Although dependent on malformations, cyanosis is not always manifested at or immediately after birth. Of 71 cases analyzed by Stillé with respect to this point, it was congenital in 40, and occurred in the remaining 31 cases at various periods after birth. It may not occur until several years after birth. When this is the case, it is reasonable to presume that some disease of the heart or lungs has been added to the malformations, increasing the venous obstruction occasioned by the latter. It has been observed to follow a blow on the chest. The development of cyanosis after birth has been accounted for by supposing that in these cases a communication between the two sides of the heart either takes place or is enlarged at the time when the cyanosis occurs. Rupture or perforation of the foramen ovale may happen after birth, or the size of an existing aperture may be increased. The same may be said with regard to the interventricular septum at the undefended space. This explanation is based on the supposed importance of the admixture of the venous and arterial blood in the production of cyanosis. That it is applicable to certain cases is not improbable. On the other hand, cyanosis in some instances exists at birth and afterwards diminishes. It may even disappear; but such cases must be extremely rare.

Although cyanosis is regarded as a distinct affection, it is sufficiently evident that it is only a symptom of certain congenital affections of the heart. It has no claim to be considered as an individual disease. It is associated with other symptoms of malfor mation, viz., palpitation, dyspnoea, etc. When present, habitually, in a marked degree, the patient generally is remarkably susceptible to cold, and the temperature of the body is lowered. The muscular power is deficient. The muscles do not attain to a full development. The faculties of the mind are also often imperfectly developed and feeble. Enlargement of the pulpy extremities of the fingers, with incurvation of the nails, constituting what is called "clubbed fingers," is observed in some cases. I have met with this charge in a marked degree, in connection with organic lesions of the heart occurring after adult age, not associated with tuberculosis of the lungs.

The diagnosis rarely involves much difficulty. Discoloration of the surface, either general or partial, present habitually, or occur. ring whenever the action of the heart is excited; existing at, or developed shortly after birth in the great majority of instances; accompanied by palpitation, dyspnoea, tendency to syncope, etc., either constantly or in paroxysms; muscular weakness, abnormal

coolness of the surface and susceptibility to cold; these are diagnostic points pertaining to the symptoms. In addition to these points, physical signs denoting malformation of the heart are generally determinable, consisting of those which denote enlargement of the organ, together with organic murmurs, the latter being often referable to the pulmonic orifice. The lividity due to certain pulmonary affections in children, is to be discriminated by the previous history, taken in connection with the presence of symptoms and signs pointing to the lungs as the seat of disease, and the absence of the symptoms and signs of malformation of the heart.

The prognosis in cases of malformation of the heart accompanied by cyanosis, is unfavorable. If the discoloration be congenital, intense, and persisting, it denotes a condition of the heart which is generally incompatible with a duration of life beyond a few weeks or months. If moderate or slight, or occurring only in paroxysms, patients sometimes live for many years, and even long life is possible. The statistics collected by Stillé with regard to the duration of the disease, show, at a glance, the diversity of cases in this respect. Of 40 cases, in all of which the cyanosis was congenital, death occurred within 23 days after birth in seven; between 23 days and 10 weeks, in three; between 10 weeks and 1 year, in seven ; between 1 year and 10 years, in ten; between 10 years and 20 years, in ten. Of these 40 cases life was prolonged to 29 years, to 35 years, and to 57 years, respectively, in a single instance.

The treatment of cyanosis resolves itself into that of malformations of the heart. The few remarks already made comprise all that it is necessary to say under this head.

CHAPTER VI.

CERTAIN AFFECTIONS INCIDENTAL TO ORGANIC DISEASES OF THE HEART.

FORMATION OF CLOTS AND FIBRINOUS COAGULA IN THE CAVITIES OF THE HEART.-Clots formed after death and at the close of life-Fibrinous coagula formed during life-Their pathological connections-Their formation in organic affections of the heart-Symptoms denoting their formation-Physical signs and diagnosis-Prognosis-Treatment. POLYPI OF THE HEART.

ANGINA PECTORIS.-Symptoms characteristic of-Description of paroxysms-Exciting causes-Pathological character and relations-Infrequency of the affection-Influence of age and sex-Gravity and prognosis-Diagnosis-Treatment.

ENLARGEMENT OF THE THYROID BODY AND PROMINENCE OF THE EYES.-Phenomena descriptive of the enlargement of the thyroid body-Morbid appearances of the heart in fatal cases-Cases observed by the author-Supposed pathological connection with excessive action of the heart-Phenomena descriptive of the prominence of the eyesDifferent explanations-Diagnosis-Prognosis in cases of enlargement of the thyroid body and prominence of the eyes-Indications for treatment. REDUPLICATION OF THE HEART-SOUNDS.-Different varieties of reduplication and their relative infrequency-Cases of reduplication of both sounds-Cardiac lesions found after death in cases of reduplication-Mechanism of reduplication-Bearing of the facts pertaining to reduplication on the mechanism of the normal heart-sounds-Mode of distinguishing the different varieties of reduplication-Pathological import and diagnostic significance of reduplications-Treatment.

THE caption to this chapter includes several pathological events which are liable to occur in cases of organic disease of the heart, but which do not belong exclusively to the clinical history of any par ticular lesions. They occur in different forms of organic disease, and all of them do not involve, of necessity, the existence of an antecedent structural lesion. Hence, although these events are quite dissimilar in character, they may conveniently be grouped together. The first of these events which will be considered is the formation of clots and fibrinous coagula within the cavities of the heart; the second is the occurrence of pain and other symptoms in paroxysms, commonly known as angina pectoris; enlargement of the thyroid body and prominence of the eyeball will be next noticed, and, finally, reduplication of the heart-sounds. These subjects will be treated of only so far as, with our present knowledge, they are of interest and importance in a practical point of view.

FORMATION OF CLOTS AND FIBRINOUS COAGULA WITHIN THE CAVITIES OF THE HEART.

The cavities of the heart are usually found to contain, after death, coagulated blood, or clots, in more or less abundance. These are found oftener and in greater abundance in the right auricle and ventricle than in the cavities of the left side of the heart. This is owing to the fact that, at the time of death, the cavities of the right side of the heart contain, in general, a much larger quantity of blood than the left auricle and ventricle. Other things being equal, the size and number of clots will be proportionate to the amount of blood remaining in the heart-cavities after life has ceased. The clots to which reference is now made are formed post-mortem. The blood in the cavities coagulates after death, as it does when drawn from the vessels by venesection during life. These clots are variable as regards size, form, consistence, and color. They are sometimes uniformly dark and friable. In other instances they are more resisting, but never extremely dense, and present, on the surface extending more or less over the periphery, a layer of fibrin devoid of red globules, or hæmatin. The latter is identical with the buffy coating of blood coagulated, in certain cases, after venesection. It is sometimes tolerably firm, and, in some instances, probably from the imbibition of serum, it is of a soft, jelly-like consistence. A distinctive feature of the clots now referred to is, they are loose, i. e., not attached to the endocardium, and not strongly intertwined with the tendinous cords or fleshy columns. They may extend from one cavity to another through the auriculo-ventricular orifices, and into the large vessels, the arteries and veins, connected with the heart. It is not uncommon to find prolongations of considerable length contained in the large arteries, especially the pulmonic artery, consisting of fibrin, more or less solid, and colored, to a greater or less extent, by the presence of red globules. The occurrence of post-mortem clots undoubtedly depends, in a great measure, on the condition of the blood. They are more likely to be formed in those diseases in which the fibrinous constituent of the blood is in excess (hyperinosis); and, under these circumstances, the proportion of colorless fibrin in the clots will be increased. On the other hand, after

certain fatal affections, as is well known, the blood coagulates imperfectly, and sometimes not at all, the cavities of the heart being filled with blood entirely liquid.

To the clots just described the older pathologists attached much importance. They were regarded as ante-mortem productions, and included in the class of the so-called polypi of the heart, being supposed to give rise to a multitude of symptoms during life, and to be frequently the cause of death. That they are formed after death is certain, but the question arises, whether they may not sometimes be formed during the last moments or hours of life, and, in fact, prove the immediate occasion of the cessation of the circu lation. It is difficult, and indeed impossible, to settle this question demonstratively, but the affirmative is highly probable. That coagulation does take place before death in certain cases, and arrests the circulation, is not to be doubted. The coagula that are indubitably of ante-mortem formation will be presently considered. The question now relates to clots, loose or unattached, and not differing from those which are due to coagulation after death. It may be readily conceived that in certain diseases of the heart, and in various affections exclusive of these, at the close of life, when the circulation becomes so enfeebled that the blood accumulates and remains nearly stagnant in the cavities, coagulation may take place, and, to quote the language of Prof. Meigs, "the last fatal blow is struck by the formation of a heart-clot of greater or less size." The distinguished author just named accounts in this way for sudden death, in some puerperal cases, during syncope induced by assuming suddenly the erect posture, when recent delivery bas been accompanied or followed by a large amount of hemorrhage. The explanation is, to say the least, plausible; and its extension, by the same author, to account for the final cessation of the circulation in various chronic and acute diseases, is not irrational. This, however, can only be a matter for conjecture, since the clots found in the cavities of the heart do not differ from those which are formed by coagulation after death.

Masses of considerable size, consisting of coagulated fibrin, are often found in the cavities of the heart in post-mortem examina. tions which furnish intrinsic evidence of having been formed during life. This evidence consists in their density, the absence of

1 Vide paper by Prof. C. D. Meigs, in the Philadelphia Medical Examiner, March," 1849. Also treatise on Obstetrics.