THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES A TREATISE DISEASES OF THE HEART. /' y^A.A> A TREATISE DISEASES OF THE HEART, O'B. BELLINGHAM, M.D., F.R.C.S., MBMBER OF THE COCRT OF EXAMINERS OF THE ROYAL COLLEGE Of SDRGEONS IN IRELAND, ONR OF THE MEDICAL OFFICERS OF ST. VINCENT'S HOSPITAL, AND ONE OP THE SECRETARIES TO THE SCRGICAL SOCIETY OF IRELAND. DUBLIN : FANNIN AND CO. LONDON: LONGMAN & CO. EDINBURGH: MACLACHLAN, STEWART & CO- 1853. DCBLIM : PRINTED BY JOHN MULIASV, 47, Fleet -Street. 7K0O BWt m3 ARTHUR JACOB, M.D., F.R,C.S., PROFESSOR OF ANATOMY AND PHYSIOLOGY TO THE ROYAL COLLEGE OK SURGEONS IN IRELAND, AND SURGEON TO THE CITY OF DUBLIN HOSPITAL, DISCOVERER OF THE MEMBRANA JACOBI OF THE HUMAN EYE, AND AUTHOR OP SEVERAL TREATISES ON OPHTHALMIC SURGERY, PROPRIETOR OF Cf)e JBubltn JVleliical ^vess, THE FOLLOWmG PAGES ARE KSCRIBED, AS A TEIFLING TESTIMONY OF THE AUTHORS ESTIMATION OF HIS TALENTS; NO LESS THAN TO MARK HIS SENSE OF THE SERVICES RENDERED BY DR. JACOB TO THE MEDICAL PROFESSION, THROUGHOUT IRELAND, IN FOUNDING AND CONDUCTING THE FIRST IRISH WEEKLY MEDICAL PERIODICAL, AND HIS OPINION OF THE ABILITY AND ENERGY WITH WHICH THE RIGHTS AND PRIVILEGES OF THE MEDICAL PROFESSION HAVE BEEN INVARIABLY ADVOCATED BY DR. JACOB IN THE PAGES OF THAT JOURNAL, PREFACE. The diseases which constitute the subject matter of this treatise are sufficiently frequent, and sufficiently distress- ing, to have always attracted a large share of the at- tention of the Profession ; it is only, however, since the discovery of auscultation that they admitted of being diagnosed with accuracy ; or, that the symptoms which characterize each, admitted of being laid down with precision ; and the School of Dublin may claim some share of the credit of having brought about this desir- able result. The present treatise is, in a great measure, founded upon Clinical Lectures delivered at different periods in St. Vincent's Hospital ; some of these lectures appeared at the time in the pages of the " Dublin Medical Press," others in the " London Medical Gazette ;" they were fa- vourably received by the profession ; and the author having been invited to publish them in a distinct form, has carefully revised them, added much additional matter, and re-written a considerable portion. The work consists of two Parts : the first contains a description of the healthy heart, its size, weight, and the VIU PREFACE. measurements of its chambers and orifices ; followed by sufficiently full details respecting its motions and sounds. The examination of the heart in disease is then entered upon, commencing with the physical signs ; the general signs, and the secondary or remote symptoms of cardiac disease are described in succession. The second part is devoted to the individual diseases of the heart, which are arranged according as their seat is the investing membrane, the lining membrane, or the muscular tissue of the heart, followed by a description of the functional or inorganic affections of the heart. The author's object in tliis publication has been to give a concise, though sufficiently complete, description of the heart in health, and disease. No point of any practical importance has been omitted that he is aware of ; and he has endeavoured, as far as lay in his power, to assign the credit of every original discovery or im- provement, in theory or practice, to its legitimate source. Kildare-streety May, 1853. CONTENTS. PAGE. Dedication, . . , . . v Preface, vii PART I. CHAPTER I. EXAMINATION OF THE HEART IN HEALTH. Description of the several parts of the Heart — Shape of the Heart — Divisions of the Heart — Circular and Longitudinal Grooves — Position of the Heart — Relations of the Heart — Connexions of the Heart, ... 1 Chambers of the Heart — Mode of Opening the Heart — Right Auricle — Right Ventricle — Tricuspid Valve — Pulmonary Orifice — Sigmoid Valves — Sinuses of the Pulmonary Artery — Left Auricle — Left Ventricle — Mitral Valve — Aortic Orifice — Semilunar Valves — Corpora Arantii — Sinuses of the Aorta 8 The Pericardium — Capacity of the Pericardium — Fibrous Layer of the Peri- cardium — Serous Layer — Cardiac Fascia — White Patches on Pericardium — Seat of — Nature and Causes of, .21 The Endocardium, 29 The Muscular Tissue of the Heart, 30 Nerves and Blood-vessels of the Heart, . . . . . .33 CHAPTER H. DIMENSIONS OF THE HEALTHY HEART. Length of the Heart — Breadth of the Heart — Conclusions respecting the Size of the Heart, 36 X TABLE OF CONTENTS. PAGE. Weight of the Heart— Absolute Weight of the Heart — Ratio of the Weight of the Heart to the Body — Comparative Weight of parts of the Heart — Conclusions respecting the Weight of the Heart, 39 Thickness of the Walls of the Heart — Left Ventricle — Right Ventricle — Septum Ventriculorum — Auricular Walls — Conclusions respecting the thickness of the Parietes of the Heart 42 Diameter of the Orifices of the Heart — Right Auriculo-ventricular Orifice — Left Auriculo-ventricular Orifice — Aortic Orifice — Pulmonary Orifice — Conclusions respecting the Diameter of the Orifices of the Heart, 47 Relative position of the several parts of the Heart to the Parietes OF the Chest — Relative position of the Orifices, .... 51 CHAPTER III. MOTIONS OF THE HEART. Auricular Systole — Auricular Diastole — Ventricular Systole — Ventricular Diastole — Order of succession of the Heart's Motions — Periods of Repose of the Heart, 55 FREaUENCY OF THE HeaRt's AcTION AND OF THE PULSE EffcCtS of PostUlC on the Pulse — Cause of the Influence of Change of Posture on the Pulse, 62 Ratio of the Pulsations of the Heart to the Respirations — Rapidity of the Passage of the Blood through the System — Force with which the Blood is propelled by the Left Ventricle, 67 Mechanism of the Action of the Valves — Auriculo-Ventricular Valves — Sigmoid and Semilunar Valves— Safety Valve function of the Tricuspid Valve, . . . . . . .70 CHAPTER IV. IMPULSE AND SOUNDS OF THE HEALTHY HEART. Mechanism by which the Impulse is Produced— Site of the Impulse — Alteration of the Impulse in Inspiration and Expiration — Double Iihpulse of the Healthy Heart, 76 Sounds op the Heart — Normal Limits and Intensity of the Heart's Sounds — Mechanism by which the Sounds are Produced, 81 TABLE OF CONTENTS. XI PAGE. Theories of the Cause of the Sounds of the Heart— First Sound — Theory of Sound being Produced by the Impulse — Theory of Muscular Contraction — Theory of the CoUision of the Opposite Walls of the Ven- tricles — Valvular Theory — Theory of Sound being Produced by the Motion of the Blood — Second Sound — Theory of the Sounds of the Heart most generally received — Remarks upon this Theory, 84 Theory of Friction between the Blood and the Parietes of the Ori- fices of the Heart as the cause of its Sounds — Pathological Evi- dence in favour of this Theory, 92 CHAPTER V. EXAMINATION OF THE HEART IN DISEASE. Impulse of the Heart — Diminution and Increase of the Impulse — Alteration in the Site of the Impulse — Metallic Cliquetis, 104 Turgescence and Pulsation of the Jugular Veins, .... Ill Fremissement Cataire — Circumstances under which Fremissement Occurs — Cause of Fremissement Cataire, 114 Signs Furnished by Percussion — Auscultatory Percussion — Alterations in the Extent and Degree of the Heart's Superficial Dulness — Conclusions respecting Percussion, 117 CHAPTER VI. SIGNS FURNISHED BY AUSCULTATION. Alterations of the Normal Sounds of the Heart — Alterations in the Intensity and Tone of the Sounds — Alterations in the Duration of the Sounds — Alterations in the Limits within which the Sounds of the Heart are Audible — Alterations in the Frequency of the Sounds — Alterations in the Rhythm of the Heart — Alterations in the Number of the Heart's Sounds, 123 Abnormal Sounds — Pericardial Friction Sounds, 132 Endocardial or Valvular Murmurs — Bruit de Soufflet — Circumstances under which Bruit de Soufflet is heard — Mechanism of Production of Bruit de Soufflet, 136 Xll TABLE OF CONTENTS. PAGE. Sawing, Filing, and Grating ValvulaH Murmurs, .... 146 Musical Valvular Murmur, 147 Arterial Murmurs— Arterial Bruit de Soufflet — Rough or Grating Arterial Murmurs, 149 Venous Murmurs — Continuous Venous Murmur — Musical Venous Murmur — Seat of the Venous Murmurs — Mechanism by which they are Produced, . 154 CHAPTER VII. GENERAL SIGNS OF CARDIAC DISEASE. Countenance in Heart Disease — Prominence of the Eyes — Arcus Senilis, 163 Posture of the Patient, . . . . . . . . . .166 Palpitation — Palpitation depending upon Organic Disease of the Heart — Palpitation independent of Organic Disease — Immediate Cause of Palpi- tation, 167 Epigastric Pulsation — Epigastric Pulsation in Emphysema of the Lungs — Epigastric Pulsation the Result of Congestion — Epigastric Pulsation in Pericardial Adhesion — Nervous and Hysterical Pulsation — Anaemic Pul- sation — Pulsation Communicated to Abdominal Tumours, . . .174 Angina Pectoris — Causes of Angina — Conclusions respecting Angina Pectoris 177 The Pulse in Cardiac Disease — Pulse in Hypertrophy of the Left Ven- tricle — Pulse in Dilatation of the Left Ventricle — Pulse in Aortic Regur- gitation — Cause of the Jerking Pulse — Pulse in Contraction of the Mitral Orifice — Pulse in Mitral Regurgitation — Pulse in Contraction of the Aortic Orifice — Pulse in Softening of the Heart — Summary of ths Princi- pal Varieties presented by the Pulse, 184 CHAPTER VIII. SECONDARY SYMPTOMS OF CARDIAC DISEASE.^ Congestion — The Pulrao-cardiac Function — The Vcno-pulmonary Function — Effects of Congestion, ' . ,196 Congestion of the Heart, 202 TABLE OF CONTENTS. Xlll Congestion of the Lungs — (Edema of the Lungs — Dyspncea — Starting in Alarm from Sleep — Cough — Haemoptysis — Pulmonary Apoplexy, . . 202 Congestion of the Liver, ......... 215 Congestion of the Gastro-Intestinal Mucous Membrane, . . 219 Congestion of the Brain — Disturbance of the Cerebral Circulation — De- ficient Supply of Blood to the Brain, 221 Polypoid Concretions in the Cavities of the Heart, .... 228 Cardiac Dropsy, 234 CHAPTER IX. CAUSES, PROGRESS, AND TERMINATION OF CARDIAC DISEASE. Causes of Cardiac Disease, 241 Progress and Duration of Cardiac Disease, ..... 245 Termination of Cardiac Disease, . . 250 ON DISEASES OF THE HEART. CHAPTER I. EXAMINATION OF THE HEART IN HEALTH— DESCRIPTION OF THE SEVERAL PARTS OF THE HEART. The Heart, the central organ of the circulation by which the blood is transmitted to the lungs, and to the remotest parts of the body, and to which the blood from the lungs and from every part of the system is returned, is a hollow muscular viscus, di- vided in its interior into several compartments, covered exter- nally and lined throughout by distinct membranes ; situated in the middle mediastinum, near the centre of the cavity of the thorax, about the junction of the superior with the two inferior thirds of the body ; lying between the lungs and the two layers of pleura which constitute the mediastinum, and enclosed in a proper fibro- serous capsule, the pericardium. The heart occupies the first place in the circulatory system ; its functions yield in importance to those of no other organ, for life is dependent upon its regular and constant action, and the healthy exei'cise of the functions of every other organ mainly de- pends upon its integrity. Hence its physiology and pathology have always constituted subjects of the highest interest to the medical inquirer, and its diseases have occupied the pen of some of the brightest ornaments of the medical profession. B 2 DESCRIPTION OF THE HEART. Although much valuable information, upon various points con- nected with our subject, existed previous to the discovery of aus- cultation, much, also, it must be confessed, remained unknown. Ijaennec's beautiful discovery opened up an altogether new means of investigating the diseases of this organ ; it added, in fact, a new sense to our other methods of detecting and distinguishing between them ; and it gave an impulse to the study of diseases of the thoracic viscera which has continued unabated to the present day. So that there are scarcely any other organs the physiology and pathology of which have made more rapid advances, and the present state of our knowledge of which so remarkably contrasts with that which prevailed at a period comparatively recent. If it be true, as a general rule, that abnormal conditions of organs cannot be recognised or distinguished without a knowledge of what constitutes their healthy state, and that derangement of function cannot be explained without an acquaintance with the functions in health, to no organ does this so peculiarly or with such force apply as to the heart ; and yet, until within a few years,. we had little positive information upon points apparently so simple as the size and weight of the healthy heart : erroneous opinions likewise prevailed respecting the thickness of the walls, the capacity of the cavities, and the diameter of the orifices of the healthy heart ; and nothing certain was known as to the mechan- ism by which its sounds are produced. It is obvious that unless correct ideas on these heads are entertained, we shall not be in a position to decide whether the parietes of the heart are hypertrophied or attenuated ; whether its chambers are dilated or preserve their normal dimensions ; or whether its orifices are increased or diminished in diameter. Unless the exact size and shape and position of the heart are known, deviations from its normal condition are liable to be over- looked, or functional derangement to be mistaken for organic disease ; and unless we are familiar with the normal sounds of the heart, with the situation at which they are best heard, and with the mechanism by which each is produced, we shall not be in a position to recognise abnormal sounds, iiiuch less to trace them to their source, or to determine their cause. I propose, therefore, previous to entering upon diseases of the heart, to consider briefly the anatomy and physiology of this DIVISIONS OF THE HKART. 3 organ ; to describe its exact position, and the relation of its several parts to points upon the surface, and to give a summary of the re- searches which have been made respecting its weight and size, the thickness of its parietes, the capacity of its cavities, and the dia- meter of its orifices. Shape of the Heart The shape of the heart is almost too well known to require description; the older anatomists compared it to a pyramid, or to a flattened cone ; but a flattened cone (as Winslow remarked) is not a cone. The heart, taken as a whole, has not a regular geometrical figure ; and as the term cordiform has been generally adopted, and is familiar to most persons, it will be sufficient to say that the heart has a cordiform shape, the auricles forming the upper and broader part, the ventricles the lower, narrower, and more conical part ; this conical form of the ventricular portion of the organ being produced by the peculiar arrangement of the muscular fibres which go to form its walls. The base of the heart is formed by the auricles, its apex by the left ventricle alone, as the right ventricle does not descend as low as the left. The anterior surface of the ventricular portion of the heart is convex ; the posterior surface, which rests upon the diaphragm, is flattened. The left border or edge of the heart is obtuse and rounded ; the right edge is more acute. Divisions of the Heart. — The heart, although apparently a single organ, is in reality double, and consists of two symmetrical hearts joined together, each with its own system of vessels, each circulating a different kind of blood, and each performing a distinct office ; the one circulating the blood through the lungs, the other through the system ; the one receiving and transmitting venous, the other arterial blood, but both simultaneously performing their functions. One of these divisions of the heart is termed the right, the other the left side of the organ ; but from their relative position, the former should rather (as was long since pointed out by Winslow) be termed the anterior, the latter the posterior side of the heart. These terms are retained from the earlier anatomists, having been applied at a period when the knowledge of anatomy was derived chiefly from the dissection of animals, in which the heart lies vertically in the chest, not obliquely as in the human subject. Each of these divisions of the heart consists of two 4 DESCRIPTION OF THE HEART. cavities, an auricle and a ventricle, which communicate with one another but have no direct communication with their corresponding cavities : the auricle on both sides is above, the ventricle below. The parietes of the right side of the heart, particularly of the ventricular portion, are much thinner than those of the left ; the right ventricle has merely to transmit its blood through the lungs, while the left has to transmit its blood throughout the system. The pvilmonary artery, likewise, has thinner coats and more deli- cate valves than the aorta, evidently because so much power of resistance was not required. The right side of the heart, owing to its receiving and trans- mitting dark or venous blood, was named by Bichat, "coeur a sang noir ;" the left side, from its receiving and transmitting red or arterial blood, was termed by him, "coeur a sang rouge." The right auricle is sometimes termed the sinus of the vena3 cava3 ; the left, the sinus of the pulmonary veins. The right ventricle is sometimes termed the pulmonary ventricle ; the left, the aortic or systemic ventricle. Circular and longitudinal Grooves. — The distinction between these parts is marked by grooves upon the surface of the heart ; two of which are longitudinal, and one circular. The anterior longitudinal groove runs from the base of the ventricles to the right side of the apex of the heart, dividing this part into two unequal halves : in it, the principal division of the anterior or left coronary ai'tery is lodged. Upon the posterior surface, a similar groove, which divides the ventricular portion of the heart into two nearly eqvial parts, lodges a large branch of the posterior or right coronary artery. These grooves, which are often in a great measure obli- terated by adipose tissue, mark pretty exactly the site of the septum ventriculorum. In some instances, owing to the anterior longitudinal groove being continued through the apex, this part has the appearance of being double or forked. Morgagni found this well marked in five out of eighteen subjects, which he examined for the purpose. The circular groove, which runs round the heart between the base of the ventricles and the auricles, lodges the trunk of the posterior or right coronary artery, and a large branch of the anterior or left coronary artery : it marks the line of separation between the auricles and the ventricles. The fat which accumulates upon the surface of the heart is POSITION OF THE HEART. always first deposited in these grooves : in the circvdar groove first ; next in the anterior ; and next in the posterior longitudinal groove: when a larger amount occurs, it will be found along the thin edge of the right ventricle, and upon the margin of the appendices of the auricles, particularly the left. It is usually met with in persons who have a general tendency to obesity ; but a considerable amount is occasionally found in subjects dying of chronic disease, accompanied by the absorption of all the sub- cutaneous fat. Fat is altogether absent in the heart of the infant, and M. Bizot has shown that sex has some influence upon its de- position, as it is more frequent in the female than the male ; and this holds good even in diseases accompanied by much emaciation; thus in eleven males who died of phthisis, fat was completely absent in six ; while in twenty-six females who died of the same disease, it was completely absent in only three. Position of the Heart — In order to determine the exact and the relative position of the heart, the most eligible plan to adopt is to dissect away the soft parts from the front of the chest, with the intercostal muscles, in a subject where the parts are perfectly healthy : the pericardium being then laid open, the position of the heart, and the relation of its several parts to fixed points upon the surface, can be readily determined. The heart is situated obliquely in the cavity of the thorax from above downwards, from before backwards, and from right to left: it lies behind the middle and lower bone of the sternum, also behind the cartilages of the 3rd, 4th, and 5th right ribs near the sternum, and the cartilages of the 3rd, 4th, 5th, and 6th ribs on the left side, in front of the bodies of the 6th, 7th, and 8th dorsal vertebrae, and immediately above the diaphragm, upon the cordiform tendon of which it rests, the serous layer of the peri- cardium only being interposed. Owing to its oblique position, the base of the heart looks upwards and backwards towards the right shoulder, its apex downwards and forwards towards the space between the cartilages of the 5th and 6th ribs on the left side, where its impulse may be felt during life. In the early period of intra-uterine life the heart lies vertically in the chest, as in mammalia generally : it is not until the beginning of the fourth month that it commences to assume the position which it afterwards retains. b DESCRIPTION OF THE HEART. Relations of the Heart In tlie healthy chest, the heart is overlapped laterally, and in a great measure in front, by the lungs ; posteriorly the oesophagus and descending aorta lie between it and the bodies of the dorsal vertebrce. Inferiorly, the heart rests upon the cordiform tendon of the diaphragm, the serous layer of the pericardium only being interposed. The base of the heart is on a line with the interval between the cartilages of the 2nd and 3rd ribs : its apex is a little below the 5th left rib, slightly to the left of the junction of this rib with its cartilage. During life, its im- pulse is felt between the cartilages of the 5th and 6th left ribs, at a point about two inches below the nipple (in the male), and three inches to the left of a vertical line through the centre of the sternum ; the nipple in the adult male being immediately opposite the lower edge of the fourth left rib, a little more than an inch to the left of the junction of this rib with its cartilage. Region of the Heart's superficial duhiess. — The anterior border of the lungs in the healthy subject corresponds above to a vertical line through the centre of the sternum : about the middle of this bone, and pretty nearly on a line with the cartilage of the fourth ribs, the margins of the opposite lungs begin to separate from one another, the line of the left being much more oblique than that of the right. Thus, a small portion of the heart's sur- face is uncovered by lung, which has a triangular shape, the base below, the apex above : it consists of a portion of the apex of the right ventricle, and part of the left ventricle near its apex. This triangular space is seated on a plane below the nipple and the fourth rib : its base is on a line with the cartilage of the sixth ribs; its right boundary is nearly a vertical line through the centre of the sternum ; its left an oblique line through the carti- lages of the fifth and sixth ribs on the left side. This is the part of the prsecordial region where the heart is in contact with the parietes of the chest, and where a dull sound is yielded by per- cussion. The relations of the lungs to the heart, and consequently the amount of the surface of the heart which comes in contact with tlie parietes of the chest, are altered, it must be recollected, by respi- ration, particularly by a forced inspiration or expiration : they are likewise materially altered by disease. On a full inspiration the lungs expand, and the heart is more overlapped by these organs ; CONNEXIONS OF THE HEART. 7 at the same time the contraction of the muscular fibres of the dia- phragm draws downwards its central tendon (to which the peri- cardium is attached), and with it the heart : hence the region of the heart's dulness will be both diminished laterally and will be on a plane lower down than natural. " The deepest possible inspiration, however, even in cases of emphysema, never (ac- cording to Dr. Sibson) obliterates the region of the heart's dulness." "It is often, under such circumstances, quite below the sternum, and behind the xyphoid cartilage, and the cartilages of the 6th, 7th, and 8th left ribs." On a full expiration, the volume of the lungs is diminished, less of the heart's surface is overlapped by them, and the region of the heart's dulness will be enlarged laterally ; while, owing to the ascent of the diaphragm, and the diminished volume of the lungs, it will be on a plane somewhat higher than natural. In persons with narrow chests, the region of the heart's dulness is almost always greater than in individuals with broad and expanded chests. Connexions of the Heart — The heart, I have said, rests upon the diaphragm : it is connected to it by the fibrous layer of the pericardium which is inserted into the cordiform tendon, as well as by the serous layer which lines the central aponeurosis of the diaphragm where the fibrous layer is deficient. It is still further connected to it by the ascending vena cava ; the orifice in the tendinous portion of the diaphragm, by which this vein passes from the abdomen to the thorax, is close to the junction of the inferior cava with the right auricle of the heart ; and the tendinous fibres which come off from the margin of the foramen in the diaphragm proceed upwards and downwards upon the anterior, posterior, and lateral surfaces of the vein, and unite the two parts very closely together. The opening in the diaphragm, through which the as- cending cava passes, corresponds to the upper part of the xyphoid cartilage : it is on a line with the cartilage and lower margin of the fifth ribs in front, and with the body of the ninth dorsal ver- tebra posteriorly. The heart is retained in situ by the pericardium, by the two layers of pleura which constitute the mediastinum, and by the great vessels which convey the blood to and from it ; above, the aorta and pulmonary artery proceed from the base of the ventricles; posteriorly, upon each side of the left auricle, the pulmonary veins 8 DESCRIPTION OF THE HEART. open into it ; on the right side, posteriorly, the ascending and de- scending venae cavaj open into the right auricle ; the former vein, as I have said, being intimately united to the diaphragm'. The base of the heart, from its connexion with the great vessels, is in a great measure fixed : the apex and body of the ventricular portion are free, but the motions of this part are limited by the pericardium. The whole organ is, however, liable to slight changes of position during inspiration or expiration, and in the erect or recumbent posture : during inspiration the heart descends slightly ; during expiration it ascends slightly ; in the recumbent posture the heart recedes from the parietes of the thorax ; in the erect posture it approaches them. In diseased states of the lungs or pleura, the heart may be displaced considerably : thus, when a large amount of fluid is effused into the pleura on one side, the heart will be pushed towards the opposite side : in emphysema of the lungs of long standing, the heart is protruded downwards; while in large abdominal tumors, in ascites, pregnancy, &c., it will be pushed upwards. In cases of large introthoracic tumors, the heart may be displaced either upwards, downwards, forwards, backwards, or laterally, according to the situation and size of the tumor, and the rapidity of its growth. These matters will, how- ever, be fully considered when we come to describe the diseased states of the organ. CHAMBERS OF THE HEART. The chambers of the heart are four in number — two auricles, and two ventricles. The auricles are two musculo-membranous sacs, which occupy the upper and posterior part of the organ, forming its base, separated from one another by a thin musculo- membranous septum ; the ventricles are two muscular cavities, which form the body and apex of the heart, separated from one another by a thick muscular septum. The auricle and ventricle upon each side communicate with one another by a large orifice, through which the blood can pass readily from the former into the latter cavity, but is prevented from returning by a valvular appa- ratus. The right auricle receives the venous blood from the system generally, from which it passes into the right ventricle, by which it is propelled through the lungs. The left auricle receives the arterialized blood from the lungs, from which it passes into MODE OF OPENING THE HEART. 9 tlie left ventricle, by which it is propelled through the system. The auricles and ventricles contract and dilate alternately, and a double circulation is thus constantly going on — a lesser and a greater, or a pulmonic and systemic, and the blood traverses two circles in its course — a greater and a lesser, which are conti- nuous the one with the other. The organs which belong to the greater or systemic circulation are the left ventricle, the aorta and its branches, the veins of the body, and the right auricle. The organs which belong to the lesser or pulmonic circulation are the right ventricle, the pulmo- nary artery and veins, and the left auricle. The greater or systemic circulation commences in the minute ramifications of the pulmonary veins, and terminates in the capillaries of the arteries of the body. The lesser or pulmonic circulation begins in the capillaries of the veins of the body, and ends in the ultimate rami- fications of the pulmonary artery. Thus the blood which has served the purposes of nutrition is brought by the ven» cavce to the right side of the heart, by which it is transmitted to the lungs, where it is submitted to the action of atmospheric air and assumes the bright red colour of arterial blood. It is then returned by the pulmonary veins to the left side of the organ, to be again distri- buted throughout the system. Mode of opening the Heart — In order to display the interior of the ventricles, and to permit of the examination of the valves, some care is reqvxired in opening the heart. The most simple and most convenient method appears, to me, to be to commence the incision in the pulmonary artery, carrying it through this vessel into the right ventricle, cutting between the sigmoid valves, and continuing it to the apex, keeping close to the septum. A transverse incision, meeting the other about its centre, may then be made in the walls of the right ventricle. The aorta being next separated from the pulmonary artery, a similar incision is to be made through it into the left ventricle, and continued to its apex, keeping close to the septum. This incision can then be continued on through the apex iipon the posterior surface of the heart. To display the interior of the right auricle a crucial incision may be made upon its anterior aspect, while the left auricle may be opened upon its posterior aspect, between the orifices of the opposite pul- monary veins. 10 DESCRIPTION OF THE HEART. Right Auricle The right auricle forms the right, the inferior, and a portion of tire anterior surface of the base of the heart. Its anterior surface lies to the right of the sternum ; its posterior sur- face rests upon the diaphragm. It consists, in general terms, of a sinus, and an auricular appendix. The sinus of the auricle re- ceives the blood from the descending and ascending venae cavse ; the auricular appendix, which lies behind the cartilage of the third right rib, its tip resting against the right side of the ascending portion of the arch of the aorta, pretty nearly on a line with the sigmoid valves of the p'.dmonary artery, has a rude resemblance to the ear of a dog, from which it received the name, which has come since to be applied to the entire chamber. It varies some- what in size and shape in different subjects. Its margin is often notched or serrated, something like the edge of the comb of a cock (to which the earlier anatomists compared it). This ap- pearance is, however, usually better marked in the appendix of the left than the right auricle. The capacity of the cavity of the right auricle exceeds that of the left (as first pointed out by Vesalius) : its parietes are also thinner. Between the orifice of the superior cava and the ap- pendix of the auricle a thick fasciculus of muscular fibres projects upon the interior, from which smaller fasciculi come off at a right angle, and run parallel to one another towards the appendix. The latter have received the name of musculi pectinati, from their fancied resemblance to the teeth of a comb, the thick fasciculus before mentioned forming its back. This is more evident in hearts in which the walls of the auricle are hypertrophied. In the auricular appendix the adjoining fasciculi are connected together by transverse branches, which gives its interior a reticu- lated appearance. In the interstices of these fasciculi the parietes of the auricle, when put on the stretch, will be observed to be semitransparent in some places, the pericardium and endocardium being at these points in contact, and alone forming its walls. On its right side posteriorly the right auricle receives the blood from the descending or superior, and the ascending or inferior vena cava. The former returns the blood from the head and upper extremities, and opens into the superior and anterior part of the auricle ; the latter, which is on a plane posterior to it, returns the blood from the abdomen and lower extremities, and RIGHT AURICULO-VENTRICULAR ORIFICK. II opens into the lower and back part of the auricle, near the septum auricular um. The manner in which the two venas cavse commu- nicate with the auricle is such, that the blood from the superior cannot fall into the orifice of the inferior cava. The current oi the superior cava is downwards and forwards towards the auriculo- ventricular orifice : the current of the inferior cava is backwards and to the left side, towards the septum of the auricles, and it enters the auricle nearly at a right angle with the rest of the vein, immediately above the Eustachian valve, which directs the cur- rent towards the fossa ovalis. The left posterior wall of this auricle is formed by the septum auricularum, at the lower part of which, immediately above the orifice of the inferior cava, we see the remains of the foramen ovale, through which, during foetal life, the blood passed from the right to the left auricle, particularly that conveyed by the ascending vena cava, which is directed towards this orifice by the Eustachian valve. It is by no means rare to find the foramen ovale only partially obliterated in hearts otherwise perfectly healthy, and in subjects who had never exhibited any symptom of morbus coeru- leus. The opening is usually valvular, is seated at its upper part, and will frequently admit a probe or the handle of a scalpel. M. Bizot states, that he found the foramen ovale in the same condition in which it is at birth, or only partially obliterated, in eighteen out of seventy-three male subjects, and in twenty-six out of eighty-two female. Right auriculo-ventricidar Orifice — Inferiorly the auricle is united to its corresponding ventricle, and here the orifice of com- munication between the auricle and the ventricle is seated. This, the right auriculo-ventricular orifice, has an elliptic shape, the long diameter from before backwards, as the heart lies in situ : it is larger than the corresponding orifice of the left side, and its margin, like that of the latter, consists of dense, white, fibrous or tendinous tissue. By the older anatomists this was termed the right tendon of the heart. "It is plainly," Bell observes, "the place of union between the auricle and the ventricle, which are in the foetus (the chick, for example) distinct bags." The right auriculo-ventricvilar orifice is situated behind the sternum, pretty nearly on a line with the junction of the cartilages of the fourth ribs with that bone. Between the Eustachian valve and the 12 DESCRIPTION OF THE HEART. auriculo-ventricular orifice the opening of the coronary vein is situated, provided with a valve formed by a semilunar fold of the lining membrane, vv^hich partially closes its orifice, and prevents regurgitation into it. Right Ventricle. — The right or pulmonic ventricle forms the right anterior and inferior portion of the body of the heart. The greater part of it lies behind the sternum. On the left side of this bone it extends under the sternal extremity of the cartilages of the third,* fourth, fifth, and sixth left ribs : on the right side of this bone a small portion of it extends under the cartilages of the fourth and fifth right ribs, close to the sternum. Its inferior margin is about on a line with the junction of the xyphoid cartilage and the sternum. The base of the right ventricle is connected to the auricle of the same side : its apex is a little above the apex of the heart : its anterior wall, Avhich lies immediately under the sternum, is convex : its inferior wall, which rests upon the diaphragm, is flattened : its left or posterior wall is formed by the septum ventriculorum. The parietes of the right ventricle are much thinner, its columnaj carneJB are smaller, and its cavity (as was first pointed out by Vesalius) is somewhat larger than that of the left ventricle ; this has been supposed to depend upon its parietes being more yielding than those of the left, and from the blood accumulating in, and distending it after death ; but accurate measurement has shown that its cavity exceeds the left in capacity. The right ventricle has not a regular or symmetrical shape — it is broader, but not so long as the left ; the septum, which is convex towards its cavity, belongs more to the left than the right ventricle : and as Bell remarked, "the right ventricle seems to be wrapped round the left," while the latter alone forms the apex of the heart. The right ventricle ascends higher than the left : hence the orifice of the pulmonary artery is on a plane higher than that of the aorta. The cavity of the right ventricle consists of two parts, as first particularly described by Lieutaud — viz. an arterial and an auri- cular portion, separated from one another by a prominent bundle of muscular fibres, and by the largest division of the tricuspid valve. The arterial portion — the ^^ conus arteriosis" of Wolff, the " injundibulum" of Cruveilhier — is very smooth xipon its surface, TRICUSPID VALVE. 1 3 leads towards the pulmonary artery and is prolonged upwards above the level of the rest of the ventricle ; in it the current is established by the systole of the ventricle, which is continuous with that of the pulmonary artery. The auricular portion, on the other hand, is very irregular upon its surface, owing to numerous prominent bundles of muscular fibres (carneaj columnse) which exist here ; it receives the blood directly from the right auricle, and into it there is a current through the auriculo-ventricular orifice until the closure of the tricuspid valve. Mr. Serle, in his account of the arrangement of the muscular fibres of the heart, describes the cavity of the right ventricle as consisting of three parts: an "auricular," a "pulmonary or ventricular," and an "apicial ;" the pulmonary and apicial form the arterial portion of Lieutaud. " The pulmonary (according to him) is that formed by the fibres which arise from the root of the pulmonary artery at its entire circumference : the apicial channel is that which forms the channel of communication between the other two, and which extends to the apex." The carneae columnse are very numerous in the auricular por- tion of the ventricle : many run from the apex towards the base, others cross them, leaving deep sulci between them : some of these fleshy columns are attached in their whole length, others only by their extremities, and others again only by one extremity, the opposite giving insertion to the chordae tendinese of the tricuspid valve : the latter, which are sometimes termed musculi papillares^ are fewer in number than either of the other kinds. At the base of the ventricle two orifices are situated : one (the auriculo-ventricular orifice) communicates with the auricle on that side ; the other is the orifice of the pulmonary artery : each is provided with a valvular apparatus. The auriculo-ventricular orifice is situated at the posterior and right side of the base of the ventricle ; the pulmonary orifice is to the left side, immediately above the septum of the ventricles, on a plane anterior to, and three-quarters of an inch higher up, than the other. Tricuspid Valve — The right auriculo-ventricular orifice is encircled by a valve, formed by a duplicature of the lining membrane, strengthened by fibrous tissue, which comes off from the margin of the orifice : the free extremity of this valve hangs down into the ventricle, where, by means of the chordae tendineae 14 DESCRIPTION OF THE HEART. it is connected to the carneae columnse, and so with the walls of the ventricle. This valve is termed tricvispid (three-pointed), by the older writers, triglochine (three-angled), its free margin forming three principal divisions : the chordje tendinese are the tendons, the carnea^ columnae the muscles of this valve; the tendi- nous cords converge from the point where they are attached to the valve, and several of them are inserted into a single fleshy column : when the latter contract, the tendinous cords are made tense ; hence, as the fleshy columns contract during the ventri- cular systole, the valve is shortened, and prevented from being reversed. Three principal divisions of the tricuspid valve are distin- guished — an anterior, a right, and a posterior : the anterior division separates the auriculo-ventricular from the pulmonary orifice, and is supposed to prevent the blood from passing into the pulmonary artery during the dilatation of the ventricle ; but (as was remarked by Senac long since) this can scarcely be necessary, because during the ventricular diastole the sigmoid valves close the arterial orifice ; the second division of the valve lies to the right side ; and the third, which constitutes the posterior division, lies behind. It would be more natural to consider this valve, like the mitral, as composed of two principal divisions : an anterior, which would include the anterior and right division, and a posterior, which would correspond to the posterior division : in describing the valve, however, it is convenient to consider it as composed of three curtains. The anterior curtain is connected by its chordae tendinese prin- cipally with one large and long fleshy column, which has two roots: one of these roots springs from the anterior wall of the ventricle ; the other, which runs transversely, is attached to the septum of the ventricles : this is the portion which Mr. W. King terms the " long moderator band." The right curtain is con- nected by its fleshy columns to the parietes of the ventricle, not to the septum : two fleshy columns are attached in front ; the others, which are much shorter, are attached to the posterior wall of the ventricle. The fleshy columns of the posterior division of the valve are much shorter than those of either of the others, and some of its tendinous cords are inserted without the intervention of any fleshy columns : they are all inserted into the septum. SIGMOID VALVES. 15 A single slender tendinous cord, not proceeding from any fleshy column (which, however, is absent in some hearts), is attached by one extremity to the anterior division of this valve, sometimes near where the chordae tendinese join the fleshy cokimn, more fre- quently to the fleshy column itself, either near its base or apex, from which it runs towards the right wall of the ventricle, into which it is inserted, or to the base of the fleshy columns of one of the other divisions of the valve. The action of this tendinous cord will be to prevent the anterior curtain of the valve from being applied to the orifice when the ventricle is much distended ; and from its insertion into the yielding wall of the ventricle, the more the ventricular cavity is distended the more open will it keep this curtain of the valve ; while when the ventricle is not over-dis- tended, it will not interfere with the perfect action of the valve. Pulmonary Orifice The orifice of the pulmonary artery is situated on a plane about three-quarters of an inch higher than the auriculo-ventricular orifice, to its left side and more anteriorly ; the surface of the ventricle from which it arises, and below this point, is perfectly smooth. The pulmonary orifice lies pretty nearly on aline with the junction of the cartilages of the third ribs with the sternum, very little to the left of this bone ; it has a circular shape, is smaller than the auriculo-ventricular orifice, and is provided with a valvular apparatus at the point where the artery joins the ventricle, formed of folds of the lining membrane, strengthened by fibrous tissue. Sigmoid Valves The valves at the orifice of the pulmonary artery are three in number ; they are analogous to the valves at the orifice of the aorta, but are thinner and more delicate. Mor- gagni gave them the name sigmoid, while those at the aortic orifice he named semilunar : these terms are, however, nearly indiscrimi- nately used. The sigmoid valves have a crescentic shape as they lie against the walls of the artery : they are attached at the point where the pulmonary artery joins the ventricle, and this point or their base corresponds to a line across the inferior margin of the cartilage of the third ribs. One of tliese valves is anterior, another posterior or to the left side, and the third to the right side ; each is attached by its convex margin, the concave or free margin being loose : their edges are a little thicker than the other parts, and in 16 DESCRIPTION OF THE HEART. the centre of each near the margin a very minute nodule is seated, though in some instances scarcely a trace of it is to be found. The sigmoid valves, when the blood is passing out of the ventricle, lie against the walls of the pulmonary artery and present no impediment to its passage ; when the ventricle ceases to contract, the blood in the artery above gets behind them, they fall down, close the orifice, and prevent regurgitation into the ventricle. Sinuses of the pulmonary Artery. — Behind each sigmoid valve is a little dilatation of the vessel where its coats appear to be thinner : these are the sinuses of the pulmonary artery ; their use evidently is to enable the blood to insinuate itself behind the valves when the ventricular systole ceases, by which they are pressed down, the orifice closed, and regurgitation into the ventricle prevented. These sinuses also allow a space for the sigmoid valves to lie back in during the ventricular systole, by which the outlet of the artery is rendered perfectly smooth and even, as the blood is passing from the ventricle into the pulmo- nary artery. Left Auricle. — The left auricle occupies the upper, the pos- terior, and the left side of the base of the heart ; it has an irregular square form, the transverse exceeding the vertical diameter ; its parietes are thicker, and its cavity is smaller than that of the right auricle; its interior is smooth, the muscular fibres in it do not leave interspaces between them, and musculi pectinati are fewer. It consists, like the right, of a sinus and an auricular appendix ; the former receives the blood from the four pulmonary veins, and forms its principal bulk ; it occupies the posterior part of the base of the heart, facing the bodies of the dorsal vertebrae, so that no part of it is visible when the pericardium is laid open. The auricular appendix (which is longer and narrower than that of the rio-ht side, and has its edge in general more deeply notched, or serrated), is situated at the lower and left side of the auricle, below the orifices of the left pulmonary veins ; it comes forward at the left side of the base of the ventricle, where it lies to the left of the root of the pulmonary artery, and eventually a little in front of it ; it is the only part of the left auricle which is visible when the pericardium is laid open, and will be found immediately under the cartilage of the third left rib. At the point where the auri_ LEFT AURICULO-VENTRICULAR ORIFICE. 17 cular appendix joins the sinus of the auricle, there is a narrowing or contraction of the diameter of the cavity : this is sometimes termed one of the orifices of the auricle, but incorrectly, because the sinus and appendix form but a single cavity. In the interior of the left auricle five orifices are seen ; the largest is the auriculo- ventricular orifice, the other four belong to the pulmonary veins ; the latter open, one immediately above the other, at each side of the sinus, the two right at its posterior and right side, the two left at its posterior and left side. The two upper orifices are larger than the lower, and sometimes the two pulmonary veins of the left side open by a common orifice, some- times there are three veins on the right side. The right wall of the auricle is formed by the septum auricularum ; this, which ia sometimes described as the base of the auricle, is convex towards the left side : in it we observe the depression which marks the site of the foramen ovale. Lieft Auriculo-ventricular Orifice This orifice, which forms the communication between the auricle and ventricle, is situated in the floor of the auricle ; it has an elliptic, or more correctly, a crescentic shape, the long diameter being nearly transverse ; it is smaller than the corresponding orifice of the right side ; its margin is smooth, and consists of dense, white, fibrous or tendi- nous tissue. The left auriculo-ventricular orifice is on a plane posterior to and to the left side of the tricuspid orifice, but nearly on the same level, as the heart lies in situ : it is situated behind the sternum, and upon a line with the junction of the cartilage of the fourth rib with that bone. Left Ventricle. — The left, the aortic, or systemic ventricle, forms the left and posterior part of the body of the heart ; it has a conical form, the base above where it joins the auricle, the apex below where it forms exclusively the apex of the heart ; its parietes are convex externall}'-, and concave internally, equally upon the side of the septum, as in its left and posterior wall, so that the septum seems to project into the cavity of the right ven- tricle. The walls of the left ventricle are strong, thick, and muscular, about three times the diameter of those of the right ventricle, as was first pointed out by Riolanus ; they preserve, consequently, their convex form after the cavity of the ventricle is emptied, while the parietes of the right ventricle collapse under c 18 DESCRIPTION OF THE HEART. similar circumstances. The left ventricle is longer than the right, but its cavity is smaller, and its carnese columnse are much thicker and stronger. A small portion only of the left ventricle is seen when the pericardivun is laid open ; this is to the left of the sternum, ex- tending from the cartilage of the third left rib, to the interspace between the fifth and sixth left ribs, near where the cartilage joins the body of these ribs. The appendix of the left auricle, which comes forward directly beneath the cartilage of the third left rib, surmounts the left ventricle here. In the cavity of the left ventricle, as in that of the right, two parts are distinguished, an arterial and an auricular portion, sepa- rated from one another by the right or anterior division of the mitral valve. The former is the smooth surface leading to the aortic orifice ; it is smaller than the corresponding portion of the right ventricle, and is bounded on the right side by the i:pper part of the septum of the ventricles, and posteriorly by the anterior or right curtain of the mitral valve. The auricular portion forms the larger part of the ventricular cavity : it commu- nicates directly with the avxricle on the same side. The auriculo-ventricular and the arterial orifices lie much nearer each other on the left than on the right side of the heart, being only separated by the right or anterior curtain of the mitral valve. The aortic orifice is on a plane above, anterior to, and to the right of the auriculo-ventricular orifice : the right or anterior division of the mitral valve which separates them is supposed to prevent the blood from entering the aorta while the ventricle is filling ; but as the semilunar valves are closed at this period, it can scarcely have this use. Mitral Valve — From the margin of the tendinous ring which surrounds tlie left auriculo-ventricular orifice, a valve composed of a double fold of the lining membrane, enclosing tendinous fibres, proceeds, the free surface of which hangs down into the ventricle ; this valve is analogous in ofiice to that of the right side, but is larger and stronger in all its parts : its chordae tendineaj are stronger, and its carnese columns are thicker. This valve has more strictly two divisions than the tricuspid, and is properly termed bicuspid from this circumstance : one of these is anterior, the other posterior ; the former being more to AORTIC ORIFICE. 19 the right side is sometimes termed the right division, the latter the left. Vesalius compared this valve to a bishop's mitre, '■^quas mitrcB episcopali non admodum inepte contuleris" and the name mitral has been almost invariably applied to the valve since. The anterior or right division of the mitral valve is the larger ; it ascends higher than the other, reaching to the base of the pos- terior and right semilunar valves of the aorta : its curtain forms in a great measure the septum between the aortic and the auriculo- ventricular orifices, so that when we remove it the two orifices seem almost to constitute but one ; indeed, it was formerly termed the valvular septum of Lieutaud from this circumstance. The carneae columns of the mitral valve are all attached to the poste- rior wall of the ventricle : those of the anterior curtain arise from opposite sides of the posterior wall, each by two strong columns : the tendinous cords connected with them run towards one another, so that if continued along the curtain of the valve they would cross each other. The carnese columnse of the posterior division of this valve are three in number ; they are shorter, broader, and less cylindrical than the fleshy columns of the anterior division. The strength of the chordEe tendinese of this valve, notwithstanding their tenuity, is very remarkable : Senac tested it by isolating a single one, and attaching to it a four pound weight, which it supported for some time. Aortic Orifice — The aortic orifice, like the pulmonary, has a circular shape ; it is situated at the upper and right corner of the base of the ventricle, behind the orifice of the pulmonary artery, and on a plane lower down. It lies anterior to, higher up, and to the right side of the auriculo-ventricular orifice, but very close to it ; these two orifices being merely separated, as I have said, by the right or anterior curtain of the mitral valve. Semilunar Valves — The aortic orifice is provided with three valves, named semilunar by Morgagni, which are attached by their convex margin at the point where the aorta and left ventricle become continuous ; their concave margin is free. They lie behind the sternum, towards the left side of this bone on a line with the space between the cartilages of the third and fourth ribs ; their free edge corresponds (M. Gendrin observes) to the base of the pulmonary valves ; a line drawn across the inferior margin of 20 DESCRIPTION OF THE HEART. the tliird rib corresponds to the free border of the aortic valves, and to the base of the valves of the pulmonary artery. The semilunar valves of the aorta resemble the valves of the pulmonary artery but are thicker and stronger. They consist of duplicatures of the lining membrane, strengthened by tendinous bands ; of these bands, one runs along the free margin of each valve, another along its base, and another, which is broader, runs upon each side of the corpus Arantii, and takes a semicircular course from this body to the attached margin of the valve. These tendinous bands have been recently described by M. Monneret as muscles : the action of one set of fibres (according to him) is to raise the valve, the other set are antagonists, and serve to depress them. But as the semilunar valves are elevated and depressed mechanically by the flux and reflux of the blood, it is not easy to perceive, (Magendie observes,) what purpose muscles placed be- tween the membranous folds of these valves could serve. Corpora Arantii — Near the centre of the margin of the free edge of each valve a little fibro-cartilaginous body is seated, termed " corpora Arantii," after Arantius, a pupil of Vesalius, who first accurately described them, though they had been noticed previ- ously by Vidus Vidius; sometimes they are termed ''corpora se- samoidea," or " noduli Morgagni." These little bodies are more distinct and larger in the semilunar valves of the aorta than in those of the pulmonary artery ; their use is said to be to strengthen the central point where the valves meet, where the pressure is considerable, and the resistance least; as well as to fill up the little space which would be left in the centre when the valves fall down : but as these little bodies are not seated at the very margin of the valves, they could hardly, effect the latter object, which, indeed, is unnecessary, as the valves slightly overlap one another in the healthy subject. The use of the corpora Arantii appears to me to be to serve as points of attachment for the tendinous bands already mentioned, by which the valves are strengthened ; without some provision of this kind these valves would much more fre- quently become reversed, and permit regurgitation. Sinuses of the Aorta. — Behind each semilunar valve the pa- rietes of the artery are dilated, and a little pouch or sinus is formed, where the parietes of the artery are thinner than in other PERICARDIUM. 21 parts ; these are tlie sinuses of Morgagni, or the lesser sinuses of the heart. They are better developed in the aorta than in the pulmonary artery, and in old age than in young subjects. In these sinuses the orifices of the two coronary arteries are seen, and Dr. Chevers distinguishes those from which the right and left coronary arteries arise, by the names right and left ; the third he calls the intermediate sinus. The disposition of the fibres of the sclerous coat of the aorta in these sinuses, by which the parietes are strengthened, and the attachment of the valve secured, has been well described by him. The use of these sinuses is similar to that of the same parts at the origin of the pulmonary artery ; they allow a space for the blood to insinuate itself behind the valves when the ventricular systole ceases, by which they are pressed down and the orifice closed ; and they aflford a space for the semilunar valves to lie back in during the systole of the ventricle, by which the channel along which the blood passes is rendered perfectly smooth. The aorta is connected to the left ventricle by the endocardium within, and by the serous and fibrous layers of the pericardium externally, which are continuous with one another in the heart and artery. When these are removed, the junction of the fibrous membrane of the artery with the muscular tissue of the heart is seen to be by three crescentic prolongations or festoons, each of which has its convex margin towards the ventricle, and between each is a small triangular interval, the base of which corresponds to the base of the ventricle. The place where the aorta joins the ventricle is marked by a tendinous ring {zona tendinosa) : the semilunar valves of the aorta are situated at this part, the convex margin of each being attached opposite to the convex margin of the crescentic prolongation above described, and each receiving tendinous fibres from this rintj. PERICARDIUM. The pericardium belongs to the class of fibro-serous membranes and consists of two layers, an external fibrous and an internal serous. The fibrous layer is strong and resisting, though having but little thickness : it forms what is called the sac of the peri- cardium, and encloses the heart and the origin of the large vessels which come oflf from its base. The serous layer is thin and 22 DESCRIPTION OF THE HEART. delicate in comparison: it closely invests the heart, covers the origin of the large vessels, and is then reflected upon the internal surface of the fibrous layer, which it lines throughout. Thus, as is the case with other serous membranes, the heart, although invested by the pericardium, is not contained in its cavity. The pericardial sac has a pyriform shape, the base below, the apex above ; exactly the reverse of that of the heart. Its base is on a line with the upper part of the xj'phoid cartilage ; its apex a short distance above the origin of the large vessels, and gene- rally on a line with the articulation of the cartilage of the second ribs with the sternum. I have, however, found it to extend, in a healthy subject, as high as the level of the articulation of the first ribs with the sternum. Its apex is higher upon each side of the aorta than immediately opposite to that vessel. The pericardial sac is wider in the centre than at its base, and here it extends more to the left side. Its widest part is on a line with the greatest transverse diameter of the heart. Capacity of the Pericardium The capacity of the pericar- dial sac is somewhat greater than the volume of the heart; and, as its cavities are never all distended at the same moment, there is always abundant room for the apex and body of the organ to move freely in it. For the same reason, effusion of fluid to a moderate extent may take place into the cavity of the peri- cardium without interfering much with the heart's movements, provided it is efi'used slowly and gradually. On the other hand, even a moderate amount of fluid suddenly efiused will be attended with formidable symptoms, because the fibrous nature of this membrane does not permit of its yielding suddenly. In chronic cases of disease, however, the pericardial sac is capable of becom- ing enormously dilated, as we shall afterwards see. The actual capacity of the pericardium has been endeavoured to be determined by injecting fluid into and forcibly distending its sac. Dr. Sibson, in a recent number of the London Journal of Medicine, has given the following table of the results of some ex- periments made by him : Boy, set. 6, pericardium injected to distension, held . ^ 6 oz. „ 9, 6 oz. „ 13, about 6 oz. Adult male . 15 oz. Male, aet. 50 ' . 22 oz. Adult female (heart enlarged) 26 oz. FIBROUS LAYER OF PERICARDIUM. 23 "From these and other observations," Dr. Sibson says, "it may be inferred that in the adult, when the heart is healthy, the pericardium when fully distended, can contain from twelve to fifteen ounces of fluid." " It is worthy of remark," he adds, " that the right cavities of the heart in the adult male, when distended, hold the same quantity of fluid as the pericardium." Fibrous layer of Pericardium The fibrous layer of the peri- cardium is dense and strong, and is composed of tendinous fibres, some of which run vertically from the base towards the apex, others cross each other in various directions. Its tissue is semi- transparent, permitting the heart to be seen through it. It is very intimately united inferiorly to the central tendinous aponeu- rosis of the diaphragm : the fibres of each (as Lancisi observed) mix, and are confounded with one another ; so that the pericar- dium seems as if it were a prolongation of this aponeurosis. It is also connected with the fleshy portion of the diaphragm on the left side, but the adhesion here is less intimate. Superiorly the fibrous layer of the pericardium is closely united to the trunks of the large vessels which come off from the base of the heart. It gives them sheaths ; and, after accompanying them for a short distance, it becomes continuous with the thoracic fascia. The inferior cava alone receives no fibrous sheath from it. Ante- riorly a small portion of its surface is only separated from the sternum by cellular tissue. Laterally, it is connected with the pleura upon each side, the phrenic nerve on the left side being in- terposed. Posteriorly, the pericardium, which is of small extent compared with its anterior surface, lies in front of the posterior mediastinum, being separated from the bodies of the dorsal verte- brae by the oesophagus and descending aorta. The fibrous layer of the pericardium does not form a com- plete capsule for the heart ; it is deficient inferiorly, where it is replaced by the central tendinous aponeurosis of the diaphragm ; the reflected serous layer, which is attached to this part of the diaphragm, forming its capsule here. Owing to its density and strength the fibrous layer of the pericardium serves both to sup- port and to limit the motions of the heart ; while, it retains it in situ. From its firm attachments, above, below, and laterally, if as not unfxequently happens from disease, the opposed serous sur- faces become adherent to one another, the motions of the heart must be, in a certain degree, interfered with. 24 DESCRIPTION OF THE HEART. Serous Layer of Pericardium. — The serous layer of the peri- cardium which invests the heart is thin and delicate, compared with the fibrous layer. It consists of two layers, a proper serous and a fibrous layer : the latter forms the capsule of the heart ; the former, after covering the heart, ascends, from an inch and a half to two inches, upon the aorta, and upon the pulmonary artery as high as its bifurcation, where it is reflected upon the internal surface of the pericardial sac. Hence the greater portion of the ascending part of the arch of the aorta is said to be within the sac of the pericardium ; and hence aneurism of this part of the vessel occasionally bursts into it. Where the serous layer lines the sac of the pericardium, it is very intimately adherent to it ; where it covers the origin of the large vessels, it is much less so. Inferiorly, where the fibrous portion of the pericardial sac is deficient, the serous layer lines the central aponeurosis of the diaphragm. Cardiac fascia. — The serous layer of the pericardium, which invests the heart, was always described as a single membranous layer, until Dr. Robert Lee* demonstrated two layers in it, which are connected together by cellular tissue. The outermost of these layers is the proper serous coat : the inner layer, from its structure and function, and from the important office which it performs, Dr. Lee considers may be regarded as the fibrous membrane or fascia of the heart. This expansion " is possessed of great strength and firmness. It is glistening, semitransparent, and resembles in all respects the aponeurotic expansions, or fasciae covering muscles, in other parts of the body." "It is much stronger over the ventricles than the auricles, and it adheres so firmly to the muscular substance under- neath that its separation cannot be effected without tearing up some of the muscular fibres to which it is attached." " From the inner surface of this fascia innumerable strong fibres pass to the blood-vessels, nerves, muscular fasciculi, and adipose matter, which accompany and surround all the blood-vessels and nerves ; and they are interlaced together so as to form a peculiar stroma, if it may be so termed, of considerable thickness, between the fascia and all the various structures beneath, which it invests and binds together in the strongest possible manner. These fibres form a • Philosophical Transactions, 1848. CARDIAC FASCIA. 25 complete sheatli around all the arteries, veins, and nerves, on the surface of the heart, and accompany them as they dip down be- tween the muscular fasciculi, to which their branches are distri- buted throughout the entire walls of the heart, from its surface to the lining membrane." " The cardiac fascia," Dr. Lee observes, " is obviously one of the principal causes of the firmness and strength of the central organ of the circulation, as it binds together into one mass, and gives support to the muscular fibres, like the fascia which invests other muscles." " The cardiac fascia is to the heart, I believe, what the external fibrous coat is to an artery ; and it must have nearly the same effect in preventing dilatation and rupture of the ventricle during violent exertion." " The feeble serous covering of the heart can possess little influence, and add nothing to the strength of the parietes ; and probably, but for the fascia now described, the heart would often yield in all directions, especially at the apex. In a physiological point of view, it therefore has appeared to me that this fascia of the heart is one of its most im- portant strictures." " In a pathological point of view," Dr. Lee observes, " the cardiac fascia is perhaps not less worthy of notice. Muscular structure, it is well known, is not liable to attacks either of com- mon or of specific inflammation. It is impossible to avoid sus- pecting that rheumatic inflammation of the heart has for its principal seat this dense fibrous membrane lying between the serous and muscular coats of the heart, and that attacks of rheu- matism of the heart do not commence primarily in the muscular structure." The opposed serous surfaces of the pericardium are very smooth, and constantly lubricated : hence, in the normal condition of the . parts, they glide over one another during the motions of the heart without producing sound. If, however, as is not un- frequently the result of disease, these surfaces become rough or uneven, increased friction must take place between them during the heart's motions, and sounds will be developed which become audible when the ear or stethoscope is applied to the parietes. These constitute the pericardial friction sounds, afterwards to be considered. Owing to the intimate connexion of the pericardium inferiorly 26 DESCRIPTION OF THE HEART. with the diapliragm, it must follow the movements of the latter ; and from its attachments above and below, its shape and state of tension must be somewhat different during inspiration and expir- ation ; while if much fluid be effused into its sac, not only will the movements of the heart, the ascent of the diaphragm, and the expansion of the hings be more or less interfered with, but the lungs will be pushed aside, a larger surface of the pericardium will come in contact with the parietes of the chest in front, and the region of the heart's superficial dulness on percussion will bo increased in proportion. The effect of the forcible distension of the pericardium, in Dr. Sibson's experiments, was to make the central tendinous aponeurosis of the diaphragm convex towards the abdomen, and to lower this part about one inch. White Patch on Pericardium. — Nothinsf is more common than to find upon the portion of pericardium investing the heart, a white patch of variable size and shape ; this is the milk spot or milk patchy of the German writers, and it is so often found in hearts, which, in other respects, are perfectly healthy, that it has been regarded by some as a natural appearance. The anterior sur- face of the right ventricle is its most frequent seat ; occasionally it is observed upon the surface of the left ventricle, or upon the auricles ; in general only one exists, sometimes several are found upon the same heart ; they have a white colour similar to that of healthy tendon; their shape is very variable, often somewhat circular or oval, occasionally more or less linear, and extending in the line of the coronary vessels. The size of these patches varies from a fourpenny piece to a crown, or even larger : when one only is present, it is usually larger than when several occur upon the same heart. They are much more common in the adult than in early life, but have been observed in the infant under three months; they are larger and better marked in advanced life, and they are more comnion upon the male than the female heart. Seat of the White Patches, — Some difference of opinion exists among pathologists as to the exact seat of these opaque patches, some placing it upon the free surface of the pericardium, others upon its under surface, and others in the proper tissue of the membrane. Thus Baillie, Laennec, Louis, and Todd,* state that * Cyclopsedia of Anatomy and Physiology. WHITE PATCH ON PERICARDIU5I. 27 these opaque patches can easily be dissected or peeled off from the visceral layer of the pericardium, leaving this membrane entire. Corvisart, on the other hand, says, that these patches are seated upon the under surface of the membrane, and that they cannot be dissected off without bringing the pericardium with it. Dr. Hodgkin says, he has met with a few instances where they might be dissected off; but in by far the greater number of cases these patches depend on a deposit on the attached surfaces. Mr. T. W. King considers the actual seat of the deposit to be the proper tissue of the serous membrane. Mr. Paget* says, these patches are " generally easily stripped off; but in no case after they are organized can they be separated from the subjacent tissue without dividing numerous connecting filaments, and leaving the surface from which they are removed flocculent and shreddy." Nature and Causes of. — A similar diversity of opinion exists among pathologists respecting the nature and cause of these opaque patches. By some they are referred to inflammation, and supposed to be always the result of partial pericarditis. ]\Ir. Paget, who advocates this view exclusively, observes, " with these spots there almost constantly coincides some adhesion by organ- ized lymph between adjacent parts of the pericardial membrane." " The adhesions generally consist of slender threads passing across the furrow between the aorta and vena cava superior, or between the aorta and pulmonary artery at some little distance from their connexion with the heart." In 40 cases noted by Mr. Paget, in which white patches were found upon the heart, 35 presented abnormal adhesions, or their remains. If these white patches were always the result of inflammation, pericarditis, in a latent form, must evidently be a much more fre- quent disease than is commonly supposed ; but as in the majority of cases the serous membrane at the part preserves its smooth and glistening appearance, the opacity can hardly be due to lymph deposited upon it; besides, adhesions between the visceral and the reflected layer of the pericardium, instead of being very rare in connexion with these patches, ought to be frequent, if they were always the result of the deposition of lymph. Other pathologists regard these opaque patches as the effect of attrition between the surface of the heart and the parietes of the * Med. Chir. Trans, vol. xxiii. 28 DESCRIPTION OF THE HEART. thorax ; as tliey are found most frequently upon the anterior surface of the right ventricle. Dr. Hodgkin* is of opinion that pressure is their cause, and that they are the result of a kind of inflammation originatin'g in attrition and irritation. Mr. T. W. Kingf says, "the situation of these patches wherever they occur, implies to my mind a degree of attrition at the part more than belongs to the pericardium generally," and he suggests the name "patches of attrition," or "patches of distension" for them. It militates, however, against this theory, that these white patches are not unfrequent upon parts of the heart where attrition cannot take place. Other pathologists are of opinion that these patches are not to be regarded as a pathological phenomenon, because they are found on the most healthy hearts, and where the patient has never laboured under any affection referable to the heart ; and because similar opaque patches are found upon other viscera which are covered by serous membrane ; as the liver, intestines, &c. M. Bizot, whose researches have tended to elucidate many doubtful points connected with the normal anatomy of the heart, has shownj that these white patches are of two descriptions, one probably consecutive to inflammation ; the other not a product of inflammation, but appearing to be in some way connected with the progress of age. The first variety, or that which is the result of inflammation, is the rarest, it may occupy any part of the visceral layer of the pericardium, but its most usual situation is the anterior surface of the ventricles ; the opacity freqviently also extends along the coro- nary veins, or adhesions exist between the base of the auricular appendages and adjoining parts. The shape of these patches is very irregular, the surface is often smooth, sometimes not ; they can usually be detached without difficulty from the serous mem- brane underneath. The second variety, which is not the resvilt of inflammation, consists of a thickened state of the pericardium itself, which undergoes slow transformation and loses its transparency ; it can- not, of course, be detached from the membrane. This is the most frequent variety, M. Bizot states that in 156 subjects he found it 45 times ; it is more frequent in the male than in the * Lect. on Morb. Anat. of Serous Membranes. f Guy's Hosp. Reports. I Mem. de la See. Med. d'Observatiou, Tome i. ENDOCARDIUM. 29 female. The anterior surface of the right ventricle is its most frequent seat. In 45 instances, noted by M. Bizot, it occupied the centre of the anterior surface of the right ventricle in 20 ; in 18 it occupied, also, the anterior surface of the left ventricle ; in 7 only it was found exclusively upon the left ventricle. The influence of age upon its development is also remarkable ; it was not found in the male under 1 7 years of age, or in the female under 22. After 40 years of age, in both sexes, these patches were not only better marked, but larger. The following table, given by M. Bizot, shows its frequency at different ages, and in the two sexes : MALE. FEMALE. Age. No. of subjects. No. of examples Age. No. of subjects. No. of examples 1 to 17 18 „ 39 40 „ 79 16 24 32 8 23 1 to 22 23 „ 39 40 „ 89 31 23 30 5 9 ENDOCARDmM. The interior of the cavities of the heart is lined throughout by a transparent, delicate membrane named first by M. Bouilland en- docardium. This membrane is very smooth, and highly polished, it is continuous with the lining membrane of the large vessels which open into the heart, as well as with the arteries and veins of the heart itself ; it lines every part of the interior of the cavities of both the auricles and ventricles, covers the chordae tendinese, and carnea3 columnaB, and is reflected upon itself at the arterial and auriculo- ventricular orifices, to assist in forming the valves. It is thinner in the right cavities of the heart than in the left, and is said to be thickest in the left auricle ; it is so adherent to the tissue un- derneath that it can only be detached by the scalpel in small patches, the adhesion being closer about the valves than at any other part. According to Luschka, " the endocardium is made up of the same structures which exist in the coats of the arteries, pressed to- gether, and reduced to their extremest tenuity. The heart may thus be regarded as an expanded and modified vessel, with 30 DESCEIPTION OF THE HEART. muscular fibres disposed outside it." According to Rokitansky* " the endocardium consists essentially, besides the epithelium of a longitudinal fibrous coat (Henle) under which there is a very considerable layer of elastic and cellular tissue, which is most dis- tinct in the auricles, and on which rests the muscular substance of the heart. In the left side of the heart, more especially in the left auricle, a layer similar to that of the circular fibres of the ar- teries is occasionally found under the longitudinal fibrous coat." The epithelium and longitudinal fibrous coat, which constitute the true endocardium, are, like the inner coat of the arteries, non-vascular, but the subjacent tissue is abundantly supplied with vessels. According to M. Bizot, the endocardium in early life has the same transparency, thickness, and consistence, in every part of the interior of the heart. Subsequently, a slight opacity begins to make its appearance in the vicinity of the semilunar valves of the aorta, and gradually increases, but is always most marked at the point at which it was first observed. As the membrane be- comes opaque it appears also to become slightly thickened ; but this is not due to the presence of a false membrane, it is a sim- ple opacity, and appears to be analogous to the white patch upon the visceral layer of the pericardium. This appearance is only observed upon the left side of the heart. M. Bizot has never found it upon the right side ; and age appears to have a marked influence upon its development ; for it is very rare under puberty, and very frequent in old age. MUSCULAR TISSUE OF THE HEART. The muscular tissue which forms the principal bulk of the heart is situated between the endocardium on the one hand, and the pericardium on the other, and differs from the muscles of ani- mal life in several respects ; the latter are connected together by cellular tissue, and with the naked eye are seen to consist of bun- dles of fibres, while the former interlace and cross in different directions : under the microscope, also, other differences are ob- served, — as the granular appearance of the fibres, and the less distinctness of the transverse striaj. The substance of the heart * Manual of Pathological Anatomy, vol. 4. MUSCULAR TISSUE OF THE HEART. 31 contains a larger amount of muscular fibre for its size than any other part, and its tissue is compact, firm, and close ; for this rea- son the heart of animals when cooked, cuts uniformly smooth in every direction, and " eats short, not offering that elastic resistance which other muscles do during mastication." The use of the cellular tissue which connects together the fibres of the muscles of animal life, and which forms their sheaths, ap- pears to be in a great measure to retain the muscular fibres within their proper sphere of action, and to strengthen them. In the heart cellular tissue was supposed to be less necessary, in con- sequence of the manner in wliich the muscular fibres themselves are arranged ; but Dr. Robert Lee * has recently shown that the heart is provided with a fascia which binds together and gives sup- port to the muscular fibres in the same way as the fascia which in- vests the muscles of animal life. This, which he terms the ^^ car- diac fascia^'^ lies immediately under the true seroiiscoat, and, after investing every part of the auricles and ventricles, it sends pro- longations from its under surface, which surrovmd the blood-vessels and nerves, forming sheaths for them, and accompanying their branches between the muscular fasciculi through the entiie walls of the heart, from the surface to the lining membrane, investing and binding all the parts together in the strongest possible man- ner, and giving firmness and strength to the organ. A vast deal of pains, time, and labour, have been expended by anatomists in endeavouring to unravel the course of the mus- cular fibres of the heart; in many instances "they have succeeded (it has been observed) only in giving unintelligible descriptions." Recently Mr. Searle has undertaken the task ; his account of the arrangement of the muscular fibres of the heart is contained in the " Cyclopaedia of Anatomy and Physiology ;" his desciiption would, however, be utterly unintelligible with^^vit the figures with which his paper is illustrated ; and, even with the assistance of these, the peculiar manner in which the bands, fasciculi, and layers, which enter into the formation of the heart, are arranged could scarcely be understood without quoting his description at length. It will be sufficient here to observe that each ventricle has its own distinct set of fibres, which form its sac ; that another set of fibres surrounds, encloses, and unites together the two ventricles ; * Philosophical Transactions, 1849. 32 DESCRIPTION OF THE HEART. that in tlie left ventricle six layers of fibres have been distinguished j in the right, but three, which are arranged into a superficial, a middle, and an internal set ; that the fibres are disposed in a spiral direction, "some winding round and round the ventricle," "some taking a larger sweep, and surrounding both ventricles ;" that they interlace with one another, and that some are continuous with the carneae columnse in the interior of the ventricles. The septum is described by Mr. Searle as consisting of three layers — a left, a middle, and a right ; the two former belong pro- perly to the left ventricle ; the right layer exclusively to the right ventricle. In the auricles the fibres are disposed in two layers : its fibres "arise chiefly from the tendinous margins of the annulus venosus and annulus arteriosus." The peculiar shape of the appendices depends upon the manner in which the fibres are arranged, as also the appearance known under the name of the musculi pec- tinati. The fibres of the right auricle are prolonged so as to form the outer part of the wall of the left auricle, which, as it receives additional bands of fibres, is necessarily thicker than the right auricle. The septum of the auricles receives fibres from three sources — superiorly, in its middle, and inferiorly. The cause of the conical form of the ventricular portion of the heart is explained by Mr. Searle as follows : — " Along the central cavity of the left ventricle are placed the two carneae columneae, the length of which is equal to the lower three-fourths of the length of the axis of this cavity. The fibres of these two bodies radiate, and the radiated fibres wind round the axis closely upon them. By this radiation, instead of all the fibres passing longitudinally, which would have preserved these bodies in a state of equal thick- ness throughout their length, they are progressively parting with their fibres, retaining but a few, which by their longitudinal course, reach the apex ; consequently these columns gradually diminish, becoming pyramidal, and form together an inverted cone ; and as the fibres in well-formed hearts wind closely round these columns the entire ventricle gently assumes the form of a cone : and al- though the right ventricle is as it were appended to the left, yet it is not so connected to it as to destroy the conical form, but, on the contrary, in such a manner as to form a concave parabolic section of a cone, which adapts itself to the gentle cone of the left BLOOD-VESSELS OF THE HEART. 33 ventricle. The two ventricles thus united assume the form of the more rapid cone of the heart." NERVES AND BLOOD-VESSELS OF THE HEART. The heart receives its nerves from both the gangUonic and cerebro-spinal system ; the former are derived from the three cer- vical ganglions of the great sympathetic, and sometimes from the first dorsal ganglion ; the latter are derived from the par vagum or pneumo-gastric nerve, &nd from its branch, the recurrent or inferior laryngeal nerve. The three cardiac nerves upon each side, which are termed respectively the superior, the middle, and the inferior, come from the superior, the middle, and the inferior cervical ganglia of the great sympathetic. The superior cardiac nerve communicates with the middle and with the pneumo-gastric nerve ; the middle communicates with both the superior and inferior, as well as with the pneumo-gastric and recurrent ; the inferior communicates with the middle and with the recurrent nerves. The cardiac ganglion receives the superior cardiac nerves on each side, and a branch from the pneumo-gastric, and sends branches to the cardiac plexuses. The great cardiac plexus is formed by the middle and inferior cardiac nerves from opposite sides ; it receives branches also from the pneumo-gastric and re- current : it lies behind the ascending portion of the arch of the aorta, in front of the trachea, near its bifurcation. From it lesser plexuses are formed, termed the anterior and posterior cardiac or coronary plexuses, which accompany the coronary vessels, supply the substance of the heart, and communicate with the pulmonary plexuses. The experiments of Volkmann go to prove, that the move- ments of the heart are independent both of the brain and spinal cord ; and that its movements " depend upon the ganglia and the nerve-fibres contained within itself; whilst centripetal fibres of these ganglia are found in the vagus, sympathetic, and in the spinal cord." It is to Dr. Robert Lee, however, that we are principally indebted for our knowledge of the ganglia and plexuses of the heart, — a subject which he has investigated with a patience and skill deserving of every praise. He has shown* that every artery * Philosophical Transactions, 1849. 34 DESCRIPTION OF THE HEART. distributed throughout the walls of the heart, and every muscular fasciculus is supplied with nerves, upon which ganglia are formed. The number of these ganglia may be estimated by the fact, that as many as ninety are visible upon the nerves on the anterior surface of the heart. The following conclusions, under this head, are given by Dr. Lee : 1 . That the blood-vessels, and the muscular structure of the auricles and ventricles of the heart, arfe endowed with numerous ganglia and plexuses of nerves, which have not hitherto been de- scribed or represented in the works of anatomists. 2. That the nervous structures of the heart, which are distri- buted over its surface, to the apex and throughout its walls, to the lining membrane and columnae carneae, enlarge with the natural growth of the heart before birth, during childhood and youth, until the heart has attained its full size in the adult. 3. That the ganglia and nerves of the heart enlarge, like those of the gravid uterus, when the walls of the ventricles are affected with hypertrophy. 4. That the ganglia and nerves, which supply the left auricle and ventricle in the natural state, are more than double the size of the ganglia and nerves distributed to tlic right side of the heart. Blood-vessels of the Heart The heart, although always more or less full of blood, cannot appropriate any of the fluid which passes through its cavities to its own nutrition ; but, hke every other organ, has peculiar vessels set apart to supply it : these are the two coronary arteries, which come off at the sinuses of Morgagni, immediately above the free margin of the semilunar valves. The principal division of the anterior or left coronary artery lies in the anterior longitudinal groove ; its other branch runs round the base of the left ventricle, in the circular or auri- culo-ventricular groove. The posterior or right coronary artery is lodged in the circular or auriculo-ventricular groove, and a large branch of it runs down the posterior longitudinal groove ; they inosculate very freely with one another. The returning blood is principally conveyed by the great coronary vein which opens into the right auricle, between the Eustachian valve and the right auriculo-ventricular orifice. A valve formed by a semi- lunar fold of the lining membrane of the heart partially closes the BLOOD-VKSSELS OF THE HEART. 35 orifice, and prevents regurgitation. The grooves in wliicli the coronary vessels run, mark the site of the septum of the ventricles as well as the line of separation between the auricles and ventri- cles ; and owing to their position in these grooves, " they cannot," Dr. Wardrop observes, " suffer compression sufficient to interrupt their circulation, either from the auricular or ventricular con- traction." 36 CHAPTER II. DIMENSIONS OF THE HEALTHY HEART.— SIZE AND WEIGHT OF THE HEART. CAPACITY OF THE CAVITIES AND DIAMETER OF THE ORIFICES OF THE HEALTHY HEART. In order to determine whether the heart is increased or diminished, or preserves its normal dimensions, it is absokitely necessary to have correct ideas respecting the size and weight of the heart ; but as these vary with the age of the subject and with the sex of the individual, it is obvious that we can have no single standard for the adult heart. Laennec laid it down that the closed hand, of the subject, was pretty nearly a mark of the size of the heart. This, however, is far from being the case : the heart of the infant at birth is hrger than its closed hand, while the size of the hand varies according to the nature of the occupation of the person. It was supposed at one time that stature had considerable influence upon the size of the heart, and that this organ was always larger in tall than in short persons, in consequence of the greater distance to which the blood has to be transmitted. M. Bizot has, however, shown that stature has not the influence which was once supposed, and that whatever it exerts is rather in the opposite direction, the absolute size of the heart in both sexes being slightly less in tall persons : this, however, has been denied by M. Bouillaud. According to M . Bizot, the breadth across the shoulders has a greater influence than stature ; the mean size of the heart and the width of the shoulders in both sexes being in a pretty regular ratio. That the heart increases in size with the age of the individual, that in advanced life it is larger than in the adult, and that it is larger in proportion in the male than the female at every age, has been satisfactorily proved by M. Bizot. The results of accurate measurements of the heart in 156 individuals of all ages, given SIZE OF THE HEART. 37 by him, show that this organ regularly and progressively increases in all its dimensions — length, breadth, and thickness — up to the latest period of Hfe ; the increase being more rapid before twenty- nine years of age than after that period : and that the heart of the female at every period of life is smaller than that of the male. The late Ur. Clendinning, whose researches were carried on about the same time, but without any knowledge of M. Bizot's labours, arrived at very nearly similar conclusions : his inquiries were particularly directed to determine the absolute weight of the heart in health and disease, as well as its relative weight to the entire body. Dr. Ranking, likewise, from the examination of a number of healthy hearts, and M. Neucourt from researches carried on at the Salpetriere, in the service of MM. Valleix and Beau, have been able to corroborate some of M. Bizot's conclusions. M. Neucourt's examinations were limited to females in advanced life. Length of the Heart The length of the healthy heart in the adult, according to Meckel, measured from the centre of the auri- cles, is between five and six inches, four of which are for the ven- tricular, and one and a-half for the auricular portion. Senac con- sidered from three and a-half to four inches to be the average length of the ventricular portion of the heart. According to M. Bouillaud, the mean length of the heart, from the base of the left ventricle or from the aortic orifice to the apex of the organ, in nine subjects was three inches seven lines and three-quarters. Dr. Ranking* from an accurate examination of thirty-two healthy hearts (fifteen male and seventeen female) gives as the mean length of the heart, measured from the point where the aorta emerges to the apex of the organ, four inches and one-third for the male, and three inches and a-half for the female. In my examinations, the length of the heart, measured from the summit of the appendix of the right auricle to the apex of the left ventri- cle, ranged from four inches and a-quarter to five inches and a- half. I look iTpon five inches and a-half to be the full length of the healthy adult heart. Breadth of the Heart The breadth of the heart across the base of the ventricles Meckel considers to be three inches ; Senac, between two, and two inches and a-half; M. Bouillaud states that * London Medical Gazette. 38 DIMENSIONS OF THE HEART. the average in eight hearts was three inches seven and a-half lines, and the mean circumference at the base of the ventricles eight inches nine hnes and three-sevenths. Dr. Ranking gives the mean circumference of the base of the heart in the male as slightly above nine inches and a-half; in the female, about eight inches and a-quarter. In the examinations which I have made, I have found the breadth of the heart across the ventricles to range be- tween three inches and a-quarter and four inches. The following table, given by M. Bizot, shows the progressive increase in length and breadth of the heart from infancy to old age, as well as the comparative size of the heart in the male and female at different ages. The measurements are given in lines ; the length is measured from the base of the ventricular por- tion to the apex ; the width, at the part where the auricles and ventricles join one another. MALES. FEMALES. Age. Number of subjects. Length. Breadth. Age. Number of subjects. Length. Breadth. 1 to 4 5 to 9 10 to 15 16 to 29 30 to 49 50 to 79 7 3 3 18 23 19 22| 314 34 42t% 43^ 45H 27 33 37 45H 47M 52if 50 to 89 8 10 5 14 27 19 221 261 29^ 38^ 4^\ 42tV 25i 29 314 42t\ 44^V 46ii- Conclusions respecting the size of the Heart. — From the pre- ceding details, it appears that — 1. The heart in both sexes gradually and progressively in- creases in size from infancy to old age ; the increase being more rapid up to twenty-nine years of age than after that period. 2. The heart of the male is larger in all its dimensions, at every period of life, than that of the female ; and the ratio is nearly the same at all ages except infancy. 3. The breadth across the base of the ventricles exceeds the length of the ventricles at every age, and in both sexes. 4. The mean length of the ventricular portion of the healthy heart of the male, at the period of life when this organ attains its maximum development, is slightly under three inches ten lines ; in the female, under three inches seven lines. WEIGHT OF THE HEART. 39 5. The mean breadth of the ventricular portion of the healthy heart of the male in advanced life is below four inches five lines ; in the female, below three inches eleven lines. 6. In persons of elevated stature the absolute size of the heart is not only not greater than in individuals of medium height, but, from M. Bizot's researches, appears to be rather less. 7. The capacity of the thorax, indicated by the width of the shoulders, has a greater influence upon the size of the heart than stature ; and this organ is larger, as a general rule, where the shoulders are wide apart than in individuals with narrow shoulders. WEIGHT OF THE HEART. Lancisi was the first to endeavour to determine the normal condition of the heart by weighing it ; but until within the last few years we had no positive' information respecting either the absolute weight of the healthy heart, or the ratio which the weight of the heart bears to that of the entire body ; and it is to the re- searches of the late Dr. Clendinning that we are principally in- debted for statistics under these heads. He has shown* that the absolute weight of the healthy heart varies with the age and sex of the subject ; that in the female the weight is always below that of the male ; and that in the male the weight increases gradually with the years as life advances ; while in the female, although the absolute weight is rather less in old age than about fifty, the rela- tive weight to the entire body increases as life advances after that period. Absolute weight of the Heart Senac considered the weight of the healthy heart of the adult to be between eight and ten ounces. Meckel lays down ten ounces as its average weight ; Lobstein esti- mated it at between nine and ten ounces ; Cruveilhier at between six and seven ounces; and Sanson at eight ounces and a-half. Bouillaud says we may fix the mean weight of the heart in the adult between twenty-five and sixty years of age, at between eight and nine ounces ; in thirteen cases given by him, the average was eight ounces three drachms, the maximum being eleven ounces, and the minimum being six ounces two drachms : the former, he observes, belonged to a subject of colossal stature, and of strong constitution : the latter to a subject of only sixteen years of age. * Med. Chir. Transactions. Male. Female 8i OZ. . 8i OZ. 84 . . 8i n nearly 8 H , 8 40 DIMENSIONS OF THE HEART. The following table, given by Dr. Clendinning,* sliows the net average weight of the healthy heart, at different ages, in the two sexes. Forty-eight of the subjects were males, and ninety- eight females ; none are included in the table in which the weight of the heart reached eleven ounces avoirdupois : — Age. 15 to 30 30 to 50 50 to 70 70 to 100 Ratio of iceight of Heart to the Body The ratio which the weight of the heart bears to the entire body is different at different ages, and in the two sexes. According to Meckel, in the infant soon after birth the ratio is as one to one hundred and twenty, while in the adult it is as one to two hundred. But, as Dr. Clendinning remarks, Meckel has not given particular observations, and possibly did not pay sufficient attention to differences of age, sex, and disease. The following table, given by Dr. Clendinning, shows the ratio which the weight of the heart bears to the entire body at different ages, and in the two sexes. This table includes twenty-three subjects under puberty, most of whom were under five years of age : forty-two males and fifty-eight females above puberty :■ — Age. Male. Female. Under puberty . 1 to 146 1 to 153 15 to 30 . 1 to 164 I to 169 30 to 50 . 1 to 150 1 to 161 50 to 70 . 1 to 161 1 to 187 70 and upwards . 1 to 155 1 to 121 "The absolute weight of the healthy heart may therefore," Dr. Clendinning observes,* " be assumed to average for the whole of life above puberty, about nine ounces for the male, and eight ounces, or a little more, for the female ; and to bear after death to the entire body the ratio of about one to one hundred and sixty for the male, and one to one hundred and fifty for the female. So that a male adult heart considerably exceeding the, 160th part of the whole subject, might, for a person of the working classes, and * London Medical Gazette, Vol. xxii. WEIGHT OF THE HEAKT. 41 of ordinary fatness, but of much muscularity, be held to be normal ; while a heart of like absolute dimensions, but occurring in a subject of average stature and muscularity, would be justly considered hypertrophous, although, owing to general obesity or oedema, it should not exceed, or should even fall short of, the 160th part of the weight of the person. And this observation applies, mutatis mutandis^ to the female ; in whom, I think, the extremes of obesity and leanness more frequently occur than in the male." "The female stature and muscular development vary consider- ably less than the male, and the limits of normal nutrition, and the volume of the heart, are consequently narrower ; so that any female heart greatly exceeding eight ounces in weight or volume may ipso facto be suspected of hypertrophy, whatever may be its apparent anatomical condition ; and but few instances indeed, if any, will be met with, I apprehend, of female hearts exceeding nine ounces in volume, or nine and a-half in weight, in the persons of individuals of ordinary stature and conformation, that had been quite free from pectoral disease during their lives." Comparative weight of parts of the Heart — We possess but few statistics bearing upon the comparative weight of the several parts of the heart one to another. According to Valentin, the weight of the left ventricle is double that of the right ; and he calculates from this that the force exerted by the right ventricle in its systole is only half that of the left ; allowing two-thirds of the force of the septum to the left ventricle and one-third to the right. Ludwig states as the result of weighing the muscular sub- stance of the ventricles, in both a moist and dry state, that the tissue of the left ventricle contains much less water than the right ; consequently it has a much greater relative weight when dried. Conclusions respecting the iceight of the Heart : — 1 . The absolute weight of the heart increases with the years, as life advances, in a very perceptible manner in the male. In the female there is no increase in its absolute weight after fifty years of age. 2. The absolute weight of the heart is greater in the male than in the female at every age. 3. The average absolute weight of the healthy adult heart 42 DIMENSIONS OF THE HEART. may be set down as nine ounces for the male, and eight ounces, or a little more, for the female. 4. The ratio which the weight of the heart bears to the entire body is different at different ages, and in the two sexes. 5. In infancy, in both sexes, the ratio of the weight of the heart to the entire body is greater than in the adult. In ad- vanced life it is greater than at the middle periods. 6. In the female in advanced life the ratio of the weight of the heart to the entire body is much greater than in the male at the same period of life. 7. In estimating the weight of the heart, in doubtful cases, the relative as well as the absolute weight of the organ ought to be taken. THICKNESS OF THE WALLS OF THE HEART. The parietes of the several cavities of tl^.e heart have not the same thickness : as a general rule, the walls of the left chambers are thicker than those of the right, and the parietes of the ventricles much exceed those of the auricles ; the left ventricle has much thicker walls than the right, and the walls of the left auricle are a little thicker than those of the right. Left Ventricle. — According to M. Bouillaud,* the average thickness of the walls of the left ventricle, near its base, in ten subjects, was six lines and a-half ; we may consider (he adds) seven lines as the average thickness of the parietes of this ventricle. According to Dr. Ranking,! the mean thickness of the walls of the left ventricle in the male, at a point about an inch distant from the origin of the aorta, is 27-48ths of an inch; in the female 23- 48ths of an inch. M. Bizot's researches} prove that the parietes of the left ventricle, in both sexes, go on increasing in thickness from youth to advanced age ; and that the thickest part of its walls is at the middle, next at the base, and that the thinnest part is at the apex. The accompanying table, given by him, shows the mean thickness (in lines) of the parietes of the left ventricle at those three points, in the male and female, at different ages. * Traite des Maladies du Coeur, 2nd edition. f London Medical Gazette. X Mem. de la See Med. d'Observation, tome'i. THICKNESS OF THE WALLS OF THE HEART. LEFT VENTRICLE. 43 MALE. FEMALE, Age. Base. Middle. Apex. Age. Base. Middle. Apex. 16 to 29 30 to 49 50 to 79 Mean average between 16 and 79 4 2-9 4 17-46 4 37-38 4 65-122 3 7-9 5 1-11 5 29-38 5 19-122 3 4-9 3 13-23 4 1-29 3 95-122 16 to 29 30 to 49 50 to 89 Mean average between 16 and 89 4 2-7 4 1-9 4 1-2 4 3-8 4 7-13 3 27-54 5 4 4-5 3 5-28 3 6-27 3 3-4 3 13-30 Right Ventricle According to M. Bouillaud, the average thickness of the walls of the right ventricle in ten subjects was two lines three-fifths : we may therefore, he says, consider two lines and a-half as the average thickness of the parietes of the right ventricle. According to Dr. Ranking, the mean thickness of the walls of the right ventricle in the male, at a point about an inch distant from the origin of the pulmonary artery, is 8-48ths of an inch ; in the female 6-48ths of an inch. According to M. Bizot, the thickest part of the parietes of the right ventricle is not at the same point as on the left side, but is close to the base of the heart ; and the parietes of this ventricle remain nearly sta- tionary at the different periods of life, being, however, a little thicker in advanced life than at an earlier period. The following table, given by M. Bizot, shows the mean thickness (in lines) of the parietes of the right ventricle at three distinct points, in the male and female at different ages. RIGHT VENTRICLE. MALE. FEMALE. Age. Base. Middle. Apex. Age. Base. Middle. Apex. 16 to 29 30 to 49 50 to 79 Mean average between 16 and 79 1 1 27-38 1 39-46 ■i 1-19 1 113-122 1 8-19 1 7-23 1 53-168 I 99-244 I 1-19 45-46 81-84 1 2-61 16 to 29 30 to 49 50 to 79 Mean average between 15 and 59 14-7 1 19-22 1 1-4 1 2-3 12-7 1 13-54 1 1-4 1 7-21 25-28 25-27 1 673-720 44 riMKNSIONS OF THE HEART. Septum Ventriculorum — According to Dr. Ranking, the mean thickness of the septum of the ventricles, taken at its centre, in fifteen males between 26 and 65 years of age, was 22-48ths of an inch. In seventeen females, between the age of 18 and 62, 14- 48ths of an inch. M. Bizot's researches show that the thickness of the septum of the ventricles goes on increasing from infancy to an advanced period of life ; and that it is thicker in the male than in the female. The following table, given by him, shows the average thickness (in lines) of this part at its centre, in the male and female at different ages. ^ge. Male. Female. 16 to 29 30 to 49 50 to 79 4 17-18 4 21-23 5 1-3 4 11-14 4 11-27 5 3-19 Auricular Walls. — The walls of the left auricle exceed those of the right in thickness ; but statistics are wanting under this head. M. Bouillaud is almost the only writer who has given measure- ments. According to him, the average thickness of the parietes of the left auricle in four subjects was one line and a-half; of the right auricle one line. Conclusions respecting the thickness of the Parietes oj the Heart. — From the preceding details it appears that — 1. The parietes of the left ventricle are thicker in the male than in the female heart at every age. 2. The parietes of the left ventricle and of the septum ventri- culorum increase in thickness as age advances in both sexes. 3. The parietes of the right ventricle increase also in thickness as age advances in both sexes, but in a much less ratio. 4. The thickest part of the parietes of the left ventricle is at the centre, next at the base, and it is thinnest at the apex. 5. The thickest part of the parietes of the right ventricle is at the base. 6. The thickest part of the septum ventriculorum is at its centre. 7. The mean thickness of the parietes of the left ventricle, or of the septum, in tlie healthy heart of the male in advanced life. CAPACITY OF THE CAVITIES. 45 when the walls of the heart attain their maximum development (viz. between 50 and 79 years of" age), and at the thickest part, is under six Knes. 8. The mean thickness of the parietes of the left ventricle in the female between 50 and 89 years of age, is five lines. 9. The mean thickness of the parietes of the right ventricle in the healthy heart of the male, between 50 and 79 years of age, and at its thickest part, is a fraction above two lines ; in the female, one line and a-quarter. 10. The mean thickness of the parietes of the left ventricle is, therefore, in both sexes, nearly three times as great as that of the right ventricle, as was long since laid down by Riolanus. CAPACITY OF THE CAVITIES. The capacity of the several cavities of the healthy heart is not the same : the auricles exceed the ventricles in this respect ; the right auricle likewise exceeds the left, and the capacity of the right ventricle is greater than that of the left. The capacity of both ventricles increases gradually as life advances in both sexes ; the increase is more rapid in youth ; after fifty years of age it is less marked, although it still goes on ; so that, both in infancy and old age, the ratio between the capacity of both ventricles is the same. That the capacity of the right ventricle is greater than that of the left was suspected long before it was actually proved. Senac says repeated examinations have convinced him that the capacity of the right ventricle exceeds that of the left ; but that the diflPer- ence is almost insensible in some subjects. M. Bouillaud repeats nearly Senac's words: he says — "the medium capacity of the right ventricle exceeds that of the left ; but the difference is really very shght." This position has, however, been denied by some writers, and the apparently increased capacity of the right ven- tricle has been supposed to depend upon the accumulation of blood in the right cavities of the heart after death. " There is much reason to believe," Dr. A. Thomson observes,* " that the greater capacity of the right auricle and ventricle depends in part upon the accumulation of blood which generally takes place in most kinds of slow death in the pulmonary arteries ; and in part also * Cyclopaedia of Anatomy and Physiology. 46 DIMENSIONS OF THE HEART. upon the greater thinness, and consequent distensibility, of the right ventricle. In men dying suddenly, and in animals killed purposely, in which the pulmonary artery is opened so as to allow of the free egress of the blood from the right side of the heart, the capacity of this ventricle is not greater than that of the left, and the proportions of the capacity of the two sides of the heart usually found after slow death are sometimes reversed when a ligature is placed on the aorta, and the pulmonary artery is opened." But, as was long since remarked by Senac, " since in the foetus the capacity of the right ventricle exceeds that of the left, it would be strange if in the adult they should have the same capacity ;" while M. Bizot's researches have proved that the right ventricle exceeds the left in capacity at every age, that this is the normal condition of the parts, and that it is not at all owing to the ac- cumulation of blood during the last moments of life. The actual capacity of each of the ventricles has been endea- voured to be determined by filling their cavities with fluid or with injection ; but, as the parietes of the right ventricle are much more yielding than those of the left, this method is C9,lculated to lead into error ; indeed, Senac says he has introduced a pound and a-half of injection into the cavities of the heart without using much force. According to him, each ventricle holds about two ounces of fluid ; but the excess over this is very variable, the right sometimes holding from one' to four drachms more. Hales esti- mated the capacity of the left ventricle at one fluid ounce and a- half, and that of the right at two fluid ounces. Each ventricle, on an average, it is generally considered, will contain a hen's egg^ and, when moderately distended, is capable of holding from an ounce and a half to two fluid ounces, or a little more. M. Bizot determined the capacity of the ventricles by laying open their cavities, and measuring accurately the internal surface from above downwards, and transversely. From his researches it appears that both ventricles are wider than long in both sexes, and at every age ; that the length, but particularly the breadth of the right ventricle, exceeds that of the left at all ages ; that the capacity of the ventricles is greater in the male than the female ; and that the relative capacity of the two ventricles is pretty nearly the same in advanced life and in infancy. The capacity of the right auricle exceeds that of the left : the DIAMETER OF THE ORIFICES. 47 proportions established in the " Memoires de I'Academie" between them are as twenty-four to thirteen ; according to Santorini, as five to three ; but the inequality is seldom so marked in the per- fectly healthy heart. According to Dr. Sibson,* the capacity of the right auricle is about the same as that of the right ventricle ; while the capacity of the left auricle is less than that of the left ventricle. He, however, estimates the capacity of both ventri- cles as the same. Conclusions respecting the capacity of the Cavities of the Heart : — 1. The capacity of both ventricles increases gradually as life advances in both sexes, the increase being more rapid in youth. 2. The ratio between the capacity of each ventricle is pretty nearly the same at all ages. 3. The capacity of both ventricles is greater in the male than in the female. 4. The capacity of the right ventricle much exceeds that of the left at all ages, and in both sexes. 5. The right ventricle holds, when moderately distended, about two fluid-ounces; the left ventricle about one ounce and a-half. 6. The capacity of the right auricle exceeds that of the left ; and the capacity of the auricles is greater than that of the corres- ponding ventricles ; but further statistics are required under this head. DIAMETER OF THE ORIFICES. The size, as well as the shape, of the arterial and auriculo-ven- tricular orifices is different : the former have a circular, the latter rather an elliptic form ; the left auriculo- ventricular orifice has more of a crescentlc shape than the right. The orifices of the right side of the heart exceed in size those of the left: this, however, applies more to the auriculo- ventricular than to the arterial orifices, as in advanced life the aortic orifice rather ex- ceeds the pulmonary in size. M. Bizot's researches likewise show that the diameter of all the orifices of the heart is greater in the male than in the female, and that their size progressively increases as life advances in both sexes from puberty to old age. * Trans, of Prov. Association, vol. xii. 48 DIMENSIONS OF THE HEART. In order to determine the diameter of the orifices of the heart, the most convenient method is to lay open the part by an incision through it, and take its circumference, from which the diameter is readily calculated. When the orifice is diseased, or if we wish to preserve the preparation, we mvist be content with measuring the diameter by means of a pair of compasses. Right auriculo-ventricidar Orifice. — According to Cruveilhier, the long diameter of this orifice is from sixteen to eighteen lines ; its short diameter twelve lines. M. Bouillaud found the average circumference of this orifice in three healthy hearts to be three inches ten lines ; the maximum being four inches, the minimum three inches nine lines. According to Dr. Ranking, the mean circumference of this orifice in fifteen males was 4 inches 35-48ths ; in seventeen females, 4 inches 8-48ths. In the measurements which I have made, I have found the long diameter of this orifice to ranore between fourteen and sixteen lines and a-half. The following table, given by M. Bizot, shows the mean cir- cumference (in lines) of this orifice at different ages in the male and female. RIGHT AURICULO-VENTKICULAR ORIFICE. MALE. FEMALE. Age. Lines. Age. Lines. 16 to 29 30 to 49 50 to 79 50 9-19 54 5-23 57i 16 to 29 30 to 49 50 to 89 37 12.13 47 4-27 49 13-19 Mean Mean average between 16 and 79 54 12-61 average between 16 and 89 48^ Left auriculo-ventricular Orifice — According to Cruveilhier, the long diameter of this orifice is from thirteen to fourteen lines ; its short diameter from nine to ten lines. M. Bouillaud states that the average circumference in three hearts examined by him, was 3 inches 6^ lines ; the maximum being 3 inches 10 lines, the minimum 3 inches 3 lines. According to Dr. Ranking, the mean circumference of this orifice in the male is 3 inches 45-48tlis ; LEFT AURICULO-VENTRICULAR ORIFICE. 49 in the female, 3 inches 22-48ths. In the examinations which I have made, the long diameter of this orifice, measured from the auricle, ranges between ten and twelve lines. M. Bizot has given the following table of the mean circum- ference (in lines) of this orifice in the two sexes at different ages : LEFT AURICULO-VENTRICULAR ORIFICE. MALE. FEMALE. Age. Lines. Age. Lines. 16 to 29 30 to 49 50 to 79 Mean average between 16 and 79 41 48 9-22 48 13-19 45 17-30 16 to 29 30 to 49 50 to 89 Mean average between 16 and 89 38 40 17-26 44 4-19 4U Aortic Orifice According to M. Boiiillaud, the average cir- cumference of the aortic orifice in four healthy hearts was 2 inches 5\ lines ; the maximum being 2 inches 8 lines ; the minimum, 2 inches 4 lines. According to Dr. Ranking, the mean circum- ference of this orifice, on a line with the insertion of the semilunar valves, in fifteen males between twenty-six and sixty-five years of age, was nearly 2| inches ; in seventeen females, between eighteen and sixty-two years of age, 2 inches 22-48ths. According to Dr. Chevers, the circumference of the aortic orifice, immediately below the semilunar valves, is 36i- lines ; above them, 34 lines. In the examinations which I have made I have found the diameter of this orifice to range between ten and twelve lines. The accom- panying table, given by M. Bizot, shows the mean circumference (in lines) of the aortic orifice, at the free border of the semilunar valves, in the male and female, at different ages. AORTIC ORIFICE. MALE. FEMALE. Age. Lines. Age. Lines. 16 to 29 30 to 49 50 to 79 26 10-19 30 20-23 36 16 to 29 30 to 49 50 to 89 24 3-9 28 3-27 32 5-6 Mean average between Mean average between 16 and 79 31 15-61 16 and 89 28 4-5 50 DIMENSIONS OF THE HEART. Pulmonary Orifice — M. Bouillaud found the mean circum- ference of the pulmonary orifice in four healthy hearts to be 2 inches 7| lines; the maximum being 2 inches 10 lines; the minimum, 2 inches 6 lines. According to Dr. Ranking, the mean circumference of the pulmonary orifice in the male is 2 inches 34-48ths ; in the female, 2 inches 24-48ths. The following table, given by M. Bizot, shows the mean cir- cumference (in lines) of this orifice, at the free border of the sig- moid valves. PULMONARY ORIFICE. MALE. FEMALE, Age. Lines. Age. Lines. 16 to 29 30 to 49 50 to 79 Mean average between 16 and 79 29 2-19 31 12-23 35 32 21-61 16 to 29 30 to 49 50 to 89 Mean average between 16 and 89 28 3-14 29i 32 17-36 30 7-60 Conclusions respecting the diameter of the Orifices of the Heart From the preceding details it appears that, 1 . The diameter of all the orifices of the heart is greater in the male than the female, at every age. 2. The diameter of all the orifices of the heart increases gra- dually from birth to old age in both sexes. 3. The auriculo-ventricular orifices exceed the arterial orifices in size at every age, and in both sexes. 4. The right auriculo-ventricular orifice exceeds the left in size in both sexes, and at every period of life, except in the female between the ages of sixteen and twenty-nine, when, according to M. Bizot, there is a very slight excess of the left over the right. 5. The pulmonary orifice exceeds the aortic orifice in size in both sexes, up to the age of fifty ; after this period the aortic orifice slightly exceeds the pulmonary orifice. 6. The mean circumference of the right auriculo-ventricular orifice, in the healthy heart of the male, in advanced life, when the RELATIVE POSITION OF THE ORIFICES. 51 orifices of the heart attain their maximum size — viz. between fifty and seventy-nine years of age — is, omitting fractions of lines, 4 inches 9 lines ; of the left auriculo- ventricular orifice, four inches. 7. The mean circumference of the right auriculo-ventricular orifice in the female, between fifty and eighty-nine years of age, is (omitting fractions of lines) 4 inches 1 line ; of the left, 3 inches 8 lines. 8. The mean circumference of the pulmonary orifice in the male in advanced life, is 2 inches 1 1 lines ; of the aortic orifice, 3 inches. 9. The mean circumference of the pulmonary orifice in the female, between fifty and eighty-nine years of age, is about 2 inches 8 lines ; of the aortic orifice, 2 inches 8 lines. RELATIVE POSITION OF THE SEVERAL PARTS OF THE HEART TO THE PARIETES OF THE CHEST. A knowledge of the exact position of the several parts of the heart, particularly of its valves and orifices, and of their relation to fixed points on the surface of the chest, is of considerable im- portance in the diagnosis of the diseases of this organ, as it enables us to determine the size of the heart in the living subject, to as- certain whether it is increased or diminished in any of its diameters, or whether it is displaced, and the amount of the displacement ; and by it we can often determine which of the valves or orifices is diseased, as well as the nature of the morbid change. The apex and body of the heart being capable of some change of position, according to the posture of the patient, and according to the motions of the diaphragm ; and the base of the organ, from which the large vessels proceed, being more fixed, the latter is the most convenient point from which to trace the outline of the heart, or to determine what parts correspond to certain fixed points upon the surface of the chest. The sternum in front, with the cartilages of the true ribs late- rally, form in a great measure, the anterior boundaries of the heart ; a small portion only of this organ near its apex extends on the left side beyond the cartilages of the ribs. The base of the ventricular portion of the heart is from three to three and a-half inches below the clavicle, and on a line with the junction of the cartilage of the third left rib with the sternum. The impulse of 52 DIMENSIONS OF THE HEART. the apex of the organ is felt between the fifth and sixth left ribs, near where the body of these ribs joins the cartilage. A line, therefore, drawn between these two points gives the length of the ventricular portion of the healthy heart. In addition, the nipple in the male constitutes a useful guide : it is situated immediately opposite the lower edge of the fourth rib, a little more than an inch to the left of the junction of this rib with its cartilage, and as the edge of the left ventricle reaches the nipple on that side, and as the right ventricle extends a little to the right of the sternum, a line drawn between these two points gives its transverse diameter. The greater part of the right ventricle lies behind the sternum, at its upper part it extends slightly to the right of this bone, its apex is to the left of the sternum. It is overlapped by both the right and left lung ; below where the margins of the lungs separate from one another a small triangular space is uncovered by lung. The left ventricle is covered by the left lung ; all its anterior surface is to the left of the sternum ; its left margin reaches to the nipple on the left side. The right auricle lies to the right of the sternum, and is entirely covered by the right lung ; its appendix lies behind the cartilage of the third right rib ; its tip rests against the right side of the ascending portion of the arch of the aorta, and is on a line with the pulmonary valves. The left auricle is entirely covered by the left lung, its ap- pendix is the only portion seen when the pericardium is laid open ; it lies behind the cartilage of the third left rib, close to the sternum, resting against the left side of the commencement of the pulmonary artery. The base of the heart — that is, of the auricular portion — is on a line with the interval between the junction of the second and third ribs with the sternum, the greater portion of it being under the sternum. The base of the ventricular portion of the heart on the left side rises as high as a line drawn across the junction of the cartilage of the third left rib with the sternum ; that is, about three inches below the clavicle on that side. On the right side, owing to the oblique position of the heart, the base of the right ventricle corres- ponds to a line across the upper margin of the junction of the car- tilage of the fourth right rib with the sternum. RELATIVE POSITION OF THE ORIFICES. 53 The apex of the left ventricle is a little below the fifth left rib, to the left of the junction of this rib with its cartilage, and on a line with the articulation of the xyphoid cartilage with the sternum. RELATIVE POSITION OP THE ORIFICES. The right auriculo-ventricular orifice lies behind the centre of the sternum, on a line with the lower margin of the articulation of the cartilages of the fourth ribs with the sternum. The left auriculo-ventricular orifice is on tlie same level, but on a plane posterior to the right ; it lies behind the cartilage of the fourth left rib, near the sternum. * The pulmonary valves are on a line with the space between the cartilages of the second and third ribs, to the left of the sternum, and very close to this bone. In some instances they lie a little lower down — viz., on a line with the junction of the cartilage of the third left rib with the sternum, and immediately under it. The aortic valves lie behind the sternum, on a line with the junction of the cartilages of the third ribs with the sternum, and towards the left edge of this bone. When the valves of the pulmonary artery are situated lower down, the semilunar valves of the aorta will be lower also, and on a line with the interval between the insertion of the cartilages of the third and fourth ribs. The free edge of the semilunar valves of the aorta corresponds accurately, M. Gendrin observes, to the base of the pulmonary valves. A line drawn across the inferior margin of the third ribs corresponds to the base of the valves of the pulmonary artery, and to the free border of the aortic valves. The right ventricle ascends higher than the left, and the left ventricle descends lower than the right. Hence the origin of the pulmonary artery is on a plane above that of the aorta. The pulmonary orifice is the highest up, as well as the most anterior, of all the orifices of the heart. The aortic orifice lies behind it, and on a plane lower down. The left auriculo-ventri- cular orifice is immediately behind the aortic orifice, but on a plane lower down. The right auriculo-ventricular orifice is nearly on the same plane as the left, but more anterior. The Aorta. — The ascending portion of the arch of the aorta 54 DIMENSIONS OF THE HEART. comes to the right of the sternum, between the cartilages of the second and third ribs. In this part of its course it is witliin the pericardial sac, and in the dead subject lies at the depth of one inch and a half from the surface, the margin of the right lung and the pericardium being between it and the parietes of the chest. The transverse portion of the arch of the aorta crosses the trachea at the centre of the first bone of the sternum, on a line with the lower margin of the articulation of the cartilages of the first ribs with the sternum, and at a still greater depth from the surface. The arch of the aorta approaches most closely to the parietes at the point at which the arteria innominata comes off; that is, on a line with the junction oi the cartilage of the second right rib with the sternum. The -pulmonary Artery The origin of the pulmonary artery is on a line with the ju^nction of the cartilages of the third ribs with the sternum ; the tip of the left auricle resting against its left side ; it ascends about two inches before it divides ; and a portion of the margin of the vessel here comes to the left of the sternum, between the cartilages of the second and third ribs. The division of the artery is on a line with the upper edge of the cartilage of the second ribs, where they join the sternum; the apex of the pericardial sac being on a line with the junction of the cartilages of the second ribs with the sternum, though it is sometimes higher up, and on a line with the cartilage of the first ribs. 55 CHAPTER III. MOTIONS OF THE HEART.— FREQUENCY OF THE HEART'S MOVEMENTS, AND OF THE PULSE.— EFFECTS OF POSTURE ON THE PULSB.— MECHANISM OP THE ACTION OF THE VALVES. % The heart we have seen to be composed, essentially, of muscular tissue. As a muscular organ, it is adapted to perform certain mo- tions. These consist in alternate contractions and relaxations of its muscular fibres ; but the heart being a hollow viscus, and di- vided in its interior into distinct chambers, the contraction and relaxation of its muscular parietes must necessarily occasion the diminution and enlargement of its cavities, and of course react upon the blood they contain. The ventricles are the parts of the heart upon which the circvdation mainly depends ; the auricles (as was remarked by Hunter) are to be considered rather as reser- voirs, " capable of holding a sufficient quantity of blood to sup- ply the ventricles, and ready always to fill them as they are in need of it." The function of the heart, it is scarcely necessary to observe, is the circulation of the blood ; it is the principal agent in this important process ; and, as life depends upon its regular and con- stant action, the motions of the organ are altogether independent of the will. The heart, therefore, considered as a muscular viscus, belongs to the class of involuntary muscles, its movements being not only uninfluenced by the will of the individual, but carried on without his consciousness. The manner in which the motions of the heart are performed the order in which they succeed each other, and the phenomena which characterise its movements, have been determined by an examination of the heart in animals, where the parietes of the thorax had been removed and the heart exposed, the animal having been previously deprived of sensation, and artificial res- 56 MOTIONS OF THE HEART. piration kept up. The opportunity has likewise been occasionally afforded of examining this organ in the human subject in certain rare cases of congenital malformation, where an infant was born with a deficiency of the anterior parietes of the thorax, and the heart presented itself naked and uncovered to the view. Few parts of our subject have been more frequently or more carefully investigated than this, and there are few upon which a greater amount of time, labour, and talent have been bestowed. The motions of the heart consist, as I have said, of alternate contractions and relaxations of the parietes of its several cavities. The contraction of the ventricles, or their systole, as it is commonly termed, constitutes their active state ; as soon as this ceases, the muscular tissue relaxes, their cavities enlarge, and return to a state of fulness ; when the ventricle is said to dilate, or its diastole as it is termed, occurs. By the ventricular systole, the blood is propelled into the aorta and pulmonary artery ; as the ventricles re-expand, the blood, favoured by gravity, passes in a full stream from the auricles into the ventricles, to be again expelled when the ventricular systole ensues. From the Report of the Committees of the British Association for 1838-39 and 1839-40, it appears that "the visible systolic and diastolic motions are first perceived at the bases or fixed parts of the cavities ; viz. in the auricles at the sinuses, and in the ventri- cles at the fundls cordis ; and that the apices of the auricles and ventricles, or free parts, are brought into full action after the others, and only just before the supervention of the opposite and next succeeding condition of the cavities respectively, whether that condition be systole or diastole." It will now be necessary to consider separately the motions of each of the cavities of the heart. Auricular Systule. — The systole of the auricles is a quick, short, sudden motion. Lower says its rapidity equals the explosion of gunpowder. It immediately precedes the ventricular systole, the one motion appearing to be propagated into the other. It commences in the sinus, and extends to the appendix, but by a very minute interval. According to some authorities, it is first observed in the appendices. In feeble states of the heart's action it becomes vermicular. The auricular systole is most apparent in the appendices, and VENTRICULAR SYSTOLE. 57 is very feeble compared with that of the ventricles. By it a small additional quantity of blood is propelled into the ventricles ; but its contraction is too slight either to empty the auricular ca- vities or to cause the dilatation of the ventricles. In the majority of cases, likewise it is too feeble to produce sound. Nevertheless, in some of the experiments of the Committee of the British Asso- ciation, and in those conducted in America by Drs. Pennock and Moore, sound, though faint, was sometimes heard, which, in a great degree, merged into that of the ventricular systole, but still was real. The auricular systole occurs towards the end of the period of repose "of the heart; its duration is about the eighth part of an entire beat of the heart. Auricular Diastole. — The diastole of the auricles is a passive movement; these cavities are gradually and progressively dis- tended, from the sinus to the appendices, by the blood which enters from the vense cavse and pulmonary veins. It continues from the termination of one auricular systole to the commence- ment of the next, so that it persists through the systole of the ventricles, during their diastole, and during part of the interval of repose. M. Cruveilhier states, that the right auricle during its diastole (in a case of ectopia of the heart, which he had an oppor- tunity of examining,) seemed ready to burst, so distended was it, and so thin its parietes ; the left did not exhibit the same appear- ance, at least so decidedly. The duration of the diastole of the auricles is about seven-eighths of an entire beat of the heart. Ventricular Systole The systole of the ventricles is a gradual, progressive, and gliding movement, and performed with great force : it commences suddenly, instantly succeeding the auricular systole, so that the one movement appears to be propagated into the other. During their systole the parietes of the ventricles be- come pale, hard, and convex ; the vertical and transverse diame- ters are diminished, the apex is approximated to the base, and de- scribes a spiral motion from right to left, and from behind for- wards, coming in contact with the parieties of the thorax between the cartilages of the fifth and sixth ribs on the left side, where the impulse of the heart is felt. Dr. Sibson* (in some experiments made by him) says, the ventricles in contracting, felt " Hke the pushed, revolving point of a pencil." " Wherever (he observes) * Traus. of Prov. Association, vol. xii. 58 MOTIONS OF THE HEART. "the junction of the left ventricle to the auricle could be observed, the apex and base of the ventricle were seen to approach each other steadily during the whole systole ; so that at the end of the systole, the apex was about the third of an inch nearer the left auricle than at the beginning, and the aorta was drawn downwards about a quarter of an inch." In the experiments performed by Drs. Pennock and Moore,* the apex of the left ventricle was not observed to be approximated to the base during its systole. The expulsion of the blood from the ventricle (they observe) is effected by an approximation of the sides of the heart only, and not by a contraction of the apex towards the base : during the systole, the heart performs a " spiral movement, and becomes elongated." All other observers have, however, noticed the shortening from above downwards of the ventricular portion of the heart dviring the systole ; and from the manner in which the fleshy columns of the valves are inserted, such would appear to be essential to the perfect action of the auriculo-ventricular valves, when the ventricles contract. The phenomena presented by the systole of the ventricles have been well described by M. Cruveilhier,t as observed by him in a case of ectopia of the heart, in an infant which lived for about fourteen hours. " During their systole the ventricles become pale, their sur- face wrinkled, the superficial veins swollen, and the spiral fibres which form the apex of the heart become more evident. At the same time the ventricles diminish in all their diameters, the ap- pearance of shortening being most perceptible in the vertical dia- meter." "During the systole of the ventricles, the apex of the heart (that is, of the left ventricle) describes a spiral or turnscrew mo- tion from right to left, and from behind forwards. This spiral movement is slow, gradual and as it were, successive ; and it is to it that the impulse of the apex of the heart is due. The ventri- cular systole is not accompanied by a motion of projection of the heart forwards ; it is the spiral contraction exclusively which pro- jects the apex of the organ against the parietes of the thorax." The ventricles do not appear to empty themselves completely during their systole; this, however, cannot be ascertained with * Medical Examiner, Nov. 1839. f Gazette Medicale. VENTRICULAR DIASTOLE. 59 certainty, owing to the thickness of their parietes; but, as Dr. Hope observes, the diminution of their volume is not in general so great as to convey the impression that they do. During the ventricular systole the blood is propelled with considerable force into the arterial orifices, the first sound of the heart is heard, and the impulse and pulse are felt. The systole of the ventricles oc- cupies about one-half the period of an entire beat of the heart ; that is, it is as long as the diastole and the period of repose toge- ther, and is double the length of the ventricular diastole. Ventricular Diastole. — The diastole of the ventricles instantly succeeds the systole ; it is a sudden and instantaneous movement ; in it the ventricles increase in all their dimensions, the apex re- cedes from the base, the heart becomes elongated, the surface smooth, and it assumes the shape and position which it had pre- vious to the systole. This movement of tlie heart has been divided into two stages; "the first, which immediately follows the ventri- cular systole, is sudden, the apex being pushed downwards, and apparently passing deeper into the chest, and is occasioned by the return of the heart to its state of rest." "The second is also sud- den, and attended by a rapid but not very extensive enlargement of the heart in all its dimensions." The force with which the ventricular diastole is accomplished is very considerable : in large animals, the hand grasping it is forcibly opened. M. Cruveilhier gives the following account of the phenomena observed by him in the case of the infant before alluded to : " The ventricular diastole was sudden and instantaneous; the ventricular cavities became filled, swelled out, elongated, and the apex was projected downwards : it seemed at first sight as if this constituted the active movenient of the organ, so rapid and ener- getic was it. One forms no idea of the force with which the di- latation overcomes any pressure upon the heart ; the hand closed round it is violently opened." " The ventricular diastole is accompanied by a movement of projection of the heart downwards, which was carried to the max- imum when the infant was placed vertically. This motion was so decided that at first I was inclined to think that it was during the ventricular diastole that the impulse of the heart against the thoracic parietes occurred." During the ventricular diastole the blood passes in a full stream 60 MOTIONS OF THK HEART. from the auricles into the ventricles : it is not impelled by the auricles, neither is it the entrance of the blood which causes the ventricles to dilate ; the utmost force of the auricular contraction could not cause the dilatation of the ventricles. Besides, the auri- cular systole does not occur until after the ventricular diastole. The duration of the diastole of the ventricles is brief compared to that of the systole, being about half the length of the former movement, and about one-fourth of the period of an entire beat of the heart ; the second sound of the heart is synchronous with it. Order of succession of the Hearths motions. — The systole pre- cedes the diastole in both the auricles and ventricles. The sys- tole of the right and left auricle is synchronous, as is their diastole. The systole of the two ventricles is also synchronous, as is their diastole. The systole of the auricles occurs during the latter part of the period of repose of the ventricles. The diastole of the auricles occupies the remainder of the period of repose of the ventricles, and the entire period of the ventricular systole and diastole. The systole and diastole of the ventricles occurs at the same period as the auricular diastole. The order in which these several motions succeed each other is as follows : 1. The auricular systole. 2. The ventricular systole. 3. The ventricular diastole. 4. The period of repose of the ventricles ; during the latter part of which period the auricular systole occurs again. From the termination of the diastole of the ventricles until the commencement of the next systole, " the ventricles are in a state of perfect repose, their cavities remaining full but not distended." If the duration of these movements be divided into four equal periods, the ventricular systole would, according to Laennec, oc- cupy about two; the ventricular diastole something more than one; and the interval of repose something less than one. Or in portions of a second, the ventricular systole would occupy about half a second ; the diastole a little more than a quarter of a se- cond ; and the period of repose something less than the quarter of a second. PERIODS OF REPOSE. 61 Dr. Williams divides the period, from the commencement of one pulse to the commencement of another, into five equal parts. Of these the two first are occupied by the ventricular systole, one- fifth is occupied by the diastole, in part of which occurs the short second sound. The period of natural rest and silence succeeds, occupying the remaining two-fifths. If the duration of the movements of the auricles be divided into eight equal parts, the auricular systole would occupy about one -eighth — their diastole the remaining seven-eighths : the auri- cular systole occupying part of the period of the repose of the ventricle ; the auricular diastole occupying the remainder of the period of repose, as well as the period of the ventricular systole and diastole. Periods of repose of the Heart — When the heart's action is very rapid, the alternate movements succeed each other so quickly that there appears to be no interval of repose. On the other hand, when it is very slow, two distinct intervals are distinguished — one short between the systole and the diastole of the ventricles ; the other longer, between the diastole and the next succeeding systole. The first of these intervals M. Gendrin proposes to call the peri- systole ; the second, the peri-diastole. According to MM. Barth and Roger, the shorter period of repose has the same duration as the diastole of the ventricles ; and the longer period of repose, about the same duration as the ventricular systole ; and, if the whole period be divided into six equal parts, the systole would occupy about two, the short period of repose one, the diastole one, and the long period of repose about two. According to Dr. Walshe,* when the heart is beating with moderate frequency, as 60 in the minute, if the period of an entire revolution of the organ be divided into ten equal parts, the systole would occupy four, the post-systolic silence one, the diastole two, and the post-diastolic silence three. It would therefore appear that the period of repose of the ven- tricles, and of their active state, has about the same duration, which would give about twelve hours' rest out of the twenty-four to the muscular fibres of the ventricles. But, as the muscular fibres of the ventricles are relaxed during their diastole, the period occupied by it may be added, which will make the period of repose or rest of the ventricles considerably longer. As the auricular systole * On Diseases of the Lungs and Heart. 62 MOTIONS OF THE HEART. occupies only one-eighth part of an entire beat of the heart, and the diastole the remainder, the auricles (if the period of their diastole be considered as a state of repose,) may be said to be at rest for twenty-one out of the twenty-four hours. FREQUENCY OF THE HEART'S ACTION, AND OF THE PULSE. The rapidity of the heart's action is not the same at every period of life : it varies also according to the sex, the temperament, and the idiosyncrasy of the individual; it differs at different periods of the day, and in different positions of the body, and it is remarkably influenced by affections of the mind. In the female, the heart's action is iHore rapid than in the male ; the pulse of the adult female exceeding in frequency the pulse of the adult male, of the same mean age, by from nine to ten beats. According to Dr. Guy,* " the average pulse of the adult male may be stated at 70 ; that of the adult female at 80." " The female pulse (he observes) differs little from the male pulse during the first seven years of life ; but after seven years of age the mean pulse of the female exceeds that of the male by from six to fourteen beats, the average excess being nine beats." In early life, the heart's action is much more rapid than in the adult ; and in the adult it is somewhat more rapid than in advanced life. Thus, while in infancy the number of the pulsations of the heart averages from 120 to 140 in a minute, the number in old age is usually between 50 and 70. The following table, given by Miiller,t shows the average frequency of the heart at different ages: In the embrj'o, the number of beats in a minute is . . . 150 Just after birth from 130 to 140 During the first year „ 115 „ 130 „ „ second year „ 100 „ 115 „ „ third year „ 90 „ 100 About the seventh year „ 85 „ 90 „ „ fourteenth year . . . . „ 80 „ 85 In the middle period of Ufe . . . . „ 70 „ 75 In old age. „ 50 „ 65 It was formerly supposed that the rapidity of the heart's action gradually and progressively diminished from birtL upwards ; that it was quickest soon after birth ; and that there was a gradual and * Cyclopaedia of Anatomy and Physiology. f Elements of Physiology, vol. i. FREQUENCY OF THE HEART's ACTION. 63 sensible diminution in its frequency after that period. The re- markable fact has, however, been ascertained, that the pulse of the infant soon after birth is not unfrequently as slow as that of the adult. M. Billard* first called attention to this phenomenon, which has also been investigated and corroborated by M. Valleix.f According to him, the mean frequency of the pulse in thirteen healthy infants, from two to twenty-one days old, when asleep, averaged 87 in a minute ; when awake, from 90 to 100 : but it was readily excited by motion or emotion. From the seventh to the twenty-seventh month, the average was 119 for the male, and 124 for the female infant; and it continued a little above 100 up to the age of six years. According to Mr. Gorham,+ the mean frequency of the pulse in sixteen infants under one day old was 123; in forty-two obser- vations on infants from one to seven days old, the average was 128. Dr. Guy says, the observations of MM. Billard and Valleix are by no means borne out by his experience. " There is reason to believe (he thinks) that these low frequences of the pulse of infants occur in that state and degree of debility, without disease, which gives rise to an infrequent pulse in the adult, and that they do not occur in strong and vigorous health." The heart's action is less rapid during sleep than when awake ; this is probably connected with posture. The decrease in fre- quency of the heart's action occasionally observed in the foetus in utero, has been attributed to the sleep of the embryo. The action of the heart is much slower when the individual is at rest than during or after bodily exertion. Dr. Bryan Robinson§ states that the pulse of the adult, which ranged when at rest from 64 to 74, rose to 100 when walking at the rate of two miles an hour; to 140 when walking at the rate of four miles an hour; and when running fast, to 150 or more. The heart's action is usually slightly accelerated after meals, particularly after the use of warm or spirituous liquors ; and con- trary to the opinion at one time entertained, it is perceptibly quicker in the morning than in the evening. Dr, Knox, 1| who was the first to establish this fact, says the pulse is quicker by * Traite des Maladies des Enfans. f Mem. de la Soc. Med. d'Observation, T. 2. X Medical Gazette, vol. xxi. § Treatise on the Animal Economy, 3rd edition. II Ed. Med. and Surg. Jour. vol. xi. 64 MOTIONS OF THE HEART. eleven beats, on an average, in the morning than in the evening. Dr. Guy's * experiments corroborate those of Dr. Knox. In the article "Pulse," in the Cyclopffisdia of Anatomy and Physiology, he has given a series of tables showing the diurnal variations of the pulse in the two sexes; "the facts contained in which may (he observes) be taken to establish the general law first set forth by Dr. Knox, that the pulse is less frequent in the evening than the morning ; but it is obviously subject to numerous exceptions." Effects of posture on the Pulse — Posture has a remarkable influence upon the rapidity of the heart's action : it is more fre- quent in the sitting than in the recumbent posture ; and more frequent in the erect than in the sitting posture. Attention was first called to this remarkable fact above a hundred years ago, by Dr. Bryan Robinson, of Dublin, in his " Treatise on the Animal Economy." In the third edition of this work, published in the year 1738, he states that the pulse, which in the recumbent pos- ture was sixty-four, rose to sixty-eight in the sitting posture, and to seventy-eight in the erect posture. The late Dr. Macdonnell, of Belfast, so long ago as the year 1784, determined experi- mentally this influence of change of posture on the pulse ; he termed it " the differential pulse :" the results of his observation were communicated to the profession at the meeting of the British Association in Dublin. This phenomenon has also been investi- gated with much care by Dr. Graves of Dublin, by Dr. Knox of Edinburgh, and by Dr. Guy of London. According to Dr. Graves,t the difference between the pulse in the erect and recumbent posture in the healthy adult is from six to fifteen beats in a minute: "if the pulse is but sixty, the diffe- rence is generally not more than six or eight, and this difference increases with the frequency of the pulse at the time of the expe- riment : thus, if it has been raised to 90 or 100 by moderate exercise, it is not vmusual to find the difference twenty or thirty." That it is not the muscular exertion necessary to raise the body from the recumbent to the erect posture which occasions this dif- ference, was proved. Dr. Graves says, by altering the position without the necessity of any muscular exertion on the part of the person experimented on. He tried also the experiment of inverting the position, placing the person with the head downwards and the * Guy's Hospital Reports, No. ix. f Clinical Medicine, 2nd edition. EFFECTS OF POSTURE ON THE PULSE. 65 feet in the air : the frequency of the pulse was not, however, altered, but its strength diminished often very considerably, and it not unusually became irregular. Dr. Knox* has shown that the increase in frequency of the pulse occasioned by change of posture, is different at the different periods of the day. "During the morning, the mere change of posture from the horizontal to the erect will increase the pulse by about fifteen or twenty beats ; at mid-day, this increase will be ten ; and in the evening, only four or six." Dr. Guy instituted an elaborate series of experiments to deter- mine the alterations effected on the pulse by change of posture. The following are some of his conclusionsf under this head : " 1 . In the healthy adult male, the mean Nos. of the pulse are — standing, 79; sitting, 70; lying, 67. » " 2. In the healthy adult female, the Nos. are — standing, 89 ; sitting, 82 ; lying, 80. "3. In both sexes, the extremes are very remote from the mean results, and the exceptions to general rules very numerous. "4. In both sexes, also, the effect of change of posture increases as the frequency of the pulse increases. "5. The effect of change of posture on any given frequency of the pulse, is much srreater in the male than in the female. " 6. The effect of change of posture on the pulse is greater in the forenoon than in the after part of the day. " 7. The inverted posture of the body lessens the frequency of the pulse. "8. The varying frequency of the pulse in different postures of the body is due to muscular contraction." In- states of debility, as in patients recovering from fever, the difference between the frequency of the pulse in the erect and re- cumbent postures becomes (Dr. Graves observes) a useful guide in the treatment: "the greater the difference the greater the de- bility." In hypertrophy, with dilatation of the ventricles, on the other hand. Dr. Graves found the pulse to be very little altered with respect to frequency on changing the position. In anaemic and chlorotic females, and in individuals who have suffered from profuse haemorrhage, I have observed that the difference between * Edinburgh Medical and Surgical Journal, vol. xi. t Cyclopaedia of Anatomy and Physiology — article, Pulse. 66 MOTIONS OF THE HEART. the frequency of the pulse in the recumbent and sitting postures is very marked ; but these morbid states are always accompanied by more or less debility ; and the pulse, in respect to frequency, is always above the normal standard. Cause of the Injiuence of Change of Posture on the Pulse. — With respect to the cause of this alteration in the frequency of the pulse in different positions of the body, writers are not agreed. Dr. Guy refers it exclusively to muscular contraction ; by others it has been attributed to the altered position of the heart, its valves and orifices in the different positions ; wlnle Dr. Graves says " he cannot advance even a plausible conjecture concerning the reason why a change of posture should so affect the frequency of the pulse." " The two postures (Dr. Guy observes) between which there is the most marked difference in the frequency of the pulse, viz. the erect and sitting postures, are precisely those in which there is no difference in the position of the heart or its valves, and very little difference in the resistance offered to the circulation ; while the sitting and recumbent postures, between which there is so slight a difference in the number of the pulse, are accompanied by a marked change in the position of the heart and its valves, and of the column of blood to be propelled. On the other hand, the difference in the amount of muscular contiaction, required to support the body, in the erect and sitting postures is much more considerable than that required to support the body in the sitting and recumbent positions — differences in strict conformity with the observed frequencies of the pulse in the several postures." Dr. Wardrop* accounts for the difference of the pulse in the erect and recumbent postures by his ingenious theory of the mus- culo-cardiac function. According to him the contraction of muscles not only accelerates the flow of blood in the veins towards the heart, but the compression exercised on the arteries by the same contraction of the muscles impedes more or less the flow of blood in the arteries ; the cavities of the heart thus receive a larger amount of blood, and as the energy of the heart's action depends, within certain limits, upon the quantity of blood it contains, it will be accelerated by the change from the recumbent position, in which the muscles are relaxed, to the sitting or erect posture, in which many of the muscles are in a state of contraction. * Treatise on Diseases of the Heart. RATIO OF THE PULSE TO THE RESPIRATIONS. 67 It appears to me, that writers, in seeking to explain the in- fluence of position upon the pulse, have erred in endeavouring to refer it exclusively to a single cause : it probably lies more in the lungs than in the heart ; the latter organ being indirectly excited in consequence of the increased frequency of the respiration, while it is very probably favoured by muscular contraction. For instance, the chest expands less, and less air is taken in in inspiration, in the recumbent than in the erect or sitting postures ; there is less of the feeling, likewise, which inclines to frequent renewal of the air in the former than in the latter position. In certain diseased states, this becomes sufficiently obvious : whenever dyspnoea is urgent, no matter what may be its cause, the patient is imable to remain in the recumbent posture, and seeks to obtain ease by sitting up. As there is less necessity for the blood to circulate quickly through the lungs in the recvimbent than in the erect or sitting posture, the respirations are less frequent, and the general circulation is likewise less rapid. At the same time, there can be no doubt that the venous blood is returned, from the head and upper extremities, to the right side of the heart more quickly and more freely in the erect and sitting than in t\\e recumbent posture, being remarkably favoured by gravity in the former positions ; the pulmonary circu- lation and the respirations necessarily, therefore, increase in fre- quency ; the left side of the heart then feels its influence, the blood being conveyed more rapidly to it, and the general circulation becomes quickened in the same ratio. Hence there is no diffi- culty in understanding why the pulse should be more rapid in the one position than the other. Its increased rapidity in the erect over the sitting posture is no doubt favoured by muscular con- traction. Ratio of the Pulsations of the Heart to the Respirations. — Under ordinary circumstances, the proportion which the respirations bear to the pulsations of the heart is about as one to fo7/.r ; this was the ratio established by MM. Prevost and Dumas : the average number of respirations in a minute, in a healthy adult, being between sixteen and twenty, and the number of pulsations of the heart, between sixty-four and eighty. When the heart's action is accelerated by motion or by exercise, the respirations are accele- rated in the same ratio ; and when its action becomes slow again, the respirations become also less frequent. 68 MOTIONS OF THE HEART. Mr. Hutchinson* has given a table of the number of respi- rations, in a minute, in 1714 healthy adult males, when in the sitting posture ; from which it appears that the majority make between sixteen and twenty-four respirations in a minute — of these, a large number make twenty ; and in the greater number there were four beats of the heart for one inspiration. The following table, given by Dr. Guy, shows the average proportion of the pulse to the respiration in 238 experiments ; the pulse varying from 44 to 85 beats, and the respirations from 15^ to 20^ : the majority of the experiments were made in the sitting posture : No of Observations. Pulse. Proportion 8 . . . . 45-50 . . . 2-75 to 1 37 .... 50-55 . . . 3-05 to I 50 .... 55-60 . . . 3-31 to 1 50 ... . 60-65 . . . 3-52 to 1 50 .... 65-70 . . . 3-59 to 1 27 .... 70-75 . . . 3-82 to 1 12 .... 75-80 . . . 4-18 to 1 4 . . . . 80-85 . . . 4-31 to 1 The following tablet gives the average result of some expe- riments made on himself, by Dr. Harden, in order to determine the ratio of the pulse to the respiration in dilFerent postures : standing. Sitting. Lying. 80 . . . . 70 . . . . 66 16 . . . . 14 . . . . 12 Pulse .... Respirations According to M. Parrot,^ the frequency of the heart's action increases in a corresponding ratio with tlie elevation above the level of the sea. Thus — When the pulse at the level of the sea was 70 at 3282 feet above its level it rose to 75 at 4875 „ „ „ 82 at 6500 at 8125 at 9740 at 13UU0 90 95 100 no The cause of the heart's action increasing in frequency accord- ing to the elevation above the level of the sea, appears to lie in the lungs rather than in the heart. We know that aS the air becomes more rarilied the respirations become more frequent ; the heart, therefore, is only indirectly excited in consequence of the increased * Med. Chir. Trans., vol. xxix. t Miiller's Physiology, vol. i. t Amer. Jour, of Med. Sciences, vol. v., 1843. FORCE WITH WHICH THE BLOOD IS PROPELLED. 69 frequency of the respiration, and the ratio between the number of respirations and the number of pulsations of the heart is, probably, the same at each level. Staff Surgeon Hunter,* whose opportunities for observation have been very extensive, states, on the other hand, that " he has never noticed the least difference in the pulse from elevation, whether at Madras, or Bombay, on the level of the sea ; Poona and Belgaum, 2000 feet above it; Candahar, 4000; Kelat or Cabul, 6000 ; or Ghuznee, or along the range of the Suliman mountains, 8000, or 9000." "Along the latter," he says, "we several times chanored our elevation, from 1000 to 2000 feet in the day; and I cannot but think," he adds, "that the presumed dif- ference has been originally based upon theory, and continued without further inquiry." Several pathological conditions have great influence upon the frequency of the pulsations of the heart : in but a few it becomes slower; in the large majority of diseases it becomes more rapid than natural ; while in certain morbid states the ratio between the number of the respirations and the number of pulsations of the-: heart becomes altered. These are matters, however, for subsequent consideration. Rapidity of the Passage of the Blood through the System. — The rapidity with which the blood passes through the system can be estimated, if the amount which is transmitted into the aorta at each systole of the left ventricle is known, and if the entire quan- tity of blood contained in the vessels is determined — the number of pulsations of the heart being given. Thus it has been estimated that the whole amount of blood contained in the vessels is about twenty-eight pounds ; and that an ounce and a-half is expelled at each systole of the left ventricle. If, then, the heart of the adult beats seventy-five times in a minute, 1 1 2^ ounces, or a little more than seven pounds of blood, would pass through the ventricle in a minute ; in four minutes the entire twenty-eight pounds would pass through the heart ; and in every hour it would pass through it fifteen times. Force tvith ichich the Blood is Propelled by the Left Ven- tricle The force with which the blood is expelled by the left ven- tricle has been variously stated by physiologists. Hales made many * London Medical Gazette, August, 1850. 70 MOTIONS OF THE HEART. experiments, with the object of determining this point ; he esti- mated the force with which the blood is propelled into the aorta at four pounds six ounces : "seven feet and a half being the height to which he supposed the blood would rise in a tube connected with the large arteries." M. Poiseuille invented an instrument for measuring the momentum of the current of blood in the large arteries, to which he gave the name of hemadynamometer, from which he estimated the force with which the blood is propelled into the aorta at four pounds three ounces ; "a result which agrees remarkably with that obtained by Hales." In employing compression for the cure of external aneurism, I have found that the weight which was sufficient to diminish materially, or to check the current in a large artery, differed considerably in different subjects: in some instances a pressure equal to four pounds upon the femoral artery in the groin was suf- ficient to check the pulsation of a popliteal or femoral aneurism ; in the majority of cases, a pressure equal to six or eight pounds was necessary to effect the same object; while sometimes a weight of ten pounds was requisite. MECHANISM OF THE ACTION OF THE VALVES. The valves at the arterial orifices of the heart are, Hunter* ob- serves, "inelastic membranes having no action within themselves;" they are raised or depressed simply by a mechanical process, which can be effected equally well in the dead as in the living heart. The valves at the auriculo-ventricular orifices, on the other hand, being connected to the parietes of the ventricles by muscular co- lumns, the shortening or lengthening of which are essential to the due performance of their valvular functions, cannot be made to act perfectly in the dead subject. Auriculo-ventricular Valves It has been already stated that the auriculo-ventricular valves are composed of curtains, of tendi- nous cords connected with these curtains, and of fleshy columns, which are attached by one extremity to the tendinous cords, and by the other to the parietes of the ventricle. Anatomists, in de- scribing the mode of action of these valves, state, that one use of the fleshy columns is, by their contraction, to draw down the cur- tains of the valve, and so to approximate the edges of the valves * Treatise on the Blood. MECHANISM OF THE ACTION OF THE VALVES. 71 and close the orifice. It must, however, be recollected that, at the period at which the auriculo-ventricular valves close their ori- fices, viz., at the very commencement of the ventricular systole, the ventricles are full of blood ; hence the contraction of the carneaa columnse, and the tension of the tendinous cords, instead of ap- proximating the edges of the valves and closing the orifices, would tend rather to hold the curtains of the valves open, because the fleshy columns all run, more or less, towards the apex of the heart to be inserted into the parietes of the ventricles- It was long since remarked by Senac, that " in order for the auriculo-ventricular valves to close their respective orifices, the apex of the ventricle must be approximated to the base, as in the dilated state of the ventricle they are too short to do so." Hunter in describing these valves, observes — "the tendinous cords are inserted into muscular columns, the intention of which is very evident ; for if they had gone the whole length in the form of ten- don, they would have been too long when the ventricle contracted, and the valves in such a case would have allowed of being pushed into the auricles ; but the carneae columnse keep the valves within the ventricle in its contracted state." The use of the carneae co- lumnse appears, then, simply to be to adapt the valve to the al- tered state of the ventricle during its systole and diastole, and to prevent them from being reversed during the systole. When the apex of the ventricle is approximated to the base during the ven- tricular systole, if these valves were not provided with muscular columns which shorten as the ventricle shortens, the valves would be reversed ; but from the direction of the fleshy columns, as the ventricle is shortened, the carnese columnse must be shortened at the same time. The use of the carnese columnse therefore evidently is, not to close the curtains of the valves ; this is effected by the mechanical operation of the blood contained in the ventricle, as was long since shown by Lower, though recently advanced as a novel view by Baumgarten and Hamernjk. The blood which enters from the auricle during the ventricular diastole, falls by its own gravity to the bottom of the ventricle, the curtains of the valve are thus floated towards the base of the ventricle ; the auricular systole then impels a small additional quantity of blood into the ventricle, the systole of the latter instantly ensues, and the curtains of the 72 MOTIONS OF THE HEART. valve are applied and pressed together so as to close the oiifice. Hence the blood which enters the ventricle becomes, in a great measure, the means by which the auriculo-ventricular valves are closed, and regurgitation prevented. The curtains of the mitral valve in closing the orifice, " meet (Mr. T. W. King * observes) not only by their free edges, but by the marginal portions of their auricular surface ; and thus on each curtain there is a broad line or surface of contact situated just within the auricle, or between it and the ventricle, varying in breadth, regularity, and distinctness." These he terms " the sur- faces of contact or attrition ;" very slight traces of them are dis- coverable in the healthy adult heart. As soon as the ventricular systole ceases, the muscular fibres forming the walls of the ventricles, and the carnese columnse of the auriculo-ventricular valves, are relaxed ; the curtains of these valves, no longer pressed upwards by the blood, separate from one another : this fluid enters in a full stream from the auricle until its systole again ensues, when the phenomena mentioned before are repeated. Sigmoid and Semilunar Valves The mechanism by which the valves at the orifices of the aorta and pulmonary artery close their respective orifices, is, as I have said, simply mechanical ; be- hind each of these valves a little sinus (sinus of Morgagni) is seated, into which the blood readily insinuates itself as the ventri- cular systole ceases ; and the valves are pressed down by the weight of the column of blood above. Without some provision of this kind, the blood could with difficulty get behind those valves, and regurgitation into the ventricles, of necessity, would frequently take place during the diastole of these cavities. When the ventricular systole ensues, the sigmoid and semilu- nar valves are elevated and pressed against the sides of the aorta and pulmonary artery, by the blood in its passage into these ves- sels ; and here again another use of the sinuses of Morgagni comes into operation — viz., to afford a space for'the valves to lie back in, at this period of the heart's action, and thus to render the interior of the aorta and pulmonary artery perfectly smooth and even at the part. If there had not been some provision of this kind, these valves would project, in a certain degree, upon the interior of the * Guj's Hospital Reports. MECHANISM OF THE ACTION OF THE VALVES. 73 artery, render this portion of the vessel uneven, and of course in- crease the friction between the blood and the interior of the artery in its passage through it. When the aortic valves become rigid from disease, they cannot lie back in their normal position during the ventricular systole, and not only is the blood in its passage from the ventricle into the aorta impeded, but regurgitation into the ventricle is, as we know, frequently permitted. The little fibro-cartilaginous bodies (corpora Arantii) which are situate near the centre of the free margin of each of the semi- lunar valves, are supposed by some anatomists to serve the pur- pose of filling up the small space, which they suppose would be left in the centre, when the valves fall down ; but, as these little bodies are not seated at the very margin of the valves, they could scarcely effect this object, which indeed is unnecessary, because it has been shown by Dr. Duncan that the arterial valves, particu- larly those of the aorta, overlap one another, indeed, Mr. King says ' ' the surfaces of contact are not unfrequently equal in extent to the remainder of the curtain of the valve." The use of these little bodies evidently is to strengthen the valves, by serving as points of insertion for the tendinous bands which enter into their formation. Without this provision these valves would be very liable to become reversed. Safety-valve Function of the Tricuspid Valve. — Mr. Hunter,* in describing the action of the tricuspid valve, observes — " I have reason to believe that the valves on the right side of the heart do not so perfectly do theix duty as those of the left ; there- fore we may suppose it was not so necessary." Mr. Adams, f after quoting the foregoing remark of Hunter, observes — " This circumstance, in my opinion, has not been sufficiently noticed, nor the influence that such a structure may have on the circula- tion in its natural or morbid state, considered. I look upon this difference in the valves of the right and left side of the heart to be a natural provision to allow of a partial reflux into the right auricle on those occasions when, from any cause, the passage of the blood through the arterial opening is retarded. Such a provision was absolutely necessary in the right or pulmonary ventricle, as various natural causes must momentarily retard the passage of the blood through the lungs." * Treatise on the Blood. t Dublin Hospital Reports, vol. iv. 74 MOTIONS OF THE HEART. More recently, Mr. King,* in an elaborate paper on "the Safety-valve Function in the Right Ventricle." has entered at length upon the subject, and pointed out the mechanism in the construction of this valve by which he considers regurgitation to be permitted. "In the same communication he has given a minute description of the tricuspid valve, and of the manner in which its fleshy columns are connected with the ventricular walls. The fleshy columns of the anterior and right division of this valve are principally inserted (he observes) into the yielding wall of the ventricle ; those of the posterior division into the septum : the latter is conseqixently more fixed. The anterior and right divi- sions of the valve he calls " the curtains of distension," and he considers them the agents by which the orifice is opened so as to permit of regurgitation into the auricle. In the normal state of the tricuspid valve, and of the orifice of communication between the right auricle and ventricle, and when the ventricle is only moderately distended, regurgitation is not permitted : it does, however, occur if the right ventricle at the commencement of its systole is much distended : this may occur in a state of health when the heart's action is increased by any cause ; but it subsides when this ceases. Dr. Blakistonf objects to the theory that the tricuspid acts as a safety-valve ; he thinks the chances of life would not be im- proved " did nature thus attempt to relieve arterial congestion by means calculated to induce venous engorgement." " When re- gurgitation takes place to any extent, it is impossible," he says, " to conceive a more powerful obstruction than is thus offered to the passage of the blood from the veins into the heart by a strong counter-current forced backwards by the systole of the right ventricle." Whatever difference of opinion may exist respecting the mode of action of the valve at the right auriculo-ventricular orifice, there is none as to that on the left side ; the mitral valve always per- fectly performs its valvular function, and never, unless it has undergone some morbid change, permits regurgitation. Indeed, the effect of disease upon these two orifices is generally quite the reverse: in the majority of cases in which tlie mitral valve or orifice is altered from its normal condition, the opening is con- * Guy's Hospital Reports, vol. ii. f On Diseases of the Chest. MECHANISM OF THE ACTION OF THE VALVES. 75 tracted ; while the tricuspid orifice, on the other hand, is more frequently dilated; and the phenomenon known as "jugular pul- sation" almost always attends the latter state. " The mitral valve (Mr. Adams* observes) so perfectly closes the aperture of communication between the left auricle and ven- tricle, that in the natural state no reflux whatever is admitted : this, so useful at the right side of the heart, would have been not only useless, but injurious, at the left side of the organ, as we find the general arterial system at all times equally ready to receive the blood during the systole of the left ventricle ; and if the mitral valve did not close the left auriculo-ventricular aperture, a great deal of the force of the aortic ventricle would be wasted, whereby it would be incapable of moving the mass of blood which was destined to fill the arterial system." " Pathologists, in looking (he adds) to the different nature of the lining membrane at the two sides of the heart, as a means of explaining the greater liability of the left side to disease, have perhaps too much overlooked this circumstance — that while, from the unyielding nature of the mitral valve, all reflux into the auricle is prevented, from this very cause, which renders it efiective in the circulation, is it exposed to more frequent injury, from which organic disease may arise, and the ventricle to which it belongs becomes more liable to be ruptured by its own efforts." * Dublin Hospital Reports, vol. iv. 76 CHAPTER IV. IMPULSE OF THE HEART.— SOUNDS OF THE HEART.— MECHANISM BY WHICH THE NORMAL SOUNDS OF THE HEART ARE PRODUCED. The impulse of the heart accompanies the systole of the ventricles, and the first sound of the organ, and has its cause in the apex of the heart coming in contact with the parietes of the thorax. In the healthy subject, with a well formed chest, the impulse is so slight as not to be perceptible to the individual himself; and is visible only in a circumscribed space, between the cartilages of the fifth and sixth left ribs, about mid- way between the left edge of the sternum, and the nipple, and from an inch to an inch and a-half below the latter. It varies, even in the healthy subject, according to several circumstances, as the age and sex of the subject, the size of the chest, the stature of the individual, the amount of sub- cutaneous fat, the posture, whether recumbent or erect, the state of inspiration or expiration, the amount of distension of the abdomen, and, whether the examination is made after exercise or mental excitement. The mechanism by which the impulse is produced was long a disputed point, and various have been the theories advanced by physiologists to explain it : even the period of the heart's action at which it occurs has been the subject of dif- ference of opinion. Thus it was at one time maintained, and the theory has been recently revived by Mr. Robert Cartwright* and Mr. Brown of Cobham, that the impulse occurs during the diastole of the ven- tricles. This opinion appeared to derive confirmation from the fact that when the heart of a frog is exposed (which will continue to pulsate for a considerable time after being laid bare), the ven- tricle, during its diastole, is seen to expand, and to approach the parietes ; while during the systole the apex is simply approximated to the base. In this animal, therefore, the heart approaches the * Lancet, December, 1851, and January, 1852. IMPULSE OF THE HEART. parietes during the diastole, not during the systole of the ventricle, and any impulse which is given must be at the period of the ven- tricular diastole. An experiment was performed by Oesterreicher,* which consisted in removing the heart of the frog from the body, and laying upon it a substance sufficiently heavy to press it flat, and yet so small as not to conceal the heart from view. He states that during the systole of the ventricle the weight was raised, but that during its diastole the heart remained flat. This experiment has been quoted by Miiller and others, to prove that the diastole of the ventricles is not a muscular act, in ignorance apparently of the foregoing peculiarity in the action of the heart in this animal. In warm-blooded animals, however, experiments and observations repeated over and over again have proved that the impulse occurs at the period of the ventricular systole, and that it is due to the apex of the heart coming in contact Avith the parietes of the chest. Mechanism hy which the Impulse of the Heart is Produced — It will not be necessary to delay to notice the various theories which have been advanced in order to explain the mechanism by which the impulse of the heart is produced, many of which are founded on erroneous views. It will be sufficient to observe, that during the ventricular systole the walls of the ventricle become more convex upon the surface, the apex of the heart describes a spiral motion from behind forwards, and from right to left : in performing this spiral movement, the apex glides obliquely upon the pericardium, is approximated to the base, comes in contact with the parietes of the thorax in the intercostal space between the cartilages of the fifth and sixth ribs, and thus causes the impulse. Indeed, this part of the heart is naturally so close to the parietes of the chest that no tilting forward of its apex is necessary to pro- duce the slight shock felt at this period. It was the received opinion until within a few years, that during the diastole of the ventricles the heart receded from the parietes of the chest, and that the impulse was produced by a blow, or shock given to the ribs by its apex, during the systole. Harvey, Haller, Senac, and Hunter, may be quoted as authorities for this theory. The experiments which have been performed upon animals of late years, and the examination of the action of the organ in cases of ectopia of the heart, have, however, shown that * Muller's Physiology, vol. i. 78 IMPULSE OF THE HEART. this theory has no foundation, and that the heart "does not suffer any changes in consequence of its own efforts (exclusive of the movements of the lungs and diaphragm) except in its shape and size, in the thickness and tension of its parietes, and in the capacity of its cavities," which are quite sufficient to produce the slight shock felt when the hand is laid on the parietes of the chest. M. Ritter has recently advanced this as a novel doctrine, in ignorance probably of the results of the experiments of the " Com- mittees of the British Association." His experiments are entirely corroborative of those previously made. " The portion of the heart's surface (he observes) which is in immediate relation to the walls of the chest is at all times in close contact with them ; and it is impossible that in any of its motions it can act so as to with- draw itself from the thoracic walls, or so as to leave a space between them." " Being thus fixed, therefore, it follows that, when the heart contracts and assumes a more globular form, it will exert its distending force on the yielding intercostal spaces against which it rests, and will thrust them forwards, so as to produce the impulse. This distending force cannot be exerted with any effect against the unyielding ribs or their cartilages ; and, consequently, the impulse is not perceived by the finger placed over the cartilages of the fourth, fifth or any other rib. If the impulse was caused by an actual stroke or blow of the heart against the walls of the chest, it would be perceived on these parts and on the sternum as clearly as it is in the intercostal spaces, and every person would feel the impulse of his own heart just as a pregnant woman feels any violent movements made by the foetus in utero." Sound sometimes Produced by the Impulse of the Healthy Heart — Although in the healthy subject, when the circulation is tranquil, and the heart's action is normal, no sound is produced by the impulse, yet it occasionally happens that when the heart is excited to increased action — in other words, when palpitation ensues, whether the cause be mental emotion or corporeal exertion, but particularly the former — the apex of the heart does come in contact with the ribs, the patient feels the blow or shock produced by the impulse of his own heart ; and this is accompanied by sound, which of course will be heard at the period of the first sound of the heart. In diseased states it is sometimes so loud as to be audible without the stethoscope, and it may be heard at a short ALTERATIONS OF THK IMPULSE. < 9 distance from the patient. This point will be again alluded to when we come to consider the abnormal conditions of the heart. Site of the Impulse of the Heart — The point at which the impulse of the heart is felt in the healthy male is the intercostal space between the cartilages of the fifth and sixth ribs upon the left side, to the sternal side of the nipple, and about two inches below this point. In the female, owing to the habitual use of stays, the impulse is often a little higher up — viz., between the cartilages of the fourth and fifth left ribs ; and in the latter months of pregnancy, for an obvious reason, it is felt higher up than natural, and the apex is pushed more to the left side. The impulse of the healthy heart is naturally slight : it is more marked in the erect than in the recumbent position, because in the latter position the heart, by its own weight, recedes slightly from the parietes of the chest. For the same reason the impulse becomes more distinct if a person leans forward, and more in- distinct if he lies upon his right side. In the erect posture the impulse is said to be slightly lower than in the recumbent posture ; but the difi^erence, if any, is very trifling. In very fat persons the impulse is scarcely perceptible to the eye or hand ; in very lean persons it is very obvious to both. When the lungs are largely developed they will overlap the heart more than usual ; when the lungs are small, less of the heart will be covered by these organs : in the latter case, therefore, the impulse will be better marked than in the former. Alteration of the impulse in inspiration and expiration. — In inspiration, particularly on a full inspiration, the impulse of the apex of the heart will be felt lower down than natural, as low as between the cartilages of the sixth and seventh ribs, or, in the epi- gastrium, between the line of the xyphoid cartilage. This is partly owing to the connection of the heart with the lungs, and partly to the connection of the pericardium with the diaphragm. On a full inspiration the lungs expand from above downwards, as well as from before backwards ; and, according to Dr. Sibson, from the manner in which the pulmonary veins are joined to the left auri- cle, the heart is drawn down by the descent of the lungs. The principal cause of this descent of the heart in inspiration appears to lie rather in the intimate connection of the pericardium with the central tendon of the diaphragm ; as the latter descends it 80 IMPULSE OF THE HEART. must bring with it the heart ; and from the connection of the in- ferior vena cava with the diaphragm, it must follow the move- ments of the latter, and draw down the right auricle. On a full inspiration, the impulse, in addition to being lower down, will be less marked than natural, because the lungs, when fully inflated meet so as almost to cover the heart, and prevent its apex from coming in contact with the parietes of the thorax. On a forced expiration, on the other hand, owing to the as- cent of the diaphragm, the impulse of the heart is felt higher up viz. on a line with the space between the cartilages of the fourth and fifth ribs on the left side ; it is likwise more marked than na- tural, because the heart is less covered by lung. The point at which the impulse of the heart is felt is altered in some diseases of this organ, or of the lungs, or pleura, as well as in diseases of the abdominal viscera. These matters will, however be consi- dered when we come to describe the diseased states of the heart. Double Impulse of the Healthy Heart. — The impulse of the healthy heart has been almost always described as single ; Magen- die,* however, who attributes the first sound of the heart to the shock of the apex during the ventricular systole, lays it down that the second sound is due to the shock given by the ventricles to the parietes of the thorax during their diastole. " The ventri- cles in dilating (he observes) in a great measure under the influ- ence of the rapid influx of the blood, give a shock to the anterior parietes on the right side of the thorax, and thus produces the se- cond clear sound." Dr. Sibson, t in his valuable essay upon the " Changes in the Situation of the Internal Organs," observes : — "A second impulse is often felt in persons whose lungs are dimi- nished, and whose great vessels come close to the sternum. This is synchronous with the second sound, and must, I conceive, be due to the sudden springing forwards of the walls of the right ventricle after the systole." In the year 1848, in a communica- tion if upon the subject of "Aneurism of the Aorta," made to the Surgical Society of Ireland, I called attention to the fact that the impulse of the healthy heart, when the organ is acting vigor- ously, is double, not single. The impulse of the healthy heart, 1 observed upon that occa- • Elements of Physiology. f Trans, of Prov. Association, vol. xii. X Dublin Medical Press, vol. xix. SOUNDS OF THE HEART. 81 sion, has been always described as single, just as that of aneurism of the arch of the aorta was supposed to be. If we carefully ex- amine this organ, however, when it is beating vigorously, we shall find that a second but slighter impulse is perceptible, which quickly succeeds the other ; and, on applying the stethoscope, we shall find that this second impulse accompanies the second sound of the heart ; it appears as if the agency which gives rise to the second sound was capable of communicating a distinct sensation to the hand or stethoscope. In the healthy heart the second impulse is scarcely felt, unless the organ beats vigorously; when the ventricles are somewhat hypertrophied, and their cavities somewhat dilated, the second impulse becomes better marked ; when this has arrived at an ex- treme degree, it becomes very evident, and constitutes, then, the " back stroke of the heart," or the diastolic impulse. This dias- tolic impulse, except in cases of disease, is never so strong as to be perceptible to the eye, but is readily distinguished when the ear is applied to the stethoscope laid iipon the prsecordial region. It is perceived at the same part of the chest as the systolic impulse, and is more marked the larger the surface of the heart uncovered by lung, and the stronger the action of the organ. When describing the motions of the heart, we saw that during the ventricular diastole the apex of the heart recedes from its base, the organ becomes elongated, the ventricles increase in all their dimensions, and the hand, grasping the heart, is forcibly opened! Now, when we consider how closely the anterior surface of the ventricular portion of the heart lies to the parietes of the thorax, there is no difiiculty in understanding how an impulse may be communicated during this movement equally as during the ven- tricular systole ; it appears only surprising that it should have been so very generally overlooked. SOUNDS OF THE HEART. If the ear, either with or without the stethoscope, is applied to the prsecordial region in a healthy subject, two sounds are heard, which succeed each other quickly, but are readily distinguished from one another, and are followed by a pause or interval of repose ; after which, the same phenomena are repeated. If the heart's action is very slow, a short but distinct interval may be re- G 82 SOUNDS OF THE HEART. cognised between these two sounds, and the pause or interval of repose is longer ; if, on the other hand, the action of the heart is very quick, the sounds follow one another with such rapidity that there scarcely appears to be any interval of repose. The sound which occurs first in order after the pause is termed the first sound of the heart, sometimes the systolic sound; that which follows it is termed the second sound, sometimes the dias- tolic sound. The first of these sounds, compared with the second, has a dull character, and its duration is longer ; the second sound is short and clear, and was compared by Laennec to the lapping of a dog, or to the falling back of a valve. The first sound is heard at the period of the ventricular systole, and for this reason has been named the systolic sound ; it is synchronous with the impulse of the heart, and with the pulse. The second sound occurs at the period of the ventricular diastole, and for this reason is sometimes termed the diastoUc sound ; it immediately precedes the pause or interval of repose. Both these sounds are readily distinguished at every part of the prsecordial region : both are well marked at that part of this region where a dull sound is elicited by percussion ; that is, where the heart approaches most closely to the parietes of the chest. Cruveilhier, in his examination of an infant born with the heart exposed, ascertained that both sounds increased in intensity from the apex towards the base of the heart, and that the maximum intensity of both sounds was at the same place, " hence (he ob- serves) it is at the base of the organ we are to look for the cause of these sounds." Both sounds of the heart are usually well marked at the point where the apex is felt to beat, as well as over the base of the ventricles. The first sound has, however, its greatest intensity on a plane lower than the second; and M. Pigeaux, from this circumstance, proposed the name inferior sound for the first, and superior sound for the second. The sounds deve- loped at the orifices of the right ventricle are better heard towards the right edge of the sternum ; those developed at the orifices of the left ventricle are better heard towards the left edge of this bone ; and the American experimenters determined that the ven- tricular systolic sound on the right side was sharper and clearer than that on the left, which was more dull and prolonged. The double sound of the heart. Dr. Williams observes, may be SOUNDS OF THE HEART. 83 represented by the words luhb^ dup. Dr. Walslie is of opinion that no single articulate symbol is applicable to the heart's sounds in more than one point, and he gives the following table to repre- sent these sounds at different parts of the praecordial region : First Sound. Second Sound. At the left apex iibb dup At the right apex up tiip At the left base up tup At the righi base ub tiipp Normal limits and intensity of the Heart's sounds There is considerable difference, even in health, in different individuals in the intensity, as well as in the extent over which the sounds of the heart are audible : in some subjects they are limited to the praecordial region, and are comparatively feeble there ; in others, they extend much beyond the precordial region, and are loud there. Whether the sounds are feeble or the contrary, and whether they are limited to the praecordial region or not, will depend upon a variety of circumstances — as the intensity of the sounds themselves, which is different in different subjects; as the coverings of the chest are thick or thin ; as a larger or smaller surface of the heart comes in contact with the parietes ; as the lungs are largely developed and overlap the heart, or the contrary ; and, as the chest is capacious or narrow. Dr. Latham,* in his admirable lectures, speaking of the " natural limits of the heart's sounds," observes — " It is a pre- liminary point which some have thought most important to be determined with precision ; but no good ever comes from pre- tending to more precision than the thing itself admits of — and I am sure this matter does not admit of much. The praecordial region, it has been said, defines it ; but surely the second sound always exceeds that limit, and is audible also in the course of the aorta, of the pulmonary artery, and of the carotids." "With respect to the first sound, I should be at a loss to mark the exact space within which healthy proportion and healthy structure always required it to be heard — and in neither more nor less. There are so many circumstances — some consistent -with health in the largest sense, and some exclusive at least of its disease — which make the systolic sound of the heart more or less extensively audible, that (I am persuaded) two healthy persons would not easily be found in * Lectures on Diseases of the Heart, vol. i. 84 SOUNDS OF THE HEART. whom it would be heard exactly within the same thoracic space. Whether a man be fat or lean will always make a great difference. In the one, it will be kept within the praecordial region ; in the other, it will be carried beyond it. Fat is so bad a conductor, that, where it greatly abounds, it will restrict the sounds to less than the entire proecordial region, even to a very small part of it ; so that you will not be able to hear the heart further than you can feel its impulse, or further than its apex — but mere skin and bone are such good conductors, that in very thin persons the sounds will be spread very far beyond the praecordial region, and will be heard at any part of the chest to which you apply your ear." MECHANISM BY WHICH THE SOUNDS OF THE HEART ARE PRODUCED. We come now to the most difficult part of the subject — the cause of the sounds of the heart, or the mechanism by which they are produced : it is the one upon which the greatest differ- ence of opinion has existed among physiologists and anatomists, and for the explanation of which the greatest number of hypo- theses have been advanced. Theories of the cause of the first sound. — It must be borne in mind, that at the period at whicli the first sound of the heart is heard, 1st. The muscular walls of the ventricles contract, and the cavity of the ventricles is diminished. 2ndly. The mitral and tricuspid valves suddenly pass from a state of relaxation to one of tension, and close their respective orifices. 3rdly. The blood is propelled with considerable force into the aorta and pulmonary artery. 4thly. The valves at these orifices are suddenly elevated ; and 5thly. The impulse of the apex of the heart against the parietes of the chest takes place. Now, the first sound of the heart must obviously be due to one or other of these acts, or to a combination of them ; and it will be necessary to notice, shortly, the theories which have been advanced under this head. As it has been completely proved that the first sound of the heart accompanies the ventricular systole, any theory founded upon a different order of succession of the heart's motions must be rejected ; such as, that it is due to the systole of the auricles. THEORIES OF THE CAUSE OF THE SOUNDS. 85 or to the diastole of the ventricles, or to the systole of the left ventricle alone — the second sound being attributed to the systole of the right ; because, it is well known, that the two ventricles contract simultaneously; that the ventricular diastole occurs at the period of the second not of the first sound ; and that the auri- cular systole does not take place at the period of the first sound of the heart. The theories which have been advanced in order to explain the mechanism by which the first sound of the heart is produced, may, for convenience sake, be considered as the cause is sup- posed to be extrinsic or intrinsic to the heart. Thus, under the first, it has been attributed to the impulse of the apex against the parietes of the chest ; under the second head, it has been attributed to muscular contraction — in other words, to the successive shorten- ing of the muscular fibres of the parietes of the ventricles. This is the oldest theory : it was adopted by Harvey, Haller, Senac, Bichat, and Corvisart. 2ndly. To the sudden tension of the auriculo-ventricular valves. 3rdly. To the friction of the blood against the parietes, of the interior of the ventricles, or of the orifices of the large arteries. 4thly. To the collision of the op- posite internal surfaces of the ventricles at the conclusion of the systole. 5thly. To the sudden elevation of the sigmoid and semi- lunar valves, caused by the wave of blood transmitted by the ventricles. 6thly. To the concussion of the blood transmitted by the systole of the left ventricle with that contained in the aorta ; and lastly, to two or more of the foregoing causes combined. Theory of the sound being produced by the impulse. — Majendie is the principal supporter of the theory, that the first sound of the heart is caused by the impulse communicated by the apex of the organ to the parietes of the thorax dviring the ventricular systole. M. Skoda likewise refers the first sound in part to this cause. It has, however, been distinctly heard in experiments upon animals, where the anterior parietes of the chest were removed and the heart fully exposed, as well as in infants labouring under ectopia cordis. Theory of muscidar contraction. — Those who refer the first sound of the heart to the muscular contraction of the walls of the ventricles include two phenomena under this head — viz., " the sound of muscular extension or tension," and the "bruit muscu- 86 SOUNDS OF THE HEART. laire" or "rotatoire." Dr. Hope refers tliis sound essentially to muscular extension; which, according to him, is " a lovid smart sound, produced by the abstract act of sudden jerking extension of the already braced muscular fibres at the moment that the auricular valves close." " It is (he observes) essentially difierent from the bruit musculaire, since it may be produced in a dead muscle, and may attain a high degree of loudness or sharpness ; whereas bruit musculaire can only be produced in a living muscle, and is never more than dull and subdued." Other physiologists suppose the cause of this sound to lie exclusively in bruit mus- culaire. Dr. Blakiston is of opinion that it is caused by " the friction of the muscular fibres of the walls of the ventricles inter se." Theory of the collision of the opposite walls of the ventricles. — By some physiologists, the first sound of the heart has been attri- buted to the collision of the opposed internal surfaces of the ven- tricles at the conclusion of the systole ; but, as it is a doubtful point Avhether the ventricles completely empty themselves during their systole, and as it is quite certain that no such collision of the opposite walls of the ventricles takes place, this theory may be dismissed. Valvular theory. — By other physiologists, the first sound of the heart has been attributed to the sudden tension of the mitral and tricuspid valves at the moment of the ventricular systole. Dr. BilHng in England, and M. Rouanet in France, are the most dis- tinguished advocates of this theory. But, as the auriculo-ventri- cular valves close their respective orifices at the very commence- ment of the systole of the ventricles, this act is certainly not capable of producing the prolonged first sound of the heart. According to M. Cruveilhier, on the other hand, the first sound is due, not to the closure of the mitral and tricuspid valves, but to the straightening or elevation of the sigmoid and semilunar valves, caused by the wave of blood transmitted by the ventricles. Theories of the motion of the Mood — According to M. Pisfeaux, the first sound of the heart is due to the friction of the blood against the walls of the ventricles, and^lhe orifices and parietes of the large arteries, during the ventricular systole. Ac- cording to M. Gendrin, it is due to the " vibrations which result from the sudden change of form which the blood experiences THEORIES OF THE CAUSE OF THE SOUNDS. 87 during the ventricular systole." According to others, to the col- lision of the particles of the blood against each other, and against the walls of the ventricles, during the systole. Dr. Leared,* in a recent interesting communication upon the mechanism of the sounds of the heart, details some experiments which show, that a sound closely allied to the normal first sound of the heart can be produced "by the shock occurring between two portions of a liquid of a certain consistence, one of which, on being forcibly propelled by an intermittent action, is brought into contact with the other in a state of rest, or comparatively so." He gives the following explanation of the mechanism by which he supposes the first sound of the heart to be produced. " Sub- sequent to the elastic reaction of the aortic walls, which we must suppose does not occupy the entire period of the diastole of the ventricle, the column of blood in the upper part of the aorta attains a state of momentary repose. This column in a normal state is under considerable tension, and it is perfectly isolated from the contents of the ventricle by the semilunar valves — when the systole occurs, the valve with its superposed blood is forcibly thrown forward by the vigorous propulsion of blood from the ventricle ; concussion now ensuing between the active and passive portions of blood, a sound is produced on the same principle, and from the same cause as in my experiments; and this cceteris paribus^ is the essential element in the normal first sound of the heart." Theories of the cause of the second sound. — The second sound of the heart is heard at the period of the ventricular diastole ; and it must be borne in mind that during this act 1 St. The muscular fibres of the walls of the ventricles are re- laxed, and the ventricular cavities become enlarged. 2ndly. The auriculo-ventricular valves are opened, and the blood passes from the auricles into the ventricles, through the mitral and tricuspid orifices. 3rdly. The sigmoid and semilunar valves are pressed down by the column of blood above them, and the aortic and pulmo- nary orifices are closed. The second second of the heart must, thererefore, have its cause in one of these acts, or in a combination of them ; and any * Dublin Quarterly Journal, May, 1852. be SOUNDS OF THE HEART. theory founded on a different order of succession of tlie heart's motions cannot be correct — as that this sound is due to the auricu- lar systole (Laennec), because the auricles contract immediately before the ventricles ; or that it is due to the auricular diastole (Beau), because no sound is produced during this act ; or that it is due to the systole of the right ventricle (Piorry) — because both ventricles contract simultaneously. The theories which have been advanced to explain the me- chanism by which the second sound of the heart is produced may, like those of the first sound, be considered under the head of causes extrinsic to the heart, and causes intrinsic to it. Thus Ma- jendie attributes the second sound to the impulse communicated by the ventricles to the parietes of the chest during their diastole]; Dr. Turner to the falling back of the heart against the pericardium at the moment of the ventricular diastole ; and M. Skoda supposes it to be due, partly to the sudden disengagement of the apex of the heart from the opposed pericardium. But the second sound was heard in experiments upon animals when the ribs and ster- num were removed and the pericardium laid open, as well as in infants labouring under ectopia cordis. Those who refer the second sound to causes intrinsic to the heart, consider that, like the first sound, it may have its cause in muscular action, in valvular action, or in the motions of the blood. Thus, this sound has been supposed to be due, 1st, to the stretch- ing of the muscular fibres of the ventricles in their diastole ; but the muscular fibres are relaxed during this period of the heart's action. 2nd, to the rush of blood through the auriculo-ventricu- lar orifices during the ventricular diastole. 3rd, to the shock of the blood against the parietes of the ventricles during their diastole. 4th, to the sudden closure or tension of the sigmoid and semi- lunar valves at the moment of the ventricular diastole. 5th, to the recoil of the column of blood in the aorta and pulmonary artery upon the sigmoid and semilunar valves at the moment that the ventricles dilate. 6th, to the " molecular collision of the blood during its recoil from the suddenly-closed semilunar valves." The latter. Dr. Davies thinks, has been too much neglected in Skoda's theory of the second sound. Dr. Hughes * compares it to " the recoil-noise heard when the closure of a stop-cock sud- • Clinical Introduction to Auscultation. THEORIES OF THE CAUSE OF THE SOUNDS. 89 denly arrests the flow of water through a pipe." Dr. Leared con- siders that the second sound of the heart, equally with the first, is a concussion sound ; here, however, the concussion is "between a fluid and a membraneous expansion, instead of between two fluids." Theory of the sounds of the Heart most generally received. — The theory of the mechanism by which the sounds of the heart are produced, which is most generally received, is as follows : — First sound The first sound of the heart is regarded as a compound sound, partly valvular and partly muscular, the valvular portion being its first and loudest part, and being due to the sud- den tension or closure of the mitral and tricuspid valves. The muscular portion of the sound, which is dull and prolonged, is supposed to be caused by the contraction of the muscular fibres of the walls of the ventricles, and to be due essentially, according to Dr. Hope, to "muscular extension," but receiving a "pro- longation, and possibly an augmentation, from bruit musculaire ;" according to others, to bruit musculaire alone, or to friction be- tween the fibres of the muscular tissue of the ventricles. That this sound is partly due to the sudden tension of the mitral and tricuspid valves, is considered to be proved " by the sound being loudest over the parts of the ventricles nearest to the auricular valves;" 2ndly, "when valvular extension was pre- vented by holding the mitral valve open (in experiments upon animals), this greatly diminished the first sound ;" 3rdly, " when- ever the auricular valves were destroyed, or the blood evacuated out of the ventricles, the sound became dull and obscure ;" and lastly, by the character of the first sound in dilatation with atte- nuation of the ventricles, when it closely resembles the second sound. That the first sound of the heart has its cause, likewise, in con- traction of the muscular fibres of the walls of the ventricles, is considered to be proved by the " character of the sound " — by its continuing during the entire systole — by its being still heard, although weaker, in the heart of animals removed from the body — " by its being heard, although modified, in animals, when the auriculo-ventricular valves were prevented from acting, or when the blood was prevented from entering the cavity of the ventricles by pressing upon the orifices," — " by the sound being louder 90 SOUNDS OF THE HEAKT. over the surface of the ventricles than over the origin of the large arteries, — and finally, by the sound being loud and short, when the w^alls of the ventricles are thin ; and dull and prolonged when its walls are thick ;" because a thick ventricle, cseteris paribus, takes a longer time to contract than a thin one. Second sound. — The second sound of the heart is supposed to be due either to the sudden tension of the valves at the orifices of the aorta and pulmonary artery ; or to the shock of the column of blood in the aorta and pulmonary artery, which recoils upon these valves at the moment of the ventricular diastole. This theory is supposed to be proved " by the second sound of the heart being loudest over the sigmoid and semilunar valves, and a little above them " — " by the sound ceasing in experiments made upon animals, when the reflux of the blood upon the semilunar valves was prevented by compressing the arterial orifices with the fingers" — and " by its being diminished when a semilunar valve in one artery was hooked up, and replaced by a murmur from re- srursfitation when the same was done in both arteries." The following experiment was made by M. Bouillaud, to prove that the second sound of the heart is caused by the reflux of the column of blood upon the sigmoid and semilunar valves. He attached one extremity of a short glass tube, of an inch bore to the aorta immediately heloio the semilunar valves, and to its other end a bladder full of water. Another tube four feet long, was connected with the aorta above the semilunar valves. The bladder was suddenly compressed at intervals, so as to jerk up the fluid, and each time that the pressure on the bladder ceased, and the column of liquid was allowed to fall back upon the valves, a sound very analogous to the second sound of the heart was heard. A somewhat similar experiment was made by Dr. Corrigan, but with a diflferent result. He removed the heart and ascending aorta of an ass, and then " tied it on the end of a leaden tube of a corresponding diameter, about five feet long ; about two or three inches of the aorta then being free firom the lower extremity of the tube. In this state, holding the sides of the aorta together below, he filled the tube with water, and then placing the thumb on the upper end, so as to close it, the fingers were withdrawn from the lower end, and the upper end still remaining closed, the external pressure of atmospheric air kept the two sides of the THEORIES OF THE CAUSE OF THE SOUNDS. 91 aorta below together, and no fluid escaped. The ear was then applied to the lower end of the tube, close to the aorta, and the thumb being suddenly withdrawn from above, the whole column of flviid came suddenly down, and distended the aorta and valves ; and yet there was no sound whatever similar to the second pro- duced." He then " attached a piece of sounding-board, to assist the ear, and the result was the same as before." Remarks on the foregoing theory. — The foregoing theory, it will be observed, omits from the elements capable of producing the sounds of the heart, all consideration of friction between the blood and the parletes of the orifices of the heart, in its passage into and out of the ventricles, during their systole and diastole. Yet when we come to describe the abnormal sounds heard in dis- eased states of the valves and orifices of the organ, we shall find that this very element, which is rejected as incapable of pro- ducing the normal sounds, is set down as the one which almost exclusively gives rise to the abnormal sounds of the heart. Now when we consider the force and rapidity with which the blood is propelled by the ventricles, particularly by the left, there can be no doiibt that there is a considerable degree of friction between the blood and the parietes of the orifices through which it passes ; and that this can scarcely happen without producing sound, ap- pears evident, because even a slight impediment to the current of blood is sufficient to convert the normal first sound of the heart into a murmur. Thus, in experiments made upon large animals, when the ca- libre of the aorta near its origin was narrowed, by pressing upon it during the ventricular systole, the first sound of the heart was converted into a murmur. Again, if the stethoscope is applied over a large artery, a short, slight, single sound is heard at each systole of the left ventricle ; but, if pressure is made upon the vessel so as to diminish its calibre, a murmur will take the place of the normal sound. Again the blood in its passage through the veins causes no sound appreciable to the ear ; under certain cir- cumstances, however, sound is developed in particular veins, when their coats are made tense, and when their calibre is diminished by pressure with the stethoscope. This sound is familiar to us as the venous murmur. Now, in each of these instances there is an obstacle or impe- 92 SOUNDS OF THE HEART. diment to the passage of the blood, and the increased friction which necessarily ensues is sufficient to convert the normal sound into a murmur. It seems probable, therefore, that abnormal sounds, are nothing more than exaggerated normal sounds, exag- gerated because the friction between the blood and the parts through, or along which it passes, is increased ; and if we admit, as the foregoing instances seem to prove, that normal sounds can be converted into abnormal sounds, simply by increase of friction, it seems not unreasonable to conclude that both are developed by the same agency. In addition, we know that in aneurism springing from the arch of the aorta, a double sound is constantly audible, and this double sound remarkably resembles the double sound of the heart; so close indeed is the resemblance, that the second sound of aneurism in this situation is erroneously supposed by many to be the second sound of the heart transmitted to the aneurismal sac. We also know that the first, or the second, or both the aneurismal sounds are not unfrequently converted into murmurs, which have precisely the character of the murmurs heard in cases of valvular disease of the heart. Now, in aneurism, in tliis situation, we have simply a sac com- municating with a large artery by a single orifice, which is con- stantly patent ; the sac is traversed by the blood propelled at each systole of the left ventricle, and into it the blood regurgitates at each diastole of the ventricle ; yet every variety of normal and abnormal sound developed in the heart, with its muscular walls* and valvular apparatus, may be produced also in an aneurismal sac which has neither the one or the other. It is scarcely, therefore, unreasonable to conclude, that the agent which is capable of ge- nerating sound in the one case is capable of developing analogous sounds in the other ; and that, as sounds almost precisely similar to those of the heart, in its healthy as well as in its morbid state, can be produced independent of valvular extension, or muscular contraction, the latter are not such essential agents in the pro- duction of the heart's normal sounds as is generally supposed. THEORY OF FRICTION BETWEEN THE BLOOD AND THE PAttlETES OF THE ORIFICES OF THE HEART. From what precedes, it would appear that sounds in every respect analogous to the normal sounds of the heart may be de- THEORIES OF THE CAUSE OF THE SOUNDS. 93 veioped Independent of valvular action, or of muscular contraction ; while we know that the normal sounds of the heart are readily- converted into murmurs, simply by increase of friction between the blood and the parietes of the orifices of the heart. Now, when we consider the rapidity and the force with which the blood enters and is expelled from the ventricles ; and when we consider the amount of friction which must necessarily take place between this fluid and the parietes of the orifices of the heart, it seems not unreasonable to refer the normal sounds of the heart to this cause rather than to valvular action or muscular contraction : the first sound to the friction between the blood and the parietes of the arterial orifices during the ventricular systole ; the second sound to the friction between the blood and the parietes of the auriculo- ventricular orifices during the ventricular diastole. First sound. — The first sound of the heart we know is synchronous with the ventricular systole : in this act, the blood, compressed by the contraction of the powerful muscular walls of the ventricles, is propelled with considerable force into the aorta and pulmonary artery, the sigmoid and semilunar valves of which are suddenly elevated. In the rapid passage of the blood from a wider to a narrower area, there must be considerable friction be- tween this fluid and the parietes of the arterial orifices ; quite suffi- cient, in my mind, to produce the prolonged first sound of the heart. This sound necessarily has a distinct character from the second sound of the heart, because the resistance to be overcome is so much greater, and the passage of the blood through these orifices is more gradual ; it is likewise more prolonged, because sound must be developed during the entire period that the blood is passing from the ventricles into the large arteries: and the slower the action of the heart, the more prolonged will this sound be. Second sound The second sound of the heart we know is synchronous with the ventricular diastole : during this act the muscular fibres of the ventricles are relaxed, the cavity of the ventricles enlarges, and the walls of the ventricles re-expand; the curtains of the auriculo-ventricular valves open, and there is a sudden influx of blood from the auricles through the auriculo- ventricular orifices. It is scarcely necessary to say, that it is not the contraction of the auricles which propels the blood into the 94 SOUNDS OF THE HEART. ventricles at this period of the heart's action ; nor is the dilatation of the cavities of the ventricles the result of the entrance of the blood from the auricles, as some have supposed. It is not, either, necessary for the production of this sound that the diastole of the ventricles should be an active process like the systole ; the ven- tricles being hollow muscles, the state of relaxation of their mus- cular fibres is a state of dilatation of their cavities : hence a vacuum would be created in them if the auricles were not at this period full of blood ready to supply them, but, as the latter had been filling during the whole period of the ventricular systole, this cannot happen, and the blood passes through the auriculo-ventri- cular orifices in a full and rapid stream, and with sufficient force to generate sound. That the blood enters the ventricles with considerable force, would appear from what has been observed in experiments upon animals, as well as in the human subject. Cruveilhier says that, in a case of ectopia of the heart in an infant, when the organ was grasped with the hand during the ventricular diastole, it was violently and forcibly opened, — so much so, that he was at first under the impression that the diastole was the active state of the ventricles. The second sound of the heart is much shorter than the first sound, because the relaxation of the muscular fibres of the ventri- cles in the diastole is rapid, and the motion is sudden and instan- taneous. It has a difierent character from the first sound, because the blood has no impediment to overcome in entering the ventri- cles from the auricles. Objections to the theory of valvular tension as a cause of the first sound — It is said that the heart, being a muscular organ, and its orifices being each provided with a distinct valvular apparatus, the contraction of the muscular tissue of the ventricles, or the action of its valves, ought to be capable of producing sound. Now, the first sound of the heart cannot have its cause exclu- sively in the sudden tension of the auriculo-ventricular valves, because this act takes place at the very commencement of the systole ; and the first sound is a dull, prolonged sound, which per- sists during the entire systole ; again, it occasionally haj^pens that the mitral valve is rendered rigid and immoveable by disease, without any murmur from regurgitation occurring, yet the first THEORIES OF THE CAUSE OF THE SOUNDS. 95 sound is still perfectly well marked, which could not be the case if it was due to valvular tension. That any part of this sound is produced by valvular action seems to be doubtful, because the curtains of the mitral and tricuspid valves are floated towards the orifices by the blood which distends the ventricles ; and, when the ventricular systole commences, the auriculo-ventricular orifices are mechanically closed by the pressure of the blood against the curtains of these valves. Objections to the theory of muscular contraction as a cause of the first sound. — It remains, therefore, to consider how far the first sound is due to muscular contraction. This is supposed to be proved by the first sound having been heard in experiments upon animals when the organ was removed from the body and continued to contract, because there was then neither collision of the blood nor valvular action ; but when a heart contracts and dilates under such circumstances, air must enter the ventricles during their diastole, and be expelled during their systole, and the friction of the air against the parietes of the orifices of the heart, is quite as capable of developing sound, as the friction of a fluid. Three theories, of the manner in which sound is produced by the contraction of the muscular fibres of the ventricles of the heart, have been proposed. Dr. Hope, as 1 have already observed, refers it to " muscular extension ;" Dr. Blakiston,* to friction between the muscular fibres themselves during the act of contraction ; and others to *' bruit musculaire." According to Dr. Hope, the sound of muscular extension is " a loud, smart sound, produced by the abstract act of sudden jerking extension of the . already braced muscular walls, at the moment when the auricular valves close." With respect to this theory of the production of sound, I must confess I do not exactly understand how sound can be produced in this way, at all resembling the first sound of the heart. By many physiologists the first sound of the heart has been referred to " bruit musculaire," which, according to Mr. Bowman,! is " an exceedingly faint, silvery vibration." The mechanism by which bruit musculaire is produced, may (he thinks) be explained * Practical Ohservations on Diseases of the Chest, t Philosophical Transactions. 96 SOUNDS OF THE HEART. " by supposing the several fasciculi to be in rapid and constant motion, one against the other, by varying amounts of contraction in different fasciculi and parts of fasciculi." Dr. Blakiston's theory of friction between the muscular fibres themselves, and Mr. Bowman's theory of the mechanism of bruit musculaire, seem, therefore, to be pretty nearly the same. Laennec* was the first to call attention to bruit musculaire in connexion with the sounds of the heart. In the part of his work where he endeavours to explain the mechanism by which bruit de soufflet is produced, he observes : "When the naked ear or the stethoscope is applied over a muscle in a state of contraction, or, better still, upon one extremity of the bone to which the muscle is attached, we hear a sound analogous to that of the wheels of a carriage at a distance, and which, though continuous, is evidently formed by a succession of very short and quickly succeeding sounds ; or if, with the head resting upon a pretty firm pillow, the masseter muscles are strongly contracted, and then contracted with less force ; in the former instance the wheel seems to roll with great rapidity upon a hard surface, in the latter it seems to roll over a rough pavement." Dr. Williams,t who refers the prolongation of the first sound of the heart to bruit musculaire, observes : " Whenever there is strong, abrupt, muscular action in any part of the body, like that of the heart, there will be heard a sound which will resemble that of the ventricular systole, in proportion as the muscles, in which it is produced, resemble in thickness and density the tissue of the heart ; as when we apply the stethoscope to the adductor muscle of the thumb of the closed hand, and contract the muscle strongly and quickly ; or, to avoid the possibility of the joints being the seat of the sound, if we apply the end of a flexible tube to the abdominal muscles, and start them into sudden vigorous action, we may thus get sounds quite as loud as those of the ventricles, and very like them in character. By varying the mode of this muscular action, different kinds of sound may be produced. When the contraction is slow or sustained, however strong, we have only the dull rumbling noise which Dr. Wollaston described, and which he attributed to a vibration depending on a regular inter- mittence in the force of the contraction. When the contrac- * Traite de I'Auscultation Med. tome ii. t 0" Diseas^es of the Chest. THEORIES OF THE CAUSE OF THE SOUNDS. 97 tion is gentle and slow, it may cause no sound at all ; as we have seen that the auricles produce no sound, neither do the ventricles when their contraction is very feeble." Dr. Watson,* who likewise adopts the theory of bruit mus- culaire, observes, in reference to the first sound of the heart : "If during the stillness of the night, when lying in bed, you set the teeth firmly, you will hear a continuous dull rumbling, caused evidently by the action of the masseter and the temporal muscles." Now, the dull rumbling sound which is heard under such cir- cumstances, if it is to be taken as the type of bruit musculaire, is very unlike the first sound of the healthy heart. It is a con- tinuous, dull, rumbling noise, and has a much greater resemblance to the venous murmur heard in the jugular veins in cases of anaemia than to it. Indeed, I am convinced that this sound has not its seat in the masseter or temporal muscles, for it is heard only in the ear which rests against the pillow, not in the opposite ear. The ear must likewise be pressed pretty firmly against the pillow, by which the air is confined between the tympanum and the external ear. Indeed, a sound altogether similar will be heard if the ear is stopped with the finger, and the temporal and masseter muscles are then strongly contracted. The sound has certainly nothing of the "faint silvery vibration" which, accord- ing to Mr. Bowman, characterises bruit musculaire ; and the theory which refers the prolonged portion of the first "Sbund of the heart to it, appears to me to rest upon too hypothetical grounds to entitle it to be considered as the cause of this sound, or of any portion of it. Objections to the Theory of the Recoil of the Blood upon the Arterial Valves as a cause of the Second Sound. — The second sound of the heart is generally supposed to have its cause in the sudden tension of the sigmoid and semilunar valves ; or in the recoil of the column of blood contained in the aorta upon these valves, or in both combined. That these valves close their respective orifices at the period in question, we know ; but that their sudden tension, or the recoil of the column of blood upon them is the cause of the second sound, I have considerable doubts, thus : 1. The closure of these valves is described by some as a * Lectures on the Practice of Medicine. 98 SOUNDS OF THE HEART. sudden flapping motion. But these valves do not flap against one another, and it cannot be against the blood which then begins to enter tlie ventricles by the auriculo-ventricular orifices, because the arrangement of the tricuspid and mitral valves is such, that the blood does not reach them at this period. 2. The instant the onward current from the ventricles ceases, the blood in the aorta insinuates itself into the little sinuses behind these valves, and by its simple weight presses them down and closes the orifices. 3. The amount of force with which a column of blood should fall upon them, in order to develop tliis sound, would necessarily soon cause these valves to be reversed ; and, if they were exposed to such a rude shock at every diastole of the ventricles, few persons could attain adult age in whom they woifld not permit regurgitation. Those who adopt the foregoing theory, of the mode of pro- duction of the second sound of the heart, seem to argue as if the arteries were inelastic tubes, and that the blood in the aorta and pulmonary artery had a backward as well as a forward motion. If this were so, it could hardly fail to be pei'ceived in the large arteries which come off from the arch of the aorta : while, for a column of blood to come in contact with these valves with suffi- cient force to develop the second sound of" the heart, presupposes an empty space in the artery above them, into which the blood falls back at each ventricular diastole. But as long as the artery preserves its elasticity, nothing of the kind can occur ; the blood does not recoil with any force, or from any distance, upon these valves, because the artery immediately above them is filled equally with the other parts of the tube. In fact, the instant that the onward current from the ventricles ceases, the blood by its simple weii^ht depresses these valves, and as long as the parts are healthy there is no recoil of a column of blood upon them. But when, as occasionally happens, the arch of the aorta loses its elasticity, and becomes dilated, there is then certainly a recoil of the blood con- tained in it upon the semilunar valves ; and this state almost always eventually ends in patency of the aortic valves. Pathological evidence in favour of the Theory of Friction^ between the Blood and the parietes of the Orifices, as a cause of the Sounds It will now be necessary to adduce some patholo- gical evidence that the sounds of the heart are caused by friction THEORIES OF THE CAUSE OF THE SOUNDS. 99 between tlie blood, and the paiietes of tlie orifices of the ventricles, during their systole and diastole. I have already said, that a double sound, which cannot be distingiiished from the normal double sound of the heart, is heard in cases of aneurism of the arch of the aorta ; and that in certain instances the first of these sounds, in others the second, and in others again both these sounds, are converted into murmurs, altogether analogous to the murmurs which accompany diseased states of the orifices and valves of the heart. That the aneurismal sounds are caused by friction be- tween the blood, and the parietes of the orifice of the sac, requires no proof, because there is no other agency to which they could be referred. This is at least evidence that a valvular apparatus and muscular walls are not essential to the production of sounds analo- gous to those of the heart. The conditions common to both are, a cavity into and out of which the blood passes with more or less force and rapidity ; and if the friction between the blood and the parietes of the mouth of the sac of an aneurism is capable of deve- loping, not merely a double sound similar to that of the heart, but murmurs which differ in nothing from those developed in diseased states of the heart, the same agent is evidently equal to produce analogous sounds at the orifices of the ventricles. First sound. — If the first sound of the heart has its cause in the friction between the blood and the parietes of the arterial orifices; and if murmurs are nothing more, in the great majority of cases, than exaggerated normal sounds, then the normal first sound of the heart ought to be converted into a murmur, whenever an impediment is offered to its exit ; when the blood is propelled with increased force and velocity, or when the qualities of the blood are altered, and this fluid loses its viscidity and becomes more watery than natural ; because in these several cases the friction between the blood and the parietes of the orifice is increased. The sound ought to diminish in intensity, or in duration, when less blood is transmitted by the ventricle, or when it is transmitted with less force ; and it ought to be more prolonged than natural when an increased quantity of blood is transmitted by the ven- tricle during its systole : and this is exactly what does occur. For instance : 1. Whenever the aortic orifice or its valves become diseased so as to obstruct the outward current of blood, the normal first 100 SOUNDS OF THE HEART. sound of the heart is converted uito a murmur, which will have either a blowing, or harsh character, according to the amount of the obstruction, and to the force and velocity of the current. 2. When the walls of the left ventricle are hypertrophicd, and the blood is propelled through the aortic orifice with in- creased force^ althongh there is no impediment to its exit, the normal first sound may be converted into a mnrmur. In the or- dinary explanation of the mechanism by which the first sound is produced, a murmur from this cause ought not to occur. 3. When the viscidity of the blood is diminished, and this fluid is propelled with increased velocity through the aortic orifice, the normal first sound is converted into a murmur. 4. When the walls of the left ventricle are attenuated, the first sound of the heart comes to resemble the second sound, be- cause the blood is propelled with less force, less blood is transmitted through the arterial orifice, and the systole lasts a shorter time. 5. When the walls of the left ventricle are softened, or have undergone fatty degeneration, the first sound of the heart be- comes more feeble, because the blood is propelled into the aorta with less force j and, when the aortic orifice or the semilunar valves are diseased so as to obstruct the outward current from the ventricle, no abnormal sound will be heard, because the force of the current in such cases is too feeble to convert the first sound of the heart into a murmur. 6. When the cavity of the left ventricle is dilated, and its walls are increased in thickness, a larger amount of blood will be transmitted at each ventricular systole, and the first sound of the organ will necessarily be prolonged. It may be objected to the foregoing theory, that the abnormal sound does not always replace the normal first sound of the heart, and that the latter is still heard in some cases of valvular disease along with it. But as valvular disease is almost limited to the left side of the heart, the abnormal sounds are limited in the same proportion to the left side ; and, if a normal sound is audi- ble along with the abnormal, it may be the normal sound of the right side of the organ, which the murmur was not sufficiently intense to mask completely. Second sound — If the second sound of the heart has its cause in friction between the blood and the auriculo-vcntficular orifices, THEORIES OF THE CAUSE OF THE SOUNDS. 101 it ought to diminish in intensity whenever there is an impedi- ment to the entrance of the blood from the auricle, or when the ventricle remains distended, owing to its inability to empty itself. This sound is very seldom converted into a murmur, because there is nothinsr to increase the force with which the blood enters the ventricles from the auricles, though there are several which may diminish the force or velocity of the current from the auricles into the ventricles. For instance : 1. When the mitral orifice is much contracted, the second sound of the heart will diminish in intensity ; and, when the con- traction is extreme, it is scarcely audible, because but little blood can enter the ventricle from the auricle during the ventricular diastole. 2. When the ventricles of the heart of animals, submitted to experiments, were gorged with blood the second sound was scarcely heard, or ceased, because a sufficiently strong current of blood could not enter the ventricle to develop sound. This was noticed both in the experiments performed in the United States and in England. " The second sound (Drs. Pennock and Moore observe), by the congestion of the ventricles ceasing first on the right side." " When the heart was gorged, towards the conclusion of the experiments, the first sound (Dr. Hope observes) only was heard." 3. Although the second sound itself is seldom converted into a murmur, a murmur which masks the second sound is by no means rare, and is heard whenever the aortic valves permit re- gurgitation. Why a murmur should be heard in this case, or why the second sound of the heart should be seldom converted into a murmur, is easily understood. When the mitral orifice is contracted, less blood can enter the ventricle during its diastole, and the second sound becomes more feeble than natural : it is not converted into murmur, because the force with which the blood enters the ventricle from the auricle is too slight to produce this effect. On the other hand, when the aortic valves permit regurgitation, as these valves are on a higher plane than the auri- culo-ventricular orifice, and as it is the blood contained in the aorta above these valves which regiu'gitates into the ventricle, the amount of friction between the blood and the abnormal orifice is sufficient to generate a murmur in this case, thougli not in the 102 SOUNDS OF THE HEART. former ; but, the force with which the blood regurgitates into the ventricle never being so great as that with which it is expelled from the ventricle, the murmur of aortic regurgitation is usually soft and blowing, and seldom acquires the rough, harsh character which a systolic murmur often presents. In addition, we know, that when patency of the aortic valves exists, two currents of blood must enter the ventricle at each diastole ; that through the aortic orifice being the stronger, for the reasons already given, a smaller amount of blood will there- fore necessarily enter by the auriculo- ventricular orifice ; and the force with which it enters will be diminished, because the ven- tricular cavity is partially filled by the backward current through the aortic orifice. Hence, we have another reason why the normal second sound should become more feeble than natural, and why it should be so readily masked by the louder sound of aortic re- gurgitation. liastly, the occurrence of intermission of the heart's sounds, or irregularity of the heart's action, which are with difiiculty explained on the theory of the heart's sounds ordinarily received, admit of a ready explanation on this. For instance : If too little blood is expelled by the left ventricle at each systole to communicate a pulse to the radial artery, and if this occurs at every second, third, or fourth beat, as the case may be, there will necessarily be an intermission of the pulse ; while, if the amount of blood is too small, or the force with which it is propelled too slight to occasion friction at these periods between the blood and the parietes of the orifice, the heart's sounds them- selves will be intermittent. If the left ventricle becomes overloaded with blood, or its parietes are weak, the systole of the ventricle may be repeated several times for one diastole ; and this may occur at short in- tervals, so that the pulse may be felt to give several rapid and small beats, and then several stronger and more regular beats, as if it were the pulse of two different persons { and the same irregularity will be perceived in the sounds of the heart when the stethoscope is laid on the prajcordial region. These phenomena, which scarcely admit of explanation ac- cording to the ordinary theory of the heart's sounds, admit of a ready explanation if we allow that the sounds are due to THEORIES OF THE CAUSE OF THE SOUNDS. 103 friction between the blood and tlie parietes of tlie orifices of the ventricles ; that if little blood is transmitted, or it is transmitted with little force, little sound can be produced ; while, when the force and velocity of the circulation are increased, the friction will be increased in proportion ; and, when an impediment is offered to "the passage of the blood under such circumstances, the normal sound will be converted into a murmur. 104 CHAPTER V. EXAMINATION OF THE HEART IN DISEASE.— SIGNS FURNISHED BY INSPECTION OF THE CHEST, AND THE APPLICATION OF THE HAND.— SIGNS FURNISHED BY PERCUSSION. The anatomy and physiology of the healthy heart having been dwelt upon at sufficient length, we have next to consider the heart in disease, and to describe the several methods of proceeding, in order to determine the nature, the situation, and the extent of the morbid changes. And here we shall find the advantage of the preceding details, inasmuch as we shall be in a position to recognise readily any alteration in the heart's impulse, either as respects its strength, or the situation in which it is felt ; we shall be able to detect any difference in the extent and degree of the heart's super- ficial dulness, or any change in the character of its sounds. In cases where the heart is diseased, or suspected to be so, several distinct methods of examination require to be employed ; the eye, the touch, the ear, are each capable of afibrding us assist- ance in arriving at a diagnosis, and the indications afibrded by each mutually assist the others. These methods of examination may, for convenience sake, be considered under the heads — inspection of the chest ; palpation, or the application of the hand to the parietes ; percussion and auscultation — upon each of which it will now be necessary to delay for a short time. Inspection of the Chest — In other words, the examination of the external surface of the thorax, and the application of the hand to the prsecordial region should never be omitted ; they are capable, alone, of affording positive information in several diseased condi- tions ; they aid and assist our other means of arriving at a diag- nosis ; and, as preliminary steps to other and more difficult methods of exploration, they can scarcely be dispensed with, if we wish to make an accurate examination. As these two methods of physical examination-mutually assist I IMPULSE OF THE HEART. 105 one another, they may be considered together. Thus, by inspection of the chest, we determine the exact point at which the apex of the heart comes in contact with the parietes of the chest, and by the application of the hand we determine the strength or feebleness of its impulse. By inspection of the chest we ascertain whether the two sides of the thorax are symmetrical, and we detect any protrusion in the precordial region ; by it we recognise unusual pvilsation at any part of its parietes, in the large arteries which come off from the arch of the aorta, as well as in the jugular veins, or in the epigastric region. By the application of the hand we de- termine the force of the pulsation, we judge of the frequency or slowness of the heart's action, and of the regularity or irregularity of its movements. By the application of the hand, likewise, we recognise the peculiar phenomenon known under the name of fre- missement cataire, or purring tremor ; and by the same means we can detect friction between the opposed and roughened surfaces of the pericardium in inflamed states of this membrane. Impulse of the Heart. — The application of the hand to the prsecordial region is necessary, in order to judge of the strength or feebleness of the heart's impulse : with this view, the hand may either be placed directly upon the surface of the chest, or, holding the ear-end of the stethoscope, we apply its opposite extremity to the part, when the extent to which the instrument is elevated, and the force with which this is accomplished, will give us a pretty accurate idea of the strength of the heart's impulse. This kind of mediate palpation is principally useful in hypertrophy, or hyper- trophy with dilatation of the ventricles. The impulse of the heart varies, even in healthy individuals, according to the development of the chest, according to the size of the lungs, according to the fatness or leanness of the individual, according to the stature of the subject, and to the size of the abdomen. In the healthy subject, with a well-formed chest, the impulse of the heart is so slight as not to be perceptible to the in- dividual himself, and is felt only at one point — viz. between the cartilages of the fifth and sixth ribs on the left side ; that is, from one to two inches below the nipple, and to the sternal side of this point. When the parietes of the chest are much loaded with fat, the impulse is scarcely perceptible to the hand ; while in thin per- sons it is evident also to the eye. In such cases, when the heart's 106 EXAMINATION OF THE HEART IN DISEASE. action is vigorous, it will be perceived to be double ; and this in certain states of disease becomes very perceptible. In examining the heart, it is necessary to bear in mind that the impulse is somewhat stronger in the erect than in the recum- bent posture ; that in a forced inspiration the impulse is diminished, and felt slightly lower down than natural ; a deep inspiration ele- vating the ribs without raising the heart in the same degree, while it depresses the diaphragm. That in a forced expiration the im- pulse becomes more perceptible, and is felt slightly higher up; a forced expiration depressing the ribs and elevating the diaphragm. It may therefore be necessary to make the patient vary his position, and to examine the heart both during inspiration and expiration. In some individuals the impulse is naturally weak ; in others, natu- rally strong : the same may be said of the pulse and of the sounds of the heart, although the parts arc in a perfectly normal condition in each. As the impulse is increased by exercise, or exertion, or by mental excitement, we should be careful to examine the heart suspected to be diseased when the patient is perfectly calm and tranquil. In some morbid conditions of the heart or lungs the impulse is either very slight or altogether absent. In others, it is so strong as to be disagreeable to the individual, and to be visible without removing the patient's clothes, and the extent of surface over which it is felt is much increased. In others, the impulse becomes per- ceptibly and strongly double ; in others, the seat of the impulse is altered, or it becomes irregular in rhythm and force ; or, finally, it may be altogether absent. Diminution of the Impulse. — Diminution of the imp>ulse of the heart may depend, either upon feebleness of the action of the heart, which may have its cause in disease or alteration of its muscular tissue, or in general debility of the system ; or it may depend upon the apex of the organ being prevented from coming in contact with the parietes of the chest, with sufficient force to communicate an impulse, owing to disease in the lungs or pericardium. The impulse of the heart is circumscribed or feeble in softening- of the heart, and in fatty degeneration of its tissue. In states of considerable general debility, it is feeble. The impulse is dimi- nished, likewise, in attenuation of the walls of the ventricles, with dilatation of their cavity. If the anterior margin of both lungs is INCREASE OF THE IMPULSE. 107 emphysematous, and tliey overlap the heart, the apex may be pre- vented from coming in contact with the parietes, and the impulse will be much diminished. In cases of considerable effusion into the sac of the pericardium, the impulse is absent altogether, or it is unequal and undulating, as if propagated through a fluid. In cases even of hypertrophy with dilatation of the ventricles, the impulse may be diminished, "it becomes a mere oppressed struggle," if the heart is overloaded with blood and the lungs are much congested. Increase of the Impulse. — Increase of the impulse of the heart, as a general rule, occurs under the very opposite conditions of the organ to those under which diminution of its impulse is observed, and, in the majority of cases, it has its cause in some morbid state of the heart itself. The impulse is stronger than natural in hyper- trophy of the walls of the left ventricle, and it arrives at its utmost limit in hypertrophy with dilatation of the ventricles ; in such cases the impulse is slow, gradual, heaving, double, and occasion- ally so violent as to shake the bed on which the patient lies. The character of the impulse of the heart thus becomes a most valua- ble sign of hypertrophy with dilatation ; " the slow, progressive, heaving impulse could be produced by no other cause." In such cases, likewise, the extent of surface over which the impulse of the heart is felt, is much increased ; and the whole side of the chest is sometimes elevated by the movements of the organ. It is in this form of disease that the double impulse is so well marked, the diastole as well as the systole of the ventricles being accompanied by an impulse : this is sometimes termed the back stroke of the heart, more correctly the diastolic impulse. The ventricles may, however, be considerably hypertrophied, and the heart much en- larged, without any increase of the impulse. Thus in a case, re- cently under my care, where the heart, upon a post-mortem exami- nation weighed 28 ounces, the impulse was not increased, owing to the pleura of opposite sides having contracted adhesions with one another, and with the outer surface of the pericardial sac; by which the apex of the heart was prevented from coming in contact with the parietes. M. Piorry says, that in aged females at the Salpetriere very little impulse is often felt, although the heart is frequently much thickened ; while in nervous subjects with small hearts the impulse is frequently very strong. He is of opinion 108 EXAMINATION OF THE HEART IN DISEASE. that increased impulse is to be considered " an indication rather of the force of the blow than of the thickness of the parietes of the ventricles." In hypertrophy with a predominance of dilatation, the impulse, as Laennec observes, is abrupt, short, and knocking, and in the fits of palpitation the shock resembles the blow of a hammer. " The blow seems (as Dr. Hope remarks) to strike a small space : it expends itself, as it were, on the thoracic parietes, and does not communicate a heaving proportionate to its force." " It differs from the impulse of great hypertrophy, in the circumstance that in the latter the ventricles, in a distended state, seem to heave with their whole length against the thoracic parietes, which yield to the effort : while, in the former, the point only of the heart seems to strike the parietes with a sharp, smart, accurately circumscribed blow, only capable of producing a sort of concussion, rather than a real heaving." The impulse of the heart is stronger than natural in the early stage of endocarditis, and of pericarditis; likewise, in attacks of palpitation from any cause ; and it is apparently stronger wdien a morbid growth behind the heart protrudes the organ forwards, as in certain rare cases of aneurism in the descending portion of the thoracic aorta. The impulse becomes sharper and more knocking in nervous and hysterical subjects, particularly during fits of pal- pitation : in such cases it is often very troublesome to the patient, and is occasionally accompanied by perceptible sound. Alteration in the situation of the Impulse. — The situation at which the impulse of the heart is felt is iiot unfrequently altered by disease, either of the heart itself, of the lungs, or pleura, by the development of morbid growths in the cavity of the thorax, or by morbid or other changes in the contents of the cavity of the abdo- men ; and, these alterations in the site of the impulse, may be the result either of the increased volume which the heart itself attains, or of displacement of the entire organ. Thus : In hypertrophy of the left ventricle with dilatation of its cavity, the heart being increased in length, its impulse will be felt lower • down than natural, more to the left side, and, occasionally, on a line with the axilla. In hypertrophy with dilatation of the right ventricle, the impulse will, for the same reason, be felt lower down and more to the right side than natural, and, not unfrequently, on METALLIC CLIQUETIS. 109 aline with the xyphoid cartilage. In the former case the Impulse is progressive, heaving, and strong, elevating the head of the ob- server, and is felt over a much larger surface than natural ; in the latter the impulse is neither heaving, prolonged, or very strong, and is felt over a more circumscribed space. The entire organ is displaced laterally in cases of empyema, towards the left side when the right pleural cavity is its seat, and towards the right side when the left pleural cavity is its seat : in the latter case the impulse is frequently felt upon the right side of the sternum. The heart is pushed upwards, and the impulse is felt on a plane higher than natural in ascites, in cases of large ovarian, or other abdominal tumors, in hysterical tympanitis, and the advanced stages of pregnancy. The heart is displaced slightly downwards in cases of emphysema of both lungs of long standing, and the impulse is felt on a plane lower than natural, not unfre- quently in the epigastric region. In cases of effusion of fluid into the pericardial sac, the site of the impulse is somewhat elevated ; when the amount of fluid is greater, the impulse becomes weaker, unequal, undulatory, or irregular ; when the amount of liquid effusion is very considerable, the impulse will be altogether absent. When the parictes of the ventricles have undergone fatty degene- ration, or when they are softened, or much thinned, the impulse is generally irregular. In individuals with narrow, deformed, or contracted chests, the impulse will be perceived beyond its normal limits. In individuals, on the other hand, with broad and ex- panded chests, the site of the impulse is usually circumscribed. Metallic Cliquetis. — Although under ordinary circumstances, sound is not produced by the impulse of the heart, and no shock or blow is given to the parietes of the chest by the apex of the organ during the ventricular systole — the intercostal space between the cartilages of the fifth and sixth left ribs being merely elevated by the apex of the heart in the gliding movement performed by it at this period of the heart's action — yet, under certain circum- stances, sound is really produced by this act, which in certain rare cases is sufficiently loud to be heard without the stethoscope, and at a short distance from the patient, or is audible to the patient himself. Corvisart only once witnessed this phenomenon. Laennec states that in at least twenty instances which he met, tliis sound 110 EXAMINATION OF THE HEART IN DISEASE. was sufficiently loud to be audible at a distance of from two inches to two feet from the patient's chest. " In only three or four of these cases, at the utmost, organic disease of the heart existed ; in all the others, the palpitation was purely nervous. Bruit de souf- flet and fremissement often existed in a slight degree in the heart, but, particularly in the arteries of those who presented this phe- nomenon." In order that this sound shoidd be produced, the heart must act strongly, the subject must be thin, the heart must be a good deal uncovered by lung, and the apex of the organ must come in contact with the rib or its cartilage with sufficient force to produce sound. According to Dr. Hope, the manner in which the sound is produced is as follows : " The heart in gliding forwards and up- wards during its systole strikes with its apex against the inferior margin of the fifth rib, and thus creates an accidental sound, at- tended with cliquetis when the blow is smart. It may be pre- vented at pleasure, by pressing the edge of the stethoscope, or any thing else, into the intercostal space, by which that space is put internally on the same plane as the rib, over which the heart then glides without catching." He adds, that, *'he has never found the sound to occur in any but the meagre, because in the well- conditioned the intercostal spaces are full and resistant, and con- sequently the edge of the rib is not exposed." In order to hear the metallic click, M. Bouillaud says it is better not to employ a stethoscope, " this sound being sometimes heard with the naked ear when it would be inaudible with the stethoscope" — Dr. Ormerod,* who has investigated this pheno- menon with much care, has met with it under four different con- ditions — viz., 1st, in nervous, ana3mic subjects, when the action of the heart was sharp ; 2ndly, with more violent action of the heart ; 3rdly, at the commencement of pericarditis ; and 4thly, with a rough, almost scaly state of the pericardium about the base of the heart; to which he thinks may be added adhesion of the pericardium. He says "there are three explanations of the mode of production of this sound — namely, costal percussion, friction of free surfaces, and movement of connecting areolar tissue; each probably applies to a limited number of cases — * Gulstonian Lectures, Medical Gazette. JUGULAR PULSATION. Ill tliere does not appear to be any one general explanation, nor considering the nature of tlie sound, ought we, perhaps, to look for one." Turgescence and pulsation of the jugular veins. — Among the signs which are evident on inspection of the chest, and which accompany the advanced stage of some forms of cardiac disease, a state of permanent turgescence or distension of the jugular veins, with or without pulsation, is by no means unfrequent. The former is the most common, and may occur in any case in which an impediment exists to the free passage of the blood throucrh the right side of the heart. The latter is observed in cases in which, in addition, the tricuspid valve imperfectly closes the right auriculo-ventricular orifice, and free regurgitation into the auricle is permitted at each systole of the right ventricle. Turgescence and pulsation of the jugular veins were first noticed, by Lancisi, as signs of cardiac disease. He referred them to dilatation with hypertrophy of the ventricles, or, as it was then termed, " anevirism of the heart." Corvisart had little con- fidence in them as sisjns of disease of the ri^ht side of the heart. Laennec, however, regarded the turgescence without pulsation of these veins as a frequent attendant upon dilatation of the right cavities of the heart, and he says that " pulsation in the same veins was present in every case which he had met with of considerable hypertrophy of the right ventricle." The internal and external jugular veins receive the blood from the interior and exterior of the head, from the face and neck. Now, if there is any impediment to the free passage of this fluid through the right side of the heart, whether depend- ing upon disease in the right or left side of the organ, or of tlie lungs, these veins become distended and turgid. If, in addition, the tricuspid valve does not close the right auriculo-ventricular orifice, a portion of the blood, at each systole of the right ven- tricle, instead of passing into the pulmonaiy artery, will be trans- mitted backwards into the right auricle, and will re-act upon its contents, and through it upon the blood descending by the superior cava and its branches, when a pulsation will be com- municated to the jugular veins at each systole of the right ven- tricle, which will persist although pressure be made upon the vein above it. 112 EXAMINATION OF THE HEART IN DISEASE. The diseased condition of the heart in which turgescence of the jugular veins is most frequently observed, is dilatation of the right auricle and ventricle, with or without hypertrophy of the same parts. It is, however, by no means to be considered as a symptom belonging exclusively to this form of disease, for it is often the result of obstruction, or regurgitant disease at the left side of the heart. It may accompany any impediment to the free circulation of the blood through the cavities of either side of the heart. It is observed sometimes in aneurism of the arch of the aorta, as well as in diseased conditions of the lungs, ac- companied by obstruction to the pulmonary circulation. The turgescence is usually limited at first to the external jugular veins, particularly on -the right side: it is not constant, and can always be removed by compressing the vein above. Eventually both the internal and external jugular veins become distended and turgid, sometimes to an extreme degree. This state is per- manent, though it can still be removed by pressure upon the vein higher up. In some few cases, the veins, in addition to being dilated, become tortuous, and present the appearance with which we are familiar in the varicose state of the veins of the lower extremity. The veins in which pulsation is observed are the internal jugulars, those vessels not being provided with valves like the external. The pulsation is always most evident immediately above the clavicles, and it may extend half-way up the neck when the latter is short; but I have never found it to reach higher. It is usually best marked on the right side, and is fre- quently perceived upon both sides, and sometimes, though rare- ly, only on the left side. The pulsation is too feeble in the great majority of cases to be felt by the linger, but, in several instances which have come under my observation, a pulsation was communicated to the finger placed lightly upon it. This could not be confounded with the pulsation of the artery underneath, which is likewise generally Increased at the same time — ^as it was very feeble, was perceptible only on slight pressure, and disappeared when this was increased — wlien the impulse of the^ artery alone was felt. The movement in jugular pulsation is rapid, vermicular, and double ; the backward current of blood forming the first and JUG ULAll PULSATION. 113 Strongest movement, and the direct current its second and slighter movement. According to Dr. Sibson, there is in the healthy state ** a constant visible pulsation, both in the deep and super- ficial jugular veins, which pulsation, though perfectly visible, cannot be felt." It is much diminished, and in many persons rendered invisible, during a deep inspiration. " The mere ex- istence of jugular pulsation (Dr. Sibson observes) is anything but an indication of disease, either in the pulmonary valves, or elsewhere." " In those diseases (he adds) where the flow of blood through the lungs and heart is impeded, the jugular veins contain more blood, and their pulsations are more visible than in health ; but where the impediment is extreme, the veins are in a state of constant distension, and no pulsation is visible." Pulsation of the jugular veins is present in every case in which the tricuspid valve imperfectly closes the right auriculo- ventricular orifice, and free regurgitation occurs at each ven- tricular systole, provided the walls of the right ventricle are suffi- ciently strong to communicate a backward impulse to the current of blood which descends by the jugular veins. Hence it is almost always observed in hypertrophy with dilatation of the fight cavi- ties of the heart. Pressure upon the vessel between the site of the pulsation and the heart is always sufficient to stop it. The cause of jugular pulsation was first satisfactorily ex- plained by MM. Bertin and Bouillaud — viz., that it depends upon regurgitation into the great veins during the contraction of the right ventricle ; and this theory of its cause has been almost universally adopted. Dr. Hope, however, supposed that it might have its cause in the recoil of the tricuspid valve upon the blood, when the hypertrophied ventricle contracted with increased force, and that the column of blood descending into the ventricle would be repelled with sufficient force to propagate its impulse as far back as the jugular veins. From the explanation which has been given of the manner in which the curtains of the auriculo- ventricular valves close their respective orifices, it would appear that jugular pulsation could scarcely be produced in this way. Why regurgitation is permitted at the tricuspid orifice so fre- quently, as well as the exact manner in which it occurs, have been already alluded to in treating of the " safety-valve function of the tricuspid valve." I 1 14 EXAMINATION OF THE HEART IN DISEASE. FREMISSEMENT CATATRE. Another sign whicla is recognised only by the application of the hand is the " fremissemcnt cataire" of Laennec, the "purring tremor" of English writers, the " frottement fremissemcnt on vi- bratile" of Gendrin ; named so by Laennec, from its resemblance to the peculiar sensation experienced if the hand is laid upon the back of a cat when the animal is making the peculiar purring sound which it does when pleased ; and compared by M. Bouil- laud to the thrill felt on placing the hand upon the larynx of a person singing. It is a peculiar thrill, or vibratory sensation, very easily recognised, sometimes perceptible on very slight pres- sure sometimes requiring a stronger pressure in order to be felt, and communicated equally by the large arteries as by the heart. This phenomenon had been recognised as a sign of cardiac disease previous to the discovery of auscultation. Corvisart, speak- ing of the symptoms of disease of the left auriculo-ventricular orifice, observes — *' Among the symptoms of this affection there is a peculiar confused sensation, difficult to describe, felt by the hand applied to the precordial region." He supposed it to indicate a contracted state of the mitral orifice, causing an impediment to the passage of the blood from the left auricle into the left ven- tricle. Burns evidently alludes to this phenomenon when he speaks of a "jarring motion accompanying the pulsation of the heart ;" and, as he noticed it in several cases where, on a post- mortem examination, the opposed surfaces of the pericardium were adherent, he attributed it to this lesion. Fremissemcnt cataire is not limited to the heart, but is per- ceptible also in the large arteries, and in aneurism, particularly in varicose aneurism, in which it is better marked tlian in the heart. It is felt over the large arteries when the lining mem- brane of these vessels is extensively diseased, as well as in cases where no morbid alteration of the parts exists ; and its cause, or the mechanism by which it is produced, do not seem to have ever been fully explained. Laennec* observes — "It would seem tliat the immediate cause of a phenomenon so marked as fremisse- mcnt cataire would be easily discovered. I confess, however, that, notwithstanding the pains which I have taken in this re- * Auscultation Mediate, torn. ii. FREMISSEMENT CATAIRK. I \5 spect, I have not been able to find any satisfactory reason." " It appears to me (he adds) extremely probable that it is owing to some peculiar modification of innervation." M. Boiiillaud,* in the second edition of his work on the heart, expresses himself in some- what similar terms : " What are the other causes capable of pro- ducing this phenomenon, I am ignorant. It appears to me that there is a certain condition of the blood, as well as of the parietes of the heart and arteries, which favours its production. But in spite of the assiduous researches to which I have devoted myself on the subject, I have not yet been able to determine properly all these conditions." Circumstances under loliich Fremissement Cataire occurs. — In every instance in which fremissement cataire is perceived, a murmur of some kind is audible on auscultation, which is generally blowing, sometimes rough or harsh. It is obvious, therefore, that the cause which produces the latter is connected with that which gives rise to the former ; but, as fremissement cataire is not felt in evei^y case in which an abnormal sound is heard, it is obvious that there must be something superadded when the latter is felt to allow of this peculiar sensation being communicated to the hand. The morbid condition of the heart in which this phenomenon is most generally perceptible is where the left auriculo-ventricular valve permits regurgitation, and the ventricle is at the same time hypertrophied and dilated ; it has occasionally also been noticed in cases of disease of the aortic valves with considerable contraction of the orifice, but this is rare. The morbid conditions in which it is felt in the arteries, are where the aortic valves permit free regur- gitation, or where the arch of the aorta is dilated, its lining mem- brane rough and irregular from adventitious deposit, and the large vessels which come off from its arch are likewise dilated ; where an aneurismal sac springs from a large artery, where a fi-ee com- munication exists between a vein and artery, as in varicose aneu- rism ; or, finally, where the blood is altered, its viscidity diminished, its watery parts increased, and the vessels are in an unfilled state. Two or more of the foregoing states may be combined, by which the thrill will be increased. Thus dilatation of the arch of the aorta may be combined with disease of its lining membrane, and both may be associated with a state of the aortic valves pcr- * Traite des Maladies du Cccur, torn. i. 1 1(5 EXAMINATION OF THE HEART IN DISEASEc )iiitling regurgitation ; or dilatation of the large arteries, or regur- gitant disease of the valves of the heart, may be combined with a state of anfcmia and alteration of the blood. Cause of Fremisseinent Cataire. — In every case in which fremissement cataire is felt, whether in the heart, or in the arteries, or in aneurism, the cavity or the vessel is in an unfilled state. Thus in the heart it becomes perceptible when the mitral valve permits regurgitation ; in the large arteries, when the aortic valves are patent, when the arteries themselves are dilated, when an aneurism exists, or when a communication exists between a vein and artery. Now I consider this unfilled state of the vessels, com- bined with a certain amount of force and velocity of the current of blood, to be the immediate cause of this phenomenon : the thrill or vibration communicated to the hand being more marked when the lining membrane of the part is rough or irregular from disease. For instance, we can produce a fremissement at any time in a large artery in a healthy subject by making pressure upon it ; the thrill is not felt at the point upon which the pressure is made, nor between it and the heart, but at the distal side of the point of pressure, and where the vessel must necessarily be in an unfilled state : a murmur is heard at the point compressed, and both cease as soon as the pressure is removed. We know, too, that a thrill, identical with fremissement cataire, is felt in cases where the heart and arteries are perfectly healthy, but where the vessels are in an unfilled state, as in anaemia, depending upon haemorrhage or other causes. A certain amount of force and velocity of the current of blood appears to be likewise necessary to its full development ; because we find that this phenomenon diminishes or even disappears in diseased states of the heart, when the action of the organ becomes tranquil, and that it reappears again when the heart's action is ex- cited by exercise. It disappears likewise when the action of the heart becomes feeble ; and ceases altogether in the last stage of valvular disease, when the circulation through the heart is much impeded. The jarring pulse in the radial artery, with which we are familiar in cases of patency of the aortic valves, appears to be nothing more than the fremissement cataire felt in an artery of small calibre. The thrill communicated to the finger is character- SIGNS FURNISHED BY PERCUSSION. 117 istic of an unfilled state of the arteries, and becomes perceptible whenever the semilunar valves of the aorta imperfectly close the orifice, or when regurgitation occurs into the aorta from the large arteries which come off from its arch. The same character of the pulse is observed in cases where profuse hcemorrhage has occurred ; and in a less marked degree in cases of anaemia from other causes. Fremissement cataire is or is not a si^n of organic disease according to its situation ; thus, whenever it is felt in the proe- cordial region, accompanies the ventricular systole, and is well marked, it indicates valvular disease ; and the form of valvular disease which will be found under such circumstances is, in the great majority of cases, a state of the mitral valve or orifice per- mitting regurgitation. In the large arteries, on the other hand, a fremissement may be felt, although no organic disease of the vessel exists. In some instances, this phenomenon is perceptible when the hand is laid gently upon the parietes : in others, stronger pressure is required in order to develop it. Thus in varicose aneurism, a thrill is communicated to the finger on the slightest touch ; while in cases of anasmia some pressure upon the artery is required in order to make it evident. A peculiar thrill or vibration is occasionally perceptible in the region of the heart, which must not be confovinded with the phe- nomenon just described, and which arises from the direct friction of two rough surfaces during the motions of tlie heart : here it de- pends upon friction between the opposed layers of the pericardium, roughened by the deposition of lymph ; the thrill has a different character from that of fremissement cataire, and is felt at a different part of the pra^cordial region. A somewhat similar feel is oc- casionally experienced when the hand is laid upon the side in cases of pleurltis or pleuro-pneumonia with false membranes ; in bronchitis, likewise, when the sonorous rale is loud, a sensible vibration is sometimes communicated to the hand : in the latter cases, however, it accompanies the respiratory movements, not the heart's action. SIGNS FURNISHED BY PERCUSSION. The praicordial region includes the whole of that portion of tlic chest beneath which the heart is situated ; and, in a healthy subject with a well-formed chest, the extent of surface in this 1 1 8 EXAMINATION OF THE HEART IN DISEASE. region which yields a dull sound on percussion is limited. We have seen that the lungs are in contact with the greater portion of the anterior surface of the thorax, and, of course, wherever they are, the sound elicited by percussion will be clear. Where the margin of the opposite lungs separates from one another, the anterior surface of the heart comes in contact with the thoracic walls, being only separated by the pericardium and cellular tissue. The portion of the heart uncovered by lung is very small, seldom exceeding two inches in any direction : it has a triangular shape — the base below, the apex above ; it consists of a portion of the apex of the right ventricle, and of part of the left ventricle near its apex, and is seated on a plane below the nipple and the fourth ribs ; its base is on a line with the cartilage of the sixth ribs ; its apex is at the point where the margins of the opposite lungs begin to separate from one another, viz., immediately below the fourth rib ; its right boundary (which is constituted by the thin edge of the right lung) is nearly a vertical line through the centre of the sternum ; its left boundary (which is constituted by the thin margin of the left lung) is an oblique line through the cartilages of the fifth and sixth left ribs. This, then is the only portion of the heart which, in the healthy subject, is in contact with the parietes of the chest, and it is the only portion of the praecordial region which yields what can be termed, a dull sound on percussion. It is not, however, quite correct to term this a dull sound ; it is less dvdl than that yielded by the hepatic region : the liver being a solid organ, and the heart hollow, the sound elicited by percussion over the former is more dull than over the latter. Indeed, as Dr. Latham* observes, " percussion here conveys to the ear a sense rather of less reso- nance than of positive dulncss." On stronger percussion, a dif- ference in the sound can be detected where the thin margin of the lungs covers the heart. The sound here is intermediate between the clear sound heard on percussion over the lungs, and that yielded by the part of the proecordial region where the heart is in contact with the parietes of the chest. In employing percussion in cases of disease, we m^ay commence the examination of the praecordial region either above, below, or laterally, we may trace the sounds yielded by the lungs above and upon each side to this region ; or, commencing below, we may * Lectures on Diseases of the Heart, vol. i. AUSCULTATORY PERCUSSION. 119 truce the sounds from the region of" the stomach, and of the left lobe of the liver, upwards. The mode of manipulation recom- mended by Dr. Hope* is "to lay one finger over the decidedly 5ea^ef/ dulness in the healthy adult subject, extends transversely from the left nipple to a little to the right of the sternum, and vertically from the third to the sixth ribs. 122 EXAMINATION OF THE HEART IN DISEASE. 5. The region of the heart's superficial clulness may be di- minished, or it may be increased, or the degree of duhiess may become more marked, owing to disease. It is much more fre- quently increased than diminished. 6. It will be diminished if the heart is atrophied or congenitally small, or the lungs are large and overlap the organ ; and it may disappear if the anterior margin of both lungs is emphysematous. 7. It will be increased whenever the ventricles are hyper- trophied, or their cavities are dilated, or when fluid is contained in the pericardial sac. 8. The region of the heart's deep-seated dulness will be in- creased if the pulmonary tissue around is condensed or solidified ; or, from the presence of a morbid deposit in this situation ; and it may be altered by liquid effusion into either pleura, or by the growth of intro-thoracic tumours. 9. The seat of the diminished resonance extends higher up, and is more extensive from above downwards, and laterally, when much fluid is contained in the sac of the pericardium, than when hypertrophy or dilatation of the heart exists. 10. The degree of dulness is always much more pronounced, and the resistance to the finger is greater when fluid is contained in the sac of the pericardium, than when the heart is enlarged. 123 CHAPTER VI. SIGNS FUKNISHED BY AUSCULTATION. -ALTERATIONS OF THE NORMAL SOUNDS OF THE HEART.— ABNORMAL SOUNDS.— PERICARDIAL AND ENDO- CARDIAL MURMURS.— ARTERIAL AND VENOUS MURMURS. Auscultation, like percussion, may be either immediate or mediate. Altliough immediate auscultation is preferred by some, there are several objections to it. Thus, in tlie case of females it is indelicate ; in dirty persons it is disagreeable ; v?hile in con- tagious diseases it is not without risk : besides, there are some situations in which either the ear cannot be applied, or in which the stethoscope is much more convenient. In examining the prgecordial region in cases of valvular disease, or where there is a suspicion of it, mediate is always to be preferred to immediate auscultation : indeed, the exact situation, or the limits of an ab- normal sound, can in the majority of cases be satisfactorily deter- mined only by the assistance of the stethoscope. As the sounds heard in a healthy state of the heart must be the standard of comparison in judging abnormal sounds, it is necessary to be familiar with them before commencing the examination of cases of disease : yet this is a matter too frequently overlooked by the student. He begins by examining the cases of disease which come under his observation in hospital, without, perhaps, any pre- vious knowledge of the normal sounds. Now it is scarcely neces- sary to say, that, unless the character, duration, intensity, and other qualities of the normal sounds of the heart are known, the student is not in a condition to appreciate the numerous modifi- cations or alterations which these sounds undergo in disease. It would, in fact, be almost as absurd to commence the study of anatomy by entering at once on pathology, without any knowledge of the healthy appearance of the organs, as to commence the practice of auscultation by examining cases of disease. 124 EXAMINATION OF THE HEART IN DISEASE. In cases where tlie heart is diseased, or suspected to be so, it is often advisable, before concluding the examination, to make the patient walk quickly up and down stairs, or backward and forward in the room, with the view of accelerating the circulation and in- creasing the heart's action — by which, abnormal sounds will be often rendered more evident, or a murmur which was inaudible previously may become distinct. Thus, a musical murmur is sometimes audible, only when the action of the heart is increased by exercise, a simple bruit de soufflet replacing it as the circulation becomes tranquil. When a murmur, which was inaudible as long as the circulation was tranquil, becomes evident when the heart's action is increased, it is highly probable that there is, as Dr. Latham* observes, "a mechanical obstacle at an orifice of the heart, but that it is of small amount, not enough to cause the re- quisite degree of vibration when the current of the blood is slow and undisturbed, but quite enough when it is more rapid and forcible." Again, in some cases it is necessary to examine the patient in the sitting or erect as well as in the recumbent position, or to make him lean forwards. Thus, in a case of pericarditis, under ray care in hospital, the friction-sound at one period became nearly inaudible in the recumbent posture, although sufficiently evident in the sitting posture, and still more so when the patient leaned forward. Or the friction-sound may diminish in intensity in the sitting posture, and become well marked in the recumbent position ; obviously depending on the difference of the situation in which lymph is deposited. It may, in addition, be sometimes necessary to make the patient hold his breath, for a few seconds, during the examination, particularly if a murmur is not well marked or the sonorous or sibilant rales of bronchitis are loud. Lastly, if any difficvilty should be experienced in distinguishing between the first and the second sound, or in determining to which a murmur should be referred, the finger ought to be kept on the radial pulse, or, better still, upon the carotid artery, during the examination ; and the stethoscope should be applied on the right side of the sternum, and the sounds of the right cavities traced towards the left side. Lacnnec has made the remark, that Avhen a portion of lung is * Lectures on Diseases of the Heart, vol. i. ALTERATIONS OF THE NORMAL SOUNDS. 125 interposed between an enlarged heart and the parietes of the chest, the impulse of the organ, by compressing the lung and expelling the air from it, may give rise to an abnormal sound resembling some of those heard in disease of the heart. " A strong impulse of the heart on a portion of lung may (Dr. Williams* observes) forcibly press the air from it ; and, if there happen to be any partial obstruction or mucus in its tubes, a short sibilant or mucous rhoncus may accompany each beat." " The character of these additions, and the circumstance that they accompany the breathing also, and are more or less diminished by holding the breath, or by posture altering the manner in which the heart beats on the lung, may serve to distinguish them from the true cardiac sounds." Again, it sometimes happens that, in the advanced stage of phthisis, each impulse of the heart is accompanied by a tinkling sound, resembling the tintement metallique. This occurs in cases in which a large tubercular cavity, containing a certain amount of fluid, occupies the greater portion of the upper lobe of the left lung, its lower lobe being at the same time solidified by tubercular deposition, and the action of the heart strong. The sound here may accompany both the impulse of the heart and the respiratory movements. In a case which was in hospital some time since (where this abnormal sound was sufficiently loud to be audible without applying the stethoscope, and at some distance from the patient's bed), it accompanied only the impulse of the heart, not the respiration, during a portion of the time that the patient was under observation. In diseased states of the heart, its valves, or orifices, the sounds are variously modified or altered. Thus, in some instances, their intensity is greater or less than natural ; in others their character or tone is altered ; and in others their duration is aflfected. Some- times the extent of surface over which they are heard is increased or diminished, or they may become more frequent, sometimes less frequent than natural ; or their rhythm may be variously disturbed. Lastly, and in a very numerous class of cases, new sounds are superadded which either accompany the normal sounds or take their place. Alterations in the intensity and tone of the Sounds of the Heart. — The intensity of the heart's sounds varies in different in- * On Diseases of the Chest. 12G EXAMINATION OF THE HEART IN DISEASE. divicluals, and tinder different circumstances : varieties are likewise met with in the character of its sounds, some of which are observed in cases of disease, while others occur independently of any morbid change in the heart. Thus, in persons in whom the parietes of the thorax are loaded with much fat, or where these parts are cedematous — in muscular subjects in whom the chest is largely developed, and whose lungs are ample, the sounds of the heart have less intensity than in individuals in whom the chest is narrow or deformed, in whom its coverings are thin, or in whom the car- tilages of the ribs are ossified. Whenever, likewise, the energy of the heart's action is increased, the sounds as a general rule become loud. Thus, in nervous and hysterical subjects; in pal- pitation from any cause — under the influence of mental emotion, or after exercise — its sounds become more intense than natural. On the other hand, when the energy of the heart's action is lessened from any cause, the intensity of the sounds will be diminished. The intensity or the tone of the sounds of the heart is fre- quently modified by disease ; but this applies more particularly to the first than to the second sound : thus, when the walls of the ventricles are hypertrophied, the first sound becomes duller than natural ; when the cavity of the ventricles is dilated, the first sound becomes clearer than natural ; when the walls of the ventricles are attenuated, combined with dilatation of their cavities, the first sound somewhat resembles the normal second sound, while the second sound is feeble ; when the muscular tissue of the heart is flabby or softened, both sounds become more feeble and obscure, besides undergoing other changes afterwards to be mentioned. In the advanced stage of fever accompanied by considerable debility, the sounds of the heart sometimes become extremely feeble ; during the state of syncope, also, its sounds are indistinct, and the second sound is often inaudible. In dilatation combined with some hypertrophy of the ventricles, both sounds are loud ; when, however, the hypertrophy predominates over the dilatation, and this diseased state has arrived at an extreme degree, both sounds, but particularly the first, become obscure. Clearness of the first sound of the heart is very generally con- sidered to be an indication of dilatation of the ventricles ; this, however, must be taken with some limitation, for this character of ALTKRATIONS OF THE NORMAL SOUNDS. 127 the first sound is observed when neither dilatation or hypertrophy are present ; thus, if the stomach is much distended with flatus the sounds might become clearer and louder than natural. Dr. Clendinning* says he has found the first sound of the heart to be abnormally short, shrill, and clear, approaching the character of the second in numberless instances, in hearts proved post-mortem to be much and even enormously hypertrophied. According to him, " a short, clear, systolic sound indicates not so much any particular anatomical state of the heart, but rather a defective dynamic condition ; that it indicates, in a word, not attenuation of the parietes, but merely debility.'' M. Piorry, likewise, attri- butes little importance to diflerence in the clearness of tone of the sounds, as a sign of hypertrophy, or dilatation of the ventricles. He says, he has "frequently found the parietes thickened when the sound was clear, and vice versa, and the tone frequently varies in the same person if subject to palpitation." He attributes clearness of tone to the amount of blood contained in the cavity, the sound being clearest when the heart is most empty, yet is contracting with energy, as in palpitation. Alterations in the duration of the Sounds of the Heart, — The sounds of the heart are modified or altered in their duration, as well as in their intensity, in some diseased states of the organ. Thus, in hypertrophy of the walls of the ventricles, the first sound is more prolonged than natural ; in dilatation of the ventricles, tlie first sound is shorter than natural. " The transition of a thick muscle from slack to tight can never be so complete and sudden (Dr. Williamsf observes) as that of a thin one ; where there are many fibres, they cloak and muffle each other's vibrations, hence the first sound is dull and prolonged ; a thin ventricle, for the same reason, will give a louder and sharper sound." But if a thick ventricle takes a longer time to contract upon its contents than a thin ventricle, the blood must obviously pass out of the cavity more slowly in the former than in the latter ; and as sound appears to be produced during the entire period that the blood is being transmitted from the ventricle, the first sound must necessarily be prolonged in this diseased state. Alterations in the limits icithin ivhich the Sounds of the Heart are audible — The extent of surface over which the sounds of the * Croonian Lectures, Medical Gazette, vol. xxv. f On Diseases of the Chest. 128 EXAMINATION OF THE HEART IN DISEASE. heart are audible on auscultation, in the healthy and well-formed chest, is not great, being pretty nearly limited to the prsecordial region ; and as the stethoscope is moved from this part, they become more and more indistinct. There is, however, considerable dif- ference in this respect in different subjects ; in individuals whose chest is covered with much fat, and in whom the impulse is slight or hardly perceptible, the sounds are more limited ; while in thin subjects, in children and females, in individuals whose chest is contracted or deformed, and in nervous subjects, the sounds are audible over a wider area. The sounds produced at the right side of the heart are more perceptible upon the right side of the pra3cordial region, while those produced in the left cavities are more distinct at the left side of this region. When the sternum is short the sounds of the heart are usually audible in the epigastric region. In several diseased states of the heart or lungs, the sounds become audible over the greater part of the anterior surface of the chest, and sometimes, in addition, in the lateral and posterior regions upon both sides : while in other morbid states the sounds are very obscure, even in the pra^cordial region. Whenever the intensity of the sounds is increased, or whenever the heart itself is enlarged, its sounds, as might be expected, are audible beyond their normal limits, provided the circulation through the heart and lungs continues free ; hence in dilatation of the ventricles, and in dilatation combined with hypertrophy, the sounds are widely dif- fused. In palpitation from any cause, particularly in anasmic, nervous, and hysterical individuals, the sounds of the heart will be heard over great part of the anterior surface of the chest, particu- larly if the subject is emaciated. The sounds of the heart, however, frequently become audible on auscultation beyond their normal limits, even over the greater portion of the chest, independent of any alteration of the heart. This happens whenever the density of the pulmonary tissue is in- creased, by which its power of conducting sound is augmented : hence, in solidification of the lungs from hepatization, from tuber- cular deposition, or from any other cause., the sounds of the heart will be audible to a considerable distance beyond their natural limits, and this very extension of the heart's sounds becomes a useful sign in these diseases of the lungs. In displacement of the ALTERATIONS OF THE NORMAL SOUNDS. 129 heart the situation at which the sounds are heard will be of course altered ; but, as the seat of the impulse is likewise changed in such cases, it need not be dwelt upon here. A large amount of fluid in the pericardium might prevent the sounds of the heart from reaching the ear ; but there are other signs by which this diseased state may be more readily diagnosed. Alterations in the frequency of the Sounds of the Heart — The sounds of the heart may be more frequent than natural, or they may become slower than natural, or they may be intermittent or irregular. They are more frequent than natural in all inflam- matory affections of the heart or its coverings, as well as in nu- merous diseases of other parts, in states of debility, in cases of anaemia, and generally whenever palpitation arises, whatever be its cause. The heart's sounds much less frequently become slower than natural ; when they do, the cause lies more frequently in disease of the nervous centres than of the heart. Fatty degeneration of the heart appears to be the only diseased state ever accompanied by diminution in the frequency of the heart's action. In hyper- trophy of the ventricles the heart's action is said to be sometimes slower than natural, it is not, however, an ordinary occurrence, because, although the first sound is more prolonged than natural, the interval of repose is usually shortened in proportion. Dr. Willis* observes that, when considerable contraction of the aortic orifice exists, the pulse becomes much slower than natural : " here the ventricle, engaged in squeezing its charge through a hole little or no larger than a goose-quill, perhaps, has been found contracting with no greater frequency than twenty-five, twenty, and even sixteen times in a minute." It is not easy to understand how contraction of the aortic orifice can render the action of the heart slow, although it must, no doubt, considerably diminish the amount of blood transmitted at each systole of the ventricle. Alterations in the Rhythm of the Heart. — In all the cases which we have been hitherto considering, whether the sounds of the heart were increased or diminished in intensity, whether they were more frequent or slower than natural, the rhythm of the organ was regular ; the two sounds succeeded one another, and were followed by an interval of repose, which varied in length according to the dm'ation of the previous systole, and according to * Medical Gazette, vol. i. 1842—43. K 130 EXAMINATION OF THE HEART IN DISEASE. the rapidity with which the sounds succeeded each other. It not unfrequently happens, however, that after a certain number of per- fectly regular beats, a sudden pause or silence occurs ; the heart's action and sounds appear to be arrested or suspended for a moment and then go on regularly, as before, when, after a certain number of beats, the same phenomenon is repeated. This constitutes in- termittence or intermission of the heart's action ; and it may occur after every fourth, eighth, or tenth beat, or at longer or irregular intervals. It is occasionly observed in individuals who are other- wise in perfect health : but it also occurs in diseased states of the valves or orifices of the heart, where either some impediment exists to the direct passage of the blood, or where regurgitation is permitted. In the ordinary theory of the mechanism of the heart's sounds intermission is with difficulty explained ; but if it be admitted that the sounds of the heart have their cause in friction between the blood and the parietes of the orifices of the heart, we can easily understand how, in certain diseased states, so little blood may be expelled from the left ventricle, or it may be propelled with so little force, that there is not friction sufficient to generate a sound, or force enough to produce an impulse, or to communicate a pulse to the radial artery. We know that the circulation may go on when the sounds of the heart are scarcely audible, and when no impulse can be felt in the prsecordial region, as in syncope ; yet, in such cases, the valves must perform their functions, and the muscular walls of the ventricles contract and dilate. It sometimes happens that every systole of the left ventricle is not sufficiently strong, or the amount of blood transmitted by the left ventricle is not sufficiently great to communicate an impulse to the radial artery, and the pulse intermits : but on applying the stethoscope to the prsecordial region, the sounds are still heard, although more feebly, and there is no real intermission of the heart's action. If this should occur at every second ventricular systole the pulse will appear to be preter-naturally slow : and this probably is the true explanation of some of the cases of slow pulse which have been recorded. The error would have been corrected by laying the stethoscope on the prsecordial region. In certain diseased states of the muscular tissue of the heart, of its valves, or orifices, the rhythm of the heart's sounds undergoes ALTERATIONS OF THE NORMAL SOUNDS. 131 Other alterations, the relative duration of the sounds to the intervals of repose is altered, and the latter may be increased or diminished. Alterations in the post-sjstolic silence are not easily recognised, unless the heart's action is slow ; alterations in the post-diastolic silence, or the natural period of repose of the heart, are more fre- quent, and more easily distinguished. - A more frequent alteration, however, consists in irregularity of the rhythm, the double sound of the heart being rapidly repeated twice or thrice, followed by two or three slower repetitions of the same sounds, some of these being strong, others weak, particularly the second sound which is sometimes imperceptible. This is observed in cases where the circulation through the heart or lungs, or through both, is impeded, and occurs in the advanced stage of several diseases of the heart, as in considerable contraction of the mitral orifice, in softening of the muscular tissue of the ventricles, in pericarditis with copious liquid effusion ; or where fibrinous concretions are developed in the cavities of the heart previous to death. It is of course a much more unfavourable symptom than simple intermission. Alterations in the number of the Hearfs Sounds. — Another alteration in the rhythm of the heart's sounds, occasionally observed in cases of disease, is where, instead of the ordinary double sound, we have a triple sound, each systolic sound being repeated twice for one diastolic, or each diastolic sound being repeated more than once for one systolic sound. In other cases both the systolic and diastolic sounds are doubled, and four sounds are heard for one impulse of the heart. Lastly, it sometimes happens that only one sound is audible, in place of the ordinary double sound, and it is then always the second sound which is absent. When we hear a triple sound in place of the ordinary double sound of the heart, it is more frequently owing to a reduplication of the systolic than of the diastolic sound. This reduplication of the first sound is compared by M. Bouillaud to the tattoo of the drum : it also resembles what is called in Ireland "the Kentish fire." When the diastolic sound is doubled, the triple sound closely re- sembles the footsteps of a cantering horse heard at some distance, to which Dr. Williams compared it. This reduplication of the heart's sounds is seldom heard except in cases of disease, and, in many instances, some abnormal sound is audible at the same time. Sometimes this phenomenon is only 132 EXAMINATION OF THE HEART IN DISEASE. observed when the heart's action is quickened, and it subsides as the action of the organ becomes tranquil. M. Bouillaud is of opinion that the reduplication of the first sound is caused by the ventricle contracting twice in succession, in consequence of its in- ability to expel its contents ; and that the reduplication of the second sound may be explained in the same way. Others have accounted for it by supposing a want of synchronism between the movements of the right and left ventricles. From the manner in which the muscular fibres of the two ventricles are arranged, it is difficult to understand how this could occur in the healthy heart ; but if the right ventricle is much hypertrophied, and dilated, while the left remains of the normal size, such an occurrence is possible. In two cases recently under my care, where the triple sound was very well marked, (the reduplication being in the first sound), and where the opportunity was afibrded for a post-mortem ex- amination, I found the right ventricle much hypertrophied and dilated ; in each forming the apex of the heart ; the left ventricle was normal in one, and slightly dilated in the other, but the valves at the left side of the heart were sound, and no murmur had been audible in either case. An additional sound is sometimes produced by the apex of the heart impinging against the inferior edge of the fifth left rib during the ventricular systole, which is not to be confounded with the phenomenon just described. ABNORMAL SOUNDS DEVELOPED DURING THE HEARTS ACTION. The sounds which either replace or accompany the normal sounds of the heart, and which are new, morbid, or abnormal sounds, were first named murmurs by Dr. Forbes, and this term has been very generally adopted since. They present difierent characters in difierent cases of disease, being sometimes blowing, sometimes resembHng rather the sounds of sawing, fifing, grating, whistling, &c. : and this circumstance has been deemed by some writers of sufficient importance to form the ground of their classi- fication, and they have been divided into the " sounds of blowing," and " sounds of friction ;" but, as in every instance, they are the result o^ friction, generally between a liquid and a solid, sometimes between two solids, they would be more correctly classified ac- PERICARDIAL FRICTION-SOUNDS. 133 cording to tlieir seat. Thus, sometimes tliey have their seat exterior to the heart, and between the opposed serous surfaces of the pericardium : these are the pericardial friction-sounds, or the peripheral or exocardial murmvirs. Sometimes they have their seat within the heart, and at the orifices of the ventricles : these are the endocardial, or valvular murmurs. Sometimes, again, they have their seat in the large arteries ; at others, in certain veins : the former are the arterial, the latter the venous murmurs. These abnormal sounds will be considered here in the follow- ing order : 1. The pericardial or exocardial murmurs, or the peripheral friction-sounds ; which accompany the movements of the heart, but do not interfere with its intrinsic sounds. 2. The endocardial or valvular murmurs, subdivided into the systolic and diastolic, which either take the place of the normal sounds of the heart, or prevent them from being heard. 3. The arterial murmurs. 4. The venous murmurs. 1 shall now describe these sounds ; to be appreciated, however, they must be heard ; no verbal description can supply its place. PERICARDIAL FRICTION-SOUNDS. The abnormal sounds which have their seat between the op- posed serous surfaces of the pericardium are termed attrition murmurs, or friction-sounds, from their character ; and pericardial, exocardial, or peripheral murmurs, from their seat. Although all abnormal sounds ai'e the result of friction, the exocardial are best entitled to the name, because the friction here takes place between two solids ; in the others, one of the agents in the production of the sound is a liquid. In a state of health, the opposed serous surfaces of the peri- cardium being exceedingly smooth, and constantly moist, glide over one another, during the motions of the heart, without pro- ducing any sound, or, at least, any which can be detected by the ear applied to the parietes of the chest. When, however, as the result of inflammation, lymph is effused upon this membrane, and its opposed surfaces become rough, unequal, or irregular, friction to a greater or less degree takes place during the movements of the heart ; and this friction developes sound, which becomes 134 EXAMINATION OF THE HEART IN DISEASE. audible when the stethoscope is laid upon the parietes, and is fre- quently sufficiently strong to communicate a distinct vibratory sensation to the hand, as first pointed out by Dr. Stokes ; and ac- cording as the action of the heart is violent or feeble, and as *' the lymph effused is small in quantity, partially deposited, and forms a thin, smooth layer, or is copious, hard, and irregular, the sounds will vary from the slightest degree of rubbing, to a loud, harsh, grating, or creaking sound." The attention of the profession was first called to the friction- sounds of pericarditis by Dr. Stokes. M. Collin,t it is true, had described the bruit de cuir neuf, one of the rarest of these sounds, and BroussaisI had noticed a friction-sound in pericarditis similar to that of two dry bodies, like parchment, rubbing against one another ; but their remarks attracted no attention : it was reserved for Dr. Stokes to point out the distinctive auscultatory signs of the two forms of pericarditis ; to determine those which belong to the variety of the disease in which the opposed surfaces of the peri- cardium are coated with lymph ; and to demonstrate that this form of pericarditis, which heretofore had been supposed to yield no stethoscopic signs, was really the one in which auscultation is of the greatest assistance to the diagnosis. The friction-sounds of pericarditis have received various names. They may all, however, be included under the following heads, originally laid down by Dr. Stokes : 1. " ^ slight friction-sound, perceptible only at the very com- mencement and at the termination of each diastole and systole of the heart." 2. " ^ rasphig-sound^ very similar indeed to that produced in the worst cases of ossification of the valves. In others the sound is similar to the frottement of pleurisy, only modified by the action of the heart." 3. " The sound resembling the creaking ofneio leather." The slight friction-sound, the " bruit de frolement" of the French, resembles the sound produced by rubbing the hands together, or the rustling noise produced by crumpling the paper of which bank-notes are made (to which M. Bouillaud compares it), * Dublin Journal of Med. Science, September, 1833. t Las Diverses Methodes d'Exploration de la Poitrine. Paris 1824. X Commentaires des Propositions de Pathologic, tome i. 1829. PERICARDIAL FRICTION-SOUNDS. 135 or the rustling of silk ; or, when stronger, the crackling of parch- ment. According to Dr. Hope, this sound is produced by the presence of soft wet lymph upon the opposed surfaces of the peri- cardium. It appears probable, that when this sound is alone heard, and where all through it preserves the same character, it is due to the lymph being deposited merely upon one surface of the peri- cardium. The rasping sound. — The bruit de rdpement or hruit de frot- tement of the French, has, as its name denotes, a harsh rasping or grating character ; it often resembles accurately the rasping or the sawing of wood. The sound which it appeared to me most closely to resemble on several occasions was that which would be produced by scratching with the nail the surface of dry bone. It constitutes the to-and-fro rubbing sound of Dr. Watson. Dr. Hope refers this sound to the presence of firm and rugged lymph, the sound being loud in proportion as the lymph is rough, and the action of the heart strong. The creaking sound of neto leather^ the hruit de cuir neuf is one of the rarest of these sounds ; it resembles, accurately, the creaking of a new saddle, but is not so loud ; it may be imitated, Dr. Hope observes, " by rubbing together the fingers made sticky by resin." I had lately a case in hospital where a sound very similar to this was developed in the bronchial tubes, owing to their obstruction by tough mucus : here, however, it of course accom- panied only the respiratory movements. This creaking sound was supposed by Dr. Hope to depend upon the adhesive nature of the lymph, and to be an indication that adhesions were about to take place. More recent observations have, however, shown that this is not necessarily the case. Dr. Coj)land* refers it to thicken- ing or condensation of the sub-serous and serous tissues of the pericardium, especially of that portion reflected over the heart ; and the formation of a dense and elastic false membrane. Another sound has been described by Dr. Hope under the name of the "continuous rumbling murmur," which he refers to the presence of a small quantity of fluid in the sac of the peri- cardium, the opposed surfaces of which are also coated with lymph. He supposed that the agitation or " churning of the fluid during the motions of the heart produces the sound." It is more rare * Diet, of Pract. Medicine, vol. ii. 136 EXAMINATION OF THE HEART IN DISEASE. than any of the other pericardial murmurs, with the exception perhaps of the bruit de cuir neuf. Finally, Dr. Walshe has re- cently described, in addition a " clicking murmur," and a "murmur produced by bending of layers of exudation matter." Conclusions respecting the Pericardial friction-sounds. When I come to speak of pericarditis, I shall have occasion again to recur to these sounds. It will be sufficient here to observe — 1. That they are almost limited to cases of inflammation of the pericardium ; that they are pathognomonic of one form, and con- stitute the most valuable diagnostic signs of it. 2. That they have more or less, a friction or attrition character. 3. That they are generally double, and are sometimes louder during the diastole than the systole of the ventricles. 4. That they appear to be superficial and near, and are seldom audible beyond the limits of the praecordial region. 5. That they do not, like the murmurs next to be described, replace the ordinary sounds of the heart, but are independent of them. 6. That their duration is usually short ; frequently ceasing en- tirely after ha\ang been heard for a few days, and not unfrequently changing their character or seat within the period that they are audible. 7. That they are frequently accompanied by a peculiar vi- bratory thrill sensible to the hand laid upon the parietes. 8. That a bruit de soufflet at one of the orifices of the left side of the heart (the result of endocarditis), not unfrequently coincides with these sounds. ENDOCARDIAL OR VALVULAR MURMURS. The abnormal sounds which have their seat at the orifices of the ventricles, and which replace or accompany the normal sounds of tlie heart, constitute the most valuable signs of disease of the valves or orifices of the left side of the organ. They present several varieties — being sometimes blowing, when they constitute the varieties of bruit de soufflet ; sometimes rough and harsh, re- sembling the familiar sounds of sawing, rasping, or filing ; and at other times having a whistling or musical character, constituting varieties of the musical murmur. BRUIT DE SOUFFLET. 137 Bruit de soufflet or bellows-murmur, (as the name denotes,) has a blowing character, and is by many degrees the most fre- quent abnormal sound heard in diseased states of the valves or orifices of the heart. It was discovered and named so, by Laen- nec, from its similarity to this well-known sound, to which it often bears a most ridiculous resemblance. Bruit de soufflet does not always however, present the same character : sometimes it is perfectly smooth and soft ; at other times it is loud and rough ; sometimes it is a mere whiff : at others it is prolonged and length- ened out. It may accompany or replace either the first or the second sound of the heart, or it may pass into a sawing, rasping, or musical murmur. In the vast majority of cases of disease, it is limited to the left side of the heart. Circumstances under lohich Bruit de Soufflet is heard. — Bruit de soufilet is heard in various and different lesions of the valves and orifices of the heart ; it is not, however, limited to diseased states of this organ, but becomes audible under a variety of other circumstances. Thus, it is heard when there is any obstacle to the free passage of the blood through the orifices of the left side of the heart, or when the valves imperfectly perform their func- tions, and permit regurgitation. It is heard in aneurism of the left ventricle and in congenital malformations of the heart, where a communication exists between the ventricles. It is heard in cases where the lining membrane of the arch of the aorta is dis- eased, and in aneurism of the large arteries. It is heard in aneu- rismal varix, where a communication exists between an artery and a vein ; in varicose aneurism where a small sac exists between them, and in the pulsating form of aneurism by anastomosis. It is frequently heard in cases where no disease of any kind exists in the heart or arterial system, but where the quality of the blood is altered; where this fluid has become more watery and less viscid than natural. Finally, it can be produced at any time in the heart and arteries by suddenly abstracting a large quantity of blood, as first pointed out by Dr. Marshall Hall ; or in a large artery by making pressure upon it so as to diminish its calibre. Bruit de soufilet will be heard when a tumor of any kind comes to press upon the aorta or its branches, or upon the pulmonary artery ; or in malformation or deformity of the chest, from disease of its bony parietes, by which the heart's movements are impeded 138 EXAMINATION OF THE HEART IN DISEASE. or the large vessels are compressed. Bruit de soufflet is said to be sometimes heard for the first time, a short period previous to death, in pulmonary or cardiac disease : M. Bouillaud refers it then to the formation of fibrinous concretions in the cavities of the heart, which interfere with the action of the valves, or ob- struct the orifices. It is temporarily heard in violent palpitation in hysterical subjects, or in attacks of palpitation in cases where the left ventricle is hypertrophied, and its cavity dilated : here it disappears as the palpitation subsides. Bruit de soufflet, in a very marked form, is likewise heard from the fourth month to the end of pregnancy : here its site is usually the iliac fossa, some- times on both sides, more frequently only on one side. Dr. Graves* has noticed the remarkable fact, that a bruit de soufflet is sometimes audible, in the second stage of pneumonia, over the affected lung, which disappears as the symptoms of the inflammation subside : it is not perceptible in the subclavian or carotid arteries of the same side, and probably, when present, depends upon presure on the branches of the pulmonary artery. Dr. Lathamt has called attention to the circumstance that a gentle bruit de soufflet, which coincides with the ventricular sys- tole, is heard occasionally in phthisis : it is not perceived in the praecordial region, but in a circumscribed space above it on the left side. M. ZehetmayerJ has confirmed the correctness of Dr. Latham's observation, and would appear to have noticed this murmur previous to the publication of Dr. Latham's work. He says, " I have repeatedly heard, in phthisical persons, in the second intercostal space, a decided bellows-murmur, instead of the first sound of the pulmonary artery ; and in a place where there was no doubt that tubercular infiltration was present. No altera- tion in the vessel could be detected on post-mortem examination." Dr. Latham supposes that this murmur may have its cause in the pressm-e exercised by the diseased lung upon the pulmonary artery, and its first branches. In both the latter cases, the con- densed lung, having become a better conductor of sound, conveys a murmur to the ear which would probably be inaudible if the lungs were healthy. M. Gendrin§ has called attention to the circumstance that, in the cold stage of intermittent fever, a bruit * Clinical Lectures, vol. ii. t Lectures on Diseases of the Heart, vol. i. I Die Herzkrankheiten, 1844. § Le9ons sur les Maladies du Coeur, tome i. BRUIT DE SOUFFLET. 139 de soufflet, analogous to that heard in cases of chlorosis, is audible on auscultation of the heart. As individuals who have been the subject of ague for any length of time are, however, in general more or less anaemic, the murmur is probably due to this cause. Conditions under ichich Bruit de Soufflet is developed. — Whenever bruit de soufflet is heard in the heart, it arises either from contraction or some other diseased state of the valves or orifices of the heart, which impedes the free passage of the blood ; from a condition of the valves which prevents them closing the orifice, and permits regurgitation ; from the blood being impelled with increased force and velocity through the aortic orifice, or through an abnormal orifice, as in aneurism of the left ventricle, and con- genital malformations of the heart ; from some alteration in the quality of the blood itself, or in its quantity ; firora the formation of fibrinous or other concretions in the cavities of the heart, which interrupt the play of the valves, or impede the orifices ; or where morbid growths are developed in the cavity of the chest, which compress or displace the heart ; or where the bony walls of the thorax are deformed, and this cavity is much narrowed. Whenever bruit de soufflet is audible in the arteries, it arises either from roughness of the lining membrane of the vessel ; or from the calibre of the artery being diminished, owing to pres- sure upon the part ; or from an altered condition of the blood ; or from an aneurismal sac springing from a large artery ; or where an abnormal communication exists between a large artery and a vein ; or where an aneurismal sac is seated between an artery and a vein, through which the blood passes from the one to the other. Bruit de soufflet is therefore a symptom in endocarditis, where the aortic or mitral valves are rigid, thickened, or indurated ; or where vegitations form upon them, or upon the orifices ; as well as in the chronic forms of disease of the valves or orifices, ac- companied by contraction of the orifices, by ossific or other deposit upon the valves, or adhesion of the valves to one another or to the parietes. It will likewise be heard where rupture of a valve or of a tendinous cord takes place, or in cases of congenital mal- formation of the valves, as where a cribriform condition of their curtains exists. Bruit de soufflet is likewise a symptom in dila- tation of the orifices of the left side of the heart without any disease of the valves, or where they are prevented by any other cause 140 EXAMINATION OF THE HEART IN DISEASE. from perfectly fulfilling tlieir functions. It is a symptom in aneu- rism of the left ventricle ; in congenital malformations of the heart ; in cases of morbid growths in the cavity of the thorax ; in aneurism of all the large arteries; in aneurism al varix, and varicose aneu- rism ; in disease of the lining membrane of the arch of the aorta ; and, in anaemic states of the system. Mechanism of production of Bruit de soufflet Laennec attri- buted bruit de soufflet to spasm, or to a vibratory action of the heart ; Bertin, to the increased friction produced by the passage of the blood through a contracted orifice. Other physiologists have endeavoured to explain it by referring it to increased velocity of the cii'culation, or to very energetic action of the heart, or to "a certain resistance given to the blood moving with a certain force." Dr. Leared* regards bruit de soufflet as " the result of a diminution mutually exerted in the pressure of the particles of a body of fluid in motion, the consequence of which, is, the main current becomes split into numerous smaller ones, the particles in place of a progressive motion, in which an equable relation to each other was preserved, assume new and irregular movements." Others have referred it to modifications or alterations in the tissue or structure of the parietes of the heart, or to morbid conditions of the blood itself M. Bouillaudf is of opinion that bruit de soufflet may be produced under three conditions — viz. increased action of the heart ; narrowing of any portion of the canal through which the blood passes ; or roughness of the surface over which the blood flows. Dr. Corrigan,:}: who has written at length upon this subject, and who made several experiments with the object of determining the question, arrived at the following conclusions respecting the conditions necessary for the production of this sound. " 1. A current-like motion of the blood (instead of its natural equable movement), tending to produce corresponding vibrations in the sides of the cavities or arteries through which it is moving ;" and "2. A diminished tension of the parietes of the arteries or cavities themselves, in consequence of which their parietes are easily thrown into vibrations by the irregular current of the con- tained fluid ; which vibrations cause, on the sense of touch, fre- missement — and, on the sense of hearing, bruit de sioufflet." * Dublin Quarterly Journal, May, 1852. f Archives Gen. de Medecine, tome xi. + Dublin Journal of Medicinft, vols. x. and xfv. BRUIT DE SOUFFLET. 141 In every instance in which bruit de soiifflet is audible, it is clear that some physical agent, capable of producing it, must be in operation : now the only physical agent that is invariably in ope- ration, and under every variety of circumstances where bruit de soufflet is heard, is increased friction between the blood and the parts along or through which it passes ; which appears to be amply sufficient, not only to develope a murmur, but to convert the normal sounds of the heart into one. Thus : 1. When the orifice of the aorta is contracted, or its valves are diseased, so as to impede the direct passage of the blood, there must necessarily be increase of friction ; and the normal first sound of the heart will be converted into a murmur. 2. When the mitral valve is diseased, and permits a refluent current of blood into the left auricle at each ventricular systole, a murmur will be developed, which, from its louder tone, will ob- scure or render inaudible the first sound of the heart. 3. When the semilunar valves of the aorta imperfectly close the orifice, the blood must regurgitate from the aorta into the left ventricle at each ventricular diastole ; and that this occurs with sufficient force to generate a murmur, which obscures or renders inaudible the normal second sound of the heart, is well known. 4. When the left auriculo-ventricular orifice becomes dilated, and the valve cannot, from this cause, fulfil its function perfectly, regurgitation of the blood occurs at each ventricular systole, and a bruit de soufflet is developed, which is usually sufficiently strong to obscure the normal first sound of the heart. 5. When the blood is propelled with greatly augmented force, and with increased velocity, through the aortic orifice, the amount of friction between the blood and the parietes of this orifice must be increased ; and if it is sufficiently strong to generate a murmur, this will have the character of bruit de soufflet, and will take the place of the normal first sound of the heart. 6. When the lining membrane of the ascending portion of the arch of the aorta loses its natural smoothness and polish, the friction between the blood and the part along which it passes must be in- creased ; and, if the heart's action is strong, a murmur will be de- veloped, which will be synchronous with the first sound of the heart, and will often be audible in the large vessels which come off from the arch of the aorta. 142 EXAMINATION OF THE HEART IN DISEASE. 7. When the viscidity of the blood is diminished, and its watery parts are increased, a greater amount of friction will take place between this fluid and the orifice of the aorta, in its passage out of the ventricle, as well as in the large arteries, which is usually quite sufficient to convert the normal first sound of the heart into a murmur. 8. When the blood is propelled into an abnormal cavity, or through a preternatural orifice, and the action of the left ventricle is strong, the friction will be sufficient to generate a murmur which will obscure the first sound of the heart. 9. When the large arteries in the cavity of the thorax are com- pressed by the growth of a tumor within, or by deformity of the bony cavities from disease without, the diminution of their calibre is often sufficient to generate a murmur, which will have the cha- racter of bruit de soufflet. 10. When fibrinous concretions form in the cavities of the heart and obstruct the orifices, or impede the movements of the valves, if the action of the heart is strong, sufficient friction may be produced to develop a murmur ; but as this scarcely ever occurs, except during the last few hours or days of life, the current of blood is generally too feeble to develop a murmur. Lastly, the bruit de soufflet, heard after the fourth month of pregnancy, when the uterus has risen out of the pelvis, and which is generally, but incorrectly, termed the placental souffle, has its cause partly in an altered condition of the blood, but principally in the pressure exercised by the enlarged uterus upon the iliac arteries, or their branches ; indeed Professor Von Kiwisch places its seat, exclusively, in the epigastric arteries. Thus it always accompanies the ventricular systole, it is audible usually only in one iliac fossa : and an exactly similar murmur has been heard by Dr. Montgomery* in cases where the uterus itself was enlarged from disease, or where an abdominal tumor compressed the aorta. In addition, M. Bouillaud has found that, by changing the position of the patient, the site of the murmur is altered ; and Dr. Cowant observes that the bruit de soufflet, in these cases, " can be detected in the femoral arteries immediately below the arch," and that " the sound may, by change of position, be transferred from one femoral artery to the other, always corresponding with the side of the uterine murmur." * Cyclopaed. of Pract. Med., art. Pregnancy, f Medical Gazettee, vol. xvii. 1836. BRUIT DE SOUFFLET. 143 In the majority of the foregoing examples the bruit cle soufflet is heard at the period of the ventricular systole, and replaces or accompanies the first sound of the heart; the force with which the blood is propelled by the left ventricle being much greater than that with which it enters it, the friction between the blood and the parts along or through which it passes must be much more con- siderable in the former than the latter. In the former it is generally sufficient to generate a murmur, in the latter it only occasionally does so : and, when a murmur is developed, it has a different character. For instance, when the mitral valve or orifice is diseased, so as to permit regurgitation, a bruit de soufilet will be heard at the period of the ventricular systole, which quite obscures the normal fixst sound of the heart ; when the aortic valves permit regurgitation, a bruit de soufflet is audible at the period of the ven- tricular diastole, which likewise obscures the normal second sound of the heart. But the two murmurs have a different character, that which accompanies mitral regurgitation is usually loud, strong and blowing; that which accompanies aortic regurgitation is usually soft and whispering, because the force with which the blood is propelled from the ventricle is much greater than that with which it enters it. Two or more of the conditions described above are not un- frequently combined in the same subject ; and we may have a murmur taking the place of, or obscuring both sounds of the heart ; or the bruit de soufflet may pass into a sawing, rasping, or musical murmur; or, finally, the valvular disease may be complicated with an anemic state of the system, by which the difficulty of the diagnosis is sometimes considerably increased. Bruit de Soufflet at the right side of the heart. — The foregoing remarks have reference, more particularly, to bruit de soufflet at the left side of the heart : in fact, this abnormal sound is very rare at the right side, because the force with which the blood enters or is expelled from the right ventricle is generally too feeble to generate a murmur; while valvular disease at this side of the heart is uncommon. Dr. Clendinning* has shown, from statistics in 100 cases, that valvular disease is sixteen times more frequent at the left than at the right side of the heart. When we consider, too, that in cases of anaimia the murmur is limited to the left side, * Medical Gazette. 144 EXAMINATION OF THE HEART IN DISEASE. and that murmurs from regurgitation are scarcely ever produced at the right side of the heart, we can understand why bruit de soufflet should be so rare at this side. For instance mitral regur- gitation is one of the most frequent causes of bruit de souflflet at the left side of the heart : on the other hand, tricuspid regurgitation is even more frequent ; but it is not accompanied by any morbid sound, and is usually recognised by another sign — viz. jugular pulsation. Again, aortic regurgitation is a frequent cause of a murmur at the left side of the heart, but a very uncommon cause of a murmur at the pulmonary orifice. " I believe (Dr. Hope* observes) diastolic murmur of the pulmonic valves to be exceedingly rare from disease of the valves themselves, as I have never met with a case, or been able to find one recorded." " From a rude numerical calculation (he adds) deduced from the cases that I have seen, I should think that there would be at least thirty chances to one against a murmur connected with the semilunar valves being seated in the pulmonic set." Although the second sound at the right side of the heart is scarcely every converted into a murmur, owing to regurgitation through the sigmoid valves of the pulmonary artery, this sound is sometimes altered, augmented, or rendered sharper, owing to hypertrophy with dilatation of the right ventricle, consequent upon disease of the mitral valve, as first pointed out by Skoda and Zehetmayer.f According to Skoda, when the left auriculo-ven- tricular valve permits regurgitation, the second sound at the pul- monary orifice becomes more intense, or sharper ; which he ex- plains by the impeded circulation through the lungs reacting upon the right side of the heart, in consequence of which the blood in the distended pulmonary artery reacts with unusual force vipon the sigmoid valves of this vessel. He is even of opinion that, from this augmentation of the second sound at the pulmonary orifice, we might diagnose disease of the mitral valve or orifice previous to any abnormal sound being heard at it. Zehetmayer considers that this phenomenon is never absent in cases of mitral regurgitation, and that the diagnosis of the latter cannot be positively made unless it is likewise perceived. A murmur at the pulmonary orifice, or in the pulmonary artery, accompanying the ventricular systole and the first sound, * Treatise on Diseases of the Heart, 4th edit, f Die Herzkrankheiten, I8J4. BRUIT DE SOUFFLET. 145 is less rare than any murmur at the right side of the heart. It seldom, however, depends upon disease of the sigmoid valves ; in general it arises from the presence of a tumor, or from a diseased lung compressing the pulmonary artery. Dr. Hope relates a case in which an aneurism at the origin of the aorta compressed the pulmonary orifice, and contributed to produce a systolic murmur ; and another, where extensive ossification of the pulmonary artery, gave rise likewise to one. Dr. Elliotson met with two cases where portions of cartilage in the pericardium pressed upon and contracted the pulmonary artery so as to produce a murmur. The value of bruit de soufilet as a sign of disease of the valves or orifices of the heart, depends, 1. Upon the period of the heart's action at which it occurs. 2. Upon the situation at which it is best marked. 3. Upon its character or tone. 4. Upon its being constantly present or not. In organic disease of the valves and orifices of the heart, bruit de soufilet is in a great measure limited to the left side of the organ and has its seat either at the aortic or mitral orifice. When it re- places the first sound of the heart, it depends, in almost all cases, either upon obstructive disease of the aortic orifice, or regurgitant disease of the mitral orifice. When it occurs at the period of the ventricular diastole, and of the second sound of the heart, it almost always has its cause in a state of the aortic valves permitting regur- gitation. When bruit de soufflet accompanies both the systole and the diastole of the ventricles, it may have its cause either in obstructive disease of the aortic orifice, combined with a state of its valves permitting regurgitation ; or in the mitral and aortic valves, both permitting regurgitation. The first sound of the heart is not unfrequently replaced by bruit de soufilet when no disease of the valves or orifices exists ; but a murmur is never heard at the period of the second sound of the heart, unless in cases of disease. A murmur at the right side of the heart is, as has already been observed, extremely rare ; and when it is heard, it will be found to depend more frequently upon disease of other parts, than of the valves or orifices of the right ventricle. 146 EXAMINATION OF THE HEART IN DISEASE. SAWING, FILING, AND GRATING VALVULAR MURMURS, The valvular or endocardial murmurs next to be considered have a harsh, rough, or grating character : tliey were first described by Laennec and have received various names : as the " sawing murmur" (bruit de scie) ; the " rasping or grating murmur" (bruit de rape) ; and the " filing mvirmur" (bruit de lime) ; which more or less re- semble these familiar sounds. Although the rough valvular mur- murs are distinguished by different names, they are by no means to be regarded as characteristic of distinct forms of disease ; in fact, they are nothing more than degrees or varieties of rough sounds, having the same origin as bruit de soufflet, although less common than it, and more decidedly pathognomonic of organic disease of the valves or orifices of the heart. It is a common opinion, that the harsh, grating, valvular mur- murs are the result of cartilaginous or calcareous degeneration of the valve at which they have their seat, and that they always in- dicate a more advanced state of disease of the valves, or a greater amount of contraction of the orifice than bruit de soufflet. This was the opinion of Laennec, and this appears to be the view taken by M. Bouillaud ; it is far, however, from being correct ; these sounds are heard in cases where the valves have undergone neither calcareous or cartilaginous degeneration ; and a very advanced state of disease of a valve is often indicated simply by bruit de soufflet, while in a still more advanced stage it may disappear, and no murmur of any kind be audible. This is sometimes observed at the mitral orifice, when the contraction becomes so extreme as not to permit a sufficient current of refluent blood through it to de- velop a murmur. Although these harsh grating sounds do not necessarily indicate either calcareous or cartilaginous degeneration of the valves, and are often not heard in cases where valvular disease is much advanced ; yet, when they are well marked, we may conclude that the degree of friction between the blood and the parietes of the orifice at which they are developed, is greater than where simply bruit de soufflet is heard In the majority of cases this is owing to hypertrophy, or hypertrophy with some dilatation of the ventricle, complicating the valvular disease, by which the contractile power of the ventricle is increased, and the blood is transmitted MUSICAL VALVULAR MURBIUR. 147 with augmented force through the diseased orifice. Hence the rough valvular murmurs are loudest at the period of the ventri- cular systole and first sound of the heart, and are not heard in inorganic affections of the organ, in which bruit de soufflet is so common. In almost every instance, too, they are preceded by bruit de soufilet ; the one insensibly passes into the other ; and they are to be regarded as merely more intense degrees of the latter. Conclusions from the presence of a Rough Valvular Murmur. 1. The harsh, grating valvular murmurs are to be regarded as nothing more than bruit de soufilet exaggerated. 2. They are limited to the left side of the heart, and are heard only in cases of organic disease of the valves or orifices. 3. They are often audible only at the period of the ventricular systole, and they then generally indicate obstructive disease of the aortic orifice. 4. When heard at the period of the second sound, they are always accompanied by a rough systolic murmur ; and they have their cause, then, in a combination of disease of the coats of the aorta, with regurgitant disease of the semilunar valves. 5. In almost every instance, hypertrophy with dilatation of the left ventricle, accompanies the valvular disease. 6. They do not necessarily indicate osseous or calcareous de- generation of the valves. MUSICAL VALVULAR MURMUR. The musical mvirmur of the heart — the "bruit de soufflet musical ou sibilant" of the French writers — is a very remarkable and rather rare sound : it resembles sometimes, as the name de- notes a whistle : sometimes the notes of a wind instrument, or the cooing of a dove. It may consist of only a single note, or of two or three ; seldom more : it is sometimes so loud as to be audible without the stethoscope, and at some distance from the patient ; and it may accompany either the systole or diastole of the ven- tricle. We are indebted to Dr. Elliotson* for the earliest description * Lumleyan Lectures. 148 EXAMINATION OF THE HEART IN DISEASE. of this murmur : he first called attention to it as a sign of valvular disease, and described the particular lesion of the valve in which he had met with it. Laennec says he never heard a musical mur- mur in the heart, but he has described a musical murmur of the arteries : the latter, however, we know now has its seat in the veins. The musical valvular murmur is to be regarded as nothing more than a variety of bruit de soufflet ; which precedes it, and usually takes its place when it intermits or subsides, or when the exciting cause has been removed. In fact, as both Dr. Hope and M. Bouillaud remark, " there is no greater difference between the two sounds than there is between blowing with the lips, and whistling." Thus, in a case which was in hospital some time since, a loud musical murmur was heard upon the day of the patient's admission, after the exertion of walking to the hospital ; on the day following, when the circulation had become tranquil, this murmur had disappeared, and was replaced by bruit de soufflet. On a post-mortem examination, the valvular lesion was found to consist in a cribriform condition of the curtains of the mitral valve, by which regurgitation had been permitted. In a case of acute endocarditis, which was in hospital a short time since, bruit de soufflet was first heard ; and when the patient had been submitted to treatment for a short time, this was replaced by a musical murmur, which continued to be audible as long as the patient re- mained under observation. Like the sawing, and other rough valvular murmurs, the musical murmur is almost always a sign of organic lesion of one of the valves or orifices of the left side of the heart ; and, so far as I have had the opportunity of observing, it is limited to the regur- gitant lesions of the aortic and mitral valves. This murmur is frequently accompanied by fremissement cataire, and may be audible in any case in which the semilunar or the mitral valves imperfectly fulfil their functions, provided the aperture through which regurgitation occurs is small, and that the heart acts vigorously. As regurgitation cannot occur in a healthy condition of the valves, and, as the musical murmur is in a great nieasure limited to cases of regurgitation, it is a valuable physical sign of valvular disease, when present, and it may be regarded as almost pathog- ARTERIAL MURMURS. 149 nomonic, if combined with other symptoms of organic disease of the heart. The division of abnormal sounds, which we have next to con- sider, have their seat in the arteries, or in the veins, or in both. They all, with one exception, come under the head " inorganic murmurs." They are, 1. The arterial bruit de soufflet. 2. The rough, grating, arterial murmur. 3. The continuous venous murmur, or " bruit de diable." 4. The musical venous murmur. ARTERIAL MURMURS. The abnormal sounds which have their seat in the arteries may, like those developed at the orifices of the heart, have either a blowing or a rough grating character. It is only in the large arteries that they are heard ; and in investigating them it is always necessary to employ the stethoscope, indeed, M. Vernois has pro- posed a modification of this instrument for the sole purpose of examining the arteries, which consists in "excavating the two opposite points of its circumference for the reception of the vessel subjected to examination," by which the pressure upon the artery, caused by the stethoscopes ordinarily employed will be obviated. This appears to be an unnecessary refinement, as the instruments in common use are quite sufficient for every purpose. Arterial Bruit de Soujflef The abnormal sound heard most frequently in the arteries is bruit de souffiet. In a state of health, the blood, in its passage through the large arteries, causes such slight friction that very little sound is produced : this is short, single, and repeated at equal intervals, from sixty to eighty times in a minute, and is synchronous with the ventricular systole and with the pulse. If slight pressure be made upon the vessel with the finger, or with the stethoscope, this sound increases in intensity ; and, if the pressure be increased, it is converted into a murmur having the character of bruit de soufl3et. Increase of friction between the blood and the lining membrane of a healthy vessel, produced by merely diminishing the channel through which the current flows, is therefore sufficient to develop a murmur in a large artery. Again, one of the most important properties of the blood is its 150 EXAMINATION OF THE HEART IN DISEASE. viscidity. In some morbid conditions of the system this property is impaired ; the blood becomes impoverished, attenuated, and watery, the red globules diminish, serum superabounds, and, as a natural consequence, the viscidity of this fluid is less than natural. In other cases, the actual amount of blood in the system is di- minished, as after profuse haemorrhage, or when venassection has been carried to an extreme degree. In both cases, the amount of friction between the blood and the lining membrane of the arteries must necessarily be greater than natural ; and this increased friction is capable of developing a murmur analogous to that pro- duced by pressure upon a healthy vessel. In order that the murmur be well marked, it is necessary that a certain degree of velocity of the current above the natural standard should occur in addition. The arteries in which bruit de soufflet is most commonly heard are the aorta, the carotids and svibclavians, the iliac and femoral arteries. It may be audible in any of these vessels, when the blood is propelled with increased force and velocity through them ; when the calibre of the artery is diminished by pressure from without ; when the coats of the arteries have lost their natural and healthy state of tension; or when the blood is more or less attenuated, owing to its watery parts being increased, and the red globules di- minished, the result either of profuse haemorrhage, or of a chlorotic state of the system. The latter are frequently accompanied by the abnormal sounds (presently to be described) which have their seat in the veins, and the arterial bruit de soufflet is sometimes ac- companied by a murmur at the aortic orifice, depending upon the same cause. The bruit de soufflet, which has its seat in the large arteries, has been mistaken for a valvular murmur, particularly when heard over the arch of the aorta, or in the carotid and subclavian arteries. It may be distinguished, 1. By its character, which, as Dr. Hope observes, is "usually a mere whiffl" 2. By not being heard at the period of the ventricular diastole and the second sound of the heart. 3. By being audible in several arteries at the same time. 4. By the facility with which the murmur "is altered by varying the pressure of the stethoscope, by which it may be converted into a hissing or whistling murmur. - ARTERIAL MURMURS. 151 5. By not being constantly present : by subsiding occasionally ■vvlien the circulation becomes tranquil, and returning when palpi- tation ensues. 6. By the general signs of anaemia being present. 7. By the absence of the physical or general signs of organic disease of the heart. 8. By entirely disappearing under treatment calculated to re- lieve the anaemic state of the system. Rough or grating Arterial Murmurs. — It is a very general opinion, that bruit de soufflet is the only abnormal murmur deve- loped in the large arteries. This, however, is far from being the case : a rough, sawing murmur is not unfrequent ; but its scat is limited to the arch of the aorta, and it is not confined to the period of the ventricular systole, but it frequently accompanies the ventri- cular diastole likewise. It is probably owing to these circum- stances that the phenomenon has been overlooked, the murmur, when heard, having been confounded with a cardiac murmur. In a healthy state of the arterial system, the arteries, we know, are constantly filled ; when the amount of blood transmitted to them is increased, the artery dilates, in order to accommodate itself to the increased quantity ; when the amount of blood is diminished, the arterial coats contract upon their contents, and the calibre of the artery is diminished in proportion ; but, whether the amount of blood is greater or less, these vessels are always full. This de- pends upon the peculiar property possessed by arterial tissue, usually termed elasticity, but which is evidently something more than mere elasticity, which is a property common to dead as well as living tissues. The aorta, in a healthy state, possesses this pe- culiar vital property in a high degree ; which is due, not only to its proper fibrous coat, but to its subserous or sclerous coat, which, in this artery is very well developed, as first described by Dr. Chevers.* It not unfrequently happens that the coats of the arch of the aorta suffer from disease, which impairs its elasticity ; the tube becomes rigid, and its calibre cannot alter with the increased or diminished amount of blood transmitted to it. At the same time, the natural smoothness and polish, which its lining membrane presents in the healthy state, is diminished ; and, the interior of the * Guy's Hospital Keports. 152 EXAMINATION OF THE HEART IN DISEASE. artery becomes rough and uneven from adventitious deposit ; while very generally its calibre becomes increased. During the systole of the left ventricle, the arch of the aorta is necessarily more distended than during the ventricular diastole : in the morbid condition under consideration, however, as its coats are incapable of contracting upon their contents, and as the calibre of this part of the vessel remains the same at these diflferent periods of the heart's action, a vacuum would occur here when the ventri- cular systole ceases, did not the blood regurgitate from the carotid and subclavian arteries to occupy it ; and this can scarcely occur without producing sound, which will, of course, accompany the ventricular diastole and the second sound of the heart. In this diseased state of the arch of the aorta, not only is the artery rigid and inelastic, but often its interior, owing to adven- titious deposit, becomes uneven and rough ; there will therefore necessarily be increased friction between the blood and the lining membrane of the vessel, and a murmur will be developed, which will be heard at the period of the ventricular systole, and will be synchronous with the first sound of the heart, and with the pulse. As the ventricular systole ceases, the blood from the large vessels which come off from the arch of the aorta regurgitates into it, and the passage backwards of this fluid over a similar rough surface causes a second murmur, which will, of course, be synchronous with the ventricular diastole, and the second sound of the heart. When the stethoscope is applied over the first bone of the sternum in this diseased state of the arch of the aorta, a short, double, sawing murmur will be heard, loudest over the first bone of the sternum and audible frequently as low as the base of the heart, sometimes a little lower down, but never at the apex of the organ. The first of these sounds is synchronous with the ventri- cular systole, and the pulse ; the second, with the ventricular diastole. Both sounds appear to be near, and both are short and rough, not either prolonged or blowing. In some instances a murmur is present only with the first sound, or even this may be absent, and the second sound may be neither rough or harsh. This will occur when the arch of the aorta, although rigid and in- elastic, has not lost, in any great degree, its natural smoothness and polish, but still permits regurgitation into it : the double sound then heard resembles very closely the double' sound of the ARTERIAL MURMURS. 153 heart, and is commonly supposed to be it transmitted beyond its normal limits. It may even happen that the arch of the aorta is dilated, rigid, and inelastic, and its lining rough and irregular, and yet no murmur will be developed : this will occur when the heart's action is feeble from softening or other alteration of the muscular tissue of the left ventricle, or when the arterial system is congested ; or when the cavities of the left side of the heart are loaded with blood. Under similar circumstances, we know that a murmur may be absent in cases of considerable disease of the valves or orifices. In addition to the physical signs above mentioned, this dis- eased state of the arch of the aorta is accompanied by the peculiar jarring of the pulse which was supposed to be characteristic of regurgitation through the aortic valves ; by visible pulsation of the carotids ; and by a visible and locomotive pulse in the arteries of the upper extremities. The peculiar jerking of the pulse, and the visible and locomotive pulsation of the arteries, depend upon the same cause as where the aortic valves permit regurgitation : here, however, the regurgitation is into the aorta itself. These signs will be more marked if the arch of the aorta, in addition to being rigid and inelastic, is at the same time dilated, and if the action of the heart is strong. The physical signs of this diseased state of the arch of the aorta have been hitherto confounded with those of valvular dis- ease at the aortic orifice : no writer that I am acquainted with seems to have been aware, that regurgitation into the arch of the aorta, from the larger vessels which come off from it, ever occurs, or that a backward current of blood in this part is capable of de- veloping a murmur. This has probably arisen from the general symptoms, in the early stage, not being such as to attract particu- lar attention ; and, as patency of the aortic valves is one of the consequences of the long continuance of this diseased state of the aorta, when the latter lesion has been found after death, the symp- toms have been referred to it alone. The form of cardiac disease with which this diseased condition of the coats of the arch of the aorta has been most frequently con- founded, is a state of the aortic valves permitting regurgitation, which it resembles in a murmur synchronous with the second cardiac sound, accompanying both morbid conditions, in the jar- ring pulse, and the visible pulsation of the arteries of the neck 154 EXAMINATION OF THE HEART IN DISEASE. and upper extremities, which are common to both. It may, how- ever, be distinguished by the character of the murmur with the second sound, which, in this diseased state of the aorta, is short, rough, and harsh, while in patency of the aortic valves it is usually prolonged, and blowing ; as well as by the situation in which the murmur is transmitted to the ear. In patency of the aortic valves it is audible from the base to the apex of the heart : in this morbid condition it is loudest over the first bone of the ster- num, and it is not heard below the base of the heart ; at least, it is very indistinct below this point. Besides, in this diseased state, when a murmur accompanies the second sound, one is like- wise always heard with the first, which is not the case in simple patency of the semilunar valves. VENOUS MURMURS. The abnormal sounds, which have their seat in the veins, may have either a blowing or a musical character. They all come under the class '* inorganic murmurs," and have received a variety of names ; as the venous murmur, or venous hum, the sound of continuous blowing, bruit de diable, and musical venous murmur. They may all be included under the heads, continuous, and musi- cal venous murmur. Continuous venous Murmur. — The continuous venous mvu'mur, or venous hum, is termed so from its being a continuous uninter- rupted sound, and venous from its seat. M. Bouillaud named it " bruit de diable," from its resemblance to the familiar sound made in the spinning of a kind of humming top, which is known under the popular name of diable in France, and this name has been very generally retained since. It resembles pretty accu- rately the sound heard when a large univalve shell is held close to the ear ; it has also been compared to the noise of the sea upon a distant strand, or to the buzz produced by a number of people talking together in a large room ; and it may be imitated, as Dr. Hope observes, "by forcing the breath in whispering a continuous who." It is often accompanied by the arterial bruit de soufflet, which appears to increase its intensity at each systole of the ven- tricle, and it often acquires increased loudness at each inspiration, owing to the expansion of the thorax, which allows the blood more rapidly to descend to the right side of the heart. VENOUS MURMURS, 155 The veins in which the continuous murmur is heard, are the jugulars, particularly the internal jugular, and the veins which open into them. The situation in which it is best marked is immediately above the clavicle : it is not audible close under the chin ; it may often be heard at both sides of the neck, though usually it is more feeble upon one side ; or it may be limited to one side, and, in my experience, it is both more frequent and more intense upon the right than the left side, though M. Bouillaud states that he most frequently finds it upon the left side. The more direct course of the veins upon the right side of the neck, to reach the vena cava, may account for its greater frequency upon the right side. The position in which to place the patient, in order to hear this murmur, is the sitting or standing posture, with the face inclined towards the opposite shoulder, and the chin somewhat elevated. The continuous venous murmur sometimes subsides suddenly at the point where it was audible a few minutes previously ; slight change of position of the patient's head will produce this effect, or will alter the character of the sound. This depends upon the pressure exercised on the vein by the parts lying over it, which varies with the motions of the head. M. Bouillaud says, that drawing the larynx towards the opposite side will diminish the murmur suddenly, or cause it to cease ; it does so by putting the orao-hyoid muscle upon the stretch, by which the deep cervical facia is rendered tense, and pressure is made upon the internal jugular vein. Altering the pressure of the stethoscope alters the character of this murmur in a remarkable manner, sometimes di- minishing, sometimes considerably increasing its intensity, and rendering it hoarse, or converting it into a musical murmur : when pressure sufficient to obliterate the current through the vein is made, either with the edge of the stethoscope or with the finger above, the murmur instantly ceases. Musical venous Murmur The musical venous murmur is less frequent than the continuous murmur: it has, however, its seat in the same vessels, is audible in the same situation and oc- curs in precisely the same kind of cases. It is less common in the male, and, like the continuous murmur, is more frequently heard upon the right than the left side of the neck. Like the latter, also, it intermits, changes its character, or ceases from very 156 EXAMINATION OF THE HEART IN DISEASE. trifling alterations in tlie position of the patient : it is always pre- ceded by tlie continuous murmur, which takes its place when it subsides. In order to hear either murmur, it is essential to em- ploy the stethoscope : and although it is sometimes audible on very gentle pressure by the stethoscope, it generally requires stronger pressure with the instrument than is sufficient to develop a con- tinuous murmur. The musical venous murmur sometimes resembles a whistle with the lips, or the prolonged whistling sound of a current of air through a key-hole ; sometimes it is more like the chirping of a bird, or the humming of a fly. It often consists of a single note, sometimes of two, more rarely of several distinct notes. The French writers, who place its seat in the arteries, term it the chant of the arteries ; and both Laennec's and Bouillaud's works contain a scale, in which they have endeavoured to represent by musical notes the melody heard in some cases. The musical venous murmur appears to have the same relation to the continuous venous murmur as the musical valvular murmur has to the bellows murmur ; the one is preceded by, and passes into the other, and the former is to be regarded as nothing more than an exaggerated variety of the latter. There is, in fact, no greater difference in the nature of the sounds, and in the mode in which they are produced, than there is (Dr. Hope observes) "be- tween blowing with the lips, and whistling." Seat of the the venous Murmurs. — The continuous and the musical venous murmurs were for a long time supposed to have their seat in the large arteries which come off from the arch of the aorta : this was the opinion of Laennec, who first discovered them ; and it has been advocated by almost every French writer from him to M. Bouillaud, MM. Barth and Roger, and M. Beau, the latest authorities upon the subject. The first to correct this error was Dr. Ogier Ward ;* he it was who first demonstrated that the veins, not the arteries, were the seat of these murmurs, and he first pointed out the distinguishing marks between the ve- nous and the arterial murmurs. In many cases, the continuous or the musical venous murmur are accompanied by the arterial bruit de soufl[let already described ; they may always, however, be readily distinguished from each * London Medical Gazette. VENOUS MURMURS. 157 otlier : the arterial murmur is an intermittent sound, the venous a continuous sound ; the arterial murmur is a short whiffing sound, while the venous has a humming or whistling character. That the continuous and the musical murmur have their seat in the veins is proved by their diminishing, or ceasing altogether, when pressure with the finger is made upon the vein above, or when the stethoscope is pressed firmly on it, so as to obliterate the current : the feeble bruit, which is still occasionally audible, comes from the small venous branches in the neighbourhood. M. Bouillaud, who places the seat of these murmurs in the arteries, observes that "pressure above the vessel with sufficient force to interrupt the current will cause a cessation of the murmur," which is quite true : but it is not quite so easy as M. Bouillaud seems to think, to "interrupt the current" in the carotid or subclavian arteries ; the degree of pressure required would cause rather more pain than most patients would like to submit to often ; while the moderate degree of pressure necessary to interrupt the venous murmur would, if it had its seat in the artery, render it louder, instead of interrupting it. In fact, the trifling pressure which is necessary to cause the cessation of these sounds is the best proof that they have their seat in the veins ; and that they are not seated in the arteries, is proved by the true arterial bruit de soufflet being very often heard at the same time, and by its continuing to be audible when the venous murmur has been checked by the pressure of the finger or the stethoscope. Mechanism of production of the venous Murmurs. — In pre- vious chapters I have endeavoured to prove, that every sound, whether normal or abnormal, developed in the heart or arteries, is produced by friction between the blood and the lining mem- brane of the part along or through which it passes ; that abnormal sounds are nothing more than exaggerated normal sounds, and that the character of the abnormal sounds will vary according to a variety of circumstances ; as the roughness or smoothness of the lining membrane, the nature and amount of the obstruction to the current of blood, the rapidity and strength with which the blood is propelled, and the physical condition of the circulating fluid, particularly its density and vicidity. In the cases in which the continuous or the musical venous murmur are heard, the organs of circulation are in a healthy state ; 158 EXAMINATION OF THE HEART IN DISEASE. but the blood is altered, its density is diminished, its watery parts are increased, and its viscidity is less than that of healthy blood, while the current is more rapid than in health — conditions suf- ficient to develop a murmur in the arteries ; and accordingly the arterial bruit de soufflet is very generally audible in such cases. The current through the veins being naturally feeble, compared to that through the arteries, their coats being lax and readily dis- tensible, no great amount of friction can occur between the blood and the lining membrane of these vessels, even though this fluid be altered in the way that I have mentioned. In order, therefore, that a murmur should be developed in a vein, the friction between the blood and its lining membrane must be mechanically increased. The murmurs which we are considering have their seat essen- tially in the jugular veins; principally, I believe, in the internal jugulars. Now, in order that friction sufficient to develop sound should take place between the blood and the lining membrane of these veins, it is necessary that the tissues covering them, viz., the skin, the platisma, and the cervical fascia, should be rendered tense ; which is effected by turning the patient's head towards the opposite shoulder, and elevating the chin, by which a moderate degree of pressure is exercised upon these veins in their whole course in the neck, and they are placed in a favourable condition for the development of sound. If the stethoscope be now applied, its pressure will slightly diminish the calibre of the vein, the fric- tion between the blood and the lining membrane of the vessel will be increased, and a murmur will be developed, which will of course have a continuous character, because the current through the vessel is continuous. If increased pressure be made by the ste- thoscope, the character of the murmur will be altered ; it will be rendered harsher, or hoarser, or converted into a whistle, or other musical murmur, as the case may be ; while, if the stethoscope is pressed still more strongly upon the vein, so as to obliterate the current, the murmur will instantly cease. I am therefore of opinion that the continuous and musical venous murmurs, unlike the cardiac and arterial murmurs, are not naturally present in the veins, but that they are mechanically developed by the pressure of the stethoscope, when the coats of the vein have been rendered tense, by putting the parts covering it upon the stretch. Thus, if we completely relax the fascia and VENOUS MURMURS. 159 muscles of the neck, by making the patient incline the head forward, and then apply the stethoscope, the murmur will be in- audible, or scarcely heard ; while, if we turn the patient's head slightly towards the opposite side, the murmur will be loudly heard, although the same degree of pressure is made by the ste- thoscope. Again, the bruit de diable is described by writers as being often audible one day, and inaudible the next ; and as disappearing suddenly at a point where immediately previous it had been loud. Now, if we examine the connections of the deep fascia of the neck with the sheath of the cervical vessels, and with the muscles, we shall perceive that a very trifling alteration in the position of the patient's head will render this fascia tense, or the conti-ary ; and we can easily understand, therefore, how the pressure of the ste- thoscope may, in one position of the patient, fail to develop the murmur, while in another position, the same amount of pressure will render it loud. The venous murmur (as has often been observed) diminishes or subsides when the face is turned quite round towards the opposite side. Now the effect of this position is to render tense both the cervical fascia and the muscles which cover the internal jugular, by which so much pressure is made upon the vein as greatly to diminish the current through it, when of course the murmur will either subside or become very feeble. The venous murmur is sometimes heard on both sides, sometimes only on one side, and is usually better marked upon the right than the left side. This is readily explained by the more direct course of the blood towards the heart on the right side. When this murmur has been only heard on the left side, the French writers (who suppose the carotid artery to be its seat) are obliged to refer it then to " some irregular distribution of the left carotid artery, by which this vessel is rendered more superficial." " We must allow (M. Beau observes) a large share to the anomalies so frequent in the arterial system." The continuous murmur ceases or diminishes materially in the recumbent posture, and returns again in the sitting or erect posture. This may be accounted for partly by the effect of gravity upon the circulation in the jugular vein, and partly owing to the rapidity of the circulation being greater in the erect or sitting 160 EXAMINATION OF THE HEART IN DISEASE. than in the recumbent posture. In cases of anaemia, change of posture exercises a more remarkable influence upon the rapidity of the heart's action than in the healthy subject: and, as rapidity of the circulation is one of the conditions necessary for the deve- lopment of the venous murmur, it follows that it ought to be more evident in the erect or sitting than in the recumbent posture. Besides, in the recumbent posture the fascia of the neck is more or less relaxed, and the vein is placed in an unfavourable state for the development of sound. The arterial and venous murmurs will be again alluded to, when I come to speak of what are termed "inorganic affections." It is only necessary here to observe, that these abnormal sounds are very common in chlorotic and ansemic subjects, and in indivi- duals who have suffered considerable loss of blood ; and they are heard in all cases where the blood is altered, its serous portion in- creased, and its viscidity lessened. We seldom or never examine a chlorotic subject in whom some of these sounds are not present, and the more advanced the stage of anaemia the more intense in general are the murmurs : as the anaemic condition is relieved by treatment, the sounds diminish in intensity, and eventually, when the patient's health is completely restored, they disappear. 161 CHAPTER VII. GENERAL SIGNS OF CARDIAC DISEASE.— COUNTENANCE.— POSTURE OF THE PATIENT.— PALPITATION.— EPIGASTRIC PULSATION.— ANGINA PECTORIS.— THE PULSE AS A MEANS OF DIAGNOSIS. The general signs of the advanced stage of cardiac disease have considerable similarity, and the symptoms most generally present, are common to several diseased conditions of the heart. In the majority of cases, they have their origin in some impediment to the free passage of the blood through the left side of the organ, by which the circulation through the heart or through the lungs, or through both, is impeded. Disease of the heart may lead to disease of the lungs, and vice versa. In a healthy condition of the parts, there is a perfect equi- librium between the development and the capacity of the two organs : the exact amount of blood is transmitted by the right ventricle to the lungs, which, in the latter organs, can be converted into arterial blood ; and the exact amount of blood is returned by the pulmonary veins, which can pass freely through the left chambers of the heart. But, if this equilibrium is disturbed ; if the pulmonary circulation is obstructed, owing to disease in the lungs, bronchial tubes, or pleura, the right auricle and ventricle become distended, and eventually, if the cause continues in ope- ration, dilated or hypertrophied. If, again, there is an impe- diment to the free passage of the blood through the left side of the heart, congestion of the lungs as a natural consequence ensues ; oedema follows, then haemoptysis or pulmonary apoplexy. The effect of the obstruction of the pulmonary circulation extends to the right side of the heart ; its cavities become distended, then dilated, or their walls become hypertrophied. The great venous trunks not being able to empty themselves, become distended, and the whole venous system congested : hence the lividity of the face and extremities, the congestion of the lungs, liver, and other ab- M 162 EXAMINATION OF THE HEART IN DISEASE. dominal viscera, wliicli is partly relieved by tlie escape of the serum of the blood into the cellular tissue of the extremities, giving rise to anasarca ; or into that of the lungs, causing oedema pul- monum ; partly by its effusion into the abdomen or thorax, con- stituting ascites or hydrothorax ; and sometimes by the escape of the blood itself upon the CQngested mucous surfaces, giving rise to epistaxis, hasraoptysis, &c. ; or into the pulmonary tissue, con- stituting the state with which we are familiar as pulmonary apo- plexy. The general symptoms of the advanced stage of cardiac disease are pretty constant; while those of its early stage vary as the disease is acute or chronic ; they vary likewise according to its nature, and to the parts of the heart engaged. Thus, while in the early stage of the chronic forms of disease, there is scarcely anything characteristic in the symptoms, those which accompany the early stage of acute diseases of the organ are usually very well marked. Among the general symptoms of heart disease, palpitation is usually one of the first which attracts attention. More or less dyspnoea is often present, which may or may not be accompanied by cough. The pulse, likewise, sometimes exhibits diagnostic characters. When the disease is more advanced, or when obstruc- tion to the pulmonary or the general circulation has set in, other symptoms are usually superadded ; signs of congestion of the lungs, liver, kidney, spleen, or gastro-intestinal mucous membrane make their appearance ; orthoj)noea supervenes upon the dyspnoea ; and the over-loaded or over-distended vessels are relieved, in part, by the escape of the serum of the blood into the general cellular tissue, or into the serous cavities ; or sometimes by the escape of the blood itself upon some of the mucous surfaces, or into the pul- monary tissue. Before entering upon the consideration of these symptoms, it may be well to delay for a moment to consider whether there is anything in the expression or character of the countenance of a patient labouring under heart disease, or in the posture which he assumes, from which information as to its nature may be gathered. In the acute inflammatory affections of the in\^esting or lining membrane of the heart, information may not unfrequently be ob- tained by attention to these particulars. In the' chronic forms of COUNTENANCE IN HEART DISEASE. 163 disease notliiiisf is to be learned from them as lonor as the disease is recent; but when the disease is advanced, they are sometimes sufficiently characteristic. Before the discovery of auscultation and percussion, and before diseases of the heart could consequently be diagnosed with certainty, these points received a much larger share of the attention of practitioners than at the present day : they are, however, of sufficient importance to deserve a short notice. COUNTENANCE IN HEART DISEASE. In the acute inflammatory affections of the lining or investing membrane of the heart, the countenance early acquires an anxious and depressed character ; indeed, it is often so marked as imme- diately to attract attention ; and, from it alone the practitioner has been induced to institute a minute examination into the condition of the central organ of the circulation, although the patient made no complaint of any symptom referable to it. This applies par- ticularly to cases of acute rhe-imatism, in which the articular inflam- mation comes to be complicated with pericarditis, or endocarditis, or both. It is explained by the sympathy which subsists between the respiratory nerves of the face and the cardiac nerves. In affec- tions of this nature, in infancy particularly, we commonly observe an elevation and depression of the alse nasi in the respiratory act ; movements depending upon the influence of the portio dura of the seventh pair (the respiratory nerve of the face, of Sir C Bell), which are more marked in proportion as the respiration is more difficult. Indeed, in acute affections either of the lungs or heart in children, this is often a useful guide, and sometimes indicates a greater amount of disease than the general symptoms would lead us to suspect. In the chronic forms of cardiac disease, little is to be learned atjirst, either from the expression of the countenance, or from the character of the individual features ; in the advanced stage, how- ever, the countenance becomes sometimes almost pathognomonic. Thus, in cases where the pulmonary circulation is much impeded, the venous system throughout the body becomes congested, the capillaries injected, the extremities swollen and cold, and the nails blue ; the face becomes bloated and dusky, the eyelids puffed, the eyes staring, the conjunctiva suffused, the lips and 164 EXAailNATION OF THE HEART IN DISEASE. cheeks purple, the respiration laborious, the air passages are loaded with mucus, and the jugular veins distended or pulsatile. On the other hand, it not unfrequently happens that in an equally advanced stage of some other form of cardiac disease, there is neither oedema or swelling of the extremities, the face instead of being puffed and dusky, is very pale and often expressive of pain ; if dyspnoea occurs, it is in paroxysms, during which the respiration is gasping ; there is a painful sense of constriction or impending dissolution, or the patient utters exclamations of pain which is re- ferred to the praecordial region, or which shoots from the region of the heart to the spine or left scapula, and extends to the arms, particularly the left. Corvisart* first made the remark, that in persons of the lym- phatic temperament, the face instead of assuming a purple tint, becomes more pale than natural in the advanced stage of cardiac disease. Dr. Hope repeats the same remark : "In persons of the sanguine temperament (he observes), who are naturally florid, the lips and cheeks often become injected,; and the countenance bloated, while in individuals of the lymphatic temperament, who are natu- rally pale, it usually becomes still more so. Dr. Ormerodf attri- butes more influence to age than to temperament, and describes the character of the countenance in the advanced stage of valvular disease as being different in childhood, and adult age. Undoubt- edly, age and temperament may modify the appearances in some respects ; but, I do not think that either of them can be regarded as the cause of this difference, which appears to me to depend upon the nature of the organic lesion, and whether this has or has not occasioned congestion of the lungs. Thus, when it consists in a very contracted state of the mitral orifice, with hypertrophy and dilatation of the right ventricle, in which congestion of the lungs is a necessary result almost, the face will be congested and bloated, the lips and cheeks purple, and the lower extremities livid and anasarcous. On the other hand, in cases of disease of the aortic valves permitting regurgitation into the left ventricle, the face is not bloated, the lips and cheeks are not purple, and the extremities are not livid or anasarcous ; but the face becomes pale, and the countenance anxious, and expressive of suffering. When congestion of the lungs is combined with congestion of * Essai sur les Maladies du Cceur. f Gulstonian Lectures, Medical Gazette. 1 COUNTENANCE IN HEART DISEASE. 165 the liver, tlie complexion as Dr. Budd* remarks, " becomes purplish, and at the same time sallow" " As the blood, when its passage through the lungs is impeded, is imperfectly decarbonized and gives a purplish colour to the face, so, when its course through the liver is impeded, the blood is not completely freed from the principles of bile, and the countenance acquires a slightly jaundiced or sallow tint." This had not escaped the observation of Dr. Bright, who remarks : " When obstruction takes place to the cir- culation tlirough the chest, but more particularly when the heart becomes over-distended with blood, we observe the countenance gradually assume a dingy aspect, in which the purple suffusion of carbonized blood is mingled -with the yellow tint of jaundice ; the conjunctiva is more decidedly tinged, and if the disease con- tinues long, sometimes completely prevails over the purple tint." Prominence of the Eyes — A prominence of the eye-balls, giving the eyes a peculiar, staring appearance, as if they were larger than natural, or as if they were protruded forward, has been noticed in a few instances in connection with cardiac disease, or with symptoms simulating it, of which the most prominent was palpitation. It coincided in the majority of cases with an en- largement of the thyroid gland. The subjects were females, often of an hysterical habit ; and the attacks of palpitation in some in- stances were prolonged and severe. In Dr. Parry's posthumous work,t several cases are related under the head "enlargement of the thyroid gland, in connection with enlargement or palpitation of the heart ;" the subjects were all females, and the majority were examples of organic disease of the heart ; in only one, pro- trusion of the eyes is mentioned. Recently, Dr. Graves and Dr. Macdonnell have called attention to this phenomenon, and have alluded particularly to the prominence of the eye-balls. It appears to me to have a doubtful connection with cardiac disease. In" one case, where the subject of it was an extern patient of the hospital, she had continued for several years much in the same state. In another, who presented the same peculiar appearance of the eyes, but without any enlargement of the thyroid body, and who died in hospital, a small tumor growing from the dura mater was found, on a post-mortem examination. In a third case, where the subject was also a female, about 25 years of age, and where * On Diseases of the Liver. f Collections from unpublished writings, vol. ii. 166 EXAMINATION OF THE HEART IN DISEASE. protrusion of the eye-balls was also marked, and was complained of by the patient, which she said felt as if swollen, there was en- largement of the thyroid body ; but neither palpitation or other symptom referable to the heart. Arcus Senilis Another peculiarity connected with the eye, deserving of attention, is that which is familiar to us as the arcus senilis. Mr. Canton first demonstrated this to be the result of fatty degeneration of the cornea ; and both he, and Dr. Williams have shown that it is sufficiently often met with in cases of fatty degeneration of the heart, to be entitled to be considered a diag- nostic siofn of this diseased state of the organ. POSTURE OF THE PATIENT. In the early stage of the chronic forms of cardiac disease, nothing is to be learned either from the position of the patient or from the posture which he assumes. He is usually able to rest in the horizontal posture, and seldom finds greater difficulty in lying upon one side than the other ; sometimes he prefers the supine posture : frequently it is with great reluctance that he remains in bed. In acute affections, more particularly in that form of pericarditis where a large amount of fluid is rapidly effused into the peri- cardial sac, the patient is quite unable to lie down, or to obtain rest in the horizontal posture. Sometimes, the restlessness is so extreme that he cannot remain for more than a few minutes in any one position, and he is continvially changing it; at others, he obtains partial relief only in one particular posture ; any deviation from which is sure to add considerably to the dyspnoea and distress. In the advanced stages of valvular disease, when the circula- tion through the lungs becomes greatly impeded, or when fluid is effused into one or both pleural cavities, the patient cannot lie down ; he must have the head and chest elevatedj or he is unable to remain in bed, and is forced to preserve the sitting posture. In extreme cases, he is often onl}'^ able to snatch momentary rest by leaning forward and resting his head upon his knees, or upon a table. Sometimes the dyspnoea is so extreme, that he obtains ease only by lying on his face ; this, however, is more frequently ob- PALPITATION. 167 served in aneurism of the aorta pressing upon the trachea than in organic disease of the heart. When, in addition, effusion to a considerable amount exists in the peritoneal cavity ; or when the lower extremities have become much swollen, the position of the patient will be influenced in some measure by these complications. I have seen the dyspnoea aggravated in a remarkable degree by merely bringing the ana- sarcous lower extremities to the same level with the body ; and the patient could not rest unless they hung down by the side of the bed. In many such cases, indeed, the patient refuses to remain in bed, and sits constantly in a chair. In other instances, where there is neither anasarca of the lower extremities nor ascites, but where pain or dyspnoea are the most prominent symptoms, and where the dyspnoea occurs in paroxysms of extreme severity, the position which the patient assumes in the paroxysm is peculiar : he sometimes seizes upon some fixed object against which he strongly presses the sternum ; or he fixes the arms firmly, so as to call every muscle of inspiration into action ; or he writhes about, and almost screams with agony. A patient was in hospital some time since, who during the par- oxysms, was unable to obtain ease in any position but sitting upon the ground with the back firmly pressed against a wall. Dr. Hope has drawn a vivid picture of an aggravated case of this kind : " Incapable of lying down, the patient is seen for weeks, and even for months together, either reclining in the semi-erect position supported by pillows, or sitting with the trunk bent forwards and the elbows or forearms resting on the drawn-up knees." " With eyes widely expanded and starting, eyebrows raised, nostrils dilated, a ghastly and haggard countenance, and the head thrown back at every inspiration, he casts round a hurried, distracted look of horror, of anguish, and of supplication ; now imploring in plaintive moans, or quick, broken, accents and half-stifled voice, the assistance already often lavished in vain ; and now, in an agony of despair, drooping his head on his chest, and muttering a fervent invocation for death, to put a period to his sufterings." PALPITATION. Among the general signs of cardiac disease, some may be said to be direct, others indirect : the former have obviously more value 1G8 EXAMINATION OF THE HEART IN DISEASE. than the latter. Among the direct symptoms palpitation is one of the most common ; the character of the pulse being also occa- sionally diagnostic, may be included under this head : under it, also, turgescence ofthe jugular veins, pulsation in these veins, and freraissement cataire may be included : the latter have, however, already been considered. The indirect — or, as they are more correctly termed, the secondary symptoms — are common to diseases of the lungs as well as of the heart. Under this head may be in- cluded congestion of the lungs, cough, dyspnoea, orthopnoea, haemoptysis, pulmonary apoplexy, congestion ofthe liver, spleen, kidneys, and brain, anasarca, and effusion into the cavities of the pleura and peritoneum. Among the direct signs of cardiac disease, palpitation is perhaps the most constant and most frequent : it is often the first symptom which attracts the patient's attention ; and it frequently distresses and harasses him throughout every stage of the disease. On the other hand, palpitation is frequently a prominent and troublesome symptom, when the heart itself is in a perfectly healthy state. It has already been said that, in the healthy subject, where the chest is well formed and the heart and lungs have their normal proportions, the impulse of the apex of the heart is so slight that the individual is not sensible of it himself : the motion, in fact, is performed without his consciousness, and is only perceived in a very limited space when the hand is laid upon the parietes of the chest. Whenever, consequently, a person becomes sensible of the beating of his own heart, it may be said to constitute palpi- tation. Palpitation may therefore be defined : An unusual ac- tion of the heart, perceptible to the individual and inconvenient to him ; the impulse being often stronger than natural, and the action of the oi'gan either more rapid than in health, or intermit- tent, or irregular. Palpitation presents numerous varieties ; sometimes it is so slight that the patient is unconscious of it, or makes no complaint unless questioned ; at other times, it is so violent as to elevate the clothes and shake the bed upon which he lies. Sometimes the impulse communicated is a slight, smart shock ; sometimes it is strong, prolonged, and heaving, elevating the head ofthe observer ; at other times the impulse is not altered, or is even weaker than natural. Sometimes the sounds of the heart are increased in inten- PALPITATION. 169 sity, and, in rare cases, so much, that the patient can hear them himself when he lies upon the left side ; at others, the sounds are not at all increased in intensity. In some cases palpitation sets in suddenly ; in others, it makes its approaches very gradually. Sometimes the fits are short, quickly subside, and the patient is perfectly free from it in the intervals ; at others, the fits are longer and more severe, or more or less palpitation is constantly present. Sometimes the palpitation is accompanied by uneasiness, by a sense of constriction, or of weight or pain in the region of the heart, or by a sense of sinking or of fluttering in the epigastrium ; sometimes by dyspnoea or orthopnoea ; sometimes by headache, ver- tigo, or noises in the head : at others, nothing of the kind is ob- served, and palpitation is the only symptom we are called upon to treat. Palpitation, although one of the commonest symptoms of mor- bid states of the heart, frequently occurs independent of any or- ganic change in this organ, and is not unfrequently a greater source of anxiety or alarm to the patient under such circumstances than in cases of organic disease. Thus it is a symptom in plethora ; and in the very opposite condition, anaemia; it is a common attendant upon dyspepsia and derangement of the digestive organs, and it arises in debility from any cause : it is a frequent symptom in hys- teria and hypochondriasis ; it is not unusual in the early or ad- vanced stage of pregnancy ; and it accompanies several diseased states of the pulmonary organs. The value of palpitation as a symptom, mainly depends upon whether it is symptomatic of diseased states of the heart, or whether it is sympathetic of some other afiection : hence, it is of considerable importance that its cause should be determined. We shall therefore consider it here under two heads : viz., as it has its cause in organic disease of the central organ of the circulation, or as it occurs independent of cardiac disease. Palpitation depending upon Organic Disease of the Heart — Palpitation depending upon organic disease of the heart, usually, unless in cases of acute inflammation of the investing or lining membrane of the organ, comes on slowly and insidiously, and in- creases gradually ; it is constant, although more distressing at one period than another; it is very generally combined with de- rangement of the general circulation, or with disorder of the res- 170 EXAMINATION OF THE HEART IN DISEASE. plration ; and it is very generally also accompanied by well- marked physical signs, or by other general symptoms of cardiac disease. Palpitation will therefore be a symptom in pericarditis and endocarditis, in hypertrophy, and in dilatation of the ventri- cles, or when these two states are combined ; in diseased condi- tions of the valves or orifices of the left side of the heart, causing obstruction, or permitting regurgitation; in adhesion of the peri- cardium, the result of pericarditis ; and in softening of the heart. Thus, in acute pericarditis, or endocarditis, palpitation is often one of the first symptoms which attracts the attention of the patient or practitioner ; the heart's action is more rapid than natural, and the impulse is increased. Cases, however, occasionally occur where palpitation is very slight, or entirely absent. Again, palpitation is one of the commonest symptoms of hypertrophy of the ven- tricles : here the impulse is increased, often considerably, but the action of the heart is not more rapid than in health. In dilatation of the ventricles, the palpitation is accompanied by increased loudness of the heart's sounds, but the impulse has not much real strength. In the combination of these two states, or hypertrophy with dilatation of the ventricles, particvilarly when the disease is advanced, the palpitation is often very distressing, and the par- oxysms are frequently prolonged and severe. In organic disease of the valves or orifices of the left side of the heart, palpitation is very generally and constantly present ; but, as it is usually accompanied by hypertrophy, or dilatation of the ventricles, and as it always tends to produce these morbid states, the palpitation has its cause partly in the complication. Finally, in softening of the muscular tissue of the heart, palpitation is fre- quent ; here, however, it is of the passive kind ; the impulse is feeble, and the heart's action usually intermittent and irregular. Palpitation independent of Organic Disease of the Heart — Palpitation, independent of organic disease of the heart, is more common in the female than the male : it usually sets in suddenly, and is almost always intermittent. The impulse is often sharp and knocking, never heaving or prolonged, and the action of the heart is generally rapid. The palpitation occurs in paroxysms, often when the individual is in a state of repose : it is readily ex- cited by mental emotion ; and the physical and general signs of valvular or other disease of the heart are absent. PALPITATION. 171 The palpitation which occurs under these circumstances pre- sents several varieties, and may be traced to several causes, some of which are intrinsic to the heart, others are extrinsic to it. Thus, palpitation will ensue when the blood is returned to the heart more rapidly than in ordinary ; or, when the motions of the heart are impeded, whether the exciting cause be seated in the lungs, in the parietes of the chest, or in the abdomen. Palpitation occurs in states of debility, whether this depends upon excessive evacuations, or arises in convalescence from acute disease ; as well as in certain states of the nervous system, whether this be constitutional or acquired. Finally, it may ensue when two or more of the foregoing conditions are combined. Thus : 1. In a healthy subject, violent exercise on the one hand, or the indulgence in intoxicating liquors on the other, will hu.rry the circulation, and give rise to palpitation ; but as soon as the exciting cause is removed, the effect ceases. In states of plethora, likewise, where blood is rapidly formed, and the vascular system becomes oppressed, more or less palpitation is generally present. 2. In cases where the bony parietes of the thorax are con- tracted and deformed ; in adults whose chests are narrow and ex- tremities long ; or in young persons about puberty, whose growth has been rapid, palpitation is often complained of. Here its cause appears to lie in the narrowness of the chest, which interferes with the free play of the heart, or with the free expansion of the lungs. Palpitation is also occasionally complained of in the ad- vanced stage of pregnancy, in cases of large ovarian or other abdo- minal tumors, or in ascites, in which the descent of the diaphragm is interfered with, or pressure is exercised upon the large vessels. 3. Palpitation is a very frequent symptom in states of debility ; in anaemia, whether this arises from profuse hsemorrhage or ac- companies amenorrhoea ; or where profuse evacuations of any kind have occurred ; under this head, sexual excesses and manustrupatio may be included. Palpitation likewise is a symptom of mercurial erithismus ; and it not unfrequently arises during convalescence from acute diseases, particularly where mercury had been freely given ; and after protracted fever it is by no means rare. 4. In persons of what is called the nervous temperament, pal- pitation is common, and is readily excited by mental emotion or by trifling causes. In hysteria, particularly in that form which 172 EXAMINATION OF THE HEART IN DISEASE. gets the name of spinal irritation, it is an ordinary symptom ; and in cases of hypochondriasis it is by no means unfrequent. 5. Palpitation is not unfrequently induced by excessive study, by late hours, by the habitual use of strong tea, or the inordinate use of tobacco in the form of smoking ; by the suppression of some habitual discharge ; by prolonged mental excitement, whether of an exciting or depressing nature ; or by a sudden shock or fright. In these cases it partly depends upon derangement of the digestive organs, and partly upon debility, or constitutional or induced irri- tability. Lastly, palpitation is frequent in persons of a gouty habit ; indeed, the first symptom indicating the approach of a fit is often palpitation, with fluttering and intermission of the heart's action. Palpitation is also a common accompaniment of dyspepsia ; here it is partly due to flatulence, which, by resisting the descent of the diaphragm, impedes the free expansion of the lungs, and interferes with the motions of the heart ; partly to the reflex sympathy be- tween the parts concerned. It not unfrequently happens in practice, however, that organic disease of the heart is associated with derangement of the di- gestive organs ; with an anaemic state of the system ; with a nervous, irritable, or gouty habit ; or with some of the other causes capable of giving rise to palpitation ; by which the difficulty of the diagnosis will be considerably increased. In the following Table the more prominent characters of the palpitation, which depends upon organic disease of the heart, are contrasted with those of palpitation arising independent of disease of this organ : PALPITATION DEPENDING UPON OR- PALPITATION INDEPENDENT OF OR- GANIC DISEASE OF THE HEART. GANIC DISEASE OF THE HEART. 1. More common in the male than the 1. More common in the female than female. the male. 2. Palpitation usuallycomes on slowly 2. Palpitation usually sets in suddenly, and gradually. 3. Palpitation constant, though more 3. Palpitation not constant, having marked at one period than at another. perfect intermissions. 4. Impulse usually stronger than na- 4. Impulse neither heaving or pro- tural ; sometimes remarkably increased, longed ; often abrupt, knocking, and cir- heaving, and prolonged ; at others irre- cumscribed, and accompanied by a flut- gular and unequal. tering sensation in the prsecordial region, or epigastrium. PALPITATION. 173 5. Percussion elicits a dull sound over 5. Extent of surface in the region of an increased surface, and the degree of the heart, which yields naturally a dull dulness is greater than natural. sound on percussion — not increased. 6. Palpitation often accompanied by 6. Auscultatory signs of diseased the auscultatory signs of diseased valves, valves absent ; bruit de soufflet often present in the large arteries, and a con- tinuous murmur in the veins. 7. Rhythm of the heart regular, irre- 7. Rhythm of heart usually regular ; gular, or intermittent ; its action not ne- sometimes intermittent ; its action gene- cessarily quickened. rally more rapid than natural. 8. Palpitation often not much com- 8. Palpitation often much complained plained of by the patient ; occasionally at- of by the patient; readily induced by tended by severe pain, extending to the mental emotion, and frequently accom- left shoulder and arm. panied by pain in the left side. 9. Lips and cheeks often livid ; coun- 9. Lips and cheeks never livid ; coun- tenance congested ; anasarcaof lower ex- tenance often chlorotic ; anasarca absent, tremities common. except in extreme cases. 10. Palpitation increased by exercise, 10. Palpitation increased by sedentary by stimulants and tonics &c. ; relieved occupations ; by local and general bleed- by rest, and frequently, also, by local or ing, &c. ; relieved by moderate exer- general bleeding, and an antiphlogistic cise, and by stimulants or tonics, par- regimen, ticularly the preparations of iron. Immediate cause of Palpitation The blood which circulates through the cavities of the heart, is considered to be the natural stimulus to the contractions of the organ : thus, in a state of health, when this fluid is returned to the right side of the heart more quickly than in ordinary, its action becomes more rapid. In this way exercise increases the frequency of the heart's contractions, and hurries the circulation, which returns to its normal frequency after the patient has remained at rest for a time. In states of plethora, in which blood is rapidly formed, palpi- tation we have seen to be a common symptom ; there is here an increased amount of blood in the vessels, and this fluid is of a more stimulant nature, perhaps ; the palpitation which ensues in these cases is not accompanied by quickened action of the heart. In the very opposite condition to this — viz., anaemia — where the blood is poor and watery, and deficient frequently in quantity, palpitation is also extremely frequent, and the heart's action is more rapid than in health : here the heart appears to contract more frequently, to compensate for the deficiency in the quality of the blood. Again, when the valves or orifices of the heart are diseased, and the passage of the blood out of, or through its clianibers is im- 174 EXAMINATION OF THE HEART IN DISEASE. peded, palpitation ensues, and the organ is excited to increased action in order to overcome the obstacle to the transmission of the blood. Palpitation is, however, by no means rare, independent of any of the foregoing circumstances ; in such cases, the nervous system is probably at fault, though the exact mode in which this causes palpitation is not quite clear. When we come to speak of functional derangement of the organ, we shall have occasion to return to this point. Before dismissing the subject of palpitation, I may observe that this symptom frequently is present in a marked degree in the class of patients who present themselves at hospital, without their appearing to be conscious of it. When questioned, they allow that they feel some oppression in the prascordial region, but hardly admit that it amounts to palpitation, though, when we come to examine the chest, the action of the heart is often much increased, and its impulse so strong as to raise the head of the observer. This, no doubt, arises in some measure from the sensibility being blunted by the ill oxygenation of the blood ; and in some measure, also, from the parts having had time to accommodate themselves to their altered condition. On the other hand, it is no less re- markable, how often, when palpitation depends simply upon functional derangement, the patient's attention is directed mainly to it; he is most unhappy in consequence, and can scarcely be made to believe that he is not the subject of organic, and, in his opinion therefore, of incurable disease of the heart. EPIGASTRIC PULSATION. A pulsation in the epigastric region which is evident to the eye, and perceptible to the hand, and of which the patient himself is conscious, is by no means uncommon ; it is occasionally symp- tomatic of organic disease of the heart, or of some part of the arterial system ; sometimes it is a sign of simple functional de- rangement ; and at others it is independent of either. In describing the normal position of the heart, we saw that this organ rests upon the cordiform tendon of the diaphragm ; now, if the sternum is short and the heart's action strong, there is no more difficulty in accounting for the heart's impulse being seen and felt in the epigastrium under such circumstances, than for an im- pulse being communicated to the abdominal parietes^ by the act of coucjhing. EPIGASTRIC PULSATION. 175 Epigastric Pulsation in Emphysema. — When the volume of the lungs is increased, as in emphysema of these organs, the heart will be pushed somewhat downwards, and its pulsation will be evident in the epigastric region ; and as this condition of the lungs is in general associated with enlargement of the right side of the heart, particularly when it has persisted long, the pulsation is usually well marked. This form of epigastric pulsation is observed high up in this region, it is quite perceptible to the hand, and it is evidently produced by the heart itself. It occasions less distress than some of the other forms, and we are not often called upon to treat it alone. Pulsation the result of Congestion — When hepatic is com- bined with gastro-intestinal congestion — the result of impediment to the return of the venous blood to the right side of the heart — this may react upon the arteries which supply these viscera, and through the cseliac axis, and superior and inferior mesenteric ar- teries upon the abdominal aorta; the pulsation of this vessel be- comes more distinct, and stronger, constituting one form of epi- gastric pulsation, and resembling that described by Dr. Faussett,* which was referred by him to local or visceral congestion, or to sub-acute inflammation. This variety of epigastric pulsation is accompanied by " pain on pressure at the epigastric region, or towards the umbilicus, with considerable fulness at the part ; the digestive organs are deranged, the bowels torpid, and the feet cold. The pulsation is most severe towards the afternoon, or soon after dinner, and is accompanied by a sense of vital depression. On auscultation, a loud whizzing sound is heard ;" we may, however, have this form of epigastric pulsation without any murmur being audible on auscultation. A pulsation of the abdominal aorta, or its immediate branches, which is symptomatic of inflammatory disease in the abdomen has been noticed by Dr. Stokes. f It consists in "a throbbing gene- rally commensurate with the disease, removed by treatment cal- culated to relieve enteric inflammation, and aggravated by every thing which increases it." " In other words, we may have (he observes) from enteritis or peritonitis a throbbing of the abdominal aorta, or its branches, perfectly analogous to the morbid action of the radial artery in whitlow, or of the carotids or temporal arteries * Dublin Journal of Mefiicine, vol. ii. f Ibid, vol. v. 176 EXAMINATION OF THE HEART IN DISEASE. in cerebritis." The diseases in which this pulsation was observed were gastro-enteric fever, peritonitis, and fever consecutive to cor- rosive poisoning. Epigastric Pulsation in adhesion of the Pericardium. — Pul- sation in the epigastric region was one of the earliest mentioned diagnostic signs of adherent pericardium ; Mr. Burns* considered it to be a constant symptom ; " when the ventricles contract they drag the pericardium with them (he observes), and the pericardium again pulls the diaphragm after it, so that by the alternate ele- vation and depression of this septum, the chief pulsation comes to be referred to the epigastric region." The pulsation in these cases is rather an undulatory movement of the parietes than a dis- tinct pulsation ; it is perceived high up in the epigastric region, but it has no real strength, for when the hand is laid upon the part, or when pressure is made, no impulse is communicated. Nervous and Hysterical Pulsation A form of epigastric pul- sation, observed in subjects in whom the heart is perfectly healthy, occurs occasionally in nervous and hysteric females ; which is nothing more than the pulsation of the abdominal aorta communi- cated to the parts resting on it, owing to temporarily increased action of the heart. The pulsation is most marked below the epigastrium, and the impulse communicated to the hand is a short, smart shock, very unlike that of aneurism. On ausculta- tion, a short whiff is audible, particularly when the stethoscope is pressed firmly upon the part. This variety of epigastric pul- sation has remissions or complete intermissions ; it is excited or aggravated by mental emotion, deranged digestion, or in- temperance ; and is sometimes a source of considerable distress to the patient. Ancemic Pulsation — A pulsation in the epigastric region com- municated by the abdominal aorta, occurs likewise in anaemic subjects, particularly when this state has been brought on by pro- fuse hemorrhage. The pulsation is strong, abrupt and knocking, accompanied by a short, whizzing murmur, leading, sometimes, to the suspicion of aneurism. The pulsation, which is evident to the eye as well as perceptible to the hand, is most marked below the epigastrium, and is in a great measure limited -to the line of the artery. In such cases, visible pulsation is present, and a * Treatise on Diseases of the Heart. ANGINA PKCTORIS. 177 similar sound on auscultation is audible in tlie large vessels which come off from the arch of the aorta. Pulsation communicated to abdominal Tumors. — Diseased states of some of tlie contents of the abdomen, as of the omentum, mesentery, or pylorus ; or air or foeces confined in the transverse colon, occasionally have an impulse communicated to them, where they rest upon the aorta below the diaphragm. The pulsation is both evident to the eye and perceptible to the hand, and has been mistaken for abdominal aneurism. It may be distinguished by the impulse wanting the heaving character of the impulse of aneurism in this situation, and by the absence of lateral impulse ; by no murmur being audible on auscultation, or by its different character ; by the mobility of the tumor, by the previous history of the case, and by the absence of pain, and other signs of abdo- minal aneurism. Dr. Baillie,* many years since, called attention to a variety of epigastric pulsation of which he had met several examples, and which probably belongs to one of the forms already noticed. He observed it in persons about the middle period of life, most frequently in the male ; the pulsation which was often visible to the eye, was stronger in some subjects than in others ; varied in strength at different periods, and was usually most marked in the horizontal posture. He believed it to be connected with deranged digestion and an irritable constitution. It is apt (he observes) to cause a good deal of unnecessary anxiety in the patient : it does not depend upon any diseased condition of the artery, for he has known it to continue well marked during twenty-five years without the health suffering ; and in two instances in which he made a post-mortem examination, the artery was perfectly healthy. ANGINA PECTORIS. Among the secondary symptoms of cardiac disease, one occa- sionally met with is familiar, by name at least, to practitioners, as " angina pectoris." It presents itself in several degrees, some- times in a mild, at others in a very intense form ; but, whether mild or severe, its prominent feature is pain, and pain of a pecu- liar kind. * Trans, of College of Physicians, vol. 4. N 178 EXAMINATION OF THE HEART IN DISEASE. A paroxysm of angina, when well marked, is characterised by sudden, severe, constrictory or burning pain, referred to the lower part of the sternum, or to the prsecordial region, extending through the chest to the left scapula and up the sternum to the root of the neck, which compels the patient if walking, instantly to stop, and almost prevents inspiration. Pain is felt likewise in the left shoulder, which reaches to the elbow, rarely to the hand, often with a sensation of numbness in the parts ; accompanied by a feeling of constriction of the chest, by a tendency to syncope, or by intense anxiety and a sensation of approaching dissolution, with or without palpitation, or irregular action of the heart. The paroxysm of angina varies in length and intensity ; it occurs at irregular intervals, but is generally brought on by mus- cular exertion of some kind, as running or walking quickly up a hill, particularly after a full meal ; or by mental emotion, as a fit of passion ; and it is most common in persons of a gouty habit, who have passed the meridian of life ; and in males rather than females. In many instances angina occurs in a mild form, the patient suffers merely from constrictory pain in the praecordial region on walking quickly, or ascending a height, which lasts but a few seconds and then passes off. In others, however, the paroxysms are more intense and of longer duration, they occur more fre- quently ; while they are excited by more trifling circumstances, such as the simple acts of dressing or undressing, passing from a warm to a colder atmosphere ; or, they may supervene during sleep. Causes of Angina. — In the generality of treatises on diseases of the heart, angina pectoris is classed apart as a distinct disease. The earlier writers upon the subject, supposed it to have some mysterious connexion mth ossification of the coronary arteries ; while others referred it rather to excessive disposition of fat upon the heart. Modern pathologists having failed not unfrequently in discovering either of these morbid changes, and seeing the suddenness with which it supervenes and subsides, refer it to " spasm of the heart." This is the view taken of it by Dr. Latham ; Dr. Chever's* definition is however more precise, he regards it as "a spasm of a loeakened heart." Other pathologists again, looking more to the character and intensity of the pain, * Pract. Treatise on Diseases of the Heart, Calcutta, 1851. ANGINA PECTORIS. 179 regard it as a form of neuralgia, and describe it under the title ^^ neuralgia of the heart.'' I do not think sufficient evidence has been adduced to entitle angina pectoris to be regarded as a distinct disease ; neither do I think it necessary to call in the aid of spasm or neuralgia, when there are circumstances in its clinical history and pathology which seem to be quite capable of explaining all its phenomena inde- pendent of either. Thus, angina, in a well-marked form, is not seen except in cases of organic disease of the heart ; and as a general rule, it is not observed even in these, unless something occurs either to disturb the action of the heart or to hurry the circulation. The immediate cause of angina pectoris appears to me to be a sudden impediment to the coronary circulation, particularly to the return of the blood by the coronary veins ; itself, in general, the result of a temporarily over-distended state of the chambers of the heart, and an inability in them to empty themselves, wliether owing to weakness of the muscular tissue of the parietes of the left ventricle, or to other causes. For instance, if the cavity of the left ventricle is considerably dilated, or its walls are attenuated or softened, or have undergone fatty degeneration, the contractile power of its muscular tissue will be impaired in pro- portion ; and if the circulation happens to be suddenly hurried, or the heart's action to be suddenly disturbed, the cavity of this ventricle might become so much distended as to render it in- capable of contracting upon its contents, which would be quickly followed by distension of the auricle on that side, and, if relief is not soon experienced, by distension of the right side of the heart. It is scarcely necessary to say, that in a normal state of the circulation all the chambers of the heart are never full of blood at the same moment. When the ventricles are filled, the auricles are comparatively unfilled, and vice versa. Here, however, we would have a suddenly distended state of the chambers on both sides of the heart at the same moment. From the position of the coronary vessels in the grooves of the heart, they cannot, we know, suffer compression during the alternate movements of the ventri- cles and auricles ; but if the auricle and ventricle upon each side of the heart are distended at the same time, these vessels, but par- ticularly the veins, must suffer compression, by which their circu- lation will be impeded ; and the great coronary vein, in addition, 180 EXAMINATION OF THE HEART IN DISEASE. may be prevented from freely emptying its contents into the right auricle, in consequence of tlie distended state of this cavity. We know, likewise, that the normal capacity of the pericardial sac is but little greater than that of the heart in its ordinary state of distension ; and that this membrane is composed of tissue which does not suddenly yield. The parietes of the heart would there- fore, under the circumstances that I have described, be placed between two compressing forces — an undue amount of blood in the chambers of the organ, and the unyielding pericardium upon the outside. The effect of this compression of the heart's tissue would necessarily be to impede still further the coronary circu- lation, and to clog still more the movements of the organ ; and the condition of the heart would be somewhat analogous to that in which a large amount of fluid was suddenly effused into the pericardial sac, from rupture of a vessel or other cause. The organic lesions of the heart most likely to be attended by angina would therefore be, a condition of the aortic valves per- mitting free regurgitation, with a rigid, dilated state of the ascend- ing portion of the arch of the aorta, which permits the blood from the large vessels to regurgitate into it, combined with, either 1 . Dilatation of the cavity of the left ventricle ; or, 2. Attenuation of the parietes of the left ventricle ; or, 3. Softening or fatty degeneration of the muscular tissue of this ventricle. For instance, when the aortic valves permit free regurgitation, there is, at each ventricular diastole, a reflux of blood from the aorta into the ventricle at the same time that the current is enter- ing it from the auricle ; the left ventricle consequently is unable to empty itself, the state of distension in which it is kept leads to permanent dilatation of its cavity, which tends still further to em- barrass the circulation by enfeebling the ventricle, and diminish- ing its power of expelling its contents. It has been shown by Hales, that " each square inch of the surface of the interior of the ventricles has a pressure upon it during the systole equal to about four pounds ;" and " as the re- sistance which the heart has to overcome in contracting is, ac- cording to hydrostatic laws, in proportion to the extent of the inner surface of the cavity at the commencement of the systole," if the cavity of the ventricle is dilated, more force'will be required ANGINA PECTORIS. 181 to enable the ventricle to expel its contents ; and the greater the amount of the dilatation the less able will the ventricle be to over- come the resistance. In such a state of the aortic valves, and in such a condition of the ventricular cavity, if the parietes of the left ventricle are, in addition, attenuated or softened, the ventricle will be still less capable of overcoming the resistance, and a very trifling muscular exertion, or a sudden mental emotion, may lead to over distension of its cavity, followed by distension of the other chambers of the heart. If, at the same time, the arch of the aorta is dilated, and its coats are rigid and inelastic, permitting the blood from the large arteries which come oflf from the arch, to re- gurgitate into it, the coronary circulation will be necessarily im- peded, and a paroxysm of angina may be the result. Any one of the foregoing morbid conditions of the heart may be present, or two or more of them may be combined, without angina necessarily occuring ; indeed, as long as the circulation continues tranquil, and as long as the left ventricle is able to get rid of the blood which enters its cavity, the latter cannot become over-distended. If, however, the heart's action is disturbed by some sudden mental emotion, or other cause ; or even without this occuring, if the stomach is loaded with indigestible food, and it and the intestines are distended with flatus, by which the cavity of the chest is encroached upon, and the heart's movements are impeded, a paroxysm of angina may be the result. Hence, in persons who have had previous attacks, it is liable to supervene during sleep, when it may be the result of a frightful dream, dis- turbing the heart's action ; or, of considerable distension of the stomach by flatus, impeding the movements of the organ. Dr. Forbes,* in his able article on the subject, has shown that plethora is a very common complication of angina ; a state which, if combined with a weak heart, would give a further predisposi- tion to the attack. Thus, " the subjects of angina (Dr. Forbes observes) are mostly of the male sex, above 50 years of age, and a great majority of them belong to that class of persons who are enabled to indulge in full living, without the necessity of under- going severe bodily labour." Again, "gout is a very frequent disease in persons subject to angina, and obesity is extremely common." " The very existence, too, of angina tends (he adds) * Cyclopaedia of Practical Medicine. 182 EXAMINATION OF THE HEART IN DISEASE. to produce plethora if it did not previously exist ; a sedentary life and abandonment of all active bodily exertions, are almost inevi- table consequences of the disease." It may, perhaps, be objected that the foregoing explanation of the cause of angina is insufficient to account for the peculiar pain which accompanies a paroxysm. I cannot, however, imagine any state more likely to be attended by intense distress, anxiety, and suffering, with a sensation of impending dissolution, than such as I have described — where the chambers of the heart are im- moderately distended, the coronary circulation temporarily ob- structed, the heart's movements clogged or impeded, or its mus- cular tissue compressed. It has been objected to this theory, that " in cases of emphysema with bronchitis, where the heart is greatly congested, and usually becomes enlarged and softened, angina hardly ever occurs." But the injurious effects of emphy- sema and chronic bronchitis are exerted upon the right not the left side of the heart, and over-distension of its cavities is re- lieved by the provision which permits of regurgitation tlirough the tricuspid orifice whenever over-distension of the right ventricle occurs. Angina pectoris, in its most marked form, is almost peculiar to advanced life; thus, of 84 cases recorded by Dr. Forbes, 72 were above 50 years of age, and only 12 under that age. The reason of this is sufficiently obvious ; the morbid conditions upon which it depends are, in some measure, limited to advanced life. Again, when a person has been once the subject of angina, subse- quent attacks are very likely to ensue if the exciting causes come into operation, because the diseased states on which it depends are irremediable. Lastly, angina is rare in the female compared with the male; because the diseased state of the aorta so frequently associated with it, is very seldom met with in the female ; in- deed, regurgitant disease of the aortic valves, itself, is less frequent in the female than the male. In conclusion then, I would say, that angina pectoris ought to be regarded rather as a symptom of organic disease of the heart than as a distinct form of disease ; in fact, what dyspnoea is to the lungs, angina appears to be to the heart ; and it might without im- propriety be termied the dyspnoea of the heart. Thus both are met with in very variable degrees of intensity ; both have some- ANGINA PECTORIS. 183 times apparently almost purely a spasmodic character, and both are often the result of mechanical causes — in the one case, of some impediment to the free passage of the air into or out of the lungs ; in the other, of an impSSiment to the circulation in and through the heart. It would indeed, in my mind, be almost as absurd to class dyspnoea apart, and describe it as a distinct affection, as it is to make angina a separate disease. As dyspnoea may arise under variable and opposite states of pulmonary disease, so angina may ensue in different forms of cardiac disease. We can, likewise, easily understand from what precedes, that if the paroxysm of angina is slight, it may pass off spontaneously ; or under the influ- ence of stimulants and other appropriate measures, the heart may be enabled to get rid of the blood which distends its cavities ; while, if the paroxysm is severe and continued, complete arrest of the coronary circulation may ensue, followed necessarily by cessa- tion of the heart's action, and the death of the patient. Conclusions respecting Angina Pectoris. The conclusions which I would draw from what precedes are, 1. That angina pectoris is to be regarded as a symptom of disease of the heart, not as a distinct affection. 2. That it does not occur except where organic disease of the heart, generally of long standing, exists. 3. That its connexion with spasm, or neuralgia, is doubtful. 4. That its probable cause lies in impediment to the coronary circulation, particularly to the return of the blood by the coro- nary veins. 5. That the diseased states of the heart in which it is most liable to ensue, are a condition of the aortic valves permitting free regurgitation, with a rigid dilated state of the ascending portion of the arch of the aorta ; combined with, either dilatation of the cavity, or attenuation or softening of the parietes of the left ven- tricle. 6. That even in these diseased states, angina may not occur unless the heart's action is suddenly disturbed, or its movements are clogged, or impeded by some mechanical cause. 184 EXAMINATION OF THE HEART IN DISEASE. THE PULSE AS A MEANS OF DIAGNOSIS IN CARDIAC DISEASE. Previous to, and even for some time subsequent to the dis- covery of auscultation, the pulse as an aid fb diagnosis in cardiac disease, was of very little value ; indeed, it is obvious that until the order of succession of the movements of the heart was known, and the auscultatory signs which characterise the several diseased states of the valves were laid down with some precision, any in- formation derived from the characters of the pulse must have been very vague. The ol)scurity which formerly invested this subject has, however, now been in a great measure dispelled ; and the labours of successive investigators have shown, that certain forms of cardiac disease are capable of impressing peculiar and well- marked characters upon the pulse. The pulse is produced by the contraction of the left ventricle, which at each systole propels a certain amount of blood into the aorta ; " the blood not being able to escape from the arteries as quickly as it is forced into them by the ventricle, on account of the resistance it experiences in the capillaries, necessarily exerts a pressure on the elastic coats, and thus gives rise to the pulse." The pulse, therefore, corresponds with the ventricular systole, and with the first sound of the heart ; and when the heart, the arterial system, and the blood, are each in a normal condition, the force, the strength, the frequency, and the fullness of the radial pulse, may be taken as a measure of the strength or feebleness of the systole of the left ventricle — of the rapidity with which the movements of the heart are performed, and of the amount of blood transmitted at each systole of the left ventricle. At each systole of the left ventricle the arterial tubes become elongated ; hence, in situations where these vessels have naturally a curve, this curve is increased ; and where they are naturally straight, they become slightly curved ; when the ventricular sys- tole ceases, they return to their former position. In thin subjects this locomotive movement is perceptible in vessels near the surface, as in the temporal artery and in the radial at the wrist ; and this which is in reality a natural phenomenon is not unfrequently set down as a sign of disease. It, undoubtedly, becomes more marked in cases where regurgitation through the aortic valves, or into the aorta itself occurs ; but a visible and locomotive pulse in these VARIETIES PRESENTED BY THE PULSE. 185 arteries, unless accompanied by other signs of disease, has no value by itself, and is frequently observed in cases where the heart and arterial system are healthy. At the moment that the pulse is felt, the arteries, in addition to becoming elongated, dilate, and increase in volume. " Every fluid exposed to pressure from behind," Weber* observes, " reacts on the surrounding parts, not merely in the line of direction of that pressure, but on every side ; and, therefore, at each con- traction of the ventricle, the blood the arteries contain, reacts in consequence of the impulse pressure of the injected blood, not merely longitudinally, but laterally, the arteries being fixed at both extremities." It has been denied by some physiologists that any dilatation of the arteries occurs : it does, however, take place ; and M. Poiseuille,t by means of an apparatus, capable of being applied round an artery, has determined the amount of this in- crease to be, for the larger arteries about the one-eleventh of their diameter. The increased capacity of the arterial tubes depends more, however, upon their elongation than upon their dilatation. The beat of the pulse in the radial artery is a little later than the ventricular systole ; but the interval is almost inappreciable, unless the pulse is unusually slow: in arteries further from the centre of the circulation this is somewhat more marked. Thus, according to Weber, the beat of the anterior tibial artery upon the dorsum of the foot, is between the sixth and the seventh part of a second later than that of the axillary artery. According to Hamersyk,J the pulse at the wrist, in the temporal artery, and in the femoral, near Poupart's ligament, is perfectly synchronous ; and according to Weber, the pulse of the axillary artery, and of the external maxillary artery, is synchronous. The radial pulse is said to follow the ventricular systole by a more appreciable in- terval when the aortic valves permit regurgitation : if it really does so, it is not a sign of any importance. " In debilitated and atonic states of the system the radial pulse," Dr. Williams § observes, " follows the first sound of the heart by a distinct interval, which is occupied by the transmission of the wave along the course of the comparatively lax and yielding artery." In some individuals, to all appearance in perfect health, the pulse * Quoted in Dublin Journal. f Magendie's Journal. t Gazette Medicale. March, 1844. § On Diseases of the Chest. 186 EXAMINATION OF THE HKART IN DISEASE. is preternaturally slow ; in others, it is preternaturally quick ; and in others, again, it is intermittent. These peculiarities are con- nected with a similar condition of the heart's action ; they appear to be the result of idiosyncrasy, and are sometimes hereditary. The curious fact has been occasionally noticed, that in an individual whose pulse in health intermitted, it became regular on the inva- sion of illness of a febrile character. It is important to bear in mind that these peculiarities in the pulse are occasionally met with, lest they should be too hastily set down to disease of the heart, with which they may have no connexion. Disease of the right side of the heart exercises no direct influence upon the pulse, but valuable information may sometimes be obtained from its characters in diseased states of the left side of the organ. Although the radial pulse is, in the great majority of cases, an indication of the frequency of the contractions of the left ventricle, it does not ne- cessarily indicate the force of the contraction. Thus, in some cases of disease, although the action of the heart is violent, and its impulse strong, the radial pulse is small and feeble ; while, on the other hand, we know that in cases of local inflammation, the artery going to an inflamed part may beat very strongly, although the heart's action is not increased. In all doubtful cases, therefore it is advisable to place one hand upon the praecordial region, or to auscultate the region of the heart, while the finger is on the radial pulse. " We can thus," Dr. Williams observes, " take a far more accurate survey of the condition of the circulation, than by ex- amining these parts separately ; and the utility of this method is by no means confined to afl:ections of the heart." In several morbid conditions of the heart, the pulse becomes quicker than natural : I am not aware of any diseased state of the organ in which it necessarily becomes slower, though this con- dition of the pulse is occasionally observed in softening of the muscular tissue of the organ, more rarely in very contracted states of the aortic orifice. The pulse, in some diseased states of the heart, becomes stronger, fuller, and harder than natural ; in others, softer, weaker, smaller, or feebler than natural; and in others, again, it becomes jerking and receding. In all these cases the pulse may be regular; but it not unfrequently happens that its rhythm is disturbed, when the pulse intermits, or becomes unequal or irregvilar ; and these conditions of the pulse may be either VARIKTIKS PRESENTED BY THE PULSK. 187 combined together, or with some of the other states mentioned above. The morbid conditions under which these varieties of the pulse occur, may consist in inflammation of the investing or lining mem- brane of the heart ; in alterations of its muscular tissue ; in changes in the capacity of its cavities ; in diseased conditions of its valves or orifices ; in alterations of the blood ; in diseased states of the arteries ; and in derangement or disease of other organs reacting upon the heart. The quality of the blood contained in the vessels exerts a material influence upon the pulse ; when this fluid is attenuated, when its red particles are diminished, its serous part increased, and its viscidity lessened, whether this depends upon profuse hsemorr- hage, or arises under other circumstances, the contractions of the heart become more frequent, and the radial pulse is consequently quickened ; at the same time, the blood is impelled with less force ; while the healthy tension of the arteries being diminished, and their tubes not being filled, the pulse acquires a jerking character resembling the pulse of aortic regurgitation. The quantity of the blood contained in the vessels, no less than its quality, exercises some influence upon the pulse. " When there is a due correspondence between the capacity of the vascular system, and the quantity of blood circulating in this system, the coats of the arteries will (Dr. Copland observes*) be kept in that state of healthy tension, or tone, favourable to a regular, firm, free, natural, or healthy pulse, varying chiefly in frequency with the state of the heart's action." When the amount of blood in the system is greater than natural — in other words, in that state of the system denominated plethora — the pulse is full and hard, but not increased in frequency. The sensation produced by an artery in cases of excessive vascular fulness. Dr. Copland designates by the term " oppression ;" the vessel feeling as if "it were kept in a state of tension, or of distension, in the interval between the beats." Pulse in hypertrophy of the left Ventricle — When the parietes of the left ventricle are increased in thickness — in other words, in hypertrophy of the ventricle — its systole will be strong in pro- portion, the blood will be propelled into the aorta with increased force, and the radial pulse will be strong and hard : its velocity * Diet, of Pract. Medicine. loo EXAMINATION OF THE HEART IN DISEASE. will not, however, be increased ; but, as the systole of an hyper- trophied ventricle takes a longer time to be completed, the pulse will "dwell longer under the finger." When some dilatation of the cavity of the ventricle is combined with hypertrophy of its walls, the pulse, as long as the circulation continues free, will have the same character, and, in addition, it will be full, because a larger amount of blood will then be impelled at each systole. Pulse in dilatation of the left Ventricle. — When the cavity of the left ventricle is dilated, and its walls are attenuated, or even though they may preserve their normal thickness, the ventricular systole will be performed with less vigour, and the blood will be propelled with less force than in a healthy state of the heart : hence the radial pulse will have nearly opposite characters to those of the former state ; and, instead of being hard and strong, and dwelling long under the finger, it will be soft and weak, though it may be large. Pulse in aortic regurgitation When the aortic orifice, or its valves, become altered by disease, or when, from any other cause, the valves imperfectly fulfil their function, the blood will regur- gitate into the left ventricle at each diastole, and the pulse in con- sequence will acquire a peculiar character, being jerking and re- ceding, though regular, while the pulsation of the arteries of the upper extremities and neck is visible and locomotive. This, which is sometimes termed the pulse of unfilled arteries, is very peculiar, and when once felt can scarcely be mistaken. In well-marked examples, it appears as if the blood was divided into separate little balls, which pass in rapid succession under the finger. This sen- sation becomes more marked if we apply the finger to an artery of larger calibre than the radial, as the brachial ; and if we lay two or more fingers upon the line of the artery. Cause of the jerking pulse of aortic regurgitation. — The ex- planation of the cause of this peculiarity in the pulse is sufficiently simple. We have seen that the arteries, at the moment that the ventricular systole occurs, dilate ; when the diastole occurs they return to their former state, owing to the elasticity of their coats. We have seen, also, that the arteries in the healthy state are always filled : there is a continuous column of blood in them ; and the fresh portion transmitted into the aorta at each contrac- tion of the left ventricle, displaces a column of blood of equal VARIETIES PRESENTED BY THE PULSE. 189 size ; an impulse is communicatedj and the pulse is felt. Thus when an artery is wounded, or divided across, the blood escapes in a continuous stream, but is accelerated at each ventricular sys- tole ; the continuous stream being produced by the elasticity of the artery reacting upon the blood, in the intervals between the systole of the ventricle. Now, when the aortic valves imperfectly fulfil their office, the moment that the ventricular systole ceases a portion of the blood returns from the aorta into the left ventricle, there is a backward motion of the blood in the aorta as the ventri- cle dilates, which may be favoured by the elasticity of the coats of the vessel. The arteries of the upper extremities and neck of course feel the effect most ; they are less perfectly filled, the healthy state of tension of their coats is diminished, they react with less force upon their contents, and the blood has a forward motion, or, at least, is propelled with any force only during the period that the ventricular systole lasts : hence the column of blood appears to be interrupted, and the pulse has this jerking and receding character. In cases of ansemia, the same effect seems to be produced by the coats of the arteries losing tone or elasticity in consequence of deficient nutriment : the vessels are consequently imperfectly filled, and the blood is moved forward apparently only at the period of the ventricular systole. This peculiarity of the pulse is not how- ever limited to the cases mentioned, it is observed sometimes in aneurism of the ascending or transverse portion of the arch of the aorta ; as well as in cases of disease of the aorta itself, when this vessel has become rigid and elastic from adventitious deposit, which condition is often accompanied by dilatation of the artery. Here it is produced by the regurgitation of the blood from the large arteries, during the ventricular diastole, into the aorta itself, or into an aneurismal sac. In addition, in patency of the aortic valves, the pulsation of the superficial arteries of the head, face, and upper extremities, is visible and locomotive ; as first pointed out by Dr. Corrigan.* This phenomenon is most remarkable in the temporal and radial arteries and their branches, in which "the arteries sometimes (as Dr. Williams observes) appear like worms under the skin, wrig- gling into tortuous lines at each pulse." Delay of the radial pulse * Edinb. Med. and Surg. Journal, vol. xxxvii., 1832. 190 EXAMINATION OF THE HEART IN DISEASE. has been set down as a symptom of patency of the aortic valves ; but, as Dr. Douglas* observes, "it has a doubtful connexion with valvular disease ; and it does not occur except in conjunction with more or less dilatation." He says he has met with it alto- gether apart from valvular disease. The radial pulse, in the majority of cases is an index of the strength, as well as of the frequency of the ventricular systole ; in nervous palpitation, however, althougli the impulse of the heart may be strong tlie pulse is weak, but as the palpitation subsides it becomes fuller; again, it may happen that every contraction of the left ventricle is not propagated to the radial artery, owing to its sys- tole being too feeble to propel the blood with sufficient force to give an impulse capable of being felt with the finger. If this recurs with regularity at every second beat, the pulse will appear to be preter- naturally slow ; and this, no doubt, was the condition in some of the cases of remarkably slow pulse reported previous to the discovery of auscultation. The error will be corrected by laying the stetho- scope upon the prsecordial region, while the finger is upon the pulse. Intermission and Irregularity of the Pulse. The rhythm of the heart and the regularity of the contraction of the ventricles, are in general manifested by the pulse at the wrist : the heart's action cannot be intermittent or irregular with- out its being communicated to the radial artery; but the pulse may intermit, although the heart contracts regularly, if every fifth, sixth, or seventh ventricular systole, as the case may be, is too feeble to propel a sufficient quantity of blood to communicate an impulse to the radial artery. Intermission may be regarded as the slightest degree of de- rangement of the heart's action. It is not uncommon, as has already been observed, in individuals in whom the heart and arterial system are healthy ; the intermissions may occur at regular or irregular intervals, and this state may continue through life. This form of derangement of the rhythm of the heart's motions is not uncommon in persons advanced in life, in gouty subjects, and in individuals labouring under derangement of the digestive organs, accompanied by flatulence. It is frequently likewise met with in cases of disease of the valves, or of the muscular tissue of * Edinburgh Mgnthly Journal. VARIETIES PRESENTED BY THE PULSES. 191 the heart, when it is often accompanied by irregularity, or in- equahty of the pulse, and it becomes then a sign of considerable importance. By an unequal pulse we understand one in which some pulsa- tions are_ strong and others weak. By an irregular pulse, one in which a few rapid beats are succeeded by one or more slower beats, and when the interval between them is different. In- equality and irregularity of the pulse are much more unfavourable signs than simple intermission, and are not observed except in cases of disease. Both are frequently met with in the same cases, and both accompany certain diseased states of the valves at the left side of the heart, of the muscular tissue of the organ, and of its investing membrane, the pericardium. Pulse in contraction of the left auriculo-ventricular Orifice. — When the mitral valve or the left auriculo-ventricular orifice become diseased, so as to impede the passage of the blood from the left auricle into the left ventricle, the radial pulse will be weaker than natural, and will occasionally intermit. When this condition of the valve or orifice is more advanced, and the ob- struction to the passage of the blood through the orifice becomes greater, the pulse, in addition to being weak and intermittent, will become small, irregular, and unequal, although the heart's action continues to be strong. Mr. Adams,* of this city, was the first to call particular attention to the want of correspondence be- tween the strength of the pulse at the wrist and the impulse of the heart in this form of disease : " the heart often beats so violently (he observes) as to shake the patient in his bed, while the pulse is small, weak, and irregular," "I know not how," he adds, *'to describe it otherwise than by saying that it appears as if there were two pulses ; one slow and deliberate for two or three beats, succeeded by three or four rapid and indistinct pulsations." Pulse in mitral regurgitation. — When the mitral valve im- perfectly closes the left auriculo-ventricular orifice, and regurgita- tion into the auricle occurs at each ventricular systole, the pulse will be scarcely affected if the aperture is very trifling ; when larger, the pulse will become weak and small, and will intermit particularly when the circulation is hurried. When the mitral orifice is much enlarged, and permits a considerable portion of the * Dublin Hospital Reports, vol. iv. 192 EXAMINATION OF THE HEART IN DISEASE. blood to regurgitate into the auricle at each ventricular systole, the pulse, in addition to being small and weak, will become irre- gular and unequal, resembling the pulse of considerable contrac- tion of this orifice. Hence in the advanced stage of these two opposite conditions of the mitral orifice, the pulse presents similar characters : thus when this orifice is much contracted, a smaller amount of blood can enter the ventricle from the auricle at each diastole ; the ven- tricle therefore is imperfectly filled, and less blood than natural is transmitted into the aorta at each systole of the latter ; the pulse therefore is necessarily small and feeble, and eventually intermit- tent, irregular, and unequal. Again, when the mitral orifice is much dilated, a portion of the blood is transmitted backwards into the left auricle at each ventricular systole, and the same re- sult follows, a smaller quantity than natural is transmitted into the aorta at each systole, and the pulse becomes small, weak, ir- regular, or unequal in proportion. Pulse in contraction of the aortic Orifice — When the aortic orifice is slightly contracted, the stream of blood transmitted into the aorta at each systole of the left ventricle must be somewhat less than natural ; but as the walls of the ventricle under such circumstances almost always become hypertrophied, what is want- ing in quantity is made up by the strength of the ventricular sys- tole, and the pulse will be neither weaker nor smaller than natu- ral, and will be perfectly regular. When the contraction, how- ever, becomes extreme, as sometimes happens, though much less frequently than at the mitral orifice, the pulse will then become small, and intermittent, or irregular, resembling the pulse of con- siderable contraction of the mitral orifice, or of free regurgitation through it. Slowness of the pulse has been said to be sometimes the result of considerable contraction of the aortic orifice ; but we have not sufficient clinical evidence of the fact. Pulse in softening of the Heart. — A small, weak, irregular, and unequal pulse is not, however, peculiar to cases of valvular disease ; the radial pulse has the same characters, and in a still more marked degree, in the advanced stage of softening of the heart, fi-om fatty degeneration, or other cause, particularly when com- bined with dilatation of the cavity of the left ventricle. The con- tractile power of the ventricle being necessarily weakened when VARIETIES PRESENTED BY THE PULSE. 193 tlie muscular tissue is softened, tlie force with which the blood is propelled into the aorta, v/ill be diminished ; while the weakened ventricle, being unable to empty itself at each systole, the quantity of blood which it propels into the aorta is less than natural : hence, not only is a smaller quantity of blood transmitted into the aorta, but, it is transmitted with diminished force, and the pulse under such circumstances becomes, sometimes, so small, weak, irregular, and unequal, that it is impossible to count it. Combined with weakness, and irregularity, or independent of either, the pulse is sometimes much slower than natviral in this diseased state. Dr. Stokes,* recently, has called attention to the circumstance, in one of his cases the pulse ranged between 28 and 36 ; in another between 35 and 40. Dr. Quain, in alluding to this point, says,t " tlie slowness of the pulse is sometimes quite remarkable ;" in one instance, it was only 24 in the minute in the recumbent posture, and never above 32. A small, weak, and irregular pulse is also observed in cases of pericarditis, accompanied by copious liquid effusion, by which the heart's movements are materially impeded ; or where fibrinous concretions form in the cavities of the heart previous to death, by which the passage of the blood through them is obstructed ; or in any case where much embarrassment of the cardiac or pulmonary circulation exists, as towards the close of several diseases of the heart or lungs. SUMMARY OF THE PRINCIPAL VARIETIES OF THE PULSE. In the following summary of the more prominent characters of the pulse, in the several diseased states we have been considering, the varieties of the pulse are arranged according to their regu- larity or irregularity. The first division includes the cases in which the pulse is usually regular ; the second, those in which the pulse is usually irregular. PULSE REGULAR. 1. In plethora the pulse is full, hard, and resistant, but not more frequent than natural. 2. In anaemia, the pulse is smaller, weaker, and quicker than natural, and in addition has a jerking character. * Dublin Quarterly Journal, Aug., 1846. f Medico. Chirurg. Transactions, vol. xxxiii. 194 EXAMINATION OF THE HEART IN DISEASE. 3. In hypertrophy of the left ventricle, the pulse is " strong and prolonged." When dilatation is combined with the hyper- trophy, the pulse is in addition full. 4. In dilatation of the left ventricle without hypertrophy, the pulse is large, but weak. 5. In dilatation with attenuation of the left ventricle, the pulse is weak and soft, easily quickened, and occasionally intermittent. 6. In patency of the aortic valves, the pulse is jerking, visible, and locomotive, but its frequency is not increased. 7. In diseased states of the coats of the arch of the aorta, with increase of the calibre of the vessel, the pulse has the same charac- ters, but in a somewhat less marked degree. 8. In aneurism of the arch of the aorta, the pulse may have a different strength in each wrist, or it may be absent altogether in the radial artery on one side. It might also have a jerking character, resembling that of aortic regurgitation. PULSE IRREGULAR. 1. In extreme contraction of the mitral orifice, the pulse is small, weak, intermittent, irregular, and unequal. 2. In regurgitation through the mitral orifice, when slight, the pulse is little altered ; when extreme, the pulse has the same characters as in considerable contraction of the orifice. 3. In contraction of the aortic orifice, the pulse presents no peculiarity unless the degree of contraction is extreme, when it becomes small, irregular, and intermittent, rarely slower than natural. 4. In fatty degeneration of the muscular tissue of the left ven- tricle, the pulse, in the advanced stages, is small, weak, irregular, and unequal, sometimes slow. 5. In pericarditis with copious liquid efiusion, the pulse pre- sents somewhat similar characters. 6. In cases where fibrinous concretions form in the cavities of the heart, the pulse suddenly becomes small, weak, intermittent, and irregular. 7. In adhesion of the pericardium, the radial pulse is occa- sionally intermittent and unequal. From what has been said, it may be gathered, that in several forms of cardiac disease, the characters presented by the pulse are VARIETIES PRESENTED BY THE PULSE. 195 of a nature, materially, to aid the diagnosis : and if the different cardiac lesions were met with always distinct from each other, and uncomplicated with other affections, the signs derived from the pulse would be most valuable. Unfortunately, however, this is not often the case. Two or more forms of structural disease are frequently combined ; for instance, hypertrophy and dilatation of the left ventricle are very frequently associated ; and, as these morbid conditions are the ordinary result of disease of the valves, we may have obstructive or regurgitant disease of the aortic or mitral valves, or of both, combined with hypertrophy, or dilata- tion of the left ventricle, or with the two latter states. In addition, disease of any part of the heart may be associated with a state of anaemia or hysteria, with functional derangement, a gouty or a nervous habit, or with some of the other morbid conditions that have been alluded to ; when the pulse, if trusted to alone, would be more likely to lead into error, than to assist the diagnosis. It must be borne in mind, too, that intermission or irregularity of the pulse may ensue in any diseased state of the heart, when the pulmonary circulation becomes greatly obstructed. It should be also recollected, that a very trifling morbid alteration of the valves at the left side of the heart, which may be accompanied by a loud bruit de soufflet, often causes no alteration of the pulse ; while, in a very advanced stage of the same disease, when the pulse is inter- mittent and irregular, an abnormal sound may be absent. Finally, as the systole of the right ventricle exercises no direct influence upon the pulse, the walls of the right side of the heart may be hypertrophied, or their cavities dilated ; or its valves or orifices might be diseased, without the pulse indicating in the slightest degree the morbid alteration. 196 CHAPTER VIII. SECONDARY SYMPTOMS OF CARDIAC DISEASE.— CONGESTION— CONGESTION OF THE HEART, LUNGS, LIVER, INTESTINES, AND BRAIN.— POLYPOID CONCRETIONS IN THE CAVITIES OF THE HEART.— DROPSY. The secondary, the indirect, or the remote symptoms of cardiac disease, are, in the majority of cases, the result of some impediment to the return of the blood, conveyed by the pulmonary veins to the left side of the heart, or to that of the venous blood from the system generally through the right side of the organ, which in their turn are frequently the result of an obstruction to the free passage of the blood through the chambers of the heart. The blood, being retarded and delayed in the large veins, accumulates in the smaller vessels and capillaries ; they become distended and dilated, their healthy state of elasticity or tone is impaired or di- minished ; and congestion is the result, wliich may be limited to the lungs and bronchial mucous membrane, or may extend to the liver, spleen, kidneys, and gastro-intestinal mucous membrane, causing more or less derangement of function in these organs. When we speak of congestion, therefore, we mean a state in which there is a preternatural accumulation of blood in the minute veins and capillaries, with a weakened, retarded circulation, and a loss or deficiency of tone in the coats of the dilated vessels ; in consequence of which they " react imperfectly upon the blood transmitted to them," and are unable to " transmit the force of the current in the proper direction," " vessels which have lost their tone becoming inelastic and tortuous, and, by the very stagnancy of the blood in them, opposing an increasing obstacle to its passage through them." The cause of the motion of the blood in the capillaries, is now generally considered to lie in the impulse given to this fluid by the contraction of the ventricle. An experiment which was per- formed by Dr. Sharpey seems to confirm this. "A syringe, with CONGESTION. 197 a hsemadynamometer, to show the amount of pressure used, was adapted to the aorta of a recently dead animal, the vena cava being divided ; warm water was then injected, and, with a force which raised the mercury in the hgemadynamometer only three inches, the water passed through the capillaries, and out of the vena cava. When the pressure was increased so as to raise the mercury six inches, the flow was very free ; and on adapting another hsemady- namometer to the vein, the pressure in this, was found to rise as high as three inches. The pressure thus used in the arteries (six inches of mercury) was not greater than the natural pressure in the arteries of a living animal ; and the pressure transmitted to the veins (three inches of mercury) was greater than that in the veins of a living animal — thus, showing, that the force of the heart, sustained by arterial tension, is quite adequate to effect the circu- lation without other aid." Hence, when the contractile power of the left ventricle is weakened, owing to dilatation of its cavity, to attenuation of its parietes, or to softening of its tissue, the blood must necessarily pass with greater difficulty through the systemic capillaries ; while, if the circulation through the left side of the heart is impeded, the capillaries of the lungs will become congested in the first instance, followed by general venous congestion and the train of symptoms presently to be described. It was at one time a very general opinion, that cerebral con- gestion and apoplexy on the one hand, or haemoptysis and pul- monary apoplexy on the other, had their cause, the former in hypertrophy of the left ventricle, the latter in hypertrophy of the right ; their occurrence was, in fact, looked upon simply as an example of cause and efiect, the increased force with which the hypertrophied ventricle transmitted the blood to the brain or lungs being considered sufficient to produce congestion in these organs, terminating in serous or sanguineous effusion, or in rupture of the coats of the small vessels. This theory is, however, ill sup- ported by pathological facts and, so far as the lungs are con- cerned, may be said to be exploded ; the congestion which occurs in the latter organs, as the result of cardiac disease, being much more frequently the result of obstruction to the free passage of the blood through the chambers of the left side of the heart. Because, even though the propulsive power of the ventricles is increased, if there is no impediment to the return of the blood by 198 SECONDARY SYMPTOMS OF CARDIAC DISEASE. the veins, the circulation will only be carried on more vigorously ; the veins returning the blood as rapidly as it is transmitted by the arteries. Indeed, congestion is much more liable to occur when the force with which the blood is propelled by the ventricles is diminished, as in dilatation and attenuation of the ventricles or in softening of the tissue of the heart, than when this fluid is propelled with increased force by an hypertrophied ventricle. Dr. Wardrop* has recently called attention to a function per- formed by the lungs, and to another by the subcutaneous veins, by which, he is of opinion, congestion is prevented ; the former he terms the pulmo- cardiac function ; the latter, the veno-pulmonary function. Pulmo-cardiac function " Whenever the systemic blood can- not find a ready exit from the left ventricle, and when, at the same moment, there is no diminution in the supply of venous blood to the right auricle, an accumulation or congestion of blood (Dr. Wardrop observes) must take place within the cavities of the heart ; and, therefore, in order to prevent such undue accumulation, the effects of which would be more or less injuri- ous" an accessory function of the lungs comes into operation ; " the pulmonary vessels serving as a recejjtaculum, or reservoir, for receiving any surplus quantity of blood, whether venous or arterial, which the cavities of the heart cannot admit." " To fulfil this pulmo-cardiac function, the structure of the lungs is admirably adapted. The pulmonary vessels, being im- bedded in a soft and yielding substance, are susceptible of various degrees of distention, so that they readily give way for the re- ception of any surplus quantity, whether of venous or of arterial blood, and retain it until it can be received within the heart. The very same structure with which the lungs are endowed to enable the air-cells to accommodate themselves to those differences in the quantity of air which take place during respiration, also enables the pulmonary vessels, in their turn, to accommodate them- selves for the reception of the various quantities of blood which may be impelled into them." "A function is, therefore, performed by the respiratory organs which is quite unconnected either with arterializing the blood, with aiding the return of the venous blood to the right heart, * On Diseases of the Heart. EFFECTS OF CONGESTION. 199 or with assisting the circulation in the puhnonary vessels ; and when it is considered how often, and by what slight causes, the current of the arterial blood is hindered from leaving the left heart; and, how frequently the retu.rn of the venous blood is accelerated to the right heart, the puhno-cardiac function must be regarded as one of primary importance." Veno-pulmonary function While the pulmo-cardiac function is employed to relieve the heart of any surplus quantity of blood which it cannot receive within its cavities, the veins will, in like manner (Dr. Wardrop observes) be found to relieve the pulmonary vessels of any superabundant blood which they are not capable of receiving without interruption to the great function of respi- ration. This office of the veins, he terms the veno-pulmonary function. " In the limbs, the deep-seated veins which are in- termingled with the muscles are influenced by every muscular contraction ; whereas the subcutaneous or superficial veins, being placed external to the fascia^ are not affected by the action of the muscles of the extremities. Whilst, therefore, the chief func- tion of the veins is to convey the blood back to the heart, there are likewise other offices especially executed by each of these subdivisions of the venous system." " No more striking example can be given of this office of the subcutaneous veins, than their distended appearance in the limbs of a person after making any violent exertion, or beneath the delicate skin of a race-horse after a severe gallop." " But neither this accessory function of the subcutaneous veins, the increase in the heart's action, nor the aid which the respiratory organs afford, are always (he observes) sufficient to prevent a congestion of blood within the cavity of the chest." Effects of congestion When congestion is carried to an ex- treme degree, or has lasted for a considerable time, the overloaded or overdistended vessels relieve themselves by allowing the more watery parts of the blood to transude, and serous effusion occurs, or the blood itself may escape, or rupture of a vessel and extra- vasation of blood may occur. Long-continued congestion fre- quently leads to more or less alteration of the tissue of the con- gested organ ; its size is frequently increased ; and this may or may not be accompanied by pain, or by tenderness on pressure. This is most frequently witnessed in the liver, and, if the cause 200 SECONDARY SYMPTOMS OF CARDIAC DISEASE. continues long in operation, the increase in size may be permanent. Dr. Clendinning* has shown that the lungs acquire increased development and weight under such circumstances ; " the inter- vesicular and interlobular textures becoming, Dr. Williams ob- serves, hypertrophied, with partial consolidation of the vesicular structure itself." These changes are best marked in the posterior part of the lungs, near their roots. In the great majority of cases, congestion is owing either to, 1st. Feebleness of the heart's action, the result of dilatation of the left ventricle, of attenuation of its parietes, or of softening of its muscular tissue, or to two of them combined ; in consequence of which the contractile power of the left ventricle is diminished, and its systole is insufficient to propel the blood through the systemic capillaries; 2ndly. To free regurgitation through the tricuspid orifice, the result of dilatation of this opening, combined with hypertrophy and dilatation of the right ventricle ; by which the return of the blood from the venaj cavse to the right auricle is greatly impeded, leading to its accumulation, first in the large venous trunks, and next in the smaller veins and capillaries ; and 3rdly. To a contracted state of the mitral orifice, impeding the passage of the blood from the left auricle into the left ventricle, or to a state of the mitral valve or orifice which permits free re- gurgitation through it ; owing to which much of the contents of the left ventricle is transmitted backwards into the left auricle at each systole. In the first of these cases the congestion commences in the capillaries of the systemic circulation, and extends to the veins ; in the second it commences in the large veins, and extends to the capillaries; in the third it commences in the pulmonary capillaries and extends to the large veins. In addition, it has been shown by MM. Becquerel and Rodier,t that the effect of long-standing disease of the heart is to occasion changes in the quality and relative constituents of the blood. Thus, the globules undergo diminution in advanced cases of disease of this organ ; the fibrin is likewise diminished remarkably, mani- fested by the occurrence of hsemorrhage from mucous surfaces. The albumen of the serum of the blood is also diminished, by which the occurrence of dropsy is favoured ; and, there is in addition an increase in the watery part of the blood. * Croonian Lectures: Med. Gaz. f rUnion^Iedicale. EFFECTS OF CONGESTION. 201 The organs in which congestion most readily occurs are, as a general rule, those which are most vascular — viz., the lungs and bronchial mucous membrane, the liver, spleen, kidneys, and gastro-intestinal mucous membrane. Indeed, the secondary or indirect symptoms of cardiac disease depend essentially upon the amount and degree of congestion which it occasions, and they vary according to the organs particularly engaged. In the slighter forms of congestion, the functions of the organ the seat of the congestion may be little affected : in the advanced stage its functions are frequently seriously impaired. Thus in congestion of the lungs and bronchial mucous membrane we have dyspnoea, passing into orthopnoea, with oppression, cough, and expectoration, which may or may not be followed by haemoptysis or pulmonary apoplexy ; the secretion from the bronchial mucous membrane is often remarkably increased, and this may prove one of the most troublesome symptoms. Congestion of the liver is accompanied by an increase in size of the organ, and by im- peded or vitiated secretion, or by arrest of the biliary secretion, frequently with pain or tenderness on pressure. When the gastric mucous membrane is congested, the disturbance of function may be indicated by increased or altered secretion, or we may have nausea, or antiperistaltic action of the organ, or pain may be the most prominent symptom, or loss of appetite may be alone com- plained of. When the spleen is congested, the organ sometimes attains a remarkable size ; this, however, is more frequently ob- served as an effect of ague than of cardiac disease. When the liver and gastro-intestinal mucous membrane are both congested, we may have pain, deranged digestion, loss of appetite, flatulent distension, vomiting, hepatic derangement, hsemateraesis, diar- rhoea, haemorrhoids, jaundice, or ascites. When the brain is con- gested, its sensibility is sometimes impaired, sometimes increased, and we may have headache, tinnitus aurium, vertigo, sense of weight in the head, confused vision, or disordered volition, or a semi-comatose state, which, in extreme cases, may terminate fatally, with or without the rupture of any vessel. Finally, when the kidneys are congested, the urine becomes scanty, high-coloured, turbid, and albuminous, followed by anasarca which is slight at first, and commences in the most dependent parts, but eventually becomes general. 202 SECONDARY SYMPTOMS OF CARDIAC DISEASE. CONGESTION OF THE HEART. The circulation through the chambers of the heart cannot be impeded without the coronary circulation suflfering ; and this cir- culation cannot be deranged without the functions of the heart being disturbed. The integrity of a muscle, and its healthy action depend in a great measure, we know, upon its receiving a due supply of arterial blood ; if this is sufficient, and of a good quality, the functions of the muscle will be performed with vigour ; while if the supply is insufficient, or the quality is deteriorated, the func- tions of the muscle will be impaired. Now, the heart being a muscular viscus, requires for the vigorous performance of its func- tions an efficent supply of arterialized blood ; and although the blood which circulates through its chambers is the ordinary stimu- lus to the motions of the organ, if the coronary vessels become distended and overloaded, and the coronary veins are unable to empty themselves; or, if the coronary arteries convey blood of deteriorated quality, congestion of its tissue must ensue, and its functions must be imperfectly performed. Thus when the circulation through the chambers of the heart has been long impeded, when considerable obstruction exists in the pulmonary circulation, and the venous blood does not undergo the necessary changes in the lungs, the coronary circulation be- comes not only impeded and retarded, but the coronary arteries convey a mixture of venous and arterial blood to the tissue of the heart. The functions of the muscle are in consequence impaired, its irritability diminishes, it is no longer obedient to the stimulus of the blood which distends its cavities, and its action becomes feeble and intermittent, or unequal and irregular. Indeed, the immediate cause of death in valvular and other disease of the heart is probably often the result of impeded coronary circulation. CONGESTION OF THE LUNGS. The lungs, from their physiological position between the right and left chambers of the heart, must suffer whenever the circu- lation through the heart is not free, or when disease^;© any extent exists in the valves or orifices of the left side of the organ. Thus when the mitral orifice is contracted, the left- auricle, being CONGESTION OF THE LUNGS. 203 unable to empty itself, becomes distended, and the blood return- ing by the pulmonary veins cannot freely enter the auricle ; the right ventricle at the same time continuing to transmit the blood by the pulmonary artery, the capillaries of the lungs become overloaded, and the pulmonary tissue and the bronchial mucous membrane congested. When the mitral valve imperfectly fulfils its functions, and much of the contents of the ventricle is trans- mitted backwards at each systole, the same results may follow as where the mitral orifice is contracted. When the aortic orifice is diseased, so as to obstruct the orifice considerably, the same results sometimes follow; but as Dr. Blakiston observes, a considerable amount of disease of the aortic orifice may exist for a number of years without seriously affecting the general health, more particu- larly if hypertrophy of the left ventricle is joined with it. The congestion of the lungs and bronchial mucous membrane which occurs under such circumstances is always of the passive form, and is always a secondary or consecutive lesion. When it has lasted long, or when the patient has suffered frequent attacks of it, a condition of the part remains, in which, inflammation or a state approaching to it, is very liable to be set up, and sometimes by causes which woidd be incapable of giving rise to it in a healthy condition of the parts : hence we not unfrequently observe in addi- tion a real determination of blood to the lungs, the result of in- flammation of the parenchyma of these organs. The important function which the lungs perform in the con- version of venous into arterial blood must obviously be seriously interfered with when the circulation through the pulmonary ca- pillaries is retarded and impeded, and the minute vessels are considerably engorged. The capillary vessels of the lungs form, we know, a net-work around each vesicle or air-cell ; they are exceedingly numerous, and in greater abundance in a given space here than in almost any other part of the body. Now as the blood must all pass through them before it arrives at the commencement of the systemic circulation, it is obvious that any impediment to its passage will be felt throughout the system ; while, if the blood is prevented from undergoing the change from venous to arterial in the pulmonary capillaries, the pulmonary veins will convey venous as well as arterial blood to the left auricle. Hence, when the congestion is considerable in degree, and engages 204 SECONDARY SYMPTOMS OF CARDIAC DISEASE. much of the pulmonary tissue, and the air-cells of the part scarcely permit of the entrance of atmospheric air during inspiration, the blood will be imperfectly oxygenated, its carbonic acid will be incompletely removed, and the renewal of the fibrine will be im- perfectly accomplished ; a mixture of venous and arterial blood will then circulate in the arteries, which is unfit for maintaining the functions of the various organs in a healthy condition, or for supplying nutriment to their tissue ; the brain, the nervous system, the heart, and the other organs, the maintenance of the function of which depends upon a due supply of arterial blood, suffer ; the muscular system receives less fibrine, the animal heat diminishes, and the entire system feels the depressing influence. When the pulmonary capillaries have been congested for a long time, or to a considerable degree, the overloaded vessels are relieved by the transudation of the watery, saline, albuminous, and sometimes of the fibrinous constituents of the blood; or the blood itself may be effused upon the surface of the bronchial mu- cous membrane, or into the air-cells ; or rupture of a vessel may take place, with extravasation of blood upon the mucous surface, or into the pulmonary tissue ; accompanied by oedema of the lungs, dyspnoea (which in extreme cases amounts to orthopnoea), cough, and watery expectoration ; or haemoptysis, and pulmonary apoplexy. Long-continued congestion not only interferes with the func- tions of the congested organ, but it also frequently affects its nu- trition and structiu-e. " It generally tends" as Dr. Williams ob- serves " to cause an increased deposit in them, constituting a va- riety of hypertrophy." "In the lungs, long-continued congestion may" he remarks, " cause hypertrophy of the intervesicular and interlobular textures, and in some cases partial consolidation of the vesicular structure itself." " Such chano-es" he adds " are fre- quently met with in connexion with long-standing disease of the heart, and abound most in the posterior parts of the lungs and near their roots, the most vascular parts." (Edema of the Lungs. — When the congested capillaries of the lungs have relieved themselves by allowing the serous or thinnest portion of the blood to transude ; and when the air-cells, the mi- nute ramifications of the bronchial tubes, and the interlobular cel- lular tissue have become infiltrated with this fluid, it constitutes (EDEMA OF THE LUNGS. 205 the state known under the name of oedema of the lungs ; and, as in oedema, or anasarca of the extremities, the fluid gravitates to the most dependent parts, and will generally be found to occupy the base of the lungs, or the posterior parts of these organs. (Edema of the pulmonary tissue is necessarily therefore a symp- tom only in the advanced stages of cardiac disease, and the forms of disease with which it is usually associated are those in which a considerable impediment exists to the passage of the blood tlarough the left chambers of the heart, particularly valvular disease. It is most common in the obstructive lesion of the mitral orifice ; in- deed, few cases of this form of disease go through their stages without this condition being present in a greater or less degree. It is usually preceded or followed by anasarca of the cellular tissue, and is always accompanied by more or less dyspnoea, cough, and expectoration, frequently of a thin mucous or serous fluid, as well as by certain physical signs, the most remarkable of which are dullness on percussion, and a moist sub-crepitant rale on ausculta- tion of the base of the lungs. CEdema of the lungs, though no uncommon effect of cardiac disease, is by no means limited to diseased states of the heart, but is met with in several other morbid conditions ; thus it may accom- pany general dropsy, it is observed in chronic bronchitis, and per- tussis ; it follows the resolution of pneumonia ; and it is met with as a sequela of measles and scarlatina. Dyspncea — The respiratory movements, like the motions of the heart, are involuntary, though the former are much more un- der the influence of the will than the latter : they belong to the class of movements termed " excito-motory " by physiologists. The object of the respiratory process, it is scarcely necessary to say, is to bring the venous blood in contact with atmosphenc air, which is accomplished through the medium of the innumera- ble capillaries that ramify upon the air-cells of the lungs ; and the changes which ensue in the blood and in the air take place through the delicate membraneous walls of these cells. From the manner in which these parts are arranged, every particle of the blood, in its passage through the capillaries of the lungs, is ex- posed to the action of the oxygen of the air ; and anything which impedes or interrupts the process tends to derange or to disturb the general circulation. 206 SECONDARY SYMPTOMS OF CARDIAC DISEASE. When the respiration is perfectly tranquil, the respiratory- movements are performed almost entirely by the diaphragm, which, contracting in inspiration, enlarges the diameter of the thorax from above downwards, and relaxing in expiration, returns to its former state. When the respiratory movements are carried on more ac- tively, the thorax is enlarged in all its diameters — the antero- posterior, lateral, and vertical. When, finally, the respiration becomes difficult and laborious, all the muscles, in addition, which receive filaments from the system of respiratory nerves are brought into action. In a state of health, the exact amount of venous blood is trans- mitted by the right ventricle to the pulmonary artery which can be converted into arterial blood in the lungs; and the exact amount of arterial blood is returned, by the pulmonary veins to the left auricle, which will pass freely through the chambers of the left side of the organ. At the same time, an amount of atmos- pheric air is taken into the lungs at each inspiration, sufficient to convert the blood contained in its capillaries into arterial blood. We have likewise seen that, in a state of health, there is an exact ratio between the pulsations of the heart and the respirations in a given period : thus, when the circulation is hurried by exercise, the respiration becomes more frequent in proportion ; and, as the circulation becomes again tranquil, the respirations diminish in frequency. There is, therefore, in health, a perfect equilibrium between the circulation and the respiration, and if from any cause this equilibririm is disturbed, dyspnoea ensues. It sometimes happens that the blood is transmitted with too little force, by the right ventricle, to pass freely through the pul- monary capillaries: more frequently, however, the blood is im- peded in the latter vessels, owing to some obstruction to its passage through the left chambers of the heart. Again, it sometimes happens that the blood is transmitted with increased force, or in greater quantity than natural, by the right ventricle : more frequently, however, the air cannot enter the air-cells of the lungs in sufficient quantity to decarbonize the blood ' transmitted to these organs. In either case, there will be a want of due pro- portion between the extent of the oxygenating surface and the amovmt of blood ; the respiration will become hurried, or difficult, or laborious, according to circumstances; the dyspnoea DYSPNCEA. 207 will pass into orthopncea, whichj in extreme cases, may termi- nate in asphyxia. Dyspnoea will therefore ensue whenever the pulmonary capil- laries contain more blood than can be oxygenated by the air ad- mitted into the air-ceils, or whenever too little air can enter the air-cells to oxygenate the blood contained in the pulmonary capil- laries. In either case, the respirations may be more frequent than natural, or the number of the respirations and of the pulsations of the heart may not bear their normal proportion to one another. Under such circumstances, the respiration is no longer an involun- tary act, but requires the aid of a number of the voluntary muscles, particularly in inspiration, in order that a sufficiency of air may be taken in to convert the venous into arterial blood. In extreme cases all the muscles which receive branches from the respiratory nerves — viz., the facial, the external respiratory nerve, the spinal accessory, the glosso-pharyngeal, the par-vagum and its laryngeal branches, and the spinal nerves distributed to the muscles of the trunk — are called into almost convulsive action. Dyspnoea, in its mildest form, when the individual is merely short-winded, or readily put out of breath, or finds a difficulty in ascending stairs, although a frequent attendant upon disease of the heart, is observed in many cases where this organ is not in the least engaged. Indeed, dyspnoea is seldom marked in cardiac disease until the pulmonary tissue and the bronchial mucous membrane become secondarily engaged, and it is then often one of the most distressing symptoms. Dyspnoea, to a considerable extent, may however exist, and yet the patient will deny its ex- istence, either unconscious of it or regarding it as too triffing to be mentioned. This is not unfrequently witnessed in the class of patients whom we see in hospital, in whom the dyspnoea has made its approaches so gradually that they have become habituated to it. It, no doubt, is in some measure due to the parts having had time to adapt themselves to the altered circumstances, and in some measure, also, " to the sensibility being gradually blunted by the circulation of ill-oxygenated blood." Thus, as Dr. Williams* observes, " Persons affected with extensive emphysema of the lungs are habituated to an imperfect state of respiration, which is shown by a constant lividity of the lips and cheeks: such an * Principles of Medicine. 208 SECONDARY SYMPTOMS OF CARDIAC DISEASE. appearance would be a sign of approaching death in other persons." The severity of the dyspnoea, both in disease of the lieart and lungs, is, in the majority of cases, in proportion to the suddenness with which this symptom has set in : thus in capillary bronchitis, in pneumonia engaging a considerable portion of both lungs, in pleuritis with copious effusion, it is the most prominent symptom. It is likewise so in the acute forms of cardiac disease, as where a large amount of fluid is suddenly effused into the pericardial sac — the result of pericarditis ; or where the circulation through the heart becomes suddenly impeded or obstructed ; as occurs in some of those cases of acute endocarditis which prove rapidly fatal. When more or less dyspnoea is constantly present, and yet no signs of pulmonary disease can be detected, or there is no mani- fest cause for its presence, " we may," Dr. Furnivall* observes, "suspect disease of the heart almost from this symptom alone." In some cases which he met, " this was the only symptom for a long time observable, and it appeared long before the characteristic murmur of the diseased mitral valve could be detected." The diseased states of the heart, in which dyspnoea is a pro- minent symptom, are — pericarditis, with copious liquid effusion ; endocarditis, with obstruction in the orifices or chambers of the heart ; dilatation of the ventricles, with thinning of the parietes ; hypertrophy of the ventricles in an advanced stage, and a combi- nation of hypertrophy with dilatation ; valvular disease, particu- larly considerable contraction of the orifices of the left side of the heart, or free regurgitation through the mitral orifice ; or aneurism of the aorta compressing the trachea, or large bronchi. Dyspnoea, however, is not limited to cases of organic disease of the heart ; it is a frequent symptom of the anasmic, or of the plethoric state. In such cases, however, the dyspnoea is not constant, but is experi- enced on walking quickly, or ascending stairs, or on making any unusual exertion. In the former of these cases the dyspnoea, according to Andral, arises from there being too much air rela- tively to the quantity of blood to be oxygenated ; in the latter, from there being too much blood relatively to the air entering the bronchial tubes. Patients labouring under valvular disease, in an aggravated * The Lancet, 1846. COUGH. 209 form, complicated with dilatation of the ventricles, and accom- panied by congestion of the pulmonary tissue, are predisposed to attacks of bronchitis or pneumonia, which aggravate remarkably the habitual dyspnoea, and usually hurry on the disease to a fatal termination. Starting in alarm from sleep. — In connexion with dyspnoea, a symptom sometimes observed in cases of heart-disease of long standing is a sudden starting in alarm from sleep, accompanied by a distressing feeling of oppression and violent action of the heart, often following a frightful dream. This symptom. Dr. Willis* observes, is probably connected with impeded circulation through the lungs. "As we fall asleep," he observes, "the respiration becomes considerably slower than it was immediately before : in very deep sleep each respiration is an effort, and is apparently only performed from the increasing urgency of the uneasy sensa- tion that is at once allayed by taking in a new draught of air. The pulse at the same time falls in frequency, and the balance is maintained between the activity of the circulation and that of the respiration. But, with a heart acting faultily, pushing rather more blood, perchance, into the pulmonary artery than it can transmit, or, on the contrary, refusing readily to receive so much as returns to it by the pulmonary veins, the balance between the activity of the circulation and that of the respiratory system is destroyed, accumulation takes place in the lungs, the patient awakens in alarm, and, plying the muscles of respiration more vigorously, shakes off the sense of suffocation that was beginning to be imminent." Cough. — Cough is not a necessary symptom of cardiac disease ; few cases, however, go through all their stages without this symp- tom being present in a more or less marked degree, particularly if congestion of the lungs ensues. The act of coughing, which consists in a sudden voluntary or involuntary expiratory effort, is almost always the result of some irritation of the mucous mem- brane lining the larynx, trachea, or its ramifications. The nature of this irritation varies in different cases ; thus it may depend upon inflammation of some portion of the mucous membrane which lines the air-passages, in consequence of which the sensibility ol the membrane is increased, and its secretions, which are not irri- * London Medical Gazette. 210 SECONDARY SYMPTOMS OF CARDIAC DISEASK. tative in a healthy state of the membrane, bscome so, and occa- sion cough ; or it may arise from the accumulation of the secre- tion in the air-tubes, by which the free admission of air is inter- fered with, and cough is excited in order to get rid of it. Again, it sometimes happens that the calibre of the air-tubes is diminished by submucous infiltration, or by a morbid growth pressing upon and flattening one, when the irritation excited gives rise to covigh. When cough arises in diseased states of the heart, it may depend upon any of the causes just mentioned ; most frequently, however, it arises from the irritation occasioned by the increased quantity of fluid poured out into the air-passages, the amount of which is sometimes considerable, and which, by its simple presence, excites irritation, or, by its quantity or situation, impedes the passage of the air during respiration, and cough is excited in order to get rid of it. In the early stages of cardiac disease, if cough is present, it is in general due to an accompanying bronchitis. In the advanced stage of certain forms of disease of the organ, cough is scarcely ever absent, and it is always associated with more or less dyspnoea. In such cases, oedema of the pulmonary tissue is generally present ; the congested condition of the lungs being in part relieved by the transudation of the more watery parts of the blood into the air-cells and minute tubes : but this very eflbrt of nature to relieve the congested state of the capillaries of the lungs becomes often the source of considerable distress to the patient ; the copious secretion poured out, as it can only be removed by coughing, excites and keeps this up ; while, if the secretion from the bron- chial mucous membrane is at the same time very profuse, and the patient much debilitated, the expectoration becomes difficult, and not unfrequently the patient dies asphyxiated from this very cause. The diseased states of the heart in which cough is most fre- quently a symptom, are the same as those in which dyspnoea is observed ; indeed, the latter is seldom prominently marked, without cough being likewise troublesome. The cough at first may be dry, or accompanied by expectoration ; when congestion or oedema of the lungs supervenes, it becomes free, the expectoration is copious, and consists frequently of a colourless, watery, -or muco-serous fluid. The cough, too, comes on in paroxysms, and in the ad- vanced stage the fits are sometimes both frequent and prolonged. HEMOPTYSIS. 211 by which congestion of the lungs is still further increased. Patients in whom the pulmonary circulation is much obstructed, and in whom congestion of the lungs has lasted long, appear likewise to be more subject than others to bronchitis, by which the habitual dyspnoea and cough are considerably aggravated. It is scarcely necessary to observe, that whenever the trachea, or a large bronchial tube, is compressed by the growth of an aneurismal or other tumor in the cavity of the thorax, cough is a prominent symptom. In such cases, the sensation experienced by the patient is, often, as if something existed in the air-tubes which he would be relieved by expectorating, and he makes many in- effectual efforts to do so. Eventually, the act of inspiration or of expiration, or both, are accompanied by peculiar sounds, which in general are sufficiently characteristic, and when once heard can scarcely be mistaken. HcBmoptysis. — The blood which escapes upon the mucous sur- face of the air passages, and is expectorated, may have its source either in the bronchial or the pulmonary vessels ; and may come, either from a ruptured vessel or it may transude without the rupture of any vessel. We have already seen how intimately related the functions of the heart are to those of the lungs ; and how liable the pulmonary circulation is to be impeded when the valves or orifices of the heart are diseased, and prevent the free passage of the blood through its chambers. We have likewise seen the manner in which the over-distended capillaries of the lungs are relieved by the transudation of the serous portion of the blood, giving rise to oedema of the pulmonary tissue. If the im- pediment to the passage of the blood becomes still more consider- able, the capillaries may relieve themselves by allowing the blood itself to transude, when it will be expectorated ; or rupture of a vessel may take place, and the blood be effused into the tissue of the lungs, constituting the state termed pulmonary apoplexy. Hjemoptysis is a symptom only of the advanced stage of car- diac disease, and is limited to certain forms of it ; it is most common in young subjects, and in individuals who at some former period had laboured under acute endocarditis. It was at one time a common opinion, and is probably still with some, that when hemoptysis takes place in the progress of cardiac disease, or when pulmonary apoplexy occurs in such cases, they depend upon 212 SECONDARY SYMPTOMS OF CARDIAC DISEASE. hypertrophy of the right ventricle, transmitting the blood to the lungs with so much increased force as to cause rupture of the minute vessels, and effusion of blood, either upon the mucous surface or into the pulmonary tissue. This, however, is not a correct view of the subject; because, even thoiigh hypertrophy of the right ventricle did exist, the blood would find no difficulty in returning by the pulmonary veins to the left side of the heart. But hypertrophy of the right ventricle is itself almost always a secondary lesion, often of valvular disease at the left side ; par- ticularly contraction of the mitral orifice. We have seen that this form of valvular disease is a frequent cause of pulmonary congestion ; and, if hypertrophy of the right side is superadded, the pulmonary circulation being placed between a strong right ventricle propelling the blood with increased force into the pul- monary artery, and a contracted state of the left auriculo-ventri- cular orifice, by which the pulmonary veins are prevented from freely pouring their blood into the left auricle, it is not surprising that the blood-vessels should relieve themselves by allowing their contents to transude, or that rupture of a vessel should take place. Haemoptysis would be much more frequent in such cases, if, as the right ventricle became hypertrophied and dilated, the tricuspid orifice preserved its normal dimensions; but as a general rule, almost, when the cavity of the right ventricle becomes dilated, and its walls hypertrophied, the tricuspid orifice increases in size, by which free regurgitation is permitted into the right auricle : part of the strength of the ventricular systole is thus wasted, and the injurious consequences which might otherwise ensue are pre- vented. Haemoptysis is a more common symptom of pulmonary than of cardiac disease ; the source of the haemorrhage is not the same, however, in the two cases : the appearance of the blood is likewise often somewhat disimilar, while the circumstances under which the haemorrhage occurs and the condition of the circulation at the time, are different. For instance, the haemoptysis which occurs in phthisis is of the active form, and arises from determination of blood ; the general circulation is quickened, and the hemorr- hage comes (as was first pointed out by Dr. Graves*) from the bronchial vessels. Pure blood is frequently expectorated, which is * Clinical Lectures. H-EMOPTYSIS. 213 frothy, and of a briglit florid hue, though it is often also in clots, and of a dark colour if it has lain for any time in the air-tubes : the quantity expectorated is sometimes considerable, and in the in- tervals the sputa are frequently streaked with blood : finally, this form of haemoptysis is seldom associated with pulmonary apoplexy. On the other hand, the hsemoptysis which occurs in the advanced stage of cardiac disease is of the passive form, and is the result of venous congestion not of local determination, while the cir- culation is not quickened generally. The blood expectorated comes from the pulmonary vessels, and the amount is sometimes considerable. This vnll, however, in some measure, depend upon whether the hsemorrhage is owing to rupture of a vessel, or depends simply upon the transudation of the blood : in the former case the blood may have a florid hue, or it may present a dark or grumous appearance ; in the latter, the blood is frequently in- timately mixed with the sputa. Finally, hsemoptysis from this cause is occasionally associated with pulmonary apoplexy. The diseased conditions of the heart in which haemoptysis most frequently occurs are : 1st. Considerable contraction of the mitral orifice. 2nd. Dilatation with attenuation of the left ventricle. 3rd. Extreme contraction of the aortic orifice. 4th. Hypertrophy and dilatation of the right ventricle. This, however, is very often consecutive to valvular disease of the left side of the heart. Few cases of considerable contraction of the left auric alo- ven- tricular orifice go through all their stages without the occurence of some heemoptysis. It is rare in the regurgitant lesions of the orifices of the left side of the heart ; particularly so in aortic regur- gitation. The explanation of the cause of the haemoptysis in all these cases is pretty nearly the same. Thus, when the mitral orifice is contracted, and the passage of the blood through it is impeded, con- gestion of the lungs in general sooner or later follows ; particularly if the parietes of the right ventricle become hypertrophied : under such circumstances, any sudden or continued exertion on the part of the patient, or anything which hurries the heart's action, may give rise to hosmoptysis, the over-distended vessels allowing of the transudation of the blood, or rupture of a vessel ensuing. When, 214 SECONDARY SYMPTOMS OF CARDIAC DISEASE. again, the cavity of the left ventricle is dilated, and its parietes are attenuated, the weakened ventricle is unable to propel its contents with sufficient force to pass through the capillaries ; the blood accumulates in the left cavities of the heart, the pulmonary veins are unable to empty themselves, congestion of the lungs ensues, followed as in the preceding case by haemoptysis. Pulmonary apoplexy. — When the blood, in addition to being expectorated, is extravasated in the tissue of the lung, it consti- tutes the state with which we are familiar as pulmonary apoplexy. There is then always rupture of a vessel, and the effused blood may fill the air-cells, or the areolar tissue of the lungs may be infiltrated with this fluid, by which the air-cells of the part are compressed or obliterated, and no longer permit of the entrance of air. Pulmonary apoplexy, although very generally accompanied by hajmoptysis, may occur without it ; and, according to its extent, to the quantity of blood extravasated, and to the amount of lung engaged, it may prove immediately fatal, or only so after a longer or shorter interval ; or, the patient may recover. The attack may be sudden or otherwise, and the symptoms will vary in in- tensity according to the circumstances just mentioned. It is usually accompanied by increase of palpitation and dyspnoea, by oppression of the chest, by pain referred to some part of the front of the chest, or to the sides, or shoulders, or by a sensation of heat in the chest — by anxiety, by cough with more or less hcemoptysis, by paleness of the face if the amount of blood ex- pectorated is considerable, or by injection of the face if it is less, as well as by certain physical signs upon which it is not necessary to dwell here. The diseased states of the heart in which pulmonary apoplexy is most likely to supervene are those in which the impediment to the return of the blood to the left side of the heart is greatest : consequently, it is most frequently observed in diseased states of the left auriculo-ventricular orifice ; particularly in a very con- tracted state of this orifice. When this morbid condition has followed rapidly upon an attack of acute endocarditis, and when the subject is still young, pulmonary apoplexy, as M. Gendrin* observes, is more liable to occur than when the disease has come * Lejons sur les Maladies du Coeur. - CONGESTION OF THE LIVER. 215 on gradually, and when the congested state of the lungs has been in some measure relieved by the escape of the serous portion of the blood, constituting oedema of the lung, or when anasarca of the cellular tissue has supervened. CONGESTION OF THE LIVER. The connexion which exists between a congested state of the liver and morbid conditions of the heart, was alluded to by Cor- visart, and has been noticed more or less by succeeding writers. Indeed, next to the lungs, the liver is more liable than any other organ to become congested, as the result of cardiac disease ; and there are several good anatomical reasons why this should be so. 1st. Owing to the structure of the liver ; 2nd. To the large amount of blood which circulates through it ; 3rd. To the blood which reaches it by the vena portae having already passed through ca- pillary vessels, and having consequently lost whatever influence the contraction of the left ventricle had upon it ; 4th. To this blood having to pass through two sets of venous capillaries before it reaches the branches of the ven£e cavffi hepaticje ; and 5th. To the returning blood of the liver having to arrive at the right side of the heart against gravity. The substance of the liver, in general terms, may be said to consist of a close net-work of capillary vessels and ducts, arranged in lobules, and enclosing in their meshes nucleated cells ; the tissue of the organ is soft and yielding, and it readily becomes increased in size when its vessels are distended. Again, the whole of the venous blood from the abdominal viscera (with the excep- tion of that from the kidneys, bladder, and uterus) must pass through the liver before it can reach the right side of the heart ; which large amount of blood circulates through the capillaries of the liver, in addition to that which it receives by its own nutri- tious artery. The circulation of this venous fluid through the liver must necessarily be slow, in consequence not only of the ab- sence of the influence of the contraction of the left ventricle, but from the large size of the capillaries, and the blood having, as has already been observed, to pass through two sets of venous capil- laries. Now, if any impediment exists to the passage of the blood through the right chambers of the heart, owing to disease seated in the lungs, or in the left side of the heart : or if the blood as- 216 SECONDARY SYMPTOMS OF CARDIAC DISEASE. cending by the inferior cava cannot freely enter the right auricle, the circulation in the venae cavae hepaticse becomes retarded, which reacts through the intermediate vessels upon its capillaries. The capillaries of the vente cavee hepaticse have their origin in the centre of each of the lobules, and the circulation through them being impeded, they, as well as the intermediate vessels, become distended. This constitutes the slightest form of conges- tion of the liver, and has been termed by Mr. Kiernan " the first stage of hepatic venous congestion." A section of the liver under such circumstances presents a mottled appearance, the centre of each lobule having a deeper colour than the rest. When the im- pediment to the return of the blood to the right side of the heart increases, the capillaries of the venas portse, which occupy the circumference of the lobules, next suffer. The blood in both sets of capillaries being retarded, they become distended, constituting a still more advanced stage of congestion of the liver ; or, what Mr. Kiernan calls " the second stage of hepatic venous congestion." Here " a section of the liver presents likewise a mottled appear- ance, but now the pale portion will be in spots." Both sets of vessels may be congested without the function of the liver being impaired, or without any considerable impediment to the secretion or escape of the bile. In many cases, however, when the congestion has lasted long, and the impediment to the return of the blood to the right side of the heart is considerable, the biliary plexus, and the minute ducts which ultimately form the excretory duct, suffer from the pressure ; the bile is prevented from freely escaping, it accumulates in the lobules, and biliary is superadded to sanguineous congestion. A section of a portion of the liver will then present the appearance with which we are fa- miliar as nutmeg liver. Congestion of the liver may, therefore, be limited to the rami- fications of the venae cavae hepaticaj, or it may extend to the ca- pillaries of the venae portae ; or both may be combined with biliary congestion. The first has been termed the passive form of con- gestion, the second the active form ; but, when congestion of the liver depends upon cardiac disease, it is always of the passive form. The congestion of the liver may be partial, and occupy only a portion of the organ, or it may engage the entire viscus; and this cannot occur without occasioning an increase in the size CONGESTION OF THE LIVER. 217 of the organ, which will be in proportion to the degree of the congestion ; to the increased amount of blood contained in the distended vessels ; to the length of time the causes which pro- duced it have been in operation ; and to the condition of the liver at the time. " In young subjects, and in persons in whom the liver is healthy, and its capsule thin. Dr. Budd* observes, the liver will necessarily enlarge much more for a given force of distension than in persons in opposite circumstances." " When the liver (he adds) has become unnaturally firm and tough, by the inter- stitial deposit of new fibrous tissue, an impediment to the free passage of blood from it towards the heart, unless it be long con- tinued, will produce but little increase of its size; but it will exert the same, or even greater pressure on the other elements of its texture, and be as apt therefore, or even more apt, to cause secondary biliary congestion." The size which the liver may attain under these circumstances is remarkable : it sometimes extends downwards to below the umbilicus ; anteriorly it forms a swelling evident sometimes to the eye, but always perceptible to the hand, while its enlargement upwards causes it to encroach upon the right lung. It must be borne in mind, however, as observed by Dr. Clendinning,t that the liver may be enlarged, and yet not extend below its normal limits. "A large liver, well sustained superiorly, or strongly pressed upwards by tympanitis, or ascites, might pass (he observes) for small or normal ; and a small liver, pushed down by emphy- sema, or pleuritic effusion above, or by stays outside and around, might pass for abnormally large." The actual size which the congested liver attains may be pretty accurately determined by percussion of the hepatic region. Enlargement of the liver the result of congestion, may usually be distinguished from enlarge- ment of the organ from other causes by the liver preserving its normal shape, which is more or less altered in diseased states of this organ, as well as by the suddenness with which the enlarge- ment supervenes and subsides under treatment. Indeed, the ra- pidity with wliich the liver enlarges, and the great increase in size which it attains, has sometimes excited unnecessary alarm in the mind of the practitioner. When the congested state of the liver has caused considerable * Diseases o£ the Liver. f Croonian Lectures, Medical Gazette. 218 SECONDARY SYMPTOMS OF CARDIAC DISEASE. increase in size of the organ, tlie enlargement upwards, which is sometimes from two to three finger-breaths above its normal limits, and as high as the inferior angle of the scapula, or above it, will impede the descent of the diaphragm, and will cause the left side of the thorax to be encroached upon — by which dyspnoea will be aggravated. In addition, the patient usually complains, more or less, of an uneasy sensation in the hepatic region, parti- cularly of a sense of weight : he does not suffer from pain unless pressure is made upon the part, and but seldom even then. When biliary is combined with sanguineous congestion, the se- cretion of bile may be interrupted, or its escape may be impeded, owing to the pressure exercised upon the biliary plexuses and interlobular ducts, or to the swelling from congestion of the mu- cous membrane lining the ducts themselves. The patient will suffer from various symptoms of gastric derangement; as thirst, loss of appetite, vomiting, costiveness, or diarrhaa, with colicy pains, followed by jaundice, in a slight or more marked degree, and frequently with diminished secretion of urine. "The gastric derangement which ensues in such cases has a pernicious reaction," Dr. Furnivall* observes, " on the original disease, the gastric irri- tation adding to the cardiac irritation, and aggravating the pa- roxysms of dyspnoea as well as exciting them ; while the retention of those matters which should be excreted from, and by the agency of the liver, deprives us of one of our principal means of relieving the load of labour which is imposed on the heart." Frequent attacks of, or the long continuance of congestion of the liver, are followed by permanent increase in size of the organ, which becomes harder and more irregular, by congestion of the mucous lining of the alimentary canal, by cachexia, hasmorrhoids, and in aggravated cases, by hasmatemesis, or intestinal haemorr- hage, and when the patient's constitution has become much en- feebled, ascites generally sets in. Any form of cardiac disease which directly or indirectly occa- sions an impediment to the return of the blood ascending by the inferior cava may give rise to congestion of the Itver ; the forms of cardiac lesion with which it is most frequently associated are : 1st. Considerable contraction of the mitral orifice : here congestion of the lungs always precedes the hepatic congestion. Next in fre- * Lancet, 1846. CONGESTION OF GASTRO-INTESTINAL MUCOUS MEMBRANE. 219 quency, it occurs in cases where the tricuspid orifice is enlarged, and free regurgitation occurs at each ventricular systole : here the lungs are not engaged, but the venous system generally is en- gorged. Lastly, congestion of the liver is frequently associated vsrith dilatation of the ventricles, with or without thinning of their parieties ; this is frequently combined with a state of the tricuspid orifice permitting free regurgitation ; and the congestion is partly due to it, partly to the impediment to the circulation through the heart, and partly to the pressure exercised upon the ascending vena cava, as it is about to enter the right auricle, by the enlarged organ. Congestion of the liver is occasionally consecutive to lesions of other organs beside the heart ; thus it may ensue in any diseased condition of the lungs in which the pulmonary circulation is im- peded. Among these, pulmonary emphysema is one of the most frequent. The latter condition itself, however, is no unfrequent accompaniment of diseased states of the heart, and, when conges- tion of the liver occurs, it may depend as much upon it as upon the emphysematous state of the lungs. CONGESTION OF THE GASTRO-INTESTINAL MUCOUS MEMBRANE. The portal vein receives the blood from the superior and in- ferior mesenteric veins, from the splenic and gastric veins ; con- sequently the blood returned from the spleen and pancreas, from the small and large intestines, must pass through the liver before it reaches the right side of the heart. It is easy, therefore, to understand that if congestion of the liver occurs it will react upon the arriere current of blood ; and, if long continued, that conges- tion of these organs will ensue. Hence, congestion of the intes- tines is necessarily a secondary lesion to congestion of the liver, and seldom occurs unless congestion of the liver has preceded it ; and may be regarded as purely the result of a mechanical obstacle to the return of the venous blood from these parts. In the slightest form, where the free return of the venous blood from the gastro-intestinal mucous membrane is merely impeded, the venous trunks simply become congested. When the im- pediment is greater or the causes have been longer in operation, along with this state of congestion of the veins, " an injection of the small vessels in streaks, stripes, patches, or points, with opacity 220 SECONDARY SYMPTOMS OF CARDIAC DISEASE. of the injected parts, will," Dr. Copland* observes, *' be found ; and, in tlie highest degree, a partial effusion of blood into the sub- mucous cellular tissue, forming ecchymoses, or into the cavity of the part, colouring red the matters contained therein." " The mucous membrane lining the intestines, or even the entire mem- branes of the intestines, may present," Rokitanskyf remarks, "an uniform reddish-black colour, the tissue being saturated with blood, and no injection of blood-vessels being distinguishable : the larger vessels, and particularly the venous trunks, are distended even as far as the mesenteries, and overcharged with blood. In either case hemorrhage may take place into the cavity of the intestines." The simple form of congestion, when temporary, is not accom- panied by any prominent symptom. When the congestion is more marked, when it has persisted for some time, and when the impediment to the return of the venous blood is greater, the train of symptoms which are laid down as characterizing dyspepsia set in, and the patient may refer all his complaints to the abdominal complication, so that it is possible the diseased condition of the heart might be overlooked. " Congestion generally," as Dr. Williamsl observes, " impairs the vital properties of internal organs ; natural contractility and sensibility are lowered, but pain, spasm, and morbid sympathies are often excited, although in a manner much less distinct and constant than in inflammation or determination of blood. When the gastro-intestinal mucous membrane has been long or considerably congested, its functions are more or less impaired, and its secretions, as the result, may be either increased or di- minished, or vitiated ; and according as the gastric mucous mem- brane or that lining the large and small intestines, is particularly engaged, the symptoms will vary somewhat. ThiTS, when it is limited to the stomach, we may have nausea, vomiting, loss of appetite, and epigastric pain ; when the mucous membrane, lining the intestines, is much congested, we shall have flatulent distension, irritation, pain, and constipation, or diarrhoea, according as the secretion is increased or diminished, or altered ; when the lower portion of the large intestine is congested, we may have haemorr- hoids in addition. * Diet, of Practical Medicine. t Path. Anat. vol. ii. J Elements of Medicine. CONGESTION OF THE BRAIN. 221 *' A congested state of the entire portal system is the least favourable condition imaginable," Dr. Chevers* observes, "for active digestion, and proper nutrition ; hence, arise flatulent dis- tension of the stomach, (which as it alone will, in some cases, excite symptoms nearly resembling those of angina, invariably produces a most painful interference with a dilated and irritable heart,) and defective assimilation, which, of course, immediately conduces to the deterioration of the fluids, and consequent increase of congestions, dropsical effusions, &c., as well as to the further impairment of every deteriorated organ, including the muscular struction of the weakened and failing heart itself." Dr. Dickf is of opinion, that flatulent distention of the stomach may react upon the heart, by its pressure upon the aorta, or ascending vena cava. " Pressure on the latter will," he observes, " tend to produce a vacuum in the right auricle and ventricle ; pressure on the former, will tend to cause distention of the upper part of the aorta, and of the left ventricle." In this way it is that the apoplexies of full meals are produced ; the course of the blood to the lower extremities being impeded by the pressure of a heavy stomach on the aorta, it is forced to the superior part of the body, and the carotids too strongly inject the brain. We must, however, take into account, as Dr. Chevers observes, " the concurrent in- fluence of sudden increase of fluids, from rapid assimilation, in these cases of post-prandial apoplexy." The retardation of the circulation in the minute veins and capillaries, and the congestion of the mucous membrane which is the result, may be relieved in part by the transudation of the serous or aqueous parts of the blood, giving rise to diarrhoea with watery stools ; or, by the escape of blood itself upon the mucous surface, giving rise to hsematemesis ; frequently by more or less copious discharges of blood from the hasmorrhoidal vessels. The secretion of urine is almost always at the same time diminished, and ascites usually begins to show itself at this period — always, however, pre- ceded by anasarca. CONGESTION OF THE BRAIN. That a connexion exists between organic disease of the heart and cerebral disease, was noticed so long ago as the time of Morgagni ; * Treatise on Diseases of the Heart, Calcutta, 1851. t On Derangements of the Organs of Digestion, 1843. 222 SECONDARY SYMPTOMS OF CARDIAC DISEASE. many clinical observations have been since brought forward to prove it, and abundant evidence of the fact has been, within the last few years, adduced by Dr. Clendinning,* Dr. Burrows,! Dr. Kirkes,! Dr. Law,§ and Dr. Wardrop. (| The circulation in the brain may be disturbed in more than one way, as the result of disease of the heart. — Thus : 1. The blood may be transmitted to the brain in increased amount, or with undue force, by an hypertrophied left ventricle. 2. There may be an impediment to the free return of the venous blood from the brain to the right side of the heart, owing to disease in the latter organ. 3. The blood may not undergo the necessary changes in the lungs, the effect of disease of the valves or orifices of the heart, when a mixture of venous and arterial blood will circulate through the brain. 4. The blood may be transmitted to the brain in deficient quantity, owing to obstructive disease of the orifices at the left side of the heart, as pointed out by Dr. Law. 5. A part of the brain may be insufficiently supplied with blood, the cfiect of obstruction of one of the cerebral arteries by a portion of fibrin detached from a diseased valve, as pointed out by Dr. Kirkes. Lastly — Independent of disease of the heart, the blood itself may be thin, watery, and deficient in some of its constituents, as in anasmia ; or it may be rich and quickly formed, as in plethora. Writers upon diseases of the heart, have laid considerable stress upon the influence of hypertrophy of the left ventricle, in causing cerebral congestion, by its transmitting the blood in in- creased quantity or with augmented force, to the brain. The arteries which supply the brain run a short course from the arch of the aorta, and they receive, almost immediately, the force of the impulse of the left ventricle ; the circulation in the head and face is consequently active, indicated by the greater heat of these parts than of the extremities. Hence, we should expect, that when the left ventricle is hypertrophied and dilated, cerebral con- gestion would be likely to ensue ; but in most instances, hyper- * Croonian Lectures, Med. Gazette. § Dub. Jour, of Med., vol. xvii. t Disorders of the Cerebral Circulation. || Treatise on Diseases of the Heart. J Med. Chir. Trans, vol. xxxv. - CONGESTION OF THE BRAIN. 223 trophy of the left ventricle is itself a secondary aifection, the re- sult of some impediment to the passage of the blood through, or out of the chambers of the heart. Hence, although the heart's action may be strong, the pulse is often weak, showing that the strength of the current is not necessarily augmented, and that the amount of blood transmitted by the ventricle is not always increased under such circumstances. In considering congestion of the liver, we found that one of its effects was to cause an increase in the size of the congested part ; and, we can readily understand that such a delicate organ as the brain, which is enclosed within solid bony walls, could not undergo even slight enlargement, without the cerebral substance and nerves suffering compression. That injurious effects do not more fre- quently ensue, has been explained by Dr. Burrows, as follows : — 1st " Owing to the great development of the venous system within the cranium and spinal canal, which affords a ready exit for the redundant blood ;" and 2dly " Owing to the existence of the cerebro-spinal fluid." This fluid he has shown to play a most im- portant part, as — "by its capability of oscillation between the ventricles of the brain and the spinal canal, it compensates for variations in the quantity, or tension of the circulating fluids of the brain. When by increased action of the heart, more blood than common is thrown upon the cerebral vessels, the cerebro- spinal fluid subsides into the spinal canal, and injurious pressure upon the cerebral pulp is thus, within certain limits, abated ; and on the other hand, if less blood than usual pass into the brain, the fluid rises into the cranium, and the equilibrium of tension is pre- served." Although cerebral congestion might be the result of hypertro- phy of the left ventricle, this state is even more likely to ensue if there is an impediment to the free return of the venous blood from the brain. In a state of health, this fluid readily returns from the head, being assisted by gravity, and anything which interferes with it is quickly felt ; thus, if the head remains for any length of time on a plane lower than the body, symptoms of cerebral ple- thora will ensue ; as the internal jugular veins are not provided with valves, there is no provision to prevent the reflux of their contents towards the brain. Indeed, persons partly asphyxiated by submersion, or in a state of stupor from intoxication, have often 224 SECONDARY SYMPTOMS OF CARDIAC DISEASE. been deprived of life by being carelessly removed in a position which allowed the head to hang downwards. When the circulation in the brain is disturbed, from any of the causes mentioned, the patient may suffer from headache, ver- tigo, tinnitus aurium, or ocular spectra. " Many who are suffer- ing from a permanent disorder of the heart, have," Dr. Wardrop observes, " peculiarities in their sight, which are caused by changes in the circulation within the head, so that certain distur- bances in the functions of the retina become as important diagnos- tic symptoms in disease of the heart as those which take place in the organ of hearing." These are "false images, or the appearance of bodies floating before the eyes, sparks of fire, dimness of sight even to blindness ; all which symptoms may either exist separately and in one or both eyes, or they may be combined with other dis- turbances in the cerebro-spinal system." In some instances, dis- agreeable sensations in the head of rushing, beating, or throbbing are experienced by the patient ; in others, the sensation is rather of weight, tightness, or heaviness. In some instances, insomnolence is complained of, or if the patient sleeps his rest is disturbed by frightful dreams ; in others, drowsiness or somnolency are more marked. The face may be flushed, the lips and cheeks congested ; or, on the other hand, it may be very pale. When the disturb- ance of the cerebral circulation is more considerable, the drowsi- ness or somnolency may be succeeded by coma ; or the insomno- lence by epileptic or hysterical convulsions. In some instances, as Dr. Furnivall observes, " headache is early complained of, and is both severe and long continued. This is doubtless caused by cerebral venous congestion, and it and other cerebral symptoms have been sometimes so prominent as to mask and to draw atten- tion from the original and originating disorder." When the ve- nous blood is not entirely converted into arterial in the lungs, a mixture of venous and arterial blood is conveyed to the brain, evidenced by drowsiness and stupor, or by wandering of the mind, and a transitory and sometimes pleasing kind of delirium. The latter results are not, however, observed as often as might be ex- pected ; the majority of those who die of cardiac disease preserve their intellects perfectly to the close. Dr. Wardrop in his recent valuable treatise,* dwells at consi- * On Diseases of the Heart, 1851. DISTURBANCE OF THE CEREBRAL CIRCULATION. 225 derable length upon this part of the subject. He is of opinion that many anomalous symptoms, and many affections, to which the name nervous is usually applied, depend upon a primary disorder of the heart; and he has given the following table of the symp- toms which may arise from irregularities, or inequalities, or other alterations in the supply of blood to the cerebro-spinal system, the result of functional, or organic disease of the heart : Watchfulness — insomnia. Ocular Spectra — musci volitantes. Somnolency — sopor. Neuralgia. Coma. Angina. Fainting — syncope. Palsy — hemiplegia-paraplegia. Dreaming, sleep-walking, nightmare. Apoplexy. Headache. Epilepsy. Mental Irritability. Catalepsy. Mental Aberration. Hysteria. Giddiness — vertigo. Convulsions — chorea — subsuUus — tremors. Ringing in the ear — tinnitus aurium. Apoplexy and paralysis are regarded, by several writers, as direct results of hypertrophy of the left ventricle. Dr. Burrows says, *' hypertrophy of the left ventricle must be admitted as a powerful predisposing, or even exciting cause of apoplexy and sudden hemiplegia." Dr. Hope, in the " Cyclopaedia of Medi- cine," and subsequently in his "Treatise on Diseases of the Heart," observes: "Instances of apoplexy supervening upon hy- pertrophy have been so frequently noticed, that the relation of the two, as cause and effect, is one of the best established doctrines of modern pathology. Eight or nine cases of suddenly fatal apo- plexy, and numerous cases of palsy from hypertrophy, have within a few years fallen under our observation ; whence we are led to the conclusion, with MM. Richerand and Bertin, that hypertro- phy forms a stronger predisposition to apoplexy than the apoplectic condition itself." It appears to me, however, that the influence of hypertrophy of the left ventricle, in causing sanguineous apoplexy or hemi- plegia, has been overrated ; for though in many instances where these affections terminate fatally in individuals advanced in life, the heart is found to be enlarged, we generally find the coats of the arteries of the brain to be likewise diseased ; besides, we know, that, in the majority of cases, hypertrophy of the left ventricle Q 226 SECONDARY SYMPTOMS OF CARDIAC DISEASE. is itself a secondary afFection, the result of some impediment to the circulation — " Arterial cerebral apoplexy not unfrequently," Dr. Chevers* observes, " occurs in association with hypertrophy of the heart. The same causes, especially an excess of circulat- ing fluid, tend to produce both ; and the state of the heart may, in some cases, be immediately operative in occasioning the effu- sion." " I believe, however (he adds), that this accident occurs far less frequently than is generally supposed." Corvisart goes even still further, he says he never saw organic disease of the heart directly occasion apoplexy and death. " I have," he says, "many times in cases of this kind, seen all the vessels of the brain, and particularly the sinuses, gorged with blood, but I have never met with extravasation of blood either in the substance of the brain, or in its cavities." " In several of the cases (he adds) related elsewhere, the death was sudden ; I cannot, however, assert that I have ever seen a single case of apoplexy which was evidently the result of cardiac disease." It is not usually, as M. Lallemandj remarks, in the apoplec- tic cases of heart disease, that we observe the livid lips and cheeks, or the oedema, which point to obstruction of the circu- lation in the veins." " It is in comparatively early cases," as Dr. Ormerod+ observes, *' where the general symptoms of heart disease are scarcely developed, that sanguineous apoplexy most commonly occurs ; not in those patients whom a cold winter sends into our hospitals, loaded with dropsical accumulations and with venous blood — cold, livid, and struggling for breath. These are rather the subjects of softening of the brain or of serous effusion, than of sanguineous apoplexy." Deficient supply of blood to the Brain. — Dr. Law§ was the first to call attention to the injurious effects of a deficient supply of blood to the brain, as a result of cardiac disease. " Patho- logists hitherto," he observes, " have almost entirely confined their attention to the excess of the normal quantity of blood, or the congestion produced in organs by disease of the heart, but have overlooked the deficiency that must necessarily result to other organs, and consequent hurt to their nutrition and function. Thus • Treatise on Diseases of the Heart, Calcutta, 1851. t Recherches sur I'Eacephale. % Gulstonian Lectures, Med. Gaz. § Dub. Jour, of Medicine, May, 1840. DEFICIENT SUPPLY OF BLOOD TO THE BRAIN. 227 in disease so affecting tlie mitral valve as to lead to a considerable narrowing of the opening between the auricle and ventricle, ex- clusive attention has been directed to congestion of the lungs, liver, &c., and no notice has been taken of any ill effects re- sulting to other organs, from their supply of blood being propor- tionably diminished." In the valuable paper from which the foregoing is an extract. Dr. Law has recorded cases, showing that ramollissement of the brain may occur in connexion with diseases of the heart, whose effect is either directly or indirectly to diminish the supply of blood to the brain ; and that this cerebral lesion may be connected with disease of either the mitral or aortic valves or orifices. It is most common in cases of considerable contraction of the mitral orifice : next, in obstructive disease of the aortic orifice ; rarely in cases of mitral regurgitation. Dr. Fleming* has, however, recorded one where semi-apoplectic attacks, with temporary hemiplegia, occurred in connexion with a very dilated state of the mitral orifice, permitting free regurgi- tation through it. When the parietes of the left ventricle are softened or at- tenuated, or have undergone fatty degeneration, the weakened ventricle is incapable of propelling its contents with sufiicient force through the system ; and the brain may, under such circum- stances, be insufficiently supplied with arterial blood. Those syncopal attacks and semi-apoplectic seizures which sometimes occur in this condition of the ventricle, and which leave no trace of paralysis behind, are probably due to this cause. Recently, Dr. Kirkesf has brought forward evidence that soften- ing of a portion of the brain (from imperfect nutrition) may result from obstruction of a main cerebral artery by the arrest of a portion of fibrin in its canal, detached from a vegetation upon the valves at the left side of the heart, and conveyed by the circulating blood. The artery which was obstructed in his cases, was the middle cerebral ; which he considers the most likely to arrest a portion of fibrin floating in the blood transmitted to the brain by the internal carotid artery. " Once arrested at the angle or within the canal of the middle cerebral artery, a mass of fibrin, if large enough to block up the vessel, becomes," he observes, "at * Dub. Jour, of Medicine, vol. xvii. f Med. Chir. Trans, vol. xxxv. 228 SECONDARY SYMPTOMS OF CARDIAC DISEASE. once the cause of loss of function, and subsequent atrophy, to almost all that portion of the brain supplied by the obstructed vessel ; for, although by the arrangement of the vessels composing the ' circle of Willis,' ample provision is made against obstruction ensuing in any of the main arterial channels of either side, previous to their arrival at the circle, there is comparatively little provision for an obstruction ensuing in any of the main branches into which this arterial circle breaks up. This remark applies especially to the middle cerebral artery, which if plugged up at its origin, be- comes at once almost useless as a blood-vessel ; for nearly all its divisions, especially those for the central parts of the brain, proceed to their several destinations without receiving any anastomosing branch from the other divisions of the ' circle of Willis.' " Dr. Kirkes believes that his cases establish the following con- clusions : 1. "That softening of a portion of the brain, with attendant loss of function, might result from obstruction of a main cerebral artery by the lodgment of a plug of fibrin within its canal." 2. " That the foreign substance thus obstructing the vessel is probably not formed there, but is derived directly from warty growths situated on the left valves of the heart." He thinks it, likewise, not improbable, that " many cases of partial and tem- porary paralysis suddenly ensuing in one or more limbs of young persons, especially if accompanied by signs of cardiac disease, might be due to interruption of a proper supply of nutriment to the brain by the temporary plugging up of a principal cerebral artery by fibrin, detached from a diseased valve on the left side of the heart." POLYPOID CONCRETIONS IN THE CAVITIES OF THE HEART. The term polypi applied to the concretions which occasionally form in the ca\dties of the heart is rather an unfortunate one, these bodies having no analogy whatever with polypi, either in composition, or in the manner in which they are developed ; while the views which have been advanced respecting them appear to be in several particulars erroneous. Dr. Hope describes three species, viz. : 1. Unorganized polypi. 2. SHghty organized. 3. More completely organized. M. Bouil- laud likewise makes three species ; his description pretty nearly POLYPOID CONCRETIONS. 229 coincides with that given by Dr. Hope. These concretions, it appears to me, may be all included under the four following heads : viz. 1 . Concretions consisting of a coagulura coated with fibrin. 2. Concretions composed exclusively of fibrin. 3. Con- cretions composed exclusively of lymph. 4. Concretions consist- ing of lymph coated with fibrin. 1. Concretions consisting of a coagulum coated loith fibrin. — These (which, however, scarcely deserve the name inasmuch as they are either a post-mortem occurrence, or are formed only during the last hours of life,) consist of a more or less firm co- agulum of blood, partially or completely coated with fibrin, which fills and distends one or both the cavities of the right side of the heart particularly, frequently extending into the large vessels, but not adherent to the parietes. They occur in cases in which the blood had accumulated during the last hours of life in the right cavities of the heart ; and their occurrence is to be re- garded rather as a pathological phenomenon than as a circum- stance of any practical importance. The three other forms are developed during the life of the patient, are accompanied usually by sufficiently well-marked symp- toms, and are frequently the immediate cause of death ; whether the diseased state under which they arise have its seat in the heart itself, in the lungs, or in some other part. 2. Concretions composed exclusively of fibrin. — These which are the most freqiient, have a yellowish- white colour, are semi~ transparent, more or less elastic, and more or less adherent to the parietes, particularly to the carnese columns and tendinous cords of the valves. They occur in cases, where a considerable impedi- ment to the circulation had existed for some time previous to the patient's death ; whether this impediment was seated in the heart or in the lungs ; in consequence of which, the fibrin separates from the other constituents of the blood, and concretes vipon the valves or orifices, or upon the parietes of the ventricles or auricles. These fibrinous concretions may be developed in any disease in which the circulation through the cavities of the heart is much impeded. They are met with in acute bronchitis, in pneumonia, and in the advanced stages of valvular disease ; and they are not unfrequently the immediate cause of death in these diseases. 3. Concretions composed exclusively of lymph. — These, which 230 SECONDARY SYMPTOMS OF CARDIAC DISEASE. are the most rare, are altogether different in their origin from the preceding; while the former are developed by the mechanical separation of the fibrin from the other constituents of the blood, in its transit through the heart, the latter are deposited by the vessels of the part. This form of concretion occurs in cases of inflammation of the lining membrane of the heart ; it usually has its seat upon the valves or orifices of the left side of the heart, and it is deposited by the vessels of the part the seat of the inflam- mation : in fact, as it is derived from the vessels which supply the tissue of the heart with blood, its source is as different as is the blood which circulates through the heart, from that which sup- plies nutriment to the organ. 4. Concretions consisting of lymph coated with fibrin. — This form of concretion is a combination of the two last ; it is more frequent than that last described, but more rare than the two former species. In it, the nucleus is lymph, which is deposited upon the valves or orifices as the result of endocarditis ; but the great bulk of the concretion consists of fibrin deposited upon it, sometimes in concentric layers, as we see in aneurismal sacs. This form of concretion occurs in cases where the lining membrane of the heart had been at a former period the seat of inflammation, and where an impediment to the circulation through this organ had existed for a longer or shorter time previous to the patient's death. Like the last species, it is found in the left cavities of the heart. These four forms of concretion are not all of equal frequency, some are sufficiently common, others are exceedingly rare ; some are usually only found upon the right side of the heart, others only upon the left. The concretions composed of coagulated blood or of fibrin are most frequent in the right cavities of the heart, and often extend through the auriculo-ventricular orifices, or into the large vessels. Those which consist of lymph, or of lymph coated with fibrin, are most frequent in the left cavities of the heart. The former are sometimes of such a size as to fill and distend the cavities of the heart ; the latter, in general, merely impede the action of the valves. When composed of coagulated blood or of fibrin, they are smooth upon the surface, and moulded to the shape of the cavity in which they are contained ; when composed of lymph exclusively, their surface is -uneven and their POLYPOID CONCRETIONS. 23 I sliape irregular. The concretions consisting of coagulated blood are not adherent, though they may be entangled among the carnese columnse, or cordae tendineae; those which consist of fibrin are more adherent, but may still always be detached ; those composed of lymph, or in which the nucleus consists of lymph, are adherent to the part upon which they are deposited. The concretions which consist of fibrin are sufficiently fre- quent, and the opinion has been advanced on very respectable authority, that these fibrinous masses not only become organized, but that they undergo the same changes as organized tissues in other parts, such as softening, the formation of pus, &c. ; and that they are sometimes united by cellular tissue to the lining mem- brane of the cavities of the heart. Thus, Bouillaud, describing them, observes ; " They are white, decolourized, elastic, gluti- nous, adherent to the parietes of the heart, and confused with the tendinous cords and fleshy columns. They are in some sort half- organized, and very analogous either to the inflammatory crust of the blood, or to false membranes. Some present here and there points, or red lines, which are really nothing more than the rudi- ments of vessels." Dr. Hope observes, speaking of the slightly organized polypi : "It may be premised as a fact ascertained by observation, that fibrin separated from the blood, and become con- crete in a living organ (whether the hearty the blood-vessels, or serous, cellular, or other tissues into which it had been extrava- sated), retains its vitality, and is susceptible of organization in an equal degree with inflammatory lymph^' This view of the sub- ject is evidently incorrect : these masses of fibrin are unorganized, and incapable of becoming organized ; nor are they ever united to the lining membrane of the heart by cellular tissue. Indeed, a knowledge of their composition, and of the manner in which they are formed, ought to have been sufficient to set aside such an ab- surd idea, consisting as they do simply of one of the constituents of the blood, mechanically separated from the others in its transit through the heart. The concretions which consist of lymph, instead of being de- rived from the blood which circulates through the heart, are de- posited by the vessels of the inflamed tissue, and being analogous to the false membranes secreted by serous surfaces, may evidently become organized : in fact, the vegetations found upon the valves 232 SECONDARY SYMPTOMS OF CARDIAC DISEASE. and orifices of the heart, consecutive to endocarditis, are nothing more than these concretions upon a small scale. Deposits of lymph in the cavities of the heart, of such a size as to deserve the name of polypoid concretions, are however very rare ; more fre- quently the nucleus is lymph, and the great bulk of the con- cretion is made up of fibrin, deposited upon it either in amorphous masses or in regular stratified layers. In some instances, however, such an amount of lymph is secreted as not only to impede the action of the valves, but to obstruct the circulation through the cavities of the heart, and to occasion the death of the patient; an example of which was communicated by me, some time since, to the Surgical Society of Ireland ; and the preparation is now in the Museum of the College of Surgeons. The symptoms of polypoid concretions in the cavities of the heart, are such as might be expected to arise from an impediment to the passage of the blood through the central organ of the circu- lation, and the intensity of the symptoms will of course be pro- portionate to the size of the foreign body and the rapidity with which it is formed. As the coagula coated with fibrin, which have been classed by writers with these formations, appear not to be formed during life, we may omit their consideration here. When these concretions are developed rapidly, and when they quickly attain a considerable size, they give rise to a most in- tensely severe and distressing train of symptoms, most agonizing to the sufferer, and most distressing to witness. These have re- ference to the lungs rather than to the heart : they are dyspnoea suddenly arising accompanied by a feeling of impending suffocation and a distressing sense of oppression ; with which are associated sleeplessness, anxiety, restlessness, inability to assume the recumbent posture, coldness of the surface, congestion, or extreme paleness of the face. The pulse is small, feeble, and hurried, or it is im- perceptible, although the action of the heart may be strong. In two cases,* related elsewhere, in one of which the concretion oc- cupied both ventricles, there was no intermission or irregularity of the pulse, nor any abnormal murmur accompanying the heart's sounds; neither was there any increased extent of dulness in the preecordial region, nor was the action of the heart confused or * Dublin Medical Press, vol. xxi. POLYPOID CONCRETIONS. 233 irregular: symptoms which have been laid down by writers as almost pathognomonic. The diagnosis must always be one of some difficulty, particu- larly if we have not seen the patient previous to the occurrence of the symptoms due to their formation ; the difficulty will be some- what less if the patient had been for some time under observation, when, if the train of symptoms enumerated suddenly set in, the formation of a polypoid concretion in the heart is probable, pro- vided the disease under which the patient labours is such as to impede the circulation through the lungs or heart ; and the diag- nosis will be confirmed if there is no evidence either of large ef- fusion of fluid into the pericardium or pleura ; or, of the secretion of mucus into the bronchial tubes, either in such a quantity as to impede the entrance of air, or of so viscid a nature as to obstruct the passage of air into the lungs. The development of these concretions in the cavities of the heart, particularly when they are of such a size as materially to interfere with the circulation through this organ, is usually quickly followed by the death of the patient. With respect to treatment, it is clear that we can do little more than palliate symptoms, and support the powers of life. As to bringing about their resolution, the idea seems too absurd almost to be entertained ; nevertheless, we find writers recommending the administration of substances supposed to be capable of dissolving polypi, or of rendering the blood more fluid, such as the salts of potass, or diluent drinks given freely; while others, among whom M. Bouillaud is the most conspicuous, consider that bleeding is the best measure that can be employed when these concretions have once formed. The following conclusions appear to be deducible from the preceding details : 1. That the concretions which occasionally form in the cavi- ties of the heart during life, and impede the action of the valves, or obstruct the passage of blood through this organ, although termed polypi, have no analogy whatever with polypi, either in appearance, composition, or mode of development. 2. That these concretions may consist either of fibrin, or of lymph, or of lymph coated with fibrin. Those composed of fibrin are most frequent upon the right side of the heart, but may occur 234 SECONDARY SYMPTOMS OF CARDIAC DISEASE. on both sides; those which consist of lymph, or of lymph coated with fibrin, are usually found only on the left side of the organ. 3. That the concretions composed of fibrin, whether they occur in amorphous masses, or in stratified layers, are mechanically se- parated from the blood which circulates through the heart. That the concretions composed of lymph, whether this forms the sub- stance of the mass or merely its nucleus, are deposited by the vessels which supply the heart itself with blood. 4. That fibrin, whether it constitutes the substance of these concretions, or whether it is deposited in concentric layers in the sac of an aneurism, is perfectly unorganized, and perfectly inca- pable of becoming organized ; that lymph, on the contrary, is an orcranizable substance. 5. That where pus has been found in fibrinous concretions contained in the heait, its presence is to be regarded as the result of phlebitis, not as a product of inflammation in a substance which being unorganized, is incapable of undergoing such a change. 6. That increased extent of dulness in the praecordial region, confused or irregular action of the heart, intermission or irregu- larity of the pulse, or an abnormal murmur accompanying the heart's sounds, are not necessarily symptoms of the development of these concretions. 7. That no means are known by which polypoid concretions in the heart, once formed, can be dissolved ; consequently, the administration of substances which render blood, when removed from the body, more fluid, or which are supposed to be capable of dissolving them, can have no effect. CARDIAC DROPSY. Dropsy is a common secondary symptom of the advanced stage of cardiac disease, and usually also a late symptom. It makes its appearance as oedema or anasarca, and this may be the only form up to the close. The dropsical effiision, which is partial and slight at first, commences in some instances with a pufflness of the eyelids, more frequently as oedema about the ankles ; by slow degrees it ascends towards the trunk, and ultimately often engages the upper extremities and face. When general, those parts in which the cellular tissue is lax, as the scrotum in men, CARDIAC DKOPSY. 235 and the labiae in females become sometimes enormously swollen ; and as tlie patient at tliis period is usually confined to bed (owing perhaps to the unwieldy state of the lower extremities), the infil- tration predominates in the most depending parts, the posterior surface of the trunk when he lies upon the back, or one side of the face, or one hand, or arm when he lies upon his side. Towards the close, effusion very often takes place into one or both pleura, increasing the dyspnoea, aggravating materially the pa- tient's sufferings, and hastening the fatal result. Ascites to any very great extent, on the other hand, is uncommon. The first appearance of dropsy in cases of organic disease of the heart marks, as Dr. Latham* observes, "an eventful period: it marks the period when a new law is beginning to take effect in the circulation, and to gain a mastery over the law of health. The law of health (of which the sound heart is the prime agent) retains the blood within the blood-vessels, or dispenses it only for the needs and uses of health. The new law (of wliich the un- sound heart is the prime agent) suffers, or forces the blood, or some of its constituents to escape, and to form accumulations of serum out of the courses of health. A little oedema of the ankles, or a little oedema of the face, is a sufficient notice of the first yielding of the blood-vessels to this new law, which is no other than a mechanical necessity, against which they can no longer hold out. It is the earliest beginning of serous effusion, which may go on increasing until it has pervaded the entire cellular structure, and filled every serous cavity of the body." The theory of the production of dropsy in cardiac disease is sufficiently simple : the return of the venous blood to the right side of the heart being iinj)eded, general venous congestion en- sues ; after a time, the ovev-distended state of the capillaries and minute veins is relieved by the exudation or transudation of the thinnest part of the blood (the serum or liquor sanguinis) into the subcutaneous areolar tissue. This, as a matter of course, occurs first in the most dependent parts, and the lower extremities con- sequently are its earliest seat, because the returning blood has to ascend in them against gravity. No fact is better established than that local anasarca will follow obstruction to the return of the blood by the veins of a limb ; thus the oedema of the lower ex- * Lectures on Diseases of the Heart, vol. ii. 236 SECONDARY SYMPTOMS OF CARDIAC DISEASE. tremities in advanced pregnancy has its cause in the pressure of the gravid uterus, upon the large veins which return the blood from these parts. Again, aneurismal or other introthoracic tu- mours, which compress the superior cava, occasion first distension of the large veins above, and eventually anasarca of the face, neck, and upper extremities. The fact has also been demonstrated by direct experiments upon animals ; thus Lower placed a ligature upon the inferior cava of a dog, which was followed by anasarca of the posterior extremities ; in another, he tied the jugular veins, and anasarca ensued in the parts above the ligature. Although the immediate cause of cardiac dropsy, as a general rule, is some mechanical impediment to the return of the venous blood to the right side of the heart, there are certain circum- stances which favour its occurrence. Thus, in organic disease of the heart, as well as in other chronic diseases, the blood undergoes changes which predispose to dropsy. These, as MM. Becquerel and Rodier* have shown, consist in the diminution of the glo- bules, fibrin, and albumen, and increase in the watery portion of the blood. The diminution of the fibrin favours the occur- rence of haemorrhage from mucous surfaces ; the diminution of the albumen of the serum of the blood leads more particularly to dropsy. Again, we know that in cases of general venous con- gestion, the liver or the kidneys are liable to become engaged, by which the predisposition to the occurrence of dropsy is ma- terially favoured. In many instances, likewise, disease of the right side of the heart is the result of long-standing disease of the lungs, particularly chronic bronchitis with emphysema, which itself is capable of giving rise to dropsy of the cellular tissue, or of the serous cavities. Cardiac dropsy, properly speaking, occurs only in cases of or- ganic disease of the heart ; it is almost always preceded by general venous congestion, and it is to be regarded as an effort of nature to relieve the over-distended state of the vessels, when a considera- ble and permanent impediment exists to the return of the venous blood to the right side of the heart. Cardiac dropsy is most com- mon in valvular disease ; and the forms of valvular disease in which it is met with, in the order of their frequency, are : * L'Union Medicale. CARDIAC DROPSY. 237 1. Considerable contraction of the left auriculo-ventricular orifice. 2. Dilatation of the right auriculo-ventricular orifice, with hypertrophy and dilatation of the right ventricle. 3. A state of the mitral valve and orifice permitting free re- gurgitation. 4. Considerable contraction of the aortic orifice. Thus, when the mitral orifice is much contracted, there is a permanent impediment to the passage of the blood from the left auricle into the left ventricle, the auricle becomes distended, and the pulmonary veins are unable to empty themselves ; congestion of the pulmonary tissue and of the bronchial mucous membrane fol- lows, which may be relieved for a time by artificial means, or spontaneously by increased secretion from the bronchial mucous membrane. At length, the right cavities of the heart sufier, the auricle becomes dilated, and the ventricle hypertrophied, the right auriculo-ventricular orifice participates in the dilatation, and the tricuspid valve permits free regurgitation ; the vense cava are thus prevented from unloading themselves, general venous con- gestion ensues, followed sooner or later by dropsy. When the left auriculo-ventricular orifice is dilated, or when the mitral valve is diseased, so as to permit free regurgitation into the left auricle at each ventricular systole, the same results follow, but in a less marked degree than in cases of extreme contraction of the orifice. Dr. Blackiston,* however, looks upon it as the most frequent cause of pulmonary congestion. Dilatation of the tricuspid orifice, with hypertrophy, and dila- tation of the right ventricle is one of the commonest secondary effects of obstructive or regurgitant disease at the mitral orifice ; but it also frequently occurs independent of either, and it is an or- dinary efiTect of chronic bronchitis with emphysema. When this orifice is dilated, whatever be its cause, and when much of the contents of the right ventricle regurgitates into the auricle at each systole, particularly if the ventricle is at the same time hypertro- phied, the return of the blood by the venae cavge to the right auricle will be materially impeded, which will react upon the venous system throughout the body, general venous congestion will ensue, * On Diseases of the Chest. 238 SKCONDARY SYMPTOMS OF CARDIAC DISEASE. followed, sooner or later, by dropsy, just as in the cases where the impediment to the circulation commenced at the left side of the heart. Dropsy, in my experience, does not supervene so early, and when it does occur, the anasarca is neither so extensive nor so prominent a symptom in regurgitant disease of the mitral orifice as in a contracted state of this orifice ; it is also more amenable to treatment in the former than the latter. Dropsy to any extent is rare in regurgitant disease of the aortic valves, indeed many cases of this form of valvular lesion terminate fatally either without the occurrence of dropsy, or with merely cedematous swelling of the ankles. The period which intervenes, in cardiac disease, before the occurrence of dropsy is very variable, and depends upon a variety of circumstances ; such as the part of the heart engaged, the nature or amount of the cardiac lesion, and its cause ; the age of the patient, and the state of his health ; whether he is debilitated, anaemic, or the subject of pulmonary, renal, or hepatic disease ; the habits of the patient, whether he is temperate or intemperate ; his occupation or trade, whether it is healthy or otherwise, or whether it is one in which much muscular exertion is required or the contrary ; his station in life, whether it is such as to place him above the necessity of labouring for his daily bread, exposed, per- haps, to all the vicisitudes of the weather, or whether it is such as to save him from experiencing the ill efiects of insufficient nutri- ment, or the contrary. As a general rule, almost, dropsy super- venes earlier, the earlier that general venous congestion ensues ; as a general rule, likewise, it sets in sooner among the labouring orders than the better classes, although the kind and amount of cardiac lesion may be the same in both. Indeed, as Dr. Ormerod* observes, "The history of patients (suffering from dropsical effu- sion in connexion with cardiac disease) who seek admission into our hospitals, commonly speaks of exposure to cold, or distress, or of unusual exertion." Cardiac dropsy is at first amenable to treatnient in the great majority of cases. We have constantly patients in hospital labour- ing under heart disease, and dropsy ; the dropsical effusion is re- moved by treatment, and the patient returns to his occupation : * Gulstonian Lectures, Medical Gazette, 1851. CARDIAC DROPSY. 239 before long, however, it recurs, he again seeks admission into hospital ; and this not unfrequently happens several times. Even- tually, remedies fail to produce the same effects ; renal is super- added to cardiac dropsy, the patient's strength fails, his constitu- tion gives way, and he sinks under the disease — death being very generally preceded by effusion into the pleura upon one or both sides, or being hastened by intercurrent attacks of pneumonia. In some rare instances, the anasarca has disappeared entirely a short time before death. The urine in cardiac dropsy is sometimes highly albuminous, although no disease of the kidneys exists. The mode in which albumen finds its way into the urine in these cases, has been pointed out by Dr. O'Beirne.* We have seen that venous con- gestion always precedes anasarca ; now, when the ascending cava is prevented from returning its contents freely into the right auricle, and the circulation in it is impeded, the renal veins, being unable to empty themselves, become distended, and ultimately the renal circulation is relieved by the exudation of the serous portion of the blood into the infundibula of the kidneys, which mixing with the urine causes it to afford evidence of the presence of albumen when tested, and according to the amount of the serum, the urine will either yield merely a trace of albumen, or will be highly charged with it. The presence of albumen in the urine is sometimes, however, really indicative of renal disease ; thus, when the impediment to the circulation has been of long duration, if the patient has suffered several attacks of dropsy, and congestion of the kidneys has lasted for some time, renal comes to be superadded to cardiac dropsy, and the urine on examination presents evidence of the presence of albumen. Dr. Millerf says " he has rarely seen general dropsy occupying the entire supei'ficial areolar tissue, which was ascribed to cardiac disease, that had not conjointly a renal origin." The anasarca which accompanies the advanced stage of some forms of valvular disease, particularly considerable contraction of the mitral orifice, is usually more extensive, the swelling and dis- tension are greater, and the pain is more severe then when anasarca supervenes upon other diseases. The lower extremities occasion- * Dublin Medical Press, vol. viii. t The Pathology of the kidney in Scarlatina. 240 SECONDARY SYMPTOMS OF CARDIAC DISEASE. ally attain an enormous size, and the sufferings previous to the fatal termination are sometimes extreme, and protracted. The in- teguments, too, are liable to run into gangrene, and this is still more likely to occur, if we are induced to give exit to the serum by punctures in the legs, or upon the dorsum of the foot, although a fine needle be employed for the purpose; inflammation of an erysipelatous character running into gangrene quickly ensues, ac- companied by intense pain, and soon terminating life. 241 CHAPTER IX. CAUSES OF CARDIAC DISEASE.— PROGRESS AND DURATION OF CARDIAC DISEASE.— TERMINATION OF CARDIAC DISEASE. The causes of cardiac, as of other diseases, may be either indirect, remote, or predisposing ; or direct, immediate, or exciting ; many of the former, however, in the present instance, partake likewise of the characters of the latter. Among the indirect or predisposing causes, may be enumerated hereditary predisposition, the rheu- matic or gouty diathesis, pre-existing morbid states of other organs, or of the fluids of the body, particularly of the blood ; the sanguine temperament, a plethoric habit, a particular conformation of body, certain occupations or trades, which either require long continued or occasional unusual muscular exertions, or which impede the movements of the diaphragm, and interfere with the motions of the heart ; intemperance and excesses of all kinds, and powerful mental emotion, whether of an exciting or depressing nature. The immediate, or exciting causes of cardiac disease have themselves been classified by systematic writers ; by some they have been arranged under three heads, viz. the " extrinsic, the in- trinsic, and the accidental." Dr. Copland (whose classification is one of the best), makes four sub-divisions, viz. the "mechanical or traumatic, the physical, the moral, and the pathological." By others, they have been arranged according as the disease has its origin, apparently, in abnormal states of the blood, the lungs, the nervous system, or the heart itself. Inasmuch, however, as the same disease of the heart may arise under very opposite circumstances, and as any one morbid con- dition may be the result of several distinct causes, and when once developed, may itself be the cause of several other morbid states, it is very difficult to lay down any classification of the kind which shall be precise. For instance, a diseased state of the aortic orifice, or of its valves, or any impediment to the current of the 242 CAUSES OF CARDIAC DISEASE. blood at a distance from these valves, may be the immediate cause of hypertrophy of the left ventricle ; prolonged physical exertion, or the habitual indulgence in intoxicating liquors to excess, may be followed by the same result ; any of them, however, in place of causing hypertrophy, may give rise to dilatation of the same ven- tricle ; and any of tliem might be in operation for a considerable time without being followed by either ; moreover, disease of the aortic orifice or of its valves, is itself the result of previous disease, and may be due to several different causes. Corvisart, in the chapter of his work in which he treats of the causes of heart disease, quotes the well-known truism — " the first day of life is but the first step towards the grave." Tlie machinery which carries on the functions of the animal economy in which life consists, is we know not destined to last for ever, it contains within itself the elements of decay, and this applies with peculiar force to the heart, no other organ performing such unceasing duties ; — functions which cannot be disturbed without every other organ sympathizing, and motions which cannot be interrupted, even for a few seconds without death ensuing. In addition, the heart above all the other organs is most readily acted on by mental impressions, emotions of the mind the most opposite, the exciting as well as the depressing passions, hurrying, increasing, or otherwise disturbing its action. Hence, we ought rather to be surprised (as Corvisart remarks) that the heart is not more fre- quently diseased than it is. It sometimes happens that the heart is malformed at birth, there is a deficiency in some part, or an irregularity in the origin of the large vessels which spring from it (the aorta and pulmonary artery), in consequence of which a mixture of venous and arterial blood is frequently permitted. Omitting, however, for the present the consideration of these congenital malformations, which con- stitute a distinct and original source of disease, there can be no doubt that some individuals are born with a predisposition to disease of this organ, its parietes being thinner than natural, or thicker ; or the whole organ does not bear that proportion to the rest of the body which it should in a well formed subject, being either too large or too small for the capacity of the chest. Again, the relative proportion between the heart and the capacity of the chest may be altered, owing ta contraction or CAUSES OF CARDIAC DISEASE. 243 other deformity of the parietes of the latter, the result of disease setting in early in life. In such subjects, frequent or protracted physical exertion, or the continued and habitual use of stimulants will be much more likely to be followed by disease of the muscular parietes, or of the valves, or by dilatation of the cavities of the heart, than if the same causes came into operation in an individual in whom no such predisposition existed. In a great many instances, cardiac disease may be traced, either immediately or remotely, to inflammation of the investing, but particularly of the lining membrane of the heart, whether this has its cause in acute rheumatism, which is by far the most frequent, or in exposure to cold ; or whether it accompanies morbid states of the blood, or of the general system ; yet, this most fruitful source of cardiac disease was scarcely recognised as a cause until within, comparatively, a few years. Injuries of the left side of the chest, such as blows, contusions, or falls, probably by giving rise to inflammation, are likewise occasional causes of cardiac disease ; I have seen several cases where it could be distinctly traced to a blow or fall, or to a severe contusion of the part : these were all young subjects. Morbid conditions of other organs occasionally react upon the heart, and may thus become an exciting cause of disease. For instance, chronic bronchitis with emphysema of the lungs, by ob- structing the pulmonary circulation, gives rise, first, to distension of the right chambers of the heart, followed by dilatation of the right ventricle, usually with, sometimes without hypertrophy of this ventricle. Indeed, Dr. Taylor* is of opinion, that pulmonary obstruction may cause not only enlargement of the right ventricle but also of the left ; the impediment at the right side to the return of the blood reacting upon the arterial capillaries of the general system, and backwards upon the arteries and left ventricle, the increased eflforts of which lead to hypertrophy. In the majority of cases, however, the systemic capillaries relieve themselves by allowing the more watery parts of the blood to transude, and anasarca of the extremities rather than hypertrophy of the left ven- tricle is the result. Certain trades or occupations which require the body to be maintained for a long time in a constrained or unnatural position, * The Lancet. 244 CAUSES OF CARDIAC DISEASE. sucli as that of tailor, shoemaker, &c., may likewise, by impeding the descent of the diaphragm, and thus interfering with the free movements of the heart, indirectly bring about disease of this organ. When the heart's action is frequently, and for a length of time accelerated by inordinate muscular exertion, this may lay the foundation for disease ; increased action leading to increased nu- trition, and increased nutrition to increased development. Under such circumstances, if the subject is young and healthy, hyper- trophy of the muscular parietes of the heart may ensue. On the other hand, if the muscular fibre is lax, and the individual is de- bilitated by previous illness or other cause, the walls of the ven- tricles instead of increasing in thickness, may yield to the distending force from within, and their cavities eventually become dilated. M. Flogel* thinks that among the determining causes of cardiac disease, immoderate, long-continued, or even only momentary bodily efforts, especially of the mviscles of respiration, of such kinds as interfere with the free performance of respiration, have not received the attention their importance deserves. He gives five cases in which the patients referred their cardiac symptoms to muscular efforts. Dr. Taylor, on the other hand, considers it doubtful if either unusual muscular efforts, or habits of intemperance ever cause hypertrophy. Advanced age would appear to be a predisposing cause of cardiac disease ; we seldom, in examining the bodies of aged subjects, find the endocardium covering the valves in a perfectly normal condition, this tissue would appear to undergo a change as life advances (for the same reason that the prostate gland enlarges), it becomes opaque, loses something of its elasticity, and eventually becomes, often, the seat of atheromatous or calcareous deposit. This frequently occasions little or no disturbance of the heart's functions ; it becomes a source of danger, however, if inflammation of other organs supervenes, particularly of the lungs or bronchial mucous membrane. Corvisart looked upon protracted mental emotion, whether of an exciting or depressing nature, as a powerful predisposing cause of cardiac disease. It must be recollected, however, that Cor- visart's remarks are founded upon cases which came under his * Brit, and For. Med. Rev., 1845. PROGRESS OF CARDIAC DISEASE. 245 observation during, and subsequent to the first French revolution ; indeed he ahudes to this very circumstance himself, in the chapter upon the causes of cardiac disease. " The scenes of the revolu- tion, and the dreadful results which succeeded — the sudden re- verses of fortune — the grief, the misery, and the violent emotions occasioned thereby, have recently furnished numerous proofs of the influence of mental causes in the development of organic disease, and of the heart in particular." " How frequently have we had in hospital individuals who were formerly in opulence, now reduced to the lowest state of poverty, who anxiously looked for death as a termination of their misery, which disease of the heart brought less rapidly than tliey desired." PROGRESS AND DURATION OF CARDIAC DISEASE. It is a common opinion, and not limited to non-professional individuals, that disease of the heart once established must termi- nate fatally ; and a person whose case is pronounced to be such, is impressed with the conviction, that it must have a fatal and perhaps a sudden termination. This opinion has received con- firmation from the writings of medical men themselves, and the well-known motto to Corvisart's work, " hceret lateri lethalis arundo" has been often quoted in support of it. Since the dis- covery of auscultation, however, our means of diagnosis have been considerably improved, the distinction between the several forms of cardiac disease has been laid down with much greater precision, and it does not admit of doubt, that, many morbid con- ditions of this organ have not the tendency to run on to a fatal termination that was formerly supposed; and, many of them likewise may be kept in check by appropriate remedial measures. " Confirmed organic heart-disease, absolutely insusceptible of cure as it is, carries with it," Dr. Che vers* observes, " the re- deeming point, that, in its ordinary forms, the victim's life is allowed a more lengthened respite than is the case in any other description of destructive chronic disease with which we are acquainted — a respite which, it is true, is fraught with some amount of suffering, great need of self-denial, and many perils ; but during which, if the self-denial be rigorously maintained, while the sources of peril are carefully avoided, the suffering may * Treatise on Diseases of the Heart, Calcutta, 1851. 246 PROGRESS OF CARDIAC DISEASE. be in a great measure mitigated, and the term of existence be prolonged to a degree, the full limits of which are probably far more extended than we are at present aware of. We know that the most ordinary forms of exocardial and endocardial disease — adherent pericardium and valvular contraction, certainly do not, generally and of necessity, destroy life by their own advance, and by the influence which they exert in gradually impairing other organs, in less than from ten to fifteen years ; and the duration of their progress is found to be occasionally longer even than this." The rapidity or the slowness of the progress of cardiac disease is influenced by a variety of circumstances, such as the seat, the nature, and the form of disease under which the patient labours ; its acute or chronic character, and whether it is simple or com- plicated ; its stage, and whether it has, or has not been succeeded by secondary lesions of the heart itself^ or of some other im- portant organ ; whether it is or is not associated with a morbid condition of the blood, or with a cachectic state of the general system. The age of the patient will also have some influence, his habits, whether intemperate or the contrary ; his occupation or trade, and particularly his station in life, whether it places him above the necessity of daily toil, or whether he is obliged to labour for his bread, exposed perhaps to every vicissitude of the weather, with perhaps an insufficient supply of food, or scanty clothing. The acute inflammatory affections of the heart are the most rapid in their progress, and they may either end in resolution, or terminate fatally in the acute stage, or pass into the chronic form. Cardiac disease is, however, seldom fatal in the acute stage, unless some serious complication exists ; or unless the disease arises in a broken down constitution. If, however, the inflammation passes certain limits, although the patient recovers, organic changes ensue which are permanent, and will necessarily tend to shorten life. The diu'ation of the chronic forms of cardiac disease is very variable ; as a general rule, almost, their progress is slow ; and although, when once established, organic disease of the heart is incurable, we can in most cases mitigate some of its ill effects, we can prevent congestion, or remove it when it occurs ; and, under favourable circumstances, we are able in many instances to ward off" dropsy, and to prolong life. PROGRKSS OF CARDIAC DISEASE. 247 The progress of the chronic forms of organic disease of the heart is by no means uniform ; in many, indeed in most instances, there are remissions, sometimes amounting ahnost to intermissions of the symptoms, lasting for a longer or shorter period, and oc- curring at variable intervals. This is not peculiar to disease of the heart, for the same thing is not unfrequent in aneurism of the arch of the aorta : in some cases of the latter, there are periods during which, if auscultation were not employed, the disease would appear to be almost latent. The remissions in organic disease of the heart are often, of course, the result of treatment, but they occur in- dependent of any ; indeed sometimes when the patient had violated all dietetic, or other rules laid down for his guidance. The period of remission in these cases is termed, by Dr. Ritchie* " the period of latency or quiescence ; it may remain undisturbed," he observes, " in favourable circumstances, if the case be aortic, for so long a time as 15 or 20 years." This, however, must be very rare. " It happens chiefly," he adds, " in persons not exposed to causes which disturb the circulation, increase the quan- tity of blood, or diminish greatly the vital energy." The original cause of the exacerbation is generally some indiscretion on the part of the patient, as intemperance, exposure to cold, fatigue, damp, over-exertion, too free living, or strong mental emotion, &c., and its immediate cause is generally congestion of the lungs, or bronchial mucous membrane, of the liver, or other abdominal viscera. The seat and nature of the cardiac lesion, as well as its extent or amount, have considerable influence in this respect; thus a diseased state of the aortic valves, permitting regurgitation, is a more formidable lesion than a state of the mitral orifice permitting regurgitation ; and it is scarcely necessary to say that a very con- tracted condition of either of the orifices at the left side of the heart, is a much more serious lesion, than such an amount of disease as does not materially interfere with the circulation through the organ. Again, the cause which has given rise to the disease is not without its influence ; thus, a valvular lesion, the result of inflam- mation, is generally a more serious affection than a morbid state of the valve, the result, simply, of adventitious deposit in advanced * Edinburgh Medical and Surgical Journal, No. 185. 248 PROGRESS OF CARDIAC DISEASE. life ; owing to the subsequent shrinking and contraction which takes place in the exudation poured out, as the result of inflamma- tion ; by which the orifices are further diminished in size, or the valves are rendered less capable of fulfilling their functions. On the other hand, in subjects advanced in life, who have died of various diseases, atheromatous or calcareous deposit is frequently found upon the valves at the left side of the heart, although the patient during life had never exhibited any symptom leading to a suspicion of its presence. Hypertrophy of the muscular tissue of the ventricles, is almost always secondary to some other affection of the heart, of the great vessels, or the lungs ; when an impediment has existed for a longer or shorter time to the passage of the blood through, or out of the heart. When moderate in degree, and when uncomplicated with disease of other parts, hypertrophy is not the formidable affection it was once supposed, and a person, the subject of it, may enjoy good health, and may attain advanced age, provided his habits are temperate, and he is not exposed to those disturbing influences which tend to deteriorate the general health. Indeed, hypertrophy instead of being regarded as a form of disease which requires remedies directed towards its removal, is now, very properly, looked upon as a compensatory process, and nature's remedy for overcoming obstruction, guarding against over distention of the cavities, and preventing dilatation. Dr. Ridge, and Dr. Chevers have strongly advocated this view ; "I have not seen or heard of any case," Dr. Chevers* observes, " in which it was demonstrable that excessive muscular development, and strengthening of the walls of the heart existed, otherwise than as a compensation for impediment of some kind, or for the weakening attendant upon temporary or permanent dilatation of its cavities ; nor have I been able to meet with a heart in which the amount of hypertrophy appeared to be more than compensatory for the coincident dila- tation or impediment : whereas, in nearly every complete case, the symptoms during life, as well as the sum of the morbid appear- ances, rendered it almost a matter of demonstration, that the amount of hypertrophy was not, and had never been, fully sufli- cient to counteract the impediment or embarrassment to which the organ was subject. * On Diseases of the Heart. PROGRESS OF CARDIAC DISEASE. 249 Some dilatation of the cavity of the ventricles, invariably, accompanies hypertrophy of the muscular walls of the heart ; when the dilatation, however, much preponderates over the hypertrophy, but particularly when dilatation is combined with attenuation of the parietes of the left ventricle, the prognosis is always more un- favourable, and the progress of the disease is likewise more rapid. If, in addition, the muscular tissue of the heart is softened, or has undergone fatty degeneration, or fat has taken the place of the muscular fibre, we can do little more than palliate symptoms, and endeavour to prolong life. The prognosis, it is scarcely necessary to say, is exceedingly unfavourable, and death is frequently sudden. The occupation of the patient, and the kind of life which he leads, have also an influence upon the rapidity of the progress of organic disease of the heart. If the patient's trade is laborious ; if it is one in which he is constantly exposed to the vicissitudes of the weather ; if, in addition, he is addicted to intemperance and ex- cesses, and if, at the same time, he is badly fed, badly clothed, and badly lodged, the disease, whatever it is, will run its course rapidly, and treatment will have little effect. " The man," as Dr. Latham says, " who having an unsound heart, must traffic with his sinews for his daily bread, has a poor chance of benefit from medicine." Age exerts a decided influence upon the duration of cardiac disease ; thus, congenital lesions or malformations often prove fatal soon after birth ; and Corvisart has made the remark, which experience fully bears out, that cardiac disease, particularly val- vular disease developed in infancy, generally terminates fatally, from the twelfth to the sixteenth year. Indeed, endocarditis, in very young subjects, not only runs a more rapid course than in the adult, but, if the patient survives the attack, the heart remains seriously involved, and a train of phenomena follow, which are highly characteristic, of which we occasionally have the opportunity of seeing examples in hospital ; I allude to a defective development of the muscular and osseous systems, and an apparent cessation of growth, dating from some period subsequent to the invasion of the heart disease. It is generally observed in individuals, who, when young, had laboured under pericarditis and endocarditis, termi- nating in valvular disease ; and the affection can be often traced 250 TERMINATION OF CARDIAC DISEASE. to an attack of acute rheumatism, though it is also observed in individuals who have never suffered from the latter disease. If the patient is a female, the mammae at the approach of puberty are scarcely developed, the catamenia do not make their appearance, the pelvis resembles that of a child, and the limbs have not the rounded form vs^hich they acquire in healthy females at this age. If the patient is a male, the signs of approaching puberty are hardly evident ; the genital organs are but little de- veloped; the beard scarcely shows itself; the bones are small, and the muscles small and flabby. In both sexes the countenance acquires an anxious and sorrowful expression ; the stature is stunted, the thorax narrow, and often malformed, the left side bulging outwards in the praecordial region, the ribs being protruded, and this side predominating over the right, with, often, lateral curvature of the spine. In some cases the mind even appears to partake of the want of physical development of the body. "None of the functions being performed with vigour," robust health is never enjoyed. Indeed it is easy to conceive (as Dr. Willis observes), " that vigorous health of the body at large, is incompatible with failure of function in the organ, upon which all parts of the body depend immediately for their supplies of nutriment." We have had several patients in hospital who verified these observations completely, and who, though approaching puberty, appeared from their size not to be more than nine or ten years of age. In the majority of these cases, the cardiac affection could be distinctly traced to an attack of acute rheumatism ; in the re- mainder, to pericarditis or endocarditis subsequent to exposure to cold, or following an injury of the left side of the chest. TERMINATION OF CARDIAC DISEASE. Disease of the entire heart is seldom or never met with ; the morbid alteration may originate in, and be limited to the investing membrane, to the lining membrane, or to the muscular walls of the heart, or to a small portion only of one of these tissues. Again, the two sides of the heart scarcely ever suffer in an equal degree, for while morbid conditions of the valves at the left side of the organ are extremely common, disease of the same parts upon the right side is extremely rare. TERMINATION OF CARDIAC DISEASE. 251 Organic disease of the heart more frequently owes its fatal ter- mination to its complications, and to the secondary lesions which result from it, than to direct failure of the heart's action. Indeed, " this organ," as Dr. Chevers remarks in the valuable work from which I have before quoted, "is endowed with an almost endless variety of beautiful compensatory resources, and means of adapting itself to circumstances of temporary embarrassment, and of fixed disease, so that no shock which falls short of absolutely suspending its nervous supply, nor any injury which is less than sufficient to destroy some vitally essential portion of its mechanism, has the power at once to disable it wholly." The termination of cardiac disease is sometimes sudden ; in the majority of cases, however, it is gradual, and the patient dies after a more or less protracted struggle ; the immediate result being hastened by pulmonary or bronchial congestion, or inflammation, by effusion into the pleural cavities, or by the formation of fibrinous concretions in the cavities of the heart. It were a sad story, as Dr. Ormerod,* in his admirable lectures observes, to tell how patients with disease of the heart die ; the tragedies, so to say, of the medical wards of our large hospitals ; " How some wrung with pain, have struggled in the week-long agony of death. How some have, for days together, fixed them- selves in the most fantastic postures, the only way in which they could find relief; some leaning forwards, resting their heads on a stool to catch a few minutes' sleep ; some on their hands and knees, till the approach of death, blunting their sensations, allowed them to lie down — a sure sign of coming dissolution." The patient usually preserves his senses perfectly to the close, though when a considerable impediment to the pulmonary circulation existed, and the venous blood has been prevented from undergoing the ne- cessary changes in the lungs, death is occasionally preceded by stupor, or by a mild kind of delirium. When the death is sudden, it may be the result of rupture of the parietes of the heart, or of cerebral or pulmonary apoplexy, or syncope may supervene, from which the patient never rallies; or on some slight exertion on the patient's part, the over distended and weakened left ventricle becomes incapable of contracting upon * Gulstonian Lectures— Medical Gazette. 252 TERMIXATION OF CARDIAC DISEASE. its contents, the coronary circulation is impeded or interrupted, and the lieart's action necessarily ceases. The immediate cause of sudden death in the majority of these cases, is, probably, impediment to the coronary circulation ; and when we come to examine such cases post mortem, we are some- times surprised, rather that the heart should have continued so long to perform its functions, than that it should have ceased to act at that particular moment. BY THE SAME AUTHOR. Lately published^ 127WO, cloth, price As. OBSERVATIONS ON ANEURISM AND ITS TREAT- MENT BY COMPRESSION. OPINIONS OF THE PRESS. " Dr. Bellingham has ably advocated the cause of compression, as a highly useful and successful mode of treating numerous cases of external aneurism." — Lancet. "In our opinion, he has conferred a signal benefit upon the art of surgery, by his improvement of the mode of employing pressure ; and upon the science, by his ingenious and philosophic exposition of its operation." — Medico- Chirurgical Review. " Dr. Bellingham's little work is well worthy of attentive perusal, and we feel a confident hope that, henceforth, another formidable ope- ration (as ligature of the femoral vessel, even under favourable cii-- cumstances, unquestionably is) may in a great majority of instances be avoided." — American Journal of the Medical Sciences. " The very excellent and practical essay lately published by Dr. Bellingham, to which we would refer our readers as containing a most masterly account of the treatment of aneurism by compression." British and Foreign Medical Review. " I conceive, that for a just exposition of the principles on which that mode of treatment should be conducted, as well as for some valuable improvements in the mode of procedure itself, the surgical profession is mainly indebted to you." — Sir Philip Crampton's Letter to the Author. LONDON: JOHN CHURCHILL, PRINCES-STREET, SOHO. DUBLIN : FANNIN & CO. GRAFTON-STREET. UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below.