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DISEASES OF THE HEART: 
 
 DIAGNOSIS AND TREATMENT. 
 
 BY 
 
 DAVID WOOSTER, M. D. 
 
 MEMBER OF THE BOTAL ACADEMY OF BiTEDICINE AND SURGEEY OF TURIN, 
 
 Assistant Surgeon in tlie "Mexican War," Surgeon (Major) in 
 the late Civil War, Author of " Diphtheria and Congen- 
 ital Asphyxia " (1859), Founder and former 
 Editor of "The Pacific Medical and 
 Surgical Journal," etc., etc. 
 
 :\ui£ L/e/^ 
 
 SAN FRANCISCO: 
 H. H. BANCROFT AND COMPANY. 
 
 1867, 
 

 Entered according to Act of Congress, by David Wooster, in the 
 Clerk's Office of the District Court of the United States for the Northern 
 District of the State of California, in the year 1867. 
 
 Printed by Thompson & Co., 
 No. 536 Market Street, opposite Second, 
 
 SAN FJBANCISCO. 
 

 TO 
 
 William Henry Patterson, Esq., 
 
 of San Francisco, I dedicate this volume, as a token of 
 admiration and long personal friendship. 
 
 David Wooster. 
 
 14 Geary street, San Francisco, 
 September, 1867. 
 
 11689? 
 
PREFACE. 
 
 In writing the following pages, I have been scrupulously 
 careful not to place my own unsustained assertions in oppo- 
 sition to the results of clinical demonstrations or extreme 
 probabilities. I have also endeavored to give the anatomy, 
 or topography, of the structures under consideration, with as 
 much accuracy as possible. 
 
 There are no such obstacles now, in the way of writing 
 intelligibly on diagnosis of diseases of the heart, as there were 
 even twenty-five years ago. If medicine has not yet become 
 a science, it has, at least, so far advanced as to recognize its 
 own defects, and to be conscious of its absolute knowledge. 
 Physicians now know where their knowledge ends and their 
 theories begin ; and in this they are far in advance of their 
 forefathers. 
 
 My aim has been to limit myself, as closely as possible, to 
 known facts, and to indulge in no idle speculations, for the 
 purpose of introducing some favorite theory of my own, in 
 order to make myself seem original. I need not tell my in 
 telligent readers that this treatise is merely an abstract ; but 
 it is hoped that they will find it what the author designed it 
 to be, a careful and conscientious epitome of the knowledge 
 now possessed by the profession on the subject of which it 
 treats. My only claim to their commendation will consist 
 in having placed .the knowledge already possessed in a more 
 accessible form, of having made the facts we daily need to 
 use more tangible, by stripping them of some of their garni 
 ture, and grouping them in closer and more obvious relations 
 to each other. 
 
ii PREFACE. 
 
 I have endeavored to condense the statement of facts into 
 a much smaller compass than they appear in the standard 
 authors, without omitting anything necessary to a clear un- 
 derstanding of the subject treated. In the process of con- 
 densation, I have frequently used several successive words, 
 just as they occurred in the authority consulted, and perhaps 
 occasionally a full sentence, without quotation marks. But, 
 while I make no pretence to having written a work original 
 in material, I have endeavored to avoid the crime of plagi- 
 arism. 
 
 • I have ventured to make some suggestions in diagnosis, 
 not of a radical kind, but merely as to applicability and im- 
 port of certain signs, and also to indicate additional treatment 
 in some forms of heart disease to that which authors 
 generally recommend ; but, as I have at the same time 
 pointed out wherein I have ventured to differ with the mas- 
 ters, the reader vrill not be beguiled into mistaking my 
 treatment for that of authors whom he may with just reason 
 hold in higher estimation. I have insisted with some perti- 
 nacity on the reflex treatment of unsoundness of the heart, 
 but for my opinions on the value of this kind of treatment, 
 I am indebted to Radcliffe, Brown-Sequard, and others who 
 have investigated the more recondite departments of human 
 physiology. 
 
 I have had much less to say of treatment than of diagnosis, 
 because in reality much lesr^ is known of the former than of 
 the latter. We are yet entirely ignorant of the manner in 
 which, or of the prime cause why the heart becomes unsound 
 by the deposition of anahjgous tissues, in most cases, and 
 until we have acquired this knowledge, we cannot do much 
 more than treat certain symptoms, which are common to 
 either acute or chronic inflammations. But thanks to our 
 almost exact knowledge of the beginning and process of 
 acute inflammations, derived from a multitude of clinical 
 
PREFACE. iii 
 
 cases, carefully observed in all countries, by eminent and 
 conscientious physicians, we are now able to treat symptoms 
 with a degree of rationality which will accomplish a purpose 
 predetermined on the part of the physician, and which will 
 generally result in success in curable cases, and in the 
 alleviation of the most hopeless. 
 
 Cases of heart disease are of alarming frequency in Cali- 
 fornia, yet, in the absence of statistics, it would be improper 
 to say categorically that this affection is excessively frequent 
 here ; still I feel convinced that it is, and were its etiology 
 within the scope of this treatise, I think it could be satisfac- 
 torily shown why disease of the heart is more likely to be 
 prevalent in newer than in older civilizations, and in this 
 climate than in many others ; and under the special, moral, 
 mental and hygienic influences which characterize us, than 
 under those which predominate in other centres of popula- 
 tion. For example : the physical aspect of the country and 
 metropolis — mountainous and hilly — reverse of fortune and 
 the vital depression consequent upon it ; family ties rudely 
 sundered, and the despair resulting ; the insatiable thirst 
 for riches, and the unusual energy employed in acquiring 
 them, to the deprivation of mind and body of essential rest ; 
 the exposure, night and day, to which our mining popula- 
 tion is subject ; the tunnel and deep drift work of the quartz 
 miner ; the excessive intemperance in drink — the thousand 
 disappointments, and misfortunes, and endless unrest to which 
 a population anxi6us to become rajjidly rich, like ours, must 
 ever suffer, are so many reasons why the heart should be- 
 come diseased and exhausted under the great labor of pro- 
 viding for such extravagant use of all the functions of life. 
 
 It is on account of my opportunities for observation during 
 the seventeen years I have been practising medicine in Cali- 
 fornia, and the hope that I might add some little to the 
 facility of diagnosis, and the success in the treatment of 
 
iv PREFACE. 
 
 affections of tlie heart, and that I might materially diminish 
 the labor of finding the knowledge that has already been 
 published, that I determined to make this slight addition to 
 medical literature. 
 
 This small work has been prepared during the intervals of 
 daily toil, and hence it lacks that unity of design and unin- 
 terrupted sequence of subjects and sentences which are desira- 
 ble in a strictly systematic treatise ; but inasmuch as it 
 does not aspire to that category, I trust it will be con- 
 sidered with some indulgence in this respect. Those who 
 desire a complete, systematic and exhaustive treatise, written 
 with the most logical clearness, will find that of Walshe on 
 " Diseases of the Heart" unsurpassed in any language. 
 
 I have freely consulted Walshe, Hope, Latham, Stokes, 
 Bennett, Markham, Skoda, Rokitansky, Radcliffe, Brown- 
 Sequard, See, Virchow, Claude Bernard, Flint, Piorry, and 
 numerous other authors ; also, current medical literature of 
 standard authority. 
 
 I am under many obligations to my friend Dr. J. N. Brown, 
 of San Jos6, one of the most learned and successful physi- 
 cians in California, for valuable suggestions and criticisms 
 during the compilation of this epitome, I am conscious of 
 many imperfections in it, both in -diction and manner of 
 arrangement. With many misgivings, I offer it to the pro- 
 fession, asking for it merely the indulgence which a con 
 scientious author has a reasonable right to expect of a 
 conscientious reader. 
 
 DAVID WOOSTER. 
 
 San Francisco, September, 1867. 
 
CONTENTS. 
 
 Dedication. page. 
 
 Preface. 
 
 Contents. 
 
 Chapter I. 
 
 Introduction. Causes of Discrepancies of Opinion in 
 
 Cases where Exactness is possible 5 
 
 Chapter II. 
 Anatomical and Physiological Facts concerning the 
 Location of Valves, and Origin of Heart's Sounds. 10 
 Chapter III. 
 
 Diagnostic Signs of Endocarditis Pericarditis, and 
 Insufficiency of the Mitral Valve. Cases and 
 
 Treatment 19 
 
 Chapter IV. 
 
 Disease of the Semilunar Valves of the Aorta. Direct 
 and Regurgitant Murmurs — Differential Diagnosis 
 of. Treatment of Disease of the Aortic Valves, 
 and its Complications 48 
 
 Chapter V. 
 Valves of the Pulmonary Artery. Constriction of the 
 Mitral Orifice. Constriction of the Right Auriculo- 
 
 Ventricular Orifice 86 
 
 Chapter VI. 
 Inorganic Murmurs — How Distinguishable from Or- 
 ganic. Diastolic Inorganic Murmur 96 
 
 Chapter Vn. 
 Pericarditis and Endocarditis. Endo-pericarditis. Car- 
 ditis 103. 
 
11 CONTENTS. 
 
 Chapter VIII. page. 
 
 Hypertrophy. Dilatation 134 
 
 Chapter IX. 
 Fatty Metamorphosis or Degeneration, or Fatty Sub- 
 stitution of the Heart. Rupture of the Heart. 
 
 Cases 150 
 
 Chapter X. 
 Thoracic Aneurisms : Diagnosis and Treatment. 
 Cyanosis and Atelectasis. Appreciation of the 
 
 true cause of Cyanosis 172 
 
 Chapter XI. 
 
 General Rules for Diagnosis and Treatment of Dis- 
 
 eases^of the Heart 179 
 
 Chapter XII. 
 General Reflections as to Prognosis in Organic Dis- 
 eases of the Heart 187 
 
 Appendix A. — First Sound of the Heart 201 
 
 B.— Intermittent Pulse 201 
 
 C. — Causes of Dropsy 203 
 
 D. — ^Mode of Death in Mitral Disease. 
 
 Cause of Pain 204 
 
 E.— Pericardial Effusion 205 
 
 F. — Absence of First Sound in Softening 
 
 and Pericardial Effusion ... 206 
 
 G. — Saline Evacuants 206 
 
 H. — Embolism, how developed. Cause of 
 
 Coagulation of the Blood 207 
 
 " I. — Tables of the Thickness of Ventricles. 
 
 Order of Valvular Diseases 209 
 
 Errata. 
 
 Diagram, exhibiting the relationship of the heart and 
 great vessels to the limgs, (in moderate inspira- 
 tion,) and to the regions of the chest.. 210 
 
 Index. 
 
Y- TH£ 
 
 ''^ 
 
 CHAPTER I. 
 
 Introduction. Causes of Discrepancies op OprNioN 
 IN Cases where Exactness is Possible. 
 
 1. Many works have been written on diseases 
 of the heart, and its affections have been de- 
 scribed and treatment recommended in all stand- 
 a.rd works on the practice of medicine ; but 
 it has occurred to me that the matter might 
 be much condensed, without detriment to scien- 
 tific exactness and with great benefit to actual 
 sufferers^ 
 
 2. Physicians well know in their own minds 
 that a very small proportion of the practitioners 
 of medicine are able to diagnose an affection of 
 the heart with even tolerable exactness ; not 
 only are they unable to say what valve is affec- 
 ted, but they do not distinguish the side of the 
 heart ; still worse, many who listen cannot dis- 
 tinguish normal from abnormal sounds, the beat 
 of a healthy from the throb of a diseased heart. 
 
 This inability of discriminating sounds, with 
 some is a natural defect, a physiological defi- 
 
h DISEASES OF THE HEART ! 
 
 ciency in the ability to compare small discrep- 
 ancies. But the inability generally is less seri- 
 ous ; it is a lack of the acquirement and recol- 
 lection of facts which may be acquired and re- 
 membered by most persons of intelligence. 
 These facts can be acquired only by diligent 
 study, and numerous examples, carefully and 
 rigidly observed. For example : a person who 
 has acquired the elements of Latin, when he 
 attempts to translate a sentence of Latin into 
 English, if he is really acquainted with the 
 structure of the original, is altogether sure 
 Avhen he has rendered its true meaning. If he 
 have less or more than the true meaning, he 
 will be conscious of the deficiency or redundancy; 
 or if different from the true he will know 
 wherein the difference consists. But one who 
 lacks this knowledge of the principles of the 
 original language, will never be quite sure of 
 his translation ; there will always remain some 
 doubt in his own mind about the exactness of 
 his rendering. No 'amount of labor, without a 
 knowledge of the fundamental facts, will be of 
 any avail. So he who practices physical diag- 
 nosis, must first of all, be well grounded in the 
 meaning of natural sounds and signs, and in 
 
THEIR DIAGNOSIS AND TREATMENT. 7 
 
 tlieir topography on and in the body. Of what 
 use is it to recognize crepitus if we do not know 
 what crepitus indicates. Of what use to recog- 
 nize murmurs if we know not from whence they 
 proceed, their cause and significance? Two 
 physicians, with diplomas from respectable med- 
 ical colleges, will examine a chest the same day. 
 One will say there are softened tubercles in a 
 lobe of the right lung, but that the left lung is 
 natural ; the other will say th*^ right lung is 
 not affected at all, but he finds one or more 
 cavities in the left lung. Now, if the patient 
 goes on to other physcians, perhaps the next 
 will tell him he has a bronchitis or a catarrh ; 
 the third will tell him his "lungs are more than 
 half gone,'^ while a fourth will tell him categor- 
 ically, his lungs are perfectly sounds but that he 
 has disease of the heart. 
 
 All physicians recognize this gamut of opin- 
 ions on the same case, examined the same week. 
 Whence do such discrepancies arise ? They do 
 not always arise from inability on the part of 
 the examiner, less frequently from lack of frank- 
 ness. Yet the result is the same on the mind 
 of the patient and his friends and of the com- 
 munity, as if the disagreement in opinion were 
 
8 DISEASES OF THE HEART : 
 
 the result of ignorance; In some cases, doubt- 
 less in most, when the discrepancy is so irrecon* 
 cilable, the doctors have examined superficially^ 
 and the ear of each has been placed over a dif- 
 ferent portion of lung, and the examination has 
 not been minute and exhaustive. One listened, 
 perhaps, at a lower lobe, the other at an upper^ 
 one placed his ear just below a clavicle, the 
 other placed his just behind a scapula ; one 
 listened carefullj^ on one and carelessly on the 
 other side, while the other observed closely 
 both sides of the chest ; and finally one knew 
 not the meaning of the sounds elicited, or 
 heard with the ear, while the other appreciated 
 their precise significance. 
 
 But until professional opinions shall more 
 nearly harmonize on matters of simple. fact in 
 physical diagnosis, the people, will not have 
 implicit confidence in the opinion of any one of 
 us, however excellent. 
 
 If a patient with aortic insufficiency, or tuber- 
 cular cavity under the right clavicle, should be 
 examined by twenty physicians in succession, 
 and the whole twenty should verify the insuffi- 
 ciency in the same place, or the cavity in the 
 same portion of lung, and if similar harmony 
 
THEIR DIAGNOSIS AND TREATMENT. 9 
 
 of opinion on matters within the reach of exact 
 diagnosis, should prevail even with twenty phy- 
 sicians in one large city, where there are five 
 hundred doctors, as there are in San Francisco, 
 I say, if twenty would agree- on ascertainable 
 facts, the profession would very soon possess the 
 entire confidence of the people. The fault is in 
 our own carelessness or inability ; and whether 
 we are careless or ignorant, the result is* much 
 the same. * 
 
 4. I purpose in the following pages to give 
 a brief summary of what is known about diag- 
 nosis and treatment of diseases of the hearty and 
 to show how simple it is for all educated physi- 
 cians to say positively what portion of the heart 
 is affected in most cases, and to show in the few 
 cases in-which positive diagnosis is unattainable 
 that an extremely probable diagnosis may be 
 given, sufficiently exact at least to form the 
 basis of rational treatment. 
 
10 DISEASES OF THE HEABT : 
 
 CHAPTER II. 
 
 anatomicaii and physiological facts coxcerking 
 Location of Valtes, and Origin of Heart's Sounds. 
 
 1. No two hearts are the same size. No two 
 persons' hearts beat precisely aUke, or so nearly- 
 alike, but that a practiced ear would distinguish 
 the deference in the dark. Yet the healthy 
 beat of the heart is so different from the un- 
 healthy, that the practiced listener would be 
 able to say without seeing the patient's face, 
 whether the heart was health^^ or affected. 
 
 2. The heart has a more or less conical form, 
 and is suspended obliquely in the chest ; its base 
 corresponds with the median line of the breast 
 bone, but is directed upwards and backwards 
 towards the backbone, while its apex is directed 
 downwards and forwards and to the left, so that 
 when the heart contracts the apex is felt and 
 seen to strike the chest between the fifth and 
 sixth ribs, below and a little to the right of the 
 left nipple, ivlien the person stands erect. If he 
 lean forward the beat strikes not only the fifth 
 intercostal space, but the fifth rib and a little 
 farther towards the breastbone. If he lie down 
 
THEIE DIAGNOSIS AND TREATMENT. 11 
 
 on his back, the apex beat is imperceptible any- 
 where. If he turn on his left side he renders 
 it more perceptible than in the erect position, 
 but in a larger space more towards the nipple 
 than the sternum. And, finally, if he turn on 
 his right side, the heart's impulse against the 
 chest is scarcely, or not at all perceptible. 
 
 These are obvious facts, but well worth re- 
 membering. 
 
 3. Aside from all nice distinctions, the ear 
 recognizes hvo natural sounds of the heart. 
 These are known as the first and second sounds 
 of the heart. 
 
 4. The first sound is heard most distinctly 
 over the anterior surface of the heart, on 
 the fifth costal cartilage, left side, at a point 
 midway between its junction with the sternum 
 and its junction with the rib. *' It is long, dull, 
 and smothered in tone, and occupies one-half 
 the duration of a single beat.'' It corresponds 
 in time with the impulse of the heart in the 
 precordial region. 
 
 5. The precordial region is certainly found by 
 describing a circle, with a radius of one inch, 
 from a point in the fifth costal cartilage, left 
 
12 DISEASES OF THE HEART: 
 
 side, midway between its junction with the rib 
 and its junction with the sternum. '' In this case 
 we suppose a well formed chest." (Latham.) 
 
 6. The second sound is heard most distinctly 
 in the situation of the aortic and pulmonic 
 valves ; it follows immediately upon the first 
 sound, with scarcely an appreciable interval. 
 It is short, sharp, and distinct in tone, and 
 occupies one quarter of the whole of a pulsation. 
 
 7. " A line drawn through the inferior margins 
 of the third rib, across the sternum, passes 
 through the pulmonic valves a little to the left 
 of the mesial line, and those of the aortia lie 
 behind them, but about half an inch lower 
 down." (Hope.) 
 
 " The aortic and pulmonary valves are situa- 
 ted under the sternum, at the level of the third 
 costal cartilage." (Dalton.) 
 
 8. The first sound of the heart is caused by 
 the closure of the auriculo-ventricular valves — 
 mitral and tricuspid valves — valves between the 
 left ventricle and auricle, mitral ; valves be- 
 tween the right ventricle and auricle tricuspid. 
 
 9. *' A horizontal line drawn through (''along?" 
 Latham) the under edge of the sterno-costal 
 
THEIR DIAGNOSIS AND TREATMENT. 13 
 
 articulations of the fourth ribs will cut across 
 nearly the middle of the length of the mitral 
 valve, when drawn outwards and downwards by 
 its tendinous cords and fleshy columns, and 
 pass about two or three lines above that por- 
 tion of the tricuspid which most nearly ap- 
 proaches it, the latter valve lying undeuneath 
 the sternum, and the former immediately to 
 its left.'^ (Joy.) 
 
 10. The second sound is undoubtedly caused 
 by the closure of the semi-lunar valves (aortic 
 and pulmonic). The first and second sounds 
 occur in the same order as the closure of the 
 two sets of valves : 1st, the two auriculo-ventri- 
 cular valves — mitral and tricuspid, shut back, 
 
 first sound ; directly upon this the two sets of 
 semi-lunar valves, aortic and pulmonic, shut 
 back ; second sound. 
 
 11. The sounds of the heart, their cause, and 
 the location from whence they proceed being 
 granted, and their quality being ascertained 
 from the examination of persons in health, the 
 inference is clear that any marked variation 
 from this standard will be abnormal, and a sign, 
 considered by itself, of disease of the particular 
 
14 DISEASES OF THE HEART: 
 
 Structures from which the marked variation 
 proceeds. 
 
 12. Persons die of .''heart disease" almost 
 daily, but whether of disease of the inside or 
 outside of the heart, whether of the valves or 
 of the substance of the heart, the record scarcely 
 ever ishows. A distinguished London physi- 
 cian said, after thirty years of practice, that 
 two-thirds of his professional life passed before he 
 could discriminate between an inflammation of 
 the cavities of the heart and of its outside j before 
 * he could tell an endocardial from an exocardial 
 murmur. No physician in the world could make 
 this distinction before 1826. And yet it is of 
 great importance to know there is a distinction,, 
 and to know what the distinction suggests of 
 the health and probabilities of life to the pa- 
 tient. 
 
 «. We will say then categorically, that an 
 educated ear can, in almost every, if not every 
 case, distinguish an exocardial from an endocar- 
 dial murmur ; and hence a pericardial from an 
 endocardial affection. 
 
 &. Perhaps in nine-tenths of the cases in which 
 the heart is diseased, its inside rather than out- 
 
THEIR DIAGNOSIS AND TREATMENT. 15 
 
 side is aflfeeted. Affections of the outside of the 
 heart, or of the pericardium are comparatively 
 rare. 
 
 c. Men are more liable to heart disease than 
 women ; adults are more liable than youths 
 and children; residents of cities are more liable 
 than residents of the country ; dissipated peo- 
 ple are more liable than those of regular habits. 
 The rich are more liable than the poor. 
 
 d. Courtezans rarely have disease of the 
 heart I 
 
 6. Excessive indulgence of the erotic passion, 
 is, on the contrary, in men a great aid to the 
 development of endocardial disease, and also 
 of acute rheumatism, which is a conspicuous 
 and very common forerunner of pericarditis. 
 
 /. It is obvious there is no opposition in 
 propositions d and e, but rather correlation. 
 There is all the difference conceivable in the 
 physiological effect of erotism in man and 
 woman. 
 
 13. It may be said in general terms that 
 every acute disease of the heart is an inflamma- 
 tion, and if rationally treated, does not necessa- 
 rily cause death. 
 
 But the world is much more concerned with 
 
16 DISEASES OF THE HEART'. 
 
 those diseases of the heart which are not inflam- 
 mation, and that do not result from any direct 
 injury, or any sudden or acute disease. 
 
 Certain growths in the body are called hetere- 
 logous as tubercle, carcinoma, cepbaloma, etc., 
 and the heart even is not exempt from hetero- 
 logus growths of this nature ; but they are ex- 
 ceedingly rare, so much so as to be almost be- 
 yond the field of research. 
 
 Bat permanent disease of the heart is derived 
 from the deposition in some portion of it, of 
 analogous tissues ; that is analogous to healthy 
 tissues. The cartilage and bone deposited in 
 the heart and arteries is analogous to cartilage 
 and bone in the joints, though not exactly like, 
 either chemically or physiologically. It is dis- 
 ease of the heart caused by these deposits, and 
 that caused by the deposition of fat in the 
 substance of the heart and also that caused by 
 atheromatous deposits, either alone or in com- 
 pany' with cartilage and bone, with which we 
 are most concerned. 
 
 14. With the pathological history of these 
 diseases I shall have but little to do in this 
 monogram. Their beginning, progress and cul- 
 
THEIR DIAGNOSIS AND TREATMENT. 17 
 
 mlnation^ and the causes of their beginning, 
 duiJ-ation and termination, are pretty well known 
 to observers, but just why cartilage, and bone, 
 and fat, one or all, should be deposited slowly, 
 so slowly as not to attract the attention of the 
 victim, in the heart of a habitual drinker more 
 than in the heart of an excessive feeder, we 
 cannot explain; but the same thing is done in 
 old age even in those who have lived the most 
 regular lives. Therefore, for this reason alone 
 it is probable, and we know by observation that 
 it is certain, that excess in drinking induces 
 premature t)ld age, and the deposit in the heart 
 of organic substances, analogous to the healthy 
 tissues, but of a lower formative grade, composed 
 of dwarfed or defective form elements, just as 
 we observe in old age. 
 
 15. This slow, permanent unsoundness of the 
 heart is caused by something equivalent to old 
 age, and the result will be the same, death, 
 unless the habit is changed and reparation made 
 for#loss sustained. Hotvever much we do the 
 result will alivays fall short of complete resfora- 
 iion of the heart to as sound a condition as it 
 tvas before the deposit of the analogous tissue.*]. 
 
 16. We are accustomed to say that heart 
 
18 DISEASES OF THE HEART : 
 
 disease comes of itself. If one has an inflamed 
 eye, we say the eye has been recently hurt, or 
 exposed to a cold wind or some contagion ; if 
 one has a fever, we say he has been exposed to 
 its cause recently. We recognize these causes, 
 and always refer to them for the solution of the 
 phenomena of acute affections } not so with 
 chronic diseases, we are apt to say they come of 
 themselves ; and yet they have causes as defi- 
 nite and appreciable as an intermittent fever or 
 a pneumonia ; but they are so long in acting 
 that we keep no record of them, and do not 
 seek them until the disease take^ form and 
 
 place. 
 \ 
 We do not know why this premature old 
 
 age seizes on the heart rather than the lungs or 
 liver ; why it does not at the same time cause 
 wrinkles, and parchment coloration of the skin. 
 These negative inquiries are unprofitable, and 
 if answered would not elucidate the unsolved 
 problem ; why are analogous growths deposited 
 in the heart at all ? They are deposited be- 
 cause one dissipates. But why does dissipation 
 cause them ? Because it induces old age? But 
 why does old age cause these deposits? Because 
 nutrition is defective, and hence the form ele- 
 
THEIR DIAGNOSIS AND TREATMENT. 19 
 
 meats are dwarfed and imperfect. But why 
 is nutrition defective in old age ? Here the 
 oracle returns no longer any satisfoctor}^ an- 
 swer, and hence the first question remains un- 
 answered and Unanswerable ; that is, we do 
 not, and probably never can know wljy anala- 
 gous growths are deposited in the heart at all. 
 
 CHAPTER m. 
 
 BiAG^^osTic Signs of Ekdocarditis Pericarditis, and In- 
 
 SUFFICIENCY OF THE MlTRAL VaLVE. CaSES.^ TREAT- 
 MENT OF Mitral Insufficiency. 
 
 1. We haye seen that the first sound of the 
 heart is caused by the closure of the auriculo- 
 ventricular valves— mitral and tricuspid. '^ 
 
 2. That the second sound is caused by the 
 closure of the semilunar valves of the aorta and 
 pulmonary artery shutting back at the same in- 
 stant. 
 
 3. Endocardial murmurs are distinguishable 
 from exocardial/Hc^i07?.s. 
 
 4. The ear cannot mistake a murmur for a fric- 
 tion, nor the contrary — hence when there is a 
 persistent murmur the affection is surely within 
 the heart. 
 
 * I do not venture to say that there is no other element in 
 the causation of first sound, but the closure of auriculo- 
 ventricular valves is the only cause of any practical import- 
 ance. 
 
20 i)tSEASES OP THE HEART ! 
 
 5. When there is a friction sound, persistent or 
 not, there is pericarditis acute ot chroliic ; and 
 the disease is outside the heart. 
 
 6. Now, if murmurs proceed from diseased 
 valves, the murmur should, other things equal, 
 be heard loudest when the ear is nearest the 
 affected valve. 
 
 If the mitral valve is affected the murmur will 
 coincide with a part or all of the first sound ; and 
 lie heard most distinctly, either at the apex of the 
 heart that is where the heart is seen and felt to 
 strike the chest below the left nippje, or, a little 
 above the left nipple, to the left of the sternum, 
 between the fourth and fifth ribs, directly over 
 the mitral valve. If the disease is of the mitral 
 valve, the sound will be heard distinctly at the 
 apex of the heart, and perhaps for some dis- 
 tance below it in the same right line ; but if 
 the aortic valves are affected, the murmur will 
 be heard loudest just about where the mitral 
 murmur was heard loudest; but in place of being 
 heard more distinctly in the direction of the 
 apex, it will be heard" more distinctly in the 
 direction of the aorta, that is over the sternum, . 
 opposite the second rib. (The aorta ascends 
 behind the sternum, obliquely upwards and for- 
 
THEIR DIAGNOSIS AND TREATMENT. 21 
 
 wards towards the right side until it reaches 
 the upper border of the second costal cartihige.) 
 Whether the murmur proceed from the mitral 
 valve or the aortic valves, the murmur will at- 
 tend the systole of the heart ; that is, it will 
 coincide with the first sound. Whether the 
 murmur proceed from the aortic valves or the 
 mitral valve in nine cases out of ten it will be 
 heard loudest in the precordial region, with 
 the ear or stethoscope placed over the costal 
 cartilage of the fourth rib. By listening over 
 the precordial .region only, no man can say 
 which valve* is diseased, because the stethoscope 
 will cover all the valves if it is an inch and a 
 half in diameter ; and most physicians will con- 
 fess that it would be impossible to say from 
 which portion of the circle included in the 
 mouth of the stethoscope the murmur proceeded 
 in a given case, but if on moving the stetho- 
 scope towards the apex of the heart, the mur- 
 mur should be heard louder than it would be if 
 moved up the arch of the aorta, or in the di- 
 rection of the pulmonary artery, the diseased 
 valve would almost certainly be the mitral, if 
 the murmur coincided with the hearts systole. 
 In this case the murmur would result from the 
 
22 DISEASES OF THE HEART ! 
 
 blood being repelled backwards from the left 
 ventricle into the left auricle, through the im- 
 perfect mitral valve. It will be borne in mind 
 that in health of the heart the contraction of the 
 left ventricle impels the blood forwards through 
 the aorta. Now the aorta is composed of 
 powerful elastic tissues, and hence it reacts with 
 violence on the current forced through it by 
 the ventricular systole, and it is obvious that 
 when the aortic valves are open, as they are 
 during the ventricular systole, that if the mi- 
 tral valve were open also, there would be 
 nothing to prevent the aortic resistence, to- 
 gether with the contraction of the ventricle 
 from repelling the blood through the mitral 
 orifice ; and it is also obvious that this repul- 
 sion would be synchronous with the ventricular 
 systole, hence the resultant murmur would be 
 synchronous with the same systole, and would be 
 }ieard best, not in the direction of the aorta, 
 but of the axis of the ventricle, that is in the 
 direction of *the apex of the heart, which is the 
 apex of the left ventricle. 
 
 And by the same reasoning it can be shown, 
 that if the murmur proceeds from the aortic 
 valves, roughened with analogous growths, but 
 
THEIR DIAGNOSIS AND TREATMENT. 23 
 
 not SO impaired as to prevent them from closing, 
 that the murmur will be synchronous with the 
 first sound, and heard louder in the direction of 
 the aorta, that is of the onward current of the 
 blood, than in the opposite direction, that is, 
 towards the apex. 
 
 But again. If the mitral \'alve is sound, and 
 a murmur be heard synchronous with the second 
 sound, louder in the direction of the apex than 
 in the direction of the aorta, or if it be about 
 equal in both directions, there will be imper- 
 fect closure — insufficiency of the aortic valves 
 and the murmur is not direct, but regurgitant, 
 proceeding from the resilience of the aorta, re- 
 pelling a portion of the current back through 
 the aortic valves into the ventricle from whence 
 it issued ; but as this regurgitation is not abso- 
 lutely synchronous with the forward current 
 of arterial blood in the aorta, it would be ex- 
 pected that the murmur of regurgitation would 
 be carried downwards rather thaij along the 
 aorta, because the course of the blood at the 
 moment of the development of the murmur is 
 downwards into the left ventricle, in which di- 
 rection the murmur should be propagated. But 
 this is too nice a distinction to be always made 
 
24 DISEASES OF THE HEART : 
 
 out definitely ; for at times the murmur is so 
 loud as to be heard distinctly in all directions 
 from its origin, and in a radius of tvvo inches 
 no difference in pitch may be appreciable ; but 
 if the ear recedes some distance, it will always 
 be found that in regurgitant aortic murniur the 
 sound is propagated downwards, and is coinci- 
 dent with the second sound, while in merely 
 roughened, but not insufficient, valves, the mur- 
 mur is coincident with the first sound and is 
 propagated upwards. 
 
 Diagnosis of Organic Disease of the Heart. 
 1. — First, it is premised that the auscultator or 
 physician is aware of the following summary of 
 facts, Tiamely : that there are two sounds — a 
 first and second ; the first longer and less ac- 
 cented than the second ; the first propagated 
 downwards, in the direction of the heart ; the 
 second^ upwards in the direction of the ascend- 
 ing aorta ; the first coincident with the pulse, 
 t\\Q second a,moment subsequent to the pulse. 
 
 ^\iQ first sonnd is caused by the closure of the 
 auricTilo- ventricular valves — tricuspid right side, 
 mitral, left side of heart. (All the valves are 
 situated under a little circle not exceeding an 
 inch and three-quarters in diameter, w^hich may 
 
THEIR DIAGNOSIS AND TREATMENT. ' 25 
 
 be described on the skin over the base of the 
 heart.) 
 
 2. The second sound is caused by the closure 
 of the semilunar valves of the aorta and of the 
 pulmonary artery ; the valves of these two ves- 
 sels close at the same instant, and hence, though 
 each emit a sound in closing, the ear of the 
 listener at the precordia appreciates but one 
 sound. Now, if the two sounds are normal ii: 
 pitch, and tone, and accent, and if the impulse 
 of the heart is not excessively strong, nor re- 
 markably weak, if no friction sound, or bellows 
 murmur is heard, we say the heart is sound. 
 But if a friction sound is heard over the heart, 
 proceeding from the heartj there is organic dis- 
 ease of its outside. 
 
 If a bellows murmur, or rasping murmur, is 
 heard over the heart proceeding from the heart, 
 and the patient is not pale or anaemic, and if the 
 murmur is persistent, there is organic disease of 
 the inside of the heart. 
 
 a. A friction sound indicates pericarditis. 
 
 h, A blowing sound — murmur — indicates either 
 acute or chronic disease of some portion of the 
 heart's cavities. 
 
 c. A friction sound and a murmur at the same 
 
26 DISEASES OF THE HEART : 
 
 time^ indicate that endocardial and exocardial disease 
 cO'txist. 
 
 y d. We nether can be sure, of pericarditis until we 
 hear the friction murmur. 
 
 e. We never can be sure of endocarditis until we 
 hear the blowing murmur. 
 
 3. Latham says, from simply listening to a 
 murmur and asking no questions, we are not able 
 to tell what it means. In one who a few days 
 since, while in perfect health, was seized with 
 fever, it means one thing ; in one out of health 
 for some time, with difficult breathing and palpi- 
 tation, it means another ; in one deformed from 
 birth, another ; and in the pale chlorotic girl, 
 another. Yet it is the same kind of murmur, the 
 murmur simulating the sound of bellows, in all ; 
 and being the same, it cannot entirely explain 
 itself — it cannot be its own interpreter. It re- 
 quires aid from concomitant circumstances to 
 decide its meaning in each particular case. The 
 aid it needs is often very little ; but that little 
 it must have, and then it tells its story clearly 
 and explicitly. 
 
 Case 1st. Miss A. D., unmarried, aged twenty, 
 pale and short-breathed, cold hands and feet, 
 occasional flush on one cheek, sometimes a short 
 dry cough, often dizziness, headache, constipa- 
 
THEIR DIAGNOSIS ANI>-.XREATMENT. 27 
 
 tion, palpitation, says she lias been told by Dr. 
 
 she has " heart disease^' and is incurable. 
 
 On listening at precordia, hear bellows murmur, 
 with first sound loudest in direction of aorta y 
 this murmur is persistent for a week, pulse 96, 
 feeble, accented ; heart sounds distinct and snap- 
 pish, that is, unusually definite ; eye-lids at times 
 " pufiy.^^ She was assured she was anemic, and 
 had no heart disease, and was curable. 
 
 Treatment. — To retire at 9 o'clock, to keep her 
 feet dry, to eat beef-steaks and mutton-chops, and 
 take three raw eggs daily, to drink cofiee or 
 chocolate, to work but little, to take passive ex- 
 ercise in the open air — (ride in cars or carriages). 
 
 The only medicine ordered, if medicine it 
 could be called, was equal parts of cod liver oil, 
 whisky and simple syrup in table-spoonful doses 
 three times a day. Result : in two months the 
 bellows murmur could be developed only after 
 violent exercise, such as swinging dumb-bells. At 
 the expiration of four months, both paleness, and 
 murmur, and palpitation had disappeared. I 
 should mention she had used vaginal abluents of 
 a solution of tannic acid for leucorrhoea, which 
 was thus arrested. 
 
 This was not a case of organic heart disease, 
 proved by the crucial test of complete recovery. 
 
28 DISEASES OF THE HEART : 
 
 Case 2d. Mrs. B., has been under my care 
 eleven years, during which time slie has had no 
 acute disease, and during which time I have seen 
 her, at least, twice every week. Bellows murmur, 
 coincident with the first sound, heard h)udest at 
 the base and in the course of the aorta — swell- 
 ing of the lower extremities so as to require 
 shoes two numbers larger — little oppression of 
 respiration, except on rapid fatigue, when the 
 face becomes purple and congested, and the ex- 
 tremities pale ; frequent headache ; assimilation 
 good ; tendency to corpulency ; appetite always 
 good ; excretory functions well performed ; pulse 
 • eighty, not strong, split, irregular, intermittent 
 from one to ten times per minute often when in 
 repose ; much more frequently intermittent in 
 sleep than when awake ; murmur audible, but the 
 first sound is of the tricuspid ; diagnosi&j thick- 
 ening and roughening of aortic walls ; mitral 
 insufficiency slight ; hypertrophy of left ven- 
 tricle. 
 
 4. Theory of Diagnosis. — By exclusion ; the 
 aortic valves shut back distinctly : murmur pro- 
 pagated upwards, not coincident with second 
 sound ; hence aortic valves are competent ; no 
 jugular pulse, hence tricuspid not incompetent. 
 
 By the thickened walls of aorta, left ventricle 
 
THEIR DIAGNOSIS AND TREATMENT. 29 
 
 is always overtasked ; hence hypertropied ; and 
 from excessive work and the resistance of the 
 thickened aorta, we have momentary forgetful- 
 ness of the heart (oubiie du muscle), hence inter- 
 mittent pulse and irregular pulse. The blood is 
 impelled with diminished force, in consequence 
 of inelastic aorta ; hence there is capillary en- 
 gorgement and cellular infiltration. 
 
 5. Lastly : Theory of mitral incompetency : 
 the murmur not heard loudest at apex ; were the 
 murmur only mitral, it would be loudest at apex ; 
 but it is a composite murmur, composed of ele- 
 ment a, aortic murmur, element Z>, mitral murmur, 
 the two absolutely synchronous, but a very much 
 louder than 6, so that by comparison total mur- 
 mur is heard loudest in the direction of the aorta. 
 
 6. The quick exhaustion, the purple face after 
 exercise, the almost daily headache, without or 
 with constipation indifferently, the inability to 
 endure close rooms or large assemblies, are so 
 many affirmative signs of mitral disease. Add to 
 this, the mitral murmur is heard with extreme 
 distinctness as high as under the middle of left 
 clavicle, and under angle of left scapula ; lower 
 toned than over aorta, because it is a lower and 
 different murmur. Increased second sound of 
 pulmonary artery can not be made out positively. 
 
30 DISEASES OF THE HEART : 
 
 Treatment, — Mrs. B. has taken abont a quart 
 of compound spirits of lavender, and four ounces 
 of spirits of ammonia, about one ounce of qui- 
 nine, about six hundred aloetic pills, has been 
 bled at the arm twice, four to six ounces for 
 angina pectoris with fever, has been dry-cupped 
 and leeched at the precordia for pain in the 
 heart during fever, has taken digitalis occasion- 
 ally for excessive rapidity of heart-beats, has 
 taken large quantities of bitartrate of potassa as 
 a diuretic, for swelling of feet and legs, and this 
 with a cathartic of oleum ricini has always 
 afforded immediate relief to the circulation with* 
 out impairing health. She has taken perhaps 
 ounces of muriatic acid in three drop doses after 
 eating, to promote digestion, which for the last 
 three years has been painful without the acid. 
 (The hint concerning muriatic acid in dyspepsia, 
 occasioned by organic disease, I get from Trous- 
 seau.) 
 
 8. Result, — Her present condition is not unsat- 
 isfactory, when the incurable nature of the affec- 
 tion is considered. The hypertrophy has greatly 
 increased : there is more frequent complaint of 
 uneasiness about the heart ; fatigue is not so well 
 borne ; digestion is accomplished with more diffi- 
 culty ; constipation is habitual ; hematosis is less 
 
THEIR DIAGNOSIS AND TREATMENT. 31 
 
 complete ; the muscles are becoming flabby ; the 
 extremities do not swell so much as formerly, 
 because assimilation is less active, but on the 
 whole she seems in pretty good health, and by 
 treating symptoms as they arise, according to 
 rational ideas now possessed by the profession, 
 she may live yet many years ; perhaps ten, or 
 even twenty, but without constant care and close 
 observation, she might die in a few months, that 
 is, simply by leaving the disease to take its own 
 course. The object of treatment is, in this case, 
 to diminish the labor the heart has to perform, 
 by guarding the integrity of the functions of the 
 skin, lungs, alimentary canal, renal organs, liver, 
 etc., and last, but far from least of all, the 
 nervous system, by preventing mental and moral 
 disturbances, and keeping all causes of grief, de- 
 pression, anxiety and hopeless desires out of the 
 way. Late physiological researches have made 
 it probable that no causes are so potent in has- 
 tening the fatal course of organic disease of the 
 heart as those which act reflexly from impres- 
 sions made on the nerves of special sense ; and, 
 on the other hand, through these same means the 
 advance of heart disease may be greatly retarded 
 and occasionally held at a stand-still for months 
 or years. 
 
32 DISEASES OF THE HEART : 
 
 9. Summary, — Is there a certain infallible sign 
 pathognomonic of incompetency of the mitral 
 valves? I do not believe there is any one sign 
 or symptom on which we can rely. But if there 
 is a murmur heard loudest above the left nipple, 
 synchronous with the heart's impulse against the 
 ribs, and at the same time there is increase in the 
 intensity of the second sound of the pulmonary 
 artery, (heard in the second left intercostal space, 
 about half an inch from the sternum, and propa- 
 gated directly upwards), it is as certain as any- 
 thing can be that there is mitral regurgitation. 
 But this increased second pulmonic sound cannot 
 always be made out ; still we cannot say, there- 
 fore, that the diagnosis cannot be made ont. It 
 cannot be made out with the same rigid cer- 
 tainty, but it can be made so clear as not to 
 leave a reasonable doubt. For example : the 
 murmur is heard above the nipple, the pulse alike 
 weak in both wrists, patient not seeming in good 
 condition as to blood-making power, uncomfort- 
 able feeling in the chest, quick exhaustion and 
 lividity of face on rapid exercise, hypertrophy 
 of heart. 
 
 10. With two or three of these signs well estab- 
 lished, we are sure of mitral regurgitation ; a 
 persistently weak, irregular or intermittent pulse 
 adds to the certainty of the affection. 
 
THEIR DIAGNOSIS AND TREATMENT. 33 
 
 a. All that is known of the cause of intermit- 
 tent pulse may as well be suggested here, as there 
 will be constant occasion of naming it, to aid in 
 explaining organic lesions. The proximate cause 
 of intermittent pulse is arrest of the systolic 
 movement of the heart, and the remote cause of 
 this arrest is a difficult and unsolved problem in 
 pathology ; but there is reason to believe its 
 origin lies rather in a lesion of some portion of 
 the cerebro-spinal axis, than in any alteration in 
 the structure of the heart itself. This inter- 
 mittent pulse is the clue that leads us to the re- 
 mote cause of the organic alterations in the heart, 
 viz. : a primary alteration of the molecular sub- 
 stance of those portions of the brain and cord 
 which preside over nutrition and elimination. 
 This is not an attempt at an explanation of the 
 efficient cause of intermittent pulse, but a dim 
 suggestion as to the places in which that cause is 
 to be sought. It seems sometimes to depend on 
 some obstruction acting like a valve at the ori- 
 fice of the aorta. The ear is conscious of a sys- 
 tolic movement, and of its arrest when about to 
 be completed ; and during this momentary arrest 
 there is neither sound nor murmur, but the blood 
 itself seems to stand still in the whole arterial 
 system ; and, indeed, it no doubt does, for the 
 arrest occurs directly after the diastole, and ex- 
 
 D 
 
34 DISEASES OF THE HEART : 
 
 tends not only over the pause between that and 
 the systole, but also occupies the period of part 
 or all of the systolic movement ; and sometimes 
 the arrest is longer than a complete pulsation. 
 In the latter case, there is a sense of suffocation, 
 attended with feeling of profound exhaustion, 
 and a feeling of *' waves^' in the brain, wliich 
 latter feeling interrupts consciousness, and even 
 sensation, for an appreciable instant. The pa- 
 tient often seems abstracted or pre-occupied, 
 and gives postponed and undecided answers 
 to simple questions, from inability to decide 
 quickly and respond promptly, because the brain, 
 from unequal supply of red blood is not always 
 ready to command. 
 
 h. Intermittent pulse, considered by itself, is 
 without significance in the present state of 
 knowledge ; but taken in connection with hy- 
 pertrophy of the left ventricle, mitral incompe- 
 tency and direct aortic murmur, it still adds ^to 
 the dangerous import of other symptoms. It 
 aids us in the discrimination of aneurism from 
 valvular affection ; for in the former the pulse 
 may be absent from one wrist, but not intermit- 
 tent in both ; while in valvular disease nothing 
 is more common than intermittent pulse. If there 
 is aneurism and the pulse is intermittent, we may 
 be sure there is valvular disease also ; and it 
 
THEIR DIAGNOSIS AND TREATMENT. 35 
 
 will be quite probable that the mitral and aortic 
 valves are incompetent, particularly the mitral. 
 There is an intimate relation between the fre- 
 quency of the hearths beats and intermittent 
 pulse. Under the immediate effect of a dose of 
 ammonia and lavender, the intermittence will 
 disappear. It seldom or never occurs when the 
 pulse is above 85. It is very common when the 
 pulse sinks below 75, either from unknown 
 causes, or under the influence of digitalis. Yet, 
 if there be no organic disease, digitalis will not 
 develope the intermissions ; but, however exten- 
 sive the organic lesion, cardiac stimulants, during 
 their action, abolish the intermission. 
 
 a. It is remarked above, that " it" (intermit- 
 tence) " seldom or never occurs when the pulse 
 is above 85." This needs explanation to seem 
 exact. It is understood that the patient is in 
 repose ; not under the influence of any mental, 
 moral or bodily excitement, and that the heart is 
 not driven beyond the limit of endurance, {a) by 
 some temporary stimulus, for example : excessive 
 indulgence in stimulating drinks ; {h) by violent 
 exercise, such as running uphill, or with all pos- 
 sible speed ; (c) by fright or anger ; {d) by mania, 
 or delirium tremens ; (e) by the agony of angina 
 'pectoris^ and the violent motions of desperation 
 in the effort to breathe, such as beating the air, 
 
36 DISEASES OF THE HEART : 
 
 clutching the throat, rapid change of position, 
 etc., etc. Under any of these unusual circum- 
 stances or conditions, the pulses will " hang,'' 
 or intermit, even while the ventricles succeed in 
 accomplishing even 120 beats a minute, as in 
 Case 3 below ; but in such cases, when the usual 
 condition of the patient, as to repose, etc., re- 
 turns, the pulse will become slower ; the inter- 
 missions will give place to simple irregularity in 
 time and tone, and finally under remedies pro- 
 perly selected and graduated, the pulse will be- 
 come regular in time first, and (if the dilatation 
 of the heart is not too far advanced, or if the 
 fatty degeneration be only incipient,) soon after 
 in tone ; but if the sedative — say digitalis — be 
 continued until the pulse falls below 70, though 
 it be full and strong, the intermittence will re- 
 turn, either as to a part of a systole, while the 
 pulse in the intervals of the intermissions, say for 
 ten, twenty, forty, or even a hundred beats, may 
 be regular in time and tone. 
 
 b. When the heart is affected with organic 
 disease, excessive increase of its function from 
 external causes develope irregular, remittent and 
 intermittent pulse ; excessive retardation in the 
 heart's beats induce remittent and intermittent, 
 but not otherwise irregular pulse. It is not 
 affirmed that similar causes never induce similar 
 
THEIR DIAGNOSIS AND TREATMENT. 37 
 
 states of the pulse in persons in good health, free 
 from anemia, and free from organic disease ; 
 but one may venture to remark that such a result 
 is at least improbable, and is rarely observed, 
 though sought for with great diligence. The 
 rhythm of the heart is so hedged about by all in- 
 fluences, that any material disturbance is almost 
 inconceivable in the absence of alteration of the 
 blood as to quality or quantity in. special locali- 
 ties, (local congestions or local anemias,) or of 
 abnormities of the heart, arteries, or cerebro 
 spinal axis. But respectable gentlemen and 
 respectable authors assert that intermittent pulse 
 'per se is no evidence of a pathological condition 
 anywhere. One must be permitted to doubt the 
 essential truth of unproved affirmations. Inter- 
 mittent pulse is not a normal condition, and if 
 persistent independently of volition, under cer- 
 tain definite conditions, such as those suggested 
 above, it cannot fail to be of grave significance. 
 
 c. There are rare cases of rhythmical inter- 
 mittence, depending on some congenital abnor- 
 mity, and there are well^ attested cases, but en- 
 tirely exceptional, in which the systoles-are some- 
 what under the control of volition, and in which 
 intermittence can be caused by mere volition ; 
 but such cases must be acknowledged to be ab- 
 
B8 DISEASES OF THE HEART : 
 
 normal, and they are so rare that they may be 
 omitted in diagnosis. 
 
 d. The irregularity of the heart in anemia or 
 spanaemia of any kind, is not inconceivable, on 
 the theory here suggested. 
 
 e. The normal condition of the heart can be 
 normally performed only when the organ is 
 sound in structure, and supplied with proper 
 nutrition in proper quantity, and when it has 
 natural or healthy blood to exercise its function 
 upon, and in quantity proportional to its dynamic 
 structure. Depraved blood supplied to the cor- 
 ronary arteries may cause both irregularities and 
 pain : even spasm, genuine angina pectoris^ may 
 be produced from the same cause. Anemic pa- 
 tients often complain of uneasiness and even pos- 
 itive pain about the heart, and I have seen re- 
 cently a case of anemia in which there was fixed 
 pain in the third left interspace close to sternum. 
 
 Precordial uneasiness in anemic subjects, is as 
 constant a symptom as irregular and feeble pulse ; 
 and there is every reason to believe this pain 
 and this uneasiness ara the results of defective 
 nutrition' of the heart itself; and it is quite cer- 
 tain, as the anemic condition disappears, as 
 red blood discs increase in number, the uneasiness 
 and pain diminish and disappear at the same 
 
THEIR DIAGNOSIS AND TREATMENT. 39 
 
 time with the irregular pulse, and the complete 
 restoration of the blood. 
 
 9. Pain is probably always the result of abnormal 
 or defective nutrition ; and uneasiness is pain in 
 a less accented degree. 
 
 h. Finally, extreme excitement and extreme 
 depression develope intermittent pulse from the 
 same cause — defective nutrition and innervation, 
 either relative or absolute ; but in repose the 
 pulse seldom or never intermits, unless it falls 
 below 70 per minute, and then irregularity is less 
 marked than remission or intermission. 
 
 11. In mitral regurgitation the heart increases 
 more in width than length. It is important, 
 when there is any doubt of the degree of semi- 
 lunar incompetency attending the mitral defect, 
 to take this fact into consideration ; for, if the 
 heart is not sensibly elongated, the aortic valvular 
 incompetency will be very slight or entirely ab- 
 sent. 
 
 12. Treatment, — a. For m/itral regurgitation 
 a great deal of passive exercise in the open air 
 is of the first importance. This can be accom- 
 plished by riding, or sea voyages. Walking 
 should not be recommended, nor indeed any 
 considerable voluntary exercise ; but passive ex- 
 ercise cannot be too much or too constantly in- 
 sisted upon. 
 
40 DISEASES OF THE HEART : 
 
 h. Well ventilated sleeping-room — that is, a 
 room in which air is admitted through an open- 
 ing of two square feet, with no gauze or curtain 
 over it ; comfortable warmth to be maintained 
 by bcd-clotheSj not by the exclusion of the at- 
 mosphere. 
 
 c. A quiet mind and an even temper aid 
 greatly in prolonging life, and the prevention of 
 suffering. 
 
 d. A meat is better than a vegetable or mixed 
 diet ; no objection to fruit ; diet spare. 
 
 e. Arterial stimulants must be avoided. 
 
 /. Tobacco is very injurious in all kinds of 
 heart disease. 
 g. Coffee is seldom tolerated with impunity. 
 
 A. If the pulse runs above 80, digitalis and 
 solution of perchloride of iron are indicated. 
 
 /. If the pulse is very weak, heef juice must be 
 given freely, say a pint a day. 
 
 k. If the patient is strong and full-blooded, a 
 purge should be given whenever there is any 
 tendency to congestions or effusions ; the non- 
 stimulatino- diuretics are always serviceable, 
 given two or three days, at intervals of two or 
 three days. 
 
 /. Frequent bathing is much and imperatively 
 
THEIR DIAGNOSIS AND TREATMENT. 41 
 
 required in almost all afFections of the heart and 
 arteries ; plain water, hot, is quite as good as 
 any medicated bath. 
 
 The labor of the heart must be lightened from 
 time to time, in bad cases, by purging, by diure- 
 tics, and even by leeching and cupping over 
 the base of the heart, or by leeches at the anus. 
 
 It is doubtful whether bleeding at the arm, or 
 in any considerable quantity, would ever be indi- 
 cated in mitral regurgitation. The angina pectoris^ 
 which comes on with such violent paroxysms, 
 will yield to dry cups in two or three minutes, 
 quite as certainly as to scarifications or leeches 
 followed by cups. 
 
 13. Case 3. On the 12th of February last, 
 
 Mr. Turk street, with mitral disease and 
 
 aortic incompetency, had a most frightful par- 
 oxsym. His face and hands were purple ; he 
 beat the air wildly with his arms : suffocation 
 seemed imminent ; his pulse had ceased ; the 
 heart beat 130 per minute ; irregular and inter- 
 mittent. He was bathed in a sweat of agony, 
 gasping for breath, with doors and windows 
 open. Four cups were placed over the region of 
 the heart, but before the fourth one had been set, 
 his paroxysm began to subside, and within less 
 than five minutes, his pulse became tolerably 
 
42 DISEASES OF THE HEART : 
 
 regular at the wrist, and the heart beats had 
 fallen to 120, and much increased in strength. 
 The cups were left on three hours, and, on being 
 removed, contained more than a drachm each of 
 serum and blood, which had been drawn through 
 the skin. 
 
 14. I am not quite sure the cups would not do 
 as well on some other part of the body ; indeed, 
 there is reason to believe they would, inasmuch 
 as their beneficial effect must be principally re- 
 flex ; but the patients always want something 
 done about the region of ihe heart, where they 
 say the anguish centres. ^ 
 
 15. I said above, A. " If the pulse run above 
 90, digitalis and solution of perchloride of iron 
 are indicated." If there is bronchial irritation, 
 with dark muco-sanguineous expectoration, I 
 would add tartrate of antimony, in small doses, 
 to the digitalis and iron. 
 
 a. The iron and antimony should be alternated 
 with the digitalis, instead of being given at the 
 same time. A drachm of the solution of the per- 
 chloride of iron with five grains of potassio tar- 
 
 * I sliaU have occasion in the following pages to allude 
 to mitral disease many times, and will attempt to explain 
 the mode of death in this affection in some subsequent para- 
 graph. 
 
THEIR DIAGNOSIS AND TREATMENT. 43 
 
 trate of antimony in a pint mixture, composed of 
 equal parts of distilled water and simple syrup, 
 will constitute a preparation of which a teaspoon- 
 ful or more may be given every two hours, with 
 decided diuretic and tonic effect. If there is albu- 
 minuria, it modifies or arrests it very promptly, 
 unless the kidneys, one or both, are acutely in- 
 flamed. If such is the case, leeches, or scarifica- 
 tion and cups over the kidneys, followed by warm 
 fomentations will be required before the diuretic 
 effects of the iron can be realized. 
 
 b. The passage of the iron into the circulation 
 and through the kidneys should be verified by 
 adding gallic acid to the urine subsequently 
 voided, when if iron be present, the urine will 
 instantly become inky. I constantly employ this 
 mixture of iron, or the mixture with the antimony 
 omitted, as a tonic, diuretic, and a sedative to the 
 heart ; and it seems to me to greatly aid the 
 action of digitalis. The perchloride of iron ad 
 ministered thus largely diluted, is probably both 
 preventive and curative of anemia, and thus it 
 must tend to protect and restore the heart itself 
 in the overwork to which it is constantly subject 
 wl\en organically affected. 
 
 c. It requires a strong will, an intelligent voli- 
 tion on the part of the patient to persist in a 
 
44 DISEASES OF THE HEART : 
 
 proper and rational diet in affections of the heart. 
 For this reason, it would seem fit that he should 
 be early informed of the nature and tendency of 
 his disease, and the reasons of the modifications 
 which are requisite in diet, exercise, etc. It is a 
 mistake to suppose a patient can be made mate- 
 rially worse by being informed of his true condi- 
 tion ; the deterioration will be only temporary, 
 and when the first fright or dread has passed off, 
 the patient will be in a better condition for treat- 
 ment than when oppressed with vague and irra- 
 tional fear^, or hopes which he will too soon 
 learn are baseless or improbable. No medication 
 will avail, without the most carefully and ration- 
 ally regulated diet, both as to quantity and 
 quality. 
 
 d. Nothing is more fatal than the theory of 
 treatment which proposes absolute rest in bed, 
 with low vegetable diet for organic diseases of 
 the heart. It will hasten death in almost every 
 case, by the additional injury it entails on the 
 heart's substance, by deteriorating the quality of 
 the blood supplied to the coronary arteries, and 
 to the ganglia, which preside over cardiac in- 
 nervation. 
 
 e. What we want is to diminish the whole 
 weight of the body, blood and all, while the Mood 
 
THEIR DIAGNOSIS AND TREATMENT. 45 
 
 is maintained at its normal standard of excel- 
 lence, or as nearly so as possible with the con- 
 stant progress of a disease whose tendency is 
 always fatal. 
 
 /. I said (12 e.) arterial stimulants must be 
 avoided ; this needs qualification. For example, 
 the following : 
 
 Case 5. — The patient, now under treatment, 
 has mitral regurgitation, with all its attendant 
 and consequential ills; hypertrophy and dilatation 
 of both ventricles, aortic semilunar, and tricuspid 
 insufiiciency, oedema of the lungs, and cough with 
 venous blood-tinged mucous : dropsy universal, 
 orthopnoea uninterrupted, dyspnoea so great as 
 to induce almost constant perspiration, g. Here 
 are the clinical symptoms observed at last 
 visit. A large-framed man, aged 35, is sitting 
 almost perpendicular in bed, (his constant atti- 
 tude,) his face is moist, his breathing labored, 
 cough frequent, venous blood-tinged expectora- 
 tion, universal dropsy, everywhere in lungs 
 coarse moist rales, and occasional whistling res- 
 pirations — no first sound at apex, but an indis- 
 tinct murmur ; intensely increased second pul- 
 monic sound heard over third left cartilage ; 
 aortic second sound replaced by a murmur heard 
 loudest on sternum, between ends of third ribs — 
 
46 DISEASES OF THE HEART : 
 
 aortic regurgitant murmur — tbe radial pulse full, 
 strong, visible, large, resisting and regular, and 
 120 ; the epigastric pulsation of abdominal aorta 
 is much more forcible and visible than apex 
 impulse ; the carotids throb ; when the two in- 
 dex fingers are placed on the subclavian arteries 
 in the subclavian triangles, the arteries strike 
 the finger ends at each systole, with the abrupt 
 tap of a hammer — a short, quick, flat, decided 
 blow. Mechanism of first sound appreciated 
 by the ear at apex, but no sound ; hearths im- 
 pulse two inches to the left of nipple in fifth 
 and sixth interspaces ; systolic thrills, to the 
 touch, all over the lieart, especially in third and 
 fifth interspaces, and third right space close to 
 sternum. Jugular pulse ; basic systolic mur- 
 mur not audible above the second right cartilage ; 
 heart beats exceedingly tumultuous, with mode- 
 rate but marked heaving impulse at the pre- 
 cordia ; large, full veins everywhere on arms 
 and legs ; nails purple ; a semi-livid hue to the 
 whole body. Copious pink urates have been de- 
 posited for months ; liver much enlarged ; head* 
 ache constant, but mind clear ; appetite absent ; 
 digestion and assimilation very bad ; bowels 
 constipated ; pulse 120 ; temporal arteries crawl 
 like worms. 
 
 h. Now, I think there can be no question of 
 
THEIR DIAGNOSIS AND TREATMENT. 47 
 
 diagnosis in this case, nor of prognosis. Death 
 is certain and imminent. In this case, though 
 purgatives, diuretics, expectorants and even dia- 
 phoretics and perhaps precordial depletion are 
 indicated, and absolutely necessary to the pro- 
 longation of life, even for a few days, yet stimu- 
 lants, and tonics, and concentrated nutrients are 
 equally and quite as imperatively required. 
 
 And this is the treatment pursued, and directly 
 it is suspended, even for a few hours, all the 
 symptoms and subjective sufferings are worse and 
 much less tolerable. 
 
 i. Here whiskey, ammonia, especially the mu- 
 riate, [because while it, the muriate of ammonia, 
 unloads the liver and fortifies the heart indirectly, 
 if not directly, it certainly diminishes the tumult 
 of the heart, and steadies and retards its beats,] 
 and perchloride of iron, and elixir of bark, and 
 beef juice, and egg-nogg may be given not only 
 with impunity, but with great advantage, and 
 well-founded expectation of adding weeks, or 
 even months, to life by their judicious use. Such 
 a case should occupy a room twenty feet square 
 and fifteen feet high, and the mercury should 
 stand at 60, while two large windows should re- 
 main wide open day and night. He should also 
 be wheeled about the room in a chair, that he 
 
48 DISEASES OF THE HEART : 
 
 might have the benefit of passive exercise in the 
 prolongation of life. 
 
 I am the more minute in all this detail of 
 treatment because it is applicable to all forms of 
 heart disease, with obvious restrictions and limi- 
 tations. 
 
 CHAPTER IV. 
 
 Disease of the Semilunar Valves of the Aorta. 
 Direct and Regurgitant Murmurs — Differential 
 Diagnosis of. Treatment of Disease of the Aortic 
 Val^^s, and its CompijcAtions. 
 
 1. The time and location at which the murmur 
 is heard mark the lesion, [Brown.] 
 
 2. A murmur with the heart's systole, louder 
 in the direction of the aorta than in any other 
 direction, indicates roughened semilunar valves 
 of aorta, [provided that the chest is not deformed, 
 and there is no anemia.] 
 
 3. A murmur coincident with the second sounds 
 or replacing second sound, heard loudest between 
 third and fourth ribs, left side, and close to the 
 breast-bone, and hence downwards indicates 
 aortic regurgitation. 
 
 4. The regurgitant aortic murmur is often 
 heard distinctly down the sternum from the 
 
THEIR DIAGNOSIS AND TREATMENT. 49 
 
 fourth rib, and when so heard can only be con. 
 founded with tricuspid murmur, or the murmur of 
 of aneurism of the descending aorta. It can be 
 distinguished from the tricuspid murmur : a, 
 because in the murmur from incompetency of the 
 tricuspid there is jugular pulse coincident with 
 hearts systole, while the aortic regurgitant is 
 coincident with the diastole of the heart, h, in 
 roughened but not incompetent tricuspid valves, 
 the murmur is synchronous with the hearths dias- 
 tole, that is with the second sound, and is propo- 
 gated down the sternum ; hence by auscultation 
 and percussion alone, aortic regurgitation and 
 direct tricuspid murmur cannot be distin- 
 guished ; and it is probable that by the nature of 
 the proposition these two affections can never be 
 distinguished in this manner ; but, if we hear the 
 murmur loudest between third and fourth ribs, 
 close to sternum on left side, coincident with the 
 heart's diastole, or the second sounds (emitted by 
 still healthy pulmonic valves,) it is certainly 
 aortic regurgitation, and the murmur heard down 
 the sternum will proceed from this cause alone, 
 or from this and tricuspid roughness combined. 
 But as the tricuspid roughness is of infinitely 
 less consequence than aortic valvular incompe- 
 tency, it may be merged in the latter and ig- 
 nored in tbo diagnosis and the treatment, with- 
 
 F 
 
50 DISEASES OF THE HEART : 
 
 out the least detriment to the patient. 
 
 c. We distinguish aortic regurgitant murmur 
 from that of aneurism, by the fact that the mur- 
 mur of aneurism is always synchronous with the 
 heart's systole^ while tlie regurgitant murmur is 
 always synchronous with the diastole. If there is 
 any difficulty in establishing these synchron- 
 isms, on account of rapidity of heart's movements, 
 it can be remedied by giving small doses of digi- 
 talis, every half-hour, until the pulsations are 
 reduced to sixty or seventy beats per minute, 
 when the discrimination will not be very difficult. 
 
 25. There may or may not be dropsy of the 
 extremities in aortic regurgitation ; and, if the 
 feet and legs are swollen, this condition may 
 be irregularly intermittent, depending upon the 
 diet, activity of the alimentary canal, or of the 
 functions of the skin and kidneys, by which the 
 circulation may be so far relieved as to prevent 
 or reduce cellular infiltration of the extremities. 
 
 26. All valvular diseases, in fact all diseases 
 of the circulatory apparatus, are, iheoretically, 
 likely to produce dropsy of the extremities. But 
 in practice, long standing cases of valvular in- 
 competency [three years, Walshej have been seen 
 in which there was no oedema of the extremities. 
 
 a. If the capillary circulation depend upon the 
 
THEIR DIAGNOSIS AND TREATMENT. 51 
 
 vis a fergo, which consists in the ventricular sys- 
 tole, reinforced and supplemented by arterial 
 elasticity, it is difficult to understand -how if the 
 vis a terfro is removed, as it is to a great extent, 
 in incompetency of the aortic valves, there should 
 not be uniformly hemic stasis in the capillaries, 
 and consequential serous infiltration of the ex- 
 tremities, h. In point of fact, I believe that the 
 cases of long standing in which dropsy of the ex- 
 tremities is absent are exceptional. 
 
 c. The following sentences of Walshe per- 
 haps explain the frequent absence of oedema 
 in this affection. '' The cerebral capillaries can 
 only be affected secondarily through the pul- 
 monary class ; and the systemic capillaries are 
 much in the same position. Regurgitation may 
 exist to the highest amount without oedema of 
 the extremities." Grant that arterial pressure, 
 aided by muscular contractions, valves in the 
 veins, and diastole of the right ventricle, might 
 keep the blood in equable and uniform motion 
 through the capillaries, still how could the arte- 
 rial pressure take eflfect and urge the blood to- 
 wards the apex of a hollow cone, the base of 
 which remains open, as it does in aortic incompe- 
 tency.? Until cases are cited to verify assertion 
 to the contrary, it will still be probable that the 
 amount ofcedema of the extremities will be one of 
 
52 DISEASES OF THE HEART : 
 
 the measures of the degree of incompetency of the 
 aortic or tricuspid mitral vatves. "^ 
 
 d. The sequential hypertrophy or that attending 
 aortic incompetency, while at each ventricular 
 systole it increases the distension of the aorta, 
 and while this very distension increases the 
 force of the succeeding recoil, must have a 
 tendency, by adding to the impelling force of 
 the blood, to diminish the tendency to capil- 
 lary stasis and transudation ; hence hypertrophy 
 in aortic regurgitation is alleviative until it 
 becomes excessive, or until mitral incompetency 
 sets in, and thus retrograde pressure through the 
 pulmonic vessels on the right ventricle, and so 
 on the cavas, and their venous and capillary 
 tributaries, annuls the benefit of, or renders in- 
 jurious the advancing hypertrophy. 
 
 e. When this stage is reached, the advance of 
 hypertrophy is the advance of the whole disease 
 towards a fatal termination. 
 
 27. Pain in the region of the heart is an ex- 
 ceptional symptom in either mitral or aortic val- 
 vular disease. There is always, if the patient's 
 attention be called to it, a sense of discomfort, 
 fullness, or pressure, or weight, or unnatural so- 
 lidity about the lieart ; and when aortic valvular 
 and mitral diseases co-exist, as they do in the 
 
 * See Appendix, " Causes of Dropsy." 
 
THEIR DIAGNOSIS AND TREATMENT. 53 
 
 great majority of cases, the sense of discomfort is 
 greatly increased, and there is generally consid- 
 erable oppression of the chest, and often a dry 
 coughs disposed to be paroxysmal, or to result 
 from fatigue rather than to be continuous. To 
 persons afflicted with aortic regurgitation, close 
 rooms are intolerable ; any weight on the chest, 
 or tight garments compressing the thorax, are 
 unendurable, without great suffering ; violent 
 exercise causes lividity of face and hands, and a 
 sense of imminent suffocation. The patient often 
 feels, on ascending a hill or stairs, as though he 
 must inevitably fall on arriving at the top, and in- 
 stinctively seizes something for support. There 
 are occasional flashes of oblivion of all things, sub- 
 stantial or abstract ; a sort of suspension of every 
 trace of intellection and special sense, for an 
 appreciable instant ; there is reiterated tendency 
 to heart forgetfuhiess ; that is, the heart seems 
 inclined to rest, and is re-aroused by a sudden 
 inspiration, or throwing up of the hands, or by a 
 start. 
 
 28. The hypertropy of the heart that attends 
 this disease is often very manifest to the naked 
 eye, as well as to percussion. The ribs are seen 
 to be sensibly higher over the left than right 
 side ; the hearths impulse is felt over a wider 
 space, and more to the left, and lower. There is 
 
54 DISEASES OF THE HEART : 
 
 a metallic clang to the systole, and especially is the 
 clang heard over the beginning of the pulmonary 
 artery, hetweeii the second and third ribs, left side, 
 close to the sternum. The precordial dullness on 
 percussion is increased in extent, and in jecoral 
 similarity. The j)ulse should be diminished in 
 force, in consequence of regurgitation, pure and 
 simple ; but if the mitral incompetency, co-exist- 
 ing with that of the semilunar valves, is slight, 
 and the hypertrophy considerable, the pulse 
 may be strong and full, but will have an appre- 
 ciable recoil, sufficient to suggest the idea of a 
 backward current in the artery. In short : 
 
 b. The aortic semilunar valves are certainly 
 incompetent when tJiere is a murmur without a 
 sound, prolonged and heard above the base of the 
 heart, synchronous with the hearts diastole ; and 
 when this same murmur is heard at the same time 
 down the sternum, there being no jugular pulse, and 
 when there is_ also hypertrophy and dilatation of the 
 left ventricle, 
 
 I must not omit the sign pathognomonic of Dr. 
 Corrigan :• that is, visible pulses of all the super- 
 ficial arteries, and vermicular onward motion of 
 the tortuous arteries ; the artery moves forward 
 in the direction of its axis — locomotion of the 
 pulses — the radials, temporal and tibials, where 
 
THEIR DIAGNOSIS AND TREATMENT. 55 
 
 they run nearest the surface, are those in which 
 the moving pulses are most frequently visible ; 
 *' but in highly marked cases, the carotid, bra- 
 chial, axillary, femoral and external iliac arteries 
 distinctly present it." (Walshe.) 
 
 But although there are few or no cases of aortic 
 incompetency without visible pulses, there are 
 certainly many cases of visible pulses without 
 aortic incompetency. I saw a case not many 
 weeks since, in which all the superficial pulses 
 were visible, a case of aortic aneurism and hy- 
 pertrophy of left ventricle, in which the pulse 
 was 120, when uncontrolled. The patient died 
 of rupture of the aneurism into the esophagus ; 
 the aortic valves were perfectly competent, tested 
 by water poured into the cut aorta, and by in- 
 spection of the valves. Though always present 
 in, visible pulses are not pathogomonic of semi- 
 lunar incompetency. 
 
 c. Hypertrophy of left ventricle is determined by 
 percussion^ locus of apex impulse, vigor of contrac- 
 tion, 
 
 d. Dilatation of ventricle is determined princi- 
 pally by clearness and quickness of the systolic 
 movement of the heart ; for though the systolic 
 sound, first sound, be abolished by mitral and 
 tricuspid incompetency, yet the systolic movement 
 
56 DISEASES OE THE HEART : 
 
 remains as a determinable fact, and occupies an 
 appreciable time, and takes place in -an apprecia- 
 ble manner ; and it is by the manner and time 
 occupied in this systolic movement^ other things 
 not opposing, that dilatation of the ventricle is 
 made out. If all the facts mention^ in para- 
 graph h are present, aortic valvular incompetency 
 is absolute, (if there is no deformity in the chest 
 of the patient, no tumor, etc..) but if one of those 
 facts are wanting, the diagnosis lacks demonstra- 
 tion. For example, if hypertrophy and dilatation 
 are absent, incompetency is improbable. If the 
 murmur down the sternum be absent, the upper 
 murmur may depend upon roughness on the inner 
 surface of the aorta ; but in this case, the murmur 
 will generally be hounded hy a sound, that is, wil 
 terminate in the click of closure of the aortic 
 valves, though not always, especially if there is 
 mitral regurgitation, fatty degeneration of heart 
 tissue, constricted mitral orifice, or when the 
 aortic valves or the aorta itself is thicker and 
 less elastic than natural ; in all these cases, the 
 pound, though its mechanism be present, may not 
 reach the most practised ear ; but the diagnosis 
 of aortic valvular incompetency is made certain 
 only by the concurrence of the facts mentioned 
 above. 
 
 29. As aortic incompetency and mitral incom- 
 
THEIR DIAGNOSIS AND TREATMENT. 57 
 
 petency are as|||^iate affections, the treatment of 
 one is the treatment of the other, under limita- 
 tions. 
 
 a. Aortic incompetency, in its beginning, may 
 exist alone, or without mitral defect. In such 
 case the lungs will not have become congested, as 
 in mitral lesion, and we shall not have to contend 
 with the annoying cough, or the spitting of dark 
 blood, transuded from the pulmonary vessels. 
 But there will be the same need of lessening the 
 labor of the heart by all means consistent with 
 the hygiene of the whole system. For example? 
 in aortic incompetency, absolute quiet is indicated 
 for that alone ; but absolute quiet is incompati- 
 ble with digestion and nutrition, and the case 
 would terminate fatally all the sooner in conse. 
 quence of a low grade fever which would be gen- 
 erated. The treatment is rest, as to voluntary 
 exercise, but passive exercise in the open air, 
 without a day's interval, such as travelling by 
 stage or rail, in ordina-ry vehicles, or on horse- 
 back ; the absence of all excitement and annoy- 
 ance ; a light but nutritious diet. The patient 
 may eat a little at a time, four times a day, much 
 rather than an abundant meal twice a day. 
 Small meals disturb the circulation much less 
 than large. 
 
58 DISEASES OF THE HEART : 
 
 But, UDfortunately, few persoi|j|^an follow the 
 passive exercise treatment. They lack the means, 
 or they are hindered by family ties, or the dread 
 of being away from friends, or a disinclination to 
 this species of exercise, and principally would 
 they be hindered by a doubt of its efficiency : 
 and this no doubt would increase, when after 
 several months they found themselves no better ; 
 whereas, a patient should be abundantly satisfied, 
 in almost all lesions of the heart, if he gets no 
 worse. When we hold an affection of the heart 
 in check, we accomplish all that can with any 
 reason be asked of us. When we alleviate symp- 
 toms — not entirely remove them^ — we do all that a 
 tolerably well educated patient will believe pos- 
 sible. We can prolong life, but we cannot say 
 to our patient that he is no more liable to death 
 than he would be were his heart perfectly sound. 
 
 d. In aortic incompetency, the patient is liable 
 to sudden attacks of fainting, from anger or vio- 
 lent excitement, or over exercise. Absolute 
 quiet, free exposure to the air, dry cups to the 
 precordia, or if cups are not at hand, a few drops 
 of boiling water over the base of the heart, or a 
 mustard plaster will restore the circulation. A 
 copious draught of cold water might cause instant 
 death, by reflex shock to the already exhausted 
 
THEIR DIAGNOSIS AND TREATMENT. 59 
 
 heart. A spoonful of brandy and water, or a few 
 drops of spirits of ammonia, with spirits of lav- 
 ender and water, would aid immediate restora- 
 tion ; hot applications to the soles of the feet, or 
 leeches to the end of the alimentary canal, are 
 slow but unobjectionable temporary remedies. 
 
 The bowels must never be constipated for a 
 day ; this can be avoided by taking daily at bed- 
 time an aloetic or compound rhubarb pill, or a 
 pill of the following : 
 
 a. R. Aloes, Rhei, Comp. ext. Colocynthidis, 
 aa, dr. ij ; Ext. Xucis Vomicae, scruple j. Mix, 
 and make, according to art, into sixty pills. 
 
 29. Formula a will be found convenient and 
 efficient in almost all cases, and rarely contra- 
 indicated. If dropsy should occur, either general 
 or local, it is to be treated not as an idiopathic 
 dropsy, id est, a hydremia, or anemia, but it must 
 be met with purgatives, diuretics, low diet and 
 diaphoretics, that the overloaded circulation 
 which is its cause may be relieved as soon as 
 possible ; and to assist this purpose, absolute rest 
 should be enjoined, and the hearths action dimin- 
 ished with small doses of digitalis, often repeated, 
 or digitalis alternated with aconite. 
 
 Digitalis has been objected to in many diseases 
 of the heart by high authorities, (Corrigan, Hen- 
 
60 DISEASES OF THE HEART : 
 
 derson, Walshe, etc) and especially in aortic 
 incompetency. The argument against it is this, 
 and nothing more : 
 
 a. Aortic incompetency admits reflux of blood 
 into left ventricle, at the instant when the direct 
 current is entering it through the mitral orifice ; 
 hence the ventricle is overloaded and gradually 
 enlarged — dilated and hypertrophied— the more 
 frequent the heart beats the less the opportunity 
 for regurgitation, and hence the less the ventri- 
 cular engorgement ; but digitalis '' slews'^ the 
 heart beats, and hence allows more time for 
 aortic regurgitation, and hence increases the dila- 
 tation of the ventricle. 
 
 b. Now, all this is true, but still it is no objec- 
 tion to the guarded use of digitalis. The argu- 
 ment against it deals with logical extremes, and 
 is conclusive against digitalis from that point of 
 view ; but the drug should be given to slow an 
 excited heart, beating with excessive frequency, 
 say more than 90 per minute, but not to reduce 
 it below 80 or 85, for then it would become in- 
 jurious, not only by favoring dilalation, but by 
 increasing the already almost peculiar tendency 
 to sudden death. Digitalis may be given, but 
 with more caution than in any other valvular 
 disease, and with quite as much caution as in 
 
THEIR DIAGNOSIS AND TREATMENT. 61 
 
 dilatation of the left ventricle. A minute dose 
 often repeated — say every fifteen minutes — is in- 
 finitely safer than a larger dose at correspond- 
 ingly long intervals ; a half a drop of the fluid 
 extract every ten or fifteen minutes will often be 
 found sufficient to keep the pulse at 85, when 
 without it, it would ascend to 100 or 110. 
 
 c. I am in the habit of giving, empirically, in 
 every affection of the heart, where there is un- 
 easiness, pain or much discomfort, a fourth of a 
 grain of quinine, with the sixteenth or thirty- 
 second part of a grain of opium from three to 
 six times a day. I double or quadruple the dose 
 at times, when there is renal, pleuritic or hepa- 
 tic pain, and patients more frequently ask for a 
 repetition of this remedy than of any other ; but 
 if there is headache, which is of frequent occur- 
 rence in valvular diseases, the smallest dose of 
 opium appears to make it worse, while small 
 doses, one fourth or one-half grain of quinine, 
 often repeated, gives prompt and steady relief. 
 
 The weight of the patient must be reduced from 
 time to time by diminished diet, such as lean 
 meat and dried meats, with a little stale bread, 
 in small quantities, without vegetables or liquid 
 food. Even water should be drank sparingly. 
 By these means the blood may be diminished in 
 
62 DISEASES OF THE HEART : 
 
 quantity, pari pasu, with the decreasing weight 
 of the body, and at the same time its quality re- 
 main unimpaired. 
 
 It is by no means desirable to add any form of 
 spangemia to organic disease of the heart ; and, 
 although reduction of the heart's work is imper- 
 ative, it is of the highest importance not to re- 
 duce its own strength and tone, while attempting 
 to diminish the blood, which is at once it susten- 
 ance and its burden of toil. 
 
 The law applicable here is applicable in every 
 organic disease of the heart, with modifications 
 suitable to each case ; to wit : the heart must be 
 aided by diminishing the labor it has to perform, 
 without diminishing its own proper vigor or 
 functional ability. 
 
 5. .Aortic obstruction — constriction of aortic 
 orifice — is indicated by a murmur coincident 
 with the systole. The^r^^ and second sounds of 
 the heart may remain unimpaired, but as aortic 
 constriction must induce hypertrophy, we should 
 find the impulse of the heart occupying a larger 
 space, and the systolic shock increased, but in 
 practice this is not always so. "^ . 
 
 * If the aortic valves are also incompetent, the impulse 
 win always be much increased. 
 
THEIR DIAGNOSIS AND TREATMENT. 63 
 
 But it may as well be stated here, that there is 
 no known pathognomonic sign or signs of aortic 
 constriction. Its existence may be made out with 
 extreme probability, but never with the absolute 
 certainty of mitral or aortic regurgitation. 
 
 6. Nothing can be determined by the pulse of 
 exclusive significance ; it is likely to be regular 
 in force and rhythm ; but if the hypertrophy of 
 the ventricle is pronounced, it will be hard and 
 and small, and have a wiry feel. Systemic dropsy 
 is not a concomitant of aortic constriction ; cough 
 is not present, although there must be tendency 
 to engorgement of the lungs, when the blood flow- 
 ing into the ventricle from the pulmonary veins, 
 encounters, as it must, an amount of blood en- 
 tirely excessive. There may be a slight cough, 
 but if it is persistent, and the lungs not inflamed 
 or tuberculous, and if there is no catarrh, either 
 constriction or incompetency at the mitral orifice 
 must be suspected as a complication. A persistent 
 aortic constriction entails (Walsh) a dilatation of 
 the mitral orifice, and hence the murmur of mitral 
 regurgitation from insufiiciency, when the mitral 
 valve itself is perfectly sound. 
 
 7. The anemic murmur is not persistent ; mur- 
 mur from unevenness of the internal surface of the 
 ascending aorta, is heard louder farther up the 
 sternum than that from constriction of the orifice. 
 
64 DISEASES OP THE HEART : 
 
 a, A marked fact in constriction of aortic 
 orifice, is that the murmur is frequently heard in 
 so many places and at such remote distances from 
 its origin. It is heard under the right clavicle 
 near the axilla ; it is heard in the carotid, in the 
 interscapular spaces, in all the intercostal spaces 
 as low as the sixth, and in nearly as many of the 
 left interspaces. 
 
 h. It is of slow progress towards a fatal termi- 
 nation, and is susceptible of becoming null as to 
 its injurious systemic effects, by the hypertrophy 
 of the ventricles, left and right. I say left and 
 right, because this is the order in which their 
 hypertrophy occurs in aortic constriction. 
 
 8. JVarroiving of the aorta is sometimes a con- 
 genital condition, probably an intra-uterine arrest 
 of development. The striking case mentioned 
 by Latham exhibited the aorta and all its prin- 
 cipal branches entirely free from disease, but 
 more than one-half less than their natural capa- 
 city ; the heart was found enormously enlarged 
 and its cavities dilated. In Meckel's case (1750) 
 quoted by Latham, the patient was a puny girl of 
 18. She had been from time to time subject to 
 palpitation, and anguish, and trembling of the 
 limbs, from infancy to her fourteenth year, and 
 thenceforward the palpitation and anguish had 
 
THEIR DIAGNOSIS AND TREATMENT. 65 
 
 become constant and more severe until her death. 
 Upon dissection, the heart was found enormously 
 enlarged, and the aorta, throughout its whole 
 course, especially through the -chest and all its 
 principal branches, marvellously narrowed. The 
 heart had both its ventricles dilated, and their 
 substance more soft than natural ; its auricles 
 also dilated, but the left to a degree far greater 
 than any other cavity. It was capable of con- 
 taining the enormous quantity of twelve ounces, 
 while the corresponding ventricle only contained 
 foHr. The aorta was not more than half the 
 diameter of the pulmonary artery." 
 
 These were evidently congenital malformations 
 of the aorta, and the enlargement of the heart 
 was a necessary consequence, and perhaps an in- 
 dispensable condition for the continuance of life. 
 
 But constriction of a short segment of the 
 aorta will have the same effect on the heart 
 as this general narrowing of the aortic trunk and 
 its principal branches. 
 
 9. The treatment of aortic constriction is in no 
 wise peculiar, and would be the same, with limi- 
 tations, as that of aortic or mitral regurgitation. 
 When the patient becomes over fatigued or ex- 
 cited, the pulse is very likely to become oppres- 
 sively intermittent, perhaps to the extent of eight 
 
 H 
 
66 DISEASES OF THE HEART : 
 
 or ten times a minute. When such a condition 
 supervenes, absolute quiet should be enjoined, 
 and the heart stimulated to regular contractions, 
 by a dose of lavender and ammonia, or by dry 
 cups. A little blood abstracted from the pre- 
 cordia by leeches, or scarifications and cups 
 would almost instantly relieve the overtasked 
 organ, not entirely by reflex action, but by 
 absolutely diminishing the fullness of the ves- 
 sels near the base of the heart, for it will be 
 borne in mind that the internal mammary artery 
 rests upon the costal cartilages, a short distance 
 from the margin of the sternum ; it sends 
 branches to the upper part of the pericardium — 
 pericardiac arteries — also to the skin covering the 
 base of the heart — anterior perforating arteries — 
 hence blood abstracted from the precordia would 
 be abstracted from the near vicinity of the heart 
 itself — namely, from the membrane investing it. 
 And it is for this anatomical reason that local 
 depletion is insisted upon in pericarditis by a 
 late author (Markham). 
 
 But however this matter be explained, one 
 thing is well known to all observers, that the 
 local abstraction of blood in the vicinity of the 
 hearths valves rapidly relieves all cases of angina 
 pectoris in the various forms of unsound heart. 
 
THEIR DIAGNOSIS AND TREATMENT. 67 
 
 I am not oblivious of an apparent discrepancy 
 in this statement with a fact previously stated, 
 that neuralgic pain, of which angina pectoris is 
 undoubtedly an example, depends on some local 
 anemia. But this is more apparant than real — 
 for the anemia may [be relative or absolute — 
 absolute when the total mass is diminished ; 
 relative when there is merely obstruction to its 
 movement through some part. Again, a structure 
 may be overwhelmed with venous blood in a state 
 of stasis ; for example, the arm below a ligature ; 
 the brain and upper extremities from a tumor 
 pressing on the descending cava. In this case 
 there would be pain in the head, perhaps, and 
 yet there is excess of blood ; but there is diminu- 
 tion of arterial blood circulating in the obstructed 
 parts — this is relative anemia. 
 
 Excess of non-oxygenated blood is equivalent 
 as to the production of pain, to diminution or 
 defect of arterial blood — anemia. The pain in- 
 duced by this venous stasis or retardation, might 
 be relieved by local depletion, while pain from 
 direct anemia of red blood should be relieved 
 by arterial stimulants and hsematogens. The 
 pain of angina 'pectoris is probably often if not 
 always caused by local retardation of the blood 
 current, that is, by venous congestion — relative 
 anemia. 
 
68 DISEASES OF THE HEART : 
 
 But it cannot be ignored that this local deple- 
 tion is much more applicable to acute inflamma- 
 tions of the inside or outside of the heart, espe- 
 cially of the latter, than to sudden accessions of 
 congestion or anguish in chronic changes of the 
 heart's structure, such as the affection under con- 
 sideration — constriction of the aortic orifice. If 
 the paroxysm or excessive palpitation in this 
 chronic affection of the heart, or of most others 
 of the same organ be not promptly relieved by 
 dry cups, sinapisms, or by leeches or scarifica- 
 tions, the overtasked heart should be relieved by 
 a small amount of blood taken from the arm. 
 This is rational in theory and verified in prac- 
 tice. *' I consider that T have seen life preserved 
 by timely abstraction of blood (by venesection) 
 in cases of chronic valvular diseases of the heart, 
 where the organ was so overwhelmed and labor- 
 ing as to render death imminent.^' (Markham.) 
 
 10. Care must be taken that too much blood, 
 relatively to the condition of the patient, be not 
 taken from the arm, lest by the alteration of the 
 normal ratio of globules and fibrin, or by the 
 feeble action induced in the heart, the formation 
 of clot be favored, and death be caused in an in- 
 stant. Such accidents have occurred, to the hor- 
 ror of the physician, who bled with the most 
 
THEIR DIAGNOSIS AND TREATMENT. 69 
 
 honest intentions, and under the influence of the 
 dictation of the classic authors in medicine. But 
 under the present rational ideas of the uses of 
 blood-letting — merely to relieve an immediate 
 and urgent necessity — there is little danger of a 
 careful physician allowing more blood to flow 
 than is absolutely requisite to relieve the con- 
 gestion of the heart or lungs. Concerning the 
 treatment of aortic constriction itself, we know 
 absolutely nothing. All we can do is to prevent 
 the accidental complications which attend it from 
 suddenly destroying life. 
 
 11. Like all other chronic diseases of the heart, 
 it has no known essential (denoting its essence) 
 symptom ; and hence we cannot direct our treat- 
 ment t(^g^e cure, or the arrest, or even the dete- 
 rioration of the disease in its intimate nature. 
 We see not the disease, but its effects ; namely, 
 constriction, incompetency, etc. These are the 
 anatomical alterations which the disease has pro- 
 duced, but they are not the disease itself. This 
 lies behind the visible effect. It exists anterior 
 to it in the blood, and in the ultimate structure 
 of nerve and brain substance. 
 
 In chronic affections of this kind, then, we can 
 only treat symptoms. But what are symptoms ? 
 Latham has eloquently and well said, *' They are 
 
70 DISEASES OF THE HEART : 
 
 not mere signs of the disease, but they are direct 
 emanations from it ; not things in themselves 
 nugatory, but eminently real. They are natural 
 sensations unduly exalted, or unduly depressed, 
 or variously changed or perverted. They are 
 natural functions hurt, hindered or abolished. 
 So that a man may often with stricter propriety 
 be said to be ill of his symptoms than to be ill of 
 his disease, and, what is more, to die of his symp- 
 toms than to die of his disease. 
 
 Accordingly, it often happens, even where the 
 disease is best understood, that we treat the 
 symptoms of the disease only, just as if we had 
 no knowledge of anything beyond them. There- 
 fore, when we have confessedly no strict knowl- 
 edge beyond them, (which is the case ipi chronic 
 aflfections of the heart,) and the aim of our prac- 
 tice must need centre in the symptoms; we are 
 not to lament over the shortcomings of our art, 
 and its straitened capacity for doing good ; for, 
 it does not follow that, if we knew the disease 
 ever so well, we would treat it otherwise than we 
 are now treating its symptoms, or that what we 
 are now doing for the symptoms would not be 
 the best and would not be all that could be done 
 for the disease itself." 
 
 Aortic regurgitation cannot he mistaken for aor- 
 
THEIR DIAGNOSIS AND TREATMENT. 71 
 
 tic constriction or obstruction. In the former case, 
 the murmur is coincident with second sound — of 
 the pulmonary artery, when that of the aorta is 
 replaced by the murmur — in the latter case, the 
 murmur is synchronous with the first sound, and 
 both first and second sounds are audible. It is 
 more common in old people, but young people 
 are by no means exempt from it. 
 
 Were I called upon for an opinion in a sus- 
 pected case of this kind, I should attempt a diag- 
 nosis by .exclusion. It could be determined that 
 the murmur was not mitral regurgitation from 
 its location and direction, and from the persist- 
 ence of mitral^r^^ sound, if the mitral orifice were 
 not also incompetent. It is not aneurismal from 
 the absence of dysphagia, of sense of a foreign 
 body in the thorax, of thrill on digital pressure 
 in the intercostal spaces. It is not aortic regur- 
 gitant, for it is not coincident with the diastole, 
 etc., etc. 
 
 I^ must not leave the consideration of alter- 
 ations of the aortic orifice, without alluding to an 
 unexplained fact in connection with aortic regur- 
 gitation ; that is, extreme tendency to instanta" 
 neous death. 
 
 The patient drops dead without the slightest 
 premonition, and probably without any excita 
 
72 DISEASES OF THE HEART : 
 
 tion of the circulation, as well as when walking 
 or when motionally excited. The freer the heart 
 is from any other lesion, Walshe says, the more 
 likely is the patient to instant death from aortic 
 regurgitation. The- assurance of life is much 
 longer if to the aortic, mitral regurgitation and 
 ventricular hypertrophy ,be added. Even the 
 addition of that most fatal of all valvular affec- 
 tions tricuspid insufficiency^ is preferable to aortic 
 regurgitation, pure and simple. 
 
 The instant death can be guarde^against, 
 
 theoretically, by seeing that blood be noFmade in 
 
 excess, in fact that it be abstracted from the re- 
 
 ' gion of the heart from time to time, if there is 
 
 the least evidence of labored circulation. 
 
 Death occurs from syncope. It is a " fainting 
 away'' from which the patient never awakes. 
 This peculiar tendency in aortic regurgitation 
 was first publicly noticed by Chomel, and next 
 by Aran. (Walshe.) 
 
 I have condensed the following additional ob- 
 servations on this subject from the Gazette des 
 HopitauXj 9th June, 1860. 
 
 " In 1844, M. H., Minister of Finance under the 
 reign of Louis Phillipe, was working one morning 
 with one of the ministry. The absence of a docu- 
 ment compelled the latter to absent himself for 
 
THEIR DIAGNOSIS AND TREATMENT. 73 
 
 a few moments. When he returned, five minutes 
 or more after his departure, he found th€ minister 
 with his body inclined backwards over his chair, 
 his right arm hanging over the arm of the chair, 
 still holding the pen with which he had designed 
 to write his signature to the document. All the 
 means employed in such cases were resorted to 
 in order to restore M. H. to life, but in vain ; he 
 was dead. 
 
 The autopsy, made by Blandin, revealed no 
 lesion either in the brain or lungs. The heart 
 was very large and loaded with fat ; its right 
 cavities, distended with black blood, were a little 
 dilated and very much thinned. The left ven- 
 tricle was greatly hypertropied and enormously 
 dilated. Excepting a few nodosities, the mitral 
 valve was healthy ; but the aortic orifice was 
 much constricted, and the sigmoid valves entirely 
 ossified. There were a few cretacious deposits in 
 the aorta. 
 
 It is important to add that the health of M. 
 H, had exhibited no grave derang^ement which 
 could have presaged the sudden stroke which 
 teiininated his existence. He had never had any 
 of the general symptoms pertaining to diseases 
 of the heart, 
 
 ''Thirteen years after, in 1857, Mauriac, fre- 
 
 I 
 
74 DISEASES OP THE HEART : 
 
 quently saw at La Pitie, a sub-officer of the guard 
 of Paris, who had long frequented the hospital 
 for advice concerning palpitation of the heart, 
 and a constant difficulty of respiration. In this 
 case there was ascertained to be a double hruit 
 de souffle at the base of the heart, and the diag- 
 nosis was aortic insufficiency. He had neither 
 dropsy nor anasarca. For many months M. 
 Mauriac did not see this patient, when he learned 
 that he had died suddenly. One of his comrades, 
 who was on duty with him, left him alone to copy 
 some document ; when he returned, at the expi- 
 ration of a few moments, he found his friend dead 
 in front of his desk. At the autopsy, no lesion 
 was found anywhere, except insufficiency of the 
 valves of the aorta, with hypertrophy and dilata- 
 tion of the left ventricle of the heart. 
 
 One year after this, Mauriac observed the fol- 
 lowing case : A young man, twenty-six years old, 
 of robust constitution, about five months before 
 entering into the hospital, had suffered for a fort- 
 night with pains under the left false ribs. Six 
 weeks before;* he had palpitation for the first 
 time, and one month previous, that is, on the 3d 
 of March, he was taken with obstructed or im- 
 peded respiration and pains in the left groin, 
 which radiated along the lower extremity of the 
 same side. The* 2d of April, his condition was 
 
TJ^Em DIAGNOSIS AND TREATMENT. 75 
 
 as follows : Slight emaciation : partial distension 
 T3f the veins of the neck; visible arterial pulsa- 
 tions ; skin warm and moist ; 88 to 92 pulsations, 
 vibrating, irregular, intermittent at the arterial 
 diastole from time to time. The heart is consid- 
 erably enlarged. The maximum of impulsion 
 takes place in the fifth intercostal space, 11 centi- 
 meters ^ from the axis of the sternum ; it mea- 
 sures vertically 11 centimeters upon the median 
 line, and more than IC centimeters obliquely 
 from right to left. The impulsion is thrilling, 
 and accelerated at times, as if the heart struggled 
 to overcome an obstacle. The ear applied over the 
 apex, perceives a double bruit de souffle, the* second 
 much softer, more mellow and prolonged than 
 the first. Ascending towards the base of the 
 heart, this double stethoscopic phenomenon per- 
 sists and seems to reach its maximum of in- 
 tensity under the second and third intercostal 
 spaces, on the left side, in the vicinity of the 
 sternum, also under the corresponding portion of 
 this bone. This double bellows-murmur is also 
 very marked in the aorta, the dullness of which 
 is sensibly increased. Finally, in whatever 
 place the ear is applied, there is not heard 
 
 * A centimeter is four-tenths of an inch nearly ; a milli- 
 meter is .0S9 inch. 
 
76 DISEASES OF THE HEART : 
 
 any trace of the second normal beat of the heart. 
 Bellows-murmur diastolic, intermittent, and very 
 strong in the carotids. There is neither fever 
 nor oedematous swelling of the abdominal ex- 
 tremities. 
 
 The 8th of April, the 6th day after his entrance 
 into the. hospital, the patient died suddenly, at 
 seven o'clock in the morning. During the last 
 few days of his life he complained of a feeling of 
 severe oppression and a sensation of uneasiness 
 at the epigastrum ; the morning of the day before 
 his death, he complained of great difiSculty of 
 respiration ; however, he still kept about ; in 
 the evening he supped as usual ; during the night 
 he had some suffocating attacks, his sleep was 
 agitated and painful • at seven o'clock in the 
 morning he awoke and lay tranquilly in bed. 
 All at once he lost all consciousness, his head fell 
 back, his limbs straightened and were convul- 
 sively agitated, his face became rapidly purple, 
 and almost immediately grew pale, and in less 
 than ten minutes he died. 
 
 The heart, emptied of its clots, measures 0.13 
 centimeters from base to point, also transversely 
 at the level of the base. The pulmonary orifice 
 was 0.075 millimeters in circumference. The 
 ventricle is a little dilated and hypcrtropied. 
 
THEIR DIAGNOSIS AND TREATMENT. 77 
 
 The right auriculo-ventricular orifice is somewhat 
 enlarged ; its valves are supple and transparent ; 
 the left presents some granulations on the auri 
 cular surface. Very marked dilatation of the 
 right auricle. 
 
 The aorta is dilated immediately after its issue 
 from the heart in such a manner as to assume a 
 position more anterior than usual, and crowd the 
 pulmonary artery backwards; the dilation ex- 
 tends as high as the origin of the left subclavian ; 
 it has, however, preserved the flexibility of its 
 walls ; finally, in the neighborhood of its orifice 
 it exhibits a beginning of atheromatous altera- 
 tion. The left ventricle is enormously dilated. 
 The dilatation affects solely the arterial portion, 
 and the mitral valve is forcibly pushed back- 
 wards, also the fleshy columns inserted into it, 
 which latter are atrophied rather than hyper- 
 tropied. The diameter of this ventricle is 7 
 centimeters, the thickness of its walls 13 milli- 
 meters. The mitral valve is supple, but the ten- 
 dons which subtend it are thickened. Insuffi- 
 ciency of the sigmoid valves of the orifice of the 
 aorta. A clot is prolonged to a height of 52 
 millimeters above the origin of the vessel, and 
 adheres to the greatly altered right valve. The 
 anterior and posterior sigmoid valves are thick- 
 
78 DISEASES OP THE HEART t 
 
 ened and indurated, and have lost their elasticity, 
 and contain, particularly at their bases, cretace- - 
 ous and cartilaginous granules ; their separating 
 partition is much thickened. The right valve is 
 almost entirely destroyed at its middle. 
 
 Dr. Mauriac proceeds to investigate the mech- 
 anism of sudden death, to study the elements of 
 prognosis, and the therapeutical indications to be 
 deduced from a knowledge of this mechanism. 
 
 When there exists, says M. Mauriac, an insulfi* 
 ciency of the sigmoid valves of the aorta, and 
 when the hiatus which is the consequence of this 
 is insufficiently large to permit the re-entrance 
 of a considerable quantity of blood, at the instant 
 of the hearths diastole, into the interior of the 
 left ventricle, the latter becomes more or less 
 distended, and it is compelled to increase its ac- 
 tivity to impel into the whole arterial system 
 this excess of blood, added to the amount which 
 comes from the lungs. There results a hyper- 
 trophy of the walls and a dilatation of the cavity 
 of this ventricle. 
 
 So long as these lesions do not go beyond a 
 certain point, and particularly so long as they 
 remain simple, that is to say, not complicated 
 with any other morbid change, they oppose the 
 stagnation of the blood in the lungs and in the 
 
THEIR. DIAGNOSIS AND TREATMENT. 79 
 
 cardiac cavities ; and are, therefore, salutary 
 because they prevent the insufficiency from pro- 
 ducing any considerable perturbation in the equi- 
 librium of the general and pulmonary circulation. 
 But hypertrophy and dilatation of the left ven- 
 tricle of the heart, consecutive to valvular insuffi- 
 ciency, tend almost always to indefinite increase ; 
 and in proportion as they increase they lose 
 more and more the character of a, so to speak, 
 normal and physiological hypertrophy and dila- 
 tation, because they become the seat of vsecondarj 
 lesions, which embarrasses the circulation in the 
 hearths own vessels and alter its muscular fibre. 
 
 Nevertheless, when the hiatus of insufficiency 
 is small, when there is not considerable stricture 
 of the aortic orifice, or complete rigidity of the 
 aortic valves ; when the inflammatory morbid 
 process which has produced the insufficiency and 
 the lesions at the origin of the aorta, is arrested 
 and definitively extinguished, it is possible that 
 the hypertrophy of the left ventricle having 
 reached that degree which the maintenance of 
 the equilibrium of the circulation requires, will 
 desist in its progressive development and remain 
 stationary during the remainder of life. M. 
 Mauriac considersit certain that such a condition 
 exists in those individuals who have been for a 
 long time aflfected with aortic insufficiency, and 
 
80 DISEASES OF THE HEART : 
 
 who finally suffer only slight inconveniences re- 
 ferable to the heart, such as palpitations or mo- 
 mentary dyspnoea, etc. He has seen cases in 
 which auscultation left no doubt of the existence 
 of an insuflSciency of the aortic semilunar valves, 
 who had not even supposed they had any disease 
 of the heart ; percussion in tliese cases revealed 
 only slight enlargement of the heart. The hyper- 
 trophic process had no doubt subsided, and to 
 this cause they were indebted for their undis- 
 turbed health. 
 
 Unfortunately, hypertrophy and dilatation of 
 the left ventricle rarely remains circumscribed 
 within these limits. There are many causes which 
 tend constantly to augment these two lesions in 
 which consists all the danger of insufficiency, and 
 the action of which culminates in perturbations 
 of the hearths own circulation. 
 
 The organo-pathological development of hyper- 
 trophy and dilatation of the left ventricle, con- 
 secutive to sigmoid insufficiency, presents three 
 stages : one stage of simple and salutary hyper- 
 trophy and dilation which augments the labor of 
 the heart, and may counteract in part for the in- 
 jurious' effects of the valvular alterations ; a stage 
 of hypertrophy and dilatation complicated with 
 the preceding lesions, and with more or less fatty 
 
THEIR DIAGNOSIS AND TREATMENT. 81 
 
 degeneresceiice. Fatty degenerescence is very 
 frequent in aortic insufficiency ; it is the last step 
 of morbid organization of which the ventricular 
 walls become the seat, when hypertrophy and 
 dilatation are not arrested in their first stage. 
 Among the numerous causes of this complication, 
 M. Mauriac thinks that which plays the greatest 
 part is the progressive enfeeblement of the inter- 
 stitial circulation of the heart, either when this 
 enfeeblement depends upon aortic insufficiency 
 itself, or, at the same time, upon alterations in 
 the origin of the aorta and cardiac arteries. 
 Still, as these alteration? run a course essentially 
 chronic, as well as the valvular lesions, it results 
 that it is only at a very advanced period of car- 
 diac disease that degenerescence is observed. 
 
 When it has invaded the whole organ, there is 
 observed a considerable thinning of the walls, 
 dilatation and extreme flaccidity. Hypertrophy 
 of the walls is, then, in this phase of the malady 
 replaced by their atrophy ; but the dilatation 
 persists and tends even to become increased, if 
 death does not intervene and suddenly remove 
 the patient. • 
 
 Hence, we arrive at the conclusion that the 
 organic cause which induces sudden death in cases of 
 aortic insufficiency^ is hypertrophy and dilatation of 
 
 J 
 
82 DISEASES OF THE HEART : 
 
 the left ventricle, complicated with congestion or 
 degenerescence of the heart, 
 
 4* 
 
 From the instant these lesions have taken place, 
 the patient is momentarily in danger of sudden 
 death. Finally, this mode of the termination of 
 life never occurs in those cases that, consecutively 
 to innoclusion of the aortic valves, have only 
 moderate dilatation and hypertrophy. All the 
 observations collected by M. Mauriac prove this 
 fact in a categoric manner. 
 
 These premises admitted, he explains the me- 
 chanism of sudden death. 
 
 The heart, the centre of sympathy, upon which 
 are accumulated, by reflex movement, all the 
 impressions of the organism, whether morbid or 
 physiological, becomes, in consequence of the 
 lesions suffered, excessively susceptible to the 
 perception of these impressions. Thus, every 
 moral perturbation, every affection of the mind, 
 which disturbs or tires the centres of innervation, 
 all fatigue proceeding from excessive muscular 
 exercise, or from whatever expense of nervous 
 influx, are so many eausQs which may accident- 
 ally induce *death. 
 
 Under the influences of any of these causes, the 
 ventricular systole is enfeebled, becomes incom- 
 plete, drives into the arterial system only a por- 
 
THEin DIAGNOSIS AND TREATMENT. 83 
 
 tion of the blood which was accumulated in the 
 ventricular cavity, at the moment ot the diastole. 
 But the elasticity and contractility of the aorta 
 and its branches not being duninished, it re-acts 
 upon the blood-columns, and impels a recurrent 
 jet through the hiatus of insufficiency with the 
 same energy as previously. 
 
 It follows that, after the second systole, the 
 heart is overcharged with a mass of blood ex- 
 ceeding the amount it contained at the instant it 
 was surprised with the debilitating action of the 
 accidental cause. If it recover its energy, the 
 circulating equilibrium may be restored ; but if 
 its feebleness continue, the difficulty increases, 
 and the quantity of blood which accumulates in 
 its cavity is augmented at each systole, and at 
 each reaction of the aorta upon the liquid column 
 which is no longer shut off from the heart by the 
 complete partition which is made in the normal 
 state by the aortic volves. 
 
 The accumulation in the ventricular cavity of 
 the blood which comes from the lungs and the 
 different arteries, dilates the left ventricle more 
 and more ; and, finally, it can no more contract. 
 
 From all that precedes, it follows, that as to 
 the prognosis, that of all the diseases of the hearts 
 there is none the result of which is so difficult to 
 
84 DISEASES OF THE HEART : 
 
 be foreseen, or that exposes the physician to more 
 deception and risk of mistake. 
 
 Here are a few signs which may enlighten him 
 upon the gravity and result of the affection : ^ 
 
 Shock of the point of the heart several times 
 the thickness of a finger outside of a line vertical 
 with the left nipple, energy of its impulse, ab- 
 sence of normal resonance over a considerable 
 extent, indicating that the hypertrophy and dila- 
 tation of the left ventricle have reached that de- 
 gree where sudden death by instant cessation of 
 the movements of the heart becomes imminent ; 
 all these are signs of the worst significance. 
 
 In general, only uncertain inferences as to the 
 result can be drawn from abnormal murmurs. 
 
 The depressihility of the pulse, which is observed 
 at its highest degree when the hiatus of insufiS- 
 ciency is very large, should be regarded as a sign 
 of bad import. Among functional troubles, ac- 
 cessions of dyspnoea, above all^ when accompa- 
 nied with violent palpitations, are also of serious 
 significance ; it is the same with syncope, which, 
 extremely grave in all affections of the heart, 
 without exception, is much more so in aortic 
 insufficiency than in any other disease of the 
 organ. 
 
I THEIR DIAGNOSIS AND TREATMENT. 85 
 
 The resources of science are, unfortunately, too 
 often powerless in this affection. All the efforts 
 of the physician should be directed against the 
 most imminent danger, that of syncope, by all the 
 hyt^ienic means susceptible of detaining in its 
 progress the evolution of the organic lesions. 
 The facts demonstrate the danger of the method 
 of Valsalva, of which indications have been 
 imagined to exist in the fullness and apparent 
 force of the arterial diastoles. Bleeding should 
 be practiced only with very great moderation, 
 and only in cases where there exists an engorge- 
 ment of the lungs which impedes the general cir- 
 culation. 
 
 Sedatives and cardiaco-vascular hyposthenisants 
 are indicated as palliatives in all cases where 
 there are violent palpitations, dyspnoea, or pre- 
 cordial anxiety. Finally, the true curative indi- 
 cations are deduced from the course of the morbid 
 process, of which the walls of the heart are the 
 seat ; it is especially by revulsive treatment, 
 (cupping, scarifications, temporary blisters, cau- 
 teries, etc..) that the indications of treatment are 
 fulfilled. 
 
86 DISEASES OF THE HEART t » 
 
 CHAPTER Y. 
 
 Valves op the Pulmonaky Aktery. Constriction of 
 THE Mitral Orifice. Constriction of the Right 
 AuRicuLO- Ventricular Orifice. 
 
 1. Skoda says he has never observed deficiency 
 of the valves of the pulmonary artery, or constric- 
 tion of its orifice^ in consequence of faulty valves, 
 [By '* faulty'^ he means diseased or altered, but 
 not defective or incompetent.] Should incom- 
 petent pulmonic valves occur, the incompetency 
 would be certainly recognized by a murmur in 
 place of the second sound, of the pulmonary 
 artery, and this murmur would be heard loudest 
 between second and third ribs, near sternum left 
 side, and from that point directly dow^nwards. 
 There would be hypertrophy and dilatation of 
 the left ventricle in a less marked degree than in 
 aortic regurgitation, and hence the impulse of 
 the heart would be felt over a less extent than in 
 the latter affection. The murmur of pulmonic 
 regurgitation has a sighing quality, (Hope) not 
 observed in aortic regurgitation. This sighing 
 murmur is also heard in connection with dimin- 
 ished second pulmonic sound, when the valves of 
 the pulmonary artery are slightly defective, but 
 not so much so as to prevent the flapping of the 
 valves. (Hope's experiment.) 
 
THEIR DIAGNOSIS AND TREATMENT. 87 
 
 2. The pulmonic valves are also liable to be- 
 come roughened, in a chronic manner, from exu- 
 dation of plastic matter, or from the deposition 
 of analogous tissue, without destroying their 
 competency. In such case there would be a 
 murmur synchronous with the systole, heard 
 loudest in second left interspace, and propa- 
 gated directly upwards. 
 
 3. Hope never saw or found recorded a case of 
 pulmonic regurgitation from disease of the pul- 
 monary valves. He created the murmur artifi- 
 cially in the heart of an ass poisoned with woo- 
 rara. 
 
 4. The slightest compression, as of a tumor, 
 a congested portion of lung, a foreign body upon 
 the pulmonic artery or aorta, produces murmur 
 and thrill synchronous with the hearths systole. 
 
 5. The second sound, much diminished, might 
 be heard in many places on the chest, even were 
 the pulmonic valves utterly incompetent, if those 
 of the aorta were still sound ; but the second souna 
 heard would proceed from the aortic, not the pul- 
 monary valves ; and so, when the aortic valves 
 are incompetent, so as to furnish no sound, a 
 much diminished second sound will quite pro- 
 bably be heard in the second left interspace, pro- 
 ceeding from the sound pulmonic valves ; for the 
 
88 DISEASES OF THE HEART : 
 
 second sound is caused by the shutting back, at the 
 same instant, of both sets of sigmoid valves, just 
 as the first sound results from the synchronous 
 closing of right and left auriculo-ventricular 
 valves. Practically, lesions of the pulmonic valves 
 may he ignored in the diagnosis of unsound heart, 
 
 6. Constriction of the mitral orifice. Diastolic 
 murmur from this cause is exceedingly rare, even 
 when the constriction is considerable ; this defect 
 of murmur results from the feeble force with 
 which the blood flows from the left auricle into 
 the left ventricle. The auricle is a feeble muscle, 
 and not being supported by a valve, could hardly 
 inject the blood flowing into it from the pulmonary 
 veins into the ventricle, with force sufficient 
 to develope a murmur, unless the constriction 
 should not have a very small orifice, and even then 
 the murmur must be feeble, and would certainly 
 be preceded by a loud murmur of mitral regur- 
 gitation. 
 
 7. Mitral diastolic murmur is certainly very 
 rare. Latham says it is a clinical curiosity ; there 
 is no murmur because there is no impelling force 
 from behind. Markham met with less than a 
 dozen cases in eight or nine years, a, Austin 
 Flint, on the contrary, seems to have been pecu- 
 liarly fortunate in detecting this murmur ; he 
 
THEIR DIAGNOSIS AND TREATMENT. 89 
 
 says : *' It [mitral direct murmur] is by no means 
 so rare as has been supposed. I saw at one time 
 last winter six cases of it in Belle Vue Hospital) 
 and several others at Blackwell Island Hospital.'^ 
 
 h. I have never yet been able to detect mitral 
 direct murmur, although I have had many cases 
 in which there could scarcely be a doubt of 
 mitral constriction. 
 
 8. Sometimes the murmur is attended with a 
 palpable thrill at the left 2^^(ix—fremissement 
 cataire; in well marked cases where the action is 
 vigorous, a loud and prolonged murmur is heard 
 at apex and upwards, in direction of left nipple. 
 This affection causes hypertrophy of left auricle 
 and right ventricle, pulmonary congestions; aortic 
 sounds and beat of arteries, weak in proportion 
 to constriction ; hasmoptysis of venous blood fre- 
 quent and easily excited ; breathlessness easily 
 induced by over-exertion ; rest and quiet in an 
 especial manner produce ease and comfort. 
 Skoda^s symptom, increased second sound of 
 pulmonary artery, is here well marked, and rela- 
 tively intensified on account of the weakness of 
 the Ze/if ventricular systole and diminished second 
 sound of aortic valves. 
 
 9. Walshe has never heard this murmur of 
 great intensity, nor high in pitch ; it is, however, 
 
90 DISEASES OF THE HEART : 
 
 sometimes prolonged. The murmur is sometimes 
 wanting, where the constriction is found after 
 death. The absence of the murmur may be 
 reasonably attributed to weakness of auricular 
 systole, or to smoothness of constricted orifice. 
 The murmur comeS and goes even wlien orifice is 
 greatly contracted : this is probably due to vary- 
 ing force of heart's action. 
 
 10. Skoda says, in mitral constriction hyper- 
 trophy occurs rapidly ; that it is attended with a 
 prolonged murmur, extending even into the period 
 of the systole of the ventricle. During systole 
 no sound, or an indeterminate sound, in heard in 
 left ventricle ; again, a murmur (systolic) may 
 he heard there, because deficiency of the mitral 
 valves is generally associated with constriction 
 of mitral orifice. Sounds of aorta weak, heart's 
 impulse increased and perceptible even, over a 
 greater extent than natural. 
 
 11. Hope says the murmur is feeble, soft, usually 
 on a lower key than a whispered who; absent 
 unless the contraction is considerable ; absent 
 also when the contraction is greats providing the 
 current is perternaturally weakened by softening, 
 or extreme dilatation of heart, or by both. In 
 such cases, there is almost invariably murmur of 
 regurgitation ; hence the disease of the valves 
 
THEIR DIAGNOSIS AND TREATMENT. 91 
 
 would not be overlooked. This murmur is ex- 
 ceedingly rare, originally thought frequent by 
 confounding it with a murmur of regurgitation. 
 '•' I have never known purring tremor accompany 
 a diastolic mitral murmur, the current being too 
 feeble to produce it.'^ When contraction is great, 
 pulse is more or less small, weak, intermittent, 
 irregular and unequal, in consequence of the 
 supply of blood to left ventricle being insufficient 
 and irregular. 0. J. B. Williams, quoted by 
 Hope, says : " When there is contraction of the 
 mitral orifice, there is usually more hypertrophy 
 than dilatation in the left ventricle." 
 
 12. In this last quotation, there must be perfect 
 accord among all thinkers. Also in the dilata- 
 tion with hypertrophy of the left auricle and 
 right ventricle, but the discrepancies concerning 
 the thrill— fremissement cataire — from mitral dis- 
 ease, are seemingly irreconcilable. Markham 
 says, it is frequent. Corvisart says, it is " sensi- 
 ble a la main appliquie sur la region precordialeJ^ 
 Hamernik says, it is like the hum of a spinning- 
 wheel. Skoda says that in certain cases vibra- 
 tions are felt when the hand is laid on the pre- 
 cordial region — the fremissement cataire of Laen- 
 nec. 
 
 1 3. Hope never heard or felt it, and does not be- 
 
92 DISEASES OF THE HEART : 
 
 lieve it occurs as a consequence of mitral obstruc- 
 tion. Walshe has never observed the thrill, but 
 believes it possible. 
 
 14. There is a case in this cit}^ now in which the 
 thrill is indubitable ; but it no more resembles 
 the purr of a cat or the hum of a wheel than it 
 does the filing of a saw — but it does accurately 
 simulate the thrill felt by placing one's finger on 
 a gum-elastic tube, a few lines in diameter, con- 
 nected with a hydrant with the water turned on. 
 The obstruction of the water produces a palpable 
 thrill and an audible murmur closely simulating 
 mitral murmur and thrill ; but in the case to 
 which allusion is here made, mitral regurgitation 
 is undoubted, yet neither Walshe nor Hope ever 
 observed the thrill in any valvular disease. It 
 is probable that the occurrence of the thrill is 
 extremely rare, and in a diagnostic point of view 
 entirely valueless, for pressure on any blood- 
 vessel by any substance might develope a thrill 
 under favorable circumstances. 
 
 15. I cannot leave this disputed ground without 
 one more allusion to Skoda's very positive dicta 
 — yet it should be observed that his assertions 
 are unsupported by accompanying clinical facts, 
 and that while they seem logical, they are nulli- 
 fied by the case cited by Walshe, and by two or 
 
THEIR DIAGNOSIS AND THEATMENT. 93 
 
 three others cited by Hope, where mitral con- 
 striction was greats and yet there was no diastolic 
 murmur. 
 
 16. But to Skoda ; he says : " The more con- 
 stricted the mitral orifice is, the longer will be 
 the time necessary for the flow of the blood into 
 the ventricle, and the more prolonged and louder 
 the murmur. It is in cases of this kind especially 
 that vibrations are felt, when the hand is laid 
 upon the prsecorclial region/^ — the cat-purr of 
 Laennec. 
 
 17. The first clause of this quotation is obvi- 
 ously exact ; but the second, '' the more pro- 
 longed and louder the murmer/' is doubtful in 
 theory, and contradicted by the facts above al- 
 luded to. The blood flowing from the auricle 
 through a smooth^ circular or regularly elipliform 
 contraction into the ventricular cavity, would be 
 in the last degree unlikely to developc a murmur, 
 however great the hypertrophy of the auricle. 
 Liquid flowing through the constricted end of a 
 tube, if the constriction be smooth^ does not gene- 
 rate a murmur, unless the impelling force be 
 relatively (to the size of the stream) very great. 
 
 That is, murmur depends not on the contrac- 
 tion or roughness merely, but on the momentum 
 of the liquid flowing through the aperture ; and 
 
94 DISEASES OF THE HEART . 
 
 in mitral constriction the momentum will be 
 slight, except in cases of great hypertrophy of 
 left auricle, and only in such cases will murmur 
 be likely to be developed, and then it will occur 
 only at the moment of the auricular contraction 7 
 that is, barely pre systolic — so near the systole as 
 to be easily confounded with regurgitant diastolic 
 murmur ; and as the mechanism of this murmur 
 is the same as that of the regurgitant, it should 
 be no mere sighing, but should have the same 
 abrupt blowing character. Liquid flowing with 
 great velocity and continuously from the end of 
 a tube emits a sighing murmur, but not when it 
 depends on an interrupted vis-a-tergo, like the 
 contraction of an auricle suddenly. But liquid 
 flowing through a constriction in the continuity 
 of a tube, whether the constriction be rough or 
 smooth, will be attended with murmur^ and if 
 rough with thrill also ; and in cases where the 
 thrill is manifest, it would be well to exclude 
 aortic regurgitation, and even mitral regurgita- 
 tion, by the most rigid logic, before attributing 
 the thrill to constriction of the mitral orifice. 
 
 18. But there being necessarily any murmur at 
 all, and e?=pecially its being attended with palpable 
 or visible thrill would seem to be as much opposed 
 to theory as to facts. Still, it would be extremely 
 
95 THEIR DIAGNOSIS AND TREATMENT. 
 
 fortunate if we had some sign pathognomonic of 
 mitral constriction, for it is the one of the affec- 
 tions of the heart next to aortic regurgitation 
 and tricuspid constriction most likely to teraii- 
 nate rapidly and suddenly, and it is one, if recog- 
 nized positively, that may be treated with every 
 expectation of prolonging the life of the patient 
 far beyond the limit it would reach if the case 
 were left to itself. Verification of hypertophous 
 dilatation of the left ventricle, exclusion of aortic 
 regurgitation, the presence of pulmonic conges- 
 tion and hemoptysis, increased second sound of 
 pulmonary artery, a feeble, irregular, unequal, 
 intermittent pulse, would render positive the 
 existence of mitral constriction, even if no mur- 
 mur at all were present. 
 
 19. Thus in constriction of this orifice, if a mur- 
 mur be developed at all, it will immediately pre- 
 cede a systolic regurgitant murmur, and will be 
 propagated towards the left apex, and diminish 
 and disappear before arriyin,!^ at the second in- 
 terspace. 
 
 20. Constriction of the mitral orifice would 
 add to the unfavorable prognosis of mitral regur- 
 gitation. The same principles of treatment are 
 applicable here as in other cardiac lesions. The 
 heart must not be alloVed to beat too fast — more 
 
96 DISEASES OF THE HEART : 
 
 than 80 — the weight of the body must be dimin- 
 ished, while tlie quality of the blood is maintained 
 at a healthy standard. • Abundant passive exer- 
 cise in the open air, more a meat than vegetable 
 diet, a quiet mind, slow bodily movements, baths, 
 diuretics, aperients, occasional precordial counter- 
 irritation, or even depletion ; all these may be 
 requisite, according to the condition of the body 
 and the general health. It is not possible to 
 follow any prescribed details of treatment for 
 any length of time. The treatment must be con- 
 stantly modified, to suit the ever varying exi- 
 gencies of each case. 
 
 CHAPTER V^I. 
 
 Inorganic Murmtjrs — How Distinguishable from Or- 
 ganic— Diastolic Inorganic Murmur. 
 
 21. In a former chapter, two diagnostic signs, 
 one of endocarditis — a murmur ; one of pericar- 
 ditis — a friction sound, were given. It was not said 
 said that the affections could exist without these 
 relative diagnostic signs ; but it is not probable 
 that an endocarditis ever occurs and runs its 
 course without developing and maintaioing during 
 much of its progress a bellows murmur. It is not 
 probable that the friction sound is ever absent at 
 all times during the course of a pericarditis. 
 
THEIR DIAGNOSIS AND TREATMENT. 97 
 
 a. The friction sound is less persistent' in peri- 
 carditis than murmur in endocarditis, because of 
 the early effusion of serum in the former affection 
 by which the serous surfaces are kept apart, and 
 thus friction prevented. But as no such effusion 
 takes place in inflammation of the heart's cavities^ 
 the murmur indicating it is likely to.be. persistent 
 until its termination in death, recovery, or in 
 permanent unsoundness of the heaf t without in- 
 flammation ; in the latter contingency, the 7nwr- 
 mur continues and becomes an index of ^hi^onic 
 disease of the valves. 
 
 22. But murtnurs may exist and closely sfmu- 
 late endocardial murmur, from inflammation of 
 the inside of the heart, or from valvular disease 
 and yet they may indicate neither the one nor 
 the other. Whenever there is meclianical im- 
 pediment to the circulation from valvular disease, 
 thereJ is iti almost every case a mi^rmwr audible. 
 But there are murmurs without the valvular im- 
 pediment, yet not without cause ; but this cause 
 is not always an impediment to the circulation^ 
 
 23. Take, for example, those cases in. which 
 the murmur comes and goes, as it does sometimes 
 in convalescence from rheumatic endocarditis. 
 Hejie the murmur doubtless depends on so«ie?^7 
 struction at the orifices of the heart wbiehi^, sjo 
 
 L 
 
98 DISEASES OF THE HEART : 
 
 nearly removed by the process of recovery as to 
 cause a murmur only during exertion — during 
 increased action of the heart ; while directly the 
 patient is in repose and the heart has had rest, 
 the murmur vanishes, to recur upon subsequent 
 exertion, and finally to vanish altogether when 
 the patient is well. 
 
 24. A patient has uneasiness about the heart ; 
 it is even painful. The pulse is accelerated ; the 
 impulse of the heart is increased ; the sound 
 louder ; nothing more ; or, perhaps the patient 
 says he gets fatigued sooner than formerly ; no 
 murmur is heard on auscultation, if the patient 
 have been some moments in repose ; but if he be 
 directed to swing his arms violently, or walk 
 briskly, and the ear be then applied to the pre- 
 cordia, endocardial murmurs are immediately 
 manifest, and gradually vanish, even while one 
 is listening. Now, here then is possibly the be- 
 ginning of unsoundness of the heart, and possibly 
 the murmur is the result of some alteration, of a 
 temporary character in the quality or quantity 
 of the blood relatively to the dynamic condition 
 of the heart at that particular time, or during a 
 period of one or more days. Should the murmur 
 continue, that is, become persistent, even though 
 it continue of the ^' come and go'^ character, it is 
 
THEIR DIACxNOSIS AND TREATMENT. 99 
 
 an organic murmur, simply because inorganic 
 murmurs from spaneemia, or merely dynamic 
 changes in the heart itself, are in the very nature 
 of the proposition not persistent, because their 
 cause is not persistent, neither in its existence 
 nor in its consequences. 
 
 25. There are cases in which a systolic mur- 
 mur is developed immediately before death ; and 
 in the absence of post-mortems, it is impossible to 
 say whether such murmurs are the result of in- 
 flammatory action — pericarditis — set up at that 
 moment, of coagulation of the blood near the 
 pulmonic or aortic orifices, of coagulation in the 
 mitral orifice, by which its valves are rendered 
 incompetent, of span^emia, or finally of dynamic 
 alterations in the heart itself, occurring immedi- 
 ately before dissolution ; and the inquiry for the 
 cause is unprofitable, for the patient dies, and 
 the murmur is a mere declaration that death is 
 imminent, and no longer to be warded off. 
 
 26. A murmur is easily developed in children, 
 by pressure of the ear, or of the stethoscope, 
 when there is no cause of a murmur within the 
 body, a, A murmur may occasionally be de- 
 veloped in adults in the same manner, but in such 
 case, the practised ear will easily distinguish tlie 
 false from the true murmur by its quality. /;. 
 
IQO ' -BISEASES OF THE HEART ! 
 
 Chicken- breast, though scarcely a deformity, may 
 so displace and impinge the heart as to develope 
 a murmuri Increase of area of precordial dull- 
 ness to percussion, and extensive precordial im- 
 pulse, are diagnostic signs of hypertrophy. Yet 
 both these signs occur in chicken-breast ; and if 
 to these be added a systolic murmur, we have the 
 complete signs of hypertrophy with valvular dis- 
 ease; and yet there is neither the one nor the 
 other. Iri this case the murmur is easily pro- 
 duced, if absent, by the pressure of the stetho- 
 scope'/ ' 
 
 tnuC' Tie respiratory murmur can be excluded as 
 a source of .error, by directing the patient to hold 
 his breath an instant, d, Latham says a murmur 
 4s often heard between the upper edge of the 
 'Second and the lower edge of the third left costal 
 cartilage, and an inch along and between each of 
 these ribs the murmur is systolic bellows-like, 
 unmistakable in character. At the same time it 
 is heard nowhere else in the heart, or arteries, 
 or lungs. It occurs in phthisical patients, or in 
 those who are justly suspected of being so. Whe- 
 ther this murmur proceed from tlie pulmonary 
 ^artery in its first division, in consequence of its 
 own disease, or in consequence of pressure upon it 
 from consolidated or altered lung, is unknown. 
 
THEIR DIAGNOSIS AND TREATMENT. 101 
 
 Whenever there is suspicion of tuberculosis, the 
 presence of this murmur will tend to confirm it ; 
 otherwise, it has no known value. 
 
 27. There is also the well known anemic mur- 
 mur. These murmurs may be present not only 
 in typical anemia — aglobulia — that is, defect of 
 red blood globules, but also in hemorrhagic ane- 
 mias, in typhus, in cholera, in all exhaustive 
 afi'ections, and in alm^ost every variety of span 83- 
 mia. 
 
 28. Just how depravity of the blood causes 
 murmurs in the heart, we cannot say ; but the 
 fact remains ; and so soon as we remove the blood 
 disease, the murmur disappears and returns no 
 more. The anemic murmur cannot be confounded 
 with that of unsound valves, on account of the 
 accompanying symptoms. These are overwhelm- 
 ing in number and obviousness : '* the surface Dale 
 and cold, palpitation and dyspnoea, appetite per- 
 verse, digestion imperfect, nutrition insufficient, 
 secretions scanty and unhealthy, pain every- 
 where, a shattered nervous system and an enfee- 
 bled brain." These are not symptoms of unsound 
 heart, but almost peculiar to anemia. 
 
 29. It has been considered a law, that a dias- 
 tolic murmur proceeding from the heart is always 
 an organic murmur, and that if it take the place 
 
102 DISEASES OF THE HEART : 
 
 of the second sound, it is of valvular origin — 
 semilunar — but there is reason to believe that a 
 diastolic murmur may be generated in certain 
 dynamic conditions of the heart, depending upon 
 defective innervation, through particular nerve 
 filaments, by which the function of a segment of 
 a valve might be temporarily impaired so as to 
 render the whole valve incompetent for a limited 
 period. A clot might also so entangle a valve 
 as to prevent its closure for a time, and yet 
 eventually be all washed away and carried iiito 
 the torrent of the circulation, either in complete 
 solution or as emboli, to cause obstructions in 
 remote organs. Walshe says that he has met 
 with some few instances of inconstant murmur- 
 like quality of the diastolic sound at the base, 
 which appeared to him to be possibly dependent 
 on disordered dynamism of the aortic valves. 
 *' It remains for future inquiries to determine, 
 also, whether temporary reflux, with its murmur, 
 may not be caused by dynamic imperfection, with- 
 out structural change in the valves." 
 
 30. Those haemic murmurs that characterize 
 aneurisms, or indicate pressure on arterial or 
 venous trunks, by abnormal growth, or foreign 
 bodies, either in or out of the body, are excluded 
 from consideration in this estimate of inorganic 
 murmurs. 
 
THEIR DIAGNOSIS AND TREATMENT. 103 
 
 There is little doubt that one accustomed to 
 auscultation of the heart would distinguish an 
 inorganic from an organic murmur, in almost 
 every case, by the mere quality, pitch, tone, 
 streno;th and duration of the murmur alone. 
 
 CHAPTER VII. 
 
 Pericarditis and Endocarditis. Endo-pericarditis — 
 Carditis. 
 
 31. By inflammation of the heart's membranes, 
 is understood something altogether different from 
 " disease of the heart.'' The latter phrase is 
 vulgarized in and out of the profession so as to 
 mean the concrete condition of the heart in a 
 state of chronic, not acute, unsoundness. Inflam- 
 mation of the heart's membranes is a phrase the 
 import of which would be understood by the pro- 
 fession, and the use of which is limited to the pro- 
 fession. It is divided into two varieties, one per- 
 taining to the inside — endocarditis — the other to 
 the outside of the heart — pericarditis. These 
 two affections originate in similar though not con- 
 tinuous membranes ; the one, endocarditis, attacks 
 the lining membrane of the heart's cavities ; the 
 other, pericarditis, attacks their investing mem- 
 brane — the sack in which the heart is enveloped. 
 
104 DISEASES OF THE HEART : 
 
 a. Omitting details of gTeat interest, but not ab- 
 solutely necessary to accurate diagnosis, these 
 diseases are distinguished by signs so exclusively 
 characteristic, that if the heart's membranes are 
 inflamed at all, it can generally be made out 
 whether the affection is one or both of the varie- 
 ties mentioned. 
 
 h. The characteristic sign of endocarditis is 
 an endocardial murmur^ systolic in time, occur- 
 ring suddenly in a person with fever or acute 
 rheumatism, in whom it had never occurred be- 
 fore. One can never be absolutely certain of the 
 endocardial inflammation, until the bellows mur- 
 mur is heard, no matter how great the pain in 
 the heart, how gred-t the palpitation, how irreg- 
 ular, or intermittent or unequal the pulse, or how 
 hot and livid the skin. Treatment of course 
 should not be postponed until the murmur be 
 heard, neither can it be positively said there is 
 no endocarditis before the murmur is heard ; but, 
 on the contrary, it may be reasonably suspected 
 without the murmur; but not positively made 
 out. c. The murmur is essential to the positive 
 diagnosis, (Latham.) 
 
 c/. The murmur occurring for the first time, 
 during the presence of constitutional inflamma- 
 tory symptoms, determines that the general in- 
 flammation has touched the endocardium. 
 
THEIR DIAGNOSIS AND TREATMENT. 105 
 
 e. The seat of the greatest intensity of the 
 murmur determines — in limits — the chief seat of 
 the inflammatory process. The murmur is usually 
 heard loudest at those parts of the thoracic walls 
 which are nearest that portion of the heart from 
 which the murmur originates. A systolic mur- 
 .mur may be heard over the right or left ventricle, 
 or over the aorta alone, or over the pulmonary 
 artery, or over two or more of these parts at the 
 same time. 
 
 /. The sounds may be normal, or louder, or 
 duller, or more indistinct, or shorter than natural, 
 and at times they may be almost inaudible, from 
 the weakness or temporary restraint of the hearths 
 contractions ; or, in consequence of great ejffusion 
 in the sac of the pericardium, when that mem- 
 brane is also affected. 
 
 g. The valves are sometimes rendered incom- 
 petent for a few hours or days only, and during 
 this time a murmur of regurgitation — mitral — 
 may be heard at left apex, or a diastolic murmur 
 may be heard over the third left cartilage, and 
 thence down the sternum from incompetency of 
 the aortic valves. 
 
 32. If the pulmonic valves should become in- 
 competent, (a thing which scarcely ever occurs,) 
 a diastolic murmur would be heard, loudest in 
 second (pulmonic) interspace, and thence directly 
 
 M 
 
106 DISEASES OF THE HEART : 
 
 upwards. The aortic diastolic murmur is not in- 
 frequent after the first few days of endocarditis. 
 33. Pericarditis is not known to be an idio- 
 pathic disease. It is chiefly the result of acute 
 rheumatism ; rarely of Bright's disease of the 
 kidneys. It may attend or directly follow ^ny 
 of the exhaustive diseases — as typhoid fever, 
 variola, scarlatina, diphtheria, pyaemia frequently, 
 (one in seven cases of pyaemia have pericarditis, 
 but pysemia itself is very rare) ; it is sometimes 
 associated with pleuritis, or pleuro-pneumonia, 
 but has no known dependency on the?e lesions ; 
 with albuminuria from any cause — wherever there 
 is albuminuria, the heart should be watched for 
 endo-pericarditis. I have seen it with scurvy in 
 three instances in the late civil war ; with influ- 
 enza, erysipelas and consumption; hepatic abscess 
 of left lobe — a case observed by the author at Fort 
 Yuma in 1861, verified by post-mortem examina- 
 tion — very rarely with cancerous and tuberculous 
 diatheses. Of course it may be produced by any 
 direct injury to the pericardium, as wounds, 
 blows, fractured ribs. etc. 
 
 It is more likely to follow or attend rheu- 
 matism in youths than in adults ; in females than 
 in males ; hence it is more frequent in these 
 classes of persons than in adult males. Soldiers 
 are more liable to scurvy than civilians, hence 
 
THEIR DIAGNOSIS AND TREATMENT. 107 
 
 they are more liable to pericarditis and endo- 
 pericarditis from this cause. 
 
 a. Its moir't obvious "^jmi^tom is the anxious and 
 drawn expression of the features, and the abso- 
 lute immobility of the patient, as to voluntary 
 muscular motions ; but this symptom is not al- 
 ways present, and when present is also a sign of 
 pleuritis. 
 
 6. The characteristic, the diagnostic audible 
 sign is a friction murmur, or rather a friction 
 sound. If one attempts to describe the abnormal 
 murmur he hears in pericarditis, it will be by 
 some similie into which enters the friction of two 
 surfaces of a greater or less degree of moisture, 
 or dryness, or roughness. It would never occur 
 to imitate the friction sound of pericarditis by 
 modifications of the respiratory act, while it 
 would never occur to imitate the '* bellows mur. 
 mur'^ — '' bruit de souffle f murmur of endocarditis 
 in any other manner except one called in the aid 
 of external atmospheric murmurs. 
 
 The friction sound may be loud or low-toned, 
 sharp or dull, single or double, but it always sug- 
 gests the idea of attrition, and never that of 
 expiration or inspiration, or blowing ; and so the 
 contrary. 
 
 b. The chief local symptom of pericarditis is 
 
108 DISEASES OF THE HEART. 
 
 pain (Walshe) ; but the same author says that in 
 the majority of cases pain is either absent or of 
 slight severity. 
 
 c. The pericardium is peculiarly insensible 
 when inflamed, in Bright s disease, and patients 
 often persist' in denying the existence of symp- 
 toms referable to the heart ; but in these cases 
 pressure with the flat hand over the heart will 
 cause a degree of uneasiness which is intolerable, 
 although it may not be precisely pain ; and this 
 insensibility is not confined to pericarditis in 
 Bright's disease, but occurs especially in asthenic 
 pericarditis. Hence the ** chief local symptom'^ 
 (pain) avails little in diagnosis, much less than im- 
 mobility and lying on tlie back, the anxious look, 
 attendant rheumatism and inflammatory febrile 
 pulse. 
 
 d. The distinction between endocardial mur- 
 mur and exocardial friction is occasionally im- 
 possible. (Walshe.) 
 
 e. There may or may not be bulging of the 
 precordia from pericardial efi'usion. There may 
 or may not be friction — fremitus — appreciable to 
 palpation. The heart's impulse is generally 
 greater in extent but not in force, and may even 
 be much weaker than natural. 
 
 h. Pericardial effusion may develope apparently 
 endocardial systolic murmurs, by pressure on the 
 
THEIll DIAGNOSIS AND TREATMENT. 109 
 
 roots of the great vessels, thus leading to the 
 suspicion of endocarditis, when the endocardium, 
 valves and vessels may be entirely healthy. 
 
 34. It is believed, also, that pleuritic effu- 
 sions, in very rare instances, so contort the ves- 
 sels at their orifices as to produce incompetency 
 of valves, thus causing diastolic murmurs heard 
 even at the apex and down the sternum, the pecu- 
 liar seats of orgastic regurgitant murmurs, 
 
 35. I recently saw, for a few moments, during 
 my first and only visit, a case of pericarditis^ 
 remarkable for the rapidity of its progress and 
 for its fatal termination. When I saw the 
 patient, he was suffering with frightful dyspnoea, 
 which was supposed by his attendants to be 
 ** asthma, aggravated by wind on the stomach" — 
 [There was epigastric fullness, which is not un- 
 common in pericarditis, second stage] — for 
 which they were administering stimulants and 
 nauseants, in bulky doses, to cause emesis ; the 
 patient was held, sitting upright, although he 
 desired to lie down ; his skin was livid and 
 bathed in viscid perspiration ; his pulse was 
 exceedingly rapid, small, irregular, intermittent, 
 unequal ; his extremities cold ; his voice reduced 
 to a whisper ; deglutination, even of fluids, diffi- 
 cult. Percussion of the precordia was impracti- 
 cable, but during the instant I listened at the 
 
110 DISEASES OF THE HEART: 
 
 heart, I heard a dull, wet* second sound, (no first 
 sound,) and a faint murmur, systolic in time — no 
 friction sound. My diagnosis, to my own mind, 
 was rapid but not exhaustive : pericarditis, with 
 either very considerable effusion, incompetent 
 mitral valves, or fatty heart with incompetent 
 mitral valves. The fatty heart was rendered 
 doubtful, by the persistence of the pulse, which 
 in the last hours of this affliction is generally 
 absent, or answers to the systoles perhaps ten or 
 twenty times only in a hundred. The absent 
 first sound was as accountable on the supposition 
 of effusion, as of softened heart ; t hence, on the 
 pulse alone, I excluded the latter. I had the 
 melancholy good fortune to assist at the j)ost 
 mortem^ some forty-eight hours later. The left 
 ventricle was generally dilated ; the mitral valves 
 were incompetent from analogous deposits ; the 
 beginning of the aorta was atheromatous ; there 
 were some patches of lymph on the vir-ceral du-* 
 plicature of pericardium, and very considerable 
 serous effusion ; amount not measured, but sup- 
 posed to reach eight ounces. The proper tissue 
 of the heart was softer than natural — not ex- 
 amined microscopically. 
 
 * A sound like that of striking a table with a wet 
 napkin. 
 
 f See Appendix F. 
 
THEIR DIAGNOSIS AND TREATMENT. Ill 
 
 The duration of this case might have been 
 indefinitely prolonged, had the serious damage 
 to the heart been recognized at the beginning 
 instead of the end of the last week of life. A 
 recumbent position, aconite and veratrum viride 
 in minute and alternate doses, saline evacuants, "^ 
 saline diuretics, leGches and cups at the precordia, 
 sinapisms to the knees, ankles and elbows, sus- 
 pension of food, except beef juice in small quan- 
 tity, no stimulants, properly so called, except on 
 the special indication of failing pulse and threa- 
 tened syncope ; then, brandy, or ammonia and 
 lavender. With this treatment from the begin- 
 ning, it is probable that the pericarditis would 
 have terminated in complete recovery ; the mitral 
 disease being slight, would have been harmless 
 for the time ; the fatty degeneration, if certainly 
 present, which was not proved, would not neces- 
 sarily have caused death so soon. 
 
 36. There seems to be great discrepancy in 
 authors, Latham and Skoda, for example, con- 
 cerning the distinctive characters oi friction sound 
 (exocardial) and bellows murmur (endocardial). 
 
 37. To my mind it is clear that a sound whose 
 similie is friction must in the natu re of the propo- 
 sition be dissimilar from one whose similie is 
 
 Bee Appendix G. 
 
112 DISEASES OF THE HEART! 
 
 murmur ; and this is the precise actual difference 
 between the two murmurs. They are recognized 
 by distinct names, friction murmur and bellows 
 murmur^ all through the literature of diseases of 
 the heart, from Corvisart to Walshe. 
 
 38. Walshe and others say, the murmur, 
 when there is doubt of its extra.- or intra-cardiac 
 origin, may be identified as exocardial, by being 
 more superficial and more diffused than endocar- 
 dial murmurs, Skoda says flatly that in his 
 opinion they cannot be so distinguished. Boillaud 
 experienced great difficulty in discriminating 
 attrition and valvular murmurs. 
 
 39. Hope makes the distinction by no means 
 difficult. The existence of the two classes of 
 murmurs is indubitable, as all writers on the 
 heart, since Collin, in 1824, distinguish them as 
 being referable ; the valvular murmurs to the 
 endocardium ; the attrition murmurs to the exo- 
 cardium. 
 
 40. Skoda recognizes the existence of the two 
 classes of murmurs. After acknowledging the 
 new-leather attrition sound, which is very rare, the 
 rustling and rubbing sound (frequent), the scratch- 
 ing sound, from bony, chalky, or fibro-cartilagi- 
 nous concretions, rubbing against each other, or 
 some part of the pericardium during the heart's 
 movements, he says : " There is no doubt that all 
 
THEIR DIAGNOSIS AND TREATMENT. 113 
 
 these different friction sounds of the pericardium 
 have a real existence. -se- ^ ^ * ^ 
 According to my own experience, there is no kind 
 of endocardial murmur, with the exception of the 
 whistling, which may not be imitated by a fric- 
 tion sound of the pericardium ; and no pericardial 
 murmur which may not resemble an endocardial 
 murmur.^' 
 
 41. Hope and Markuam believe the distinction 
 of the murmur from the friction not difficult ; the 
 former did not find it difficult to discriminate 
 between attrition sounds and murmurs, '' even 
 when the two classes of sounds existed simulta- 
 neously and each was double.'^ The former dis- 
 criminates by listening for the murmurs of the 
 semi-lunar valves two or more inches up the aorta 
 or pulmonary artery, where attrition murmurs are 
 generally inaudible ; and by listening to the 
 murmurs of the auriculo-ventricular valves, a 
 little above the apex of the heart, where they are 
 sure to be loudest, whereas, attrition murmurs 
 may be louder at other parts of the heart where 
 they happen to be generated. 
 
 42. He further distinguishes them by the fol- 
 lowing peculiarities : 
 
 a. Attrition murmurs have usually a much 
 
 N 
 
114 DISEASES OF THE HEART : 
 
 rougher quality of sound than the valvular mur- 
 mur, so that when the two co-exist, the one may 
 be hoard through the other. 
 
 b. When a murmur with the second sound is 
 rough, as rasping, creaking, croaking, etc., it is 
 certainly from attrition. 
 
 43. Second sound valvular murmurs — diastolic 
 murmurs — are never rough, as the diastolic cur- 
 rents are in the nature of the forces causing them, 
 too feeble to produce rough murmurs. A diastolic 
 mitral murmur is faintly audible; a diastolic aortic 
 murmur is louder, but still smooth. Diastolic 
 pulmonic murmurs almost never occur.. Systolic 
 tricuspid murmur is known by its smooth blow- 
 ing quality, and by the attending jugular pulse. 
 
 44. '' Attrition murmurs are almost always 
 attended by vibratory tremor." This " tremor" 
 I have never been able to verify, even where 
 pericarditis was undoubted before and verified 
 after death. 
 
 45. Markham says : '* a fremitus is said to be 
 sometimes felt over the precordial region when the 
 hand is laid thereon." Skoda places no reliance 
 upon this sign. On the contrary, Latham relied 
 greatly upon it as a distinctive sign. He has 
 often seen an undulatory motion between the 
 cartilages of the second and third ribs, or be- 
 
THEIR DIAGNOSIS AND TREATMENT. 115 
 
 tween cartilages of third and fourth ribs, left 
 side, during the dull percussion and exocardial 
 murmur period of pericarditis. He also often 
 felt vibratory motion in the same interspaces, 
 second and third, and nowhei'e else. The undu- 
 latory motion and vibratory motion often oc- 
 curred simultaneously, but he thought the vibra- 
 tion the more frequent. They were sometimes 
 present between the cartilages of second and 
 third, and third and fourth left ribs, simultane- 
 ously — tactile fremitus, 
 
 46. Walshe says it is rarer and more migra- 
 tory and superficial to the touch than valvular 
 thrill, distinguished from pleural fremitus by 
 causing the patient to hold his breath ; not im- 
 plicitly reliable, because its mechanism is un- 
 known, and it may arise from causes external to 
 the pericardium, and be present during suspen- 
 sion of the breath. But, if present with the exo- 
 cardial friction, it is a valuable aid in the diag- 
 nosis. 
 
 47. Stokes says, attrition murmurs are apt to 
 undergo frequent and sudden changes of char- 
 acter and of situation which are very pathogno- 
 monic, because valvular murmurs change little in 
 character, and not at all in situation. 
 
 48. This last, though agreeing with Walshe, 
 
116 DISEASES OP THE HEART: 
 
 Hope and others, is very discrepant with La- 
 tham, who never observed the fremitus, except 
 in the second and third left cartilage interspaces. 
 Can it be possible so careful an observer as 
 Latham mistook a pulmonic valvular thrill for a 
 pericardial /remito ? 
 
 49. Finally, concerning the murmurs. It is 
 probable they are distinguishable by most ob- 
 servers — the attrition from the valvular — or that 
 the cases in which they are undistinguishable are 
 exceedingly rare, or that there are cases in which 
 both classes of sounds occur, each being modified 
 by the other, so that each becomes unrecognizable 
 for a longer or shorter period ; but patient and 
 repeated observation would in the end discrimi- 
 nate in almost every case between an attrition 
 and valvular murmur. 
 
 50. But it is of no vital importance whether 
 the distinctive diagnosis be made at all, for the 
 two diseases are essentially similar in immediate 
 effects, and in indications of treatment ; and the 
 indications of treatment are by far of greater 
 importance than any theoretical considerations of 
 the distinctive characters of the two diseases. 
 
 51. Pericarditis is a much less frequent disease 
 in warm than in cold climates, other things equal. 
 
THEIR DIAGNOSIS AND TREATMENT. 117 
 
 It is by no means so frequent in San Francisco as 
 in Edinburgh or London. 
 
 52'. In more than a hundred cases of rheuma- 
 tism treated by me in Arizona and Southern 
 California during the years 1862 and 1863, I saw 
 but one in which I was able to verify that the 
 inflammation had afiected the heart ; yet in every 
 case I sought diligently and frequently the symp- 
 toms of rheumatic carditis. 
 
 The following is from my notes of this case 
 taken in the field. 
 
 Case of Acute Endocarditis^ apparently idio- 
 pathic^ with Emboli. — Argo, a soldier, aged 25, 
 tall, fair-haired, muscular, came on the sick list 
 for a cough. Ordered brown mixture — he did 
 not seem much sick. 
 
 Second day. Argo breathed short; •had fever 
 in the evening. Ordered saline purge and qui- 
 nine, five grains with half a grain of opium, when 
 his fever should go ojQf; continue cough mixture. 
 He had no crepitation in chest ; some few rather 
 coarse rales ; no pain in the chest, but coughed 
 severely at times ; little or no expectoration : 
 respiration 45 ; pulse 110, feeble, small. 
 
 Third day. A. has an anxious look face cada- 
 veric and perspiring ; appearance of great agony, 
 
118 DISEASES OF THE HEART : 
 
 but he is able to walk ; his respiratien 45 ; pulse 
 90, very weak and small ; nails, ears, lips, etc., 
 livid ; says he has no pain, but feels " tight here," 
 placing his hand on the sternum, at its junction 
 with fourth and fifth ribs. 
 
 Auscultation revealed no abnormal sounds in 
 either of the lungs ; over some portions of the 
 lung respiration scarcely audible, and in other 
 small portions, no air entered. 
 
 The hearths impulse, at the fifth space to the 
 right of left nipple, very feeble ; sounds are ex- 
 ceedingly weak. There was something indetermi- 
 nable and undefinable about the quality of the 
 stytole, and this with the tightness over the base 
 of the heart, made me uneasy about the result. 
 Ordered cups and sinapisms over the precordia, 
 syrup of ijenega for the cough, and beef tea for 
 diet. At four a. m. he died, without any of the 
 nurses in his ward observing him until he was 
 quite dead. They heard a very " wheezy breath- 
 ing" a few moments before he was found dead. 
 
 Post-mortem at nine a. m. same day. On open- 
 ing thorax, anterior aspect of lungs appeared 
 natural ; no adhesions of either lung ; no tuber- 
 cles. On lifting out lungs, lower lobes of both 
 were found congested posteriorly, and very dark, 
 
THEIR DIAGNOSIS AND TREATMENT. 119 
 
 with fluid blood ; upper lobe of right lung con- 
 gested posteriorly. 
 
 Size of heart and external aspect normal ; no 
 effusion in pericardium ; no lymph patches, no 
 white spots, nor congested coronary vessels. On 
 removing and washing heart, in both right and 
 left ventricles were found pale clots, like strips 
 of washed muscle wound and interlaced with 
 fleshy columns and tendinous cords, and under 
 the valves. The right auricle was completely 
 plugged with a semi-organized looking clot, 
 which I peeled out from its matrix, as a false 
 membrane peels out from the sinuosities of the 
 fauces. These clots, after being removed and 
 thoroughly washed of all their soluble portions, 
 weighed ninety grains. The endocardium pre. 
 sented numerous signs of inflammation, especially 
 about the auricles and valves ; left auricle con- 
 tained no clot ; valves were competent, and no 
 orifice was appreciably constricted. These clots 
 must have been formed before death, which evi- 
 dently occurred the moment the right auricle 
 became so filled with the clot that no more blood 
 could enter and pass through it from the vencs 
 cavce. 
 
 The man lived four days after he first com- 
 plained of '* tightness in the chest." At the time 
 
120 DISEASES OP THE HEART : 
 
 of this occurrence, there were many cases of 
 rheumatism in camp, which was attributed to 
 sleeping on the green salt grass, with only 
 one blanket. I do not think this was a case 
 of simple embolism from the accidental de* 
 velopment of the coagijjlatlng principle ^ of the 
 blood, and I am sure it did not result from fatty 
 degeneration of the heart, by which it was ren- 
 dered incapable of emptying its cavities, for the 
 heart's substance was firm, and normally free 
 from fat. 
 
 54. During the last four years, I have seen 
 several cases of pain and uneasiness about 
 the heart during the course of acute rheumatism. 
 In one there was great anxiety of expression, 
 and extremely small and feeble pulse, which 
 made me fear carditis and the formation of em- 
 boli, I gave in this case whiskey and water, 
 alternated with fluid extract of digitalis, in minute 
 doses, every hour, without interrupting the usual 
 rheumatic treatment with propylamin and lau- 
 danum. The patient recovered. 
 
 55. The treatment of pericarditis and endo- 
 carditis, or the two conjoined, is essentially the 
 same. 
 
 * On Embolism, see Appendix H. 
 
THEIR DIAGNOSIS AND TREATMENT. 121 
 
 56. The diet must be diminished in quantity 
 a'nd in blood-making quality, if the disease, as 
 most frequently happens is of acute rheumatic 
 origin — in othei; words, if it is sthenic in quality. 
 
 57. Blood may be taken (if the patient be full- 
 blooded, or in good blood-making condition,) 
 from the arm, to the extent of a pound, early in 
 the attack, the earlier the better, and this may 
 be followed by five, ten or twenty leeches (ac- 
 cording to the violence of the attack and condi- 
 tion of particular case,) to the precordia, and 
 these may be followed by compresses, wrung out of 
 hot water, laid over the leech bites, not merely 
 to promote the flow of blood, but to alleviate the' 
 precordial anxiety and tightness of the chest, 
 which will be thus accomplished in a surprising- 
 manner. 
 
 58. The dose of propylamin, providing we are* 
 treating the rheumatism with propylamin, may 
 be quadrupled immediately. 
 
 59. If the heart beats more than 90, and espe- 
 cially if its beats are not rhythmical, half a drop 
 of fluid extract of digitalis and five drops of 
 McMunn's elixir of opium may be given every 
 hour, until pulse falls to 75, and increases in size 
 and regularity. Syncope must be guarded against 
 instantly and hourly. 
 
 
 
122 DISEASES OP THE HEART. 
 
 60. It will rarely be found necessary to bleed 
 at the arm at all. 
 
 61. Leeches, scarifications and cups to pre- 
 cordia, sinapisms and friction to the joints, a 
 blister around each knee or elbow joint, with a 
 brisk and certain purge, (calomel fifteen or twenty 
 grains at one dose, is the best,) followed by saline 
 diuretics, combined with minute doses of tartrate 
 of antimony and posassa, (say tlie thirty-second 
 part of a grain hourly,) hot bottles to the loins 
 and feet. Some or all of tliese means, or others on 
 the same principles, will, in most cases, be found 
 quite sufiBcient to mitigate the attack, and con- 
 duct the disease to its usual result, namely, 
 termination in recovery. 
 
 62. It is very rare that rheumatic pericarditis 
 or endocarditis treated rationally, or let alone, 
 terminates fatally ; but it is altogether probable 
 that the worst consequences — chronic unsound- 
 ness of the valves from endocarditis, or pericar- 
 dial adhesions from pericarditis, maybe prevented 
 altogether, or greatly modified by rational treat- 
 ment. 
 
 63. In the nature of the case, this theoretical 
 probability can never bo demonstrated ; for, if 
 some time after, a case of marked endo-pericar- 
 ditis, treated rationally, and apparently entirely 
 cured, should die of some other aifeciion, and the 
 
THEIR DIAGNOSIS AND TREATMENT. 123 
 
 heart should be found intact, it would not follow 
 that the treatment had saved it ; and were it found 
 chronically diseased, it would not follow that the 
 treatment had been defective, excessive or erro- 
 neous. 
 
 64. But, if a patient of mine should die appa- 
 rently of rheumatic pericarditis, I should doubt 
 my diagnosis, or be dissatisfied with the energy 
 or rationality of my treatment. Not so with the 
 asthenic forms of pericarditis ; these are much 
 more likely in their own nature to be fatal from 
 the beginning. 
 
 65. In asthenic rheumatism, no matter from 
 what source the asthenia springs, pericarditis 
 should not be treated antiphlogistically. Car- 
 bonate of potash and of ammonia internally, 
 counter-irritation, good nourishment and mode- 
 rate doses of wine or brandy, form the staple 
 agents of treatment. (Walshe.) 
 
 66. I would caution, in the use of alcoholic 
 stimulation, to watch its effects constantly. The 
 pulse should not be carried above 85 ; on the 
 other hand, it should not be allowed to fall below 
 70. It can be maintained in these limits gene- 
 rally, (except when the pericarditis accompanies 
 renal degeneration,) with small doses of digitalis 
 and laudanum. 
 
124 DISEASES OF THE HEART : 
 
 67. Alkalies — bicarbonate, of potash, liquor 
 potassse, are tlieoretically if not practically 
 worthy of trial in very large doses in the fibrin- 
 ous diathesis, especially if there be any suspicion 
 of emboli in the heart or arteries. I need not 
 say these remedies are to be largely diluted. 
 
 68. If a stimulant is required, carbonate of 
 ammonia, or aromatic spirits of ammonia and 
 tincture of lavender ^ may be given in conjunc- 
 tion with the alkalies (69). 
 
 69. The enormous doses of brandy, a pint or 
 more a day, recommended by Todd and Bowman, 
 are repugnant to theory and prohibited by un- 
 prejudiced clinical experience, a. Can any one 
 doubt that intoxication induces venous congestion 
 of the corronary veins, as of others ? 
 
 Can any one doubt that congestion of the heart 
 and lungs increases the labor of the heart (al- 
 ready requiring alleviation,) and thus diminishes 
 its dynamism ? Is it supposed that impaired 
 dynamism of the heart is conducive to the restor- 
 ation of its inflamed serous envelope ? 
 
 70. It cannot be denied that brandy diminishes 
 the coagulability of the blood, and thus would tend 
 to prevent the formation of intra-ventricular clot 
 
 * Sp. ammon. aromat. dr. i ; sp. la vend. comp. dr. vij. M. 
 Sig. Dose a teaspoonful as olten as required, in water. 
 
THEIR DIAGNOSIS AND TREATMENT. 125 
 
 in endocarditis ; but so does chloroform diminish 
 or prevent coagulability ; so does electricity and 
 many poisons, but we cannot deduce from this 
 one fact, their therapeutic utility. 
 
 71 . We know that alcohol given in large doses 
 to sthenic or plethoric patients increases their 
 fever, adds to their irritability, congests the 
 liver, impairs pulmonic funqtions, diminishes the 
 action of the skin, and does not always act on 
 the kidneys ; that it impairs appetite and assimi- 
 lation ; that it is unquestionably objectionable 
 in Bright^s disease, even in not very large doses. 
 
 72. I do not object to brandy in any disease, 
 but I cannot help thinking that it ought to be 
 used in much smaller quantities in acute affections 
 than recommended by the distinguished authors 
 just mentioned. 
 
 73. Patients with any form of organic affec- 
 tion of the heart bear brandy very indifferently, 
 and generally object to it very strongly, from a 
 firm conviction that it makes them worse. Be- 
 sides, in organic affections of the heart, acute 
 or chronic, the liver is rarely exempt, and all 
 drinkers know the antipathy of this organ, 
 whenever so little disturbed, to large doses of 
 brandy or whiskey. Soda-water suits it much 
 better. 
 
126 DISEASES OF THE HEART : 
 
 74. It seems to me. the general experience of 
 mankind should be somewhat regarded in refer- 
 ence to the commonest articles of daily use, and 
 this general experience is opposed to excessive 
 employment of the hydro-carbons in acute and 
 inflammatory diseases. 
 
 75. Recapitulation. — a. The treatment of peri- 
 carditis and endocarditis is nearly the same. h. 
 The latter is more injurious in its consequences, 
 and hence requires more care in treatment, c. 
 There are two forms : the sthenic and asthenic 
 of both lesions . d. The sthenic is treated anti- 
 phlofristically^ in the rational sense, by which 
 neither salivation nor exhaustive depletion is 
 understood ; that is, it is treated with aperients, 
 watery diuretics, alkalies, digitalis, opium, propy- 
 lamin, counter-irritation, heat locally applied) 
 local depletion, general depletion to relieve a 
 pressing need, but not to arrest inflammation, etc. 
 e. The asthenic is treated on general principles, 
 specially applied. /. Haematogens — beef-juice, 
 egg-nogg, vegetable alkaloids, bromide of potas- 
 sium, perhaps cod-liver oil — counter-irritation 
 and frictions, dry cups to the precordia, arterial 
 and nerve stimulants, nutritious diet. 
 
 Mr. Ure (Braithwaite's Retrospect, vol. 1, p. 
 846,) proposes the use of sulphate of manganese^ 
 
THEIR DIAGNOSIS AND TREATMENT. 127 
 
 not omitting but supplementing the alkaline 
 treatment of rheumatism, to prevent it attacking 
 the heart. 
 
 M. Gemlin ascertained that this remedy aug- 
 ments remarkably the secretion of bile, and it has 
 often been noticed that when uric acid increases* 
 bile decreases, and visa versa,. Hence, if we in- 
 crease the bile, we diminish the rheumatism. 
 Mr. Ure recommends a drachm of this sulphate 
 to be dissolved in half a pint of water, and swal- 
 lowed before breakfast. It will be followed by 
 one or more motions, of biliary description. 
 
 /. This remedy is worthy of trial on theoretical 
 grounds, especially as it is harmless. 
 
 g. Nitrate of potash has been much recom- 
 mended, on account of its property of dissolving 
 fibrin. 
 
 h. It may be given because it is an alkali, to 
 prevent the tendency of the blood to become acid, 
 and also as a solvent of fibrin, to prevent the 
 precipitation of this material on the valves of 
 the heart and other portions of the endocardium. 
 It is probable that the fibrinous matter found on 
 the valves of the heart is produced both from 
 inflammation of the lining membrane and from 
 precipitation, when it is in excess in the blood, 
 and when, the circulation is very much impeded 
 
128 DISEASES OF THE HEART :'• 
 
 or very much slowed, even for a moment, from- 
 any accidental cause. I am aware that stasis 
 alone will not induce coagulation, but it is not 
 denied that coagulation is thus hastened, under 
 favorable conditions. ^ 
 
 i. Opium is often needed in enormous doses, 
 to produce any sensible effect. 
 
 j. As a diuretic in pericarditis in Bright's dis- 
 ease, I should expect great benefit from gallic 
 acid, in from thirty to sixty grains at a dose in 
 as- much- water as the patient could conveniently 
 drink, four or five times a day. The hot-air or 
 vapor-bath is especially recommended as a sudo- 
 rific in this variety of pericarditis, because it can 
 be' administered in bed, without disturbing the 
 patient and without raising the head, which often 
 causes great prostration. 
 
 k. Purgatives are to be employed with great 
 caution, in either the sthenic or asthenic forms,' 
 but especially in the latter. Suphate of mag^" 
 nesia should not be employed. 
 
 76. The chronic forms of these lesions are to 
 be treated on general principles, it being under- 
 stood that they can be alleviated, but not cured. 
 
 W. For example, if life is in imminent jeopardy' 
 
 * See Appendix H. 
 
THEIR DIAGNOSIS AND TREATMENT. 129 
 
 by the accumulation of fluid in the pericardium, 
 there can be no question of the propriety of tap- 
 ping near the base of the heart, upper angle of 
 fourth left interspace, and re-injecting a small 
 quantity, of equal parts, tincture of iodine and 
 distilled water, at the temperature of the blood, 
 before removing the canula of the trocar. Iodine 
 injections are recommended by Aran. This 
 iodine liquid has been proved harmless to serous 
 membranes in numberless examples. 
 
 a. Seton at the praecordia, mercurial inunction, 
 iodine ointment, or dilute tincture of iodine are 
 seemingly beneficial. 
 
 78. Blisters applied near the praecordia might 
 promote absorption. 
 
 79. A dry nutritiojis diet and diuretics are 
 recommended, with great reason. Iodide of 
 potassium taken internally could not retard 
 absorption of lymph and serum, and by many is 
 supposed to materially aid this process. But I 
 have never observed such a result either in this 
 or allied effusions. 
 
 80. Here passive exercise in the open air, and 
 even sea voyages may be advised, with prospect 
 of alleviation and arrest of the slow inflamma- 
 tory process. The trial of alkaline springs should 
 be made, if possible. 
 
130 DISEASES OF THE HEART : 
 
 a. It should be borne in mind that the prognosis 
 as to fatality is more serious in pericarditis than 
 in endocarditis. The latter is rarely fatal, whereas 
 the former terminates in death with sufficient 
 frequency to have induced M. Louis to estimate 
 the deaths from this cause at one in six of the 
 cases attacked. Walshe had seen only seven or 
 eight fatal cases of fatal rheumatic pericarditis. 
 Death rarely occurs in pericarditis *' before the 
 tenth or twelfth day." It may occur, however, 
 within thirty-six hours, or be postponed some 
 weeks. 
 
 h. We have also chronic forms of both these 
 affections, but from what has been already said 
 of the acute forms. and of valvular diseases, the 
 treatment of chronic endocarditis is obvious, and 
 that of pericarditis requires but mere mention. 
 The hypertrophy and dilatation of the left ven- 
 tricle attending chronic pericarditis are less 
 serious than when these affections are the result 
 of valvular disease ; the treatment of these con- 
 ditions of the heart will be considered in a sub- 
 sequent chapter. As for the rest, the treatment 
 is to be directed to the absorption of the effused 
 fluid, and to fortifying and controling the action 
 of the heart. It is doubtful whether local appli- 
 cations to the prjBcordia will be of much benefit, 
 except for the modification of reflex symptoms ; 
 
THEIR DIAGNOSIS AND TREATMENT. 131 
 
 but most of the discutient class of unguents, 
 tinctures and liniments, as well as blisters, setons, 
 cauteries, etc. are still recommended as of possi- 
 ble utility. In chronic pericarditic effusion, 
 paracentesis of the pericardium, as already sug- 
 gested, is unobjectionable, after a reasonable 
 trial of other remedies. ♦ 
 
 c. Acute and chronic endo-pericarditis can be ap- 
 preciated and treated by the principles already 
 suggested. 
 
 d. Acute carditis is not susceptible of diagnosis 
 in the present state of knowledge; that it has a 
 real existence is well proven by post mortem ob- 
 servation, but it has no known clinical signs by 
 which it can be discriminated from endo-pericar- 
 ditis. Hence, it is obvious its separate treat- 
 ment it not a subject of rational consideration. 
 Fortunately it is a rare affection. Similar re- 
 marks are applicable to the chronic form of 
 carditis, 
 
 e. Hemorrhage within the proper substance of 
 the heart does occur, but we have no diagnostic 
 symptoms. So effusion of the blood into the 
 pericardium — hcemo-pericardium — and under the 
 endocardium — hcemo-endocardium — are without 
 diagnostic symptoms of any value. (Edema of 
 
132 DISEASES OF THE HEART : 
 
 the heart exists, but cannot be diagnosticated in 
 the present state of knowledge. 
 
 /. Hydro-pericardium is recognizable, if the 
 dropsy be considerable by the pyramidal outline 
 of pragcordial dullness, the same as in the effu- 
 sion stage of ])iricarditis. (The apex of the dull- 
 ness being aBove its natural point, and rising to 
 the second or perhaps to the first cartilage, Avhile 
 the base does not fall proportionally, indeed not 
 at all, but remains at the lower margin of the 
 sixth rib.) The visible impulse is undulatory, 
 unless the effusion be slight. A sensation of op- 
 pression at the praecordia is often though not 
 always felt ; the pulse is not affected. The dropsy 
 must depend on some altered condition of the 
 blood, conjoined with some other organic lesion ; 
 hence the general symptoms will be those of the 
 subjacent affection, and the treatment will be the 
 same as that of other dropsies, though diuretics 
 and cathartics will be found less efficient. Dry 
 cupping, blisters and electricity, one or the other, 
 may be applied at or near the praecordia with 
 considerable hope of benefit. 
 
 g, Paracentisis, and subsequent iodinized in- 
 3ections, so as to excite adhesion of the pericardial 
 surfaces, may be found advisable under particular 
 circumstances ; but the principal hope of cure 
 
THEIR DIAGNOSIS AND TREATMENT. 133 
 
 lies in the alleviation or removal of the disease 
 on which this effusion depends. 
 
 h. The diagnosis and treatment of cases in which 
 air or gasses find ingress to the heart's cavities 
 or beneath its membranes cannot be rationally 
 considered, and hence the treatment must be sug- 
 gested by the special indications, in any suspected 
 case. 
 
 i. Cardiac atrophy, whether limited to the mus- 
 cular walls or valves of the heart, is clinically 
 unrecognizable, and an anatomical curiosity, and 
 may be clinically ignored. 
 
 j. Hypertrophy of the valves of the heart, would, at 
 first view, seem to be the result of endocarditis, 
 but it may rationally result from excessive func- 
 tion, and consequently excessive nutrition, as a 
 result of hypertrophy pure and simple. It cannot 
 be recognized clinically, and if suspected its 
 treatment is merged in that of hypertrophy. 
 
184 DISEASES OF THE HEART : 
 
 CHAPTER Vm. 
 
 Hypertrophy. Dilatation. 
 
 81. Hypertrophy \^ not very frequently an idio- 
 pathic disease. Like dilatation, it is generally 
 the outgrowth of some previously existing lesion 
 of the valves or vessels proceeding from the heart; 
 of some impediment, (as of a tumor or a consoli- 
 dated lung,) to the free movement of the heart. 
 
 82. It may be caused by excessive nourishment, 
 too free living, and excessive drinking, excessive 
 labor in which the strength is taxed to the ut- 
 most. Gymnasts, stevedores, furniture-movers, 
 iron-moulders, athletes, all furnish examples of 
 pure hypertrophy. It is comparatively rare in 
 females, except in those who have borne many 
 children. 
 
 83. Obstructions in the lungs would cause hy- 
 pertrophy of right sooner than the left ventricle. 
 
 84. The hypertrophy attending free living and 
 sedentary habits is apt to be attended with fatty 
 metamorphosis, and is of much more dangerous 
 significance than hypertrophy pure and simple 
 from excessive function. 
 
 85. The left ventricle is by far the most fre- 
 quently affected ; next, the left auricle, then the 
 
THEIR DIAGNOSIS AND TREATMENT. 135 
 
 right ventricle ; the right auricle is very rarely 
 hypertrophous. 
 
 86. Left ventricle in a hypertrophous state is 
 recognized by praecordial bulging, widened inter- 
 spaces, heaving, sustained impulse, when the side 
 of the observer's head is laid over the heart ; 
 regular rhythm, force of impulse unequal ; extent 
 of, increased ; maximum of, about the left nipple. 
 
 a. Unless there is associated dilatation, the 
 apex beats will rarely extend to the left of left 
 nipple, or below thq seventh rib. h. If there is 
 dilatation alsp, the apex may be carried much 
 farther beyond the nipple, and as low even as the 
 eighth rib. c. In this case the visible impulse 
 will be much greater, more knocking, heard dis- 
 tinctly and clearly some indies from the thorax ; 
 the impulse is also less heaving ; the heart merely 
 strikes, without raising the ribs and interspaces, 
 and the whole prsecordial surface, down as far as 
 to the left of and below the left nipple, seems 
 agitated in extreme case of dilatation with hy- 
 pertrophy. 
 
 87. In the case I have in mind, Mrs. D , of 
 
 San Francisco, a young married lady, the thump- 
 ing of the heart could be heard several feet, and 
 the appearance of the impulse was that of the 
 skin over the emaciated thorax, being raised in 
 
136 DISEASES OF THE HEART : 
 
 numerous places in a sort of undulating rhythm, 
 suddenly and a hundred and twenty times a 
 minute. This was a case of enormous eccentric 
 hypertrophy, and terminated fatally a few days 
 after my first and only visit. 
 
 88. Dullness to percussion may extend from 
 the second to the eighth rib, and from two inches 
 to the right of the sternum to three inches out- 
 side of a vertical line drawn through the left 
 nipple. In exceptional cases, " the percussion 
 sound may be toneless and high-pitched all over 
 the left lateral regions of the thorax, and vocal 
 fremitus null, just as if pleural effusion existed." 
 (Walshe.) 
 
 89. The diagnosis of hypertrophy, without or 
 with marked dilatatfon, is not difficult, a. Be- 
 sides the percussion and auscultory signs men- 
 tioned, there is in hypertrophy the marked symp- 
 tom of persistent force of the pulse. 
 
 b. The pulse may vary in the course of a single 
 day from 65 to 110, and from being full, hard 
 and resistant, to being compressible, full and 
 soft — rarely irregular or intermittent ; and when 
 these conditions are present, other lesions exist 
 in the heart. c. The patient will be strong, 
 vigorous and full-blooded, of florid complexion, 
 and apparently robust health, d. A case of this 
 
THEIK DIAGNOSIS AND TREATMENT. 137 
 
 kind now on my mind is a young man, aged 25, 
 who can lift six hundred pounds, and who is in 
 the habit of lifting two and three hundred at a 
 time daily. 
 
 e. The strength is not lessened, but the dysp- 
 noea becomes intolerable, from prolonged or 
 excessive exertion, and cough supervenes. 
 
 f. The patient wants his head tilted forward 
 when he sleeps, rather than have his shoulder 
 raised with his head. There is no orthopnoea, 
 but the liead aches if lying in a line with the 
 trunk. This symptom is not always present. 
 g. The varying frequency of the pulse is doubt- 
 less exceptional in the case now under consider- 
 ation, h. There is no dyspepsia, but little pain 
 in the heart, but more or less uneasiness, and a 
 sense of fullness ; frequently dizzy on stooping ; 
 the conjunctiva habitually red ; sleep disturbed 
 with strange dreams. [In this case the symptom 
 was removed by thirty grains of bromide of 
 potassium daily, at bed. time.] i. No increase 
 of sexual desire in this case, as has been supposed 
 on theoretical grounds, j. There is a systolic 
 blowing murmur at base of varying loudness 
 and not persistent. When the heart beats with 
 unusual violence the murmur is very distinct ; 
 when " slowed^' and subdued with digitalis, it is 
 
 Q 
 
138 DISEASES OF THE HEART : 
 
 inaudible, /c. I suspect this murmur is not rare, 
 for water forced through a tube of varying cali- 
 bre with considerable violence, emits a murmur 
 at the point of variation in the diameter of the 
 tube. /. The extremities do not swell, nor is 
 there ascites, m. In this case there is frequent 
 pain in the right side, and occasional congestion 
 of the liver, n. The bowels are disposed to con- 
 stipation ; nutrition and hematosis is excellent. 
 0. There is no lividity of the nails, or ears, or lips; 
 no coldness of hands or feet, except occasionally 
 some hours after excessive fatigue, p. Dilatation 
 may have begun in such a case, and be yet so 
 slight as to be overshadowed by the hyper- 
 trophy. 
 
 90. The treatment of hypertrophy is directed 
 to the retardation of the disease, probably to its 
 arrest, possibly -to its cure. 
 
 91. Few physicianji now believe in the cure of 
 hypertrophy. " On the other hand, it is not 
 difficult to remove or greatly mitigate the symp- 
 toms of simple hypertrophy in the majority of 
 cases, and render life, not merely tolerable, but 
 comfortable.'^ 
 
 92. The heart's action is to be quieted, and 
 the amount of blood diminished, without deterio- 
 rating its quality. 
 
THEIR DIAGNOSIS AND TREATMENT. 139 
 
 a. I have elsewhere (p. 61 passim) shown how 
 this may be done, by diminishing the weight of 
 the body, by means of restricted and dry diet. 
 b. The heart must have less blood to impel, but it 
 must have good blood for its own sustenance, or 
 we may have fatty metamorphosis added to our 
 hypertrophy, c. The patient may be cupped or 
 leeched at the prascordia once a week, if neces- 
 sary ; purged occasionally ; take diuretics most 
 of the time — solution of perchloride of iron and 
 digitalis, with antimony — baths every other day ; 
 plenty of passive exercise, until he is made quite 
 comfortable, and all severe symptoms are re- 
 moved, d. If the hypertrophy were caused by 
 excessive exertion or labor, that must be stopped, 
 of course ; if by excessive eating and idleness, a 
 restricted diet and some exercise must be en- 
 joined, but much more caution in depletion will be 
 required in treating this class of cases, than that 
 in which the hypertrophy results from excessive 
 function of the heart i tself. 
 
 Case. — Mrs. J. S. consults me concerning 
 bronchitis. She has taken all the nostrums and 
 specifics, has been relieved often ; sometimes has 
 thought herself cured ; but the annoying cough 
 and frothy expectoration returns again and 
 again, when she thinks she is nearly cured. On 
 
140 DISEASES OF THE HEART : 
 
 listening at the prsecordia, I hear a systolic mur- 
 mur ; move my ear to left apex and it is much 
 louder ; hearths impulse increased in extent and 
 vigor. Apex beat farther to left than normal ; 
 the head is lifted by the throb of a hypertrophied 
 heart ; the sounds are nearer to the ear and 
 more neatly accented than normally. She has 
 incompetent mitral valves, dilatation with hyper- 
 trophy, the latter still in excess ; turgescence 
 of lungs from refluent current ; mechanical com- 
 pression of left lung from enlarged heart ; hence 
 initative cough, with increased mucous expecto- 
 ration. 
 
 Give a calomel purge, followed by syrup of 
 wild cherry and tincture of aconite ; restrict 
 diet one half. In three^ days the cough has dis- 
 appeared, and the patient feels much better, 
 though her garments fitting less snugly, she 
 " fears she is losing flesh f^^ 
 
 She is losing flesh, and must never again carry 
 so much flesh, if she hopes to be free from her 
 *' bronchitis." This is one case of a whole class 
 in which loss is gain. A heart which will utterly 
 fail to impel 16 or 17 pounds of blood — the nor- 
 mal amount — will get along with 14 or 15 pounds 
 with little or no difficulty. It must not be in- 
 ferred from this, that therefore bleeding to the 
 
THEIR DIAGNOSIS AND TREATMENT. 141 
 
 amount of one or two pounds will answer the 
 purpose and prove beneficial. The weight of the 
 body must b^ diminished in the same proportion. 
 If we wish to abstract a pound of blood from a 
 patient with dilated heart, we must do so by 
 reducing the patient eight pounds in flesh, by 
 means of low diet, or, in cases of urgent need, by 
 total abstinence from food until the effect is pro- 
 duced, it is remarkable how soon the overtasked 
 heart will recover its tone when the patient en- 
 tirely abstains from food, and takes small doses 
 of some nerve sedative to quiet the irritability 
 which hunger sometimes induces. The pressure 
 disappears from the chest, as weight diminishes, 
 and very*soon, say from three to five days, the 
 patient, if not yet in the dropsical stage, will say 
 he is better than ever, and that he scarcely knows 
 he has a heart. Even now, a single full meal 
 will bring back all his consciousness of his heart 
 and of its unnatural condition. 
 
 93. Pure and simple hypertrophy is not apt to 
 destroy life, a. It is only when other organic 
 diseases have come on, or when dilatation be- 
 comes excessive that life is in jeopardy. 
 
 94. Dilatation will not be difficult of diagnosis, 
 a. This has already been given to some extent 
 (IF 89) in speaking of hypertrophy. 
 
14^2 . DISEASES OF THE HEART : 
 
 95. a. The pulse is weak and irregular in force 
 and rhythm ; rarely intermittent, b. Apex beat 
 indistinct and not lowered ; percussion dullness 
 increased vertically more than transversely ; 
 impulse undulatory ; ribs not bulged, unless there 
 is also hypertrophy ; systolic sound, shorter, 
 clearer and more superficial than in health ; de- 
 fective nutrition ; dyspepsia more or less marked, 
 dropsy, especially of lower extremities; tendency 
 to emaciation ; cold extremities ; feeling of being 
 chilly from defective circulation ; palpitation on 
 the least excitement; great praecordial uneasiness; 
 ringing of the ears, headache, indisposition to 
 any labor, mental or bodily ; somnolence, in the 
 advanced stages of the disease ; eviderK^e of con- 
 gested liver and kidneys ; sexual inclination 
 weakened ; superficial pulses not visible ; symp- 
 toms of bronchitis and pulmonary oedema ; in 
 the last stages of the disease, orthopnoea complete: 
 asthmatic paroxysms ; occasional respiratory for- 
 getfulness, a fatal symptom; frequent nausea and 
 anorexia ; livid discoloration in spots; occasional 
 sphacelus of the finger tips or toes, from capillary 
 stasis ; leaden, almost black lips, particularly in 
 the morning. 
 
 96. Some or all of these symptoms may be 
 present in a single case, a. When but a few of 
 them are present, even the auscultatory and per- 
 
THEIR DIAGNOSIS AND TREATMENT. 143 
 
 cussion signs only, the diagnosis is established. 
 
 97. The differential diagnosis of hypertrophy 
 and dilatation is obvious from what has been 
 already said. 
 
 98. As to the treatmeritj it is radically differ- 
 ent from hypertrophy. a. The treatment is 
 eminently sustaining, directed to the improve- 
 ment of the quality of the blood, without diminu- 
 tion of its quantity even, for it is not likely to be 
 in excess. 
 
 99. Solution of perchloride of iron, largely 
 diluted, is here of special service as a diuretic 
 and tonic, a. Opium and quinine combined are 
 constantly required, not more than two or three 
 grains of quinine a day is requisite. It may 
 be given in three or four pills, one at a time, each 
 pill to contain from an eighth to half a grain of 
 opium. 
 
 b. If the pulse be rapid, above 90, digitalis may 
 be given in syrup of wild cherry, in half drop 
 doses hourly, until the pulse fall to 85, but it 
 must be given with greater caution than in any 
 affection of the heart, except fatty degeneration. 
 
 c. The bowels may be moved daily with any 
 mild aperient; perhaps formula a, page 59, will be 
 found convenient. An aloetic pill daily at bed- 
 time, or a castor-oil capsule maj^ answer as well. 
 
144 DISEASES OF THE HEART : 
 
 d. Taraxacum and calomel are recommended 
 for the same purpose, and are often indicated. 
 
 e. Dry cups to the heart in case of extreme 
 palpitation or anp^ina often afford instant and 
 enduring relief. /. Blood must rarely be taken. 
 g. Passive exercise is of great utility, h. The 
 patient must lead a cheerful life, and not be ex- 
 posed to annoyances and hardships ; voluntary 
 exercise, such as walking or horseback riding 
 must not be tolerated, except with great caution. 
 No violent emotion or passion should be indulged. 
 ('* rupture of a dilated heart has occurred in actu 
 coitus^) Animal diet is preferable ; much drink 
 of any kind, even if it be milk, is to be avoided; 
 the diet should be rather dry than the contrary, 
 but well prepared and easily digestible. Cold 
 sponge baths may be used, if they agree with the 
 patient, not otherwise. Perhaps tepid or hot 
 salt water bathing is on the whole the best. The 
 clothing, especially of the extremities, should be 
 warm and light; intercurrent diseases must be 
 treated on general principles modified to suit the 
 actual condition of the heart. 
 
 100. Ammonia and lavender will afford speedy 
 relief to depressed nervous sensations, and prse- 
 cordial faintness. a. In the •latter stages, the 
 patient should be always watched in sleep, on 
 
THEIR DIAGNOSIS AND TREATMENT. 145 
 
 account of the strong tendency to respiratory for- 
 getfulness, by which life might be suddenly ar- 
 rested, long before the necessary fatal issue of the 
 disease. I will close the consideration of dilata- 
 tion by a condensed abstract of a peculiar mode 
 of treatment suggested by Piorry, of Paris, in 
 1858. 
 
 101. By a series of observations, carefully 
 made, with the aid of the plessimeter, Piorry 
 satisfied himself that the heart and liver of a per- 
 son in health diminish in bulk by forced inspira- 
 tions. He next undertook to apply this discovery 
 to the diagnosis and treatment of enlarged liver 
 and heart, I have not attempted to repeat his 
 experiments, but they seem rational, and the 
 opinion of M. Piorry, who has applied himself to 
 percussion and auscultation for now nearly forty 
 
 * years, will hardly be contradicted. But to the 
 facts. 
 
 102. M. Piorry selected a hysterical patient, 
 who had nothing the matter with either the heart 
 or liver ; he limited the heart by percussion, 
 and found it occupied a space of 11 centimeters ^ 
 from right to left ; the liver occupied a space of 
 14 centimeters, from above downward. (I omit 
 the other measurements.) This done, he directed 
 
 * See note page 75. 
 
1^6 DISEASES OP THE HEART . 
 
 the patient to breathe forcibly twenty times in 
 succession, and then repercussed: instead of 11 
 he found 9 to 9| for the heart ; andinstead*of 14, 
 about 12i for the liver. This is not all. He 
 now directed the patient to hold her breath, 
 whereupon he demonstrated that the two organs 
 named not only returned to their natural di- 
 mensions, but that they slightly increased in bulk. 
 
 103. Now, as this experiment has had the same 
 result on all patients, it is easy to see its influence 
 upon the diagnosis and treatment of diseases of 
 these two organs. 
 
 a. What is said above, is, moreover, in com- 
 plete accord with what is daily observed in path- 
 ological anatomy. Uniformly, when a person 
 dies of asphyxia from mucous engorgement of the 
 bronchi, the heart and liver are found to be much 
 enlarged and gorged with blood ; whereas, on 
 the contrary, when the respiration is unobstructed 
 up to the last moment of life, these organs are 
 found to be small and bloodless. 
 
 104. The practical applications of this phe- 
 nomenon are the following : It aids in establishing 
 the diagnosis : a. Of hypertrophy and dilatation 
 of the heart ; h. Of hepatemia (congestion of the 
 liver), together with lesions of nutrition of this 
 organ. 
 
THEIR DIAGNOSIS AND TREATMENT. 147 
 
 105. It aids in determining the rational treat- 
 ment of dilatation and congestion of the heart, 
 and ©f some of the organopathic conditions which 
 are the consequences of these* diseases. 
 
 106. Diagnosis of dilatation and of hypertrophy 
 of the heart. Hitherto we have had but little 
 more than the following symptoms by which to 
 distinguish dilatation from hypertrophy of the 
 heart : more extensive dullness at the praecordial 
 region, heart beats feeble, absence of impulse ; if 
 these signs were perfectly well marked, we could 
 establish the diagnosis of dilatation beyond ques- 
 tion ; but in the majority of cases there was room 
 for doubt of the exactness of the diagnosis ; but 
 by the aid of the physical signs I am about to 
 describe, the diagonsis cannot for a moment re- 
 main doubtful. 
 
 107. Let us suppose two well-marked cases, 
 one of hypertrophy^ the other of dilatation of the 
 heart. Let us now limit the volume of the heart 
 very accurately, by the aid of percussion ; now 
 let us cause the patient to breathe forcibly several 
 times in succession ; let us now measure the heart 
 again with the same accuracy ; we shall find in 
 the case of hypertrophy that tlie heart has under- 
 gone no change ; whilst in the case of dilatation, 
 we shall find that the heart has returned to about 
 
148 DISEASES OF THE HEART : 
 
 its normal volume, (that is, to a transverse mea- 
 surement of about 11 centimeters.) 
 
 108. If it be a case of partial dilatation, "or a 
 partial hypertrophy^^ the cavities of the heart, 
 only the dilated cavity will return to its normal 
 state, while the hypertrophied ventricle will re- 
 main unaltered by the forced respirations. 
 
 109. If, as most frequently happens, the dila- 
 tation be accompanied with hypertrophy, the 
 diagnosis will be still more easy, because in such 
 case, the only slight diminution of the increased 
 volume of the heart, will indicate dilatation with 
 hypertrophy. 
 
 110. In dilatation, the heart diminishes, by 
 emptying itself of the blood which it contains. 
 A long time ago, Piorry observed that after 
 bleeding a patient with dilated heart, this organ 
 was found diminished in bulk. 
 
 111. The application of this same principle to 
 diagnosis of congestions, or permanent alterations 
 in the volume of the liver is at once obvious. 
 
 112. Treatment of dilatation of the heart, and its 
 consequences. The treatment of hypertrophy or 
 dilatation, or the two conjoined, follows directly 
 from the means of diagnosis, 
 
 113. In these cases, if the patient be made to 
 take deep inspirations from time to time, (the more 
 
THEIR DIAGNOSIS AND TREATMENT. 149 
 
 frequently the better,) amelioration of the symp- 
 toms will very soon become manifest. In most 
 cases, especially in dilatation with hypertroph3'5 
 the cure will not be so radical, but the patient 
 will experience great relief, and by the disease 
 being thus kept stationary, existence may be pro- 
 longed far beyond the limit it would otherwise 
 only reach. Piorry says he has cured or relieved 
 a great many cases by these extremely simple 
 means. 
 
 The resultant dropsies, also, often rapidly dis- 
 appear under the same treatment. This is equally 
 applicable to similar conditions of the liver, and 
 to the serous infiltrations resulting from obstruc- 
 tion to the portal circulation. It is only by the 
 aid of the plessimeter that these nice variations 
 in the volume of the heart or liver can be made 
 out. 
 
 Whatever one may think of this mode of diag- 
 nosis and treatment, it is certainly worthy of 
 trial, especially as it is in the last degree harm- 
 less. 
 
150 DISEASES OF THE HEART : 
 
 CHAPTER IX. 
 
 SoFTENiisG, Fatty Metamorphosis or Degeneration, 
 OK Fatty Substitution of the Heart. Rupture 
 OF THE Heart. Cases. 
 
 114. The diagnosis of softening of the heart is 
 not easy nor absolute. This affection occurs in 
 consequence of adynamic diseases, typhus, ty- 
 phoid, diphtheria, variola, scarlatina, etc. ; and 
 it results from diathetic conditions of the blood, 
 in which the quality ef the fibrin is deteriorated, 
 or the proportion of the red globules is dimin- 
 ished, or that of the white globules increased, as 
 in cyanosis, purpura, scurvy, leucohaemia, glyco- 
 haemia and acute phthisis. 
 
 115. The heart softens, at least superficially, 
 in pericarditis, and throughout the thickness of 
 its walls in carditis, in hemorrhagic or serous 
 infiltration, in fatty external deposit it is softened 
 superficially, and in fatty degeneration it is soft- 
 ened in portions of the walls of one or both ven- 
 tricles or auricles, or throughout its entire sub: 
 stance, ventricles, auricles, valves and investing 
 membrane. The detailed analysis of these con- 
 ditions does not come within the scope of this 
 epitome. 
 
 116. What I wish now to consider, is simple 
 
THEIR DIAGNOSIS AND TREATMENT. 151 
 
 softening of the muscular substance of the heart, 
 without metamorphosis of its histological ele- 
 ments. 
 
 Can this kind of softening be verified clinically 
 and exclusive of softening from fatty infiltration 
 or fatty degeneration ? T think this question 
 may be promptly answered in the negative. Nor 
 are the causes of the different varieties of soften- 
 ing so clearly appreciable that we may with great 
 probability infer that, in a given case, the soften- 
 ing is or is not attended with fatty degeneration 
 or infiltration. 
 
 Still most careful observers will have a settled 
 opinion in their own minds, based on more or 
 less satisfactory reasons. Indeed, the diagnosis 
 of softening, as distinguished from degeneration^ 
 can be rationally made out, and that too with 
 sufficient nearness to constitute a basis for 
 rational treatment, 
 
 a. For example : a young adult of active hab- 
 its, and accustomed to plain food and to total 
 abstinence from alcoholic drinks, is attacked with 
 typhoid fever, and in the course of one, two or 
 three weeks presents the symptoms of softening, 
 viz.: feeble, irregular pulse ; much diminished or 
 absent first sound of the heart (there being no 
 mitral regurgitation); heart's impulse invisible 
 
152 DISEASES OF THE HEART : 
 
 at times, and when visible unaltered in location ; 
 impulse, also, but slightly appreciable to the 
 touch, or entirely impalpable ; the extremities 
 presenting a leaden hue (all valvular diseases 
 susceptible of exclusion) ; suppose this case to 
 have prsecordial uneasiness, vrith occasional 
 transient pains in the vicinity of the heart ; 
 would it not be extremely probable that he 
 had simple softening without degeneration or 
 even dilatation ? Yet the symptoms and phy- 
 sical signs are undistinguishable from those of 
 degeneration. 
 
 117. In such case, if the diagnosis of simple 
 softening were correct, the patient would in all 
 probability rex^over within a period of from six 
 to twelve months, under the use of tonics, nutri- 
 tious diet, moderate exercise, both passive and 
 active,' dry frictions, and cold or tepid sponge- 
 baths, morning or evening, as should best agree 
 with the particular case. Such a case might be 
 allowed moderate doses of whiskey or brandy, or 
 half an ounce, three times a day, of a mixture 
 composed of equal parts of cod-liver oil, whiskey, 
 and syrup of wild cherry bark, or perhaps, better 
 still, Guffroy's cod-liver extract. 
 
 118. Is it not possible that the cases of soften- 
 ing of the heart (supposed fatty) mentioned by 
 
THEIR DIAGNOSIS AND TREATMENT. 153 
 
 Markham (London, I860,) as having been bene- 
 fitted by " cod liver oil in combination with steel,'' 
 were subjects of softening without degeneration ? 
 
 119. However this may be, we would hardly 
 on theoretical grounds give cod-liver oil to a 
 case with fatty heart; and we should be extremely 
 cautious in the use of stimulants ; while, in a 
 case of this kind, both would be indicated in 
 reasonably large doses. As intimated above, 
 (115) the prognosis in softening — non-fatty — is 
 very favorable, and would suggest an early and 
 complete recovery. 
 
 120. The diagnosis of fatty degeneration, though 
 never absolute and exclusive, is made out with 
 so much rationality as to be practically but little 
 less than demonstration. 
 
 The diagnosis is based on the symptoms already 
 mentioned (115 &,) to which may be added de- 
 fective memory of recent events, inability to 
 perform mental or bodily labor for any consider- 
 able length of time; in bad cases, the pulse less 
 frequent than the systole of the heart. Respira- 
 tory forgetfulness is often observed ; dyspnoea is 
 not unfrequent; and whenever this occurs, the 
 liver habitually congested, rapidly enlarges; 
 relative increased sharpness to second sound of 
 heart. 
 
 8 
 
154 DISEASES OF THE HEART : 
 
 121. The arcus senilis has no value as a symp- 
 tom of this disease, except in so far as it*is in 
 harmony with the general leaden hue of the nails, 
 lips, ears, ete. 
 
 122. Syncope, and loss of consciousness with- 
 out fainting, are likely to occur several times in 
 the slow course of this disease ; for it is emi- 
 nently a chronic affection, lasting from a few 
 years to the number of years of human life. 
 
 123. Its favorite subjects are persons of luxu- 
 rious and epicurean habits. Persons who take 
 no exercise and drink freely, are especially liable 
 to this form of softening. 
 
 124. Case. — G. N., of San Francisco, height 
 5 feet 10 inches, corpulent, weight 170ft)s., single,- 
 living in perfect idleness on ample income, a very 
 free-liver, aged 38. Drank more than usual on Feb. 
 7th, 1867, his last birth-day ; in the evening fell 
 in a^fit. On coming out of this, a few hours after 
 he fell again, but quickly recovered, having sus- 
 tained no injury but a cut in the skin of the 
 occiput. Fits epilepti-form. 
 
 125. He took 30 grains of bromide of potassium, 
 repeated every six hours ; had several good naps 
 during the night, and seemed much better on the 
 morning of the 8th. Before night signs of deli- 
 rium supervened. He talked clearly of all mat- 
 
THEIR DIAGNOSIS AND TREATMENT. 155 
 
 ters of his past life, told anecdotes with clearness 
 and fluency, but could not remember anything 
 then occurring, from one minute to another ; did 
 not recollect whether he had eaten or drank, or 
 taken the medicine ordered. At 11 a. m., 8th, no 
 pulse except at intervals, then exceedingly weak ; 
 Tieart beats 150 per minute ; respiration varying 
 from 50 to 80 in three successive minutes ; deli- 
 rium very mild and subjective ; heart's impulse 
 feeble. The apex strikes the thorax in the fifth 
 interspace, directly under the left nipple. No 
 murmurs on auscultation ; first sound of the heart 
 exceedingly feeble, as if it were an attempt at a 
 contraction which it was unable to complete. 
 The second sound was also muffled, or defective 
 in accent. Respiratory murmur good, except 
 where the left lung was pushed upwards, and con- 
 densed by the enormous liver. My diagnosis Avas 
 fatty degeneration, with dilatation; the epilepti- 
 form fits resulting from defective supply of arte- 
 rial blood to the brain, in consequence of heart 
 disease; also, mild delirium tremens. 
 
 9th. 11 A.M. Heart beats 140 ; no pulse at 
 wrist ; sweat drenching in abundance, but not 
 viscid nor cold. Has persistent clonic spasms, 
 particularly of fingers and wrist joints. He lies 
 flat on his back, and will have no pillow except 
 
156 DISEASES OF THE HEART r 
 
 the corner of one to raise his head to the level 
 of his body. Bromide of potassium, digitalis, 
 whiskey and beef juice fail to produce any ame- 
 lioration ; by the advice of his consulting phy- 
 sician, he is allowed to have laudanum in such 
 doses as are usually given in delirium tremens, 
 which the consulting physician believed he had," 
 pure and' simple. At the fifth dose, given half- 
 hourly, he was asleep ; heart beats 140, no pulse ; 
 respiration 32 ; eyes closed, sleep profound, some 
 stertor, clonic spasms of mouth and jaw, pupils 
 not larger in the shade than the head of a pin. 
 One hour later, that is, the 9th, at 10 p.m. he 
 died without having awoke. His respiration was 
 the same, 32, and his heart beats 140 up to the 
 instant of death. His heart stopped, not grad- 
 ually but abruptly and finally at the same instant. 
 There was no final convulsion. 
 
 126. Post mortem fourteen hours after, in the 
 presence of several distinguished physicians. 
 There was found fatty degeneration of heart and 
 liver. Heart increased about one-tliird in size. 
 There was no sign of inflammation in or out of 
 the heart ; no dropsy ; no clots in the heart or 
 vessels ; heart pale and flabby ; both sets of 
 valves examined with care and found perfect ; 
 liver extended above the third rib, was extremely 
 friable and pale. The heart was very soft, being 
 
THEIR DIAGNOSIS AND TREATMENT. 157 
 
 easily rubbed to a pulp between the thumb and 
 finger ; on section, it presented pale fawn-colored 
 spots on the cut surfaces of both ventricles; these 
 were more distinct than on the surfaces of the 
 heart before being cut. Examination under the 
 microscope showed abundance of oil-globules and 
 amorphous pale muscular substance, but few 
 striated fibrillar. Externally the heart was not 
 encumbered with more than the usual amount of 
 fat, and this was principally about the base of 
 the right ventricle. 
 
 This man never knew he had any disease of 
 the heart, but had complained of oppression 
 about the pra)cordia before the 7th Feb., and had 
 told a friend he was going to have his heart 
 examined some day, soon. An opiate in large 
 doses is the very worst drug that can be given 
 in degeneration. In this case it is not probable 
 that it hastened the fatal result, for the case 
 would have died in a few hours more, in convul- 
 sions, had the nervous system been left to itself; 
 but it is observed that it diminished respiration 
 (from an average of 65 to 32) without affecting 
 the heart beats, which was equivalent to increas- 
 ing the dyspnoea ; the dyspnoea increased the 
 congestion of the liver and the engorgement of 
 the hearths cavities. 
 
158 diseases of the heart 
 
 127. Case of Rupture of the Heart ; Fatty 
 Softening ; Dilatation. — Q., died suddenly. The 
 autopsy revealed the following facts : The begin- 
 ning of aorta was atheromatous ; the right cor- 
 onary sinus v/as converted into an aneurismal 
 sac the size of a hen's egg. The coats of the 
 artery were so lar ruptured on the anterior part 
 of the sac, that ecchymosis was visible under the 
 external serous covering. This rupture was in- 
 complete, and about the size of the little finger 
 nail. There was also rupture of the apex of left 
 ventricle, through the ventricular wall which at 
 this point was not a line in thickness. The rup- 
 ture was incomplete, like that of the aneurismal 
 sac, extending only to the viceral layer of peri- 
 cardium, which was glossy, and exhibited no sign 
 of inflammation.- No blood had escaped, either 
 from the aneurismal sac, or the apex of ventricle 
 under the pericardium. There was a faint attempt 
 at reparation in both places, shown by the depo- 
 sition of lamince of fibrin, but this attempt had 
 evidently been quite abortive ; the deposited 
 laminae were almost black, and dirty looking. 
 The place of rupture of the ventricle was indi- 
 cated externally by the ecchymosis seen through 
 the pericardium. The heart was full twice the 
 normal size, very soft, and evidently degenerated, 
 by the sub^tit.ition of fat for sarcous elements. 
 
THEIR DIAGNOSIS AND TREATMENT. 159 
 
 Mitral valves incompetent ; aortic valves perfect ; 
 the other valves were not examined. The subject 
 was a quadroon, aged 30, fine-looking, not ema- 
 ciated. The pleural sac and peritoneum were 
 distended with effusion ; the liver was much 
 enlarged, the lungs healthy. There were several 
 chafes of pleuritis, with deposition of lymph, on 
 the mural layer of pleura, near the apex of the 
 left lung, posterior aspect. 
 
 128. This was a case of sudden death. The 
 f)ost mortem reveals the proximate cause to have 
 been rupture of the left ventricle. The rupture 
 occurred in consequence of dilatation, conjoined 
 with degeneration of structure elements. The 
 aneurismal incomplete rupture was also much 
 aided by 4he fatty degeneration of the aortic 
 walls. 
 
 129. Violent traumatic rupture of the heart, 
 even when the laceration is very extensive, does 
 not necessarily cause instant death, not even 
 fainting. Morel-la-Vallce saw a case in detail 
 at the hospital of St. Anthony, Paris, in 1858. A 
 man of sixty was thrown from an omnibus, a 
 wheel of which ran over his chest, crushing it in 
 a frightful manner. He was immediately carried 
 into the hospital in front of which the accident 
 occurred. Although in a dying condition, he 
 
160 DISEASES OF THE HEART . 
 
 made some signs to his wife, who was with him, 
 breathed a few times, but was pulseless, and 
 expired. On examination, the left ventricle was 
 lacerated the whole length of its anterior aspect; 
 the upper part of the septum of the ventricles 
 and the left auricle were also torn completely 
 through ; the mitral valve was torn in pieces, the 
 tendinous cords were torn out, and remained 
 hanging to the shreds of a fleshy column. 
 
 130. The injury to the heart appeared to result 
 from excessive pressure. Although the sternum 
 and ribs were much fractured, no osseous frag- 
 ment corresponded with any rent of the heart. 
 
 131. This case, though not properly within the 
 scope of my subject, is interesting in a physiolo- 
 gical point of view, as showing what extensive in- 
 jury the heart itself may sustain without causing 
 instantaneous death, or even loss of consciousness. 
 But to return to my subject— fatty heart — is recog- 
 nized with great difficulty ; but tlie most reliable 
 negative symptom, is the absence of dropsy. The 
 most reliable positive symptoms are, liability to 
 " heart faintness" and intermittent pulse, while 
 the systoles of the ventricles are regular and 7iot 
 intermittent. In the advanced stage of fatty 
 degeneration — and this is the stage in which our 
 attention is most frequently called to it — this 
 
THEIR DIAGNOSIS AND TREATMENT. 161 
 
 symptom of pulse weak or absent, out of propor- 
 tion to the systoles, is nearly always present. 
 There is another marked symptom in this stage ; 
 that is, a muffled toneless first sound, quite distia- 
 guishable from the accented sound from dilatation 
 without degeneration, and also, relatively higher 
 toned and more accented second sound. Precor- 
 dial uneasiness or distress is also a marked and 
 frequent symptom. 
 
 132. Summary of Treatment , — There is scarcely 
 a doubt that fatty degeneration may be arrested, 
 and that the unaffected portions of the heart may 
 be so far fortified as to perform the work of a 
 sound organ, so that its deficiencies will cause no 
 suffering, or even uneasiness, to the subject. This 
 amelioration can be brought about by hygienic 
 and medicinal means in many cases. 
 
 133. The hygienic means are frequent bathing 
 — twice a week — pure air night and day; uniform 
 temperature of the surface of the body, by light, 
 warm clothing, passive exercise in salubrious dis- 
 tricts of country; such as carriage, boat and horse- 
 back riding ; little or no benefit from walking 
 need be expected. Food should be nutritious 
 and easily digested. Fish, meat, game, and a 
 rather limited amount of vegetable food may be 
 allowed. Less fatty, starchy or saccharine matter 
 should enter into the diet than in other diseases, 
 
162 DISEASES OF THE HEART : 
 
 except there be good reason to believe that the 
 softening of the heart is non-fatty. All alcoholic 
 beverages should be avoided, except for the im- 
 mediate feeling of faintness. All sudden excite- 
 ments, or causes of emotions^ should be avoided 
 vrith great care. 
 
 134. The most relioble medicinal remedies are 
 solution of ] erchloride of iron, largely diluted — 
 a drop to a drachm of water — strynchia, brucia, 
 arsenic. * Quinine and opium are not to be for- 
 gotten (see page 63, c.) ; aloetic pills, or some 
 equivalent, are required from time to time, or 
 formula a, (page 57,) may be employed with ad- 
 vantage. Electro-magnetism, of very low tension, 
 applied over the pneumogastric nerves, or over 
 the heart itself is worthy of trial. I have no 
 experience of its eJBfects in these cases, but theo- 
 retically believe it must be beneficial, if applied 
 once or twice a day, with great caution, for many 
 months. The use of it for a few times could have 
 no result. 
 
 135. Finally: fatty heart is very frequent in 
 this city, and has proved fatal in many instances 
 
 * Of all the preparations of arsenic, that first recom- 
 mended by Athar Ali Khan, of Delhi, is most used by me. 
 R. White arsenic, grains 2 ; black • pepper, grains 100. M. 
 Make, according to art, into sixty pills. S. Dose, one a day 
 for a week, and finally three a day indefinitely. 
 
THEIR DIAGNOSIS AND TREATMENT. 163 
 
 within my own observation. It favors the form- 
 ation of clots in the heart — a cause of sudden 
 death. In almost all cases of rupture of the heart, 
 without external violence, fatty degeneration is 
 the predisposing cause — all cases of rupture die 
 within a few moments. 
 
 136. It is one of the diseases of the heart that 
 may be treated with the most rational hopes of 
 amelioration and indefinite prolongation of life, 
 if recognized and treated before it has become 
 complicated with excessive dilatation, or before it 
 has reached that stage in which the pulse is 
 irregular, very weak, tremulous and intermittent 
 at the wrist, before fainting fits are frequent ; in 
 short, before the greater, instead of the less por- 
 tion of the heart has undergone fatty substitution. 
 In this last stage, any treatment — the most ra- 
 tional — can barely alleviate temporarily, without 
 the slightest hope of retarding the onward pro- 
 gress of the disease. 
 
 137. Angina Pectoris, or '* sujffocative breast 
 pang," is a disease from which the poor are 
 usually exempt. It attacks about nine males to 
 one female. It scarcely ever occurs before the 
 fortieth year, seldom before the fiftieth. It is 
 usually protracted in its course. Death lias been 
 known to follow within two hours of the first 
 
164 DISEASES OP THE HEART : 
 
 attack in a patient aged 74. (Latham.) The 
 average duration is unknown. 
 
 138. No disease of the heart is more certainly 
 recognizable than angina pectoris. It consists of 
 spasm and pain in the breast, generally about the 
 lower portion of the sternum, but sometimes as 
 high as the upper end of this bone. The pain 
 runs through the breast to the back, and down 
 the left arm. There is a sense of suflocation, 
 and a feeling that death is imminent. This feel- 
 ing of speedy dissolution is never wanting, any 
 more than the pain, the suffocation and the con- 
 striction about the heart. It comes suddenly, 
 without warning, and goes suddenly and com- 
 pletely. A patient of mine was walking in the 
 street; all at once he dropped down on the pave- 
 ment, with intense tearing pain, and a feeling of 
 suffocation and instant death. He immediately 
 arose, before two gentlemen near him, who sprang 
 to his assistance had -time to reach him. For an 
 instant, he says, he must have been unconscious, 
 %r he does riot remember falling, but was con- 
 scious while getting up. The gentlemen who 
 wished to help him asked how he came to fall so 
 suddenly and get up instantly. He answered 
 that he did not know, and asked how long 
 he had been down ? They replied, '' No time at 
 
THEIR DIAGNOSIS ANJ) TREATMENT. 165 
 
 all ; 3^011 got up as soon as you fell, before wo 
 could get to you.-' This man has had no attack 
 since, but by my advice lie has arranged his 
 affairs. A paroxyir^^m of angina pectoris may last 
 several minutes ; that this was a case in which 
 material unsoundness of the heart, its valves and 
 of the thoracic aorta were present is indubitable, 
 from examinations carefully made, previous and 
 subsequent to his fall. 
 
 139. In order to appreciate the manner of 
 diagnosis J it is proper to glance at the usual 
 pathological condition of the heart in fatal cases, 
 
 a. In almost all cases, the heart walls, espe- 
 cially of the right ventricle are thinned. The 
 heart is usually softened, generally by fatty meta- 
 morphosis. Neither clots in the heart nor em- 
 boli in the arteries have been found. The cor- 
 ronary arteries are frequently more or less ossified 
 or constricted by atheromatous deposits. JYo 
 matter what the cadaveric rigidity may be, the 
 ht art will always be found soft;. 
 
 140. The pain of angina is neuralgic, not that 
 of tenderness. It depends, then, on lack of sup- 
 ply of red blood to the heart itself, or upon im- 
 paired nutrition or irritation of that branch of 
 tlie vagus which supplies the heart. 
 
 Any cause which will have the effect of tem- 
 
166 DISEASES OP THE HEART : 
 
 porarily diminishing the supply of arterial blood 
 to, or retard the return of venous blood from the 
 heart; or any cause which shall impair the nor- 
 mal function of the vagus may produce a paroxysm 
 of angina pectoris. No causes could be more likely 
 to induce such defect of blood supply to the heart 
 than fatty metamorphosis, or dilated heart, or nar- 
 rowed corronary arteries — the three precise con* 
 ditions in which we find angina most likely to 
 occur. Here, for the hundredth time, theory and 
 fact coincide. 
 
 141. We may expect in most cases of angina 
 pectoris a feeble, small and over frequent pulse, 
 as in dilatation; but from the pulse alone nothing 
 can be determined in this affection. The diagnosis 
 rests entirely on the character — the unmistakable 
 character of the paroxysm — great dread of death, 
 a feeling of inability to breathe, for fear of hurt- 
 ing the heart, or causing death, more than a 
 conscious ness of real inability to take a full in- 
 spiration. 
 
 The Treatment of the attack itself is not often 
 committed to the physician, because it is over 
 before he arrives ; but in protracted paroxysms, 
 or in those of frequent recurrence in the same 
 day he may be present. 
 
 142. Dry cups to the praecordia afford the most 
 
THEIR DIAGNOSIS AND TREATMENT. 167 
 
 prompt relief. Stimulants, in small, often re- 
 peated doses, should be given at the same time, 
 if the patient can swallow. A touch of the 
 cautery between the shoulders, will undo the 
 spasm of the heart most promptly. If the stomach 
 is full, it should be relieved by a prompt ^emetic 
 — sulpliate of zinc or powdered ipecac, a large 
 dose in a goblet of tepid water. If the patient 
 be of full habit, and if it be known that the heart 
 is not dilated, and if serious fatty degeneration 
 be not suspected, ard if the pulse be nearly natural 
 in size and fullness and not slow, bleeding at the 
 arm is certainly indicated, or blood may be 
 taken by scarification and cups from the prae- 
 cordia, if not thought proper to risk the open- 
 ing of a vein. 
 
 143. But the most important part of the treat- 
 ment of a subject of angina pectoris is that 
 directed to the postponing of the recurrence of 
 the attack, which is sure to come again, sooner 
 or later, and with more violence ; and the more v 
 frequently the greater the number of paroxysms 
 already* endured. All emotional influences must 
 be avoided. The temper must be controlled. 
 The passions indulged with the greatest modera- 
 tion. The natural calls of the body obeyed with 
 deliberation ; hence the bowels must not become 
 
168 DISEASES OF THE HEART : 
 
 costive, nor the bladder distended. There must 
 be no violent or forced work, or exercise, or 
 amusement. No severe or rapid intellectual labor; 
 no excesses of any kind — moral, esthetic, phy- 
 sical, mental or emotional. Daily passive exer- 
 cise in^ the open air ; slovr walking on level 
 ground in open spaces, as in the country or sub- 
 urbs, or unfrequented streets, may be permitted. 
 
 144. Riding in a carriage is much preferable 
 to riding on horseback, however easy the gait of 
 the animal, because of the labor of mounting 
 and dismounting, and the risk of sudden motions 
 of the horse, which might bring on a fatal par- 
 oxysm. 
 
 Tonics are generally indicated, also stimulants 
 and nitrogenous nutrients, in rational quantities. 
 If anemia be present, iron must be employed, and 
 cod liver oil, in the modes already stated, as in 
 dilatation, or in softening, without^ fatty meta- 
 morphosis. 
 
 145. Dr. Walshe, with great theoretical prop- 
 riety, says, " The removal of gout, chronic rheu- 
 matism, or old standing skin diseases, should be 
 very cautiously, if at all attempted, in the subject 
 of angina ; relief of those complaints is unques- 
 tionably sometimes followed by increased severity 
 of the cardiac affection.^' 
 
THEIR DIAGNOSIS AND TREATMENT. 169 
 
 146. Rheumatism^ which occupies so important 
 a place in the consideration of pericarditis and 
 endocarditis, requires mere mention. It is justly 
 dreaded on account of the occult effects it is 
 likely to leave in the organism. Persons who 
 had rheumatism years ago, are constantly seek- 
 ing medical advice for some trouble about the 
 heart, although at the time of the rheumatism no 
 heart symptoms were observed. Is it not pro- 
 bable that some lesions of the heart, though not 
 derived from rheumatism result from similar 
 diseased aetion, or from the presence in the 
 blood of similar morbific elements ? 
 
 147. I will assume that rheumatism is recogni- 
 zable by all physicians, and will merely allude 
 to what appears to me to be two well-marked 
 varieties of this affection. The one I will call 
 inflammatory rheumatism, which is most to be 
 dreaded, as to its effects on the heart ; the other 
 I will call neuralgic rheumatism. The former is 
 attended with fever, tenderness and acute pain and 
 immobility of the muscles and joints implicated. 
 The latter is recognized by a persistent dull 
 ache, increased to an ache with partial numb- 
 ness, by excessive use of the affected limb or 
 part, but never attended with those flashes of 
 agony which characterize pure neuralgia. This 
 
170 DISEASES OF THE HEART ; 
 
 kind of rheuraatism is certainly curable in the 
 great majority of cases with quinine and opium 
 in combination, given in small doses, aided by 
 colchicum and whiskey given in regular doses 
 and in mixture. Alcoholic beverages are to be 
 avoided ; vinegar, sugar and fruits must not be 
 used. If there is anemia, cod-liver oil, with syrup 
 of wild cherry and whiskey will hasten the cure. 
 From one to six months of this treatment will be 
 required, in neuralgic rheumatism of the hip 
 joint after gonorrhoea, or in neuralgic rheuma- 
 tism of the lumbar region, or of the shoulders, or 
 feet and ankles. 
 
 148. Acute or chronic inflammatory rheuma- 
 tism is certainly curable in a great majority of 
 cases by propylamin and laudanum, and aloetic 
 aperients. But I am of the opinion that it will 
 often be found requisite to give ten times the 
 dose recommended by Dr. Awenarius, who first 
 recommended it in this disease. I have cured so 
 many cases with these means alone, that I now 
 use scarcely anything else. I have had no suc- 
 cess with stimulants, nor with fatty food. Here, 
 as in neuralgic rheumatism, vinegar, sugar, fruits, 
 fermented beverages, etc., are not tolerated, ex- 
 cept there be anemia as a complication. 
 
 149. Leeches afford temporary relief, so do 
 
THEIR DIAGNOSIS AND TREATMENT. 171 
 
 stimulating liniments, and anodyne cataplasms; 
 indeed, moist heat, no matter how applied, so 
 that the air is excluded from the affected part. 
 Cathartics and small bleedings are no doubt 
 often of great benefit in the beginning of the 
 affection, if the patient be of full habit and in 
 good blood-making condition ; but after the first 
 few days, bleeding is worse than useless. The 
 aloetic pills, on the other hand, may be continued 
 during the whole course in laxative doses. 
 
 150. Absolute rest, in an apartment of uniform 
 and rather high temperature materially hastens 
 the cure. The diet should consist of rather thin 
 broths, with plenty of salt and no pepper. No 
 other alkali than the propylamin will be needed. 
 
 The sulphate of manganese, already mentioned, 
 I have no experience in, but it is well worthy of 
 trial as a preventive of the cardiac effects of 
 rheumatism. 
 
172 DISEASES OF THE HEART : 
 
 CHAPTER X. 
 
 Thoracic Aneurisms: Diagnosis and Treatment. 
 Cynosis and Atelectasis. 
 
 151. The anatomical relations of the g;reat 
 blood vessels of the chest render the diseases of 
 these structures most dangerous in their ten- 
 dencies and results. 
 
 152. Under the head of thoracic aneurism 
 may be comprehended aneurism of the aorta, or of 
 the innominata, pulmonary or bronchial arteries. 
 The diagnosis of thoracic aneurism in its earlier 
 stashes is always difficult and frequently quite 
 impossible ; for although its presence is always 
 attended with more or less objective and subjec- 
 tive symptoms, still there is no known pathogno- 
 monic indication upon which we can place im- 
 plicit reliance. As the tumor progresses in 
 growth, and fluctuation and pulsation become 
 evident, of course there can no longer remain 
 any doubt as to the nature of the disease. The 
 diagnosis of aneurism of the aorta will be aided 
 by a consideration of the mechanical effects such 
 an enlargement might be expected to produce, 
 and also the peculiar functional disturbances 
 which would most likely ensue from the conse- 
 quent pressure upon surrounding and adjacent 
 structures. 
 
THEIR DIAGNOSIS AND TREATMENT. 173 
 
 153. Thus, if a patient present no satisfactory 
 evidence of a stricture of the oesophagus, and yet 
 dysphagia be present, with an apparent obstruc- 
 tion to the passage of food at a point just oppo- 
 site the second intercostal space, aneurism of the 
 arch may be suspected. A similar obstruction 
 in the oesophagus at a lower point might be own- 
 ing to enlargement of the descending aorta, and 
 if still lower and just above the diaphragm, 
 aneurism of the thoracic aorta where this vessel 
 is crossed by the oesophagus would be probable. 
 The attendant functional derangements vary 
 with the location of the aneurism. Thus, spas- 
 modic laryngeal aflections would indicate pres- 
 sure upon the recurrent branch of the pneumo- 
 gastric nerve, at a point corresponding with the 
 posterior and inferior portion of the arch of the 
 aorta, and hence be suggestive of aneurism at 
 this point, or of the arteria innominata. If con- 
 striction of the chest be a prominent symptom, 
 aneurism of the ascending portion of the arch, 
 with consequent pressure upon the cardiac plexus 
 would be probable ; if orthopnoea or asthma, the 
 commencement of the descending portion, etc. 
 
 154. Displacement of the heart, not otherwise 
 accounted for — weak systole — contraction of the 
 pupils from pressure upon the sympathetic nerve, 
 evidence of aneurismal diathesis, hasmoptysis, 
 
174 DISEASES OF THE HEART : 
 
 angina pectoris, raucous voice, aphonia, inter- 
 costal neuralgia ; pain radiating from the chest, 
 or fixed at the upper portion of the thorax, swell- 
 ing of the feet or infiltrated condition of the eye- 
 lids are signs which will be construed by the in- 
 telligent physician, as their import in any given 
 case may jastify. 
 
 155. As the tumor enlarges, it may project 
 above the sternum, or by its pressure produce ab- 
 sorption of the osseous and cartilaginous walls of 
 the chest, presenting itself as a soft, palpable and 
 pulsating tumor. The above remarks are all, 
 more or less, applicable to aneurism of either the 
 pulmonary arteries or of the innominata ; the 
 peculiar modifications dependent upon the anato- 
 mical relations of these vessels being remem- 
 bered. Thus, in aneurism of the innominata, the 
 tumor can be felt and its boundaries defined ; it 
 may also produce dyspnoea and dysphagia, by its 
 pressure upon the nerves concerned in respiration 
 and deglutition. Its pressure upon the subcla- 
 vian artery may obliterate the pulse at the right 
 wrist ; or, if upon the trachea, threaten sufibca- 
 tion. A full consideration of the lesions of this 
 short but important artery belongs more properly 
 to the province of surgery than to that of prac- 
 tical medicine. 
 
THEIR DIAGNOSIS AND TREATMENT. 175 
 
 156. Aneurisms of the pulmonary or bronchial 
 arteries are comparatively rare, and their diag- 
 nosis is, perhaps, in most cases impracticable. 
 We should here, however, expect the symptoms 
 to be more intimately connected with pulmonary 
 complications than in similar affections of the 
 aorta or innominata. In such obscure cases the 
 practitioner should be guided by the light of 
 anatomy and physiology, without which the most 
 simple problem in diagnosis may become an in- 
 comprehensible mystery. 
 
 157. Auscultation and percussion are invalu- 
 able as enabling us in many instances to diagnose 
 thoracic aneurisms before their presence could be 
 communicated to the senses through any other 
 channel ; they are neither, however, infallible, 
 and as is true of all other means at our command, 
 are only susceptible of a limited practical appli- 
 cation. 
 
 158. The ''aneurismal bruit'^ is neither con- 
 stant nor pathognomonic, but is of value when 
 taken in connection with other signs. 
 
 159. When this bruit is present, it is not unlike 
 the sound produced by whispering the letters 
 h-w-he e u-w, thrown together in the form of a 
 word ; it may, however, vary in pitch and inten- 
 sity, be slightly musical, rasping or blowing, or 
 
176 DISEASES OP THE HEART : 
 
 all these variously combined. A "jogging^' 
 sound is supposed to indicate aortic dilatation. 
 When these sounds are heard, they are, of course? 
 systolic, and must be distinguished from valvular 
 murmurs by their location, direction of propaga- 
 tion, etc. Percussion may be of value. It can 
 prove that resonance is decreased over the region 
 of the disease in these cases ; it tells- us nothing 
 more, however, except the probable size of the 
 tumor. It does not tell us whether the dullness 
 is caused by a fibrous, encephaloid or aneurismal 
 growth. 
 
 160. Treatment, — The disease is incurable; and 
 if we can prevent, temporarily the fatal issue, it 
 is all that can be expected. Spontaneous cure is 
 a theoretical possibility, but too remote to con- 
 stitute a foundation for reasonable hope. The 
 treatment should consist of such management of 
 the case as will be most likely to keep the circu- 
 lation equalized, and in theory better still if the 
 heart's action is constantly kept below its normal 
 force. The habits of the patient should be strictly 
 regular and temperate in all things. Venereal 
 excesses should be especially forbidden, and pas- 
 sive rather than active exercise permitted. In 
 some advanced cases, absolute rest must be en- 
 joined. Tracheotomy may temporarily prolong 
 life where laryngeal symptoms threaten imme- 
 
THEIR DIAGNOSIS AND TREATMENT. 177 
 
 diate suffocation. The treatment of aneurisms 
 of the innominata is more properly a surgical 
 topic. The innominata has been ligated a num- 
 ber of times, but only once successfully. 
 
 161. Cyanosis is generally the result of a con- 
 genital defect in the heart, such as the non-closure • 
 of the foramen ovale, and of the ductus-arteri- 
 osus. There may be a congenital opening in the 
 septum ventriculorum. It may also depend on 
 arrest of growth, either before or after birth, of 
 the root of the pulmonary artery, whereby its 
 orifice is rendered permanently too small ; this 
 may be the only congenital defect, the venous and 
 arterial blood not mixing at all. In this case, 
 the blue tinge of the skin is as easily accounted 
 for as in the other malformations. 
 
 RoKiTANSKY has seen cases of narrowed pul- 
 monary artery without cyanosis. This fact has 
 been often remarked by other observers. The 
 foramen ovale is frequently open, and yet there 
 is no commingling of arterial and venous blood, 
 unless the pulmonary orifice is constricted. Hence 
 it is probable that obstruction at the ostia of the 
 heart, from constriction or other cause, combined 
 with patent foramen ovale, open septum ventri. 
 culorum, patent ductus arteriosis, or insufficient 
 tricuspid valves, is necessary to the production 
 
 V 
 
178 DISEASES OF THE HEART : 
 
 of cyanosis. The venous stasis, and red and 
 purple blood mixture, theories are neither true 
 alone, but when both exist at the same time, 
 cyanosis must result. But really the consid- 
 eration of this disease hardly comes within my 
 theme— it belongs to works on malformations 
 of the heart, among which that of Dr. Peacock is 
 excellent; but I will merely add, that we shall 
 find hypertrophy of the right ventricle, etc., etc.. 
 the same catalogue as that which results from 
 mitral obstruction and patency. The treat- 
 ment is not peculiar, but more difficult, because 
 it has to do with children who have not yet ar- 
 rived at accountable age. Passive exercise, slow 
 movements, restricted and select diet, pure air, 
 special treatment on reflex principles, of the par- 
 oxysms of dyspnoea or syncope that frequently 
 occur, are all that can be suggested. The affec- 
 tion is in the end fatal, and this result may be 
 postponed, but not averted, even by the most 
 rational treatment. 
 
 162. The lividity of atelectasis of the lungs, 
 (non-distension of air vesicles,) sometimes mani- 
 fested in the new-born, cannot be mistaken for 
 cyanosis, resulting from malformed heart. The 
 former sometimes disappears after a violent fit of 
 coughing ; the latter is persistent during life. 
 
THEIR DIAGNOSIS AND TREATMENT. 179 
 
 CHAPTER XI. 
 
 GENERAii Rules for Diagnosis of Diseases of the 
 Heart. 
 
 I. If the patient, otherwise in good health, 
 complain of uneasiness in the prsecordial region, 
 cardiac disease may be expected. 
 
 II. If a murmur be heard at the base systolic 
 in time, (that is, with the first sound of the heart) 
 which diminishes in intensity as the ear is moved 
 towards the left nipple, it indicates roughness of 
 the semilunar valves, or constriction or roughness 
 of the aortic orifice. 
 
 III. If a systolic murmur be heard at the prse- 
 cordia, and if it increase in intensity as the ear 
 is moved toward the left nipple, and diminish as 
 the ear is moved up the sternum, it indicates 
 mitral regurgitation^ that is, insufiiciency of the 
 mitral valves, 
 
 IV. A murmur heard at the base of the heart 
 (about the junction of the third ribs with the 
 sternum,) thence down the sternum, coincident 
 with the diastole, (second sound of the heart,) 
 indicates aortic regurgitation. If to this sign be 
 
180 DISEASES OF THE HEART; 
 
 added visible superficial pulses, and a liammering 
 pulse at the wrist, aortic regurgitation is certain. 
 
 V. A murmur coincident with the second sound 
 heard about the left nipple, or in the fifth inter- 
 space below and to the right of left nipple, and 
 along the heart towards its base, and no where 
 else, indicates mitral constriction; [\his murmur 
 is very rarely heard.] If to this be added a slight 
 cough, the lungs being .sound, and hypertrophy 
 of the right ventricle — mitral constriction is 
 indubitable. 
 
 VI. A murmur heard loudest above the base 
 of the heart in the upper part of the thorax, indi- 
 cates aneurism of the aorta, or innominata, or 
 subclavian artery. If to this sign be added a 
 pulse of unequal strength in the two wrists, or 
 absent in one wrist, aneurism is almost cer- 
 tain. Difficulty of deglutition and paroxsyms 
 of dyspnoea add greatly to the probabilities of 
 aneurism ; indeed, with the preceding signs, ren- 
 der it indubitable. 
 
 VII. If there be bulging o'f the left side, near 
 ' the mid.sternum, and heaving impulse of the 
 
 heart, and strong full pulse, there is hypertrophy 
 of the heart. 
 
 VIII. If there be a visible undulatory impulse, 
 no heaving of chest if the pulse be not strong 
 
THEIR DIAGNOSIS AND TREATMENT. 181 
 
 nor very resistant, if the first sound of the heart 
 be clear and more distinct, and seem nearer the 
 ear, and have more of a knocking character, 
 than normal, there is dilatation of the heart. If 
 there be much bulging of the interspaces, and 
 if the pulse be strong for dilatation and not 
 strong enough for hypertrophy ; if the apex be 
 outside of the left nipple and below the sixth 
 rib, there is hypertrophy with dilatation. If 
 there be also dropsy of the lower extremities, the 
 probabilities of dilatation become certainties. 
 
 IX. Basic murmur, coincident with first sound, 
 heard loudest at the junction of the third costal 
 cartilage with the sternum, and thence down the 
 sternum, attended with persistent jugular pulse, 
 indicates almost positively tricuspid regurgi- 
 tation — insufficiency of the tricuspid valves — if 
 to these two signs general turgidity of the venous 
 system be added tricuspid regurgitation becomes 
 certain. 
 
 X. An endocardial murmur^ whether systolic or 
 diastolic, whether at the base or apex, heard 
 suddenly during the course of an acute rheuma- 
 tism, or after a violent blow on the prsecordia, 
 or during Bright^s disease of the kidneys, indi- 
 cates endocarditis in the most positive manner. 
 
 XI. An attrition or friction sound heard over 
 
182 DISEASES OP THE HEART: 
 
 the prJECordia, (IT 5, p. 11.) that is, over the fifth 
 left costal cartilage, while the patient holds his 
 breath, indicates pericarditis, in the most positive 
 manner. 
 
 XXL Softening of the heart, without fatty de- 
 generation, occurs only in cases of asthenic or 
 adynamic diseases of an inflammatory nature. If 
 in such cases the pulse grow feeble out of ratio, 
 with the intensity of the adynamic disease — for 
 example, a typhus or typhoid fever — and remain 
 weak and unequal, become easily excited and 
 fluttering, if at the same time the patient feel 
 steady praecordial uneasiness, softening, of the 
 non-fatty variety, is extremely probable. 
 
 XIII. If the same symptoms mentioned in the 
 foregoing rule be observed ivi^hon-vivant of luxu- 
 rious and idle habits, especially if he be at the 
 same time an intemperate drinker, /a/^y degener- 
 ation of the heart is almost indubitable. If to 
 these symptoms be added epileptiform seizures, 
 and if the respiration varies greatly in uniformity 
 as to frequency and force without any external 
 cause, and at the same time the patient be over 
 forty years old, fatty degeneration may be con- 
 sidered certain. 
 
 XIV. Angina pectoris cannot be mistaken if 
 
 ! 
 
THEIR DIAGNOSIS AND TREATMENT. 183 
 
 the suffocation praecordial pain, the dread of im- 
 minent death, have once occurred, so as to be 
 described by the patient in these or similar terms, 
 without having been questioned by the physician. 
 The symptoms pertain, in their clearness and 
 pertinence, to no other affection. 
 
 XY. A murmur coincident with the first sound 
 heard at the base and propagated up the aorta, 
 in an anemic person, or in a person whose blood 
 under the microscope exhibits defect of red or 
 excess of white globules, is an inorganic murmur, 
 and indicates merely altered condition of the 
 blood, or altered dynamism of the heart. 
 
 General Principles of Treatment of Diseases of 
 THE Heart. 
 
 I. The first and most important principle to 
 be kept in view in treating a diseased heart is 
 to diminish the labor it has to perform. 
 
 II. This is done in two ways, a. Directly, by 
 diminishing the amount of blood in the body; h. 
 By diminishing the functional activity of all tlie 
 organs not directly concerned in secretion, and by 
 increasing the functional activity of the skin, 
 liver, kidneys, lungs and ialimentary canal. 
 
184 DISEASES OF THE HEART : 
 
 HI. a. Bbod may be abstracted directly, either 
 from the arm by venesection, or from the prae- 
 cordia by cups, when from general plethora or 
 overwhelming local congestion, a sudden diver- 
 sion to the blood current is deemed essential; 
 or the total quantity of blood in the system may 
 be diminished by reducing the weight of the 
 body — the loss of eight pounds of weight is the 
 loss of one pound of blood. 
 
 h. Blood never is to be taken with a view of 
 cutting short an inflammation, or curing either 
 an acute or clironic affection, but merely for ihe 
 purpose of relieving an urgent symptom, or ar- 
 resting an imminent catastrophe. 
 
 c. On the other hand, bleeding is not so hazard- 
 ous as many would wish us to believe, d. If the 
 digestive organs are unimpaired, loss of blood 
 by hemorrhage is restored with astonishing ra- 
 pidity, e. In this respect, anemia from traumatic 
 hemorrhage or venesection is widely different 
 from pathological anemia, depending on lesions 
 of nutrition, assimilation and innervation ; in 
 short, on lesions of all the organs of the body. 
 /. Blood deterioration in this case is repaired 
 with extreme slowness, and this is not to be used 
 as an argument against venesection, leeching, or 
 cupping. A few pints of beef tea will restore as 
 
THEIR DIAGNOSIS AND TREATMENT. 185 
 
 many red globules as are removed by a copious 
 bleeding. 
 
 TV, So local bleeding, even in anemia of slow 
 growth and long duration, is not always objec- 
 tionable to mitigate a threatening local symptom. 
 a. For example : take a case in another depart- 
 ment of pathology. A child of six months, more 
 or less, badly nourished with insufficient mother^s 
 milk, and cow^s milk and farinaceous mixtures, has 
 chronic diarrhoea. In the course of treatment 
 we intentionally diminish without arresting the 
 diarrhoea : the child now has tonic spasm of the 
 fingers and toes, the eyes pitch back under the 
 brow, or look straight onward, seeing nothing; it 
 rolls its head and moans, and starts with sudden 
 shrieks. This child is anemic, very pale, waxy 
 almost, but its head is burning hot. Now, if a 
 single leech be applied at the anterior fontanello 
 and allowed to fill, and after it drops oflP, the 
 bleeding be encouraged by the application of 
 compresses wrung out of hot water, not only over 
 the bite, but over the whole top of the head, for 
 the space of a whole hour; if this be done within 
 the first twelve hours after the tonic spasm be- 
 comes manifest, the chances are more than two 
 in three the child will recover, providing it be 
 nourished with beef juicCj and medicated solely 
 
186 DISEASES OP THE heart: 
 
 with minute doses of creosote subsequently, and 
 kept warm at the abdomen and extremities. 
 6. Now, (his is a case in which an apology is 
 needed for bleeding, if an apology is ever needed; 
 yet I have bled in twenty recorded cases in this 
 manner, and in seventeen have had the satisfac- 
 tion of seeing my little patients recover. 
 
 V. As a general rule, depletion by bleeding is 
 not required in diseases of the heart. 
 
 YI. By abstinence from hard labor, mental or 
 physical; by abstinence from all severe exercise, 
 and by avoiding all violent emotions or passions, 
 the demands of the heart are obviously lessened, 
 and hence its labor lightened. 
 
 YII. By aperients regularly taken, by diure- 
 tics often repeated, by hepatic stimulants taken 
 from time to time, by unobstructed access to the 
 atmosphere at all hours of the day and night, by 
 baths, frictions and abundant passive exercise, 
 the functions of the liver, skin, lungs, kidneys and 
 alimentary canal are certainly increased, and 
 that not in a way to be detrimental to alimenta- 
 tion, assimilation and nutrition. 
 
 VIII. Whatever degree of sedative impression 
 we desire to make on the heart, must be made 
 slowly, not suddenly. A violent blow on the pit 
 of the stomach will stop the heart forever. A 
 
THEIR DIAGNOSIS AND TREATMENT. 187 
 
 thousand light blows or a heavy weight would 
 produce but little effect. Small doses of cardiac 
 sedatives, often repeated and carefully watched, 
 are better than large ones, however judiciously 
 administered. 
 
 IX. The quality of the blood must he main' 
 tained as near the normal standard as 'possible^ while 
 its quantity may he diminished by restricted diet, 
 and certain evacuants^ in proportion as the disease of 
 the heart advances. 
 
 CHAPTER XIL 
 
 General Reflections as to Prognosis in Organic 
 Diseases of the Heart. 
 
 163. Heart disease destroys life in three ways: 
 a, by syncope ; 5, by apncea ; c, by so interfering 
 with assimilation as to cause gradual destruction 
 of life from inanition — starvation, not from defec- 
 tive food or defective appetite, but from defective 
 assimilation and aeration of the blood. 
 
 By far the most common special organic disease 
 of the heart is that of the mitral valves. Insuffi- 
 ciency of the mitral valve is exceedingly common 
 in this city : cases may be counted by hundreds. 
 Now, what is the result ? Insufficiency of this 
 
188 DISEASES OF THE HEART : 
 
 valve is not incompatible with the longest life. 
 If the insufficiency be slight, but little blood is 
 repelled at the ventricular systole into the left 
 auricle, and this becomes slightly or not at all 
 hypertrophied ; the left ventricle in such case 
 may remain unhypertrophied. But the usual 
 course is, the left auricle thickens; the pulmonary 
 vessels become congested, more or less, with the 
 refluent blood; this reacts on the right ventricle, 
 which becomes hypertrophied. Here the case 
 may remain stationary for years, or for life; and 
 rational treatment may greatly help to insure 
 this result ; but usually, from neglect or other- 
 wise, the disease advances. The thin-walled 
 right ventricle, being only designed for impelling 
 the venous blood through the pulmonary arteries 
 and capillaries around to the left side of the 
 heart, laboring under the great burden of re- 
 jecting the increased volume of blood thrown 
 back up*on it from the powerful left ventricle, now 
 itself reinforced by hypertrophy, and aided in its 
 damaging ability by the dilated pulmonary ves- 
 sels, begins to dilate. Now nature steps in again, 
 to counteract one disease by another. The tri- 
 cuspid valves become incompetent, from the dila- 
 tation of the right ventricle, and part of the 
 venous blood is repelled by the systole of the 
 right ventricle upon the vena cavce, and again 
 
THEIR DIAGNOSIS AND TREATMENT. 189 
 
 there is rest. Even now, by judicious treatment, 
 by reducing the weight of the body, and hence 
 the volume of blood, while assimilation is not 
 allowed to become impaired, life may continue 
 for many years, and the patient die perhaps of 
 old age. But generally no steady persistent 
 treatment is permitted by the patient. He goes 
 from one good physician to another, and obeys 
 none long enough to receive permanent benefit, 
 and in the nature of the case he is unable 
 to treat himself judiciously ; hence the disease 
 enters on its third and last stage. The heart in 
 its enfeebled condition being overworked, by 
 having to impel too much blood relative to its 
 ability, makes new efi'orts at reparation in detail, 
 only to hasten the ultimate result : that of ren- 
 dering the heart totally incapable of performing 
 its functions ; thus, the left ventricle becomes 
 more hypertrophied, and if the left auricle has 
 not yielded to dilatation in excess of hypertrophy, 
 the left ventricle may also become slightly di- 
 lated at first ; but this dilatation never advances 
 far, for the left auricle soon yields, and becomes 
 so dilated as no longer to be able to afiect the 
 ventricle by its contractions. By this time the 
 dilatation of the right ventricle has become enor- 
 mous, and in excess of its hypertrophy. The tri- 
 cuspid is now constantly insufiicient ; the jugular 
 
190 DISEASES OP THE HEART : 
 
 pulse is always visible, night and day ; the lungs 
 are congested ; the breath gives out on the least 
 hurry. There is oedema of the lower extremities, 
 dyspepsia, congested liver, still more oppressed 
 respiration, greater lack of aeration of blood in 
 the pulmonic>esicles; face looks purple, or deep 
 red, perhaps maroon-colored. The patient is very 
 much disposed to be cold, seldom perspires; there 
 is occasional spitting of blood; the pulse becomes 
 weaker and less uniform, even in its weakness. 
 The end of such a case is obvious; but often such 
 a progress and result might be almost indefinitely 
 postponed. Insufficiency of the mitral valve, 
 while it is the most comnjon, is fortunately the 
 least fatal in its tendency of all the organic dis- 
 eases of the heart, and the most controllable by 
 systematic treatment. 
 
 164. Mitral constriction, if slight, is not in- 
 compatible with tolerable health and long life; 
 but when the constriction is considerable, its con- 
 sequences follow in more rapid succession. Here 
 the left heart remains unaffected, or may become 
 atrophied for lack of work ; for obviously, if the 
 constriction is so great as to admit but half the 
 blood current in a given time, the left heart has 
 but half work to perform. A moderate constric- 
 tion nature compensates, by the hypertrophy of 
 
THEIR DIAGNOSIS AND TREATMENT. 191 
 
 the right ventricle, and probably of the pulmonary 
 arterial walls also. The right ventricle also be- 
 comes hypertrophied all the more when the con- 
 striction is considerable, and this is, of course, 
 curative in its tendency; and if the hypertrophy 
 of the right ventricle balance the constriction 
 of the mitral orifice, so that by its action the 
 same amount of blood is forced through in a given 
 time, as though it were not constricted, then the 
 hj-pertrophy is absolutely compensatory, and prac- 
 tically the patient is cured. This no doubt does 
 sometimes happen and continue through a long 
 life. But generally it is far otherwise. 
 
 165. The blood not being able to flow into the 
 left ventricle in normal volume, accumulates in 
 the left auricle, which hypertrophies by increased 
 function ; but still being unable to impel the 
 blood onward as fast as it arrives, part of its 
 contractile force is expended backwards upon the 
 pulmonary veins, which becoming congested, im- 
 pede the onward current from the pulmonary arte- 
 ries, and so back to the right heart, as in mitral 
 insufficiency. Insufficiency being almost always 
 joined with constriction, we get the same train 
 of symptoms exaggerated, to which may be added 
 tendency to syncope, and sometimes, though 
 rarely, death from this calise ; because enoufrh 
 
192 DISEASES OF THE HEART : 
 
 blood may not reach the arteries, in consequence 
 of the constriction, to supply the brain ; but 
 almost always death occurs by apncea, as previ- 
 ously stated. 
 
 166. Disease of aortic valves, whether insuffi- 
 ciency or constriction, produces an opposite train 
 of symptoms, and is more speedily lethal in 
 its tendency; and, indeed, is less controllable by 
 treatment, whether hygienic or remedial. 
 
 167. Aortic obstruction, indicated by a sys- 
 tolic murmur, loudest at the base, that is, about 
 the middle of the sternum, opposite to the third 
 intercostal spaces, and aortic insufficiency, indi- 
 cated by a diastolic murmur, heard loudest at the 
 same place, and propagated down the sternum, 
 are more commonly met with jn middle or ad- 
 vanced age than in earlier life, and more fre- 
 quently in males than females; while females are 
 more liable to mitral disease than to any other 
 affection of the heart. 
 
 168. These two affections of the aortic valves, 
 when of long standing, are generally attended 
 with enormous eccentric hypertrophy of the left 
 ventricle, and final incompetency of the mitral 
 valve, congestion of the pulmonary vessels, and 
 finally, if the patient live long enough, hypertro- 
 
THEIR DIAGNOSIS AND TREATMENT. 193 
 
 phy and dilatation of the right heart, tricuspid 
 regurgitation, engorged systemic veins, impaired 
 blood, serous infiltrations, dyspnoea, cough, syn- 
 cope and death. The order mentioned is the 
 usual one in which nature attempts restoration at 
 every step of the advancing disease. 
 
 169. Hypertrophy of the left ventricle is com- 
 pensatory of obstruction or regurgitation at the 
 aortic valves, or of both; dilatation is a new 
 step in the fatal direction, and then mitral regur- 
 gitation comes in as. compensatory to that. Left 
 auricular hypertrophy and dilatation tends to 
 prevent the excessive injury to the pulmonary 
 vessels, by recoil from the ventricle, and then, 
 when this resource fails, the pulmonic valves in- 
 crease in strength, and the right ventricle takes 
 on hypertrophy, as a new compensation for the 
 ever widening mitral orifice. 
 
 170. Then another step in disease is dilatation 
 , of the right ventricle, followed by a compensa- 
 tory lesion, namely incompetency of the tricuspid 
 valves, with its attendant regurgitation ; then 
 disease, in the giving way of the valves of the 
 veins, before the refluent venous current and the 
 attendant venous congestions; then a final and 
 last effort at compensation in serous exosmosis or 
 dropsy. 
 
 X 
 
194 DISEASES OF THE HEART: 
 
 171. Thus it is seen that each advance of the 
 disease is met bj a compensatory lesion, which, 
 while it adds to the sum total of organic damage, 
 retards the fatal progress of each integral lesion, 
 reinforced, as it is, with all its antecedents. 
 
 172. At each of these compensatory struggles, 
 art is able to give nature valuable aid in the 
 prolongation of life, and in averting sudden acci- 
 dents. 
 
 173. A small aortic obstruction or a trifling 
 insufficiency of the semilunar valves, may be so 
 accurately compensated for by hypertrophy as to 
 produce inappreciable results, and not noti(;^bly 
 shorten life. A considerable insufficiency, with- 
 out obstruction, may be so compensated by hyper- 
 trophy as to produce no evil consequences, so 
 long as the mitral valves remain competent ; and 
 this latter result may be indefinitely postponed 
 by such treatment as has been suggested in former 
 chapters. . 
 
 174. The narrowing of the aortic orifice to 
 one-fifth its normal condition, is not incompatible 
 with the continuation of life and the enjoyment 
 of unsuspected health, providing it be recognized, 
 and the patient placed under rational treatment 
 and constant care; for it is quite probable the 
 left ventricle may become so strengthened 
 
THEIR DIAGNOSIS AND TREATMENT. 195 
 
 by hypertrophy and innervation, as to be able to 
 propel the blood with a velocity sufficiently in- 
 creased to compensate for the defective aperture 
 through which it has to pass. 
 
 175. Still it is not denied that aortic valvular 
 diseases are generally fatal at no long period 
 after their recognition, much more promptly than 
 other valvular lesions. A little hurry, a violent 
 passion, a sudden motion, is liable to surprise the 
 heart and cause its arrest for an instant, during 
 which syncope takes place, from lack of supply 
 of arterial blood to the ganglia, and this syncope 
 is too often final. 
 
 176. Tricuspid regurgitation is a fatal affection 
 and only less dangerous as to the imminence of its 
 result than aortic valvular disease. A fatal ter- 
 mination may be a long time postponed, by dimin- 
 ishing the volume of blood in the system, by means 
 of restricted diet, diuretics, evacuants, etc., ac- 
 cording to the general principle often suggested 
 in the course of this volume ; that is, by reducing 
 the iveigkt of the body without impairing the quality 
 of the blood. But the progress of tricuspid lesions 
 cannot be retarded to the same degree as those 
 of the mitral or even semilunar valves. And, 
 while it is well known that occasional dynamic 
 incompetency of the tricuspid, or slight organic 
 
196 DISEASES OF THE HEART : 
 
 incompetency is not incompatible with unsus- 
 pected health, yet it is no less true that consider- 
 able incompetency of this valve is incompatible 
 with assimilation, and with oxygenation of the 
 blood, and hence must prove fatal within a com- 
 paratively short period from the moment when it 
 becomes well established. 
 
 177. Fatty degeneration^ admits of postpone- 
 ment within narrow limits, as to its result ; but 
 the fatal end will arrive when least expected, 
 and often much sooner than the symptoms would 
 seem to render probable. 
 
 Acute pericarditis is seldom fatal. Acute eiido- 
 carditis is somewhat more frequently fatal, but 
 not more so than pneumonia. It almost always 
 leaves disease of tlje valves, which in the end 
 but perhaps not for half a century, produce death 
 by annulling the function of the heart. 
 
 178. Fibrinous-clots in the heart almost always 
 cause death in from three hours to as many days. 
 
 179. Ruptures of the heart, de natura suarum 
 are rapidly, though not instantly fatal. Cardiac 
 dropsies are curable by means already indicated. 
 
 180. Hypertrophy y or hypertrophy with dilatation^ 
 pure and simple, are possibly curable ; but such 
 a result is as improbable as that both or either 
 of these lesions can exist without organic disease 
 
THEIR DIAGNOSIS AND TREATMENT. 197 
 
 of the valves, of the lungs, or of the arteries ; or 
 at least without the presence of some external 
 obstruction to the circulation of great and 
 persistent inertia. 
 
 Finally : it may be affirmed that after the first 
 chronic lesion of the heart, the others come on — 
 first, compensatory; second* deteriorative; third, 
 compensatory ; fourth^ more deteriorative ; fifth, 
 compensatory ; and so on, until its function is 
 annihilated. 
 
 Corrollary, The whole object of treatment is 
 to aid nature in these purposes, by diminishing 
 the work the heart has to do, in proportion as its 
 functional ability diminishes, that is, in propor- 
 tion as its organic lesions advance. 
 
198 DISEASES OF THE HEART : 
 
 Matter Inadvertently Omitted in Chapter V. 
 
 Incompetency and constriction of right auriculo- 
 ventricular orifice, — Incompetency of the tricuspid 
 valves is recognized by tolerably certain signs, 
 not difficult of recognition or appreciation. Thus, 
 if there be persistent jugular pulse in all posi- 
 tions of the body, especially the upright, tricus- 
 pid incompetency is almost certain. There may 
 or may not be a blowing murmur heard over the 
 tricuspid, (that is, over the sternum between the 
 ends of the fourth interspaces at the right margin 
 of the breast-bone,) such a murmur would be 
 propagated up and down the sternum, in the 
 direction of both the venae cavae; but on account 
 of the feeble condition in which the right ven- 
 tricle usually is, from dilatation, at the period of 
 tricuspid incompetency, the murmur would be 
 inaudible a short distance from its origin; it is, 
 perhaps, never heard at the apex. The murmur 
 is much less frequent than the disease it indi- 
 cates, because, as already remarked, it is not 
 always audible ; and, moreover, it is often 
 marked by a loud regurgitant murmur, as mitral 
 incompetency generally precedes and co-exists 
 with tricuspid incompetency. Tf the incompe- 
 tency is considerable, there is generally oedema 
 of the lower extremities, though dropsy is not a 
 
THEIR DIAGNOSIS AND TREATMENT. 199 
 
 necessary result of any degree of valvular disease. 
 This affection is likely to induce headache from 
 cerebral congestion, and perhaps true softening 
 of the brain, from habitual venous congestion. 
 The treatment is that of dilatation^ and other val- 
 vular diseases. 
 
 Tricuspid constriction will rarely, if ever, fur- 
 nish an audible murmur. If heard at all, it 
 should be loudest at the ensiform cartilage, or 
 over the cartilage of the fourth right rib ; if 
 associated with tricuspid incompetency, there 
 might be a double murmur. In the present state 
 of knowledge, the positive diagnosis of tricuspid 
 constriction is simply impossible. This is not 
 much to be regretted, for it must be miraculously 
 rare, and if present, it has no fatal or dangerous 
 significance, unless it be very considerable. 
 
ERRATA. 
 
 There are several typographical mistakes, and some errors 
 in syntax in different forms, the proofs of which I did not 
 have an opportunity to revise, but as they do not affect the 
 meaning of the text, they are not referred to in the errata. 
 
 Omit " backwards," first line, page 22 ; page 102, for 
 "growth" read growths ; page 160, for "shreds of a fleshy 
 column" read shreds of the fleshy colunms ; page 95, for 
 " hypertrophous dilatation" read hypertrophy with dilata- 
 tion. 
 
APPENDIX. 
 
 A. 
 
 T 8, page 12. " The first sound of the heart is caused by 
 the closure of the auriculo-ventricular valves, mitral and tri- 
 cuspid," etc. In asserting this, I mean that the closure of 
 the auriculo-ventricular valves is the chief cause of the first 
 sound, and a cause which is no longer debatable, since it has 
 been repeatedly demonstrated as the most efficient, and at 
 least the climax of all the causes of the first sound. But 
 every well-practiced ear will appreciate the beginning of a 
 sound in the systole of the heart, of which the sudden tension 
 of the auriculo-ventricular valves is the complement ; thus, 
 in incompetent mitral valves, we appreciate a dull, muffled, 
 indefinite systolic sound, terminated by the murmur of regur- 
 gitation, instead of by the click of closure of a perfect mitral 
 valve. This dull, prolonged, muffled, undulatory sound, is, 
 to my mind, undoubtedly the muscular element of the first 
 sound, reinforced by the pressing stroke of the heart against 
 the thorax, and perhaps also by the rush of blood through 
 the aorta and pulmonary artery. I am sure the mechanism 
 and time of the first sound is appreciable, by the duration and 
 force of an indeterminable muffled sound, even when both the 
 tricuspid and mitral valves are incompetent. 
 
 B. 
 
 a, page 33. " But there is reason to believe its origin — 
 [arrest of the systolic movement of the heart] lies rather in 
 lesion of some portion of the cerebro-spinal axis, than in«,ny 
 
 a 
 
303 APPEl^DIX. 
 
 alteration in tlie structure of tlie heart itself." I grant tins 
 suggestion admits of no positive proof in the present state of 
 knowledge. The lucid experiments of Claude-Bernard have 
 shown that irritation of the pneumogastric nerve slows or 
 arrests the heart's contractions. Now, this is accomplished 
 whether the irritation be applied directly to the pneumogas- 
 tric nerve, between the heart and brain, or to the roots of the 
 pneumogastric in the lateral tract ; or to a branch of the 
 pneumogastric ramifying on the heart itself ; or, in short, to 
 any sensitive filament in any part of the body not of the 
 pneumogastric. If the irritation affects a sensitive nerve, it 
 is instantly reflected through the sympathetic upon the 
 heart ; and if the sensation be sufficiently violent or painful, 
 the heart is arrested either temporarily or forever; if mo- 
 mentarily, the pulse intermits ; if temporarily, the pulse 
 stops several beats ; if the arrest is only partial, the pulse 
 hesitates, but goes on. Now, all these phenomena are ob- 
 served in the variations of the pulse in the different lesions 
 of the heart. Hence I am compelled to modify the suggestion 
 in the text, quoted at the head of this note, and substitute 
 something like the following formula : There is reason to 
 believe the origin of arrest of the systolic movement of the 
 heart lies sometimes, in lesions, of the cerebro-spinal-axis — 
 for example, lack of supply of arterial blood to the portion of 
 the encephalon, in which the vagus originates ; [in conse- 
 quence of an atheromatous or ossified artery, etc., etc.,] or 
 some defect in the cerebrum, by which the motor function 
 fails to respond promptly to sensation, or irritation, etc. But 
 it is altogether probable that the cause of arrest of systolic 
 movement, whether temporary or perpetual, may and does 
 often exist in the very substance of the heart itself, or in the 
 quality or quantity of the blood circulating through it, or in 
 the occasional irritation produced by some analogous or 
 heterologous growth in or about the heart. So whether the 
 influence, irritation, sensation or impression, come from the 
 
APPENDIX. 203 
 
 surface of the body through the sensitive filiments, through 
 the cerebrospinal axis, or from the internal organs or tis- 
 sues through the sympathetic, or from the cerebrum enceph- 
 alon itself, in consequence of an intellection, an emotion, 
 or physical impediment, it is liable to cause arrest of the 
 systolic movement, or complete suspension of the heart's 
 action for a moment or forever, according to the nature and 
 force of the influence, etc. 
 
 Causes op Dropsy. — Dropsy is caused by something more 
 than mere venous or capillary obstruction. The blood must 
 become deteriorated in albumen before true dropsy can take 
 place. Dropsy is a demonstrative evidence of anemia. There 
 can be no dropsy without anemia, but there may be excessive 
 anemia without dropsy, because the transudation of serum 
 does not take place, even in true hydremia of the blood, un- 
 less there is also obstruction to the circulation. Dropsy does 
 not take place until the protein principles (which in the 
 blood are 79 in 1,000,) are reduced to 63 or 58 in 1,000. It 
 will be understood that dropsy is not an exudation of inflam- 
 mation ; the dropsical liquid contains no coagulable fibrin, an " 
 exudation does. The cause of dropsy in Bright's disease is 
 the diminution of albumen in the blood by the albumenuria, 
 in consequence of which the serum charged with still more 
 albumen, is apt to transude, and thus the blood is still fur- 
 ther impoverished, not merely by the abstraction of albumen 
 and fibrin in solution, but by the endosmosis chloride of 
 sodium [eight jDarts of chloride of sodium replace one of albu- 
 men] and water for its solution. The diminution of albumen 
 and increase of salts andtcater are rigorously coincident facte. 
 This diminution of albumen in the blood, then, is the true 
 cause of its capability of transudation ; and now, if we have 
 any obstruction to the circulation, we have dropsy. 
 
 From what is here suggested, it is easily understood why 
 
204 APPENDIX. 
 
 extreme constriction of tlie tricuspid orifice may be present 
 and dropsy be absent. Here we may have only one condition 
 of dropsy — obstruction to the venous circulation — wliile the 
 blood may contain its normal ratio of albumen, and so be in- 
 capable of transudation : but once impair this ratio from 
 75 to 60 in 1,000, and we.have dropsy. The integrity of the 
 blood is maintained by respiration and alimentation ; ob- 
 struct either and we induce a condition favorable to dropsy ; 
 hence the necessity of just alimentation, and the freest res- 
 piration in chronic diseases of the heart, since these are 
 always obstructive to the circulation. 
 
 The true indication of treatment for the cure of dropsy 
 is obvious — restoration of the blood to its normal condition 
 as to albumen, and removal of the obstruction to the circula- 
 tion. The latter in case of heart disease is impossible in a 
 direct but not in a relative sense. Thus, the weight of the 
 body may be reduced, and so the blood 1 to 8 ; and in some 
 cases it is practicable to so reduce the quantity of blood, 
 without impairing its quality, that the obstruction may be- 
 come null. If the blood be restored to its normal quality at 
 the same time, the transudation will be arrested, and the 
 existing dropsy will disappear by the natural secretory func- 
 tions, stimulated to unusual activity for a few days. 
 
 D. 
 
 On page 42, I said I would attempt, in a subsequent para- 
 graph, to explain the mode of death in disease of the mitral 
 valve. 
 
 It is now well understood that the cause of death in lesions 
 of the aortic valves is the lack of supply of arterial blood to 
 the ganglia, both cerebro-spinal and sympathetic, and that 
 the mode of death is by syncope. The immediate cause of 
 death in aortic lesion is very well stated by M Mauriac, 
 page 82. 
 
APPENDIX. 205 
 
 The cause of death in mitral lesions is altogether different. 
 Death is here caused by habitual congestions of all the organs 
 behind the mitral valve, the lungs, liver, kidneys, etc. Death, 
 when it occurs immediately, in mitral disease, is always by 
 apncea, and 'never by syncope. The breathing becomes diffi- 
 cult, long before death; the engorged capillaries transude 
 their excess into the cellular tissue, and cause those oedema- 
 tous infiltrations of the lower extremities so frequent in 
 mitral regurgitation. There are attacks of acute congestion 
 and even of inflammation of the kidneys, attended by albu- 
 menuria, by which the blood is stil more permanently deteri- 
 orated. As the disease advances, albumenuria becomes more 
 frequent and less curable. Now there is progressive loss of 
 flesh, recurring serous infiltrations (which are removable by 
 purgatives, dry diet, diuretics, expectorants, etc. ;) but the 
 struggle of art with an incurable disease cannot last always, 
 and if the patient does not die in a sudden paroxysm of 
 apnma, from pulmonary congestion and bronchial engorge- 
 ment, he eventually succumbs to the exhausting nature of the 
 disease, and dies from defective alimentation and aeration of 
 the blood combined. 
 
 For the views expressed on page 67, et passim, concerning 
 the cause of pain, I am indebted to " Radclifie on Pain," etc. 
 
 " E. 
 
 d. page 108. I do not wish to be imderstood that any 
 considerable eff'usion into the pericardium would not cause 
 prsecordial bulging, but simply that an efl"usion may be so 
 slight as to cause no appreciable alteration in the contour of 
 the thoracic walls. I have also omitted a sign which is very 
 distinctive of the effusion stage of pericarditis, when the effu- 
 sion is considerable ; that is, the marked increase of trian- 
 gular dullness in the direction of the apex of the rude tri- 
 angle represented by the heart and roots of the great vessels. 
 
206 APPEI^DIX. 
 
 The apex of this dullness has been known to rise as high as 
 the left clavacle, and the whole triangular dullness to occupy 
 the whole front and lateral portion of the thorax, w^liile the 
 base of the triangular dullness did not fall below its usual 
 place, the lower margin of the sixth rib. 
 
 F. 
 
 Page 110. " The absent first sound was as accountable on 
 the supposition of effusion, as of softened heart." This has 
 has been objected to, because it is said water is a good con- 
 ductor, and should transmit the first sound if it were present 
 In answer, I have only to say, that in this case more than 
 half of the first sound was absent by defect of mitral valves ; 
 and it is certain that the remaining portion could not be 
 heard as well through eight ounces of effusion as if the effu- 
 sion were not present ; moreover, the absence of the first 
 sound in fatty degeneration in the last stage is unaccountable 
 if the two sets of auriculo-ventricular valves are competent ; 
 that is, the absence of that portion of the first sound caused 
 by the click of the auriculo-ventricular valves ; for although 
 from the degeneration of the fleshy columns, on the contrac- 
 tion of which depend the click of the valves, the sound should 
 be diminished, yet if they shut with suflScient force and 
 promptness to resist the resilience of a sound aorta, they 
 should emit a sound as audible at the praecordia, as that pro- 
 ceeding from the same valves when the heart is oppressed 
 with a distended pericardium, and its own dynamism thereby 
 materially diminished, as also by the impediment to the 
 circulation of the blood in its own substance, which must 
 further materially diminish the vigor of the systoles. Hence, 
 the proposition quoted seems to me not inexact. 
 
 G. 
 
 Page 111. " Saline evacuants," are to be used only when 
 emaciation is still slight, or when with much loss of adipose 
 
APPENDIX. 307 
 
 and atrophy of muscular tissue, there is considerable dropsy. 
 In this latter condition only temporary benefit can be hoped 
 for, and the salines cannot be used with the same energy and 
 persistence as in the less asthenic dropsies. As a general 
 rule, whenever there is defective alimentation, and hence 
 impaired hematosis, the " warm" aperients or carthartics are 
 preferred to the salines : aloetic, or compound colocynth, pills, 
 or pills of rhubarb, aloes and senna, to which some carmina- 
 tive may be added, are perhaps the best, both in theory and 
 practice. But if the dynamic condition of the patient is such 
 as to tolerate it, (and that of the case mentioned was such 
 an one,) the saline treatment is much the best. A diuretic 
 mixture, composed of infusion of digitalis, acetate of potash, 
 spirits of nitrous ether and cinnamon water, is one of the 
 most- active diuretics with which I am acquainted. [We 
 need not exceed a drop an hour of the fluid extract of digi- 
 talis.] It must be remembered that diuretics produce less 
 effect on effusions in the pericardium than on cellular infiltra- 
 tions. 
 
 H. 
 
 Page 120, ^ 53. " Embolism from the accidental develop- 
 ment of the coagulating principle of the blood." The coag- 
 ulating 'principle (which is globulin, according to A. Schmidt, 
 who demonstrated it, and whose experiments have been 
 repeatedly verified,) is never developed " accidentally" in 
 point of fact, but is often left undestroyed by accident, and 
 this accident is doubtless the chief cause of emholism. Oldb 
 ulin is a principle common to all the histologic elements, but 
 it is an integral part of the blood globule itself — hence the 
 superior coagulating energy manifested by blood globules. 
 Blood drawn slowly, coagulates slowly, because the lining of 
 the blood-vessels in its normal state has the power of neu- 
 tralizing the globulin, else the blood could not remain fluid. 
 It may be stated, then, that so ^ong as the blood is uncon- 
 
208 APPENDIX. 
 
 taminated with any substance containing free globulin — as, 
 for example, a slired of lymph — and so long as the walls of 
 the vessels are in their normal condition, coagulation of 
 blood in the vessels will not take place, however, slow or 
 frequently interrupted the circulation may become, whether 
 from the action of veratria, by which the contractility of the 
 heart is impaired, or from the action of digitalis, or potassium 
 salts, by which the vagi are probably irritated and the 
 heart's systoles thus retarded, or whether from incompetent 
 mitral valves, by which a systole is wasted,'as to its effect in 
 propelling the blood ; none of these cause or even tend to 
 cause coagulation of the blood without the presence of the 
 coagulating principle. But directly a blood-vessel becomes 
 diseased in any one spot, say from inflammation so extensive 
 as to cause exudation of lymph on its inner coat, on that 
 point, we have a coagulating principle present, and the pro- 
 duction of minute emboli or thrombi begins. So, if there be 
 calcarious deposit in an artery, on a valve, or the endocardium, 
 and the deposit be not covered with the healthy lining of the 
 artery, or the healthy endocardium at that point, we have a 
 present negative cause of coagulation of the blood before 
 death — negative, because the action of the living lining of 
 the vessel is necessary to the decomposition of the globulin. 
 So uhenever, from any cause, a portion, small or large, of 
 surface of a vessel, or of the heart in contact vyith the blood, has 
 lost its vitality — that moment coagulation may begin at that 
 point. The torrent of the blood may prevent the formation 
 of emboli, and thus secure the patient from harm. Thus, in 
 the living organism, fluidity of the blood is maintained by 
 the healthy vascular walls, and by the simple physical action 
 of the decomposition of the globulin, or its transformation 
 into fibrinogen. 
 
 I have objected to giving sulphate of magnesia (page 128, 
 Jc,) because of its tendency when absorbed to induce coagula- 
 
APPENDIX. 
 
 tion of the dissolved fibrin of the blood ; thus it should favor 
 the production of thrombi in all lax conditions of the system. 
 Of course it would be less injurious in stlienic than in asthenic 
 inflammations ; it is less likely to do harm in large than in 
 small doses, because less likely to be absorbed. 
 
 L 
 
 The following tables of Bigot, on the thickness of the 
 walls of the ventricles, from Walshe, are of real practical 
 value. The measurements are in French lines. 
 
 MALES. 
 
 Left Ventricle - 
 
 Septum 
 
 Right Ventricle 
 
 Base, 
 t €8-122 
 4 5- 12 
 1 113-12! 
 
 Middle. I Apex. 
 5 19-122j3 95-122 
 
 1 29-24411 2- 61 
 
 rEMALES. 
 
 Base. 
 
 Middle. 
 
 Apex. 
 
 Left Ventricle - 
 
 4 3-8 
 
 4 4-5 
 
 3 13- 30 
 
 Septum .... 
 
 
 4 1-36 
 
 
 Right Ventricle 
 
 1 2-3 
 
 1 7-24 
 
 .673-720 
 
 " The mean thickness of the wall of the right auricle has 
 been estimated at about one line French by M. BouUand, 
 that of the left at one line and a half." 
 
 Valvular diseases are dangerous to life, and cause annoy- 
 ance and suffering in the following order : 
 Tricuspid incompetency. 
 Mitral constriction and incompetency. 
 Incompetency of aortic valves. 
 Pulmonary constriction. 
 Aortic constriction. 
 Incompetency of pulmonary orifice and constriction of the 
 tricuspid orifice, are so infrequent, and so little known, that 
 they cannot be estimated as to their effects. 
 
 Valvular diseases are not generally causes of sudden death ; 
 they are susceptible, as to their effects, of great alleviation, 
 and perhaps to arrest as to their progress. But it must al- 
 ways be borne in mind in estimating the prognosis, that one 
 of them— aortic incompetency — is liable to kill suddenly, and 
 without any marked warning of imminent danger. 
 
The following illustration of tbe thoracic regions and their contents, 
 copied from Walshe on the Heart, may be found convenient. 
 
 DiAQRAM, exhibiting the relationship of the heart and great Teasels to 
 the lungs, (in moderate inspiration,) and to the regions of the heart. 
 
 1 to 10 inclusive, ribs; a a supra-clavicular region; 6 6 clavicular; 
 c c infra-clavicular; d d mammary; e, t infra- mammary; /supra sternal; 
 g upper sternal ; h lower sternal; i i integuments turned back; ff 
 nipples; k right auricles; I right ventricle; m left auricle, appendix 
 almost solely seen; n left ventricle; o pulmonary artery; p arch of 
 aorta; the letter g^ indicating upper sternal region, is also on the 
 aortic arch, transverse portion; p (farther to the right) vena) cavte supe- 
 rior; rr innominate veins; s innominate artery; tt subclavian veins. 
 The dotted lines indicate the outlines of the thoracic regions; the dark 
 lines the edges of the luugs. The heart and vessels are supposed to be 
 
^z^ 
 
INDEX 
 
 Ao&TA, disease of ralves of, 179, 
 194, 195, 48, 85. 
 
 cause of sudden death in dis- 
 eases of valves of, 81, 22. 
 Aortic regurgitation, 172, 70. 
 
 obstruction, 192, 62. 
 
 incompetency, 54. 
 
 valves, location of, 12. 
 
 diastolic murmurs, 106. 
 
 orifice, narrowing of, 194. 
 
 valves, consequence of disease 
 of, 192. 
 Arteries, vermicular movement of, 
 
 64. 
 Ammonia, muriate of, 47. 
 
 and lavander, 144, 124. 
 Apex of heart, 10. 
 Atiricles, location of, see diagram. 
 Anatomical facts, 10. 
 Age, old, effects on nutrition, 18. 
 Auriculo- ventricular valves, 12, 13. 
 Arterial stimulants, 40, 45. 
 Antimony, 42. 
 Anemia, pulse in, 38. 
 
 perchloride of iron in, 43. 
 
 precordial uneasineai in, 38. 
 
 murmurs in, 101. 
 Anisurisni, 172, 180. 
 
 treatment of, 176. 
 
 bruit of, 175- 
 Arcus senilis, 154. 
 Argo. case ot, 117. 
 Angina ptctoris, 38. 41, 163. 
 
 pain of, neuralgic, 165. 
 
 diagnosis of, 164. 
 
 treatment of, 166. 
 
 Walsh e on, 168. 
 Animal diet, 144. 
 Arsenic pills, 162. 
 Atelectasis, 11 '^. 
 Alkaline springs, 129. 
 Alkulies, 121. 
 Alcaohulio 9timulii8, caution, 123. 
 
 Asthenic rheumatism, 123. 
 Attrition or Friction Murmur, 181. 
 
 Blowing Sound, 25. 
 
 Bromide of Potassium, 154, 137 . 
 
 Bright's Disease, 106, 108, 128. 
 
 Beef tea, 184. 
 
 Beef juice, 185. 
 
 Bleeding, local, 185. 
 
 in anemia, 185. 
 Blood, non-oxygenated, its effect!, 
 67. 
 
 when to be taken, 184. 
 Brandy, 124. 
 Blood deterioration, 184. 
 Blisters, 129. 
 
 Coffee, 40. 
 
 Causes of discrepancies of opinion, 
 
 5-8. 
 Courtezans, 15. 
 
 Constriction of mitral orifice, 95, 
 88. 
 
 aortic orifice, 62. 
 Chicken-breast, 100. 
 Corvisart, 112, 91. 
 Collin, 112. 
 Coagulation, not induced by itasis, 
 
 1-^8. 
 Cardiac atrophy, 133. 
 Cold sponge baths, 144. 
 Cyanosis, 177, 
 Case of inorganic murmur, J"6. 
 
 of organic murmur, ^.S. 
 
 of general disease of the heart, 
 45. 
 Capillary circulation, 50. 
 Cod-liver oil, 153.. 
 Clots in the heart, 163. 
 Cups, 42. 
 
 Carbonate of ammonia, 124. 
 Cod-liver oil, 170. 
 
INDEX. 
 
 Daiton, 12 
 
 Digitalis, ]43. 
 
 Digitalis, antimony and iron, 42. 
 
 argument against answered, 
 60. 
 Diagnosis of organic disease of the 
 heart, 24. 
 
 tricuspid regurgitation, 181. 
 
 of dilatation, i8u. 
 
 of endocarditis, 181. 
 
 of pericarditis, ]81. 
 
 of hypertrophy, 180. 
 
 of aneurism, 17 2, 180. 
 
 of mitral constriction, 180. 
 
 of aortic regurgitation, 179. 
 
 of roughness or constriction of 
 the aortic orifice, 179. 
 
 of inorganic murmur, i83. 
 
 of softening of the heart, 182. 
 
 of fatty degeneration, 132. 
 
 of angina pectoris, 183. 
 
 of hypertrophy of left ven- 
 tricle, 135. 
 Dropsy, 60. 
 
 cardiac, 196. 
 
 Appendix C. 
 
 of the extremities a measure 
 
 of valvular disease, 51, 52. 
 
 Differential diagnosis of endocarditis 
 
 and pericarditis, 104. 
 Dilatation, diagnosis of^ 141. 
 
 pulse in, 142 
 
 sexual inclination, 142. 
 
 treatment of, 143. 
 
 Piorry's treatment of, 145. 
 
 General rule in treatment of heart 
 
 diseases, 187. 
 Growths heterologous, 16. 
 Guffroy's cod-liver extract in ■oft- 
 
 ening, 152. 
 
 HxART, form and location of, 10. 
 
 acute disease of, 14. 
 
 forgetfulness, 53. 
 
 oedema of, 132. 
 fiope, 90. 
 
 Ilydro-pericardium, 132. 
 Hypertrophy, 134, 193, 196. 
 
 of right ventricle, 193. 
 Hypertrophy of valves, 133. 
 
 and dilatation, 134, 196. 
 
 diagnosis of, 136. 
 
 bromide of potassium in, 137. 
 
 treatment of, 138. 
 
 pulse in, 136. 
 
 caae of, 140. 
 
 with fatty metamorpboiii, 
 134. 
 Haemo-pericardium, 131. 
 
 endocardium, 131. 
 Heart's cavities, 133. 
 
 Introduction, 6. 
 
 Inflammation of heart's membranes, 
 
 103. 
 lodinized injections after 
 
 pericardium, 132, 
 Iodide ol potassium, 129. 
 
 tapping 
 129. 
 
 Jot, 13. 
 
 Jugular pulse, 46. 
 
 Erotic passion, 15. 
 
 Endocardial Murmur, significance Latham, 26. 
 
 of, 181. 
 
 Endo-pericarditis, acute and chro. 
 nic, 131. 
 
 Frimissement Cataire, 89, 91. 
 Friction sound, 97. 
 Fatty degeneration, diagnosis of, 
 153. 
 
 case of, 154. 
 
 pulse in, 155. 
 
 difficulty of diagnosis of, 160. 
 
 treatment of, 161. 
 
 prognosis in, 176. 
 Fibrinous clots, 196. 
 First sound, 11. 
 Flint Austin, 88. 
 
 Gtllic acid in Bright's disease, 128. 
 
 Laennec, 71. 
 Life, liow destroyed by heart dii- 
 ease, 187. 
 
 Murmurs and frictions how diatin- 
 guished, 19, 20, 21. 
 propagation of, 22- 
 from roughened valves, 24. 
 organic and inorganic, 96. 
 "come and go," 98. 
 diastolic not always organic, 
 
 101. 
 regurgitant aortic, 48, 24. 
 mitral diastolic, or direct, 48. 
 in disease of pulmonic valves, 
 
 84, 87. 
 systolic tricuspid, 114. 
 Mitral valve, location of, 12. 
 
Mitral Valve, diagnosis of incom- 
 petency of, 32. 
 diastolic murmur of, 88. 
 constriction, treatment of, 95, 
 Meckel's case of narrowing of aorta, 
 
 64. 
 Markham, 114. 
 Manganese, sulphate of, 126. 
 Mitral constriction, consequences 
 of, 190. * 
 mode of death in, 192. 
 
 Nitrate of potash, 127. 
 
 (Edema of heart, 132. 
 
 Order of frequency of affection of 
 
 heart's cavities, 134. 
 Opium, 128. 
 Order of advent of cardiac lesions, 
 
 197. 
 Obstructions in lungs, effects of, 
 ]34. 
 of tricuspid, 200. 
 
 Pulse, intermittent. Si., 
 see Appendix B. 
 rhythmical intermittence of, 
 
 37. 
 jugular, 49. 
 how reduced, 61. 
 depressibility of, 84. 
 Pulses, visible, 64. 
 Purgatives, 128. 
 
 Praecordial region, how found, 11. 
 Permanent disease of the heart, 
 
 whence derived, 16. 
 Pain, 52. 
 
 Palpable or visible thrill, 94. 
 Pericarditis, 106. 
 
 characteristic sign of, 107. 
 
 treatment of, 1 20, 
 
 rheumatic, 1'22. 
 
 alkalies in, ]24. 
 
 sthenic and asthenic, 126. 
 
 purgatives in, 
 
 and endocarditis, treatment 
 
 of, !28. 
 tapping in, 129. 
 hypertrophy from, 130. 
 Propylamin, 121, 170. 
 
 and laudanum in rheumatism, 
 Piorry's diagnosis and treatment of 
 dilatation and hypertrophy, 
 145. 
 PrfiBCordial region, 11. 
 Principles of treatment of disease of 
 heart, 283. 
 
 Prognosis in diseases of heart, gen- 
 eral reflections on, 187. 
 Perchloride of iron, 143. 
 
 Rheumatism, 169. 
 
 of two kinds, 169. 
 
 sulphate of manganase in, 171. 
 Rokitansky 177. 
 
 Regions of the chest, see diagram. 
 Region praecordial, 11, 12. 
 Rest in bed, etc., 44. 
 Right ventricle, dilatation of, 173. 
 
 hypertrophy of, 173. 
 Rupture of heart, 158, 196. 
 
 Morel la Vallee's case, 169. 
 Rules of diagnosis of disease of heart, 
 179. 
 
 Second Sound, 13. 
 
 how produced, 25: 
 
 where heard, 12. 
 Sounds, how propagated, 24. 
 Sound first, how caused, 12. 
 
 Appendix A. 
 Systoles retarded, see Appendix B. 
 Sign, Dr. Corrigan's, 54. 
 Skoda, on mitral constriction, 90. 
 Sudden death, Mauriac's cases of, 
 72-5. 
 
 in disease of heart, mechanism 
 of, 78. 
 Sedative impression on the heart, 
 how it should be made, 186. 
 Softening of heart, 150. 
 
 causes of, 150. 
 
 simple, or non -fatty, 157. 
 
 Simple, treatment of, 162. 
 
 simple, prognosis in, 153. 
 
 fatty diagnosis of, 153. 
 
 fatty, case of 154. 
 
 pulse in, 156, 161. 
 
 case of, with rupture, 168. 
 
 first sound in. 161. 
 
 treatment, 161. 
 
 prognosis in, ]63. 
 
 connection with rupture, 168, 
 
 see Appendix F. 
 Sulphate of manganese, 129. 
 
 Tricuspid constriction, murmur of, 
 
 199, 
 Taraxacum and calomel, 144. 
 
 Valves, location of, 24. 
 aortic, 12, 194. 
 of pulmonary artery, 12. 
 mitral and tricuspid, 13. 
 
INDEX. 
 
 Valves, differential diagnosis In j Talves, tricaspld incompetency and 
 disea'-e of. 49. i constriction of; 175, 178, 
 
 of pulmonary artery, disease! 199. 
 
 of, 86. 
 
 tricuspid, temporarily in- 
 competent, 105. 
 
 pulmonic, second sound of, 
 
 32. 
 
 mitral mode of death in dis- 
 ease of, Appendix D. 
 Veins, valves of, 193. 
 Visible impulse, 135 
 
 
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