a rule applicable, at least, to diseases of the heart, that the difficulty of diagnosis is inversely in proportion to its practical importance. This lesion affords an illustration of the rule. Induration proceeding from either of the conditions mentioned, is irremediable. It was conjectured by Laennec that the heart-sounds would be intensified by an indurated state of the walls, so as to be heard at a distance from the chest in some cases. Clinical observation, however, has shown, on the contrary, that the sounds are enfeebled. This would be expected in view of our present knowledge of the mechanism of the sounds.

CARDIAC ANEURISM.

The term aneurism was formerly applied to enlargement of one or more of the compartments of the heart, due either to hypertrophy or dilatation. This application of the term is manifestly inappropriate, and is now discontinued by most writers. Cardiac aneurism is properly a circumscribed or pouch-like dilatation occurring in one or more of the anatomical divisions of the organ. In the great majority of instances it is seated in the left ventricle. It does not occur in the right ventricle, but, in a very small proportion of cases, it has been observed in the left auricle. It is an extremely rare lesion, yet Mr. Thurman was able to collect for analysis, from various sources, accounts of seventy-four cases. The aneurismal dilatation forms a tumor varying in size in different cases from that of a small nut to a sac as large as the heart itself. It contains layers of condensed fibrin and various forms of coagula, like arterial aneurisms. It is sometimes lined or studded with calcareous matter. It occurs in the great majority of cases at the apex, but it may be situated at any point on the anterior or posterior surfaces of the ventricle, and on the inter-ventricular septum. The cavity of the sac communicates with the ventricular cavity by an aperture varying in different cases as respects form and size, being sometimes

'Mr. Thurman's paper was published in the Medico-Chirurg. Transactions, London, vol. xxi., 1838. The reader will find an abstract of it in Hope's Treatise on Diseases of the Heart, etc., Am. ed., 1842, p. 313. Also in Bellingham on Diseases of the Heart, part ii., 1857. In the latter, the reader will find copious references to the literature of the subject.

direct and in some cases sinuous. The walls of the sac, in some cases, include the endocardial and pericardial membranes unbroken, the muscular substance having mostly or quite disappeared; or there has occurred solution of continuity of the endocardial membrane. In the latter case, according to Rokitansky, the aneurism may be considered as an acute, and in the former as a chronic affection. When the endocardial membrane is perforated, the lesion probably commenced by disease of this membrane, the other tissues undergoing dilatation from the pressure of the blood. This is analogous to the false aneurism of surgical writers. The tumor, under these circumstances, does not attain to a great size. In chronic cases, without perforation of the endocardium, the walls of the heart yield to the pressure of blood and become dilated in consequence of a morbid condition at the part affected. This condition generally results from circumscribed inflammation, and consists of softening, or the substitution of new structure for the muscular tissue. The affection, when thus induced, is analogous to the true aneurism of surgical writers. It is supposed that a circumscribed abscess of the walls of the heart, opening into the cavity of the ventricle, may lead to aneurism. This is a very brief synopsis of the views held by pathologists concerning the formation of cardiac aneurism. For a fuller consideration of the subject, the reader is referred to works on morbid anatomy. Two or more aneurismal tumors are sometimes present in the same case. The affection occurs much oftener in the male than in the female.

Cardiac aneurism may be associated with enlargement of the heart by hypertrophy or dilatation, and with valvular lesions, but these affections do not uniformly exist, although present in a large proportion of cases. In the cases analyzed by Mr. Thurman, valvular lesions coexisted in ten, and were stated not to exist in eight, the whole number of cases of aneurism of the left ventricle being fifty-eight. In ten cases only of the whole number, i. e., of fiftyeight, was the absence of hypertrophy or dilatation stated. Adhesion of the pericardial surfaces over the tumor takes place in some instances, and is wanting in others. Aneurismal dilatation of the mitral valve will be more properly noticed under the head of valvular lesions.

Aneurism of the heart may end in rupture and sudden death,

1 Rokitansky treats of this subject at considerable length. An abridgment of Rokitansky's views is contained in the work by Jones and Sieveking.

the blood being poured into the pericardial sac, provided adhesion of the free surfaces of the pericardium have not taken place, and, if so, the opening may take place into the left pleural cavity. But, prior to the occurrence of this event, a fatal result may take place in consequence of the embarrassment of the circulation occasioned by the tumor, and by the concomitant lesions with which it is generally associated.

The existence of this affection is not determinable during life. In no case as yet observed, has the diagnosis been made, nor is it probable that any diagnostic criteria will be ascertained by farther clinical observation. The symptoms in the cases which have been reported, are those denoting some grave cardiac affection, but they are generally due, in a great measure, to coexisting valvular lesions or enlargement, or to both. Nor are the physical signs more distinctive. The passage of blood currents into and from the sac, is likely to give rise to a murmur, which may accompany either sound of the heart, or both sounds. A friction murmur may also be produced. But there are no circumstances which can possibly lead the diagnostician to pronounce that these signs are due to an aneurismal tumor. He may be led to suspect this affection, but he is never justified in deciding with any positiveness that it exists. The circumstances favoring such a suspicion, are those which show that some anomalous form of disease is present. For example, as remarked by Hope, an endocardial murmur may be found which is not referable to the arterial or auricular orifices by the rules of localization to be hereafter considered. Valvular lesions, as the source of the murmur, being thus excluded, and the murmur being evidently due to some organic affection, the hypothesis of cardiac aneurism is admissible; but intra-ventricular murmur is sometimes produced, not referable to the orifices, and, on the other hand, aneurismal dilatations do not always give rise to murmur. So a pericardial or friction murmur may proceed from various conditions, irrespective of present pericarditis. In short, the diagnosis is necessarily unattainable. The affection is one of the rare forms of disease which give rise to more doubt and difficulty, the better acquainted the practitioner is with the diagnostic signs and symptoms of cardiac lesions. He may be aware that he has to deal with some anomalous affection, but he is unable to determine its character. Here, as in other similar instances, the inability to arrive at the diagnosis is not, in a practical point of view, to be deplored; for, were the existence of cardiac aneurism determinable, the treatment would

be that which is indicated by the symptoms without this knowledge. The lesion is irremediable, and the measures best suited to retard the dilatation and prolong life, are those which are applicable to cases of valvular lesions and enlargement, with which the affection is often associated.

RUPTURE OF THE HEART.

Spontaneous rupture of the heart is a lesion of very rare occurrence. It may fairly be doubted if it has ever occurred as a result purely of the violent muscular activity of the organ. In a physical point of view, a broken heart is a poetical license, exclusive of the cases in which the event is dependent on some prior morbid condition of the cardiac parietes. It is an accident incidental to different local affections. In the great majority of cases, it takes place in consequence of softening from fatty degeneration. It may follow extravasation into the muscular substance, constituting the condition called by the French writers apoplexy of the heart, which has been investigated fully by Cruveilhier; great attenuation of the walls in some cases of dilatation; circumscribed abscess; ulcerative perforation of the endocardium; and softening from inflammation. The seat of rupture, in the vast majority of instances, is the left ventricle, either on the anterior or posterior surface. Statistics differ as to the relative liability of the two surfaces. It has been observed in the auricles as well as in either ventricle. Usually a single opening takes place, varying in size from a very minute aperture to a rent of considerable size; but instances have been reported of rupture simultaneously at several different points. It occurs oftener in the male than in the female, and almost always at an advanced period of life. The coexistence of hypertrophy or of aortic obstruction favors its occurrence. It may be attributable to some unusual muscular exertion acting as an exciting cause, but in a large proportion of the reported cases, the patients were in a state of repose when it took place. The only instance of rupture which has fallen under my observation occurred in a patient admitted into

Vide paper by Dr. Hallowell, of Philadelphia, giving an analysis of thirty-four cases, in the American Journal of Medical Sciences, 1835. For copious references to the literature of this subject see Bellingham, op. cit., part II., 1857.

the Charity Hospital at New Orleans with delirium tremens. I did not see the patient during life. He died suddenly and unexpectedly, no affection of the heart having been suspected. On examination after death, a rent was found at the upper and anterior part of the right ventricle near the pulmonary artery. The inner layer of muscular fibres was torn over a space wider than the external opening, showing the gradual progress of the disruption from within. The heart was enlarged, weighing a fraction over fourteen ounces. The ventricular walls were not increased in thickness. The right ventricle was covered with fat, and the walls presented both the gross and microscopical characters of advanced fatty degeneration. At certain points, fatty matter appeared to have replaced the greater part of the ventricular walls, the muscular tissue being reduced to a thin layer, not more than a line in thickness. The patient was about sixty-five years of age. The previous history of the case was not ascertained.

Rupture of the heart is almost inevitably fatal, and death generally follows at once. In some instances, however, life has continued for several hours. The aperture in these instances was quite small, or the escape of blood was retarded by the formation. of a coagulum at the point of rupture. A repair of the solution of continuity is perhaps not impossible, although infinitely improbable. Dr. Walshe states that one case has been recorded of death from rupture in which a former rupture was discovered, firmly filled by a fibrinous coagulum adherent to the wall of the heart. The mechanism by which the fatal result is produced has given rise to considerable discussion. Blood is poured into the pericardial sac with more or less rapidity according to the extent of the rupture. But this sac will not contain sufficient liquid for death to be referred to the hemorrhage alone. Paralysis of the heart from the mechanical compression of the accumulation of blood within the pericardial sac is doubtless an important agency.

Time and opportunity are seldom offered for an investigation with reference to diagnosis. If life be prolonged for some hours, the symptoms are those which denote syncope with præcordial distress, and coma may ensue before dissolution. Happily here, as in other instances in which a positive diagnosis is unattainable, it would not, if attainable, affect the treatment. The indications derived from the symptoms alone are those which would be furnished by the knowledge of the accident which has occurred. Death occurring suddenly, or a few hours after the sudden develop.