolic murmur Presystolic and diastolic mitral with systolic mitral and tricuspid murmurs ...... Systolic aortic and mitral murmurs Systolic and diastolic aortic and pulmonary murmurs . Systolic murmur with maximum intensity in four areas Systolic murmur of tricuspid origin Presystolic and systolic mitral with diastolic jjulmonary murmur Systolic mitral and tricuspid jnurmurs with diastolic pulmonary murmur ........ Presystolic systolic and diastolic mitral and )iresystolic and diastolic tricusjiid murmurs ...... Tricuspid and mitral presystolic murmur Tracing from the radial artery in a case of mitral incompetence Tracing from the radial artery in a case of mitral incompetence Ll.Vr OF ILLUSTRATIONS. 78. 79. 80. 81. 82. 84. 85. m. 87. 88. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 10.3. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. Tracing from the pulse of a healthy man aged 36 Diagram of pulse tracing in health Tracing from a case of advanced atheroma of tlie arteries Diagram of pulse of low pressure Diagram of pulse of high pressure Tracing from radial artery showing low pressure with sclerosis of vessels ...... Pulse from a case of pericarditis showing dicrotism . Pulse from a case of enteric fever showing hyperdicrotism Diagram of fully dicrotic pulse Diagram of hyperdicrotic pulse .... From acute pneumonia in a patient suffering from aortic regurgita tion ........ Tracing from the radial artery in a case of mitral stenosis P-ulsus bigeminus d altcrnans in aortic disease Tracing from the radial artery in a case of aortic incompetence Tracing from the radial artery in a case of aortic stenosis Pulsus 'paradoxus in adherent pericardium Tracing from right radial artery in aneurysm . Tracing from left radial artery in aneurysm . Tracing from vein on the back of the hand in a patient with acute pneumonia and aortic incompetence Tracing from internal jugular vein Tracing from internal jugular vein Tracing from internal jugular vein Tracing from internal jugular vein Tracing from internal jugular vein Tracing from internal jugular vein Tracing of Cheyne-Stokes' breathing . Diagram of the connections of the cardiac nerves Cutaneous distribution of the sensory nerves . Cutaneous distribution of the sensory nerves . Transposition of aorta and pulmonary artery . Patent ductus arteriosus . Patent ductus arteriosus Clubbing of fingers in congenital heart disease Clubbing of toes in congenital heart disease . Chest tracing from Case 1 . Physical signs in Case 2 . . Fibrinous pericarditis .... Fibrinous pericarditis in a child Microscopic appearances of fibrinous pericarditis. x 20 Acute pericarditis secondary to pneumonia. x 300 Acute pericarditis following pneumonia. x 1000 Area of audition of pericardial friction Temperature chart from Case 6 Temperature chart from Case 7 Temperature chart from Case 8 Fibrinous pericarditis. x 20 . I'Afii;. 180 ISO 182 184 184 185 185 185 186 186 187 188 188 190 190 191 193 193 197 202 202 202 203 203 203 216 241 242 243 290 294 295 306 307 307 309 320 321 322 323 324 331 352 354 355 359 xviii LIST OF ILLUSTRATIONS. FIG. PAGE. 12-4. Pjliy of tlie riglit auricle and ventricle from combined mitral and tricuspid olistruction and incompetence. The heart is seen from the front ..... 594 LIST OF ILLUSTRATIONS. xix FIG. PAGE. 165. Great dilatation and hypertrophy of the right auricle and ventricle from combined mitral and tricuspid obstruction and incompetence. The heart is seen in profile from the right . . . 595 166. Transverse section through the heart in combined mitral and tri- cuspid obstruction and incompetence .... 507 167. Presystolic and systolic mitral and tricuspid murmurs in Case 41 . 601 168. Murmurs of tricuspid and mitral obstruction and incompetence in Case 43 606 169. Tricusp)id and mitral presystolic murmur in Case 44 . . . 608 170. Tracing from Case 48 . . . • • • .636 171. Distribution of murmurs in Case 48 ..... 637 172. Cardiac dulness and murmur in Case 49 ... . 639 173. Pigmentary atrophy. x 300 . . . • ■ .642 174. Section of myocardium from a case of pernicious ansemia. x 250 . 655 175. Section through wall of left ventricle in acute myocarditis. x 250 . 675 176. Intei'stitial myocarditis from coronary sclerosis . . . 683 177. Section of wall of lef b ventricle in chronic myocarditis from coronary occlusion. X 60 . . . ■ ■ • ■ 684 178. Section of wall of left ventricle in chronic myocarditis from coronary occlusion. X 250 ....... 685 179. Section of left ventricle showing effects of infarct. x 100 . . 686 180. Great dilatation of the right ventricle with some hypertrophy, from a case of emphysema ...... 701 181. Cardiac aneurysm affecting the left ventricle, which had undergone rupture ........ 714 182. Cardiac aneurysm viewed from inside of left ventricle . . 715 183. Spontaneous rupture of heart afl'ecting the right ventricle . . 718 184. Hypertrophy of the left ventricle in chronic renal disease . . 738 185. Section longitudinally through the left ventricle of an old-standing case of hypertrophy. x 300 ..... 741 186. Bullet wound through conns arteriosus .... 754 187. Distribution of the pain, the cardiac murmurs, etc., in Case 57 . 787 188. Area of pain and tenderness behind in Case 57 . . . 788 189. Cardiac and liver dulness and distribution of pain in Case 59 . 790 190. Areas of pain in Case 59, seen from behind .... 790 191. Distribution of pain in a case of angina pectoris, probably due to coronary sclerosis ....... 791 192. Distribution of pain in Case 61 ..... 793 193. Atheroma of coronary artery, x 50 . . . . . 816 194. Changes in the aortic walls leading to aneurysm . . . 832 195. Sacculated aneurysm arising within the sinus of Valsalva and in- volving the interventricular septum .... 835 196. Dissecting aneurysm of the ascending aorta .... 837 197. Tracing from fusiform aneurysm of the innominate and common carotid arteries . . . . . . .839 198. Tracing from sacculated aneurysm of the ascending aorta . . 839 199. Dilatation of ascending aorta ...... 862 200. Aneurysm of the ascending aorta ..... 864 201. Aneurysm of the descending thoracic aorta .... 868 LIST OF ILLUSTRATJOXS. 202. Aneurysm of the iilxloiuinal aorta 203. Tracing with JIarey's stethouraj^h 204. Tracing from right radial artery 205. Tracing from left radial artery 206. Tracing of ]iulsating areas in Case 7!' 207. Heart and aneurysm seen from the right side 208. Heart and aneurysm seen from the left side . 209. Rupture of the aorta in its ascending jiortion . 210. Skiagram of tlie chest in cninpletc tians]i(isitiiiii il' the viscer; I'.VOB. 870 871 873 873 878 881 882 884 887 DISEASES OF THE HEART AND AORTA. DISEASES OF THE HEART AND AORTA. CHAPTER L MOEPHOLOGICAL. Intkoductoey. The aim of the circulation is to render possible the continuous interchange between the blood and the tissues through which it flows. If this interchange were a constant quantity, the .maintenance of the circulation would be a simple physical problem, and a purely mechanical apparatus would serve all its purposes. The metabolic processes, however, are subject to great fluctuations. There are not only changes occurring through the entrance of new materials from the alimentary viscera, but there are also modifications produced by intrinsic activities, as well as alterations caused by external agencies. These and many other analogous influences render some means of adapting the circulation to the wants of the tissues an essential and necessary condition for the maintenance of life. And, if the variations taking place under conditions which may be considered within the limits of health, demand some means of adjustment, such a possibility of adaptation is much more required to provide for the alterations effected by disease, whether occurring in the form of changes in the composition of the blood, or of modifications in the structure of the tissues through which it flows. There are thus some purely mechanical questions connected with the provision for 1 2 MORPHOLOGICAL. a circulating niediuni, and there are also some complex vital problems relating to the adjustment of that nutritive and depurative medium in varying- conditions. in order to have a thorough understanding of the circu- lation it is necessary to study it from every point of view, and the difficulty in such a work as this is to decide what it is needful to include, and what it may be possible to omit. All facts which can elucidate the subject are of use, but some of them are of much greater importance than others ; to present the subject, therefore, in a proper perspective requires the exercise of considerable selective judgment. It may seem needless to enter upon a discussion of em- bryological facts in a work written, as this is, with a view to practical ends. In recent years, however, every department of medicine has largely gained by a study of the phases of development, and that dealing with the circulation at least as much as any other. The short sketch of the circulation during embryonic life, with which this work begins, is restricted to the consideration of such points as are necessary to bring into relief the main facts of development, and to provide the data from which important general conclusions may be drawn. How far the introduction of anatomical and physiological considerations is necessary or expedient in such a volume as this must always be a question difficult to decide. Many facts with reference to these aspects of the circulatory organs must be regarded as familiar to every one, and it would be simply a waste of time to recall them. But before entering upon the study of the heart in diseased conditions it is clearly necessary to have a definite conception of medical anatomy and physiology. Such a conception renders the description of the special affections of the heart and great vessels a matter to be more easily accomplished, and at the same time facilitates a complete grasp of the whole subject, more especially if the facts of general pathology, as applied to the circulation, receive preliminary consideration. A systematic analysis of the general symptomatology, and of the principles of therapeutics, with regard to the circulation, will also be found to facilitate the comprehension of many EMBRYOLOGICAL CONSIDERATIONS. 3 details belonging to the special diseases to be afterwards discussed. Holding such views, it has therefore seemed to me essential to give a somewhat full preliminary statement of many matters of a general character, in order to pave the way for their systematic consideration in the various special departments into which they naturally fall. EMBRYOLOGICAL CONSIDERATIONS. On account of difficulties inseparable from the subject, there are many gaps in our knowledge of the development of the human embryo. As the general history of the process, however, is closely similar to that seen in other mammals, it is possible, notwithstanding certain differences in detail, to supply many of these deficiencies. In the following short account of the development of the circulatory system, the facts are taken as far as is possible from observations on the human embryo ; many points, nevertheless, are elucidated by reference to what has been described in other mammals, and even in animals belonging to lower vertebrate classes. The Heart and Great Vessels. — The vascular system makes its first appearance in the form of two simple lateral tubes in the anterior part of the embryo, occupying spaces con- tinuous with the pleuro-peritoneum ; they are composed of two layers, apparently developed respectively from the mesoblast and hypoblast, and are continuous in front with the cephalic mesoblast, while connected behind with the omphalo-meseraic or vitelline veins. These tubes are developed in the lateral part of the embryo, which, on the folding downwards of the body walls, becomes the ventral wall of the pharynx ; and when this wall is completed they meet in the middle line, and become fused so as to form a single channel. This tube remains in connection with the vitelline veins behind, and bifurcates in front, giving rise to the primitive aortse. At this stage in the development of the vascular apparatus, the single median tube begins to pulsate ; a fact of far-reaching importance, which will be described more fully in the sequel. 4 MORPHOLOGICAL. The central vascular tube, at a slightly later stage, becomes curved by bending over to the right ; and at the same time its posterior extremity, connected, as already seen, with the venous channels behind, assumes a position dorsal to the other parts. At this period of development, superficial constrictions appear upon the tube, dividing it into the venous sinus, the auricle, the ventricle, and the aortic bulb. While these changes are going on, muscular fibres are for the first time seen in the substance of the vascular apparatus. This is another important fact, for the appearance of pulsation before the development of muscular tissue raises some interesting problems. The venous sinus receives the posterior veins already mentioned, and the primitive veins from the cephalic region. It at first communicates freely with the auricle, but afterwards is guarded by venous valves. The common auricle continues to develop behind the curved ventricular portion of the tube, and in time the right venous valve forms the Eustachian and Thebesian valves, while the left venous valve disappears. The common ventricle, or curved ventral portion of the tube, re- ceives the blood from the common auricle at its left end, and terminates at its right end in the aortic bulb. It contains in its early stages a fine spongy substance. A slight contraction on its outer surface marks the future separation into right and left ventricles, and a septum, composed of muscular tissue, begins to grow upwards and forwards from below and behind. This is completed at a later stage by the development of a fibrous septum, which grows downwards from above and before to join the partial muscular partition. At the same time the spongy tissue in the cavity of the ventricular portion of the apparatus begins to be gathered together in distinct masses — the musculi papillares and columnte carnese of the fully developed heart. The common auricle is gradually raised upwards and for- wards, so that the opening into the ventricular portion assumes a position over the inter-ventricular septum, which grows up, and, with the assistance of flaps, to be described below — the future auriculo-ventricular valves — divides the orifice into two divisions. A septum is developed in the common auricle from EMBRYOLOGICAL CONSIDERATIONS. 5 above and behind, downwards and forwards, in which the fora- men ovale is formed. Before this inter-auricular septum is produced, the pulmonary vein is developed. The foramen ovale is freely open until the fourth month, but about that period the valvular apparatus guarding the opening is developed, and in the last three months of foetal life the blood can only pass from the right to the left auricle. While these changes are proceeding, the aggregation of the spongy tissue of the ventricles into distinct masses goes on, and by this means the columnse carnese, as well as the musculi papillares with their chordae tendinese, are formed ; the latter becoming attached to the flaps developed at the auriculo- ventricular orifices. The inter-ventricular septum grows up into the aortic bulb and separates it into two divisions, i.e. aorta and pulmonary artery, each communicating with its respective ventricle. Folds of the lining membrane grow up at the junction of the bulb and the vessels, and by their division into segments form the semilunar valves. The auriculo-ventricular valves appear, from the researches of the younger His, to be composed, in birds and mammals, of five layers, derived from : (1) the endocardium of the auricle ; (2) the muscular wall of the auricle ; (3) the pericardium, which breaks through the muscular wall in the auriculo-ventricular region, and forms the greatest part of the valve in the adult ; (4) the ventricular muscle — a layer specially related to the papillary muscles, when they are developed; and (5) the endo- cardium of the ventricle. The two muscular layers become gradually altered, that from the ventricle passing into fibrous tissue attached to the chordae tendinese, and that from the auricle forming the muscular tissue of the auriculo-ventricular valves discovered by Kiirschner and more fully described by Joseph and Darier. The development of the great arterial trunks must receive some attention. From the aortic bulb two arterial arches spring, each running forwards, outwards, and backwards, behind the primitive heart, to form the primitive aorta of its own side. The two primitive aortee unite at an early period in the middle line about the dorsal region. To these arterial arches four other lateral pairs are in succession added, forming 6 MORPHOLOGICAL. five on each side. Of these arches the first and second become the external carotid artery and its branches ; the third forms the internal carotid artery. The fourtli, on the right side, becomes the subclavian artery, and on the left side it forms the arch of tlie aorta. The fifth, on the right side, develops as the right pulmonary artery, and its distal portion vanishes ; on the left side it forms the left pulmonary artery, and the portion beyond remains during foetal life as the ductus arteriosus. The right descending primitive aorta entirely disappears in its anterior part ; the left remains as the per- manent descending aorta, and joins the posterior part of the right primitive aorta behind, to form the posterior portion of the permanent descending aorta. Haller pointed out that the heart in the embryo of the fowl begins to pulsate before any other structure shows a trace of irritability, and Bischoff attributed this to an inherent tendency in the heart muscle ; inasmuch, however, as the pulsation Ijegins before the appearance of any muscle cells — a fact first noted by Eckhard — we are driven to conclude that rhythmic pulsation may be independent of muscular structure. >Since the heart movements begin before the evolution of any nervous elements, as was shown by Preyer, it is obvious that they must be due to some, as yet unknown, indwelling property of the embryonic heart tissue. From the researches of the younger His, it appears that in the embryo of the fowl the heart commences to pulsate about thirty-six hours after the beginning of incubation. The pulsation is at first irregular, but after the first two days have f)assed it becomes regular ; its rate varies with the external temperature. About the fourth or fifth day the structure of the heart wall is considerably altered. Hitherto the cells of which it is composed are circular, but about this period they become elongated and begin to form the trabeculae on the inner aspect of the walls. At the same time the pulsation changes its character. Hitherto a simple peristaltic wave, passing uniformly over the entire cardiac structures, it now begins with a pulsation of the venous sinus, which, after a slight pause, passes over the auricles ; then, succeeding a longer pause, EMBRYOLOGICAL CONSIDERATIONS. 7 ensues the ventricular contraction, followed immediately by the pulsation of the aortic bulb. At this time no nervous structures have made their appearance, and it is not until the sixth day that ganglionic cells are found. From the researches of Fano it is quite clear that from the outset the individual parts of the embryonic heart possess different characteristics ; they react differently, for example, to stimuli, and their behaviour under the influence of cardiac poisons is not the same. The development of the cardiac ganglia in the embryonic heart does not, according to His, produce any noteworthy change in the action of the heart, the phenomena observed on the seventh day of the embryo of the fowl being in all respects similar to those seen on the fifth. These observations, origin- ally made on the fowl, have been verified by the same observer in fishes, frogs, and rabbits. It is worthy of remark that Pfliiger observed pulsation of the heart of a human embryo of three weeks, and it is well known that the earliest ganglia appear in it at the end of the fourth week. It is impossible, after considering these observations, to avoid the conclusion that the heart is endowed with a tendency to rhythmic pulsa- tion, altogether independent of any special nervous stimulus. During the later stages of foetal life the circulation has certain peculiarities of arrangement, which disappear soon after birth. In the first half of intra-uterine life the foramen ovale, as has been noted above, is freely open, but during the later months of foetal existence, in consequence of the development of the valve of the foramen, it is only open for the passage of blood from the right to the left auricle. At this later period also the Eustachian valve has come into existence, and directs the current of blood, reaching the right auricle by the inferior vena cava, towards the foramen ovale. By means of the ductus arteriosus, whose origin has been described, there is free communication between the aorta and pulmonary artery; this does not cease until the obliteration of the ductus, usually at the end of the first week after birth. This free opening between the two great vessels must of necessity tend to equalise the blood pressure in them. As is well known, the thickness of the walls of the two 8 iMORPHOLOGICAL. ventricles is almost equal during foetal life, a fiict which seems obviously due to the nearly equal pressure caused by the com- munication between the two sides of the system, as was, indeed, suggested by Harvey. In order to ascertain the relation borne liy each ventricular wall at different stages of growth, the subject has within recent times been investigated by Lockhart Gillespie and myself The method followed was to make a series of sections through the ventricular portion of the heart of the foetus at riofht angles to its axis, and measure the thickness of the walls half-way between the auriculo-ventricular groove and the apex. The following is a summary of the results : — 1. Fcetus, 3i- months 2. Fcetus, 4 months • . 3. Fcetus, 6 months . 4. Fcetus, full term, never breathed 5. Fcetus, full term, never breathed 6. Fcetus, full term, lived 24 hours 7. Female infant, 11 months 8. Male infant, 22 months . These figures show that the left ventricle progressively increases in thickness from the third month, while the right ventricle increases up to the hour of birth, and then rapidly diminishes, the thickness of its wall nearly two years after- wards being actually smaller than in the sixth month of foetal life. From these facts it is clear that the thickness of the walls of the cardiac chambers is proportional to the work which each has to do. They are in every respect supported by observations made by us on the foetal heart of the horse, cow, sheep, pig, dog, and cat. The consideration of these points in development is by no means a matter only of scientific interest ; on the contrary, the facts which have been briefly described in the preceding pages render it more easy to show how different malformations are possible through arrested or perverted development. They point, moreover, to certain important truths. The pulsation of the primitive vascular tube, for in- stance, before the growth of any muscular fibres in its sub- Wall of Right Wall of Left Ventricle. Ventricle. . 1-5 mm. 1 mm. . 1-5 0'5 . 4 3 . 4 3 . 5 5 . 3 4 . 2 5 . 2 8 EMBRYOLOGICAL CONSIDERATIONS. 9 stance, appears to be evidence in favour of the existence of an inherent tendency to rhythmic propulsive movements in the vascular mechanism. And, as during fcetal life the blood pressure must be nearly the same on both sides of the heart, it is undoubtedly a circumstance of real importance that up to the time of birth the thickness of the vi^alls of the two ventricles is almost equal on the two sides. This fact may be taken to prove that the amount of strength developed is strictly proportional to the work that has to be done. Such results lead to far-reaching conclusions in regard to the possibility of the heart adapting itself to widely different morbid conditions. The Blood Vessels. — The blood vessels take their origin in the mesoblast and hypoblast. They appear first as irregular spaces and canals, formed by the separation from one another of the mesoblast cells. The cells surrounding these spaces undergo modification in character and arrangement, and be- come altered so as to form blood vessels. But the network which is produced becomes connected with the hypoblast, from which are derived the capillaries, as well as the endothelial lining of the larger blood vessels, around which the muscular and con- nective tissue grows from mesoblast structures. The primitive blood corpuscles appear to have a double origin ; some are cells enclosed within the lacunse, others are produced by budding from the walls of the vessels. The Course of the Blood. — The course of the fcetal circulation differs from that of the child after birth on account of the special conditions imposed by intra -uterine existence — the presence of the placental arrangement for purifying the blood, and the absence of any pulmonary functions. The extension of the hypogastric as umbilical arteries, ending in the placental capillaries, and the presence of the single umbilical vein, which represents the left allantoic vein — the right having disappeared — terminating, by means of the ductus venosus, in the inferior vena cava, form the mechanism which provides for the placental circulation. The absence of any respiratory function in the lungs necessarily removes almost entirely the need for a free supply of blood by the pulmonary circuit, and apparently the pulmonary artery only conveys enough of blood to its branches to keep them I o MORPHOL O GICAL. open. Ill order to cany out this distriljutioii two structural provisions are present in the foetus. By means of the fora- men ovale, much of the blood returned by the inferior vena cava Hows from the right into the left auricle, and through the ductus arteriosus a large proportion of the blood sent into the pulmonary artery finds its way into the aorta. At birth, the commencement of the respiratory functions of the lungs and the arrest of the placental circulation pro- duce changes in the course of the blood, attended by structural alterations in the heart and vessels. The blood begins to liow freely through the lungs, and the hypogastric vessels are left empty. The ductus veiiosus becomes obliterated as well as the umbilical vein ; the foramen ovale becomes closed ; and the ductus arteriosus together with the hypogastric arteries shrivel up. All these changes are eftected within eight days from the date of birth, and henceforth the course of the blood is as ill adult life. Anatomical Considerations. The facts regarding the anatomy of the circulatory apparatus may fitly begin with the heart and its relations ; reference to the peripheral lilood and lymph vessels being made after- wards. Peeicaedium. — The pericardium may most conveniently be considered from the point of view of its two-fold arrange- ment, comprising as it does the parietal or outer, and the visceral or inner portion, often termed the epicardium. The parietal pericardium consists of two layers, the ex- ternal or fibrous and the internal or serous. Although closely applied to the structures which it covers and protects, it is nevertheless extremely extensible, no doubt on account of the large proportion of yellow elastic fibres wliicli it comprises. Eesting below on the central tendon, with which it is intimately connected, and in front on the anterior muscular portion of the diaphragm, the filjrous pericardium extends upwards in an irregularly conical form to a point aljout two inches above the origin of the aorta. It is attached in front by two fibrous bands, often called the superior and inferior sterno-pericardial ANATOMICAL CONSIDERATIONS. n ligaments, to the body of the sternum and to the xiphoid cartilage. Posteriorly it is attached to the vertebral column by the fibrous tissue of the posterior mediastinum. At its upper extremity it has four openings — for the aorta, the two divisions of the pulmonary artery, and the superior vena cava, respectively. Posteriorly there are also four apertures through which the four pulmonary veins pass, and in foetal life there is also an opening for the ductus venosus. The fibrous pericardium is everted at these openings, and is intimately united to the outer coats of the vessels. As the vessels have reflections of the cervical fascia, the pericardium is indirectly attached to the clavicle and upper ribs. The inferior surface of the fibrous pericardium presents an opening for the passage of the inferior vena cava, but here the membrane is not everted in consequence of its relation to the diaphragm, and it does not become so closely incorporated with the wall of this vessel as with the outer coat of the others which pass through it. It is not to be forgotten that the fibrous pericardium is covered on its outer surface by the parietal layer of the pleura through- out great part of its extent, only an elongated triangular portion in front, and an irregular area behind, in connection with the great vessels, being uncovered by the pleura. The serous lines the fibrous layer of the pericardium throughout its whole extent, excepting a small area posteriorly where they are separated by some of the great venous trunks. The fibrous pericardium may therefore be regarded as invested on both aspects with serous membrane to a great extent, so that it is often termed the pleuro-pericardium. The serous layer is reflected from the fibrous envelope upon the aorta and pulmonary artery to form the visceral pericardium. These vessels have a common serous covering which extends over them for about two inches from their origin. Passing from the root of the aorta and pulmonary artery to the auricles, the visceral pericardium envelops the entire external surface of the heart, the anterior aspect of the superior vena cava for about an inch, and the anterior, inferior, and posterior surfaces of the pulmonary veins to a variable extent. ExTEEiOE OF THE Heart. — The form of the heart changes greatly, not only in its A^arying phases of activity, but also in the 1 2 MORPHOL O GICAL. cUfterent positions it may be placed in. Many discrepancies in the descriptions ^vhiell have been given of it are probably therefore tlependent on its having been described while in ditterent stages of contraction or relaxation, or in diverse positions. The best general idea of the organ as a whole is undoul)tedly obtained by studying a specimen which has been fully injected ; this, however, although presenting the fully distended condition of every part, is misleading, inasmuch as it produces a state of matters which does not occur during life, since the auricles and ventricles are never at the same time fully distended. The heart presents an irregularly and obliquely conical form, flattened in such a way as to show three surfaces, rather indefinitely bounded by five borders. The anterior surface, which is convex and generally regarded as somewhat triangular in outline, is in reality of an irregularly oblique rhombic shape. It is formed by the right auricle with its appendix, the right ventricle, and the left ventricle, as well as by the roots of the aorta and pulmonary artery, and by the tip of the appendix of the left auricle. Its component parts are separated from one another by the auriculo-ventricular, and the inter-ventricular sulci, in which lie the coronary arteries, with the cardiac veins and the coronary plexuses. The posterior surface, which is quadrangular and convex, is formed entirely of the auricles, and presents the shallow inter-auricular sulcus in which are a branch of the right coronary artery, tributaries of the coronary sinus, and twigs from the right coronary plexus. The inferior surface, flat and irregularly four-sided, is formed by the right auricle, right ventricle, left auricle, and left ventricle. It is traversed by the auriculo-ventricular sulcus containing the right and left coronary arteries with the coronary sinus, as well as the great, right, and oblique cardiac veins and branches from the right and left coronary plexuses. The posterior inter-ventricular sulcus also intersects this surface, in which runs the descending branch of the right middle coronary artery, with the cardiac vein, and branches from the right coronary plexus. ANATOMICAL CONSIDERATIONS. 13 Inteeiok of the Heart. — The four chaml^ers of which the heart is composed vary greatly in form according to the condition of the heart as regards contraction. The riglht auricle may be regarded as naturally possessing two divisions in free communication with each other by means of an opening admitting the little finger ; the one, larger and posterior, termed the sinus venosus or atrium ; the other, smaller and projecting forward, known as the auricular appendix. The former portion is irregularly pyriform in shape, with the wider end directed upwards and backwards, and the auricular appendix projects forwards and inwards from the upper part of the anterior aspect. The interior of the atrium is smooth throughout the greater part of its extent, but around the opening into the appendix the surface is marked by the ridges known as the musculi pectinati. The interior of the appendix is also furrowed in the same way. The direction of these furrows is obliquely upwards and backwards to their end in the crista terminalis. The posterior wall of the atrium is in great part formed by the inter-auricular septum, and presents, near the entrance of the inferior vena cava, with which indeed it blends, the fossa ovalis, partially surrounded above by the annulus Vieussenii. This is connected, as will be seen below, with the left end of the Eustachian valve guarding the inferior vena cava. Above the annulus is the tubercle of Lower, varying in prominence in different individuals. Below the fossa ovalis is the mouth of the coronary sinus. The foramina Thebesii, or openings of the small cardiac veins, are to be seen in different parts of this surface. The anterior surface presents no feature of interest save the opening into the appendix above, and the pectinated muscles. The superior vena cava enters at the upper and anterior part, and alone among the vessels opening into the auricle is unprovided with a valve. The mouth of the inferior vena cava is at the posterior part of the auricle near the inter-auricular septum, and is guarded by a thin fold of the endocardium, the shrunken remains of the great Eustachian valve of the foetus. The coronary sinus opens at the lowest part of the posterior wall and is protected by a thin fold of u MORPHOLOGICAL. tlie lining nienilirane known as the Thebesian valve. The right auriculo-ventricular orifice is situated at the lowest part Fii;. 1.— Longitudinal section of heart seen from riglit. The rijiht auricle and ventricle are to the right ; the left ventricle and aorta to the left. of the auricular cavity and is closed by the tricuspid valve, which must be separately described AJVA TO MICAL CONSIDER A TIONS. 15 The interior of the rvjlit ventricle is of triangular form, when seen in a vertical section whether in an antero-posterior Fig. 2. — Longitudinal section of heart seen from left. The right auricle and ventricle are to the left ; the left ventricle and aorta to the right. or lateral plane, and has its base towards the auricle. A horizontal section shows the cavity to be crescentic, with the convexity towards the front and right, and the concavity 1 6 MORPHOL O GICA L. towards the back and left, on wliich side it is bounded by the ventricular septum. The left or posterior wall is practically coextensive with the septum, and is much thicker than the right or anterior wall. This latter forms the greater part of the ventricular region of the heart seen from the front. The basal portion of the right ventricle is somewhat irregular, in consequence of being prolonged upwards and to the left as the conus arteriosus. The apex of the right ventricle falls short of the anatomical apex of the heart, and reaches the right border at the junction of the anterior and posterior inter- ventricular sulci. The inner aspect of the wall, excepting the part of the conus arteriosus nearest to the origin of the pul- monary artery, is irregular on account of the columnse carneie which project from the interior throughout its whole extent. Some of these are attached to the wall through their entire length, others at both ends, and others only at one end. These latter are aggregated together to form the musculi papillares. As will be more fully detailed when the construction of the valves is described, these musculi papillares are usually three in number. A transverse muscular band stretches from the anterior of these papillary muscles across the cavity of the septum, constituting the moderator band. The left auricle is rudely pyriform in shape, with its larger end directed upwards and backwards, and the smaller end down- wards and forwards to the left ventricle. At the upper part, towards the anterior and left side, is the auricular appendix, communicating with the atrium by means of an aperture which is smaller than the corresponding one on the right side. The left appendix is less than the right. The interior of the atrium is smooth except at the opening into the appendix where the musculi pectinati, which are found in that part of the heart, begin. The part of the wall corresponding to the inter- auricular septum has a slight de- pression, bounded inferiorly by a crescentic ridge. These are the remains of the foramen ovale and its valve. There are four openings into the left auricle by which the pulmonary veins discharge the blood returning from the lungs. The two brino-ing the blood from the right lung enter close to the auricular septum ; the two from the left lung open near ANATOMICAL CONSIDERATIONS. 17 the appendix. None of these have valves of any kind. The communication between the atrium and appendix is smaller, as has been already mentioned, than the corresponding opening in the right auricle. At the lowest part of the atrium is the left auriculo-ventricular orifice, guarded by the mitral valve. The left ventricle is longer and narrower than the right. Its cavity is triangular when seen in vertical section in any plane, and is circular or oval in a transverse section. The apex of the cavity corresponds to the apex of the heart as a whole, the base is not so oblique as the base of the right ventricle. Fig. 3.— Transverse section of heart looking towards apex. The internal surface is rough and irregular on account of the columnse carneee, which are arranged after the same manner as on the right side. The musculi papillares are thicker than those of the right ventricle ; they are usually two in number, but in many hearts there are three. The general form of the cavities of the heart may be seen in the accompanying illustrations. Figs. 1 and 2 show longi- tudinal sections through the long axis, about half-way through each ventricle, and give a good idea of the form of each cavity in ventricular systole. Fig. 3 gives a transverse section through the heart, about half-way between the base and apex of the ventricular portion ; 2 1 8 MORPHOL O GICAL. it brings out the somewhat circular form of the left ventricular cavity, and the crescentic form of the right. The Orifices and Valves of the Heakt. — The four great cardiac orifices and their valves require separate and special consideration, inasnuK'h as upon a clear understanding of their mechanism depends a thorough grasp of the central force of the circulation. The venous orifices, or auriculo-ventricular openings, are placed at the junction of the auricular and ventricular cavities. The right auriculo-ventricular orifice is situated Ijehind and to the right, while the left occupies a position further back and to the left. The aortic orifice occupies the angle in front of these venous openings, and the pulmonary orifice is in the space between the mitral and aortic openings, almost in front of the former. It must not be forgotten that the venous orifices, although supported as is described elsewdiere (p. 43) by cartilaginous rings, are surrounded by muscular fibres, while the arterial openings are simply bounded by the walls of the arteries strengthened by connective tissue. There is a great difference in the construction of the venous and arterial valves. The former are not only directed downwards, and have their inferior or ventricular surfaces attached to the chordte tendineee, but the separate segments are united to each other for a short distance from their connection with the walls of the orifices. The aortic and pulmonary valves are directed upwards, and are quite free at their unattached borders, as well as ununited to each other at the edejes of their connection with the vascular walls. The auriculo-ventricular orifices are both somewhat oval in shape, and in both the longer diameter is approximately transverse. The arterial orifices are almost perfectly circular. The right auriculo-ventricular, commonly known as the tricuspid, and sometimes as the trogiochine, valve consists almost invariably of three, but occasionally presents four, cusps. The segments are so arranged that one, the largest, is posterior and to the left ; it is from its position often termed the septal cusp. Another, in front, is called the infundibular, and the third to the right is known as the external cusp. ANATOMICAL CONSIDERATIONS. 19 These cusps are perfectly smooth on their upper or auricular surface, but the lower or ventricular aspect is broken by the attachments of the chords tendineae, which are not only inserted into the margins, but into different points along the lower surface, and are even, as Noel Paton has recently shown, continued to the ring. The papillary muscles of the right ventricle vary considerably in their origins and attachments. There are three main groups, arising for the most part from the trabecular tissue in the apical part of the ventricle, but they differ somewhat in their connections with the ventricular walls. In some instances they are more closely united to the septum, in others they have more intimate connections with the external wall. When this latter arrange- ment prevails the moderator band is well developed. The three papillary muscles are : (1) superior, arising below the pulmonary orifice and sending chordae to the septal and infundibular cusps ; (2) anterior, arising from the trabecular tissue, being specially connected with the septum, and giving chordae to the infundibular and external cusps ; (3) posterior, having its origin in the trabecular tissue with especial relation to the outer wall of the ventricle, and sending chordae to the external and septal cusps. Besides these three great papillary muscles, there are usually some smaller masses projecting from the septum, and sending chordae to the septal cusp. The left auriculo-ventricular or mitral valve has its two cusps so placed that one is anterior and to the right, the other posterior and to the left. In general appearance they are similar to the tricuspid segments, but they are much thicker and stronger. The papillary muscles of the left ventricle, two in number, are likewise much larger and stronger than those of the right ventricle. In their arrangement one papillary muscle is placed in front and to the left, the other posteriorly and to the right. Both arise from the external and septal walls of the ventricle, and each has chordae inserted into both cusps, the anterior papillary muscle" being connected with the left edge of the cusps, the posterior with the right. The circular opening of each arterial orifice is guarded by a valve consisting of three cusps, each of which is in form an equilateral triangle, with the arc of a circle for its base. The 20 MORPHOLOGICAL. convex base is attached to the walls of the artery ; the other borders, which are slightly concave, are free. At the angle formed by the meeting of the free l)orders is a little nodule named the corpus Arantii. The cusps are strengthened b}' three bands, one along the attached bolder, another along the free edge ; a third curves from the nodule across the valve, so as to have a crescentic interval, called the lunula, along the edge. Each cusp swells somewhat towards the cavity of the ventricle, and on the wall of the artery opposite each segment is a depression termed the sinus of A'alsalva. So far the arrangement is similar in the case of the pulmonary and aortic orifices. The aortic are, however, much stronger than the pulmonary cusps, and the sinuses of Valsalva are in the aorta considerably larger than in the pulmonary artery. The cusps of the pulmonary artery are so arranged that one is posterior and two anterior ; those of the aorta are, on the contrary, one anterior and two posterior, of which the one to the left is intimately connected with the anterior mitral cusp. In relation to two of the aortic cusps are the origins of the coronary arteries. The anterior coronary artery has its origin opposite the anterior cusp, while the posterior coronary artery arises opposite the left posterior segment. It must be observed that the mouths of these vessels are at a higher level than the free edges of the cusps, which seldom cover them. As was pointed out by Savory, the arterial valves are provided with an important mechanism, by means of which they are supported when bearing the strain of the blood pressure, during the phase of closure. The posterior cusp of the pulmonary valve is placed upon a cushion, formed by the upper part of the ventricular septum, and upon this support the cusp rests when filled with blood. The aortic valve has a similar provision which is much more pronounced. The anterior cusp of this valve is situated above a very prominent cushion, also formed by the ventricular septum, and by its means the valve is aided in withstanding the strain of arterial pressure. As will be shown in another section, tlie cusps thus supported are those situated at the lowest level and are the first to close during diastole. ANATOMICAL CONSIDERATIONS. 21 The Blood Vessels of the Heart. — The Ijlood supply of the heart is a subject of the greatest importance, for upon its integrity depends the entire energy of the organ ; any disturb- ance of the cardiac circulation inevital)ly produces more or less interference with its functions. The two coronary arteries arise from the root of the aorta. The right coronary artery arises from the anterior sinus of Valsalva and passes round in the auriculo-ventricular groove to the posterior aspect of the heart, as far as the inter- ventricular groove, where it meets the left coronary artery. It gives off two main branches, one of which passes down the posterior inter-ventricular sulcus, while the other descends along the right margin of the heart. The left coronary artery has its origin in the left posterior sinus of Valsalva, and passes behind the pulmonary artery towards the posterior surface of the heart, where it meets the right coronary artery. In its course it gives off a large branch which runs downward in the anterior ventricular groove. The two coronary arteries encircle the base of the heart at the auriculo-ventricular groove, and in their course give off numerous branches to the auricles and the ventricles. The right is the main source of the blood supply to the right auricle and ventricle, while the left may be regarded as almost entirely the source of nutrition for those of the left. The arrangement of the cardiac veins is by no means similar to that seen in regard to the arteries. It may be said that blood returns from the heart by three channels. The veins which course in the substance of the heart, known as the Thebesian veins, open directly, by several small apertures previously mentioned, into the right auricle. The veins which course upon the surface of the heart terminate in two different ways, the anterior cardiac veins, on the front of the right ventricle, opening directly into the right auricle, while the other superficial veins empty their contents into the coronary sinus. The great cardiac vein arises upon the an- terior surface of the heart at the apex, ascends in the anterior inter-ventricular groove to the base, and passes round to the left auriculo-ventricular sulcus to gain the posterior surface of the heart, where it ends in the coronary sinus. In its course it 2 2 MORPHOLOGICAL. receives numerous tributaries from the ventricular and auricular portions of the heart, and at its opening into the sinus it is guarded by a bicuspid valve. The right cardiac vein lies in the auriculo-ventricular furrow between the right auricle and right ventricle. It opens into the coronary sinus and is guarded by a valve. There are several posterior cardiac veins, running upon the posterior surface of the heart, ending in the coronary sinus, and guarded in each case by a valve. But one of these which is much larger than the others is termed the middle cardiac vein, and occupies the posterior inter-ventricular groove. One other vein deserves mention on account of two peculiarities. The oblique vein of ]\Iarshall, passing along the posterior aspect of the left auricle, opens into the coronary sinus near its termination. Its mouth is not protected by any valve, and it represents the obliterated left superior vena cava of the embryo. IxNERVATiON OF THE Heaet. — The Upper cervical ganglia of the sympathetic, lying between the internal carotid artery and the rectus major muscle, opposite the second and third cervical vertebrse, are connected with the glosso-pharyngeal, pneumogastric, and hypoglossal nerves, as well as with the upper four cervical spinal nerves, and give rise to the superior cardiac nerves. These nerves, which in many instances also receive branches from the sympathetic cord, take the same course on both sides of the neck, behind the carotid sheath, and have connections with the pneumogastric nerves, and its external and recurrent laryngeal branches, but differ in their distribution after entering the thorax. The right superior cardiac nerve passes along the innominate artery, giving small branches to the great vessels in its course, towards the back of the aorta, and ends in the deep cardiac plexus. The left superior cardiac nerve accompanies the left conmion carotid artery to the arch of the aorta, in front of which it usually passes, to terminate in the superficial cardiac plexus. Occasion- ally it ends in the deep cardiac plexus instead of taking its usual course. The middle cervical ganglia, lying near the inferior thyroid arteries, have connections with the fifth and sixth cervical spinal nerves, and give rise to the middle cardiac nerves. These nerves pass down behind the carotid sheath ANATOMICAL CONSIDERATIONS. 23 commimicating with the recurrent laryngeal and the superior cardiac nerves, and, entering the thorax in close proximity to the subclavian vessel, end in the deep cardiac plexus. The lower cervical ganglia lying between the last cervical vertebra.- and the jfirst ribs, receive communicating branches from the two lowest cervical spinal nerves, and give origin to the inferior cardiac nerves. These inferior cardiac nerves pass inwards, communicating with the recurrent laryngeal and middle cardiac nerve, behind the subclavian arteries, to end in the deep cardiac plexus. Sometimes, on the left side, the inferior blends with the middle cardiac nerve. The vagus nerves also give rise to cardiac branches. The cervical cardiac branches are usually divided into the upper, of which there are several, small in size, ending in the sympathetic cardiac nerves, and the lower, single on each side, of which the right, joining a sympathetic cardiac nerve, ends in the deep, while the left terminates in the superficial cardiac plexus. The thoracic cardiac branches take their origin on the right side from the pneumogastric trunk itself and from the recurrent laryngeal nerve ; on the left side they arise from the recurrent laryngeal nerve. These nerves end in the deep cardiac plexus. The great network known as the cardiac plexus, is, for convenience of description, regarded as consisting of two parts — the superficial and the deep — but these are intimately con- nected. The superficial cardiac plexus occupies part of the space between the arch of the aorta and the right pulmonary artery. It receives, as we have seen, the left superior cardiac nerve from the sympathetic, and the left lower cervical cardiac branch of the vagus nerve. It furnishes some small branches to the anterior left pulmonary plexus, and terminates in the anterior coronary plexus. The deep cardiac plexus lies between the posterior aspect of the aortic arch and the trachea, and above the bifur- cation of the pulmonary artery. With the exception of the two nervous branches ending in the superficial plexus, all the cardiac nerves — sympathetic and pneumogastric — terminate in the deep plexus, which is much larger than the superficial, and is commonly regarded as having a right and left division. It gives off right and left branches. On the right side the plexus 2 4 MORPHOLOGICAL. furnishes some lilanients to the anterior puhuouary plexus and posterior coronary plexus, together with many branches to the right auricle, but most of the fibres unite with those from the superficial plexus which form the anterior coronary plexus. On the left are some filaments going to the anterior pulmonary plexus, and a few branches to the superficial cardiac plexus, but most of the branches terminate in the posterior coronary plexus. The anterior coronary plexus, formed by branches from the superficial and both divisions of the deep cardiac plexus, accompanies the left or anterior coronary artery ; the posterior coronary plexus, mostly derived from the left, but in part also from the right part of the deep cardiac plexus, follows the right or posterior coronary artery in its course. These facts may be seen at a glance from the accompanying diagram (Fig. 4), which has been constructed partly from dissec- tions, and partly from the works of Flower, Turner, Cunningham, and Bramwell. The following is the description of the figure. D, DeejD cardiac plexus ; S, superficial cardiac plexus ; C, coronary plexus ; SCG, superior, MCG, middle, and ICG, inferior cervical sym- Ijathetic ganglia ; SDG, stellate ganglion, and 2-5 DG, otlier dorsal sympathetic ganglia ; AV, annulus of Vieussens ; SA, sjjinal accessory with branches to sterno-mastoid and trapezius muscles, SM and T ; V, vagus ; GP, glosso-pharjTigeal, SL, svijierior laryngeal, EL, external laryngeal, and EL, recurrent laryngeal nerves ; i", v, -y, branches from vagus to cardiac nerves ; s, s, s, communicating twigs between sympathetic cardiac nerves ; RR, branches to recti ; EC, rami communicantes ; SO, small occipital ; (i A, great auricular ; CL, clavicular ; ST, sternal ; AC, acromial ; P, phrenic ; SS, sujjrascapular ; SCL, subclavian ; ER, nerve of Bell ; EAT, external anterior thoracic ; SSS, subscai^ular ; MC, musculo-cutaneous ; M, median ; MS, musculo-sisiral ; U, ulnar ; IC, internal cutaneous ; LIC, lesser internal cutaneous ; ICH, intercosto-humeral. The spinal cord is I'epresented as divided into two lateral halves, right and left ; the Roman niunerals denote the segments corresponding to the eight cervical and U2jper dorsal nerves, whose anterior and j^osterior roots are shown, the latter characterised by their ganglia ; the connections between the spiral segments and sympathetic ganglia are marked c^-c^ and (}}-0^. Dimensions of the Heart. — Many discrepancies will be found in the statements made by different authors with refer- ence to the weights and measurements of the healthy heart. The figures given by Peacock, Reid, Clendinning, Eankine, and ANATOMICAL CONSIDERATIONS. 25 26 MORPHOLOGICAL. Bizot differ widely, and the explanation of the want of cor- respondence between their statements can only be sought in a possible want of care in selecting healthy individuals. The most recent facts are those of Hamilton, from observations upon healthy individuals who met their death suddenly from traumatic causes. He finds that the weight of the heart in men varied between 10 and 16 oz., with an average of 10 to 13 oz. In women the weight ranged from 7 to 15^ oz., and its commonest weight was from 10 to 11 oz. His results show, as was previously suspected, that there is no real ratio between the size of the body and that of the heart ; yet they indicate that, as a rule, the heaviest hearts are to be found in the tallest persons. Observations on the length of the ventricular cavities, estimated by measuring the distance from the apex of the cavity to the base of the nearest valvular cusp, show that the left ventricle varies in men from 2^ to o\ in., with an average of 3^ in., and in women from 2^ to Z\ in., with an average of 3 in. The right ventricle in men was from 3 to 4 in. in length, giving a mean of 3| in. ; and in women from 3 to 3|- in., with an average of 3 j^g. in. The thickness of the wall of the left ventricle is about \ in. at the apex and \ in. at the base in both sexes, while that of the right ventricle is, in every case on an average, \ in. all over in both sexes. The diameters of the various orifices are given by Hamilton in the following table : — Diameters of Orifice — Male. Greatest. Least. Average. Aortic . . 1-3 in. •9 in. 1 in. Mitral . . 1-8 „ 1-1 „ 1-4 „ Pulmonary Tricuspid . 1-5 „ • 2-2 „ 1 „ 1-3 „ 1-2 „ 1-8 „ Diameters of Orifice- -Female. Greatest. Least. Average. Aortic . . 1 in. •8 in. •9 in. Mitral . . 1-5 „ 1 „ 1-2 „ Pulmonarj^ Tricuspid . 1-3 „ • 1-7 „ 1 „ 1-4 „ 1-1 „ 1-5 „ Position and Eelations of the Heart and Gkeat Vessels. — The position of the heart and great vessels in the ANATOMICAL CONSIDERATIONS. 27 thorax, and their relations to the other viscera of the chest, are subject to great variations even in conditions of health ; from the general average of observations, nevertheless, a certain mean is obtained, which may be considered as the standard. In the present section of the work this standard will be described, and changes in the position and relations of the central organs of the circulation will be discussed elsewhere. The heart occupies the space in the thoracic cavity between the anterior and the posterior mediastinum, but, according to the age of the individual and the form of the thorax, its posi- tion may be very different. The anterior mediastinum, or the space between the sternum in front, the pericardium behind, and the two pleurae on either side, contains the triangularis sterni muscle, and the origin of the sterno- hyoid and sterno-thyroid muscles, along with the remains of the thymus gland and some areolar tissue. The posterior mediastinum, bounded in front by the pericardium and the roots of the lungs, behind by the vertebral column, and laterally by the two pleurae, has for contents the thoracic duct, the vena azygos, the oesophagus, the trachea, and the aorta, as well as the sympathetic and splanchnic nerves. The intervening space between these spaces, commonly known as the middle mediastinum, is occupied by the heart and its great vessels. The heart with the origins of the great vessels may, therefore, be said to be embraced by the lungs, the sternum, and the spine. It is necessary, however, to look more closely into its relations, and the best method of doing so is to consider those relations from above downwards. Starting with the highest point of the arch of the aorta, there are in front the sterno-thyroid and triangularis sterni muscles, the two pleurae, a small portion of each lung, and some areolar tissue. The internal mammary vessels, as a rule, lie external to the aorta and superior vena cava. Some- what lower down the internal mammary vessels become approximated more closely to the mesial plane, and lie in front of the great vessels. The two pleurae with their lungs meet near the left edge of the sternum, so as almost entirely to cover the great vessels in front, and, about the level of the pulmonary orifice, the right auricular appendix curves 2 8 MORPHOL O GICAL. round so as to be almost in front of the pulmonary artery. The same relationship persists until reaching the level at which the left pleural sac with its contained lung turns out; in front of the heart below this level there is a considerable space altogether uncovered by lung. Posteriorly, the great vessels have behind them some areolar tissue, the trachea, tlie esophagus, the azygos vein, and the sympathetic nerves. Just behind the trachea lies the trunk of the right vagus nerve, and at the left edge of the trachea, between it and the aorta, is the recurrent laryn- geal branch of the left vagus nerve. At a lower level the heart is in front of the cesophagus, the two bronchi, the azygos vein, and the sympathetic nerves, while the aorta lies behind the left bronchus. Soniewhat further down, below the level of the bronchi, there are, posteriorly, from right to left, the CESophagus, the vena azygos, and the aorta. The left vagus lies between the heart and the vena azygos, and the right vagus lies in the angle formed by the heart and the oesophagus. At a still lower level the heart has behind it the liver, and behind that viscus are the cesophagus, the aorta, and the vena azygos ; here the left vagus lies between the cesophagus and the liver, the aorta between the oesophagus and the vena azygos. The left phrenic nerve lies in the angle formed by the liver and the cesophagus, while the right phrenic nerve lies between the liver and the posterior edge of the right lung. On the right side of the great vessels above is the right lung with its pleura. Between the superior vena cava and the lung lies the right phrenic nerve. The same relationship is preserved on descending to a lower level, but the phrenic nerve inclines somewhat further towards the back. On the left side, from above downwards, are the left lung with its pleura, and between the lung and the ascending aorta is placed the phrenic nerve, while between the lung and the descending aorta is placed the left vagus nerve. At a little lower level the left auricular appendix comes round to the left side of the pulmonary artery. The phrenic nerve lies in the pleuro - pericardium between the lung and the auricular appendix. Still lower the pleuro-pericardium and the lung ANATOMICAL CONSIDERATIONS. 29 form the entire boundary of the heart, with the left phrenic nerve lying between the serous layers, and, at the lowest point, there is nothing to the left of the heart excepting the pleuro-pericardium and the left lung. The consideration of longitudinal sections through the thorax leads to most useful information as regards the relations of the heart and neighbouring structures within the thorax. The three following illustrations are reproductions of photo- graphs obtained by the kindness of Professor Cunningham Fig. 5. — Sagittal section tlirongli the thorax of a male adult at a point half an inch inside the- mid-Poupart plane. ii, Left Inng ; o, left ventricle of the heart ; p, liver ; (/, spleen. from sections of a male adult in his possession, and show some of the most important relations of the heart and other thoracic viscera. Tig. 5, obtained at a point half an inch to- the inside of the mid-Poupart plane, shows the heart lying within the pericardial sac and surrounded for about three- quarters of its circumference by the lung tissue. In front, a part of the heart corresponding to the superficial cardiac dulness is seen to be uncovered by the lung, and below, half of the inferior surface of the heart at this level has also no 30 MORPHOLOGICAL. relations to the lung, being only separated from the liver by the pericardium, the diaphragm, and the peritoneum. • Fig. 6, obtained at a point one quarter of an inch to the left of the left edge of the sternum, shows that in a plane close to the vertebral column and the edge of the sternum the heart and great vessels occupy the entire antero-posterior diameter of the chest. The section shows part of the right ventricular cavity, terminating in the conus arteriosus and the |)uhii(>nary artery, the right Ijranch of which is seen passing Fio. G.— Sagittal section through the thorax of a male adult at a point one-quarter of an inch to the left of the left margin of the sternum, g. Vena azygos major ; 7t, aorta ; j, left bronchus ; 7c, coronary sinus ; 7, left auricle ; w, left ventricle ; n, right ventricle ; o, i)ul- monary artery ; p, left subclavian artery ; fy, left common carotid artery ; I, left internal jugular vein ; n, sterno-hyoid and sterno-thyroid muscles ; )'•, remains of thymus gland. over to its proper side. The inferior extremity of the in- fundibular cusp of the tricuspid valve and its chord* may be observed towards the lower portion of the ventricular cavity, and the pulmonary cusps mark the termination of the conus and the commencement of the artery. Behind the right ventricle is a portion of the left ventricular cavity running upwards in the direction of the origin of the aorta. At a level above the pulmonary artery is seen the arch of the aorta ANATOMICAL CONSIDERATIONS. 31 passing backwards and downwards as it comes over from the right side to become the descending aorta. It is closely applied to the heads of the ribs. Between the aorta and the posterior wall of the heart is the oesophagus, and between the aorta and the pulmonary artery is the left bronchus. In front of the heart in its upper part is a small portion of the Pig. 7. — Sagittal section through the thorax of a male adult immediately to the right of the mesial plane. 6, Liver ; o, right auricle (the letter is at the edge of the crista terrainalis) ; d, inferior vena cava ; c, right lung behind the auricle ; /, right pulmonary veins ; g, right pulmonary artery ; 7i, right bronchus ; i, greater azygos vein ; J, left innominate vein ; I, innominate artery ; ift, superior vena cava (the directors are pushed upwards into the innominate and azygos veins) ; r, pericardium in front of superior vena cava ; s, liuig in front of great vessels. left lung, while below it is the liver. Eig. 7 is taken slightly to the right of the mesial plane. It shows the atrium of the right auricle with which the superior and inferior vense. cavas communicate, and upon the walls of which are the pectinated muscles ending in the crista terminalis. A portion of the auricular appendix is seen projecting upwards into the upper part of the pericardial sac. In front of the upper jDortion of the auricle there is a small part of the right lung, while a 32 MORPHOLOGICAL. considerable thickness of the right hiiig is seen between the heart and its vessels and the vertebral column. Between the superior vena cava and the lung are the vena azjgos major, the right bronchus, the right puhuouary artery, and the right pulmonary veins. Below the heart is the liver. The study of transverse sections of the thorax affords equally important information as to the relations of the heart. These may be seen in the accompanying illustrations obtained by the kindness of Professor Symington from sections of a Fig. 8. — Section through eighth dorsal vertebra, u, Ascending aorta ; h, jjulmonary artery ; c, right auricle ; d, auricular appendix ; e, pulmonary vein ; /, brancli of pulmonary artery ; g, descending aorta ; h, \-ena azygos ; i, bronchial tube ; j, cesophagus ; Ic, left phrenic nerve ; I, right phrenic nerve ; in, vagus and sympathetic nerves ; .);, sternum ; y, third cttstal cartilage ; z, eighth dorsal vertebra. male adult in his possession. As the subject was 57 years old, the position of the viscera is necessarily somewhat lower than in a younger man. Fig. 8 is at the level of the eighth dorsal vertebra, and the third costal cartilage. It shows the pulmonary artery so close to the valve that the right cusp has been cut across, and the ascending aorta somewhat further from its valve. Behind these great vessels is the left auricle, into which two of the pulmonary veins may be seen entering, while the superior vena cava lies in the angle between the aorta and the auricle. The descending aorta, azygos vein, and oesophagus are seen behind the auricle, with the vagi and ANATOMICAL CONSIDERATIONS. 33 sympathetic nerves in the intervening space. The phrenic nerves lie between the surrounding kings and the roots of the Pi(j_ 9. — Section through nintli dorsal vertebra, a, Left ventricle with aortic cusps ; 6, conus arteriosus ; c, left auricle ; d, right auricle ; e, pulmonary vein (right) ; g, descending aorta ; /t, vena azygos ; j, cesophagus ; fc, left phrenic nerve ; I, right phrenic nerve ; ni, sympa- thetic and vagus nerves ; x, sternum ; i/, fourth costal cartilage ; z, ninth dorsal vertebra. Fig. 10.— Section through disc between ninth and tenth dorsal vertebra, a. Left ventricle ; 6, right ventricle ; A, right auricle ; (7, descending aorta ; /i, vena azygos ; j, oesophagus ; fc, left phrenic nerve ; I, right phrenic nerve ; m, vagus and sympathetic nerves ; x, sternum ; y, fifth costal cartilage ; 2, disc between ninth and tenth dorsal vertebra. aorta and pulmonary artery in the pleuro-pericardium. Fig. 9 is taken at the level of the ninth dorsal vertebra and fourth 3 34 MORPHOLOGICAL. costal cartilage. The seetinii shows the coiius arteriosus iu front, while the root of the aorta is cut through so near the level of the arterial N'alve that the left posterior cusp has disappeared, while the right and anterior cusps remain. The right auricle is shown to the right of the aortic cusps, and the left lies behind. Fig. 10 gives a representation of the rela- tions at the level of the disc between the ninth and tenth dorsal vertebra and of the fifth costal cartilage. At this point the right auricle is seen opening into tlie ventricle, and septal and external cusps of the tricuspid valve lie between the two cavities ; the left ventricle is cut across immediately above the papillary muscles, the right of which may be seen with the cut ends of the chordi?e tendineie. SUKFACE PtELATiONS. — The heart is so placed that its long axis is at an angle of about 60° to the long axis of the body. The base of the heart is directed upwards and to the right ; the apex downwards and to the left. When the limits of the heart are projected upon the surface of the body, they are found to exhibit many individual variations. But amongst these a certain average is found to oljtain, which may be taken as the healthy standai'd. Position and limits of the Heart. — The highest point which the heart reaches is at the upper edge of the third left costal cartilage, close to the sternal margin, and from this point the cardiac boundaries run outwards and downwards on both sides. The base, formed by the termination of the conus arteriosus of the right ventricle, and by the right auricle with its appendix, starting from the point just mentioned, crosses the sternum to the right articulation between it and the third rib. The right edge, formed by the right auricle, runs down- wards and slightly outwards until it reaches the fifth costal cartilage, about an inch and a half from mid-sternum. The left edge, formed by the left ventricle, extends from the upper level of the third left costal cartilage, running considerably outwards as well as downwards. It crosses the third costal cartilage, the third interspace, the fourth rib, the fourth inter- space, the fifth rib, and terminates in the fifth intercostal space about 3^ inches from the raid-sternal plane. The inferior edge, which is formed by the right ventricle and the apical portion AJVA TOMICAL CONSIDER A TIONS. 35 36 MORPHOLOGICAL. of the left, extends from the tifth right costal cartilage to the fifth left intercostal space. The right auricular appendix lies behind the riglit half of the sternum at the level of the third costal' cartilage. The left auricular appendix occupies the second left intercostal space on the outer aspect of the pul- monary artery. The four great cardiac orifices, although A'arying considerably in position, present an average relation to the surface in the healthy adult. The pulmonary orifice is found at the lowest level of the second left intercostal space, and the adjoining portion of the sternum. It is so situated that its axis is directed upwards, backwards, and to the left. The aortic orifice is underneath the sternum, its junction with the third left costal cartilage, and a small part of the second left intercostal space. Its axis is directed upwards, backwards, and to the right, and about one-quarter of the orifice is covered by the pulmonary orifice. The mitral orifice lies below the left half of the sternum, at the level of the third intercostal space and fourth costal cartilage. Its axis is directed upwards, backwards, and to the right. The tricuspid orifice is under- neath the left half of the sternum, from the fourth to the fifth intercostal space. Its axis is also directed upwards, backwards, and to the right. It is to be remarked that the mitral and tricuspid orifices have but slight direction upwards ; their main axis is to the right and slightly to the back. The tricuspid orifice, in some instances, crosses the mesial plane, so that it may in part lie underneath the right half of the sternum. The pulmonary and tricuspid orifices are superficial, and lie comparatively near the chest wall, but the aortic and mitral orifices are much more deeply placed. The relation of the heart to the thoracic parietes is shown in Figs. 11, 12, and 13, from a specimen in the possession of Professor Cunningham. Position of the Large Vessels. — The aorta takes its origin liehind the left half of the sternum, opposite the third left costal cartilage, and it runs upwards and to the left, with a slight inclination forwards, until it reaches the second right costal cartilage, from which point it runs inwards and backwards behind the sternum, which it crosses at the level of the first intercostal space. The pulmonary artery has its origin in the second left intercostal space at its sternal end, and in ANATOMICAL CONSIDERATIONS. 37 this interspace it runs outwards and Ijackwards for about one inch. The right innominate vein has its origin behind the sternal end of the right clavicle, and runs almost vertically downwards to meet the corresponding vein from the left side. The left innominate vein, lying immediately aTjove and in contact with the arch of the aorta, begins behind the sternal end of the left clavicle and lies behind the upper part of the manubrium sterni ; it joins the right innominate vein behind the first right chondro-sternal articulation. The superior vena cava lies to the right side of the arch of the aorta behind the first and second right cartilages and the intervening intercostal space, and terminates behind the second intercostal space. In relation to the back of the chest, the heart occupies a position in front of the 5th, 6th, 7th, and 8th dorsal vertebrae. The highest part of the arch of the aorta is at the level of the 3rd dorsal vertebra. It reaches the spine at the 4th, and becomes the descending aorta at the 5th, dorsal vertebra. The bifurcation of the pulmonary artery takes place at the level of the 4th dorsal vertebra, at which point also is the bifurca- tion of the trachea. The great thoracic landmarks may be best summarised in such a table as that which follows on next page. The heart is enveloped by the lungs throughout almost its entire extent, only a small portion of its anterior surface being uncovered by them. The anterior margins of the lungs, approaching each other as they descend, almost meet behind the left half of the sternum opposite the 1st intercostal space. From this point the two margins descend side by side, and the right lung continues its course downwards until it reaches the 6 th costal cartilage, at which point it turns outwards while still continuing its downward course, and obliqiiely crosses the 6th intercostal space, the 7 th rib, the 7th intercostal space, and in the mid-axillary line is at the level of the 8 th rib. Proceeding backwards this margin crosses the 8th intercostal space, the 9th rib and interspace, the 10 th rib and interspace, and reaches the spine posteriorly at the level of the 10th dorsal vertebra about its upper end. 38 MORPHOLOGICAL. ^ 2 §^ = >.' ■f c- 2 5 ~ t. 2 « - = -—-=- - ^ 2" tJci-Sciopg ~ c m" _ _2 '"s =^"3 !5 -= 3 Oi :iSi-8«g?2 § ^ |-o| S- — _^ •- "^ "" = "" ~ K J -S "== 5 rt :5 '^ 5 5 J S S § cr '5 »: 5 4J^ 2 I 2 I tJ -^ n d " " 3 S •- OS 5 S 2 '^^ - S- bo i^ SB O rt -te c3 o -^ ^ ^H rt '^ a3 o -= -t^ & h tri -►:> S3 " c! •-. rt _, 3d of &3 1 1 ci cS v. u c r^ C := c ?• t c ^ ^*" lo S c OJ •^ 7: 5 5 '^ % "i > S 5 ^ a ^ c rt ^ ^ -*-* ■i: '^ °c rt > '3 v. > 3 i^ ,S 5 i.j S"" •^ ' ,S ''^ oj ?^ 5 5 V-.r:; ^^^ "rt 2 ' '?■- S* " •" X op t- , "^ =^ 3 a M re) a - ^ ;; -3 r- r- ■'■■ +j o. ^ J 5 c i: cG o I ^ 1 2 .2 1 g .5 -5 >.s ^ >:^^< s &"S ^a 5 £'i ~ -g - ^ -< 1 1 i :^ 1 1 1 a oa-j^oo T3 2 2,a >, <;il,^H ►2=^o'= 4^Hq = p I I 2 a M 'o J; C cS ►3 s oj ¥ ^o_ '7; "c 1-^ ^~~ '- 1 s 1 _c 6 b rt K c , ^ ;::: ^ ANATOMICAL CONSIDERATIONS. 39 C3 ■" ^ ^ --S '55 O "^ '-^ £3^ m '^ /-i-j Li "^ "^ U^ ^ 2 §. g-|^^^«« o s O W. Sh Ph S "§ -s ^ ''^ £^ a^ O ?3 kS §■ - ^' S|. 9 S §3 .2 .« ^8 ^ s ^ -i^, cq ^ c!3 1 P,=<3 1 .'-' S ^ ^ ^S^^ ?5 i~^ k3 g s s ^^ S ^ 'r >; X ^ ci S" < & it ^ m'^ 40 MORPHOLOGICAL. The anterior margin of the left hing turns out at the level of the 4tli costal cartilage, and obliquely crosses the 4th intercostal space and the oth rib. But at this point it usually turns in again \nitil it reaches the Gth rib, when it turns out- wards once more and crosses the Gth intercostal space, the 7th and 8th ribs and interspaces, so as to reach the 8th intercostal space in the mid-axillary line. It then crosses the Otli and 10th ribs and interspaces, and reaches the spine at the IfAver level of the 10th dorsal vertebra. Tt thus leaves a some- what rudely triangular part of the anterior aspect of the heart uncovered. It is usual to divide the thorax into certain conventional areas, by means of arbitrary vertical and horizontal lines. C)f the vertical lines one may be drawn corresponding to the mesial plane, but it is more general to draw two parallel lines, one along each edge of the sternum as far as the costal attachments. Two vertical lines are also drawn through the middle point in Poupart's ligament, which is termed the mid-Poupart plane. Two other vertical lines are drawn at the level of the anterior fold of the axilla, two others at the posterior fold of the axilla, and two more vertically drawn througli the innermost portions of the posterior edge of the scapula?. The horizontal lines are : one drawn at the level of the clavicle at its inner end, a second at the level of the lowest part of the third rib, another at the tip of the xiphoid process of the sternum, and another at the lowest point of the costal margin. These arbitrary lines give respectively the clavicular, the mammary, the xiphoid, and the sub-costal planes, and subdivide the thorax into a number of conventional areas. The anterior areas are : in the middle line, the superior and inferior sternal ; laterally, above the clavicles, the supra-clavicular areas ; below the clavicles, the infra-clavicular and the mammary ; the axillary, and the infra- axillary. Posteriorly, the areas are : the supra-spinous, the infra-spinous, the inter-scapular, and the infra-scapular. The contents of these different areas, that is to say, the viscera which lie underneath them, can be best expressed in such a table as that which is subjoined. The modern development of photography l)y means of the x-rays has permitted the relations of the heart to the skeleton ANATOMICAL CONSIDERATIONS. 41 to be clearly made out. This subject will be taken up under Symptomatology. Structure of the Heart. — A consideration of the structure of the heart naturally falls into divisions cor- responding to the layers of which it is composed. It is also necessary to make reference to its more special adaptations to particular uses, and to give some consideration to the special facts of vascular and nervous supply. The Pericardium. — The parietal layer of the pericardium is, in its structure, a strong tough membrane composed of in- terlacing fibres, containing much yellow elastic tissue, lined on its inner aspect by a layer of flattened polygonal cells, which are nucleated. The lining, or serous layer, is reflected over the heart. The only point of distinction between this serous membrane and similar structures elsewhere is that no lymphatic apertures have yet been found. The Endocardium. — This consists of a single layer of flat polygonal endothelial cells lying upon a thin elastic layer. Underneath the elastic layer is a stratum of nucleated white fibrous tissue, connected with the myocardium by loose areolar bundles and yellow elastic fibres. There are also some muscular fibres, which resemble the general muscular tissue • of the myocardium, and some fat. The relative proportion of these different elements varies in the different regions of the heart, the elastic fibres, for instance, being more fully developed in the auricles than in any other part. The Myocardium. — The myocardium, or muscular layer, has for its structural basis a nucleated columnar cell, with processes, and without sarcolemma. The cell is united by cement at its ends to similar cells in such a way as to form a striated fibre, while its processes join others and give rise to a network. Amongst these muscular elements there is a ramifi- cation of connective tissue, bearing blood and lymph vessels, and the myocardium is so liberally supplied with both, but particularly with the latter, that it has been aptly compared to a sponge. The muscular tissue of the heart is not continued along the great arterial trunks, but spreads along the great veins, venaB pulmonales as well as venae cavte, which open into the auricles. 42 MORPHOLOGICAL. Arrangement of Muscular Fibres. — The method of arrange- luent of the muscular filires of the lieart was carefully studied by Lower, who clearly made out their somewhat spiral course. His work is illustrated by figures which must infallibly arouse the admiration of any one who takes the trouble of studying them. Senac devoted a considerable amount of attention to this subject, and the portion of his work dealing with the structural arrangements of the muscular filjres is also well worthy of perusal. A great advance was made by I'ettigrew, who, with painstaking diligence, investigated the different layers into which the muscular fibres resolve themselves, and who was able to make out that these may be separated into seven distinct layers. j\Iore recently the subject has been again studied by Hesse, Krehl, and Romberg. Their observa- tions have been of service in leading to a clearer understanding of the structure of the heart. The structural basis of the left ventricle is a circular arrangement of muscle fibres, consisting of several layers which intermingle to a considerable extent, but form a closed circuit. In this way is produced the greatest part, not only of the outer wall of the left ventricle, but of the inter-ventricular septum. This circular muscle, as it may be called, has an opening at the base and another at the apex, and it is covered externally by muscular fibres, which have their origin in the region of the auriculo- ventricular sulcus. The latter pursue a course downwards to the apex, and pass through the opening in the circular muscle at that part in order to gain its inner surface, up which they proceed, giving origin to the papillary muscles and columns carneae in their course towards the auriculo-ventricular region. The circular muscle is therefore embraced, as it were, by these longitudinal fibres, and for practical purposes the left ventricle may therefore be regarded as composed of three layers, separated, but yet closely united by fibres passing from one to the other, more particularly aljout the region of the papillary muscles. The structure of the right ventricle is quite different, and it may be regarded as only possessing two distinct layers. The outer of these is formed by fibres, which, arising from the posterior part of the left ventricle and from the base of the heart, run downwards ANATOMICAL CONSIDERATIONS. ' 43 towards the apical region of the heart. Within this layer is another running, for the most part, from the base to the apex of the heart, parallel, for the most part, to the long axis of the ventricle. This inner layer forms the largest portion of the right ventricle. The papillary muscles of the right ventricle have their origin in fibres connected with both layers coming from all points. The Orifices and Valves. — The orifices of the heart are supported by processes extending from the central mass of fibro-cartilage placed in the space between the two auriculo- ventricular and the aortic orifices, which are continued into the fibrous rings surrounding the auriculo - ventricular and arterial orifices. The fibrous rings are distinct from each other, except in front of the mitral orifice, where they are connected. Both the auriculo-ventricular and semilunar cusps are duplications of the endocardium, containing a large amount of elastic tissue, but there are differences in structure between the venous and arterial cusps. In the former the fibrous tissue ramifies in every direction ; in the latter it is collected in the bands already described. The former also contain a considerable amount of striated muscular tissue arising from the auricular myocardium, and extending about a third of the distance from the attachment of the cusp to its free margin. During foetal life, according to Langer, there is much more muscle in these valves. Muscular tissue is entirely absent from the semilunar cusps. Luschka de- scribed both auriculo - ventricular and semilunar valves as being abundantly supplied with blood vessels ; but, according to the researches of Langer and Coen, there is a great difference between the two series of valves in regard to vascular supply. The auriculo-ventricular cusps are supplied, at any rate in the upper part, by blood vessels, which seem to accompany the muscular fibres. The semilunar cusps, on the other hand, are destitute of blood vessels, so that, like the greater part of the endocardium, they must be nourished simply by lymph vessels, with which they are well supplied. According to Luschka and Darier fine prolongations of the arterial system of the papillary muscles are continued along the chordcC tendinefe. The Blood and Lymph Vessels. — The blood vessels, 44 MORPHOLOGICAL. which 8uppl}- the heart, are abundantly distributed throughout the interstices of the myocardium in every part. Lymph vessels are also widely spread throughout the tissues ttf the heart, especially in tlie sub-ondMcardial and sub -pericardial substance, and appear to arise in the form of spaces lined by epithelioid cells. The Vcssc/.s. — In order to complete this brief sketch of the leading anatomical foots of the circulation, a rapid glance may be given to the structure of the vessels engaged in the convey- ance of the blood and lymph. The structure of the arteries is much more complicated than that of the veins or capillaries. The arterial wall con- sists of three more or less distinct layers. The inner coat, or tunica intima, is composed internally of a layer of flattened fusiform cells longitudinally arranged, on the outside of which there is a fenestrated basement membrane, varying in thick- ness with the size of the vessel, and commonly known as the internal elastic lamina. The middle coat, or tunica media, consists of one or more layers of spirally arranged muscular fibres. In the larger vessels, where there are several strata of muscular fibres, these are separated by layers of connective tissue. The outer coat, or tunica adventitia, often also known as the tunica extima, is composed of bundles of nucleated con- nective tissue fibres longitudinally arranged, and of yellow elastic fibres. This outer coat blends with the surrounding connective tissue in the case of the smaller vessels, and in the case of the larger arteries it is protected by a distinct sheath. The arteries are provided with their own nutritive arteries, the vasa vasorum, which proceed inwards from the outer layers as far as the middle coat. The walls of the capillaries are composed of fusiform flattened cells, provided with nuclei, longitudinally arranged and cemented together. They lie in the connective tissue, and are surrounded by lymph spaces. The structure of the veins is somewhat similar in the main to that of the arteries, and the venous wall also shows three layers, which are not, however, so distinct as those seen in the arteries. The inner coat has a layer of flat polygonal cells, and another of fine filjres which are felted together. The ANATOMICAL CONSIDERATIONS. 45 middle coat consists of white connective tissue, with a few elastic fibres, and an extremely variable amount of muscular tissue. In some veins, as those of the brain, there are few, if any, muscular fibres ; in others, such as the venae cavte and portal vein, muscular tissue is abundant. The outer coat is composed of white and yellow fibres, with scattered muscular tissue in some cases. The veins, like the arteries, are supplied with vasa vasorum. The Lyiwphatic Vessels. — The blood vessels are surrounded on every side by plasma spaces — irregularly shaped lacunte, into which fluid transudes. The lymph capillaries with a distinct endothelial wall unite as they pass upwards to form larger lymphatic vessels. The walls of these trunks are possessed, as in the case of the arteries and the veins, of three coats. The intima consists of a longitudinal fibrous layer, lined by a nucleated endothelium. The media is composed of circular unstriped muscular fibres with some elastic tissue. The adventitia consists of a loose fibrous tissue with a few longitudinally arranged unstriped muscular fibres. The walls of the lymph channels, therefore, as has been so clearly put by Hamilton, consist first of a homo- geneous cement substance, then of an endothelium with elastic internal coat, later of endothelial and elastic tunica intima and tunica media, and lastly of vessels with three coats. The main trunks of the lymphatic, channels are provided with valves which prevent the regurgitation of fluid, and at the mouth of the thoracic duct into the subclavian vein there is a large bicuspid valve which guards the opening. CHAPTER 11. PHYSIOLOGICAL. The conditions of the blood liow, as regards the forces by which it is maintained, and the influences by which it is modified, must be fully grasped in order to approach the problems of disease with any prospect of successful study. It is, however, im- possible in such a work as this to do more than cast a rapid glance at the general phenomena of the circulation, in order to ascertain the principles underlying the important functions which it subserves. It seems natural in considering the circulation to take up, in the first place, the phenomena presented by the heart. Kot only is the development of its functions the most striking fact in the embryonic circulation, but in later life the indications which it gives are of the highest import as regards diagnosis and treatment. The action and reaction of the heart and vessels must be considered together as a whole, but the first place in a general survey of the physiology of the circulation must be accorded to the appeai- ances connected with the heart. The Heart. The essential function of the heart is to pr(xluce in the arterial system such a pressure as will cause the blood to tlow continuously onwards and outwards. This is strictly analoo-ous to what is termed " a head of water " in practical hydraulics. The object is attained by the vital process of contraction, through which the necessary force is pro- CA RDIA C MO VEMENTS. 47 duced, and the mechanical device of valves, by wliich the flow is directed. The heart is accordingly, as has so often been remarked, at once a suction pump and a force pump, but the feet cannot be too strongly insisted on that it is instinct with life, and brought into harmonious action with the other structures concerned in the circulation Ijy the nervous system. The Cardiac Movements and Sounds. — Under ordinary circumstances there is little obvious evidence of the pulsation of the heart ; a slight impulse seen over the praBCordia, and the movements of some of the superficial vessels, are the only appearances to be observed. To ascertain the course of events it is necessary to resort to experiment, in order to render the movements of the heart and great vessels visible. On watching the exposed heart of any of the larger mammals, as has been done by every physiologist since the observations of Harvey, it is not difficult, after the eye has become accustomed to the rapid changes of form which it undergoes, to follow the sequence of movements presented by its dilferent parts. The earliest of the cycle of events to be seen, after the long pause, is a slight flickering contraction of the superior vena cava, known to Haller and observed by Senac. A similar contraction can be observed in the inferior vena cava and the pulmonary veins, by specially exposing them, and it has been ascertained by the investigations of Colin, as well as of Brunton and Fayrer, that these movements continue after every part of the heart has ceased to contract. The quivering movement of the great veins is immediately followed by the systole of the auricles, seen most distinctly in that of the right. Its sudden swift contraction causes the sinus almost entirely to disappear, while the appendix, drawn back- wards and to the right, becomes small and pale. A short pause ensues, and the heart remains to all seeming quite at rest ; this brief period of repose is followed by two events — the relaxation of the auricles, and the beginning of the ventri- cular systole — which to the most careful scrutiny of the un- aided eye seem perfectly simultaneous ; it has, nevertheless, been proved that the auricles remain contracted until the ventricles commence their action. The right auricle becomes once more dark in colour as it resumes its former size and shape. 48 PHYSIOLOGICAL. The apex of the heart tilts forwards and to the right, and the whole of the ventricular portion suddenly alters its form, so that instead of presenting a flattened curve it assumes a rounded outline; at the same time it loses its flaccidity and becomes hard to touch. The ventricles continue to contract, and while the long axis of the A'entricular portion increases slightly in length, the transverse diameter is gradually reduced in size. It is quite clear that there are three distinct phases in the ventricular systole ; in the first, the ventricles produce suffi- cient pressure to overcome that in the great arterial trvuiks, and in doing so they alter their form and become hard to touch ; during the second, which is accompanied by a diminu- tion in size, they expel their contents as the pressure upon theni rises to a sufficient level ; during the third, they remain for a brief time contracted after expulsion. In one of the larger mammals, a distinct expansion of the aorta and pulmonary artery can be seen along with the systole of the ventricles, and if the finger be applied to one of these vessels an impulse may be felt. The final phase of the cycle is a somewhat sudden return of the ventricles to their flaccid condition and flattened outline, and this is accompanied by an impulse, which may be seen and felt, in the great arterial trunks. Two sounds accompany the movements of the heart. One of these, commonly known as the first, is lower in pitch and longer in duration than the other, usually termed the second sound. The first sound is followed by a short pause : the second by a longer interval. These sounds, known in some measure previously, but only understood during the present century, are still a source of controversy amongst physiologists. The first sound was correctly recognised by Laennec as occurring along with the ventricular systole, but the second, supposed by him to coincide with the systole of the auricles, was first placed by Turner with approximate accuracy at the end of the ventricular systole, and the fact was more thoroughly established by the researches of Hope and his coadjutors. External Movements. — Attention must be bestowed upon the movements in somewhat greater detail. Since the obser- CARDIAC MOVEMENTS. 49 vations of Liidwig it has been recognised that the long axis of the heart increases during the systole, while the size of the other diameters varies according to the extrinsic conditions under which the heart is placed during systole and diastole. If the heart of any mammal under observation is allowed to be in the thoracic cavity, it assumes during diastole a flattened form on account of the nature of its support, and during systole the transverse diameter diminishes while the antero- posterior increases. But if the heart is suspended in such a way as to rest upon no support during diastole, it has during that phase a more conical form; in the first stage of systole, according to Noel Paton, the antero-posterior diameter increases, and during the second stage both transverse and antero-posterior diameters diminish. Under all circumstances the long axis becomes greater during systole, as Ludwig found in a long series of observations. The movements of the heart may be analysed by means of the graphic method. Since Marey applied the cardiograph to the investigation of the movements of the heart, many observers have devoted themselves to researches in the same direction, but unfortunately their results have been so far from harmonious that the interpretations of the tracings obtained have been nearly as numerous as the workers. Tracings may be obtained from the pulsation of the heart through the walls of the thorax, but much moi'e may be learned from a study of curves from cases in which, on account of malformation of, or operation on, the walls of the chest, the movements of the heart have been easily accessible. The information, even when obtained under such favourable circumstances, has many limitations, and the results have been almost confined to the determination of the sequence and duration of the different phases of cardiac activity. The character of the tracing depends entirely upon the part of the heart to which the cardiograph is applied — a point specially investigated by von Frey — and in the case of curves obtained from the pulsation of the heart through the walls of the chest, there is not only some difficulty as to the exact region of the heart giving the impulse, but also some uncertainty in regard to the nature of the intervening struc- tures. The tracing is also modified by the amount of pres- 4 50 PHYSIOLOGICAL. sure applied by the instrument employed, as lioy and Adami have illustrated by their observations. It must further be remembered that the details of the curve are conditioned by the nature of the instrument made use of in obtaininq- tracings. These considerations are sufticioit to show that the form of the curve has large possibilities of variation, and since the publica- tion of the first cardiogram by Marey, the tracings of those who, like Landois, Edgren, and Martins, have devoted special attention to the subject differ widely in many respects. It is not possible in this place even to refer to the points in which these curves vary. The appearances presented by an ordinary cardiographic tracing will be discussed in the section devoted to the investiga- tion of clinical phenomena. The cardiographic curve only gives the relation of the movements of the heart in regard to time and place ; it throws no light on the strength or force of the cardiac contraction. Tracings obtained from the exposed hearts of the larger mammals present a general resemblance to those taken from the human heart under favourable conditions, and such curves have been of some real utility in showing the differences which exist between the movements of the sevei'al parts of the heart, even of neighbouring parts of the same ventricle, according to the site occupied by the instrument. Several observers have been able to take tracings from the heart hi cases of sternal or costal deficiency. In comparatively ancient times the famous case of Groux attracted much atten- tion, and was the subject of study by almost every physiologist of eminence, but the opportunity presented by his extensive sternal fissure occurred before the graphic method was thoroughly established. An instance of sternal fissure in a healthy young man, whose case was fully described by Malet and myself some years ago, afforded an occasion for obtain- ing numerous cardiographic tracings. In this case there was a wide fissure in the upper part of the sternum extending as far as the fourth costal cartilages, and in the lower part of this opening the movements of the heart were re- markably prominent. There could be no doubt that the movements were caused by the conus arteriosus. Not only did the pulsation occupy the anatomical position of that part CARD I A C MO VEMENTS. 5 i of the heart, but the character of tlie moveineiits seemed to bear out this conchision. In the lower part of the liollovv caused by the sternal deficiency, the pulsation sliowed the following character : — the state of rest was a prominent degree of fulness ; the cycle commenced with a sudden increase of the swelling, followed by a swift wave-like subsidence downwards ; this was in turn succeeded by a short sharp impulse, after which there was a rapid return of the fulness. On palpation the same sequence of events was ascertainable, the short sharp impulse being especially marked, and the sinking of the swell- ing gave to the jfinger a distinctly vermicular feeling passing from above downwards. Over the areas usually auscultated the cardiac sounds were quite normal. By means of the binaural stethoscope, which allowed of light pressure, the pulsating area was carefully auscultated. Accompanying the increased fulness, which began the cycle, was a faint blowing murmur, immediately followed by the first sound, which com- menced with, and lasted until the end of, the downward subsidence, being accompanied by a soft low murmur ; the short sharp impulse coincided with the second sound, which was very loud ; the return of the swelling was attended by a scarcely audible blowing murmur. With a direct cardiograph many tracings were obtained, and the movements were compared with the carotid pulse, as well as with the cardiac sounds. The apex beat unfortunately could only be felt when the patient was sitting or standing, and it was therefore useless for graphic purposes. Placing a finger upon the carotid artery, and watching the cardiograph when in motion, the arterial pulse appeared to be synchronous with the swift fall of the lever ; still watching the instrument, and listening to the heart sounds with the binaural stetho- scope, the commencement of the first sound was clearly simultaneous with the abrupt rise of the lever to its highest elevation, and it continued until it descended almost to its lowest level ; the sharp impulse which followed was exactly coincident with the second sound. The tracing obtained by means of the cardiograph with the cylinder revolving at a slow rate gives the respiratory curve as well as that of the cardiac movements. 52 PJIYSIO LOGICAL. Fig. 14.— Tracing from conns arteriosus in sternal fissure. Fig. 15.— Simultaneous tracing from conus arteriosus and carotid artery. CARDIA C MO VEMENTS. 5 3 By means of two levers the curves shown in Fig. 15 were obtained, in which the upper tracing is taken from the carotid artery, and the lower from the conus arteriosus. In this figure it is clear that the arterial impulse coincides exactly with the sinking of the conus. The starting-point in the cycle of movements, as shown in Fig. 14, is a, which, from its relative rhythm, is caused by the auricular systole. The ascent of the curve which follows is due to the latent period of ventricular contraction, and it is followed by the sinking of the curve produced by the expulsive phase. The abrupt, but Fig. 16. — Tracing from conus arteriosus with curve of tuning-fork. small, rise at c, coinciding as it does with the diastolic shock and second sound, and being synchronous with the katacrotism of the arterial tracing c\ marks the commencement of diastole. Succeeding this little rise, which so clearly marks the commencement of diastole, is the filling up of the heart by the blood entering during its relaxation, which causes the ascent of the line. Both figures read from left to right. To analj^se the movements more fully and to measure their duration further investigations were carried out by me ; the cardiograph being employed with a rapidly revolving cylinder, on which were registered, along with the cardiac curve, the movements of a tuning-fork vibrating in hundredths 54 PHYSIOLOGICAL. of a second. Tart of one of the curves so obtained is shown in Fig. IG, which is to be read from left to right. It is needless to give a description of the curve shown by the tracing : it is only necessary to mention that a marks the beginning of auricular systole, l>^ tlie commencement of ventricular systole — coinciding with the beginning of the first sound — and c} the occurrence of the second sound. In the tracing given here, there is on the descending curve fiom Ir to V-^ — which is caused by the emptying of the ventricles of the heart — a shoulder marked h^ ; and there is also, in advance of t^, which marks the incidence of the second sound, an elevation c^. On looking at the measured intervals of time recorded below the curve, an interesting ftict will be noted. The period elapsing between 1? and c^ is precisely the same as that between li^ and c^ The conclusion is obviously that (} and d^ represent the diastolic recoil on the sigmoid valves, while 5^ and Jj^ are the terminations of ventricular emptying on the two sides. ]\Iany other tracings taken from the same case show no shoulder in the position of V, and no elevation in the position of r^, a point which will be referred to in a subsequent section. The measurements of the different jDhases, obtained by counting the numl)er of complete excursions of the tuning-fork, are given in the figure to save trouble and facilitate comparison. Is S II > 1 "3 'r^ 6 Is c 5 5 Entire Cycle. 1. I. •115 •345 •605 1-065 10. II. •105 •390 -690 1-185 2. I. •120 ■350 •670 1-140 11. I. •105 •365 -465 •935 3. I. •125 •355 •670 1-155 II. -100 •380 •495 •975 4. I. •130 ■375 •660 1^165 III. -100 •355 -485 •940 5. I. •125 ■335 •455 •915 12. I. -130 •385 -625 ri40 •125 ■345 •455 •925 II. -105 •375 •615 1 ^095 6. I. •125 ■360 •490 •975 III. -105 •355 •575 1-035 •125 ■355 •575 1^055 13. I. -115 •390 •555 1-060 7. I. •115 •375 •570 r060 II. •110 •375 •555 1-040 •110 ■360 •525 •995 III. -110 •365 •470 -945 8. L •105 ■375 •565 1^045 IV. -110 ■380 •465 -955 •110 ■380 ■560 1-050 14. I. -105 •390 •605 1-100 9. L •105 •335 •675 M15 II. -105 •390 ■690 1-185 •105 •325 ■675 1^105 III. -100 •380 ■600 1-080 10. L ■110 •395 •685 M05 IV. -115 -390 ■625 1-140 CARD I A C MO VEMENTS. 5 5 In the preceding table are embodied the measurements of at least one complete revolution of every cardiogram obtained, taken on the basis of the second sound being the point of separation between systole and diastole. The average absolute duration of each phase and that of the entire cycle are as follows : — Auricular Ventricular -r.- i i tt. <--,-, i Systole. Systole. Diastole. Entire Cycle. •112 sec. -368 sec. -578 sec. 1-057 sec. The limits of absolute duration of each phase, as well as the difference, may be stated in this way : — Longest. Shortest. Difference. Auricular Systole . . . -130 - -100 = -030 sec. Ventricular Systole . . . -395 - "325 = -070 „ Diastole -690 - -455 = -235 „ and the difference, as compared with the shortest absolute duration, expressed in percentages, gives the following table : — Auricular Systole . •030 : •100 = 30 percent Ventricular Systole •070 : •325 = 21^3 Diastole •335 : •455 = 51-6 •which clearly shows the extent to which the duration of each phase may vary from its lowest limit. Leaving the absolute duration of the individual parts of the cardiac cycle, the variations in the relative duration of each, as compared with the entire revolution to which it belongs, may be arranged in the following percentages : — Shortest. Longest. Auric. Syst. in 14.11. is 8 "8 per cent, and in 5. Lis 13^7 percent, Ventric. Syst. „ 9. II. „ 29-4 „ „ 13. IV. „ 40-6 „ Diastole, „ 5. II. „ 49-1 „ „ 9. II. „ 61-1 „ All these tables show clearly that the most stable part of the cardiac revolution is the ventricular systole. The duration of the diastole — upon which the rate of the heart beat mainly depends — is the most variable, and next to it must be ranked the contraction of the auricles. The measurement of the phases of the cardiac cycle has during modern times been the subject of careful investi- 56 PHYSIOLOGICAL. gations by other observers besides myself. Volkmann attempted to estimate the duration of the movements, but the first approximation to accuracy was made by Bonders. The latter observer, who accompanied the sounds of the heart l)y movements which were registered along with electric signals from a clock, found that the interval between the first and second sounds, which he took to represent the ventricular systole, varied between the limits of "oOO and '327 sec, and was tolerably constant for the same individual with a high as well as with a low pulse-rate. In the sitting posture the systole, as compared with the whole cycle, was relatively shorter although absolutely longer. From such considerations Bonders concluded that the systole has an independence of its own. By means of a Marey's sphygmograph, Landois carefully measured the different movements of the heart at the apex beat. To afford the means of easy comparison with my own results, the following table is taken from his paper : — «.. Dauer der Vorliofcontraction bis zuin Beginn der Ventrikelsy stole . . 0,170 0,177 h. Dauer der Ventrikelcontraction . . 0,155 0,192 c. VerlaarrendesVentrikels in der Contraction 0,088 0,082 d. Vom Beginn der Diastole bis zum Scliluss der Semilunarklappen . . . 0,066 0,072 e. Dauer der Diastole vom Scliluss der Semi- lunarklappen bis zum Beginn der Pause 0,259 0,200 /. Dauer der Herzpause .... 0,393 0,407 Dauer des ganzen Herzsclilages . . 1,133 1,133 In this table &, c, and d represent the systole as measured by Bonders. As the result of a long series of observations Edgren gives the following average duration of the cardiac phases : — I latent period . . -0934 sec. \ Systole "I expulsion „ . . -0990,, ■ -3276 sec. ( residual ,, . . '1352 „ ) T^. ^ , f commencing relaxation -0520 ,, 1 .,„,, q ^^^^*«^^i residual „ '4828 „ j '^'^^ " Entire cycle for pulse-rate of 70 . . "8624 „ The variability of the diastolic phase with different rates of pulse, which was so well brought out by my own results, has CARDIAC MOVEMENTS. 57 been shown in the lower animals by Baxt, who caused a shortening of the cycle by stimulating the accelerating nerves. From his results it is clear that great changes in the diastolic phase are thus produced, while the systole is but little affected. The following measurements bear this out : — Normal Heart. Accelerated Heart. Systole. Diastole. Systole. Diastole. •253 -299 -210 "044 Internal Movements. — The changes which take place in the interior of the heart during its different phases are, on account of inherent difficulties, by no means absolutely known. By the anatomical method the condition of the walls and the position of the valves may be ascertained with considerable certainty ; by experimental research, attempts have been made to investigate the movements of the valves, but the results are not yet beyond the possibility of misconception. Anatomical researches into the position and relations of the different parts of the interior of the heart throw much light upon the mechanism by which the blood flow is carried on. Such investis^ations have been from time to time undertaken by different physiologists, and the matter has recently Ijeen the subject of an elaborate research by Noel Paton, in whose work will be found full references to the observations of pre- vious writers. By an ingenious method of fixing the heart in the latent phase of contraction — before the opening of the arterial valves — and in the final phase of residual contraction — after the blood has been entirely expelled — he has been able to compare the position of the cavities and valves during ventricular systole and diastole. According to his observations, during the latent period the cavity of the right ventricle diminishes in its transverse diameter from drawing in of the external wall, while the antero-posterior increases on account of bulging forward of the anterior wall in the infundibular region. During this phase the septal cusp is closely applied to the septum, while the external cusp is pulled towards it, and the infundibular cusp is pressed closely against it from the action of the superior and anterior papillary muscles ; the outer part of the auriculo-ventricular ring is at the same 58 PHYSIOLOGICAL. time pulled downwards by the combined action of the papillary muscles, and of the muscular fibres surrounding the orifice. During this pliase the cavity of the left ventricle is narrowed transversely and widened antero-posteriorly. The two cusps are at this time raised from the ventricular walls and drawn towards each other by the action of the papillary muscles. One important function of these muscles, and of the anterior mitral cusp, is to aid in keeping the aortic orifice open by their action on the membranous part of the auriculo-ventricular ring, as was in part appreciated by Onimus. In the pliase of residual contraction the cavity of the right ventricle is flattened and obliterated, except the conus arteriosus below the pulmonary cusps. The septal cusp is pressed against the septum, and the other segments are closely applied to it. The cavity of the left ventricle is entirely obliterated except a small cylindrical part below the aortic orifice. The two mitral cusps are applied flat against each other almost throughout their entire extent, only a small wedge-shaped space being left towards the auricles at the upper part of the valve. From these observations Noel Paton concludes that instead of the auriculo-ventricular valves being floated into a horizontal posi- tion, they are simply applied face to face, and close their respective orifices without any strain being placed upon them. With regard to the arterial orifices, Noel Paton lays stress upon the fact that the anterior cusp of the aortic valve is placed upon the muscular cushion formed by the ventricular septum, originally described, as stated in the previous section, by Savory, so that this cusp, which, as Pettigrew showed, closes first and supports the other two, has an efficient buttress diminishing the stress it undergoes. A similar muscular support is found underneath the left posterior pulmonary cusp, upon which the other two cusps rest. These results prove conclusively that much of the teaching contained in some of even the best of our systematic works on physiology as to the position of the valves is erroneous, and demonstrate the truth of the views advocated by Meckel, Burdach, Mayo, Eeid, Pettigrew, Kilss, and Marc See. Attempts have been made to obtain tracings of the move- ments of the internal parts of the heart. Of such investiga- CARD I A C MO VEMENTS. 5 9 tions the most important have been the researches of Hoy and Adami, who obtained simultaneous tracings from the interior and the exterior of the heart. Their method was to introduce a hook into the cavities of the heart, which caught the cusp of the auriculo-ventricular valve, while the free end was attached by a string to a light lever. This traced the movements of the cusp on a revolving cylinder, which at the same time recorded the curves of the lever connected with the exterior of the heart. Eoy and Adami came to the conclusion that the contraction of the papillary muscles was later in its commencement and shorter in its duration. There can be but little doubt of the fact that the papillary muscles are appreciably later in their contraction than the walls, the difference in time between the two events being, from the researches of Fenwick and Overend, about -05 seconds. But, as will be seen later, the inferences which Eoy and Adami have drawn from their investigations are as yet unproved. Intra-cardiao Pressure. — The variations of the intra-cardiac pressure have been investigated in two different ways : — by registering the curves obtained from the different cavities by the simple manometric methods of Chauveau and Marey, Tick, Fredericq, and Hiirthle ; or by the maximum and minimum manometer of Goltz and Gaule. According to the experiments of Chauveau and Marey on the horse, the pressure in the right auricle is 2*5, right ventricle 24*0, and left ventricle 128*0 mm. of mercury. The investigations of Goltz and Gaule showed that the maximum pressures might reach 20 mm. Hg. in the right auricle, and 62 mm. Hg. in the right ventricle. With an exposed heart de Jager found that the right auricle could produce a negative pressure of from 2 to 6 mm. Hg., while in the corresponding ventricle there was a negative pressure of 5*38 mm. Hg. Such a negative pressure speaks for an aspiratory force attracting blood to the heart. It must further be borne in view that the pressure in the chest is, as was long since shown by Donders, negative. During an ordi- nary inspiration there is a negative pressure of about 11 mm. Hg., which rises during forced inspiration to about 70 mm. During the phase of expiration the negative pressure is about 6o PHYSIOLOGICAL. ;> mm. Hg., but forced expiration may give u positive pressure of 90 mm. Hg. Cause of the Ilovcments. — It would serve no purpose to recall the different views which have been held at various times as to the cause of the rhythmic movements of the heart, but a passing glance may be cast at those which have most materially contributed to the elucidation of the subject. The earliest theory of modern times is that of Haller, who believed the heart to be endowed with an inherent irritability, inde- pendent of all nervous influence, and excited to activity by the contact of the blood entering the cavities. This view was somewhat modified by Senac, whose opinion tended in the direction of allowing more influence to the nervous system. We have seen that the movements of the heart begin with the great veins, pass thence to the auricles, and finally reach the ventricles. When the heart has been removed from the body of any animal the different parts of the heart die in the same order, and as the nervous ganglia are more numerous upon the terminations of the great veins and the adjacent sinuses than upon the rest of the auricles, and much more so than upon the ventricles, it used to be thought that they were the cause of the contractions of the heart. But the parts destitute of these ganglia may be caused to beat perfectly, as is stated l;»y Foster, without in any appreciable degree differing from the ordinary movements. From the facts in regard to the movements of the heart in the embryo, it must be clear that these movements are inde- pendent of nervous structures, and that the rhythmic contrac- tions of the embryonic heart must be due to some inherent property of its protoplasm. The phenomena may fitly be compared to the periodic movements of many of the lower invertebrates. The rhythmic movements of many pelagic acalephie, for example, are an expression of the same inherent property. The results obtained by embryological observation and Ijy experimental research lead therefore to the same conclusion, that the heart is endowed with an independent power of rhythmic pulsation — that it is, in short, automatic. But there are one or two other points arising from a con- CARDIAC MOVEMENTS. 6i sideration of the behaviour of the dying heart. It i« easy to see that instead of being regular or rhythmic the pulsations of the heart become irregular or arhytlimic. Sometimes, as Pano has described, the movements fall into groups ; a second and larger periodicity being imposed, as it were, upon the original rhythm. It is also not difficult to determine that the auricles and ventricles cease to preserve their normal relationship ; the former often contract twice or thrice for one ventricular systole. The converse never happens — a ventricular contraction is always preceded by an auricular beat. As to the real cause of the contraction we know nothing. It is beyond all possi- bility of doubt that the pulsations are automatic ; but so far we can only assume that they are produced by an inherent power of rhythmic activity in the ultimate muscle structure, and that the special characters of the cardiac muscular move- ments, as compared with those of the skeletal muscles, is due to the less differentiated condition of the heart-muscle. Propagation of Movements. — With regard to the propaga- tion of the pulsation from the auricles to the ventricles we are no longer in doubt, as the recent researches of His have cleared up the difficulties connected with the subject. Eecog- nising that the cardiac contractions are automatic, and believing " that the muscular fibres of the auricles are not continued into the ventricles, it has not been easy to understand how the wave of contraction could be propagated from the base to the apex. The observations to which reference has just been made, however, have shown that there is a continuous band of muscular tissue which extends from the posterior wall of the right auricle to the attachment of the aortic cusp of the mitral valve. The contraction of the muscular fibres of the heart is characterised by some special features. When a stimulus has been applied to the muscular tissue the curve is marked by its long latent period, its gradual rise and its slow fall. In one important particular the cardiac muscle differs from ordinary muscle — the amount of contraction does not depend on the amount of the stimulus employed. The effects of stimuli moreover differ greatly according to the time when they are ap- plied. Such considerations show that the muscular tissue of the heart is essentially different from that of the skeletal muscles. 62 PHYSIOLOGICAL. Cause of the Heart Sounds. — The method of production of the second sound has been carefully studied by Ceradini, who employed an apparatus by means of which he could study the closure of the valves in the isolated conus arteriosus of the right ventricle. His conclusions are that the moment the blood pressure within the artery comes to equal that of the ventricle, the valvular segments fall together and initiate the second sound, which is only augmented, not originated, by any of the events of the diastole. His conclusions have been controverted by Sandborg and Worm Muller. Using the entire heart in an apparatus representing the circulation, they found that, at the instant the pressure below the semilunar valves is removed, and the pressure in the artery exceeds it, the blood flows towards the heart and initiates a movement ending with the closure of the semilunar valves. The closure of the valves is therefore produced by a backward movement of the blood in the lowest part of the artery, and is absolutely diastolic in time. Fredericq has carried out similar experi- ments with results of the same character. And Boyd lias more recently investigated the subject, with the result of supporting the conclusions of Sandborg and Worm Miiller, as well as of Fredericq, that the closure of the valves is diastolic. The production of the first sound of the heart can scarcely yet be regarded as absolutely settled. Williams, in his address to the first Dublin meeting of the British Association, mentioned that it was produced by muscular action. His oTounds for the statement were that in the heart of an ass, from which the blood had been removed so that the valves were in consequence unable to act, the first sound was still heard with each contraction of the ventricles. The results were corroborated by a committee consisting of Williams, Todd, and Clendinning, appointed to report on the subject. These observations were repeated with some modifications in different directions by Ludwig and Dogiel, and, in later years, by Yeo and Barrett. It must, therefore, be allowed that the heart in its contraction produces at least part of the first sound. There can, nevertheless, be no doubt of the fact, which is generally admitted, that the first sound of the heart is not the same in the bloodless heart as in one acting normally. Haycraft, CARDIAC SOUNDS. 63 who has, within recent years, devoted attention to this subject, points out that the first sound is far lower in pitch after the removal of the blood. The difference can only be that, in the normal heart, the tension of the auriculo- ventricular valves produces acoustic vibrations which are absent in those hearts from which the blood has been removed. There are without doubt some difficulties in regard to the muscle sound, which is, according to all observers from WoUaston to Helmholtz, a low-pitched sound, having the period of a body vibrating not more than 40 times per second ; whereas the first sound of the heart is, according to Haycraft, in the base clef, and has the pitch of a body vibrating between 100 and 200 times per second. Helmholtz proved that the sound produced by the con- traction of a skeletal muscle was almost entirely a mere resonance sound, the muscle itself undergoing disturbances at a period too low to be audible. Haycraft has pointed out that movements, due to want of co-ordination between the fasciculi within the skeletal muscle, take place, and he holds that these movements cause the membrana tympani of the observer to vibrate at its own period of 40 per second. He regards the muscle sound as a simple resonance sound. Intensity of Sounds. — During recent times the intensity of the heart sounds has been carefully studied, more particularly by Vierordt. The method followed in his investigations was by inter- posing, between the chest-wall and the ear, pieces of gutta percha, which conduct sound indifferently, and noting the number necessary for the disappearance of the sounds. The average results of his estimation in healthy people are given in the following table : — The Relative Intensity of the Heart Sounds. First sound : 4-10 Years. 11-20 Years. 21-40 Years. 41-50 Yean The left ventricle . 751 758 768 637 The right „ . 491 577 602 516 Second sound : Aortic . 626 492 481 546 Pulmonary . 778 660 568 539 64 PHYSIOLOGICAL. It will be seen on comparing the figures for different ages that, during early years, the first sound on the left side of the heart is relatively much louder than that on the right. During later years the intensity of the sound generated at the tricuspid orifice increases, and the difference becomes less. With regard to the aortic and pulmonary orifices, it will be noticed that there is a progressive diminution in the intensity of the ])uluionary second sound, and that, although the aortic second sound also becomes less distinct, it is, when compared with the pulmonary, relatively louder in later years, and at length absolutely exceeds it in intensity. Belation of Sounds to Movements. — The relationship existing between the sounds and the movements of the heart has long- been the subject of much controversy. The position of the first sound at the commencement of the systole of the ventricles is universally accepted, but it is far otherwise with the second sound. If we compare the work of Edgren, for example, with that of Martins, we find the greatest discrepancy in the position of the second sound in their tracings ; Fredericq, who has carefully analysed their results, agrees with Edgren in placing it in the second part of the descending curve. Electromotive Changes in Cardiac Activity. — The heart beat is accompanied by definite electromotive phenomena. These have been studied by several observers, amongst whom may be mentioned Engelmann, Marchand, and Burdon Sanderson and Page. AVithin recent times the whole subject has been thoroughly investigated by Waller. The electric variations of the heart may be investigated by means of Lippmann's capillary electro- meter, which demonstrates the variations of potential associated with cardiac contraction. By leading off' to the electrometer with a pair of electrodes (zinc, covered with chamois leather, and moistened with brine) strapped to the front and back of the chest, the mercury in the capillary tube may be seen to move with each Ijeat of the heart. A record of the movements of the column of mercury may be obtained by photographing the oscillations on a travelling plate simultaneously with the movements of a cardiograph. Each contraction of the heart is accompanied by an electric variation. Analysis of isuch records shows that the electric variation precedes the ELECTROMOTIVE CHANGES. 65 contraction of the heart by an average time difference of about "015 sec. The electric variation of the human heart may be easily demonstrated by leading off' by the two hands, or one hand and one foot, plunged into separate vessels of salt solution connected with the two sides of the electrometer. The column of mercury may be seen to move with each beat of the heart, but its movements are less than when the electrodes are strapped to the chest. By simultaneous records of the move- ments of the mercury and of the heart it may be seen that the former slightly precede the latter. On closer investigation of the phenomena it is found that on leading off . to the electro- meter from two points, one near the apex and the other near the base of the heart, there are several events accompanying the contraction. There is an initial phase preceding the systole, during which any point near the apex is negative to any.point near the base. There is, further, a terminal phase preceding the diastole, during which the basal region is negative to the apical. According to the observations of Bayliss and Starling, the initial phase is itself double, and the phenomena are, therefore, triphasic. This, as Waller shows,: is unquestion- able proof that the variation is physiological, for there is no possibility of such an arrangement of altered contact at the' chest wall. The Eorces which fill. the Heart in Diastole. — Several factors are concerned in filling the ^chambers of the heart during their diastolic phase. Amongst these may be noticed the negative pressure existing, under ordinary circumstances, in the thoracic cavity, first recognised by Donders. ■ This negative pressure within the thoracic cavity necessarily tends, by a process of aspiration, to draw blood from the systemic veins towards the heart, and it must be regarded as one of the most important forces in filling the heart. In addition to this there is, further, the negative pressure produced in its chambers by the active diastole of the heart. This negative pressure, first experimentally shown, as already mentioned, by Goltz and Gaule, gives, as the result of several experiments on the dog, in the left ventricle, from 100 to 3'20 mm. water, and in the right ventricle from 1 to 2 5 mm. water, 5 66 PHYSIOLOGICAL. Similar experimeuts have l.»eeu carried out by several other observers, of which those of de Jager seem to be the most important. "With the chest wall open and the heart exposed — the aspiratory action of the lungs therefore entirely excluded — he found m the right ventricle a negative pressure of from 5 to 08 mm. mercury, and in the right auricle one of from 2 to 6 mm. The result of these researches is to establish as an incon- trovertible fact that during diastole the heart manifests an aspiratory action, and draws blood into its cavities. The explanation, however, of this force is beset with difficulty. "Whether it be by the mere elasticity of the cardiac fibres, as was suggested by Magendie — an explanation apparently accepted by Goltz and Gaule, as well as by de Jager ; or, as Spring suggested, that the longitudinal are constricted by the trans- verse muscular fibres during systole, and by their expansion during diastole bring about the dilatation ; or whether, as Luciaui urges, the muscular fibres are endowed with the faculty of actively lengthening themselves, cannot, in the present state of our knowledge, be definitely decided. One fact of the greatest importance must be mentioned here. Stefani found that the diastolic dilatation of the heart was more active while the vagi were left intact than when they were severed. It is further to be remembered that the flow of the blood through the coronary arteries, which continues after the termination of systole, may have some influence in causing an active dilatation, and may, therefore, aid the aspiratory functions of the heart muscle. It seems probable that the general blood pressure and blood flow may be regarded as factors in filling the heart during diastole. But, inasmuch as the pressure and current in the venous system are small, they cannot be regarded as exerting much influence. The Xuteitiox of the Heaet. — One of the most important subjects connected with the causation of cUseases of the muscular substance of the heart is connected with its nutri- tion. It is a well-known fact that, when a muscle is in action, the blood current through it is increased in rapidity, and it could hardly be expected that the heart would form an exception to this general rule. Certain observers, never- NUTRITION OF THE HEART 67 theless, have held a contrary view. During last century, for instance, the opinion was expressed by Thebesius, that during the ventricular systole the semilunar valves closed the openings into the coronary arteries, and that it was, therefore, impossible for blood to enter them during that phase. Briicke revived this view in the middle of the present century, stating that no blood entered the coronary arteries during systole, and that the heart was flushed with blood during the diastole. Upon this view he founded the idea of an important regulating mechanism, holding that if blood entered the coronary arteries during systole the contraction of the ventricles would be hindered, while, on the other hand, if the blood entered these arteries during diastole its high pressure would favour the diastole. His opinion was opposed by Hyrtl, who, in the great majority of 117 autopsies, found the openings of both coronary arteries, or at least of one of them, to be higher than the free margin of the aortic cusps. Elidinger observed that in the majority of cases the valves do not reach the opening of the coronary arteries. Briicke, on the other hand, stated that he, in 100 cases, only found four in which the coronary arteries were above the sinus of Valsalva. Ceradini and Krehl have confirmed the anatomical facts of Hyrtl, by showing experimentally that during systole the aortic cusps do not touch the arterial walls. There can be no doubt that in the overwhelming majority of cases the coronary arteries are above the level of the aortic cusps, and the valve, therefore, can in no sense interfere with the passage of blood into the coronary arteries during the systole of the heart. That Briicke's views are erroneous has been decisively proved by the result of experiment. IlTot only did Hyrtl show that on cutting across a coronary artery in a living animal a jet of blood was thrown out in the beginning of the systole of the ventricles — a fact, however, which might possibly be open to a different interpretation as to the cause of the jet — but Chauveau and Eebatel have demonstrated that the pressure and the velocity of the blood increase in the coronary arteries with the commencement of ventricular systole. It was, however, observed that, while the blood 68 PHYSIOLOGICAL. pressure remains high during the systole, the velocity fiills to a very low level. This is probably caused by the very strong contraction of the heart which compresses the blood vessels, thereby sustaining or increasing the pressure, but interfering with the blood stream. At the end of the systole, without any increase of pressure, the flow in the coronary arteries is again increased, no doubt by the relaxation of the blood vessels. Their conclusions have been supported by the experiments of Martin and Sedgwick, who, by means of manometric investigations on dogs, found the blood pressure in the carotid and coronary arteries to increase simultaneously. The whole matter is a question of blood pressure and blood flow. As will be seen later, so long as the pressure is higher in the aorta than in the coronary arteries, the blood will certainly flow from the former into the latter. While Briicke, therefore, was in error as regards the filling of the coronary arteries during the systole, he was, to some extent, right with reference to the blood flow during diastole. 8taU of the Coronary Arteries. — The earliest experiments on the coronary circulation were made by Erichsen, who found weakening and stoppage of the heart on ligation of the coronary arteries. These were followed by the researches of Panum, who observed that when the coronary arteries were obstructed by substances that had been injected, there was a gradual slowing and cessation of the pulsation. The size of the coronary arteries is the means of fixing the nutritive possibilities of the heart. It will be seen in a subsequent section that changes in the lumen of the coronary arteries, caused by disease, produce profound effects upon the myocardium. In this chapter the results of experiments upon these vessels must be considered. On clamping one of the coronary arteries in the rabbit, von Bezold observed that, after two or three minutes, th-e contractions of the left ventricle iDecame irregular and peristaltic, and were followed by a perfectly arhythmic flickering, which speedily ended in still- stand. The contraction of the right ventricle usually lasted somewhat longer than that of the left, but the appearances on the right side soon followed and resembled those of the left. NUTRITION OF THE HEART 69 Similar appearances have been observed by Cohnhcini and von Schultess-Eechberg in dogs. In their experiments the liberation of the coronary arteries never brought Ijack the ordinary pulsations after fibrillary twitchings had once ap- peared. Indeed, after a short time the normal beat disappeared, even if the ligature were loosened before the appearances of fibrillary twitchings. See, Bochefontaine, and Bouzy produced similar effects, by injecting lycopodium powder into the coronary arteries. By von Bezold these results were regarded as the result of an interference with the nutrition of the heart muscle. As Tigerstedt, however, has shown, the blood supply to the ventricles may be stopped in the rabbit by firmly clamping the auricles. The aortic pressure falls to its minimum, and no blood flows into the coronary arteries, yet the clamp may be left for at least five minutes, and on its removal the heart resumes its normal pulsation. He concludes that it is through direct injury to the ventricular muscle that the pulsation is disturbed. These observations do not throw any clear light upon the pathological changes to be afterwards described in connection with coroi^iary lesions. Effects' of the Condition of the Blood. — The blood must have certain properties, in order to render it possible for the heart to perform its healthy functions. If it is deficient in the normal nutritive substances, or if it contains any toxic bodies, the cardiac energy must be impaired. It has been shown experimentally by Kronecker that, if the blood is replaced by a dilute solution of common salt, the pulse rapidly sinks so as to be imperceptible, while the heart, after exhibiting some feeble flickering movements, ceases to beat, and is unable to produce the least movement with the strongest stimuli. When oxygenated blood or serum is again given, the heart begins to manifest some feeble trembling movements, followed by a weak pulsation, which gradually increases until the beat is restored almost to the ordinary condition. Stienon has further investigated the effects of different conditions of the blood serum upon the heart beat. He observed that blood serum, after the removal of its sodium 7 o PHYSIOL GICAL. carbonate by ueutralisatioii by a fixed acid, slightly increased the activity of the heart, and that serum which had been boiled had an unfavourable effect, whilst fibrinoplastic sub- stances were unable to restore its activity to an exhausted heart. He also sought to discover which of the substances contained in the serum must be present in order to give the heart the possibility of powerful and regular pulsation, and concluded that the presence of from -^ to 1 per cent of carbonate of sodium in a 6 per cent solution of common salt, in the presence of a soluble organic substance, probably of albuminous nature, provided the best possibilities. Martins, from a series of observations, came to the conclusion that only those fluids containing serum albumin possessed the power of nourishing the heart, and he found that such substances as peptone, syntonin, egg-albumin, and milk casein possessed no powers of nutrition. The Wokk doxe by the Heart. Very different estimates have been formed as to the quantity of blood which leaves each ventricle during systole. A summary of these is given by Hoorweg. From 45 cubic centimetres, as estimated by Young, to 188, the figure stated by Volkmann, which form the extreme statements, there are a great many intermediate in amount. That which has l^een most commonly accepted is given by Vierordt, according to whom 180 c.c. is the average quantity ejected from each ventricle during systole. It is extremely probable that Vierordt's estimate is considerably in excess of the usual amount, and there can be but little doubt that the volume of blood leaving the ventricles varies considerably from time to time. As was stated previously, there is always a certain residuum of blood left in the valvular portion of each ventricle ; it seems likely, moreover, that this quantity may, under certain circumstances, be largely increased. From the varia- bility of the amount ejected during systole, it necessarily follows that any estimation of the work done by the heart must be merely approximate. Whatever may be the quantity THE WORK DONE BY THE HEART 71 of blood leaving the heart, there can l^e no question of the fact that it must be equal on both sides of the heart. For, if either of the two ventricles ejected more than the other, there would at once be a disturbance of the balance between the systemic and pulmonary circuits. The pressure in the aorta and pulmonary artery has to be overcome by the outflowing blood, and the amount of this pressure necessarily varies within wide limits. The pressure in the aorta may be taken as 150 mm. Hg., while in the pulmonary artery it amounts to about 60 mm. Hg. The force exerted and the work done by the heart may approximately be estimated by considering the pressure overcome. The left ventricle expels its contents against a resistance of about 150 mm. mercury, which must also be borne by the walls of the cavity. The force exerted must, therefore, exceed this resistance. In other words, as expressed by Tigerstedt, the force must be greater than would support a column of mercury with a base of 1 sq. cm., and a height of 150 mm. If the force be . taken as equal to a column of 2 mm. the calcula- tion is — 200 mm. x 100 sq. mm. x 13*6 gm, = 272 gm. ; that is, the force is equal to the weight of 272 gm. resting on every sq. cm. As the pressure of the pulmonary artery is about -| of that of the aorta, the force of the right ventricle may be estimated as 109 gm. for each sq. cm. If the amount of blood ejected during each systole be 100 gm., and the aortic pressure 150 mm., or "150 m. Hg., it follows that 100 gm. X "150 m. X 13-6 = 204 gm. metres. But the velocity has also to be taken into consideration, and taking this as 0"5 m., with the standard 9 "8 m. as the velocity of a falling body for one metre, and the formula -^— ^ , 2G- we obtain as the law of efflux of fluid 100x0-5 m.' , ^„ = 1"28 gm. m. 2 X 9-8 m. * 7 2 PHYSIOLOGICAL. The total is therefore 204 +1-28 = 205-28 gm. m. The energy exerted by the muscular Nvall of the heart is in part changed into potential energy in the increased dis- tension of the arteries, and in part into the kinetic energy represented by the momentum of the moving blood. The work done at each cardiac contraction may, as it is put by Starling, be calculated from the formula 2G' where W stands for the work, B for the amount of blood expelled at each systole, E for tlie arterial pressure, and V for the velocity of the blood. In this equation BE is the work done in overcoming BV- . resistance, and — r^ is the energy employed in imparting the 2Ct velocity to the blood. If we take the usually accepted figures of 100 gm. of blood as the amount expelled from the left ventricle at each contraction, half a metre per second as the velocity of the blood in the aorta during systole, and 150 mm. Hg. as the pressure in the aorta, BE = 204 gm. metres BY- of work, and — -;- = 1"28 gm. energy required to produce the 2Gr velocity. The velocity factor may therefore be neglected in con- sidering pathological changes in the work thrown upon the heart. Any important increase in the work done by the heart can only be conditioned by an increase in one or both of the other two factors B and E, i.e., the amount of blood expelled, and the resistance offered by arterial pressure. The Arteries. It has been recognised since the work of Weber that the flow of any fluid in a system of tubes is different according as these tubes are unyielding and rigid, or disten- sible and elastic. With a continuous and uniform flow, the course of the fluid is practically similar in both kinds of THE ARTERIES. 73 tube, but when, as is the case with the circulation of the Wood, the fluid is driven in a series of rhythmic pulsations, the effect with the two forms of tube is entirely different. In the case of a tube composed of unyielding or rigid material, it escapes at the distal end in a series of intermittent jets ; but when it is so driven into a yielding but elastic tube, it escapes in a continuous stream. The effect of elasticity is not only to convert an intermittent into a continuous flow, but also to relieve the force propelling the fluid by allowing, through expansion, only part to be driven on. An interesting effect of intermittence has been shown by some experiments of Hamel. This observer found that when a-continuous stream was kept flowing through a frog's muscle, an oedematous condition was produced, and that when the stream was rendered intermittent the oedema disappeared. The pressure of the blood, apart from variations produced by cardiac energy, arterial tone, and peripheral resistance, is subject to the ordinary laws of hydrostatics, and undergoes differences produced by gravitation. The pressure is equal in the same horizontal plane, and variations in hydrostatic pressure are due to differences of level. Following Thoma, the hydrostatic pressure of the blood may be spoken of as hcTemostatic, while the pressure produced by the different factors of the circulatory mechanism may be termed hemo- dynamic. Differences in haemostatic pressure may be stated in terms of the difference of level of a column of blood, or, for greater convenience, of a column of mercury. As the specific gravity of blood is on an average about 1"05, while that of mercury is 13 '5 9, the latter may be said to be approximately thirteen times heavier than the former. The haemostatic pressure may be estimated from the point of exit at the heart, and this pressure may be termed f. In the erect posture, the hemostatic pressure at the head, a 520 distance of about 520 mm. will be equal to ]) — -— ;- — i^ — 40 lb mm. Hg. On the other hand, the hemostatic pressure at the 1300 foot, under similar conditions, may be expressed as jj + -—^ — = 2)+ 100 mm. Hg. The hemostatic pressure is, to some extent, 74 PHYSIOLOGICAL. counterbalanced liy the vascular tone, and it is, therefore, to some extent, under the control of the nervous system. But there are special provisions to meet it in the structure of those parts of the body wliich are more specially influenced by it. In the veins of the leg, for example, there are more valves than in any other part of the body, while the walls of the vessels of the leg are consideral)ly thicker than elsewhere. The actual pressure of the blood is the sum of the hemostatic and lui'modynamic pressures. If the pressure of the blood leaving the heart Ije taken as 150 mm. Hg., the hcemostatic, hsemodynamic, and actual pressures may be expressed in the following taljle : — Level of Head , , Heart Foot Static. Dynamic. Actual. I) - 40 mm. Hg. I) mm. Hg. ^j + 100 mm. Hg. Vein. ] +20 + 20 Artery. + 100 + 150 + 100 Vein. Artery. -20 + 60 +150 + 120 +200 The Flow ix the Arteries. — Several factors influence the course of the blood along the arteries. The most important of these is the propulsive force of the heart, but, in addition to this, we have to consider the amount of blood which is ejected, the nature of the arterial walls, and the resistance in the periphery. The sectional area of the vessels increases with distance from the heart, and towards the periphery of the vascular system there is in consequence larger storage for the blood. It follows from this that the course of the blood stream becomes slower with increased distance from the heart. It has been shown that the flow of fluid differs in certain particulars according as it passes along unyielding or yielding tubes, and that the arterial walls are endowed with a very high degree of elasticity, but it is necessary to look into the facts regarding this elasticity a little more closely. That the degree of elasticity brought into play is a variable quantity has been recognised since the observations of Wertheim, and it has further been recognised that the amount of elasticity THE FLOW IN THE ARTERIES. 75 in operation becomes greater the higher the pressure. But this subject has, in more recent times, been carefully investigated by Eoy, who observed that in healthy arteries the distension, from which recovery could take place, increased with greater pressure up to a certain limit, bearing a definite relationship to the total extensibility of the arteries, and that, when this limit was passed, the amount with still further increased pressure gradually became less. Zwaardemaker also observed that the elasticity of arteries showed its maximum with medium pressure. As the result of these investigations it follows that, with high arterial pressure, each increase in the amount of blood driven out of the ventricle must in a high degree increase the blood pressure. The distensibility and elasticity of the arteries cannot be regarded as in any sense independent forces in the maintenance of the blood flow. They simply constitute a reservoir of energy and a means of regulation. It has previously been stated that the smaller arteries and arterioles are endowed with a high degree of contractility, and the amount of contraction which is present in the peripheral arterioles has a most important effect upon the flow of blood in the arterial system. The causes which lead to such con- traction of the arterioles will be discussed further on, but one important point must be brought forward in this place. It has been shown by Eoy and Adami, as well as by Johansson and Tigerstedt, by means of plethysmographic observations on the heart, that, when the arterioles are con- tracted to a certain but not too great degree, the heart drives out more blood than when the pressure is low. If, however, on the other hand, the contraction is still higher, the amount of blood driven out by each systole becomes smaller. It therefore follows that a medium pressure is that which is most favourable for the onward progress of the blood. There can be no doubt that the resistance is also in part under the influence of metabolic changes in the tissues, and that when, from any reason, whether blood impurity or cellular inactivity, there is a diminished attraction of blood to the tissues, the resistance must increase. Another point of im- portance to remember is that, when from any reason the 76 PHYSIOLOGICAL. absorption l.)y the l}-iu})liatics is impaired, the peripheral resist- ance must rise. The Blood Pressure. — The conception of arterial pressure may be said to date from the experiment of Hales, who, by means of a long tube placed in communication with an artery, observed that the blood rose to a considerable height. No additional knowledge upon this subject was obtained until Poiseuille, pursuing a similar line of research, employed a U-tube filled with mercury, and in this way was able to estimate more exactly the amount of pressure in the artery. The simple instrument employed Ijy him was afterwards improved by Ludwig, and, as the kymograph, is now part of the outfit of every physiological laboratory. The blood pressure varies very considerably in animals. In the horse, for instance, it often reaches 300 mm. mercury, in the dog it is about 170, and in the rabbit about 100. In man it probably varies from 100 to 200, and the average pressure in the aorta is generally estimated as being about 150. In different parts of the body the arterial pressure varies, and it may be stated as a general principle that it is some- what less at a distance from the heart than near it. This, however, is only a relative truth, because, as Hiirthle has in recent times demonstrated, the pressure in the femoral artery is often higher than in the carotid. There are three main agents in keeping up the arterial pressure, connected with the heart, with the arteries, and with the blood itself. The energy with which the heart contracts in systole has an important influence upon the blood pressure, as is well seen when the cardiac contractions are modified by interfer- ence with the vagus nerve. If the inhibitory influence of the vagus is removed, there is at once a considerable rise in the arterial pressure, and when the inhibitory influence of that nerve is brouglit into play, by stimulating the peripheral cut end, the blood pressure at once falls to a low level. The resistance in the peripheral arterioles is a powerful factor in maintaining blood pressure. The amount of blood in the arteries is also a most important agent, winch is not only seen in morbid conditions. THE VELOCITY OF THE BLOOD. 77 but which has been demonstrated experimentally. Direct losses of blood, as shown by Tappeiner, cause a remarkable fall in the pressure. The use of dry food, by withdrawing Ijlood from the general circulation into that of the digestive organs, also, according to Pawlow, produces a considerable fall, and, as shown by the same observer, the ingestion of a nutritive fluid, such as soup, produces a proportional rise in pressure. Tree secretion from any of the glandular apparatus produces a fall of pressure. The Velocity of the Blood. — The velocity of the blood, or the amount passing through a given space in a given time, has been measured by a number of physiologists. It is found to vary greatly in different animals, as well as in different arteries of the same animal ; it is also subject to much greater variations than the blood pressure. In the carotid artery of the dog, for instance, Yierordt observed that the velocity during systole reached 297 mm., while during diastole it only attained 215 mm. per sec. ; and Chauveau, in the horse, found that in the carotid artery, during these two phases, the rate was respectively 520 and 150 mm. per sec. The conditions of the blood in the arteries present two main facts for consideration. There is, in the first place, a rise of pressure during systole, which is propagated onwards as a form of wave motion. This wave motion is to be absolutely separated from the flow of the blood itself. There is, in the second place, the propulsion of the blood itself, as it streams from the heart outwards to the periphery. The arterial pulse consists in a wave of increased pressure, travelling from the centre to the periphery of the arterial system. It is therefore to be regarded as an oscillation of blood pressure above and below a mean level, in consequence" of which the blood always travels in one direction, that is, from the higher to the lower pressure level. The factors upon which the arterial pulsation depends are the amount of the blood, the energy of the heart, and the resistance of the blood vessels. The features of arterial pulsation depend entirely upon the relations to each other of these three factors. The energy produced by the heart, leaving out of account the loss sustained through friction, is expended in two different direc- 78 PHYSIOLOGICAL. tions. The larger proportion, as has been pre^•iously shown, is transformed into the potential energy stored up in the walls of the distended arteries. The smaller proportion is manifested as the kinetic energy of the moving column of blood. The features of the arterial pulse will be described in the section devoted to the investigation of clinical appearances in health and disease. In regaril to the second consideration, its great result is the conversion of an intermittent jet into a continuous stream. During diastole, when the heart ceases its contraction, the swift wave of pressure and the slower flow of the blood tend to produce a negative pressure in the great arteries issuing from the heart, and this tendency causes a backward wave of pressure and, to some extent, a backward flow of blood. The Capillaeies. The principal agency in propelling the blood through the capillaries is the high arterial pressure, but there can be no douljt that the flow through these vessels is aided by the attraction of the tissues in which they lie. The flow of the blood in the capillaries is mainly character- ised by l^eing continuous, and by the fact that not merely transudation of plasma, but also the transmigration of corpuscles is freely allowed, under certain circumstances, through the walls. The blood pressure in the capillaries has been estimated by several observers, more particularly by von Kries, and by Eoy and Graham Brown. The principle upon which these investigations have been carried out is that of ascertaining what degree of pressure upon a region rich in capillaries is required to empty these vessels. As the result of such investigations, the capillary pressure in the frog has been estimated as from 7 to 11 mm. Hg. In man it is probably equal to between 20 and 30 mm. Hg. The velocity of the current in the capillaries is estimated Ijy observing, with the microscope, the passage of the corpuscles in the axis of the stream and measuring by means of the micrometer the time occupied in traversing a certain distance. THE FLO W IN THE VEINS. 79 Such observations have been made by many inquirers, more particularly by Vierordt, who found that the rate of flow was from "5 to "9 of a millimeter per second. One remarkable feature connected with the flow of the blood in the capillaries is that the coloured corpuscles keep the axis of the stream, while the colourless move alonu' in its periphery. The most probable explanation of this appearance is that of Hamilton, who attrilmtes the fact to a difference in the specific gravity of the corpuscles. Hamilton holds that the red blood corpuscles are of about the same density as the plasma, while the white blood corpuscles are of lighter specific gravity, and that they, therefore, tend to float upwards and to be displaced by those which are heavier. The aim of the capillary circulation is to bathe every tissue in the body with blood, and it may be said that the purpose of this is twofold. The object of most of the capillaries, as for instance those of the muscles, is to supply fresh blood containing suitable nutriment, and, at the same time, to remove from the tissues impure substances, which are carried back into the general circulation. The obvious intention of other capillaries is mainly depurative. This is well seen, for instance, in the renal vessels, as almost the sole function which they perform is to remove from the blood impure substances. The . Veins. The flow of the blood in the veins is mainly produced by the high pressure in the arterial system, but after passino- through the capillaries this force, primarily derived from the energy of the heart, is greatly reduced, and other agencies assist the current along the veins towards the heart. The venous valves contribute to this end, because, directed forwards as they are, they prevent the possibility of a venous reflux, and, therefore, make provision for the onward passage of the blood when any lateral pressure is exerted upon the veins. Such lateral pressure comes from two main sources — muscular contraction by compressing the veins drives blood onwards, and, in the case of many veins which accompany arteries, the expansion of the arteries following the cardiac So PHYSIOLOGICAL. systole produces a similar effect. But a large number of veins in the body have no valves. There are, however, other in- fluences which assist the flow in such vessels. The negative pressure in the thoracic cavity, as already seen, has a powerful influence in drawing blood towards the heart, and the negative pressure produced by the cardiac diastole has the same efl'ect. The venous pressure is greater in the peripheral veins than in those which are nearer the heart. In the femoral vein of the sheep, for example, as observed by Jacobson, the blood pressure was 11"4, while in the brachial it was 4*1, in the facial o"0, and in the subclavian, jugular, and innominate veins it was 0"1 mm. Hg. It is quite obvious that these degrees of pressure, as the veins approach the heart, must be caused by the aspiratory force within the thorax, as otherwise, with the diminishing area of the veins near the heart, there could not fail to be an increase of pressure. A true venous pulse, by which is understood a perceptible pulsation in the veins from the periphery to the heart, is sometimes observed, and will be fully described in the chapter upon symptomatology. It is only necessary in this place to say that it is produced by the direct transmission through the capillaries of the oscillations of pressure in the arteries. The Pulmonary Cieculation. The circulation of the blood through the lungs must be briefly noticed. It is influenced by most of the factors aflecting the systemic circulation, but it is more affected by certain of these influences, while others are, for the pulmonary circulation, non- existent. Since the force exerted by the right ventricle is much less than that of the left, it follows that the blood pressure in the pulmonary circulation is much lower than in the systemic. The pressure in the pulmonary artery has been ascertained by several observers. Beutner, investigating the pulmonary pressure of the dog, found it from 28 to 31 mm. Hg. ; Licht- heim found it from 10 to 33 mm. Hg., and Bradford and Dean observed a pressure of from 16 to 20 mm. Hg. As already mentioned, the amount of blood ejected by the rif'ht ventricle must be exactly equal to that driven out by the THE PULMONAR V CIRCULA TION. 8 1 left, otherwise the circulation would very speedily be Ijrouglit to a standstill. The respiratory movements of the thorax exercise not only great influence upon the pulmonary circulation, but produce distinct effects upon the systemic blood current. In ordinary inspiration there is in the air-passages a negative pressure of about 1 mm. Hg., while in ordinary expiration it Ijecomes a positive pressure of about 2 mm. Hg., and these pressure varia- tions influence the blood in all the vessels within the thorax. These varying pressures within the thorax affect all the intra-thoracic organs of the circulation, but mora especially act upon the auricles and veins, on account of the thinness of their walls. The elasticity of the lungs in their distended condition necessarily bears part of the atmospheric pressure. The ten- sion of the lungs results in a negative pressure equal to 1 mm. Hg. during inspiration, and of 5 during expiration. If along with this pressure we consider the pressure within the respira- tory passages, that is to say, the pressure of — 1 and + 2 mm. Hg. already mentioned, for inspiration and expiration, we get during inspiration a total negative pressure of 11, and during expiration of 3 mm. Hg. In other words, the pressure upon the heart and great vessels, taken as at sea level, may be expressed as equal to760 — 11 = 749 mm. Hg. during inspira- tion, and 760 — 3 = 757 mm. Hg. during expiration. There is, in short, a difference of pressure equal to 8 mm. Hg. between inspiration and expiration. These changes in pressure produce a variation in the flow of the blood, more particularly by their effects upon the right auricle and the vense cavas ; during inspiration there is an increased flow towards the heart, and during expiration it is diminished. A larger amount of blood therefore must be allowed to flow into the aorta and pulmonary artery imme- diately after an inspiratory effort, and in these vessels there must in consequence be necessarily a higher pressure, while during expiration the opposite will take place. With forced respiratory efforts the varying intra-thoracic pressures become much more marked, since it is well known that during forced inspiration the negative pressure may amount to 70 mm. Hg., while during forced expiration the positive pressure may be 6 82 PHYSIOLOGICAL. equal to 90 inni. Hg. Eespii'ation of raietied air leads to an increased blood pressure, and l)reatliing compressed air reduces it. The systole and diastole of the heart affect the air pressure in the respiratory tubes, and the fluctuations of pressure in the contained air are apparently produced by the variations in the size of the heart. Curves have been obtained by Landois and Haycraft and Edie, which show diminution of pres- sure during cardiac systole, and increase during diastole. As is well known, an analogous phenomenon is met with on auscultating the lungs. In many instances, either on account of a lack of elasticity in them, or possibly an increased size of the heart, the respiratory murmur is interrupted or jerky, in consequence of the cardiac movements. During inspiration there is a widening of the pulmonary capillaries, so that more blood is drawn into the lungs. During expiration there is an opposite effect, and from the greater pressure during this phase blood must be expelled from the lungs. It has been shown by Spehl that during natural inspiration the lungs contain from ^j to ^ of the entire Ijlood in the body, while during ordinary expiration they only contain from yL. to -jV of it. The Dueation of the Blood Circuit. The length of time occupied by any given particle of Ijlood in completing the entire circuit of the systemic, as well as the pulmonary circuit, has been often measured. The first attempt in this direction was made Ijy Hering, and since the date of his researches all other observers have employed similar methods to those which he used. The essential feature of his method was the injection of some innocuous, but easily recognised, substance into a vein, and the examination at short intervals of Ijlood from another vein in order to see how soon the injected material would appear. Hering's observa- tions were made upon horses, and from them he concluded that the time occupied in completing a circuit from the jugular vein of one side, to the corresponding vein of the other, was about 26*2 seconds. Vierordt somewhat improved THE LYMPH CIRCULATION. 83 the details of the method employed by Hering, and from many mvestigations came to certain definite conclusiona. He found that the average duration of a complete circuit of the blood differs considerably in different animals, and that it is always shorter in those which are smaller. He further observed that the number of pulsations necessary to drive the entir<' quantity of blood once through the body in all animals, independent of their size, is almost equally great, varying as a rule from 26 to 29. This is shown in the following table : — Animal. Duration in seconds. Pulse-rate per minute. Number of pulsations. Kabbit . 7-46 210 26-1 Goat . 14-14 110 26-0 Do» . 16-7 96 26-7 Vierordt further found that the average duration of the blood circuit in different animals is related to the average duration of an entire cardiac cycle, so that the quantity of blood which flows in a given time through a given weight of body, does so the more quickly, the smaller the animal. For example, the quantity is for the rabbit 592 gm. per kgm. per minute, in the goat 311, in the dog 272, and in the horse 152. In the same way the amount of blood leaving the heart is greater in relation to the body weight in smaller than in larger animals. The following table shows this : — Animal. Blood gm. Per minute proportion. Body kgni. Weight proportion. Rabbit 812 10 1-37 10 Goat 1,166 14 3-75 27 Dog Horse 2,504 . 58,800 31 720 9-2 380-0 67 2,770 Inasmuch as the blood pressure in different animals varies comparatively little, it follows that the work of the heart in relation to the size of the body is greater in small than in large animals. The Lymph Cieculatiox. The lymph wdiich bathes the tissues is simply a transuda- tion from the ultimate ramifications of the blood vessels, and is present in such an amount as suf&ces to render the metabolic 84 PHYSIOLOGICAL. processes possible. In health there is no tendency to any accumulation or excess. The lymph differs from blood plasma in the proportion of its constituents. It contains less albumin and more water, while there are also the products of tissue change. Its specific gravity is from 1012 to 1022. It has an alkaline reaction, and a very feeble power of coagulating spontaneously. The amount of lymph which is present depends on the relative amount of transudation and resorption, on the balance between afflux and etHux. The transudation of the tluid is manifestly connected with the blood pressure and varies directly as it is increased or diminished. Tlie resorption depends on the natural circulation of the lymph. This apparently is partly due to the pressure in the plasma spaces derived from the blood pressure. The circumstance that the pressure within the large veins, into which the main lymphatic vessels open, is less than that in the tissues, which in turn is less than that within the small arteries and capillaries, is also an important factor. It must also be borne in mind that the movements of respiration have an aspiratory influence upon the lymph channels as well as upon the great venous trunks, that the lymph vessels have contractile walls, and further, that the contraction of the muscles must favour the return of lymph. The Innervation of the Heart and Blood Vessels. Although, as has been fally insisted upon, the pulsations of the heart are absolutely automatic, and the vessels are possessed of elasticity, so that, as a mere piece of mechanism, the heart and blood vessels are perfectly able to sustain the circulation, the apparatus would, notwithstanding, speedily cease to work smoothly, were it not in some way regulated. This regulation is effected by means of the nervous system. In all mammals — in fact, in most vertebrates — when the vagus is divided iu the neck there is usually an increased frequency of the pulsations of the heart. This effect is by no means constant ; in many instances no change is produced on section of the nerve, but if the lower end of the cut nerve Ije stimulated by electricity there is weakening, slowing, or arrest INNERVATION OF HEART AND BLOOD VESSELS. 85 of the pulsations, according to the strength of current which has been employed. On the other hand, if the sympathetic in the neck be cut, no effect may be produced ; if, however, it be stimulated, the beats of the heart become increased in strength and frequency. The primary effects produced by stimulation of the vagus are followed by a period of greater activity after the interval of rest, while the converse takes place in the case of the sympathetic. The vagus nerve, therefore, is a channel by means of which inhibitory influences are carried to the heart, while the sympathetic nerve may be regarded as the means by which augmentor impulses are conveyed to it. Such influences may be conveyed by reflex action as well as directly. The familiar illustration afforded by the ear of the white rabbit furnishes an excellent example of the nervous control of the circulation. When the ear is attentively observed it may be seen to undergo alternate redness and pallor. In the former condition all the blood vessels are seen to become wider, in the latter they are observed to contract. They, for the most part, however, maintain an intermediate condition which is that commonly known as vascular tone. If, now, in such a rabbit under chloroform, the sympathetic nerve be divided in the neck, the ear becomes redder and warmer, losing, from the time of the operation, the rhythmic movements of contraction and dilatation of the blood vessels. On stimulating the upper end of the cut sympathetic, the ear becomes pale, and the blood vessels are seen to have shrunk to their smallest possible limits. But on ceasing to stimulate the upper end of the sympathetic the ear at once becomes flushed and warm again. These facts prove that influences commonly called vaso-con- strictor pass upwards by the sympathetic to the ear. Another familiar illustration is furnished by the sub- maxillary gland. If the chorda tympani in its course to it be divided, but little effect is produced, but if the cut end of the nerve nearest to the gland be stimulated, it becomes enormously enlarged, its vessels undergo great distension, and a direct venous pulse may be seen beyond it. These observations prove that influences of a vaso-dilator character are carried by the chorda tympani to the gland. The nerves connected with the circulation naturally fall 86 PHYSIOLOGICAL. into two groups, those which are connected with the heart, and those wliicli are connected with the hlood vessels. The course of the nerves passing to the heart has already 1 >een fully described. The cardiac nerves include inhibitory and aiigmentor fibres passing to the heart and depressor fibres coming from the heart. The inhibitory fibres pass down to the heart in the trunk of the vagus nerve. They do not, however, belong to the vagus, but start from the spinal cord l)y means of the spinal accessory nerve. It has l)een shown that if the roots of this nerve are divided, while the vagus nerve is uninjured, stimu- lation ()f the ^•agus trunk fails of its usual effects. The aug- mentor filjres have their origin in the anterior roots of the second and third dorsal nerves, and, reaching the sympathetic system by the white rami communicantes, they pass through the first dorsal or stellate ganglion, through the annulus of Vieussens and the inferior cervical ganglion, whence they reach the heart usually through the lower cardiac nerves. In some animals, c.rj. the rabbit, the depressor fibres pass upwards in a separate definite nerve, which can be anatomically isolated, join the superior laryngeal liranch of the vagus, and thus reach the bulb. In human anatomy, the depressor filjres pass upwards by the cardiac nerves to the superior laryngeal and vagus trunk, whence they pass to the bulljar centre. There are some differences in structure in these fibres. Gaskell has shown that the inhibitory fibres are medullated throughout their course in the spinal accessory, vagus, and cardiac nerves ; and that they probably remain medullated in their entire course. The augmentor fibres are medullated in the anterior roots, communicating branches, and sympathetic channels as far as the stellate and inferior cervical ganglia ; they are, however, from this point outwards non-medullated. The vaso-constrictor nerves have their origin in the spinal cord. They leave the spinal cord by the anterior roots of the dorsal nerves and pass to the sympathetic system by white communicating branches. The branches from the upper dorsal nerves reach the cervical ganglia and pass upwards, furnishing also branches to the arms through fibres passing from the stellate ganglion to the brachial plexus. Tlie lower dorsal INNERVATION OF HEART AND BLOOD VESSEIS. 87 nerves give branches which join the splanchnic nerves of the abdomen, and furnish nerves going to the lower limljs. The vaso-dilator fibres have not been so far thoroughly- traced. The only fact as to their origin is that, like the vaso- constrictor nerves, they emerge from the spinal cord by the anterior nerve roots. Gaskell has pointed out that the two kinds of vaso-motor nerves are distinguishaljle from each other. Both are of the small medullated kind, and both leave the cord by the anterior nerve roots ; but the vaso-constrictor nerves pass from the spinal nerves to the sympathetic system by white communicat- ing branches, and return to the mixed nerve by gray communi- cating branches ; while the vaso-dilator nerves accompany the spinal nerves and remain medullated until they reach their final visceral ganglia. From an anatomical point of view the cardiac and arterial nerves fall into two groups. Vaso-constrictor and cardio- augmentor constitute a well-defined class ; while vaso-dilator and cardio-inhibitory constitute another. The nerves belong- ing to the first class are non-meduUated and excite muscular action ; the nerves of the second group are medullated and restrain muscular contraction. CHAPTER III. PATHOLOGICAL. The special details of morbid changes in structure and function do not present themselves for consideration in this chaptei' — they will naturally arise in connection with the individual diseases to be described afterwards ; the general principles connected with disturbances of the circulation must form the sole subject of the present part of the work. In order to render this short sketch in some degree comprehensive it is necessary to consider in a concise manner some general facts regarding the causation, the production, and the results of circulatory disturbances. Etiology. Considerations in regard to the general etiology of circula- tory disturbances can alone be allowed a place in this connec- tion. The special causes of particular diseases will Ije discussed under their proper heads, but some facts of a more general character may be grouped together in this place. Such etiological factors fall naturally into two groups. Certain influences belong to the individual and may therefore be regarded in the light of personal or intrinsic causes, others are exerted from without and may in this way be looked upon as impersonal or extrinsic causes. Inteinsic Causes. — Heredity plays a considerable part in the evolution of cardiac disease. Instances illustrative of this fact will be adduced in the sequel, and some of the most ETIOLOGY. 89 important observations of previous writers will Le referred to. Heart disease is present in certain cases at birth, sometimes in the form of congenital malformations, sometimes in the form of more restricted lesions which are not usually classed under this head. In many other instances, moreover, cardiac lesions develop in after life in the children of those who have been victims to similar affections, and it must be granted that the descendants of such persons show a tendency to the evolu- tion of the diseases in question. Age is an important member of this group. Certain diseases which have a tendency to leave a legacy of circulatory disorders are most frequently found in early life. Of this group rheumatism must be cited as the most frequent cause. It follows that those types of circulatory disease most likely to have their origin in this affection will be found during the early periods of life. Pericarditis and endocarditis in their acute forms are accordingly diseases essentially of youth. A further deduction may also justly be made, that those valvular lesions most likely to take their origin in acute endocarditis will also be found more particularly in youth, and hence mitral disease, for example, is most commonly found in early years. To more advanced periods of life belong the degenerative affections of the heart and blood vessels, such as arterio-sclerosis, which, linked on the one hand with cirrhosis of the kidney, and on the other with dilatation of the aorta and hypertrophy of the left ventricle, may be taken as a type of disease essenti- ally belonging to advanced periods of life. This particular affection may justly be regarded in the light of a general disease, in which the circulatory system undergoes the greatest local disturbance. Along with, and in great part resulting from, such degenerative processes, are aneurysms connected with the great arteries, and local dilatations of the heart, to which the term cardiac aneurysm is commonly applied. From one or other of these conditions may arise rupture with all its dramatic phenomena. None of these are at all common before middle life, although some of them do occur occasionally in comparatively early years. Age may even be held to have some degree of influence as regards the incidence of certain functional disturbances. Palpitation of dynamic origin, for 90 FA THOL O GICAL. instance, is much more frequently found in early years than in the more advanced periods of life. On the other hand, many disturbances generally considered to l:)e functional, such as interferences with the rate and rhythm of the heart, along with the graver forms of cardiac pain, are rarely found before middle life. These, however, are for the most part associated with morbid structural changes. Sex is a factor of some importance, although it is ex- tremely difficult to explain many points in connection with its influence. It is an undoubted fact that mitral disease is more common in women than in men, while aortic disease presents a converse relationship. It is not difficult to explain why aortic disease is more connnon in men than in women, seeing that it arises undoubtedly in many cases from long- continued physical strain, to which men are necessarily more subject than women, but the reason why mitral disease should be more frequent in women than in men is, so far as can be seen at present, inexplicable. Occupation has a very powerful effect upon the condition of the circulatory organs. Incessant demands upon the activity of the heart produce results which vary with its nutritive possibilities. When there is an adequate supply of nourishment the muscular wall of the heart increases in size on account of hypertrophy, but if the nourishment be inade- quate the muscular wall undergoes dilatation. Long-continued stress upon the blood vessels gives rise to loss of elasticity, and compensatory sclerosis, along with degenerations of the endocardium and arterial intima. Indolence and self-indulgence give rise to fatty infiltration of the heart, probaljly arising in part from excessive nutritive material circulating in the blood, but in some measure also from diminution of the metabolic processes. Personal habits in the use of certain articles of luxury, and in excesses of various kinds, play an important role in the evolution of cardiac and vascular affections, as will be seen in detail in the sequel. ExTKiNSic Causes. — The existence of previous disease exerts the most powerful of all influences upon the state of the circulation. Amongst previous diseases most potent in this way are some of those which we are fain to regard as consti- ETIOLOGY. 91 tntional ; that is to say, diseases which in our present state of knowledge may be considered as having their origin in causes arising within the body. Eheumatism may be allowed to hold the most important position in this group. Whatever the poison of acute rheumatism may be, it certainly has a remarkable affinity for the serous membranes, both endocardial and pericardial. This, however, is not all, because even in perfectly latent forms rheumatism plays also another important part in the evolution of cardiac disease. It is extremely probable that many of the instances of hereditary heart disease are due to the presence of the rheumatic poison. It is held by many that rheumatism is probably produced by a specific organism. This may in the future be proved, yet it may at present be provisionally allowed that a chemical poison is adequate to explain the phenomena. Other disorders, such as renal disease, give rise to cardiac affections resembling those produced by rheumatism, no doubt by means of the retention of faulty chemical substances. More- over, as will be shown immediately, the action of organisms is a chemical process. Gout is less important as a cause of cardiac disease. It nevertheless gives rise to affections both of the external and internal serous membranes of the heart. It is far more potent, however, as an agent in the production of degenera- tive lesions of the blood vessels. By its effect upon the peripheral arteries it gives rise on the one hand to increased pressure followed by cardiac hypertrophy, while, on the other hand, by its influence on the coronary arteries, it brings about various degenerative changes in the heart. Diabetes, scorbutus, and purpura, as well as other consti- tutional affections, give rise to certain definite cardiac and vascular disorders, which will be dealt with in subsequent portions of this work. Of the members of the large group of diseases which owe their causation to influences acting upon the system from without there are many which more or less frequently induce circulatory diseases. Among these are, in the first place, the acute infectious diseases, many of which, as scarlet fever, have malign effects upon the pericardium and endocardium. The 92 PATHOLOGICAL. pyrexia which forms the most important s}'mptom of these diseases has, moreover, as is also the case in rheumatism, a powerful effect upon the myocardium, even in those who recover. This is probahly due to cloudy or hyaline changes, which may in minor degrees temporarily impair, if they do not permanently disable the muscular fibres. Bacteriology has supplied the link which was wanting in order to render the connection between these general diseases and the circulatory organs clear. The presence of micro- organisms has been definitely established in most, if not all, of the acute and subacute diseases of the heart. In many in- stances the introduction of these organisms seems to be the sole cause of the disease, as, for example, in the case of septic endocarditis and septic pericarditis. In other cases, however, it cannot be doubted that double infection is present, as for example in many cases of acute rheumatism attended by endo- carditis, in which the presence of various organisms can be detected upon the diseased valves. The manner in which such organisms act has caused a considerable amount of discussion. It now seems clear that they produce their effects by chemical irritation. Buchner has shown that dead bacteria, or even the protoplasm of which they are composed, will set up changes in the tissues at least as thoroughly as the living organisms. The process is one of positive chemiotaxis with determination of leucocytes to the affected part. The chemical processes set up have a further influence in the prevention of coagulation. To these two methods of action must be added a third, that is destruction of tissue. Under the chemical influences induced by bacterial action the tissues are dissolved and disintegrated. These effects may possibly be due to a peptonising action of the bacteria or their products. These three different factors are associated with the tissue reaction which attempts to curb the influences at work by means of cell proliferation and new formation. On account of the intimate connection which exists between the circulation and some of the most important organs of the body, certain local disturbances exert much influence upon the circulatory mechanism. Two instances PROCESSES. 93 of this fact may be cited in this comiection, albeit they are but examples of what may be found in many other parts of the body. Disturbances of the circulation within the lungs produce great effects upon the right side of the heart in con- sequence of the obstacle to the passage of the blood, while changes in the kidneys, by acting in a similar way, powerfully influence the left side of the heart. Some of the more chronic processes produced by external agencies are at times concerned in the production of cardiac and vascular lesions. Tubercle and syphilis may be referred to in this connection. Both have affinities for the blood vessels, more particularly in .certain regions such as the brain. Both mani- fest also at times a tendency to invade the central mechanism of the circulation. In the invasion of the system by malignant new formations the heart is sometimes attacked. Whatever may be the laws bearing upon this subject, they are at present quite obscure. Peocesses. The various morbid changes which take place in lesions of the heart and vessels must have some consideration from the standpoint of General Pathology, since a brief reference to the processes of disease met with in connection with the circulation will render it more easy to appreciate the nature of the lesions to be afterwards discussed. Degenerative Changes. — The heart, like other muscular substances, undergoes that simple form of degeneration commonly known as cloudy sivelling. In the course of most infective fevers, and also in some local diseases, such as acute Bright's disease, that have a powerful effect upon the general system, the changes summed up under this term are found. They are probably the result of the action of toxic substances which modify the protoplasm. Tjie heart is somewhat enlarged, and has a pale cloudy appearance on section. The appearances observed are a swelling of the cells or fibres which become granular and cloudy, while the nuclei become less distinct. Changes in the distribution of fat occur in very varied conditions, and the effects oi fatty changes wsivj with the different methods in which the tissues are invaded. There may be, in 94 PA THOL O GICAL. the tirst place, an accumulation of fat in those parts which normally contain it, as, for instance, the epicardium. Such deposits may be temporary or permanent. Whether the accumulation is due to excessive supply of fat - producing substances, or to faulty removal, it is impossible to say ; proT)- ably both of these processes are effective in varying degrees. If the deposit is large or long continued, it necessarily impairs the functions of the heart, and is apt to lead to further changes. There may, in the second place, be a deposit of fat in tissues which are normally free of it, as, for example, in the inter- nuiscular tissues of the heart. In the fatty heart, which has just been referred to, there is a great tendency on the part of the epicardial fat to spread between the muscle fibres, more parti- cularly of the right ventricle, and the process may extend as far as the connective tissue underlying the endocardium. These two forms of fatty deposit are usually included under the term fatty infiltration. It is not easy to state the causes of such accumulations of fat, l3ut it must be obvious that there are hereditary tendencies in this direction, while certain habits, including faulty diet and deficient exercise, possess consider- able influence. There is, in the third place, fatty degenera- tion. This differs from the two forms of fatty infiltration in the important particular that the fat is formed at the expense of the protoplasm of the cell. This change may follow in the wake of fatty accumulation and infiltration, but it is produced by a number of processes causing serious disturbance of the nutrition. Amongst the more important of these are («) changes in the blood, as in various forms of cachexia and inanition ; (&) lessened nutritive value of the Ijlood, as seen after profuse haemorrhages and in pernicious antemia ; (c) interference with the vitality of the tissues, as in pyrexia and venous engorgement ; and {d) toxic conditions, whether arising from organisms as in diphtheria, or chemical substances as in alcoholism. The appearance of the heart differs somewhat according as the process is general or localised. When it is general, the entire organ appears paler and softer than in health ; when localised, there are patches of paler colour alternating with others of normal hue, as in the tabby heart of pernicious aniemia. The cellular substance 'is obscured, DEGENERATIVE CEIANGES. 95 and contains fatty globules which may entirely obscure the nature of the tissue and the nucleus of the cell. The proto- plasm is destroyed, and on dissolving the fat out of tlie tissue the cell appears vacuolated. Occurring, so far as is known, as the result of certain coagulative processes, hyaline degeneration is usually oljserved in acute diseases. The muscle substance apparently absorljs some material which has the power of producing coagulation. In certain cases the tissue breaks up into hyaline masses from this coagulative change. This is more especially the case in some of the infective diseases, such as enteric fever and diphtheria. The fibres are, as a rule, broader than the un- changed fibres. The organ on naked eye examination has a somewhat cloudy appearance. Under ordinary circumstances, as has already been men- tioned, the heart goes on increasing in size during the entire lifetime of the individual, notwithstanding the loss of l^ulk undergone by other tissues during advanced years. In many cases of phthisis, and in the course of the cachexia of malig- nant disease, the heart undergoes atro])liy. This must obviously be produced by a diminution in the size of the cellular elements, or by a diminution in their number ; probabl}' in most instances there is both diminution in size and decrease in numbers. These changes must be the result of loss of balance between decay and regeneration. There is a physio- logical limit to the repair of waste, and therefore, when the cells reach the senile stage, atrophy becomes evident. In many such instances there is simple atrophy without degenera- tion. Having played its part a cell disappears from the stage, and its place is not refilled. This is an entirely different process from the wasting produced by degeneration, in which the cells undergo some of the changes which have been referred to, and are either removed or replaced by lower tissues. Deposits of calcium, either in the form of carbonates or phosphates, are often found and are usually associated with some of the salts of magnesium. This process is termed calearcous infiltration. It may occur in senile tissues, especially the vessel-walls — more particularly the intima or the media — in which case infiltration is generally preceded by fibrosis 96 PA THOLOGICAL. or atheroniii. In such a case there must be a previous weakening of the circulation of the part which favours the deposition of lime salts. It is also to be seen in the connective tissue which owes its origin to chronic irritation, as, for example, in the newly-formed fibrous tissue of the pericardium in chronic pericarditis. The nature of the process which leads to the deposition of lime salts is absolutely un- known. Some salts of lime are always present in the blood and lymph, and no more definite hypothesis can be assumed at present than that soluble become altered into insoluble salts. The well-known change usually termed 'pigmentary atrophy is essentially a senile process. With advancing years there is a tendency to the deposition of pigment in several organs, one of which is the heart, but the causation of this process is unknown. In certain localities, such as the liver, the pigment is ferruginous and may therefore be directly obtained from the blood, but the pigment which is deposited in the muscular fibres of the heart is free of iron. It is collected chiefly around the nuclei, in which position it obscures the striation of the cells. It is by no means always confined to old ao"e, and appears as a consequence of cachexia or marasmus. When so excessive as to give rise to a brown discolouration of the heart, it is termed brown atrophy. Eeaction Processes. — Certain acute processes nmst be considered, inasmuch as these changes are found in many different parts of the circulatory apparatus. Whether seen in the serous membranes, muscular substances, or connective tissues, they give rise to some of the most noteworthy dis- turbances of the circulation. All these changes must be reo-arded as the reaction of the tissues to irritation, and the processes present a uniform type, varying without doubt in deo-ree but not in kind. Such reactions are only possible in tissues containing blood vessels or in close connection with them. The changes present two different aspects for observation, one of which may be termed exudative, the second proliferative. The exudative process is more particularly seen in connection with the blood vessels, and marks the earlier stages. The exudation of coagulable lymph takes place attended by the DEGENERATIVE CHANGES. 97 presence of some leucocytes and red corpuscles. The prolifera- tive process occurs at a later stage and is observed in the endothelium and connective tissue, as well as in the blood vessels. The connective tissue cells multiply, as do also the endothelial cells. The products of proliferation undergo a change into fresh connective or fibrous tissue. These reaction processes differ considerably according as the seat of the process is upon a membrane, like the pericardium, which is rich in blood vessels ; or one like the endocardium, covering the valves, which has few or no blood vessels ; or in a muscular structure like the myocardium, in which the Ijlood supply is extremely free. In the pericardium the dilatation of the arteries and the increased velocity of the blood, followed by dilatation of capillaries and veins with retardation of the current, marginal arrangement of leucocytes, and diapedesis, lead to exudation. In the endocardium covering the valves, such processes are greatly modified, not only by the small number of vessels ramifying in the parts, but by the mechanical arrange- ment of the cusps ; in connection with the valves, never- theless, considerable exudation may be seen, leading even to fusion of the cusps. The changes occurring in the myocardium are modified by the special structure of the tissue in which they take place. Acute processes usually produce enlargement of the nuclei, or even proliferation, but without karyokinesis. The muscle cells are swollen and lose their transverse striation ; they are usually altered in outline and are probably softer than in health. There is a swelling of the intermuscular substance, which may be invaded by leucocytes and form the starting- point of an abscess, or may be the seat of newly-formed fusiformed cells going on to the production of fibrous tissue. The further processes as regards the changes undergone by such a serous membrane as the pericardium may be noted. Part of the fluid exudate which is poured out coagulates, and may form a regular membrane upon the surface. The serous effusion which follows is due to the exudation of a fluid less coagulable, possibly on account of some inhibitory influence exercised upon it by products of bacterial activity. If there be great emigration or proliferation of leucocytes" with a small tendency to coagulation, the exudate becomes purulent. 7 98 PATHOLOGICAL. Many of the cells \vhich are present in pus are dead or even degenerated, but numbers of them still preserve amoeboid riiovements and act as phagocytes. In certain cases there may be excessive diapedesis of red corpuscles, possibly due in great part to the severity of the exciting cause or to lowering of the resistance of the tissues. It is to l)e remembered, however, that mechanical injuries or malignant invasion may be the cause of such hpemorrhagic exudations. The proliferative changes go on imri 'pamu with some of those which have been considered, but no doubt they are best seen when the exudation is passing away. Such proliferative changes may be present to a smaller or a greater extent. They may lie present only in slight degree, and recovery may take place by resolution. They may, on the other hand, be present to a much greater degree, when repair occurs by means of proliferation. In many of the stages of proliferative repair phagocytosis is still seen. Occasionally these acute processes manifest destructive tendencies. The extent to which they take place depends upon the relative activity of the irritant and the reaction of the tissues. If proliferation is able to make headway, young connective tissue is formed and the process is brought to an end. If, on the other hand, the irritation is more powerful than the resistance of the tissues, ulceration results. Some of the secondary results of such processes require also brief mention. The processes produced by organisms are apt to be followed by remote effects in distant regions. The organisms or some of their toxic products may not remain localised, but be carried from the seat of the lesion either by the lymphatics or the blood vessels. In croupous pneumonia, for example, the pneumococcus may be carried to the peri- cardium or endocardium. In endocarditis, streptococci may be carried to the kidney or other organ, and in this way secondary infection may be set up. Bacterial emboli may enter the venous channels at any point and find a temporary stopping- place on one of the cardiac valves, producing there infective endocarditis, whence a shower of bacterial emboli may be distributed through the whole body. There are several chronic processes due to irritation which vary considerably according to the tissues in which they COMPENSATION. 99 take place, and to the extent of the irritation. In the case of a serous membrane, chronic irritation results in thickening, sometimes with a considerable amount of contraction, often witli a large amount of newly-formed fibrous tissue, and occasionally with a deposit of lime salts. Chronic processes taking place within the myocardium are characterised by the large amount of fibrosis which occurs. The fibrous tissue separates and compresses areas of muscle fibres, constituting what is commonly known as chronic inter- stitial myositis. Such chronic processes are essentially hyper- plasias of the connective tissue. The processes of repair in the higher animals are vastly inferior in their scope to those found amongst more lowly forms of life, inasmuch as regeneration only takes place by the production of certain elements of the tissue instead of the growth of entire organs. Epithelial and connective tissues are the results of reparative processes. In regard to the circulatory organs this is directly true, and destruction of any part is only made good by the growth of the less specialised tissues. The repair which takes place in the serous membranes may be largely homologous. In the muscular structures it can only be heterologous. Compensation. — Hypertrophy may be regarded within physiological limits as a process of adaptation ; in pathological circumstances it must be looked upon as a process of compensa- tion. All structures may increase in size under certain condi- tions, pathological or physiological, and if such enlargement takes place without any structural changes, the process is termed hypertrophy. Every part of the healthy body possesses considerable reserve of energy. In health, the demands made upon the various organs are far below their possible responses, and, if calls on their functional activity are sustained, they adapt themselves. Under abnormal conditions, the process of hyper- trophy is produced by the power which the different structures of the body possess of responding to the demands made upon them by readjustment of the tissues, and so long as this process of hypertrophy is adequate all symptoms of disturbance may be absent. An excellent example of such readjustment is to be found in chronic cirrhosis of the kidneys attended by loo PATHOLOGICAL. increased thickness of the middle tunic of the arteries and hypertrophy of the left ventricle. IfEPAii;. — llestitution or reco^^ery may without doul.)t occur in serous membranes. j\Iany cases presenting absolute proof of pericarditis are found at later dates to have no trace of any structural change. It is possible that the same thing may occur in endocarditis, and in another place attention has Ijeen given to the subject. When, however, such a structure as the myocardium undergoes structural alteration, absolute restitution is out of the question. In interstitial myocarditis, for instance, there is, as a result of the process, a development of fibrous tissue in which the newly formed tissue impairs the strength of the heart, and may produce the most serious symptoms. Eesults. Disturbances of the circulation are the results of a large number of individual factors, but when these are carefully analysed it is possible to arrange them in a limited number of groups. Disordered conditions of the circulation owe their origin to factors producing their chief morbid effects respectively upon the heart, the blood vessels, and the blood. It is no doubt true that many causes operate by influencing more than one, sometimes all, of these structural divisions of the circulatory mechanism, yet it is convenient, and even necessary, to classify the various agencies for the purpose of thorough investigation. Feom Distukbances connected with the Heart. — The equilibrium of the circulation may be disturbed by many pathological factors having their origin in, or acting directly upon, the heart. Pericardicd. — Some of these causes interfere with the functions of the heart by pressure from without. The best example of this class is to be found in pericardial ettusion. It is a well-known clinical fact that serous pericarditis causes considerable embarrassment to the course of the blood. Adamkiewicz and Jacobson have shown that in healthy conditions there is a negative pressure of 3"5 mm. Hg. in the pericardial sac. When there is any considerable effusion, RESULTS. loi however, this negative pressure becomes positive ; and Cohn- heini proved by experiment how such a positive pressure interferes with the circulation. By connecting one of the veins of the neck with a soda manometer, and one of the carotid or femoral arteries with a mercurial manometer, Cohn- heim provided the means of observing the effects of pericardial pressure on the venous and arterial flow. The pressure in the sac was varied by connecting the parietal pericardium with an oil manometer. The pressure in the sac might be raised to 30 or 40 mm. of oil without any change in the vascular pressures, but if the oil manometer showed a pressvire of 60-70 mm. there was a fall of arterial pressure of about 20-30 mm. Hg. and a rise of venous pressure of about 60 mm. Na ; an intrapericardial j^ressure of 100-120 mm. oil, produced a great fall of that of the artery, while that in the vein rose to a high level. By increasing the pressure of oil still further, the arterial curve fell to zero, while that of the vein rose higher still. If the experiment was not continued too long the normal conditions could be restored on relieving the pericardial pressure, the first effect being that the arterial curve rose to a higher level than previous to the experiment, before resuming its normal height. Starling has repeated Cohnheim's experiment, with two modifications. In the first instance, he estimated simultane- ously the pressures in the inferior vena cava, in the portal veins, and in the arterial system, under the influence of peri- cardial injections. In the second place, he observed the effects of such injections on the volume of the limbs. In the first set of experiments cannulas were connected with a splenic vein, an iliac vein, and a carotid or femoral artery. The cannulse attached to the veins were connected with mano- meters filled with a coloured solution of sulphate of magnesium, while the arterial cannula was connected with an ordinary mercurial manometer. After the attachment of the mano- meters, the chest was opened in the middle line, and a cannula tied into the pericardium, for the injection of oil by means of a graduated burette. In one such experiment the following results were obtained : — PATHOLOGICAL. Carotid. Sl>lenic. Iliac. Hg. MgSU4. MgSOj. mill. Illlll. Illlll. Before inject ion of oil 90 128 36 After 20 cc. oil . 90 128 36 „ 40 )) 90 128 40 „ 60 j> 90 128 58 „ 70 )) 134 76 „ 90 )) 56 IGO 124 „ 100 H 18 215 215 After escape of oil 146 322 36 Later 84 148 40 This experiment shows that but little intiuence was exerted on the pressures until 20 cc. of oil had entered the pericardium, and that the limits of compensation possessed by the heart and vascular system for the hindered diastolic expan- sion were only reached when 70 cc. of oil had been injected. The possibilities of diastolic expansion came to an end when 100 cc. of oil had been injected. Some of the results are rather difficult of explanation, and perhaps this is especially the case as regards the enormous rise in arterial pressure which occurred directly after the recommencement of cardiac activity. It is, however, probable that at the point when the heart stopped the arterioles were in a state of constriction, and that when the heart, richly supplied with blood from the dis- tended venae cav^e, propelled this into the arteries, it had to overcome the resistance in the arterioles. The other series of experiments performed by Starling was devised in order to ascertain the effects of pressure changes on the A'olume of the limbs. An experiment similar to that above referred to was carried out, while at the same time the limb was enclosed in a plethysmograph. In this experiment it was found that, while the arterial pressure remained constant, practically no change occurred in the volume of the limb, although there was a rise of jpressure both in the portal veins and vena cava. A'^Tienever compensation became insufficient and the arterial pressure conmienced to fall, the volume of the limb diminished. The volume of the limb, and probably the pressure in its smaller vessels, is therefore directly proportional to the arterial pressure, and is not altered by considerable changes in the venous pressures consequent on heart failure. PERICARDIAL— ENDOCARDIAL. 103 The conclusion seems to be obvious that even with vascular constriction the effect of heart failure must be a fall and not a rise of blood pressure in the capillaries and smaller veins of the limbs. This conclusion is at variance with the view usually accepted, for the most part on the authority of Cohn- heim, that failure of compensation in heart disease produces a general rise of venous and capillary pressures in all parts of the body, at least in brief interferences with the conditions of the circulation. When they are long continued other influences come into operation. Starling has further set himself to ascertain whether any of the conditions in heart failure might lead to plethora suffi- cient to raise the venous and capillary pressures in the limbs in the absence of any arterial rise, and has come to the conclu- sion that the results of a number of observations on cases of cardiac failure lend no support to the view that failing com- pensation is attended by plethora. The results tend rather to show that the amount of blood in the circulation is below the normal, . and that there is a condition of hydrsemia, not of plethora. The conception that the pressure in the capillaries and veins all over the body in failure of compensation is elevated must be renounced, as the pressure must follow the arterial pressure and be lowered. There are other causes of interference with the heart functions by pressure from without. The existence of any considerable aneurysm or tumour within the chest produces a similar effect, and pleural effusion or pneumothorax has the same result. Such causes are operative by hindering the return of blood to the heart, and this is effected by interference with its aspiratory or suction-pump action. External causes may further interfere with the systole of the heart. In adherent pericardium, for example, there may be considerable hindrance to the contraction of the heart, in other words, the force-pump action is retarded. Endocardial. — When the internal mechanism of the heart is disordered another group of causes comes into play. Valvular affections, by obstructing the outlet, or by allowing escape back- wards, lead to much disturbance. In the case of any orifice which has been narrowed by disease, whether from endocarditis or 1 04 FA THOLOGICAL. degeneration, there is a hindrance to the liow of the blood through it, and, unless the obstacle is in some way overcome, there must be a lessened current through the opening. The valves closing the orifices of the heart may be incom- petent from several causes. The cusps themselves may be in fault, on account of some endocardial change which has caused them to shrivel up. The orifices may, on the other hand, have become too large for the cusps to be adequate. It is possible, moreover, that when, without any stretching of the orifices, there is dilatation of the ventricles, the cusps cannot accurately close the auriculo-ventricular openings on account of lack of adaptation of the different parts of the mechanism — papillary muscles, chordte tendineffi, and valvular segments. In both these lesions, obstructive and regurgitant, the outward flow of the blood is lessened — in other words, the force-pump action of the heart is hindered — by an obstacle to the onflowing current, or a loss of part of it backwards. The attractive force of diastole is also interfered with directly or indirectly ; obstruction, at any rate at the venous valves, prevents the full aspiratory action, while regurgitation by the backward escape causes some of the blood to be drawn towards the heart more than once. Myocardial. — There are also causes operative through weakness of the walls of the heart. Such processes are almost invariably secondary to diseased conditions elsewhere. To this class belongs myocarditis, both in its acute and chronic forms, but more commonly the latter ; the various degenerations, fatty, pigmentary, and hyaline, as well as the cloudy swelling often present in acute diseases, and the fragmentation which may occur in them ; together with simple debility of the muscle, from acute or chronic disorders of the nutritive functions. Disturbance of the coronary circulation is followed by inevitable changes in the muscular substance of the heart. If there is any diminution in the calibre of the coronary arteries, there is certain to be a degeneration of the myo- cardium, and if septic emboli reach their distriljution, septic myocarditis is an invariable sequel. It has already l:)een shown in the previous section that experimental pathology has so far thrown a somewhat uncertain light upon the facts of RESULTS ON THE CIRCULATION. 105 sudden death and angina pectoris ; it is nevertheless an undeni- able fact that the entire adequacy of the heart depends upon the integrity of the coronary circulation. Eesults of these Disturbances. — All processes which lessen the energy of the muscular substance of the heart have a twofold effect. They diminish the aspiratory or suction-pump action of the heart during diastole, and also, to a proportionate extent, lessen its expulsive or force-pump action during systole. It follows that such lesions as those just referred to, which give rise to a reduction of the energy of the heart, both as regards aspiration and expulsion, have effects of far-reaching consequence upon the entire circulation. It has already been shown in the physiological section, that the energy produced by the heart appears partly as the potential energy of the distended arteries, partly as the kinetic energy of the moving blood. The work done by each cardiac systole may be estimated from the formula previously given — where W stands for work, B for amount of blood expelled at each systole, E for arterial pressure, and v for velocity of blood. As was previously demonstrated, velocity may be disregarded in considering pathological changes as affecting the work of the heart. Any real increase in its work can only be produced by an increase in one or both of the two factors B, E, that is to say, in the amount of blood expelled, or the resistance offered, by arterial pressure. Most cases of heart disease present an increase in one or both of these factors. In aortic obstruction, for example, E may be largely increased. In aortic regurgita- tion, on the contrary, E may be diminished, but, as during diastole the ventricle receives blood from both sides, and in compensation the heart expels almost all the excess of blood which it has received, there is an increase in B. When obstruction is associated with regurgitation both B and E are increased. The healthy heart has a large amount of reserve power, as Cohnheim has shown, and can therefore answer to greatly increased demands by doing more work. This power of 1 06 PA THOL GICAL. adaptation may Ijg tested by the experimental imitation of pathological conditions. The resistance to be overcome l)y the heart may be increased three or four times without causing any cliange in the amount of blood expelled at each lieat. A ligature may be placed round the pidmonary arteries or the aorta, and the lumen of the vessel may be reduced to one-third of its size without materially interfering with the arterial pressure. If a manometer, however, l)e connected with the cavity of the ventricle, it is found that tlie amount of energy which it is exerting is increased to three or four times its normal amount. Instead of increasing the resistance to the outflow the inflow may be experimentally increased l)y destroying the semi- lunar cusps, in which case but little disturbance is produced in the blood pressure, although the amount of energy of the ventricle is greatly increased as tested by the manometer. Experimental observations have shown that on exciting the peripheral end of the divided vagus, the heart is slowed, the diastole lengthened, and the amount of blood expelled at each systole augmented. There is nevertheless a fall of arterial pressure, and the increased outflow is not proportional to the diminished frequency of the heart ; E and B being both lessened, the work done by the heart is therefore diminished. On stimulating the nerves which reach the heart through the sympathetic system, the heart is quickened, the diastole shortened, and there is often a rise of blood pressure. In almost every case of such stimulation of the sympathetic system the outflow is raised above the normal, so that the work done by the heart is increased. These nerves may be thrown into action by the medullary centres by direct or reflex influences. The most important are probably those reflex influences taking their origin in the heart itself, which, acting reflexly on the medullary centres, bring about inhibition or acceleration of the heart, or a rise or fall of blood pressure. Starling j^oints out that these reflex mechanisms are not so much directed to com- pensation of vascular disorders by increased efforts, as to sparing the heait by the production of some reflex effect counteracting the original disturbance. A sudden rise in arterial blood pres- sure, for instance, greatly increases the work of the ventricles, POWER OF ADAPTATION. 107 but any such rise of arterial pressure is accompanied by a slowing of the heart in consequence of stimulation of the vagus centre. The stimulation may Ije partly the effect of the high pressure of the blood circulating in the brain, partly a reflex influence from the heart itself The power of adaptation possessed by the cardiac muscle is apparently closely associated with susceptibility to tension. Whenever increased work is thrown on the heart muscle the contraction is preceded or accompanied by increased tension of the muscle. In aortic stenosis, for example, the increased tension occurs during contraction. In aortic regurgitation the increase of tension is present just before the contraction in consequence of the increased diastolic filling of the heart. When other forms of contractile tissue are examined an increased tension or increased resistance acts as an additional stimulation, so that the contraction occurring under such conditions is more powerful and more extensive than under ordinary circumstances. The effect of this tension in increas- ing the energy of muscular contraction is more strikingly shown if the increase is applied before the beginning of the contraction. This subject has recently occupied the attention of Horvath, and his views will be fully discussed in the chapter dealing with hypertrophy. One most interesting proof of this is found experimentally. If the lower third of the ventricle of the frog be isolated physiologically by crushing a ring of tissue between it and the upper part of the ventricle, it will not beat again under normal conditions, but it may be caused to beat rhythmically on clamping the aorta, so that there is increased intraventricular pressure and augmented tension of the muscular fibres. Dilatation of the cardiac cavity is a very common sequel to valvular disease. It may occur under conditions perfectly physiological. The experiments of Eoy and Adami, as well as of Johansson and Tigerstedt have showai that the ventricles are never under any circumstances emptied by their contrac- tion, and his researches have shown that the amount of blood remaining in the ventricle depends on, first, the resistance in the arteries, second, the diastolic filling of the ventricles. There is a constant increase in the systolic volume of the heart if io8 PATHOLOGICAL. there be any rise of arterial pressure or any increase of the ■(.liastoKc intlow. In all tliese cases, whether there be diminished aspiratory or propulsive energy, the result is a diminution in the amount of blood in the arterial, and an increase in the venous system. It does not follow as a necessary consequence that because there is less blood in the arteries the pressure of blood within them will be diminished, nor is it necessary that the venous pressure will Vie raised because the veins contain more blood — the blood pressure depends upon too many factors for such effects to be the inevitable consequence of changes in the amount of blood. It is quite possible, as Thoma says, on the authority of Worm jMliller, that the blood pressure may not be altered, notwithstanding a change in the amount of blood, since the vascular tone may be so modified as to equalise the alteration in the quantity of blood. As a matter of fact, however, the comparative distension of the veins and the I'elative emptiness of the arteries produces a con- siderable alteration in blood pressure, the arterial falling while the venous rises. The consequences of the venous distension is to allow the hccmostatic factors to overcome the hemodynamic, and in consequence of the venous engorgement several effects become manifest. On account of transudation there is oedema into the dependent parts of the body and dropsy into the great serous sacs. From the slowness of the current the blood absorbs too much carbonic acid, and is depri^'ed of more of its oxygen than is the case under healthy circumstances ; as a consequence, cyanosis results. And also on account of the slowness of the circulation there is a longer period of radiation of heat from the surfaces ; the superficial parts of the body, therefore, become cold. If the processes are unchecked, hypostasis is the inevitable result. "V\Tien subjected to long-continued engorgement the liver liecomes enlarged and assumes the appearance commonly termed the " nutmeg liver." In consequence of the venous stasis in the radicles of the hepatic vein, there is interference with the distrilnition of the blood brought by the portal circulation, in addition to stagnation of bile in the ducts. From the interference with their functions, simple atrophy and STRUCTURAL RESULTS. 109 fatty degeneration take place in the hepatic cells. From the fatty degeneration in the circumference of the lobule, it has a white border contrasting with the ruddy tint of the engorged hepatic veins and the yellowish hue of the oljstructed ducts ; hence the name by which this condition is commonly known. It has been held that in addition to these changes hyper- tropliy of the connective tissue arises, but, when this occurs, it is usually the result of concomitant causes, and it is proljably, as Coats says, a mistaken view that cirrhosis of the liver arises simply out of passive hyperemia. Infarction of the kidney is frequently found. Infarcts are usually of a pale colour and dense consistence. From coagula- tion necrosis there is seldom much heemorrhage, but a little commonly occurs at the margin, or even, if its area be small, the htemorrhage may extend throughout the whole infarct, while, around it, there is a zone of hyperemia. When haemoptysis occurs on a large scale, it is almost invariably the result of rupture of the capillaries in the alveoli. A great amount of discussion has been devoted to hemorrhagic infarction of the lung, into which it is impossible in this connection to enter. It may, however, be said that such infarction appears from the researches of Panum and Cohn- lieim not to be of embolic origin, but usually from rupture of the alveolar capillaries, the so-called pulmonary apoplexy, as it is often absurdly termed. The opinion that pulmonary infarct takes its origin in emboli arising from coagulation within the right cavities of the heart is founded on simple speculation, and is, according to Hamilton, a theory of the most unwar- ranted character. My own opinion is, however, that it may often be produced by thrombosis. In the majority of cases the vessel is found to be blocked by a coagulum. Effusion into the serous sacs takes place under conditions somewhat similar to those which obtain in the subcutaneous tissues, but there are necessarily some points of difference. Starling and Leathes attempted to produce pleural effusion by an increase in the capillary pressure. As the blood returning from the pleura has several different channels, the only possi- bility of producing a rise of capillary pressure is by the injection of large quantities of normal saline solution into no FA THOL GICAL. the circulation, but, in addition to employing this method, .they also made at the same time an attempt to increase the rise of pressure by obstruction of the vena azygos and thoracic duct. The result was a large amount of oedema in the retro- peritoneal tissue and in the posterior mediastinum, but the pleural cavities only contained 2 or 3 cc. of fluid. The injection of small quantities of jequirity into the pleural cavity gave rise to endothelial changes, and the injection afterwards of large quantities of normal saline solution into the circulation produced a great transudation of fluid through the injured capillaries into the pleural cavities, and death by asphyxia. The hydrothorax of heart disease seems, therefore, like the oedema of the limbs, to be dependent in the first instance on an increased permeability of the vessel, produced by the stagnation and poor quality of the blood. The peritoneum has two separate capillary systems, one or both of which may produce ascites : — the capillaries of the spleen and alimentary tract forming the radicles of the portal vein, and the hepatic capillaries ending in the hepatic vein. From the experiments already described it has been shown that there is a considerable difference as regards their per- meability, as well as in the effect of various changes of the circulation on the pressure within them. Cardiac failure, for example, produces a rise of pressure in the hepatic capillaries, and a fall in the intestinal capillaries. As regards changes in the portal system of capillaries, it seems probable that the result of increased flow of lymph depends on the condition of the endothelium of the peritoneum. Ligature, for example, of the portal vein causes a great increase of the flow from the thoracic duct, but very slight transudation into the peritoneal cavity. If, however, the permeability of the capillaries is in- creased, as may be done, by plunging some coils of intestine into hot water, or even distilled water at the temperature of the body, there is a considerable transudation into the peritoneal cavity, although the lymph flow from the thoracic duct is scarcely affected. It seems probable that in heart disease the most important source of ascites is the liver. In one of Star- ling's experiments ligature of the thoracic duct and obstruction of the inferior vena cava above the liver, followed by the produc- COMPENSA TION FOR DISTURBANCE. 1 1 1 tion of hydriemic plethora through the injection of 15,000 cc. of normal saline solution, produced 100 cc. of ascites. In another experiment the hepatic lymphatics were ligatured as they emerged from the portal fissure and a hydremic plethora produced in the same way ; this was followed by the presence of 2 3 cc. of ascites. We know that the capillary pressure in the liver is considerably increased in heart disease, and we are warranted in concluding that the chief source of ascitic fluid in such affections is to be sought in the capillaries of the liver. Compensation foe these Disturbances. — The heart, having considerable reserve of energy, in most cases is able to meet minor degrees of disturbance of its functions successfully. If such disturbances, however, are permanent, so that the organ is subjected to continuous stress, certain changes in function and structure take place, whereby it is enabled to overcome the strain. The processes by which these changes are brought about unfold themselves gradually, and they are, therefore, not always obvious. Many of them may, nevertheless, be traced during their gradual evolution, and there are but few gaps in our knowledge which require to be filled up by inference instead of by observation. The various changes which ensue are summed up under the term " compensatory." It has been said above that by means of its reserve of energy the heart is able to deal successfully with lesser dis- turbances of the circulation, and Cohnheim and his followers proved that even considerable changes in the mechanism of the heart may be produced without disturbing the equilibrium of the circulation. It is a subject of the highest import that after destruction of the aortic cusps in the dog there was no change in the arterial or venous pressure. On the production of stenosis, whether of the aortic or pulmonary orifice, or, to be more correct, of one of the great arteries immediately beyond these cusps, the arterial and venous pressures were found to remain completely unchanged until the stenosis was carried to a very considerable extent. But when this point was passed the arterial pressure underwent a sudden fall, while the venous pressure rapidly rose. From such experiments, which have been repeated more recently by 112 FA THOLOGICAL. Ptosenbach, much has been learned. They prove absolutely that the heart is endowed with a considerable margin of energy. They show, moreover, the influence of destruc- tion on the character of the individual pulsations. The narrower the lumen of the vessel, and the higher the cardiac pressure, the more amplitude do the single contrac- tions acquire. At first, as Cohnheim showed, these greater pulsations do not occupy more time than the normal pulsa- tions did before the commencement of the experiment, but, when they exceed certain limits, they cannot be maintained without more time being occupied by each of them ; i.e., the pulsations become larger, and also, at the same time, less frequent. But the consideration of the artificial stenosis places before us the explanation of some other points connected with compensation. The extent of the stenosis may be increased, and the resistance, consequently, intensified, yet the heart overcomes those and expels as much blood as previously, so that the mean arterial and venous pressures are maintained at their normal height. But when the resistance becomes too great, so that the contractions of the heart are unable to over- come it completely, the circulation comes absolutely to an end. The experiment upon positive pericardial pressure described by Cohnheim and previously referred to, stands in marked con- trast to those artificial valvular lesions. As previously said, it shows that when there is a hindrance to the afflux of blood to the heart, there is from the first a change in the relative arterial and venous pressures. The explanation of this is simple. When a smaller amount of blood is allowed to reach the heart and to be sent on into the arterial system, there is of necessity a state of relative overfilling of the venous, and of relative underfilling of the arterial vessels. And there is, in this case, no adequate provision to meet its requirements. It is abundantly clear, from a consideration of the relative force of suction and of expulsion, that a very much smaller dis- turbance will interfere with the former than with the latter. In the case of lesions of the orifices and valves, there are some other considerations wdiich require attention. In such lesions provision is made for a larger quantity of blood in the COMPENSA riON FOR DISTURBANCE. 1 1 3 chambers of the heart. The blood is expelled from the heart less frequently, although with greater force, and it therefore must follow that a larger quantity is allowed to accumulate in the chambers during diastole. The heart must, therefore, undergo a considerable amount of distension, just as happens in the case of all hollow viscera, such as the stomach, when their contents are retained for a longer period than usual. In order to overcome the various obstacles with which we have been dealing, the heart acts with more energy. In all cases where the heart is able to survive any damage it may have sustained, it must have been primarily endowed with that reserve of energy which has already been spoken of ; and if the disturbance to the circulation were transient, this in itself would be sufficient to maintain the balance. Most of the lesions to which the heart is subject are permanent in their effects, and compensation is carried out by means of another process. This is hypertrophy of the walls of the heart. Speaking generally, it may be said that hypertrophy may be total or partial, according as the disturbance affects the whole heart or only a part of it. When there is a call for additional energy on the part of the entire heart, as in synechia of the pericardium, the walls of each chamber become increased in thickness, in consequence of the increased energy which it manifests. If there be, on the other hand, a disturbance affecting only one chamber, that particular portion chiefly undergoes hypertrophy. It cannot be said that each individual chamber is alone affected, for, as Gairdner showed long ago, such a thing as hypertrophy affecting one chamber alone is practically unknown. When there is hypertrophy of one side of the heart, the other is usually to some extent involved. It is unnecessary in this place to tread the well-worn path of the usual series of events in compensation for valvular disturbance. The entire subject will be discussed in a future chapter. When there is any lesion at the aortic orifice, whether it be obstructive or incompetent in its nature, the additional stress so produced falls of necessity for the most part upon the left ventricle, and it therefore becomes hypertrophied to meet the obstacle. If there be a lesion of the mitral orifice or its cusps, the walls of the left auricle become thicker. In the 114 PATHOLOGICAL. case of the puliuunaiy uiitice or valves, it is the right ventricle which increases in bulk ; and when the tricuspid orifice or its valves are abnormal, the right auricle undergoes hypertrophy. "When there are combined lesions of the orifices or valves, there are of necessity combinations of hypertrophy. Hypertrophy is only possible when the nutrition of the heart is good. It can only, therefore, occur when there is an adequate supply of healthy blood, and this necessarily means that the lilood itself nnist be healthy, and that the coronary arteries must be sufticiently pervious to allow an adequate supply of such healthy blood to reach the heart muscle. The process of hypertrophy is therefore subject to individual limits, when nutrition is at a low level it may fail to appear ; when there is any inherent narrowness of the lumen of the coronary arteries its extent is circumscribed. In every instance, the end at last comes when the heart has outgrown the nutritive possibilities granted by the conditions present. It has often been held that there is no hypertrophy without a certain amount of fatty degeneration. This, as Hamilton has pointed out, is probably a grotesque exaggeration ; yet it cannot be gainsaid that, at the end of a long existence of hypertrophy, some fatty degeneration steps in. It is the only argument in favour of the view recently expressed by Meigs that compen- satory hypertrophy has no existence. When a heart has outgrown the nutritive possibilities with which it is endowed, there is said to be failure of compensation. This may be general or it may be local. From Disturbances connected w-ith the Blood Vessels. — It has already been seen that the blood vessels are endowed in various degrees with contractility and elasticity. The contractility of the blood vessels entirely depends upon the state of the muscular coat. As was seen in a previous section, the muscular tissue of the blood vessels is char- acterised by a high degree of tonicity, and a considerable development of rhythmic action, while rapidity of contraction is almost absent. The elasticity of the blood vessels is not to be regarded as an independent force, but simply as a means of storing energy in a potential condition which may be liberated in the kinetic form when required. VASCULAR DISTURBANCES. 1 1 5 It has further been seen that the blood vessels ai'e supported in various degrees by the tissues in which they run, according to their different situations. This fact, long ago pointed out by Bonders, and recently insisted on by Hamilton, is apt to be lost sight of in considering the functions of the blood vessels. The different degree of support afforded by the tissues in different parts of the body explains how it is that certain blood vessels are more liable to destructive changes than others. In the brain and lungs, for example, the vessels have not, by any means, the same amount of support as they have in the more solid or firm viscera, and it is in these situations that vascular disasters are most common. As part of the natural processes resulting from advance in years, the contractility and elasticity are apt to diminish, while, at the same time, the support afforded by the tissues fails on account of shrinkage. It is perfectly true that such events take place at very different periods in different persons : in one the blood vessels appear to be endowed with such a degree of vitality as to exist in a comparatively healthy condition until an advanced age has been attained ; while in another the blood vessels undergo retrograde changes in comparatively early years. This well-known fact has given rise to the epigram that " a man is as old as his blood vessels." The facts which we know as to changes in the condition of contractility and elasticity are mostly connected with con- ditions in which these are diminished. Long continued stress of the blood vessels induces thickening of the intima, wasting of the muscular coat, and stretching of the adventitia. In consequence of these changes both contractility and elasticity are gradually lost. This has been well recognised since the days of Boerhaave, who described changes in the walls of the great blood vessels in deer which had been allowed to live in a wild condition, while the same animals reared in confinement showed no such changes. These facts, accepted and expanded by numerous writers, form the earliest observations upon this subject. When the normal properties of the arteries are interfered with, there is a natural tendency by which some of the effects 1 1 6 PA TJIOLOGICAL. are minimised ; an increased growth of tibrous tissue takes place, constituting tlie process known as fibrosis. It must be regarded as a compensatory change, whereby the walls of the l)lood Vessels are strengthened in order to support the stress which they have to endure. Thoma holds that the result of these changes is an increase of elasticity. This has been objected to by me. AVhat occurs is that greater rigidity takes the place of lessened elasticity. It is in truth a singular con- ception that increase of elasticity should be the precursor of dilatation or rupture of the arterial walls. In several diseases there are characteristic changes in the blood vessels which are scarcely to be regarded as belonging to the compensatory category. In the uric acid diathesis there is undeniably a great tendency to increase of fibrous tissue, and later to the deposition of lime salts in the walls of the blood vessels. In the tertiary stage of syphilis, and in some chronic renal conditions, there is also a characteristic endarteritis obliterans. Both these processes involve, at a later stage, various interferences with the circulation. Elasticity and contractility cannot be held to attain any point of development at any time above the normal, but, as was seen before, both are at their highest level when the blood vessels are full and high pressure is present. We know much less of conditions in which peripheral resistance is diminished than of those in which it is increased. We are able to observe, nevertheless, that, just as external warmth dilates the blood vessels and lowers the blood pressure, so when the initial stage of pyrexia has passed away the resistance is diminished. Loss of blood and wasting diseases also lead to a similar reduction of resistance. In considering the changes in the blood vessels, we have hitherto dealt only with conditions having their origin in these vessels. It is necessary to cast a rapid glance at some of the changes in which, from alterations in the structure of other organs, modifications of tlie circulation are produced through interference with the blood \'essels. Since the writings of Briglit it has been recognised that changes in the circulation are produced Ijy chronic disease of tlie kidney, and, as was shown l)y Gairdner, there is considerable inter- VASCULAR DISTURBANCES. n? fereiice with the circulation in chronic bronchiti.s und emphysema. Other puhnonary conditions, such as induration, silicosis, and collapse, also interfere with the circulation in the blood vessels. It is a most interesting fact that in phthisis pulmonalis there is comparatively little interference, and this has received adequate explanation by the experiments of Lichtheim. Lichtheim found that by tying the left branch of the pulmonary artery there was absolutely no change in regard to the pressure of the blood in that vessel. He was aljle even to occlude several branches of the right pulmonary artery before such a change ensued. We may, therefore, assume that nearly three-fourths of the sectional area of the pulmonary blood vessels may be absolutely obliterated without producing any change in the blood pressure ; the reason for this is not far to seek — it depends upon the remarkable ease with which the pulmonary blood vessels dilate. In Lichtheim's experiments, the whole of the blood normally Ijassing through the entire pulmonary vessels passed with perfect ease through the third or fourth part of these blood vessels not interfered with by his experiments. The effect of the various changes which have been con- sidered is to throw an extra amount of work upon the heart, in order to overcome the increased resistance, and the effect upon the heart is hypertrophy. In their simplest form, i.e. loss of arterial distensibility, elasticity, and contractility in elderly people it explains why the heart, alone of all the viscera in the body, goes on progressively increasing in size with the advance of years, as was first shown by Bizot and afterwards explained by Perls. Some of the special effects which have just been referred to have been carefully studied by Hamilton, and will be fully discussed elsewhere. When the peripheral resistance is diminished, the heart, as is well known, has a tendency to race, and unless it be checked it is liable to run down. The nervous system in such cases, however, fortunately steps in and relieves the heart from the excessive waste of energy involved in continued increase of rate. And when this is not the case, if the inhibitory nerves do not reduce the rate of the heart within moderate limits. 1 1 8 FA THOL O GICAL. that organ rapidly undergoes destructive changes. It is well known that in such febrile diseases as enteric fever, a high pulse rate is a prognostic sign of evil omen. When arterial sclerosis is found throughout the body the coronary arteries of the heart frequently undergo the same change, and if it is sufficiently extensive to produce diminution of the blood supply to the heart, degenerative changes result. The most common of these degenerative changes is fibrosis. But fatty changes are also of frequent occurrence, either alone or in combination with a certain amount of fibroid degeneration. The results of experiments on the coronary arteries do not afford us much assistance in studying these chronic changes, for they are not only, as was already seen, somewhat difficult of explana- tion in themselves, but they also cannot be held to throw any light upon a gradual and long continued process such as coronary sclerosis. One other effect of vascular changes must be referred to. The distribution of arteries to the papillary muscles, as originally shown by Swan and recently insisted on by Fenwick and Over- end, is terminal in arrangement, and, if there be any change in one part of the arterial supply, there is no possibility of compensatory supply from adjacent vessels. This must be regarded as the reason for the frequency with which the papillary muscles undergo degenerative changes in many diverse conditions. Fro]\[ Disturbances connected avith the Blood. — The con- dition of the blood constantly varies in consequence of the tissue changes throughout the entire system. It is undeniable that a condition of oligtemia may be present in consequence of direct loss or continuous drain. It must be admitted that an opposite condition, polytemia, may be produced in conditions involving an excess of production over loss. This latter con- dition of polysemia or plethora is, however, rather suggested than determined, since much more than the total quantity of blood at any time present in the body could be easily accom- modated in the veins. It seems absolutely certain that con- ditions of oligemia and polyiemia are only transient, the various processes connected with the circulation being amply sufficient to restore the normal balance with great rapidity. BLOOD CHANGES. 119 Changes in the number of blood corpuscles and of the hfemogiobin contained by the red corpuscles are of very much more importance than alterations in the total amount of the blood. We may speak of oligocythsemia in the sense of a diminution of the blood corpuscles without distinguishing between the relative diminution of either form, and of the con- verse condition, polycythsemia, when there is an increase in the number of the corpuscles. The former condition is pro- duced as a symptom of many wasting diseases, the latter condition is usually the result of backward pressure. The hsemocytes or red blood corpuscles not merely vary within wide limits in regard to number, but they also differ considerably in size and form. Megalocytes or giant cor- puscles, microcytes or dwarf corpuscles, as well as poikilocytes or irregularly formed corpuscles, are often present in different varieties of oligocythemia. The leucocytes or white blood corpuscles have a wider range of variation, both in number and size, than is found in the case of the red corpuscles. The hsematoblasts or blood plates are reduced or increased in number in u great many different conditions, but their relations are still in doubt. The amount of haemoglobin contained in the red blood corpuscles is diminished in a very large number of diseases, while it can scarcely be said to be increased except in the con- valescence which follows acute diseases, and as the result of backward pressure from primary or secondary changes in the heart. It has already been shown experimentally that the heart beat is modified by the quantity and quality of blood passing through it. If the heart, for instance, be washed out with any indifferent fluid its pulsations fall into groups and it finally comes to stillstand, thus throwing light upon the occurrence of intermission and asystole. If, after all the pulsations have been arrested, the heart is again fed with blood, it begins once more to beat normally. It has also been shown experimentally that, if the blood be acidulated, there is an increased expansion of the cardiac muscle, while if it be rendered more alkaline the expansion is lessened. The effect upon the heart of conditions in which the blood contains less nutriment is to I 2 o PA THOL O GICAL. impair its energy. The cavities tend to dilate, the walls become atonic — in short, dilatation is inevitable. Upon the blood vessels the effect of impoverished blood is to impair their nutrition, and, therefore, to lessen their con- tractility and elasticity. But, in addition to such effects upon the heart and upon the blood vessels, a diminution of the nutritive properties of the blood is also of importance. There can be no doubt that, when the blood does not contain the elements necessary for active tissue change, the vis a frontc must be reduced. This is, prob- ably, the explanation of the increased blood pressure often observed in conditions where the blood has been impoverished. CHAPTER IV. SEMEIOLOGICAL. The appearances presented by patients suffering from cardiac disease vary so widely that it is no easy task to arrive at any generalisation with regard to the subject. Between the pale tint of aortic incompetence and the dusky flush of mitral obstruction there is a wide gulf; there also exists an immense difference between the translucent pallor of profound cedema and the deep lividity of intense cyanosis. Inasmuch as a good many factors are concerned in the production of such changes in the complexion, it nevertheless often happens that two lesions, practically alike in nature and extent, may give rise to singularly diverse appearances. The expression is often apathetic when circulatory disturb- ance has reduced the activity of the cerebral cells; it is frequently anxious when breathlessness and palpitation are prominent symptoms ; it is always apprehensive in severe cardiac pain. The attitude is occasionally of some use from the diagnostic point of view. In severe dyspnoea it is impossible for the patient to assume the recumbent posture. Cardiac pain causes a tendency to assume a position as rigid as possible. In thoracic or abdominal aneurysm the patient sometimes strives by bending forward to relax the parietes as far as possible, and in this way to relieve the symptoms of pressure. It is well known that the symptoms of which patients complain, even in well-marked cases of circulatory disturbance, are often absolutely unconnected with the heart, and the more special cardiac symptoms require to be sought for. The 1 2 2 SEME 10 L O GICAL. relation existing between different groups of symptoms fluctu- ates extremely, and it is not easy to make any general statement in regard to the degree of frequency with which these make themselves manifest. There can be little doubt, however, that the most frequent complaints expressed by patients suffering from cardiac disease are connected with the respiratory processes — breathlessness, especially on exertion, as well as cough and expectoration, being extremely common symptoms. Symptoms connected with the subcutaneous textures and the urinary functions are probably next in point of frequency, although various digestive symptoms are almost equally common, such as want of appetite, nausea, and vomiting, along with alterations in the intestinal functions. The nervous system frequently shows disturbances like giddiness or faintness, while overpowering drowsiness or troublesome insomnia are also common. Any or all of these symptoms may be associated with others more directly connected with the heart, such as pain, or palpitation, and fluttering or trembling sensations. It is impossible in a systematic work to do otherwise than consider the symptoms of disease in groups. They will therefore be examined and analysed according to the systems by which they are manifested. It must, however, be clearly kept in view, not only that many symptoms have both subjective and objective aspects, but also that those mainly belonging to one system may be so closely interwoven with another group as to be separated therefrom only with extreme difficulty. The line of demarcation is there- fore somewhat uncertain, and the discussion of a symptom belonging to one class will often be found to necessitate the consideration of matters connected with other groups. In the following pages the symptoms directly connected with the circulation will be considered in the first place, and thereafter the effects of circulatory disturbances will be traced throughout the other systems of the body. So far as is possible these symptoms will be not only described but also explained. It therefore follows that this section must inevitably overlap to some extent those devoted to physio- logical and pathological considerations. SYMPTOMS CONNECTED WITH THE HEART. 123 Symptoms connected with the Heart. The pulsation of the heart was observed by most of the ancient writers on medicine, and Herophilus discovered the fact that its movements were simultaneous with those of the pulse. The descriptions of these old authors are, however, so inter- mingled with the fanciful ideas of the times as to Ije of comparatively little use, and it is not until we reach the observations of Harvey, Lower, Lancisi, and Senac that results based upon the inspection of the chest come to have any real value. The gradual acquisition of our knowledge in regard to the appearances presented by the prsecordia as observed by the eye, will be noted as the various subjects are discussed in the following pages. Inspection. — The prsecordia or portions of the thoracic wall lying in front of the heart have already been described from the anatomical standpoint. The form varies considerably, not merely in the two sexes, but in consequence of age and individual peculiarities, but it may be said that as a general rule the prsecordia are characterised by some flattening over the region of the sternum with a slight elevation on either side of it, which is rather larger on the left than on the right. By inspection information is gained as regards the form of the chest and the movements which it undergoes. Alterations in Form. — -Changes in the form of the chest are not produced by cardiac affections to any very considerable extent. It occasionally happens, however, that hypertrophy of the heart produces a certain amount of bulging of the prsecordia, and this is more particularly the case if the hypertrophy occurs during early years. Thus it comes about that in congenital heart disease a distinct forward projection may be observed. In pericarditis attended by considerable effusion there may be bulging of the intercostal spaces — this, nevertheless, is one of the rarer manifestations of the disease. Projection of the thoracic parietes may be produced by aneurysm. Aneurysm of the ascending portion of the arch of the aorta gives rise in many instances to an obvious tumour in the region of the second and third right intercostal spaces, and it not infrequently happens that the adjacent costal cartilages or 1 2 4 SEME 10 L O GICAL. ribs ibrm part of the mass. Aiieurysiu of the transverse portion of the areh of the aorta produces a general projection Of the upper part of the sternum and adjacent costal cartilages and intercostal spaces, which is not by any means easily distinguished from some of the alterations in Ibrni iivuduced by ])ulnionary disease, unless distinct pulsation should l)e present in tlie region. Cardiac Movements. — The cardiac impulse may be observed by inspection, but the facts so ascertained recpiire to l)e verified, amplihed, and corrected by the employment of palpation. In perfect health the only impulse perceptible over the prfficordia is that commonly termed the apex beat, and this even is in many normal conditions by no means distinct. It is produced by the impact of some part near the anatomical apex of the heart upon the chest walls. The part of the heart which thus comes in contact with the parietes may be either the left or the right ventricle, according to circumstances. When the right ven- tricle is dilated and hypertrophied, it is obvious that it must displace the left ventricle backwards, and the position of the apex beat in such cases is quite in accordance with this fact. The production of the apex beat has been a fertile source of discussion. By Alderson, Gutbrodt and 8koda, Jahn, and Hiffelsheim it has been regarded as produced by the recoil of the heart in consequence of the jet of blood sent into the aorta ; Ijy Kiwisch and Ludwig it has been considered as entirely caused by the change of shape of the heart itself; Ijy Kornitzer it has been attributed to the somewhat spiral arrangement of the great blood vessels at the base of the heart ; while by Aufrecht it has been held to have its origin in a flattening of the aorta during the outpouring of the blood. It is proljable that each and all of these views contain some element of truth ; but beyond question the greatest factor in the precordial pulsation is the alteration of form which has already been discussed in the chapter devoted to physiological considerations. The position of the apex beat, in the youthful adult, is in the fifth left intercostal space, between 2-|- and 3 inches from mid-sternum. In the child it is very common to find the apex beat occupying a higher position, even in the fourth intercostal space relatively farther also from the middle line, while in the CARDIAC MOVEMENTS. 125 aged it frequently occupies the sixth intercostal space, some- what nearer the mid-sternum than in the normal standard. The apex beat undergoes some passive changes in position. With forced breathing it moves downwards and up- wards respectively with in- spiration and expiration. It further undergoes an altera- tion in position when the posture is modified. While lying on the right side the heart moves nearer to the mesial plane ; and, on the other hand, while lying on the Fig. it. —upward displacement of thoracic 1 n, . ■) ., +' fl organs in ascites. The dotted line gives the ieit SlCle It passes larcner away margins of the lungs ; the double continuous from that plane so as to ap- l"ie the upper borders of the heart and liver ; .,- - . the cross marks the apex beat. proach the axillary line. In consequence of abnormal conditions the position of the apex beat may undergo considerable alteration in its position. In the presence of ascites, meteorism, tumours, or any condition whereby the con- tents of the abdominal cavity are increased to any considerable extent, the heart tends to be moved upwards. Such a condition may be seen in the illustration (Fig. 17), which represents the apex beat, along with the extent of cardiac dulness in an old-standing case of ascites. A similar change of position may occur in spinal curvature, as is shown in Fig. 18. When the right pleural cavity is occupied by extensive Fig. is. — Upward displacement of the heart in scoliosis. The dotted line shows the margins of the lungs ; the continuous line the cardiac and hepatic dulness. 126 SEMEIOL O GICAL. effusiou, or much air, the apex l^eat is moved farther to the left than the normal ; the same change in position is also produced if there Ije any considerable retraction of the left lung, such as is common in fibroid phthisis, and sometimes occurs as the result of interference with the root of the lung. In pneumothorax on the left side or extensive tiuid efi'u- sion into the left pleural sac, the heart is often moved far over to the right side so as to reach at times the Fig. 19.— Displacement of the heart to the right mammillarV line, in pleurisy of the left side. The dotted line ™, . . n i marks the anterior border of the right lung ; ihlS IS WCil ShOWn 111 the upper continuous double line the right ill ngtrationS 1 9 and ^ border of the h^art and the upper margin of the liver ; the lower continuous double line the A similar cliaUgC of inferior limit of the dulness of the liver and the i^i^n QCCUrS in COU- pleural ertusion ; the cross the apex beat. J- secpience of retraction of the right lung, as is shown in Fig. 21. The heart may Ije displaced downwards by various thoracic con- ditions, some of which are connected with the circulatory system, while others are produced by conditions of the thoracic contents other than cir- culatory organs. In cases of emphysema of both lungs the heart is dis- placed downwards ; but, as will shortly be shown, the apex beat often tends to disappear entirely in Fio. 20.— Displacement of the heart in left pneumu- p -1 • , thorax. The double line luarks the i)Osition of the consequence 01 tne inter- ,,33,.^ ^^.j ^j^.g^. . ^,,g pj.,„j. t,^g ^pex beat. CARDIAC MOVEMENTS. 127 Fig. 21. — Displacement of the heart to the right from old fibroid changes in the right lung. The dotted line shows the margins of the lungs ; the continuous double line the heart and liver dulness. position of the distended lung between the heart and the parietes. In aneurysm of the arch of the aorta at almost any point the heart tends to be displaced down- wards as well as outwards ; it has, however, to be borne in mind that in such con- ditions lesions of the aortic cusps are extremely com- mon, and their results upon the left ventricle have to be taken into account as in part responsible for the changes in position. The incidence of dilatation and hypertrophy gives rise to alterations in the position of the apex beat. In such affections of the left ven- tricle, the long axis of the heart is increased, and, as might be expected from the examina- tion of such hearts after death, the apex beat during life is found to be displaced, chiefly downwards, so as to reach even the sixth intercostal space, and only slightly outwards. In dila- tation and hypertrophy of the right ventricle, the breadth of the heart is increased to a greater ex- tent than its length, so that the chief alteration in the apex beat is one in an outward direction with- out much displacement It must here be noted that in consequence of the Fig. 22. — Complete transposition of the viscera. The double lines show the dulness of the heart, liver, and spleen. The dotted lines mark the margins of the lungs ; the cross the apex beat. downwards. 128 SEMEJOLOGICAL. enlargement of the left ventricle the apex l)eat is very com- monly produced hy }iavt of that ventricle, and it is therefore far from coinciding with the anatomical apex of the heart. In addition to all these changes in the position of the apex beat there is one still more striking. In conditions of congenital transposition of the viscera the apex beat, instead of occupying tlie lelt half of the thorax, is found upon the opposite side, as may be seen in the accompanying illustration (Fig. 22). It represents the outline of the heart, lungs, liver, and spleen in a healthy schoolboy of sixteen, who was kindly sent to me by Dr. Cattanach. The extent of the area over which pulsation can be seen is subject to alterations, more in consequence of conditions extrinsic to the heart, than connected with the heart itself. The area over wliich the apex beat can be seen is much larger in those who are thin than in those who are fat. It is also uuich increased when from any cause there is retraction of the left lung, while, on the other hand, it may be completely obliterated by the presence of such a condition as emphysema. Pulsations of the prfecordia may take their origin in move- ments of other parts than the apical region of the heart. One of the most common of these is the impulse often seen in tlie second left intercostal space. Movements in this region have been the cause of considerable discussion, as will be described in the sequel ; but it may safely be asserted in this place that they are produced by the movement of the conus arteriosus or pulmonary artery during the systole of the right ventricle. A pulsation is occasionally, but very rarely, to be seen to the right of the sternum in the third and fourth intercostal spaces in consequence of movements of the right aiiricle. Much more common is a pulsation in the epigastrium, which may take its origin in several distinct causes. It may be caused by the throb of the right ventricle, communicated through tlie dia- phragm in cases of dilatation or hypertrophy of that portion of the heart. It may be produced by an expansile pulsation of the liver in consequence of a reflux from the right chambers of the heart in cases of tricuspid incompetence, or it may be caused by the aorta, either by a simple exaggeration of its pulsation, or in consequence of an aneurysm. CARDIAC MOVEMENTS. 129 Thoracic pulsations in the vicinity of the pr£ecordia may also be produced by aneurysm of the aorta. Such pulsations occur in the situations which have been above referred to as the site of elevations of the surface. The rhythm of the apex beat may be roughly estimated by the eye, but this is one of the points in regard to which the results of inspection require to be corrected by palpation. It is nevertheless possible to judge approximately as to the regularity or irregularity of the cardiac pulsations, and it may even be possible to determine whether the several heart-beats give rise to an equal amount of displacement. One point yet remains to be noted. A retraction of the interspaces around the apex beat may be observed in certain conditions. Chief amongst these is obliteration of the peri- FiG. 23. — Cardiogram from a case of adherent xjericardium. The details of the case are to be found on p. 363. cardial sac by adhesions, but in the total absence of such con- ditions there may be an indrawiug of the interspaces, as, for instance, in examples of considerable cardiac hypertrophy. Skoda and his followers, c.cj. Guttmann, describe a retraction of the apex beat in pericardial adhesion. This, however, is an absurdity. We know that the long axis of the heart is always lengthened during systole, and an in drawing of the apex beat is out of the question. The tracing (Fig. 23), taken from the apex beat in a well-marked case of pericardial adhesion, accompanied by great retraction of the interspaces surrounding the apex, shows quite distinctly that the apex beat is as usual a forward thrust and not a retraction. Palpation. — By means of palpation the facts observed by inspection may be verified and corrected, while additional phenomena may at the same time be determined. Form, of Prcvcordia. — The form of the prtecordia may be 9 I30 SEMEIOLOGICAL. more fully investigated by adding the results of palpation to those obtained by inspection, and palpation may also, in cases where there is bulging of the intercostal spaces, give some indication as to the medium that has produced the bulging. Position of Cardiac Jmjmlsc. — As regards the position of the impulses and their exact time-relations, palpation is of the greatest service, inasmuch as it not merely brings into greater prominence those which have been seen on inspection, but, furthermore, reveals the existence of degrees of pulsation too small to be detected by the eye. On palpating the cardiac region in a healthy person, a difluse shock is felt, which, however, culminates in a sustained throb in the region of the apex. In those who are not very thin this is all that can be felt, but, when the thoracic parietes are slender, the sustained throb may be followed by a distinct, sharp jerk, pro- duced by the recoil of the blood upon the sigmoid cusps during diastole. In a large proportion of individuals this distinct jerk can only be felt at the base of the heart, and more par- ticulaiiy in the second left intercostal space ; in others, however, it may be felt over a wide area, including the apical region. Charade/' of I^njnilsc. — In many instances a distinct move- ment somewhat like the peristaltic wave may be felt passing over the pr?ecordia. It occurs in thin persons with vigorous hearts, but it is more characteristic of those cases in which from retraction of the left lung the heart is very largely uncovered. Force of Iinpulse. — Alterations in the force of the impulse can only be estimated by palpation. On the introduction of the cardiograph, its results were looked forward to with the greatest interest, in the hope that they would throw much light upon this point. Any hopes, however, of assistance as regards estimating the energy of the heart from the cardiograph have proved fallacious, and its sole value lies in giving the record of the time of the cardiac movements, and, to a less extent, of their form. The force of the impulse may be diminished by causes external to the heart. The presence of fluid or air in the pericardial sac, the existence of emphysema of the lungs, and sometimes even pneumothorax, pleurisy, and hydrothorax, may lessen the force of the impulse as felt by the hand. The CARDIA C IMPULSE. 1 3 r pulsation may also be enfeebled by causes acting upon the heart, such as nervous interference with its action, and general causes which affect its energy, as, for instance, in pyrexia, antemia, and inanition. The force may further undergo changes as the result of local causes operative upon the organ itself, as when myocarditis results from pericarditis or endocarditis, and when cardiac failure occurs as the result of long -continued valvular disease. The force of the pulsation may appear to be increased from extrinsic causes. In those who are thin the pulsation is more distinctly felt than in those who are fat, and in retraction of the left lung, from any cause whatsoever, there is not merely an increased area, but an exaggerated force of the pulsation. Nervous interferences with the action of the heart give a more forcible pulsation, and muscular exertion at all times increases its energy. In the earlier stages of pericarditis and endocarditis the apex beat is almost invariably augmented in force, and, as the result of hypertrophy following valvular lesions, pericardial adhesions, renal and pulmonary affections, and other extrinsic causes of alteration, the force is increased. Systolic Recession. — The recession or indrawing of the intercostal space around the apex beat has already been mentioned as regards inspection. This may be more distinctly appreciated on the application of the hand. On palpation in such a case the thrust of the apex beat is felt to be accompanied by a distinct drawing in\yards of the parietes around it. This, however, is not all, for a distinct impulse of rebound or recoil is felt along with the diastole ; and the existence of the systolic recession and diastolic recoil constitute the most characteristic symptoms of adherent pericardium. Bhythiii of Impulse. — By palpation the rhythm of the cardiac movements may be estimated with great accuracy. Simple irregularity in the succession, and inequality in the size, of the pulsations are extremely common symptoms in cardiac failure. Grouping of the pulsations may take place ; the beats occurring in twos, or threes, or in larger numbers, giving the cardiac phenomena associated with the bigeminal pulse and its analogues. 1 3 2 SEME 10 L OGICAL. A double impulse, consisting of a stronger pulsation followed by a weaker one, was described long ago by Skoda, and more recently by Leyden and lioy. It has been at- tributed by these observers to alteration in the systole of the heart, consisting in a contraction in which both ventricles participated, followed by another in which one alone took part. To this opinion it is perfectly inip(jssible to subscribe. The two ventricles are so intimately united in structure by the interlacing of their fibres, that it is theoretically improbable that such an explanation as that which has l^een advanced ]jy those observers can account for the appearances. It is, no douljt, true, that when the heart is dying some of its chambers persist in pulsating independently of the others ; but, when this occurs, the form of the systole is entirely modified, and it is in the highest degree unlikely that for long periods the right ventricle should pulsate twice for one pulsation of the left. While fully admitting, therefore, that the left ventricle may give rise to pulsations of a character too feeble to produce a pulsation in the radial or other distant artery, it is impossible to allow that it does not pulsate at all ; and, as has been shown by j\Iackenzie in some instances of this kind, a feeble pulsation may l^e made out in the carotid artery, while there is none in the radial. Accompaniments of Impuhc. — The contraction of the heart may be attended by certain accompaniments only to be appreciated by palpation. Such adventitious phenomena may be produced by causes outside the heart proper, or by its internal mechanism. It occasionally, but not very commonly, happens that, on applying the hand over the pnecordia, friction may be felt. It gives a sensation of roughness exactly similar in character to that which is felt over a patch of dry pleurisy. From the time of Senac it has been known that fluctuation may be felt over the heart, in copious pericardial effusion. In a patient whose case is recorded by this author, the fluctuation was felt during palpation of the heart, and its position was in the tliird, fourth, and fifth intercostal spaces. The accompaniments which are found along with the CARD I A C IMPULSE. 1 3 3 cardiac movements as the result of internal disorders are of the nature of vibrations or thrills. Corvisart was the iirst author who referred to this phenomenon, and he speaks of it as, " Un bruissement particulier difficile a decrire." By Laennec the thrilling vibration was termed " Fremissement cataire," in consequence of its resemblance to the sensation experienced by the hand on stroking a cat contentedly purring. Although this physical sign was first described as pathognomonic of mitral obstruction, the thrill may be produced at any of the cardiac orifices. At the aortic orifice both systolic and diastolic thrills are common, although the former, denoting obstruction, is much more frequent than the latter, indicating regurgitation. The systolic thrill is occasionally felt throughout the whole chest ; the diastolic thrill is rarely felt except in the praecordial region, more especially towards the lower part of the sternum and in the neighbourhood of the apex beat. Thrills produced at the mitral orifice are in the greatest proportion of cases of presystolic or diastolic rhythm, and denote obstruction at the left auriculo-ventricular orifice. They are always felt with their greatest intensity about the region of the apex and are not, as a general rule, propagated to any considerable distance from it. This rule is, nevertheless, subject to certain exceptions, and thrills of either rhythm may be transmitted over a considerable area of the parietes. Systolic mitral thrills are exceptional. When present, they probably depend upon a considerable degree of narrowing as well as of rigidity of the mitral orifice. Such systolic thrills may be conducted to a very considerable distance over the parietes, but their maximum intensity is about the apex. Thrills originating at the pulmonary orifice may be systolic or diastolic. On account of the proximity of the pulmonary orifice to the surface, lesions of the cusps, whether obstructive or regurgitant, in most instances give rise to vibratile sensa- tions ; as pulmonary lesions are, however, far from common, such thrills cannot be regarded as frequent symptoms. They are necessarily much more common in congenital heart disease than in any other condition. Tricuspid thrills are excessively rare. Even when there 134 SEMEIOLOGICAL. is tricuspid obstruction, presystolic and diastolic thrills are seldom to lie felt, wliile a systolic thrill accompanying re- gurgitfition is practically unknown. As tricuspid incompetence is the commonest of all valvular lesions this fact is extremely significant. Occasionally there is a systolic thrill accompanying the expansile pulsation over an aneurysm of the aorta or one of the srreater arteries, and in cases in which the aorta is dilated and projects up to, or farther than, the summit of the manu- brium sterni the thrill is not at all infrequently present. In those cases, already referred to, furnishing a systolic impulse in the second left intercostal space, produced by the pulmonary artery or conus arteriosus, the systolic impulse occasionally, although rarely, is accompanied by a thrill. In the second left intercostal space there is a much more pronounced symptom of this kind in certain instances of congenital heart disease. When the ductus arteriosus is permanently patent a very distinct thrill is to be felt — a thrill which distinctly follows the systole of the heart, and persists until the diastolic phase has existed for some time. The reason for this is obvious, inasmuch as the blood stream flows from the higher pressure of the aorta to the lower pressure of the pulmonary artery. It must therefore generally occur after the aortic pressure has reached a certain level, and will persist until it has fallen, at least to some extent. In some of these cases the thrill is to be felt persisting throughout almost the entire cardiac cycle. It might be expected that l3y means of the cardiograph a record of the vibrations constituting a thrill might be obtained. The tracings published by some observers give appearances somewhat like the movements which the lever might be supposed to give in consequence of vibratile impulse, as, for example, in the series of tracings in mitral obstruction obtained by Galabin. When these tracings, however, are carefully examined, it will be seen that the apparent vibrations are not sufficiently frequent to correspond to the thrill, and they are, therefore, probably produced by jerks communicated to the lever from slightly interrupted movements of the heart. No satisfactory result has ever attended any of my SIZE OF HEART. i35 own efforts in this direction, and the tracing (Fig. 24) which is annexed, obtained by means of the cardiograph with a rapidly revolving cylinder, from a patient with mitral obstruc- FiG. 24. — Tracing from the apex beat of a case of mitral obstruction with marked thrill. tion giving rise to a most marked presystolic and diastolic thrill, shows absolutely no trace of the vibrations. Percussion. — It seems probable that the method of per- cussion was in vogue amongst the early Greek physicians, for, as Gee infers, it had apparently been established before the time of Celsus for the purpose of distinguishing between ascites and tympanites. It was never applied, however, to the diagnosis of chest affections until last century, when Auen- brugger produced that work which was the forerunner of all modern methods of physical examination. Corvisart, who translated and annotated Auenbrugger's work nearly half a century after its appearance, earned un- dying recognition for calling attention to the importance of percussion and for extending its application, more particularly to the diagnosis of heart disease. In the portions of his Treatise devoted to the heart Auenbrugger is by no means so luminous or so accurate as in the Observations referring to affections of the lungs. In the twelfth and thirteenth Observations he mentions the changes in the percussion sound produced by effusion into the pericardial sac, and by dilatation of the heart, linking such changes with other characteristic symptoms of these affections. Such are the earliest references to the method of percussion as applied to affections of the heart. The great principle discovered by Auenbrugger is that all percussion sounds must be explained by reference to the ,36 SEMEIOLOGICAL. physical condition which is present. This principle appears incontrovertible. Xevertheless, after universal acceptance during a few years, heretical views were enunciated by Piorry, who attempted to found the new theory that every organ of the body yields its own characteristic sound on percussion. Skoda turned the minds of men back to the truth of Auenbrugger's position, very clearly expounded his principle, that the percussion sounds produced depend upon the physical conditions which underlie them, and demanded that all observa- tions must be reconciled with the laws of sound. The method of percussion practised by Auenlirugger was direct or immediate, that is to say, he tapped the chest directly with the tips of the fingers drawn together and stretched straight out, the chest being covered by a garment, or the hand by a glove, which was not to be of smooth leather. Corvisart followed the same method, and it was not until the investigations of Piorry that mediate or indirect percussion was substituted for immediate or direct. Piorry introduced a pleximeter made of ivory placed between the chest and the fingers used to percuss, and he describes that the fingers should be kept half bent so as to employ their tips — the method which is now universal. The plessor or percussion hammer was introduced by Wintrich ; the employment of the pleximeter and plessor is attended by doubtful benefits. Percussion as applied to the heart is necessarily of no value in regard to changes in its structure ; it can only throw- light upon its size and relations. There is therefore a twofold aim in applying percussion to the investigation of the heart. First, to determine the total space in two dimensions occupied Ijy the heai't, projected as it were upon an approximate plane ; secondly, to ascertain how much of it is covered by lung tissue, and to ascertain the presence or absence of any abnormal structure in contact with the heart or great vessels. In mapping out the extent of the thorax occu23ied by the heart, the extent of the deep or relative dulness is the object to be investigated. For this purpose percussion must be carried out with considerable firmness, and in this way the whole of the lateral and superior boundaries of the heart may be ascertained with a precision which is almost absolutely SIZE OF HEART. 1 37 accurate. The results of percussion have been frequently verified by myself at post-mortem examinations. This has been clone by delimiting the extent of the deep dulness, and introducing barbed wires vertically ; these retain in the deeper regions of the chest the lines marked out before opening the thorax. On no occasion has it ever occurred to me to find that the real position was at any point more than one-eighth of an inch from that which had been marked out by percussion. It is therefore impossible to agree with Guttmann when he says that the right edge of the heart cannot be defined. The inferior border of the heart, resting upon the liver, cannot Ije dis- tinguished by percussion, inasmuch as the physical character- istics of the two viscera are such as to give rise to similar acoustic phenomena. The best method of ascertaining the total area occupied by the heart is to make out in the first place the upper limit of deep liver dulness in the right mammillary line, and thereafter to percuss from without inwards along the ribs and interspaces until the relative dulness at the cardiac margin becomes manifest. The same course is to be followed round the entire margin of the heart. The highest point at which the cardiac dulness may be determined is at the upper border of the third left inter- costal cartilage close to the sternum. From this level it runs inclining slightly downwards across the sternum to the right, and curving more and more, comes to be about two inches from mid-sternum at the fourth right costal cartilage, beyond which, on account of the presence of the liver, it cannot be made out. From the highest point the left border runs outwards and downwards in a crescentic line, and at the level of the fourth rib it is between three and four inches from mid-sternum. The best method of ascertaining the boundary between the heart and the liver is to map out the entire areas occupied by the two organs, when a line drawn from the angle where the margins — ascertained by the deep dulness of the two viscera — meet, to the right of the sternum, is to be drawn to the point where the left end of the liver and the lower margin of the heart are found to be in contact. The superficial or absolute dulness of the heart corresponds exactly with the portion of the right ventricle which is left 1 3 8 SEME 10 L O GICAL. uncovered by the lungs. It is therefore somewhat triangular in form and may be regarded as having tliree sides, two of which, only can be ascertained directly by means of percussion. The l)Oundaries of this area vary in health with the respiratory movements. In quiet respiration or when the lungs are altogether at rest the right border of the superficial dulness of the heart is usually at mid-sternum. The left border begins at the upper border of the fourth costal cartilage, and curves outwards and downwards, crossing the fourth intercostal space and the fifth rib until it reaches the fifth intercostal space, at which point it curves slightly inwards, until it reaches the sixth rib, at which point the superficial cardiac and hepatic dulness merge. The average extent of the superficial dulness of the heart under such conditions may be stated by giving its vertical extent from the upper level of the fourth costal cartilage to the level of the sixth chondrosternal articulation as 2 inches, and its breadth at the level of the fifth costal cartilage as being 1^ inches. On forced inspiration and expiration the size of this area becomes respectively diminished and increased. The size of the deep cardiac dulness is modified by all changes in the size of the heart. It therefore happens that in hypertrophy, and still more in dilatation, the area of cardiac dulness becomes enlarged in certain directions. In such affections of the right side of the heart the transverse extent of the dulness is chiefly enlarged, and in the case of similar changes on the left side of the heart the vertical extent is more particularly enlarged. Changes in the extent of cardiac dulness occur sometimes with a good deal of rapidity, especially in conditions of cardiac dilatation, probably on account of fluctuations in the quantity of the l)lood which the cavities of the heart contain. In cases of considerable pericardial effusion alterations in the area of dulness are effected by changing the position of the patient. In the recumbent posture the dulness on percussion is somewhat smaller than when the patient sits upright, and the apex beat is more appreciable than in the sitting posture on account of the tendency of the fluid to gravitate backwards in the recumbent position and forwards in the erect posture. CARDIAC SOUNDS. i39 In cases of effusion into the pericardial sac, the extent of the deep cardiac dulness is considerably increased, and it at the same time assumes a characteristic form which is fully- described in the section dealing with such conditions. The size of the area of superficial dulness is not so much affected by circulatory disturbances as by modifications in the condition of the respiratory organs. It nevertheless undergoes modifications in some affections of the heart. In cardiac hypertrophy and dilatation the area is often increased to some extent, and in pericarditis with considerable effusion this is even more conspicuously the case. Such alterations of the area of superficial cardiac dulness are small compared with the alterations which it undergoes in certain diseases of the lungs. In cases of collapse or retraction of either or both of the lungs the extent of superficial dulness may be enormously increased, while, on the other hand, in pulmonary emphysema it may be absolutely obliterated by the encroachment of the anterior borders of the lungs. Auscultation. — The causation of the heart sounds has already been fully discussed, and in the present section the clinical phenomena of health and disease alone require to be , studied. Cardiac Areas. — It need hardly be remarked that for con- venience in clinical observation there are four conventional areas in which the characters of the sounds relating to the different orifices are ascertained. The aortic area is situated at the second right chondro- sternal articulation, for the reason that the aorta is nearer the surface at this point than at any other, so that sounds gener- ated at the aortic orifice are best conducted to this spot. Murmurs taking their origin in abnormal conditions of the aortic orifice and cusps are frequently, however, heard more distinctly at other points in the neighbourhood than in the aortic area itself, to which fact reference will be more fully made at a later stage. The mitral area is situated at the apex of the heart. This does not necessarily mean the \dsible or tangible apex beat, because in certain conditions, more particularly in dilatation or hypertrophy of the right ventricle, the apex beat is not produced by the apical part of the I 40 SEMEIOL O GICAL. heart. In any case of doubt the correct position of the curJiac apex must be determined by means of percussion, which clears up any doubt as regards its true position. At this point the left ventricle comes comparatively close to the parietes, and, therefore, serves as a means for the conduction of any sound vibrations arising at the mitral orifice. The pulmonary area occupies the inner end of the second left intercostal space, at which point the pulmonary orifice and its cusps are very near the surface. The tricuspid area m^ they are usually all but blended into one another. But sometimes, as in Fig. 68, in which the mitral systolic was associated with an aortic systolic murmur, they remain discrete. On the other hand, as in Fig. 70, the systolic murmur, heard over almost the entire prsecordia, and presenting four points of maximum intensity cor- responding to the four areas, cannot be resolved into its constituent elements except close to each point of greatest intensity. Pulmonary systolic and diastolic murmurs of organic origin have almost invariably their point of maximum intensity at the sternal end of the second left intercostal space. Those which Fig. (54. — Systolic propagated more widely than presystolic murmur. I70 SEMEIOLOGICAL. we shall afterwards see to be in all probability produced at the tricuspid orifice from relaxation of the cardiac muscle, may be situated somewhat lower down than is here mentioned, in fact, Fig. 65. — Presystolic propagated more widely than diastolic murmur. Fio. GO. — Diastolic propagated more widely than presystolic murmur. at any point between the recognised tricuspid area and that recognised as pulmonary. Such a murmur is shown in Fig. 71. An excellent example of combined systolic and diastolic pulmonary murmurs of organic ~^^ origin, full details of which will be given subsequently, is shown in Fig. 69. The dia- stolic pulmonary murmur produced, as will be more fully described in a later chapter, by dilatation of the orifice from strain without organic affection of the cusps, is not infrequently met with. Its position and extent may be made out in Figs. 72 and 73, in the former of which it was associated with presystolic and systolic mitral murmurs, while in the latter it was accompanied by systolic murmurs in the mitral, tricuspid, and pulmonary areas. Tricuspid murmurs are usually heard most distinctly at the junction of the lower left costal cartilages with the sternum, that is over the superficial cardiac dulness. In an excellent Fig. 67. — Presystolic and diastolic mitral murmurs with systolic mitral and tricuspid. CARDIAC MURMURS. 171 Fig. 68. — Systolic aortic and mitral murmurs. example in which tricuspid and mitral lesions co-existed, the distribution of the murmurs was as is shown in Fig. 74 ; in another instance, in which there was a loud pre- systolic murmur heard over a wide area with its maximum intensity close to the edge of the sternum at the level of the fourth costal cartilage, it was im- possible to come to any other conclusion than that there was obstruction of both orifices. The full de- tails of this case are given below. It is shown in Fig. 75. The systolic tricuspid murmur has its maximum intensity about the fifth left chondro- sternal articulation, and is conducted from that point in every direction. It is, how- ever, very common to find that it is loudest somewhat higher up ; the exact signifi- cance of this will be dis- cussed later. There can be no doubt that the conduction of mur- murs is chiefly dependent upon the vibrations produced in the chest wall. It is not easy, however, to decide what parti- cular kind of murmur is likely to be best carried in this way. Certainly it is not always the murmur of loudest intensity. In several instances this was tested in the cases referred to. Tor instance, the case furnishing Fig. 66 presented greater Fig. 69. — Systolic and diastolic aortic and pulmonary murmurs. 17: SEMEIOLOGICAL. Fig. 70.— Systolic murmur with maxiiuum intensity in four areas. intensity of the presystolic than of the diastoHe murmiu-, as tested by the method of Vierordt, that is, by the interposition of non-conducting plates between the chest of the patient and the ear of the observer. Notwithstanding this greater intensity of the presystolic murmur, it was not conducted so widely as the diastolic murmur. Ex- actly the converse was found in the case shown in Fig. 65 ; here the diastolic mur- mur was of louder sound but more restricted distribu- tion. That the presystolic is sometimes, if not indeed often, carried more widely than the systolic murmur can be seen in Figs. 62, 63, and 74. It may be accepted as certain that the mode of conduction of any murmur is in the first place conditioned by the cardiac tissues in the immediate neigh- bourhood of the orifice at which it is produced. Some of the valves, the aortic for instance, have intimate relations with the interventricular septum, by means of which vibrations, communicated from the blood, can be transmitted to the whole heart. Other cusps, as the pulmonary, are not so closely associated with the muscu- lar substance of the heart, and sound vibrations must be less easily communicated to it. Some of the recent observations of Ewart and Habershon on the conduction of the sounds of the heart may doubtless be usefully extended to the difficult problem of murmur propagation. Fio. 71.— Systolic murmur of tricuspid origin heard most distinctly near pul- monary area. CARDIAC MURMURS. 173 In the remarks which have been made on this subject the usual method of studying the sounds and murmurs, as — Presystolic and systolic mitral with diastolic pulmonary munnur. Fig. 73. — Systolic mitral and tricuspid murmurs with diastolic pulmonary murmur. practised in this country, has been followed. No advantage can, in my opinion, accrue from the adoption of the method of Fig. 74. — Presystolic systolic and dia.stolic mitral and presystolic and diastolic tricuspid murmurs. Pig. 75. — Tricuspid and mitral presystolic murmur. Potain, according to which the prtecordia is divided into apical, mesocardiac, and basic regions. These three main regions are respectively subdivided into (1) apical proper, parapical, endapical, and supra - apical ; (2) left ventri- cular, xiphoid, and sternal; and (3) pre-aortic, and pre- 174 SEMEIOLOGICAL. infuudibular. Such a system is faulty in many ways, but chiefly by reason of confusing external landmarks and internal structures in its nomenclature. It is surely much better to fol- low the established terminology, such as is well given by Ewart, than to lend any countenance to a scheme of doubtful utility. This is probably the most fitting place in which reference may be made to the method of investigation termed auscultatory percussion, which has been recently employed and recommended. Having by repeated observations convinced myself of the abso- lute accuracy of our ordinary mode of percussion, as regards the heart, the plan of auscultatory percussion does not commend itself to my judgment. It is satisfactory to find myself in entire agreement with the opinion of Broadbent on this point, as the method is of absolutely no utility or value in any respect. Symptoms connected with the Vessels. The appearances connected with the peripheral circulation furnish symptoms of great importance ; in fact, they yield evidence of the highest diagnostic value. The most systematic course in considering the subject is to deal separately with the arteries, capillaries, and veins. The Arteries. — The physiological factors concerned in the production of the arterial pulse have been sufficiently detailed, and the clinical phenomena to which they give rise remain for consideration in this place. The, Pulse. — The arterial pulse has received the attention of the physician from the early days of medicine, but it is impossible that there can have been any real appreciation of the indications which it furnishes until the discovery of the circulation of the blood. Hippocrates, according to Adams, makes no mention of the pulse, but in the edition of Littrci several references to its dif- ferent conditions maybe found. Aristotle observed that the pulse throughout the whole body was simultaneous ; that the heart beat and arterial pulse were synchronous became known to Herophilus. The last-mentioned author described the different qualities of the pulse under the headings of size, frequency, force, and rhythm. Paifus in a short treatise analysed many of the properties of the pulse, and recognised such characters THE ARTERIES. 175 as size, rapidity, frequency, strength, and resistance, besides naming certain special types of pulse. It is of much interest to note that he recognised the movements of the fontanelles in children to be produced by arterial pulsation. Galen spent a considerable amount of his indefatigable industry upon the pulse, and produced seven distinct treatises on the subject. As regards the circulation, his most important work was the discovery that the arteries contained blood. He also, however, observed the influence of many factors on the pulse. With an excessive degree of subtlety he analysed its different features. Some of the most important of his opinions are summarised by Broadbent in his work on the pulse, in which he justly remarks of Galen that the general effect of his writings " is to confuse the essential features of the important variations of the pulse by overwhelming them in minute distinctions of no practical significance. Indeed, his point of departure is not observation, but theory, and the varieties are not described from nature, but deduced from axioms." No progress was made in regard to the study of the pulse until the appearance of Harvey's immortal work rendered the comprehension of its causation possible. Notwithstanding the light thrown by his investigations upon the relation of the heart beat and the arterial pulse, no real advance in the investigation of the latter was made until the time of Hales, who for the first time attempted to estimate the arterial pres- sure by means of a glass tube introduced into the aorta of the horse. He was followed in these investigations by Vierordt and Poiseuille, but it is more particularly to Ludwig and Fick that we are indebted for methods of investigation of the arterial pressure. Wilkinson King in the early years of the present century demonstrated variations in the contents of the veins by means of slender rods of glass or shellac, and Vierordt, following in his footsteps, placed a straw across the arm, by means of which he traced the movements of the radial artery upon a travelling surface. Such were the beginnings of the sphygmograph evolved by Vierordt from such simple methods. It is principally to Marey that we are under obligations for the development of sphygmography, but in addition to him must be mentioned Sanderson, Foster, Mahomed, Landois, Sommer- 176 SEMEIOLOGICAL. brodt, Eoy, and von Frey. The development of our knowledge connected with this branch of the subject, as well as with the characters and factors of the arterial pulse, may be studied in the works of Landois, Ozanam, Broadbent, and von Frey. Inspection of the Pulse. — The arterial pulse may be observed by means of inspection. In healthy youth the pulsation of the arteries can only be seen in a few situations. It usually is seen in the carotid arteries of the neck ; it is frequently visible in the temporal artery ; it may sometimes be detected in the radial artery above the wrist. In elderly people, more especially when thin, pulsation in many of the arteries may be seen, and in conditions producing considerable changes in the structure of the arterial walls, or in the variations of arterial pressure, inspection affords useful indica- tions. In arterio-sclerosis, for example, the temporal arteries may be seen pursuing a tortuous course upon the sides of the face and head. Many of the superficial arteries of the limbs may also present the same feature, while in aortic incompetence the great variations of arterial pressure make themselves manifest by the excessive pulsation of all the superficial arteries, which can, however, be best seen in the arteries of the neck. Palpation of the Pulse. — Of much greater importance from the point of view of practical medicine is the observation of the arterial pulse by the sense of touch. The arterial pulse may be investigated with the finger most satisfactorily in the radial artery. The part of the vessel most available for the purpose of observation is that which lies immediately above the wrist, between the prominent ridge of the radius on the outer, and the flexor tendons of the hand on the inner side. The arteries are in this situation only covered by the skin and the subcutaneous tissues, and they are therefore particularly well adapted for investigation. As the artery, more- over, rests almost immediately upon the radius at this point, there is a firm base against which it may be pressed, and in this way many of its features may be brought out with greater ease. The condition of the pulse should always be ascertained while the patient is sitting or reclining, and the arm which is employed for the purpose of determining the condition of the pulse must be allowed to rest upon some object, or must be THE SPHYGMOGRAPH. \n supported by the hand of the observer, which is not made use of in palpating the artery. The observer should place himself either in front, or to the right, of the patient, whose right arm ought to be in the semi-prone position with the elbow slightly flexed ; he must then pass his right hand across the radial surface of the patient's wrist and lay the tips of his index, middle, and ring fingers upon the radial artery. If the patient's left radial artery is to be examined the observer should stand to the left and employ his left hand in a similar manner ; if both radial arteries are to be examined at the same time he should, as far as possible, stand in front of the patient and use his right hand for the right artery and his left for the left. Experience teaches that the pulse may be best palpated with three fingers in such a way that the index finger will be nearest to the heart, and thus be able to produ.ce changes in the pulsation that may be appreciated by the other fingers. Attention to these details may seem unnecessary, but the adoption of such a method will be found to render the examination of the pulse at once more easy and more precise. The Sphygmogra'ph.- — The invention of the sphygmograph, by means of which the graphic method of investigating movements has been applied to the arterial pulse, was at one time regarded as affording high promise of clinical utility. These anticipations have unfortunately not been fulfilled. It is perfectly true that the sphygmograph has been of great value in throwing light upon some points previously obscure in the physiology of the circulation, and in clinical research it must be regarded as being of some service as a means of demonstrating certain qua-lities of the pulse. It is, nevertheless, unnecessary for diagnosis, and useless in prognosis ; it is therefore of no value in the treatment of disease. It has revealed no new fact by means of which affections may be discovered that were unknown before its invention. It brings into prominence, however, certain points which are less definite without its aid, and it is therefore on this account of some clinical interest. It must be remembered that there are some aspects of the pulse which can be much more accurately estimated by means of the finger than by the help of the sphygmograph, and the most enthusiastic advocate of this 12 178 ' SEMEIOLOGICAL. instruuieiit cannot regard it as being mure than a supplement to the finger of the observer. It is to be borne in mind that tracings taken by the sphygmograph from the same artery and at the same time, but by means of different forms of instrument, or even by different persons employing the same instrument, may present absolutely different appearances. The best forms of sphygmograph are all in their essence based upon the model adopted by Marey, which is still deservedly a favourite with those who make use of the instrument. The chief differences as regards the mechanism of the sphygmograph lie in the method by which the pressure of the instrument is adapted to the vessel. In Marey's original instrument, and in its modifications by Mahomed and von Frey, the pressure is regulated by means of a spring; while in the sphygmograph devised by Sommerbrodt the pressure is managed by means of weights bearing directly upon the pad which rests on the artery. Several other forms of sphygmograph are in use, but none of them are so reliable as those which have been referred to. It is therefore un- necessary to deal with them. In the application of the sphygmograph care must be taken to have the patient in a position of ease. If not lying in bed, or reclining on a couch, he ought to be seated comfortably. The arm and hand must rest easily upon the pad employed for the purpose, with the arm supinated, the wrist bent slightly backwards, and the fingers semi -Hexed. This position brings the artery into greater prominence and relieves it from interference by the adjacent tendons. A line is then to be drawn with the clinical pencil along the course of the radial artery, so that it is easy to ascertain at any moment if the instrument is in proper position. After winding up the clockwork of the instrument, it is to be applied to the wrist in such a way that the ivory pad lies over the radial artery, on the inner side of the styloid process of the radius. The paper, blackened Ijy smoke from a piece of burning camphor, or from a lighted candle, is to be placed in its proper position by means of the fi^ame. The point of the pen must then be adjusted so that in its oscillations it will occupy the central part of the paper. By means of the spring or weights, according to the THE SPHYGMOGRAPH. 179 type of instruineut employed, the pressure is to be adjusted so as to bring out the largest amplitude of movement, and the tracing is then to be taken by starting the clockwork. Some of the features ascertained by means of the sphygmograph will be referred to in detailing the characters of the pulse in the succeeding pages. To show how tracings obtained from the same artery at Fig. 7(5. — Tracing taken with Marey's sphygmograph from tlie radial artery in a case of mitral incompetence ; pressure 2 oz. the same time and by the same observer, but with different instruments, may differ, the accompanying curves (Figs. 7 6 and 77) are useful. They were obtained by me from a patient suffering from mitral incompetence. The normal characters of the radial pulse vary of necessity Fig. 77. — Tracing tal^en witli Somnierbrodt's sphygmograph from tlie radial artery in a case of mitral incompetence ; pressure 2 oz. within wide limits, but it may be said that the wall of the artery should be yielding, yet elastic, while the vessel should be well filled with blood, although easily compressible. The rate of pulsation exhibits great differences in frequency according to circumstances, but the rhythm of the pulsation should be absolutely regular. Each individual pulsation should be of moderate and uniform size and force, while neither too long nor too short in duration. i8o SEMEIOLOGICAL. A sphygmographic tracing of the pulse in health, as shown in Fig. 78, is characterised by a sudden and uninterrupted line of ascent and a much more gradual line of descent marked by two distinct undulations. These points are diagrammatically shown in Fig. 79. The line of ascent, a-h, inclines slightly Fio. TS. — Tracing froui pulse of licaltliy luaii agud 3G ; pressure '11 ov.. forwards when obtained by means of sphygmographs writing, like Sommerbrodt's, with a lever at right angles to the paper. It may be perfectly vertical or even inclined somewhat back- wards when obtained with sphygmographs, \vhich, like Marey's, write with the lever in the axis of the travelling paper. This line of ascent is commonly called the percussion wave, and it results from the sudden entrance of the blood from the left ventricle into the arterial system. It is in no sense to be regarded as caused bv a wave of blood. It is entirely produced by the wave of increased pressure resulting from the cardiac energy which drives the blood into the aorta. The height of the up-stroke or percussion wave depends on the extent of pressure produced in the arteries by the influx of blood from the left ventricle, and it must be conditioned by the volume of blood issuing from the ventricle, by the amount of outflow into the capillaries, and by the resistance of the arterial walls. The termination of the up-stroke would naturally be expected to pass gradually into the line of descent, and the fact that it as a rule ends in a sharp apex has usually been Diagram of pulse tracing in health. THE PULSE. i8i accounted for by the inertia of the sphygmogruph. lioy and Adami, however, believe that the sharp apex is produced by the contraction of the papillary muscles, and adduce in support of this view comparative tracings from the root of the aorta and the left ventricle of the dog. As has been previously shown, their views on the contraction of the papillary muscles cannot yet be accepted, at least until further evidence in support of them is advanced. The line of descent (b-(j in Fig. 79) results from the gradual diminution of arterial pressure after the cessation of the cardiac systole. It is interrupted by two important eleva- tions. The first of these {c-d) is often termed the tidal wave, or, avoiding theory, the predicrotic wave. It is commonly be- lieved to be produced by the current of blood passing along the artery, and according to Eoy and Adami this portion of the pulse curve agrees in form with the intra-ventricular curve. It is termed by them the outHow-remainder wave. To this succeeds a second interruption of the line of descent (e-/), which is universally accepted as due to an onward wave of increased pressure resulting from the recoil of blood upon the aortic cusps. This recoil is consequent upon the diminution of pressure in the first part of the aorta, after the cessation of ventricular systole, which is produced by the inertia of the column of blood, as is beautifully described by Foster. Both of these secondary waves are found to be higher upon the line of descent in the case of arteries close to the heart than in the case of those situated at a greater distance. The sphygmographic curve simply gives an approximate repre- sentation of the variations of pressure within the arteiy, and furnishes no measure of the fulness of the vessel. The sphygmograph, from what has been said, can only be regarded as a means of amplifying the information obtained by the finger in regard to one or two aspects of the pulse. Method of Studying the Pulse. — To facilitate the investiga- tion of the arterial pulse the various details should be con- sidered in a definite order, and the system which is adopted in the following pages is that which experience has taught me to regard as giving the most satisfactory results. The Wall of the Vessel. — The condition of the arterial 1 8 2 SEMEIO LOGICAL. walls shuukl ill every ease be tirst investigated. In health the vessel slionld be yielding, giving at the same time a feeling of elasticity to the fingers. Any departure from this state of matters must be regarded as abnormal. In febrile conditions and in many states of malnutrition the walls of the artery are too yielding, and do not furnish the healthy feelhig of elastic return on diminishing the pressure of the finger. On the other hand, the artery may be so hard and resistant as to roll from side to side under the pressure of the finger. This con- dition is common in advanced years, and depends upon arterio- sclerosis, often associated with chronic renal disease, and attended by cardiac changes. It is always advisable to pass the fingers up the forearm in order to ascertain if there is any sinuosity or tortuosity of Fii;. SO. — Tracing taUeii liuiii a case of advanced atheroma of the arteries ; pressure 3 oz. the artery. Such conditions are very common in arterio- sclerosis, and are produced by lengthening of the vessel through changes involving growth of fibrous tissue, by means of which loss of distensibility and elasticity is compensated by increased rigidity. Thoma holds that the growth of the connective tissue produces an increase of elasticity. In this use of the term, however, he is clearly in error, as has been elsewhere pointed out by myself It is not always easy to distinguish this condition from high arterial pressure, but a state of high pressure without any change in the vessel-wall is unaccompanied by any liard- ness of the artery, and there is no sinuosity or tortuosity in it. Sphygmographic tracings obtained from patients exhibiting the features of arterio- sclerosis show a moderate up -stroke, w^ith a blunted apex, and little tendency to any interruptions of the curve during the line of descent, as may be seen in the illustration (Fig. 80). THE PULSE. 183 The limited range of movement, the blunt axjpearance of the summit, and the absence of the secondary waves on the down-stroke are produced by the rigidity of the arterial wall. Blood Supply. — The state of the blood supply may Ije esti- mated by ascertaining the fulness of the artery, and the degree of blood pressure. These two features of the pulse might be expected to stand to each other in some definite relation ; this, however, is not the case. Both depend upon the three great factors already mentioned — the amount of blood in the arteries, the degree of cardiac energy, and the resistance in the arteri- oles ; differences, nevertheless, in the relations borne by each of these factors to the others may produce such apparently paradoxical conditions as a full pulse of low pressure, or an empty pulse of high pressure. The former may sometimes be seen in chronic renal disease, the latter is occasionally found in peritonitis. The fulness of the vessel is to be judged by its size during the interval between two pulsations, and the educated touch is the only means by which this may be determined, the sphygmograph rendering no assistance in this respect. A full artery {pulsus plenus) may be attended by large pulsations, in which case there is of necessity only moderate or even low arterial pressure ; it is, however, more common to find with full arteries that the pulsation is small. A full pulse is found in those who present increased resistance in the arterioles and capillaries, as may be seen in many conditions found in those commonly termed plethoric. It is also observed in the early stages of arterio-sclerosis and chronic renal disease. An empty artery (pulsus vacuus) is often found associated with a large and bounding pulse, as in that characteristic of aortic incom- petence. An empty pulse is also found in many conditions of relaxation of the small arteries and arterioles. In convalescence from acute affections, in wasting diseases, and in malnutrition the pulse is almost invariably empty. The blood pressure is to be estimated by the amount of force necessary to obliterate the artery during the interval between the pulsations. A pulse of low pressure is com- pressible, while one of high pressure is incompressilile. To some extent this quality may also be estimated by the amount i84 SEMEIOLOGICAL. of expansion which the artery undergoes during the cardiac systole, a pulse of high pressure being less distensible than one of low pressure. Sphygmographic tracings furnish important indications in regard to pressure, seeing that the size of the tidal, or outflow-remainder, wave stands in direct relation to the extent of pressure. If a line be drawn from the summit of the tracing to the lowest point of the dicrotic notch, the tidal wave sometimes does not reach it, and at other times it passes beyond it. If it be below it, as in Fig. 81, the pulse is of low or moderate pressure; but if, as in Fig. 82, it is higher than the line, the pulse is of high pressure. With high pressure the pulse wave is usually small, but this is Ijy Fio. 81. — Diagram of pulse of Kio. S2. — Uiagraiu of pulse of low pressure. high pressure. The finely-dotted line represents the normal curve. no means invariably the case, and although with low pressure the pulse wave is very commonly large, yet in many cases it remains small. High pressure is found in many circumstances which produce increased resistance in the arterioles, such as the early stages of acute diseases, such diathetic conditions as lithfemia and arterio- sclerosis. Low pressure is, on the other hand, found in the later stages of acute diseases, and in many con- ditions of malnutrition ; it is also found in conditions which impair cardiac energy, such as aortic and mitral lesions — par- ticularly aortic incompetence and mitral obstruction. It might be thought that arterio-sclerosis would be incom- patible with low pressure. This, however, is not the case, and although the proof is not easy in advanced changes it is not difficult in earlier stages. The annexed tracing (Fig. 83) is THE PULSE. 185 from a patient with a cousideraljle degree of arterio-sclerosis ; it nevertheless shows the characteristic features of low pressure. One of the most prominent features resulting from low pressure is dicrotism. On palpation of the radial artery under Fig. S3. — Tracing from radial artery showing low pressure with sclerosis of vessels ; pressure 2 oz. ordinary conditions only one pulsation can be felt correspond- ing to each cardiac systole; in certain conditions, however, a second wave can be felt immediately following it. A tracing of such a pulse is shown in Fig, 84. It reveals an entire Pig. 84. — Pulse from a case of pericanlitis showing dicrotism ; pressure li oz. absence of the tidal wave with an exaggeration of the di- crotic notch. When the notch reaches the base line of the tracing, as is shown in the diagram (Fig. 86), the pulse is said to be fully dicrotic. When the notch sinks below the Fig. 85. — Pulse from a case of enteric fever showing hyperdicrotism ; pressure 2 oz. base line, as in Fig. 85 and Fig. 87, the pulse is said to be hyperdicrotic. That the condition of dicrotism is the direct result of low pressure has been frequently proved by such observations as those of Winternitz on the effect of hot baths on the pulse ; the result being to change a pulse manifesting all the features of high pressure, with a well-marked tidal wave, into one of low pressure, with extreme dicrotism. The condition is more I 86 SEMEIOL O GICAL. particularly luuiid as a clinical I'eature in the later stages of acute febrile affections. J^aturc of Pulsation. — The character of the pulsation has to be considered in regard to the rate and the rhythm of the pulse. The rate of the pulse is to be estimated by the number of pulsations in a given interval of time, as was first introduced, it is interesting to remember, by Kepler, the great astronomer. It is subject to alterations in the cardiac energy, the blood supply, and the arterial tone. In an adult man the number of pulsations is usually between 60 and 70 per minute, but Fio. 86. — Diagram of fully clicT'jtie Fi the circumstances in existence. If there be no tendency to the retention of fluid in the system, an abundant supply of distilled water may be administered, but if there is any tendency to a water-logged condition of the system, the combination of alkalies with the cardiac tonics to be considered immediately will be found beneficial, or such drugs as caffeine may be employed. Removal of Fluid. — The treatment of many cases of cardiac disease must be carried out on the lines of anti- hydropic methods, as Hayem terms them, especially when there is an accumulation of serous fluid in the cellular tissue or in closed cavities — that is to say, the spaces which are regarded as belonging to the lymphatic system. This serous fluid is, as has already been shown, not lymph. It differs from it in its composition and physiological properties ; particularly, it contains fewer formed elements, and has not the property of coagulating spontaneously. It is also different from exudations, due to reaction processes, which contain red and white corpuscles, and are able to deposit a considerable amount of fibrin. The one point in which the exudation resembles the transudation is that they both come from the vessels. If a large quantity of dropsical serum is injected into the peritoneum of a dog in a healthy condition, in a few hours the entire fluid will be absorbed. When, how- ever, ascites is produced by tying the portal vein, the fluid accumulates in the peritoneum until the obstacle is removed. Hayem rightly regards all dropsies as of mechanical or of dyscrasic origin. The indications furnished are in the case of mechanical dropsies to increase the arterial pressure, and in the case of dyscrasic dropsies to improve the condition of the blood. Sometimes when the subcutaneous tissues are very oede- matous, and internal remedies have no power to bring about reabsorption of the fluid, it is necessary to have recourse to other methods of obtaining relief. This has for long been carried out by means of punctures or scarifications of the skin. Such methods are, however, attended by a considerable amount of discomfort from soaking the bedclothes with large 264 THE RAPE UTICAL. quantities of fluid, and the introduction by Southey of his needles and tubes is in every way a vast improvement. By means of these, the fluid is allowed to drain into receptacles instead of wetting all the clothes and bedding. Such processes require to be carried out with most rigid antiseptic precautions, in order to avoid all possibility of infection. In many cases where the serous cavities contain large quantities of fluid, it is also necessary to obtain relief by mechanical means, through the withdrawal of fluid. From time immemorial this has been done by means of the trocar and cannula, but the introduction of the aspirator by Dieu- lafoy has revolutionised these more primitive means of evacuation. It is but too true that a resort to aspiration is often the prelude to the closing act of the drama. In certain cases, nevertheless, after aspiration has been carried out, recovery, not of a merely temporary, but of a more permanent character undoubtedly ensues. Great relief is frequently obtained by bloodletting. In many cases of serious backward pressure with profound cyanosis, it is imperatively demanded, and according to circum- stances it may be on a larger or a smaller scale. In many instances, the application of a few leeches will be found eminently serviceable. The amount of blood which they with- draw is inapprecialjle, but by the application of hot fomenta- tions a larger amount may flow after their withdrawal. This method often gives great relief in cases even of profound hyperemia. The process of wet-cupping is also most useful, more especially when there is any sudden and serious hypenemia of the lungs ; but beyond these processes, general bloodletting by venesection is often of the greatest utility, and sometimes rescues a patient from a state of great peril. The amount of blood to be withdrawn must be subject to the exigencies of each case. Exercise,. — This must be ensured in order to assist the processes of tissue change, and according to the condition of the patient may be passive or active. In the case of those unable to rise, massage must be employed along with passive movements of the limbs. The resistance exercises of Schott are also for such purposes of real importance. In the case MEANS OF RELIEVING DISTURBANCES. 265 of persons who are able to go about, graduated active exercise is of the greatest importance, and a progressive increase in the amount employed may safely be recommended. The ascent of gentle acclivities, with frequent stoppages to recover breath, after the manner recommended by Oertel, is worthy of careful attention. These three methods of mechanical treatment — passive movements, resisted movements, and active movements — are applicable, as Lauder Brunton remarks, to different degrees of severity of heart disease. Absolute rest for some days, followed by gentle massage and cautious passive movements, are of singular utility in the grave forms of heart disease when there is real inadequacy. The resistance exercises introduced by the brothers Schott are fully described by Bezly Thome, and more recently also in the works of Lauder Brunton, Broadbent, and Morison. The resistance exercises consist in carefully regulated active movements of the different groups of muscles, gently resisted by an operator ; they are never repeated twice in succession, and are always followed by a period of rest. The patient when performing these movements is carefully observed, and, if there be the slightest symptom of interference with the circulation or respiration, the movements are at once suspended. Any change in tint, whether pallor or duskiness, about the lips or cheeks, any undue dilatation of the nostrils, any contraction about the corners of the mouth, or any moisture upon the forehead, is regarded as a reason for terminating the treat- ment. If the patient, further, should show any appearance of weariness, such as yawning, or if he should complain of perspiration or palpitation, no further movement is executed. While the movements are carried out the patient ought to breathe regularly, and if this is not done in a perfectly natural manner, he is asked to count in whispers during the movements. While the exercises are carried out, the body and limbs should be absolutely free, so that there is no compression of the vessels. The exercises comprise a series of nineteen movements. Each as it is performed is gently resisted by the operator. The following is a complete list : — (1) The arms are stretched out in front of the body at the 266 THERAPEUTICAL. level of the shoulders, with the palms meeting each other. The arms are then carried ouiwards until they are extended laterally in line with each other, and thereafter are brought liack to their first position. (2) The arm and hand are placed in the fully supinated position, hanging down, and the forearm is liexed upon the arm, without any movement of the latter, until the fingers touch the shoulder ; thereafter the arm is extended to its original position. This movement is carried out first with one arm, and then with the other. (3) The arms, hanging down, are supinated, and raised outwards until the thumbs meet over the head, after which they are brought back to their original position. (4) The fingers of the hands, flexed at the first phalangeal joints, are pressed together in front of the lowest part of the body, and the arms are raised until the hands are above the head, after which they are •brought back to their original position. (5) The arms, hanging in the position of " attention," are raised forwards parallel to each other until they are elevated to a vertical position, and are then brought back to that from which they started. (6) The body is bent forwards and then brought back to the erect position, the knees not being moved. (7) The body is rotated without any movement of the feet, first to one side, then to the other, and finally back to its original position. (8) The body is bent laterally as far as possible, first to one side, then to the other, and afterwards restored to its original erect posture. (0) This is a movement precisely similar to No. 1, except that it is cari'ied out with the fists clenched. (10) The arms are moved in the same way as in exercise No. 2, l)ut the fists are firmly clenched. (11) The arms, starting from the position of "attention," describe a circle by moving forwards and upwards MEANS OF RELIEVING DISTURBANCES. 267 until they are raised vertically. Eacli palm is tlion turned outwards, and the arms descend backwards to their original position. (12) The arms, starting from the position of " attention," are moved upwards and backwards as far as can be done without bending the trunk, and are then brought back to their original position. (13) The patient, standing with the feet side by side and supporting himself by leaning with one hand upon any object, flexes the opposite thigh as far as it is possible, and afterwards extends it until the feet are again side by side. Thereafter leaning on the other hand, he carries out a similar movement with the other thigh. (14) The patient, leaning as in the last exercise, first Ijends the whole lower extremity of one side, kept extended, as far forwards as possible, then backwards as far as he can, and afterwards brings it beside the other. A similar movement is thereafter carried out with the other leg. (15) Supported by leaning both hands in front on the back of a chair, the patient flexes first one leg and then the other upon the thigh as far as he can. (16) Eesting on one hand, the patient raises the extended opposite lower extremity outwards as far as possible, and then brings it beside its fellow. A similar movement is then carried out with the other limb. (17) The arms, held horizontally outwards, are rotated forwards and backwards at the shoulder joint. (18) The hands, held in the extended position, are first bent backwards and then forwards as far as possible, after which they are brought back to their original position. (19) The feet, held in their ordinary position, are first bent downwards and then upwards as far as possible, after which they are brought back to their original position. The resistance in all cases is carried out by the operator placing the palmar surface of his hand upon the aspect of 2 6 8 THE RAPE UTICAL. the patient's limb towards which the niovenient is to be directed. In the case of the sixth, seventh, and eighth move- ments, the resistance is effected by the palm of the operator being placed upon the Iwdy, on that aspect towards which the movement is being carried out. The movements in the seventeenth exercise are resisted by the operator closing his thumb and forefinger round the wrist. It is not to be understood that these movements are always carried out entirely or in the order which has been above mentioned. Some of them cannot be carried out under certain circumstances, as for instance in the case of patients who have to remain in bed, and the medical attendant in any case decides in how far it may be possible to use these movements. When these exercises are employed they must always be begun very cautiously, and with every care as regards the appearance of fatigue. While undergoing a course of exercises, the patient will require a liberal supply of food, and Schott attaches comparatively little importance to the amount and nature of the food, so long as it is nutritious. He does not lay much stress upon the amount of fluid taken during the treatment. These exercises produce considerable effects upon the circulation, as is shown by diminution of the rate, and increase in the volume, of the pulse. In addition, they lessen the area of cardiac dulness, and cause the apex beat to return towards its normal position when dilatation is present. How far these two effects are due to enlargement of the thoracic cavity cannot be determined. Oertel's methods comprise two aims : first, diminution of the fluid contained in the body, and more especially that of the blood ; and, second, correction of the circulatory dis- turbances and strengthening of the heart by mechanical means. The first of these consists in the reduction of the amount of fluid allowed to the patient, and the selection of a diet not containing large quantities of water. The second consists in graduated exercise, more especially in the ascent of different degrees of altitude. The changes which Oertel found to attend his system were noteworthy — the disappearance of cardiac irregularity, palpitation, and uneasiness, better filling of the arterial system, reduction of the frequency of the pulse, MEANS OF RELIEVING DISTURBANCES. 269 increase of the energy of the lieart, and absence of all respiratory distress. On percussion of the heart Oertel thought that he was able to detect a slight reduction of the cardiac dulness. With regard to the lungs the respiration became much more easy, the circumference of the thorax was in- creased, and the vital lung capacity augmented. The amount of renal secretion was increased, and all tendencies to oedema disappeared, whilst throughout the whole system there was a diminution of fat, shown partly by a loss of weight and a lessening of the circumference of the abdomen. Baths. — The treatment of circulatory disorders by means of baths, although advocated by Hope, has not until within the last few years occupied much attention, but recently it has come greatly into favour, chiefly from the labours of Beneke, Groedel, and August and Theodor Schott. It is by no means a new discovery that the employment of medicinal waters, either internally or externally, produces a powerful influence over the circulation indirectly, by affecting the metabolic pro- cesses^many waters have for long been utilised in this way. The use of baths, however, as a means of directly affecting the circulation is of recent origin, and the method has been care- fully elaborated at Nauheim. Nauheim nestles at the foot of the Johannisberg, a small hill on the north-eastern slopes of the Taunus range in the Grand Duchy of Hesse, and is 452 feet above the level of the sea. It possesses several springs, some of which are employed in- ternally, of which nothing need at present be said, while the others are used for the baths. The latter come from a depth of nearly 600 feet below the surface, and have a tempera- ture varying from 82° to 95° Fahr. These waters contain from 20 to 30 parts of sodium chloride, and from 2 to 3 parts of calcium carbonate, in 1000, along with smaller proportions of potassium, lithium, magnesium, strontium, barium, iron, manganese, zinc, bromine, and arsenic. They also contain a very large amount of carbonic acid, amounting, by weight, to as much as almost 4 in 1000, and by volume 1340 in 1000. These springs rush bubbling and foaming from their outlets, one of them rising to a height of 56 feet in the air. Absolutely limpid on issuing from their sources, z 7 o THE RAPE UTICAL. they always become riuUly on .standing, from the deposit of insoluble iron compounds after the escape of the carbonic acid. As baths the waters are employed in three ways : (1) brine baths; (2) effervescing baths; and (3) effervescing current baths. Of these, the first -mentioned are employed at a strength of 15 per thousand of sodium chloride and 1 per thousand of calcium chloride, at a temperature of 94" or 95° Pahr., the carbonic acid having previously been allowed to escape. The strength is gradually increased day by day, and the temperature is modified according to circumstances. The effervescing baths contain the full amount of salts and gas, the temperature being varied to suit the individual require- ments. The effervescing stream baths are the same as those just mentioned in all respects save one — the water is allowed to stream into and out of the baths while it is being used. No one who has been to Nauheim can for a moment doubt the powerful activity of these baths under physiological conditions, or their beneficial effects in certain pathological states. The simple saline baths seem to have no influence beyond that of ordinary water at the temperature which is employed ; that is to say, when the temperature is so high as to be nearly that of the body the pulse becomes somewhat more frequent and rather larger, without any perceptible change in the condition of the heart. The effervescing baths produce results very different from these. In health the effect is seen only upon the pulse, which becomes less frequent in rate, fuller in volume, and higher in pressure. At first the respirations are deeper and more frequent, but after a very short time they return to the normal. Similar effects are seen in many cases of cardiac affections, along with some reduction in the area of relative cardiac dulness. A recent visit to Nauheim afforded me an opportunity of determining these facts on my- self and on others. In my own person the effects of the effervescing and the effervescing stream baths were very well marked. The pulse, which was 72 or 73 while sitting quietly in the shade in front of the bath-house, fell during the ten minutes of immersion to 61, and became at once fuller as regards its contents and larger in respect of the pulse wave. MEANS OF RELIEVING DISTURBANCES. 271 Two hours later, after having taken a short walk and written a few letters, the rate was only 66, and the characters remained much as they were when leaving the bath. The opportunity was allowed me of examining some patients of my own, and some under the care of other physicians, and there could be no doubt of the reduction of the cardiac dulness, as well as of the increase of the cardiac energy, under the influence of the baths. The method of employing the baths is to begin with the weak brine baths at a temperature of 9 5° Fahr. or thereby, the duration of the first bath not exceeding five minutes. There- after the bath is used with greater strength and lower temperature, while its duration is gradually increased to ten minutes. It is usual to intermit the bath every second or third day. The number of these baths varies with each individual case. As soon as the patient can stand the effer- vescing bath it is then administered, beginning with a temj)era- ture of from 92° to 95° Fahr. for about six minutes, and gradually employing a cooler temperature and longer immersion. If at all possible, the effervescent stream bath is employed finally. In certain cases, especially if there be any digestive or urinary troubles, the internal use of the drinking waters is enjoined, especially of the Kurbrunnen or the Karlsbrunnen. The main points in regard to these waters is, that they contain from 10 to 15 parts of sodium chloride and about 1 part of calcium chloride per mille, along with smaller quantities of other chlorides and some bicarbonates. Another spring, the Ludwigsbrunnen, is used if there be any well-marked arthritic tendencies ; it has fewer chlorides and little calcium, but contains bicarbonate of sodium. The Schwalheimerbrunnen contains much more iron than the others, and is used if there is anaemia. The ISTauheim baths may be closely imitated without difficulty. In order to produce the weak bath, with which the treatment should be commenced, 1 lb. of sodium chloride and 1^ oz. of calcium chloride must be dissolved in 10 gallons of water, at a temperature of 95°. The duration of the baths should be, as at Nauheim, about five minutes. Each subsequent bath should be rendered stronger by the addition of more of 272 THERAPEUTICAL. the ingredients, until the hniit of 3 11 >. uf the sodium and 4^ oz. of the calcium chloride to 1 gallons of water is reached. At the same time the temperature of the bath is to be lowered, and its duration lengthened, until a temperature of 85" is reached, along with a duration of from a quarter of an hour to twenty minutes. The baths should not be given oftener than on alternate days, or on two days out of three ; and it is needless to add that, as at Nauheim, the patient should lie down for some time after each bath. In aljout a fortnight it will usually be found that the patient is able to tolerate the effervescing baths. Sometimes, however, this period is con- siderably longer ; it is rarely shorter. In order to produce the effervescing baths, sodium bi- carbonate and hydrochloric acid are added to the full strength of the brine bath. After having dissolved 3 lb. of sodium and \\ oz. of calcium chloride in 10 gallons of water, 2 oz. of sodium bicarbonate must be thoroughly mixed with the water ; o oz. of hydrochloric acid are then to be added just before the bath is used. This may be done by having the acid in a bottle, the stopper of which is removed at the bottom of the bath, and the acid distributed throughout the lower layer of water ; or Sandow's Tablets may be used instead. The baths must be rendered more powerful day by day until 8 oz. of the alkali and 1 2 oz. of the acid are used for a bath of 10 gallons. The bath must be employed with the same care as that mentioned in regard to the natural baths of Nauheim, with a period of rest after each, and frequent inter- missions between them. The effects produced l)y such artificial baths are in all respects similar to those obtained at Nauheim. The influence of baths so prepared was carefully watched by me, when associated with Sir Thomas Grainger Stewart in the Eoyal Infirmary of Edinburgh ; their results were investigated by us, and we were led to the conclusion, which indeed is admitted by every one, that the consequences of artificial and natural baths are identical. It has been customary to explain the action of these baths by an increase in tissue changes produced by greater power of absorbing oxygen by the cells. Such is the explanation given MEANS OF RELIEVING DISTURBANCES. 273 by Schott, and he pleads that it accouuts for the need of rest and sleep following the administration of each hath. He holds that this increased tissue change demands great care on the part of the physician, lest an irritable and excitable state of the nervous system should be produced by excess of bathing. When injudiciously used the baths are apt to cause restlessness and sleeplessness, followed by lack of appetite and loss of strength. Schott holds that there is a reflex stimulation of the heart producing more complete and thorough contraction, as the result of which the heart becomes hypertrophied ; but he is also of opinion that there may also be some direct physiological stimulation of the arterioles and capillaries by the passage of gas through the skin, so as to come in contact with the deeper tissues. Broad- bent is of opinion that there is more probably a physiological dilatation of the capillaries in the skin, so that the resistance to the blood is lessened, and the left ventricle is enabled to complete its systole. In this way a more rapid transfer of blood from the venous to the arterial system would be possible. Broadbent, however, admits that the chief objection to such a view is the slowing of the pulse occurring in the bath, seeing that diminished peripheral resistance might be expected to accelerate rather than retard the pulse rate, and he throws out a suggestion that the slowing of the pulse may be attribut- able to reflex stimulation. It has been said above that similar effects are produced whether the baths are natural or artificial. The effect of the exercises, moreover, must be the same wherever they are carried out, provided the operator is equally skilful. It must, nevertheless, be admitted that the results of treatment are very different when carried out in. this country and at Nauheim. The reasons for this are not far to seek. The patient under treatment there is removed from the scene of his daily labours, and in most cases without doubt from numerous worries, in order to lead an existence characterised by abundance of rest and absolute quiet. The climatic conditions are usually such as to allow him to utilise the fresh bracing air of the district, and he can enjoy a large amount of sunshine, provided with sufficient shade to protect him from the direct rays of the 18 2 74 THERAPEUTICAL. suu. His life at Xauheini is one of peaceful routine. He gets up between seven and eight in the morning and goes to the Wells^ where, if enjoined to use the springs, he sips the water, as is usual in such bathing-places, with the accompaniment of an excellent orchestra. He then returns quietly to his hotel for breakfast, or enjoys it in some shady nook outside, and after glancing over the morning paper, has his bath. After this he lies down, and almost certainly falls into a calm sleep, from which he probably does not awake until it is time for luncheon. After luncheon he again rests until the heat of the day is past, probably sleeping part of the time, and then has the resistance movements, or some gentle exercise, until it is time for dinner, after which he is glad to seek repose. In this way, as has been frequently described to me by patients, and as my own observations have shown me, life at Nauheim is restful in the highest degree. Thus it is that there is a difference between the effects of the baths at Nauheim and any imitations of them in this country. The special indications for the use of these baths at home, or for a visit to Nauheim, will necessarily evolve from time to time in the sequel. Care- ful estimates of the effects of the baths are furnished by Broadbent and Morison in their recent works, and the entire system was the subject of a useful discussion introduced by Sir Thomas Grainger Stewart at the meeting of the British Medical Association in 1896. The most carefully written papers in this country, besides those mentioned, are those of Saundby and Leith. Special Circulatoi^y Remedies. — Over and above all such means of treatment, however, are the methods of acting directly upon the circulatory organs by means of drugs. The great aims of treatment as regards the effect of drugs on the heart and vessels are to modify the force and rate of the former and the fulness and pressure of the latter. By exerting influences of different kinds upon the walls of the heart and of the vessels, important effects may be produced. There are many medicinal substances which directly affect the circulation, almost all of which belong to Schmiedeberg's great class of nerve and muscle poisons. The first point which must be met in regard to the nerve SPECIAL CIRCULATORY REMEDIES. 275 and muscle poisons is that their effects vary greatly, l^oth with the amount which is given, and with the time which elapses after administration. By this is meant that many of the substances act as stimulants or tonics in small doses, while they act as sedatives or depressants in larger doses : in other words, many of them have an immediate action in one direc- tion, and a remote effect of an opposite kind. Another important consideration is that a distinction must be made between cardiac stimulants and circulatory stimulants. Many drugs have the power of exciting the activity of the heart, while they have no influence upon the rapidity of the circula- tion ; many others can produce acceleration of the blood flow while possessing no effects of an exciting kind upon the heart. It is therefore extremely difficult to classify the various nerve and muscle poisons from a purely physiological point of view, and it is certainly more convenient to arrange them in a series of pharmacological groups after the manner of Buchheim. The Alcohol GrouiJ. — The alcohol group includes a large number of drugs which are important in the treatment of cir- culatory affections. Almost all the substances belonging to this group produce, in small or moderate doses, a dilatation of the arterioles and acceleration of the heart, and in larger doses they bring about depression of all the great vital centres, including those controlling the circulation. The researches of Zimmerberg make him doubtful if there is any direct influence upon the heart; the circulatory changes appear to him due to effects upon the nerve centres. It is, nevertheless, the general experience of clinicians that in moderate doses the alcohol series possesses considerable influence upon the heart, not only in increasing the frequency of its action — which might be due to vascular dilatation— but in causing augmented force. Ethyl alcohol in almost any of its protean forms is of use both as a stimulant and as a food. The form which is most suitable for employment must of necessity depend upon the various attendant circumstances which accompany circulatory disturbances, more particularly upon the conditions manifested by the digestive organs. The various substances containing alcohol produce a feeling of well-being, and while in moderate doses never reaching anything which might be regarded as 2 7 6 THE RAPE UTICAL. approachinii" a tendency to anaesthesia, they nevertheless have spothmg etiects. Ether acts powerfully as a stimulant, and this result is attended by sedative effects, while, given as a general anaes- thetic, it may be of great use in many of the painful affections of the heart. Chloroform, although of no benefit as a stimulant — it is, in fact, a powerful cardiac depressant — is eminently service- able as a sedative and anaesthetic. In the form of spirit of chloroform it is most useful, since the stimulant effect of alcohol is united with the sedative influence of chloroform. It is in this way sometimes very useful in combination with other cardiac drugs given by the mouth. In angina pectoris its inhalation proves most beneficial. Chloral is sometimes administered as a hypnotic. The large amount of chlorine in the molecule gives powerfully de- pressing effects to the drug. It is therefore not to be regarded as a very safe agent on account of its influence upon the vital nervous centres — this has been well shown by Harnack and Witkowski. Paraldehyde, sulphonal, and trional are worthy of much more confidence as hypnotics of this group. The nitrites are closely associated with the alcohol group, although the characteristic action of the class is distinctly modified by special components. Spirit of nitrous ether, nitrite of amyl, and nitro-glycerin are the most important of these substances, while nitrite of sodium is a connecting link between it and another group. The special action of all these substances is dilatation of the arterioles along with a fall of the blood pressure. These drugs, which owe their introduc- tion to Lauder Brunton, have therefore been widely employed in modern times for the purpose of reducing the blood pressure in cases manifesting too much peripheral resistance. Under the action of the nitrites the hsemoglobin of the blood, as was noticed by Jolyet and Regnard, undergoes a characteristic change from the formation of methsemoglobin, and the oxy- genation of the tissues is in this way interfered with. By their antispasmodic effects on the unstriped muscle of the bronchial tubes, the nitrites are of signal use in certain forms of cardiac dyspnoea. SPECIAL CIRCULATORY REMEDIES. 277 The Ammonia Grouii. — There is a very general Ijeliei', founded on empiricism, that the different members of the ammonia group are powerful stimulants, and although phar- macological investigation in modern times can scarcely be held to furnish any rational basis for this belief, notwithstanding the observations of Funke and Deahna, the effects oljserved after the administration of some of them warrant the accept- ance of the empirical ideas. Ammonium carbonate and the aromatic spirit of ammonia certainly raise the blood pressure. They are therefore frequently employed, especially in comljina- tion with cardiac tonics, in many circulatory disorders. Under their influence a certain amount of vascular dilatation takes place, and the addition of such substances as the aromatic spirit of ammonia to any cardiac tonic, which is apt to give rise to contraction of the arterioles, may, in cases where such increased resistance is not desirable, be beneficially employed. It must further be remembered that in many instances, showing catarrhal conditions of the respiratory mucous membrane, excellent effects may be produced upon it by the use of the ammoniacal expectorants. The Gamidhor Group. — The members of this class have a somewhat powerful direct stimulating effect upon the cardiac muscle, according to the observations of Heubner, and of Harnack and Witkowski, and also upon the great nerve centres, more especially in the medulla oblongata. They are therefore most useful aids in the treatment of many circulatory conditions in which there is a tendency to failure of the nervo-muscular apparatus. The Caffeine Group. — Substances belonging to this group have stimulant effects, and besides exciting nerve centres, produce an increased frequency of the pulse. As will be mentioned in the sequel, they have, when taken in excess, a tendency to produce various disturbances of the nervous system, and they are therefore to be regarded as one of the many sources of functional cardiac diseases. Inasmuch as the muscle curve undergoes alterations in its character, chiefly shown by shortening of the period of muscular contraction, it is possible that these drugs act directly upon the heart. This, however, cannot be regarded as established. The substances belonging 2 78 THERAPEUTICAL. to this group produce but little effect upon blood pressure. A very slight rise is sometimes observed and is followed by a fall. .The researches of Aubert and Leveu give contradictory results, and we must conclude that the effects of the group on blood pressure and pulse rate are slight. Upon the kidney the drug acts, as was shown by Brakenridge, as a diuretic, apparently by acting upon the renal epithelium. In this way it is often of much use in cardiac dropsy. The Morphine Group. — The complex actions of the mem- bers of this class may often be advantageously employed for the purpose of relieving some of the effects of circulatory disease. Some of their effects are of the greatest advantage ; others, however, are harmful. The beneficial effects are obtained through their actions as sedatives, anodynes, and hypnotics. The action of morphine upon the nervo-muscular apparatus in general, in small doses, is at first stimulant — in fact it raises the blood pressure ; after a time, however, it acts as a depressant, producing its effects in various degrees upon the different parts of the system. Upon the sensory tracts and centres more powerful effects are produced than upon those concerned in motility, and it has therefore to be noted that there are more depressant effects upon the respiratory than upon the circulatory mechanism. In small and moderate doses the members of this group have a tendency to cause acceleration of the circulation, but in larger doses the cardiac pulsations become less frequent. It is probable that these phenomena are the result of the interferences with respiration, as suggested by Gscheidlen. The consideration of these effects shows that the drugs belonging to this class may be utilised with great advantage while proper care is exercised in their employment. In those diseases of the heart characterised by serious sensory symptoms, the various derivatives of opium are of the greatest value. In haemor- rhages due to venous stasis, the hypodermic injection of mor- phine may be relied upon with confidence as our most useful haemostatic. The disturbance of the alimentary functions, and the paralytic effects upon glandular secretion, must be regarded as baneful. They are not present to the same degree after the administration of morphine as of opium. The former, therefore, is to be recommended. SFE CIAL CIR C ULA TOR Y REMEDIES. 279 The Atro'pine Growp. — The substances belonging to this group have a well-marked series of effects common to all, but varying somewhat in degree and activity upon different parts of the organism. They are at first stimulants and afterwards depressants to most, if not all parts of the nervous system, and they produce these effects also upon the nervous mechanism rejjulating the circulation. Their effects on the circulation were very fully studied by von Bezold and Blocbaum. Upon the heart there is for a brief period a retardation of the rate of pulsation, followed by a much more marked acceleration, due to the effects produced on the vagus, while upon the vasomotor system there is probably a contraction of the peripheral blood vessels, not yet thoroughly known, so that the total effect is to produce considerable rise in pressure. Larger doses produce contrary effects. In combination with morphine, atropine is useful in certain conditions of cardiac distress. TI1& Aconite Group. — Aconite and its alkaloid have depressant effects upon the entire nervous system. Upon the circulatory mechanism there is a powerfully depressant effect, shown by frequency, irregularity, and feebleness of the cardiac contractions, along with continuous fall of blood pres- sure. These drugs have sometimes been employed in order to obtain sedative effects in acute diseases of the heart, more especially in endocarditis. According to my way of thinking, however, they are absolutely inadmissible in all such conditions. Aconite probably acts by dilating the blood vessels, but the work of many observers, amongst whom may be mentioned Bohm and Einger, have not yet cleared up its mode of in- fluencing the circulation. The Veratrinc G^'oup. — At first stimulant, and afterwards depressant, in slight degree to the nervous system, veratrine, according to KoUiker, and von Bezold and Hirt, specially acts upon the muscles. The muscle curve undergoes a very characteristic alteration, the descending portion being wonder- fully lengthened. Upon the heart similar effects are pro- duced, and therefore the diastolic phase is greatly prolonged. Along with this there is a rise of blood pressure. In larger doses, the pulsations become accelerated and irregular, along 2 So THERAPEUTICAL. with a considerable fall of l.ilood pressure. Used to some extent in America, veratrine has not obtained any position in this country, and it is impossible to conceive of any utility which it could possess. The DiSainsbuiy, and Koljert. In their actions digitalis and strophantlms are very similar. They equally reduce the frequency and increase the energy of the heart, and they augment the blood pressure. The one point on which opinions differ is in regard to their effects on the arterioles. Fraser holds that they produce little or no contraction, while Einger and Sainsbury, as well as Kobert, profess a different view. It is generally admitted that the effect on the arterioles is much less than that of digitalis. From the therapeutic point of view, these actions of the digitalis group are almost all of advantage. By diminishing the frequency of the heart, it is allowed more rest, and along with this there is a much more thorough interchange between the blood and the muscle cells. Harnack is of opinion that too much stress is laid by physicians on this action of these drugs, but with his views it is impossible to agree. By increasing the energy of cardiac contraction, and by raising the arterial pressure, as well as by increasing diuresis, the drugs belonging to this group lessen passive hyperemia and remove oedema, whether in the form of anasarca of the dependent parts of the body and limbs, or of effusion into the serous sacs. At the same time catarrhal conditions are removed when they depend upon passive hypersemia. As regards the difierences in action exhibited by the various members of the group, it is unnecessary in this place to do much more than compare digitalis and strophanthus. No other member of the group is worthy of a place in the same rank as that justly accorded to these two. From long and careful observation of the actions of digitalis and stro- phanthus, there is no doubt left in my own mind as to their relative advantages. In cases requiring rapid effects, digitalis must be admitted to be of less value than strophanthus. Digitalis, on the other hand, is of much more importance than strophanthus in most cases presenting oedema, and more especially is this the case in mitral affections. Strophanthus is of very real importance in many instances of dilated senile heart ; many examples of this condition which have been for years under my care have convinced me of its pre- 282 THERAPEUTICAL. eminent usefulness in the treatment of such conditions. Strophanthus has much less tendency to produce nausea and vomiting than digitalis. It is one of the greatest drawbacks to the latter drug that so many patients find it impossible to take it on account of hyperemesis, a result extremely rare in the case of stroplianthus. It must be admitted that idiosyncrasy alone appears to have any controlling influence upon such appearances. An important point has lately l^een brought out by Deucher — that the effects of digitalis are much more marked when it is given subcutaneously as digitalinum verum. He has shown that this is due to the action of the gastric fluid on the drug when given by the mouth. Acute Diseases. — In the treatment of acute diseases some special points require to be referred to, but these can only be adverted to in general terms, as they will be fully dealt with in the chapters devoted to such special affections. The general directions with regard to rest, sleep, diet, and ventilation, which are applicable to all circulatory disturbances, are necessarily of even greater importance with regard to them. When an acute affection of the heart supervenes in the course of some general disease, such as rheumatism, the treatment which has been already in operation will require to be steadily persevered with, while in addition such further measures as the additional condition demands must be commenced. By the use of external remedies, something may be done to check the onset of pericardial and endocardial lesions. The application of ice is, in some instances, of undeniable utility. On the other hand, however, better effects are sometimes found to follow the employment of hot applications. Counter-irritation has been for long employed, but latterly Caton has suggested the re- peated application of blisters, as will be more fully described in dealing with the special diseases. The use of local blood- letting by the application of leeches is also in certain of these diseases to be recommended. With the progress of bacteriology, hopes have arisen that some system of inoculation might be found of use in acute diseased conditions of the heart. Such hopes appear to have passed from the region of expectation into the domain of DYNAMIC DISEASES— TOXIC CONDITIONS. 283 realisation, seeing that in septic endocarditis brilliant results have followed the use of antistreptococcic serum. This was used, so far as is known to me, for the first time by Sainsbury, and his results will be more particularly mentioned in the chapter on endocarditis. Dynamic Diseases. — In functional diseases of the circulation, the most important point is to arrive at the real cause of each affection, and it will be found, as is fully detailed in subsequent sections of this work, that very many of those disorders which are commonly classed as functional, are but expressions of some deep-seated structural modification. A large number of such dynamic or functional diseases will be found to require treatment directed towards the improvement of the cardiac tissues. Toxic Conditions. — There remains, however, a considerable number of disordered conditions of the circulation owning toxic or reflex causes, in which it is probable that little or no structural alteration has taken place. Some of these are quite transient, and disappear as soon as the influence pro- ducing them is removed. This is more especially true of those disturbances due to reflex causes. Disorders taking their origin in various poisons are not by any means so easily treated, as many of these conditions are produced by an intimate union between the poison and the tissues, sometimes, no doubt, with structural modifications, and the removal of such conditions can only be effected gradually. CHAPTER VI. CONGENITAL HEAET DISEASE. DoAvx to cumparatively modern times malformations were attriljuted to malign spiritual influences. This was indeed gravely stated by Licetus. Such ideas gradually gave j)lace to a careful study of anatomical appearances, and the pages of Senac and Morgagni contain excellent descriptions of con- genital affections of the heart. In early times antagonistic ideas were held with regard to abnormalities in development. Lemery, for example, held that such changes were due to primitive defects in the germ, while AVinslow regarded them as having their origin in accidents occurring after fecundation. Concessions were made by the successors of those who held these dift'erent views, and it may be mentioned that Haller seems to have adopted an intermediate opinion. Scientific investigations of such conditions really began with the investigations of Meckel, whose work unfortunately was marred by the doctrines of his time with regard to the development of the human embryo, the various phases of which were brought into a more or less unnatural comparison with different types of animal morphology. Bouillaud clearly enunciated the view that malformations might have a double origin ; that they might be produced by diseases arising during the course of development, or might have their cause in a defec- tive primitive constitution of the germ ; he distinctly indicates that changes belonging to the former class are only to be regarded as true diseases, supervening during the period of intra-uterine life, and he would reserve the term monstrosity to original or primordial defects of the germ itself, but ETIOLOGY. 285 he admits such an origin of malformations to Ije rather hypothetical. He may be held, therefore, as considering congenital malformations of the heart as due almost, if not always, to fostal diseases. Friedberg undertook a patient investigation of the development of the circulatory organs in the human embryo, and classified the malformations of the heart into groups corresponding to the three most important periods of the heart's growth. Eokitansky, in his epoch- making work on pathological anatomy, gave a complete classi- fication of the anomalies of the heart and blood vessels. Influenced by the teaching of Dittrich, Dorsch published the result of observations upon fcetal diseases, made under the guidance of his master, and in this work brought the element of foetal disease prominently forward. Chevers collected a large amount of material relating to diseases of the pul- monary artery, and Peacock, with wonderful diligence, not only reviewed most of the previous observations, but classified and criticised them, abstaining carefully from committing him- self in favour of intra-uterine disease. Meyer, about the same time, analysed and grouped the many independent con- genital lesions and their various combinations, attempting at the same time to attain to accurate information with regard to their causation. More recently, Heine, Kussmaul, and Lebert have filled up the gaps in our knowledge, and quite lately Theremin has brought out the results of a long series of careful observations upon the subject. Etiology. — The attempt to peer into the darkness which surrounds the origin of such congenital lesions is now, as it has been during the whole of modern times, a matter which has a singular fascination for the scientific inquirer. Unfortunately the facts which serve for the foundation of theories upon the subject are still defective. Now, as formerly, congenital lesions of the heart are explained by two alternative hypotheses. There is, in the first place, what may be called the embryogenic view, which regards congenital diseases as pro- duced by some inherent defect in development, whereby either arrest or excess of growth leads to malformation. That such a tendency exists is undoubted. It is proved by tlie co- 2 86 CONGENITAL HEART DISEASE. existence of other iiialt'ormations in the same individual, as well as by the presence of anomalies in other members of the same family. Such a tendency is linked in the closest way with hereditary transmission. Attempts have been made to investigate the possible canses. Geoff'roy Saint-Hilaire, in the early years of the present century, found that by shaking a hen's egg violently, or by coating its surface with varnish, he was able to modify the development of the chicken, and give rise to different perversions of growth. Panum and Dareste have followed out similar lines of investigation, and have been able to produce irregular forms of development by different methods of procedure. Valuable observations have also been made upon this subject by Fol, who has found that in echino- derms, if several sperm elements, instead of one, enter the '^■erni, irregular cleavage results, and malformations follow. Within recent years Fere has found that great modifica- tions in development may be produced by the injection of pathogenic germs and their toxins into eggs undergoing incuba- tion. This shows that agents, which produce disease in the individual during extra-uterine and later intra-uterine existence, o'ive rise to the formation of malformations during the earlier phases of development. As Ballantyne so well puts it, the same causes are in action at both periods, but when influencing an embryo so far developed as to have specialised organs, the result is disease. When, on the other hand, influencing an embryo, in which such specialisation has not been carried on to the same extent, the result is a malformation. In the one case the results are pathological, in the other they are terato- logical. The conclusion is therefore justified that the causes of diseases and malformations are similar, if not identical, and that differences in the results are caused by different degrees of resistance in the organisms acted upon. Antenatal life may be divided into three periods, during all of which morbid influences may affect the product of re- production. There is, first, the period which exists previous to the union of the germ cell and sperm cell ; at this time those elements, like the rest of the body, may be influenced by morbid tendencies, as is taught by everyday experience. The second period begins with impregnation, and exists until ETIOLOGY. 287 the development of the speciahsed organs and the endjiyo, that is to say, until about the eighth or ninth week ; during this time also, different morl^id agents may produce modifica- tions of growth. During Loth of these earlier periods the results of morbid intiuences are probably almost entirely terato- logical. The third period of antenatal existence begins with the appearance of specialised organs in the embryo, and exists until birth, and this epoch allows the development of foetal diseases instead of foetal malformations. In tracing onwards the development of the heart as was done in a preceding section, it is possible to correlate, as Hamilton has done, different malformations with different periods of development. When the developmental processes stop at the stage when there is an auricle, a ventricle, and an aortic bulb, a malformed heart may result, consisting only of one auricle and one ventricle — one of the rarer anomalies. If an arrest takes place during the growth of the inter- ventricular septum, so that this structure becomes incomplete, a perforated septum ventriculorum results, the aperture most commonly occupying the undefended space — one of the most frequent of cardiac malformations. When a change occurs during the partition of the auricles, so that the septum is incomplete, a patent foramen ovale results, the most common of all cardiac malformations ; or under other and much less common circumstances, an aperture may be left in the septum at another point, while the foramen ovale becomes closed as under ordinary circumstances. If alterations take place in the evolution of the great arterial trunks out of the aortic bulb, a number of different malformations may have their origin. A double aorta may, for example, be the result, or a communication may be left between the aorta and the pulmonary artery, or these two arterial trunks may be transposed. Still later in the process of development there may be constrictions or dilatations of the great arterial trunks, with or without the persistence of the foetal ductus arteriosus. There may, however, be minor malformations during the evolution of the complex arrange- ments of the branches taking their origin from the different arterial aortic arches. It need scarcely be added that at 2 88 COXGEXITAL HEART DISEASE. different periods of growth duplication of any part, or even of the whole heart, may be present. Malformations taking their origin in intra-uterine disease may be termed nosogenic, and are frequently seen. The best examples of the existence of such antenatal diseases are ex- hibited by the results of the infectious diseases, and by acute rheumatism. In all these cases the poisons appear to be transmitted by the mother to the child. It has been held that the placenta affords adequate pro- tection against poisons circulating in the maternal blood, and that micro-organisms are incapable of penetrating it. There can, however, be little difficulty in accepting it as extremely probable that the toxins produced by the activity of micro-organisms can readily transude from the maternal capillaries into those of the foetus. The common results of such infective processes are seen in the production of endocarditis, which leads to a number of consequential changes. A stenosis of the pulmonary orifice, for instance, leads through the changes in intra-cardiac pres- sure, which it induces, to a patent inter-ventricular septum, to a permanent foramen ovale, to persistent ductus arteriosus, and even to a transposition of the aorta and pulmonary artery, in consequence of the septum being pushed over to the left from the higher pressure on the right side. Such are the conclusions of some of the warmest advocates of nosogenic malformations. There are difficulties in the way of accepting the sweeping conclusions of those who would have us to believe that all congenital diseases of the heart are due to such foetal diseases. One of the greatest stumbling-blocks has been clearly shown by Osier, who points out that it is hard to suppose an endo- carditis limited to the pulmonary cusps of an embryo about an inch long, whose heart could not exceed a few lines in size. The fact is undoubted that the endocardium is peculiarly liable to intra-uterine disease, and it is of interest to note that such changes are very much more common on the right side of the heart than on the left. The pulmonary orifice is more frequently affected than the tricuspid. Lesions occurring, how- ever, at both of these orifices produce obstruction and incom- MORBID ANATOMY. 289 petence. It must be obvious that the greater liability of the right side of the heart to inflammation during fcetal life arises from the relatively higher pressure and greater strain which it has then to undergo. Such lesions are very commonly associated with abnormal inter-auricular and inter-ventricular openings, and it cannot be doubted that these have their origin in disturbances in the normal pressure within the heart. It is not without interest to note that male are apparently more liable than female children to congenital affections of the heart. It is stated, for instance, by von Dusch that of the cases he collected 64"6 per cent, were males and 3 5 '4 per cent, females. Morbid Anatomy. — Some malformations are of a com- paratively simple kind, consisting merely of slight variations in form and structure ; but many of the changes depend upon arrest or excess in the normal processes, and lead to important structural alterations. Many of the malformations of the heart and great blood vessels render life impossible, and are therefore of comparatively little practical importance. Others do not so materially interfere with vital processes, and may be seen in those who have even attained adult age. It is extremely difficult to classify the malformations of the heart, chiefly on account of the fact that in most instances several different structural defects are associated together. The most satisfactory, although perhaps not the most scientific method appears to lie in following out the different anomalies from the simpler to the more complex. Displacements constitute the simplest of the modifica- tions in the development of the heart and blood vessels. The most frequent example of this alteration is simple trans- position, in which the heart bears the relation to the right side of the body which it normally ought to do to the left. The other viscera in cases of this kind are also almost always transposed, but this is not an invariable rule, some instances to the contrary having been recorded by Breschet. In such cases the heart may be perfectly well formed, as in the instance described by Samson — cases similar to which occasionally occur — or, on the other hand, various anatomical defects may be present. 19 290 CONGENITA L HE A R T DISEA SE. The lieart is sometimes situated entirely, or partly, outside of the chest. In sucli instances of ectopia cordis the organ may lie entirely external to tlic chest wall, it may protrude Fifi. 107. — Tran.sposition of iiortjt and imlnioiiavy arteiy along with patency of the ductus arteriosus and an opening througli the ventricular septum. through the diaphragm into the abdominal cavity, or it may be found in the region of the neck. Transposition of the great arterial trunks, first observed by Baillie, sometimes occurs, the aorta taking its oriifin from the MORBID ANATOMY. 291 right ventricle and the pulmonary artery from the left ; these anomalies are usually associated with other structural modifications, as in the case figured in the accompanying illustration (Fig. 107) from a specimen descrihed by Gordon Sanders, and placed at my disposal. It would seem no easy task to attempt an explanation of the transposition of the great arterial trunks, yet Eokitansky and Meyer have expressed some views which are not only extremely ingenious, but are also at the same time so reasonable that tliey may be accepted as a provisional explanation of the transposition. It has already been shown that the ventricles are separated from each other by the upward growth of the septum, which begins to make its appearance about the fourth week, and that the common arterial trunk is also separated into right and left halves by a septum taking its origin in an indentation of the walls of the vessel. The septum of the ventricles and the septum between the two halves of the arterial trunk become applied to each other, so that each ventricle is finally placed in communication with one-half of the vessel. It has to be borne in mind that the arterial end of the ventricles and the common arterial trunk undergo a rotation in the course of development, so that the portion of the trunk which finally becomes the pulmonary artery is twisted round in front of and to the left side of that which ultimately forms the aorta. Now, if through any cause this rotation is impeded at a period anterior to the coalescence of the arterial and ventricular septa, it is, as Eokitansky showed, possible for the aortic portion of the trunk to communicate with the right ventricle, while the pulmonary portion is in connection with the left ventricle. Such a cause may be present in a pericardial adhesion, as described by Meyer. In a very large proportion of instances of transposition of the great arterial trunks, there is an open septum ventriculorum, so that there is practically a free communication between both the ventricles and each of the arteries. Malformations characterised by defect are frequent. Total absence of the heart is seen from time to time in infants who are not viable ; such acardiac embryos have very commonly anomalies in other parts of the body. The pericardium is 2 92 CONGENITAL HEART DISEASE. occasioually entirely wanting, and the mediastinum, in such cases, consists only of the layers of the pleura- with some cellular tissue. One of the earliest instances on record was described by Baillie, and examples have since been seen from time to time. Simple malformations of individual portions of the heart may take their origin in very slight UKxlitications of ordinary developmental processes or in intra-uterine affections. The valves, for example, which guard the orifices of the heart may differ in number from the normal standard ; there may be more cusps or there may be fewer than the usual number. Such minor changes may probably owe their existence either to a favdty partition of the valvular folds, or to some endo- cardial disease during foetal life. Narrowing of one or other of the orifices of the heart is found with comparative frequency. Stenosis or atresia of the . auriculo- ventricular orifices may be attributed with extreme plausibility to some abnormal partition of the primitive heart during the growth of the inter- ventricular septum ; it is, how- ever, quite as probable that it has its origin in some foetal disease. Obstruction at the arterial orifices is much more frequent, particularly in regard to the pulmonary orifice. Stenosis or atresia of this channel is very common indeed, and may be seen in the pulmonary artery at its orifice, or in part of the conus pulmonalis. To Kussmaul must be given the credit of having established the fact that a large number of the other malformations of the heart are caused by pulmonary stenosis, but, long before, Morgagni and Hunter had enunciated a similar view. This is not a theory of universal applicability. Peacock has shown that an obstruction of the pulmonary orifice from coarctation of its cvisps is sometimes associated with a patent septum ventriculorum, and as the septum is completed before the valves are developed, it is difficult to understand how the causal nexus can be apj)lied in such instances. Longstreth suggests that a reopening of the septum may take place in such cases, but to my mind it is more likely that two different causes have been at work. The aorta and its orifices are much less commonly affected. MORBID ANATOMY. 293 but the aortic orifice is occasionally found in a condition of stenosis, or the aorta itself in the neighbourhood of the ductus arteriosus may be contracted. According t(j Virchow a con- genital narrowness of the whole aorta is found in connection with chlorosis. Abnormal width of the orifices has sometimes been recorded. The aortic orifice and aorta, for instance, have been described as enormously dilated, and this lesion has most frequently been found in association with narrowing of the pulmonary orifice and artery. Whether such changes are brought about by a developmental modification of the normal partition of the primitive aortic bulb, or produced by intra- uterine disease, is impossible to determine. On account of absence of the internal septum, in whole or in part, the heart may consist of only two, or only three, chambers. When both inter -auricular and inter- ventricular septa are absent, the heart has been said to resemble that of the fish in plan, and when such is the case the great vessels arise by a common trunk — the primitive aortic bulb. Such bilocular hearts are incompatible with independent existence. When the inter-ventricular septum is incomplete, while the inter-auricular is more or less -perfectly formed, the heart has been likened to the type seen amongst some of the reptiles. Here the blood vessels take their origin in the normal manner, and there is a possibility of existence even until the period of adult life. Instead of such grave defects there are more commonly openings through the septa. The most common of these is the persistence of the foramen ovale between the auricles. It has been shown previously that the foramen ovale becomes, to a considerable extent, closed during the last month of foetal life, but this sometimes does not take place, and an opening, more or less guarded by a valve, may persist. According to Peacock, the opening is sometimes extremely large, and absolutely unprovided with any valvular apparatus ; the aperture may be of relatively natural size, but the valvular folds may be too small to shut the opening ; the valve may be of sufficient size, but it may be perforated by one or more apertures ; or the valve may not be sufficiently well adjusted to close the orifice. The first three classes are not commonlv 294 CONGENITAL HEART DISEASE. seen : tlie Inuith tnriu is liy far the most coiniiiuu inalfunuii- tioii ill the heart. It is held hy some observers, amongst whom uuiy be mentioned Longstreth, that this abnormality in the vastly preponderating luimber of cases results from Fig. 10s. — Patent ductus urterio.sus. obstruction at the pulmonary orifice. My own observations, however, lead me to dissent from this opinion, for a very large number of cases of patent foramen ovale are unattended liy any otlier lesions. It is, nevertheless, often found with changes at the pulmonary or tricuspid orifice, and even with lesions of MORBID ANATOMY. 295 Fig. 109. — Patent ductus arteriosus. the aortic and mitral orifices ; these probahly have a causal relationship by altering the course of the ftetal circulation. Partial defects of the inter-ventricular septum are most commonly found in tlie membranous part at the anterior end, but apertures may occur in different parts of the septum at its basal end. Two or three such openings may be present. Some of the foetal channels between the great blood vessels, which usually become obliterated at birth, may remain permanently open. The most frequent ab- normality of this kind is a patent ductus arteriosus, which is most commonly associated with other lesions to which it is probably secondary. It is shown in Figs. 108 and 109, from specimens kindly lent to me by Dr. John Thomson. This constitutes a malformation perfectly compatible even with adult life, and, as will be seen in the sequel, patients present themselves with the diagnostic symptoms of this defect not at all infrequently. This foetal channel, on the other hand, seems to become closed in certain cases at too early a period of development, and in consequence leads to structural altera- tions in order to compensate for its obliteration. It is possible that such a defect may arise from the absence of certain of the branchial arches. Complex defects produced by combinations of the individual malformations, which have just been referred to, are more com- monly met with than any of the lesions separately, with the sole exception of the patent foramen ovale. The combined changes most frequently met with are stenosis of the pulmonary orifice along with septal defect, usually of the inter -ventricular wall at its basal end. In this case it seems probable that the pulmonary stenosis is the primary factor, leading by increased pressure to interference with the normal growth of the septum. These combined defects are 296 CONGENITAL HEART DISEASE. often seen in association witli a permanent foramen ovale, so that there is free communication between the auricles, as well as the ventricles. It has already been seen that congenital affections of the aortic orifice are rare in themselves, and they are also un- common in association with other defects ; instances, never- theless, are on record presenting inter-ventricular communica- tions along with aortic atresia. The auriculo-ventricular orifices are by no means so commonly affected, but narrowing of one or other, along with some arterial defect, is not altogether a rare occurrence. As will be mentioned in the chapter on affections of the tricuspid orifice, there is good reason for believing that obstruction at the right auriculo-ventricular opening is for the most part of congenital origin. Sometimes, associated with pulmonary atresia, tricuspid inadequacy is present, probably caused by the change at the arterial orifice. Congenital lesions of the mitral orifice and its cusps are much rarei'. A lieautiful example of this defect was recently described by Carmichael. Such conditions are not infrequently associated with defective growth allowing of intercommunication between the two sides of the heart, or between the great arterial trunks ; the presence of the further alteration seems to depend on the amount of interference with the blood current. Patent ductus arteriosus in itself is rare, but it is one of the commoner malformations in association with pulmonary stenosis, and an inter-ventricular opening is often associated with these defects. The consequences resulting from cardiac affections arising during fretal life vary widely according to the seat and extent of the changes. Many of the defects referred to render life impossible ; others produce but little interference with the circulation. Speaking generally, it may be said that the mere fact of a communication between two chambers of the heart causes less disturbance to the circulation than an obstacle to the onward How of the l:)lood ; and it is a well-known fact that, with a free comnnmication between the two sides of the heart, there may not even be cyanosis. The usual pathological ^ YMPTOMA TOL OGY. 297 effects, however, of the different lesions are cyanosis and various results of venous stasis as seen in the extremities and dependent parts. Laennec believed that cyanosis was in some degree an- tagonistic to tuberculosis, and this opinion was taken up and more strongly urged by Eokitansky, who asserted tliat cyanosis provided a complete protection against tuberculisation. Since the observations of Gregory and Louis, however, it has been known that there is no truth in such assertions, and Peacock has expressly proved that there is an increased liability to tubercle in cyanotic conditions. He states that out of fifty- six patients with different forms of malformation who survived the age of eight, nine or 16 "7 per cent, died of tubercular affec- tions, while about the same period the deaths from consumption amounted to only 9'1 per cent, of the total number in the population at large. Lebert has with great diligence examined the facts bearing on this question, and has found that there is hardly a disease so commonly followed by tuberculosis as pul- monary obstruction. Duguet and Cadet de Gassicourt hold that this tendency is simply due to deficient hsematosis. Symptomatology.- — -Just as there are frequently no general symptoms in organic disease of the heart, even in its most serious forms, so in congenital heart disease there is often an entire absence of any clinical phenomena. Cases of the kind are in consequence only detected by physical examina- tion. An instance has been mentioned by Duroziez, in which a very large opening between the two auricles was discovered in a woman who died of erysipelas at the age of seventy-six. The central factor upon which depends the presence or absence of general symptoms of congenital heart disease is the balance of the circulation. If there be no disturbance of the attractive and propulsive forces of the circulation, there are no outward and visible symptoms. In many cases, on the other hand, in which there is an interference with the onward flow of blood, it is possible to determine the presence of con- genital heart disease at a glance. Of the general symptoms present in congenital heart disease, that which is most prominent is cyanosis, the highest 298 CONGENITAL HEART DISEASE. degrees of which are only found in cases of such affections. In addition to the livid hue of the integument, which reaches a deep violet in the lips, nose, ears, lingers, and toes, more particularly in the nails, there is a characteristic prominence of the lips and nostrils. The tint of the skin always deepens with nniscular exertion, and mental excitement is usually sufdcient to deepen the duskiness of the skin. It need hardly be added that a paroxysm of coughing produces a great increase in the depth of the colour. The well-known clubbing of the fingers and toes is usually present also, and the nails show a well-marked arching. Examination of the eye in almost all instances shows a sinuosity or tortuosity of the veins of the retina, which in itself is much more dusky than in health. The condition of the blood, fully described in a previous chapter, is characteristic. The specific gravity may be above 1070 ; the haemoglobin may reach 160 per cent. ; the number of red blood corpuscles per c.mm. may rise to above 9,000,000, and that of the white blood corpuscles to 16,000. There is often a great tendency to haemorrhage, which appears to be closely linked with the presence of cyanosis. The capillaries of the nose and of the gums, and even those of the respiratory mucous membrane, are apt to allow of the escape of blood. There is also frequently a considerable tendency to transudations into the subcutaneous textures, and even into the serous sacs. Children sufferina; from the effects of congenital heart affections frequently complain of cold, and shiver with the least fall of the external temperature. It often happens that the skin in such cases feels cold on applying the hand to it, and the superficial temperature, taken in the axilla, is low, while that of the mouth or rectum is usually quite normal. Breathlessness is one of the most pronounced symptoms. There may be no dyspnoea while the child is at rest, but with any bodily or mental exertion the patient begins to pant for breath. At times there are asthmatic paroxysms quite analogous to the cardiac asthma of acquired heart disease in adults. S YMF TO MA TOL OGY. 299 As a rule children born witli heart lesions manifest u lethargic or apathetic condition. The mental balance remains frequently unstable for a longer period than is common, in healthy children, and there is great difficulty in educating a child suffering from congenital heart disease. It is not at all uncommon to find convulsions produced as a consequence either of exertion or coughing. The development of the entire system is retarded. The patients remain stunted, and very frequently have other malformations in addition to the cardiac disease. An arching forward of the prsecordia may often be seen. This is quite distinct from what is known as pigeon-breast, and it is probably caused by an enlargement of the heart while the walls of the chest are still very plastic. Laennec did not have occasion to investigate the physical signs of cardiac malformations, and the first observers who attempted to systematise the means of diagnosing such condi- tions were Bertin and Hope. It must be admitted that the differentiation of the various cardiac malformations is frequently attended by extreme difficulty. Some of them are unrecognisable during life, and others are so complicated as to render their absolute diagnosis impossible. When such cases are, however, discounted, there remains a certain proportion in which it is possible to determine the nature of the lesion which is present. Entire absence of the heart may be passed over without comment, inasmuch as it is quite incompatible with the independent life of the individual. Absence of the pericardium does not seem in any instance to have given rise to clinical phenomena by means of which it could be recognised. It might, nevertheless, be reasonably inferred that some physical signs indicative of this condition should be present, analogous to those which are found in adherent pericardium from fibrinous pericarditis. Medical literature, however, contains no reference to anything of the kind. In congenital malpositions of the heart it may occupy very various situations, and ectopia cordis may be cephalic, abdominal, or extra-thoracic. In the first and last named of these conditions physical examination reveals the position of 300 CONGENITAL HEART DISEASE. the organ, and in extra-thoracic cases the heart gives rise to very definite phenomena. Simple transposition of the entire heart gives rise to physi- cal signs by which tlie condition is easily recognisable. The apex beat is found mi the right side of the chest, the area of dulness on percussion shows the priiecordia to occupy the position on the right side which under ordinary circumstances it holds to the left, and the intensity of the heart sounds is greater on the right instead of the left side of the chest ; but over and above these facts it is not to be forgotten that in cases of transposition the other organs of the body are also in almost every instance transposed. On examination, there- fore, of the abdominal viscera, the liver will be found on the left side and the spleen on the right. In all cases where the malposition of the heart is present the situation of the abdominal viscera must be carefully investigated, and if they are found in their ordinary situations, every possible morbid source of acquired displacement must be rigidly excluded before it is possiljle to determine that the malposition is con- genital. In most of the diseases affecting its internal mechanism the pulse is empty and compressible. It is rather more frequent, as a general rule, than the normal rate. It is not uncommonly irregular. Each individual pulsation is for the most part small. The further particulars in regard to the pulse along with the other physical signs will be dealt with under the individual diseases. Affections of the Pulmonary Orifice. — In obstruction at the pulmonary orifice more or less cyanosis is present, and becomes exaggerated on exertion. There may be no persistent breath- lessness, but dyspnoea manifests itself with any excitement or movement. There is very commonly clubbing of the fingers and arching of the nails. The pulse is small and empty. A certain amount of prominence of the prrecordia ]nay be seen. If there are no changes in the veins or arteries of the neck, the apex beat usually occupies its ordinary situation. A thrill is often felt over the left basal portion of the heart. The cardiac dulness is enlarged to the right side, and there is a loud, usually rough, systolic murmur heard with its maximum S YMF TO MA TOL OGY. 30' intensity in the second left intercostal space ; the second sound in the pulmonary area is weak. The murmur is often very widely propagated, and may be heard over the entire thorax, both back and front. It is said to be occasionally conducted up to the carotid arteries ; no instance of this has ever presented itself before me, and in simple uncomplicated instances of pulmonary affection it is difficult to understand by what mechanism the murmur can be so propagated. Pulmonary incompetence is far from common amongst congenital affections. When it is present it is usually associated with obstruction, and the symptoms and physical signs are therefore due to a combination of the two lesions. In addition to cyanosis, dyspnoea, and clubbing of the fingers, there may be a diastolic thrill at the base of the heart, the right border of the heart extends farther to the right than is normal, and there is a diastolic murmur, some- what high-pitched in its tone, which has its maximum intensity along the left edge of the sternum and about the level of the third intercostal space or fourth costal cartilage. This murmur is not widely propagated, but may be heard as far down as the xiphoid cartilage. Right Atcriculo - ventricular' Orifice. — Affections of the tricuspid orifice are much less frequent than lesions at the pulmonary orifice, but, as will be mentioned in the appropriate chapter, it seems extremely probable that many cases of tricuspid obstruction are of congenital origin. Structural alterations at the tricuspid orifice do not produce by any means so much general disturbance of the balance of the circulation, and therefore cyanosis and dyspnoea are much less prominent features, while clubbing of the fingers is for the most part absent altogether. The pulse does not give any special features. The most characteristic physical signs of disease at the tricuspid orifice are pulsation or turgidity of the veins of the neck, a heaving impulse in the epigastric region, enlargement of the area of cardiac dulness to the right, and on auscultation, murmurs, presystolic or systolic, according as there is obstruction or incompetence. When obstruction is present a distinct presystolic thrill may be felt in the region of the xiphoid cartilage. 30 2 CONGENITAL HEART DISEASE. Defects ill the Septum of tJte Auricles. — A patent foramen ovale, or other opening between the two auricles, very often produces neither general symptoms nor physical signs, and the lesion, even when on a large scale, is unexpectedly found after death even in those who have lived long lives. Several specimens exemplifying these facts are in my own possession, and my experience simply repeats that of numerous other observers. Cyanosis is not produced by defects in the auricular septum, and is only present if there be some valvular lesion, causing retardation of the blood current. Dyspncca is also only present as the result of other lesions. It may be said, in fact, that a patent foramen ovale frequently prevents the incidence of cyanosis, and of dyspncea, by providing to some extent a means of equalising the work of the two sides of the heart. Senac quaintly observes that when the foramen remains permanently patent it allows of prolonged diving, and even of suffocation up to a certain pf)int. It has been held by Eichhorst that a presystolic murmur is produced by an opening between the auricles, and that this may be heard at the third and fourth left costal cartilages. If this be so, the murmur must be produced by a hypertrophied condition of one or other, of the auricles, seeing that the intra-auricular pressure under ordinary circumstances is nearly equal. Some interesting clinical features occur in cases of open auricular septum complicated by other lesions ; a venous pulse in the neck, for instance, has been seen in mitral incom- petence and patent foramen ovale, while cerebral embolism has not been uncommon in thrombosis of one of the veins of the leg, part of the thrombus having gained access to the left auricle by means of a patent foramen ovale. Defects in the Se^yfiim of the Ventricles. — Openings between the two ventricles cause more disturbance to the general circvi- lation, and therefore reveal themselves by more obvious clinical features than is the case with defects of the auricular septum. They may be held to produce systemic symptoms somewhat resembling those resulting from mitral incompetence, with this essential difference that the lungs escape the effects of backward pressure. It must he allowed, nevertheless, that from the stream of blood entering the ric!;ht ventricle there is 6" YMPTOMA TOL OGY. 303 augmentation of pressure and some consequent disturljance with the functions of the lungs. On excitement or exertion cyanosis and dyspna3a may make themselves manifest if they are not continuously present. The further symptoms depend entirely upon the presence or absence of other lesions. If there be lesions at the pulmon- ary orifice, the symptoms produced by these lesions entirely overshadow those resulting from the patent septum. If there be obstruction or regurgitation at the tricuspid orifice, the clinical features are for the most part simply those of the tri- cuspid disease. In the great majority of instances of patent septum, some of these lesions are present, and the physical signs properly belonging to the septal defect are rarely met with ; along with an enlargement of the cardiac dulness to the right, nevertheless, a systolic murmur has been heard in some cases at the fourth left costal cartilage close to the sternum. Persistence of the Arterial Duct. — As previously mentioned, a patent ductus arteriosus is uncommon as an isolated anomaly. Instances are, on the other hand, of frequent occurrence in association with other congenital lesions. There is usually some dyspnoea on exertion, and this is accompanied by a slight degree of cyanosis. No doubt both these symptoms are produced by the strain which is placed upon the right ventricle in consequence of the stream of blood which enters the pulmonary artery from the aorta. Inter- ference with the voice has been seen in cases when aneurysmal dilatation of the duct has, by pressure upon the left recurrent laryngeal nerve, produced paralysis of the left vocal cord. On inspecting the chest there is occasionally a fulness in the second left intercostal space, about an inch from the edge of the sternum, and on applying the hand over this spot a distinct thrill, accompanying or following the apex beat, may be felt. The heart on percussion is usually somewhat enlarged towards the right, but the left edge is also not infrequently farther to the left than the normal. The most characteristic physical sign is a murmur in the second left intercostal space over the septum where the thrill is felt, and this murmur is of late systolic rhythm, that is to say, that when compared with the apex beat it distinctly follows it. The murmur is usually 304 CONGENITAL HEART DISEASE. somewhat long in its duration, and of a high-pitched character ; it is usually louder on deep inspiration. It is further frequently accum})anied l)y consideral)le accentuation of the pulmonary second sound, due to the increase of pressure in the pulmonary artery. A change in the relative size of the pidse in the radial and femoral arteries occurs in consequence of the loss of blood in the aorta through the patent duct, and Franc^ois-Franck has remarked that during deep inspiration the radial pulse becomes smaller on account of the inspiratory expansion of the lungs and aspiration of blood from the pulmonary artery. Diagnosis. — There is as a rule little difficulty in deter- mining that a congenital heart affection is present. There are, however, instances of heart disease in the adult, as will be referred to from time to time in subsequent portions of this work, in which, although the lesions appear to have their origin in fcetal conditions, absolute certainty is unattainable. Examples of such conditions are seen more frequently in connection with the pulmonary and tricuspid orifices than with any other part of the circulatory system. The differ- entiation of some of the congenital lesions is attended by mu.ch difficulty, more especially in young children. The limited size of the thorax, and the ease with which murmurs are conducted, render analysis of the clinical features difficult. The differential diagnosis of various congenital lesions must be conducted in accordance with the general principles applic- able to heart disease which is not of antenatal origin. Prognosis. — A forecast of the future in any instance of congenital heart disease must depend for the most part upon the nature of the lesion. It must, however, be subject to con- siderations connected with the family tendencies. It is a well- known fact that many patients with serious congenital lesions suffer but little, while others with exactly the same condition succumb only too readily. The difference in the outlook is conditioned by the possibilities of compensatory changes, and such possibilities naturally arise from the general nutritive conditions of the individual cases. Slight obstruction at orifices of the right side of the heart are not attended by any considerable degree of impaired health. TREATMENT. 305 Openings in the septa, whether of the auricles or ventricles, are frequently found on post-mortem examination of patients who have died in advanced years ; such imperfections do not necessarily interfere seriously with life, unless in the case of patent ventricular septum, where the opening is of large size. A certain amount of obstruction of the pulmonary artery may be present without seriously interfering with vital func- tions. A patient under the care of Graham, for instance — ■ described by Craigie — had been able for very hard work as a railway labourer until the age of 44, and another case was narrated by Fallot, in which the patient reached 63 years of age. On the other hand, when there is a high degree of obstruction there is not merely greater interference with functions, but there are likely to be secondary defects com- pensatory in their origin, and life is much shortened. Trans- position of the main arteries is incompatible, as Peacock says, with the maintenance of life for any considerable period after birth. Simple malpositions of the heart are productive of no disturbance, and absence of the pericardium causes so little interference that it is but rarely diagnosed. The prognosis will be guided by the liability manifested by individual cases towards various symptoms. If there be a tendency, on the one hand, to dyspnoea, haemorrhage, or convulsions, or, on the other, to pulmonary complications such as atelectasis, capillary bronchitis, broncho -pneumonia, or phthisis, the outlook is rendered by so much the more serious. Teeatment. — It is not an easy task to lay down definite rules for the management of congenital heart disease in general, but it may be said that this must be in every case symptomatic. In those instances which present no symptoms there can be no question of treatment, but when patients show any clinical features of heart failure in any of its forms, they should be met by appropriate means. In the treatment of congenital disease of the heart, climate is of importance, and there can be no doubt that a dry, warm climate is best adapted to ensure the comfort and well-being of patients suffering from such diseases. The avoidance of all conditions involving mental excitement and physical exertion 20 3o6 CONGEXITAL HEART DISEASE. is essential in eases where the cireulatory equilibrium is un- stable. The food must be such as will not in any way strain the digestive organs, while it must, on the other hand, be such as will' uftbrd sufficient, nourishment, and render blood forma- tion easy. A sufficient amount of regular exertion, along with fresh air and sunlight, must be enjoined, and it is also essential that the clothing, while light, should be warm. The fact has been clearly recognised since Gintrac's observations, that alcohol exercises a prejudicial influence in cases where cyanosis is a marked feature, a fact which Walshe, in his latest edition, associates with the well-known effects of alcohol under evil atmospheric surroundings. The use of the bromides has been found by me of real service in those cases of congenital heart disease where there is a tendency to erethism. Illustkative Cases. — In presenting a few illustrative cases of congenital heart disease, it is unnecessary to describe instances characterised by absence of symptoms, as shown by several cases of patent foramen ovale which have been under my own observation. Those which follow are examples of unmistakable affections. Case 1. Pnlmonarii Obstruction and Patent Ventricular Septum. — T. K., aged eight years, was admitted to the Deaconess Hospital on October 25th, 1894, com- plaining of breath - lessness on exertion. Both parents were alive and had always been healthy; he was one of a family of eleven, of whose members two sons had died, one from scarlet fever, and another from hydro- cephalus, but the remaining six sons and two daughters were in good health. At the time of his birth the patient was apparently a healthy infant, but, when a few months old, he became bluish in colour and had always Fig. no. — Cliibbiii;^ of lingers in congenital heart disease. ILLUSTRATED CASES. 307 Fm. 111. — Clubbing of toes in noiigpnital heart disease. since been delicate He had an attack of scarlet fever some years liefoi'e admission, from which he recovered joerfectly. On admission he was ob- served to be deeply cyanosed ; the skin everywhere was of a bluish tint, the lips were almost black, and the conjunctiva", were dusky. Tlie fingers and toes were markedly c;luljl)ed, and the nails, which were much curved, were almost black. These appear- ances are seen in Figs. 110 and 111. The patient was three feet nine inches in height, and weighed 2 st. 10 lb. The temperature was usually below normal, but fluctuated between 97° and 99° F. The alimentary system showed no symptoms of disturbance. The second dentition was in progress. The tongue was clean, l)ut of a very dark purple colour. The liver exactly reached the costal margin in the right mammillary line. The htemopoietic system presented some interesting f facts. The spleen reached to the mid-axillary line, and was there- fore of the usual size. On examination of the blood the haemoglobin was found to be 110 per cent., the red corpuscles were 8,470,000 per cubic millimetre, while the white corpuscles num- bered 12,000. The spectroscope showed the characteristic double band of oxyhsemoglobin. With regard to the circulatory system, the patient on any exertion became much more cyanosed and panted violently, but when lying quietly in bed showed much less cj^anosis and almost no breathlessness. On inspection there was no visible Fro. ii2.-Chest tracing from Case 1. The double pulsation in the neck, and in the continuous line shows the area of dulness of , . , . , , the heart and liver; the line ^yith the dashes prOiCOrdial region there waS no the borders of the lungs ; the dotted line the impulse save the apex beat in the area over wliich the systolic murmur was flfth left intercostal space. The heard; the cross the apex beat; and the star . -^^ ^^^^ g^ ^^ 114_ the maximum intensity of the murmur. ^ The vessel was rather emptj^, the pressure low, the pulsation regular. No thrill was felt in the pra?cordia, but an impulse with both systole and diastole, and the apex beat was 3 o 8 CONGENITA L HE A R T DJSEA SE. (lelei'iniiied to be one imli ami tlurt'-ciuartei'.s liDiu mid-sU'riuim. On percussion the borders of the cardiac dnlness were Ibnnd at the level of the fourth costal cartilages to be one inch and a half to the right and two inches and a half to the left of the mid-sternal line. A loud rasjiing murmur was heard nver the entire jiriecordia ; its maximum intensity was at the left edge oi' the sternum at tlie level of the fourth costal cartilage, and it was propagated ujnvards as far as the external ends of both clavicles — to the right as far as the mammilla, to the left four inches beyond the mammilla and downwards along each costal margin to the same extent, viz., two inches and a half beloAv the level oi the xijihoid cartilage. No murmur could be heai-d in any vessel. These physical signs are shown in Fig. 112. The priecordia were distinctly arched. There were numerous rhonchi throughout the chest, but otherwise the respiratory system i^resented no symiJloms requiring notice. The respirations numbered 24 per minute. The urine was pale in colour and acid in reaction; its specific gi'avity was 1022. It contained no aVmormal constituents. The integumentary system was, apart from the high degree of cyanosis, not distinguished by any sjjecial characters, and the nervous system was in all respects normal. Although the patient had never been taught, on account of his state of health, he was an intelligent and observant boy, always enjoying high spirits. The diagnosis of the cardiac lesion was attended by some difficulty. There could be no doubt that the condition was congenital, for although the cyanosis only showed itself after the lapse of some months from the date of birth, the patient had not during the interval suffered from any acute disease capable of causing endocarditis. In this respect the history of the case was in accord with that of most congenital heart lesions. The maximum intensity of the murmur being almost in the tricuspid area might favour the view that there was regurgitation at the right auriculo-ventricular orifice ; but such an explanation was negatived by the al)sence of any venous symptoms in the neck. On the other hand, the murmur might be produced by obstruction at the pidmonary orifice, and heard with greatest intensity over a dilated and hyper- trophied right ventricle, such as undeniably was present in the case ; or, again, the murmur might be the result of a com- munication between the two ventricles, allowing a stream of blood to flow from the left cavity to the right, and thus to produce over the right ventricle a systolic murmur. The lesions probably present, judging not only from the clinical facts of this case, Imt also from the experience of similar ILLUSTRATIVE CASES. 309 cases, were obstruction at the pulmonary orifice and an imperfect ventricular septum. Such was the provisional diagnosis of the case. The little patient improved considerably under symptomatic treatment, and returned to his home in the country after a few weeks' residence in the hospital. During the course of the following year, however, he died from some pulmonary affection. No autopsy could be obtained. Case 2. Pulmonary Obstruction and Patent Ventricular Heptum. — M. S., aged nine, appeared as an out-patient in the medical waiting-room of the Roj'al Infirmary on November 25th, 1895, complaining of breath- lessness. In accordance with my advice she was admitted to Ward 25. Both her parents were in good health, as were all her brothers and sisters, with the exception of one who died in infancy of scarlet fever. Ever since her infancy the patient had been of a blue tint and had suffered much from breathlessness on exertion. During the two or three weeks immediately preceding her admission to the hospital the breathlessness had become more troublesome, and the little patient had been feeling somewhat sickly. On admission she was observed to be extreraelj' cyanotic. The skin was of a universal bluish colour, the lips were so deeply violet as to be almost black ; the ears, alee nasi, lingers, and toes were also extremely dark and distinctly clubbed. The tongue was slightly furred, but there were no other symptoms of alimentary distur- bance. The liver was at the costal margin in the right mam- millary line. The spleen reached the mid-axillary line. On ex- amining the blood it was found to contain 95 per cent, of haemo- globin ; the coloured corpuscles numbered 6,800,000 and the Pi- colourless corpuscles 10,000 per c.mm. The spectroscope gave the double band of oxyhemoglobin. Any excitement or any exertion produced a much greater degree of cyanosis, accompanied by considerable dyspnoea, but when the patient lay quietly in bed, the cyanosis and dyspnoea did not cause her any distress. The pulse was empty and compressible ; its rate was about 90-100, and the pulsations were small in size. There were no abnormal phenomena connected with the neck or prfecordia. The apex beat was . 113. — Physical signs in Case '2. The double line marks the cardiac and li-^-er dulness, and the cross the apex beat. The area over which the systolic murmur was lieard is shown by the horizontal lines, and the point of maxi- mum intensity by the circle. 3IO CONGENITAL HEART DISEASE. in the fourth intercostal space, four inches and a half from mid-sternum ; the right border of the heart was two inches, and the left border was two inches and three-quarters from mid-sternum at the level of the fourth costal cartilage. On auscultation a loud systolic murmur was heard over the entiiH; prjvcordia, in fact over most of the anterior aspect of the chest, as maybe seen in the accouipanying illustration (Fig. 113). The maximum intensity of the murmur was at tlie junction of the left edge of the sternum witli the fourth costal cartilage, and from this point it became gradually less distinct on passing outwards in every direction. Tlie murmur was not conducted into the arteries of the neck. As regards the respiratory organs, there were no symptoms with the excejition of the dyspnoea. The thorax was perfectly well formed without the least tendency to bulging, and there were no physical signs of any pulmonary mischief. The integumentary and urinary systems presented no abnormality, and in regard to the nervous system the patient was a placid, contented, happy child, who slept well and was remarkably intelligent. On examining the eyes with the ophthalmoscope, Dr. Mackay described the veins as being turgid and sinuous, with a deeper tint and a broader calibre than usual. In this case the diagnosis of the exact nature of the cardiac lesion presented the usual difficulties. As in the case mentioned previously, the position of the murmur might be held to prove that there was tricuspid incompetence, but this was negatived by the absence of any symptoms connected with the veins of the neck, and it seemed to me that in this case there was probably obstruction at the pulmonary orifice with patent septum ventriculorum, the same diagnosis, in short, as that which was arrived at in the preceding case. The little patient remained for two or three weeks in the ward, and received considerable benefit from the rest and the cardiac tonics which were administered to her. Case 3. Patent Ductals Arteriosus. — A. M., aged 26, married, was admitted on 12th September 1895, to Ward 25, then under my charge. She complained of palpitation, of pain below the left breast, of a choking sensation, and sickness. Her father and mother were both alive and in good health. One of her grandfathers had died of heart disease ; two brothers and one sister had died in infancy, and a brother had died at the age of twenty-eight of rheumatic fever. The sole remaining member of her family was a brother who enjoyed good health. The patient had suffered from measles as a child, and had been operated on as a baby, and again at the age of seven years, for talipes equino-varus. Three years before admission she had suffered severely from palpitation. The present attack only began the day before admission, when the patient had lifted a heavy weight, and in consequence began to ILLUSTRATIVE CASES. 311 suffer from the pain in the breast. She had, however, for some time previously been very alcoholic. She had no appetite, but a raginjf thirst, and vomited constantly. The abdominal organs presented no abnormality. The spleen reached the mid-axillary line, and was therefore of normal size. The haimocytes were 4,500,000 and the leucocytes 9000 per c.mm. The patient complained greatly of pali^itation. The pulse was a little over 100, the vessel wall was healthy and the artery was full and com- pressible. The pulse was absolutely regular, and the pulse wave large and bounding. On examining the neck and pra3cordia, nothing abnormal could be made out on inspection, but on applying the hand over the front of the chest there was a widely diffused systolic thrill, extending from the clavicles to the costal margins on both sides, and as far as the angle of the scapula on the left side behind. The maximum of this thrill was in the second left intercostal space, one inch and a half from mid-sternum. The apex beat was in the fifth intercostal space, four inches from mid- sternum, and was characterised by its extremely forcible impulse. The margins of the heart at the level of the fourth costal cartilage were two inches and a half to the right and five inches to the left of the mid-sternal line respectively. The heart was therefore considerably enlarged. On auscultation a loud rough systolic murmur was heard everywhere through- out the thorax ; in fact, it was propagated as far as the knees and elbows, but its maximum intensity was in the second left intercostal space, just at the point where the thrill could be felt most distinctly ; and on careful auscultation with the hand over the apex beat, the murmur was distinctly later than the apex beat. It was, in short, what is so commonly called a late systolic murmur. The second sound in the pulmonary area was greatly accentuated. The respiratory and urinary systems presented nothing abnormal, but the case presented features of extreme nervous excitement and insomnia. In this case the characteristic features of patent ductus arteriosus were extremely distinct. The locahsation of the thrill and murmur, the fact that the murmur was of late systolic rhythm, that it was followed by an accentuated second pulmonary sound — these points were sufficient to prove the existence of an open arterial duct. The only question in regard to which there could be any difficulty was the determina- tion of the presence or absence of some lesion at the pulmonary orifice, and while unable altogether to negative the possi- bility of some slight degree of obstruction, it was clear, on account of the absence of cyanosis and other symptoms produced by pulmonary obstruction, that any such obstacle must be very slight. The lateness of the murmur, moreover, was almost sufficient to show that there was no such affection. By means of absolute rest and sedatives the patient's nervous 312 CONGENITAL HEART DISEASE. symptoms speedily disappeared, and she was able to leave the Intirnuii y in the conrse of two or three weeks. Case 4. Patent Arterial Dud. — E. R., aged 23, consulted me on the 23rd October 1894 on account of palpitation on exertion. The iiatient's family history presented no point bearing upon her condition. She had been known to suffer from congenital heart disease all her life, a patent ductus arteriosus having been diagnosed by the late Dr. Warburton Begbie when the patient was a few weeks old, and the prognosis given at that time was bad. Slie had, nevertheless, enjoyed tolerably good health all her life, and had passed through most of tlie usual infective diseases of childhood without serious trouble. The functions of the digestive system were carried out satisfactorily, and tlie h;emopoietic system called for no remark. The jDatient complained of breathlessness and of palpita- tion on the slightest exertion, and stated that occasionally if she had been standing a great deal, a slight degree of swelling at the ankles appeared. The pulse was full and of moderate pressure, perfectly rt'gular, but vary- ing considerably in rate, the limits being from 80 to 100 per minute. There were no abnormal appearances in the neck except under excitement or on exertion, when the carotid arteries jjulsated violently. The apex beat was very obvious and occupied the fifth intercostal sjDace, three inches and three-quarters from mid-sternum. A distinct thrill was felt in the second intercostal space, two inches from mid-sternum. The area of cardiac dulness was increased, and at the level of the fourth costal cartilages it reached respectively three and four inches to the right and left of the middle line. On auscultation a loud murmur could be heard over most of the prsecordia, but its maximum intensity was in the second intercostal space at the point where the thrill was most distinctly felt. The murmur distinctly followed the first sound and was continued after the second, and in the pulmonary area the second sound was considerably accentuated. The functions of the respiratory and urinary systems were normal. The patient jiresented some symptoms of nervous excitement. In this case also there could be no doubt of the existence of a patent arterial duct, and the fact that the murmur began at an appreciable interval after the apex beat and first sound, distinctly proved that there was no pulmonic obstruction. The administration of some tonic remedies speedily got rid of the symptoms from whicli the patient suffered, and she has, since tlie date mentioned, remained in tolerably good health. CHAPTER VIL DISEASES OF THE PEKTCAEDIUM. Pericaedial lesions were observed by Galen in the lower animals, as Senac mentions, and were apparently suspected by him in man. Clearly recognised by Lower, they received adequate description at the hands of Senac and his followers. Vieussens first called attention to adhesions between the layers of the pericardium. In more recent times, an addition to our knowledge of pathological conditions of the pericardium was made by Griesinger, who, in an unpublished lecture, referred to by Widenmann, pointed out the thickening of the pericardium and adjacent anterior mediastinum, often called mediastino- pericarditis. Eondelet and Eiverius recognised some of the symptoms produced by pericardial diseases, and these were added to by Senac, Morgagni, and others. Auenbrugger applied his method of immediate percussion to the heart and observed that, in some instances of pericardial affection, the dulness was increased ; but this observation cannot be said to have been placed upon any sound basis until his translator, Corvi- sart, worked at the subject independently for himself. Laennec speaks of a sound like the creaking of new leather. At first he imagined this might be a sign of pericarditis, but was afterwards convinced that he was mistaken ; and the honour is certainly due to Collin, who generously mentions Devilliers as having at the same time come to similar conclusions, of demon- strating that the friction sound was produced by this affection. The connection between rheumatism and pericarditis noticed, as Wells states, by Pitcairn in 1788, was more 314 DISEASES OF THE PERICARDIUM. distinctly enunciated by Dundas, and more fully expounded by "Wells and Latham. liiolan proposed tapping the pericardium, and Senac strongly advised the operation and described how it might be done. But so far as can be ascertained, pericardicentesis was first performed by Eomero. The latest additions to oui' knowledge are connected with the dependence of pericarditis upon micro-organisms, and, as will be described in the sequel, Netter, Weichselbaum, Banti, and others have shown us how frequently, if not invariably, such a causal nexus ol)tains. PERICARDITIS. There are several varieties of pericarditis. The disease may present the features of a fibrinous exudation upon the surface of the membrane, accompanied by the effusion of very little serum, or it may be essentially characterised by the large quantity of serum poured out — the fibrinous exudation preceding this being but a slight incident ; the exudate may contain a large number of leucocytes, so that it possesses purulent characters ; this suppurative variety, further, may be putrid ; it may have a large number of red blood corpuscles, and so be fairly entitled to the term hfemorrhagic ; it may be accompanied by, or depend upon, the growth of tuliercle ; or it may be the consequence of a carcinomatous invasion. Some idea of the relative frequency of different varieties of pericarditis may be obtained from the observations of Breitung. Of 324 cases of pericarditis, examined in the Pathological Department of the Charite Hospital in Berlin, he e loilowmg proportions : — Sero-fibrinous 108 Htemorrhagic 30 Purulent .... 24 Tubercular (secondary) 24 Tubercular (primary) 2 Partially adherent . 111 Totally adherent 23 Ossified .... 2 Total 324 PERICARDITIS. 315 The numerical relations of pericardial lesions must necessarily fluctuate within wide limits. During the last five years, according to the statistics collected by Lockhart Gillespie, there were, amongst a total of 23G8 cases of heart disease admitted to the Eoyal Infirmary, 119 of peri- carditis — 68 males and 51 females, of whom 36 and 14 respectively died, i.e. a death-rate of 5 2 "9 and 2 7 '4 per cent. Of this total of 119, 68 were free from valvular complication, whose admissions and mortality have been thus tabulated : — Admissions. Age. Males. Per cent. Females. Per cent. Total. Per cent. 1-9 1 2-5 2 7-1 3 4-4 10-19 8 20-0 11 39-2 19 27-9 20-29 12 30-0 8 28-4 20 29-0 30-39 10 25-0 4 14-3 14 20-5 40-49 4 10-0 1 3-5 5 7-2 50-69 3 7-5 1 3-5 4 5-8 + 69 Total . 2 5-0 1 3-5 3 4-4 40 58-8 28 41-2 68 Mortality. 1-9 10-19 3 37-5 3 27-2 6 31-5 20-29 5 41-6 1 12-5 6 30-0 30-39 8 80-0 2 50-0 10 71-4 40-49 3 72-8 3 60-0 50-69 3 100-0 1 100-0 4 100-0 + 69 Total . 2 100-0 2 66-6 24 60-0 7 25-0 31 45-5 3i6 DISEASES OF THE PERICARDIUM. Etiology. — Pericarditis has a \vide range of causes, which, in accordance with custom, may Ije grouped under the heads of predisposing and exciting agents. Prcdisposin;! Cav.ses.—-T\\Q. disease is cerlaiidy more common in men than women, no doubt liecause the primary affections to which it is consecutive are also more frequently seen in the male sex. It is essentially a disease of adolescence and early manhood. Every age, undoubtedly, may be attacked ; it is, however, not a common affection either in childhood or advanced middle life : old age, nevertheless, shows a slightly increased preference for it, more especially in the presence of certain diathetic conditions. Climatic intluences play a very inconsiderable part in the etiology of pericarditis ; they no doubt, however, lessen the resisting power of the body by lowering the vitality. Occupation and environment act in a perfectly analogous manner, and when they are of such a character as to induce an enfeeblement of the system, they must render it more prone to the different noxious agents to be mentioned immediately. Exciting Causes.— In the light thrown on diseased processes by modern methods of investigation the direct causes of peri- carditis have to be regarded from a new point of view. It is therefore unnecessary to discuss the well-worn theme whether the disease is at any time idiopathic. It may ho, said at once that any idea of the kind is untenable. When the admitted infrequency of cases recognised as idiopathic, and the many fallacies surrounding them are taken into account, such instances as those described by Biiumler and Fagge can only be regarded as due to misconceptions. Idiopathic pericarditis has never been demonstrated. On careful in- vestigation of all the facts belonging to any case sup- posed at first to be idiopathic, it is invariably found that the attack has been preceded, accompanied, or followed by some ailment, often of the most trifling description, but un- deniably bearing some relation to an infective process or constitutional affection. Even those cases in which peri- carditis has been attributed to direct injury can now only be considered as due to a twofold causation — external violence, and bacterial infection or chemical irritation. In all these PERICARDITIS, 3 • 7 instances the injury, by producing a contused condition of the membrane, usually with a considerable amount of lia^morrliage, paves the way for the inroads of micro - organisms or the activities of toxic substances. The direct causes of pericarditis naturally fall intfj three groups : infective processes, constitutional diseases, and direct extension. Every acute general disease due to infective processes may be accompanied by pericarditis, and many of them are frequently its cause. Scarlet fever has, since Krukenberg first noticed the fact, been recognised as a somewhat frequent cause. Measles rarely gives rise to it, but cases have been seen by Barthez and Eilliet. Whooping cough has been observed by Eacchi to be followed by the disease, and organisms obtained from the sac after death when introduced, after cultivation, into animals produced a convulsive cough. Smallpox, since the observations of Andral and Brouardel, has been well known as a cause, and erysipelas as a factor has been studied by Jaccoud. Influenza, during recent epidemics, has sometimes been complicated by pericarditis. In diphtheria it has been seen, but it is very rare. Enteric fever has often been accompanied by the affection, usually in a fibrinous form ; Griesinger, however, has met with serous pericarditis, and the purulent form has been described in this disease by de Boyer. Paludism, according to Eaynaud, sometimes gives rise to it. Tuberculosis often produces peri- carditis, which may be primary, or which may be simply part of a general invasion of the serous sacs. Syphilis is not a common cause, but it undoubtedly gives rise to definite forms. Gonorrhcea, and gonorrhceal synovitis, are sometimes compli- cated by pericardial sequelte. Septic affections, finally, are fertile sources of pericarditis, yet it is not so often found as is pleurisy in these diseases. Of all constitutional diseases rheumatism has been known, since the time of Pitcairn, to stand pre-eminent as the chief cause of pericarditis. As a general rule, the pericardial com- plication appears during the second half of the first, or the early part of the second week of the disease ; but, as was noticed by Graves and Stokes, the pericarditis may precede the articular symptoms. Statistics, in regard to this subject, 3 1 8 DISEASES OF THE PERICARDIUM. are nut open to the serious objections which will lie shown to be inseparable from those dealing with endocarditis, inasmuch as the means of diagnosing pericarditis are practically inftillible, while the diagnosis of endocarditis varies with the idiosyncrasies of the observer. The best known statistics are those of Sibson, who found that of 32G cases of acute rheumatism 63 suffered from pericarditis, i.e. nearly one-fifth, or 20 per cent., of the total numlier of cases of acute rheumatism were complicated by pericarditis. This percentage, however, differs consideral)ly from that observed by other authors; the lowest being 7 "5 and 14 in the practice of Latham and von Bamberger, while much larger figures are shown liy the results of such writers as Ormerod, The relative proportion of cases of pericarditis having a rheumatic origin has been often investigated. The percentages vary lietween 13 as given by Chambers, and 71 '7 by Ormerod. Connected with this subject must be mentioned chorea, which is by no means infrequently associated with pericarditis. According to Osier it was present in 19 out of 73 autopsies which he collected, and in only 8 of these was there arthritis. Amongst constitutional diseases gout, more especially in elderly people, is frequently accompanied by pericarditis. Diabetes is at times associated with it. Some of the Idood diseases usually grouped amongst affections regarded as constitutional give rise to pericarditis. Amongst these may be mentioned scorbutus and purpura. One local disease produces effects closely resembling those arising in the course of a constitu- tional disease like gout. This is Bright's Disease, as first observed by Taylor. According to the observations of von Bamberger, 14 per cent, of cases of Bright's Disease develop pericarditis, but Sibson only found 8 per cent., Kosensteiu 7 per cent., and Frerichs 4 per cent. The affection is equally common in parenchymatous nephritis and renal cirrhosis according to Grainger Stewart, while Lecorche and Talamon hold it to be more frequent in the interstitial form of the disease. Whether in cases of gouty and nephritic pericarditis the cause lies in chemical irritation, secondary infection, or ptomaine poisoning, as suggested by Hanot in analogous cases of endocarditis, cannot yet be determined. Pericarditis often has its origin by extension in pleurisy PERICARDITIS. 3 1 9 and pleuropneumonia, as well as in endocarditis and myo- carditis. It must not be forgotten, however, that in jmeu- monia the source of pericardial infection may be through organisms conveyed by the blood, and pericarditis from pneumococci has been seen without pneumonia. Septic diseases of the mediastinal glands, as well as destructive processes in the lungs, may produce pericarditis by extension, while acute affections of the bones — the sternum and ribs in front, and the vertebrse behind — have been seen to give rise to it. Septic diseases and cancerous infiltration of the cesophagus are occasionally causes. Diseases of the abdominal viscera less frequently give rise to it. Malignant pericarditis may, instead of taking its origin in direct extension, be produced by the growth of neoplasms secondary to others previously developed elsewhere. There are certain difficulties connected with the pathogeny of pericarditis in some of these disease processes ; it is not easy, for example, to understand how such a disease as enteric fever, in which the organisms very sparingly enter the blood, can produce pericardial changes. The complication must arise in such cases in one of two ways : by means of toxins formed by the organisms and carried by the blood, or by infection through another poison, for which the pericardium has been prepared by the primary disease. Direct injury appears capable of producing the affection. No doubt in most instances it only prepares the way for the action of micro-organisms, yet it must be allowed that non- infective pericarditis may occur from violence. It has long been known that the presence of an aneurysm or a tumour may cause pericarditis, and the rupture of an aneurysm sometimes induces it, as in an instance recorded by Lee Dickinson. Williams has narrated^ an interesting example of wound of the heart and pericardium, produced by a stab three-quarters of an inch to the left of the sternum, throuoh and in the lono- axis of the fifth cartilage. The wound, besides involving the internal mammary vessels, was found to have produced an incision in the pericardium about one and a quarter inch in length, with a puncture of the heart about one-tenth of an 320 DISEASES OF THE PERICARDIUM. inch lonu', halt' an inch to the right of the right coronary artery and between two of its lateral branches. The wound Fig. 114.— Fibrinous pericarditis. From a specimen kindly lent to me by Dr. Nathan Raw. in the pericardium was closed by a catgut suture, the parietal flap was replaced, and the wound dressed. Pericarditis and pleurisy supervened. The patient nevertheless made a com- plete recovery, and was reported three years afterwards as being perfectly well. PERICARDITIS. 321 Morbid Anatomy.- — As the processes involved in peri- carditis pursue a somewhat similar course in all its varieties, and vary in degree much more than in kind, the most satis- factory plan in considering them is to trace out the general -Fibrinous pericarditis in a child. From a specimen Icindly lent to me by Dr. Nathan Raw. sequence of events, and point out in what particulars the different types have special features. Pericarditis may be local or general ; the former is usually seen mostly at the base of the heart, about the origin of the great vessels ; both forms affect the epicardium more than the pericardium. 21 DISEASES OF THE PERICARDIUM. The earliest appearance iu acute pericarditis is a duluess of the membrane, which presents a more or less ruddy tint, and often shows arborescent blood vessels, which may even liave little points of hii'morrhage. Upon this a fine layer of fibrin is de- posited. It sometimes presents a smooth surface, but more com- monly gives rise to an appearance like that of ripple markings on the seashore, or the surface of a honeycomb, or the reticu- lum of the second stomach of the calf, as remarked by Cor- visart ; the surface frequently looks, as was said by Laennec and afterwards by Hope, as if butter had been pressed by the dairy implements known as "Dutch Hands," which were after- wards separated. This latter appearance is well seen in different degrees in the accompanying illustrations (Figs. 114 and 115). The pericardial substance is sometimes so roughened by the de- posit as to merit the term of " cor villosum hirsutumve " applied to it by the older anatomists, as mentioned by Meckel. It is of in- terest to note, as showing the fanciful ideas which obtained until com- paratively recent times, tliat this appearance was, down to last century, deemed characteristic of men with bold and ad- venturous dispositions. There is usually a certain amount of fluid which may be almost clear, or opaque from the presence of leuco- cytes, or coloured from an admixture with blood. Microscopic examination reveals layers of fibrin, felted together like the strata of a schistose rock, between the layers of which are small round cells, with leucocytes and hcemocytes. Both the epi- Fio. IIG. — Fibrinous pericarditis (x20) sliowiug : n, pericardium ; 6, epicardiuui ; c, myocardium ; d, tibrinous exudation showing organisation from both serous surfaces. PERICARDITIS. 323 cardium and pericardium show traces of infiltration by small cells. A little later organisation may be seen to proceed, as is shown in Fig. 116, from both endothelial surfaces. In most of the septic cases, as well as in those taking their orisin in acute >*«^-N,, 's%'°»°: % 'Jo© « (^ ®o O e ^s 0®o <*- (S> AQ pneumonia, masses of organisms may be seen amongst the fibrin. An in- vasion of the heart wall by fibrin and microbes, accom- panied by the presence of leuco- cytes and heemo- cytes, and attended by distinct changes in the structure of the muscle, is clearly to be recognised. The changes are well shown in the illustra- tions (Figs. 117 and 118). The cells, which are contained in the serous fluid, have their origin in proliferation of the endothelial layer. In serous peri- carditis the quantity of fluid effused varies very greatly in amount and sometimes reaches a gallon, as in a case described by Alouzo Clark. When such is the case the pericardium is greatly distended, and on opening the fluid may form a jet, as men- tioned by Eadcliffe. The form assumed has been studied by means of injections by Eotch. The fluid may be clear and trans- FiQ. 117. — Acute pericarditis secondary to pneumonia (x300) showing : a, masses of pneumococci ; b, leucocytes, hfemo- cytes, and fibrin invading the heart wall c, necrosed muscle fibres ; d, healthy muscular tissue ; e, engorged blood vessels. W^^^^^W^:^-^' changes a -^'^']^j}-kjr^^)^^M'^, ill fibrinous Jk:^Xy-a^ry^CWif^ it is ot 324 DISEASES OF THE PERICARDIUM. parent, or slightly turl)id and rather opatj^uc. Its colour may be yellowish, greenish, or grayish, and it contains small flakes which, on examination with the microscope, are seen to be com- posed of fibrin. Some leucocytes and red blood corpuscles are ,-x_.. r^i usually detected on micro- be.')! .^^^U--"^ 'V^' //^'Abti/' scopic examination. Sections Gw^ :n4^r^ Im;_i'/ ,' ''r^ i ■^T-i.-i.j-, :,_. r^^i. ^ii/i^ _v- negative pressure within the pericardial sac, described in '^_/;^ ■l"^' \^ §'§}'■%■ the physiological introduc- "' .^,. #■ ':.: ^;,; ,0~::.^ tion, plays an important part ~ in the production of the Fig. 118. — Acute ijericaruitis foUowuig putuinoiiia -^ showing pneuinococci in pairs and groups SSrOUS effusioil, aS Is allowed entangled amongst librinous n.eshes and , Hamilton. While, far associated witli leucocytes and hwmocytes «/ ' (xiooo). from denying the possibility of such an influence, it seems to me that, if this negative pressure played a preponderating part, a considerable quantity of fluid should be present in every case ; and it is much more probable that the altered processes of the serous membranes, already described, are of greater importance. It is quite conceivable that irritants of different degrees of intensity may produce varying amounts of efiusion by causing a variable effect on the capillaries. There are some differences between the morbid appearances found in acute pericarditis as it occurs in the course of Bright's disease, and that which accompanies such a disease as rheu- matism. These differences have been more especially insisted upon by Sibson. In only a small proportion of the cases of pericarditis of renal origin is there the characteristic pale rough surface formed by the fibrin, and in the great majority the exudation presents some peculiarities. There is a greater tendency to adhesion of the membranes, to the formation of pus, and the presence of blood. The pericarditis of Bright's disease may therefore be regarded as in many cases forming a transition towards the purulent, or the hcemorrhagic form. PERICARDITIS. 325 Purulent pericarditis is essentially connected with pyi£mic processes, or has its origin in some adjacent suppuration. The fluid in the pericardial sac is opaque and has a greenish yellow colour, varying in its depth according to tlie relative amount of fluid and cells. Sometimes the amount of fluid is very considerable, giving rise to great distension of the pericardium and displacement of the neighbouring viscera, particularly of the left lung. The epicardium in purulent pericarditis is often thick and woolly, but sometimes the plastic lymph has disappeared and there may even be ulcer- ation into the deeper layers of the sub-epicardial tissues. The fluid, on microscopic examination, is found to contain a very large quantity of leucocytes along with some hsemocytes, and there are frequently also fibrinous flakes. Many of the leucocytes undergo fatty degeneration. A section of the epicardium shows changes closely resembling those found in fibrinous pericarditis, but there are greater structural changes in the deeper layers. In that form of purulent pericarditis which is often, on account of the decomposition of the pus, termed putrid, and which most commonly has its origin in a communication with some suppurating cavity that has been exposed to external influences, the fluid has somewhat similar characters on inspection, but is marked by its offensive odour. It teems with the organisms found in putrid suppurations, and there are frequently fatty crystals. Hemorrhagic pericarditis is almost always associated with a malignant invasion, as in cancer : some constitutional disorder, such as scurvy and purpura; some acute infection, such as small- pox ; or a renal affection. It may be caused by an aneurysm weeping into the pericardial sac, which has been irritated by the previous pressure. Wounds of the heart of small size may act in a similar way. The amount of blood present is extremely variable. In the early stages of the affection it may be coagulated and the red blood corpuscles unaltered, but in the later stages red blood corpuscles break down and set free the colouring matter, which is then diffused through a serous effusion. In the case of aneurysms and wounds, the amount of blood may be great. The epicardium and pericardium are always deeply stained with the colouring matter of the blood. 326 DISEASES OF THE PERICARDIUM. and they frequently show extravasations. On microscopic examination there is a fibrinous deposit upon the surface of the serous membrane. This contains a large number of hremo- cytes, and in some parts the endothelium and even the elastic layer beneath it are seen to be destroyed. In malignant cases, cancerous deposits may be seen with their characteristic structure. Tubercular pericarditis is sometimes the result of localised masses in the epicardium, but at other times it is but part of an outbreak of miliary tuberculosis. In the form most commonly seen some nodules may be observed in the epi- cardium, sometimes threatening to invade the muscular wall. These are surrounded by fibrinous deposits and by organising tissue, in which, as shown in the illustration on p. 378, there are frequently giant cells. The pathological consequences and terminations of peri- carditis present many varieties. The most favourable termina- tion of sero-fibrinous pericarditis is a reabsorption of the exuda- tion and complete resolution. Instead of this, however, there are often left thickenings upon the epicardium, which give rise to the milk spots or macuke tendineie so often observed. There may even be larger masses of newly-formed connective tissue, which may merit the term polypoid sometimes applied to them. Pericarditis very frequently ends in a more or less adherent pericardium. After the reabsorption of the fluid, a portion of the fibrinous exudation is in part organised by the pericardium and epicardium, from which it derives a newly-formed vascular supply ; and there is in consequence a more or less complete adhesion. Partial synechia pericardii is most common at the base of the heart close to the great blood vessels. It may be composed of fine delicate bands of fibrous tissue, or of a more or less widely-spread membranous deposit. Complete synechia pericardii results in absolute obliteration of the pericardial sac, the place of which is taken by a thicker or thinner layer of connective tissue, which effects the union of the visceral and parietal pericardium. Adherent pericardium is not, by any means, an uncommon occurrence. The statistics of Breitung, previously referred to, may be mentioned here. He found that of 324 cases of pericarditis 134, i.e. 41 '3 per cent., resulted in adhesion. PERICARDITIS. 327 The adhesions occasionally extend Ijeyond the pericardium, which then becomes closely connected with the surrounding tissues. It may, in this way for instance, become attached to the anterior chest wall in front ; to the oesophagus, aorta, and vertebral column behind ; to the lungs and the com- plementary portion of the pleural sac ; to the diaphragm below. Occasionally fatty degeneration takes place in the newly-formed fibrous tissue, and a deposit of inorganic salts may follow. Cases have been recorded in which there was such a degree of calcification as to leave it a matter of surprise that any movements of the heart were in any way possible. In all cases of adherent pericardium there are consequent altera;tions in the heart muscle. Some hypertrophy, usually with dilatation, is commonly present, and there is fre- quently fatty degeneration or brown atrophy of the muscular fibres. These changes will be described under the affections of the myocardium. Sometimes the pericarditic processes extend to the pleura or to the tissues of the mediastinum, and in this way they may set up pleurisy or give rise to mediastino- pericarditis. This change results in adhesions of different kinds, and some- times leads to suppuration. In certain cases, as originally described by Griesinger and afterwards more fully analysed by Kussmaul, the great vessels connected with the base of the heart are interfered with by means of direct or indirect attachments to the vertebral column, oesophagus, trachea, or sternum. Occasionally in suppurative pericarditis perforation of the pericardium results, leading to the development of sinuses or abscesses, which may lead to far-reaching consequences. Many different complications occur as results of such changes. This subject would be incomplete without referring finally to the presence of micro-organisms in connection with peri- carditis. In the remarks made upon the etiology of the disease, the discoveries of many observers have been referred to ; but, in order to complete the subject, the existence of micro-organisms in the fibrinous or in the serous effusion must be mentioned. Tubercular bacilli have been seen by many observers ; pneumo- 32 8 DISEASES OF THE PERICARDIUM. cocci were tirst discovered by Banti ; staphylococci were first seen by Wilson ; streptococci by Friinkel ; and micro-organisms were found by Eacchi in a case of pericarditis occurring in the course of whooping cough, which, on cultivation and inocula- tion, gave rise to cough and pericarditis in rabbits. SYMPTO>rATOLOGY. — In the evolution of its clinical features pericarditis presents many different phases. Certain forms of the disease, moreover, pass through several distinct stages ; some of these constitute practically the same conditions as are represented by other varieties in their fullest development, and the assemblage of symptoms is therefore at once multifarious and extensive. Fibrinous Pericarditis. — Fibrinous pericarditis sometimes gives rise to no rational symptoms, but in most instances it reveals its presence by clinical features, which it is impossible to misunderstand. Amongst the general symptoms the temperature gives extremely variable results. It is in many cases normal, or even subnormal ; it is, however, in the majority of cases slightly elevated. This is more particularly the case amongst youthful patients. It sometimes, although not commonly, happens that the attack is ushered in by a rigor. The facts connected with the temperature are entirely dependent upon the origin of the affection. If pericarditis occurs as a complication of an acute disease, there may be on its occur- rence a slight increase in the pyrexia already present ; but it is, on the other hand, not at all uncommon to find the tempera- ture undergoing no change, and it sometimes even falls. This latter fact is held by Paul to be relatively common in its occurrence. But his opinion is neither in accordance with the observations of most authors, nor with my own experience. If pericarditis takes its origin during the period of defervescence, or after the disappearance of the pyrexia, in any general disease, it almost invariably causes a rise of temperature. One rather uncommon symptom in fibrinous pericarditis is dysphagia. This was noticed by Morgagni, and since his time it has been observed by several others. Sibson has placed three cases on record. PERICARDITIS. .329 Sometimes fibrinous pericarditis is accompanied \)^ palpita- tion, but this is by no means a prominent subjective symptom, although, as will be seen, the impulse becomes more forcible. Breathlessness is occasionally present. Petit is inclined to think it a common symptom, differing, therefore, from Potain, and states that it has occasionally led him to a correct diagnosis in cases where there were no other subjective symptoms. When it is present in this affection it must owe its origin either to reflex nervous causes, propagated from the irritated serous membrane to nervous centres and reflected to the respiratory muscles, or it must be produced by extension of the lesion to the myocardium or to the lung. Subjective sensory symptoms are sometimes present. It has already been shown that the heart in its healthy condition is not endowed with any great degree of sensibility, but the experiments of Bochefontaine and Bourceret have shown that, when there is any pericarditic lesion, the sensibility becomes greatly augmented. The nature and extent of the sensory disturbances are extremely variable. Usually there is nothing more than a feeling of uneasiness in the precordial region, as indefinite in position as it is indistinct in character. This may be so much greater in degree as to become a sensation of oppression or of pain, even of a particu- larly intense kind. The position of the pain is usually prse- cordial, but it is sometim.es experienced in the epigastric region. It may be situated in the back between the shoulders or beneath the left shoulder-blade, and it sometimes, but rarely, is found in the region of the sterno- mastoid and trapezius muscles. In a few cases there are attacks closely resembling typical paroxysms of angina pectoris, in which the prsecordial pain radiates towards the left arm and is attended by all the accompaniments of that affection. Excellent examples of this have been described by Andral and by Stokes. In almost all cases where there are painful sensory symptoms there is hyperaesthesia, which indeed may be present without subjective symptoms. Nothing need be said in this place with regard to the explanation of all these appearances, since they have been fully analysed in chap. vi. The pain at times is so severe as to produce a restrained 330 DISEASES OF THE PERICARDIUM. action of the diaphiagin. liaiiow more particularly brought forward this symptom as a useful diagnostic indication, and referred to the case of a boy who kept a broad belt tightly round his body in order the more effectually to restrain the movements of the diaphragm. He also mentioned another instance in which the movements of the diaphragm were much restricted, and in which no other symptom of pericarditis could be made out. Death occurred in this case, and at the autopsy the pericardium was found full of pus. In his classical lectures Hilton refers to this as a well-known symptom. The physical examination of cases of pericarditis furnishes far more important indications than can possibly he obtained from the general symptoms ; and it is the duty of the physician, in every case which is lialile to l)e complicated by pericarditis, to examine the heart most sedulously eveiy day. The pulse undergoes many changes. During the onset of the affection there is often a considerable increase in its frequency, and this frequently disturbs the ordinary pulse- respiration ratio ; i.e., while the respiration is but slightly if at all accelerated, the pulse rate is greatly augmented. This increase in I'ate is not at first attended by any considerable change in the other features connected with the pulse, but after a longer or shorter period, usually very few days, the vessel becomes empty, the pressure falls, the pulsation tends to become dicrotic and irregular. These latter symptoms are probably due to extension of the lesion to the myocardium, resulting in paralytic myocarditis. Inspection never reveals any change in the conformation of the chest due to a purely fibrinous pericardial affection, but the apex beat is sometimes observed to be more violent than in health. When the hand is applied to the pnecordia it appreciates at first a considerable increase in the force of the apex beat, and this may be, in certain cases, a useful warning, as was shown long ago by Graves. The accentuation of the cardiac pulsation, however, is of brief duration, and in a few days — sometimes in a few hours — it becomes enfeebled, probably in every case, by the spread of Xhe process to the myocardium. PERICARDITIS. 3 3 1 Sometimes, as Eaynaud has said, the apex appears to be glued to the superficial tissues, and to crawl along under the hand. Palpation sometimes furnishes another important sign. The friction of the epicardium against the pericardium occasionally produces a trembling vibration which is felt on palpation. This is held by Potain to be a frequent occurrence, but it is not common in the experience of most observers. This friction fremitus is at times an accompaniment of the systole ; at other times it accompanies both systole and diastole. According to Potain it does not coincide exactly with the movements of systole and diastole, but is a late systolic or late diastolic phenomenon. On percussion there is no change in the area of cardiac dulness in the early phases of the disease, but after the lapse of a few days it is often possible to determine that it is slightly enlarged on account of a degree of dilatation of the heart. Auscultation furnishes the most important physical signs produced by pericarditis. The friction sound, heard and mis- understood by Laennec, has, since the observations of Collin, been known to be the most reliable evidence of this affection. The character of the friction murmur has been compared to sounds produced by a great many different sub- stances. In its slighter manifestations there is a softness in its character somewhat resembling the sound produced by gently rubbing silk, parchment, or paper together. When more intense it gives the character of friction produced by rubbing two surfaces of new leather together, or of rough wood. Whatever may be its peculiar character, it invariably presents an obvious impression of being superficial. The friction sound, as first observed by Stokes, is increased on pressure, but if the stethoscope is ... Fig. 119. — Area of audition of allowed to press too heavily, it may, pericardial friction. especially if the heart is weak, put a stop to the sound altogether. One great characteristic of the pericardial friction is that it is conducted to a very slight extent. 332 n/SE.-iSES OF THE PERICARDIUM. This is shown in Fig. 110. The slight degree of propagation manifested by the friction shows that the sound waves which are produced have hut little power of setting up vibrations in the walls of the chest. The friction murmur is, however, sometimes conducted to a certain distance, and this is more particularly the case when the lieart is in close contiguity to some patch of consolidation in the lung. In some cases, where a pulmonary cavity is situated close to the heart and is surrounded by consolidation acting as a means of conduction, the friction sound may be propagated into it, and may even present metallic characters, that is to say, it echoes with a metallic character within the cavity. Pericardial friction frequently varies in loudness with the state of the respiration. The majority of authors appear to consider that it is loudest during inspiration, on account of greater displacement of the opposed pericardial surfaces during that phase of respiration. This, however, is by no means always the case, and the maximum intensity of the friction sound is not infrequently found to occur during the phase of full expiration. Potain, Traube, and Eichhorst strongly support the former as the more common occurrence, while Paul and Chabalier consider the latter to be more frequent. This has been explained as probal)ly due to an approximation of the pericardial surfaces through expansion of the lungs and contraction of the diaphragm. Chabalier goes the length of stating that all those cases, in which the friction is most intense during inspiration, are connected with emphysema, and that the amount of emphysema dominates the intensity of the friction. The position of the patient exercises considerable influence upon the intensity of the friction, which is, for the most part, heard most distinctly when the patient is sitting up, or even leaning forwards ; while on lying back it sometimes disappears. The reason for this change is probably connected entirely with gravitation. One interesting obsei'vation is that of Lewinsky, who found that, in a case where the friction was most intense during expiration, there were considerable adhesions between the pulmonic and mediastinal pleura. PERICARDITIS. 333 The friction murmur accomjjanies the cardiac movements, and thus may be distinguished from that of pleurisy. Some- times it is only heard during the systolic phase. It is, however, more commonly met with as an attendant upon both systole and diastole ; and it is by no means infrequently present as a threefold sound, accompanying the auricular systole, the ventricular systole, and the diastole. This latter condition was first observed by Traube. Sometimes the friction seems to be even more broken up, the systolic or diastolic portion being separated into more or less distinct parts by inter\'als, as was described by Gerhard t. The main point of interest is that the friction does not absolutely coincide with the phases of cardiac activity, than which it is somewhat later. The reason of this lack of syn- chronism between the pericardial friction and the cardiac sounds is exactly the same as in the case of pleural friction, which also follows the respiratory movements. A certain amount of movement of the one surface upon the other must take place before the one pericardial layer travels past the other, and in this way gives rise to the friction sound. Paul states that in the region of the pulmonary artery the friction sound is never double ; but this does not accord with my own experience, in which the sound is often not only double but even triple over the base of the heart. The sound is sometimes triple at the base and double towards the apex ; while, on the other hand, these conditions may be reversed. The duration of the pericardial friction is extremely vari- able. When its course is not modified by treatment, it may be present for any period of time — from a few minutes to a few hours or days — and it is to be remarked that the friction remains even after the effusion of fiuid, unless this is present in great quantity. At the commencement of an attack of acute pericarditis the heart sounds often undergo some modification in rhythm. A doubling of the first sound is the most common change, so that one form of the cantering sound is present. Potain has given an ingenious explanation of this sound. He holds that, on account of the lesion of the epicardium, the myocardium loses in part its resistance ; in consequence of this the blood is 334 DISEASES OF THE PERICARDIUM. allowed to tiow without ol)Stacle into the ventricular cavity, until the moment when its repletion suddenly distends the wall. A presystolic impulse is the result, he thinks, of this sudden tension, and it is this which constitutes the first part of the canter ; the normal cardiac sounds follow, constituting the two other elements in it. It is impossible to agree with this explanation, and the doubling does not in any respect require a different theory than that which has already been given. Although the friction sound is almost pathognomonic, it is, nevertheless, sometimes, although not often, found in the absence of pericarditis. Tuberculosis and cancer give rise to a friction sound. j\Iilk spots upon the pericardium, dryness of its surface, and ecchymoses into the subserous tissues have long been recognised as causes. Sclerosis of the coronary arteries, as in a case recorded by myself, and even hyper- trophy, in the absence of all other conditions, as strongly insisted on recently by Chabalier, may also produce a friction sound. The total number of such cases is, however, so inconsiderable that the sound may almost be considered as characteristic of pericarditis. The course of simple fibrinous or dry pericarditis is vari- able. It very frequently makes its appearance in one of the general diseases previously mentioned, and entirely passes away within a few hours. It may, however, be succeeded by serous exudation and give the symptoms of pericarditis with effusion. Serous Pericarditis. — When exudation of lluid takes place several characteristic symptoms make their appearance, while a change comes over some of the clinical features which have preceded the effusion. The temperature, as a rule, undergoes but little alteration at this stage. If there has been, however, a high temperature during the earlier stage, it is, on the whole, more common to observe a fall when the fluid is poured out. In this stage, as at any other period of the affection, nervous symptoms may be present. Slight disturbances, such as headache, want of sleep, or mild, wandering delirium at night, are extremely common : while, less frequently, comatose conditions or noisy PERICARDITIS. 3 3 5 delirium may show themselves. It is probable that such symptoms are produced by the primary condition causing the pericarditis rather than by the pericarditis itself. Difficulty in swallowing may occur. It was studied by Testa, and was present in thirteen of Sibson's cases of rheu- matic pericarditis. The special characteristics of difficulty in swallowing during the stage of effusion are that the difficulty is greatest when the effusion is at its height, and, further, that it varies with the posture of the patient. Deglutition may be extremely difficult in the recumbent position, but, when the patient sits up, the act of swallowing is rendered comparatively easy. These facts do not require a word in explanation. The tint of the face is often extremely pale, but if there be much febrile reaction it may be characterised by a flush. Very commonly there is a considerable degree of cyanosis, and it is to be remarked that this is some- times an extremely localised phenomenon only to be seen in the face and upper extremities. It is, however, on the other hand, very often general instead of local. Oppolzer has observed a considerable degree of cyanosis with the total absence of dyspnoea. There may be more or less cedema, which, like the cyanosis, is sometimes purely local, showing nothing but slight puffiness of the face with fulness of the neck and upper extremities. Much more commonly, however, this oedema is general and is especially found in the dependent parts. The urine is scanty, deeply tinted, and of high specific gravity. It sometimes contains albumin from venous stasis. The breathing undergoes characteristic changes. There may be merely an increase in the frequency and depth of the respirations, that is to say, a slight persistent anhelation is present. This, however, is very frequently attended by paroxysms of dyspnoea, and it is no uncommon experience to see the patient obliged to maintain an upright position, or one in which the body leans forwards, while the respirations are laboured and frequent. These respiratory symptoms depend entirely upon, and vary according to, the amount of fluid which is present, and the rapidity with which it has appeared. In all cases where the fluid is in large quantity, the breathing is much interfered with, but it is a circumstance worthy of 33(> DISEASES OF THE PERICARDIUM. attention that, when the thiid is giaiUially eftused, dyspncea is by no means so prominent — no doubt on account of a gradual process of adaptation to new conditions. ruhnonary cedema is often present. Hiccough is said by Peter to be present occasionally from interference with the phrenic nerve. It is possible that this symptom may be caused by pressure on the diaphragm. Alterations in the voice have been observed. One most interesting case of this kind was recorded by Sibson, in which there was a considerable degree of aphonia. He considers that the case " tends to support the view that the left laryn- geal recurrent nerve may become so affected by the contiguous inHammation as to paralyse the lungs." Similar instances have been described by Stokes and Biiumler, but by the last mentioned observer the symptom is attributed to the pressure of the exu- dation upon the recurrent laryngeal nerve. Eichhorst speaks of interference also wuth the right recurrent nerve, and mentions that it has been considered as the result of compression by means of swollen veins. If pain has been a prominent symptom during the onset of the affection, it usually becomes less intense and its place is taken by other sensations, which, in the absence of any previous pain, now become for the first time manifest. The sensations are of a somewhat vague character, and may consist simply in some indefinite feelings of uneasiness, weight, op- pression, or sinking, in the region of the praecordia. Syncope is by no means uncommon. The pulse, during the stage of fluid exudation, becomes of less volume and lower pressure. It is, as a rule, fully dicrotic ; irregularity, as well as inequality, may often be determined ; the bigeminal, or alternate, or even paradoxical pulse may be found. Traube observed the left radial and carotid pulses smaller than the right in one case, and the same was seen, along with dilatation of the left pupil, by Smith. Such symptoms denote pressure on the arterial trunks and sympathetic system. The veins of the neck undergo, in many instances, a considerable degree of dis- tension : or undulations may ho, seen in them. According to Friedreich these venous movements are definite regurgitant PERICARDITIS. 337 waves, but Eiegel has shown with justice that they are simply from the auricular contractions. A real venous pulse in peri- carditis speaks for an accompanying tricuspid incompetence. An inspiratory swelling of the veins of the neck is at times seen. These appearances are more especially associated with cyanotic symptoms. All these symptoms are the direct result of the fluid in the pericardium, as Lower clearly showed two centuries ago. By its presence it compresses the lungs, and more particularly the left lung ; while it also lessens the movements of respiration. It, at the same time, interferes more especially with the diastolic movements of the heart, and by both processes it interferes with the oxygenation of the blood. The cyanosis and oedema are the direct results of backward pressure. Experimental proof of this has been furnished by the obser- vations of Cohnheim, which were previously described, and which have been repeated by Starling. The fact must not be overlooked that some of the symptoms may not be altogether dependent upon mechanical interference with the heart from the presence of the fluid, but may take their origin in a paralytic myocarditis, produced either by extension, or by identical etiological factors, affecting the myo- cardium and pericardium simultaneously. The least resisting portions of the heart — the auricles — are mostly interfered with by the presence of fluid; hence the venous stasis, not only in the systemic vessels, but also, and perhaps more particularly, in those of the lungs. In this way oedema and cyanosis are accounted for. On inspection of the prsecordia a fulness or even a distinct swelling may be seen. The presence or absence of such a bulging does not altogether depend upon the amount of fluid which is present ; several other factors are concerned in its appearance. It is, for instance, by no means such a promi- nent feature in those who are well nourished, as in those who have a spare habit of body. It therefore happens that certain cases present this symptom, although a comparatively small amount of fluid is present ; while, on the other hand, there may be no arching forward in other instances where a large amount of fluid has been effused. When such a bulging 22 338 DISEASES OF THE PERICARDIUM. is present, it is usually found along the left edge of the sternum, extending from the third to the fifth rib ; but it is sometimes more extensive and may occupy the space existing between the second and the sixth ribs. The impulse of the heart becomes less distinct, and it may be impossible to see it. The apex beat is more mobile, in some cases, from the enlargement of the sac. Skoda, who has been followed by most authors, held that the fluid, being of less specific gravity than the heart, in a recumbent posture occupies the anterior part of the sac. That this is erroneous has recently been shown by Kehn and Schaposchinkoff. On palpation the cardiac impulse, which has been described as exaggerated in the stage of fibrinous exudation, becomes less and less distinct after the fluid has made its appearance, until it usually becomes, as has just been said, so feeble as to be inappreciable to touch. The vocal fremitus over the sternal region loses some of its intensity. Fluctuation has sometimes been observed. The most characteristic symptoms in pericarditis with effusion are elicited by percussion. Skodaic resonance may be heard over the adjacent lung tissue from its relaxed condition. The area of cardiac dulness steadily increases during the pro- cess of fluid exudation until it attains its maximum, and, when this has occurred, it begins, after a longer or shorter interval, to diminish. The increase in the cardiac dulness takes place in every direction, and it affects both the deep, or relative, and the superficial, or absolute, dulness. Eotch has stated that in an early stage dulness may be elicited in the fifth right inter- costal space. This cannot be depended upon. The extent of the relative dulness necessarily depends altogether upon the amount of the fluid, and the form which it assumes is, in cases where it is at all extensive, extremely characteristic, as was shown by Sibson. Its outline has been compared, sometimes aptly but much more often inaptly, to various objects. It, in almost every instance, has an outline closely resembling that of a pear hanging downwards by its stalk. The narrow upper portion of the cardiac dulness forms, as Sibson showed, a peak ; and, at the upper and left boundary of the dull area, there is an indentation. This characteristic outline may be modified by PERICARDITIS. 3 3 9 pericardial adhesions, or by some adjacent affections ; it is, nevertheless, an extremely useful point in diagnosis, in spite of the adverse opinion of Shattuck. In certain cases there is a patch of dulness, as shown by Ewart, over the lower thoracic region behind. The features, ascertained on auscultation, are to a consider- able extent conditioned by, but are not altogether dependent upon, the amount of fluid. The vocal resonance over the lower part of the sternum, like the fremitus, wanes in intensity. As was noted by Gendrin, the auscultation of the voice over the preecordia, while the patient is in a sitting posture, some- times reveals the presence of cegophony. Sometimes there is bronchial breathing in the infra-mammary and infra-scapular regions, to which Ewart has called attention. The heart sounds always become feebler ; partly, no doubt, from the presence of the fluid, which not only lessens the afflux of blood and so interferes with the suction-pump functions of the heart, but also interferes with its driving powers. In many cases, however, the weakness of the heart sounds must be, in part at least, produced by myocarditis extending inwards from the affected surface. The friction sound sometimes disappears on the advent of the effusion, but in many cases it remains throughout the whole course of the disease. It has been found by 6ejka to persist even when the sac contained 1000 c.cm. of fluid. This may sometimes be due, no doubt, to the small amount of the effusion ; but it is also probable that, in those cases where a considerable amount of effusion has occurred, some fibrinous attachments may have been caused. In every case, however, in which the friction murmur persists, it becomes considerably weakened after the effusion has set in. In cases previously presenting no endocardial murmurs, the development of systolic mitral and tricuspid murmurs is common from weakening of the myocardium. The usual result of serous pericarditis is more or less com- plete resolution. The fluid is reabsorbed, and even the fibrinous exudation may undergo the same process, leaving the membrane almost intact. Not uncommonly, however, a certain amount of organisation takes place, and some adhesions are formed between the pericardium and epicardium. In such cases symptoms of 340 DISEASES OF THE PERICARDIUM. ulilitei'iitioii of Uic sac to a greater or lesser degree are gradually developed. There may, on the other hand, be a change in the contents of the sac, and purulent or hiuniorrhagic pericarditis may then possibly be detected. But, over and above all these contingencies, the morbid process may become arrested from lack' of tissue reaction ; in such an eventuality chronic peri- carditis is the result. Purulent Pericarditis. — The clinical features in purulent pericarditis present differences according as the formation of l)us has been present from the first or has occurred in con- secpience of an alteration in the type of the morbid process. Sometimes when pericarditis has been from the first characterised by purulent exudation, it may be so masked by the preceding or accompanying conditions as to have scarcely any recognisable clinical features. When it occurs, for example, in the course of a septicaunic affection, there may l^e no altera- tion in the general conditions, and the only possibility of recognising the pericardial complication lies in the presence of physical signs. Even these may fail in certain instances, as in Case 9, which is described on p. 356. In cases of this kiiul, nevertheless, the accelerated, feeble, and often irregular pulse may call attention to the probability of a pericardial complication. In those cases of pericarditis, however, which form the principal, and sometimes the earliest manifestation of invasion l)y pyogenic organisms, and which may therefore be termed primary purulent pericarditis, the symptoms are more character- istic. In such instances well-marked rigors are common. The temperature is as a rule high, and subject to the characteristic fluctuations seen in septic diseases. The pulse is frecjuent l)ut varialjle, and the respiration is accelerated. Profuse perspirations are also of common occurrence. It must ne^'ertheless 1jc admitted that purulent })ericarditis may l)e found with a temperature almost normal, and occasionally even subnormal, along with but little alteration in pulse and respiration. The physical signs, further, in purulent pericarditis, present many varieties. Considerable acceleration of the pulse, as has just been mentioned, is common, and the vessel is empty. PERICARDITIS. 3 4 1 while the pressure is low. High degrees of dicrotism are also frequently present, while irregularity is common. There may be no characteristic appearances on inspection of the pri^ecordia, or there may be a degree of prominence accompanied by dis- appearance of the apex beat, which may be imperceptible on palpation. On percussion the area of cardiac dulness is in- creased ; but as will be seen in the case described below, when mediastinal abscesses are present it may be impossible to determine this point. On auscultation a friction sound may be heard ; but here again the element of difficulty is sometimes present, inasmuch as, from beginning to end, pericardial friction may never be developed. When an exudation, previously of a simple serous type, becomes purulent, it is a matter of greater ease to arrive at correct conclusions. In a case of this nature there is almost invariably shivering, followed by characteristic fluctuations of temperature, pulse, and respiration, accompanied by excessive perspirations and the development of a hectic condition with rapid wasting and great prostration. The physical signs do not necessarily undergo any change, and in many cases manifest no modification on the transformation of the exudation. The pulse, however, has an undeniable tendency to become irregular and dicrotic, while the extent of cardiac dulness may be in- creased. In such cases as these it is the duty of the physician by aspiration to determine the character of the exudation. Hmmorrhagic Pericarditis. — The exudation in pericarditis contains blood in a considerable proportion of cases, more particularly when it occurs in the course of an already existent cardiac or renal disease. In old age, as well as in chronic cases of alcoholism, a sanguineous exudation is apt to occur, and in the course of tubercle and cancer of the pericardium it is common. Beyond these causes blood may occur in the pericarditis which complicates some cases of the hsemorrhagic eruptive fevers, and in scorbutus and purpura it almost constitutes a special affection. Sometimes the phenomena present in such cases present but little that is characteristic, but if there be any consider- able degree of hcemorrhage, it reveals itself by phenomena 342 DISEASES OF THE PERICARDIUM. resembling those of severe lueniorrhage in general ; that is to say, a tendency to vertigo, oppression in the chest, cold perspirations, irregularity and emptiness of the pulse, chilliness of the extremities, and syncope, often leading to sudden death. The occurrence of such symptoms in the course of any disease likely to lead to hiemorrhage might justly lead to the suspicion that the pericardium was implicated. Chronic Pericarditis. — A word or two must be added with regard to chronic forms of the disease. As a rule, chronic pericarditis is simply the remains of an acute pericarditis, in which resolution has been impeded at one of its stages, but there are cases in which from the first the disease is chronic. This is more particularly the case in old people, as well as in those who are alcoholic, or who suffer from kidney disease. In the case of an acute pericarditis arrested during the progress of resolution, the clinical I'eatures presented are simply those of the stage at which the disease has arrived when the arrest occurs. When, however, the disease is from the first chronic, it very commonly pursues an entirely latent course. There may be weakness of the circulation and interference with the breathing. Sometimes there is a sense of oppression in the pracordia produced by free effusion ; pain is very rarely complained of. On examination of the chest in such cases the physical signs are : — an enlarged area of cardiac dulness ; weakness of the heart sounds ; sometimes a friction murmur. In the absence of the friction sound the condition may closely re- semble hydropericardium, more especially when the course of the disease has been insidious. Diagnosis. — The recognition of pericarditis is not in the great majority of cases a matter of difficulty, although it must be allowed that some of its forms may either be latent, or so masked by other conditions, as to render detection difficult. The general symptoms are seldom so characteristic as to be of great value in the diagnosis of pericarditis, and even the physical signs may be misleading, as, for example, in case Xo. 9, on p, 356. It might at first sight seem improbable that the friction sound could Ije mistaken for any other phenomenon revealed PERICARDITIS. 343 by auscultation ; yet, in addition to the possibility of its IjeiDg generated by pericardial roughness or dryness previously referred to, there are dangers of misinterpretation. The exocardial friction sound may, in the first place, be mistaken for an endocardial murmur. It is, as has been seen, usually louder on inspiration than on expiration, while the endocardial murmur is as a rule of less intensity during the inspiratory phase of respiration. As shown by Traube, however, endo- cardial murmurs are occasionally rendered louder by inspira- tion, and the general principle is, therefore, subject to con- siderable variations, inasmuch as the friction sound may be louder during expiration. The friction sound is of a more superficial character, and a more grating quality. It is rarely propagated beyond the prtecordia, and is usually increased in intensity by gentle pressure with the stethoscope, while an endocardial murmur undergoes no change with such increase of pressure. It is sometimes remarked that both exocardial and endocardial sounds are weakened if the movements of the heart are interfered with by too great external pressure. The position of the patient is occasionally, but by no means commonly, of assistance, at any rate in distinguishing between systolic endocardial murmurs and any external friction sound. Systolic murmurs are almost invariably louder while the patient is in the recumbent posture, while the exocardial friction sound is usually loudest while the patient sits up or even leans forwards. According to Gerhardt and Bernheim, if an adventitious sound is only heard when the patient sits up it is always pericardial. This is far from being the case — many presystolic mitral murmurs are only rendered audible in an upright posture. On carefully attending to the rhythm of any exocardial murmur, a distinction can be made out between it and endocardial murmurs, because, as has been seen previously, the friction sound follows with a slight interval, or at least does not accurately coincide with, the cardiac sounds. After it has been determined that a friction sound is present, there is still, in the second place, a possibility of misinterpretation. The pericardial may be mistaken for pleural, or even peritoneal, friction ; that is to say, an error may be made in the localisa- 344 DISEASES OF THE PERICARDIUM. tion of the physical sign. Such an error is most likely to occur in connection with the pleural pericardium than any other part. It is not uncommon to find a friction sound in pleurisy over that part of the left lung which projects forward at the inferior border of the absolute cardiac dulness. The part of the pleura, which encloses this small projecting portion of the lung, is necessarily in intimate connection with the heart. Pleurisy in this region presents difficulties in consequence of the fact that the friction sound accompanies the movements of the heart as well as the movements of respiration. On deep inspiration a loud friction sound may be heard, and if the patient be made to hold the breath in this phase of respiration, every trace of the friction sound will disappear ; but if, on the other hand, the breath is held at the end of expiration, a distinct pericardial friction sound will be heard, which, how- ever, dies out after two or three pulsations have taken place. A friction sound has been described in tubercular peritonitis, produced, in consequence of the movements of the heart, hy the rubbing of the rough surfaces of the diaphragmatic peritoneum and that investing the liver. Emminghaus has carefully studied the occurrence of this physical sign, which is certainly very rare. Difficulties in diagnosis may also be present after fluid effusion has occurred. The increased area of cardiac dulness may be mistaken for a heart enlarged by dilatation, or for the presence of hydropericardium. There is also the possibility of error from its being taken for mediastinal tumour or abscess, or for thoracic aneurysm. Cases, like those of Smith, with differences in the radial pulses and in the pupils may be extremely like instances of aneurysm. Consolidation of the lung, or localised and encysted pleurisy may even be a cause of error. The characteristic form of the area of dulness should render the diagnosis easy, yet it may be modified by pericardial adhesions, or by the jDresence of some accompany- ing affection. In pysemic cases a dull area of large size may be produced by the presence of an abscess along with pericarditis. In most instances the conditions under which pericarditis arises will prevent the possibility of its being mistaken for any of these conditions, while the mode of onset and physical signs of tumours, aneurysm, pulmonary consolidation, or PERICARDITIS. 3 4 5 encysted pleurisy, ought to obviate any possibility of mis- conception. Some forms of pericarditis may readily enough be mistaken for hydropericardium ; in the latter condition, nevertheless, the state of the circulation, or the condition of the kidneys, ought to furnish reliable indications. The difficulty cannot be so readily solved as in the analogous difficulty between pleurisy and hydrothorax, since it cannot be considered justifiable to explore the pericardium with the aspirating needle unless it be urgently called for by the con- dition of the patient. Prognosis. — The prognosis in pericarditis depends largely upon the personal characteristics of the patient. It is, for example, much more serious during early childhood and again in advanced years. It is, further, more fatal in women than in men ; but, over and above the factors of age and sex, the individual peculiarities of the patient exercise considerable influence. The existence of any affection, such as renal disease, by means of which metabolic functions are retarded, renders the outlook less favourable, while alcoholism and exhaustion, whether from excess or fatigue, are to be regarded as reasons for caution in formulating the prognosis. The condition of the valves and of the cardiac muscle have to be taken into account. If, from causes connected with either of them, there is any interference with the circulation, the outlook is rendered worse. The nature of the underlying disease is the most important factor dominating the course of the disease, and consequently influencing prognosis. As a complication of acute rheumatism, pericarditis must be regarded as an affection of no great severity, and the same may be said of those circumstances in which it accompanies one of the less serious general diseases. The case, however, is quite otherwise when pericarditis has its origin in some septic condition, or when it is associated with tubercle, cancer, or kidney disease. The amount of fluid exudation plays an important part in the prognosis, and it may be laid down as an axiom that every additional ounce renders the case more serious. The nature of the fluid which is present is of much importance, and instances of purely serous pericarditis are mild 346 DISEASES OF THE PERICARDIUM. in comparison with those in which pus makes its appearance. When the pus has become putrid, matters have reached a serious pass, and haemorrhagic pericarditis has at all times to be regarded as one of the most grave conditions. Treatment. — In the course of any affection likely to be complicated by pericarditis the question will naturally arise, whether it is possible to avert the tendency ; in other words, w^hether prophylaxis may be advantageously employed. When salicin and the salicylates were first introduced in the treat- ment of acute rheumatism, and found to have such excellent results, it was fondly hoped that they would, in addition to cutting short the disease, obviate many of its complications. These hopes, unfortunately, have not been realised. It is impossible to speak with absolute certainty upon this point, because statistics, although collected by the most accurate observers, are open to misinterpretation. The relative frequency of pericarditis in acute rheumatism necessarily varies in some degree, and this consideration renders the comparison of statistics not absolutely reliable. When every aspect of the question has been considered, it must be admitted that pericarditis is probably as common under salicin treatment as under any other. Many attempts have been made to prevent the onset of pericarditis in rheumatism and other diseases likely to produce it. Only two methods of procedure appear to have any influence. One of these consists in the systematic ap- plication of cold over the prtecordia, either by means of the ice-bag, or iced cloths, or, still better, Leiter's tubes. The other consists in the continuous application of small blisters over the pnecordia. This has been more particularly insisted upon by Caton, who speaks strongly in its favour. If acute pericarditis has made its appearance, and is recog- nised by means of physical signs, the patient must be treated in accordance with general principles. It is sometimes un- necessary to adopt any special measures, and each case must be managed according to its particular features. The principal indications for treatment are to curb the process and remove its results. These indications may be fulfilled by diminishing the cardiac energy, while removing all painful and distressing PERICARDITIS. 347 symptoms. The removal of tlie products of the disease may be aided by medical or surgical measures. Absolute rest is necessary, and sleep is essential ; if in- somnia be a marked feature, it should be combated. Simple sedatives, such as the bromides, are, as a rule, quite sufficient for this purpose, but if there be much depression it is better to administer such a drug as paraldehyde, which will produce a stimulating effect in addition to producing sleep. Milk diet is in most acute cases absolutely indicated, and if there be much thirst, abundant simple drinks may be given. After the first two or three days of the affection, different kinds of soup may be added to the dietary, which may be extended day by day in every direction. The functions of the bowels must be watched, and, if there be constipation, an enema or saline aperient should be administered. With regard to drugs, it need hardly be said that if peri- carditis has arisen in the course of an acute general disease, the lines of treatment already adopted in that disease will require to be steadily pursued, and only in the case of definite indications is it necessary to administer special remedies, or to have recourse to further measures. In the case of rheumatic pericarditis, the combination of sodium salicylate with potassium bicarbonate gives most satisfactory results, from fifteen to twenty grains of each drug being administered every four hours. Aconite is sometimes recommended, but is absolutely un- worthy of confidence. There is only too great a tendency to reduction of cardiac energy as part of the disease, and drugs belonging to this class should be shunned. The salicylates are quite sufficiently depressing in themselves. If the temperature, in spite of the action of the salicylate, tends to become too high, it is advisable to employ some antipyretic, and experience shows that the most useful drug for the purpose is phenacetin. It may be given while the salicylate is steadily continued. Antipyrin, antifebrin, and other remedies of the same class may, however, be used in some cases with advantage. If the pulse has a tendency towards undue frequency, the administration of alcohol in any form most agreeable to the patient, while at the same time unlikely to interfere with the 348 DISEASES OF THE PERICARDIUM. functious of digestion, may be given, but it is often necessary at this point to step in with one of the cardiac tonics, such as digitahs or strophanthus. If there be much pain, it may be reheved by the applica- tion of cold in any of the forms mentioned, but it is sometimes found that heat is more soothing to the patient than cold, and hot poultices or fomentations may in such instances be employed. In many cases it is very quickly relieved by the application of two or three leeches to the prsecordia. When there is much distress along with great pain, general blood- letting, as advocated by Fagge, may be resorted to, and four or six ounces of blood removed from the arm. It must not, however, be forgotten that the pain may be so severe as to require the employment of morphine or some other derivative of opium. There is absolutely no danger in the use of these drugs, since opium not only regulates, but even increases, the cardiac energy when given in small doses. It may be applied externally by means of fomentations, or administered internally in any suitable form, but sometimes it is more advantageous to exhibit morphine hypodermically. This is more particularly the case when the digestive functions are disordered. When effusion has taken place, new considerations arise. If the fluid remains moderate in amount, it is unnecessary to do more than maintain the treatment already employed, and to watch for the development of such symptoms as may be expected from the fluid exudation. If the fluid becomes large in quantity, diuretics and purgatives may be advisable, while counter-irritation is employed externally. It must be borne in mind that when the pericarditis is of renal origin iodine is to be applied instead of cantharides. The best remedies for internal use are iodide of potassium along with acetate of potassium. On account of the danger produced by the iutrapericardial pressure, the question of operative relief must always be borne in mind. liiolan proposed paracentesis of the pericardium, and this was also advocated by Senac. Desault performed paracentesis for a supposed pericardial effusion, but it was found on post-mortem exa}nination that the case was one of circumscribed pleural effusion. The first actual paracentesis PERICARDITIS. 349 of the pericardium was performed by Komero, who reported three successfid cases to the Faculty of Medicine of Paris. The Faculty would not allow the report of these cases to he printed in their Transactions, since they declined to sanction the operation, but they are described by Mcrat. Karawagen, Schuh, Kyber, and Aran were his immediate followers, and, like him, they were remarkably successful in their results. The most important writings regarding paracentesis are those of Trousseau, Eoberts, Hindenlang, Clifford Allbutt, Grainger Stewart, Fiedler, and West. The statistics of all the known operations up to the year 1880 have been collected with indefatigable industry by Eoberts, and his work is a storehouse of information upon the subject. The earliest operations were performed by means of the bistoury and scissors, but during the intermediate period the trocar and canula were always employed. Since the intro- duction of the aspirator, it has for the most part been relied upon in the first instance, but in purulent or hsemorrhagic cases free incision has been practised. The considerations which have to be borne in mind in connection with paracentesis pericardii are the determination of suitable cases, the selection of the most favourable site for operation, and the best method to be adopted. It is not difficult to determine when paracentesis pericardii is advisable. The presence of symptoms denoting great inter- ference with the circulatory functions, and the physical signs of a considerable effusion into the sac, will furnish sufficient proof of the necessity or advisability of the operation. Opinions have differed a good deal as to the most suitable site for the operation, and, without discussing all the different views which have been advocated, it may be said that there are two posi- tions which are least open to objection. The first of these is the fifth intercostal space just inside of the mammillary line ; the second is the angle between the ensiform cartilage and the left costal margin. In most instances the latter is the most advisable site, inasmuch as by means of it the lowest portion of the pericardial sac can readily be reached, and with a distended sac there is but little likelihood of damaging any of the neighbouring viscera. Undoubtedly the 3 5° X>ISEASES OF THE PERICARDIUM. most suitable instrument for employment is the aspirator, by means of which fluid may be easily withdrawn without any risk of introducing air into the pericardial sac, but in those cases where the contents of the sac are purulent, it may after- wards be necessary to make a free incision with antiseptic precautions. Such an instance has recently been described by Underhill. The great dangers attendant upon paracentesis are the possibility of wounding the lung or pleura in operating in the fifth intercostal space, or the superior epigastric artery if the site of the operation be in the angle between the xiphoid cartilage and costal margin, while in both localities there is a possibility of puncturing the heart. These risks are, how- ever, probably somewhat exaggerated. If the fifth inter- costal space be selected, the sac is as a rule so distended as to have pushed the left lung altogether aside, and the passage of the aspirator through the pleural sac is unattended by any trouble. If the epigastric site be selected, there is but little danger of wounding the superior epigastric artery if the aspirator be inserted quite close to the sternum, seeing that the artery is about half an inch away from the sternal margin. The third danger connected with the fear of puncturing the heart has also been greatly exaggerated, and such cases as those of Hulke, reported by Evans, and of Sloan show that even when the heart has been punctured and blood has been withdrawn from it accidentally, the symptoms are improved instead of rendered worse. Eoberts' statistics deal with sixty cases of paracentesis pericardii, twenty-four of which ended in recovery, while death occurred in the remaining thirty-six. The mortality, there- fore, has been 6 per cent. ; this is remarkably good consider- ing the extremely serious natm-e of the afiections for which the method was employed. Ca8E 5. Fcricarditin fruin lihciivLu(isn). — V. F., aged seven, scliool- boy, was admitted to AVard 22 of tlie Eoyal lulinuaiy, 27th June 1893, complaining of breatlilessness on exertion. His j^arents were both healthy, and all his brothers and sisters were perfectly well. Both his grand- mothers were alive, and enjoyed good health. His paternal grandfather died of bronchitis : his maternal Grandfather died of heart disease and PERICARDITIS. 35 1 dropsy. These facts are mentioned in case the atavistic tendency mani- fested by the patient should perchance be of real interest. His social conditions had always been excellent. When he was eighteen months old he suffered from measles and whooping cough. Seven months Ijefore admission he had suffered from a sore throat accompanied by a rash, in regard to which no definite facts could be ascertained, and three months before admission he had passed through a severe attack of acute rheuma- tism from which he had never entirely recovered. On examination the j)atient was found to be a bright intelligent boy, with a clear transparent skin through which a bright Hush appeared high upon the cheeks. His temperature was normal. The tongue was almost clean, and there were no symptoms connected with the alimentary system. The pulse varied extremely in rate, fluctuating between 120 and 160 per minute. The vessel was empty and the blood pressure was low. The rhythm was regular and the pulsations were small. On applying the hand to the pra^cordia, the apex beat was found to be diftuse, the impact of the heart was apparently behind the fourth rib, the right and left borders of the heart were respectively two and three inches from mid -sternum. On auscultation a loud but soft blowing systolic murmur was heard in the mitral area, and was j^ropagated for about a couple of inches in every direction, but the most characteristic feature of the case was the presence of pericardial friction. This was heard over almost the entire praecordial region and extended slightly beyond it, both above and below. Over almost the whole of this area it was of twofold rhythm, systolic and diastolic, but in the region of the mitral and tricuspid areas it had a distinct threefold rhythm, presystolic systolic, and diastolic. These appearances have been shown in Fig. 119, p. 331. One fact of much interest is that on auscultation through the dressing-gown and night- shirt only the systolic endocardial murmur could be heard. The case was of interest especially on account of the fact that the triphasic rhythm was confined to the apical region, while it was diphasic at the base. Under absolute rest and counter-irritation by means of some small blisters, followed by moderate doses of digitalis along with iron, the patient rapidly improved and was dis- charged free of all pericardial symptoms in the course of three weeks. Case 6. Bheuviatic Endocarditis foUoived by Pericarditis. ■ — J. C. aged 20, soldier, was placed under my care in Ward 22 of the Royal Infirmary by Surgeon-Captain Will, on 5th August 1892, complainino- of pains in his joints and breathlessness. No special hereditary tendencies could be elicited, and apart from the inevitable exposure connected with garrison duty, there was nothing in his social conditions predisposing to 352 DISEASES OF THE PERICARDIUM. disease. He had been perfectly liealtliy all bis life. Three days before admission he began to suffer from pains in his joints and feverishness. The patient's temperature on admission was a little over 103°. The face was pale, and the skin was bathed in profuse perspiration, with characteristic rheumatic odour. The tongue was covered by a white fur, but there were no symptoms connected with the alimentary system. On admission there were no symptoms indicating any cardiac implication. The pulse rate was a little over 100. The fulness was slightly below, while the compressibility was slightly above the normal, and the pulse was jjerfectly regular. The only point, on examination of the pra^cordia, calling for mention is that the right border of the heart was slightly enlarged, extending two inches and a half from mid-sternum. During the few days which elapsed after the patient's admission it was obvious that endocardial changes were in progress. The heart was not merely enlarging, but, in addition to systolic murmurs in the mitral and tri- cuspid area, undoubtedly jsroduced by dilatation, there was an aortic A ,gu sf Septei nber 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 102 101° 100° 99° 9<3° 97° 9G° ^ A l[ . ■a c. -39° / / \A / \f\ A "5. A A h T y Y 1/ 1/ \ -38° r V^ N / V 1 / / V. h \ /^ / y il \ ;t V y / iA \ y 2 \ / r k ^ -37 V tT ^ 1 / \ y J ^<§ Pig. 120. — Temperature chart from Case 6. systolic murmur. By the 15th August such suspicions were absolutely confirmed. The pulse, still frequent but perfectly regular, had become empty and compressible, and manifested well-marked dicrotism ; on elevat- ing the arm, moreover, there was considerable tendency towards the water- hammer pulse. Inspection of the prtecordia gave no abnormal symptoms, but on palpation the right border of the heart was found to be three, and the left four and a half inches from mid-sternum. On auscultation there were loud but soft blowing systolic murmurs in the mitral and tri- cuspid area. There was a distinct aortic systolic murmur, and occasionally a soft diastolic murmur could also be heard. The second sound in the pulmonary area was considerably accentuated. At this period, therefore, it Avas clear that along with dilatation of the heart, produced by the pyrexia, there was endocarditis affecting the aortic cusps. The temperature, which under the influence of salol had fallen at once, was seldom above 100°, yet it never quite fell to the normal ; by the end of August, how- ever, it was only 99° in the evenings, and subnormal in the mornings. On 5th September the temperature began again to rise, and on the 7th it almost reached 103°. The pulse also increased in frequency, yet the most sedulous examination of the heart failed to reveal any cause. On the 11th September intense praBCordial pain began in the forenoon, PERICARDITIS. 353 and early in the afternoon a distinct pericardial friction sound was present. It was characterised by a distinct double rhythm, systolic and diastolic. During the next two days the condition remained unchanged, except for a fall in the temperature to little above 100° ; on the 14th September, however, at the base of the heart there was a most distinct triple rhythm in the friction sound. The temperature from this date rapidly came within ordinary limits, and the friction speedily waned. Little or no serous effusion took place, for the area of cardiac dulness became smaller, and the patient was dis- missed a couple of weeks afterwards in a fair state of general health. The tricuspid systolic murmur had disappeared, the mitral systolic murmur was shorter and sharper, and the accentuation in the pulmonary area had disappeared. There was, however, a loud rough systolic murmur, followed by a soft diastolic murmur, in the aortic area. This case is interesting as showing a contrast to Case 5 as regards the localisation of the triphasic friction sound. Case 7. Pericarditis from BrigMs Disease. — T. W., aged 35, engineer, was admitted to Ward 22 of the Royal Infirmary, 28 th June 1893, complaining of shortness of breath and cough. His family had no special disease tendencies, and his social conditions had always been com- fortable, but his occupation exposed him to sudden vicissitudes of temperature. His previous health, nevertheless, had been perfectly good. Two months previous to admission he had a severe chill when fishing, and he had never been well since that time. On examination the patient manifested a considerable degree of hebetude. In answer to questions his utterance was extremely slow, although quite distinct. There were some muscular twitchings in the face as well as in the extremities. The temperature was 97°. The lips and mouth were extremely dry, the tongue of a bright red hue with a glazed surface, and the teeth much decayed. There was frequent vomiting, and there had been constipation. None of the abdominal viscera showed any abnormality. The patient complained of pain below the left mammilla, which was increased with every move- ment and distinctly aggravated by percussion. The pulse was about 100 jper minute. The vessel was full and the pressure high. The pulsation was perfectly regular and distinctly tardy. The apex beat was in the fifth left intercostal space, four inches from mid-sternum. The impulse was forcible and prolonged. The right and left edges of the heart were respectively two and a half, and four and a half, inches from mid-sternum, and on aus- cultation there were distinct mitral and tricuspid systolic murmurs. The second sound was nearly equal in intensity in the aortic and pulmonary areas, and was in both distinctly accentuated. There was a copious frothy expectoration stained with blood. At the bases of both lungs the percussion sound was somewhat muffied, the breathing tended towards the bronchial type, and was accompanied by crepitations. There was considerable pain in the loins. The urine amounted to forty ounces. 23 .54 DISEASES OF THE PERICARDIUM. It was pale in colour and acid in reaction, with a siDecific gravity of 1013. It contained 187 grains of urea and a large amount of albumin. Hyaline and granular casts were present. In addition to the obvious nervous phenomena above referred to, the patient sull'ered much from headaches, and was sleepless. It was clear that chronic nephritis had been left by a previous acute attack, and that it was accompanied by dilatation and hypertrophy of the heart. The patient was treated by means of milk diet, along with vapour baths and purgatives, while Fig. 121. — Temperature chart from Case 7. sulphonal was administered in order to ensure sleep. On 30th June, a diuretic mixture was begun. On 2nd July, auscultation revealed the presence of a to-and-fro friction murmur, which was most intense towards the base of the heart. Three leeches were applied to the prpecordia. During the next four days little change occurred in the patient's condition, but on the 7th July pleuritic friction made its appearance over the right side, and, at the same time, comparative dulness was found on percussion over the base of the left lung, which was accompanied by great dyspna-a, and became almost absolute, while the br*eath sounds and vocal resonance disappeared, show- ing the presence of hydro thorax. The following day the breathlessness became excessive and aspiration had to be resorted to, but in spite of every endeavour the patient died. No autopsy was obtained. Case 8. Pericarditis from Pleuro-imeumonia. — L. G., aged 21, domestic servant, was admitted to Ward 25 of the Royal Infirmary, 15th December 1895, complaining of cough and pain in the chest. Her family history was satisfactory, and her surroundings had always been good ; her previous history had also been satisfactory. The illness for which she was admitted began two days before Avith a well-marked rigor, attended by severe pain in the left side of the chest and a harsh, hacking PERICARDITIS. 355 cough. On admission, the patient was found to be well-nourished and muscular. Her face was pale, with a brilliant flush upon each malar pro- minence. Her temperature was 103° ; the pulse and breathing 126 and 44 per minute. There was a copious expectoration of rusty-coloured sputum, which, it may be mentioned, on further investigation, was found to contain numerous pneumococci. The tongue was coated with a brown fur and was somewhat tremulous. The digestive system otherwise gave no indications, and there were no symptoms connected with the circulatory organs. On examination of the chest, it was observed that the left Januanj Pig. 122. — Temperature chart from Case 8. side did not move so freely as the right. The vocal fremitus was increased over the lower portion of the left lung. On percussion there was almost absolute dulness over that area, and on auscultation there was high-pitched bronchial breathing, with a few fine crepitations on inspiration, and greatly increased vocal resonance. The urine contained almost no chlorides, and had a very copious precipitate of urates. The patient was in a somewhat soporose condition with slight muttering delirium at night. The case was obviously one of pneumonia, and from the considerable pain present, as well as from the friction sound, it was clear that a certain amount of pleurisy was also present. During the following day the temperature came down somewhat sooner than had been expected, but on the following day or two it oscillated considerably. 356 DISEASES OF THE PERICARDIUM. On the 19tli it rose still higher. On this date examination of the heart, which had been sedulously carried out day by day, revealed the presence of distinct pericardial friction accompanying the systole and diastole of the heart. This friction sound was heard over almost the entire prtecordia, and it was unattended by any symptoms. In two days it entirely disappeared, but, with its disappearance, an ominous flush upon the al;\' nasi and adjacent portions of the cheeks made its appearance, and the temperature began again to run up. A day later there could be no mistake as to the condition which was present, for the flush was obviously erysipelatous, and the temperature was still rising. The patient was therefore transferred to the observation wards and carefully tended there. In five days, under treatment with sulpho-carbolate of sodium, the erysipelas had disappeared, and when all danger of infection had been removed, she was again transferred to Ward 25, where her recovery went on rapidly. This case could only be regarded as an instance of peri- cardial infection by means of the pneumococcus, as the erysipelas distinctly followed the pericarditis. Case 9. Sejitic Pericarditis. — C. P., aged 75, retired manufacturer, began to complain in April 1893 of a swelling above the clavicle on the right side, along with a dull pain in the chest and weakness. The family tendencies presented no facts bearing upon his case, and his social conditions had always been excellent. He had during his earlier years suffered from small-pox and from typhus fever, and he had met with several accidents. The swelling of the neck began insidiously, and it had been preceded by a hard, dry cough which had existed for some weeks before. The patient's appearance was somewhat sallow, although his complexion had previously been good. The skin was constantly moist, the temperature rose a couple of degrees at night, the tongue was covered by a moist yellow fur ; the pulse ranged between 120 and 130 — it was empty and compressible, with a regular but small pulse wave. There were no symptoms either on inspection or palpation of the pra;cordia, and, on percussion, the upper level of cardiac dulness was at the third left costal cartilage, the right border two inches and a half to the right, and the left three inches to the left of the sternum. Examination of the respiratory system failed to reveal any cause for the cough. The condition of the urine was absolutely normal. The skin, as already mentioned, was constantly moist, and on the least exertion profuse perspiration was induced. Sleep was disturbed, but the patient suffered from no headache or other over-nervous sj^mptom. In this case there were few definite characters. The evening rise of temperature and the condition of the skin caused a suspicion that septic infection might be the origin of the condition, and this became more evident in the course of two or three days, when the cervical glands assumed a softer consistence, and fluctuation was elicited in them. Mr. ADHERENT PERICARDIUM. 3 5 7 Joseph Bell saw the patient along with me and incised the suppurating glands, while quinine was administered in large doses. The surgical intervention produced no amelioration in the symptoms. The tem- perature continued to rise at night, and the profuse perspirations occurred as before, while the pulse rate remained steadily between 120 and 130. The pain in the chest also tended to become worse instead of lessening, and the feeling of weakness also increased. It was obvious that the pulse rate was kejjt up either by some general toxic agent, or by some local disturbance. The most careful examination of the circulatory organs gave no symptoms further than those which have been referred to, and it could only be a matter of inference as to the nature of the irritation keeping up the pulse rate. We feared the development of some deeply- seated suppuration connected with the mediastinal glands, possibly involv- ing the pericardium, but of this there was absolutely no proof. On consultation with Mr. Joseph Bell, it was arranged that the patient should seek the benefit of change of air, and he therefore went to the country, and was placed under the care of Dr. Hall, of Rothesay. After remaining in the country for two or three weeks, he returned in May to Edinburgh with his condition practically unchanged. His temperature still rose at night, his pulse maintained the same frequency of rate, the profuse perspirations constantly recurred, and the objective symptoms remained as they were before. Early in June the condition of the patient changed for the worse. He began to emaciate rapidly, and the weakness, always present, increased rapidly. The temperature, which had been always moderate, now became somewhat higher at night, and the perspirations became more excessive. The heart sounds enfeebled steadily and the jaulse rose to 140 and 150, but on most careful examination of the praecordia, no change could be determined. The downhill course of events swiftly brought about a fatal termination on the 20th June. A post-mortem examination was performed the following day by Dr. Leith, which, omitting unnecessary details, revealed the fact of septic suppuration of the posterior mediastinal glands with implication of the pericardium, which contained a quantity of purulent fluid, abounding in streptococci. This case furnishes an excellent instance of septic peri- carditis, in which the circulatory complication although suspected could not be diagnosed with confidence. ADHEEENT PERICAEDIUM. Amongst ancient writers obliteration of the pericardial sac was regarded as a congenital absence of the mem- brane ; Vieussens and Lancisi are the first authors who recog- nised the true character of the condition. Senac, Morgagni, and other observers gradually unfolded many of the clinical 358 DISEASES OF THE PERICARDIUM. as well as anatomical features of the condition, but it is to Sibson, Friedreieh, and lieigel that we are indebted for the most careful study of the symptoms of the disease. Etiology. — It appears proljable that synechia of the peri- cardium may follow in some degree every variety of pericarditis, but it is undoubtedly much more common in certain types. Fibrinous pericarditis is more likely to give rise to adhesions than any of the other forms, with the exception of the peri- carditis which is an accompaniment of renal disease. In this form, as already mentioned, partial or general pericardial adhesions are frequent. The formation of adhesions may occur in an early stage of the disease, while a perfectly dry fibrinous pericarditis is present, or it may, and much more commonly does, take place after the reabsorption of an effusion. Possibly feeble action of the heart may tend to its production, and increased energy may cause the adhesions to break away. It appears to be a common result in those forms of pericarditis which become chronic, and more particularly in those which recur, a good example of which will be described below. Weakening of the energy of the heart must certainly act as a predisposing agent. It is an extremely common experience to find pleural as well as pericardial adhesions, and synechia pericardii is in many instances found associated with other pulmonary affections. Statistics have often been collected with regard to the frequency of adherent pericardium, and vary very widely. Leudet, for instance, from the investigation of 1003 necro- scopies, states that partial occur in 5 per cent, and total adhesions in 2 '5 per cent, of autopsies, while the results of the Charite Hospital of Berlin, according to Breitung, give 156 cases of adherent pericardium in 324 cases of pericarditis. MoKBiD Anatomy. — The extent of the adhesions is ex- tremely variable — from the slightest attachments by means of a few fibrinous bands to complete synechia there is an unbroken series of intermediate forms. The union is effected by layers of fibrin in which a certain number of cells are entangled. The appearance on section is shown in Fig. 123. The adhesions may take the form of bands or mats, which are mostly found at the base. Further changes occur, of which the ADHERENT PERICARDIUM. 359 most common is fatty degeneration of the newly-formed tissue, although calcareous infiltration not infrequently occurs. According to Sibson, when the adhesions are long and loose, and the heart is free from valvular disease or other influence tending to produce hyper- trophy, the size of the heart is usually unaltered. If, however, the adhesions are short and powerful, and there are any pleuro- peri- cardial attachments, there is a greater tendency to hypertrophy. According to this observer, in two-thirds of his cases without valvular disease (12 in 19) the heart was considerably enlarged ; in one-fifth of them (5 in 19) it was rather large; and only in one-tenth of them (2 in 1 9) the heart was of normal size. When peri- cardial adhesions are attended by valvular disease, as is usually the case, the heart is invariably enlarged. The enlargement is usually due to combined dilatation and hypertrophy, and there is a great tendency in all cases to degeneration. Symptomatology. — Cases of adherent pericardium, latent throughout their whole course, may be discovered accident- ally by physical examination, or only, indeed, revealed after death. On the other hand, there may be such symptoms as palpitation, breathlessness, cyanosis, and oedema. Ascites occasionally presents itself, in which the default of all possible causes, with the exception of some history of a pericardial lesion, raises the suspicion that adhesions, by compressing the inferior vena cava, are the source of the affection. In a few instances of adherent pericardium anginous symptoms make Fig. 123. — Fibrinous pericarditis (x20) showing: a, pericardium ; h, epicardium ; c, myocardium ; d, fibrinous exudation showing organisation from both serous surfaces. 36o DISEASES OF THE PERICARDIUM. their appearance, and towards the end of life syncopal attacks are prone to occur. The pulse sometimes presents no abnormal features. It often, however, is irregular, and is marked by greater oscilla- tions of pressure than are present in health. There is frequently a well-marked dicrotic tendency. Xot infrequently the paradoxical characters described by Kussmaul in mediastino- pericarditis are present, as was the case in a well-marked instance described below. On examining the chest, there is occasionally to be seen a fulness in the left part of the pnecordia, but more common than this is a flattening of the chest wall to the right, as well as to the left, of the region of the apex beat. When the move- ments of the heart are carefully inspected in patients who are reasonably thin — and in my experience adherent pericardium is mostly found in those who are slender — it will be seen that there is a retraction of the left half of the epigastrium with each beat of the heart, a symptom which was described Ijy Kreysig, whose attention w^as called to it by Heim. There is also a drawing in of the intercostal spaces surrounding the apex beat, to which Eiegel has devoted much attention, and in the lateral as well as posterior part of the chest, as insisted on by the younger Broadbent. Skoda held that the apex beat was drawn in with each systole, and this has been more particularly insisted upon by Friedreich and Guttmann. These statements are due to faulty observation, and are also based upon misconception of physiological facts. The re- traction of the epigastrium, and of the interspaces surrounding the apex beat, may be determined in almost every case of adherent pericardium, but there is no indrawing at the apex itself. It has already been shown, from the physiological point of view, that, while during systole the ventricular portion of the heart lessens its transverse and antero - posterior diameters, it does not diminish its long axis, and this ex- plains how there is retraction around, but not at the apex. Inspection also shows another weighty symptom, that inspira- tion is not accompanied by the normal expansion of the inferior part of the left side. If the patient be caused to change his posture, it will be found that it does not move with change of ADHERENT PERICARDIUM. 361 position, that, in short, it retains the same position whether the patient lies upon his right or left side. As was observed by Sibson, the inspiratory movements of the central portion of the abdomen are considerably diminished. The central move- ments in health are from two to three times as great as the lateral movements of the abdomen, but in adherent pericardium the amount of movement is in some cases about equal in the central and lateral portions. It is by no means uncommon to find that during inspiration there is an indrawing of the lower portion of the sternum. An interesting fact, originally ob- served by Friedreich, is that during the diastole of the heart there is a most distinct collapse of the veins of the neck. One very important symptom is the diastolic rebound of the heart. This appearance, which can be appreciated by inspection, but more thoroughly realised by palpation, is one of the most characteristic features of the disease. On applying the hand, there is said to be weakening of the apex beat, unless it is accompanied by hypertrophy of the heart. No case of simple adherent pericardium has ever presented itself before me. There has been some valvular affection in every one, accompanied by a considerable amount of hypertrophy. In the majority of cases of adherent peri- cardium, as has already been shown, there is more or less hypertrophy, and the apex beat must in these be increased in force. The area of cardiac dulness entirely depends upon the presence or absence of hypertrophy or dilatation. As a rule it is enlarged, both to right and left, and this is more particularly seen when pericardial obliteration is accompanied by valvular lesions. The dulness does not change its position on any alteration of the posture of the patient. It also undergoes no modification on the deepest inspiration and expiration. On auscultation the heart sounds are sometimes weakened, but on the other hand, in cases where there is hypertrophy, they are distinctly accentuated. It is impossible for me to say anything definitely on this point, seeing that no uncom- plicated case has afforded me an opportunity for its observa- tion, A metallic character of the heart sounds has been described by Eiess. 362 DISEASES OF THE PERICARDIUM. Diagnosis. — The recognition of obliteration of the peri- cardial sac is a matter of careful physical exploration, so frequently is it latent and absolutely unattended by any general symptoms. No single physical sign can be regarded as of much diagnostic value, with the sole exception of the immobility of the heart in varying postures, and the diastolic rebound of the parietes. The systolic retraction of the epi- gastrium and of the intercostal spaces around the apex beat may occur in any condition in which there is cardiac hyper- trophy along with lack of elasticity in the lungs. The diastolic collapse of the cervical veins is of some utility when added to the other physical signs, but in itself it cannot be regarded as in any degree pathognomonic. The diagnosis, therefore, of synechia pericardii must be based upon the assemblage of symptoms present ; and if there be a paradoxical character of the pulse, a diastolic collapse of the cervical veins, a systolic retraction of the epigastrium and intercostal spaces, a fixed position of the apex beat under all conditions, an immobility of the area of cardiac dulness, and a diastolic rebound of the chest wall, the diagnosis of adherent pericardium may be regarded as certain. The characters of the heart sounds are too variable, and bear too little relation to the condition of the pericardium, to be of any value. It need hardly be added that if there is a history of previous pericarditis, it will render the diagnosis more certain. Peognosis. — The outlook in obliteration of the pericardial sac in itself is in no respect serious, inasmuch as the heart is surrounded by pulmonary tissue marked by such a high degree of extensibility and elasticity ; the mere fact that there are adhesions between the pericardium and epicardium cannot in itself seriously interfere with the movements of the heart, and, as has been seen, uncomplicated adherent pericardium does not produce any great tendency to hypertrophy. When oblitera- tion of the pericardial sac, however, is associated with valvular lesions, the complex pathological condition is one of most serious import. Not only does the heart suffer from the disturbances produced by the valvular lesions, but the additional strain, which it undergoes in consequence of the external adhesions, gives rise to a greater tendency to hypertrophy, and the heart. ADHERENT PERICARDIUM. 363 as will be explained more fully in a subsequent section, is prone to grow beyond its nutritive possibilities. When there is an association of valvular lesions and pericardial adhesions, there is a great liability to heart failure, and some of the most striking instances of sudden death take place under such circumstances. Tkeatment. — During the resolution of pericarditis it would seem probable that prophylactic measures might aid natural processes and lessen any tendency to pericardial adhesions. The use during this stage of deobstruent remedies, as iodide of potassium, together with external counter-irritation, would seem on theoretical grounds to be advisable ; and if, during the period of regression, the heart in any case should give evidence of weakness, it would certainly seem advisable to use such remedies as are calculated to increase its energy. The com- bination, therefore, of digitalis with iodide of potassium is to be strongly recommended. When adhesions have formed, medical measures are power- less, and treatment can only be symptomatic. In simple cases of pericardial obliteration there is but little interference with circulatory processes, and all that is necessary in such cases is to recommend abstinence from all excessive physical "exertion, which might at once put a heavy strain upon the heart, and cause considerable oscillations of intrapulmonary pressure. The food, at the same time, ought to be such as will not cause any tendency to gastric dilatation. When, in consequence of adherent pericardium, there is a tendency to cardiac failure, its symptoms must be met by the method which will be afterwards fully described for cases of that description. Case 10. Adhere^it Pericardium. — F. B., aged 24, stationer, was under my care in Ward 22 of the Royal Infirmary, complaining of un- easiness in the chest and breathlessness on exertion. The patient's family seemed entirely free from all hereditary tendencies connected with his affection, as his father had died at the age of sixty of a tumour in the neck, and one sister had died from a suppurating affection of her arm, while the patient's mother, two brothers, and four sisters were in the en- joyment of perfect health. His environment had been all that could be desired. The patient suffered at the age of twelve from a severe attack of acute rheumatism, which was repeated at the age of sixteen, and again 364 DISEASES OF THE PERICARDIUM. M-lien he was seventeen years old. During the seven years which had elapsed between the third attack of acute rheumatism and the present illness the patient had felt perfectly well. Four montlis before admission the attack for which he came under treatment began. There was at first merely a feeling of oppression and of breathlessness on any un- wonted exertion or excitement ; this had become more pronounced, so that there was a constant feeling of uneasiness and weight in the chest, along with breathlessness on the least exertion. The patient complained of no symptoms beyond those which have been mentioned. His digestive functions w-ere absolutely normal in every respect. His teeth w^ere by no means good, but the tongue was clean. The patient was fair with a clear skin, through which the blood mantled brightly upon the malar prominences. The lips were ruddy, and the conjunctivie well coloured. The tint of the nails was bright, and there was no arching of them or clubbing of the fingers. There were no abnormal symptoms referable to the htemopoietic viscera. The pulse was of extremely variable frequency, the rate oscillating between 70 and 90. The vessel was somewhat empty and the blood pressure was low, Fig. 124. — Pulsus paradoxus in adherent pericardium ; pressure 3 oz. but each wave was high, although collapsing. It presented, in short, some of the features of Corrigan's pulse. The fact in regard to it, how- ever, Avhich was of greatest interest, was connected with its relation to respiration. Careful investigation by means of the finger revealed the fact that during deep inspiration the pulse wave became smaller, while it again during expiration increased in volume. The pulse furnished, in short, as far as could be judged by the finger, the characters usually termed paradoxical. A tracing obtained with Marey's sjDliygmograph brought out these characters very distinctly, and they are shown in the accompanying illustration (Fig. 124). On examining the patient's neck and chest, two appearances at once caught the eye. There was a considerable increase in the arterial impulse in the neck, but this was entirely overshadowed by the phenomena seen in the lower part of the prascordia. The systole of the heart, shown by the bounding arteries of the neck and a pronounced apex beat in the sixth intercostal space, was accompanied by a sinking in of the left half of the epigastrium, in the angle between the ensiform cartilage and costal margin, and by a most distinct recession of the fourth, fifth, and sixth intercostal spaces, both inside and outside of the apex beat, which was four inches and a half from mid-sternum. The systole was succeeded by a very well marked diastolic rebound, Avhich could be seen over the ADHERENT PERICARDIUM. 365 entire prfecordia. On applying the hand, tlie apex beat was felt to be violent, and it gave the hand a distinct impact. All the parts, however, around the immediate apex beat withdrew themselves from the hand, and this could also be made out very distinctly in the epigastrium. Far from there being any recession in this case of the apex beat, therefore, thei-e was a most distinct, almost violent, impulse. Tracings were obtained by means of the cardiograph from the apex, which is rei3roduced in Fig. 125. On percussion the cardiac dulness was found to begin at the third costal cartilage on the left side. The right margin at the level of the fourth rib was two inches and a half, while the left was five inches from mid-sternum. At the level of the xiphoid cartilage, however, the left margin of the heart was five inches and a half from mid-sternum. The heart was therefore greatly hyj)ertrophied. On auscultation a shrill, rough, systolic murmur was heard, with its maximum intensity in the mitral area, propagated for a considerable distance in every direction. The first sound in the tricuspid area was distinct, although Fig. 125.^ — Cardiogram from a case oi adherent pericardium. ■accompanied by the mitral murmur. In the aortic area systolic and diastolic murmurs were heard, of which the former had its maximum intensity half-way up the manubrium sterni, and was propagated into the carotid and subclavian arteries, while the diastolic murmur was most distinctly heard about the level of the fourth costal cartilages. In the pulmonary area there was an accentuated second sound. It was evident that in this case there was obstruction as well as incompetence at the aortic orifice, and from the high-pitched and harsh characters of the mitral murmur, it could not be doubted that there were also obstruction and regurgitation at the mitral orifice. There were no symptoms calling for remark connected with any of the other systems, and they may be passed over without comment. Absolute rest followed by some resistance exercises after a few days relieved the patient of all his troublesome symptoms, and he was discharged much improved. The patient furnished an excellent example of the physical signs of adherent pericardium, and it is of interest to note the salient features of the case. There was an entire absence of any diastohc collapse of the cervical veins. A distinct impulse was produced by the apex, accompanied by a recession of all 366 DISEASES OF THE PERICARDIUM. the surrounding parietes, and followed by a very pronounced diastolic rebound. The paradoxical pulse is of especial interest as showing the worthlessness of this appearance in the diag- nosis of niediastino-pericarditis. MEDIASTINO-PERICAEDITIS. During the course of pericarditis, as was previously mentioned, there is occasionally a tendency for the morbid processes to pass beyond the pericardium, and to involve the textures of the mediastinum. As a consequence of this extension of the affection there is at times a considerable amount of thickening of the mediastinal tissues with the formation of adhesions of different kinds, which may implicate the great vessels in the neighbourhood of the base of the heart. Griesinger, according to Widenmann, about forty years ago, had occasion to observe a patient in whom a purulent pericarditis was associated with fibrinous mediastinitis. In this case a con- siderable amountof induration of the connective tissues surround- ing the great vessels was found on post-mortem examination, and the newly formed tissue had produced a considerable amount of constriction of the venous trunks, as well as of the aorta. There was almost entire obliteration of the pericardial sac, except at one point, where a circumscribed space containing pus was seen. It was observed during life that the pulse showed a distinct intermission during inspiration. About twenty years later Kussmaul observed similar cases in which he suspected an indurated mediastino-pericarditis on account of the state of the pulse. He was enabled, therefore, to study the conditions presented by such cases. Etiology. — It is probable that the ordinary causes of pericarditis may, under conditions favouring their develop- ment, produce such extension of the morbid processes as to involve the mediastinal textures ; but in some of the cases which have been described the lesions have had their origin in affections of the lungs, pleurte, or mediastinal glands. MoKBiD Anatomy. — Several different pericardial lesions have been described under indurated mediastino-pericarditis. Fibrinous, serous, purulent, or hiemorrhagic pericarditis, with MEDIASTINO-PERICARDITIS. 367 adhesions, as well as hypertrophy, dilatation, or degeneration of the myocardium, have also been seen. Various lesions of the lungs and pleurae were present in some of the cases which have been recorded, but an essential feature of this particular affection is the presence of membranous or cord-like adhesions, directly or indirectly binding the base of the heart and the great blood vessels to the mediastinal textures, to the sternum, to the spinal column, or to the oesophagus. Symptoms. — In some of the patients whose symptoms have been carefully recorded, breathlessness, cyanosis, and dropsy have been present. The principal features of the affec- tion, however, are derived from careful physical examination. On examination of the pulse it has, as a rule, been found to be somewhat empty, of moderate pressure, and considerable frequency, but its principal character is a fall of pressure, or a degree of intermission during inspiration ; that is to say, the pulse presents the characters of the pulsus inspiratione intermittens, or pulsus paradoxus. On inspecting the neck, the jugular bulbs, or even the entire visible veins of the neck, are described as swelling up during every forced inspiration and subsiding again on expiration. The prsecordia has some- times presented some appearances connected more or less directly with the condition. There has been, for example, inspiratory retraction of the epigastrium, as well as systolic retraction of the intercostal spaces surrounding the apex beat. Palpation has shown that the apex beat remained fixed in every posture which the patient assumed, while percussion has also shown some enlargement of the cardiac dulness. On auscultation the heart sounds have sometimes been unaltered, but they have also been described as weak and muffled. The important point is that there has been but little change during inspiration and expiration, notwithstanding the change in the pulse. Diagnosis. — The recognition of this particular form of pericardial affection must be admitted to rest upon a some- what uncertain foundation. The two features which have been relied upon in establishing the diagnosis are connected with the arterial pulse and the cervical veins. Traube, Baumler, and Griiffner observed the paradoxical pulse in cases 368 DISEASES OF THE PERICARDIUM. of serous pericarditis without any affection of the mediastinum, and later observers have frequently substantiated their ob- servations. The same appearances have been observed in aneurysm, and Eiegel has discovered that the pulse may give characters extremely like, if not absolutely identical with, those of the pulsus paradoxus in individuals apparently healthy. It is therefore clear that the paradoxical pulse in itself cannot be relied upon as an infallible proof of adhesions surrounding the great blood vessels. The inspiratory swelling of the veins of the neck must, however, be allowed rather more weight when taken together with other symptoms proving the implication of the pericardium. Prognosis. — The outlook in cases of this nature will depend entirely upon the attendant conditions, since the fact of adhesions about the base of the heart and the great vessels, although interfering considerably with some of the circulatory functions, does not necessarily involve serious consequences. Treatment. ^ — The management of any case in which mediastiuo-pericarditis is present must be regarded as entirely symptomatic. If pain be a prominent symptom, it may in most cases be speedily removed by the application of two or three leeches to the pra?cordia ; but in some instances their application is not sufficient to procure relief, and the sub- cutaneous injection of morphine may be required. If the temperature tends to become too high, the employment of phenacetin, or its addition to such remedies as have already been employed, may prove useful, but the local application of the ice-bag, or of Leiter's tubes, must also be taken into consideration. When frequency and irregularity of the pulse make their appearance, it may be necessary to administer diffusible stimulants, such as alcohol and ammonia. It may further be absolutely necessary to prescribe digitalis or strophanthus for cardiac failure. PNEUMOPEEICAEDIUM. The existence of gas in the pericardial sac was observed by Voigtel and briefly described by Laennec. The most important observations upon the subject which have since PNE UMOPERICARDIUiM. 3 69 been made are those of Graves, Bricheteau, Stokes, Friedreich, and Begbie. Pneumopericardium is without doubt one of the rarest of cardiac affections. Schrotter states that, during thirty- five years' service amongst the enormous cHnical material of the General Hospital of Vienna, he has never had the opportunity of seeing this affection, and Skoda had a similar experience. A very large proportion of hospital physicians have the same tale to tell. Etiology. — Pneumopericardium owes its origin to causes falling into two groups, which may be termed fistulous and traumatic. Produced by the first class of agents are those cases in which, from extension of morbid processes in adjacent structures, a communication is established with air-containing viscera. Illustrations of this are to be found in extension from pyopneumothorax, as described by Eisenlohr ; from a pulmonary cavity, by Stokes ; from cancer of the oesophagus, by Begbie ; from gastric ulcer perforating the diaphragm, by Saxinger ; and from hepatic abscess perforating both stomach and pericardium, by Graves. Under the second category fall those cases in which thie entrance of air into the pericardial sac is due to injury. Openings into the pericardial sac through the chest- wall have been described by several authors — gunshot wound, by Bodenheimer ; incision by sharp instruments, by Peine ; puncture by a trocar, by Aran ; fracture of the ribs, by Morel-Lavallee. A similar cause has also been described by Walshe, in a most interesting case, where an oriental juggler perforated the pericardium in the attempt to swallow a long blunt instrument. The belief that gas may be spontaneously developed within the pericardial sac has never been altogether left without witness. A number of instances have been re- corded in which such an occurrence was accepted as the cause of pneumopericardium, and one of the most recent writers upon the subject. Petit, confidently asserts that an event of the kind is only a particular instance of the phe- nomenon, very well known in the present time, of pneumatosis taking place in closed collections of pus. He even states that this cause appears to be tolerably frequent. It cannot be denied that on post-mortem examination, gas is occasionally 24 370 DISEASES OF THE PERICARDIUM. found ill the pericardial sac. The patients have, for the most part, during life manifested no clinical features connected with the pericardium, and on investigating such cases, they are almost always found to have been instances in which there was a considerable amount of post-mortem decomposition with all its possibilities. Such instances cannot therefore be accepted as proof of a spontaneous generation of gas within the pericardial sac. The statements with regard to the presence of gas within closed collections of pus are open to question, not in respect of fact, but of theory. It is to be borne in mind that cases of abscess containing gas have always been found near some viscus in which air is present, or in superficial parts to which ready access from the atmosphere has been per- mitted. The inference is obvious. It is equally clear that a small communication established between the pericardial sac and one of the air -containing organs surrounding it may rapidly heal, the air being closed within the sac and gradu- ally absorbed by its membrane. Such is the probable explana- tion of the interesting cases described by Love and by Lundie. The analogy of pneumothorax renders this suggestion more than likely. Cases of what have been called spontaneous pneumothorax, i.e. the entrance of air into the pleural sac without any known previous disease, are seen occasionally. An instance was recently described by me, to which was appended a summary of similar examples previously recorded. In such cases, after the air has obtained admission the wound heals up and the air is gradually absorbed. There is no difficulty in applying similar reasoning to the case of the pericardium. It must further be remembered that many at least of those cases in which spontaneous pneumopericardium has been believed to be present, and in which the patient has recovered with astounding rapidity, afford considerable possi- Ijilities of error in diagnosis. It probably falls to the lot of most hospital physicians to be asked to see patients in whom pneumopericardium has been diagnosed upon insufficient evi- dence — cases in which dilatation of the stomach has caused some of the clinical features of pneumopericardium. The discovery, a few years ago, of the bacillus aerogenes capsulatus by Welch, and its further study by him in associa- PNE UMOFERICARDIUM. 3 7 r tiou with Nuttall and Flexner, have gone a long way to clear up some difficulties surrounding the subject. The organism has been found to be the cause of subcutaneous emphysema in connection with wounds, and when this has occurred, gas is found in the blood and tissues generally, as well as in the pericardium, pleura, and peritoneum. In traumatic cases, therefore, pneumopericardium is possible. MOKBID Anatomy. — Pneumopericardium has invariably been attended by pericarditis, and pathological anatomy has therefore revealed the existence of definite changes in the peri- cardial sac. For obvious reasons there has been, in addition to the gas, a certain amount of exudation, either purulent or hsemorrhagic. On reflecting the osseous framework of the thorax, the pericardium has usually been seen to bulge forwards in consequence of its distension. This, however, has not invariably been the case, because, as in Begbie's patient, for instance, a free communication may exist, and distension be altogether absent. In cases where the pericardium was inflated and stretched by its contents, the gas escaped on incision with a hissing sound, and had a somewhat foetid odour. So far as can be ascertained by investigation of previous observations, no analysis of the gaseous contents of the pericardium has ever been attempted. When the sac has been freely opened, both the investing and reflecting membranes have presented various degrees of pericarditis. A fibrinous exudation has usually been found upon the epicardium as well as upon the pericardium, and a certain amount of organisation has even been seen forming recent adhesions. A smaller or larger quantity of yellowish, brownish, or reddish fcetid fluid has always been present. Some retraction of the lungs and depression of the diaphragm have usually been observed. Symptoms. — In cases which have permitted the careful observation of the patient from the onset of the disease, rigors have been present, followed by the development of a high but fluctuating temperature, the remissions of which have been, as a rule, attended by profuse perspirations. Sleeplessness is an extremely common feature of the affection, and evening delirium is also frequently observed. 112 DISEASES OF THE PERICARDIUM. Breathlessness is always present, and l'ie(|uently constitutes a marked symptom of the affection. It is, as may be well imagined, frequently accompanied by cyanosis and oedema. Severe pain over the front wall of the chest has been com- plained of, sometimes amounting to agonising anginous attacks. Palpitation and syncope have also been frequently observed. The pulse is empty, compressible, and irregular. On inspection of the chest a slight bulging of the prcecordia has been noticed, Init this seems to be a somewhat rare appearance, and the most striking feature has in most cases been the disappearance of the visilile pulsation of the heart. On palpation, feebleness or absence of the cardiac impulse is the prominent symptom. Percussion gives most striking phe- nomena. All observers are at one in regard to the tympanitic character of the percussion sound, and it has been possible for some of them — Stokes, for example — to determine not only this tympanitic character, but to find sometimes a distinct cracked- pot sound. Perhaps the most important point is, that on changing the position of the patient the character of the percussion sound varies. While the patient is in the recum- bent position, the tympanitic percussion sound may lie heard over almost the entire pnecordia, but in a sitting posture the lower portion becomes dull on account of the change in the position of the fluid and gas. The extent of the area over which the tympanitic sound may be heard has in some cases been co-extensive with the praicordia itself. In other cases it has only been over its lower portion, i.e. over the lower portion of the sternum and adjacent cartilages, while the upper prsecordial area has given as usual a percussion sound of absolute dulness. On auscultation the sounds observed are of the most characteristic nature. Splashing noises like those of a water-wheel, or of a churn, occurring periodically along with the pulsations of the heart, and therefore rhythmic or arhythmic according as the action of the heart is regular or irregular, form a most striking combination of sounds. These sounds have a distinct metallic character, and appear to echo within a closed space. Sometimes other sounds are present also. There may, for instance, be a certain amount of friction, and there may also be endocardial murmurs. These sounds, PNE UMOPEKICARDIUM. 3 7 3 however, are entirely overshadowed by the wonderful splashing noises. The sounds produced by the pulsation of the heart have occasionally been heard at a considerable distance from the chest. Such was the case in the patient described by Stokes, and Laennec laid considerable stress upon this fact. It might be expected that in cases of pneumopericardium, succussion sounds might be produced, but in the whole litera- ture connected with the subject no observation of this kind has been recorded. The physical signs in pneumopericardium have frequently been seen in patients where the pericardium has been opened for the treatment of pericardial affections. In most of the undoubted instances of pneumopericardium death has rapidly supervened. A few hours have in some cases been sufficient to produce a fatal result, but two or three days have been more commonly observed to intervene. "When death has occurred it has usually been the result of cardiac failure, probably produced by a paralytic myocarditis. So far as is known to me from a careful survey of the literature of the subject, no case of fistulous pneumopericardium has recovered. On the other hand, traumatic pneumoperi- cardium has sometimes been followed by recovery, and in the cases presenting this favourable termination, the gas has been observed to disappear with a rapidity almost marvellous. Many of the instances of pneumopericardium described as occurring spontaneously are invested by such an atmosphere of what^may charitably be termed romance as to merit little criticism. Brown recorded an interesting case in which a patient, consequent upon a heavy fall of earth upon him, manifested fre- quent, painful respiration with coughing and haemoptysis, accom- panied by intense pain in the cardiac region. On examination there was a loud double friction sound accompanied by a bubbling and splashing noise which could be heard two inches from the chest wall. The diagnosis was a rupture between the pericardium and the lung. There was little pyrexia, and the pulse and respiration gradually improved day by day, the splash- ing and bubbling disappeared by the fourth day, the rough friction sound persisted for three weeks, but after the expiration of that period the patient was perfectly well. 374 DISEASES OF THE PERICARDIUM. Diagnosis. — The rueognition uf pneumopericardium cannot be regarded as presenting any considerable difficulties. The tympanitic percussion sound over the upper part of the pra?- cordial region, or over the entire area, according to the posture of the patient, and the striking combination of splashing and metallic sounds on auscultation, are absolutely diagnostic. It is sometimes held that a pneumothorax on the left side, or a large pulmonary cavity close to the heart, might be mistaken for pneumopericardium, but this is in the highest degree un- likely. The auscultation of the breath and voice sounds as well as the presence of an approximately normal size of percussion dulness — abnormal probably, however, in its position — are sufficient to distinguish the conditions. The chief difficulty lies in the possibility of mistaking a dilated stomach for pneumo- pericardium. In some cases of gastric dilatation an area of tympanicity may be determined in the lower portion of the prascordia, more especially on forciljle percussion, and on auscultation the heart movements are sometimes accompanied by splashing sounds. It is to be noted that the upper part of the proecordia in such cases is never tympanitic, and that on causing the patient to assume a sitting posture, the splashing sounds disappear. Prognosis. — Pneumopericardium is one of the most serious affections of the circulation, but the prognosis is much graver in fistulous cases than in those which take their origin in traumatism. In the former, the conditions under wdiich the lesion takes place are in themselves of a nature calculated to lead to a fatal termination, such as a septic abscess opening into the pericardial sac, or a cancer of the oesophagus causing erosion into the sac. In the latter class of cases the wound may heal up rapidly, and the air 1)6 speedily absorljed. If the wound, however, occurs in connection with any tissue which has been affected by a diseased process, as in the case just described, the consequences are apt to be more serious. Treatment. — In pneumopericardium caused by a com- munication with some adjacent focus of disease, the treatment must Ite simply palliative ; but in traumatic cases, strict anti- septic treatment must be adopted at the earliest period possible, while the general condition of the circulation is PNE UM OPE RICA RDIUM. 3 7 5 watched with a view to obviate any tendencies to cardiac failure. In any cases where i:)ericarditis constitutes a pro- minent feature, it nmst be treated on the general principles already laid down, and if there be much exudation, particularly of a purulent character, its removal by appropriate means must be employed. Case 11. Traumatic Pneumopericardium. — Once, and once only, has any case of pneumopericai'dium come under my own personal observation. The occurrence took place during my student days. A patient was admitted to the old Koyal Infirmary suffering from pleurisy with effusion. As the effusion did not yield to ordinary medical treatment, aspiration was resolved upon, and, in the absence of the resident physician, it was carried out by his substitute. On the conclusion of the aspiration it was found that the condition of the patient had, instead of improving, become worse. The dyspncea, which had been expected to diminish after the removal of the pleural effusion, became exaggerated. The patient was unable to lie down except for short periods and at long intervals, and the pulse became empty, compressible, and irregular. On examination of the heart the explanation of the change in the condition of the patient was obvious. One of my friends, at that time attached to the ward in which the patient was, requested me, at that time a clinical clerk in an adjacent ward, to see the case, and its clinical features have been stamjjed upon my memory ever since. The patient was seated in bed, leaning forward so as to rest upon his knees. His countenance was of a livid pallor, with a deep bluish tinge of the lips, nostrils, and ears. Drops of perspiration stood upon his fore- head, and he panted violently for breath. The radial pulse showed an emptiness of the arterial system and a low pressure of the blood. It was extremely frequent and very irregular. There were no characteristic appearances on inspecting the thorax, all local phenomena connected with the praecordia being overshadowed by the severe dyspnoea, and on palpation the only characteristic feature was the extreme indistinctness of the cardiac impulse. On percussion, almost the entire preecordial region gaA^e a ringing tympanitic percussion soiind, but at the lower part there was absolute dulness. Auscultation revealed sounds Avhich were very striking. The heart sounds themselves were scarcely audible, but with every movement of the heart there was a loud splashing, extremely like that produced by a churn, and this was followed almost every time it occurred by a distinct metallic tinkling, closely resembling that of fluid dropping in a closed space, such as is to be made out occasionally in large pulmonary vomicae and in pneumothorax. It was only too clear that in this case, by some regrettable misadventure, the pericardium had been punctured by the aspiration needle. The course of the affection in this case 376 DISEASES OF THE JERICARDIUM. was extremely rapid, and the patient died on the second day after the unfortunate occurrence. The dramatic circumstances attendant upon the evolution of the symptoms in this case place it in the same category as tliat to which belong the instance described by Walshe, in which the juggler perforated his pericardium with a pointed instrument, and that described by Aran, in which the pericardium was punctured by means of a trocar. PEEICARDIAL TUBEECULOSIS. Corvisart recognised the existence of tubercle in affections of the pericardium, and Laennec and his successors extended his observations. In recent times a large number of authors have devoted attention to the subject. Simple pericarditis, that is to say, pericarditis in tubercular subjects which is un- attended by the formation of the characteristic lesions of tubercle, is not at all an infrequent affection, and it is not to be confounded with tubercular pericarditis and pericardial tuberculosis. In these two latter conditions there are char- acteristic tubercular lesions of the pericardium. Tubercle of the pericardium may in rare instances be primary and affect the pericardium alone, as in a very interesting observation recorded by Virchow. It is, however, very much more frequent as a secondary process either taking origin from extension of neighbouring organs, or as part of a general infection. Etiology. — Tuberculosis of the pericardium may affect every age, but it is more common between the ages of 15 and 30. Duckworth has recorded a case occurring in a child of eio;ht months, while Lee Dickinson and Eolleston have met with instances in children aged nine months. Lejard, on the other hand, has described a primary case in an old woman of 88. According to Osier, it is considerably more common in men than in women. Primary tubercular pericarditis can only be explained on the assumption that, as in the cases occurring in very young children just mentioned, the patients have been born with the disease present, or that, as is likely in older patients, there has been an inherent weakness or some preceding affection ; PERICARDIAL TUBERCULOSIS. 377 the pericardium may have thus been prepared for the growtli of the tubercular bacillus, which has in some obscure way obtained entrance to the sac. Secondary tubercular pericarditis is most commonly associated with tubercular affections of the pleura or lung, or of the mediastinal or bronchial glands. The latter glands more especially seem to be a source of infection, and many cases which have been regarded as primary, are in reality due to a secondary implication, having origin in an unnoticed tuberculosis of these glands. The course followed by the infective process in some instances is rather obscure, as, for instance, in a case recorded by Schrotter, where tuberculosis affecting the epicardium and the myocardium was associated with no other lesion save a single tubercular mass in the apex of the right lung. Tubercular pericarditis as part of an acute general tuber- culosis only shows itself, according to Osier, when the other serous sacs are also implicated, and it may be termed, with Strilmpell, a tuberculosis of the serous membranes. MoEBiD Anatomy. — The appearances presented by the peri- cardium after death fall into two groups. There is, in the first place, the form which may be strictly termed tubercular -pericarditis. The appearances in this group show a certain amount of exudation of fibrin, and of fluid. The fibrinous exudate goes on to a varying degree of organisation, and in the fibrous tissue so arising is the development of tubercular nodules. Within the organising tissue giant cells may be seen on microscopic examination, as is well shown in the illustration, Fig. 126. In some cases of tubercular pericarditis there are no tubercles. One case of much interest is narrated by Kast, in which pericarditis had its origin in a tubercular affection of an adjacent mediastinal gland, and the purulent exudation within the pericardial sac contained tubercular bacilli, but no tubercular lesions were present. There is also, in addition, the much less common form of affection which may be termed pericardial tuberculosis. This in its turn presents two perfectly distinct forms of affection — miliary tubercles may be developed along the small blood vessels, ramifying in the epicardial tissues, and therefore seen most 378 DISEASES OF THE PERICARDIUM. distinctly in the sulci ; or larger tubercular masses, of grayish tint externally, and with a yellow caseating centre, may be found in some part of the membrane, more particularly about the base of the heart. Tn all cases where tubercle is present there is a great P:w^i^i ("fTTi ' '-■ "^r^^k-.-r.Jff^&^i^A- -■:t ■'■"' '■''"'-' ■'■■■'^SSjJf'i"" " .■■?/■ Fic. 12ii.— Chronic tubercular pericarditis ( x 00). a, Small tubercular nodules in the epicardiuni ; h, giant cells ; (■, organising tissue ; d, fibrin ; c, muscle fibres. tendency to hemorrhage. Sometimes superficial ulceration of the pericardial or epicardial structures is seen, and this process may be so serious as to involve, as in an instance recorded by Eichhorst, perforation of the cardiac muscle and rupture of the heart. Symptoms. — Tubercular affections of the pericardium may be absolutely latent throughout their whole course, so that. PERICARDIAL TUBERCULOSIS. 379 unsuspected during life, they are discovered on post-mortem examination. There are most commonly general symptoms of tuber- culosis, excessive fluctuations of the temperature, profuse perspirations, emaciation, and weakness, in short, the develop- ment of hectic. The direct evidences of the affection must be sought for, as they are very rarely present in such a form as to attract attention. When present, the local symptoms and physical signs closely resemble those found in an ordinary case of pericarditis. The distinguishing feature of the local manifestations of the disease is the tendency towards chronicity, so that there is much more persistence of the clinical features. Diagnosis. — The recognition of the tubercular nature of a pericardial affection may be comparatively simple from the combination of unmistakable physical signs of pericarditis with the general features attendant upon tuberculosis. The dia- gnosis will be rendered easier if tubercle is present in some of the adjacent organs. In doubtful cases in which symptoms of chronic pericarditis remain for a considerable period, it may be advisable to have recourse to aspiration in order to discover the nature of the exudation. Pkognosis. — The prognosis in tubercular affections of the ■ pericardium is always unfavourable, as the disease almost invariably leads to a fatal result, either by cachexia or by some less common termination, such as rupture of the heart. There is no doubt a considerable proportion of cases in which, on account of fibrous changes, a certain amount of recovery ensues, but in such cases the tubercular process follows its course in other organs, and the inevitable result is not far off. Tkeatment. — The treatment of tubercular affections of the pericardium should be carried out on general principles. An attempt to antagonise the tubercular tendency is necessary, while every means is to be adopted to support the strength of the patient. In particular, such methods as avail to avert cardiac failure should be resorted to. If there should happen to be such an amount of exudation as to interfere with the functions of the heart, it may be necessary to have recourse to aspiration or even to free incision. 3 So DISEASES OF THE PERICARDIUM. Case 12. Tuherodar Pericarditis. — L. D., aj^'eil 19, engineer, was under my care in the lloj'al Infirmary, on account of cougli and pain in the chest. No family tendencies to disease were present, and the patient's general surroundings had been satisfactory. His previous health, save for the ordinary cliildren's diseases, had been good until eighteen months before admission, when, in consequence of a fall, the left knee was injured, and he was lame for about a month. The knee had always since then been stiff, and ankylosis was threatening. During the month of April the patient suffered from what he was told was inflammation of the right lung, followed by a pleuritic attack, which in turn Avas succeeded by bronchitis. During the month of July he was sent to Musselburgh in order to seek the benefits of change of air, but as he did not improve he came into the Infirmary. Tlie patient on admission was seen to be a pale, slender youth. His evening temperature rose to about 102°, while it was very often subnormal in the morning. Tlie patient's tongue was loaded with a creamy fur, his teeth were bad. He had suffered from tliarrhtea liefore admission, and this continued after he entered the ward. The abdominal viscera presented no abnormality. The jnilse varied considerably in frequency, but it was usually about 100 per minute. The vessel was empty, the blood jjressure was low, and well-marked dicrotism was shown. Inspection showed pulsation in the third and fourth intercostal spaces. On palpation the apex beat was felt in the fifth intercostal space three inches from the mid -sternal line. On percussion the right border of the heart was found to be two inches, and the left border of the heart three and a half inches, from mid- sternum. On auscultation, tlie heart sounds although feeble were heard to be perfectly clear, but they were accompanied by pericardial friction, which extended over the entire prcecordia, but' Avas most intense in the third and fourth left intercostal spaces. Over the whole of this area it was charac- terised by a threefold rhythm, and at the end of expiration it became much more intense. There was a muco-purulent sputum with a tendency towards nummular characters, and on microscopic examination it was found to contain numerous tubercular bacilli. There was flattening of the chest in both infra-clavicular regions, over which, as Avas also the case in the supra-spinous areas posteriorly, the vocal fremitus was greatly inci'eased. These changes were more pronounced on the left side. On percussion there was dulness in these regions, more particularly on the left side. On auscultation of the left infra-clavicular and supra-spinous regions the character of the breath sounds Avas bronchial. The expiration Avas prolonged, and pectoriloquy Avas present. There Avere occasional crepitant rales, and sometimes sibilant rhonchi. On the right side in the same regions the breath Avas of puerile type Avith prolonged expiration. The vocal resonance Avas exaggerated, and there Avere crepitations and sibilations. One most important point in the case Avas that in the second and third left intercostal spaces there Avas distinct 2-)leuritic friction. There Avere no symptoms calling for remark connected Avith any other system of the body. PERICARDIAL SYPHILIS. 381 The treatment adopted was the administration of cod-liver oil and iodide of iron, together with the external application of iodine. Perfect rest and ample food were enjoined. In two or three weeks the jiatient was discharged with no evidences of the pericardial ail'ection, which had become latent. This case furnished a good example of tubercular implica- tion of the pericardium consequent upon a tubercular disease of the lung and pleura. PEPJCAEDIAL SYPHILIS. Syphilitic implication of the pericardium is even less common than in the case of the myocardium, and only a few exceptional instances are on record. Lancereaux observed gumma of the pericardium, without other cardiac lesions, associated with a large syphilitic mass in one of the lungs. Wanitschke, in a newly -born child, affected by hereditary syphilis, saw a characteristic affection of the pericardium associated with a large mass in the upper lobe of the left lung, which, through adhesions with the parietal pericardium, led to a sero- fibrinous pericarditis. The whole subject has been recently studied by Mracek, whose observations and -investigations present the best picture of the affection as it affects the pericardium. Etiology. — In most instances the implication of the peri- cardium takes place as a late secondary or tertiary manifesta- tion of the disease, but, as has just been seen, it may have its origin in congenital syphilis. MoEBiD Anatomy. — The formation of characteristic gum- mata is a rare feature of the disease ; more frequently there is infiltration leading to the formation of fibrous tissue, so that there are adhesions between the pericardium and epi- cardium. These very rarely lead to any considerable oblitera- tion of the sac, and they are not infrequently attended by a certain amount of fluid exudation. Symptoms. — Such affections have for the most part remained unnoticed during life, and have only been found on post-mortem examination. The affection therefore presents to some extent a contrast to syphilitic lesions of the endocardium 382 DISEASES OF THE PERICARDIUM. and inyocanliuiu, which sdiuetinies lead to characteristic symptoms. Diagnosis.— The determination of a syphilitic lesion of the pericardium can only he possible when, in addition to proof of the existence of syphilis, there are also physical signs of pericarditis. Prognosis. — This must entirely depend upon the amena- bility of the disease to treatment, and it will be the more favourable the sooner symptoms of improvement set in under appropriate remedies. Treatment. — Since the pericardial implication occurs in the late secondary and tertiary stages, iodide of potassium is the most useful remedy, but it is sometimes rendered more efficacious by the addition of perchloride of mercury, while one of the simpler mercurial ointments is applied externally to the pra^cordia. PEEICAEDIAL NEOPLASMS. Cancer and sarcoma of the pericardium are by no means common ; judging by my own experience, they are less fre- quent than similar neoplasms of the endocardium. Etiology. — Primary cancer and sarcoma of the pericardium are extremely rare indeed ; in fact, the only instance which appears to have been absolutely established is one observed by Forster. Secondary manifestations of these affections are somewhat less infrequent, and they have usually been found in connection with malignant disease of the mediastinal crlands, pleura, lung, or cesophagus. Occasionally they have followed upon the development of the disease in distant organs. Morbid Anatomy. — New formations affecting the peri- cardium present the characteristic structural features of the disease which may be present, accompanied by a certain amount of infiltration of the serous membrane and of the subserous textures. There is in every case some fluid in the sac, which may be purely serous, but is much more commonly htemorrhagic, and may even be purulent. In cases where the new formation has caused compression of some of the cardiac veins, the amount of transudation may be considerable. HYDROPERICARDIUM. 383 Among the uncommon affections of the pericardium is actinomycosis. Cases of this kind have been described by Mlinch. In these cases the parasitic invasion has Ijeen associated with lesions in other parts, and the possibihty that the pericarditic complications were of this nature was in this way shown. As pathological curiosities, hydatid cysts of the pericardium have been recorded by Habershon, Landouzy, and Bernheim. None of these cases were recognised during life ; they were only discovered on post-mortem examination. If any pericardial symptoms were present in a case of hydatids in other organs, the recognition of the nature of the disease would be rendered possible. Bouchard, about thirty years ago, described the presence in the pericardial sac of fringes somewhat like those found in the synovial membranes. These sometimes become detached and form free bodies in the sac. Symptoms. — New formations of the pericardium are usually to be regarded as pathological curiosities, inasmuch as the effects produced are inconspicuous, so that their detection is impossible during life. There may, however, be symptoms of pericarditis attended even by characteristic physical signs, "and accompanied by the general appearances of a malignant cachexia. Diagnosis. — The probability that any pericardial affection had its origin in some new formation, would be strengthened by the existence of the presence of such a disease in some other part of the body, and by interference with the functions of such adjacent organs as the trachea or oesophagus. Peognosis. — The prognosis in all cases of this kind is absolutely unfavourable. Tkeatment. — It is impossible in cases of malignant disease of the pericardium to do more than meet the symptoms and obviate the consequences of the disease. HYDEOPEEICAEDIUM. The pericardial sac is found in almost every instance after death to contain a varying but moderate amount of clear 384 DISEASES OF THE PERICARDIUM. yellowish fluid, which is coiunioiily termed the liquor pericardii. The ainouiit of tliis tiuid after death has probably but little relation to that which is contained by the pericardium during life, and it appears to be a well-established fact that when the death agony has been prolonged, the amount of tiuid is increased. The quantity usually found is on an average from 5 to 10 c.cm., but it may rise to 90 or 100 c.cm. "\Mien this amount is surpassed it may be regarded as the result of pathological conditions. Hydropericardium or pericardial dropsy consists in a serous transudation which accumulates in the sac, and is analogous to hydrothorax and ascites. By the earlier authors of modern times the presence of fluid in the pericardium was very commonly recognised, as for instance by Lower, Schellhammer, Senac, and ]\Iorgagni, but as in those earlier days no distinction was made between exudation and transudation, the observations are now of comparatively little value. Etiology. — Hydropericardium is necessarily always a secondary affection, and has its origin in the various conditions producing oedema which were previously considered. It is produced by general venous stasis, having its origin in valvular disease or myocardial changes, and it may arise in a more remote manner from affections of the lungs, pleura, or kidney. Local venous stasis may be produced by pressure upon the cardiac veins in consequence of some new formation connected with the heart, pericardium, or mediastinum. Pericardial dropsy may also be produced by various cachectic conditions. Certain authors, and more particularly von Bamberger, have attempted to prove the existence of what has been called " hydropericardium ex vacuo." The theory is that in conse- quence of shrinking of the lung or atrophy of the heart, the tendency to produce a vacuum has led to the development of transudation. As has already been sufficiently pointed out, there is under normal circumstances always a negative pressure in the pericardial sac, and yet the amount of fluid which it contains is small. Such a supposed cause of transudation cannot therefore be accepted, and Friedreich was perfectly right in declining to entertain its possibility. A transudation can only occur in consequence of such disturbances of the serous HYDR OPERICARDIUAI. 3 8 5 membrtaue, the blood vessels, or the blood itself, as have in a previous section been fully described. MoEBiD Anatomy. — The fluid found in the sac in hydro- pericardium is clear, and of a yellowish or greenish tint, with a dichroic tendency. Sometimes it has a reddish colour from the presence of blood, or, if the broken-down colouring matter of the blood is present, it may be of a dirty brownish hue. The specific gravity of the fluid is usually about 1015. Some- times the fluid is somewhat flocculent, and, when this is the case, endothelial cells are found on microscopic examination of the deposit which is thrown down on standing. These epithelial cells are usually granular. A small amount of round cells, also usually granular, may be seen, and there are not infrequently small fibrinous masses. According to von Dusch and Eichhorst, cholesterin crystals are not infrequently present. The quantity of the transudate not uncommonly reaches 1000 c.c, and in a case recorded by Corvisart there were actually, unless some error has crept into the record, 4000 c.c. On examining the pericardium after death, it is found to be distended according to the amount of fluid which is present, and to show distinct fluctuation. The serous surfaces are ■smooth, shining, and free from any fibrinous exudate. They are usually pale on account of the pressure on the vessels of the membrane. The pericardium is sometimes very thin, but at other times — and this is more particularly the case when the accumulation has been gradually developed — it may be considerably thickened. The sub-epicardial fat to a con- siderable degree disappears, and the subserous tissues are pale and macerated, or even oedematous. This oedematous condition may also be found in the adventitia of the coronary vessels, and of the great vessels, at the base of the heart. The right ventricle and right auricle are often considerably dilated, and the muscular tissue of the heart in general is pale and flabby. There is frequently oedema of the cellular tissues of the medi- astinum, and compression of the lower lobe of the left lung is very commonly present. Symptoms. — Since hydropericardium is in most instances only part of a great complex of pathological conditions, the 25 386 DISEASES OF THE PERICARDIUM. symptoms which it produces are usually overshadowed l;>y the clinical features belongiug to the primary affection with which ■ it is associated. It may be said to step in as the closing link of a • pathological chain, and once it has made its appearance it unites with the other morbid conditions to form a vicious circle of fatal import. Hydropericardium is not necessarily associated with any pyrexia ; it is not, indeed, uncommon to find it attended by subnormal temperature. It at times gives rise to sensations of oppression in the chest ; dyspnoea, cyanosis, and oedema are also of almost constant occurrence in at least some degree. Attacks of syncope are often found. Patients in whom dropsy of the pericardium has occurred often present various nervous symptoms. A soporose tendency may be constantl}' present, or there may be, more especially in the evening, mild muttering delirium. The attitude assumed is very often an upright one, or the patient leans forward, resting his arms upon the knees. On examination, the pulse is usually empty, compressible, frequent, and irregular. The veins of the neck are turgid. There may be a fulness of the prtecordia and a widening of the intercostal spaces. The cardiac impulse is imperceptible even when the patient leans forward. The vocal fremitus over the priecordia is diminished. There is an increased area of cardiac dulness, which assumes the form which has been seen to be characteristic of a pericardial exudation. The heart sounds become extremely feeble, and if any adventitious murmurs have previously been present, their intensity is also' diminished. There never is, under any circumstances, a friction sound. On examination of the abdomen, the liver is often found to be enlarged and ascites to be present. The amount of urine is diminished, and it often contains albumin. The bases of the lungs may, by means of muffling of the percussion sound and crepitations, reveal the presence of cedema pulmonum, or by dulness of the percussion sound', and absence of voice and breath sounds, that of hydrothorax. Diagnosis. — The diagnosis of hydropericardium must rest upon the presence of signs of effusion in the absence of any proof of pericarditis. It is usually facilitated, however, by the existence of sufficient causes to produce the effusion. H^MOPERICARDIUM. 387 Prognosis. — The prognosis in hydrothorax is entirely dependent upon its etiology. Some of its causes are to some degree remediable, as in the case of acute nephritis, and when this is the case the outlook is more hopeful, but in the overwhelming proportion of cases the etiology of the affection renders it as grave as possible. Treatment. — Since hydrothorax is practically a symptom of some primary affection, its management depends upon the treatment of the original disease ; but in addition to the appropriate means for such a condition, the administration of dry food, and the employment of diuretics and purgatives, are strongly indicated. If the hydrothorax so aggravates the primary condition as to produce urgent symptoms, it may be necessary to have recourse to paracentesis. H^MOPERICAEDIUM. Those forms of pericarditis in which blood is present have already been referred to, more particularly the forms which occur in the course of scurvy, cancer, and tubercle, as well as in renal diseases and alcoholic conditions. Hsemopericardium is in no way connected with such affections, and in its structural "alterations and clinical features presents no relationship to hsemorrhagic pericarditis. Etiology. — The causes of heemopericardium may be traumatic, from direct or indirect violence, or pathological, in various diseased processes. Amongst traumatic causes are wounds inflicted by projectiles or sharp instruments, or, arising in consequence of a blow or fall ; in these two latter cases, however, it is probable that some structural alteration has been present, predisposing to rupture of the heart. Of the pathological causes of hsemopericardium may be mentioned : — rupture of the heart, taking place, as a rule, during some violent exertion, but resulting usually from structural disease ; rupture of one of the coronary arteries iii profound arterial degeneration ; ulceration of the heart or of one of its vessels ; rupture of a degenerated aorta or of an aortic aneurysm opening into the pericardial sac — all these are not uncommon examples of the causation of liEemopericardium. 3 88 DISEASES OF THE PERICARDIUM. Morbid Anatomy. — On exaiuination of the pericardium after death, the amount of blood poured out is found to vary very considerably. In cases characterised by rapid development and sudden death, the amount of blood is usually small ; instances of slower evolution and more lingering death furnish examples of amounts wliich may be very considerable. The blood may be entj^-ely coagulated or it may be altogether fluid. The most common condition, however, is one in which a certain amount of coagulation has taken place, but in which some of the blood remains fluid. The examination, it need hardly be added, reveals, in such cases as merit the name of haemopericardium, the source of the blood. The condition is, as a rule, entirely diverse from those forms of pericarditis in which a certain amount of blood is present, and in which its source is occasion- ally quite obscure. SviiPTOMS. — The clinical features presented by patients suffering from hsemopericardium furnish extremely variable pictures. At times the events unfold themselves with a swift- ness that is appalling — the patient, one moment, to all appear- ance in ordinary conditions of health, and, it may be, engaged in some occupation ; the next moment, lying collapsed and pulseless. On the other hand, the opposite extreme shows a somewhat protracted and lingering passage into asystole. Sometimes at the onset of the affection the patient complains of a sudden sharp pain in the prrecordia, or of a feeling as if something had given way. Giddiness and faintness are apt to follow upon such sensations, or they may themselves be the earliest manifestations of the disaster which has occurred. The feeling of faintness commonly passes into unconsciousness, while the giddiness occasionally leads to convulsive seizures. The patient usually presents a deathly pallor, sometimes with a cold perspiration bedewing the features. The pulse is empty, feeble, and irregular. On examining the chest there is, as a rule, a total absence of all characteristic phenomena, and only in those forms in which the affection has come on slowly, is it possible to find any physical signs that might be useful. In such cases the area of dulness may be somewhat enlarged. The most characteristic instances of htemopericardium which have come under my notice have occurred in consequence HJEMOPERICARDIUM. 389 of wounds, ruptured aorta, and ruptured aneurysm. They will be referred to in subsequent sections. Diagnosis. — The recognition of the nature of the event in htemopericardium is only possible when the existence of some affection likely to produce it has been previously established, and it can only be determined with any degree of probability when sudden collapse is associated with the physical signs of enlargement of the area of precordial dulness. Peognosis. — With few exceptions, the prognosis in cases of hfemopericardiuni is absolutely hopeless. Treatment. — Therapeutic measures in almost every case are impotent. CHAPTER VIII. DISEASES OF THE ENDOCAEDIUM. Affections of the endocardium have been recognised since the dawn of modern pathology. Senac, Morgagni, and Boerhaave described with greater or less exactness various changes in the lining membrane of the heart, and paved the way for later observers. The association of endocardial lesions with acute rheumatism was suspected by Baillie, and was mentioned by Kreisig ; these observers, however, did not lay any particular stress upon the co-existence of the diseases, and it was left to Bouillaud to show the distinct connection between the general disease and the local complication. To Bouillaud is also due the credit of having directed attention to the frequent associa- tion of other acute diseases and valvular lesions, while he also introduced the term endocarditis. The next advance was made by Kirkes, who laid the foundation for our knowledge of the more serious types of endocarditis, and of the embolic origin of septicaemia and pyaemia. His researches were pushed further by Virchow and many subsequent writers. The connection between micro- organisms and endocarditis has Ijeen gradually established during recent years. Winge appears to have been the first observer who really made out the presence of organisms in en- docarditis, and he was followed by Heiberg and Koster. Klebs stated that many different organisms might be the cause of endocarditis. Weichselbaum and Wyssokowitsch determined the presence of pyogenic organisms in the endocardium, and their investigations were completely verified hj the researches of Friinkel and Siinger. The presence of the tubercular bacillus ENDOCARDITIS. 391 in endocarditis was mentioned by Cornil and Babes, and this observation has been amply verified and greatly enlarged by Tripier. The pneumococciis was observed by Netter in endocarditis associated with pneumonia, and Weichselbaum has also described this organism in endocarditic affections. The experimental production of endocarditis in animals will be re- ferred to in considering the etiology of the disease, and it need only be said in this place that the observations of Eosenbach and Wyssokowitsch have thrown considerable light upon the origin of the disease. ENDOCAEDITIS. Many attempts have been made to classify endocarditis. JSTone of these, however, are perfectly satisfactory. By the classification which is most in vogue, the disease is sub- divided into an acute, including malignant and benign varieties, and a chronic form. Such an arrangement on exam- ination breaks down in many ways. All acute forms of endo- carditis—and they are many — if not due to, are attended by, the presence of micro-organisms ; the same micro-organisms being present in those forms commonly regarded as malignant or infective, and in those which are not. The lesions which are found after death are frequently identical in cases which would be considered as belonging clinically to difierent classes. The diagnosis of cases which are to be regarded as infective can only be determined by the employment of bacteriological tests after death. From the clinical point of view the separation of malignant and simple acute endocarditis is a matter of extreme difficulty. Many instances, which appear for a time to be free from any malignant tendency, suddenly undergo a change in their symptoms, and end disastrously, while others, which have set in with the most serious pysemic symptoms, undergo a favour- able alteration in their clinical features, and end in resolution. In the following pages, therefore, a different classification is adopted. No attempt is made to differentiate the malignant, septic, or ulcerative forms of endocarditis, as regards pathological characters, from the benign, simple, or verrucose varieties, and 392 DISEASES OF THE ENDOCARDIUM. the disease is considered chietiy from the cHiiical side. From this point of view the aflection naturally I'alls into the three groups of acute, subacute, and chronic endocarditis which were long ago adopted in the excellent work of von Dusch. Frequency. — The numerical results given in regard to endocarditis cannot be accepted with the same confidence as is the case with pericarditis, since the diagnostic factors relied upon are far from uniform. The statistics of the lioyal Infirmary for the last five years, as given Ijy Gillespie, are of interest if of less value than the corresponding facts relating to pericarditis. In a total of 2^^)68 cardiac cases, 50 were diagnosed as endocarditis — 26 males and 24 females, of whom 14 and 18 respectively died, ix. a death-rate of 53'9 and 75'0 per cent. The details are as follows: — [Table. END O CARDITIS. 393 1 ADMISSIONS. ; Age. Males. Per cent. Females. Per cent. Total. Per cent. 1-9 1 3-8 2 8-3 3 6-0 10-19 5 19-2 7 29-0 12 24-0 20-29 7 26-9 6 25-0 13 26-0 30-39 3 11-5 5 20-8 8 16-0 40-49 6 23-0 3 12-5 9 18-0 50-69 3 11-5 1 4-1 4 8-0 + 69 Total . 1 3-8 1 2-0 26 52-0 24 48-0 50 MORTALITY. 1-9 2 100-0 2 66-6 10-19 3 60-0 4 57-1 7 58-3 20-29 1 14-2 3 50-0 4 30-7 30-39 2 66-6 5 100-0 7 87-5 j 40-49 4 66-6 3 100-0 7 77-7 1 50-69 3 100-0 1 100-0 4 100-0 + 69 Total . 1 100-0 1 100-0 14 53-9 18 75-0 32 64-0 i Etiology. — Among the ijredisposing causes of endocarditis individual circumstances or personal conditions are of some importance. Acute endocarditis is essentially a disease of the active period of adult life, its occurrence being most frequent between the ages of twenty and forty. Many statistics have been published with regard to the incidence of acute endocarditis, of which those based upon the results of morbid anatomy are alone of any value. For reasons which will be given in dealing with the symptoms of the disease, statistics founded upon 394 DISEASES OF THE ENDOCARDIUM. clinical observation in acute endocarditis are notoriously un- reliable. It has been regarded as a well-established fact that the more serious types of endocarditis are most frequently found amongst women, while the simpler forms are more common amongst men. These facts have been held as true also for children. "Wlien acute endocarditis affects youthful patients, its graver forms have been said to be found more amongst girls than boys, and the less serious forms to be more common amongst boys. The recent observations, however, of Kelynack, as well as of Kanthack and Tickell, throw some doubt upon the accuracy of these views. Kelynack found amongst his cases of fatal infective endocarditis that 68 per cent, were of the male, and .32 of the female, sex. Kanthack and Tickell, from the analysis of all the cases of latal infective endocarditis at St. Bartholomew's Hospital from January 1890 to March 1897, give the following table of 8-4 cases: — Age. Males. Females. ! Total. 1 Under 10 3 1-5 = 1 5-10 = 2 2 1-5 = 5-10 = 2 5 10-20 9 10-15 = 2 15-20 = 7 11 10-15 = 4 15-20 = 7 20 20-30 13 20-25 = 5 25-30 = 8 6 20-25 = 4 25-30 = 2 19 30-40 19 30-35= 9 3.5-40 = 10 3 30-35 = 2 35-40 = 1 22 40-50 5 40-45 = 2 45-50 = 3 6 40-45 = 4 45-50 = 2 11 50-60 2 50-55 = 55-60 = 2 5 50-55 = 4 5.5-60 = 1 7 Total 51 = 60 "71 per cent. 33 = 39-29 per cent. ENDOCARDITIS. 39 S As regards the age, so far as the males are concerned, most of these cases occurred between the ages of 20 and 40 years, namely, 6 2 "7 per cent., while among females most cases occurred between 10 and 30 years, viz. 51*5 per cent., 3 3 '3 per cent, occurring between 15 and 25 years. Amongst the predisposing causes previous valvular disease is a most potent factor. This was first observed by Paget. Kelynack found it in 80 per cent, of his cases, and Kanthack and Tickell in rather more than 64 per cent. Congenital disease has long been known to act in the same way as acquired valvular affections. The exciting causes of endocarditis fall into the classes of infective processes, and constitutional affections. Direct exten- sion, which has been seen to occur not infrequently as a cause of pericarditis, may practically be excluded as a real factor in the evolution of endocarditis, except in some cases of septic myocarditis. Many of the acute infectious diseases are connected with attacks of endocarditis. Scarlet fever has been known since the days of Bouillaud as a frequent cause. There are some interest- ing points regarding the connection between the two diseases. A strong suspicion has long been entertained that very probably the endocarditic sequelse are determined by a secondary infec- tion through the rheumatic virus. This was more particularly urged by Trousseau and Peter. In such cases streptococci have been. detected upon the affected valves, which strongly supports the view of mixed infection. Such observations, however, are of but little import, inasmuch as streptococci are found in almost every variety of endocarditis. Measles is occasionally complicated by the affection, as originally recognised by Bouillaud. The coincidence of the two affections, however, is very rare. Smallpox has been accompanied by endocarditis. To this point Simonet, Trousseau, and Duroziez have paid particular attention, and from their observations it is known that such complications are much more common in the con- fluent type of smallpox. Influenza, as we know from the recent epidemics, may give rise to, or be accompanied by, endocarditis. The most important work upon this subject is that of Piessiuger. It appears doubtful whether diphtheria can give rise to endo- 396 DISEASES OF THE ENDOCARDIUM. carditis. Talamou and Osier, in 138 autopsies of patients dying of diphtheria, never once encountered the condition. The coincidence of the two affections has from time to time been signalised, but probably in such cases double infection has been present. Endocarditis, in the case of patients who have died of diphtheria, has revealed recent changes in the mitral cusps with the presence of various micro-organisms. In erysipelas the affection may arise, and Denuce has described the special organisms of erysipelas in the affected cusps. Endo- carditis is rare in enteric fever. The concurrence of the two affections, nevertheless, was notified Ijy Griesinger, and his observations liave been corroborated l)y those of other workers. Girode has l)een able to determine the presence of the enteric bacillus upon affected valves — a somewhat remarkable fact, seeing that this organism appears to have the greatest difficulty in living in the blood. Pneumonia frequently gives rise to endocarditis. The clinical fact has been known since the second edition of Bouillaud's work appeared, but experience has varied greatly in regard to the numerical relation. Osier found it in 15 per cent, of his cases of pneumonia. In recent times the characteristic organism of pneumonia has been determined on the cusps by Netter and other observers. It is most in- teresting to note that endocarditis characterised by the presence of pneumococcus upon the affected cusps has been seen by Weichselbaum and other oljservers in the absence of any pneumonic affection ; the observer mentioned has met with it along with cerebro- spinal meningitis, in which the lesions contained the characteristic cocci, in the absence of pneumonia. In many of those instances the pneumonic coccus is accom- panied by other organisms, more particularly by streptococci and staphylococci. The disease is not by any means a frequent sequel to malarial influences, yet several observers, and more particu- larly Duroziez and Lancereaux, have insisted on the effects of paludism upon the endocardium. So far the presence of the Plasmodium malaria^ has not been ascertained in the lesions of endocarditis, and the question must remain obscure until such has been done. ENDOCARDITIS. 397 Pysemia in its various forms is fruitful in the production of the affection. In the puerperal condition it was described many years ago by Simpson, and it has in its protean mani- festations been recognised by numerous observers as the determining factor in endocarditis. In gonorrhcea it is seen from time to time, and the con- nection seems to have been first suspected by Brandes. The gonococcus has been determined on the affected valves, so that the relationship has been placed beyond the possibility of douljt. Tubercular endocarditis has long been suspected, but only recently found. It is perhaps more common in acute tuber- culosis than in any other manifestation of the disease. The lesions have been more particularly studied by Perroud and Tripier. Endocarditis arises in the course of many constitutional diseases. Acute rheumatism is the most fertile cause of the affection. This, as already mentioned, attracted the notice of Baillie, and it was more particularly observed by Kreisig ; the connection between the two affections, nevertheless, was not thoroughly established until Bouillaud enunciated his famous laws, which, stated shortly, are : — 1. That in acute articular rheumatism of a violent type and general distribution, the coincidence of pericarditis and endocarditis is the rule, and the non-coincidence the exception. 2. That in acute articular rheumatism of a mild type and partial distribution, the non-coincidence is the rule, and the coincidence the exception. Statistics with reference to the frequency of endocardial complications in acute rheumatism have been frequently com- piled. In this country the best known statistics are those of Latham and Sibson. The former found that in 136 cases of acute rheumatism the heart was affected in 90 and exempt in 46. Of the 90 cases in which there was a cardiac affection 63 had solely endocardial, and 7 purely pericardial lesions ; both membranes were involved in 11 cases ; in 9 the case was doubtful. The latter out of 325 cases of acute rheumatism found 130 in which endocarditis occurred, 54 in which both endocarditis and pericarditis were present, and 9 in which pericarditis alone made its appearance ; in 3 of which, how- 398 DISEASES OF THE ENDOCARDIUM. ever, it was doubtful whether endocarditis was present or not. Continental statistics give extremely variable figures; the statistics furnished by observers such as Bamberger and Jaccoud show a percentage of from 20-30. During child- hood rheumatism exercises a more serious influence over the endocardium than is the case in adult life. Every observer has the same experience to relate in this respect. The statistics of West give 61 "3 per cent, of heart complications in the course of this disease, while the percentage is 81 according to Cadet de Gassicourt. As was seen by Bouillaud and Trousseau, endocarditis may precede articular manifesta- tions, and this, which has frequently been observed since, can only be regarded as a consequence of the rheumatic poison reversino- the usual order of its mode of incidence in con- sequence of greater endocardial proclivity. This is not the place to discuss the proljable nature of the rheumatic poison, but it may 1 le said that it becomes more and more manifest that it is either of a nature akin to that of those producing the acute infectious diseases, or is attended by such an agent, since its complications are so commonly microbic in orioin. The recent researches of Bouchard have gone a long way towards the determination of this important point, il Just as chorea, even in the absence of all overt rheumatic symptoms, may give rise to pericarditis, as shown by Bright, so it may also produce endocarditis. In such cases the toxin products of the rheumatic poison may be held to have a greater affinity for the cardiac and cerebral membranes than for the membranes lining the articulations. In 71 cases of chorea, Ptoger found that 47 presented diagnostic signs of endocarditis alone, while 19 more had both pericarditis and endocarditis. Similar statistics have been collected by other observers. Chorea is not the only affection in which the rheumatic poison in a marked form occurs. Erythema nodosum was shown by Trousseau to occur with endocarditis, and there cannot be the shadow of a doubt that this skin affection is connected wdth the morbific agent of rheumatism. Mackenzie's observations on this suljject are of great value. In the gouty diathesis the evolution of endocarditis is ENDOCARDITIS. 399 vincommon. It is perfectly true that valvular lesions have their origin in the course of this affection, but such valvular lesions are for the most part of degenerative type, and have little in common with endocarditis. It neverthe- less happens that the uric acid diathesis is accompanied by endocarditis, which, however, may be determined by the presence of a microbic poison in no way connected with the gouty affection, save in so far as the latter paves the way for the influence of the organisms. It would, however, be in the highest degree unscientific to deny that faulty chemical pro- cesses give rise to products which may set uj) endocarditis. True, tophaceous deposits upon valves have been seen by Lancereaux and others, but, if connected with endocarditis, they must be of the nature of sequelae. Endocarditis is frequently attributed to renal disease, and there can be no doubt of the direct relationship in the case of primary infective nephritis, but when the case of simple nephritis is considered, the matter is by no means so clear. The great majority of endocardial affections in simple nephritis are of the nature of degeneration. There are, nevertheless, many instances in which acute endocarditis takes its origin in the course of such renal disease. In many of these cases the determining cause may be a secondary infection by means of streptococci, for which the renal condition has simply prepared the soil, or it may be that some intercurrent affection, such as acute rheumatism, has taken place ; yet, when such considerations have been discussed, it must be admitted with Hanot that there is a possibility of the generation of ptomaines, with the power of producing endocarditis. In renal disease the endocarditis may be acute, subacute, or chronic. Closely associated with such constitutional and local dis- orders as have been discussed are the effects of certain chemical products. Alcohol and its congeners belong to this group. The abuse of alcohol has a most hurtful influence over the endocardium, and it at any rate produces a liability to endocarditis in its chronic forms. In addition to these causes, long-continued muscular strain has an undeniable influence in the production of endocardial disorders. Boerhaave observed that wild deer were very much 400 DISEASES OF THE ENDOCARDIUM. more liable to changes in the lining membrane of the heart and great blood vessels than those which were kept in captivity, and he rightly attributed the dit'lerenee to the much greater muscular exertion undergone by the former. His views were accepted l)y jMorgagni and by Haller, and they may be said to have laid the foundation for our present knowledge in regard to tlie relations between excessive strain and endocardial or endarterial disease. It is a matter of connnon observation that certain classes of men \\\\o are in the habit of undergoing great physical exertion are liable to such changes — a subject which has during recent times attracted much attention from many workers at heart disease, amongst whom may be mentioned Myers and Clifford Allbutt. It is necessary before leaving this subject to consider in greater detail some facts relating to bacterial infection. Micro-organisms, as was shown l)y Ivlebs and Krister, are found in all forms of endocardial vegetation. This has been verified by Osier, and more recently placed beyond all possibility of doubt by Friinkel and Sanger. Many different kinds of micro-organisms have been detected. Pyogenic microbes are the most frequent organisms seen in the diseased valves, but many other bacilli and cocci are found, although more rarely. Some special forms have been de- scribed, as, for instance, the bacillus endocarditis capsulatus of Weichselbaum, the bacillus endocarditis griseus of Weich- selbaum and Netter, the bacillus immobilis et fretidus of Friinkel and Simger, and the micrococcus endocarditis rugatus of Weichselbaum. Others have been described, but their characters are somewhat less positive than those just men- tioned. In most instances only one organism can be detected, but cases have been described in which several different kinds have CO -existed. When secondary changes have occurred through embolism, the same organism found in the heart has frequently been found also in the secondary deposits. A large series of investigations has been carried out in order to discover how these organisms can produce endocarditis. Klebs enunciated the opinion that the organisms circulating in the blood simply acted upon the endocardium by attacking its surface. Koster, on the other hand, was of opinion that ENDOCARDITIS. 401 the organisms were carried by the blood into the substance of the endocardium, and produced emboHsni. This view is beset by difficulties arising out of the facts previously given as to the absence, in great part, of blood vessels in tlie valves. Wyssokowitsch found that by injecting staphylococci and streptococci into a vein, after wounding the cardiac valves by means of a stylet introduced through a carotid artery, acute endocarditis of the valves was produced, and it was shown previously by Eosenhach, as well as by Wyssokowitsch, that the wounding of the valves by means of a sterilised instrument did not produce endocarditis. Pdbbert, however, found that the introduction of staphylococci by a vein of the ear was in itself sufficient to set up endocarditis, and Dresch- feld was successful in cultivating organisms from the vegetations of endocarditis destitute of malignant or ulcerative features ; these organisms, when introduced into the rabbit, produced most extensive vegetations on the mitral and aortic valves. The same streptococcus was found in the vegetations and in the heart from which, the organisms were derived. Prudden has summarised much of this recent work. It seems clear that in certain instances the blood may contain a poison whose virulence is sufficient to produce endocarditis without previous damage ; in other cases previous lesions have, nevertheless, been in existence. This is not only true experimentally, but also as regards the results of morbid anatomy, for acute endocarditis is very frequently grafted upon old-standing valvular lesions. It seems also probable that the lymph circulating through the interstices of the valve may be unable to supply them with proper nourishment, and in this way they may be predisposed to infection. A new phase regarding the poisons in acute endocarditis has begun with the observations of Sidney Martin. Chemical examination of the blood and of the spleen in a case of infective endocarditis with staphylococci which could be cultivated, revealed two chemical substances — the one, a proteid, consisting of proto-albumose and deutero-albumose ; the other, a non-proteid body with strong acid reaction. The albumoses, when injected into animals, gave rise to pyrexia, varying in degree with the amount employed. The coao-ula- 26 402 DISEASES OF THE ENDOCARDIUM. bility (if the blood was lessened, ami, after death from over- doses, fatty degeneration of the heart was found. The conclusions of Hanot regarding the pathogenesis of endoGarditis are worthy of careful consideration. Whether in respect of the special nature of the microbe, of difference in the intensity of its action, or of varying powei- of resistance, there may be two modes of development. Tn tlie one case, the lesions in endocarditis consist of changes with a tendency to localise and concentrate themseh'es, to resemble more and more the hlirous tissue of a scar, and, in this way, to a certain degree, to lose infectious characters. Such is attenuated infectious endocarditis or Ijenign endocar- ditis of the physician, which allows the individual to pass from an acute to a chronic condition. On the other hand, the endocardial lesion may preserve in a high degree its original infectious character, when the morbid tissue has a tendency to break down and be resolved into particles, which assist in transporting the infectious agent and penetrating deeply into the organism. Such is malignant endocarditis, infectious and infecting, brought iirst into prominence Ijy Senhouse Kirkes. The analysis of eighty-four cases Ijy Kanthack and Tic] t3 - A Total, 23 = 45 per cent, of all males, or 71 '87 per cent. of all males with cardiac disease. Total, 15 = 45-45 per cent, of all females, or 68 "IS per cent, of all females with car- diac disease. M. 3 F. 4 M. 3 F. 1 M. 1 F. M. P. 2 M. 1 P. M. 1 P. Total = 38, or 70 '2 per cent, of all car- diac cases. Total = 16, or 29-8 per cent, of all cardiac cases. (Males = 28 '13 per cent. ; females = 31'81 per cent.) Bronchiectasis, empyema, vaginal or uterine affections, and also influenza, must be regarded as pyogenic sources of infection. Exception might be taken to the inclusion of influenza in this group since it is caused by a specific bacillus, but pyogenic organisms are always present in the lungs in this disease, and in the case given in the table streptococci were found both in the lungs and in the heart's blood. Hence among the infective processes there were found nine cases of pyococcus infection, and seven cases of pneumococcus infection. In thirty cases old cardiac changes were absent, that is, in 3 5 "7 3 per cent., but in twenty of these, infective processes were discovered which had appeared either before or with the infective endocarditis. Of the ten where infective processes were not evident, four were complicated by malignant disease and one possibly by pneumonia ; it may therefore be said that twenty-five presented certain or probable sources of infection, 404 DISEASES OF THE ENDOCARDIUM. while in live none were found. Among the sources of infection were pneumonia and pyogenic lesions, including otitis media, puerperal aftections, and typhoid ulceration. All these cases have -been arranged as follows : — Infective Endocarditis without Pre-existing Cardiac Disease. Without Infective Processes. With Iiit'i'ftivr Processes. M. 5 F. Remarks. Pneu- monia. Pyo- genic. Em- pyema. Vaginal and Uterine. otitis. Tuber- cle. Ty- phoiil. 5 4 were eases of ma- lignant disease, 1 possibly pneu- monia, in 1 head not examined. M. F. 5 .. 1 M. 3 P. 3 M. 1 F. M. F. 2 M. 2 F. 1 M. 2 F. M. 1 F Total = 10, or 33 -3 per cent, of all cases with- out cardiac disease. Total = 20, or 66 '6 per cent, of all cases without cardiac disease. (Males = 14; females = 6.) Pneumonia occurred five times, and pyogenic infections thirteen times, including vaginal and uterine infections, otitis media, empyema, and tuberculosis. The latter may fairly be included, since it is well known that the tubercle bacillus is generally associated in the lungs with pyococci ; only one case, however, can be added to the pyogenic infections, because in one case there was a tubercular endocarditis. It may also be remarked that in the typhoid case both typhoid bacilli and cocci were found in the heart's blood. It is note- worthy that in those cases in which old cardiac disease was absent, evident sources of infection were far more numerous than in those cases in which old valvular lesions were present ; for the former group there is a percentage figure of 66"6, and for the latter of 29-8. Averaging together all the cases with a manifest infective process, whether cardiac disease was present or not at the same time, they amount to thirty-six, or 42-85 per cent, of all the cases collected. These are tabulated as follows : — ENDOCARDITIS. 405 Endocarditis with Infective Lesions. Pneu- monia. Pyogenic. Otitis. Vaginal and Uterine. Empyema. Bronchi- ecta.sis. Tubercle. Influenza. Typlioid. 12 10 3 4 2 1 2 1 1 Adding all the pyogenic lesions together, they amount to twenty-four, or 28*56 per cent, of all cases, while pneumonia occurred in 14 "2 5 per cent, of all cases, otitis in 3 "5 5 per cent. One of the most interesting points is, that an antecedent pneumonia occurred in 14"28 per cent, of all instances of infective endocarditis. In these cases which appear in the course of croupous pneumonia, the pneumococcus is the cause of the endocarditis, and can readily be separated after death. It seems, further, that a pre-existing cardiac lesion attracts the pneumococcus, for, of twelve cases of pneu- monic endocarditis, seven were complicated by old cardiac disease. Infective endocarditis is by no means common in typhoid fever ; on the contrary, it is distinctly rare. When it occurs, either streptococci and other pyococci or typhoid bacilli have been found in the heart's blood. Kanthack and Tickell found the Eberth-Gaffky bacillus in the heart's blood, not in pure culture but along with streptococci. Similarly, in those out-of- the-way cases of endocarditis appearing during the course of diphtheria or gonorrhoea, the Klebs-Loffler bacillus, the Neisser coccus, or streptococci and other pyococci, may be present, and there may be a distinct tubercular endocarditis ; mixed in- fections are common in all these cases. There may be, therefore, when an endocarditis appears in the course of an infective fever : (1) homologous, or (2) hetero- logous, or (3) mixed infection of the endocardium. Morbid Anatomy. — Acute endocarditis is much more common on the left than on the right side of the heart. ISTo adequate reason for the great disproportion existing between the number of instances affectins; the left and right sides of 4o6 DISEASES OF THE ENDOCARDIUM. the heart has yet been adduced, but it is generally believed that there are two factors causing the disparity. The greater "pressure on the left side must render the endocardium more liable to changes, and in addition the arterialised condition of the blood on the left side must be more favourable to the development of micro-organisms. Amongst the more serious varieties of acute eudocarditis — those often clinically termed malignant — however, a somewhat larger proportion affect the right side, and it seems probable that the reason for this lies in the fact that septic poisons on entering the system are more likely to encounter the right side of the heart in the first instance. Bramwell is of opinion that eudocarditis affects the right Fig. 127. — Acute endocarditis of the mitral valve. One of the inu.sculi papillares has been cut through. side of the heart much more commonly than is usually believed, and he further holds that acute changes in the tricuspid valve frequently subside altogether and entirely disappear. As the evidence, however, upon which he relies for the diagnosis of endocarditis cannot be considered absolutely satisfactory, the point nmst be regarded as far from proven. It must be remembered that Albini's bodies are very common. These consist of fusiform cells, elastic fibres, and connective tissue, and are most frequently found on the borders of the auriculo- ventricular cusps. They are present in a large percentage of the autopsies of the newdy born, and may lead to mis- apprehension. ENDOCARDITIS. 407 Acute endocarditis may affect the endocardium in any part. When it is present upon the membrane lining the cavities of the heart, it is commonly termed parietal, when — as occurs in the overwhelming proportion of cases — it Fig. 128. — Acute endocarditis of the aortic \aive. attacks the valves, it is termed valvular, endocarditis. The part of the valves almost invariably affected is the surface exposed to the blood current ; that is to say, the auricular surface of the venous valves, and the ventricular surface of the arterial. The lesions are situated not quite at the edges of the valves, but, as was first noticed by Hodgkin, at that part which comes strongly in contact with another cusp, as is 4o8 DISEASES OF THE ENDOCARDIUM. shown ill Fig. 128. It cannot be doubted that this is the effect of strain. A large series of lesions may be established in endo- carditis, which obviously depend upon the severity of the process, the extent of the reaction, and the duration of the disease. It is impossible to draw any definite line separating these lesions from one another. They form a chain of which the ends, although extremely diverse, are yet united by links presenting a perfect gradation. Such changes as thickening, roughness, granulations, abrasions, and ulcerations may be seen, and the reaction processes may lead to union of the affected cusps producing still further alterations. Acute Endocarditis. — The earliest stage in the development of acute endocarditis is a slight dulness of the membrane from accumulation of the products of irritation, along with cloudy swelling of the tissues. As these changes increase, a thickening of the part occurs, and a distinct prominence is produced, which may present a colourless, grayish, or greenish aspect. This can sometimes be removed by gentle pressure, and if it can be so removed, it leaves a distinct abrasion of the surface, which is sometimes distinctly reddish in colour. Smaller projections arise from the free surface of the little prominence, and give rise to a somewhat cauliflower- like body. The process may liecome less acute, and the mass in this case assumes a firmer aspect, and a harder consistence. On the other hand, in the most serious cases the thickened portion gives way and produces an ulcer, or, after vegetations have arisen, a destructive process may step in, and the vegetations be thrown off. The necrotic process may be so extensive as to produce perforation of a valve, or even of the heart itself, with the separation of large fragments, and the total disorganisation of the valvular mechanism. The microscopic examination of acute endocarditis in the earliest stage shows the presence of numerous small I'ound cells, arising from proliferation of the connective tissue cor- puscles. These are at first aggregated in a mass, but soon stretch in every direction. These small cells are oliserved in the fibrous layer beneath the endothelium, l:iut they extend into the areolar tissue next to the mvocardium, and even invade ENDOCARDITIS. 409 the intermuscular septum of the myocardium itself. Tlie endothelium covering the affected part gives way, so that the small cell infiltration projects freely, and deposits of fil)rin in wavy masses are seen upon the surface. In the interstices between the layers of fibrin, as well as upon the free surface, are numerous masses of organisms, as may be seen in Fig. 129, and Fig. 130. If the process goes on with- out any serious ne- crotic change, the mass finally becomes fibrous, but it may be modified at any stage, and there may be breaking down of the newly formed tis- sue with ulceration and its sequels. The illustrations give the microscopic appearances from a section of the wall of the left auricle in a case of acute, following chronic, endocarditis, and ac- companied by mul- tiple embolism of the kidney. Large masses of micrococci (staphylococcus pyogenes aureus) are seen upon the surface. A layer of necrosed tissue, showing numerous leucocytes and red blood corpuscles, is immediately underneath it, while still more deeply is situated a layer of organising tissue with young connective tissue cells and new blood vessels. Fig. 129.— Section of the left auricle from a jjatch of acute endocarditis following a chronic lesion, x 200. «, Layer of micrococci ; h, layer of necrosed tissue ■nith leuco- cytes and hismocytes ; c, layer of organising tissue, with young connective tissue cells, and newly formed vessels ; rf, layer of muscle cells nearly healthy. A-^"; ^^^f; •«P°". 410 DISEASES OF THE ENDOCARDIUM. Even in this instance, which may be regarded as belonging to the type usually termed malignant, there is a very considerable etfort on the part of the organism to protect the deeper tissues from the effects of the disease. In the illustrations the small cell infiltration of the endo- cardium may be distinctly recognised, and the deposit of fibrin undergoing organisation is very obvious, while a recent deposit of filjrin is to be seen upon the surface of the vegetation. During any part of the disease embolism may take ,..:'M.:1k- " -:.;i=** place, giving rise to simple ^^^^!^^' ..?. ... " infarction or pyiemic abscess ^ l"^" ■• .,^^^ -^ in other parts. When the • '••'•• ••' " •' .";' left side of the heart is ^'^ •:■• /'■■':.' affected the organs most •-■*?--'': ■• - . .^^ likely to suffer are in order V:;.v> .■'~ ' '* • .V of frequency the kidneys, ' ". .■ ^, . the spleen, the brain, and the ■ /• ^ .■> /*'°'. ■■ liver. In rare cases emboli lc':?:fE;c?;- r-5 \° "' ' -'. may block the coronary ,-.-"te ," '''" °°-, ..■■■:- arteries. In endocarditis ■^ :T:' w' affecting the right side (jf the •'";^;: ' heart, the embolic processes ,r : implicate the lungs. Con- "#■ - :^ ... nected with this aspect of ■■■ ' -'" "■■);■■/'•' the subject is the fact that ' .■■ ' ■ '■■ ' when there have been lesions Fig. 130.— The same .section of acute endocarditis, gf the eudarterium, VCgCta- xlOOO, showing a layer of staphylococcus • • .1 pyogenes aureus on an ulcerated surface, tlOllS are apt tO ariSC lU tUe with cocci scattered through the deeper rliggagorl tisSUeS necrosed tissue. Siibac vie Endocarditis. — The tendency of the disease in subacute endocarditis is much more conservative than in the acute form, and the resulting lesions are accordingly much more vegetative or verrucose. On account of the greater tendency to the formation of filjrous tissue, the granulations are more permanent, and there are also at once more adhesions between the cusps, and less loss of tissue. The appearances presented by the diseased structures are END O CARDITIS. 41 1 thickenings of the endocardium with firm vegetations. Ad- hesions of the cusps to one another are also common. Microscopic examination reveals an infiltration of the endo- cardium with small round cells and filjrinous granulations, partly formed from the endocardium, but partly also having origin in a deposition of fibrin from the blood. These appear- ances are seen in Fig. 131. The presence of micro-organisms can often be determined -d Fig. 131. — Section of subacute endocarditis of the auricular surface of a mitral valve, x20. o, Fibrinous coaguluni ; h, recent fibrin on the surface of the vegetation ; c, endocardium infiltrated with small round cells ; d, wall of the valve. in such cases of subacute endocarditis. The bacteria found in them are identical with those referred to in connection with the acute variety. Chronic Endocarditis. — In this special form of the disease the reparative and conservative processes are still more in the ascendant ; it therefore happens that the presence of firm vegetations, resistant thickenings, and rigid union of the cusps is particularly characteristic of this variety. The deposition of lime salts is very common. The lesions constitute one large 412 DISEASES OF THE ENDOCARDIUM. group of the chronic valvular lesions to lie separately discussed. The appearauces found in chronic endocarditis are, there- fore, various degrees of deformity of the valves, and deposits upon the endocardium else- \ " •■ 1' '-"'; ''■'. \ M i' '''^ ~ . ■ -F ■' ,' m • ■ ''',■'■■ . :'. ■ ■' I,'/ '■Xp'.' s ^■M 7 '-y/ ' ■ ^ r i^:/ :■<-/ / .. _ h where. These lesions often 0- : ':^l-\-^- ""-^ >~^*%. assume an intensely tirin char- Z'Kf' ■ '"'■~- > • •; :^^^^^ acter from calcification. It ' ' - ' " was long ago ponited out by Hodgkin that the masses connected with the valves have a tendency by friction to set up changes in near structures. iff ''.-^i-- '-.', '■' -^■:y-!y';'(-')'^f^ Microscopic examination of sections of chronic endo- carditis shows dense fil^rous tissue, usually arranged in strata, often associated with deposits of freshly formed fibrin upon the surface. In this fibrin various organisms are found. There may also be masses of a calcareous -.^^ a nature amongst the fibrous ,\\ i tissue. The ordinary struc- ture is shown in Fig. 132. Fig. 132.— Section of chronic endocarditis of The Statistics of Spcrlmg the aortic valve, x 15. «, Healthy part of f^.Q^^ ^\^^ Berlin Pathological the valve ; h, ventricular surface ; c, small . _ " cell proliferation; d, dense fibrous tissue Institute, in regard tO the Z:ZV^:S^i:^^'^'^'' incidence of endocarditis and the occurrence of embolic sequels, are of so much importance that they may well be given here. [Table. END O CARDITIS. 413 300 Cases of Endocarditis in the years 1868-70. 268 cases = 89 per cent, left side of the heart affected. 3 „ = 1 „ right „ „ 29 „ =10 „ both sides Total 300 Affection of one Valve only. 200 Cases = 66-7 per cent. Of which : Mitral valve . only, 157 cases = 78*5 per cent. Aortic valves . „ 40 „ = 20-0 „ Tricuspid valve . „ 3 ,, = 1*5 ,, Pulmonary valves „ „ = „ Comhined Valvular Lesions. 100 Cases = 33-3 per cent. Of which : Mitral and aortic 71 ( jases > = 7 1 per ( ,, tricuspid . 9 = 9 » ,, pulmonary 2 = 2 Aortic and pulmonary 1 = 1 ,, tricuspid . = Mitral, aortic, and tricuspid 16 = 16 „ „ „ pulmonary = Tricuspid, pulmonary, and mitral = „ „ „ aortic = All four valves 1 = 1 „ Emholism. 84 Cases = 28 per cent. Of these 76 occurred in connection with the left side, and 8 with the right side of the heart. Kidney 57 cases. Spleen Brain Digestive organs Skin 39 15 5 4 If in the above table any of the combinations of valvular lesions are wanting, it must not be supposed that they are never observed ; the figures occurred in the course of the years in which the statistics were compiled, and only refer to them. 414 DISEASES OF THE ENDOCARDIUM. Symptomatology. — Endocarditis producL's an immense variety of symptoms. Xo two examples of the disease are "ever exactly alike, yet the different clinical features form a continuous series. It is therefore by no means an easy task to draw distinctions between different varieties, and it is im- possible to read without a certain degree of admiration some of the systematic descriptions of the different forms of the disease in which, with a cheerful confidence, they are separated into distinct types. From the clinical standpoint it seems possible to take as the rallying point of certain forms of the disease three great types, using this phrase with the reservations already mentioned, these being : first, the acute, malignant, or ulcerative ; second, the subacute, verrucose, or vegetative ; third, the chronic, sclerotic, or contracting. Acute Endocarditis. — Cases falling under this head show very different symptoms, yet they are marked by one or other of two diverse tendencies. There is, in the first place, a class in which the symptoms are characterised l)y typhoid characters. The temperature in such cases is high and sustained ; the pulse is empty and compressible, usually frequent, and often dicrotic, or even hyperdicrotic. It is at first usually regular, but in the later stages it may be extremely irregular. The respiration is shallow and hurried. There are profuse perspirations. The tongue is dry throughout, having often, in the earlier period of the disease, a brown fur in the centre bordered by red edges ; it may, however, be cracked or fissured, As the disease progresses there is often meteorism and sometimes diarrhoea, occasionally melcena. Choleriform diarrhoea was described by Trousseau. The spleen is usually enlarged, the urine often contains aibumin, and sometimes blood. A lethargic or soporose condition is common, tending in some instances to pass into coma, and characterised in others by low muttering delirium. There are in some cases rosy papules upon the skin, and sudamina are extremely common. Purpuric appearances have been seen, and Claisse found the same organisms in them as on the valves. Patients who present this particular group of symptoms have, in many instances, extremely few physical signs connected ENDOCARDITIS. 4 1 5 with the heart, except weakness of the cardiac impulse and sounds. If the affection, however, is not rapidly fatal, evidence of cardiac implication shows itself hy an enlargement of the area of dnlness, more particularly to the right, along with a progressive diminution in the intensity of the first sound, and the development of murmurs. These murmurs are for the most part confined to the mitral and tricuspid areas, and they are systolic in rhythm, but they may be presystolic in these situations, while in the aortic and pulmonary areas systolic, and even diastolic, murmurs may be heard. In consequence of embolic processes many aiDpearances arise, connected not only with internal organs but with super- ficial parts of the body ; in fact, owing to the severity of the general symptoms, the former are apt to be overlooked, and the latter therefore assume greater importance. Upon the skin there may be papules which, from their pale or yellow centre, show their embolic origin ; these sometimes become vesicular, in a herpetic or pemphigoid manner, or may sup- purate, and give rise to pustules. These appearances are often accompanied by erythematous blushing, or subcutaneous extra- vasation of blood. The mucous membrane of the lips, crums, and tongue may have small haemorrhages, which show their embolic origin by a pale centre. In one such instance, Eichhorst mentions that he has seen subsequent ulceration of the mucous membrane. The conjunctiva is often bloodshot from embolism of its blood vessels, and sometimes, as w^as pointed out by Litten, on ophthalmoscopic examination there are haemorrhages in the retina, which, by means of the pale central portion, reveal their origin. Occasionally in the less rapid cases there is necrosis of the retina. The course of acute endocarditis in this typhoid form is usually rapid. In a case described by Eberth, death occurred on the second day of the disease, and in one mentioned by Eichhorst a fatal result occurred on the fourth day. It may, however, happen that the affection passes into a somewhat less acute form, and may even assume the features of chronic endocarditis. Death most commonly occurs on account of acute general infection, but sometimes from heart failure, in consequence of paralytic myocarditis ; it may, however, be 41 6 DISEASES OF THE ENDOCARDIUM. through iiuplieation of the nervous system by enil)oli:?ui, or liy complication connected with the thoracic viscera. The other form in which the disease shows itself is characterised by its septicanuic features, commeneing with severe and usually repeated rigors. It presents for the most part the characters of an intermittent pyrexia. The tem- perature is extremely irregular and intermittent. The pulse rate undergoes great lluetuations, and the febrile periods very commonly terminate by means of profuse perspirations. There is usually complete anorexia, and the tongue is heavily furred. Various digestive disturbances, such as tympanites and diarrhoea, occur. The spleen is very commonly enlarged, and during the attacks of pyrexia there is often delirium. The most careful examination of the circulatory organs often fails to give any definite indication of a lesion. The pulse is as a rule empty and compressible, often fully dicrotic, and sometimes extremely irregular. The cardiac impulse is usually feeble, and the area of dulness is often enlarged, espe- cially towards the right. Systolic murmurs in the mitral and tricuspid regions, as well as near the pulmonary area, along with accentuation of the second pulmonary sound, are common, but all these symptoms are no more than may be found in any acute pyrexia. Obstructive murmurs may develop themselves while the patient is under observation, and in this way give valuable evidence with regard to the lesion which is present. Embolic symptoms are often present. The sudden onset of pain in the back, followed by heematuria, may show that embolism of the kidney has taken place. A rapidly occurring hemiplegia may indicate cerebral embolism. The occurrence of peritonitis and of pleurisy can sometimes be traced to the same process, affecting the serous membranes ; and various affections of the skin and mucous membranes, such as have been referred to previously, may own the same origin. This septicemic form of acute endocarditis is sometimes specially characterised by the cerebral symptoms to which Osier has particularly called attention ; it is then frequently associated with meningitis, and it may be noted that Xetter has detected pneumococci in the meningeal exudation. It cannot be too strongly insisted upon that a great many END CARDITIS. 4 1 7 cases of this affection run a perfectly latent course, and only reveal themselves by a sudden disturbance of the circulatory system, through changes taking place in the heart, or embolic processes occurring in other organs. An irregular and inter- mittent pyrexia may give rise to considerable difficulty in diagnosis, when the sudden development of a previously absent valvular lesion, or the onset of cardiac failure, may show that a profound change is taking place in the heart. There may be, on the other hand, along with a similar febrile type, characteristic appearances denoting the incidence of embolism. Forms of endocarditis, such as have been here mentioned, often run a prolonged course. The disease may continue in its acute form for weeks, and cause death by asthenia, or by one of the many complications to which it is liable ; it may pass into a less acute form with occasional exacerbations, and continue for months, or it may even assume a still more chronic form. The end, however, has, until lately, been almost invariably fatal. Subacute Endocarditis. — rSubacute, verrucose, or vegetative endocarditis is frequently unattended by any general symptoms. When it occurs as a complication of some general disease, as in acute rheumatism, it frequently does not even cause any elevation in the temperature, and but little alteration in the pulse or respiration. Even in those instances in which sub- acute endocarditis has taken its origin in some chronic disease, as in the case of chronic nephritis, the cardiac affection can sometimes only be detected by careful physical examination of the heart. It may, on the other hand, be attended by a rise of temperature, with accelerated pulse and hurried breathing. In some cases there are subjective sensations connected with the heart, such as uneasiness, even amounting occasionally to pain, and palpitation, which is sometimes almost entirely a subjective symptom. Syncopal tendencies may be present. The pulse may undergo no alteration, but it is more common to find that it becomes less full and more com- pressible than in health, with increased frequency, and some- times irregularity. In some instances pulsations may be observed in the veins of the neck. The apex beat becomes feeble, although from the excitement of the heart, its sharp impulse is apt to be mistaken for an exaggerated beat. It is 41 S DISEASES OF THE ENDOCARDIUM. often further to the left than in health, and it may be attended by a thrill. The cardiac area of duhiess is very commonly increased, particularly to the right. On auscultation tliere are great -possibilities of error. In idl febrile conditions, such as so often lead to endocarditis, the heart is apt to undergo dilatation, and not only is there a change in the cardiac sounds but systolic murmurs are extremely common at the auriculo- ventricular orifices, along with accentuation of the pulmonary second sound. Such murmurs may obviously be caused by changes in the cardiac walls, or in the papillary muscles, and therefore have no necessary connection with endocarditis ; as has already been remarked, reliance upon these murmurs as an indication of endocarditis has rendered most clinical statistics connected with the suliject open to the gravest suspicion. It cannot be urged too strongly that the only absolute diagnostic means consists in the appearance of murmurs of obstruction at one or other of the orifices. Sibson regards the existence of a mitral systolic murmur, in a first attack of acute rheumatism, as a direct sign of endocarditis. This statement is much too absolute, and is not borne out by the after history of such cases. It seems to me that the views of Sansom on this subject are extremely just. He considers that great weight should be allowed to the date of the development of the murmur. Those cases presenting the evidence of mitral incompetence at an early period of the febrile attack are probably endocarditic in origin, since there has not been time for the development of regurgitation by means of muscular relaxation ; in others, with a late appearance of such features, the probability is that the valves are unaffected. Sibson is beyond all ques- tion justified by clinical and pathological experience in lielieving that systolic tricuspid murmurs, in febrile affec- tions liable to produce endocarditis, are due to the " safety- valve action " of the right venous cusps. Surely he goes too far, however, when he concludes that systolic tricuspid murmurs in such cases are the result of left-sided endocarditis. The determination of the probable condition in any given case can only be attained by carefully weighing the whole evidence available, and the possiljility that murmurs of incompetence END O CARDITIS. 4 ' 9 at the venous valves may be due to acute' myocarditis must not be overlooked. This latter suggestion v^ill be again referred to in another section. If a patient, while under observation, develops a pre- systolic murmur in the mitral area, or a systolic murmur in the aortic area, there can be no doubt that endocarditic lesions have made their appearance on the cusps of the respective valves. The evolution of an aortic diastolic murmur is often to be traced in endocarditis, and it always means that part of the valvular apparatus has, in consequence of the local lesion, been retracted, or that in consequence of vegetations the cusps are prevented from fully closing the orifice, or that part has been swept away in the blood current. It is not uncommon to find the development of a pulmonary diastolic murmur while endocarditic processes are going on. Breathlessness, cough, and other pulmonary symptoms may arise in consequence of implication of the lungs from weakness of the heart. Albumin, blood, and casts may be present from the secondary effects of cardiac failure on the kidneys. Headache, restlessness, and sleeplessness may in the same way be produced by the failure of the circulation to supply the brain, as well as by the influence of the febrile process. As in the case of the more serious malignant forms of endocarditis, the variety now under consideration frequently leads to embolic processes. Sudden pain in the loins, with rigors, followed by haematuria, may give evidence of renal embolism. Pain in the left hypochondrium, also frequently attended by shivering, and followed by an enlargement of the area of splenic dulness, may be significant of splenic embolism. The sudden development of paralytic symptoms may be traced to cerebral embolism. Pain, with haemorrhage from internal mucous membranes, may point to the probability of embolism of some part of the alimentary tract, and local absence of the pulse with cold surfaces, lancinating pains, and paralytic symptoms, may result from embolism of an artery of a limb, leading, in the case of an important vessel, to gangrene. Sudden death from cardiac failure may be the consequence of coronary embolism. 420 DISEASES OF THE ENDOCARDIUM. Erythema nodosum is not infrequent as an accompaniment of subacute endocarditis. It has been held to be a result of embolism, but as it is in every instance associated with rheu- matism, it is much more probable that, like chorea, it has its origin in the local action of some as yet unknown toxic body, produced by the action of an organism, or of some poisonous substance from perverted chemical activity. Other complications may arise in the course of subacute endocarditis. It is extremely probable that in a large pro- portion of cases myocarditis arises by direct extension from the diseased endocardium, and, by its paralysing effects, is the cause of the weak, irregular, and frequent pulse, the feeble heart sounds, the dyspna?a and syncopal seizures so often observed. It is equally probable that the pericarditis, which can often be made out by physical examination, is likewise a result of direct extension. The possibility, however, must not be overlooked that all these cardiac lesions may have their origin in the primary affection from the same cause. Acute aortitis has been described as a sequel of the disease more especially by Petit. It may be suspected, as will afterwards be more particularly mentioned, by pain, radiating towards the shoulder, and by a dulness of the second sound in the aortic area. Other acute complications, such as pneumouia and pleurisy, are usually the result of the primary cause. The course of subacute endocarditis is, as a general rule, more lengthy than even that of the intermittent type of the acute form of the disease, and its termination is commonly gradual recovery of the patient with a chronic valvular lesion as the local result. It is held by several authors, as has already been mentioned, that absolute recovery may ensue, but to my mind the evidence in favour of such a view is open to question. Chronic Endocarditis. — Chronic endocarditis is unattended by any general symptoms, apart from those which are a result of the circulatory disturbances having their origin in it. Pyrexia is only present if an acute attack of endocarditis is grafted upon the chronic process, or if some complication arises in consequence of the liability to acute changes in parts affected by venous stasis. The temperature is not. ENDOCARDITIS. 421 therefore, necessarily altered in chronic endocarditis, and the changes of pulse and respiration found in pyrexia are absent. The local symptoms and physical signs of chronic endo- carditis are solely connected with the valvular lesions which it produces, and the circulatory disturbances resulting therefrom. They will therefore be considered under the head of chronic valvular lesions. Diagnosis. — The recognition of the acute form of endo- carditis is attended by very considerable difficulty. In addition to the care necessary to determine the presence of endocardial disease, along with septic infection, there are certain other diseases for which it is apt to be mistaken, more particularly enteric fever, acute tuberculosis, and septicaemia. Septicaemia is above all others the disease for which acute endocarditis is apt to be mistaken. Little wonder need be caused by this, seeing that most cases of acute endocarditis are of septicaemic origin. In all septicaemic affections, whether com- plicated by the existence of an endocardial lesion or not, there are characteristic features of pulse, skin, and temperature. The sole distinction that can be drawn between cases with and without endocarditis must be deduced from the physical examihation of the heart. Acute tuberculosis is less likely to be confounded with endocarchtis. Not only are periodic fluctuations of pulse and temperature, as well as profuse nocturnal perspirations, more regular in their appearance, but there is also much more rapid wasting. There are often, moreover, definite clinical features of a local implication, e.g. of the lungs, or of the brain. In the event of any pulmonary symptoms there may be some evidence of an apical change, and it may even be possible to discover the tubercular bacillus if there be any expectora- tion. In almost all cases, lastly, of general tuberculosis, the heart gives absolutely negative evidence on physical examination. Enteric fever may exist in such obscure forms as to be readily mistaken for other affections such as endocarditis. Every clinical feature of diagnostic value, such as the rash or 42:2 DISEASES OF THE ENDOCARDIUM. the stools, may be absent, iiud hhrIi difficulty in diagnosis is thereby introduced. Xevertheless, even in sucli doubtful cases the regularity and infrequency of the pulse, and the character- istic ^temperature curve, may be useful in distinguishing the disease from endocarditis, even when cardiac symptoms and signs are present. It need hardly be added that at the present time, any doul)t ^V(luld at once l)e submitted to the arl)itrament of V)acterioh)gical investigation; that tlie Iteautiful phenomena produced by the l)lood when added to a culture of enteric bacilli, as discovered liy Grul)er and Widal. wnuld at once be sought for. The physical signs of auriculo-ventricular incompetence may obviously arise either from endocarditis or myocarditis. Both these affections are common in acute febrile diseases ; in many cases, no doubt, the myocarditis is the result of, or at least is caused by extension from, an affection in the first instance of the endocardium ; many instances ol' myo- carditis, notwithstanding, are undoul)tedly produced Ijy the action of toxines directly on the heart -muscle. In such instances it may be absolutely impossil)le to determine whether the heart muscle or the lining membrane is affected, in the absence of physical signs of obstruction at an orifice. The recognition of subacute endocarditis is not attended by so much difficulty, and it only requires care on the part of the observer during the course of such affections as are likelj^ to be complicated by its presence. As in the case of peri- carditis, so here also endocarditis must be sedulously watched for during the course of acute rheumatism, acute pneumonia, and all other conditions liable to lie complicated by the development of endocardial affections. The chief difficulty in the diagnosis of subacute endocarditis lies in the possibility of mistaking a simple dilatation, produced Ijy pyrexia, for an endocarditis, and it cannot be too strongly insisted upon that systolic mitral and tricuspid nnirmurs are in themselves apt to be misleading. It is only in the presence of murnuirs of obstruction or of a diastolic aortic murmur that it is possiljle to attain certainty. Murmurs of regurgitation, nevertheless, when developed early in the course of the acute disease, are, as has previously been stated, of more value as diagnostic ENDOCARDITIS. 423 indications. Much, however, depends on the severity of the initial disease. A prolongation and muffling of the first sound has Ijeen regarded by many authors as the most frequent early sign of endocarditis. Gull and Sutton, Sibson, and Sansom all a^ree on this point. The reasons adduced previously as to the doubtful value as evidence of a murmur of regurgitation apply here also with almost greater force. The diagnosis of chronic endocarditis is practically that of valvular disease, and the only difficulty is to distinguish between the' probability of a valvular lesion l)eing the result of endocarditis or degeneration. This subject belongs naturally to the chapter which is devoted to valvular disease. Peognosis. — The outlook in endocarditis may be regarded as steadily brightening on passing from the acute, through the subacute, to the chronic form of disease. The prognosis in the acute variety is still gloomy, but with the light thrown on the disease by modern research, and the aid rendered by recent investigations, there are grounds for hope that the disease will shortly be deprived of its former hopeless prospect. Subacute endocarditis may be regarded in the main as tending towards a favourable immediate termination, yet it is some- times directly fatal. Chronic endocarditis being, from the standpoint of practical medicine, simply a part of chronic valvular disease, need not be discussed here. In forming a prognosis in any case of endocarditis several facts must be steadily kept in view. Among these may be mentioned the character of the primary affection causing the lesion. In all instances in which the affection is simply part of a general infection much depends upon its severity. Cases of septicaemia, for example, are so frequently fatal in themselves that the cardiac complication is but an episode. In the course of enteric fever, on the other hand, the original factor is not so serious. Notwithstanding such a consideration, however, it must be remembered that, in consequence of mixed infection, a fatal attack of endocarditis may be grafted upon a disease in itself of no great severity. The state of the heart itself, as well as of the circulation in general, must therefore receive the greatest consideration, 4^4 DISEASES OF THE ENDOCARDIUM. ami such symptoms as point to cardiac failure must be allowed great weight in coming to a conclusion. Treatment. — The management of endocarditis provides a wide . tield for the exercise of practical medicine. The exten- sive range of primary causes and the variability of clinical features render it somewhat difficult to lay down dehnite rules, but general principles of treatment may easily be formulated. As regards, in the first place, acute endocarditis, it will naturally occur to the physician in charge of any general or local disease liable to this cardiac complication to watch for symptoms warning him of its approach, and, if there be any suspicion that it is imminent, resource will be had to prophylactic measures. Until quite recently the only methods available have been sought in antiseptic remedies. Now, however, the knowledge of serum therapeutics has placed in the hands of the physician a means of combating the disease directly. The whole subject is, at present, however, in an experimental phase, but the results obtained thus far are full of encouragement. Seeing that the most common agents in acute endocarditis, whether it arises in consequence of a single or mixed affection of the endocardium, are pyogenic organisms, the particular form of serum to be employed will necessarily be anti- streptococcic serum. But, when other forms of infection are determined or suspected, the appropriate serum for each case will be resorted to. There need be no hesitation in the use of these serums. Frequent use of them in many different conditions has convinced me that they are absolutely harmless, and it is, therefore, our bounden duty to have resort to such measures in order to cope with these forms of endocarditis which have hithetto been regarded as hopeless. It need hardly be added that, from the point of view of prophylaxis, careful attention must be given to the general conditions by which the patient is surrounded. Cases in which acute endocarditis has already occurred do not afford so much possibility of relief ; yet even in them the disease cannot be regarded as beyond hope. Absolute rest, free ventilation so as to ensure oxygenation of the blood. ENDOCARDITIS. 425 warmth of the extremities, in order to ease the peripheral circulation, and appropriate food, must be ensured. If there be any tendency to cardiac collapse, the employment of alcoholic and ammoniacal stimulants, along with cardiac and nervine tonics, will be employed. Such antiseptic drugs as qu.inine, salol, naphthol, and the sulpho-carbolates have been largely employed in the past, but now various blood serums give much more hope of benefit. Sainsbury and other writers have placed on record instances successfully treated in this way, and there can be no doubt of the efficacy of antistreptococcic serum. It must always be a matter of doubt whether, in cases in which the affection has got a considerable start of treatment, the inoculation will be able to overtake and antagonise the disease process ; but the results of several cases which have been recorded are sufficient to render it probable that this can be done. In one case, seen by me with Dr. Boyd at the Deaconess Hospital, which will soon be published, most ex- cellent results followed the use of the serum. Of anti- streptococcic serum the first dose should not exceed 5 c.c, but the quantity may rapidly be increased to 20 c.c. One injection should be given every day, with rigid aseptic pre- cautions. At the same time the action of the heart is to be supported by the use of strophanthus or digitalis, along with stimulant remedies. It is doubtful if any local measures are of the least utility in this disease. The employment of ice to the preecordia has been advocated, but is apt to be depressant to an already enfeebled circulation. Warmth certainly is of more value. Counter -irritation by mustard, or even by blisters, has also been advocated, but there is a want of common sense in the use of such agents when a general infection is in process. The same may also be said of the extraction of blood by means of leeches. Turning in the next place to subacute endocarditis, the first question which will naturally arise is whether, in cases liable to be complicated by its presence, any prophylactic measures may be adopted with fair prospect of success. As any acute process that may be present will doubtless be under treat- ment of an appropriate kind, the measures already employed 426 DISEASES OF THE ENDOCARDIUM. must be diligently persevered with. Since the overwhelming proportion of cases occurs in the course of acute rheumatism, the use of some member of the salicyl series of drugs will no doubt be the chief element of the treatment, and this must be followed out. But certain other measures seem also to be beneficial. The addition of iodide of potassium to the specific remedies employed, and the systematic use of counter-irrita- tion Ijy blistering the pnecordia, afford the best promise of relief Caton has more especially advocated the latter method, and recommends a succession of small blisters. From his results it cannot be doubted that such treatment does lessen the liability to endocardial complications. The ex- planation of the action is not easy, but it is probable that the effect upon the peripheral nerves is carried by way of the spinal segments, and their connections with the sympathetic ganglia and nerves, to the heart, where an influence is exerted on the Ijlood vessels of the endocardium. In the case of other general diseases, whether constitu- tional or specific, the appropriate treatment for them should also be carried out. When there is any danger of an endo- cardial complication in acute gout, the special remedies — colchicum and alkalies — are to be pushed. If there is any suspicion of endocardial implication in such an affection as scarlet fever, for which, so far, no known specific remedy exists, the general treatment must be sedulously carried out. In all such cases the use of counter-irritation is to be strongly recommended. Inasmuch as many of these general diseases are complicated by mixed infection, through the addition of pyogenic organisms, an effort should l)e made to detect such microbes in the blood, and, in the event of a positive result, antitoxic inoculation should be adopted. When the existence of suljacute endocarditis has been determined, the question is no longer one of prophylaxis, but becomes one of remedial treatment. The lines upon which the primary disease has been managed must still be carried out, and such additional measures adopted as are demanded by the new aspect of the case. The necessity for absolute rest, sufficient slumber, abundant air, and suitable clothing need scarcely l)e insisted upon, but a word ENDOCARDITIS. 427 may be specially added in regard to food and drink. Pood should be administered every two hours. During the early stages of the affection it should consist solely of milk ; this may be diluted with abundant pure water, which may be hot or cold according to the wish of the patient, unless there be any tendency to collapse, when warm fluids are best. The addition of alkalies certainly seems to be useful, and the water may be aerated if it does not give rise to gastro-enteric dis- tension. The action of the bowels should be watched, and gentle saline aperients given if necessary — Rochelle salt or sulphate of sodium acting very well. In many cases no further treatment is required, except the employment of external measures l)y counter-irritation. This may be carried out as above mentioned. In some cases when pain over the prsecordia is a prominent feature, leeches may be applied, or hot fomentations or poultices used ; it is certainly good practice, moreover, in such instances to add the internal administration of anodynes. Of all these, the best for this purpose is morphine. The physician must be on his guard against cardiac failure. Paralytic myocarditis may ensue with alarming rapidity, and suddenly end the scene. Against it the cardiac ■tonics, digitalis and strophanthus, along with free stimulants, are the best antagonists ; of all means, Niemeyer's pill of quinine,, opium, and digitalis seems to me to be most useful. It may be necessary to have recourse in certain cases to the use of strychnine hypodermically, in order to sustain the nervous centres, and inhalations of oxygen should also be resorted to if the respiration becomes embarrassed. After the more acute stage has passed off, the food may be varied by the addition of eggs, fish, and chicken, gradually added to until ordinary diet is reached. Absolute rest must for a considerable time be enjoined. Iron, arsenic, quinine, and strychnine may be given in varying combinations, but whatsoever of such a nature is administered, it seems to me of even greater use to persist in the use of iodide of potassium for a prolonged period. It is unnecessary in this section to deal with the treatment of cJ( ronic endocarditis ; the management of its different forms 428 DISEASES OF THE ENDOCARDIUM. will fitly fall under the diseases of the orifices and valves to which it so largely contributes. The following cases are illustrative of some of the points which have been dealt with. Case 13. Acxite Eiidocanlitis n-ith Intei-raittent Course. — A. L., aged sixteen, domestic servant, was admitted to Ward 25 of the Royal Infirmary, 19th October 1891, suft'erin*,^ from acute rheumatism. There ■were no hereditary tendencies of any importance as regards the disease from which the patient was suffering. Her previous health had always been excellent. She had from early years been accustomed to hard work, but her surroundings had always been satisfactory. Eleven Anjs, before her admission the patient had developed a severe attack of acute rheumatism, which, after a few days, led to cardiac complications, when she was recommended to the Infirmary. On admission the patient was very anaemic and extremely weak. Her tongue was heavily coated with a white fur, and there was complete anorexia. There was no alteration in the condition of the digestive viscera on physical examination. The spleen was not enlarged. The pulse was empty and compressible, but perfectly regular, varying between 100 and 120, with a small weak pulse wave. There were slight venous undulations in the neck. The apex beat was in the fifth intersjDace, four inches from mid-sternum. It was so feeble as to be difficult of detection. There was no thrill over any part of the prsecordia. The upper border of the heart reached the third rib. The right border was one inch and a half to the right of the mid-sternal line ; and the left extended four inches and a half to the left of mid- sternum. Faint murmurs, presystolic, systolic, and diastolic, could be heard in the mitral area. A tricuspid systolic murmur was distinctly audible. In the aortic area a distinct systolic murmur and a very faint diastolic murmur were heard, but sometimes the diastolic murmur was inaudible, and reduplication of the second sound was present. A loud systolic murmur was present in the pulmonary area, but this could not be differentiated from the tricuspid murmur. Cerebral breathing was present. There were no urinary symptoms, but the nervous system was obviously depressed, for the patient manifested a lethargic condition with a stolid aspect and dull senses. It was quite clear that in this case, in addition to a febrile dilatation of the heart, as evidenced by the systolic mitral and tricuspid murmurs, there was also some obstruction at the mitral and aortic orifices, no doubt produced by recent vegetations, and it could not be doubted that there was either some slight destruction or retraction of one or other of the aortic cusps, as evidenced by the diastolic aortic murmur. The escape, however, was but slight, and the cessation at times of the diastolic murmur showed that the structural change could not be extensive. The patient was kept absolutely at rest and placed upon milk diet. On account of the depressed condition of the nervous system, she received END CARDITIS. 429 gentle stimulation by means of small doses of brandy, along with some strychnine, and as, notwithstanding the dull condition of the nervous system, she was unable to sleep, chloralamide was administered at night. During the two days which suc- ceeded the patient's admission there was but little change in her condition. On the 22nd October albuminuria suddenly appeared, possibly from embolism. It was not, however, accompanied by any htematuria. On the 25th October pericardial friction was heard, but it passed away before the next day. After this the patient improved under the influence of tincture of digitalis and solution of acetate of ammonium, but on the 10th November there was an attack of cardiac failure with dyspncea, cyanosis, and intermittence of the ]3ulse, followed by free hsematemesis, and on the following morning there were all the characters of Corrigan's pulse, with a very loud diastolic aortic murmur. It seemed more than probable that some of the aortic vegeta- tions, perhaps even part of a cusp, had been swept off by the blood current and had been carried to one of the gastric arteries. From this date a steady improvement occurred, and on 22nd November the patient was able to rise. On 1st December a relapse took place, with aggravation of all the symptoms, but from this, in the course of a week, she again recovered. At her own desire she was allowed to go home on 15 th December, and she died a few days later of sudden asystole. No autopsy could be obtained. The course of the temperature is seen in Fig. 133. The case may be held to furnish a good example of the intermittent type of acute endocarditis. c> "0 "CO CO CO s 2 lt7firlB^ HjJjJ. i- 5 s •2 r I S2 % z s £ { 'i. o> I. £ a 2 i~ » CD >• E n , i- 2 •t ?• 1 ^ ra < s « -J Q % - -7 ■z < >.! s s >• % s < >^ s s / > E s < » E s «: ^1^ E rt < %. s » E s dSO. iu3 l}"cl E c! > E g * » E B 4^ . E s »• -z. t •<--. » E £ < , E IS •^:. E * •*-> £ !5 •^- » E 2 •C > E = •( » •s. 7;u/J 3)U/ 3Sin^ iV^ SHOES' E 01 , E CO , E 1- % E (D F C ?n " * ' •0 Lil F E CO - — • ^ % ^ •<. E - K- E m •- ~~-i. E ° '>. S •s S •^ E S % N ir S UOI OIJJ I''!!- J bo;. ^.^•s w t> V "C — -^ g & - S 1 4 1 T 1 ■^ „-°M °c< °= °o °o °a °r» ?^2 2 2 o)Q 430 DISEASES OF THE ENDOCARDIUM. Case 14. Acute Intermittent Endocarditis. — A. S., aged 22, factory girl, was sent to see me on 10th February 189G, in the out-patient department of the Royal Infirmary, by my colleague, Dr. Maddox. She had for two or three weeks been attending the eye department, and Dr. Maddox desired a report on the state of the heart. The patient's father and mother were alive and had always been well. Her only brother had died as a baby, two sisters also died in infancy, and one, after miscarriage, in child-birth. Her two remaining sisters were in good health. So far as could be ascertained, there were no family tendencies towards circulatory disease. The jDatient's social conditions were not unfavourable, and her previous health had always been perfectly good, with the exception of an attack of measles. Daring the month of November of the previous year the patient somewhat suddenly began to suffer from breathlessness, and it was noticed that her complexion became pallid. Amenorrhtea had been present since the New Year. She continued her work, nevertheless, until, about a month before she was sent to me, she found that the sight of her right eye was affected, and she sought advice in the eye department of the Infirmary. The patient was 5 ft. 1 in. in height and weighed 7 st. 2 lb. She was slenderly formed, but well nourished, with an extremely pale com- plexion and bloodless lips and gums. The temjDerature was normal. There were no symptoms connected with the alimentary system. The spleen and lymphatic glands showed no abnormality. The pulse was 94, the vessel was empty, the blood pressure low, the pulse wave large, bounding, and collapsing, but perfectly regular. On causing a reddened patch on the forehead, distinct capillary imlsation was visible. The fingers were clubbed and the nails arched. They also showed a capillary pulse. On examining the chest, it was seen that there was very distinct i^ulsation in the carotid arteries, but there was no other abnormality on inspection. On palpation, the apex beat, which was forcible, was found in the fifth intercostal space, four inches from mid- sternum. Percussion showed that the upper border of the heart was at the third costal cartilage, the right border one inch and three-quarters, and the left five inches from mid-sternum. Auscultation revealed loud systolic and diastolic murmurs, heard over the whole pnecordia, indeed throughout the whole chest ; the point of maximum intensity of the systolic murmur was at the upper edge of the manubrium sterni, almost in mid-sternum ; the diastolic murmur at its point of maximum intensity was at the left edge of the sternum, where it was joined by the third costal cartilage. There were no abnormal sounds except these murmurs over the prtecordia. The respiratory and urinary systems gave no sign of disease, and, with the exception of the blindness, there was no nervous symptom. This case appeared to be probably one of an insidious endocarditis, but the most rigorous examination failed to elicit any definite causation. It was quite obvious that the main valvular affection was connected with the aortic cusps, but on account of the absence of any definite END O CARDITIS. 431 second sound, and of the localisation of the murmurs, it was impossible to avoid the suspicion that there might also be some affection of the pulmonary valves. This suspicion was undeniably strengthened by the appearance of the patient's fingers, for there was a degree of cluljbing and arching difficult to explain in the absence of any symptoms of backward pressure. The patient was sent back to Dr. Maddox with a report upon her condition, but, as matters did not seem to me to bode well for her future, she was requested to present herself again in a week for further ex- amination. On her return she was clearly in a worse condition than when seen the week before, and she was therefore recommended to remain in the Infirmary in order to obtain the benefit of further treatment, to which Fig. 134. — Fields of vision in Case 14. suggestion she gladly consented. She was therefore admitted to Ward 25 on 17th February 1896. Her residence in the Infirmary allowed of further observations, and the facts which have been already mentioned were more fully determined. In addition to these, however, some other points were ascertained. The temperature was found to be almost always elevated. It did not rise to any very great extent, but fluctuated for the most part between 99° and 100°, rising, however, at times to 103°, and sinking at other times to 98°. The examination of the blood showed 20 per cent, of htemoglobin, and 2,300,000 red blood corpuscles. The examination of the fields of vision showed that of the left eye to be quite normal, while that of the right eye was greatly restricted in its nasal portion. Oi^hthalmoscopic examination explained this symptom, for it showed characteristic appear- ances of embolism. The patient remained under treatment until 23rd April. Her condition fluctuated considerably, but under the influence of salol, iron, and arsenic, with digitalis from time to time, she somewhat improved, and when she left, her temperature was steadier and her general 432 DISEASES OF THE ENDOCARDIUM. condition better. On the 8th May she again presented herself with all her symptoms exaggerated, and she was at once admitted to the ward. Examination of the heart showed that there was great enfeeblement. Botli in the mitral and tricuspid areas the fir!?t sound was very faint ; its condition otherwise remained as it was when she was admitted for the first time. She sulfered greatly from breathlessness. The temperature on her admission was subnormal. The pulse, however, was 116 and the resjjirations 36. There was a considerable amount of cough, and a large quantity of frothy sputum, greenit^h for the most jiart in colour, but tinged in parts with red. Examination of the lungs revealed some dulness on percussion at the right apex, but the sound elsewhere was unaltered. Auscultation showed that the breathing at the right apex was bronchial, elsewhere it was vesicular. There were crepitations Fig. 135. — Temperature chart from Case 14. widely scattered throughout both lungs, and the vocal resonance was greatly increased over the right apex, but was normal elsewhere. There was some cedema about the ankles, but there was no albumin in the urine. The temperature oscillated a good deal during the few days immediately succeeding her admission, as is seen in Fig. 135, and she suffered greatly from the respiratory symptoms. On this occasion she was again treated by means of salol. Strophanthus was also exhibited along with aromatic spirits of ammonia, sedatives, and warm aj^i^lications. Day by day, however, the patient grew steadily worse, and in spite of every method of treatment, she died on 23rd May. A post-mortem examination could not be obtained. This case presents a considerable number of difficulties, but taking everything into account, the most probable ex- planation is that of an intermittent acute endocarditis, which might be regarded as of a malignant type. ENDOCARDITIS. 433 Case 15. Subacute Endocarditis. — J. W., aged 25, coiuniercial traveller, was seen by me in consultation with Dr. Veitch, 25th March 1897, on account of the consequences of an attack of acute rheumatism. The patient's family showed some slight tendencies towards rheumatism. Both his parents were alive and healthy, as were also his brothers and sisters, but one of the brothers had suffered from time to time from undeniable rheumatic symptoms. The patient had been married about two years, and one child, a strong healthy boy, had been l)orn of the marriage. The patient's surroundings and occupation had been perfectly satisfactory. The illness for which he was under treatment had begun about three weeks previously, and had presented every feature of a mild attack of acute rheumatism, the temperature having reached a level of 101°, while the disease had attacked the knees. • On examination the patient was found to be somewhat emaciated, with a large bright flush on his cheeks and an eager intense look in his brilliant eyes. He occupied a semi - recumbent posture and panted violently. The skin was absolutely dry, the temperature was 99'6°. The lips were bright coloured, the tongue was very slightly coated by a grayish fur. The patient complained that he did not receive sufficient food to satisfy his hunger. The digestive functions were thoroughly carried out, and the abdominal viscera presented no departure from health. There was no glandular change and the sjjleen was normal in size. The radial artery was healthy, the vessel was moderately filled, and the blood pressure was low. The rate of the pulse Avas 135. It was perfectly regular and nearly equal. The carotid arteries pulsated somewhat strongly, and on looking at the prsecordia, distinct pulsa- tion could be seen in the third, fourth, and fifth intercostal spaces. On applying the hand, no abnormal impulse could be detected, and there was no thrill. Percussion showed the right border of the heart to be two inches, and the left to be three and a half inches, from the mid- sternal line. The upper border was at the superior edge of the third left costal cartilage. On auscultation in the aortic area, there was a loud yet soft systolic murmur propagated over the whole of the manubrium sterni, towards the upper portion of which it was loudest. This murmur could be heard distinctly in both carotid arteries. In the mitral area a short, sharp, blowing, systolic murmur Avas heard, which was propagated well into the axilla and towards the angle of the scapula. In the pulmonary area there was slight accentuation of the second sound, and in the tricuspid area a loud, low-pitched, blowing, systolic murmur, propagated up the sternum principally, but in every direction for a short distance ; this murmur was quite different in character from that heard either in the aortic or mitral areas. The patient's breathing varied in rate between 40 and 50 respirations per minute. It was characterised by considerable depth, as well as frequency. Examination of the chest failed to reveal the slightest departure from conditions of health, there being no evidence of hydro- thorax or of hypersemia of the lungs, and it seemed probable that the 28 434 DISEASES OF THE ENDOCARDIUM. dyspnoea was partly produced by eretliisni, and partly the result of cardiac debility. No other system presented almormal symptoms, and it may be noted in passing that the patient had been sleeping -well at nights. In this case there could be no doubt that the mitral cusps had undergone some damage on account of suljacute endocarditis. The change, however, could not be great, and probably consisted of the presence of a few small vegetations, since there was not the least evidence of aortic incompetence. The mitral and tricuspid valves were obviously incompetent, but the incom- petence was probably produced by weakness of the cardiac muscle and not by any organic lesion of the cusps. The worst point about the case was the extreme acceleration of the pulsation and respiration. Tachycardia, as has already been mentioned, is always a symptom of grave prognostic import. In this case, however, both the tachycardia and dyspnoea appeared to Dr. Yeitch and myself to be produced more by erethism than by any other cause, and we felt ourselves, therefore, justified in giving a satisfactory prognosis, which was warranted by the result. Case 16. Subacute Endocarditis. — A. M., aged 20, laimdress, was admitted to the Koyal Infirmary, 10th July 1893, comjilaining of pains in her joints. It w'as impossiljle to ascertain whether there were any special family tendencies, since the only facts that could be elicited were, that the patient's father died at the age of 74, after a long ilhiess, and that her mother died, somewhere about the age of 40, quite suddenly. All her brothers and sisters, two and three respectively, were perfectly well. Her social conditions had been satisfactory, but her occupation exposed her to consideral )le vicissitudes of temperature. The patient had pre- ■\-iously suffered three times from subacute rheumatism, and had passed through an attack of pneumonia five or six years before admission. She had, further, had the usual infectious diseases of childhood. The attack for which the patient came imder treatment began three weeks liefore admission, with j^ains in the joints. The temperature was 102° on the evening of her entrance into hospital, and for a few days it ranged between 100° and 102°, while the jmlse oscillated between 80 and 100. The patient was somewhat pale, and the surface was Ijedewed with copious perspiration. The tongue was coated with a heavy white fur. There were, how- ever, no other alimentary symptoms. The radial arteries were healthy ; the pulse rather empty, and of moderate tension. It varied in frequency, END O CARDITIS. 4 3 5 as above mentioned, bnt was always perfectly regulai' and e(Hial. On inspection of tlie j)reecordia, no aljnornial symptoms could be detected. The aj)ex beat was situated in tlie fifth intercostal space, 4i in. fronx mid- sternum. It was unattended by any thrill, and no vilaration could l;e perceived over any part of the prtecordia. The cardiac dulness extended Wly in. to the right, and 5 in. to the left of the middle line at the level of the fourth costal cartilages. On auscultation, a systolic murmur was heard over almost the whole prajcordia. On careful investigation, it was found to resolve itself into several constituents, which, ho■\^'ever, blended into each other. There were four points of maximum intensity, one at the apex beat, another at the junction of the fifth costal cartilage with the left edge of the sternum ; another at the summit of the manuljrium sterni, immediately to the left of the mesial plane ; and the fourth occupied the second left intercostal space, 1^ in. froipi mid -sternum. The systolic murmur heard over the manubrium was conducted up the carotid arteries. In this case, it was clear that there was some dilatation along with hypertrophy of the heart, associated with some disturbance of the mechanism of the aortic cusps. CHAPTEE IX. CHKOXIC AFFECTIONS OF THE OEIFICES AND VALVES. By valvular disease is generally understood the entire series of affections of the orifices and valves of the heart. In many of these diseases the valves are only secondarily affected. Very many instances of incompetence, for instance, owe their origin entirely to dilatation of orifices, or, as in the case of the aurieulo- ventricular valves, to disturbances of the papillary muscles or tendinous cords ; but, inasmuch as inadequacy of the valves is the determining factor in allowing regurgitation, such cases may well be, and usually are, regarded as falling under the group of valvular diseases. Our knowledge of valvular disease is the result of a gradual growth of information. During the earlier periods of modern medicine, most of tlie ol)servations connected with valvular disease were concerned almost entirely with morbid anatomy, while during later times pathological investigation and clinical observation have gone hand in hand. Even during the former, there were, nevertheless, some interesting observations. Riverius and Willis in the end of the seventeenth century, and Vieussens, Meckel, and Morgagni during the first half of last century, gave some excellent descriptions of structural changes, along with some clinical details ; these are, however, in consequence of their date, necessarily inadecjuate. In the end of last century, John Hunter, in that monumental work on the Blood to which we owe so much, gave some striking facts in regard to a case of aortic disease. In the early years of the present century diseases of the FREQUENCY. a 37 valves were for the first time adequately treated Ijy Corvisart, Burns, and Kreisig. From the standpoint both of morbid anatomy and of clinical teaching, these works arouse admira- tion. Corvisart's work is remarkable for the excellent account of the morbid appearances in valvular diseases, as well as from his application of the method of physical exploration which he did so much to popularise. Burns not only extended the pathological knowledge of these affections, but, with regard to symptoms, he almost anticipated later discoveries, inasmuch as he describes a hissing sound observed by Brown in valvular disease. It may be said that, if Hooke can be regarded as in some sort a prophet when he looked forward to the possibility of recognising the sounds generated within the human body, so Burns may be held to have vaguely fore- shadowed the observations of Laennec. The work of Kreisig, most suggestive as it is in regard to the whole realm of cardiac disease, is perhaps of greatest import in regard to the causation of endocardial disease. With the appearance in 1819 of the immortal work of Laennec, the new era in the study of diseases of the chest began. Laennec's work, although imperfect and even errone- ous in many parts, laid the foundation of all subsequent knowledge, and was followed by the works of Bertin, Hope, and Bouillaud, all of which still further extended the knowledge of valvular disease. These writers have been succeeded by later observers, who will be referred to from time to time in subsequent pages in connection with the special observations for which we owe them our gratitude. Frequency. — The relative proportion of cases of chronic disease of the orifices and valves to disease in general, as well as the ratio of different forms of disease of the orifices and valves to each other, necessarily varies considerably in different statistics. Lockhart Gillespie has carefully collected and analysed the statistics of the Eoyal Infirmary of Edinburgh during the last five years, and the results that follow furnish useful information. During the five years, among 2368 cases of cardiac disease there were 1914 admissions with valvular lesions, of which the followiuCT classification has been made :-^ 43« CHRONIC AFFECTIONS— ORIFICES d- VALVES. XuMBEi! OF Admissions fok Valvulak Disease. Lesions. Aortic Valvp. :Mitral Valvp. Two or more Valvi's. Tricuspid and Pulmonary. Total. Males . . . Females . . 354 or 28-5 per cent. 57 or 8*4 per cent. 597 or 48-1 per cent. 523 or 77-7 per cent. 278 or 22-4 per cent. 90 or 13-3 ]ier cent. 12 or 0-96 per cent. 3 or 0'5 per cent. 1241 673 Total . . 411 or 21 -47 per cent. 1120 or 58-5 per cent. 368 or 19-2 per cent. 15 or 0-78 per cent. 1914 A glance at the figures will show at once striking differ- ences in the distribution of the male and female cases. In the males, those with mitral lesions only are slightly more than double in number those with lesions of the aortic and mitral valves together, or with these lesions in addition to affections of the tricuspid or pulmonary orifices ; while they are rather less than twice as numerous as those with aortic affections only. The females with purely mitral lesions number 7 7' 7 per cent, of their total, or nearly ten times the number with aortic disease, and six times the number with double lesions. Taking both sexes together, the cases with purely mitral lesions are more than half the total ; those with aortic disease are only slightly more numerous than the cases in which the two or more valves were affected ; and tlie cases of tricuspid or pulmonary valvular disease alone only represent 0"78 per cent, of the total. The following tables give the analysis of the admissions for valvular diseases, in whicli, for the sake of economising space, symbols represent the valvular lesions present. These symbols have proved most useful in the ordinary routine work of the Medical Eegistrar. Incompetence is expressed by a " minus sign," obstruction by a " plus," and a double lesion by a " plus-minus " ; the initial letter of the name of the valve is used to designate it ; thus A — represents aortic incompetence, M± mitral obstruction and incompetence, or AdrM — , a ca.se with double aortic lesions along with mitral incompetence. FREQUENCY. 439 Admissions for Valvular Diseases. Age. AOETIC LESIONS. Males. Females. Totals.": A- 6 15 26 31 44 5 6 6 6 12 A± Total. A- A-F A± Total. A- A-f A± Total. 1-9 . 10-19 . 20-29 . 30-39 . 40-49 . 50-69 . 69+ . 7 22 34 58 70 6 13 43 66 95 126 11 1 8 2 3 3 1 1 5 2 11 5 10 5 2 15 14 13 13 6 16 34 33 47 5 9 7 7 17 9 33 39 68 75 6 15 58 80 108 1-39 11 Total . 127 30 197 354 14 10 33 57 141 40 230 411 Age. MITEAL LESIONS. Males. Females. Totals. M- M-f M± Total. M- M-f M± Total. M- M-f M± Total. 1-9 . 10-19 . 20-29 . 30-39 . 40-49 . 50-69 . 69 -f . 8 37 43 51 46 146 11 3 17 27 32 18 36 6 24 22 23 17 . 28 2 17 78 92 106 81 210 13 6 42 55 39 35 62 4 2 44 65 31 16 13 2 28 30 26 12 11 10 114 150 96 63 86 4 14 79 98 90 81 208 15 5 61 92 63 34 49 8 52 52 49 29 39 2 27 192 242 202 144 296 17 Total . 342 133 122 597 243 171 109 523 585 304 231 1120 440 CHROXIC AFFECTIONS— ORIFICES c- VAI VES. Percentage of Numbek at Age to Totals. Age. AORTIC LESIONS. Males. Females. Totals. A- A+ A± Total. A- A-f A± Total. A- A-f A± Total. 1-9 . . 10-19. . 47 3-5 3-6 6 3-5 4-2 3-9 3-6 20-29 . . 11-8 20 11-1 12-1 7-1 30 33-3 26-3 11-3 22-5 14-5 14-1 30-39 . . 20-4 20 17-2 18-6 57-1 10 15-1 24-5 24-1 17-5 16-9 19-4 40-49 . . 24-4 20 29-4 26-8 14-2 10 30-2 22-8 23-4 17-5 29-5 23-8 50-69 . . 34-6 40 35-0 35-5 21-4 50 15-r 22-8 33-3 42-5 32-6 33-5 69-f . . 3-9 3-0 3-1 3-5 2-6 2-6 Per ceiit.'\ of totals 1^ to total 35-8 8-4 55-6 - 24-5 17-5 57-89 - .34-3 9-7 55-9 - for valve j Age. MITRAL LESIONS. Males. Females. Totals. M- M-i- M± Total. M- M-1- M± Total. M- M+' M± 3-4 Total. 1-9 . . 2-3 2-2 4-9 2-8 2-4 1-1 1-8 1-9 2-3 1-6 2-4 10-19 . . 10-8 12-7 19-6 13-0 17-2 25-7 25-6 21-7 13-6 20-0 22-5 17-1 20-29 . . 12-5 19-8 18-0 15-4 22-6 38-0 27-5 28-6 16-1 30-2 22-5 21-6 30-39 . . 14-9 24-0 18-8 17-7 16-0 18-1 23-8 18-3 15-3 20-9 21-2 18-0 40-49 . . 13-4 13-2 13-9 13-5 14-4 8-8 11-0 12-0 13-8 11-1 12-5 12-8 50-69 . . 42-6 26-4 22-9 35-5 25-5 7-6 10-0 16-4 37-2 16-1 16-9 26-4 69+ . . 3-2 1-6 2-0 1-6 0-7 2-5 0-8 1-5 Per cent. ^ of totals 1 to total!" for valve; 57-2 22-2 20-4 - 46-4 32-7 20-8 - 52-2 27-1 20-6 - FREQUENCY. 441 : 10 (M i-i oti iM >0 CO F-H CO T-^ 1-H I-H O-l 'SH 10 1^ C^ 10 10 CX> T-H CO 1^ CO to 1^ l-H CO 00 Oi t-H • t^ O CO I l^ ■* 5D OJ CO CO in ■ (N *"' |§S:-;?# -^;; " • -y .y ...'/ '^;- "1 Fig. 136. — Hicmorrhage into the tricuspid valve of a sheep, x 40. The section sho\v.s prolifera- tion of the endothelial cells, and exudation of leucocytes into the clot, with commencing organisation. commonly found in connection with the mitral valve than in the case of any other. Hcemorrhagic Processes. — As in some degree connected with vascular processes, a word may be said on valvular haemor- rhages, such as have been described by myself and Garel. The only instance which has come under my notice was a small purple mass, about the size of a pea, upon the auricular surface of one of the right auriculo-ventricular cusps of a sheep. The endocardium covering it was perfectly healthy. The microscopic appearances, which are shown in the accom- MORBID ANATOMY. 451 panying illustration (Fig. 13 G), are tliose of a blood-clot under- going organisation. Garel's observation concerned the tricuspid valve of a man, on which was a mushroom-like mass, consist- ing of a large extravasation associated with some vegetations. Degenerative Lesions. — The results of degenerative pro- cesses so frequently constitute the lesions in chronic valvular disease that it is impossible to agree with the dictum of LetuUe : — " Dans le language courant, affection valvulaire est synonyme d'endocardite valvulaire chronique." The most common form of this kind of change is sclerotic thickenino- of the membrane. Patches of thickening, often with some elevations upon the surface, are to be seen. They consist of masses of firm tissue, often indistinctly organised or even almost homogeneous, and are to be regarded as analogous to the lesions of arterio-sclerosis. It is possible that they are produced by reaction processes, to compensate for loss of normal structural characters. The sclerotic patches are often associated with fatty or calcareous changes, and are then commonly termed atheroma. Fatty changes are not infrequent, more particularly in cases of fatal ana?mia and some forms of marasmus. Such alterations are more common on the endocardium of the left side, and more especially of the mitral cusps. They form larger or smaller patches upon the opposed surfaces of the cusps, and give rise to valvular disturbances. Other degener- ative processes are occasionally found, but are relatively so uncommon as to merit no attention in this connection. Neoplasms. — New formations are rare sources of obstruc- tion. Endocardial tumours, as will be afterwards mentioned, are not by any means uncommon, but those which interfere with the valvular apparatus are certainly rare. Sometimes such tumours have their origin in the walls of the heart, as in the well-known case recorded by Gairdner, in which tricuspid obstruction was diagnosed ten years before the death of the patient, or they may arise from the valves themselves. Garel has collected the observations which have been made upon this subject in the paper already referred to. Traumatic Lesions. — The changes produced by injury have been already fully mentioned as regards the relative propor- 45- CHRONIC AFFECTIONS— ORIFICES d- VALVES. tiou lit' ilin'en'iit lesions. The characters of tlie lesions found after death depend upon the situation of the injury — whether it affects a cusp or a tendinous cord — and upon tlie length of time which has elapsed since the violence. In most instances the primary lesion has been followed Ijy the development of vegetations, and the result has lieen the production of obstruc- tion and incompetence. Incompetence may be directly produced by affections of the cusps themselves such as have just been described. As the result of both acute and chronic processes there may be a loss of substance from ulcerative processes, or the cusps may become shrivelled and shrunken, or they may be bound by adhesions in such a way that they fail to close the apertures correctly. Disturbances of the functions of the valves can be pro- duced by causes other than those directly affecting the cusps. The orifices may be widened so that the cusps will not meet, or, as happens in the case of the auriculo-ventricular valves, the papillary muscles and the tendinous cords may be in fault, or the ventricles may be so dilated as to produce a want of correspondence in the relation of the cavities and the valvular arrangements. Stretching of the orifices may have its origin in simple strain from stress — the so-called overstrain of the heart — or in loss of elasticity resulting from weakness, or in acute or chronic structural alterations of the myocardium. Atrophic and degenerative processes affecting the papillary muscles diminish their different performances of function, while the tendinous cords may stretch or shrink in consec[uence of disease. Dilatation of the cavity of the heart may produce a want of proper adjustment of the valvular mechanism, and, as a result, regurgitation is allowed at the auriculo-ventricular orifices. All these are examples of what is often termed functional or relative incompetence of the valves, in which the cusps themselves may be perfectly healthy. All of them, as will be seen in a subsequent part of this work, are more common on the right side of the heart than on the left, and they are practically unknown in connection with the aortic orifice. Effects. — Many secondary results follow affections of the EFFECTS. 453 orifices and valves, some of which are more or less directly connected with tlie heart itself, while others are remote con- sequences produced by disturbances of the circulation. In that part of this work dealing with the general effects of diseased processes upon the circulation, the chief considerations have been fully dealt with, and some of the effects will be again discussed in those chapters which are devoted to the special lesions of the valves. It is, therefore, unnecessary in this place to do more than refer briefly to some points which require slight amplification. The chronic processes affecting the orifices and valves have by no means the same tendencies to spread Ijy extension as is the case in regard to the acute and subacute forms of endocarditis, and the effects which are produced upon the heart itself are brought about by more indirect processes. There are, nevertheless, some direct effects upon the heart, as for instance the morbid changes set up by friction which were pointed out by Hodgkin. In the case of large indurated masses floating with a certain degree of freedom in the l;)lood current, it is no uncommon thing to find that, at the points of impact, where they come in contact with the interior of the heart or great vessels, there are thickenings and roughenings of the surface. It may be held as a general principle that there are some characteristic differences between the effects of obstruction and incompetence. Such is the case in principle, but, as has been shown previously, the results of Hamilton's careful investiga- tions show some effects which would not altogether be expected. Beyond the obstructive orifice there must be less blood supply, and in consequence there will be diminished blood pressure, and a tendency to lowering of the general nutritive processes. Behind the obstructed orifice there is a consider- able amount of hypertrophy, without any great degree of dilatation. Beyond valves which are incompetent there is not neces- sarily any reduction in the amount of blood sent out into the general circulation, but in consequence of regurgitation there is a diminution of the mean blood pressure, which more particularly affects the peripheral circulation. Behind the 4 54 CHROXIC AFFECTIOXS— ORIFICES d- VALVES. incompetent valves there is dilatation with liypertrophy. The dilatation is much greater tlian behind pure obstruction. .Certain structural alterations of the cardiac walls, chiefly chronic myocarditis and myocardial degeneration, are apt to ensue in consequence of long-continued disturbance of the valvular mechanism. The full discussion of dilatation and hypertrophy must be reserved until the affections of the myo- cardium are taken up, and the same may be said in regard to the degenerations of cardiac failure. Diseases of the orifices and valves of the left side of the heart lead to disturbances of the pulmonary circulation, with dilatation of the veins and capillaries of the lung, resulting in venous hypertemia and oedema, which are in turn followed by dilatation of the pulmonary artery and its branches, frequently leading to atheromatous changes in their walls. Affections of the orifices and valves of the right side of the heart give rise to dilatation of the venre cavae and their tributaries, leading to engorgement of the neck, legs, and internal viscera, as shown by cyanotic changes in the solid organs, and catarrh of the mucous membranes. In consec[uence of the reduction of the rapidity of the circulation, the blood is apt to coagulate both in the chambers of the heart, and in the great venous channels, so that clots are produced, which may be coloured, or colourless, according to the date of coagulation. Embolic processes may arise not only as regards coagida formed within the heart, but also in respect of vegetations affecting the valves. Hremorrhage may result from any of the engorged blood vessels, but it is much more frequently found in the lungs than in any other situation. Symptoms. — It may be stated as a broad general principle that, with the exception of the physical signs caused by diseases of the valves and orifices, these lesions do not of themselves directly produce characteristic symptoms ; it is only when their secondary effects are produced that they give rise to any characteristic clinical features. These effects have already been fully analysed, and require but little considera- tion in tliis place. Their association with the special valvular lesions will be discussed in subsequent chapters. DIA GNOSIS— PR O GNOSIS. 4 5 5 Diagnosis. — The differentiation of the various valvular lesions, whether single or coml^ined, must be considered when treating of the different diseases. Prognosis. — The outlook in chronic valvular disease can only be correctly estimated after a thorough consideration of every factor which has influence upon the present, and may affect the future condition. In making inquiry into the conditions and relations of any given case of valvular disease every influence must be carefully investigated. The family history of the patient is of real influence, since from the family tendencies a prophetic light may be cast upon the prospects of the patient. A family proclivity to long life or to early death is of much service in forming an estimate of the outlook, and more particularly so when parents or ancestors have been victims of valvular disease. Age is a factor of great importance, since valvular diseases, which in themselves during the active period of life may not be serious, assume a much graver aspect at the extremes of life ; more especially is this to be considered in dealing with valvular disease in childhood. It is no uncommon experience to meet with instances of mitral obstruction durins; childhood, and the fact cannot be gainsaid that in a very considerable proportion of such patients a fatal termination occurs during the readjustment of all the bodily functions at the time of puberty or adolescence. The occupation, habits, and surroundings of patients suffer- ing from valvular disease are points which must be taken into consideration. It need only be said in this place that if these are satisfactory the prognosis will be by so much the better, and the converse also holds good. The medical history of the past will in every case furnish indications of utility. This not only gives information as to the power of resisting the disease evinced by the individual — a consideration of much importance — but the presence or absence of certain conditions must be ascertained. The abuse of alcohol, a tendency to the uric acid diathesis, the presence of any renal affection or of specific affection — these and many other analogous considerations must be taken into account. 4 56 CHRONIC AFFECTIOXS— ORIFICES <,^ VALVES. The nature of the lesion, its mode of origin, tlie lengtli of its duration, and its effects upon the heart itself and the system at large, are most important matters directly connected \\\\\\ valvular disease. Great differences exist in the gravity of different lesions. Aortic obstruction, for instance, is much less serious than mitral obstruction, while aortic incompetence is very much graver than mitral incompetence. The extent of the lesion is one of the most difficult matters to determine. "Whether a serious obstruction or a free regurgitation is present is, as will be seen in the sequel, difficult indeed to determine. The evidences furnished by physical examination of the heart itself do not, as a general rule, throw any light upon this subject, and the nearest approach to exact information is to Ije derived from a study of the effects of the lesion upon the heart and circulation. Eeferring to the Edinburgh statistics of Lockhart Gillespie, it will be seen that the incidence of mortality with regard to age differs markedly from the incidence of admissions. In the tables for all the cases with aortic lesions, no deaths are shown until after the age of 19. The rates for each period until 6 9 is passed are very similar ; the male results, however, exhibit a marked rise between the years of 20 and 29 ; and the females show a great excess over the males from the age of 39 to 69. The maximum mortality among males falls between 20 and 29, among females between 40 and 49. The maxi- mum mortality in both sexes taken together, from aortic incompetence, occurs between 50 and 69 ; from aortic obstruc- tion, between 40 and 49, as also in double aortic lesions. The greatest proportion of males with aortic incompetence or obstruction occurs between 50 and 69, but in those with double lesions the years from 20 to 29 are the most fatal. The female maximum in aortic incompetence and aortic obstruction falls between the years 49 and 50, and in the first is much higher than in the males; the 100 percent, at that age in aortic obstruction is only fortuitous, the one female case admitted at that age having died. In double aortic lesions no deaths among females are recorded, except between the ao;es of 40 find 69. PROGNOSIS. 457 The figures representing the mortality i'rom all mitral lesions in both sexes rise progressively with the age, the female rate always a little over that of the males, until after the age of 69, when three deaths out of four female admissions raise it to 75 per cent. The rates in mitral incompetence are very similar to those for all mitral cases, except for a more pronounced mortality between 30 and 39. Mitral obstruction proves most fatal from 30 to 39 in the males, and from 40 to 49 in the females. The female rate between 20 and 29, 40 and 49, and 50 to 69 is higher than in males. In cases of double mitral lesions both males and females show a death-rate between the years 10 to 19 above that for the next decade. The male maximum falls between 30 and 49, the female between 50 and 69. The highest rate for the two sexes occurs between 50 and 69. Aortic incompetence with mitral lesions proved most fatal between 1 and 9 years, Avhere one case out of two admissions died. The decade between 30 and 39 shows the high rate of 44'4 per cent., due to a rate of 50 per cent, in the males, and 3 3 "3 per cent, in the females. In the females, however, the rate is higher between 40 and 49 — 40 per cent. Where aortic obstruction is associated with mitral lesions, few deaths fall to be recorded, and all of these between the years 20 and 49. The highest rate here is 33*3 per cent, in males between 30 and 39. The death-rates in cases of double aortic with mitral lesions are highest — 30 '9 per cent. — between 40 and 49 ; lowest — 9 "6 per cent. — between 10 and 19 ; while no deaths are recorded between 1 and 9 of the three cases admitted, or in the case of the one admission over 69 years of age. Five of the six cases reported as suffering from lesions of more than these two valves proved fatal, or 8 3 '3 per cent.; while of the fourteen admissions in which symptoms of tri- cuspid incompetence were found, three died- — all of them males — giving a death-rate of 21*4 per cent, of the total, or 27"2 per cent, of the males. In order to ascertain what amount of correspondence obtains between the current conceptions regarding the gravity of different lesions and the facts observed in the Eoyal Infirmary, the tables of Lockhart Gillespie may be laid 458 CIIROXIC AFFECTIONS— ORIFICES d- VAIVES. under coiilrilmtiDii. 'I'lie luUuwing table gives the imn'tality of diftereut valvular lesions: — Number of Deaths and Mortality among the Cases OK A'alvulaii Disease. Lesions. Aortie Valvo. 52 or U-6 per cent. 10 or 17 '5 per ceuc. Jlitral ViilvH. Two or more Valves. Tricuspid and Xot.il. Puhnouary. | Males . . . Females . . 72 or 12 jier cent. m or 13-2 per cent. 67 or 24-1 per cent. 20 or 22-2 per cent. ! 3 or 25 per i 104 cent. 1 Total . . 62 or 15-0 per cent. 141 or 12-5 l)er cent. 87 or 23-6 per cent. 3 or 20 per | 293 cent. The highest mortality occurs among the cases with Ijoth aortic and mitral disease, and is rather higher among the males. The aortic cases present a higher rate than the mitral, while here the disparity between the rates among the males and the females is greatest, being in fact in the females 2-0 per cent, over the figure for the deaths among males, or 20 i^er cent, of an excess compared with the male rate. The fatal cases in relation to age and lesion are embodied in the following table : — [Table. PROGNOSIS. 459 Deaths from Valvular Diseases. MALES. Ages. 1 + < -t] < < 1 + 41 1^ a ^ 1 1 <( 1 + 1 1 + + + 1 + 41 1 -H -X! 1 = [5 1 1-9 ' 10-19 . 1 2 3 1 2 1 1 ! 1 6 1 20-29 . 3 5 8 4 2 6 2 1 4 4 11 1 . 30-39 . 3 6 9 7 5 5 17 6 3 1 2 1 2 14 40-49 . 4 10 14 5 2 4 11 3 1 S 1 1 2 15 1 1 50-69 . 10 2 8 20 25 2 5 32 4 10 1 1 16 1 2 +69 . 1 1 3 3 Total . 21 2 •29 52 45 11 16 73 17 5 1 2 25 3 10 63 4 3 FEMALES. Ages. 1 + < < 1 + + S ^ 1 1 < + 1 < 1 < + + -H + 1 -H <1 + -H + 'it 1-9 10-19 . 4 3 7 20-29 . 4 7 2 13 1 1 1 2 5 30-39 . 3 3 9 3 3 15 3 1 3 6 7 40-49 . 1 1 2 4 4 4 2 10 1 1 1 1 1 5 50-69 ' . 1 1 1 3 16 1 4 21 1 1 1 +69 . 3 .. 3 1 .. 1 1 Total . 5 2 3 10 40 15 14 G9 2 4 1 1 1 4 2 4 1 J9 TOTALS. Ages. 1 + < < 1 + -« S S ^ 1 1 1 + 1 <1 1 <1 1 + 1 + <1 + <1 1 < + <1 VALVES digitalinum veium is by no means so active as the tincture or infusion, and in spite of the most careful aseptic precautions it has very often set up severe subcutaneous disturbances. In" the case of strophanthus the tincture is the only preparation in common use, but in many instances the employment of strophanthin hypodermically may be resorted to with advantage. When the cardiac failure of valvular disease is associated with much catarrh of the digestive mucous membranes, the employment of alkalies along with cardiac tonics is ad- vantageous ; but in such circumstances the addition of mercury is also of the greatest use. Small doses of blue pill, gray powder, or calomel may be used for this purpose, and it need hardly be said that when such conditions are present without much oedema, the food should largely consist of milk and other fluid substances. In those cases in which there is considerable enlargement of the liver, along with jaundice, more particularly if a tendency to ascites should make itself manifest, the combination of cardiac tonics and mercurial substances is most useful, and the old-fashioned combination of blue pill, digitalis, and squill is admirable. If the blood is obviously impoverished either in respect of the haimocytes or haemoglobin, the addition of iron or of arsenic to the other remedies employed is strongly to be recommended. It is to be remembered, however, that such symptoms are frequently the result of diminished removal of fluid from the system, and that anhydropic methods of treat- ment may in themselves bring about an approximation to the normal standard. It is scarcely possible to treat dyspncea and cyanosis apart from each other. Both may have their origin in simple deficiency of driving power on the part of the heart, from lowered nutrition of the blood, or from some mechanical interference with the aerating surface of the lungs. When these appearances are produced entirely by venous stasis, the usual cardiac remedies will suffice to cause their disappearance, and for both, the use of the special cardiac remedies, along with stimulants both alcoholic and ammoniacal, as well as attention to the general principles of treatment, will obviate TREATMENT. 469 the troubles incidental to them. When alterations in the composition of the blood through deficiency of hoemogloljin produce these symptoms, their effects may be lessened by due attention to nutrition and the use of hsematinics. In all serious cases marked by those symptoms the hypodermic injection of strychnine and the inhalation of oxygen are of the highest value. When cyanosis is extreme, general bloodletting is certainly necessary, and is often successful in averting disaster. In cases which are desperate the operation of cardi- centesis may even be resorted to. One most interesting and successful case has been narrated by Sloan, who has in connec- tion with it given a very useful summary of the literature of the subject. Through his kindness an opportunity was recently afforded me of examining the patient, who is now in excellent health. When breathlessness and cyanosis owe their presence to oedematous conditions, the special means for their removal must be such as will be mentioned immediately. All cases presenting features of oedema show by the presence of this symptom that the hydrostatic conditions are gravely disturbed. For their treatment it is advisable to place the patient in such a posture as to favour the return of blood from the extremities, and to pay due attention to ventila- tion, while gentle massage is of great utility in assisting the course of the blood. The use of dry diet in such circumstances cannot be overestimated, while the eliminating channels require to be carefully studied. Little doubt is left in my own mind that amongst the cardiac tonics of most use in such conditions the infusion of digitalis is of paramount importance, and it may be that this is due to the fact that it mainly contains digitonin. By combining this preparation with an alkali, more especially with the acetate or citrate of potash, most excellent results may be attained ; while other remedies, to be mentioned immediately, which act upon the renal epithelium, may also be employed. At the same time the functions of the skin should be favoured by warmth and such simple diaphoretics as ammonium acetate. The use of saline aperients, more par- ticularly in the concentrated form advocated by Hay, should also find a place in this connection. Of such remedies, 470 CHRONIC AFFECTIONS— ORIFICES c^ VALVES. sulphate of soda, or the double tartrate of potash and soda, will be found most serviceable. "When, in spite of remedies acting on the heart, the intestines, the kidneys, and the skin, an cedematous condition persists, or even becomes worse, the transudations, whether subcutaneous or serous, may require removal by mechanical means. For the former Southey's tubes, and for the latter Dieulafoy's aspirator, are most useful. The renal secretion requires most careful watching, not merely in regard to its quantity, but with reference also to its contents. The quantity is a useful index as to the action of the cardiac tonics. Under the influence of digitalis or stro- phanthus a diminished secretion usually increases by leaps and bounds, until a certain point has been reached, whence it diminishes again to something like the normal. So long as this is retained the action of such drugs is entirely beneficial ; but if the quantity sh9uld fall much below this level, it is, as a rule, evidence that the drugs have been employed with sufficient freedom. The amount of urea is helpful as an index of the tissue changes, while the presence of albumin is proof that by stasis the epithelium of the kidney has been damaged. It is sometimes impossible by means of the cardiac tonics to increase the excretion, and under such circumstances the employment of caffeine may supply the want. My experience has shown that this drug is in every way superior to the combinations of theobromine, commonly sold under attractive names, and there seems little doubt that the inference of Brakeuridge as to its direct action upon the renal epithelium is correct. When sleep is disturbed, as it often is in valvular diseases, it may be possible by simple remedies to secure it. The use of some warm mixture containing alcohol at the hour of repose may sometimes be sufficient, or one of the modern hypnotics, such as paraldehyde, sulphonal, or trional, may bring about the desired result. In many cases, however, no drug save morphine is adequate, and there should be no hesitation about the employment of this remedy, seeing that it has actual stimulant effects upon the circulation. Such are the general principles which require attention TREATMENT. 47 1 m the treatment of valvular diseases with failure of compen- sation. In the most serious cases every means may be necessary. The exhibition of general stimulants, such as alcohol and ammonia, of cardiac tonics, as digitalis or strophanthus, and of nervous excitants, as strychnine, may be imperative ; at the same time inhalations of oxygen may be absolutely necessary, massage may be needful in order to effect such results as can only Ije attained by passive exercise, the excretory channels ma}^ require to be acted upon, and hypnotics may be unavoidable. At the same time the diet and the surroundings of the patient must be matters of most careful arrangement. In cases of less serious import, as well as in those which have to a considerable extent recovered from more grave conditions, the measures applicable to myocardial weakness will be employed. Chief amongst these are careful attention to air, exercise, diet, and surroundings. For such cases the employment of baths and resistance exercises is most useful, and will in most cases lead on to the more active exertion advocated long ago by Stokes, and more recently by Oertel. CHAPTER X. AFFECTIONS OF THE AOETIC OEIFICE. In the overwhelming proportion of cases of aortic disease a double lesion is present, giving rise both to obstruction and incompetence. The reason for this is obvious. Most lesions which produce obstruction of the orifice involve in greater or less degree the cusps, and, by causing contraction or loss of tissue, they interfere with their closure. Aortic obstruc- tion without incompetence is very much more common than incompetence without obstruction, and a moment's con- sideration is quite sufficient to explain this well-known fact. A certain degree of obstruction may be produced by lesions of the cusps or orifices which do not in any way interfere with the mechanism of the valves ; while on the other hand almost every lesion which gives rise to incompetence interferes, more or less, with the exit of blood, and therefore induces obstruc- tion. Incompetence of the valves must be very rarely, if ever, produced by widening of the orifice itself, because from the nature of its construction a stretching of the ring sur- rounding the origin of the aorta is extremely uncommon. Statistics bearing upon the relative proportion of cases of pure obstruction and of pure incompetence are highly mis- leading, inasmuch as in many cases where, as usual, a double lesion has existed, the diagnosis recorded has been that of the affection which appeared to be the more pronounced. It is, nevertheless, of interest to consider the results brought out by Gillespie's analysis of the Eoyal Infirmary cases during the last five years. The figures are as follows : — Aortic obstruc- A OR TIC OBSTR UCTION. 473 tiou, 40 ; incompetence, 141 ; obstruction and incompetence, 230. These results do not accord with my own experience. AOKTIC OBSTKUCTION. This disease was observed by Eiverius in the year 1646, and was again described by Vieussens shortly afterwards. It was well known to those old pathologists whose observations on chronic valvular disease have been already mentioned. Its recognition during life is of much more recent date. The remarks of Laennec in regard to this affection are by no means definite, and the first clear light thrown upon it is to be found in a very valuable, but unfortunately little known, paper by Hodgkin. Corrigan in a celebrated article, which will be more fully referred to in connection with aortic regurgitation, con- siders the facts of obstruction. The first edition of Hope's treatise contains rules for its recognition, which are clearly and succinctly laid down ; and from that date the great features of the disease have been well known. Modern additions to our information will be referred to in connection with the descrip- tion of the special aspect of the disease with which they are associated. Aortic obstruction may be absolute or relative ; i.e., the orifice may be constricted so as to have less than its normal calibre, or, while the orifice remains of the same diameter as in health, it may, in consequence of the dilatation of the aorta beyond, produce physical signs somewhat similar to those which have their origin in a narrowing of the orifices. This latter condition, however, really belongs to the affections of the aorta itself, and it will be considered in the chapter dealing with its diseases. This section will, therefore, be devoted to obstruction of the aortic orifice from interference with its lumen. Etiology. — While aortic obstruction may occm" at any age, and in both sexes, it is more frequently found in middle life and advancing years, and it is more common in men than in women. It is a disease, further, which is often seen amongst those who are engaged in hard physical exertion, and many occupa- 474 AFFECTIONS OF THE AORTIC ORIFICE. tions, ill which loiig-coiitiiiued severe muscular efforts are demanded, are especially likely to produce it. Endocarditis — acute, subacute, and chronic — accounts for Fig. 137. — Aortic obstruction of vegetative type witli iiicomijetence. a considerable proportion of cases, but it is especially the chronic form of endocarditis which is most prone to lead to aortic obstruction. Even more important than endocarditis as a cause of aortic obstruction is sclerosis. Nothing need be said here as A OR TIC OBSTR UCTION. 475 to the factors leading to the sclerosis ; they have been fully discussed already. Morbid Anatomy. — The situation of the obstruction may be at the border, or on any part of the arterial aspect of the cusps ; at the line of their attachment to the aorta ; or at the real origin of the arterial channel, more particularly at that part of the interventricular septum where the aortic cusp of the mitral valve is attached. Vegetations existing at this spot may, as was shown by Che vers, produce the physical Fig. 13S. — Funnel-shaped obstruction of aortic orifice with incompetence. signs of aortic obstruction, although the cusps themselves are perfectly free from disease. The nature of the lesion is extremely variable. In these cases which are caused by endocarditis the obstruction may be due to vegetations, as is well shown in Fig. 137. These vegetations differ extremely in size from insignificant granu- lations to large cauliflower -like masses. They sometimes undergo degenerative changes, or become the seat of calcareous deposition. On the other hand, the valves may be simply thickened along their margins, but this is usually accompanied by a considerable amount of retraction, with degeneration and 476 AFFECTIONS OF THE AORTIC ORIFICE. calciticiitiuu. The cusps nut ini'requently Ijecome attached to each other, and this union gives rise to the formation of a greatly diminished aperture occupying, as it were, the summit of a funnel whose apex projects into the aorta. Such a condition is clearly seen in the illustration, Fig. 138, the details of which are given in Case 22, p. 511. In those cases produced by degeneration, the obstruction is for tlie most part caused by thickening and sclerosis of the cusps, or of their line of attachment. Obstruction from injury, whether direct or indirect, is usually produced by one of the cusps floating in the blood current and thus interfering with its outward passage. The muscular wall of the heart, in cases of pure aortic obstruction, is found to be hypertrophied, without any corresponding degree of dilatation. This condition of matters may exist for a considerable time, but as a rule a certain degree of dilatation ensues. It may in turn lead to incompetence of the mitral cusps, in which case dilatation and hypertrophy of the left auricle ensue, and these in turn may be the starting-point of passive hyperaeinia of the lungs and of consecutive changes on the right side of the heart. The walls of the aorta may be perfectly healthy, but in many cases are the seat of sclerotic changes ; when this is the case, there is often dilatation, which may be uniform, but is commonly irregular, giving rise more particularly to bulgings on the concave side of the vessel. It must not be forgotten, and this will be particularly insisted on in a later portion of the work, that in the sclerotic forms of aortic disease there is apt to be some occlusion of one or both of the coronary arteries, and that when this is the case degenerative changes take place in the myocardium. Sv^rPTOMS. — In many cases, when there is ample com- pensation, aortic obstruction gives rise to no subjective symptoms, and the patient has absolutely no feeling of dis- comfort. Cardiac pain is, however, frequent, and it often presents all the characteristics of angina pectoris, with its different accompaniments. There is sometimes dyspnoea on exertion, along with palpitation. AORTIC OBSTRUCTION. 477 Aortic obstruction in itself produces but little change in the aspect of the patient, excepting a tendency to pallor, but this, as a rule, is very slight in degree. It must not be for- gotten that, as many instances of aortic disease have their origin in, or are connected with, general conditions, the complexion may present features altogether unconnected with the aortic lesion. The inspection of a patient suffering from aortic obstruc- tion reveals no symptoms connected with the peripheral circulation, unless in those cases in which it is associated with arterial sclerosis. In such instances the more superficial arteries may often be seen to stand out prominently, and to show not only the tortuosity of the vessel, but the characteristic alterations in its axis produced by the pulse wave. Such features are rarely to be observed in the neck. There is sometimes a perceptible bulging of the prrecordia, and distinct pulsations are sometimes to be seen in the third, fourth, and fifth intercostal spaces on the left side. The apex beat is displaced downwards and to the left. Palpation of the arteries, and particularly of the radial arteries, shows that different conditions of the vessel wall and of the pulse pressure may be present. When there is no considerable sclerosis of the artery, the walls are yielding but elastic; if the lesion is associated with arterial sclerosis the vessel is rigid, and has lost to a greater or lesser degree its elasticity. The blood pressure is also variable, being some- times above and sometimes below the normal. This fact is easy of explanation. Aortic obstruction in itself produces but little change upon the blood pressure, and this, therefore, depends entirely upon the resistance of the peripheral circula- tion and the energy of the heart. The pulse is usually in- frequent, regular, tardy, and sustained, but it necessarily loses some of these characters in cases manifesting the appearances of cardiac failure. They may also be modified by the super- vention of any intercurrent affection which produces changes in the circulation. Sometimes a thrill may be made out in the larger arteries in aortic obstruction, and this is found to follow the apex beat by an interval longer or shorter according 478 AFFECTIONS OF THE AORTIC ORIFICE. to the distance of the vessel tVoiii tlie heart. Tlie sphygmo- graphic tracing is often possessed of characters such as are seen in Fig. 139. ■ When the hand is placed over the pra^cordiu the apex beat is found, as a general rule, to he displaced downwards and outwards so that it may occupy the sixth intercostal space and be situated as far as four or even five inches from mid- sternum. In quality the apex beat is usually strong and sustained, and it is sometimes accompanied by a systolic thrill. On palpation of the base of the heart, there is sometimes a distinct thrill, absolutely corresponding in time with the apex beat. Sometimes this thrill is conducted, not only over the whole prrecordia, but throughout tlie entire chest ; as a Fio. 139. — Tracing liom the radial artery in a case of aortic stenosis ; ]>ressure 2i- oz. rule, however, it is confined to the manubrium of the sternum and the parts immediately adjacent. It may be present along with such a thrill at the apex as has just l:)een mentioned, the two, however, not being conducted into each other. In this case it seems probable that the thrill at the base is conducted directly from the aorta, while that at the apex is conducted through the left ventricle. On percussion the area of deep cardiac dulness is almost invariably found to be enlarged, and this enlargement is most distinct towards the left side. The right margin of the heart, in uncomplicated cases, undergoes little alteration in posi- tion, but the left margin extends somewhat further outwards, and reaches a point considerably below its usual termination in health. There is, as a rule, no alteration in the extent of the superficial cardiac dulness. The characteristic feature of aortic obstruction on auscul- AORTIC OBSTRUCTION. 479 tatioii is a systolic murmur. In time, the murmur is ab- solutely synchronous with the apex Ijeat, and although its duration varies considerably, it is usually continued well on towards the second sound. It may, therefore, l^e represented by the following diagrams (Figs. 140 and 141). The character of this murmur varies innnensely. It may be soft and blowing, or harsh and rasping; while, in some Fig. 140. — Aortic systolic murmur accompanying first sound. cases, it actually assumes a quality which may fairly be termed musical. The murmur has its point of maximum intensity above the aortic cartilage, usually about the middle, or even the upper part, of the manubrium sterni. The position of its greatest intensity is, however, extremely variable, although it may be held as a general rule to be above the level of the Fk;. 141. — Aortic systolic murmur replacing first sound. conventional aortic area. The murmur may be propagated throughout the whole chest, but, in its most characteristic mode of conduction, it is carried upwards to the summit of the sternum and outwards along the clavicles, as well as down- wards by the sternum and ribs to a less extent. It is also, however, conducted along the great arteries. It may be heard up the carotid vessels, and through them may be heard over the skull, outwards by the subclavian arteries, so as to be heard far down the arms, and it may also be conducted by the femoral vessels for a considerable distance down the lower extremities. 48o AFFECTIONS OF THE AORTIC ORIFICE. It is by no mertiis uucoiiimon for the luunuur of aortic obstructiou, like the diastolic aortic iimnnur, to have its greatest intensity to the left of the sternum ; and in such cases it is only by the assemblage of the symptoms which accompany it that any certainty can be obtained with regard to the origin of the murmur. This point will be more fully discussed in connection with murmurs generated at the pulmonary orifice. The aortic second sound presents many different variations, but it is most commonly increased in loudness. It might theoretically be expected to be diminished if the obstruction were excessive ; practically, however, this is extremely rare. The first sound in the mitral area is usually of increased intensity and lower tone ; it may be roughened in quality, while, when dilatation of the ventricle has occurred, it may be replaced by a murmur. The sounds generated on the right side of the breast are only altered when there are con- secutive or attendant changes in the right ventricle. Diagnosis. — The determination of aortic obstruction does not in most cases present any noteworthy difficulties. The condition of the pulse may vary within such wide limits as to render it of little importance as a guide in the diagnosis of this condition. There may be a total absence of any thrill over the base of the heart, and there may be so little hyper- trophy that it hardly reveals itself by any appreciable increase of the cardiac dulness ; the sounds, nevertheless, which are generated at the obstructed orifice, are in themselves sufficient in most cases for the establishment of a positive diagnosis. The systolic mm^mur carried into the vessels of the neck and arms is almost enough to furnish the basis of accurate con- clusions. The only difficulties in regard to the recognition of the lesion arise from the possibility of a confusion between it and a few other affections of the base of the heart or the great blood vessels. The diseases most likely to be mistaken for aortic obstruction, or for which it may be mistaken, are pressure upon the aorta by means of a mediastinal tumour ; aneurysmal dilatation of the ascending aorta ; obstruction of the pulmonary orifice ; and patent ductus arteriosus. AORTIC OBSTRUCTION. 481 Intrathoracic tumours causing stenosis of tlie uorta take their origin most commonly from the remains of the thymus gland, or the mediastinal connective tissue. They some- times, however, arise from some other structures, as, for example, the parietal pericardium or the periosteum of the thoracic walls. Most of these tumours consist in a small cell invasion, and may occur in the course of lymphadenoma or leucocythajmia ; they may, however, present the structural features of sarcoma or carcinoma. In other instances the invasion may be by means of tubercular or syphilitic changes. In the case of a mediastinal tumour pressing upon the aorta and causing constriction, there may be, as will be seen later, such definite pulsation from the proximity of the aorta to the anterior chest wall, that the case closely resembles an aneurysm. But in other instances, and these are precisely the cases which require such reference in this place, there may be no apparent pulsation, and yet on auscultation the systolic murmur is heard over the manubrium of the sternum, and is often carried along the great arteries. In such a case there is an area of dulness on percussion corresponding to the invasion, which in itself is sufficient to differentiate the condition from simple obstruction of the aortic orifice. •There is, in addition, no necessary alteration in the structure of the arteries throughout the body, and there is almost invariably no alteration in the character of the second sound in the aortic area. Aneurysmal dilatation of the ascending aorta will be more fully considered in a later portion of this work, but a passing reference to it is necessary at this point, in order to show how it may be differentiated from obstruction at the aortic orifice. The only form of dilatation at all likely to be mistaken for aortic obstruction is the fusiform type, inasmuch as the sacculated variety is most unlikely to cause any difficulty on account of the well-marked physical signs to which it gives rise. Simple fusiform dilatation of the aorta reveals itself by three physical signs, one of which, however, is frequently wanting. On mapping out the cardiac dulness in this con- dition, it is not infrequently found to extend further outwards to the right than usual at the level of the second and third 31 482 AFFECTIONS OF THE AORTIC ORIFICE. costal cartilages. This is the physical sign which is most likely to he absent, and when tliis is the case there remains only the evidence furnished by the ear. On auscultation, there are two important physical signs in simple dilatation of the aorta. There is, in the first place, the soft blowing systolic murmur produced by eddies which take their origin within the dilated aorta ; for it must be remembered that a dilatation of that vessel gives rise to practically the same physical conditions as are present when there is an obstruc- tion of the aortic orifice. There is, in both instances, a wider channel beyond a narrower orifice, through which the blood is driven. In this way, dilatation of the ascending aorta comes to present what may be termed relative obstruction of the aortic orifice. The murmur so produced is carried along the vessels of the neck and of the arms precisely as is the case in aortic obstruction, and in itself, therefore, the murmur furnishes no criterion as to whether there is absolute, or only relative, obstruction. The other physical sign furnished by auscultation is accentuation of the aortic second sound, caused by the greater column of blood falling backwards upon the aortic cusps. This furnishes, on the whole, the most im- portant evidence of dilatation of the ascending aorta. There is, nevertheless, a combination of circumstances in which accentuation of the aortic second sound may be present with- out any dilatation of the aorta. In arterial sclerosis, more particularly when accompanied, as is often the case, with chronic cirrhotic changes in the kidneys, the aortic second sound may be very greatly accentuated. It must be remem- bered, moreover, that in such a combination of circumstances there is very frequently some endocardial mischief about the aortic cusps, and that here, therefore, there may be a systolic aortic murmur along with accentuation of the second sound. In such a condition, and it is one far from uncommon, the second sound has not the drum- like character, and there are also, as a rule, other appearances to guide the observer to correct conclusions. The presence of albuminuria, of dimin- ished urea secretion, and of albuminuric retinitis, as well as the peculiar characters of the pulse, may render valuable service in this respect. AORTIC OBSTRUCTION. 483 Pulmonary obstruction is occasionally simulated by the disease now under discussion. The characteristic systolic murmur in aortic disease may be heard, as already mentioned, with its greatest intensity to the left of the sternum, and when this is the case, it may readily be mistaken for a pul- monary systolic murmur. The pulmonary systolic murmur can never, by any possibility, be propagated into the great arteries at the root of the neck, and this alone is sufficient to prevent any confusion between the two affections. Patent ductus arteriosus, as has been fully shown when the congenital affections of the heart were under consideration, is characterised by a loud systolic murmur, heard with its greatest intensity in the second left intercostal space about one inch and a half to the left of mid-sternum. This murmur may be propagated, not only throughout the whole upper part of the chest, but, indeed, throughout the whole body, as is also the case with many murmurs produced by aortic obstruction. The great points of difference between the auscultatory phenomena in these two conditions are that the murmur has its maximum intensity in the position just indi-- cated, and that it is late systolic in rhythm, while it frequently, if not usually, continues beyond the second sound. It is, however, never carried into the vessels of the neck or of the arms. It may seem unlikely that this condition could ever be mistaken for aortic obstruction, but one of the cases de- scribed has been more than once diagnosed as an instance of aortic obstruction. Prognosis. — Aortic obstruction is, in itself, less serious than any other organic valvular disease. Free from many of the disturbing clinical features common to other valvular lesions, it has, moreover, not the tendency to sudden death manifested by aortic regurgitation, and its duration is more prolonged than is the case in the other organic valvular affections. These considerations, however, must be qualified by the re- membrance that the lesions of aortic obstruction are apt, in common with all pathological alterations of the orifice and its valves, to interfere with the coronary arteries. When this is the case there may be distressing symptoms, and even sudden death. This fact of sudden death in cases of uncomplicated 484 AFFECTIONS OF THE AORTIC ORIFICE. aortic obstruction has recently been the sul)ject of an interest- ing communication by Kelynack. Tkeat.aient. — There is, as a rule, in this disease no need for special treatment, and attention to general principles is all that is necessary. In the group of cases taking their origin in chronic sclerotic processes, it is probable that the course of the lesions may be, to some extent, diminished l)y the careful regulation of habits as to food and drink, exercise and rest. The use of food which is not too highly nitrogenous, and the employment of ample diluents, must certainly be recommended. All physical and mental stress must be, as far as possible, elimin- ated, although sufficient exercise must be enjoined in order to assist the metabolic processes of the body. It is probable that the use of iodide of potassium retards the sclerotic process, and its long-continued use in moderate doses should certainly be tried. When cardiac failure ensues, as it is at last apt to do, the treatment must be conducted upon the general principles which have already been laid down. Case 17. — J. O'B., aged 64, widower, itinerant pliotograplier, was under my care in the Eoyal Infirmary suffering from breatlilessness. The patient's father died at an advanced age of apoplexy. His mother lived to a considerably greater age, and died, according to the patient's account, from decay. A brother and two sisters always enjoyed good health ; one brother was killed by an accident, and one sister died from a cause unknown. The patient's social conditions had been satisfactory, but his mode of life had not been conducive to health. He had suft'ered during the previous ten or eleven years from bron- chitis during each succeeding winter, but liad not had any other ailment, with the exception of the usual children's diseases in youth. The present iUness began in the year preceding admission, with breathlessness. There ■was never any swelling of the ankles. There were no symptoms connected Avith the digestive organs, but the tongue was coated and fissured. The glandular system presented no evidence of disorder. The sujjerficial arteries were rigid and tortuous. The radial pulse was full and of high pressure. The pulsation was 61 per minute and perfectly regular. Each individual pulsation was tardy and sustained. There were no aljnormal appearances connected with the arteries or veins of the neck. Some epigastric pulsation was present. The apex beat was distinctly to be seen in the fifth intercostal space in the mammillary line. On palpation, the apex beat was felt to be diffused. The area of cardiac dulness extended two and four inches respectively to AORTIC OBSTRUCTION. 485 the riglit and left of the mid-sternum. On auscultation, a loud and somewhat harsh systolic murmur was heard over the whole; prtecordia. Its maximum intensity was over the upper part of the manuhrium sterni, and it was propagated over the whole of the prsecordia, into the left axilla, and as far as the left scapular angle behind. It was also conducted up the cairotids, and could be heard on auscultation up to the vertex of the skull as well as along the subclavian arteries, so that it could be heard as far as the wrist, and down the femorals as far as the knees. The second sound, although loud, was not tympanic. A few sonorous rhonchi could be heard over the chest. The urinary secretion was considerably increased, the average amount being from seventy to eighty ounces per day. Under treatment with iodide of potash and rest he greatly improved. This case is an excellent example of uncomplicated aortic obstruction obviously due to degenerative changes, and accom- panied by renal cirrhosis. Case 18. Aortic Obstruction. — K. C, aged 21, unmarried, housemaid, came imder observation in the Eoyal Infirmary, 29th June 1893, com- plaining of a choking sensation, and general shaking over the whole body. Her father had died at the age of 45 of some liver affection ; her mother at the same age of consumption. All her brothers and sisters, three and two in number respectively, had enjoyed excellent health. The only affection from which the patient had suffered in the past was a severe attack of measles, which was followed by abscess of the jaw. The attack for which she sought advice began quite insidiously. She had undergone somewhat arduous labour for a considerable period |and found herself becoming gradually weaker. The patient's general aspect was quite healthy. Her lips were ruddy, and her cheeks bright. Her teeth were much decayed ; the tongue was furred, and there were complaints of weak digestion. The radial walls were perfectly healthy, and the vessels full with rather more than average pressure. The pulse varied slightly from day to day, but was usually a little below or above 80. It was somewhat tardy and sustained, but absolutely regular and equal. On inspection of the neck and chest, no abnormal appearances could be detected. There was no visible pulsation of the vessels of the neck, and no abnormal movements over the prsecordia. Palpation revealed that the apex beat was in the fifth intercostal space two and three-quarter inches from mid-sternum. No thrill could be felt in any j)art of the chest. By percussion, the right and left borders at the level of the fourth costal cartilages were found two and three inches from mid-sternum. On auscultation,- a distinct systolic murmur was heard over the base of the heart. Somewhat harsh in character, its maximum intensity was at the attachment of the first right rib to the sternum, from which point it was conducted to some extent in every direction, but more particularly along the right clavicle, and the parts immediately below it, as well as up both carotid arteries. The second sound in the aortic area was accentu- 486 AFFECTIONS OF THE AORTIC ORIFICE. ated, being nuicli louder than tlie second sound in the puhnouary area. It was also i'retiucntly doiililed, a fact ■which cuuld also he ascertained in the pulmonary region. The first sound in the mitral and tricuspid regions was clear and distihct. It could, in fact, be heard with perfect distinctness over the whole pra'cordia, being obviously only accompanied at the liase by the murmur which more or less obscured it. There were no symptoms of disturbance connected with the respiratory or any other system. It ^vas clear that in this case there was simple aortic obstruction, without any regurgitation. The only point of difficulty was the determination of the nature of the obstruction, whether it was to be regarded as absolute, from some change in the orifice or its cusps, or as a relative obstruction, produced by dilatation of the aorta beyond the orifice. The tardy pulse was strong evidence in favoitr of the former view, while the great accentuation of the aortic second sound was a powerful argument in favour of the latter. Taking all the facts into consideration, it seemed probable that there was a combination of organic change in the orifice along with some dilatation of the aorta. The origin of such lesions was necessarily a matter of pure speculation, but it seemed probable that endocarditis was the potent factor, associated in all probability with severe physical stress. By means of absolute rest and careful diet, along with the use of strophanthus and nux vomica, the patient re- covered from the symptoms for which she came under treat- ment, and although she necessarily left the Infirmary with the physical signs unaltered, her general condition had greatly improved. AOETIC INCOMPETENCE. In consequence of his views on the second sound, it was of necessity an impossibility for Laennec to arrive at any diagnosis of this disease, and its discovery was reserved for some of his immediate successors. Hodgkin, in the paper which has already been referred to, published, in 1829, the first clinical description of the disease. It is somewhat singular that for many years his observations escaped general notice ; in fact, until the puljlication of a note AORTIC INCOMPETENCE. 487 on the history of valvular diseases by Wilks, they appear to have attracted no attention. In his paper Hodgkin describes, amongst others, the case of a medical friend who suffered from very violent, although perfectly regular, arterial action, with a thrill in the arteries, and great throbbing of the carotids. But he goes further than this, because he describes a murmur which, he says, " presented this peculiarity, that it was double, attending the systole as well as the diastole." These facts show that Hodgkin had fully grasped the most important clinical featvires of aortic incompetence, and from the patho- logical point of view, as has been mentioned previously, as well as from the standpoint of etiology, his important paper is well worthy of perusal. It is of great interest to observe tliat he attributes the aortic lesions in some cases to excessive muscular effort. ■Corrigan has almost universally had the credit of being the first to describe the symptoms and to connect them with the lesions of aortic obstruction, but his paper was published three years later than that of Hodgkin. It must be noticed also that while his descriptions are in most points lucid and complete, there is nevertheless some little ambiguity as regards the murmurs produced by aortic incompetence. In the year ■which witnessed the publication of Corrigan's celebrated paper, appeared the classical work of Hope, in which the diastolic murmur of aortic incompetence was, for the first time, in- corporated in a systematic treatise. The further additions to our knowledge of aortic obstruction will be described as they emerge in the sequel. Aortic incompetence is extremely rare as an isolated lesion, but from the statistics which have been already referred to it is in association with obstruction of the orifice one of the most frequently observed cardiac diseases. The reason for this is not difficult to find. The aortic orifice is supported by an extremely resistant fibrous ring which seems almost incapable of dilata- tion under ordinary circumstances, so that regurgitation from the aorta into the left ventricle can only take place by means of absolute incompetence of the cusps, not through any increase in the size of the orifice. Etiology. — The causes which produce incompetence of the 488 AFFECTIONS OF THE AORTIC ORIFICE. aortic cusps are practically those Avhieli liave been already mentioned as leading to obstruction of the orifice. Endocarditis arising in consequence of any of the factors which have been previously discussed may give rise to lesions of the cusps resulting in their inadequacy. There can be no doubt, as is indeed generally allowed, that endocarditis does not play such an important part in the evolution of aortic as of mitral diseases, and when this form of valvular lesion takes place it is found most commonly in association with similar changes in the mitral valve. The incompetence may have its origin, as is certainly more commonly the case, in sclerotic changes, produced, as has been mentioned before, by long -continued stress, although there cannot be a doubt that certain toxic agents, of which alcohol may be taken as a type, play an important part also in the evolution of this more chronic form. The association of this cardiac lesion w^ith locomotor ataxia, first noted by Vulpian, and Berger, and Eosenbach, has led some writers, and more particularly certain members of the modern French school, to theorise upon the possible mode in which they are connected. Grasset, for instance, is of opinion that a reflex dilatation of the heart produced by the influence of the pain may lead to the aortic lesion, a view which must to an ordinary intelligence appear somewhat fanciful ; Wood is inclined to regard the aortic lesions as resulting from trophic lesions produced by the affection of the posterior nerve roots ; LetuUe and Martin believes that the spinal lesions and the aortic changes are due to the same cause, endarteritis obliterans, and this view is not without weighty arguments in its favour ; Eaymond considers that the association is purely accidental and that the two lesions are not directly connected with each other. Aortic incompetence is the most frequent cardiac lesion produced by injury. This has been particularly referred to in connection with the etiology of valvular affections in general, and the only point requiring further reference in this place is that the damage, as was first pointed by Foster, is usually con- fined to the left posterior cusp. MoitBiD Anatomy. — Incompetence of the aortic valve, as tested by its capability of retaining fluid, is for practical AORTIC INCOMPETENCE. 489 purposes to be regarded as always brought about by an affection of the cusps themselves. The possibility, however, of regur- gitation by means of a dilatation of the orifice rendering it too wide to be closed by the cusps must theoretically be granted. It was admitted by Corrigan in his original paper and has been a subject of discussion ever since, more particu- larly in France. Suffice it to say that this conjecture has never been proved, and that it must for the present remain merely a speculative possibility. The most frequently observed lesions permitting of regurgitation are due to sclerotic pro- cesses, in consequence of which there is shrinkage and de- formation of the cusps, along with thickening. These are frequently associated with changes in the walls of the aorta, such as patches of sclerosis, atheroma, and calcification, often along with dilatation of the aorta beyond the orifice, which may be either general or partial. Frequently associated with such changes are alterations at the openings of the coronary arteries, which are very apt to be obstructed in consequence of the lesions of the aortic walls. Next in point of frequency are the alterations of the cusps which take their origin in some form of endocarditis. The lesions which are produced in this way may be vegetative, in which case a number of vegetations of extremely variable size and consistence are found upon that side of the cusps opposed to the blood current. These are illustrated by Fig. 137 on page 474. Very frequently in this case there is some loss of substance in consequence of ulcerative change, and perhaps still more commonly there are deformities produced by re- traction of the cusps. It need hardly be added that in old -standing instances of disease there are often calcareous deposits producing a very considerable amount of rigidity. Instead of vegetations the endocarditic process appears in some instances to have a tendency rather to produce a fusion of the cusps at their free edges, so as to bring about the pro- duction of a small aperture often of a curious form. In this case also the growth of fibrous tissue and the deposit of in- organic salts may lead to excessive hardness and rigidity. Fig. 138, p. 475, furnishes a capital example of this. It must be obvious that in all these conditions the result 490 AFFECTIONS OF THE AORTIC ORIFICE. upon the circulation must be to produce at once obstruction of the orifice and incompetence of the cusps, and it therefore follows, as was mentioned above, that aortic incompetence is extremely rare except in combination with obstruction. The effects of aortic incompetence are felt in the first place by the left ventricle. As a result of the escape of blood with each diastole, there is an increased amount of blood in the ventricle during that phase, the consequence of which is that the ventricle becomes surcharged. It has accordingly an increased amount of work to do, as well as a larger amount of blood to accommodate. The wall becomes hypertrophied in order to meet the one requirement ; the cavity becomes dilated for the purpose of adapting itself to the other. So long as the nutritive possibilities of the coronary arteries are not impaired, and the character of the blood is such as to afford an adequate supply of material to meet the metabolic requirements of the myocardium, the process of hypertrophy provides for every contingency, and the process of compensation leads to perfect equilibrium. In one or two ways, however, the balance may be upset. The process of hypertrophy may in itself defeat the ends which it is obviously intended to subserve, because the heart may outgrow the possibilities afforded by the coronary arteries to maintain its nutrition. It will be more fully mentioned in the sequel that hypertrophy is very commonly associated with degenerative changes apparently even from the first, and when the coronary arteries are not competent to support the muscular wall, some form of de- generation is inevitable. From that moment dilatation is in excess of hypertrophy, and cardiac failure is the result. On the other hand, in consequence of the severe strain to which it is subjected, the mitral orifice may become dilated, or its cusps may be damaged. So long as there is integrity of these cusps there is no implication of the circulation in the lungs, and the right side of the heart is not interfered with. It is far otherwise when the mitral cusps fail to close the left auriculo - ventricular orifice. "When this happens, there is backward pressure upon the left auricle, the pulmonary veins, and the lung tissue, as a result of w^iich passive venous hyperoemia takes place, entailing all its consequences upon AORTIC INCOMPETENCE. 491 the right side of the heart, and, through it, upon the general venous circulation. In aortic incompetence, moreover, it must not be forgotten that the regurgitation of blood leads to troubles connected with the periphery of the arterial circulation. The inter- ference with the integrity of the cusps leads to an excessive difference in arterial pressure during cardiac systole and diastole, and its swift fall at the commencement of the diastole causes the flow in the arterial system to become less continuous. It therefore results that the larger vessels near the heart are subject to enormous variations in blood pressure, while those which are far away are not so thoroughly supplied with blood as in health. It may further be remarked in this place that these alterations, affecting as they do the coronary arteries, tend to lessen their nutritive possibilities, and if these coronary vessels should be affected by arterio- sclerosis, the interference with the nutrition of the heart must be greatly increased. Symptoms. — Aortic regurgitation gives rise, as a general rule, to very few symptoms so long as compensation preserves the equilibrium of the circulation. The only exceptions to this statement are furnished by those cases in which one or more of the cusps have been ruptured by traumatism, or have undergone very rapid destructive changes in consequence of grave endocarditis. In such cases as these, the onset of general symptoms may be almost dramatic. The rupture of a valve in consequence of injury or strain may at once lead to severe pain and dyspnoea, along with disturbances to the circulation. Such instances as these are of rare occurrence. An aortic incompetence remains, in the overwhelming proportion of cases, absolutely latent for a considerable period. Examples proving the correctness of this statement frequently present themselves before every physician. One of the most striking which has come under my own notice was the case of a friend between forty and fifty years of age, with whom it was my custom to spend some time every year. On one occasion, after a forty-mile walk, embracing the ascent of Cader Idris, he informed me that he felt a little uneasiness and palpitation, 49^ AFFECTIONS OF THE AORTIC ORIFICE. und would like me to auscultate his chest. On doing so there were, to my consternation, all the evidences of serious aortic incompetence. With the avoidance of all severe physical exertion for the future, my friend lived with every appearance of excellent health for some years, but, having one day somewhat imprudently hurried to catch a train, he fell back dead a few minutes after being seated in it. In this instance, as in so many others, the heart was quite able by means of perfect compensation to overtake all ordinary work, but our forty-mile walk had proved, unfortunately, too much for it. Even where compensation appears to lie adequate, there are sometimes symptoms of disturbance. During repose there may be nothing to direct attention to the circulation, while on any exertion there is palpitation or fluttering of the heart. Breathlessness on exertion may also make its appearance, and sometimes attacks of this kind may really deserve the term of cardiac asthma. Certain of the instances in which such an occurrence takes place are apparently due simply to the mal- aeration of the blood through interference with its return. In other cases, however, they are associated with changes in the kidney which have taken place along with arterio-sclerosis. The fact, further, must not lie overlooked that some patients presenting this prominent symptom have morbid changes in the lungs, interfering with the area of aerating surface. Petit lays considerable stress upon symptoms of painful dyspepsia, and such accompaniments must be admitted as not altogether uncommon. They make their appearance, as a rule, after excessive exertion. Cardiac pain is one of the commonest symptoms, and may present all degrees of intensity, from very slight uneasiness to the most profound agony. Such painful sensations are fully dealt with elsewhere, and the subject requires no further comment in this place. Patients who suffer from aortic in- competence are not infrequently liable to various symptoms connected with the cerebral functions. Besides the sensation of throbbing, which is often present, there may be headache and giddiness, both of which are more conspicuously present on exertion, and are frequently attended also by subjective AORTIC INCOMPETENCE. 493 sensations connected with the ears, and less commonly also with the eyes. There may he sleeplessness and disturbance of the higher faculties. One and all of these are due to the disturbance of the peripheral circulation within the cranium. There is, as a rule, pallor of the surface, produced by the disturbance of the peripheral circulation ; this arises some- times entirely in consequence of the valvular defect, l)ut sometimes is due also in part to sclerosis of the arteries. On examining the behaviour of the peripheral circulation there are certain important appearances of common occurrence. On any part of the skin normally pale, which has been rendered red by pressure or by friction, there may be seen what is known as the capillary pulse. This is an increase of the redness following each systole of the heart, and a paleness with every diastole. The causation of this is suffi- ciently obvious. It is due to the relatively unfilled condition of the peripheral vessels allowing of great oscillations of the blood pressure. This symptom appears to have been first described by Quincke, and it has been the subject of exhaustive observations in later times. The same alter- nating flushing and paling of the surface is often present, as was pointed out by Hirtz, in the halo surrounding the patch . of urticaria when this occurs in a patient suffering from aortic incompetence. A similar appearance may be detected close to the lunules at the base of the nails. It is best exhibited when the free border of the nail is slightly pressed downwards. On examining the fundus of the eye with the ophthalmoscope, increased pulsation of the arteries may be observed. Miiller called attention to pulsatory movements and swelling of the palate, uvula, and tonsils. Balfour does not admit that these appearances are of any value in diagnosis, and it must be allowed that they may occur in conditions permitting a free passage of blood through the arterioles and capillaries into the veins. In point of fact the capillary pulse is, as Whittaker remarks, an indication of the force of the left ventricle. The most characteristic appearance presented by any patient suffering from aortic incompetence is the excessive pulsation of all the arteries. This is without doubt best 494 AFFECTIONS OF THE AORTIC ORIFICE. exhibited by the carotid arteries in the ueek, which are seen by their violent throbbing to produce extensive movements of the neck ; but branches of the facial and temporal arteries may be seen to throb violently, while the subclavian and brachial arteries also show excessive movements. In the case of male patients with beards or whiskers, these appendages are seen to execute lively movements, and the pulsation is in some instances so violent as to give rise to distinct movements of the head. It need hardly be added that the superficial arteries of the lower limbs also show the same exaggerated pulsation. The radial pulse on palpation shows those striking charac- ters summed up under the term Corrigan's pulse. Corrigan did indeed give an excellent description of these features, but, as has been mentioned above, they were studied previously by Hodgkin in full knowledge of their connection with this disease. The essential points, indeed, were noticed long ago by Vieussens. The principal features of this pulse are that the vessel is far from full in general, yet the pressure is often above the normal. The pulse may be frequent or rare ac- cording to circumstances, but the rhythm is, in the great proportion of cases, perfectly regular, and the pulsations are equal or nearly so. These characteristics undergo modification when cardiac failure comes on. Each individual pulsation is abrupt and large, but it is of short duration, falling away from the fingers in the instant when it reaches them. It gives the feeling to the fingers laid lightly upon the artery as if a small shot had touched them and had instantly recoiled. From its giving the fingers this sensation, it has been well termed the water-hammer pulse, since the sensation which it produces is remarkably like that of the throbbing caused by the vibration of that toy. A sphygmographic tracing of the pulse and the radial artery brings out some of these points very distinctly. The ascent of the curve is abrupt and steep, rising to a higher level than in almost any other condition. The descent is almost as swift, and there may be a considerable tidal wave, but the most remarkable feature is that the dicrotic notch and wave are very slightly marked. These characters are shown in Fiw 142. AORTIC INCOMPETENCE. 495 There is one appearance sometimes, but not very commonly, seen in cases of aortic incompetence — the development of a direct venous pulse in the peripheral veins. This is a wave passing from the periphery towards the centre, and distinctly following the systole of the ventricle. It is best seen in the veins upon the back of the hand, but it may be seen in other superficial veins, and it is a gentle undulation. Sometimes there is sufficient movement to allow of a tracing, as will be seen in Case 20, narrated below (p. 506). The examination of the front of the chest shows in general no alteration in form, except where a small chest is associated with considerable enlargement of the heart. It Fig. 14-2. — Tracing from the radial artery in a case of aortic incompetence ; pressure 3 oz. may happen in such a combination of circumstances that there is a considerable amount of bulging forward, but apart from this there is no abnormal appearance. In most instances the apex beat occupies a position farther down and to the left than in health. In point of fact, it is extremely common to see it in the sixth left intercostal space quite outside the mammillary line. Its position cannot always be determined by simple inspection, as it may be diffuse, as is more particularly the case when it impinges upon the sixth rib. That the cardiac systole is considerably augmented in force can usually be seen from the distinct movements of the praecordia — move- ments which at once occupy a wider area, and are characterised by greater amplitude. The application of the hand at once reveals the fact of increased force of pulsation. It shows, moreover, that not merely is the cardiac systole more powerful, but that the diastolic recoil is increased. Palpation further brings out 496 AFFECTIONS OF THE AORTIC ORIFICE. the exact position of the apex beat, and proves that its force is increased. But there is another sensation communicated to the hand at the apex, a sensation as if the apex beat were accompanied by something like a thrill. This is the result of the greatly increased energy of the heart, resulting from its hypertrophy. There is occasionally a distinct thrill felt, more especially in the superior sternal region, which accompanies the diastole. It may be felt over the whole prtecordia, and very distinctly even at the apex of the heart. This thrill when present is due to vibrations produced by the escape of the blood backwards from the aorta. The area of cardiac dulness, as ascertained by percussion, is always increased, and the form which it assumes is length- ened in the vertical direction as well as widened horizontally. The right border of the heart is not so much displaced outwards to the right as is the left in the opposite direction, and the most characteristic change is that the cardiac dulness is found beyond the fifth intercostal space as far as the sixth ; sometimes indeed it reaches the seventh rib. Auscultation reveals the characteristic diastolic murmur. The character of this murmur has wide limits of variability. It often has a perfectly soft blowing sound, but it may be harsh and rasping in quality, and it is above all others that which most frequently assumes the character of a musical sound. These differences must of necessity depend upon the size of the orifice through which escape is allowed, the nature of its borders, and the arterial pressure. The harshest murmurs are those which have their origin in those cases where a cusp has been ruptiired, or in which there has been some loss of texture. The position of maximum intensity of this aortic murmur is also subject to considerable variation, but it may be laid down as a general principle that its maximum intensity is very rarely in the conventional aortic area. In the majority of cases it is heard most distinctly over the right half of the sternum, about the level of the fourth costal cartilage ; it is not an uncommon experience to find that it is most distinctly heard to the left of the sternum altogether, about the third costal cartilage or third intercostal space ; it may sometimes AORTIC INCOMPETENCE. 497 be heard only at the apex of the heart and nowhere else. The explanation of these divergent results is at present im- possible. They can only be attributed to individual ])eculi- arities lying beyond the reach of observation. The diastolic aortic murmur is for the most part conducted downwards in the direction of the xiphisternum and of the apex of the heart. The extent of its propagation has some relation to the harshness of the murmur — a rule which is not, however, without some exceptions. The soft blowing type of murmur is as a rule not heard farther than the junction of the body of the sternum with the xiphoid cartilage, and it very often fails to reach the apex of the heart. A harsh or musical murmur, on the other hand, may not only be heard throughout the whole chest, but it may even be heard by a bystander without the necessity of applying his ear to the chest at all. In those cases where the diastolic murmur is distinctly heard at the apex, there is, according to Foster, a lesion of the left posterior aortic cusp. About thirty -five years ago Elint called attention to a discrepancy between the results of clinical observation and pathological investigation as exemplified in two cases under his own care. In each of the two patients there was a " presystolic murmur, which in both possessed a blubbering character. After death, in the first case, it was found that " the aorta was atheromatous and dilated so as to render the valvular segments evidently insufficient. The mitral valve presented nothing abnormal, save a few small vegetations at the base of the curtains as seen from the auricular aspect of the orifice." After death, the post-mortem examination in the second case showed that " the aortic segments were contracted, and evidently insufficient. The mitral curtains presented no lesions ; the mitral orifice was neither contracted nor dilated, and the valve was evidently sufficient." Flint attempted to account for the discrepancy in the follow- ing way : — The explanation involves a point connected with the physiological action of the auricular valves. Experiments show that when the ventricles are filled with a liquid, the valvular curtains are floated away from the ventricular sides, approximating to each other and tending to closure of the 32 49 S AFFECTIONS OF THE AORTIC ORIFICE. auricular orifice. In fact, as first shown by Baumgarteu and Haniernjk, of Germany, a forcible injection of liquid into the left ventricle through the auricular opening will cause a complete closure of this opening by the coaptation of the mitral curtains, so that these authors contend that the natural closure of the auricular orifices is effected, not by the contrac- tion of the ventricles, but l)y the forcible current of blood propelled into the ventricles by the auricles. However this may be, that the mitral curtains are floated out and brought into apposition to each other by simply distending the ventricular cavity with liquid, is a fact sufficiently established and easily verified. Now in cases of considerable aortic insufficiency, the left ventricle is rapidly filled with blood flowing back from the aorta as well as from the auricle, before the auricular contraction takes place. The distension of the ventricle is such that the mitral curtains are brought into coaptation, and when the auricular contraction takes place the mitral direct current passing between the cm^tains throws them into vibration and gives rise to the characteristic blubbering murmm\ The physical condition is in effect analogous to contraction of the mitral orifice from an adhesion of the curtains at their sides, the latter condition, as clinical observation abundantly proves, giving rise to a mitral direct murmur of a similar character." Charlewood Turner narrated two cases in which a pre- systolic murmur was associated with aortic incompetence, and in which no mitral lesion was found on post-mortem examina- tion. In the same communication he placed on record another case in which a presystolic murmur attended by a thrill was heard distinctly during the life of the patient, and in which on post-mortem examination the condition of the orifices and valves was perfectly healthy, with the exception of a small patch of atheroma on the anterior mitral cusp adjacent to the aortic valve. The aortic cusps were perfectly normal. Turner maintained the presystolic murmur to be the result of regurgi- tation, he himself being a stout champion of Barclay's views alluded to in another chapter. Guiteras narrated an instance of aortic disease in which, with the diastolic murmur of aortic regurgitation, there was a AORTIC INCOMPETENCE. 499 presystolic murmur at the apex of the heart running up to a weak first sound, and in which on post-mortem examination there was besides the aortic lesion only a little thickening of the base of the mitral cusps without any change in their edges. The same writer in a subsequent article described another case in which with similar appearances there was a total absence of any mitral lesion. He expresses the opinion that obstructive functional mitral murmurs frequently occur in aortic regurgitation, more especially when the posterior aortic segment is affected, and explains them by the direction of the regurgitant stream which is brought to bear directly against the anterior cusp of the mitral valve. Osier placed two cases on record in which, along with aortic disease, there was a presystolic mitral mm'mur with integrity of the mitral cusps on post-mortem examination. Steell on one occasion found a healthy mitral valve in a case of aortic disease presenting symptoms of mitral obstruction. Bramwell published an instance in which, with all the evidences of aortic incompetence, there was a presystolic murmur at the apex along with, however, a systolic murmur conducted to the scapula, and in which from cardiographic tracings he concluded that probably there was no mitral obstruction. As no post-mortem examination was obtained, this case is bereft of the last link in the evidence required. He is of opinion that the occurrence of the presystolic murmur " may perhaps be explained by supposing that in those rare cases in which it is met with, the lesion chiefly affects the posterior coronary segment of the aortic valve, with the result that the full force of the regurgitant current falls, as it were, upon the great anterior segment of the mitral valve, forcing it into the position which Flint has described as essential for the production of the murmur." This is identically the same explanation as that advanced by Gruiteras. Gairdner recorded a very interesting case in which an auriculo-systolic murmur was heard, and in which there was an aperture in the right curtain of the aortic valve, about half an inch in diameter and with the upper part about one-eighth of an inch from the edge of the curtain. The aperture was surrounded by lobulated projections of a white colour. In 500 AFFECTIONS OF THE AORTIC ORIFICE. this instance by inference the mitral cusps were healtliy, although no express statement is given in regard to this point. Maguire has very carefully recorded two cases quite analogous to those, in one of wliicli there was only a little thickening of the mitral cusps, and in the other only a few scattered patches of atheroma on the anterior mitral cusp. In a careful review of the opinions of previous writers, and of the eleven cases placed on record up to the appearance of his paper, he expresses the view that in aortic regurgitation the anterior mitral cusp during diastole lies between two blood streams, irregularities in which would readily produce vibra- tions in the cusp. When the aortic regurgitant stream is very copious a diastolic murmur may be heard, as in mitral obstruction, near the apex of the heart, and actually produced by the mitral curtain, not merely conducted by it from the aortic orifice ; further, that, when the contraction of the auricle increases the rate of the stream coming through the auriculo-ventricular opening, a presystolic murmur might be produced. Maguire very justly criticises the theory of Flint on account of his misapprehension of the mechanism of the cusps, for as has been already fully mentioned in the anatomical introduction, the mitral cusps hang vertically from the mitral orifice during diastole, and there is no such phenomenon as the floating-up which he described. Lees described four cases of a similar character to those above referred to, and sees no difficulty in accepting the view- that the mitral cusp is thrown into ^qbrations by two inde- pendent blood currents impinging on its opposite sides. Lesperance fully entered into the question, and concluded that the murmur is produced by the presystolic shock of the heart upon the layer of lung in front of the heart. Sansom is of opinion that, if the mitral cusps are brought nearly together withovit completely closing the orifice, there is a possibility of the presystolic murmur, and allows that there may be two explanations : — The force of the current impinging upon the lower surface of the anterior mitral cusp might, by obstructing the stream from the auricle, produce a de facto impediment at the end of eacli diastole, or vibrations might AORTIC INCOMPETENCE. 501 be directly communicated by the aortic regurgitant stream to the mitral cusp. In the contribution of Potain he accepts the explanation that the presystolic murmur has its origin in vibrations of the great cusp of the mitral valve, produced by the two currents which impinge upon its surfaces. Being thoroughly conversant with Flint's views since the appearance of his second paper, the points under discussion have been diligently sought for by me ; so far, however, without result. Cases have frequently presented themselves no doubt in which, with absolute evidence of aortic disease, there has been a presystolic murmur, but in every one of these, without exception, post-mortem examination has revealed mitral obstruc- tion as well as aortic lesions. The observations of so many able physicians have raised this subject beyond all possibility of doubt, and the only element of uncertainty surrounding it is as regards its causa- tion. The opinion expressed by Flint is of course absolutely untenable. No one with any knowledge of the physiology of the intracardiac movements could for one moment uphold it. The other explanation, which has been advanced by Guiteras and accepted by subsequent writers, may very well be accepted as a valid explanation of the facts unless an even simpler supposition might serve the purpose. — that of the mingling of the two currents in the neighbourhood of the apex of the heart. Duroziez directed attention to a phenomenon ascertained on auscultation of the arteries in aortic incompetence. On auscultation of an artery with the circulation in a condition of integrity, one sound is usually heard ; occasionally there may be two. If the stethoscope is firmly pressed upon an artery in this condition a distinct murmur will be heard immediately following the ventricular systole, and if there have previously been two arterial sounds, this murmur will be followed by the second of these. In cases of free aortic regurgitation two murmurs are heard, one immediately succeeding the systole of the ventricles, the other im- mediately following their diastole. These murmurs are of local origin, and are produced by the narrowing of the lumen 502 AFFECTIONS OF THE AORTIC ORIFICE. Iroiii pressiu'e of the stethoscope. The tirst of these two murmurs accompanies the wave of increased pressure during the ventricular systole, and may be produced in all conditions. The second can only be heard when there is a backward current towards the heart in free aortic regurgitation. Duroziez allowed that the double murmur might be heard in conditions other than those of aortic regurgitation, Init Balfour holds that " a true ventricular-diastolic murmur audible in the arteries is never heard except when aortic incompetence exists." With this opinion my own experience leads me to agree ; there can be no doubt, moreover, that lie is quite correct in his remark : — " aortic incompetence exists in many cases in which no such mm'mur is audible." Diagnosis. — The recognition of aortic incompetence is as a rule easy. The peculiar character of the radial pulse, the behaviour of the arteries in general, the condition of the left ventricle, and the diastolic murmur along the right edge of the sternum form a group of symptoms which are unmistakable. If to these there should be added capillary pulsation and a double murmm^ in the larger arteries, the diagnosis is by so much rendered the more secure. The diagnosis of this affection is sometimes rendered less easy by individual peculiarities, chief among which must be mentioned the exceptional position of maximum intensity of the diastolic murmur to the left of the sternum, as in Case 25, p. 517, narrated below. This may lead to a possibility of error, but if there should happen to be excessive pulsation of the arteries, along with a capillary pulse, and no clubbing of the lingers, there will be little likelihood of such a mistake being com- mitted. To this subject, however, further reference will be made in dealing with pulmonary valve disease. The remote possibility of mistaking the diastolic murmur often found in mitral obstruction for that of aortic incom- petence should not be overlooked, but the differentiation of the two murmurs and of the diseases in which they are found is as a rule perfectly easy. The diastolic mitral murmur is heard with its maximum intensity in the neighl)Ourhood of the apex beat, and the character of the murmur is as a rule harsh. These two points in most cases suffice to distinguish AORTIC INCOMPETENCE. 503 the murmurs, and it is hardly necessary to add that in un- complicated mitral disease the arterial and capillary phenomena of aortic disease are absolutely wanting. It is held by some authors that an aortic aneurysm, or a dilatation of the aorta, may, in the total absence of any implication of the aortic cusps, give rise to a double murmur. This cannot be accepted as a common occurrence. If a double murmur is found in any case, whether there is absolute or relative obstruction, the aortic cusps are incompetent. There can be no question of differential diagnosis in such conditions, and the whole clinical features are those of two distinct lesions present at the same time. The few exceptions which may be held to prove the rule will be referred to in the chapter on aneurysm. The lesions in aortic incompetence may undergo consider- able alteration, and a healing process resulting in recovery has been seen. In one most interesting case described by Walshe, incompetence of the aortic cusps passed into stenosis by a process of endocarditis. On the other hand, lesions in a case of traumatic aortic incompetence have been seen in which cicatrisation had taken place. Both of these cases, however, must be regarded as pathological rarities. Prognosis. — Many diverse views have been held as to the gravity of aortic incompetence. It is generally recognised as being the cardiac lesion in which above all others the life of the patient hangs by a thread, but Stokes held stoutly to the contrary opinion that mitral disease tended to sudden death. The prognosis is dependent upon several different factors, such as the cause and nature of the aortic disease, the presence or absence of other valvular lesions, the in- tegrity or implication of the arterial walls, the condition of the kidneys, and the general condition of the entire system with regard to nutrition. Speaking generally, those cases in which the disease has arisen from endocarditis have a more hopeful outlook than those belonging to the degenerative type, inasmuch as the latter are more likely to produce inter- ference with the coronary circulation. Instances of aortic incompetence, uncomplicated by any other valvular lesion, afford a more hopeful prognosis than those in which there 504 AFFECTIONS OF THE AORTIC ORIFICE. is such a complication. Degenerative changes in the arteries, especially if attended by anginons seizures, necessarily lead to a less hopeful forecast, seeing that in such circumstances there is great liability to interference with the coronary circulation. Tf there be any interference with the circulation through the kidneys there will be much greater strain thrown upon the damaged heart ; such a combination is thus of evil import. Tf the general nutrition of the individual, further, is at a high level, there is more hope of the heart surviving for a longer period the damage which it has sustained. If hypertrophy keeps pace with the circulatory disturbance, if the second sound is distinct in the cervical arteries, and if the pulse pressure is good, the outlook is favourable ; but if the cardiac systole is enfeebled, the sounds weakened, and the pressure of the pulse lowered, the future cannot be regarded otherwise than with apprehension. Tkeatment. — Cases of aortic incompetence do not call for any special treatment Ijeyond attention to such general rules as will necessarily be dictated by the presence of a lesion leading to considerable hypertrophy. The avoidance of fatigue, whether muscular or mental, careful attention to diet, and caution in the use of alcohol and tobacco, must be enjoined, while a healthy life with regard to food, exercise, and rest must be recommended. Some special points nevertheless require a word in passing. In dealing with any case which is of sclerotic origin, with rigidity of the arteries and anginous attacks, the use of the iodine series of drugs is followed by marked benefit. Of all those drugs iodide of potassium is of the greatest importance, as has been recognised since it was first recommended by Graves. The dose does not require to be large, but the employment of the drug must be long continued. Doses of five grains three times a day may be continued for months without any result other than improvement of the symptoms. Sometimes iodide of potassium is, on account of some idiosyn- crasy, badly tolerated, in which case iodide of sodium may take its place in similar doses to those just mentioned. The syrup of hydriodic acid may be employed, when neither of the salts is suitable, or iodine wine may be tried. For further AORTIC INCOMPETENCE. 505 remarks on the treatment of anginous attacks, reference must be made to the section of this work dealing with that subject. If a failure of compensation leads to a breakdown of the balance of the circulation, the treatment must be based upon the principles which have been laid down in the general remarks on treatment. The only point to which reference need be made at present is in regard to the long controversy over the employment of digitalis. In Corrigan's original memoir he discountenanced the use of digitalis in aortic disease, and in this he has been followed by many writers, especially by Fothergill, and, to some extent, by Morison. The fears which have been expressed are based upon the supposed evil of prolonging the diastolic period, and so allowing the regurgita- tion to exert its baneful influence during a greater length of time on the left ventricle. These ideas, however, are scarcely to be regarded as substantial, and everyday experience teaches that Balfour is right in his contention that digitalis or one of its congeners is imperatively demanded when cardiac failure makes its appearance in aortic incompetence. It must be remembered that, as Broadbent has well put it, there are aortic cases with mitral symptoms. These luust be treated like mitral cases. Case 19. Aortic Incompetence. — E. O'N., aged 38, married, miner, presented himself in the medical waiting-room of the Eoyal Infirmary, 17th October 1892, complaining of pain in the chest. The patient was unable to give any very distinct account of his family history. His own health had always been good until the present illness began, and he had particularly never suffered from rheumatism in any form. His occupation had involved a good deal of hard work, but no excessive strain. For some weeks he had experienced some vague un- easiness, often amounting to pain, in the chest ; he was, however, unable to localise it distinctly. He complained of no breathlessness. On examination the alimentary and blood-glandular systems furnished no evidence of disturbance. The patient's skin was somewhat pale, and on reddening a portion of the forehead a distinct capillary pulse was to be seen. It was difficiTlt to say whether there was anything of the kind in the finger nails. All the superficial arteries throbbed violently'. The radial artery was somewhat hard, but not tortuous. Between the pulsations it gave a sensation of being empty, but the pressure was fair ; its rate was between 60 and 70, and its rhythm perfectly regular. Each individual pulsation was swift and large, collapsing, however, at once, and giving, therefore, the well-marked characters of Corrigan's pulse. The apex beat 5o6 AFFECTIONS OF THE AORTIC ORIFICE. was in the sixth intercostal space, four and three-i^uarter inches from niid-sterniun. No thrill could be made out on palpation. The area of cardiac dnlness extended three inches to the right and five inches to the left of mid-sternum. On auscultation the first sound was perfectly clear over the whole praicordia, and there was no trace of a murmur in the carotid arteries. The second sound was replaced by a loud and some- what high-pitched diastolic murmur heard over a large area, but having its maximum intensity about half-way down the sternum. There were no symptoms of disorder connected with any other system of the body. The patient in this case was one of the most remarkable instances of uncomplicated incompetence of the aortic cusps ever seen by me, and the causation was probably some sclerotic change producing shrinking of one or more of the aortic cusps. Case 20. Aortic Obstruction and Incompetence. — J. E., aged 28, a married woman engaged in gardening, was admitted to Ward 25 in June 1891, suffering from cough and pain in the side. Her father died at the age of 50 of heart disease. Her mother was in good health. She had one brother and three sisters all well, no member of tlie family having died. Her social conditions had always been indifferent. Except for an attack of typhus fever when young, the patient's health had always been good until a few years before admission, when she had been troubled with some breathlessness. The patient had been suffering from pain in the chest for about three weeks before admission, and as this gradually became worse she presented herself in the waiting-room. On admission the patient was found to have a temperature of 103-5'; the pulse rate was 108, that of the resj)iration 42. There was a deep flush upon both cheeks, and there was profuse perspiration. A consider- al)le amount of diarrhoea was present on admission and for a few days there- after. The tongue was moist and covered with a thick fur. No other digestive symptoms were present. The spleen was not enlarged and the lymjjliatic glands were in no respect altered. On examination of the blood a considerable degree of leucocytosis was found, as ^vill be seen from the following table, kindly furnished by Dr. A. C E. Gray, the resident physician : — Red Corpusclf 17tli .Tiuu- 5,500,000 18th ,, 5,500,000 19th ,, 5,750,000 20th ., 5,675,000 21st ., 5,350,000 22nd ,, 5,875,000 2.3rd ,, 5,700,000 24th ., 5,500,000 25th ',, 5,512,500 From the 25th onwards the ratio rapidly came l)ack to the normal. tatio of White to Re.l. 1 to 100 , 75 , 55 , 56 , 78 , 75 , 80 , 110 , 110 AORTIC INCOMPETENCE. 507 On examination of the pulse the wall of the artery was found to be soft and yielding. The vessel was moderately full and the pressure was about the normal. The pulsation was bounding and collapsing, presenting, in short, the typical characters of the water-hammer pulse. A tracing of it, obtained with the sphygmograph, is given in Fig. 143. On examining the neck the only appearance observable was excessive pulsation of the carotid arteries. There was no morljid appearance connected with the cervical veins. On the back of the hand a direct venous pulse could be seen travelling u]5 wards fi'om Fig. 143.— Tracing; from acute pneumonia in a patient suffering from aortic regurgitation ; pressure 2 oz. the knuckles to the wrist. This followed the sj^stole of the heart by a considerable interval. A tracing obtained from it by means of an extremely light lever is seen in Fig. 144. On causing a red patch on the forehead by friction, a very distinct capillary pulse could be seen. Inspection of the prtecordia did not reveal any abnormality, save the fact that the apex beat situated in the fifth intercostal space was farther to the left than in health. There was no fremitus on palpation. . The borders of the heart as ascertained by percussion were one inch and Fig. 144.— Tracing from vein on tlie back of the hand in a patient with acute pneumonia and aortic incompetence. a half to the right, and four and three quarter inches to the left, of mid- sternum. The superior border of the heart was at the upper level of the third rib. On auscultation two distinct murmurs were determined, one of which, systolic in time, had its maximum intensity at the right edge of the sternum opposite the first intercostal space. It was loud and rough, and was distinctly propagated up the arteries of the neck, and along the subclavian arteries as well. The diastolic murmur had its maximum intensity about mid-sternum opposite the fourth costal cartilages, but it could be heard distinctly at the apex of the heart, as well as at the xiphoid cartilage. The patient suffered from a considerable amount of cough attended by a characteristic rusty viscid sputum. On examination of the chest it was found that the right side did not move so freely as the left, that there was greatly increased ^■ocal fremitus over the lower lobe. 5o8 AFFECTIOXS OF THE AORTIC ORIFICE. wliicli was dull uu puiviir^sidii, ami that uwr IJa- wlmle ul' the lower lobe there was liigh-pitclied bronchial breathing, with a lew tine crepitations towards the end of inspiration, and greatly exaggerated vocal resonance. Over the whole of the left lung the breathing wa.s puerile, but there was no other departure froni healthy conditions. The urinary secretion was slightly diminished, of high specific gravity, and dark colour. It con- tained a consideralile increase of lU'ates, and almost no chlorides. There were no abnormal jjhenomena connected with the nervous system. The patient w'as treated Ity means of copious nourishment, free alcoholic stimulation, and a comlnnation of digitalis and ammonia, imder which she matle a rapid and complete recovery from the pxilmonary con- dition, and left the hospital in due course. It was obvious that the patient in this case was sutfering from acute loLar pneumonia in its most characteristic form. It is probable that the pyrexia which accompanied it was in part at least responsible for the direct venous pulsation wliicli formed one of the chief points of interest in the case. Properly speaking this case should be placed amongst instances of combined obstruction and regurgitation, but, see- ing that they have been described to illustrate the direct venous pulse of aortic incompetence, tliey may well have a place liere. AOETIC OBSTEUCTION AND INCOMPETENCE. As has Ijeen already insisted upon, aortic obstruction and aortic res-urgitation are in themselves much less common than a comlnnation of the two lesions. The Eoyal Infirmary statistics, previously given in detail, show that out of 4 11 cases of aortic disease, 141 were diagnosed as aortic incompetence, 40 as aortic obstruction, and 230 as combined obstruction and incompetence. These figures mean that considerably more than half of all the aortic cases have the combined lesions. These figures do not, however, appear to me to be even approximately correct. Aortic incompetence in itself is rather a rare affection, and that it should occur two and a half times as commonly as aortic obstruction, is to me matter for surprise. There can be no doubt tliat many cases of double aortic disease are returned as aortic incompetence, simply because that aspect is the most outstanding feature. AORTIC OBSTRUCTION AND INCOMPETENCE. 509 Etiology and MojtBiD Anatomy. — JSut little rcMjuires to be said on these heads. The factors which produce the double lesions are the same as those concerned in the origin of either obstruction or regurgitation. As regards the structural altera- tions which are present, they show similar changes to those which have been already described ; but in every case where the twofold effects of obstruction and regurgitation are present, there is always some roughening or thickening of the cusps, along with some retraction or deformation which hinders tlieir closure. Symptoms and Diagnosis. — The essential features produced by combined obstruction and incompetence are the mingling of the appearances peculiar to each. The clinical picture is, therefore, somewhat more shifting than is the case as regards either lesion in itself. While the general symptoms cannot be held to depart from those manifested by either lesion, the effects are usually more severe, and the symptoms, therefore, are apt to be more pronounced. Physical examination of the circulatory organs reveals the characteristic features belonging to each of the two lesions which are combined. Sometimes the one set, and sometimes the other, are in the ascendant. The pulse while perfectly regular and equal, as it is in either lesion, sometimes gives the characteristics of the pulsus tardus, at other times of the pulsus celer. The apex beat is, as might be expected, displaced downwards and outwards, and thrills systolic, or diastolic, or both, may be present. The area of cardiac dulness is considerably increased, and systolic and diastolic murmurs are heard. From the point of view of diagnosis, nothing need be added here. The determination of either lesion must be conducted on the principles already laid down. Prognosis and Treatment. — While the combined lesions produce a state of matters much more serious than obtains in the case of a simple aortic obstruction, it cannot be held that the combination is much more serious than simple aortic incompetence. This belief must be allowed to have no absolute foundation on statistical evidence. It, nevertheless, is the result of much careful observation. The treatment of combined aortic lesions comes practically lo AFFECTIOXS OF THE AORTIC ORIFICE. to 1)6 tluit tit" aortic incompetence, seeing that it constitutes the most disturbing element in the combination. Nothing, therefore, need be added to what has Ijeen already said upon this suliject. Case 21. Aortic Ubsf ruction and Regurgitation. — T. S., iwt. 65, horse-dealer, ha.s frequently consulted nie in the out-patient department of the Royal Infirmary on account of weakne.*??, shakiness, palpitation, and uneasiness in the chest. His father died at the age of 77 from the eftects, on the patient's showing, of alcohol ; his mother at the age of 94, of old age, according to him. He had three brothers, all of whom died some years before the patient was first seen by me, one fronr an accident, and the two others in consequence of acute pulmonary aft'ections induced by irregular habits and imprudent exposure. Three sisters, alive at the date of my last seeing the patient, had always enjoyed excellent health. The patient's social conditions might have laeen eminently satisfactory for his position in life but for his dissipated habits. According to his own statement he had been greatly addicted to alcohol, and his general conduct had been sadly in need of reformation. His previous health had always been satisfactory, and the onset of the malady for which lie sought advice had been in the highest degree insidious. The patient had a high complexion, and venous stigmata were dotted abundantly upon the cheeks and nose ; the tongue was very tremulous and somewhat furred ; the digestive functions other- wise were satisfactory. There was great dilata- tion of the right pupil. The arteries of the neck throbbed very distinctly, and there was also great pulsation of the right suliclavian artery. The radial arterj- was hard and tortuous, as were the other superficial arteries throughout the body. The jnilse wave was large and l:)Ounding, but well sus- tained ; its rate was usually about 70 and it was jDer- fectly regular. On jjalpa- tion of the arteries of the neck, a systolic thrill was perceptible, and this was more distinct in the right subclavian artery than elsewhere. The apex beat was in the sixth intercostal space, five and a half inches from mid-sternum ; it was unaccompanied by any Fig. 145.— Aortic systolic and diastolic iimrinui> AORTIC OBSTRUCTION AND INCOMPETENCE. 511 thrill — none, indeed, could be felt (jver any part ui" the prtecordia. On percussion, the right border of the heart at the level of the fourth costal cartilage was two inches from mid-sternum ; the left border at that levcd was three and a half inches from mid -sternum, and in the tiftli and sixth intercostal spaces it was five and a half inches from mid-sternum. On auscultation two distinct murmurs were present. A systolic murmur with its maximum intensity over the manubrium sterni was heard at the junction of the second rib with its right border. Its area of audibility was a small one, being confined to an oval space surrounding the maximum intensity and measuring five inches in length by two and a half inches in breadth. This murmur was somewhat harsh in its character. A diastolii; murmur was also heard with its maximum intensity at the apex. The area over which it could be heard showed a most curious distriljution ; mapped out on the surface of the chest, it extended from the upper border of the manubrium sterni to somewhat below and outside of the apex beat, form- ing a figure somewhat resembling a boomerang in shajje. Tliis murmur was, like the systolic one, somewhat harsh in its character. There were no respiratory or urinary symptoms, and -with regard to the nervous system there was no appearance of any disturbance apart from considerable tremulousness of the whole muscular system, and the dilata- tion of the right pupil already referred to. In this case it was perfectly clear that the patient pre- sented combined obstruction and incompetence of the aortic valve, produced apparently by long-continued physical stress and alcoholic abuse. The points of greatest interest in the case were the curious distribution of the cardiac murmurs and the fact of some dilatation of the subclavian artery, producing irritation of the right sympathetic nerve. Case 22. Aortic Obstruction and Regurgitation. — M. A., aged 43, married, housewife, was admitted to Ward 25 of the Eoyal Infirmary on 16tli May 1892, complaining of breathlessness and swelling of the ankles. Her father fell victim, at the age of 45, to cardiac disease result- ing from rheumatism. Her mother died, when 80, of chronic bronchial troubles. She had never had any brothers or sisters, but had two daughters, both in excellent health. Her surroundings had always been good, and her health excellent ; more particularly, she had never suft'ered from rheumatism. Four or five weeks before admission she observed some swelling of the ankles, and began to sufter from breathlessness. On admission, there were no sjDecial symptoms of alimentary or haimopoietic origin. The patient was pale. The subcutaneous tissues were very cedematous in the dependent parts. No capillary pulse could be observed anywhere. The superficial arteries were someA\'hat rigid and slightly tortuous. The radial pulse had more than the normal pressure. Its rate was 100. It was perfectly regular, and the pulsations were small and sustained. There was no excessive throbbinof in the vessels of the 512 AFFECTIONS OF THE AORTIC ORIFICE. neck. The apex beat was in the sixtli intercostal space, three and three quarter inches from mid -sternum. No thrill was observable. The , cardiac dulness extended two and a half inches to the right, and four incLeji to the left, of the middle line. On auscultation at the base of the heart, two murmurs Avere lieanl, corresponding to the systole and diastole. They were both someAvhat liarsli in character. The former had its maximiun intensity over the manubrium sterni and was propa- gated into the vessels of the neck. The latter had its point of maximum intensity opposite the third costal cartilage, and was extended to the xiiihisternum. In the mitral area there was a systolic murmur, haisli also in its character, liut different in tone from the systolic murmur at the base. It was conducted into the axilla and ronnd to the angle of the scapula. In the tricuspid area there Av-as yet anothei' murmur, softer altogether in its character than the two sj^stolic murmurs M-hich have been described. On examination of the respiratory system, there A\'as some mufiling of tlie percussion sounds at the bases of both lungs, and there were abun- dant moist crepitations. The patient was unable to sleep in the recum- bent posture on account of the severe dyspnoea. The urinary secretion was scanty and of high specific gravity, containing a small quantity of albumin. Ill this case it was obvious that a double aortic lesion was present, probal)ly of sclerotic origin, and it seemed probable from the character of the mitral systolic murmur that there was also an organic mitral lesion, together with dilatation of the right ventricle. In spite of sedulous attention, the patient steadily grew worse, and notwithstanding stimulat- ing treatment of every kind she died. The following is an abstract of the autopsy, performed by Dr. Muir : — External Appearances. — Eigor and lividity were present, the face and neck being livid. Considerable oedema. Stri;e aline were seen on the abdomen and thighs. Thorax. — Rather more than two pints of fluid Avere found in the right pleura. There were pleural adhesions over the upper half of the left lung, Avhile, in the lower half of the cavity, there were 12 oz. of fluid, and the adhesions also were ccdematous. There was about 1 oz. of fluid in the pericardium. Heart. — Its weight Avas 1 lb. 2 oz. There Avas a large milk spot on the right ventricle, and a similar one on the left. There Avas recent soft black clot in both ventricles. The aortic valves Avere incompetent. The cone diameter of the aortic orifice Avas 0-3". The vah-es Avere united, rigid, and calcareous. The pulmonary diameter Avas 1-0". The mitral orifice Avas also contracted, the valves being thickened, fibroid, and cal- careous. Its cone diameter Avas -55". The tricuspid orifice measured AORTIC OBSTRUCTION AND INCOMPETENCE. 513 1"25". The left ventricle was liypertropliied and filjroid ; its wall was firm. The right ventricle was dilated, and its wall was liypertrophiefl. Both auricles were dilated and hy2:)ertroijhied. Lungs. — The left lung weighed 1 lb. 10 oz. It was congested and oedematous, and the j)uhiionary artery was atheromatous. The right lung weighed 1 lb. 6 oz., and resembled the left. The chief interest here lay in the very small aortic orifice shown in Fig. 138, p. 475. Case 23. Aortic Obstruction and Regurgitation. — J. C, aged 31, a married tailor, formerly a trooper in the Scots Greys, was ad- mitted to Ward 22 of the Royal Infirmary, in August 1893, on account of palpitation. His father and mother were both alive and in good health. His wife had never had any children. His social conditions had always been satisfactory. In November 1891, the patient suffered from acute rheumatism, and had never been well since that date. The alimentary system presented no features of interest, and there was no alteration in the blood-glandular system. The pulse was, as a rule, about 80, and presented the well-marked features of Corrigan's pulsation. There was a well-marked capillary pulse in any area that had been reddened. The carotid arteries pulsated in a very exaggerated manner. On inspection of the proecordia a tremendous heaving could be seen, not merely excessive in amount of movement, but also in its extent. The apex beat could be seen in the sixth intercostal space, five and a half inches from mid-sternum. On palj^ation the force of the impulse was found to be enormous, but there was no thrill. The right border of the heart Avas three inches, and the left border five inches from mid-sternum at the fourth costal cartilage, but at the upper level of the xiphoid cartilage it was six inches from mid-sternum. Measured diagonally from the right border at the fourth costal cartilage to the left border at the xi]Dhoid level, the heart measured nine and a quarter inches. The upper border was at the level of the lower part of the second intercostal space. On auscultation a loud rough systolic murmur was heard most distinctly over the right half of the manubrium sterni about half-way up, and there was also a diastolic murmur somewhat softer in character, but also extremelv loud, whose point of maximum intensity was in mid-sternum about the level of the fifth costal cartilage. The systolic murmur was propagated over a considerable distance along all the arteries, and throughout most of the chest. The diastolic murmur had also a somewhat wide distribution. In this case a very large amount of dilatation had accom- panied the development of the hypertrophy. As a contrast to it the following is of interest : — Case 24. Aortic Obstruction and Regurgitation. — P. R, aged 38, a married labourer, was admitted to Ward 22, in August 1893 complaining of pain in the chest. His father was 94 years old and in remarkably good health, considering his age. His mother 33 514 AFFECTIONS OF THE AORTIC ORIFICE. liad died when 70 years old of chronic bronchial trouble. In early life the patient had acquired specific infection, and he had suffered from acute rheumatism nine yeare before the date of his admission. He had about six yeai-s previously developed a popliteal aneurysm, for which he had been treated in London by Mr. Hickman Godlee. Six weeks before his admission he began to suffer from the pain in the chest, and this became so severe that he found it necessary to seek advice. There were no indications of disturbance connected with any system excepting the circulatory. The jjulse varied beetween 75 and 85, the artery was resistant and slightly tortuous, the vessel was moderately iull, the pressure was ratlier high, the pulsation was bounding and collapsing, uianifesting in brief most features of the water-hammer pulse. A distinct capillary pulse could be seen over a reddened area on the forehead. All the visible arteries pulsated very freely. On examination of the praj- cordia, the apex beat was seen to occupy the fourth left intercostal space, three and a half inches from mid-sternum. No thrill could be ascertained on palpation. The right Ijorder of the heart was one inch and three- quarters to the right, and the left was foiu? inches to the left, of mid-sternum at the level of the fourth costal cartilage. The upper border of the heart was in the second left intercostal space at its lower part. Systolic and diastolic murmurs were present, the former with its point of maxi- mum intensity half-way up the manubrium sterni and a little to the left of the middle line, propagated in the carotid and subclavian vessels, as well as throughout a considerable part of the chest ; the latter heard best at mid-sternum half-way between the levels of the third and fourth costal cartilages, but distinctly carried to the xiphisternum and the apex. In this case it seemed probable, from the existence of the anginous symptoms, that the small size of the heart was con- ditioned by some interference with the coronary circulation, very likely of the nature of sclerosis. As showing that aortic murmurs may have their loudest intensity about the pulmonary area, the following case is useful : — Case 25. Aortic and Mitral Disease. — Esther C, set. 46, housewife, was admitted to Ward 25 of the Eoyal Infirmary on 3rd July 1893, suffering from dropsy and dyspnoea. The patient was so ill that it was not possible to disturb her by any prolonged examination, but it was ascertained that she had suffered more than once from acute rheumatism, and that four years before admission she had been attacked by hemiplegia of the right side. She was deeply cyanosed, and could only breathe when sitting upright in bed. The fingers and toes were most distinctly clubbed, and there was much arching of the nails. The right side of the face was rather vacant in expression, and its muscles were weak, while the right arm and leg were almost powerless. The feet, legs, and thighs were very edematous. AORTIC OBSTRUCTION AND INCOMPETENCE. 5'5 and there was some ascites. The pulse was irregular, and did not give any definite indications, although the pulse wave was of brief duration. The cardiac impulse was feeble, but the apex beat was felt in the sixth intercostal space. No thrill could be discovered. On account of the patient's condition, it was not considered right to trouble her by per- cussing the praecordia, and the size of the heart was not therefore ascer- tained. For the same reason it was not possible to study the auscultatory phenomena so fully as could have been wished, but the following facts were definitely established. At the apex of the heart there was a rough first sound, accompanied by a blowing systolic murmur propagated into the axilla, and also, but to a less degree, towards the sternum. At the base, a rough systolic was followed by a softer, although still somewhat harsh, diastolic murmur. Both of these murmurs were heard over the whole of the upper part of the chest, but their maximum intensity was to the left of the sternum, in the neighbourhood of the third costal cartilage. The diastolic murmur, in particular, had its point of maximum loudness in the third left intercostal space, about an inch to the left of the sternal edge. The systolic murmur was distinctly propagated along the carotid arteries. The respiratory system showed symptoms and physical signs of hydrothorax and oedema of the lungs. The urine was scanty, and contained albumin. The patient had almost complete paralysis of the right leg and arm, with weakness of the facial muscles of the right side, and on the same side there was a considerable degree of wasting of the muscles, with contracture. In this case the original clinical features were to a great extent modified by the obvious failure of the cardiac muscle. It could not be doubted that there was a double lesion at the mitral orifice, producing obstruction and incompetence. It was clear also that there was aortic obstruction and incompetence. But, as has been noted, the maximum intensity of the diastolic, as also of the systolic murmur, was to the left of the left sternal border, which fact, taken along with the clubbing of the fingers and toes, together with the profound respiratory disturbance, caused some doubt whether there might not be some lesion of the pul- monary valve or orifice. The conclusion arrived at, however, was that, in consequence of the backward pressure resulting from the mitral lesion, the clubbing of the fingers had resulted, while the combined effect of the mitral and aortic affections had been to cause the serious condition of cardiac failure. In spite of all treatment the state of the patient became gradually worse, and she died somewhat suddenly on the 12th July. The post- mortem examination was performed on the 14th July by Dr. Muir, whose notes are appended. External Appearances. — Body well nourished. Some dropsy of lower limbs. Rigidity well marked. Thorax. — Left pleura contained 24 oz. of serous fluid, with fibrous adhesions here and there ; right pleura, about 15 oz. Pericardium con- tained about 3 oz. serum. Heart considerably enlarged on both sides. The right auricle was 5i6 AFFECTIONS OF THE AORTIC ORIFICE. somewhat dilated, and filled with dark clot. Aortic orifice distinctly incompetent. Pulmonary orifice competent. The cone-diameters Avere as follows: — aortic =-65; pulmonary = 1 ; mitral = •?; tricuspid = 1 -7. The aortic cusps showed extensive chronic vegetative endocarditis. («) The two posterior cusps were much thickened at their junction and also calcareous. The margins were also thickened. {b) The anterior cusp was considerably ulcerated, and there were large irregular vegetations hanging down from it. The orifice was stenosed from the chronic endocarditis, and also markedly incompetent. The mitral segments were much thickened and indented, and had become adherent for a considerable distance, giving rise to stenosis. The chordti; tendinea) were also thickened and contracted somewhat, as were also the apices of the papillary muscles. There was also evidence of more recent endocarditis along the margins of the segments. The tricuspid and pulmonary valves were normal. Left ventricle, 4 in. in length by -g- to | in. in thickness ; slightly dilated and hypertrophied. Right ventricle much hypertrophied ; its walls measured ---^ in. in thickness. The inner surface of both ventricles showed commencing fatty change in the myocardium. No ante-mortem thrombi. Lungs. — Right, 1 lb. 12oz. ; showed chronic venous congestion. The bronchi were deeply congested, and contained frothy secretion. The posterior part of the lower lobe was going on to hypostatic pneumonia. There was also slight interstitial change in places. Left, 1 lb. 8 oz. ; at the posterior j)art about middle line there was anasarca, in which part the bronchi were considerably dilated, with considerable interstitial change around. Some of the bronchi contained a purulent fluid. There was a similar patch in the lower lobe. The general condition resembled that of the other lung. Abdomen. — Peritoneum contained about 40 oz. of serous fluid. Liver. — Weight, 2 lb. 10 oz. ; it showed chronic venous congestion. The tissue was indurated, and the capsule in places was thickened. Spleen. — Weight, 10 oz. ; showed typical chronic venous congestion. Kidneys.- — Each weighed 7 oz. ; they showed foetal lobulation, and also several irregular depressions owing to old infarcts. The infarcts had been in both kidneys, but were more numerous in the left. The other organs showed chronic venous congestion. There were no recent infarcts. Brain. — There was nothing abnormal to see on the surface, and tlie vessels at the base were practically normal ; none appeared to have been the site of embolism. On opening the brain, there was found an old area of softening in the left side, which implicated the following structures : — at its lowest level, the posterior part of the lenticular nucleus, the external capsule and the claustrum, with the convolution (in part) of the island of Reil, were softened. The posterior end of the internal capsule was also affected, and there were one or two minute points of softening in the optic thalamus. Higher up, the lenticular nucleus was more destroyed, but the internal capsule was practically unaffected. The softening ran up for some distance along its outer aspect. AORTIC OBSTRUCTION AND INCOMPETENCE, sn The convolutions (with the exceptions mentioned) were unaffected. No change could be seen on naked-eye examination either in the pons or medulla. The morbid anatomy of the heart is shown in Fig. 137, p. 474. The consideration of the clinical and pathological facts presented by the patient whose case has been described, leads to the conclusion that the mere position of the maximum intensity of murmurs in itself may lead to erroneous con- clusions ; and that even when definite appearances, strongly suggestive of pulmonary lesions, are present, they may he susceptible of other explanations. That the murmurs produced at the aortic orifice may be loudest in, or even to the left of, the pulmonary area, is a well-known fact. As one of several patients presenting this feature, which have come under my notice, the clinical features of the following case may be shortly described : — Case 26. Aortic Obstruction artd Incomfetence. — Bella W., eet. 19, domestic servant, presented herself as an out-patient at the Royal Infirmary on 29th May 1893, complaining of a rash on her skin. Her family history was in every respect satisfactory, and her sur- FiG. 146. — Aortic systolic and diastolic murmurs. roundings had always been favourable. She had suffered from acute rheumatism some years ago, but had otherwise enjoyed good health. The affection of the skin — well-marked psoriasis — had for some months been gradually increasing ; with the exception of slight uneasiness in the prsecordia, it was the only symptom of which she complained. 5i8 AFFECTIONS OF THE AORTIC ORIFICE. The alimentary and hanuopoietic systems sliowed no abnormal phenomena. The pulse was usually about 80 per minute, and perfectly rej^'ular ; the vessel Avas somewhat empty, and the tension low ; the pulse wave was large and bounding, but short and collapsing, — in a word, it was a well-marked water-hammer pulse. The arteries of the neck pulsated rather strongly. Inspection of the pra2cordia showed no abnormality, and, on palpation, the apex beat could be felt beating strongly in the fifth intercostal space. No thrill was present. The deep cardiac dulness extended from 1\ in. to the right to 2^ in. to the left of the mid- sternal line. On auscultation, two very distinct murmurs were heard, systolic and diastolic in time. The systolic murmur was loudest at the junction of the second left costal cartilage with the stei'iium, and was propagated up the neck, out to the shoulders, and around the thorax on both sides to the vertebral column behind. The diastolic murmur had its maximum intensity in the second left intercostal space rather more than \\ in. to the left of the sternal border, and it was conducted to the upper end of the manubrium sterni, along the clavicles, and over most of the prtecordia. The distribution of these murmurs is shown in Fig. 146. There was no clubbing of the fingers, and no symptoms of backward pressure were present ; in fact, no other point of clinical importance, except the psoriasis, was found. This case shows very well how, in an undoubted instance of aortic disease, the auscultatory phenomena were most distinct in the pulmonary area. Such instances might be multiplied almost indefinitely, were it necessary to do so. CHAPTER XL AFFECTIONS OF THE MITKAL OPtlFICE. There is an essential difference between the two disorders which may he present at the mitral orifice. Mitral obstruc- tion is comparatively rare as an isolated lesion. In the preponderating majority of instances it is accompanied by incompetence of the valve. It is far otherwise with regard to mitral incompetence. Mitral incompetence, it will be seen, may be produced by causes and lesions exerting no influence upon the free access of blood from the auricle into the ventricle ; it therefore often exists without any obstruction. It must, nevertheless, be admitted that mitral incompetence as an isolated lesion is far from common. As the result of endocarditis it is usually an attendant upon obstruction. Frequently the determination of the latter lesion is difficult, and the diagnosis is more a matter of inference than demon- stration, yet from the results of clinical observation and pathological investigation there can be no doubt of the usual combination of the two lesions. When, on the other hand, mitral incompetence occurs from causes other than lesions of the cusps, it is in the overwhelming proportion of cases associated with incompetence also of the tricuspid valve. Facts in sup- port of this view will be adduced in the proper place. MITEAL OBSTEUCTIOK Obstruction of the mitral orifice was recognised as a lesion in the early period of the modern study of medicine, but its 5 20 AFFECTIONS OF THE MITRAL ORIFICE. recognition from the elinieal point of view has been gradually developed during the present century. Morgagni and other authors very fully described lesions found in this affection. Corvisart showed the value of the thrill which is so frequently found in mitral obstruction, and Fauvel discovered the dis- tinctive murmur which accompanies this disease. The further development of our knowledge of the affection is due to so large a number of industrious workers that it seems almost invidious to cite any as more particularly worthy of mention, yet on account of the value of their olxservations, the writings of Stokes, Gairdner, Hayden, Balfour, and Hilton Fagge must be particularly mentioned. The presystolic murmur of mitral olistruction appears to have been heard by Bertin, who, as Hayden says, " actually founded thereon the positive diagnosis of left auriculo- ventricular contraction." As he, how^ever, believed with Laennec that the second sound was produced by the contrac- tion of the auricles, he regarded the murmur as being diastolic in rhythm. Adams, three years later, and apparently quite independently of Bertin's observations, made out some of its special characters, but apparently did not grasp the exact rhythm of the murmur or of tlie attendant thrill. Valuable though the writings of Hope are, there is in his first edition a total misconception of the phenomena of mitral disease, and even vip to the third edition of his work this subject is left in considerable obscurity. The real clinical history of mitral obstruction begins therefore with Fauvel. Etiology. — Obstruction at the mitral orifice is more common in women than in men. The relative proportion in which the two sexes are affected necessarily fluctuates somewhat in different statistics, but the facts of the admissions to the Eoyal Infirmary are that for 133 males admitted in five years there were 171 females. The affection is one essentially of early life, for although often not detected until a later period, it is found, on diligent inquiry, to have had its beginnings at a much earlier period. According to the Edinburgh statistics the largest number of the admissions occur l^etween the ages of twenty and thirty. The disease is sometimes even congenital, although patients MITRAL OBSTRUCTION. 521 do not come under treatment for it during t)ie first decade of life to any considerable extent. According to some observers mitral obstruction is to be regarded as a developmental lesion. Mitral obstruction rests more frequently upon endocarditis as a causative factor than does aortic obstruction. Statistics bearing upon this point vary within wide limits. The endo- carditis may have its origin in any of the causes which have been previously considered, but rheumatism in one or other of its protean manifestations is beyond all question the most potent agent in its production. In a certain proportion of patients the most diligent inquiry altogether fails to reveal any definite cause for mitral obstruction, inasmuch as there has been no history of any endocarditis, or of any of the affections which usually lead to that condition. It must, nevertheless, be allowed that in a certain proportion of instances there may be a latent cause operating in the direction of endocarditis, and it occasionally happens that years after a patient has suffered from mitral obstruction the development of certain aberrant forms of rheumatism throws a significant light upon the etiology of the cardiac lesion. Notwithstanding this admission, it must be granted that in some cases of mitral obstruction the causation is quite obscure. It has been suggested by Potain that mitral obstruction may possibly prove to have its origin sometimes in pulmonary tuberculosis. He suggests that the cardiac lesion may be secondary to the tubercular infection and be produced by the bacilli in the circulation affecting the borders of the valves. Potain has observed that in fifty-five cases of pure mitral ob- struction there were nine instances of pulmonary tuberculosis presenting fibrous or cretaceous lesions. It has already been shown that tubercular endocarditis has a real existence, and it is somewhat difQcult to understand why, if there be any basis for the suggestion of Potain, there should only be a simple mitral lesion showing no tendency to tubercular endo- carditis. The view of Potain is certainly one of much interest. If it should prove to have any reality it would be a beautiful example of a compensatory process, since there cannot be the 522 AFFECTIONS OF THE MITRAL ORIFICE. shadow of a doubt that mitral stenosis stands in direct antagonism to phthisis puhnonalis. MoEBiD Anatomy. — The lesions which produce mitral obstruction are found to occupy two distinct zones. In one group they are situated at the level of the orifice itself, i.e. at the level of the auriculo-ventricular ring. In the other they are connected with the cusps. Of these two positions of the lesions the latter is by far the more common. At the level of the auriculo-ventricular ring there may be different types of structural alteration. Vegetations resulting from endocarditis form one well-marked group of lesions, while sclerotic processes, mostly of degenerative origin, constitute another. In old-standing cases, however, of mitral disease it is not an unusual occurrence to find a combination of both, in which, moreover, a certain amount of calcification has occurred. Much more common than such lesions are changes under- gone by the valves and the chordte tendineae. The lesions in this case are threefold in their variety. The cusps may be united by their margins to a greater or smaller extent, as Bouillaud was the first to emphasise and explain. The result- ing lesion in this case is that a restricted aperture is left, varying very considerably in its size and form. Sometimes, apparently in consequence of considerable retraction of the cusps, the mitral orifice appears almost closed by a diaphragm perforated by the small aperture which is left. Such a lesion is shown in Fig. 166, p. 597. It is, however, much more common to find that the united cusps project downwards into the ventricle in a funnel shape. In many cases the aperture is termed a " button-hole '" orifice in consequence of its close resemblance in form to that object. It is well shown in the illustration mentioned. In such cases the chordte tendinepe become almost invari- ably thickened and rigid, so that they must still further interfere with the movements of the cusps. In anothei' large group of cases the structural alterations are vegetative in type and consist essentially in an outgrowth of granulations residting in verrucose structure. The customary position for such vegetations is the auricular sm-face of the cusps near, but not quite at the free border, as has already MITRAL OBSTRUCTION. 523 been seen in dealing with endocarditis. These vegetations are often associated with thickening of, and deposits upon, the chordae tendinese, so that the cusps and their attachments pre- sent a greatly increased thickness with roughness and rigidity, as is shown in Fig. 147. 524 AFFECTIONS OF THE MITRAL ORIFICE. There are also changes produced apparently by purely sclerotic processes, consisting in thickening of the cusps with patches of deposit, frequently atheromatous and often calcare- ous. ' These result in deformities of tlie cusps, with great rigidity and interference with tlieir proper functions. Whatever be the nature of the process producing mitral obstruction, there are always certain well-marked consequences which follow in more or less direct ratio to the obstacle which is thereby present. The effects of the interference with the forward passage of the blood are felt mostly by the left auricle. This was pointed out long ago by Adams. The consequence, as might naturally be expected, is a degree of h}"|5ertrophy proportional to the increased amount of work which the auricle has to undertake. A statement, repeated in many works, is that tlie result of mitral obstruction is, in so far as the left auricle is considered, a condition of dilatation and hypertrophy. This statement rests upon a somewhat unsubstantial foundation. It is per- fectly true that in many old-standing cases of mitral obstruc- tion, in which cardiac failure has occurred, there is dilatation along with hypertrophy, but, in cases uncomplicated by cardiac failure, hypertrophy without dilatation is undoubtedly the condition present. The recent observations of Samways have thrown much light on this subject. Samways points out that during the four years 1888-91 inclusive, there were 70 cases of mitral obstruction reported on in the post-mortem room of Guy's Hospital. Of these 70 cases, 36 had severe obstruction, and 34 a less degree. Hypertrophy of the left auricle occurred in 3 6 of these cases. In 1 5 of the 3 6 severe cases the left auricle was hypertrophied without dilatation. In 11 other cases the auricle was both dilated and hypertrophied. In only 3 cases was the auricle dilated without being hypertrophied. No definite statements were made in regard to 7 cases. There was therefore hyper- trophy of the left auricle in 26 of the 36 severe cases. Dilatation existed only in 14 cases, and was associated with hypertrophy in 11 of these cases. That dilatation is chiefly a breakdown phenomenon, Samways concludes from the fol- lowing consideration. The 70 cases referred to included 18 MITRAL OBSTRUCTION. 525 which came from the surgical wards. In only one of these cases was there dilatation of the auricle. The absence of dilatation in the surgical cases, and its absence in the majority of the slighter medical cases, leaves very little basis for the assumption that in the earlier stages of mitral ol)struction the left auricle dilates. The left auricle frequently contains blood clots, partly of ante-mortem, partly of post-mortem, origin. The condition of the left ventricle is controlled by circum- stances of a character exactly opposite to those which obtain in regard to the left auricle. In consequence of the reduction in the amount of blood which passes from the auricle to the ventricle, the latter has necessarily a smaller quantity to propel into the aorta, and it has as a result a smaller amount of work to overcome. It might naturally be expected, there- fore, that the ventricle would undergo changes in a direction the converse of hypertrophy, and this is the result in many instances of uncomplicated mitral obstruction without cardiac failure. It is not surprising, however, to find that instead of retaining its normal size and thickness, or of being even reduced in both, the left ventricle undergoes hypertrophy. It has to be remembered that if there be any failure of com- pensation, the backward pressure thence resulting tells back upon the venous system, so that there is an obstruction to the passage of the blood from the arterioles into the venous channels ; this in turn leads to an increased amount of the work thrown upon the left ventricle, and is probably the reason why in a considerable proportion of cases there is some hypertrophy of the ventricle. Another consideration must be admitted as a possible explanation of the hypertrophy of the left ventricle, and it is one which has been more particularly urged by Giuffr^. The diastolic aspiration performed by the left ventricle must be hindered in mitral obstruction, and if diastole be regarded, as it is by many authors, as an active muscular process, it follows that a certain amount of hyper- trophy will be produced by interference with it. The right ventricle is almost invariably involved when mitral obstruction is present, because no matter how thorough may be the attempt at compensation by means of the left 526 AFFECTIONS OF THE MITRAL ORIFICE. auricle, there still remains a certain increased stress upon the pulmonary veins, capillaries, and artery, by means of which an increased amount of energy is demanded of the right ventricle. It therefore becomes hypertrophied, as was indeed thoroughly understood by Corvisart. If failure of the energy of the heart makes its appearance, dilatation ensues, and as a consequence, more or less permanent tricuspid regurgitation results, which leads in turn to implication of the right auricle, showing itself both by hypertrophy and dilatation as a general rule. In most instances of mitral obstruction there are evidences of chronic venous stasis in the lungs. Dilatation of the pul- monary capillaries and brown induration are the common results observed. Kupture of some of the blood vessels is apt to occvir with resulting ha?morrhage. If compensation fails venous stasis passes into cedema, and when the right side of the heart fails there is apt to be hydrothorax. Brockbank lias recently called attention to a very interesting fact : — that gall-stones are much more frequently found in mitral obstruction than in other conditions. His results are that while cases without heart disease have a percentage of 5 "4 of gall-stones, cases of mitral obstruction show 21-8 per cent. Symptoms. — Mitral obstruction may be absolutely latent ; there are many cases in which a lesion, quite insufficient to produce any retardation of the onward passage of the blood, may yet give rise to interference with the current such as may be able to produce some of the characteristic physical signs by w^hich obstruction is recognised. In such instances as these, and they are by no means uncommon, there is obstruction which may be termed relative. The earliest symptoms of mitral obstruction are connected, as might well be expected, with the pulmonary circulation. Inasmuch as the hindrance to the access of blood brings about disturbances in the pulmonary veins and their tributaries, in- terference with the aeration of the blood is an early symptom. Breathlessness is accordingly one of the first, as it is one of the most persistent, symptoms of mitral obstruction, when the equilibrium of the circulation is disturbed. It may only be present on exertion, the patient at other times suffering MITRAL OBSTRUCTION. 527 from no inconvenience, Ijut in those instances which present some lack of compensation the breathlessness is apt to be con- stant, and on exertion it becomes serious dyspnoea. Paroxysmal dyspnoea, not infrequently periodic, makes its appearance in a considerable number of cases. These are to be regarded as falling under the title of cardiac asthma. As a result of the venous stasis in the lungs, there is a great liability to pulmonary affections such as broncho- pneumonia, and when the retardation of the blood current is more seriously interfered with, passive hypersemia and conse- quent oedema make their appearance. To breathlessness there are therefore added such symptoms as cough, attended by the expectoration of sputum, very fluid in character and often con- taining blood. In consequence of the long-continued backward pressure, some of the blood vessels may rupture, and the pul- monary hcemorrhage so produced reveals itself by the expec- toration of blood in a more or less unchanged condition, attended by the general symptoms of pulmonary hsemorrhage. It is to be remembered that the bronchial veins, which end in the right auricle, are not involved unless the right ventricle has begun to suffer in consequence of the mitral lesion ; as the bronchial arteries, nevertheless, do not supply as -much blood to the walls of the bronchial tubes as in health, on account of the reduction of the general arterial pressure, the bronchial tubes are liable to pathological changes. When, in addition to reduction of pressure in the bronchial arteries, there is produced, by interference with the right ventricle, a condition of high pressure in the bronchial veins, chronic bronchial catarrh is inevitable. Pain cannot be regarded as a frequent symptom of mitral obstruction. It nevertheless occurs in a proportion of cases, and it is more likely to be localised over the anterior chest wall with little tendency to radiate into the shoulder and arm. As a consequence of the reduction of pressure in the arteries, the brain often suffers. Insomnia and headache frequently present themselves in the course of the disease. When the right side of the heart fails in consequence of mitral obstruction, there occur all the characteristic symptoms of pronounced tricuspid incompetence. There is oedema of all 5 28 AFFECTIONS OF THE MITRAL ORIFICE. dependent parts. The functions of the digestive viscera are perverted, so that there is gastro-enteric catarrh, feeling of , weight in the region of the liver, enlargement of the abdomen if ascites should supervene, increase of breathlessness if hydro- thorax should occur, alarming tendency towards syncope if hydropericardium be present, scanty urine containing albumin, and suppression of the catamenia. The appearance of any patient presenting pronounced symptoms of mitral obstruction is often eminently character- istic. Even in the case of patients who have but little cyanosis there is a tendency towards a dusky flush high up upon the cheeks, between which and profoundly cyanotic phenomena there is every intermediate gradation. It would be erroneous, however, to allow such a statement to pass with- out remarking that this mitral facies is frequently absent, and there may be nu obvious change in the external appearance of the patient. One of the most common forms of mitral ob- stuction is to be found in young women of purely chlorotic appearance. Pallor of the skin, blanching of the mucous membranes, dyspncea, palpitation, constipation, and catamenial and nervous troubles are present. To this special variety particular attention has been directed by Petit. The pulse in mitral obstruction is sometimes destitute of any special characters, but much more commonly it has some noteworthy features. During the early phases of the disease the only characters present are that the vessel is rather empty, and shows a degree of pressure somewhat below the normal, but it is perfectly regular and quite equal. A sphygmographic tracing taken at this stage may closely resemble many obtained in apparently perfect health. Later on, however, in the development of the disease, the pulse manifests features showing much greater departure from the normal. The vessel becomes more empty and the pressure falls to a much lower level, while at the same time the rhythm becomes extremely irregular and the pulse waves are very unequal. A sphygmographic tracing taken at this period is often extremely characteristic, as is shown in Fig. 148. On inspection of the neck some morbid appearances may be seen connected with the veins, but as these are the effect MITRAL OBSTRUCTION. 529 of the tricuspid incompetence resulting from the mitral affec- tion, consideration of them will be delayed until the tricuspid disease is considered. The prsecordia usually shows some diffuseness or indefinite- ness of the apex beat, which is frequently displaced outwards to the left, and it may in addition give evidence of some pulsation to the right of the sternum as well as in the epi- gastrium. Palpation sometimes furnishes no evidence of any par- ticular importance, but in many cases it yields information of sufficient value to effect a diagnosis. No phenomenon may be perceived on the application of the hand, with the exception of diffuseness of the apex beat and increased pulsation to the right of the sternum, as well as around the xiphoid cartilage. Fig. 148. — Tracing from the radial artery in a case of mitral obstruction ; pressure 2| oz. but in many cases a thrill is felt at the apex of the heart. This may be presystolic or diastolic in rhythm, and it is, with the exception of those few aortic cases previously referred to, pathognomonic of mitral obstruction. The sensation which is communicated to the hand is extremely well indicated by the name applied to it by those who studied it first in France, from its resemblance to the vibrations produced by the purring of a cat. The thrill is most commonly felt immediately before, and leading up to, the apical impulse. It is also quite common, however, immediately following the second sound ; and of very frequent occurrence, moreover, is a series of vibrations beginning with the impulse accompanying the second sound, and filling up the entire period until the occurrence of the apex beat. When this is the case the thrill may be found to wane somewhat during the post-diastolic period, and to wax again in intensity as it approaches the apex beat. It is obvious that there are three factors at work 34 530 AFFECTIONS OF THE MITRAL ORIFICE. in producing this thrill. There is, in the first place, the force, necessarily small in degree, exerted by the blood returning into the auricle by the pulmonary veins. There is, secondly, the aspiratory attraction produced by the active diastole of the left ventricle, and there is, thirdly, the energy produced by the contraction of the left auricle. The diastolic thrill is the result of the suction resulting from the active diastole of the left ventricle. The presystolic thrill is the direct consequence of the contraction of the left auricle ; both of them are prob- ably in part produced by the onward flow of the blood return- ing from the lungs, and in those cases presenting a continuous thrill, beginning with diastole and ending with systole, it is probable that this latter force fills in the interval between the diastolic and presystolic portion of the thrill. It is not at all improbable, however, that in such cases the systole of the left auricle begins somewhat earlier than is its wont, so that its commencement may immediately follow the cessation of the diastole of the ventricle. Eolleston points out that in some cases a vibration of the chest wall is caused by the action of an energetic heart on rigid ribs. He throws out the useful hint that, if there be any difficulty in determining whether an intra-cardiac origin is present or not, the fingers should be separated and placed in the intercostal spaces where the real valvular thrill is to be felt, while the osseous vibration disappears. Cardiographic tracings taken from the apex beat in cases of mitral obstruction might be expected to reveal some import- ant facts connected with this thrill. Much experience with this instrument has, however, failed in my hands to yield any profitable results. It might be thought that the various vibrations which go to make the thrill would be represented in a tracing taken from the apex beat. This, however, is seldom the case. The explanation is probably that the vibrations are in a great measure too subtle for our present means of investigation. An example of the tracing obtained by means of the cardiograph from a typical case is given in Fig. 24, p. 135. Palpation frequently fui-nishes another important indica- tion. At the base of the heart a very distinct impulse may MITRAL OBSTRUCTION. 531 be detected attendant upon the closure of the semilunar cusps. This impulse is best felt over the second left intercostal space, and is produced by the increased pressure within the pulmonary circuit ; it is of considerable importance from the point of view, not only of diagnosis, but also of treatment. On percussion the area of cardiac dulness is sometimes absolutely unaltered. This is particularly the case when the obstruction is but slight, and the right heart therefore but Fig. 149. — Presystolic murmur. little involved. It is, however, more common to find that the transverse diameter of the area of dulness is more or less increased to the right as well as to the left — in fact the increase is usually greater towards the right than towards the left. The facts ascertained by auscultation constitute the most characteristic feature in most instances of mitral obstruction. These consist in alterations in the rhythm and character of Fig. 150.— Diastolic murmur following second, sound. both cardiac sounds, as well as in the presence of abnormal sounds or murmurs. It may be stated as a general rule that those cases which present no characteristic murmurs of ob- struction, but in which there are alterations in the character of the normal sounds of the heart, are more serious than those in which distinct obstruction murmurs are present. In cases of pure mitral obstruction unattended by regurgita- tion, and uncomplicated by any disturbance of the right heart, or other result of failing compensation, the physical sign 532 AFFECTIONS OF THE MITRAL ORIFICE. found on auscultation is the characteristic murmur. This murmur may be presystolic, early diastolic, or late diastolic in rhythm, as shown in the accompanying figures. That is to say, it may be produced by the contraction of the left auricle, by the aspiratory force of the left ventricle, or possibly by the onward flow of the blood impelled by the energy of the right ventricle. This last factor cannot be regarded as so absolutely certain as the other two ; yet it is extremely probable. The causation of the diastolic murmur of mitral obstruction has lately been the subject of an interesting paper by EoUeston. The murmur is always rough in character. The same features which are translated by the sense of touch as a thrill give rise to the perception of sound, and, as in all other cases of this kind, when a thrill is perceived the sound which Fig. 151. — Late diastulic inurmur. accompanies it is harsh. The degree of harshness is not the same in the three different periods. The presystolic is almost invariably harsher than the diastolic murmur, and the early diastolic is always harsher than the late diastolic murmur. Many controversies have arisen in regard to the presystolic murmur. These have, in so far as is necessary, been men- tioned in the section dealing with murmurs in general, and require no further remark in this portion of the work. The presystolic murmur usually terminates in a more or less accentuated first sound, and in instances of simple obstruc- tion the sound is quite clear, being neither accompanied nor followed by any systolic murmm\ These murmurs are sometimes entirely absent, and many cases of mitral obstruction escape detection in consequence. It has abeady been seen that amongst cardiac murmurs those which are the result of mitral obstruction are much the most variable, and cases of pure obstruction of this orifice may at one time give a well-marked presystolic murmur, ending with MITRAL OBSTRUCTION. 533 a loud first sound; at another there may be a characteristic diastolic murmur; and yet again a late diastolic murmur may make its appearance. Mitral obstruction is very frequently accompanied by accentuation of the pulmonary second sound, or doubling of the second sound at the base, in which the pulmonic element is the louder. The explanation of this phenomenon has already been fully discussed in a former chapter of this work, and the subject need not again be entered upon. This doubling of the second sound undergoes considerable variation, not only in the intensity of the sounds and in the interval by which they are separated, but there is also a great tendency towards the dis- appearance and reappearance of the doubling. In very many instances mitral obstruction fails to yield any characteristic phenomena on auscultation. As already seen, the presystolic and diastolic murmurs are extremely variable in their occurrence ; their disappearance and reappear- ance are matters of everyday observation. The doubling of the second sound at the base of the heart, moreover, may also be absent, and even when it is present it is not of diagnostic importance, inasmuch as it may have its origin in some cause other than obstruction at the left auriculo-ventricular orifice. As a rule, in mitral obstruction the first sound is somewhat roughened, even when there is no evidence of a presystolic murmur, a subject which has already been described in a previous chapter. Diagnosis. — The recognition of mitral obstruction when its physical signs are fully present can never be a subject of any difficulty. The thrill, the murmur, and the doubling of the second sound, with pulmonic accentuation, present a triad of symptoms quite unmistakable. It is, however, far otherwise when all these fail ; this they often do, for in the case of im- complicated mitral obstruction there may be absolutely no evidence upon which a diagnosis may be based. As will be seen in dealing with combined mitral lesions, there is almost invariably sufficient evidence of both lesions, but in simple obstruction it is otherwise. Nevertheless, there is in most instances a degree of roughness about the first sound which throws some light upon the case, and this harshness in the 534 AFFECTIONS OF THE MITRAL ORIFICE. quality of the first sound, especially if associated with a double second sound, is often sufficient to justify the inference of obstruction. If is difficult to say how it would be possible to determine in the case of double aortic murmurs associated with a pre- systolic murmur heard at the apex, whether this latter should be regarded as proof of a coincident mitral obstruction, or as being simply the aberrant murmur first noticed by Flint. The condition of the pulmonary second sound might possibly furnish some evidence. It must, however, be borne in mind that when there is obliteration of the aortic, there is no criterion by which to judge of the intensity of the pulmonary second sound. The state of the base of the lungs, and the condition of the right side of the heart, might also be helpful. Such points would require the most careful consideration, and might be really useful in diagnosis. This murmur has never come under my notice, or, as it might be better put, no presystolic murmur at the apex has ever been under my observation in which subsequent post-mortem examination has not revealed a mitral lesion ; all this is accordingly pure speculation on my part. Obstruction of the mitral orifice by means of a peduncu- lated thrombus attached to the wall of the left auricle has recently been described by Ewart and Eolleston. The rational symptoms and physical signs were identical with those of mitral obstruction and incompetence, and there could in such a case be no possibility of reaching a correct diagnosis. Prognosis. — In simple uncomplicated mitral obstruction the outlook cannot be regarded as very serious. In most instances where obstruction exists alone it is not very great, and it therefore interferes but little with the circulation. When obstruction is present in a higher degree it is almost invariably accompanied by regurgitation as well, and the prog- nosis in such cases must be considered elsewhere. Even in simple uncomplicated mitral obstruction the prognosis must always be given with reservation. There cannot be a doubt that any extra fatigue, physical or psychical, may in such cases produce a total breakdown of the circulatory equilibrium, which may be followed by fatal results. Furthermore, the patient who has any lesion of the mitral cusps is liable under the influence MITRAL OBSTRUCTION. 535 even of apparently trivial affections to suffer from a lighting up of the valvular disease. As contrasted with other valvular lesions, mitral obstruction may be said to be rather more serious than aortic obstruction ; somewhat less serious than mitral incompetence ; and very much less dangerous than aortic regurgitation. It is hardly necessary to say that when compensation has been disturbed the outlook is much more serious, and symptoms showing that there is any implication of the lungs are to be regarded as warnings not to be overlooked. When oedema shows itself, or when the abdominal viscera are involved, the prognosis becomes even more serious. Treatment. — In cases of mitral obstruction the great aim of treatment must be to obviate, in so far as may be possible, the tendency to pulmonary disturbances, seeing that the first symptom of failing compensation is an implication of the pulmonary veins. While therefore undertaking the treatment of mitral obstruction on the general principles applicable to all cases of valvular disease, the principal care in regard to this lesion must be devoted to preventing or removing any complica- tions connected with the lungs. The avoidance of sudden vicissitudes of temperature should be strictly enjoined, and if there be the least appearance of any pulmonary complication, it is well to confine the patient at once to a thoroughly ventilated apartment, with an equable temperature, and if necessary, to employ steam, either simple or medicated, as an inhalation. At the same time, even in those cases in which compensation is apparently perfect, it is advisable to employ strophanthus or digitalis in moderate doses, along with some ammoniacal stimulant. The further methods of treatment are those which have been described from the general point of view. Case 27. Mitral Obstruction. — B. R, aged 20, engaged in house-work, ■was admitted to Ward 25 of the Eoyal Infirmary, 1st February 1897, suffering from palpitation and breathlessness. There were no well-marked hereditary tendencies, and the patient's occupation and surroundings had always been satisfactory. At the age of 10 the patient suffered from chorea for about a month. About the age of 12 she frequently observed swelling of the ankles at night, but this entirely passed away and no 536 AFFECTIONS OF THE MITRAL ORIFICE. recurrence took place until recently. Slie liad often been attacked by sore throat, but there had beeii no other rheumatic symptom. Five yeax's before atlmission the jiatient's attention was attracted to breathlessness on exertion, often attended by pal]iitation. Both of these symptoms lessened on resting. In spite of medical assistance these symjitoms remained, with occasional improvement and relapse, but during tlie few months preceding her admission she liad been entirely incapacitated for any work. On admission the patient was found to be 4 ft. 11 in. in height and 8 St. 11 lb. in weiglit. The temiJerature was normal. There were no obvious CA-idences of disease with the exception of a somewhat bright flush on the cheeks. The teeth were much decayed, the appetite was good, thirst was complained of. On examination of the abdominal viscera no abnormality could be detected. Slight enlargement of the lymphatic glands in the region of the jaws was obvious. The patient complained of some pain in the region of the sternum if the surface was chilled. Pal2)itation occurred on the least exertion or emotion, and there was a sensation, sometimes as if the heart were turning over, sometimes as if it had stopped. Breatlilessness always attended those symptoms, and was excited liy tlie least exertion. There were no apjiear- ances of cyanosis connected with the miicous meml)ranes. The radial artery had perfectly healthy walls. The pressure was low, the rate of the pulse 66 jier minute, and the rhythni perfectly regular. On inspection of the prajcordia the apex beat was clearly visible oiitside of the left mammary line, five inches from mid-sternum. On palpation the impulse of the heart was felt to be of moderate intensity and preceded by a distinct purring thrill. The area of cardiac dulness extended two inches to the right and six to the left of the mid-sternal line, its upper border being at the lower level of the second left intercostal sjjace. On auscul- tation in the aortic area no abnormal somids were audible. In the mitral area there wa-s a distinct murmur of mitral obstruction, commencing shortly after the second sound, waning somewhat in intensity and increasing again in loudness up to the first sound, Avhich was distinctly slaiJjaing in character, but jjerfectly closed. This murmur was harsh in character. In the pulmonary area the second sound was much accentuated but not doubled. In the tricuspid area no abnormal sounds could Ije heard. The resj^ir- atory system revealed absolutely no symptoms of disturbance, and no other organ of the body was implicated. By means of absolute rest and appropriate food, along with digitalis, she rapidly improved. This was followed in a week by strychnine and arsenic, and on 1 7th February the patient left hospital greatly improved in every resj)ect. This was a most excellent example of pure uncomplicated mitral obstruction in which compensation had been fairly well established but was liable to be disturbed. If the patient had been in a position in which it would have been necessary for her to go on wnth her work at all costs, there would inevitably MITRAL OBSTRUCTION. 5 37 have been implicatiou of the right side of the heart and a total breakdown. Case 28. Mitral Obstruction ivith Anaimia and Leucocytusis. — M. S., aged 20, a ward maid in tlie Eoya] Infirmary, liad been from time to time mider my observation, and was admitted to Ward 25, 6tli January 1896, on account of breatlilessness and deliility. Her family history showed no facts bearing on the affection for which she was under treatment, and her social conditions had always been satisfactory. She had suffered from no disease which could in any way be connected with the affection in regard to which she sought advice. For some months she had suffered from the symptoms for which she was admitted. On examination she was found to be 5 ft. 3 in. in height and 7 st. 13 lb. in weight. Her face was marked by a considerable degree of pallor ; the lips, gums, and conjunctiva were also pale. The radial artery had healthy walls ; it was fairly full and the blood j^ressure was moderate. The rate of the pulse was 78 ; its rhythm perfectly regular and the character of each pulse wave showed no departure from the health standard. There were no marked appearances connected Avith the veins of the neck or any other j)art of the j)eripheral circulation. Inspection showed the ajoex beat to be in the fifth left intercostal space, three inches from mid-sternum. No other impulses were visible. On palpation, a rough thrill was found in the apical region, which began with the second sound and was continued up to the ventricular systole. The right border of the heart was found to be one and a half inches from mid-sternum, and the left was four inches from that point. On ausculta- tion, a harsh murmur was heard in the mitral area, which commenced with the second sound and was continued, waning at first, and aftenvards waxing in intensity, until it culminated with the first sound. The first sound itself was clear and unattended by any murmur. No evidence of any further abnormality could be detected in any other area, and there was almost no accentuation of the pulmonary second sound. The condition of the patient calls for no further remark except in regard to the state of the blood, on investigating which it was found that the hsemoglobin amounted to 50 per cent, and the number of the red blood corpuscles to 3,000,000, while the white blood corpuscles reached 20,000. Dr. Eobert Muir kindly examined the blood along with me, and reported that the increase of the leucocytes more especially concerned the multinucleated forms, although eosinophile cells were also more numerous than usual. He regarded the con- dition as simply a leucocytosis, although the cause of the condition was not evident, as in cases of chlorosis the leucocytes are usually diminished in number. In this case the red blood corpuscles were somewhat altered in form, as often occurs in 538 AFFECTIONS OF THE MITRAL ORIFICE. cases of chlorosis. There were uo nucleated red blood corpuscles and the blood plates were about the normal. It is quite possible that the case may be justly regarded as one of tliose linked with, if not depenilent upon, chlorosis in some obscure pathological nexus. In this case the use of protochloride of iron and arsenious acid along with rest caused a rapid disappearance of the symptoms for which she was admitted to the ward, and in twenty-one days she was dismissed. MITRAL INCOMPETENCE. Little need be said in regard to the history of our know- ledge of mitral regurgitation. The lesion was anatomically recognised by the old authors to whom reference has so fre- quently been made, and the clinical recognition of the affection was due to the indefatigable exertions of the early auscultators of this century. The remarks of Laennec upon this subject are unfortunately most obscure, even in the later editions, as for example that which is so well known through the medium of Forbes' translation. With the work of Hope, the facts in regard to mitral reguroitation assumed definition and correct- ness, since he taught that regurgitation was denoted by a murmur attending upon the first sound. It must be admitted that his localisation of the murmur left a good deal to be desired, seeing that he stated that it was " louder opposite to the mitral valve (viz. at the left margin of the sternum, between the third and fourth ribs, i.e., about three or four inches above the point where the apex of the heart beats) than elsewhere." From this time onwards gradual additions were made as regards the details of the clinical features of mitral incom- petence, to some of which reference will be made in the sequel. As in the case of the aortic, the mitral orifice is not pro- vided with any means by which a reflux of blood can occur under strictly physiological circumstances. There is no provision whereby a safety-valve action can occur, such as is character- istic of the tricuspid valve. This fact was noticed last century by Hunter, and was emphasised long ago by Adams, who stated in his remarkable paper, " that the mitral valve so MITRAL INCOMPETENCE. 539 perfectly closes the aperture of communication between the left auricle and ventricle, that in the natural state no reflux whatever is admitted. This (the reflux) so useful at the right side of the heart, would have been not only useless but injurious at the left side of the organ, as we find the general arterial system at all times equally ready to receive the blood during the systole of the left ventricle ; and if the mitral valve did not perfectly close the left auriculo- ventricular aperture, a great deal of the force of the aortic ventricle would be wasted, whereby it would be incapable of moving the mass of blood which was destined to fill the arterial system. Pathologists, in looking to the different nature of the lining membrane at the two sides of the heart, as a means of explaining the greater liability of the left side to disease, have, perhaps, too much overlooked this circumstance, that while, from the unyielding nature of the mitral valve, all reflux into the auricle is pre- vented, from this very cause, which renders it effective in the circulation, is it exposed to more frequent injury from which organic disease may arise, and the ventricle to which it belongs becomes more liable to be ruptured by its own efforts." This most interesting passage, from a monograph which really laid the foundations for much of our present knowledge of cardiac pathology, is eminently worthy of consideration. Etiology. — Mitral incompetence may be produced by changes in the cusps themselves or in the tendinous cords. Such alterations may result from endocarditis taking origin in the many different causes which have already been passed in review in dealing with that subject. It may, on the other hand, be the result of degenerative changes occurring in later life, or from long -continued strain. It may, further, be caused by traumatic agencies of direct or indirect origin, the result of which is to rupture some part of the valve, or tear some of the chordae tendinese. The lesion is also produced by changes in the myo- cardium which interfere with the normal adaptation of the cusps. All causes which lessen the nutrition of the heart wall can in this way give rise to escape at the mitral orifice. Amongst such causes may be mentioned the febrile state, wasting diseases, ansemia, simple debility, myocarditis, and 540 AFFECTIONS OF THE MITRAL ORIFICE. muscular degeneration. It need hardly be added that muscular stress in such states is a determining factor. The incompetence may be brought about by interference with the muscular ring, or sphincter as it may be termed, whereby the normal systolic reduction in the size of the orifice is lessened, as was emphasised by Macalister. It may, moreover, be pro- duced by dilatation of the ventricular cavity and disturbance of the functions of the papillary muscles, whereby the ap- proximation of the segments is interfered with. Mitral incompetence arising from those valvular lesions belonging to the first category is absolutely incurable. When produced by the causes belonging to the second group it is not infrequently a remediable disorder. Morbid Anatomy. — In those forms of mitral incompetence resulting from endocarditic processes there is almost, if not quite, invariably some contraction of the orifice, as well as incompetence of the valve — the combination, in short, of obstruction and incompetence. The cusps, therefore, present the appearances which have been already discussed in dealing with mitral obstruction. The lesions which produce the incompetence are shrinking of the cusps and fusion of their margins, frequently attended by the presence of vegetations. Degenerative changes producing mitral incompetence do so by giving rise to rigidity and contraction of the cusps, resulting in deformity, and often associated w^ith the different deposits, fibrous, fatty, and calcareous, which have been previously described. When produced by traumatic causes, mitral incom- petence usually shows rupture of the chordte tendinese, or of the cusp close to the attachment of the tendinous bands. The various causes which lead to mitral incompetence by acting on the cardiac muscle may do so in a threefold manner. There may be simply an enlargement of the auriculo-ventricular orifice by means of relaxation of the muscular structures sur- rounding it. Such a widening of the orifice must of necessity render it more difficult for the cusps to be adapted to each other, and thus an incompetence is produced. An enlargement of the ventricular cavity may in the next place produce mitral incompetence in consequence of want of adaptation of the cusps, seeing that the ventricular walls may MITRAL INCOMPETENCE. 541 become enlarged to a greater extent than the papillary muscles. In conditions of muscular relaxation it is quite obvious that this may occur, seeing that the relative extent of the ventri- cular wall as compared with the papillary muscle is so much greater. If the ventricular cavity enlarges to a greater extent than the papillary muscle, there must necessarily be a want of adaptation of the cusps. In many cases these two different processes are found to be associated. A dilatation of the orifice is attended by an enlargement of the ventricular cavity, so that there is not merely a wider opening than can be closed by the cusps, but there is also a diminished power of adaptation from the disturbance of the relations between the papillary muscles and chordce tendinese, on the one hand, and the size of the cavity, on the other. It must ever be remembered that a good many of the causes and effects which have just been considered are associated together. It is very common to find shrunken cusps fused together, and not merely studded with vegetations but altered by degenerative processes and associated with an enlargement of the orifice or even of the ventricular cavity. The effects produced upon the heart by mitral incompetence are seen mostly in the left auricle and on the right side. The condition of the left auricle depends largely on the amount of regurgitation. When the regurgitation is free, the left auricle is found to be very considerably dilated, as well as hyper- trophied. If, however, the regurgitation is not excessive, the condition is more like that which has been seen in mitral obstruction; i.e., there is more hypertrophy of the auricular wall than dilatation of the cavity. The condition of the right side of the heart is entirely dependent on the amount of interference with the passage of the blood through the lungs, and it there- fore bears some relation to the degree of regurgitation, and the consequent changes in the left auricle. The right ventricle is usually at once dilated and hypertrophied. The relative degree of dilatation and hypertrophy appears to be conditioned mostly by the nutritive possibilities of the heart. The condition of the left ventricle is a matter which has been much disputed. It might at first sight appear that the 542 AFFECTIONS OF THE MITRAL ORIFICE. left ventricle should not undergo any considerable alteration in consequence of a change in the mitral orifice. Nevertheless, it has to be remembered that when regurgitation backwards into the left auricle is allowed, a larger amount of blood must be poured by the auricle into the ventricle during auricular systole, and the ventricle must therefore have a larger amount of blood within it at the commencement of systole. Its work is therefore augmented, so that, as is well put by Petit, " le ventricule gauche subit indirectement le contre-coup de I'in- suffisance." This appears to be the explanation of the common occurrence of dilatation and hypertrophy of the left ventricle. The cavities on both sides of the heart frequently contain ante-mortem and post-mortem clots deposited upon the walls and amongst the tendinous cords, to which they are some- times found firmly adherent. Dilatation of the radicles of the pulmonary veins is almost invariably present, and in consequence of the long-continued stress to which they are subjected, the ramifications of the pulmonary artery and pulmonary veins are often found to be atheromatous. As results of these changes in the pul- monary vessels, more distant effects are found in the lungs. Chronic venous stasis leads to a condition of hypertrophy and oedema, in which the lung presents a close superficial re- semblance to the spleen, and the presence of haemorrhages is extremely common. The liver, the spleen, and the kidneys undergo the various changes consecutive to cardiac failure, mostly in the direction of fibrous increase, giving hardness and toughness, and the hollow viscera are found in a state of chronic venous enlargement with catarrh of the mucous membranes. The heart itself, when not undergoing fatty chansres, is also the seat of fibrous increase. The brain has venous hypersemia with oedema and effusion. Symptoms. — Mitral incompetence is often latent. So long as the heart is possessed of reserve energy, and is therefore able to restore the disturbed balance of the circulation, the existence of compensation prevents the development of any functional disturbances. It is otherwise when the equilibrium is lost, when various subjective and objective symptoms obtrude themselves. MITRAL INCOMPETENCE. 543 Uneasiness, sometimes amounting to pain but more com- monly giving the sensation of weight, is experienced in the region of the prsecordia. Such sensations are not commonly complained of while patients are at rest, but they make themselves manifest on the slightest exertion. Breathlessness is a very common symptom, and it also is chiefly found on exertion. Cough is extremely frequent in mitral incompetence, and in those cases characterised by cardiac failure the cough is attended by a watery sputum. Nausea is often experienced, and occasional vomiting is its result. Sensations of faintness and of giddiness, often accompanied by feelings of fulness in the head, or even by pronounced headache, are of common occurrence in this disease, and it is above all others that which is most likely to give rise to insomnia, and even brain symptoms such as illusions, hallucina- tions, and delusions. The victim of mitral incompetence frequently shows the same appearances as have already been mentioned in regard to mitral obstruction. The dusky flush upon the cheeks, the cyanotic hue of the lips, ears, and nostrils, the arborescent capillaries upon the surface, the congested aspect of the eyes, — all are present in this disease and are somewhat more marked than in obstruction. A certain degree of jaundice is quite common in mitral incompetence, and when associated with cyanosis it produces a striking green shade of the complexion. (Edema of the dependent parts of the body coming on at night in the less severe cases, but persistent in those which are more serious, is seldom absent. In uncomplicated mitral regurgitation the pulse may have little trace of departure from the normal standard, and sphyg- mographic curves may present a comparatively natural appear- ance, as shown in Fig. 152. The chief alterations undergone by the pulse lie in the direction of reduced pressure without much interference with the rhythm. In the later stages of the affection, however, and in those cases of organic incom- petence when it is associated with obstruction, the pulse becomes empty, its pressure is low, its rate is accelerated, and its rhythm disturbed. In such instances the typical mitral 544 AFFECTIONS OF THE MITRAL ORIFICE, pulse may make its appearance, characterised by simple inter- mittence or extreme irregularity along with inequality of the , pulsation. Examination of the neck frequently shows venous pulsation due to interference with the right side of the heart. The priecordia may present no morbid })henomena on in- spection. It is, however, on the other hand, a very common occurrence to find the apex beat displaced outwards to the left. The impulse may be diffuse, and its situation, therefore, rather difficult to determine. There is not infrequently a distinct movement from above downwards in the third, fourth, and fifth intercostal spaces, and heaving in the epigastrium is of common occurrence. In this place reference may be made in Fig. 1o2.— Tracing taken with Marey's spliygmograph from the radial artery in a case of mitral incompetence ; pressure 2 oz. passing to the pulsation in the second left intercostal space, which is regarded by Naunyn and Balfour as the result of regurgitation from the left ventricle into the left auricle; the consideration of this subject, however, will be taken up when the different myocardial changes are discussed. On placing the hand over the prsecordia the cardiac systole may be found to present very different forms of impulse. Most commonly it produces a somewhat diffuse and rather feeble beat, often followed by an extremely sharp impulse accompanying the second sound, produced by the increased pressure within the pulmonary artery. Uncomplicated mitral incompetence is never accompanied by any thrill. This is a point to which particular care has been devoted by myself, and during many years' experience of this disease no case has ever presented itself for my observation in which a thrill was perceptible. Petit describes a systolic vibration commencing MITRAL INCOMPETENCE. 545 with the apex beat and accompanying the entire systole almost up to the second sound, and he attributes it to the vibrations, produced under the energetic contraction of the ventricle, by the blood wave passing through the orifice into Fig. 153. — Sy.stolic luuniiur following first sound. the auricle. Such a phenomenon has never presented itself before me. Percussion of the" cardiac area reveals an enlargement laterally in both directions. The left border of the heart is enlarged outwards, so that it may extend beyond the mam- PiG. 154. — Systolic murmur accompanying first sound. miliary line, while the right border passes considerably farther outwards than in health. It is probable that the enlargement in both directions is due to the dilatation and hypertrophy of the right side of the heart, which causes it therefore to be projected farther over towards the left. Fig. 155.— Systolic murmur replacing first sound. On auscultation in the mitral area the characteristic murmur, following, accompanying, or replacing the first sound, is heard with its maximum intensity at that point. The rhythm of each variety is shown in Figs. 153, 154, and 155. The character of this murmur varies immensely, being some- times low, soft, and blowing, and at other times high, rough, 35 546 AFFECTIONS OF THE MITRAL ORIFICE. and rasping. From the differences in the sound there is sometimes a tendency to draw certain conclusions as to the probable nature of the incompetence, yet he would be a some- what bold observer who ventured to predict with too much refinement the exact nature of the lesion proljahly to be found. Nevertheless, in cases of mitral incompetence produced by organic changes in the cusps, the murmur is generally higher in pitch and harsher in quality — therefore presenting charac- teristics which may be summed up in the word shrill — than is the case in regurgitation resulting from muscular relaxation. The point of maximum intensity of the murmur of mitral incompetence is almost invariably at or close to the apex beat. It is propagated from this region in every direction, but to a different extent ; for as has been shown in a previous section of this work, it is conducted to a greater distance in the direction of the axilla and scapula. In many instances it can be heard throughout the whole chest, as well over the riojht as the left side. A mm^mur often heard outside of the pulmonary area, in the left second intercostal space, is regarded by Naunyn and Balfour as one of mitral incompetence propagated upwards from the seat of origin, at the valve, by means of the auricle to the appendix. This will be found discussed in a future chapter. The position of maximum intensity of the systolic murmur in mitral incompetence is not altogether easy to explain. The close proximity, however, of the ventricular wall affords an easy means for the transmission of the sound, and it has to be remembered that the escape takes place through the cusps which are drawn down in the direction of the a.pex. The observations of Bergeon tend to show that the con- duction of the murmur towards the apex is in part due to the eddy of the blood between the valvular cusps and the ventricular wall. Very frequently the murmur is found to have a position of intensity almost as great as that over the apex beat at a point between the left shoulder-blade and the vertebral column, and there cannot be the shadow of a doubt that the conduction of the murmur to this point is due to the proximity of the left auricle. MITRAL INCOMPETENCE. 547 The intensity of the murmur presents many variations. It occasionally is only an accompaniment of a well-marked first sound. At other times it entirely replaces the sound, and apparently these different appearances are produced Ijy the relation existing between the strength of the muscular wall and the condition of the incompetent cusps. The second sound in the pulmonary area almost invarialjly undergoes changes in mitral incompetence. It may be merely accentuated, or it may be doubled, and as will be described in the subsequent section dealing with the affections of the pul- monary valve, there may be a diastolic murmur of escape through the pulmonary orifice from high pressure. Diagnosis. — The diagnosis of mitral incompetence is always an easy matter, but, while the mere determination of regurgitation can never present any difficulty, it is not so simple to deal with the differentiation between incompetence due to a valvular lesion and that due to muscular relaxation. It may be said, as a general rule, that when there is any evidence of obstruction as well as incompetence, the latter is due to an organic change in the valves, and the presence, therefore, of any of the features already detailed as pointing to the presence of mitral obstruction is of use in this regard. It is sometimes stated that doubling of the second sound is pathognomonic of obstruction, and that its presence always indicates in cases of mitral incompetence the existence also of some valvular occlusion. This, however, as has already been stated previously, is an erroneous conception, and doubling of the second sound is not to be regarded as being of any dia- gnostic import. Prognosis. — The prognosis in mitral incompetence depends upon so many different circumstances that it is by no means easy to deal with. Simple mitral incompetence of slight degree may exist for many years without appreciable interfer- ence with health. The difficulty comes in, however, on attempting to determine in any given case whether the amount of regurgitation is small or large. The evidence afforded by physical examination is not altogether unmistakable, and the persistence of good general health and freedom from pul- monary symptoms, in spite of the existence of mitral incom- 548 AFFECTIONS OF THE MITRAL ORIFICE. petence, will be found to atiurd a Itetter l)asis upuii which to rest a hopeful prognosis than any results of investigation. The absence of any symptoms of venous stasis, the freedom of the right side of the heart from any serious implication, the existence of an energetic cardiac impulse, and the presence of a loud first sound, are elements in any individual case which should justify a hopeful prognosis ; and it may be added that, as a general rule, the outlook is more favourable in those cases in which a loud systolic murmur is present than in those in which an extremely feeble murmur can be detected. The existence of fair arterial pressure, and regular as well as equal pulsation, are also to be regarded as fiivourable appearances. Excessive frequency of the pulse is, as in almost all other conditions, a feature of the gravest import. Mitral incompetence commencing in early life is necessarily of greater severity than when it is established at a later period, since it interferes with the processes of develojDment and leads to disturbance of the general nutrition. Treatment. — It often happens that the physician is placed in a position which allows him to observe the develop- ment of mitral incompetence. This occurs when the lesion takes its origin in some febrile affection. In such circum- stances, Ijy the exercise of care a considerable amount of influence may lie exerted upon the future of the disease. By means of absolute rest, fluctuations in Ijlood pressure may be avoided, as far as possible, while the use of general tonic remedies will, by acting through the blood, increase the nutrition of the cardiac muscle ; in this way much may be done to avert the mitral change and thus to obviate the consequences to which it leads. The conditions are analogous, in many instances leading to mitral incompetence by means of malnutrition, and the exercise of caution in such states will prevent the development of mitral incompetence. Such cases depend entirely upon the muscular apparatus ; they will, accordingly, be described in dealing with the myocardium, and are only mentioned here in order to show their relationship to valvular lesions. When mitral incompetence has been fully developed, the general yjrinciples of treatment should be based upon the con- MITRAL INCOMPETENCE. 549 sideration of its principal consequences as it affects the lungs and the right side of the heart. Every care must be exer- cised in order to prevent, so far as is possible, interference with the circulation through the lungs, and every means adopted which will increase the aeration of the blood. Full details in regard to the treatment of mitral incompetence have already been given in the section devoted to the general treatment of valvular affections. Case 29. Mitral Regurgitation. — J. M., aged 13, schoolboy, was admitted to the Eoyal Infirmary, 1 2th December 1892, complaining of pain in the region of the heart. His father and mother, as well as a family of four brothers and sisters, exclusive of the patient, were in excellent health. The patient's environment had always been in every way satisfactory. His health was perfectly good until October 1891, at which date he suffered from rheumatic fever, and was confined to bed for three months. The pains at that time affected all his joints, but were unattended by any cardiac complications. About a week before his admission he began again to suffer from pain. It made its appearance somewhat suddenly, and was rather severe. On cross-examination he admitted that from time to time since his recovery from the acute rheumatic attack, he had felt it, but never severely. It was, in his opinion, always intensified by carrying any heavy weights, such as he was used to do in his mother's shop. On examination of the patient there were absolutely no obvious morbid phenomena of any description. The alimentary system appeared to be healthy, and there was no enlargement of any of the glands. No dropsy occurred even when the patient was up all day. The pain from which he suffered was felt over the prBecordia, rather to the left of the mesial plane, and it extended upwards to the left shoulder. The neck afforded no abnormal movements. The patient was distinctly pigeon-breasted. The movements of the heart were visible in the third, fourth, and fifth left intercostal spaces. The radial artery was soft and elastic ; the vessel was moderately full, and its pressure was about the average for the patient's age. The pulse rate was 88 ; it was perfectly regular and equal, and there was no undue celerity or tardiness as regards the individual pulse-waves. Palpation showed that the apex beat was in the fifth intercostal space 2f in. from mid-sternum ; the cardiac dulness extended li- in. to the right and 3 in. to the left of that line at the level of the fourth cartilages. On auscultation, the second sound in the aortic region was found to be rather louder than in the pulmonary, and hence might be regarded as slightly accentuated. There was no doubling of the second sound. In the mitral area there was a soft -blowing systolic murmur propagated towards the axilla, but audible for a short distance around the apical region. The first sound in the tricuspid I'egion was absolutely free from any accompaniment and was well closed. 5 50 AFFECTIONS OF THE MITRAL ORIFICE. There were no morbid phenomena connected with any other region of the body. The little patient, after treatment for a few days by means of strophanthus and complete rest, was put upon moderate doses of iron, and in the course of a short time was so relieved of all his symptoms that he could be dismissed. This case affords an excellent example of the difficulty in determining whether regurgitation at the mitral orifice is due to some valvular lesion, or to relaxation of the sphincter of the orifice. There could he no question of dilatation of the heart, seeing that it was of such moderate dimensions, and therefore the diagnosis could only he that of relative incom- petence through relaxation of the structures surrounding the orifice, or from the valves themselves. It seems to me that in such a case as this an absolute decision is almost impossible. Had there been much accentu- ation of the pulmonary second sound, or a doubling of that sound, the diagnosis would probably have been that of com- bined obstruction and incompetence. It is, indeed, possible that in this case such a double lesion was present, but its absolute determination was beyond the possibility of certainty. It is probable that such a case as this, in which it was possible there was some endocarditic lesion of the cusps, would be reported as mitral incompetence, and it is an excellent illus- tration of the liability to error in statistics. Case 30. Mitral Incomfetence with slight Escape at the Tricnqyid Orifice. — J. D., aged 25, housemaid, was admitted to Ward 27 of the Royal Infirmary, 13th October 1897, complaining of breathlessness and weakness. Her father was w^ell ; her mother died at the age of 45, of bronchitis ; one sister died of acute rheumatism ; the other members of the family were well. Her environment had been healthy, and her duties not un- duly severe. In regard to her previous health it may be said in a word that it had been satisfactory. For some months she had been gradually losing strength and energy, and at length acted on a recommendation to enter the Royal Infirmary. On admission she was found to be pallid in complexion with little colour in the mucous membranes. The appetite was indiff'erent, but the digestion was not very faulty, save for some constipation. The tongue was pale, but free from fur ; the teeth were good ; the abdominal viscera of their normal size. The hfemoglobin amounted to 45 per cent, and the red blood corpuscles numbered 3,500,000. The spleen, thyroid gland, and lymphatic glands showed no change. MITRAL OBSTR UCTION d- RE G UR GIT A TION. 5 5 1 No morbid phenomena could be observed in tlie neck or pr.'ccordia. The radial artery was soft and yielding ; it was rather empty, and its pressure low ; the pulse rate was 80 ; the rhythm was regular, and the pulsations equal. The apex beat could be felt somewhat diffusely in the fourth and fifth left spaces ; its chief impact being ?>\ in. from mid-sternum in the fourth space. The ujoper border of the cardiac dulness was at the superior edge of the third left cartilage ; at the level of the fourth ribs it extended 1^ and 4 in. to right and left of mid- sternum. On auscultation there was weakness of all the cardiac sounds, and two soft- blowing murmurs were present. One had its maximum intensity in the mitral area, from which it was carried a short distance in all directions ; the other, a very gentle, nay, almost imperceptible, mur- mur, could only be heard at the inner end of the third left rib. There was no accentuation of the pulmonary second sound, and no doubling was present. A continuous venous hum was heard in the neck. The facts regarding the other systems call for no remark, except that there was some scantiness of the catamenia, which, however, were regular. By means of rest and protochloride of iron along with arsenic the patient speedily recovered. It was clear that in this case the chief condition was one of anaemia, and the point of greatest interest lay in the fact that the cardiac dilatation mainly affected the left ventricle. As will be shown in another chapter, dilatation of the heart from anaemia usually implicates both ventricles at once, but the right is, as a general rule, more affected than the left. In this case the area of dulness showed that there was less enlargement of the right than the left side of the heart, and the distribution of the murmurs corroborated this fact. MITEAL OBSTKUCTION AND KEGUEGITATIOK The combination of obstruction and incompetence is always, as would naturally be expected, due to organic disease, and is very much more frequent in its occurrence than either lesion singly. Etiology and Morbid Anatomy. — Combined obstruction and incompetence may be produced either by endocarditic changes or degenerative processes, of which the former are considerably more frequently met with. The various factors which have been already considered in the production of endocarditis play their most important role in the evolution 5 52 AFFECTIONS OF THE MITRAL ORIFICE. of this double lesion. It is often possible to trace out directly the connection between cause and effect. It is also, however, a frequent experience to have no distinct evidence of the connecting link, in which case the lesion has been developed insidiously. Mitral obstruction and incompetence do not take their origin by any means so frequently from degener- ative processes ; but it must be allowed that in elderly people the combined mitral lesion occurs purely from such processes. Examination of the heart in such cases shows in the main three distinct types of lesion. The cusps may have vegetations adherent to them, which produce at once some obstruction and at the same time bring about a maladaptation, whereby re- gurgitation is allowed. A further step in lesions of this type is found when the cusps have become shrunken and retracted, so that they can by no possibility close the aperture. The second great type is found in those cases in which the valves are thickened and often roughened, wdiile they, as well as the tendinous cords, are harder and more resistant than in health. Here a certain amount of obstruction is present, and in con- sequence of rigidity the cusps cannot be adapted to each other, and incompetence therefore results. The third group includes all those cases in which the cusps become fused to- gether so as to form a slit of small dimensions, which from the infiltration or deposition going around it produces incom- petence as well as ol:)struction. The effects produced by the combined lesion are more serious than those which take place in either obstruction or regurgita- tion. The implication of the auricle is greater, and it therefore shows a considerable degree of dilatation as well as hypertrophy. In many instances dilatation alone is found, and the walls of the auricle are very thin. There is more tendency to Imck- ward pressure upon the pulmonary circulation, and more distinct implication of the right side of the heart, which, becoming interfered with at an earlier period of the disease, allows greater disturbance of the systemic veins. The effects, therefore, upon all the internal viscera are more pronounced. Symptoms and Diagnosis. — The clinical features produced by the combined lesions show a blending of those properly MITRAL OBSTRUCTION QT' REGURGITATION. 5 53 appertaining to each ; but the combination gives rise; to more niarkecl symptoms than does either disease Ijy itself. It is needless to traverse the ground already gone over as regards the general symptoms and physical signs ; but it may Ije remarked that, with the greater disturbance not merely of the pulmonary, but of the systemic circulation, the clinical features of the combined lesion are much more marked than in simple obstruction or incompetence. As regards evidences of pul- monary hyperemia dilatation of the right ventricle, cedema of the dependent parts, enlargement of the solid viscera within the abdomen, and catarrhal conditions of the mucous mem- brane, the combination is swifter in effecting their production than is either lesion singly. The pulse is much more likely to become irregular at an early period in the development of the disease. Venous pulsation or turgescence in the neck, and epigastric pulsation in the abdomen, are frequently found. The size of the heart as ascertained by percussion is considerably exaggerated, and on auscultation the combined murmurs may be heard. It is here that the chief element of difficulty is apt to step in ; seeing that the presystolic and diastolic murmurs arising at the left auriculo- ventricular orifice are the most fugitive of all, it is no wonder that some uncertainty occasionally arises. On auscultating a case of combined obstruction and incom- petence, it is very common indeed to find that no murmur is to be heard with the exception of the systolic mitral murmur. Along with this, however, there is almost invariably a rough- ness in the cha,racter of the first sound, and the well-known remark that this often sounds as if it were the " b " of the syllable " rub," of which the previous part had disappeared, is singularly apt. Accentuation of the pulmonary second sound is usually more marked in the case of the double lesion wdien only one aspect of it, whether obstructive or regurgitative, is found. The existence of considerable irregularity in the cardiac pulsations, along with a rough first sound passing into a systolic murmur, and followed by an accentuation of the pulmonary second sound, may be regarded as significant of the double lesion. It is unnecessary in this place again to refer to the fact that occasionally a presystolic murmur may t;54 AFFECTIO.XS OF THE MITRAL ORIFICE. have its origin without mitral obstruction. This subject has been already thoroughly discussed. Prognosis and Treatment. — There cannot be the least doubt that when ol)struction and incompetence are united, the prospect for the patient is much more gloomy than when there is only ol)struction or incompetence. From the greater severity of the effects, there is much more disturbance of every function connected with the nutrition of the heart, and the prognosis is theref »re much graver than in either single lesion. Although, as a rule, free from the intensely painful sensations experienced in many cases of aortic disease, it nevertheless liappens that from cond^iued obstruction and incompetence at the mitral orifice there is more long-continued distress than in any other valvular combination. Little need be said in regard to treatment, as it is practically that which has been enjoined for the individual lesions by themselves. The management, however, recpiires to be carried out more sedulously than in the case of either of the lesions by itself Case 31. Mitral Obstruction and Eegurgitation. — W. N., aged 8, school- boy, was admitted to AYard 22 of the Eoyal Iiihrmary, in March 1897, sufifering from breathlessness and pali^itation. His father was in good health. His mother died at the age of 31 of mitral disease. The patient had one brother and one sister — both well. He had never been robust, but had not suffered from any serious atfection until the present illness began. Its commencement Avas quite insidious, the little patient gradually beginning to feel ill and lose strength some months before his admission. D^'spncea had for some time been constant, and there had been some swelling of the legs and other dependent parts of the body. On admission the patient was found to be pale and bloodless in appearance, with a small bright flush on either cheek. The alimentary system yielded no symptoms of any importance. The spleen was not enlarged. The pulse varied from 96 to 112 during the first few days of his residence in hospital. The vessel was compressible and moderately full. The pulsation was perfectly regular and equal, and each j^ulse wave, although not large, was well sustained. There were no abnormal phenomena connected with the neck or pra^cordia on inspection. The apex beat was in the fifth intercostal space 3 in. from mid-sternum. On applying the hand a well-marked thrill was ascertained at the apex beat. Tlie thrill obviously commenced with the diastolic recoil, and ran on, first diminuendo and then crescendo, to the systolic impulse of tlie heart. On percussion, the right and left borders of the heart at the level of the fourth costal cartilages were respectively 1^ and 2h in. MITRAL OBSTR UCTION d- RE G UR GIT A TION. 5 5 5 from mid-sternum. On auscultation in the aortic region, a faint blowing' systolic murmur could be heard, but on passing downwards it was found to be propagated from below. In the mitral area there was a systolic murmur accompanying, but not obliterating, the first sound. It was soft and blowing in character, and was propagated in every direction to some extent, but more especially towards the axilla. The second sound was immediately followed by a rough diastolic murmur which gradually diminished in intensity, and this became louder as it passed into a very harsh presystolic murmur running up to the first sound. In the pul- monary area the second sound was obviously accentuated, but not to any very great extent. Auscultation of the tricuspid area revealed the exist- ence of a soft -blowing systolic murmur. There were a good many crepitations at the bases of both lungs posteriorly. The other systems call for no remark, as they presented no abnormal phenomena. There could be no difficulty in diagnosing obstruction of the mitral orifice, and incompetence of the mitral and tricuspid valves. The chief interest in the case which has just been narrated lies in the fact of the hereditary predisposition to disease exhibited by the patient. Case 32. Mitral Obstruction and IncomiMence. — T. E., aged 39, compositor, frequently consulted me as an out-patient at the Royal Infirmary on account of breathlessness and cough. He stated that he was unaware of the presence of rheumatism at any time among any of his relations. His mother, nevertheless, died about two years before he presented himself at the Infirmary, of heart disease. This may, however, have been some senile form of cardiac affection. His father died of apoplexy about twenty years before the patient came under observation. He himself had suffered from scarlet fever on one occasion, and had several times been attacked by sore throat. Eighteen months before coming under observation he began to be breathless, and a few months later a persistent cough developed. These symptoms gradually became worse until he applied for relief at the Infirmary. On examination, a slight tinge of jaundice was observable along with some lividity of the lips. His teeth were carious and the tongue was furred, yet the appetite was good and the other digestive functions excellent. The abdominal viscera were normal in size. The patient complained very much of constant palpitation, of frequent faintness, and of occasional giddiness. Dyspnoea was constant. The radial walls were healthy ; the vessel was moderately full, and of fair pressure. The pulse was extremely irregular in rhythm, but its rate was always under 60, being usually about 52. The character of the pulsation was tardy. On examination of the neck, well-marked pulsation could be seen in the jugular veins. There was a degree of prominence of the prae- cordia, more especially in the region of the fourth left costal cartilage. The apex beat was in the fifth intercostal space. On palpation there was a 5 5<'' AFFECTIONS OF THE MITRAL ORIFICE. long rough diastolic thrill at the apex beat, of which no evidence could be obtained with the cardiograph. On percussion the ujrjpor limit of cardiac duhiL'SS was at the third left costal cartilage. The right border extended \'-\ in. to the left of mid-sternum, while the left extended 'i\ in. outwards at the level of the fourth rib. On auscultation in the aortic area a double second sound could be heard. In the mitral area a soft systolic murmur accompanied the first sound, and there was a rough purring murmur beginning with the second sound and lasting over more Fig. 10('i. — Tracing from tlio apex Ijeat in Case 32. than half of the long pause. In the pulmonary area a soft systolic murmur was perceptible, but this was propagated from below. The second sound was distinctly douliled, and the later part of it was the louder in this area. In the tricuspid area there was a soft -blowing systolic murmur, which on being followed up was found to be the same as that heard in the pulmonary area. There were no symptoniS or physical signs connected with the lungs or urinary organs. He had for some time been suffering considerably from insomnia. The patient improved under treatment, and was able to attend to his duties for two or three years. Finally, however, a systole set in, of which he died. The chief interest in this case lay in three points. The hereditary tendency requires notice in the first place, linked with the insidious origin of the disease. The absence of any presystolic, and the extreme roughness of the diastolic, murmur are also worthy of attention. The case, further, seemed to be one in which a cardiographic tracing might be expected to yield some evidence of the vibrations. A tracing was accord- ingly taken from the apex beat by means of a direct cardio- graph, but, as can be seen in the accompanying figure, it throws Init little light upon the condition. Case 33. Mitral Ohstrudion and Itecjurcjitation of Insidious Orifjin. — C. W., aged 13, schoolgirl, was admitted to the Eoyal Infirmary, 5th MITRAL OBSTRUCTION 1 that she was strongly advised to come into the Infirniury, in order to undergo thorough treatment, and in consequence she was admitted to Ward 25, on 17th February 1896. On her admission the patient was found to be extremely ])ale, but her nutrition was in no way defective ; she was, in fact, quite i:)lump. Her height was 5 ft. | in., and her weight 7 st. 2 lb. The alimentary system furnished no symptoms of any abnormal condition. Examination of the blood showed that the hasmoglobin was 20 per cent., and the number of red blood corpuscles was 2,300,000 per c.mm. There was slight oedema of the ankles, but the most characteristic peculiarity connected with the extremities was a considerable degree of clubbing of the toes as well as of the fingers, with distinct arching of the nails. The radial palse was 94 per minute; the vessel was healthy and the pressure was low ; the rhythm regular and equal ; there was nothing approximating to the Corrigan type of pulsation. There were no abnormal phenomena connected with the neck. The apex beat could be seen in the fifth intercostal space, four and a quarter inches from mid-sternum. On palpation, no abnormal pulsation could be detected, but there was a distinct thrill at the base to the left of the sternum. On percussion, the right border of the heart, at the level of the fourth rib, was two inches, and the left, at the same level, four and a half inches from mid-sternum. At the fifth rib the left border was five inches from mid-sternum. On auscultation, loud mur- murs could be heard everywhere with the systole and diastole ; but these murmurs, on careful examination, were found to have their greatest loudness at the base of the heart. The systolic murmur had its point of maximum intensity at the u]Dper edge of the manubrium sterni rather to the left of the middle line. The diastolic murmur was loudest opposite the third costal cartilage and slightly to the left of the middle line. From these points the two murmurs faded away gradually in every direction. A very soft murmur was present during the cardiac systole in the carotid arteries. On examination of the respiratory system, there was an impaired per- cussion sound over the bases of both lungs, and a diminution of the respiratory murmur and vocal resonance, but there were no adventitious sounds. The urinary system yielded no symptom of importance. There had been amenorrhoea since Christmas. The nervous system gave no evidence of any disturbance with the exception of the ocular phenomena in the right eye. The consideration of this case, which has been utilised for another purpose in a previous chapter, left, to my mind, no doubt as to its being one in which there was a double lesion at both the aortic and pulmonary orifices. The former was rendered probable by the fact that although there was no w-ater-hammer character in the pulse, or capillary pulsation, there was yet no clear evidence that the aortic cusps closed, as there was no distinct second sound anywhere. As above 568 AFFECTIONS OF THE PULMONARY ORIFICE. mentioned, the systolic inurniur was propagated np tlie arteries of the neck, which was proof of an aortic obstruction, seeing that no dilatation of tlie aorta could be thought of. The latter was also, to my mind, absolutely clear, in conse- quence of the clubbing of the fingers and toes, as well as on account of the fact that the systolic murmur was quite different from, and far harsher in character at its point of maximum intensity than, the sound which was propagated into the arteries of the neck. The reason why this case is placed under the heading of pulmonary obstruction is, that it appeared to be much more an instance of obstructive lesion than of incompetent valves. The further details will be found on p. 430. PULMONAKY INCOMPETENCE. The earliest instance on record of pulmonary re- gurgitation is that mentioned by Chevers, which was not, however, diagnosed during life. In the fourth edition of his work, Hope describes a most interesting case, in which, with other lesions, pulmonary incompetence was a prominent featm'e. Although a large number of cases have been placed on record since the date of these observations, the detection of pulmonary incompetence is still surrounded by serious difficulties. In the following pages it is not my intention to enter upon the historical aspect of the subject. This has been rendered unnecessary, seeing that, in one of the most valuable contributions to the study of cardiac disease during recent years, Barie has not only followed the develop- ment of our knowledge of this particular lesion, but has also given a brief statement of the facts recorded in 5 8 cases, two of which were observed by himself. His memoir on this subject will, for future workers, remain a storehouse of clinical and pathological facts, for which he deserves the cordial thanks of all interested in diseases of the circulation. Etiology. — Pulmonary incompetence is certainly an affection of early life ; according to the researches of Barie, its greatest frequency is between the ages of 18 and 34. It occurs frequently as a congenital affection, but, in this case, PULMONARY INCOMPETENCE. S^>9 it is always accompanied by obstinctioii of tlie orifice. It occurs with equal frequency in both sexes. The most frequent exciting causes are rheumatism and acute infectious diseases, more especially the eruptive fevers. Degenerative processes giving rise to sclerosis and atheroma have been occasionally described, and this form of etiology has been attributed, with more or less reason, to chronic alcoholism. Morbid Anatomy. — Congenital lesions of the pulmonary cusps, such as anomalies in their number or alterations in their form, have already been referred to in the section dealing with congenital heart disease, and require no further remark in this place. Pulmonary incompetence as a disease acquired during the separate existence of the individual, shows for the most part the results of endocarditis or of degeneration. The cusps are usually thickened and indurated, as well as shrunken in size and distorted in form. There are occasionally ulcerations upon- the surface of the cusps, or they may be perforated by larger or smaller apertures. The orifice of the pulmonary artery is in some instances found to be dilated. It is more common, however, to find that it is contracted, as in the accompanying illustration. Fig. 158. In other instances the orifice is possessed of its normal calibre. The secondary results upon the heart are those of hyper- trophy with dilatation of the right ventricle, and usually of the right auricle also. There is frequently some fatty de- generation in the muscular substance of the right ventricle. Secondary lesions are found in various internal organs affected by interference with the return of blood to the heart, and its proper aeration in the lungs, but these present no features of particular interest. In some instances there exist, along with pulmonary incompetence, other lesions, such as communications between the two auricles, or between the two ventricles, or patency of the ductus arteriosus. When such structural alterations are present they will inevitably lead to the conclusion that the pulmonary lesion is probably of congenital origin. 570 AFFECTIONS OF THE PULMONARY ORIIICE. Eelative or functional incompetence of the pulmonary cusps undoubtedlv exists. There is a natural provision for re- fiuroitation under certain circumstances at both the orifices on the right side of the heart, which appears to have been first observed by Hunter. " The valves of the pulmonary artery," 0t\-^ Fig. loS. — Pulmonary incompetence with obstruction, the cone diameter of the orifice being -85 in. he says, " do not do their duty so completely as those of the aorta ; and if we inject a pulmonary artery towards the right ventricle, it does not so completely hinder the injection passing into that cavity ; nor are the two portions of injection com- pletely separated, when the artery is injected from the ventricle, as in the left side. So far as respects injection, the same observations are applicable to the valvidcr tricusjnchs ; therefore, I believe the valves of the right side of the heart are P ULMONAR Y INCOMPE TENCE. 5 7 1 not so perfect as those of the left ; from hence we may suppose that the universal circulation recjuires to Ije more perfect than that through the lungs." Little notice was taken of these observations until Adams investigated the subject. To him is due the merit of showing clearly that what is necessary towards the maintenance of the systemic would be injurious to the pulmonic circulation, where so many eases must temporarily retard the passage of blood through the lungs. From the clinical point of view the first writer who dealt with this subject was Stokes, who in the following passage enunciates very clear views in regard to it. " There is another form of insufficiency of the valves which arises, not from disease of the valves themselves, but from dilatation of the cavities when carried beyond a certain point. It is probable that this condition will be found more frequently at the right side, where it may affect both orifices, and be attended with dilatation of the pulmonary artery." Gouraud, in an interesting monograph on the influence of pulmonary affections on the right side of the heart, devotes a section of his work to relative incompetence of the pulmonary cusps, and in this he follows the views of Stokes. In a contribution made by me to the study of affections of the right side of the heart, some years ago, wdiile in ignor- ance of the observations of Stokes and Gouraud, the con- clusions arrived at from some experiments on the pulmonary valves of the heart were given, and may be briefly quoted here. As the average result of a series of experiments made with a column of fluid, it was there stated " that from the semilunar valves of the pulmonary artery of the sheep a strong jet escaped until the column of fluid reached 14|- in., from which height it trickled until the valves became incompetent with a column of 9 in. In the ox a strong- jet was emitted down to 12 in., and dropping of the fluid reduced the superincumbent column to the height of 6 in., when competence was established. In the healthy human heart a jet escaped down to 13 in., and the valves were competent with 8 in. of fluid resting on them. Xow, in each case of the pulmonary valves, with a column of fluid exceeding 6 ft. in height, perfect competence was obtained in 572 AFFECTIONS OF THE PULMONARY ORIFICE. a very simple luaniK'r liy constricting the pnlnionaiy artery. A cord tied round the artery, exactly at the attachment of the valves, gave the means of perfect control over the escape, so that, by varying the amount of tightening, the jet was con- verted into a drop falling quickly or slowly, and this in turn was totally stopped. The whole diminution of circumference only amounted to a few lines. This shows clearly that the escape is caused by distension of the elastic artery, and relative incompetence of the valves." It may be added that, tested in the same way, it was found that the aortic valves never allowed any escape, and the paper referred to goes on to say : " Such experiments show with certainty that the orifices of the right side of the heart are not closed so perfectly as those of the left, and point to the ease with which they probably allow escape with any supernormal pressure." Althouoh these observations convinced me that there was probably some escape at the valve whenever there was any considerable increase of x^i'essure in the pulmonary artery, no case came under my notice, until comparatively recent years, in which there was absolute evidence in proof of the correct- ness of the view based on them ; but in the interval other observers, who have successfully devoted much attention to the diseases of the circulation, have independently advanced the opinion that a diastolic murmur occurs in consequence of high pressure in the pulmonary artery. In his little work on the heart, Graham Steell, after referring to the diastolic murmur of aortic dilatation, says : " I am inclined to believe that a murmur of similar mechanism occurs in the right side of the heart, when there is much obstruction to the pulmonary circulation with a dilated pulmonary artery." Duckworth described a case of mitral and tricuspid stenosis in which there was a temporary pulmonary diastolic murmur, which he considered as due to the dilated state of the vessel. It disappeared before death, and at the autopsy the pulmonary cusps were not found to 1)6 markedly altered. The whole subject was again reviewed more recently by Graham Steell, who proposes to call this diastolic murmur. PULMONAR V INCOMPE TENCE. 5 7 3 occurring independently of disease or deformity of the valves, " the murmur of high pressure in the pulmonary artery." These views receive emphatic support from some remarks by Barr on mitral stenosis, in which, writing on the oljstruc- tive diastolic murmur of mitral stenosis, he says : " I am convinced that it is often confounded with a short, soft- blowing diastolic murmur, which not infrequently occurs in this disease at the pulmonic valve, and which arises from slight regurgitation into the right ventricle, owing to the high pulmonic tension." The whole subject was fully discussed, four years ago, in a paper by myself, dealing with the diagnosis of pulmonary incompetence. Symptoms. — The affection might be expected to produce considerable influence on the functions of the lunos throuo;h interference with their blood supply, and no doubt this is to some extent in every case its effect ; yet the degree of dis- turbance for which it is responsible is difficult to estimate on account of the extreme rarity of regurgitation except in association with some other lesion. It must produce some dyspncea and cyanosis, and such special appearances haA'e always been found in the cases which have been recorded. These symptoms, except towards the close of life, are in most cases only found on exertion. During repose they cause but little inconvenience to the patient. When the closing scenes of cardiac failure make their appear- ance, the dyspnoea becomes continuous, and the patient presents a deeply cyanosed appearance. Such symptoms are frequently attended by cough and other evidences of lung disorders. In consequence of stress, the right ventricle undergoes changes. It becomes dilated as well as hypertrophied, and regurgitation at the tricuspid orifice accordingly takes place. There is consequently early implication of the systemic venous circulation. Venous stasis in its various forms is inevit- able, resulting in enlargement of the solid abdominal viscera, catarrh of the mucous membranes, anasarca of the dependent parts, and effusion into the serous sacs. In this affection, just as in pulmonary obstruction, clubbing of the fingers and arching of the nails are frequently to be seen. 574 AFFECTIOXS OF THE PULMONARY ORIFICE. The physical signs present in puhnonary incompetence are mainly those of dilatation and hypertrophy of the right ventricle, along with the evidences furnished by auscultation. There may be turgescence, or obvious pulsation of the veins of the neck. The radial arteries may yield no features of special import, yet the artery is, as a rule, but poorly filled and the blood pressure is low. The volume may be large or small, the pulse frequent or rare, and the rhythm regular or irregular. It is obvious that these conditions are not directly connected with the affection of the right side of the heart. The apex beat may be farther to the left than in health, so that its pulsation may be observed outside the mammillary line. A distinct pulsation may also be observed in the epigastrium, and this, moreover, has occasionally been seen in the inter- Fio. l.J'J. — Diastolic murmur accompanying second sound. costal spaces to the right of the sternum. Palpation gives further evidences of these facts, and reveals in some cases a thrill at the base of the heart, coincident with the second sound, and having its greatest intensity to the left of the sternum. The area of cardiac dulness is found to be in- creased both to the right and to the left. On auscultation a diastolic murmur is heard. This murmur may be diffused over a wide area, but it appears invariably to have its maximum intensity in the second left intercostal space. It is propagated towards the apex of the heart, and its line of conduction is chiefly to the left of the sternum. The char- acter of this murmur varies considerably. It may be soft and blowing, or harsh and rasping. In those cases in which it is associated with a similar lesion of the aortic cusps, it is usually louder than the murmur produced by the latter. Its rhythm is shown in Fig. 159. Diagnosis. — The diagnosis of pulmonary incompetence should not present any great difficulties, yet it is a subject which requires a considerable amount of care. The affection PULMONAR Y INCOMPE TENCE. 5 7 5 most likely to be confounded with it is aortic incompetence. At first sight it may appear extraordinary that the two lesions should ever produce symptoms which might Ije mistaken, seeing that the position of the murmur in each case should lead to correct conclusions, but, as has been shown by two illustrative cases of aortic disease (Case 25 and Case 26, pp. 514 and 517), the maximum intensity of the murmurs may Ije (|uite deceptive. The characteristic murmur of aortic incompetence is not infrequently to the left of the sternum, a fact which certainly should induce caution in effecting a diagnosis. It might be thought that the conduction of the murmur would be of more importance than the mere position of maximum intensity of the murmur in each case. The propagation of the murmur, however, does not materially aid. There are, nevertheless, two points as regards murmurs, of some value. The diastolic pulmonary murmur is not propa- gated directly towards the apex, and if a murmur of this rhythm is heard distinctly at the apex of the heart, it is probably of aortic origin. A diastolic murmur, moreover, heard over the carotid arteries is proof positive of aortic incompetence, showing, as has previously been seen, such a degree of regurgitation as will allow of the generation of a murmur in the carotid. The presence of the characteristic Corrigan's pulse, and of capillary pulsation, must of necessity be regarded as most important evidence of aortic incompetence, while cyanosis, dyspnoea, and clubbing of the fingers must be allowed to weigh considerably in favour of pulmonary incompetence. All these, however, may occur in any valvular lesion from cardiac failure. The chief difQculty in diagnosis as between aortic and pulmonary incompetence arises when both lesions are present in the same individual. In the patient whose case is recorded below (Case 37, p. 576) there could not possibly be any doubt that aortic disease was present, and the only uncertainty was as regards the presence or absence of a pulmonary affection. In such cases the maximum intensity and lines of conduction of the murmurs do not greatly help in the differential diagnosis. The other accompaniments afford evidence of higher value. 576 AFFECTIONS OF THE PULMONARY ORIFICE. Patent ductus arteriosus is not likely to be mistaken for incompetence of the pulmonary valve, and the converse is also not likely to occur. The thrill and murmur present when the arterial duet remains open are of late systolic rhythm, and with care this fact is always easily determined ; although the general symptoms are somewhat alike in the two conditions, more especially in regard to the presence of cyanosis and dyspnoea, the rhythm and the murmur and thrill should be suthcient to allow of an accurate diagnosis. PkoCtNOSIS. — The prognosis in this valvular affection is, of necessity, always grave, inasmuch as, from the implication of the functions of the lungs, there is great liability to complica- tions, and the further disturbance of the circulation tells fatally upon the right side of the heart. Bronchitis and broncho-pneumonia are especially likely in this way to aggra- vate the condition and to bring about a fatal result. It need hardly be added that when the disease exists in childhood whooping cough is a very dangerous addition. Frerichs pointed out that pulmonary tuberculosis is frequently found in association with this affection — a fact which has been discussed in the section on congenital disease. Treatment. — The treatment in cases of pulmonary incom- petence must be more particularly directed to the possibility of pulmonary complications, and prophylaxis will therefore have especial reference to those conditions which may induce or aggravate bronchial catarrh. The evidences of unfavourable conditions, not merely as regards the external air but as regards the ventilation of the apartments occupied by the patient, will require close atten- tion. Treatment must also have especial reference to the condition of the lungs in every instance ; apart from this, it is but an aspect of the general treatment of cardiac failure. As an excellent example of combined obstruction of the orifice and incompetence of the valve, in which tlie latter was the predominant feature, associated with aortic disease, the following case deserves notice. Case 37. Aortic and Pulmonary Disease. — Charles W., baker, set. 45, married, was admitted to Ward 22 of the Eoyal Intirmary, on 15th May 1893, complaining of breathlessness, and swelling of the feet and legs. PULMONARY INCOMPETENCE. 577 His father was 70 years old, and in good liealth. His mfjtlicr liad died at the age of 64, of bronchitis. Of three brotliers, one was in good health, another had died in infancy, and the remaining one had Ijeen killed by an accident. Of five sisters, four were alive and well, but one had died in infancy. The patient's social conditions had always been fairly good. He had in early years enjoyed very good health ; but latterly, in consequence of three attacks of acute rheumatism, he liad never felt well. The illness for which he sought admission began, about four months previous to his entrance into the hospital, with breathless- ness, which was followed by the development of swelling of the lower limbs. The j)atient was pale, with bloodless lips and gums, but the pallor was to some extent masked by a certain degree of cyanosis. There was con- siderable oedema of the lower limbs. The fingers, as well as the toes, were clubbed at their extremities, and the nails were distinctly arched. The appetite was small and capricious. Constipation and diarrhoea fre- quently alternated. The teeth were much decayed ; and the tongue, which was pale, was covered by a slight fur. The abdomen showed no ascites. The liver extended six inches in the mammary line. The htemojioietic system presented no abnormal features save those of anaemia. The radial arteries were soft and elastic, the vessels empty, the tension low ; the rate of the pulse was from 70 to 80, it was perfectly regular, each pulse wave was of large size and short duration, — in short, the 23atient had a typical Corrigan's pulse. On producing a flush over the forehead by friction, it was seen to become paler and redder with the alternate systolic and diastolic phases. On inspection of the neck, a violent pulsation was seen in the carotid arteries, as well as some undulation in the external jugular veins, while over great part of the jarsecorclia there was an extrejiiely distinct systolic imjjulse, which gave to the hand, however, the sensation of short dura- tion. The apex beat was felt in the sixth intercostal space, four inches from mid- sternum. No thrill could be detected on paljjation. The deep cardiac dulness in the left jDarasternal line began in the second intercostal space, nearer the second than the third cartilage ; it extended, at the level of the fourth cartilage, from two and a quarter inches to the right, to four inches to the left, of the mid-sternal line. On auscultation, two murmurs were heard ; one accompanied the first, the other replaced the second sound. Both of these murmurs were loudest at the base : the systolic, which was loud and rough, having its point of maximum in- tensity at the junction of the third left costal cartilage with the sternum ; while the diastolic, which was quite as loud, though somewhat less rough, had its point of maximum intensity over the third left costal cartilage and the adjacent part of the fourth intercostal space, one inch and a half from mid -sternum. Both murmurs were heard with diminishing intensity over the entire praecordia, — the systolic extending farther down- wards and to the left ; the diastolic slightly farther upwards and to the right. A slightly increased intensity of the systolic murmur could be discovered both in the mitral and tricuspid areas, and a distinct systolic 37 578 AFFECTIONS OF THE PULMONARY ORIFICE. Fio. 160. — Pulmonary systolic and diastolic murmurs. murmur was heard in the carotid artt-iifs. Thi- distribution of these murmurs is sho^^^l in Fig. 160. The patient was very breathless, and coughed a good deal, the cough being accompanied l\v a frothy serous expectoration. The only physical sign connected with the resjiiratory system was a rather coarse crepitant rale over the bases of both lungs. The xu-ine, Avliich Avas small in amount, contained a trace of albumin. The patient was restless and sleepless, but those symptoms were in great part due to the dyspnoea. The diagnosis in this case presented, in one respect, some difftculty. There could be no doubt that there was stenosis of the aortic orifice — the proijagation of a systolic murmur up the carotid arteries was sufficient proof of this ; and there could also be just as little question in re- gard to the fact of aortic incom- petence, since there was the charac- teristic water - hammer pulse, and the significant caijillary pulsation. The considerable hj-pertrophy of the left ventricle also sujjported this. The point round which some difficulty hung was with regard to the condition of the pulmonary orifice and its valves. The position of the maximum intensity of the murmurs seemed to indicate a probability that both obstruction and incompetence existed, and this seemed the more likely, seeing that there was some cyanosis, with distinct clulabing of the fingers and toes. On the other hand, the small degree of cyanosis might have been the result simply of cardiac failure, and if this had recurred from time to time, it might also have given rise to the change in the ends of the phalanges. It was my opinion that, Avhile the diagnosis of aortic sten- osis and incompetence was absolutely estaljlished, and while admitting the probability of a pulmonary lesion, it was better to leave it an opeir question whether such an aft'ection was present. It seemed to me, how- ever, extremely likely that, if the pulmonary valves were healthy, there was such a pulmonary regurgitation, as will be described in the sequel, produced by a functional inability of the pulmonic cusps to close completely, in consequence of the high pressure within the pulmonary, circuit. In spite of every method of treatment, the j^atient became steadily worse. The dependent parts developed more csdema ; ascites and hydro- thoi-ax came on ; the urine fell oft' in C[uantity, and contained more albumin ; and the dyspnoea and cyanosis increased. Death occurred quietly on 7 th July. PULMONAR V INCOMPE TENCE. 5 7 9 The post-mortem examination was performed the following day by Dr. Leith, whose notes are appended. External Afpearmices. — Rigidity absent. Lividity marked. Con- siderable dropsy. Thorax. — There were extensive old adhesions in Ijoth i^leural sacs. Heart. — The pericardium was adherent all over ; the adhesions being slender, and easily broken through. They were extensive both in front and behind, chiefly consisting of fine threads attaching the two surfaces together. There were two large irregular nodulated masses of osseous consistence : one to the right of the pulmonary artery, which was the larger, about the size of a hazel nut ; the other to the left of the artery. Both were very irregular in shape, very jagged and nodular on their external surfaces, and lay in both layers of the pericardium, the two layers being here inseparable. The jDulmonary valves were incompetent, as were also the aortic. The cone-diameter of the pulmonary was -85 in., and of the aortic -6 in. All the pulmonary cusps were thickened. This was especially marked at their attachments, which were almost cartilaginous in consistence. The lunules also showed considerable thick- ness, although not so j)ronounced. The condition was one of well- marked chronic endocarditis. There were some recent vegetations at the junction of the anterior and right posterior cusps. At the right margin of the right posterior aortic cusp there was an irregular perforation larger than a crow-quill ; the margins were irregular and stained pinkish. Above it, and slightly to the right, there was a small aperture in the commencement of the intima of the aorta, i.e. just at the upjjer part of the sinus of Valsalva. This aperture led into an aneurysmal sac a little to the right, about the size of a bean. The left ventricle was considerably dilated, its wall being but slightly thickened. The muscle was somewhat paler than usual, and besides some fatty change was probably the seat of a chronic myocarditis. There was some fatty change in the wall of the right ventricle, and its muscular substance was somewhat hypertrophied. The cone diameter of the tricuspid orifice was 1'3 in. The cusps were slightly but uniformly thickened. The cavity of the right auricle was dilated, and its walls a little hypertrophied. The cone diameter of the mitral orifice was -88 in. The cusps were chronically thickened, the anterior markedly so. The thickening was not uniform. It was greatest at the contiguous margins of the valves. The wall of the left auricle was hypertrophied, but the cavity was not dilated. The heart, with the pericardium, weighed 1 lb. 10 oz. Lungs. — Left weighed 1 lb. 15 oz. There were old pleuritic patches over both lobes and between them. There was marked cedema in both lobes, and brown induration in the lower lobe. Right weighed 1 lb. 14 oz. ; it showed old pleurisy at the base, the apex, and between the lobes. There was oedema and congestion of all the lobes. Liver weighed 3 lb. 6 oz. The gall-bladder contained blackish green bile, somewhat inspissated. The liver substance was firm. The surface was granular towards the anterior margin. On section, there was a nutmeg 5 So AFFECTIONS OF THE PULMONARY ORIFICE. condition present, witli considerable tatty clianpte of the peripheral portion of the lobules, but not much bile-staining. Spleen weighed 14 oz., and showed some perisplenitis. It was large and firm. On section, the Malpighian bodies were distinct, and stood out as white points upon a dark purple. There was no reaction with iodine. Kid7ieiis. — The lel't weighed 7^ oz., and was tirni. On section, it was pale. The superficial cortex showed irregular areas, and was diminished in places. There was a cyst about the size of a pea in it. The capsule stripped off badly. There was some superficial cirihosis, and some slightly waxy change. The right weighed 6^ oz. It resembled its fellow. Stomach. — The stomach contained some brownish fluid, and showed a chronic catarrh, but was otherwise healthy. The result of the post-mortem examination in this ease showed it to be possible to be too cautious in the diagnosis of rare lesions. Functional pulmonary incompetence, shown by the diastolic pulmonary murmur of high pressure, is most excellently illus- trated by the three cases with which this chapter may fitly conclude. Case 38. — Functional Pulmonary Incomiietence. — Maggie G., a^t. 18, engaged in household duties, was admitted to Ward 25 of the Royal Infirmary, on 5th June 1893, complaining of pains in her wrists and elbows. Her father and mother, both aged 42, had always been in good health. She had four brothers and one sister, all very strong, but three brothers had died in infancy. The patient's social surroundings had always been good. She had never been very robust, and four years before admission had suffered from a rheumatic attack, since when she had never felt quite well. About four months before entering the hospital, pains had begun in the joints, and had persisted ever since. On her admission, the patient was found to be somewhat pale, with a bright spot on each cheek. The skin was moist. The tongue was slightly furred, but the digestive system was otherwise healthy. There was no symptom connected with the ha?mopoietic system. She complained of some palpitation and a slight degree of breathless- ness. The pulse was of low tension and moderate volume, perfectly regular, and varying in rate from 80 to 90. There was some pulsation in the veins of the neck, and a very distinct impulse in the second left intercostal space. On palpation, the apex beat was found to be in the fifth left intercostal space, 3^ in. from mid-sternum. The i^ulsation, systolic in time, in the second left intercostal space, was found to be most distinct 1;| in. from the mid-sternal line. A tracing obtained from it by means of a revolving cylinder is given in the accompanying figure (Fig. 161). No thrill could be detected over any part of the pra^cordia. The PULMONAR V INCOMPETENCE. 5 8 1 cardiac dulness extended 1 in. to tlie right, and 4 in. to the left, of the middle line at the level of the fourtJi rib. On auscultation, a venous hum was heard in the neck, and there were murmurs, systolic in rhythm, over the whole prsecordia, which on careful analysis proved to be twofold. Around the region of the apex beat, and with its maximum loudness in the fourth interspace Z\ in. from mid-sternum, there was a harsh-blowing systolic murmur, conducted as far as the edge of the sternum to the right, and beyond the anterior axillary line to the left. Over almost the entire sternal region there was a soft-blowing systolic murmur, quite different in character from that heard at the apex. It had the same tone throughout the whole sternal region, but it seemed to have two points of maximum intensity ; to be more exact, it was loudest in the pulmonary region, exactly over the area of pulsation, from which point it waned in its intensity in every direction until near the lower end of the sternum, when it became louder, again culminating at the point where the left side of the sternum was joined by the sixth costal cartilage ; but in this Fig. 1(51. — Tracing from conus arteriosus in Case 38. situation the murmur was not quite so loud as over the area of pulsation in the pulmonary region. The second sound was frequently reduplicated, and the later of the two second sounds, which could by auscultation be determined to be that due to the pulmonic cusps; was instantly followed by a short, sharp, high-pitched murmur perfectly soft in character. This murmur was extremely restricted in its distribution, being only heard over a small triangular area 2;^ in. in vertical, and 2 in. in horizontal measurement, extending along the left border of the sternum from the lower border of the third costal cartilage to the upper border of the fifth. This murmur was perfectly soft in character, and was absolutely unlike the obstructive diastolic murmur which is found in mitral stenosis. It could not be due to aortic disease, of which there was no indication, and it could only, therefore, be a murmur of regurgitation from the pulmonary artery into the right ventricle, due to the increased pressure and con- sequent dilatation of the orifice, with relative and transient incompetence of the cusps. All these murmurs are shown in Fig. 162. 582 AFFECTIONS OF THE PULMONARY ORIFICE. The other systems presented no symptom of disease, with tlie sole exception of a few crepitations at the bases of both lungs. The diagnosis was regurgitation, produced cartliac l>y the dilatation, with mitral and triciispid febrile att'ection, but it was considered probable that some obstruction at the mitral orifice might be insidiously progressing, although this was a mere supposition not based on any direct evidence. The crepitations at the base of the lungs were regarded as the expression of passive congestion from mitral incompetence ; and the diastolic murmur was assumed to be one of pulmonary escape, in consequence of the strain on the artery from the high pressure within it. By means of salol and similar Fig. i62.-Systolic mitral ami tricuspid remedies the patient was relieved of her murmurs with dia.stolic pulmonary rheumaticsymptoms,and theadministra- murmur. ^q^^ of jj,qj;^ with other tonics greatly im- proved the cardiac condition. The dia- stolic murmur disappeared and the lungs cleared up, but at the time of the patient's departure from the Royal Infirmary, on 17th July 1893, she still had the systolic murmurs, and the pulsation in the second intercostal space. She presented herself at the hospital on the 2nd March 1894, when the diastolic murmur was found to be still absent, but the s^^stolic murmurs were present as before. The first sound in the mitral area, pre- ceding the systolic murmur, was, however, loud and clanging in character, which seemed to bear out the view that a stenosis of the mitral orifice was gradually and insidiously developing. In this case there was fortunately no opportunity of verifying the diagnosis, but in the following instance this was possible. Case 39. — Functional Pxdmonary Incompetence. — N. W., tablemaid, aged 16, was admitted to Ward 25 of the Royal Infirmary, 22nd July 1896, complaining of cough and breathlessness. The patient's father died of disease of the aortic and pulmonary valves at the age of 45. His case is recorded on p. 576 (Case 37). Her mother, aged 44, was in good health. There had been three brothers and two sisters. One brother had died of scarlet fever. The others were quite well. The patient's previous health had never been at any time very strong, and she had suffered from acute rheumatism at the age of 8. The patient, on admission, was found to be a delicate looking girl of slender build, and slight muscular development. The skin was pale in tint, excepting upon the cheeks, where there was a deep flush ; the lips, ears, and nostrils were cyanotic. There was some fulness about the P ULMONAR Y INCOMPE TENCE. 5 8 3 ankles which pitted on pressure. The teinjijcrature on admission was 101-4°. Height 5 ft. 1^ in. Weight 6 st. %\ lb. The tongue was furred, but there was little apparent interference with the digestive processes. The liver was normal in size, and there were no morbid symptoms connected with the abdominal organs including the spleen. The pulse rate was 128. The vessel was healthy, and the tension was low. The pulse was slightly irregular, and also somewhat unequal. On inspection of the neck, there were no morbid movements of the vessels, and the veins were not turgid. The apex beat was in the fifth intercostal space 3^ in. from mid-sternum. The upper part of the heart reached to the second left intercostal space. The right border at the fourth costal cartilage was 2^ in. from mid-sternum ; the left border was 4 in. from mid-steruiim. On auscultation two distinct murmurs could be determined. One of these — a high-pitched harsh murmur — had its point of maximum intensity 2 in. to the left of the mid-sternal line, at the level of the upper end of the ensiform cartilage ; it was, therefore, situated almost half-way between the mitral and tricuspid areas. This murmur was propagated for a considerable distance over the prsecordia. The other murmur, diastolic in time and extremely soft in character, was heard most distinctly in the third left intercostal space, its point of maximum intensity being 1-| in. from mid -sternum. This murmur immediately followed an extremely distinct second sound, which was very much louder to the left than to the right of the sternum. It could only be heard for a very short distance in every direction, but more particularly downwards towards the ensiform cartilage. The respirations numbered 44 per minute, and were laboured. There was frequent cough attended by a considerable amount of frothy, serous expectoration. On examination of the lungs, it was found that the respiratory murmur was of a harsh vesicular description, with greatly prolonged expirations, attended by fine crepitations and sibilant rhonchi, but without any alteration in the vocal resonance. These features were presented by both lungs, but they were more pronounced on the right side. The tirine was extremely scanty, but during the first four days of her residence in the ward it rose from 8 to 32 oz., under the influence of the remedies employed. It contained no abnormal constituents. The skin was bedewed with perspiration. The patient slept badly, but this was in great part the result of the harassing cough. With the exception of this insomnia, there was no alteration as regards the nervous system. Consideration of the various features presented by the patient led to the conclusion that it was a case of organic mitral disease. The high- pitched, harsh systolic murmur situated midway between the mitral and tricuspid areas, conducted in every direction to a considerable distance, and propagated more particularly to the axilla and round to the neck and the scapula, could not but be sufficient evidence that there was mitral regurgitation, while the harshness and high pitch of the murmur seemed to prove most decidedly that the regurgitation took place through a constricted orifice. It was impossible to determine whether there was 584 AFFECTIONS OF THE PULMONARY ORIFICE. also a tricuspid imirmur, since the iinujiuir already described was so loud as to obscure every other sound occurring during tlie systole of the heart. But from the imidication of the peri])lieral veins, as shown by the cedenia of the ankles, it seemed perfectly obvious that the right side of the heart was involved. The chief difficulties presented by the case centred themselves, how- ever, around the diastolic murmur. The mere localisation of this murmur in itself could not be held, in view of what has been already remarked, as evidence of any great value. It might have been either aortic or pulmonic in its origin, but the careful examination of the pulse showed that there was absolutely no tendency to the type of Corrigan, while the most diligent observation of the skin when reddened by friction failed to give any indication of a capillary pulse. The ex- tremely soft character of the murmur, moreover, negatived any possibility of its being a diastolic murmur of a constricted mitral orifice. The conclusion, therefore, was inevitable that the murmur was due to pulmonary incompetence ; and two considerations rendered it almost certain that the incompetence was of the transient tyjje produced by greatly increased pressure within the artery. There was, in the first place, not the slightest ajsproach to any clubbing of the fingers, and, in the second place, the murmur varied greatlj^ in its intensity from day to day, being at times almost inaudible and becoming verj^ greatly intensified on the occurrence of any event throwing a greater strain upon the circulation. The diagnosis arrived at, therefore, was mitral obstruction and in- competence with regurgitation at the pulmonary and tricuspid orifices, in consequence of dilatation from strain. The patient was treated by means of hot poultices applied to the chest, with digitalis, ether, and ammonia internally. The temperature fell, during the two days subsequent to her admission, to normal. The pulse rate and the resijiration rate were also considerably diminished, while the functions of the kidneys w^ere considerably improved. The temperature again rose, however, after falling to the normal, but became practically steady within a fortnight of her admission. The condition of the lungs underwent great improvement, and the oedema disappeared from the ankles. During August and the first half of September this improvement continued, so that the patient was able to sit up and even move about the ward, but during the second half of Sejitember and the month of October a number of untoward symptoms returned, and in spite of every means adopted to meet them she died on the 21st October. The result of the post-mortem examination was as follows : — External Affearances. — The body was rather poorly developed, the surface was pale, with the exception of the face, which shoAved lividity. Rigidity was well marked. There was no dropsy. Thorax. — The pericardial sac was normal. There were some scattered adhe.sions over both lungs. PULMONAR Y INCOMPETENCE. 5 8 5 B.mrt. — It was considerably enlarged, tlie left side being propor- tionately small. The right ventricle was much enlarged. The arterial valves were competent. Aortic =•%" ; Fulmonary = VO" ; Mitral = -^5" ; Tricuspid = 1 -3". The mitral valve was extremely stenosed, forming a typical "button-hole" orifice. The .segments were much thickened, adherent at their edges, j)artly calcified, and presenting a roughened margin on their auricular aspect. The chordse tendinea; were thickened and shortened, but not to so great an extent as is often the case. The other valves were normal. The left ventricle was Z^ in length, and its thickness of wall was §". Part of the left ventricular wall was rather thinned. The left auricle was dilated, and its endocardium thickened and opaque. The right ventricle was much enlarged, and its wall greatly hypertrophied ; its thickness at some places was f". Its columnae carneee were thick and powerful, contrasting with those of the left ventricle, which were considerably atrophied. The right auricle was dilated, and there was a small thrombus in the appendix. The myo- cardium of the left ventricle was rather soft, but of normal appearance ; that of the right ventricle was firm and rather pale. Weight of Heart = 14i. oz. Lungs. — The right weighed 2 lb. It contained several large pul- monary infarcts ; the largest was at the lower part of the upper lobe, and measured about 3" across. Those of larger size were of dull reddish colour, with some yellowish patches, and only a few areas of purple colour. The smaller were darker in colour. The lung tissue was in a condition of advanced chronic venous congestion, and was very tough. The left weighed 1 lb. 12 oz. and was in a similar condition ; it also contained several infarcts, some of which were of large size and similar appearance to those in the other lung. There was some recent fibrinous exudation between the upper and lower lobes. Abdomen. — The peritoneum was normal. The liver weighed 3 lb. 6 oz. and showed typical chronic venous congestion of the " nutmeg " condition. The spleen weighed 5 oz. It was of firm consistence ; pulp of dark purple colour. Chronic venous congestion. The kidneys each weighed 6 oz. and showed chronic venous conges- tion. No infarcts in spleen or kidneys. The result of the post-mortem examination amply justified the diagnosis which had been made. The mitral obstruction was verified, and the absence of any structural changes at the pulmonary orifice proved that the diastolic murmur was caused in the manner suspected. One other case of this kind may be mentioned, as pre- senting the same features connected with the pulmonary valve, but associated with different mitral appearances. 586 AFFECTIONS OF THE PULMONARY ORIFICE. Case 40. — Fimciional PulTnoimry Incom'petencc. — A. L., aged 19, was admitted to Ward 25 of the Royal Infirmary in March 1897, sufl;'ering from chorea and debility. The ixatieut's father, aged 42, and mother, aged 43, were in excellent health, as were three brothers and two sisters. Another sister had died of infantile diarrhtea at the age of seven mouths. Since the age of 7, the patient had always been somewhat delicate. At that age she had an attack of chorea, Avhich had since then frequently recuri-ed. During the last two or three years she had been getting gradually weaker. She had never suffered from acute rheumatism. The patient was well nourished, but presented a mingled appearance of cyanosis and ana;mia. The face was pallid, with the exception of a dusky flush over the malar bones, the nose was thick, and the alte nasi were bluish, as were also the lips and ears. The teeth were bad, but there was no symptom of digestive dis- turbance. The abdominal viscera were normal in size, including the spleen. The hiiemoglobin was 45 %, and the number of red blood corpuscles was 3,425,000. The radial artery Avas soft, elastic, and moderately full, Avith fair pressure. The pulsation was regular and equal, and the pulse rate was 80. There was no capillary pulse in the nails or over patches of redness produced by friction on the forehead and chest. There was no abnormal appearance connected with the neck or prjecordia, but on palpation a very distinct thrill was perceptible at the apex of the heart, which was situated in. the fifth intercostal space, 5 in. from the mid - sternal line. Careful palpation of this thrill showed that it coincided with the diastole, and died away before the systole. The apex beat was unattended by any palpable vibrations, but the closure of the semilunar cusps could be felt as a very distinct impact over a considerable area of the prpecordia. On percussion, the right border of the heart was found, at the level of the fourth costal cartilage, to be 1-|- in. from mid-sternum. At the same level the left border extended 5 in. from the mid - sternal line. In the fifth intercostal space the border of the heart was 5| in. from mid-sternum. On auscultation in the aortic area, both sounds were clear and distinct. In the mitral area there was a soft-blowing systolic murmur propagated across for some distance towards the sternum, and for a considerably greater distance towards the axilla. There was also a harsh murmur commencing with the second sound, and prolonged over a considerable portion of the diastolic phase, but ceasing some time before the first sound. In the pulmonary area the first sound was pure, but the second sound was greatly accentuated, and was immediately followed by a short soft murmur rather high-pitched in tone, and entirely different in all its characters from the diastolic murmur heard in the mitral area. The maximum intensity of this murmur was at the sternal end of the third left intercostal space. It was conducted about half-way up the manubrium sterni, but there was no trace of murmur over the carotid arteries. In the tricuspid area the sounds were unaltered. There were some crepitations at the bases of both lungs, but otherwise the respiratory system presented no symptoms requiring notice. The PULMONAR Y INCOMPE TENCE. 5 8 7 only other point in the case which requires any remark is in regard to the nervous system. The patient presented characteristic choreic move- ments, mostly confined to the left side, but as this hemichorea has no immediate connection with the subject under discussion, it is unnecessary to dwell upon it. Under treatment with arsenic and digitalis the patient rapidly recovered and was discharged. The case which has just been narrated furnishes a most typical example of relative pulmonary incompetence. That the soft-blowing diastolic murmur which immediately followed the accentuated second pulmonary sound was due to a reflux at that valve, could not for a moment be doubted. It was certainly not the diastolic obstructive mitral murmur, since the characteristics of the two were so essentially different. It was impossible further to conceive of it as being due to any aortic lesion, since there was no evidence in the arteries or capillaries of any disturbance at the aortic cusps. One important fact has impressed me very strongly on considering cases such as these. This murmur of high pres- sure in the pulmonary artery does not seem to be usually associated with tricuspid incompetence, and it is probable that the existence of free regurgitation at the right auriculo- ventricular orifice is able to lessen the pulmonary pressure to such a degree that the murmur cannot be produced. PULMONAEY OBSTEUCTION AND EEGUEGITATION. A discussion of the pathological and clinical featm^es of combined obstruction and incompetence at the pulmonary orifice would be quite out of place, seeing that the results are sim.ply those of a double lesion in which one or the other element preponderates. CHAPTER XIIL AFFECTIONS OF THE TKICUSPID ORIFICE. Lesions affecting the right auriculo-ventricular orifice present a remarkable contrast in respect of frequency. Tricuspid obstruction is one of the rarest valvular lesions ; regurgitation at this orifice is beyond compare the most common. Statistics do not bring this fact out with such clearness as they should. The reason, however, is not far to seek. Incompetence of the tricuspid valve does not in itself seriously impair the general course of the circulation, and it is therefore often found amongst those who, although under treatment for various affections, have no cardiac symptoms. It accordingly escapes observation unless especially sought for. TEICUSPID OBSTRUCTION. The anatomical features of this lesion have been known since the time of Morgagni, who described a case in which the lesion was discovered after death in association with a similar affection of the mitral orifice. Corvisart carefully recorded the symptoms observed during life and the lesions found after death in a case of combined tricuspid and mitral obstruction, and he further mentions a pathological specimen obtained from a patient with similar morbid changes, adding that he could have giA^en several other instances of the same nature. Horn shortly afterwards recorded a case in the person of a woman, aged 25, whose heart was observed, post-mortem, to have obstruction of both right and left auriculo-ventricular orifices caused by valvular changes. TRICUSPID OBSTRUCTION. 589 Burns, a year later, gave a full and clear account of the symptomatology and pathology of similar double lesions as they occurred in a young woman, 19 years of age. Bertin described an instance of obstruction of both right and left auriculo-ventricular orifices, and another in which the tricuspid orifice alone was involved. He further cites a case which had been recorded by Corvisart, Leroux, and Boyer. Bouillaud incorporated in his work the description of the case of the general officer, which was recorded by Corvisart, Leroux, and Boyer, and referred to by Bertin. The lesions found in this case after death were somewhat singular. The tricuspid valves were so united as to close the orifice with a diaphragm penetrated by three apertures, two of which opened from the auricle into the ventricle, while the third ended in the left ventricle. In this case the left side of the heart was other- wise in a normal condition. Since the date of these observations many cases of tricuspid obstruction have been recorded, but comparatively few of them were recognised during life. Before the date of Laennec's great discovery, Kreysig attempted to formulate rules by which tricuspid obstruction might be diagnosed, and, after the intro- duction of auscultation, Hope drew up a clear statement of the local symptoms and physical signs which might be expected to occur. In most of our systematic treatises, whether devoted specially to the diseases of the heart or embracing the wider sphere of general medicine, the subject of tricuspid stenosis is dismissed in a few theoretical sentences. This is the case not only with the majority of our English works, but with those also by transatlantic and continental authors. A small number of writers, however, have laid before us some positive observations on this form of valvular disease, from which useful general principles as to diagnosis may be drawn. The extremely interesting case which Gairdner placed on record in 1862, and which he has since fully described, was the first instance of a diagnosis of obstruction of the right auriculo- ventricular orifice made during life and verified by post-mortem examination. Haldane showed at a meeting of the Edinbui'o-h Medico-Chirurgical Society, in 1 8 6 4, two specimens of obstruction of the tricuspid orifice, in both of which mitral obstruction was 590 AFFECTIONS OF THE TRICUSPID ORIFICE. also present. In one of these the patient during life presented no physical signs which could lead to a diagnosis of the tricuspid lesion, and in this respect it closely resembles a case which Philip has narrated. In the other patient the lesions were recognised during life by the existence of a presystolic luurniur heard at the apex, and another of similar rhythm at the lower end of the sternum, between which points of maximum intensity the murmur was not so loud. Duroziez described ten cases, two in men and eight in women. AValshe would appear in his long experience only to have met with a single case in which this lesion probably existed, but as there was no post-mortem examination he in consequence speaks very guardedly on the subject of diagnosis. In the exhaustive work of Hayden there is an account of a large number of cases recorded in the United Kingdom and America, including three observed by the author, two of which w^ere recognised during life. In every one of these instances there was a lesion of the mitral as well as of the tricuspid orifice. Bedford Fenwick, when showing two cases of tricuspid obstruction at the Pathological Society, analysed the facts presented by 46 instances on record. The most important conclusions to which he was led are, that it is more common in women than in men in the proportion of 41 : 5, that it is almost always associated with mitral obstruc- tion, and that there is a history of rheumatism in about 5 per cent, of the cases observed. By the researches of Leudet, 117 instances of acquired tricuspid obstruction have been collected from medical literature, including those embraced by the previous writers already mentioned. In 114 of these cases there were post-mortem examinations, allowing a wide field for observation. Of these cases, 86 occurred in women, 22 in men, and in 6 the sex was not mentioned. Leudet's results with regard to the implication of the different orifices in tricuspid obstruction are as follows : — Obstruction of tricuspid alone 11 ?) tricuspid and mitral . 78 )j tricuspid and pulmonary . 3 )) tricuspid, mitral, and aortic . 21 )» tricuspid, mitral, and pulmonary . 1 114 TRICUSPID OBSTRUCTION. 591 Herrick has brought the tale of recorded cases down to the present date. He finds that since the publication of Leudet's work in 1888, 40 cases with autopsies have been narrated, 28 of which occurred in women and 10 in men, while in 2 cases the sex was not noted. The valvular lesions present in those 40 cases were — Obstruction of tricuspid alone . ' . ,, tricuspid and mitral . ,, tricuspid and pulmonary ,, tricuspid, mitral, and aortic „ tricuspid, mitral, and pulmonary ,, tricuspid, mitral, aortic, and pulmonary „ tricuspid and aortic 1 40 Summing the results furnished by Leudet and Herrick there have therefore been 154 cases more or less thoroughly recorded, of which 114 occurred in women and 32 in men, while in 8 the sex was not mentioned. The results of post- mortem examination in those 154 cases showed the following associations of valvular lesions : — Obstruction of tricuspid alone ,, tricuspid and mitral ,, tricuspid and pulmonary ,, tricuspid, mitral, and aortic ,, tricuspid, mitral, aortic, and pulmonary ,, tricuspid, mitral, and pulmonary ,, tricuspid and aortic 12 96 3 39 1 2 1 154 Etiology. — The influence of sex has already been shown in presenting the results of previous observers. In 146 cases verified by post-mortem examination, in which the sex is mentioned, 114 occurred in women and 32 in men; that is, in the proportion of 3 '5 : 1. A considerable number of cases of tricuspid obstruction are of congenital origin, and the proportion is believed by Peacock and Eosenstein to be so great as to constitute the majority of cases of the affection. The views, however, of these authors are not borne out by the observations 592 AFFECTIONS OF THE TRICUSPID ORIFICE. of the majority of authors, and in the larger proportion of cases the affection nndeniahly takes its origin after hirtli. Kheiimatism and chorea give rise to a considerable number of cases. The painstaking researches of Herrick show that in TRICUSPID OBSTRUCTION. 593 the 154 cases which he has analysed, rheumatism was present in 51, doubtful rheumatism in 4, chorea in 2, while there was no history of rheumatism in 28, and in 69 no facts bearing on etiology were noted. It is probable that some of the acute specific diseases are responsible for cases of tricuspid obstruction, as in an instance recorded below. When all sources are investigated, there remain, nevertheless, many without any obvious origin ; that chronic valvulitis produced by severe exertion may cause it, appears to me at least reasonable. MoEBiD Anatomy. — The structural alterations which take place in tricuspid obstruction are in the main similar to those found in obstruction of the left auriculo- ventricular orifice. The most frequent alteration observed is the union of the cusps so that they form a funnel-shaped structure surrounding the orifice. Sometimes, but rarely, the union of the cus]3s produces such a degree of obstruction as scarcely to admit the point of the little finger. Lesions of this kind have been more particularly described by Duroziez, but they are far from common. In other cases, in addition to a certain amount of union of the cusps, there is some contraction with rigidity, and there may even be some deposition of inorganic salts. There may be vegetations, either of recent origin or of older standing. In some instances, as in that figured in the accompanying illustration (Fig. 166, p. 597), the lesions consist in fine transparent granulations, in other cases these granulations have undergone the fibrinous changes already described in the case of the mitral orifice. The secondary results upon the heart have never been very clearly studied, since, with few exceptions, the affection has always been accompanied by a similar lesion of the mitral orifice. It would naturally be expected that some hypertrophy of the left auricle would follow the development of the lesion, and this, as a matter of fact, is the case. It has, however, in addition, been accompanied by a certain amount of dilatation, as will be seen to have been the case in some of the instances narrated below. The illustrations (Figs. 164, 165, and 166) show some of these effects. They are from Case 42, in which (p. 604) the full details can be read. They show enormous dilatation and hypertrophy of the right auricle and ventricle. 38 594 AFFECTIONS OF THE TRICUSPID ORIFICE. These results are, however, ahuost certainly produced by the ffreat constriction of the mitral orifice, and throw no light Fig. 164. — Great dilatation and hypertrophy of the right auricle ami ventricle from combined mitral and tricuspid obstruction and incompetence. The heart is seen from the front. upon the consequences of tricuspid obstruction. When the affection has been of congenital origin it has been accom- panied, as might be expected, by some other malformations. TRICUSPID OBSTRUCTION. 595 such as pulmonary obstruction, patent foramen ovale, or patent Fig. 165. — Great dilatation and hypertrophy of the right auricle and ventricle from combined mitral and tricuspid obstruction and incompetence. The heart is seen in profile from the right. ductus arteriosus. Upon the circulation the effect of the 596 AFFECTIONS OF THE TRICUSPID ORIFICE. disease is to bring about a considerable degree of venous stasis, and this shows itself by characteristic clinical features. Symptoms. — On account of the almost invariable association of tricuspid obstruction with some other cardiac lesion, it is difficult to be certain how much of the symptomatology is due to the right -sided lesion; many symptoms which present themselves are due without doubt to secondary changes in the right side of the heart. There may be absolutely no evidence leading to suspicion of the tricuspid lesion. In cases, never- theless, where a very considerable degree of obstruction of the tricuspid orifice has existed, there is some dyspncea, exag- gerated on exertion, but there is a greater degree of cyanosis than of breathlessness, and it is associated with chilliness of the extremities and great susceptibility to cold. As Foster pointed out, there is more tendency to stasis of the systemic than of the pulmonic veins. On observing the general appearance of any patient, there- fore, suffering from this disease, the complexion is usually seen to be dusky, with dark lips, nostrils, and ears. There is commonly some oedema about the ankles. The urinary secretion is scanty and high coloured, often containing albumin. The cerebral faculties are often impaired in one direction or another, and, on physical examination, the liver and spleen are somewhat enlarged, while ascites may be present. It is highly probable that many of these symptoms are not directly produced by the tricuspid obstruction, but they must in many instances be exaggerated by it. The physical signs are sometimes extremely well marked. On examining the veins of the neck they are sometimes seen to be turgid and motionless, in other instances they show well- marked venous pulsation. The investigations of Mackenzie, already discussed, have thrown much light on this subject. The radial artery may present no alteration. It may be of average fulness and pressure, and show no alteration in rhythm or rate ; but it may, on the other hand, be empty, compressible, irregular, and frequent. Palpation has in some instances revealed a well-marked purring thrill. The area over which this thrill is felt is usually wide, and sometimes it has been possible to make out TRICUSPID OBSTRUCTION. 597 two points of maximum intensity, one at the apex of the heart at the fifth intercostal space, the other just outside the left edge of the sternum. But in other cases the thrill has its point of maximum intensity somewhere between the mitral and tricuspid areas, as was the case in one of the instances narrated below. ■''^^ Fig. 166. — Transverse section through the heart in combined mitral and tricuspid obstruction and incompetence. The button-hole mitral orifice is fused with the chorda; tendinea; ; the triangular tricuspid orifice, partly hidden by the papillary muscles, has vegetations on its margins ; the right ventricle is dilated and its walls greatly hypertrophied. No constant condition is found on percussion, but in most instances the area of cardiac dulness is increased transversely, both borders of the heart being situated too far out. In some instances there can be no doubt that the right auricle is con- siderably dilated. On auscultation the characteristic phenomenon is a pre- systolic or diastolic murmur, heard with its greatest intensity 598 AFFECTIONS OF THE TRICUSPID ORIFICE. at the junction of the fifth and sixth ribs with the left side of the sternum. Occasionally the nuumur begins with the second sound and fills up the entire interval between it and the first sound with some presystolic reinforcement. It must be admitted, however, tliat in many cases no murmur has ever been detected during life, and, therefore, tlie lesion occurs as a post-mortem surprise. Diagnosis. — The recognition of tricuspid obstruction depends almost entirely on the presence of positive physical signs, seeing that the symptoms produced by interference with the circulation are similar to those arising from the secondary results of mitral disease, which has been seen to be almost invariably associated with tricuspid obstruction. The appear- ances in the veins of the neck to which reference has been made are precisely those found in secondary implication of the right ventricle in the course of mitral disease, and the same may be said of the enlargement of the area of cardiac dulness to the right. It is otherwise, however, with the evidence afforded by auscultation. The presence of the presystolic or diastolic murmur with its maximum intensity in the tricuspid area must be allowed to be pathognomonic of obstruction of the right auriculo- ventricular orifice. In certain cases a murmur of one or other of these rhythms is accompanied by a murmur of mitral obstruction, in which case the murmurs have separate points of maximum intensity, one in the tri- cuspid, the other in the mitral area. In other cases, as in one (No. 44, p. 607) described below, only one murmur can be determined, having a point of maximum intensity intermediate between the mitral and tricuspid areas. It must be admitted in such instances that the diagnosis is a matter for discussion, and each instance of this nature must be judged on its own merits. In a large proportion of cases of tricuspid obstruction the lesion appears to elude observation, probably in consequence of the absence of the murmur. Just as murmurs of mitral ob- struction are variable, it is probable that similar tricuspid murmurs have a tendency to appear and disappear. Hayden, in his remarks on tricuspid obstruction previously referred to, mentions a case in which he had diagnosed aortic TRICUSPID OBSTRUCTION. 599 and mitral obstruction. These lesions were found on post- mortem examination, but there was also tricuspid obstruction which had not been diagnosed. The author reproduces some observations which he made at the Dublin Pathological Society, which may well be quoted here. He remarked that " dia- gnostically the case is of considerable interest. It is perfectly novel to me, and, with the light it affords, I should have no difficulty in diagnosing, in a similar case, the existence of con- striction of the two auriculo-ventricular openings. The jjoint on which the diagnosis turns is this, that whereas the murmur of mitral constriction is always at the apex of the heart, and, in the great majority of cases, strictly limited to the area of the mitral opening, in this case a murmur of the same rhythm was audible to the left of the sternum. Between these two points there was a portion of the chest over which no murmur was distinctly audible." Profiting by the experience thus gained, the author just quoted was able, as mentioned previously, to diagnose during life, and verify after death, two later cases of tricuspid stenosis. Balfour speaks of a boy, who, he says, " had a presystolic murmur so loud and rough that I have selected it as a measure of the extent to which such murmurs could be propa- gated. In mapping out the propagation of his murmur, I found it to extend so much further to the right than usual that the thought struck me, is it possible that we can have in this case not only a mitral but also a tricuspid stenosis ? But I dismissed the idea as in the highest degree improbable, and referred the great propagation to the loudness and roughness , of the mitral murmur. The result shows that in this I was mistaken, though unquestionably there were no other symptoms present but the excessive propagation of the murmur which could countenance the former idea." In this case considerable obstruction of both mitral and tricuspid orifices was found on post-mortem examination. The result of this case was such as to lead Balfour to diagnose in a similar case combined mitral and tricuspid obstruction ; but as down to the time of the publication of the second edition of his work the patient was alive, the diagnosis was not absolutely confirmed. Mackenzie has suggested that, in the frequent absence of a 6oo AFFECTIONS OF THE TRICUSPID ORIFICE. presystolic luurmur, obstruction of the right auriculo-veiitricular orifice may be suspected when pulsation of the liver exhibits an auricular type — that is to say, when the principal impulse takes place in advance of the ventricular systole. The ex- planation which he gives is that in consequence of the obstruction the liypertrophied auricle sends blood backwards as well as forwards, and this produces the auricular liver pulse. His conclusions were based on the examination of seven cases of tricuspid obstruction, in live of which the condition was confirmed Ijy post-mortem examination. Prognosis, — A forecast of the future must of necessity be difficult in cases of tricuspid obstruction, since the affection is almost invariably complicated by the presence of other lesions, and the prognosis can only be the result of careful considera- tion in regard to each individual case. Duroziez has, never- theless, boldly attempted to formulate rules for guidance in respect of prognosis. He has pointed out that, while the average age of death is thirty-two years in the case of such obstruction as will not admit the point of the finger, the duration of life reaches forty-two years in those cases where the orifice allows the passage of two fingers. This must be allowed to be a matter of small concern to the practical physician, from the obvious fact that w^e have no means even of guessing the size of the orifice. Treatment. — Tricuspid obstruction if at all considerable diminishes the blood supply to the lungs, and must in this way be attended by persistent dyspncea. It also causes retardation of the return of blood from the systemic veins and thus leads also to general venous stasis. The indications for special treatment are, therefore, to get rid of any local troubles which may tend to increase the interference with the functions of those parts more particularly implicated, while carrying out the general lines of treatment applicable to A'alvular disease. Case 41. Mitral and Tricuspid Obstruction and Incompetence. — Isabella F., set. 31, domestic servant, was admitted on 1st April 1892 to Ward 25, then under my care, suffering from right-sided hemiplegia, with ajjhasia. Her father died at the age of 72, of bronchitis. Her mother, 65 years old, always enjoyed good health. She had three brothers and four sisters, who had always been healthy. Her social surroundings were satisfactory. Ten years before she had sxxft'ered from TRICUSPID OBSTRUCTION. 60 1 a severe attack of acute rheumatism, since which time her health had not been so good as formerly. The present attack began about nine months before admission. After undergoing some mental troubles the patient suddenly found that she had lost the power of moving the right arm, and, on attempting to inform some one of the circumstance, discovered that she was unable to do so. She was told by another servant that her face was drawn to the left side. It was deemed advisable that she should go to bed, and after betaking herself thither the patient gradually lost the power of moving the right leg. After the lapse of a few weeks she partly regained the use of the leg and arm, and to a less extent that of the face, but speech was only restored in a very slight degree. On examination it was found that the alimentary and hfemopoietic systems were in no way affected. Inspection showed a faint double reflux — auricular- and ventricular-systolic in rhythm respectively — in the veins of the neck. The apex beat was very distinct on account of the thinness of the patient ; it was situated in the sixth intercostal space, 4-| in. from the middle line. There was some pulsation in the epigastrium. On palpation it was noticed that there was at times a faint diffuse thrill immediately preceding the cardiac impulse. It was felt to be most distinct at the apex, but could be traced almost as far as the xiphoid cartilage. The radial pulse was of moderate fulness and pressure ; its rate was usually about 80, and its rhythm regular. The cardiac dul- ness began above at the lower edge of the third left costal cartilage. The right borderof the heartwas l-|,and the left Al\ in. from the mid-sternal line. At the apex there was a distinct, but not loud, murmur of presystolic rhythm and rough character, which was succeeded by a soft blowing sj's- tolic murmur, followed in its turn by a double second sound. When these mAirmurs were traced, it was found that the one of presystolic ti me could only be heard for about an inch to the left of the apex, but that it was propagated as far as the ensiform cartilage, slightly diminishing in loudness for a certain distance, and, after that point had been passed, increasing in intensity and altering in character as the lower end of the sternum was approached. The systolic murmur was conducted as far as the axilla on the one hand, and to the xiphisternum on the other, but, as in the case of the presystolic murmur, there was a decrease of intensity on auscultating across the space from the apex to the sternum, followed by a gain in loud- ness when the ensiform process was approached. There were, in short, presystolic and systolic murmurs having maximum intensity both in the mitral and tricuspid areas. At the base of the heart the first sound was Pig. 167. — Presystolic and systolic mitral and tricuspid murmurs in Case 41. 6o2 AFFECTIONS OF THE TRICUSPID ORIFICE. very feeble, and the second sound reduplicated, the puliuonarv part of it being at once louder and later than the aortic. The position and extent of the abnormal sounds are shown in Fig. 167. The respirator)' system had but moderate deviations from the standard of healthy conditions, there being a little muliling of the jjercussion sound, a slight increase in the roughness of the respiratory murmur, and a few scattered crepitations over the whole of the thorax. Neither the in- tegumentar}' nor urinary functions were in any way affected. With regard to the nervous system, it was found that there was no alteration in sensibility, ordinary or special. The right leg and arm were able to perform most movements, but in a weak and sluggish manner, and the toes and lingers moved very imperfectly. The mouth was drawn slightly to the left side when the patient smiled, and the tongue tended towards the right on protrusion. The muscles of the right leg and arm were wasted, and the face on that side was expressionless. The right half of the entire muscular system showed diminished reaction both to galvan- ism and faradism. The temperature of the paralysed side was lower than that of the other. The plantar and other superficial reflexes were exaggerated on the right side of the body, and on that side there was great increase in the knee jerk, and a marked ankle clonus, as well as an exaggeration of the elbow jerk, and a distinct wrist clonus. Even from the date of the paralytic seizure, the patient had been able to under- stand everything said in her presence, and to read with perfect ease ; she had, in point of fact, spent most of her time in reading. At the time of the attack she was unable in any way to express her ideas, but she had gradually regained the power of saying a few words, and had taught her- self to write answers to questions with her left hand. The diagnosis arrived at in this very interesting case was obstruction of both auriclilo-ventricular orifices, with incompetence of their respective valves, and embolism of a branch of the left middle cerebral artery, in- volving the motor tracts corresponding to the centres for the leg, arm, face, and speech. After some gradual improvement in the general condition, and in the state of the nervous system, the patient's circulation showed symptoms of failure. The lungs became oedematous, and some anasarca of the lower extremities followed. Under appropriate treatment these symptoms, especially as regards the limbs, lessened to some extent, but on the 27th April death occurred suddenly from cardiac failure. The post-mortem examination was performed on the day after death by Dr. William Russell. The following is the description of the morbid anatomy from the books of the pathological department : — External Affearances. — Body spare. Rigor present. Face, neck, and upper part of thorax livid. No anasarca. Thorax. — There were a few ounces of fluid in each pleural cavity. No adhesions were found. There were about two ounces of clear fluid in the pericardium, and a patch of pericardial adhesion over the base of the right ventricle. Heart. — There was a large and tough pinkish clot in the left ventricle, TRICUSPID OBSTRUCTION. 603 which extended into the aorta. There was a similar clot in the right ventricle extending into the pulmonary artery, accompanied l^y a little post-mortem clofc in the same chamber. Diameters of orifices : aortic, •97 ; pulmonary, 1-2 ; mitral, 1-1 ; tricuspid, 1 in. The aorta was normal, with the cusps slightly thickened, but not at all shrunken. Both cusps of the mitral valve were tliickened and fibroid, as also were the chorda? tendinete and apices of papillary muscles. From the anterior cusp there was suspended an irregular elongated mass of vegetation, which evidently hung free in the blood stream, and the tendinous cord with which it was united showed a small warty mass of vegeta- tion. The auricular aspect of the posterior segment, and the auric- ular endocardium continuous with it, were occupied by an extensive warty growth, covering an area of about 1^ in. square. The left ventricle was dilated, and its muscle soft, pale, cloudy, and somewhat fatty. The left auricle was dilated and slightly thickened. The pulmonary artery was somewhat dilated. The right ventricle was elongated, but not much dilated ; its wall was not hypertrophied, and its muscle was in the same condition as that of the left ventricle. The tricuspid valves were so united as to form a ring which admitted two fingers, constituting stenosis. The ring was adherent to the endocardium three - quarters of an inch below the pulmonary valves. The right auricle was much dilated, and the foramen ovale was closed. The heart weighed 1 lb. 6 oz. The appearance of the heart is shown in Fig. 163, p. 592. Lejt Lung weighed 1 lb. 4 oz. It was emphysematous, antemic, and edematous. Fdijlit Lung weighed 1 lb. 15 oz. It was emphysematous, and showed slight chronic venous congestion, with cedema. Head. — Brain weighed 3 lb. 2 oz., and was extremely pale and blood- less. A vertical section through the ascending parietal convolution, re- vealed in the parietal fasciculus above the island of Reil an area of brownish pigmentation, with a degree of softening which was no doubt due to embolism. The other parts of the brain and the upper part of the cord were normal to the naked eye. No embolism in large vessels. Abdomen. — Liver weighed 4 lb. 1 oz., was congested, and the margins of the lobules fatty. The gall bladder was oedematous, and contained a little greenish bile. Spleen weighed 1 lb. 2 oz. The capsule was tight and thickened. On section the organ was firm, the fibrous tissue was very prominent and thickened, and the Malpighian bodies were somewhat enlarged. Left kidney weighed 6i- oz. This was very anaemic and mottled with a diffuse gray colour. The capsule was adherent, and the markings in cortex were obscured and broken up. Eight kidney weighed 6^ oz. ; in the same condition as its fellow. In this case the diagnosis of the double cardiac lesion which we were led to form in consequence of the distribution of the murmurs, was justified by the result of the post-mortem examination. 6o4 AFFECTIONS OF THE TRICUSPID ORIFICE. Case 42. Obstruction and Regurgitation of Mitral and Tricuspid Orifices, with Aortic Obstruction and Ptilmonarn Incompetence. — J. L., aged 25, domestic servant, was admitted to the Royal Infirmary on the evening of 9th December 1897 on account of dropsy and l)reath- lessness. Her condition on admission was serious, and jn-ecluded the possibility of obtaining exact information as regards the history of the illness as well as that of her family. Unfortunately no opportunity was allowed me of seeing the patient during life, but my resident physician. Dr. J. AV. Simpson, has kindly furnished me with notes of the case. There was a slight degree of cyanosis as evidenced by the dusky tint of com2ilexion, the dark purple of the lips, and the lividity of the ears and nostrils, as well as the nails of tlie hands and feet. There was great oedema of the legs, of the arms, and of the back, and extensive ascites was also present. The tongue was dusky in hue, with a slight fur upon the surffice. The liver extended from the fourth rib to 3 in. below the costal margin, or 5^ in. in total extent in the line of the mammilla. The radial arteries were healthy, the pulse pressure low, and the iiulsa- tion irregular ; its rate was 80 soon after admission. On examination of the neck and prrecordia, there was gi'eat distension of the jugular veins, and a general heaving impulse over the entire i)ra>cordia. On placing the hand over the chest, a faint presystolic thrill could be made out over the mitral area. The area of cardiac dulness appeared to be enlarged both to the right and to the left, but on account of the condition in which the patient was, no attempt was made to define the borders accurately. On auscultation both a presystolic and a diastolic murmur were heard ; the jiresystolic murmur was somewliat ^\"idely diffused. The systolic miirmur was heard o^•er the entire pra;cordia. The respirations were 36 jier minute soon after admission, and there was evidence at the bases of hypera?mia, if not oedema, the j^ercussion sound being somewhat dulled and crepitations being aliundant. The renal secretion contained bile and all^umin. In spite of every eftbrt to relieve the patient, she sj)eedily sank into a comatose condition, and died early on the morning following her admission. The post-mortem examination, which was performed by Dr. E. A. Fleming, revealed an interesting condition of mattei's. There was well- marked lividity and some rigidity, more especially of the lower limljs, the arms being almost flaccid. Marked oedema was present both of arms and legs. The body was well nourished and the muscularity fair. The pericardial sac contained 8 oz. of a slightly blood-stained fluid. The heart weighed 1 lb. 5 oz. l^efore being opened. Both auricles were greatly enlarged ; the right measured 5 in. longitudinally, and 3i in. transversely ; the left aiiricle was considerably dilated and somewhat hypertrophied. The right ventricle was enormously dilated and hyper- troj^hied, its cavity was 3|^ in. long, and its walls from |- to -| in. thick ; the left ventricle was smaller than usual, its cavity being 2| in. long, and the thickness of the wall ^ to ^ in. The aortic cusps were competent, tlie pulmonary were markedly incomjietent, and the orifice greatly dilated. The mitral orifice was TRICUSPID OBSTRUCTION. 605 greatly contracted, the cusps, chordae tendiiiete, and tips of tin; papillary muscles being fused so as to form a thick partition Ijetween the auricle and the ventricle, perforated by a button-hole mitral oritice showing a cone diameter of -3 in. The musculi papillares were greatly hyper- trophied. The tricuspid orifice was also obstructed, the three cusps being fused at their extremities, and the chordte tendinete being shortened and thickened ; the papillary muscles and fleshy columns were much in- creased. Upon the three margins of the triangular orifice thus jiroduced were some recent vegetations. The orifice showed a cone diameter of '5 in., the aortic orifice had a cone diameter of -7 in., and the cusps were the seat of numerous vegetations. The pulmonary orifice measured "9 in. by the cone ; its cusps were healthy. The coronary arteries were tortuous and thickened. The right ventricle formed the anatomical apex of the heart. The right lung weighed 22 oz. and the left 15 oz. ; both showed marked hypostatic congestion and oedema. There was a small patch of collapse in the left lung near the apex of the upper lobe, and in the right lung, near the lower part of the upper lobe, there was a nodule about the size of a walnut which contained caseous material, which had undergone some calcareous degeneration. There was one small recent pulmonary hajmorrhage in the lower lobe of the left lung. The liver weighed 3 lb. 6 oz., and showed very marked perihepatitis both of old and recent develop)ment. It showed well-marked cyanotic atrophy, but there was no evidence to the naked eye of any connective tissue increase in the portal spaces. On microscopic examination some commencing perivascular cirrhosis was observed. The spleen weighed 7 oz. and showed marked perisplenitis along with chronic venous congestion. Each kidney was 6 oz. in weight, and each showed chronic venous stasis. It was most unfortunate that this case, so interesting in its morbid anatomy, did not come under more extensive clinical observation. It must be added to the category of those only realised on the table of the pathologist. Case 43. Tricus'pid and Mitral Obstruction and Incompetence. — Mrs. W., aged 30, hawker, was admitted to Ward 27 of the Royal Infirmary, 26th February 1898, on account of cough and breathlessness. Her mother had died suddenly at the age of 49 from heart disease ; her father died when she was very young, and she never knew the cause of his death. The family consisted of one brother and three sisters, who were perfectly well. She had been married for eleven years, but had never had any children, and for one year she had been a widow. Her general surroundings had not been particularly good, as her house was damp and draughty, while her occupation exposed her to adverse weather influences. There were no previous illnesses of much imj)ortance ; in 6o6 AFFECTIONS OF THE TRICUSPID ORIFICE. fact, with the exception of measles, and catarrhs, shi- liad never Ijeen ill ; in particular, there had never been any rheumatic symiitoms. For the three yeai-s previous to admission she had l)een troubled with winter cough, Init during the warm weatlier it always disappeared. The patient was found to be a ijlump and healtliy-looking woman, with ruddy cheeks, and clear complexion. The merest trace of cyanosis was present at the time of her admission, but speedily ])assed away. Her height was 5 ft. \\ in., and her weight 6 st. 6 ll.>. The alimentary system showed absulutely no abnormal symptoms, and the alxlominal viscera were of normal size, the liA-er in particular extended from the upper border of the fourth rib to the costal margin, a distance of 5 in. The spleen was not enlarged, and the lymphatic glands through- out the body were normal. For about two years before admission the patient had sutfered from occasional attacks of pain in the prrecordia. This was sometimes dull in character, but at other times was extremely sliarp and caused her to hold her breath. There had lieen l^reathlessness on exertion for aljout the same period of time, and occasionally it seemed to take the form of cardiac asthma, Avhich prevented her lying do^^^l during the night. There had latterly been some feelings of faintness, but never any loss of consciousness. Palpitation was present on exertion. Diffuse pulsation was visible in the fourth, fifth, aird sixtlx left inter- costal spaces, as well as in the epigastrium and episternal notch. There was some pulsation of the veins on the right side of the neck ; the im- pulse preceded the apex beat, and therefore was auricular. On palj)ation the diffuse impulse was found to have its maximum intensity in the fifth intercostal space, 3i in. from mid-sternum, Ijut it was widely conducted. The impulse was accomiiaiiied by a distinct i^resystolic thrill, running up to the apex beat, and there w'as also an im- pulse corresponding to the second sound, occasionally fol- lowed by a diastolic thrill On percussion the upper border of the heart ■s^-as found to be at Fig. 168.— Murmurs of tricuspid and mitral the inferior edge of the third left obstruction and incompetence in Case 43. costal cartilage, and the cardiac duhiess extended 1^ in. to right, and 4 in. to left of mid-sternum at the level of the fourth costal cartilage. On auscultation over almost any part of the prajcordia a more or less definite presystolic murmur could be heard, and on follo\\'ing this murmur over the prt^jcordia it was found to ha^'e two points of maximum intensity. One of these, at which it was most distinct, was within the conventional tricuspid area at a point corresponding to the sternal end of TRICUSPID OBSTRUCTION. 607 the fifth left costal cartilage. The other i^oint of iiiaxiiuurii intensity was within the mitival region, its loudest point Ijeing just inside of the apex beat. The presystolic murmur was much louder in tlie tricuspid region than in the mitral, and the two murmurs were distinctly different in tone. In the mitral area it was followed Ijy a soft blowing systolic murmur, which practically replaced the first sound, and was succeeded by an accentuation of the second sound, from which a short rough diastolic murmur tailed away. In the tricuspid area the presystolic murmur was followed by a distinct first sound, which, however, jaassed into a faint blowing systolic murmur. The second sound in this area seemed to be of normal intensity, and there was no diastolic murmur. In the aortic area the sounds in no way differed from those of health, and in the pulmonary area there was a distinct accentuation of the second sound. The area of conduction of the presystolic mui'mur was extremely wide, measuring 12 in. vertically and 14 in. horizontally. The diastolic murmur was limited to a very small area, around the apex beat, measuring 2 in. transversely, and 1-| in. vertically. The systolic murmur was somewhat more widely conducted, and occupied an area of *l\ in. by 4^ in. The arteries throughout the body showed evidence of slight thickening. The vessels were full, and the pressure within moderate limits. The rate of the puLse was 68. It was ahnost regular in time and equal in size. Each individual pulse wave was somewhat smalL The respiratory system gave evidence of some subacute bronchitis on admission. This speedily passed away. There were no symptoms of disturbance connected with any other system in the body. After two or three weeks' tonic treatment the patient was able to leave hospital. The physical signs remained as above described. There could be absolutely no doubt that in this case there was obstruction and regurgitation at the tricuspid, as well as at the mitral orifice. Case 44. Marion R., aet. 21, machinist, presented herself as an out- patient on the 5th November 1892. Her father, get. 62, had for some time suffered from asthma ; her mother, set. 58, was in good health. Two brothers and two sisters were in perfect health. One brother had died of peritonitis, and a sister of exophthalmic goitre. The patient had always been in comfortable cir- cumstances. She had enjoyed good health throughout most of her life, but had once been in the Royal Infirmary for a few weeks, on account of haemoptysis. The pains for which she sought advice had troubled her for three weeks. On making a routine examination of the physical condition of the patient, it was found that with the exception of the circulatory organs every system presented phenomena in all respects normal. No symptoms were present that could be referred to the heart. On inspection, a slight oscillation was seen in the veins of the neck, preceding in time the pulsation of the carotid arteries. The patient was 6o8 AFFECTIONS OF THE TRICUSPID ORIFICE. somewhat plump, and no impulse of any kind could lie seen in the pne- cordia. Palliation deternuned that the apex beat was in the fifth inter- costal space, 3 in. from nnd-sternum. It revealed in addition another fact, viz., that there was a very distinct thrill preceding the cardiac impulse, and not confined to the region of the ape.x, but felt widely spread in every direction round that area. The radial pulse, 76 per minute, Wiis full, of moderate tension and perfect regularity. The upper limit of -,^__y— cardiac dulness Avas found to be at the level of the upper border of the third costal cartilage. The right border was 2i and the left 3^? in. from the middle line. On ausculta- tion, a loud rough presystolic mur- mur was heard over an area laiger than, and eml:iracing the whole of, the prtecordia. The point of maxi- mum intensity was exactly at the junction of the fourth left costal cartilage with the sternum, and from this spot it was conducted in every direction toditfei'entdistances. It was audible 3-| in. upwards, Z\ in. downwards, A^\ in. horizontally to the right, 5|- in. horizontally to the left, 4i- in. diagonally down wards to the right, and 6 in. downwards to the left. The facts are shown in Fig. 169. Although the maximum intensity was at the junction of the fourth left costal cartilage with the sternum, there was very little change in loudness for aljout a couple of inches in every direction around this spot ; the murmur, for instance, was almost equally loud at the ensiform process and near the cardiac ajDex. There was absolutely no change in the character of the murmur when the mitral and tricuspid areas were carefully compared. The first sound was everywhere perfectly closed, the second sound was reduplicated, and the pulmonary element was both later in time and relatively louder than the aortic. After a few days' rest and treatment by means of salicylate of sodium, the patient was freed from her symptoms. Fio. 169. — Tricuspid and mitral iJre.sy.stolic iiinriimr in Case 44. ISTow the results of auscultation in this case — which are shown in the tracing — are not absolutely free from the possibility of different, even antagonistic, interpretation. It may be held, on the one hand, that the presystolic murmur was entirely due to obstruction of the tricuspid orifice, or on the other, that it was caused solely by obstruction of the mitral orifice. It seems to me that the possibility of such a view as this latter hypothetical opinion may be at once dis- TRICUSPID OBSTRUCTION. 609 missed, for if, with a presystolic inuriiiur having its point of maximum intensity in the situation above described, there should be no tricuspid stenosis, " we shall," as Gairdner has so well put it, " have to rewrite our whole cardiac diagnosis and pathology of murmurs ; for it is impossible to find a stronger case than this for the absolute diagnosis of tricuspid obstruc- tion." This reasoning was strongly urged by me when the case was previously published. No doubt another consideration supported the view that in this case there was a double lesion. If diagnosed as at any rate in part one of tricuspid obstruction, the rarity of this lesion without coincident mitral obstruction is a strong argument, when unopposed by the facts of physical diagnosis, in favour of combined mitral and tricuspid obstruction. With reference to this very interesting case, one final remark must be made. It will be remembered that, with the sole exception of an attack of ha3moptysis on a former occasion when she was an inmate of the Eoyal Infirmary, her health has always been good. She has, in particular, never had a rheumatic symptom unless the pains for which she presented herself in November are of this nature, and it seems possible that the valvular lesions might have been congenital. From the total absence of any symptoms, the obstruction was probably caused by some roughening of the auricular surfaces of the auriculo-ventricular valves, without any con- siderable narrowing of the orifice, and there could not be any interference with the closure of the valves, as there was no evidence of regurgitation. Some time afterwards the subsequent events of the patient's life came to my knowledge. She was seized on 1st February 1893 with acute pleuro-pneumonia affecting the base of the left lung, and was attended by Dr. Eobert Thin, to whom I am indebted for the information. The attack was very serious from its beginning, and the pneumonic con- solidation rapidly extended so as to invade almost the whole of the lung. On the morning of the 6th, oedema of the other lung set in rapidly, and she died the same evening. Unfor- tunately no post-mortem examination was obtained. The two cases (Nos. 43 and 44) which have been narrated 39 6io AFFECTIOXS OF THE TRICUSPID ORIFICE. offer in certain respects a marked contrast. In the first, there was not only' incompetence of both auriculo-ventriciilar valves, shown by the distinct murmurs of systolic rhythm in the tricuspid as well as mitral area, but an easy means of differentiation of the mitral and tricuspid presystolic murmur was afforded by their separate points of maximum intensity. This case also differed from the second in the presence of some definite results of valvular disease, i.e. the venous congestion of the lungs, and the cedema of the lower extremities. The second case, which has been previously discussed by me, presented considerable difficulty on account of the maximum intensity of what almost seemed to be a single presystolic murmur, and this murmur was absolutely free from anything tending to point in the direction of regurgitation. TEICUSPID INCOMPETENCE. Eegurgitation at the tricuspid orifice, formerly regarded as infrequent, is now admitted to be the most common valvular affection. According to Stewart Stockman, it is very common in the lower aniiuals. There is a natural provision whereby some regurgitation is allowed at the tricuspid orifice when the intracardiac pressure on the right side of the heart is excessive. It appears to have been first observed by Hunter, and, as was mentioned previously, he based his opinions upon the results of injections. Little notice was taken of these views until Adams investigated the subject and extended the observations. To him is due the merit of showing clearly that what is necessary towards the maintenance of the systemic, would be injurious to the pulmonic circuit, where so many causes would temporarily retard the passage of blood through the lungs. Adams appears to have been the first to point out that the natural tendency to incompetence of the tricuspid valve saves it from injuries, to which the mitral valve is, from its unyield- ing nature, exposed. "Wilkinson King published some most luminous observations upon this subject, and explained the mechanism, or " safety-valve action," by means of which he considered the regurgitation to be allowed. These views were at one time stoutly opposed, especially, perhaps, by Blakiston TRICUSPID INCOMPETENCE. 6ii and Walshe, but this natural function of the tricuspid valve is now almost universally admitted. Tricuspid incompetence naturally falls into two great classes. The first group includes instances which, on account of some lesion connected with the valves themselves, may result from endocarditis or degeneration. The second group includes cases in which there is incompetence as the result of some affection of the muscular substance of the heart. The first-mentioned group is numerically small as compared with the second, to which belongs the overwhelming proportion of instances of tricuspid regurgitation. It therefore follows that the two groups stand to each other in well-marked antithesis. Etiology. — Tricuspid insufficiency having its origin in purely valvular lesions may be produced by acute, subacute, or chronic endocarditis. It may, on the other hand, be produced by degenerative processes. In this class, the lesions of the tricuspid valve are very rarely isolated. Not merely is in- competence of this type associated, as a rule, with obstruction, but the tricuspid affection is linked with some other valvular lesion, more particularly with structural alteration of the mitral cusps. The factors which lead to incompetence of the tricuspid valve in consequence of muscular changes are extremely numerous. It is worthy of note that this form of incom- petence may be the sole cardiac affection present, and yet it can never, in any sense, be regarded as primary ; it is on the contrary invariably consecutive to some other condition. Tricuspid incompetence resulting from dilatation of the right ventricle may be brought about by causes acting mechanically upon the muscular walls. It is obvious that the lesions acting most directly upon the right ventricle, which may, in consequence, produce dilatation with incom- petence of the tricuspid valve, are connected with the pul- monary artery. Obstruction of the pulmonary orifice or incompetence of its valve always leads to changes in the muscular substance of the right ventricle, producing hyper- trophy, with or without dilatation according to circumstances. As pulmonary lesions are of but rare occurrence, they cannot be regarded as common causes of tricuspid incompetence. 6i2 AFFECTIONS OF THE TRICUSPID ORIFICE. With the exception of lesions of the puhnonaiy orifice, tlie affections which act most immediately upon the right ventricle are connected with the lungs. It is worthy of note that the disorders which lead in this way to most disturhance of the functions of the right ventricle, are those interfering with the distribution of the pulmonary artery, or the return of the blood by the pulmonary veins. It is, therefore, emphy- sematous and fibroid changes which lead directly to disorders of the right ventricle. Bronchial affections, unless they cause interference with the access of air, have but little influence directly upon the right ventricle. Their blood supply is derived from the l)ronchial arteries which are of aortic origin ; 1 tut inasmuch as chronic diseases of the bronchial tubes usually lead not merely to dilatation of the tubes, but also to emphysematous changes in the luno- tissue, they in a more remote manner also cause dilatation of the right ventricle and tricuspid insufticiency. The only form of pulmonary phthisis which leads to such chano-es in the right ventricle is chronic fibroid phthisis. Mitral lesions, by interfering with the circulation in the lunos, produce the same effects. It is a difficult matter to assess the relative influence exerted by obstruction and in- competence at the mitral orifice in the production of tricuspid incompetence; but this is a matter of less moment, seeing that the two affections are so frequently conjoined. Aortic diseases, in the absence of any mitral complication, have absolutely no influence over the right ventricle, for, so long as the mitral cusps are competent and the cardiac hypertrophy adequate, there can be no backward pressure upon the pul- monary circulation. When, however, in consequence of the heart outgrowing the nutritive possibility of the coronary arteries, the left ventricle becomes enfeebled, there is, as a con- sequence, some backward pressure upon the lungs, and, as a result, interference with the right ventricle. When there is, as the result of hindrance to the passage of blood through the kidneys, increased pressure upon the left .side of the heart, the left ventricle frequently becomes dilated and permits venous stasis in the lungs, and, therefore, interference with the right ventricle. It must not be for- TRICUSPID INCOMPETENCE. 613 gotten, however, that here the pathogeny is somewhat more complex. There can be no doubt that degeneration of the muscular substance of the heart in cases of renal disease may be brought about by faulty nutrition, consequent upon the deterioration of the blood, and there is, further, a possibility of degeneration of the coronary vessels which will still more interfere with the nutrition of the heart. In addition to such mechanical causes of interference with the right ventricle, leading to tricuspid incompetence, there are a great many factors of a more general nature which lead to analogous results. The causes which are operative in this way will be looked at in greater detail in the consideration of diseases of the myocardium ; but to complete the subject of the etiology of tricuspid incompetence, it is advisable in this place briefly to refer to a number of causes falling under this group. Pyrexia, if of more than brief duration, almost invariably leads to dilatation of the right ventricle and tricuspid in- competence. It does so sometimes from simple relaxation of the muscular substance, but in other cases by means of hyaline degeneration. Toxic influences belonging to almost every class produce the same effects ; the toxines produced by micro-organisms (sometimes in the absence of all pyrexia), the organic poisons, such as alcohol, the inorganic poisons, such as lead, act in precisely analogous fashion. Mal- nutrition, whether arising from some morbid process, as malig- nant invasion, from deficient absorption, as in such a simple affection as dilatation of the stomach, or from some deficiency of food, — all lead to the same end. A long experience of out- patient service in our great hospitals enables me to bear witness to the extreme frequency of tricuspid regurgitation in atonic conditions of the stomach. Such disorders as anaemia, in which the nutritive power of the blood is lowered, are also to be considered as potent causes of tricuspid incompetence. Morbid Anatomy. — In those cases in which tricuspid incompetence is of valvular origin, there are anatomical alterations of the cusps analogous to those of the mitral valve. The normal thinness and translucency of the cusps may be replaced by thickening and induration. Such are the 6i4 AFFECTIONS OF THE TRICUSPID ORIFICE. most usual appearances shown by the cusps when they have suifered from endocarditis, and thickening and roughening of the chorda? tendinete frequently attend upon these changes. In addition to such alterations, however, there are sometimes vegetations. These are more frequent in the endocarditis of early life. Degenerative changes are sometimes to Ije seen presenting characters similar to those already described in connection with the mitral cusps. These degenerative changes, whether fibrous or calcareous, produce considerable distortion of the cusps resulting in their incompetence. In cases of tricuspid incompetence it is much more common to find no structural alteration in the cusps, the sole alteration consisting in more or less dilatation of the auriculo-ventricular orifice. Further than this, there may not be any perceptible widening of the orifice, and the cause of the regurgitation must be assumed to lie in dilatation of the ventricle, causing want of adaptation of the valvular segments. The associated alterations found in tricuspid incompetence are for the most part confined to the right auricle, which is sometimes dilated to an enormous extent. Sometimes there is hypertrophy of its walls in whole or in part. Instead of hypertrophy it is not at all uncommon, however, to find the thickness of the auricular walls considerably reduced. The great veins which empty their contents into the right auricle are always more or less dilated. The superior vena cava and its tributaries are sometimes so enlarged as to resemble those of aquatic mammals, and the valves which guard the entrance to the veins of the neck are incompetent. The inferior vena cava is even more dilated, Ijut at the point where it passes through the diaphragm it is necessarily allowed less scope for distension. The more distant effects are seen in general venous stasis with subcutaneous cedema, serous transudations, mucous catarrhs, and hypostatic congestion. The liver in particular suffers in tricuspid incompetence, and is often found to be greatly enlarged. Symptoms. — In slight cases of incompetence there may be a total lack of all subjective symptoms, but when there is any considerable degree of regurgitation the patient becomes TRICUSPID INCOMPETENCE. 615 conscious of some of its effects. The symptoms which may l;e noticed are swelling of the ankles at night, feelings of heavi- ness in the right hypochondrium, some digestive troubles, such as dyspepsia, and diarrhoea along with scanty urine. Headache is a common symptom, and only less frequent is a sensation of giddiness. Patients who suffer from high degrees of tricuspid incompetence are also prone to suffer from various disturbances of sleep. It is apt to be broken by frightful dreams, from which the patient awakes with a start, or insomnia may make its appearance, with the peculiarity that while the patient is unable to obtain repose at night a balance is attempted by means of a soporose tendency during the day. Further alterations in the functions of the brain are sometimes in evidence — illusions, hallucinations, and delusions being by no means uncommon. A tendency to cyanosis is common in all cases of tricuspid incompetence, and in serious cases it forms one of the most marked features. Sometimes in consequence of venous stasis in the liver, and disturbance of the functions of this organ, the cyanosis is associated with a certain amount of jaundice, and when this is the case a somewhat singular greenish tint is the consequence. Dyspnoea is almost always present on exertion, and in grave cases it is a distressing feature. It must be ranked as connected with the causes as well as the effects of tricuspid regurgitation. The fact must never be overlooked that right-sided disturbances are more likely to produce interference with the functions of the pleura than affections confined to the left side of the heart, inasmuch as the blood circulating in the pleural membrane is in over- whelming proportion returned to the heart by the bronchial veins, which discharge their contents on the right side by means of the vena azygos, and on the left side by means of the superior intercostal veins. Their destination is therefore the right auricle. When disturbance of the functions of the right side of the heart occurs, there is as a consequence con- siderable liability to backward pressure upon the pleural membrane resulting in hydrothorax, the various factors of which have previously been fully discussed. This is the cause, in a considerable proportion of instances, of persistent 6i6 AFFECTIONS OF THE TRICUSPID ORIFICE. breathlessness which is often t'uuml in cases of tricuspid re- gurgitation. In the same way, and liy the same mechanism, long-continued tricuspid escape tells upon the l)ronchial veins, leading to catarrh as the result of hypera-mia. Swelling of the ankles is extremely common, but, except in serious cases, it disappears when the patient retains the recumbent posture. In grave cases, however, it is per- sistent, and is apt to be associated with anasarca of all the dependent subcutaneous textures. In severe cases an en- largement of the abdomen may be produced by the ascites resulting from backward pressure, and it need hardly be added that physical examination occasionally reveals the presence of fluid in the abdomen in the absence of all apparent enlarge- ment. The area of hepatic dulness is enlarged in most of tliose cases which give rise to venous stasis, and there is not merely such an enlargement as may be made out by percussion, but an enlargement which can be detected by palpation. The enlarged liver is not infrequently tender to touch, as v/ell as subjectively painful. The quantity of urine, as has already been remarked, is diminished, and on examina- tion it is found to be deeper in colour and of higher specific gravity than in health. The amount of urea, although diminished as a rule, may yet be relatively increased as regards the amount per ounce of urine. Albumin is very frequently present, sometimes accompanied by blood, but more frequently by tube casts of different kinds, the most common amongst which are hyaline and blood casts. It occasionally happens that htematemesis and mehena occur as the result of backward pressure upon the portal system. The radial pulse in tricuspid incompetence gives in itself little evidence of any circulatory disturl)ance. It is usually of smaller volume and of lower pressure than is the case in health. In the purely functional cases of tricuspid regurgita- tion the rate and rhythm of the pulse undergo no necessary alteration unless the tricuspid incompetence is the result of some disturbances of the left side of the heart, to which are to be attributed the alterations in the character of the pulse. Examination of the neck fre(|uently furnishes most charac- teristic appearances connected with the cervical veins. It TRICUSPID INCOMPETENCE. 617 has already been shown that the jugular veins may present a considerable number of interesting phenomena whenever the continuous flow of blood from the veins to the heart is interrupted at its entrance into the right cavities of the heart. As this subject has been fully discussed in a previous section, it is unnecessary to do more than refer to the appearances which present themselves. In tricuspid incompetence any of the various conditions of the veins which have been described may be present, from a slight fulness showing respiratory influences and circulatory movements, to great turgescence, in which the veins stand out in a condition of profound disten- sion as if they would burst. On examination of the body abnormal impulses may be observed. The most common is an undulation of the epi- gastrium, produced, so far as can be seen, by the movements of the enlarged right ventricle. Much less commonly, impulses are to be seen in the third and fourth right intercostal spaces close to the sternum. These are occasionally caused by the contraction of the right auricle, but are more commonly the result of ventricular systole, and are due to the reflux of blood from the ventricle into the auricle. Palpation reveals no additional facts, and simply supports the evidence derived from inspection. The area of cardiac dulness is more or less enlarged bilaterally, but more particularly towards the right. Auscultation furnishes in a very large proportion of cases of tricuspid incompetence, more particularly of the functional variety, the sole evidence of the lesion. Yet it must be re- membered that in many cases of tricuspid incompetence there may be no murmur, although other facts prove that incom- petence is present. When the safety-valve action has un- doubtedly developed into pronounced incompetence, as proved by the appearances in the veins of the neck, there may be a total absence of any evidence on auscultation. Even in such cases, however, it is very common to find that the first sound in the tricuspid area is somewhat weak, and it is not un- common to find an apparent doubling of the first sound. The characteristic murmur heard in most cases of tricuspid incom- petence is systolic in rliythm, while its character is soft and blowing. Its point of maximum intensity is usually about 6i8 AFFECTIONS OF THE TRICUSPID ORIFICE. tlif j auction of the fifth aud sixth left costal cartilages with the sternum, but this is suljject to slight indi^'idual differences. It is propagated from its point of maximum intensity in every direction, and it sometimes requires considerable care to dis- tinguish it from aortic and pulmonic murmurs. The condition of the second sound in the pulmonary region is subject to considerable variations. It might naturally be expected that in those cases in which tricuspid incompetence takes its origin from some disease of the left side of the heart, or from some interference with the passage of blood through the lungs, the resulting accentuation of the pulmonary second sound would be lessened when tricuspid incompetence occurs. That this does take place can be easily determined by any one who watches the progress of such a case. The question, how- ever, is a matter of degree, and in sucli cases, even after regurgitation has been established at the tricuspid orifice, there may nevertheless be accentuation of the pulmonary second sound, and also be a doubling of this sound at the base of the heart. So long as the pressure in the pulmonary circuit re- riiains relatively increased, while that in the systemic circula- tion is relatively lessened, there must be a tendency to such accentuation or doubling. This has been very distinctly shown by Balfour. Diagnosis. — In slight cases of tricuspid incompetence there may be no evidence of the lesion beyond that furnislied by auscultation, and it is precisely in such cases that there may be some difficulty in determining its nature. A simple systolic murmur heard in the tricuspid area may be produced at the right auriculo-ventricular orifice, or it may be propa- gated to that area from one of the other regions. If care be taken, however, in regard to the position of maximum intensity there should be no difficulty in recognising the exact signifi- cance of such murmurs. In cases accompanied by venous phenomena in the neck there is never any difficulty in arriving at a correct conclusion, as the association of such symptoms with enlargement of the right side of the heart, added to the evidence furnished by auscultation, will afford diagnostic indications which cannot l;)e mistaken. TRICUSPID INCOMPETENCE. 619 Even in the entire absence of any nmrmur in the tricuspid area regurgitation may be determined Ijy free venous pulsations in the neck, as has been held by almost all the important writers on cardiac affections. Complete references to these authors will be found in a contributioii to the subject by myself Prognosis. — The prognosis in cases of tricuspid incompe- tence must be based upon the general conditions which are present. In those instances which will be afterwards dealt with in connection with disorders of the myocardium, where the tricuspid incompetence is produced by some temporary weakness of the wall of the ventricle, the prognosis is excellent. The same may be said of cases in which regurgitation occurs as the consequence of some temporary interference with the functions of the lungs. It is far otherwise, however, as re- gards tricuspid regurgitation as the sequel of disease of the left side of the heart, since when the right side of the heart has failed, the reserves may be said to have given way. Teeatment. — But little requires to be said in regard to the special treatment of tricuspid incompetence. The main lines of treatment suggested for valvular lesions in general must be followed, but there will require to be more especial care as regards the effects on the systemic veins. In those cases in which the affection is the result of mitral lesions, treatment must in the first instance be devoted to such symptoms as may be present. When the tricuspid incom- petence is produced by some pulmonary disorder appropriate measures for relieving the pulmonary troubles must be adopted. If the incompetence is produced by relaxation of the ventricle from some general cause, such as pyrexia or ansemia, the treatment should be directed towards the relief of the primary affection. When, as is very often the case, tricuspid regurgitation has its starting-point in faulty diges- tion, more particularly chronic gastric catarrh and atonic dilatation of the stomach, these factors require to be eliminated. If, lastly, the primary cause be cardiac strain from overstress, the influences which have produced the condition must be removed. In all cases the use of cardiac tonics must be adopted. It is often said that digitalis and its allies have but little effect on the right ventricle. Morison, for instance, speaks of them 620 AFFECTIOXS OF THE TRICUSPID ORIFICE. as not only useless l)ut dangeruus. These drugs, nevertheless, liave proved, in my experience, in all remediable instances of tricuspid incompetence of the greatest service, and cannot he too strongly recommended. In those instances presenting symptoms of enlargement of the liver, and gastro- enteric catarrh, the combination of digitalis and mercury will Ije found most useful. To these is sometimes added squill, l)ut tliis is of more doubtful utility. AVlien there is gastric dilatation, nux vomica along with digi- talis or strophanthus can be confidently recommended. In all such cases, when there is any digestive inadequacy, the regulation of the diet must be a prime consideration. The treatment of tricuspid incompetence from cardiac strain and analogous conditions will be referred to in the chapter on myocardial conditions. Case 45. Cardiac Dilatation and Tricuspid Incompetence from Malaria. — J. B., aged 24, cab driver, married, presented himself as an out-patient at the Eoj^al Infirmary, 4t]i March 1891, complaining of jiain in the region of the abdomen. There had been no heieditary tendencies to disease. The patient's father and mother were perfectly well, as were also all their children, with the exception of one daughter who had died of cerebral abscess, in consequence of ear disease. The social conditions had always been satisfactory. His health had been good xmtil he suffered from a severe attack of malai-ia while in Massachusetts during the year l:)efore he was seen. The pain for which he sought advice began four months before he did so, and had continued ever since. He was somewhat ancxnnic in appearance, with pallor of the lips, gums, and tongue, as well as of the conjmictiv;e. The alimentary system was obviously free from any disturbance. The organs were all of their iisual size. There was no enlargement of the spleen. The luemoglobin was 50 per cent. ; the red blood corpuscles numbered 4,230,000 ; there was no in- crease in the number of the white corpuscles. The blood contained a considerable number of pigment granules, and there was some alteration in the aj^i^earance of the red blood corpuscles, there being large and small varietie-, as well as many with a change in shape. No organisms were detected. The radial artery was healthy, the vessel moderately full, and the pressure low. The pulsation was perfectly regular, its rate Avas 86, each wave was large, bounding, and dicrotic. There was well-marked jugular jnilsation in the neck. The apex beat was in the fifth intercostal s])ace, 3 in. from mid-sternum. There was a visible pulsation in the third and fourth left intercostal spaces. Xo thrill could be elicited on the applica- tion of the hand. The area of canliai' dnhiess extended 2-| in. to the right TRICUSPID INCOMPETENCE. G21 and 3| in. to the Jeft of niid-slci'iiuiu ;it IIk; le\e] of the. fourtli costal cartilage. On auscultation there was a loud venous lium iu tlie neck, and in the standing or sitting posture a very faint systolic murmur was aiidible at the junction of the sixth left costal cartilage with the sternum. No othei- abnormal symptom could be detected in these positions, but when the patient lay down the tricuspid murmur became loud, harsh, and almost musical. It still retained the same j)Osition of maximum intensity in the tricuspid area, but in the recumbent j^osture it was distinctly propa- gated up the sternum almost as far as the aortic and jiulmonaiy areas, but it was not conducted outwards on either side of the sternum. There was no symptom of disease connected with any other region, excepting that the jjatient was decidedly weak and lacked energy. Under treatment with arsenic and digitalis the patient rajtidly im- proved, the first evidence of this being an increase in the intensity of thc^ murmui' and an enlargement of its area of audibility. This, howe^•el■, after a few weeks gave place to gradual disappearance of the murmur altogether, and the blood at the same time showed a return to health. There could be no doubt that iu this case the toxic effects of the malaria by acting on the blood had interfered with its nutritive possibilities, and in this way brought about the cardiac dilatation. Case 46. Tricuspid Incompetence from Bronchicd Affection. — A. N., aged 44, widow, engaged in household duties, was admitted to Ward 25, 4th April 1892, sulfering from breathlessness. Her family history showed no hereditary disease tendencies, and her social condition had always been fairly satisfactory. Her health had been good until the last two or three years, during which she had suffered a good deal from Avinter cough, accompanied by breathlessness. She had a furred tongue, little appetite, and constipation on admission. The jugular veins were seen to Ije turgid on inspection, with slight oscilla- tions in them, occurring both with the respiratory movements and with the auricular systole. The apex beat was invisilile, but it could be felt on palpation in the fifth intercostal space, 4 in. from mid-sternum. Palpation revealed no thrill or other abnormal phenomena. On percussion the right border of the heart was found to be 3 in., and the left 4-|- in. from micl- sternum. On auscultation in the mitral area there was a distinct doubling of the first sound ; in the tricuspid area this double first sound was also present, but it was immediately followed by a soft-blowing systolic murmur, having its maximum intensity at the union of the sixth left costal cartilage with the left edge of the sternum, and propagated upwards as far as tlie third costal cartilage. In the aortic and pulmonary areas the first soiind was unaccompanied by any murmur. The second sound was distinctly doubled, and the later of the two sounds — much louder than the one which preceded it — had its maximum intensity in the j^ubnonary area. 62 2 AFFECT/OXS OF THE TRICUSPID ORIFICE. The patient's resiiirations Avere luinied, vavvint; fruin 35 to 40 per inimite at the time of her adiiiissiou. All the respiratory iinisoles were brought into play. Tliere was a great deal of rhouchial thrill, but no increase of A'oail fremitus. On percussion the chest was perfectly- clear throughout, excej^t towards the bases of the lungs behind where the sound was slightly muffled. The bre stance, and it contains a large amount of granular material ; this is often found accumulated in a longitudinal arrangement at each end of the nucleus. Mention must also be made of pigmentary atrophy, in which more or less pigment, doubtless having its origin in the haemoglobin, is dis- tributed in the muscle cell around the nucleus, somewhat in the same way as in the case of granular atrophy, so that it almost seems to prolong the extremities of the nucleus. These masses of pigment are of a brownish hue. A certain amount of pigment is normally present in every heart after youth has been passed, and it is by no means easy to say what quantity is to be regarded as abnormal. Letulle points out that all causes of nutritive disturbance usually give rise to some pigmentation, that, in short, a senile condition of heart, whether normal or abnormal in its relation to age, is shown by more or less destruction of the haemoglobin of the muscles. Such changes are always most marked in that part of the heart which suffers the greatest amount of strain. Degenerations of the cardiac muscle are frequently found to be the lesions revealed clinically by cardiac weakness. Nothing need be said on this subject in this place, as they are accorded a section to themselves. Symptoms. — The clinical features of cardiac weakness are often superadded to others, already present, characteristic of such general or local diseases as have given rise to the debility of the heart, and they are therefore apt to be overshadowed by them. The symptoms belonging to the cardiac condition are simply breathlessness and palpitation, such as may occur in any condition interfering with the energy of the heart, with occasional faintness and giddiness ; but there may be subcutaneous cedema, and accumulation in the serous cavities. The pulse is usually empty, and the pulse w^ave small. The rate is subject to great differences, sometimes being very infrequent and at other times extremely frequent. The rhythm is apt to become irregular. The cardiac impulse is feeble or imperceptible. The area of cardiac dulness may 630 AFFECTIONS OF THE MYOCARDIUM. be absolutely iiuriiml, or it may be enlarged, in \vhieli case the feebleness of the muscle has led to dilatation. The lieart sounds are weak, so much so as often to be almost imperceptible, and the first sound invariably suffers more than the second. It is extremely uncommon to find that all the cardiac sounds have disappeared, but in severe acute cases of disease the first sound is often entirely obliterated. There may, on the other hand, sometimes be soft blowing systolic murmurs entirely replacing the first sound in the mitral and tricuspid areas. Along with such local appearances there may be others which result from them as consequences. Amongst these are venous stasis, with all its effects, whether hyperaemic or cedematous, and, in consequence of these, great interference with all the functions of the body. This appears to be the most suitable connection in which to discuss the much-debated appearances found in many con- ditions of cardiac debility. The symptoms have been adverted to in the general analysis of circulatory phenomena, but, since they belong to weakness of the heart, this is the proper place for their fuller elucidation. Several years ago considerable interest was shown in certain discussions as to the cause of the clinical facts observed in cases of cardiac debility. The principal subjects under debate at that time were the explanations which had been advanced regarding two of the phenomena commonly oljserved in feeble conditions of the heart. The first of these, and that the more frequent in its occurrence, is the systolic murmur heard in the second left intercostal space, at or near the pulmonary area ; the second, not so often presenting itself to the observer, is the systolic impulse seen and felt in the same locality. To the investigation and explanation of these appearances several observers devoted much attention, and many of the points connected with the physical signs under discussion were virtually settled. As one who took part in the discussions on this question, it seems to me nothing more than simple justice to those whose views then differed from my own to state frankly and candidly the opinions which have been borne in upon me since the time referred to. In attempting to do so, it will be well to avoid unnecessary CARDIAC WEAKNESS. 631 reference to older observers. This may be done the more easily, as Eussell has given a complete and masterly summary of the views of previous authors in his work on this subject. For the present purpose it is only necessary to recall a few facts. In order to account for the systolic murmur and accompanying pulsation sometimes seen in the second left intercostal space, in cases of mitral incompetence, Naunyn advanced the hypothesis that both appearances are produced by the backward stream from the left ventricle into the left auricle. According to this view the systolic murmur is of mitral origin, and is conducted by the regurgitant current into the dilated left auricular appendix, while the pulsation is caused by the same stream distending the appendix and thereby producing an impulse on the thoracic parietes. Balfour applied this hypothesis to the corresponding ]Dheno- mena so commonly seen in the feeble heart of ansemia and allied conditions. In his work on diseases of the heart, as well as in separate papers dealing with this special question, he has strongly advocated this explanation, and his opinions were warmly supported in some contributions made at the same time by myself. We were, however, unable to adduce any evidence obtained from morbid anatomy in favour of our views, and although many of the clinical features appeared to be explained by them, they could not be regarded as resting on any sure pathological basis. Eussell brought to the elucidation of the questions under discussion a large number of clinical and pathological observa- tions, from the consideration of which he came to very different conclusions. He showed that, in many cases where the systolic pulsation in the second left intercostal space had existed before death, post - mortem examination proved that the impulse could only have been caused by the conus arteriosus, which, in consequence of dilatation of the right ventricle, was so far to the left as to occupy the site of pulsation in the left intercostal space between the second and third cartilages. With regard to the basic murmur, heard in cardiac debility, Eussell proposed two explanations. He suggested that in some cases it might be produced by dilata- tion of the left auricle, which, pressing upwards upon the 632 AFFECTIONS OF THE MYOCARDIUM. pulmonary artery, gives rise to a narrowing of its lumen, while in other cases it is simply the systolic murmur of tricuspid incompetence propagated upwards to the conus arteriosus. The main points at issue in the discussions regarding this subject were very critically examined and judicially weighed by Bramwell in his systematic work. As the result of a very careful review of the arguments which have been advanced by Balfour and Eussell, he rejects the theories of l)oth with regard to the production of the basic systolic murmur, and attributes it to the sudden pulsation of a large blood wave of abnormal composition into the vessel, which he tliinks may probably Ije dilated. Handford holds that the pulmonary systolic murmur, which he describes as disappearing in the erect position and reappearing when the patient is recumbent, is produced by the pressure of an enlarged, flabby, and dilated heart on the pulmonary artery. Foxwell has, like Kussell, found the pulmonary artery to be displaced considerably upwards. He regards the murmur in the pulmonary area as caused by a complicated change in the shape and position of the pulmonary artery, whereby its curve becomes increased, its axis and that of the right ventricle lie at a different angle from that existing under healthy conditions, and the vessel is flattened against the aorta. At the same time, however, he accepts Kussell's view of a distended right auricle as the cause of the murmur in some cases. In the last place, Sansom, after an examination of the views of Balfour and Eussell, which leads him to dissent from both, advances the opinion that the basic murmur can be initiated at the overstrained portion of the right ventricle, the conus just below the pulmonary valves, by the production of a fibrillar tremor. He is, however, also inclined to believe that the cusps may themselves vibrate in the current. It is easy for me now to consider the questions involved in a perfectly dispassionate and impartial spirit, inasmuch as Eussell has, in my opinion, disproved the views of all observers previous to himself. He has demonstrated that the left CARDIAC WEAKNESS. 633 auricular appendix does not reach the anterior wall of the thorax, and that the pulsation in the second left intercostal space is produced by the conus arteriosus. The observations of Foxwell, Harris, and Mackenzie support him in this, and it seems to me that the explanation of Naunyn and Balfour has thus been refuted. This decision leads of necessity to the further conclusion that the hypothesis of Naunyn and Balfour with regard to the origin of the systolic murmur heard in the pulmonary area falls to the ground, for since the left auricle never touches the parieties there is no medium for the conduction of a mitral murmur towards the base of the heart. But it must further be stated that in a large proportion of cases there is no evidence of any mitral incompetence, and that it is a mere begging of the question to assume it. The view advanced by Bramwell may be regarded as in every respect a compromise, as Eussell puts it, between the explanations of Hope and Beau, and it has, like their theories, been effectually disposed of by him. But while granting freely that Eussell has disproved all previous theories, it seems to me that part of his own explanation will not bear investigation. He has yet to prove that in early stages the left auricle is dilated. In truth, the conditions appear to be the very reverse of those which he postulates. The mitral cusps are often perfectly competent, and as long as there is no mitral regurgitation the pressure in the pulmonary artery must be greater than that in the left auricle. The view of Handford cannot be accepted as a probable explanation for most cases, not only because the basic murmur is heard very frequently indeed while the patient is in the erect position, but also because it makes its appearance before there is any noteworthy enlargement of the ventricles. The same argument applies with equal cogency to the reasoning of Foxwell, while his experiment of forcing water into the right ventricle of a debilitated subject after tying the pulmonary artery is so unlike anything in nature that it cannot be held to prove anything. Sansom, finally, is obviously in error, as, if overstrain of 634 AFFECT/OXS OF THE MYOCARDIUM. the ventricle were a valid eiuise for a murmur, such a pheno- menon would be of much more common occurrence than is the case. Almost every case of chronic renal cirrhosis, for example, would be attended by a murmur produced by the strain thrown on the left ventricle. My own view is that the impulse in the second left inter- costal space — the am-icular impulse of Balfour — is produced by the conus arteriosus. The systolic murmur heard in the same position is, in my opinion, caused by tricuspid incompetence, but it is perfectly possible that for some cases Handford's explanation is admissil)le. The views to which my adhesion has been given were fully published within recent times. Diagnosis. — The recognition of the enfeebled condition of the cardiac muscle is easily reached. The characters furnislied by the pulse, and the appearances ascertained on examining the prcecordia, are sufficient to reveal the cardiac debility. This, however, is only one step in the determination of the nature of the affection. Any definite conclusion as to the exact structural change present can only be a matter of inference. The considerations which carry weight in attempt- ing to form a probable conjecture as to the nature of the alteration are connected witli the causes of the weakness and the general state of the patient. Conditions of malnutrition, Ijloodlessness, and pyrexia, when neither severe nor prolonged, are likely to produce simple relaxation of the muscular tissues, or some slighter degree of one of the atrophic processes ; while profound cachexia, grave aniiemia, and high fever, more especi- ally if long continued, tend towards the degenerative changes, or chronic myocarditis. Youth is more liable to the less serious alterations — age to those wiiich are more severe. Prognosis. — The prospects in simple cardiac weakness are usually good, so that, if the probabilities are in favour of a diagnosis of this condition, the prognosis may confidently be hopeful. The chief care must be directed towards the con- clusion that the causes of the cardiac change and of the general state of the patient warrant the exclusion of atrophic and degenerative processes. TPtEATMENT. — Simple weakness of the heart must be treated by meeting tlie causes of, and obviating the tendencies in, each CARDIAC WEAKNESS. 635 case. When arising in the course of any acute disease it passes away, with few exceptions, on the favourable termination of the primary affection. No special treatment is therefore necessary. As the result of alcoholism the condition also undergoes speedy improvement on removing the cause. If produced by symptomatic antemia, or by chlorosis, cardiac weakness can be readily removed by the use of iron, and the general means of treatment employed in such cases. As it is too often but the precursor of serious structural lesions when occurring in the course of grave cachectic states, treatment cannot be of much avail ; the usual methods in every class must nevertheless be employed. In every instance the general lines of management for impaired cardiac energy must be adopted as regards rest, diet, air, and surroundings, while massage and cardiac tonics are of great advantage. It is in cases of this kind that baths and exercises produce their best results. In order to present the clinical features under discussion in a concrete form, the following case is worthy of record. It has already been otherwise utilised in a previous chapter, p. 580. Case 48. Cardiac Weakness from Pyrexia. — Maggie G., fet. 18, un- married, engaged in Lousehold duties, was admitted to Ward 25 of the Royal Infirmary on 5tli June 1893, complaining of pains in her wrists and elbows. Her father and mother, both aet. 42, had always been in good health. She had four brothers and one sister, all very strong, but three brothers had died in infancy. The patient's social surroundings had always been good. She had never been very robust, and four years before admission had suffered from a rheumatic attack, since when she had never felt very well. About four months before entering the hospital, pains had begun in the joints and had persisted ever since. On her admission the patient was found to be somewhat pale, with a bright spot on each cheek. The skin was moist. The tem^jerature was normal. The tongue was slightly furred, but the digestive system was otherwise healthy. There was no symptom connected with the hfemo- poietic system. She complained of some palpitation and a slight degree of breathlessness. The pulse showed low pressure and moderate volume ; it was perfectly regular, varying in rate from 80 to 90. There was some pulsation in the veins of the neck, and a very distinct impulse in the second left intercostal space. On palpation the apex beat was found to be in the fifth left intercostal space, 3^ in. from mid-sternum. The pulsa- 636 AFFECTIONS OF THE MYOCARDIUM. tion, systolic in time, in the second left intercostal space was found to be most distinct 1 \ in. from the mid-sternal line. A tracing obtained from it by means of a revolving cylinder is given in the acconijianying figure (Fig. 170). No thrill could be detected over any part of the pr;ecordia. The cardiac dulness extended to 1 in. to the right and 4 in. to the left of the middle line at the level of the fourth rib. On auscultation, a venous hum was heard in the neck, and there were murmurs, systolic in rhythm, over the whole pra^cordia, which, on careful analysis, proved to l)e twofold. Around the region of the apex beat, and with its maximum loudness in the fourth intei'space 3^ in. from mid-sternum, there was a harsh-blowing systolic murmur, conducted as far as the edge of the sternum to the right, and beyond the anterior axillary line to the left. Over almost the entire sternal region there was a soft-blowing systolic murmur, quite different in character from that heard at the apex. It had the same tone throughout Vu:. 170. — Tracing from C:iS(; 48. the whole sternal region, but it seemed to have two points of maximum intensity — to be more exact, it was loudest in the pulmonary region, exactly over the area of pulsation, from which point it waned in its intensity in every direction until near the lower end of the sternum, when it became louder, again culminating at the point where the left side of the sternum was joined by the sixth costal cartilage ; but in this situation the murmur was not quite so loud as over the area of pulsation in the pulmonary region. The second sound was frequently reduplicated, and the later of the two second sounds, which could be determined to be that due to the pulmonic crisps, was instantly followed by a short, sharp, high-pitched murmur, perfectly soft in character. This murmur was extremely restricted in its distribution, being only heard over a small triangular area 'i\ in. in vertical and 2 in. in horizontal measurement, extending along the left border of the sternum, from the lower border of the third costal cartilage to the upper border of the fifth. This murmur was perfectly soft in character, and was absolutely i;nlike the obstructive diastolic murmur which is found in mitral stenosis. It could not be due to aortic disease, of which there was no indication, and CARDIAC WEAKNESS. 637 it could only, therefore, be a murmur of regurgitation from the pul- monary artery into the right ventricle, due to the increased pressure and consec[uent dilatation of the orifice, with relative and transient incom- petence of the cusps. The production of this murmur has been discussed in Chapter XII. All these murmurs are shown in Fig. 171, in which the areas over which the murmurs were audible are distinguished in the usual way. The other systems presented no symiDtoms of disease, with the sole exception of a few crepitations at the bases of both lungs. The diagnosis was cardiac dilata- tion, with mitral and tricuspid re- Pig. lyi.-Uistribution of munnurs in gurgitation, joroduced by the febrile Case 4S. affection ; it was nevertheless con- sidered probable that some stenosis of the mitral orifice might be insidiously progressing, although this was a mere supposition, not based on any direct evidence. The crepitations at the bases of the lungs were regarded as the expression of passive congestion from mitral incompetence, and the diastolic murmur was assumed to be one of pulmonary escape, in conse- quence of the strain on the artery from the high pressure within it. By means of salol and similar remedies the patient was relieved of her rheumatic symptoms, and the administration of iron with other tonics greatly improved the cardiac condition. The diastolic murmur disappeared, and the lungs cleared up, but at the time of the patient's departure from the Royal Infirmary, on 17th July 1893, she still had the systolic mur- murs, and the pulsation in the second intercostal space. She presented herself at the hospital on the 2nd March 1894, when the diastolic murmur was found to be still absent, but the systolic murmurs were present as before. The first sound in the mitral area, preceding the systolic murmur, was, however, loud and clanging in character, which seemed to support the view that a stenosis of the mitral orifice was gradually developing. This case brings into prominence the systolic impulse in the second left intercostal space, as well as the systolic murmur in the same position. From the physical signs there could be no doubt of the presence of mitral and tricuspid incompetence, and it may be remarked here that the pulsation in the second left intercostal space is never observed except in cases which present so much dilatation as to allow of regurgitation at both auriculo-ventricular orifices. The diastolic murmur has been 63S AFFECTIONS OF THE MYOCARDIUM. fully discussed in the chapter referred to. The systolic mur- mur heard over the sternal region of the piu'cordia appeared to be the same throughout, with two points of maximum intensity, and seems to me easily explained in this way, that, while at the lower end of the sternum it is heard with great distinctness, owing to the proximity of the muscular wall of the right ventricle and of the tricuspid valve, it is also heard with at least as much intensity over the conus arteriosus. It appears to me, in short, to he purely a murmur of regurgitation at the tricuspid orifice. While liussell's view as to the causation of the systolic pulsation in the second left intercostal space is to my mind absolutely proved, the murmur heard in that situa- tion in the heart in debility seems to me to be simply a tri- cuspid systolic nnirmur propagated upwards by means of the conus arteriosus. It is quite analogous to the murmur pro- duced at the right side of the heart in cases of heart strain, which is undeniably of tricuspid origin. To show that this murmur may have its greatest loudness close to the spot commonly known as the pulmonary area, the following case may be brought forward : — Case 48. Cardiac Weakness from Alcohol. — Sylvester N., set. 24, unmarried, strapper in a stable, was admitted to Ward 6 of tlie Koyal Infirmary on 26tli June 1893, witli obvious symptoms of alcoholism. His father, tet. 61, and mother, 33t. 60, were in excellent health. Of ten brothers and sisters, only two brothers and one sister were alive, seven having died in their infancy. His social condi- tions were fairly good, except at times from his own fault. The patient's previous health had been quite good, but he had been much addicted to drink. The attack for which he was brought to the hospital began about Christmas 1892, since which time he had been drinking very heavily ; about the middle of May pains in the legs, with some swelling of the ankles, set in. On admission the patient was found to have great thirst and little appetite ; the tongue was furred and shaky ; the breath heavy and foul. No other symptoms connected with the alimentary or hiemopoietic systems were present. There was breathlessness on exertion, and swelling of the ankles and legs. The pulse was of low pressure, moderate fulness, and perfect regu- larity. The rate was usually from 80 to 90. There was a well-marked venous pulsation in the neck. On inspection of the prsecordia no impulse could be seen, and the apex beat could only be felt when the patient was placed on his left side. The deep cardiac dulness extended 2| in. to the ritrht and Ah in. to the left of the middle line at the level of the fourth ATROPHY 639 cartilage. On auscultating the heart a soft systolic murmur was heard over a great part of the prsecordia, with its maximum intensity over the left half of the sternum opposite the attachment of the third cartilage, as is shown in Fig. 172. It was obviously a murmur of tricuspid regurgitation, heard most distinctly over the infund- ""X^^ ibulum. ^ No abnormal symptoms connected with the respiratory or urinary systems were present. The patient had some insomnia, followed by restless slumber with alarming dreams, and he had a distinct tremor throughout the entire muscular system. Under appropriate treatment the nervous disturbances passed away, and the patient was transferred to Ward 22, where, under the influence of cardiac tonics, he speedily lost all the swelling and breathlessness. The physical signs connected with the heart had in great part disappeared when he was discharged. -Cardiac duluess and lauriiiur in Case 49. In this case there could be no doubt that the murmur described was due to escape at the right auriculo-ventricular orifice, and its localisation throws much light on the question that has been discussed. ATEOPHY. A number of atrophic processes may be traced in the heart, which present a somewhat indefinite group of affections. It is beyond the sphere of this volume to discuss some of the con- ditions commonly termed atrophic, as for instance fibrillary, fragmentary, and pigmentary changes ; with the exception, therefore, of retrogressive changes accompanied by alterations in the pigment, this section will be devoted to simple atrophy of the heart, or, in other words, cardiac emaciation. The condition of cardiac atrophy, or a diminution in the size and weight of the heart, produced by lessening of the amount of its muscular tissue, has been recognised since the birth of morbid anatomy. It was, so far as is at present known, first scientifically observed by Eiolan, and it was fully 640 AFFECTIONS OF THE MYOCARDIUM. described by Seiiac. lUiviis, IJertin, and IJouillaiul gave in succession capital descriptions of the condition, and it lias been generally recognised by all subsequent writers. Etiology. — There are apparently some instances of small sized hearts of congenital origin, as was first observed by Burns. No liereditary influences, so far as has been discovered, are at work in the production of this condition. In such cases, the body has been otherwise well developed, but in other instances there has been a retention in adult life of some childish characteristics, so that the condition may have been part of what the modern French writers term infantilism. It is right to add that Parrot does not believe that such examples are really congenital ; he holds that they are caused by a simultaneous arrest of the development of the heart and all other organs at puberty. The common cause of simple atrophy of the heart is some wasting disease, such as, amongst many others, cancer, tuber- culosis, syphilis, and diabetes. The statistics of Quain are probably the most important upon this suljject, and may be consulted. It is sometimes said that interference with the coronary arteries produces simple atrophy ; but there will l3e abundant opportunity to show that they are more likely to give rise to degenerative changes. It has also been said that pericardial lesions, by producing compression of the heart, sometimes cause atrophy. Chevers appears to have been the first to suggest such a connection. As has already been shown, and as will be again referred to, there is more likelihood of hyper- trophic than atrophic effects, and Kennedy only found 5 instances of atrophy in 9 cases of simple pericardial adhesions. The presence of an excess of fatty deposit occasionally gives rise to some degree of myocardial wasting. This, however, is excessively rare. One of the best examples is mentioned by AVilks and Moxon. MoEBiD Anatomy. — It. has been common since the days of Bouillaud to speak of concentric, simple, and eccentric atrophy, as has been the case in regard to hypertrophy. That which was termed concentric by Bouillaud, followed by Walshe, or simple atrophy, as it has been called by Hayden, is the variety ATROPHY. 641 almost invariably met with. A simple reduction in weight, from thinness of the walls — the simple atrojjhy of Bouillaud — is certainly rare, while the excentric atrophy characterised by diminished weight of the heart, along with an increase in the size of its cavities, is to be regarded as dilatation, and will be dealt with in the section devoted to that subject. The great feature of cardiac atrophy is loss in weight, but in almost every instance there is also a diminution in the size of the heart affecting every dimension. The weight of the heart may be reduced in an adult to a very few ounces ; in his Lumhian Lectures, Quain refers to the case of a girl, aged fourteen years, whose heart only weighed 1 oz. 14 dr. The cause of death in this instance was phthisis. The great characteristics of the heart, in addition to those just mentioned, are the removal of almost all the fat from the surface of the heart, so that its outline is less rounded than usual, and the blood vessels are more distinctly seen. The muscular substance, as seen with the naked eye, may be apparently normal. Some- times, however, it is paler in colour and softer in consistence than is natural; but, on the contrary, it is sometimes darker and tougher than in health. In the case of simple atrophy the colour is unchanged, but the consistence may be somewhat firmer, and if there be paleness or darkness of tint it means that there is some fatty or some pigmentary alteration ; in other words, it is no condition of simple atrophy, but is on the one hand fatty degeneration, or on the other brown atrophy. On microscopic examination, in simple atrophy the muscular fibres are found to be smaller in size, and, according to Letulle, the muscular cells, in addition to being diminished in size, lose their cylindrical aspect, and have a tendency to fusiform outline. According to this author there is, further, an increase rather than a diminution in the transverse striation and longitudinal fibrillation. The morbid conditions constituting cardiac atrophy may be attended by other changes, as, for instance, the general or local affections which have produced the change. To these it is un- necessary to devote any further attention. It has been noticed by Bamberger that the amount of pericardial fluid is increased, apparently as a consequence of the atrophy. From my own 41 64: AFFECTIONS OF THE MYOCARDIUM. observations, however, it seems to me that in most instances the pericardial sac contains rather less than more fluid. When coloured tissues undergo atrophy or involution, there • is almost invariably a concentration of the pigment. This is more particularly seen in the muscles, and especially in the myocardium, where it constitutes the well-known pigment- ary atrophy. In the hearts of almost all above middle life there is some collection of the pigment around the nuclei, but this does not exist to such an extent as to constitute the disease in question. Pigmentary atrophy is the result of a number of affec- tions interfering with general nutrition. The heart in this lesion is small, hard, and tough. Its vessels are frequently somewhat tortuous. The section is of a chocolate tint. When examined under the microscope the fibres may be small ; they retain their striae, and around the nuclei are deposits of pigment form- ing fusiform collections are composed of hsematoidin. There is often also some newly-formed fibrous tissue. The microscopic appearances are seen in Fig. 173. Symptoms. — The clinical features in cases of cardiac atrophy necessarily depend in great part upon the conditions mider which it takes its origin. When it is produced, as is so commonly the case, by some malignant invasion of the digestive organs, it is possible to make out the appearances with considerable precision ; 1jut if the case should be a tuberculous affection of the lungs, certain of the appearances must be discounted as being the result Fio. 173.— Pigmentary atrophy, x 300. a, Muscle fibres showing concentration of pigment at the poles of the nuclei ; &, vascular connective wllich tissue between the fibres. , Q-ranular ATROPHY. 643 of alterations in the chest, produced by the pulmonary- changes. The general symptoms are, as a rule, simply those of the condition which has induced the atrophy ; but it has to be remembered that atrophy following upon the primary condition accentuates some of the symptoms, as for example the general weakness from which the patient suffers. Debility and breathlessness are the most common complaints, but palpita- tion on exertion is not uncommon. There is not infrequently oedema of the dependent parts. Physical examination shows, as a rule, empty arteries and low blood pressure. On inspection of the prsecordia, the impulse may be weak or strong according to circumstances ; all depends upon the condition of the chest. If there be retraction of the lungs, especially of the left lung, the apex beat may appear to be further to the left than normal, and may be more distinct than in health. The same is true in regard to the results obtained on palpation, since if the heart is uncovered, the apex beat may appear to be strong even when there is considerable atrophy and less energy. On percussion, the area of cardiac dulness is reduced. Here it must be noticed that there is a possibility of error, as in cases of emphysema the cardiac dulness sometimes appears to be very considerably reduced. It is probable that in such cases, from the increase in the breadth of the chest antero-posteriorly, the heart comes to lie more directly backwards and forwards, so that the area of dulness is in such conditions reduced. The cardiac sounds are, as a rule, diminished in intensity ; but if the heart is close to the surface, as is often the case, the sounds may appear abnormally clear and ringing. Diagnosis. — Diminution in the area of cardiac dulness is the sole criterion during life by which cardiac atrophy may be determined ; but in order to do this, the possibility of emphy- sema, or any other lung condition interfering with the area of dulness, must be eliminated. With care in this respect, the presence of diminished cardiac dulness, along with feeble pulse, breathlessness, and weakness, may be regarded as sufficient evidence, in the presence of some condition likely to give rise to atrophy, to warrant the diagnosis of the condition. 644 AFFECTIONS OF THE MYOCARDIUM. Prognosis. — The prospects are entirely subsidiary to the primary coiiditiou ^vhieh lias y,iveii rise to the atrophy, and, as a rule, in this condition it is hopeless. Treatment. — The aim in treating cases of cardiac atrophy must always be, if possiljle, to coml)at the conditions which have produced it, and seeing that these are for the most part fatal, but little can be done to remedy the cardiac condition. DEGENEEATION. There are several regressive processes, commonly classed as degenerations, by which the heart is affected. Fatty, amyloid, and hyaline degeneration are found in connection with the myocardium, but they occur in very different degrees of frequency. Fatty degeneration is very common, while waxy and hyaline changes are comparatively rare. In this section the abnormal conditions connected with the amount and distribution of fat will alone be considered, seeing that amyloid degeneration constitutes a mere pathological curiosity, and the hyaline transformation will be more fitly discussed in connection with another section. THE FATTY HEAET. Under the general term fatty heart are included not merely many degrees of change, but even aljsolutely distinct processes. There is, for instance, in the first place, simply accumulation of fat in the situations where it is usually found, more particularly in the epicardium. There is, secondly, in- filtration of fat in situations which usually contain none, as for instance in the intermuscular tissues of the heart, or in the connective tissue of the endocardium. In the third place, there is true fatty degeneration, characterised by loss of the normal protoplasm of the cell and the formation of fat instead of it. An excess of fat in the sulj-endocardial tissues was ob- served by Harvey, Bonet, and Lancisi ; it has been referred to by almost every subsequent writer. Senac sedulously investigated the amount of fat proper to different periods of FA TTY INFIL TRA TION. 6 4 5 life, and Morgagni even more carefully investigated the con- dition from the pathological standpoint. Portal attempted to correlate the fatty overgrowth in the heart with an adipose condition of the skeletal muscles. Corvisart not only refers very fully to the condition of fatty overgrowth, Ijut actually distinguished between it and true fatty metamorphosis. Fatty metamorphosis of the muscles concerned in voluntary movements was observed by Haller and Vicq d'Azyr, and Corvisart states that some pathologists, with whom he agreed, were of opinion that similar changes might be the explanation of some abnormal cardiac symptoms. Duncan and Cheyne must be allowed the credit of having observed changes in the heart which to all seeming were instances of fatty infiltration going on to degeneration. Laennec was undoubtedly the first to describe fully the characters of fatty degeneration, and to determine its identity with the processes discovered by Haller and Vicq d'Azyr ; it is to him that we owe the name of fatty degeneration. Several other writers dealt with the subject immediately after the publication of Laennec's great work, to whom it is unnecessary particu- larly to refer. Eokitansky's investigation of the microscopic characters of fatty degeneration must, however, be mentioned, as it served as a point of new departure. He was followed by Peacock, Paget, and Virchow, while the entire subject of fatty diseases of the heart was most fully discussed in an elaborate memoir by Quain, whose treatment of the subject has been followed by most subsequent authors. FATTY INFILTEATIOK Accumulation of fat may be only transitory in consequence of some temporary disturbance of ordinary processes, or it may be permanent, from some lasting interference with tissue changes. In the former case it may almost be regarded as physiological, but in the latter it is pathological. Infiltration is almost invariably a sequel to accumulation, and it is to be regarded as an encroachment upon the healthy tissues by a deposit spreading inwards from positions where it is normally present. 646 AFFECTIONS OF THE MYOCARDIUM. Etiology. — The factors which lead to such changes are manifold. Hereditary tendency cannot be doubted, and fatty overgrowth of the heart is very commonly associated with a lialiility to general fat accumulation. It is probable that the male sex is more prone to such changes than the female. The statistics of Quain and Hayden are distinctly in favour of this view. Age is of even greater importance, the fatty overgrowth being rare in early life, and becoming more frequent until the middle and later portions are reached. It seems to be most common between the ages of fifty and sixty. Lack of exercise and want of fresh air are also important agents. Food seems to have important effects, but it may be doulDted whether it is so much the nature as the amount of food which plays the greater part. It is believed that starch, sugar, and fat in excessive quantity lead to the deposition of fat in the tissues. Nitrogenous food, however, is quite capable of rendering a considerable amount of fat to the tissues when metabolism is defective. The abuse of alcohol, more especially in the form of heavy malt liquors, is decidedly powerful in producing deposits of fat. Apparently certain abnormal conditions of some of the great viscera concerned in meta- bolism, more especially the liver, may give rise to accumulation and infiltration. It is obvious that such changes must be due either to an excessive supply of material out of which fat may be formed, or to a diminution of the processes by means of which the fat after being formed is disintegrated and removed. This is, however, merely stating the facts without attempting any ex- planation of them. It is, in fact, impossible to arrive at any reasonable explanation of the process. Under precisely similar conditions in two individuals, one may show well-marked fatty accumulation and infiltration, while another seems to be absolutely exempt from any tendency of the kind. MoEBiD Anatomy. — The usual positions for fat in the healthy heart are in the grooves between the auricles and ventricles, and between the two ventricles ; but from these tlie fat passes over the ventricles, more especially upon the right ventricle, and lies in the sub-epicardial tissue. An excessive amount of fat sometimes obscures the w^hole of the heart. FA TTY INFIL TRA TION. 647 More commonly, however, some ruddy isles of normal tissue are seen in the midst of a yellow sea of fat. If the pro- cess goes on further, the fatty deposit encroaches upon the myocardium by spreading along the intermuscular textures, so as to reach the sub-endocardial tissue. In this latter case condition is properly termed infiltration. When the con- dition persists for any length of time, there is apt to be a degeneration of the muscular fibres in consequence of inter- ference with their nutrition. This, however, must be con- sidered in the section which follows. Symptoms. — The usual symptoms of which complaint is made are feelings of oppression and breathlessness on any exertion, as well as the consciousness of being easily fatigued by exercise, whether of brain or muscles. Faintness and giddi- ness are often experienced. It may be taken as the common experience that the digestive processes in this affection are but little, if at all, disturbed ; in fact the primary functions connected with digestion are in most cases only too good. The stomach is not uncommonly somewhat dilated from long-continued dis- tension, and the liver is quite as frequently enlarged from an excessive supply of nutriment. The symptoms connected with the heart are usually the result of enlargement of the organ and enfeeblement of its action. There may, however, be considerable fatty deposit without any obvious increase in the size of the heart. One of the most usual symptoms is a cyanotic tendency on exertion, attendant upon the dyspnoea above referred to. The general adipose condition of the subcutaneous textures renders inspection of the neck and chest, as a rule, negative. But sometimes, and this is more especially the case when fatty infiltration is combined with hypertrophy of the heart, there is a wide diffuse prsecordial heaving, with some indefinite pulsatile movements of the neck. Palpation generally reveals feebleness of impulse, unless hypertrophy is also present. The heart is frequently of nearly normal size, but there is commonly some increase of dulness ; this is usually from dilata- tion, but often from hypertrophy — rarely from fatty deposit alone. The heart sounds are feeble. Even in the presence 648 AFFECTIONS OF THE MYOCARDIUM. of hypertrophy they are low in tone and weak in intensity, partly from the adiposity of the parietes, but also from interference with the energy of the heart. The first sound suffers more than the second. It is by no means common to find murmurs, but the first sound may be replaced by systolic miu-miu's over both sides. The pulse presents many different varieties. The wall is sometimes rigid, the vessel full, and the pressure high ; at otlier times these are respectively elastic, empty, and low. Different combina- tions may be produced by modifications of the factors concerned in the pulse. When there is any degenerative change from pressure on the fibres by accumulation and in- filtration, a periodicity of the pulse, to be discussed in the sequel, may appear. There are sometimes different forms of ^regularity. Periodic changes in the breathing, of the Cheyne- Stokes type, may be present. If there be failing power of the heart, pulmonary oedema may give its characteristic physical signs. In the same way there may be scanty urine and albuminuria, as well as oedema of the dependent parts. The nervous system is sluggish, and soporose or sleepless tendencies, with impaired memory, are often noticeable. The disease is apt to be progressive unless measures are taken to avert its further development. It is one of the common causes of sudden death, and this may be brought about by syncope or by rupture. More usually there is a gradual failure of energy throughout the whole system. Diagnosis. — The determination of fatty infiltration may be attained, if, along with an adipose condition of body, there is evidence of weakness of the cardiac impulse and sounds. Prognosis. — The prognosis depends on general con- siderations regarding age and energy, but there are two special points of importance — family tendency and personal habits. Beyond a doubt, hereditary tendencies exercise a powerfully determining influence and should be taken into account, while the possibility of self-control figures almost as largely in an estimate of the future. Teeatment. — The general management of this form of fatty heart is based upon that of corpulence ; it therefore essentially concerns itself with the regulation of the habits of FATTY DEGENERATION. 649 the patient. The food must be arranged so that, with ade(j[iuite nutriment, there must be no excess. Quantity is of more importance than quality as regards food ; at the same time, starch, sugar, and fat should not be allowed to bulk largely in the diet. Exercise must be inculcated, both of body and mind. Attention should further be directed to the functions of the skin and bowels, and both these eliminating channels must be kept in an active state. In many cases treatment by baths and exercises is highly beneficial, but it must only be the prelude to a thorough rearrangement of every habit. The treatment of those cases in which infiltraion has led to degeneration will be discussed under the next head. FATTY DEGENEEATION. The second form of fatty heart, taking its origin in struc- tural alterations of the muscle cell, now demands attention. Etiology. — The causes which produce fatty metamorphosis of the cardiac muscle may very naturally be arranged in the groups of predisposing and exciting. The predisposing causes are by no means of equal importance as compared with those to be regarded as exciting, and yet they must not be altogether neglected. It is, however, to the exciting causes that fatty degeneration in the overwhelming proportion of cases is to be solely attributed. Amongst the predisposing causes heredity has an important place. There is an inherited tendency to fatty degeneration, so strong that it almost seems as if many persons were destined from birth to such structural alterations. It is well known that sudden death is common in certain families, and, amongst the lesions which underlie the occur- rence of such abrupt terminations to life, fatty degeneration is one of the most important. Men are certainly more liable to this degeneration than women. According to Quain the proportion is about four to one, but the previous observa- tions of Ormerod, and the later statistics of Hayden give respectively three to one, and two to one. As regards age, while every period of life has exhibited examples of fatty degeneration, from the child of two, mentioned by Kerkering, 6 so AFFECTIONS OF THE MYOCARDIUM. ouwards, it is far more common iu middle age and in elderly people, and iu them it appears to be but one aspect of a general senile change. The general habits have some influ- ence, but this is by no means so well marked as has occasion- ally been held ; still, sedentary habits lead, as will be seen below, to a tendency in this direction, and it will be also mentioned in the sequel that the abuse of alcohol is an important factor. The exciting causes of fatty degeneration are associated with alterations (1) in the quality of the blood, (2) the blood supply, and (3) the amount of work which the heart muscle is called upon to perform. The condition of the blood may be modified by a number of different disturbances, many of which are chronic and long- continued, while some are acute and rapid in producing their effects. Any condition of cachexia may give rise to fatty degeneration, as was apparently first noticed by Ormerod. Instances are most common in such diseases as long- continued suppuration and phthisis, but are by no means uncommon in cancer and sarcoma. Inanition may likewise lead to it in the absence of any destructive lesion in any part of the body. Ansemia of every kind may be followed by fatty degeneration of the heart. It has been produced experi- mentally by repeated blood-letting in the lower animals, and it occurs in every variety of anasmia in the human race. It is, however, relatively rare in chlorosis, while extremely common in pernicious anaemia. In leucocythsemia it is almost as frequently met with as in this form of aneemia. It occurs as one of the results of diabetes, and here it may possibly be the result of some form of intoxication, produced by de- composition of the products circulating in the blood. Scurv}^ purpura, and haemophilia have all been found linked with the change. Chronic gout may produce fatty degeneration, but it is probable that this result is brought about not so much through the direct influence of retained waste products in the circulation as by the undeniable tendency to interference with the lumen of the blood vessels in the arthritic diathesis, as chronic renal disease is not infrequently found to be associated with it. It is probable that the metamorphosis FA TTY DEGENERA TION. 6 5 1 has its origin in retention of effete products within the lilood vessels. A very large number of acute diseases give rise to fatty degeneration by acting through the blood. The associa- tion of fatty degeneration in acute diseases was observed, in the first place, by Laennec, but it is more particularly to Louis and Stokes that we owe our early knowledge of the changes in the myocardium which take place in acute diseases. It is found in typhus fever, enteric fever, erysipelas, diphtheria, smallpox, and septicremia, as well as in many tropical diseases. In pneumonia it has often been found, and the tendency to this complication is undoubtedly one of the reasons for the great liability to cardiac failure so often seen in the course of this disease. Arising in the course of some of these affections, the myocardial change may be regarded as an infection ; that is to say, the organisms actually circulate in the blood, and thus produce the destructive alterations. In some cases the process is to be regarded as an intoxication, and the products only of bacterial activity circulate in the blood. Certain poisons introduced into the system from without have a powerful effect upon the myocardium. The one which is most commonly encountered is naturally alcohol, although it is probably not by any means that which is most potent. This substance has been proved to increase the quantity of fat in the blood to a notable extent. Phosphorus is probably the most active substance as a cause of fatty degeneration. Within a very few days after the administration of phosphorus, even in a small quantity, fatty degeneration sets in, and affects the heart as well as almost all the internal organs. Alterations in the amount of blood are believed to pro- duce fatty degeneration. The change has been repeatedly seen after severe losses of blood, and the experiments of Perls have shown that frequent blood-letting in the dog can produce the structural alterations now under discussion. In all such conditions the parts of the heart which suffer to the greatest extent are the papillary muscles. In conditions of sympto- matic anaemia there must be a hydrsemic tendency, as the quantity of the blood is very speedily brought back to the normal by the absorption of lymph from the tissues. Venous engorgement was brought into prominence by Jenner, as a not 65 2 AFFECTIOXS OF THE MYOCARDIUM. unimportant factor. It will lie seen afterwards as one of the causes of fibrosis, and it is probable that while it may give rise either to fibroid or fatty changes, according to the indi- vidual peculiarities of the case, changes in the coronary vessels are not uncommonly followed by some fatty degeneration. The terminal arrangement of the blood vessels, already referred to in previous sections, which was first observed by Swan, and applied to the explanation of cardiac changes by Quain, renders it impossible for any deficient supply to be compensated by encroachment from a neiahbourino- zone. Here, as in the case of venous engorgement, precisely similar changes in the coronary vessels may produce in one individual fibroid effects, and in another fatty degeneration. Fatty overgrowth, when encroaching upon the muscular tissue, has an undeniable tendency to produce degeneration in it, and hence it is ex- tremely common to find in the later stages of fatty infiltration that degeneration is associated with it. Exactly the same effect is found in cardiac hypertrophy, in which, when there is any considerable increase in the muscular tissue of the heart, a well-marked fatty degeneration occurs. This is, indeed, such a noteworthy fact as to lead some observers to assert that fatty degeneration is always associated with hypertrophy ; and one of the most recent writers upon this subject has gone so far as to deny the existence of a compensatory hypertrophy alto- gether. The pressure of new formations, and more particu- larly of gumma, may give rise to fatty changes, but it is possible that in the latter case the specific infection has some- thing to do with the change. It is a well-known fact that the ordinary skeletal muscles undergo fatty degeneration from disuse. It is impossible, however, to believe that such a state of matters can occur in regard to the heart, seeing that it is always in action ; but although absolute disuse is out of the question, lessened activity may indirectly give rise to fatty tendency. The amount of energy displayed by the heart is proportional to the general activities of the body, and when these are lessened the heart must necessarily have diminished exertion, while all the metabolic functions are throughout conducted on a low level. The heart itself does not receive sufficient stimulus, and its FA TTY DE GENERA TION. 6 5 3 nutrition may reasonably be expected to be less than under ordinary circumstances. Whether any process comparaljle to the degeneration of an ordinary skeletal muscle after it has been separated from its proximal centre ever occurs with respect to the heart, has never been determined. It is, however, within the region of speculative possibility that from certain structural changes in the vagus some alterations may occur in the muscles. Morbid Anatomy. — The appearances arising in consequence of this form of degeneration are far from uniform, and differ chiefly according as the change is general or local. The heart is not increased in size in pure fatty degeneration, but as fatty degeneration frequently accompanies or succeeds conditions of dilatation and hypertrophy, it is common to find large hearts showing every appearance of this degenerative change. It occasionally happens that the heart may look larger on account of dilatation, which has followed upon the degeneration, and it has often been remarked that the organ looks enlarged even when its size is normal, simply on account of its want of consistence, which produces a tendency to flatten itself out, and therefore cover a larger area when placed on any object. Instead of being enlarged, the heart in fatty degeneration is .often found to be diminished in size. This occurs more particularly when the degeneration is the result of some long-continued chronic disease. When taking origin in acute disease the process is usually a widespread one affecting almost the whole heart, although even in such cases the effects are more obvious in the left than in the right ventricle. The muscular tissue of the heart is commonly dark in colour, on account of staining from blood destruction. In these instances it may not at first be very apparent that fatty degeneration is present ; even under such circumstances, however, there is often, at least in parts, some diminution in tint. In other cases arising in consequence of chronic affections, such as profound anemia, the colour of the whole heart is paler than usual ; but there are usually areas in which the pallor is more conspicuously seen. Even in acute diseases the heart is sometimes pale instead of deep in colour, and it was 6 54 AFFECTIONS OF THE MYOCARDIUM. described by Laennec as that of a dead leaf. This is the case more particularly as regards the papillary muscles and the sub-endocardial tissues. In degeneration arising from such chronic causes as local ol)struction of the blood supply, the chanoe is purely local. It is much more common in the left ventricle than in the right. In such local manifestations the result is invariably to produce an area characterised by paleness. No matter where or how widespread the changes, they are accompanied by alterations in the consistence of the part which is soft and easily torn, as well as friable. The resistance of the tissue is so greatly reduced that there can be no doubt it may be torn by energetic systole of the heart. It has also a feeling of greasiness, and, although the fact has been doul)ted, there is an increase in the amount of fat in the tissues. According to the researches of Bottcher and Krylow, the amount is increased from something like 2 or 3 to 4 or 5 per cent. As has been said, the left ventricle usually suffers more than the right, and it will be well, before leaving the subject of the naked-eye appearances of such a heart, to observe that in all general fatty degeneration the left is more affected than the right ventricle, if it be not, indeed, solely implicated. From his investigations upon the subject, Quain came to the conclusion that in about half of the cases both the ventricles are affected, and that when only one ventricle is diseased, the left is affected twice as often as the right. The auricles suffer much less than the ventricles. The observations of Ormerod led him to be sceptical as to the implication of the auricles, but there can be no doubt that they occasionally suffer. It is necessary in every example of structural alteration of the heart to study the condition of the coronary arteries. They are found to be affected in most of the cases of localised fatty change. The most common change in the coronary vessels is arterial sclerosis, often with some calcification in the walls, as weU as some thrombosis within the lumen of the vessels. There is also, however, in localised fatty changes, embolism, which has nothing to do with, and usually occurs without, arterial sclerosis. Fatty degeneration may be found in other organs, as in FATTY DEGENERATION. 65i the cells of the liver, the epithelium of the kidney, and the intima of many of the arteries. All these changes are closely linked with the cardiac alterations, and own the same causes. There are, moreover, alterations in other organs consecutive to the cardiac changes. These are due to want of energy. Amongst such effects must be mentioned venous stasis of the dependent parts, and its consequences. It is unnecessary to pass any view on the different modifications of tissue which result in this way ; suffice it to say that there is no means of distinguishing between such changes and those which take place as the result of cardiac failure from valvular disease, especially affecting the mitral cusps. The microscope reveals the existence of fatty degeneration when it is in such an early stage as to be absolutely un- recognisable by the unaided eye. The first appearance which is to be detected consists in the presence of a small number of fine granules within the muscular fibres. They are usually arranged in a longitudinal manner, parallel to, and perhaps between, the fibrils, but are occasionally irregu- larly scattered through the fibres. In such an early phase there is little, if any, change in the transverse striation, and the sole alteration, therefore, is restricted to the existence of the granules. These can be best seen in sections stained with osmic acid. In later stages there is an increase in the number of the granules, with a corresponding loss of striation, and the nuclei Fig. 174. — Section of myocardium from a case of pernicious anfemia showing fatty degeneration, x 250. Osmic acid, a, Fibres with numerous oil-droplets ; 6, fibres unaffected by the change. 656 AFFECTIONS OF THE MYOCARDIUM. in the affected fibres coniiiiuuly disappear. There are usually some portions of the section under examination in which fibres may be observed to be free from granules but deprived of striae, so as to present an appearance nearly homogeneous, or only marked by the longitudinal fibrillation. All these changes may be seen in Fig. 174, which shows the early phase, with granules and striae, and the later, in which the granules have increased and the stria3 disappeared. There are also at one or two points some almost homogeneous portions of fibres. In still more advanced conditions the granules become larger and yield the appearance of globules, with a translucent aspect. They vary much in size, but are not often larger than a blood corpuscle. The longitudinal arrangement is still preserved as a general rule, but there are many exceptions, in which an indiscriminate distribution can be seen. Some of the fibres are seen to contain nothing but such globules, but more commonly some portions of even the most affected fibres have comparative freedom. One point is clear. In their localisation the globules constantly accumulate, as Gowers insists, between the primitive bundles, but it has not been, and probably cannot be, determined whether this is due to coalescence of granules formed there, or to passage outwards from the fibres. Just as there is a strong tendency for the selection of certain spots as the principal points of attack by this form of metamorphosis as seen by the naked eye, so under the micro- scope there is a singular grouping of the affected fibres — of two adjacent fibres one may be healthy and its neighbour diseased, nay, one small part of a fil^re may be hopelessly destroyed, while the rest is sound. The nature of the process resulting in fatty degeneration is at present absolutely obscure. Fat exists in every animal tissue, but in such a state of fine division as to be invisible under the microscope, and to be recognisable only by chemical analysis. The amount contained in the heart is from 2 to 3 per cent, of the total weight of that organ. When moderate fatty degeneration is present, so that the granules and globules may be seen in the muscular fibres under the microscope. FA TTY DE GENERA TION. 6 5 7 there is, according to Ormerod, no increase iu the absolute quantity of fat, and it therefore seems that the first step of the degeneration, as Gowers says, is a separation and pre- cipitation of the fat previously combined. Possibly some of the granules first seen as al3ove described, in the process oi' degeneration, are not all composed of fat, and it is to Ije remembered that Virchow suggested that albuminoids may become altered into some soluble extractive and be absorbed, leaving behind the fat in a state of precipitation. When the change proceeds further, the amount of fat is larger than can be explained in this wa}^, since the amount of fat, as above mentioned, may be double that normally present. One explanation is, that it is produced by a metamorphosis, a chemical process, in which, by impaired tissue change, there is a destruction of the fibre. The fact is undoubted that fat may be formed from nitrogenous substances. The formation of adipocere has been cited by Quain in illustration of this fact, and he himself showed that by prolonged maceration in dilute acetic acid, healthy muscular fibres undergo fatty degeneration. As an explanation of the possibilities by means of which such metamorphosis may take place, Eindfleisch has shown that in cloudy swelling the granules in the cells are soluble at first in acetic acid, but that this condition passes into another in which the granules do not dissolve in that acid, but are readily soluble in ether. The fact that regions from which the blood supply is altogether cut off, by embolism or thrombosis, undergo fatty degeneration, is sufficient to prove that such changes may be entirely due to alterations going on within the tissues. It must be admitted, however, that in addition to such altera- tions, some of the fat may be brought from without. Eohin and Verdeil, Ormerod, and Walshe believed, indeed, that all the fat seen in the muscular fibres was introduced from without. This is extremely improbable in such instances as the acute fatty degeneration of the febrile state, and it is impossible in those localised patches of degeneration which occur as a consequence of vascular occlusion. It must, nevertheless, be allowed that in a very large number of cases showing fatty changes both processes may be at work. 42 658 AFFECTIONS OF THE MYOCARDIUM. Symptoms. — The clinical features produced by fatty defeneration are characterised by indefiniteness. This arises not only from the fact that the changes in the muscular wall have their origin in a good many different conditions which in themselves give rise to disturbances of the circulation, but also from the circumstance that the various appearances yielded by fatty degeneration may have their origin in other conditions of weakness. The most common complaints made by patients suffering from this affection are breathlessness, especially on exertion, and debility, manifested on attempts to employ the muscles. There is also, in some instances, a degree of uneasiness, or even pain, in connection with the chest, while interferences with the functions of the brain, as regards sleep, memory, and intellectual processes, are not uncommon. The general appearance in fatty degeneration is so dependent upon the conditions under which it arises, that no general statement can be hazarded. It is customary to say that the face is usually pale, but this is only true of certain cases, and well - marked fatty alterations may be present in those who are ruddy. Between the appearance of the face in cases of fatty degeneration in pernicious anaemia, and those attendant upon a similar change in the course of chronic alcoholism, there is every gradation. It must, how- ever, be admitted that the chronic alcoholic patient most liable to fatty degeneration is more likely to manifest a waxy pallor than a ruddy glow. Senile patients in whom, from free habits of living and inefficient exercise, fatty infiltration has passed on to degeneration, have frequently a mixture of ruddiness and pallor, along with yellowness of the conjunctivae from adipose tissue, and the arcus senilis, which has been proved to be the result of fatty degeneration. Sometimes there are evidences of cedema, more especially in the dependent parts, but this is not, as a rule, great, except in those cases which have led to considerable cardiac dilata- tion. It is rather common, on the whole, to find a tendency to chilliness of the extremities. In chronic forms the temperature is usually subnormal. The digestive functions are, as a rule, impaired. There FA TTY DE GENERA TION. 6 5 9 is commonly deficient appetite and sluggishness in the per- formance of all the various functions concerned in digestion, and in addition, there is not infrequently gastro- enteric catarrh. Needless to add, in the type of fatty degenera- tion resulting from infiltration, it is by no means uncommon to find some enlargement of the liver. The condition of the blood depends entirely upon the conditions which have led to the degeneration. As tested by the usual clinical methods, there may be deficiency of the hiTemoglobin, hsemocytes, and leucocytes, as in cases of pro- found aneemia ; or, as in other instances in which cardiac dilatation has ensued upon chronic degenerative processes, there may be, as the result of cyanosis, an increase in all. The more special symptoms connected with the circulatory apparatus are, like those which have been considered, subject to considerable variation. Uneasy sensations, often amount- ing to actual pain, may be felt in the prsecordia, and may radiate upwards and outwards to either one or other shoulder and arm, or may even implicate both sides. There are fre- quently sensations of disordered movement within the chest, such as tremor cordis. Syncopal attacks, sometimes produc- ing absolute unconsciousness, often occur, and overshadowing all these symptoms there may be the awful sense of approach- ing death. These subjective sensations present a very close resemblance to angina pectoris ; in fact, it would be better to say that in such instances angina pectoris in its varied manifestations constitutes a feature of fatty degeneration. The pulse almost invariably reveals some well-marked changes. The arterial wall may be soft and yielding when the affection has had origin in some acute disease or anaemic condition, but it is, on the other hand, rigid and inelastic in many of the senile forms of the disease. The pressm^e is almost invariably diminished, but this is sometimes rather difficult to estimate in the forms marked by arterial sclerosis. The vessel is almost invariably rather empty ; the rate of the pulse presents great differences. In the more acute forms the rate is usually accelerated, so that the pulse may be persistently more than 100 per minute. In the more chronic forms, especially those which are senile, the rate of the pulse 66o AFFECTIONS OF TJIE MYOCARDJUM. is coiuiiiuuly (liiuiuislu'd, and tor long periods of time it is possible to determine that the rate is never above 40, and sinks to 20, or even less. The rhythm may also present different cdiaracters. In some instances it is perfectly regular, excepting when a transitory tiimultuons action comes on, but many different changes in rhythm may be present. Simple irregularity is common, but a grouping of the pulsations is by no means infrequent. One feature lias on several occasions attracted my attention : a singular periodicity of the pulsa- tions has occurred both as regards the rate and the fulness of the pulse, so as to give appearances which might be regarded as somewhat analogous to the Traube-Hering curve, revealed by physiological experiments in the case of the arteries. Over and above such appearances, there may be a distinct loss of some of the heart beats in the passage of the blood wave to the periphery, so that the number of pulsations, as observed in the radial artery, may l)e sniallei' than tlie number of cardiac contractions. The neck and priecordia rarely give any noteworthy appearance, with the exception of absence of all apparent impulse. The apex beat may be perfectly invisible, and no impulses may be seen in the lower sternal region, in the jugular fossa, or in the neck. The application of the hand to the prfficordia largely confirms this negative CAadence, since the apex beat is commonly found to be extremely feeble. It usually occupies a situation very near the normal position, and it gives the feeling of a short feeble tap to the hand. Even this may not be perceptible, when the only impulse to be felt is at the lower end of the sternum at its left edge. This observation was originally made by Stokes, to whom we owe so much in the study of cardiac degenerations. The area of cardiac dulness is not, as a general rule, much altered, unless some degree of dilatation is present, in which case the extent of outline conforms to that which will be described under that head ; but it must be remembered that in those cases of fatty degenera- tion which have taken their origin in, or have been associated with, hypertrophy, the area of cardiac dulness may be con- siderably augmented. The heart sounds invariably undergo considerable change. The most common experience is to find FATTY DEGENER/IT/ON. 66 1 such a degree of enfeeblenient of the Ih'st sound as to render it less audible than the second, and sometimes, as was pointed out by Stokes, on listening at the apex, only the second souiid may be heard. In most cases, at the lower end of the sternum the first sound is present, although it may be extremely weak. When there is acceleration of the rate of pulsation, the heart sounds, from equidistance and equal loudness, may assume a foetal character. Systolic murmurs may replace the first sound over both the left and the right ventricles, more particularly in cases arising from febrile disturljance or profound anfemia. The respiratory system almost invariably yields distinct symptoms on investigation. Dyspnoea on exertion is at once an early and persistent accompaniment of the condition, but in later stages constant anhelation may be present, and the breathing has often a suspirious character. The rhythm often undergoes alterations so as to present periodic appearances. Oheyne-Stokes' respiration is occasionally present. Stokes believed tliat this ascending and descending respiration was pathognomonic of fatty degeneration, but, as has been shown previously, this was soon found to be a baseless supposition. Certain of the modified respiratory movements are common in fatty degeneration. A persistent tendency to sighing, or irresistible inclination to yawning, may be mentioned amongst these. The renal secretion is almost always scanty, high coloured, and of increased specific gravity. Not infrequently it contains albumin and tube casts. The painful sensations experienced in the region of the prsecordia have already been referred to, and require no further comment. Feelings of faintness and giddiness are common. The functions of the brain are often interfered with, more particularly as regards sleep. A persistent soporose tendency is highly characteristic of fatty degeneration, and even after having slept for the greater part of twenty- four hours, the patient on being awaked may complain of being unrefreshed. But, on the other hand, insomnia is occasionally found, or — and this has been frequent in my experience — the nights have been passed in fruitless endeavours to fall asleep, while the 662 AFFECTIONS OF THE MYOCARDIUM. daytime has been spent in a vain struggle to overcome an overwhelming desire to sleep. A gradual alteration in the higher mental processes may often be determined ; the memory, more particularly, suflers, but all the mental operations Ijecome blunted, and the temper is at the same time apt to undergo changes, usually for the worse. The brain powers appear to be easily exhausted by even slight mental exertion. In addition to such persistent appearances there are often others of a more transient character. Attacks of an apoplectiform or epilepti- form nature are sometimes observed, the latter presenting close resemblance to fetit mcd. Transitory unconsciousness and passing aphasia are the most connnon appearances to lie classed under these heads. The course of the disease is marked by the same variability as obtains in the evolution of the symptoms. In the slowly developed forms of the affection, arising from accumulation and infiltration, the duration is lengthy, but in the rapidly produced lesions of acute diseases and profound anaemia the course is much less prolonged. The termination is, in most instances, brought about by lieart failure, gradual or rapid, according to circumstances. It is in this cardiac disease above all others that sudden death from asystole most commonly takes place. An abrupt termination to life in aortic incompetence is most commonly associated with this degeneration, so often attendant upon the inevitaljle hyper- trophy arising from that valvular lesion. This manner of death is not, however, the only startling close of life. Eupture of the heart, although perhaps more common in fibroid changes, takes place in fatty degeneration also, and furnishes another example of sudden death. Diagnosis. — There can be no question that Balfour is correct in douljting the possibility of absolutely diagnosing a fatty heart. From the different symptoms, general and local, there may be a reasonable probability of the existence of this degeneration, l)ut the diagnosis cannot, except in very rare cases, pass from the region of inference to that of certainty. The clinical features directly connected with the circula- tion are solely those of loss of heart energy — feeble cardiac impulse, weak heart sounds, and snuill arterial pulsation, with FA TTY DEGENERA TION. 663 cyanosis and dyspncea in most instances. These appearances have nothing characteristic in themselves. When accompanied Ijy painful sensations and syncopal attacks, there M^ill necessarily be some suspicion of myocardial change, and if there be at the same time any impairment of the cerebral functions, a reason- able presumption in favour of fatty degeneration may arise. Each and all of these features may be found in chronic myocar- ditis, and the differentiation of the two lesions is rarely possiljle. Stress has been laid by many writers upon the existence of similar changes in other regions, as lending weight to the supposition of fatty degeneration of the heart. Evidences of arterial degeneration are often mentioned as confirmatory, more especially by G-owers, but it seems to me that such changes are always more in favour of the diagnosis of cardiac fibrosis, and that they cannot be allowed much weight in the diagnosis of fatty disease. The arcus senilis has, since Quain's observations, been accepted as furnish- ing an important symptom. While in itself of no moment, it may, along with the general features of a failing heart, be allowed to contribute slightly towards the probabilities in favour of fatty heart. When a valid cause of degeneration is present it will materially help the diagnosis. It is unnecessary to say that a failing heart in acute disease, profound ansemia, and analogous conditions, is most probably in any case determined by fatty changes ; this goes without saying. But where chronic heart failure occurs, without previous valvular disease, in any one who is of alcoholic tendencies, there will naturally be an inclination towards the diagnosis of fatty degeneration. In a similar way any one with a full habit of body and a large heart, who gradually develops the features of cardiac failure, will reasonably be judged to have degeneration as the result of infiltration. Peognosis. — Any attempt to form a forecast of the probable future of fatty degeneration must be largely based upon the causes which have led to the myocardial change. The pro- gnosis, therefore, is very different in those cases which have their origin in acute, and in those arising from chronic disease. The acute form of defeneration constitutes the danger so 664 AFFECTIONS OF THE MYOCARDIUM. iinicli dreaded in the course of the continued levers, diphtheria, pneumonia, and similar diseases. 'When it shows itself l>y those features of cardiac depression which are so umnistakahle, an estimate of the outlook will i)rol)al)ly he l)ased upon the period of the disease at which tlie chantre shows itself, and the vitality and energy of the patient. Speaking generally, if the cardiac weakness is manifested at an early stage of the disease, the forecast' will necessarily l)e more serious than when it occurs at a later period. Similarly, in the weak and debilitated the prognosis is more serious than in tliose who are roljust and healthy. As Gowers has so well put it, acute forms of degeneration are " those in which the immediate danger is greatest, hut at tlie same time, the ultimate prognosis is usually favourable." In the forms of degeneration occurring as the result of clironic disease, the immediate danger is not so great, l)ut tlie ultimate prognosis is more serious. Here the whole future depends upon the possibility of removing the cause operative in the production of the affection. It is unnecessary to refer to prognosis in degeneration taking its origin in some incurable malady, such as malignant invasion of the system, or when the changes arise in consequence of senile degeneration, in which the conditions are, for the most part, unalterable : but in some forms of fatty degeneration caused by blood changes, toxic processes, and hygienic errors, the prognosis is more hopeful. In many forms of amemia the primary disease may lie entirely removed, and when tliis is the case the result may Ije perfectly satisfactory. In the same way, alcoholic fatty degeneration may be removed on cutting short the prime causal factor. Similarly, fatty degeneration fol- lowing upon fatty infiltration may be averted by the adoption of such thorough-going treatment as will remove the deposit. Treatment. — The management of the cases of fatty de- generation from acute processes, and from chronic disturbances, differs entirely. In the former case absolute rest, appropriate food, and diffusible stimulants, are above all else necessary. It is usually advisable to give the patient such cardiac tonics as digitalis or strophanthus, which may be most advantageously combined with strychnine, ammonia, and ether. The inhala- FA TTY DE GENERA TION. 6 6 5 tioii of oxygen is often of the greatest ])enefit, and may cause a recovery when all otlier means seem likely to fail. If the blood sliould be in an im])overished condition, the use of iron or arsenic, or both drugs, must l)e enqjloyed. Tlie views of Hunter, as lias been stated by me elsewhere, seem so reasonable as to merit a careful trial, and in my own hands the use of internal antiseptics in profound anaemia has certainly been beneficial, as elsewhere stated. In cases arising from toxic causes, no treatment is of any avail unless these causes are withdrawn, and in all chronic forms the oljserver would do well to inquire most diligently as to the possilnlity of alcoholic abuse. In those instances resulting from fatty accumulation and infiltration the treatment consists in the careful regulation of the diet and the inculcation of exercise. In all cases of chronic fatty degeneration the habits, surroundings, and occupation of the patient may be watched. In some forms of fatty degeneration the method of treat- ment carried on at Nauheim is most advantageous, and a course of baths, accompanied by resistance exercises, and followed by carefully arranged exercise, will be found of in- calculable benefit. In addition to all these considerations, attention must be given to the necessity in many cases of employing cardiac tonics and stimulants. If there be any tendency to increased peripheral resistance, such cardiac tonics should be combined with the nitrites, and more particularly with nitro-glycerin. In many of these cases the iodides are of even greater utility, and iodide of potassium combined with infusion of digitalis can be cordially recommended. If pain is a prominent symptom, such remedies will be found in most instances quite sufficient to curb it, l)ut it is sometimes necessary to step in and ad- minister nitrite of amyl, if there be apparently much arterial spasm ; ether or chloroform may be required, while in certain cases it is absolutely necessary to give the patient a sub- cutaneous injection of morphine. Case 50. Fatty Infiltration. — W. H., aged 70, retired manufacturer, frequently consulted me during the last few years on account of some un- easiness in the back of the chest, and consideralile breathlessness on exertion. His family history was satisfactory, hut showed some lialulity 666 AFFECTIONS OF THE MYOCARDIUM. on one side to heart affections ; his father, belonging to a healthy house, lost his life, at the age of 40, by a boating accident ; his mother died at the age of 64 of cardiac failure. One brother died, aged 59, from cerebral disease, a second at 40, from " weak lieart " ; another was quite well ; a sister" died of congenital heart disease, another of heart disease, and the only other one had a weak heart. All his sons and daughters, four and two in number respectively, were healthy, but there was a tendency to cardiac weakness auiongst them, sho^\■n by a liability to dilatation under any strain. The patient had, on the whole, been a healthy man, but about the age of 50 he had to take a long holiday on account of cardiac weakness, undoubtedly due to muscular debility. Since that tlate, he had engaged very actively in business. The patient was 5 ft. 10 in. in height, weighing between 16 and 17 stone; he always presented a healthy ai)pearance, with a slight j)urplish tint, however, about the lips. He frequently complained of coldness of the extremities, which sometimes awoke him during the night. The skin acted very freely, the least exertion giving rise to profuse perspiration. The alimentary system was only marked by a slight fur upon the tongue, and an enlargement of the liver, which extended from the fourth cartilage to a couple of inches below the costal margin, or 7 in. in all. The thyroid gland and spleen were of normal size. The l)lood was never examined. The pulse, usually 64 j^er minute, was full, large, regular, and equal, Avhile the walls of the vessel were in no respect altered. On inspection of the neck and pra3Cordia there was absolutely no impulse to be seen, but this could not be wondered at, since the parietes were so well clothed. A diffuse impulse could be felt in the fourth and fifth left intercostal sj)aces, at a point 4|^ in. from mid-sternum. Oil percussion the cardiac dulness was found to extend 2| in. to the right and 5^ in. to the left of the middle line at the level of the fourth cartilage. The cardiac dulness began at the level of the third left costal cartilage. The first sound both at the apex and in the tricuspid area was distinct and clear, but not so intense as the second at the base, which was consider- ably louder in the pulmonary than in the aortic area. No accompaniment was ever detected. On examination of the lungs there Avas constantly a slight imi^airment of the percussion sound at the bases behind ; and on auscultation fine crepitation accompanying the inspiration was to be heard over both. The extent over M-hich the crepitation could be heard varied at difl'erent times, but was usually confined to a zone, about 3 in. broad, along the inferior margin of each lung. When there was any slight pyrexial attack, such as even a simple coryza, the area over which the crepitation could be heard was distinctly increased, and it sometimes reached almost as high as the angle of the scapula. Attacks of subacute bronchitis were frequent, but there never was hydrothorax. The urinary system was never in the slightest degree implicated. The integumentary system, apart from the tendency to profuse pei'spiratiou, A\-as always unaltered, and no trace of oedema was ever observed. The nervous system showed not the slightest deviation fronr healthy conditions. Some strophanthus and nux vomica, with regulation of diet, rest, and exercise, have always sufficed to restore equilibrium. FA TTY DEGENEKA TION. 667 This may be taken as an excellent instance of fatty infiltration, possibly associated with some degeneration, but which may perfectly well be a simple example of accimiulation. It is of interest to observe that there has never been the slightest tendency towards anginous seizures, or any discomfort excepting that dull pain in the back which is so often found in cases of passive hypenemia of the bases of the lungs. Case 51. Fatty Degeneration from Pernicious Anaemia. — T. S., aged 36, steel grinder, was admitted to Ward 22 of the Royal Infirmary, 7tli December 1892, complaining of weakness. The patient's father had died at the' age of 45 of some malignant affection, and his mother at the age of 56 from some pelvic disorder. The family had consisted of six brothers and two sisters, of whom the former were all alive, but the two sisters had died from causes about which the patient knew nothing. His social conditions had been eminently satisfactory, and his conduct all that could be desired. His previous health had been in all respects good until about three years before admission, since which time he had been gradually becoming worse. The general appearance of the patient was somewhat striking. He was a man of medium height, 5 ft. 7 in., weighing 11 st. 81 lb. His hair and eyes were of a dark brown hue, forming a startling contrast to the tint of the face, which was of a pale straw colour. The lips were intensely pale, as was the interior of the mouth, and on turning down the lower eyelid, the mucous membrane lining it was also found to be extremely blanched. The patient complained of no symptoms connected with the digestive system, but the tongue was large, pale, and flabby, and the liver extended in the mammillary line from the fourth rib do\\Ti wards for a distance of 8 in. None of the lymphatic glands were enlarged, and the thyroid was of normal size, but the spleen reached the anterior axillary line. On examination of the blood, it was found only to contain 40 per cent, of hajmoglobin, and 1,600,000 red blood corpuscles. The corpuscles showed a great variety of sizes and shapes ; megalocytes and microcytes were present, as well as a large mimber of poikilocytes. The white blood corpuscles were practically normal in number. He suffered much from breathlessness and palpitation, especially on the least exertion. The pulse was somewhat increased in frequency, being usually 106 or 108 per minute. The artery was soft and elastic; the vessel was rather empty, and its pressure was low ; the pulsation was perfectly regular and equal. The heart was somewhat enlarged, its borders being respectively 2^ in. and 41 in. to the right and left of mid-sternum. On auscultation systolic murmurs were heard, one in the mitral area, and another .uj) and down the sternum, with its maximum intensity between the tricuspid and pulmonary areas. On examination of the respiratory, urinary, and integumentary systems, no abnormal points could be elicited ; l^ut as regards the nervous system, examination of the retina showed that there 668 AFFECTIOXS OF THE MYOCARDIUM. were a iiumlioi' of retinal lin'iiuinlia^es. Tliese were more jiarticularly seen in tlie fundus ut' the right eye, Imt were also present in llie lei't. The erect image of tlie riglit eye showcil oni' large dense liaMiiorrhage around the fovea centralis, while several smaller lia'inoi'rhages were scattered about between that sjjot and the disc. A number of smaller patches of haemorrhage were scattered widely throughout the fundus. The erect inicOge of the left eye showed a few patches of luemorrhage around the fovea, and some others in the upjter ]iart of the fundus, more especially in the angle formed by the two main branches of the retinal 1)lood vessels. There can be no doubt tlial this case was an example of pernicious aniHimia of a somewhat pronounced type. He was accordingly treated from the first with /3-naphthol, receiving 3 grs. in pill three times daily. At the same time he was confined absolutely to Ijed, and his food consisted largely of farinaceous inaterial. Under this treatment he made somewhat rajjid imi^rovement with a few fluctuations, and by the 13th of March he stated that he felt perfectly well. His hiemoglobin had reached 55 per cent., and the red blood corpuscles numbered 3,360,000. The condition of the circulation was also greatly improved ; the mui'murs had almost disajji^eared, and the heart sounds were loud and distinct, while his comjjlexion, instead of lieing mai'ked l)y a ])ale straw tint, was clear and almost rosy. He was accordingly, on 13th March, sent to the Convalescent House. On the 30th March he rejiorted himself, and it was then fcnind that his ha2moglol)in was 60 j^er cent., and the red blood corpuscles 4,000,000. On examination of the fundus of the eye it was seen that the retinal haemorrhages had absolutely disappeared. The patient was therefore allowed to go home. In order to present a succinct statement of the improvement he underwent, the following table may be given, i'rom wliii'h the condition of the Ijlood will be seen : — December 7 9 J, 21 ,, 22 January 1 ,, 20 , ^ 28 February 2 ,, .5 j^ ,, 11 J, 13 ,, 16 !) 21 21 ,, 27 March 3 , , / >> 10 13 ,, 30 Corpuscles. Iln-moglobin. 1.600,000 40 per cent. 2,000,000 30 ,, 2,100,000 18 ,, 1,600.000 18 ,, 1,100,000 18 ,, 1,800,000 20 ,, 2,000,000 30 ,, 2,120,000 38 2,400,000 40 ,, 1.800,000 40 2,000,000 46 2,700,000 46 2,080,000 42 2,100,000 46 „ 2,144,000 54 ,, 2,720,000 58 2,640,000 60 ., 2,560,000 52 2,664,000 56 ,, 3,360,000 55 ., 4,000,000 60 „ FA TTY DE GENERA TJON. 669 All weut well for u .sliori time, Init in a few weeks the jialieiit I'dmucd in a grave condition, the corpuscles having suddenly fallen to 800,000, and the luenioglobin to 16. In sj)ite of every means employed, including transfusion of Ijlood, he rapidly sank, and died. The post-mortem examination was performed the day afti;r death hy Dr. Eobert Muir, from wliose report the following condensed account is taken. The body was well nourished. There was extreme palloi- oi' the whole surface, with slight ccdema of the legs and dependent jjarts ; well- marked rigidity and slight lividity were present. There was diffuse ecchyniosis on either side of the outer surface of the pericardium, and the sac contained 2 oz. of serum. The left jjleura contained 20 oz. of serum. There were adhesions on the posterior part of the lung, and over the apex. The right pleura contained 1 6 oz. of serum, but had no adhesions. The heart weighed 13 oz. There were s^me minute ecchymoses over the auricles. There was no diminution of the fat upon the surface of the heart. The aortic and pulmonary cusps were competent. The cone diameters of the orifices were as follows : — Aortic, 1 ; j^uhnonary, 1 -2 ; mitral, 1'5 ; tricusjoid, 1*95. There was very extensive fatty change in the myocardium, both in the left and right ventricles, but esp)ecially in the former. The endocardium showed a very fine yellow speckling. The valves were normal, there being only some early atheromatous change at the beginning of the aorta, and in the anterior cusp of the mitral valve. The left ventricle was 4 in. long, and | in. thick at the thickest part. It was therefore somewhat hypertrophied and dilated. The columncie carnese were thin. The left lung weighed 1 lb. 8 oz., the right 1 lb. 12 oz. There was a large number of white fibrous nodules in the pleura, about the size of a pin's head, along the junction of the interlobular septa. These showed no signs of caseation. There were some nodules of a similar kind in the lung, but fewer in number. There were, further, some small caseous masses in the upj)er lobes, evidently of old standing. The lungs were anasmic, and posteriorly cedematous. Both lungs exhibited these conditions, and the right in addition had some miliary tubercles. The peritoneum was healthy. The liver weighed 4 lb. 12 oz. It showed a number of small depressions with thickening of the capsule, which gave an irregular character to the surface, especially over the right lobe. There were no corresponding fibrous bands running in from these. The liver showed marked fatty degeneration, especially in the centre of the lohes, with pigmentation at the periphery. On the addition of hydrochloric acid and ferrocyanide of jDotassium, a distinct iron reaction was obtained. The pigment was apparently abundant, and a section of the organ had a peculiar chocolate-like colour. The spleen weighed llJ^ oz. It was considerably enlarged, but a section seemed normal, and gave no iron reaction. The left kidney weighed 07^- oz., the right 8l oz. The cortex was enlarged, and showed well-marked yellow and red mottling. Fatty degeneration was well marked in both. The stomach was conoested 670 AFFECTIONS OF THE MYOCARDIUM. posteriorly, but otherwise healthy. The duoilenuni and first part of the jejunum showed diffuse hivniorrhages into the mucous membrane, and were deeply Ijile stained. The rest of tlie intestine was normal. Tlie pancreas and suprarenal bodies were quite healthy. Tlie bone marrow in the shaft of tlie femur was completely transformed into the red variety, and there was some softening of the bone trabecuh^. On microscopic examination this showed numerous nucleated red corpuscles. Some of these were of large size, reaching 20 //., with irregular nuclei. There were also some cells containing fragments of brown jjigment. This case presented an excellent example of the charac- teristic fatty degeneration so common in fatal cases of pernicious antemia. Its unfortunate termination simply repeats an occurrence witli which all are but too well acquainted. AVhen Htinter brought forward his views in regard to the nature and treatment of this disease many were full of high hopes that a satisfactory means of effecting recovery had been found. Eesults of a most satisfactory kind have been published by myself. It must be frankly, but sorrowfully, confessed that these hopes have proved vain, as further experience has failed to confirm the beneficial effects seen at first. Intestinal antiseptics, like all other remedies, only produce a transitory improvement, and we seem as far as ever from a reliable means of bringing about permanent recovery. Case 52, Cardiac Dilatation from Fatty Degeneration. — E. M., aged 55, housewife, was admitted to Ward 25 of the Eoyal Infirmary, on 2nd April 1894, complaining of breathlessness. Her father died early in life, of what affection the patient did not know. Her mother was alive, and, for the a"-e of 75, enjoyed good health. There had been one brother, who died early in life, and one sister still alive and well. The patient had been the mother of eight children, of whom three died in infancy, and one bov at the age of 4. The other four children were strong and well. Her social conditions had been satisfactory. Her previous health had been. good. Two years before her admission she began to suffer from some breathlessness, and she was at the same time heavy and sleepy. These symptoms passed off, and she gradually improved, remaining pretty well until shortly before admission, when she began again to feel breath- less and weak. On admission the patient was observed to be of small stature and of undue bulk, her height being 4 ft. 10 in, and her weight 10^ stone. Her face was deeply cyanosed, the lips being almost the colour of a ripe blackberry ; wdiile the ears and nostrils were of a dull purplish hue. The cheeks were livid, and marked by intensely injected arborescent veins. FA TTY DE GENERA TION. 6 7 1 The tongue, wliicli, like all the mucous membrane of tiie mouth, was of a deep purplish hue, had a thin fur upon it. Many of the teeth were gone, and the gums were somewhat spongy. The liver was found to be rather enlarged, extending from the upper margin of the fourth rib downwards for 6^ in. in the mammary line. The spleen was also slightly enlarged, reaching the anterior axillary line. There was considerable distension of the viscera, but no fluid in the peritoneal sac. The pulse, wliich was 96 on admission, fluctuated diiring the week succeeding that date from 100 to 120. The vessel was somewhat rigid, and slightly tortuous. It was rather empty, but the pressure was fair. The pulsation was irregular and the beats unequal, being withal somewhat variable in type. There was seen to be a great distension of the jugular veins, which stood out like large knotted cords on the sides of the neck, with scarcely any perceptible movement. The prtecordia showed no abnormal phenomena ; in fact, no movement whatsoever could be detected. Palpation failed to detect any impulse. Percussion fixed the right border of the heart at 1\ in. and the left at 4|- in. from mid-sternum. On auscultation nothing could be heard except extreme feebleness of the heart sounds. At the base of the heart the first sound was almost inaudible, and the second sound was much louder in the pulmonary than in the aortic area. At the apex the first sound was dull in character and very feeble, and the second sound quite overshadowed it. The same Avas the case practically in the tricuspid area ; but the first sound was a little more distinct. The patient had a considerable amount of cough, attended by a fluid frothy sputum, slightly blood-stained. Physical examination of the chest only revealed the existence of numerous crepitations through both lungs, especially at their bases behind. The renal secretion was very scanty, never exceeding 14 oz. on any of the first three days after her admission. The subcutaneous textures showed considerable cedema of the dependent parts, especially of the ankles and feet. The patient was in a somewhat dull and listless mental condition, tending towards stupor. It was obvious that in this case the myocardium had entirely given way, and that whatever might be the cause of the breakdown, there could be but one termination, unless speedy relief were afforded. The patient was therefore treated with Henry's solution, and a mixture was ordered, containing 10 minims of tincture of digitalis and 15 minims of tincture of squills, along with 15 grains of acetate of potash, in a table- spoonful of decoction of scoparius, which was to be administered every four hours. As on the second and third days after admission there was no appearance of improvement, the patient, on the other hand, becoming more cyanotic and verging upon coma, it seemed to me that there was but one course open — general blood-letting. On the 4th Aj)ril, therefore. Dr. Garbutt performed venesection on the left arm, and withdrew 10 oz. of blood. The effect of this was most marked, the patient becoming much more wide-awake. The cyanosis became less, the pulse gained in strength, and even the heart sounds were more distinct ; while coincident with these symptoms of improvement there was a noteworthy increase in the renal secretion, which at once bounded up to 60 oz. The administration 672 AFFECTIONS OF THE MYOCARDIUM. of digitalis and squills, with acetate of potash and scoi:)arius, was continued, and occasional doses of Henry's solution were administered ; and as there was still considerable crepitation over the base of tlie lungs, the back was dry-cupped. The cyanosis steadily disappeared, and all the symptoms ameliorated, the heart sounds in particular became very nuicli more distinct ; but the digestive functions caused more trouble after a few days, probably on account of the digitalis. She was therefore treated thence- forward by means of tincture of strophanthus, 5 minims Ijeing administeretl every four hours. Although a few vicissitudes took place, her progress was eminently satisfactory, and it was discovered after she had regained a considerable degree of strength, that there were systolic and diastolic murmurs in the aortic area. By the 28th of April she was able to be sitting up, and she returned to her home on the 2nd of May. She has since then reported herself from time to time, the last time on which she came to see me being 3rd November 1896, on which date she was free from all symptoms of cii'culatory disturbance, showed no trace of cyanosis or of venous engorgement anywhere, and the heart sounds were distinct and clear, except in the aortic area, where a systolic as well as a diastolic murmur could be detected. It was certain that in this ease we had to deal with a chronic myocardial alteration, but whether it was of the nature of a filjrous or a fatty change, could not be determined. Clearly the myocardial lesion was grafted upon an affection of the aortic cusps, almost certainly of sclerotic type ; possibly, therefore, a certain amount of interstitial myocarditis may have been present. From the general habit of body of the patient, it was certain, however, that fatty infiltration was present, and it seemed to me that the most reasonable explana- tion of the whole condition lay in an invasion of the muscle elements by fatty degeneration in consequence of the accumula- tion and infiltration. MYOCAEDITIS. j\Iyocarditis presents itself in two distinct varieties, acute and chronic, w^iich have, whether in respect of causation, structure, or effects, so little in common that they may almost be regarded as different diseases. ACUTE MYOCAEDITIS. In the pages of Morgagni and Senac there are clear indications that these observers were acquainted with such a ACUl^E MYOCARDITIS. 673 process, and Corvisart mentions it as an accompaniment (jf acute changes in the pericardimn and endocardium. Laennec devoted an important section of liis great work to the suljject, and Bouillaud beheved in its existence apart from acute lesions of the membranes. Hamernjk described the microscopic ap- pearances for the first time. Latham and Craigie threw much light upon the whole subject, while Stein carefully studied the various aspects of the disease in a luminous monograph. Since the date of his work, many observers, some of whom will be mentioned afterwards, have filled up the gaps in our knowledge. A considerable amount of difficulty still surrounds the nature of this affection, inasmuch as some examples of the disease are mainly characterised by degenerative changes of the muscle cells with little or no structm-al alteration of the inter- stitial tissue, while in others the disease processes affect both muscular fibre and interstitial tissue in an almost equal ratio. Some instances might, therefore, almost be classed as an acute degenerative process. Etiology. — The affection is always secondary to some morbid process elsewhere. It is most frequently found in connection with general or constitutional diseases. Scarlet fever, enteric fever, diphtheria, pyaemia, and rheumatism are the more frequent primary affections. Its occurrence, however, in the course of such affections is brought about in an indirect manner. There are two modes of oriein. In one of these endocarditis or pericarditis has resulted from the primary disease, and by extension lights up the process in the adjacent muscular tissue. In the other, toxic influences are produced by emboli carried in the blood stream and deposited in the muscular tissues ; this is more particularly the case in septic conditions. Traumatic influences are some- times regarded as causes of acute myocarditis, but it is probable that in all such instances the disease has owned a double causation, an infective process having been present as well as the direct violence. Morbid Anatomy. — The structural alterations are some- times general, involving the muscular substances indiscrimin- ately ; much more commonly, however, the changes are partial 43 674 AFFECTIONS OF THE MYOCARDIUM. and are coufiued to one region. If general in their distribu- tion, they may affect the whole structure of the heart uniformly ; if partial, there may be widely-scattered lesions of small- size. When it results from pericarditis, it may be found widely distril)uted, but affecting only the superficial layers of the heart. During fcetal life the right ventricle appears to be more frequently affected than the left, but after birth the converse takes place. The auricles are rarely affected. The appearances presented by the disease yield consider- able differences according to the stage which has been reached. In the earlier phases of the disease, the affected portions are of a deeper tint than in health, and the tissues are swollen and soft. Extravasation of Ijlood is often seen in the affected part. At a later stage the tissue becomes paler in hue, often presenting a grayish appearance, and it becomes still softer than at first. Even with the naked eye, muscular fibres may be observed to be separated from each other sometimes by a serous infiltration containing blood corpuscles and proliferating cells. The change may go on to the formation of a true alDscess, with so much destruction of muscular fibres as to form a cavity containing pus alone. This is more particularly the case when septic processes have produced the disease. Such abscesses have at times produced a connection between different cavities of the heart. It is stated by Gowers that, even after pus has been formed, caseation may occur, and the caseated mass may shrink and undergo calcification. On the other hand, the acute process appears in certain instances to subside leavino- behind it a formation of increased fibrous tissue. In acute myocarditis the essential alterations observed on microscopic examination vary witli the intensity and duration of the disease. In an early stage tlie muscular fibres are larger and paler than in health, and the tranverse striation is almost, if not quite, obliterated. Between the muscular fibres the inter- stitial tissue contains some proliferating cells mingled with red blood corpuscles and leucocytes. At a somewhat later stage the muscular fibres are granular and exhibit various stages of resolution into their component cells, separated by a collection of oil globules and masses of pigment. The interstitial tissue at this stage contains more leucocytes, but in some instances. ACUTE MYOCARDITIS. ^>7S mmmm where conservative processes are in the ascendant, there is an increased amount of interstitial connective tissue. These changes are shown in Fig. 175. At a still later stage the process may advance to such a degree of disorgan- isation as to leave few traces of the normal structure, or, on the other hand, interstitial connective tissue may be so much increased as to form a fibroid degenera- tion of the heart. It has been customary since the publication by Yir- chow of his views to separate acute myocarditis into parenchymatous and interstitial ; but, as a matter of fact, both forms of the affection are associated together. Certain secondary results of acute myocarditis are com- monly found. In the more acute forms of the disease an abscess may lead, as above mentioned, to perforation, and fistulous communications may thus be established between different cavities. When the process is less acute there is a tendency to dilatation in consequence of weakening of the wall of the heart. From the diminished energy of the heart, blood- clots are apt to occur. Any, or all, of these effects may produce disturbance in consequence of involving the valves, chordae, or capillary muscles, or by weakening the wall of the heart. It need hardly be added that in consequence of these disturbances remote effects are produced in other organs in consequence of retardation of the blood current and embolic Fig. 1T5. — Section through wall of left ventricle in acute myo- carditis, X 250. a, Healthy muscle fibres ; 6, muscle fibres undergoing necrosis ; c, accumulation of leucocytes ; d, extravasation of red blood corpuscles. 676 AFFECTIONS OF THE MYOCARDIUM. processes. In this way hypt'ia'inia, catarrh, cedema, and infarction are conmiun results. Symptoms. — The clinical features in acute myocarditis are certainly far from definite, and are characterised for the most part by lessened energy of the heart along with the general symptoms of acute disease. Tlie onset of the disease may be ijuite insidious, but is occasionally marked by characteristic features, occurring lor the most part in the course of previous disease. The affection of the myocardium is sometimes announced by rigor followed by a rise of temperature ; on the other hand, the temperature, previously elevated, may be still further increased without any shivering. The temperature in cases which have been recorded has been so different that it is impossible to attain to any definite conclusion with regard to it. According to Schrotter, the temperature as a rule is only slightly increased, but Wunderlich and "Wagner have recorded one case in which the temperature, continuously elevated, sometimes reached 107°. The digestive processes are usually interfered with, nausea and vomiting being frequent. Jaundice has often been observed. Painful su.bjective sensations connected with the heart have several times been noted. Dropsical appearances have been described. The pulse has usually been feeble, frequent, and irregular. The impulse of the heart has been imperceptible or extremely feeble. The cardiac dulness for the most part has been increased on account of dilatation. On auscultation the chief characteristics of the cardiac sounds have been weakness and irregularity. Sometimes there has been doubling of the second sound with accentuation of the pulmonary portion. Systolic murmurs are not infrequent, but Stein has observed that in cases with previous valvular disease the effect of acute myocarditis is to cause the disappearance of symptoms. Eespiratory symptoms are common — breathlessness and cough, calling attention to disorders of the bronchial tubes, lung tissue, or pleural membrane. The commonest affections are bronchial catarrh, pulmonary oedema, and pleural effusions. Eenal affections are very commonly linked with acute myo- carditis. The urinary secretion is diminished, and contains ACUTE MYOCARDITIS. 677 blood as well as albumin, while xecently formed casts are also found. The nervous system is subject to many disturljances — headache, giddiness, and convulsions — or delirium, lethargy, and coma may be developed. The course of the disease is, as a rule, rapid, and most cases appear to have terminated within a week. Oppolzer has indeed narrated an instance in which death occurred within a few hours of the onset of the affection. Demme, however, has recorded one in which the duration existed six weeks. Such examples are uncommon. Undoubtedly some local forms resulting from endocarditis or pericarditis undergo recovery, but it is probable that when the lesion is at all widely dis- tributed an unfavourable termination must take place. Death usually occurs through cardiac failure, but it has sometimes been brought about by rupture of the wall of the heart. In some cases pulmonary or cerebral complications are an apparent cause of death. Diagnosis. — This is a question rather of theory than of practice, in consequence of the infrequency of the disease and the uncertainty of its symptoms. There can be no doubt of the extreme difficulty which surrounds the diagnosis. Many symptoms may be produced by other affections, while many instances of the disease are attended by extreme latency of clinical phenomena. The rapid development of cardiac failure in the course of affections liable to be complicated by myocarditis, such as endocarditis or pericarditis among local diseases, and pyaemia or enteric fever among general diseases, might lead to the sus- picion of acute myocarditis. The differentiation of acute endocarditis and acute myo- carditis is a matter beset by great difficulty, seeing that in both affections there may be an almost total absence of physical signs, and, even when physical examination reveals distinct morbid appearances, the evidence which these furnish may be conflicting. It may, for example, occur that in one of the general diseases liable to be followed by endocarditis or pericarditis, incompetence of the auriculo-ventricular valve ensues. In such a case it may be almost, if not quite, im- possible to determine whether this complication is due to 678 AFFECTIONS OF THE MYOCARDIUM. muscular or to valvular affection. The diagnosis can there- fore only be attained by carefully estimating the preponderance of evidence in favour of cardiac implication. Prognosis. — If it be possible to diagnose myocarditis, the question of prognosis must of necessity arise. It need hardly be said that in general or diffuse forms of myocarditis, arising from septic conditions, the prognosis is perfectly hopeless. It would be somewhat less grave in cases of local myocarditis if it were possible to determine the presence of such, while in the superficial form arising in consequence of pericarditis the outlook would be distinctly more favourable. Seeing that the diagnosis of such changes is absolutely uncertain, these remarks are purely speculative. Treatment. — From the difficulty of recognising acute myocarditis, there can be no doubt that most instances have been treated for the primary affection which has been present rather than for the cardiac complication. Even in those cases in which it is suspected, if not determined, the treat- ment will necessarily be symptomatic. Absolute rest and appropriate diet must be enjoined. The use of cardiac stimulants will be demanded in consequence of the failing energy of the heart, and nerve tonics may well be combined with them. Many local means have been advocated by different writers. The application of cold to the prtecordia is some- times thought to have some influence in curbing the disease. This may be so, but with the lowered vitality and usual un- easiness it is probable that heat would be more useful. Counter-irritation has also been recommended, but it is doubtful if any good can accrue from such local treatment. CHEOiTIC MYOCAEDITIS. Several distinct processes undoubtedly fall to be considered under this head, and a considerable amount of confusion is to be observed in the literatiu'e of the subject in consequence of the failure to discriminate between different, although related, lesions. The different terms which have been employed show how diverse are the opinions which have been expressed as CHRONIC MYOCARDITIS. 679 regards the morbid changes undergone by the muscular tissue. Cardiac sclerosis, cardiac cirrhosis, fibroid degeneration, sclerotic myocarditis — such are some of the names employed to desig- nate forms of chronic myocarditis. It seems to me that in the light of our present knowledge the only philosophical way in which chronic myocarditis can be regarded is as including all chronic conditions in which there is a general or local increase of fibrous tissue. It is probable that all these con- ditions are connected with reaction phenomena. Morgagni was the first writer to call attention to this affection, and since his time it has been referred to by most subsequent writers on cardiac affections, although it must be admitted that until comparatively recent times the disease was but little understood. Morgagni regarded the process as, in some respects, a degeneration. No real advance was made until quite recent times, and om^ modern knowledge has been somewhat rapidly developed. In connection with such a sub- ject as this, presenting so many different aspects, it is by no means easy to arrange the work of the different authors who have thrown light upon the different lesions, and it would be impossible to mention them all. Only those, therefore, whose work is really helpful will be referred to. The close connection existing between changes in the coronary arteries and fibroid lesions of the myocardium was observed by Gairdner a good many years ago, but he laid no stress upon the association. It was therefore left for Weigert, in his suggestive paper on tissue coagulation, to prove how intimately the lesions are related in the sense of cause and effect. He pointed out that when the circulation is gradually lessened by sclerosis of the arteries, wasting and destruction of the muscular fibres occurs, with consequent changes in the connective tissue. He showed, moreover, that in the case of sudden arrest of the circulation the muscular fibres and the connective tissue lose their nuclei as the result of acute necrosis, while yellow masses like coagulated fibrin make their appearance, around which, apparently from reaction, many round and spindle cells are to be found. Turner almost im- mediately afterwards dealt with the subject, and emphasised the close connection between the coronary circulation and the 6So AFFECTIONS OF THE MYOCARDIUM. myocardium, and suggested the possibility of the origin of local fibroid changes as a result of arterial obstruction or venous thrombosis, in consequence of injury from overstraining the \valls of the ventricles. Huber shortly afterwards discussed the question, and l.jrought together the results of many observations ; besides adding very largely to the facts of etiology as connected with the coronary circulation, he defined the relationship between the process and other conditions with which it has been confused. LetuUe also entered upon the subject and laid great stress upon periarteritis in this connection as the starting-point of the change. In this country the most valuable work on this subject has been done Ijy Lindsay Steven, who has, in two important contrilnitions, not only brought together a critical summary of the literature of the subject, bvit added materially to our knowledge of its pathology. Several facts brought to light by his industry will be discussed in the sequel. Amongst authors who have throw^n light upon different aspects of the ►subject may be mentioned Jenner,who has dealt with the results of long continued hypertemia ; Lancereaux, with important observations upon primary chronic myocar- ditis, as a result of toxic influence, and secondary, as a result of pericarditis or endocarditis ; Fagge, wdth careful descrip- tions of the localised characteristics of fibroid changes ; Thur- nam, with observations on its association with cardiac aneurysm ; Eenaut, with his suggestive, but, as yet, unproven, observations on chronic segmentary myocarditis ; and Ziegier, with his valuable contribution on myomalacia cordis from coronary changes. Etiology. — It is an undoubted fact that families show a hereditary tendency towards chronic myocardial changes. After the most careful exclusion of every possible cause, there is sufficient evidence to show that a proclivity exists to such myocardial changes. With regard to the influence of sex, the results of Lindsay Steven appear to agree pretty well in the main with those of other observers. In a series of 21 cases, 14 occurred in men and 7 in women. It is essentially a disease of advanced life. CHRONIC MYOCARDITIS. 68 1 and here again Lindsay Steven's facts may be appealed to. In 1 9 of his 2 1 cases, the age was ascertained. Of these, 3 were between forty and fifty years of age ; 8 between fifty and sixty ; and 8 between sixty and seventy. The age is stated by some authors as being without marked influence. This, however, is certainly wide of the mark, and there can be no doubt that occupations involving long continued severe muscular exertion are more likely to give rise to interstitial myocardial changes than any others. The condition of the blood supply is of an importance which cannot be over-estimated. The Ijlood itself may be modified by causes taking their origin within the body, or acting upon it from without, and the amount of blood circu- lated through the heart may be modified either l)y changes in the energy with which the blood is driven, or interferences with its local distribution. Among factors modifying the condition of the Idood arising within the body may be mentioned such affections as lithtemia, glycsemia, and all other faulty conditions of the blood arising from defective metabolic processes. Of those having their origin from without are some dependent upon the introduction of chemical substances, such as alcohol. It cannot be doubted that all agents which interfere with tissue change are liable to set up chronic lesions of the myocardium. In addition to these, some infective diseases are undoubtedly prone to give rise to chronic myocarditis, as for example enteric fever, as has been proved by Landouzy and Sired ey. The most important of all the infective diseases in this regard is syphilis, first shown by Wilks, but its mode of action is somewhat indirect, since it acts both by the production of gummata, which form foci of irritation, and through obliterative endarteritis, which interferes with the nutrition of the part. The supply of blood may be interfered with by causes which diminish the rapidity of its flow. Valvular diseases, especially those of the mitral valve, lead to venous stasis, in vfhich the coronary circulation participates. Not only is the blood in such cases stagnant, but it is necessarily less pure, and, as a result, there is chronic induration of the walls of the heart, analogous to what is found in all other organs subject 682 AFFECTIONS OF THE MYOCARDIUM. to backward pressure. Similar conditions may be produced as secondary results of lesions elsewhere. In cardiac failure due to lung or kidney disease, analogous alterations are to be seen. The influence exerted by the condition of the coronary arteries is the most important factor which has to be con- sidered. All changes in the coronary arteries, whether affect- ing their walls or tlieir lumen, lead to alterations in the myocardium. Endarteritis deformans, whether in the difPuse or nodose variety, with or without atheroma or calcification, is the most frequently observed vascular change. The presence of such chronic vascular changes is often associated with the existence of chronic renal disease, and indeed with the tend- ency to general filirous increase throughout all the tissues of the body. Endarteritis obliterans is also sometimes found, and is attended by a development of gummata within the myocardium. The processes of thromljosis and embolism play an important part in the evolution of chronic interstitial myocarditis. Thrombosis may take place in situ ; when the coronary arteries are seriously diseased by any form of endar- teritis there is a great tendency to coagulation of tlie blood within the lumen of the vessel. Embolism may take place in consequence of valvular vegetations or coagulation of the blood within the cavities of the heart. In addition to all these different processes, chronic myocarditis undeniably results from extension. In cases of pericarditis with adhesions it may most particularly be seen, but in all cases of endocarditis and pericarditis there is more or less tendency to a spreading of the process into the adjacent layers of the myocardium. Morbid Anatomy. — Arising in consequence of so many different causes, it is little wonder that the appearances in chronic myocarditis are extremely varying. In almost all its forms it is a local change, but even in the most circumscribed form it produces alterations involving, in almost every case, a considerably larger area of the heart. The structural alterations are practically confined to the ventricular portion of the heart. These morbid changes are far more common on the left than on the right side. Since the observations of Morgagni, it has Ijeen recognised that the CHRONIC MYOCARDITIS. 683 lesions are much more common near the apex and the inferior part of the ventricular septum than elsewhere. Chronic myo- carditic changes are sometimes found, more especially affecting the right ventricle. The heart in chronic myocarditis is almost invariably Fig. 17(3. — Interstitial myocarditis from coronary sclerosis. enlarged in consequence of dilatation ; it may, or may not, be accompanied by hypertrophy. As a general rule, it is in- creased in weight as well as in bulk. While the total volume of the heart is usually increased in chronic myocarditis, the affected portion of the w^alls is almost invariably found to be thinner than it should be. This is seen in Fig. 176. The diseased region is paler in colour than 684 AFFECTIONS OF THE MYOCARDIUM. & the rest of the heart, having-, as a rule, a grayish or yellowish tint. Occasionally there are small points deeply stained with blood in consequence of small seats of throm1)osis. The part involved generally gives a sensation of hard- ness when touched; l)ut the variety particularly described by Ziegler under the name of myomalacia cordis yields to a sensation of soft- ness. According to Ziegler, it is simply an early stage of the sclerosis. In this form of myocarditis ^j'; (jilj the coronary ar- e almost found to be the seat of ..,,► ,///,, /"/ ■ r ••/,'M alterations. The %.''l/l\!r'!mMi^H''W^i^ which is most '■.'-' ('■ '''i '1,'' '■' '''\'M I ', :M frequently aftect- ::v;,Oj,'/ii'':;'MkvAi "■ ■■■- :. . : ■,-■/;>'/, '^^V I' I' I'/;/ ||H I, 'l^-'\'m^'*^^^^^ teries are :■■. ,; J,4''(fV '.'K/l' ^\\m be the ed. The change I' i '■ liv'ij may be at the li'j orifice, which may be obstruct- FiG. 177. — Section of wall of left ventricle in chronic myocarditis gj-j ^y atheroma from coronary occlusion, x 60. a, Sub-endocardial tissue ; &, "^ ' nuiscular fibres, largely altered ; c, new fibrous tissue. Or the lumCn 01 the vessel Ijeyond may be reduced Ijy endarteritis. The changes, whether at the mouth or in the course of the artery, are often attended by deposits of lime salts ; such are the arterial changes most commonly associated with the chronic sclerotic changes pre- senting hard and resistant masses. In the case of myomalacia, it is more common to find an embolus or a thrombus in one of the coronary vessels. Very frequently the aorta shows forms of degeneration, and it is not an uncommon experience to find the aortic cusps also diseased. "Widespread sclerosis through- CHRONIC MYOCARDITIS. 685 out the arterial system, along witli cirrlicjsis of the kidneys, and, in fact, an increase generally in the fibrous tissue through- out the body, may also Ije frequently determined. There are, moreover, in many cases, evidences of the secondary results of cardiac failure in hypertemia and ?> - . — The same section under a higher power, x 250. «■, Muscular fibres, many undergoing destructive changes ; h, engorged blood vessels ; c, newly formed fibrous tissue. Such changes are 686 AFFECTIONS OF THE MYOCARDIUM. times — iut'avetiou results. The appi'i nances presented by the affected area differ according to the time which has elapsed after the stoppage has taken place. If seen shortly afterwards, the only change in appearance is concerned with colour, the part retaining its normal consistence, but being pale. When a longer interval has occurred, the part affected is soft and pale, the tint varying from pale brown to yellowish white. Under the micro- scope the fibres are found to be disintegrated and altered. The stria? dis- appear, and they have a perfectly hyaline appearance. This is the myomalacia cordis of Ziegier. In the zone sur- rounding the affected area fim,i VP) 'msV^ •'•''• '*/^'t''''/^,' •'.-••' .'; proliferation is found, and a (^■■./ ■ ^ ^i:j'''' ■ -V^ ''';■ '.■:';' reaction process of fibrosis ,a%' V^-' ,,/ PI _' ki-fi,., is the result. Such changes { 0'.;© nV ,'' /;V 'H , are seen in Tig. 179. ■i^, ■' .. ,,.'. ''' / i ; ;l- Symptoms. — Inasmuch im '■ I i' ■'} as instances of chronic myo- __i c carditis constitute a some- ,•'/ ' ,: , what irregular and rather / / i'l] ! 1 indefinite group of affections, the clinical features which result are exceedingly A^ari- FiG. 179.— Section of left ventricle showing eflects able, and it might bc pOSSiblc, of infarct X 100. a Healthy inuscijlar fibres j indeed been doUC by with distinct nuclei ; o, young connective J tissue with numerous vessels growing around SOme autllOrS, tO Separate OUt the infarct ; c, necrosed muscular fibres which , ^^ ^' f f are hyaline, and have lost their nuclei. SCVCral CllStinCt typCS aC- cording to the main symp- toms. As the appearances presented by such different varieties pass gradually into one another, so as to form an almost continuous series, such a classification would not be so simple or satisfactory as might on the face of it at once appear. In some instances, features of increased excitability and activity of the circulation — the erethism and hyperkinesis of authors fond of using learned terminology — make their CHRONIC MYOCARDITIS. 687 appearance. Here the main complaints are of palpitation of the heart, of throbbing of the arteries throughout the body, of surging noises in the ears, and even of flashes of light before the eyes. There may, on the other hand, be complaints of fluttering in the region of the heart, along with attacks of breathlessness, attended by giddiness and faintness. Both of these somewhat characteristic groups of symptoms are frequently attended by anginous attacks. There is no necessary disturbance of the functions of the alimentary system, unless cardiac failure be present, in which case it may be accompanied by its common manifestations as regards enlargement of the solid viscera, with catarrh of the mucous membranes, and the pres- ence of some transudation into the peritoneum. The condition of the blood may, or may not, be normal. There is no necessary connection between it and the myocardial change. As above mentioned, painful sensations are often complained of, and these may present every feature of profound angina pectoris. Such cardiac pain may be accompanied by fluttering or palpi- tation of the heart, and there is not infrequently the alarming sensation of cardiac stoppage, along with the overwhelming sense of impending dissolution. The appearance of the patient presents nothing that is actually characteristic, unless during an anginous seizure. On close inspection a tortuosity of the temporal arteries may be determined, and there may be ex- cessive pulsation in the jugular fossa, or of one or both of the carotid arteries, as well as sometimes venous pulsation in the neck. Inspection, as a rule, fails to reveal any abnormal phenomena connected with the prsecordia. The radial arteries are commonly found to be somewhat degenerated, and are frequently hard and tortuous. The vessels are usually some- what fuller than in health, and the pressure may be elevated. Infrequency of the pulse is relatively common, but occasionally the opposite condition of acceleration may be in evidence. It is, however, to be remembered that when cardiac failure is present, as is apt to be the case towards the termination of this affection, the pulse may show exactly opposite conditions, that is to say, it may be somewhat empty and of low pressure, while the pulsation is marked by irregularity and inequality. The apex beat is generally displaced somewhat outwards 688 AFFECTIONS OF THE MYOCARDIUM. to the left, as well as duwinvaids, since either hypertrophy or dilatation, or both, may be present. The area of cardiac dulness is likewise usually increased. The cardiac sounds are almost always affected. Perhaps the most fre(pient manifesta- tion of disturbance is an accentuation of the second sound in the aortic area, along with doubling. In the mitral area the first sound is usually lo^ver in pitch than in health, and some- what mutiied ; but a systolic murmur is extremely common, in conse(|ueuce of relative incompetence of the mitral cusps as a result of cardiac dilatation. A systolic murmur in the tricuspid area may often also be determined. Dyspnoea, whether shown in the form of breathlessness on exertion, or as a recurrent asthma, is often developed, and it not infrequently happens that Cheyne-Stokes' respiration makes its appearance whenever the patient falls asleep. Cough frequently calls attention to some changes in the condition of tlie lungs, such as bronchial catarrh or pulmonary oedema, which may be determined by examination ; hydrothorax is also often present. The functions of the kidney are usually disturbed, the secretion being of diminished quantity and high specific o-ravity ; containing besides, in many cases, albumin. In addition to the painful subjective sensations, other nervous disturbances are found, more particularly sleeplessness, restlessness, loss of memory, and other expressions of cerebral trouble. The course of the affection differs much in individual instances. It may often pursue a somewhat lengthy course, and end in a gradual cardiac failure, attended by many of the symptoms above mentioned. It may, on the other hand, terminate in sudden death. Diagnosis. — In all these symptoms there is really nothing that is characteristic, and this indefiniteness of the clinical features constitutes tlie chief difficulty in the determination of the nature of the affection. It is, for instance, by no means an easy task to differentiate between chronic myocarditis and fatty degeneration. There can be no doubt that in the latter condition it is not so common to find evidence of arterio- sclerosis. Yet, it must be remembered, fatty degeneration often occurs along with the cardiac hypertrophy attendant CHRONIC MYOCARDITIS. 689 upon these two conditions. It will, notwithstanding, bo ad- mitted that when there is arterial degeneration with a fairly- vigorous cardiac systole, and an accentuation of the aortic second sound, associated with some cardiac pain, the prob- ability is strongly in favour of the condition being one of chronic myocarditis rather than of fatty degeneration. The chief difficulty comes in when, as the final result of chronic myocarditis, cardiac failure ensues. The differentiation of certain forms of valvular disease and fibroid myocarditis is also by no means easily effected. Taking, as an example, the physical signs of mitral incompetence, it may be a matter of the utmost difficulty to arrive at a conclusion whether this is produced by some lesion primarily of valvular origin, or is a relative incompetence produced by dilatation of the orifice or ventricle. The history of the case, however, comes to the aid of the observer in such an instance, and when there is no distinct history of a valid cause of valvular disease ; when there is, further, no evidence of there being any obstruction, and when some of the symptoms of fibroid myocarditis, as above described, have been developed, it may be possible to conclude that the lesion is due to a myocardial affection. Prognosis. — When a diagnosis of chronic myocarditis has been achieved, the prospects of the patient will next require consideration. Probably the history of the affection con- stitutes a more useful guide in attempting to formulate a prognosis than the mere condition which may be present. If the condition has evidently only been developed after the lapse of a considerable time, and if the cardiac impulse and first sound are satisfactory, the outlook may not be especially gloomy. The effect of muscular exertion should always be ascertained, and if the result of walking upstairs, or some other gentle exercise, be to cause any considerable perturbation of the cardiac action, it means that the myocardium is inadequate. Attacks of angina pectoris and syncopal seizures are of evil omen, and when such are present they necessarily render the outlook more gloomy. Treatment. — The treatment of chronic fibroid degenera- tion must be, to a considerable extent, conducted on the same lines as our experience shows to be useful in cardiac failure. 44 690 AFFECTIONS OF THE MYOCARDIUM. The careful regulation of all the habits with regard to rest and exercise, food and drink, must also be enjoined here. Every means by which the metabolic processes throughout the body can be stimulated must be employed. The use of abundant diluents will be found of great utility, and general massage may also be employed with the greatest benefit. When dealing with cases in which it appears to be satis- factorily determined that the myocardial change under dis- cussion is in progress, but has not gone too far, the employ- ment of baths, such as those of Nauheim, may be safely recommended, and along with them resistance exercises may be advised. Amongst drugs at such a period, beyond the use of gentle salines, there is but one which promises any good effects — that is, iodide of potassium. When this is continued over a long period in small doses, it undeniably is of consider- able benefit. The various symptoms are lessened, and the heart in particular certainly gains energy. It is more especially useful when there are any anginous threats. It need hardly be said that in such cases manifesting the symptoms of cardiac failure, the use of the cardiac tonics, and, in short, all the methods applicable to failure of compensation, must be had recourse to. Case 53. Chronic Myocarditis from Coronary Obstruction. — D. S., a tinsmith, set. 36, complaining of cough and breathlessness, was admitted to Ward 22 of the Royal Infirmary under my care on 12th March 1893. The patient seemed to have no hereditary tendencies to disease, and, until a short time before admission, his surroundings were good in all respects. His previous health was excellent, and, in jaarticular, although he had complained of vague j^ains in the joints and muscles, he had never suffered from any definite rheumatic attack. For a few months before coming to the hospital he had been ailing, but, as his wife was confined to bed on account of a severe illness, he had struggled on until, a fortnight before his admission, he had been compelled to take to his bed. In addition to the cough and dyspncea, the patient comj)lained of weakness and sleeplessness. The appetite was very poor, and the 23atient had frequently vomited undigested food. The bowels were constipated. The liver was slightly enlarged, extending from the fourth ril) to an inch below the costal margin in the mammary line. There was no ascites. The patient was distinctly anremic, and so pasty looking as to suggest renal disease. There was no morbid appearance connected with the spleen or glands. Dyspncea CHRONIC MYOCARDITIS. 691 was constant, but witli paroxysmal exaggeration, especially at iiiglit. Some prtecordial pain and consideraljle palpitation were complained of. The neck and chest yielded no aljnonnal symptoms, except that the cardiac impulse was extremely weak. The radial arteries were somewhat hard, but the vessels were unfilled, and the pressure was moderate. The pulse was extremely frequent, varying from 130 to 150 ; it was perfectly regular, and the wave small. Cardiac dulness extended from 2-| in. to the right to A.\ in. to the left of the mid-sternal line. The heart sounds were extremely faint. A soft systolic murmur was heard over the prtecordia, but it was so feeble that it was difficult to follow its distribution with accu.racy. There could be no doubt that it was loudest at the lower end of the sternum, but there was a probability that there were two other points of maximum intensity, one towards the apex of the heart, the other over the manubrium. Absolute dulness was present at the bases of both lungs, along with almost total suppression of the breath and voice sounds, on account of double hydrothorax, and many crepitations were to be heard above the level of the fluid on either side. The urine was scanty, varying from 1 8 to 24 oz. per diem. It contained no albumin or tube-casts. Consider- able oedema of the subcutaneous tissues was present in the lower limbs. The patient complained much of sleeplessness and restlessness. The diagnosis arrived at was cardiac failure, with mitral and tricuspid incompetence, in consequence of arterial degeneration, probaljly attended by some changes in the aortic cusps from chronic atheromatous processes. The patient was treated by means of cardiac tonics : strophanthus was administered, as well as iron and strychnine, but his condition did not improve. Stimulants were also freely exhibited — alcohol, ether, and ammonia being given at short intervals. Although the patient slept better than before admission, the dyspncea became worse, and on Sunday, 19 th March, the breathlessness was so distressing that the resident physician. Dr. Donald Macaulay, found it necessary to remove some fluid from the right pleural sac by aspiration. Some temporary relief was obtained, but in a very short time pronounced oedema of both lungs followed, with a copious expectoration of frothy sanguineous fluid. The stimulation was increased, and gentle counter-irritation employed, but the patient's condition became rapidly worse, and he died suddenly on the following day. The following is a summary of the chief facts observed at the post- mortem examination, which was performed by Dr. Muir on the 21st March. The body was well nourished, and there was marked dropsy of the lower limbs. Heart. — The 1 pericardium was normal. The heart was considerably enlarged, and weighed 15 oz. The right side was distended mth dark clot ; the left ventricle, on the contrary, was rather collapsed, and its wall could be felt to be thin, especially along the anterior aspect, where it also had a peculiar stift' consistence. The aortic valve was verj^ slightly incompetent, not sufficiently so to be of any importance. Diameters of 692 AFFECTIONS OF THE MYOCARDIUM. orifices : aortic, '9 in. ; puhuonary, 1 in. ; mitral, 1-2 in. ; tricuspid, 1-8 in. The aortic cusps were .uoriiial appearaucc-s could be dett-cti'd ovi-r tlu- ]>i"i'curdia. The feeble apex beat was found to be in the tifth intercostal space, nearly live inches from mid -sternum. The riglit and left borders of the heart Avere respectively 2^ and 5^ inches from mid-sternum. The heart sounds -were obserA'ed to lie extremely feeljle, more particularly in the mitral and tricuspid regions, where the tii-st soimd could with some diffi- culty lie determined : the second sound was more distinct, particularly in the ijulmonic area. There was some cough, accompanied l)y frothy serous expectoration, and physical examination of the lungs showed slight im- pairment of the clearness on percussion at the bases liehind ; while there were numerous crepitations o^-er the "whole of the lungs. In order to meet the indications furnished by the cardiac failure, the patient was treated by means of 10 minims of tincture of digitalis and 20 grains of acetate of jDotasli every four hours for a week. By that time auscultation showed a distinct systolic murmur in the mitral area, propa- gated to the axilla, and another systolic murmur of a different character and tone in the tricuspid area. On the 16th Octolier the digitalis and acetate of potash Avere replaced by Easton's syrup, and by the 22nd all the murmurs had disappeared ; the heart was reduced so considerably in size as to be only 2 inches to the right and 4v^ to the left of mid- sternum, while all symptoms of cardiac failure had disappeared. In this case the cardiac dilatation may have been in part due to syphilitic changes in the myocardium, yet since complete recovery ensued as the result of treatment designed in no way to meet the possibility of specific changes, it is unlikely tliat this was really the case. More probably the dilatation and failure resulted from physical stress. It is of much interest to note that the heart developed murmurs while undergoing restitution, and entirely lost them when equilibrium was regained. CAEDIAC ANEUEYSM. Arising in consequence of such alterations of the myocardium as have been discussed, localised bulging of any cavity may occur, to which is applied the term aneurysm of the heart. So far as is known to me, the change was first observed l;)y Galeati, but attracted little attention until the work of Cor- visart, who was followed by Breschet, Thurnam, Eokitansky, and other writers. A very careful study of the condition was made by Pelvet, in which may be found copious references to the previous literature. Since the appearance of his work, further CARD I A C ANE UR YSM. 7 1 3 investigations have been made by many observers, some of whom will be mentioned in the sequel. Aneurysm of the walls of the heart is commonly divided into the great groups : — the one, termed acute or some- times false, aneurysm, arising in consequence of acute endocarditis or acute myocarditis, under which lesions it has been already mentioned; the other, called chronic, or true cardiac aneurysm, produced in consequence of gradual changes in the walls of the heart. The few remarks which follow deal entirely with the latter affection. Cardiac aneurysm is a somewhat rare affection, and is, for the most part, a post-mortem surprise to the observer. Etiology. — The usual cause producing aneurysm of the wall of the heart is an alteration in the consistency of the myocardium. The most common change in the myocardium is chronic myocarditis. This change may be produced by any of the factors which have been previously considered, but that which is most common is some interference with the lumen of the branches of the coronary arteries, as was clearly brought into prominence by Huber in this connection. The most usual change in these vessels is arterial sclerosis followed by thrombosis. Endarteritis obliterans, however, must not be overlooked, and atheroma of the aorta at the mouths of the coronary vessels has also been observed. These vascular changes lead, as has been shown previously, to alterations in the myocardium, rendering it liable to yield when subjected to much stress. There can be no doubt that besides myomalacia produced by coronary obliteration, other changes of the mus- cular wall may be sufficient to produce aneurysm. Chronic changes of the kind may be set up by endocarditis, and it seems probable that, as suggested by Eendu, pericardial adhesions may have a similar effect. MoEBiD Anatomy. — Cardiac aneurysm is usually single, but two, or even three, have been described in the same heart. The usual seat of the lesion is the left ventricle, close to the apex, but cases are on record in which the change was situ- ated higher up. The aneurysm forms a definite swelling of hemispherical shape, as may be seen in Fig. 181, from a specimen kindly placed at my disposal by Dr. Harvey Little- 714 AFFECTIONS OF THE MYOCARDIUM. John ; sometimes, however, it projects to a greater degree and forms a globular mass. Its size is not usually great, but it Fig. ISl.— Cardiac aneurysm atlecting the left ventricle, which had undergone rupture. has been described as attaining almost the size of the heart itself. The cavity has a free communication with that of the ventricle, of which, indeed, it is simply in most instances a bulging. This is shown in Fig. 182, from a specimen for which I am also indebted to Dr. Harvey Littlejohn. In rarer CARD I A C ANE UR YSM. 7 1 5 cases there may be a more restricted orifice leading from the heart into the aneurysm. The wall of the aneurysm is always found to be considerably altered. It is not only thin, but its structure is greatly modified. The muscular fibres are found to have in great part disappeared, and connective tissue has taken their place. The pericardium has often been described as thickened, and adhesions have been seen. Sometimes in Fig. 182. — Cardiac aneurj'sm, viewed from inside of left ventricle. a, large proportion of cases, indeed, alterations in some of the branches of the coronary arteries have been found. Symptoms and Diagnosis. — The clinical features of cardiac aneurysm are so indefinite that its determination during life is seldom possible. The common symptoms which have been found are breathlessness, palpitation, and prsecordial uneasiness, with weak pulse, feeble impulse, en- largement of the cardiac dulness, and diminution of the intensity of the sounds. These, however, are but the features of cardiac failure, and present nothing significant of cardiac aneurysm. 7i6 AFFECTIONS OF THE MYOCARDIUM. A characteristic attitude has been claimed for this affec- tion by Bucquoy. This ol)server asserts that patients who suffer from cardiac aneurysm have a great tendency to lean forward when sitting until the chest almost touches the knees. Paul observed in one case a diastolic murmur without aortic incompetence, which he considered due to reliux from the aneurysm into the ventricle at the time of diastole. Eendu called attention to a doubling of the second sound, caused, according to him, by a state of tension of the sac. It cannot be held that any of these observations have lieen of real service to us in the detection of cardiac aneurysm. The instances on record have presented the clinical appear- ances of cardiac failure, and after a longer or shorter course the lesion terminates life, in most cases by asystole, but in some a rupture of the heart is the cause of death. Prognosis and Treatment. — Inasmuch as the determin- ation of a probable cardiac aneurysm can only be the result of inference from uncertain premisses, it is unnecessary to dwell upon the outlook in the disease, while the treatment in most cases will probably be that of cardiac failure. SPONTANEOUS KUPTUEE. Laceration of the heart occurs as a result of traumatism, but lesions of this kind will be considered in a subsequent section devoted to wounds ; in the present connection rupture of the heart taking place spontaneously has alone to be considered. So far as can be ascertained, the first notice of such an accident is due to Harvey. Morgagni observed several cases of this kind, and one in particular, that of a woman aged 75, in whom the rupture was associated with pronounced fatty changes in the heart. Many observers since those early days have mentioned or discussed the subject, and some of the observations will be referred to in the brief summary of spontaneous rupture which follows. Etiology. — It may be asserted, without fear of contra- diction, that spontaneous rupture never occurs in a healthy heart, and some preceding lesion of the walls has always been in existence. In all cases a degenerative process, such as SPONTANEOUS RUPTURE. TM will be mentioned below, has been detected, and the degener- ative changes have most commonly been the result of inter- ference with the lumen of a branch of one of the coronary arteries, which has led by ischtemia to myomalacia cordis. In some very rare cases, embolism has led to changes of a similar character, but more rapid development. It might naturally be expected that, associated with such predisjDosing causes of rupture, severe muscular effort might be the deter- mining or exciting influence, and this without doubt has sometimes been the case. It must, however, be remembered that a considerable proportion of cases have been described as occurring during the night. Morbid Anatomy. — By far the most common seat of rupture is in some part of the left ventricle, and more par- ticularly in that half which terminates at the apex. Odrio- zola found that in 71 cases the rupture occurred 10 times near the base, 28 times in the middle portion, and 33 times near the apex of the left ventricle. The most common portion of the ventricle to give way is the anterior surface. A rupture of the posterior aspect is rare, while the left border and the apex are almost exempt. Although the left ventricle is much more commonly affected than any other part of the heart, spontaneous rupture of the wall of any cavity may occur. According to Odriozola, dealing with 132 recorded instances, the left ventricle was affected 96 times, the right 22 times, the right auricle 10 times, the left auricle twice, and the auriculo-ventricular sulcus also twice. The rupture in the recorded cases has almost always been single, but according to Letulle, 18 out of 110 recorded cases presented more than one opening. The dimensions of the opening vary greatly, but the most ordinary size is between half an inch and an inch in length. The form of the opening is extremely diverse. When small it is usually a slit, but is less frequently rounded. When larger it is occasionally in form like a curved line, but quite commonly it presents the appearance of a cross, of the letter Y, or even of a more complicated outline. The aspect of the opening on the inner side of the wall is often described as difficult to find, hidden as it is by the fleshy columns of the 7i8 AFFECTIONS OF THE MYOCARDIUM. ventricle, or by clots. The external aspect, although com- monly hidden by clot, is easily seen after the coagulated blood has l.ieen washed away. It is in most instances larger than the inner opening. The direction of the rupture is Fio. 183. — Spontaneous riiiiture of heart, aflecting the right ventricle. sometimes straight, ]jut it is also not infrequently oblique, and in some instances it is so sinuous that the two ends of the opening have been far from each other. The pericardium always contains a large amount of Ijlood, usually in the form of clot. Fig. 183 gives the aspect of the external opening in SPONTANE US R UPTURE. 7 1 9 a specimen for which I am indebted to iJr. Harvey Littlejohii. The form of opening is linear. The appearance of the myocardium on inspection with the naked eye is of interest. It is commonly paler than in health, but the pale tint is often described as broken up by numerous red patches due to haemorrhages. Sometimes those patches are of the nature of hemorrhagic infarct, resulting from thrombosis or embolism of a coronary branch. On micro- scopic examination, according to Letulle, the wall of the heart in the neighbourhood of the rupture shows habitual absence of fatty changes, while various atrophic lesions of the muscular elements, of a granular or pigmentary nature, are common. A diminution of the striation is often seen along with seg- mentation of the fibres, or fragmentation of the cells. An increase in the amount of fibrous tissue is also frequently determined, and it must be added that rupture is occasionally found as the termination of cardiac aneurysm. This is shown in Fig. 181, p. 714. In the larger proportion of cases the coronary arteries are diseased, endarteritis deformans and ob- literans being the most common lesions, associated with thrombosis. It need hardly be added that in very many in- stances valvular lesions and other endocardial changes are found in connection with cardiac rupture, and, in some cases, pericardial affections also. Symptoms. — It is only occasionally that the clinical features attendant upon cardiac rupture are so definite as to afford sufficient data upon which a diagnosis might be founded ; for the most part, the symptoms are simply those of asystole. Sometimes the accident is accompanied by severe prsecordial pain — pain which may be as agonising as that of angina pectoris, and which may, like it, radiate towards the shoulder and arm of one, or other, or both sides. The pain is accompanied, or speedily followed, by paleness and coldness of the surface, and extreme weakness and irregularity of the pulse. Giddiness has often been described, and vomiting has also been frequently noticed. There is usually a speedy loss of consciousness, and the breathing rapidly terminates. The accident may be even more start- lingly rapid than this, and in such cases the patient has been 720 AFFECTIONS OF THE MYOCARDIUM. described as falling down in pallid unconsciousness, to die after a few irregular respirations. Such was the case in 71 out of 100 cases of rupture analysed by Quain. On the other hand, life may be maintained for a few hours, or even a few days. Five of the 100 cases discussed by Quain lived for two davs. Peter cites a case in which life was maintained for twelve days ; Beadles one in which death took place after the lapse of 1 6 8 days ; and Eostan has recorded a remarkable instance of cardiac rupture in which the aperture was closed by pericardial adhesion and fibrinous clots, resulting in the prolongation of life for fifteen years, at the end of which period death occurred by means of another rupture. When the patient has not perished instantly there is usually a consider- able amount of precordial distress, along with the general features of cardiac failure. When life is sufficiently prolonged to permit of a careful examination of the chest, the cardiac pulsations are extremely feeble, the area of dulness increased, and the sounds almost imperceptible. Diagnosis. — The determination of a cardiac rupture must always be difficult, and the diagnosis almost impossible. Inference alone is possible in the cases attended by instant- aneous death, while in those living long enough to permit of careful examination, the clinical features are too indefinite to be of diagnostic importance. Many instances closely simulate the asystole of cardiac debility or degeneration, and the re- mainder may be well mistaken for severe angina pectoris. The only point of difference between the two lies in the condition of the pulse, which in rupture is extremely feeble and usually irregular, while in angina pectoris it is very com- monly resistant and regular. PROGNOSIS AND Tkeatment. — These aspects of the sub- ject require no comment. CAEDIAC HYPEETEOPHY. Hearts of large size appear to have been first noticed by Massa, and increased thickness of the walls was undoubtedly observed by Albertini. The first clear conception of increase in the size of the heart as the result of some obstacle is, CARDIAC HYPERTROPHY. 721 however, due to Mayow, who described it as occurring in mitral disease, and by Vieussens, who recorded an instance of enlargement from aortic disease. An increase in the thick- ness of the walls, without dilatation of the cavities, was studied by Morgagni, and from his time cardiac hypertrophy has been systematically investigated by almost every writer on cardiac disease. Bertin showed by microscopic examination that in hypertrophy there is an increase in the amount of muscular tissue, and he distinguished the three classes — into which hypertrophy of the heart was so long divided — concentric, simple, and excentric. As was mentioned in considering the method of percussion from a general standpoint, Auenbrugger employed his discovery as a means of detecting cardiac enlarge- ment. The diagnosis of cardiac hypertrophy can scarcely, however, be regarded as having been > practicable until the appearance of Laennec's work, in which he, for the first time, correctly described the modifications of the heart sounds in this condition. Etiology. — Since hypertrophy is a natural process, in- tended to compensate for the effects of morbid influences, it cannot really be held, as Gowers remarks, to have any morbid predisposing causes. For the occurrence of hypertrophy there must be, in truth, rather a combination of favourable con- ditions, allowing the possibility of such a compensatory pro- cess. It is, therefore, more correct to inquire into the conditions which further the healthy processes leading to hypertrophy, than to enter upon a fruitless quest for predis- posing causes. The state of the general nutrition is necessarily of supreme importance. Its limits must always be to a considerable extent dependent upon individual peculiarity, impressed on every one, not merely from birth, but from the earKest development of the germ plasm. The possibilities afforded by the general nutrition are always greater in early youth than at later periods of life, during which they gradu- ally wane. They are reduced by all conditions, whether general or local, that impair the nutritive energy of the system at large, and they may be increased by careful atten- tion to the various means of elevating the standard of general 46 722 AFFECTIONS OF THE MYOCARDIUM. health. The quality of the blood is one of the most important general factors, and when the metabolic processes are ade- quately performed, so that a sutticient amount of the various substances required by the cardiac tissues is supplied, hyper- trophy is possible. Among the local conditions allowing the occurrence of hypertrophy, is, first and foremost, the integrity of the cardiac blood vessels. This consideration has been so fully discussed in previous chapters as to require little more notice here. The condition of the l;)lood pressure within the coronary arteries and their ramifications is really the predominating factor permitting or preventing cardiac hypertrophy. This was observed long ago by Corvisart, and has in our own time been often emphasised. If the coronary arteries are narrowed or obstructed, hypertrophy is not seen as it is when these vessels are healthy. The relation between the work and the repose of the heart is also of great moment. Muscle cells, as well as brain cells, require their period of rest, and the only repose the heart is allowed is the period of inaction following upon the diastole. Increased frequency in the action of the heart means diminished rest ; lessened frequency, the converse. If, in any case, there is an acceleration of the contractions, the amount of rest allowed to the heart is correspondingly curtailed. The real exciting cause of cardiac hypertrophy is increased muscular activity, and the thickness of the myocardium may be said, with approximate accuracy, to be directly proportional to the amount of work which it must do. Even from embry- onic life important lessons may be learned on this subject. It has already been shown, from the researches of Gillespie and myself, that during fcetal life, when the blood pressure on the two sides of the heart is practically equal, the thickness of the walls of the two ventricles is similar. This fact in itself furnishes absolute proof of the proposition that the thick- ness of the walls of the ventricles is exactly proportional to the work which they have to perform. The causes operative in producing the increased activity may be such as affect the whole body at large, or such as influence the circulation alone, or, indeed, only one individual CARDIAC HYPERTROPHY. 723 part of the heart. In the latter case, however, sooner or later, there is an implication of almost the entire circulatory ap- paratus. The particular mechanism by means of which increase of work produces muscular hypertrophy is at present unknown. It is generally recognised that blood circulates more rapidly and more thoroughly through a muscle in a state of contrac- tion than through one in a state of rest, and it is therefore possible that the increased nourishment leads to the over- growth. This, however, is by no means the whole truth of the matter, and there seems to be in some way a direct influence of the increased contraction on the growth of the fibre. Eejecting the view that a simple increase of work can give rise to hypertrophy, and starting with the theory of Fick in regard to muscular tone, Horvath believes that the conditions which permit of the production of hypertrophy are present in the occurrence of muscular contraction — or a stimulus to contraction — during a state of greater extension than the normal. He therefore holds that without these two concurrent factors — greater stretching and the occurrence of contraction during its presence — there is no place for the theory of Fick. Extending this idea, he shows that a muscle can be greatly stretched, even to the point of destruction, without the condi- tions of Fick being present, since contraction has not occurred, and no stimulus thereto has been present ; while, on the other hand, these conditions may also be absent if there be no stretching of the muscle beyond the normal when contraction takes place. In the increased stretching of the cardiac walls at the instant of systole, it need hardly be added he finds a combination such as is postulated. Increased resistance is the most powerful agent in the production of cardiac hypertrophy. Such increase in the obstacles to be overcome may have origin in the heart itself, either externally or internally, in the arterial system, in the condition of the blood, or in the organs to which the blood is supplied. Obstruction to the action of the heart may be altogether external to it, as in pericardial adhesions. This was observed 724 AFFECTIONS OF THE MYOCARDIUM. by Morgagni and urged by Hope. It is a matter of common observation that in adherent pericardium a degree of hyper- trophy of both ventricles is present, but Wilks has found that the right ventricle undergoes greater change than the left. In a previous part of the present chapter it has been shown that dilatation is a result of external adhesions, and probably the condition of over-distension is the cause of the hyper- trophy. My own oljservations do not enable me to pronounce any definite opinion in regard to this subject, since every case of adherent pericardium which has fallen under my notice has been accompanied by some valvular lesion. In derangement of the internal mechanism of the heart there exists a large field for the production of hypertrophy, directly or indirectly. The general principles involved in the development of hypertrophy have been discussed in the chapter dealing with general pathology. Some of the same details connected with the evolution of local hypertrophy have also been considered under the head of diseases of the orifices and valves. It is therefore unnecessary to advert to such facts except to emphasise one or two particulars. The in- fluence of a mechanical derangement may be entirely produced by an obstacle to the onward progress of the blood. In such cases the effect of the obstacle is felt by the chamber situated immediately behind. Thus, in aortic obstruction the left ventricle is directly implicated ; in mitral obstruction the left auricle undergoes immediate effects ; while in pulmonary and tricuspid obstruction the right ventricle and right auricle respectively show compensatory changes. In all such instances of retro-hypertrophy from simple obstruction, it is more likely to occur unassociated with dilatation. The probable explana- tion of the hypertrophy in all such cases is that the obstacle to the outflow of the blood gives rise to over-distension of the cavities, so that when contraction occurs it has not only to move a larger mass of blood, but it has to force it through an orifice smaller than the normal. Incompetence also directly produces hypertrophy. It has already been shown that in mitral regurgitation there is almost invariably some hypertrophy of the left ventricle. It is needless to spend time reiterating what has already been CARDIAC HYPERTROPHY. 725 said in regard to this siil)ject, seeing that it has already been fully explained by reference to the increased amount of blood which reaches the ventricle in consequence of the regurgitation into the auricle. In such an instance as this the hypertrophy is not attended by any considerable degree of dilatation. When regurgitation is combined with obstruction, the chamber behind the diseased orifice shows the effects in their highest expression. In combined obstructive and re- gurgitant lesions of the aortic orifice, there is at once a high degree of hypertrophy and dilatation. The fact must not be overlooked that mechanical derange- ment, whether caused by obstacle or incompetence, pro- duces hypertrophy indirectly : mitral lesions, for instance, almost invariably give rise to hypertrophy of the right ventricle by increasing the resistance within the pulmonary circuit. The converse, although far from being so common, does undoubtedly occur, and obstruction in the pulmonary system may lead to hypertrophy of the left ventricle. In order to analyse in a scientific fashion the effects of valvular disease on the orifices, cavities, and walls of the heart, Hamilton has summed up the effects of his cases of heart disease in the following table : — [Table. 726 AFFECTIONS OF THE MYOCARDIUM. 2I :s _: r<» "^.^ r-«I H- -tM "H '-«1 r+T -l* •= + + + -^ + + -; A -;m 13X Lii r.- c:j: -^m --> -^m H:i •= + + + L. V. R. V. CO ^ri -ci s:!-r r-n ^-t -:ri HM -l-^cococo-* CO CO CO •= -'z + + CO --■CO- •pitOAV •ZO UI 11lSl8A^ =5 ''W rt-f f.!-i< -:^' ^:-f< -^-t -■?! '-'^COIMtSO CI ^(Nt-i MOTOR AFFECTIONS. and passed down the whole of tlie arm and forearm from a little above the attachment of the deltoid to the tijjs of the fingers. The areas are shown in Figs. 187 and 188. The pain was of a sharp, lancinating character, and was accomiianied by faintness, l)reathlessness, and palpitation. All of these were worse on exertion and excitement, and during one of the attacks, about a year before admission, he had fainted entirely away. On testing the areas over Avliich pain was experienced, they were found to manifest considerable hj'p)era;sthesia, and in front of the chest especially, there was exqxiisite tenderness. The pulse was 72. There was no alteration in the arterial walls, Ijut the vessel was poorly filled ; the pulsation was regular and equal, but the pulse was short, sharp, sudden and col- lapsing. It could not be ascertained that there was any alteration in the pulse pressure on the occm-rence of the pain. There was violent pulsation of the carotid arteries in the neck, and the apex beat, situated in the sixth inter- costal space 4^ in. from mid-sternum, was forcible, Ijut short in duration. On percussion the heart ex- tended 2 in. to right, and 5 in. to left of mid -sternum. On auscultation two mur- murs were heard at the base, Avith their greatest intensities near the aortic cartilage, and a somewhat wide area of propagation, which can be seen in the illustration. Fig. 187. In the mitral area there was simple impurity of the first sound. There was accentuation of the pul- monary second sound, and the tricuspid first sound was somewhat muffled. There were no features worthy of note in connection with any of the other systems. There could be no doubt that in this case there was a o-enuine angina pectoris connected with disease of the aortic orifice. It is of interest to notice that this was probably of rheumatic, not degenerative origin, but the fact of his having suffered from acute rheumatism some years before, does not necessarily negative the possibility of some degeneration of the aortic and coronary walls, of which, nevertheless, there was no proof in the condition of the radial artery. The 2)atient was treated with moderate doses of iodide of potassium, along with some digitalis. He was for some days confined absolutely to Fig. 18S.— Area of paiii and tenderness from behind. ANGINA PECTORIS. 789 bed, but afterwards was allowed to get up, and move aljout the ward. In less than a month all the sul;>jective sensations had disappeared, and even walking sharjjly outside of the hospital produced no feeling of pain. At his own special request, he was therefore allowed to return home. He reported himself to me from time to time at the Infirmary, and, con- tinuing to take the iodide, all went well. In a few weeks, how- ever, he sought readmission on account of a return of the pain froiu which he had previously suffered, and once more entered the ward. It was found that there was almost no pain in the prfecordia or in the arm, l3ut that he suffered from excessive pain and exquisite tenderness over the left half of the nape of the neck corresponding to the distriliution of the third cervical nerve according to Head. The iodide treatment was persevered with, biit did not seem to have much power of alleviating the symptom. Nitro-glycerin and nitrite of amyl were also employed without any noticeable benefit, but the symptom yielded rapidly to phena- zone. It remained a knotty point, the solution of which could not be determined, whether this pain was of cardiac origin, or whether it was not a form of neuralgia. As soon as the pain had quite disappeared, he begged to be allowed to go home, and, on receiving permission to do so, he left the hospital. Having heard nothing of him for some weeks, it occurred to me one day, when in the vicinity of his abode, to inquire how he had got on, when the information was vouchsafed to me that, on the evening of the day on which he left the Infirmary, he had gone to bed feeling particularly well, but, within half an hour of lying down, had suddenly leaped from bed with the cry that he was dying, and expired instantly. Case 59. Aortic Disease luith Angina Pectoris. — G. M., aged 54, engaged in hawking, formerly employed as a ship-carpenter, came under my care in the Royal Infirmary, 10th September 1894, on account of pain in the chest. His father was drowned at sea when 60 years old. His mother died aged 50, and the patient stated that the cause of death was " the change of life." He had eight brothers and sisters, who were all well. He was the father of eight children, who were all, as was also his wife, in good health. His social conditions had been on the whole satis- factory, but when employed in shipbuilding he had undergone severe toil for twenty-five years. He had never been guilty of alcoholic excess, and had never had any venereal aff'ection. The patient stated that he had suftered from smallpox, malaria, and scurvy. For three years he was engaged on one of the Indian troopships, and underwent great changes of temperature, varying between that of the refrigerator and that of the tropical sun. He had suftered from lumbago, and from pain in one of the great toe-joints. Nineteen months before admission he was attacked by severe pain in the chest, which darted up to the right shoulder and down the right arm. Treatment brought about considerable relief for a time, but the pain again returned, and attacked the left shoulder and arm, as well as those of the right side. The patient, on examination, was found to be a man of 5 ft. 2 in. in height, and 7 st. 9 lb. in weight. Although slenderly built, he was 790 COMPLEX SENSORY e^' MOTOR AFFECTIONS. Fig. 1S9. — Cardiac and liver dulness and dis- tribution of pain in Case 59, seen from before. well developed as regards the muscles. The face was deeply marked by smallpox. The teeth and giims were bad, many of the former being absent, and round the few relics of them wliich remained there was great sponginess of the gums. The tongue was flabby. The patient complained of flatulence and l^yiosis, and stated that sometimes after taking food the pain im- mediately liegau. The hollow viscera were of normal size, and the liver extended from the fourth cartilage to the costal margin, occupying 5^ inches. The blood- forming apparatus showed no morbid phenomena. Any exer- tion, whether physical or mental, induced a paroxysm of pain, with a somewhat singular distri- bution. In the upper part of the prsecordia the pain seemed to form a circle surrounding an area in which no uneasiness was experienced, and from this circle it passed botli doMniwards and upwards — downwards to form the maigins, as it were, of a harp -shaped figure, and upwards as far as both shoulders, whence it passed down the inner side of the arms BO as to reach the finger-tips. It also occupied each scapular angle. The areas are shown in Figs. 189 and 190. The pain was ac- companied by severe palpitation and great dyspnoea, as well as giddiness. Such were his com- plaints of the worst kind of seizure. At other times the attacks were much less severe, the pain failing to reach further than the shoulders, and having no palpitation, dyspnoea, or giddiness. He was frequently seen in one of those paroxysms, and at such times the pulse was found to have a rise of pressure, the expression became anxious, the perspiration stood upon the forehead, Fig. 190. — Areas of pain in Case 59, seen from behind. fece turned jaale, and beads of Examination of the circulatory ANGINA PECTORIS. 791 organs showed tliat the radial artery was rigid and tortuous ; the vessel was full and its pressure somewhat high. The pulsation was regular, and usually about 70. The pulsations were somewhat quick, but not collapsing. There was a diffuse impulse in the fifth and sixth left intercostal spaces, and the apex beat was determined to be in tlie latter, 3^ in. from mid-sternum. The right and left l^orders of the heart were 2^ and 4 in. from mid- sternum ; the upper border was at the superior mai-gin of the third left costal cartilage. On auscultation in the aortic area there were systolic and diastolic murmurs. In the mitral and tricuspid areas systolic murmurs were audible, and the pulmonary second sound was considerably accentuated. The respiratory system only showed some scattered crepitations over the base of the left lung, and there were no morljid appearances connected with any other system of the body. The patient was obviously suffering from cardiac failure consecutive to arterial degeneration and aortic lesions. He was treated by means of nitro-glycerin in combination with digitalis, and amyl nitrite for the paroxysms. By the use of these remedies he considerably improved, and was dismissed at his own request. This must be regarded as another instance of angina pectoris from aortic changes, probably affecting the coronary arteries, followed by myocardial effects. Case 60. Angina Pectoris probably from Coronary Changes. — J. W., engineer, aged 46, had consulted me on account of pain in the chest from time to time at the Royal Infirmary, and was kindly brought to see me there by Dr. Jamieson, 5tli June 1898. His father had died at the ase of 72, and his mother at 71 from causes un- known to the patient. one died accidentally when an inmate of an asylum. Three sisters were in ex- cellent health, and one was a patient in an asylum. The patient had enjoyed good health all his life, with the excep- tion of a few un- important illnesses, but he had passed through the stress of much hard work, and exposure to different climates. For some years he had suffered from pain in the chest Ijrothers Avere alive, Pig. 191. — Distribution of pain in a case of angina pectoris prob- ably due to coronary sclerosis (Case 60). The areas marked by crosses indicate the painful and tender regions. and left arm. This, on careful investigation, was 792 COMPLEX SENSORY d- MOTOR AFFECTIONS. found to be confined to an oval-shaped area in the infra-clavicular aad mammary areas of the left side, and to extend from above the elliow on the inner side of the left arm, down to the tips of the ring and little fingers. The distribution is sho^\^^ in Fig. 191. It corresponded, in short, to" the distribution of the anterior thoracic and ulnar nerves. While the pain was present, hyjierivsthesia of the painful areas was xisually experienced, but, on the date mentioned, when the jjain was almost entii'ely absent, it was found tliat the.se areas were less sensitive than the cori'esponding spots on the I'ight side. The arterial walls were somewhat thickened and slightly rigid. The radial arteiy was moderately full, and of ftiir pressure. The pulse I'ate was 88, its rhythm slightly irregular, and the pulsations rather unequal. No abnormal ajipearances were visible in connection with the neck or chest, and the apex beat could not be seen on account of the well-clothed condition of the patient's chest. It was felt, however, in the fifth inter- costal space, somewhat diffuse in character, and Avith its chief intensity 4 in. from mid-sternum. The right border of the heart was 2 in., and the left 4| in., from mid-stemum. The upper border of the heart was at the superior margin of the third costal cartilage. In the aortic area, the second sound was accentuated, and at the apex the first sound was slightly blurred. No other almormal characters could lie made out. This case presented every feature of angina pectoris in one of its milder forms, and the affection proljably depended upon a slight degree of alteration in the coronary arteries. The use of iodide of potassium and the careful regulation of every habit brought al^out so much improvement that uneasiness was seldom experienced. Case 61. Angina Pectoris from Arteriosclerosis and Cardiac Enlarge- ment. — G. B., aged 60, joiner, entered Ward 22, 5th April 1894, on account of pain in the chest. His father had died at the age of 70 of some disease about which he could give no information ; his mother, when he was very young, from causes also unknown to him. His only brother died of apoplexy ; his only sister had always been perfectly well His social condition had always been perfectly satisfactory, and he had led a temperate life. His previous health had Ijeen so excellent that he had, as he expressed it, " never Ijeen ill a single day." Three months before admission, when walking home one afternoon after finishing his day's work, he was seized by a violent pain in the chest, and every day subsequently imtil the date of his admission he had a recurrence of the pain. The patient was a remarkably healthy-looking man, with a clear complexion, ruddy lips, and bright eyes, but his expression was somewhat anxious, and at times even ajiprehensive. The alimentary and the htemopoietic systems showed no obvious de- partures from health. The patient described the pain as beginning at the xiphoid cartilage, with a sensation as if his inside were being tightly ANGINA PECTORIS. 793 squeezed. From tliis point the pain spread upward.s until close to tlie junction of the manubrium and Ijody of the sternum, -vvliere it split into two parts, each of which darted outwards to near the shoulder, and jiro- ceeded down as far as the elljow. The distrilnition of the pain is sliown in the illustration. Fig. 192. The pain was always accompanied by breathlessness, so that he had to pant for breath, and yet was almost afraid to do so. It was also attended by Ijursts of perspiration. Tlie radial arteries were somewhat hard, and slightly tortuous. The vessels were full and the pressure was high. The pulse rate was 102 ; it was jjerfectly regular and equal. The pulse waves were somewhat tardy and sustained. There was perfect regularity and equality. The ajiex Ijeat was somewhat diffuse, but it presented a point of maximum intensity in Fig. 192. — Distribution of i)ain in Case 61. the fifth intercostal space, 4 in. from mid-sternum. It was slightly heaving in character, and was unaccoinj)anied by any thrill, or any other abnormal appearance. On jjercussion the cardiac dulness reached 2^ in. and 4^ in. to right and left of mid-sternum. The aortic second sound was considerably accentuated. The mitral and tricuspid first sounds were low in tone and somewhat muffled in quality. The pulmonary second sound was of approximal normal .intensity. No other al^normal pheno- mena were present. The jDatient was treated by means of iodide of potas- sium in infusion of digitalis, and absolute rest. In the course of a few days he lost every trace of uneasiness, and he was able to return home much relieved. This case gives a good example of angina pectoris due to chronic degenerative changes in the heart and arteries, probably with coronary obstruction. Case 62. Angina Pectoris. — D. C, aged 70, a civilian retired from India, was seen by me along with Dr. Arthur AVilson on 19th January 1898 on account of severe pain in the chest. The patient's family history 794 COMPLEX SENSORY d- MOTOR AFFECTIONS. was absolutely negative in I'egard to cardiac tendencies. His previous health had been most satisfactory in all respects, excepting for a few attacks of subacute fever in India. For about six months he had been complaining of a feeling of oppression in the chest, along with some uneasiness, amoitnting to actual pain, darting from the elbows to the tijjs of the fingers, no finger being more affected than the rest. He disregarded these feelings, howevei', and went about as usual. They gradually wore off, so that Ijy the 15th January he was feeling as well as he had ever felt in his life. He had a good deal of exercise that day, and on retiring at night intended to have a hot l:iath, but, by some misadventure, the water was scarcely warm, and the bath which he took was almost cold. On the following day, which was Sunday, he got up early, and started after breakfast to walk to church, in connec- tion with which he su^^erintended the Sunday School. The church was situated at a consideraljle distance from his house, and great part of the road was uphill. During his ascent he was overtaken by a feeling of faintness, and feared he would never be able to reach church. This, how- ever, he did, and performed Ms usual duties. Feeling tired, however, he remained quietly at home the rest of the day, and retired early to rest. About four o'clock in the morning he waked up from a sound sleep to find himself the victim of excruciating agony in the chest, situated more par- ticularly at the lower portion of the sternum, whence it radiated upwards to both shoulders, and down the arms to the tips of the fingers. He at once sent for Dr. Wilson, who attended immediately, and administered nitrite of amyl Ijy inhalation, along with alcohol and strophanthus. He obtained consideraljle relief by means of these remedies. Dr. Wilson enjoined absolute rest and easily digested food, while lie persevered in the course of treatment which he had adopted. AVhen seen by me he was not suffering from any pain or uneasiness. His expression was placid, even cheerful, and the face betokened no circulatory disorder. The radial arteries were somewhat rigid and tortuous, as were also the temporals. The pulse j)ressure was not more than moderate, and the vessels were moderately full. The pulsation was perfectly regular, 70 per minute, but rather tardy. On inspection of the chest a slight flickering pulsation, auricular in rhythm, Avas observed at the lower end of each external jugular vein. The apex beat was invisible, but on applying the hand it was determined to be 4^ in. from mid-sternum in the fifth intercostal space. It presented no abnormality save a certain amount of weakness. No other impulse could be detected. On percussion the borders of the heart were 2 in. and 4^ in. to right and left of mid-sternum. On auscultation the cardiac sounds Avere feeble over both ventricles, but this was particularly so at the apex. The second sounds at the base were normal. There were no abnormal clinical features connected with any other system. This patient showed evident arterial changes with some cardiac dilatation. The treatment adopted by Dr. Wilson was continued, but was from time to time modified according to ANGINA PECTORIS. 795 circumstances. Much improvement followed, and the con- dition has remained satisfactory to the present date. Case 63. Angina Pectoris from Fatty Accumulation. — A. M., aged 75, a widowed lady, has consulted me during the last few years, chiefly on account of breathlessness on exertion. Her family history was remarkably good, her father having lived to the age of 84, and her mother to the age of 83. All her brothers and sisters, with the exception of one brother and one sister, who died from afi'ections unconnected with the circulation, were in the enjoyment of excellent health. The whole family had, how- ever, suffered considerably from irregular gout in many of its protean forms. The patient was the mother of three daughters, two of whom were in good health, while the third suffered from some spinal symptoms due to an accident in early youth. The patient's previous health, until after middle life was jjassed, had been satisfactory, with the exception of one or two acute diseases from which she had suffered. About the age of 55 or thereby, she observed that she was apt to be breathless on exertion, and required to be somewhat more careful in regard to her health than had hitherto been the case. During the two or three years previously she had been more troubled in this way than formerly, and another symptom made itself manifest — a feeling of oppression in the chest, and pain running down the left arm. The patient was of medium height, and decidedly plump. There was no arcus. senilis, and the hair was very slightly gray. The tongue was clean, and the digestive functions were carried out most satisfactorily in all respects. The temperature presented a somewhat interesting course. It was frequently taken morning and evening for a length of time, and the average reading in the morning was 98°, while the evening was only 97.4°. The liver was somewhat enlarged, extending from the fourth cartilage to 2 in. below the costal margin, or 7 in. in extent. The sj)leen was normal in size. The patient was always some- what breathless on exertion, and any slight exercise, as well as any mental excitement, was apt to produce uneasiness in the chest. This usually assumed the form of a feeling of tightness and weight in the prsecordia, passing backwards to the shoulder-blades, and outwards to the left shoulder, but not infrequently of a painful sensation darting down to the left elbow, and sometimes reaching the little and ring fingers of the left hand. These sensations were usually attended by feelings of fluttering within the chest, attended by breathlessness. The radial artery was remarkably healthy, having but Little tendency to rigidity, and absolutely no tortuosity. The pulse pressure was moderate, the rate 68. It was absolutely regular, and each pulse wave was somewhat tardy and sustained. One j)eculiarity of the pulsation arrested my attention — the amplitude of the wave underwent periodic alterations, becoming smaller in extent for a time and again resuming its former size. On examination of the pr^ecordia no impulse could be detected, but on applying the hand, the apex beat was felt diftusely in the fifth intercostal space between 3 and 4 in. from mid-sternum. On percussion the margins of the heart were 796 COMPLEX SENSORY Q^ MOTOR AFFECTIONS. 2 in. and 4i in. respectively from iniil-stfrmiiii, and tin- luart reached tlie upper boi-der of the third rilj al)o^■e. On au.scullatiun in tlie aortic area the sounds were dear and distinct, the second, however, predominating. In the mitral area, the first sound wa.s low in tone, and somewhat short in duration, and here the second sound was also more distinct than the first. In the pulmonai'y area, the second sound was somewhat accentuated. In the tricusjjid area, the first sound was distinctly louder than in the mitral region, yet it was still much less distinct than the second sound. The examination of the lungs revealed no alteration, save comi)aratiAe dulness over the left base posterioi'ly, at which point some crepitations were heard. There was no alteration in the breath sound, or A'ocal resonance in any part of the chest. The renal secretion was somewhat scanty. The skin acted very freely. The only imi^lication of the nervous system was seen in disturbance of sleep, which was apt to be troubled during the night, while during the daytime a soporose tendency was often present. The opportunity was aftbrded me on one occasion of witnessing one of the attacks of which she complained. The patient was sitting up in bed ; the complexion was marked l^y Avhat can only be called a livid pallor ; drops of persi:)iration were hanging on the forehead, and anxietj' was ex- pressed in every lineament. The pulse was extremely irregular, and the heart A'ery tumultuous. No doubt hcas existed in my mind that this was an in- stance of angina pectoris caused by fatty accumulation in- vading the myocardium. By means of the occasional em- ployment of nitro-giycerin or erythrol tetranitrate, along with strophanthus, often alternated with strychnine and arsenic, or colchicum and bicarbonate of potash, the disagreeable symptoms could be kept at bay. Case 64. 6'%/ii Anginous Attacks from Tobacco. — A. M., aged 24, student of medicine, consulted me, 13th December 1897, on account of pain in the chest, attended by considerable palpitation. His family history showed some tendency towards circulatory disturbances, as his father was a sufferer from a weak heart ; his mother had died of some spinal affection. All his brothers and sisters were in excellent health. His social conditions had been excellent, and his previous health (j^uite satisfactory. The symptoms for which he sought advice had commenced two or three weeks previously, whilst he was training for an athletic competition. The patient was a tall, powerful, well-built man, with a remarkaljly healthy appearance. His height was 5 ft. 11 in., his weight 12 st. 2 1))., and his chest measurement 40 in. on inspiration. The tongue Avas slightly furred and rather tremulous, and the fauces somewhat congested, Ijut there were no other symptoms of alimentary disturlmnce. The pain which Avas complained of Avas situated in the loAver sternal region. It ANGINA PECTORIS. 797 was persistent, and was more a sensation of dull soreness tlian of sliarp pain. It showed no tendency to radiate in the direction of either shoulder or arm, but it was attended by a sense of tightness and con- striction across the whole chest. These sensations were invarialjly increased on exertion, and they were associated with considerate palpita- tion, which, although more frequent on exertion or excitement, had a tendency to appear sj)ontaneously at irregular times. The arteries were perfectly healthy but rather empty, and the blood pressure was low. The pulsation was slightly irregular and unequal, its rate being 82. On ex- amination of the prsecordia, there was a diffuse pulsation over a wide area, yet the apex beat was quite distinct in the fifth intercostal space, 3 1 in. from mid -sternum. The character of the pulsation was short and sharp. The area of cardiac dulness reached the upper border of the third left costal cartilage, and at the fourth it extended 2|- in. and 4 in. to right and left of mid-sternum. On auscultation the first sound was everywhere weak by comparison with the second. This was more particularly observable at the apex, where the first sound was rather high- pitched in tone, ringing in character, and short in duration. There was no systolic murmur in the tricuspid area even when the patient lay on his back, and the first sound was rather more distinct than at the apex. The second sound in the pulmonary area was considerably louder than in the aortic. There were absolutely no abnormal symptoms connected with any other system. On investigating the habits of the patient, it was found that he was addicted to smoking heavily, and there was no doubt in my own mind that the features were those of a commencing tobacco angina. He was recommended to desist entirely from training for some time, and to renounce tobacco, while small doses of strophanthus and nux vomica were prescribed. In less than a month all the symptoms had disapjDeared, and the patient was restored to his usual health. The case may be regarded, as a most typical example of the cardiac pain which is characteristic of the excessive em- ployment of tobacco, in one of its mildest forms. Case 65. Severe Anginous Attacks from Tobacco. — D. M., a medical man aged 28, consulted me several times during the year 1896 on account of pain in the chest, and breathlessness on exertion, accompanied by paljjita- tion. His family history was absolutely satisfactory, while his previous health and social conditions left nothing to be desired. The jDresent attack had begun a few weeks previously, with a sense of weight and constriction in the chest, which gradually assumed the proportions of jjain, for which he sought advice. His general appearance was healthy, save for a slight degree of blood- lessness. The alimentary system called for no remark. The pain, of which complaint was made, was situated in the lower sternal region, with a tendency to pass upwards and to the left, but it could not be said to reach higher than the second left intercostal space. It was by no means 798 COMPLEX SENSORY 6- AW TOR AFFECTIONS. pliavp, and was rather a feeling of a dull weight, accompanied by tight- ness ; but on exertion it became more severe, and was accompanied by violent palpitation and considerable breathlessness. One interesting point was that these symptoms not only followed exertion, but often arose alter meals, and sometimes had caused him to awake during the night by occurring spontaneously. He was seen by me on many occasions, and it was easy to determine that considerable alterations in the physical signs were present. The arteries were absolutely healthy and moderately filled, while the blood j^ressure was low. The pulsation of the radial arterj' was exceedingly variable ; while it would at one time be beat- ing regularly and evenly at a rate of 74, at another it would be irregular and uneven, with a rate of more than 100. There were no abnormal appearances on inspection of the neck and prajcordia. The apex beat occupied the fifth intercostal space, and was by no means diffuse. On palpation it was determined at a point 3^ in. from mid- sternum. It was very sharp and badly sustained, but unaccompanied by any thrill. The cardiac dulness extended to the upper edge of the third costal cartilage, and its borders were 2 in. and 3| in. to right and left of mid-sternum. On auscultation the heart sounds, like the pulsations of the arteries, underwent considerable variations. At one time they might be heard regulai-ly and evenly with no modification of the sounds, save that in the mitral area the first sound was high-i^itched, shar^), clear and ringing, while in the tricuspid region it was slightly muffled, and the second sound in the pulmonary was considerably louder than in the aortic area. At another time the sounds were extremely irregular, a succession of them occurring with great rapidity, so that they appeared almost to run into each other, the series being followed by a longish pause, and several pulsations separated by longer periods from each other. These alterations in the sounds coincided with the modifications in the pulse above mentioned. There were no symptoms connected with the other regions of the body, and there were no objective abnormal phenomena on examination, save some tremulousness of the muscles. The patient in this case had been in the habit of sitting ^x^ very late at night, and smoking a large amount of tolaacco while at Avork. In this instance, both strophanthus and digitalis were found to aggravate the symptoms, but the patient rapidly improved under the use of strychnine three times a day, along with some bromide of ammonium at night, followed after the lapse of two or three weeks by the administration of arsenic. The case was a more severe variety of tobacco angina than that which has just been described. Case 66. Hysterical Angina Pectoris. — A. C, aged 4 5, housewife, was admitted to Ward 27 of the Eoyal Infirmary, 22nd January 1898, on account of an attack of acute bronchitis. The patient's father was alive and in good health ; her mother had died of consumption at an early age. A sister had also fallen a victim to phthisis, and a brother died ANGINA PECTORIS. 799 at the age of eleven days with rather ill-defined symptoms. One brotlier and one sister survived, and were in excellent health. Her social condi- tion had always been good, and her general surroundings perfectly satis- factory. She had passed through most of the usual children's dis(!asfts, and a point of much interest lay in the fact that when five years old she had suffered from an attack of dropsy, for which she had been tapped. Of importance also were the facts that when sixteen she had passed through scarlet fever, and that when about twenty she had been confined to bed for three months with acute rheumatism. From that time she had never been entirely free from breathlessness and palpitation. She had a second attack of acute rheumatism four years afterwards, which laid her up for two months, and a third attack fifteen years later, by which she was con- fined about the same period. In the month of March 1897 she had been troubled with swelling of the lower extremities and of the body, attended by severe prascordial pain, and a high degree of breathlessness. During the ten years previous to her admission she had been subject to pain in the prajcorclia, which varied greatly in severity and frequency, no attack occurring for months at one jperiod, while at another time attacks were very frequent. It is unnecessary to recite the facts which led to the breakdown for which she sought admission. Suffice it to say that during a heavy washing she was exposed to cold, and bronchitis ensued. It was attended by great swelling of the legs and abdomen, and as it was difficult for her to obtain sufficient rest and attention at home. Dr. George Dickson recommended her to the ward. The patient was found to be a strongly-built, well-nourished woman. Her complexion was somewhat dusky, the eyes looked suffused, there was dilatation of the veins of the cheeks and nose, and the lips were cyanotic. The fingers were distinctly clubbed. There was considerable oedema of the legs, arms, and abdomen. The attitude on admission showed con- siderable disturbance of the circulation, and the patient was unable to assume the recumbent posture. The temperature for some days after admission ranged between 101° and 103°. The pulse at the same time was usually about 100. There was almost no appetite, but considerable thirst. Constipation had been the general rule during the past, but there were no other abnormal symptoms connected with the digestion. The abdomen was very prominent, but this was on account of plumpness ; all the abdominal organs were apparently healthy. The liver extended from the fourth rib to the costal margin, and the lower border of the stomach was mid- way between the umbilicus and the xiphisternum. The whole glandular system was normal, and the spleen reached the mid-axillary line. The patient complained of frequent attacks of stabbing pain in the region of the apex beat. This pain had always been worse after exertion or excitement, but had frequently awaked the patient during the night. The pain reached the left shoulder and shot down the left arm, producing a tingling sensation in the fingers. Each attack only lasted,, as a rule, for a few minutes, and was not accompanied by any sensa- tion of faintness, but a considerable degree of palpitation attended 8oo COMPLEX SENSORY &- MOTOR AFFECTIONS. the pain, aud a profuse perspiration was almost ahvays present during an attack. Breathlessness was more or less constantly present, and was invariably worse on exertion. There was hyper;esthesia over the region of the apex beat and in the infra-clavicular region, as well as down the arm, but of greater interest was the fact that firm pressure over the region of the apex beat produced a sensation of faintness. If greater pressure were employed, a sharj) jiain shot through the chest. The patient's eyeballs were turned tipwards, and the upper lids drooped so as to nearly cover the globes, while an expression of almost fatuous content spread over her face. The patient expressed her belief that she could not open the eyes, and certainly remained in a somnolent condition for a considerable time, during which it was ditiicult to elicit any response to stimuli. There was dilatation of the superficial veins over the left side of the chest. No pulsation of any kind could Ije seen in the pra;cordia, but on palpation the apex beat was found in the fifth left intercostal sj)ace, 4^ in. from mid-sternum. The impulse A\-as sharp aud ibrciljle, but not sustained, and it was markedly irregular in force and I'hythm. It was accompanied by a well-marked presystolic thrill. The pulse rate was 76 to 80 after the bronchial attack passed off. The walls of the artery were slightly thickened, and the vessel was fairly full, while the pressure was moderate. The pulsation underwent remarkable cyclical changes, the vascular contents, the blood pressure, and the size of the blood wave undergoing a periodic increase and decrease. The upper border of the heart reached the upper edge of the third rib ; the right border was 1 1 in. and the left border 5 in. from mid-sternum. There was a rough systolic murmur in the aortic area, which almost entirely replaced the first sound, and was conducted upwards into the carotid arteries. The second sound was markedly accentuated. In the mitral area a high-pitched and rough presystolic was followed by a softer and lower pitched systolic murmur, along with the latter of which could be heard the first sound. In the pulmonary area a blowing systolic murmur could be heard, which was found to be propagated uj) from below. The second sound was weak. In the tricuspid area there was an ajjparent reduplication of the first sound, immediately followed by a systolic murmur. It would be tedious to recount the various symptoms and physical signs connected with the lungs. It is only necessary to state that on admission there was a pretty sharp attack of subacute bronchitis. There were no symptoms connected with the integumentary system. The renal secretion was copious, varying from 42 to 72 oz. Its specific gravity was 1015, and its reaction acid. It contained no abnormal constituents. There was no symptom which might be considered as heralding the meno- pause. The nervous system appeared to be quite stable. The only change as regards the sensory functions consisted in a frequent headache over the front and top of the head, while the sight had been becoming somewhat dull during the four years previous to admission. There were neither antesthetic nor hypereesthetic regions, with the exception of that which has Ijeen mentioned at the apex of the heart. The motor and reflex functions were in no way modified, and the vasomotor and troj)hic were MOTOR AFFECTIONS. 80 1 likewise healthy. There was absolutely no evidence of any embarrassment of the cerel^ral functions. On admission the patient was treated for the bronchitis by means of a tent into which steam medicated with benzoin was led. She also had stimulant expectorants, with some digitalis on account of the cyanotic tendency. By means of this treatment the bronchial attack entirely dis- appeared within ten days, while the dyspnoea and cyanosis had almost vanished. With the disappearance of the respiratory troubles, however, the subjective sensations in the prfecordia became somewhat more violent. By means, nevertheless, of saline aperients, along with nitro -glycerine, considerable improvement was produced. In this case there was, along with some degeneration of the arteries, an enlargement of the heart. The extent and form of the cardiac dulness seemed to me more characteristic of dilatation and hypertrophy — in the final stage of failure — from increased peripheral resistance, than of changes consecu- tive to mitral disease. Be that, however, as it may, there were distinct structural changes in the circulatory organs, with which might well be linked attacks of angina pectoris. There was no reason to doubt that the attacks were anginous, but, from the singular phenomena by which they were accom- panied, the case seemed to me to fall very properly under the neurotic class. MOTOE AFFECTIONS. The motor disturbances, which may be, and sometimes without doubt really are, of functional origin, have been fully considered from the semeiological point of view in an earlier chapter. The simple alteration in rate shown by bradycardia, or diminished, and tachycardia, or increased frequency, as well as the more complex appearances of tremor and delirium cordis, palpitation, and syncope, have been discussed as symptoms, while their association with certain of the morbid changes in various structural lesions of the heart, and the appropriate methods of treating them, have from time to time been mentioned in previous chapters. There remain for considera- tion two groups or syndromes of symptoms, which on account of their intrinsic importance require separate description. 51 8o2 COMPLEX SENSORY d- MOTOR AFFECTIONS. EECUEEENT TACHYCAEDIA. The symptom- complex, now commonly recognised by this term, appears to have been first observed by Cotton, who was immediately followed by Edmunds, Watson, and Bowles, while further observations were made shortly afterwards by Nunnely, Cavafy, and Farquharson. The name tachycardia seems to have been introduced by Gerhardt, and the more distinctive title, paroxysmal tachycardia, was employed for the first time by Bouveret. Within recent years, besides many individual cases of the disease, some excellent studies of the affection have been published — among them, Probsting, Bristowe, Taylor, Larcena, Kirsch, Martins, Herringham, and Williams. The investigations of Martins and Herringham deserve special mention, on account of the care with which they were carried out, and the valuable conclusions which were reached. Etiology. — Among the predisposing causes of this curious affection, hereditary transmission has been placed beyond doubt by an observation of Qj^ttinger on its occurrence through four generations. With regard to sex, of 53 cases collected by Herringham, 30 occurred in men and 23 in women. In 40 of these cases the ages were definitely ascertained, and of those 7 had begun to suffer from the affection in childhood, 12 between the ages of twenty and thirty, 1 3 between thirty and forty, 10 between forty and fifty, and 3 beyond the age of fifty. Previous diseases appear to exert some influence. Eheumatism, influenza, diphtheria, and measles have been observed in this connection, while the association of the affection with malaria has been described by Eaisans. The exciting causes are usually such as give rise to physical disturbance. A blow over the heart has been recorded, but sudden exertion and mental excitement are very much more common, while gastric disorders, no doubt by mechanical inter- ference, sometimes produce the symptom. Morbid Anatomy. — Only six cases of this interesting affection have hitherto been examined after death ; in one there was fatty degeneration of tlie heart muscle, in two there was chronic interstitial myocarditis, and in three there was RECURRENT TACHYCARDTA. 803 cardiac dilatation. In several other cases different cardiac lesions have been determined during life, such as diseases of the orifices and valves, or dilatation and hypertrophy of the myocardium, but the six instances referred to are the only ones in which a post-mortem examination was obtained. It is of interest to notice that no trace of any nerve lesion has ever been detected. Symptoms. — The essential nature of the affection lies in its recurrent and paroxysmal character. Attacks come on, as a rule, without any approach to periodicity, and their duration varies from a few minutes to several days. Subjective sensations, such as uneasiness, or even pain, in the chest, numbness, or tingling, in the arm, palpitation, fluttering, or some other motor disturbance, are occasionally experienced by patients, and there is apt to be some disturb- ance of the function of sleep. There is rarely any consider- able degree of breathlessness. The aspect of the patient is generally characterised by pallor, but cyanosis may be pre- sent. Some exaggerated pulsation of the carotid arteries in the neck may be visible, but, instead of this, a very evident jugular pulsation may be found. The pulse becomes enormously accelerated. It is, on account of fluctuations in force, often difficult to determine its rate by the sense of touch, so that it may be neces- sary to estimate the rate by auscultation of the heart sounds. The arteries are in general rather empty, and the pressure is distinctly low. The rate may be far above 200 per minute, and the character of pulsation may be both irregular and unequal. It is an interesting point that during an attack the pulse maintains the same rate during the night and the day. On examination of the prsecordia the area of cardiac pulsation is found to be enlarged, while the force is almost invariably diminished. The area of cardiac dulness almost always surpasses the normal boundaries, and the sounds, particularly the first, lose some intensity. JSTeedless to add, in certain cases there are cardiac murmurs of different kinds. Associated with those cardiac symptoms, there may be some pulmonary hypersemia or subcutaneous cedema, or albuminuria. 8o4 COMPLEX SENSORY d- MOTOR AFFECTIONS. The intrinsic nature of the aftection must be purely a matter of inference. Tuchzek suggested the theory, which has since been widely accepted, that the condition is due to paralysis of the vagus. Irritation of the sympathetic system has also been brought forward by Nothnagel as a probal)le cause. The affection is termed l)y Debove and Boulay a bulbo-spinal neurosis ; Talamon, on the other hand, suggests that the affection is of epileptic nature. There has never, however, been any proof in favour of any of these hypotheses. It need hardly be added that all such views are purely specu- lative. As already mentioned, fatty degeneration and inter- stitial myocarditis were present in half of the cases examined after death, and it seems to me that West is probably correct in his opinion that the myocardium is the seat of the lesion. Herringham observes that, if an implication of the nerve-end- ings is admitted, the facts of the affection seem strongly in favour of West's view. This is undoubtedly the best expla- nation of the condition. As is very well known, brief attacks of delirium cordis are common in myocardial degenerations, and paroxysmal tachycardia must be regarded as a somewhat analogous condition, differing mostly from it in respect of greater duration. My own opinion as to the essential nature of paroxysmal tachycardia is, that it must be regarded as analogovis to the respiratory changes grouped under the term Cheyne-Stokes breathing. It is impossible to start from any other stand- point than that of the automatic activity of the heart muscle, seeing that the cardiac ganglia and their connections are only means by which the cardiac movements may be modified. It has already been shown that periodic respiration is probably the result of an interference with the normal rhythm of respiration through malnutrition of its centre. One of the illustrations employed to explain this view was the observa- tion of Steiner that Medusae, when kept in sea water insuffi- ciently renewed, showed remarkable modifications in the movements of the calyx, which fall into periodic groups separated from each other by pauses. The essential cause of paroxysmal tachycardia seems to be a periodic variation in the functional activity of the heart muscle, but it would be RECURRENT TACHYCARDIA. 805 unphilosophic to deny that some diminution or perversion of the tonic influence of the nervous system over the heart may be partly responsible for the condition. Diagnosis. — But little remark is called for in respect of this aspect of the subject, seeing that the determination of the affection rests upon such well-marked symjjtoms. Pkognosis. — The outlook cannot be regarded as satisfac- tory. There is an undeniable tendency in this condition to become worse until it ends in death. Herringham points out that after 30 years of age a patient suffering from this affec- tion is never safe from death, and he has analysed the cases on record with a view to determining the ages at which death has occurred. Before the age of 30 there have been only 2 deaths; between 30 and 40, 5 ; between 40 and 50, 5; and over 50, 4. Teeatment. — The treatment must necessarily depend in great part upon the conditions which have preceded the affec- tion, as well as those which underlie it. If there be any dis- coverable evidence of cardiac degeneration, treatment must be adopted to arrest and obviate the process. The general lines upon which this must be conducted have already been suffi- ciently discussed. If dilatation, apparently due to weakness, is present, the use of baths and exercise will be found to be of benefit. Pressure upon the thorax, as recommended by Eosenfeld, seems to be helpful in the attack itself. Pressure on the vagus nerve as it passes down the neck, seems occasionally to be useful, but it often fails. Naturally the remedies which might be tried would be those which have an influence over the rate of the heart, more especially digitalis, and its con- geners ; none of them can be claimed as producing any effects of real benefit. Case 67. Recurrent Tachycardia. — A. W. C, aged 71, fisherman, attended as an out-patient in tlie waiting-room of tlie Eoyal Infirmary- complaining of faintness and giddiness. So far as could be ascertained, there were no hereditary tendencies towards any particular disease. His occupation, that of a fisherman, not only exposed him to very consideralile physical stress, but to great exposure to the weather. His surroundings otherwise were perfectly satisfactory. He was a native of, and had lived all his life in, Burra, 8o6 COMPLEX SENSOR Y d- MOTOR AFFECTIONS. one of the south-western of tlie Shetland Islands. His previous health was unmai'ked bj' any morbid incidents of special importance ; in short, he appeared to liave been -wonderfully exempt from illness of any kind. About ten yeai-s before his visit to the Royal Infirmary he had been complaining of attacks of giddiness, often passing into a sensation which Avas described as a "dwam," and this faint feeling often forced him to desist from any occupation in which he might be engaged. It was not attended by any uneasiness in the chest, and there was no breathlessness at any time. The patient was a tall, well-built, nuiscular man, with a pale com- jjlexion. His gait was marked by a slight stoop, yet his movements were somewhat more active than might have been expected from his years. The lips were healthy in colour, as were the mucous membranes of the mouth and eyes. The temporal arteries were somewhat tortuous. The pulse, after be had sat qiuetly for a few minutes, was found to be 250 per minute. The artery was rather rigid and slightly tortuous, but the vessel was somewhat empty, and the pressure of the blood low, so far as could be made out on account of the alteration in the arterial walls. There was a slight flickering in the external jugular, and the area of cardiac pulsation was enlarged. The cardiac impulse was found to be diffuse and feeble. Percussion showed that the borders of the heart were to right and left 3 and 4 in. respectively from the middle line. The heart sounds were feeble, more especially the iirst sound in the mitral and tricuspid areas, and the sounds there Avere in strong contrast to the second sounds at the base, which, nevertheless, were by no means loud. The aortic and pubnonary second sounds were so similar in intensity that it was impossible to determine which was the louder. There were no symptoms of respiratory disturbance beyond breathlessness on exertion, and the physical examination of the lungs revealed no abnormality. The other systems of the body called for no remark. The patient stated that he had been seized by one of his attacks on his way to hospital, and that he was exhausted and giddy while being examined. By the time the examination was concluded, he described himself as feeling better, and when the pulse was examined at that time, its rate was found to have undergone a great change, Ijeing much less frequent ; in fact, when it was timed, it was found to be only 78 or 79 per minute. The arterj^ was also fuller, its j)ressure higher, and the pulse wave larger. It was still perfectly regular, as it had been when first examined. It was quite clear that this was a case of paroxysmal tachycardia, but its severity was l)y iio means so great as has been commonly described by the various writers who have devoted attention to the subject. The production of the symptoms seemed to belong essentially to a condition of chronic myocardial change of a fibroid character, associated with arterial sclerosis. RECURRENT TACHYCARDIA. 807 He was recommended to enter the Infirmary for a short time in order to be carefully watched, but, as he preferred .to remain outside and report himself later, he was treated by means of digitalis and nux vomica. Some days later he re- turned, stating that he was better, and that no paroxysm had recurred during the interval. He went northwards the follow- ing day. Since that time information has from time to time been sent to me, from which, so far as could be gathered, he continued in fairly good health. Case 68. Fat^ Infiltration with Paroxijsmal Tachycardia. — A. M., a lady aged 64, was seen by me along with Dr. Craufurd Dunlop, 1st December 1897, on account of extreme breatUessness. Her father bad died from heart disease at the age of 85, and her mother at 87 from chronic bronchitis. There were two brothers and two sisters in good health ; two brothers had died, when two years old, of measles. The patient's health had been satisfactory until the spring before she was seen by me, when she passed through a troublesome attack of cardiac failure, since when she had never been quite so well as formerly. The patient was extremely plump, and, from deep cyanosis, presented a purple tint of face, with lips of the colour of a ripe blackberry, and a tint like that of the bilberry in the nostrils and lobules of the ears. Her hair was snow- white, and there was a well-marked arcus senilis in each eye. The tongue was clean, and the alimentary system showed no alteration, not even any enlargement of the liver dulness. The spleen and thyroid gland were normal in size. There was no opportunity of examining the blood. The pulse was usually between 110 and 120 when seen by Dr. Dunlop, but it went up to 150 and 170 at times. On the occasion when we saw her together its rate was 172. The vessel wall was but little altered. The artery was moderately full, and the pressure fair. The piilsation, although extremely frequent, was perfectly regular and equal, and it was impossible to make out any periodic variations in rate, rhythm, or size. On examining the neck and chest no pulsation could be seen, and on placing the hand over the preecordia it was impossible to ascertain whether any pulsation was present or not. The cardiac dulness extended 2 in. and 4f in. to right and left of mid-sternum respectively, and the area of dulness reached the level of the third rib. Auscultation showed that the sounds were clear and ringing, but high in pitch, and short in duration, while at the apex the first sound was doubled. The patient suffered much from orthopnoea, yet, on examining the chest, there Avas absolutely no sign of hypertemia ; not the faintest impairment of the percussion sound, or the slightest accompaniment of the breath sounds being elicited. The integumentary system, apart from its adiposity, was in all respects natural, and the urinary and nervous systems were intact. There could be no doubt that in this case a considerable degree of fatty infiltration was present, and it seemed prob- 8o8 COMPLEX SENSORY d- MOTOR AFFECTIONS. able that it had to some extent interfered with the action of the heart, probably from resulting degeneration. Dr. Dimlop kindly informed me that on his next visit he found the rate of the heart between 80 and 90, and on a subsequent occasion, when we again saw the patient together, the pulse was one or two beats below 80. The treatment adopted was absolute rest, light food, and strophanthus along with sal- volatile. EECUEEENT BEADYCAEDIA. A condition in most respects the opposite of that which has just been discussed was first observed by Adams. The same condition subsequently attracted the notice of Smith, and Stokes studied it with great care. It has been adverted to by several writers since these three great Dublin physicians gave it prominence ; but the writer who has, within recent times, most carefully studied the condition is Huchard, who has proposed to attach the names of Adams and Stokes to the complex of symptoms. Etiology, — The affection is certainly more common amongst elderly people than amongst those who are young and middle-aged. The original patient described by Adams was 68 years old, and those of Stokes were aged 50 and 68 ; advanced years must be regarded as an important factor in the production of the condition. Certain acute general diseases appear to have considerable influence ; this was remarked by Stokes ; chief amongst these is certainly influenza. Such causes are responsible for most of the cases coming on in early or middle life. In addition to such causes, the various factors which give rise to the structural alterations, about to be mentioned, are necessarily of importance in the production of this group of symptoms. Such agents have already been fully described in the section dealing with myocardial diseases. Morbid Anatomy. — The lesions which have been most commonly observed in recurrent bradycardia have belonged to the class of myocardial degenerations. In the original cases described by Adams, Smith, and Stokes adipose changes were RECURRENT BRAD YCARDIA. 809 prominent. It is rather difficult, on account of the com- parative rarity of the affection, to have any statistics of value as to the relative frequency of different lesions, but it seems probable that fibroid changes are rather more frequent than alterations of a fatty character. The condition is especially associated with arterial sclerosis, and it is therefore only what might be expected that interstitial myocarditis should be often found. Huchard is strongly of opinion that sclerotic changes in the arteries of the brain, and more especially of the medulla oblongata, are constantly in association with the group of symptoms. Symptoms. — The principal features of this condition, which indeed overshadow the others, are connected with the con- dition of the nervous and respiratory functions, and complaints of giddiness, faintness, or even transient unconsciousness attended by breathlessness, lead to investigations which reveal the real nature of the case. There is nothing characteristic in the general appearance of the patient, unless the attitude should betoken respiratory distress. Pallor is, however, usually present, but sometimes a considerable degree of cyanosis may obscure it. On ob- serving the patient more closely, there will often be seen some changes in the temporal arteries. All the arteries are, as a rule, rigid and tortuous, but they are, for the most part, less well filled than should be the case, and the blood pressure is below the normal. In some cases the fulness and pressure are above normal. These appearances are, no doubt, produced by failure of a heart which has been previously hypertrophied, and the pulse condition is that which has been described by Broadbent as that of " virtual tension." The rate of the pulse is in most cases permanently reduced, and during the recurrent attacks it falls to a still lower rate. In a case of Halberton's it fell to 5. It is quite usual to find the pulse perfectly regular, but irregularity and inequality may be present. Cyanosis, as has been mentioned, occasionally occurs, and there may be oedema of the dependent parts. Different varieties of cardiac pain have been described, but many cases are entirely free from any uneasy sensations in the chest. On inspection of the praecordia the apex beat, when 8io COMPLEX SENSORY a^ MOTOR AFFECTIONS. observable, has usually been found to be further out than in health. It yields very varying results on palpation, some- times giving the impulse characteristic of hypertrophy, at other times that which is found in dilatation. The area of cardiac dulness is generally increased. The first sound may be, as in hypertrophy, long and low, or, as in dilatation, short and sharp. It is usually surpassed in intensity by the second sound, especially in the pulmonary area. The sounds may be obscured by the murmurs characteristic of different valvular lesions. Dyspnoea is a common feature of this interesting complex of symptoms, and occasionally it make take the form of severe cardiac asthma. At other times well-marked Cheyne-Stokes respiration is present, and this is more particularly the case when the paroxysmal attacks are present. The urine is often scanty. Even when renal cirrhosis is present in association with arterial sclerosis, the cardiac failure commonly present renders the amount smaller. All3umin and tube casts may be present. Cerebral symptoms almost surpass all the others. During those periods of rare pulsation such brain symptoms are mostly seen. They manifest considerable variability. Sometimes there are merely sensations of giddiness and faintness, but at other times there may be lapses of memory, or even total un- consciousness ; on the other hand, convulsive seizures have been described. The starting-point of the complex of symptoms is to my mind clearly the heart. When the sclerosis of the arteries of the brain diminishes its blood supply, and when the heart lessens its activity, the c^uantity reaching the brain is too small to sustain the cerebral functions, hence the faintness, giddiness, unconsciousness, and convulsions. Why the heart should manifest such infrequency of con- traction is at present impossible to understand. Eecurrent tachycardia is found in conditions closely resembling, if not identical with, those underlying the condition now under consideration, and by no reasoning can a valid explanation be evolved. It is futile to peer further at present into the gloom surrounding the suljject. Until we know why such a disease RECURRENT BRAD YCARDIA. 8 1 1 as influenza can cause in two patients, apparently closely resembling one another, tachycardia on the one hand, and bradycardia on the other, we must be content to leave this question unsolved. Hucliard attempts to explain the whole group of symptoms by arterio-sclerosis of the vessels of the hind brain, and appeals to the well-known facts of permanently infrequent pulse in lesions of the upper cervical ]part of the vertebral column in proof of his views. A permanent reduction of rate is, no doubt, common enough in such cases, but they have no paroxysmal attacks. Diagnosis. — Infrequency of the cardiac pulsations is common enough as the result of many different conditions, such as degenerative changes in the myocardium, and the effects of specific poisons, like that of influenza. Such symptomatic bradycardia must be carefully distinguished from the syndrome now under consideration, the essential feature of which is that, with a permanent diminution in the frequency of the cardiac impulse, there are paroxysmal attacks of still greater infrequency. In this lies the diagnosis of the condition, and it is therefore easy to determine its presence. It need hardly be added that the rate must be determined by the examination of the heart as well as the pulse. Prognosis. — Paroxysmal bradycardia is usually associated with grave structural alterations of the heart, and it is, for the most part, of evil prognostic omen. Cases, however, have been recorded of the affection coming on in the prime of life, and, under appropriate treatment, passing away. With the exception of a few cases of this kind, the group of symptoms now under consideration usually persists until death, which is commonly somewhat sudden. Teeatment. — The great aims to be set forth in the management of this group of symptoms are, while strengthen- ing the heart, to diminish the peripheral resistance. All general measures which can increase the nutritive activity of tlie whole system must be adopted, and the lines of treatment are such as have been described in the chapter upon myocardial degenerations. The drugs which are of the most importance are iodide of 8i2 COMPLEX SENSORY d^' MOTOR AFFECTIONS. potassium, and nitro-glycerin, continued over a considerable length of time. These drugs may Ije given in combination with general tonic remedies, and if cardiac failure should be a prominent symptom, they may be most advantageously associated with strophanthus, strychnine, and nitro-glycerin. The two last mentioned are strongly recommended by Morison. Digitalis has in my own hantls invariably failed of any bene- ficial effects. Case 69. Recurrent. Bradijcardia. — A. M., aged 82, was seen by Dr. Balfour and myself, along with Dr. Marshall of Hamilton, on account of severe breathlessness and oedema. The family history showed a consider- able tendency to arthritic and arterial lesions. Both jiarents had, how- ever, lived to advanced years. An only brother had been cut off early in life with some infectious fever. One sister had died in ad^^anced years of chronic bronchitis and cardiac failure, and another, also at a late jieriod, of arterial degeneration and asystole. Two other sisters enjoyed tolerably good health, but one had a weak heart and a liability to syncope, while the other had well-marked arterial sclerosis. The patient was pale, with a tendency to lividity of the dependent parts, and there was slight oedema about the ankles. The pulse rate was iTsually a Kttle above or below 60, but when seen by us it was 34, and it was stated to have frequently fallen to between 20 and 30. The arteries were hard and tortuous, indifferently filled, and with low pressure. There was well-marked venous pulsation in the neck. The apex l)eat was rather beyond the mammillary line. Its impulse was forcil^le, but slaj^ping in character, and there were soft blowing murmurs of systolic rhythm, in both the miti'al and tricuspid areas. The aortic second sound was loud and ringing, but it was surpassed in intensity by that in the pulmonary area. There was great dyspnoea, with a tendency towards the Cheyne-Stokes rhythm. The respirations were extremely deep. During the periods of diminished frequency of the pulse, the condition of the mental powers underwent great alteration, periods of dulness, if not complete obscuration, being present. There could be no doubt that this case furnished a striking example of the condition under discussion. It was obvious that along with arterial sclerosis there was cardiac dilatation probably from fibrosis, succeeded by failure. Digitalis had been tried in order to obviate the threatened asystole, but was attended by such distressing aggravation of all the symptoms that it had to be discarded. By means of ammoniacal, ethereal, and alcoholic stimulants, along with strychnine, some temporary relief was obtained, but in a few days the patient passed away in one of the attacks. CHAPTER XVI. DISEASES OF THE AOETA. The aorta is subject to structural alterations, similar to those which are found throughout the arterial system in general ; these changes, however, although essentially the same in kind, vary considerably in degree, since they are influenced by the special structure of the aorta on the one hand, and the local conditions of blood pressure on the other. In the aorta it is possible to make out the three arterial coats, but these depart in some respects from the strata of one of the smaller arteries. The intima differs from the same tunic in other arteries, not only by being much thicker, but also by containing some muscle cells, more connective tissue, and elastic fibres arranged in laminae. The middle coat, instead of being almost entirely composed of unstriped muscular fibres, is for the most part formed by connective tissue and yellow elastic fibres ; the latter form thick layers alternating with the muscle cells, and are embedded in delicate connective tissue, with a branching network of fine elastic fibres. The adventitia is very much thinner than in the case of the smaller arteries. It follows from these distinctive structural features that the aorta, while less contractile, is endowed with more resistance to stress, and greater elastic recoil after distension. On account of its proximity to the heart, the aorta is subject to much greater vicissitudes of pressure than any other blood vessel in the body. It must, therefore, necessarily be especially liable to such affections as have their origin in excessive pressure. There is another consideration to which attention must be 8 14 DISEASES OF THE AORTA. called. All parts of the aorta are not equally subject to the stress produced by the circulation. The greater curvature of the vessel receives the direct impact of the blood as it leaves the heart. The aorta presents at its root the three bulgings known as the sinuses of Valsalva, and, farther up, a transverse section shows an oval instead of a circular outline. This is caused by a bulging of the wall on its greater curvature, usually known as the great aortic sinus. It has often been regarded as really aneurysmal, but, as Cunningham has more particularly emphasised, it is found in the embryo, and cannot therefore be produced in this way. It has been the habit of certain observers, as, for example, Quincke in his exhaustive monograph on vascular affections, to divide arterial diseases into groups, according as they have their origin in the external, middle, or internal tunic. Such analysis does not fall within the scope of the present work, nevertheless, some brief reference to this aspect of the subject may well be allowed a brief reference in these introductory remarks. Exarteritis, commencing with the adventitia, is occasionally met with in the aorta as a secondary process, consecutive to some acute process in the neighbouring .tissues. As examples of this special affection may be mentioned the implication of the external coat of the aorta in pericarditis, mediastinal abscess, and ulceration of the trachea or oeso- phagus. Cases of this kind have been narrated by Sprengler and Leudet. The resulting lesions in the artery are some- times characterised by an increase in the connective tissue with cellular infiltration, but the process may be so acute as to end in suppuration. The more chronic variety gives rise to thickening and adhesions to the adjacent structures ; the more intense may lead to acute aneurysmal dilatation or to rupture. Alterations in the structure of the tunica media are always secondary. An increase in the thickness of this coat may result from causes operative through continuous irritation from without, as in the hyperplasia which has just been mentioned, or from increased stress, as is sometimes found in aortic incompetence with cardiac hypertrophy ; this latter point has been more especially described by Quincke. Atrophy and INTR on UCTOR V. 815 degeneration of the media are, however, mucli more commonly observed. Their causes are as yet by no means tlioroughly understood, but they seem undoubtedly in many cases to have their origin in hereditary tendencies, while long -continued overstrain and changes in the intima are the commonest existing factors. It is possible that some alteration in the vasa vasorum, such as will be referred to in the section on aneurysm, is intimately connected with the atrophic and degenerative processes. The inner coat is that which is most liable to morbid processes ; as it, however, is the main subject of the following pages, it is unnecessary to dwell upon it at present. The evolution of our present views in regard to this subject is full of interest. While observations on certain of the lesions were made by Scarpa, the first serious attempt at a classification was that of Hodgson, who recognised three changes — cartilaginous, pulpy, and purulent. Craigie also described three types — calcareous, atheromatous, and steato- matous. Both these observers seemed to consider the lesions as deposits. Eokitansky first recognised that the changes occurred in the intima, and resulted in two chief lesions, atheromatous and ossific, i.e. calcareous. Virchow finally placed the correct construction upon the nature of the process, by showing that it was due to an increase of the connective tissue normally present, and he accordingly introduced the term endarteritis. Most of the lesions of the aortic walls are found in con- nection with arterial sclerosis, and, therefore, a few preliminary observations must be made upon this subject. Arterial sclerosis, undoubtedly, takes its origin in a condition of weakness and loss of elasticity. This is essentially a senile change, but it makes its appearance at very variable ages, according to the individual peculiarities of those subject to it. In some families it may occur in the third decade, or even in the second, whilst in others it never appears at all. As will be remembered, Harvey recorded that the celebrated Thomas Parr, who died at the age of 152, had arteries absolutely free from any structural change. To compensate for the loss of resistance and of elasticity, several different processes ensue. 8i6 DISEASES OF THE AORTA. In the first place, the intima undergoes considerable thicken- ing, and this is commonly found to occur in the situations most exposed to stress. The media usually becomes also greatly thickened, while an increase in the adventitia is often to be seen. These changes result in an increase of resist- ance, or, as it may be termed, a tendency towards rigidity. Fig 193. — Atheroma of coronary artery, x 50. a, Greatly thickened patch of intima, with degenerative changes in the deeper layers ; h, muscular coat ; c, adventitia with engorged vessels ; d, muscle fibres of the heart. Thoma prefers to regard the result of these changes as pro- ducing an increase of elasticity, but in so doing he shows a mis- conception of physical terminology. The property of returning to the previous size and form after distension, to which alone the term elasticity can be applied, is distinctly diminished ; these changes accordingly pave the way for dilatation of the vessels. It is impossible for any one correctly trained in the principles of physics to imderstand how Thoma should have been led into such an unfortunate misuse of the term. The ACUTE AORTITIS. 817 subject has been fully discussed by Tlioma and myself within recent times, Ou examining a section of an artery which has undergone sclerotic changes, it is found that the inner coat is considerably thickened throughout its whole circumference, but more especi- ally in one spot, in the deeper layers of which there are frequently degenerative changes, shown by the presence of fatty globules, cholesterin crystals, .and calcareous deposits. The internal elastic lamina is distinct in most instances. Sometimes, how- ever, it may be observed to be broken up in some parts, while thickened in others. The middle coat is also increased in thickness, and under a high power may be seen to have more connective tissue amongst the muscle cells. There is likewise a thickening of the adventitia. These alterations are well shown in Fig. 193. These changes are commonly diffused widely throughout the arterial system. It has been the habit to speak of diffuse sclerosis when the change involves great part of the arterial system, and to apply the term nodose to the form in which it is restricted to distinct patches. Such alterations may be found through the whole arterial system, and lead to narrow- ing and obliteration, or widening and rupture of vessels. ACUTE AOETITIS. This process presents a twofold manner of occurrence, and the cases, therefore, fall into two categories. In one of these, the affection is found in the course of acute diseases, of which, therefore, it may be regarded as simply forming a part ; in the other, it occurs as a primary lesion unac- companied by any features denoting the presence of an acute general disease. It is of interest to note that in a very large number of cases of acute aortitis there has been some chronic change in the walls of the aorta before the acute process has begun. This is always the case as regards primary aortitis, but it is not invariably found in the primary form of the disease. Bureau is therefore perfectly correct in stating that there is probably no real primary acute aortitis, 52 SiS DISEASES OF THE AORTA. and that the disease is always secoudaiy either to a chronic aortitis or a general affection. Etiology. — The acute general diseases, proved to have an intimate relation with the development of aortitis, are some- what numerous. Like endocarditis, it may have its origin in rheumatism. Scarlet fever, measles, and smallpox have been, according to the researches of Landouzy and Siredey, Huchard, and Brouardel, followed by acute aortitis. Influenza has been observed in this connection by Fiessinger, while Huchard has observed acute aortitis following upon tubercular conditions. In such instances the affection is absolutely primary, and not to be engrafted upon a previous chronic change in the walls of the aorta. Acute aortitis, arising independently of any general disease, seems, from the results of all observers, to be invariably associated with the previous existence of chronic disease. The affection is occasionally a, sequel to acute endocarditis, and it cannot be doubted that, in some instances, the propagation is by direct infection. It is sometimes associated with pericarditis, pneumonia, and pleurisy ; but whether the association is accidental, or an instance of cause and effect, cannot at present be determined. The affection has been found to follow upon renal disease in some instances. Pregnancy and parturition have been complicated by acute aortitis. The affection has been produced by over-fatigue and traumatism in the presence of impure blood. Boinet and Eomary find infections and intoxications the sole exciting causes. Morbid Anatomy. — The aorta is almost invariably some- what enlarged, and presents a fusiform aspect. On opening it there may be old-standing atheromatous lesions, but in the class of cases arising in the course of a general disease such appearances may be wanting. The surface is always rough and irregular, and the unevenness is due to patches, soft in consistence, and reddish or grayish in colour. These areas have a translucent aspect, so as to merit the term of gelatinous often applied to them. The patches have a tendency to run into each other, so as to form irregular outlines. Abrasion or ulceration of the surface is sometimes found, and it A C UTE A OR TITIS. 8 1 9 will readily be understood that destructive changes of this kind may form a starting-point for the far-reaching effects of embolism. It sometimes happens that ecchymoses are present upon the aortic intima ; these must be due to the rupture of some of the nutrient arteries. Not infrequently the whole of the internal tunic is deeply stained by the imbibition of the colouring matter of the blood, and the character- istic gelatinous patches may be almost of the colour of a blackberry from the same cause. Usually the middle and external coats of the aorta are somewhat thickened. They often contain a large number of newly formed blood vessels, and hsemorrhages take place into their tissues. In the more acute forms of the disease, the pericardium often shares in the acute process from direct extension. Microscopic ex- amination of the affected patches shows that the internal tunic in its more superficial layers is invaded by a small cell infiltration, while large nucleated cells are also found. These are mingled with the ordinary stratified endothelial cells of the intima. The middle tunic is usually somewhat broken up by cell infiltration, and newly formed blood vessels ramify amongst the tissue elements. The same alterations may be found in the adventitia. The affection has sometimes been found to set up changes in the cardiac plexus, and on rare occasions it seems to have been the starting-point of pleurisy. It is not infrequently associated with alterations in the aortic cusps, but these may be accidental coincidents, although facts in some cases seem to have proved that the aortitis has preceded the valvular lesion. Two classes of acute aortitis have been described — one, characterised by the presence of vegetations, usually associated with a similar lesion of the aortic cusps, but occasionally, as in a case described by Boulay, found isolated ; the other, resulting in suppuration, which has, within comparatively recent times, been very carefully investigated by Leudet. Symptoms. — It must be remarked that since acute aortitis so frequently arises in the course of another disease, its clinical features may be altogether overshadowed and completely masked by those of the affection which has preceded it. If it occurs in the course of an acute general disease, there may 820 DISEASES OF THE AORTA. already be some features of aortic implication, so that the aortitis causes but little additional disturbance ; while in the case of pneumonia, or pleurisy, or, more particularly, endo- carditis, there may be so many morbid appearances connected with the chest as to render the symptoms of aortitis almost imperceptible. Amongst the general symptoms, it must be remarked that pyrexia is frequently absent ; in fact, in most cases, it is never found. There is almost invariably a feeling of tightness in the chest, which very often occurs in paroxysms ; or this feeling of weight and tightness may pass into a veritable angina pectoris. The pain in this case is distinguished from that of ordinary angina pectoris hj the fact that in the latter there are periods of complete relief from all uneasiness, while in aortitis there is always a constant feeling of uneasiness and heaviness. The persistent feeling of uneasiness has been described by Leger as a burning sensation, occupying a posi- tion apparently in relation to the arch of the aorta, and passing to the back and down the spinal column. This has also been emphasized by Grainger Stewart. Tenderness, which has been more particularly investigated by Peter, is sometimes found in the first, second, and third intercostal spaces to the left of the sternum. Not infrequently complaints are made of dysphagia, which appear to be connected with the proximity of the aovta and the cesophagus. Vomiting, meteorism, and other symptoms of alimentary disturbance are sometimes described. Breathlessness may be persistent, but it more commonly occurs in the form of dyspncea on exertion. Cough is a common symptom, and it is often attended by a considerable amount of expectoration. Patients suffering from this affection are usually pale. They manifest, in short, the facies of aortic disease ; no doubt, however, when there is an elevation of the temperature, there is a tendency to a higher tint upon the cheeks. On inspec- tion of the neck, a considerable amount of throbbing may be found in the carotid arteries, and Ijy Laboulbene and Faure an observation has been made, which is interesting in itself, whatever be the interpretation put upon it. This is, that the right subclavian artery pulsates more vigorousl.y than the left. ACUTE AORTITIS. 821 The observers just mentioned believed the cause of this phenomenon to be that the innominate artery is less likely to be implicated than the left subclavian. Such a symptom is more apt to be caused by some previous chronic, endarteritis. The peripheral arteries may have healthy walls, or there may be some degeneration in them. Be that as it may, the radial artery is usually found to Ije only moderately filled, and its pressure is not high. The pulse wave is, as a rule, large and bounding, occasionally manifesting features like the pulse of Corrigan in regard to the duration of the wave. It may be regular or irregular according to attendant circum- stances. It is not uncommon to find that the pulse wave is different in the two radial arteries ; when this is the case, the left is usually smaller than the right, the reason for the difference being that some patch of disease interferes with the mouth of one or other of the arteries. The prsecordia may present no aljnormal features on inspection. As, however, most cases of this affection follow a previous sclerotic change in the aorta, it is common to find that the apex beat is displaced somewhat outwards and down- wards, while palpation reveals an increased intensity and prolonged duration of the impulse. It depends entirely, how- ever, upon the stage at which the patient is seen, as towards the termination of a prolonged illness of this kind the heart usually fails, and the character of the impulse in such instances is like that described in dilatation. Percussion reveals, in the majority of cases, an increased area of cardiac dulness. The most important point elicited by this method, however, is an increased aortic dulness to the right of the sternum. On auscultation there may be nothing but an in- crease in the intensity of the aortic second sound. As a rule, however, the first sound in the aortic area is accom- panied by a soft systolic murmur, followed by the accentuated second sound, and it is not uncommon to find that during the course of the disease a diastolic murmur is produced by implication of one or other of the aortic cusps, producing regurgitation. The cou.rse of the affection is chiefiy characterised by remissions. The disease is apt to be prolonged, and its 822 DISEASES OF THE AORTA. termination is so often fatal that it is scarcely an exaggeration to say that recovery is the exception. Death is brought about in certain cases suddenly by cardiac asystole, or by aortic rupture. When it occurs slowly and gradually, it is by cardiac failure, and is marked Ijy the presence of cedema and other symptoms of a failing circulation. Diagnosis. — The recounition of acute aortitis is l)ased upon the situation of the pain, and physical signs which denote an aortic affection. The means of differentiating between the pain of this affection and that present in angina pectoris, lies in the fact that in aortitis there are remissions but no real intermissions in the subjective sensations. If septic phenomena, such as great fluctuations of tempera- ture, and profuse perspirations, should be present, they will suggest the possible presence of suppurative aortitis ; rapid loss of strength and tendency to cardiac failure will be found in such cases. If the appearances significant of embolism in any part should be present, they will inevitably suggest that some ulcerative process is taking place in the aorta. The sudden appearance of cyanosis with acute heart failure is to be regarded as almost pathognomonic of rupture of the aorta. Prognosis. — The outlook in this affection is always serious. It is somewhat less unfavourable in cases taking their origin in the course of • some acute disease ; it is absolutely hopeless in primary acute aortitis. Treatment. — -Absolute rest and appropriate food must be enjoined. The application of five or six leeches in the upper part of the sternal region has been found beneficial, especially when followed by the application of warmth, so as to favour bleeding. On the other hand, the use of the ice-bag, or of Leiter's tubes, has been of considerable service. The employ- ment, further, of counter irritation has in certain instances been found to alleviate the symptoms. The pain ■ is some- times so severe as to imperatively demand a hypodermic injection of morphine. Of internal remedies, those which dilate the arterioles and lessen the blood pressure are chiefly serviceable ; amongst them nitro-glycerin is certainly of most importance. The use of iodide of potassium will naturally suggest itself, and if there be much nervous disturbance, CHRONIC AORTITIS. 823 bromide of potassium may be combined therewith. In cases characterised by a tendency to cardiac failure, the heart must be sedulously watched, and cardiac tonics administered if a condition of asystole should, appear imminent. It need hardly be added that all these measures are rarely followed by recovery, except in a few of the cases having their origin in some acute general disease. CHEONIC AOETITIS. The chronic forms of aortitis form a group of affections characterised by considerable variety, as well from the stand- point of pathological anatomy, as of clinicar medicine. The lesions are of the deepest' significance, inasmuch as they lead to so many consecutive changes. " Etiology. — -The disease is usually part of general arterial sclerosis, and it therefore is produced by the factors which lead to that process. It is, in the first place, frequently observed in those who have a hereditary predisposition to degenerative processes in the arteries. It is essentially a senile disease, and is more common, therefore, in advanced years. The male sex is certainly more prone to it than the female. Certain disease tendencies produce a liability to chronic aortic changes. This remark is not intended to refer to hereditary tendencies, but to general acquired constitutional affections. Amongst these must be mentioned the diathesis which commonly bears the name arthritic, and there can be. no doubt that the uric acid diathesis induces a liability to these affections. In one sense heredity plays an important part in this connection, seeing that the children of those who have an arthritic diathesis are certainly more prone to acquire it. There, can be no doubt that specific infection has great influence in .the production of such changes. Many observations have within recent years been made upon this subject by many authors, such as Welch, Lecorche and Talamon, Paul, Jaccoud and Dohle. On the other hand, Lancereaux throws some doubt upon the conclusions to which these ; observers have been led, and urges that im- pa,ludism is a very much more common cause. He forgets, 824 DISEASES OF THE AORTA. however, in making this statement, that the affection in this country, where it is so common, cannot often be produced by such a cause. Occasionally chronic aortitis is left behind by an . acute process arising from an infection in the course of some general disease. This is, however, very much less frequent than the converse, and, as has been previously remarked, acute aortitis is much more likely to be engrafted upon a chronic process. Above all these factors, that which has been, of most importance in tlie production of chronic aortitis is long continued overstrain of the aorta. The observations, commencing with Boerhaave, and culminating with Clifford AUbutt, have been mentioned, and need not in this connection be again referred to. Morbid Anatomy. — The lesions in chronic aortitis are some- times entirely confined to the aorta, but it is much more com- mon to find that the local alterations are only part of a general process widely spread throughout the whole arterial system. From comparison of the lesions in different individuals, as well as from the not infrequent coexistence in the same individual of different pathological appearances, it can easily be determined that the process goes through several distinct stages. The earliest stage consists in the development of patches characterised by opacity. These extend to some extent in all directions, and become raised above the surface, so as to form elevations ; these may be flat — in which case each patch has the appearance of a plateau, or rounded — so as to present some resemblance to a button. These patches, which at first are somewhat grayish and gelatinous looking, become yellowish and doughy, with a great tendency to the development of hard masses, owing to the deposition of lime salts. The superficial portions of these elevated patches Have a tendency towards erosion, which leads to the development of ulcers. These atheromatous ulcers present a somewhat rough floor of a yellowish colour, and the tissues which constitute them are obviously composed in part of fatty material. The aorta itself is almost invariably dilated ; and in addition to such an increase in size, it is marked by the pre- sence of smaller bulgings, which indicate the beginnings of aneurysmal changes. The aorta, when the condition is fully CHRONIC AORTITIS. 825 developed, shows these various atheromatous alterations scattered widely throughout its extent, hut they are more particularly seen close to the aortic orifice. One point of importance is that the lesions are very commonly seen at the origin of arterial hranches. They are to be seen around the mouths of the coronary arteries, the great arteries of the neck and upper extremities, and even the intercostal arteries. The changes occasionally result in the formation of large calcareous plates, separated from each other by tissues more or less altered by the other atheromatous processes just mentioned. On microscopic examination, the intima is found in the affected region to be sparsely invaded by round and fusiform cells enclosed in a fine network of fibrous tissue; according to Coats and Auld, characteristic branching cells, resem- bling those of the normal intima, are mingled with those which have been mentioned. In the deepest portions of the inner coat are masses composed of granular debris, mingled with oil globules, and crystals of cholesterin and margarin. These fatty changes take place in the cells of the intima in the first place. The middle and outer coats are always found to be vascularised as well as thickened, and they show an invasion by newly formed cell elements. These changes are undoubtedly compensatory. This brief sketch of the morbid appearances would not be complete without some reference to the fact that chronic aortitis sometimes leads to rupture of the aorta, while, during the process of ulceration, embolism of distant organs may be the result of the separation of some of the necrosed tissue. Symptoms. — The clinical features presented by cases of aortitis do not form a uniform group. In some instances the affection may be perfectly latent until rupture of the diseased portion of the aorta brings about death in dramatic fashion ; while, on the other hand, there may be appearances so distinctive in character as to be almost pathognomonic. The common complaints are of uneasiness, weight, or constriction, along with palpitation or fluttering, as well as breathlessness, which may present the type of anhelation on exertion, or of paroxysmal cardiac asthma. Troublesome cough is not infrequently mentioned, and there may be 826 DISEASES OF THE AORTA. sjniptoms of giddiness or swiimuing connected with the nervous system. The pain is fret^uently of the true cardiac type — that is to say, it has the sternal position and the tendency to radiate along the great trunk lines already fully descrilied. It is, moreover, often accompanied Ijy the sensa- tion as if the heart were going to stop, as well as by a consciousness of the near presence of death. On careful examination of the circulatory system there is, in most instances, obvious implication of other arteries. The temporals, for example, are commonly rigid and tortuous, while the arteries of the extremities may give the feeling of twisted cords to the fingers of the observer. It is common to find that not only do the carotid and subclavian arteries pulsate excessively, Init that in the jugular fossa the aorta itself may be found to give a well-marked impulse. The radial pulse, besides giving the sensation of hardness and tortuosity, is usually full, and manifests a high degree of blood pressure. The pulse wave is not usually large, although, from the; sinuous or tortuous channel through wdiich the wave of increased pressure travels, there may be a sensation as if the artery leaped from its bed. The pulse wave is sustained and dies gradually away with but little dicrotism. Such are the general features observed when there is a widespread arterial sclerosis. In the rarer cases, however, of localised aortitis, the radial pulse may manifest Ijut few divergences from that which is normally found. A point of some importance is that the pulse may be strikingly different in the two radial arteries on account of the presence of a patch of atheroma at the mouth of one or other of them. The examination of the pnecordia usually reveals the fact that the apex beat is further to the left and more diffuse than in health. On applying the hand, it is found to have the heaving sustained impulse of hypertrophy. If con- secutive heart failure is undergoing development, however, the impulse may not present those characters, and may be short and sharp as in dilatation. The area of dulness is usually somewhat enlarged, more especially to the left. On percussion of the region to the right of the sternum from, the third costal cartilage upwards, some dulness may be found considerably beyond the sternum in consequence. ,of aortiQ dilatation. On CHRONIC AORTITIS. 827 auscultation in the aortic area, the most significant feature is the character of the second sound. This has the distinctly musical character produced Ijy a tap on a drum, whence I'otaiii has aptly termed it hruit de tdbourka, from its resemblance to the sound produced by the little Arab drum. The first sound in this region may be perfectly normal. Commonly, however, it is somewhat blurred, and, if aortic dilatation has followed upon aortitis, a systolic murmur may be present. In the mitral area the first sound is usually low and booming, but it may be high and sharp, according to circumstances. The pulmonary and tricuspid areas may call for no notice, but, if consecutive cardiac failure is present, there may be great accentuation of the pulmonary second sound, or the presence of a systolic tricuspid murmur may be determined. It is not uncommon to find that cedema of the dependent parts is present in cases of , old-standing, and, if this be the case, there is very apt to be implication of the bases of the lungs, shown by muffling of the percussion sound, pro- longed expiration, and crepitations. Two accidents are apt to befall the lungs ; one of these is rupture of one of the arterial branches, or thrombosis in it ; the other is the rapid develop- ment of acute oedema. That the renal system is implicated is commonly proved by symptoms significant of cirrhosis. Affec- tions of the nervous functions sometimes point to the existence of structural alterations produced by haemorrhage, thrombosis, or embolism. Diagnosis. — As a general rule, the recognition of chronic aortitis, and its differentiation from other affections, ]3resent no difficulties. The characteristic physical signs connected with the aortic region and the absence of any proof of valvular disease, together with evidence of arterial sclerosis throughout the - circulatory system, are sufficient to determine that the lesion is present. The chief difficulty arises when the chronic arterial change is purely local. It must be admitted that in many instances the affection may be absolutely latent, since, if no anginous symptoms are present, and there is no increased peripheral resistance from generalised sclerosis of the arteries, both symptoms and physical signs may be in default. If there be such subjective symptoms as have been referred to, along 82 8 DISEASES OF THE AORTA. with the characteristic second soinul, the aft'ection may be legitimately suspected. Prognosis. — Once established, chronic aortitis never dis- appears. In this sense the prognosis of the affection is accordingly grave. As it is, nevertheless, possible to retard the disease processes by appropriate management, the outlook is very largely dependent upon the attendant circumstances. If the condition of the general nutrition and energy, as well as the state of the heart and circulation, should be fairly satisfactory, the prognosis need not be very grave. Treatment. — The management of chronic aortitis is practically that of arterial sclerosis. Abundance of rest, sufiiciency of fresh air, diet mostly composed of white meat, vegetable substances and milk, with free diluents not con- taining alcohol — such are the most useful lines of treatment. Of medicinal substances, those which act upon the blood vessels are of most service, and amongst them iodide of potassium is the most valuable. In many instances the action of the iodide is increased by combining it with arsenic. When cardiac failure steps in, it must be treated on general principles, and any paroxysms of angina pectoris will require the special remedies applicable to that symptom. ANEUEYSM OF THE AOETA. So far as is known, the earliest notice of aneurysm of the aorta is that of Eernel, but the first diagnosis during life is due to Vesalius. Baillon observed abdominal aneurysm, while Albertini and Valsalva not only extended the existing know- ledge of the clinical features of the disease, but introduced some of the therapeutic methods still in vogue. The great work of Lancisi remains to this day a wonderful storehouse of facts regarding the disease, and the pages of Morgagni teem with most interesting observations on it. The name of Scarpa will ever be indissolubly associated with aneurysm, in consequence of his work on it. Corvisart and Laennec were the pioneers in the modern diagnosis of the affection, while its morbid anatomy received its first real impetus from Hodgson. ANEURYSM OF THE AORTA. 829 In so far as is possible, the names of those who have made advances in the study of the disease will be remembered in the following pages. Etiology. — Numerous causes predispose to aneurysm. Many of these have already been mentioned in connection with endarteritis, and but little remark is necessary in refer- ence to them. fSome of these factors, however, have a more marked influence in the production of aneurysm than of endarteritis, and their relations are, therefore, of more im- portance in this connection. There can be no question of the much greater tendency towards aneurysm of the aorta manifested by men as compared with women ; since the observations of Hodgson and Bizot this fact has been matter of universal recognition. The former of these observers found that of 6 3 cases, 5 6 occurred in males, and 7 in females; while the latter in 189 instances found 171 in men as against 18 in women. Browne has recently in his analysis of 173 cases found 153 in men and 20 in women. That the influence of sex is brought about by the different conditions under which average men and women live, is well shown by an observation of Coats, who points out that, while aortic aneurysm occurs in a preponderating manner in men, cerebral aneurysm is found almost equally in both sexes. Age is found to show an interesting relation in regard to the incidence of aneurysm of the aorta. The most important series of statistics dealing with this question is that of Crisp, who found that out of 505 cases of different aneurysms, 198 occurred between thirty and forty, and 129 between forty and fifty. Of 1 6 3 cases Browne found 6 7 between the ages of thirty- five and forty-five, and 46 between forty-five and fifty-five. Similar statistics, although on a smaller scale, have been col- lected by other authors, and from these the conclusion is unavoid- able that aneurysm is more frequent in the fourth decade. Coats remarks with great justice : " Aneurysms coincide with the time of life when the period of greatest bodily vigour over- laps the beginnings of the period of occurrence of atheroma." Endarteritis shows itself at a somewhat later period. Eace appears to have some influence, and there can be no doubt that the inhabitants of the British Isles are more liable 830 DISEASES OF THE AORTA. to the aftection than other nations. This is ahnost certainly clue to the much greater stress under which many of them have to live on account of special occupations. Among pre- disposing causes, certain diathetic conditions are certainly of importance. The uric acid diathesis in its various mani- festations must here be accorded an important place, and it is probable that rheumatism also must lie allowed some influence of a similar kind. Specific invasion, as asserted by AVelch, probably plays a somewhat important part in the production of conditions leading to aneurysm. A very great amount of discussion has been devoted to the subject ; Douglas Powell and CtuII, for example, have been sceptical as to the connection between syphilis and aneurysm, while Jaccoud has supported the views of Welch. The coexistence of infection and aneurysm cannot for a moment be doubted, and it seems to me that the demands for a special type of lesion underlying the develop- ment of aneurysm, which have been put forth hj the opponents of Welch's view, may just as well be made against the view that any dyscrasia exercises an influence in the production of the disease. The abuse of alcohol and other toxic agents may un- doubtedly predispose to aneurysm by leading to degenerative processes, and the same observation may be made in regard to all lesions of the arterial walls by which their elasticity is diminished. The exciting causes of aneurysm, at least as regards the thoracic aorta, are almost entirely based on the conditions of blood pressure. It must be allowed that the abdominal aorta, like the arteries of the limbs, may be the seat of the disease in consequence of traumatism, but it must be rarely indeed that either direct or indirect violence can produce thoracic aneurysm. With the exception of this possibility, the deter- mining factors in the production of aneurysm are centred in an increase of blood pressure. It is through this agency that age and sex have their chief influence in giving rise to aneurysm. Severe exertion of any kind produces an elevation of the blood pressure, and it is found that all occupations which cause great fluctuations in the blood pressure are especially prone to aneurysm. ANE UR YSM OF THE AORTA. 831 It should be added that amongst the determining causes it is possible that direct injury from the impact of emboli upon the arterial walls must be included. This was suggested originally by Church, and the idea has been further elaborated by Ponfick. Although it must be admitted that such a cause may be operative in regard to aneurysm arising from the smaller arteries, it certainly seems in the highest degree unlikely that such an etiological factor obtains in the case of the aorta. Another consideration as regards the etiology of aneurysm also requires notice. As has long been known, a change in the walls of the aorta is sometimes found to follow the lines of distribution of the nutrient vessels. By Martin, the conception of an obliterative endarteritis affecting the vasa vasorum has been regarded as the starting-point of the changes in the wall of the aorta which precede the development of the disease. MoKBiD Anatomy. — There can be no doubt of the relations existing between sclerosis and aneurysm. The connection is absolutely proved by the presence of athero- matous changes in every case of aneurysm of the aorta. The relations of the two lesions, which have been recently the subject of exhaustive investigations by Coats and Auld, and by Hollis, can be studied most satisfactorily in such cases as manifest the commencement of the aneurysmal change in small depressions or patches on the inner surface of the aorta. Even with the naked eye it may be determined that the hollow coincides with a patch of disease, and on microscopic examination of a section of such a depression it is found that the media has vmdergone atrophy. The middle coat becomes gradually thinner on passing from the periphery of the depression towards its centre, and at this latter point it is often almost entirely absent. There can be no doubt that this change in the middle coat is produced by a previous alteration in the intima, which by invading the media leads to atrophic processes with or without definite reaction pheno- mena. When the latter are present there may be cellular proliferation and vascularisation, whereby attempts at com- pensation are produced. These different processes are con- 83^ DISEASES OE THE AORTA. tinued after the productiou of the aneur}'sni, and great part of its wall is composed of connective tissue formed by such reaction processes. The microscopic appearances are shown in the accompany- ing illustration (Fig. 194). The appearances presented by aneurysm have been subjected to a process of analytic classification of the most searching ^J f 'M^ y^ O Fig. 194.— Changes in the aortic walls leading to aneurysm. The intinia (") is greatly thickened ; the media (6) shows great atrophy, and, at one part, almost total disappearance ; the adventitia (c) has [considerable increase, and, in its engorged and dilated blood vessels, furnishes evidence of great vascularisation. kind. It is not my intention to follow in the suit of such unnecessary, if ingenious, subdivision. It is quite sufficient to arrange aneurysms in three great groups : — true, dissecting, and false. By true is meant the condition in which the arterial tunics in whole or in part form the walls of the aneurysm ; the term dissecting is applied to conditions in which the blood has passed between the coats, amongst which it forces its way so as to separate them from each other ; while the variety termed false cannot be regarded as in reality an aneurysm at all, seeing that it is produced by a rupture of ANE UR YSM OF THE AORTA. 833 the arterial walls, leading to the formation of what is simply hsematoma. The first-named variety is that to which alone full consideration will be given in the following pages, although a word may be allowed in regard to some of the appearances produced by dissecting aneurysm. True aneurysm gives rise to morbid appearances usually classed under two heads, but these can be regarded as the two extremes of a series united by intermediate forms. Dilatation of the aorta, or fusiform aneurysm, is most commonly found in the ascending and transverse portions of the arch. It is much less commonly found in the descending aorta. As a rule the dilatation does not only affect the aorta, but also the arterial branches which arise from the part affected. In dilatation of the ascending and transverse portions of the arch, it is extremely common to find that the innominate artery and even its branches have undergone a similar change. In this respect simple fusiform dilatation is very different from sacculated aneurysm, which is rarely linked with dilatation of any of the arterial branches. The dilatation is, for the most part, almost uniform. In the abdominal aorta, for example, if there be any fusiform enlargement, it is almost invariably equal in every direction. This, however, is not the case when the dilatation affects any portion which is curved, as in the case of the arch of the aorta; it. then is found to be much wider on the side of the larger curvature, no doubt from the direction of the stream of blood upon it. The walls of the aorta are always thicker than in health. This is due to a change in all the coats. The intima shows some of the alterations described under chronic aortitis ; the middle tunic is almost invariably diminished in thickness ; the adventitious coat is always augmented to a considerable extent by the result of reaction processes. There is much less tendency towards coagulation of blood in a fusiform aneurysm, and there is accordingly much less deposition of fibrinous layers on the inner aspect of the cavity. Sacculated aneurysm presents iminense varieties in size. Indeed, it may be held, without straining the facts, that its dimensions may vary from a bulging in the wall of the aorta not exceeding the size of a large pea 53 834 DISEASES OF THE AORTA. to an enormous sac as large as a man's head. The walls of an aneurysm are always formed, in part at least, by the arterial coats, but the extent to which they participate in the formation of the sac is subject to considerable variations. The intima invariably has some share in the formation of the sac, and it can be traced from the edge of the opening for some distance along the inner lining. In the smaller-sized aneurysms it may be continued throughout almost the whole of the sac, but in those of larger size it, for the most part, is only carried along the inner aspect for a comparatively short distance. The middle tunic fades away close to, or even outside of the commencement of the sac. This is what might be expected from the fact of its undergoing a previous atrophic change. The adventitious coat, which has already been shown to be relatively thinner in the aorta than in other arteries, becomes greatly increased in aneurysm by reaction processes taking place in it. It also becomes very much more vascular, and, as will be mentioned below, has a tendency to adhere to neighbouring tissues. The opening between the lumen of the aorta and the cavity of the aneurysm is subject to great variations in size. In some cases it does not exceed two or three lines, while in others it may reach two or three inches. The cavity may present one or more chambers, since it is sometimes broken up by partitions, formed by organised deposits. The inner aspect usually presents a some- what rough surface. A considerable quantity of newly formed tissue is disposed in a laminated manner upon the inner aspect, and the layers so deposited, along with organised blood clots, give rise to irregularities. The contents partly consist in the blood in a fluid state, but along with this there are usually some coagula, which may be more or less recently formed. The walls of the aorta elsewhere are usually found to be altered in appearance, the various changes which have been described under the head of chronic aortitis being present. In a few cases, with the exception of the portion of the aorta immediately adjacent to the aneurysm, the walls may be found wonderfully healthy. This, however, is decidedly rare. The intima is very frequently implicated by sclerotic or athero- matous changes at the origin of the arterial branches. In a ANEURYSM OF THE AORTA. 835 very large proportion of the cases of aortic aneurysm there is some affection of the semilunar cusps. Most frequently such changes are of the nature of sclerosis, obviously having origin in factors analogous to, if not identical with, these which have given rise to the formation of the aneurysm. The state of the heart has been much discussed. Eeference to this subject has been made in the consideration of cardiac hypertrophy, and all that requires to be mentioned in this connection is the fact, more particularly emphasised by Stokes and Axel Key, that hypertrophy of the heart is by no means an invariable or necessary sequel to aneurysm. Browne shows that in only 72 out of 173 cases of aortic aneurysm did hypertrophy occur. Fig. 195. — Sacculated aneurysm arising within the sinus of Valsalva and involving the interventricular septum. Aneurysm, by its presence, effects considerable changes in adjacent textures. In the first place, it invariably gives rise to more or less displacement. In aneurysm of the thoracic aorta, the position of the heart itself may be modified, and the lungs, the trachea, the bronchi, the oesophagus, and the various structures within the mediastina may undergo con- siderable displacement. Such alterations in position are almost as well marked in the case of aneurysm of the abdominal aorta. By pressure upon neighbouring structures, moreover, tissue changes are also produced. Adhesions are formed between the wall of the aneurysm and the textures upon which it presses, while erosion of certain of these tissues is common. There is 836 DISEASES OF THE AORTA. further a great tendency to obliteration of hollow viscera, and alteration of the texture of such organs as are compressed. Total occlusion of a bronchus with resulting collapse of the corresponding lung has often been observed, while it is a matter of everyday experience to find that by compression the lung tissue may undergo such changes as to render it remark- ably like the spleen in its naked eye appearance. In rarer cases the heart walls may be invaded, as in the case kindly placed at my disposal by Dr. Harvey Littlejohn, from which the preceding illustration, Fig. 195, was taken. In it an aneurysm arose in a sinus of Valsalva and involved the interventricular septum. It occasionally happens that an aneurysm undergoes spontaneous resolution, so to speak, either because the sac becomes entirely obliterated by deposits from the blood, or by closure of the orifice leading to it. Such results are extremely rare in the case of aortic aneurysms, and they therefore present a marked contrast to the events which are commonly found in the case of aneurysm of the peripheral arteries, in which, by pressure upon the artery from which the sac projects, it may be obliterated, and the sac thereupon becomes filled with organised blood clot. A very much more common event is rupture of the wall of the aneurysm, and escape of its contents into some neighbouring part. Browne found that this occurred in 84 of the 173 cases which he analysed. Dissecting aneurysm is produced by rupture of the internal tunic, permitting the presence of blood between it and the middle coat, or between the layers of the middle coat. In either of these positions it is apt to find its way for some distance along the vessel, and may establish a communication again with the lumen of the vessel, so that the false passage forms the main arterial channel. On the other hand, it occa- sionally, by penetrating the outer coat, causes rupture of the aorta. Kelynack has recently published the history of this affection. A beautiful example of this affection, kindly pre- sented to me by Dr. Harvey Littlejohn, is shown in Fig. 196. Symptoms. — The symptoms of which complaints are made by those who suffer from aortic aneurysm are extremely variable, but the most common are undoubtedly pain, palpitation, and ANEURYSM OF THE AORTA, 837 breathlessness. It is by some authors the custom to divide the symptoms of the affection into direct and indirect ; while Fig. 196. — Dissecting aneurysm of the ascending aorta. The walls of the aneurysm are kept apart by a pencil stem. The aorta shows great atheroma. by others it has rather been the custom to separately study the rational symptoms and physical signs. It is certainly easier to marshal the facts if they are systematically analysed 838 .DISEASES OF THE AORTA. according to the systems affected. The symptoms must, how- ever, be classed imder the heads of general and local. General Symptoms. Circulatory Syjiqitoms. — It frequently happens that sub- jective sensations of the kind observed in cardiac disease make their appearance. Anginous attacks, radiating to one or other shoulder and arm, according to circumstances, are tolerably frequent. Along with such sensations there are not uncommonly feelings of fluttering or throbbing, which call attention to the fact of some circulatory disturbance. Inspection of the patient may show the pallor which is common in aortic disease, and the arteries of the neck often pulsate with excessive vigour, while a capillary pulse may be observed along with these phenomena, if there be, as is so commonly the case, aortic incompetence. The apex beat may be observed in its ordinary position, but it is common to find it displaced in different directions. Some modification in the form of the chest may be present. Sometimes this occurs in the form of a diffuse bulging, but at other times it constitutes a distinct tumour. In either case the part thus prominent presents the appearance of pulsation. On palpation, the apex of the heart may be found to give the characteristic impulse of cardiac hypertrophy ; more commonly, however, it is unchanged or manifests un- mistakable evidences of dilatation. On applying the hand over the swelling, if such be present, the fact of pulsation is amply confirmed, and it can usually be determined that it is of an expansile character, while in a certain proportion of cases it is accompanied hy a distinct thrill. The sense of touch often reveals the fact that the pulsation of the tumour follows that of the apex of the heart by an appreciable, if short, interval, which, speaking generally, "can rarely be ascertained hj the unaided sense of sight. By attaching two flags to the chest with wax, one over the apex and another over the swelling, the fact may be better seen. Tracings obtained from aneurysms show considerable divergences from the usual arterial curve. A sphygmogram from a dilatation of the innominate and carotid arteries is ANEURYSM OF THE AORTA. 839 given below (Fig. 197), and it shows a swift ascent, a flat- tened summit, and a rapid descent. A curve of a somewhat similar character is seen in Fig. 198, which is a tracing taken from an aneurysm of the ascending aorta. In both the double summit is distinct, and it is the graphic representation of the twofold impulse often felt. A change in the position of the heart may be determined Pig. 197.— Tracing from fusiform aneurysm of the innominate and common carotid arteries, obtained by means of the direct cardiograph. by percussion, and sometimes also an alteration in its size, in the direction of enlargement. Over the swelling or tumour the percussion sound may be absolutely dull, and the total extent occupied by the aneurysm may be ascertained with considerable exactitude by this means ; percussion occa- sionally also reveals the presence of dulness in situations where inspection and palpation fail to detect anything abnormal. Fig. 198. — Tracing from sacculated aneurysm of the ascending aorta, obtained by means of the direct cardiograph. This is especially the case in aneurysm of the descending aorta above the diaphragm. In cases of this kind, percussion may furnish most useful evidence, taken in association with the results of other methods of examination. Over the seat of the lesion either the normal arterial sounds or abnormal murmurs may be heard. When pure sounds are audible in the case of aneurysms situated near the heart, the sounds are double, that is to say, the two sounds heard over 840 DISEASES OF THE AORTA. auy large artery are present. These sounds were originally studied by Stokes, Bellinghani, and Lyons, and a very consider- able amount of discussion took place as to their production. All this may now be regarded as matter only of historic interest, and tiie sounds must be regarded as propagated from the heart, just as is the case in the arterial sounds, which have been discussed previously. In many instances these sounds are not present, one or both being replaced by murmurs. By far the most frequent abnormal sound is a systolic murmur, the origin of which is probably by no means always the same. It is possible that it may be produced by a current passing into the aneurysm and causing vibrations ; it is, however, more probable that the murmur is produced by eddies within the sac, which have their starting-point in the current as it passes the aperture, or in the small quantity of blood which enters the sac. There is another mode of production which may reasonably be expected to occur frequently, that is, the pressure of the sac upon the aorta, which may cause an alteration in the lumen, and thus furnish such conditions as are well known to produce a murmur. In many instances some obstruction of the aortic orifice is associated with an aneurysm of the aorta, and a systolic murmur in such cases, having its origin at the orifice, is simply propagated by means of the sac. This may be held to be the cause of the systolic murmur in a good many cases. A diastolic murmur is not infrequently heard over the aneurysm, and a considerable amount of discussion has arisen with regard to its method of causation. It may be said, with- out fear of contradiction, that in almost every case presenting a diastolic murmur there is coincident incompetence of the aortic cusps. Quincke usually has the credit of having called attention to this undoubted fact, but, long before the appear- ance of any work of his upon the subject, Corrigan had described it. Within my knowledge, there are only four well -authenticated cases of sacculated aneurysm in which a diastolic murmur was present along with a healthy con- dition of the aortic cusps — the interesting case described by Balfour, who himself confesses his inability either to ex- plain or understand the production of the murmur, and those recorded by Legg, Bryant, and Pringle. That it is produced ANEURYSM OF THE AORTA. 84 r by a reflux during cardiac diastole out of the sac into the artery may well be doubted, not only since the amount of blood which passes out of the sac during diastole must be comparatively small, but because on the cessation of the cardiac systole with perfectly competent aortic cusps, the diminution of blood pressure which ensues occurs as a somewhat gradual process, and cannot produce the necessary conditions for the origin of a diastolic murmur. It may be, as Quincke suggests, that aortic regurgitation is sometimes found as a purely functional disturbance without any struc- tural alterations ; but this, to say the least of it, must at pre- sent only be regarded as an unproven hypothesis. A distinct diastolic murmur was described by Marey as occurring in a case of dissecting aneurysm communicating with the aortic channel at one of the sinuses of Valsalva, apparently without aortic incompetence. The explanation of such a condition is certainly difficult, but it is quite possible that, after the termination of the systole, the blood in the inter- mural space might, while the aortic pressure was falling from its continuous peripheral outflow, escape into the intramural channel with sufficient force to generate a murmur which would necessarily be late diastolic. Auscultation of the heart very commonly gives evidence of aortic murmurs, denoting obstruction, regurgitation, or both, and it is an interesting point that such murmurs are occasion- ally less distinct in the conventional aortic area than over the aneurysm. The same may be said of the sounds heard over the heart, which are sometimes less distinct than over the sac. Auscultation furnishes proof in some instances of mitral ob- struction or incompetence, but by no means so commonly as is the case with the aortic orifice. The arteries, where they are accessible, are usually hard and tortuous, but are sometimes, on the contrary, perfectly yield- ing and elastic. The radial pulse may manifest considerable variety in its appearances. The walls are usually rigid, but the fulness of the vessel presents no uniform condition. In some instances the contents are certainly much above the normal, but in others the vessel may be much less full than in health. The pressure also is subject to similar variations. 842 DISEASES OF THE AORTA. The rate, as a rule, is rather lower than the healthy average. With regard to rhythm, the pulsation is, except in cases of approaching cardiac failure, perfectly regular. The individual pulsations have considerable variations in different cases. Sometimes the wave is small, tardy, and sustained ; at other times, and this is perhaps more commonly the case, the wave is large, swift, and evanescent. The differences in regard to the pulse depend upon two considerations : in the first place, whether there be much general arterial sclerosis, and in the second place, whether aortic incompetence be present or not. The pulsation in the different arteries of the body occa- sionally reveals facts of considerable interest, and even of dia- gnostic importance. When the radial pulse of the two arms is compared, it may be found to present differences both in time of occurrence and form of curve. It has long been held, as indeed has been stated by Quincke, that the difference in size and time is due to the fact that the sac acts as a sort of reservoir. This, however, has long seemed wanting in con- clusiveness as an explanation, and the idea may be said to have received its deathblow at the hands of von Ziemssen, who has shown that such a difference is produced either by direct pressure upon the mouth of the branch in which the retardation and diminution are to be found, or that some patch of atheroma has caused occlusion at that part. Sphyg- mographic tracings, showing such changes as have been re- ferred to, will be found in the sequel. A considerable amount of venous stasis and cyanosis may be found in consequence of pressure upon one of the great venous trunks, and consequent interference with the return of the blood. Amongst other phenomena, a direct venous pulse lias been described, but this is never the result of the affection itself, and is only found associated with it when aortic in- competence is also present. This statement does not apply to cases of aneurysm in which, from some pyrexia, a direct venous pulse has been produced through dilatation of the arterioles. Pulsation of the arteries in the retina has been described by Becker, and in one instance of aneurysm of the arch the pulsation was found to be more distinct on the left side than on the other. ANEURYSM OF THE AORTA. 843 Alimentary Symptoms. — The digestive system may be implicated directly or indirectly. By pressure upon the oiso- phagus some difficulty in swallowing is often produced, as has been known since the observations of Morgagni. Besides this, there may be spasm of the pharynx and reflex dysphagia. All these symptoms connected with the cesophagus are found more particularly when the lesion affects the transverse portion of the arch and the descending thoracic aorta, but Walshe mentions such a result of abdominal aneurysm. In consequence of the yielding character of the abdominal contents, aneurysm of the aorta below the diaphragm does not produce many direct symptoms in connection with the digestive organs, yet it must be remembered that while direct implication is by no means common, a good deal of reflex disturbance may be produced in consequence of interference with some of the visceral nerves. There may, therefore, be symptoms of excessive or diminished nervous activity connected with the abdominal organs. Hccm^opoietic Symptoms. — The hsemopoietic system does not commonly show many changes, but there are two which may be referred to. One of these, originally observed by Laennec, is pressure upon the thoracic duct by aneurysm of the descending aorta. When this takes place, it produces considerable inter- ference with the blood-forming apparatus, and emaciation may be the result, associated with enormous distension of the thoracic duct. Another rare occurrence has been described — the pro- duction of pigmentation of the skin, in every way resembling Addison's Disease, from pressure upon the semilunar ganglia, in the total absence of any change in the suprarenal capsules. Respiratory Symptoms. — The respiratory functions are often interfered with, and breathlessness may have an immediate or remote origin. By direct pressure upon the lung itself, the aerating space may be considerably reduced, while by pressure upon one of the bronchi there may be collapse of an entire lung ; in both these instances there is therefore a direct cause for dyspnoea. In certain rare instances, dyspnoea has also been produced in a somewhat direct manner by pressure upon, and occlusion of, the pulmonary artery, while pressm-e upon the pulmonary veins has likewise, through the production of stasis, also led to breathlessness. In addition to these more 844 DISEASES OF THE AORTA. or less direct methods of production of breathlessness, the symp- tom may have its origin in interference with the vagus nerve, in which case a reflex dyspnoea results. Cough may be caused by pressure upon the trachea in the case of aneurysm of the transverse portion of the aorta. In such a case, the cough is of a peculiarly harsh, strident description, so much so as to merit comparison to the cough of a gander, as has been suggested ^J Wyllie. When there is pressure by an aneurysm of the descending aorta upon the left bronchus, a persistent cough is also often present, but in this case its character is much less peculiar than when the trachea itself is compressed. Cough, like breathlessness, may also be of reflex origin, and when there is implication of the vagus nerve, or its branches, such an indirect cough is often found. Hicraoptysis may attend the cough. This may be the result of congestion from pressure, but the possi- bility must ever be borne in mind that it may have its origin in weeping from the aneurysm into some part of the respiratory tract. Suffocative symptoms cannot be regarded as of frequent occurrence, but they nevertheless present themselves occasion- ally as the result of interference with the glottis through pressure upon the laryngeal nerves. This subject will again be referred to in considering the nervous effects of the disease. Wheezing noises, having their origin in the respiratory tubes, are of very frequent occurrence, and sometimes present the characters of intense stridor. Many cases of this kind, in which aneurysm was ascertained to be the cause, may be found in the pages of Morgagni. An alteration in the form of the chest is sometimes found in consequence of recession of some part of the chest. When this occurs, it is usually the result of pressure upon one of the larger bronchial tubes, if not on a bron- chus. In cases of this kind there may further be seen less movement upon the affected side. Occasionally diminished movement of the left half of the diaphragm may be found in consequence of interference with the phrenic nerve, as will be afterwards more fully mentioned. One important symptom connected with the respiratory organs is observed on inspection, that is, the symptom of tracheal tugging, first observed by Oliver, MacDonnell, and Ewart. This is observed when the ANEURYSM OF THE AORTA. 845 patient bends the head backwards, so as to put the tissues in front of the neck on the stretch. In this position the trachea will be found to be dragged downwards with each contraction of the heart, and if the finger be placed between the thyroid and cricoid cartilages, and the former be gently pulled upwards, there will be a distinct sensation of dragging with each cardiac revolution. If not absolutely pathoguomonic of aneurysm of the transverse portion of the arch of the aorta, this symptom is, at any rate, seldom observed when it is situated elsewhere. On palpation, if well-marked stridor be present, the vibrations may be distinctly felt, and if there be collapse of any part of the lung from pressure, increased vocal fremitus may be elicited. Dulness may be found over any region which may have undergone consolidation from compression or collapse in consequence of obliteration of the respiratory channel. There may be an increase or decrease of the respiratory murmur. In those cases marked by consolidation, in which the affected area is in connection with any of the larger air-tubes, the breathing may be of extremely harsh vesicular character, or may even pass into the bronchial type. On the other hand, if obliteration of a bronchus has taken place, there may be an almost total loss of the breath sound, and it need hardly be added that the voice undergoes analogous increase or diminu- tion under similar circumstances. Various accompaniments of the breath sounds may be present according to the conditions which have been induced. When there is much interference with the circulatory conditions in the lungs, there may be some moist sounds, but entirely surpassing these is the presence of the stridor already mentioned. Loud as it is to the by- stander, it is still more distinct and characteristic on ausculta- tion, and it may present wide gradations in pitch and harsh- ness. Over and above all these respiratory symptoms, there may occasionally be the development of such characteristic foetor and cachexia as, along with the physical signs of lung implication, to prove the development of pulmonary gangrene. Cutaneous Sym'ptoms. — The skin, as has already been mentioned, may show cyanosis, either locally or generally, and, along with the subcutaneous tissues, it may exhibit oedema of the dependent parts from consecutive cardiac failure, or of 846 DISEASES OF THE AORTA. some restricted area corresponding to one of the great venous trunks. One very interesting observation, originally made by Gairdner, which occasionally presents itself, is a unilateral, or, indeed, strictly localised perspiration from interference with the sympathetic nerves. The skin has also been observed by "VValshe to have localised areas of temperature higher than that of the rest of the body. Urinary Symptoms. — The urinary system may be said to be wonderfully exempt from interference, save in the few cases showing albuminuria from pressure on the renal veins. Generative Symptoms. — -The generative apparatus in the male may undergo structural changes ; thus Walshe mentions atrophy of the testicle from pressure on the spermatic artery. It might theoretically be expected that in women the existence of aneurysm low down in the abdomen might directly affect the uterus and ovaries, l3ut this is, so far as is known to me, unrecorded. Nervous Symptoms. — The nervous effects of aneurysm are multifarious. Many different sensory symptoms have, since Morgagni's original descriptions, been well known. Sensations of weight, of tightness, of soreness, or of pain are felt in many different degrees. Some of these pains are due to direct pressure upon nerves of ordinary sensibility, as, for instance, when a thoracic aneurysm interferes with an intercostal nerve. Most of them, however, are of the nature of referred sensations, and must be placed in the same category as the cardiac pain already fully discussed. In a large proportion of cases of aneurysm of the arch of the aorta, angina pectoris, in its most pronounced and unmistakable forms, is present. It is probable that inter- ference with afferent nerves is the cause of many spasmodic symptoms, such as a spasm of the glottis, or of the pharynx, from interference with the vagus nerve ; but it must not be overlooked that the former may possibly be an early symptom of interference with the motor nerve of the larynx. The recognition of paralysis of the laryngeal muscles, from pressure upon the vagvis or recurrent laryngeal nerve, is often ascribed to Traube, but was previously observed and explained by Stokes. The left vocal cord is that which is usually implicated, seeing that the recurrent laryngeal nerve of that side passes ANEURYSM OF THE AORTA. 847 round the transverse portion of the arch of the aorta. In the case of dilatation of the ascending portion of the arch, extend- ing into the innominate and subclavian arteries, a similar result occurs on the right side. Both cords have been affected from unilateral pressure, as seen by Baumler and Johnson. Semon has recently shown that the abductors suffer first. When the larynx is examined with the laryngoscope, the cord of the affected side is found to occupy the position known as the cadaveric. The unilateral paralysis of the diaphragm, as originally noticed by Burns, may result from aneurysm pressing upon the phrenic nerve. This occurs on the left side when the descending aorta is the seat of the lesion. Changes in the size of the pupil are of common occurrence, as the result of pressure upon the sympathetic nerve anywhere above the lower extremity of the cilio-spinal portion of the gangliated cord. This interesting phenomenon was first brought into prominence by G-airdner. Pupil changes, from pressure by other lesions upon the sympathetic nerve, had been previously described as mentioned by Eeid, and Walshe noted, but did not explain, them in aneurysm. It was nevertheless Gairdner who elevated the symptom into an important sign of the disease. The observations of Ogle and Argyll Eobertson on this subject are also of real interest. The appearances are by no means uniform. In an early stage of pressure upon the sympathetic nerve, the pupil on the affected side is often widely dilated, and its size varies, not merely from day to day, but from hour to hour, while its condition becomes much less marked in the case of an aneurysm which is undergoing improvement ; at a later stage, when the sympathetic nerve has evidently been destroyed by pressure or adhesions, the pupil becomes much contracted from the unbalanced action of the circular fibres. Such symptoms may be found in thoracic aneurysm arising from almost any part of the aorta, while similar effects have been described by Seaton Eeid as the result of aneurysm of the abdominal aorta. Amongst motor symptoms, it must not be forgotten that paraplegia may be produced by erosion of the vertebral column and spinal cord, but is d,ecidedly rare. Osseous Syvi'ptoms. — The bones frequently undergo destruc- 848 DISEASES OF THE AORTA. tive changes iu consequence of pressure. The sternum and ribs in front of the thorax, and the spine and ribs behind, are all liable to undergo erosion and necrosis from pressure upon them, and consequent interference with their nutrition. The result of such changes is to interfere very greatly, not only with the form, but with the movements of the chest. Local Symptoms. It is advisable to consider the symptoms of aneurysm of the aorta in different situations, in order to bring together the clinical features characteristic of its various positions. Aneurysm of the ascending portion of the arch of the aorta gives rise, in the great majority of cases, to a distinct pulsating tumour, situated to the right of the sternum in the second and third intercostal spaces. Some rare instances, in which the sac projects backwards and inwards from the lesser curvature of the aorta, do not produce the localised pulsating swelling. The apex beat is usually displaced some- what outwards and downwards, and it is easy to determine that there are two points of maximum impulse upon the chest. On applying the hand over the tumour, a double impulse is usually felt, the first of the two impacts being occasionally attended by a thrill. Percussion affords the means of defining more accurately the exact position and size of the aneurysm. On auscultation, there may be the two sounds previously described, or more commonly a systolic murmur followed by a short sharp sound, unless in those cases associated with incompetence of the aortic valve, when systolic and diastolic murmurs are both heard over the sac. Such are the most frequent direct appearances found in aneurysm in this position. Some other features may be present. On auscultation, for instance, pericardial friction is occasionally found, connected, as was seen in dealing with diseases of the pericardium, with the pressure of the aneurysm. The right pulse may be smaller in size, and even slightly later in time than that of the left, if the aneurysm causes interference with the mouth of the innominate artery. Localised cyanosis or oedema of the right side of the face and neck, as well as the right arm, may be present. There is ANEURYSM OF THE AORTA. 849 frequently intense pain darting down the right arm, and it i,s not uncommon to find that the muscles of that limb are decidedly weak, or even atrophic. In some instances there may be aphonia, from paralysis of the right vocal cord, if the disease implicates the innominate and subclavian arteries, as is sometimes, but rarely, the case. Contraction of the right pupil is much more common than any affection of the larynx, since the aneurysm is much more likely to interfere with the sympathetic than with the right recurrent laryngeal nerve. Breathlessness, cough, and expectoration, not of dia- gnostic importance in themselves, frequently lead to a careful examination of the lungs, when it is common to find a con- siderable amount of retraction of the right lung. Aneurysm of this portion of the arch very commonly ruptures into the pericardial sac, but it also not infrequently bursts into the right pleural cavity, or by means of adhesions it may become attached to, and finally rupture into the right lung. Sometimes it opens into the superior vena cava. In other cases it brings about a fatal termination by rupturing externally through the thoracic walls. Aneurysm of the transverse 'portion of the arch of the aorta gives rise to a diffuse heaving impulse in the upper sternal region, and episternal notch. In some cases, which are, however, by no means common, the aneurysm by erosion produces a distinct swelling, projecting through some portion of the upper sternal or upper costal region. The impulse which is felt on laying the hand over the praecordia cannot be so distinctly made out to be double. This may, however, sometimes be ascertained with sufficient distinctness. On the other hand, a thrill is occasionally, but not at all commonly, found. A difference in the character of the two radial pulses is much more frequently found with the lesion in this position than anywhere else. On percussion a very large area of dulness may be found in the upper sternal region, and on auscultation the double cardiac sound, or a systolic murmur followed by the second sound, or a systolic followed by a diastolic murmur, may be determined. The respiration is often characterised by a loud rough stridor, and on auscultating the chest this may be heard throughout its 54 850 DISEASES OF THE AORTA. most distant regions. When this is the case, there is fre- quently obstruction to respiration with sulijective symptoms of disturbance. Tracheal tugging is almost, if not always, pathognomonic of aneurysm of this portion of the aorta. Aphonia belongs especially to an affection in this position. Interference with swallowing is extremely common, and there are frequent complaints of a feeling as if the food reached a certain point, and was there arrested. Pain is not such a marked feature of aneurysm in this position as when the ascending aorta is the seat of the disease, yet from implication of the cardiac plexus or its connections, severe pain in all re- spects resembling that of angina pectoris is present. Eupture may take place into the trachea and bronchi, the oesophagus, the great veins, the pleura, or the mediastinum. Aneurysm of the descending portion of the arch of the ciorta is somewhat less definite as regards its physical signs than when in the two situations just considered, and in many instances it remains to all intents and purposes latent. When it affects the descending portion of the arch, and the upper portion of the descending aorta, it may give rise to an alteration in the precordial appearances. The apex beat, for example, may be altered in its position on account of transposition of the heart towards the right, and when that is the case, the significant doubling of the impulse, or " double jogging " of Hope, may be made out on palpation. Percussion of the prtecordia determines more accurately the position of the heart, but usually reveals no other area of dulness, and auscultation probably fails to give any results. On percussion of the chest behind, an area of dulness may be made out to the left of the vertebral column, about the level of the third, fourth, fifth, and sixth dorsal vertebric, and auscultation of this area may reveal distinctive symptoms. Most commonly the stetho- scope reveals a single sound — the accentuated arterial sound ; but at other times two sounds are present, or instead of any such propagation of the cardiac sounds, there may be a systolic murmur. Sometimes there is some delay in the femoral pulse, but this cannot be regarded as a frequent symptom. Occasion- ally there is considerable dilatation of the veins of the chest in consequence of pressure upon the azygos veins. Difficulty ANE UR YSM OF THE AORTA. 851 in swallowing is extremely common, in fact, this is usually the symptom which calls the attention of the patient to the fact that there is anything wrong. Well-marked wheezing may be heard by the bystander, and on auscultation there is not uncommonly characteristic stridor over the left side of the chest. Sometimes, however, great changes in the physical signs furnished by the left lung may be discovered, such as diminished movement, loss of vocal fremitus, impairment of clearness on percussion, and absence of breath and voice sounds ; these may point to occlusion of the left bronchus, and com- mencing collapse of the lung. In other cases, increase of the vocal fremitus, dulness on percussion, harsh vesicular, or even bronchial or cavernous breathing, with moist accompaniments and foetid breath, may show that gangrene has resulted from pressure on the root of the lung. Pain is sometimes present in the left side of the chest, and may follow the line of the intercostal nerves corresponding to the position of the aneurysm, or it may radiate towards the left shoulder and arm. Cases have been described in which the sac has eroded into the spinal canal, and produced symptoms of irritation or depres- sion of spinal functions. Changes in the pupil of the left eye are common. Aneurysm of the descending tlioracic aorta, especially if so situated as to be close to the diaphragm, commonly gives expansile pulsatory appearances, and it may even cause en- largement of the affected side. Sometimes the diffuse pulsation which it produces is accompanied by a thrill, which can easily be determined. Dulness on percussion shows approximately the extent of the aneurysm, and auscul- tation usually reveals either a single sound or a late systolic murmur. No case has ever afforded me an opportunity of detecting either a double sound or a double murmur, yet it is conceivable, although the aneurysm is situated at a considerable distance from the heart, that a double arterial sound might be present, or in the case of aortic incompetence, a double murmur might be found. There is still some trouble in swallowing when the lesion is in this position, and regurgitation of food is often found. Stridor is never produced by aneurysm close to the diaphragm, but, on account of considerable compression 85 2 DISEASES OE THE AORTA. of the left lung, there may he interference with hreathing, shown hy dyspnoea, while cough, sometimes with blood stained expectoration, increased vocal fremitus, comparative duluess, harsh, vesicular, or even bronchial breathing, with increased vocal resonance, and sometimes moist accompaniments, may show that some consolidation is produced by compression. When rupture occurs, it usually takes place into the pleural sac or the cesophagus, but it not infrequently opens into the lung, and sometimes into the spinal canal. Aneurysm of the ahdominal aorta is in a position readily accessible, and most of its symptoms are therefore easily elicited. A pulsatile swelling may be seen, and the movements thoroughly investigated by palpation, while its size may be ascertained both by palpation and percussion. Auscultation usually furnishes evidence of a systolic murmur, but sometimes there is only a single arterial sound. The femoral arteries not infrequently show a delay of the pulse, as Compared with their normal relation to the apex beat and the radial pulse. Dysphagia is usually shown by regurgitation of food immediately after it has been swallowed, while attacks of vomiting may result either from direct interference with the stomach, or from reflex disturbance through some of the splanchnic nerves. The intestinal functions are often modified, and diarrhoea or constipation may result. An icteric tint of the skin is some- times found when the aneurysm is so situated, and so extensive as to interfere with the liver. The discoloration of the skin forming one of the symptoms of Addison's disease has been observed from interference with the semilunar ganglia or their connections. Pain is usually experienced, and is most com- monly of a colicky character radiating throughout the abdomen, but when the aneurysm is situated lower down, it may inter- fere with lumbar and sacral nerve roots, and thus give rise to painful sensations darting around the lower part of the body, as well as down the inferior extremities. Paralysis of the lower extremities has been described as a result of pressure upon the anterior nerve roots. Aneurysm of the abdominal aorta most commonly ruptures into the retroperitoneal tissues, and spreads in every direction upwards and downwards. Sometimes, however, the escape takes place into the general ANEURYSM OF THE AORTA. 853 peritoneal cavity, while in rare cases, through the formation of adhesions to the abdominal viscera, with subsequent erosion, there may be a discharge of the aneurysmal contents into one or other of them. The course of aneurysm is almost entirely dependent upon three factors : — the condition of the arterial walls, the integrity of the aortic cusps, and the energy of the cardiac muscle ; the general state of nutrition of the body, as a rule, however, exercises very considerable influence over the pro- gress of the affection, and it need hardly be added, that the occupation and environment are of the greatest importance. When the arteries have undergone widespread sclerotic changes, so as to resemble rigid tubes, the oscillations in blood pressure are much greater than when the arteries retain their distensibility and elasticity. It follows from this that in such circumstances there is a much greater tendency to destructive changes than when the pressure is regulated and equalised by the normal properties of the arteries. In a similar way, when the aortic cusps are incompetent, there are much greater fluctuations of pressure than when the valves are competent. Aortic regurgitation therefore prevents the conservative process of coagulation of the blood within the sac, while it tends in the direction of rupture. If the energy of the cardiac muscle is excessive, as is certainly the case in many instances of hypertrophy attendant upon aortic aneurysm and arterial sclerosis, the tendency to rupture is greatly increased. On the other hand, when the cardiac energy threatens to fail, there is always a risk of death from asystole. It is unnecessary to add that the habits and surroundings in any case of aneurysm may be such as to exercise a beneficial or deleterious influence on the course of the disease. According to the different combinations existing amongst these different factors, the progress of the disease may be longer or shorter. In many instances, aneurysm exists for a number of years, and does not in the end directly bring life to a termination, death being caused by some inter- current disease, absolutely unconnected with the aneurysm. In another group of cases, aneurysm indirectly produces a tendency towards death, which ensues at last from asthenia. 854 niSEASES OF THE AORTA. In a third class, aueurysm more immediately produces con- ditions which lead towards a fatal result by cardiac failm'e. In a considerable proportion of instances, death occurs directly by rupture of the sac. This result, when it occurs after a brief period, is commonly found to be associated with a considerable amount of arterial degeneration, incompetence of the aortic cusps, and hypertrophy of the left ventricle, while it usually occm^s during exertion. The exertion need not necessarily be of a very violent kind ; a fit of coughing, for example, is often quite sufficient to produce rupture, and its fatal results. Diagnosis. — The recognition of aneurysm, more especially when situated within the thoracic cavity, is often extremely difficult. The diagnosis must be based upon the presence of some of the symptoms which have been fully detailed above ; but as every one of these may be produced by lesions of a totally different nature, there can hardly be said to be any pathognomonic symptom of the disease. The decision in any given case must therefore be largely concerned with questions of probability, and, indeed, the diagnosis is very frequently reached by exclusion. The state of the arterial walls, the condition of the aortic cusps, and the size and energy of the heart are probably of the greatest use. Mediastinal tumour frequently furnishes a considerable number of symptoms absolutely identical with those produced by aneurysm, and the differentiation of the two diseases is extremely difficult. Every pressure symptom may be present. There may be displacement of the thoracic viscera ; a pulsat- ing tumour with an area of dulness closely resembling in position and extent that which might be expected in a case of aneurysm ; even a systolic murmur ; and yet, from the integrity of the arterial walls, the character of the aortic second sound, and the size and beat of the heart, it may seem to be without doubt a new formation in the mediastinum in contact with the aorta. Mediastinal abscess is not so likely to give rise to diagnostic error. In most instances of this affection there are general symptoms of pyrexia, and sometimes even un- mistakable evidence of septictemia, while there are few, if any. ANEURYSM OF THE AORTA. 855 direct symptoms, and those from pressure are not so definite as might be expected from an aneurysm. Cardiac enlargement is commonly mentioned as a possible source of error in diagnosis, but in enlargement of the heart, whether from dilatation, or hypertrophy, or both, there is but one point of maximum intensity of impulse, while in the case of aneurysm there are two spots where the pulsation shows maximum force. Effusion into the pericardial sac can scarcely be mistaken for aneurysm, seeing that the area of pulsation is single, and its intensity is reduced, while the area of dulness has a characteristic outline, and the sounds on auscultation are diminished in force. Pulsating empyema seems to be an occasional source of error, yet in such a condition the position of the area of dulness, and the alteration in the physical signs revealed on auscultation, are in themselves sufficient to establish a differen- tial diagnosis. It is possible that changes in the pulmonary tissues, of tubercular, syphilitic, or cancerous nature, might, if in contact with the heart or aorta, give at once a conducted impulse, and propagated heart sounds. Careful examination of such cases, nevertheless, always shows that the position of the alteration is incompatible with the presence of aneurysm. Pkognosis. — Based, as it is, upon an irremediable change in the tissues of the greatest of the blood vessels, the outlook in aortic aneurysm is always serious, and the prognosis is usually therefore somewhat grave. It must always be dependent upon the facts which dominate the course of the disease in any case under consideration, such as the state of the arterial walls, the aortic valves, and the cardiac muscle, together with the resulting conditions of blood pressure. The degree of general nutrition is also of importance, seeing that it largely controls the circulation. Two other considera- tions are of great importance in prognosis. Speaking generally, the gravity of the prognosis is directly propor- tional to the size of the aneurysm ; the larger it is, the more liable is it to undergo rupture, in accordance with well-known hydrodynamic principles. The general habits and surroundings 856 DISEASES OF THE AORTA. of the patient are most inliuential either for good or evil. These are simply the conditions which have been above referred to as exercising a powerful influence upon the course of the disease, and the prognosis is necessarily entirely dependent upon them. TreatiMENT. — The subject of treatment, it must be confessed, is somewhat discouraging. In very many cases little can be done except to palliate suffering. In a con- siderable proportion, however, it is possible, by careful treatment, not only to alleviate the symptoms, but even to aid in bringing about recovery. It must never be forgotten that the results of post-mortem examinations furnish a very considerable number of instances in which aneurysm has been unsuspected during life and has been seen in a condition of more or less complete obliteration after death. The one great aim in all cases is to favour the coagulation of the blood in the sac. This may be done by diminisliing the pressure and velocity of the blood, by the introduction of agents which will directly induce coagulation, or by producing changes in the walls of the sac. Eeduction of the pressure and velocity of the blood may be caused by the simple methods of absolute rest and restricted diet. Eest is imperatively demanded, and, if it be possible, it should be complete. By means of rest alone, without any modification of diet, and without the addition of any drug, there is a considerable change in the number of pulsations and in the pressure of the blood. The blood pressure, further, does not undergo much variation, and the natural tendency to coagulation within the sac is thereby increased. While absolute physical rest is enjoined in cases where it may seem to Ije necessary, and they form the greater proportion of cases of aneurysm, there should also be, as far as is possible, a cessation of mental effort, since this also is attended hj changes in blood pressure and pulse rate. The diet, further, should be, as Douglas Powell put it, " restricted in quantity, but enriched in quality." According to Morgagni, the recumbent posture and starvation diet were employed by Alljertini and Valsalva, along with other means, which will be mentioned in the sequel. The combination of A NE UR YSM OF THE AORTA. 857 absolute rest and appropriate diet formed the treatment intro- duced by Tufnell. He recommended an extremely restricted diet :— for breakfast, 2 oz. of bread and liutter, and 2 oz. of milk ; for dinner, 2 or 3 oz. of meat, along with 3 or 4 oz. of milk ; and for supper, 2 oz. of bread and 2 oz. of milk. It is believed that this low diet lessens the amount of blood ; it certainly reduces the blood pressure, and, therefore, favours coagulation. It is further held to increase the amount of fibrinogen, and in this way to aid the process of recovery by deposition within the sac. This is, however, doubtful. Certain drugs are of importance in this connection, inasmuch as they assist rest and diet in the treatment of aneurysm. Nay more, we may say that even in spite of deficient rest and careless diet, some of these remedies are still beneficial. The most famous of such remedies is iodide of potassium. This drug, first introduced by Graves of Dublin, as a means of alleviating painful affections of the fibrous tissues and nervous system, was observed by Craig to have produced perfect relief from pain in a case of aneurysm, as he stated in a private communication to Balfour. Somewhere about the same time the use of iodide of potassium appears almost simultaneously to have been investigated in Europe and Asia by different observers. Bouillaud in Paris, and Chucker- butty of Calcutta, found that great relief was obtained by the use of the iodide in cases of aneurysm, and that almost complete recovery ensued if the drug were sufficiently persevered with. Eoberts somewhat later employed this remedy in a large number of cases, but it is to Balfour that we owe the extended employment of this drug. Unfortunately, we do not yet understand the modus operandi of iodide of potassium. It was held by Chucker- butty that the drug increased the coagulability of the blood. This, however, is more than doubtful when we consider that the remedy is one which has such a marked effect as a deob- struent. It is well known that iodide of potassium has some influence in reducing blood pressure and in diminishing the frequency of the heart. The amount of reduction of blood pressure, however, is extremely small, and the diminution in 858 DISEASES OF THE AORTA. the rate of the heart is iuappreciable witli ordinary doses of the drug. It has been shown by See and Lapicque that the first effect of iodide of potassium in a small dose is to increase tlie blood pressure, as well as to diminish the frequency of the pulse, and that, if the dose is increased, the blood pressure falls, while the rate of pulsation rises. Balfour strongly recommends that, in the administration of iodide of potassium, such a dose should be administered as will produce some reduction of the blood pressure without any acceleration of the pulse. He holds that the essential process whereby relief is obtained is through thickening and contraction of the wall of the sac. We may admit it to be extremely probable that, under the influence of iodide of potassium, the nutri- tion of the walls of the sac, as well as of the whole of the arterial system, undergoes improvement, and that some of the adventitious products may be relieved ; but that there is any specific influence of this kind may well be doubted. One of the most remarkable effects produced by iodide of potassium is the rapid disappearance of painful sensations. This is, without a doubt, the most constant and, at the same time, one of the most useful results obtained by using the drug. The iodide does not only remove or lessen the continuous dull aching attendant upon aneurysm, but it also obviates or arrests the ano;inous attacks which occur from time to time. How it does this is still obscure, and we are just as little able to explain the analgesic effect of the drug as to explain the undoubted fact that its administration aids in the relief of the other symptoms of aneurysm. The dose of the drug used to be large — almost as great as that em- ployed in tertiary syphilis — nowadays it is found that results quite as satisfactory in every way may be obtained by the exhibition of doses not exceeding five or ten grains. Certain other remedies have been employed instead of iodide of potassium. Amongst these may be mentioned the nitrite series, including nitro-glycerin, nitrite of sodium, and nitrous ether, as well as the modern synthetic group of which phenazone may be cited as an example. The effect of these drugs is in every way less valuable than is the case with the iodides. ANEURYSM OF THE AORTA. 859 The internal administration of remedies which are believed to act as astringents has often been recommended. Acetate of lead was vaunted by Dusol and Legroux, while tannin, as well as ergotin, has been very frequently employed. The effects of these drugs cannot be regarded as thoroughly established, but recoveries have been reported. It is often necessary to add certain auxiliary remedies in order to relieve symptoms. Morphine, for example, must in many cases be employed from time to time as an ancillary remedy, in order to allay pain ; and some hypnotic, it may be an opiate, or one of the newer remedies, may be urgently required from time to time. In addition to the use of drugs, we have certain other means at our disposal whereby the symptoms of aneurysm may be alleviated by reduction of blood pressure. One of the simplest of these methods is general blood-letting, originally proposed by Albertini and Valsalva, strongly advocated by Hughes Bennett, and also recommended by Fagge. The abstraction of four or five ounces of blood from the arm often brings about a striking amelioration of the distressing symptoms by relieving the pressure effects. The influence of this method of treatment may justly be regarded as in every way analogous to that of the drugs which lower the blood pressure by dilating the arterioles. The effects are from the nature of things evanescent, since the blood pressure speedily rises again ; the method may nevertheless serve to turn a dangerous corner. Diminution of pressure within the sac by compression of the vessel on the proximal side, such as is often so service- able in aneurysm of the peripheral arteries, is inapplicable in the case of the thoracic aorta, but it has been employed with benefit by Murray, Moxon and Durham, G-reenhow, Heath, and Philipson in abdominal aneurysm. Another class of remedies consists of various agents brought to bear directly on the contents of the sac. Amongst these may be mentioned the injection of chemical substances, such as perchloride of iron. The results of these attempts to produce coagulation are not such as to tempt their repetition. Electrolysis has been greatly employed by Petrequin, 86o DISEASES OF THE AORTA. Ciniselli, and Duncan. The method adopted is to pass a continuous cm-rent through the contents of the aneurysmal sac. Two needles carefully insulated, except at their points, and connected with the poles of a galvanic battery, are passed into the sac, care being, of course, taken that the points do not touch each other. It is, perhaps, better to employ only one needle connected with the positive pole, and to connect the negative pole with a large rheophore applied to the surface of the body in the neighbourhood. In this way a firm clot is sometimes obtained. Several patients treated by galvanism in this way have been under my care or under my observa- tion. The result in none of these cases was very satisfactory. Probal)ly, however, in every instance the treatment was only adopted when it was obvious that all other means would fail. It seems to me quite likely that this method of practice has scarcely ever had a perfectly fair trial. Another system of treatment, originally introduced by Moore, but usually associated with the name of Loreta, con- sists in the introduction of metallic wire into the aneurysmal sac, with the aim of producing coagulation of the blood upon the foreign body so inserted. Fine iron wire is the material which has been most commonly used, but fine wire made of other metals has also been employed, and horse hair has also been introduced. The general effect of this procedure is unfavourable ; it is apt to lead to inflammation, so that it aggravates the symptoms and precipitates the termination of the disease. The results of the recorded cases down to 1887 — 2 recoveries in 16 cases — have been collected by White and Gould. They are certainly not such as to encourage sanguine expectations. A combination of the methods of Ciniselli and Moore has recently been adopted by Hershey. It consists in the introduction of a coil of gold wire into the sac, and the passage of a continuous current through it. By this means in one case a most successful result was attained. Macewen has been remarkably successful in the treatment of aneurysm by a method introduced by himself. His pro- cedure is extremely simple, consisting in transfixion of the aneurysm with a needle, and manipulation of it within the ANEURYSM OF THE AORTA. 86 1 sac. After rendering the skin thoroughly aseptic, tlie needle is introduced so as to penetrate the sac, and pass through its cavity until it comes into contact with the further side, which it should touch without doing anything more. The needle may then be left, so that the impulse of the blood current may move it about in such a way as to produce irritation of the inner wall of the sac, or it may be moved about by the operator, so as to tear gently the lining of the sac. If the former plan be followed, the needle should only be left a few hours, but Macewen says its retention for twenty-four or thirty-six hours appears to have a greater effect. He is of opinion that it should never remain more than forty-eight hours in the aneurysm. If the other method be employed, after moving the needle backwards and forwards over the opposite wall of the aneurysm for ten minutes, the point should be shifted to another spot without withdrawing it ; after having manipulated the new area, another spot may be dealt with, and the process continued in this way, until the greater part of the internal surface opposite has been treated. In Macewen's hands this method of treatment has been markedly successful. No opportunity has yet been allowed me of practising it on any patient under my own care, but some cases, which have been under my observation, induce me to speak in the most favourable way in regard to it. It is but rarely that the surgical methods of treatment applicable to peripheral aneurysms, such as compression or ligation, can be employed in those of the thoracic or abdominal aorta. In presenting some cases of aneurysm as examples of common clinical and pathological features, they will be grouped in a definite manner : — a case of fusiform aneurysm in its most usual position ; cases of sacculated aneurysm in different situations, to illustrate the facts of localisation ; cases to show the relations of aneurysm to the radial pulse ; cases of affec- tions which might be mistaken for aneurysm ; and a case to show how long life may be maintained and symptoms allevi- ated by appropriate treatment. Case 70. Dilatation of Ascending Aorta and Innominate Artery. — J. B., aged 54, gardener, frequently consulted me in the out-patient 86: DISEASES OF THE AORTA. department of the Eoyal lutirmary on account of cough and dyspncea. The family history of the patient was somewhat indefinite, but he had a strong impression that his father had died of heart disease, while it was absolutely certain that one of his brothel's had been cut off in early life in consequence of some form of heart affection. His social conditions had •it--' > ev' Fig. 190. — Dilatation of ascending aorta in Case 70, always been satisfactorj'. The pre^■ious health called for but little remark, except that, about ten years before he came under observation, he had suffered from attacks of faintness. The illness for which he sought ad^dce began a few months before he was first seen by me, and he believed that it had been induced by a violent fit of coughing. The general appearance of the patient was healthy. The alimentary system ANEURYSM OF THE AORTA. 863 revealed no symptoms of an almormal kind. He liad no sulijective phenomena connected witli tlie circulation. On inspection, there was a consideraljle amount of throbl:)ing in tlie carotid arteries, and this was more especially the case on the right side. The apex beat occupied the fifth intercostal space, 4 in. from mid-sternum ; it was somewhat dift'use and sustained. Palpation of the uj^per region of the chest to the right of the sternum gave rise to a feeling of impact, hut it was by no means very distinct. The area of cardiac dulness was found to extend considerably further upwards than the normal — in fact, it reached the level of the episternal notch and the U23per margin of the clavicles. Just below the clavicles it extended 3 in. to the right, and 2 in. to the left of the middle line. At the level of the fourth costal cartilage it was 3 in. to the right and 4 in. to the left of that line, and in the fifth intercostal space the border of the heart was 5 in. from mid-sternum. Auscultation revealed a systolic, as well as a diastolic, murmur in the aortic area, and a distinct sej)arate systolic mitral murmur in the mitral area. There was a distinct difference between the two radial arteries, the pulse wave in that of the right being somewhat smaller than that in the left, but there was no retardation of either. There was no evi- dence of interference with the respiratory system, and the only other symptom of any importance was the presence of some myosis of the right eye. The diagnosis in this case was fusiform dilatation of the ascending and transverse portions of the aorta. " For some time the patient per- sistently declined to enter the Iniirmary as an inmate, but as, in spite of the continuous employment of iodide of potassium and tonic remedies, he steadily lost ground, he at last consented to become an in-patient, and was placed in Ward 22, at that time under my care. Notwithstanding every means to avert it, he rapidly became worse, and manifested evi- dences of cardiac failure, of which he died suddenly. The post-mortem examination revealed a considerable dilatation of the ascending and transverse portions of the arch of the aorta. The aortic cusps were thickened and incompetent. The left ventricle was somewhat dilated and greatly hy^Dertrophied. The apjoearances are seen in Fig. 199. The case furnishes a good example of simple dilatation of the aorta, with lesions of the cusps from sclerotic changes. The following instances form a regular series : — Case 71. Aneurysm of the Ascending Part of the Arch of the Aorta. — Arthur M., aged 57, formerly a soldier, and latterly a railway porter, was admitted to the Eoyal Infirmary under my care on account of pain in the chest. His father diejl from the eftects of an accident at the age of 40 ; his mother of bronchitis when 75 ; of his brothers and sisters he could tell nothing. He was the father of six children, who had always been in good health. In early life he suffered great hardships both in the Crimean War and the Indian Mutiny, and since his discharge he t>64 DJSEASES OF THE AORTA. underwent a great deal of hard wurk, more especially in the lifting of heavy weights. His health, however, had been very good until the ill- ness for which he came to the Intirmary. About eighteen months before his admission, he l)egan to suffer from severe jiain in tlie right side of the chest, which extended upwards to the slumhh'i' and down the arm of that Fig. 200. — AiiBUrysm of the ascending aorta ; the position of the rupture is denoted by the pencil which is inserted through the opening. side. He nevertheless continued to do his work, although with increasing difficulty, inasmuch as Ijreathlessness began to trouljle him, and gradually became more severe. The patient when examined was found to have these symptoms to which reference has just been made, and he had also a hard dry cough, but this cough was not of the harsh strident character produced by pressure on the trachea. There was no difficulty either in breathing or in swallowing. ANEURYSM OF THE AORTA. 865 On inspection tliu riglit pupil was seen to be Larger than tlie left. TIk; right side of the chest at the level of the second, third, and fourth costa] cartilages, with the intercostal spaces between them, was prominent, and distinct pulsation Avas seen over the area of tlie swelling. Palpation showed that the impulse was expansile, Init not accompanied by any thrill. The apex beat was in the sixth left inteixostal space 6 in. fi'om mid-sternum. The cardiac dulness extended outwards to tlie right 4 in. at the level of the second, 3^ in. at the third, and 3 in. at the fourth costal cartilage. To the left it extended 5 J- in. at the ]'/,vel of the fifth cartilage. On auscultation, loud systolic and diastolic murmurs were heard over the entire prascordia. The walls of the radial arteries Avere wonderfully soft and healthy. The pulse was bounding and collapsing, equal both in time and size on each side ; it was perfectly regular and its rate was about 80 per minute. There was some compara- tive dulness of the upj)er lobe of the right lung, obviously due to the direct effect of j)ressure on the lung itself. Both lungs elsewhere were free from any sign of disorder. The patient presented no e^adence of any disturbance connected with the other systems. In this case there could be no doubt as to the diagnosis of an aneurysm arising from the right side of the ascending part of the aorta. The patient was kept absolutely at rest and treated by means of iodide of potassium with appropriate diet, and, when the pain rendered it neces- sary, small doses of morphine were administered. For some time he appeared to undergo a certain amount of improvement, but the symptoms afterwards became more severe, and he died very suddenly one morning, apparently from rupture of the aneurysm. At the autopsy it was found that the heart was greatly hypertrophied, the aortic cusps were thickened and incomjDetent, and there was a large aneurysm arising from the con- vexity of the aorta on its ascending portion. The immediate cause of the patient's death was a rupture of the aneurysm into the pericardial sac, where the pericardium surrounds the aorta. The appearances pre- sented by the heart and aneurysm are shoAvn in the accomjianying illus- tration (Fig. 100). The case furnished a good clinical picture of sacculated aneurysm of the first part of the arch. Case 72. Aneurysm of the Transverse Part of the Arch of the Aorta. — John R, aged 46, rope-spinner, came under my care in the Royal In- firmary, complaining of pain in the chest. His father, who was 69 years old, was well ; his mother died at 5 1 years of age of some liver affection. He had seven brothers and one sister, all healthy. Of twelve children of his own, six died in babyhood, the remaining children were strong. His surroundings and previous health had been always good. About two years before admission he began to suffer from pain in the left shoulder ; this had continued to trouble him ever since, and on the day of his admission his voice suddenly became hoarse and monotonous. Such were his com- plaints when he was received into the ward. 55 866 DISEASES OF THE AORTA. On examination, it ^\•a.•^ luuncl that there \VL-rL' no otlier subjective symptoms — no evidence of such i:)ressure on the trachea, oesophagus, veins, or lungs, as to produce interference with their functions. The prc¥coi-dia showed no bulging, but there was an evident pulsation in the upper sternal region. The impulse in this neighbourhood was distinctly felt on palpation ; it was unaccompanied by any thrill. The precordial dulness was found to Ije considerably increased upwards. At the level of the second costal cartilage the dulness extended 2i in. to the right, and an equal distance to the left of the mid-sternal line, opposite the third rib the figures were 3 and 3i, while at the fourth rib they were 2^^ and 4i. No murmur could be heard over the heart, but tlie second sound was greatly exaggerated over the aortic area and the adjacent parts of the manubriuni sterni. The pulse in the right radial artery M'as much larger than in the left, and it Avas earlier in time. On elevating the thyroid cartilage, a distinct downward dragging was found with each systolic phase. Laryngoscopic examination of the larynx and trachea revealed, as was anticipated, a complete paralysis of the left vocal cord. There were no further physical signs of disturbance in connection with any of the other systems. There could be no doubt that in this case there '\\as aneurysm of the transverse part of the aortic arch. Under treatment, by means of iodide of potassium and rest, the subjective symptoms somewhat improved, but there was little change in the physical signs when he left the hospital. The case exemplifies many of the features of aneurysm of the transverse part of the arcli. Case 73. Aneitrysm of the Descending Part of the Arch of the Aorta. — William M., aged 46, engineer, came under my care in the Royal In- firmary for breathlessness, cough, and weakness. He could giA-e no facts in regard to his father, but his mother was alive, and, in spite of being TO years old, was still a strong woman. He had no brothers or sisters. His surroundings had always been favourable, but his work was hard. He had never suffered from any serious illness. About a month before admission his breathing had become troublesome, and, after having struggled with breathlessness for some time, a cough was developed with some indefinite pain in the back and chest. The patient had no symp- toms of disorder of the digestive system, and in particular no difficulty in swallowing. The apex beat was in the fifth left intercostal space 5 in. from mid- sternum. The cardiac dulness extended liom 2 in. to the right to 5 in. to the left of the mid-sternal line, at the level of the fourth cartilages. On auscultation there were murmurs both of systolic and diastolic rhytlun referable to the aortic orifice. There was no dift'erence in the radial pulses, which had a character api^roaching that of Corrigan. On percussion of the chest posteriori}', there was an area of dulness to the left of the spinal column, beginning at the levid of the seventh cervical ANEURYSM OF THE AORTA. 867 and extending as far down as the tliird dor-sal spine, a distance of 3| in., and over tliis patcli the heart sounds were heard with great distinctness, but no murmur was audible. A deep-toned rhonchus was heard over great part of the left lung posteriorly. These facts led to the diagnosis of aneurysm of the descending portion of the arch. Eest and iodide of potassium speedily relieved the more important symj)toms, but the patient became tired of hospital and left before any conspicuous benefit could be obtained, In this case it was quite clear that the symptoms and physical signs might have been explained by the diagnosis of an aneurysm arising from the descending part of the arch of the aorta, or of a tumour in the posterior mediastinum, and, if it had not been for the presence of the affection of the aortic orifice, there would have been little evidence in favour of either view as against the other. The fact, however, that there was a lesion of the aortic cusps was a strong point in favour of the diagnosis which was adopted. Case 74. A^ieurysm of the Descending Thoracic Aorta. — John K., aged 45, sea-cook, was admitted under my care in the Eoyal Infirmary com- plaining of pain in the chest. His father had died of some convulsive attack, and his mother of phthisis. He never had any brothers, but of two sisters one was in good health, the other had died of typhus fever. His surroundings had been those of a seaman, but he had gone through some severe experiences, one of which must be specially referred to. The patient had suffered from malaria and typhus fever, and about eighteen years before admission he had contracted syphilis. Sixteen years before entering hospital he underwent great hardships. His own narrative showed that when rounding Cape Horn in the barque HomeiKird Bound, with a cargo of coal, and a crew of fourteen hands all told, smoke was dis- covered coming from the fore-hold on the 19th of June 1878, while the ship was labouring heavily in a high sea. After fighting the flames for five days, it was clear that the barque must be left. When the crew were about to take to the lifeboat, they could not find the captain ; he had disappeared during the night. The remaining thirteen had great sufferings, being adrift from the 24th of June until the 10th of July, from which four died. Two Germans jumped OA^erboard in a distraught condition ; the mate cut his throat the very night before they were rescued. Only six were left in the boat when it was picked up by the Italian barque Giranna, of Genoa, bound for New York, and but three lived to land at New York, which was reached on the 21st of August. It may be added that the second mate and the boatswain, who were, along with the patient, the sole survivors, died some years previ- ously, and he was therefore the last of the crew of the ill-fated barque. Ten months before admission, he began to suft'er from pain in the left side of his 868 DISEASES OF THE AORTA. chest, but continued to -work at the ducks foi' live mouths, after Avliich he found work out of the question. On examination it was found that, although the digestive processes were carried out very well, there was considerable difficulty in swallowing. After the food had passed down a certain distance it appeared to meet AS'ith some obstacle, and to pass it only with a painful effort. The chest was observed to pulsate very strongly in the entire lower part of the left side, in front as well as behind. Tlie sensation experienced by the hand ANEURYSM OF THE AORTA. 869 Avlien applied to the thorax was that of an expansile impulse, and it was not accompanied by any thrill. The cardiac dulness was found to extend 2 and 4-1 in. to right and left of niid-sternuni at the level of the fourlli costal cartilage. Posteriorly there was a patch of dulness extending along the left border of the vertebral column from the sixth to the twelfth spine, measuring 6|^ in. vertically, and 5 in. horizontally. On listening over the prcecordia the second sound in the neighbourhood of the aortic cartilage was greatly accentuated, but there was no murmur over any part of the cardiac region except at the xiphoid cartilage, where a murmur was audible half-way between the first and second sounds. Over the patch of dulness posteriorly the two heart sounds were heard M'ith great distinctness, but no murmur could be detected in this position. The radial arteries were almost healthy, the tension was moderate, the rate of the pulse 72, and the rhythm regular. In this case the heaving pulsation and dull area in the lower part of the left side of the chest, over which the heart sounds could be heard so distinctly, made it almost certain that we had to deal with an aneurysm of the descending aorta ; and the accentuation of the second sound in the aortic area rendered this more probable. The dysphagic symptoms made it clear that the sac must be situated above the lower end of the oesophagus, and the diagnosis was that of aneurysm of the descending aorta arising above the pillars of the dia- phragm, and extending towards the left. The patient was treated in the usual way by means of complete rest and iodide of potassium. The pain was so severe and continuous that it was found necessary to administer opiates freely. In spite of the treat- ment the patient did not make satisfactory progress, and the question of adopting electrolytic treatment was under discussion, when he died suddenly during a fit of coughing. The post-mortem examination showed an aneurysm of large size in the position suspected, and the immediate cause of death was rupture of the sac into the left pleural cavity. The vertebrse were much eroded. The appearances of the heart and aorta, with the large aneurysm, are shown in the preceding illustration (Fig. 201), taken from the right side. A flexible tube has been passed into the sac at the site of the rupture, and can be seen coming out of the lower cut end of the aorta. The case illustrates the clinical features of aneurysm of the descending thoracic aorta very thoroughly. Case 75. Aneitrysm of the Abdominal Aorta. — Jane A., aged 43, laundress, was under my care in the Eoyal Infirmary on account of swell- ing and pain in the left side. Her father, who died at the age of 60, was a rheumatic man ; her mother died of acute pneumonia at 40. All her 870 DISEASES OF THE AORTA. luotliers and sisters died in iufaiicy except one brother, who was in good health. The patient was married wlien 16 veal's old, and had two children — a boy who died when 2 years old, and a danghter now married and the .mother of three children. Her surroundings were not unfavourable, but her occupation exposed her to (^nld, and her food had sometimes been scanty. > Fig. 202. — Aneurysm of the abiloniinal aorta. The two tubes pass from the aorta into the sac, are continued into the aorta below, and emerge by means of the two iliac arteries. She never had rheumatism, but suffered once from erysipelas, and the year before her admission she had been in the ward with pain in the chest and breathlessness, accompanied by jaundice and dropsy. Although she lost these symptoms, she never quite recovered, and six months before being admitted for the second time, she began to experience a sharp pain in the left side. The pain, although continuous, was aggravated by ANEURYSM OF THE AORTA. 871 exertion, and wa;^ followed, thi'ee montlis later, by a swelling in the left hypocliondrium, wliicli gradually increaf3ed. The patient was obviously anaiinic, with bloodless lips and gums. She lay on the back and left side, and could not turn on her right side without greatly increasing the pain. Her teeth were bad, and her tongue foul. She suffered from much thirst, and had little appetite. Once or twice after admission there was some hsematemesis, but no melsena. The area of the stomach was within healthy limits, and the hepatic dulness extended from the fifth rib to the costal margin in the mammillary line, a distance of 6 in. A pulsating tumour was visible in the left hypocliondrium ; it was expansile on palpation, but could not be fully investigated in this way, as pressure produced great pain. It was dull on percussion, and the dulness merged iaa that of the spleen, heart, and liver. In the left anterior axillary line it extended from the sixth rib to a point just below the costal margin, and measured 8 in. A loud systolic murmur of soft character was audible over the whole of this dull area. In addition to pain, the patient suffered from palpitation and Fig. 203. — Tracing with Marey's stetliograpli, from Case 75. dyspnoea. There was much pulsation in the suprasternal and supra- clavicular spaces. The apex beat was diffuse, and occupied the fifth space at the mammillary line. The cardiac dulness was found to extend 1|- in. to the right and 4|^ to the left of the middle line at the fourth cartilage. In the aortic area there were murmurs of obstruction and incompetence, and there Avere, further, two independent murmurs signi- ficant of tricuspid and mitral regurgitation. The radial vessels were soft, the pulse full, and of moderate pressure ; its rate was about 70 and its rhythm regular, but it had to a considerable extent the characters of a Corrigan's pulse. There was no difterence between the two radial pulses, and the loss of time between the radial and femoral pulsation was quite imperceptible. There Avere no symptoms of disorder connected Avith any of the other organs. There could be but little room for any difference of opinion in regard to this case save in regard to the exact localisation of the aneurysm, and from the position of the pulsation it seemed to be probable that the aneurysm would be found to have its origin about the coeliac axis. Cyrtometer tracings of the tAvo halves of the body at the level of the pulsation shoAved that the left side was 2|- in. larger than the right, the figures being respectively 13|- and 16. Tracings obtained Avith Marey's stetho- graph gave in an interesting Avay the expansion of the whole circumference of the body with each pulsation, as may be seen in Fig. 203. 872 DISEASES OF THE AORTA. The patient improved in some measure on iodide treatment, and after a residence of a few weeks in the Infirmary decided upon going home. She had not, however, been there for more than a couple of weeks, when she again presented herself, and was found to he suffering from an attack of a febrile character resembling septicemia, under which she rapidly succumbed. The autopsy Ijrought to light a large aneurysm of the abdominal aorta at the origin of the eccliac axis, along with obstruction and incom^^etence of the aortic, and incompetence of the mitral and tricuspid valves. Ko cause could be found for the septicivmia, the existence of which was amply proved Tiy the presence of purulent deposits in the synovial structures, and in the slu-aths of the vessels, as well as by the jiresence of streptococci. The appearances presented by the aneurysm are seen in the illustration (Fig. 202). These five cases form an instructive series, and in order to present their main features in a graphic manner, they are grouped in the following talile : — Cases. 2 3 4 Symptoms. 1 Tumour . . . . . . x Area of dulness . . . . . x Expansile pulsation . . . . x Murmui's over sac — Systolic . . . . .---XX Systolic and diastolic . . . . x - - - — Accentuated aortic second sound . . . — x - x — Cardiac murmurs — Double aortic . . . . . x - x - x Systolic mitral . . . . — - - - x Systolic tricuspid . . . . — - - - x State of radial pulse — Eight lai'ger and earlier . . . — x - - — Pressure on — Veins . . . . . ______ Nerves — Sympathetic . . . . x - - - - Eecurrent larpigeal . . . - x - - — Sensory . . . . . x x x x x Trachea — Causing " tugging " . . . - x - - - Causing stridor . . ______ Bronchus — Causing rhonchus . . . - — x - - CEsophagus . . . . . - - — x — Bones . . . . . . - - - x - N.B. — In the above table a cross indicates the presence, and a dasli the absence of the symjitom. ANEURYSM OF THE AORTA. 873 Case 76. Aneurysm of the Trannverse Portion of the Arch of the Aorta. — J. H., aged 53, wool-packer, came to ste me at the Eoyal Infirman-, 21st June 1895, complaining of hoarseness, and pain in the chest. There were absolutely no tendencies to any particular disease in the family history. His father had been lost at sea ; his mother had died of cholera ; the entire family had consisted of himself and a brother, who had always been in perfect liealth. He had been married for twelve years, and had one child, aged 11, who was very welL The social conditions had been excellent. His previous health left nothing to Ije desired, except in the imjiortant particular that he had suffered from Fig. 204. — Tracing from right radial arterj% Case 7t?. syphilis thirty years before the date of our interview. The attack for which he sought relief began with hoarseness seven months before his appearance at hospital, which, about a month after its onset, was followed by the development of severe pain behind the sternum ; this passed towards the left shoulder and ran down the inside of the left arm to the ulnar fingers. This pain was associated with considerable numbness. The patient's general appearance was that of health ; his height was 5 ft. 8 in., his weight 9 st. 13 lb. He was well-built and muscular. The digestive functions presented no symptoms of special importance. Fig. 206. — Tracing from left radial artery, Case 70. Beyond a furred tongue and bad teeth, there were no abnormal features, and, in particular, deglutition was perfect, there being absolutely no trace of obstruction. The glandular apparatus showed no abnormality. The circulatory system gave the subjective phenomena to which reference has been already made. The pain was unattended by any palpitation, but there was distinct dyspnoea on exertion. The cervical veins on the left side were full. There was diffuse heaA'ing of the upper part of the sternum, closely following upon the apex beat, and there was some pulsation in the epigastric regi'on. On applying the hand over the upper part of the sternal region, the pulsation was found to be strong, although diffuse, and with one hand upon this region, and the other OA'er the apex 874 DISEASES OF THE AORTA. l>eat, there was Ibuiul to be a Vi-iy slij^^lit interval of time, tlie apex beat sliglitly preceding the sternal impulse. The apex beat occupied the sixth intercostal space. On percussion it was found that there was great increase in the pr;ecordial dulnes.s, which extended up to the episternal notch, and the upper edge of the clavicles. At the episternal notch the dulness extended %\ in. to the right, and 1:V in. to the left of the mesial plane, and at the level of the fourth costal cartilages its lateral boundaries were 2i^ and 5 in. respectively from mid-sternum. The left cardiac border at the level of the apex beat was 6i in. from mid -sternum. On auscultation there were two murmurs, systolic and diastolic, with their maximum intensity in the aortic area, and they showed the mode of propagation characteristic of such murmurs. The arteries throughout the body were rigid, and most of them showed high pressure. There was a distinct difference between the pulsation in the riglit and left radial arteries, the right being full and quick, Avhile the left was empty and slow. The left also distinctly followed the right in point of time. The pulse rate was 52. The characters of the pulse, as ascertained by the sjihygmograph, may be seen in the tracings (Figs. 204 and 205). The patient's voice w^as hoarse, but no wheezing W'as heard. There was a slight cough, dry in character, but not presenting the typical character of tracheal obstruction. There was well-marked * tracheal tugging. The examination of the chest produced absolutely negative results, but on examination of the larynx with the lar^Tigoscope, the left vocal cord was found to be absolutely jiaralysed. There were no symptoms connected with the urinary and integumentary systems, and the only point in I'egard to the nervous system was that the right puijil was somewhat smallei' than the left. This case furnishes an interesting example of auemysm of the transverse portion of the arch of the aorta, and it is narrated here in order to show the differences in the radial pitlses. It is of interest to observe that there were so few symptoms of pressure upon the hollow viscera passing down the mediastinum, the cesophagus and the trachea being almost exempt from all disturbance, while there was also but little interference with the return of blood from the periphery. Along with the absence of such symptoms, there was con- siderable disturbance of the nervous tracts by pressure upon different nerves. Case 77. Aneurijsm of the Ascending Part of the Arch of the Aorta. — James T., aged 55, engaged as a porter, complained of palpitation, breathlessness, jjain in the right side of the chest, choking sensation after eating, singing in the ears, and weakness of the legs. The patient's father enlisted as a soldier and was lost sight of. His mother died of cholera. He had one brother who died of heart disease, and a sister who was ANE UR YSM OF THE A OR TA. 875 said to have died of debility. He liad eight children, of whom six were in good health, and two had been carried off by whooping cough. He had himself suffered from enteric fever, and had, about twenty years before admission, had some luematemesis and meLiena. His social condi- tions had been satisfactory. The illness for which he sought admission l)egan six months before he presented himself, and the earliest symptoms were pain and palpitation on exertion, which gradually increased in severity until his admission. His lips and gums were blanched ; his teeth were Ijad, and his tongue furred. When swallowing, food gave him tlie sensation of being stopped in its descent about the epigastrium, and after it had been swallowed there was considerable throbbing of the heart. The liver dulness extended from the fourth rib to below the costal margin, a distance of 8i- in. Its inferior border was found in the middle line at the umbilicus. The spleen reached the anterior axillary line. The number of the red blood corpuscles was exactly one million per cubic millimetre, and the haemo- globin was 25 per cent. On inspection of the thorax, a slight bulging of the right side, beyond the mammillary line, could be detected from the fourth rib to the costal margin. Pulsation was visible in the epi- gastrium and third right intercostal space. On palpation the apex beat was found in the sixth intercostal space in the left mammillary line. A distinct pulsation could be felt in the second, third, and fourth right intercostal spaces ; this was most distinct 3 in. from mid-sternum, and was ]3erfectly synchronous with the apex beat. On percussion the cardiac dul- ness was found to extend 2| in. to tlie right and 5\ to the left of the middle line at the fourth cartilage. There were systolic murmurs, with different characters, and separate points of maximum intensity, in the mitral and tricuspid areas, and over the pulsating arch to the right of the heart. There was a very loud second sound in the aortic area. The radial arteries Avere atheromatous, the left being especially hard and tortuous ; both had numerous rough deposits, probably calcareous. The left radial pulse was very much smaller than the right. There was a loud systolic murmirr over the left clavicle and subclavian artery. In this case the diagnosis was aneurysm of the ascending part of the arch of the aorta, and the difference in the radial pulses was considered to be caused by an atheromatous change in the left subclavian artery. It was further concluded that the patient was suffering from pernicious anaemia. As time went on, in spite of arsenic, iron, and iodide of potassium, the patient's condition became worse, the blood assumed more character- istic changes, and he gradually sank. At the post-mortem examination a large sacculated aneurysm of the ascending aorta was found ; the heart was fatty, its cavities dilated, the mitral and tricuspid orifices enlarged, the aortic and pulmonary cusps healthy. The left subclavian artery was nearly obliterated by a large patch of atheroma. The liver gave a characteristic reaction with hydro- chloric acid and ferrocyanide of potassium. 8 70 DISEASES OF THE AORTA. In this ease, therefore, the difference in the radial pulses was quite unconnected with the aneurysm ; it may be said, however, that the alteration in the arterial pulses and the development of the aneurysm were (hie to the same patho- logical process. Case 78. Aacarysm of the I'ransvcrse Fart of the Arch of the Aorta. — Autliouy K., aged 41, coal-porter, was admitted suffering from paiu in the cliest and loss of voice. His father had died in early life of cholera ; his mother at the age of 70 of some acute disease, probably pneumonia ; his only brother was killed in the Indian Mutiny ; one sister was aliA'i' and in excellent health, the other sister had died some years before in consequence of her husband's ill-usage. The patient's social surroundings had always been fairly good. His previous health had been excellent. Two years 1)efore admission he began to sufi'er from pains in the chest, general ^\•eakness followed, and lattei'ly he had lost his \-oice. The alimentary system showed no symptoms except at times ditticulty in swallowing. The hepatic dulness in the mammillary line extended to 5^ in. The spleen, glands, and blood presented no abnormal symptoms. No alteration in form could be seen on examining the thorax, and there was no pulsation visible except the apex beat in the fifth interspace. Palpation revealed nothing save a slight systolic liea\'ing about the manubrium sterni. On percussion the cardiac dulness at the level of the fourth rib was found to extend 2 in. to the right and 3^ in. to the left of the middle line ; it reached a higher level than usual, and in the first inter.spaces was 3| in. across. Loud aortic murmurs, systolic and diastolic, were heard. Tlie radial arteries were abuost healthy, with soft elastic walls. The volume was moderate, the pressure low, and the type of pulsation bounding — in fact, it was a Corrigan's pulse. The pulsation in the two radial arteries was absolutely erpial. A well-marked capillary pulse could be seen, causing a blush on the forehead. Tugging of the trachea was present, and a characteristic stridor, with harsh Ijrassy cough, from pressure on the trachea. The left vocal cord was seen on laryngo- scopic examination to be absolutely motionless from pressure on the left recurrent. The right pupil was widely dilated from pressure on the sympathetic. This ease was an excellent instance of aneurysm of the transverse part of the arch of the aorta, without any altera- tion in the radial pulse. Under appropriate treatment the patient improved considerably, and was discharged relieved. Case 79. Malignant Stricture of the CEsoj)hagus simulating Aneurysm. — L. E., aged 43, was admitted to the Eoyal Infirmary under my care, suffering from loss of voice and difficulty in s\\'allowing. The family history was negative, and the general habits and social conditions were excellent. The patient's jn'^vious health had always been good. The ANEURYSM OF THE AORTA. 877 attack for wliicli lie caine uiidei' observation l)egau a month before liis admission with some difficulty in swallowing, especially of fluids. It day by day became worse, and led to regurgitation of part of the food, which appeared to be arrested at a j)oint behind the manubrium ol' the sternum. A little later, pain between the scapuhe began to show itself, and this was followed by the loss of voice. The jjatient had an excellent appetite, Ijut found considerable difficulty in swallowing all substances, but more especially fluids. Sometimes after eating there was some discomfort in the ripper abdominal region. Inspection furnislied no abnormal phenomena connected with the circulation. Palpation showed that the aj)ex beat occupied the fifth intercostal space 3 in. from mid-sternum ; its characters were in no way modified. On jDassing the finger deeply into the suprasternal notch, a slight pulsation could be felt, more particularly towards the left side. The cardiac outline was found to be quite within ordinary limits, extending iq^wards to the upper border of the third rib, and at the level of the fourth rib reaching 2 in. and 3|- in. respectively to right and left of mid- sternum. On auscultation no symptom of disturbance could l)e elicited save accentuation of the aortic second sound. The arteries through the whole body were extremely atheromatous, and the radial showed exactly similar ajDpearances on both sides. The vessels were somewhat rigid and tortuous, and the blood pressure was -rather above the ordinary standard. The pulsation was perfectly regular and equal. There was no interference with resjDiration, and most careful examination of the chest failed to show any abnormality, but on examining the larynx with the laryngoscope, the left vocal cord was found to be paralysed. There were no symptoms connected with any of the other organs. This case presented some difficulty in diagnosis. The difficulty in swallowing, and the paralysis of the left vocal cord, raised the suspicion that an aneurysm of the transverse portion of the arch of the aorta might be present, and the atheromatous condition of the arteries, as well as the accen- tuation of the aortic second sound, gave a certain amount of plausibility to such a conception. As there was, however, no abnormal pulsation in any part of the chest, and no increase in the cardiac dulness, it seemed highly improbable that aneurysm could be the cause of the symptoms. Taken in connection with the somewhat rapid emaciation, it seemed to to be clearly a case of invasion of the oesophagus by means of some new formation. After he had been under observation for about a fort- night, in addition to losing flesh rapidly, the patient developed two new symptoms. One of these was that on coughing a 878 DISEASES OF THE AORTA. little blood stained mucus was expectorated ; the other was the gradual appearance of a harsh brassy cough, and a per- sistent growling stridor. On gently passing an cesophageal tube, it was found to meet with considerable obstruction. Pr(.>fessor Annandale kindly saw the patient along with me, and by means of the l)ougie determined that there was an annular stricture of the tesophagus situated just l)eliind the top of the sternum. He therefore concurred in the diagnosis of malignant disease, which was afterwards veritied. Ca.se 80. Mediastinal Tumour, yieldiinj Symptoms rcsembliny those of Aneurysm. — T. A., aged 39, wood-turner, Avas uuder my care in tlie Royal lutirniary on accoimt of hoarseness and dysphagia. Tlie family Fio. 200.— Tracing of pulsating areas in Case SO. The upper curve is from tlie pulsation at the base of the heart ; the lower from near the apex. , tendencies were somewhat sigiiificant, since his father had died at the age of 52 from phthisis, and his mother at 45 from malignant disease of the liver. His brothers and sisters were in good health, and his foiu' children were perfectly well. His social conditions had always been ex- cellent. As regards his previous health, he had met with an accident to the second right costal cartilage at the age of 27, and, two years before admission, he had suffered from acute pneumonia. Shortly after this attack he began to suffer from throat symptoms, more esjjecially from pain on using the throat in any way. This condition became gradually -worse, and was complicated by the development of persistent cough and constant breathlessness, so much so that he found it impossible to keep the recumbent posture. The patient was extremely emaciated, and weighed 6 st. 13 lb., whereas, two years previous to admission, his weight had been 10 st. 2 lb. His height was 5 ft. 7 in. He was extremely sallow, accompanied by a jaundice tinge. There was considerable trouble in swallowing. The mesenteric glands were enlarged. The liver extended from the upper ANEURYSM OF THE AORTA. 879 border of the fifth costal cartilage to the margin of the rilj.s — a distance of 5 in. The spleen was somewhat enlarged, and in the inguinal region there was increased size and matting together of the lymphatic glands. On inspection of the preecordia, the aj^ex beat was seen in the fifth intercostal space, and there was, in addition, a distinct pulsation in the second, third, and fourth left intercostal spaces. Simultaneous tracings from the basal impulse and a spot near the apex are shown in Fig. 206. On placing the hand over the praecordia, the apex beat was determined to be 3 in. from mid-sternum ; it presented no characters other than those normally found, but over the pulsating region at the base there was a distinct systolic thi'ill. On jDercussion, the heart was found to reach the second left intercostal space, and to extend at the level of the fourth costal cartilage 2 in. to the right, and 4 in. to the left of the mesial plane. On auscultation a systolic murmur was detected at the base of the heart, which had its maximum intensity over the centre of the pulsating area in the third intercostal space. The arteries were everywhere soft and compressible, and the blood pressure Avas below the normal. The left radial artery had a smaller blood wave than the right, but they were absolutely synchronous. There was a considerable degree of huskiness of the voice. Examina- tion of the chest showed evidences of slight consolidation of both apices, and inspection of the interior of the larynx showed that the left vocal cord was somewhat swollen, but freely movable, while the right was fixed in the cadaveric position. The other systems of the body showed no abnormal symptoms. There could be little doubt in this case, in spite of a slight superficial resemblance between its symptoms and those which might be produced by aneurysm of the transverse portion of the arch of the aorta, that the lesion was an invasion of the mediastinal glands, probably by tubercular processes. The symptoms of interference with the larynx became rapidly worse, so much so that, to prolong life, it became necessary to have recourse to tracheotomy, which was performed by Professor Annandale. This gave considerable relief, but the patient became extremely anxious to reach home, and he was therefore allowed to leave the Infirmary. His doctor informed me afterwards that he had died on 26th February, but that no post-mortem examination was allowed. These two cases furnish instructive examples of affections presenting so many features of aneurysm as to give rise to a certain amount of debate before arrivino- at a definite diagnosis. 88o DISEASES OE THE AORTA. Case 81. lu'sultf! of luixi-continni-d 2'n'atinent uf Aortic Anciinjfun. — "W. D., a^t. 39, now a laini:)ligliter, formerly a seaman, came under my notice during tlie year 1880 at the New Town Disiiensjiry, complaining of pain in the chest, throbbing, and breathlessnes^s on exertion. His family liistory was good in every respect. From boyhood he had followed the sea, at first for several years in Her Majesty's Navy, and afterwards in the Merchant Service. During tlie two or three years previous to coming under my observation lie had been engaged as a lamplighter, and, in accordance witli the aiitinuate;! custom then in vogue in this city, he required to run up a lachler in order to light each street-lamp. In both occupations he had, therefore, undergone a very considerable amount of jihysical exertion. Many years l)efore he had suffered from specific infection, but, with this exception, his liealth had always been satisfectory. He was not able to fix very definitely when the symptoms began to trouble him, but they had been present for some months. His symptoms began with pain, but the palpitation and breathlessness de- veloped rapidly after the onset of the pain. On examining the patient, it was found that there was a distinct bulging in the third and fourth intercostal spaces on the right side, extending outwards to about 3 in. from mid-sternum. This swelling showed well-marked pulsation, and, on ap^slyiug tlie hand over the jaart, the pulsation was found to be of an expansile character. The ai^ex beat was in the fifth left intercostal space, 3| in. from mid-sternum. There was no thrill over any part of the j)ra3cordia. The cardiac dul- ness was found to begin at the upper border of the third left costal cartilage. The left border was situated almost 4 in. from mid-sternum, and, opposite the fourth right costal cartilage, dulness existed out- wards also to very nearly 4 in. from the mid-sternum line. The cardiac sounds were everywhere normal, with the exception that in the aortic area the second sound was considerably accentuated. Over the swell- ing there was a soft systolic murmur, which was conducted over the upper part of the chest on the right side, and was also carried into the carotid and subclavian arteries. The walls of the radial arteries were healthy, the vessels being neither rigid nor tortuous. The blood pressure was moderately high, the pulsation was regular, and there was no difference in volume or time between the two radial arteries. There was no interference Avith any other system of the body ; there was no cough or dysj)ncea, no iiiterference with the nervous system, apart from the jiain from which the patient suffered, and no disturbance of the digestive apparatus. In this case there were one or two points which rendered the prognosis less grave than it might otherwise have been. The patient was under middle age, the aneurysm arose from the ascending portion of the aorta, and there was no incompetence of the aortic valves. These facts formed the elements of a better prognosis tlian is often the case. ANE UR YSM OF THE A OR TA. 881 His condition was fully explained to liini, and he was strongly advised to enter the Royal Infirmary, in order to have the best possiltle opportunity of obtaining relief. To this advice he gladly consented, and he was, therefore, idaced under the care of Dr. Brakenridge in Ward 31, on 30th September 1880, where he was treated by means of absolute rest, restricted diet, and iodide of iiotassium. Under this treatment he rapidly improved, and in about a month he was discharged Fig. 207.— Heart and aneurysm seen from the right side. at his own request from the Royal Intirmary, and placed himself once more under my care as an out-patient of the New Town Dispensary. In sj)ite of strong advice to the contrary, he persisted in following his occupation as a lamplighter, and, in consecjuence of bronchial comjDlica- tion, no doubt due to over-exertion and undue exposure, his symptoms became aggi'avated, and he was again advised to enter the Royal Infirmary, which he did on the 19th January 1881. He was placed under the care of Dr. Balfour in Ward 32. On this occasion the line of treatment adopted was practically identical with that pursued in Dr. Brakenridge's 56 882 I)ISir,-lS£S OF THE AORTA. "Ward, but he roinaiued betwcou two and three months in the Infirmary, and left it very considerably im])ro\-ed. For i — yet .stouijiiig to sucli an extent as to render his stature apparently nuu-li less than it was, round-shouldered and exceedingly thin — his weight being only 8 stone 8 lbs. — he presented the aspect of a middle-aged man prematurely old, rather than that of Fig. '209 — Riiiiture of the aorta in it.s asceiidiug portion. a boy. His expression was listle.-;s, even apathetic, and his shrunken featiu'es were cyanotic in tint. The digestive system showed no de- parture from a healthy standard, and all the abdominal viscera were of usual size, including the spleen. The blood was, unfortunately, not ex- amined. The pulse during the early days of his re.«idence in the hospital RUPTURE OF THE AORTA. 885 varied in rate between 80 and 104. The artery was soniewliat more rigid than it should have l^een for the age of the jiatient, but showed no sinuosity ; the rhythm of the pulse was rather irregular and unequal ; the individual beats were somewhat tardy yet not sustained. The chest was markedly pigeon-breasted, but .showed some prominence of the left portion of the praicordia. The apex beat was in the sixth left inter- costal space, nearly four inches from midsternum, and was short and slapping in character. The area of cardiac dulness extended upwards to the third left costal cartilage, and I'eached from 2 inches to the right to 4 inches to the left of the mesial plane. An aortic systolic murmur was j)ropagated up the cervical arteries, and there were systolic murmurs in the mitral and tricuspid areas. The respirations were, as a rule, some- what hurried, numbering about thirty-five, l3ut the rate sometimes fell to twenty per minute. There was some cough, with slight frothy exjiectora- tion. Physical examination of the respiratory system gave no evidence of disturbance save crepitations at both leases. Tlie urinary, cutaneous, and nervous systems were free froiii any abnormal symptoms. The case was one of some difficulty. The aortic systolic murmur might have been produced by some lesion of the cusps, but there was no history of any disease likely to have caused any disturbance of the kind. Taken with the unyield- ing character of the arteries, it seemed probable that in spite of the youthful age of the patient there was some degenerative process at work, giving rise to sclerosis of the arterial system with aortic dilatation and consecutive cardiac dilatation. He Avas kept absolutely at rest, and treated by means of ten-grain doses of iodide of potassium in half ounces of infusion of digitalis. For a few days he ajipeared to improve, but on 23rd January, when in the act of taking dinner, he suddenly fell back and passed away without a sound. His death was deemed to be due to asystole, but, at the post-mortem examination, Avhicli was performed by Dr. Cattanach on the following day, the pericardium was found to be distended with blood, which had escaped from a small linear opening towards the posterior part of the ascending aorta at the highest level of the pericardium. The ventricles were considerably dilated, the mitral and tricuspid orifices enlarged, the aortic cusps healthy, the aorta atheromatous and dilated. The lungs were oedematous. Fig. 209 shows the appearance of the unopened heart, and the position of the rupture, through which a pen has been introduced. The facts present an excellent instance of arterial degenera- tion and its consequences in early youth, and bring forward with dramatic vividness one of the less common terminations in such conditions. APPENDIX I. APPLICATION OF EADIOGRAPHY. Since the introduction of the Rontgen rays as practical aids to medicine and surgery, many attempts have been made to render Fig. 210. — Skiagram of the chest in complete transposition of the viscera. them useful in the diagnosis of cardiac affections. Many dijSi- culties have stood in the Avay of realising such aims. Not only 888 APPENDIX I. are there serious mechanical obstacles in the way of carrying out the processes, but on the part of the heart itself there are certain impediments. On account of its rhythmic movements it is quite impossible to obtain an absolutely sharp outline of its margins, and .considerable scepticism is permissible in regard to the observa- tions, based on radiography, intended to show diminution of the size of the heart as the result of certain methods of treatment. There are two directions in which the employment of the rays may be of real utility. They may demonstrate a change in the i^ositiou of the heart, and they may reveal the presence of an aneurysm or intra- thoracic tumour. A beautiful example of their ap})lication in cases of the former description is shown in Fig. 210, which is a skiagram of the chest in the case of complete transposition of the viscera, Avhich has already been mentioned and figured on p. 127. It should have been placed in that position, but was not obtained until the sheet had passed through the press. For it my warm thanks are due to Dr. John Macintyre, of Glasgow, whose work on this subject is so Avell known. It brings out with remarkable clearness the whole bony framework of the chest and upper extremities, and shows the apex of the heart pointing towards the right, while the dense mass of the liver can be made out on the left side. Dr. Macintyre has been able in several cases to obtain most excellent results in cases of aneurysm and tumour within the thorax. It may be said by some that radiography is unnecessary in thoracic disease, since the facts which it discloses can be ascertained by other and older methods. It must be conceded that this argument is to some extent true, yet it may well be claimed that every new mode of investigation furnishes at least the possibility of additional knowledge, Avhile the method now under discussion is actually able to reveal an obscure aneurysm or tumour, which would else elude detection. APPENDIX. II. BIBLIOGKAPHY. CHAPTER I. His, jun., Arb. a. d. vied. Klin, zu Leipzig, 1893, S. 21. — Kurschnek, " Handwortevbuch der Physiologie," herausg. v. R. Wagner, Braunschweig, 1841, Bd. ii. S, 42.— Joseph, Virchow's Archiv, 1858, Bd. xiv. S. 244.— Darier, A^rh. de 2)hysiol. norm, et •path., Paiis, 1888, tome ii. pp. 35 and 151. — Haller, " Eleraeiita Physiologise," Lausaniise, 1757, vol. i. p. 430. — Bischoff, Arch. f. d. ges. Physiol., Bona, 1877, Bd. xv. S. 505. — Eckhard, BrAtr. z. Anal. u. Physiol. (Eekhard), Giessen, 1858, Bd. i. S. 151. — Preyer, " Specielle Physiologie des Embryo," Leipzig, 1885, S. 26. — His, jun., Op. cit. S. 17. — Fano and Badaxo, Arch, per Ic sc. mecl., Torino, 1890, tomo xiv. p. 113. — Pfluger, Arch. f. d. gcs. Physiol., Bonn, 1877, Bd. xiv. S. 628. — Harvey, " Exercitatio anatomica de Motu Cordis et Sanguinis in Animalibus," Fran- cofurti, 1628, p. 66. — Gibson, Verhandl. d. X. internal, vied. Cong., Berlin, 1890, Bd. ii. S. 144. — Gibson and Gillespie, Edin. Med. Journ., 1893, vol. xxxviii. p. 429. — NoiiL Baton, Trans. Roy. Soc. 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J). 122. — QiTTiXGEii, Semaine wt'd., Paris, 1894, tome xiv. p. 470. — Faisans, Bi'U. ft mem. Soc. mid. d. h6p. de Paris, 1890, Ser. 3, tome vii. ]). 904. Tl-ciizek, Dciilsches Arch. f. Min. Mcd., Leipzig,. 1878, Bd. xxi. S. 102.— Nothnacel, TFicn. mcd. Bl., 1887, Bd. x. S. 1 and 73. — Dehove and Boi'lav, Bull, et mem. Soc. med. d. h6p. de P((ris, 1890, St'r. 3, tome vii. p. 953. — Talamox, Scmainc mtd., Paris, 1891, tome xi. p. 13. — West, Trans. Med. Soc. London, 1890, vol. xiii. p. 318. — Kosexfeld. Verhandl. d. Cong. f. innerc Med., Wiesbaden, 1893, Bd. xii. S. 327.— Adams, Duhlin Hos/k Eep., 1827, vol. iv. ]>. 448. — Smith, Duhlin Journ. Mcd. and Chem. Sc, 1836, vol. ix. p. 411. — Stokes, "Diseases of the Heart and Aorta," Dublin, 1854, j). 302.— Huchakd, " Traite clinii|ue des maladies du cceur et des vaissoaux," 2nd ed., Paris, 1893, p. 309. — HALiiEHTOX, Mcd.-Chir. Trans., London, 1841, vol. x.xiv. p. 76. CHAPTER XYI. CrNNiNGHAM, " Manual of Practical Anatomy," Edin. and London, 1894, vol. ii. p. 64. — Quincke, " Cyclopiedia ol' the Practice of Medicine," edited by V. Ziemssen, London, 1876, vol. vi. p. 346. — Sphexgleu, Virchou-'s Archiv, 1852, Bd. iv. S. 166. — Lecdet, Arclt. yen. de vied., Paris, 1861, Ser. 5, tome xviii. p. 575. — Scakpa, "Sull 'Aneurisma," Pavia, 1804, p. 1. — Hodcjson, "Diseases of the Arteries and Veins," London, 1815, p. 55. — Ciiaigie, Edin. 3Icd. and Surg. Journ., 1841, vol. Ivi. p. 427. — Rokitansky, "Ueber die ■\vichtigste Krankheiten der Arterien," Wien, 1852, S. 3. — ViiicHOW, Virchoir's Archie, 1848, Bd. i. S. 272.— Hauvey, "Works," Syd. Soc, London, 1847, p. 589. — Thoma, " Text-book of General Pathology and Pathological Anatomy," trans, by A. Bruce, London, 1896, vol. i. ji- 247. — Gibsox, Lancet, London, 1896, vol. ii. p. 804. — Bureau, "Etude sur les aortites," Paris, 1893, p. 23. — Laxdoi'zy and Siredey", Per. clcmed., Paris, 1887, tome vii. p. 928. — Huchakd, "Traite clinique des maladies du cceur," 2nd ed., Paris, 1893, p. 451. — BnouAiiDEL, Arch. gen. dx med., Paris, 1874, Ser. 6, tome xxiv. p. 641. — Fiessixger, Ga,z. m&l. de Paris, 1892, Ser. 8, tome i. p. 529.— Huchard, Op. cit., p. 506. — Boixet and Romary', Arch, dc med. exp&r. et d'anat. 2^ath., Paris, 1897, tome ix. p. 902. — Boulay', Ball. Soc. ,ancU. dc Paris, 1890, Ser. 5, tome iv. p. 520. — Leudet, Ldc. cit. — Leger, "Etude sur I'aortite aigue," Paris, 1877, p. 42. — Graixger Stewart, Trans. Med. Soc. London, 1891, vol. xiv. p. 283. — Peter, "Maladies du cceur," Paris, 1883, p. 39. — LABOULiiEXE, Bull. Acad, dc m&l., Paris, 1874, Ser. 2, tome ii. p. 1192. — Faure, Arch. g6n. dc mM., Paris, 1874, Ser. 6, tome xxiii. p. 22. — Welsh, Lancet, London, 1875, vol. ii. pp. 769, 899. — Li^corch^ et Talamox', "Etudes niedicales," Paris, 1881, p. 418. — Paul, "Diagnostic et traitement des maladies du cceur," Paris, 1887, p. 342. — Jaccoud, " Le9ons de clinique medicale dela Pitie," Paris, 1886, p. 130 ; and Semaine oned., Paris, 1887, vol. vii. p. 332. — Dohle, Deiitsches Arch. f. klin. Med., Leipzig, 1895, Bd. Iv. S. 190.— Laxcereaux, "Traite d'anatomie pathologique," Paris, 1879-81, tome ii. p. 899.- — Boerhaave, "Prai- lectiones Academicie," Lugd. Bat., 1741, tomus iii. p. 725. — Allbutt, St. George's Hasp. Pep., London, 1870, vol. v. p. 23. — Coats and Auld, Journ. Pcdh. and Bactcriol., Edin. and London, 1897, vol. iv. p. 93. — Fekxel, "Medicina," Venetiis, 1555, De Partium Morbis, Lib. v. f. 147. — A^esalius, referred to by Bonet, "Sepulchretum," Genevoe, 1700, tomns iii. p. 290. — Baillox, " Consilia medicinalia," Parisiis, 1635, tomus i. ]). 501. — Albertixi and Valsalva, referred to by Morgagni, " De Sedibus et Causis Morborum," Venetiis, 1762, tomus i. p. 160. — Laxclsi, " De Motu Cordis," Lugd. Bat., 1740, p. 197. — jNIorgagxi, Op. cit., tomus, i. \k 168. — Scarva, "Sull BIBLIO GRAPHY. 9 1 3 'Aueurisma," Pavia, 1804, p. 14.^Corvi.sakt, " E.ssai sur les maladies et les lesions organiqiies du coeur," Palis, 1806, p. 312. — Laennec, " De I'ausculta*- tion mediate," Paris, 1819, tome ii. ji. 432. — Hodgson, Loc. cit.; Op. cit., ]}. 87. — BizoT, M6m, Soc. m6d. d'ohs., Paris, 1851, tome i. p. 262. — Browne, "Aneurysms of the Aorta," London, 1897, p. 4. — Coats and Auld, Joiwn. Path, and Bacteriol., Edin. and London, 1897, vol. iv. p. 104. — Cms]', "Structure, Diseases, and Injuries of Blood Vessels," London, 1847, p. 115. — Coats, "Manual of Pathology," London, 1895, p. 484. — Wklch, Med. -Chir. Trans., London, 1876, 2nd Series, vol. xli. p. 59. — Duuai.As Powell, Lancet, London, 1875, voL ii. p. 770.— Gull, Ibid., 1875, vol. ii. p. 771. — -Jaccoud, Loc. cit. — Church, St. Earth. HosiJ. Rep., London, 1870, vol. vi. p. 99. — PoNFiCK, Virchovfs Archiv, 1873, Bd. Iviii. S. 528 ; and 1876, Bd. Ixvii. S. 384. — Maetin, Hev. de med., Paris, 1881, tome i. p. 379. — Coats and Auld, Journ. Path, and Bacteriol., Edin. and London, 1897, vol. iv. p. 78. — Mollis, Ibid., 1896, vol. ii. pp. 1, 359. — Stokes, " Diseases of the Heart and the Aorta," Dublin, 1854, p. 579.— Axel Key, N'ord. mod. Ark., Stockholm, 1869, Bd. i. S. 7. — Browne, Op. cit., p. 17. — Kelynack, Edin. Med. Journ., 1898, N.S., vol. iv. p. 162. — Stokes, Dublin Journ. Med. and Chevi. Sc, 1834, vol. v. jj. 400. — Bel- lingham, Dublin Med. Press., 1848, voL xix. pp. 260, 340, 355, 371, 405.— Lyons, Dublin Quart. Journ. Med. Sc, 1850, vol. ix. p. 319. — Quincke, " Cyclopaedia of the Practice of Medicine," edited by von Ziemssen, London, 1876, vol. vi. p. 430. — CoREiGAN, Udi^i. Med. and Surg. Journ., 1832, vol. xxxvii. p. 237. — Balfour, "Diseases of the Heart and Aorta," London, 1876, p. 400. — Legg, St. Barth. Hosp. Fi.ep., London, 1880, voh xvi. p. 258. — Bryant, Med.-Chir. Trans., London, 1872, Ser. 2, vol. xxxvii. p. 225.— Pringle, Ibid.,^ 1887, Ser. 2, vol lii. p. 261. — Quincke, Loc. cit. — Marey, "Physiologic medicale de la circula- tion du sang," Paris, 1863, p. 458. — Quincke, Op. cit., p. 422. — von Ziemssen, Dcutsches Arch. f. klin. Med., Leipzig, 1890, Bd. xlvi. S. 285. — Becker, Arch. f. Ophth. ,19,72, Bd. xviii. Abth. i., S. 206.— Morgagni, Loc. a'i.— Walshe, Op. cit., p. 522. — Laennec, Journ. de med., Paris, 1806, tome xii. p. 159. — Wyllie, Ldin. Hosp. Pep., 1893, voL i. p. 66. — Oliver, Lancet, London, 1878, vol. ii. p. 406. — Macdonald, Lancet, London, 1891, vol. i. pp. 535, 650, 810. — Ewart, Brit. Med. Journ., London, 1892, vol. i. p. 596. — Gairdner, "Clinical Medicine," Edinburgh, 1862, p. 557. — Walshe, Op. cit., p. 497. — Morgagni, Loc. cit. — Traube, Deutsche Klinik, Berlin, 1860, Bd. xii. S. 395 ; and 1861, Bd. xiii. S. 263. — Stokes, "Diseases of the Heart and the Aorta," Dublin, 1854, p. 569. — Semon, Brit. Med. Journ., London, 1898, vol. i. p. 1. — Burns, "Observations on some of the most Frequent and Important Diseases of the Heart," Edinburgh, 1809, p. 252. — Baumler, Ibid., 1872, vol. xxiii. p. 66. — Johnson, Trans. Path. Soc. London, 1873, vol. xxiv. p. 42. — Gairdner, Monthly Journ. Med. Sc. , London, 1855, vol. XX. p. 71 ; and "Clinical Medicine," Edinburgh, 1862, p. 526.— Reid, Edin. Med. and Surg. Journ., 1838, vol. xlix. p. 132. — Walshe, "Diseases of the Lungs and Heart," 2nd ed., London, 1853, p. 759. — Ogle, Med.-Chir. Trans., London, 1860, Ser. 2, vol. xxiii. p. 397. — Argyll Robertson, Edin. Med. Journ., 1869, voh xiv. p. 696.— Seaton Reid, Dublin Hosp. Gaz., 1860, N.S., vol. vii. p. 260. — Walshe, "Diseases of the Heart and Great Vessels," 4th ed., London, 1873, p. 521. — Hope, "Diseases of the Heart and Great Vessels," 4th ed., London, 1849, p. 423. — Douglas Powell, Reynolds's "System of Medicine," London, 1879, voh v. p. 44. — Morgagni, Op. cit., tomus i. p. 160. — Albertini and Valsalva, quoted by Morgagni, loc. cit. — Tufnell, Brit. Med. Journ., London, 1868, vol. ii. p. 383 ; and Med.-Chir. Trans., London, 1874, Ser. 2, vol. xxxix. p. 83. — Graves, "System of Clinical Medicine," Dublin, 1843, p. 669. — Balfour, "Clinical Lectures on Diseases of the Heart," London, 1876, p. 369. — BouiLLAUD, Gaz. d. h6p., Paris, 1859, p. 61. — Chitckerbutty^, Brit. Med. Journ., London, 1862, voL ii. pp. 61, 85. — Roberts, Ibid., 1863, vol. i.'p. 83. — Balfour, Edin. Med. Journ., 1869, vol. xiv. p. 33 ; 1870, voL xv. p. 47; St. Andreic's Med. Grad. Ass. Trans., London, 1870, vol. iv. p. 68 ; "Clinical Lectures on Diseases of the Heart," 1876, p. 367. — S:^E and Lapicque, Btdl. Acad, de m&l., Paris, 1889, tome xxii. p. 328. — Dusol and Legroux, Arch. g6n. de med., Paris, 1839, Ser. 3, tome v. p. 443. — Hughes Bennett, "Clinical 58 914 APPENDIX II. Lectures on the Principles and Practice of ^ledicine," 4tli ed., Edinburgh, 1865, p. 634. — F.VGCK, "Text-book of the Principles and Practice of ilediciue," London, 1893, vol. ii. p. 110. — llruu.VY, "On the Rapid Cure of Aneurysm by Pressure," London, 1871, p. 13 ; and Mcd.-Chir. Trans., London, 1864, vol. xlvii. p. 187. — Moxox and Di'iiham, Ibid., 1872, vol. Iv. p. 213. — Guuexhow, Ibid., 1873, vol. Ivi. p. 385. — Heath, Brit. Med. Journ., London, 1867, vol. ii. p. 287. — PHILLIP.SOX, Ibid., 1877, vol. ii. p. 247. — PiiTiiKijrix, Cumpt. rend. Acad. d. so., Paris, 1845, tome xxi. p. 992. — Cinisei.li, Oazz. vied, di Milam, 1847, tomo vi. p. 9. — Duncan, Edin. Med. Journ., 1866, vol. xi. p. 920 ; 1867, vol. xiii. p. 101. — Moore, Med.-Chir. Trans., London, 1864, vol. xlvii. p. 129. — Lor.ETA, referred to by White and Gould, vide infra. — White and Gould, Mcd.-Chir. Trans., London, 1887, Ser. 2, vol. lii. p. 287.— Macewen, Brit. Med. Journ., London, 1890, vol. ii. pp. 1107, 1164.— Heushey, Thcrop. Gaz., Detroit, 1897, vol. xx. p. 590. INDICES. GENERAL INDEX. PAGE. PAGE. Aconite, . 279 Aorta, diseases of. 13 Adaptation, power of, 107 ,, narrowness of. 293 Adventitious sounds, external, . 153 ,, pressure in the, 71 jj ,, internal, . 155 Aortffi, primitive 3, 5 Age, influence of, 89 Aortic bulb. 4 Air, . 261 ,, incompetence. 486 Alcoliol, . 275 ,. ,, cases, 505 Amenorrlicea, .... 237 , , . , diagnosis 502 Ammonia, 277 ,, ,, etiology. 487 ,, aromatic spirit of, 277 , , , , morbid anat- Ammonium carbonate, 277 omy. 488 Anfemia, . 208 ,, ' ,, presystolic Anatomical considerations. 10 murmur in 497 Aneurysm, ibdominal aorta. 852 ,, ,, prognosis, 503 ,, iscending aorta, 848 , , , , symptoms. 491 ,, jases. 861 , , , , treatment. 504 J, iescending aorta, . 850 ,, lesions, combined, . .508 ,, iiagnosis. 854 ,, ,, ,, ca.ses, 510 ,, iissecting. 836 ,, obstruction, . 473 .J fusiform, 833 ,, ,, cases, . 484 ,j c;eneral symptoms, . 838 ,, ,, diagnosis. 480 7 ; ocal symptoms. 848 ,, ,, etiology, 473 arognosis. 855 ,, ,, morbid anat- ,, sacculated. 833 omy. 475 ,, symptoms. 836 , , , , x^rognosis. 483 ,, ;ransverse aorta. 849 ,, ,, symptoms. 476 J J treatment. 856 ,, ,, treatment, 484 Aneurysms, true, dissecting, false ,832 ,, orifice, affections of. 472 Angina pectoris, 757 ,, second sound, accentua ,, , cases. 785 tion of, 142 J , diagnosis, 777 ,, ,, ,, diminution , , etiology, . 762 of, 143 , morbid anatomy 765 Aortitis, acute. 817 , prognosis, 778 ,, ,, diagnosis, . 822 , , symptoms. 767 , , , etiology, . 818 , , treatment, 779 , ,, morbid anatomy 818 Annulus Vi eussenii, . 13 , ,, i3rognosis, . 822 Antenatal h fe, . 286 J , , symptoms. 819 Aorta, aneu rysm of, . 828 , , , treatment, 822 ,, etiology, . 829 , chronic. 823 j^ , morbid anat- J , , diagnosis. 827 omy. 831 , ,, etiology, 823 9i8 GENERAL INDEX. I>AA(iE. Fatty infiltration, diagnosis, . G4S ,, ,, etiology, . 64(5 ,, ,, morbid anat- omy . 646 ,, ,, prognosis, . 648 ,, ■ ,, symptoms, . 647 ,, ,, treatment, . 648 First sound, double, . . .153 ,, doubling of, . . 151 Fluctuation, pericardial, . . 132 Fluid, removal of, . . . 263 Flushing, ..... 121 Fti'tal circulation, ... 9 Foramen ovale, persistence of, . 293 Foramina Thebesii, ... 13 Fossa ovalis, . . . .13 Friction, . . . . .132 ,, iiericardial, . . 153 Ganglia, lower cervical, . . 23 ,, middle cervical, . . 22 Giddiness, . . . .252 Glands, 211 Gout, as cause of disease . . 91 Hrematemesis, .... 207 Hiematoblasts, .... 119 Htemocytes, . . . .119 Hferaoglobin, .... 119 Hfemopericardium, . . . 387 Hremopoietic system, symptoms connected with, . . . 208 Hfemoptysis, . . . 109, 226 Hemorrhage in congenital heart disease, ..... 298 Hallucinations, visual, . . 252 Head, fulness, .... 253 Headache, .... 253 Hearing sense, .... 252 Hematinics, .... 262 Heart, absence of, . . . 291 ,, blood vessels of, . . 21 ,, deep or relative dulness of, ... . 136 ,, development of, . . 287 ,, dimensions of the, . . 24 ,, displacement of, . 126,289 ,, electric variation, . . 65 ,, electromotive changes, . 64 ,, energy of, ... 72 ,, exterior of the, . . 11 ,, external movements, . 48 ,, in diastole, forces Avhicli fill, .... 65 ,, innervation of, . 22, 84 ,, inspection of, . .123 ,, interior of the, . . 13 ,, movements of the, . . 49 nutrition of the, . . 66 PAOE. Heart, orifices and valves of. IS , , position and limits of the, 34 ,, ,, and relations ot the. 26 , , production of first sound, 62 ,, ,, of second sound. 62 ,, sounds, cause of, . 62 ,, structure of the, 41 ,, sujierficial or absolute dulness of, . 137 ,, symptoms connected witl " the, . . . . 123 ,, transposition of. 127 ,, upward displacement of 125 ,, work done by. 70 Heredity, influence of. 88 Hiccough, 226 Hyaline degeneration. 95 Hydropericardium, 383 ,, diagnosis. 386 ,, etiology. 384 ,, morbid anat omy, 385 ,, prognosis. 387 ,, symptoms, 385 ,, treatment, 387 Hydrotliorax, 110 Hy perdicrotism , 185 Hypertrophy, . . 99, 11 3, 720 ,, diagnosis, . 745 ,, etiology. 721 ,, morbid anatomy. 735 , , prognosis, . 746 ,, symptoms, . 742 ,, treatment, . 748 Hypostasis, 108 Impulse, accompaniments of. 132 ,, character of. 130 ,, force of, 130 ,, double. 1.32 ,, rhythm of, . 131 Incompetence, artificial, . 111 Infarct, jjulmonary, . 109 Infections as cause of disease, . 91 Inhibitory fibres. 86 ,, influences. 85 Integumentary system, sympton s connected with. 227 Intensity, changes in, . 142 Internal movements. 57 Interstitial myositis. 99 Inter- ventricular se})tum, incom plete, .... . 293 Intra-uterine disease, . 285 Intrinsic causes of disease. . 88 Jaundice, 207, 230 GENERAL INDEX. 921 Karyokinesis, Kidney, infarction of tlie, Kinetic energy, . Lactation, . Lesions, degenerative, ,, traumatic, . Leucorrhcea, Light, Liver, cirrhosis of the, Lividity, . Lymph circulation, . Malformations, . Mediastino-pericarditis, Mediastinum, anterior, , , middle, ,, posterior, Megalocytes, Melffina, Menorrhagia, Mental exercise, Meteorism, Microcytes, Mitral first sound, accentuation of, ,, ,, diminution of Mitral incompetence, ■ ,, cases, ,, diagnosis, ,, etiology, ,, morbid ana- tomy, ,, symptoms, , , treatment, obstruction, . ,, cases, . , , diagnosis, . etiology, . ,, morbid ana- tomy, , , prognosis, . ,, symptoms, . ,, treatment, . ,, and regurgita- tion, ,, ,, cases, , , . , diagnosis, ,, etiology, , , , , morbid ana tomy, . ,, ,, i3rognosis, ,, ,, symptoms, , , , , treatment, orifice, affections of, Moderator band, Morphine, ..... Motor aifections. I'AflE. 97 109 72 238 451 451 238 261 109 121 83 285 265 366 27 27 27 119 207 237 260 207 119 145 145 538 549 547 539 540 542 548 519 535 533 520 522 534 526 535 551 554 552 551 551 554 552 554 519 16 278 801 VXf.V.. Motor disturbance, sensations, . 250 Movements, passive, . . . 265 ,, tracings of internal, 58 Murmurs, ..... 155 ,, auricular systolic, . 157 ,, cause of, . . .155 ,, character of, . .162 ,, combinations of, . 162 ,, conduction of, . . 165 ,, diastolic, . . . 160 ,, intensity of, . .163 ,, post-diastolic, . . 161 ,, presystolic, . 157, 158 ,, protosystolic, . . 158 ,, rhythm of, . . 157 ,, systolic, . . .159 ,, ventricular-diastolic, 160 ,, ,, -systolic, . 159 Muscles, fjapillary, anterior, . 19 ,, ,, posterior, . 19 ,, ,, superior, . 19 Muscular fibres, arrangement of, 42 Musculi papillares, . . .16 ,, pectinati, . . 13, 16 Myocardial disturbance, . . 104 Myocarditis, . . . .672 ,, acute, . . . 672 ,, ,, diagnosis, . 677 ,, ,, etiology, ■ . 673 ,, ,, morbid anat- omy, . 673 ,, ,, prognosis, . 678 ,, ,, symptoms, . 676 ,, ,, treatment, . 678 ,, chronic, . . 678 ,, ,, cases, . 690 ,, ,, diagnosis, 688 ,, ,, etiology, . 680 , , , , morbid anatomy, 682 ,, ,, prognosis, 689 ,, ,, symptoms 686 ,, ,, treatment 689 Myocardium, affections of, . 624 ,, anatomy, . . 41 , , chronic infective processes, . . 749 ,, new formations, . 751 Nauheim, 269 Nausea, 207 Neoplasms, .... 451 Nerve, left phrenic, ... 28 ,, ,, vagus, ... 28 ,, right phrenic, . . 28 ,, ,, vagus, . . . 28 Nerves, cardiac branches of vagus, ... 23 ,, cervical spinal, . . 22 GENERAL INDEX. Xerves, external and recurrent laryngeal, ,, glosbo-pliaryngeal, ,, hypoglossal, ,, inferior cardiac, . ,, " left superior cardiac, ,, middle cardiac, ,, pneuniogastric, ,, right superior cardiac, ,. superior cardiac, . ,, sympathetic, ,, vaso-constrictor, . ,. vaso-dilator, Nervous system, symptom connected with, New formations, Nitrites, .... Nutmeg liver, . Occupation, infiuence of, . CEdema. .... Oligfemia, .... Oligocythajmia, Opium, .... Orifice, right auriculo-ventricu lar, congenital lesions, . Orifices, .... ,, and valves, chronic af- • factions of, etiology, ,, frequency. Oxygen, use of, . . 261. Pain, ..... Pallor, . . . . 12L Palpitation, Parturition, Pathological considerations. Percussion, , , auscultatory, . ,, method of, ,, results of, Pericardial disturbance, ,, experiment, ,, neoplasms, ,, pressure, . ,, sac, ol)literation of, ,, syphilis, . tuberculosis, Pericarditis, cases, clironic, symptoms, diagnosis, etiology, fibrinous, , , symptoms, hsemorrhagic, , , symptoms, morliid anatomy, . 22 22 23 22 22 22 22 22 28 86 87 2-38 93 276 108 90 230 118 119 278 301 43 436 443 437 469 238 228 129 238 88 135 174 136 137 100 112 382 100 357 381 376 314 350 342 342 316 322 328 325 341 321 Pericarditis, prognosis, ,, purulent. 324, Pericardium, serous, . ,, symptoms, . symptomatology, . treatment, tubercular ,, case, absence of, . adherent, . 326 ,, cases, . , , anatomy, ,, diseases of, . , , paracentesis, , , parietal, ,, serous, . , , synechia, Phagocj'tosis, Physiological considerations. Pigmentary atro[)hy, ,, degeneration, . Plethora, .... Plexus, anterior coronary, . ,, ,, pulmonary, ,, cardiac, ,, deep cardiac, ,, posterior coronary, ,, superficial cardiac. Pneumopericardium, . ,, cases, ,, diagnosis, etiology, , , morbid anatomy, ,, prognosis, . ,, sym[)toms, ,, treatment, Poikilocj'tes, Polyajmia, .... Polycythfemia, . Potential energy, Prfecordia, form of, . Pregnancy, Pressure, hsemodynamic, ,, liEemostatic, , , hydrostatic, , , intra-cardiac, ,, intra-thoracic, ,, venous. Processes of disease, . PAGE. 345 340 323 334 328 346 326 380 10 291 357 363 diagnosis, 362 etiology, 358 morliid an- atomy, 358 prognosis, 362 sj'mptom- atology, 359 treatment, 363 41 313 348 10 11 358 98 46 642 96 118 24 24 23 . 23 24 22, 23 368 375 374 369 22 371 374 371 374 119 118 119 72 129 238 73 73 73 59 81 80 93 GENERAL INDEX. 923 PAfJi:. •AdK. Proliferation of leucocytes, 97 Recurrent bradycardia, case, 812 Pulmonary artery, 71 ,, ,, diagnosis, 811 ,, circulation. 80 ,, ,, etiology, . 80S ,, incompetence, . 568 , . , , morbid >! >> cases, 576 anatomy, 808 ;) 11 diagnosis. 574 , , , , prognosis, 81] J ) 11 etiology, 568 , , ) , symptoms. 809 functional 580 , , , , treatment. 811 ,, morbid ,, tachycardia, 802 anatomy , 569 ,, ,, cases. 805 ,, ,, prognosis. 576 ,, ,, diagnosis. 805 J! )> symptoms. 573 ,, ,, etiology, . 802 1; treatment. 576 , , , , morbid ,, ■ obstruction, 561 anatomy, 802 >! cases, 566 , , , , prognosis, 805 J > ? ) diagnosis, 565 ,, ,, symptoms, 803 etiology, 562 ,, ,, treatment. 805 ■' morbid Relations, surface, 34 anatomy 562 Remedies, digestive, . 262 >) ,, prognosis. 566 ,, special circulatory, . 274 J) ,, symptom- Repair, processes of, . 99 atology 563 Reproductive system, symptoms ij treatment. 566 connected with. 237 ,, orifice, affections of. 561 Reserve power of heart. 105 ,, second sound, accent Respiration, cog-wheel, 154 nation of 143 ,, periodic. 216 ,, ,, diminution of 144 Respiratory system, symptoms Pulsation, nature of 186 connected Avith, 212 , , venous, 199 Rest, ..... 259 Pulse, 174 Restitution, .... 100 ,, -gauge, . 194 Retraction of the interspaces. 129 ,, liigli pressure 184 Rheumatism as cause of disease. 91 ,, in different v jssels. 192 Rhythm, changes in. 147 ,, inspection of. 176 ,, low pressure. 184 Scarlet fever as cause of disease. 91 ,, method of studying, 181 Scorbutus as cause of disease. 91 ,, palpation of. 176 Second sound, double. 151 ,, rate of, . 187 ,, ,, doubling of. 148 ,, true venous, 80 Sections, longitudinal, of the ,, wave, character of, . 189 thorax, . 29 Pulsus alternans. 188 ,, transverse, of the thorax. 32 , , bigemiuus. 188 Semeiological considerations. 121 ,, deficiens, 188 Sensations, subjective. 250 , , frequens, 186 Sensory afiections, 757 , , intercidens, 188 Serous sacs, effusion into, . 109 ,, magnus. 189 Serum, antistreptococcic, . 283 ,, paradoxus, 190 Sex, influence of. 90 , , parvus, . 190 Sinus of Valsalva, 20 , , plenus, . 183 Skin moisture, .... 230 ,, rams. 186 ,, swelling, .... 230 , , trigeminus, 188 Sleep, . . . .253 260 ,, vacuus, . 183 Sleepiness, . ■ . 253 Purpura as cause of disease, 91 Sleeplessness, .... 253 Sounds and movements, relation. 64 Reaction processes. 96 ,, conduction of. 165 Readjustment, . 99 ., intensity of, . . 63 141 Recession, systolic. 131 ,, splashing, 154 Recovery, . 100 Spasm, vasomotor, 249 Recurrent bradycarc ia. . 808 Sphygmograph, . . 174 175 924 GENERAL INDEX. Siiliygnionianoineter Siilij-giiiometer, Spleen, Spontaneous rupture of heart, Stenosis, artiticial, Sternal fissure, Stolves- Adams disease Strophantlius, . Syphilis, . PACE. 197 194 211 716 112 50 808 280 3, 749 Tenderness, .... Therapeutic considerations, Thrill, diastolic, ,, in patent ductus arteri- osus, .... ,, systolic, ., ,, in aneurysm, . Thrills, ,, aortic, .... ,, mitral, ,, presystolic, . ,, pulmonary, . ,, tricuspid, Thyroid gland, .... Toxic conditions, Transudation, .... Treatment, indications i'or. Tricuspid first sound, accentua- tion of, ,, ,, diminu- tion of, ,, incompetence, . 2.39 255 133 134 133 134 133 133 1.33 133 133 1.33 211 283 108 255 146 147 610 620 618 611 ,, ,, diagnosis, >» ,j t^tiology, ,, ,, morbid anatomy, 613 ,, ,, prognosis, 619 ,, ,, symptoms, 614 ,, ,, treatment, 619 ,, obstruction, . . 588 ,, ,, cases, . 600 ,, ,, diagnosis, 598 ,, ,, etiology, 591 , , , , morbid anatomy, 593 ,, ,, prognosis, 600 ,, ,, symptoms, 596 ,, ,, treatment, 600 orifice, affections of, . 588 ,, ,, "safety-valve action," . 610 Tubercle, . . . . 93, 749 of Lower, . . .13 Urinary system, symptoms con nected witii, . Valve, Eustachian, . ,, of Thebesiiis, . ,, tricuspid, ,, troglochine, . Valves, .... ,, development of, A^alvular affections, . ,, disease, diagnosis, ,, ,, eti'ects, . ,, ,, endocarditic changes, , , , , prognosis, ,, ,, sym})toms, ,, ,, treatment, , , hivmorrhages, Vaso-constrictor influences, ,, -dilator influences. Vein, azygos, ,, oblique of Marshall, . ,, cesojihagus, ,, trachea, . Veins, .... ,, auscultation of, ,, cardiac, . ,, flow in, . ,, .structure of the, ,, vitelline. Velocity of blood. Venous hum, ,, sinus, . Ventricle, left, . right, _ . . _ Ventricles, congenital defects in the septum of the, . Veratrine, Vessel, condition of, . ,, fulness of. Vessels, blood and lymph, ,, lymphatic, . ,, position of the lai'ge, ,, sectional area of, . Vibrations, Viscera, transposition of the. Vision, dimness of, . Vomiting, .... Wave, dicrotic outflow-remainder , , percussion, , , predici'otic, ,, tidal. Wounds of the heart. Yawning, . INDEX OF AUTHOKS. PAGE. PAGE. Aekermann, 286 Baumgarten, . 498 Adanii, 50, 59, 75, 107, 181 Bjiumler, . 316, 336, 367, 847 Adanikiewicz, 100 Baxt, . 57 Adams, 174, 445, 520, 524, 538, Bayliss, . 65 571, 610, 699, 808 Beadles, . 720 Albertiiii, . 720, 828, 856, 859 Beau, . 683 Alderson, . 124 Becker, . 842 AUbutt, Clifford ' 349, 400, 735, 444, 764, 824 Begbie, Bellingliani, 369, 371 . 840 Andral, 317, 329 Bellini, . . 761 Aiistie, 249 Beneke, . 269 Aran, 204, 349, 369, 376 Bennett, Hug les . 859 Aristotle, . 174 Bergeon, . 162, 546 Aubert, 278 Berger, . 488 Aiienbrugger, 135, 136, 313, 721 Bernheim . 343, 383 Aiifrecht, . 124 Bertin, 228, 299, 4 37, 447, 520, Auld, 825, 831 589, 640, 694, 721, 738, Babes, 391 Beutner, . 739 . 80 Baillie, 290, 292, 390, 397 Bezold, von, 'di , 69, 279 Baillon, 828 Bischoff, . 6 Balfour, 150, 1 58 250, 251, 280, Bizot, 26, 117, 728, 736, 829 493, 5 02, 505, 520, 544, Black, . 761 546, 5 61, 599, 618, 631, Blakistoii, . 610 632, 6 33, 634, 662, 763, Bloch, . 194 7 74, 780, 840, 857, 858 Bloebaum, . 279 Ballantyne, 286 Bochefontaine 69, 329 Bambergei", von 148, 199 , 206 Bodenheimer, 369, 752 318, 384, 398, 641 Boerhaave, 115, 390, 399, 444, 824 Banliolzer, 209 Bohm, 279, 280 Banti, 314, 328 Boinet, . 818 Barclay, 158, 498 Bollinger, . . 728 Bard, 210 Bonet, . 644 Barie, 162, 447, 448, 568 Bottcher, . . 654 Barlow, 330 Bouchard . 383, 398 Barnard, 194, 195 Bouillaud, 148, 284, 390, 395, Barr, '. 150, 152, 573 396, 397, 398, 437, Barrett, 62 447, 522, 589, 640, Barry, 198 641, 673, 736, 780, Bartels, 729 857 Barthez, 317 Boulay, 804, 819 Bascli, von , 194 Bourceret, . 329 926 IXDEX OF A UTHORS. Bouveret, . Bouzy, Bowleg, Boyd, Boyer, de, Bradbmy, . Bradford, . Brakeiiridgi', BramwL'll, 24, 151, 219, Braiides, . Brcituug, . Brescliet, . Briclieteaii, Briglit, Bristowo, . Broadbent, 116, 147, 174, 265, 273, Brockbaiik, Brouardel, Brown, Graham Brown, Browne, Brlicke, Brunton, 47, 248, 249, Bryant, Buchheini, Buchner, . Bucquoy, . Buhl, Buuge, Burdach, . Bureau, Burns, . 248, 437, Caheu, Carmicliael, Carville, . Caton, Cavafy, Cejka, Celsus, Ceradini, . Chabalier, . Chambers, Charcot, . Chauveau, . Chevers, . Cheyne, Christiani, Chuckerbutty, Church, Ciniselli, . Claisse, Clark, Clark, Alonzo, Clendinning, i'A(;e. . 802 . 69 . 802 62, 151, 736 317, 589 . 782 . 80 278, 470 406, 499, 632, 633 . 397 314, 326, 358 229, 289, 712 . 369 398, 729, 732 . 737, 802 175, 176, 274, 360, 505, 700, 809 158, 526 317, 818 . 78 373, 437 829, 835, 836 67, 68 265, 276, 280, 771, 781 . 840 . 275 . 92 . 716 227, 730, 732 . 262 58 . 817 589, 640, 847 228, . 249 . 209, 296 . 280 . 282, 346, 426 . 802 . 205, 339 . 135, 752 62, 67 . 332, 334 . 318 . 248 . 59, 67, 77, 156 285, 475, 568, 640 . 645 . 213 780, 857 . 831 . 860 . 414 463, 465, 731 . 323 24, 62, 736 Coats, Coen, Cohnheim, 69, 111, 233, Colin, Collin, Cornil, Corrigan, 156, Corvisart, 133, • 322, 520, 645, Cotton, Coupland, . Craig, Craigie, Crisp, Cruveilhier, Cutter, Cunningham, Curtillet, . Czerniak, . 109, 825, 101, 103, 105, 112, 150, 209, 235, 337, 626, 732, . 153, 473, 487, 489, 505, 135, 136, 229, 376, 385, 437, 526, 588, 589, 673, 694, 712, 727, 305, 624, Da Costa, . Dareste, Darier, Deahna, Dean, Debove, Demnie, Denuee, Desault, D'Espine, . Deucher, . Devic, Devilliers, Dickinson, Dickinson, Lee, Dieulatby, Dittrich, . Dogiel, Dbhle, Donders, . . 56, 59, 6 Dorsch, Dreschfeld, Duckworth, Duguet, Duncan, . Dundas, Dunlop, Craufurd, Durham, . Duroziez, 297, 395, 396, 24, 29. 829, 831 43 109, 232, 627, 735, 737 . 47 313, 331 . 391 494, 575, 840 313, 447, 624, 722, 749, 828 . 802 . 750 780, 857 673, 815 . 829 . 738 . 732 , 36, 814 Dusch, von, Dusol, 289, 501, 590, 385, . 210 . 192 . 735 . 286 . 5, 43 . 277 . SO . 804 . 677 . 396 . 348 . 151 . 282 . 158 . 313 158, 236 319, 376 264, 470 285, 562 62 . 823 115, 198 . 285 . 401 376, 572 297, 562 645, 860 . 314 . 732 . 859 502, 593, 600 392, 771 . 859 INDEX OF A UTHORS. 927 PAOE. l"A'!E. Dybkowski, .. 280, 281 Friedruicl), 200, 206, 360, 336, 358, 36], 369, 384 Eberth, . . 415 Funke, . 277 Ebstein, . 261 Eckliard, . 6 Gairdncr, 113, 116, 140, 157, 158, Ed£,a'en, ^ 50, 56, 64, 192 159, 160, 250, 451, 499, Edie, . 82 520, 589, 609, 679, 727, Edmunds, . . 802 733, 762, 763, 767, Eichhorst, 302 332 336 378, 385, 415 769, 775, 846, 847 Eicliwald, . . 249 Galabiii, . 134 Eiseulohr, . . 369 Galeati, . 712 Emminghaiis, . 344 Galen, 174, 175, 199, 313 Engelmann, 64 Gallais, . 216 Erichsen, . 68, 626 Garel, . 446, 451 Evans, . 350 Gaskell, '86 , 87, 243, 244 Ewald, . 218, 730 Gassicourt, Cadet d e,. . 297, 398 Ewart, 172, 174, 339, 534, 845 Gaule, Gee, . . 59, 65, 66 . 135 Fagge, 157, 158, 249, 316, 348, 520, 680, 859 Geigel Gendrin, . 199 156, 157, 399 Faisans, . 802 Gerhardt, . 333, 343, 802 Fallopiiis, . . 753 Gibson, 8, 63, 116, 154, 182, 199, Fallot, . 305 210, 218, 220, 226, 238, Fano, . 7, 61, 225 370, 445, 446. 450, 571, Farquharson, . 802 573, 610, 619, 631, 634, Faure, . 820 665, 670, 317 Fanvel, 157, 158, 520 Gibson and Gillespie, 8 Fayrer, . 47 Gibson and Malet, . 50 Feine, . 369 Gibson and Muir, . 692 Fenwick . 59, 118, 590 Gibson and Russell . 140 F^re, . ■ . . 286 Gillespie, Lockhart 's, 315, 392, Fernel, . 828 437, 456, 457, Festa, . 335 472, 627, 722 Fick, '59, 175, 723, 739 Gintrac, . 229, 306 Fiedler, . 349 Girode, . 396 Fiessinger, . 395, 818 Giuffr(^ . 525 Filehne, . . 219, 220 Goltz, . 59, 65, 66 Finlayson, . . 217 Goodhart, . . 624 Fischer, . 753 Gould, Pearce, . 751, 860 Flexuer, . . 371 Gouraud, . . 571 Flint, 497, 499, 500, 501, 534 Gowers, 656, 657, 663, 664, 674, 721 Flower, . 24 Graffner, . . 367 Fol, . . 286 Graham, . 305 Forbes, . 155, 538 Grasset, . 488 Forget, . 699 Graves, 317, 330, 369, 504, 780, 857 Forster, . 382 Grawitz, . . 210, 730 Foster, 60, 167, 175, 181, 447, 488, 497, 596 Greenfield, Greenliow, . 624 . 859 Fothergill, 505, 735, 761 Gregory, . . 297 Fox, Wilson, . 227 Griesinger, 313, 317, 327, 366, 396 Foxwell, . . 632, 633 Groedel, . 269 Francois -Franck , . 304 Groux, 50 Frankel, . 328, 390, 400 Gruber, . 422 Frautzel, . . 735 Grunmach, . 192 Eraser, . 280, 281 Gscheidlen, . 278 Fredericq, . . 59, 62, 64 Guiteras, . 498, 499. 501 Frericlis, . . 318, 576 Gull, 423, 730, 830 Frey, von, . 49, 176, 178 Gutbrodt, . . 124 Friedberg, . . 285 Guttmann, 12£ ,137 , 148 , 151, 164, 360 928 IXDEX OF A UTHORS. I'A(iE. I" ACE. Hal)er.slion, 172, 383 Home, . 246 Haddou, . 246 Hooke, . 437 Hahn. . 758 Hoorweg, . 70, 192, 194 HallHTtoii, . 809 Hope, 48, 229, 261, 269, 299, 322, Haldane, . . 589 437, 473, 487, 520, 538, Hales, ■ . 76, 175 561, 568, 589, 633, 724, 850 Hall, .Marshall . 626 Horn, . 588 Haller, 6, 47 ', 60, 19S, 284, 400, 645 Horvath, . 107, 723, 739 Hallopeau, . 751 Huber, 624, 680, 713 Haniel, . 73 Huchard, 249, 250, 757, 762, 775, Hamernjk, 199, 204, 205, 498, 673 776, 808, 809, 811, 818 Hamilton, 26, 45 , 79, 109, 114, Hulke, . . 350 115, 117, 236, 287, Hunter, John, 216, 436, 538, 570, 324, 453, 702, 703, 610, 760, 761 725, 731, 733, 734, 736, 740 Hunter, AVilliam, Hunter, Williani, j uuioi 229, 292 665, 670 Haudford, . 632, 633, 634 Hiirthle, . 59, 76 Hanot, 318, 399, 402 Hyrtl, . . . 67 Harnack, . 276, 277, 281 Harris, . 633 Immermann, . 199 Harvey, 8, 47, 123, 175, 239, 694, 644, 716, 815 Israel, . 730 Hay,. 262, 469, 781 Jaccoud, . 317, 398, 823, 830 Haycraft, . . 62, 63, 82 Jacobsou'', . 80, 100 Hay den, 151 520 590 598, 627, Jfiger, de . 59, 66 640, 646, 649, 697 Jahu, . 124 Hayeni, . 263 Jenner, 651, 680, 761, 765 Haygartli, . 761 Johansson, 75, 107 Head, 240, 242, 244, 245 Johnson, . 151, 729, 847 Heath, . 859 Jolyet, . 276 Heberden, 248, 760, 761, 762, 769 Joseph, 5 Heiberg, . . 390 Jullieu, 750, 751 Heidenhain, 232, 235 Heini, . 360 Kantliack, 394, 395, 402, 405 Heine, 246, 285 Karawagen, . 349 Helmholtz, 63 Kast, . 377 Hepp, . . 740 Kelynack, 394 395 484, 836 Hering, 82, 83 Kennedy, . 640, 697 Herophilus, 123, 174 Kepler, . 186 Herrick, . 591, 592 Kerckringius, . . 649 Herringhani, 802, 804, 805 Key, Axel, . 835 Hershey, . . 860 Keyt, . 192 Hesse, 42 King, "Wilkinson, 175, 610 Heiibner, . -,,',1- . 277 Kirkes, 390, 402, 744 Heynsius, . 157 Kirsch, . 802 Hltfelsheim, . 124 Kiwisch, . . 124 Hill, . 194, 195 Klebs, 390, 408 Hilton, 259, 330 King, . 287 Hindenlang, . 349 Kobert, . 251 Hippocrates, 174, 216 Kcihler, . 100 Hirt, . 279 Kolliker, . . 279 Hirtz, . 493 Kornitzer, . . 124 His, . 5 , 6, 7, 61 Kijster, 390, 400 Hodgkin, . 407 412 453, 473, Krehl, 42, 67, 209 486 487, 494 Kreysig, . 360 390 397 437, 589 Hodgson, . 231 815 828, 829 Kriege, . 152 Hoft'mann, . 757 Kries, von . . 78 Hollis, . 831 Kronecker, . 69 Honiberg, . . 199 Krukenberg, . 317 INDEX OF A UTHORS. 929 I'AflK. PAGE. Kvylow, .... . 654 Lower, 12, 123, 313, 337, 384 Kiirscliner, ... 5 Luchsinger, . 225 Kus.s, .... . 58 Luciani, 66, 220, 221, 223, 225 Kussmaul, . 285, 292, 327, 360, 366 Ludwig, . 49, 62, 75 , 76, 124, 175 Kyber, .... . 349 Lundie, Lusclika, . . 370 . 43 Laache, .... . 735 LuMsana, . . 240 Laboulbene, . 820 Lyons, . 840 Laennec, 48, 133, 153, 155, 204, 228, 240, 249, 297, Macalister, . 540 299, 313, 322, 331, Macdonald, . 238 368, 373, 376, 437, MacDonnell, . 845 447, 473, 486, 520, Macewen, . 860, 861 538, 589, 645, 651, Macintyre, . 888 654, 673, 694, 721 828, 843 Mackenzie, 1 32, 200, 208, 240, Lancereaux, 247, 249, 381, 396, 244, 398, 596, 599, 633 399, 680, 751, 767, 823 M'Vail, . . 158 Lancisi, 123, 199, 357, 443, 644, 828 Magendie, . . 66 Landois, 50, 56, 82, 175, 176, 192, Maguire, . . 500 249, 773 Mahomed, 175, 178, 731 Landouzy, . . 383, 681, 818 Malassez, . . 209 Langendortf, . 225 Malet, . 50 Langer, . 43 Marchand, . 64 Lapicqne, . 780, 858 Marckwald, . 224 Larcena, . . 802 Marey, 49, 50, 59, 175, 178, 180, Larcher, . . 729 194, 199, 841 Latham, 248, 314, 318, 397, 624, Marie, 210, 211, 685 673, 762, 763, 775 Martin, 68, 401, 488, 831 Laycock, ..... . 240 Martins, . 50, 64 t, 70, 802 Leathes, . 109 Massa, . 720 Lebert, 285, 297 Mayer, . 562 Lecorche, 318, 823 Mayo, . 58 Lees, . 500 Mayow, 694, 721 Leger, . 820 Meckel, 58, 284, 322, 436 Legg, 626, 840 Meigs, 114, 740 Legroux, . 859 Merat, . 349 Leitli, . 274 Mercier, . 210 Lejard, . 376 Merkel, . 217 Lemery, . 284 Merrill, . 758 Leroux, . 589 Meyer, 285, 291 Lesperance, . 500 Meynet, . 562 LetuUe, 451, 488, 625, 629, 641, Moore, . 860 680, 717, 719, 738, 739, Morel-Lavaii.d, . 369 741 Morgagni, 198, ] 99, 228, 229, 238, Leube. . . , 217, 218, 444 284, 2 92, 313, 328, 357, Leudet, . 358, 590, 591, 814, 819 384, S 90, 400, 436, 520, Leven, .... . 278 561, 5 88, 624, 645, 672, Lewinski, .... . 832 679, e 82, 694, 716, 721, Leyden, . . . 132, 217 724, 7 53, 758, 828, 843, Licetus, .... . 284 844, 846, 856 Lichtheini, 80, 117, 232, 233 Morison, 249, 2 65, 274, 505, 619, Litten, .... . 415 771, 774, 812 Littlejohn, Harvey, 713, 714 , 719, 836 Mosso, 194, 224, 225 Littre, .... . 174 Moxon, 640, 859 Long.streth, 292, 294 Mracek, 381, 750 Loreta, .... . 860 Miiller, . 493 Lorry, . 758 Miinch, . 383 Louis, . . .228 297, 651 Murray, . 859 Love, . 370 Murrell, . 781 59 930 INDEX OF A UTHORS. PAGE. Musser, ..... 775 Myers, .... 400, 735 Naumann, .... 200 Nauuyil, . . 544, 546, 631, 633 Netter, . 314, 391, 396, 400, 416 Nicolas, 216 Nothnagel, 244, 247, 249, 773, 804 Nunneley, 802 Nuttall, . . . . 371 Odriozola, Oertel, . . 265, CEttiiiger. Ogle, Oliver, Oppolzer, Ormerod, 158, 318, 649, Osier, 250, 288, 318, 376. 400, 416, 499, 627, Overend, . Ozanam, . 68, 248, 333, 562, Paget, . Panum, Parrot, Parry, Paton, Noel, Paul, 328, 332, Pawlow, Peacock, 24, 297, Pelikan, Pelvet, Penzoldt, Perls, Perroud, Peter, Petit, 227, 329, Petrequin, Pettigrew, Pfliiger, Philhouze, Philip, Philipson, . Phillips, . Pierson, Piorry, Pitcairn, . Pitt, Newton, Poisenille, . Polaillon, . Ponfick, 228, 285, 305, 449. 238, 240 336, 395. 369, 420. 542. . 717 268, 269, 471 . 802 . 847 . 194, 844 . 335, 677 650, 654, 657 377, 396, 762, 763, 773, 774 59, 118 . 176 64 229, 395, 645 109, 286, 626 . 640 761, 765, 770 19, 49, 57, 58 563, 564, 716, 823 77 292, 293, 591, 645, 736, 737 280, 281 . 712 . 209 117, 651 . 397 247, 249, 720, 767, 820 492, 528, 544, 750, 752 . 859 42, 58 7 . 562 . 590 . 859 . 751 . 444 . 136 313, 317 . 750 175, 198 . 280 . 831 PAOE. Portal, 645 Potain, 148, 155, 173, 194, 200, 248, 329, 331, 332, 333, 501, 521, 827 Powell, Douglas, 250, 765, 830, 856 Preyer, ..... 6 Priugle, 840 Probstiug, 802 Prudden, 401 Quaiii, 626, 640, 641, 645,-646, 649, 652, 654, 657, 663, 720, 744 Quincke, . 493, 814, 840, 841, 842 Racchi, Radcliffe, . Ranking, . Ranvier, Raymond, . Raynaud, . Rebatel, Regnard , . Rehn, Reid, . 24, 58, 217 Raid, Seaton, Reigel, . 200, 337, Renaut, Rendu, Reuss, Ribbert, Ricord, Riess, Rilliet, Rindfleiscl], Ringer, Riolan, Riverius, . Roberts, . . 349, Robertson, Argyll, Roliin, Roger, Rokitansky, 228, 285 Rolleston, Romary, Romberg, . Romero, Rondelet, . Rosenbacli, Rosenfeld, Rosenstein Ross, Rostan, Rotch, Rougnon, Roy, 376, 530. 112, 221 50, 59, 75, 78, Riidingcr, . 317, 328 . 323 24, 736 . 231 . 488 317, 331 . 67 . 276 . 338 225, 736, 847 . 847 360, 368 . 680 713, 716 231, 232 . 401 . 749 . 361 . 317 . 657 200, 279, 281 314, 348, 639 313, 436, 473 350, 780, 857 . 847 . 657 . 398 291, 297, 645, 712, 815 532, 534, 627 . 818 42, 249 . 314, 349 . 313 222, 391, 401, 488 . 805 . 318, 591 . 240 . 720 . 323, 338 758, 759, 760 107, 132, 175, 181 67 INDEX OF A UTHORS. 931 Rufus, .... Russell, . . 631, 632, Sainsbury, . 200, 281, Saint-Hilaire, Geoffroy, Samson, Samways . Sandborg, . Sanders, Gordon, . 155, Sanderson, Burdon, 418, 500, 236, Sansom, 148, 150, 152, Saundby, Savart, Savory, Saxinger, Scarpa, Schaposchnikoft Schellhamnier, Schepelern, Schmall, . Schmiedeberg, Schneider, Schott, , 264, 265, Schrotter, . . 369, Schuh, Schultess-Rechberg, von Sedgwick, . See, Germain, 69, 214, 249, 735, 752, 780, S6e, Marc, Seitz, Semmola, . . . Semou, Senac, 42, 47, 60, 123, 284, 313, 314, 384, 390, 624, 672, 694, 727, Senator, Seneca, Shattuck, . Sibson, 318, 324, 328, 338, 358, 359, 361, Siebert, .... Simonet, .... Simpson, .... Siredey, .... Skoda, 124, 129, 132, 136, 262, 268, 377, 226, 781, 132, 348, 640, 735, 335, 397, Sloan, Smith, Solmon, Solokow, . Sommerbrodt, Sotnitscliewsky, Southey, . Spehl, Sperling, . 336, 175, /■A OK. 1 174 633, 638 283, 425 286 289 524 62 163, 291 64, 175 390, 400 423, 632, 633 274, 731 156 20 , 58 369 815, 828 338 384 218 152 274, 280 209 269, 273 753, 676 349 69 68 227, 783, 858 58 735 751 847 228, 357, 644, 753, 766 733 757, 760 339 336, 418, 423 225 395 397 681 818 338, 360 369 350 469 344 808 562 225 178 180 730 264 82 412 Sprengler, Spring, Starling, 65, 72, 106, Steell, Stefani, Stein, Steiner, Steven, Lindsay, Stewart, Sir Thomas 272, 274, Stienon, Stille, Moreton, Stockman, Stockman, Stewart, Stokes, 164, 248, 336, 369, 471, 503, 660, 661, Striimpell, Sturge, Sutton, Swan, Talamon, Tanchon, Tappeiner, Taylor, Thebesius, Theremin, Thin, Thoma, 101, 102, 109, 110, . 624, 624, 626, Grainger. 318, 349,' 317, 329, 372, 373, 520, 571, 727, 808, 118, 318, 396, 73, 108, 116, 182, Thorne, Bezly, . Thurnam, .... Tickell, . . 394, 395, Tigerstedt, . . 69, 71 Todd, .... Toeniessen, Traube, 218, 219, 221, 332, 336, 343, 367, 729, Tripier, . . . 158, Trousseau, . 349, 395, Tuchzek, Tufnell, . Tunnicliffe, Turner, Charlewood, . 158, Turner, J. W., . Turner, Sir William, Underbill, PAOK. . 814 . 66 103, 234, 337 499, 572 . 66 673, 676 225, 804 680, 681 250, 731, 820 69 . 228 . 262 . 610 331 465^ 651, ■ 835, 840, 846 . 377 . 240 423, 730 626, 652 804, 823 . 752 . 77 318, 802 . 67 . 285 . 609 730, 816, 817 . 265 680, 712 402, 405 , 75, 107 . 62 208, 209 333, 730, 846 391, 397 398, 414 . 804 . 857 . 280 498, 679 . 48 24 . 530 Valsalva, 198, 814, 828, 841, 856, 859 Van der Byl, . . . .737 Vaquez, .... 209, 210 Verdeil, 657 Vesalius, 828 93- INDEX OF A UTHORS. PAOE. Viault, 210 Vicq d'Azyr, .... 645 Vierordt, 63, 70, 77, 79, 82, 83, 141, 172, 175 Vieussens, 229, 313, 357, 436, 473, 494. 694, 721 Vimont, 562 Virchow, 244, 293, 376, 390, 624, 645. 657, 675, 749, 815 Voigtel 368 Volkniauu, Vulpian, . Wagner, Wah], von, Waldenburg, Wall, Waller, . Walshe, 229, 306, 590, 611, 756, 773, Wauitsclike, Ward, Ogier, Watson, Weber, Weichselbaura, 314, Weigert, Weil, Weitbrecbt, Welch, Wells, Wertheim. West, 56, 70 . 280, 488 . 676 . 562 . 194 . 761 64, 65, 225 369, 376, 503, 640, 657, 742, 774, 843, 846, 847 . 381 . 204 . 802 72, 192, 205, 704 390, 391, 396, 400 . 624, 679 . 195, 205 . 192 370, 823, 830 . 313, 314 . 74 349, 398, 626, 804 Wliite, Whittaker, Widal Widenmauii. Wild, Wilks, Williams, . Willigk, . Willis, Wilson, Winge, Winslow, . Winternitz, Wintrich, . Withering, Witkowski, Wolf, Wollaston, Wood, Worm-Miiller, AVunderlich, Wyllie, . Wyssokowitsch Yeo, . Young, Ziegler, Zielonko, . Ziemssen, von, Zirumerberg, Zuntz, Zwaardemaker. 487, 62, 229, PAor;. . 860 . 493 . 422 . 313, 366 . 763 640, 681, 724 280, 319, 802 . 752 436, 694 . 328 . 390 . 284 . 185 136, 205 . 280 276, 277 . 753 . 63 . 486 62, 104 . 671 140, 408 390, 391, 848 . 62 . 70 680, 684, 686 . 741 . 842 . 275 . 210 . 75 THE END. I F.C681 G25 Gibson L i >^i-:>>{- ^•:i:i 1 ■•:'!►:•' •r'^'t'iK'tWl