wrong in ascribing to the softened heart a large share in procuring the fatal result.

"Again, in fevers, when the skin is dusky, and the impulse and systolic sound of the heart both fail, and death is imminent and threatening, and yet under the seasonable use of wine and stimulants the skin brightens and the heart is again felt and heard, and with its returning impulse and sound all inauspicious symptoms are gradually cleared up and recovery is finally complete, then surely we cannot be wrong in believing, first, that the heart had been softened, and had afterwards recovered its natural texture and power; and secondly, that this recovery of its natural texture and power was mainly instrumental in saving life.

"This softening of the heart in fevers is no new fact. But the knowledge of the precise auscultatory signs which denote its softening, and of the precise auscultatory signs which denote its recovery, this indeed is new knowledge, and we owe it to Dr. Stokes, of Dublin. And further, the detection, in these same auscultatory signs, of one precise and plain indication to guide us in a most difficult point of medical practice, viz. the administration of stimulants in fever, this too is new, and this too we owe to the same sagacious physician. Whoever discovers a single new indication of treatment, which shall prove just and true and comprehensive, does a better service to mankind than if he found out twenty new remedies."-P. 264.

A similar condition of the muscular substance of the heart has been observed in Scurvy, Chlorosis, and such like diseases.

Dr. Latham is of opinion-contrary to that of several writers on the subject that the softening of the heart, induced by Fever, Scurvy, or Anæmia, very rarely terminates in a permanent lesion of that organ, after the fever, &c., has long ceased to exist. The cure of the producing disease appears to be generally sufficient to effect a cure of the cardiac affection.

The softening that occurs independent of all constitutional cachexy, is of a much more serious character: it is, indeed, one of the most dangerous of all cardiac diseases. It generally occurs in persons advanced in years, or prematurely old from excesses or irregularities in living; and, before it is recognised, there is almost always some other visceral disease, such as enlargement of the Liver, granulation of the Kidney, &c., or perhaps extensive arterial degeneration, associated with greater or less derangement of the nervous system. Besides, the heart in such cases is not merely softened; it is also very generally either hypertrophied or it is attenuated; and one or both of the ventricles are very usually dilated at the same time.

Before proceeding to notice any other diseases or morbid conditions of the heart, let us here dwell, for a few minutes, upon some of the most frequent and serious lesions that are apt to be induced in several of the viscera, by organic changes in the central organ of the circulation.

As might be reasonably conjectured, the organs which suffer first and most severely in almost all cardiac diseases, are those of respiration; in other words, the Lungs are the most frequent seat of the congestions and effusions, hæmorrhages and inflammations, which are the results and concomitants of heart-disease. The converse, too, of this proposition is equally true; for never are the cardiac symptoms so promptly and so distressingly aggravated as when pulmonic congestion or inflammation supervenes; and, as cases of this complication of evils are of very frequent occurrence, it behoves the medical man to be thoroughly acquainted with the phenomena

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which declare its impending or actual existence. The truth of the following graphic description will be recognised by all experienced practitioners.

"A man has hypertrophy of the heart in a moderate degree with some small amount of valvular injury or with none at all. Hitherto he has been tolerably free from painful palpitation and dyspnoea, except under excitement or extraordinary exertion. But suddenly he is found gasping and struggling for breath and expecting instant dissolution. What is this, and what is to be done? Truly one might be excused for thinking of angina pectoris or some spasm of the heart, and flying to ammonia, and æther, and opium, for relief. But putting my ear upon the chest I have found a small crepitation diffused through the half of one lung, or in the half of one lung I have been unable to catch any audible murmur whatever, either natural or morbid. A single cupping upon the chest, just opposite the portion of the lung that labours, has swept away the crepitation, or has removed the dulness and brought back the respiratory murmur; and the patient has been restored in a day or two to his ordinary state of comfort. Here, in one instance, there has been sudden and extensive effusion into the extreme bronchial ramifications or vesicular structure of the lung, and in another there has been sudden and extensive congestion.

"Such cases as these are very striking. All that belongs to the disease, and all that belongs to the remedy is so clear, so marked, and unequivocal; pulmonary congestion and effusion suddenly coming on, and life brought into instant peril; and then, with the use of the proper remedy, congestion and effusion suddenly gone, and life restored to safety."-P. 321.

The direct anatomical connexion between the circulatory and respiratory organs sufficiently accounts for their close and very immediate sympathy in a state of disease. Nature has evidently designed that the lungs should, when occasion requires, act as a channel of relief to the heart, when it is oppressed with blood which it cannot easily discharge. Pulmonary Congestion is an almost invariable accompaniment of advanced cardiac disease; and the profuse bronchial secretion, and occasionally also the expectoration of blood, are only means by which the system seeks for relief. It is therefore by duly regarding these and such like symptoms as processes set up by Nature to relieve first the congested state of the lungs, and secondarily the oppressed condition of the heart, that the physician will be best enabled to conduct the management of such a case. A cure is not to be thought of; but much may be done by judicious treatment to mitigate the many distresses that are inevitably present. The grand object should be to watch how Nature herself is seeking relief to herself, and to assist her in the effort; at one time by cautiously unloading the gorged state of the bloodvessels, by means either of a few leeches, or of the cupping-glasses applied over the seat of the pulmonic congestion; at another, by attenuating the bronchial secretion and promoting its more abundant and easy discharge.

"Thus for months and months together, and even for years, we may keep people alive and give them incalculable comfort by aiding the lungs in the office of relief, which they are striving to perform, to an unsound heart. This is done by drawing blood from, or by producing vesication or counter-irritation on, the walls of the chest, just when and where, and to the extent that may be required. We should endeavour to make out from time to time, by careful auscultation, what parts of the lungs chiefly labour, where they chiefly crepitate or where they are becoming dull, and to the surface of the chest immediately opposite those parts apply our remedies. Thus, by taking a few ounces of blood by cupping or leeches, or by applying a blister or a mustard poultice on the right spot, and at

the right time, we shall often obtain a degree of relief for our patient, which nothing but experience could lead us to expect. And we shall obtain the like relief in the same case again and again, always provided we take the same care to choose the right spot and the right time in the application of our remedies to the walls of the chest. And what is the secret of our success? The secret (I believe) is this. We are aiding nature in the very channels through which she is seeking to obtain succour for herself. Therefore our remedies are the more effectual."-P. 324.

The influence of digitalis in many such cases, and more especially when the action of the heart is unusually violent, is often of the most marked benefit. We must be cautious, however, in the use of this potent medicine, not to administer in such doses, or continue its administration so long, as to bring down the action of the hypertrophied heart to, or below, the standard of health.

We need scarcely say that the pulmonic disorders coincident with an hypertrophic and over-active state of the heart are, on the whole, much more manageable than those which accompany an attenuated and perhaps softened condition of this organ, and a feeble action of the general circulation. It may still be necessary to relieve the congested state of the pulmonary vessels by the use of leeches or of the cupping instruments applied over the seat of the mischief; but the relief thus obtained is neither so decided nor so abiding as in the former case. While we mitigate the local malady by such means, it may be necessary, at the very same time, to sustain the flagging powers of the heart itself by cordials and gentle stimulants.

The Brain is probably, after the lungs, the organ which most frequently suffers from organic disease of the heart. When the right ventricle is dilated and weakened, the patient will be exposed to the risk of cerebral congestion, and consequently of an apoplectic or paralytic seizure. On the other hand, if the left ventricle be enlarged and thickened, the opposite condition, that of high cerebral excitement, is apt to ensue. "The head is racked with continual pain; there is little or no sleep; the patient becomes delirious, then maniacal, then convulsed, and he at last sinks from exhaustion of his nervous system."

Among the other secondary disorders attendant upon, and indeed induced by, cardiac disease, especially when the right cavities of the heart are chiefly affected, enlargement, congestion, and various disorganizing structural changes of the Liver and Kidneys deserve the attentive consideration of the physician. The dropsy, that so generally complicates the

*

* M. Bouillaud has the following observations :-" Among the influences that are apt to retard the pulsations of the heart, must be enumerated all gloomy, sad, and depressing emotions of the mind. The presence of the elements of the bile in the blood occasions a remarkable retardation of the pulse. In almost every case of apyretic Icterus, we shall find that such is the case. This curious phenomenon, which has hitherto escaped the attention of physicians (?), has been observed by me in nearly 200 instances. In certain persons of the bilious or melancholic temperament, the pulse has been remarked to be usually slower than in other individuals. Corvisart tells us that Napoleon's pulse seldom exceeded 60 in the minute. I have noticed the same thing in other persons of the same temperament, and in whom the mental energy was great."

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latter stages of heart-disease, may, in a very great many cases, be traced to the disordered condition of these two great viscera as its more immediately exciting cause. Hence the obvious importance of assiduously attending to the state of the biliary and urinary secretions in the treatment of all organic affections of the heart, and particularly in those which are seated in its right cavities, and in which there is consequently a greater or less obstruction to the free return of the venous blood. The engorgement of the Liver that is thus induced is known to every medical practitioner; and it seems highly probable that the albuminous condition of the urine, which is not unfrequently observed to be present in cases of cardiac disease, is (often at least) attributable to a congested state of the Kidneys, arising in the manner alluded to. But we cannot pursue this subject at present; and must pass on to other matters.

On the very important subject of Dropsy in connexion with cardiac disease, Dr. Latham remarks, with his accustomed analytic skill—

"In every case of unsound heart the first appearance of the least dropsical symptom marks 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 which the unsound heart is still 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 ædema of the ancles 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.

"All this calls at once for medical treatment. But what is to be done? The circulation must have the relief it seeks somehow. Disburden itself it must. There is a physical necessity in the case from which we cannot set it free. Or if we could, it must be by interfering remedially with the actuating cause, i.e. by curing the unsound heart. But this is impossible. What then can be done?

"This can be done and this only. Seeing what nature is doing and must do, we can only go along with her and seek to aid her in accomplishing her own purposes through other and less hazardous channels. Nature is seeking relief by directly evacuating the blood-vessels of their contents. We must try to gain for her the same relief by augmenting natural secretions and so evacuating the blood-vessels through natural channels. The kidneys and the intestinal canal and its subservient viscera are the most eligible for the purpose."-P. 346.

We need scarcely say that the success of our treatment will depend very materially upon the circumstance, whether there be coincident disease in some of the other internal viscera-the lungs, the liver, or kidneys-besides the heart itself, and whether there be any cachectic condition of the blood itself or not, at the same time.

Angina Pectoris. To the consideration of this frightful and mysterious malady, Dr. Latham devotes his two last Lectures. Its essential characters are, it is well known, an agonizing pain in the region of the heart or immediately under the sternum, accompanied with a sense of imminent dissolution. These are its essential and pathognomonic symptoms. They are often attended with others, but not necessarily so. The most

frequent of these is the extension of the pain to one or both arms, most frequently to the left, and stopping at the elbow. Dr. Copland's definition of the disease is, on the whole, exceedingly good:

"Acute constrictory pain at the lower part of the sternum, inclining to the left side, and extending to the arm, accompanied with great anxiety, difficulty of breathing, tendency to syncope, and feeling of approaching dissolution."-Dictionary, Vol. I., p. 62.

The agony is generally sudden in its invasion, and often equally sudden in its cessation. It is now universally admitted, that the disease is of a spasmodic or spasmodico-neuralgic nature, and that it is not necessarily associated with any one organic alteration of the heart in particular. It has been found, "where there has been ossification or obstruction of the coronary arteries, where there has been dilatation of the aorta, where there has been valvular unsoundness, or hypertrophy or atrophy, or softening or conversion of the heart's muscular substance into fat, it has been coincident with one and one only of these forms of disease or disorganization, or with two or more of them in combination. And it has existed where no form of disease or disorganization whatever has been found either in the heart or in the blood-vessels nearest to it."*

The three cases, whose histories are detailed by Dr. Latham, are, each and all of them, very interesting.

The first occurred in a gentleman 50 years of age, who had felt himself in perfect health until within a fortnight of his first applying for medical advice. Indeed, in the preceding summer, he had made a walking tour through Switzerland; and, after returning home hearty and well, had enjoyed the sport of shooting during the autumn. It was while walking up the hill towards Hampstead, one day in the beginning of January, that he first experienced an attack of angina. During the next fortnight, the paroxysms increased in severity and frequency. At first they occurred every two or three days, then daily, and now, (when he consulted Dr. Latham,) several times a day; at first with, and now without, a cause. The only irregularity discoverable, upon auscultation of the chest, was an "exceeding feebleness of the heart's impulse." Next morning, he had a paroxysm more severe than any he had yet experienced; but when Dr. L. saw him, he looked to be quite well. In the afternoon, however, of the same day, he was seized with another paroxysm and died at once. Dissection." The heart was of its natural size, its cavities of their natural capacity, its walls of their natural thickness, and its internal lining and valves bearing no marks of disease. Its muscular substance was more loose of texture than natural, but not softened in an extreme degree, and both its coronary arteries were entirely converted into calcareous tubes as far as they could be traced. The aorta throughout the chest and the abdomen did not present the smallest space free from disease. In some parts calcareous matter was deposited between its coats, in others cartilaginous, and in others a matter between cartilage and bone. This disease, besides

*

Perhaps attenuation and softening of the muscular parietes of the cardiac ventricles are the lesions that have been found more frequently than any other in fatal cases of Angina Pectoris.-Rev.