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CLINICAL LECTUEES 
 
 ON 
 
 DISEASES OF THE HEART AND AOETA 
 
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CLINICAL LECTURES 
 
 ON 
 
 DISEASES OF THE HEAET 
 AND AOETA 
 
 BY 
 
 GEORGE WILLIAM BALFOUR 
 
 3I.D. St. And., LL.D. Edix. a.nd St. And., F.R.C.P. Edin., F.R.S. Edik. 
 
 CONSULTING PHYSICIAN TO THE ROYAL INFIRMARY, EDINBURGH, ETC., ETC., ETC. 
 
 THIRD EDITION 
 
 LONDON 
 ADAM AND CHARLES BLACK 
 
 1898 
 
DEDICATED BY PERMISSION 
 
 TO THE 
 
 ^ost BonourabU tlj£ JJlarrju^ss of %nU, %M. 
 
 LL.D. of the Universities of St. Andrews 
 Edinburgh, and Glasgow 
 
 Hector of the UNn'ERSiTY of St. Andrews 
 Etc. Etc. Etc. 
 
 AS A TOKEN OF THE RESPECT AND ESTEEM 
 
 ENTERTAINED FOR HIM AS A MAN OF LEARNING 
 
 A PATRON OF LEARNING 
 
 AND A WARM FRIEND TO THE UNIVERSITY OF ST. ANDREWS 
 
 BY THE 
 
 AUTHOR 
 
PREFACE TO THE THIRD EDITION 
 
 Advantage has been taken of the present opportunity to 
 revise and entirely rewrite these Lectures, A considerable 
 amount of new matter has been incorporated, and it is hoped 
 that this new edition may be found worthy of the favour 
 with which former editions were received. 
 
 Edinburgh, December 1897. 
 
PREFACE TO THE SECOND EDITION 
 
 I HAVE to thank the profession for the kindly manner in 
 which the first edition of this work has been received, not- 
 withstanding its many faults. The present edition has been 
 almost entirely rewritten and is somewhat enlarged, advantage 
 having been taken of this opportunity to obviate certain 
 misconceptions to which some of the statements in the former 
 edition seem to have been exposed. The living cases formerly 
 narrated have been brought down to date, one or two having 
 fallen out of siglit. An attempt lias also been made to explain 
 the action and to formulate rules for the use of digitalis in 
 disease of the heart, and of iodide of potassium in aneurysm, 
 which, if not absolutely accurate, are at least in accordance 
 with the results obtained by pharmacologists, and will, it is 
 hoped, prove useful to practitioners. As formerly, I desire 
 all my statements of facts, or what I believe to be facts, to 
 be carefully tested ; but as no human work is perfect, I claim 
 indulgence for the manner of stating. 
 
 Edinburgh, December 1881. 
 
PREFACE TO THE FIRST EDITION 
 
 " I hold every man a debtor to his profession ; from the which, as men 
 of course do seek to receive countenance and profit, so ought they 
 of duty to endeavour themselves, by way of amends, to be a help 
 and ornament thereunto." — The TForks of Francis Bacon (London, 
 1859), vol. vii. p. 319. 
 
 With Latham I may say that mine is but " a limited 
 purpose — it is to regard the diseases of the heart only in 
 one point of view, i.e. as they appear in the living man." 
 As this is the object of clinical teaching, I have called these 
 lectures clinical, though otherwise the term is somewhat of 
 a misnomer, as the illustrations have been mainly taken from 
 patients who have passed from the clinique into the domain 
 of morbid anatomy. One obvious advantage of this method 
 is the definite connection, provided the cases are sufficiently 
 numerous, of certain distinct pre-mortem phenomena with 
 equally well-defined post-mortem appearances ; a sufficient 
 guarantee for the accuracy of this connection being to be 
 found in the publicity inseparable from a large teaching 
 hospital like the Edinburgh Infirmary, and also in the fact 
 that the life history is closed by the physician in the case- 
 book before the pathologist commences his record of the 
 morbid appearances. In a work such as the present it was 
 impossible to avoid narrating cases, but I have restricted 
 these to as few as possible, giving only the histories of those 
 patients who may be regarded as affording well-marked 
 examples of the phenomena attending any given lesion. 
 
X CLINICAL LECTURES ON DISEASES OF THE HEART 
 
 No two cases of any disease are ever exactly alike, even 
 though depending on a similar lesion. The object of all 
 clinical teaching is to show how we are led to determine 
 what is the central lesion in any given case, and to explain 
 how the apparently inexplicable phenomena, which constitute 
 what we term the disease, group themselves naturally round 
 that lesion in accordance with physical and physiological 
 laws ; and, finally, to show how we can influence that 
 central lesion by remedies, and how effectually this modifi- 
 cation of the cause modifies also the concomitant phenomena, 
 though now and then some of these become so developed 
 as to require special and independent treatment, a treatment 
 which can never be anything but palliative, while that of 
 the central lesion may not infrequently be really curative. 
 All this I have endeavoured to do in relation to cardiac 
 disease, and though none of the lectures have ever been 
 actually delivered as they now stand, they yet comprise the 
 essence of my clinical teaching in regard to diseases of the 
 heart and aorta during the last eight years. By putting 
 this into lecture form, I have been enabled to write with 
 more ease to myself, and, what is of more importance, I 
 have been enabled to avoid noticing any special subject 
 which has not happened to come under my own observation. 
 I have thus been enabled to avoid the mere repetition of 
 the statements of those who have preceded me in the 
 same field of inquiry, and by transcribing my descriptions 
 of disease directly from the book of nature, and basing my 
 explanations of the phenomena observed — and, to a large 
 and most important extent, their treatment also — upon 
 physical laws and the results of experimental physiology,^ 
 
 ^ I may as well state here, that though I myself never performed one 
 single experiment upon a living animal, and though I deprecate as much as 
 any one can the undue multiplication of such experiments, I yet hold it to 
 
PREFACE TO THE FIRST EDITION XI 
 
 I have done what I could to remove the diagnosis and 
 treatment of these diseases from the domain of mere 
 speculative opinion, and to place them under direct scientific 
 control. And if in any respect I have failed in doing so, 
 the failure is undoubtedly due to my own ignorance, and 
 will by and by be remedied by some worthier successor, 
 who will base liis diagnosis upon a more successful applica- 
 tion of the laws and facts of physics to the explanation of 
 the phenomena connected with cardiac disease, and rest 
 his treatment upon more accurate physiological knowledge ; 
 for '■' the thoughts of men are widened by the process of 
 the suns." To trace this process in the diagnosis and 
 treatment of cardiac disease we neither require to go very 
 very far back in medical history nor even to read many 
 books. For though in 1531 the pulmonary circulation 
 was shown by Servetus to be reasonably probable,^ yet it 
 was not till 1628 — nearly a century afterwards — that 
 Harvey first gave to the world a full account of the double 
 systemic and pulmonary circulation, which he had already 
 publicly taught and demonstrated since 1619.^ Of course 
 any attempts at the diagnosis of cardiac diseases previous 
 to this period can possess no scientific value whatever, and 
 even their treatment must have been founded on the vaguest 
 empiricism. For long after this era, as before it, the various 
 essays upon diseases of the heart are of no value except 
 
 be true that mucli that is now plain iu cardiac diagnosis, and definite in the 
 treatment of cardiac disease, has been made so by means of experimental 
 physiolog}', and that manj' patients now living owe their lives primarily to 
 this method of investigation, a method of investigation which, kept within 
 due bounds, cannot be regarded as inconsistent with Christian humanity, 
 when we reflect that to save one life alone a whole herd of swine were sent 
 into the depths of the sea of Gennesareth, and that we are also told "ye are 
 of more value than many sparrows," or frogs either. 
 
 ^ De Trinitatis Erroriius, Basil, 1531. 
 
 ^ Exercitatio Anntomica de Motxi, Cordis et Sanguinis in Anijnalibus, 
 Francoferae. 1628. 
 
xii CLINICAL LECTURES ON DISEASES OF THE HEART 
 
 in SO far as they contain a number of curious pathological 
 observations. Even Senac's great work, the first complete 
 monograph upon diseases of the heart, is solely valuable 
 in this respect.^ Thus, while Harvey may be considered 
 to have founded the modern physiology of the heart and 
 the circulation in 1628, and Morgagni must be equally 
 regarded as the founder of the modern pathology of the 
 organs concerned in 1762," it is only from Corvisart that 
 we date the origin of the modern system of diagnosis of 
 their diseases in 1806.^ Corvisart was first physician to 
 the great Napoleon, and was said to have been the only 
 man of independent mind about his court, having been 
 not more remarkable for his modesty than for his skill, 
 especially in diagnosis. As a sample of the high estimation 
 in which his diagnostic powers were held both by the 
 laity and the profession, two anecdotes may be related. In 
 one he is represented as standing before a portrait and 
 saying, " If the artist painted this picture correctly from 
 the life, the original of this portrait must be already dead 
 from disease of the heart." It is added that this was 
 actually the case. In the other, Dupuytren is represented 
 as saying, " I have often observed the marvellous skill 
 with which Corvisart not only pointed out the nature and 
 position of a cardiac lesion, but also indicated almost to a 
 line the exact size of that cardiac orifice he had diagnosed 
 as contracted." We know very well that no amount of 
 diagnostic skill would, even nowadays, justify either state- 
 ment, though by a species of evaro^^ia Corvisart might 
 by chance have been right enough in occasional instances. 
 
 1 Traite de la Structure du Cceur, dc son Action, et de ses Maladies, 
 Paris, 1749. 
 
 - De Sedibus ct Causis Morhoruvi per Anatomea indagatis, Venet. 1762. 
 
 2 Essai sur les Maladies ct Ics Lesions Organiqucs du Cceur et des gros 
 Vaisseaux, Paris, 1806. 
 
PEEFACE TO THE FIRST EDITION Xlll 
 
 He was the first to make practical use of Auenbrugger's 
 invention (1761) of percussion/ and he was also in the 
 habit of listening to the sounds made by the heart ; but it was 
 to Lsennec, as every one knows, that we owe the first (1819) 
 attempt at the scientific application of auscultation to the 
 diagnosis of disease." And it is to Bouillaud (1824) that we 
 owe the first application of scientific auscultation to the 
 diagnosis of cardiac disease/ thus opening up the means of 
 attaining an accuracy, the possibilities of which are as yet only 
 dawning on the professional mind. But it is to the clinical 
 experience, and, above all, to the practical experiments of 
 James Hope (18.32),"* that we owe a very considerable 
 advance in our knowledge of the causes of cardiac murmurs 
 in particular. I believe he is the first who noted the occur- 
 rence of mitral regurgitation from simple dilatation of the 
 ventricle, the orifice being healthy. To Bouillaud, however, 
 following Lsennec, w^e owe the distinct statement that the 
 auricle is found to pulsate alternately with the ventricle in 
 certain cases of disease, particularly in cases of mitral con- 
 striction And this observation, which is altogether slighted 
 by Hope, had no doubt its influence in leading M. Forget 
 (1851)^ to his doctrine of retro-dilatation,^ which is the 
 first distinct, though very imperfect attempt at the founda- 
 tion of a physiologico-pathology of the morbid heart, a mode 
 of investigation which seems destined to produce very im- 
 portant results in the detection of cardiac diseases. Closely 
 
 ■' Liventum Novum ex Pcrcussione Thoracis Immani, ut signo abstrusos 
 2Kctoris morbos detegendi, Vindobonpe, 1761. 
 
 - De r Auscultation mediate, Paris, 1819. 
 
 •' Traite Cliniquc cles Maladies du C'ceur, Paris, 1824. 
 
 * Trecdise on Diseases of the Heart ami Great Vessels, London, 1832. 
 
 " Precis Tkt'orique et Praticjue des Maladies du Cceur, Strassbourg et 
 Paris, 1851. 
 
 " Clp. cit. p. 18. 
 
XIV CLINICAL LECTURES OX DISEASES OF THE HEART 
 
 following Forget, we have the very instructive work of 
 Stokes^ (1854), whose interesting chapters upon the con- 
 dition of the heart in fevers, and upon the effect of defective 
 cardiac power upon the cerebral circulation, are amongst 
 the most important additions made in recent times to our 
 knowledge of cardiac pathology. The only other work that 
 I have to add to this list, fully to bring down the history of 
 cardiac diagnosis to the present day, is tlie admirable com- 
 pendium of Yon Dusch " (1868), which has, in my opinion, 
 no equal in any language as a practical exposition of the 
 art of diagnosing diseases of the heart. 
 
 It is not yet seventy years since science in any form 
 became applied to the diagnosis of cardiac disease ; each of 
 the works which I have enumerated constitutes an era in 
 the history of the development of this diagnosis, and a 
 consideration of the half-dozen works I have recorded is 
 sufficient to enable us to trace the progress of cardiac 
 diagnosis from its earliest dawnings quite down to the 
 present day. To mark more accurately the gradual but 
 decided advance, I have purposely quoted the first edition 
 of each work ; for the views first promulgated by Bouillaud 
 and Hope, for instance, were very much modified in subse- 
 quent editions, and the student loses very much the sensation 
 of gradual progress if he reads only the last edition of either. 
 In this brief survey of the progress of cardiac diagnosis I 
 have purposely restricted myself to practical treatises on 
 diseases of the heart. To extend the survey wider would 
 be to give an entire bibliography of the subject, which 
 seems to me quite unnecessary. I may, however, add that 
 the only two modern works on percussion and auscultation 
 
 ^ The Diseases of the Ueart cind (he Aorta, Dublin, 1854. 
 - Lelirbucli (hr Herzkrankheiten, Leipzig, 1868. 
 
PKEFACE TO THE FIEST EDITION" XV 
 
 which contain important novelties in the practical applica- 
 tion or the scientific explanation of these arts are those of 
 Skoda ^ and of Paul Memeyer - ; and I may also mention 
 the work of Allan Burns ^ as containing some important 
 observations, especially in regard to mitral stenosis and 
 epigastric pulsation ; the paper by Billing,^ on the sounds 
 of the heart, as containing the first promulgation of views 
 in regard to their production, which have since been adopted, 
 and upon which much of modern diagnosis hangs, and in 
 this respect Eouanet's ^ paper is also of importance ; also 
 Corrigan's ^ important paper on aortic regurgitation ; and 
 the papers by Fauvel,^ Gairdner,^ HUton Fagge,^ and 
 Galabin ^° upon mitral stenosis. 
 
 In regard to the treatment of cardiac disease, it is only 
 in recent times that any important advance has been made. 
 Senac says : " A mesure qu'on penetre dans les maladies du 
 Cceur la medicine parait plus sterile ; que peut-on esperer des 
 medicaments, par exemple, dans les dilatations du Cceur ? " 
 But to this doleful query modern medicine has given a most 
 triumphant reply, and can truly say that there are few 
 diseases more amenable to treatment than moderate dilata- 
 tion of the heart, while every form of cardiac disease is sus- 
 ceptible of a degree of relief which but a few years ago was 
 
 ^ Ahhamllung iiber Permission und AuskuUation, Wien, 1839. 
 
 - Theoretischcn mid Minischen Handhuch der PerJcussion icnd AusktiUation, 
 Erlangen, 1870. 
 
 ^ On some Diseases of the Reart, Edinburgh, 1809. 
 
 * Lancet, May 1832. 
 
 ^ Jo^ornal Hehdomadaire, No. 97. 
 
 ^ Edinburgh Medical and Surgical Journal, vol. xxxvii. 1832. 
 
 ■7 " Memoire sur les signes Stethoscopiques du Retrecissement de I'Drifice 
 auriculo-veDtriculaire gauche du C(b\xv," Archives Generates de Medicine, tome 
 i., 1843. 
 
 ^ Edinburgh Medical Journal, November 1861. 
 
 8 Guys Hospital Reports, third series, vol. xvi. 
 
 1" Ibid. vol. XX. 
 
 ^1 Op. cit. vol. ii. livre iv. chap. iv. p. 328. 
 
XVI CLINICAL LECTURES ON DISEASES OF THE HEART 
 
 wholly undreamed of ; but for a further consideration of this 
 I must refer to the body of this work generally, and particu- 
 larly to Lectures iii., vi., vii., xii., and xiv. ; and I believe 
 that a comparison of these chapters with even the latest 
 works on cardiac therapeutics will show that a very con- 
 siderable advance in this respect has been made in quite 
 recent times, and that this advance is undoubtedly due, or 
 at all events owes much of its precision, to the researches of 
 physiologists. I regret 1 can give no definite statistical 
 information as to the prevalence of the various forms of 
 disease of the heart, because my own time and attention 
 have been otherwise occupied, and I find that those statistics, 
 accumulated for me by my various resident physicians, are 
 not of much practical value. During the eight years I have 
 been connected with the Eoyal Infirmary here, I have had 
 under my care in its wards considerably over 2000 cases of 
 general disease, exclusive of cases of continued and eruptive 
 fevers. Some of the ward journals have gone amissing, but 
 I have records of 1968 cases, of whom 200 were cases of 
 cardiac disease. Of these 67 are recorded under the head 
 of aortic regurgitation alone, and 18 under that of aortic 
 and mitral disease ; there were therefore 8 5 in whom aortic 
 regurgitation was the most important lesion; 77 cases are 
 recorded under the head of mitral stenosis, and 48 simply 
 under that of mitral disease ; of these, therefore, a pre- 
 systolic murmur must have constituted tlie predominant 
 sign in the first series, and a systolic murmur in the second 
 — 125 cases in all of mitral disease, and 218 in all of aortic 
 and mitral disease, exclusive of cases of simple dilatation, of 
 dilated hypertrophy, of tricuspid regurgitation or obstruction, 
 or of pulmonary obstruction. These statistics are obviously 
 of no value except as affording an approximate indication of 
 
PKEFACE TO THE FIRST EDITION XVll 
 
 the numbers of cardiac cases coming annually under my 
 observation in the Infirmary alone. 
 
 I have also to apologise for the large number of cases 
 recorded in the chapter on the treatment of aortic aneurysm, 
 as well as for their fulness of detail, but the subject ap- 
 peared to me of so much importance as imperatively to call 
 for full information. I may add that I have had under 
 my care in the Infirmary during the last eight years over 
 30 cases of aortic aneurysm, of whom 31 were cases of 
 thoracic aneurysm, 23 of them males and 8 females, and 5 
 were cases of abdominal aneurysm (aortic), all males. 
 
 In conclusion, I may say that no one can be more 
 conscious of the many shortcomings of this work than I am 
 myself, or, I may add, more desirous that any opinions ad- 
 vanced in it should only be received in so far as they shall 
 be found to be consistent with the truths of those sciences 
 upon which the successful practice of our profession is 
 based. 
 
 Edinburgh, December 1875. 
 
CONTENTS 
 
 LECTUEE I 
 
 PAGE 
 
 On the Diagnosis of Cardiac Disease generally, with 
 
 SPECIAL REFERENCE TO THE STilPTOilS AND PHYSICAL SiGNS 1 
 
 LECTURE II 
 
 On Incompetence of the Aortic Valve, with special re- 
 ference TO THE Diagnostic Signification of the 
 Murjiurs ...... 48 
 
 LECTURE III 
 
 On Incompetence of the Aortic Valve, with special re- 
 ference TO THE Mode in which the Disease progresses, 
 its Prognosis, and its Treatment . . .75 
 
 LECTURE IV 
 
 On the Murmurs and other Physical Signs distinctive 
 
 OF Mitral Stenosis . . . . .110 
 
 LECTURE V 
 
 On the Murmurs and other Physical Signs distinctive 
 of Mitral Stenosis, continued, including those of 
 Incurable Mitral Eegurgitation . . .135 
 
XX CLINICAL LECTURES ON DISEASES OF THE HEART 
 
 LECTURE VI 
 
 PAGE 
 
 On Curable Mitral Regurgitation ; its various Causes, 
 THE Physical Signs by which tt is Revealed, and 
 its Treatment. . . . . .167 
 
 LECTURE VII 
 
 On Tricuspid Regurgitation, Curable and Incurable . 197 
 
 LECTURE VIII 
 
 On the Murmurs audible in the Pulmonary Area, their 
 
 Varieties, and Diagnostic Signification . . 217 
 
 LECTURE IX 
 
 On the Variation and Vanishing of Cardiac Murmurs 247 
 
 LECTURE X 
 
 On Intermittency and Irregularity of the Pulse ; 
 Palpitation, Cardiac and Aortic ; Tremor Cordis ; 
 Tachycardia ; Bradycardia ; and Delirium Cordis . 262 
 
 LECTURE XI 
 
 On some of the Secondary Results of Cardiac Disease 289 
 
 LECTURE XII 
 
 Upon Paroxysmal Angina Pectoris and other Forms of 
 Cardiac Pain, with some Remarks upon the Diagnosis 
 of Fatty Heart . . . .310 
 
CONTENTS XXI 
 
 LECTURE XIII 
 
 PAGE 
 
 On Pericarditis, Endocarditis, Myocarditis, and Cardiac 
 
 Hypertrophy apart froii Valvular Disease. . 335 
 
 LECTURE XIV 
 
 On the Therapeutics of Cardiac Disease . . 357 
 
 LECTURE XV 
 
 On the Simulation op Aneurysm by Malposition of the 
 
 Aorta due to Eickets . . . .386 
 
 LECTURE XVI 
 
 On the Diagnosis of Aortic Aneurysm, its Course and 
 
 Treatment . . . . .402 
 
 LECTURE XVII 
 
 On the Treatment of Aneurysm by Potassium Iodide . 437 
 
Slightly altered from Sibsou (Medical Anatomy, plate xix.) 
 
LECTUEE I 
 
 ON THE DIAGNOSIS OF CARDIAC DISEASE GENERALLY, WITH 
 SPECIAL REFERENCE TO THE SYMPTOMS AND PHYSICAL 
 SIGNS 
 
 In gathering together the prominent facts in relation to 
 the circulatory system, few things are more remarkable 
 than the apparent irrelevance of the symptoms complained 
 of. Thus if a patient complains of palpitation, irregular 
 action, or of his heart generally, you may, if he is young, 
 assure him without much fear of being wrong that his 
 heart is all right, and that he is only weak, nervous, and 
 probably dyspeptic. In those past middle life the case is 
 different, in them every symptom is of importance, however 
 trifling it may seem.-*^ 
 
 We continually meet with cases in which serious valvular 
 lesion has existed for many years altogether unnoticed by 
 the patient, notwithstanding that he has been leading an 
 active and laborious life. Such a lesion is said to be mute ; 
 it has been perfectly compensated, and it never asserts itself 
 as a disease until the compensation has been ruptured by 
 accident, or by the gradual advance of those organic changes 
 associated with it, either as cause or effect. In the one case 
 the ruptured compensation is reparable, and comparative 
 health may be restored ; in the other, it is irreparable, 
 
 ^ Vide The Senile Heart, by George W. Balfour, M. D. Adam and Charles 
 Black : London, 1894. 
 
2 CLINICAL LECTURES ON 
 
 though judicious treatment may prolong life and postpone 
 the inevitable end. 
 
 A truly cardiac patient — one suffering from actual disease 
 of the heart — as a rule comes to you complaining not of his 
 heart, but of one or other of the secondary results of his 
 lesion. He complains of breathlessness or of dropsy, either 
 or both of which may result from that lesion if it be in- 
 sufficiently compensated, or if the compensation be ruptured. 
 
 If breathlessness is complained of, you will find that 
 cardiac breathlessness presents certain peculiarities by 
 which it is readily distinguished from pulmonary breathless- 
 ness. The most striking of these differences, and one which 
 at once attracts attention, is the perfect tranquillity of the 
 breathing while the patient is at rest, while the slightest 
 exertion at once produces so anxious a desire for more air as 
 can be expressed by no fitter term than the air-hunger of 
 the Germans. The amount of lesion is not to be measured 
 by this breathlessness, but its seriousness, as dependent upon 
 the degree in which the compensation is ruptured, may 
 certainly be so. Thus a patient may only puff considerably 
 on going up a hill or ascending a stair, or his shortness of 
 breath may be so great as speedily to compel him to call a 
 halt on attempting either of these feats ; or it may be so 
 extreme as to prove distressing on making such a perfectly 
 trifling exertion as sitting up or turning in bed. But withal 
 there is no true dyspnoea, no difficult breathing properly so 
 called ; there is no obstruction either to inspiration or to 
 ■expiration ; there may even be no curtailment of the air-space 
 in the lungs from any cause whatever ; the breathing while 
 the patient is at rest is perfectly quiet and natural ; yet such 
 is the difficulty — from cardiac causes — of getting the blood 
 aerated, that the slightest exertion produces such a gasping 
 inquietude as is extremely characteristic. This is one form 
 of cardiac asthma, as it is termed ; but there is another in 
 which the breathlessness, though not dependent on exertion, 
 is yet equally independent of pulmonary lesion. This latter 
 
DISEASES OF THE HEAET 3 
 
 variety may come on at any time, but it is, perhaps, most 
 usual at night, and wakes the patient from his first sleep 
 gasping and alarmed ; he has palpitation, occasional pain 
 (angina), almost always irregular action of the heart, which is 
 always feeble ; now and then the patient is sick, and some- 
 times he vomits a mouthful or two. This form of cardiac 
 asthma is mostly senile in character, and associated with 
 muscular degeneration rather than with valvular lesion. It 
 is caused by some sudden rise of blood-pressure of reflex 
 origin, and it is often the beginning of the end to those 
 affected — the first intimation that " the pitcher is broken at 
 the fountain," and that death has already seized upon the 
 very citadel of life. 
 
 Such patients, however, never come to see you — you are 
 always sent for to see them; and I only mention this 
 affection now as an illustration of the fact that exertion is 
 not always necessary to produce cardiac breathlessness, and 
 that the panting and the absence of true pulmonary distress 
 are always characteristic. 
 
 Breathlessness depends upon imperfect aeration of the 
 blood, and in the absence of any pulmonary lesion it may 
 depend upon sorqe lesion of the heart or of the blood itself. 
 Thus, though a patient presents all the characteristics of 
 cardiac breathlessness, we must not set him down as certainly 
 labouring under cardiac disease, he may be only anaemic or 
 spansemic. The heart may be right enough and only the 
 red corpuscles deficient ;' but as ansemia and heart disease 
 frequently coexist, the assured presence of the former, evinced 
 by the pallor of the lips, gums, etc., does not exclude the latter. 
 Breathlessness having the characteristic symptoms described, 
 makes us certain we have to do with a hsemic or a cardiac 
 lesion ; which it is we must determine by further inquiries. 
 
 Dropsy depending upon cardiac disease always ^ begins 
 across the instep, and gradually fills up the lower extremities, 
 
 ^ " Almost invariably," says Walshe, "any exception being excessively 
 rare." — Diseases of the Heart, 3rd edition (London, 1862), p. 302. 
 
4 CLINICAL LECTURES ON 
 
 the face and upper parts of the body remaining free. But as 
 the cedema of simple debility begins in a similar position and 
 follows a similar course, dropsy in this position can only be 
 accepted as a hint that possibly the heart may be affected, 
 and not as a proof that it is. 
 
 Wlieyi a patient, then, breatJies easily when at rest hut 
 complains of hreathlessness on exertion, or has swelled feet with 
 or even without marked hreathlessness, we suspect his heart, and 
 v:e confirm or set aside this suspicion hy further inquiry. 
 
 In further examining the condition of the patient we 
 begin by feeling both radial pulses simultaneously, noting 
 whether the arteries are firmer or more tortuous than usual 
 (atheroma). If there is a marked difference in size between 
 the two radial arteries, we feel both brachials simultaneously ; 
 if these be equal, the difference between the two radials is 
 probably due to irregular distribution, which must be looked 
 for. If the brachials also differ in size, there is probably some 
 abnormal physical cause for this irregularity — possibly an 
 aneurysm. Should the radial pulses be equal and regular, but 
 small and feeble, we raise the wrist to a level with the top of 
 the head, if the patient be sitting or standing ; if he is lying, 
 we raise the arm to its full length perpendicularly to the body. 
 Should the pulse on this procedure become extinguished, or 
 nearly so, the patient is ansemic, and probably anaemia is the 
 sole complaint. But as we can never rely upon one symptom 
 for a diagnosis, we merely note the fact observed as one step 
 in our progress. Should the pulse, after elevation of the 
 arm, remain distinct though small and feeble, any cardiac 
 disease present affects the mitral orifice. Irregularity, if 
 present, helps to confirm this suspicion ; and extreme 
 irregularity with a small pulse points to the probability of 
 this mitral affection being stenosis rather than simple 
 insufficiency. Should the pulse, though small, feeble, and 
 irregular, not only remain distinct after elevation of the arm 
 but apparently become more so, the impulse seeming more 
 forcible from the sudden and complete collapse of the artery 
 
DISEASES OF THE HEAET 5 
 
 which immediately follows, then we know we have to do 
 with a double lesion, with regurgitation through the aortic 
 as well as through the mitral opening. This form of pulse 
 cannot be relied upon unless the collapse is distinct ; un- 
 fortunately it is seldom well marked, and is not, therefore, 
 easily detected. The ordinary water-hammer or Corrigan's 
 pulse ^ of simple aortic regurgitation is readily distinguished 
 by the peculiar sensation conveyed to the finger, a sensation 
 which is generally well marked, and frequently so exagger- 
 ated by elevation of the arm as to be wholly unmistakable, 
 and sometimes almost painful. 
 
 While certain general symptoms indicate with greater or 
 less prohability tlie existence of cardiac disease, the examination 
 of the pulse cdone may not only confer more or less certainty 
 on the suspicions thus aroused, hut may even enahle us in some 
 degree to predicate the nature of the lesion. 
 
 We next examine the patient by a careful inspection 
 of his thorax and neck. A normal thorax is perfectly 
 symmetrical on both sides of the sternum. The chest walls 
 gently rise and fall rhythmically with inspiration and expira- 
 tion, and the only break in the monotony of this gentle un- 
 dulation is a slight tap visible between the fifth and sixth ribs, 
 about two inches from the left edge of the sternum.^ This 
 tap is the beat of the heart's apex upon the inner surface of 
 the chest wall, it is an outward thrust rather than a tap, and 
 it averages four thrusts to each respiratory wave. Any 
 deviation from these appearances is abnormal, though not 
 necessarily of much importance. Alterations in the shape of 
 the chest from rickets, scoliosis, or unilateral pulmonary 
 disease, are only of consequence in the present connection 
 when the pulmonary circulation is so interfered with as to 
 induce secondary affection of the right heart, or when parts 
 
 ^ Edinlnirgli Medical OAid, Surgical Jounud, vol. xxxvii. (April, 1832), pp. 
 227, 229, where the phenomena referred to are described for the first time by 
 the late Sir Dominic Corrigan. 
 
 ^ Those who have worked with female patients will appreciate the dis- 
 carding of the nipple as a fixed point. 
 
6 CLINICAL LECTURES OX 
 
 ordinarily covered get exposed, revealing pulsations that are 
 apt to be taken for aneurysms. In many cases the precordial 
 region is more prominent than the similar region on the 
 right of the sternum. Of itself this is of little importance, 
 but it is frequently associated with enlargement of the heart 
 or with effusion into the pericardium. In ascertaining its 
 presence we must be careful not to be misled by any rachitic 
 bulging of the ribs, or by any unusually distinct pulsation 
 of the heart in children or in meagre individuals. Bulgings 
 due to arterial disease (aneurysm) invariably commence 
 above the fourth rib, and appear as mere local tumours. 
 Depression of the pra^cordial region is much less comiion 
 than bulging ; it occurs, but very rarely, as a result of 
 pericarditis, following adhesion of the visceral and parietal 
 layers of the pericardium and of the superjacent pleura ; 
 more commonly, but still rarely, there is a mere systolic 
 recession of the prsecordial region from the same cause, but 
 this systolic recession is more usually due to atmospheric 
 pressure during the systole of a large heart, quite apart from 
 any pericardial adhesion. Any alteration in the position and 
 extent of the apex beat is readily observed, and must be 
 carefully noted for further investigation. Above the chest 
 wall in the neck we note whether there is any undue pidsa- 
 tion in the carotid arteries or in the tracheal fossa ; this is 
 often found in advanced life when the vessels are athero- 
 matous and tortuous, but if symmetrical and excessive it is 
 invariably associated with regurgitation through the aortic 
 valves, and coexistent dilatation and hypertrophy of the 
 left ventricle. Visible venous pulsation, on the other hand, is 
 invariably associated with dilatation of the right ventricle, 
 and its distinctness may be accepted as a measure of the 
 persistence and degree of that dilatation, because venous 
 pulsation in this situation is never seen till long-continued 
 congestion has destroyed the competency of the valves at the 
 root of the jugular vein, and this does not happen till some 
 considerable time after tricuspid regurgitation has been 
 
DISEASES OF THE HEART 7 
 
 established. Venous pulsation is generally best seen in the 
 right jugular vein and is brought out by compressing the yein 
 about the middle of the neck, the natural supply of blood 
 from above is thus cut off, and the vein is seen to fill from 
 below in a succession of waves synchronous with each 
 cardiac pulsation. Simple undulation of the jugular vein is 
 caused by the propagation of each systolic impulse of the 
 right ventricle through the congested auricle and along the 
 turgid vein, the jugular valves remaining intact. Jugular 
 undulation thus indicates a much shorter duration of tricuspid 
 regurgitation than is betokened by jugular pulsation. A 
 mere flicker at the root of the jugular vein is of no import- 
 ance, it is seen in most healthy people lying supine. Venous 
 pulsation is often difficult to detect in ansemic persons, 
 especially if they are young, as the veins are small and apt to 
 be concealed by the subcutaneous fat, always more abundant 
 than in older people. 
 
 Below the anterior chest wall we may observe pulsation 
 in the epigastric region from various causes. Epigastric 
 pulsation is sometimes associated with absence of the apex 
 beat from its normal position, and is then to be looked upon 
 as one form of its displacement. When the right ventricle 
 dilates it pushes the left ventricle back from the chest wall 
 and communicates its own pulsation to the lower part of the 
 sternum and to the liver, which may then be seen to pulsate 
 in the scrobiculus cordis. It may be doubted if such pulsa- 
 tion is ever seen in a perfectly normal condition of the heart 
 and neighbouring organs, but it is certainly often observed 
 when no actual disease of the heart exists. Whenever 
 pulmonary congestion is present, even as the result of such 
 simple and temporary causes as strenuous exertion or 
 bronchial catarrh, some degree of dilatation of the right 
 ventricle always exists, and may give rise to epigastric pulsa- 
 tion. This is more easily seen when circumstances favour 
 the transmission of the cardiac impulse to the abdominal 
 wall, as when there is effusion into the pericardium or 
 
8 CLINICAL LECTURES ON 
 
 enlargement of the liver, the last common enough in connec- 
 tion with a dilated right ventricle. The systolic impulse of 
 regurgitation through the vena cava inferior in such cases is 
 sometimes great enough to communicate a distinctly expansile 
 pulsation to the whole liver, a pulsation not confined to the 
 scrobiculus cordis, but perceptible over the whole right 
 hypochondriac region.^ A large aneurysm resting above the 
 right lobe of the liver sometimes communicates pulsation to 
 that organ of so extensive a character - as to simulate expan- 
 sion. The pulsation of the abdominal aorta is sometimes 
 distinctly visible in the epigastric region simply from 
 thinning of the abdominal walls from emaciation, or the 
 aortic pulsation may be communicated to the surface by 
 some overlying tumour, and in this case the pulsation may 
 be limited in its vertical direction and may even extend 
 transversely. Now and then we have a saccular aneurysm 
 projecting from the anterior surface of the abdominal aorta, 
 and perhaps more frequently we have a mere neurotic 
 throbbing strictly limited to the abdominal aorta itself. In 
 certain rare cases a pulsatory movement is communicated to 
 the epigastrium by the heart's apex pulling upwards an 
 adherent pericardium, diaphragm, and liver during the 
 
 ^ Allan Burns was the first to describe this form of hepatic pulsation in 
 his Observations on Some of the Most Frequent aiul Important Diseases of the 
 Heart (Edinburgh, 1833). At p. 265 he quotes a case from Senac, in which 
 direct pulsation was communicated to the epigastrium by a vena cava inferior 
 the size of a man's arm. At p. 266 he also mentions a case in which epigastric 
 pulsation was produced by repercussion from solidified lungs. 
 
 - Extract from a letter from a late physician, who suffered from an 
 aneurysm of the thoracic aorta projecting through the sternum: "I am 
 satisfied that your view of the origin of the liver pulsations from the aneurysm 
 mainly is the correct one, however discouraging to myself that may be. But 
 I have this to say on the more cheerful side, that if an enlarged liver has had 
 
 nothing to do with them (as Dr. says), and which by decreasing in bulk 
 
 has caused them to be less felt, the very great decrease in them which lias 
 occurred since I began the iodide is very favourable to the conclusion that 
 under its action the sac must have contracted considerably. Eai-ly in 
 February, before I had reason to suspect any increase of the liver, the pulsa- 
 tions had the effect of expanding the opposite sides of the hypochondria at each 
 beat, an effect which is not now perceptible, though I am supposing the liver 
 to be larger, in which, however, I may be mistaken." Dated 3rd May 1870. 
 
DISEASES OF THE HEART 9 
 
 ventricular systole.-^ This movement is exactly the reverse 
 of that in ordinary epigastric pulsation, there is a systolic 
 depression instead of a systolic outward thrust. As so 
 extensive an adhesion is, as a rule, the result of severe 
 inflammation affecting the vrhole surface of the heart, it 
 happens in such cases that the cardiac pulsation is apt to 
 appear as a mere undulatory movement, and it may be 
 difficult to time any particular part of this movement so as 
 to determine whether it is systolic or diastolic, especially 
 if the heart's action is at all rapid (over ninety beats per 
 minute). To this end we must attach a short bristle carrying 
 a tiny paper flag, by means of a pellet of beeswax to the skin 
 over the apex of the heart, and we place a similar flag over any 
 other point in regard to whose time (position in the cardiac 
 cycle) there may be a doubt. The eye readily discriminates 
 any difference in time in the movements of the flags, and 
 with care we can generally determine whether the movement 
 in question precedes or follows the apex beat. This method 
 of investigation is often useful in the case of pulsations above 
 the fourth rib, which may either be auricular or aneurysmal 
 (aortic) ; in the former case the pulsation may precede the 
 apex beat, in the latter it must either be synchronous or 
 follow it. In certain rare cases we get intrathoracic pulsa- 
 tions which originate from the heart, and yet have no 
 connection whatever with any disease of the circulatory 
 organs. Thus in some cases of pneumonia the hepatised 
 lung conveys to the surface of the chest a pulsatory thrill; 
 in certain cases of malignant disease of the lung the pulsation 
 is even more perceptible ; and in cases of purulent effusion 
 into the pleural cavity (empyema) pulsation is often very 
 visible. 
 
 From IXSPECTIOX v:e learn the general confi 'juration of 
 tlie chest, and any ajjpa.rent cleviaMons from the normal; the 
 eye also notes a/ny movements — other than the rhythmic resfAratory 
 
 •^ A remarkable instance of this ■will be found detailed on p. 214 of 
 Copland's DktioiW/ry of Practical Medicine, vol. ii. 
 
10 CLINICAL LECTURES ON 
 
 movements and the isolated tap of the heart's apex — that inay 
 he seen on the neck, the chest wall, or the epigastric region, hut 
 these are noted only in order that their exact nature may he 
 fully investigated hy other methods of exploration. A single 
 glance reveals to a man of experience the prohahle nature of 
 these ahiormalities, hut a student must painfully inquire into 
 every detail. 
 
 On placing the hand over the cardiac area, we can, by 
 PALPATION, if the chest wall is thin, readily perceive the alter- 
 nate movements of systole and diastole over both the auricular 
 and ventricular areas. A forcible ventricular impulse is a 
 probable indication of hypertrophy ; but a feeble impulse is 
 not to be looked upon as any certain indication of atrophy, 
 predominant dilatation, or even of debility of the heart (myo- 
 cardium) from any cause. A feeble impulse may mean any of 
 these, or it may be caused by considerable effusion into the 
 pericardium, by pulmonary emphysema, excess of fat over- 
 lying the heart {cidi^wsitas coi^dis), or merely by increased 
 density of the thoracic wall. If we cause the patient to sit 
 up and lean well forwards the cardiac impulse is more 
 readily felt in every case, and specially so when the dis- 
 placement from the chest wall has been due to fluid in the 
 pericardium. The greater or less distinctness with which 
 any pulsation is to be felt, and its exact position, must be 
 carefully noted in every case. Forcible pulsation above the 
 fourth rib, and within the cardiac area (vide frontispiece), 
 may be aneurysmal (arterial) in character, but it may also 
 depend upon dilatation and hypertrophy of the auricle, 
 especially when it occurs on the left of the sternum. Forcible 
 pulsation below the fourth rib and to the left of the cardiac 
 area is associated with depression of the apex beat below the 
 normal (fifth interspace), and indicates dilatation and hyper- 
 trophy of the left ventricle. Forcible pulsation beneath the 
 lower end of the sternum, with displacement of the apex 
 beat to the right of its normal position (two inches from the 
 left edge of the sternum), indicates dilatation and hypertrophy 
 
DISEASES OF THE HEART 11 
 
 of the right ventricle, the increased size of the ventricle being 
 to some extent measurable by the force of the impulse and 
 the amount of epigastric pulsation present. When the 
 whole heart is dilated and hypertrophied, a more or less 
 violent shock may be felt over the entire cardiac area ; and 
 when the size of the heart is considerable this shock may 
 be double — the first forcible and systolic, the second less 
 forcible and diastolic, the result of the rebound of the enlarged 
 heart from the posterior thoracic walls. 
 
 In the normal state inclination of the patient to the left 
 displaces the apex beat to the same side, sometimes even a 
 little farther to the left than a point equidistant between its 
 normal position and the axillary line. If we incline the 
 patient to the right, the apex beat grows faint or disappears, 
 the right ventricle being felt to beat distinctly beneath the 
 lower end of the sternum or even in the epigastric region. 
 When fluid is effused into the pericardium during an attack 
 of pericarditis the heart's apex falls back from the chest wall, 
 and it is the comparatively immobile base of the heart that is 
 felt beating, often as high as the fourth interspace and slightly 
 towards the left of the normal position of the apex. The 
 apex in such a case is said to be displaced upwards. When 
 there is much fluid in the right pleura the heart is displaced 
 towards the left ; when the effusion is into the left pleural 
 cavity the heart is turned round and forced over to the right 
 side, sometimes as high as the fourth interspace.-^ In hyper- 
 trophy with dilatation of the left ventricle, the apex passes 
 downwards and to the left. In a similar condition of the 
 right ventricle, the apex disappears from its normal position 
 and a diffuse impulse is found at the lower end of the 
 sternum. 
 
 When from any cause the left lung is retracted from the 
 base of the heart, the pulsation of the pulmonary artery may 
 be felt between the second and third ribs, close to the left 
 edse of the sternum ; and even the click of the semilunar 
 
 ^ Collected Works of Francis Sibson, 3I.D. (London, 1881), vol. iii. p. 221. 
 
12 CLINICAL LECTURES ON 
 
 valves may be perceived, because sound is caused by vibrations 
 \vhicli maybe felt as well as heard when the conducting medium 
 is suitable. Hence the palpating hand can readily feel the 
 friction produced by the rubbing together of the two layers of 
 the pericardium roughened by adherent lymph, and may even 
 recognise the vibrations of valvular murmurs. When these 
 murmurs are rough the term of purring thrill — frcmissement 
 cataire — has been applied to the vibrations felt, because the 
 sensation produced resembles that perceived on placing the 
 hand on the body of a cat in the act of purring. Abnormal 
 pulsations along the course of the thoracic aorta are most 
 readily perceived in connection with the ascending and 
 transverse portions of that vessel, they may be due to dis- 
 placement and uncovering of the vessel, as occasionally 
 happens in deformed and rickety chests, or they may be 
 caused by aneurysmal bulgings. They are to be sought for 
 in the tracheal fossa, and between the ribs along the course 
 of the aorta, especially during expiration, when such pulsa- 
 tions, if faint, are most readily felt. Abnormal pulsation may 
 also be felt along the course of the descending aorta, close to 
 the left side of the spinal column posteriorly, but only when 
 the aneurysm has attained some considerable size. 
 
 Froj7i this v:c sec that a great amount of information 
 necessai^ for diagnosis is to he obtained hy PALPATIOX. The 
 points to be specially noted are — 1st, tJie position of any per- 
 ceptible pulsation ; 2nd, its extent and force ; Zrd, its rhythm, 
 v:hether systolic, diastolic, irregido.r, or intermittent; and 4zth, 
 tchethcr any vibratUe sensations are perceptible over the seat of 
 p)ulsaAion, and if so, their rhythm. 
 
 Having registered all the information to be obtained from 
 the inspection and palpation of the patient, we proceed to 
 percuss him. 
 
 Percussion, in medical parlance, is the art of ascertaining 
 the size and shape of the internal organs of the body by 
 percussing, or tapping, the overlying surface. Percussion 
 may be made by tapping with the tips of the fingers directly 
 
DISEASES OF THE HEART 13 
 
 on the surface of the body : this is called immediate per- 
 cussion. Or we may employ a hammer, or plessor as it is 
 called, to strike with, and a finger or piece of ivory to receive 
 the blow, this interposed recipient of the blow being called a 
 pleximeter : this mode of percussion is called mediate. When 
 we use the fingers directly, we not only hear the sounds 
 produced, but our tactile sensation enables us to recognise 
 the density of the body struck. On the other hand, the use 
 of a hammer and pleximeter enables us to produce a louder 
 sound, and is thus advantageous in teachiug a class. When 
 we strike or percuss any body sufficiently tense to be thrown 
 into independent vibrations, it gives out a note of its own by 
 which it is at once recognised. But if it be not tense enough 
 to be thrown into independent vibrations, it simply gives out 
 no note at all. When bodies vibrate on being struck in the 
 open air they produce a distinctly recognisable tone, but 
 devoid of fulness or duration ; but if the same object is set 
 in vibration over a resonance box the tone at once acquires a 
 remarkable fulness and persistence, from the air within the 
 box being thrown into consonating vibrations which strengthen 
 and reinforce the original tone. Eesonance, consonance, or 
 reinforcement happens when the vibrations of the object 
 struck synchronise with those into which the air within the 
 box is thrown. This can only happen when the depth of the 
 box — length of the air-column contained — exactly equals one- 
 fourth of the wave-length of the original tone. That is to say, 
 a resonance box — or rather the air within it — consonates 
 with and reinforces only that tone one-fourth of whose wave- 
 length exactly equals its depth, and is silent to all others. 
 The thorax is a large resonance box within which lie the 
 heart and large blood-vessels ; these organs, in their normal 
 condition, contain no air, and are never sufficiently tense to 
 be themselves thrown into sonorous vibrations by percussion ; 
 when struck, therefore, mediately or immediately, they give 
 forth no sound at all, they are said to be dull on percussion. 
 In their normal position and condition the heart and large 
 
u 
 
 CLINICAL LECTURES ON 
 
 blood-vessels are surrounded on three sides by the lungs, 
 which normally are filled with air and therefore resonant; 
 on the fourth side the heart rests upon the liver, like itself 
 a dull, non-resonant body, from which we can separate it 
 more or less perfectly by measures presently to be described. 
 On percussing the anterior chest wall, the veriest tyro can 
 
 Fig. 1. 
 
 at once distinguish a dull area at the lower part of the right 
 chest, and extending into the left chest as a more or less 
 triangular patch below and to the right of the nipple (Fig. 1 ^). 
 
 ^ This figure is a diagramraatic representation of Fig. 4 — organs healthy — 
 of "Illustrations of the Morbid Anatomy of the Organs of the Chest," by Francis 
 Sibsou, ])ublished in the twelfth volume of the I'ransactions of the Provincial 
 Medical aiid Surgical Association. It has been selected because the area of 
 cardiac dulness approaches more nearly in configuration the ordinary conven- 
 tional idea of such dulness than that of any of the other figures in the same 
 work. How greatly this may vary may be seen by a reference to those other 
 figures representing bodies with healthy organs. 
 
DISEASES OF THE HEART 15 
 
 On the right side this dulness is entirely due to the liver. 
 On the left side it is partly due to the liver and partly to the 
 heart ; to separate the heart dulness from that of the liver is 
 impossible, but we practically attain this end by feeling for 
 the apex beat and tracing a straight line from it to the upper 
 part of the liver dulness on the right side ; all the dulness 
 above this line and to the left of the sternum may be con- 
 sidered as due to the heart alone. This area of marked, easily 
 detected, or as it is called, superficial dulness is an exact 
 measure of that part of the heart in immediate contact with 
 the chest wall. It is no indication of the size of the heart 
 generally, but only of the extent of that organ uncovered by 
 the lung, and as this varies according to the size of the heart 
 itseK, and the degree of expansion of the lung, the positive 
 information conveyed has but a limited value. To ascertain 
 accurately the size of the heart we must map out the entire 
 area of cardiac dulness, both superficial and deep, to use for 
 the nonce those anatomical expressions which are so con- 
 stantly applied to acoustic phenomena, in spite of Auen- 
 brugger's vigorous protest that acoustic phenomena only 
 reveal physical conditions, and from these the anatomical 
 relationship of the organs can only be deduced by a process 
 of reasoning.^ 
 
 The heart and large blood-vessels occupy the centre of 
 the thorax, extending from the upper border of the third rib 
 to the lower end of the sternum, and almost entirely fill up 
 the space between the sternum and the vertebrae. In this 
 position the ventricles encroach more upon the left lung, and 
 the auricles upon the right one, the whole of the right cavities 
 lying in front and slightly to the right of the left cavities. 
 The axis of the right ventricle in relation to the pulmonary 
 artery is almost vertical, the broadest part of the ventricle 
 being that most distant from the pulmonary orifice. The 
 
 ^ Inventum Novum, 17, 18, scholia. Auenbrugger was the first to apply 
 the art of percussion to the discrimination of diseases of the chest. The 
 earliest edition of his work was published at Vienna in 1761. 
 
16 CLINICAL LECTURES ON 
 
 axis of the left ventricle is almost horizontal in relation to 
 the aorta, the narrowest part of the ventricle heing that most 
 distant from the aortic orifice. From this peculiar formation 
 of the ventricles, and from the anterior position of the right 
 one, it happens that the pulmonary artery rises in front and 
 to the left of the aorta. 
 
 From the formation and position of the heart, it is obvious 
 that, though we can and may percuss out the whole of the 
 cardiac dulness, this is quite unnecessary ; it is only of 
 importance to ascertain the limits of this dulness vertically 
 and transversely. Increase of the vertical dulness, in the 
 parasternal line, rarely indicates any alteration in the size of 
 the heart itself, but is usually due to effusion into the 
 pericardium or to liepatic enlargement. Dulness from the 
 former cause lies above the tliird rib, and from the latter, as 
 a rule, below the sixth rib ; these conditions have to be noted 
 for further investigation. A simple change of position of the 
 heart, which may arise from various causes, is indicated by a 
 transference of the normal dulness upwards or downwards, 
 without any change in its extent. Except in certain abnormal 
 states the apex beat is, from the formation of the heart, that 
 part of it which lies farthest to the left, and being as a rule 
 perceptible to the touch, it only requires to be percussed out 
 in those exceptional circumstances in which the apex beats 
 beneath a rib, and not in an interspace. The right auricle is 
 that part of the heart which lies farthest to the right, and 
 being extremely dilatable, and readily influenced by any 
 obstacle to the onward flow of the blood, the transverse dulness 
 at the level of the fourth rib comes to be an important 
 indication of enlargement of the heart, chiefly in its auricular 
 region, due to some obstruction to that onward flow. 
 
 The chief points in regard to the state of the heart, there- 
 fore, upon which percussion supplies us with information, are — 
 
 The presence of dulness above the fourth rib, in the para- 
 sternal line, which, as a rule, indicates effusion into the 
 Ijericardium. 
 
DISEASES OF THE HEART 17 
 
 And, secondly, marked increase of the transverse dulness aJ, 
 the level of the fourth rib, u'hich indicates obstruction to the 
 circulcttion of the blood. 
 
 If, along with this increase of the transverse dulness, the 
 apex beat is displaced downwards and to the left, this 
 obstruction is most probably of aortic origin, and has 
 primarily influenced the left ventricle. But if the apex beat 
 is displaced to the left but not downwards, the obstruction is 
 either of mitral or of pulmonary origin. 
 
 In further endeavouring to map out the exact size of the 
 cardiac dulness, we must not forget that the heart is an organ 
 which is perpetually changing in size, and in its relation to 
 the surface, and that it is surrounded on three sides by the 
 lungs, organs which are themselves continually undergoing 
 changes in size, dependent on respiration. So that but little 
 experience is needed to assure us that even the normal heart 
 undergoes many rapid alterations in the extent of its percus- 
 sion dulness.-^ Thus, though percussion is a valuable means 
 of determining the superficial area of the heart, it is only 
 after an average of several observations has been obtained 
 that we can arrive at even an approximate conclusion as to 
 that, while any inference as to the relative condition of the 
 cardiac walls and ca%dties (state of hypertrophy or dilata- 
 tion) can only be made after a careful collation of other 
 correlative data. In percussing the region of the heart, we 
 must remember that, so far as the three sides surrounded by 
 the lungs are concerned, the passage of the percussion note 
 from clear to dull is not abrupt, but transitional, the heart 
 on these three sides being covered by a gradually decreasing 
 layer of lung. Practically we find that the percussion note 
 ranges from above downwards, in the parasternal line, from 
 
 ^ Vide " Perkussionsverlialtnisse am normalen Herzen," von Dr. M. 
 Heitler, TFiener Uinische Wochensclirift (1890), Nos. 41 and 42. In this 
 paper the periodical variation of the cardiac dulness is sho^vn to be entirely- 
 independent of any change in the liings, as increased dulness occurs normally- 
 three or four times a minute, and coincides -n-ith the inspiration as often as 
 ■with the expiration. These variations are sometimes very considerable. 
 
 2 
 
18 
 
 CLINICAL LECTURES ON 
 
 clear and full just above the upper border of the third rib 
 to perfectly dull somewhere below the lower border of the 
 fourth rib, — the note becoming gradually less full but still 
 remaining perfectly clear until the upper limit of superficial 
 dulness is attained. 
 
 A perfectly dull sound is produced by percussing over a 
 mass of solid flesh, such as the thigh, and indicates that 
 
 Fig. 2. 
 
 there is neither air nor any gaseous body beneath the part 
 percussed. 
 
 A glance at the accompanying diagram (Fig. 2 ^) shows 
 that, in the normal condition, a mass of air-containing lung 
 
 ^ This figure is a diagrammatic rej^resentation of Fig. 2, table 5, of Fasciculus 
 2a of Pirogoff's Anatoviia Topographica Seelionibus per Corpus Humanuvi 
 congelatuTTi triplici ductus illustrata (Atlas, Petrop., 1859). The section 
 passes at the upper part through the left sterno-clavicular articulatioD, at 
 three Paris lines from the internal margin of the head of the left clavicle. 
 The lowest rib anteriorly is the seventh, cut through ten lines from the 
 sternum ; posteriorly, it is the twelfth rib, cut through nine lines from its 
 vertebral extremity. In this section the lung descends lower than is usual, 
 so that perfect dulness would not commence till the lower edge of the fifth 
 rib, instead of that of the fourth rib, as is customary. 
 
DISEASES OF THE HEART 19 
 
 occupies the whole of the thoracic c'kvity above the third 
 rib. Beneath the third rib this air-space is seen to be gradu- 
 ally encroached upon by the heart as it approaches the 
 anterior chest wall, with which it comes in contact about the 
 lower border of the fourth rib. In percussing along the 
 parasternal line, the note elicited above the third rib is full, 
 that is, of a duration and volume proportionate to the size of 
 the air-space (resonance box). The sound is also clear in 
 proportion to the elasticity of the chest wall, and the readi- 
 ness with which this is thrown into vibration. Beneath the 
 third rib the sound elicited on percussion gradually gets less 
 full until it is lost in the cardiac dulness, and a glance at the 
 diagram shows the reason for this in the gradual diminution 
 of the air-space beneath the part percussed. Skoda has 
 applied the term le^r, or empty, to a sound thus lessened in 
 volume by filling up the air-space from below. A percussion 
 sound that becomes gradually empty may remain perfectly 
 clear to the last, provided the chest wall is elastic, until the 
 perfectly empty sound merges in its equivalent, the perfectly 
 dull sound of the heart below the fourth rib. Should the 
 chest wall be less elastic, the sound elicited on percussion is 
 muflBed or dulled just in proportion to the decreased capacity 
 of the medium percussed for undergoing sonorous vibrations. 
 A percussion sound becomes emptier, less full, the duller or 
 more muffled it becomes ; but it by no means necessarily 
 grows duller as it gets emptier, because a sound may be very 
 empty and yet perfectly clear. The terms full and empty 
 are thus synonymous with a greater or less intensity of 
 sound, the quality of intensity depending on the volume of 
 sound that reaches the ear. 
 
 Acoustic phenomena are generally spoken of in relation 
 to their intensity, pitch, and clang or timhre. By many 
 observers the phenomena just referred to intensity, and 
 spoken of as full or empty sounds, have been attributed to 
 pitch, and regarded as low or high sounds ; and, indeed, an 
 emptying of the sound is necessarily accompanied by a 
 
20 CLINICAL LECTUKES ON 
 
 heightening of its pitch. The length of a column of air 
 which most perfectly resounds to the vibrations of a tuning- 
 fork is exactly equal to one-fourth of the length of the 
 sound-wave produced by the fork, and the vibrations con- 
 stituting this sound-wave increase in rapidity as the wave 
 itself decreases in length ; the more rapid the vibrations, 
 and the shorter the sound-wave, the higher is the pitch of 
 the sound produced, as we learn from experiments on the 
 syren. Hence the shallower any air-space, the higher the 
 note with which it most perfectly resonates ; a percussion 
 note becoming emptier becomes, therefore, also higher in 
 pitch. Not that there is any alteration in the general rate 
 at which any membrane vibrates because the resonance box 
 over which it is stretched is shallow, but because the air- 
 space beneath the part percussed resonates only with certain 
 of the vibrations, and raises them only to the dignity of an 
 audible tone. 
 
 Pitch is that quality of sound most readily recognised by 
 the average ear; it is also a strictly acoustic term, which 
 dulness is not. It is therefore sufficient for the student to 
 note the alterations in pitch obtained on percussing the 
 chest wall, assured that whenever the pitch of the percussion 
 note rises, the air-space beneath the part percussed is pro- 
 portionately diminished. A knowledge of anatomy will 
 enable the student to recognise whether his phonographic 
 map of the chest wall is normal, or whether he will require 
 to call pathology to his aid to explain the abnormal alteration. 
 
 Clang is produced by the mingling of the overtones or 
 harmonics of the vibrating body itself with its fundamental 
 note, and therefore varies with the nature of the structure 
 thrown into sonorous vibrations by percussion — varies, there- 
 fore, as we percuss the intercostal tissues, the ribs, or the 
 sternum ; varies even with the nature of the plessor or of 
 the pleximeter employed. Nay, more, clang mingled with 
 resonance has its influence in changing the character of the 
 percussion note in those cases where, from emaciation and 
 
DISEASES OF THE HEAET 21 
 
 the size of the pleximeter, the latter rests upon two ribs, 
 leaving an air-space of varying depth beneath. 
 
 As clang varies with structure, tension, and elasticity, we 
 must — to avoid its confusing influence in estimatino- the 
 exact quality of a percussion note — be careful in percussing 
 from above downwards to compare rib with rib, and inter- 
 space with interspace. Eor the same reason, in percussing 
 transversely, we must be careful to percuss along a rib or 
 along an interspace, and avoid shiftmg indefinitely from one 
 to the other. Both pleximeter and plessor must also be as 
 much as possible free from clang themselves, and the former 
 must be capable of close and accurate application to either 
 rib or interspace. In these respects no instruments are 
 comparable to the forefinger of the left hand for a pleximeter 
 and the first two or three fingers of the right hand as a 
 plessor, the only drawback to their use — and it mainly 
 applies to class teaching — is the comparatively little intensity 
 of the sound produced. This, however, is readily overcome 
 by the use of a Winterich hammer as a plessor ; by means 
 of this an adept can produce a note of perfectly sufficient 
 intensity, without injury to the finger pleximeter. An un- 
 skilful percussor using such a hammer is apt not to tap 
 smartly enough. He may hit hard enough, there is not 
 much likelihood of failure in that respect ; but he does not 
 lift the hammer quickly enough, and he thus muffles or 
 stops the sonorous vibrations it is his object to excite. It 
 occasionally happens that the rise in pitch due to the right 
 auricle is not appreciable to the right of the sternum, and 
 under these circumstances the clang of the sternum may be 
 so sonorous as, in percussing transversely, apparently to do 
 away with all cardiac dulness. But, unless under very 
 exceptional circumstances, we can remedy this by percussing 
 from above downwards, and by eliciting the sternal note 
 above the aorta we can readily recognise the rise in pitch 
 due to the heart lying beneath the sternum. One great 
 advantage of employing the fingers as plessor and pleximeter 
 
22 CLINICAL LECTURES ON 
 
 is that we can thus readily recognise the resistance, and 
 this sensation of resistance supplements and confirms the 
 auditory phenomena. 
 
 In percussing the cardiac area we must always remember 
 that the aorta does not extend like a bow across the sternum, 
 as Piorry has figured it, but that, as anatomy teaches, it is 
 in close contact with the heart and pulmonary artery, and 
 can only be mapped out by percussion as a somewhat rounded 
 projection at the base of the heart. We must also remember 
 that, as a rule, the dulness of the innominate artery is scarcely 
 perceptible, while that of the left carotid, as well as that of 
 the left subclavian, is altogether imperceptible. For this 
 the clang of the ribs over them is partly to blame ; but it is, 
 no doubt, chiefly due to what is called the inflection of sound, 
 by which a sonorous wave embraces a non-resonant body on 
 all sides, and may so far extinguish the dulness of a small 
 one as to make it quite inappreciable. Hence marked dul- 
 ness in these regions is usually significant of some considerable 
 morbid alteration. 
 
 As the heart rarely rises above the level of the third rib, 
 and if it does so, it rises, as a rule, equally on both sides, it 
 is obvious that Piorry's line of oblique dulness, from apex to 
 base, is of no special practical value. And from all that has 
 been already said, it follows as a corollary that in the per- 
 cussion of the heart there are only two lines of any practical 
 importance, viz. a vertical and a transverse one. The first 
 of these, the parasternal line, must be thrown so far to the 
 left as to be uninfluenced by either the aorta or the pulmonary 
 artery, and a very convenient and suitable position for it is 
 at one inch from the left edge of the sternum. In percussing 
 from above downwards in this position from the lower edge 
 of the left clavicle, 76-e have, in the normal condition, first of 
 all the clear, full sound of the lung, low in 'pitch and of con- 
 siderable duration, dovm to the upper border of the third rib. 
 From the third rih dovjnu'ards the percussion sound gradually 
 rises in pitch and shortens in dtcratioji, becoming, as it is 
 
DISEASES OF THE HEAKT 23 
 
 called, gradually emptier, hut still clear down to the lower 
 horder of the fourth, or the upper harder of the fifth, rih ; 
 heneath this there is perfect dulness till we reach the tytripanitic 
 clang of the stomach or intestine. 
 
 Any deviation from this normal gradation of sound in 
 the parasternal line is abnormal, and its explanation must 
 be sought for by other methods of investigation. In like 
 manner we must carefully map out the transverse dulness 
 in the line of the fourth rib, which is that mainly affected 
 by any distention of the right auricle. In doing this we 
 must percuss from without inwards on each side — that is to 
 say, from the lung to the heart, as in that way alone can 
 we appreciate the gradual rise in pitch, and also eliminate 
 the clang of the sternum. 
 
 The accompanying diagram (Fig. 3 ^) exhibits the per- 
 cussion dulness of the normal cardiac area, with the lines 
 of practical importance (vertical a to h, transverse c to d) 
 specially indicated. As the heart invariably rests upon the 
 diaphragm, unless separated from it by fluid, it is never an 
 easy matter to separate the lower part of the heart from the 
 liver. Any change of pitch between the cardiac and hepatic 
 dulness is inappreciable ; the only possible change arises 
 from the upward conduction of the tympanitic note of the 
 stomach or intestines, and, of course, is not always present. 
 We can only separate the heart from the liver approximately, 
 by ascertaining the position of the apex beat upon the left 
 side, and the highest point of the hepatic dulness on the 
 right side, and joining the two by a straight line. This line 
 of separation can never be absolutely accurate, but it is 
 sufficiently so for all practical purposes. 
 
 It is sometimes of importance to map out the aortic 
 dulness, and this is by no means a difficult task if set about 
 in the right way. As already observed, it is impossible to 
 separate the aortic dulness from that of the heart ; the only 
 
 ^ This diagram is taken from the same subject as Fig. 1. Percussion is 
 to be made in the direction of the arrows. 
 
24 
 
 CLINICAL LECTURES ON 
 
 part in which these organs are not in contact being occupied 
 by the pulmonary artery, and the percussion note of this 
 cannot be differentiated from that of the aorta. The normal 
 aortic dulness is indicated in the diagram (Fig. 3) as a more 
 or less rounded area of dulness rising out of, and inseparable 
 from that of the heart, but recognised as aortic from its 
 position above the upper limit of cardiac dulness in the 
 
 Fig. 3. 
 
 parasternal line a to &. Increase of this dulness in any 
 direction is probably due to morbid enlargement of the 
 aorta; but the differential diagnosis of these abnormal ex- 
 tensions of the aortic dulness depends upon the collation of 
 a variety of physical facts, of which percussion dulness is 
 but one. 
 
 Absence or diminution of the precordial dulness is 
 occasionally, though rarely, caused by the presence of air or 
 
DISEASES OF THE HEART 25 
 
 gas within the pericardium ; less seldom it is due to atrophy 
 of the heart ; and much more frequently it is brought about 
 by an increase of the area of pulmonary resonance, due to 
 emphysematous expansion of the lung. 
 
 Increase of the area of cardiac dulness is a more common 
 phenomenon. Increased dulness in the cardiac area may 
 depend upon the presence of fluid in the pericardium, and in 
 this case the dulness is pyramidal with the base downwards, 
 and the cardiac pulsation is annulled, enfeebled, or displaced. 
 Or the increased dulness may depend upon enlargement of 
 the heart itself; in this case the pyramidal shape of the 
 dulness is less marked, but the broadest part is always above. 
 When, in enlargement of the heart, hypertrophy predominates, 
 the cardiac shock is increased ; should, on the other hand, 
 dilatation be most marked, this shock may be almost annulled. 
 We must never forget that these conditions may be variously 
 modified, and to make our diagnosis correct, we must base it 
 not upon one or two facts only, but upon all the phenomena 
 which can be ascertained in regard to the physical condition 
 of the heart. 
 
 Auscultation is the next method we employ to ascertain 
 the physical condition of the heart ; by this we understand the 
 method of determining the perfection, or imperfection, of the 
 cardiac mechanism, from the character of the sounds produced 
 by the passage of the blood through the heart. If we place 
 our ear over the cardiac area, we recognise that the progress 
 of the circulation is accompanied by sounds alternated with 
 silences. If we listen over the heart of an infant, we dis- 
 tinguish only a uniform ticking, in which the sounds are 
 alike in intensity, and the silences similar in duration. But 
 while listening to the hearts of older individuals, we become 
 conscious that as adult life is approached these sounds, with 
 their intervening silences, assume a peculiar rhythm, which 
 the ear thus educated readily appreciates. And we also dis- 
 cover, that while the sounds and the silences remain the 
 same over all the cardiac area, their rhythm varies according 
 
26 CLINICAL LECTURES ON 
 
 to the position in that area in which they are heard. Thus, 
 in listening over the apex, we distinguish two pauses or 
 intervals of silence — a long pause and a much shorter one. 
 Immediately following the long pause we hear a dull, pro- 
 longed sound that terminates in the short pause or silence, 
 and this is succeeded by a short sharp sound, immediately 
 followed by a renewal of the long pause. In this situation — 
 over the heart's apex — the accent is upon the prolonged or 
 first sound, as it is called, that follows the long pause, making 
 what is known in prosody as a trochee, "-^." On the other 
 hand, we find on listening over the base of the heart that, 
 though the relation of the sounds to the silences remains the 
 same, the accent in this situation falls upon the second sound 
 instead of on the first, so that following the long pause we 
 have, instead of a trochee, an iambus "w-." 
 
 Though the cadences of these sounds thus vary with the 
 position in which they are heard, they can, in the normal 
 adult, be readily enough recognised to be first and second by 
 their relation to the periods of silence. But whenever the 
 heart's action becomes rapid from fever, debility, or any other 
 cause, the long pause is shortened, and the rhythm of the 
 sounds resembles that of an infant, so that when the heart 
 beats over ninety per minute it is almost impossible to 
 distinguish which is the first sound and which the second. 
 To do so we must employ a double stethoscope, and by 
 placing one end over the apex and the other over the base a 
 little attention will enable us to differentiate the first sound 
 from the second, by paying due regard to the slight differences 
 between the two sounds, and by a careful attention to the 
 position in which each sound is most distinctly to be heard. 
 Apart from those alterations in rhythm, due to the rate of 
 cardiac action, the heart-sounds vary in distinctness in each 
 individual. Experience has taught us that in thin -walled 
 hearts with relatively large cavities (dilated), the first sound 
 is particularly loud, clear, and distinct ; while in hearts that 
 are thick-walled (hypertrophied) the first sound is always 
 
DISEASES OF THE HEAET 27 
 
 muffled and indistinct. The second sound is unaffected by 
 these conditions, it varies indeed both in distinctness and 
 intensity, but always from causes which are extra- cardiac. 
 We cannot, of course, securely base a diagnosis of the state 
 of the walls of the heart upon the greater or less distinctness 
 of the first sound, but this phenomenon supplements and 
 confirms the information we obtain in other ways. 
 
 Besides the alterations in rhythm dependent upon varia- 
 tions in the rate of cardiac action, and alterations in distinct- 
 ness or intensity of the cardiac sounds depending upon 
 alterations of the myocardium, dilatation, hypertrophy, or 
 upon some extra-cardiac cause, these sounds are occasionally 
 replaced by noises, hruits, or murmurs, as we call them, 
 which are totally different from the sounds they displace, and 
 which vary with the cause producing them. 
 
 Physiologists teach us that the first sound coincides with 
 the contraction or systole of the ventricles, and is composed 
 of several elements, of which the shock of the heart's apex 
 on the chest wall, the sound that accompanies muscular 
 action, and that produced by the closure of the auriculo- 
 ventricular valves, are the most important. Eor all practical 
 purposes the last is all-sufficient, as we find that whenever 
 these valves are from any cause — such as dilatation of the 
 ventricle — rendered incapable of closure, the valves themselves 
 remaining healthy, the first sound is either partially or wholly 
 replaced by a murmur which more or less obscures the 
 muscular sound, and to a less extent the shock. The second 
 sound, on the other hand, as it immediately follows the 
 ventricular systole, must coincide with the ventricular 
 diastole, and therefore with that moment of time when the 
 semilunar segments of the arterial valves are closed by the 
 recoil upon them of the blood compressed by the arterial 
 systole. Accordingly we find that when these valves are 
 from any cause incapable of closure, the second sound is more 
 or less completely replaced by a murmur, according to the 
 degree of imperfection present. 
 
28 CLINICAL LECTURES ON 
 
 The heart, however, is a double organ, with two auriculo- 
 ventricular openings, and two large arteries springing from it, 
 and in the case of valvular imperfection it is of importance 
 to determine to which heart this imperfection belongs. But 
 it so happens that all the cardiac valves lie so close together, 
 that a superficial area of half an inch square will include a 
 portion of all the four sets of valves in situ, while an area of 
 about one quarter of an inch will include a portion of all of 
 them except the tricuspid.^ It is obvious, therefore, that it is 
 impossible to differentiate the sounds or murmurs produced 
 by one valve from those produced by another, by merely 
 listening with an ordinary stethoscope over the place of 
 origin. By the rhythm alone we can readily distinguish a 
 first sound from a second one ; but to differentiate a right first 
 or second sound from a left first or second sound we must 
 take measures to separate the sounds from each other. This we 
 do by taking advantage of the facts that sounds produced in 
 one medium lose in intensity in passing into another, and that 
 sounds produced in any fluid in motion are invariably trans- 
 mitted in the direction of the onward current.^ Hence sounds 
 produced in any cavity of the heart are usually heard with 
 most distinctness over that part of the thoracic wall at which 
 the given cavity approaches the surface most closely. Thus, 
 the only point at which the left ventricle directly impinges 
 on the chest wall is where the apex beat is felt, and that is 
 
 ^ Walshe, op. cit. p. 6. 
 
 ^ Sound is reflected, inflected, and refracted like light, and is readily 
 conveyed to almost any distance in smooth tubes. The difficulty which 
 sound finds in passing from one medium to another, even though these should 
 be only strata of the atmosphere of varying densities, is well indicated by the 
 remarkable statement that battles liave been lost for want of reinforcements 
 actually waiting, within what was thought to be ear-shot, for the sound of the 
 cannon to indicate the moment to advance ; vide Tyndall On Sound (London, 
 1869), p. 23, etc. A most remarkable instance of acoustic opacity of the 
 atmosphere, associated with optic lucidity, is to be found at p. 234 of the 
 Philosophical Transactions for 1874, vol. clxiv. pt. 1, where it is recorded that 
 Mr. M'Lean and General Randolph were, at a distance of one mile and a half, 
 for two hours spectators of the battle of Gain's Farm, in which 50,000 men 
 and 100 field-guns were engaged, without hearing a single sound. Yet in a 
 different direction the cannonading was distinctly audible 100 miles away. 
 
DISEASES OF THE HEAKT 29 
 
 precisely tlie spot where the first sound, produced within the 
 left heart by the closure of the mitral valve, is most distinctly 
 heard ; a space of about one inch in diameter around the apex 
 beat is therefore termed the mitral area. Nearly the whole 
 of the right ventricle is uncovered by lung, and impinges 
 directly on the lower part of the sternum ; at this part, 
 especially along the left edge of the sternum, where it is 
 joined by the cartilages of the fourth, fifth, and sixth ribs, the 
 first sound, produced within the right heart by the closing of 
 the tricuspid valve, is most clearly to be heard ; the triangular 
 space lying over the position of the right ventricle is therefore 
 called the tricuspid area. In the normal condition the two 
 ventricles act simultaneously, and the two sounds differ so 
 little that it is impossible to differentiate the one from the 
 other. If from any cause, however, these sounds become 
 irregular or are replaced by murmurs, they may be readily 
 enough differentiated by a reference to these special areas of 
 audition, and as a rule there is always plenty of confirmatory 
 proof. 
 
 On the other hand, both in health and in disease there is 
 a marked difference between the aortic and the pulmonic 
 second sounds, and it is often important to differentiate the 
 one from the other, and clearly to recognise the distinctive 
 characteristics of each. The aorta and the pulmonary artery 
 spring from the heart close to one another. The orifice of 
 the pulmonary artery with its valve lies about the middle of 
 the cartilag-e of the third rib on the left side, one half of the 
 valve lying to the left and the other to the right of the left 
 edge of the sternum, which divides it exactly in two {vide 
 frontispiece). From its point of origin, the pulmonary artery 
 rises to the lower edge of the second left cartilage, where it 
 divides into its two great branches going to the right and left 
 lungs respectively. The second left interspace close to the 
 sternum is thus the point at which the pulmonary artery 
 most closely approximates the chest wall, and here, or still 
 better at the sternal end of the third left cartilage, the 
 
30 CLINICAL LECTURES OX 
 
 pulmonary second is most distinctly to be heard. On the 
 other hand, the aorta rises a little below, behind, and to the 
 right of the pulmonary artery, its valve corresponding in 
 position to the lower edge of the cartilage of the third rib on 
 the left side, behind and to the right of the pulmonary valve. 
 From its origin the aorta passes upwards, forwards, and to 
 the right, till it reaches the upper border of the cartilage of 
 the second rib on the right side, it then passes obliquely 
 backwards and to the left, forming what is called the arch of 
 the aorta. At the second cartilage on the right the aorta is 
 nearest the surface of the chest, and the arterial walls as well 
 as the blood-current coincide in conveying to this point those 
 resonant vibrations which result from the closure of the aortic 
 valve, — here therefore the aortic second is most distinctly 
 to be heard. The sternal end of the second cartilage on the 
 right side, and of the third cartilage on the left side, are the 
 aortic and the 'puhnonary areas respectively. In a state of 
 health the aortic second is ordinarily louder and more 
 distinct than the pulmonary second, both vessels are, how- 
 ever, normally covered with lung, and as, from various 
 causes, congenital or morbid, one or other may become un- 
 covered, and thus brought nearer the surface, its correspond- 
 ing sound may be heard more distinctly than its normal, and 
 the ordinary condition may be either intensified or reversed. 
 But this does not happen without the occurrence of other 
 phenomena, which enable us to detect and explain the cause 
 of the abnormality. Fi'om the close proximity of the two 
 arteries to each other at their origin, it sometimes happens — 
 especially when the sternum is more than usually resonant 
 — that the loudest sound is heard in the pulmonary area 
 instead of in the aortic area, or towards the left of the 
 sternum instead of towards its right. But this need give us 
 no concern, as the aortic second can always be readily 
 separated from the pulmonary second by carrying the stetho- 
 scope to the right or left of the sternum respectively, along 
 the line of the second intercostal space. Besides the greater 
 
DISEASES OF THE HEAET 31 
 
 distinctness of one sound over the other dependent upon 
 anatomical causes, we have occasional alterations of one or 
 other of these sounds from intrinsic causes alone. The 
 peculiar alteration of the second sound now referred to has 
 had a variety of terms applied to it ; it has been called 
 booming, ringing, clanging, pumping, cavernous, and accentu- 
 ated ; and perhaps booming or accentuated are the most un- 
 objectionable expressions we can employ to define this 
 peculiar change in the second sound, in which the element 
 of tension seems united with an increase of distinctness. 
 This accentuation of the second sound may be either of 
 aortic or pulmonary origin, and may be heard either at the 
 second right or the third left costal cartilage. Skoda long 
 ago pointed out that accentuation of the pulmonary second 
 was an important aid in the diagnosis of affections of the 
 mitral valve ; but the importance of accentuation of the 
 pulmonary second is not limited to lesions of the mitral 
 valve, as it is constantly present in every form of cardiac 
 lesion involving obstruction to the onward flow of the blood. 
 It is the most persistent of all the acoustic phenomena 
 connected with cardiac disease, and is occasionally the only 
 thing markedly abnormal to be detected. In the absence, 
 therefore, of any pulmonary disease capable of giving rise to 
 congestion, persistent accentuation of the pulmonary second 
 is to be regarded as invariably indicative of cardiac valvular 
 lesion. The mechanism of its production is very simple. 
 The comparatively trifling difference between the arterial and 
 venous blood-pressures within the pulmonary circuit necessi- 
 tates of course a very slight resistance to the flow through 
 the pulmonary capillaries, in order that, in any given time, 
 there may be through them a blood-flow equal to that which 
 passes through the capillaries of the systemic circulation, 
 where very different conditions prevail. From this absence 
 of capillary resistance, as well as from the absence of vaso- 
 motor nerves within the lungs, it follows that mere mechanical 
 influences play a much more important part in the pulmonary 
 
32 CLINICAL LECTURES OX 
 
 circulation than they do in that of the system generally. 
 Hence there can be no obstruction to the blood-flow, either 
 through arteries or veins, within the pulmonary circuit with- 
 out the blood-pressure within the pulmonary artery being 
 raised. But a rise of the blood-pressure within the pulmonary 
 artery causes the segments of the pulmonary valve to be 
 closed with greater force than usual ; the pulmonary second 
 is accentuated. It is probably impossible to detect minor 
 degrees of this accentuation, but as soon as the pulmonary 
 second equals or exceeds the aortic second in intensity of 
 sound there can be no doubt about it. 
 
 In the systemic circulation the conditions are very 
 different, it is impossible by any means, experimental or 
 otherwise, to produce such a rise of the general blood-pressure 
 as shall cause an accentuation of the aortic second. In 
 health the aortic second is always louder and more distinct 
 than the pulmonary second, and it is even more difficult to 
 detect any slight increase in its intensity ; there is nothing 
 with which it may be compared, or by which the intensity 
 of its sound may be gauged. It is only when some distinct 
 quality is superadded, such as that which is very fairly 
 expressed by the word booming, that we can speak with 
 perfect confidence ; and my own experience is that whenever 
 an aortic second is heard possessing this quality, some degree 
 of dilatation of the ascending aorta is always present, or if the 
 aorta be not found actually dilated after death it is flabby 
 and dilatable — the sine qiut non for the production of an 
 accentuated aortic second being the presence in the ascending 
 aorta of a column of blood greater and heavier than usual. 
 Accentuation of tJu pulmonary second, unaccom'panicd hy any 
 diseccse of the lungs, is tlierefore invariably a sign of some 
 cardiac lesion ; and accentuation of the aortic second is as in- 
 variably a sign of actucd dilatation, or of a flabby dilatable 
 condition of the ascending aorta, vjhen these accentuated sounds 
 are heard in their normal ijositions, — the third right and the 
 second left costal cartilages. 
 
DISEASES OF THE HEAET 33 
 
 Outside of the normal area of cardiac dulness, as depicted on 
 Fig. 3 (p. 24), we occasionally hear the normal cardiac sounds 
 more distinctly than usual, and this may depend either upon 
 increased resonance within a condensed portion of lung lying 
 beneath the spot at which they are heard, or upon the 
 presence of an aneurysmal bulging of the aorta at that spot. 
 In the latter case the normal cardiac sounds may be heard 
 louder than usual at that spot ; or if the cardiac sounds be 
 abnormal, these abnormal sounds are more distinctly heard 
 just at that place than they are in its immediate vicinity ; or 
 an accentuated second sound alone may be heard in this 
 abnormal position ; or this abnormally placed accentuated 
 second sound may be preceded by a locaKsed systolic bruit, 
 or more rarely still the second sound may in this position be 
 replaced by a localised diastolic bruit. When the cardiac 
 sounds are heard toith unusual distinctness outside of the normal 
 a.rea of cardiac dulness, this indicates either disease of the lung or 
 of the aorta, if the sounds are identical vnth those heard within 
 the card.iac area ; hut if they vary from these, then they indicate 
 disease of tlie aorta, 'pro'bahly aneurysm ; and in any case they 
 have only to lie noted for future more careful examination. 
 
 In the normal condition of the heart the sounds and 
 silences succeed one another in the manner already described, 
 each ventricular systolic sound being accompanied (im- 
 mediately succeeded, they are not quite synchronous) by an 
 arterial pulse perceptible in the radial arteries. It some- 
 times happens that these sounds and silences succeed one 
 another with perfect regularity in the cardiac area, and yet a 
 radial pulse may not follow each ventricular systole; the 
 pulse intermits, as it is called. At other times the inter- 
 mission extends to the cardiac action itself ; or the cardiac 
 sounds and silences as well as the radial pulse may all be 
 extremely irregular ; and all these phenomena must be care- 
 fully observed and noted for subsequent inquiry, 
 
 Eeduplication of the cardiac sounds is an interesting, and, 
 except in its rarest varieties, by no means an uncommon form 
 
 3 
 
34 CLINICAL LECTUKES ON 
 
 of irregularity. The most extreme and rarest form of this 
 irregularity is when there are four instead of two sounds, two 
 first sounds and two second sounds, the two hearts acting 
 separately, and not simultaneously as visual. More commonly 
 there are three sounds instead of tw ; two first sounds and 
 one second, which is comparatively rare and seldom to be 
 heard with any distinctness ; or two second sounds and one 
 first, which is a matter of common occurrence, and may be 
 heard even in health. Eeduplication of the second sound 
 may be heard as a bruit cle rajypd either at the base of the 
 heart, at its apex, or at both. It may be vocalised by the 
 syllables ta-ta, and closely resembles the sound made by a 
 hammer which strikes the anvil, rebounds, and strikes again, 
 remaining motionless. Eeduplication of the second sound is 
 occasionally to be heard even in health, under conditions 
 presupposing considerable pulmonary congestion, as after 
 violent exertion, and it is of common occurrence in mitral 
 stenosis in which this congestion is permanent. We know 
 that the increased blood -pressure within the pulmonary 
 circuit is in these cases sufficient to close the valve with a 
 louder snap than usual — to accentuate the pulmonary second ; 
 but not infrequently this accentuation is replaced by redupli- 
 cation. Reduplication of the second sound is by many 
 supposed to be due to a want of sijnchronism in the closure of 
 the aortic and the pulmonary valves; the lightly -filled left 
 ventricle is supposed to empty itself with unusual readiness 
 into the comparatively vacuous aorta, so that the systole of 
 this vessel closes its valve a trifle before that of the pulmonary 
 artery, and thus reduplicates the second sound. As this 
 theory presupposes no alteration in the circulation through 
 the right heart, nor in the closure of the pulmonary valve, it 
 is difficult by it to account for the absence of pulmonary 
 accentuation so conspicuous in cases of reduplicated second ; 
 neither does it explain the presence of a reduplicated second 
 when, as occasionally happens, there is only one set of valves 
 to produce it. There is, however, another theory capable of 
 
DISEASES OF THE HEAET 35 
 
 providing an efficient explanation of reduplication of the 
 second sound in all the various circumstances in which it can 
 arise, and this theory seems the most probable. Ceradini 
 tells us that the moment the blood-pressure tvithin the artery 
 equalises that tvithin the ventricle the valve segments fall together 
 with an a.udihle snap that initiates the second sound, which is 
 only strengthened, hut not produced, hj all the succeeding events 
 of the ca/rdiac diastole and arterial systole} If we adopt this 
 theory and apply it to the explanation of a reduplicated 
 second sound, we see at once how completely it fulfils all the 
 conditions needful to explain the phenomena observed. In 
 the first place, the high blood-pressure within the artery is 
 speedily equalised with that within the ventricle, hence the 
 valve segments snap together in the face of a supporting 
 column of blood, audibly, but without accentuation. In the 
 second place, as the segments of the valve are already in 
 apposition, the arterial systole itself is unable to do more 
 than produce an audible repetition — reduplication — of the 
 second sound, but still without accentuation. In the normal 
 condition of the heart, Ceradini supposes that there is always 
 a snapping together of the valve segments at the close of the 
 cardiac systole, but this is so immediately followed by the 
 arterial systolic closure of the valve that the two sounds are 
 heard as one, the first event being merely strengthened by 
 the second. As this happens both in the aorta and in the 
 pulmonary artery, we may have a reduplication of the second 
 sound in either of those vessels whenever the blood-pressure 
 rises sufficiently to separate the one event from the other. 
 This reduplication may come and go according to the varia- 
 tion in the intra-arterial blood- pressure, the action of both 
 ventricles continuing to be both regular and synchronous. 
 ISTay, more, this theory enables us readily to understand how 
 we may have a reduplication of the (pulmonary) second 
 accompanying free aortic regurgitation ; an unusual, but not 
 unknown complication. 
 
 ■^ Der Mechanismus der halbma7idfar7}iigen Ile'/'zHappen (Lei-pzig, 1872), S. 62. 
 
36 CLINICAL LECTURES ON 
 
 Eeduplication of the cardiac sounds in disease are more 
 common and more permanent ; in health they are more apt 
 to be fugaceoiis, appearing one instant and disappearing the 
 next. They are abnormal exaggerations of a phenomenon 
 which with care may be detected in every one ; reduplication 
 of the first sound occurring at the end of the expiration or 
 commencement of the inspiration ; reduplication of the second 
 sound occurring at the end of the inspiration or commence- 
 ment of the expiration. These normal reduplications depend 
 upon the variation in the pressure produced by the respiratory 
 movements at the origin of the arterial and venous systems.^ 
 The first sound may be suppressed — inaudible — when from 
 any cause the myocardium is enfeebled ; this is common in 
 advanced typhus, and not infrequent in weak dilated hearts ; 
 it is also said to be a sign of fatty degeneration, but this is 
 certainly not always the case, as many hearts affected in this 
 way have had a distinct first sound to the last (vide postea sub 
 voce). The first sound is also frequently inaudible when the 
 heart is separated from the chest wall by fluid, as in peri- 
 cardial effusion. The second sound is less frequently sup- 
 pressed, but always from a similar cause — some enfeeblement 
 of the cardiac action, or some hindrance to the conduction of 
 the sound to the chest wall. 
 
 Within the cardiac area a murmur may take the place of 
 one or other, or even of both of the cardiac sounds, or it may 
 occupy the time of one or other of the silences. A murmur 
 may thus occupy the whole period of a cardiac cycle, or it 
 may occupy any portion of it. Such murmurs may either be 
 of exocardiac or of endocardiac origin, and as endocardiac 
 murmurs are most frequent, and are chiefly due to valvular 
 
 1 Potain, "Note sur le Dedoublements Normaux des Bruits du Cojur," 
 L' Union Mcdicale (1866). In my own experience reduplicated first sounds 
 have been comparatively rare. One of the most perfect instances of this kind 
 was strikingly confirmative of Potain's view, inasmuch as impeded respiration, 
 due to a distended ovarian cyst, was always accompanied by a reduplicated 
 first sound, which invariably disappeared after tapping. This occurred 
 repeatedly. There was no other cardiac abnormality. 
 
DISEASES OF THE HEART 37 
 
 incompetence, it is a good rule to endeavour first of all to 
 associate all murmurs with a valvular origin, and only after 
 exhausting this hypothesis to proceed to determine the prob- 
 abilities in favour of their exocardiac origin, or of their depend- 
 ence upon some endocardiac cause apart from valvular lesion. 
 Of all the signs of cardiac disease, murmurs are usually 
 those most implicitly confided in, and yet their evidence 
 must be accepted with caution — first, because we may have 
 murmurs of exocardiac origin which simulate very closely 
 those of valvular origin ; and, second, because murmurs truly 
 of valvular origin may disappear temporarily or permanently.-^ 
 Thus we may have a murmur apparently of valvular origin 
 which is really exocardiac ; second, we may have a murmur 
 truly of valvular origin, yet without valvular lesion, which 
 may disappear, leaving the heart uninjured ; and, lastly, we- 
 may have a murmur truly of valvular origin which may 
 disappear temporarily or permanently, the valvular lesion 
 still continuing. It is obvious, therefore, that murmurs can- 
 not of themselves be accepted as certain indications of 
 permanent cardiac lesions, even although we may be able to 
 connect them positively with imperfection of a definite valve, 
 because that imperfection may be only of a temporary and 
 curable character. To this there is but one positive exception, 
 and that is the auricular-systolic, the so-called presystolic 
 murmur, though there is obviously a greater or less prob- 
 ability of any of the other valvular murmurs being also 
 connected with permanent lesion of the valve implicated. 
 That probability, however, falls to be considered when we 
 come to discuss the signs indicative of the lesion of each 
 separate valve. What we have now to consider are the 
 various sounds that may be heard in the cardiac area apart 
 from those we have already learned to recognise as normal, 
 and to point out the measures we adopt to determine the 
 greater or less probability of these sounds being connected 
 
 ^ "On the Variation and Vanishing of Cardiac Organic Valvular Murmurs," 
 by W. R. Sanders, M.D., Edinburgh MedicalJournal (January 1869), p. 584. 
 
38 CLINICAL LECTURES ON 
 
 with any valvular lesion. Always remembering that no 
 murmur, other than that already referred to, can ever be 
 accepted as a certain proof of actual and permanent cardiac 
 disease, but must be simply noted, to be afterwards duly 
 considered along with the other information derived from 
 inspection, palpation, and percussion, when we come to 
 estimate the probabilities for and against the existence of 
 any special lesion. 
 
 When we hear over any part of the area of cardiac 
 dulness any sound which differs from those we have already 
 learned to recognise as the normal sounds of the heart, our 
 first care is to ascertain at which part of the cardiac area this 
 abnormal sound is most distinctly to be heard ; this is termed 
 the position of maximum intensity. This position either coin- 
 cides with one or other of those areas already described as 
 the mitral, the tricuspid, the aortic, or the pulmonary area, 
 or it does not. If the position of maximum intensity of this 
 abnormal sound coincides with one or other of these normal 
 areas, it most probably depends upon some lesion, temporary 
 or permanent, of that valve whose normal sound is audible in 
 that area, and which it either obscures, replaces, precedes, or 
 follows. If this position of maximum intensity does not 
 coincide with one or other of those normal areas, this 
 abnormal sound is certainly not of valvular origin, unless it 
 is heard over the lower part of the sternum, or just to the 
 left of the pulmonary area and in the same plane. And to 
 vindicate its claim to a valvular origin the murmur must be 
 diastolic in the former position, and systolic in the latter; 
 the reasons for this are to be found in the anatomical 
 relations of the parts connected with the valves at which 
 such murmurs originate, and in the mode in which sound is 
 conducted. 
 
 Our next care is to determine the actual rhythm of the 
 murmur or abnormal sound, that is its positive relation to those 
 several physiological acts which constitute a cardiac pulsatioti or 
 cycle. To recognise this rhythm we must, first of all, have a 
 
DISEASES OF THE HEAET 
 
 39 
 
 clear conception of those various physiological acts which 
 make up a cardiac cycle ; and secondly, we must be able to 
 recognise them. The accompanying figure (Fig. 4, slightly 
 altered from Gairdner^) represents diagrammatically the 
 several acts of a cardiac pulsation in the normal adult heart, 
 in which a long sound precedes a short silence, followed by a 
 short sound, and that again by a long silence. So long as 
 
 Carotid 
 
 Pulse 
 
 Radial Pulse 
 
 Fig. 4. 
 
 the heart-beats are not over ninety per minute, there is never 
 
 1 To Dr. Gairdner we owe the first attempt to represent a cardiac pulsation 
 diagrammatically. Fig. 4 is slightly altered from Gairdner's with the view 
 of making it more physiologically accurate. The apex beat and the two 
 sounds are represented as occupying, as they do, appreciable periods of time 
 during the cardiac cycle. The heart's action is represented as continuous 
 and without actual pause or rest, though at times soundless. The carotid 
 pulse is placed in the position which Valentin says it ought to occupy m 
 relation to the apex beat, and the radial pulse is placed as nearly as possible 
 in its usual position in relation both to the apex beat and the carotid pulse. 
 The foot pulse is nearly synchronous with the radial ; according to Mr. A. H. 
 Garrod the difference between the two, with a pulse at 75, amounts to only 
 0'0012 of a minute. 
 
40 CLINICAL LECTURES ON 
 
 any difficulty in making out the several relations of these 
 sounds and silences. But when the heart-beats are over ninety 
 per minute, the long pause and the long sound shorten with 
 the increasing rate, so that the sounds and silences gradually 
 lose their distinctively adult character and approximate the 
 uniform tic-tac of the infant, and the more nearly this is the 
 case the greater is the difficulty experienced in determining 
 which sound is long or first, and which is short or second. 
 To ascertain this with precision, we must either wait till rest 
 or treatment has slowed the heart-beats down to ninety, or we 
 must trust to our accuracy in the use of a double stethoscope, 
 knowing that under all circumstances the first sound is 
 always relatively long at the apex and short at the base ; or 
 we may determine which sound or murmur is synchronous 
 with the apex beat or the carotid pulse, as that must coincide 
 with the ventricular systole. But we must carefully avoid 
 any reference to the radial pulse as irrelevant and misleading, 
 as even in the normal condition this pulse is separated from 
 the apex beat by an interval which may amount to about 
 one-sixth of a second, and this interval may be increased in 
 disease to a period amounting to the half or even to the 
 whole of an entire cardiac pulsation. 
 
 Having determined the position of maximum intensity 
 and the rhythm of a murmur, we are prepared to state the 
 nature of the lesion upon which it depends. For this all we 
 need is simply to remember that, in the normal state of the 
 heart, the auriculo-ventricular valves are closed during the 
 systole of the ventricles, and the arterial valves are open. 
 During the diastole of the ventricles the action of these 
 valves is reversed, the arterial valves are closed and the 
 auriculo-ventricular valves are open. These statements apply 
 to both sides of the heart, which normally act synchronously 
 and simultaneously. When we hear a murmur with a 
 position of maximum intensity in the mitral area, we know 
 it to depend upon some defect of the mitral valve. If this 
 murmur be synchronous with the systole of the ventricles, it 
 
DISEASES OF THE HEAET 41 
 
 depends upon some defect in the closure of that valve, and is 
 a murmur indicative of regurgitation of blood backwards into 
 the auricle. But if this murmur be synchronous with the 
 diastole of the ventricles, it depends upon some obstruction 
 to the flow of the blood through the open mitral valve, and is, 
 therefore, a murmur of obstruction. A murmur of mitral 
 regurgitation ruiis off from the a'pex heat, and riiore or less 
 completely replaces the normal first sound. A , murmur of 
 mitral obstruction accovijMQiies or follows the second sound, hut 
 in no respect interferes vjith its production. This murmur of 
 obstruction to the onward flow of the blood at the mitral 
 valve may be audible throughout the whole of the ventricular 
 diastole ; more usually it is only to be heard at an appreciable 
 interval after the second sound, running up to and ending 
 with the first sound. From this circumstance this murmur 
 is very generally termed a presystolic murmur. A reference to 
 the diagram (Fig. 4) shows that, as physiology teaches, the 
 period of time immediately preceding the commencement of 
 the ventricular systole is occupied by the systole of the 
 auricles, so that a so-called presystolic murmur is really 
 auricular-systolic in rhythm. It is not only a murmur of 
 obstruction to the onward current of the blood, but it is 
 also a murmur of obstruction to direct cardiac action, and, 
 like all such murmurs, it is always rough in character. 
 It is the only generally recognised cardiac murmur which 
 is invariably associated with actual disease of the valve 
 affected. 
 
 These three murmurs — the mitral systolic, the mitral 
 diastolic, and the presystolic or auricular-systolic — may each 
 be heard separately in separate cases ; or any two of them 
 may be present ; or more rarely all three are to be heard 
 together, and then we have a murmur whose position of 
 maximum intensity is in the mitral area, and which runs 
 right through the cardiac cycle. In all these instances the 
 first sound is either much altered or entirely replaced by the 
 murmur ; while the second, though not always to be heard at 
 
42 CLINICAL LECTURES OX 
 
 the apex, is always to be heard at the base of the heart, and 
 the pulmonary second is always accentuated and sometimes 
 very greatly so, unless, indeed, we hear two seconds immedi- 
 ately following each other forming the reduplicated second 
 just described, when accentuation of the pulmonary second 
 is always much modified, and often entirely absent. These 
 murmurs are most common on the left side, but may also be 
 heard over the right heart. A systolic tricuspid murmur is 
 of frequent occurrence, a presystolic tricuspid is occasionally, 
 though rarely, to be heard, but a diastolic tricuspid murmur, 
 though possible, is yet, so far as I am aware, hitherto un- 
 recorded. In making this statement I refer to a diastolic 
 murmur clearly attributable to the right auricle or ventricle 
 alone, both pulmonary and aortic second sounds remaining 
 distinctly audible, and with entire absence of any symptom 
 or sign of aortic regurgitation. This is a very necessary 
 warning, because it often happens that a diastolic murmur, 
 arising from defective closure of the aortic valves, is heard 
 loudest over the lower part of the sternum, partly conducted 
 downwards by the descending current of the blood, and 
 partly by the resonating properties of the sternum. We 
 shall afterwards see that a diastolic murmur, of purely aortic 
 origin, may have its position of maximum intensity over the 
 lower part of the sternum — in the tricuspid area — or even in 
 the mitral area itself, and that this is said to depend upon 
 the segment of the valve affected. 
 
 At the base of the heart the murmurs audible seem to 
 le less complicated than at the apex, because at the base 
 there is no presystolic murmur, and the only possible 
 murmurs are either systolic or diastolic. But the causes of 
 these are so various as to give rise to much speculation, and 
 the pulmonary region has not undeservedly been called the 
 region of romance, from the variety of theories propounded 
 in explanation of the murmurs to be heard there. While 
 the physical causes of aortic murmurs, and the physical 
 relations of the aorta itself are so complicated, and so 
 
DISEASES OF THE HEAET 43 
 
 efficiently modify tlie conduction of these murmurs, that 
 though it is quite usual to say that a systolic murmur, having 
 its position of maximum intensity at the sternal end of the 
 second right costal cartilage, is due to aortic obstruction, this 
 is by no means always the case. And in like manner, 
 though a diastolic murmur, audible in the same position, is 
 most probably due to aortic regurgitation, yet the absence 
 of such a murmur cannot be accepted as proof of the absence 
 of regurgitation, because the murmur due to regurgitation 
 is sometimes only audible beneath the level of the aortic 
 valves. 
 
 In noting the characteristics of any murmur, the chief 
 points to be determined are, first, its position of maximum 
 intensity as a probable indication of the valve affected; 
 second, its rliythvi, presystolic, systolic, or diastolic, indicating 
 its position in the cardiac cycle ; and lastly, we must note 
 what has happened to the valve sound normally heard in any 
 given position, whether it is wholly replaced 'by the murmur, 
 or is only altered in duration and character. We must also 
 remember that even the presence of a well-defined murmur 
 is not by any means a certain indication of actual lesion 
 of the valve implicated, it may only signify incompetence 
 without either disease or deformity. Neither are we justified 
 in regarding the absence of a murmur as any certain proof 
 of the non-existence of valvular disease. The characteristics 
 of a murmur, and its relations to the normal sounds and 
 silences, must merely be noted and afterwards duly con- 
 sidered in connection with the other physical signs already 
 commented on. 
 
 Endocardiac murmurs of other than valvular origin are 
 occasionally, though rarely, observed. Sometimes these 
 murmurs are due to congenital deficiency of some part of 
 the septum between the two hearts ; and in that case they 
 only intensify those valvular murmurs which almost in 
 variably coexist, and extend the area of their audibility. 
 Where no valvular lesion exists, as in those rare and 
 
44 CLINICAL LECTURES ON 
 
 problematical murmurs said to occur, in a heart otherwise 
 healthy and normal, from the presence of a flake of lymph 
 or other vibrating substance attached to one of the cordm 
 tcndinecc, the position of maximum intensity and the rhythm 
 may closely simulate those of a valvular lesion. But a due 
 consideration of the other physical signs associated with 
 them, as well as of the physical facts already pointed out as 
 indicative of actual or constructive obstruction to the 
 onward flow of the blood, will be sufficient to enable us to 
 avoid the commission of any glaring error in diagnosis. 
 
 Exocardiac murmurs frequently simulate in their timbre 
 those of endocardiac origin, and when they also coincide in 
 rhythm with the systole or diastole of the heart, there may 
 be some little difliculty in distinguishing such a murmur 
 from one of endocardiac origin. Exocardiac murmurs, 
 however, are chiefly due to friction of the roughened visceral 
 and parietal portions of the pericardium upon each other, or of 
 the pericardium upon the pleura, and, unless in very exceptional 
 circumstances, this friction is always greatest over the centre 
 of the heart, and neither at its apex nor exactly at its base. 
 An exocardiac murmur, therefore, does not coincide in 
 position of maximum intensity with any of the recognised 
 valvular areas. It has a distinctly superficial character, it 
 radiates equally all round its place of origin, but never to 
 any great distance. It is not propagated along any blood- 
 current, nor is it associated with any accentuation of the 
 second sound, nor with any of the physiological indications 
 of obstructed circulation. Moreover, a friction sound only 
 rarely simulates the soft blowing murmur of valvular in- 
 competence, more often it resembles the crackling of parch- 
 ment, the creaking of new leather, or a mere grating or 
 rubbing sound of greater or less intensity. Whatever its 
 timbre or rhythm, we must treat it as we ought to treat 
 every sound heard over the cardiac area, by carefully noting 
 its character, position of maximum intensity, rhythm, and 
 direction in which it is propagated, to be afterwards sub- 
 
DISEASES OF THE HEAET 45 
 
 mitted, along with any other facts ascertained, to a careful 
 and discriminating scrutiny. 
 
 A similar remark may be made in regard to those 
 murmurs audible in various positions out of the cardiac 
 area, and which owe their origin to the passage of the 
 blood through the vessels. Such murmurs are sometimes 
 heard in the arteries and at others in the veins. They are 
 chiefly systolic in rhythm, but at others they are diastolic, 
 or they may continue throughout the whole cardiac cycle. 
 In the arteries these murmurs may be strictly localised, or 
 they may be audible over every part of the arterial system. 
 In the veins, as a rule, they are audible everywhere, provided 
 certain conditions are complied with, though they are only 
 permanently present in certain parts of the body where 
 these conditions exist naturally. Such intravascular murmurs 
 are of the most various significance, and can only be most 
 briefly referred to now. Sometimes they signify serious 
 lesion of the vessels themselves ; at other times, nothing 
 worse than some slight deformity of the chest, probably the 
 result of rickets ; and at still other times, only an alteration 
 in the constitution of the blood itself, which may arise from 
 various causes. 
 
 I cannot conclude this lecture without a cursory reference 
 to the manner in which these murmurs are believed to be 
 produced, not only because this is a subject interesting in 
 itself, but also because distinct and accurate ideas as to 
 the causation of murmurs must necessarily lead to greater 
 accuracy in diagnosis. The crude notions of our forefathers 
 culminated in the opinion that a murmur is produced by 
 friction of the blood-current on its containing walls. This 
 idea has been completely set aside by the researches of 
 Poiseulle, and others, which show that however rough the 
 bed of the blood-current may be it flows smoothly over it, 
 without giving rise to any friction whatever. Corrigan was 
 the first to start the theory that murmurs occurring in the 
 course of the circulation are due to vibrations produced by 
 
46 CLINICAL LECTURES ON 
 
 eddies in the blood-column itself. This theory has been 
 reduced to scientific simplicity by Mr. A. Chaveau/ who 
 has with great probability referred the causation of all 
 murmurs, whether intracardiac or intravascular, to the 
 
 ^ Com2)tcs Fundus de I'AccuUmie dcs Sciences (1858). — "Toute veine fluide 
 est le siege de vibrations susceptibles de produire des sons, 
 vibrations qui ebranlent aussi I'Drifice d'ecoulement de la veine " 
 —p. 841. Even the intravascular murmurs of anaemia (spansemia) 
 are due "aux vibrations de la veine fluide intravasculaire, vibra- 
 tions qui se produisent quand le sang penetre avec une force 
 suffisante dans une partie r^ellement ou comparativement dilatee 
 de I'appareil circulatoire " — p. 933. 
 
 The nature of a fluid vein may be more readily understood 
 from a short account of the conditions under which it is known 
 to be formed. When fluid escapes through a perforation in a 
 thin plate forming the bottom of an open vessel kept constantly 
 full, Torricelli supposed that the efflux could be ascertained 
 by the following theorem: Q = ts J2gh, in which Q represents 
 the outflow, t the time occupied, s the sectional area of the 
 orifice, g the acceleration of gravity, and h the height of the 
 surface above the orifice. The actual outflow, however, is, when 
 measured, always about one-third less than that given by calcula- 
 tion, and the discrepancy has been found to be due to the fact 
 that the velocitj'^, on which the calculation is based, is only 
 true of the central part of the jet, the outer part of this being 
 retarded by the interference of the currents converging from all 
 sides of the vessel. The convergence of these currents also causes 
 the jet to taper off to '6 of its original dimensions at a distance 
 from the orifice of one-half its diameter, and if the sectional 
 area of this narrow portion, the vencc contracta, as it is termed, 
 is substituted for that of the original orifice, the actual outflow is 
 then correctly expressed by Torricelli's theorem. Up to this 
 narrowed portion the jet is clear and pellucid, but at this point, 
 probably from the conflict between the tendency to diverge 
 inherent in the outer currents and the attractions of cohesion 
 and gravity, the jet loses its transparency and breaks up into 
 those vibrating fluid veins the phenomena of which have been 
 described by Felix Savart as follows. The part of the vein 
 ah (Fig. 5) is steady and limpid, presenting the appearance 
 ^''■- ^- of a solid rod, which obstructs vision and wets the finger when 
 it is passed through it. This limjiid rod decreases in diameter till it reaches 
 a point of maximum contraction (just above h), beyond this it is turbid and 
 unsteady, marked by periodic swellings and contractions, does not wet the 
 finger when passed through it, and does not obstruct vision, even though 
 the fluid be mercury. At b, in fact, the lic^uid is no longer continuous, but 
 resolves itself into a series of liquid spherules, which have an appearance 
 of turbid continuity, from their rapid succession not permitting the primary 
 impression to fade from the retina till succeeded by a second. Fig. 6 shows 
 this fluid vein illuminated by an electric flash, the drops of which it is com- 
 
DISEASES OF THE HEART 
 
 47 
 
 sonorous vibration of fluid veins, such as have been observed 
 by Savart, and which are capable of being transferred, as 
 Marey has experimentally shown, to the surrounding fluid 
 within which the vein has formed, as well as to the vessel 
 containing it. The roughness of the murmur and the tactile 
 perceptibility of the vibrations are in some degree 
 proportionate to the force exerted in producing 
 this sonorous vein, while its musical character 
 must depend upon the rapidity of these vibrations, 
 as well as on the physical structure of the parts 
 to which these vibrations are communicated. 
 
 But the mode in which the production and 
 conduction of these sonorous vibrations may be 
 modified by evident or imperceptible alterations 
 in the action of the heart itself, or by changes in 
 the anatomical relations of the parts concerned, 
 produced by alterations in the posture of the 
 patient himself, are problems yet to be investi- 
 gated. It may be that a careful and experimental 
 examination of these problems may be of the 
 utmost value in promoting a more accurate diagnosis 
 of cardiac and vascular diseases. 
 
 posed are seen as it were motionless in the air, and the cause 
 of the periodic swellings and contractions is at once apparent. 
 For the drops when first detached are seen to have their long 
 axis vertical, abandoned to their own molecular forces they seek 
 to become spheres, and, like a pendulum in motion seeking to 
 return to rest, their contraction goes too far and they become 
 flattened spheroids, which again elongate vertically. Hence the 
 appearance of alternate swelling and contraction. Savart traced 
 the production of these pulsations to the orifice through which 
 the fluid vein passed, but did not regard them as the result of 
 friction. Under moderate pressui-e they succeed each other sufficiently 
 rapidly to produce a feeble musical note, the pitch of which may be de- 
 termined by allowing the drops to fall upon a stretched membrane. Vide 
 Tyndall On Sou7id (London, 1869), p. 224, etc. By attaching tubes of 
 various forms to the original orifice, the formation of a fluid vein may be com- 
 pletely prevented, and the outflow may even be increased beyond the quantity 
 calculated by Torricelli. It seems not improbable that the relations of the 
 several parts of the circulatory system to each other may be so adjusted that 
 sonorous fluid veins are only formed when disease of the vessels, or some 
 change in the constitution of the blood, has altered these normal relations. 
 
 Fig. 6. 
 
LECTUEE II 
 
 ox incompetence of the aortic valve, ^y1tr special 
 eeference to the diagnostic signification of the 
 mue:mues 
 
 There is no disease of the heart, of conmion occurrence, 
 which possesses so many elements of interest as aortic 
 incompetency, whether we regard its pathology in relation to 
 the many causes which may give rise to it, to the concomitant 
 morbid alterations in the aorta, in the heart itself, and in the 
 circulation, which may be so various ; or whether we regard 
 its diagnosis, which involves a careful discrimination of the 
 causes of the incompetence, as well as of the consecutive 
 changes in the heart, if we wish it to be of value in its 
 application to either prognosis or treatment. 
 
 In aortic incompetence, as in all cardiac affections, our 
 information is derived from the state of the pulse, and from 
 the inspection, palpation, percussion, and auscultation of the 
 patient. A due consideration of the information thus derived 
 enables us to predict with considerable certainty the condition 
 of the aortic valves, and to determine the degree in which the 
 walls of the heart and the circulation generally have been 
 affected by the persistence of this abnormal condition. 
 
 Confining our attention for the present to the phenomena 
 revealed on auscultation, you are aware that the murmur 
 indicative of aortic incompetence is a diastolic murmur of a 
 more or less soft and blowing character, audible, as is usually 
 said, at the base of the heart. But this is by no means 
 
DISEASES OF THE HEAET 49 
 
 always the case. Sometimes this diastolic murmur is only 
 audible, and that but faintly, just below the aortic valves, at 
 mid-sternum, a little beneath the level of the third rib. Very 
 rarely, it is loudest at the left apex ; ^ very frequently, it is 
 loudest and sometimes only to be heard — except in the 
 arteries — at the ensiform cartilage, or more nearly in the 
 position of the right apex. At times it is loud and distinctly 
 audible over every part of the cardiac area, and then it is also 
 to be heard in every part of the arterial system to which the 
 stethoscope has access. While at still other times it is 
 inaudible above the level of the aortic valves, and is not to 
 be heard in any artery. I have already mentioned that a 
 murmur is produced by the formation of a fluid vein at any 
 point in the blood-current,^ and a moment's reflection shows 
 us that, in most cases, the same cause that produces a fluid 
 vein at the aortic orifice during the diastole of the heart, 
 must be equally potent during its systole. Hence in most 
 cases of aortic incompetence we have a double murmur, a 
 hruit de va et vien, a see-saw murmur of which the first or 
 systolic portion is usually rough, and the second or diastolic 
 portion always soft and blowing, though sometimes the one 
 and sometimes the other may be loudest. The propagation 
 of the systolic portion of this double murmur is subject to the 
 same vagaries as that of the diastolic portion, being at one 
 time audible all over the cardiac area, at another time only 
 to be heard at and above the aortic orifice, and yet again it is 
 chiefly audible in the arteries alone. The term double aortic 
 lesion is thus a common and, as we see, by no means an 
 inapplicable designation for that affection of which incom- 
 petence of the aortic valves forms always the most distinctive 
 though rarely the sole important feature. The variations in 
 
 ^ This position of maximum intensity of the murmur of aortic incompetence 
 is said to be an indication of rupture or disease specially affecting the posterior 
 or mitral segment of the semilunar valve ; vide Dr. Balthazar Foster's Essays 
 on Clinical Medicine (London, Churchill, 1874), p. 121. Most observers are, 
 however, agreed that this idea is highly problematical. 
 
 ^ Vide antea, p. 46. 
 
 4 
 
50 CLIXICAL LECTURES OX 
 
 the manner in which the constituents of this double murmur 
 are propagated are not mere vagaries in the conduction of 
 sound, they are important facts depending upon physical 
 causes, and convey most valuable information to the under- 
 standing mind of him who hears. 
 
 The following cases have been selected to show the chief 
 varieties of aortic regurgitation, and the manner in which the 
 condition of the valves influences the production and propa- 
 gation of the murmurs : — 
 
 Case I. Janet M'Gowau,^ aged twenty-two, admitted 25th 
 March 1874, to Bed 2, Ward XIII., complaining of subacute 
 wandering pains in her joints. This attack commenced twelve 
 months ago, and was at first accompanied by great pain and 
 some swelling in the region of the heart, for which a fly blister 
 was prescribed ; after this the swelling disappeared, and the 
 pain subsided, but it has never altogether ceased. Three 
 years and a half ago she had an attack of rheumatic fever, 
 but apart from that has always enjoyed good health, except 
 suffering from measles and scarlet fever when a child. The 
 patient is well developed ; expression natural ; integuments 
 moist ; temperature 986^; limbs somewhat wasted ; joints 
 noways deformed, but occasionally painful, chiefly the shoulder 
 and elbow joints ; no anasarca ; arteries and veins normal on 
 inspection; pulse 73, slightly jerking, but this is not per- 
 ceptibly increased on elevating the arm at right angles to the 
 body as the patient lies in bed. On percussion the cardiac 
 dulness, at one inch from the left edge of the sternum, 
 extends vertically from the upper border of the third rib till 
 it meets the tympanitic resonance of the stomach, and 
 extends, in the line of the fourth rib, from three-quarters of 
 an inch to the right of the sternum, transversely across the 
 chest, for a distance of four inches and three-quarters. The 
 heart's apex beats firm and full between the fifth and sixth 
 ribs, two inches and three-quarters to the left of the sternum. 
 On auscultation in the mitral area the first sound is heard 
 
 ^ Condensed from the notes of Mr. J. H. Clarke, clinical clerk. 
 
DISEASES OF THE HEAET 51 
 
 loud, thumping, and accompanied by a systolic murmur ; no 
 diastolic sound nor murmur is audible. In the tricuspid 
 area the first sound is loud, distinct, still somewhat thumping, 
 and accompanied by a systolic murmur, followed by an 
 equally distinct diastolic one. Above the fourth rib the 
 thumping character of the first sound is lost, while the systolic 
 murmur increases in intensity. In the aortic area neither a 
 systolic nor a diastolic sound is audible, they are replaced by 
 a very loud and distinct double murmur ; the systolic portion 
 of this murmur is extremely rough, and propagated with 
 great distinctness into the carotid arteries, while the diastolic 
 portion is quite inaudible in them. In the pulmonary area 
 a double murmur is heard, the systolic portion of it entirely 
 replaces the first sound, while the diastolic portion partially 
 obscures an accentuated second sound. Her respirations are 
 32 per minute ; no cough, and no dyspnoea, except on exertion, 
 and then not to any great amount ; pulmonary physical signs 
 normal. Nervous system normal. Appetite defective ; 
 bowels regular ; urine normal, specific gravity 1015 ; men- 
 struation regular till twelve months ago, since then irregular. 
 On 15th May it is noted that a well-marked presystolic 
 murmur has been developed, and this continued till the 
 patient was sent to the Convalescent Hospital on 20th May, 
 completely relieved of her rheumatic symptoms. 
 
 You will observe that this patient came under treatment 
 solely for her subacute rheumatic affection, and though 
 labouring under serious cardiac disease, which will un- 
 doubtedly shorten her days, this had been so completely 
 compensated as to be altogether mute. The hypertrophy of 
 the left ventricle was sufficient to counterbalance its dilata- 
 tion, and also to compensate the obstruction to the circulation 
 due to the regurgitation through the incompetent aortic valves. 
 For the present I omit as irrelevant all reference to the state 
 of the mitral valve, and shall direct your attention solely to 
 the aortic murmurs present, and to their mode of propagation. 
 
 You will note first of all that the systolic murmur, more 
 
52 CLINICAL LECTURES ON 
 
 or less audible over the whole cardiac area, has its position of 
 maximum intensity in the aortic area, and is therefore clearly 
 of aortic origin. But the essential part in the production of 
 a murmur is the formation of a fluid vein at the point of 
 origin — here the aortic orifice, and to produce this fluid vein 
 there must be some real or constructive constriction at this 
 point. Either the aortic orifice must be obstructed, or the 
 aorta beyond must be dilated so as to produce a relative 
 constriction. In this case there is no increase of dulness 
 over the upper part of the sternum, and no pulsation in the 
 tracheal fossa ; no sign, therefore, of any actual dilatation of 
 the aorta. Is there any reason to suspect any relative 
 dilatation due to actual obstruction at the aortic orifice ? The 
 answer to this is not difiicult. From the history of this 
 patient there is every reason to believe that she has had an 
 attack of inflammation of the pericardium, this we deduce 
 from the swelling and pain in the praecordial region present 
 during the early period of her rheumatic attack. The more 
 or less constant cardiac pain accompanied by a thumping 
 first sound, and the subsequent development of a presystolic 
 murmur, conclusively prove that this pericarditis has been 
 associated with a more or less chronic endocarditis that has 
 stiffened and deformed the mitral valve. It is natural to 
 suppose that a similar effect has been produced upon the 
 aortic semilunar valves. The result of the thickening and 
 deformity of these valves is that they obstruct the onward 
 current of the blood, causing an actual constriction of the 
 aortic orifice and a relative dilatation of the aorta beyond, 
 just the condition needful to give rise to a fluid vein when 
 the blood is forced through this constricted orifice by the 
 ventricular systole. This fluid vein gives rise to an audible 
 murmur, systolic in time, and rough in proportion to the dis- 
 proportion between the size of the blood- wave and the orifice 
 through which it is thrown, as well as to the ventricular force 
 exerted in expelling it. In accordance with the laws of 
 sound, a murmur thus produced is carried with most dis- 
 
DISEASES OF THE HEAET 53 
 
 tinctness with the onward current of the blood, and is to be 
 clearly heard in the carotid arteries; it is also propagated 
 with greater or less distinctness, according to circumstances, 
 in every other direction. The history of this case is thus 
 in complete accord with this most probable explanation 
 of the systolic portion of the aortic murmur, and we may 
 accept it without hesitation. 
 
 But if the aortic valves are so thickened and crumpled as 
 to obstruct the onward flow of the blood, they can scarcely 
 be expected to be perfectly competent. They may be com- 
 petent, but this is unusual. Most generally, as we can readily 
 suppose, such crumpled valves do not meet accurately, 
 they are incompetent, and then the same cause that gave 
 rise to a fluid vein and a murmur during the systolic outflow, 
 gives also rise to a fluid vein and a murmur during the 
 diastolic regurgitation of the blood into the ventricle. The 
 diastolic murmur is always much softer and more blowing 
 than the systolic aortic murmur, because the forces that 
 conduce to regurgitation are much less powerful than the 
 systole of the left ventricle. Evidently this has been 
 the course of events in this case. We are not yet in a 
 position to explain, in every case, why a diastolic murmur 
 originating at the orifice of the aorta should at one time be 
 heard loudest above that part, as in the so-called aortic area, 
 and at another time lower down the sternum. At present 
 we can only state it as a fact, and indicate the probability 
 that the reason will ultimately be found to be closely linked 
 with the nature of the obstruction, as well as with the readi- 
 ness with which the vibrations of the fluid vein are propagated 
 outwards through the wall of the vessel in one case, and 
 downwards with the regurgitating blood in another. There 
 seems some reason to suppose that the greater the obstruction 
 and the more vibratile its connection with the arterial walls, 
 as well as the firmer it is in texture, the more likely the 
 murmur is to be localised in the aortic area. When the 
 obstruction is less, and less vibratile in its structure and 
 
54 CLINICAL LECTURES ON 
 
 connections, the murmur tends rather to be propagated 
 downwards with the blood-current, or possibly it may first 
 develop as sound at that part of the heart on which the 
 fluid vein impinges, propagation in other directions ensuing 
 in accordance with the laws of sound. These attempts to 
 explain the reasons for the different directions in which 
 aortic murmurs are propagated have, at least, probability on 
 their side, and the more we inquire into the various forms of 
 aortic incompetence the greater will this probability appear. 
 In the present case both the systolic and diastolic murmurs 
 are most distinctly to be heard in the aortic area. The 
 incompetence of the aortic valve is not very great — (1) 
 Because the apex beats in its normal plane, though a little 
 outside of its normal position ; the heart has more of the 
 purse shape usual in mitral disease, than of the conoid form, 
 due to dilatation of the left ventricle, so common in aortic 
 incompetence. (2) Because there is but little jerking to be 
 felt in the pulse or seen in the carotid or brachial arteries. 
 This jerking of the pulse is due to the marked contrast 
 between the rapid distention of the arteries with a large 
 systolic blood- wave, and the sudden collapse that accompanies 
 cardiac diastole ; it signifies free regurgitation and a strong 
 and capacious left ventricle. The absence of jerking is not in 
 this case, as in some, due to mere weakness of the ventricular 
 wall, because the apex of this heart beats both firmly and 
 forcibly, but it is evidently due to the absence of any great 
 dilatation of the left ventricle, and, as an ultimate cause, to 
 the absence of any great aortic incompetence. And lastly, the 
 aortic incompetence is not great because, though the diastolic 
 murmur is so loud at the base of the heart, it is quite inaudible 
 either in the carotid or crural arteries. We shall presently 
 see that a diastolic murmur may be audible in the arteries 
 even though inaudible at the base of the heart, and that 
 a diastolic murmur so propagated is invariably associated with 
 all the signs and symptoms of great valvular incompetence ; 
 in the present case the diastolic murmur is loudest in the 
 
DISEASES OF THE HEAET 55 
 
 aortic area, and inaudible in the arteries, and the signs and 
 symptoms all indicate a triiling degree of incompetence. 
 There are therefore strong reasons for believing that in this 
 case — confining our attention to the aortic valves — there is a 
 stifiened and somewhat shrivelled or crumpled condition of 
 these valves due to rheumatic vahuilitis. This is the funda- 
 mental lesion. The valves maybe also atheromatous, or covered 
 "with dense vegetations, possibly both, but of these possible 
 conditions we have no indications : on the other hand, the 
 incompetence due to their shrivelled condition is not great, 
 but the coexistence of the mitral lesion makes the prognosis 
 more grave than it would otherwise have been. 
 
 The following somewhat similar case is an example of the 
 manner in which murmurs of aortic incompetence vary even 
 in cases which are fundamentally alike, it shows also that 
 these variations are probably due to slight alterations in the 
 physical causes of these murmurs, which only require a 
 larger and more accurate experience to enable us to interpret 
 correctly : — 
 
 Case II. Mary Anderson,-^ married, a laundress, aged 
 thirty-one, admitted to Ward XIII., 3rd December 1872, com- 
 plaining of severe pain in the region of the heart, a choking 
 sensation in the throat, a troublesome cough and spit, and com- 
 plete loss of sleep. Xine years ago she suffered from a sharp 
 attack of rheumatic fcA'er lasting eight weeks, six of which were 
 passed in hospital At that time she had severe pain in the 
 region of the heart, both in front and behind, accompanied by 
 palpitation. A fortnight after dismissal she was able to 
 return to work. A similar but less severe attack has recuiTed 
 each winter since that time. The present attack commenced 
 eight weeks ago with severe pain in the cardiac region, 
 swelling of the legs, and a choking sensation in the throat, 
 which did not interfere with swallowing. She also suffers 
 from atonic dyspepsia, temporarily relieved by vomiting ; and 
 the amount of urine passed has gradually diminished. 
 
 ^ From the notes of Mr. O'Connor, clinical clerk. 
 
56 CLINICAL LECTUEES ON 
 
 Patient's family history is good. She has two children, both 
 alive and healthy. Her face is somewhat livid, her fingers 
 slightly clubbed, her legs oedematous, the joints normal, 
 temperature 99^", sensation and intelligence normal. She lias 
 slept well the two nights following her admission. Her pulse 
 is 112, irregular, somewhat forcible, and felt to be distinctly 
 jerking on elevating the arm at right angles to the body as 
 she lies in bed. Considerable pulsation is visible at the root 
 of the neck, both in the carotids and in the tracheal fossa. 
 No venous pulsation is to be seen. The apex beats somewhat 
 forcibly between the sixth and seventh ribs, about three and a 
 half inches from the left edge of the sternum. In the para- 
 sternal line, one inch from the left edge of the sternum, dulness 
 begins at the upper border of the second rib and extends down 
 to the liver dulness. Transverse dulness in the line of the 
 fourth rib commences at three-quarters of an inch to the 
 right of the sternum, and extends across for four inches and 
 three-quarters. On listening over the apex beat, a slight 
 thump is heard, forming, as it were, the last portion of a 
 presystolic mui mur ; the first sound is obscured by a murmur. 
 The second sound in this area is replaced by a soft diastolic 
 murmur. In the tricuspid area the first sound is distinctly 
 audible, notwithstanding that the obscuring murmur is even 
 louder there than in the mitral area ; the diastolic murmur is 
 still soft, but also more distinct than in the mitral area. In 
 the aortic area, the first sound, audible in both the mitral and 
 tricuspid areas, is completely replaced by a systolic murmur 
 which is loud and rough, and attains its maximum intensity 
 in this position ; the second sound is wholly wanting, being 
 replaced by a soft, low, but distinct diastolic murmur, which 
 has its position of maximum intensity at mid-sternum, just 
 below the fourth rib. In the pulmonary area, the first sound 
 is wholly replaced by a loud systolic murmur, and the second 
 sound is heard loudly accentuated, but somewhat obscured by 
 the diastolic murmur propagated across from the aortic area. 
 In the carotid and femoral arteries a loud systolic murmur 
 
DISEASES OF THE HEAET 0< 
 
 alone is audible; tlie diastolic murmur is quite inaudible. 
 The respirations are 32 per minute. The cough is sharp and 
 harsh, accompanied by a slight eatery expectoration. The 
 pulmonary percussion is everywhere normal. On auscultation 
 crepitation is heard over both lungs in front ; behind this is 
 mingled with occasional rhonchi. The tongue is clean, but 
 red and raw-looking at the tip. There is great craving for 
 food, some flatulent distention of the stomach, especially after 
 a meal ; bowls irregular ; liver dulness normal Patient has not 
 menstruated for twelve months. Her urine varies in quantity 
 from 36 to 52 oz. of a clear straw colour; on admission 
 there was a trace of albumin, but this has now disappeared. 
 
 The history of this patient is that of rheumatic fever, 
 accompanied by an affection of the heart, which inspection, 
 palpation, and percussion agree in showing has resulted m 
 dilatation, particularly of the right auricle and of the left 
 ventricle, with some hypertrophy of the latter. The slight 
 thump preceding the first sound is readily recognised as the 
 last remaining portion of a presystolic murmur, quite as 
 distinctive to an educated ear as a well-marked auricular- 
 systolic murmur, and equally with it a sign upon which it is 
 safe to rely as proof of existing stenosis of the mitral 
 opening. Mitral stenosis is a common result of rheumatic 
 endocarditis, and of itself a sufacient cause of the puhnonary 
 congestion and cedema, as revealed by the accentuated 
 pulmonary second, the cough, and the watery expectoration, 
 —as well as of the gxeat interference with the systemic 
 circulation evinced by the livid countenance, the cedema of 
 the lower extremities, the albuminuria, and the flatulent 
 dyspepsia. Stenosis of the mitral opening has, however, no 
 influence in promoting dilatation of the left ventricle, rather 
 the reverse, so we must look elsewhere for the cause of this. 
 It is not difficult to find. In the aortic area there is a loud 
 systolic murmur, with its maximum intensity in that position. 
 This is propagated with great distinctness into the arteries, 
 affording proof that the same process that has deformed the 
 
58 CLINICAL LECTURES ON 
 
 mitral valve has also thickened and stiffened the segments of 
 the aortic valves, and made them a hindrance to the egress 
 of the blood from the ventricle. In the same area we have 
 also a soft diastolic murmur replacing the aortic second, 
 showing that the valvulitis which has thickened the valves 
 has also shortened them and made them unable to close the 
 orifice, has made them incompetent. This incompetence, 
 though sufficient to give rise to a murmur audible at and 
 below the aortic orifice, is yet so trifling and has so little 
 influence on the arterial circulation that the diastolic murmur 
 is not to be heard in the carotid arteries. It seems to be 
 conveyed to the aortic area chiefly through the bones 
 (sternum and ribs), but it is more readily conveyed down- 
 wards, because in this direction the regurgitating blood-current 
 aids the conduction of the sternum. An incompetence so 
 trifling would be readily compensated in an otherwise healthy 
 heart, in the present case it is uncompensated, and greatly 
 intensifies the evil influence of the mitral stenosis. Together 
 they form an obstruction to the circulation sufficient to 
 account for all the serious symptoms that are present, as well 
 as to make the prognosis most grave in this patient already 
 enfeebled by repeated rheumatic attacks. 
 
 The patient was treated with nourishing unstimulating 
 diet, with half- ounce doses of the infusion of digitalis and 
 5 grains of carbonate of ammonia thrice a day, 15 grains 
 of chloral being given at bed -time to allay her cough 
 and cardiac pain, and to procure sleep. At first she did 
 well, but towards the end of December (21st) she began to 
 complain of pain in her joints, the oedema of her legs 
 increased, and there was also considerable pain over her 
 stomach and liver, the latter organ commencing to enlarge 
 and to become tender to touch. 
 
 She now received 10 minims of the tincture of digitalis, 
 with 5 minims of the liquor arsenicalis and a similar 
 quantity of the tincture of the perchloride of iron, three 
 times a day. She gradually got worse ; in the beginning of 
 
DISEASES OF THE HEAET 59 
 
 January diarrhoea set in, but was kept in check by 
 appropriate treatment. The pain in the chest, the breathless- 
 ness, and the pain over the liver continued, and she died at 
 
 I A.M. on the 15th of January 1873. 
 
 Autopsy} — l7th January. Heart considerably enlarged ; 
 mitral opening constricted, admitting only one finger ; aortic 
 valves atheromatous, the cusps covered with vegetations. 
 Several haemorrhagic infarctions in the lungs, which are 
 otherwise healthy. Liver weighs 4 lbs. 14 oz., is of firm 
 consistence, slightly hypertrophied, and exhibits all the 
 characteristics of extreme chronic congestion. Spleen weighs 
 
 II oz., firm and congested. Kidneys are slightly congested, 
 and exhibit several depressions, the result of previous infarc- 
 tions ; the right kidney weighs 6i oz., and the left 5| oz. 
 Other results unimportant. 
 
 These two cases may be accepted as examples of the 
 character of the murmurs, and the manner of their propaga- 
 tion, in those whose aortic valves are crumpled, thickened, 
 and atheromatous, as the result of rheumatism in the young, 
 or of more chronic disease in those who are older. Such 
 valves are too stiff to be moved out of the way by the blood- 
 current, consequently they narrow the opening and give rise 
 to the formation of fluid veins which are the cause of a loud 
 systolic murmur, carried by the blood-current into the 
 arteries, always therefore audible in the carotids without any 
 compression of their calibre, and dying gradually off within 
 the arteries as the distance from the heart increases. These 
 thickened valves are not much moved by the systolic cardiac 
 current, they have no distance to fall, and the cusps being no 
 longer membranous, every source of tensile vibration is 
 wanting. There is no second sound, not because the valves 
 are destroyed, — they still exist, larger and thicker than in 
 health, though imperfect. Under other circumstances we 
 may have a second sound accompanied and followed by a 
 
 1 From the Pathological Reco7'ds of the Royal Infirmary. Weight of 
 heart not recorded. 
 
60 CLINICAL LECTURES ON 
 
 diastolic murmur ; in such cases as the present we have no 
 second sound because the cusps are immobile and have 
 entirely lost their membranous elasticity. The deformity of 
 the cusps, however, prevents the valve from closing perfectly, 
 hence there is regurgitation, the formation of fluid veins, and 
 a diastolic murmur entirely replacing the second sound. As 
 the valves still obstruct the regurgitation it is seldom great ; 
 the diastolic murmur, however loud it may be, is never 
 propagated into the carotid arteries. It may be heard all 
 over the cardiac area, chiefly propagated through the bones, 
 the sternum acting as a sounding board. Its position of 
 maximum intensity is usually about mid-sternum, just below 
 the fourth rib, and under all circumstances it is propagated 
 downwards with most distinctness. In the class of cases 
 described the essential characteristics of the physical signs 
 quoad the murmurs are, the loudness of the systolic murmur 
 in the aortic o.rea and its ready propagation into the carotids ; 
 while the diastolic m^urnuir is most distinctly heard just over 
 the aortic valves, or immediately heloio them, and it is never 
 propagated into the carotid arteries, or only in the faintest 
 possible manner. Propagation of the diastolic murmur into 
 the arteries is always to be regarded as an indication of 
 considerable regurgitation. 
 
 The next case I shall relate presents phenomena which 
 are exactly the reverse of those just described, and indicate 
 a lesion of a totally different character. 
 
 Case III. James Bailey,^ aged thirty-five, unmarried, a 
 labourer residing in Leith, was admitted to Bed 2, Ward V., 
 on 19th February 1874, complaining of a severe cold, constant 
 cough, and pain in the epigastrium. The patient says that he 
 has been short of breath as long as he can remember, and 
 he thinks this has got worse as he grew older. Twenty years 
 ago he had fever (probably typhus), for which he was treated 
 in this infirmary. Nine years ago he was for one month 
 under treatment in this infirmary for rheumatic fever ; during 
 
 ^ From the notes of Mr. A. Field, clinical clerk. 
 
DISEASES OF THE HEART 61 
 
 this illness he was delirious for two or three nights. About 
 three years ago he was again in this infirmary for a less 
 severe attack of rheumatism. He has always been well fed, 
 comfortably housed and clothed, but his occupation necessi- 
 tates constant exposure to all kinds of weather. About three 
 weeks ago he was more than usually exposed to severe 
 weather, and except the dyspnoea, all his ailments date from 
 this time. Patient is fairly well developed, height 5 feet, 
 weight 8 stone 9 lbs., muscularity good. He usually sleeps 
 on his left side, but is often obliged to sit up in bed for a 
 time on account of his dyspncea. Expression of his face is 
 normal, integument normal, temperature 98°, limbs and joints 
 natural; pulse 75 per minute, full, jerking, and delayed 
 about half a pulsation (cardiac cycle) behind the apex beat ; 
 very evident pulsation is to be seen in both carotids and in 
 both brachials. On inspection, the apex is seen to beat with 
 tolerable distinctness in the seventh intercostal space, five 
 inches to the left of the xyphoid cartilage. Prom this an 
 undulatory pulsation is diffused up to the fourth rib, the 
 most remarkable part of which is a systolic depression, great- 
 est between the fifth and sixth ribs. In the scrobiculus cordis 
 a slight pulsation is distinctly visible, and this is seen to be 
 communicated to the entire hepatic region. On palpation, 
 the diffuse apex beat is felt to extend over several inches ; 
 this diffuse apex, as well as the whole left ventricle, com- 
 municates a heaving, but not forcible impulse to the hand. 
 In the parasternal line, dulness commences at the third 
 interspace and extends downwards to the liver dulness. At 
 the level of the fourth rib, the transverse dulness extends from 
 half an inch to the right of the sternum to half an inch beyond 
 the left nipple, a distance of six inches and a half. On aus- 
 cultation in the mitral area, the first sound is obscurely heard, 
 and of an impure quality, but without distinct murmur ; 
 the second sound is heard obscured by a diastolic murmur. 
 In the tricuspid area, the first sound is much more clear and 
 distinct than in the mitral area ; no second sound is audible. 
 
62 CLINICAL LECTURES ON 
 
 it is completely replaced by a loud and well-marked but soft 
 diastolic murmur. In the aortic area the first sound is 
 obscurely heard, much as at the apex, and without distinct 
 murmur ; the second sound is replaced by a distinct diastolic 
 murmur. In the pulmonary area, the first sound is impure ; 
 the second sound accentuated, but obscured by the diastolic 
 murmur. The diastolic murmur is heard over every part of 
 the chest, but is loudest over the sternum, beneath the aortic 
 valves ; it is even to be heard over the chest posteriorly. In 
 the carotid and femoral arteries, a well-marked and distinct 
 double murmur is readily heard. The percussion of the lungs 
 is everywhere normal, but on auscultation a good many 
 rhonchi and crepitant rattles are heard distributed over them. 
 Liver dulness is normal ; and except some flatulent, atonic 
 dyspepsia, there is nothing else of importance about this 
 patient. Bailey continued gradually to improve under treat- 
 ment till 14th April, when he was discharged. Since then 
 he has written from Ireland to say that he has given up all 
 remedies, and feels quite well. The treatment consisted 
 mainly in the administration of digitalis, at first in the form 
 of half-ounce doses of the infusion, with 5 grains of the 
 carbonate of ammonia, three times a day. Latterly the 
 tincture was given with iron and arsenic. The lung symptoms 
 were the result of a severe catarrh engrafted upon a state of 
 chronic pulmonary congestion, due to the aortic insufficiency, 
 and were only of consequence as an aggravation of his serious 
 heart affection. There were several very interesting points 
 in this case : (1) The great dilatation and hypertrophy of 
 the left ventricle, revealed by the low position of the true 
 apex, which beat beneath the edge of the eighth rib, the 
 general slow heaving impulse of the ventricle, and the 
 systolic dimpling of the surface of the ventricle, evidently 
 due to displacement of the lung by the large ventricle, and 
 the pressure of the atmosphere on the walls of the chest 
 during the systolic recession of this large ventricle. (2) 
 The absence of any special implication of the right ventricle, 
 
DISEASES OF THE HEAET 63 
 
 notwithstanding the great amount of disease upon the left 
 side. (3) The impurity of the first sound in the mitral area, 
 probably depending upon some shght rheumatic alteration 
 of the mitral valve. (4) The absence of a marked systolic 
 murmur from the aortic area. (5) The loud diastolic 
 murmur audible over all the cardiac area, beneath the level 
 of the aortic orifice. And lastly, the markedly distinct 
 character of both murmurs in all the arteries, especially in 
 the carotid and femoral arteries. The absence of any distinct 
 systolic murmur from the aortic area points to the impurity 
 of the first sound in the mitral area being due to rheumatic 
 alteration of the valves rather than to mere dilatation of the 
 ventricle, and also indicates the absence of any well-marked 
 obstruction at the aortic orifice ; indicates, therefore, the 
 preponderance of retraction or crumpling, or it may be of 
 ulceration, over calcification of the valves. The absence of 
 marked obstruction at the aortic orifice also accounts for the 
 very free regurgitation indicated by the great collapse of the 
 pulse, the distinctness of the (cardiac) diastolic murmur heard 
 in the arteries, and also the distinctness of this murmur in 
 the cardiac area. The latter, however, depends partly on 
 the condition of the valve as it still exists, and its capacity 
 for originating a fluid vein, though the force of the regurgitat- 
 ing current— largely depending on the freedom of regurgita- 
 tion — must have its influence in making this fluid vein more 
 sonorous. The condition of the sternum, and its connection 
 with the ribs, in relation to its capacity for conducting sound, 
 has also undoubtedly an important influence in propagating 
 the murmur over the chest. 
 
 The points to which I wish particularly to direct your 
 attention at present are what may be termed the specialities 
 of this case : the absence of a systolic murmur from the 
 aortic area, and the presence of a well-marked double murmur 
 in all the arteries. I have already pointed out that the 
 absence of a systolic murmur from the aortic area is due to 
 the almost entire absence of any obstruction from the aortic 
 
64 CLINICAL LECTUKES ON 
 
 orifice. Some degree of obstruction is, however, present, the 
 valve segments are not entirely obliterated, and to this it is 
 due that the systolic murmur is more distinct in the in- 
 nominate artery than it is in the aortic area. Some trifling 
 fluid vein is formed at the aortic orifice, passes with the 
 onward current and intensifies the other sources of murmur 
 inherent in the artery itself. The systolic murmur is louder 
 in the innominate artery than in the aortic area, but falls 
 far short of that heard in the carotid artery, where com- 
 pression with the stethoscope causes an independent fluid 
 vein that increases and intensifies the murmur. Compression 
 of the artery intensifies the murmur, but does not produce it ; 
 it is loud enough to be readily heard on placing the stetho- 
 scope merely in the neighbourhood of the artery. The 
 systolic arterial murmur is composed of two elements, it is 
 partly due to the fluid vein produced at the aortic orifice, 
 but chiefly to the vibration of the arterial coats, caused by 
 the sudden tension produced by the wave of blood, dispro- 
 portionate to the arterial calibre, sent forward by the greatly 
 dilated and hypertrophied left ventricle. Consequently in 
 the carotid arteries, at the moment of the ventricular systole, 
 a loud murmur is to be heard which is partly produced by 
 a fluid vein originating at the aortic orifice, but in a much 
 greater measure by vibrations caused by the sudden tension 
 of the arterial coats. 
 
 A loud systolic murmur may thus be audible in the 
 arteries in two very different conditions of the aortic orifice : 
 where there is much obstruction from calcified valves, the 
 murmur is loudest at the arterial orifice, is fropagated into 
 the arteries and gradually dies away as we recede from the 
 heart. Where there is great destruction of the valves, and con- 
 sequently hut little obstruction, the murmur is always less 
 audible over the aortic orifice than over the arteries, and the 
 diminution in intensity on receding from the heart is not so 
 great. In both cases the rhythm of the murmur alters as we 
 approach the periphery, it is always in unison with the 
 
DISEASES OF THE HEAET 65 
 
 rhythm of the pulse, and not with that of the heart. A 
 ventricular- systolic murmur in the carotids may thus become 
 ventricular- diastolic when it reaches the radial or femoral 
 arteries; or if it still remain ventricular-systolic, then the 
 cardiac systole with which it is in unison is not that which 
 originated the murmur, but its immediate successor, as we 
 may readily ascertain by tracing it down the arteries. The 
 diastolic murmur, liowever, which in the carotids immediately 
 follows the ventricidar- systolic murmur, is in every part of 
 the arterial system synchronous with the arterial systole, 
 whatever relation that may bear to the cardiac diastole, and 
 has hut one origin, viz., free regurgitation into the ventricle. 
 It is inaudible until we compress the artery with the stetho- 
 scope so as to cause the formation of a fluid vein at that 
 point ; then it is always to be heard with greater or less 
 distinctness, according to the amount of regurgitation present. 
 The readiness with which we hear this ventricular-diastolic 
 murmur in the arteries may be received as a measure of the 
 freedom of the regurgitation into the ventricle, but its absence 
 is not to be accepted as a proof that no regurgitation is 
 present, as, if much obstruction exists at the aortic orifice, 
 this murmur may be quite inaudible above the aortic valves. 
 I agree with Jaccoud ^ when he states that, on placing the 
 stethoscope lightly over an artery at the moment of its 
 diastole, only a slight membranous click is heard in the 
 normal condition, synchronous with its sudden expansion. 
 A stronger pressure may increase this sound, but it produces 
 no distinct murmur. When, however, the artery is forcibly 
 expanded by a large blood -wave coming from a dilated 
 hypertrophous ventricle, the very slightest pressure converts 
 this membranous sound into a loud systolic murmur. Should 
 this condition be associated, as it frequently is, with free 
 regurgitation, a slightly increased pressure brings out clearly 
 enough a soft diastolic murmur immediately succeeding the 
 systolic one, while a still stronger pressure extinguishes all 
 
 ^ Legons de Clinique Midicale (Paris, 1869), p. 185. 
 5 
 
66 CLINICAL LECTURES ON 
 
 nmrmurs and ultimately all pulsation. I agree also with 
 Duroziez ^ in thinking this double arterial murmur to be in 
 a great measure an artificially produced phenomenon, of 
 which the elements certainly exist naturally in all suitable 
 cases, but which can only be made audible by artificial means. 
 But I differ from him entirely in his estimate of this double 
 arterial murmur as an important sign in the diagnosis of 
 aortic incompetence. In one respect I go further than 
 Duroziez, for I have no hesitation in saying that a true 
 ventricular-diastolic murmur is never heard in the arteries 
 unless aortic incompetence exists.^ But 1 have just as little 
 hesitation in saying that aortic incompetence may exist in 
 many cases in which no such murmur is to be heard. Traube^ 
 believes that when aortic regurgitation is extreme, we can 
 hear in the femoral arteries a double sound — not a double 
 murmur — and that this double sound originates spontaneously 
 iu the artery itself, without any intervention of the observer. 
 He regards the systolic sound as produced by the vibrations 
 of the arterial walls, caused by their great and sudden dis- 
 tention, and the diastolic sound as caused by their equally 
 sudden relaxation. But the idea of a sound being produced 
 by sudden relcuvation of the arterial coats is so untenable 
 from a physical point of view, that there is little wonder that 
 the element of truth upon which Traube's theory was based 
 has for a time escaped due recognition, especially as the 
 phenomena concerned have no special relation to aortic in- 
 competence, and are often well marked in widely different 
 conditions. When we auscultate below Poupart's ligament, 
 or at the root of the neck, or just below the clavicle, we can 
 often hear one, two, or even three short, sharp sounds. In 
 aortic regurgitation, one of these, always the second if two 
 
 ^ " Du Double Souffle Crural comme signe de I'lnsuffisance Aortique,'' 
 Archives General de Medicine, 1st April 1861. 
 
 - Duroziez says that this double murmur is also heard in cases of enteric 
 fever, ohlorosis, and lead poisoning. 
 
 ^ Gesaimnclte Beitrdge zur Pathologic und Physiologie (Berlin, 1871), Bd. i. 
 S. 793 ; and Berliner hlinische WochenschHft (1872), No. 48, S. 573. 
 
DISEASES OF THE HEAKT 67 
 
 sounds only are present, or the third if there be three, is the 
 sound of arterial distention already referred to, and it is 
 readily converted into a blowing murmur by pressure on the 
 artery. The other sounds are heard most distinctly over the 
 veins in the situations referred to, and no amount of pressure 
 ever converts them into murmurs, even when that pressure 
 can be effectively applied, as over the femoral vein. Pressure 
 may extinguish these sounds, but it never transforms them 
 into murmurs. These sounds are occasionally to be heard in 
 aortic incompetence, at least as often in other forms of cardiac 
 disease, as also in pulmonary affections, and they are always 
 associated with tricuspid regurgitation. Friedreich ^ ascribes 
 them, and I agree with him, to the sudden sharp closure of 
 the venous valves, in the situations referred to, by the re- 
 gurgitant blood-wave. When these phenomena are produced 
 in the veins alone, the sound may be single or double ; in 
 the first instance it is produced by the ventricular systole 
 alone, in the second, the first sound is due to the contraction 
 of the auricle, the second to that of the ventricle. These 
 venous sounds are to be heard in every form of disease of 
 the heart or of the lungs which is capable of causing tri- 
 cuspid regurgitation, but the arterial element only comes 
 into play when we have to do with a case of aortic regurgita- 
 tion. The sounds may then be double or triple ; the arterial 
 portion is always the last,— because the auricular contraction 
 invariably comes before the systole of either ventricle ; and 
 the regurgitant wave from the right ventricle, favoured by 
 the congested state of the veins, precedes the pulse-wave 
 from the left ventricle, which is more than usually delayed 
 by the altered physical condition of the arteries {vide p. 90). 
 ITaturally these sounds have not the significance ascribed to 
 them by Traube ; a double sound is not always to be heard 
 when regurgitation is extreme, and it is often present when 
 there is no aortic incompetence. Moreover, the venous sounds 
 
 ^ "Ueber Doppelton an der crural Arterie, sowie iiber Tonbildung an den 
 crural Venen," Deutsches ArcMvfur Minische Medizin, Bd. xxi. S. 205. 
 
68 CLINICAL LECTURES ON 
 
 cease to be heard as soon as the congestion is great enough 
 to make the venous valves incompetent. 
 
 In the normal state of the heart and blood-vessels, the pulse- 
 wave set agoing by ventricular contraction is generally 
 believed to be arrested at the capillaries, but this is by no 
 means always the case. Even in those who think themselves 
 healthy, and whose condition certainly closely approximates 
 the normal, the cardiac pulsation is occasionally propagated 
 not only into the capillaries, but even into the veins, as was 
 first recorded by Quincke, Such cases are, however, really 
 abnormal, an abnormality due to failure of one or other of the 
 three great factors of the circulation.^ These are (1) the force 
 and frequency of the heart's action, which must be suf&cient 
 to keep the arteries overfilled, that is to maintain the normal 
 blood-pressure ; (2) the peripheral resistance, that normal 
 state of constriction of the arterioles called their tone, which 
 helps to keep the arteries distended by preventing too rapid 
 an outflow ; and (3) the elasticity of the arterial coats, which 
 when called into play by the two factors just described, con- 
 verts the intermittent supply from the heart into the contin- 
 uous flow of the capillaries and veins. 
 
 In aortic regurgitation the arteries are dilated, and their 
 elasticity is greatly lost, and though the blood-pressure is not 
 low in proportion to the freedom of regurgitation, yet the 
 conditions are always favourable for the production of a 
 capillary pulse-wave, which is more or less recognisable, and 
 which is more marked and is more distinctly seen to pass 
 into the veins the larger the ventricle and the more forcible 
 its action. Hence a capillary or even a venous pulse — and 
 now of course I speak of a direct venous pulse ruiming up 
 the arm, and not of mere jugular regurgitation — is frequently 
 to be seen in cases of aortic incompetence, not only in 
 inflamed or erysipelatous parts, but also in such parts as the 
 nails, cheeks, and retina in their normal state. This capillary 
 or direct venous pulse is alway an important indication of 
 ^ Foster's Physiology, 3rd edition (1879), p. 136. 
 
DISEASES OF THE HEAET 69 
 
 impairment of one or other of the three great factors of the 
 circulation ; it is frequently to be seen in aortic incompetence, 
 but is by no means pathognomonic of that affection.-^ 
 
 From the very free regurgitation in Bailey's case he pre- 
 sented a well-marked example of all the peculiar phenomena 
 just referred to. In the spring of 1875 he was again for 
 several weeks under observation in Ward V. His cardiac 
 phenomena remained unchanged, and he was again discharged 
 much relieved. For one or two years Bailey returned to us 
 during the cold weather of spring, and then ceased to appear. 
 It is an interesting circumstance connected with his case that 
 to the last he maintained himself as a coal porter, and was 
 daily in the habit of carrying bags of coal to the upper stories 
 of some of our highest houses. A very good example of the 
 little breathlessness and discomfort that attend a compensated 
 aortic incompetence, however free the regurgitation may be. 
 
 The next is the last case I shall comment upon at present, 
 and I bring it before you now as an illustration of a third 
 form in which aortic incompetence may occur. 
 
 Case IV. Matthew Murray, one of our city police, aged 
 thirty-nine, admitted to Bed 7, Ward V., on 19th March 1874, 
 complaining of pain in the chest and breathlessness, from which 
 he has suffered greatly since last October, He was originally 
 a farm-servant, but has been in the police force for eleven 
 years and a half. He is 5 feet 9 inches in height, stout, and 
 healthy-looking ; he has always been sober, weU fed, clothed, 
 and housed, and has never suffered from any serious disease — 
 in particular, has never had rheumatism. Seven years ago he 
 had sores on his penis, but they were not followed by any 
 sore throat, or by any eruption, etc. In his earlier days he 
 was in the habit of making violent and laborious exertions ; 
 
 ^ Vide Mr. T. Wilkinson King, Guy's Hospital Reports, Nos. 4 and 12 ; 
 Stokes on Diseases of the Heart and Aorta (Dublin, 1854), p. 202; Lebert, 
 Handbuch der practischen Medicin (Tiibingen, 1862), vol. i. S. 725 ; Quincke, 
 " Beobachtungen iiber Capillar- und Venenpuls," Berliner Minische JVochen- 
 schrift (1868), No. 34, S. 357 ; Grandclement, " De la valeur des Battements 
 de I'Artere Centrale de la Retina dans les Affections Cardiaques," Lyon 
 M6dical (1874), No. 12, p. 136. 
 
70 CLINICAL LECTURES OX 
 
 latterly he lias not done so. He has never been in the army, 
 and cross belts on the chest form no part of his official 
 costume. About seven years ago he received a severe blow 
 on the chest from one of the shafts of a lorry, while trying to 
 stop a runaway horse. On inspection, marked pulsation is 
 visible both in the carotid and brachial arteries ; the cardiac 
 pulsation is abnormal, no apex beat is to be seen, but there is 
 slight pulsation in the scrobicv.lus cordis ; both pupils are 
 normal. On palpation, the radial pulses are felt to be equal, 
 the pulse beats at the rate of 75 per minute, it is jerking and 
 accompanied by a well-marked thrill. This thrill is not so 
 perceptible in the carotids as in the brachial and radial 
 arteries. The jerking character of the pulse is markedly 
 increased on elevating the patient's arm above his head as he 
 sits. The heart's apex is scarcely to be felt ; it beats between 
 the fifth and sixth ribs, three inches and a half from the left 
 edge of the sternum. The heart's impulse is everywhere 
 feeble. On percussion in the parasternal line, dulness begins 
 at the upper edge of the third rib, and extends down to the 
 liver dulness. Transversely in the line of the fourth rib, 
 dulness conmiences half an inch from the right edge of the 
 sternum, and extends across for a distance of six inches. On 
 auscultation in the mitral area, the first sound is heard 
 obscured by a systolic murmur, which is found to have its 
 position of maximum intensity in the aortic area. This 
 systolic murmur is heard to obscure the first sound in the 
 mitral, in the tricuspid, and in the pulmonary areas ; in the 
 aortic area it entirely replaces it. In the aortic area 
 there is no second sound, it is wholly replaced by a diastolic 
 murmur, and this murmur replaces the second sound in 
 all the areas except the pulmonary, where it greatly 
 obscures an accentuated second that is only faintly to be 
 heard. This double murmur is more or less audible over the 
 whole chest, both before and behind, but it has its position of 
 maximum intensity in the aortic area. The aortic dulness 
 reaches to within one inch and a quarter of the top of the 
 
DISEASES OF THE HEART 71 
 
 sternum. A distinct double murmur is heard both in the 
 carotid and in the femoral arteries. Dyspnoea and cough are 
 chiefly remarkable when the patient lies down at night. 
 Percussion over the left lung is normal, over the right lung 
 it is slightly higher in pitch (emptier), especially over its 
 lower lobe. Auscultation is normal over the left lung ; over 
 the right lung the vesicular murmur is weakened, especially 
 over the lower lobe. In other respects the patient is 
 normal. 
 
 After what has been already said, this case seems to require 
 but little explanation, the mere recapitulation of the physical 
 signs have revealed its nature, though to a tyro some may 
 seem misleading. Thus the extent of the transverse dulness 
 might lead one to suspect great dilatation of the right heart, 
 but the very trifling character of the impulse in the scrohiculus 
 cordis at once forbids this assumption. Again the free 
 regurgitation through the aortic valve negatives the idea that 
 the impulse between t?ie fifth and sixth ribs is likely to be 
 that of the true apex ; while the forcible character of the 
 blood- wave, as perceived in the arteries, is opposed to any 
 idea that the feeble ventricular impulse is a true indication 
 of the condition of the ventricular walls. But a little con- 
 sideration leads at once to the conclusion that the increased 
 breadth of the cardiac dulness is due to the oblique position 
 of the heart, which lies more transversely and also deeper than 
 usual, the defective impulse being due to the increased depth 
 of lung covering the heart, and not to any preponderance of 
 dilatation over hypertrophy. The cause of this pushing of 
 the heart backwards and to the left must be sought for in 
 some derangement of its normal relations, and a very efficient 
 cause is to be found in the aneurysmal condition of the 
 aorta. This vessel is not only largely dilated, as shown 
 by its increased breadth of dulness, but it also has an 
 aneurysmal bulging on its ascending portion just above the 
 heart, pressing on the right bronchi, and chiefly upon that 
 distributed to the lower lobe of the right lung, as indicated 
 
72 CLINICAL LECTURES ON 
 
 by the rise in the percussion note specially marked over that 
 lobe (vide antea, p. 20), as well as by the enfeeblement of the 
 respiratory murmur over the corresponding part of the chest. 
 In this case the aorta is probably in a state of cirsoid 
 aneurysm, largely dilated, with at least one bulging just above 
 its origin. The case is given now merely as an example of a 
 third mode in which aortic incompetence may be produced 
 and its murmurs propagated. This patient has never suffered 
 from rheumatism, and the incompetence of his aortic valves 
 seems to be entirely due to dilatation of the aorta itself. 
 As already stated {vide antea, p. 32), the first effect of dila- 
 tation of the first part of the aorta is to cause the 
 aortic valves to close with unusual force, so that the second 
 sound becomes markedly accentuated. As the dilatation 
 increases, the valves become too narrow to close perfectly the 
 enlarged orifice, and accompanying this accentuated second 
 we have a diastolic murmur of greater or less intensity. 
 Such an aorta is always more or less atheromatous, but 
 unless there are projecting spiculse the diastolic murmur 
 is not generally audible above the valves ; should the vessel, 
 however, be roughened by projecting spiculse, the diastolic 
 murmur may commence high above the valves, and in any 
 case it may be prolonged and loud enough completely to 
 obscure the second sound. In the earlier stages of this 
 affection, appropriate treatment not infrequently so favours 
 the contraction of the vessel as to cause the complete dis- 
 appearance of the diastolic murmur, but the second sound 
 remains permanently accentuated, and as we may readily 
 suppose, the diastolic murmur in such circumstances is 
 exceedingly apt to recur. In all similar cases the valves are 
 seldom much calcified, they are frequently quite flexible, and 
 when this is the case they present no obstacle to the egress 
 of the blood from the ventricle. Under these circumstances 
 the systolic portion of the murmur is occasionally, though 
 rarely, due to fluid veins formed by projecting spiculse ; 
 more often to tensile vibrations produced in the arterial walls. 
 
DISEASES OF THE HEART 73 
 
 by the wave of blood disproportionate to their calibre sent 
 forward by the dilated and hypertrophous ventricle ; but by 
 far its most common and important cause is the production of 
 fluid veins at the comparatively narrow orifice of the aorta, by 
 the large blood- wave passing through it into the aneurysmal 
 dilatation of the vessel beyond. If there be projecting 
 spiculse attached to the aortic walls, the diastolic murmur 
 may be partly due to them ; it is always, however, mainly 
 caused by the formation of fluid veins by the regurgitating 
 blood at the aortic orifice, which forms a comparatively narrow 
 strait between two parts of wider calibre — the dilated aorta 
 and the ventricular cavity. This diastolic murmur has its 
 position of maximum intensity at or below the aortic orifice, 
 and owes its propagation over the cardiac area, and the chest 
 generally, to the resonant qualities of the sternum and ribs. 
 The double murmur in the arteries arises from causes similar 
 to those which have been shown to have this result in the 
 immediately preceding case, and has exactly the same signifi- 
 cance. From the foregoing cases we learn, that amongst 
 all the various signs which enable us to detect aortic 
 incompetence or to predict its significance, the murmurs that 
 accompany it, and their mode of propagation, are not the 
 least important. And we must remember that though a 
 diastolic murmur at or beneath the level of the aortic valves, 
 in the line of the sternum, is pathognomonic of incompetence 
 of the aortic valves, yet in regard to prognosis the mode in 
 which this murmur is propagated is of more consequence 
 than its mere detection. 
 
 The points of importance which have just been illustrated 
 may be summarised as follows : — A diastolic murmur at or 
 helow the level of the aortic valves, chiefly audible in the line 
 of the sternum, is significant of aortic incompetence. If this 
 diastolic murmur is inaudible in the carotid arteries, it is 
 invariably accompanied by a systolic murmur, having its 
 maximum intensity at the aortic valves or in the so-called 
 aortic area, and this indicates comparatively trifling incom- 
 
74 CLINICAL LECTURES ON DISEASES OF THE HEART 
 
 iMence with considerable obstruction at the aortic orifice, most 
 probably due to calcified semilunar valves. 
 
 If this diastolic murmur is distinctly audible in the carotid 
 arteries, it is invariably preceded by a loud systolic murmur 
 audible in these arteries, but not always to be heard in the 
 aortic or in any part of the cardiac area, and this indicates 
 very free regurgitation (considerable incomiMence) with eom- 
 paj-atively trifling obstruction. What has just been said in 
 regard to the murmurs in the carotid arteries refers equally 
 to murmurs audible in the femoral, as well as in all the other 
 arteries. Each case differs from another ; in practice we find 
 the most marked examples of great regurgitation with slight 
 obstruction, shading off into instances of great obstruction 
 with but slight incompetence, and the murmurs indicative of 
 these different lesions vary accordingly. The cases used as 
 illustrative examples are fairly well-marked and pure in- 
 stances of the three principal forms in which the murmurs 
 of aortic incompetence present themselves. 
 
 A double murmur in the arteries is always the result of 
 great incompetence. If associated with a history of rheumatism, 
 this incompetence is due to great retraction and loossibly ulcera- 
 tion of the semilunar valves, and accompanied by the absence, 
 more or less complete, of the systolic murmur from the cardiac 
 area. But if not associated with a distinct history of rheuma- 
 tism, the systolic portion of the murmur will be ^vell marked 
 over all the cardiac area, and the lesion will be found to be 
 arterial {aortic dilatation), and not primarily valvular in its 
 origin. 
 
LECTUEE III 
 
 ON INCOMPETENCE OF THE AOETIC VALVE, WITH SPECIAL 
 KEFEEENCE TO THE MODE IN WHICH THE DISEASE PRO- 
 GRESSES, ITS PROGNOSIS, AND ITS TREATMENT 
 
 In the previous lecture on Aortic Incompetence I have 
 specially directed attention to the diagnostic significance 
 of the murmurs accompanying it, because it is from these 
 murmurs that we learn the probable character of the 
 regurgitation present, a matter of some moment, as upon 
 the comparative freedom of regurgitation, or the reverse, 
 many of the consecutive phenomena and much of the 
 prognosis depends. 
 
 When regurgitation takes place through the aortic valve, 
 the left ventricle, during its diastole, fills from two sources 
 instead of one — from the aorta as well as from the auricle. 
 The first and most immediate effect of this is a sudden 
 diminution of the arterial tension, which impresses its char- 
 acter on the pulse in exact proportion to the amount of 
 regurgitation present. The second effect of the diastolic 
 filling of the ventricle from two sources is, that when the 
 systole of the auricle takes place, the left ventricle is over- 
 distended, and the left auricle incompletely emptied. The 
 result of this obstruction to the onward flow of the blood is 
 passive congestion of the lungs, revealed, as such obstruction 
 always is, by an accentuation of the pulmonary second. 
 This passive congestion of the lungs, once started, must of 
 course — if no compensating change were possible — go on 
 
76 CLINICAL LECTUKES ON 
 
 increasing with each cardiac pulsation. Ere long, in fact, 
 jpari passu with the pulmonary engorgement, the right 
 ventricle gets over-distended, the tricuspid valve becomes 
 incompetent, and the right auricle dilated, followed by 
 passive congestion of the systemic veins, terminating in 
 general dropsy, and a gradual lowering of the arterial blood- 
 pressure till it falls below that compatible with life, and 
 death ensues under symptoms of a gradually increasing 
 asthenia.^ This, in fact, is a common mode of dying in other 
 forms of cardiac disease, though it is comparatively rare in 
 aortic incompetence. Because the lesion (regurgitation) 
 which in this affection obstructs the onward flow of the blood 
 is able, under circumstances, to produce directly, and at once, 
 such a fall in the blood- pressure as can only be brought 
 about by other lesions indirectly, and after a long lapse of 
 time. 
 
 In all cardiac lesions there is, however, a tendency to 
 postpone this ultimate result by the production of secondary 
 changes in the heart itself, which more or less perfectly com- 
 pensate these lesions ; and the great object of treatment is to 
 promote this compensation, to make it as perfect as may be, 
 and to maintain its efficiency as long as possible. 
 
 We often accidentally discover the existence of aortic 
 incompetence in those apparently in perfect health, but they 
 never come to consult us unless compensation is ruptured, 
 and then the overloaded state of the heart gives rise to many 
 distressing symptoms ; such as breathlessness, uneasiness or 
 pain in the cardiac region, with irritability of the heart itself, 
 evinced by palpitation on the slightest provocation, direct or 
 reflex, such as the most trifling exertion, or the mere ingestion 
 of food. It is this ruptured compensation we have to remedy, 
 not the aortic incompetence, which is beyond our skill; a 
 
 ^ "Systemic death consists in decline of aortic pressure. This decline 
 may occur rapidly, as in syncope ; but usually, even in deaths by violence, it 
 is very gradual. In deaths from disease it may last (gradually decreasing) 
 for days, weeks, or even months." — Handbook for the Physiological Laboratory 
 (London, 1873), p. 209. 
 
DISEASES OF THE HEAET 77 
 
 distinct remembrance of this will often be a great help to us 
 in attaining the object we aim at. 
 
 When aortic incompetence is established, and the ventricle 
 fills from two sources instead of one, the first effect is of 
 course to overfill that organ, and the earliest attempt at 
 compensation is the accommodation of the left ventricle to 
 the increased amount of blood it is required to contain. This 
 is readily brought about through the elasticity of the myo- 
 cardium itself. The first step in compensation is thus dilata- 
 tion of the left ventricle, but this only provides a receptacle 
 for the blood delayed, and not a means of restoring it to the 
 circulation. This dilatation itself must therefore be com- 
 pensated before the balance of the circulation can be so 
 efficiently restored as to make the lesion mute. But as 
 the heart always works well within its powers, it has no 
 difficulty in disposing of its fuller contents and sending on 
 a larger blood-wave; this larger blood-wave distends the coro- 
 naries and thus provides an improved metabolism of the 
 myocardium, so that pari 'passu with its dilatation the wall 
 of the ventricle becomes thicker and stronger, it hypertrophies. 
 In cases of disease in which regurgitation is only slowly 
 developed this all takes place with so little disturbance of the 
 heart or of the circulation generally, that it is often only after 
 the lapse of many years, frequently passed in strenuous 
 labour, that the patient learns to his astonishment that he 
 has in all probability been for so long the subject of heart 
 complaint.^ On the other hand, if regurgitation has been 
 suddenly developed in an extreme degree, as in the case of 
 accidental rupture of one or more segments of the aortic 
 valve, the immediate effect has occasionally been so great a 
 disturbance of the circulation, that complete compensation 
 
 ^ I found this statement on the fact that I have seen many cases of aortic 
 incompetence in whom the compensation had been accidentally, or unavoid- 
 ably ruptured twenty years or more subsequent to one single attack of 
 rheumatic fever, from which, in all probability, the lesion dated, coupled 
 with my own knowledge that some have certainly suffered for nearly as long 
 from aortic regurgitation without ever being conscious of it. 
 
78 CLINICAL LECTURES ON 
 
 lias never been established, the patient continuing to suffer 
 till in no long time death has ensued.^ 
 
 "WTieu aortic incompetence has developed as the result 
 of local disease in a moderately healthy subject, in whom 
 dilatation and hypertrophy of the left ventricle have gone on 
 pari passu, so as to develop and maintain what is called 
 perfect compensation for the lesion, a time at last arrives 
 when this is no longer possible. Previous writers on this 
 subject seem to have assumed that when this so-called com- 
 pensation is once attained, — it may be after a longer or shorter 
 period of cardiac perturbation, — it is maintained, accidents 
 excepted, till nutritional changes in the myocardium render 
 its longer continuance impossible." But from this it appears 
 that too much attention has been directed to the vital forces, 
 and too httle to the simple mechanical agencies involved in 
 aortic incompetence, mechanical agencies which are, however, 
 of vast importance in producing injmy, and which have always 
 to be considered and counteracted in all our therapeutic 
 attempts to relieve the symptoms that accompany that lesion. 
 
 ^ Balthazar Foster, in his Clinical Medicine, p. 139, says that four years 
 and a half covers the date of death in all such cases of traumatic lesion of the 
 aortic valves. But I myself have seen, post laortem, aortic cusps which had 
 been torn from their attachments, the lesion healed, and yet no serious 
 symptoms developed till years subsequently. At this moment I am ac- 
 quainted with a patient who more than twenty years ago had symptoms 
 and signs apparently due to rupture of one of his aortic cusps, yet he still 
 survives in much improved health. Experimental investigation is entirely at 
 one with this experience, and quite opposed to the idea of such an accident 
 being speedily fatal except under special and exceptional circumstances. 
 
 "^ Thus Jaccoud says: — "Quelque parfaite que soit la compensation des 
 lesions cardiaques, elle est temporaire ; I'equilibre artificiel au moyen duquel 
 elle maintient une circulation a pen j^res normale pent durer des annees, mais 
 il faut qu'U se rompe, cela est fatal ; le tissu musculaire du cceur atteint dans 
 sa nutrition subit a la longue une transformation regressive, generalement 
 graisseuse, et lorsque cette alteration secondaire, dont Paget et Stokes ont 
 montre toute I'importance, presents une certaine etendue, le ventricule, quoique 
 augmente de volume, quoique hypertrophie en apparence, ne contient plus 
 assez d'elements contractiles pour faire face au travail excessif que la lesion 
 lui impose ; sa force propulsive diminue, il se vide mal, evacuation du systeme 
 veineux est par suite genee, la compensation est detruite, et comme cette 
 rupture resulte d'une condition anatomique sur laquelle nous n'avons aucune 
 prise il faut que le cceur s'arrete, et que le malaJe succombe." — Le<^ons dc 
 Cliniqiie Mddicale (Paris, 1869), p. 215. 
 
DISEASES OF THE HEART 79 
 
 The effect of a leakage, however trifling, once established 
 between the segments of the aortic valve is, with the patient 
 in the erect position, in accordance with Pascal's law,-^ that 
 the interior of the left ventricle is constantly exposed to the 
 dilating influence of a force equivalent to the weight of a 
 column of blood the height of the top of the cranium above 
 the heart, and of the diameter of the ventricular lumen. 
 From the moment the leakage is once established till the 
 cessation of life, this hydrostatic pressure never ceases, though 
 it is modified by position : its action is not only continuous, 
 but it increases, in accordance with the law referred to, pari 
 'passu with the gradual dilatation of the ventricle. All that 
 the organism has to oppose to this powerful dilating force is 
 first of all the natural elasticity of the myocardium itself, and 
 second, the exercise of that well-known law whereby all 
 hollow muscles hypertrophy and increase in strength in 
 proportion to any obstacle opposed to the exercise of their 
 function (Paget), provided their metabolism remains perfect. 
 The danger to which such patients are exposed is thus very 
 evident, as well as the manner in which any disturbance of 
 the metabolism — general or local — may increase that danger. 
 For example, if the system is in a depressed condition at 
 the moment that aortic leakage is established, there may be 
 a difficulty, or even an impossibility, of establishing com- 
 pensatory hypertrophy, and the result may either be sudden 
 death from asystole, or a greatly prolonged period of cardiac 
 disturbance. Similar results may arise from similar causes at 
 any moment during the persistence of the leakage, that is at 
 any after-period of the patient's existence, and it is in the 
 history of this lesion and its relation to cardiac metabolism 
 that a great part of its interest lies. 
 
 If we regard compensation, once established, as perfect and 
 complete, it is obvious that, apart from accidental disturbance, 
 
 ' Pressure exerted anywhere upon a mass of liquid is transmitted un- 
 diminislied in all directions, and acts with the same force on all equal 
 surfaces, and in a direction at right angles to these surfaces. — Traites de 
 V Equilibre des Liqueurs, etc., par Blaise Pascal (Paris, 1763). 
 
80 CLINICAL LECTURES ON 
 
 we must wait the development of local nutritional changes 
 before we can have any disturbance of the compensation. 
 If, however, we look upon compensation as always incomplete, 
 though practically sufficient for the carrying on of the 
 circulation, then a time must come when compensation is 
 ruptured from purely physical causes, quite independent of 
 any disturbance of either the general or local metabolism ; 
 and the latter seems the more correct view to take. 
 
 In aortic incompetence there are three possible conditions 
 of the left ventricle, for it is to the state of that cavity that 
 our inquiry in this matter is practically limited. 
 
 1. There is said to be occasionally a condition of over- 
 compensation, in which the left ventricle is hypertrophied in 
 excess of its requirements, and which is said to give rise to 
 many disagreeable and possibly dangerous symptoms. This 
 is a state of matters frequently referred to by many writers ; 
 
 'it must, however, be one of extreme rarity, if it occur at all. 
 It is a condition quite beyond my own experience, and one 
 for which I can discover no rational explanation, and I am 
 persuaded that for aU practical purposes we can well afford 
 to discard all consideration of any such hypothetical con- 
 dition. 
 
 2. The balance of compensation may be perfect ; the 
 amount of compensation may be just sufficient to counter- 
 balance the dilating effect of the regurgitation, and with a 
 slightly dilated and hypertrophied heart the circulation may 
 go on as before, till, from accidental or inevitable nutritional 
 changes, compensation is ruptured, and disturbance of the 
 circulation sets in. 
 
 3. We may have, from the moment that aortic leakage 
 sets in, a dilating power acting on the left ventricle, which, 
 from physical causes, must gradually increase in energy. 
 This dilating force acts as a hindrance to the onward flow of 
 the blood ; the ventricle reacts against this obstacle, and for 
 a time successfully, so far as maintaining the circulation is 
 concerned, but always at a disadvantage. The dilatation 
 
DISEASES OF THE HEART 81 
 
 which commenced the organic disturbance continues in 
 advance, the compensating hypertrophy which followed con- 
 tinues ever to lag behind, till at last a period is reached when 
 asystole is threatened from physical causes alone, because the 
 weight of the dilating fluid is in excess of the contractile 
 force of the ventricle. At this moment, fortunately for the 
 patient, the dilating force of the blood separates the segments of 
 the mitral valve, and at the moment that ventricular paralysis 
 is threatened by over-distention, the over-burdened ventricle 
 is relieved by regurgitation into the left auricle, and the 
 inevitable end is postponed. In the sequence of events just 
 narrated every one must recognise the ordinary history of an 
 uncomplicated case of aortic incompetence, and must also be 
 fully aware that, even after the case has progressed so far, a 
 patient may die with his ventricular muscle in a state of 
 comparative health. We must all, therefore, be prepared to 
 acknowledge the importance of Pascal's law in the sequential 
 production of the organic changes consequent on aortic 
 regurgitation, quite apart from any nutritional changes in the 
 ventricle itself. But, though the hydrostatic influence 
 developed by the incompetent condition of the aortic valve 
 ultimately and inevitably gives rise to the condition just 
 described, this may be precipitated by any general or local 
 disturbance of nutrition. Whenever from general debility 
 the metabolism of the left ventricle is interfered with, any 
 sudden call for exertion or any violent emotion may be 
 followed by asystole and sudden death even at a very early 
 period of the affection ; or similar causes may produce over- 
 distention of the ventricle and mitral regurgitation at a 
 similarly unusually early period. This over-distention may 
 be recovered from and fully compensated, but it marks a stage 
 in the downward progress that is only too apt to be followed 
 by an exceptionally early fatal termination. Similar results 
 are threatened at any period of the disease when general 
 nutrition is accidentally interfered with by privation, over- 
 work, or any debilitating illness. In these circumstances the 
 
 6 
 
82 CLINICAL LECTURES ON 
 
 disease ceases to be mute, cardiac disturbance sets in, and the 
 patient comes under treatment. But the ruptured compensa- 
 tion may still be restored by appropriate management, and 
 the patient may be reinstated in comparative health. It is 
 otherwise, however, when the nutritional disturbance is local, 
 and solely due to the progress of the disease. Judicious 
 treatment may yet suffice to prolong life, but efficient com- 
 pensation can no longer be restored, and though the end may 
 be postponed, it is inevitable. The immense importance of a 
 perfect metabolism to an organ doing so much work as the 
 heart (equivalent, in its normal condition, to raising its own 
 weight — 10 oz. — 13,860 feet high every hour) is self-evident, 
 and we can readily understand how any impoverishment of 
 the blood from age, privation, overwork, or disease, must 
 impair the working power of the heart. And when we reflect 
 that any impairment of the contractile force of the ventricle 
 must tend to induce residual accumulation, and by the 
 operation of physical laws still further to increase the obstacle 
 with which the weakened ventricle has to contend, then we 
 are able to form some idea of the difficulties with which such 
 a heart has to cope, and the evils to which such a patient 
 is exposed. 
 
 In order to have a clear understanding as to the manner in 
 which aortic incompetence progresses, its probable duration, 
 and its treatment, we must have a distinct understanding 
 as to the physical agencies involved in that progression, 
 and the mode in which the heart is enabled to resist them. 
 
 Now and then it happens that a morbid anatomist 
 holding up a heart allows us to see water trickling through 
 an aortic valve, the incompetence of which had not been 
 detected during life. This need not give us any concern, 
 because a certain force of stream is required to produce a 
 fluid vein, and without a fluid vein there can be no murmur, 
 and consequently no recognition of valvular incompetence. 
 The crumpling of a rheumatic valve goes on so slowly that 
 there is no reason to doubt that, in many cases at least, a 
 
DISEASES OF THE HEAET 83 
 
 leakage between the segments of the valve has been long 
 established before it attains force enough to reveal itself by 
 a murmur. During all this time the leakage has been 
 gradually increasing, and dilatation of the left ventricle, with 
 its compensatory hypertrophy, have been equally slowly and 
 gradually brought about through the agency of those physical 
 and pathological laws formerly referred to,-^ so that we 
 never hear a murmur of aortic incompetence without being 
 at the same time able to detect some degree of eccentric 
 hypertrophy of the left ventricle. When the incompetence is 
 arterial in its origin, and depends primarily on dilatation of 
 the aorta itself, accentuation of the aortic second often long 
 precedes any other sign, and may even be associated with 
 a systolic murmur of aortic origin for an indefinite period 
 before the development of any sign of aortic patency, as 
 has been pointed out by Stokes,^ who has recognised and 
 described these signs as early indications of a progressively 
 advancing incompetence, which begins as slowly and as 
 imperceptibly as in the rheumatic heart. Even when 
 incompetence is suddenly developed by rupture of one 
 of the aortic cusps, there is no reason to suppose that the 
 accident is always attended by serious disturbance of the 
 circulation. At least, I have repeatedly had occasion to 
 observe cicatrices at the root of depressed and incompetent 
 cusps, where there was no history of any sudden disturb- 
 ance, and where circulatory troubles have only arisen after 
 an indefinite period of calm following an accident, to 
 which the rupture of the cusp seemed to have been due. 
 It is true this is not always the case, and in some these 
 troubles arise quickly and rapidly progress to their close, 
 but this seems rather to depend on the previous state of the 
 cardiac muscle than on the nature or position of the lesion. 
 Eosenbach^ has shown that when the aortic valves of 
 
 ^ Vide antea, p. 79. 
 
 ^ Diseases of the Heart and Aorta. (Dublin, 1854), p. 227. 
 ^ " Ueber artificielle Herzklappenfehler," von Dr. Otto Rosenbach, 
 Archivfiir experimentelle Pathologie uvd Pharniacologie (Leipzig, 1878), S. 1. 
 
84 CLINICAL LECTUEES ON 
 
 healthy animals are suddenly destroyed there is no inter- 
 mediate period, however short, of cardiac disturbance, but 
 the heart at once adapts itself to its altered condition, 
 without a trace of any fall in the arterial blood-pressure, 
 such as must have been observed had there been but a 
 momentary falter on the part of the heart. The dilatation ^ 
 necessitated by the overfilling of the left ventricle from 
 two sources, instead of as ordinarily from one, is provided 
 for by the natural elasticity of the walls of the ventricle, 
 and the increased power needed to expel the surplus blood 
 is, at first, readily supplied by the reserve force of the heart, 
 as that organ always has in health a considerable margin of 
 reserve energy upon which the maintenance of life itself 
 depends in many morbid conditions. But the extra large 
 blood-wave sent out by the ventricle flushes the myocardium 
 at a higher pressure, and thus aids the ventricle slowly to 
 hypertrophy, under the influence of Paget's law, so that 
 the reserve energy is from the first supplemented and 
 ultimately fully replaced by an actual increase of muscular 
 force. In this way dynamic compensation is for long 
 efficiently maintained, though perfect structural compensa- 
 tion is never fully attained, the hypertrophy always lags 
 slightly behind the dilatation. 
 
 It was formerly supposed that the heart could only be 
 flushed with blood during its diastole, and by the agency 
 of the arterial systole^ — 1st, because the blood-current 
 during ventricular systole flows at right angles to the 
 orifices of the coronary arteries, and only a small portion of 
 
 ^ Rosenbach errs in supposing that the dilatation in such a case differs 
 in character from that occurring under other circumstances. He fancied that 
 in aortic incompetence dilatation preceded hypertrophy, and that in other 
 cases hypertrophy always preceded dilatation, op. cit. S. 12. But the only 
 difference is one of degree, the mode of production is essentially the same 
 under all circumstances. 
 
 " Vide Stroem, in Haller's Elem. Physiol. Vol. i. Lib. iv. S. 5, §§ 18, 19. 
 (Lausanne, 1757) ; Thibesius, Dissertcdio med. inaug. de circiilatione sanguinis 
 in cordx (Lugd. Batavonim, 1708), §§ 24, 25 ; and Briicke, " Physiologische 
 Bemerkungen fiber die Arteriae Coronariae Cordis," Sitzb. d. k. k. Akcul. 
 der JViss. zu JFien, cl. Bd. xiv. (1854), S. 345. 
 
DISEASES OF THE HEAET 85 
 
 the blood-wave could be supposed to find its way into them ; 
 2nd, because the myocardium during systole is so firmly 
 contracted as still further to limit the quantity of blood 
 getting into it at that time ; and 3rd, because in a consider- 
 able number of individuals the coronary arteries open so 
 far within the valvular zone, that at the moment of 
 ventricular systole their orifices are closed by the segments 
 of the aortic valve thrown back on the arterial wall by the 
 advancing blood-wave, so as completely to shut off any 
 possibility of a systolic flushing of the cardiac muscle. 
 
 But Gaskell ■*■ has shown that even tetanic contraction of 
 a muscle favours the arterial blood-flow through it, instead 
 of obstructing it. 
 
 Hyrtl^ has shown, from a special examination of 117 
 bodies, that in the greater number the orifices of both 
 coronaries are above the free margin of the semi-lunar 
 valves, and that one at least always is so. Hyrtl also 
 states, as the result of numerous experiments on rabbits, 
 cats, and dogs, that section of the coronary arteries is 
 invariably followed by an intermittent blood-spurt coincident 
 with the systole of the ventricle, and this he thinks 
 conclusively proves that closure of the coronary opening 
 by the segments of the aortic valve never occurs.^ Moreover 
 Ceradini has shown by a reference to the physics of the 
 valve segments, as well as that of the blood-current, that the 
 
 1 Ludwig's Arleiten (1876) ; Journal Anat. and Physiol, xi. 360. 
 
 - " Beweis dass die Ursprunge der Coronar-Arterien wahrend der Systole 
 der Kammer von den semilunar Klappen niclit bedeckt werden," \\. s. w. 
 Sizb. d. k. Tc. Akad. d. Wiss. zu Wien, cl. Bd. xiv. S. 373. 
 
 ^ Ueber die Selhststeurung des Herzens, ein Beitrag zur Mechanik der 
 Aorta Klarppen (Wien, 1855), S. 59, u. f. The self-regulative power of the 
 heart, which means that the flushing of the coronaries is necessary for the 
 diastolic expansion of the heart, is shown to be a myth by the fact that the 
 heart of a frog or a shark will beat for hours even when altogether empty of 
 blood. Panum and Von Bezold also found that the hearts of dogs and 
 rabbits beat for hours after the coronary arteries had been completely 
 blocked with wax. Yide Virchows ArcMv, Bd. xxv. (1862), § 308, etc., and 
 Untersuckimgen aus deni physiologische'ii Laboratorium in Wv/rzhurg (Erster 
 Theil, 1867), § 256, etc. The error attached to Hyrtl's theory does not affect 
 the truthfulness of his facts. 
 
86 CLINICAL LECTURES ON 
 
 valve segments are not closely applied to the arterial wall 
 during the ventricular systole, but float in the blood, main- 
 tained in equilibrium by the central or axial stream on the 
 one hand, and on the other by reflux currents which 
 originate at the exterior of the axial stream, flow outwards 
 and downwards against the arterial wall, and are reflected 
 from it upon the posterior surface of the segments of the 
 aortic valve.^ These facts seem conclusively to prove that 
 the coronary arteries are patent to the blood-flow during the 
 ventricular systole ; the meaning of this being that the 
 coronaries are flushed not merely by a reflux current of 
 unknown value, but by a blood-current which, through the 
 influence of Pascal's law, has the minimum aortic pressure 
 of 200 mm. Hg. The cardiac muscle is thus freely supplied 
 with highly oxygenated and nutritive blood at the full 
 normal pressure at the very moment it most requires it, 
 when the transformation of energy, from potential to kinetic, 
 within its substance is at its height. This is in complete 
 consonance with the fact that, except in very advanced cases 
 of long standing, or where other causes have been at work, 
 the heart in aortic incompetence is always found to be 
 well-nourished and free from signs of degeneration. It also 
 helps to explain the remarkable fact that sufl'erers from 
 aortic incompetence are not necessarily short-lived ; they are 
 certainly liable to sudden death in a higher ratio than other 
 men, but such patients often lead useful and wonderfully 
 active lives quite unconscious of the existence of any serious 
 disease. One of the most remarkable instances of this was a 
 clergyman who had his first and only attack of rheumatism 
 thirty-four years before I first saw him. His disease was 
 then far advanced and only too surely approaching its 
 termination, yet he assured me that till two or three mouths 
 previously he had been perfectly unaware that anything 
 
 ^ Der Mechanismus der halhmondformigen Herzklappen (Leipzig, 1872). 
 Ceradini's work contains a very complete epitome of the literature of the 
 subject. 
 
DISEASES OF THE HEART 87 
 
 ailed him. He was a married man with a family, and knew 
 that all his life his heart had beat stronger than other hearts, 
 but he regard£d this as a sign of vigour rather than the 
 reverse. Over-exertion at lawn-tennis precipitated the 
 breakdown of his compensation, and this was too near its 
 natural close to permit of recovery; he died three months 
 after I first saw him. He was a man who discharged 
 faithfully all the duties of his station, and took his share in 
 all the amusements open to him, even indulging in such 
 minor athletics as lawn tennis, curling, etc. I have seen 
 many similar cases, some of them of even longer duration. 
 Such patients are largely exempt from the troubles that 
 afflict those labouring under mitral disease ; the breathless- 
 ness, the frequent recurrence of dropsy, and of bronchitis, as 
 well as the multiform uneasiness due to cardiac weakness, 
 from which mitral patients suffer so much and so often, are 
 largely unknown to those labouring under aortic incompe- 
 tence. It is well it is so, as such accidents are of much more 
 serious import in aortic than in mitral disease. The special 
 immunity from cardiac symptoms enjoyed by those having 
 well-compensated aortic incompetence has been noted by 
 Memeyer, who says that " such persons are frequently not 
 even short of breath — a symptom never missed in mitral 
 disease."^ And he specially mentions a huntsman from 
 Greifswald, who, though labouring under extensive stenosis 
 and incompetence of the aortic valve, with immense eccentric 
 hypertrophy of the left ventricle, was yet able to go through 
 all the manoeuvres and forced marches of the Pranco- 
 Prussian war without difficulty.^ And this remarkable 
 immunity from symptoms is readily understood when we 
 consider the manner in which the heart is nourished, the 
 mode in which compensation is established, and the fact that 
 
 1 A Text-hook of Practical Medicine (London, 1871), p. 347. This immunity 
 of aortic patients from pulmonary symptoms is also referred to by Rosenstein, 
 vide Ziemssen's Cyclopedia of the Practice of Medicine (London, 1876), vol. vi. 
 p. 139, and by others. 
 
 2 Niemeyer, loe. cit. 
 
88 CLINICAL LECTURES ON 
 
 SO long as the myocardium keeps healthy one of the best- 
 nourished and most powerful muscles in the body prevents 
 the development of any discomfort. Herein too lies the clue 
 to successful treatment not only of aortic incompetence but of 
 every form of cardiac failure : strengthen the myocardium by 
 improving its metabolism and every unpleasant symptom 
 will speedily vanish, but of that more anon. 
 
 This imperfect structural compensation long preserves its 
 dynamic perfection, ever slowly advancing towards its natural 
 termination when the heart has outgrown the feeding powers 
 of its coronary arteries. Then the heart ceases to grow 
 stronger; and if its walls still grow thicker, this is due to 
 venous congestion and the secondary development of fibrous 
 tissue. The advancing dilatation is no longer closely followed 
 by hypertrophy of the ventricle ; in no long time the segments 
 of the mitral valve cease to come into apposition at the 
 commencement of the ventricular systole, mitral regurgitation 
 is gradually established, and though still liable to death from 
 asystole, the natural termination of the disease is now by 
 gradual asthenia, and is often preceded by considerable dropsy. 
 The history of aortic incompetence is well fitted to awaken 
 in our minds the highest respect for the recuperative power 
 of the heart, even when it is irremediably injured. It ought 
 also to impress upon all our minds the extreme unadvisability, 
 to say the least of it, of treating a disease of this character, 
 which may have only signs and no symptoms, as in such a 
 case our duty is clearly to watch and wait, avoiding the 
 nimia diligentia, yet prepared at any moment to act with 
 energy and firmness. 
 
 The pulse of aortic incompetence is, as was first pointed 
 out by Sir Dominic Corrigan, something entirely sui generis. 
 In its most typical form it is large and full, quickly projected 
 against the finger, and as rapidly falling off. Sometimes it 
 communicates a vibratile jar to the finger. Scarcely has the 
 shock of the impulse been perceived than the arterial tension 
 drops to a minimum, from the aortic reflux, and the sensation 
 
DISEASES OF THE HEART 89 
 
 vanishes. This pulse — ^pulsus celer et infreqiuens — has been 
 likened to the successive propulsion of shot against the 
 finger, or to the jarring shock of the toy called a water- 
 hammer. It is generally regular, and its characteristics are 
 intensified by raising the extremity (arm or leg) in which we 
 feel it perpendicular to the body as it lies horizontal, or by 
 raising the arm above the head in the erect posture. But the 
 characteristics of this form of pulse are subject to variations, 
 and may be greatly modified by circumstances. Thus great 
 obstruction, which also diminishes regurgitation, may lessen 
 the distinctness of the jar very considerably, and this jar is 
 often materially increased if much ansemia is present. A con- 
 secutive or coexisting mitral affection frequently impresses 
 upon such a pulse the mitral characteristics of smallness, 
 feebleness, and irregularity so strongly that its characteristics 
 are entirely lost. Occasionally under these circumstances 
 elevation of the arm brings out with tolerable distinctness 
 the collapse so distinctive of aortic incompetence ; but this is 
 not always easily detected, and cannot be relied upon unless 
 well marked. When it is distinctly recognisable, we are 
 justified in assuming, from the twofold character of the pulse, 
 the existence of a double lesion — aortic and mitral. 
 
 If we feel the apex beat of the heart and either of the 
 radial pulses simultaneously in a perfectly healthy individual, 
 it will be found that they do not beat together, but that the 
 radial pulse lags behind that of the heart by a distinctly 
 appreciable interval of time, which may vary slightly in each 
 individual with special relation to the rapidity of the heart's 
 action. But the radial pulse in health always precedes the 
 second sound. This delay of the pulse is due to the fact that 
 the arteries are elastic and not rigid, and that the blood 
 moves along them as a wave, and not merely as a mass one 
 end of which is extruded as the other intrudes. Even in 
 health there are trifling variations in the rate at which the 
 pulse- wave passes from the centre to the periphery, depending 
 mainly on the blood-pressure and on the coefficient of the 
 
90 CLINICAL LECTURES ON 
 
 elasticity of the arterial walls (the more rigid the vascular 
 walls, the more rapidly the pulse is propagated).^ In aortic 
 regurgitation the dilated and hypertrophied left ventricle 
 sends a larger blood-wave than usual into the arteries, and 
 with greater force. From the forcible distention by this 
 large blood-wave the arteries become more dilated and longer 
 (more tortuous) than in health, and each pulsation is accom- 
 panied by greater arterial movement than usual (visible 
 locomotive pulse). These phenomena are not, however, 
 distinctive of aortic incompetence, as they may be due to 
 other causes, though usually, in such cases, to a much less 
 degree. In aortic incompetence the arteries are not only 
 longer and more dilated than usual, but, from the reflux into 
 the ventricle, they are also less distended ; the blood-wave is 
 thus longer of reaching its maximum, and the pulse is delayed. 
 This delay of the pulse in aortic incompetence is invariable, 
 as was first pointed out by the late Dr. Henderson,^ the only 
 apparent exceptions being those cases in which the delay is 
 so great that the radial pulse coincides with the ventricular 
 systole immediately succeeding that which has produced it. 
 Any possible mistake in such a case may be prevented by 
 tracing the blood - wave from the ventricle through the 
 carotid and brachial artery to the radial, — not a difficult 
 thing to do by the hand ; while it may be both traced and 
 timed with perfect accuracy by Brondgeest's Pansphygmo- 
 graph,^ or by the electric methods devised by M'Kendrick ^ 
 and by Landois.^ 
 
 Whenever, therefore, we have a visible, locomotive radial 
 pulse,^ which is delayed beyond the commencement of the 
 
 ^ Vide Hermsinn' B ITajidbuch der Physioloc/ie {heipzig, 1880). Vierter Band, 
 Erster Theil, S. 248 ; and Frey Die Untersuclmng der Pulses (Berlin, 1892), 
 S. 137. 
 
 ^ Edinburgh Medical and Surgical Journal, vol. xlviii. (1837), p. 369. 
 
 ^ Laiidois, Lchrbuch der Physiologie (Siebente Auflage, Wien und Leipzig, 
 1891), S. 130. 
 
 * Edinb^irgh Medical Journal (July 1874), p. 8. 
 
 ® Die Lehre vom Arterien-Puls, von Dr. L. Landois (Berlin, 1872), S. 302, etc. 
 
 " Von Frey, op. cit. S. 235. 
 
DISEASES OF THE HEAET 
 
 91 
 
 relaxation of that ventricular systole which originated it — as 
 marked by the occurrence of the pulmonary second sound — 
 then we have to do with an aortic regurgitation, which is 
 probably great in proportion to the delay of the pulse. 
 
 The pulse of aortic incompetence is graphically represented 
 by the accompanying figures (Figs. 7 and 8). In these 
 tracings there is nothing to indicate undue delay of the pulse. 
 
 Fig. 7. 
 
 I have just pointed out how that is to be ascertained. Here 
 we have the graphic representation of the local succession of 
 events as they occur in an artery relaxed in all its dimensions, 
 and more or less imperfectly filled. You will note the beak, 
 or, as French observers call it, the crochet, at the summit of 
 the abrupt line of ascent with which each tracing commences. 
 This beak is due to the percussion- wave transmitted by the 
 arterial wall outstripping the propulsion or blood -wave 
 
 Fig. 8. 
 
 transmitted within the arterial lumen, and it may be increased, 
 or more fully brought out, by taking the pulse-tracing with 
 the arm elevated ^ ; because, although in aortic regurgitation 
 both kinds of waves are delayed, as a loose string vibrates 
 more slowly and with larger undulations than one more tense, 
 and an unfilled elastic tube is longer of reaching its maximum 
 distention than one more fully distended, yet by the elevation 
 of the arm the effect of gravitation on the blood increases the 
 
 1 Loraine, Sur le Fouls (Paris, 1870), p. 258, etc. 
 
92 CLIXICAL LECTURES ON 
 
 delay the pressure -wave experiences in reacliing the distal 
 end of the vessel, while there is no additional obstacle 
 opposed to the advance of the percussion-wave. 
 
 The comparative longevity, and the comparative frequency 
 of sudden death in aortic and in mitral incompetence have 
 been the subject of much debate and of much variance of 
 opinion. These are questions which could only be decided 
 by an appeal to statistics based on an accumulation of 
 accurate data, involving the histories of many such patients, 
 which unfortunately have yet to be collected. There can be 
 little doubt, however, that the general impression is correct 
 which assigns a sliorter life to aortic than to mitral regurgita- 
 tion. I have seen many cases of aortic incompetence who 
 have been known to have suffered from that affection for 
 thirty-five to forty years, but, on the other hand, I have also 
 known many cases of mitral regurgitation who have suffered 
 from their ailment for even longer, and one old friend, if his 
 own statements could be trusted, and I believe they were 
 trustworthy, had suffered from mitral regurgitation for close 
 upon seventy years, and had lived an active and useful life 
 for nearly all that time, nor was his heart the first to fail 
 even at the last. Hospital patients, who belong to the 
 labouring classes and have their compensation frequently 
 disturbed by privation and overwork, have not so good a 
 prospect of life under any circumstances, but even amongst 
 them mitral regurgitation is always more favourable to life 
 than aortic incompetence. Sufferers from mitral regurgita- 
 tion often break down and return again and again to get re- 
 habilitated ; sufferers from aortic incompetence are not so 
 fortunate, and, though there must be exceptions, four years 
 reckoned from the day of admission will include the day of 
 death in by far the larger proportion of those aortic cases 
 who come under hospital treatment on account of serious 
 disturbance of compensation. The limits of life in such 
 cases may be said to lie between three months when serious 
 rupture of the valve has occurred, and forty years in cases of 
 
DISEASES OF THE HEAET 93 
 
 disease occurring under favourable circumstances, •which may 
 vary much in character. Within these limits our prognosis, 
 always uncertain, must be determined by the circumstances 
 of the patient, such as the necessity for manual exertion, his 
 habits — temperate or otherwise, as well as any other condi- 
 tions likely to influence his general health. Family longevity 
 is also not to be discarded, as it affords a probable indication 
 of a greater or less tendency to muscular degeneration. 
 Further, the probable period during which the disease has 
 already existed, the progress which it has already made, and 
 the present condition of the cardiac muscle, all form im- 
 portant elements in relation to prognosis. Moreover, the 
 temperament of the patient must not be neglected, as nervous 
 excitability, whether revealed in sudden bursts of passion, or 
 in irregular spurts of violent exertion, is always unfavourable, 
 as whatever conduces to irregular action of the heart is in- 
 jurious in all forms of cardiac disease, and is more frequently 
 fatal in aortic incompetence than in any other. 
 
 Death from cardiac disease arises always — apart from 
 accident — from syncope brought about in one of two ways, 
 either by gradually increasing asthenia, in which the aortic 
 blood-pressure slowly fails from day to day ^ till it drops at 
 last below what is compatible with life, and death ensues ; or 
 by asystole, in which the blood-pressure suddenly falls below 
 that necessary to maintain life because the heart ceases to 
 act. No statistics are required to prove that the former 
 accident is most likely to happen in mitral disease and the 
 latter in aortic incompetence. 
 
 When the myocardium is enfeebled by inflammatory in- 
 filtration, fatty or fibrous degeneration, the heart may suddenly 
 cease to act at any moment, either in systole or diastole — 
 
 1 This is what seems to happen. But it may really be as when the 
 ascending arch of the aorta in a dog is gradually narrowed by a screw-clamp, 
 while the blood -pressure is recorded by a mercurial manometer connected 
 with one of the carotids, that the blood-pressure does not actually fail till it 
 suddenly drops just before death. Vide Roy and Adami, British Medical 
 Joitrnal (15th December 1888). 
 
94 CLINICAL LECTURES OX 
 
 more often the latter — and with this cessation of action life 
 comes to an end. Death from this cause may happen with 
 or without valvular lesion. If any valvular lesion is present, 
 there are, as we have seen, both anatomical and physiological 
 reasons why it should be incomparably more frequent in 
 connection with aortic incompetence than with any other 
 valvular lesion. Even in the most extreme form of mitral 
 stenosis, enough of blood always reaches the ventricle to 
 enable life to be maintained, if only in a feeble fashion, while 
 no obstacle is opposed to the free action of the ventricle. In 
 free mitral regurgitation there is no want of blood in the 
 ventricle, and provided the action of that organ is powerful 
 enough, a sufficient quantity is always sent on to provide for 
 the maintenance of life ; and as the blood, in such cases, has 
 always two ways of escape, ventricular systole, though it may 
 be difficult, is always possible, except in the presence of 
 muscular degeneration. In these two forms of disease, 
 therefore, sudden death from asystole must be and is a some- 
 what rare accident ; the more usual mode of death being 
 syncope from asthenia brought about by secondary affections 
 such as dropsy, with or without albuminuria, or jaundice, 
 unless in those exceptional cases where death is hastened by 
 sudden embolism of the brain or lungs, or by suffocation 
 from an acute access of pulmonary oedema. On the other 
 hand, in aortic incompetence the constant and continually 
 increasing dilating pressure of the blood column acts as a 
 permanent obstacle to ventricular contraction; and we can 
 readily understand why comparatively trifling exertion, 
 wliich raises the aortic blood-pressure, and also why emotional 
 excitement, which through the vagus inhibits the action of 
 the katabolic nerve, should in many cases be followed by 
 sudden death. The inhibitory action, even with a compara- 
 tively healthy ventricle, permits the dilating force, already 
 barely compensated, to turn the scale, and after a few feeble 
 attempts to overcome the obstacle, the primary syncope 
 passes into death from asystole, the heart remaining in a 
 
DISEASES OF THE HEAET 95 
 
 permanent diastole.-^ If tliis be the case with a comparatively 
 healthy ventricle, we can readily understand that it is much 
 more readily brought about when the muscular tissue is 
 diseased (fatty, fibrous, or both), as is so frequently the case. 
 When the mitral valve has become incompetent from 
 secondary dilatation, death from asystole is not so readily 
 induced, though it is not altogether prevented. But as the 
 congested cavity is no longer represented by the heart alone, 
 but includes also the lungs, there is a possibihty of relief to 
 the oppressed heart by rupture of the turgid pulmonary 
 capillaries. The relief thus obtained is mostly temporary, 
 however, and only postpones the end. The mechanical cause 
 always present in aortic incompetence, acts with continual 
 increasing efficiency in the direction of one or other of these 
 modes of death, and from the dilated and diseased condition 
 of the pulmonary capillaries, and the consequent readiness 
 with which they may be ruptured, we can readily understand 
 that those cases of aortic incompetence which escape death 
 from asystole mostly die from pulmonary apoplexy, or from 
 a combination of the two. It is only rarely that dropsy and 
 other secondary diseases of a serious character are established 
 in such cases, death then occurring from asthenia. This is 
 pretty much a question of animal mechanics, which statistics 
 may confirm, but can never disprove. The manner in which 
 death is caused, and the morbid appearances after death from 
 asystole are precisely similar whether the end has come on 
 the street, or at a public meeting, in the midst of apparent 
 health, or after a longer or shorter period of more evident 
 illness. In illustration of it I therefore prefer to give two 
 cases in which the disease was known to have lasted for 
 some time, because their history has an important bearing 
 on the treatment of such cases. 
 
 Case V. Isabella Stewart, aged thirty-five, employed in a 
 
 ^ This question has been very fully gone into by Dr. Mauriac. Vide bis 
 Essai sur les Maladies de Cczur. Be la. Morte SvMte da-ns I' FasuffisaTice de 
 I'Aorte (Paris, 1860) ; vide also The Senile Hea/rt, by George "W. Balfour, 
 M.D. (A. and C. Black, London, 1894), pp. 31, 39, and 41. 
 
96 CLINICAL LECTURES ON 
 
 paper-mill, admitted on SOth May 1870 to Ward XIII., com- 
 plaining of cough, which troubled her for the first time about a 
 fortnight ago, and of palpitation of the heart, from which she 
 had suffered for about eighteen months. Her previous health 
 had been good. Family history unimportant. Her expres- 
 sion was anxious, muscularity flabby, skin dusky, but 
 naturally so. The lower extremities slightly oedematous, 
 joints normal, she has never had rheumatism. Pulse 93, 
 presenting in a well-marked form all the characteristics of 
 the Corrigan or water-hammer pulse. On inspection and 
 palpation the area of the cardiac impulse was found to be 
 somewhat extended, the impulse itself feeble. There was 
 visible pulsation of all the superficial arteries, particularly at 
 the root of the neck, but this was by no means well marked. 
 The apex of the heart was found to beat under cover of the 
 sixth rib, at a distance of three inches and a half from the 
 left edge of the sternum. At the level of the upper edge of 
 the third rib, one inch from the left edge of the sternum, 
 dulness commenced, and extended downwards to the liver 
 dulness. At the level of the fourth rib, dulness connnenced 
 half an inch to the right of the sternum, and extended trans- 
 versely across the chest for a distance of five inches. On 
 auscultation over the apex, the first sound was heard much 
 obscured by coarse crepitation, and rendered impure by the 
 presence of a murmur, which, on being traced upwards, was 
 found to have its position of maximum intensity at mid- 
 sternum between the third and fourth ribs. The second 
 sound is wholly replaced by a soft, diastolic murmur. This 
 double murmur is audible with varying distinctness over the 
 entire cardiac area ; it is also propagated into the arteries, 
 but the diastolic portion is only faintly heard in them. In 
 the pulmonary region the pulmonic second is much obscured 
 by the diastolic murmur, but on moving the stethoscope 
 along the second interspace it is distinctly audible about an 
 inch to the left of its usual position. The respirations are 
 24 per minute ; the cough troublesome ; sputa thin, watery, 
 
DISEASES OF THE HEAET 97 
 
 and somewhat frothy, amounting to about 3 oz. in two 
 hours. The pulmonary percussion is everywhere normal. 
 On auscultation the normal respiratory sounds are entirely 
 obscured by crepitation, cooing, and sonorous rhonchi. 
 Appetite gone ; some thirst ; urinary and other systems 
 normal. Diagnosis — acute bronchitis engrafted on and 
 aggravated by an cedematous and congested condition of both 
 lungs, the result of aortic incompetence. Prognosis — grave, 
 death being threatened by cardiac asystole. Treatment — full 
 diet, 6 oz. of wine daily, dry cupping to the chest, with 
 a large jacket poultice afterwards, and a mixture con- 
 taining digitalis, carbonate of ammonia, iodide of potass, 
 and tincture of hyoscyamus, every four hours. It is 
 noted that up to 15th June the patient's condition had 
 been repeatedly aggravated by attacks of pulmonary con- 
 gestion and threatened asystole, from which she had been 
 relieved by dry cupping, stimulants, and the use of the 
 mixture prescribed. On 15th June there was almost no 
 cough, the expectoration was nearly gone, vesicular re- 
 spiration everywhere audible ; pulse 88, full and strong ; 
 patient was lying quietly, and 'expressed herself as quite 
 relieved. On 18th June she was up at visit, and was 
 apparently quite well. On the 22nd she had another attack 
 of pulmonary congestion, with threatened asystole ; from 
 this she was temporarily relieved by treatment, but she died 
 suddenly on 26th June. At the ^ost-mortem examination of 
 the body, which took place fifty-six hours after death, the 
 heart was found more dilated than hypertrophied ; it weighed 
 19 oz. ; both ventricles were filled with dark-coloured clots, 
 of which that on the left side extended some distance up the 
 aorta, presenting one continuous mould of the interior of both 
 ventricle and aorta. The aorta itself was slightly dilated, its 
 valves thickened and incompetent, a considerable angular 
 aperture being left between the edges of its cusps. The 
 pulmonary, mitral, and tricuspid valves were healthy and 
 competent. A portion of the muscular substance of the 
 
 7 
 
98 CLINICAL LECTUKES ON 
 
 heart was somewhat inflamed.^ The right lung was healthy 
 in appearance, and also on section, except at its lower margin, 
 where there was a patch of pulmonary apoplexy. The 
 pulmonic glands were infiltrated with black pigment, and 
 there was a good deal of pigment on the surface of the lung. 
 The left lung was adherent all round to the chest wall, 
 especially posteriorly, the connecting lymph was receut, and 
 in some places quite one-fourth of an inch in thickness. 
 The lung itself was oedematous, and the bronchial mucous 
 membrane congested. Iodine produced a slight mahogany 
 tint on the cut surface of the liver, which was fatty, and 
 presented a nutmeg appearance. The spleen was healthy, 
 the kidneys congested, but otherwise healthy ; the Malpighian 
 bodies were slightly prominent, but gave no reaction with 
 iodine. 
 
 This case presents a well-marked example of death from 
 asystole, in which compensation had never been fully 
 developed, and in which death was hastened by inflammatory 
 complications. 
 
 In the following case asystole was the result of long- 
 continued disease, which had been fully compensated, but in 
 which the compensation had been accidentally ruptured. 
 Even in this case, therefore, death was a preventable accident, 
 though the unavoidable end was not long forestalled. 
 
 Case VI. William Yorkston, a blacksmith, aged fifty-four, 
 admitted to Ward V., 14th November 1870, complaining of 
 orthopnoea, cough, expectoration, occasional pain in the chest, 
 and swelling of the legs. About six weeks ago he caught 
 cold after prolonged exposure to heat at his work, and this 
 cold was aggravated by fresh exposure about a fortnight ago. 
 He has hitherto enjoyed good health, and has never had 
 
 ^ This is all that is noted in regard to this matter in the Pathological 
 Hecords: — Myocarditis is always a grave complication in serious valvular 
 lesions ; unfortunately, we cannot detect it with certainty, and are seldom 
 even in a position to suspect its existence. I shall subsequently have occasion 
 to relate a case of aortic incompetence in which myocarditis had an undoubted 
 influence in promoting fatal asystole. 
 
DISEASES OF THE HEAET 99 
 
 rheumatism ; but for the last three or four years he has been 
 working hard and drinking heavily. His father and mother 
 both died of cholera. The patient was tall and muscular, his 
 expression anxious, his face pale, his lips livid, his skin and 
 joints normal, his legs cedematous up as far as the knees. 
 The radial pulse jerked slightly, but not in any noticeable 
 way : it beat 90 per minute. The jugular veins pulsated 
 visiblv : the rigi;ht carotid sh^htlv, the left carotid not visibly. 
 The cardiac impulse was diffuse and feeble : the apex beat 
 diffusedly between the sixth and seventh ribs. At one inch 
 from the left edge of the sternum, dulness on percussion 
 commenced at the upper border of the third rib and extended 
 down to the liver dulness. Transversely on the line of the 
 fourth rib, dulness commenced half an inch to the right of 
 the sternum, and extended across for a distance of five and a 
 half inches. In the mitral area a murmur was heard replac- 
 ing the first sound : a second sound was audible. On 
 tracing the systolic murmur upwards along a line joining the 
 mitral and aortic areas, it was heard to grow gradually fainter 
 as it neared the sternum, and it became again gradually 
 louder as it approached the sternal end of the second rib 
 on the right, where it attained a second maximum. In this 
 position the second sound was wholly replaced by a loud but 
 soft diastolic murmur; the systolic portion of the murmur 
 alone was propagated into the carotids. In the pulmonary 
 area a second sound was audible obscured by the diastohc 
 murmur ; it became more distinct when the stethoscope was 
 moved off the sternum along the second interspace. At the 
 lower end of the sternum the systolic murmur was very loud 
 and distinct, and wholly replaced the normal sound of the 
 tricuspid. The respirations were 26 per minute ; cough hard 
 and frequent ; sputum watery, frothy, and small in quantity, 
 no blood. The percussion of the lungs was normaL On 
 auscultation sonorous and sibilant rhonchi were heard over 
 the whole chest, partly obscuring the vesicular breathing. 
 Appetite defective, bowels costive, urine scanty, no albumin 
 
100 CLINICAL LECTURES OX 
 
 Patient slept none at night. He was ordered full diet and 
 4 oz. of whisky daily. 
 
 R Tincturoe scillse, 
 
 Tincturse digitalis, a a 5 ii 
 Aquae Cassise, 5 vss. Misce. 
 Signetur — One tablespoonful every four hours. 
 
 R Elaterii gr. ^ fiat pihila — One such to be taken every four hours 
 till the bowels are freely moved. To have 20 grains of chloral 
 every night at bed-time. 
 
 On the 21st of November it is noted that the patient 
 slept the previous night for the first time in the recumbent 
 posture. His dyspnoea was comparatively trifling, the cough 
 gone, the respiration free, the oedema of the legs entirely 
 gone, the cardiac impulse stronger, the pulse more markedly 
 jerking, only 80 per minute. The radial pulse is delayed for 
 the full half of a cardiac cycle beyond the apex beat ; the 
 superficial arteries pulsate now in a marked manner, the 
 jugular veins less distinctly. Over the mitral and tricuspid 
 areas the systolic murmur is not so loud as formerly, and 
 cannot be so distinctly localised. He was kept some time 
 under observation, and then discharged much improved. On 
 the 18th of August 1871 he was readmitted, and died 
 suddenly next day. At the post-mortem examination the 
 body was found to be well developed ; skin and conjunctivae 
 of a yellowish colour. The heart was greatly enlarged, 
 dilated and hypertrophied, weighing thirty ounces. Both 
 ventricles contained large black clots. The aortic valves 
 were atheromatous and incompetent ; the aorta itself was 
 greatly dilated. The mitral and tricuspid openings both 
 admitted five fingers. The right lung was very dark in 
 colour, greatly congested, and apoplectic ; it weighed 2 lbs. 
 2 oz. The left lung also contained an apoplectic clot, and 
 was covered with recent lymph. The liver weighed 3 lbs. ; 
 it was fatty, and its ducts congested and obstructed 
 by catarrhal mucus. The kidneys were enlarged and 
 congested. 
 
 These two cases illustrate very well the condition of the 
 
DISEASES OF THE HEAET 
 
 101 
 
 heart found after death from asystole in aortic incompetence. 
 Both ventricles in diastole, and both, but especially the left 
 one, distended by a large black clot extending into the aorta. 
 It appears as if death in these cases was due to paralysis of 
 the heart from over-distention, which, as we have seen, may be 
 brought about in various ways, and is that mode of dying in 
 which death primarily invades the heart in aortic incom- 
 petence. One great object of our treatment of such cases is 
 to prevent this mode of death which is continually threatened, 
 and in obviating this primary danger we are also able, in a 
 great measure, to prevent many of the secondary causes of 
 death, or at all events to delay their fatal result. 
 
 Fig. 9. 
 
 Fig. 10. 
 
 Ill Case V. it is noted that the first sound over the mitral 
 area was obscured by a systolic murmur, which had its focus 
 of maximum intensity in the aortic area. This we ascertained 
 by tracing the murmur upwards along a line joining the 
 mitral and aortic areas. The result is graphically shown in 
 the accompanying diagram (Fig. 9). 
 
 In Case VI. the systolic murmur is stated to have had 
 two foci of maximum intensity. In tracing this murmur 
 upwards along a line joining the mitral and aortic areas, it 
 was found gradually to decrease in intensity as we approached 
 the sternum, and it again became louder and more distinct 
 as we got nearer to the aortic area. This is graphically 
 represented in the accompanying diagram (Fig. 10). 
 
102 CLINICAL LECTURES ON 
 
 This is the method to be pursued when we wish to 
 determine whether we have to do with a systolic murmur of 
 mitral or of aortic origin, or with a systolic murmur of 
 twofold origin — arising at both orifices. These diagrams 
 represent graphically the method we employ and the result 
 obtained in two out of the three hypothetical cases. When 
 the systolic murmur is of purely mitral origin, its graphic 
 representation is of course exactly the reverse of that depicted 
 in Fig. 9. 
 
 In the treatment of aortic incompetence, we must care- 
 fully distinguish between those in whom the disease is only 
 to be recognised by signs, and those in whom it is revealed 
 by symptoms. In the former class the affection is dynamic- 
 ally compensated and is mute ; in the latter the compensation 
 is incomplete or ruptured. Those in whom the affection is 
 only revealed by signs require no special treatment. Such 
 patients or their friends must be cautioned against over- 
 excitement or any sudden or violent exertion ; they should 
 be well fed, protected as far as possible from cold or any 
 risk of chill, and stimulants should either be altogether 
 avoided, or only used pro re nata, as their constant use 
 has a tendency to weaken the myocardium. Apart from 
 these cautions the patient must be left pretty much to his 
 own devices, as continual watching and coddling, while it 
 embitters life, yet affords no perfect security against the 
 occurrence of sudden asystole, which is the only risk the 
 patient runs at this stage of his disease — a risk moreover 
 which is by no means certain to emerge even though a dia- 
 metrically opposite course of conduct be pursued from that just 
 recommended. A knowledge of this, a result of the great 
 recuperative power of the heart, will prevent us from making 
 the life of any one miserable merely because he happens to 
 have a murmur of aortic regurgitation, and will enable us to 
 view with comparative equanimity many departures from the 
 strict laws of prudence on the part of those so affected. Such 
 patients have generally good health, are quite capable of 
 
DISEASES OF THE HEAET 103 
 
 enjoying life, and have no need of any special treatment. 
 Iron, strychnine, and arsenic are useful tonics, when such 
 remedies seem to be indicated, and we ought always, in such 
 cases, to avoid any perturbative treatment likely to depress 
 the vital powers. 
 
 "When, however, compensation is ruptured and symptoms 
 are superadded to signs, then we require to act more 
 energetically ; and should the disease be not too far advanced, 
 our energetic action will often be followed by the happiest 
 results, compensation will be restored, and life prolonged, 
 sometimes for many years. 
 
 In aortic incompetence a most injurious effect is produced 
 by the dilating force of the column of arterial blood, which, 
 no longer resting upon the closed aortic valve, acts as a 
 dilating force within the ventricle, according to Pascal's law, 
 in proportion to its height and the area of its basis, and our 
 primary object is to reduce as far as possible both of these 
 elements. First of all, therefore, we put the patient to bed 
 and endeavour to get him as nearly recumbent as possible, 
 so as to diminish the height, and thus lessen the distending 
 power, of the arterial column. With this view we deaden his 
 sensibility by the administration of chloroform, chloral, or 
 morphia, either by the mouth or hypodermically. The 
 orthopnoea, which is so distressing a feature of this disease, 
 has reference solely to the congested and cedematous con- 
 dition of the lungs, and is established by nature to give the 
 patient's respiratory muscles a better purchase in elevating 
 the chest walls. A wise physician knows that whatever 
 risk may underlie the condition of the lungs, there is much 
 greater and more immediate danger connected with the state 
 of the heart. He does not argue the point with nature, but 
 he calms her instinctive fears with the means at his command, 
 and feels he has gained a victory for science and a benefit 
 for his patient when he has got him fairly recumbent. The 
 inexorable mechanics of the circulation are appeased, and we 
 have leisure to attend to the physiological part of the diffi- 
 
104 CLINICAL LECTURES ON 
 
 culty. So intricately involved, however, are all our vital 
 actions that we cannot appease the mechanical part of the 
 difficulty without advantage to the physiological part, and 
 ■vice versa we cannot improve the physiological condition of 
 the heart without simultaneously appeasing its mechanical 
 difficulty. It is advantageous, therefore, to carry out both 
 parts of our treatment at once. And though this may look 
 like an empirical treatment of symptoms, a deeper knowledge 
 of the mechanics and physiology of an aortic heart, and of 
 their mutual interdependence, shows that we are really 
 employing scientific means according to scientific method, 
 and that we apparently thwart nature only the quicker to 
 secure the benefits she is aiming at. While, therefore, we 
 endeavour to get the patient into the recumbent posture, so 
 as to lower the height of the distending column and thus at 
 once relieve the cardiac circulation and diminish the pul- 
 monary congestion, we also endeavour to secure a similar 
 relief by diminishing the area of the base of the arterial 
 column, by contracting the heart and especially the left 
 ventricle. So far as our present therapeutical armamentarium 
 extends, there is only one drug by which this contraction 
 may be certainly and safely secured, and that is digitalis. It 
 is not so long since digitalis was regarded as the opium of 
 the heart ; now we know that it acts by increasing muscular 
 elasticity, especially that of the myocardium and of the 
 muscles of the arterioles, and by improving the metabolism 
 of the myocardium.^ It is still regarded by many as not 
 only useless but dangerous in aortic incompetence, because 
 it slows the heart's action and by prolonging the diastole 
 gives longer time for regurgitation, and is supposed thereby 
 to promote over-distention of the left ventricle and to increase 
 the tendency to asystole, that very accident which digitalis 
 is the most powerful agent we can employ to prevent. We 
 know that the prolonged diastole in bradycardia promotes 
 
 ^ Vide Neio Official Rer)iedies, by Ralph Stockman, M.D. (London, 1891), 
 p. 58 ; also Lecture XIV., " On the Therapeutics of Cardiac Disease." 
 
DISEASES OF THE HEAET 105 
 
 distention of the cardiac cavities, and that in these cases 
 attacks of syncope, if not of asystole, are common enough. 
 But in bradycardia the heart is filled by the blood in the 
 course of its onward flow, and, as the heart's action is often 
 slowed down to 40, 30, or even less than 20 beats per minute, 
 the blood has often more than double the normal diastolic 
 pause during which to distend the heart. In aortic incom- 
 petence the pulse is ordinarily much quicker than usual. 
 Corrigan reckons it as averaging 110 per minute,^ and it is 
 neither necessary nor desirable to slow it down by any treat- 
 ment much below the normal (say to 70). In fact in the 
 case just narrated all the benefit desired was obtained without 
 the pulse-rate falling below 80. There is thus no question of 
 any abnormal prolongation of the diastole, and to suppose that 
 to reduce the pulse-rate to normal is to induce a dangerous 
 prolongation of the diastole, is to presuppose aortic incom- 
 petence to be much more dangerous to life than it really is, 
 and to regard the danger as greater the more normal the rate 
 of the circulation. The dynamics of the heart involve many 
 problems which have not yet been solved, and one of the 
 most interesting of these is the effect of prolongation of the 
 diastole upon regurgitation through an incompetent aortic 
 valve. One or two questions connected with this subject 
 I am able to answer : Does undue prolongation of the diastole 
 promote the occurrence of asystole ? ISTever in my experience. 
 Is asystole the result of over-distention, or is over-distention 
 the consequence of asystole ? In all the cases of aortic in- 
 competence which I have seen terminated by sudden asystole, 
 this has always seemed to have been brought about by some 
 sudden interference (emotional or otherwise) with the action 
 of the katabolic nerve, and the over-distention has seemed to 
 follow and not to precede this interference. For all thera- 
 peutic purposes it seems sufficient to know that it is never 
 necessary to prolong the diastolic pause beyond the normal 
 to obtain all the benefits which digitalis is capable of bestowing, 
 
 ^ Edinburgh Medical and Surgical Journal (April, 1832), p. 241. 
 
106 CLINICAL LECTURES ON 
 
 and to add that never in the course of a long experience have 
 I ever seen any harm follow the use of digitalis, while I have 
 many a time seen the greatest benefit follow the emploj'-ment 
 of that drug. As an indication of the nature of these benefits 
 I may give the following quotation from a letter sent me by 
 a patient, himself a highly educated medical man, a professor 
 in one of our Northern Universities, who had long suffered 
 from aortic incompetence : " When first I saw you my pulse 
 was irregular and feeble. In the morning I could only walk 
 about 250 yards. This took me from nine to twelve minutes, 
 and I had to pause to gain breath three or four times on each 
 occasion. In the afternoon, with usually the assistance of an 
 arm, I could walk half a mile, resting say three times, but 
 being troubled with occasional dull pain in the heart, constant 
 distress from a feeling of constriction in the lungs, and a 
 feeling of strain and weakness in the muscles. My stride 
 was little more than half its natural length ; and this half 
 mile took me always over half an hour to accomplish. The 
 night before I took the digitalis was the most trying and 
 distressing which I can remember. My breathing was just 
 a succession of rapid gasps, which ceased whenever I seemed 
 about to fall asleep, when I had to draw a breath by an effort 
 of will. The inhaled air did not seem to get fully into the 
 chest. There was mental confusion, if not absolute cowardice. 
 The feebleness and irregularity of the pulse were extreme, 
 and my condition was altogether so painful that a sense of 
 duty alone restrained me from desiring death. I had to walk 
 all night till five in the morning. After the first day of 
 taking digitalis all this was for the most part changed. Even 
 then, as I expressed myself to you, I was ' a different man.' 
 I think any one might be satisfied who has a pulse like mine 
 now ; I sleep well, the stride has lengthened out, five to six 
 minutes now suffice for the 250 yards ; with sometimes no 
 rest at all I have walked about a mile and a half Though 
 there is occasionally a little panting, the air seems to get to 
 the bottom of my chest, which is altogether free from any 
 
DISEASES OF THE HEAKT 107 
 
 feeling of constriction. In fact for a week I have been en- 
 joying life ; there is a kick in my pulse which tells of every- 
 thing firming up, and there is not in my mind an atom of 
 doubt as to the ;post hoc 'pro'pUr hoc in my case." 
 
 The action of digitalis on the myocardium is to increase 
 its elasticity and to improve its metabolism ; it is therefore 
 the tonic of all others most useful in aortic incompetence, as 
 it enables the myocardium not only better to withstand the 
 dilating influence of the blood-column, but also to overcome 
 its inertia with greater vigour. This increased elasticity 
 lessens the distention of the heart, and contracts its volume 
 without increasing its hypertrophy, while the improved meta- 
 bolism of the myocardium increases its contractile force, and 
 enables it to maintain the equilibrium of the circulation. 
 Digitalis has no influence in itself in promoting hypertrophy, 
 that is the result of an organ "being more than usually 
 exercised in its office," ^ and is the ultimate and necessary 
 effect of the increased amount of work thrown on the ventricle 
 by the incompetence of the aortic valve. By improving the 
 elasticity and increasing the vigour of the muscle, digitalis 
 rather retards than promotes the need for any muscular over- 
 growth. Hence digitalis is a drug which may be given in 
 moderate doses at any period of the disease, not only without 
 harm, but with positive benefit. Still it is a remedy not 
 specially indicated so long as the affection is only revealed by 
 signs alone and not by symptoms also. With a heart failing 
 from any cause (ruptured compensation) it is different ; then 
 digitalis is urgently called for and may be freely given with 
 the utmost benefit. As the elasticity of the myocardium in 
 an aortic heart has to be restored in the face of a gradually 
 increasing strain, a large dose is always required, and in my 
 experience has always been well borne. In the case just 
 referred to the dose given was half an ounce of the infusion 
 of the Edinburgh Pharmacopoeia (equivalent to gr. iii. of the 
 powdered leaves) night and morning for many weeks, with 
 ^ Paget's Surgical Pathology (London, 1870), p. 49. 
 
108 CLINICAL LECTURES ON 
 
 nothing but increasing benefit. This may be reckoned about 
 an average dose for such cases, and it may be increased or 
 diminished according to circumstances. In one remarkable 
 case of persistently threatened asystole, I was only able to get 
 the patient removed from the infirmary, and taken home a 
 distance of a hundred miles, by the continuous administration 
 of half-drachm doses of the tincture of digitalis every two 
 hours for several days.^ This was, by the way, a case in which 
 asystole ought to have been precipitated instead of being 
 averted by the treatment, if the fears of Corrigan and his 
 followers had any foundation in truth. This patient was not 
 only able to be taken home in safety, but she lived for some 
 time afterwards. Naturally in giving such large doses it is 
 needful to keep a watchful eye upon the patient, though I 
 have never seen the development of any untoward symptoms 
 in any such case. Aortic cases not only require large doses, 
 but they also seem to bear them well. The pallor of the 
 countenance so common in aortic incompetence is greatly 
 more due to defective circulation than to mere want of iron 
 in the blood, but iron is always a good tonic in such cases, 
 though it should not be given along with digitalis, as the com- 
 bination is extremely apt to induce sickness. Arsenic may 
 be very beneficially combined with digitalis ; it is an excellent 
 cardiac tonic, and its effects in relieving anginous pain, especi- 
 ally that form of it associated with diseased aortic valves, is 
 often marvellous. Arsenic is perhaps more often conjoined 
 with strychnine than with digitalis, as these two are most 
 excellent tonics for ordinary use, the digitalis being only 
 specially required when the compensation is ruptured. All 
 such patients require to be nutritiously yet moderately fed, as 
 the defective aortic pressure reacts injuriously on both the 
 gastric and hepatic secretions, limiting both their supply and 
 efficiency. Alcoholic stimulants, in moderation, are often 
 useful in aortic cases, but their use must be watched and 
 
 ^ Agnes Butler, admitted to Ward XIII., 19th October, discharged 16tli 
 November 1872. 
 
DISEASES OF THE HEAET 109 
 
 regulated. They are chiefly of value in helping to tide over 
 a period of weakness, and have neither the special advantages 
 of digitalis nor the important tonic effects of arsenic and 
 strychnine. 
 
 When there is much starting from sleep, the suhitanea 
 excitatio e somno of the older writers, it generally dies away 
 in a few days under the use of digitalis, and is much relieved 
 by the use of morphia, though it does not always require it. 
 Now and then cases of aortic incompetence are associated 
 with mental aberration of a more or less violent character ; 
 there can be no fixed rule of treatment for such aberration, 
 which must depend upon its degree, its character, and its 
 cause. In several cases which have occurred to myself, and 
 in which cortical anaemia seemed to be the chief exciting 
 cause, full doses of morphia hypodermically, with digitalis, 
 and a nutritious dietary were attended by the happiest 
 results. 
 
LECTUEE IV 
 
 ON THE MURMURS AND OTHER PHYSICAL SIGNS DISTINCTIVE 
 OF MITRAL STENOSIS 
 
 If asked to state the sign that is supposed to be most 
 distinctive of disease of the mitral valve, probably nine 
 persons out of ten would without hesitation reply, a systolic 
 murmur loudest at the apex. Yet this belief, though 
 a common one, is far from being true. A systolic apex 
 murmur is by no means a proof of any positive derangement 
 of the cardiac mechanism. A murmur in this position may 
 be of exocardiac origin, and the valves in this case may be 
 perfectly healthy, and their action normal, notwithstanding 
 the persistence of a murmur with the characters described. 
 It is even alleged that a murmur of this kind may be of 
 endocardiac origin, the valvular mechanism remaining intact ; 
 and though such a murmur must be very problematical, it is 
 yet a possibility we cannot altogether ignore in estimating the 
 probabilities in favour of our diagnosis. But systolic apex 
 murmurs of exocardiac, or even of endocardiac origin, unaccom- 
 panied by valvular derangement, are not of course associated 
 with regurgitation into the auricle, and are therefore free 
 from any of the signs and symptoms associated with that 
 accident. Moreover unequivocal proof that regurgitation does 
 exist along with a systolic apex murmur is not a certain sign 
 that disease or deformity of the mitral valve is actually pre- 
 sent, because in a considerable proportion of those cases in 
 which both of these phenomena occur the mitral valve is 
 perfectly healthy. In fact the mitral valve may be free from 
 
CLINICAL LECTUEES ON DISEASES OF THE HEAET 111 
 
 disease, and the auriculo-ventricular opening perfectly natural 
 and undilated, and yet regurgitation may, and often does 
 occur. How this may be I shall take another opportunity of 
 explaining,^ for the present it must suffice to state that even 
 when mitral regurgitation is clearly established, this is no 
 certain proof that the valve is diseased. On the other hand, 
 there is a murmur so invariably associated with disease of the 
 mitral valve that, when once heard, it may be accepted as a 
 positive proof of a permanent deformity of that valve, and that 
 even although the murmur itself may cease to be heard, as 
 not infrequently happens. This murmur, so truly pathogno- 
 monic of mitral disease, has been termed, jpar excellence, the 
 presystolic murmur, because it precedes any external mani- 
 festation of the cardiac systole. Nevertheless it is a direct 
 murmur, occurring in the course of the onward flow of the 
 blood, and produced by the contraction of the auricle which 
 a glance at the diagram (Fig. 4) on page 39 shows comes at 
 the end of the long pause and is the actual commencement 
 of the cardiac cycle. 
 
 The history of the presystolic murmur commences with 
 M. Fauvel,^ who, in 1843, not only described its characteristics 
 as a loud, rough murmur, running up to and terminating with 
 the first sound, un hruit de rape intense, 'pr6c6dant le premier 
 hruit, finissant avec lui — but also represented it as pathogno- 
 monic of stenosis of the mitral opening, and gave it the name 
 by which it is best known among us — presystolic — because 
 he recognised that it immediately preceded the ventricular 
 systole. He also showed that this murmur really occupied 
 the time of the auricular systole, and was due to the friction 
 of the blood forced through a constricted mitral opening. 
 
 ^ Fide Lecture VL "On Curable Mitral Regurgitation." 
 ^ Archives Gendrales de Medicine, 4me serie, tome i. p. 1 ; vide also "The 
 Evolution of Cardiac Diagnosis from Harvey's days till now," by George W. 
 Balfour, M.D., Ed. Med. Jour. (June 1887), p. 1076. Fauvel borrowed the 
 term presystolic from Gendrin, but Gendrin used it in a different sense ; he 
 applied it to the latter half of the long pause, terminating before the auricular 
 contraction, which he rightly made part of the systole. Vide Leqons sur les 
 maladies du Cceur (Paris, 1841), tome i. p. 111. 
 
112 CLINICAL LECTURES ON 
 
 British physicians are, however, mainly indebted for a clear 
 understanding of this important murmur to the lucid de- 
 scriptions and instructive diagrams of Professor Gairdner of 
 Glasgow, first published in 1861. Gairdner gave to this 
 murmur the new name of auricular-systolic, expressing by this 
 happy combination both its mechanism and its rhythm. 
 There is every reason to believe that this most expressive and 
 distinctive epithet helped to fix in the minds of observers the 
 chief points connected with this murmur, and by so doing 
 hastened its recognition in this country. In France, on the 
 other hand, this recognition seems to have been delayed 
 partly by the division of the cardiac cycle into a premier 
 temps, including the systole of both auricles and ventricles, and 
 a second temjos, including the diastole of both these organs, 
 and partly by Fauvel's adoption of the perfectly incon- 
 sequential term presystolic, a term that had been already 
 employed by Gendrin in a more easily comprehensible sense. 
 
 In estimating the nature of any murmur supposed to be 
 of valvular origin, there are two facts in regard to which we 
 must be absolutely precise : the first of these is the position 
 of maximum intensity of the murmur on the cardiac area ; 
 and the second is its rhythm — that is its exact relation to 
 the several physiological acts which constitute a cardiac cycle. 
 These points being determined, the ascertaining of the lesion 
 upon which the murmur depends is a simple matter of 
 ratiocination in which it seems hardly possible to err. 
 
 The presystolic murmur — as we may now call it for 
 shortness sake, without any fear of misapprehension — has a 
 fixed and determinate position within which it is most dis- 
 tinctly heard, viz. that part of the chest wall already described 
 to you as the mitral area — that is the area of a circle of about 
 one inch in diameter described round the point where the 
 heart's apex impinges as a centre. This murmur is not much 
 propagated in any direction ; an educated ear may no doubt 
 note that modification of the first sound which always accom- 
 panies this murmur wherever the heart's sounds are to be 
 
DISEASES OF THE HEAET 113 
 
 heard, yet it is only over a very limited area that it is audible 
 as a true murmur, being as a rule only indistinctly to be 
 heard above the third rib, and its propagation is almost 
 equally limited in every other direction. To give you an idea 
 of the limitation of this propagation, I may mention that 
 there is a lad of eighteen now in Ward V. with a murmur of 
 this character. It is so loud and rough that on admission it 
 was easily recognised through three shirts (two of them flannel), 
 a waistcoat, coat, and topcoat. Yet when the lad is stripped 
 this rough murmur is not distinctly audible above the third 
 rib, nor below the middle of the sixth interspace ; nor does it 
 pass farther to the left in the nipple line than a line let fall 
 perpendicularly from the anterior border of the axillary space ; 
 while on passing to the right the murmur is already less 
 rough at the left edge of the sternum, and is quite lost half 
 an inch beyond its right edge.-^ I give you this as excellent 
 illustration of the remarkable limitation of propagation even 
 of an exceedingly loud and rough presystolic murmur ; but 
 this murmur is not always limited to so small an area, though 
 exceptions are much rarer in regard to its propagation than 
 its character. In accordance, therefore, with the laws of the 
 propagation of murmurs already laid down, this position of 
 audition, as we may term it, stamps this murmur as of mitral 
 origin, and, coupled with other concomitant phenomena, even 
 hints its probable rhythm to an intelligent mind. 
 
 The rhythm of a murmur, as you are already aware, is its 
 relation to the several physiological acts which constitute a 
 complete cardiac cycle — that is those several acts which 
 occupy the time between two consecutive apex beats. During 
 this period we have the ventricular systole, synchronous with 
 the apex beat, the first sound, and the first silence ; the 
 ventricular diastole, synchronous with the second sound 
 and the second silence ; and lastly the systole of the auricles, 
 
 1 W. C, Ward V. — The murmur in this case passed farther to the right 
 than usual. He subsequently died, and his case will be found detailed farther 
 on, where the reason for this will appear ; vide Case IX., p. 122. 
 
114 CLINICAL LECTURES ON 
 
 which coincides with the latter part of the ventricular diastole, 
 and immediately precedes the ventricular systole, into which, 
 indeed, it ruus.-^ In timing any murmur, therefore, we first 
 of all ascertain whether it takes the place of either the first 
 or second sound, or, if it does not, then we must determine 
 accurately the exact relation of the murmur to these sounds, 
 which of them it precedes, or which of them it follows, and 
 at what interval. Now in this matter there is this fallacy, 
 that the first and second sounds are not always audible 
 together at either apex or base, either in health or disease, 
 and when this is the case in disease the murmur present is 
 apt to be taken as replacing the absent sound. This is 
 specially apt to happen in connection with the murmur of 
 which I am now speaking, for in the mitral region this 
 murmur is not infrequently followed by a single loud 
 accentuated sound, and most students at once assume the 
 case to be one of mitral regurgitation (systolic murmur) with 
 an accentuated second sound. To correct this error it is only 
 necessary to time both the murmur and the sound by the 
 pulse in the carotid artery, when the murmur will be found 
 immediately to precede and to run up to the carotid pulse, 
 with which the sound is distinctly synchronous. But we 
 know that the carotid pulse is synchronous with the first 
 sound of the heart, and precedes the second one. The sound 
 we hear is therefore the first sound of the heart, and as the 
 murmur immediately precedes it and runs up to it, it must 
 occupy the time of the auricular systole. Inasmuch as the 
 ventricular systole is the first portion of the heart's action 
 that gives rise to audible or tangible phenomena, it is usually 
 called par excellence the systole, and this murmur occurring 
 just before it has been termed presystolic. But this is a 
 misnomer ; this murmur is truly systolic both in rhythm and 
 character, but the systole on which it depends is that of the 
 auricles, and not that of the ventricles ; it is an auricular- 
 systolic murmur. In timing this murmur we must be 
 
 ' Vide diagram, Fig. 4, p. 39. 
 
DISEASES OF THE HEAET 115 
 
 careful to employ the carotid and not the radial pulse ; the 
 former is always synchronous with the ventricular systole 
 and the apex beat, but the latter even in health is always 
 delayed to an appreciable extent — one-sixth of a second ; 
 while in disease, especially such as interferes with arterial 
 contractility, this delay is notably increased, and sometimes 
 amounts to an entire cardiac pulsation. A reference to the 
 radial pulse is thus always embarrassing and may greatly 
 mislead; but a reference to the carotid pulse is a perfectly 
 safe guide, only liable to the misconception inseparable from 
 the difficulty of comparing an audible with a tangible 
 phenomenon. But this difficulty is trifling, and such as it is 
 we can readily overcome it by practising on hearts which are 
 either naturally slow or have had their action artificially 
 retarded. 
 
 Various combinations of vowels and consonants have been 
 employed to represent phonetically the healthy sounds of the 
 heart and its morbid murmurs. No murmur lends itself more 
 readily to this phonetic treatment than the presystolic, the 
 symbols rrrb or mot, when vocalised, conveying to the ear 
 sounds almost identical with those produced within the heart.^ 
 Indeed the- very accent with which these symbols are pro- 
 nounced may be made to represent the changes which are 
 noted in different murmurs, or in the same murmur at 
 different times. The last consonant in each symbol is coin- 
 cident with the apex beat. 
 
 Furthermore, sounds are only audible vibrations, and in 
 many cases these are to be felt as well as heard. The audible 
 
 1 Sounds indeed which cannot be mistaken for anything but what they 
 actually represent. Thus Duroziez scofi's at " this famous presystolic murmur 
 of which every one speaks ; which no one understands ; which Hope never 
 heard, and Bouillaud neglects and even denies." Yet Duroziez vocalises the 
 murmur of mitral stenosis, heard at the base as vout-ta-ta, and heard over the 
 apex as ffout-ta-ta-rou, vocables which no one at all acquainted with the 
 matter could pronounce without recognising that he had before him a case 
 presenting a presystolic murmur, a reduplicated second, and a mitral diastolic 
 murmur.— Vide Archives Ginirales cle Medicine, 5ieme serie, tome xx., p. 
 390, 1862. 
 
116 CLINICAL LECTUEE3 ON 
 
 rattle of carriages along a street is also perceived as a tremor 
 within the houses that line it ; and if we strike a tumbler 
 sharply so as to produce a musical note, the vibrations causing 
 this note are readily felt by a finger placed on the edge of the 
 glass, and the sound ceases at once when we stop these 
 vibrations. Nay, more, the sounds produced by friction of a 
 moistened finger along the edge of glasses partially filled with 
 water are not only to be felt as vibrations, but may be seen 
 as crispations on the surface of the water. In like manner 
 the vibrations which give rise to cardiac murmurs may be 
 frequently felt by the finger at their point of origin. As the 
 rougher the murmur is the more readily the vibrations causing 
 it are to be perceived, and as few murmurs, if any, are so 
 rough as the presystolic, so it more frequently than any other 
 gives rise to a distinct sensation of vibration. Tliis feeling of 
 thrill is termed the fr^missement cataire, or purring tremor ; 
 it is rarely absent in cases of mitral stenosis, being sometimes 
 to be felt in the mitral area when the murmur, of which it is 
 the tactile representative, is either entirely absent or only 
 imperfectly developed. It is interesting to note in such 
 cases that this thrill runs up to and terminates in the apex 
 beat, just as the murmur which it represents is heard to end 
 in the accentuated first sound. 
 
 A murmur, then, presenting the characteristics just 
 described, which is rough and capable of being vocalised by 
 the sounds symbolised by the letters rrrh or voot ; which is 
 separated from the second sound by a longer or shorter but 
 always readily appreciable interval ; which distinctly precedes 
 the apex beat and the carotid pulse, usually running quite up 
 to them, but occasionally separated from them by an extremely 
 short but appreciable interval ; whose rhythm may be thus 
 graphically rendered (Fig. 11) ^ and which is (almost) always 
 accompanied by a purring tremor over the mitral area ; is 
 
 ^ Figure 11 represents graphically various phases of the presystolic murmur : 
 
 (1) represents an ordinary presystolic murmur running up to the first sound ; 
 
 (2) represents a murmur prolonged during the whole of the ventricular diastole 
 to the commencement of the ventricular systole ; (3) represents a diastolic 
 
DISEASES OF THE HEAET 
 
 117 
 
 invariably an evidence of deformity of the mitral valve 
 accompanied by stenosis of the mitral opening, and is that to 
 which alone is applicable the term presystolic, or more 
 accurately auricular-systolic. If this murmur is once heard 
 and recognised, then we are certain that after death we shall 
 find more or less constriction of the auriculo- ventricular 
 opening, and more or less deformity of the mitral valve. The 
 murmur may, and often does disappear, but the lesion is 
 permanent. 
 
 The way in which this murmur sometimes disappears 
 temporarily or permanently is somewhat remarkable, and has 
 given rise to many unlucky contretemps not altogether 
 creditable to practitioners of medicine. Tor instance : — 
 
 Case VII. I well remember a gentleman with a dis- 
 appearing presystolic murmur who possessed quite a bundle 
 of certificates from medical men ; one half of these testified 
 that he laboured under organic disease of the heart, while the 
 other half certified equally strongly that he was altogether 
 free from cardiac disease. After a time this patient died, 
 and his mitral valve was found to be deformed, the mitral 
 opening constricted, and the appendix of the left auricle 
 filled with an organised clot. 
 
 In every case of cardiac disease there are always various 
 subsidiary phenomena which prove the existence of a cardiac 
 lesion apart altogether from the presence of a murmur; of 
 these I shall speak more at large presently. 
 
 murmur separated from a succeeding presystolic murmur by a short but definite 
 pause, while the auricular-systolic murmur is seen to pass directly into a 
 ventricular-systolic murmur. 
 
118 CLINICAL LECTUKES ON 
 
 For quite ten years after the publication of Gairdner's 
 masterly exposition this presystolic murmur continued to be 
 regarded, especially south of the Tweed, as both rare and 
 difficult of detection. And it was not till after the publica- 
 tion (in 1871) of Hilton Fagge's comprehensive treatise on 
 the direct mitral murmur, both from a historical and clinical 
 point of view,^ that the auricular- systolic murmur may be 
 said to have obtained general acceptance as a special murmur 
 perfectly distinctive of stenosis of the mitral opening. But 
 though the cause of the murmur has thus been universally 
 conceded, its rhythm as ordinarily understood has not been 
 accepted by all. Thus the late Dr. Andrew Barclay of 
 London,^ Dr. Leaming of New York,^ Dr. Frank Donaldson of 
 Maryland University, U.S.A.,'' Dr. W. H. Dickinson,'' and 
 others have argued that its rhythm is not auricular-systolic 
 but ventricular-systolic, that is that the murmur does not 
 coincide with the systole of the auricle but with the first part 
 of the systole of the ventricle. It does indeed seem remark- 
 able and even mysterious that the comparatively feeble and 
 brief contraction of the auricle should be associated with a 
 murmur so loud and rough, nevertheless the facts in favour of 
 the ordinarily accepted rhythm of this murmur seem quite 
 incontrovertible. These facts may be comprehensively stated 
 as follows : — 
 
 1. There is never any doubt as to the position of maximum 
 intensity of this murmur : this is unmistakably in the mitral 
 area. Neither thrill nor murmur are distinctly perceptible as 
 such above the third rib (vide antea, p. 113). Notwithstand- 
 ing its distinct and rough character this murmur has an 
 extremely well - defined area of diffusion, and is never 
 propagated over the cardiac area, into the aortic area, or into 
 
 ' Guy's Hospital Reports, vol. xvi. p. 326, 1871. 
 
 * Lancet (March 1872), pp. 283, 353, and 384. 
 •' New York Journal of Medicine, June 1868. 
 
 * Paper from Author, read before the Medical and Chirurgical Faculty 
 of Maryland, April 1874. 
 
 5 Lancet (1887), vol. ii. pp. 650, 695, and 985 ; also Lancet (1889), vol. ii. 
 pp. 779, 1032, and 1083. 
 
DISEASES OF THE HEART 119 
 
 the auricular area, as the soft blowing murmur of mitral 
 regurgitation is, 
 
 2. In many cases of mitral stenosis the appendix of the 
 left auricle is greatly dilated and lies close to the anterior 
 chest wall in the second interspace. When this is the case 
 the contraction of the auricle may be felt to coincide with the 
 auricular-systolic murmur, just as in the same or other cases 
 the contraction of the ventricle may be felt to coincide with 
 the apex beat and the first sound, or with the systolic murmur 
 if present.^ 
 
 3. In commencing dilatation of the heart it not in- 
 frequently happens that a true ventricular-systolic murmur 
 is found to occupy the first portion of the ventricular systole, 
 and is followed by a first sound : precisely as some imagine 
 the conditions to be in mitral stenosis. But a true ventricular- 
 systolic murmur of this character is always soft and blowing, 
 and is only heard as a murmur in the second interspace just 
 outside the pulmonary area, where, as Walshe says, "the 
 appendix is visible anteriorly, as the organs lie in situ." " In 
 mitral stenosis the appendix of the left auricle is almost 
 invariably dilated and in close proximity to the anterior 
 chest wall,^ yet notwithstanding the presence of conditions so 
 favourable to the propagation of a systolic murmur into the 
 auricular area the rough presystolic murmur is never to be 
 heard there. 
 
 4. The direct mitral murmur, like the direct (systolic) 
 aortic murmur, is always rough, partly, no doubt, because 
 both are caused by the direct (onward) current of the blood, 
 while in both cases a regurgitant murmur is soft and blowing. 
 Between the two murmurs (systolic and diastolic) there is 
 interposed a scarcely appreciable soundless pause, or, what is 
 more common in the mitral area, a well-marked sound. Over 
 
 •^ As pointed out by Sansom, vide Lancet (15th Oct. 1887), p. 782 ; and by 
 myself, vide p. 155 ; 2nd edition, p. 154 ; 1st edition, p. 144. 
 
 - Diseases of the Heart, etc., 3rd edition (London, 1862), p. 4. 
 
 ^ Journal of Pathology and Bacteriology (Edinburgh and London, 1896) 
 p. 75 ; and The Senile Heart (A. and C. Black, London, 1894), p. 55. 
 
120 CLINICAL LECTUKES ON 
 
 the apex of a heart with a stenosed mitral opening and this 
 combination of murmurs the sounds may be phonetically 
 represented by the symbol rrrbfff. In this symbol the rrr 
 represents the presystolic portion of the murmur. The h 
 represents the accentuated first sound, but it may also be 
 taken as indicating, though not as phonetically representing, 
 that abrupt change in the character of the murmur, that 
 interval between the two murmurs sometimes present, and 
 which, as Gairdner has said, is almost " too brief to appear 
 soundless to the listening ear," ^ while the fff or p7w), as it 
 may also be represented, marks the soft ventricular-systolic 
 (regurgitant) murmur. 
 
 These facts show, that whatever mystery may attend the 
 production of so rough a murmur by the comparatively 
 feeble and brief contraction of the auricle, all the available 
 evidence is strongly in favour of its auricular-systolic rhythm.^ 
 
 Now is perhaps the most appropriate time to refer to the 
 opinion of the late Dr. Austin Flint, who, while agreeing as 
 to the auricular-systolic rhythm of the presystolic murmur, 
 yet conceived that in some three instances he had heard this 
 murmur where, after death, the mitral valve was found to be 
 perfectly healthy, the only discoverable lesion being free regur- 
 gitation throuQ-h the aortic valve. Mint's idea was that the free 
 regurgitation from the aorta floated the segments of the mitral 
 valve into such close apposition that the auricular contraction, 
 forcing the blood between these segments, produced a 
 presystolic murmur of what he called " a blubbering 
 character." Since Flint's day some dozen of similar cases 
 have been placed upon record, none of them more convincing 
 
 1 Lancet (Oct. 1887), p. 782. 
 
 - Other evidence of a similar character will be found detailed b}' myself 
 at p. 714 of the Lancet for 25th May 1872 ; and by Gairdner at p. 781 of the 
 Lancet for 15th Oct. 1887 ; also at p. 884 of the Lancet for 29th Oct. 1887, 
 etc. The evidence of the cardiograph is also distinctly in favour of the 
 auricular-systolic rhythm of this murmur ; for this I may refer to Dr. 
 Mahomed's paper in the Medical Times ami Gazette, April 1872 ; and to Dr. 
 Galabin in Guys Hospital Rejwrfs, 1875 ; also to a paper by Dr. W. Fenwick 
 and Mr. Walker Overend in the Lancet for 26th Oct. 1889, p. 843. 
 
DISEASES OF THE HEAET 121 
 
 tlian his own.^ In regard to this matter I can only say that 
 I have never heard a presystolic murmur without finding 
 after death an actual — not merely virtual — stenosis of the 
 mitral opening ; and also that free aortic regurgitation is so 
 common an occurrence that if it could ever give rise to an 
 auricular-systolic murmur these murmurs would be of even 
 greater frequency than they now are.^ 
 
 The condition of valve generally associated with the pre- 
 systolic murmur is that usually termed a diaphragmatic 
 valve, in which the two segments of the mitral valve are 
 united and stretched like a diaphragm across the auriculo- 
 ventricular opening. This diaphragm, as we may call it, is 
 thickened especially at the edges of the central opening ; 
 sometimes it is almost cartilaginous ; and its surface is 
 usually smooth, though a few small and frequently calcareous 
 vegetations are occasionally attached to the edge of the 
 opening. The central opening varies in size from a button- 
 hole too small to admit even the point of the little finger, up 
 to an aperture not much less than normal. An unusually 
 loud, rough, and persistent murmur by no means indicates 
 that the opening is more constricted, or the valve rougher or 
 denser than usual. Eoughness of the murmur is quite 
 independent of roughness of the valve, or of any remarkable 
 hypertrophy of the auricle, as is very well shown in the 
 following case : — 
 
 ^ A full account of this view and the cases on which it is based will be 
 found in the following documents : — Flint, Lectures on Diseases of the Heart, 
 (Philadelphia, 1870), p. 207 ; also International Journal of Medical Science 
 (1886), p. 35. Gairdner, Glasgow Medical Journal, vol. xxviii. p. 226 ; and 
 International Jourtud of Medical Science (1889), p. 137. Bramwell, Interna- 
 tional Journal of Medical Science (1888), p. 236. Guiteras, Medical News, 
 (Nov. 1885), p. 533 ; and Transactions of the Association of American Physicians, 
 vol. ii. p. 39. Osier, Transactions of the Associcction of American Physicians, 
 vol. iii. p. 138. Maguire, Medical Chronicle (June 1890), p. 180. 
 
 ^ In the normal state of the heart "the segments of the mitral valve at 
 the end of the ventricular diastole are so close as to be nearly in contact." 
 — Pettigrew, Transactions of the Royal Society of Edinburgh, vol. xxiii. part iii. 
 p. 796 ; vide also ISToel Paton " On the Action of the Valves of the Mammalian 
 Heart," Transactions of the Royal Society of Edinburgh, vol. xxxvii. part 
 i. p. 187. 
 
122 CLINICAL LECTURES ON 
 
 Case VIII. Margaret Eoss was an inmate of Ward XIII. 
 for a whole year, suffering from general dropsy, depending on 
 kidney disease (large wliite), for which she was repeatedly 
 tapped, etc. What chiefly concerns us now is that she had 
 over her heart's apex a persistent and well-marked presystolic 
 murmur accompanied by thrill. At the post-mortem 
 examination her kidneys were found diseased as expected ; 
 her heart was enlarged, weighing 15 oz., with milk spots 
 on its anterior surface ; the left ventricle was in a state of 
 concentric hypertrophy, and its walls considerably thickened 
 (this being ascribed to the kidney disease) ; the segments of 
 the mitral valve were united and thickened throughout, but 
 chiefly at their margins ; the surface of the valve was per- 
 fectly smooth, and there were one or two minute vegetations on 
 the edge of the central opening, which was so contracted as 
 only to admit the point of the middle finger; the cordm 
 tendineco were contracted and matted together ; the aortic 
 cusps were competent and natural ; the right side of the 
 heart was apparently natural. 
 
 This was a well-marked case in which, as we see, the 
 diagnosis during life was fully confirmed by the appearances 
 found after death. 
 
 Case IX. William Craig had a presystolic murmur so 
 loud and rough that I selected it as a standard of the area 
 over which such a murmur could be heard. In mapping out 
 this area I found that it extended unusually far to the right, 
 and the thought occurred that possibly we might in this case 
 have a stenosis of the tricuspid as well as of the mitral valve. 
 But the idea was dismissed as in the highest degree im- 
 probable, and the wide area over which this murmur was 
 heard was ascribed to its unusual loudness and roughness. 
 As it happened, the result showed that in this I was mis- 
 taken, though there were no other symptoms or signs present 
 but the wide area over which the murmur was heard which 
 could countenance the former idea. The patient was ansemic, 
 and there were consequently no jugular throbbings present. 
 
DISEASES OF THE HEART 123 
 
 and the increased transverse dulness of the heart could not, 
 of course, be accepted as a definite proof of tricuspid stenosis. 
 The patient died of latent pneumonia following, and appar- 
 ently induced by scattered patches of pulmonary apoplexy 
 (embolic pneumonia), a condition which had been recognised 
 during life. On opening the thorax, the enormous size of the 
 right auricle at once attracted attention. It measured inside 
 eight inches and a half in circumference by two and three- 
 quarters vertically, and contained a large clot, half an ounce 
 of which was decolorised. The walls of this auricle were 
 somewhat thickened, but irregularly, varying from one line to 
 a quarter of an inch. The musculi pectinati were singularly 
 well developed. On looking down on the tricuspid valve 
 from the auricular aspect its segments were seen to be matted 
 together, and the opening so constricted as only to admit the 
 point of the middle finger ; the endocardium in its neigh- 
 bourhood was slightly thickened ; a few small vegetations 
 were attached to the free margin of the valve. The right 
 ventricle was slightly dilated ; its walls not hypertrophied ; 
 the cordce tencUnece contracted ; and no distinctive traces of 
 the three segments of the valve were to be found. The left 
 auricle was so dilated as to admit a ball two inches in 
 diameter ; its walls were not hypertrophied ; its endocardium 
 was thickened. The mitral opening from the auricular aspect 
 scarcely admitted the tip of the little finger ; the upper 
 surface of the valve was covered by many calcareous spiculse, 
 and a few small vegetations beset its free margin. The left 
 ventricle was apparently normal both as to walls and cavity. 
 The aortic and pulmonary valves were competent and healthy. 
 The rest of the dissection is omitted as unimportant. The 
 boy's illness, according to his own statement, dated only a 
 few months back. There was no history of rheumatism in 
 either of these individuals. 
 
 Cases illustrative of this peculiar murmur and its 
 accompanying lesion are of such common occurrence that it 
 is quite unnecessary to multiply them here. 
 
124 CLINICAL LECTURES OX 
 
 With a mitral valve deformed in this peculiar manner 
 closure of the opening seems necessarily impossible, and 
 regurgitation to a greater or less extent must be present in 
 every case ; yet a systolic murmur is frequently wanting, as 
 in the two cases just narrated, while perhaps quite as 
 frequently, as I shall presently point out, the systolic murmur 
 is the only one distinctly audible, and in yet a third series of 
 cases both murmurs are to be heard separated by an apex beat, 
 a first sound, or an almost inappreciable soundless interval. 
 
 The pulse in this form of cardiac disease is naturally 
 weakened in exact proportion to the amount of stenosis 
 present, and is more or less irregular,^ though not markedly 
 so if no pyrexia co-exist. The following diagram may be 
 
 Fig. 12. 
 
 accepted as a graphic representation of an average pulse of 
 this character (Fig. 12), 
 
 The rough presystolic murmur just described, though 
 certainly most common, and most characteristic of diaphrag- 
 matic mitral stenosis, is far from being the only kind of 
 murmur heard in such cases. Of the variously complicated 
 
 ^ ^larey, in his Physiologic Midicale de la Circulation du Sang (Paris, 1863), 
 p. 526, has expressed his opinion that a mitral stenosis, when sufficiently 
 marked to give rise to a diastolic (presystolic) murmur, suppresses the 
 irregularity of the pulse. A glance at the tracings by which he seeks to 
 confirm this view shows at once upon what he founds it. When the stenosis 
 is not extreme, and the compensation is good, the murmur is usually loud and 
 rough, and the pulse tolerably full and regular. Marey has evidently taken 
 his illustrations and based his opinions on cases of this kind. But we see such 
 cases only incidentally. Like all other cardiac cases, those with mitral 
 stenosis only come to us as patients when compensation fails ; an early result 
 if not also a cause of this is defective nutrition of the myocardium, and as a 
 consequence irregularity of the heart's action and of the pulse, more marked 
 in this form of cardiac affection than in any other, only occasionally emulated 
 in atherosis of the coronary arteries, or in cases of extreme dilatation of the 
 ventricles, and often amounting to a veritable delirium cordis. Physiology is 
 quite at one with clinical experience in this matter. 
 
DISEASES OF THE HEAET 125 
 
 murmurs to be heard in connection with a valve thus deformed 
 the two following cases afford striking examples : — 
 
 Case X. Mary Macmurray, aged thirty-one, admitted into 
 Ward XIII. on 26th May 1870, complaining of great pain across 
 the chest, loss of appetite, and general debility. She stated that 
 she had never been very robust, and had suffered from acute 
 and subacute rheumatism on three separate occasions ; the 
 first of these attacks occurred nine years ago, the second 
 seven, and the third three years ago. She also suffers 
 almost constantly from chronic rheumatic pains in her limbs 
 and chest. She states that her head was affected (delirious) 
 towards the close of her first attack. About ten months ago 
 her feebleness increased, she lost her appetite, and suffered 
 from severe pains in the precordial region. Since that time 
 she has got gradually worse. Her urine was found to be 
 acid and normal in quantity; spec. grav. 1016; it con- 
 tained one-fourth of albumin, and also epithelial, granular, 
 and hyaline casts. This kidney affection was her most 
 serious ailment, and was that indeed of which she ultimately 
 died; but in relation to our present subject her thoracic 
 signs and symptoms were by far the most interesting, and 
 were as follows : — Her pulse was 104 and feeble, both radial 
 pulses alike, and both pupils normal. The heart's apex beat 
 behind the fifth rib, as ascertained by percussion, and two 
 inches and a quarter to the left of the sternum. In the 
 parasternal line one inch from the left edge of the sternum the 
 percussion note was quite clear from the clavicle down to the 
 upper edge of the second rib. From the upper edge of the 
 second rib to that of the third rib the percussion sound was 
 comparatively dull, and it was perfectly dull from the upper 
 edge of the third rib to the lower edge of the fifth, where the 
 tympanitic sound of the stomach became audible. Along 
 the upper edge of the fourth rib complete dulness extended 
 from half an inch to the right of the sternum to a distance 
 of two and a half inches from its left edge, while for half an 
 inch beyond this there was comparative dulness. Along the 
 
126 CLINICAL LECTUEES OX 
 
 lower edge of the second rib dulness extended for two inches 
 and three-quarters to the left of the sternum. In the dull 
 part between the second and third ribs on the left side a 
 pulsation was distinctly to be felt, but less forcible than that 
 of the cardiac apex. On listening over the apex beat a 
 distinct presystolic murmur was usually but not always to be 
 heard. The systolic sound was roughened and occasionally 
 replaced by a soft blowing murmur; the second sound was 
 followed by a loud, musical, diastolic murmur. Between the 
 second and third ribs on the right side the first sound was 
 heard muffled, and there was considerable accentuation of the 
 second sound, followed by a diastolic murmur. Between the 
 second and third ribs on the left side, close to the sternum, 
 the second sound was more markedly accentuated, and the 
 diastolic murmur more distinct. A little farther to the left 
 the same sounds were heard, and a distinct sense of pulsation 
 was conveyed to the ear by the stethoscope. The accentua- 
 tion of the second sound and the diastolic murmur were, 
 however, most distinct immediately behind the sternal end 
 of the second rib at the left side. The accentuation was 
 distinctly propagated into the left subclavian artery, but not 
 the murmur. Into the left carotid both sounds were pro- 
 pagated, but not distinctly. Into the right carotid and 
 subclavian both sounds were distinctly propagated. On 
 auscultating up the right edge of the sternum, the second 
 sound and the diastolic murmur were heard to become 
 gradually louder as the" upper edge of the sternum was 
 approached, where it is joined by the first rib ; but nowhere 
 on the right did they attain the same loudness and distinct- 
 ness as on the left of the sternum. A slight humming 
 noise was occasionally audible in the jugular veins. 
 For the last month of her life the patient's urine became 
 more scanty, ursemic sickness and vomiting were frequent, 
 and she gradually sank and died on 21st December, the 
 immediate cause of death being an absolutely latent pleuro- 
 pneumonia, which was entirely devoid of any subjective 
 
DISEASES OF THE HEART 127 
 
 symptoms whatever. Her cardiac signs remained unchanged 
 to the end. At the autopsy, on 23rd December, the lower 
 lobes of both the right and the left lungs were found hepatised, 
 and were covered externally by a thin layer of perfectly 
 recent lymph, presenting a honeycomb appearance. The 
 left lung was slightly retracted, uncovering the heart to a 
 greater degree than usual. The heart itself was purse-shaped 
 and somewhat enlarged, its substance healthy. The aortic 
 valves were competent, but the cusps were thickened and 
 their whole under (ventricular) surface was covered by 
 numerous vegetations. The mitral valve was thickened and 
 its opening contracted, scarcely admitting two fingers, with 
 some threads of recent lymph attached to its edge ; the upper 
 surface of the aortic segment of this valve was thickly 
 studded with rough stumpy vegetations of varying size. The 
 liver was healthy. The spleen weighed 15 oz., and on its 
 posterior border had seven hsemorrhagic infarctions of a 
 triangular shape, varying from the size of a pea to that of a 
 small bean (of embolic origin) ; it was otherwise healthy. The 
 kidneys were slightly enlarged ; the right weighed 5, and the 
 left 6 oz. The cortical substance was lessened ; the capsule 
 natural, and when peeled off exposed a smooth organ. The 
 intestines were congested, and the rectum and lower part of the 
 sigmoid flexure of the colon were thickened. 
 
 The next case is equally instructive, but wants the crucial 
 decision of o, post-Tnorteon examination. I shall confine myself 
 solely to the cardiac phenomena. 
 
 Case XL J. H., aged eighteen, was sent up to Ward XIII. 
 from the fever house, convalescent from typhus, on 6th June 
 1871. She stated that two years ago she had a severe attack 
 of rheumatism, which affected all her joints, but not her 
 chest, and lasted for four months. After her recovery she 
 began to suffer from pains in her cardiac region, palpitation 
 of her heart, and shortness of breath on going upstairs. Three 
 months previous to the attack of typhus, from which she has 
 just recovered, she first observed some slight swelling of her 
 
128 CLINICAL LECTURES ON 
 
 feet. Since her fever the pains in her chest have been more 
 severe, but she has no dyspnoea while lying still in bed. Her 
 pulse is 84, rather small, steady and regular ; there is a per- 
 ceptible thrill over the apex of the heart. The vertical dulness 
 of the heart is normal ; its transverse dulness in the line of 
 the fourth rib extends from the right edge of the sternum 
 towards the left for a distance of three inches and a half 
 The apex beat is between the fifth and sixth ribs, three inches 
 and a half from the left edge of the sternum. On auscultat- 
 ino- over the apex a somewhat prolonged murmur is heard, 
 the first portion of which is rough and precedes the apex beat ; 
 the second portion of the murmur follows the apex beat and 
 is soft and blowing. Between the second and third ribs on the 
 ri"ht side there is a systolic murmur prolonged upwards and 
 followed by a normal but feeble second sound. Between the 
 second and third ribs on the left side, close to the sternum, 
 there is a systolic murmur followed by a markedly accentuated 
 second sound, which is immediately succeeded by a soft, 
 blowing, diastolic murmur. This diastolic murmur ceases to 
 be audible at a distance two inches and one-third from the left 
 edcre of the sternum along the second interspace. On auscul- 
 tating downwards from the third rib at one inch from the 
 sternum this diastolic murmur continues to be heard till about 
 the middle of the fourth rib ; after this it ceases, the presystolic 
 and systolic murmurs alone being audible beneath this point. 
 Over the sternum tliis diastolic murmur is only to be heard 
 between the second interspace and the fourth rib. The 
 systolic murmur is slightly propagated into the carotid 
 arteries, as is also the aortic second sound which remains 
 pure. During the progress of the case the ventricular-systolic 
 murmur over the apex was frequently absent, and the 
 diastolic murmur at the base became more limited in its area. 
 This patient was discharged improved on 12th August.^ 
 
 ^ J. H. Gradually developed aortic incompetence, with all its usual results. 
 She married in 1879, had her first child early in 1880, and died under my 
 care from asystole due to advanced aortic disease in March 1880. I was un- 
 able to procure an examination of her body. 
 
DISEASES OF THE HEART 129 
 
 The nmrmurs in these two interesting cases differ consider- 
 ably in some respects, yet both belong to the same category, 
 examples of which, though not of everyday occurrence, can 
 yet scarcely be called rare. The first remark I shall make is 
 that the systolic basic murmur on the right or aortic side of 
 the sternum, in the second case, probably depended on a similar 
 roughened condition ofthe under side ofthe aortic cusps which 
 we had in Macmurray. In Macmurray's case the first sound 
 was only muffled ; there was no murmur, its absence being 
 probably due to a feeble blood-current. On the other hand, if 
 we look upon this systolic murmur as propagated from the 
 left side, it belongs to quite a different category, but in that 
 case it would not likely have been so distinctly propagated 
 into both carotids. The first point having a distinct bearing on 
 the subject in hand — the diagnosis of mitral stenosis — is the 
 occurrence in both of these cases of a diastolic murmur, loudest 
 at the left edge of the sternum at the base of the heart. In 
 H.'s case there never was any doubt as to the diastolic char- 
 acter of the soft blowing murmur ; in Macmurray's case her 
 ordinary pulse of 104 had to be brought down to 84, by the re- 
 cumbent posture and the use ofdigitalis, before I could positively 
 satisfy myself that her musical murmur was truly diastolic 
 in rhythm. The region ofthe pulmonary artery, in the neigh- 
 bourhood of which these murmurs are frequently heard,^ has 
 been not inaptly termed the region of romance, because of the 
 variety of murmurs audible there which have given rise to 
 much speculation. Laennec, it is well known, taught that 
 the second sound was due to contraction of the auricles. 
 Hope, though well aware that the second sound was caused 
 
 ^ The position of maximum intensity of this mitral diastolic murmur varies 
 in each case ; it is usually most distinct at the sternal end of the fourth rib 
 on the left side, though sometimes it is heard in the mitral area, and frequently, 
 as stated in the text, in the pulmonary area. The soft, slightly musical, 
 diastolic murmur audible in such cases in the mitral, or more faintly in the 
 pulmonary area, is undoubtedly mitral in character and may disappear as the 
 disease progresses. A soft, blowing, diastolic murmur, heard at or below the 
 level of the aortic valve, is just as certainly due to commencing regurgitation 
 through this valve, and gradually increases as the disease progresses. 
 
 9 
 
130 CLINICAL LECTURES ON 
 
 by the closure of the semi-lunar valves, yet taught that 
 " when the mitral valve is contracted, a murmur accompanies, 
 and sometimes entirely supersedes, the second sound," the 
 influence of Laeunec's teaching marring no doubt the excel- 
 lence of his own observation, for a diastolic murmur of 
 mitral origin never obscures the second sound, though it 
 often, as in the cases just described, immediately follows it. 
 Sometimes, as happened in them, it is separated from the true 
 presystolic mumiur by an appreciable interval [vide Fig. 11, 
 p. 117, (3)]; at other times this murmur begins with the 
 diastole and runs right up to the apex beat, thus terminating 
 with the rough presystolic murmur [as represented in Fig. 
 11, (2)]. In both classes the first portion of the murmur is 
 distinctly soft and diastolic in character and rhythm, the 
 latter portion — whether separated from the first by a sound- 
 less interval or not — is always rough in character and auricu- 
 lar-systolic in rhythm : the direction of the blood-current is 
 the same during both periods, but during the latter period we 
 have the influence of muscular propulsion superadded and 
 revealed by the roughening of the murmur. In Macmurray's 
 case there is positive proof that the pulmonary valve was 
 competent and that its condition had nothing to do with the 
 production of the diastolic murmur. In J. H.'s case the 
 absence of any symptoms of disease of the right heart, the 
 rarity of affections of the pulmonary artery, and the compara- 
 tive frequency of diastolic murmurs in cases of mitral stenosis, 
 make it most probable that this murmur depends in this case 
 also upon the same cause. The appreciable interval which, 
 in both cases, existed between the diastolic and the presystolic 
 murmurs makes it impossible that prolonged auricular con- 
 traction, encroaching on the ventricular diastole, could have 
 been the cause of these diastolic murmurs. In the face of a 
 continuously contracting auricle, no theory of the production 
 of these murmurs could account for a soundless interval inter- 
 posed between a soft and a rough murmur, though the gradual 
 roughening of the murmur towards its close is easily explic- 
 
DISEASES OF THE HEAET 131 
 
 able. On the contrary, if we suppose two different causes, 
 following each other, and acting in the same direction in the 
 production of these murmurs, we have a sufficient explana- 
 tion of the difference in character of the first portion of the 
 murmur from the second. If we further suppose the first 
 cause to diminish to zero before the second begins to act, then 
 we have an efficient explanation of the pause occasionally 
 interposed between the soft and the rough murmurs, and we 
 can readily surmise an efficient reason for the occasional 
 absence of this pause. It must be evident that the more 
 nearly the mechanism of the heart approaches the normal, so 
 much the more closely will the various acts approach the 
 physiological norm. The presence or absence of an appreci- 
 able pause in the sequence of these acts may thus be regarded 
 as a measure of the abnormality existing, an indication 
 of the magnitude of the obstacle to the onward flow of the 
 blood — of the degree of stenosis present ; just as the presence 
 or absence of a diastolic murmur may also be accepted as a 
 probable indication of an unusually great intra-pulmonic 
 blood-pressure or the reverse, as this cannot but be a most 
 important element in its production, seeing that no murmur 
 can arise unless the blood passes through the constricted 
 opening avec une force suffisante} 
 
 If we take an india-rubber bag-syringe, and, after emptying 
 it of air, insert its nozzle into water, it will be found to fill 
 with a rapidity proportionate to the size of the opening in its 
 nozzle. If any particle of dirt gets into this nozzle the bag 
 either fills more slowly, or, if the opening be quite stopped, it 
 ceases to fill at all. So it is with the heart ; in the normal 
 condition of the auriculo- ventricular valves the diastole is 
 completed at once, the blood from the distended auricle 
 closely following the expansion of the ventricular walls, for of 
 course there is neither in the heart nor anywhere throughout 
 the circulation any vacuous cavity or air -filled space into 
 which the blood can be, strictly speaking, said to flow. 
 
 ^ Vide anted, p. 46. 
 
132 CLINICAL LECTURES ON 
 
 Throughout the diastole the blood continues to pass into the 
 heart, floating up the segments of the mitral valve into ap- 
 position, till the rhythmic wave of systole seizes upon the 
 auricles, forces them into contraction, and expels their contents 
 into the already full ventricles. When the auriculo- ven- 
 tricular opening is narrowed from any cause, the ventricles — 
 like the india-rubber bag — must fill more slowly. This delay 
 in the expansion and filling of the ventricle must increase 
 in proportion to the amount of stenosis present, until it may 
 be that the wave of systole seizes the auricle before the 
 ventricle has become filled, before its diastolic expansion is 
 completed. In these circumstances pulmonary congestion 
 must, of course, be very considerable, and the consequent rise 
 of blood-pressure within the pulmonary circuit favours that 
 reduplication of the second sound, already described,^ which 
 is so common an occurrence in mitral stenosis as to be almost 
 pathognomonic, and which is always a matter of some 
 importance in the diagnosis of obscure cases. The flow of 
 blood through the contracted mitral opening in such cases of 
 prolonged diastole may be altogether soundless, or it may be 
 accompanied by a murmur which is probably always faintly 
 musical, and which presents none of the harshness of the 
 auricular- systolic murmur in which it not infrequently 
 terminates, and this notwithstanding that both are equally 
 direct murmurs so far as the blood-current is concerned. It 
 seems probable that the distinctly musical character of this 
 murmur in Macmurray's case was due to the vibrations of 
 the stumpy vegetations covering the upper surface of the 
 aortic segment of her mitral valve. In other cases a distinctly 
 humming, though less musical, character may be given to the 
 murmur by the peculiar tension of the valve itself. In the 
 normal state of the heart a perfectly soundless interval 
 intervenes between the close of the second sound and the 
 commencement of the first, during this soundless period the 
 ventricle completes its diastole and the auricle its systole 
 1 Vide p. 32. 
 
DISEASES OF THE HEAKT 133 
 
 {vide Fig. 4, p. 39), so the more nearly tlie diseased heart 
 approaches the normal one — that is the less stenosis there is 
 — the more likely we are to have a soundless interval between 
 the diastolic and the auricular-systolic murmurs. The absence 
 of such an interval may, according to this view, be taken as 
 an indication of considerable stenosis ; and you will observe 
 that Macmurray's heart bears out this view. In her case the 
 pause was well marked, and the mitral opening actually 
 admitted two fingers, indicating but a moderate degree of 
 stenosis. You will observe that this explanation of the manner 
 in which a prolonged murmur, occupying the whole of the 
 ventricular diastole, is produced is not only consistent with all 
 we know of the physiological action of the heart, but is also in 
 perfect agreement with the character of the sounds heard. It 
 also does away with all the difficulties in the way of explaining 
 how or when an auricle is to be filled if a murmur occupying, 
 as it frequently does, the whole of the diastole is produced by 
 continuous auricular contraction ; -^ the pulmonary congestion 
 very efficiently accounting for the reduplicated second sound. 
 Murmurs such as these are graphically represented by the 
 second and third illustrations [(2) and (3)], Fig. 11, p. 117, 
 the first exhibiting these murmurs as continuous, and the 
 second when — as in the two cases just related — there is a 
 pause between them, a break in the shading to the right of 
 the centre indicating this pause. Phonetically they may be 
 vocalised by the symbols rrrrh, or, when softer and more 
 musical, by roo-oo-oo-ooh, and when a reduplicated second is 
 present by rooo-oo-oo-ooh-ta-ta. A systolic murmur in the 
 pulmonary region or in that neighbourhood is by no means 
 distinctive of mitral stenosis. I shall describe its mechanism 
 and significance on another occasion.^ 
 
 1 At p. 709 of the Ud. Med. Journal for February 1871 I have gone very 
 fully into the murmurs and other signs in Macmurray's case in connection 
 with the diagnosis of substernal aneurysm. The occasional absence of the 
 presystolic portion of the murmur in her case gives it a striking resemblance to 
 that of Harriet H. (Case LXVII. ) in Dr. Hilton Fagge's interesting paper on the 
 "Murmurs attendant on Mitral Contraction," at p. 326 of Guy's Hospital 
 Reports, vol. xvi. 1871. ^ Fi'c^e^osfea Lecture VI. 
 
134 CLINICAL LECTURES ON DISEASES OF THE HEART 
 
 Stenosis of the mitral opening is not always associated 
 with a diaphragmatic valve ; sometimes the valve is funnel- 
 shaped, the opening being at the apex of the cone which dips 
 into the ventricle. I have no dissection of any such case to 
 relate, consequently I know not whether this form of valve 
 gives rise to any modification of the murmurs. Now and 
 then we have a prolonged murmur with an exaggerated first 
 sound, which may be thus vocalised rooo-oo-oo-lu;p ; this is the 
 kind of murmur most apt to be mistaken for a ventricular- 
 systolic murmur and an accentuated second ; it is also a form 
 of murmur that for a time I was inclined to attribute to this 
 funnel-shaped valve. The perfect closure of the valve 
 indicated by the lup in the symbol just given, seemed to be 
 easily explained by the readiness with which the sides of a 
 long and somewhat loose valve, with only a small opening, 
 could be collapsed upon each other. One of the best marked 
 of such murmurs, long under observation, at last developed a 
 short, rough, presystolic murmur, which has since then varied 
 frequently in character. The complete change in this man's 
 murmur clearly indicates that as yet we have no reliable 
 pathognomonic sign for a funnel-shaped valve. 
 
 Such then are the murmurs specially distinctive of stenosis 
 of the mitral opening ; I shall presently take up the physical 
 signs diagnostic of this condition when there is either no 
 murmur present at all, or when the only murmur to be heard 
 is a systolic one. The mere addition of an apex systolic 
 murmur to those described as distinctive of mitral stenosis in 
 no ways affects the diagnosis ; the consideration of this com- 
 bination is therefore omitted. 
 
LECTUEE V 
 
 ON THE MURMURS AND OTHER PHYSICAL SIGNS DISTINCTIVE 
 OF MITRAL STENOSIS, CONTINUED, INCLUDING THOSE OF 
 INCURABLE MITRAL REGURGITATION 
 
 From the previous lecture we have learned that the essence 
 of the cardiac affection in mitral stenosis is obstruction 
 to the onward current of the blood at the auriculo-ven- 
 tricular opening from deformity of the mitral valve. We 
 deduce this from the fact that the only murmurs distinctive 
 of this lesion are those which, from the position in which 
 they are best heard, are known to originate at the mitral 
 opening, and from their rhythm are recognised as occurring 
 during the ventricular diastole, and the most characteristic 
 during that part of the ventricular diastole occupied by the 
 ' auricular systole. These murmurs, as described, are perfectly 
 distinctive of mitral stenosis, and once the existence of one or 
 other of them has been satisfactorily ascertained deformity of 
 the mitral valve may be predicted with the perfect certainty 
 that it will be found after death. These murmurs are un- 
 fortunately not always to be heard ; in most cases the diastolic 
 portion of the murmur is wanting, and in many even the 
 auricular-systolic portion is absent for long, if not for always, 
 as we know from a hospital history of two and even of three 
 years. Moreover each portion of the murmur may vanish tem- 
 porarily for a longer or shorter period, and this sometimes in 
 the most puzzling and unaccountable manner.-^ Further, as a 
 
 ''■ In the Practitioner for December 1873, p. 481, Dr. Gowers has directed 
 attention to the influence of posture in altering the character of these murmurs, 
 and has pointed out that in some the presystolic murmur is absent while the 
 
136 CLINICAL LECTURES ON 
 
 necessary result of the condition of the valve in the most usual 
 form of mitral stenosis (the diaphragmatic valve), we have a 
 permanent regurgitation into the auricle revealed by a variety 
 of murmurs. Sometimes a systolic murmur in the auricular 
 area is all that is to be heard ; -^ in the larger number of cases 
 in which the presystolic murmur is present, this regurgitation 
 is not accompanied by any ventricular-systolic murmur in the 
 mitral area. In a smaller number of cases both the auricular- 
 systolic and the ventricular-systolic murmurs are constantly 
 present in the mitral area. In a much smaller number these 
 murmurs present themselves in a most irregular fashion, both 
 murmurs being audible for one or two beats, and then the 
 auricular -systolic or the ventricular -systolic — chiefly the 
 latter — recurring by itself for an irregular number of beats, 
 while in a considerable number of cases, even when very 
 great stenosis exists, the ventricular-systolic murmur alone is 
 to be heard and is always present. Moreover, when the 
 patient gets enfeebled from any cause, a ventricular-systolic 
 murmur often replaces the pre-existing auricular -systolic 
 murmur, and this may again return should the patient regain 
 his strength. 
 
 These, then, are the various and often complicated varieties 
 of murmur to be heard in cases of mitral stenosis. It would 
 be easy to narrate cases illustrative of each variety, Ijut it is 
 quite unnecessary, and would only oppress your memory with 
 needless details. So far as murmurs are concerned, those 
 only are distinctive of mitral stenosis which have been 
 already described, and of these the most characteristic is the 
 presystolic ; whenever that is recognised as persistent, or can 
 even be picked out as occasionally recurring amid a complica- 
 tion of other murmurs, the case is quite clear and needs no 
 further proof. "When, however, no presystolic murmur, or 
 possibly no murmur at all is to be heard, then we are forced 
 
 patient is erect, and is only to be heard when he is recumbent. This only- 
 holds good for a minority of such cases ; in the greater number the presystolic 
 murmur is most distinct, and often only to be heard in the erect posture, and 
 after exercise. ^ Vide Lecture VI. 
 
DISEASES OF THE HEAET 137 
 
 to unravel the case by a careful investigation of the various 
 subsidiary phenomena evolved during cardiac action, as well 
 as of the relative condition of the different cardiac cavities. 
 In this way we shall frequently be able to detect a stenosis 
 of the mitral opening when the only murmur audible is one 
 of re^urffitation, or even when no murmur at all is to be 
 heard. 
 
 Amongst the most remarkable of these subsidiary pheno- 
 mena must be reckoned irregularity of rhythm, which is 
 almost invariably present in a greater or less degree/ and is 
 sometimes so marked as to be a diagnostic phenomenon of 
 considerable importance. This great irregularity appears to 
 be due to defective nutrition of the myocardium and its 
 ganglia. It is not in these cases due to dilatation of the left 
 ventricle, because in mitral stenosis that is comparatively 
 rare and is never excessive. This irregularity is often just 
 as little marked in cases of great dilatation of the right 
 ventricle, as when the left ventricle is hypertrophied, and the 
 right ventricle comparatively unaffected. On the other 
 hand general debility seems to have considerable influence in 
 developing this irregularity, and it is always lessened by 
 measures directed towards improving the general health and 
 especially the cardiac power. But it is chiefly the co- 
 existence of pyrexia which most strikingly conduces to the 
 development of this irregularity, and that quite independent 
 of the degree of stenosis present. Indeed irregularity is 
 prone to occur in other forms of cardiac disease whenever 
 pyrexia is developed, affording thus a proof that it is due to 
 exhaustion of the energy of the myocardium and its ganglia.^ 
 
 ^ Naturally I speak here only of those with ruptured compensation, not 
 of those in whom the lesion is dynamically compensated, nor of those in 
 whom compensation has been restored by treatment, vide note p. 124. 
 
 ^ The reserve energy of the heart {vide p. 84), upon which its recuperative 
 power when exposed to injury or disease depends, seems to result from the 
 fact that the heart works well within its powers, and is able to exercise its 
 function for hours (Pan^im) or for many minutes (Von Bezold) after it has 
 been completely deprived of arterial blood. Long continuance of imperfect 
 nutrition materially impairs the cardiac metabolism and necessitates anabolic 
 
138 CLINICAL LECTURFS ON 
 
 In mitral stenosis the cardiac nutrition is always below par ; 
 in this state, therefore, this organ is specially obnoxious to 
 lesions of innervation affecting motility. The following 
 diagram graphically represents this extreme irregularity in a 
 sufficiently marked manner (Fig. 13). 
 
 Case XII. William Donald, aged thirty-seven, admitted 
 to Ward V. on 10th March 1871, was a labourer, and had been 
 recently working in a gaswork, where he had been much ex- 
 posed to sudden alternations of heat and cold. He had always 
 enjoyed good health till four weeks ago, when he caught a 
 severe cold; since then he had been feverish and ill, with 
 increasing debility, some cough, and bloody expectoration. 
 
 Fig. 1:3. 
 
 On admission he looked exhausted, his breathing was hurried, 
 his pulse 120 and extremely irregular. On percussion the 
 cardiac dulness was found to be normal, the apex beat in its 
 normal position. On auscultation in the mitral area the 
 first sound was found to be slightly thumping, impure, but 
 unaccompanied by any murmur ; no thrill was perceptible 
 over the apex. Between the second and third ribs on the 
 left side close to the sternum, the second sound of the 
 pulmonary artery was heard greatly accentuated. Between 
 the second and third ribs on the right side close to the 
 sternum, the aortic second was comparatively weakened. At 
 the base generally, but most distinctly at midsternum on a 
 
 interference whenever the heart is called upon for greater exertion than it is 
 equal to. The interference between anabolic and katabolic action thus 
 brought about in the interest of self-preservation sets up irregular action 
 (Roy and Adami, Transactions of the Royal Society, vol. clxxxiii. p. 293, etc.), 
 and previous malnutrition has a most important influence in necessitating 
 this anabolic interference. Hence the obstinate irregularity of advanced 
 mitral stenosis, of atherosis of the coronaries, and even of a greatly dilated 
 heart. 
 
DISEASES OF THE HEAET 139 
 
 level with the fourth rib, marked reduplication of the second 
 sound was heard. On percussion over the left lung anteriorly, 
 the upper lobe was normal, and the lower lobe somewhat 
 dull ; posteriorly on the same side there was a small dull 
 patch about the centre of the scapular space ; from the lower 
 border of the scapular space downwards the lung was dull. 
 Over the right lung the percussion note was everywhere 
 normal except at the lower border of the scapular space, 
 w-here it was dull. Over the dull portions the respiration 
 was more or less obscured ; over the rest of the chest it was 
 vesicular, mingled with occasional coarse crepitating rattles. 
 The expectoration was catarrhal, largely mixed with pure blood. 
 
 The diagnosis was bronchial catarrh, occurring m a 
 patient affected with mitral stenosis, and complicated with 
 pulmonary apoplexy (embolism with infarction). 
 
 The history of an ordinary febrile attack, accompanied 
 with cough, catarrhal expectoration, and occasional coarse 
 crepitation over the chest, persisting for four weeks after 
 seizure, sufficiently confirmed the first part of this diagnosis. 
 The copious expectoration of blood, coupled with the presence 
 of dull patches, over which the respu-ation was obscured,^ 
 also confirmed the latter part of it. While the diagnosis of 
 mitral stenosis was based upon — 1st, the slightly thumping 
 character of the impure first sound ; 2nd, the reduplication 
 of the second sound, which, though found in other circum- 
 stances, is never so persistent as in mitral stenosis ; 3rd, the 
 weakened character of the aortic, and the markedly accentu- 
 ated character of the pulmonary second sound ; and, 4th, the 
 extreme irregularity of the pulse, always an indication of 
 weakness (imperfect metabolism) of the myocardium, and 
 therefore confirmative of the diagnosis of mitral stenosis 
 when other signs point in that du-ection. 
 
 ^ The bronchi passing through the hemorrhagic masses were quite 
 occluded, there was no air within them ; no resonance could therefore be 
 developed within them, hence there was no bronchial breathing to be heard, 
 notwithstanding the solidification of the lung — a fact that goes to confirm 
 Skoda's theory of the origin of this phenomenon. 
 
140 CLINICAL LECTUKES ON 
 
 The thumping character of the first sound duly recognised 
 by a practised ear is, I believe, quite pathognomonic of mitral 
 stenosis ; it is the accentuated first sound which generally 
 follows the rough presystolic murmur, the & of the vocalised 
 apex sounds rrrrh — all the r's being expunged. This variety 
 of the apex sounds in such cases is associated with a feeble 
 heart, and therefore with more or less irregularity of the 
 pulse, though this is not often so extreme as it was in the 
 case before us. The persistent reduplication of the second 
 sound was strongly confirmative of the diagnosis, especially 
 when associated with the signs just referred to, and this was 
 still further strengthened by the subsidiary, and, from a 
 diagnostic point of view, comparatively unimportant pheno- 
 mena of pulmonary accentuation and haemoptysis. 
 
 After admission the patient gradually fell into a state of 
 low muttering delirium, from which he w^as roused by the 
 moderate exhibition of stimulants and the free use of digitalis. 
 For a couple of days he seemed to rally, and faint hopes of 
 ultimate recovery were beginning to be entertained, when 
 symptoms of subacute peritonitis set in, and two days after- 
 wards he died, on 20th March, ten days after admission, the 
 cardiac symptoms remaining unaltered to the close. At the 
 dissection the small intestines were found matted together 
 with recent lymph; they were congested and friable, and 
 the omentum was adherent to their surface, 3 oz. of 
 bloody serum being found in the recto-vesical pouch, etc. 
 The heart weighed 17 J oz. The right auricle was distended ; 
 the left auricle flaccid. Both ventricles were distended with 
 black clots; the right ventricle was somewhat dilated, its 
 auriculo-ventricular opening admitted seven fingers ; the left 
 ventricle was somewhat hj^ertrophied, its cavity not dilated. 
 The aortic and pulmonary valves were competent ; a small 
 vegetation was attached to the corpus aurantii of the posterior 
 cusp of the aortic valve. On laying open the left auricle 
 several vegetations were seen encroaching on the auriculo- 
 ventricular opening, one of them quite cartilaginous but 
 
DISEASES OF THE HEAET 141 
 
 movable, the others softer. The mitral orifice admitted two 
 fingers easily ; its aortic cusp was shortened and thickened, 
 especially at its free margin. Each pleural sac contained about 
 a pint of fluid. Over the right lung there were many adhesions ; 
 over the left only a few at the apex. The upper lobe of the 
 left lung contained two dark -coloured solid htemorrhagic 
 masses just beneath the pleura, one two inches and a half from 
 the apex on the posterior aspect of the lung, the other two 
 inches and a half from the interlobular fissure on its anterior 
 aspect ; the lower lobe contained four similar masses, all just 
 in contact with the pleura, two as large as an orange, the other 
 two each the size of a walnut ; the largest was in the inter- 
 lobular fissure, and extended down to the base ; the next largest 
 was in the posterior aspect of the lung. The apex of the lower 
 lobe of the right lung contained four hsemorrhagic masses. 
 
 These post-mortem appearances, extracted from the patho- 
 logical records of the Eoyal Infirmary, thus completely con- 
 firmed the diagnosis. 
 
 In the following very similar case the diagnosis was 
 confirmed, fortunately for the patient, not by any patho- 
 logical research, but by improvement in the patient's strength 
 and the subsequent development of those murmurs which are 
 recognised as pathognomonic of the condition diagnosed : — 
 
 Case XIII. A. M., aged thirty-one, admitted to Ward V. 
 on 23rd March 1871. This patient had not previously 
 suffered from rheumatism, nor from any serious illness, and 
 had always been able for his work up to the commencement 
 of his present illness, which dated only five days back. He 
 had then been seized with shivering and slight febrile 
 symptoms, accompanied almost from the first with haemop- 
 tysis. He was somewhat breathless, with a hot skin, some 
 cough, copious bloody expectoration, pulse 120, extremely 
 irregular, its sphygmographic tracing closely resembling that 
 of the preceding case. On examination his heart was found 
 nearly normal in size, the apex beating between the fifth and 
 sixth ribs slightly within the nipple Hne. The heart's action 
 
142 CLINICAL LECTURES ON 
 
 was extremely irregular, and on placing the hand over the 
 apex, a thrill running up to the apex beat was occasionally, 
 but not always to be felt. On auscultating over the mitral 
 area, the first sound was found to be impure and slightly 
 thumping in character, but no murmur w^as to be heard. 
 The pulmonary second was accentuated, the aortic somewhat 
 weakened ; the two sounds seemed not to be simultaneous, 
 but presented the phenomenon of reduplication, which was 
 most distinctly to be heard about midsternum opposite the 
 end of the fourth rib. Auscultation and percussion were 
 normal over both lungs, except posteriorly in the infra- 
 scapular regions, where some dulness existed over both lungs, 
 and the vesicular murmur was much weakened, almost 
 extinct. The diagnosis in this case was slight febricula, 
 complicated with mitral stenosis and pulmonary apoplexy 
 (embolism with infarction). This patient was treated with 
 ten minims of tincture of digitalis and of squill in water 
 every six hours. Under this treatment the haemoptysis 
 gradually lessened, the pulse became more regular, and fell 
 to 90, and after about a fortnight's treatment an ordinary 
 presystolic murmur was heard in the mitral area, and a dia- 
 stolic murmur became audible at the end of the fourth rib 
 just where it joined the sternum. The reduplication of the 
 second sound continued to the last. He was sent to the 
 Convalescent Hospital, and at the end of three weeks re- 
 admitted for a slight exacerbation of his cardiac symptoms, 
 but without haemoptysis. The murmurs continued as de- 
 scribed till he was discharged relieved and declaring himself 
 fit for work. 
 
 These cases indicate in a marked manner the importance 
 of great irregularity of the heart and pulse as a symptom of 
 mitral stenosis, especially when associated with haemoptysis. 
 Extremely suspicious under all circumstances, these symptoms 
 may, I believe, be regarded as quite pathognomonic when 
 associated with persistent reduplication of the second sound, 
 especially if accompanied with a presystolic thrill, notwith- 
 
DISEASES OF THE HEAET 143 
 
 standing the absence of all murmur. Pulmonary accentua- 
 tion is of comparatively slight diagnostic importance, as it 
 is usually absent and rarely well marked when reduplication 
 is present, and is really due to a less degree of pulmonic 
 congestion, which may be consequent on many various lesions. 
 
 Apart from the presence of any presystolic murmur, or 
 of any great irregularity of the pulse, mitral stenosis is not 
 infrequently revealed solely by a systolic mitral murmur ; it 
 is therefore always a matter of interest and sometimes of 
 importance to determine the exact nature of the lesion upon 
 which this murmur depends. The two following cases, 
 besides the individual interest which they possess, are of 
 consequence as showing some of the data upon which this 
 diagnosis may be founded. 
 
 Case XIV. Agnes Gunn, aged eighteen, was admitted into 
 Ward XIII. on 27th October 1870, complaining of dyspnoea, 
 cough and expectoration. There was no history of rheumatism, 
 but she had suffered from chorea about two years ago. 
 About twelve months ago she was admitted into Ward XI. 
 under Dr. Laycock, with symptoms similar to those now 
 present, and in the record of her case it is stated that she 
 then had a mitral murmur succeeding and partly replacing 
 the first sound, and that the tricuspid dulness was increased. 
 At the date of her admission under my care, her face was 
 observed to be full, puffy, and rather livid ; her expression 
 was dull and heavy, yet not devoid of anxiety. There was 
 some oedema of her feet and legs, great dyspnoea, consider- 
 able hard cough, and copious watery expectoration. On 
 laying the hand over the lower part of the sternum, the 
 right ventricle was felt to beat with a slow, heaving pulsation; 
 the impulse in the normal position of the apex was only 
 faintly to- be felt ; that between the third and fourth ribs on 
 the left side was greater than normal. On percussing in 
 the parasternal line one inch from the left edge of the 
 sternum the cardiac dulness was found to extend from the 
 upper border of the third rib down to the liver dulness. On 
 
144 CLINICAL LECTURES ON 
 
 the level of the fourth rib this dulness extended from one 
 inch to the right of the sternum transversely across for a 
 distance of six inches. On auscultation in the mitral area 
 the apex beat was found to be accompanied with a sHght 
 thump, followed by a murmur which completely replaced 
 the first sound. The second sound was distinctly audible 
 at the apex. On carrying the stethoscope to the left 
 the systolic murmur gradually faded, and about the middle 
 of the infra-axillary space was replaced by an impure first 
 sound which continued to be heard round to the base of the 
 scapula. Over the tricuspid area a loud blowing murmur 
 completely replaced the first sound. At the base between 
 the second and third ribs on the right side an impure first 
 sound was heard followed by a feeble second. Between 
 
 Fig. 14. 
 
 the second and third ribs on the left side the first sound was 
 also heard impure, and was followed by a distinctly accentu- 
 ated second sound. There was no venous pulsation to be 
 seen in the neck, but the veins were small, empty and 
 obscured by general superficial turgidity. The pulse was 
 76, small, feeble and ii-regular ; its character is graphically 
 represented in the annexed diagram (Fig. 14). 
 
 Agnes Gunn continued under treatment — mainly with 
 digitalis and squill — till the 29th of December, when she 
 was discharged, relieved of all her more urgent symptoms. 
 
 The elements mainly relied upon in this case, in proof of 
 the existence of a mitral stenosis, were — 1st, The slight 
 thump preceding the systolic murmur, an imperfect and 
 abortive attempt at a first sound frequently observed in those 
 cases of mitral stenosis in which the presystolic murmur is 
 
DISEASES OF THE HEART 145 
 
 absent. It is equivalent to the h of the phonetic symbol 
 formerly given, and may be looked upon, either as part of 
 the first sound, or perhaps rather as the tail and only re- 
 maining part of the rough presystolic murmur; it is generally 
 too sharp and short for my ear accurately to time. In other 
 cases it is undoubtedly due to imperfect closure of the mitral, 
 as can be accurately ascertained by timing it by the carotid 
 pulse ; in such cases it is an impure first sound, the thump 
 is more prolonged and the systolic murmur frequently absent. 
 2nd, The fact that the systolic murmur was not distinctly 
 propagated beyond the middle of the infra-axillary space. 
 This is a common, but not an invariable occurrence in mitral 
 stenosis ; the systolic murmur is not lost but the remnant of 
 the first sound is so much more distinctly propagated that it 
 speedily becomes merely an impure first sound, in which the 
 systolic blow is always more or less clearly to be recognised. 
 This is never the case in a purely regurgitant murmur ; such 
 a murmur may become fainter as we pass to the angle of the 
 scapula, but it never assumes any of the elements of a first 
 sound. These two phenomena are perfectly distinctive ; they 
 are never observed save when mitral obstruction exists. As 
 corroborative signs we had dilatation of the left auricle, 
 shown by the unusual pulsation above the fourth rib, which 
 was both seen and felt to precede the ventricular pulsation ; 
 and the early occurrence and rapid development of dilatation 
 of the right auricle and ventricle, indicating considerable 
 obstruction to the onward flow of the blood, an obstruction 
 still further indicated by the small and feeble arterial pulse 
 {vide upstroke of tracing in Fig. 14), the weakened aortic 
 second, and the persistence of pulmonic accentuation in 
 spite of free tricuspid regurgitation as evinced by the loud 
 tricuspid murmur. This proof, from the state of the right 
 heart, is even stronger in those cases in which there has been 
 no co-existent bronchitis, as is occasionally observed.^ Even 
 
 ^ Especially in Ellen Harkins, admitted to "Ward XIII. on 20th April, and 
 discharged improved on 12th June 1871. In her we had all the percussion 
 
 10 
 
146 CLINICAL LECTURES ON 
 
 in this case, though there was evidently great pulmonary 
 congestion and copious expectoration of watery fluid, yet the 
 absence of rhonchi and the presence of crepitation showed 
 that the condition present was more allied to the general 
 turgescent oedema of the body than to true bronchitis ; that 
 we had, in fact, to do with an oedema of the lungs, rather 
 than with a true catarrhal condition ; it was therefore all the 
 more valuable a proof of obstructed circulation. 
 
 On 27th March 1871 Agnes Gunn was readmitted for an 
 exacerbation of all her symptoms, induced about a month 
 previously by going from the wash-tub to an outside well 
 one cold day while scantily clothed. Her cough, shortness 
 of breath, watery expectoration, and cardiac distress were 
 much increased. The jugular veins, though still small, were 
 now seen distinctly to pulsate synchronously with the heart ; 
 her face, neck, and extremities, especially the lower limbs, 
 were very oedematous. Her heart was much as formerly, 
 with this exception, that the impulse just beneath the lower 
 end of the sternum was less marked, and the apex beat was 
 more readily to be felt. This, it was suggested, was probably 
 due to increased dilatation of the right ventricle, which had 
 pushed the left ventricle backwards into the chest and thrust 
 itself into the position usually occupied by the true apex. 
 This was evidently the only explanation possible in the face 
 of an increasing cardiac affection, now fast becoming serious, 
 which from the first had so largely implicated the right 
 heart. It was impossible to suppose that a left ventricle, 
 defectively nourished and from the first unable to hold its 
 own, could have recovered itself suJBEiciently to re-assert its 
 position, apart from any marked evidence of improvement 
 in the onward circulation, which was entn-ely absent. The 
 view taken was perfectly consistent with the usual progress 
 in such cases ; the change effected is only rarely observed in 
 so extreme a degree. Gunn remained in Ward XIII. till her 
 
 signs of tricuspid dilatation, with distinct jugular pulsation, but no tricuspid 
 murmur, and an entire absence of any history of bronchitis. 
 
wmm 
 
 DISEASES OF THE HEART 147 
 
 death, on the morning of 12th July. During this period she 
 had an attack of hemichorea ; the sufferings induced by this 
 were rapidly subdued by hydrate of chloral and full doses of 
 arsenic, but it persisted for many weeks as a slight twitching 
 of the thumb and forefinger of the right hand, finally dis- 
 appearing many weeks before her death. This choreic attack 
 rapidly broke down her cardiac energy, and she never rallied, 
 dying under symptoms of pulmonary apoplexy, with gradually 
 increasing cardiac asthenia. The autopsy was made on 13th 
 July, thirty hours after death. Her body was moderately 
 fat ; her legs very oedematous ; her face and lips livid. On 
 opening the thorax the pericardium was found distended by 
 from 15 to 20 oz. of slightly turbid serum. The heart 
 was considerably enlarged, weighing 16i oz. The right 
 ventricle concealed the left, and formed the apex of the heart ; 
 it was much dilated, and its walls hypertrophied, measuring 
 half an inch in thickness. The tricuspid valve was slightly 
 dilated, admitting five fingers easily ; on its right cusp, near 
 the free margin, there was a small vegetation about the size 
 of a millet seed, soft and elastic. The right auricle was 
 greatly dilated, not hypertrophied. The aortic valve was 
 competent. The left ventricle was shghtly hypertrophied, 
 not dilated. The mitral opening was so contracted as barely 
 to admit the point of the little finger ; the valve itself was 
 much thickened, and its cusps glued together by their 
 margins ; on the auricular surface of each cusp there was a 
 row of small vegetations like millet seeds. The left auricle 
 was slightly dilated, and its walls much hypertrophied, being 
 about twice their natural thickness. The left lung contained 
 two large and recent hsemorrhagic clots (infarctions) present- 
 ing on section a dark venous surface. One of these was 
 situate along the anterior margin of the superior lobe, 
 extending from the apex downwards for a distance of four 
 inches, while it measured transversely one inch and a half. 
 The other was in the inferior lobe, near its anterior margin, 
 and was about the size of a large orange ; its circumference 
 
148 CLINICAL LECTUEES ON 
 
 was pretty sharply defined. The right lung contained no 
 recent extravasations, but in the inferior lobe, immediately 
 beneath the middle of its external surface, there was a 
 yellowish -gray wedge-shaped patch, with its base to the 
 pleura, evidently the remains of an old embolic infarction. 
 There were several emphysematous patches over the surface 
 of the right lung, especially on its anterior margins. 
 The liver weighed 4 lbs. 2 oz., was much congested, and 
 slightly cirrhotic, the lobules being very distinctly differ- 
 entiated by the interlobular cellular tissue. The spleen 
 weighed 5 oz., was of firm texture, and contained two hse- 
 morrhagic infarctions, each about the size of a walnut, tough 
 in texture, and of a bright yellow colour. The kidneys were 
 healthy, and weighed each 5| oz. The dissection in this case 
 also completely confirmed the diagnosis made during life. 
 The marked hypertrophy of the left auricle, in contrast with 
 the simply dilated condition of the right auricle, in spite of 
 the great preponderance of regurgitation on the right side, is 
 a sufficient indication of the influence of obstruction in 
 developing hypertrophy as a supplementary vis a tergo, while 
 it is a singular fact, from a diagnostic point of view, when we 
 consider the entire absence of any presystolic murmur in 
 this case. 
 
 The next case I shall quote is also instructive as to the 
 signs upon which we have to rely for the diagnosis of mitral 
 stenosis in those cases in which there is only the ventricular- 
 systolic murmur of regurgitation to be heard. 
 
 Case XV. Alexander Milne, a printer, aged seventeen, 
 was admitted into Ward V. on 28th November 1870, com- 
 plaining of palpitation, cough, shortness of breath, and pain 
 in the cardiac region. From his history it was gathered that 
 he had suffered from similar cardiac symptoms from the age 
 of six, and that to these a cough had been superadded about 
 a year ago. Since that time the j)ain in the cardiac region 
 had been much worse. The patient was pale and anaemic- 
 looking ; he had never any rheumatism ; his family history 
 
DISEASES OF THE HEAET 149 
 
 was unimportant. On inspection, greater pulsation than 
 usual was visible over the cardiac region, especially at its 
 lower part. The apex beat was distinct between the fifth 
 and sixth ribs, two and five-eighth inches from the left edge 
 of the sternum. On percussing downwards in the parasternal 
 line one inch from the left edge of the sternum, cardiac dulness 
 was found to commence at the upper edge of the third rib, and 
 extended down to the liver dulness ; on the level of the fourth 
 rib dulness did not commence till the right edge of the sternum, 
 but it extended to the left for a distance of fully three inches. 
 On auscultating over the mitral area, the first portion of a 
 first sound was heard followed by a loud systolic murmur, 
 closed by an imperfectly heard second sound. This systoHc 
 murmm- was propagated to the right, and was distinctly 
 heard over every part of the right ventricle, followed by a 
 reduplicated second. It was not so distinctly propagated to 
 the left, becoming very faint on passing the middle of the 
 infra-axillary space. Over the right ventricle a slight but 
 distinct heaving was communicated to the ear by the stetho- 
 scope. Between the second and third ribs on the left side, 
 distinct accentuation of the pulmonary portion of the second 
 sound was heard, the sound being here reduplicate. It was 
 also reduplicate on the right side, where, between the second 
 and third ribs, the aortic portion of the second was heard 
 tolerably natural. Over the jugular veins a haemic murmur 
 was audible, but no pulsation was to be seen. The pulmonary 
 physical signs were normal, and the cough left him entirely 
 after a short residence in the Infirmary. The digestive system 
 was normal, except that there was but little appetite for 
 food. The urine was smoky, contained numerous blood- 
 corpuscles, a few small granular casts, and one -sixth, of 
 albumin. 
 
 The peculiar character of the first sound, the mode in 
 which the systolic murmur was propagated, and the persistent 
 reduphcation of the second sound, gave me reason to state 
 that in this case also we had to do with a stenosis of the 
 
150 CLINICAL LECTURES ON 
 
 mitral opening. The loud tricuspid murmur, and the evident 
 dilatation and hypertrophy of the right ventricle, gave a 
 seriousness to the prognosis, which was not lessened by the 
 persistent hsematuria and the anaemic condition of the 
 patient. 
 
 Under treatment the patient's cough speedily ceased, his 
 cardiac symptoms moderated, the pain left him, even the 
 kidney symptoms were modified, the tube-casts disappeared, 
 the hsematuria lessened, and his general health was much 
 improved. He was sent to the Convalescent Hospital on 
 23rd February. After being some time at home Milne 
 became gradually worse, weaker, and more distressed by his 
 cardiac symptoms, and in this state he was readmitted 
 to Ward V. on 6th April 1871. His cardiac signs were 
 unaltered, but his weakness was greatly increased. The 
 hfematuria continued, and there was a good deal of general 
 oedema. In a short time he was confined to bed suffering 
 much from orthopnoea, and after lingering on in this state 
 till the 24th of May, he died exhausted, having spat a good 
 deal of blood during the last few days of his Ufe. At the 
 autopsy there was found great general oedema of the body. 
 The face, which had been livid before death, had assumed a 
 roseate hue, and a quantity of froth exuded from the mouth. 
 Over both lungs there were numerous pleuritic adhesions ; 
 the left lung was congested and oedematous ; the inferior 
 lobe of the right lung was hepatised, the middle lobe partially 
 consolidated, the base of the upper lobe was also partially 
 consolidated, and the whole lobe was oedematous. The heart 
 weighed 22 oz. The pericardium was universally adherent ; 
 the adhesions were tough and fibrous. The right side was 
 dilated and filled with dark clot ; the tricuspid opening 
 admitted five and a half fingers. The left side was excentric- 
 ally hypertrophied and filled with a partially decolorised 
 clot ; the mitral opening was constricted, admitting only one 
 finger and a half; its cusps were adherent and greatly 
 thickened. The aortic valve was competent. The nutmeg 
 
DISEASES OF THE HEART 151 
 
 liver weighed 3 lbs. 9 oz. ; the spleen weighed 12 oz. ; the 
 kidneys weighed each 6| oz. ; they were enlarged, the capsules 
 non-adherent, the surface a marble-gray studded with stellate 
 vessels and hgemorrhagic spots, the cortical portion speckled 
 with yellowish opacities. 
 
 These cases are sufficient to show the peculiar character 
 of that ventricular-systolic murmur that indicates its depend- 
 ence on a stenosed condition of the mitral opening, and that 
 quite apart from the presence of either of those murmurs — 
 the auricular-systolic or the auricular-diastolic — which are 
 known to be usually connected with this condition, both of 
 which are frequently absent in such cases as those referred 
 to. These cases completely disprove the idea that actual 
 mitral regurgitation is never present unless we can carry the 
 murmur distinctly round to the lower angle of the left 
 scapula. But it would be equally erroneous to suppose that 
 even when we can carry the ventricular-systolic murmur of 
 regurgitation right round to the inferior angle of the left 
 scapula, unpreceded by any thump and unmodified by any 
 attempt at a first sound, we have necessarily to do with 
 regurgitation only and not also with stenosis. Among many 
 instances to the contrary I have selected the following, not 
 only as a well-marked example of the condition I speak of, 
 but also as an instructive instance of the changes which the 
 murmur of mitral stenosis may undergo in the progress of 
 the disease : — 
 
 Case XYI. Andrew Ormiston, a miner, aged seventeen, 
 admitted to Ward Y. on 1st November 1869, complaining of 
 shortness of breath and pain in the cardiac region. The 
 patient stated that he had been ailing for about a year, but 
 before that had never ailed, with the exception of having had 
 chicken-pox and scarlatina in childhood ; in particular he had 
 never had rheumatism. He had been in hospital once during 
 the past year for complaints similar to those he now had. 
 The patient's shortness of breath was aggravated by coughing 
 or by exertion ; his expectoration was grayish, but sometimes 
 
152 CLINICAL LECTURES ON 
 
 bloody. He had occasional paroxysms of pain in the epi- 
 gastrium, coming on about half- an -hour after taking food. 
 He was small for his years, but of a ruddy countenance and 
 fresh, healthy complexion. He was pigeon-breasted, the 
 chest being flattened laterally. On palpation a thrill is felt 
 over the heart's apex preceding its impulse. Cardiac dulness 
 extends from the upper edge of the third rib down to the 
 liver dulness, and transversely along the upper border of the 
 fourth rib from the right edge of the sternum to the left 
 nipple, a distance of four and a half inches. On listening in 
 the mitral area a well-marked rough murmur was heard to 
 precede and run up to the first sound. The pulmonary second 
 sound was accentuated ; the aortic second somewhat weakened. 
 The accentuation of the second sound was markedly increased 
 whenever he happened to cough, and also after exertion. 
 His pulse was 88, soft, and only slightly irregular. The 
 respiratory system was normal. Tongue clean, appetite 
 variable, bowels regular, urine normal. During his residence 
 in hospital his general symptoms varied as he happened to 
 suffer from incidental catarrh or dyspepsia. He was sent to 
 the Convalescent Hospital on 15th December, and was 
 recommended to give up mining, and if possible to procure 
 some easy indoor occupation. For some time he took charge 
 of a village library ; latterly he assisted in a grocer's shop. 
 He grew considerably, and became a well -grown, healthy- 
 looking lad of his years, though quite unfit for manual labour, 
 as his sufferings were always increased by any unusual 
 exertion. He came occasionally under observation, without 
 showing any material alteration in his symptoms, until 29th 
 May 1873, when he again came under treatment with his 
 condition in every way materially deteriorated. His history 
 was that in the preceding February he had a severe bronchitic 
 attack, which confined him to bed for three months, and 
 caused serious aggravation of all his symptoms. So soon as 
 he was able he returned to Ward V., where he was found to 
 labour under considerable dyspnoea, aggravated by the 
 
DISEASES OF THE HEAET 153 
 
 slightest exertion, occasional palpitation, and slight cough. 
 His heart was found to have undergone a most serious altera- 
 tion for the worse. There was distinct jugular pulsation ; great 
 and manifest heaving at the lower part of the sternum, with 
 very evident pulsation above the fourth rib and to the left of 
 the sternum, preceding the ventricular pulsation. At the 
 level of the fourth rib the transverse cardiac dulness was 
 much increased, and measured no less than six inches across, 
 extending for two inches and a quarter to the right of mid- 
 sternum. There was still some thrill to be felt in the mitral 
 area, over the diffuse apex beat, the point of strongest 
 impulse being between the fifth and sixth ribs, three inches 
 and a quarter from midsternum. In this area a presystolic 
 murmur could no longer be heard, but instead a loud systolic 
 murmur, which was propagated distinctly round to the lower 
 angle of the scapula, as well as less distinctly into the aortic 
 and pulmonary areas. In the mitral area no second sound 
 was to be heard. In the tricuspid area there was a very loud 
 systolic murmur of a somewhat higher pitch, and a distinct 
 second sound. In the aortic area the second sound was 
 much weakened. In the pulmonary area the second sound 
 was reduplicated and accentuated. Under appropriate treat- 
 ment, of which digitalis was the most important part, he 
 gradually improved, his heart contracting so that after only 
 a few weeks' treatment the tricuspid murmur was replaced 
 by a first sound, and the mitral murmur became preceded in 
 the mitral area by a portion of the first sound, and in the 
 middle of the infra -axillary space the first sound wholly 
 replaced the systolic murmur. But the feeble constitution 
 had received too severe a shock ever fairly to rally ; the 
 myocardium never fully regained its former tone. The 
 slightest illness or fatigue, the mere ordinary life-work of the 
 day, seemed sufficient to exhaust the heart and lessen its 
 contractile force, so that the almost normal tricuspid sound 
 heard in the mornmg was often replaced at night by a 
 distinct systolic murmur. The presystolic murmur never 
 
154 CLINICAL LECTURES ON 
 
 returned. He was sent to the Convalescent Hospital on 14th 
 August 1873, considerably improved. Ever after he continued 
 feeble, and frequently came under treatment for cardiac 
 symptoms or pulmonary complications, and for the last time 
 on 4th September 1874. His cardiac signs were much as 
 last described. A loud systolic murmur, free from every 
 trace of presystolic thump or of a first sound, was heard in 
 both mitral and tricuspid areas, and was carried right round 
 to the lower angle of the scapula, and propagated into both 
 the aortic and pulmonary areas. These sounds continued 
 unchanged till his death on 5 th October 1874. 
 
 At the autopsy the body was found to be well nourished, 
 there was oedema of the lower limbs, 6 to 8 oz. of fluid in 
 the pericardium, and some effusion into both pleurae. 
 
 The heart was much enlarged, weighing 17 oz. ; all its 
 chambers were dilated. The right ventricle was specially 
 dilated and elongated, so that it projected beyond the left 
 ventricle, and formed the true apex of the heart. The cavity 
 of the left ventricle was found to be slightly dilated, and its 
 walls very much hypertrophied. The mitral valve was 
 extensively diseased ; its opening admitted only the tip of 
 the little finger ; its cusps were greatly thickened, and 
 adherent at their edges ; each cusp contained calcareous 
 matter. The left auricle was greatly dilated, and somewhat 
 hypertrophied. The aorta was below its natural size, its 
 lumen being only half an inch in diameter. The aortic valve 
 was competent and natural. The right ventricle was greatly 
 dilated and hypertrophied. The pulmonary artery was also 
 greatly dilated, its lumen measuring one inch in diameter. 
 The valve was competent. The tricuspid orifice was dilated, 
 admitting seven fingers. The right auricle was greatly dilated, 
 but not hypertrophied. 
 
 The right lung weighed 1 lb. 15 1 oz., and contained 
 several circumscribed masses of effused blood, some quite dark 
 and recent, others pale and gray. The whole of the middle 
 lobe was thus solidified. The lung was free from pleuritic 
 
DISEASES OF THE HEAET 155 
 
 adhesions. The left lung was bound to the chest wall by 
 firm adhesions. It was engorged and oedematous. The base 
 was solidified as if from some old pulmonary infarction. The 
 liver weighed 3 lbs. 10| oz. It was intensely congested 
 with venous blood, somewhat cirrhotic, and also somewhat 
 fatty. The spleen weighed 6 oz., and was hard, fibrous, and 
 congested. The kidneys weighed 5| oz. each, and were 
 somewhat congested. 
 
 It would not be easy to find a more instructive case than 
 this, where we had five years of intelligent observation of a 
 most interesting cardiac lesion, followed by a careful post- 
 mortem examination. This case is indeed an epitome of all 
 that is most interesting in the history of mitral stenosis, with 
 the sole and somewhat remarkable exception that though the 
 murmurs varied they did not vary capriciously, nor were 
 they at any time much altered by the position of the patient. 
 So long as any trace of a presystolic thump remained it was 
 most perceptible in the upright posture, and was much 
 increased by exercise, but when this presystolic thump had 
 finally disappeared it was not restored either by position or 
 exercise, and the case then presented a well-marked example 
 of incurable mitral regurgitation — that is, a regurgitation 
 depending upon actual disease of the mitral valve, in contra- 
 distinction to curable mitral regurgitation depending on loss 
 of tone of the myocardium, of which I shall have more to 
 say presently. In all stages of this affection well-marked 
 pulsation occupied the position of the dilated left auricle 
 above the fourth rib to the left of the sternum, and this 
 pulsation could be both seen and felt to precede that pulsation 
 below the fourth rib, which coincided with the apex beat. 
 The superior pulsation, both in position and rhythm, was 
 coincident with the left auricle and its systole, just as the 
 inferior pulsation was coincident with the left ventricle and 
 its systole. The auricular pulsation was, as it always is, 
 synchronous with the thrill running up to the apex beat and 
 with the presystolic murmur, showing clearly the dependence 
 
156 CLINICAL LECTUEES ON 
 
 of both of these phenomena upon the systole of the auricle, and 
 not upon that of the ventricle, which they distinctly preceded. 
 The next point of interest in this case was that the 
 presystolic murmur persisted jper se so long as the myocardium 
 retained its normal tonicity ; so soon, however, as the 
 pulmonary congestion became sufficient to determine great 
 secondary dilatation of the right ventricle with general 
 venous remora, and consequent interference with the 
 metabolism of the myocardium, then the presystolic murmur 
 dwindled to a mere presystolic thump preceding a systolic 
 mitral murmur, which at this stage was heard to pass into 
 an impure first sound about the middle of the infra-axillary 
 space as the stethoscope was moved to the left in the plane 
 of the apex beat. When the weakness of the cardiac muscle 
 became extreme, as happened during the last few weeks of 
 this patient's life, even this thump disappeared, and a pure 
 systolic murmur alone remained. This systolic murmur 
 differed somewhat in pitch in the tricuspid and in the mitral 
 areas, but it could be carried from the mitral area right 
 round to the lower angle of the scapula without any break 
 or alteration of its pitch. This systolic murmur was not 
 solely due to tricuspid regurgitation,^ because appropriate 
 treatment was at first able to restore the tricuspid first 
 sound more or less perfectly, but it did not restore the 
 mitral first sound ; the most it could do in this direction was 
 merely to bring back the presystolic thump preceding the 
 systolic murmur in the mitral area, and an impure first 
 sound in the middle of the infra-axillary space. We are often 
 more successful in this matter. A patient may come under 
 treatment with a systolic murmur over the left apex, or it may 
 
 ^ In the case of John M'Owen, first admitted to Ward IV. on 10th 
 December 1878, and subsequently repeatedly under observation, I satisfied 
 myself that this is true, and that though it is a plausible idea to refer the 
 systolic murmur in such cases to the right side alone, and its progress to the 
 left to the gradual dilatation of the right ventricle, this is not really the 
 case. M'Owen had a remarkable pigeon-breast, and his left apex never left 
 the chest wall, yet after a time he had only a systolic murmur which could 
 be carried right round to the scapula. 
 
' DISEASES OF THE HEAKT 157 
 
 be over both right and left apices, and by appropriate treat- 
 ment we first bring back a first sound to the right apex and 
 with that a thump preceding the systolic murmur in the mitral 
 area, and by and by, as the myocardium regains strength, 
 there is a distinct presystolic murmur developed,-^ followed by 
 a mitral systolic murmur, or by the usually accentuated first 
 sound. In the case now under consideration there were 
 only temporary and very imperfect attempts at closure of 
 the right ventricle, and there never was any reproduction 
 of the presystolic murmur after its disappearance. It seems 
 of some importance to inquire why it is so much easier 
 to produce comparative rehabilitation of the myocardium 
 in some cases of mitral stenosis than in others. The answer 
 to this seems to be primarily that the greater the degree 
 of stenosis the more difficult it is to get any improve- 
 ment in the metabolism of the myocardium, upon which 
 the success of our treatment alone depends; and, second, 
 that the earlier in life stenosis has occurred the more the 
 development and nutrition of the heart is hampered. It is 
 evident that in this matter the degree of stenosis is all- 
 important. 
 
 It is obvious that when blood is detained in the lungs 
 by a stenosed condition of the mitral opening, the intra- 
 pulmonary blood- pressure rises j9ari passu with the increas- 
 ing congestion. So long as the myocardium retains its 
 normal tone, the right ventricle is able more or less success- 
 fully to resist the dilating force acting upon its interior, 
 even although that dilating force is sufficient, as in this case, 
 to produce considerable dilatation of the pulmonary artery, 
 which probably commenced long before any great or 
 permanent dilatation of the tricuspid valve. The right 
 auricle, it is true, is very early affected, and consequently 
 there are few cases of mitral stenosis in which we cannot 
 detect increased dulness to the right of the sternum, in the 
 
 ^ In Case I., p. 50, we have an instance in which a presystolic murmur 
 became developed as the myocardium regained strength. 
 
158 CLINICAL LECTUEES ON 
 
 auricular region — the plane of the fourth rib. But so long 
 as the tricuspid valve acts normally, this distention of the 
 right auricle interferes but little with the carrying on of 
 the circulation, and such cases often continue for years to 
 present but few, if any, symptoms of the serious disease 
 with which they are affected. But no sooner does the 
 myocardium lose its tone than all this is changed, and 
 serious cardiac symptoms at once set in. In this climate 
 this loss of tone is most commonly brought about by an 
 attack of bronchitis or feverish catarrh,- and in quite recent 
 days that mysterious complaint influenza has had a most 
 widespread and injurious effect in this direction, and we 
 constantly find patients in whom the mitral stenosis was 
 either congenital or dated from early infancy ascribing their 
 illness to some catarrhal affection of quite recent date. 
 The loss of vital tonicity of the myocardium involves an 
 inability to cope with the normal and still less with any 
 abnormal increase of the blood-pressure,^ and this leads to 
 dilatation of the cardiac cavities.^ Hence a severe attack of 
 bronchitis is not infrequently accompanied by tricuspid 
 regurgitation. And bronchitis engrafted on a lung or lungs 
 already congested through obstruction to the onward flow 
 of the blood by a stenosed mitral opening exerts a most 
 disastrous influence upon the muscle of the right ventricle, 
 already slowly yielding before the abnormally high intra- 
 pulmonary blood-pressure. Dilatation of the right ventricle 
 and regurgitation through the tricuspid opening occurring 
 in these circumstances are fraught with ominous import to 
 the safety of the patient. Hitherto he has been gliding 
 along amid the calm if treacherous stillness of a mute 
 disease, now he is plunged into the midst of those rapids 
 where, with but few quiet intervals, he must for the 
 future do battle for his life. 
 
 1 Vide Lectures VI. and VII. ^ Vide Lecture VI. 
 
 ^ Vide The Senile Heart, p. 220 and p. 40 ; also Roy and Adami, 
 op. cit. p. 213. 
 
DISEASES OF THE HEART 159 
 
 Whenever the mitral opening is constricted the blood 
 gradually though slowly accumulates behind the stenosed 
 opening, and it is to this slow transference of the blood 
 from the arteries to the veins, and the equally gradual 
 impairment of the metabolism and consequently of the 
 energy of the myocardium, that even in the most favourable 
 cases death is ultimately due from asthenia, accompanied 
 and indicated by the gradual accumulation of serum in the 
 cavities of the body. It can only be in the rarest of cases, 
 if ever, that this natural result of mitral stenosis is not 
 precipitated by the intercurrence of some febrile ailment in 
 the manner just referred to. A dilated right ventricle, the 
 result of pyrexial relaxation coupled with the remediable 
 congestion of a simple bronchitic attack, the heart being 
 otherwise normal, is readily recovered from. But a per- 
 sistent cause of increased intra-pulmonary blood-pressure, 
 such as that due to limitation of the area of the pulmonary 
 capillaries by destruction of the air-cells in emphysema, 
 induces a permanent and incurable dilatation of the right 
 ventricle. And we can readily understand that any per- 
 manent cause of pulmonary congestion, such as we have in 
 mitral stenosis, must have a similar effect in preventing 
 rehabilitation of the dilated right ventricle in exact pro- 
 portion to the degree of stenosis present. In many cases of 
 extreme mitral stenosis we have also another alteration of 
 the vascular system (hypoplasia of the aortic system), which 
 still further blocks the onward flow of the blood and hastens 
 the rapidity with which the blood accumulates in the veins, 
 increasing the readiness with which compensation may be 
 ruptured, and which is itself a certain indication that 
 stenosis has occurred at an early period of life. This makes 
 us regard mitral stenosis commencing in early life as much 
 more serious than when it happens later ; and the earlier in 
 life we discover mitral stenosis so much the graver must our 
 prognosis be, even when it is not congenital but can be 
 definitely connected with a preceding rheumatic attack. 
 
160 CLINICAL LECTURES ON 
 
 As we shall presently see, the first effect of a rheumatic 
 attack is pyrexial relaxation of the myocardium, and as the 
 result of this we have a murmur of regurgitation frequently 
 audible in the mitral area, more often only to be heard in the 
 auricular area/ but of a curable character, and which dis- 
 appears naturally or under treatment at the close of the 
 attack. But we may also have an endocarditis of an acute, 
 sub-acute, or chronic character, of rheumatic origin, which 
 shrivels, thickens, and often mats together the fibrous tissues 
 of the mitral cusps and of the chordce tcndinece. This endo- 
 carditis occasionally starts in the early stages of the pyrexia, 
 or it may follow it more or less slowly, with or without an 
 intervening period of apparent cardiac health. The inevitable 
 termination of such an endocarditic attack is more or less 
 stenosis of the mitral opening. As the cardiac tissues are 
 thus affected by rheumatism in a twofold manner, so we 
 may have a curable form of mitral regurgitation which passes 
 off as convalescence is established, or it may persist with 
 more or less of cardiac pain and uneasiness till it terminates 
 in stenosis of the mitral valve. At other times the curable 
 regurgitation passes off, and there may be no symptom present 
 beyond a little cardiac irritabihty ; yet after the lapse of a 
 year or eighteen months the signs of mitral stenosis will be 
 found developing. When this result of rheumatism occurs 
 in adult hfe, this stenosis follows the usual course and has 
 attached to it the ordinary prognosis of mitral stenosis. But 
 should a rheumatic attack in childhood or early youth be 
 followed by any considerable constriction of the mitral opening, 
 the effect of this is to dam the blood behind the constricted 
 opening, to diminish the size of the blood-wave sent onwards, 
 and thus to lessen the normal distention of the aorta, and to 
 impair the metabolism and stunt the growth of all the tissues. 
 In this way we have produced that arrested development so 
 well known as the result of serious cardiac disease of an 
 obstructive character occurring in early life, technically 
 ^ Vide Lecture VI. 
 
DISEASES OF THE HEAET 161 
 
 termed hypoplasia, affecting primarily the aortic arterial 
 system, and secondarily all the organs of the body. Of this 
 we had a moderate example in this patient (Ormiston), in 
 whom the aorta measured only half an inch in diameter. But 
 this hypoplasia is occasionally much more marked ; Allan 
 Burns relates one instance in which the aorta barely admitted 
 the little finger.^ So extreme a degree of hypoplasia of the 
 aortic system points to the development of stenosis of the 
 mitral opening at a very early period of life ; it may be even 
 to a congenital stenosis of this opening, as Allan Burns has 
 supposed.^ The occurrence in some cases of an extreme 
 degree of mitral stenosis with marked hypoplasia of the aortic 
 system, with stunting of the growth of the body generally as 
 well as of every organ in it, quite apart from any trace of a 
 history of rheumatism or of any known cause of endocarditis, 
 certainly favours this supposition.^ Be this as it may, the 
 important point for us to consider is that this hypoplasic 
 condition of the aorta increases very materially the difficulty 
 of rehabilitating the right ventricle, once this becomes dilated, 
 presenting as it does a second and most material obstacle to 
 the onward progress of the blood, which strengthens and 
 
 1 This patient was a girl, delicate from birth, of nineteen years of age ; 
 the mitral valve was a tendinous septum, rigid and in some parts ossified ; at 
 its centre there was a puckered opening barely large enough to admit the tip 
 of the little finger. Vide Olservations on sovie of the most Frequent and Import- 
 ant Diseases of the Heart, by Allan Burns (Edinburgh, 1809), p. 32. 
 
 2 His sixth species of congenital malformation of the heart consisted of 
 those cases where the mitral valve is malformed, leaving merely a small 
 opening leading from the left auricle into the ventricle ; op. cit. p. 12. 
 
 ^ VirehOw, in his pamphlet Ueher die Clilorose und die damit zusammen- 
 hangenden Anomalien im Gefassapparate (Berlin, 1872), pp. 18, 19, attributes 
 the valvulitis affecting chiefly the mitral, but occasionally also the aortic 
 valves, in cases of aortic hypoplasia to the irritating results of intravascular 
 pressure, the ventricle having more blood to send on than the aorta can 
 receive. The usual result of such a state of matters is to produce cardiac 
 dilatation in older people ; there seems no reason why it should act differently 
 in younger patients. Besides there seems a little difBiculty in accounting for 
 a superabundance of blood in a hypoplasic organism. On the other hand 
 intra-uterine or infantile endocarditis ending in stenosis of the mitral opening 
 must inevitably lead to hypoplasia of the aorta and of all the organs to which 
 it is distributed, by cutting off the nutritive pabulum during the period of 
 development. 
 
 11 
 
162 CLINICAL LECTURES ON 
 
 reinforces that already existing in the stenosed condition of 
 the mitral opening. Hence we see that the earlier the period 
 of life to which the origin of mitral stenosis can be traced, so 
 much the more readily may dilatation of the right ventricle 
 and tricuspid regurgitation be produced by even comparatively 
 slight secondary causes, and so much the more serious must 
 be our prognosis, because under such circumstances it is 
 never possible perfectly to rehabilitate the right ventricle, 
 and the necessarily fatal transference of the blood-pressure 
 from the arteries to the veins is inevitably hastened. 
 
 It will be remembered, then, that mitral stenosis is a 
 common result of rheumatism, and that some degree of it is in- 
 variably present whenever the mitral valve has become diseased 
 as the result of endocarditis of a rheumatic or a non-rheumatic 
 origin. Whenever this stenosis occurs in infancy or early 
 childhood, some degree of aortic hypoplasia is probably always 
 concomitant, as it invariably is in those not infrequent cases in 
 which mitral stenosis is congenital, whether as the result of 
 intra-uterine endocarditis or simply of imperfect development. 
 
 Further, it will also be remembered that this stenosed 
 condition of the mitral opening is to be recognised by the 
 occurrence of a rough murmur preceding and running up to 
 the apex beat and the carotid pulse, which is pathognomonic 
 of this lesion. This murmur may, and often does, commence 
 as a somewhat musical diastolic murmur following the second 
 sound and growing rough towards its termination. This 
 murmur is sometimes to be heard over the whole cardiac 
 area, more usually, especially as to the strictly diastolic 
 portion, just over the mitral valve where the fourth rib joins 
 the sternum. Any portion of this prolonged murmur may be 
 absent, and it may either be continuous or broken by a pause 
 having the rhythm, though not the duration, of the normal 
 soundless interval (second silence) of the cardiac cycle. The 
 length of the pause varies with the amount of stenosis present, 
 and may be accepted as an exact indication of this — the 
 shorter the pause, the greater the stenosis. A purely mitral 
 
DISEASES OF THE HEART 163 
 
 diastolic murmur is of course unaccompanied by any signs of 
 aortic regurgitation ; it has a clear aortic second preceding it, 
 and is accompanied by no jerking of the pulse produced or 
 increased by elevation of the arm, and by no dilatation of 
 the left ventricle evinced by depression of the apex beat. 
 This murmur is more or less prolonged and frequently slightly 
 musical in character, and is chiefly to be heard in the mitral 
 area or just over the mitral valve, A short, soft, simply 
 blowing murmur, even though only audible at the sternal end 
 of the fourth rib, must always be viewed with suspicion as 
 probably always of aortic origin. Cases of pulmonary 
 regurgitation are so rare that they can scarcely be regarded 
 as in any way likely to complicate the diagnosis or to throw 
 any dif&culty in its way. Such cases are chiefly of congenital 
 origin ; there are only a few cases on record, and in none have 
 any signs been observed in any way likely to obscure the 
 diagnosis of a mitral diastolic murmur.-^ Extreme irregu- 
 larity of the pulse either with or without pyrexia is very 
 suggestive of the presence of mitral stenosis, and the prob- 
 ability of this is increased if there is an audible thump 
 preceding or accompanying the apex beat ; if there is haemo- 
 ptysis, and if there are signs of enlargement of the right side 
 of the heart, and reduplication or accentuation of the second 
 sound, most distinctly audible at the third left costal cartilage, 
 the accentuated second being always the pulmonary. 
 
 A simple systolic apex murmur of mitral regurgitation is 
 occasionally the sole indication of mitral stenosis, but in such 
 cases this murmur is preceded by a more or less evident 
 thump, and it generally ceases at or about the middle of the 
 infra-axillary space, being there replaced by a more or less 
 impure first sound. In those cases in which the systolic 
 murmur can be carried right round to the angle of the scapula 
 
 ^ At pp. 999 and 1000 of Ms Diseases of the Heart and Aorta (Dublin, 
 1875), Dr. Hayden lias published notes of four cases of regurgitation through 
 the pulmonary valves, which confirm the view taken in the text that even 
 apart from the rarity of such cases there is but little risk of confusion likely 
 to arise from the signs themselves. 
 
164 
 
 CLINICAL LECTURES OX 
 
 we invariably have a heaving impulse at the lower part of 
 the sternum, and over this another systolic murmur of a 
 different pitch, pointing to considerable dilatation of the 
 right ventricle with tricuspid incompetence, confirmed l)y the 
 
 Fig. 15. 
 
 presence of marked hepatic pulsation. In all cases of mitral 
 stenosis there is very generally a distinct pulsation visible 
 in the auricular area above the fourth rib ^ and to the left 
 
 ^ Fig. 15 gives an excellent representation of a large auricle lying along 
 the anterior base of the heart, as it not infrequently does in mitral stenosis. 
 Vide Journal of Pathology ami Bacteriology (July 1896), p. 75. 
 
DISEASES OF THE HEART 165 
 
 of the sternum ; this pulsation is either wanting or it is at 
 least inconsiderable in cases of simple regurgitation in which 
 the valve is unaffected. A systolic murmur is often to be 
 heard in this auricular area as an indication of regurgitation 
 in mitral stenosis ; and indeed a murmur in this area is 
 generally one of the earliest indications of regurgitation from 
 any cause whatever. 
 
 The prognosis of mitral stenosis is favourable so long as 
 the right side is unaffected, and the rough presystolic murmur 
 persists ; this favourable prognosis being subject to modifica- 
 tion according to the circumstances of the patient, but 
 especially according to the period of life at which the stenosis 
 originated, being more favourable the later in life this has 
 happened. But whenever the right ventricle becomes 
 secondarily dilated the prognosis at once becomes serious, and 
 all the more serious the earlier in life this occurs, because the 
 probability is then greater that the stenosis dates from early 
 childhood or infancy and the co-existence of hypoplasia of the 
 aortic system is more certain. But the coincidence of 
 dilatation of the right ventricle with hypoplasia of the aortic 
 system at once makes the prognosis most grave, and reduces 
 the expectation of life from many to only a few years, except 
 under the most favourable circumstances. 
 
 Sufferers from mitral disease are not liable to sudden 
 death from heart failure, like those labouring under aortic 
 incompetence ; they die normally from asthenia preceded by 
 dropsy. Many pass through a long life with comparatively 
 little inconvenience ; most, however, suffer a good deal from 
 breathlessness, palpitation, and irregularity of the heart's 
 action, the latter being often extremely persistent and 
 annoying during the latter years of life. Cerebral embolism 
 is an occasional cause of sudden death in cases of mitral 
 stenosis, but pulmonary embolism is a much more frequent 
 and quite as serious an accident, though death in these 
 circumstances is never so sudden. Euptured compensation 
 from various causes is much more common in mitral than in 
 
166 CLINICAL LECTLTIES ON DISEASES OF THE HEART 
 
 aortic disease, but it is of much less serious import and is 
 more easily recovered from, except under the special circum- 
 stances already referred to. 
 
 The treatment of such cases must be purely tonic. While 
 compensation is perfect, nutritious diet and the avoidance of 
 all over-exertion are all that is required, though arsenic and 
 iron, or arsenic and strychnine may be usefully combined. 
 "\Mien compensation is ruptured, tonic doses of digitalis are 
 called for, and if extreme irregularity is present large doses 
 of digitahs for a time are of great service, though even this 
 form of heart trouble yields to moderate doses of digitalis if 
 they be conjoined with a light but nutritious diet and 
 abundance of rest. The great object of treatment is to main- 
 tain and, when needful, restore the tone of the myocardium. 
 Even when there is considerable haemorrhage from pul- 
 monary infarction it is seldom that any other treatment is 
 requii'ed, though an embolic pneumonia is much benefited 
 by the conjunction of moderate doses of chloral with the 
 digitalis. 
 
 As we never have mitral stenosis without some degree of 
 regurgitation, so some hypertrophy of the left ventricle is 
 generally present, but it is of slow growth and is never exces- 
 sive Marked dilatation of the left ventricle is less common 
 and depends upon pyrexial relaxation of the myocardium, or 
 increased obstruction to the circulation from arterial atherosis, 
 or secondary cirrhosis of the liver or other organs, the result 
 of venous remora. 
 
LECTUEE VI 
 
 ox CURABLE MITRAL REGURGITATION ; ITS VARIOUS CAUSES, THE 
 PHYSICAL SIGNS BY WHICH IT IS REVEALED, AND ITS 
 TREATMENT 
 
 In a former lecture ^ I pointed out that the only un- 
 equivocal proof of the actual existence of disease of the 
 mitral valve is the presence of an auricular-systolic, or, 
 as it is commonly termed, a presystolic murmur, or at all 
 events proof that such a murmur has been heard at some 
 former period of the patient's life ; for, though this murmur 
 frequently disappears or alters its character, the lesion upon 
 which it depends is permanent. It would have been more 
 correct to have said that the only unequivocal proof of disease 
 of the mitral valve is the determination of a constriction 
 of the auriculo -ventricular opening, however that may be 
 established, for stenosis of that opening is the usual 
 condition when the mitral valve is diseased, and though it is 
 always present when a presystoHc murmur is to be heard, it 
 also frequently exists when that murmur is not only absent at 
 the time of examination, but has never been recognised at any 
 past period of the history of the case, though even in these in- 
 stances the presence of stenosis is frequently revealed by certain 
 signs which have been already described.^ As in the lecture 
 referred to, however, I alluded chiefly to the character of the 
 murmur distinctive of disease of the mitral valve, the state- 
 ment may be accepted as correct to that extent. At present 
 
 1 Lecture IV. p. 110. ^ Lecture V. p. 135. 
 
168 CLINICAL LECTURES ON 
 
 I intend to refer to mitral regurgitation unaccompanied by 
 disease of the mitral valve, and shall have to traverse 
 cursorily a wide series of diseases in which this lesion is 
 found more or less frequently. In a large proportion of these 
 cases it is happily permanently curable, though revealed by 
 what to many even yet seems the certain sign of incurable 
 organic mischief — a systolic mitral murmur. The importance 
 of this observation needs no comment. To the patient it 
 involves the issues of life and death, a comparatively short 
 illness, and thereafter a normal and, it may be, a long and 
 healthy life ; or permanent ill health, an abnormal life, and 
 shortened days. To the physician it brings home the para- 
 mount importance of an accurate diagnosis, and substantiates 
 in a most striking manner the value of appropriate treatment. 
 The vigour of any muscle depends upon the perfection of its 
 metabolism, and as tlie heart is not only able to originate 
 spontaneous rhythmic movements but also to store up a large 
 reserve of energy, its metabolism is of a much higher charac- 
 ter than that of the ordinary skeletal muscles ^ and is readily 
 affected by any changes in the quantity or quality of the 
 blood which furnishes its basis. Hence pyrexial diseases or 
 such as interfere with the general metabolism exert an 
 injurious effect upon the myocardium, and impair the dis- 
 charge of its function.^ But the function of the heart is to 
 maintain the circulation by contracting on the blood within 
 its cavities and forcing it onwards, and whatever impairs this 
 function leads to residual accumulation within the ventricles 
 and to gradual dilatation of their cavities.^ The result of 
 even a slight dilatation is the establishment of so-called 
 
 1 Foster's Physiologtj (1883), p. 344. 
 
 ^ Old hearts as well as young ones are liable to have their function im- 
 paired by similar causes, but are not often curable. For an account of the 
 results of impairment of function on them, vide The Senile Heart, A. and 0. 
 Black: London, 1894. 
 
 ^ " The amount of residual blood (in the ventricle) is always increased 
 whenever, the aortic pressure remaining constant, the force of the ventricular 
 contraction is reduced from malnutrition or other causes." — Vide Roy and 
 Adami, Philosophical Transactions, vol. 183, p. 213, 
 
DISEASES OF THE HEART 169 
 
 relative insufficiency, not because the auriculo-ventricular 
 opening itself is dilated — that does happen, but at a later 
 period of the affection — nor because the segments of the valve 
 are unable to close the opening, as one alone of these seg- 
 ments is almost sufficient for this purpose : but because, 
 owing to the separation of the cardiac walls, by dilatation of 
 the cavity, the insertions of the chordce tendineoe into the 
 papillary muscle are set so wide apart and so far from the 
 centre of the ventricle that the triflmg pressure of the 
 auricular blood is unable to bring the valve-segments into 
 apposition just before the commencement of the ventricular 
 systole.-^ But any interference with the instantaneous closure 
 of the valve at the moment of ventricular systole favours 
 regurgitation,^ and in these cases this is a constant phenomenon, 
 varying in degree at different times. 
 
 In all these cases there is a more or less impure first 
 sound audible in the mitral area, or a transient systolic whiff 
 may terminate in an apparently normal first sound, and in 
 still other cases a murmur is heard throughout the whole of 
 the systole from its commencement to its end. 
 
 This is quite in accordance with the account just given. 
 In slight dilatation at the commencement of the ventricular 
 systole the valve -segments are not in apposition as they 
 ought to be, and there is some regurgitation, but this ceases 
 as the systole progresses and the valve-segments are perfectly 
 closed. When the dilatation is greater the valve-segments 
 never come together, and the regurgitation persists through- 
 out the whole of the systole. 
 
 At a very early stage of its dilatation the right ventricle 
 forces the apex from the chest wall into the thoracic ca\dty. 
 How slight is the dilatation necessary for tins may be learned 
 by placing a finger on the apex and stopping the respu-ation. 
 Even durins; the few seconds we can hold our breath the 
 
 ^ Vide Ludolph Krehl, Archiv fur Anatomie unci Physiologic (Leipzig, 
 1889), S. 291. 
 
 ^ Vide Pettigrew, Transactions of the Royal Society of Edinburgh, vol. 
 xxiii. p. 796, note. 
 
170 CLINICAL LECTURES ON 
 
 apex will be found to have receded so far as to be almost 
 imperceptible. WTien this dilatation of the right ventricle is 
 from a more permanent cause, it is readily recognised by the 
 more forcible beat communicated through the stethoscope 
 applied over the lower part of the sternum long before the 
 development of any tricuspid murmur. This altered relation 
 of the apex to the chest wall, coupled with the probable low 
 tension and comparatively trifling force of the fluid veins 
 formed at the mitral orifice at the commencement of 
 ventricular systole, are sufficient to account for this murmur 
 never reaching the mitral area otherwise than as at the most 
 a slight impurity of the first sound at this stage. On the 
 other hand, there are but few exceptions to the rule that no 
 sooner have we any certain indications of even slight dilata- 
 tion of the left ventricle than we are able to pick up a faint 
 but distinct systolic murmur in the auricular area, due to the 
 impingement of these fluid veins upon the auricular wall, 
 and the communication of their vibrations to the anterior 
 chest wall, with which the appendix of the left auricle is in 
 immediate contact. As I have already stated, it is chiefly in 
 connection with mitral stenosis that the appendix of the left 
 auricle attains so great a size as to lie round the base of the 
 heart in close juxtaposition to the anterior chest wall,^ but 
 we know from Walsh e that an inspection carried on for many 
 years of the bodies of male subjects cut off by various diseases 
 had convinced him that in almost every instance the 
 appendix of the left auricle is visible anteriorly, as the organs 
 lie in situ.' Walshe says that the middle point of the auricle 
 in this position from above downwards corresponds to the 
 cartQage of the third rib (vide frontispiece). This is the 
 position in which a systolic murmur is generally to be heard, 
 and a systolic pulsation occasionally to be felt, as an early 
 indication of commencing dilatation. We know that the left 
 
 1 As figured at p. 164 ; vide also Journal of Pathology and Bacteriology 
 (Edinburgh and London, July 1S96), ]>. 75. 
 
 ^ Diseases of tlie Heart ami Great Vessels, 3rd edition (London, 1862), p. 2. 
 
DISEASES OF THE HEAET 171 
 
 edge of the sternum divides the pulmonary artery ; one-half 
 lies beneath the sternum, and the other in the second inter- 
 space. If we place the tip of the finger in the second 
 interspace close to the sternum so as to cover the pulmonary 
 artery, the position of maximum intensity of this auricular 
 murmur will be found to lie just to the left of the finger. 
 There are comparatively few cases in which the appendix 
 auriculi is too short to reach the chest wall, even when 
 slightly dilated, and there are still fewer in which an 
 elongated appendix gets twisted backwards, and so prevented 
 from reaching the chest wall. In all these cases auricular 
 pulsation and an auricular murmur are naturally wanting. 
 Pulsation in the auricular area is sometimes great and well- 
 marked, so much so that a late distinguished professor and 
 teacher of clinical medicine upon one occasion sent me a case 
 of chlorosis with auricular pulsation as one of aortic aneurysm.^ 
 Skoda was the first to point out that when the right 
 ventricle was dilated and hypertrophied as the result of 
 mitral disease a systolic murmur was often to be heard, as he 
 supposed, in the pulmonary artery. This he ascribed to 
 softening of the lining membrane of the artery.^ Joseph 
 Meyer has shown that this hypothetical alteration of the 
 lining membrane of the pulmonary artery in such cases is a 
 pure myth, and he has attempted to explain this peculiar 
 phenomenon by another equally untenable supposition.^ 
 The murmur itself is well known, and has been described 
 and variously explained by many writers on the subject,^ but 
 it was reserved for Naunyn to point out that a murmur of 
 this character, whether it accompanies a systolic murmur in 
 the mitral area, or is itself the sole indication of mitral re- 
 gurgitation, has its position of maximum intensity not in the 
 
 1 Vide Lancet (September 1877), p. 386. 
 
 " Ahhandlung iiber Perkussiommd Auskultation, 3. Auflage (Wien, 1844), 
 S. 223. 
 
 ^ Virchow's Archiv, Bd. iii. Heft 2, S. 277. 
 
 ■* By Friedreich, Krankheiten des Herzens, 2. Auflage (Erlangen, 1867), S. 
 173 ; Bamberger, Lehrhuch der Krankheiten des Herzens (Wien, 1857), S. 92 ; 
 Von Dusch, Lehrhuch der Herzkrankheiten (Leipzig, 1868), S. 205, etc. 
 
172 CLINICAL LECTURES ON 
 
 pulmonary area, but to the left of it, where the appendix of 
 the left auricle comes up from behind. Naunyn's explana- 
 tion is the only one consistent with the facts, and is now 
 universally received.-^ 
 
 Daily experience in the sick-room has long since taught 
 us that all pyrexial diseases are accompanied by muscular 
 relaxation and debility, and from the experiments of Eoy and 
 Adami we know that any increase in the aortic blood- 
 pressure, or, the aortic pressure remaining constant, any 
 diminution in the force of the ventricular contractions results 
 in increase of the residual blood and ultimate dilatation of the 
 ventricle.'-^ When the gradual wasting of the tissues — as in 
 phthisis or carcinoma — is accompanied by a diminution of 
 the mass of blood, the heart simply atrophies in all its 
 dimensions, and its cavities are correspondingly diminished 
 in size (concentric atrophy).^ But in other complaints, 
 whether associated with pyrexia or debility, the heart is 
 liable to undergo slow and gradual dilatation by the agencies 
 just referred to, provided the morbid influences are long 
 enough maintained. I have elsewhere described the many 
 interesting and peculiar symptoms associated with failure of 
 the senile heart,* and I shall not further allude to them 
 here, except to remark that some of these are now and then 
 engrafted on younger hearts, partly because age is a matter 
 of tissue change and not of years, and partly because some 
 of those symptoms are liable to affect weak hearts at any 
 age, though they are more commonly observed after middle 
 
 ' " Ueber den Grund weshalb bin und wieder das systoliscbe Gerausch bei 
 der mitral Insufficienz am lautesten in der Gegend der Pulnionalklappe zu 
 vernehmen ist," Berliner Minischcr Wochenschrift (1867), No. 17, S. 189 ; 
 vide also Paul Niemeyer, Ilaiulbuchdcr Percussion und Auscultation {'E.v\?Lngen, 
 1870), Bd. ii. Abtbeil i. S. 140, and Gerhard's Lchrhuch der Auscultation und 
 Percussion, 2. Auflage (Tiibingen, 1871), S. 283. 
 
 - British MedicalJournal (Deaembev l?>a),]}. 1320, etc ; also Philosophical 
 Transactions, vol. 183, p. 213. 
 
 ^ Walshe considers that the sustainment of the heart at par in those cut 
 off by such wasting diseases must be regarded as the equivalent of hyper- 
 trophy, op. cit. p. 274. 
 
 ■* The Senile Heart, its Symptoms, Sequelce, and Treatment. 
 
DISEASES OF THE HEAET 173 
 
 life. Neither shall I make here any special reference to 
 cardiac dilatation due to pyrexial disease, as it arises in a 
 similar manner, is revealed by similar signs, and follows a 
 similar course to that occurring in connection with more 
 chronic diseases in which the various stages are more readily 
 investigated.'^ In former days cardiac murmurs were divided 
 into organic and functional; the former were recognised as 
 dependent on irremediable valvular lesions, the latter were 
 supposed to occur independently of any alteration of the 
 organ. Functional, or inorganic, murmurs were classified 
 under two heads — hsemic and dynamic. A haemic murmur 
 is one supposed to be produced by the passage of abnormal 
 blood through a perfectly normal heart. It is always systolic 
 in rhythm, and has been regarded by most observers as 
 always basic in position. A dynamic murmur, on the other 
 hand, though always systolic in rhythm, is apical in position 
 and regurgitant in character, and is supposed to be produced 
 by a perturbed or irregular action of the cardiac muscle, 
 quite independent of any abnormality of the blood, which, 
 however, always co-exists. 
 
 Chlorosis and the chlorotic cardiac murmur is the typical 
 hffimic murmur ; chorea and the apex murmur that so often 
 accompanies it is the typical dynamic murmur. In chlorosis 
 the blood lesion is primary and paramount ; in chorea the 
 blood lesion is essentially secondary to pyrexia, and specially 
 to the exhaustion that follows the continuous morbid jactita- 
 tion so characteristic of this disease. Now we know that the 
 so-called functional murmurs of both kinds essentially depend 
 upon dilatation of the heart due to residual accumulation 
 from imperfect discharge of its function by a heart unable, 
 through debility, to cope with the blood-pressure which is 
 either natural or only slightly raised. As the development 
 
 ^ In severe and fatal typhus the heart was sometimes found to be as " limp 
 as a piece of wet rag." Quoted from Louis by Stokes, Diseases of the Heart 
 and Aorta (Dublin, 1854), p. 368. In less serious cases a systolic murmur 
 was frequently developed, as in other pyrexial diseases, during the course of 
 the fever, op. cit. p. 423. 
 
174 CLINICAL LECTUKES ON 
 
 of this affection is essentially similar in all the various 
 diseases with which it is found connected, and as in chlorosis 
 this development is more gradual and can be more readily 
 followed, it will be most instructive to consider the rise and 
 progress of the chlorotic cardiac murmur. 
 
 It is unnecessary to enter particularly into the pathology 
 of chlorosis ; it is sufficient to describe it as a form of 
 spanffiuiia of common occurrence, especially among country 
 girls who, for the first time, find themselves exposed to the 
 unhealthy surroundings inseparable from domestic service in 
 a town, and in whom the prominent derangement of the 
 genital function is amenorrhoea. It is also common enough 
 in town-bred girls of a better class, especially about the age 
 of puberty, and in them the menstrual discharge is pale and 
 usually scanty, menorrhagia being exceptional, and always 
 followed by great exhaustion. The lips of such patients may 
 be rosy, and the cheeks present a certain amount of youthful 
 bloom, but the interior of the lips, the gums, and especially 
 the conjunctivae of the lower eyelids, are pale and bloodless. 
 The face inclines to be puffy rather than clear cut or sharp 
 in its outlines ; the ankles are slightly oedematous ; the 
 appetite is irregular and capricious, and there is breathlessness 
 and palpitation on the slightest exertion. This condition is 
 also signalised by the constant occurrence in the veins of the 
 well-known hruit de diable or humming-top murmur; this 
 venous murmur is continuous and audible during both systole 
 and diastole, its intensity increasing with thoracic and cardiac 
 aspiration, and diminishing with expiration and the cardiac 
 systole, so that the venous hum waxes and wanes as these 
 alternate. 
 
 This venous murmur is caused by the production of 
 Savart's fluid veins ^ at the point where it is heard, and it is 
 readily produced in spansemic individuals by moderate 
 pressure over any vein of tolerable size, such as the external 
 jugular. It is also readily heard over the eyeball, over tlie 
 
 1 Lecture I. p. 46. 
 
DISEASES OF THE HEART 175 
 
 torcular HeropMli, over the upper part of the innominate 
 veins, especially the right one, and over other parts of the 
 venous system where there exists naturally, what is produced 
 artificially by pressure, a flow of blood through a part rela- 
 tively constricted to that beyond it. As this venous murmur 
 is readily heard, in appropriate circumstances, in certain 
 positions, such as the torcular Hero-phili, where there is a 
 normal relative constriction insufficient to produce sonorous 
 veins, there can be little doubt that the increased narrowing 
 of the opening is due to increased friction between the wall 
 of the vein and the layer of spanaemic blood next it, leaving 
 uninfluenced the axial portion of the stream in which these 
 fluid veins are formed. Besides an appropriate condition of 
 the vessel, and of the blood, a certain amount of current force 
 is needful to produce these sonorous veins ; hence they are 
 often inaudible in the recumbent posture, and become at 
 once audible when the force of the blood current is increased 
 by elevating that part of the body at which we are listening. 
 Many observers (" London Heart Committee," Liman, Win- 
 terich, etc.) have pointed out that a venous murmur is often 
 to be heard in those who appear to be in perfect health, but 
 in those individuals this murmur is altogether wantmg in 
 that loud and sonorous character so remarkable in well- 
 marked cases, and all that this observation proves is that a 
 certain amount of spansemia is not inconsistent with ap- 
 parent health. 
 
 But the venous murmurs that accompany chlorosis are 
 of much less interest and importance than those heard within 
 the cardiac area. These cardiac murmvirs are always systolic 
 in character, but their position of maximum intensity has 
 been located on various parts of the cardiac area by difl'erent 
 observers. The classic position of the chlorotic murmur is 
 the aortic orifice, as narrated by Hope,-^ Bellingham," Potain,^ 
 
 1 A Treatise on Diseases of the Heart (London, 1839), p. 106. 
 
 2 Diseases of the Heart (Dublin, 1853), p. 137 and p. 142. 
 
 ^ Dictionnaire Encyclopedique des Sciences Medicales, tome iv. p. 392. 
 
176 CLINICAL LECTURES ON 
 
 Marey/ and others, but the aortic origin of the chlorotic 
 murmur in its early stage is absolutely negatived by the fact 
 that at this stage it is not propagated along the course of the 
 arteries ; as Hay den has said, " it has no definite line of pro- 
 pagation."^ Parrot^ has supposed that this murmur is 
 always of tricuspid origin, and Stark ■* has shown that it may 
 be of mitral as well as of tricuspid origin. Most observers 
 are, however, agreed that the cardiac murmur heard in the 
 early stage of chlorosis is basic in position and has "no 
 definite line of propagation," while its position of maximum 
 intensity is the neighbourhood of the pulmonary artery, 
 where it is always best marked and often only to be heard. 
 So usual indeed and so well defined is this position of 
 maximum mtensity that Marshall Hughes^ has suggested 
 the pulmonary artery itself as the source of this murmur. 
 But no murmur of strictly pulmonary origin could possibly 
 be referred to all the four cardiac orifices in turn, as has been 
 the case with the chlorotic murmur ; and indeed careful 
 observation teaches us that this murmur, though audible in 
 the pulmonary area, has its position of maximum intensity 
 not there, but in the second interspace just to the left of the 
 pulmonary artery, exactly where the appendix of the left 
 auricle comes up from behind. It is in fact an auricular 
 murmur, a murmur of mitral regurgitation audible in the 
 auricular area {vide p. I7l), and its further development is 
 strictly in accordance with the ordinary mode of evolution of 
 such murmurs in the course of progressive dilatation of the 
 heart.^ In chlorosis we have first the hruit de diable — the 
 
 ^ Physiologie Medicale dc la Circulation du Sang (Paris, 1863), p. 479. 
 Marey reverted to this view apparently because it suited with his idea that a 
 low blood tension in the aorta favours the formation of fluid veins at its 
 orifice. It is rather unfortunate for this theory that this murmur is often onlj- 
 to be heard in the neighbourhood of the pulmonary artery, where an ac- 
 centuated second sound assures us that the blood tension is always increased. 
 
 2 Op. cit. p. 252. 
 
 " Archives Gin. de Medicine, 6ieme serie, tome viii. 1866 ; vol. ii. p. 158. 
 
 * ArcUv der Heilkurule (1863), p. 47 ; and Gaz. Hebdom. (1863), p. 262. 
 
 ^ Guy's Hospital Rrports, second series, vol. vii. p. 161. 
 
 « Vide The Senile Heart, p. 56. 
 
DISEASES OF THE HEART 177 
 
 venous hum of serous polysemia — chiefly audible in the right 
 jugular vein ; next we get accentuation of the pulmonary 
 second, as the earliest indication of obstruction to the circula- 
 tion from residual accumulation in the ventricles; and 
 accompanying this accentuated pulmonary second, or speedily 
 following its development, a systolic murmur in the auricular 
 area, where a distinct pulsation is very often both to be seen 
 and felt {vide p. 164). This auricular murmur radiates all 
 round its position of maximum intensity, but, owing to the 
 resonant properties of the sternum, it is most distinctly pro- 
 pagated to the right in the direction of the aorta, but it is 
 never propagated into the arteries. Accompanying this 
 auricular murmur there is always an impure first sound in 
 the mitral area, and this frequently passes into a systolic 
 murmur. There is always more or less pulsation at the 
 lower end of the sternum, with more or less evident undula- 
 tion or pulsation of the jugular veins, indicating engorgement 
 and dilatation of the right ventricle, but a distinct tricuspid 
 murmur is not a very usual phenomenon in spansemic cases, 
 unless we look upon the murmur audible in the mitral area 
 in advanced cases as of tricuspid origin, which there are some 
 good reasons for doing. In still more advanced cases, when 
 the ventricles have become not only dilated but somewhat 
 hypertrophied, we get a systolic murmur originating at the 
 aortic orifice and propagated along the arteries, and no doubt 
 the same thing happens at the pulmonary orifice, the murmur 
 in each case being due to the large blood-wave sent on by 
 the dilated ventricles coupled with the relative constriction 
 at the arterial orifices due to the abnormal friction of the 
 spansemic blood.-^ We can seldom trace the development of 
 these murmurs, because when a patient comes under treat- 
 ment she gets cured and the evolution of the murmurs 
 ceases. But in every case we can trace their gradual involu- 
 
 ^ Beau, TraiU d' Auscultation (Paris,''1856), pp. 366 and 565 ; vide also 
 "The Position and Mechanism of the Hajmic Murmur," Lancet (September 
 1877), p. 383, etc. 
 
 12 
 
178 CLINICAL LECTUKES ON 
 
 tion in the reverse order to that in which they have just 
 been described as arising, the aortic murmur being the first 
 to disappear, and every trace of the auricular pulsation and 
 of the auricular murmur vanishes long before the venous 
 hum ceases to be heard. Further, though the primary 
 murmur is in most cases an auricular one, yet we know that 
 there are exceptional cases in which the appendix auriculi 
 does not reach the surface ; in these cases there can be no 
 auricular murmur,^ and the murmur may be ascribed to any 
 one of the four cardiac orifices at each of which in turn it 
 presents itself with well-defined intensity. Thus the dis- 
 crepancies in the -vaews regarding the point of origin of this 
 spanaemic murmur have obviously been based upon accurate 
 observations imperfectly understood. 
 
 The cause of the cardiac dilatation is readily understood. 
 The spansemia of chlorosis is what Beau has termed a serous 
 polysemia, a state analogous to that produced by repeated 
 venesections, in which the red corpuscles are diminished and 
 the serum relatively, and in some cases actually increased. 
 In this condition, as we can readily understand, there is great 
 impairment of the cardiac metabolism and consequent re- 
 duction in the force of the ventricular contractions, with 
 residual accumulation within their cavities, resulting in in- 
 competence first of the mitral, and ultimately of both mitral 
 and tricuspid valves. Beau found that repeated venesection 
 produced in dogs and rabbits a spansemic condition, to which 
 he gave the name of serous polysemia. He also found that, 
 when bled to death, the hearts of those animals in whom 
 serous polysemia had been fully developed were not only 
 larger, more dilated, but also weighed from one-fifth to one- 
 sixth more than those of healthy animals killed by one fatal 
 haemorrhage from a severed carotid.^ The dilatation is 
 
 ^ The Senile Heart, p. 55. 
 
 ^ Archives G6n6rales de MMicirve, 4ieme serie, tome ix. (Paris, 1845), p. 156. 
 The following case shows that similar results follow a similar cause in man : — 
 "W. R. aet. 55, admitted to Ward XXXII., New Royal Infirmary, 27th April 
 1880, labouring under serous polyfemia of a serious character (pernicious 
 
DISEASES OF THE HEART 179 
 
 primarily compensated by the reserve force of the heart, and 
 the hypertrophy is slowly developed by means of the agencies 
 already referred to when speaking of a similar condition in 
 connection with aortic incompetence (vide p. 84). 
 
 Beau/ Bamberger,^ Friedreich,^ Wunderlich,* and Stark,^ 
 have all noted that the heart in chlorosis is large — dilated 
 and slightly hypertrophied — the serous polysemia of disease 
 having evidently a similar effect on the heart to that pro- 
 duced by haemorrhage. The true aortic murmur of chlorosis 
 is a late development, and the conditions on which it depends 
 are more serious than those subsisting at an earlier period 
 of the disease ; still they are known and acknowledged to be 
 curable. But dilatation and hypertrophy are not always 
 curable in one set of conditions, and always incurable in 
 another; the degree of curability depends upon the size of 
 the heart, partly on the amount of dilatation present, more 
 perhaps upon the degree of hypertrophy, to some extent 
 upon the cause of the affection, and even more upon the 
 patience and skill of the physician. If the cause be curable, 
 the result may certainly be remedied by nature or more 
 surely by art. I know many who years ago were believed 
 by competent observers to labour under incurable disease 
 of the heart, who for long have been perfectly free from any 
 trace of such disease ; in my own experience many have been 
 rescued from such a condition by the skilful use of remedies, 
 and I shall presently relate the histories of a few of these. 
 
 anaemia) the result of heemorrhage from the bowels of long standing. All 
 the murmurs of chlorosis were present in this case. He died 14th May 1880. 
 On post-mortem examination the whole surface of the body was blanched and 
 ansemic, rigor slight. The heart weighed 12| oz. ; its muscular fibre on both 
 sides was flabby and anemic, not fatty. The aortic valves were competent ; 
 the cone diameter of the aortic orifice was 1 inch, of the mitral 1 "5, of the 
 pulmonary artery 1"2, and of the tricuspid 2 inches. The left ventricle 
 measured 3 inches in length ; its wall from ^ to J inch in thickness. The 
 right ventricle measured 4 inches in length ; its wall J of an inch in thickness. 
 All the organs were blanched ; no special cause of death was found. 
 
 1 Op. cit. p. 169 ; vide also his Traite d' Auscultation (Paris, 1856), p. 355. 
 
 2 023. cit. S. 88 and S. 246 (Stuttgart, 1856), Bd. iv. S. 354. 
 
 3 Op. cit. S. 172. ■* Handbuch der Pathologic und Therapie. 
 5 Archiv der Heilkunde (1863), S. 47, and Gaz. Hehdomadaire, p. 262. 
 
180 CLINICAL LECTUEES ON 
 
 But to this hopeful view there is also a reverse, and it has 
 fallen to my lot to see sufferers from incurable cardiac 
 disease who, not many years previously, had been assured 
 by most skilful physicians that they had only a functional 
 ailment out of which they would grow. But so-called 
 functional murmurs are always murmurs of dilatation, and, 
 except under the most favourable circumstances, nature 
 only too often fails to remedy this. Even skilful treatment 
 may fail to completely restore the heart to its pristine con- 
 dition, but it always arrests the progress of the complaint, 
 and the benefits it confers are often more evident as years 
 roll on. Many years ago I vainly endeavoured to procure 
 the contraction of a flabby, dilated, chlorotic heart; in 
 time and with my sanction she was happily married, and 
 is now the mother of several healthy children. Her heart 
 has given no trouble, and though a loud systolic murmur 
 was long present, of late this has become less obvious and 
 it is now only occasionally to be heard faintly. 
 
 The early recognition of those so-called functional 
 murmurs, coupled with the more accurate knowledge we 
 now have as to their causation, will doubtless in the future 
 be the means of enabling us to avert the drifting into 
 incurable disease of many of these cases, and to restore to 
 usefuhiess many youthful lives that would otherwise have 
 been doomed to sad despair. 
 
 In the person of Helen Christison, Ward XIII., Bed 9, 
 admitted 12th February 1875, we have had an excellent 
 opportunity of observing the gradual and consecutive dis- 
 appearance of all the murmurs described, coincident with 
 the restoration of the patient to perfect health. 
 
 In all chlorotic cases the central lesion, and, so far as 
 the circulation is concerned, that upon which all the 
 phenomena observed depend, is certainly an alteration of 
 the blood revealed by a venous murmur. 
 
 Slight venous murmur is often to be found apart from 
 any untoward sign, but when at all well marked it is 
 
DISEASES OF THE HEART 181 
 
 invariably associated with an auricular murmur, and conse- 
 quently with some degree of cardiac dilatation. Murmurs in 
 the mitral area of chlorotic origin are comparatively rare ; 
 in such cases there is usually little more than an impurity 
 of the first sound in this area. Now and then, however, the 
 murmur is exceptionally loud and distinct, and it may be 
 impossible to decide — apart from the results of treatment — 
 whether it is due to simple dilatation or to actual valvular 
 lesion. The following case is a striking instance of this : — 
 
 Case XVII. Elizabeth Heughson, a domestic servant, 
 aged nineteen, admitted to Ward XIII. on 28th March 1873, 
 first examined on 29th March. The patient is a middle- 
 sized girl, of fair complexion and ansemic appearance. About 
 two years and a half ago she suffered from acute rheumatism 
 with pain over the cardiac area ; since that time she has been 
 liable to occasional rheumatic pains in various parts. She 
 has been much exposed to cold and damp, from the condition 
 of her dwelling at Oxford, and also from having to take part 
 in the family washing. Her present illness came on in 
 November last as simple weakness, which since then has 
 been gradually increasing. She has not menstruated for the 
 last two periods ; menstruation previously had been scanty. 
 Her digestion is feeble, and her abdomen flatulent; other 
 systems normal except the circulatory. The heart's apex is 
 felt to beat somewhat diffusely between the fifth and sixth 
 ribs, two inches and three-quarters from the left edge of the 
 sternurcL. In the parasternal line, one inch from the left edge 
 of the sternum, cardiac dulness commences at the upper edge 
 of the third rib and extends downwards to the liver dulness. 
 Transverse dulness at the level of the fourth rib begins one 
 quarter of an inch to the right of the sternum and extends 
 across for a distance of five inches and one quarter. In the 
 mitral area there is a loud, blowing, systolic murmur, which 
 is propagated round the chest to beneath the angle of the 
 scapula, and is followed by an accentuated second sound. 
 In the aortic area the first sound is replaced by a murmur, 
 
182 CLINICAL LECTURES ON 
 
 followed by a weakened second sound. In the pulmonary 
 area the first sound is also replaced by a murmur, most 
 distinctly heard one inch and a half from the left edge 
 of the sternum in the second interspace ; it is followed 
 by a distinctly accentuated second sound. The pulse is 
 108, small and feeble. A loud venous hum is audible in 
 the right jugular vein. She was treated with various 
 preparations of iron, at first along with digitalis ; latterly 
 with the ammonio-citrate of iron alone. Under treatment 
 she improved in strength, and regained a more healthy 
 appearance ; her palpitations almost entirely ceased, but her 
 murmur remained unaltered. On the 23rd of May she was 
 sent to the Convalescent Hospital, whence she returned for 
 examination on the 19th of June. She was then found to 
 have completely regained all the appearance of health, her 
 cardiac murmurs had entirely disappeared, the accentuation 
 of the pulmonary second was gone, and the venous hum had 
 ceased. In spite of the distinct history of rheumatism, 
 which made the prognosis doubtful, the cure was complete. 
 The result of treatment showed that the valves had been 
 quite unaffected, and that the whole of the very striking 
 phenomena had been due to simple dilatation of the left 
 ventricle, the result of chlorotic spantemia. The complete 
 disappearance of the accentuation of the pulmonary second 
 sound is conclusive proof that here we had an actual cure 
 by contraction of the ventricle, and not merely an example 
 of the vanishing of a murmur, the lesion remaining. 
 
 I need not say that in cases of acute rheumatism, as in 
 other pyrexial diseases, we frequently have the development of 
 a systolic mitral, an auricular or so-called pulmonary murmur 
 and a systoHc aortic murmur — the mitral murmur some- 
 times alone, the auricular occasionally by itself, but the aortic 
 murmur is never to be heard unless one or other, if not both, 
 of the before-mentioned murmurs is also present. All these 
 phenomena ordinarily disappear on the return of health. After 
 what has been already said, this is readily understood. The 
 
DISEASES OF THE HEAET ,183 
 
 defective metabolism of the heart, resulting from the depraved, 
 spansemic condition of the blood, weakens its contractile 
 force and causes residual accumulation in the ventricle. 
 The resulting dilatation of the cavity separates the papillary 
 muscles from its centre and prevents the chordce tendinece 
 from bringing the valve segments into apposition at the 
 moment of systole, hence regurgitation, varying in degree at 
 different times, the murmur itself varying in position and 
 intensity with the degree of regurgitation, as already pointed 
 out.^ When the normal healthy condition of the blood is 
 restored cardiac metaboHsm again becomes perfect, the 
 muscle recovers its healthy tone, the valve segments close 
 normally, and all signs of a cardiac affection disappear. 
 Should, however, the fibrous tissue of the valves or of the 
 chordce tendinece become thickened or shrivelled as the 
 result of the rheumatic process, then all the signs of 
 incurable mitral disease become developed. Sometimes this 
 follows consecutive to those of the curable form, the one set 
 of signs passing uninterruptedly into the other. At other 
 times the curable form of the disease is apparently perfectly 
 recovered from, and the incurable form is subsequently 
 developed after a varying interval of seeming health, some- 
 times as the result of the primary rheumatic affection, at 
 others, more or less evidently caused by the persistence of 
 rheumatic valvulitis in a chronic, sub-acute, or recurrent form. 
 Mitral murmurs of a curable character are frequently 
 found in connection with chorea. The close connection that 
 has long been recognised to subsist between chorea and 
 rheumatism ^ enables us to understand that many murmurs 
 originating during the course of chorea may become per- 
 
 ^ Vide antea, p. 169 ; also Roy and Adami, Philosophical Transactions, 
 vol. 183, p. 213 ; and also Ludolpli Krehl, Archiv fur Anatomic und 
 Physiologic (Leipzig, 1889), S. 291. 
 
 2 In his Contribution to Practical Medicine (Edinburgh, 1862), p. 68, etc., 
 Dr. James Beghie has well described the intimate connection between these 
 two diseases, and has told us the history of the discovery of this connection. 
 I myself have repeatedly seen patients in whom choreic movement alternated 
 with rheumatic inflammation of the joints. 
 
184: CLINICAL LECTURES ON 
 
 manent and incurable, but the larger proportion are curable 
 and disappear with returning health. Such murmurs have 
 been called dynamic, and have been ascribed to irregular 
 action of some part of the cardiac muscle, the result of clonic 
 spasm, and especially to clonic spasm of one or other of the 
 musculi papillares, similar in character to those spasms which 
 in this disease affect the voluntary muscles.-^ But clonic 
 spasm of any part of the heart muscle, though it might 
 account for an intermittent murmur, cannot be accepted as a 
 sufficient cause of a murmur, which, while it lasts, is constant 
 and unchanging. Besides, " there is no good proof that in- 
 voluntary muscular organs participate in the muscular dis- 
 order," ^ while " the admitted co-existence of rhythmical 
 action of the substance of the heart with this alleged tetanic 
 and irregular contraction of the papillary muscles, which, as 
 proved by dissection, are directly continuous with the fibres 
 of the ventricular walls, constitutes a still stronger objection 
 to this theory," ^ especially if we " bear in mind the unity 
 of the nerve centres, and the community of nerve-distribu- 
 tion enjoyed by both portions of the same fibres."* On 
 the other hand, the wasted skeletal muscles and spansemic 
 blood of a choreic patient are svifficient indications that 
 similar causes are present in this disease which are known to 
 produce a similar murmur both in chlorosis and in pyrexial 
 diseases, hence there is no difficulty in referring the murmur 
 in chorea to the same causes as in those diseases, nor in 
 recognising that haemic and dynamic murmurs do not differ 
 from one another but have a similar origin, pursue a similar 
 course, and are amenable to similar treatment. 
 
 There is scarcely any form of febrile disease in which so- 
 called hsemic cardiac murmurs have not occasionally been 
 heard. In scarlatina, relapsing and enteric fevers, such 
 murmurs are of common occurrence. In erysipelas, variola, 
 
 ^ Walshe, O71 Diseases of the Heart and Great Vessels, 3rd edition (London, 
 1862), p. 95. 
 
 ^ Kirkes, Medical Times and Gazette (1863), p. 637. 
 ^ Hayden, op. cit. p. 268. •* Loc. cit. 
 
DISEASES OF THE HEAET 185 
 
 measles, and in probably all other febrile diseases, they are 
 occasionally to be heard, but in true typhus such murmurs 
 are practically unknown.-^ ^^-lien we reflect that the cause 
 of these murmurs is inadequacy of the cardiac contractile 
 force, the result of imperfect metaboKsm due to flushing with 
 innutritions (spantemic) blood, we can readily understand 
 that in those whose general metabolism is already impaired 
 a comparatively trifling seizure may give rise to phenomena 
 which, in better nourished patients, are only occasionally 
 observed, even when they have been exposed to a more severe 
 and protracted disease. Hence the want of constancy in the 
 cardiac phenomena referred to in different cases even of the 
 same disease ; hence, too, the probably greater frequency of 
 those phenomena in hospital patients than in others. The 
 infrequency of such a murmur in typhus patients is readily 
 understood, when we reflect that to produce sonorous fluid 
 veins at any orifice, a certain amount of energy in the pro- 
 pelling force is requisite, and also remember that the cardiac 
 muscle is so enfeebled in this disease that murmurs due to 
 actual valvular disease disappear during its course, and re- 
 appear during convalescence so soon as the heart has re- 
 acquired sufiicient force.^ 
 
 In all febrile diseases in which a murmur of the character 
 described is observed, whatever may have been their nature, 
 the sequence of the phenomena, as observed by myself, has 
 been precisely similar to that observed in chlorosis. And it 
 will be readily perceived how important an observation this 
 is ; for as these chlorotic and febrile murmurs are actually 
 due to dilatation of the ventricle, and as it is also undoubtedly 
 
 ■^ For an account of the heart in typhus and in other fevers, I may refer 
 to the classic pages of Stokes in his work Tlie Diseases of the Heart aiul 
 Aorta (Dublin, 1854), p. 366. And an excellent account of the morbid 
 changes induced by protracted fevers in both the voluntary and involuntary 
 muscles is to be found in Zenker's memoir Ueher die Verdndsrungen der 
 willkurlichen Musheln iin Typhus ahdorainalis (Leipzig, 1864), and in 
 Murchison's work on The cojitinuecl Fevers of Great Britain (London, 1871), 
 p. 248, etc. 
 
 ^ Stokes, oj). cit. p. 444 ; and recapitulation, § 17, etc. 
 
186 CLINICAL LECTURES ON 
 
 true that all, or, at all events, all but a small proportion of 
 such cases make a perfect recovery,^ then we must very con- 
 siderably enlarge the area of curable cardiac affections, and 
 this we know to be nowadays (1898) duly recognised. In 
 regard to this I do not, of course, refer to the simple vanish- 
 ing of murmurs due to organic valvular lesions ; such lesions 
 are always permanent, as may be readily proved, but the 
 murmurs by which they are ordinarily revealed may, for a 
 time, cease to be heard. In these cases there is no possibihty 
 of a cure. It is different in cases of simple dilatation of the 
 heart ; in chlorotic and pyrexial dilatation, a perfect cure we 
 know to be the rule ; in dilatation from any other cause a 
 cure is perhaps the exception, but it may always be aimed at, 
 and is not infrequently attained. To Senac's mournful wail, 
 " Que peut-on esperer des medicaments, par exemple, dans 
 les dilatations du coeur ? " ^ modern medicine can now give 
 a triumphant reply. In simple dilatation of the right heart, 
 the result of bronchitis, the cure of the bronchitis is usually 
 followed by cure of the cardiac affection ; but to this there 
 are exceptions, to be subsequently detailed when speaking 
 of affections of the right side of the heart. In dilatation of 
 the left ventricle, occurring at or after middle life and arising 
 from many causes, but having as its basis a weakened myo- 
 cardium coupled with loss of arterial elasticity ,3 and often 
 precipitated or aggravated by over-indulgence in the pleasures 
 of the table by the well-to-do, or by strenuous exertion ac- 
 companied by the free use of alcohol in the poorer classes, 
 treatment is, from the essential nature of the affection, of 
 
 ^ Chlorotic murmurs are known ordinarily to result in perfect cure. In 
 regard to murmurs occurring in the course of fevers, Stokes says, "Of many 
 hundreds of cases of weak and softened hearts observed during the last twelve 
 years, we cannot adduce a single instance of organic disease of the heart 
 ■which could be traced to any injury done pending the typhous affection," 
 op. cit. p. 374. And we must remember that under the term "typhous" 
 Stokes included not only typhus, but also enteric and relapsing fevers, vide 
 Recapitulation, §§ 37, 38, 39 and 40, op. cit. p. 447. 
 
 - Traite dc la Structure du Cwur, de son Action, et de ses Maladies. Par 
 Jean Senac (Paris, 1749), vol. ii. chap. iv. p. 328. 
 
 * Vide The Senile Heart. 
 
DISEASES OF THE HEART 187 
 
 less avail. Still, even in these cases, marked improvement 
 is the usual result of appropriate treatment, and in a few a 
 positive cure — or, at all events, one of some permanence — is 
 actually attained. The following cases are interesting and 
 instructive examples of this; the cases are much condensed, 
 only the salient points in the cardiac lesion being re- 
 ferred to : — 
 
 Case XVIII. Henry Welsh, a labourer, aged sixty -one, 
 admitted to Ward V., I7th November 18 74, complaining of pain 
 in the chest, shortness of breath, swelling of the stomach, and 
 occasional palpitation. About thirty years ago this patient 
 had an attack of rheumatic fever, which he says lasted 
 twenty weeks. For the last ten years he has had occasional 
 pains in the left haunch and arm, which he calls rheumatic. 
 With these exceptions his health was perfect up to last 
 August, when he was suddenly seized with severe pain in the 
 front of the chest, accompanied by shortness of breath and 
 expectoration; this lasted about a week. After recovery 
 from this attack, he found that on attempting to work the 
 slightest exertion produced breathlessness and a great feeling 
 of weakness. The pain in the chest which was felt at first 
 has abated, but left behind a soreness which still continues. 
 About a month after his illness, he first noticed swelling of 
 his feet at night, and this still continues. The patient is a 
 well-built powerful-looking man, nearly six feet in height ; 
 his muscles are soft, and he says he has lost much flesh. 
 Till six weeks ago his head had to be raised to alleviate his 
 breathlessness ; now he can lie in any posture. Expression 
 of face natural, skin natural, temperature 98"6.° The sore- 
 ness complained of is referred by the patient to a point 
 about midsternum; it is always present, and, though not 
 very severe, it becomes worse upon any exertion. He has 
 no dyspnoea when at rest, but the slightest exertion pro- 
 duces a choking sensation referred by him to the part where 
 the pain is felt. At first he was much troubled with palpi- 
 tation, but this is not now so frequent. The pulse is 92, and 
 
188 CLINICAL LECTURES ON 
 
 is composed of alternate strong and weak beats ; at times 
 the force of each beat is fairly uniform, accompanied by- 
 intermissions and occasional double beats. The veins 
 generally are not distended, but the external jugulars are 
 slightly so, and pulsate distinctly ; they do not, however, 
 fill from below when pressure is made on them by the finger. 
 The cardiac apex beats between the fifth and sixth ribs, 
 four and a half inches from the mesian line ; no other pulsa- 
 tion is visible. On palpation the cardiac impulse is felt to 
 be feeble and irregular, both as to time and force. On the 
 left parasternal line, one inch from the sternum, the cardiac 
 dulness does not rise above the third rib. Transversely in 
 the plane of the fourth rib, dulness extends from half an 
 inch to the right of the sternum to four inches to the left of 
 the left edge of that bone. On auscultation in the mitral 
 area, a high-pitched systolic murmur is heard, accompanied 
 in three beats out of four by a partially closed first sound ; 
 in the fourth the murmur alone is audible. The maximum 
 intensity of this murmur is in the mitral area, but it is pro- 
 pagated distinctly round to the angle of the left scapula. In 
 the mitral area this murmur is followed by a somewhat 
 obscure second sound. In the tricuspid area a loud but low- 
 pitched systolic murmur is distinctly audible, accompanied 
 by some portion of a first sound, and followed by a second 
 sound, which is sharper than in the mitral area. At the base 
 the first sound is closed; the pulmonary second markedly 
 accentuated. There is no venous murmur. This patient 
 gradually improved under treatment, till, on his discharge on 
 18th February 1875, the only indication of cardiac disease 
 still remaining was a slight impurity of the first sound in 
 the mitral area, and an almost imperceptible accentuation 
 of the pulmonary second. The tricuspid murmur had en- 
 tirely disappeared. 
 
 Time alone can show whether in this case there was not 
 some slight damage of the mitral valve, dating from his 
 rheumatic attack thirty years ago ; or whether, as seems 
 
DISEASES OF THE HEART 189 
 
 probable, his lesion was solely dilatation of both ventricles, 
 dating from his febrile attack of last August, which seems 
 probably to have been bronchitic in character. In any case 
 his improvement was both marked and remarkable, and the 
 contraction of both ventricles, but particularly of the right 
 one, unmistakable. 
 
 In the following case the nature of the lesion is less open 
 to question, and the improvement — though only temporary — 
 even more remarkable : — 
 
 ■Case XIX. Euphemia Lawson, a domestic servant, aged 
 thirty-six, admitted into Ward XIII. on 26th September 
 1 872, labouring under breathlessness and swelling of the lower 
 extremities. In this case there was forcible pulsation at the 
 lower part of the sternum, pulsation of the jugular veins, and 
 slight increase of the transverse dulness of the heart. In 
 the mitral area a blowing murmur, and in the tricuspid area 
 a similar murmur of a somewhat lower pitch completely 
 replaced the first sound in the respective areas. These 
 mm-murs were propagated into the aortic and pulmonary 
 areas ; the aortic second was weakened ; the pulmonary 
 second much accentuated. Lawson never had any rheumatism 
 whatever, but she worked hard, and was rather given to the 
 abuse of stimulants. About three months after admission, 
 at the hour of visit, we were suddenly called to her bedside 
 to find her completely unconscious, and paralysed on the left 
 side. The unconsciousness passed off within half an hour ; 
 the paralysis of the arm ceased to be noticeable in a few days ; 
 and after the lapse of some weeks the paralysis of the leg 
 was only revealed by a shght dragging, which ultimately 
 quite disappeared. Under treatment all her cardiac symptoms 
 also vanished ; and at her discharge on 26th March 1873, the 
 only detectable sign of what had originally appeared to be a 
 most serious disease was a slight blunting of the first sound. 
 All the murmurs had quite disappeared, and the accentuation 
 of the pulmonary second could no longer be detected. Lawson 
 felt so well that she left the Infirmary to go direct to service, 
 
190 CLINICAL LECTURES ON 
 
 and in service she remained for over two years. During that 
 period I had repeated opportunities of examining her heart, 
 and always found it exactly as it was when she was dis- 
 charged. At last, by a repetition of the original causes, 
 Lawson's heart again dilated, and she was readmitted 19 th 
 August 1875, with some oedema of her lower extremities, 
 breatlilessness, some rhonchi and frothy, watery sputa, the 
 latter coming on after admission. Her heart was again 
 dilated, with strong pulsation beneath the lower part of the 
 sternum, no perceptible apex beat in the usual position, and 
 all the other signs as already described. The pulsation of 
 the heart was, however, more forcible than it had formerly 
 been ; it was obviously more hypertrophied, a condition 
 following of necessity on the primary dilatation. In com- 
 menting on the case at that time I stated that I still hoped 
 to be able to restore the heart, but not so perfectly as before, 
 and that shghter disturbances would bring back the dilatation, 
 until at last the case would terminate in the usual manner 
 by increasing dropsy and death from asthenia. There was 
 not a trace of her paralysis remaining, and she improved so 
 much under treatment that she was discharged on 19th 
 September with her heart once more completely rehabilitated. 
 But not for long ; as prognosticated, Lawson was not long in 
 coming back to die from asthenia, though not from dropsy. 
 She was readmitted on 9th February 1876, complaining of 
 shortness of breath, pain in the left side, and swelhng of her 
 legs. Lawson was two and a half months in the Infirmary, 
 and during that time she suffered much from repeated 
 embolisms, both in the pulmonary and systemic arteries. 
 The history of the case records that she suffered from a 
 perfect " shower " of such plugs. The pulmonary embolisms 
 were twice over the cause of localised pleurisies, which on 
 one occasion raised the temperature to 103°. The clots in 
 the systemic arteries chiefly lodged in the spleen and kidneys, 
 but a few days before her death the brachial artery was 
 occluded at its lower end by an embolus. The temperature 
 
DISEASES OF THE HEART 191 
 
 and quantity of urine varied incessantly from these causes. 
 About a month after her admission she suddenly presented 
 that rare form of cardiac irregularity of the bigeminal type, 
 in which the right and left ventricle alternately predominates, 
 the carotid artery and jugular vein pulsating alternately.^ 
 The ever-recurring embolisms gradually reduced the patient 
 to a state of extreme misery, from which she was reheved by 
 death on 29th April 1876. The Infirmary Pathological 
 Eeport states : — " Heart enlarged, weighing 1 lb. 2| oz. 
 Eight auricle and ventricle were much dilated, and the 
 tricuspid orifice was enlarged, admitting eight fingers. The 
 auricular appendix was filled with a thrombus which was 
 evidently somewhat old. It was adherent at its periphery 
 to the endocardium, and its centre was partially reduced to a 
 soft yellow pulp by fatty degeneration. The visceral peri- 
 cardium covering the appendix was white and opaque from 
 chronic inflammatory thickening. The left auricle and 
 ventricle were considerably dilated. The muscular wall of the 
 ventricle was shghtly hypertrophied, measuring five-eighths 
 of an inch in thickness. In the left auricular appendix there 
 were several small gray thrombi about the size of peas. In the 
 cavity of the ventricle there were also a number of thrombi, 
 and two of them of large size, being respectively that of a 
 walnut and of a filbert. These were of a dirty gray colour 
 and firm consistence. Superficially they presented a rather 
 delicate reticular arrangement of the fibrin, and on being cut 
 into, the larger of the two was found to present a collection 
 of fatty matter in its centre near one extremity, and a serous 
 cyst near the other. The mitral orifice admitted four fingers ; 
 cone diameter 1'55 inch. The mitral and aortic valves 
 presented atheromatous thickening, but were otherwise 
 natural." In the lungs, spleen and kidneys, there were 
 fibroid indurations, recent infarctions, and many cicatrices, 
 
 ^ This case, along with another similar one, has been published in extenso 
 by the late Professor Roy of Cambridge, ■who was at that time my resident 
 physician. — Vide "On Two Heart Cases which presented a Rare Form of 
 Irregularity," Edinburgh Medical Journal (January 1878), p. 594. 
 
192 CLINICAL LECTURES ON 
 
 the result of embolic processes. This very instructive case 
 teaches us that even after middle life we may occasionally 
 succeed in completely rehabilitating a dilated heart, but to 
 keep it so necessitates a careful avoidance of the original 
 causes of the dilatation, and an equally careful attention to 
 the maintenance of the metabolic equilibrium of the organ. 
 This case presents also a well-marked example of an unusual 
 mode of death, exhaustion due to repeated embolisms, not 
 one of which was in itself serious, but which wore out the 
 patient's strength by their continual recurrence. There was 
 no blood-poisoning, the emboli were perfectly aseptic, and 
 the fatal issue resulted from the continual irritation arising 
 from incessant variations in temperature, accompanied by 
 trifluig local inflammations occurring in an organism already 
 exhausted. This case also presented a well-marked instance 
 of that rather rare form of irregularity in which there was 
 not only a bigeminal rhythm of the heart's action, but also 
 a weakening of the alternate pulsations of each heart, so that 
 the jugular vein and the carotid artery were seen to pulsate 
 alternately at the root of the neck. This matter will be 
 referred to subsequently when treating of cardiac irregularity. 
 But perhaps one of the most remarkable cases of cure of a 
 dilated heart was that of Case XX., A. G., married, aged thirty- 
 three, who had been attacked by typhoid fever twelve weeks 
 before her admission to Ward XIII., early in 1877. In the 
 course of her fever she was prematurely delivered of her 
 sixth cliild. Considerable flooding took place after the 
 birth of her child, and, as she seemed to be gradually getting 
 weaker, she was sent to the Infirmary. On admission she was 
 intensely spansemic ; her heart was extremely feeble and 
 fluttermg ; her pulse averaged 150 to 180 per minute, and she 
 seemed to be sinking fast. After a few days of appropriate 
 treatment she regained sufficient strength to be able to turn 
 in bed, and her pulse fell to about 90, and had gained both 
 force and tension. No impulse was to be seen over the 
 cardiac area, but slight venous oscillation was visible over the 
 
DISEASES OF THE HEAET 193 
 
 jugular veins, and a distinct pulsation was to be felt in the 
 second intercostal space one inch and three-quarters to the 
 left of midsternum.^ Over the jugular veins a venous hum 
 was audible; over the auricular pulsation a loud systolic 
 murmur was audible, and this was less distinctly heard in both 
 mitral and tricuspid areas as a low, blowing murmur taking 
 the place of the first sound. After some months of treat- 
 ment she was dismissed cured ; all her symptoms and physical 
 signs had entirely disappeared. Her home was not all it 
 ought to have been, and in a few months she returned with 
 a relapse of all her symptoms. She was advised to come into 
 hospital, but as she preferred to remain at home, she was 
 dismissed with a prescription for a ferruginous tonic. She did 
 not improve, however, and she was admitted to "Ward XV. 
 in October 1877, labouring under general dropsy, and passing 
 only a small quantity of urine deeply tinged with blood. 
 Her heart, particularly the right side, was greatly dilated ; 
 there was a loud systolic murmur in all the cardiac areas, and 
 well-marked jugular pulsation. The essential part of the 
 treatment consisted in the administration of digitalis in large 
 doses for short periods, twenty or thirty minims of the 
 tincture or a proportionate dose of the infusion being given 
 every four hours till a decided effect was produced on the 
 heart. The digitalis was then pretermitted for a time, and 
 during this interval, iron and quinine, or iron and arsenic 
 were freely administered to improve the state of her blood. 
 In this way her strength was gradually improved, her dropsy 
 removed, and her heart contracted, so that in June 1878 she 
 was shown to the Medico-Chirurgical Society without a trace 
 of murmur, without any accentuation of the pulmonary 
 second, and with only a slight increase in the force of the 
 heart -beat (hypertrophy) as the sole 'indication of the 
 serious condition from which she had recovered.^ Two 
 
 1 This case as it was when first admitted will be found narrated by my 
 resident, Dr. George Gibson, in the Eclinburgh Medical Journal (October 
 1877), p. 302, who has also given a cardiogram of the auricular pulsation. 
 
 2 Vide Edinburgh Medical Journal (June 1878), p. 1120. 
 
 13 
 
194 CLINICAL LECTURES ON 
 
 years subsequently (June 1880) she continued in perfect 
 health, and presented no mdication of heart trouble beyond 
 a blunt first sound, and a slight increase in the force of the 
 apex beat. 
 
 It might not perhaps be easy to multiply cases quite so re- 
 markable as the one just narrated, but scores of similar cases 
 might be quoted if needful as proof that cardiac dilatation is by 
 no means a necessarily incurable condition. In its earliest 
 stage it may generally be recognised by the presence of a more 
 or less distinct systolic murmur, sometimes accompanied by 
 pulsation in the auricular area ; as the affection progresses 
 the systolic murmur passes mto the mitral area, and by and 
 by implicates the tricuspid also. In advanced cases there is 
 both mitral and tricuspid regurgitation, and there may be a 
 loud systolic murmur in all the cardiac areas. In its slighter 
 forms cardiac dilatation is readily curable, and is almost 
 invariably cured. Even in its more severe forms it may be 
 much ameliorated, and occasionally cured if the patient be 
 young, but in cases past middle life the conditions are 
 such that we have no right to look for more than ameliora- 
 tion. And yet even amongst them we occasionally stumble 
 on a cure. 
 
 In simple chlorotic cases it is sufficient to improve the 
 •quality of the blood, and through that the general metabolism, 
 to ensure a perfect cure ; but this is not always so easy as it 
 seems. The pale countenance and want of appetite suggest 
 fresh air and sunlight, both most excellent remedies, but of 
 no material avail apart from the one remedy which alone 
 proves efficient in the cure of chlorosis, and that is iron. Of 
 all the various preparations of this drug it does not seem 
 that there is any one that can be specially regarded as of more 
 iniportance than another in the treatment of chlorosis. 
 Neither is any special dose of more consequence than any 
 special preparation. The point of most unportance is to 
 select that preparation of iron which agrees best with the 
 patient, and to give it in the dose and in the manner which 
 
DISEASES OF THE HEAET 195 
 
 produces least disturbance.-^ Arsenic is often combined with 
 iron in the treatment of such cases, and though it is no longer 
 supposed to have any effect in increasing the number of the 
 red corpuscles or the amount of hsemo-globin, its powerful 
 tonic influence on the heart and lungs, if not also on the blood 
 itself,^ makes it wellnigh indispensable. As the heart is 
 always more or less affected in all cases of chlorosis, abund- 
 ance of rest is a most important means of averting more 
 serious cardiac trouble,^ and a month or more in bed is well 
 known to be a most important adjuvant to other treatment. 
 When cardiac dilatation is more marked the tonic influence 
 of digitalis is of the greatest value, and the dose of the drug 
 as well as the method of administration must vary with the 
 requirements of each individual case. In serious dilatation 
 it is generally well to give large doses of digitalis at regular 
 intervals until a decided effect is produced on the heart, then 
 to pretermit the drug for a time, giving iron and arsenic 
 during the interval. In less serious cases it is sufficient to 
 give smaller doses of digitalis night and morning, iron and 
 arsenic being given simultaneously along with the food. It 
 is always well to avoid giving iron and digitalis in combina- 
 tion, as sickness is very apt to be thus induced. Of course 
 good nourishing food forms a most necessary part of the 
 treatment, and, when the cure is sufficiently advanced, pure 
 country air, with moderate but gradually increasing exertion. 
 Stimulants are not to be recommended ; sometimes they are 
 useful and occasionally necessary, but they must be used with 
 caution as tonics only, and not as stimulants. As an example 
 of the benefit to be derived from tonic doses of digitalis even 
 in apparently the most untoward circumstances, I may 
 mention the case of an old gentleman who first consulted me at 
 the age of seventy-seven on account of attacks of syncope which 
 came on whenever he made the slightest exertion. His heart 
 
 ^ Vide "The Treatment of Chlorosis by Iron and some other Drugs," by- 
 Ralph Stockman, M.D., F.R.C.P.E., in the British Medical Journal for 29th 
 April and 4th ]\Iay 1893. 
 
 2 The Senile Heart, p. 270. = Op. cit. p. 47. 
 
196 CLINICAL LECTURES OX DISEASES OF THE HEART 
 
 was SO weak as to be almost imperceptible, his pulse so feeble 
 as scarcely to be felt, and the attempt to walk any distance was 
 sure to be followed by a severe faint. After taking for four 
 years ten minims of tincture of digitalis night and morning, 
 he developed a firm forcible apex beat, and an excellent pulse, 
 and he also ceased to alarm his friends by fainting. In short, 
 instead of dying from a so-called fatty heart, as had been pre- 
 dicted, he lived to be over ninety years of age, and finally did 
 not die from his heart at all but from senile asthenia. 
 
LECTUEE VII 
 
 ox TEICUSPID EEGUKGITATIOX, CUEABLE AND INCUEABLE 
 
 In speaking of the murmnrs connected with stenosis 
 of the mitral opening, I referred to one case in which 
 stenosis of the tricuspid was not only suspected during life, 
 but actually proved to exist by the results of a post-mortem 
 examination.-^ Since then we have had another case, in Ward 
 v., in which the peculiar propagation of the presystohc 
 murmur left no doubt on my mind that we had before us 
 another example of stenosis of the tricuspid as well as of the 
 mitral opening. Happily we were able to discharge this 
 patient considerably improved, and are therefore unable to 
 speak with perfect certainty as to his actual lesion.^ The 
 morbid appearances foimd in two other cases of tricuspid 
 stenosis have also been recorded by Dr. Haldane ; in one of 
 these the diagnosis was made during life.^ Thus in httle 
 more than ten years there have been four cases of tricuspid 
 stenosis observed in the Edinburgh Infirmary, so that, though 
 an infrequent affection, we cannot afford altogether to ignore 
 it. Tricuspid stenosis, when not congenital, is very generally 
 — 79 times out of 117 cases — associated with stenosis of the 
 
 1 Vide Case IX. p. 122. 
 
 2 Case of Martin Kelly, aged sixteen, admitted to Bed 6, Ward Y., on 
 26th January 1874 ; discharged 19th March eodem anno. 
 
 2 Edinburgh 3Iedical Journal (September 1S64), p. 271. These are all the 
 marked cases of tricuspid stenosis that occurred during the ten years specified, 
 but I am quite conscious of having during that time occasionally seen in the 
 post-mortem theatre other hearts in -which the segments of the tricuspid valve 
 were thickened and slightly shortened. 
 
198 CLINICAL LECTURES ON 
 
 mitral opening also, and is mostly of rheumatic origin.^ 
 Tricuspid stenosis has in every case a most unfavourable 
 influence upon the prognosis, and is always a most serious 
 complication of mitral stenosis. It is scarcely possible to 
 make an accurate diagnosis of such a condition ; the points to 
 be mainly relied upon are, first, the presence of a presystolic 
 murmur or thrill, or of both of these signs, in the tricuspid 
 area and extending to the right of the sternum. Unfortun- 
 ately both of these signs are often absent. The second 
 important indication never fails, only variat gradii, and 
 consists in the e^ddence of considerable backward pressure, 
 with but little indication of regurgitation; well-marked 
 dulness to the right of the sternum, in the plane of the fourth 
 rib — the auricular area — accompanied by considerable 
 turgescence of the jugular veins without pulsation, or with 
 only an inconsiderable indication of pulsation. Naturally 
 this sign only affords presumption, and is not infallible. 
 Mitral stenosis in its most usual form involves regurgitation 
 also, and the same is true of tricuspid stenosis, as has been 
 frequently recognised.^ Regurgitation occurring in such a 
 manner is absolutely incurable. I have already mentioned 
 that pure tricuspid regurgitation — the result of simple 
 dilatation — is a frequent concomitant of mitral stenosis, and 
 that it occurs sooner in such cases, and is more considerable, 
 the earlier in life the mitral stenosis has been developed, 
 especially if it is associated with any marked degree of aortic 
 hypoplasia, being almost invariably in all such cases the mere 
 prelude to the end.^ In cases such as these the tricuspid 
 regurgitation is always considerable, and its effects upon the 
 systemic venous circulation well marked. It is of course 
 incurable, though, as akeady noted, it may be — especially at 
 first — somewhat modified by treatment, and the inevitable 
 
 ^ Vide Essai sur le Ritridssement Tricuspidien, These pour le Doctorat 
 en Medecine par M. Robert Leudet, Paris, Steinheil, 1888. 
 
 - Edinburgh MedicalJournal (September 1864), pp. 271, 272 ; and Leudet, 
 op. cit. 
 
 ^ Lecture V. p. 135. 
 
DISEASES OF THE HEART 199 
 
 end postponed. The amount of relief to be thus obtained 
 depends upon the degree of stenosis present, as well as on 
 that of the aortic hypoplasia. But the dilated condition of 
 the right ventricle, though for a time it may be remedied, 
 speedily becomes persistent, and the hypertrophy ere long 
 becomes considerable, so that at times the right ventricle 
 forms the apex of the heart, and the left ventricle seems a 
 mere appendix attached to it.^ 
 
 The physical signs upon which we rely as certain indica- 
 tions of tricuspid regurgitation are few, simple, and easily 
 recognised. First, there is a shifting of the apex beat from 
 its normal position, about two inches to the left of the 
 sternum in the fifth interspace, to just beneath the sternum, 
 and also a change in its character from an outward thrust to 
 a diffuse impulse more or less heaving and forcible in pro- 
 portion to the hypertrophy present. These variations from 
 the normal result from the dilatation of the right ventricle 
 and arise from its anatomical position in front of the left. 
 Similar modification may be temporarily brought about even 
 in health by holding the breath as long as possible ; respiratory 
 changes being thus stopped, the lungs become congested, the 
 right ventricle, dilated by residual accumulation, swells out 
 like a water cushion in front of the left ventricle, which it 
 pushes backward into the cavity of the chest ; the apex fails 
 to reach the chest wall and ceases to be felt by a finger 
 resting on it, while the palm of the hand placed over the 
 lower part of the sternum feels an obscure pulsation. This 
 is an experiment which each one can make for himself. 
 
 Second, on percussion there is increased dulness to the 
 right of the sternum in the plane of the fourth rib ; this, how- 
 ever, is rather the result of secondary dilatation of the right 
 auricle than of any increase in the breadth of the ventricle. 
 
 Third, on auscultation the stethoscope in the very earliest 
 
 ^ Case XIV. p. 143. Many similar cases have been observed ; those 
 recorded are selected representative cases, and are to be accepted as typical 
 examples of a group, and not merely as isolated instances of any given 
 abnormality. 
 
200 CLINICAL LKCTUEES ON 
 
 stage of dilatation of the right ventricle conveys to the ear 
 a feeling of imnsual and abnormal pulsation in the tricuspid 
 area. Later on, in the same area, viz. at the sternal end of 
 the fourth, fifth, and sixth ribs, we mav have a loud systolic 
 murmur, which is propagated with more or less distinctness 
 into all the other cardiac areas, but which has its position of 
 maximum intensity in the position referred to. When mitral 
 co-exists with tricuspid regurgitation we have two foci of 
 maximum intensity for the systohc murmur, one in the 
 tricuspid, and another in the mitral area or a little to the 
 left of it ; there is often also a difference of pitch in the two 
 murmurs, but sometimes the one and sometimes the other is 
 the higher. Like all cardiac murmurs the tricuspid is 
 occasionally absent, even when all the other signs of tricuspid 
 regurgitation are certainly present, a murmur being always 
 the least reliable sign. 
 
 Fourth, even without any notable regurgitation through 
 the tricuspid valve, long-continued pulmonary congestion and 
 overfilling of the right ventricle are necessarily followed by 
 great congestion of the right auricle and of the systemic 
 veins. Hence in such cases we have the external jugular 
 veins, and especially the right one, markedly turgid, and 
 frequently undulating with a wavy motion communicated by 
 the systohc percussion of the turgid tricuspid valve acting 
 through the medium of the blood in the overdistended right 
 auricle, which has all the elasticity of compressed fluid. But 
 when long-continued distention, due to tricuspid regurgitation, 
 has made ineflicient the valve at the root of the external 
 jugular where it enters the subclavian, we have distinct 
 pulsation in the jugular vein, the vessel filling from below 
 synchronous with each ventricular systole. This venous 
 pulsation is always more or less visible, according as the 
 veins are more or less distinct, but is best marked in elderly 
 persons, in whom the veins are usually larger, and the adipose 
 tissue covering them not so abundant as in younger people. 
 By compressing the vein at the middle of the neck, we stop 
 
DISEASES OF THE HEAKT 201 
 
 the downward flow from the head and the systolic reflux is 
 more easily seen. Jugular pulsation is generally visible 
 whenever we have a tricuspid murmur, and it is sometimes 
 to be seen when no murmur is to be heard. As it is 
 always a result of great previous venous turgescence, it 
 may be accepted as a reliable indication of tricuspid re- 
 gurgitation — even though a murmur be absent — provided 
 the other signs just referred to are present. But if the 
 substernal pulsation be absent or slight, it is possible that 
 the jugular pulsation may only be the remanent result of a 
 pre-existing tricuspid regurgitation, the valve being perfectly 
 rehabilitated — incompetence of the venous valve causing 
 what would otherwise have been a mere undulation to exhibit 
 a distinctly pulsatory character. Jugular pulsation is thus 
 always either a proof of existing tricuspid regurgitation, or a 
 sign that tricuspid regurgitation has previously existed, and 
 may be readily reproduced. It is therefore a sign of some 
 importance. Pulsatory and other abnormal changes are 
 most readily observed in the jugular vein, but the jugular is 
 by no means the only vein affected by a systolic reflux. 
 From the absence of valves, the considerable size, and the 
 dependent position of the vena cava inferior, the regurgitant 
 blood must flow with great freedom and directness down 
 that vessel into the liver. Hence hepatic pulsation is a 
 phenomenon that may be observed, in many cases, even before 
 pulsation can be seen in the jugular vein. It is well to 
 remember, however, that hepatic pulsation may be produced 
 in three different ways. First, we may have a simple depression 
 of the liver, chiefly the left lobe, synchronous with the systole 
 of the ventricles, and apt to be regarded as a pulsation in 
 scrohiculo cordis of the heart itself. Second, we may have a 
 heaving of the whole mass of the liver, due to a movement 
 communicated to it by an aneurysm of the descending aorta, 
 or by the vena, cava, which may be enormously dilated.-*^ This 
 pulsation is not synchronous with the ventricular systole, as 
 
 1 Vide antea, p. 8. 
 
202 CLINICAL LECTUEES ON 
 
 may be readily demonstrated by the measures formerly 
 described (p. 9). And, third, we may have a distinctly 
 expansile pulsatory movement also communicated to the 
 whole mass of the liver by the systolic pulsation of the 
 hepatic veins ramifying within it. This pulsation is also 
 delayed and is not synchronous with the ventricular systole ; 
 its expansile character sufficiently distinguishes it from that 
 form of hepatic pulsation most nearly allied, which has 
 just been described. Excluding the pulsation produced 
 by aneurysm, the two latter forms of hepatic pulsation are 
 indications of a more advanced and more serious degree of 
 cardiac dilatation than suffices to produce the variety first 
 described. Hepatic pulsation wliich is retarded and is 
 not synchronous with the cardiac systole is, therefore, an 
 important diagnostic phenomenon, and every care must 
 be taken to expiscate its ultimate cause. There is too 
 much reason to suppose that these varieties of hepatic 
 pulsation have not always been sufficiently discriminated, 
 and that hepatic pulsation has been, occasionally at least, 
 simply referred to the ventricular impulse, even when the 
 absence of synchronism has been distinctly recognised. Allan 
 Burns, for example, refers to a most furious pulsation in the 
 epigastric region, " produced," as he says, " entu'ely by the 
 dilated heart," in which, from the absence of synchronism 
 between the heart and the pulsating liver, no one ever doubted 
 but that the cause of the pulsation was an aneurysm of the 
 coeliac artery.^ In very rare cases we may have as the 
 result of tricuspid regurgitation a reflux pulsation visible not 
 only in the jugular, but also in some of the smaller and more 
 superficial veins — as the brachial^ — but this is so uncommon 
 as to be unimportant. 
 
 It is commonly said that tricuspid regurgitation alters or 
 removes any pre-existing accentuation of the pulmonary 
 second sound. No doubt it must alter this accentuation, but 
 inasmuch as we have not the two conditions simultaneously 
 
 1 Oj). cit. p. 264. 
 
DISEASES OF THE HEAET 203 
 
 before us, we never can say to what extent or in what manner 
 it is changed. But tricuspid regurgitation can never alto- 
 gether remove pulmonary accentuation, because the same 
 increased intra-pulmonary blood-pressure which produces and 
 maintains the regurgitation also keeps up the accentuation. 
 So long, therefore, as tricuspid regurgitation persists the 
 pulmonary second must continue to be accentuated relative 
 to its norm, and must be markedly so in relation to the 
 aortic second, which from the same cause is weakened. 
 
 As can be readily understood, and has been already 
 pointed out, mitral stenosis is a frequent cause of serious 
 tricuspid regurgitation, and the earlier in life the stenosis 
 has occurred the more speedily, as a rule, does the tricuspid 
 regurgitation follow, and the more serious is the prognosis. 
 But any hindrance to the circulation through the left heart 
 may be a cause of tricuspid regurgitation, hence simple 
 mitral regurgitation, due to dilatation only, is not in- 
 frequently associated with this affection, but this is not 
 common in early life, is never relatively so excessive, and 
 the dilatation and hypertrophy usually progress on both 
 sides ;pari passu. At first by treatment we may be able to 
 rehabilitate the tricuspid valve, but unless we can also 
 rehabilitate the mitral we only gain a temporary postpone- 
 ment of the end. Still this end is never so rapidly reached 
 as in serious mitral stenosis. And from the simultaneous 
 implication of both ventricles, and the long duration of the 
 disease in many such cases, the whole heart is often enlarged 
 to a veritable cor bovinum,^ before the gradual transference of 
 the blood from the arteries to the veins culminates first in 
 general dropsy, and lastly in fatal asthenia, and skilful treat- 
 ment may do much to mitigate the evils of this condition 
 and to postpone the inevitable end. Great obstruction at 
 the aortic orifice has a similar effect to mitral stenosis, but 
 extreme aortic stenosis is so rare as to be of little practical 
 
 1 Theodor. Priscian, De Diaeta, 15, speaks of "Medulla bovina." Though 
 unusual, the adjective is strictly classical. 
 
204 CLINICAL LECTURES ON 
 
 importance as a cause of tricuspid regurgitation. On the other 
 hand, aortic regurgitation is common enough, but its own 
 peculiar sources of mortahty are such as only too frequently 
 anticipate any important alteration of the right ventricle.^ It 
 is only comparatively rarely, therefore, that aortic incompetence 
 gives rise to tricuspid regurgitation of a serious character. 
 
 Next to diseases of the left heart, diseases of the lungs 
 are those which affect the right ventricle, and only two of 
 those are of much importance in this respect. Chronic, and 
 especially tubercular diseases of the lungs only exceptionally 
 produce any alteration of the right ventricle, because with 
 the progress of these diseases there is a simultaneous diminu- 
 tion of the amount of blood circulating. Such acute diseases 
 as pneumonia never last long enough to produce any serious 
 alteration of the right heart; and even pleurisy with con- 
 siderable effusion is seldom sufficiently protracted without so 
 much diminution of the mass of blood as to make consecutive 
 dilatation of the right ventricle a comparatively rare com- 
 plication. It is otherwise with bronchitis — acute or chronic. 
 In it the obstruction to the circulation through the lungs is 
 great, lasts sufficiently long, and is accompanied by no 
 diminution in the mass of blood sufficient to nullify its 
 dilating effect upon the right ventricle. In bronchitis, there- 
 fore, we have, next to mitral stenosis, the most common 
 cause of considerable tricuspid regurgitation. But inasmuch 
 as bronchitis is a curable disease, the tricuspid regurgitation 
 produced by it is evanescent, passes away with its cause, and 
 does not always recur, even with a recrudescence of the exciting 
 and primary disease ; because to produce cardiac dilatation 
 there must be, in addition to bronchitis, some loss of tone of the 
 cardiac muscle due to pyrexia or defective metabolism, the 
 result of impaired nutrition either of general or local origin. 
 
 Emphysema of the lungs, which is the only other 
 pulmonary cause of tricuspid regurgitation of any importance, 
 is a much more serious cause than bronchitis, because from 
 
 1 Lecture IIL p. 95. 
 
DISEASES OF THE HEAET 205 
 
 what we know of its pathology the presence of emphysema 
 necessarily presupposes a greater or less limitation of the 
 area of the pulmonary capillaries, and consequently an 
 obstruction to the chculation through the lungs as permanent 
 and as incurable as that arising from any equivalent amount 
 of mitral stenosis. Tricuspid regurgitation following emphy- 
 sema of the lungs has, therefore, quite as serious a prognosis 
 in regard to curabiHty as that following mitral stenosis, but, 
 as we shall presently see, the prognosis quoad longevity is 
 not by any means so grave. Tricuspid regurgitation from 
 emphysema has, however, certain physical signs peculiar to 
 itself, to which I shall presently refer. 
 
 The following case presents a well-marked example of 
 curable tricuspid regurgitation : — 
 
 Case XXI. William Savage, aged thirty-eight, a labourer, 
 admitted to Bed 3, Ward V., on 24th March 1870, complaining 
 of great difficulty of breathing, and of cough and expectora- 
 tion. On admission the patient stated that he worked in a 
 quarry, and frequently suffered from chills, the result of 
 exposure to cold winds while heated by hard labour. The 
 present attack was the result of one of those chills. He had 
 repeatedly suffered from similar attacks, and in two similar 
 seizures he had been treated by copious and repeated vene- 
 sections. The patient was tall and strongly built. His 
 countenance was swollen and dusky; he suffered from 
 orthopnoea; his skin was cool, and his finger-tips purple. 
 On inspection his apex beat could not be seen, but instead 
 there was a pulsation beneath the lower part of the sternum 
 and in the scrohiculus cordis. On palpation the chest was 
 felt to expand equally in all directions, and a systolic heaving 
 impulse was felt beneath the lower part of the sternum, the 
 apex beat being absent from its normal position. The 
 percussion note over the chest was normal, except a slight 
 increase of the transverse dulness of the heart, which, at the 
 level of the fourth rib, commenced nearly one inch to the 
 right of the sternum. On auscultation moist crepitations. 
 
206 CLINICAL LECTURES ON 
 
 mingled with a few rhonchi, completely obscured all other 
 pulmonary and cardiac sounds, except that the pulmonary 
 second was distinctly heard to be accentuated. A large 
 jacket -poultice of linseed meal was ordered to be applied 
 over the whole chest, and half an ounce of infusion of senega 
 with ammonia and spirit of chloroform was given every four 
 hours. 2^th March. — Had slept badly on account of his 
 orthopnoea. The whole surface was livid ; condition other- 
 wise unchanged. Infusion of digitalis to be substituted for 
 that of senega. 2^th March. — To-day there was evident 
 improvement, and a systolic murmur could now be heard in 
 the mitral area, replacing the first sound. A systolic murmur 
 could also be heard in the tricuspid area, and in the aortic 
 area the first sound was replaced by a murmur, the semilunar 
 valves being distinctly heard to close. Next day, 27th 
 March, the lungs were so far free from crepitations that it 
 was possible accurately to differentiate the mitral from the 
 tricuspid murmur, and the patient could now sleep well in 
 the recumbent posture. On 29th March the patient felt 
 almost well, and had but little cough. His breathing was 
 easier, and his colour natural. On 1st April it was noted 
 that though the tricuspid murmur was still distinct, yet the 
 pulsation of the right ventricle was mostly confined to the 
 lower part of the sternum, and was hardly perceptible in the 
 epigastric region. On 2nd April it was noted that the chest 
 was quite free from crepitations, and that no murmur was to 
 be heard in any of the cardiac areas. On 9th April he had 
 an attack of pleurisy on the right side accompanied by 
 friction, but this was unattended by any return of the cardiac 
 symptoms. Under the use of poultices and iodide of 
 potassium this attack was recovered from in two or three 
 days, and the patient was discharged well on 18th April. 
 On 15th December of the same year (1870) this patient 
 returned to hospital, complaining of dyspnoea, cough, pain 
 over the lower part of the sternum, and slight pulsation in 
 the epigastrium. On auscultation the cardiac sounds were 
 
DISEASES OF THE HEART 207 
 
 found to be distinct and free from murmur, the pulmonary 
 second accentuated. Fine crepitation was audible over the 
 right base anteriorly ; percussion everywhere normal. A 
 jacket poultice and rest in bed were prescribed, and on 26th 
 December he was discharged perfectly well. 
 
 The first remark I have to make in regard to this case is 
 that, recognising the improbability of a mitral murmur 
 CO- existing with a tricuspid murmur of regurgitation, both 
 apparently due to pulmonary obstruction, every pains were 
 taken to make sure of our facts. And the co-existence of 
 these two murmurs in such a case must, I think, be accepted 
 as an important proof of the influence of pyrexial relaxation 
 in producing cardiac dilatation, even in circumstances other- 
 wise unfavourable for such a development.^ If by chance we 
 were mistaken in our assumption of the presence of a murmur 
 of mitral regurgitation in this case, this in no respect 
 invalidates the importance of the case as a remarkable 
 instance of curable tricuspid regurgitation — of which all 
 the other signs, including venous pulsation, were present — 
 depending upon pulmonary obstruction of a temporary 
 character. I have selected this case as an example of this 
 affection mainly because we had in him a subsequent oppor- 
 tunity of observing the permanence of the cure. The follow- 
 ing case is an equally instructive example of incurable 
 tricuspid regurgitation, incurable not because the right 
 ventricle was dilated, but because that dilatation was 
 
 ^ Left-side dilatation is a common enough accompaniment of right-side 
 dilatation. The singularity in the above case consists in the dilatation of 
 both sides being associated with and apparently dependent on the bronchitis. 
 Evidently the dilatation of the left heart had been primary and due to pyrexia, 
 the dilatation of the right heart being secondary, and due to pulmonary con- 
 gestion and the damming back of the blood. It is curious that C. Gerhard, 
 who distinctly recognises the influence of pulmonary emphysema in producing 
 dilatation and hypertrophy of the right heart, should yet refer the systolic 
 murmur accompanying this to mitral regurgitation. He calls this so-called 
 mitral systolic murmur "ein Zeichen localer Anaemie," and supposes it to be 
 produced in some inexplicable manner by a defective blood supply to the left 
 side of the heart and the arteries. — Vide Lehrhuch der Auscultation und 
 Percussion (Tubingen, 1871), S. 264 ; vide also Lecture VL 
 
208 CLINICAL LECTUKES ON 
 
 produced by a permanent and irremediable form of pulmonary 
 obstruction. 
 
 Case XXII.^ Andrew Laidlaw, a cabinetmaker, aged 
 forty-nine, was admitted into Bed 2, Ward V., on 23rd 
 October 1874, complaining of indigestion and breathlessness. 
 He stated that about two years ago he first suffered from 
 shortness of breath while at work, accompanied by a feeling 
 of oppression in his chest, a troublesome cough, spit, and 
 severe pain darting through the chest, from before back- 
 wards, on the occurrence of any severe paroxysm of 
 coughing. Mustard poultices had been successfully employed 
 for the relief of this pain. He also stated that he had 
 suffered from rheumatic fever, for which he could give no 
 date ; and that, at the age of nineteen, he had an attack of 
 measles, and that he has never since been free from 
 cough and spit. His personal and family history are 
 unimportant ; he has always had a comfortable home, 
 and from the nature of his occupation he has not been 
 much exposed to atmospheric vicissitudes. The patient 
 is a man of fair muscular development, 5 feet 7 inches in 
 height ; his expression is natural. He suffers from dyspnoea 
 whenever he makes any exertion. He has a good deal of 
 cough, which causes him some pain, and is accompanied 
 by the expectoration of about five ounces of muco-purulent 
 sputa daily. Two years ago he had slight hsemoptysis. 
 His respirations are 30 per minute. His pulse is 80, soft 
 and full, and he occasionally suffers from palpitation and 
 pain at the prsecordia. On inspection his thorax seemed 
 emaciated, and the intercostal spaces were apparently 
 distended, giving a rounded barrel-shaped appearance to 
 the chest. The rhythmical movements of the thoracic 
 walls seemed somewhat restricted, and were unbroken by 
 tapping of the heart's apex ; but instead a distinct pulsation 
 was seen in the epigastric region, and from this a pulsatory 
 tremor passed over the region of the livei'. On palpation 
 
 1 Reported by Mr. C. S. Hoy, clinical clerk. 
 
DISEASES OF THE HEART 209 
 
 both sides of the chest were found to expand equally but 
 imperfectly, especially over the upper part, and on passing 
 a tape round the chest, in the plane of the fourth rib, the 
 difference between deep expiration and full inspiration 
 was found to be only half an inch. No cardiac impulse 
 was to be felt in any part of the prsecordia, but a distinct 
 limited pulsation was felt in the left side of the epigastric 
 region, and synchronous with this there was also felt an 
 equally distinct but somewhat tremulous pulsation which 
 extended over what was subsequently ascertained to be 
 the area occupied by the liver. The percussion note 
 anteriorly was hyper-resonant over both lungs, especially 
 above the fourth rib. On the right side in the nipple line 
 this hyper-resonance continued to the upper border of the 
 fifth rib ; beneath that the liver dulness extended down- 
 wards for a distance of five inches. On the left side, one 
 inch from the sternum, the percussion note was hyper- 
 resonant down to the third interspace ; from the upper 
 border of the fourth rib the percussion note gradually rose 
 in pitch and shortened in duration down to the level of the 
 sixth rib ; below this the tympanitic sound of the stomach 
 alone was heard. On percussing across the chest at the 
 level of the fourth rib, cardiac dulness was noted as com- 
 mencing at the right edge of the sternum, and it extended 
 across to the left nipple, a distance of four inches. 
 Posteriorly, the percussion note was not only lower in 
 pitch and of longer duration than usual (hyper-resonant), 
 but it could also be carried down to below the twelfth 
 dorsal vertebra, though on the right side the percussion 
 note began to rise in pitch and to shorten in duration 
 directly the upper border of the sixth rib was passed. 
 On auscultation over the lungs the respiration was every- 
 where heard to be indeterminate, presenting the character 
 of an imperfect inspiratory vesicular murmur, followed by 
 prolonged expiration, accompanied by sibilant rhonchi. On 
 listening in the normal cardiac areas the heart sounds were 
 
210 CLINICAL LECTURES ON 
 
 heard faintly, but free from murmur. At the base of the 
 heart the aortic and pulmonary second sounds were heard 
 more distinctly at the sternal ends of the third rib on the 
 right side, and of the fourth rib on the left side, than in 
 their normal position at the sternal end of the second right 
 and third left ribs. Over the pulsation in the epigastrium 
 a soft blowing murmur was heard occupying the time of 
 the first sound. The patient's tongue was large, pale, 
 flabby, and indented by the teeth, which were much decayed. 
 His appetite was indifferent, deglutition perfect, but he 
 occasionally vomited the food he took. On palpation and 
 percussion the liver was ascertained to come down below 
 the ribs, and it also lay below the pulsating tumour in the 
 epigastrium. The splenic dulness was not enlarged. The 
 urine was of a dark sherry colour, specific gravity 1022, acid 
 reaction, deposited a slight mucous cloud on standing, and 
 contained nothing abnormal. He suffered occasionally from 
 severe frontal headache, had sometimes been deaf, and since 
 shortly after the commencement of his last illness he had 
 been obliged to use spectacles, but he had no other symptoms 
 of nervous change. After about a week's treatment, con- 
 sisting of five grains of carbonate of ammonia in half an 
 ounce of infusion of digitalis every four hours, an impure 
 first sound was occasionally — about every third beat — to 
 be heard over the epigastric pulsation. But the right 
 ventricle never became more perfectly rehabilitated, and 
 though the bronchitis speedily disappeared, no treatment 
 had any further effect on the condition of the heart. On 
 4th February 1875 he was discharged free from bronchitic 
 complication, but otherwise in stahi quo. 
 
 This very interesting case was sent to the Infirmary 
 supposed to be labouring under aneurysm of the abdominal 
 aorta. But an aneurysm of the aorta reaching the surface 
 in the position of the pulsating tumour in this case, just 
 below the ribs in the epigastric region, has its pulsation 
 always more distinctly expansile in character, and the 
 
DISEASES OF THE HEAET 211 
 
 pulsation itself, as well as any murmur that may be present, 
 are always delayed beyond the systolic pulsation and sound 
 of the heart, which in this case they were not. The con- 
 clusion we arrived at was that the right ventricle had been 
 depressed below its normal position, that it was dilated, and 
 that the tricuspid valve was incompetent. The physical signs 
 already detailed not only agree in confirming this, but they also 
 teach us that the cause of this dilatation of the right ventricle 
 is of such a nature as to render it permanently incurable. 
 
 The resonant percussion in the prgecordial area is not of 
 itself sufficient to determine depression of the heart; nor 
 is the co-existence of a pulsating tumour in the epigastrium 
 necessarily any aid in establishing such a diagnosis ; because 
 emphysematous hyper-resonance of the left lung might 
 extinguish cardiac dulness without depressing the heart; 
 while epigastric pulsation, even if it were clearly ascertained 
 to be cardiac, and not merely hepatic, might be solely due 
 to dilatation of the right ventricle. But when we find that 
 the vertical cardiac dulness does not commence till a whole 
 rib and an interspace below the normal position ; when 
 we also find that this vertical dulness carried down in the 
 usual parasternal line rests for rather more than a similar 
 space upon a tumour whose pulsation is the only movement 
 to be felt in that region, and that this pulsation is 
 synchronous with a sound that occupies the appropriate 
 rhythmical relation of a first sound to the aortic and 
 pulmonary second sounds, which, moreover, have their 
 position of maximum intensity depressed in exact relative 
 proportion to the apparent depression of the entire cardiac 
 dulness, the conclusion seems irresistible that we have to 
 do with an actual and not merely an apparent depression 
 of the heart. And this conviction gains strength when we 
 find that notwithstanding considerable enlargement of the 
 liver that organ is also displaced downwards, and especially 
 when we find that the condition of the lungs is such as 
 efficiently to account for this downward displacement of 
 
212 CLINICAL LECTURES OX 
 
 both organs. The hyper-resonant percussion note indicates 
 the presence of an abnormal amount of air in the lungs, 
 especially in their upper lobes; while the defective ex- 
 pansion of the chest, the imperfect character of the inspiratory 
 murmur, and the prolongation of the expiration, all indicate 
 that this abnormal condition depends upon retention of air 
 within the pulmonary tissue. This retention of air within 
 the lungs we know happens as the result of that loss of 
 elasticity always associated with over-distention and rupture 
 of the air-cells distinctive of emphysema, which is always 
 accompanied by inelastic enlargement of the parts of the 
 lung affected. This condition, if sufficiently extensive, is 
 invariably associated with depression of the heart and liver, 
 and with extension downwards — as in this case — of the area 
 of pulmonary resonance. Further, as the ultimate branches 
 of the pulmonary artery are distributed on the walls of the 
 air-cells, any destruction of these walls must be accompanied 
 by a corresponding limitation of the area of the pulmonary 
 capillaries. Consequently we have in all cases of extensive 
 emphysema an irremediable obstruction to the circulation 
 through the lungs, which must infallibly produce an incur- 
 able dilatation of the right ventricle, with tricuspid re- 
 gurgitation. The physical signs in this case give thus a 
 perfectly sufficient explanation of all the phenomena present, 
 upon the only tenable supposition, viz. that we have to do 
 with a case of emphysema of both lungs, producing depression 
 of both heart and liver, dilatation of the right ventricle, 
 regurgitation through the tricuspid valve, and secondary 
 enlargement of the liver from venous engorgement. It 
 cannot be denied that a history of thirty years of more or 
 less constant bronchitis is quite sufficient to account for the 
 emphysema present, into the pathology of which we shall 
 not enter further at present. 
 
 This case is one of the best-marked examples of incurable 
 tricuspid regurgitation I have ever seen, and with it I 
 conclude the history of this lesion. 
 
DISEASES OF THE HEAET 213 
 
 Careful attention to all the phenomena described will 
 enable any one readily enough to detect enlargement of 
 the right ventricle, and to determine its degree and its 
 seriousness as measured by that. In this respect you will 
 observe that in the case last narrated, though from its 
 cause it was certainly incurable, yet the regurgitation was 
 not great. This we deduce from several facts : first, the 
 right ventricle could be partially rehabilitated ; after but a 
 short time of treatment an impure first sound could be 
 heard every third beat or so. And, second, there was no 
 evidence of any great venous remora ; there was no venous 
 pulsation in the neck ; there was no true or distensile pulsa- 
 tion of the liver ; the pulsation of the hver was synchronous 
 with that of the heart, and was not delayed (p. 201) ; there 
 was never any trace of albumin in the urine ; and there was 
 never any dropsy. The prognosis in this case is not 
 absolutely unfavourable ; the triscupid regurgitation is 
 certainly incurable, but with care he may live a long time. 
 His cardiac affection will assuredly prove fatal in the long 
 run, but in itself it may take a long time, and he is much 
 more likely to be cut off by some intercurrent pulmonary 
 attack. 
 
 In regard to prognosis, you will remember that tricuspid 
 regurgitation associated with, and wholly caused by an acute 
 attack of bronchitis, is a perfectly remediable affection, and 
 is often permanently cured. It is a measm-e of the degree of 
 pulmonary congestion present, and to that extent of the 
 serious character of the pulmonary disease, but in itself it is 
 of little consequence. 
 
 But when associated with mitral disease, and especially 
 with mitral stenosis, as it so often is, the prognosis of tricuspid 
 regurgitation is always most grave. Under these conditions, 
 even when dilatation of the right side has been precipitated 
 by an acute attack of bronchitis, its rehabihtation is ex- 
 tremely difficult, and it is never more than temporary ; the 
 end is always hastened, and is often rapid in its advent. 
 
214 CLINICAL LECTURES ON 
 
 In connection with pulmonary emphysema tricuspid re- 
 gurgitation is equally incurable, but the prognosis as to life 
 is not so grave. It is not difficult to understand why this 
 should be, for we know that the pernicious influence of 
 tricuspid regurgitation is not to be estimated by the degree 
 of venous stasis produced, but rather by the diminution of 
 aortic blood -pressure to which it gives rise, of which the 
 venous stasis is only an approximate measure. A limitation 
 of the area of the pulmonary capillaries, though it may suffice 
 to induce tricuspid regurgitation, diminishes the amount of 
 blood in the aortic system only by the quantity of blood 
 actually cut off. So long as this is consistent with the 
 maintenance of life, no important change can take place 
 without the intervention of secondary causes. Nay, an im- 
 provement in the patient's condition is more likely to occur 
 than the reverse, because improvement must necessarily 
 follow any rehabilitation of the right ventricle, or any increase 
 of function in the healthy parts of the lung, both of which 
 are certain to follow improvement in the patient's health, the 
 result of successful treatment. Hence tricuspid regurgitation 
 arising from pulmonary causes compatible with life may, 
 though incurable, persist indefinitely until the aortic blood- 
 pressure becomes fatally lowered by some secondary cause. 
 
 But the supervention of tricuspid regurgitation upon 
 mitral stenosis has quite another and a more important 
 signification. Physical laws teach us that the force and 
 velocity with which any fluid passes through an orifice are 
 increased in a certain definite ratio by the amount of pressure 
 brought to bear upon it. It is evident, therefore, that the 
 amount of blood passing through a stenosed mitral orifice 
 during the ventricular diastole considerably depends upon 
 the amount of hydrodynamic pressure within the pulmonary 
 circuit. And it is equally evident that whenever the intra- 
 pulmonary blood-pressure is lowered by any efficient cause, 
 such as tricuspid regurgitation, the immediate result is a 
 diminution of the flow through the stenosed orifice, and a 
 
DISEASES OF THE HEART 215 
 
 corresponding lessening of the amount of blood thrown into 
 the aorta. Further, the amount of blood sent forward is 
 diminished with a rapidity and in a degree commensurate 
 with the freedom of regurgitation and with the influence 
 which the pre-existing hydrodynamic pressure has had in 
 maintaining the flow ; further, this reduction in quantity has 
 a strong tendency to be permanent, and to increase at a rate 
 proportionate to the degree of stenosis present, and with the 
 amount of tricuspid regurgitation. 
 
 In tricuspid regurgitation depending upon pulmonary 
 obstruction, therefore, the diminution in the amount of blood 
 sent forward, and the consequent impairment of all the 
 secretions and other vital functions, is to be estimated merely 
 by the amount of blood thrown back. But when tricuspid 
 regurgitation depends primarily upon mitral stenosis, its 
 influence in lessening the amount of blood thrown into the 
 aorta is to be measured not by the ratio between the stenosed 
 and the normal mitral opening, but by that plus the lowering 
 of the hydrodynamic pressure within the pulmonary circuit 
 which the regurgitation has brought about. There is no 
 difficulty, therefore, in understanding which is the most 
 serious lesion, nor why it should be so ; even if both are 
 equally incurable. In tricuspid regurgitation resulting from 
 emphysema alone, the patient may continue in moderate 
 health for long, though he will never be robust, and will 
 always be placed in extreme danger by any attack of acute 
 pulmonary congestion. But in that resulting from mitral 
 stenosis, the case is far otherwise. 
 
 In the treatment of tricuspid regurgitation, whatever 
 subsidiary measures may be employed, we must never omit 
 the use of digitalis, a drug which, by improving the elasticity 
 of the myocardium, not only benefits its metabolism but also 
 promotes the rehabilitation of the tricuspid valve. 
 
 Even in tricuspid obstruction, of which I have seen 
 but little, there appears to be no reason for withholding 
 digitalis. In both of the two cases we had under treatment. 
 
216 CLINICAL LECTURES ON DISEASES OF THE HEART 
 
 that drug did good service. And we can readily under- 
 stand that, as its action is not limited to the ventricles, 
 but is exerted on the auricles also, digitalis must do good 
 service in every case in which improvement in the elasticity 
 and of the metabolism of the myocardium is likely to be of 
 service. Nay, more, as digitalis acts upon all muscular fibres 
 in a similar manner, the improved elasticity and metabolism 
 of the muscular fibres of the circulatory system generally, 
 both arteries and veins, cannot but have an important effect 
 in increasing the energy of that systolic wave that passes 
 over the whole circulatory system, upon which the main- 
 tenance of the circulation in many of the lower animals so 
 entu-ely depends, and which is certainly not without an im- 
 portant influence in maintaining the circulation even in the 
 highest mammals.^ 
 
 ^ Note on independent pulsation of the pulmonary veins and vena cava, 
 by T. Lauder Brunton, M.D., F.R.S., and Sir J. Fayrer, M.D., K.C.S.L, 
 
 Proceedings of the Royal Society of London, vol. xxv. No. 172, p. 174. 
 
LECTUEE YIII 
 
 ox THE MUKMUES AUDIBLE IX THE PULMOXARY AEEA, THEIR 
 VARIETIES, AXD DIAGXOSTIC SIGXIFICATIOX 
 
 The pulmonary area, the space between the second and 
 third ribs just to the left of the sternum,-^ has been not 
 inaptly termed the region of romance, on account of the 
 variety of interpretations given to the murmurs having 
 their position of maximum intensity in that position. These 
 interpretations have been only too apt to vary with the views 
 and predilections of the commentators; and yet there is 
 really no place for opinion in the interpretation of a murmur, 
 whatever its position, as that interpretation must rest upon 
 those laws upon which physical diagnosis is founded. The 
 correctness, therefore, of any diagnosis depends far more upon 
 the skill of the observer in collecting the necessary facts, and 
 his ability to draw the legitimate conclusions from those facts, 
 than upon any mere ripeness of experience. The readiness 
 and accuracy' with which we can now collect from several 
 points of view the various facts which reveal the physical 
 condition of the heart, and especially of its orifices, leave but 
 little room for the influence of mere opinion on the diagnosis 
 of diseases of the heart. 
 
 Systolic murmurs, duly recognised as such by then- syn- 
 chronism with the beat of the heart's apex or of the carotid 
 artery, and most distinctly audible between the second and 
 third ribs to the left of the sternum, have two foci of 
 maximum intensity. In one series of such murmurs the 
 position of maximum intensity is not close to the sternum, 
 
 1 Vide Lecture I. p. 29. 
 
218 CLINICAL LECTUEES ON 
 
 though the murmur is also distmctly audible there, but half 
 an inch or more to the left of that bone {vide p. 171), just 
 where we know that in most cases (Walshe) the appendix of 
 the left auricle comes up from behind to the left of the 
 pulmonary artery {vide p. 170). When much dilated the 
 auricle may extend still farther to the left as well as down- 
 wards, and occasionally partly covers the pulmonary artery. 
 Yet even in its most dilated condition there is always a space 
 between the stethoscope resting on the position of maximum 
 intensity of the murmur and the left edge of the sternum 
 equal to at least the breadth of the tip of the middle finger. 
 A murmur of this character, though often attributed to the 
 pulmonary artery, is really formed in the left auricle and 
 depends upon regurgitation through the mitral orifice, as was 
 first pointed out by Naunyn.^ A systolic murmur in this 
 position is a very common one, and in by far the greater 
 number of cases it betokens merely a simple and curable 
 dilatation of the left ventricle, of which it is an early sign. 
 In chlorosis and allied conditions it is associated with a 
 venous hum and with other signs and symptoms of spantemia, 
 and it commonly passes for a hremic murmur. I have 
 already told you my reasons for adopting Naunyn's interpre- 
 tation of this murmur, and have pointed out the means of 
 diagnosing these cases and of curing them.^ In a smaller 
 proportion of cases, but still sufficiently common, a systolic 
 murmur with its position of maximum intensity in this posi- 
 tion is due to regurgitation through the stenosed mitral 
 opening, conditions which almost^ always co-exist. Many 
 circumstances favour in these cases the convection of the 
 murmur upwards to the auricular, rather than its conduction 
 downwards into the mitral area. For instance, the tip of the 
 
 1 Loc. cit., Berliner Hinische Wochcnschrift (1868), No. 17, S. 189. 
 
 '^ Lecture VL, passim. 
 
 ^ I have employed the word "almost" in this connection, because there 
 are a few funnel-shaped valves in which it seems impossible for regurgitation 
 to take place at all, and in which at all events it can only take place with 
 difficulty and to a trifling extent. 
 
DISEASES OF THE HEART 219 
 
 left auricular appendix lies normally in this position {vide 
 frontispiece, also p. 164), and the appendix tends, when 
 dilated, to come to the front round the base of the heart. 
 Next there is the readiness with which the slightest dilata- 
 tion of the right ventricle pushes the left apex backwards 
 into the thoracic cavity and away from the chest wall (vide 
 p. 169). And, lastly, there is the natural tendency of 
 murmurs to be propagated to the surface through the organ 
 in which they are produced (in this case by impingement of 
 regurgitant fluid veins upon the tense wall of the left auricle), 
 provided the conditions are suitable, as in the present 
 instance. Possibly the physical condition of the lung over- 
 lying the heart's apex may occasionally contribute to hinder 
 the propagation of a murmur outwards in this position. All 
 these circumstances, coupled with the manner in which the 
 murmur itself is actually produced, favour the convection of 
 this murmur to the auricular, rather than its conduction to 
 the mitral area.-^ 
 
 In another series of such murmurs the position of 
 maximum intensity is strictly limited to the true pulmon- 
 ary area, viz. the second interspace close to the left edge 
 of the sternum, right over the pulmonary artery, which 
 is here normally so placed that one -half of its lumen is 
 covered by the sternum, while the other half lies in the 
 interspace just to the left of that bone. This series again 
 falls to be subdivided into two categories : one associated 
 with a perfectly normal condition of the pulmonary artery, 
 and the other with an abnormal state of that vessel. I shall 
 
 1 In reference to these views Hayden, in his work on Diseases of the Heart 
 and ^orta' (Dublin, 1875), p. 1001, has pointed out that a presystolic murmur 
 is only rarely to be heard in the second interspace, and when audible there 
 may be readily recognised by its relation to the first sound and the apex beat. 
 This is perfectly correct, but has no bearing upon the occurrence of a systolic 
 murmur in the region referred to. When he also says that "a murmur of 
 mitral reflux should be readily distinguishable by its special localisation and 
 diffusion," he speaks correctly, with this proviso, that there are many cases of 
 mitral reflux in which the "special localisation" is not the mitral but the 
 auricular area ; but with these cases it is evident that Hayden had not made 
 himself familiar. 
 
220 CLINICAL LECTURES ON 
 
 consider these two categories in detail, pointing out the dia- 
 gnostic phenomena peculiar to each, and their signification. 
 
 In the whole course of my experience of cardiac disease, 
 I have met with nothing more remarkable, nor at first sight 
 more inexplicable, than the co-existence of a loud systolic 
 murmur in the pulmonary region with a perfectly normal 
 heart. Such cases simulate aneurysm of the sinus of valsalva 
 so closely in the roughness of the murmur, the distinctness 
 of the second sound, and the presence of abnormal pulsation, 
 as to be somewhat puzzling, and apt to mislead. The only 
 two points in which these cases differ from aneurysm in this 
 situation are, first, in the entire absence of pain, which we 
 know is not always present in cases of aneurysm ; and, second, 
 in the feebleness of the pulsation compared with that of the 
 heart, a sign of unquestionable value in the diagnosis of 
 aneurysm, but not one that can be wholly nor at any time 
 solely relied upon as excluding the idea of aneurysm. 
 
 Dr. H. Quincke^ of Berlin has devoted considerable 
 attention to the subject of these murmurs, and as in many 
 respects his observations coincide with my own, I shall first 
 tell you his explanation of these inorganic pulmonary 
 murmurs before narrating my own cases. First, however, I 
 may tell you Quincke has pointed out, and has related one 
 case in proof, that in certain rare cases of mitral stenosis in 
 which the right ventricle is hypertrophied but not dilated, 
 while the pulmonary artery is dilated, a systolic murmur 
 may be heard in the pulmonary area, due to the formation of 
 fluid veins at the pulmonary orifice as the blood passes 
 through the healthy but comparatively narrow opening into 
 the dilated artery beyond. This is obviously a physically 
 possible cause for such a murmur, but it must certainly be a 
 very rare one. In the case in point the left auricular 
 appendix was thrombosed and lay deep within the chest ; the 
 
 1 Beitrage zur Entstehung der Herztone und Herzgerausche, Berliner 
 klinische Wochcnschrift (1870), No. 21, S. 249 ; vide also Edinburgh Medical 
 Journal (January 1871), p. 667. 
 
DISEASES OF THE HEART 221 
 
 auricular origin of the murmur from convection was therefore 
 entirely precluded. Quincke has also related six cases in 
 which there was a systolic pulmonary murmur with perfectly 
 sound hearts and arteries, the only abnormality being a 
 retraction of the lung from the base of the heart which was 
 common to all the cases of this series. He supposes that in 
 these cases the murmur is produced by compression of the 
 pulmonary artery by the heart during its systole, fluid 
 veins being formed as the blood passes through the com- 
 pressed and narrowed portion of the artery into the uncom- 
 pressed, and therefore comparatively dilated portion of the 
 vessel beyond — a condition which, if it is proved to exist, 
 must be a very ef&cient cause of murmur. Quincke bases 
 his views in regard to this matter upon certain facts which 
 he observed. First, he found that in all these cases the 
 pulmonary artery could be felt and seen pulsating in its 
 normal position, and this visible pulsation was always asso- 
 ciated with a systolic murmur, a murmur that ceased to be 
 heard whenever the pulmonary artery was again covered by 
 limg and ceased to be perceptible to touch or sight. Second, 
 although there was not always any very obvious reason why 
 the lung should not overlap the heart, yet in most of the 
 cases there was sufficient cause for this imperfect expansion 
 of the lung. In one case pulmonary expansion was prevented 
 by pregnancy, and the murmur disappeared on the occurrence 
 of abortion ; in another case there was pneumonia ; the only 
 assignable reason in the other cases being debility from 
 various causes. So long as the imperfect expansion of the 
 luns: continued the murmur was audible, but so soon as the 
 lung expanded more perfectly the murmur ceased. On 
 measuring the chest in both conditions, Quincke found that 
 on cessation of the murmur the chest expansion was greater 
 by a few centimetres than when the murmur was audible. 
 He also noted that absolute cardiac dulness diminished pari 
 2oassu with the return of the normal lung expansion and the 
 disappearance of the pulmonary murmur. Moreover, in 
 
222 CLINICAL LECTURES ON 
 
 many of those cases forced expansion of the chest is sufficient 
 to cause complete cessation of the murmur, for just so long 
 as the breath can be held. Quincke has also anticipated 
 certain objections to his theory, due to the fact that a similar 
 systolic murmur is not always to be heard even when pulsa- 
 tion of the pulmonary artery can be both seen and felt, by 
 referring to the fact that murmurs are not always to be heard 
 even when all the conditions needful for their production are 
 present, as so often happens in cases of mitral stenosis. And 
 he has also pointed out that in certain cases any compression 
 of the pulmonary artery sufficient to cause a murmur may be 
 prevented by the conformation of the chest, and particularly 
 by any considerable prominence of the cartilages of the 
 second and third ribs. 
 
 You know very well that compression of any artery 
 sufficient to narrow its calibre materially is capable of origin- 
 ating fluid veins and a murmur at the part compressed, 
 provided the blood is sent through it with sufficient force to 
 make these fluid veins sonorous. If, then, we can connect 
 retraction of the left lung from the base of the heart with a 
 systolic pulmonary murmur, which disappears when the 
 heart is more fully covered by deep inspiration, or by the 
 natural removal of the cause restricting its expansion, and 
 which may even remain inaudible notwithstanding the per- 
 sistence of pulmonary retraction whenever compression of 
 the pulmonary artery by the heart during its systole is by 
 some cause or other precluded, then I think you will agree 
 that in such a case Quincke's explanation seems a very 
 probable one,^ provided always there is no other apparent 
 
 ^ Quincke's idea is that in the normal condition part of the ventricular 
 force during its systole is expended in forcing aside the overlapping edge of 
 the left lung ; with the lung already retracted, and the heart abnormally 
 close to the chest wall, he supposes this portion of the systolic force to be 
 employed in compressing the pulmonary artery. Hayden, op. cit. p. 1002, 
 argues that if this were true we ought to have a murmur in every case of 
 visible pulsation of the pulmonary artery. Quincke has anticipated this 
 objection and sufficiently answered and disposed of it. Hayden has also very 
 properly pointed out that in many cases of mitral stenosis we bare marked 
 
DISEASES OF THE HEART 223 
 
 source of cardiac murmur to be detected. In the case now 
 to be related you will find all these postulates present ; and 
 whatever difficulties may lie in the way of accepting Quincke's 
 explanation, it seems still more difficult to account for the 
 occurrence of such a murmur in any other way consistent 
 with the physical laws bearing on the production of sound. 
 
 Case XXIII. William M'Leod, aged thirty-two, formerly 
 a soldier, now a van-driver, was admitted into Ward V. of the 
 Edinburgh Eoyal Infirmary on 20th May 1870. He complained 
 of an occasional sensation of beating in the left breast, accom- 
 panied by great breathlessness. These symptoms were liable 
 to be brought on by exertion, and were always much increased 
 by it. While a soldier in India some years previously, he 
 had been laid up for a month with what appears to have been, 
 from his own account, an attack of rheumatic fever ; he also 
 had syphihs there about fourteen years ago. His pupils were 
 natural ; his radial pulses unequal, the left radial pulse being 
 a shade smaller than the right ; the humeral pulses were, 
 however, alike. On percussing the cardiac region transversely 
 in the nipple line (along the upper border of the fourth rib), 
 dulness was found to extend from the left edge of the sternum 
 for a distance of one inch and a half to within half an inch of 
 the nipple. On percussing in the parasternal line one inch 
 from the left edge of the sternum from the clavicle down- 
 wards, dulness was found to commence at the upper margin 
 of the second rib, and it extended down to the liver dulness 
 (left lobe). The apex of the heart beat between the fifth and 
 sixth ribs just below the nipple (two inches from the left edge 
 of the sternum). Between the second and third ribs on the 
 left side dulness extended for rather more than an inch from 
 the left edge of the sternum, and within this space a pulsation 
 
 pulsation in this region not always accompanied by a murmur, and he 
 supposes that this pulsation is due to "dilatation and distention" of the 
 pulmonary artery. But the position of the pulsation is quite to the left of 
 the pulmonary artery, and could only be produced by a large pulmonary 
 aneurysm. In such cases we find after death a dilated auricle, and never a 
 pulmonary aneurysm {vide p. 164). 
 
224 CLINICAL LECTURES OX 
 
 was to be felt, distinctly less forcible than that of the heart. 
 On auscultating in the mitral area a loud, rough murmur was 
 heard just preceding and running up to the first sound, a 
 presystolic murmur occupying the time of the auricular con- 
 traction. The first sound in this area was not pure, but there 
 was here no systolic murmur ; the heart's action was regular. 
 Between the second and third ribs, just over the pulsation 
 already noted, a loud and somewhat rough systolic murmur 
 was heard closed by an accentuated second sound. This 
 murmur was propagated on the left side down to the fourth 
 rib, and also across the sternum to the space between the 
 second and third ribs on the right side, where the aortic 
 valve was heard to close with distinctly less force. The 
 systolic murmur in the pulmonary area always became faint, 
 and occasionally inaudible, when the patient assumed the 
 erect posture ; the presystolic miu'mur remained unchanged. 
 The diagnosis of this case was mitral stenosis certainly, and 
 probably also aneurysm of the ascending aorta, arising 
 anteriorly just above the valve and passing to the left as 
 aneurysms in this position generally do. The diagnosis of 
 aneurysm was based on the presence of dulness and a pulsat- 
 ing tumom' between the second and third ribs on the left side, 
 and the fact that over this pulsation there was to be heard a 
 loud, rough systolic murmur followed by an accentuation of 
 the second much more marked than that usually heard in 
 this position even in cases of mitral stenosis. The idea that 
 this systolic mui-mur was of mitral origin propagated upwards 
 by convection was rejected : first, because there was no mur- 
 mur in the mitral area itself (at that time I was unaware 
 that a mitral systolic murmur is often to be heard in the 
 auricular area even though entirely absent from its normal 
 position) ; and, second, because of the exceedingly loud and 
 rough character of the murmur and its wide area of propaga- 
 tion. The " probably " was prefixed because we had seen so 
 many similar cases that it was evident that either aneurysm 
 in this position was more common than is usually supposed. 
 
DISEASES OF THE HEAET 225 
 
 or there was some fallacy connected with the diagnostic signs, 
 and I was inclined to hold the latter opinion. This patient 
 was discharged, greatly improved, on 20 th July. Previous to 
 his discharge he was seen and examined by the late Professor 
 Sanders, who confirmed the diagnosis in every respect and 
 especially as to the "probability" of its being a case of 
 aneurysm. M'Leod was readmitted on 16th October com- 
 plaining of irregular attacks of ague, from which he had 
 formerly suffered in India ; for this he had been taking full 
 doses of arsenic for a week without benefit. He was ordered 
 five grains of quinine every two hours, and under this 
 treatment . he rapidly improved. On the evening of 27th 
 October he had a severe rigor, followed by fever and a restless 
 night. On the 28th he was still feverish, with quick respira- 
 tions, rusty gelatinous sputa, and fine crepitation over the 
 right lung posteriorly ; there was no dulness. On the 29th 
 he was much feebler, the respirations 60, otherwise as 
 yesterday, and in spite of free stimulation he died at 3 p.m. 
 
 Autoijsy. — 1st ISTovember. On opening the thorax the left 
 lung was seen to be retracted upwards and backwards, reced- 
 ing from the mesial line opposite the second and third ribs ; 
 it dipped down opposite the fourth and fifth ribs, leaving 
 uncovered the whole of the right ventricle, the apex and 
 lower half of the left ventricle, and to a sHght extent the 
 pulmonary artery also. The amount of serum in the thoracic 
 cavity was normal. Both lungs were deeply congested, and 
 floated heavily — especially the right one — but neither were 
 properly speaking hepatised. The heart weighed 19| oz., 
 and was hypertrophied and slightly fatty. The pulmonary 
 and tricuspid valves were healthy. The cusps of the aortic 
 segments were thickened, and the valve itself slightly incom- 
 petent ; the aorta was healthy. The mitral valve was much 
 thickened, especially its aortic segment; the left auriculo- 
 ventricular opening was so contracted as only to admit the 
 tip of the little finger ; the chordce tendinem of the mitral 
 valve were thickened. There was some cretaceous deposit at 
 
 15 
 
226 CLINICAL LECTURES ON 
 
 the junction of the auricle and ventricle. The liver weighed 
 4 lbs., and presented an indistinct nutmeg appearance ; its 
 capsule was healthy. The kidneys were pale and fatty, the 
 cortical part increased one-third in volume ; the capsules free, 
 the surface beneath smooth. The spleen weighed 2 lbs. 
 1| oz. ; it was softened, and on section presented a few 
 hsemorrhagic spots from the size of a shilling downwards. 
 
 The autopsy, while confirming the diagnosis in every other 
 particular, gave no support whatever to the idea of an 
 aneurysm, as not a trace of such a lesion was to be seen. 
 For this, however, I was fully prepared by the occurrence of 
 the following still more remarkable case : — 
 
 Case XXIV. James Morrison, a bricklayer, aged thirty- 
 one, admitted to Ward V. on 25th April 1870, complaining of 
 soreness in the chest, headache, dyspnoea, and some swelling 
 of the face and body generally. I shall omit the general 
 history of the case, which was an ordinary one of Bright's 
 disease, merely premising that the patient was by no means 
 aneemic, though of a somewhat sallow complexion, and 
 that the dropsy present was merely an inconsiderable amount 
 of general anasarca, depending upon an early stage of cirrhosis 
 of the kidneys, with slight traces of amyloid degeneration, as 
 ascertained by inspection after death. Morrison was a 
 powerfully built man, and all his other functions and organs 
 were perfectly healthy with the exception about to be men- 
 tioned. His pupils were both equal, and both pulses equal 
 at the wrist. The apex of his heart beat between the fifth 
 and sixth ribs, just outside the nipple line, and was somewhat 
 diffuse. In the parasternal Kne one inch to the left of the 
 sternum dulness commenced at the lower edge of the second 
 rib and extended down to the liver dulness. In the nipple 
 line (along the upper border of the fourth rib) dulness ex- 
 tended transversely from the left edge of the sternum to the 
 left nipple, a distance of three inches. Between the second 
 and third ribs on the left side there was an evident pulsation, 
 which was most distinct on deep expiration. This pulsation 
 
DISEASES OF THE HEAET 227 
 
 extended for three-quarters of an inch from the left edge of 
 the sternum, and ended quite abruptly ; to the left of this 
 the dulness continued to be marked for quite two inches, but 
 it scarcely encroached at all upon the sternum. On auscul- 
 tation in the mitral area the first sound was heard to be 
 rather feeble, but distinct and without murmur ; the second 
 sound was somewhat accentuated. Between the second and 
 third ribs at the right edge of the sternum the first sound 
 was still heard somewhat faint, but free of murmur, while the 
 second was more markedly accentuated, and this accentuation 
 of the second increased as the stethoscope was moved across 
 the sternum till it attained its maximum over the pulsation 
 already described. At this point, between the second and 
 third ribs on the left side close to the sternum, the accentu- 
 ated second was preceded by a particularly loud and rough 
 systolic murmur, very well marked and distiiict, occupying 
 the position but presenting a striking contrast to the soft, 
 blowing, so-called hsemic murmur. This murmur could be 
 faintly heard over the innominate and right carotid arteries ; 
 but not a trace of it was to be heard over any of the other 
 vessels, though the accentuated second sound was more or 
 less distinctly audible in both subclavian and in both carotid 
 arteries. It is scarcely possible to imagine any objective signs 
 which could more closely resemble those of an aneurysm arising 
 from one of the sinuses of valsalva and passing to the left : 
 with this single proviso, that the pulsation was less forcible 
 than that of the apex beat; and this cannot after all be accepted 
 as sufficient negative evidence. Subjective symptoms either 
 of aneurysm or of any cardiac disease were entirely absent. 
 The absence of subjective symptoms is certainly not sufficient 
 to entirely discredit the existence of an aneurysm, but it 
 would have thrown a halo of suspicion around any case with 
 signs less well marked than this one appeared to possess. 
 
 While still under treatment, Morrison was unfortunately 
 seized with an acute attack of erysipelas of the head, to 
 which he succumbed upon 29th June. At the autopsy 
 
228 CLINICAL LECTUKES ON 
 
 on 1st July the left lung was found to be somewhat 
 retracted, leaving the base of the heart and the pulmonary 
 artery rather more uncovered than usual. The aorta was 
 found to be very slightly dilated, but the heart itself was 
 normal in every respect, except that the left ventricle was 
 slightly enlarged (dilated and hypertrophied). The pulmonary 
 artery was perfectly normal and its valves healthy. The 
 interior both of the aorta and of the pulmonary artery, as 
 well as that of their chief branches, was perfectly normal, 
 smooth, and wholly free from every trace of atheroma. 
 
 Case XXV. J. W.,^ aged twenty-eight, a fish salesman, 
 admitted 18th June 1874, to Bed 7, Ward V. of the Edinburgh 
 Eoyal Infirmary, complaining of lassitude, weakness, and pain 
 in the abdomen. About six months previously he had pain in 
 the chest, severe cough, night sweats, and loss of appetite, 
 brought on by exposure to cold and wet. These symptoms 
 in a great measure disappeared under treatment, but since 
 then he has always had some cough and has never regained 
 his strength. About a month previous to admission he first 
 noticed a swelling in his right side, which was painless itself 
 but accompanied by pain in the stomach after every meal, 
 and occasionally at other times also. The patient has always 
 been healthy, except that in 1869 he passed through an attack 
 of cholera, and about a year subsequently he had a fever, 
 nature unknown. His family history is good ; his father and 
 mother, three brothers, and two sisters are all alive and in 
 good health. The patient states that he has never been 
 abroad, has never suffered from ague, rheumatism, or syphilis ; 
 he has never had any suppurating wound or sore, beyond a 
 trifling scratch ; but he has been in the habit of drinking 
 beer and other malt liquors in large quantities. On admission 
 his muscles were fairly developed, but his face was thin and 
 his expression anxious. His temperature was 99°, and his 
 respirations 16 per minute. He had night sweats, and 
 occasional cough, especially at night. The hepatic region 
 ^ Reported by W. R. Gibsou, clinical clerk. 
 
DISEASES OF THE HEAET 229 
 
 was tumid but soft, and there was considerable pain on 
 pressure just above the umbilicus. 
 
 On 3rd July the patient had emaciated somewhat, his 
 muscles were soft and flabby, night sweats continued. Since 
 admission his temperature has varied from 97° to 104° in a 
 most irregular and capricious manner. Only once it has 
 been 104° (on the evening of 26th June), and it was only 98° 
 on the preceding and on the following morning ; the average 
 temperature has been little over 100° ; his respirations have 
 also varied, the average being about 20 per minute. He 
 coughed severely at times, chiefly during the night. The 
 thorax was well formed, and expanded equally on both sides. 
 Percussion was normal over both lungs. On auscultation 
 rough vesicular breathing was heard over both lungs, both in 
 front and behind, mingled with an occasional mucous rattle 
 or a rhonchus. The pulse was of fau^ strength, 90 per minute ; 
 the peripheral arteries and veins were normal. No cardiac 
 pain or palpitation was complained of; but on inspection the 
 heart's pulsation was more apparent than usual, and between 
 the second and third ribs on the left side, close to the sternum, 
 an unusual but distinct pulsation was observed, and this 
 seemed to propagate itself upwards to the root of the neck as 
 a slight tremor running superficially over the parieties. At 
 one inch from the left edge of the sternum dulness commenced 
 at the lower border of the second rib and extended downwards 
 to the liver dulness. In the intermammillary line dulness 
 commenced at the right edge of the sternum and extended 
 across for a distance of four inches. In the second interspace 
 dulness extended to the left of the sternum for a distance of 
 two inches and a half. In the mitral, tricuspid, and aortic 
 areas the normal heart sounds were distinctly audible. In 
 the pulmonary area the first sound was entnely replaced by 
 a loud, rough murmur, followed by a more than usually 
 distinct but not accentuated second sound.^ This systolic 
 
 1 There was no marked congestion of the lungs, such as we have in mitral 
 stenosis, therefore the element of tension was wanting ; vide p. 31. 
 
230 CLINICAL LECTUKES ON 
 
 pulmonary murmur was found to disappear completely when 
 the patient took a deep respiration and held his breath, 
 reappearing at once on expiration ; it was not propagated in 
 any direction. The tongue had a white coating, with a 
 triangular red patch in the centre ; the apex of this coincided 
 with that of the organ. The patient's appetite was impaired, 
 and he had a feeling of oppression in the scrobiculus cordis 
 after meals, with much thirst. The bowels were irregular, 
 most commonly loose. The abdomen appeared distended, 
 and had a peculiar tense, elastic feeling when palpated. 
 There was shght tenderness on pressure all over it, and this 
 culminated in positive pain at a point just above the umbihcus 
 in the mesial line. Eound the umbilicus the patient measured 
 thirty-one inches and a half ; three inches higher he measured 
 thirty-three inches and a half: this increase was very evidently 
 due to bulging of the liver, which was enlarged, hepatic 
 dulness in the mammary line measuring seven inches. Splenic 
 dulness was somewhat increased. Micturition was more 
 frequent than usual, and occasionally accompanied by pain 
 along the course of the urethra. The urine was of a dark 
 straw colour, acid, specific gravity 1015, and averaged from 
 50 to 60 oz. daily. On standing there was a considerable 
 deposit of mucus, and it contained a large quantity of 
 albumin, but no sugar or bile. On microscopical examina- 
 tion the deposit was found to consist chiefly of amorphous 
 matter, with epithelium and a few fragments of hyaline and 
 slightly granular casts. 
 
 The subsequent history of this case was that of gradual 
 emaciation and sinking, with an irregular temperature 
 averaging about 100" ; falling sometimes to 97^ and again 
 rising to 102"^. There was persistence and a gradual increase 
 of the diarrhoea ; the urine continued highly albuminous, 
 never under 35, and sometimes as high as 90 oz. in the day. 
 There was also a gradual but trifling accumulation of fluid in 
 the abdomen and in the cellular tissue of the feet and legs ; 
 and latterly a very shght degree of jaundice was developed. 
 
DISEASES OF THE HEART 231 
 
 On 13th July it was noted that the painful spot above 
 the umbilicus had become exceedingly tender to touch; 
 nothing special could be detected there, but low down in the 
 right iliac region a small limited hard patch was to be felt at 
 the lower border of the liver. 
 
 On 21st July the systolic pulmonary murmur had entirely 
 disappeared, and it was not again heard. 
 
 The patient gradually sank and died on 30th July. 
 
 Autopsy. — Body much emaciated; skin and conjunctivae 
 somewhat jaundiced. There were pleuritic adhesions ex- 
 tending down the whole of the left side of the thorax at the 
 junction of the ribs with the cartilages. The fibrous sac of 
 the pericardium was more fully exposed than usual, ap- 
 parently due to the lungs having collapsed very markedly 
 when the chest was opened. The heart was small, weigh- 
 ing 7 oz. ; all its chambers contained decolorised blood- 
 clot. On the anterior surface of the right ventricle there 
 was a milk spot, which measured one inch and a half in 
 length, and three-quarters of an inch in breadth. The 
 thickening of the pericardium at this spot was unusually 
 marked. The chambers of the heart were all of the natural 
 dimensions. The tricuspid and mitral valves were quite 
 healthy; the tricuspid orifice admitted four fingers, the 
 mitral three. The aortic and pulmonary valves were quite 
 competent and otherwise natural. A tough, decolorised 
 blood -clot occupied the pulmonary artery, and extended 
 along its primary ramifications into both lungs. The aortic 
 wall was free from atheroma and otherwise natural. On 
 microscopical examination the muscular fibres of the heart 
 were found to be perfectly healthy. The left lung weighed 
 14 oz. ; the right, 14| oz. ; both were somewhat congested in 
 their posterior three -fourths, and there was a little em- 
 physema at the anterior edges of both. The peritoneal cavity 
 contained rather more than two quarts of turbid serum, 
 in which floated numerous flakes of soft recent lymph. The 
 liver weighed 6 lbs. 1| oz. ; its surface was smooth, but its 
 
232 CLINICAL LECTUEES ON 
 
 capsule presented ramifying lines of white opacity, and in 
 the upper surface of the right lobe there was an opaque 
 thickening with puckered stellate edges like a cicatrix. The 
 thickening did not, however, extend beyond the capsular 
 surface. On section, the organ presented a shghtly granular 
 aspect, and felt exceedingly tough and fibrous. It also pre- 
 sented to the naked eye some of the characteristic appear- 
 ances of waxy degeneration, and it gave the usual staining 
 on the application of the iodine test, but not very markedly. 
 On microscopical examination a very marked increase of 
 connective tissue was observed, both within the lobules and 
 at their peripheries. The pancreas was of natural size and 
 healthy texture ; it weighed, with a few lymphatic glands 
 attached to it, 4| oz. Close above the margin of its head 
 and upper part of body there were a great many enlarged 
 lymphatic glands, varying in size from a pea to almost that 
 of a pigeon's egg. From the pancreas a string of these 
 glands extended up to the liver, between the folds of the 
 gastro-hepatic omentum. The mesenteric and prevertebral 
 lymphatic glands around the coeliac axis, and for two inches 
 and a half below, were enlarged, and had undergone - a 
 degeneration similar to those above the pancreas. On micro- 
 scopical examination of these glands, the lymph-cells were 
 found to have run together into waxy translucent clumps, 
 which took on the waxy reaction very markedly, as did also 
 the vessels connected with them. There was no obstruction 
 of the cystic or hepatic ducts. The spleen was much en- 
 larged ; it weighed 13| oz. Its capsule was firm and fibrous, 
 and the Malpighian corpuscles were unnaturally prominent. 
 These corpuscles were very markedly stained when the 
 iodine test was employed. The kichieys were both enlarged ; 
 the right weighed 8 oz., the left 7 oz. The cortical sub- 
 stance was much increased, and the organs were very much 
 congested. The Malpighian bodies were readily stained 
 by iodine. The mucous membrane of the intestines pre- 
 sented very markedly the waxy reaction. 
 
DISEASES OF THE HEART 233 
 
 You will observe that these cases all agree in this, that 
 there was in each of them marked retraction of the left Inng, 
 with uncovering of the heart and pulmonary artery. The 
 exposure of the pulmonary artery permitted its pulsation to 
 be readily seen and felt. This pulsation could not possibly 
 be mistaken for that of a dilated auricle, inasmuch as it 
 occupied quite a different position close to the sternum, and 
 was both seen and felt to terminate abruptly just as the 
 auricular area was reached. Moreover, the finger resting on 
 the pulsation could in every case distinctly feel the click of 
 the closure of the pulmonary valves, so that the arterial 
 origin of the pulsation could scarcely have been doubted 
 even had the left auricle been simultaneously dilated, which 
 was not the case in any of the examples given except the 
 first, and even in it the dilatation was but trifling. The un- 
 covering of the pulmonary artery brings the valve closer to 
 the surface ; hence its closure is not only readily perceived 
 by the finger, but it is also more distinctly heard, and thus 
 accentuation is simulated even when it is not actually present. 
 In the second case narrated (Case XXIV. p. 226) there was 
 slight dilatation of the aorta, too limited in extent to be 
 readily made out by percussion, but undoubtedly sufficient 
 to cause accentuation of the aortic second, as well as a 
 systohc miu-mur propagated into the arteries of the neck. 
 These facts, coupled with the greatly increased intensity of 
 the second sound over the pulsation in the second left inter- 
 space, as well as the peculiar localised roughness of the 
 systohc murmur which preceded it, comphcated the case 
 and made it to be Ions; reQ;arded as an aneurvsm of one of 
 the sinuses of Valsalva. Indeed the pecuhar loudness, 
 roughness, and localised character — not propagated in any 
 direction — of this murmur make it in every respect one 
 of the most remarkable in the history of cardiac disease. 
 In the cases narrated there is no reason to doubt that the 
 spansemia present in all of them assisted in the causation of 
 the murmur. It will be found noted in regard to the case 
 
234 CLINICAL LECTURES ON 
 
 first described (Case XXIII. p. 223) that the murmur dis- 
 appeared whenever the patient assumed the erect position, 
 probably because in this posture the compression of the 
 pulmonary artery by the heart was prevented by the weight 
 of the heart dragging it down. In the third case (Case XXV. 
 p. 228) the systolic murmur in the pulmonary artery disap- 
 peared entirely whenever the patient took a deep inspiration, 
 and did not reappear until he expired. Moreover, nine days 
 before the patient's death, when the heart must have been 
 somewhat atrophied and was certainly enfeebled, and there- 
 fore not only less able to compress the pulmonary artery, 
 but also less able to drive the blood through it with a force 
 sufficient to produce a murmur, then this murmur ceased 
 for ever. It seems impossible to account for the retraction 
 of the lung in the two first recorded cases. In the third 
 case there were two efficient causes contributing to prevent 
 complete covering of the heart during ordinary inspiration : 
 first, there was the enlargement of the liver and the 
 pain in the abdomen, and, second, there was the string of 
 interpleural adhesions along the junction of the ribs with 
 the cartilages on the left side; these, though not tight enough 
 to prevent complete covering of the heart on forced inspira- 
 tion, no doubt contributed their quota in preventing com- 
 plete covering in the ordinary restrained respiration of this 
 patient. In a fourth case, of which unfortunately I cannot 
 give full details, the cause of the retraction of the lung 
 was only too apparent. This patient was for some time 
 under my care in Ward XIII., presenting all the ordinary 
 phenomena of pulmonary phthisis, affecting mainly the upper 
 lobe of the left lung. At that time she had no cardiac 
 murmur whatever. She improved considerably, and was 
 discharged. About a year afterwards she was admitted into 
 Ward XV. under the care of my colleague, Dr. Haldane, and 
 he directed my attention to her as a remarkable case of 
 pulmonary murmur. In this case there had been several 
 small cavities in the upper lobe of the left lung ; as these 
 
DISEASES OF THE HEART 235 
 
 cicatrised the lung contracted, and ;pari passu with its re- 
 traction from the base of the heart there was developed in 
 the pulmonary area a loud, rough, localised systolic murmur. 
 These cases do not prove the correctness of Quincke's theory, 
 but they lend a strong support to it, and it is difficult to 
 conceive another theory equally simple and equally probable, 
 which will harmonise so well with all the facts associated 
 with this localised murmur as we find it in nature. 
 
 The systolic murmurs associated with an abnormal pul- 
 monary artery need not detain us long. These cases are 
 mostly congenital, and always rare ; they are more objects of 
 medical curiosity than of medical treatment. They are 
 mostly congenital, and as a rule each individual case presents, 
 besides the ever-present murmur or murmurs in the pul- 
 monary artery, other murmurs and signs of co-existing con- 
 genital malformations, which vary in each case. The following 
 case is the only one of the kind that occurred to me during 
 my connection with the Infirmary : — 
 
 Case XXVI.-^ Anne C, aged nineteen, a dressmaker, 
 born at Aberdeen, and residing at Leith, was admitted to 
 Bed 10, Ward XIII., on 1st December 1873, complaining of 
 great pain over the prtecordia, extending to the left back and 
 shooting down the left arm, and of a bad sore throat. The 
 patient is usually deeply cyanosed, but her complexion 
 varies ; the digits on all four extremities are clubbed in a 
 very marked degree and the nails aduncated. 
 
 Her mother stated that last February (1873), after a 
 fright, her daughter was seized with a sudden pain in the left 
 side, which finally settled over the prsecordia. At that time 
 she suffered much from palpitation and a feeling of general 
 oppression in the chest. This state of matters lasted till 
 May. After a short period of comparative health she was 
 seized in June with a shivering fit, and shortly after coughed 
 up two mouthfuls of dark blood, and several more of a lighter 
 colour. Since then she has been always ailing. Her mother 
 1 Case reported by Mr. Kelly, clinical clerk. 
 
236 CLINICAL LECTURES ON 
 
 also stated that ever since birth she had been of a bhie 
 colour, most marked after exertion and in cold weather. 
 Shortly after her birth her father contracted syphilis, which 
 he communicated to her mother, and through her mother to 
 herself and to all the children born subsequently. So that 
 all the children born previously are healthy, while she and 
 her mother suffer from acquired syphiHs, and all her brothers 
 and sisters born subsequently suffer from congenital syphilis. 
 Anne C. is fairly developed, rather above the average 
 height ; she weighs 8 stone 3 lbs. Her expression is dull ; 
 her complexion rosy, sometimes livid. Her Hps are gener- 
 ally livid, and the tips of her clubbed fingers are always 
 so, and the same may be said of her ankles and toes. Her 
 skin generally is not discoloured: it is sometimes warm, moist, 
 and clammy, at others cold and dry. Her temperature is 9 8 "4°. 
 Her pulse varies from 68 to 75 per minute ; it is feeble and 
 equal at both wrists. The jugular veins are small, but 
 pulsation is distinctly visible in them. She has dyspnoea on 
 the shghtest exertion, no palpitation, but severe pain over 
 the preecordia. On inspection the chest appears normal ; no 
 pulsation is anywhere \dsible. On palpation no impulse is 
 perceptible, even when she leans forward ; but a considerable 
 tlnill is felt over the base of the heart. On percussing in 
 the parasternal line one inch to the left of the sternum 
 dulness begins at the upper edge of the third rib, and extends 
 down to the liver dulness. At the level of the fourth rib 
 transverse dulness begins three-quarters of an inch to the 
 right of the sternum, and extends to the left for a distance of 
 four inches and three-quarters. The aortic dulness extends 
 upwards to within one inch of the top of the sternum. On 
 auscultation a loud systolic murmur is heard over the whole 
 of the cardiac area, and it is propagated with more distinct- 
 ness towards the left than towards the right axilla. Careful 
 auscultation at the back of the chest enables us to recognise 
 a faint systolic murmur, evidently due to propagation through 
 the bones. In the mitral area (two inches and a half to the 
 
DISEASES OF THE HEAET 237 
 
 left of the sternum in the fifth interspace) this systolic 
 murmur is shrill and distinct, followed by a faint second 
 sound. In the tricuspid area (the sternal end of the fourth, 
 fifth, and sixth ribs on the left side) the systolic murmur is 
 louder, more prolonged, and followed by a more distinct 
 second sound. In the aortic area (sternal end of the second 
 rib on the right side) the systolic murmur is shrill, distinct, 
 and followed by a clear second sound, often markedly ac- 
 centuated ; both murmur and sound are propagated into the 
 carotids.' In the pulmonary area (the sternal end of the 
 third rib on the left side) the systolic murmur is louder and 
 rougher than at any other part of the cardiac area, and it is 
 followed by a second sound which is always distinct, and at 
 times is quite accentuated. Wlien the pulmonary second is 
 best marked the aortic accentuation is least distinct. The 
 patient's respirations are 20 per minute, and she has 
 dyspnoea on the slightest exertion ; there is also pain in the 
 chest, but no cough or expectoration ; the pulmonary physical 
 signs are normal. Her voice is hoarse. Apart from sleep- 
 lessness, occasional darting pain over the left temple, and the 
 praecordial pain already referred to, her nervous system is 
 quite normal. She has considerable difficulty of swallowing 
 from sypliilitic congestion of the uvula, the tonsils being also 
 swollen and congested ; there is also slight atonic dyspepsia, 
 otherwise the digestive system is normal. The urine is of a 
 pale sherry colour; it is acid, specific gravity 1020, and 
 contains a small amount of albumin ; it is otherwise normal ; 
 there is no deposit. Menstruation is regular. 
 
 This concisely narrated history contains all the elements 
 needful for an accurate diagnosis, so far as that is possible. 
 The history and the symptoms of acquired syphilis, sufficiently 
 distressing in themselves, are yet purely episodic in relation 
 to the more serious affection under which this patient suffers, 
 an affection which, from its congenital character, has neces- 
 sarily embittered all her life, and must ultimately shorten 
 her days. The cyanotic condition of her surface, and the 
 
238 CLINICAL LECTURES ON 
 
 remarkable clubbing of all her digital extremities, point with 
 unerring accui'acy to the existence of some congenital central 
 lesion of her circulation. In regard to the production of 
 cyanosis, three views are prevalent — first, there is Morgagni's 
 view that it depends upon general congestion from some 
 obstruction to the onward flow of the blood ; second, there is 
 Hunter's idea that it is caused by an intermixture of the 
 arterial and venous blood currents ; and there is a third view 
 adopted by some who think that there must be both inter- 
 mixture and congestion before marked cyanosis can be 
 developed. This latter view seems most consistent with the 
 facts as observed in nature. Clinical experience teaches us 
 that even when the obstruction to the onward flow of the 
 blood is very great, the cyanosis is never so great as in those 
 cases where to congestion from any cause there is superadded, 
 from congenital defect, a possible intermixture of the two 
 kinds of blood. It is almost impossible to imagine greater 
 obstruction to the circulation than what must have existed 
 in the patient to whom the mitral valve — now before us — 
 belonged ; in it, as can be seen, the opening, somewhat enlarged 
 by long maceration in spirit, only measures five millimetres by 
 eight ; yet she had no marked cyanosis ; her lips alone were 
 somewhat dusky. On the other hand there are many cases 
 on record in which intermixture of the two kinds of blood 
 was at least possible, and yet in them also there has been no 
 cyanosis.-^ Of this we may be, however, certain, that when- 
 ever we have a case of marked cyanosis there is always 
 present one or more of those congenital lesions which make 
 possible this admixture of arterial and venous blood. In the 
 present case this opinion is confirmed by the clubbing of the 
 digital extremities — a condition that must have a cardiac 
 orifrin if it extends, as in this case, to all four extremities in 
 any marked degree. These conditions, therefore, enable us 
 
 ^ Many such cases are on record. I may refer specially to Rokitansky's 
 Handhudi der pathologischen Anatomie, Bd. ii. (1844), S. 513, etc.; and also 
 his work Die Defede der Scheidewdnde des Herzens (Wien, 1875). 
 
DISEASES OF THE HEART 239 
 
 to conclude with certainty that here we have to do with a 
 congenital malformation of the heart capable of permitting 
 intermixture of the arterial and venous blood. Now, apart 
 from congenital deficiencies of the septa alone — which to any 
 considerable extent are extremely rare, cause Httle if any 
 cyanosis, and either give rise to no murmurs or to murmurs 
 perfectly different in character and mode of propagation from 
 those in this case— we learn from the researches of those 
 pathologists who have made a study of cardiac malformations 
 that the probability of the original lesion being in the pul- 
 monary artery increases as the age of the sufferer exceeds 
 fifteen. The age of our patient is nineteen; there is therefore 
 a strong probability from that fact alone that her primary 
 lesion is in the pulmonary artery. And this is confhmed by 
 the presence of the rough systolic murmur audible in the 
 pulmonary area, and propagated with most distinctness 
 towards the left axilla. The distinct and accurate closure of 
 the pulmonary valve (absence of diastolic murmur) shows us 
 that the murmur probably depends upon a constriction lying 
 aboA^e this valve, as, if its segments were so malformed as to 
 obstruct the onward flow of the blood, they would almost of 
 necessity be incompetent also. But the necessary result of 
 constriction of the pulmonary artery to any extent, or for 
 any lengthened period — long-continued action being equivalent 
 to greater constriction — would inevitably result in a gradually 
 increasing congestion and dilatation of the right ventricle. 
 Of this in the present case we have ample proof in the loud 
 systolic murmur audible over the right apex (in the tricuspid 
 area), and in the distinct jugular pulsation, which shows that 
 the tricuspid regurgitation has been so considerable and so 
 long continued that it has destroyed the action of the venous 
 valves at the root of the neck, and has thus converted what 
 must at first have been a mere undulatory movement in the 
 venous current into a distinct pulsatory wave. The presence 
 of so great a dilatation of the right ventricle sufficiently 
 explains the absence of an apex beat, because the dilated 
 
240 CLIXICAL LECTURES OX 
 
 right ventricle lying in front of the left one pushes the apex 
 from the chest wall into the thoracic cavity {vide p. 199). 
 The absence of any pulsation in the scrohiculus cordis, and at 
 the lower part of the sternum, shows that the heart is feeble, 
 and that dilatation is the prevalent lesion of the right 
 ventricle. 
 
 Without entering into any exhaustive disquisition on the 
 subject, it may suffice to say that constriction of the pul- 
 monary artery may take place at various periods of intra- 
 uterine life, and the mechanical results on the development 
 of the heart must vary accordingly, and with them ixiri passu 
 also the signs and symptoms. When such a constriction 
 occurs just previous to the closure of the ventricular septum, 
 which is thus prevented, we have as a natural result a 
 complete double circulation with free intercommunication 
 between the two ventricles, one of which is connected with 
 an obstructed and the other with a patent arterial conduit. 
 As both ventricles contract with nearly equal force upon 
 nearly equal contents, the result must be that the ventricle 
 with an obstructed outlet must force part of its contents 
 through the abnormal channel into the other ventricle whose 
 outlet is unimpeded. The consequence of this is forcible 
 dilatation of the unimpeded conduit — in this case the aorta — 
 and consequently a systohc murmur of distention accompany- 
 ing the blood-wave, followed by a loud accentuated second 
 sound, the natural result of the forcible closure of the aortic 
 valve by an unusually heavy column of blood — precisely 
 the conditions and the signs usually present in this case. 
 ■Wlien from any cause, however, the pulmonary circulation is 
 more than usually obstructed, as from catarrhal congestion of 
 the lungs, then, as in the normal condition, the blood-recoil 
 upon the pulmonary valve is greatly increased, and we have 
 a temporary transference of the accentuation from the aortic 
 to the pulmonary valve — a phenomenon which repeatedly 
 occurred in this case, under the conditions described, while 
 she remained under observation. 
 
DISEASES OF THE HEAET 241 
 
 The systolic murmur in the mitral area is in all prob- 
 ability due to propagation from the aortic and pulmonary 
 areas, possibly reinforced by the murmur due to the passage 
 of the blood through the abnormal opening in the ventricular 
 septum, which I have shown is most probably present. It 
 is not likely to be due to mitral regurgitation, as there is no 
 distinct propagation round the left side to the back, and with 
 a free communication between the two ventricles there is an 
 entire absence of the conditions needful to produce overdis- 
 tention of the left ventricle and regurgitation through the 
 mitral opening. A mitral stenosis, and regurgitation from 
 this cause, would be a most unusual complication in such a 
 case as the present, and is further rendered highly improbable 
 by the entire absence of any dilatation of the left auricle or 
 of its appendix. 
 
 In this most interesting case, therefore, there seems 
 conclusive evidence of the presence of contraction of the 
 pulmonary artery above the valve, dilatation of the right 
 ventricle with incompetence of the venous valves at the root of 
 the neck, deficiency of the upper part of the interventricular 
 septum, and dilatation of the ascending aorta. There is also 
 a more or less imperfect occlusion of the foramen ovale. We 
 know of no signs by which this may be recognised, but from 
 what we know of the sequential development of the heart 
 this abnormality may be accepted as a necessary complement 
 of the other conditions present. 
 
 A mere cursory inspection of this case would lead almost 
 any one to conclude that she laboured under serious congenital 
 malformation of the heart, and it is interesting to note how 
 the physical signs present, coupled with our knowledge of the 
 mode in which these physical signs are produced, have 
 enabled us to follow up the clues thus suggested till we have 
 been able, with the highest probability, to identify the 
 primary lesion as a stenosis of the pulmonary artery. 
 
 I have only to add that this patient was able to leave the 
 Infirmary improved in every respect. For some years she 
 
 16 
 
242 CLINICAL LECTUEES ON 
 
 came occasionally under observation, her signs and symptoms 
 remaining unchanged. 
 
 An opening between the two ventricles in cases of 
 pulmonary stenosis is rather favourable to longevity than 
 otherwise, and though twenty years is but seldom attained 
 by such patients, some have been known to live to thirty and 
 forty, and one case of undoubted stenosis of the pulmonary 
 artery has been known to live to sixty-five.^ The signs in 
 every case vary with the nature and extent of the malforma- 
 tion, but this can always be ascertained with greater or less 
 probability by cross-examining the various signs and 
 symptoms somewhat after the fashion just described. 
 
 In some cases of congenital malformation of the pulmonary 
 artery, and more rarely as the result of disease after birth, 
 the pulmonary valve is incompetent, and instead of a second 
 sound we have a diastohc murmur. Dr. Warburton Begbie 
 has published a case he met with in this Infirmary.^ In it 
 the pulmonary valve consisted of four segments instead of 
 three. This incompetence of the pulmonary valve was 
 diagnosed during life, and the diagnosis confirmed by ex- 
 amination after death, which was the result of accident. 
 Incompetence of the pulmonary valves must be rarely seen 
 after childhood, but it does occur as the result of general or 
 local disease. It is not difficult to detect, but we must be 
 careful not to mistake a diastohc mitral murmur^ for a 
 diastolic pulmonary, or the converse. The diastolic murmur 
 occasionally found in connection with mitral stenosis often 
 has its position of maximum intensity at the sternal end of 
 the fourth rib, and is naturally liable to be mistaken for 
 either an aortic or a pulmonary diastolic murmur. It is 
 sometimes very difficult to be certain that there is no aortic 
 
 ^ Vide Kussmaul, " Angeborene Enge und Verschluss der Lungenarterien- 
 bahn," Zeitschrift fiir rationalle Medicin (Leipzig, 1866) ; and Peacock, Mal- 
 formations of the Human Heart (London, 1866), 2nd edition, etc. 
 
 * Beale's Archives of Medicine, No. 5 ; and Warhurton Begbie' s Works, by 
 Sir Dyee Duckworth, New Sydenham Society (1882), p. 109. 
 
 ^ Vide Lecture V. p. 135. 
 
DISEASES OF THE HEAET 243 
 
 regurgitation, and occasionally we may even have to wait 
 further development before we are able to give a definite 
 opinion. In all cases of pulmonary diastolic murmur hitherto 
 recorded there has always been, I beheve, a loud systohc 
 murmur preceding it, so that there is less danger of any 
 mistake being made in this direction. 
 
 Most of the cases of congenital affections of the pulmonary 
 artery are complicated with some abnormality of the ductus 
 arteriosus, which may either be imperfectly closed or 
 aneurysmally dilated.^ As a mere complication this ab- 
 normality is rather an advantage than otherwise, iu some, 
 indeed, contributing largely to the carrying on of the 
 circulation. But as an independent affection it is of much 
 more importance, and chiefly because the loud murmur which 
 reveals its presence causes an unimportant imperfection to 
 be invested with possibilities for the patient which loom all 
 the more seriously on his future that they are not a little 
 mysterious to the observer himself. I have only seen two 
 cases iu hospital in which aneurysm of the ductus arteriosus 
 was the predominant lesion. Both were discharged in statu 
 quo. One of them turned up subsequently in Glasgow, and 
 her case has been published by Dr. "Wood Smith.^ The only 
 case of the kind in which I know death to have occurred 
 was one, also complicated with other malformations, which I 
 saw about twelve years ago with Dr. James Foulis, under 
 whose care she was.^ But cases of uncomplicated open 
 ductus arteriosus, frequently more or less aneurysmally dilated, 
 are common enough and important enough to deserve an 
 endeavour to differentiate them from other affections with 
 which they are often associated and frequently confounded. 
 
 About twenty years ago I was asked by the late Dr. 
 
 1 Vicle Rokitansky, Ueher einige der vnchtigsten Krankheiten der Arterien, 
 (Wien, 1852). 
 
 2 Tide Glasgow Medical Journal (August 1879), p. 103. 
 
 3 Vide, "On a case of patent ductus arteriosus, with aneurysm of the pul- 
 monary artery," by James Foulis, M.D., EdAnhurgh Medical Journal (July 
 1884), p. 17. 
 
244 CLINICAL LECTURES ON 
 
 Warburton Begbie to visit and report upon the case of a 
 young lady who had been seen about ten years previously 
 by his father, Dr. James Begbie, on account of some peculiar 
 heart symptoms. I reported that I could find nothing wrong 
 with her heart, and that I believed she suffered from an open 
 ductus arteriosus, which was probably aneurysmally dilated. 
 I was then told that both Begbies — father and son — had in- 
 dependently arrived at a smiilar conclusion. The patient 
 was also seen and independently examined by the late Pro- 
 fessor Sanders, who entirely homologated our views. 
 
 This patient had considerable venous congestion of the 
 surface generally, her face was dusky, her fingers and toes 
 quite purple, and her extremities always cold. She com- 
 plained of breathlessness, increased on exertion, and of cough 
 without expectoration. The heart was normal in all its 
 dimensions, but there was distinct pulsation between the 
 second and third ribs to the left of the sternum. Over the 
 whole of the cardiac area a loud systolic murmur was heard, 
 and this was propagated into the arteries and very distinctly 
 audible down the back along the course of the descending ' 
 aorta. The position of maximum intensity of the systoKc 
 murmur was over the pulsation between the second and third 
 ribs to the left of the sternum, where it was accompanied by 
 a loud purring, revealed to a palpating hand as a purring thrill 
 — -fr^missement cataire — and radiating round the pulsation as 
 a centre, but more strongly upwards in the course of the 
 vessels. This loud purring systolic murmur was closed at 
 the moment of diastole by a loud metallic clang, most dis- 
 tinctly heard close to the pulmonary area. 
 
 The main elements in the diagnosis of this case were, 
 first of all, the length of time the signs and symptoms had 
 remained unchanged ; second, the early period of life at which 
 they had made their appearance; third, the position and 
 character of the murmur present ; and, lastly, the manner in 
 which the symptoms varied under the influence of circum- 
 stances producing alterations in the relation between the 
 
DISEASES OF THE HEAET 245 
 
 systemic and pulmonic circulations. I have seen this patient 
 repeatedly ; she has continued to improve, and the last time 
 I saw her, some four or five years ago, there was neither 
 duskiness of complexion nor any murmur left ; to appearance 
 and on careful examination nothing; was to be detected in 
 her different from any other young woman of her years. 
 Evidently the ductus arteriosus had completely closed, as it is 
 occasionally known to do even late in life, probably from 
 occlusion of its lumen by a clot which becomes organised. 
 Aneurysm of the ductus arteriosus is not a great rarity ; I see 
 a case every now and then, sometimes still in early youth, 
 more often young adults who have been baulked in some 
 object in life on account of the detection of this remarkable 
 murmur. T^Tiere the maKormation is limited to the open 
 duct, no complaint is ever made and no suffering experienced : 
 there is seldom even a trace of cyanosis ; but there remains the 
 limited pulsation in the second interspace, which, when pal- 
 pated, communicates a vibratile thrill to the hand, a thrill 
 which radiates upwards along the vessels, and upper part of 
 the left chest. On auscultation over this pulsation there is 
 always a systohc murmur, sometimes followed by a diastolic 
 one; throughout both systole and diastole there is a continuous 
 purring — frdmissement cataire — and whether there is a double 
 murmur or not the commencement of the diastole is marked 
 by a loud metallic clang. These murmurs are audible always 
 up the left side of chest and in the left carotid, and occasion- 
 ally over the whole cardiac area, as well as in the right 
 carotid artery, but naturally they vary in intensity and pro- 
 pagation in each indi\ddual case, yet always presenting the 
 characteristic purring. These cases improve as life goes on, 
 and, as we have seen, they sometimes get well The only 
 case in which death is known to have occurred is the one 
 abeady referred to, in which other malformations hastened 
 the end. In it, however, the diagnosis of an open ductus 
 arteriosus was fully confirmed by the examination of the 
 organs after death. 
 
246 CLINICAL LECTUEES ON DISEASES OF THE HEART 
 
 The remarkable series of cases narrated in this lecture 
 fully vindicates the right of the pulmonary area to be called 
 the region of romance, yet all the murmurs audible in this 
 region have each their own distinctive peculiarities, which, 
 rightly interpreted, enable us to unravel their mode of origin 
 and to discover their ultimate cause with greater or less 
 probability according to the understanding and the skill 
 brought to bear upon each individual case. 
 
 I have just one other remark to make in conclusion, and 
 that is, that systolic pulmonary as well as aortic murmurs 
 are occasionally produced by pressure from without from 
 tumours, or more rarely from disorganised lung or intra- 
 pericardial fluid. In all these cases we have the absence of 
 all the signs and symptoms indicative of any of the other 
 modes by which a murmur in this situation may be produced. 
 Occasionally we are able by percussion to detect the presence 
 of the morbid growth or altered structure. Now and then, 
 however, the diagnosis is sufficiently obscure, must be made 
 mainly jpe?" viam exdusioiiis, and is after all largely a matter 
 of probability. 
 
LECTUEE IX 
 
 ON THE VAKIATION AND VANISHING OF CAEDIAO MURMURS 
 
 It not infrequently happens that a patient presents himself 
 with a note from his medical adviser stating that So-and- 
 So labours under cardiac valvular disease, and yet on care- 
 ful examination we are unable to detect any murmur, 
 and sometimes not even any other sign that would lead 
 us to suspect the existence of a cardiac lesion. What are 
 we to say to this ? Are we wrong, or has the medical 
 attendant been mistaken ? Our experience in the wards 
 supplies a sufficient answer to this important question ; for I 
 may safely say that scarce a day passes in which we have 
 not an opportunity of observing the remarkable manner in 
 which even murmurs dependent upon recognised organic 
 lesions change and vary in character and intensity, and not 
 infrequently disappear, the lesion still remaining. This is 
 an important fact, and one too apt to be overlooked in the 
 consideration of cardiac disease. It has led to many an un- 
 lucky contretemps, and, as I have already mentioned, to the 
 awkward fact of a man dying of organic cardiac disease yet 
 possessed of quite a bundle of certificates from competent 
 medical authorities certifying that he had no cardiac disease 
 whatever.-^ 
 
 But while ignoring the fact that murmurs undoubtedly 
 depending upon incurable cardiac lesions may vary in 
 character and even vanish has led to such untoward results, 
 ignoring the equally important fact that many murmurs are 
 
 Lecture IV. p. 117. 
 
248 CLINICAL LECTURES ON 
 
 due to perfectly curable lesions has in my own experience 
 led to results even more lamentable. Many years ago a 
 patient of my own, dyspeptic and hypochondriacal, who had 
 a slight systolic murmur of mitral origm due to simple dila- 
 tation of but trifling character, consulted a physician who 
 led her to understand that she laboured under an incurable 
 affection of her heart. Foolishly connecting this diagnosis 
 with sudden death as the inevitable result of any exertion, 
 she laid herself upon her sofa, and the greatest persuasion 
 could never again induce her to take any exercise other than 
 a rare and occasional ride in a bath chair. In no long time 
 her dyspepsia was cured, her health restored, her heart re- 
 habilitated, and her murmur gone, but no persuasion could 
 induce her even for one instant to relax her watchful avoid- 
 ance of every possible form of exertion. As may be imagined, 
 she became ere long extremely obese, and after twenty years 
 of positive inaction she died of apoplexy, having thrown 
 away her life from a foolish faith in an idea of her own 
 based upon no firmer foundation than a rash diagnosis. In 
 the course of these lectures I have so repeatedly pointed out 
 the variability of murmurs and their occasional cessatian, 
 that at first sight it seems scarcely worth while to say more 
 upon the subject ; but this is a matter upon which we can 
 hardly say too much, as it is not only important to point out 
 that murmurs occasionally vanish and are often variable, but 
 also to show how a diagnosis may be made without placing 
 any undue dependence upon either their presence or absence. 
 It must be remembered, then, that it is not the loudness of 
 a murmur that indicates danger — the case is often quite the 
 reverse ; and it must also be remembered that a murmur may 
 vanish under two very different conditions : first, because 
 the heart becomes rehabilitated, the murmur ceases because 
 its cause is gone ; there is no longer any imperfection of the 
 cardiac mechanism to produce it ; there is no lesion to be 
 revealed ; and, second, the murmur may disappear, the lesion 
 still remaining. Complete rehabilitation is a matter with 
 
DISEASES OF THE HEAET 249 
 
 which the tricuspid valve only has ,been popularly credited 
 among physicians, and this largely at the expense of its 
 perfection; it has been credited with a safety-valve action 
 which was supposed to enable it to open and shut according 
 to the needs of the circulation. But indeed there is not one 
 of the cardiac valves which may not be completely rehabili- 
 tated, after established incompetence, under certain circum- 
 stances and in certain conditions. In the lectures upon 
 " Curable Mitral Eegurgitation," ^ and upon " Curable and 
 Incurable Tricuspid Eegurgitation," ^ I have already entered 
 fully into the various conditions under which the rehabilita- 
 tion of these valves may occur. It is unnecessary therefore 
 to say more upon this matter, except to reiterate the im- 
 portance of having always in view in our treatment the 
 possibility of restoring the function of those valves even 
 when free regurgitation has been established through one or 
 even through both of them. In time and with patience we 
 shall be more often successful than we perhaps dare to hope. 
 The permanence of this restoration is a different matter, and 
 depends upon the age of the patient, his habits, the natu]-e 
 of his occupation, and the primary cause of the dilatation 
 that has made these valves incompetent. So that the pro- 
 gnosis for such a patient, though hopeful in many cases, is 
 by no means so in all. In regurgitation through the aortic 
 valve the conditions are much less favourable for rehabilita- 
 tion; but it sometimes happens, though the restoration is 
 always less stable a,nd less likely to be permanent, however 
 complete it may seem to be for the time. An aortic re- 
 gurgitant murmur often varies so greatly in intensity that at 
 times unpractised ears, to which it was previously distinctly 
 audible, fail to recognise it, while any abnormal sounds 
 within the lungs may obscure it to even ears that have had 
 greater experience. Diminished intensity of an aortic re- 
 gurgitant murmur may be due to an alteration in the blood 
 itself; more often to a lowering of the arterial blood-pressure, 
 
 ^ Lecture VI. p. 167. - Lecture YII. p. 197. 
 
250 CLINICAL LECTURES ON 
 
 and probably still more often to weakening of the cardiac 
 systole. In the case of one very loud musical diastolic 
 aortic murmur the patient never felt well unless his wife 
 could hear his murmur across the dinner-table. Now and 
 then we find a pathologist exhibiting the trickhng of a small 
 stream of water between the segments of an aortic valve, 
 incompetence not having been recognised during life ; it may 
 not even have existed while the patient was alive, and any 
 way the force employed in causing so trifling a stream most 
 probably was quite insufficient to make it sonorous. Com- 
 petence seems sometimes to be restored to the aortic valve 
 by the deposition of fibrine upon the diseased segments ; ^ in 
 such a case the diastolic murmur gradually diminishes in 
 intensity until it may entirely cease, the systohc portion of 
 the murmur continuing audible, though even this may vary in 
 pitch as well as in intensity. I myself have more than once 
 had occasion to observe apparently complete rehabilitation 
 of the aortic valve, under treatment, in cases in which re- 
 gurgitation was due to separation of the segments from 
 dilatation of the ascending aorta. In these cases the diastohc 
 murmur died completely away under the use of iodide of 
 potassium, which appears to have a twofold action ; first it 
 lowers the blood-pressure, and, second, it seems to have a 
 contracting and thickening effect upon the coats of the 
 arteries themselves. That the disappearance of the diastolic 
 murmur was mamly due to the latter action seemed probable 
 from its continued absence long after the drug had ceased to 
 be given, the accentuated aortic second remaining. 
 
 Murmurs of regurgitation, may, as you know, occur at 
 any of the cardiac orifices from dilatation of the parts with 
 which the valves are connected, apart altogether from any 
 alteration or disease of the valves themselves. It is under 
 these circumstances that rehabilitation of an incompetent 
 
 ^ Of this Dr. Gairdner has recorded one case in the British Medical 
 Jourtml for 30th March 1872, p. 334 ; and Dr. Walshe another in his 
 Diseases of the Heart, 3rd edition, p. 386. 
 
DISEASES OF THE HEART 251 
 
 valve is most likely to take place, accompanied by perfect 
 restoration of the normal sound, though — be it first or second 
 — that sound may remain, for a time at least, accentuated. 
 This is specially the case with the second sound, and from 
 the prevailing conditions accentuation of it is probably per- 
 manent. With a first sound it is different ; accentuation of 
 it is not an uncommon sign of commencing dilatation of the 
 ventricle, but as a dilated ventricle is capable of more perfect 
 restoration than a dilated aorta, the sound itself after restora- 
 tion becomes more nearly normal. Murmurs of obstruction 
 belong to quite a different category ; they invariably result 
 from some direct and material obstacle to the onward current 
 of the blood, and this obstruction is never the result of 
 cardiac dilatation, though it is often its cause. The con- 
 sequence of this is, that though murmurs of obstruction 
 may vary considerably, or may even vanish, the lesion still 
 remains, there is no change in the patient's condition, and 
 the cardiac disease proceeds at an unaltered pace on its 
 downward career. It is of importance to remember these 
 facts in connection with the prognosis we may have to give 
 the patient, or rather to his friends. In the one class of 
 cases — vanishing of a murmur due to dilatation — the dis- 
 appearance of the murmur may be the first indication of 
 returning health. In the other class of cases — those in 
 which the murmur has been due to obstruction — the vanish- 
 ing of the murmur is merely an indication of some alteration 
 in the composition of the blood, in the force of the cardiac 
 systole, or in the physical relation of the parts, which may 
 either interfere with the formation of the murmur, or hinder 
 its propagation to the surface of the chest. It is not the 
 first time that the disappearance of a murmur, in circum- 
 stances when this could not depend upon the cessation of 
 its cause, has been hailed with undeserved delight as an 
 indication of renewed life. ISTay, a treatment has even been 
 instituted which could have no other end than a simple 
 masking of the affection, by influencing the physical causes 
 
252 CLINICAL LECTURES ON 
 
 engaged in the production of the murmur. I refer to the 
 method of treating cardiac disease by depletion and starvation, 
 happily not much in vogue in the present day, but which 
 played no unimportant part not so many years ago, and 
 which is now being displaced by other equally unscientific 
 and not less mjurious methods. 
 
 In my last lecture I pointed out that a systolic murmur 
 in the pulmonary artery depending upon abnormal alteration 
 in the parts concerned, might disappear whenever the 
 physical conditions were so changed as to render the pro- 
 duction of a murmur impossible. When a pulmonary systolic 
 murmur, however, depends upon actual physical obstruction, 
 variations in the murmur are less likely to happen, and I 
 have never observed any. A similar statement may be 
 made in regard to a systolic aortic murmur dependent upon 
 physical obstruction, and as this murmur depends either 
 upon physical obstruction or upon aortic dilatation, an almost 
 equally irremediable condition, I agree with a late wiiter on 
 the subject that considerable variations are less frequently 
 met with in murmurs of this character than in murmurs 
 associated with affections of other valves.-^ 
 
 It is in connection with stenosis of the mitral opening 
 that we find the greatest amount of variation prevalent. I 
 have already entered pretty fully into this matter ; - and in 
 the wards of any hospital you may have daily opportunity 
 of verifying the statements made, and of observing that 
 mitral stenosis is at least as frequently associated with an 
 entire absence of murmur, with an irregularly intermittent 
 systolic mitral murmur, or with a more permanent systolic 
 mitral murmur, as with the ordinary presystolic murmur 
 with which it is popularly more immediately connected. 
 The following case is a very interesting example of extreme 
 variability in a murmur connected with this lesion. 
 
 ^ "On the Variation and Vanishing of Organic Valvular Murmurs," by 
 W. R. Sanders, M.D., Edinburgh MedicalJourmd (January 1869), p. 584. 
 '^ Lectures IV. and V. jip. 117 and 135. 
 
DISEASES OF THE HEART 253 
 
 Case XXVII. J. Munro, aged twenty-one, admitted to 
 Bed No. 3 in Ward V. on 14th December 1870. This patient 
 had been under my care for some time three years previously ; 
 at that time he had a well-marked presystolic murmur, but 
 of so variable a character that it repeatedly vanished while 
 being listened to. Under treatment he improved much in 
 health, and after his discharge he came repeatedly under 
 observation with a slightly hypertrophied heart, and an 
 occasional presystolic murmur. He afterwards fell off greatly 
 in health, and was readmitted with a feeble heart, very 
 irritable, in an almost constant state of irregular palpitation, 
 and with a permanent systolic murmur. He was presently 
 able to be discharged somewhat improved, with the systolic 
 murmur still persisting. At the above date he was again 
 readmitted on account of catarrhal symptoms, aggravated by 
 privation and want of shelter. After treatment for some 
 time his murmur was found to have entirely vanished, 
 there was some degree of cardiac hypertrophy, a prolonged 
 first sound, and an accentuated puhnonary second, but 
 nothing more. On 1st February 1871 he was shown to the 
 Medico-Chirurgical Society without a trace of any murmur 
 remaining. This case was all the more interesting •and 
 instructive in that, from circumstances connected with re- 
 arrangement of the wards, he had been for some time under 
 the care of Sir Thomas Grainger Stewart, who was able to 
 testify as to the persistence of the mitral systolic murmur at 
 the time of the patient's discharge from his ward, and to 
 verify its complete disappearance when the patient was 
 exhibited to the Medico-Chirurgical Society.^ 
 
 Cardiac murmurs are thus, as I have just said, liable 
 to very great variations, and may even vanish entirely beyond 
 the ken of much more accomplished auscultators than that 
 hypothetical individual, the average medical practitioner, the 
 
 1 Vide Edinburgh Medical Jotmial (March 1871), p. 832. For ten years 
 subsequently this patient continued with his cardiac condition unchanged ; he 
 was then lost sight of. 
 
254 CLINICAL LECTURES ON 
 
 lesion still remaining. It is evident, therefore, how im- 
 portant it is to know how to determine in any given case 
 — such as the hypothetical case I commenced with — the 
 probable presence of a cardiac valvular lesion in the 
 absence of any murmur; and this fortunately is not so 
 impossible as at first sight it seems. From what has just 
 been said, you will have learned that aortic systolic 
 murmurs may vary considerably in intensity, but never 
 disappear entirely ; that aortic diastolic murmurs only vanish 
 in the rarest instances, either spontaneously or under treat- 
 ment, while they are always associated with a systolic 
 murmur which persists and reveals the presence of the lesion. 
 A systolic pulmonary murmur, if organic, is permanent ; if 
 non-organic it may vanish temporarily during deep inspira- 
 tion, but it only vanishes permanently with its cause. A 
 tricuspid murmur of regurgitation is most commonly 
 temporary, and when it ceases to be heard, this may be 
 accepted as an indication that the cause has ceased and that 
 the heart has become rehabilitated. A tricuspid murmur of 
 obstruction is rare, and those I have heard have neither 
 varied nor vanished. The greatest interest connected with a 
 vanishing murmur, therefore, centres in the mitral valve, the 
 condition of which we have the most ample and varied means 
 of ascertaining apart from the presence of a murmur. It is 
 fortunate it is so, for so much discomfort sometimes centres 
 round even its slighter ailments, that not long since I had 
 occasion to see a gentleman, thus obscurely affected, who had 
 travelled all the way from South America, only to obtain a 
 definite opinion as to his exact organic condition, which was 
 subject of dispute among his medical advisers in that far-off 
 region. 
 
 The most distinct and permanent indication of organic 
 lesion of the mitral valve is an accentuated pulmonary 
 second sound. In the absence of any other cardiac lesion, or 
 of pulmonary congestion from any other cause, persistent 
 accentua,tion of the pulmonary second, distinctly recognised, 
 
DISEASES OF THE HEAET 255 
 
 may be accepted as a certain indication of a lesion of the 
 mitral valve. In one case ^ this accentuation of the pul- 
 monary second was for long the only detectable indication of 
 cardiac disease, and it was many weeks before we could 
 obtain confirmative evidence by the detection of a mitral 
 murmur, though we sought it daily. Such a state of matters 
 is, however, comparatively rarely observed ; more usually 
 there are other indications which we only requu^e to feel 
 along the lines certainly to detect. As an indication of how 
 this may be done, I shall give you a case which is not al- 
 together hypothetical.^ Suppose you have a case whose 
 lower extremities are somewhat cedematous, both radial 
 pulses equal, regular or possibly irregular, and distinct, but 
 not jerking, even when the wrist is elevated. These facts 
 indicate the probability of there being some affection of the 
 heart, and the certainty if this is so that this affection is 
 mitral and not aortic. The patient's face is ruddy ; his hands 
 and feet are chilly and of a purple colour marbled with red. 
 These facts point to venous congestion with partial oxygen- 
 ation of the blood through the sMn ; greater where that is 
 fine, as on the cheeks ; less so where that is thicker, as on 
 the extremities. These signs indicate some hindrance to the 
 circulation. On being stripped and laid down we find no 
 undue arterial pulsation anywhere visible. The veins of the 
 neck are not prominent ; they exist but as thin blue lines ; 
 nevertheless on careful observation we find distinct pulsation 
 in the jugulars. This points evidently to tricuspid regurgita- 
 tion of some standing ; this regurgitation, the venous remora, 
 and the oedema might possibly be due to repeated attacks of 
 bronchitis. On inquiry, however, the patient tells us that 
 he has never had any bronchitis, and that he never had any 
 cough till subsequent to an attack of acute rheumatism from 
 
 1 Case of Elizabeth Baillie, aged nineteen, admitted to Ward XIII. 29th 
 March 1873 ; discharged 31st May 1873. 
 
 ^ I here narrate a tolerably -n-ell-marked case ; but a similar method of 
 interrogation is applicable to all, the degree of certainty attainable varying 
 with the distinctness of the facts. 
 
256 CLINICAL LECTURES ON 
 
 which he suffered some four or five years previously; this 
 naturally increases the probability that our surmise as to the 
 existence of cardiac disease is correct. On placing a hand 
 over the cardiac region we find two distinct centres of 
 pulsation; the one occupies the lower end of the sternum, 
 and there we have a diffuse, heaving, and somewhat forcible 
 impulse ; the other lies to the left of the sternum above the 
 fourth rib, and there the impulse is less forcible and occupies 
 less space, but is still diffuse ; the apex beat is absent from 
 its normal position, and it is not to be felt either below this 
 or to its left. These facts further confirm the diagnosis of a 
 cardiac lesion, and supply certain data upon which an opinion 
 may be hazarded as to the exact nature of that lesion without 
 having recourse either to percussion or auscultation ; by these 
 procedures we may indeed confirm our diagnosis, but the 
 data they afford are not so reliable as those we have already 
 ascertained. The heaving impulse at the lower end of the 
 sternum indicates the existence of dilatation with hypertrophy 
 of the right ventricle. The dilatation is confirmed by the 
 jugular pulsation, as this proves long-continued regurgitation 
 through the right auriculo-ventricular opening. Eegurgita- 
 tion through this opening might be due to stenosis with 
 permanent patency. This, however, is a condition so rare that 
 it may be practically set aside, and, besides, such a lesion has 
 special signs of its own and is seldom found connected with 
 so much hypertrophy as is present in this case. The dilated 
 hypertrophy of the right ventricle is further proved by the 
 absence of the apex beat from its normal position, the left 
 ventricle taking no part in the tangible phenomena connected 
 with the cardiac pulsation, as it is pushed backwards into 
 the chest by the right ventricle lying like a water- cushion in 
 front of it {vide p. 199). Further, the complete disappearance 
 of the apex beat indicates that the left ventricle has no share 
 in the dilated hypertrophy of the heart, even if it be not 
 somewhat atrophied. But if the left ventricle is neither 
 dilated nor hypertrophied, the left auricle is certainly both ; 
 
DISEASES OF THE HEAET 257 
 
 this is revealed by the distinct though not very forcible 
 pulsation to the left of the sternum above the fourth rib, and 
 if we can discover the cause of this dilatation we shall then 
 get into our hands the end of the clue by which we may be 
 guided through the labyrinth of all the sequential phenomena. 
 Dilatation and hypertrophy of the right ventricle, apart from 
 any pulmonary cause, which in this case does not exist, must 
 depend on some obstruction to the onward flow of the blood 
 within the heart itself. Obstruction at the entrance of the 
 pulmonary veins into the auricle is unknown, and if it did 
 exist would prevent the occurrence of dilated hypertrophy of 
 the left auricle, which in this case is present. Aortic re- 
 gurgitation has a peculiar pulse of its own, which in this case 
 is not detectable ; moreover, the consecutive changes which 
 affect the left ventricle are also wanting. Aortic obstruction 
 is incompetent to produce such an alteration on the left 
 auricle as we have here ; moreover, the changes which this 
 lesion produces, if extreme, involve the left ventricle even 
 more than the right, which is not the case here. Per viam 
 exdusionis, we thus arrive at the mitral opening as the only 
 possible position for an obstruction that could efficiently 
 produce the phenomena observed. This obstruction can only 
 be a permanently dilated state of the mitral opening, or a 
 permanently constricted condition of it. In the former case 
 regurgitation is the sole cause of obstruction, in the latter, 
 regurgitation plays a very small part in preventing the 
 onward flow of the blood. With a dilated opening the 
 obstruction is only constructive, and arises from so much 
 blood escaping backwards which ought to be thrown forwards. 
 As regards the circulation the results are similar to those of 
 aortic regurgitation (vide p. 75), though from the different 
 position of the lesion these results act very differently on the 
 heart itself. The regurgitation into the auricle, occurring 
 during early diastole while that organ is filling from the 
 lungs, tends undoubtedly to dilate that cavity; but this 
 tendency to dilatation of the auricle is counteracted by the 
 
 17 
 
258 CLINICAL LECTURES OX 
 
 patency of the pulmonary veins, as the regurgitant force is 
 thus diffused over the whole vascular area of the lungs, 
 instead of being concentrated on the auricle alone. Hence 
 congestion of the lungs, of the right side of the heart, and of 
 the general venous circulation, are early, common, and well- 
 known results of mitral regurgitation, while great dilatation 
 of the left auricle is m these circumstances almost unknown. 
 There is no hindrance to the passage of the blood from the 
 auricle to the ventricle ; this indeed is even more easy than 
 usual by reason of the wide and permanent patency of the 
 auriculo- ventricular opening. There is thus neither accumu- 
 lation within the auricle to dilate it, nor any need for 
 increased driving force to hypertrophy it. It is quite other- 
 wise in the case of stenosis of the auriculo-ventricular opening. 
 In this case there is not only regurgitation through the 
 narrow but permanently patent orifice in the valve which 
 maintains the auricle and lungs in a constant state of 
 repletion, but to this there is superadded a positive obstacle 
 to the onward flow of the blood from the diminished size of 
 the ventricular inlet. The concurrence of regurgitation with 
 obstruction naturally produces a degree of congestion in the 
 auriculo-pulmonary circuit, and a tendency to dilatation of 
 the auricle, commensurate mainly with the degi'ee of obstruc- 
 tion, as the one part of that circuit susceptible of this altera- 
 tion, I need scarcely add that the necessity of forcing the 
 blood through the constricted mitral opening causes the 
 auricle to be always more or less hypertrophied. It is there- 
 fore as the result of constriction of the auriculo-ventricular 
 opening that the auricle attams its greatest dimensions both 
 as regards dilatation and hypertrophy, and these are rarely 
 noteworthy at all except in those circumstances. There is 
 thus little room for doubt that the considerable dilatation 
 and hypertrophy of the left auricle in the case under con- 
 sideration is due to actual disease of the mitral valve causing 
 stenosis of the left auriculo-ventricular opening. Further, as 
 the considerable change in the left auricle, and the great 
 
DISEASES OF THE HEART 259 
 
 consecutive alteration in the right ventricle, as well as in the 
 circulation generally, have occupied but a short time in 
 development — only five years having elapsed since the 
 patient's first attack of rheumatism — the probability is that 
 the stenosis of the mitral opening is considerable, and the 
 prognosis is consequently grave. You see, then, that without 
 putting the stethoscope on the chest an inquiry based upon 
 Forget's law of retro-dilatation^ has enabled us to make a 
 distinct and most probable diagnosis, and to deduce an 
 evidently accurate prognosis, while the same data would also 
 enable us to propound a rational treatment. Could the use 
 of the stethoscope enable us to do more ? Certainly not. 
 Could the stethoscope alone enable us to do so much ? ISTot 
 so readily as we are apt to suppose. If we had to trust to 
 the stethoscope alone in such a case, what might we learn or 
 not learn from it ? We know that the murmur supposed to 
 be distinctive of mitral regurgitation through a dilated 
 auriculo-ventricular opening is a systolic murmur with its 
 position of maximum intensity over the cardiac apex. And 
 we also know that the murmur distinctive of stenosis of the 
 mitral opening is the so-called presystolic murmur, which 
 actually occupies the latter part of the diastole and runs up 
 to and terminates in the first sound. But, as has been already 
 pointed out {vide p. 247), a presystolic murmur is of all 
 murmurs that most frequently absent, even when the physical 
 condition of which it is distinctive is present. There are 
 many cases of mitral stenosis in which the only murmur 
 present is not presystolic but systolic in rhythm (vide p. 143), 
 and very often there is no murmur at all {vide p, 252). If 
 we trust, then, to auscultation alone ; if we attempt to dia- 
 gnosticate the exact nature of any cardiac lesion by careful 
 consideration of the audible phenomena with due regard to 
 their rhythm, and probable cause as suggested by their 
 position of maximum intensity, without being actually 
 
 ^ Precis Theorique et Pratique des Maladies du Cceur, C. Forget, Strassbourg 
 et Paris, 1851. 
 
260 CLINICAL LECTURES OX 
 
 misled, we shall yet often fail of that accuracy of diagnosis 
 which is always important and is generally quite attainable. 
 There is no case of cardiac disease in which this is more 
 likely to happen than one similar to that we have just been 
 considering. "We see, then, that in the case before us, as well 
 as in similar cases, the stethoscope alone may fail to give us 
 such distinct and positive information as will suffice to make 
 an accurate diagnosis, and yet we are enabled to attain to 
 this by a due attention to facts which were equally accessible 
 to our forefathers in the prestethoscopic ages. These facts 
 owe their significance to the modes in which each individual 
 cardiac lesion is compensated ; they vary naturally in degree 
 according to the gravity of the lesion present; but their 
 nature is always the same for similar lesions, presenting in 
 this respect a marked and important contrast to the acoustic 
 phenomena only too often impHcitly relied upon. These 
 acoustic phenomena vary not only in degree, but are often 
 loud and well marked when no important lesion exists, and 
 not uncommonly absent when serious lesions are present. 
 
 In connection with this subject I may recall to your 
 memory the statement by Belliugham ^ that in certain con- 
 ditions there may be developed a diastolic murmur of aortic 
 origin, unaccompanied by any lesion of the aortic valve or 
 by aneurysm. A case of this kind has been recorded by 
 Professor Law,^ and another by Dr. Finlayson ^ of Glasgow. 
 Like Dr. Hay den"* I have never seen such a case, and have 
 also a difficulty in understanding Bellingham's explanation 
 of the mechanism by which he supposed the diastolic portion 
 of this murmur to be produced. 
 
 A careful attention to the rhythm and position of maxi- 
 mum intensity of murmurs, and the same care directed 
 to the physio -pathology of the heart where no murmurs 
 are present, will enable us to unravel these difficult 
 
 ^ A Treatise on Diseases of the Heart (Dublin, 1857), p. 152. 
 
 - Pathological Society's Reports, vol. iii. p. 3, March 1868. 
 
 3 Lancet (1885), vol. i. p. 426. 
 
 * Op. cit. p. 845. 
 
DISEASES OF THE HEART 261 
 
 and embarrassing cases with a skill proportioned to our 
 experience. 
 
 Morbid anatomy reveals and describes a diseased structure ; 
 pathology unravels the process by which that structure has 
 become diseased. What I wish to be understood by the term 
 physio -pathology or pathological physiology is a study of 
 the consecutive changes which occur, not as part of a morbid 
 process, but which are developed as compensatory to that 
 process. Thus rheumatism may shrivel the aortic valve, but 
 it does not hypertrophy the left ventricle. This is a purely 
 physiological development induced by the necessity of com- 
 pensating changes in the physiological relations of the parts 
 caused by a pathological alteration of their structure. This 
 affords therefore an apt illustration of what I wish to be 
 understood by the term physio -pathology of the heart, of 
 which this hypertrophy and the other relative changes con- 
 stitute one phase. 
 
 While freely acknowledging the importance of the stetho- 
 scope in the diagnosis of cardiac disease, I would have it 
 remembered that it is not all-sufficient, and that in order 
 successfully to interpret all its revelations we require to pay 
 careful attention to the condition of the heart itself, always 
 remembering the consecutive manner in which those altera- 
 tions occur, which never fail to follow any special lesion. In 
 many cases a knowledge of these consecutive changes will 
 enable us to form a correct diagnosis apart altogether from 
 any acoustic phenomena, which may or may not be present. 
 By feeling along the lines indicated by our knowledge of 
 physio-pathology, we shall always be able to give a rational 
 account of our case, both in regard to diagnosis and prognosis, 
 though it may not always be so easily unravelled as the one 
 we have just been considering. 
 
LECTUEE X 
 
 ON INTERMITTENCY AND IRREGULARITY OF THE PULSE ; PALPITA- 
 TION, CARDIAC AND AORTIC; TREMOR CORDIS; TACHY- 
 CARDIA ; BRADYCARDIA ; AND DELIRIUM CORDIS 
 
 There is perhaps no single symptom connected with the 
 heart which gives rise to so much discomfort, uneasiness, 
 and feeling of insecurity as intermittency or irregularity of 
 the pulse. Yet these symptoms are quite as often found 
 apart from any serious disease of the heart as in connection 
 with it. 
 
 The heart, we know, beats because its muscular fibre is 
 incompletely differentiated, and still retains the power of 
 spontaneous movement possessed by all primordial proto- 
 plasm.^ The heart's energy resides in its muscular fibre, 
 and its quality depends upon the perfection of the cardiac 
 metabolism. 
 
 The nervous system neither initiates nor maintains the 
 rhythmic movements of the heart, but it controls and regu- 
 lates them, and through it these movements may be variously 
 modified or even arrested. 
 
 The surface of the heart, particularly at its base, is covered 
 by a network of nervous filaments, and these are connected 
 on the one hand with various ganglia scattered throughout 
 the substance of the heart, particularly at the junction of the 
 sinus venosus with the auricle, and in the auriculo-ventricular 
 sulcus. On the other hand these filaments unite in forming 
 three distinct strands or nervous cords by which they are 
 
 ^ Foster's Textbook of Physiology, 5th edition (1888), p. 288 et antea. 
 
CLINICAL LECTUEES ON DISEASES OF THE HEART 
 
 263 
 
 ■united to the central nervous system. One of these cords 
 (H, Fig. 16) passes through the first dorsal and the last 
 cervical ganglion into the sympathetic nerve, and through it 
 there pass to the heart those impulses which increase the 
 rate of its pulsations and augment their force.-^ This is the 
 kataboUc nerve of the heart,^ by its action cardiac metabohsm 
 is effected and the heart's energy set free; but we must 
 remember that its action is twofold, and that these actions 
 
 Fig. 16. 
 
 do not always coincide, thus by it both the rate and force of 
 the heart's pulsations may be simultaneously increased, and 
 we may have a rapid heart-beat with a quick, large, and full 
 pulse, or we may have only a rapid heart-beat, the pulse 
 remaining small and empty.^ 
 
 ^ Uhfersuchungen ilber die Innervation des Herzens, von Albert v. Bezold 
 (Leipzig, 1863), Erste Abtheiluug, S. 162. 
 
 ^ Gaskell, Journal of Physiology, vol. vii. pp. 41 and 46. 
 
 ^ "Sometimes the one result and sometimes the other being the most 
 prominent," Foster, 077. dt. p. 294 ; vide also Roy and Adami, Tramsadions 
 of the Royal Society, vol. clxx.xiii. p. 240. 
 
264 CLIXICAL LECTURES OX 
 
 The inferior cardiac nerve, the second of the cords con- 
 necting the heart with the central nervous system, is the 
 aimholic nerve of the heart (G, Fig. 16), and its action is to 
 inhibit the action of the augmentor or katabolic nerve. 
 
 The third nervous strand is the superior cardiac nerve 
 (F, Fig. 16) ; this conveys from the heart to the vaso-motor 
 centre in the medulla oUongata an influence which enables it 
 to regulate and control the movements of the arterioles in 
 accordance with the needs of the heart. When the blood- 
 pressm-e is too high and threatens to overpower the heart, an 
 impulse sent through this nerve inhibits the constrictor 
 influences and tempers down the blood-pressure to suit the 
 cardiac strength.^ This nerve is often called the depressor 
 nerve of the heart. 
 
 The inferior and superior cardiac nerves both enter the 
 trunk of the vagus nerve and ascend to the brain along with 
 it, but each has its separate origin as well as its special 
 function. The inferior cardiac nerve is generally regarded 
 as a branch of the vagus nerve, and its action is referred to 
 as vagus action, but it has a special root of its own, and in 
 that, as well as in action, it is much more closely connected 
 with the spinal accessory nerve than with the vagus proper. 
 
 You will remember, then, that the superior cardiac nerve 
 controls the blood-pressure in the interests of the heart 
 through the vaso-motor centre in the medulla oblongata. 
 
 The inferior cardiac, anabolic, or vagus nerve, when in 
 action, counteracts and inhibits the action of the katabohc 
 nerve, slows the heart generally, lessens the excitability of 
 the ventricles, and may even when acting moderately reduce 
 their output by as much as thirty per cent,^ thus initiating 
 residual accumulation and all the evils that may flow from it. 
 
 On the other hand the katabolic nerve, though it does 
 not initiate or cause cardiac movement, when in action ac- 
 celerates and augments it, and is itself kept in check by the 
 
 ^ Foster, op. cit. p. 351. 
 
 - Koy and Adami, op. cit. p. 217. 
 
DISEASES OF THE HEART 265 
 
 anabolic nerve. It is closely connected with the sympathetic 
 system. 
 
 The natural tonieity of the heart is the property of the 
 cardiac muscular fibre, and depends upon the perfection of 
 its metabolism ; the heart's pulsation is also muscular and 
 automatic, but its rate, rhythm, and force are controlled by 
 the interaction of the nerves just described acting under the 
 influence of various excitants. 
 
 The anabolic or vagus nerve is excited to action by in- 
 hibitory influences that pass to it from every quarter through 
 the cardio-inliibitory centre. An inhibitory influence may 
 either be physical or psychical ; it may come from a diseased 
 organ, a depraved secretion, or a mental shock. Under any 
 such influence the vagus nerve may slow and reduce the 
 action of the auricles, and may even arrest it for hours. The 
 action on the ventricles is similar, but not so powerful ; strong 
 stimulation of the vagus may indeed arrest the action of the 
 ventricles, but never for a period long enough to endanger 
 life. At a certain point of vagus inhibition, that varies in 
 different animals, the ventricles commence to beat inde^ 
 pendently of both sinus and auricles, and this idio-ventricular 
 action, which is at first slow and irregular, gradually attains 
 a reasonably rapid rate and becomes almost perfectly regular 
 in rhythm. Irregularity is brought about by the auricles 
 failing to respond to some of the contractile impulses which 
 reach them from the sinus, or by the interference of the 
 sinus and the ventricular rhythms with each other, which is 
 a usual cause of this abnormality.-^ Ultimately the cause of 
 all uTcgularity may thus be traced back to inhibition of the 
 heart through — but not by — the vagus. 
 
 The effects of vagus inhibition vary from simple inter- 
 mission to sudden death, and between these extremes we 
 have irregularity which is almost invariably accompanied 
 by a certain amount of dilatation. Therein constitutes its 
 danger, a danger which after middle life is far from being 
 1 Roy and Adami, op. cit. pp. 293, 294, etc. 
 
266 CLINICAL LECTURES ON 
 
 hypothetical. So long as the pulsation of the heart is purely 
 automatic, that is so long as the foetus remains in utero, 
 intermittence seems to be unknown ; no doubt there are 
 agencies even then which ought to give rise to intermittence, 
 but if this ever occurs, it must be very exceptional, as I am 
 not aware of a single case that has been recorded. It is 
 otherwise after birth, then injurious agencies multiply so 
 that infantile intermittence is a well-known fact. From 
 man's birth to his grave intermission is a matter of common 
 occurrence, and, as mere occasional intermittence, it does not 
 seem to have any marked injurious effect. It always, how- 
 ever, handicaps a man more or less, and for his own peace of 
 mind it is desirable to get rid of it, quite apart from the fact 
 that even simple intermission always indicates a feeble myo- 
 cardium, and if neglected may prove the precursor of more 
 serious ailment.^ 
 
 Simple intermittence is always an early intimation of 
 cardiac failure due to anaemia, overwork, or worry ; it may 
 be associated with valvular lesion, but has only an incidental 
 connection with it. The more feeble the myocardium the 
 more readily intermittence may be brought about, but it 
 seems as if even an average heart might be forced to 
 intermit if the exciting cause be powerful enough. Thus I 
 have known a young man with an apparently strong heart 
 forced to intermit by the shock of a railway accident. In 
 this case the intermissions were at first every second beat, 
 but in a few months they died down to one intermission in 
 twenty beats, and I have no doubt they ultimately ceased 
 entirely. Sir Benjamin W. Eichardson has recorded a case 
 of shipwreck in which the fear of instant death from drowning 
 caused the heart of a middle-aged man, in perfect health and 
 spirits, suddenly to stop. He was rescued and put on board 
 another vessel, and when he had regained sufficient composure 
 he found that his heart intermitted four or five times a 
 minute. At first these intermissions were so disturbing as 
 ^ Vide The Senile Heart, p. 41, etc. 
 
DISEASES OF THE HEAET 267 
 
 to prevent sleep; by and by they died away to two in a 
 minute, and the patient was no longer cognisant of them 
 unless he felt his pulse.-^ In another case also related by 
 Eichardson, mental anxiety alone developed persistent inter- 
 mittency, followed by death from the silent but sleepless 
 suffering induced,^ complicated, no doubt, by sequential dilata- 
 tion of the heart. 
 
 Emotional inhibition of the heart is often a most serious 
 matter, and may instantly and fatally arrest its action. This 
 has happened often enough in those not known to labour 
 under a,ny cardiac affection, to make it a possible occurrence 
 in any one with a myocardium weakened by age, or from 
 some definite cause at an earlier period of life. Zimmermann^ 
 has pubHshed a number of cases of sudden death from cardiac 
 inhibition, and from him we learn, what we would scarcely 
 have expected, that unexpected joy is even more dangerous 
 to life than sudden grief. 
 
 Sophocles at the age of ninety died suddenly of joy on 
 being crowned as the first tragic poet of the age. Philippides, 
 the comic writer, died a similar death. Chilon of Lacedsemon 
 died in the arms of his son who had borne away the prize 
 at the Olympic games. The famous Fouquet died of joy on 
 being set free by Louis XIV. The niece of Leibnitz died 
 suddenly of joy at finding a box containing ninety thousand 
 ducats beneath the philosopher's bed. Many other similar 
 cases have been recorded both by Zimmermann and others, 
 aU testifying to the fatal effect of excessive emotion even 
 when of a pleasing character. It seems more natural that 
 terror and grief should be more hurtful than joy, and though 
 this does not appear to be the case, yet these emotions have 
 in their turn been fatal to many. Phnip II., king of Spain, 
 enjoys the unenviable notoriety of having frightened two of 
 his counsellors to death. One of his ministers of state died 
 
 ^ Transactions of the St. Andreius Medical Graduates Association (1870), p. 
 238. 2 Op. cit. p. 239. 
 
 ^ A Treatise on Experience in Physic (London, 1782), vol. ii. p. 286. 
 
268 CLINICAL LECTURES ON 
 
 suddenly on being sharply rebuked for a hesitating answer. 
 Another, the Cardinal Espinoza, died a few days after being 
 sternly told, " Cardinal, know that I am master." Mallet's tale 
 of " Edwin and Emma " was founded upon an actual incident 
 that happened at Bowes in Yorkshire, in 1714, when a young 
 woman died suddenly on being told of the death of her lover. 
 Palmer, a celebrated comedian of last century, died on the 
 stage of the Liverpool theatre in most tragic circumstances. 
 Palmer had recently lost both his wife and a favourite son ; 
 he was acting the part of " The Stranger " in the play of that 
 name, when one of the dramatis ijersonm in the course of the 
 play asked him for his wife and family. Palmer, unable to 
 reply, became inexpressibly agitated and dropped dead upon 
 the stage. In the end of last century Prince George Louis 
 of Holstein, having removed the body of his wife from one 
 coffin to another of more costly materials, desired his valet 
 to read him some pages from a pious book, and kneeling at 
 the side of the coffin he burst into tears and died. And a 
 few years ago there occurred in France an even more 
 startling instance of the fatal effect of overwhelming emotion. 
 Dr. Deleau, a celebrated aurist, only forty-four years of age, 
 leaning over his dying daughter to receive her last farewell, 
 himself fell dead as if struck by lightning. 
 
 The effects of emotional inhibition vary with the intensity 
 of the emotion on the one hand, and the sensitiveness of the 
 organism on the other, to which we must add a third and 
 most important element, the condition of the heart itself. 
 In some, from an untoward combination of these conditions, 
 the emotion may prove suddenly fatal; in others the distvirbed 
 rhythm of the heart may persist as a fact of which the 
 sufferer cannot for one instant lose the consciousness, and 
 which as a natural sequence terminates in dilatation of 
 the heart with death looming in the distance. On the other 
 hand when the conditions are more favourable, the effect 
 dies off with the fading of the emotion which produced it. 
 There are probably but few of us who have not at one time 
 
DISEASES OF THE HEART 269 
 
 or other realised in ourselves the meaning of an emotional 
 inhibition when our heart has stood still, as the expression 
 is, in the face of some impending danger to ourselves or 
 others. It has been graphically referred to by our vernacular 
 poet Ballantyne as an indication of maternal anxiety : 
 
 " My vera heart gaes loup, loup, 
 Fifty times a day." 
 
 The "loup" being nothing but the perceptible thump, the 
 forcible systole, which succeeds a momentary intermission 
 (inhibition). Emotion acting in this way is reflected from 
 the sensorium to the cardio-inhibitory centre in the medulla 
 oblongata, and from it to the heart through the inferior 
 cardiac branch of the vagus. 
 
 But while psychical emotion may be so disturbing to the 
 heart and so disastrous to the individual, any physical 
 sensation of equivalent intensity may be no less injurious 
 both to the organ and the organism. Severe cold applied to 
 the surface has been no infrequent cause of fatal inhibition 
 of the heart, especially in those exhausted by fatigue. During 
 the Eussian campaign (1812-13) the Trench soldiers were 
 often seen to fall dead as if struck by lightning from the 
 effects of the excessive cold. At Smolensko more than 
 thirty grenadiers of the ItaKan Guard fell dead from this 
 cause, while attempting to set themselves in line on the 
 height beyond the Borysthenes.'^ A cold bath has proved 
 fatal to infants in this way, and many a one has died in the 
 water from an inhibited heart. These unfortunates are said 
 to be seized with cramp and to drown; but the cramp is 
 that of the heart fatally inhibited. Now and then such 
 victims do struggle, and are partly drowned, for inhibitory 
 paralysis of the heart, like every other form of asystole, is 
 not necessarily instantaneously complete, but may be in- 
 gravescent in character. Cold applied internally is also 
 
 1 A Treatise, on the Effects aiul Properties of Cold, by Moricheau Beaupre, 
 M.D., translated by John Glendinning, A.B. andM.D. (Edinburgh, Maclaclilan 
 and Stewart, 1826), p. 149. 
 
270 CLINICAL LECTURES ON 
 
 well known as a frequent cause of fatal cardiac inhibition. 
 The knowledge of this is of very ancient date indeed, for 
 Quintus Curtius tells us that Alexander the Great lost more 
 men from his soldiers drinking the ice-cold waters of the 
 Oxus, than he did in any one of his many serious battles. 
 Almost every summer some sudden death in the harvest 
 field, from a similar cause, su^Dplies a fresh modern illustra- 
 tion of the sudden way in which life may be brought to a 
 close by a shock thus applied. Not cold only but pain also, 
 or, in fact, any physical irritation, such as those arising 
 from acidity, flatulence, undigested food, or any depraved 
 secretion, as well as many poisons, such as tobacco, alcohol, 
 etc., used in excess, may give rise to simple intermittence, 
 or to various forms of irregularity, and ultimately to 
 dilatation of the heart. 
 
 One hundred years ago the pathology of such cases was 
 very much based upon Tristram Shandy's idea that the body 
 and soul are like a coat and its lining ; if you rumple the 
 one you rumple the other also. The intensity of any im- 
 pression psychical or physical constituted its daiiger. "A 
 passion," says Zimmermann, " without even being carried to 
 excess, will sometimes occasion a difficulty of breathing, 
 together with a sense of stricture in the breast, and an 
 hesitation to speak, the tongue remaining as it were immov- 
 ably fixed to the palate. The weaker passions speak, the 
 stronger passions are mute." ^ Great intensity of emotion 
 was supposed to collapse the heart, so that it neither received 
 nor emitted any blood, the victim dying instantaneously.- 
 It was also known that the heart occasionally ruptured from 
 the strain thus thrown upon it, as in the case of Philip V. of 
 Spain.^ Essentially popular in character, this pathology was 
 of very ancient date, and when Shakespeare makes Malcolm 
 say to Macduff: 
 
 " Give sorrow words ; the [i;rief that does not speak 
 Whispers the o'erfraught heart and bids it break," 
 
 ^ Op, cit. p. 267. ^ Loc. cit. ^ Zimmermann, op. cit. p. 274. 
 
DISEASES OF THE HEART 271 
 
 he but expresses in terse poetic form the weak periphrasis 
 of Zimmermann. 
 
 Since the beginning of this century men have ceased to 
 be contented with vague descriptions of still vaguer ideas, 
 but have sought to connect physical results with definite 
 physical causes. Among the earliest pioneers in regard to 
 the influence of injuries of the nervous system on the heart, 
 were Legallois -^ and Wilson Philip.- Yet though the patho- 
 logical acumen of Alison ^ distinctly recognised the bearing 
 of such experiments on the cardiac depression so often 
 observed in the early stages of abdominal inflammation, as 
 well as their bearing on the sudden death that results from 
 a blow on the epigastrium, we had got no farther fifty years 
 ago than to be able to connect fatal cardiac failure with 
 concussion of some part of the cerebro-spinal or sympathetic 
 system. The history of the last fifty years contains the 
 history of the inquiry by which we have been led to recognise 
 the method by which the heart's action is influenced by 
 extraneous impressions. This knowledge not only helps our 
 diagnosis, but it also directs our treatment and enables us to 
 bring it to a successful termination, not only aiding us in 
 relieving suffering of a most wearing character, but enabling 
 us to restore to comfort and health hearts that have already 
 commenced their downward career. The story of this progress 
 is to be found in the writings of the brothers Weber,^ of 
 Budge,^ Cyon,'' Von Bezold," and Eutherford,^ writings 
 
 ^ Expdrience sur la Principe de la Vie, notaimnent sur celui des inouvements 
 du Cceur et sicr le siege de ce Principe, paper read before the Institute of 
 France, 3rd June 1811. — Vide (Euvres de Cesar Legallois (Paris, 1830). 
 
 ^ Philosophical Tra7isactions, 1815 and 1817 ; vide also A71 Experimental 
 Inquiry into the Laws oftjie Vital Functions (London, 1818), 2nd edition. 
 
 ^ Outlines of Pathology and Practice of Medicine (Edinburgh, 1844), p. 12. 
 
 ^ Omodei annali universali di medicina, cxvi. pp. 225-233 (1845). 
 
 5 Archivf. Anat. u. Physiol. (1846), S. 295. 
 
 6 Bericht d. Sachs. Ges. d. Wiss. (1866), S. 308. 
 
 '' Vntersuchmigen iiber die Innervation des Herzens (Leipzig, 1863) ; vide 
 also Untersuchungen aus dem physiologischen Lahoratorium in Wurzhurg 
 (Leipzig, 1867). 
 
 ^ Papers read before' the Royal Society of Edinburgh, May 1869, published 
 in abstract in the Journal of Anatomy and Physiology, vol. iii. (1869), p. 462, 
 
272 CLINICAL LECTURES OX 
 
 which have culminated in the important work of Eoy and 
 Adami.^ 
 
 An intermittent or irregular heart, and the one may be 
 regarded as merely an advanced stage of the other, presupposes 
 an enfeebled myocardium and an adequate excitation of 
 psychical or physical origin, the stimulus acting on the heart 
 through the inhibitory centre in the medulla oblongata and 
 the vagus nerve. The more perfect the cardiac metabolism 
 the more powerful must be the inhibitory impulse to produce 
 any result, hence whatever interferes with cardiac metabolism 
 condvices to irregularity,^ and we must never forget that 
 irregularity diminishes the efficiency of the heart without 
 reducing its expenditure of energy.^ Irregularity thus con- 
 tributes to cardiac dilatation m a twofold manner ; the 
 vagus inhibition to which it is due diminishes the ventricular 
 output,^ and as this diminished output is accompanied by no 
 diminution in the expenditure of energy cardiac metabolism 
 is of necessity still further impaired. 
 
 I have occasionally observed a heart small from birth or 
 from early childhood, but apparently perfect in its metabolism, 
 to have, as age advanced, irregularity of various kinds forced 
 upon it. In such a case we may have intermission, either 
 only occasional or every second or third beat for days, or 
 with occasional mtervals for years ; or the pulse may be 
 irregular in both rate and rhythm for varying periods ; or 
 the heart may have a sudden fit of tremor, or two or three 
 forcible systoles may be followed by a reversion to the 
 normal rate and force. Such irregularities are most com- 
 monly due to gastric or intestinal troubles, but psychical 
 emotions are equally efficacious in producing them. A small 
 but otherwise healthy heart may suffer in this way for many 
 years without any apparent detriment, certainly with much 
 
 and in full in the Transadions of the Eoyal Society of Edinburgh, vol. xxvi. 
 (1872), p. 107. 
 
 ^ Philosophical Transactions, vol. clxxxiii. (1892), B. pp. 199-298. 
 
 - Von Bezold, op. cit. S. 279. ^ Roy and Adami, op. cit. p. 284. 
 
 * Op. cit. p. 217. 
 
DISEASES OF THE HEART 
 
 273 
 
 less detriment than befalls a heart similarly affected for the 
 first time after middle life. 
 
 Irregularity is only associated with valvular lesions 
 incidentally ; that is to say, no valvular 
 lesion in itself has any special influence ^HHHjjjB 
 in inducing it, except in so far as from ^H^^^^l 
 its own intrinsic character, or from its ^H^^^^| 
 effect on the circulation, it has influenced ^H^^^^H 
 the metabolism of the myocardium. Hence ^Hf^^^^H 
 irregularity is a most characteristic symptom ^H^^^^H 
 of mitral stenosis {vide cmtea, p. 124, note), ^Bj^^^^H 
 and of cardiac dilatation, chiefly in its later ^H^^^^H 
 stages or at any period if dilatation pre- ^H^^^^H 
 dominates over the hypertrophy which ^H^^^^l 
 always accompanies it; theoretically we ^H^^^^H 
 must also regard it as a symptom of ^H^^^^l 
 atheromatous coronaries, but I confess ^H^^^^H 
 never to have had unequivocal proof of ^HI^^^H o" 
 this. Associated with any other valvular |H!^^^^H ^ 
 lesion irregularity must always be regarded ^H^^^^l 
 as a symptom of cardiac failure. ^H^^^^H 
 
 The following sphygmogram (Fig. 17) ^H^^^^l 
 represents the feeble irregular pulse of a ^H^^^^H 
 patient with a perfectly healthy heart, ^Hi^^^^H 
 whose life was rendered miserable by a feeble ^B^^^^H 
 irregular pulse due to impaired metabolism ^H^^^^H 
 of his myocardium, the result of a depraved ^HH^^H 
 state of his general health due to confine- ^H^^^^H 
 ment during business hours to an unhealthy ^Hf^^^^H 
 and badly ventilated ofiice. A month's ^^EB^^H 
 holiday with tonic treatment and fresh |^H|^^0 
 air speedily restored this patient to health. 
 
 The following sphygmogram (Fig. 18) represents the ir- 
 regular pulse of mitral stenosis; in it you will observe that the 
 ventricular output (as indicated by the line of ascent), 
 though not so meagre as in the preceding case, yet maintains 
 
 18 
 
274 CLINICAL LECTURES ON 
 
 a uniform low level, not so much because the ventricular 
 output itself is dhninished as because the ventricular income 
 is persistently at a low ebb. In this matter it contrasts 
 very strongly with the annexed sphygmogram (Fig. 19) of 
 the pulse of a large dilated heart, in which small systolic 
 waves are varied every now and then by a large one. The 
 tracing shows a pulse irregular as to rate, rhythm, and also 
 apparently as to force, but this is doubtful, as the occasional 
 large ventricular output is more probably due to the acci- 
 dental coincidence of the auricular systolic wave with that 
 of idio-ventricular action. 
 
 In the treatment of intermission and irregularity we 
 have always to deal with a myocardium irritable because 
 
 Fig, 18. 
 
 ill-fed, and sometimes, as in the case of a dilated heart, our 
 principal treatment must be directed to the heart itself. On 
 a future occasion I shall describe to you what cardiac tonics 
 are, and how they ought to be employed. Strict and careful 
 attention to diet is also requisite in all cases of cardiac 
 irregularity, but as this does not differ from what is always 
 required in all cases of heart disease, this also will be best 
 considered when speaking of the general treatment of such 
 cases (vide 2}0stea, Lecture XIV.) 
 
 There is another form of irregularity observed in various 
 circumstances, and which is not uncommon when digitalis 
 has been given for some considerable time : this is the pulsus 
 higeminus of which the accompanying sphygmogram (Fig. 20) 
 gives a very good example. This tracing was taken from 
 the radial artery of a man suffering from aortic incompetence. 
 Traube gave this "twin pulse" a somewhat unen\iable 
 
DISEASES OF THE HEART 
 
 275 
 
 notoriety by ascribing to it an important prognostic value as 
 
 presaging a speedy lethal termination to ^■■■MH^ 
 
 the disease in which it showed itself.^ Later ^^^B^^H 
 
 observations have shown that this idea was ^^^B^^H 
 
 not well founded, and cases in which it has ^^|R^^H 
 
 occurred have been often enough known ^HR^^^f 
 
 to end in recovery ; it is merely a form ^BS^^H 
 
 of irregularity of no special importance. ^^^B^^H 
 
 Sphygmograms 21 and 22 represent the ^^^B^^H 
 
 usual pulse and heart-beat in a case which ^^^E^^H 
 
 frequently presented a very unusual form of ^^^^^^H 
 
 irregularity seen in the annexed sphygmo- ^^^S^^^H 
 
 grams, of which Fig. 23 shows the heart-beat ^^^B^^H 
 
 and Fig. 24 the pulse. The pulse-tracing ^^ES^^H 
 
 shows that not unusual form of irregularity ^^HE^^I 
 
 known as hemi-sy stohc bradycardia, of which ^^H^^^B 
 
 I shall speak later, but the cardiogram shows ^^Si^^H ai 
 
 that though the pulse was a bradycardiac ^^H^^|h d 
 
 pulse of the hemi-systolic type, the heart ^^^^^^^1 ^ 
 
 beating at the rate of 88 per minute and ^^^^^^^| 
 
 the pulse at only 44, the heart-beat itself ^^|B^^^| 
 
 was also bigeminal. You will observe in ^^B^^^^l 
 
 the cardiogram that the second of each ^^H^^^f 
 
 twin beat is imperfect ; it is less than half ^BS^^H 
 
 the amplitude of the first beat ; its pulse ^^|B^^H 
 
 failed to reach the radial artery and hence ^H^^^^f 
 
 the bradycardia. But the bigeminal ^^^^^^H 
 
 character of the heart-beat has impressed ^S9^^H 
 
 its own pecuUarity upon the pulse tracing, ^HH^^H 
 
 which naturally differs somewhat from a ^^^^^^^| 
 
 hemi-systolic bradycardia of the ordinary ^^K^^^^M 
 
 type. Further, this heart presented a well- ^HB^^^H 
 
 marked example of the pulsus alternans ^^^S^^H 
 
 in that, although both ventricles beat simul- ^^|H^^H 
 
 taneously, the left and right ventricle pre- ^^I^^HB 
 
 ^ GesamiiuUe Beitrdge, and Berliner Iclinisclie JVochenschrift, 1872, "Ein 
 Fall Pulsus bigeminus nebst Bemerkungen." 
 
276 CLINICAL LECTURES ON 
 
 dominated alternately. The heart beat bigeminally, and 
 the two ventricles alternated in force. As there was free 
 regurgitation with jugular pulsation, this alternation in force 
 was well seen in the neck, where the carotid artery and 
 
 Fig. 20. 
 
 jugular vein were seen to beat alternately. This heart thus, 
 and another that occurred about the same time, presented the 
 rare combination of a biseminal alternatino- heart-lieat with 
 
 Fig. 2L 
 
 a hemi-systolic bradycardiac radial pulse also of a bigeminal 
 type, forming altogether a very remarkable combination of 
 irregularities.^ 
 
 Fig. 22. 
 
 All who suffer or who think they suffer from disease of 
 the heart are prone to complain of palpitation. But this 
 term is loosely applied to every variety of cardiac abnormality. 
 In true palpitation there is no irregularity ; there is nothing 
 
 ^ Vide On two Heart Cases which presented a rare form of Irregularity, 
 from Dr. G. W. Balfour's "Clinique," by Charles S. Roy, M.B., Edinburgh 
 Medical Journal (1878), p. 594. 
 
DISEASKS OF THE HEART 
 
 277 
 
 but rapid, regular, and violent pulsation of the heart, which 
 often shakes the whole body and makes itself unpleasantly felt 
 by the sufferer, accompanied by violent throbbing of the 
 aorta, carotids, and larger arteries, but does not extend to 
 the smaller arteries, the radial pulse for instance being rapid, 
 but having no excess of force. These attacks come on suddenly, 
 and last from a few minutes to many hours; they are extremely 
 
 Fig. 23. 
 
 distressing and even alarming to the patient, but they are not 
 usually attended by any danger. Palpitation is due to reflex 
 inhibition of the inhibitory centre, which temporarily removes 
 the vagus influence, and allows the heart to be run off with 
 by the katabolic nerve acting as an accelerator only. Palpita- 
 tion occurs in weakly, anaemic individuals, and is induced 
 by psychical and gastric reflexes of various origins, never by 
 exercise. The rapid, forcible augmentor action that follows 
 
 Fig. 24. 
 
 exertion in anaemic individuals is accompanied by a full 
 and forcible radial pulse, while the heart-beat is never so 
 violent and throbbing as in true palpitation, and both cease 
 at once whenever the patient becomes quiescent. The rapid 
 action that occurs in alcoholic and tobacco poisoning is a 
 tachycardia (^.-y.) and not a true palpitation. 
 
 Palpitation is so often of psychical origin that our most 
 efficient cure is often the narcotic needle, and whatever its 
 origin large doses of the bromides will frequently be found 
 
278 CLINICAL LECTURES ON 
 
 our most useful adjuvant. Neurasthenia — imperfect meta- 
 bolism — is at the bottom of all repeated or long -continued 
 attacks of palpitation, and all our endeavours must be directed 
 to the improvement of the general health. In some cases 
 massage and forced feeding work a rapid cure ; in others 
 fresh air and exercise are of the greatest advantage. 
 Formerly horse exercise used to be greatly recommended ; in 
 the present day no exercise is preferable to the moderate 
 and prudent use of a bicycle, but no racing, nor pushing up 
 hills, both of which are fraught with danger to a feeble heart. 
 In recommending cycling for a weak heart, I necessarily 
 presume that the heart is young and free from organic 
 mischief; it is most unsafe for elderly hearts, or those with 
 valvular lesions. Naturally various tonics, such as iron, 
 arsenic, and strychnine, may be advantageously combined 
 with the tonic regimen, every possible means being taken 
 to promote a healthy htemogenesis, and every endeavour 
 made to put a stop to any undue hiemolysis. 
 
 There is a peculiar disease often complained of as pal- 
 pitation, which has, however, a totally different syndrome. 
 There is rapid action indeed, the heart beating 140 or more 
 per minute, and the heart's action is violent, but there the 
 resemblance ends, for in Graves disease, of which I speak, 
 the disagreeable throbbing is not confined to the heart and 
 large arteries but extends over the whole arterial system. 
 Add to this that in all such cases the heart sounds are loud 
 and distinct, so much so that Graves, to whom we owe the 
 earliest description of the disease, says in reference to one 
 of his cases, " I could distinctly hear the heart beating when 
 my ear was distant at least four feet from the chest." ^ The 
 phenomena distinctive of Graves' disease are violent per- 
 turbative action of the heart and arteries associated with 
 enlargement of the thyroid gland (goitre) and protuberant 
 eyeballs (exopthalmos). In marked cases all three symptoms 
 
 ^ A System of Clinical Medicine, by Robert James Graves, JLD. (Dublin, 
 18i3), p. 674. 
 
DISEASES OF THE HEART 279 
 
 are present, but often there are only two, and sometimes the 
 violent throbbing of the heart and arteries is the onlj 
 symptom present, but this is distinctive enough and quite 
 sufficient to enable us to differentiate it from every other 
 form of so-called palpitation. At first there is no change in 
 the heart itself, but the rapid perturbed action is associated 
 with diminution of the ventricular output, and this ulti- 
 mately leads to residual dilatation with all its usual results, 
 including albuminuria. 
 
 For this mysterious complaint many various remedies 
 have been suggested and employed. All the elements of the 
 tonic regimen have been more or less successfully employed, 
 in combination with iron, arsenic, and digitalis. Baths of 
 compressed air have also been used with benefit, and by some 
 good results have been said to be attained by the use of 
 thyroid extract, probably thyrocol — the active colloid sub- 
 stance of the thyroid gland might be used with better results. 
 I myself have used thymus gland with excellent results, 
 thyroid extract being too often found to increase the symptoms 
 it is employed to cure. We cannot say that the thymus 
 gland is antagonistic to the thyroid, but at least it atrophies 
 as the thyroid grows, and the idea is thus suggested that 
 there is some contrarious relation between their actions. 
 
 Tachycardia is another form of rapid heart action often 
 confounded with palpitation, from which it differs toto coilo. 
 It is an error to apply the term tachycardia to all cases in 
 which there is a rapid heart. For example nothing could be 
 more striking than the contrast between the syndrome of 
 Graves' disease and that of tachycardia : in both the heart 
 hurry may last for years, but in the one case the heart's 
 action is violent, perturbed, and noisy, and the whole arterial 
 system throbs disagreeably ; in the other the heart is rapid 
 enough but feeble, and its sounds empty, like the tic-tac of 
 the fcetal heart, while the pulse, though quick, is feeble and 
 sometimes almost imperceptible. One remarkable character- 
 istic of tachycardia is the little disturbance it gives the 
 
280 
 
 CLINICAL LECTUEES ON 
 
 sufferer, who will often be found going composedly about his 
 ordinary occupations with a pulse -rate of 150 or more. 
 Donders was the first to point out that a rapid heart-beat 
 
 I meant shortening of the systole and a 
 diminution of the ventricular output/ 
 hence shortening of the primary wave in 
 the pulse -tracing and increased depth of 
 the dicrotic notch, dicrotism of the pulse 
 and pulse-tracing. When the pulse-rate 
 is much increased, the pulse becomes hyper- 
 dicrotic ; the ordinary dicrotic notch is 
 carried on to the ascending limb of the 
 tracing, and simulates anacrotism, as in 
 the sphygmogram here given (Fig. 25). 
 This is the tracing of a tachycardiac pulse, 
 hyperdicrotous, of low tension, beating 
 . perfectly regularly at the rate of l74 per 
 ■^ minute, as counted on the sphygmogram. 
 ^ There was in this case increased precordial 
 dulness, and a feeble wobbling heart-beat, a 
 condition obviously not without danger, the 
 degree of which may to some extent be 
 gauged by the amount of dicrotism present, 
 as this indicates diminution of the ven- 
 tricular output (lessening of the heart's 
 contraction volume), and tendency to death 
 from sudden or ingravescent asystole. In 
 tachycardia the pulse-rate is said often to 
 exceed 200 per minute ; I myself am quite 
 unable to count a pulse beating over 150 ; 
 by the aid of the sphygmograph we may 
 certainly count more, but I have never found the rate up 
 to 200. 
 
 At both extremes of life we may have a rapid pulse ; in 
 infancy this depends upon the low blood-pressure and concurs 
 
 ' Nederl. Arcliiv voor Genees-en Naturk. Bd. 11 (1865), S. 184. 
 
DISEASES OF THE HEART 281 
 
 with it in promoting the diffusion of the blood plasma and 
 the rapid growth of the tissues, and it ceases as the blood- 
 pressure rises and development takes the place of growth. 
 At the other extreme of life a rapid, feeble pulse, weak 
 impulse, and empty heart sounds, often indicate failure of 
 cardiac energy and herald the approach of death. These 
 two instances may be reckoned as forms of normal or physio- 
 logical tachycardia, as may also the heart hurry that not 
 infrequently accompanies convalescence from febrile diseases, 
 the rapid pulse of some women during menstruation, and 
 also during the puerperium. Tachycardia is not infrequently 
 induced by vagus inhibition due to the immoderate use of 
 tobacco, alcohol, or other poisons. In the case of alcohol 
 the vagus inhibition is occasionally associated with neuritis, 
 and with fibro-fatty degeneration of the myocardium, and 
 tliis combination constitutes the chief source of danger in 
 dehrium tremens, and also in chronic alcoholism.^ Tachy- 
 cardia is also not infrequently the sole indication of the 
 chronic valvulitis that sometimes follows heart strain and 
 terminates in stenosis of the mitral opening. It may also 
 be due to interference with vagus action by the direct 
 pressure of an intra-thoracic tumour, or to reflex inhibition of 
 the vagus by physical or psychical causes of various origins, 
 sometimes taking the place of simple irregularity under 
 conditions the exact nature of which are as yet unknown. 
 
 When the rapid heart depends upon recent strain of the 
 myocardium the most hopeful treatment seems to be to 
 maintain for some time the fuU action of belladonna (or 
 atropine), as indicated by slight dilatation of the pupil. In 
 other circumstances, remove the cause if this be at all 
 possible, improve the metabolism of the myocardium by 
 appropriate tonics, and quiet the action of the inhibitory 
 centre by suitable sedatives properly employed. The con- 
 dition is not devoid of danger, and occasionally both time 
 and patience are required for its treatment. 
 
 1 Vide The Senile Heart, p. 76, etc. 
 
282 CLINICAL LECTURES OX 
 
 Tremor cordis is a remarkable form of cardiac irregularity, 
 most alarming to the sufferer, yet not apparently attended 
 by any danger. Like a bolt from the blue, and with as 
 little warning, a heart beating quietly and steadily is 
 suddenly seized with a rapid fluttering, and the ordinary 
 full pulse of health suddenly drops to a mere tremulous 
 thread. These attacks vary from three or four short, incom- 
 plete systoles rapidly succeeding one another up to a whole 
 series of short, rapid, and incomplete systoles, which may 
 last for several seconds, convey a tremulous sensation to the 
 hand laid upon the cardiac region, and are accompanied by 
 a small fluttering and often scarcely perceptible radial pulse. 
 The attack ends suddenly, like an intermission, with an 
 unusually forcible beat. During all these imperfect systoles 
 the ventricle has been gradually getting overfilled, the 
 augmentor nerve is called into action, and the ventricle 
 forcibly expels its contents, which escape freely and distend 
 arteries which have had time to get unusually empty. This 
 form of irregularity is never attended by any feeling of faiut- 
 ness, and seems always to be associated with the presence 
 of flatulence in the stomach, or with some other gastric 
 disturbance. It never appears to arise from any psychical 
 reflex, and the most singular fact connected with this 
 remarkable symptom is the sudden way in which an appar- 
 ently healthy heart, beating quite regularly and steadily, 
 begins to flutter in a manner most uncomfortable and 
 alarming to the sufferer. Xo doubt, in all such cases there 
 must be some weakness of the myocardium, and cardiac 
 tonics are thus indicated, but all direct heart medication 
 must be subordinated to careful dieting and to such treatment 
 as is fitted to improve the digestion and the health generally. 
 
 An unusually slovj inihe is sometimes normal, may be 
 found in very early life, and may continue to the end. The 
 pulse of the great Napoleon, according to Corvisart, was 
 never over 40 per minute ; and M. Roux tells us of an 
 agricultmist who had gone through his military service 
 
DISEASES OF THE HEART 283 
 
 without difficulty, who never ailed, and was a typical 
 example of good health, yet his pulse-rate was never over 
 34 to 40 per minute, and even a run of several minutes 
 never raised it higher than from 50 to 55, and that only for 
 a few seconds.^ Nevertheless an abnormally slow pulse is 
 almost invariably pathological in its character. Hope tells 
 us that "when one or two beats are regularly and perma- 
 nently imperceptible in the pulse, such cases constitute the 
 bulk of those in which the pulse is described by non- 
 auscultators as being singularly slow — for instance, 30 or 20 
 per minute." But he adds, " In a few cases, however, it is 
 really slow." ^ Hope is quite correct ; there are two varieties 
 of bradycardia or slow pulse — one in which the heart is 
 feeble, and one or two of its systoles regularly fail to reach 
 the radial pulse, constituting the "false intermission" of 
 Lsennec, the hemi-systohc bradycardia of modern writers. 
 Cases of true bradycardia belong to quite a different category, 
 and have quite another origin. I have already narrated two 
 cases of hemi-systolic bradycardia, one in which two cardiac 
 systoles regularly failed to reach the radial pulse, so that 
 the heart beat at the rate of 60 and the pulse at 20 per 
 minute {vide p. 275). I have also given the sphygmogram 
 of another case in which alternate systoles failed to reach 
 the radial pulse, but in it there was also this other form of 
 irregularity, that the right and left ventricle predominated 
 alternately; the pulse was a 'pulsus alternans {vide p. 276). 
 The following sphygmogram is from a third case. In it you 
 will observe that the pulse -wave rises at once to its full 
 height, the secondary dicrotic wave occupies its usual position, 
 but lower down the descending limb — just where in a normal 
 tracing a new pulse- wave ought to begin — there is a slight 
 elevation (a) due to the imperfect or abortive systole (hemi- 
 systole), imperceptible to touch and not always to be found 
 
 ^ Vide "Le pouls lent permaneut," par le docteur E. Lefiaive. Gazette 
 des Hopitauo: (1891), p. 1072. 
 
 - On Diseases of the Heart, Srd edition (London, 1839), p. 377. 
 
284 
 
 CLINICAL LECTURES ON 
 
 in the tracing. In such cases the heart is always feeble and 
 
 dilated, and sometimes fatty. It was this form of slow 
 
 pulse, doubtless, that the earlier observers — Adams/ Stokes,^ 
 
 and Richard Quain^ — connected sequenti- 
 
 Ially with a fatty myocardium ; but the seem- 
 ing connection is only a coincidence. A fatty 
 myocardium may be accompanied by a slow 
 pulse, but quickening of the pulse, increasing 
 with age, is also frequently associated with 
 the same pathological condition.* In these 
 circumstances, as in recovery from febrile 
 conditions, slow and fast pulses are inter- 
 changeable, and are indications of cardiac 
 debility, and not of any special degenera- 
 tion of the myocardium which may, or may 
 not, be present. From the conditions pre- 
 ^ valent when this form of slow pulse is present 
 I it is evident that the treatment most likely 
 to be useful is a tonic treatment, the special 
 elements being carefully selected with a 
 view to the particular requirements of the 
 heart, with due attention to the needs of 
 the general system. Later on a case will 
 be found narrated in which this treatment 
 was eminently successful. 
 
 As will be at once seen from the an- 
 nexed figure, the sphygmogram of true 
 bradycardia is very different from that of 
 the hemi-systolic variety. The tracing (Fig. 
 27) shows what appears to be a great 
 round -topped predicrotic blood -wave, as 
 if the blood -pressure was greatly increased, or as if a 
 rigid arterial wall was only slowly raised by the advancmg 
 
 ^ Dublin Hospital Reports, vol. iv. 1827. 
 
 ^ Diseases of the Heart and Aorta (1854), p. 326. 
 
 •* Medico-Ckirurgical Transactions, vol. xxxiii. p. 162. 
 
 * Quain's Dittionary of Medicine (1894), vol. i. p. 805. 
 
DISEASES OF THE HEAET 
 
 285 
 
 blood-wave. The true explanation is very different from 
 either of these. "When the heart beats slowly the ventricles 
 get more distended the longer the diastole is prolonged. At 
 each systole a larger blood-wave than usual 
 is thrown out, and, as the arteries have 
 had a longer time than usual to empty 
 themselves, it passes rapidly onwards ; the 
 secondary dicrotic wave is of greater ampli- 
 tude than usual, and occurs earlier on the 
 descending limb. A glance at the tracing 
 (Fig. 27) shows this very clearly. Here 
 the letter A marks the highest point of 
 the pulse- wave; the rounded top im- 
 mediately following is not tlie pulse- wave, 
 as might be supposed, but the secondary 
 or dicrotic wave placed near the summit 
 of the descending limb instead of about 
 its middle. In some brady cardiac sphygmo- 
 grams this dicrotic wave is so ample and 
 so premature that it seems to occupy the 
 very summit of the pulse-wave, while the 
 true apex of this Kes beneath it, giving the 
 tracing an anacrotic appearance. 
 
 The passage of the large blood-wave 
 through the arteries is naturally associated 
 with a great rise of blood -pressure, but 
 this is but momentary, as it rapidly dies 
 off from the continuous outflow through 
 the arterioles during the prolonged diastole. 
 Hence in bradycardia, as in aortic re- 
 gurgitation, we have an exceptionally high blood -pressure 
 alternating with an abnormally low one, a condition that 
 explains much that is anomalous in the history of bradycardia, 
 and has a not unimportant bearing on its treatment. 
 
 In the sphygmogram given the pulse-rate is 32, but this 
 patient's pulse varied from 28 to 36 ; the heart was markedly 
 
286 CLINICAL LECTURES ON 
 
 dilated, indicated by extension of the pmecordial dulness, 
 apex beat to the left of its normal position, and the permanent 
 presence of a systolic mitral murmur, and usually of a systolic 
 murmur in all the cardiac areas. As these slow hearts 
 generally belong to the latter half of life, and, in common 
 with all the other tissues, suffer in nutrition from the 
 extremely low blood-pressure prevailing during the prolonged 
 diastole, and as they have to cope with an extremely high 
 blood-pressure shortly after the commencement of systole, 
 we cannot wonder that they are always dilated. Such hearts 
 are also hypertrophied, but never much ; though dilated, 
 they are never weak, rather the reverse. 
 
 Eoy and Adami tell us that inhibitory impulses through 
 the vagus may slow or even arrest ventricular action for a 
 short time, but that the heart is never permanently slowed 
 in this manner, because sooner or later the ventricles take on 
 a rliythm of their own — an idio-ventricular rhythm, which 
 may be fairly rapid and almost perfectly regular.^ But 
 though impulses through the vagus are incapable of producing 
 this result, we know that irritation or injury to its important 
 branch, the spinal accessory, may be followed by temporary 
 or permanent slowing of the heart. The spinal accessory 
 rises by several filaments from the side of the cord as low 
 down as the fifth or sixth cervical vertebra, and fractures of 
 the vertebrae in this region are known to be accompanied 
 by slowing of the pulse down to 20 or 30." Concussion of 
 the spine in this region has been followed by temporary 
 slowing of the pulse to between 56 and 48,^ and Holberton 
 has recorded a most interesting case of injury in this region 
 in which inflammatory compression of the cord occurring 
 after the lapse of a year was followed by permanent slowing 
 of the pulse averaging 33, and sometimes as low as 20, 15, 
 
 1 Philosophical Traiisactimis, vol. cLvxxiii. p. 293, etc. 
 
 ^ Gurlt, Hmidhuch der Lehrc von den Knochcnbruchen, 1864 ; and Jonathan 
 Hutchinson, Loiulon Hospital Reports (1866), p. 366. 
 
 ^ Charcot, Lectures on Diseases of the Nervous System, New Sydenham 
 Society edition (1881), p. 117. 
 
DISEASES OF THE HEART 287 
 
 or even 8 per minute, and this slow pulse was accompanied 
 by syncopal attacks, ending in epileptiform seizures, in one 
 of which the patient ultimately died.-^ Various disturbances 
 of the chylopoietic functions have been found associated 
 with a slow pulse,^ and there are many poisons, both organic 
 and inorganic, which slow the pulse, and all of these have a 
 direct action on the nerves and nerve centres. But all the 
 information at present before us seems to point to direct 
 action on the spinal accessory in the neck or within the 
 chest, before or after its junction with the vagus, as an 
 essential requisite for the production of permanent slowness 
 of the pulse. 
 
 Such patients generally die in one of their epileptiform 
 attacks, but, though several of my patients have died thus, 
 I have never seen an attack. According to Holberton, a fit 
 is always preceded by cessation of the pulse for a second or 
 two. After this " the face would redden, and consciousness 
 return with a wild stare and occasionally a snorting, a slight 
 foaming at the mouth, and a convulsive action of the muscles 
 of the mouth and face." ^ The initial seizure seems thus to 
 be essentially syncopal in character, and the succeeding 
 phenomena are evidently due to the unusually large blood- 
 wave with which the tissues are suddenly flushed on the 
 return to life. Until more certain information is obtained 
 as to the essential cause of the permanent slowness of the 
 pulse, there seems to be no possibility of any radical cure of 
 the complaint, and the best palliative treatment would seem 
 to be the administration of digitalis in moderate tonic doses, 
 so as to maintain the metabolism of the myocardium, and 
 enable it to withstand the great strain thrown upon it by 
 the conditions under which the circulation is carried on.* 
 
 Delirium cordis is an extreme degree of irregularity 
 apparently always depending upon great dilatation of the 
 
 1 Holberton, Medieo-CMmrgical Transactions (London, 1841), p. 76. 
 
 2 Burnett, Medico- Chirurgical Transactions (London, 1827), p. 202. 
 
 3 Holberton, loc. cit. p. 79. 
 
 * Vide The Senile Heart, svib voce Bradycardia, also p. 293. 
 
288 CLINICAL LECTURES ON DISEASES OF THE HEART 
 
 heart, though a very good imitation of it is sometimes found 
 associated with mitral stenosis. It is not very amenable to 
 treatment, and in those cases I have seen reHeved this relief 
 has only been obtained by the use of large doses of cUgitalis 
 continued for some considerable time. 
 
 Throbbing pulsation of the ascending aorta accompanies 
 Graves' disease in a marked manner, and is naturally more 
 or less present in all forms of palpitation ; but what is 
 generally understood by aortic palpitation is an epigastric 
 pulsation of the abdominal aorta. This is a local neurosis 
 not always apparently dependent on dyspepsia, nor to be 
 relieved by tonics. I have generally found it yield to full 
 doses of the bromides in some bitter infusion. Perhaps the 
 only exception was a woman in Ward XIII., in whom this 
 excessive abdominal pulsation was accompanied by preter- 
 natural hardness of that part of the artery, and in her case 
 large doses of iodide of potassium gave great relief, though 
 nothing seemed to have any permanently curative effect. 
 
 In hospital you will not probably have many oppor- 
 tunities of seeing any great variety of the many forms of 
 irregularity just described, but in after-life you will fall in 
 with many cases, and it is well to have some information 
 about them. Nothing can make a man feel more helpless 
 than to be brought for the first time face to face with a bad 
 attack of tachycardia, or of tremor cordis, of the nature of 
 which he knows notliing, and may perhaps have never even 
 heard of its existence. 
 
LECTUKE XI 
 
 ON SOME OF THE SECONDAEY EESULTS OF GAEDIAC DISEASE 
 
 Theee are many subsidiary affections which — for physio- 
 logical reasons — naturally group themselves round cardiac 
 lesions, and now and then one or other of these affections 
 asserts itself in so marked and determinate a manner 
 as to challenge attention as if it were a primary and in- 
 dependent disease. It is of importance, however, for the 
 patient, sometimes for his safety and always for his comfort, 
 that we should recognise these ailments as secondary, and by 
 at once attacking the primary cause give speedily that relief 
 which, if obtained at all, can only be obtained in a round- 
 about and unsatisfactory manner if we treat as a disease what 
 is essentially a symptom. 
 
 The ailments to which I refer are inseparably connected 
 with those alterations in the circulation which begin with 
 the very commencement of cardiac disease, and upon the 
 greater or less rapidity with which they advance its termina- 
 tion depends. These circulatory changes may be grouped 
 under two heads — -first, changes in the intra-arterial blood- 
 pressure ; and, second, venous remora. 
 
 The absence of capillary resistance and of vascular motor 
 nerves within the lungs make mere mechanical influences 
 play a more important part in the pulmonary than in the 
 systemic circulation. Hence, as we know, any obstruction 
 to the onward flow of the blood through either lungs or heart 
 is speedily revealed by an accentuation of the second sound 
 at the orifice of the pulmonary artery ,■■• and this is speedily 
 
 ^ Vide Lecture I. p. 30. 
 19 
 
290 CLINICAL LECTURES ON 
 
 followed by dilatation and congestion of all the pidmonary 
 vessels thus predisposing to catarrhal affections of the 
 bronchial mucous membrane. In time the pulmonary capil- 
 laries become tortuous and varicose, encroaching on the air- 
 cells, limiting the air space, and, coupled with extravasions into 
 the parenchyma, forming what is known as brown induration 
 of the lung. Hence in all heart affections of long standing 
 much of the breathlessness complained of is due to this 
 condition of the capillaries, and this may be greatly aggravated 
 by many causes, such as catarrh of the bronchial membrane, 
 an oedematous condition of the air-cells themselves, or by 
 serous effusion into the pleura or pericardium, or even by the 
 great size of the heart itself, not to mention the impoverished 
 (spanaemic) condition of the blood due to the long continuance 
 of defective hsemogenesis. 
 
 In all cardiac cases there is a generally imperfect meta- 
 bolism ; this induces a defective ^dtality in the walls of the 
 vessels, especially at certain parts, as in the neighbourhood of 
 the venous valves, and this, coupled with the general remora of 
 the venous circulation and its diminished intensity every- 
 where, often gives occasion to spontaneous coagulation of the 
 blood in dilated bulgings of the systemic veias, in the arteries 
 also, especially if atheromatous, and even in the trabeculge of 
 the ventricles and also of the auricular appendices. Portions 
 of these thromhi often get detached and carried as emboli into 
 other parts of the circulation. Sometimes they block an 
 artery, causing gangrene of the part to which the vessel is 
 distributed; more often arterial blocking is caused by the 
 spreading of an autochthonous thrombus. Coming from the 
 heart or veins such emboli are sometimes large enough to 
 block the pulmonary artery and cause sudden death, or a less 
 complete occlusion of one or more branches of that vessel may 
 lead to a more gradual manner of d}T.ng. If an embolus 
 drops into a lung — and the lower part of the right lung is 
 from circumstances the most common position, though an 
 embolus may be found in any part of either lung — it gives 
 
DISEASES OF THE HEART 291 
 
 rise to an infarction, a local stasis often associated with a 
 sudden but temporary rise of temperature, a small localised 
 patch of dulness, over which crepitation is to be heard; 
 occasionally there is slight pain in the chest, and sometimes 
 haemoptysis. An infarction of a different character may be 
 produced by rupture of a vessel, often of some size, within 
 the lung ; in this case the blood is poured with a force corre- 
 sponding to the amount of intravascular tension present into 
 the bronchus with which the ruptured vessel is connected, 
 filling every part of the corresponding lobule as far as its 
 terminal sacculi. It may happen indeed that more than one 
 lobule is thus filled before coagulation finally takes place, so 
 that an infarction thus formed is often much larger than one 
 resulting from an embolus. We recognise this by the larger 
 size of the dull area lying over the part affected, and of this 
 we are also forewarned by the very considerable hsemoptysis 
 that accompanies this form of pulmonary apoplexy if it be at 
 all important. 
 
 The infarction that follows the impaction of a perfectly 
 healthy embolus gives rise to a wedge-shaped induration, 
 varying in size, colour, and consistence, according to its age. 
 Sometimes, however, an embolus may come from a septic 
 thrombus, or a purely hsemorrhagic infarct may become 
 infected by septic germs, and the result in either case may be 
 the production of a localised (embolic) pneumonia, which may 
 lead to suppuration or gangrene ; is always serious and often 
 fatal, and accompanied by all the usual symptoms of gangrene 
 of the lung, and often by those of pneumothorax or hydro- 
 pneumothorax as well.^ The consciousness that such serious 
 ailments may result from cardiac disease does not, unfortu- 
 nately, enable us to prevent them, but it ought to be an 
 incentive to us not to limit our attentions to the care of our 
 patient's myocardium, but in every way to endeavour to 
 maintain his general health in as perfect a state as possible. 
 
 1 Vide Cohnheim's Pathology, New Sydney Society edition, chapter iv. p. 
 172, etc. 
 
292 CLINICAL LECTUKES ON 
 
 From the frequency with which hsemorrhagic infarctions 
 occur in the course of cardiac disease haemoptysis is quite as 
 often dependent on cardiac as on pulmonary disease, and 
 even when actual disease of the lung is present the co- 
 existence of cardiac disease, especially if that be a mitral 
 stenosis, exercises a most important influence upon the 
 haemorrhage. In cases of frothy serous expectoration with 
 rhonchi and crepitation in the lungs, we have to look to 
 cardiac debility — if not to some more serious lesion of the 
 heart — as only too frequently the cause of that pulmonary 
 congestion that has so dangerously intensified the result of 
 some trifling chill. True cardiac breathlessness presents 
 symptoms so altogether peculiar that it can scarcely fail to 
 be recognised and its central cause detected.^ 
 
 It is, however, in the systemic circulation that we find 
 the most multifarious phenomena dependent on the one 
 central lesion — phenomena which are as varied as the 
 functions of every organ in the body, lesion of any one of 
 which is their proximate cause. Confining our attention for 
 the moment to the results of defective blood-pressure, I need 
 scarcely insist upon the importance of due recognition of the 
 cause of those pseudo-apoplectic or epileptiform seizures I 
 formerly discribed ^ as the result of failure of the heart's force, 
 or of the giddiness, threatened or actual syncope, tinnitns 
 aurium, flashings of light across the field of vision, most 
 noticeable by the patient himself on stepping into darkness 
 from light, and occasional flushings of a usually pale face, 
 which the patient describes as " puffs of heat," which are all 
 indications of cardiac debility of common occurrence and in 
 their simplest forms due to anaemia, in their most severe 
 forms to aortic regurgitation, while simple cardiac dilatation 
 is a common cause of intermediate varieties. When accom- 
 panying aortic regurgitation these symptoms are combined 
 with a full bounding pulse and are in danger of being 
 
 ^ Lecture I. p. 2. 
 " Lecture X. p. 261. 
 
DISEASES OF THE HEART 293 
 
 referred to cerebral congestion of an acute character, and are 
 liable to be treated rather differently from what they require 
 as mere indications of cardiac debility. Having already gone 
 into the treatment of such cases ^ it is unnecessary to re- 
 capitulate this at present ; I have merely referred to them as 
 examples of the many and various symptoms which, though 
 not apparently implicating the heart, are yet important 
 indications bearing not only on the need for a careful 
 examination of that organ, but also on the necessity of 
 guiding our treatment by its condition, because it is only by 
 rectifying the central lesion, so far as that is possible, that we 
 can expect to remedy the peripheral phenomena depending 
 upon it. 
 
 Failure of secretion is, as we all know, a common indica- 
 tion of failure of blood-pressure in the dying, but we ought 
 to remember that diminished secretion is also a usual accom- 
 paniment of that lowering of the intra-arterial blood-pressure 
 that is inseparable from cardiac disease. Perhaps the earliest 
 of the secretions that fail from this cause, certainly the one 
 that is earliest noticed to fail, is the secretion of the kidneys. 
 Unfortunately this may be well enough known to the patient 
 but not to his physician ; the patient himself is unaware of 
 the importance of such an apparently trifling fact and omits 
 to mention it, but it ought always to be inquired into as an 
 early indication of cardiac failure, often of extreme signifi- 
 cance, especially in heart cases of long standing which may 
 present no other indication of loss of power. Whenever we 
 find the urine persistently diminished in quantity, and its 
 specific gravity unaltered or even increased, and when we 
 find as the result of the diminished quantity of water a deposit 
 of lithates, apart from any coldness of the weather or of any 
 somatic catarrhal or febrile condition, then the condition of 
 the central organ should be inquired into ; it will certainly 
 be found defective. When the water of the urine is diminished 
 a certain soakage of the tissues takes place jpari passu, but 
 
 1 Lecture III. p. 102. 
 
294 CLINICAL LECTURES ON 
 
 this is so uniformly distributed throughout the tissues that it 
 is unobserved, and is probably only revealed by increased 
 breathlessness otherwise unaccountable. The salivary glands 
 are the only other organs in which any deficiency of secretion 
 would be equally readily detected. But, as is well known, 
 they are, so far as secretion is concerned, entu"ely separated 
 from the general circulation and placed under local influences, 
 so that any deficiency in their secretion is wholly deprived 
 of any somatic importance, so far at least as the heart is 
 concerned. 
 
 The gastric secretions are not so readily measured as 
 those just referred to, but the results of their deficiency are 
 very evident, especially to the patient himself. The flatulent 
 stomach due to gastric secretions deficient both in quantity 
 and quality has often been unavailingly treated by tonics, blue 
 pills, antispasmodics, etc., the central lesion — even when 
 recognised — having been ignored in the treatment, not having 
 been regarded as the efficient cause of this subordinate 
 phenomenon. Yet in all such cases our first inquiry ought 
 to be into the state of the urine, as a corroborative indication, 
 and our next investigation into the condition of the heart 
 itself. It is astonishing how long such subsidiary phenomena 
 may persist without progressing farther, provided there is 
 no important ailment beyond myocardiac weakness. I have 
 seen a flatulent abdomen and defective secretion of urine last 
 for twenty years without the development of any more 
 serious symptom, if we except considerable marasmus, which 
 was to be expected from the long-continued imperfect digestion. 
 And I have also seen all the more prominent symptoms in a 
 similar case vanish after a few days' appropriate treatment. 
 
 If we except the cerebral phenomena which may accom- 
 pany ansemia or may be symptomatic of aortic incompetence, 
 it is seldom that we find symptoms due to defective blood- 
 pressure apart from others associated with venous congestion, 
 and sometimes the latter alone predominate. Thus in females 
 we frequently find menorrhagia due to the venous congestion 
 
DISEASES OF THE HEART 295 
 
 arising from cardiac disease, and in both sexes we may have 
 haemorrhoids dne to congestion of the portal system, the 
 result of the remora in the systemic venous circulation. 
 Whenever there is, from any cause, failure of cardiac energy, 
 not merely in the later stages of cardiac disease, the same 
 venous congestion of the kidneys that in a lesser degree 
 causes diminution of the urine in a greater degree causes 
 the urine to be contaminated with serum -albumin, to a 
 greater or less extent according to the degree of congestion 
 present. The greater or less amount of serum-albumin found 
 in the urine of such cases depends upon the increased intra- 
 venous pressure. From the researches of Kltrschner^ we 
 know that fluids pass through animal membranes in the 
 following order : first, water ; second, saline solutions ; and, 
 lastly, albuminous or gummy fluids. Bruecke^ has also 
 shown that certain membranes allow albuminous fluids to 
 pass more readily than others, and that this probably depends 
 upon the size of the pores. And Liebig^ has confirmed 
 Ktirschner's experiments by measuring the force necessary 
 to drive the various fluids through membranes. In the 
 course of this inquiry he ascertained that the pores became 
 apparently widened by a continuance of the experiment, so 
 that after the lapse of twenty-four or thirty-six hours the 
 force of the pressure might be reduced by one-third or even 
 by one-haK, without any diminution of the result. Widening 
 of the pores of any membrane must thus be regarded as the 
 proximate cause of the passage of albumin through it, and 
 we cannot but consider the intra-venous pressure of long- 
 continued remora due to cardiac debility as a most efiicient 
 cause of albuminous transudation.^ Moreover, as long per- 
 
 ^ "Wagner's Handworterhuch der Fhysiologie, Bd. i. S. 62. 
 
 ^ De diffusione H%(,morum per Septa Mortuaet Viva (Berol. 1842), S. 55. 
 
 ^ Untersuchungen iiher einige Ursachen der Sdfteheivegung (Braun- 
 schweig, 1848), S. 6 ; vide also Henle's Rationnelle Pathologic (1847), Bd. 
 ii. S. 467-8. 
 
 * Robinson, An Liquiry into the Nature and Pathologij of Granular Disease 
 of the Kidney (London, 1842) ; Emmert, Beitrdge, etc., and Henle's Ration- 
 nelle Pathologie, Bd. ii. S. 458, etc. 
 
296 CLINICAL LECTURES ON 
 
 sistence of pressure is, as we see, equivalent to considerable 
 increase in amount, and as we learn from Kiirschner's ex- 
 periments that membranes permitting the passage of saline 
 fluids are but one step removed from those permitting the 
 passage of albummous fluids, we can readily understand that 
 the transudation of serum-albumin from the kidney is easily 
 brought about by any increase of intra- venous blood-pressure 
 so liable to occur from various causes in the course of cardiac 
 disease. We must, however, remember that diminished 
 secretion is the most sensitive test of defective cardiac energy, 
 that this depends upon deficient intra-arterial blood-pressure, 
 and that to render increased intra-venous pressure effective 
 in promoting albuminous transudation a certain degree of 
 vascular fulness is requisite. Hence if great marasmus is 
 present, diminished secretion may persist for many years 
 without the occurrence of albuminous transudation ; while 
 if much vascular turgescence be present, albuminous transu- 
 dation may be a comparatively early symptom. Even a 
 small amount of albumin in the urine is therefore always 
 an important sign of cardiac failure, when observed apart 
 from any other efiicient cause. Hyahne tube casts have no 
 other significance, as a rule, but the presence of epithelial 
 casts may be looked upon as an indication of the co-existence 
 of independent disease of the kidney. Besides, a diminished 
 amount of urine of a normal or high specific gravity, with a 
 small amount of albumin, is not found in any independent 
 form of kidney disease of any extent. A diminished amount 
 of urine with a large amount of albumin indicates inflamma- 
 tory disease of the kidneys, which has also other and more 
 distinctive symptoms. A varying, but usually large amount 
 of albumin with a large quantity of nearly normal urine, 
 indicates waxy degeneration of the kidneys, while in con- 
 tracting kidneys, which have a very close and intimate con- 
 nection with cardiac and especially with arterial disease, the 
 urine is never more than slightly albuminous, and its quantity 
 tends to increase and the specific gravity to be low, though 
 
DISEASES OF THE HEAKT 297 
 
 in the early stages there may be but little change in either 
 respect. The albuminuria of cardiac congestion thus differs 
 entirely from that of true renal disease, even in the contract- 
 ing form in which there seems to be generally some degree 
 of cardiac failure, the history of the case is such as to preclude 
 any possibility of a mistake.-^ 
 
 Whenever there is imperfect digestion from a gastric 
 juice deficient in quantity and defective in quality due to 
 cardiac debility, there is also venous congestion of the liver, 
 a diminished secretion of bile, congestion of the portal 
 circulation, and a tendency to hgemorrhoids, diarrhoea, or 
 ascites. The deficiency of bile intensifies the results of the 
 imperfection of the gastric juice, hence we have putrefaction 
 of the ingesta, abdominal flatulence, and constipated bowels, 
 with foetid stools. German authors have assumed that at 
 this stage the bile is not only diminished in quantity, but is 
 also diluted with serum (albumincholie), and thus reduced in 
 quality. This is very unlikely to be the case in the early 
 stages of cardiac disease, though it doubtless happens later 
 on when signs of serous escape (cedema) are found elsewhere. 
 In cardiac disease this can only rarely happen first at the 
 liver. 
 
 As in the congested lungs catarrhal conditions are apt to 
 be superadded, so also in the congested intestines we are 
 liable to have similar results. But as the bowels are better 
 protected from the vicissitudes of temperature, they are 
 comparatively seldom afli'ected in the early stages of cardiac 
 disease, though in the later stages we occasionally have an 
 obstinate sero-mucous diarrhcea which patients are prone to 
 look upon as an independent disease and to dignify with the 
 name of dysentery. The extension of this catarrhal condition 
 into the bile ducts is apt to produce more or less complete 
 
 ^ The connection between the gouty kidney and the gouty heart seems to 
 require serious revision ; vide The Senile Heart, p. 196. And in regard to 
 this there appears not a little to be learned from the history of the so-called 
 albuminuria adolescentiuin, which at least occasionally passes through the 
 stage of venous engorgement into the true contracting kidney. 
 
298 CLINICAL LECTURES OX 
 
 obstruction, and so to cause jaundice — a jaundice readily 
 distinguished as of cardiac origin by its greenish hue, the 
 cyanotic tint of the congested skin combining with the bright 
 yellow of the bile pigment to produce this peculiar colour, 
 and perhaps there are few things more striking than the 
 change from green to bright yellow which takes place on the 
 upper surface of the body after death in such cases, from 
 post-mortem hypostasis (sugillation). 
 
 Whenever there is long -continued congestion of any 
 organ, there must naturally be persistent turgescence of that 
 organ. From this cause alone there is, in some cases, con- 
 siderable temporary enlargement of the part affected, where 
 that is possible,^ and ultimately we have, as the result of the 
 venous congestion, hyperplasia of the connective tissue. This 
 overgrowth of the connective tissue is observed to a variable 
 extent in the lungs, more frequently and to a greater extent 
 in the liver, to a less extent in the spleen, and also in the 
 kidneys. Sir William Jenner^ has taught us that this 
 hyperplasia of the connective tissue is the direct pathological 
 result of long-continued mechanical congestion in any organ, 
 also that this new-formed tissue ultimately contracts, and by 
 destroying the secreting tissue of the organ induces atrophy 
 of the gland affected. But this is by no means a common 
 result of congestion in ordinary valvular lesions ; either the 
 disease is fatal before this stage has made much progress, 
 or, as in the case of contracting kidneys, some co- existent 
 ailment — as gouty thrombosis — is present to hasten the 
 climax. 
 
 Every case of cardiac disease involves several of these 
 
 ^ As in the liver, in which such congestive enlargements connected with 
 cardiac disease often appear and disappear in an incredibly short space of 
 time. Vide " Volumsschwankung des Herzens mit Schwankung des Pulses ; 
 korrespondirende Volumsschwankung der Leber und der Milz," von Dr. M. 
 Heitler, Wiener mediziyiischeti Wochenschrift, No. 13, 1896. 
 
 ^ Vide Medico- Chirurgical Transactions, vol. xliii. p. 199 ; and Dickinson's 
 Diseases of the Kidney, etc., part ii. p. 385, etc; also Schmaus und Horn, 
 Veber den Ausgang der cyanotischen Induration der Nieren in gramclar 
 Atrophic, Wiesbaden, 1893 ; also The Senile Heart, p. 196, etc. 
 
DISEASES OF THE HEAET 299 
 
 secondary lesions to which I have just referred ; in different 
 cases we find some of these less and others more marked 
 than usual. In the following case several of these subsidiary 
 affections were conjoined in a well-marked manner. 
 
 Case XXVIII. Ehzabeth M'Dermot, aged forty, ad- 
 mitted to Ward XIII. on 30th December 1869, complaining 
 of pain in the chest and breathlessness. She stated that 
 since the February previous she had been subject to pain 
 first in her right hypochondriac region, and latterly over her 
 heart, and that this pain had been more severe during the 
 last four weeks. She never had rheumatism nor scarlatina, 
 but for the last five years she had dysenteric attacks every 
 now and again. She had been in India, but only for a short 
 time, and she was always best when at sea. Patient was 
 of ordinary height (a little over five feet), anxious expression, 
 lips, gums, and conjunctivce blanched, and tinged of a light 
 yellow ; the whole surface of the body was of a waxen yellow 
 hue, the extreme anaemia accounting for the entire absence 
 of the usual greenish colour ; her pulse was 98, small and 
 feeble. On placing a hand over the prsecordia a distinct 
 heaving impulse was communicated to it by the heart's action, 
 and a thrill was felt immediately preceding and running up 
 to the apex beat. The heart's apex was felt to beat between 
 the fifth and sixth ribs about three inches to the left of the 
 sternum. One inch to the left of the sternum vertical dul- 
 ness was found to commence at the upper border of the third 
 rib and ran down to the liver dulness. Transverse dulness 
 at the level of the fourth rib commenced at the right edge of 
 the sternum and extended to the left for a distance of four 
 inches and a half. Over the apex a loud, rough, purring 
 murmur was heard preceding and running up to the first 
 sound. In the aortic area both sounds were distinct, the 
 second somewhat feeble. In the pulmonary area the first 
 sound was distinct ; the second markedly accentuated. The 
 patient had great difficulty of breathing, complaining 
 especially of oppression on the right side ; she had consider- 
 
300 CLINICAL LECTURES ON 
 
 able cough, and expectorated a quantity of frothy serous fluid. 
 The pulmonary percussion was normal, and on auscultation 
 rhonchi and rattles were heard over both sides of the chest. 
 The tongue was pale but tolerably clean ; the patient had no 
 appetite, but considerable thirst. The bowels were irregular, 
 with frequent attacks of watery diarrhoea; the stools were 
 always pale (clay-coloured). The liver dulness extended in 
 the nipple line from the upper border of the fourth rib to 
 about one inch above the umbilicus, a distance of over five 
 inches. The uterus was healthy. The urine small in 
 quantity, deposited urates, and contained a trace of albvnnin. 
 The prognosis from the first was unfavourable,-^ chiefly on 
 account of the anoemic and exhausted condition of the patient, 
 and she died upon 8th January 1870, her death having 
 been hastened by a recurrence of the diarrhoea. At the post- 
 mortem examination the body was not much emaciated ; the 
 skin was of a yellow tint. An unusually large quantity of 
 yellow serum was found in the pericardium. The surface 
 of the heart was fatty; the pulmonary valves were competent; 
 the segments of the tricuspid valve were slightly thickened 
 at their free edges ; the segments of the mitral valve were 
 thickened, and the auriculo-ventricular opening was narrowed; 
 the segments of the aortic valve were thickened, but the 
 valve itself was competent ; the substance of the heart was 
 pale, and apparently fatty. The bronchi were filled with 
 frothy yellow mucus, particularly on the left side ; both 
 lungs, but especially the right one, had pigmentary deposits 
 scattered through them, and the parenchyma was stained a 
 yellowish hue; they were otherwise healthy. The liver 
 weighed 4 lbs. 5 oz. ; its tissue was slightly fatty and 
 stained yellow. The gall bladder was enlarged and full of 
 dark bile ; the bile ducts were oedematous and blocked with 
 
 ^ As a rule jaundice is a late plienomenon in cardiac disease, and indicates 
 a speedy end. But I have known concomitant jaundice and dropsy to be 
 both recovered from even when associated with mitral stenosis, and I have 
 also observed jaundice to persist for several years even when concomitant 
 with an ultimately fatal stenosis of the mitral opening. 
 
DISEASES OF THE HEART 301 
 
 yellowish mucus. There were many embolic cicatrices on 
 the surface of the right kidney ; the renal tissue was paler 
 than usual and of a yellowish tint ; it was sKghtly fatty, and 
 the Malpighian corpuscles somewhat prominent. The spleen 
 weighed 8| oz. and had a lobulated surface ; on being cut 
 into its tissue was firmer than usual, but there was no 
 alteration beyond simple hypertrophy. 
 
 The general venous tiu-gescence is not, however, only to 
 be recognised by alterations in the secretions, or in the 
 ultimate changes of structure that result from it. It is 
 readily discerned in the bluish or purplish tint of the lips, 
 cheeks, and digital extremities, and in rarer cases by a dusky 
 hue — cyanosis — that overspreads the whole surface of the 
 body. iSTow and then, when the superficial congestion is not 
 extreme, and the skin is delicate as in young females, a 
 certain amount of oxygenation seems to take place through 
 the more exposed parts, and the cheeks may have all the 
 rosy hue of health, yet even in these cases the digital ex- 
 tremities are always blue and cold ; indeed the surface 
 temperature of the body is usually somewhat depressed. 
 Occasionally some of the larger external veins become turgid, 
 but congestion must be considerable before this takes place, 
 and it is not very common in yoimg persons in whom the 
 external veins are generally small. In the neck, as I have 
 already told you, the veins not infrequently pulsate, and 
 pulsation may now and then — though rarely — be seen in all 
 the superficial veins. 
 
 In all cases of cardiac disease the tissues are more or less 
 soaked with serum, and very trifling causes may precipitate 
 the occurrence of pulmonary oedema or pleural effusion. 
 The latter condition is revealed by a rise in the percussion 
 note, and a diminution of the pulmonary murmur. A slight 
 alteration in the force or distinctness of the pulmonary 
 murmur on one side as compared with the other, without 
 change in the percussion note, indicates pulmonary oedema 
 long before any crepitations are to be heard. These changes 
 
302 CLINICAL LECTURES OX 
 
 are more common in connection with mitral than with aortic 
 disease, as in the latter they rarely occur until the mitral 
 valve also has become impHcated. Sooner or later in most 
 cases anasarca sets in, commencing at the most depending 
 part, usually the instep, and gradually increasing tiU it 
 accumulates more or less in every ca^dty of the body, con- 
 stituting what is called general dropsy. The instep may 
 thus be called the position of election for the commencement 
 of cardiac dropsy, yet when the patient from any cause is 
 bedridden, oedema is first found over the back, or it may be 
 in the pleurae, or if cardiac congestion has lasted for long 
 without any serious cardiac debility, hepatic obstruction or 
 even some degree of cirrhosis may be suflicient to determine 
 the earliest indication of dropsy to be within the peritoneum 
 instead of the connective tissue, so that we have ascites 
 instead of anasarca as the commencement of true cardiac 
 dropsy. Apart from the independent yet concurrent occur- 
 rence of hepatic disease, this condition is limited to mitral 
 disease, and chiefly to mitral stenosis. 
 
 Embolism is common enough in the course of cardiac 
 disease, and gives rise to phenomena of the most diverse 
 character, according to the organ affected. Thus we may 
 have paralysis of motion, sometimes temporary, frequently 
 permanent ; paralysis of sensation alone, rarely ; aphasia, 
 often; hematuria, followed by temporary albuminuria, not 
 infrequently; haemoptysis, with pulmonary infarction, very 
 frequently ; not seldom complicated by pneumonia or effusion 
 into the pleural cavity, besides a host of pains and other 
 anomalous symptoms that frequently depend upon emboHsm, 
 though the only obvious connection may be the presence of 
 cardiac disease and the suddenness of the attack. 
 
 EmboHsm, as you know, is the term applied to a local 
 stoppage of the circulation by the sudden blocking of a vessel 
 by an embolus, that is by some foreign body carried along in 
 the blood-torrent. A few air bubbles or oil globules may, 
 under certain circumstances and in certain situations, produce 
 
DISEASES OF THE HEART 303 
 
 all the obstructive effect of more solid masses. More usually, 
 however, the obstructing mass is a bit of bloodclot, or a 
 fibrinous concretion from a vein, from an aneurysm, or from 
 the cavity of the heart, or a vegetation from a diseased valve. 
 The phenomena of embolism vary in each particular case ; 
 they depend upon the size of the embolus, as well as on the 
 function of the organ in which it happens to be arrested. 
 Yet varied as the results may be, there are probably few 
 pathological problems more simple in their essence, or the 
 steps of which can be so readily followed. 
 
 Perhaps the most instructive way in which, not to be 
 tedious, I could conclude this lecture, will be to narrate the 
 following case, in which repeated embolisms of various organs 
 occurred during the patient's residence in hospital. The 
 case itself is otherwise of considerable interest, and in spite 
 of the absence of a post-mortem examination, there can be no 
 reasonable doubt as to the cause of the repeated attacks. 
 
 Case XXIX. J. M., aged thirty-three, a wardress in the 
 Edinburgh Prison, was admitted to Bed 16, Ward XIIL, on 
 l7th April 1873, complaining of pain in her left side, extend- 
 ing down her thigh to her calf, and upwards to her left fore- 
 arm and hand. These pains had troubled her continuously 
 for three months ; they had been accompanied by repeated 
 diurnal rigors and nocturnal perspirations, and had been 
 treated as rheumatic by her medical adviser. The patient's 
 family history was good, and she herself had up to the 
 present time enjoyed good health, except that she had 
 suffered from a severe attack of rheumatic fever at the age of 
 fifteen. Her expression was weary and anxious ; she was 
 nervous and easily startled, had occasional headaches, and 
 slight haemorrhages from her nose when blown. Her respira- 
 tions were 32 per minute ; pulmonary physical signs normal ; 
 no cough nor expectoration. Her pulse was 96, soft and 
 easily compressible ; its systolic impulse was forcible, and it 
 fell rapidly off from the finger (Corrigan's pulse) — a pheno- 
 menon markedly increased by elevating her arm at a right 
 
304 CLINICAL LECTURES ON 
 
 angle to her body as she lay in bed. The heart's apex beat 
 full, diffuse, and forcible, below the sixth rib, two and a half 
 inches from the left edge of the sternum. At the level of 
 the fourth rib dulness commenced one inch to the right of 
 the sternum, and extended across the chest for a distance of 
 five and a half inches. The cardiac vertical dulness did not 
 rise above the third rib, but the aortic dulness extended to 
 the upper edge of the sternum, and the aortic pulsation was 
 distinctly to be felt in the tracheal fossa. On hstening in 
 the mitral area a rough murmur was heard running up to 
 the first sound, which was obscured, but not replaced, by a 
 systoKc murmur which, when traced upwards, was found to 
 have its position of maximum intensity in the aortic area. 
 Here this murmur was loud, rough, and followed by a soft, 
 blowing diastolic murmur, which wholly replaced the second 
 sound. In the pulmonary area there was a distinctly ac- 
 centuated second sound somewhat obscured by a diastolic 
 murmur propagated across from the aortic area, and preceded 
 by a systolic murmur coming from the same region. In 
 both carotids a distmct double murmur was to be heard. 
 The patient's tongue was clean, appetite moderate, bowels 
 regular. The urine was shghtly opalescent, and of a pale 
 straw colour, moderately acid, without deposit, but containing 
 a trace of albumin ; its specific gravity was 1026. The 
 patient had not menstruated for several months. Here there 
 could be no dispute as to the diagnosis ; evidently the mitral 
 opening was constricted from disease of the valve, and the 
 aorta dilated with a diseased and incompetent valve, but 
 from the signs present its segments were not probably 
 atheromatous to any extent, but only crumpled or shrivelled. 
 Both valve troubles were evidently due to her rheumatic 
 attack eighteen years previously, her present illness being 
 possibly but doubtfully of rheumatic character. The pro- 
 gnosis was moderately hopeful as to the issue of her present 
 illness, but serious as to the ultimate result of her cardiac 
 disease. 
 
DISEASES OF THE HEART 305 
 
 The double murmur in this case was readily audible in 
 the carotid arteries, indicating great freedom of regurgitation, 
 and therefore absence of any marked thickening of the aortic 
 segments, and as the affection was evidently of rheumatic 
 origin, and unaccompanied by any great dilatation of the 
 aorta itself, it was obvious that the valve segments must 
 be shrivelled or retracted to permit of regurgitation so free 
 as that which existed. The double murmur in the aortic 
 area, with its first element loud and rough, indicated local 
 obstruction to the egress of the blood as well as to its ingress ; 
 pointed therefore to deformity of the valve segments with 
 some stiffening of their structure, and, as so often happens 
 in similar cases, probably some vegetations on their under 
 surface. Were the valve segments comparatively normal 
 with so free regurgitation as we had in this case, the signs 
 would have been entirely different. In that case the double 
 murmur would have been audible in the arteries alone, with 
 a single diastolic murmur to be heard below the level of the 
 valve, and a comparatively mute aortic area. The persistent 
 localisation of the neuralgic pains was opposed to any idea of 
 them being purely rheumatic in character, while the alter- 
 nating rigors and sweatings were evidently more neurotic 
 than rheumatic in character, and the condition of the urine 
 agreed with this supposition. As the case subsequently 
 developed there seemed reason to suppose that the illness 
 was most probably entirely embolic in character. The 
 patient continued to improve till I7th May, exactly one 
 month after admission, when she had a sudden rigor. She 
 was much distressed, and complained of intense headache. 
 Her temperature rose suddenly to 105°; her pulse to 112; 
 and her respirations to 40. The urine contained a trace of 
 albumin ; the chlorides were apparently undiminished. On 
 examination of the chest a small localised patch was dis- 
 covered at the base of the right lung posteriorly, over which 
 fine crepitation was heard at the end of inspiration. No 
 dulness could be found on percussion ; there was no bronchial 
 
 20 
 
306 CLINICAL LECTURES ON 
 
 breathing ; no cough and no expectoration, A jacket poultice 
 was applied to the chest, and ten minims of chloroform in 
 one drachm of olive oil were given every four hours. 
 
 18th May. — Temperature, matu 104'6°, vcspere 103*6° ; 
 respirations 40 ; pulse 108. Distinct crepitation was 
 audible on inspiration over the base of the right lung ; no 
 dulness; no bronchial breathing, nor bronchophony; slight 
 cough ; no expectoration. 
 
 19th May. — Temperature, mane 102°, vespere 101*8°; 
 respirations, majie 36, vespere 28 ; pulse, mane 96, vespere 88 ; 
 crepitation on inspiration still present; urine slightly 
 albuminous ; chlorides undiminished ; tongue foul. 
 
 20th May. — Temperature 98-8° ; respirations 32 ; pulse 
 84 ; crepitation no longer to be heard ; pulmonary physical 
 signs altogether normal. 
 
 The suddenness of this attack, and its equally rapid 
 recession, correspond to the peaked ephemeral type of 
 pneumonia, a type occurring, as Wunderlich has pointed out, 
 chiefly in connection with trifling local processes, and fre- 
 quently of embolic origin. In this case the embolic origin of 
 this sudden and sharp attack was at once recognised and 
 pointed out, no credit being taken for cutting short a disease 
 the pathological course of which is generally so brief. In 
 the present day one scarcely requires to point out how 
 similar cases in olden tunes may have served to bolster up 
 the idea that the pneumonic process might be suddenly 
 aborted by active perturbative treatment. Had our patient 
 perchance been freely bled, with what chucklings might we 
 not have recorded the obvious recm-rence of the good old 
 type in her pneumonia, and its remarkable amenableness to 
 appropriate treatment. 
 
 The patient remained well till the evening of 1st June, 
 when she was suddenly seized with sickness and vomiting. 
 Her tongue was foul ; headache intense. Xothing abnormal 
 could be found anywhere except in the urine, wMch was 
 smoky, with a red deposit of blood corpuscles, as recognised 
 
DISEASES OF THE HEART 307 
 
 by the aid of a microscope ; no tube casts were observed this 
 evening, but the examination was somewhat hurried. The 
 urine contained about one -seventh of albumin; chlorides 
 undiminished. A mustard poultice was applied over the 
 epigastrium, and small bits of ice were directed to be 
 swallowed occasionally. 
 
 2nd June. — Patient in much the same state; vomiting 
 continues, and headache still intense ; urine bloody, specific 
 gravity 1015, albumin about one-seventh; epithelial and 
 granular casts were to-day observed for the first time, and in 
 considerable number ; pulse, tnane 92, vespere 104 ; respira- 
 tions 37; temperature, mane 100'2°, vespere 101'6°. 
 
 Treatment : Potassii iodidi, 
 
 Ammonii bromidi, aa 3 ii. 
 Infusi cliimapliilse, g vi. Solve. 
 Sigiietur — Capiat seger sem'unciam tertiis lioris ex aqua. 
 
 3rd June. — Headache still severe ; vomiting ceased ; a 
 vesicular eruption beginning to appear on the forehead and 
 cheeks , urine unchanged ; pulse, mane 114, vespere 120 ; 
 respirations ranged from 32 to 36 ; temperature, mane 102°, 
 veSjpere 103 '4°. Omit the iodide. 
 
 4th June. — Eruption well marked, forming transparent 
 buUce ranging in size from a split pea to that of half a (boy's) 
 marble, and full of limpid fluid (Hydroa) ; headache lessened; 
 urine unchanged, tube casts more numerous, and more of 
 them granular; tongue dry; pulse 108; respirations 36; 
 temperature, mane 105°, vespere 104*2°. 
 
 5th June. — Headache gone ; urine unchanged ; patient 
 complains of no pain, but is evidently intensely ill ; pulse, 
 mane IIQ, vespere 114; temperature, maoie 102°, vespere 1024°; 
 respirations, mane 41, vespere 34. 
 
 After this the patient went on improving till 13th June, 
 when her pulse was 86, her temperature 9 9 '4°, and her 
 respirations 25 ; tongue clean and moist ; appetite good ; 
 the blood has disappeared from the urine, which now 
 contains a mere trace of albumin, an occasional granular tube 
 
308 CLINICAL LECTUKES ON 
 
 cast being still to be detected. The eruption, obviously due 
 to the iodide of potassium, has now almost disappeared. This 
 sudden attack of hematuria, unaccompanied by any other 
 indications of renal congestion, was evidently due to renal 
 infarction following the arrest of an embolus in the kidney. 
 After the failure of the iodide of potassium the treatment 
 was purely expectant, and consisted chiefly in the free 
 administration of diluents. 
 
 On 16 th June her temperature was 98'4° ; respirations 
 24; pulse 92. At the evening visit that day, while the 
 patient herself was under examination, her right hand and 
 arm were seen to twitch convulsively, and the patient, who 
 had just previously been interpreting the language of an 
 aphasic neighbour, became suddenly sick, and complained of 
 violent headache, chiefly on the right side. 
 
 Next day, 20th June, she felt better, but still complained 
 of headache, and covild not lift her head from the pillow 
 without becoming sick. Temperature 99° ; pulse 100 ; urine 
 free from blood, and containing only a trace of albumin; 
 specific gravity 1020. Nothing else abnormal was observed. 
 
 21st June. — Pulse 100; temperature 1008°; tongue 
 very foul ; urme darker than usvial, with a copious deposit of 
 phosphates, and almost free from albumin. The abducens 
 muscle of the left eye is to-day noticed to be sluggish in its 
 movements, so that a slight squint is occasioned. 
 
 The patient continued to improve till 28 th June, when 
 the squint had almost entirely disappeared, the abducens 
 muscle having almost completely regained its normal power. 
 This sudden attack of local paralysis could obviously be 
 ascribed to nothing else than the arrest of a small embolus 
 in the brain, which rapidly broke up and was removed 
 without producing anything more serious than a temporary 
 paralysis of a single muscle; the convulsive movements of the 
 right arm were, like the headache, probably due to reflex 
 irritation. 
 
 On 3rd July, at 11.20 A.M., this patient was suddenly 
 
DISEASES OF THE HEAET 309 
 
 seized with violent headache, chiefly referred to the occipital 
 region, followed by severe vomiting ; her eyes were fixed at 
 first, but this passed off, and the patient retained her con- 
 sciousness for a time. At last, after a violent fit of retching, 
 complete unconsciousness set in, followed by gasping inspira- 
 tions, which gradually became less and less frequent, the face 
 getting more and more livid, till death occurred at 1.30 p.m. 
 During this final attack the right carotid was seen to beat 
 with much greater force than the left one. Obviously there 
 had been at first a small cerebral embolus followed by a 
 much larger one on the right side, by which so much blood 
 was cut off from the brain as to produce immediate uncon- 
 sciousness, speedily followed by death from asphyxia from 
 ansemia of the respiratory centre in the medulla. There was 
 no syncope; the heart beat forcibly to the last. No examina- 
 tion of the body was permitted, but the symptoms of each 
 attack were so evidently embolic in character, and the cardiac 
 lesion supplied so efficient an explanation of these emboli, 
 that the pathological history of this most interestmg case 
 could scarcely have been made plainer by a dissection. 
 
LECTUEE XII 
 
 UPON PAROXYSMAL ANGINA PECTORIS AND OTHER FORMS OF 
 CARDIAC PAIN, AVITH SOME REMARKS UPON THE DIAGNOSIS 
 OF FATTY HEART 
 
 Pain in the cardiac region is a common enough symptom 
 in all forms of diseases of the heart, and is specially- 
 apt to be associated with particular varieties ; it is often 
 enough complained of when no cardiac disease is present; 
 and it is an important indication of substernal aneurysm. 
 Pain in the region of the heart is always alarming; it reminds 
 one so unpleasantly of angina pectoris, of which John Hunter 
 died, after years of suffermg no doubt, but which also cut 
 short the life of Arnold of Rugby in a first attack. All 
 attacks of angina are not equally serious, but all have 
 within them the elements of danger ; fortmiately every pain 
 in the region of the heart is not angina. Hence some have 
 classified all cardiac pams under two heads — angina and 
 pseudo-angina — the latter term being apparently employed to 
 hedge the diagnosis, and give it a semblance of truth however 
 the case may turn out. 
 
 For my own part I recognise a set of symptoms indicative 
 of angina pectoris, of which the most alarming is not pain 
 but an overwhelming sense of impending dissolution. But 
 angina pectoris is not a disease : it is merely a syndrome ; 
 and the disease that underlies it is sometimes revealed by a 
 very different syndrome, of which the most striking char- 
 acteristic is seemingly causeless breathlessness — cardiac 
 asthma; while in yet another set of cases the disease is 
 
CLINICAL LECTUEES OX DISEASES OF THE HEART 311 
 
 suddenly fatal, nnpreceded hj any recognisable symptoms — 
 angina sine dolors. And I also recognise another class of 
 cases in wMch pain is the predominant symptom, and in 
 which any anxiety present is due to the fact that the pain 
 lies in the region of the heart. Sometimes this pain can be 
 referred to a definite cause and labelled with a distinctive 
 epithet. At other times no very evident cause is detectable, 
 and these cases I prefer to leave unlabelled for a time. My 
 experience is that after a longer or shorter period the cause 
 is sure to be revealed, and it seems better to wait and watch 
 rather than stifle inquiry by giving to the pain an epithet so 
 apparently satisfactory and yet so meaningless in reahty as 
 pseudo-angina. 
 
 When a patient comes to us complaining of pain in the 
 region of the heart, our first step is to ask him to point out 
 exactly where he feels this pain, and whether it is distinctly 
 localised or radiates in any particular direction, Next we 
 inquire whether the pain comes on while the patient is at 
 rest or only after exertion ; whether it is felt only during the 
 day or at night also ; and whether it is most apt to occur 
 after a full meal or has no special relation to the state of the 
 stomach. We also inquire as to the patient's age and 
 contrast this with his general appearance, and further note 
 whether he complains of any other cardiac symptoms, such as 
 breathlessness, etc. 
 
 Just recently an elderly gentleman stepped into my 
 consulting room complaining of a sharp pain in the region of 
 the heart, which came on at first during the night, but re- 
 curred during the day, and indeed was, when I saw him, 
 never much away. Neither food nor exertion seemed to 
 influence it in any way. The patient did not complain of 
 breathlessness or of any other cardiac symptom ; his pulse 
 was small, feeble, and rather quick, but regular. On ex- 
 amination the heart was found to be normal in size, with a 
 feeble impulse, and the sounds weak but pure. There was 
 no oedema of the ankles or lungs, no cough nor any difiiculty 
 
312 CLINICAL LECTURES ON 
 
 or pain connected with the respiration or with any move- 
 ments of the chest or spine. The pain was thus ip^r viaon 
 exclusionis resolved into an intercostal neuralgia, and on 
 tracing the fifth intercostal nerve upwards and backwards, a 
 patch of Herpes Zoster (shingles) was found on the lower 
 angle of the left scapula, not very large, but quite sufficient 
 to account for the pain. The patient left me much reassured ; 
 his pain was relieved by appropriate treatment, and in a few 
 weeks he was quite restored to health. 
 
 Now suppose this patient had no shingles, we should 
 have had to make our diagnosis of intercostal neuralgia all 
 the same, and to connect it — apart from disease of the spine, 
 improbable at his time of life — with some constitutional poison, 
 such as malaria, gout, or syphiHs. In malaria we should 
 look for a history of some antecedent exposure to some source 
 of malaria, and there would probably also be some periodicity 
 in the attacks, though this is not always well marked. In 
 gout there is generally some slight lesion of the heart de- 
 tectable, and in any case we must wait ulterior development. 
 In syphilis there are usually other symptoms present, and 
 probably a definite history of infection. In early middle 
 life intercostal neuralgia may occasionally be found connected 
 with spinal disease, and in one such case that came before 
 me some years ago, about a couple of years elapsed before 
 the disease unequivocally declared itself, and the true nature 
 of the case was revealed. 
 
 In chlorotic women, or in weakly antemic individuals of 
 either sex, pain beneath the left mamma is very common, 
 and when severe it is sometimes complained of as a heart 
 pain and mistaken for angina. Usually this pain is an inter- 
 costal neuralgia and may be recognised by the three painful 
 points, one over the intervertebral foramen, another about 
 the middle of the intercostal space, and the third close to the 
 sternum. Of these the first is the best marked and the one 
 most seldom absent. Very often, however, this infra- 
 mammary pain is a myalgia, and is recognised by the usual 
 
DISEASES OF THE HEAET 313 
 
 phenomena, limitation in extent, aggravation on movement, 
 .and tenderness on pressure, the tender points corresponding 
 to the tendinous origins and insertions of the muscles. In 
 myalgia the pain is limited and does not radiate into the 
 arms or along other nerves ; in intercostal neuralgia this is 
 not absolutely nor uniformly the case ; radiation of the 
 pain is always a suspicious symptom. 
 
 Constipation dependent on torpor of the colon is some- 
 times accompanied by neuralgic pains radiating from the 
 neighbourhood of the scrobiculus cordis over the edge of the 
 false ribs, and occasionally into the cardiac area itself The 
 pain in such cases is constant, with occasional exacerbations ; 
 it always radiates from some part of the colon, and may 
 extend round the chest, or into the cardiac area, but it does not 
 shoot upwards, or down either arm ; it is neither excited nor 
 increased by exertion, and it does not get worse through the 
 night. If associated with spanjemia the heart may have all 
 the usual murmurs, but the pulse is always soft and com- 
 pressible. 
 
 Torpor and congestion of the liver, so constant an accom- 
 paniment of gastro-duodenal dyspepsia, is often associated 
 with pain below either clavicle about the second interspace. 
 This probably arises from irritation of the phrenic nerve 
 radiating as pain uito the upper intercostal nerves. On the 
 right side this simulates lung disease ; on the left it is often 
 mistaken for a heart pain. 
 
 The pain of acute commencing pleurisy — if any way near 
 the cardiac area — is sometimes mistaken for a heart pain, 
 especially at first, when the respiratory movements are re- 
 stricted by the acuteness of the pain, and no friction is to be 
 heard. In cases of this character the thermometer helps to 
 keep us right. 
 
 The heart itself often suffers from acute stabbing, cuttmg, 
 burning, or stinging pains, unaffected by exertion and un- 
 accompanied by any other sign or symptom of cardiac disease. 
 In early hfe these pains are probably rheumatic in character 
 
314 CLINICAL LECTURES ON 
 
 and may pass away without serious detriment, though at 
 times they end in pericardial adhesions or possibly in stenosis 
 of the mitral opening, but not without the concomitance of 
 other symptoms which help us to recognise the true nature 
 of the case. In later life the pains described are gouty in 
 character, and frequently terminate in angina. 
 
 Finally, there is a cardiac pain dependent upon pressure 
 on the cardiac nerves. This may arise from a tumour too 
 small to be detected by physical exploration, and then it is 
 apt to be disparaged as a mere neurotic pain of no importance. 
 Should the pain be caused by the pressure of an enlarged 
 gland, the danger may be but slight and must depend mainly 
 on the cause of the enlargement. But should the pressure 
 be caused by a small substernal aneurysm, the danger is 
 great and imminent. In a few cases it is possible to make a 
 fairly accurate diagnosis of such an aneurysm, but in many 
 this seems impossible. In all we must exercise the greatest 
 care and circumspection in regard to diagnosis, and in spite 
 of the largest experience, an error may be readily committed ; 
 for the patient's sake it is better to err in excess of caution. 
 But though substernal pain is often the sole symptom of a 
 small aneurysm or tumour in this situation, this is sometimes 
 combined with more evident symptoms of angina, and is 
 occasionally associated with compression of the anabolic 
 nerve (the vagus), and is then accompanied with tachycardia, 
 depression of the dynamic force of the nerves implicated 
 lying at the root of both phenomena. 
 
 Angina consists of a congeries of symptoms in which pain 
 usually predominates, and is associated with a sense of im- 
 pending dissolution, always present, but most intense in the 
 severer forms ; moreover, as Latham has said, these symptoms 
 may be " incident to any form of organic disease of the heart, 
 but they are constant to none." 
 
 The pain of angina varies from a dull agonising ache to 
 an excruciating agony that, starting from the region of mid- 
 sternum, shoots upwards to the left, and sometimes into both 
 
DISEASES OF THE HEAET 315 
 
 shoulder joints, extending down to the elbow or along the 
 ulnar nerve to the fourth and third fingers of the left hand 
 and sometimes of both hands. Occasionally the pain shoots 
 up the neck, generally on the left side, or into the scrohiculus 
 cordis; more rarely the pain shoots into the loins or down 
 the legs. The sufferer is said to have a feeling of suffocation ; 
 so far as I have been able to judge in the attacks I have 
 observed, the feeling is rather one of intense anxiety lest the 
 slightest movement should precipitate the end which seems 
 so terribly near. The breathing is perfectly free. The 
 countenance may be pinched, ghastly pale, and covered with 
 beads of perspiration (fades Hippocratica). More often the 
 face is little changed, save only for an anxious, haggard ex- 
 pression. By the time we get to the patient the pulse is 
 intermittent, feeble, or irregular; but it is sometimes, when 
 the angina is uncomplicated by valvular mischief, quite 
 regular throughout the whole of the paroxysm. After a few 
 minutes, or more rarely withm an hour or two, the pain 
 ceases as suddenly as it came, and the patient finds himseK 
 as he was, puzzled to know what has happened to him, and 
 scared at the prospect of a renewal of the attack. There is 
 nothing pulmonary in this seizure ; the air enters freely into 
 the lungs if the patient has the courage to breathe, and full 
 inflation of the lungs has no effect on the duration or char- 
 acter of the attack. It has no connection with spasmodic 
 asthma, nor with ordinary cardiac breathlessness, but in one 
 of its forms painless breathlessness is a prominent symptom, 
 and has received the name of cardiac asthma. Angina does 
 not arise from cardiac strain, or at least from any immediate 
 or recognisable cause of stram. Some trifling exertion or 
 some emotional excitement of the heart's action are the most 
 usual excitants of an anginous seizure, but in Arnold's case, 
 as in some others, even the primary attack is devoid of this 
 provocative, the patient waking from sleep in a paroxysm of 
 anginous pain. In most cases it is not till after several and 
 often numerous attacks, brought on by trifling exertions, that 
 
316 CLINICAL LECTURES ON 
 
 the disease reaches such a height as to come on when the 
 patient is at rest or asleep. In cases of tliis character the 
 readiness with which the attack is brought on seems an indi- 
 cation of increased myocardiac failure ; when it primarily 
 occurs at night, as in so-called cardiac asthma, it apparently 
 depends upon a difference in the exciting cause. 
 
 Should death occur during a paroxysm the heart may be 
 found contracted and empty, or it may be uncontracted, 
 flabby, and full of blood.-^ In all the cases I have seen die 
 in a paroxysm, death has always been preceded by gradual 
 failure of the pulse, ingravescent asystole — a mode of death 
 which may occupy a varying time, from half an hour to a 
 week or more ; ^ it leaves the heart, as a rule, in diastole after 
 death, and is unattended by any feeling of faintness, only by 
 a sensation of impending dissolution, if there be anything 
 beyond apathy present at all. A considerable number of 
 sufferers from angina die without pain at the last, from 
 angina sine dolorc ; they do not faint, the heart simply fails to 
 contract and they die from sudden and complete asystole.^ 
 
 The lesions found after death from angina vary in each 
 case, but they are always of a similar character, one that 
 indicates serious impairment, often long continued, of the 
 metabolism of the myocardium. Atheromatous coronaries 
 are common enough, and by some have been regarded as the 
 true cause of the paroxysms ; but sclerosis of the coronaries 
 is too often met with where there has been no antecedent 
 angina to permit of their concurrence being regarded as other 
 than accidental, or, if causative at all, then only remotely so. 
 
 Fatty degeneration of the myocardium is not infrequently 
 found when angina has been present during life, and by some 
 it has been looked upon as the cause of the attacks. But a 
 fatty myocardium is often enough found after death when 
 there has been no precedmg angina, so that it also cannot be 
 
 ■^ Vide Quain's Dictionary of Medicine (1894), vol. i. p. 77. 
 2 Vide 15. 3 ; also The Senile Heart, p. 138, etc. 
 ^ Vide Tlie Senile Heart, p. 145, etc. 
 
DISEASES OF THE HEART 317 
 
 regarded as anything but an accidental concomitant. But 
 fatty degeneration we know to be due to faulty metabolism, 
 the result of local disturbance of the circulation/ and in the 
 myocardium this is more often due to sclerosis of the coron- 
 aries than to any other cause. These two lesions are thus 
 linked together as cause and effect, and when they are con- 
 comitant with angina the sclerosed coronaries may be regarded 
 as the ultimate cause of that symptom. Faulty metabolism 
 is indeed the one factor common to every condition of heart 
 found in connection with angina. Sometimes this arises from 
 the condition of the vessels, from diminution of the calibre 
 of the coronaries at their origin at the root of the aorta or in 
 any part of their course throughout the heart by embolism, 
 thrombosis, or by inflammatory, atheromatous, or syphilitic 
 processes. Earely, as in Arnold's case,^ the heart is long 
 imperfectly nourished by arteries congenitally defective in 
 size or number. More often the heart becomes enlarged — 
 dilated and hypertrophied beyond the feeding powers of 
 coronaries otherwise normal — though in this case failure in 
 the nutritive qualities of the blood plays no unimportant 
 part. SpanEemia or toxsemia — mainly from gout or malaria 
 — have also an important efiect in disturbing the metaboKsm 
 of the tissues, and in this way are frequent causes of angina.^ 
 The cardiac movements are primordial in character,^ and, 
 so long as metabolism is perfect, the heart is not only able 
 to maintain these movements in all their primitive energy 
 but also to store up a reserve so great that they continue to 
 
 ^ Thoma's Pathology, by Bruce (A. & C. Black : London, 1896), p. 415. 
 
 ^ Dr. Arnold died at the age of forty-seven of his first attack. "The 
 heart was rather large. . . . The muscular structure of the heart was in every 
 part remarkably thin, soft, and loose in its texture. The walls of the right 
 ventricle were specially thin, in some parts not much thicker than the aorta. 
 ... Its cavity was large. The walls of the left ventricle, too, were much 
 thinner and softer than natural, and the muscular fibres of the heart gener- 
 ally were pale and brown. . . . There was but one coronary artery, and, 
 considering the size of the heart, it appeared to be of small dimensions." — 
 Latham, Diseases of the Heart (London, 1846), vol. ii. p. 377. 
 
 •* Thoma, op. cit. p. 415. 
 
 ^ Foster's Textbook of Physiology, 5th edition (1888), p. 288 et antea. 
 
318 CLINICAL LECTURES ON 
 
 go on, in some animals, for hours after the organ has been 
 severed from its organism. This large reserve of energy 
 enables the heart to carry on its work with apparent efficiency 
 in spite of long-continued untoward influences, the result of 
 a nutritive pabulum deficient in quantity or defective in 
 quality. Sooner or later, however, imperfect metabohsm tells, 
 the energy of the myocardium fails, and it comes more readily 
 under the influence of those agencies which, acting reflexly 
 through the nervous system, dominate the rate and regularity 
 of its movements. Ultimately the myocardium becomes so 
 imperfect that though the heart gets along fairly well with 
 its ordinary work, yet when called upon for the slightest 
 extra exertion it either fails to respond and sudden death 
 ensues, or its imperfect action is accompanied by pain more 
 or less severe, which shoots along the course of those sensitive 
 nerves with which the sympathetic or katabolic nerve is 
 embryologically connected.^ This is angina pectoris. Angina 
 is a nerve pain, a neuralgia of the heart ; but it is something 
 more — it is a neuralgia only developed on a sudden call for 
 exertion. It differs from ordinary neuralgia in the neighbour- 
 hood of the heart in that it is always based upon imperfect 
 metabolism of the myocardium, generally of long continuance ; 
 that it invariably darts along the course of certain special 
 sensitive nerves, and that it is only developed as the result 
 of a disability on the part of the myocardium to continue its 
 function, generally brought to a crisis by some sudden call 
 for exertion on the part of the heart. The pain of angina 
 may not be exactly due to ischsemia, but it is closely allied 
 to pain arising from that cause ; to those atrocious pains that 
 attend compression of an artery for aneurysm, especially at 
 the moment the vessel becomes completely occluded; to 
 those pains due to a similar cause that precede the appear- 
 ance of senile gangrene, as well as to those which precede, 
 accompany, and follow attacks of local asphyxia (Eaynaud's 
 
 ^ Vide Gaskell, The Journal of Physiology, vol. vii. p. 1, and especially 
 pp. 41 and 46. 
 
DISEASES OF THE HEAET 319 
 
 disease). That is to say, angina is a pain — a neuralgia — 
 similar to that which affects sensitive tissues in which the 
 discharge of function is hindered by defective metabolism. 
 
 Whenever, from any emotional cause, or from the slight 
 exertion of ascending an acclivity, or from a sudden rise of 
 blood-pressure from reflex or other causes, the augmentor 
 nerve has to make a call upon the heart for increased action, 
 to which it is unable to respond because of long-continued 
 imperfect metabolism from one or other of the causes just 
 referred to, the call for increased katabolic action is at once 
 followed by exhaustion revealed as an agonising pain shooting 
 along some or all of those sensitive spinal nerves with which 
 the katabolic nerve is embryologically connected. 
 
 As causes of that imperfect metabolism to which an 
 anginous attack is primarily due, there are, besides those 
 vascular changes which give rise to a more or less positive 
 ischsemia, many causes that impair metabolism by a qualita- 
 tive ischaemia, the defect being in the quality and not in the 
 quantity of the nutritive fluid. These conditions may be 
 classed as toxsemic causes of angina ; chief among them we 
 have amongst the young — for angina and even fatal angina is 
 not confined to the old ^ — a spansemic condition of the blood ; 
 amongst those past middle life, gout ; and amongst those of 
 all ages, malaria. Tobacco, tea, alcohol, and other poisons 
 have often been spoken of as toxemic causes of angina. I 
 have seen many cases of severe palpitation and cardiac 
 irregularity from these causes, but never angina, the nearest 
 approach to this being a slight pain accompanying the action 
 of the augmentor nerve after a bad bout of irregularity. As 
 I have seen tobacco used very freely, in one case fifteen 
 large and strong cigars, and in another fifty cigarettes inhaled 
 daily, both producing about a maximum of cardiac discomfort 
 but no angina, I am inclined to believe that in those cases of 
 tobacco angina recorded some other cause must have con- 
 tributed to its production, and the most probable contributory 
 1 Vide The Senile Heart, pp. 115, 123, etc. 
 
320 CLINICAL LECTURES ON 
 
 cause seems to be imperfect metabolism due to spanaemic 
 blood ^ from gastric disturbance. Malaria is not an uncommon 
 cause of angina; of this I have seen several well-marked 
 cases yielding to antimalarious treatment. In them there 
 is always the history of exposure to the cause, more or less 
 of malarious spana?mia, and more or less distinct periodicity 
 in the attacks. Malaria is a well-known cause of neuralgia 
 which may affect the nerves in the neighbourhood of the 
 heart, but anginous symptoms do not arise until the cardiac 
 metabolism has become affected. The same remark may be 
 made of gout : gout is a common cause of neuralgia and often 
 affects the nerves in the neighbourhood of the heart, but 
 anginous symptoms do not arise until cardiac metabolism 
 has been seriously interfered with. In both classes of cases 
 there is generally some exciting cause traceable, some ex- 
 posure to cold, some trifling exertion, or some error in diet. 
 
 I have elsewhere described ^ a case of cardiac neuralgia 
 for long under observation, and by some regarded as angina. 
 The exact nature of this case was always obscure until she 
 one day told me — after twelve years' observation — that she 
 had recently been subject to occasional pain in her wrists 
 and fingers accompanied by great mitability of temper, and 
 that at these times her cardiac neuralgia completely disap- 
 peared, only to return so soon as her gouty joint pains left 
 her. As yet this patient's heart is quite imaffected, though 
 she is over fifty ; by and by, as years creep on, the cardiac 
 metabolism is sure to become impaired, and then the cardiac 
 neuralgia will probably pass into true angina. Similar cases 
 are not uncommon. So long as the gout affects the nerves 
 alone and there is only neuralgia, a fit of regular gout may 
 afford relief, but when the cardiac metabolism gets impaired 
 
 ^ As I write this I am confronted by a man of fifty who has sufFered from 
 bad angina for the last two months, for which he blames tobacco. But his 
 heart is dilated, and his blood spansemic ; besides, he has been in the habit of 
 smoking but little over 2 oz. of strong tobacco per week. This case supports 
 my view on above details. 
 
 2 Vide The Senile Heart, p. 119. 
 
DISEASES OF THE HEART 321 
 
 and the attacks are trulj anginous, then a fit of true gout gives 
 but slight if any relief, and rather tends to hasten the end. 
 
 Angina is sometimes feigned, and is occasionally of a 
 purely hysterical character, but no man of any experience is 
 likely to be deceived by either form, provided he has an 
 opportunity of observing an attack. Mrs. Chisholm, whose 
 case was formerly commented upon,-*^ was an example of the 
 former character, and a very clever impostor she was, giving 
 a great deal of trouble before she was detected. Some years 
 ago we had in the case of the girl L. a well-marked instance 
 of the hysterical variety. L. suffered from aortic regurgita- 
 tion, from which she subsequently died, and the true nature 
 of her seizures was not at first suspected. One day, however, 
 I happened to find her in one of her attacks at visit ; I at 
 once recognised its hysterical character, and took measures 
 to prevent a recurrence, which were happily successful. I 
 have seen several other cases of hysteria simulating angina, 
 but none so well marked as this one, and, let me add, never 
 any one in which there was less cause for suspecting hysteria, 
 or more apparent reason for believing the paroxysms to be 
 real.^ 
 
 Whenever we have cardiac uneasiness or irregularity 
 after middle life associated with early indications of a 
 weakened myocardium, an auricular murmur, an accentuated 
 pulmonary second, a blunt first sound, or a transference of 
 the impulse from the left to the right apex, we should be 
 exceedingly guarded in our prognosis. These are not cases 
 of angina, but they belong to the same category; the symptoms 
 depend upon failure of cardiac metabolism, and in the most 
 unlikely cases may terminate suddenly in asystole, death 
 from angina sine dolore. 
 
 Cardiac asthma is another variety of angina sine dolore ; it 
 too is an indication of failure in the cardiac metabolism and 
 
 ^ Vide first edition of this work (London, 1876), p. 279. 
 2 M. L., admitted to Ward XXXIII. on 28tli January 1880 ; died from 
 sudden asystole, 31st May 1880. 
 
 21 
 
322 CLINICAL LECTURES ON 
 
 is often the earliest indication of the approaching end. We 
 know that cold is a common cause of angina by inducing 
 contraction of the superficial vessels, raising the blood- 
 pressure and thus increasing the work of the heart, a form 
 of vaso-motor angina.-^ But a sunilar contraction of the 
 arterioles generally is often produced by some organic 
 derangement — stomach, liver, etc. — or by some impurity of 
 the blood, then we have coldness or numbness of one or more 
 of the extremities followed immediately by an attack of 
 angina. In one patient the chilliness was at first limited to 
 the right arm alone, and his heart at first was fairly good, 
 but this organ dilated considerably before his death, which 
 happened suddenly about two years after he was first seen. 
 
 Now and then towards the close of life the attacks of painful 
 angina cease, and the patient suffers from attacks of breathless- 
 ness only; at other times attacks of angina and of cardiac 
 asthma alternate, and at still other times an attack commenc- 
 ing as angina terminates in cardiac asthma. I myself have 
 assisted at the development of an attack of cardiac asthma of 
 the latter variety. A man aged fifty-seven had suffered from 
 angina for years ; the attack was brought on by exertion or by 
 emotion, and the pain shot from midsternum through to the 
 back and down the left arm, occasionally down the left leg, 
 and sometimes down the right arm also. The heart had a 
 feeble impulse ; its action was slightly irregular, the aortic 
 second was accentuated, and the first sound over the apex 
 was blunt; the radial pulse was tense — signs which in- 
 dicated a high blood-pressure, and a dilatable and probably 
 somewhat dilated heart. As I listened to the heart-sounds, 
 nervous excitement brought on an attack of angina, pain 
 accompanied by a feeling of suffocation. Gradually a distinct 
 auricular murmur was heard to develop, indicating regur- 
 gitation through the mitral valve from ventricular dilatation 
 (vide antea, p. 170), and pari passic with this the pulmonary 
 second not only became markedly accentuated but also 
 1 The Senile Heart, p. 131. 
 
DISEASES OF THE HEART 323 
 
 acquired a distinctly booming quality. Eesidual accumula- 
 tion, due to irregular and imperfect ventricular action, had 
 overdistended the ventricle, promoted regurgitation through 
 the mitral valve, and had thereby caused considerable 
 congestion of the lungs. As a consequence of this transfer- 
 ence of the blood-pressure from the aortic to the pulmonary 
 system the radial pulse, which had been full and tense, 
 became gradually small and feeble, and even while the 
 patient was at rest there was an increased breathlessness 
 that amounted to a well-marked though slight attack of 
 cardiac asthma. 
 
 Doubtless ordinary attacks of cardiac asthma have a 
 similar origin. A reflex spasm of the systemic arterioles 
 suffices to induce — without pain — residual accumulation and 
 overdistention of the left ventricle, with its natural results 
 — mitral regurgitation, pulmonary congestion, and breath- 
 lessness. 
 
 There is every reason to suppose that the arterial spasm, 
 which is so evidently the cause of local asphyxia (Eaynaud's 
 disease), and which is so important an agent in inducing an 
 attack of angina vaso-motoria, occasionally invades the heart 
 itself, either as part of a general condition, or it may be as a 
 distinctly local affection, and in this way may very possibly 
 be a cause of angina in cases where no other seems obvious. 
 
 In angina pectoris, as in other neuralgise, we have a 
 permanent lesion coupled with only occasional attacks.-^ With 
 a large experience of every variety of angina, I can safely say 
 that I have never yet seen a case of angina in which I was 
 unable to detect some of the physical signs of cardiac 
 dilatation, some marked indication of imperfect cardiac 
 metabohsm ; and I may also say that the less there seems 
 to be the matter with the heart, ' the more grave is the 
 prognosis, if the attacks be at all serious. From my point 
 
 ^ In regard to the periodicity frequently presented by neuralgise depending 
 upon grave organic lesions, vide Trousseaud's Clinical Medicine, New Syden- 
 ham Society edition, vol. i. p. 598. 
 
324 CLINICAL LECTURES ON 
 
 of view this is readily understood, for if we regard angina as 
 essentially due to imperfect metabolism, and that it has only 
 recently come on in a dilated heart, there is always the hope 
 that this may be remediable, so far, at least, as to enable us 
 to get rid of the angina. But if we find angina implicating 
 an apparently healthy heart, we at once recognise that the 
 hmdrance to the cardiac metabohsm is of an acute character 
 and is most probably due to some interference with the 
 coronary circulation, which we cannot hope successfully to 
 influence. Even these serious cases do not always die 
 immediately ; some of the most serious I have seen have lived 
 a couple of years, but life was one continuous suffering, and 
 the heart that at first had nothing detectable wrono- with 
 it showed towards the end gradually increasing signs of 
 dilatation. 
 
 I have already pointed out that after middle life cardiac 
 irregularity is not always free from danger and may quite 
 suddenly terminate in death from angina sine dolore, but even 
 in early life tumultuous action of the heart may terminate in 
 fatal angina. 
 
 Case XXX. A. S., a male, aged twenty-four, admitted to 
 Ward V. 6th October 1877, complaining of palpitation and 
 pain in the prsecordial region. The patient stated that he 
 had suffered in this way for fourteen weeks, and that the pain 
 was sometimes a mere uneasiness, and at others more acute. 
 On admission the patient presented a somewhat anxious 
 expression ; he was well nourished and all his organs healthy 
 except the heart. The heart beat rapidly (120 per minute) 
 and in a somewhat tumultuous manner ; the radial pulse was 
 quite regular. On auscultation the first sound over the 
 apex was impure ; the pulmonary second was markedly accen- 
 tuated, and a faint diastolic murmur was audible over the aorta 
 at midstemum. The case was at once recognised as a serious 
 inflammatory affection of the heart or ascending aorta, the 
 exact seat of which could not be localised on account of the 
 absence of any distinctive symptoms. The treatment 
 
DISEASES OF THE HEAET 325 
 
 consisted in the administration of full doses (15 grains) of 
 iodide of potass in a bitter infusion three times a day, with 
 perfect rest in bed, and an unstimulating diet. Under tliis 
 treatment his heart quieted down, but the pain increased and 
 became localised as a constant pain in the scroMculus cordis, 
 unaffected by pressure. This extension of the pain to the 
 epigastrium was at first regarded as due to the action of the 
 iodide on the stomach ; but as the pain recurred in a distinctly 
 paroxysmal manner, and as the pulse became rapid and feeble 
 both during the paroxysm and for some little time after, I 
 ventured to complete the diagnosis and to state that in all 
 probability there was an acute end -aortitis implicating 
 the origin of the aorta and the orifices of the coronary 
 arteries. The concomitant dilatation of the heart was un- 
 doubtedly due to febrile relaxation of the tissues, favoured 
 by imperfect metabolism, the result of the obstacle to the 
 coronary circulation. At first inhalations of nitrite of amyl 
 gave great relief, the paroxysms lasting from five to fifteen 
 minutes. But in the final attack, which commenced about 
 four o'clock on the morning of 24th October and lasted 
 for about two hours, the amyl was of no use and the only 
 relief from the intense agony was obtained by chloroform 
 inhalations. 
 
 At the autopsy on 25th October the body was found to 
 be well formed and fairly muscular. Rigor mortis and post- 
 mortem lividity were well marked. There were about 6 oz. of 
 clear serum in each pleural sac, and about 2 oz. of a similar 
 fluid in the pericardium. The blood was remarkably fluid. 
 The heart weighed 13 oz. ; the ventricular cavities were 
 slightly dilated, and their walls slightly hypertrophied. The 
 mitral orifice was enlarged, admitting four fingers ; cone 
 diameter, 1'6. The cusps were natural. The tricuspid orifice 
 was also enlarged, admitting six fingers; cone diameter, 
 1*9. In the wall of the aorta, just beyond the aortic cusps, 
 there was a ring of atheromatous thickening wliich involved 
 the whole circumference of the vessel at and a little beyond 
 
326 CLINICAL LECTURES ON 
 
 the sinuses of Valsalva. In this situation the tunica intima 
 was swollen to twice or thrice its normal thickness, and 
 presented a clear, translucent aspect, broken here and there 
 by points of fatty degeneration. The openings of the two 
 coronary arteries lay in the midst of this atheromatous area, 
 and were both so extremely contracted as barely to admit 
 the point of an ordinary surgical probe. The aortic valve 
 allowed water to leak through it slightly, but it might be 
 said to be practically competent. The cusps were slightly 
 thickened at their free margins, and above the corpora aurantii. 
 The muscular substance of the heart was everywhere of good 
 colour and consistence, and on microscopic examination it 
 presented no abnormality except the presence of a consider- 
 able number of reddish-brown pigment granules in some of 
 the fibres. All the other organs of the body were perfectly 
 healthy, but somewhat congested.-^ 
 
 In this most interesting and probably unique case you 
 will observe that we have had a fatal angina with a practi- 
 cally healthy heart. The slight dilatation, slight hypertrophy, 
 and trifling leakage through two orifices, were nothing more 
 than we may find in any spansemic heart, especially when 
 febrile excitement co-exists. Similar conditions are to be 
 found in hundreds who make perfectly good recoveries. 
 The fatal lesion was evidently the blocking of the coronaries ; 
 this was what we found, and this was precisely the lesion 
 predicted to be the most probable one. This opinion was 
 based on the obviously casual connection between the acute 
 attack and the angina, and on the fact that in by far the 
 larger number of cases angina seems to depend upon some 
 interference with the blood supply to the walls of the heart 
 itself — to the myocardium. Of this the case in point is an 
 admirable and instructive example, and the celebrated case of 
 Dr. Arnold is no less so. For though his coronary artery — 
 
 ^ Condensed from the Pathological Records of the Edinburgh Royal 
 Infirmary. A chromolithograph of this heart forms the frontispiece to 
 this volume. 
 
DISEASES OF THE HEAET 327 
 
 he had but one — was neither diseased nor obstructed, it is 
 stated that, " considering the size of the heart, it appeared to 
 be of small dimensions, and with some difficulty admitted a 
 small director " (Latham, loc. cit.) ; while the thin, soft, flabby 
 texture of the heart sufficiently testified to the inadequacy 
 of its feeding power. 
 
 Acute inflammatory angina, as in the case just narrated, is 
 certainly a rare affection, and not less so is acute traumatic 
 angina, of which the case now to be described is the only 
 example that has come before me. 
 
 Case XXXI. J. L., a married woman, aged fifty, stout, 
 healthy, and who had passed through her life without an 
 ache or a pain except those incident to maternity, slipped 
 and fell on the street in the beginning of January. Being 
 rather heavy she was considerably shaken, but apparently 
 not otherwise injured. By and by, however, paroxysms of 
 angina set in, and continued gradually to increase in severity. 
 There was nothing abnormal to be detected about her heart, 
 but she died suddenly in a paroxysm about the middle of 
 March of the same year. Unfortunately I was unable to 
 obtain a post-mortem examination; but from the sudden 
 onset of the angina, its obvious dependence on some injury 
 received at the time of falling, and the general resemblance 
 of the most prominent symptoms to those of substernal 
 aneurysm, there is every reason to believe that they were 
 due to some such cause. Probably the middle coat of the 
 aorta was fissured transversely at the time of the fall just 
 above its cardiac origin, and the angina was due to inter- 
 ference with the coronary circulation, and possibly also to 
 pressure on some of the branches of the cardiac plexus by 
 the gradually increasing aneurysm thus formed, while death 
 was probably caused by this aneurysm bursting into the 
 pericardium. 
 
 The two cases just narrated both died during a paroxysm. 
 Judging from my own experience by far the larger number 
 of fatal seizures are apparently painless. Death happens 
 
328 CLINICAL LECTURES ON 
 
 precisely as it does to animals which have had their coronary 
 arteries artificially blocked. Sometimes the heart fails 
 suddenly — angina sine dolore — often after a longer or shorter 
 period of freedom from pain. At other times complete 
 failure is preceded by a longer or shorter period of in- 
 gravescent asystole (more or less conscious sinking). The 
 pre-existing state of cardiac metabolism, and the nature of 
 the exciting cause, have all a special influence upon the mode 
 of dying. It is only rarely that patients who have suffered 
 from serious angina die from asthenia and gradually in- 
 creasing dropsy, but this sometimes happens. One old 
 friend, who for several years suffered from many compara- 
 tively slight attacks of angina, lunched cheerfully with some 
 friends, walked with apparent ease to a railway station but 
 a short distance off, sat down, and died. Others having 
 suffered more or less severely for years have died suddenly 
 without giving any indication of suffering.^ One well-known 
 literary man I myself saw die from ingravescent asystole 
 about a week after his last paroxysm. He had long suffered 
 from angina, with all the signs of a weak, dilated heart, due, 
 as was subsequently discovered, to atheromatous coronaries, 
 and I had brought him safely through two most severe 
 attacks with a comparatively painless interval of a year 
 between them. Subsequent to the last attack he had been 
 confined to bed with symptoms of pulmonary oedema, a 
 common result of a severe paroxysm. When apparently 
 convalescent he obtained permission from his medical at- 
 tendant to rise from bed, and while dressing his weak heart 
 failed, and ingravescent asystole set in. There was no pain. 
 When I reached his apartment he said, " Doctor, this is very 
 different from anything I have had before," and he died 
 quietly after drinking about half a glass of brandy given him 
 in the hope of stimulating the heart to more vigorous con- 
 traction. The whole act of dying occupied about half an 
 
 ^ Various illustrations of the modes of dying in similar cases are to te 
 found in The Senile Heart, p. 138, and at p. 144. 
 
DISEASES OF THE HEAET 329 
 
 hour. At the post-mortem examination "both coronaries 
 were found atherosed and obstructed, and in the substance of 
 the left ventricle there was an elongated patch of advanced 
 fatty degeneration. The limits of the patch were well 
 defined, and the appearance presented bore a considerable 
 resemblance to that of a hsemorrhagic infarction which had 
 undergone fatty degeneration." -^ The heart itself was some- 
 what dilated. 
 
 When a spanaemic heart is called upon for extra exertion 
 the impoverished or imperfectly oxygenated blood has to be 
 sent through the myocardium much oftener per minute than 
 healthy blood, that sufficient pabulum may be provided for 
 the muscular metabolism. To provide for this the augmentor 
 nerve is called into action and the heart-beat becomes rapid 
 and forcible. Now and then, even when defective metabohsm 
 has gone so far as to cause pain (angina) to be associated 
 with any attempt to respond to a call for increased action, 
 some are able to disregard this warning, and by a voluntary 
 effort force the heart into stronger action, flush the myo- 
 cardium with an increased blood supply and thus overcome 
 the breast pang. Perhaps this happens more frequently when 
 the angina is an accompaniment of aortic regurgitation than 
 under any other circumstances. I have already narrated one 
 such case (2nd ed. p. 273), and I can recall several others, 
 but the experiment is dangerous and failure sudden death.^ 
 
 In the treatment of angina our immediate predecessors 
 were sadly handicapped; they had nothing to trust to but 
 the external application of cutaneous irritants, and the 
 exhibition of stimulants and narcotics by the mouth — a 
 vain hope when moments are precious, and to the time 
 needed for absorption there has to be added the further 
 
 ^ I quote from a letter received from Dr. John Wyllie, at that time 
 pathologist to the Royal Infirmary, who made the dissection, the full 
 report having been unfortunately lost. The specimen is in the University 
 Museum. 
 
 ^ Forbes, Cydopceclia of Practical Medicine, vol. i. p. 94, mentions similar 
 
330 CLINICAL LECTURES ON 
 
 delay of that act caused by a failing circulation. Modern 
 discoveries have altered all this ; by inhalation we can 
 thoroughly narcotise a patient in a few seconds, and by 
 means of a hypodermic injection we can secure within a few 
 minutes a painless unconsciousness which will last for many 
 hours. 
 
 In determining how best to relieve the pain of angina we 
 must duly consider its cause, incapacity for action on the 
 part of the myocardium, the result of long-continued defective 
 metabolism, or more rarely of sudden and more or less com- 
 plete ischoemia. The state of the myocardium seems to be 
 similar to that of the leg muscles when the veins are varicose 
 or blocked. A sensation of weight, fatigue, and sometimes 
 pain, on taking exercise, suddenly compels the sufferer to call 
 a halt when the symptoms pass away. But the heart cannot 
 halt; it must either cease to act, or its action continues 
 feeble, hampered, and accompanied by pain and by all those 
 inexplicable sensations that make up the syndrome of angina. 
 The initiative of such an attack is always some sudden call 
 for extra exertion on the part of the heart ; of this I think 
 there can be no doubt ; but the question then occurs. Is this 
 initiative accompanied by any rise in the blood-pressure, by 
 any increase of the intra-arterial blood-tension ? This was a 
 theory originally started by Dr. Lauder Brunton, and it must 
 be confessed that many of the conditions that accompany the 
 circumstances that initiate an attack are of such a character 
 as most likely to give rise to an increase in the blood-pressure. 
 Accordingly, when seen early, there are probably but few 
 cases in which an initial rise of blood-pressure is not to be 
 detected, but this does not last long, and the pulse speedily 
 becomes small, feeble, and irregular, a state of pulse with 
 which those accustomed to see cases of angina are probably 
 much better acquainted than with the firm hard pulse of 
 high tension. The belief that an attack is always initiated 
 by a rise in the blood-pressure has led to the employment of 
 various vascular stimulants as means of affording immediate 
 
DISEASES OF THE HEAET ' 331 
 
 relief, and this certainly frequently follows their use, but 
 whether propter or only quia post is perhaps not always very 
 easy to determine. The remedies of this class most frequently 
 employed are the nitrite of amyl and nitro-glycerine ; the 
 former is given by inhalation and acts very quickly; the 
 latter is given by the mouth, either in the fluid form, when 
 its action is almost as rapid as that of amyl, or in the form 
 of a lozenge, when it acts somewhat slower, but this is 
 counterbalanced by convenience of carriage. These are 
 indispensable remedies ; the patient can readily carry them 
 about, and relief generally follows their employment, but not 
 always, especially in serious cases, even when used most freely. 
 I have known a pocket-handkerchief soaked in nitrite of amyl 
 laid over the mouth and nose and the amyl freely inhaled 
 and followed by all the usual symptoms without much relief ; 
 and I have also seen as much as ten minims of a one per 
 cent solution of nitro-glycerine taken without any relief at all. 
 In all cases of angina the routine treatment is to prescribe 
 nitrite of amyl, usually in glass capsules, several of which 
 may be crushed in a pocket-handkerchief and their contents 
 inhaled, or, what I prefer, nitro-glycerine in doses commencing 
 with one-hundredth of a grain. In a few cases the relief 
 obtained is sudden and complete ; more often the relief that 
 follows is gradual and doubtfully due to the treatment, while 
 in a few cases no relief seems to follow even the most 
 prodigal use of these drugs. Then we are forced to have 
 recourse to the free administration of chloroform, and this 
 must be given so freely as to narcotise the patient rapidly 
 and completely ; given in this way I have not yet seen any 
 case that has not been relieved, though I have seen several 
 in which the relief was not permanent enough to restore the 
 patient to comfort. In these cases the chloroform has had 
 to be supplemented by the hypodermic use of morphine, and 
 of this I have never hesitated to give a sufficient dose, 
 generally from half a grain to a whole grain ; such a dose as 
 this has kept the patient asleep for some hours and he woke 
 
332 CLINICAL LECTURES ON" 
 
 free from pain but exhausted. In treating any case of 
 angina we cannot shut our eyes to the serious nature of the 
 affection, and that death may possibly occur even during our 
 treatment ; this is unpleasant, but, while not forgetting the 
 possibility of such an occurrence, we are bound to run every 
 risk for the sake of reheving suffering so intense. I myself 
 have been fortunate enough never to have seen any untoward 
 result. Anstie had a dread of chloroform in such cases and 
 says that " the effect of a -powerfully charged atmosphere, 
 breathed only once or twice even, would be instantaneously 
 fatal." -^ I well remember one case of extreme cardiac pain 
 and dyspnoea in a patient almost moribund from disease of 
 her heart, and who did die only a few days subsequently, yet 
 in her the immediate effect of chloroform inhalation was to 
 restore the pulse to her radial arteries. In a few seconds, 
 instead of being pulseless, black in the face, and gaspmg for 
 breath, partly from pain, and partly from extreme dyspnoea, 
 she began to breathe freely, became quiet and natural in 
 appearance, and in a short time she was able to lie down and 
 rest quietly. But you may say that in angina the heart is 
 always flabby and ill-nourished and often fatty ; is cliloroform 
 not dangerous in cases of fatty heart ? The next case I shall 
 relate gives the best possible answer to such a query as tliis. 
 But I must first most emphatically say that I doubt the 
 possibility of diagnosticating a fatty heart. We may suspect 
 its existence, because the physical signs seem to warrant the 
 supposition, and the conditions present seem favourable to its 
 development, but little acquaintance with morbid anatomy 
 is, however, requisite to teach us that fatty degeneration of 
 the myocardium is not always present even in apparently 
 the most likely conditions, and that it is not infrequently 
 discovered where it has been wholly unsuspected.^ I may 
 
 1 0/j. cU. p. 80. 
 
 - While this is passing through the press, this statement lias received a 
 most forcible illustration in the death, from rupture of a fatty heart, of one 
 of our best-known and most esteemed medical practitioners, whose healthy 
 appearance and great vigour both of bod}- and mind were entirely opposed to 
 
DISEASES OF THE HEAET 333 
 
 refer to the case of Bridget Henry, who died from chloroforra 
 ill the Cinciiinati Hospital, U.S.A., on 13th October 1870, as 
 a well-marked example of a fatty heart with a normal 
 impulse.-^ But indeed of this there could be no more striking 
 instance than that of Mrs. Tait, which I shall presently 
 relate to you. The rapid and powerful action of chloroform 
 makes it a dangerous agent in incautious hands, and an 
 anaemic condition renders the heart more sensitive to its 
 action and more liable to be fatally overpowered by an over- 
 dose. But I know of no state of the heart which should 
 deter us from its cautious but effective employment when 
 that is otherwise indicated, as it imperatively is in certain 
 cases of angina pectoris.^ Ether has long been used for a 
 similar purpose, the chief objection to its employment being 
 that its action is not rapid enough. Chloroform acts much 
 quicker, even more effectually, and is perfectly safe. If we 
 put some chloroform in the bottom of a tumbler, or provide 
 the patient with a chloroform smelling bottle, he may safely 
 enough be entrusted to employ the drug unaided and so save 
 much time. The moment narcosis occurs the smelling bottle 
 drops, and with it rolls away all risk of an overdose. 
 
 Case XXXII. Mrs, Tait, long a nurse in the Edinburgh 
 Infirmary, died m Ward XIII, on 30th March 1871.^ She 
 was over eighty years of age, and had long suffered from a 
 dilated heart and from angina, the paroxysms of which were 
 very severe with but short intermissions. Eor the last few 
 weeks of her life she was almost constantly under the m- 
 
 all the more generally received ideas in regard to the indications of this form 
 of degeneration. — Note in second edition (1876) ; vide also note, p. 367. 
 
 ^ Chloroform Deaths, by W. W. Dawson, M. D., surgeon to the Cincinnati 
 Hospital, 1871, printed by Robert Clarke and Co., Cincinnati, U.S.A. 
 
 ^ In his work on The Bearings of Chronic Diseases of the Heart upon 
 Pregna/iicy, Parturition, and CJ-dldhed. (London, 1878), Dr. ilacdonald says, 
 oj^opos of a primipara labouring under aortic insufficiency: "The patient 
 looked pale . . . and complained that she felt ready to faint with every 
 pain." But when chloroform was given "the pulse became stronger and 
 steadier, instead of feebler and more irregnilar, as I feared it might," vide 
 p. 147. 
 
 3 Margaret Tait, admitted 3rd January, died 30th March 1871. 
 
334 CLINICAL LECTUKES ON DISEASES OF THE HEAKT 
 
 fluence of chloroform or morphine, or of both, the morphine 
 being injected hypodermically so soon as the chloroform 
 narcosis was fully established, so that its soothing inj&uence 
 might continue when that of the chloroform had passed away. 
 She died at last, not suddenly, but gradually, from asthenia, 
 worn out by her age and sufferings. After death the aorta 
 was found dilated, the orifice of the middle coronary artery 
 — there were three in her heart — almost entirely blocked by 
 atheromatous deposit. Her heart was not only thm- walled 
 and somewhat dilated, but of a pale yellowish tint, soft, and 
 thoroughly fatty. The muscular fibres were completely de- 
 generated — none could be more so — yet chloroform produced 
 in her no dangerous symptoms, and, far from shortening her 
 life, it was credited with prolonging it, and it certainly made 
 her life more endurable. I may add that the apex beat 
 continued firm to the last. 
 
 But however satisfactory our treatment of a paroxysm 
 may be, the treatment during the intermission is of much 
 more importance, and is not infrequently attended by most 
 brilliant results. This can only happen when the heart is 
 simply dilated, feeble, and ill-nourished; it is obvious that 
 no treatment can be of any permanent avail when we have 
 to do with atheromatous disease of the coronaries so extensive 
 as materially to interfere with the nutrition of the myo- 
 cardium, with thrombosis of these vessels, or with any lesion 
 that irremediably affects the circulation through the heart. 
 Inasmuch, however, as the treatment of angina — apart from 
 these conditions and from the presence of a paroxysm — differs 
 in no respect from that of an ordinary feeble heart, considera- 
 tion of it may be postponed till we speak of the treatment of 
 cardiac disease generally (vide Lecture XIV.) 
 
LECTUEE XIII 
 
 ON PERICAEDITIS, ENDOCARDITIS, MYOCARDITIS, AND CARDIAC 
 HYPERTROPHY APART FROM VALVULAR DISEASE 
 
 Though acute articular rheumatism is common enough 
 with us, yet rheumatic pericarditis is an affection com- 
 paratively unknown. This is all the more remarkable as 
 our largest ward is a. female ward, and, as you are aware, 
 rheumatic pericarditis is more prone to attack young and 
 weakly persons, especially females, than any other class of 
 patients. Were it not that rheumatic pericarditis is usually 
 an early, and rarely a late complication — occasionally even 
 preceding the joint affection — we might be inclined to attri- 
 bute its rarity to the success of our treatment. But the 
 fact that few of our patients come under treatment before 
 the fourth or fifth day, and that nevertheless severe peri- 
 carditis is a rare affection, seems to indicate that serious 
 rheumatic pericarditis is actually less common in Edinburgh 
 than it is elsewhere, as it certainly seems to be less severe ; 
 and this is a probability which has also suggested itself to 
 Dr,, now Sir William G-airdner.^ 
 
 As you are aware, the employment of salicin and the 
 salicylates has completely revolutionised the treatment of 
 acute rheumatism, so that six days is now rather a long 
 period of treatment instead of six weeks, which was the 
 former minimum. But neither salicin nor any of its de- 
 rivatives is a true specific for this complaint; it undoubtedly 
 shortens the febrile stage, but it does not appear to have any 
 ^ Edinburgh Medical Journal (January 1861), p. 630, 
 
336 CLINICAL LECTURES ON 
 
 control over the occurrence of fatal hyperpyrexia, of which 
 one remarkable instance occurred in a patient under my own 
 care in Ward XV. This patient, a young servant girl, 
 twenty-one years of age, was apparently progressing favour- 
 ably under salicin treatment. Her temperature at night was 
 only 102° ; in the early morning she seemed no worse and 
 made no complaint, but at nine o'clock she was found to be 
 unconscious, perspiring freely, with a temperature of 107°. 
 She died at half-past twelve, with a temperature of 111° F., 
 which still persisted one hour after death. On post-mortem 
 examination no lesion was found to account for this remark- 
 able and fatal hyperpyrexia, to which alone undoubtedly the 
 death was due.^ Neither has longer experience confirmed the 
 hopes at first entertained that the shortening of the duration of 
 the febrile stage would have an important effect in diminish- 
 ing the risk of ulterior affections of the heart. Acute cardiac 
 affections of rheumatic origin as a rule occur early in the 
 disease, before the patient has come under treatment at all, 
 and cannot well be prevented by anything short of an im- 
 munising treatment which would at once and rapidly ex- 
 tinguish the disease. This has still to be discovered. 
 Meanwhile we may be very well content with the results 
 obtained by the use of sahcin. The contrast between the 
 results thus obtained and those that followed former methods 
 of treatment has been very well shown in Maclagan's recent 
 work.^ Certain drawbacks have been ascribed to the use of 
 salicin and its compounds ; one of these is that there is a 
 great tendency to relapse, but the apparent relapse seems to 
 be merely a recrudescence of the disease due to too early an 
 omission of the drug, and can be readily prevented by con- 
 tinuing the treatment for a sufficient time after the acute 
 
 ^ Vide " Comments on a Case of Hyperpyrexia," by Theodore Cash, M.B., 
 etc., Edinhicrgh Medical Journal (September 1878), p. 234. 
 
 2 Rheuviatisvi, its Nature, PatJiology and Treatment, by T. J. Maclagan, 
 M.D. (London : A. and C. Black, 1896), p. 202, etc., where are to be found 
 several temperature charts under both the old and the new methods ; the 
 contrast is remarkable. 
 
DISEASES OF THE HEAET 337 
 
 symptoms have disappeared, say for a week or ten days. In 
 this way all risk of recrudescence is averted. The other 
 drawback is a very real one; it is the production of toxic 
 symptoms which may be serious or even fatal. These toxic 
 symptoms are chiefly delirium, with or without increased 
 rapidity, weakness, and irregularity of the heart and pulse. 
 These toxic symptoms are chiefly found in connection with 
 the use of salicyl compounds, and are said to be due to 
 the employment of compounds of salicylic acid prepared 
 from phenol. Whatever the cause, the danger is real, and 
 salicyl compoimds should never be employed when the pulse 
 is rapid and the heart's action enfeebled.-^ On account of 
 these toxic symptoms I myself prefer the use of pure salicin, 
 which seems to be practically free from any toxic symptoms 
 whatever. As Maclagan has told us, one ounce of sahciii 
 must be ingested before we can expect any marked benefit ; 
 the more rapidly, therefore, this quantity can be got into the 
 system the sooner relief is obtained. Thirty grains may be 
 safely given every hour till pain is reheved and the tempera- 
 ture begins to fall ; afterwards the same quantity may be 
 continued at longer intervals till the full ounce has been 
 ingested. To complete the cure a second ounce must be 
 given in similar doses, but at still longer intervals, and it is 
 often advisable to give a third ounce in half-drachm doses 
 three times a day, to ensure perfect and complete conva- 
 lescence.^ The patient must be clad in flannel and bedded in 
 blankets, according to time-honoured custom in this Infirmary, 
 which dates back to the days of CuUen,^ and his joints must 
 be wrapped in cotton -wool, and may have some anodyne 
 liniment laid over them. The diet must be chiefly milk 
 with small quantities of farinaceous food or chicken-tea if 
 preferred, but beef and all its preparations ought to be 
 
 ■• Binz, Lectures on Pharmacology, New Sydenham Society edition, vol. ii. 
 p. 271. 
 
 2 Maclagan, op. cit. p. 191. 
 
 ^ MS. Clinical Lectures, in the Library of the Royal College of Physicians, 
 Edinburgh. 
 
 22 
 
338 CLINICAL LECTURES ON 
 
 rigidly excluded till long after convalescence has been fully- 
 established. I need not enter more fully into this matter at 
 present; I have only mentioned it at all because though salicin 
 and the salicylates fail to check rheumatic affections on the 
 left side of the heart/ it is quite otherwise with rheumatic 
 affections of the pericardium, which seem to be quite as 
 amenable to salicm treatment as any other joint, and to re- 
 quire no other. beyond some little help to soothe the pain and 
 also to keep the joint itself as quiet as possible. If we take 
 cardiac pain accompanied by slight but yet detectable effusion 
 into the pericardium, or by friction at the base of the heart, 
 accompanying acute rheumatism, as signs of rheumatic peri- 
 carditis, as they undoubtedly are, then I suppose the per- 
 centage of pericarditis occurring among rheumatic cases in 
 the wards has been about the average, 25 to 30 per cent 
 according to Bamberger, and of these the mortality has been 
 nil. These cases were mostly slight and with very few 
 •exceptions the pericarditis was present on admission. 
 
 In not a few cases the rheumatic attack has been associated 
 with cardiac disease of long standing, while in almost all the 
 other cases we have been able to determine the existence of 
 the auricular murmur, which, as I have already told you, is of 
 such common occurrence in all febrile disorders, and depends 
 upon a slight degree of cardiac dilatation.^ Occasionally, 
 though rarely, this has been accompanied by a murmur of 
 similar origin audible in the mitral area. But the persistence 
 of this mitral murmur, and of its cause, the dilated left 
 ventricle, has been a very exceptional occurrence. Even 
 when valvular lesion has subsequently developed, the re- 
 storation to health has been, as a rule, apparently complete, 
 and the signs of valvular lesion have only slowly developed 
 after some time, not less than a year, occasionally apart from 
 any definite symptoms whatever; at times associated with 
 repeated trifling rheumatic attacks of short duration, and at 
 
 ^ Binz, op. cit. vol. ii. p. 267. 
 2 Lecture VI. p. 168. 
 
DISEASES OF THE HEART 339 
 
 other times with the persistence of chronic wandering 
 rheumatic pains not always obviously affecting the heart. 
 Hceret lateri letludis arunclo is an apothegm applicable to 
 rheumatism in all its forms, and if it finds its most apposite 
 appKcation in rheumatic pericarditis, it finds it so rarely as 
 to be of little consequence to the species, however important 
 it may be to the individual himself. The following case is 
 the most serious one of the kind that has occurred to me 
 during fifteen years' connection with the Infirmary : — 
 
 Case XXXIII.^ David Davidson, a tailor, aged twenty- 
 four, admitted to "Ward Y. on 16th November 1870, com- 
 plaining of pain in the chest and limbs, difficulty of breathing, 
 and dry cough. Patient said that he had always been healthy 
 till about five years ago, when he began to suffer from shght 
 rheumatic paias. The present attack commenced on 7th 
 November with pains in the joints of his lower extremities, 
 but he continued at work till the 10th. On the 12tli pain 
 set in about the heart, and on the 16th he came into hospital. 
 Both his parents are dead ; his father had been rheumatic, 
 his mother not. Upon admission his expression was anxious ; 
 his skin felt hot and was soaked with sour-smelling perspira- 
 tion. The temperature in the axilla was only 99'8°. He had 
 pain in the right knee-joint, but it was neither swollen nor 
 red. The patient felt a burning pain in the pr^ecordial region; 
 the cardiac percussion dulness was normal, but a loud, rough 
 friction sound accompanied the movements of the heart ; it 
 was heard loudest at the base and with the systole, but it 
 obscured both sounds. The pulse was 100, full, compressible, 
 and markedly dicrotic, as is well shown in the accompany- 
 ing sphygmogram (Fig. 28). The respirations were 40 per 
 minute, and he had some cough with shght expectoration. 
 The percussion note was clear over both lungs; the respiration 
 was normal on the right side, but accompanied by coarse 
 crepitations on the left. The patient's sleep was disturbed, 
 and his appetite was defective ; his tongue was coated, dry 
 
 ^ Case reported by Benjamin Tydd Hunter, clinical clerk. 
 
340 CLINICAL LECTURES ON 
 
 and brown in the centre and towards the back, white at the 
 edges. His bowels were normal. His urine was normal in 
 quantity, acid, deep amber in colour, specific gravity 1026. 
 It contained a floating cloud of urates, and gave with nitric 
 acid a deposit of nitrate of urea ; the chlorides were normal. 
 The patient was put upon infusion of digitalis with nitrate 
 of potass, and chloral at night. In two days the pulse had 
 fallen to 96, and its dicrotism could no longer be detected. 
 On 19th November the pulse had again risen to 100 ; the 
 cardiac symptoms remained unchanged, but all the joints of 
 the middle finger of the left hand and the left wrist were 
 swollen red and painful, and his loins ached much. The 
 patient was now put upon drachm doses of the tincture of 
 the actma raccmosa every three hours, and a warm linseed 
 
 Fig. 28. 
 
 poultice was kept constantly applied over the cardiac region. 
 On 22nd November the transverse dulness of the cardiac 
 area at the level of the fovirth rib on the left side measured 
 six inches ; the dulness did not rise above the third rib, and 
 it was recognised as due to effusion within the pericardium 
 by the disappearance of the apex beat, and by the dulness 
 shifting as the patient was turned from one side to the other. 
 On 24th November he had an attack of severe pleuritic pain, 
 for which he had morphine injected hypodermically. This 
 pain resulted in effusion into both pleurse, the dulness ex- 
 tending as high as the eighth rib on both sides. His other 
 symptoms moderated, and on account of the persistence of 
 this effusion on 30th November he was ordered — 
 
 R Potasii iodidi, 
 
 Potassse bicarbonatis, aa 5 ii- 
 
 Infusi calumbtie, § vi. Solve. 
 
 Signetur — One tablespoonful (half an ounce) in a wineglassful 
 
 of water three times a day. 
 
DISEASES OF THE HEART 341 
 
 After this the patient continued to improve. On 1st 
 December, the thoracic dulness continuing the same, a friction 
 sound was heard over the right base posteriorly ; next day 
 the dulness did not reach higher than the upper border of 
 the ninth rib, and friction was heard over the left base also. 
 On 4th December a faint systolic murmur became audible 
 in the mitral area. The patient continued to improve and 
 the dulness over both lungs and heart steadily decreased. 
 On 8th December all medication was stopped, and on 5th 
 January 1871 he was sent to the Convalescent Hospital. 
 After some weeks' rest this patient returned to his work as 
 a tailor, which he still continues. He married a few years 
 subsequent to the illness recorded, and has always had ex- 
 cellent health, in particular he has had no recurrence of his 
 rheumatism. His mitral regurgitation still (1897) persists, 
 but the affection is perfectly mute, though the murmur is 
 loud enough. 
 
 Now and then the diagnosis of pericarditis is beset with 
 some difficulties. For example, the sound of friction usually 
 heard at the base of the heart and generally distinct enough, 
 often scrapy and well marked and now and then creaky 
 and obscure, occasionally simulates so closely the blowing 
 sound of a valvular murmur as to be quite indistinguishable 
 from such a murmur by the sound alone. I have most 
 frequently observed this in connection with those latent 
 forms of pericarditis so apt to occur during the course of 
 Bright's disease. There is, however, never any real difficulty 
 in determining between a murmur and a pseudo-murmur of 
 frictional origin. In deciding this matter rhythm is of little 
 consequence, as a pseudo-murmur may be systolic or diastolic, 
 or it may occupy both times continuously, or the reverse — 
 discontinuously and irregularly. And we know that even 
 true valvular murmurs may vary in a similar manner ; that 
 is to say, they may be systolic or diastolic, or they may be 
 double, occupying both systole and diastole, or they may be 
 irregular. But a frictional pseudo- murmur has but rarely 
 
342 CLINICAL LECTURES ON 
 
 the same position of maximum intensity with the murmur 
 which it simulates, the chief exception to this being the 
 pseudo-diastolic aortic murmur. Pseudo-murmurs are strictly 
 localised to the cardiac area, and usually to a very small part 
 of that, not being propagated out of their position of maximum 
 intensity to any extent, and then only equally all round and 
 never in the definite lines of any special valvular murmur. 
 Moreover, all the secondary results of the valve lesion simu- 
 lated are entirely wanting, and it is only rarely that the 
 natural sounds of the heart are entirely lost in the pseudo- 
 murmur, though they are not infrequently obscured by it. 
 Whenever, therefore, we hear in any part of the cardiac area 
 a sound not distinctly a friction sound but which resembles 
 a murmur, we must always exhaust all the possibilities of 
 valvular origin before we ascribe it to a pericardiac source. 
 The only real difficulty in any such case is when a pseudo- 
 murmur occurs along with pre-existing valvular disease, then 
 indeed it may be impossible to make a perfectly accurate 
 diagnosis, but then too this is of comparatively little im- 
 portance. 
 
 A friction sound heard within the cardiac area is not 
 necessarily of pericardiac origin ; it may be pleuritic and yet 
 be audible when the heart alone is acting, the respiration 
 being temporarily suspended. This condition is unusual, and 
 when it does occur an accurate diagnosis is almost impossible. 
 When the friction is entirely absent from the base of the 
 heart over midsternum, and only audible towards the left of 
 the cardiac area, I am disposed to regard it as of pleuritic 
 origin, even though it persists during suspension of the 
 respiration. Undoubtedly this view is a probable one, but it 
 is by no means certamly correct. The subsequent progress 
 of the case may show that the pleura is certainly affected, 
 but that is no proof that the pericardium is not also impli- 
 cated; or, on the other hand, the pericardium may be assuredly 
 diseased and yet the friction may be wholly due to pleurisy. 
 These problems are among the most difficult we can come 
 
DISEASES OF THE HEART 343 
 
 across for a perfectly accurate diagnosis, yet even in the 
 most obscure case there cannot long be any great doubt 
 whether the pleuritic or the pericardiac affection stands 
 alone, or which is the essential disease when the two are 
 combined. Each case must, however, be decided on its own 
 merits ; it is impossible to lay down any hard and fast rules 
 applicable to all. 
 
 When effusion takes place into the pericardial sac the 
 apex beat is said to be displaced upwards ; the true apex is 
 really separated by the effusion from the chest wall. What is 
 now felt is the impulse of the part of the ventricle just above 
 the apex still in contact with the chest wall, and this pseudo- 
 apex appears to rise higher and higher as more and more of 
 the heart gets separated from the anterior chest wall with 
 which the base of the heart always remains in contact. 
 Hence, however great the effusion, basic friction, if it has 
 once been heard, is never effaced. Increased dulness from 
 effusion into the pericardium is first of all to be detected at 
 the base of the heart as an increase of the transverse dulness 
 at the. level of the fourth rib ; by and by the ordinary 
 pyramidal dulness of the heart, base upwards, is reversed, 
 and we have a pyramidal dulness with the base downwards, 
 while the apex may rise as high as the clavicle or even above 
 it. This dulness may also extend to the left of the usual 
 position of the apex, especially if the patient lies on his left 
 side ; but this part of the dulness is mobile, and passes to 
 the right on turning the patient on his right side. Great 
 emphysema of the lung may obscure this dulness, but it 
 never altogether annihilates it. In some cases friction is 
 entirely absent throughout the whole course of the disease, 
 not merely in cases of simple serous effusion, but even when 
 there is an abundance of fibrinous exudation. It is difficult 
 to account for this ; a soft gelatinous condition of the fibrine 
 has been alleged as a cause, but it is difficult to believe that 
 differences in this respect are sufficient to account for the 
 entire absence of friction we sometimes have. Feebleness of 
 
344 CLINICAL LECTURES ON 
 
 the cardiac action is probably at least a contributory cause, 
 and possibly some alteration in the physical condition of the 
 overlying parts, especially of the lungs, may impair their 
 conduction of sound. If with absence of friction we have 
 associated effusion into both pleurse, then we are forced to 
 surmise the co-existence of pericarditis from general symptoms 
 alone, the most important of these being a rapid, feeble, and 
 dicrotic pulse, with feebleness or absence of the cardiac 
 impulse, and delirimn ; dehrium being even in ordinary 
 rheumatic pericarditis often the only indication of danger, 
 and in all such cases it is a symptom that ought to direct 
 attention to the heart rather than to the head. In January 
 1868 a case of this nature occurred in Ward VII., in the 
 person of Andrew Dickson, a young man of nineteen, who 
 had double pleurisy with considerable effusion into the left 
 cavity, and somewhat less into the right. He also had 
 occasional haemoptysis, failure of the cardiac impulse, rapid 
 dicrotic pulse, and considerable delirium ; he had no rheu- 
 matism and never any pain in the region of the heart. Any 
 pericardiac dulness present was merged in the pleuritic 
 dulness; careful auscultation failed at any time to detect any 
 sound of friction, and though the co-existence of pericarditis 
 was surmised it could never be satisfactorily determined. 
 After death the pericardium was found distended with 
 reddish serum, and both parietal and visceral surfaces coated 
 with shaggy, mammillated, blood-stamed l}Tnph. Cases like 
 this are, however, very unusual. 
 
 The treatment of pericarditis is almost invariably merged 
 in that of some other disease — rheumatism, Bright's disease, 
 tuberculosis, or pleurisy — and there is no reason why this 
 treatment should be changed because the pericardium becomes 
 accidentally implicated. Stokes has remarked in regard to 
 the so-called active treatment of such cases that " boldness 
 of treatment often betrays the timidity of the practitioner,"^ 
 and there is no reason why the detection of a Httle extra 
 
 ^ Stokes, op. cit. p. 82. 
 
DISEASES OF THE HEAET 345 
 
 serum or of lympli within the pericardium should lead 
 us to jeopardise our patient by hazardous and unneces- 
 sary medication. Bamberger/ Niemeyer,^ Gairdner,^ and 
 Bennett* have all shown that rheumatic pericarditis is a 
 disease which runs its course more favourably the less 
 actively it is interfered with, and that all that is required is 
 fitting constitutional treatment and local palliatives, and that 
 constitutional treatment alone is fitting which is directed to 
 the disease with which the pericarditis is associated, and not 
 to the pericarditis itself. All this is true still, and with 
 modern appliances can be much more readily and efficiently 
 carried out; thus Bamberger and Niemeyer recommend 
 leeching for the relief of pain, but pain can be much more 
 effectually and more rapidly relieved by the hypodermic use 
 of morphine, and, if needful, by the subsequent use of small 
 doses of chloral repeated at regular intervals. Eheumatic 
 pericarditis must be treated simply as part of the general 
 rheumatic attack, with careful attention to keeping the chest 
 warm, to the relief of pain, and to the quieting and steadying 
 of the heart's action. 
 
 In occasional instances the question may arise as to 
 whether the pericardium should be tapped or not. It is our 
 duty to obviate death from any preventible cause ; if, there- 
 fore, the heart's action seems oppressed, and life endangered 
 by the amount of effusion, we ought certainly to tap. In all 
 ordinary cases this procedure is quite uncalled for, and those 
 symptoms that seem to indicate a need for it are only too 
 often signs that the vital powers are so depressed as to render 
 any relief thus obtained merely temporary. In the following 
 case this question of tapping arose, but as the constitutional 
 depression seemed greater than could be accounted for either 
 by the affection of the pericardium or by the amount of 
 
 ^ Lehrhuch der Krankheiten des Eerzens (Wien, 1857), pp. 131-133, etc. 
 ^ A Textbook of Practical Medicine (London, 1871), p. 389. 
 ^ Edinburgh Medical Journal, January 1861, p. 632. 
 
 * The PiHnciples and Practice of Medicine (Edinburgh, 1865), 4th edition, 
 p. 575. 
 
346 CLINICAL LECTURES ON 
 
 effusion present, the operation was postponed from a feeling 
 that there was something unusual in the case not to be 
 eliminated by tapping. Almost at the last moment my 
 resident, Mr,, now Dr. Saundby,-^ did operate, but with only 
 temporary relief, and the nature of the case was such that an 
 earlier operation would have been of no avail.^ 
 
 Case XXXIV. Thomas Fraser, aged thirteen, was admitted 
 to Ward V., Bed 1, on 21st May 1874, complaining of cough 
 with a feeling of tightness and pain in his chest. His history 
 was that about eight days before his admission he had gone 
 to bed apparently quite well, and in the morning found 
 himself unable to get up from severe illness presenting the 
 symptoms just described. He was a poor ill-thriven boy, 
 whose father had died apparently of phthisis, or at least of 
 some disease accompanied by cough and progressive emacia- 
 tion ; his mother was still alive but sickly. The patient lay 
 easily on his right side ; his face was puffy ; his insteps slightly 
 cedematous ; his countenance expressed both anxiety and pain. 
 His temperature on admission was 1024°, and during the 
 whole of his illness it ranged between 102° and 99°, being 
 usually a degree higher at night than in the morning. On 
 the day of his death his temperature was 98° ; on the previous 
 day it had been 100°. His pulse was 80, soft, and very 
 irregular in rate, but specially so in force. He complained 
 of great dyspnoea and tightness across the chest. On in- 
 spection the prtecordia seemed to bulge more than usual, and 
 upon palpation no cardiac impulse could be perceived. On 
 percussion one inch from the left of the sternum, dulness did 
 not rise above the third rib, but it extended downwards till 
 it merged in the stomach resonance. At the level of the 
 fourth rib transverse dulness commenced two inches to the 
 right of the sternum, and extended to the left across the 
 
 ^ Dr, Saundby has published this case with remarks in the Edinburgh 
 Medical Journal for March 1875, p, 799. 
 
 ^ A full account of this operation, with the history of sixty cases in which 
 it has been performed, will be found in Paracentesis of the Pericardium, by 
 J, D. Roberts, M.D., Philadelphia, 1880, 
 
DISEASES OF THE HEAET 347 
 
 sterimm for a distance of five inches more — seven inches in 
 all. On auscultation the heart's sounds were heard normal 
 enough in all the areas when the patient stopped breatliing. 
 Over the precordial region a loud friction sound was audible 
 with the respiration, ceasing when the patient held his 
 breath. The respirations were 36 per minute, and there was 
 great pain on coughing ; the expectoration mucous and trifling 
 in quantity. Anteriorly over the lungs the percussion note 
 was normal, except where interfered with by the distended 
 pericardium. Posteriorly there was dulness over the left 
 base. The patient's tongue was slightly coated, appetite 
 defective, bowels loose. The quantity of urine passed could 
 not be estimated, as much of it passed with his stools ; what 
 could be collected was of a reddish colour, acid, specific 
 gravity 1027, and contained no sugar, albumin, or bile ; 
 chlorides were present, and there was a deposit of urates. 
 The patient's face and feet gradually became more oedematous, 
 but there was no general anasarca of any consequence. 
 Permission was given to tap the pericardium on the symptoms 
 becoming urgent, without much hope of rehef from the 
 procedure, but from sheer unwillingness to leave any stone 
 unturned. Accordingly, on the evening of 10th June, the 
 pulse having become imperceptible, Mr. Saundby tapped the 
 pericardium and drew off 30 oz. of pus, with temporary relief. 
 The pulse returned to the wrist — it was 84 per minute — 
 and for a time he rallied, but died at 1.30 on the morning of 
 11th June. At the autopsy on 12th June some serous fluid 
 was found in the left pleura, and there were recent adhesions 
 over the lower part of the left pleura, chiefly anteriorly. 
 There were 36 oz. of pus in the pericardium, and the heart 
 was firmly adherent to the posterior part of that sac ; 
 anteriorly it was covered with purulent lymph. At the base 
 of the right lung there was an abscess close to the pericardium, 
 but no communi&ation could be traced between the two. 
 The rest of the autopsy was unimportant. 
 
 In spite of the apparent absence of communication, it 
 
348 CLINICAL LECTURES ON 
 
 seemed probable that the pus in the pericardium was 
 due to rupture of the abscess of the right king into the 
 pericardium, the left pleurisy arising from contiguity in a 
 feeble and worn-out constitution. Little relief could be 
 expected from tapping in such a case, but it can be so easily 
 done nowadays by aspiration that it seemed right to give 
 the patient this last chance of having his life prolonged. 
 The intra-pericardiac effusion was never excessive, and the 
 constitutional depression was so great in comparison with 
 the amount of fluid that tapping could only be permitted as a 
 dernier ressort, and possibly might as well have been left alone. 
 But it is always right to endeavour to prevent death by every 
 possible means, in the hope that some favourable change 
 may take place. Even in purulent pericarditis this is not 
 impossible, as the elements of pus are more or less present 
 in every pericarditis, and even when the fluid is wholly 
 purulent it may still break up into a pathological cream, 
 become absorbed, and the disease cured, though this can only 
 rarely be the case. 
 
 The termination of pericarditis in complete adhesion of 
 its two layers is a matter of great pathological importance, 
 but of little practical interest, because it is almost impossible 
 to diagnose it. We may surmise the existence of this ad- 
 hesion, but unless m very exceptional cases we can never be 
 certain.^ Adhesion of the two layers of the pericardium is 
 not necessarily accompanied by any indication of cardiac 
 failure, but w^here this is present its nature and character 
 depends upon the extent to which the integrity and nutrition 
 of the myocardium is involved. One of the most remarkable 
 instances of this mode of termination of pericarditis is to be 
 found in the Museum of the University of Edinburgh, and 
 is referred to by Dr. Burns in his Observations on Diseases of 
 the Heart as one in which the pericardium was unusually 
 adherent, and the ventricles so ossified (they are really 
 atheromatous) that, with the exception of the space of one 
 ^ Vide Lecture I. p. 8. 
 
DISEASES OF THE HEAET 349 
 
 cubic inch over the apex, they were as " firm as the skull/' 
 yet the patient never had any palpitation nor any pain in 
 the region of the heart.^ Fibrinous effusion into the peri- 
 cardium may compress the coronary arteries and lead to 
 angina and cardiac dilatation, and an adherent pericardium 
 may even be associated with cardiac hypertrophy, though 
 this must be rare, but it is impossible to predict these altera- 
 tions, and almost impossible to surmise them even with the 
 history of the case before us. 
 
 It has twice occurred to me to find a loud friction sound 
 over the whole cardiac area, without any subjective symptoms 
 whatever. The patients certainly felt themselves not quite 
 right, but there was no rise of temperature, nor any pain ; 
 neither was there any other disease present to account for a 
 latent pericarditis, in particular there was no kidney disease. 
 In one of these cases the friction sound came and went in 
 the most inexphcable manner ; the variations of intensity in 
 the friction in the other case were evident enough, but were 
 not so remarkable.^ It is alleged, I beheve, by some anatom- 
 ists that there are muscular fibres in the pericardium, and 
 the phenomena presented by these two cases seemed more 
 easily explicable on the supposition that the heart was 
 periodically and spasmodically grasped by the pericardium, 
 than by any other theory. 
 
 Acute endocarditis of a simple character is largely a 
 pathological disease, and not a clinical one. A systolic apex 
 murmur so often supposed to indicate endocarditis, when 
 found in connection with an acute rheumatic attack, is in by 
 far the larger proportion of cases merely an indication of 
 cardiac dilatation of a temporary and perfectly curable char- 
 acter.^ Any symptoms that may be supposed to be peculiar 
 
 1 Op. cit. p. 131. 
 
 2 Robert Hume, admitted to Ward XXXVI. , New Royal Infirmary, 23rd 
 June, and discharged 13th July 1880, the friction still occasionally recurring. 
 For some years I saw this man occasionally, looking the picture of health, 
 and to the last the friction persisted without change and equally without 
 detriment to the patient's general health. 
 
 ^ Vide Lecture VI. p. 167 paasim. 
 
350 CLINICAL LECTURES ON 
 
 to this disease, when it does exist, are merged in those of 
 any concomitant pericarditis, or simply in those of the 
 general disease. I have several times had an opportunity 
 of watching the development of stenosis of the mitral valve, 
 from a state of perfect health to the fully -developed pre- 
 systolic murmur, in non-rheumatic cases, but the symptoms 
 exhibited have never been distinctive enough to enable me 
 to lay down any certain rule for their recognition, particularly 
 in the early stages, when recognition would be of most im- 
 portance. For example, palpitation, simple, rapid action of 
 the heart and arteries, such as we find in pyrexia, not always 
 accompanied by any pain or uneasiness in the cardiac region, 
 is common enough in many forms of disease, and may even 
 exist as an independent neurosis, and yet for many months 
 that may be the only symptom present in a case where 
 mitral stenosis is ultimately developed. At this moment 
 (1898) there is a case under my care, in which, after the lapse 
 of more than a year, there are as yet no definite signs of a 
 stenosis which is surely coming, and even now is faintly 
 shadowed. 
 
 Acute ulcerative or septic endocarditis does not seem to 
 be common in our Infirmary, at least we have seen none of it. 
 As its name implies, it owes its virulent and too often fatal 
 character to the presence in the blood of pathogenic organisms. 
 Septic endocarditis is closely allied to pysemia, and, like its 
 congener, it gives rise to many septic emboHsms, accompanied 
 by irregular febrile paroxysms. Unless associated with a 
 valvular lesion, this disease may escape recognition, but the 
 type of the pyrexia, and the characteristic skin eruption, fine 
 reddish spots with a paler centre, serve to exclude typhoid 
 fever and tuberculosis, with which it is apt to be confounded. 
 The disease may be acute, subacute, or chronic ; it is not 
 amenable to treatment, but the few chronic cases that have 
 recovered have done so under the internal use of antiseptics 
 with the free administration of stimulants. 
 
 Myocarditis belongs to a similar category ; it is more often 
 
DISEASES OF THE HEART 351 
 
 discovered after death than recognised during life. I shall 
 content myself with giving an account of one or two cases in 
 which more or less extensive myocarditis was found after 
 death, nothing of the kind having been suspected during life. 
 Case XXXV. Francis Lynch, admitted first of all on 
 23rd June 1868, discharged improved on 11th July. Ee- 
 admitted on 5th October, discharged improved on l7th 
 December. Again readmitted on 2nd January, and died in 
 Ward VII. on 6th May 1869. This patient had a mitral 
 murmur of a shifting character; at times it was loud and 
 distinct, and again it disappeared entirely for weeks at a 
 time. A tricuspid murmur also present was equally variable. 
 It was impossible to make anything of his cardiac symptoms 
 except that there was a gradual failure of cardiac power, 
 accompanied by an occasional murmur, now distinctly mitral 
 in character, and at other times quite as distinctly tricuspid. 
 He was repeatedly seen by my colleagues, but nothing more 
 definite was elicited. At the autopsy on 6th May 1869 the 
 pericardium was found to contain a considerable quantity of 
 yellowish serum ; the heart was enlarged ; the apex rounded ; 
 the right ventricle projected a little beyond the left. The 
 aortic and pulmonary valves were normal. The circum- 
 ference of the pulmonary artery measured three inches and a 
 quarter. The tricuspid orifice measured six inches and 
 three-quarters in circumference. The aortic orifice measured 
 three inches, and the mitral orifice five inches in circum- 
 ference. The right ventricle was dilated and distinctly 
 hypertrophied. The left auricle was somewhat dilated. The 
 left ventricle was in some parts atrophic, but the musculi 
 papillares were distinctly hypertrophied. A considerable 
 part of the wall of the left ventricle was atrophied and re- 
 duced to half its natural thickness ; over this part the endo- 
 cardium seemed to be continuous. There was no aneurysmal 
 dilatation of the wall, but the cardiac cavity was increased 
 in size by half the thickness of the ventricle. Adherent to 
 the atrophied part of the ventricular wall there was a buff- 
 
352 CLINICAL LECTUEES ON 
 
 coloured clot, firm on its surface, and partially laminated, 
 the superficial layers being redder and apparently more 
 recent. On more careful examination the atrophied part 
 was found to be limited to the inner half of the ventricular 
 wall, the outer half being composed of apparently natural 
 muscular fibre. Quite at the apex, and at the lower part of 
 the septum, the portion atrophied was greater than that re- 
 maining, but on tracing it up towards the base, the muscular 
 substance was found gradually to increase until it occupied 
 the whole thickness of the ventricular wall. The fibrous 
 part contained some dense white lines, and was otherwise 
 composed of fine fibrous tissue. On microscopic examination 
 the muscular fibre in every part of the heart was found to 
 be fatty. In the atrophic portion there were found traces of 
 occluded blood-vessels, with granules and crystals of blood- 
 pigment within them. Mingled with these there was a 
 large amount of dense fibrous tissue, with little patches of 
 fat, and traces of muscular fibre. The branches of the 
 coronary artery leading to the atrophied part were occluded. 
 The left pleural cavity contained a considerable quantity of 
 serum, which compressed the lower lobe of the corresponding 
 lung. The right lung was congested and oedematous. There 
 was lateral curvature of the spine in the dorsal region. The 
 rest of the body was not examined. 
 
 This patient never had rheumatic fever, and was said to 
 have been perfectly well up to January 1868, when he caught 
 cold, shortly after developed shortness of breath, and ever 
 after continued ailing till he died. It is curiously indicative 
 of the anomalous character of his symptoms that though 
 seen by many physicians, his exact condition was not even 
 surmised. 
 
 Another most interesting case is solely represented by 
 the annexed drawings, which exhibit the microscopic appear- 
 ances found in his myocardium. You see that the con- 
 nective tissue of the pericardium, the sub-pericardial fat, 
 and the fibres of the myocardium, are all infiltrated with a 
 
DISEASES OF THE HEAET 
 
 353 
 
 hyperplasia of corpuscular elements. The patient to whom 
 this heart belonged laboured under aortic incompetence, but 
 had improved greatly under treatment. He had a good 
 firm apex beat, considered himself quite restored, had got 
 his discharge, and was just about to leave when he died 
 suddenly from asystole. On dissection his heart was flabby, 
 of a yellowish tint, and was pronounced fatty. My resident 
 (the late Professor C. S. Eoy, of Cambridge) secured the 
 
 Fig. 29. — Section of muscular tissue 
 of heart, a, nucleus ; b, nucleated 
 cell ; c, transverse section of mus- 
 cular fibre. 
 
 Fig, 30. — Vertical section of peri- 
 cardium and sub-pericardial con- 
 nective tissue. «, Pericardial 
 fibrous tissue infiltrated with 
 nuclei ; h, fat cell ; c, nucleus ; 
 d, capillary vessel transversely- 
 divided. 
 
 heart, and, on examining its tissues microscopically, discovered 
 the lesion described. The drawings (Figs. 29 and 30) were 
 made by Dr. Eoy, from specimens prepared by himself 
 
 It is impossible to say whether this condition would 
 have ultimately led to suppuration, or to fibrosis of the 
 myocardium. 
 
 But perhaps the most remarkable heart of this character 
 that has ever come before me was that of — 
 
 Case XXXVI. Ealph Scott, admitted to Ward V. on 
 
 23 
 
354 CLINICAL LECTUKES ON 
 
 22nd June 1877. This man was forty-five years of age, and 
 of very intemperate habits. He was not known ever to have 
 had rheumatic fever, but had long suffered from cough and 
 shortness of breath, and he was admitted to the Infirmary on 
 account of the severity of these symptoms. He was found 
 to labour under general dropsy with oedematous lungs, a 
 very large heart, and both a systolic mitral and a tricuspid 
 murmur, but nothing peculiar was observed in regard to 
 the action of the heart. Four days after admission, on 
 26th June 1877, he died suddenly after an epileptiform 
 convulsion. 
 
 Autopsy, 27th June 1877. — The body was that of a man 
 of rather a large frame, with a good deal of anasarca, 
 especially in the lower extremities. The pericardium was 
 firmly attached over the whole surface of the heart by dense 
 old adhesions. The heart itself was enormously enlarged, 
 weighino; 2 lbs. ; all its chambers were much dilated, the 
 dilatation of the right ventricle being extreme. The cavity 
 of the left ventricle was greatly dilated, and its wall was 
 much hypertrophied, measuring from three-quarters of an 
 inch to one inch in thickness. The muscular tissue of the 
 upper half of this ventricle was sound, but about the apex 
 the muscular fibre was largely replaced by cicatricial tissue 
 so dense as to creak under the knife. About one inch and a 
 half above the apex there was a pouch-like bulging of the 
 ventricular wall, which would have developed into an 
 aneurysm had life been prolonged. Over the whole area of 
 fibrous induration the pericardial adhesions were specially 
 dense, and the endocardium was thick and of an opaque 
 yellow colour. The aortic orifice was normal in size, 
 measuring three inches in circumference. The aortic valve 
 was competent and its segments natural. The mitral orifice 
 was dilated, admitting five fingers (cone diameter 1'75 inch). 
 The anterior cusp of this valve was natural, but the posterior 
 cusp was in a state of advanced disease ; its left half was 
 natural, but the right half was greatly thickened, and was so 
 
DISEASES OF THE HEAET 355 
 
 curved and bulged out from behind, by the pressure of the 
 blood upon its posterior or ventricular surface, as to press as 
 a rigid, rounded sac against the surface of the anterior cusp. 
 Behind the concave surface of the diseased cusp the posterior 
 wall of the ventricle was hollowed out into a cavity, and 
 presented the same thickening of the endocardium and 
 fibrous induration of the muscular tissue as was noted in 
 regard to the ventricular wall at and near the apex. Owing 
 to the differentiation of the posterior cusp into a sound and a 
 diseased portion, the valve itself looked curiously like a 
 tricuspid rather than a bicuspid valve. The right auriculo- 
 ventricular opening was enlarged, admitting five fingers (cone 
 diameter 1"75 inch). The aorta was normal in size but very 
 atheromatous, and some of its intercostal branches were 
 partially occluded by the consequent thickening of the tunica 
 intima, but the coronary arteries were not obstructed,-^ The 
 remainder of the autopsy is omitted as unimportant. 
 
 That a heart so crippled could yet discharge its function 
 fairly well for many years, judging from the size of the heart 
 and the fact that its history had been entirely lost, cannot 
 fail to be an encouragement to us in our attempts to remedy 
 even cases that seem apparently hopeless. 
 
 I have mentioned that hypertrophy of the heart may be 
 a result of pericarditis quite apart from valvular lesion. 
 This does happen occasionally, just as we also have apparent 
 hypertrophy of the heart from the development of gummata 
 within the myocardium, yielding to anti-syphilitic remedies, 
 but what so often passes under the name of idiopathic en- 
 largement of the heart is simply the physiological result of 
 those tissue changes that occur in our progressive develop- 
 ment. When after middle life distressing symptoms attract 
 attention to the heart, in by far the larger proportion of cases 
 these will be found to depend upon some disturbance of the 
 nutrition or of the innervation of the myocardium interfering 
 with and modifying this normal senile enlargement of the 
 
 ^ Condensed from the Pathological Reports of the Royal Infirmary. 
 
356 CLINICAL LECTURES ON DISEASES OF THE HEART 
 
 heart. Many of the most interesting, and some of the most 
 widespread varieties of cardiac disease are to be found in this 
 connection, but they depend primarily upon arterial develop- 
 ment and have been treated of elsewhere.^ 
 
 ^ Vide The Senile Heart, its Symptoms, Sequelae, and Treatment. London : 
 A. and C. Black, 1894. 
 
LECTUEE XIV 
 
 ON THE THEEAPEUTICS OF CARDIAC DISEASE 
 
 In speaking of the various forms of cardiac disease I have 
 ahceady aUuded, somewhat cursorily, to the method of treating 
 them. At present I intend to go a little more fully into 
 cardiac therapeutics generally, the remedies commonly used, 
 and the indications for their employment. 
 
 First, let me point out that as a preliminary to the treat- 
 ment of any disease, it is needful to make an accurate 
 diagnosis of the general condition of the patient, as well as 
 of the state of the organ chiefly at fault. The prominent 
 symptom complained of affords an important clue to the 
 nature of the case, as well as a guide to the treatment. But 
 that any symptom may be useful in this way we must clearly 
 understand what the patient means by his complaint, as well 
 as what the symptom means to us. In heart affections, for 
 instance, palpitation is a common complaint, and to an 
 ordinary patient it means anything abnormal in the rate or 
 rhythm of the heart's action. But palpitation, thus under- 
 stood, is a symptom having various pathological meanings, 
 and each of these indicates an entirely different line of treat- 
 ment {vide p. 276). Again, dropsy is a symptom readily 
 noticed and commonly enough associated with a diseased 
 heart, but the association may be quite accidental, and to 
 accept concomitance as an indication of relative connection 
 might result in sacrificing to routine a life that a more 
 intelligent differentiation might save. Breathlessness is 
 another symptom often connected with cardiac failure, but 
 
358 CLINICAL LECTUEES ON 
 
 this also frequently depends upon causes wholly unconnected 
 with the heart, and demanding diverse modes of treatment. 
 
 We must also remember that if a patient comes com- 
 plaining, it is our duty to relieve his sufferings, but if we 
 accidentally discover a cardiac lesion or murmur in any one 
 apparently healthy, there is not usually any call to make 
 such a one an invalid, or to employ any special treatment. 
 The chief exception to this is any young spansemic person, 
 girl or boy, with a so-called functional murmur, as the hearts 
 of all such patients must be attended to whether they com- 
 plain or not, otherwise they may find themselves seriously 
 handicapped later in life. 
 
 In estimating the value of any treatment it is an unwise 
 error to suppose that recovery or improvement has been 
 necessarily due to the use of any special drug. In past ages 
 many cardiac patients recovered from ruptured compensation 
 without any material aid from drugs. And in the present 
 day many recover, even after dropsy has set in, under the 
 influence of diet and rest alone, and this enables us to under- 
 stand the recoveries that often take place under the use of 
 drugs of no great activity.-^ Powerful drugs are always 
 potent for evil as well as for good, and in the hands of the 
 less skilful a less active drug may be actually more useful 
 than one which is more energetic, with the management of 
 which the practitioner is less acquainted. 
 
 In the treatment of cardiac disease it is, before all things, 
 needful to keep the patient cheerful and free from anxiety. 
 If there is cause for apprehension, — and no heart case is 
 altogether free from this, — it is well that the friends should 
 be warned ; but if these are injudicious, it is better to run 
 some risk of being misunderstood rather than disturb the 
 equanimity of the invalid. 
 
 With these few preliminary remarks I pass now to the 
 consideration of those remedies chiefly employed in the 
 
 ^ Vide Transactions of the Medico-Cldrurgkal Society of Edinburgh (Session 
 1895-96), vol. XV. (new series), p. 142. 
 
DISEASES OF THE HEAET 359 
 
 treatment of heart affections ; they are not very numerous, 
 but they are very valuable, and considering the importance 
 of the organ upon which their energy is chiefly expended, 
 every practitioner ought to make himself thoroughly ac- 
 quainted with the action of each of them. 
 
 Dotted all over our upland pastures there is no nobler 
 plant of our indigenous flora than the Digitalis purpurea, and 
 there is no more potent benefactor to mankind among the 
 many constituents of our materia medica. For over a 
 hundred years digitalis has been known as a sovereign 
 remedy for dropsy, but it is chiefly within the last twenty 
 years that its true action has begun to be recognised. Even 
 yet the profession are hampered by the idea that digitalis 
 is a dangerous sedative to the heart — an idea that dates back 
 to the time not so long past, when digitalis was supposed to 
 possess a number of distinct actions, all more or less antagon- 
 istic to one another.-^ Now we know that the fundamental 
 action of all that group of plants to which digitalis belongs, 
 to which it gives its name, and of which it is facile princeps, 
 is to increase the elasticity of muscular fibre so that it ex- 
 pands more slowly and contracts more perfectly.^ The effect 
 of this upon a hollow muscle like the heart is that it dilates 
 more slowly and empties itself more completely; residual 
 accumulation is thus prevented, and any dilating influences 
 are counteracted. As all the blood passes many times 
 through the heart for once that it passes through any other 
 muscle,^ the myocardium is powerfully affected while the 
 other muscles still remain practically uninfluenced. The 
 muscles of the arterioles are also early and powerfully affected, 
 though not to the same extent as the heart, as only the blood 
 
 ^ Christison's Dispensatory (Edmburgh, 1842), p. 400. Also Edinburgh 
 Medical Journal (February 1870), p. 743. 
 
 ^ Schmiedeberg, " Beitriige zur Kenntniss der pbarmakologisclien Gruppe 
 des Digitalins," Archiv filr experimentelle Pathologie und Pharmakologie, 
 Bd. xvi. S. 149. 
 
 ^ And in this respect we must not forget that ' ' the circulation through 
 the myocardium may be partly carried on by the foramina Thebesii." — 
 British Medical Journal (2nd October 1897), p. 882. 
 
360 CLINICAL LECTURES ON 
 
 going to the district supplied by these vessels passes through 
 them.-^ The increased elasticity imparted to the myocardium 
 by digitalis enables it to expand and contract more perfectly, 
 and so to throw a larger blood-wave into the arteries, and as 
 from the increased elasticity of the muscles of the arterioles ^ 
 the arteries empty themselves more slowly, the blood ac- 
 cumulates within them, the blood-pressure gradually rises, 
 and in accordance with Marey's law the heart's action is 
 slowed,^ No doubt this slowing of the heart is partly due to 
 the action on the cardio-inhibitory centre, but the action on the 
 muscles is quite sufficient to account for all the phenomena 
 observed, and it is with it we are chiefly concerned. The 
 result of this rise in the blood-pressure is that the secretions 
 are improved, and all the tissues of the body, amongst them 
 the myocardium, are fed with richer blood at a higher 
 pressure, so that metabolism is more perfect and every 
 function more efficiently performed. As the blood accumu- 
 lates within the arteries the veins are correspondingly 
 emptied; the serous soakage of the tissues is reabsorbed, 
 and the excess of water that thus gets into the blood is 
 removed by the kidneys, so that for a time the urine is 
 increased. 
 
 The improved metabolism of the myocardium enables it 
 to discharge its function more perfectly, and to resist all 
 those deteriorating influences to which a weak heart succumbs, 
 any hindrance to the circulation is fully compensated, and 
 despite the existence of a valvular lesion, the individual may 
 descend into the vale of years wholly unconscious of the 
 possession of a heart. 
 
 All the benefits we obtain from digitalis are inseparably 
 connected with its tonic action ; they flow from the power 
 
 ^ Stockman, Neio Official Remedies (London, 1891), p. 58. 
 
 - This action on the arterioles has been anew proved experimentally by 
 Dr. Lauder Brunton and Tunnicliffe, Journal of Physiology, vol. xx. p. 354. 
 
 ^ Physiologic Medicale de la Circulation du Sang, par le Dr. E. J. Marey 
 (Paris, 1863): — "Le cceur bat d'autant plus frequemment qu'il eprouve moins 
 de peine a se vider." 
 
DISEASES OF THE HEART 361 
 
 that digitalis has of increasing muscular elasticity, and the 
 improved metabolism of all the tissues, but specially of the 
 myocardium, that follows this. Digitalis is no opium to the 
 heart, as it has been called, it does not relieve by narcotising, 
 it soothes cardiac irritability and assuages some forms of 
 cardiac pain by improving cardiac metabolism, failure of 
 which has been the cause of both irritability and pain. 
 These benefits are readily obtained by moderate doses of the 
 drug, and though great advantage sometimes accrues from 
 the judicious employment of larger doses, yet the frequent 
 repetition and long continuance of even small doses are often 
 sufficient to secure the very best results. The abuse of the 
 drug, so frequently followed by distressing if not alarming 
 symptoms, proceeds upon an entire misconception of the 
 true action of digitalis. 
 
 Digitalis in every form is absorbed with difficulty and 
 only slowly excreted, hence if even a moderate dose is 
 repeated at too short an interval the drug accumulates within 
 the system, and ere long symptoms of intoxication appear. 
 This faculty of accumulation digitalis shares with many other 
 drugs. Unfortunately for its own reputation, its sphere of 
 usefulness lies among a class of cases in which sudden death 
 is no uncommon occurrence, and many a death has been 
 unjustly ascribed to this cumulative action quite irrespective 
 of the dose administered. Even yet there is an idea of 
 danger connected with this drug which limits the usefulness 
 of this invaluable remedy, and favours the adoption of less 
 active and sometimes of even more dangerous drugs. But 
 deaths from digitalis among those otherwise healthy are 
 amongst the rarest of occurrences; only a very few are on 
 record. A full account of one has been published, in which 
 211 grains of the powdered leaves were taken within five 
 weeks before the fatal result.^ Sickness, diarrhoea, faintness, 
 and slow pulse had prevailed during fully four of these weeks. 
 With ordinary medicinal doses we need never apprehend any 
 
 ^ Kohnhorn, Vierteljahrsschrift fur gericMliche Medezin (1876), S. 278. 
 
362 CLINICAL LECTURES ON 
 
 danger, and we are certain of plenty of warning of even the 
 approach of discomfort. 
 
 As may be readily supposed, saturation is more easily 
 brought about in stunted and anaemic individuals than in 
 those who are more bulky and plethoric. But any risk from 
 an overdose must be very slight indeed, as in all my ex- 
 perience of many years I have never seen any unpleasant 
 result follow a somewhat free use of digitalis. A tonic dose 
 fitted to improve the nutrition and increase the energy of a 
 feeble heart is always a moderate one, and must only be 
 repeated after a sufficient interval. One grain of the powdered 
 leaves, or an equivalent dose of any of the other preparations 
 of the drug, given every twelve hours, will be found to be 
 quite an efficient dose for this purpose. The feeble heart 
 steadily improves, and after a time an imperceptible impulse 
 becomes perceptible, and a feeble impulse a strong one, and 
 the patient recovers a sense of wellbeing and a capacity for 
 exertion to which he has long been a stranger. A dose such 
 as that described, and less will rarely do, may be continued 
 for years, if necessary, with nothing but increasing benefit to 
 the patient, and without the slightest need for any anxiety as 
 to the possible occurrence of any disturbing saturation. The 
 dose given may even be smaller than one grain, and it may 
 be given oftener than every twelve hours, but in that case 
 the various doses may not amoimt to more than one grain of 
 the drug within each twelve hours without risk of symptoms 
 of saturation appearing. 
 
 A feeble heart beats more quickly and less forcibly than 
 in health, the ventricles empty themselves less completely, 
 there is residual accumulation within their cavities, the 
 arteries get depleted and the veins over-filled. The result of 
 this venous stasis is soakage of all the tissues, and it is the 
 removal of this soakage and the improvement of the general 
 metabolism that imparts the sensation of wellbeing that 
 follows the tonic use of digitalis. By persistence of all the 
 abnormal conditions this soakage ultimately collects as dropsy 
 
DISEASES OF THE HEAET 363 
 
 in the more dependent parts of the body and within its 
 cavities. This dropsical accumulation is chiefly of conse- 
 quence as an indication of heart failure, but in the tissue 
 interspaces, especially in the extremities, it also constitutes 
 an important peripheral obstruction to the circulation, in- 
 creasing the work of an already failing heart. 
 
 In cases of dropsy our forefathers employed digitalis 
 empirically as a diuretic, often with what seems to their 
 more timorous successors to be a dangerous freedom. They 
 gave 10 to 20 grains of the leaves in powder or infusion 
 every hour or every two hours till nausea or sickness occurred; 
 the drug was then stopped, and this acute poisoning does not 
 ever seem to have been followed by untoward results, the 
 diminution or suppression of urine which accompanied it 
 was, in two or three days, followed by copious diuresis, which 
 removed the dropsy. Nowadays we do not employ digitalis 
 empirically as a diuretic, we use it as a tonic to the myo- 
 cardium, and we find that tonic doses suffice to remove 
 soakage and even a moderate amount of dropsy. But when 
 the heart is considerably dilated larger doses may be given 
 with advantage to restore the normal elasticity of the myo- 
 cardium and to overcome the tendency to dilate. Still for 
 this but a moderate dose is necessary ; 3 grains every eight 
 hours will be found very efficient, and the interval will 
 probably soon require to be increased to every twelve hours, 
 or the dose diminished. The larger the dose and the shorter 
 the interval the more watchful we must be for symptoms of 
 saturation. These symptoms — which may be looked for so 
 soon as 30 or 40 grains have been ingested in larger doses 
 than one grain, and at a shorter interval than twelve hours — 
 are diminution of a primary diuresis, abnormal slowing of 
 the pulse, or nausea, more rarely diarrhoea. If the medicine 
 is stopped on the first occurrence of one or other of these 
 symptoms the patient will suffer no damage, nor will the 
 physician be ever disappointed in any reasonable expectation. 
 Such is Withering's statement, and with it I entirely agree. 
 
364 CLINICAL LECTURES ON 
 
 When dropsy is present and saturation occurs the primary 
 diuresis diminishes, and almost complete suppression may last 
 for two or three days ; diuresis then recurs and may continue 
 till all the fluid is drained off, or it may be kept up by 
 moderate doses at regular intervals of eight or twelve hours. 
 Apart from any diuretic action, these cumulative doses, by 
 improving the tone and elasticity of the myocardium, not 
 only enable it to resist dilating influences, but in favourable 
 circumstances are able to restore a dilated heart to its normal 
 dimensions. 
 
 Much larger doses than those indicated have been thera- 
 peutically employed without detriment. It is on record that 
 a young woman ajSected with mitral stenosis took for six years 
 4| grains of digitalis in infusion night and morning, with 
 notliing but continuous benefit. Without her medicine she 
 was unable to %vork, her limbs were oedematous, flashes of 
 light dazzled her eyes, a rushing sound disturbed her hearing, 
 her heart felt full to bursting, and her urine was suppressed. 
 All these symptoms disappeared within a few hours after her 
 medicine was repeated, and she was once more an active 
 woman.-^ But such a case must be exceptional, and so large 
 a dose cannot be recommended. 
 
 The first effect of a moderate but cumulative dose of 
 digitalis is slight slowing of the pulse, with increase of its 
 tension, and a gradually increasing flow of urine. After the 
 ingestion of about 30 grains in cumulative doses, we look out 
 for signs of saturation. With moderate doses at medium 
 intervals these are an abnormal slowing of the pulse, and a 
 diminution of the flow of urine. Should these indications be 
 neglected they are speedily followed by cardiac irregularity, 
 the slow heart beat quickens, falters, and intermits on the 
 slightest exertion. Unless we remember that after 30 grains 
 of digitalis have been ingested in cumulative doses the point 
 of saturation is approached and are watchful, a slight drop in 
 the pulse-rate or in the quantity of urine is apt to pass un- 
 
 1 Biilz, Archiv cler Heilkunde (1876), S. 468, 
 
DISEASES OF THE HEAKT 365 
 
 noticed, and the patient may get plunged into all the dis- 
 comforts incident to vagus paralysis, while we are scarcely 
 aware that the drug has begun to affect him. This, however, 
 is not the fault of the drug, but the result of inattention on 
 the part of the practitioner, and can only occur when cumu- 
 lative doses are given. 
 
 The abnormally slow pulse of digitalis saturation seems 
 quite devoid of danger, but the rapid irregular pulse of 
 digitalis poisoning (vagus inhibition) indicates a condition 
 not devoid of risk, but one which may be safely tided over 
 by omission of the drug, strict adherence to the recumbent 
 posture, and the moderate use of stimulants. 
 
 The primary action of digitalis is thus that of a tonic 
 to the heart, it increases the elasticity and improves the 
 nutrition of the myocardium, refills the arteries, depletes 
 the veins, and removes dropsy. All this can be done by 
 moderate doses, quite incapable of producing any discomfort. 
 But when the heart is much dilated, or when the dilating 
 forces act powerfully — as in aortic regurgitation, — to secure 
 rapid action larger doses must be employed, and then comes 
 the need for watchfulness lest saturation and its unpleasant 
 though not necessarily dangerous symptoms should steal 
 upon us unawares. From the nature of its action digitalis 
 may be beneficially employed in all forms of cardiac failure, 
 whatever be the character of the valvular lesion with which 
 it may be connected. Corrigan long ago sounded a note of 
 warning in regard to the use of digitalis in aortic incompe- 
 tence; he looked upon that drug as a pure sedative, and 
 regarded the prolongation of the diastole as a source of 
 increased danger to the heart. It is a very instructive proof 
 of how ill understood the true action of digitalis is even yet 
 that a similar idea is still held by some. Nay, more, the 
 prevalence of such an idea is also a proof of how theory has 
 been allowed to usurp the place of observation, because the 
 most cursory observation is sufficient to satisfy us that undue 
 prolongation of the heart's diastole is never requisite to enable 
 
366 CLINICAL LECTURES ON 
 
 US to obtain all the benefit we desire. In aortic incompetence, 
 as in all forms of cardiac failure, the heart's action is quicker 
 than usual, Corrigan reckons it as averaging 110 per minute,^ 
 and it is neither needful nor desirable to slow it down below 
 the normal (say to 70), and he would be a bold man who 
 should affirm that a restoration of the heart -beat to its 
 normal rate is in the least likely to be in any way injurious 
 (vide antea, p. 105). 
 
 Digitalis fails occasionally ; thus it has no action in the 
 often protracted and ingravescent asystole of a moribund 
 heart. At first we may fail to recognise this condition as 
 terminal, and we are bound to employ that remedy which 
 seems to hold out the most hope of advantage, but when the 
 conditions are fully recognised we have no right to be dis- 
 appointed at any failure of result. 
 
 Since the days of Withering it has been known that when 
 " the limbs in anasarca are solid and resisting we have but 
 little to hope " from digitalis. The analogy here is with those 
 senile hearts whose dilatation is due to loss of arterial elasti- 
 city ; in both cases digitalis is of no use and may even be 
 hurtful until the peripheral obstruction is removed. In the 
 one case the peripheral obstruction is due to pressure of fluid 
 on the arterioles and is readily removed by purgation or 
 drainage. In the other the obstruction to the circulation 
 caused by loss of arterial elasticity is aggravated by the digi- 
 talis action on the arterioles, and this is counteracted by 
 the combination of a vascular stimulant with the cardiac 
 stimulant.- In both cases digitalis acts like a charm when 
 delivered from the incubus of peripheral obstruction. 
 
 In dilatation of the right ventricle following considerable 
 stenosis of the mitral opening, or originating in limitation of 
 the area of the pulmonary capillaries due to destruction of 
 the walls of the air-sacs by emphysema, digitalis acts as a 
 tonic and improves the condition of the heart, but it can 
 
 ^ Edinburgh Medical and Surgical Journal (April 1832), p. 241. 
 - The Senile Heart, pp. 266 and 274. 
 
DISEASES OF THE HEAET 367 
 
 never induce contraction of the right ventricle because of the 
 permanent and incurable nature of the cause of the dilatation. 
 
 Lastly, digitalis is said to act badly and even to be posi- 
 tively injurious in cases of fatty heart. But hearts diagnosed 
 as fatty are, as a rule, only feeble and dilated, and it would 
 be a sad mistake to deprive such hearts of the benefit they 
 are so certain to receive from digitalis from the dread of an 
 unrecognisable chimsera.-^ The following case affords an apt 
 illustration of the impossibility of diagnosing a fatty heart, 
 as well as of the benefit that feeble hearts, even though fatty, 
 sometimes derive from digitalis. 
 
 Case XXXVII. John Steven, a sailor, aged sixty-four, 
 admitted to Ward V. (from the Clinical Wards) on 24th July 
 1875, complaining of cough, shortness of breath, palpitation, 
 brawny swelling of the legs, and some ascites. He admitted 
 having been a hard drinker. The cardiac action was rapid, 
 irregular, and intermittent. The apex beat was quite distinct 
 though not forcible, and was felt outside of and below its 
 normal position. The sounds at the base of the heart were 
 obscured by bronchitic rhonchi, but no murmur could be 
 distinguished. The first sound in the mitral area was impure 
 but without murmur; a murmur of tricuspid regurgitation 
 was, however, occasionally to be heard. The patient's liver 
 was not enlarged, but he had a trace of albumin in his urine, 
 which three weeks before his death became considerably 
 increased. His sputa were rusty for a week before his death. 
 This patient was regarded as suffering from a weak, dilated, 
 and probably fatty heart; the latter part of the diagnosis 
 being not based upon any physical sign, or upon any symptom, 
 but mainly upon the patient's previous drunken habits. 
 
 ^ "Die einfaclie Erfahrung, dass man in vielen Fallen von Herzdilatationen 
 mit starker Unregelmassigkeit des Pulses bei der Section oft nur ein geringe 
 oder gar keine Fettmetamorphose findet, wahrend schwere Verfettung der 
 Muskelatur ohne alle Symptome von Seiten des Herzens verlaufen konnen, 
 die Erfahrung also dass die Muskelverfettung nicht in directen Verhaltniss 
 zur Schwere der klinischen Symptome steht, zwingt uns ein besonderes 
 Krankheitsbild 'Fettherz' aufzugeben," — Fraentzel, Die idiopathische Herzver- 
 grosserung (Berlin, 1889), S. 191. 
 
368 CLINICAL LECTUEES OX 
 
 Durins the ten weeks be was under treatment in Ward Y. 
 the only relief he obtained was from large doses of digitalis ; 
 15 minims of the tincture every four hours was his 
 average dose, sometimes he got more, never less, I did not 
 see him for two weeks before his death, and at the time I 
 left there still seemed a chance of the digitalis restoring his 
 cardiac energy ; he died, however, on 5th October 1875, ap- 
 parently from asthenia, culminating in asystole (ingravescent 
 asystole). On dissection, on 7th October, the body was found 
 to be greatly anasarcous and considerably decomposed. The 
 heart weighed 24 oz., the parietal and visceral layers of the 
 pericardium were adherent throughout ; the connecting 
 lymph was recent, except posteriorly, where it was somewhat 
 fibrous. The heart was both dilated and hypertrophied ; all 
 its valves were thickened by atheroma but competent, except 
 the aortic valve, which was slightly incompetent. The cavities 
 of the heart were filled with black fluid blood. The cardiac 
 muscle was everywhere soft, friable, and easily penetrated by 
 the finger. On microscopic examination it was found to be 
 in an advanced state of fatty degeneration, the striatiou being 
 entirely lost. The lungs were firmly adherent over their 
 whole extent, intensely congested, and of a dark colour ; the 
 right weighed 5 lb. 3 oz., the left 2 lb. 4 oz. The liver was 
 fatty, congested, and weighed 3 lb. 13 oz. The spleen was 
 congested, and its capsule thickened ; it weighed 5f oz. The 
 kidneys were in an advanced state of fatty degeneration, as 
 proved by microscopic examination ; the right weighed 8 oz., 
 the left 7 oz.-^ To those who had observed the great benefit 
 this patient derived from the use of digitalis during his life- 
 time, and who afterwards saw the extremely fatty state of his 
 heart, nothing could more instructively show both the power 
 of the drug over any trace of muscle that remained, and also 
 the small amount of danger to which fatty hearts are exposed 
 by the administration of digitalis. Even in aged people with 
 a feeble impulse and a tendency to syncope, in whom fatty 
 
 ^ Extracted from the Pathological Records of the Royal Infirmary. 
 
DISEASES OF THE HEART 369 
 
 degeneration may reasonably enough be suspected, I have 
 never seen any reason to withhold digitaKs, and have hitherto 
 been rewarded for my boldness.^ 
 
 Digitalis contains three important principles, digitalin, 
 digitalein, and digitoxin. Of these, digitoxin is absolutely 
 insoluble in water, but soluble in alcohol, and more or less 
 crystallisable. It is probably the most active ingredient of the 
 crude drug ; and though regarded by some as less reliable as 
 a diuretic, and more prone to excite nausea, these results 
 are more probably due to its energy rather than to any 
 specific properties it possesses. From their tardy absorption 
 the active principles of digitalis are prone to excite local 
 inflammation when employed hypodermically, Fortunately 
 rapid action is not of much consequence in those cases in 
 which most benefit is to be expected from digitalis ; when 
 'rapid stimulation is of importance, we have other drugs to 
 employ. Where the dose of the crude drug is so small as 
 that of digitalis is, it is scarcely worth while employing 
 active principles, and it seems sufficient to make ourselves 
 acquainted with the crude drug and with its galenical pre- 
 parations. Any inquiry into the most suitable preparations 
 of digitalis and their most appropriate doses must be con- 
 ducted with due regard to the action we wish to secure, 
 and perhaps a little to our geographical position, a some- 
 what paradoxical statement, yet latitude appears to have 
 some influence on the potency of this drug. The powder 
 of digitalis, prepared from carefully dried leaves not more 
 than one year old, was regarded by Withering as the 
 most active, preparation of the drug, and he considered that 
 30 grains of the powdered leaves in bulk were about equal to 
 40 grains in infusion, and that this quantity in divided doses 
 could generally be taken before the occurrence of nausea. 
 Since the days of Blackall,^ however, the powdered leaves 
 and the infusion have been regarded as of nearly identical 
 
 1 Vide Tlie Senile Heart, p. 216. 
 
 " Observations on the Nature and Ciore of Dropsy (London, 1814), p. 312. 
 
 24 
 
370 CLINICAL LECTUKES ON 
 
 value, and the action of any preparation as reasonably calcul- 
 able from the number of grains of powdered leaves it repre- 
 sents. One grain of the crude drug, or its equivalent in one 
 or other preparation, given every twelve hours, is a purely 
 tonic dose in all but the most exceptional cases. In these 
 exceptional cases even this dose, and in all others any larger 
 dose or the same dose repeated at shorter intervals than 
 twelve hours is cumulative in its action. This is indicated, 
 after the ingestion of about 30 grains, by an abnormal lowering 
 of the pulse-rate and a reduction in the flow of urine. The 
 infusion ranks next to the leaves in usefulness and probably 
 in efficiency, and it lends itself readily to combinations with 
 vascular stimulants, which are so indispensable in certain 
 forms of cardiac disease. Half an ounce of the British 
 Pharmacopoeia infusion contains rather more than one grain 
 of the leaves, but may be accepted as the equivalent of that 
 quantity. The tincture contains about a grain in each 10 
 minims, and that therefore is the tonic dose of this prepara- 
 tion. The tincture is a very uniform preparation, acts well 
 and combines readily with other tonics, but does not com- 
 bine so well with vascular stimulants. Merck's digitalin, 
 probably mainly digitoxin, is a reliable and convenient pre- 
 paration, as is also Nativelle's, said by Brunton to be also 
 mainly digitoxin ; each of Nativelle's granules contains 
 one -quarter of a milligramme (0'003858 of a grain), and 
 they are most convenient and reliable when employed as 
 a cardiac tonic in doses of one granule once or at the 
 most twice a day. In larger doses or when given at 
 shorter intervals both Merck's and Nativelle's preparations 
 are prone to excite nausea, it is not therefore convenient to 
 employ either of them for any other purpose than as a tonic 
 to the heart. Purging is reckoned by Withering to be one of 
 the actions of digitalis ; it occasionally occurs, but whether 
 ^propter or merely 2^ost I have never been able to satisfy 
 myself; when purging does occur diuresis is always lessened 
 but not necessarily put a stop to. 
 
DISEASES OF THE HEART 371 
 
 We can, by gradually increasing the dose of digitalis, so 
 contract a dilated heart as to reduce its sounds to the toneless 
 tic-tac of an embryonic heart, but there is no object to be 
 gained by this, as this condition cannot be long maintained, 
 and the heart speedily redilates when the drug is omitted. 
 Moreover, there is probably no advantage to be gained by 
 enforced contraction of the heart; our main object is to 
 restore the elasticity and improve the energy of the myo- 
 cardium, and when this is done the heart is either restored 
 pretty much to its former condition, or any remaining dilatation 
 is fully compensated, and remains indefinitely innocuous. 
 
 In using large doses of digitalis carelessly the primary 
 slight diminution of the urinary flux and the ofttimes but 
 short-lived abnormal slowing of the pulse may be unmarked, 
 and the thumping pulse and heart -beat of commencing 
 saturation may pass unnoticed into the arhythmic pulse of 
 digitalis poisoning, a state that may, however, be soon 
 remedied by omitting the drug, keeping the patient in bed, 
 and giving stimulants moderately. At times instead of 
 irregularity we have a indsus higeminus developed (vide antea, 
 p, 274), but this seldom happens unless digitalis has been 
 given for some considerable time, and it occasionally follows 
 the use of a mere tonic dose where that has been continued 
 for a year or two. No risk seems to attend this condition, 
 and it passes off in no long time when the drug is omitted. 
 
 In digitalis we have a remedy of undoubted activity and 
 of remarkable utility in all cases of heart complaint, but like 
 every other powerful agent it has certain disadvantages, and, 
 carelessly employed, it may give rise to symptoms which are 
 always unpleasant, if but rarely dangerous. But inasmuch as 
 we can obtain from digitalis results that are not only valuable 
 but also permanent, and not to be gained by the administra- 
 tion of any other drug, it is certainly worth while to make 
 ourselves thoroughly acquainted with the use of so important 
 a drug, which has the additional advantage of being indi- 
 genous. Even when employing tonic doses it is better to 
 
372 CLINICAL LECTURES ON 
 
 have the patient under observation for a week or two before 
 finally fixing on the appropriate dose. Should there be any 
 marked idiosyncrasy, which is quite unusual, if digitalis is 
 given for other than merely tonic purposes it is better to give 
 full doses for a short period rather than smaller doses for a 
 longer time. But whatever the dose employed the desired 
 results will never be observed till a certain amount of 
 saturation has been induced. 
 
 If we take one grain every twelve or every twenty -four 
 hours as a tonic dose, then from 3 to 7 grains every four hours 
 are the extremes between which a cumulative dose may 
 oscillate, and after the ingestion of from 30 to 45 grains, that 
 is, after fifteen doses in the one case and nine in the other, 
 nausea, abnormal slowing of the pulse, or diminution of the 
 flow of urine may be expected to occur, if they have not been 
 previously observed. From one to three days subsequently, 
 in cases of dropsy, the full diuretic effect of the drug may be 
 expected, the flow of urine will rapidly rise to about 200 
 ounces in the day, and in favourable cases will continue to 
 flow till all the cavities are emptied. Occasionally the diuresis 
 requires to be maintained by the administration, at regular 
 intervals, of smaller doses. The delay of diuresis does not seem 
 to depend upon any contraction of the arterioles, at all events 
 it has not been terminated or in any way affected by repeated 
 inhalations of nitrite of amyl. It is of consequence to 
 remember this delay in the diuresis that follows the ingestion 
 of full doses of digitalis, as we are otherwise liable to ascribe 
 this belated flow to the influence of some comparatively inert 
 drug that has been administered during the interval. 
 
 The fundamental action of digitalis furnishes a suSicient 
 answer to the question as to the form of heart aflection in which 
 we are to employ it. In valvular lesions in the stage of 
 compensation, which we know is never complete, digitalis is 
 never contra-indicated, but only tonic doses are applicable, 
 and in this dose the drug will do nothing but good, however 
 long it may be continued. When compensation is ruptured 
 
DISEASES OF THE HEAET 373 
 
 — la periode asystolique-;—di\g\tdlis, is imperatively required in 
 every form of heart affection, it must be given more or less 
 freely according to tlie symptoms, and generally in cumulative 
 doses. As such doses lead sooner or later to saturation 
 they must be watched, and the drug omitted or the dose 
 reduced when symptoms of this appear. In spansemic 
 hearts digitalis is often required ; generally tonic doses suffice, 
 but when there is considerable dilatation cumulative doses 
 may be advantageous, though they are not always successful 
 in contracting the heart so perfectly as we would like. A 
 neurotic heart is always weak, and tonic doses of digitalis 
 are always useful ; after middle life such a heart is almost 
 invariably gouty (senile), and digitalis is not well borne 
 unless conjoined with some vascular stimulant. 
 
 The only other member of the digitalis group that has 
 succeeded in obtaining special recognition from practitioners 
 is Stroplianthus Hispidus, an African plant belonging, not to 
 the Scroplmdariacece, but to the Apocynacem. In its native 
 habitat it is used as an arrow poison, and it has been intro- 
 duced to our materia medica as a remedy in heart affections 
 mainly on the recommendation of Professor Eraser. Though 
 stroplianthus belongs to the same group as digitalis, it acts 
 very dissimilarly. Digitalis acts equally on all muscular 
 fibre, and only more powerfully on the heart and muscles of 
 the arterioles because these organs, owing to the conditions 
 of the circulation, receive from the blood a larger dose of the 
 drug within a given time than the other muscles (vide antea, 
 p. 359). The conditions as regards the circulation are 
 permanently similar, and if strophanthus acted on all 
 muscular fibre after the manner of digitalis, there would be 
 a similar ratio between the action of the two drugs on 
 the heart and on the arterioles, but this is not the case. 
 Strophanthus acts three tJiousand times onore poiverfidly on 
 the heart ■•• than digitalis, but it acts one hundred times less 
 
 ^ Fraser on "Strophanthus Hispidus," Transactions of the Royal Society 
 of Edinburgh, voh xxxvi. pt. 2, p. 403. 
 
374 CLINICAL LECTURES ON 
 
 'powerfully than digitalis upon the muscles of the arterioles.^ 
 There is thus no similarity whatever between the action of 
 the two drugs. From the entire absence of any appreciable 
 action by strophanthus on the arterioles, the blood flows 
 freely from the arteries into the veins, and any rise of blood- 
 pressure that may occur is due entirely to the ventricular 
 systole. The typical (therapeutically induced) strophanthus 
 heart has a prolonged diastole, during which the arteries 
 have a longer time than usual to empty themselves, and 
 as the ventricle has been filling itself during this period, its 
 systole sends an unusually large blood-wave into unusually 
 empty arteries — precisely what we have in bradycardia. 
 The momentary rise of blood-pressure passes rapidly with the 
 blood-wave down the unfilled arteries ; it does not, therefore, 
 persist so long as the ventricular systole, and is consequently 
 of shorter duration than even the third of a cardiac cycle. 
 So evanescent a rise in blood-pressure can, however, have no 
 appreciable effect either on general metabolism or upon that 
 of the myocardium. Herein the action of strophanthus 
 differs essentially from that of digitalis ; there is no tonic 
 action, no improvement of the cardiac energy,- and the power- 
 fully stimulating action of strophanthus on the heart itself 
 must tend to exhaust an already feeble myocardium. 
 
 Moreover, the action of strophanthus on the heart is two- 
 fold ; ^ in small doses it may arrest the heart in diastole, and 
 in large doses it may force it into a fatal systole. 
 
 Like all its congeners of the A2)ocynacece strophanthus is 
 a cardiac poison, and not a cardiac tonic. It forces the heart 
 into increased energy of movement without providing for 
 any corresponding improvement in its metabolism, hence the 
 heart must draw upon its reserve, and the patient is only 
 
 1 Ibid. vol. xxxvi. pt, 2, pp. 438, 453. 
 
 ^ "The results derived from strophanthus are certainly not so lasting as 
 those which follow the use of digitalis." — Binz, Lectures on Pharmacology, 
 New Syd. Soc. edition, vol. i. p. 259. 
 
 ^ Fraser on "Strophanthus Hispidus," Transactions of the Royal Society 
 of Edinburgh, vol. xxxvi. pt. 2, p. 401. 
 
DISEASES OF THE HEAKT 375 
 
 saved from dire disaster by the benefit lie derives from 
 rest, warmth, and nutritions food, — that is, by the improve- 
 ment in his environment generally. It has been claimed 
 that the absence of action on the arterioles is to be reckoned 
 to the advantage of strophanthus in those numerous cases 
 where vascular stimulants require to be conjoined with 
 digitalis to modify its action in raising the blood-pressure. 
 But these cases are precisely of that class in which before 
 all others it is of importance to improve cardiac metabolism, 
 and to employ in such cases a drug like strophanthus, which 
 stimulates and exhausts the energy of the heart without 
 improving its metabolism, must be a distinct menace to the 
 integrity of the organism. Strophanthus is thus uncertain 
 in its dose, and may be dangerous in its action, and though 
 not cumulative it may be injurious or even fatal without 
 warning, so that from this point of view there may be worse 
 things than the early indications of saturation which digitalis 
 gives us in those symptoms we are accustomed to ascribe 
 to accumulation.-^ 
 
 Nux vomica is an excellent cardiac tonic, but as its 
 utility depends upon its active principle, it is more 
 advantageous and conduces to greater accuracy of dosage 
 to employ the liquor sirychnince liyclrocliloratis rather 
 than any of the more crude preparations. Strychnine has 
 a special stimulating action on the nervous system generally, 
 hence it stimulates and renders more excitable the vaso- 
 motor centre and the cardiac ganglia, probably even 
 energising that primordial power of spontaneous movement 
 possessed by the cardiac muscular fibre itself.^ In virtue 
 
 ^ For fuller information as to the action of strophanthus I may refer to 
 Professor Eraser's papers on "Strophanthus Hispidus," in the Traiisaetions 
 of the Royal Society of Edinhurgh, vol. sxxv. pt. 4, and vol. xxxvi. pt. 2 ; 
 also to a paper by myself in the Transactions of the EcJAnlvA-gh Medico- 
 Cliirurgical Society (new series), vol. xv. p. 141, entitled "A few more Words 
 on Strophanthus." 
 
 ^ An interesting account of the action of strychnine on the heart will be 
 found in a paper by Dr. Lauder Brunton and Professor Cash at p. 229 of vol. 
 xvi. of St. Bartholomew's Hospital Ee2:)orts. 
 
376 CLINICAL LECTURES OX 
 
 of this action on the heart and nerve centres strychnine 
 increases the heart's force and raises the blood-pressure, 
 acting very much like digitalis but more on the nerve 
 centres and less upon the muscles themselves. IMoreover, 
 strychnine is an admirable tonic to the stomach, particularly 
 in those catarrhal conditions accompanied with venous 
 congestion so commonly present when the circulation is 
 feeble. In this way digestion is improved and the blood 
 enriched, so that every organ in the body, and the heart in 
 particular, gets better nourished and better fitted for the 
 discharge of its function. Strychnine is cumulative in its 
 action, so that we require to be both accurate in our 
 dosa<:re and regular in the times of administration, but with 
 strict attention to these matters it may be given continuously 
 for many years with nothing but increasing benefit. The 
 proper dose of the liquor strychnince is 5 minims (yy of a 
 grain of strychnine) every twelve hours, this for the larger 
 number of mankind is a perfectly safe dose ; now and then 
 idiosyncrasy turns up, and for it we must be prepared. 
 In anaemic patients, for example, there is occasionally an 
 intolerance of strychnine, and if employed at all it must 
 be given in almost infinitesimal doses. Only rarely can 
 more than 5 minims of the liquor be given in the twelve 
 hours, and 15 minims instead of 10 in the twenty-four 
 hours are apt to be followed in no long time by symptoms of 
 saturation. In cases of feeble hearts strychnine alone often 
 suffices, but if there is marked dilatation digitalis should 
 always be combined with it. From its action on the gastric 
 mucous membrane strychnine is specially useful in cases of 
 feeble hearts whose action is made irregular by gastric 
 reflexes, and in such cases it is of advantage to combine 
 it with arsenic, and sometimes with iron. In these cases 
 a few weeks often work wonders, but in most we may have 
 to wait for months before we reap tlie full benefit. 
 
 Arsenic is also one of our most valuable remedies in the 
 treatment of heart disease. Its effect in relieving the pain 
 
DISEASES OF THE HEART 377 
 
 of angina is occasionally marvellous ; it acts most benefici- 
 ally in those congestive conditions of stomach that so often 
 accompany a feeble circulation ; add to this that its tonic 
 influence on the lungs, heart, and blood makes breathlessness 
 a thing unknown to the Styrian mountaineer, and we can 
 readily understand the good we may obtain from this 
 valuable drug. It is not so easy to explain how these 
 benefits are obtained, the use of arsenic is quite empirical; 
 like Trousseau we recognise that the patient has an 
 increased capacity for exercise, but we cannot explain it.^ 
 "I do not know what benefit you expected from the 
 treatment, but I know what I have received ; I can go 
 upstairs better than for many years, my breathing is 
 easier, and my heart steadier." The old gentleman who 
 made this remark was so sensitive to the action of arsenic 
 that he could not bear it in larger dose than one milligramme 
 of arsenious acid in the day (0"015 gr.) ; two milligrammes 
 gave him discomfort, one was well borne. Arsenic combines 
 well with digitalis and with strychnine, and the threefold 
 combination is one of our most useful tonics. In sensitive 
 patients one granule of arsenious acid containing -—^ or 
 y\-q of a grain may be given once or twice a day for 
 months or years with only increasing benefit. In com- 
 bining arsenic with digitalis or with strychnine it is better 
 to employ a fluid preparation, and the best is the liquor 
 arsenici liyclrochloricus, this is not only more active but in 
 the case of combination with the liquor strychnince it is 
 the only preparation that does not make an incompatible 
 and more or less unsightly mixture. Arsenic is a poison 
 to which the system may be gradually habituated, so that 
 even large doses may be taken for years not only with 
 impunity but with positive benefit.^ In those moderate 
 
 ■^ " J'insiste sur ce phenomene eprouve egalement par M. Masselot, et 
 signale par lui en ces termes : ' tres grande aptitude a la marche.' " — TraiU 
 de Thirapeutique, par A. Trousseau et H. Pidoux, vol. i. p. 312. 
 
 2 "On the Arsenic-eaters of Styria," by Dr. R. Craig Maclagan in the 
 Udinbiirgh Medical Journal (September 1864), p. 200, etc. 
 
378 CLINICAL LECTURES ON 
 
 doses in which it is given medicinally we need have no 
 misgivings, however long it is continued, A little caution 
 may be well employed in commencing the use of arsenic, 
 because idiosyncrasy has a marked influence in regard to 
 the use of this drug, and now and then we come across one 
 who is extra-sensitive to its action. But there is not, as was 
 at one time alleged, either risk or danger in leaving it off 
 entirely, however long it may have been continued. 
 
 Arsenic and a bitter tonic increase the leucocytes and 
 the number of the red corpuscles, but iron is wanted to 
 supply haemoglobin. For this purpose the protosalts seem 
 to be the least disturbing to the stomach and the most 
 easily assimilable, but in regard to this I would not be 
 dogmatic, only it must ever be remembered that iron in com- 
 bination with digitalis is extremely apt to induce sickness ; 
 it is, therefore, always best to give iron along with food, and 
 digitalis at some other time. 
 
 In all senile hearts, and in others wdiere the blood- 
 pressure is high, vascular stimulants require to be combined 
 with our cardiac tonics to avert mischief to the heart from 
 the embarrassment due to an increase in the blood-pressure. 
 Vascular stimulants are agents which dilate the arterioles, 
 or at all events prevent their undue contraction, and thus 
 keep the blood-pressure throughout the whole cardiac cycle 
 at a uniform level, sufficient for the needs of metabolism 
 and yet moderate enough to cause no embarrassment to the 
 heart. All the nitrites are vascular stimulants, nitrite of 
 sodium and spirit of nitrous ether are often used as such, 
 but the action of the former seems not always to be safe, 
 while that of the latter is slow and not very powerful. 
 Nitrite of amyl is rapid in its action and is also analgesic, 
 but it is not very lasting, the smell is disagreeable, and 
 the flushing of the face, the fulness in the head, and the 
 rapid action of the heart are much disliked by many 
 patients. It is a little strange that though vascular stimula- 
 tion is an action common to all nitrites, yet neither of the 
 
DISEASES OF THE HEART 379 
 
 two drugs that are most useful in this respect and most 
 convenient to employ belong to this category. Nitro- 
 glycerine, glonoine or trinitrin, is said to be a nitrate of 
 glyceril, but its action is that of a nitrite. In ordinary doses 
 of — \-^ or -rV of a grain it is much used to relieve the heart 
 
 10 5 <-' 
 
 in angina by lowering the blood-pressure, but it is also often 
 employed to keep the blood-pressure moderate during the 
 use of cardiac stimulants. For this purpose it is not advis- 
 able to combine it with the cardiac stimulant, but rather to 
 give the glonoine in sufficient dose by itself at regular 
 intervals. The action of nitro-glycerine persists from one to 
 four hours according to the dose, so that by giving a moder- 
 ate dose every three or four hours the blood-pressure may be 
 kept moderate and anginous attacks prevented. A 1 per 
 cent solution acts very rapidly, and the dose is from one-half 
 minim up to as much as ten or more minims. As tabellse 
 or lozenges, each containing ^ ^ ^ or -^ of a grain, it is more 
 easily carried about and acts nearly as rapidly if well and 
 quickly chewed. The drawbacks to nitro-glycerine are its 
 liability to produce headache, giddiness, throbbing of the 
 cerebral arteries, and palpitation of the heart, but it is 
 remarkable how seldom these are complained of. 
 
 Erythrol tetranitrate, in tablets each containing one 
 quarter of a grain, has been highly commended as a valuable 
 vascular stimulant by Professor Bradbury and others. It is 
 said to be more active and more permanent in its action 
 than trinitrin, but is apt to produce both palpitation and 
 headache. When more permanent action is required I prefer 
 iodide of potassium, which acts as a nitrite and has the double 
 advantage of being persistent and yet not too powerful. 
 A couple of grains every twelve hours is quite an efficient 
 dose, and acts admirably, more is not required for this 
 purpose, and rarely less. The only drawback to the use of 
 this drug is the gastric disturbance that it sometimes 
 occasions, and then we have to fall back upon nitro-glycerine. 
 
 I need scarcely say that in syphilitic affections of the 
 
380 CLINICAL LECTURES ON 
 
 heart iodide of potassium is our sheet-anchor, though indeed 
 a combination with perchloride of mercury in the form of the 
 soluble red iodide of mercury acts sometimes even better. 
 Potassium iodide is also extremely useful in the treatment of 
 aneurysm, but that matter I shall go fully into presently. 
 Colchicum is often of the greatest service in gouty irregularity ; 
 the powder of the seeds combines well with powdered 
 digitalis leaves, and in moderate doses both may be continued 
 for a long time with great benefit. In such cases the alkalis- 
 ing of the iwimw vice has an excellent effect, and for this 
 there is nothing better than a tumblerful of Vichy water 
 (source Celestins) one hour before each meal. A heaped 
 teaspoonful of bicarbonate of potash or of soda in a small 
 tumblerful of water acts equally well, and this thorough 
 alkalising of the 2'>t"^^ncc vice often relieves irregularity in a 
 most satisfactory manner, though it has seemed to me as if 
 this medication favoured the formation of Heberden's knobs 
 upon the digits. 
 
 An active purge, especially a cholagogue purge, is an 
 excellent thing to lower the blood-pressure, and a cholagogue, 
 by acting on the hepatic secretion, directly relieves the right 
 side of the heart. -^ 
 
 Flatulence is often a disturbing element, being a frequent 
 cause of irregularity or of tremor cordis in senile hearts, 
 regulating the diet and the administration of the old-fashioned 
 cobbler's pill — the jnhda cissafcetidcc co. of the B. Ph. — have 
 an excellent effect.^ 
 
 When severe pain is a prominent sympton there is no 
 remedy equal to a hypodermic injection of morphine, preceded 
 if need be by inhalation of chloroform, but for ordinary 
 insomnia morphine is not a very suitable remedy, from the 
 readiness with which the morphine habit is induced in some 
 people. For ordinary use cJdoralamid in forty-grain doses 
 
 ' Lauder Brunton, Disorders of Digestion (Macinillan and Co., London, 
 1886), p. 208. 
 
 2 Vide The Senile Heart, p. 280. 
 
DISEASES OF THE HEAET 381 
 
 rubbed up with spirit and flavoured ^vitb raspberry syrup 
 answers very well. Cliloralalose in doses of eigbt grains in 
 cacbet bas tbis advantage tbat it acts quickly and induces 
 refresbing sleep ; it sligbtly lowers tbe blood-pressure witb- 
 out exciting the heart, and produces neither headache nor 
 gastric disturbance ; it is an ideal hypnotic for a cardiac 
 patient. Unfortunately it has this disadvantage, that in 
 nei'vous subjects it often induces exciting dreams and some- 
 times muscular tremors. The best way to give it is to give 
 four grains in cachet at bed-time, this may suffice to give the 
 patient a good night, but should he wake after an hour or 
 two of sleep a repetition of the four-grain dose will secure 
 a good night's rest. Trional has been very successful in my 
 hands, I know of no drawback to its use. From fifteen to 
 thirty grains at bed-time is sufficient to ensure a good night. 
 These are the best and most reliable hypnotics in cardiac 
 disease, sulphonal is too depressing and is so apt to postpone 
 its action that it is not so suitable for such cases, thouo-h 
 faute de mieux it sometimes acts very well in doses of five 
 grains early in the evening and another five at bed-time. 
 FaraldeJiyde is an excellent hypnotic and may be freely given 
 in cases of heart complaint, the great drawback to it is its 
 horrible taste and smell, so objectionable not to the patient 
 only but to his relatives also. The Irroniides are not true 
 hypnotics, merely sedatives, they are invaluable in severe and 
 continuous palpitation of nervous origin, and by relieving 
 symptoms they frequently induce sleep, but except in very 
 large doses they do not act as hypnotics and cannot be 
 trusted to. 
 
 The diet in cardiac disease is easily arranged, at least in 
 its generalities. Those troubled with heart affections have 
 always feeble digestion, partly from the gastric venous 
 congestion present, and partly from a gastric juice defective 
 both in quantity and quality, hence we must restrict the 
 quantity of food, see that the gastric juice is not fiirtber 
 impaired in quahty by dilution, and lastly we must secure a 
 
382 CLINICAL LECTURES OX 
 
 sufficient interval between each meal. In health the stomach 
 requires from three to four hours to complete the digestion, 
 and it needs an hour's rest before it takes in a further supply. 
 In all with feeble circulation digestion is slower than in 
 health, we must therefore allow fully four hours for digestion 
 and one hour for rest, making the interval between one meal 
 and its successor not less than five hours. During tlie period 
 of digestion no solids must be ingested, as the introduction 
 of even the smallest bit of biscuit under these circumstances 
 arrests digestion and is a common cause of flatulence. It is 
 also of consequence that those with feeble or diseased hearts 
 should have their principal meal in the middle of the day, 
 and that all their meals should be as dry as possible ; when 
 thirst is complained of hot water — a most excellent cardiac 
 stimulant — may be taken to the extent of a pint one hour 
 before each meal. These are the general rules upon which 
 we must act, but each particular patient must be catered for 
 by himself, and it is impossible to lay down one hard and fast 
 dietary applicable to all.^ 
 
 Considering the difficulty most cardiac patients have in 
 making the slightest exertion, it seems almost superfluous to 
 insist upon the necessity of rest, yet this is a matter of 
 paramount importance only too apt to be neglected by the 
 patient himself, whose days are often brought to an untimely 
 end by ill-judged and injurious exertion. Whenever we 
 have to do with an uncompensated or imperfectly compen- 
 sated valvular lesion, whenever, in short, the myocardium is 
 from any cause debilitated, rest is imperatively indicated. 
 The heart does not differ from other muscles which require 
 rest when suffering from exhaustion,^ you must therefore 
 never forget to insist upon rest as an important part of 
 the treatment, rest which must be more perfect and complete 
 
 ^ A more detailed statement as to diet, chiefly as applicable to one form 
 of heart affection, will be found at p. 236 and following pages of the Senile 
 Heart. 
 
 ^ Lauder Brunton, Lectures on the Action of Medicines (London, 1897), 
 p. 304. 
 
DISEASES OF THE HEAET 383 
 
 the more serious the cardiac disturbance is. Eest in the 
 recumbent posture means a reduction in the pulse-rate by 
 an average of 12 (6-16) beats per minute, and in weakly ill- 
 fed patients the reduction is sometimes greater. This lowering 
 of the pulse-rate amounts cumulatively to an increase of rest 
 to the heart of over two hours in the twenty-four, and we 
 can readily understand that this increased rest, coupled with 
 warmth and better feeding, is of itself sufficient to give such 
 a fillip to the general metabolism as enables the heart to 
 recover its tone and to discharge its function more perfectly. 
 The blood-pressure rises, the balance of the circulation as 
 between arteries and veins is restored, dropsy disappears, and 
 the patient is re-established in comparative health by the aid 
 of rest alone coupled with a favourable change in his 
 environment. But though for his heart's sake we keep our 
 patient recumbent and at rest, we do not let his muscles 
 waste, we prevent this by massage, which is of itself both a 
 help to the circulation and an aid to general metabolism.-^ 
 But cardiac patients are not to be confined to bed or to a 
 Bath chair for the natural term of their life. We have 
 constant opportunities of seeing that well compensated 
 cardiac disease is not incompatible with even strenuous 
 exertions. And we have also frequent opportunities of 
 observing that after rest and appropriate treatment have 
 improved the heart's nutrition and energy, and compensation 
 has been restored, the patient re-acquires considerable 
 aptitude for exertion. And as, if metabolism be perfect, 
 every organ improves by the exercise of its function, so also 
 a weak, feeble heart, or even a heart affected with a com- 
 pensated valvular lesion may be much benefited by moderate 
 and regulated bodily exertion. This is a doctrine first 
 
 ^ "Over all Polynesia, and a part of Micronesia, the rule holds good ; the 
 great ones of the isle, and even of the village, are greater of bone and muscle, 
 and often heavier of flesh, than any commoner. The usual explanation — that 
 the high-born child is more industriously shampooed— is probably the true one. 
 In New Caledonia, at least, where the difference does not exist or has never 
 been remarked, the practice of shampooing seems to be itself unknown." — R. 
 L. Stevenson, In the South Seas : Travels and Excursions, vol. iii, p. 81. 
 
384 CLINICAL LECTUKES ON 
 
 enunciated by Stokes, who recommended graduated exercises 
 in the treatment of those weak hearts which he thought to 
 be fatty.^ If we are to believe a personal reminiscence of 
 von Ziemssen, Stokes even went so far as to compel a sufferer 
 from aortic incompetence to run behind his own carriage, a 
 proceeding which none of us are likely to imitate.^ Thus 
 you see that though rest is an important therapeutic agent, 
 yet there comes a time when exercise is not only not to 
 be debarred, but may be made a most useful adjunct to 
 other treatment. Each case, however, must be differentiated 
 and treated on its own merits, and to propound graduated 
 exercises, with or without any form of baths, as a panacea 
 for all forms of heart affection is to court certain disaster. 
 The neat little diagrams we so often see propounded as 
 proofs of the diminution in size of a dilated heart after a 
 bath are most delusive. The heart is so mobile an organ, 
 and varies so incessantly in size {note, p. 17), that any 
 attempt to define its degree of dilatation by percussion alone, 
 auscultatory or otherwise, cannot but be entirely untrust- 
 worthy. 
 
 When considerable dropsy is present it may be removed 
 by the kidneys, by the bowels, or by tapping. In cardiac 
 dropsy digitalis is a most efficient remedy properly employed ; 
 various combinations with squill, with mercury, or other 
 drugs have been used, but digitalis alone is quite sufficient. 
 Purgatives are trusted to by some, and the electuary of the 
 bitartrate of potass is an excellent adjunct to digitalis, or it 
 may be trusted to alone ; others prefer more drastic purges, 
 such as croton-oil, or elaterium, or a combination of both in 
 moderate doses given every four hours till free catharsis is 
 induced. When the limbs from anasarca are firm and tense, 
 either purgatives or drainage must first be resorted to, to 
 remove the peripheral obstruction that hinders the action of 
 
 ^ Diseases of the Heart and Aorta (Dublin, 1854), p. 357. 
 ^ Verhandlungen des Congresses filr innere Medicin (Wiesbaden, 1888), 
 S. 55. 
 
DISEASES OF THE HEART 385 
 
 digitalis/ as Withering pointed out more than a hundred 
 years ago (1775). Caffeeine has been highly commended as 
 a diuretic ; it is occasionally useful but cannot be depended 
 upon. On the other hand, in diuretin (sodic-theobromin- 
 sodio-salicylate) we have a powerful diuretic which in doses 
 of 15 grains every three or four hours is hardly known to 
 fail ; it is best given dissolved in hot water and allowed to 
 cool. The single dose is 15 grs., the maximum quantity in 
 one day should never exceed 120 grs., it need seldom amount 
 to so much. 
 
 Occasionally, however, it is desirable to relieve the patient 
 rapidly and certainly, and this is most effectually done by 
 drainage. The fluid in an uncomplicated heart case is pure 
 serum and does not irritate the skin like that effused in 
 kidney cases, we need not therefore hesitate to make suffi- 
 ciently free incisions to let the fluid escape. In this way 
 drainage proceeds rapidly, and the wounds if kept aseptic 
 heal quickly. Southey's tubes keep the bedding dry, but 
 that can be otherwise provided for. From the small calibre 
 of these tubes drainage is slow, and if they are used it is 
 well to have a larger size of tubing attached to the cannula 
 than is ordinarily supplied. 
 
 ^ Vide antea, p. 366. 
 
 25 
 
LECTUKE XV 
 
 ox THE SIMULATION OF ANEURYSM BY MALPOSITION OF THE 
 AORTA, DUE TO RICKETS 
 
 Some years ago a young man presented himself to me, 
 statins that he had been under treatment for about six 
 months for supposed aneurysm of the aorta, and was 
 desirous of having my opinion as to his present state and 
 future prospects. Upon stripping this patient, inspection 
 at once revealed that he had an abnormal pulsation between 
 the second and third ribs on the right side, extending for 
 about three-quarters of an mch to the right of the sternum. 
 It was also evident that he had a slight scoliosis (lateral 
 curvature) of his spinal column. Upon palpation the chest 
 was felt to expand a little more freely on the right than on 
 the left side ; the abnormal pulsation was felt to be distinctly 
 fluid in character, synchronous with the apex beat, and not 
 more forcible. Upon mensuration at the level of the fourth 
 rib, the right side of the chest was found to measure a full 
 inch more than the left; at full expansion the right side 
 measured fourteen inches and a half, and the left thirteen 
 inches and a half. Percussion of the chest revealed nothing 
 unusual except slight dulness over the abnormal pulsation to 
 the right of the sternum, a dulness that was strictly limited 
 to the pulsation and did not extend beyond it. Auscultation 
 also revealed nothing unusual ; the cardiac and pulmonary 
 sounds were perfectly normal. Over the abnormal pulsation 
 nothing was to be heard but the sounds normally heard over 
 the aortic area. Moreover, there was an entire absence of 
 
CLINICAL LECTURES ON DISEASES OF THE HEART 387 
 
 any signs of abnormal pressure, or even of any symptom of 
 such a thing. The young man was in perfect health, of fair 
 physical development, and he had felt quite equal to any 
 exertion up to the time when he was put under treatment. 
 From a due consideration of all the facts ehcited on examina- 
 tion, and thus cursorily narrated, I had no difficulty in 
 assuring the young man — he was no patient — that he had no 
 aneurysm, that he was in perfect health, fit for any occupation, 
 and only the subject of a trifling malformation. I need not 
 say how thankful and pleased he was. A year subsequently 
 he was passed into the army. When I last saw him his 
 chest had considerably developed, and though the relative 
 size of the two sides of the chest remain identical (right 18, 
 left 17), yet the artery was better covered, and the abnormal 
 pulsation was no longer to be felt. 
 
 This case is not unique; there are many such. Very 
 possibly there may have been some similar cases whose lives 
 have been embittered, and whose friends have been made 
 unnecessarily anxious by an unguarded prognosis ; and to 
 enable you to avoid this error is the object of the present 
 lecture. Hitherto these arterial malpositions have been — 
 from a physician's point of view — entirely overlooked.-^ From 
 an anatomico-pathological point of view, such cases have, 
 however, been long well known, and Morgagni,^ Watzel,^ 
 Vrolik,* Otto,^ Tiedemann,^ and others have recorded many 
 interesting cases. More recently the whole subject has been 
 
 ^ The earliest reference to the diagnostic importance of aortic malposition, 
 so far as I know, is contained in a short paper by myself in the Edinhurgh 
 Medical Journal, February 1871, entitled " Cases illustrative of some Diffi- 
 culties in the Diagnosis of Aneurysm close to the Heart," at p. 707. 
 
 2 De Sedihus et Causis Morhorum, Ebroduni in Helvetia (1779), 4. 
 
 ^ De efficacia Gibhositatis in Mutandis Vasorwni Dircctionibus, Trajecti 
 ad Viadrum (1778). 
 
 ■* Dissertatio de Mutato Vasorum Sangidferorum Decursu in Scoliosi et 
 CyiJhosi (Amstelodami, 1823). 
 
 5 LehrbucJi der pathologischen Anatomic (1830). 
 
 ^ Supplementa ad Tabulas Arteriorum Corporis Hioinani (Heidelburgse, 
 1846). Hartmann, Cheselden, Ludwig, and Wenzel have also described these 
 alterations in the course of the vessels, from a pathological point of view. 
 
388 
 
 CLINICAL LECTUEES ON 
 
 gone over from a similar point of view by Dr. Barkow, Pro- 
 fessor of Anatomy at Breslau, who has figured numerous 
 examples of this interesting peculiarity.-^ One of the most 
 remarkable of these is contained in the fourth plate of his 
 earlier work. The accompanying woodcut is reduced from 
 this figure; in it the ascending aorta is seen to reach the 
 surface of the chest between the third and fourth, and the 
 second and third ribs on the right side ; while the descending 
 
 Fio. 31. 
 
 aorta gets to the surface between the second and third ribs 
 on the left side, the convexity of the scoliosis being to the 
 left. 
 
 In the case of the young man just narrated, the scoliosis 
 was so slight, that in all probability the abnormal exposure 
 
 1 Die Verkrummungen der Gefdsse dargestellt, von H. C. L. Barkow, M.D., 
 etc., Fol. (Breslau, 1869), and Eridutertmgcn zurLeh7-evon den Enveitenmgen 
 mid Verkrummungen der Gefdsse, vou H, C. L. Barkow, M.D., etc., fol. 
 (Breslau, 1871). 
 
DISEASES OF THE HEAKT 389 
 
 of the vessel was due to some slight malposition of the aorta, 
 rather than to any deflection of that vessel caused by the 
 trifling curvature of the spine that existed. This, however, 
 rather enhances the importance of the case from a diagnostic 
 point of view. For while it is of consequence to remember 
 that in rickety chests the aorta may be so deflected, without 
 any marked dilatation, as to make its pulsation visible either 
 to the right or left of the sternum, and so to simulate an 
 aneurysm, it is of even greater consequence to have proof 
 that in certain comparatively rare cases a similar abnormal 
 pulsation may be due to a trifling divergence from the normal 
 course of the vessel itself, apart from any marked change in 
 the bony skeleton. But we must never forget that aortic 
 aneurysm may coexist with malformation of the thorax, with 
 or without scoliosis ; and whatever may be the condition of 
 the skeleton, any abnormal pulsation must be carefully con- 
 sidered from every point of view, before we are able to give 
 any definite opinion as to what it really is. For the art of 
 diagnosis is based upon an estimate of probabilities, and its 
 approximate accuracy depends, first, upon the accuracy with 
 which we make our preliminary observations, and, second, 
 upon the intelligence and capacity employed in our reason- 
 ings regarding these observations. For example, any cursory 
 observer who had seen, but not duly considered, the case just 
 narrated, and who shortly afterwards was brought face to 
 face with the woman Murray, now in Bed 15, Ward XIII., 
 would probably feel little hesitation — might even plume 
 himself on his sagacity — in placing both in the same category; 
 and yet he. would thereby commit a most egregious blunder. 
 It is true that Murray has an abnormal pulsation between 
 the second and third, and the third and fourth ribs on the 
 right side close to the sternum. Her left chest also measures 
 a full inch less in circumference than the right one. She 
 has no scoliosis, but in the young man this was so slight as 
 to be unimportant, and in either case the diagnosis turns 
 entirely upon quite other points, to which I shall presently 
 
390 CLINICAL LECTUEES ON 
 
 direct your attention. I shall first relate to you the histories 
 of two extremely interesting cases, in which aortic aneurysm 
 was closely simulated by vascular deformity depending upon 
 rickety malformation of the thorax. Having already pointed 
 out those negative signs which determine the diagnosis in 
 the case first referred to, I shall conclude this chapter with 
 a cursory indication of those positive signs upon which we 
 rely for the diagnosis of aortic aneurysm. A due considera- 
 tion of these signs enabled us to arrive at a very different 
 conclusion in regard to the case of the woman Murray.^ 
 
 Case XXXVIII. G. S., a shoemaker, aged thirty-five, 
 admitted to Ward V. on 5th December 1870, complaining 
 of breathlessness, cough, spit, and occasional haemoptysis. 
 Wlien about sixteen years of age, while acting as a cattle 
 herd, he was occasionally troubled with pains in his shoulders. 
 But he has neither had rheumatism nor any other disease 
 since that time, with the exception of a slight attack of ague 
 (in Iowa, U.S.A.) about two years ago. When eighteen years 
 of age he suffered from loss of appetite, and occasional attacks 
 of squeamishness and faintness. At this time he had been 
 about two years engaged at shoemaking ; he was well fed, and 
 was able to remain at work, but just at this time his thorax 
 became gradually deformed. 
 
 On admission his spinal column was found to have a 
 double lateral curvature — the thoracic curve being to the 
 right, and the compensatory dorso-lumbar curve to the left — 
 while the lower dorsal and lumbar vertebrae were so twisted 
 that their transverse processes lay somewhat diagonally. 
 The ribs were broad and flat, the upper ones apparently 
 wider apart than usual, while those below the sixth were 
 crowded together. The anterior part of the thorax was so 
 altered that the right side was round and prominent, while 
 the left was flattened and compressed. The lower part of 
 
 ■■ This patient subsequently died, and her aneurysm was exhibited at the 
 Edinburgh Medico-Chirurgical Society, on 3rd May 1876, vide Edinhunjli 
 Medical Jmirmd, June 1876, p. 1141. 
 
DISEASES OF THE HEAET 391 
 
 the sternum was concave, as is usually the case in cobblers. 
 Both feet were twisted outwards, but they were said to have 
 been so from infancy. 
 
 About a year previous to admission, he began to have, at 
 times, a severe pain across the front of his chest below the 
 mammse. This pain came on while stoopmg over his work, 
 but also when otherwise engaged, occasionally even when in 
 bed, and this it did sometimes for two weeks at a stretch, 
 compelling him continually to shift his position, and even to 
 get out of bed. He did not think that any change of posture 
 gave relief. This pain came on suddenly, was not accom- 
 panied by any breathlessness, and it usually went away quite 
 as suddenly as it came ; he attributed it to the pressure of 
 the boot or last on his breast, necessary in his trade. 
 
 About six months previous to admission, this patient 
 first began to have shortness of breath, at first only felt on 
 making any sudden movement, such as raising himseK quickly 
 from a stooping posture ; but it speedily came to follow any 
 exertion, however slowly made, especially such as ascending 
 a hill, etc. During the summer of 1870 he had considerable 
 cough, and in August of that year, when bathing, he brought 
 up some blood mixed with the sputa ; this trifling haemo- 
 ptysis lasted only one day. But his cough got worse, and six 
 weeks later his haemoptysis recurred and lasted for three or 
 four days. About one month before admission he had a 
 third attack of haemoptysis, which lasted for three weeks. 
 
 On inspection of the thorax, the points already indicated 
 were seen, and considerable heaving of the praecordial region 
 was also noted, the spaces between the fourth and fifth, and 
 fifth and sixth ribs being retracted at each diastole. Between 
 the fifth and sixth ribs lay the lowest point of cardiac pulsation 
 to be seen or felt ; beneath this the ribs closed up, they almost 
 overlapped each other, and extended down into the pelvis. 
 The cardiac pulsation referred to was, however, no apex beat, 
 but a broad impulse extending over a space of two inches 
 and a half The large arteries at the root of the neck pulsated 
 
392 CLINICAL LECTURES ON 
 
 visibly with great force, and a thrill was felt with each 
 pulsation. On laying the hand across the upper part of the 
 chest considerable thrill was felt, chiefly towards the right 
 edge of the sternum and over its upper part. On placing 
 the finger in the tracheal fossa, the aorta was felt pulsating 
 within half an inch of the upper edge of the manubrium. 
 Between the second and third ribs, on the right side, a 
 pulsating tumour was felt extending for about an inch to the 
 right of the sternum. 
 
 On percussion on the left side, one inch from the sternum, 
 the note was clear down to the upper edge of the fourth rib ; 
 beneath this there was dulness to the upper edge of the 
 sixth rib, and beneath this only the tympanitic note of the 
 stomach was to be heard. In the nipple line (level of the 
 fourth rib) dulness commenced about one inch to the right 
 of the sternum, and extended to the left for a distance of 
 four inches and three-quarters. Along the right side of the 
 sternum, dulness extended from the upper edge of the second 
 rib down to the liver dulness for a distance of one inch to 
 the right of the sternum. 
 
 On auscultating over the lowest perceptible part of the 
 cardiac impulse, the first sound was heard somewhat muffled, 
 and the second was replaced by a murmur. Between the 
 second and third ribs at the right edge of the sternum, a 
 loud rough murmur wholly replaced the first sound, and a 
 soft blowing murmur completely occupied the time of the 
 second sound. Both of these murmurs were loud and harsh 
 over the pulsating tumour already referred to, and they were 
 softer in character, though equally distinct, on auscultating 
 over the sternum. These murmurs were propagated into the 
 arteries in the neck, and across the sternum to the left. The 
 pulmonary second was distinctly audible just over the left 
 edge of the sternum close to the second interspace ; within 
 that space this second sound was only faintly to be heard 
 quite close to the sternum. 
 
 The patient's pulse was 86, full and jerking ; it was also 
 
DISEASES OF THE HEAET 393 
 
 delayed, the radial beat coming just between two cardiac 
 impulses and as nearly as possible equidistant from both. 
 On admission his cough was nearly gone, but he still had 
 a slight amount of purely catarrhal expectoration. The 
 other phenomena were unimportant — either natural, or with- 
 out bearing on the case. 
 
 In this case the whole of the urgent symptoms and signs 
 were those of incompetence of the aortic valves, a somewhat 
 rare occurrence in a case presenting so many indications of 
 a sacculated aneurysm just above the valves. For when the 
 disease has originally been a sacculated aneurysm of the 
 aorta the heart is rarely much implicated, even after incom- 
 petence of the aortic valve has been superadded. Further, 
 the signs present — especially the shght amoimt of dulness to 
 the left of the sternum, the great amount of dulness to 
 the right of that bone, and particularly the fact that the 
 pulmonary second was scarcely audible at all to the left of 
 the sternum, and was only to be heard distinctly after the 
 stethoscope had been placed upon that bone — all pointed to 
 the great probability that the heart had been slightly dis- 
 located to the right. This idea, if correct, would sufficiently 
 explain the appearance of a pulsating tumour between the 
 second and third ribs on the right side, and extending not 
 more than one inch from the rio-ht margm of the sternum, 
 as this is the precise position that would be occupied by the 
 aorta in such a case. The probabihty that the pulsating 
 tumour was of this character w^as further increased by the 
 discovery, from the augmented dulness across the upper part 
 of the sternum and from the pulsation in the tracheal fossa, 
 that the transverse portion of the aorta was dilated ; because 
 all experience teaches us that in a case of aortic incompetence 
 with a dilated transverse portion, dilatation of the ascending 
 part of the aorta is almost certain to coexist. But any dis- 
 location of the heart to the right would suffice to push even 
 a normal aorta from under cover of the sternum, and still 
 more, therefore, one wliich is dilated. Moreover, the slight 
 
394 CLINICAL LECTURES OX 
 
 increase in loudness of the abnormal murmurs, in this case, 
 as heard over the pulsating tumour, was no greater than was 
 to be expected from the closer proximity to the ear of this 
 pulsation, as compared with an artery lying beneath tlie 
 sternum, and had none of that marked accentuation which 
 these murmurs gain when heard over the sac of an aneurysm. 
 Pressure symptoms were also entirely wanting. The lung 
 on lioth sides was displaced, and to this was due the diastolic 
 dimpling of the fourth and fifth interspaces on the left side ; 
 and the greater loudness and roughness of the murmurs over 
 the tumour than over the sternum was undoubtedly due to 
 the contiguity of the aorta to the chest wall. 
 
 The sHght displacement of the heart was evidently due 
 to the deformed condition of the chest produced by rickets. 
 The base of the heart was more displaced than its apex, as 
 if the enlarged heart, resting on the cUaphragm in this de- 
 formed and stunted body, leaned somewhat forwards and to 
 the right into the bulcring ricrht half of the thorax : and this 
 I have no doubt it did. 
 
 This patient died on 1st January 1871 from acute oedema 
 of the lungs. A proper examination of the body was refused 
 by the friends, but I was enabled to ascertain satisfactorily 
 that the aorta was dilated and displaced to the right, as 
 already indicated, and that no sacculated aneurysm was 
 connected with it. 
 
 There can be no doubt that the cardiac disease, in this 
 case, was primarily due to the obstruction opposed to the 
 circulation by the sinuosity of the arterial trunks caused by 
 the distortion of the skeleton. And we scarcely need the 
 experience and assurance of Barkow to convince us that 
 obstruction of this character has, and must have, an un- 
 mistakable influence in promoting dilatation and hyper- 
 trophy of the heart.^ The larger blood-wave and the increased 
 energy of the heart have a special influence in producing 
 dilatation of the aorta, especially of its ascending portion," 
 ^ Die Verkrummungen der Gefassc, S. 15. - Op. cit. S. 35. 
 
DISEASES OF THE HEAET 395 
 
 an influence which, as we can readily understand, may be 
 very considerably modified by the structural condition of the 
 aorta itself.-^ When once dilatation of the ascending aorta 
 is produced, the secondary development of incompetence of 
 the aortic valve is merely a question of time. 
 
 The case now to be narrated was repeatedly under 
 observation, and was always an object of great interest. 
 
 Case XXXIX. M. P., a milliner, unmarried, aged forty- 
 six, admitted to Ward XIII. on 26th January 1871, com- 
 plaining of cough, feeling of oppression over the trachea, and 
 of general debility. Patient had been a milliner for thirty- 
 three years, working during the busy season from 6 a.m. of 
 one morning to 1 a.m. of the next. As the result of this 
 overwork she was never strong, and never free from head- 
 ache ; still she could take her food well, and was able to 
 continue at work. About sixteen years before admission, 
 she first noticed that her right shoulder was somewhat dis- 
 torted and her body also somewhat twisted. Since that time 
 this distortion has slowly increased, but the change has been 
 gradual, and she has suffered from no illness more severe 
 than a casual and temporary catarrh, till seven years ago, 
 when a cough then acquired became chronic, and has never 
 entirely left her. When this cough fh'st affected her, she 
 was neither ill nor feverish and was unconscious of having 
 caught cold. Two years subsequently this persistent cough 
 was aggravated by an attack of bronchitis, which lasted five 
 weeks, and broke down her health very much. Since that 
 time her distortion has steadily increased ; and about four 
 years ago her bodily distortion and weakness became so great 
 that she had to give up her occupation. Since then she has 
 been constantly subject to a dull, aching pain, referred to 
 the right shoulder-blade, the intensity of which has gradually 
 increased. She has also been subject to pain in the region 
 of the stomach, more or less constant, but worse when the 
 stomach is empty, and somewhat relieved by taking food. 
 1 Op. cit. S. 15. 
 
39G CLINICAL LECTUKES ON 
 
 For some years she has been aware of a pulsation in the 
 front of her neck, but her attention was not particularly 
 directed to it till the morning of 23rd January 1871, when, 
 after a severe fit of coughing, she accidentally observed that 
 where this simple pulsation formerly existed, there was now 
 a throbbing swelling as large as a hen's egg. A feeling of 
 tightness and choking referred to the chest and lower part 
 of the throat, which subsisted after the cessation of the 
 paroxysm of coughing, caused her to look at her throat and 
 so to discover this pulsating tumour. On admission the 
 patient was seen to be much emaciated and etiolated. There, 
 was considerable scoliosis of the spinal column in the dorsal 
 region, with right-side convexity, some protrusion backwards, 
 and a compensatory lumbar curve to the left. On the right 
 side the thorax was thrown outwards and backwards, and 
 flattened laterally ; on the left side the ribs were indented 
 and compressed together. 
 
 On palpation the only pulsation to be felt on the left 
 side was between the third and fourth ribs about half an 
 inch to the left of the sternum. To the right of the sternum 
 pulsation was found in the first, second, and third interspaces. 
 This pulsation was most forcible and distinct in the second 
 interspace, where it extended a couple of inches to the right 
 of the sternum, and in this situation considerable thrill was 
 to be felt. In the lower part of the neck, just over the 
 suprasternal notch, a pulsating tumour was felt crossing the 
 trachea and dipping beneath the right sterno-cleido-mastoid 
 muscle ; this was evidently a dilated vessel of abnormal 
 distribution ; it was apparently continuous with the right 
 subclavian artery, which was large and dilated, as was also the 
 brachial. The left subclavian was also dilated. The aorta 
 was not felt on passing the finger deep into the tracheal fossa. 
 All the arteries at the root of the neck pulsated strongly. 
 
 On percussion cardiac dulness, at one inch from the 
 sternum on the left side, was found to commence at the 
 upper border of the second rib and extended down to the 
 
DISEASES OF THE HEAin 397 
 
 liver dulness. From the upper border of the second rib on 
 the left dnlness passed obliquely across the sternum to the 
 lower border of the first rib on the right, and between the 
 first and second ribs (in the first interspace) to the right of 
 the sternum the dulness passed to the right for a distance 
 of two inches. It also passed downwards to the liver dulness 
 in the same parasternal line. At the leA-el of the fourth rib 
 the transverse dulness was four inches and a half. On 
 auscultating over the cardiac pulsation felt between the 
 third and fourth ribs, half an inch to the left of the sternum, 
 both sounds of the heart were to be heard, but neither of 
 them pure. Over the fifth rib, one inch from the left edge 
 of the sternum, these sounds were to be heard with greater 
 distinctness and purity, but no pulsation was to be felt. 
 In the left second interspace, distinct but impure first and 
 second sounds were audible. In the second interspace to 
 the right of the sternum the first sound was impure and the 
 second was obscured and almost entirely replaced by a diastolic 
 murmur. Over the pulsatmg tumoiu- already referred to as 
 chiefly l}ung between the first and second ribs to the right 
 of the sternum, where the pulsation was most fluid and most 
 forcible, there was a loud systoKc murmur followed by a less 
 distinct diastolic murmur. These two murmurs had theii' 
 position of maximum intensity in this situation, and from 
 it both radiated outwards in all directions. The systolic 
 murmur was propagated upwards with most distinctness, 
 and the diastolic murmur downwards, but less distinctly 
 jpari ]jassu, being more faint ah origine. The percussion of 
 the lungs was equal on both sides, and the respiration was 
 also equal, though neither could be held to represent an 
 average normal, as the percussion was slightly higher in 
 pitch, and the respirations slightly rougher in character 
 than usual. Xo other symptom of any importance was 
 observed, nor was any other sign present except a consider- 
 able thrill, which was perceptible over the pulsating tumour 
 alreadv described. 
 
398 CLINICAL LECTUKES ON 
 
 The diagnosis in this case was not very difficult ; the 
 absence of the sHghtest indication of any abnormal pressure 
 was quite conclusive as to there being neither a sacculated 
 aneurysm nor a cirsoid bulging of arterial origin in the region 
 of the abnormal pulsation in the fu'st interspace to the right 
 of the sternum. The absence of pressure symptoms also 
 clearly indicated that this pulsation was simply arterial in 
 character, and this was further confirmed by the strict 
 limitation of the dulness to the pulsation. But a pulsating 
 artery in the region referred to could only be the aorta, and 
 if this pulsation was only a dilated aorta it must be of 
 unprecedented dimensions to present so large a superficial 
 area of dulness. The position of the cardiac pulsation, 
 however, as well as the situation and form of the area of 
 cardiac dulness, assured us that the heart was tilted upwards 
 as well as thrown more to the right of the sternum than 
 usual. Hence we had the ascending portion of the aorta 
 passing more directly outwards to the right, and as the 
 transverse part of the arch did not rise higher nor take a 
 wider sweep than usual, it must necessarily have made an 
 unusually acute angle at its junction with the ascending 
 part of the aorta. But compression of the arterial lumen at 
 this acute angle was sufficient to account for the systolic 
 thrill and the loud systolic murmur, both being due to the 
 formation of fluid veins at this constricted part. As for the 
 diastolic murmur, in the absence of any saccular aneurysm, 
 which w^e did not believe to exist, this could only be due to 
 regurgitation through the aortic valve. This regurgitation 
 would be the necessary result of the separation of the valve 
 segments by hydraidic pressm^e of the blood accumulated in 
 the dilated ascending aorta. This ine^^.table physical result 
 might, however, be complicated and hastened by the certainly 
 less inevitable physiological result of pressure — local endo- 
 carditis with thickening and shrivelling of the valve segments. 
 
 This patient died suddenly, in Ward XIIL, on 7th 
 November 1872. At the autopsy the lungs were found 
 
DISEASES OF THE HEAET 399 
 
 congested and oedematous. The heart was tilted up, and the 
 great vessels displaced. The ascending aorta passed out- 
 wards to the right more than usual, and the transverse part 
 passed off from it at a somewhat acute angle. The innominate 
 artery was two inches long and twice its usual diameter. 
 It came off from the aorta further to the left than usual, 
 coming to the surface at the left sterno-clavicular articulation, 
 and passing across the trachea in the lower part of the neck 
 to the edge of the right sterno-cleido-mastoid muscle, be- 
 neath which it dipped and divided. The aorta was slightly 
 atheromatous and dilated at its commencement, but perfectly 
 free in every part from any saccular enlargement. The aortic 
 valve was slightly incompetent ; its segments were thickened. 
 The heart itself was hypertrophied and dilated, particularly 
 on its right side, but to no great extent. The mitral valve 
 was competent, but had a few vegetations on its upper 
 surface. The tricuspid valve was healthy; its opening 
 admitted five fingers. The pulmonary valve was healthy 
 and competent. The abdomen was filled with fluid ; the liver 
 was slightly enlarged, and the kidneys in a state of chronic 
 congestion. No other organ was examined. 
 
 This case was thus another example of rickety distortion 
 of the skeleton givmg rise to abnormal conditions of the 
 blood vessels closely simulating aneurysm. Of this simulation 
 the case now before us may be regarded as a somewhat 
 extreme example ; and between it and the case narrated at 
 the commencement of this lecture there are infinite grada- 
 tions, examples of which are of occasional, though not of 
 very common occurrence. It is well to be aware of the 
 occurrence of such cases, so that we may be prepared for 
 them, and thus avoid falling into such a mistake as happened 
 in the case with which I commenced; the anxiety and 
 worry connected with it were very serious to the poor man 
 himself and to his friends, and the unfortunate mistake 
 might very well have proved tragic to all concerned. 
 
 It is well, therefore, to remember that even a fluid 
 
400 CLINICAL LECTURES OX 
 
 pulsation in any of the intercostal spaces is not necessarily 
 an aneurysm. The absence of any history of empyema, 
 and even the distmct connection of the pulsation with the 
 aorta by continuity of dulness, is no proof of its aneurysmal 
 character, either in the sense of a saccular aneurysm or of 
 a mere dilatation. Even in the normal condition of the 
 skeleton the aorta may be exceptionally so deflected as to 
 permit its pulsations to become perceptible in one or other 
 of the intercostal spaces ; while abnormal intercostal pulsa- 
 tion of simple arterial origin is a matter of no infrequent 
 occurrence whenever the thoracic skeleton is deformed by 
 rickets. Distinctly saccular aortic aneurysms may also, of 
 course, occur even in chests deformed by rickets. 
 
 WTien there is no twisting or bending of the artery, and 
 no aortic incompetence, the case first narrated seems to 
 show that — as we would expect — there is no murmur audible 
 over the abnormal pulsation, and the only sounds audible 
 are those normally heard at the base of the heart, the second 
 in particular being in no degree accentuated. Wlienever a 
 murmur of regurgitation is developed at the base of the 
 heart, that is always more or less audible over the ascending 
 and transverse portions of the aorta. Apart, also, from any 
 obstruction or constriction at the mouth of the aorta, we 
 are sure to have a systolic murmur developed over any part 
 of the artery wliere any sharp twist or bend occurs. More- 
 over, as any abnormally situated intercostal pulsation must 
 be nearer the surface than any normally situated part of the 
 artery, all sounds and murmurs are more distinctly heard 
 over that pulsation than elsewhere, yet without accentuation. 
 "\Mienever we perceive marked accentuation of the murmurs 
 or sounds present, and especially if the normal second sound 
 be markedly accentuated, we are bound to suspect the 
 presence of a saccular aneurysm, notwithstanding the presence 
 of rickety malformation. To make our diagnosis certain, 
 however, we must be able first of all to connect the pulsation 
 directly with the aorta, and, secondly, we must be able to 
 
DISEASES OF THE HEA.ET 401 
 
 show that the dulness subtended by this pulsation extends 
 beyond its limits, and thus occupies a space greater than if 
 the pulsation were due to a simple cylindrical vessel like 
 the aorta in contact with the chest wall. Extension of 
 dulness beyond the limits of the pulsation, associated with 
 signs and symptoms of pressure upon one or more of the 
 neighbouring organs, are among the most certain indications 
 of the presence of an aneurysm, whether saccular or cirsoid. 
 Associated with these signs and symptoms we also have 
 other phenomena that indicate the dependence of the pressure 
 upon an elastic and distensile body of varying dimensions, 
 and by due attention to all the facts elicited we are often 
 able to prognosticate the existence of an aneurysm even 
 when no pulsating tumour has been detected, and will also 
 be able to determine with perfect accuracy the true character 
 of any pulsating tumour that may be perceptible. But I 
 must reserve full consideration of this matter till next lecture. 
 
 26 
 
LECTUEE XVI 
 
 ON THE DIAGNOSIS OF AORTIC ANEURYSM, ITS COURSE AND 
 TREATMENT 
 
 The diagnosis of thoracic aneurysm is sufficiently obscure at 
 times, wliile at others it seems so patent that it is difficult to 
 conceive the possibility of a mistake. 
 
 I need hardly say that an aneurysm is a local dilatation 
 of an artery ; of all its coats in a fusiform or globular shape, 
 or a mere bulging of these coats on one side of the vessel ; 
 both of these forms are often combined in the thoracic aorta, 
 in which uniform dilatation is frequently associated with 
 local bulgings. An aneurysm caused by uniform dilatation 
 of all the coats of an artery is called a true ainzurrysm. Any 
 mere bulgmg on the side of an artery is often entirely un- 
 accompanied by any general dilatation of the vessel, but 
 accompanied and apparently caused by rupture of one or 
 other of the arterial coats ; this is what is called a falm 
 aneurysm. It is also often termed a saccular a/iieurysm ; but 
 it is well to remember that this term is also frequently 
 appHed to those local bulgings occasionally associated with a 
 so-called true aneurysm (simple dilatation), especially when 
 such a bulging is solitary. During life it is scarcely possible 
 to state, even with a minimum of probability, whether a 
 saccular aneurysm is time or false. But it is quite possible 
 to say with great probability whether it is associated with 
 dilatation of the artery, and therefore probably a mere 
 bulging, or whether it stands alone, and is therefore more 
 likely to be not only a saccular but also a false aneurysm. 
 
CLINICAL LECTURES ON DISEASES OF THE HEAET 403 
 
 False aneurysms have been subdivided pathologically into 
 several varieties, according to the number and the nature of 
 the coats ruptured ; clinically this subdivision is a matter of 
 no importance, and impossible to recognise. So-called dis- 
 secting aneurysms are formed by rupture of the internal and 
 middle coats with efPusion of blood either between the layers 
 of the tunica media, or between the media and the adventitia. 
 The diagnosis of such an event is not easily made; fortunately 
 this is of little consequence so far as treatment is concerned, 
 though it might be of importance as regards prognosis. 
 Varicose aneurysms chiefly affect the arch of the aorta, and 
 are caused by abnormal communications between the aorta 
 and the superior vena cava, the pulmonary artery, or the 
 right auricle. These give rise to phenomena of great patho- 
 logical interest, are usually rapidly fatal, and are not 
 amenable to treatment. Cirsoid aneurysm of the aorta is 
 common enough if we accept Eokitanski's definition ; he says 
 that any cylindrical or fusiform dilatation of the artery 
 accompanied by an apparent increase in the length of the 
 vessel, and by saccular bulgings first on one side and then on 
 the other, so that the vessel appears to wind from side to 
 side, and lies in apparent coils, is entitled to this appellation.-^ 
 A great number of so-called true aneurysms of the thoracic 
 aorta present this appearance, and are therefore entitled to 
 be called cirsoid, though they have nothing in common with 
 the external so-called aneurysms usually recognised by this 
 term. 
 
 Again, when we speak of aneurysms of the aorta we 
 ordinarily refer to those occurring above the semi-lunar 
 valves, but it would be wrong to regard these as the only 
 aneurysms of the aorta, for, besides aneurysms of the 
 valves themselves — which ought, strictly speaking, to be 
 looked upon as belonging to the aorta, but which only reveal 
 themselves as valvular lesions — we have also aneurysms 
 immediately within the valves and above the cardiac ventricle 
 
 ^ Handbuch der pathologischen Anatomie (1844), Bd. ii. S. 551 and 557. 
 
404 
 
 CLINICAL LECTURES ON 
 
 (intra -valvular aneurysms), and aneurysms between the 
 valves (inter- valvular aneurysms), the latter form being the 
 most rare; but both forms are exceedingly uncommon.^ The 
 symptoms during life, so far as recorded, were only those of 
 valvular lesion ; clinically, therefore, they possess no peculiar 
 interest, though they are of considerable pathological im- 
 portance. 
 
 True aneurysms — simple dilatations of whatever form — 
 whether accompanied or not by bulgings, and false or saccular 
 aneurysms, arising above the valves, are those of the greatest 
 clinical importance, and they are more frequent in the 
 thoracic aorta than in any other part of its course. This we 
 learn conclusively from Dr. Sibson, who at great personal 
 trouble has collated the records of 584 cases of aneurysm, 
 and has also examined 296 specimens in museums, to which 
 no histories are attached — 880 cases m all.^ From Sibson's 
 researches the following table has been compiled : — 
 
 Situation of Aneurysm. 
 
 Total 
 Number. 
 
 Percentages. 
 
 Of these 
 
 Mere 
 
 Character of 
 
 
 there were 
 
 Dilatation 
 
 Aneurysm 
 
 
 
 sacculated. 
 
 of Vessel. 
 
 not defined. 
 
 Sinuses of Valsalva . 
 
 87 
 
 95-95 
 
 3-56 
 
 
 Ascending Aorta 
 
 141 
 
 54-75 
 
 38 
 
 7-25 ' 
 
 Do., Dissecting Aneurysm 
 
 52 
 
 
 
 
 Transverse Aorta 
 
 120 
 
 44-25 
 
 20 
 
 12-5 
 
 Ascending and Transverse Aorta 
 
 
 
 
 
 conjointl}' .... 
 
 112 
 
 40-7 
 
 85-7 
 
 
 Descending portion of Arch 
 
 72 
 
 71-9 
 
 14-55 
 
 17-7 
 
 Transverse and descending por- 
 
 
 
 
 
 tion of Arch .... 
 
 20 
 
 
 
 
 Whole Arch .... 
 
 28 
 
 
 
 
 Descending Thoracic Aorta be- 
 
 
 
 
 
 low Arch .... 
 
 71 
 
 42-4 
 
 42-55 
 
 20-4 
 
 Abdominal Aorta at Coeliac Axis 
 
 131 
 
 70-35 
 
 11-85 
 
 18-4 
 
 Do., below Mesenteric Artery , 
 
 26 
 
 
 
 
 Branches of Abdominal Aorta . 
 
 20 
 
 
 
 
 Thus of 880 cases of aneurysm no fewer than 703 belong 
 to the thoracic aorta, and if we take any one portion of its 
 
 ^ Two cases of intra-valvular and one of inter- valvular aneurysm have been 
 published by Rokitanski in the Mcdizinisches Jahrbuch (Wien, 1867), S. 174. 
 ^ Medical Anatomy (London, 1869), columns 57 and 58. 
 
DISEASES OF THE HEAET 405 
 
 course we find that by far the larger number belong to the 
 ascending aorta, which comprises no fewer than 193, 52 of 
 these being dissecting aneurysms. The transverse part of 
 the arch is much less frequently involved, its aneurysms 
 numbermg only 120 out of the 880. Aneurysm of the 
 descending aorta is still more rare, only 72 out of the 880 
 belonging to that part of the artery. Further, if we take the 
 number of aneurysms affecting the ascending and transverse 
 portions conjointly, and contrast them with the numbers 
 arising from the transverse and descending portions of the 
 arch conjointly, we find the relative numbers to be 112 and 
 20. These facts show the important relation the ascending 
 part of the aorta bears to aneurysm, evidently due to the 
 strain from the blood forcibly propelled from the ventricle 
 being most severely felt in this situation. 
 
 The middle coat is that upon which the strength, firmness, 
 and elasticity of the arterial tube depends, and loss of 
 elasticity in it must precede, and is the primary cause of 
 arterial dilatation or aneurysm, the secondary and effective 
 cause being of course the intra-arterial blood-pressure. Local 
 bulgings and saccular aneurysms are primarily due to local 
 atrophies or ulcerations of the middle coat. These affections 
 are degenerative in character, and are usually described as 
 following a primary affection of the intima (endarteritis 
 chronica) ; sometimes, however, the media itself is primarily 
 affected, and more rarely aneurysms have been found to follow 
 a circumscribed inflammation implicating the external and 
 middle coats [periarteritis nodosa), or the impaction of a sharp 
 pointed einbolus. Falls, blows, and violent exertions are 
 often the direct cause of an aneurysm, by rupturing the coats 
 of a vessel already diseased. 
 
 There is no disease the diagnosis of which is more beset 
 with difficulties than thoracic aneurysm. But there is also 
 probably no disease in which a due consideration of symptoms 
 and physical signs, as well as their modification by position, 
 exertion, etc., and of the mode in which they have been 
 
406 CLINICAL LECTURES OX 
 
 primarily developed and have subsequently progressed, is 
 more capable of conducting us to a satisfactory, if not always 
 an absolutely certain diagnosis. There is only one pheno- 
 menon positively characteristic of thoracic aneurysm, and 
 that is — The existence in some jgart of the thorax of a pulsating 
 tumour other than the heart, which heats isochronously^ ivith 
 the heart and at least as forcibly, and lohich at each pulsation 
 expands in every direction. These signs clearly recognised 
 are sufficiently distinctive, and yet they are occasionally so 
 efficiently simulated as to necessitate great care in their 
 determination. 
 
 A solid tumour lying on the aorta may by compression 
 originate a murmur and may appear to pulsate, but it only 
 rises and falls with the beating of the artery, and does not 
 expand in every direction. 
 
 A vascular tumour, be it mediastinal or pulmonic, may 
 possess not only a murmur but also a certain degree 
 of expansive pulsation ; that pulsation is not, however, 
 isochronous with the heart's action, but is always somewhat 
 delayed. 
 
 An empyema may present both bulging and expansile 
 pulsation isochronous with the heart, and when subcutaneous, 
 or even when more truly intra-thoracic, it may in these 
 respects efficiently enough simulate an aneurysm ; but the 
 pulsation, though expansile from being communicated through 
 fluid, is always less forcible than that of the heart, and there 
 is also entire absence of thrill or murmur, coupled with the 
 presence of the signs, history, and symptoms significant of 
 an empyema.^ 
 
 I have already narrated a series of cases in which 
 uncovering of the pulmonary artery gave rise to visible 
 
 ^ In one case I have found a truly aneur}'smal thoracic pulsation not to 
 be isochronous with the heart {vide p. 441, 2nd Ed.), but this exceptional 
 case in no wise invalidates the above statement. 
 
 ^ Vide an interesting paper by Dr. M 'Do wall in the Dublin Quarterly Journal 
 for March 1844, "On the Diagnosis of Empyema," especially at p. 16, where 
 the diagnosis between pulsating empyema and aneurysm is fully considered. 
 
DISEASES OF THE HEART 407 
 
 pulsation over which a systolic murmur was audible, thus 
 simulating an aneurysm, and I then pointed out the diagnosis 
 of the one from the other.^ Aneurysm is also not infrequently 
 simulated by uncovering of the aorta, which is sometimes 
 quite normal, but more usually bent or twisted upon itself, — 
 the result of deformity of the spine — scoliosis — and distortion 
 of the thorax. I have already given the details of several 
 such cases,^ so we need not enter upon their history further 
 at present. 
 
 The importance of cases such as those in relation to the 
 diagnosis of thoracic aneurysm is sufficiently evident. The 
 points of resemblance are also quite apparent. The points 
 in which they differed were — first, in the entire absence of 
 all the subsidiary phenomena dependent upon pressure on 
 the neighbouring organs, phenomena which are often obscure 
 and sometimes misleading, but to their consideration I shall 
 presently recur ; and, secondly, in the fact that the 
 isochronous pulsations are less forcible than those of the 
 heart. That aneurysmal pulsation is usually more forcible 
 than that of the heart is a diagnostic point to which much 
 attention has not hitherto been paid. It first impressed itseK 
 on my own attention as a matter of some moment in the 
 diagnosis of aneurysm in connection with those abnormal 
 arterial pulsations to which I have just referred, as well as 
 other pulsations of a less delusive character. On talking 
 the matter over with the late Dr. Henderson, Professor of 
 Pathology in the University of Edinburgh, a distinguished 
 authority on the subject, and himself a sufferer from the 
 disease, he informed me that this forcible character of 
 aneurysmal pulsation had also struck him as an important 
 point in relation to the diagnosis of aneurysm close to the 
 heart, and he thought he had made reference to this in his 
 writings. This reference I have, however, been unable to 
 verify. On the other hand, various writers on the subject, 
 
 1 Lecture VIII. p. 217. ^ Lecture XV. p. 386. 
 
408 CLINICAL LECTUEES ON 
 
 among whom I may mention Dr. Greene/ have referred to 
 it as a remarkable fact without attempting to explain it or 
 to estimate its diagnostic importance. Other writers, how- 
 ever, in narrating cases of indisputable aneurysm, have 
 mentioned that the pulsation of the sac was less forcible 
 than that of the heart. The explanation of this discrepancy 
 lies in the fact that the pulsation is only forcible when it is 
 fluid; if the sac be lined with fibrine, other elements are 
 introduced which neutralise those in force when only fluids 
 are concerned. In substernal aneurysms — those close to the 
 heart — fibrinous coagula are rarely found, and thus the 
 physical conditions upon which this forcible pulsation 
 depends remain in force just in those cases in which it is of 
 most consequence that they ought.^ 
 
 Whenever, therefore, we have a tumour in the chest 
 which pulsates isochronously with the heart, and at least as 
 forcibly, we have certainly to do with an aneurysm, which, 
 if it does not now present any marked subjective symptoms, 
 has probably at an earlier period been the cause of such, 
 pain being that symptom most apt to disappear during the 
 progress of the disease. Other symptoms and signs arising 
 from pressure upon adjacent organs are more constant and 
 more likely to increase than to decrease, if we except the 
 signs of pressure on certain veins, such as the brachial, which 
 may entirely disappear as the aneurysm shifts its position in 
 the course of its growth. 
 
 Pain is the symptom most commonly complained of, 
 and it is a most important note of warning, yet, as it may 
 arise from neuralgia (rheumatic) of the external coverings, 
 or from angina, it cannot be depended upon as an unequivocal 
 symptom of aneurysm. We accept pain as a valuable note 
 
 ^ Vide his paper ou " The Symptoms and Diagnosis of Thoracic Aneurysm. " 
 in the Dublin Jourmd of Medical Sciences (1837), pp. 233 and 236. 
 
 - Allen Thomson says the pies.sure within an aneurysm is equal to the 
 extent of its internal surface multiplied into the force of tlie blood in that 
 part of the artei'y from which it springs. — CyclopcccUa of Ayiatomy and 
 Physiology, vol. i. p. 663. 
 
DISEASES OF THE HEAET 409 
 
 of warning, and it is only exceptionally that it is anything 
 more. The pain of commencing aneurysm differs from that 
 of angina in that it is more continuous and more lancinating 
 (sharp) in character, neither is it so oppressive and depress- 
 ing. It also resembles ordinary neuralgia in that it often 
 disappears for months without any very obvious reason. 
 When the aneurysm affects the large vessels at the root of 
 the neck, or the aorta in this situation, pain shoots across 
 the chest as well as up one side of the neck or down one 
 arm, or it may extend in both directions, sometimes shooting 
 down both arms. A^Tien the aneurysm affects the descending 
 portion of the thoracic aorta pain is usually referred to one 
 spot on the back where it is constant ; but in such cases pain 
 may also shoot up the neck, or down the arms, and may even 
 localise itself in the shoulder joint. In these cases we can 
 always make out — by auscultation, if not by palpation — 
 localised pulsation just to the left of the spine where the 
 pain is complained of, generally we can also discover a 
 circumscribed dulness, and sometimes a murmur ; various 
 symptoms also serve to confirm the diagnosis. It is chiefly 
 in incipient substernal aneurysms close to the heart that 
 pain is so isolated and so important a s}'mptom as almost to 
 entitle it to be called "pathognomonic," as Dr. Greene has 
 put it. Yet careful watching even of such cases will ere 
 long elicit other symptoms more trustworthy and more truly 
 pathognomonic of aneurysm than pain alone, which is really 
 only an important warning, but always a warning with a 
 query attached. Pain in the situations referred to is chieiiy 
 produced by pressure on the intercostal nerves, or on those 
 of the brachial plexus. A constricting pain around the lower 
 part of the chest is occasionally caused by pressure on the 
 phrenic nerve, and this may also give rise to attacks of 
 dyspnoea, singultus, or more rarely to complete paralysis of 
 the diaphragm. Pressure on the pneumo-gastric nerve in 
 its earlier stages is often accompanied by vomiting, or by 
 severe dyspepsia accompanied by flatulence, which is often 
 
410 CLINICAL LECTURES ON 
 
 relieved by gentle rubbing of the tumour ; at a later stage it 
 gives rise to disease of the lung. 
 
 Dyspnoea is a frequent symptom of aneurysm ; it arises 
 from compression of the trachea, of one of the bronchi, or a 
 portion of lung, or of one of the recurrent laryngeal nerves. 
 When one of the recurrent laryngeal nerves is affected, it 
 may simply be irritated by pressure, and we have spasm of 
 a vocal cord, or its function may be destroyed with paralysis 
 as the result ; in the former case both inspiration and ex- 
 piration are affected ; in the latter, inspiration alone is im- 
 paired. The voice in these cases is altered to a vox anserina 
 (shrill whistling voice) ; more rarely there is complete aphonia. 
 Inspection by means of the laryngoscope at once reveals on 
 which side the affected cord lies. The left recurrent winds 
 round the arch of the aorta close to the origin of the left 
 subclavian artery and is the nerve usually involved; the 
 right recurrent passes round the right subclavian artery and 
 is rarely affected by any aneurysm. If, on inspection, the 
 glottis is found to open freely, and the arytenoid cartilages 
 to retain their normal movements, any dyspnoea present is 
 not laryngeal in origin, and probably depends upon pressure 
 on the trachea or on one of the bronchi. When the respira- 
 tion is diminished equally on both sides of the chest, we are 
 justified in regarding the trachea as the part compressed, 
 and in such a case the transverse portion of the arch is 
 usually at fault, though the trachea may, in exceptional 
 cases, be compressed by aneurysms either of the ascending 
 or of the descending aorta. On the other hand, compression 
 of a bronchus gives rise to diminution of the amount of air 
 in the part to which it is distributed ; in the whole lung if 
 it be a main bronchus ; in the corresponding part of the lung 
 if it be one of the smaller bronchi. This diminution of air 
 in the lung gives the percussion note a higher pitch and a 
 more tympanitic character over the part affected,^ and it 
 may give rise either to faintness of the respiratory murmur 
 ^ Skoda, Ahhaivdlung ilber Perkxission und Auskultation (Wien, 1844), S. 18. 
 
DISEASES OF THE HEAET 411 
 
 over the corresponding part of the lung, or more rarely to 
 the sound of bronchial respiration,-^ a most remarkable 
 phenomenon when associated, as in these cases, with a 
 clear tympanitic percussion note. Dyspnoea, arising from 
 aneurysmal compression of the trachea, or of a bronchus, is 
 naturally increased by exertion, and is frequently much 
 relieved by posture, as by leaning forward when the pressure 
 is on the trachea, or by leaning to one side when one of the 
 bronchi is compressed. In these circumstances air is heard 
 to enter the lung more freely when the pressure is removed. 
 Change of posture is thus not infrequently of service in 
 determinmg the exact position of an aneurysm. Dyspnoea 
 may also arise from direct pressure on the lung itself; it is 
 then frequently associated with symptoms simulating phthisis, 
 and to obtain relief from these the patient often seeks 
 advice wholly unconscious of the actual malady from which 
 he suffers. Still more rarely dyspnoea is caused by pressure 
 on one of the pneumo-gastric nerves, which may either give 
 rise to serious and fatal disease of the lung, or of itself may 
 prove fatal by inducing suffocation. Of all the organs within 
 the chest, the lungs are those most frequently compressed 
 by aortic aneurysm, hence a circumscribed dull patch is one 
 of the commonest signs of this affection. 
 
 Cough is a frequent symptom of thoracic aneurysm, and, 
 as it common]}" arises from irritation of the pneumo-gastric 
 or laryngeal nerves, it usually presents peculiarities which, 
 if not exactly pathognomonic, are at least sufficiently striking 
 to attract attention. In these cases the cough is often loud 
 and barking, and accompanied by a metallic clang. Such a 
 cough is very distressing both to the patient himself and 
 also to the bystanders, and appears far in excess of the 
 necessities of the case, being accompanied, at first at all 
 events, by the expectoration of only a small quantity of 
 
 ^ Vide a case by Dr. Halliday Douglas in the Edinhurgli Medical Journal 
 (December 1869), p. 550, also Dr. Greene, loc. cit. p. 233. The explanation of 
 this phenomenon is supplied by Skoda, op. cit. S. 108. 
 
412 CLINICAL LECTURES ON 
 
 glairy and frothy mucus. From the persistent irritation of 
 the cough the expectoration by and by becomes copious and 
 muco-purulent. When the cough arises from direct pressure 
 on the lung, the expectoration is copious and muco-purulent 
 very early in the history of the case. At times the ex- 
 pectoration may be rusty or even red, and though this ad- 
 mixture of blood often comes from the lung alone, yet one 
 cannot lielp being also anxious as to the state of the aneurysm. 
 In what is called a weeping aneurysm the cough is not 
 always severe nor the expectoration copious, but it always 
 contains some fluid blood. 
 
 Bysiilmgia is not an uncommon symptom in 'connection 
 with thoracic aneurysm ; it varies from a mere slight diffi- 
 culty of swallowing, apparently arising from some interference 
 with the oesophageal innervation, to that more complete form 
 of dysphagia dependent upon compression of the cesophagus, 
 in which the swallowing of solids is either impossible or 
 attended with great difficulty. The diagnosis between 
 dysphagia from the pressure of an aneurysm and that arising 
 from organic stricture is seldom difficult, as organic dysphagia 
 is unvarying and persistent, while aneurysmal dysphagia 
 varies from time to time — is complete at one period of the 
 day and wholly absent at another. Aneurysmal dysphagia 
 is also increased by any excitement of the circulation, and it 
 is markedly relieved by position ; thus a patient so afflicted 
 may be able to swallow quite well when he frees his oeso- 
 phagus from pressure by leaning forwards. The careful use 
 of a probang is capable of revealing in such cases, not only 
 pulsation but even a murmur, but this is a proceeding not 
 without risk, or one to be undertaken rashly. 
 
 Pressure on the blood-vessels produces various well-known 
 signs and symptoms ; amongst these we have alterations of 
 the radial pulses, so that one differs from the other in size or 
 volume. To avoid being misled by simple iri'egular distribu- 
 tion of the radial artery, we must carefully ascertain whether 
 the difference in volume extends to the brachial also. A 
 
DISEASES OF THE HEART 413 
 
 sphygmographic tracing from both radial arteries shows at 
 once whether we have to do with simple abnormal distribu- 
 tion or with an abnormal blood-wave. The alteration of the 
 blood-wave is, however, rarely, if ever, due to pressure, but 
 almost invariably to stenosis of the subclavian or brachial 
 artery from endarteritis deformans, which not only deforms 
 the pulse but may even delay it. Hence the diagnosis of 
 aneurysm can never be made with certainty from pulse 
 changes alone. ^ Pressure on the brachial veins produces 
 swelling of the corresponding arm, unaccompanied by any 
 signs of inflammation. The dependence of this swelling 
 upon aneurysmal pressure is made probable when it comes 
 on suddenly during violent exertion, and especially if there 
 is an abnormal pulsation or murmur localised in the in- 
 nominate, subclavian, or carotid arteries. Should the 
 aneurysm shift its position and develop in some other 
 direction, this swelling may disappear and a pulsation may 
 then appear about the upper part of the chest or the root of 
 the neck. Considerable compression or even obliteration of 
 the superior vena cava has been occasionally observed, 
 attended by great development of the superficial veins of 
 the arms, neck, and face. When the compression is not so 
 great, a moderate development of the superficial veins is not 
 infrequently observed ; and in some of these cases this takes 
 the form of a thick oedematous collar covered with enlarged 
 veins surrounding the root of the neck. The interference 
 with the cerebral circulation thus produced gives rise to 
 various head symptoms, headache, quasi-apoplectic seizures, 
 etc. Compression of the vena cava, descendens or of the right 
 auricle may give rise to congestion of the abdominal organs 
 and dropsy, but these are usually late symptoms, and there 
 are then plenty of other symptoms and signs present to lead 
 us to the true diagnosis. 
 
 Pressure on the heart by aneurysm is not an uncommon 
 cause of displacement of that organ. If the aneurysm 
 ^ Die Untersuchung des Pulses, vou Dr. M. v. Frey (Berlin, 1892), S. 238. 
 
414 CLINICAL LECTURES ON 
 
 implicates the ascending aorta, the heart is displacfed down- 
 wards and to the left ; if the transverse part of the arch is 
 affected the displacement may be downwards solely; and 
 when the descending aorta is affected, the heart may be dis- 
 placed to the right, or if the aneurysm is located just behind 
 the heart, that organ is compressed against the anterior wall 
 of the thorax and gives a larger and more forcible impulse. 
 Consecutive alterations of the heart connected with aneurysm 
 are rarely of any importance ; even when a double murmur 
 at the base of the heart reveals incompetence of the aortic 
 valve, a condition which in ordinary circumstances is attended 
 by great consecutive changes, these, when the incompetence 
 is caused by aneurysm, are generally so slight as to be un- 
 important, and have little bearing on the ultimate progress 
 of the case. 
 
 At times the pressure of an aneurysm is so great as to 
 depress the liver and to communicate to it well-marked 
 pulsation ; of this I have seen one very interesting example 
 {vide p. 8). 
 
 "When the pressure of an aneurysm affects the nerves issuing 
 from the spinal cord in what is called " the cilio-spinal region," 
 that is, according to Budge and Waller, from the sixth cer- 
 vical to the sixth dorsal nerve, or, according to Brown- 
 Sequard, as low as the ninth or tenth dorsal nerve, certain 
 phenomena are observed which vary with the amount of 
 pressure exerted. From the anterior roots of the nerves 
 referred to certain filaments pass through the cervical sym- 
 pathetic to the iris and are distributed to the dilatator -pupillw, 
 consequently when the aneurysmal pressure in the region 
 referred to is but slight these nerves are only irritated and 
 the pupil is dilated. When the pressure is considerable the 
 nerves are paralysed and the pupil is contracted. When 
 contraction is extreme the effect is very striking, but there 
 are a multitude of cases in which the difference between the 
 two pupils is but trifling, and in which it is difficult to decide 
 which pupil is abnormal. Further, we must remember that 
 
DISEASES OF THE HEART 415 
 
 an average of one person in fourteen has one pupil smaller 
 than the other. When we find the pupils of the two eyes 
 differing in size we must first of all carefully measure both, 
 and then proceed to test them. The contracted pupil of 
 spinal myosis is insensible to light and does not further 
 contract on exposure, but it does contract on accommodation 
 for near objects ; further, the reaction to atropine of such 
 pupils is always incomplete. When the left pupil is thus 
 ascertained to be affected with spinal myosis we know we 
 have to do with some affection of the cilio-spinal nerves, the 
 exact nature of which has yet to be discovered, but which 
 may be an aneurysm. Spinal myosis on the right side has 
 no connection with aortic aneurysm. Even on the left side 
 spinal myosis is not pathognomonic of aneurysm, but it may 
 help us to detect one by directing special attention to the 
 region involved.^ 
 
 Circumscribed dulness is always present when the aneurysm 
 reaches the wall of the thorax. From the more or less 
 globular shape of an aneurysm the tumour is invariably 
 larger than the area of complete dulness. Over this dull 
 patch we always have pulsation which is more or less fluid 
 and forcible in character, according to the thinness of the 
 walls of the sac and the amount of clot contained within it. 
 The most common situation of aneurysm, where, therefore, 
 this dull patch is most usually found, is on the right side of 
 the sternum, on a level with the second or third ribs ; more 
 rarely it is to be found on the left side of the sternum, or 
 over that bone itself, or at the back. In the latter case the 
 aneurysm usually arises from the posterior part of the de- 
 scending aorta, and it only rarely passes to the right of the 
 spinal column. As the disease progresses the circumscribed 
 dulness increases ; the thoracic wall becomes involved in the 
 
 ^ Vide Dr. Gairdner in the Udinburgh Medical Journal for January and 
 August 1855 ; Dr. Ogle in the Medico-CMrihrgical Transactions, vol. xli. ; and 
 for the physiology of the subject two interesting papers by Dr. Argyll 
 Robertson in the Edinhurgh Medical Journal for February and December 
 1869. 
 
41 G CLINICAL LECTURES 0!^ 
 
 tumour, which finally breaks through and appears on the 
 surface as a pulsating swelling; in this condition its true 
 character is not likely to be mistaken. 
 
 Over the dull pulsating tumour various sounds are to be 
 heard, and these vary in each case. Perhaps what we call 
 a murmur is the rarest of all sounds heard over a thoracic 
 aneurysm, a systolic jog being all that is appreciable in many 
 cases, though occasionally this jog is double. In these cases 
 it appears probable from the firmness of the impulse that the 
 sac is well coated with fibrine internally, but this is certainly 
 not always the case. Most commonly the sounds audible 
 over an aneurysm are merely the normal sounds of the heart, 
 and when this is the case it has long been known, having 
 been first pointed out by Dr. Henderson in 1836, that the 
 second sound, that produced by closure of the aortic valve, 
 presents what he has called " a very striking resemblance to 
 the shutting of a pump-valve in the immediate vicinity of 
 the ear," ^ and this has been variously designated by succeed- 
 ing observers as a ringing, booming, or accentuated second 
 sound. This accentuated or booming sound, when heard over 
 a circumscribed dull patch, and limited to that position, is 
 very distinctive of aneurysm. If, however, this booming 
 sound is produced so near as to be readily propagated into 
 the aortic area, it is apt to be confounded with a similar 
 accentuation due to dilatation of the ascending aorta.- Hence 
 an accentuated second heard over a circumscribed dull patch 
 out of the aortic area is almost distinctive of aneurysm; 
 heard within that area alone it indicates dilatation of the 
 ascending aorta ; but if it is also propagated to the right or 
 left of the normal course of the aorta, the probabilities 
 are in favour of the dilatation being combined with bulging 
 (cirsoid aneurysm), rather than that there is any true 
 saccular aneurysm. When a double murmur is to be heard 
 at the base of the heart, the same murmurs, only intensified, 
 
 ^ Edinburgh Medical and Surgical Journal, vol. xlv. p. 316. 
 2 Lecture L p. 31. 
 
DISEASES OF THE HEAET 417 
 
 are also heard over the aneurysm. At times a systolic mur- 
 mur of varying character is heard over the aneurysm preceding 
 the accentuated second sound, and still more rarely this 
 systolic murmur is followed hy a loud diastolic murmur. In 
 the only case in which this occurred in my own experience, 
 the opening of the aneurysm was large and smooth, and it was 
 difficult to account for the occurrence of a diastolic murmur 
 at all (vide p. 441, 2nd Ed.) A localised murmur heard any- , 
 where in the course of the aorta, or of its larger branches, is 
 always a suspicious sign, and ought to lead to further inquiry. 
 But inasmuch as a murmur of this character may arise from 
 a projecting spicula, or from the pressure of a tumour, it is of 
 little value by itself and is only conclusive when associated 
 with other confirmatory signs and symptoms. 
 
 Undue delay of the indse is a sign of endarteritis, atheroma, 
 or dilatation of the aorta, but not of saccular aneurysm, 
 which does not interfere with the normal propagation of the 
 pulse. 
 
 A knowledge of the anatomical relations of the thoracic 
 aorta teaches us that the predominance of one or other of the 
 symptoms just described may be accepted as a certain indica- 
 tion of the site of an aneurysm, and often of its size. Pain 
 on the right side is of comparatively little consequence, as an 
 aneurysm coming from the ascending aorta and passing to 
 the right lies in front of everything, and has already involved 
 the anterior chest wall before pam becomes a prominent 
 symptom. On the left side it is different, and so-called 
 rheumatic pains about the left shoulder ought always to be 
 most carefully inquired into, as not infrequently they are the 
 earliest indication of an aneurysm of the upper part of the 
 descending aorta. If an aneurysm in this situation is of any 
 size we frequently have either dilatation or contraction of the 
 left pupil ; but tMs is an inconstant sign and never an early 
 one ; it is therefore of less importance than pain. Brassy, 
 spasmodic cough, and too: anserina, lead us at once to the left 
 edge of the sternum about the first interspace, just over the 
 
 27 ■ 
 
418 CLINICAL LECTURES OX 
 
 left end of the transverse part of the arch of the aorta where 
 the left recurrent nerve wmds round it. Dyspnoea, not 
 accompanied with brassy cough, or vox anserina, and not 
 associated with any obvious affection of the lungs or heart, 
 should lead us to examine the region beneath the upper part 
 of the sternum with great care, as it will not infrequently be 
 found to depend upon pressure upon the trachea or the right 
 bronchus by an aneurysmal bulging of the first half of the 
 transverse portion of the arch of the aorta. In rare cases 
 this bulging is strictly limited to the posterior part of the 
 vessel, and a positive diagnosis is quite impossible, yet the 
 signs and symptoms are even in these cases so well marked 
 and so distinctive as to make the probability almost a cer- 
 tainty.^ Aneurysms in the posterior mediastinum present 
 the fewest symptoms of any, and are seldom even surmised 
 until they produce pain by erosion of the vertebrae, or have 
 become large enough to implicate the lung, or to interfere 
 with the circulation tlu'ough the azygos, hemiazygos, or vena 
 cava ascendens. When an aneurysm springs from the anterior 
 part of the ascending aorta, it occasionally passes to the left, 
 and, getting in front of the lung, just above and in close 
 proximity to the heart, it sometimes escapes observation until 
 by pressure it has produced considerable disorganisation of 
 the lung. 
 
 The diagnosis of abdominal aneurysm is either very easy 
 or the reverse. During a considerable part of its course the 
 abdominal aorta can be readily felt, and any alteration of its 
 calibre distinguished by palpation. Should any pulsating 
 tumour be detected, auscultation will usually reveal a systolic 
 murmur solely ; the second sound is not propagated into the 
 abdominal aorta, and a diastolic murmur is almost unknown.- 
 
 ^ The case of the late Earl St. Maur will at once recur to the reader, and 
 at p. 1123 of the Edinburgh Medical Journal for June 1S72 will be found a 
 similar case, in which an equally successful attempt at diagnosis was made. 
 
 - The only recorded case of diastolic murmur in abdominal aneurysm, that 
 I am acquainted with, is one narrated by Dr. "Wickham Legg in St. Bo^rOiolo- 
 mew's Hospital IlcjJorts for 18S0, vol. xxi. p. 258. I myself have also met 
 with one similar case. 
 
DISEASES OF THE HEART 419 
 
 When the aneiuysm springs from the anterior surface of the 
 abdominal aorta, no pain is complained of unless it arise very 
 high up in its course, and almost if not quite beyond the 
 reach of palpation. Occasionally we have flatulence and 
 other symptoms of gastric disturbance, apparently the result 
 of interference with the innervation of the stomach. The 
 immobility of a tumour is no proof of its aneurysmal character, 
 as Dr. Henry Kennedy supposed; it only shows that it is 
 fixed, it may be, by adhesions or otherwise, but it is not any 
 proof that it springs from the aorta. When an aneurysm 
 arises from the posterior surface of the aorta, and especially 
 if it be beyond the reach of palpation, it is chiefly per viatn 
 exclusionis that we arrive at our nearest approximation to the 
 truth. Perhaps the most distinctive symptom is an otherwise 
 unaccountable neuralgic pain affecting the bowels, passing as 
 a girdle pain round the body, or shooting down the spine into 
 the extremities. Tins pam is tolerably persistent, but is 
 subject to variations like all other symptoms of aneurysm, 
 and now and then it disappears for months at a time ; indeed 
 this unaccountable disappearance may be regarded as to a 
 certain extent confirmatory of the diagnosis of aneurysm. 
 Dr. Beatty of Dublin has related a most instructive case of 
 abdominal aneurysm, in wMch the tumour lay between the 
 crura of the diaphragm, and in which the character of the 
 pain led ultimately to what proved to be a correct diagnosis.-^ 
 It is to be regretted that neither percussion nor auscultation 
 down the spme were resorted to in this instance ; they ought 
 never to be omitted, as it is quite unusual to obtain no in- 
 formation from these methods of exploration, and the discovery 
 of a localised duhiess or an arterial whiz materially aids the 
 diagnosis in these cases. 
 
 The course of an aneurysm is usually chronic ; it may last 
 for years, till death takes place either gradually from asthenia 
 or dropsy, or more suddenly from oedema, gangrene, or in- 
 flammation of the lungs, or from rupture of the sac, either 
 
 1 Dublin Hospital BepoHs, vol. v. p. 166. 
 
420 CLINICAL LECTURES ON 
 
 externally, or into one of the serous cavities, or into a mucous 
 canal. Death from pure asthenia is comparatively rare, a 
 gradually increasing marasmus being usually hastened to its 
 fatal termination by some acute complication or intercurrent 
 disease, or by rupture of the sac. Eupture of the sac is not 
 always immediately fatal ; rupture into a serous cavity usually 
 is so, but there are many cases of so-called " weeping aneu- 
 rysms " in which the sac communicates with some mucous 
 surface, and pours forth small quantities of blood at irregular 
 intervals for months or years. When this leakage is in 
 connection with the alimentary tract it is not so obvious, 
 except when so copious as to give rise to ha^matemesis, a 
 state of matters but rarely followed by recovery, and yet 
 there is at least one case of this upon record.^ When the 
 blood is poured into the respiratory tract attention is at once 
 attracted to this alarming symptom. In Mr. Liston's case the 
 period that elapsed between his first copious hoemoptysis and 
 his fatal haemorrhage was five months, without any inter- 
 vening bleeding. Dr. Gairdner has related a remarkable case 
 in which, from the first leakage to the last fatal effusion, no 
 less than five years elapsed, during which there were repeated 
 slidit attacks of htemorrhage.^ But the most remarkable 
 cases of intermittent haemorrhage are those recorded as having 
 taken place from the external surface. Thus Neligan relates 
 the case of a ship carpenter, with an aneurysm of the aorta 
 opening externally about the second rib on the right side in 
 front, which for more than a year discharged blood at 
 intervals, and that sometimes so copiously and in so full a 
 stream as to be with difficulty arrested. Three weeks after 
 his last bleeding his aneurysm underwent a marked abatement, 
 and he left the hospital declaring himself to be quite well.^ 
 Nor is this case unique ; several somewhat similar cases have 
 been recorded. Perhaps the most extraordinary of these is 
 
 1 Gairdner's Clinical Medicine (Edinburgh, 1862), p. 495. 
 
 2 Op. cit. p. 509. 
 
 3 Stokes' Diseases of the Heart and Aorta (Dublin, 1854), p. 582. 
 
DISEASES OF THE HEART 421 
 
 one narrated to the late Mr. Syme, by Mr. Eamsay of 
 Broughty-Ferry, of a man with aneurysm of the arch of the 
 aorta and of the mnominate artery which ruptured opposite 
 the cartilage of the third rib. A stream of blood somewhat 
 thicker than a quill is reported to have issued from the 
 opening, the patient, nowise alarmed, held a bowl to receive 
 the contents of what he supposed to be a " bloody boil," and 
 even squeezed it with his chin to empty it faster ; when he 
 had lost about a quart of blood he fainted, and the bleeding 
 ceased. Four months subsequently he died of typhus, the 
 bleeding having never recurred.^ 
 
 Thus even rupture of an aneurysm, usually and rightly 
 regarded as almost necessarily fatal, does not always make 
 further treatment utterly hopeless ; and if the case be so with 
 a ruptured aneurysm, with how much more hope ought we 
 not to attempt the cure of one still unruptured. Unaided 
 nature has not infrequently succeeded in promoting the cure 
 of such cases ; and the medical art would be unworthy the 
 confidence reposed in it were it incapable of following up and 
 improving upon the hints afforded by nature as to the treat- 
 ment of this most serious disease. For nature can only cure 
 in certain conditions and in certain circumstances, but art can 
 change the latter and modify or fulfil the former. Art, 
 therefore, properly directed, ought to cure more than nature ; 
 and as no case is utterly hopeless even when left to nature 
 alone, so all ought to be more or less hopeful when under the 
 guidance of art ; and the more hopeful the more intelligent 
 the art that guides them is. 
 
 The spontaneous or natural cure of aneurysm is effected 
 in three modes — First by sphacelus of the tumour, the 
 arterial opening remaining closed ; second, by occlusion of the 
 artery from which the aneurysm springs ; and, thirdly, by 
 gradual occlusion of the aneurysmal sac with fibrine, the 
 artery from which it springs remaining pervious." The first 
 
 1 Monthly Medical Journal (January 1850), p. 89. 
 
 ^ Vide Hodgson On Aneurysm (London, 1815), p. 101. Many cases of 
 spontaneous cure of aneurysm are to be found in this work. 
 
422 
 
 CLINICAL LECTUKES ON 
 
 method, sphacelus, can scarcely be called a method of cure, 
 though in rare instances it has accidentally been followed by 
 this result; it certainly cannot be imitated by art. The second 
 method is that upon which the surgical treatment of external 
 aneurysms is based ; it is obviously inapplicable to the treat- 
 ment of internal aneurysms connected with the main trunks 
 of arterial supply. The medical treatment of internal 
 aneurysms has therefore been largely restricted to an en- 
 deavour to bring about the third mode of cure — occlusion of 
 the sac by fibrine. This method is of course inapplicable to 
 
 Fig. 32. 
 
 cirsoid aneurysm (those with bulgings only). Happily there is 
 a fourth method of treatment thoroughly scientific in its aims 
 and applicable to all forms of internal aneurysms, but con- 
 sideration of this I shall reserve for a future chapter. 
 
 Of the spontaneous cure of aneurysms of the aorta, I have 
 only seen two examples. The first was a small aneurysm, 
 rather larger than a large walnut, wholly filled with a firm, 
 pale, fibrinous clot, and springing from the upper part of the 
 ascending aorta just where it passes into the transverse part 
 of the arch. The specimen (Fig. 32, a is placed on the 
 aneurysm) was removed from the body of a man who died 
 from the fatty form of Bright's disease (large white kidney). 
 
DISEASES OF THE HEART 
 
 423 
 
 and was never known to have exhibited any symptoms of 
 aneurysm.-^ The second case was that of an aged woman, an 
 inmate of one of our eleemosynary hospitals in charge of the 
 late Dr. Gillespie. In this case the aneurysm sprung from the 
 descending part of the aorta, just after leaving the transverse 
 part of the arch (Fig. 33). The aneurysm passed backwards 
 into the left vertebral sulcus, and pressed upon the left lung. 
 Htemorrhage from this lung, unconnected with the artery but 
 caused by disorganisation induced by pressure, proved fatal. 
 The aneurysm was as large as an orange, was wholly filled 
 
 Fig. 33 
 
 with a laminated clot, and had presented none of the usual 
 symptoms ; it had in fact been wholly unsuspected. In this 
 case the whole of the arch had been converted into bone 
 (atheroma), and was as firm as the handle of a walking-stick.^ 
 Attempts have been made in various ways to produce this 
 favourable termination. Every variety of sedative has been 
 employed with this hope, but so unsuccessfully as to require 
 no notice here. Even their use as palliatives has been of 
 little avail, and the^most powerful anodynes have been almost 
 
 1 MinburgJi Medical Journal (July 1870), p. 82. 
 
 " Both of these preparations are in the Museum of the Royal College of 
 Surgeons, Edinburgh. 
 
424 CLINICAL LECTURES OX 
 
 useless in relieving the excruciating agony that so commonly 
 accompanies this terrible disease. 
 
 Of all the more modern attempts to cure or relieve this 
 affection there are six which seem worthy of mention, and 
 the first of these I shall notice only because it is modern, 
 and not because its employment has been either markedly 
 beneficial or desersdng of imitation. Perhaps there is nothing 
 that testifies so strongly to the dangerous character of aneu- 
 rysm, and to the inefficacy of the remedies hitherto employed, 
 than the fact that learned physicians have been found t(5 
 advocate the introduction of fine iron wire into an aneurysm 
 with the view of providing an extensive surface upon which 
 the fibrine might coagulate. The late Dr. Murchison and 
 Mr. Charles H. Moore introduced twenty-sLx yards of such 
 wire through a fine pointed cannula into a saccular aneurysm 
 of the ascending aorta. The treatment was unsuccessful ; it 
 could scarcely have been otherwise, as it was not employed till 
 it was clear that the patient had not many days to live. The 
 proposers of this treatment contend that their experiment 
 showed that the principle upon which it was based is sound, 
 and that further experiments are justifiable.^ But surely 
 nothing could justify so hazardous an experiment except the 
 full conviction that no less dangerous treatment is available, 
 and to this, of course, I demur, as I think I shall be able to 
 show that there is a treatment wholly free from danger which 
 holds out sufficient prospect of success to preclude our having 
 recourse to any such hazardous experiments. Besides, this 
 treatment is only applicable to saccular aneurysms, and it is 
 not always easy to ascertain whether an aneurysm is truly 
 saccular or not. If this condition could be distinctly recog- 
 nised there are few, I think, who would not prefer the less 
 dangerous and more efficient agency of electrolysis. Un- 
 fortunately we can never be perfectly certain that an internal 
 aneurysm is truly saccular, and in any other the risk of 
 embolism, though probably exaggerated, is yet so great as to 
 
 ^ Medico-Chh-urgical Transadioiis, vol. xlvii. p. 129 (London, 1864). 
 
DISEASES OF THE HEAET 425 
 
 prevent the use of galvano-puncture in all but exceptional 
 cases, and its employment is chiefly restricted to those ex- 
 ternal arterio- venous tumours which are known as surgical 
 " cirsoid aneurysms," in the treatment of which it is most suc- 
 cessful. Provided always that the arterial element prevails ; 
 when the venous element is in excess I can say with perfect 
 certainty that galvano-puncture is of no use if the disease is 
 of any extent. In truly medical aneurysms the chief use of 
 galvano-puncture is to prevent external rupture, and for this, 
 other measures having failed, it is admirably adapted, and is 
 therefore deserving of a short notice. Galvano-puncture was 
 originally suggested by Pravaz for the cure of external aneu- 
 rysms, in the treatment of which it has had a fair measure of 
 success, as may be seen by reference to Ciniselli's memoir,-^ to 
 which I need not now further refer. Its employment has 
 been extended to thoracic and abdominal aneurysms by 
 Ciniselli,"^ by Drs. James and John Duncan,^ and by Dr. 
 Decristoforis,* who have narrated eight cases of thoracic 
 aneurysm, in only one of which was any considerable degree 
 of success attained;^ the others were all unsuccessful. In 
 one case of abdominal aneurysm complete success seemed to 
 have been attained, but unfortunately premature exertion 
 was followed by the sudden death of the patient.^ The 
 results attained in the treatment of internal aneurysm have 
 not thus been such as to lead us to hope much from the 
 employment of galvano-puncture as a remedial agent in this 
 class of cases, while the unavoidable risks of embolism are so 
 great as to lead to its abandonment by almost all. On the 
 other handj the ease and rapidity with which clots can be 
 formed by means of the galvanic current must certainly lead 
 
 ^ Sulla elettro-puntura iiella ciira degli ane^irysmi (Cremona. 1856) ; and 
 Edinburgh Mediail Journal (April 1866), p. 926. 
 
 - Edinburgh MedicalJournal {A.-^v\\ 1866), p. 926. 
 
 3 Ibid. p. 920 ; and August 1867, p. 101. 
 
 ** Aneurysm dell' aorta ascendente trattato colV elettro-'puntiira, caso clinico 
 (Milan, 1870), etc. ; and Edinburgh Medical Journal (December 1870), p. 537. 
 
 ^ Edinburgh Medical Journal (December 1870), p. 540. 
 
 6 Ibid. (April 1866), p. 922. 
 
426 CLINICAL LECTURES OX 
 
 to its employment, as a dernier ressort, in all cases where 
 external rupture seems imminent. For galvano- puncture 
 of aneurysms steel needles are employed, about five inches in 
 lencjth, and of the thickness of 0'07 of an inch, that is Xo. 16 
 of the wire-gauge. The non-insulated portion of each needle 
 should measure one inch and one-eighth of an inch in length, 
 while the insulated portion, or that coated with \Tilcanite (or 
 ebonite) should measure three inches and three-eighths. If 
 the steel be not gilded the positive pole is rapidly coiToded ; 
 but when the wire is of the thickness prescribed, it is not 
 acted upon to such an extent as to have its efficiency seriously 
 impaii'ed. Moreover, when blood is the electrolyte, the 
 corrosion of the steel results in the production of ferrous 
 chloride and probably also of ferrous sulphate, salts which 
 coagulate albumin, and thereby the wished -for result is 
 hastened.^ Four cells of a Bunsen's battery are sufficiently 
 effective and give rise to no pain, or to only a bearable amount 
 of pain. But as even six cells sometimes produce so much 
 pain as to make the patient uncontrollable,^ if it is thought 
 desb^able to use more than four cells, the patient should be 
 put under chloroform. 
 
 The battery should have a continuous current, and the 
 needles should be introduced from the same side, near the 
 base of the external tumour, parallel to each other, and one 
 or two inches apart. The number of needles may be multi- 
 plied if the aneurysm is large, and the action may be pro- 
 longed till pulsation ceases, or till gas can be clearly detected 
 on percussion. A stance of about twenty minutes is generally 
 enough for one application, and this may be repeated as 
 necessary according to the circumstances of the case. Such 
 is a succinct account of the method of employing galvano- 
 puncture in aneurysm — a method of treatment that cannot 
 be recommended for the cure of internal aneurysms, both 
 because of the risks connected with it and also because we 
 
 ^ Edinburgh Medical Journal (August 1867), p. 119. 
 2 Ihid. p. 109. 
 
DISEASES OF THE HEAET 427 
 
 have a safer and a better method ; but it is a treatment which 
 may be very advantageously employed as a means of pro- 
 longing life in exceptional circumstances. Last winter 
 (1874-5) we had a very instructive case in which we had 
 unavailing recourse to galvano-puncture. 
 
 Case XL. Alexander M'Intosh, a mason, aged thirty- 
 four, residing at Newport, Fife, admitted to Bed 10, Ward V., 
 on 12th October 1874, complaining of a pulsating tumour at 
 the root of the neck, and another actually beneath the right 
 shoulder-blade. He is a hardworking man of temperate 
 habits, with a comfortable house, and a good family history, 
 who had met with no more serious accident than a fall on 
 his right elbow joint about six months previous to his ad- 
 mission. About six weeks before admission, while at work, 
 he was seized with a pain between his shoulders ; m itself 
 this was of no consequence and did not prevent his con- 
 tinuing at work, but it directed his attention to the spot, 
 and there he discovered a swelling. On consulting his doctor 
 he was told to stop work and apply for admission to the 
 Eoyal Infirmary. He has now no pain, only a feeling of 
 stiffness over the right shoulder and upper part of the chest. 
 With the exception of an attack of fever, about ten years 
 ago, which laid him up for about two months, he has always 
 had good health. He is a well -developed man in good 
 condition ; weight, 11 stone 4 lb. ; height, 5 feet 7 inches ; skin 
 natural; temperature 98-4 "For the last six weeks he has 
 suffered occasionally from palpitation ; he has a feeling of stiff- 
 ness about the upper part of the chest in front. Both radial 
 pulses are synchronous and of nearly equal force, though at 
 times the right seems the feebler; the pulse is weak, 90 
 per minute. Above the right clavicle there is a bluish 
 lobulated swelling, which commences a Little to the right of 
 the middle line and runs round the neck to the back ; about 
 the middle of the clavicle it measures three inches across. 
 Posteriorly in the region of the right scapula there is a 
 visible pulsation, the margins of which are ill-defined. 
 
428 CLINICAL LECTURES ON 
 
 Beneath, the pulsation extends a little beyond the scapular 
 angle ; internally, where it is most prominent, it almost 
 reaches the middle line ; externally, it reaches the posterior 
 fold of the axilla ; and above, it rises to the level of the 
 vertebra i^romincns, and merges in the swelling surrounding 
 the neck. Posteriorly the pulsating tumour does not differ 
 in colour from the natural skin. On palpation the swelling 
 over the clavicle feels soft, fluid, and relaxed, except at one 
 spot just above the clavicle, where a firm and more elastic 
 tumour is to be felt. On placing the hand lightly over this 
 soft swelling a purring tremor is felt, but no distinct pulsation 
 until we press deep enough to reach the elastic tumour just 
 alluded to, which feels rounded and beats a little later than 
 the cardiac apex. The pulsation behind is heaving, and lifts 
 the scapula at each beat ; at its upper part there is a purring 
 thrill similar to what is felt in front, but less intense. Firm 
 pressure on the elastic tumour referred to as projecting 
 above the clavicle stops the thrill both in front and behind, 
 and greatly diminishes the size of the tumour behind as well 
 as the force of its pulsation. The cardiac apex beats in the 
 fifth interspace, three inches from the middle line ; the 
 cardiac pulsation seems to occupy a larger space than usual, 
 but is not forcible ; there is no pulsation in the episternal 
 notch, but there is considerable heaving over the upper part 
 of the right side of the chest. The cardiac dulness does not 
 rise above the third rib ; at the level of the fourth costal 
 cartilage it commences at the right margin of the sternum 
 and extends to the left for a distance of five inches. On the 
 right side anteriorly the upper part of the chest is dull down 
 to the third rib; as low as the first interspace this dulness 
 reaches the middle line ; beneath that there is a space of 
 about two inches to the right of the middle line where the 
 percussion note is more resonant than over any other part 
 of the chest. Posteriorly the whole right half of the chest 
 is dull down to the lower angle of the scapula ; beneath 
 this there is normal resonance for the space of about two 
 
DISEASES OF THE HEART 429 
 
 inches, gradually shading into complete liver dulness. The 
 percussion on the left side is normal, both in front and 
 behind. 
 
 On auscultating over the heart's apex the first sound is 
 found to be impure ; the second unusually loud. Over the 
 upper part of the sternum and the dull part to its right, 
 there is a rough double murmur audible as low down as the 
 fourth costal cartilage ; at this spot, however, there is only 
 a systolic murmur to be heard followed by a second sound. 
 In the pulmonary area the second sound is obscured by the 
 diastolic murmur, but it may be picked up quite pure on 
 passing the stethoscope to the left in the plane of the second 
 interspace. The rough double murmur continues audible 
 over the innominate, but over the rounded pulsating tumour 
 above the clavicle only a loud systolic murmur is to be heard. 
 Over the bluish, lobulated, venous tumour, especially close 
 to the trachea, a loud purring whiz is audible, and this is so 
 loudly propagated into both carotids as entirely to obscure 
 any other acoustic phenomena which might perchance have 
 been audible in them. Over the upper part of the posterior 
 tumour there is a loud whiz ; over its lower part merely a 
 systolic murmur. Over the left lung the respiration is 
 vesicular, but somewhat feeble. On the right side the 
 respiratory sounds are entirely obscured by the murmurs 
 described, except in the part beneath the scapula, where the 
 respiration is vesicular but slightly liigher in pitch than on 
 the left side, and a similar statement may be made as to the 
 respiratory sounds heard over the lower part of the right 
 lung anteriorly. The patient's other organs and systems 
 are normal. 
 
 Here we had to do apparently with an aneur}' sm of the 
 ascending part of the aorta, involving the innominate and 
 subclavian, with a bulging projection from the latter vessel 
 which communicated with the veins of the neck, its history 
 and mode of origin being obscure. It was impossible to 
 decide as to the character of the posterior pulsating tumour. 
 
430 CLINICAL LECTURES ON 
 
 The patient was seen and examined by almost all of the 
 physicians and surgeons attached to the Infirmary, but no 
 definite opinion was arrived at. It seemed to be either an 
 aneurysmal dilatation of the posterior scapular artery, or a 
 cirsoid aneurysm invohdng it and its branches. There was 
 no reason to suppose that it arose from the aorta perforating 
 the chest posteriorly. Under either of the suppositions 
 sugo'ested it seemed to be a favourable case for galvano- 
 puncture, and this all the more that the pulsation could be 
 almost completely controlled by pressure above the clavicle. 
 My colleague. Dr. John Duncan, whose large experience in 
 regard to galvano -puncture is so well known, was kind 
 enough to undertake the treatment under my supervision, 
 and continued it for more than six months. After each 
 application of the needles the circulation in the tumour was 
 controlled and the pulsation suppressed by a large bag of 
 sliot firmly bandaged over the supra-clavicular space. After 
 each application the usual results followed, the development 
 of a certain amount of gas and the consequent diminution of 
 the pulsation, but it was several months before any firm 
 nodular coagula could be detected. At last, however, these 
 made their appearance and gradually spread, till we hoped 
 that a cure of this part of this poor man's ailment was about 
 to be secured. This hope was delusive ; these coagula never 
 accumulated or coalesced ; on the contrary what seemed to 
 be craiued at one stance was too often lost before the next, 
 though they were not unduly postponed, but were repeated 
 at as short intervals as possible. At last the patient was 
 discharged on 8 th May somewhat improved, and the pulsation 
 beneath the scapula lessened. I have seen him since his 
 discharge in his own house at Newport and found him much 
 as he was on admission, all that seemed to be gained having 
 been lost. I have not seen him lately, but have just (1897) 
 heard from his medical attendant, Dr. Stewart, that M'Intosh 
 is in excellent health and has been working at his trade for 
 some years without discomfort. If we cannot claim M'Intosh 
 
DISEASES OF THE HEART 431 
 
 as a cure, lie has certainly lived twenty years longer than 
 many so-called cures. 
 
 Professor MacEwen of Glasgow started the idea that 
 galvano-puncture coagula were apt to melt away because 
 they were merely red clots, and that in the cure of aneurysm 
 the only clots of any value were the white thrombi originating 
 at the point of injury to the sac wall as part of a reparatory 
 inflammatory process. With this idea he introduced a needle 
 into the sac, and by scratching the lining wall he started 
 quite a number of reparatory /oa with their white thrombi. 
 MacEwen treated four cases of aneurysm in this way, and 
 claims that he cured two of them.^ 
 
 Dr. Stewart of Philadelphia has, within the last few years, 
 introduced a combination of the wire treatment with galvano- 
 puncture which seems to combine the advantages of both 
 methods.^ Stewart introduces ten feet of snarled, coiled, fine 
 gold wire into the sac and passes a galvanic current through 
 this, with the result of rapidly filling the sac with firm 
 coagula. Three to five feet of wire is sufficient for a sac three 
 inches in diameter ; this is introduced through a needle, and 
 attached to the anode or positive pole, which should invariably 
 be the active electrode. The negative rheophore should be a 
 large clay plate, or an absorbent cotton pad made after the 
 method of Massey, and should be placed upon the abdomen 
 or the back. The current should be slowly brought into 
 circuit and its strength gradually noted by an accurate 
 milliampere-meter. The strength of the current should be 
 rather high — from forty to eighty milliamperes, and the sitting 
 long — from three-quarters of an hour to an hour and a half. 
 All areas of the sac are thus reached through the coiled and 
 snarled wire, and consolidation of the contents by means of 
 clot formation is promptly and invariably produced. Dr. 
 Stewart has given details of several cases treated by himself 
 and others in this manner, which is certainly the most 
 
 1 British Medical Journal (November 1890), pp. 1107 and 1164. 
 - lUd. (14th August 1897), p. 387. 
 
432 CLINICAL LECTUKES ON 
 
 scientific and apparently the most hopeful method of em- 
 ploying galvano-puncture.^ 
 
 The late Professor Langenheck of Berlin^ strongly re- 
 commended the hypodermic injection of crgotine as a cure for 
 aneurysm, on the strength of two cases which were thus 
 successfully treated by him. The first was an aneurysm of 
 the subclavian and innominate arteries, in a man aged forty- 
 five. He had a pulsatile swelling the size of one's fist in the 
 right supra-clavicular fossa, with excruciating pain in the 
 right arm, and consequent sleeplessness. From 6th January 
 to I7th February 1869 injections of ergotine of from half a 
 grain to three grains were made at regular intervals of about 
 three days. This treatment was followed by great relief to 
 the patient and considerable diminution of the tumour. The 
 second case was a saccular aneurysm of the radial artery, in 
 a man aged forty-two. One single injection of ergotine was 
 followed by complete subsidence of the tumour. Next day 
 the aneurysm had in some degree returned, and there was 
 slio'ht swelling and infiltration in the neighbourhood of the 
 puncture. After eight days these symptoms had all dis- 
 appeared, and not a trace of the tumour could be perceived. 
 Lano-enbeck's accuracy and skill as an observer were too well 
 known to permit his observations to be ignored ; at the same 
 time, if the action of ergotine be, as he supposed, on the 
 unstriped muscular fibre, it is difficult to see what possible 
 result this could have had on the larger tumour described, 
 as the muscular fibres surrounding it must have been few 
 and sparse indeed. It seems possible that this treatment 
 may have some effect on small aneurysms connected with 
 small arteries ; but for the reason stated it seems impossible 
 that it could have any effect on large aneurysms, especially 
 those springing from large arteries. I have employed the 
 hypodermic injection of ergotine repeatedly, and in one case 
 
 ^ Vide American Journal of the Medical Sciences, October 1892 and 
 August 1896. 
 
 - Berliner klinische TVochenschrift, March 1869, and Edinburgh Medical 
 ■Journal (November 1869), p. 461. 
 
DISEASES OE THE HEAET 433 
 
 continuously for many months, without observing the very 
 slightest result, and yet the preparation was unquestionably 
 active, as proved by the excellent results we obtained by its 
 use in haemorrhages, both in haemoptysis and in epistaxis. 
 It would, however, be unfair to omit all allusion to this 
 subject in any treatise purporting to present modern views 
 of the treatment of aneurysm. The preparation used by 
 Langenbeck was Bon jean's watery extract diluted with three 
 times as much rectified spirit and glycerine. That which I 
 employed was prepared in this country, and was undoubtedly 
 active, as proved therapeutically as well as physiologically, 
 one grain of the preparation hypodermically injected sufficing 
 to stop completely the circulation in a frog for fully five 
 minutes.^ 
 
 Pressure, as a mode of treating aneurysm, however useful 
 in regard to external aneurysms, is of course wholly in- 
 applicable to those within the thorax, and also as a rule to 
 those within the abdomen. One case of abdominal aneurysm 
 has, however, been recorded by Dr. William Murray of 
 Newcastle-on-Tyne, in which pressure on the aorta immedi- 
 ately above the tumour was successful in curing the disease. 
 The first attempt in this case, a man aged twenty-six, failed! 
 On the second attempt the patient was kept for five hours 
 under chloroform, and pressure was fully maintained by a 
 properly constructed tourniquet. The result was that in 
 three months the patient was at his work as an engine-fitter, 
 perfectly cured. The tumour itself, the aorta below it, the 
 iliac and femoral arteries were quite pulseless.^ Cases of 
 abdominal aneurysms in which this treatment is available 
 must be rare, but it may be more frequently useful in iliac 
 aneurysms, and it is well to remember that, in fitting cases, 
 
 1 Vide a paper by the late Dr. Hirschfeld, "On the Action of Ergot and 
 Ergotine," in the Medical Press and Circular (February 1870), p. 139. 
 
 - Medico-Chirurgical Transactions, vol. xlvii. p. 187 (London, 1864) ; and 
 Medical Times and Gazette (April 1865), p. 383, in which is a further report 
 of the case, showing the cure to have been complete ; vide also the PMpid Cure 
 of Aneurysm, by William Murray, M.D., F.R.C.P. (London: J. and A. 
 Churchill, 1871). 
 
 28 
 
434 CLINICAL LECTURES ON 
 
 we have iu pressure a remedy capable of producing a much- 
 to-be-desired result in a comparatively short time. The 
 treatment which, however, has for long been deemed by 
 physicians as that most suitable for internal aneurysms, is 
 that called by the name of its most strenuous advocate, 
 Valsalva's treatment, though, as we learn from Morgagni, 
 Albertini had an almost equal predilection for its use. When 
 pushed as far as its originator desired, this consisted in 
 weakening the patient by repeated blood-lettings, and by 
 gradually diminisliing his food and drink till only half a 
 pound of pudding was taken morning and evening, along with 
 a measured quantity of water. -^ This was continued until the 
 patient was so reduced that he could not lift Ms hand from 
 the bed in which, by Valsalva's orders, he lay from the 
 commencement of the treatment. After this the quantity of 
 nutriment was gradually increased till the patient's strength 
 was again restored. We have the testimony of many 
 physicians that this treatment has been useful in many cases, 
 and it can scarcely be thought necessary to adduce seriatim 
 evidence in favour of a practice originally suggested by 
 Hippocrates,- and which after a varying fashion has kept its 
 place in therapeutics ever since.^ In recent times the late 
 Dr. Bennett of Edinburgh attempted to revive this treatment. 
 His patient was repeatedly purged freely ; he twice had a 
 dozen leeches applied over the tumour; was twice bled to 3xii., 
 and several times to syncope, wliile his diet was extremely 
 low, his dinner being only 5ii. of steak and 5ii. of bread, yet 
 after forty days' treatment he retained sufficient strength to 
 walk two hundred and fifty yards to the nearest cab-stand on 
 his way from the city. Bennett expressed his satisfaction with 
 the treatment and his determination that his next case should 
 be even more rigorously treated.^ But in spite of its occa- 
 
 ^ Morgagni, Be Sedibus et Causis Morborum, Letter xvii. Art. 30. 
 - Dc Morbis, lib. i. n. 10. So Hodgson says ; the reference and the fact 
 seem both doubtful ; possibly Hodgson founds upon the 6th aphorism. 
 ^ Hodgson, op. cit. p. 145, etc. 
 * Monthly Medical Journal (1850), p. 169. 
 
DISEASES OF THE HEART 435 
 
 sional success, modern physicians have almost unanimously 
 agreed to discard this treatment, and, as we have seen, have 
 adopted the most hazardous procedures in preference. And 
 this for two reasons, the first of which, though really the one 
 of least importance, is the great difficulty with which it can 
 be carried out. In hospital practice it is almost impossible 
 to do so efficiently, on account of the childish self-will of the 
 patients and the facilities they have for transgressing. It is 
 only amongst the better classes that we find men of sufficient 
 firmness of mind fully to conform to the rigorous behests of 
 this treatment. The only patient I have seen who fuUy 
 complied with these behests was not effectually benefited, 
 though his distressing symptoms were temporarily relieved. 
 This difficulty about the dieting is, however, of little conse- 
 quence, as most physicians are now agreed — and this is the 
 second and most important reason why this treatment has 
 been given up — that, fully carried out, this treatment is more 
 apt to be injurious than remedial. From the repeated vene- 
 sections the heart's irritability is increased and its pulsations 
 are more frequent; while the long-continued rigorous diet 
 diminishes the coagulability of the blood by causing an 
 ultimate decrease in its fibrine. So much is this the case 
 that Dr. Copland remarks that he has seen aneurysmal 
 tumours which did not increase so long as the patient avoided 
 any cause of vascular excitement and continued his ordinary 
 diet, suddenly become greatly aggravated, increased in size, 
 and hastened to a fatal termination, when repeated depletions 
 were practised and vegetable or low diet adopted.-^ Tliis is 
 so consonant with physiology and with experience that I 
 shall not multiply quotations to prove it, but content myself 
 with recording it as the chief reason why this treatment has 
 ceased to be employed. On the other hand we know that it 
 is the blood-pressure that enlarges the sac and ultimately 
 ruptures it, hence lowering of the blood-pressure must be 
 and is the principal indication in promoting the cure of 
 
 ■^ Medical Dictionary (1864), vol. i. p. 77. 
 
436 CLINICAL LECTURES ON DISEASES OF THE HEART 
 
 aneurysm.^ This important truth has been fully confirmed 
 by the experience of modern surgeons, who have found that 
 to cure external aneurysms by compression, it is not necessary 
 completely to arrest the llovv of blood through the tumour, 
 but merely so to moderate the current as to make it incapable 
 of forcibly distending the sac. Hence many physicians have 
 adopted a modification of Valsalva's treatment, in which the 
 importance of the recumljent position is fully insisted upon 
 as a means of reducing the frequency of the pulse, while the 
 diet is only so far restricted as to diminish the amount of the 
 circulating fluid without impairing its physiological qualities. 
 A considerable amount of success has attended this modifica- 
 tion of Valsalva's cure, and Professor Tufnell has recorded 
 eight cases of marked improvement, some of them indeed of 
 apparently perfect cure.- On the other hand this treatment 
 has not always been so successful ; and even on Tufnell's 
 own showing it is incapable of relieving the severe neuralgic 
 pain which is so prominent a feature in many of these cases, 
 for the relief of which various other remedies were of 
 necessity had recourse to, with more or less success. 
 
 ^ Hodgson, op. cif. p. 164. 
 
 - Tufnell, The Successful Treatment of Interna! Aneurijsni, hy Consolida- 
 tion of the Contents of the Sac, second edition (Dublin, 1875). Tufnell very 
 properly insists much on the importance of recumbence in reducing the 
 frequency of the pulse, and of the impoi'tant effect this must have upon the 
 aneurysm. Graves considers that recumbence reduces the pulse in health 
 from six to fifteen beats per minute, according to its rate. In debilitated 
 and febrile conditions, the reduction is much greater. — Dublin Hospital 
 Reports, vol. v. p. 561. 
 
LECTUEE XVII 
 
 ox THE TREATMENT OF ANEURYSM BY POTASSIUM IODIDE 
 
 All the methods of treating aneurysm I have hitherto 
 described have been based upon what Tufnell has called 
 " the consolidation of the contents of the sac." To attain 
 this object, the most hazardous experiments have been under- 
 taken, for, not content with the comparatively innocuous use 
 of electrolysis, pressure, or starvation, the sac has been 
 stuffed with iron wire, sterilised catgut, or horsehair, to 
 provide a basis upon which the coagulum might form, but 
 without much success. Coagulating fluids — such as the 
 perchloride of iron — have been injected into the sac, and 
 aneurysms have been treated by manipulation, the sac being 
 kneaded and squeezed so as to break up any clots within it, 
 with the view of occluding the mouth of the sac or the distal 
 artery, or at least of providing by the broken down clots 
 fresh nuclei for further coagulation. Some cures have been 
 thus effected, but at great risk, and we hear nothing of the 
 failures. It is not, indeed, ever safe to attempt to occlude 
 the sac in this way, from the risk there is of fatal embolism 
 attending the process. But, as I have already mentioned, 
 there is a method of cure in which no risk is run, in which 
 there is no attempt to consolidate the contents of the sac, 
 but every endeavour to strengthen and consolidate its walls. 
 Wlien a hollow muscle, like the bladder, is opposed to an 
 obstacle it cannot overcome, such as an impervious stricture 
 of the urethra, it dilates and may go on dilating till it bursts. 
 But should the obstacle — the stricture — be one with which it 
 
438 CLINICAL LECTUIIES ON 
 
 can successfully cope, it not only does not dilate, it contracts 
 and hypertrophies. Upon this truth is based that other 
 treatment of aneurysm I am now about to describe. In the 
 normal condition, the coats of an artery dilate as a blood- 
 wave passes ; they contract upon it, and in thus returning to 
 their normal state they aid the onward movement of the 
 blood. But when the arterial coats have lost their elasticity, 
 they yield — but with difficulty — before the blood-wave, and 
 they contract imperfectly upon it, the circulation is hindered, 
 and the artery itself becomes in time uniformly dilated ^ — it 
 becomes a true aneurysm. In like manner when one or 
 more of the arterial coats (usually the media, vide antea, p. 
 405) has been in any way locally injured, that part is unable 
 to resist the normal blood-pressure ; it dilates and forms a 
 saccular aneurysm, which, under the continuous strain of the 
 blood-pressure, may go on dilating till it ruptures. The only 
 means that nature has at her command to prevent this un- 
 toward end is to fill up the sac with successive layers of clot; 
 and art, as we have seen, has endeavoured to promote a 
 similar cure by various procedures more or less hazardous. 
 But if by any means we could lower the blood-pressure 
 sufficiently, we would find that the arterial coats would 
 behave like a hollow nuiscle ; tlieir natural elasticity, relieved 
 from the distending force, would slowly contract, the tumour 
 would gradually diminish in size, and in course of time the 
 elastic contraction of the arterial coats would be supplemented 
 and permanently maintained by their hypertrophy, particu- 
 larly by the hypertrophy of the advcntitia. Now this is 
 exactly what we do by the use of potassium iodide ; we lower 
 the blood-pressure sufficiently to enable the natural elasticity 
 of the arterial coats to contract the sac temporarily, and by 
 and by this contraction is strengthened and made permanent 
 by hypertrophy of these coats, and mainly of the adventitia. 
 I think I shall be able to give ample proof of the truth of all 
 these statements. 
 
 • The Senile Heart, p. 15, etc. 
 
DISEASES OF THE HEAKT 439 
 
 In estimating the value of potassium iodide in the treat- 
 ment of aneurysm, we must ever remember that it is 
 absolutely innocuous ; risk of death or injury attends the 
 employment of every other method of treatment that has 
 been suggested ; the use of potassium iodide alone is ab- 
 solutely devoid of any danger. Further, while other measures 
 require to be supplemented by the free use of narcotics to 
 relieve the atrocious neuralgia which is so usual an accom- 
 paniment of aneurysm, potassium iodide relieves the pain 
 and other symptoms so effectually and so sjjeedily that it is 
 sometimes difficult to get the patient to submit to any 
 restriction whatever. So far as diet is concerned, indeed, 
 only very moderate restriction is ever necessary — to avoid 
 things indigestible; quantity may be safely left to the 
 cravings of nature, while in respect of fluids the only im- 
 portant restriction is in regard to alcohol — the patient must 
 be absolutely teetotal for the rest of his life. It is, as we 
 shall presently see, a great advantage to commence the treat- 
 ment with a few weeks of recumbency, but even this is not 
 always necessary. I was acquainted with a gentleman who, 
 in 1868, had a large and forcibly pulsating aneurysm arising 
 from the ascending aorta and passing to the right, who was 
 permitted to go about in moderation during the whole period 
 of treatment. ^N'evertheless the improvement was so great 
 that in 1871 there was only a feeble pulsation to be felt over 
 the upper part of the tumour. This gentleman was under 
 continuous treatment for a whole year, and ever after took 
 the iodide at intervals. He was so well that for two autumns 
 he shot regularly on the moors, and he was so active that it 
 was difficult to restrain his movements. His unrestrainable 
 activity cut him off at last ; after a convalescence of over five 
 years he insisted on going salmon fishing, and stood for a 
 whole forenoon up to his waist in water on a chill October 
 day, wielding a heavy salmon rod. The natural result 
 occurred : he caught a bad cold ; his aneurysm enlarged con- 
 siderably ; he had a series of fainting fits, and a serious illness 
 
440 CLINICAL LECTURES ON 
 
 from which he ultimately recovered apparently not much the 
 worse. Scarcely convalescent, he went off to business, not in 
 his own comfortable carriage but in an open tramway car, 
 caught a fresh cold, and about a week subsequently ruptured 
 his aneurysm in a fit of coughing, and died. 
 
 I need hardly say that aortic aneurysm, even of consider- 
 able size, is not always incompatible with an active life, the 
 pain either ceasing or at least being much modified after the 
 chest wall has been perforated. 
 
 Some few years ago there was in Dublin a prize-fighter 
 by profession, who had a large aneurysm projecting through 
 his sternum ; yet he suffered so little that he continued to 
 maintain himself by his repulsive calling, only taking the 
 precaution of putting an iron cage over the tumour when he 
 went to battle. One of those patients whose cases are subse- 
 quently related maintained himself as a hotel porter for ten 
 years with a large aneurysm projecting through his chest 
 wall. Thus continued immunity from suffering, and capacity 
 for exertion, prove nothing ; they may or may not be due to 
 treatment. But when we find a drug relieving suffering, 
 mitigating every symptom, and restoring capacity for exertion 
 when lost, not only occasionally but in almost every case in 
 which it has been fully tried, all who know anything of 
 aneurysm will agree that it must be a remedy deserving of 
 the fullest confidence. And our confidence is increased 
 when we find that these favourable results can be obtained 
 altogether apart from the adjuvance of diet, rest, or of any 
 special change in the habits of the patient ; not that these 
 things do not help, but that at times and for special reasons 
 they may be dispensed with. 
 
 As has been so often the case in medicine, the adoption 
 of this remedy for aneurysm has not been the result of any 
 speculative ideas as to the nature of the disease, nor has it 
 been based upon any known action of the drug, but has been 
 entirely founded upon empirical observations — observations so 
 opposed to all that was known on both of the points referred 
 
DISEASES OF THE HEART 441 
 
 to, that for long it was impossible to give any intelligible ex- 
 planation of them. The late Dr. Graves of Dublin was the 
 first to direct attention to the beneficial effects of large doses 
 of iodide of potassium in painful affections of the fasciae and 
 nerves ; and it is many years since the late Mr. Craig of 
 Eatho informed me that a patient of his, who was taking 
 seven grains of potassium iodide three times a day for a 
 chronic rheumatic affection, liad also obtained complete 
 relief from the neuralgic pains arising from a large aortic 
 aneurysm. It struck me at the time that the unexpected 
 relief might not be accidental, and that the treatment was 
 worthy of further trial, and I had already treated my three 
 first cases — XLI.,XLII.,and XLIII. — and was about to publish 
 them, when I became acquainted with the following history 
 of this method of treating aneurysm : — 
 
 About 1859 a Pole presented himself to M. ISTelaton with 
 a tumour in the lower part of his neck, which had been 
 recognised by MM. Bouillaud, Andral, and Beau as an 
 aneurysm of the innominate artery implicating the aorta. 
 This Pole stated that while in Warsaw his sufferings had 
 been much relieved by the use of potassium iodide. M. 
 Nelaton took the hint, and continued the remedy, the result 
 being, to his great surprise, a notable amelioration of all the 
 symptoms and an almost complete disappearance of the 
 tumour, so that the Pole was able to return home in a 
 satisfactory state of health. M. Bouillaud was the next to 
 follow out this plan of treatment in four cases which he has 
 narrated. The first was a woman with an aneurysm of the 
 carotid artery the size of a pigeon's egg; she had fifteen grains 
 of potassium iodide for several days, and afterwards thirty 
 grains a day for two months. At the end of this period the 
 tumour had so much diminished that it might be considered 
 to have completely disappeared. The second case was an aneu- 
 rysm of the brachio-cephalic trunk and aorta in a man, which, 
 under similar treatment, underwent considerable displacement 
 and a well-marked diminution in size. He was still under 
 
442 CLIXICAL LECTURES ON 
 
 treatment \yheii these cases were published. The third case 
 was a large aneurysm at the point of origin of the carotid 
 and subcla^'ian arteries in a man ; this had considerably 
 diminished in size after a few weeks of similar treatment. 
 The fourth case was a carotid aneurysm in a man ; it too had 
 almost completely disappeared after a few weeks of the same 
 treatment.^ 
 
 "V\lule this problem was thus being experimentally 
 worked out in our western hemisphere, an independent 
 observer in the eastern hemisphere was also empirically 
 investigating the peculiar action of potassium iodide in 
 aneurysm, to which his attention had been casually du'ected, 
 and with no less remarkable results. On commencing 
 hospital duty in August 1860, Dr. Chuckerbutty of Calcutta "' 
 found in the wards an Irishman, aged fifty, afflicted with a 
 harassing cough accompanied with profuse expectoration, 
 which continued unrelieved until potassiimi iodide was 
 administered in decoction of cinchona. Coincident with the 
 relief to the cough. Dr. Chuckerbutty was astonished to find 
 that an aneurysm of the innominate, from which this man 
 also suffered, had gradually become soKdified. This aneurysm 
 projected above the sternal notch, and was at first the size of 
 a walnut, with tliin walls, and readily emptied ; it grew 
 steadily upwards into the neck, passing beyond the median 
 line, till it attained the size of an orange, subsequently 
 becoming hard and consolidated under the use of potassium 
 iodide. Some months afterwards this man died from an 
 attack of bronchitis, and the aneurysmal sac was found to be 
 as large as a pear, and filled with dense coagula, which left 
 merely a naiTow channel on their outer aspect through 
 which the right carotid and sulx;la\'ian communicated with 
 
 ^ These cases are referred to in Dr. Roberts' paper presentlj' to be quoted ; 
 they are given in full in the Cliaique Europeene for Jul\' and August 1859. 
 M. Bouillaud's cases are quoted in the Union Medicale of 8th March 1859, and 
 are detailed in a clinical lecture published in the Gazette dcs HCjntaux of the 
 same year. 
 
 - British Medical Journal, 19th and 26th July 1862. 
 
DISEASES OF THE HEART 443 
 
 the aorta. Suspecting some causal connection between this 
 unexpected result and the remedy employed. Dr. Chucker- 
 butty proceeded to treat other aneurysms in the same manner, 
 and of these he has related three. The first of these was a 
 man, aged forty-seven, with an immense aneurysm of the aorta, 
 who obtained great temporary rehef from the use of four 
 grains of potassium iodide three times a day. This treatment 
 was continued from 7th December to 12th January, when 
 death occurred from rupture. Three hours after death the 
 sac was found to be filled with dense, solid coagula. The 
 second case was also a man with a large aortic aneurysm. 
 Though only under treatment for less than three weeks, there 
 was yet so great an amendment that the man thought himself 
 cured, and insisted on leaving the hospital to spend Christmas 
 with his friends. He did not return for more than three 
 months ; his symptoms were intensely aggravated, and he 
 died in three days. The third case was a man with an aortic 
 aneurysm, projecting as a dome-shaped tumour two inches in 
 diameter through the sternum. Various remedies had been 
 employed ineffectually, but under the use of potassium iodide 
 internally, coupled with the application of tincture of iodine 
 externally over the tumour, the patient steadily improved. 
 The thoracic pain ceased ; the tumour diminished ; the 
 haemoptysis ceased, and the patient ate and slept like any 
 other man. He was still under treatment when the paper 
 was sent home for publication. Dr. Chuckerbutty points 
 out that the important fact in the history of these cases was 
 the consohdation of the contents of the sac, and contends 
 that this depends upon some hitherto unsuspected action of 
 potassium iodide.-^ This opinion seems also to have been 
 shared by Dr. Eoberts of Manchester, to whose interesting 
 paper I shall now refer. 
 
 About the beginning of 1862, Dr. Roberts was consulted 
 by Mr. T. "Windsor in regard to a case of aneurysm, and his 
 
 ^ This very natural mistake as to the action of potassium iodide has done 
 much to retard the usefulness of this important method of treating aneurysm. 
 
444 CLINICAL LECTURES ON 
 
 attention for the first time directed to the important remedial 
 action of potassium iodide in that disease. The patient was 
 a ladj, aged twenty-nine, who liad an aneurysm of tlie aorta 
 implicating the origin of the innominate. There was exces- 
 sive pulsation at the root of the neck on the right side, 
 repeated slight attacks of haemoptysis, occasional loss of 
 voice, dysphagia, constant troublesome cough with scanty 
 expectoration, and recurrent paroxysms of pain and dyspnoea 
 so severe as to compel her to get up and walk about. Under 
 a regulated diet and strict confinement to the recumbent 
 posture her condition became steadily aggravated. She 
 became so weak and emaciated as to be unable to leave her 
 room ; the right clavicle projected half an inch beyond its 
 natural level, and the pulsation was much increased. In 
 April 1862 she was put upon potassium iodide with the 
 view of relieving the severity of the pain, and this object 
 having been attained the remedy was discontinued, having 
 only been employed one week. At last, in July 1862, when 
 she was so much worse that death seemed not far off, Mr. 
 Windsor put her upon five grains of potassium iodide three 
 times a day ; this was subsequently increased to ten grains, 
 and again reduced to five on account of profuse salivation. 
 The five -grain dose agreed, and the patient continued 
 taking it up to the time of the publication of the case,^ 
 The result of the treatment was a rapid subsidence of all 
 the general symptoms, complete cessation of cough, pain, 
 dysphagia, and haemoptysis, while the patient gained flesh 
 and strength and in a few months was able to walk six miles ; 
 the clavicle also subsided to its normal position, Dr, 
 Roberts- subsequently treated in the Manchester Eoyal 
 Infirmary a man, aged thirty-nine, in whom the first bone of 
 the sternum and its vicinity were the seat of heaving pulsa- 
 tion, while in the second left intercostal space there was a 
 conical, soft, pulsating elevation, projecting about a quarter 
 of an inch, and with a base the size of a shilling. Over the 
 ^ British Medical Journal for 24th January 1863. " Loc. cit. 
 
DISEASES OF THE HEAET 445 
 
 bulging part there was an area of dulness measuring 
 transversely four inclies and a half, and vertically three 
 inches and a half There was pain in the left side of the 
 head and shoulder, dyspnoea, dysphagia, and some cough. 
 This patient was put upon a restricted allowance of fluids, 
 and had fi^'e grams of potassium iodide given him three 
 times a day. In three days the dose was raised to seven and 
 a half grains three times a day. In six days the patient 
 declared himself to be much better, his pain gone, and the 
 cough and difficulty of breathing less troublesome. The 
 dose of the iodide was then raised to ten grains three times 
 a day, and after seventeen days' treatment the pain, the 
 dysphagia, and dyspnoea were quite gone : the pulsatino- 
 tumour had entirely subsided; the patient was allowed to 
 get up, and his restrictions were relaxed. The dose was 
 now increased to fifteen grains, and after twenty-five days' 
 treatment to twenty grains thrice a day. After this dose 
 had been continued for about five days it was reduced to five 
 grains on account of the supervention of diarrhoea. The 
 bulgmg was decidedly less ; the area of duhiess was reduced 
 to three inches and a half transversely, by two inches and a 
 half vertically. The projecting tumour had quite disappeared, 
 and the general pulsation was almost gone ; but the enlarged 
 superficial veins, and the stridulous voice, still remained to 
 show- that the cure was not complete.' In this case decided 
 emaciation was the accompaniment, if not the result of the 
 treatment. Dr. Eoberts ^ also relates a case w^hich occurred 
 under the care of his colleague. Dr. Wilkinson, of a laro-e 
 thoracic aneurysm in a man, projecting in the neck as a 
 tumour the size of a child's head, extending from the left 
 clavicle to the angle of the jaw, and apparently about to 
 burst. Fifteen grains of potassium iodide w^ere administered 
 three times a day ; the pain was lessened, and the growth 
 seemed stayed, but the patient died in seventeen days from 
 gangrene of the lung, the result of pressure upon the left 
 
 ^ British Medical Journal, 24th January 1863. 
 
446 CLINICAL LECTURES ON 
 
 pneumogastric nerve. The sac was found lined with coagula, 
 and a large, firm blanched clot, attached by a broad pedicle 
 to its upper part, floated free within it. 
 
 During the last thirty years, I have employed the 
 potassium iodide in the treatment of aneurysm with un- 
 varying success so far as relief to symptoms is concerned, 
 and with such favourable results in retarding the progress of 
 the case, and even, in some instances, promoting an apparent 
 cure, as certainly stamp this treatment as the most efficient 
 hitherto propounded for the relief of this intractable com- 
 plaint, while it has the further advantage of being in itself 
 wholly innocuous. On former occasions I have narrated in 
 full a number (eleven in all) of cases treated by this method, 
 but it is quite needless to enter into so much superfluous 
 detail ; I shall therefore content myself with giving such 
 an abstract of these cases as will suffice to show their 
 character, and to enable us to trace the manner in which the 
 true action of the potassium iodide was at first surmised 
 and finally proved, so far as such remedial actions can be 
 proved. 
 
 Case XLI. Peter Kice, a mason, aged thirty-nine, ad- 
 mitted into Ward III. on 29th April 1867.^ Patient has 
 never had rheumatic fever, but for five years past has been 
 subject to pains in his hip, leg, and back, which are severe 
 and most apt to recur during the changeable weather of 
 spring. He has been in the habit of drinking freely. About 
 twelve months before admission he fancied he was overwrought, 
 and when he got home he found he could not take a deep 
 inspiration with the usual freedom. He also felt a sharp 
 pain at a point about two inches to the right of the left 
 nipple and a little above it ; this pain has continued ever 
 since, and has latterly increased considerably. This pain is 
 stationary at the part described, but when more than usually 
 
 1 This case was at first under tlie care of Dr. Warburtou Begbie, acting 
 for Professor Laycock, and was transferred to my care when the clinical 
 wards were closed at the end of the summer session in 1867. The case is 
 partly taken from the clinical records of Ward III. 
 
DISEASES OF THE HEAET 447 
 
 severe it spreads upwards to the arm-pit and shoulder, and 
 down the left arm to the wrist ; occasionally it extends to 
 the scrobiculus cordis, and sometimes strikes sharply through 
 to a corresponding point at the back. The pain is specially 
 apt to be severe at night, preventing sleep, and is very 
 annoying when it affects his back, as he cannot lie in any 
 other position than the supine. He has occasional fits of 
 dyspnoea, and it is always painful to take a full inspiration. 
 He also has some difficulty of swallowing. He is much 
 troubled with palpitation and a distressing feeling of pulsation 
 within the chest, and these sensations annoy him most when 
 the pain is severe. At these times he gets some relief by 
 relaxing the respiratory muscles by leaning forwards and 
 resting against a wall or other support, with his hands and 
 arms extended. About a week ago his symptoms had so 
 much increased that he was compelled to cease working 
 entirely. His appetite is good; his bowels generally confined. 
 On percussion, the heart seems of normal size ; its pulsations 
 are distinct, and in their ordinary situation ; the first sound 
 is normal, the second accentuated. The right radial pulse is 
 fuller than the left. About three years ago the patient was 
 troubled with muscce, volitantes, lasting off and on for about 
 two years, and appearing only for a few seconds each time. 
 He still at times cannot see things at a distance so well as 
 he thinks he ought, and the letters seem to swim before him 
 when he reads. His left pupil is slightly dilated. Some 
 time ago he had tinnitus auriutn. His left cheek is often 
 flushed, and at times he feels it warmer than the other. His 
 lung sounds are normal, but he has an imperfect, hard, 
 clinking cough, without expectoration. He also frequently 
 perspires without any apparent cause. There is a slight 
 bulging of the walls of the chest between the second and 
 third ribs, at the left edge of the sternum, extending into the 
 manubrium sterni, and gradually declining all round, within 
 an area equal to that of the mouth of a tumbler. There is 
 dulness on percussion over this bulging, and a distinct feeling 
 
448 CLINICAL LECTURES ON 
 
 of liquid pulsation. Within this area the heart sounds are 
 extremely distinct, but there is no murmur. 
 
 Twenty grains of potassium iodide were given three times 
 a day, and a belladonna and opium plaster was applied over 
 the tumour. About a month subsequently a similar dose of 
 the bromide of potass was substituted for the iodide, and at 
 first he thought hunself Ijenefited by the change, but in about 
 a week the iodide was again had recourse to with the addition 
 of one-twelfth of a grain of iodine, Ijut in another month (7th 
 July) the iodide was stopped on account of coryza. It is 
 not known whether recourse was again had to the iodide 
 while the patient was in Ward III. ; it is, however, believed 
 that it was. The last entry is on 18th July — '• Thinks him- 
 self easier to-day." On 1st August the patient w^as trans- 
 ferred to Ward YII. and placed under my care. Eice was 
 at once given thirty grains of potassium iodide three times 
 a day, and these doses he continued to take without inter- 
 mission up to May 1868, with continually increasing benefit, 
 and without the production at any time of the slightest 
 unpleasant symptom. For several months he wore a bella- 
 donna plaster over the tumour, but at last it caused so much 
 eczema that it had to be given up. On coming under my 
 charge he was strictly confined to bed, and for long he lay 
 entirely on his back, that Ijeing the only position in which 
 he always found comparative, and latterly perfect ease. He 
 was not allowed out of bed till 2nd April, about three weeks 
 before his discharge. At first he was fed on fish, meat being 
 subsequently given when he tired of fish, but he was warned 
 to be strictly moderate both in eating and drinking ; water, 
 tea, and milk, being the only fluids supplied. Eice's progress 
 was extremely slow at first, but it was steady. In a clinical 
 lecture on his case on 19th Xovember 1867, it is stated, 
 " There is no longer any tumour visible, and it is only on 
 careful examination that you will discover any pulsation. 
 He has so far recovered that he is inclined to be rash, to 
 move about quickly in bed, and even to turn upon his side ; 
 
DISEASES OF THE HEAKT 449 
 
 but upon this the pulsation instantly returns — a sufficient 
 warning to him that he is not yet cured." It was not till 
 the beginning of March 1868 that he was able to move about 
 freely without discomfort, and without return of pain or 
 pulsation. On 1st April 1868 I showed him to the Edin- 
 burgh Medico-Chirurgical Society, just previous to his dis- 
 charge from hospital, and its members had an opportunity of 
 observing the complete subsidence of the tumour described, 
 pulsation being only obscurely felt at the spot. They also 
 heard the man's own statement that his pain, dyspnoea, and 
 dysphagia were gone, and they were able from his healthy 
 and energetic appearance to form some idea of the importance 
 and value of the treatment to which he had been subjected. 
 
 A year afterwards (1869) I reported to the Medico- 
 Chirurgical Society as follows : — " Peter Eice, labouring under 
 aneurysm of the aorta, has been repeatedly under observation 
 during the past twelve months. When first discharged, he 
 acted as night watchman for a month or two ; he was then 
 appointed to an institution for the care of orphan children ; 
 he walked about with them and took them to and from 
 school; latterly he set up a small shop as the easiest 
 way of making his living. He continued to take the 
 potassium iodide, but not regularly, and his aneurysm re- 
 mained as it was when he was discharged ; the same dull 
 thud audible in the second left intercostal space, but no 
 pain nor any uneasiness." ^ 
 
 Eice continued to present himself occasionally, till, after 
 a longer interval than usual, I found him in his working 
 clothes laying pavement on the street. He continued to 
 employ himself at his old trade of a mason for two years, 
 and his ability to pursue this laborious occupation for so 
 long and without suffering is sufficient proof of the reality 
 of his amendment. It is something surely akin to a cure to 
 be able to restore to so much usefulness one who so shortly 
 before had been crippled by the agonies of so terrible and, 
 
 ^ Edi-iiburgh Medical Journal (July 1869), p. 47. 
 29 
 
450 CUXICAL LECTURES OX 
 
 till then, so hopeless a disease as aortic aneurysm. Eice 
 died suddenly in the summer of 1872, while working in the 
 Botanic Garden ; he caught a bad cold some weeks previously, 
 and thinking and feeling himself otherwise quite well, he 
 took no care but continued to work as a labom^er up to the 
 moment of his death. The immediate cause of death was 
 haemorrhage into the pericardium from a very minute rent 
 at a comparatively thin part of the aneurysm, just where it 
 sprang from the aorta. The aneurysm itself was the size of 
 a small cocoa-nut, its walls everywhere dense and firm, save 
 just at the part where the rupture took place ; it contained 
 only ijost-mortcm clots. At the very outset of our experience, 
 we had thus a most remarkable case, in which the sufferer, 
 without risk to life, and with speedy rehef to suffering, was 
 so restored as to be able to maintain himself in comfort for 
 four years. The condition of the aneurysm was also in- 
 structive, it was contracted, its walls were dense and firm, 
 and it contained only post-niortem clots.^ It was in every 
 way a most instructive and satisfactory case ; but we had 
 much yet to learn. 
 
 ]\Iy next case, though more obscure in its diagnosis, was 
 even more immediately .satisfactory in its results. 
 
 Case XLII. John Kerr, a seaman, aged twenty-six, ad- 
 mitted into "Ward YII. on 22nd October 1867. He said he 
 had been ill for eighteen months, dating his illness from the 
 time of an arctic voyage, when he had been exposed to much 
 privation and had to make strenuous exertion in hauling 
 boats over ice and snow while in a feeble state of health. 
 In America he had been supposed to suffer from an aneurysm 
 of the abdominal aorta, and he presented himself at the 
 surgical wards of the Edinburgh Eoyal Infirmary to be re- 
 lieved of this, thence he was transferred to my care. Kerr 
 complained of intense pain in the scrdbiculus cordis extending 
 through to the back and passing round both sides. On ex- 
 
 1 The preparation is in the iluseum of the Royal College of Surgeons, 
 Edinburgh. 
 
DISEASES OF THE HEAET 451 
 
 amination a tumour could be obscurely felt a little below the 
 sternum, and just under the edge of the right false ribs. On 
 turning the patient over toward the left the tumour was 
 more readily felt ; it dropped, as it were, into the hand. Over 
 the tumour referred to, or at least as near as could be got, a 
 loud murmur was to be heard through the stethoscope. Xot- 
 withstanding the obscurity of the diagnosis, it was thought 
 desirable to give this patient potassium iodide, as likely to 
 be useful whether the tumour was solid or truly aneurysmal. 
 Accordingly he got tliirty grains of potassium iodide twice 
 a day ; he was put upon fish diet, a restricted amount of 
 fluids, and confined to bed. The result was remarkable ; he 
 got almost immediate relief from the agonising pain, the 
 uneasy pulsation felt by the man himself was at once con- 
 siderably lessened, and the force and volume of the radial 
 pulsations appeared to be also greatly diminished. He im- 
 proved steadily ; in a few months tumour and murmur had 
 quite disappeared, and on 22nd January he was discharged 
 at his own request, and engaged himself for a short voyage 
 to test his reacquired health before going to sea for a longer 
 term. The obscurity of this case is patent to all, yet the 
 signs and symptoms pointed strongly to aneurysm, and the 
 success of the treatment, coupled with the rapid manner in 
 which relief was obtained, seemed to confirm the diagnosis. 
 
 A year afterwards I reported as follows: — ■•John Kerr 
 left for a trial voyage, but never returned. In January 1869, 
 a year after his discharge, the ward nurse got a letter from 
 him dated Australia and saying he was now so well that he 
 was off to the g-old digcpings." -^ I have heard nothing more 
 of this patient. 
 
 The diagnosis in the nest case was more unequivocal, and 
 as the liistory includes the jjost-mortem appearances, we know 
 exactly what ailed him and to what extent it was remedied. 
 
 Case XLIII. James Wilson, a mason from Xewcastle, 
 aged forty-four, admitted into Ward YII. on 31st August 
 
 1 Edinhurgh Medical Journal (July 1869;, p. 48. 
 
452 CLINICAL LECTURES ON 
 
 1867. About nine mouths before admission this patieut 
 begau to have occasional attacks of lightness in the head with 
 a flashing of light before his eyes. These attacks came on 
 while he was at work, and obliged him to sit down for a 
 little to recover himself At first the seizures came only 
 once or twice a day, but they soon became more frequent, 
 and he always felt much weaker after them. During these 
 attacks he perspii'ed profusely. About the same time the 
 patient began to suffer from " beatings " in his abdomen, in 
 the left side of the chest, and on the right side of his neck. 
 A swelling also appeared at the right side of his neck w^hich 
 gave him great uneasiness, and produced a feehng of choking. 
 Getting no relief from those w^hom he consulted he came to 
 Edinburgh. On admission to the Infirmary it was found 
 that he had no pulse in the left radial artery, but for this 
 there was no apparent cause, the " beatings " on the left side 
 being evidently only cardiac palpitation ; on the other hand, 
 those in the abdomen, and on the right side of the neck, had 
 each an abnormal and e\ddent cause. In the lower part of 
 the epigastric region, towards the left side, and lying close 
 above the aorta, the course of which could be distinctly 
 traced, a tumour the size of a small orange could be distinctly 
 felt pulsating — expanding in all directions — and not merely 
 moved by the artery beneath it. Over this tumour a loud 
 systolic murmur was heard. On the right side of the neck 
 there was also a pulsating tumour extending up the neck 
 from the sterno-clavicular articulation towards the mesian 
 line. This tumour was somewhat larger and longer than that 
 in the abdomen ; it resembled in shape a large kidney potato, 
 and upon any excitement, especially when the man was up 
 and walking about, it increased considerably in size. No 
 distinct murmur could be heard over it, nevertheless it was 
 evidently an aneurysm implicating the innominate, subclavian, 
 and carotid arteries. Wilson was at once given thirty grains 
 of potassium iodide twice a day, and a diet and regimen 
 similar to that already described were prescribed for him. 
 
DISEASES OF THE HEAKT 453 
 
 but as his symptoms were not so urgent strict recumbence 
 was not insisted upon, and he was allowed to go to chapel 
 every night. The iodide was not so well borne by this 
 patient as by the two already commented on ; every now and 
 then pain in the stomach, or severe headache gave warning 
 that it was time to omit it. These symptoms always abated 
 after leaving off the medicine for a day or two. His appetite 
 always remained good, but his bowels required to be regulated 
 by medicine. No immediate effects were observed from the 
 iodide, but after some months the abdominal aneurysm was 
 found to be quite firm and apparently solid ; the murmur had 
 also disappeared, and could only be reproduced by pressing 
 somewhat strongly with the stethoscope. After a time the 
 aneurysm in the neck also ceased to swell out when he 
 walked about ; it gradually became firmer and ceased to give 
 him any inconvenience. His general health was much im- 
 proved ; he no longer had any disturbing pulsations, and 
 though he occasionally suffered from lightness in the head, 
 and from dazzling flashes of light, his condition was much 
 better than it had been, and, considering his inveterate 
 aneurysmal diathesis, he had probably reaped as much benefit 
 from the treatment as was possible. 
 
 A year subsequently I reported of him as foUows : — 
 "James Wilson, labouring under an aneurysm of the in- 
 nominate, implicating the subclavian and carotid arteries, 
 also an aneurysm of the abdominal aorta, and a general 
 diseased state of the vessels. This man worked for many 
 months comfortably and without inconvenience at his trade 
 of mason, avoiding, as desired, any heavy lifts ; he has now, 
 however, got an easier berth in connection with the Cale- 
 donian Eailway. His abdominal aneurysm is still to be felt 
 as a hard, firm knot, much diminished in size from what it 
 was. His innominate aneurysm never troubles hun, and 
 gives rise to no symptoms, but it is not consolidated, neither 
 is it any longer an aneurysm. To all intents it is nothing 
 now but an elastic artery, fusiformly dilated no doubt, but 
 
454 CLINICAL LECTUKES ON 
 
 no longer bulging as a globular pulsating tumour across the 
 trachea." ^ 
 
 This poor man presented himself every now and again for 
 inspection, and occasionally came into hospital for a week or 
 two for relief of catarrhal symptoms. On 27th June 1870 
 he re-entered hospital because of a recurrence of the symptoms 
 of abdominal aneurysm. The original abdominal aneurysm 
 was to be felt as a small hard nodule resting upon the aorta 
 just beneath a large, soft, pulsating swelling passing up 
 beneath the ribs on tlie left side. Over this tumour a 
 systolic murmur was to be heard ; the subjective symptoms 
 were confined to flatulence and occasional pain of a dyspeptic 
 character in the stomach. He was treated as formerly with 
 potassium iodide and with a similar result. By the beginning 
 of December 1870 he was about to be discharged when he 
 showed symptoms of typhus, caught through unauthorised 
 contact with fever convalescents in the infirmary chapel. 
 He was removed to the fever wards, passed through the 
 regular course of typhus, and after disinfection was received 
 back into a side-room seven weeks subsequent to his trans- 
 ference. On 24th January 1871 his abdominal tumour 
 measured six inches, from the lower edge of the hard nodule 
 of the first tumour to the point where it disappeared beneath 
 the ribs. The tumour lay along the aorta; it was three 
 inches in breadth, and could Ije readily grasped through the 
 thin abdominal parieties ; it was firm and devoid of lateral 
 pulsation ; and, unless firmly pressed upon by the stethoscope, 
 no murmur was audible, merely a dull thud. At its upper 
 extremity, however, just where it dipped beneath the ribs, a 
 slight systolic murmur was still to be heard, and this part of 
 the tumour seemed to have grown somewhat larger during his 
 illness. Wilson made a good recovery, was discharged, and 
 continued to maintain himself by manual labour till Septem- 
 ber 1873, when he was readmitted to the Infirmary for a 
 recurrence of symptoms of aneurysm, and he died there on 
 1 Edinburgh Medical Journal (July 1869), p. 48. 
 
DISEASES OF THE HEAET 455 
 
 1-itli October, over ^ix years after his first admission. The 
 large, recent abdominal aneurysm occupied the \Yhole of the 
 left h}^ochondriac region : at -fii-st its pulsations were c^uite 
 fluid, but under treatment the walls of the sac became firmer 
 and the pulsations less distinct, but it never diminished in 
 size ; indeed for this there was scarcely time before the patient 
 died exhausted. After death the whole of the aortic arterial 
 system was found to be greatly atheromatous ; the innominate, 
 subclavian, and right carotid arteries had thicker walls than 
 usual, and seemed altogether larger. The left subclavian 
 was plugged by a firm fibrinous clot just where it passed out 
 of the chest, the coats of the artery being contracted round 
 this plug. The descending aorta gradually dilated till, after 
 passing through the diaphragm, it developed into an aneu- 
 rysm the size of a large cocoa-nut, and below this there lay 
 the hard, firm nodule of the origmal aneurysm ; this contained 
 ovlj post-mortem clots, but its walls were made almost as dense 
 and hard as bone by atheromatous deposit. 
 
 Case XLIV. Peter Eeid, hotel porter, aged forty-six, 
 admitted into Ward A^I. 18th June 1868. This man was 
 drunk on admission, having avowedly taken spirits to nerve 
 himself for his apparently rapidly approaching dissolution. 
 He had intense dyspnoea, amounting to complete orthopnoea, 
 violent, harassing, but dry cough, and felt and looked as if on 
 the point of suffocation, while a large, soft, projecting and 
 pulsating tumour seemed to threaten death in another form. 
 He was ordered at once fifteen minims of chlorodyne to be 
 repeated every half-hour till the cough was quieted, and also 
 twenty grains of potassium iodide three times a day. He was 
 confined to bed, in which he was supported in a semi-erect 
 posture, and his food and drmk were somewhat restricted. 
 Within twenty-four hours this man expressed himself as much 
 relieved, and in a few more hours he breathed more freely. 
 Eeid was an old solcher, and about five and twenty years pre- 
 viously he had been cupped in a military hospital for palpita- 
 tions which continued more or less after his discharge. About 
 
456 CLINICAL LECTURES ON 
 
 ten years ago, in the end of February 1858, he was admitted 
 into this hospital on account of excruciating pain in the right 
 side and down the right arm, which had troubled him for 
 some months previously. There was also at that time a 
 slight swelling, accompanied by pulsation, to the right of the 
 sternum. The pain complained of was most excruciating in 
 winter, when he caught cold, or made any unusual exertion. 
 In about eighteen months the tumour protruded externally, 
 and then the pain ceased to be so agonising. During the past 
 eighteen months the tumour has grown more rapidly than it 
 has done for years ; this he attributes to the extreme violence 
 of his cough. 
 
 To the right of the sternum there was a large pulsating 
 tumour, extending from the third to the seventh rib, and 
 projecting fully half an inch beyond the level of the thoracic 
 wall. Part of this tumour was solid, but part, rather beneath 
 the middle, was soft, painful to touch, projecting conically, 
 and pulsating fluidly. Dulness extended for fully five inches 
 round the centre of the tumour, passing below into the liver 
 dulness. The pulse in the right arm was smaller than that 
 in the left. The heart's apex beat between the sixth and 
 seventh ribs and one inch to the left of the nipple, but there 
 were no indications of hypertrophy, and the cardiac dulness 
 was normal. There was cardiac displacement but no hyper- 
 trophy, and there were no abnormal murmurs to be heard 
 either over heart or tumour. The right pupil was somewhat 
 dilated. There was considerable pain in the right side and 
 down the right arm, but this was much less than formerly. 
 After the patient had somewhat recovered from the frightful 
 condition he was in when admitted, a belladonna plaster was 
 applied over the tumour, and the chlorodyne was gradually 
 stopped as the cough lessened. It had almost entirely ceased 
 by 12th August, at which date the patient looked, and ex- 
 pressed himself as feeling much relieved. The pulsation in 
 the tumour was much less forcible than formerly, and the 
 tumour itself was flatter and felt more solid. On 31st 
 
DISEASES OF THE HEAKT 457 
 
 August an icebag was substituted for the belladonna plaster 
 for a few days, but had to be given up, as, though it felt 
 comfortable enough and relieved the distressing pulsation, it 
 increased the cough very much. At this date he expressed 
 himself as feeling very comfortable, and able to breathe and 
 swallow easily, both of these acts having been hitherto 
 attended with much uneasiness, the tumour was also gradu- 
 ally decreasing in size. 
 
 Eeid was kept in hospital till 20th March 1869, when he 
 was discharged to go to his home in London. Thus this poor 
 dying creature was, after nine months' treatment, able to be 
 discharged in a comparatively active condition, and both 
 looking and feeling well. A cast taken from the projecting 
 tumour about a month after admission, and one taken on the 
 morning of his discharge, show the marked diminution in its 
 bulk. In a letter from my resident, the late Mr. Frank H. 
 Hodges, he says, "I called on Peter Eeid on 28th April, 
 and found him in a very satisfactory condition ; the tumour 
 has considerably diminished in size (since his discharge) ; he 
 is quite free from cough, and goes out for a constitutional 
 daily." 
 
 The next case is evidently not one of saccular, but rather 
 of true aneurysm (dilated aorta) with diseased arterial coats, 
 and gives very evident proof of what can be done for the 
 relief even of these cases by the treatment recommended. 
 
 Case XLY. Thomas Moody, aged thirty-nine, a slater 
 from Crossgates, Fife, admitted to Ward VII. on 11th July 
 1868, He stated that for sixteen months he had complained 
 of severe pain across the upper part of the sternum, and a 
 feeling of breathlessness. On percussion dulness was marked 
 across the whole of the upper part of the sternum. The 
 cardiac dulness was normal, or nearly so ; the apex beat in 
 the normal position between the fifth and sixth ribs. The 
 first sound was normal, the second wanting and replaced by 
 a double murmur ; the second or diastolic portion of this was 
 loudest at the aortic cartilage (the second right). This 
 
458 CLINICAL LECTURES ON 
 
 double murmur was propagated upwards into the arteries, 
 and its systolic portion was louder and rougher over the left 
 carotid artery than anywhere else. The finger pressed deep 
 into the tracheal fossa came in contact with a pulsating body. 
 The other organs and systems were natural. 
 
 Moody got thirty grains of potassium iodide three times 
 a day ; he was confined to bed, and had his food and drink 
 somewhat restricted. 
 
 The patient very speedily expressed himself as greatly 
 relieved. In a fortnight the rasping murmur over the left 
 carotid was much softened; the pulsation in the tracheal 
 fossa was still perceptible, but not so distinctly as formerly. 
 He was discharged at his own request on 3rd August 1868. 
 In this case there was no history either of rheumatism or 
 syphilis. 
 
 The case now to be related, on the other hand, is not only 
 a well-marked but also quite a remarkable case of aneurysm 
 of the aorta, one of itself quite sufficient to attract attention 
 to the treatment propounded, and which, as one of a series, 
 affords indeed a very marked illustration of the benefits to 
 be derived from it. 
 
 Case XLVI.^ Andrew Jamieson, a carter, aged forty, 
 admitted into Ward II. under Professor Bennett's care on 
 31st January 1868. About eighteen months before admission 
 this patient had an attack of pleurisy on his left side, but 
 with this exception he had been always healthy. About 
 twelve months ago, without known cause — as he is not 
 specially aware of having strained himself, though constantly 
 in the habit of lifting heavy weights into his cart — he began 
 to feel a severe and constant aching in the left side of his 
 chest, over a spot about the size of a crown piece about two 
 inches above the nipple. This pain was much increased on 
 exertion or on stooping. To relieve this pain he unavailingly 
 applied several mustard poultices, and took a quantity of 
 
 ^ The history of this case is partly condensed from the Clinical Records of 
 Ward n. 
 
DISEASES OF THE HEAET 459 
 
 cod-liver oil. Xotwithstandiag his sufferings he continued 
 at work till July 1867, but was then compelled to give in. 
 The pain was now more severe than ever, his breathing short 
 and wheezing; he had a troublesome cough, worse upon 
 exertion ; he had a choking feeling when he stooped, and a 
 difficulty in swallowing any solid food, the bolus seendng to 
 stick just opposite the upper margin of the sternum. His 
 voice was now also weak and somewhat hoarse — vox cmserina 
 — and he felt a disagreeable pulsation in his chest. For 
 these symptoms he sought relief in Glasgow Infirmary, and 
 finally came to Edinburgh. Up to the period of his admission 
 the pain had spread very much across the upper part of his 
 chest, but he does not think that the other symptoms had 
 increased ; he has never had either headache or haemoptysis. 
 The left radial pulse is almost imperceptible. The right 
 radial pulse is 84, of moderate strength, and slightly jerking. 
 Cardiac dulness not noted. The heart's apex beats three 
 inches below and a little external to the nipple line. Only 
 the first sound is heard at the apex ; at the base both sounds 
 are audible and are normal. Over the upper part of the left 
 chest anteriorly there is a distinct bulging, most marked over 
 the second rib and second intercostal space. Over a spot 
 about the size of a crown piece there is a distinct impulse 
 communicated to the stethoscope. Over the left chest there 
 is dulness on percussion from the cla\dcle to within two 
 inches of the nipple line ; this dulness extends across to the 
 opposite sterno-cla'vdcular articulation (vide Fig. 34). Over 
 this dull area a double blowing murmur is to be heard, " the 
 second sound, however, being very feeble, and heard most 
 distinctly over the sternum, opposite the articulation of the 
 second rib, also heard over the great vessels at the root of 
 the neck." -^ At the right pulmonary apex the inspiration is 
 harsh and the expiration prolonged. Over the left apex 
 
 ^ I quote the ipsissima verba of the report. The -n-ords ' ' second sound " 
 may have referred to the diastolic murmur, but as the points alluded to are 
 off the tumour, the statement may be quite correct. 
 
460 
 
 CLINICAL LECTURES ON 
 
 anteriorly the double murmur referred to completely obscures 
 the sounds of respiration ; everywhere else they are normal. 
 The patient has a frequent and loud cough, of a clanging, 
 metallic character, without expectoration. He complains of 
 severe, dull aching pain on the left side of the chest, from 
 below the clavicle to the level of the nipple ; this pain 
 occasionally extends to the right side. He gets only occa- 
 sional short snatclies of sleep, partly owing to the pain 
 referred to, and partly to the frequent recurrence of a 
 choking sensation referred to the throat. His tongue is 
 clean, appetite bad, but bowels regular. Urine, specific 
 
 Fig. 34. 
 
 Fig. 35. 
 
 gravity 1"030, with deposit of urates, but otherwise normal. 
 There is a slight puftiness of the integuments over the upper 
 part of the sternum, and the veins over the dull area are 
 visibly enlarged. 
 
 Up to I7th February his treatment was limited to the 
 use of narcotics for the relief of the cough ; at that date he 
 was put upon twenty grains of potassium iodide three times 
 a day; this he continued to take, though somewhat irregularly, 
 and the report on 9th June is — " Since last report he has 
 continued much the same. He sometimes complains of pain 
 in the chest, still has cough with profuse purulent expectora- 
 tion, and loud sonorous rhonchi both anteriorly and posteriorly. 
 
DISEASES OF THE HEART 461 
 
 He continues to take the sedative draught and iodide mixture. 
 On percussion the dulness is found to have extended more 
 towards the right side, now reaching to about the middle of 
 the clavicle {vide Fig. 35)." ^ On 23rd June it is stated that 
 the patient complained of great pain in the chest, which 
 seemed to be increased, and for which he frequently had 
 poultices applied. He also complained of great weakness, for 
 which he got two ounces of port wine daily. His breathing 
 was, however, easier, and the cough and expectoration greatly 
 diminished. The pulsations over the now greatly enlarged dull 
 area are, however, much increased, and the double blowing 
 murmur is more distinct than formerly. Posteriorly the 
 blowing murmur can also be distinctly heard about the sixth 
 dorsal vertebra. 20th June. — Complains of pain in the left 
 side being increased; poultices ordered. 27th June. — Still 
 complains of great pain in his left side ; for this he got a 
 hypodermic injection of about one-third of a grain of morphia. 
 He continued to improve slightly. On 16th July it is stated 
 that the patient feels very well, has little cough or expectora- 
 tion ; he takes his food well and has little pain. On 23rd 
 July the patient is said to be continuing better, his breathing 
 easier, cough and expectoration almost gone, and for the last 
 two or three days he has been walking about the ward, 
 though not yet able for much exertion. He continues the 
 use of the iodide. At this time. Ward II. being closed for 
 the autumn, he was put under my care in Ward YII. Shortly 
 after this he walked the whole length of the ward to the 
 water-closet, which is somewhat draughty ; this was followed 
 by a return of his cough, copious purulent expectoration, and 
 violent pain in the left shoulder and over the large pulsating 
 tumour, on the left of which a small projection of about an 
 inch square was thrown out; over this there was a red blush. 
 Jamieson was strictly confined to bed, a belladonna plaster 
 
 1 Figs. 34 and 35 have been accurate!)' copied from drawings by Dr. 
 Bennett's clerk. The dark spot to the left indicates the place where the red 
 projection subsequently to be mentioned was thrown out. 
 
462 CLINICAL LECTURES ON 
 
 was applied over the tumour, thirty grains of potassium iodide 
 given three times a day, and an opiate mixture for his cough. 
 In a few days his symptoms were much relieved. A further 
 exertion, however, coupled with exposure to the damp air of 
 a newly-washed ward, brought on a violent exacerbation of 
 the cough with a great increase in the size of the tumour, 
 which was wholly covered by a red blush. There was com- 
 plete loss of pulse in the left arm, accompanied by coldness 
 and excruciating pain in the limb ; the expectoration was 
 copious and purulent, and occasionally both streaked and 
 stained with blood. His left arm was ordered to be swathed 
 in flannel; the tumour to be covered with a belladonna plaster; 
 to take his iodide mixture four times a day ; to continue his 
 cough mixture, and to have fifteen minims of chlorodyne i^ro 
 re nata as often as required. The order being to keep the 
 cough quiet at all hazards, he took for many days two drachms 
 of chlorodyne in the day besides an opiated cough mixture. 
 (For this see Christison's Dispensatory, p. 839.) He bore this 
 treatment well ; his tongue kept clean and his appetite fair. 
 In eight days the expectoration began to lessen, and the 
 cough and pain to cease. By 31st August the pain and 
 cough were almost gone, and the expectoration reduced to a 
 trifling quantity of mucus ; the left arm was again warm and 
 feeling normal, and the pulse had returned to the wrist, 
 though it was still feeble. The tumour was diminished in 
 size, and apparently not pulsating so strongly. He was lying 
 quietly in bed reading, and expressed himself as feeling a new 
 man. For the next nine months Jamieson was kept on his 
 back, mostly on a water-bed ; his cough was kept quiet by a 
 free use of opiates, and he had two drachms of potassium 
 iodide daily, except for a couple of days on two occasions 
 when it had to be omitted on account of gastric irritation, as 
 evinced by pain and vomiting. At last, towards the end of 
 May, the tumour seemed sufficiently consolidated, and all the 
 symptoms so moderated as to warrant the patient's being 
 permitted to get out of bed. At this time his pulse was 100, 
 
DISEASES OF THE HEAKT 463 
 
 much fuller in the right radial than in the left ; his skin 
 moist ; his cough so slight as to be inappreciable, and rarely 
 heard during visit ; his expectoration merely a trifling 
 catarrhal mucus ; his voice still thin, and somewhat feeble, 
 but distinct and very different from what it was ; respiration 
 everywhere natural, and the percussion note posteriorly 
 normal. The heart's apex was felt beating between the fifth 
 and sixth ribs a little outside the nipple line, the heart being 
 probably elongated and certainly displaced, the lung entirely 
 covering it. In the parasternal line just outside the left 
 edge of the sternum dulness extended from the liver dulness 
 right up to the lower border of the first rib. In the nipple 
 line dulness extended -transversely to a distance of two inches 
 from the left edge of the sternum. Just at the inner edge of 
 the left clavicle there is a small patch of clear sound ; with 
 this exception, dulness extended along both clavicles, from 
 about one inch and a half to the right of the risht edge of 
 the sternum to about four inches to the left of its left edge. 
 The dulness on the right side is bounded by a semicircular 
 line joining the sternum at the upper border of the second 
 rib. On the left side the dulness is also bounded by a semi- 
 circular line the centre of which is about the middle of the 
 left clavicle, and in this position it does not descend lower 
 than the middle of the third rib. The sternal ends of both 
 clavicles were dislocated ; the right to the extent of half an 
 inch, the left to about a quarter of an inch. On the upper 
 part of the sternum there is considerable puffiness, and over 
 it and over the dull portion to its left there are many large 
 and tortuous veins. A finger pushed behind the sternum, in 
 the tracheal fossa, feels only a solid mass. Over the apex 
 beat the first sound of the heart is heard somewhat obscured 
 by the rough systolic portion of a double murmur, heard 
 loudest at the middle of the sternum just at the junction of 
 the fourth rib. This murmur is propagated upwards loudly 
 and rough into both carotids ; less distinctly into the right 
 subclavian, while in the region of the left subclavian, over the 
 
464 CLINICAL LECTURES OX 
 
 dull part mapped out, we have a solid tumour pulsating, but 
 not forcibly, and only with a movement of elevation and 
 none of expansion, over which no murmur whatever is to be 
 heard, merely a dull thud. The patient has now no difficulty 
 in breathing or swallowing; he walks up and down stairs 
 and about the airing ground ; he says he has now no cough. 
 Shortly after tliis Jamieson was sent downstairs to Dr. 
 Bennett, who exhibited him to his class, and, as I am told, 
 expressed himself satisfied with the reality of the improve- 
 ment which had taken place. 
 
 Jamieson was discharged shortly afterwards. He went to 
 the Workhouse, where he remained till 1st Xovember 1869. 
 At that date he was readmitted to Ward YII. for some 
 catarrhal symptoms, his aneurysm being in static quo. A 
 thick (Edematous collar full of tortuous veins had developed 
 at the lower part of his neck and over the upper part of 
 the sternum. He was discharged in April 1870, and went 
 to Glasgow, where he remained much the same when last 
 heard of 
 
 This very interesting case affords an instructive example 
 of the good that may be done by careful treatment even in 
 the most unfavourable cases of aneurysm, and it speaks well 
 for the treatment under consideration that it was capable 
 of relieving symptoms so severe as those of Jamieson, and of 
 prolonging life in circumstances apparently so hopeless. 
 
 I might easily multiply histories of aneurysms treated by 
 potassium iodide,^ but a sufficient number has been given to 
 illustrate the nature of the rehef obtained. I have treated 
 after this fashion a very considerable number of cases of 
 aneurysm ; most of those not related were aneurysms of the 
 aorta and chiefly of its thoracic portion : a few indeed spat 
 blood, and in them the aneurysm seemed to be weeping ; in 
 all there was a similar result — speedy relief to pain and 
 suffering, and in a few there has been so complete a subsi- 
 
 ^ In former editions of this work five other cases have been given in full, 
 but it seems quite unnecessary to reijcat them. 
 
DISEASES OF THE HEAKT 465 
 
 dence of the tumour and relief to all symptoms, as to amount 
 to an apparently perfect cure. These results are extremely 
 encouraging, and when we reflect upon the entire absence 
 of any risk to the patient, the certainty of relief to his 
 sufferings, and prolongation of his life, I think I am warranted 
 in saying that no treatment of internal aneurysm hitherto 
 devised holds out anything like an equal prospect of relief — 
 if we cannot call it cure — as that by potassium iodide. 
 
 Some have supposed that the benefit derived from potas- 
 sium iodide in the treatment of aneurysm is due to its anti- 
 syphilitic virtues. I am not prepared to accept a causal con- 
 nection between syphilis and aneurysm as so invariable as to 
 make this at all likely, and even if this were true I cannot 
 conceive what possible connection there can be between the 
 modus operandi of the drug as I understand it, and shall pre- 
 sently expound it, and any antisyphilitic virtues it may possess. 
 
 Dr. Chuckerbutty supposed the iodide to increase the 
 coagulability of the blood, and Dr. Eoberts seemed to consider 
 this a plausible theory. This, however, is quite contrary to 
 all that is known as to the action of potassium iodide, which 
 is believed to induce quite an opposite condition of blood — 
 a greater fluidity. Nor is this idea consistent with the 
 results of post-mortem examinations, because, though we 
 occasionally find the sac full of coagula, we learn from such 
 cases as Rice and Wilson that clot formation in the sac is 
 only a concomitant and not an essential phenomenon. Nay, 
 more, many ante-mortem experiences convey the same lesson. 
 How often have we found men with large and thin-walled 
 aneurysms,' which seemed to grow not only smaller but also 
 firmer and harder under treatment, as if lined by dense 
 coagula, grow weary of the restraint of hospital life, discharge 
 themselves, and after a period of loose living return with all 
 their former symptoms and with the aneurysmal pulsation 
 just as fluid as ever. This transformation was often so rapid 
 as to leave no doubt that the previous firmness and feeling 
 of density of the sac had not been due to solid coagula within 
 
466 CLINICAL LECTUEES ON 
 
 it.^ That coagulation of the blood forms no part of the action 
 of this drug was also well shown in the case of a sea-captain ^ 
 who was under treatment, in Ward V, for a very tense in- 
 nominate aneurysm projecting into the neck. He had only 
 been a few days under treatment when the aneurysm suddenly 
 ruptured, the blood apparently escaping just beneath the 
 adventitia, forming a dissecting aneurysm. A large, livid, 
 pulsating tumour, the size of a child's head, lay at the root 
 of the neck, and a boggy pulsation could also be felt between 
 the two first intercostal spaces. Fearing external rupture 
 I sent for my colleague. Dr. John Duncan, to endeavour to 
 prevent this catastrophe by galvano-puncture. By the time 
 Dr. Duncan arrived all pulsation in the tumour had ceased ; 
 no interference was attempted, and nothing was done beyond 
 continuing full doses of the iodide. The whole of the effused 
 blood, which remained fluid up to the last teaspoonful for a 
 period of eight weeks, was slowly absorbed. When this was 
 effected all trace of the aneurysm was found to have dis- 
 appeared, and the man was discharged. Some weeks after- 
 wards he returned for inspection in apparent health, and 
 without any recognisable trace of his aneurysm or any return 
 of his symptoms. He subsequently took command of a 
 small vessel belonging to himself, and died suddenly in the 
 West Indies a year or two afterwards, possibly from the 
 rupture of another aneurysm. The case of Wilson, however, 
 whose aneurysm, as I have mentioned (p. 452), could be easily 
 grasped through the abdominal parieties, and was felt to 
 grow firmer and harder as the cure progressed, kept alive 
 the myth for six years. At last, when Wilson died, and the 
 firmness and density of the aneurysm was ascertained to be 
 solely due to contraction of the sac and condensation of its 
 walls, the sac itself containing only post-mortem clots, then 
 it was felt that another explanation must be sought more 
 
 ^ The ease of Allison, p. 437 of the 2nd edition of this work, was a good 
 example of this. 
 
 2 Henry Cowan, aged thirty-eight, admitted 15th February, discharged 
 6th June 1872. 
 
DISEASES OF THE HEAET 467 
 
 consonant T\dth the actual facts. This explanation was not 
 dif&cult to iind. From the first it had been noticed that 
 nnder the influence of the iodide the pulsations within the 
 sac and even throughout the arterial system were much 
 diminished in force, and in the second of our cases (XLII., 
 p. 450) this was so marked as to attract the attention of the 
 patient himseK. This had been rightly referred to a reduc- 
 tion of the intra-arterial blood-pressure, but had been regarded 
 as nothing more than an important adjuvant to the blood 
 coagulation, hitherto the only recognised method of cure. 
 
 An aneurysm — you will remember — is formed because 
 the normal blood-pressure suffices to overcome the resistance 
 of some weak part in the arterial wall, which it gradually 
 dilates with each pulsation till it ruptures. Lowering of the 
 blood-pressure might stop further dilatation, but could not 
 promote a cure unless the sac were simultaneously filled with 
 coagula, or its walls became thickened and contracted. Ex- 
 perience during life has taught us the fallacy of the idea that 
 the sac gets filled with clots, while the results of post-mcrrtem 
 examinations have shown that under the influence of potas- 
 sium iodide coagula are only occasional and concomitant, and 
 that the essential relief is due to contraction of the sac and 
 tliickening of its wall. In one case formerly referred to (at 
 p. 389) the iodide treatment had been followed by marked 
 benefit ; the superficial pulsation had almost completely dis- 
 appeared, and there had been a simultaneous lessening of all 
 the pressure symptoms. This patient died under the care of 
 a colleague from a different disease. On examination an 
 aneurysm the size of a small orange was found to spring from 
 the ascending aorta, and from this a smaller sac, the size of 
 a walnut, projected ant-eriorly and was adherent to the 
 thoracic wall in the third interspace. Not a trace of clot 
 was to be found within the sac. Sections were made through 
 various parts of the wall of this aneurysm, and on examining 
 them microscopically the intima was found to be everywhere 
 diseased, granular degenerated, and irregular in its thickness, 
 
468 CLINICAL LECTURES ON 
 
 as if being worn away. The muscular layer of the media was 
 tolerably dense, and apparently hypertrophied, over the large 
 sac close to the artery ; over the small sac at its external 
 part the media was still present, but granular and undergoing 
 fatty degeneration. The elastic layer of the media did not 
 seem to be atrophied or degenerated in any part examined. 
 The adventitia was everywhere considerably hypertrophied, 
 but specially so over the outer part of the smaller sac.^ This 
 hypertrophy of the muscular coat, where that still exists, and 
 of the adventitia, with concomitant contraction, are found in 
 all aneurysms that have been treated with potassium iodide 
 with any measure of success. We may refer this, if we will, 
 to some hitherto unsuspected action of the drug upon the 
 muscular and fibrous tissues, but it seems more rational to 
 look upon this hypertrophy of the muscular and fibrous 
 tissues, under the conditions present, as but another mani- 
 festation of that well-known law (Paget) by which a hollow 
 muscle hypertrophies when opposed to an obstacle with which 
 it is able successfully to contend. The facts narrated have 
 been so often and so invariably observed that it is unnecessary 
 to seek further proof, but I may mention that a Eussian 
 experimentalist named Bogolepoff has pointed out that one 
 of the chief actions of potassium iodide is to lower the blood 
 tension uniformly throughout the body by dilating the arter- 
 ioles, the heart's action being at the same time diminished in 
 force. In dogs this lowering of the blood-pressure and 
 lessening of the cardiac force is frequently accompanied by 
 increased frequency of the cardiac action, unless the dose is 
 considerable, when slowing of the heart's action occurs as a 
 preliminary to cardiac paralysis. In frogs a large dose dilates 
 the arterioles and at the same time slows the heart without 
 any preliminary stage of rapid action.^ So far as the action 
 
 1 Case of Murray, p. 389 ; and Edinhtwgh Medical Journal (June 1876), 
 p. 1142. 
 
 - "Zur Frage der physiologischen Wirkung des lodkaliuni," Moskauer 
 pliarmacologische Arbeiten, S. 125 ; and Virchow's Jahreshericht (1876), erster 
 Band, S. 402. 
 
DISEASES OF THE HEART 469 
 
 on man is concerned, experience in the treatment of aneurysm, 
 as also in connection with the treatment of the senile heart,-^ 
 shows that we may accept uniform dilatation of the arterioles 
 as the cause of that lowering of the blood-pressure which 
 forms so important an element in the treatment of both forms 
 of disease. The action of moderate doses on the human heart 
 is to diminish both the force and the frequency of the pulsa- 
 tions, and this occasionally in a very marked manner. When 
 the drug is given in such large doses as twenty or thirty 
 grains twice or thrice a day, there is, however, frequently a 
 rise in the pulse-rate, which does not appear materially to 
 interfere with the ultimate improvement of the case, though 
 it probably — and I think certainly — prolongs the treatment. 
 In some few cases the action of the iodide is more injurious, 
 and the heart's action becomes unduly quickened up even to 
 170 beats per minute. This rapid pulsation has always a 
 bad effect on the aneurysm ; none of those in which it occurred 
 did well, and as this rapid action of the heart seemed, in ac- 
 cordance with Marey's law, to depend upon too free an escape 
 of the blood into the veins,^ it became necessary to prevent 
 this. In the absence of any known ratio between any certain 
 dose of the drug and a definite rate of escape through the 
 arterioles, it is necessary to proceed by way of experiment, 
 and to repeat this experiment in every case when treatment 
 is first commenced. In this way we are able to obtain better 
 results in a much shorter time than was possible under the 
 haphazard method at first pursued. Following this course 
 we put every patient to bed for a few days without further 
 treatment, the pulse-rate being taken night and morning. 
 So soon as the average pulse-rate in recumbency is accurately 
 ascertained, ten grains of potassium iodide are given every 
 eight hours. If the pulse-rate remains unchanged, the dose 
 of the iodide may be increased in a few days up to fifteen or 
 
 1 The Senile Hea/rt, p. 275. 
 
 2 Physiologie Medicale de la Circulation dih Sang, p. 206, par le Dr. E. J. 
 Marey, Paris, 1863. "Le Cceur bat d'autant plus frequemment quil eprouve 
 moins de peine a se vider." 
 
470 CLINICAL LECTUEES ON 
 
 more grains every eight hours, raising it by one grain each 
 dose until the pulse-rate begins to rise. It is only rarely 
 that we can increase the close to fifteen grains without raising 
 the pulse-rate ; indeed it is common enough not to be able to 
 increase the dose beyond ten grains without this taking place. 
 Should the pulse-rate rise, the iodide is stopped for one or 
 two days and then we go back to the highest dose that did 
 not raise the pulse and continue with that dose. When the 
 iodide has been given in this way the success attained has 
 been quite remarkable ; the cessation of pain, the lessening of 
 the pulsation, and the general improvement have been so 
 marked and so rapid as to leave no doubt that this is the true 
 method of administration. Under the old haphazard method 
 of large doses improvement of any consequence was rare 
 before the lapse of six months ; with the carefully regulated 
 dose of the present day we obtain similar results in three 
 months and often in less. Naturally we are not more suc- 
 cessful in curing our patients ; they still require more or less 
 surveillance all their lives, and the occasional use of the iodide. 
 But we are now entitled to say that the relief obtained is no 
 mere matter of chance, but is largely proportionate to the 
 period at which treatment is commenced. Thus if we get 
 the patient early enough, while some part of the media still 
 remains, the relief may be unusually rapid and the cure 
 almost complete ; while if we have nothing but the adventitia 
 to rely upon, longer treatment may be required, and the relief 
 may be less complete, though even in cases evidently of this 
 character the improvement is sometimes very remarkable.^ 
 In all my experience I have only twice seen complete intoler- 
 ance of the iodide. In one case the very smallest dose gave 
 rise to rapid pulse and to severe neuralgic pains in the 
 
 ^ This explanation of the action of potassium iodide in the treatment of 
 anem-ysm will be found enunciated in the Edinburgh Medical Journal for 
 June 1876, at p. 1142, and in the British Medical Journal for 5th April 
 1879, at p. 511, forming part of the discussion as to the treatment of internal 
 aneurysms at the Glasgow Pathological and Clinical Society on 5th March 
 1879. It will also be found in the second edition of this work. 
 
DISEASES OF THE HEAKT 471 
 
 abdomen, even when the patient was in complete ignorance 
 of what he was taking. In the other case the use of iodide 
 was so constantly followed by copious herpetic eruption — so- 
 called hydroa — that it had to be given up. Iodide of sodium 
 had a precisely sunilar effect. This was the more to be 
 regretted as in both cases the action of the iodide on the 
 disease was markedly ameliorative. 
 
 In regard to adjuvant treatment, whatever is capable of 
 reducing the frequency of the heart's pulsations without 
 impairing the strength of the patient or vitiating the quality 
 of his blood cannot but be an important adjuvant in the 
 treatment of aneurysm. It has always therefore seemed to 
 me a matter of considerable importance to enforce the re- 
 cumbent position, as a certain means of attainmg this import- 
 ant end. In the earlier days of the iodide treatment, when 
 the dose given was undoubtedly too large, very much of the 
 success attained seemed due to the perfect rest always insisted 
 upon. ISTowadays, when we know more perfectly the mode 
 of action of the drug, recumbency is not so absolute a 
 necessity, though it is always an advantage and ought to be 
 insisted upon for the first six weeks or two months at least. 
 
 Aware of the evils of starvation on the one hand and the 
 risks of plethora on the other, my patients were formerly put 
 upon a somewhat restricted mixed diet — fish, chicken, or 
 rabbit being given for dinner, at first at all events, as being 
 more easily digested than beef or mutton and less likely to 
 give rise to so-called biliousness. They were also advised to 
 be moderate in regard to quantity. At present, I still 
 give — at first — light articles of food, as less likely to disturb 
 the digestion of one put to bed without fever or any ailment 
 likely to lessen his ordinary healthy appetite, but otherwise 
 no restrictions are put upon the patients. Potassium iodide 
 is believed by some to destroy the albuminates in the blood,-^ 
 and, whatever be the cause, there is no doubt that its con- 
 tinuous administration tends to emaciation, and there is also 
 
 ^ Vide Kammerer, Yircliow's Archiv, Bd. lix. 
 
472 CLINICAL LECTURES ON 
 
 no doubt that better results have been obtained under a full 
 diet than under a restricted one. A similar remark may be 
 made as to drink. All ordinary non-alcoholic drinks may be 
 freely given, as the iodide produces so free a diuresis that 
 there is no risk of any hyperemia from that cause. Alcohol 
 in any form quickens the heart's action and is always injurious, 
 and its use should never be permitted except when absolutely 
 required, and then only temporarily. 
 
 I need hardly say that notwithstanding the great and 
 manifest relief accruing from this method of treatment, 
 positive cures can only be exceptional and of the rarest oc- 
 currence, but in all but the most exceptional cases we have 
 a right to expect freedom from suffering and prolongation of 
 life. Aneurysms may prove fatal in so many various ways 
 that a tendency to cure can only be accepted when we 
 have unequivocal proof that the aneurysm is shrinking in all 
 its dimensions. Even then incautious exertion may rupture 
 the sac at some weak point, and death may thus suddenly 
 assail one who thinks he is being cured. Compression of 
 important organs by a solidified sac may induce dangerous 
 and even fatal complications ; and under the most favourable 
 circumstances, the occurrence of a large aneurysm springing 
 from a large and important artery proves the existence of 
 such a diseased condition of the arterial coats as will 
 render the patient's life ever after more or less a precarious 
 one. 
 
 Nevertheless the results obtained from the potassium 
 iodide treatment are sometimes most marvellous, and they 
 can be and are obtained in cases in which no other treatment 
 is available. 
 
 In 1873 I had under my care a gentleman with a large 
 aneurysm of the aortic arch, the main symptoms being a 
 remarkable vox anserina, and a constant headache with a 
 flushed and turgid face, the result of compression of the large 
 veins at the root of the neck. Under the use of the iodide, 
 without any other treatment, all these symptoms were so 
 
DISEASES OF THE HEAET 473 
 
 greatly relieved, and even his voice so much improved, that 
 this patient ceased to consider himself an invalid. Over- 
 exertion subsequently caused a relapse of all his symptoms ; 
 his head and arms were so turgid, his quasi-apoplectic 
 symptoms so severe, and his aneurysm so large that a late 
 distinguished physician (Dr. Warburton Begbie) gave him 
 only a fortnight to live. Yet this gentleman lived long 
 after the doctor himself, and the last time I saw him 
 was to be reproached for my mistaken diagnosis, as some 
 medical friends had told him he had no aneurysm. Wonder- 
 ful as the improvement was, the aneurysm was still to be 
 detected ; he lived for a year or two longer and then died of 
 cerebral embolism. 
 
 Again, for many years I had charge of a middle-aged lady, 
 who, when I first saw her, about eighteen years ago, had a 
 fluid pulsation between the left scapula and the spine, arising 
 from an aneurysm of the upper part of the descending aorta. 
 This aneurysm had not only eaten its way through the ribs 
 posteriorly, but had caused erosion of the spinal column, 
 with pressure on the nerve roots, indicated by constant 
 numbness and tingling along the nerves on the left side, with 
 recurrent nerve-storms of acute pain which darted up the 
 neck and side of the head, and down to the tips of the fingers 
 and the points of the toes, ending at last in a fit of violent 
 sickness. Unfortunately every narcotic tried increased so 
 much this deadly sickness that one after another had to be 
 discarded. By and by the iodide told ; the pressure lessened, 
 the sac contracted, and the suffering gradually ceased. After 
 ten years' confinement to bed from intense suffering this poor 
 woman was so relieved as to be able to go about like other 
 people free from pain. The anemysm could still be detected, 
 many of the objective symptoms remained in a modified form, 
 but the pressure symptoms and the suffering were gone. 
 This lady died about two years ago from an attack of acute 
 bronchitis, her aneurysm remaining quiescent to the last. It 
 is difficult to imagine a more interesting case, one in which 
 
474 CLINICAL LECTURES OX DISEASES OF THE HEART 
 
 the ameliorative power of the drug could be more severely 
 tested, or one in which this remarkable property could be 
 more triumphantly displayed.^ 
 
 ^ This case, with one or two more of considerable interest, has been recorded 
 in the British Medical Journal for 6th June 1891, at p. 1220. 
 
INDEX 
 
 Accentuation of aortic second, signifi- 
 cation of, 32 
 of pulmonary second, signification 
 
 of, 32 
 Accumulation of a drug, what it means, 
 
 361 
 Adhesions pericardiac, their influence on 
 
 precordial pulsation, 5, 8 
 Albuminuria in heart disease, its cause, 
 
 296 
 Amyl nitrite, use of, in angina pectoris, 
 
 331 
 Aneurysm, abdominal, 418 
 
 thoracic aortic, signs of, 6, 8, 405 
 
 varieties of, 402 
 
 usual position of, 404 
 
 causes of, 405 
 
 diagnosis of, 406 
 
 pain as an indication of, 408 
 
 phenomena characteristic of, 407 
 
 dyspncea as a sign of, 410 
 
 cough, 411 
 
 dysphagia, 412 
 
 pressure on blood-vessels, 412 
 
 pressure on cilio-spinal nerves, 414 
 
 characteristic of dulness indicative of, 
 
 415 
 sounds heard on auscultating over, 416 
 particular signification of special 
 
 symptoms, 417 
 course and terminations of, 419 
 weeping, 420 
 
 rupture of, not always fatal, 420 
 spontaneous cure of, 421 
 treatment of — • 
 
 by introducing fine wire into sac, 424 
 
 by electrolysis alone, 425 
 
 by passing a galvanic current 
 through wire in the sac, 431 
 
 by ergotine, 432 
 
 Valsalva's method, 434 
 
 Tuflfnell's modification of Valsalva's 
 method, 436 
 
 by pressure, 433 
 
 by potassium iodide, 437 
 Angina pectoris, syndrome of, 310, 314, 
 
 318 
 lesions found after death from, 316 
 
 Angina pectoris, may be feigned, 321 
 
 may be simulated by various forms of 
 neuralgia, 311 
 
 mode of death from, 316, 327 
 
 treatment of, 331 
 Aorta, abnormal pulsation of, 288 
 Aortic valve, incompetence of, 48 
 
 signification of murmurs of, 48, 73 
 
 how compensated, 77, 84 
 
 causes of failure of compensation, 88 
 
 may exist without murmurs, 83 
 
 murmurs may disappear, 250 
 
 mode of death from, 95 
 
 longevity in, 92 
 
 not always a hindrance to an active 
 life, 86 
 
 prognosis in, 92 
 
 usual progress of, 79 
 
 treatment of, 102 
 
 use of digitalis in, 104 
 
 may be rehabilitated, 250 
 Aortic diastolic murmur said to exist 
 
 "with competent valve, 260 
 Aortic systolic murmur, causes of, 64 
 Apex beat, normal position of, 5 
 
 may be displaced variously, 11 
 Apoplexy, pulmonary, 291 
 Arsenic in cardiac disease, 376 
 Arteries, excessive pulsation of, 278 
 Asthma, cardiac, 2, 321 
 Asystole may be ingravescent, 328 
 
 mode of death from, 94 
 Auricle, pulsating, 145, 153, 155, 164 
 Auricular murmur (in position), mechan- 
 ism of, 170 
 
 Naunjm's ^-iew regarding, 171 
 Auricular-systolic murmur, vide Pre- 
 systolic murmur 
 
 facts in favour of its accepted rhythm, 
 118 
 
 Blood-vessels, pressure on, a sign of 
 
 aneurysm, 412 
 Bradycardia, hemi-systolic, 275, 282 
 
 true, 282 
 
 treatment of, 287 
 Breathlessness, cardiac, 2 
 
 may be due to condition of blood, 3 
 
476 
 
 CLINICAL LECTURES ON DISEASES OF THE HEAKT 
 
 Bromides, their use in cardiac affections, 
 381 
 
 Bronchitis a cause of tricuspid regurgita- 
 tion, 204 
 
 Bruit de didble, what it is, 174 
 
 Case 1. Aortic incompetence, 50 
 
 2. ,, .. 55 
 
 3. ., ,. 60 
 
 4. ., ., 69 
 
 5. „ „ 95 
 
 6. „ ,, 98 
 
 7. Mitral stenosis, 117 
 
 8. „ „ 122 
 
 9. „ „ 122 
 
 10. „ ., 125 
 
 11. „ ,, 127 
 
 12. „ „ 138 
 
 13. „ „ 141 
 
 14. „ „ 143 
 
 15. „ „ 148 
 
 16. „ „ 151 
 
 1 7. Curable mitral regurgitatiou, 181 
 
 18. „ „ „ 187 
 
 19. „ „ „ 189 
 
 20. „ „ „ 192 
 
 21. Curable tricuspid regurgitation, 
 
 205 
 
 22. Incurable triciispid regurgita- 
 
 tion, 208 
 
 23. Systolic murmur in the pul- 
 
 monary area, 223 
 
 24. „ „ „ 226 
 
 25. „ „ „ 228 
 
 26. Congenital malformation of the 
 
 pulmonary artery, 235 
 
 27. Mitral stenosis with vanishing 
 
 murmurs, 253 
 
 28. Cardiac jaundice, etc., 299 
 
 29. Repeated embolisms, 303 
 
 30. Angina from aortitis, 324 
 
 31. ,, traumatic, 327 
 
 32. „ aud fatty heart, 338 
 
 33. Rheumatic pericarditis, 339 
 
 34. Suppurative ,, 346 
 
 35. Myocarditis, 351 
 
 36. „ 353 
 
 37. Fatt}- heart, 367 
 
 38. Malposition of the aorta simu- 
 
 lating aneurysm, 390 , 
 
 39. „ „ „ 395 
 
 40. Aneurysm of aorta treated by 
 
 galvano-puncture, 427 
 
 41. Aneurysm of aorta treated by 
 
 potassium iodide, 446 
 
 42. „ „ ., 450 
 
 43. „ „ „ 451 
 
 44. „ „ ., 455 
 
 45. „ „ ., 457 
 
 46. „ „ „ 458 
 Chloralamid in cardiac insomnia, 380 
 Chloralose as a hj-pnotic, 381 
 
 Chloroform in angina, 321 
 Chlorosis, curable, 174 
 
 incurable, 161 
 
 murmurs heard in, 174 
 Chlorotic murmurs, how developed, 176 
 Chorea, development of murmurs in, 183 
 Circulation, changes in, following cardiac 
 
 disease. 289 
 Clang, what it is, 20 
 Colchicum in heart affections, 380 
 Corrigan's pulse, 88 
 Cough as a sign of aneurysm, 411 
 Cyanosis in cardiac disease, 238 
 Cycle, constituents of a cardiac, 39 
 
 Death sudden in aortic disease, 94 
 
 Delirium cordis, 287 
 
 Diagnosis, general, of cardiac disease, 1 
 
 of state of aortic orifice from mur- 
 murs, 73 
 
 of cardiac murmurs, 38 
 
 of mitral steuosis, 116 
 
 of curable mitral regurgitation, 197 
 
 of tricuspid regurgitation, 167 
 
 of pericarditis, 335 
 
 of aortic aneurysm, 402 
 Diet in heart affections, 381 
 Digitalis, action of, on heart, 359, 362 
 
 its use in aortic incompetence, 104, 365 
 
 fatal dose of, 361 
 
 iise of, in fatty heart, 367 
 
 most useful preparations, 369 
 
 action of cumulative dose, 364 
 
 obstacles to its action, 366 
 
 effects of large doses, 371 
 
 dosage of, 372 
 
 when to be employed, 372 
 Dropsv, cardiac, commences at instep, 3, 
 302 
 
 commences more rarely as ascites, 302 
 
 treatment of, 354 
 Ductus arteriosus, aneurysmal dilatation 
 
 of, 243 
 Dulness, cardiac, how to percuss, 23 
 
 varies frequently and rapidly, 17 note 
 Dulness, circumscribed, a sign of 
 
 aneurysm, 415 
 Dysphagia a sign of aneurj-sm, 412 
 Dyspnoea a sign of aneurysm, 410 
 
 Effusion into pericardium favours the 
 
 occurrence of epigastric pulsation, 7 
 
 Electrolj'sis as a treatment for aueurysm, 
 
 425 
 
 a novel method of emplojong, 431 
 
 Embolism a common occurrence in heart 
 
 affections, 302 
 Endocarditis, 349 
 
 septic, 350 
 Energy, source of cardiac, 262 
 
 of heart, resen'e, 84, 137 note 
 Epigastric pulsation, causes of, 7 
 
INDEX 
 
 477 
 
 Epilepsy, pseudo, the result of cardiac 
 disease, 287 
 
 Erythrol tetranitrate as a vascular stimu- 
 lant, 379 
 
 Examination of patient, mode of con- 
 ducting, 4 
 
 Exercise, its role in the treatment of 
 heart affections, 382 
 
 Fatty heart, diagnosis of, 332, 367 
 Flatulence a sequence of cardiac disease, 
 
 294, 380 
 Fremissement cataire, 12, 116 
 
 Graves' disease, syndrome of, 278 
 treatment of, 279 
 
 H^Mic murmurs, how produced, 175 
 Haemoptysis in mitral stenosis, 292 
 
 in aortic regurgitation, 95 
 Heart, auscultation of, 25 
 
 how nourished, 84 
 
 murmurs, how produced, 45 
 
 normal sounds and silences of, 25 
 
 percussion of, 23 
 
 percussion limits vary rapidly, 17 note 
 
 sounds reduplicated, 33 
 Heartbeat, cause of, 262 
 Hepatic pulsation, varieties of, 8 
 HyperpjTcxia, fatal rheumatic, 336 
 Hypertrophy of heart, so-called idio- 
 pathic, 355 
 
 compensatory, 77 
 Hypoplasia of aortic system, what it is, 
 161 
 
 a serious complication of mitral ste- 
 nosis, 159 
 
 Incompetence of aortic valve, vide Aortic 
 
 valve 
 Infarction, pulmonary, 291 
 Inhibition, fatal, of lieart, 267 
 Inhibitory nerve of heart, 264 
 Insomnia, relief of, 380 
 Inspection, information to be derived 
 
 from, 5, 9 
 Intensity, position of maximum, 38 
 Intermission, cardiac, cause of, 266 
 
 a sign of a weak myocardium, 274 
 Intestinal catarrh a result of cardiac 
 
 disease, 297 
 Iron as a hsemic touic, 378 
 Irregularity of cardiac rhythm, cause of, 
 
 265 
 a sign of mitral stenosis, 124 
 
 Jaundice as a result of heart disease, 
 
 297 
 Jugular veins, undulation and pulsation 
 
 of, 5 
 
 Longevity, comparative, in aortic and 
 
 in mitral disease, 92 
 Lung, retraction of, from base of heart a 
 
 cause of cardiac murmur, 221 
 
 Mitral area, murmurs in, 40 
 regurgitation, curable, 167 
 treatment of curable, 194 
 incurable, 143 
 treatment of incurable, 166 
 valve, relative insufficiency of, how 
 produced, 169 
 in stenosis usually diaphragmatic, 
 
 121 
 in stenosis sometimes funicular, 
 134 
 stenosis, diagnosis of, 162 
 murmur distinctive of. 111 
 murmurs in, are often variable, 135, 
 
 25'2 
 often revealed by a systolic murmur 
 
 alone, 143 
 this systolic murmur not a tri- 
 cuspid, 166 
 one cause of incurable tricuspid 
 
 regurgitation, 198 
 development after acute rheuma- 
 tism, 160 
 early, a cause of aortic hypoplasia, 
 
 159 
 mode of death from, 165 
 Morphine, use of, in heart affections, 380 
 
 use of, in angina pectoris, 331 
 Murmur, auricular (in position), its 
 history, 170 
 (in rhythm), vide Mitral stenosis, 
 murmur distinctive of 
 Murmurs, arterial and venous, 45 
 how produced, 45 
 basic, causes of, 42 
 cardiac, may be felt, 12 
 
 endocardiac or exocardiac, 36 
 how to determine their rhythm, 36 
 the lesion on which they depend, 
 40 
 not always a sign of cardiac disease, 
 37 
 chlorotic, development of, 176 
 choreic or dynamic, 183 
 diastolic mitral, 125 
 
 how produced, 131 
 endocardiac, 43 
 
 not always of valvular origin, 43 
 exocardiac, 44 
 causes of, 44 
 functional, so-called, 173 
 hsmic and dynamic, 173 
 how produced, 45 
 
 Chaveau's theory of, 46 
 in pulmonary area, 217 
 position of maximum intensity of, 38 
 
478 
 
 CLINICAL LECTURES ON DISEASES OF THE HEART 
 
 Murmurs, weakness of the myocardium 
 
 as a cause of, 168 
 Myocarditis, 350 
 
 Nauntn's theory of the auricular mur- 
 mur, 173 
 Nerves, cardiac, and their actions, 266 
 Nitro-glycerine, use of, in angina, 321 
 Nux vomica as cardiac tonic, 375 
 
 Organs, various affections of, caused by 
 heart disease, 289 
 
 Pain, causes of, in connection with heart 
 aflfections, 310 
 in angina pectoris, 314 
 in aneurysm, 408 
 remedies to relieve, 380 
 Palpation, information to be derived 
 from, 10 
 points to be noted, 12 
 Palpitation, syndrome of, 275 
 Percussion, cardiac, 12 
 
 information to be derived from, 16 
 how to perform, 17 
 Pericarditis, diagnosis of, 341 
 treatment of, 344 
 termination in adhesions, 348 
 Pericardium, question of tapping, 345 
 Polysemia, serous, what it is, 178 
 Potassium iodide as vascular stimulant, 
 379 
 as a treatment for aneurysm, 437 
 rationale of its action, 467 
 mode of employing, 469 
 Presystolic murmur, history of. 111 
 characteristics of, 117 
 rhythm of, 113 
 
 various opinions as to this, 118, 120 
 phonetic representation of, 115 
 propagation of, 113 
 Pulsation of auricle, 145, 153, 155, 164 
 capillary causes of, 68 
 epigastric, 7 
 hepatic, 8, 201 
 jugular, 20 
 method of timing, 9 
 venous direct, 68 
 regurgitant, 6, 201 
 Pulse, delayed in dilated arteries, 90, 
 417 
 effects of recumbence on frequency of, 
 
 436 
 examination of, 4 
 
 in aortic incompetence (Corrigan's), 5, 
 88 
 always delayed, 90 
 in mitral stenosis apt to be irregular, 
 
 124, 127 
 of anaemia, 4 
 
 radial, always behind apex beat, 39, 
 89 
 
 Pulse, sphygmogram of, in ancemia, 273 
 aortic incompetence, 91 
 bradycardia, true, 285 
 
 hemi-systolic, 284 
 mitral stenosis, 124, 138, 144, 274 
 of a pulsus alternans, 275 
 bigeminus, 274 
 tachycardia, 280 
 various forms of irregular, 273, 
 274, 275 
 Pupil, alteration in size as a sign of 
 
 aneurysm, 414 
 Purring thrill, 12, 116 
 Pyrexia as a cause of cardiac dilatation, 
 172 
 
 Reduplication of cardiac sounds, 33 
 Regiirgitation, aortic, 48 
 mitral, 167 
 tricuspid, 197 
 Resonance, what it is, 13 
 Rest, importance of, in cardiac disease, 
 
 382 
 Rheumatism, development of cardiac 
 
 murmurs in, 173, 338 
 treatment of, 335 
 Rhythm of a murmur, how determined, 
 
 38 
 Rickety malformation of chest apt to 
 
 mislead in the diagnosis of cardiac 
 
 affections, 389 
 Rupture of an aneurysm not necessarily 
 
 fatal, 420 
 
 Sound, inflection of, 22, 28 
 Sounds of the heart in infancy, 25 
 in an adult, 26 
 signification of, when heard outside 
 
 the cardiac area, 33, 416 
 reduplication of, 33 
 second of heart, Laennec's view re- 
 garding, 129 
 accentuation of, 32 
 Sphygmograms of various pulses, vide 
 
 Pulse 
 Spontaneous cure of aneurysm, how 
 
 effected, 421 
 Stenosis of mitral opening, vide Mitral 
 
 stenosis 
 StropJmnthus Ilispidus, action of, 373 
 difference between its action and that 
 of digitalis, 373 
 Strychnine in heart disease, 376 
 Sulphonal in heart affections, 381 
 
 Tachycardia, syndrome of, 279 
 Tapping in pericardial effusion, 345 
 Thrill, cardiac, 12, 116, 142 
 Thrombosis, cardiac and venous, 290 
 Tremor cordis, 282 
 
 Tricuspid regurgitation, signs of, 199 
 from bronchitis, 204 
 
INDEX 
 
 479 
 
 Tricuspid regurgitation, from cardiac 
 disease, 203 
 from emphysema, 208 
 Trional as a hypnotic, 381 
 Tufnell's treatment of aneurysm, 436 
 
 Ueine, diminution of, as an indication 
 of cardiac disease, 293 
 an early indication of digitalis satura- 
 tion, 363 
 
 Valves, incompetent, may be rehabili- 
 tated, 167, 249 
 Valvular lesion may be mute, 1 
 
 Vanishing and variation of cardiac 
 murmurs, 37, 117, 135, 224 
 
 Varieties of aneurysm, 402 
 
 Vascular stimulants, 378 
 
 Veins, pulsation of, 6, 68, 201 
 Savart's fliiid, 46, 174 
 
 Ventricle, dilated right, may cause 
 epigastric pulsation, 8, 201 
 
 Weeping aneurysms, 420 
 Wire introduced into aneurysmal sac as 
 a basis for coagulation, 424 
 as an internal electrode, 428 
 
 THE END 
 
 Printed by R. Sr R. Clark, Limited, Edinbu7-gh. 
 
THE SENILE HEART: 
 Its Symptoms, Sequelae, and Treatment. 
 
 By GEO. W. BALFOUE, M.D., LL.D., 
 
 Consulting Phj'sician to the Royal Infirmary, to tlie Royal Hospital for Sick 
 Children, and to the Royal Public Dispensary, Edinburgh. 
 
 Second Edition. Croiun 8vo. Cloth. Price os. 
 
 " Those who are already acquainted with Dr. Balfour's writings will be prepared 
 to find in this work a clinical study, clearly and boldly sketched, at once rational 
 and thoughtfuL Nor will they be disappointed, for they cannot fail to rise from the 
 perusal of this monograph wi.thout a sense of the thorough mastery that the author 
 has of his subject, nor to be impressed by his scientific knowledge and clinical 
 acumen, as well as his literarj" lucidity, which adds to the interest and charm of a 
 most instructive and valuable book. In conclusion, we can only reiterate the ex- 
 l^ression of the pleasure which this excellent and well- written book has given us, and 
 can commend it confidently to practitioners, who must be daily brought into contact 
 mth the conditions that it portrays." — Lancet. 
 
 " The net result of his investigations is to give increased confidence to medical 
 men in the resources of their art, and greater courage and hope to all sorts and con- 
 ditions of aged persons, whether their hearts be sound or unsound." — Tlie Hospital. 
 
 " All the most important phases of the disease are treated with lucidity in this 
 volume, which is made the more attractive by instances drawn from experience — 
 examples sho'ning in the main how largely science and skill can ameliorate dis- 
 tressing symptoms, even when a complete cure is impossible. One closes this really 
 valuable, practical volume -ftith the conviction that a great many people ought to live 
 many, many years longer than they do." — DaAly Tdeg'mph. 
 
 "The therapeutics of the senile heart are admirably denoted in these pages, and 
 many useful hints are also given for the benefit of the man who is neither a fool nor 
 a physician." — SpeaJcer. 
 
 " Twenty years have elapsed since the author's classical work on Diseases of the 
 Heart appeared, and now he offers to the profession for its acceptance and guidance a 
 treatise on the same organ as affected by age. Coming from a master of the subject, 
 and containing his matured experience, the book must, on that account alone, have 
 an exceedingly high value. ... It is a most charming production, and recalls to 
 memory the clinical lectures and essays of Su- James Paget." — Edinburgh Medical 
 .Jov/nud. 
 
 " It is not often that a medical man is furnished with so refreshing a book. Xor 
 is there, as too frequently, any lack of detail or want of clearness to set over against 
 its scholarliness. The method of the book is a model for specialists. The section 
 on gout, and the theory that there is infarction in the gouty joint, is particularly 
 suggestive. " — Scotsman. 
 
 " The condensed side-notes are of great assistance in guiding a busj- practitioner 
 to special points on which he is seeking information, but the book is one that ought 
 to be carefully read through ; it is full of instruction, and the perusal cannot fail to 
 be pleasant reading." — Mediccd Press. 
 
TEXT-BOOK OF OPERATIVE SURGERY. 
 
 By De. TH. KOCHER, 
 
 Professor of Surgery and Director of the Surgical Clinic in the 
 University of Bern. 
 
 Translated by Special Permission of the Author from the Second 
 Enlarged and Improved German Edition. 
 
 By HAROLD J. STILES, M.B., CM., 
 
 Senior Demonstrator of Surgery in the University of Edinburgh ; Assistant 
 Surgeon, Royal Edinburgli Hospital for Sick Children. 
 
 Illustrated with 185 Cuts in Text. Super Royal 8vo. Cloth. Price 20s. 
 
 " This work, which is, as the translator states, essentially a record of the author's 
 personal experience and of his own methods of operation, forms a valuable addition 
 to the surgical literature of modern times. The illustrations, which constitute a very 
 considerable proportion of the volume, are many of them new to us, and differ from 
 those usually met with in our text-books by their greater size and more artistic finish. 
 Those dealing with the vessels are excellent from a diagrammatic pouit of view, and 
 will doubtless be of great use both to the student and to the operating surgeon. We 
 can confidently recommend the book as one full of instruction, and we congratulate 
 Mr. Stiles upon the excellent English of his translation." — British Gyncecological 
 Journal. 
 
 "All operating surgeons should possess themselves of this excellent text-book. 
 The whole book is a protest against the mechanical and cut and tie practice of 
 surgery, and is suggestive, at least, of possible improvements in the technique and 
 results of even ordinary operations when anatomical and physiological facts are 
 brought fully to bear on surgical work. The author describes only sucli operations as 
 he has done and can speak of with authority ; and ' in writing this text-book, we have 
 aimed at making it not merely useful for teaching purposes, but also, in view of the 
 author's extensive experience, a reliable guide to general practitioners and surgeons 
 in operating on the living subject." — Medical Jowrnal. 
 
 " It is useless to particularise where all is good, and we can only say that all who 
 consult the book, whether hospital surgeons, general practitioners, or senior students, 
 will find it both instructive and interesting." — Liverpool Medico-Chirurgical Journal. 
 
 "This is no systematic treatise on operations, bi;f an account by a recognised 
 master of the procedure which he follows. While there is no attempt at cyclopaedic 
 statement of alternative methods, the whole field of general surgery is covered, and 
 the surgical world is indebted to the distinguished author for the account of the 
 methods which his great experience has approved." — CUasfjoiu Medical Journal. 
 
 '• We would say, in conclusion, that we have rarely read a work of less than 300 
 pages with more profit or with greater interest, and we close the volume with a 
 feeling that we have spent a few hours with an undoubted genius with real and 
 lasting benefit to ourselves. The book is well got up, and the illustrations first- 
 class. We hope every operating surgeon will, at the earliest moment, secure a copy, 
 as he will find it of the greatest value with reference to the most recent operations. 
 Dr. Stiles' translation is excellent and is very pleasant to read." — Birmingham, 
 Medical J our mil. 
 
TEXT-BOOK OF GENERAL PATHOLOGY AND 
 PATHOLOGICAL ANATOMY. 
 
 By Professor PJCHAED THOMA, of Dorpat. . 
 
 TRA2S-SLATED BY ALEX. BRUCE, M.D., 
 
 Lecturer on Pathology, Surgeons' Hall, Edinburgh, and Pathologist to the 
 
 Eoyal Hospital for Sick Children, Edinburgh. 
 
 In Two Vols., Super Royal 8vo, ivith Jj.26 Illustrations. 
 Vol. I now ready. Price oOs. 
 
 " It has not often fallen to our lot to read such a fascinating book as this, and to 
 our mind it is, without any doubt, the best book on modem pathology that has 
 appeared in the English language. The profession cannot be too grateful to Professor 
 Thoma for having -sNTitten it, and to Dr. Bruce for ha\ing translated it. The charm of 
 the book lies chiefly in the width of view of his subject taken by the author ; every 
 page that the reader peruses makes him think, and he gets up from the book not 
 only knowing more pathology than w'hen he sat down, but having exercised his mind 
 and made himself more of a reasoning, thinking physician. The style of writing is 
 concise, without being so compressed as to be unreadable ; and the author always 
 succeeds in infusing his interest in the subject into the reader.'' — Tlie Praxtitioner. 
 
 "The use of the word 'test-book' in the title of this volume conveys a very 
 meagre impression of the character of the work. Test-book it is, inasmuch as it 
 covers the iield of work usually considered in treatises on pathologj-, but it is much 
 more than this. Like so many of the volumes left as records of their lile's work by 
 men of research on vacating their academic chair, the book contains the records of a 
 vast amount of investigation of a most original character. The book is illustrated 
 ■nith a profusion of plates, and most of the drawings are original. Dr. Alesander 
 Bruce is to be congratulated on the lucid English into which he has managed to 
 render much difficult and involved reasoning." — British Medical Journal. 
 
 ■• This is a work of considerable originality and erudition. Its author, a pupil 
 of Professor Julius Arnold of Heidelberg, and for some years past himself Professor 
 of Pathology at the University of Dorpat, has made many elaborate researches upon 
 changes in the blood-vessels and circulation, and accordingly we find that the above 
 test -book devotes considerable attention to this important branch of pathology. 
 But in saying that much attention is devoted by the author to circulatory disturb- 
 ances, it must not be inferred that this book is not well abreast of modem knowledge 
 in other respects. The book may be regarded as an epitome of his career in patho- 
 logical instruction and research ; and few who read it will either fail to admire his 
 great abilities or to regret that so keen an intellect should be withdra-mi from the 
 pursuit of science. In extent and profundity it deserves a place in the front rank 
 of pathological ■^Titings, whilst for the student and pathologist one great attraction 
 of the book must be the lucidity vrith which some of the most difhcult problems are 
 handled and the marked individuality that forms one of its characteristics. We are 
 grateful to the translator and publishers for the inti'oduction of so admirable a 
 treatise into English literature." — The Lancet. 
 
 " Medical men in general, and pathologists in particrdar, owe much to Dr. Bruce 
 for giving to English readers Thoma's valuable Text-Booh of Pathology, and for the 
 able manner in which the work has been performed. A most valuable book of 
 reference for the senior student and practitioner." — Edinhiirgh Jfediad Jov.rncd. 
 
RHEUMATISM: 
 Its Nature, Its Pathology, and Its Successful Treatment. 
 
 By T. J. MACLAGAN, M.D. 
 
 Ph3'sician in Ordinary to Their Royal Highnesses Prince and Princess 
 Christian of Schleswig-Holstein. 
 
 Second Edition. Demy 8vo. Cloth. Price 10s. 6d. 
 
 " We have pleasure in calling tlie attention of our readers to the publication of 
 the second edition of Dr. JNIaclagau's work on Rheumatism. Twenty years have now 
 elapsed since he ' introduced salicin to the notice of the profession as a remedy in 
 acute rheumatism,' and the presentation of his matured view on the pathology and 
 treatment of the disease will no doubt be welcomed by medical men. The clinical 
 and tlierapeutical sections of the book are of great interest, and may be read with 
 profit and pleasure." — Glasyoir Medical Journal. 
 
 "There are, indeed, but few physicians, if any, of those now living, who can 
 point with confidence to so valuable a boon to suffering humanity as that which it 
 has been the happy privilege of Dr. Maclagan to confer. Indeed, of past and present 
 physicians, there is only one who by his own unaided and imiuspired eflforts (should 
 we rather call these inspired ?) has done so much for the elimination of prolonged 
 suffering of the most aggravated and hopeless kind. The volume in which he has 
 placed his results upon record requires no special praise of ours to recommend it. 
 It is sure to find plenty of appreciative readers." — Medical Press. 
 
 " It is now twenty years since the first edition of this work appeared, and that 
 time has amply proved how valuable, indeed how indispensable, is the treatment of 
 acute rheumatism by the salicyl compounds with which Dr. Maclagan's name is so 
 honourably associated, and which the former edition was published to make known 
 and defend. The book' is a readable one, contains many useful hints and suggestions, 
 and should serve to enhance the rejiutation of the author." — Edinburgh Medical 
 Journal. 
 
 "This work is a thoughtful and able treatise on a disease which is still sur- 
 rounded by considerable mystery. It clears up a great deal that was hitherto 
 obscure, and its pages deserve an attentive study by the practical physician." — 
 Dvhlin Journal of Medical Science. 
 
 "The service which the author of this monogi-aph rendered to practical medicine 
 when twenty years ago he introduced to notice the salicin treatment of acute 
 rheumatism, entitles us to receive all that he has to say upon this disease with 
 attention and respect. The book is one well worthy of perusal, and we congratulate 
 its author on having produced a second edition." — Lancet. 
 
 A. & C. BLACK, SOHO SQUARE, LONDON.