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The most remarkable feature in the preceding case is the rapidity with which the very great hypertrophic enlargement of the heart (it was nearly three times its ordinary size) took place; an alteration that serves to explain the improvement which occurred in the patient's symptoms: the increased muscular power of the heart overcoming in some degree the insufficiency of its valves. Another peculiarity, that is worthy of notice, was the proneness to Bronchitic attacks a result, no doubt, of the irregularity in the circulation of the blood.

Besides the foregoing case, Dr. Quain mentions two others, in which the primary cardiac lesion-a rupture of the valves-seemed to have been originated in a somewhat similar way.

A porter, in good health, endeavored, while highly excited, to force open a door with his shoulder. "He was seized at the moment with an oppressive sensation in his chest, and, when examined with the stethoscope, the aortic valves were found to be imperfect. His breathing became embarrassed, his heart hypertrophied, and his body anasarcous. He died in about eighteen months from the date of the accident. The imperfection of the aortic valves was found to depend on the convex (inferior) margin of one of them being torn from its attachments, resembling thus a pocket which had been ripped or torn at the end. The heart was much hypertrophied."

The last case occurred in a man, 54 years of age, who has never had rheumatism or any disease of the heart, of which he was aware. While carrying a very heavy load of timber on his back, and in the act of stooping to admit of its removal, he was suddenly seized with so severe a pain in the region of the heart, that he was obliged to let fall his load. Palpitation and dyspnoea commenced at the same time; and at night, on lying down, he heard a noise which has continued to distress him ever since. When he came under Dr. Quain's observation, five months after the accident, he presented strongly-marked signs of imperfection of the aortic valves and of hypertrophy of the heart. "Both sides of the chest are equal in circumference, showing therefore an increase of the left. The apex of the heart is seen and felt to beat below the seventh rib. The motion has an undulatory appearance. The strength of the impulse is not proportioned to its extent; a distinct vibratile thrill is felt over the entire region of the heart, also over the right carotid and subclavian, but to a much less degree in the left. The diastolic pulse is seen and felt. On percussion, dulness in the region of the heart is found to extend upwards from the seventh rib, in a line with the right shoulder, 5 inches; vertically from the third costal cartilage, 32 inches; and directly across the centre of the heart, 3 inches. By auscultation, the second sound is not heard, but its place is taken by a loud musical murmur, which is heard all over the chest, but most distinctly at its upper part, and over the base of the heart. There is also a murmur, but much less loud, with the first sound; it is heard in the same situation, but more distinctly in the carotids than that with the second.' His urine is slightly albuminous." He has derived relief from the use of cupping over the region of the heart, and of sedatives, &c. He still survives.

These cases of Dr. Quain are very instructive. Dr. Latham mentions an interesting one, to shew that a violent fit of Rage may (very probably)

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be the cause of the same valvular lesion which, we have seen, may be produced by a Physical Shock.

A man, in a state of the greatest excitement, seized a knife, and was just plunging it into his own throat, when his wife, with whom he had been quarrelling, rushed upon him, disarmed him, and disappointed his purpose. Some neighbours came in and secured him until his rage had burnt itself out. But from that day he had always been sensible of a palpitation of the heart, which had gradually increased until it incapacitated him for work. Then he became dropsical, was admitted into the hospital, and soon died. All was the work of not many months.

We have now seen that whatever serves to interfere with the smooth and easy play of the heart's action, has a tendency to induce Hypertrophic Enlargement of this vital organ. Such being the case, it is not wonderful that the lesion in question is a common consequence of the existence of any obstruction to the free passing of the blood through the great arterial vessels, and consequently to its easy exit from the ventricular cavities. Hence narrowing of the Aorta, in any part of its course, almost inevitably induces hypertrophy and dilatation of the heart; except, indeed, the mass of blood becomes so much reduced as that the deficient quantity of the permeating fluid makes up and compensates for the abridged calibre of the vessel through which it has to pass. It is, doubtless, in this way alone that we can account for the fact, that the right cavities of the heart are very rarely indeed found to be enlarged in cases of Phthisis, (in which disease there must be most serious impediment to the circulation through the pulmonary arteries) although such enlargement is of frequent occurrence in all the forms of Asthma-in other words, in all diseases in which embarrassment of the breathing, whether occasional or more permanent, is not accompanied with injury of the nutritive functions, and therefore with wasting of the body.

Deformity of the Chest, resulting from curvature of the spine, may become, in point of its effects upon the heart, equivalent to constriction of the aorta, to solidification of the lungs, or, in short, to any other morbid state that occasions a mechanical impediment to the free circulation of the blood, from the centre to the extremities; and thus be the producing cause of hypertrophic enlargement. But, besides the causes already mentioned of this frequent morbid condition, there are others of a less obvious character, and therefore more likely to be overlooked. The following passage points to one of these:

"The coincidence of disorganisation of the heart, especially of its hypertrophy and dilatation, with the marks of chronic disease extensively diffused throughout the arterial system, is very common. The internal lining of the arteries, here and there, in various situations, and upon the whole to a great extent, has lost its transparency, and become a little thickened, and dotted with cartilaginous and atheromatous and bony deposits; but nowhere has its change of structure been such as could be thought capable of producing injury simply by mechanical impediment. And this may be all that is found in the body to account for the heart's unsoundness. But this mere beginning of disease in the arteries, which is indeed a small matter when we see it in single blood-vessels, becomes a great matter, and capable of great effects when it spreads itself throughout the body. It may well be conceived enough to make itself felt by the heart.

"In looking over such records of cases as I possess, it is remarkable in how large a proportion of them I find this condition of the arteries coincident with

hypertrophy and dilatation of the left ventricle. And this, I have said, may be all that is found in the body to account for the heart's unsoundness. But oftentimes there is this and much more than this. We see that the disease of the arteries has reached a more onward stage, and made larger and more extensive deposits of cartilage and atheroma and bone, while the liver and the spleen and the kidneys are found enlarged and granulated; and the transparent membranes, as the pleura and peritoneum, are thickened and opaque. These are evidences and effects of chronic inflammation, and have a pathological connection one with another. And it is strange, if they have not also a connection with the disease diffused throughout the arteries; and it is strange, moreover, if they have not all a connection with the hypertrophy and dilatation of the heart."-P. 226.

Still we must remember that there is no direct evidence to show that the affection of the Heart has been the result or effect of disease of the Arteries; nay, the very converse may be nearer the truth. As yet, therefore, we must be content to know that the two morbid states are not unfrequently coincident; and that the existence of such a complication may be the cause of heart disease being very much more intractable than a more aggravated form of the organic lesion when the arterial system remains unaffected. Another occasional coincidence, if not a cause, of certain affections of the heart, that is enumerated by Dr. Latham, is granular disease of the Kidney, indicated by the albuminous condition of the urine. As with the diseases of other viscera in this cachectic state of the system, so with the heart, it is more than probable that the depravation of the circulating fluid is the agency or medium by which Bright's disease operates upon the functions-and it may be on the structure tooof this vital organ. It seems to us very doubtful whether organic disease of the heart can ever be fairly attributed to granular degeneration of the kidneys as a cause. It is more probable that the latter may be gradually induced by the former, in consequence of the stagnation and congestion of blood in the renal structure, arising from an obstruction to the free return of the venous blood into the right ventricular cavities. However this may be, there is no doubt that it is of great importance, more especially in a prognostic point of view, to watch the state of the kidneys, as indicated by the urine, in all diseases of the heart. The same thing may be said of the Liver. The increase of distress, produced by congestion of this very sanguineous viscus, cannot fail to strike the attention of every practitioner.

In forming our Prognosis in a case of Valvular Disease or other organic affection of the heart, we must take into account not only the suspected amount of the lesion of the valve or valves, but also the probable cause of the disease, as well as the character of the patient's constitution and his general habits and mode of living. When we have reason to believe that the malady has been the result of rheumatic endocarditis, the prognosis as to its duration will, cæteris paribus, be more favourable than when it has proceeded from other causes. The reason of this is obvious. By appropriate medical and dietetic treatment, the tendency to rheumatic disorders may unquest onably be very much subdued; and, as the general constitutional health may be sound, the great object of the physician is merely to prevent the recurrence of a rheumatic attack, and to guard his patient against those errors of exercise and so-forth, which are so hurtful in all cardiac maladies without exception.

"On the other hand, advanced life and a cachectic aspect, and the known habits and ailments of intemperance, or some bad hereditary disposition strongly

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marked, or frequent attacks of some constitutional disorder, such as gout, or rheumatism, or gravel, would hardly suffer us to hope that the disease was single and solitary in the mere valve of the heart which it had injured, (though auscultation did not testify to more,) but would rather lead us to fear its universality in the whole arterial system. Here indeed we fear more than we know. But this is a rational fear."-P. 241.

With respect to Treatment, it can scarcely require to be stated that our hopes of relieving our patient are to rest almost entirely upon the steady observances of a judicious hygienic regimen, and the regulation of the general health. The management of a case of organic disease of the heart can only be safely conducted by the scientific physician: the mere prescriber is more likely to do mischief than good. No two cases can be treated in exactly the same manner. We perfectly agree with our author

that the true nature of his disease should never be concealed from the patient. On the whole, it is a great mistake—and one too that may be a cause of regret ever afterwards-to suppose that the alarm, upon being made acquainted with the truth, may produce serious aggravation of the existing malady. All depends upon the manner in which the communication is made, and upon the remarks which accompany it. Woe betide that man who, whether from indifference to the feelings of others, or from a mere insolent parade of technical knowledge, cruelly proclaims the hopelessness of a malady, without one expression of sympathy or guarded encouragement to the poor sufferer!

On the subject of the treatment of Hypertrophy, there are some judicious and useful observations in the 31st Lecture. That many cases are erroneously set down in practice as examples of this lesion, merely because there is an abiding increased force in the impulse of the heart, is but too true; and the consequences of the mistake are often much to be deplored, as leading to groundless alarm as well as a most unnecessary activity in the measures adopted. The following extract contains the most valuable portion of Dr. Latham's remarks on the subject :

"Impulse of the heart, taken alone, however great and however extensive it may be, is not a sure physical sign of hypertrophy. Hypertrophy indeed cannot exist without excess of impulse, but excess of impulse can exist without hypertrophy. When the impulse of the heart is excessive, and at the same time its sounds are obtuse, muffled and indistinct, and the præcordial region presents a larger space than natural which is dull to percussion, then the signs of hypertrophy are complete. And hypertrophy so sure and unquestionable was never cured within my experience. But when the impulse of the heart is in excess, and at the same time its sounds are as loud and clear as ever, or louder and clearer still, and the whole præcordial region is quite resonant to percussion save the small space which is naturally dull, then the signs of hypertrophy are incomplete. Yet if this be enough to constitute hypertrophy, I have seen and treated it successfully in a hundred instances. But in the mean time I have not thought that I had to do with any such affection or ever claimed the least credit for curing it.

"Cases of mock hypertrophy of the heart are indeed very numerous. Young persons at the prime of life are especially the subjects of it. They are often plethoric and often sedentary, and can assign the origin of their complaint to no particular time and to no particular exciting cause. In them, the excessive action of the heart is doubtless owing to a rich and redundant blood; and the cure of their simulated hypertrophy is effected by depletion and abstinence, and the

gradual exchange of indolent for active habits. These are easy cases to deal with.

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In

Again, young persons are the subjects of it, but they are often pale and thin and dyspeptic, and very sensitive, and inactive from mere debility and nervousness. them the excessive action of the heart cannot be ascribed precisely to any one thing. The stomach and the nerves and the blood itself are all disordered, and they are all sources from which injurious influences may spring up and travel to the heart; and they all have probably their share in producing the simulated hypertrophy. Being so produced, its cure can only be effected by varied methods of treatment and after a long time, and often not until the constitution has undergone some of those changes which belong to stated periods of life. These are by no means easy cases to deal with.

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'Again, young persons are the subjects of it, but they are often neither florid nor pale, neither too full nor too empty of blood. They have no complaint that they can tell you of, and none that you can make out, except an inordinate impulse of the heart; an impulse great enough for any amount of hypertrophy, and constantly present, and admitting of severe aggravation, and ever attended with pain, while the sounds of the heart are still loud and clear, and the præcordial region is still duly resonant.

"These cases are the most difficult of all to deal with. Yet their treatment seems theoretically to lie within a narrow compass. There are no ailments of other organs to set right with the hope that through them you may reach the ailment of the heart. The heart itself contains within itself the sole indication of its treatment. Abate its violent impulse and all will be well. But bleeding will not abate it. Neither will all the variety of anodynes and antispasmodics. Neither will digitalis. For digitalis cannot be given long enough and largely enough for any fair hope of it as a remedy, without fearful hazard of it as a poison. In truth I know no certain medicine and no certain plan of medical treatment that will abate this impulse. But still I know that the very worst of these cases may get well. I have seen some such and watched them for a time and then have lost sight of them, and cannot tell how they have ended. And some I have seen again after the lapse of years, and found them as bad as ever; and some I have found perfectly well. In these last cases hen how has the cure been wrought? Why, it has not been wrought in the way, which would imply a gradual process of bringing down an overgrown structure to its natural size and dimensions. But it has been sudden and abrupt, without any strict use of appropriate means, and sometimes with an utter neglect of them."P. 262.

One or two of the most useful sedatives of the heart's actions are not so much as even named by the lecturer. Of these, Antimony, in minute doses, is unquestionably one of the most potent. Hydrocyanic Acid is also very useful in some cases. The occasional application of a blister is a good remedy. The same may be said of a belladonna plaster. But, of all external remedies, a seton over the heart is unquestionably the most efficient.

There still remain some important matters to be considered; but the examination of these must be deferred to our next Number, when we shall take occasion to compare the views of the French School on several points with those of our author. Meanwhile, we gladly seize this opportunity of expressing our cordial approbation of these Clinical Lectures. We know of no work where the reader will find so clear and easily-intelligible a view of a difficult practical subject-the Diagnosis of Diseases of the Heartas in Dr. Latham's two volumes. His interspersed remarks, too, on many questions of general pathology, stamp him as one of the most enlightened writers of the day.

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