of 7 years, the right auricle was so dilated as to contain a coagulum as large as the closed hand of an adult." Of dilatation an extreme example is given by Bouillaud, in which "the right cavities were so dilated, and their walls so attenuated, that the auricle was converted into a kind of transparent membrane, and the ventricle reduced to the ordinary thickness of the auricle."

Diagnosis.-The augmented space occupied by the enlarged and dilated heart, is traceable by percussion, while the impulse is strong, often much stronger than natural. The sound, usually loud, if not otherwise abnormal, becomes dull and grows duller when the muscular walls are thinned in marked degree. Hydrops pericardii would give the same wide space of dulness, but impulse and sound are lessened. The same is true of pleural effusion, oppressing the heart, and if not displacing it, yet interposing between the explorer and the organ. Causes. The additional causes besides those already suggested, are excesses and debauchery, pulmonary disease, "hepatic and renal affections, with atheroma and aneurism of the great arterial trunks, espe cially the aorta." Anemia and chlorosis are also mentioned here. In some instances no cause can be assigned. "Nothing can be more puzzling," says Gairdner, "than cases of hypertrophy and dilatation without valve disease, without any appreciable mechanical cause, and often without the concomitant of diseased or degenerated muscular fibre."

Prognosis.-The frequency of cases in which the above statement of the absence of mechanical causes is applicable, gives reason for a hopeful view of the subject. Where a transient series of contingencies have acted in exciting this most impressible of all organs by nervous disorder or mental emotion, by care, or grief, or anxiety, a certain degree of enlargement may take place which shall cease to go forwards when these contingencies are removed. Dyspepsia, by bringing on irregular action of the heart and frequent palpitation; pneumonia and bronchitis by their congestions impeding the pulmonary circulation, and all other similar agencies, admitting of control or removal, may give a temporary tendency to dilatation and hypertrophy. I am satisfied that I have met with several instances in which, after much suffering, health has been restored; in one such, I think, perfectly. But I have met with no examples of recovery where the physical signs of valvular change were marked and persistent.

The treatment must be directed upon principles already indicated. If the cause can be detected and is removable, it must be taken away. The general health, both of body and mind, must be carefully looked to. The irritability of the disturbed organ must be controlled by sedatives. Digitalis is much in use and is often serviceable. The veratrum viride may be made of avail. Prussic acid has been of benefit. I have derived advantage from the valerianates of zinc and iron. Indeed, all the preparations of iron have been exhibited and extolled here.

Careful venesection at intervals; the frequent use of laxatives, and low diet may be adapted to particular cases, in which some remains of inflammatory action may be present; but I cannot think them generally appropriate. I prefer to sustain the patient's strength with nour

ishing but unstimulating diet; to give him abundant fresh air and passive exercise by gestation, while I endeavor to regulate by the means above mentioned the force and frequency of the pulse. The mind must be kept as quiet as possible. In women, hysterical excitement may be checked by the use of camphor, castor, assafoetida, ether, and chloroform, and the tendency to palpitation carefully watched. Minute doses of morphine or some of the numerous preparations of opium are of great value; indeed they have seemed to me indispensable in the management of a great majority of the cases. Yet opium must be used with prudence and reserve. If pressed too far, the ultimate tendency becomes injurious.

NEUROPATHIC DISORDERS OF THE HEART.

The heart is peculiarly liable to functional disturbance and derangement; indeed, it may be affirmed, that few escape some degree of suffering from these causes, at some point in their history; usually when adolescence is approaching maturity, and life with all its passions and anxieties opens in prospect.

They excite great alarm, as they closely simulate the grave organic diseases which we have been discussing; it is therefore highly important that we should study them carefully, and distinguish them clearly.

PALPITATION. This term has been already employed to denote the vehement and irregular pulsations which attend upon cardiac diseases. It is far from being confined to these, however; it is met with in hundreds of cases of transient character; produced by mental emotion of every variety and name; a frequent symptom of dyspepsia; one of the ordinary results of impoverishment of blood from whatever cause, hemorrhage, anemia, chlorosis, inanition; one of the thousand annoyances of the nervous irritable temperament, the hysteric, the hypochondriac.

It needs no description. The inordinate action of the heart may be seen as well as felt; nay, is so violent sometimes as to agitate the patient, and even shake the bed on which he lies. It is usually irregular, and connected with intermission of pulse, but not uniformly.

The diagnosis must be made by careful exploration and patient attention. For the most part the physical signs of cardiac disease will be absent; but in the anemic we will, frequently, hear the bellows murmur. In these cases, however, there will always be periods of relief and intermission; there will have been no antecedent causative disease, as rheumatism or pleuro-pneumonia; and tonics and exercise will be better borne.

The causes are numerous; many have been already alluded to. Besides those, we may specify the use of tobacco; the effect of previous wasting disease, or of medicines given for its relief, such as digitalis; of large bleedings; secret vices and sexual excesses.

The prognosis may be declared to be favorable as a general rule;

the disorder readily enough subsides, in the great mass of cases, on the removal or avoidance of its causes.

The treatment will depend upon the apparent circumstances upon which it is built up. If connected with, or symptomatic of other definite malady, this must be got rid of or relieved. If the result of anemia, or impoverishment of blood, the preparations of iron will constitute our best remedies. When belonging to the history of general nervous disorder, the immediate effects may be palliated by a prudent use of narcotics and cordials; the valerianates of zinc, iron, and quinine, have done good service in my hands; opium, with camphor, as in the common elixir paregoric, will often give prompt relief; musk, castor, and assafoetida, are much used; prussic acid is a calmant and tranquillizer; and I should not hesitate in a paroxysm of any severity to employ chloroform, both in moderate inhalation as a partial anesthetic, and internally as a soothing cordial. I have known blisters to the thorax, and an issue or seton in the arm, of much benefit; perhaps by directing the attention of the patient from the dreaded malady to the annoying remedy.

The diet should be nourishing and rather stimulating; exercise should be taken constantly in the open air; amusement and recreation afforded duly, by change of place, travelling, and agreeable employ ment; and the cold bath or sea-bathing resorted to if within reach, pleasantly or patiently endured, and suited to the season of the year.

SYNCOPE.-Leipothymia, well defined by Cullen, "motus cordis imminutus, vel aliquamdiu quiescens." This languor or temporary suspension of the function of the heart, is the prominent point in its description or history.

Fainting comes on-sometimes, but rarely, without premonitionusually with an oppressive feeling of weakness and sinking, rapidly increasing to unconsciousness. The visage is pale or livid, the pulse is feeble or ceases to beat, the skin becomes cold, the eyes are turned upwards and half closed, the respiration is scarcely to be perceived, or there is gasping and moaning; the patient falls insensible. This state is of uncertain duration, sometimes continuing long enough to simulate actual death, at others only for a few minutes; at last the circulation is gradually restored, the breathing becomes more distinct, warmth and color return to the surface, and the consciousness and muscular strength come back. Recovery is apt to be attended with vertigo, sometimes with nausea, and even vomiting. There is much tendency to relapse on rising. I have twice seen violent convulsions -quasi epileptic-in patients not subject at all to epilepsy, attend restoration from syncope.

Diagnosis. From apoplexy it is distinguished by the paleness and coldness of the skin and face; the quickness, frequency, and feebleness of the pulse, if it can be felt; and the subdued respiration. Asphyxia from the breathing of irrespirable gases, will be known by the history and attendant circumstances. In hysteric insensibility and loss of motion, the pulse still beats regularly, and the color remains.

The prognosis is almost uniformly favorable; a few fatal cases are,

however, recorded. I am inclined to think that we should place here some of the deaths ascribed to what has been called "simple apoplexy," that is, apoplexy without any traces of cerebral lesion. Still further, deaths attributed to coup de soleil, insolation, are often, I believe, the results of absolute exhaustion, overwhelming syncope; and even those cases described by Russell and Dowler as "pulmonary, not cerebral apoplexy," may be of syncopic character, the congestion in the thoracic vessels taking place because of the sudden cessation of the heart's action, while the lungs were filled with blood from exercise and fatigue; the right ventricle-ultimum moriens-contracting last. Causes. Among the predisposing we may rank general debility from previous disease or suffering; and constitutional mobility of fibre both accidental and hereditarily transmitted. Fainting is frequent in particular families; women are much more liable to it than men, yet two of the most susceptible subjects I have known were sturdy young men; children are seldom seized with it, yet I have seen several attacks of great violence and long duration in a child when about seven weeks old.

The occasional causes may be arranged under three separate heads. The first comprises such disorders of the heart itself, as shall disturb and interrupt, mechanically or otherwise, the regularity of the action of the organ. 2d. Such contingencies as shall depress the circulatory power, directly or indirectly; hemorrhage; inanition from want or from protracted disease; inordinate discharges, whether natural or morbid; the removal of the abdominal distension in dropsy, by allowing the blood to rush into vessels from which it had long been expelled by pressure of the distending fluid; pregnancy occasions fainting fits by the undue determination of blood to the uterus, leaving the vessels of the heart and brain unsupplied. Harvey, the discoverer of the circulation, notices the fact that "fainting is apt to occur even in robust subjects at the moment of removing the fillet, as the vulgar say, 'from the turning of the blood.' I have been induced to think," he continues, "that this cold blood rising upward to the heart is the cause of the fainting." Richardson supposes it to be owing "to the heart's being overwhelmed by the additional amount of blood thrown into it while weakened. The same effect," he says, "is seen in transfusion, if the blood be injected in or forced on too quickly." The hemostasis induced in the instructive experiments of Buckley, brought on a condition approaching to fainting, but it does not appear that syncope followed in any instance the removal of the tourniquets applied to the limbs.

Under the third head I include such agents as make their primary impression on the sensorial system; pain of great intensity or of peculiar character; exquisite pleasure; sudden relief from pain; disagreeable impressions, not positively painful, as the effect of heat and bad air in crowded places, of unpleasant odors, or from idiosyncrasy, odors not unpleasant; the sight of disgusting objects; mental emotions, both gentle and violent, as pity, sympathy, impatience, joy, grief, terror. It is amusing to be told (as we are in Dickens' Household Words, No. 2) that horses not unfrequently faint when first lowered

into the deep coal-mines, where they are employed in great numbers. "The attack seems to be produced by the combined influence of fear, and motion in descent, and profound darkness. They are recovered by fanning, too, as women are."

How this last class of causes act in occasioning syncope is difficult to point out with clearness. None of them are directly sedative in their operation. Cullen ingeniously attributes their effect to a rapid and complete exhaustion of the nervous energy; but this cannot be true of them all. An active energetic lady of my acquaintance cannot witness, without fainting, the very trifling operation of vaccination. Marshall Hall tells us of fine ladies who faint from impatience in attempting to untie a knot in a silk thread.

The treatment must be modified by the condition of the patient and the cause of the attack. The patient must be placed in a recumbent position with the head low. Dash cold water in the face, apply pungent volatiles to the nostrils, and if the case be threatening and protracted, touch the eye with ammonia, or the extremities with a heated iron, or slap the whole surface sharply. Apply warmth and irritants to the surface, and have recourse to galvanism or electricity if at hand. Prevent him from rising too soon when recovering, and administer some warm nutritive fluid with wine.

To prevent recurrences of syncope, the causes must be inquired into and removed, or their influences palliated or corrected; the general health must be improved by a generous diet and proper regimen. Exercise in the open air must be enjoined, and the system invigorated by tonics, stimulants, and sea-bathing, or the shower-bath, unless contraindicated.

ANGINA PECTORIS. "Hyperesthesia of the cardiac plexus," of Romberg.— The nature of this painful and distressing affection is obscure, and in the uncertainty which has prevailed concerning its intimate character and proximate cause, each writer who has treated of it has employed a name or denomination referring significantly to his own particular views of the subject. Thus, it is called by some, syncope anginosa, to express its supposed analogy, in certain points, with common syncope or leipothymia; and thus, Darwin, dwelling emphatically on the dys pnoea which forms so prominent a symptom, has styled it "asthma dolorificum." Good has conferred upon it the title of "sternalgia, or breast-pang," a term as free from objection as any other, on the ground of its being inexpressive of and unconnected with any hypothetical notions concerning its pathology, and intended merely to bring forcibly to the attention the most annoying and uniform circumstance in its history-the pain at or under the sternum. I have, for a similar reason, adhered to the original name applied to the disease, which alludes simply to its locality and painful character.

Angina pectoris is very seldom met with before the middle term of life. It is of the paroxysmal or recurrent form-is not, however, governed by any definite periodicity in its intervals after the few first attacks, is disposed to become fixed in the constitution with the tena