APOPLEXY AND RUPTURE OF THE HEART.

Without a knowledge of this change, which has taken place in the tissue, and precedes the occurrence of these accidents, it is impossible to offer any rationale for them; but now that we are acquainted with the fact that the muscular fibre is degenerated at certain parts of, or throughout the organ, it is easy to understand that, under given circumstances, requiring an unusual effort in the heart, the weakest point will yield, and give rise to effusion of blood. It is difficult to offer an explanation for those cases in which the rupture appears to have occurred during perfect rest; but it is not unreasonable to suppose that, when patients have died from this cause, while reposing in their beds, a sudden movement of the body may have been the immediate cause of the accident; much in the same way as we see, in syphilitic and other cachectic states, the bones become so friable as to be fractured from the same trifling cause. There is no essential difference between those cases in which the hemorrhage seems confined to the muscular tissue, and those in which, owing to a laceration of the pericardium and endocardium, a passage is established by which the blood flows into the serous sac. In the latter case, we find the pericardium, on opening the body, distended with fluid blood, or, if the individual has survived some time after the accident, the blood is partly coagulated. The rent varies from an inch in length to a minute orifice; it frequently runs into the septum, and occasionally we find an accompanying rupture of the columnæ carneæ. The left ventricle is by far the most frequent seat of these disruptions; we find that six of the seven cases of spontaneous rupture of the heart, detailed in the Reports of the Pathological Society of London, occurred in the left ventricle, and only one in the right. An analysis of these cases also shows that the prevailing impression that the anterior surface is more liable than the posterior to become lacerated, is erroneous; five having occurred on the posterior, and two on the anterior walls of the heart. In all there was fatty degeneration, most marked at the seat of injury; the coronary arteries were found in an atheromatous or ossified condition, in the five cases in which they were examined; the average age of the sufferers was 691 years. Ă rather different result is obtained by an analysis of cases of rupture of the heart, following mechanical injury, without penetrating wounds; here, there is no suspicion of fatty degeneration, and a different explanation must be sought for, to account for the seat of the rupture, which appears to vary as much as the injury itself. We find that of five cases of this description, in all of which there was no penetration of the heart's substance from without, one occurred on the posterior surface of the left ventricle, one on the posterior surface of the left auricle, two on the anterior surface of the left auricle, and one on the anterior surface of the right ventricle. Here, the left auricle was three times affected, and each of the ventricles once. From what has pre

ceded, it may be gathered that we do not take Dr. Hope's view, that ulceration is the main cause of rupture of the heart; a solution of continuity of the lining membrane of the heart from this cause, is, as we

shall have occasion to mention, when considering endocardial disease, an occurrence of extreme rarity, and it does not appear to bear any direct ratio to rupture, though it may give rise to gradual perforation.

Rupture of the heart is generally immediately fatal; instances are, however, recorded, in which the patient recovered from the first shock and survived for several hours; in these cases, nature is found to have made an effort at repair, in the shape of a film of lymph, exuded between the torn surfaces.

Gangrene of the heart is a subject alluded to by pathologists, but it does not appear that any authentic cases of its occurrence are recorded. Dr. Copland looks upon it as manifestly a post-mortem alteration, accelerated by a depraved habit of body. We may, therefore, at once pass to the consideration of two conditions which are very frequent, and which are nearly allied to one another, hypertrophy and dilatation of the heart.

CHAPTER XIX.

HYPERTROPHY OF THE HEART.

IN determining the existence of hypertrophy of the heart, we must attend to two preliminary points; first, we must ascertain whether there is an absolute increase of the total bulk, as compared with hearts of healthy individuals of the same age and conformation; and secondly, whether the relative size of the walls of the different cavities has altered. Next, it will be well to inquire into the relation existing between the walls of the cavity and its capacity, and it is also necessary to remove the contents, fluid or consistent, that may distend the cavities, before we form our estimate. Laennec suggested that the doubled fist of the individual might be taken as a rough measure of the size of his heart, as he found, that, in health, the two corresponded in their dimensions; there is no objection to retaining this indication, to assist our judgment, when more accurate determinations are not at our command. The weight of the healthy adult heart varies from eight to ten ounces, while, in hypertrophy, it is found to rise to as much as five pounds.

At the same time, we must also bear in mind the fact, sufficiently well determined by Bizot,' that there is a progressive increase in the dimensions of the heart, from infancy upwards; a circumstance that does not, at first sight, appear to tally with the general law of involution, but will, in many instances, probably, find an explanation in so-called fatty degeneration. The following table shows, at a glance, the results arrived at by that inquirer :

According to this table, there is an uniform increase in all the dimensions of the heart, from infancy to old age, with one exception, viz: in females after the age of 30, where there is a falling off in the thickness of the organ, the other dimensions continuing to increase. The heart appears, subsequently to recover itself, and again to follow the general law, but not sufficiently to attain a thickness proportionate to that in the male heart of the same age. Mr. Bizot's measurements are taken vertically, from the apex to the base, round the base at the junction of the auricles and ventricles, and at the thickest part of the left ventricle. The part most commonly affected with hypertrophy is the left ventricle, and even when other portions of the heart have acquired an increase of size, there is still an increase upon the relative dimensions of the walls of the left ventricle. Bouillaud' gives the following measurements of an adult normal heart, weighing between eight and nine

In health, the relative proportion of the thickness of the left and right ventricles is as 1 : 3; if we bear these facts in mind, they will assist us in determining any relative changes, and the weight of the organ will establish the fact of an absolute augmentation of bulk.

Hypertrophy occurs in three forms, to which Bertin was the first to draw attention, and his classification has been adopted by subsequent writers. In the first, which is termed simple hypertrophy, the walls of the heart are thickened, while the cavities retain their normal dimensions; the second, eccentric or aneurismal hypertrophy, presents an augmentation both of the lumen of the cavities and of the substance of their parietes; and in the third, which has received the name of concentric hypertrophy, the former is reduced, while the latter is alone increased. The last variety, probably, has no existence as a morbid condition, but is, according to the showing of Cruveilhier and Dr. Budd, a post-mortem effect, an evidence, simply, of the powerful tonic contraction of a robust heart. The former writer observed that it occurred in almost all persons decapitated by the guillotine, and the latter has pointed out that in all concentrically hypertrophied hearts the ventricle may be easily dilated by means of the fingers, and always dilates of itself, when the rigor mortis goes off. The simple and eccentric forms, then, are the two which alone constitute actual cardiac disease.

A priori, we should expect to meet with the former, very frequently, as a mere effect of stimulated nutrition, since the heart's action is so constantly abnormally increased, and its powers unduly taxed; and also because, according to Bizot, there is an uniform increase of the heart from birth to the grave; but such cases are the exception, while, in the

Traité Clinique des Maladies du Cœur, vol. ii. p. 559. Paris, 1835.

majority of instances, some lesion may be discovered in the heart, or the larger blood vessels, which, by impeding the current of the blood, gave rise to unusual efforts on the part of the heart, and thus to hypertrophy of its tissue; in the same way as we see the coats of the urinary bladder enormously augmented in bulk, when a long-standing stricture has daily called for violent contractions for the removal of the obstacle. The left ventricle in either form of hypertrophy is the part that is most frequently affected; next in order, the right ventricle, and, lastly, longo intervallo, the auricles. There is not necessarily a relation between the increased thickness of the walls of a cavity and of the columnæ carneæ; the former may be themselves only thickened in some parts, while in others they retain their normal size; and again, we occasionally find the trabeculæ much enlarged, while the proper walls present but little variation. Hypertrophy of the heart necessarily alters, more or less, the relation between the thoracic viscera, a point of importance to the practitioner, as it also gives rise to modifications in the form and direction of the organ, which generally becomes more globular and spherical, while its apex is tilted up, and the long diameter occupies a more transverse direction than in health.

In uncomplicated hypertrophy, where we have to deal with no morbid product, but that of an increase in the amount of muscular fibre, the muscular tissue is of a deeper red than usual, and its consistency is increased; but the hypertrophy may be the result of a degenerative process, or a degeneration may have set up in the organ, subsequent to the hypertrophy having been established; the color may then be of a brownish tint, or present yellowish or fawn-colored spots, while the consistency is generally reduced. In the former case, we find the characters of voluntary muscular fibres more strongly marked than usual; the transverse striæ are more defined, and the edges have a sharper outline; in the latter, these characters are more or less altered, and we meet with further traces of the specific alteration. An analysis of the cases of fatty degeneration collected by Dr. Quain,' shows that the prevailing condition of the heart accompanying this state is one of hypertrophy, whether primary or secondary we are not prepared to determine, though it appears very probable that the change known as fatty degeneration is the result of various morbid processes, inducing a disintegration of tissue. In the thirty-three cases of Dr. Quain's first series, the heart is stated to be enlarged in twenty-one; in six the organ was of a normal size; in four the dimensions are not stated; in one there was dilatation without hypertrophy, and only in one was the heart decidedly smaller than usual.

The causes inducing hypertrophy are essentially of two kinds; "in the one kind," to use Dr. Watson's terms, "there is some mechanical obstruction to the exit of the blood from one or more of the cavities; a constricted state of the orifices is the most common condition. In the other kind, without any such mechanical drain or bar to the fluid, there is something to hinder the free and sufficient play of the organ, an ad

1 Medico-Chir. Trans. vol. xxxiii.