if the presence of a coagulum give rise to an endocardial murmur, at the same time that the striking symptoms referable to the heart occur, this constitutes strong evidence of the nature of the accident.

The prognosis in cases in which the symptoms denote the formation of fibrinous coagula is in the highest degree unfavorable. If death do not speedily follow, the utmost to be hoped for is that life may be prolonged for a few days or possibly weeks. There are scarcely any chances for improvement, and none for recovery. Bouillaud entertains the belief that the coagula are sometimes dissolved and disappear. The ground for such a belief is so small as to render it excusable to conclude that, in the instances in which this favorable termination has been supposed to take place, an error of diagnosis was committed. Correctness of diagnosis, in fact, is of advantage only in enabling the practitioner to decide that a fatal result is inevitable. As incidental to organic affections of the heart, however, it is to be borne in mind that in most instances the condition of the patient prior to this accident was hopeless. The effect of the latter, in general, is only to hasten the period of relief from the sufferings incident to incurable disease.

As regards treatment, it follows from the remarks just made that, after coagula have formed, palliative measures are alone indicated. These consist of remedies to relieve dyspnoea and præcordial distress, stimulants to maintain the action of the heart, and revulsive applications, such as fomentations, sinapisms, and stimulating pediluvia. The idea of giving remedies with a view to dissolve the solidified fibrin is absurd. To prevent the coagulation of fibrin, when circumstances are present under which it may be expected to occur, is legitimate, and may be an important object of treatment. This object involves, in the first place, obviating as far as possible the accumulation of blood in the cavities of the heart by measures which have been already considered in connection with the treatment of valvular lesions. Sedative remedies, pushed to the extent of retarding and weakening unduly the muscular contractions of the heart, are objectionable, among other reasons, on the ground that they may favor coagulation. Digitalis is by some writers regarded as a dangerous remedy on this ground in cases of advanced organic or other disease in which the organ is already enfeebled. This remedy, however, is unattended by danger with proper care, if it be true that while it retards the movements of the heart, it does not diminish the muscular power of the organ. In the second place, it is not improbable that certain

remedies may favor the solubility of fibrin, and in this way prevent coagulation. Various alkaline remedies have been supposed to have this effect. If it be true that the fibrin is held in solution in the blood by the presence of ammonia, according to the late researches by Dr. Richardson, it would seem to be a rational inference that ammoniacal remedies must be the most efficient in fulfilling this second object in the prophylactic treatment.

POLYPI OF THE HEART.

The clots and fibrinous coagula which have been considered, were regarded, as already stated, by the older pathologists as morbid growths resembling the polypi met with in the uterus, nasal passages, and other situations. They were called polypi of the heart, and the term polypoid formations is still very generally applied to them. It is needless to say that, pathologically, they bear no resemblance to polypi, since they are not morbid growths, and never become organized. They cannot, therefore, with propriety be said to be polypoid, and the use of this term has been designedly avoided in the foregoing remarks. Abnormal productions, however, may occur within the cavities of the heart, which are analogous to polypi or polypoid growths. Grisolle' gives the results of the analyses of seven cases, which he states to be all the authentic cases on record. In nearly all these cases there existed a pedunculated tumor varying in size from a pigeon's egg to a hen's egg; in six of the cases contained in the right, and in one instance in the left auricle. In all of the cases in which the point of attachment was indicated, it was at or near the foramen ovale. In four cases the tumor extended through the auriculo ventricular orifice into the ventricle. The peduncle was formed apparently by the endocardial membrane which generally extended over the tumor. The form of the polypi was pyramidal, and they presented in some instances a smooth, and in other instances a lobulated

Traité de Pathologie Interne, 1852, tome second, p. 389.

2 The museum of the Boston Society for Medical Improvement contains a specimen presenting a tumor hanging loose in the cavity of the left auricle, supposed to be malignant from the coexistence of malignant disease in the lung and about the elbow. Vide printed Catalogue, 1847, p. 88.

surface. The substance of the tumors varied in appearance. In one case it had a fleshy aspect, in one case it resembled a fungous growth, and in two cases the texture was fibrous. In every case there was hypertrophy of the auricle and the corresponding ven

tricle.

The formation of true polypi in the heart differs from that of clots and fibrinous coagula in this, viz., it goes on slowly, and considerable time must be required for the growth of a tumor of suffi cient size to occasion serious inconvenience. Hence, the symptoms are developed gradually and imperceptibly, not abruptly as in cases of coagula. When developed, the symptoms denote an organic affection of the heart, without pointing to the existence of a tumor. The physical signs, as well as symptoms, are not distinctive of the nature of the affection. They may indicate obstruction, or regurgitation, or both, associated with more or less cardiac enlargement. Taking into view the excessive infrequency of these growths, their existence can hardly be suspected from the phenomena during life. It is needless to consider the treatment. The fact of some obscure cardiac affection being determined, the indications will be derived from the condition of the heart as respects enlargement, and the symptoms.

ANGINA PECTORIS.

An extremely distressing and grave affection, occurring, happily, in a very small proportion of cases of organic disease of heart, is commonly known by the name of angina pectoris.' This name was applied to the affection by Dr. Heberden, who was the first to give a full and clear description of it in 1768. The affection is charac terized by paroxysms of intense pain emanating from the neighborhood of the præcordia, extending thence in various directions, often into the left shoulder and down the arm, accompanied by indescribable anguish, a sense of suffocation, and a feeling of im. pending death. These are symptoms characteristic of the affection in a severe form. The præcordial pain is variously described by patients, being lancinating, contusive, lacerating, burning, or con

1 ayy, to strangle.

strictive. Its centre, or focus, generally appears to be over the heart, to the left of the sternum. It is sometimes most intense beneath the sternum; and Valleix cites two instances in which the greatest intensity was referred to the right of the sternum. The pain radiates, as it were, into both sides of the chest, into the back, extending, as already stated, often into the left upper extremity, but sometimes, as in one instance under my observation, into both upper extremities, and occasionally into one or both lower extremities. Dr. Hope met with several instances in which it pervaded all the extremities. Not uncommonly it ascends to the neck in front or behind, and I have met with an instance in which it extended to the jaws and temples. The pain in the upper extremity sometimes appears to end abruptly at the shoulder, and in other cases at the elbow. I have known it to be felt acutely in the forearm, and not in the arm or shoulder. Not infrequently it seems to follow the course of the nerves, and is felt over the whole affected extremity, even to the fingers. The pain is attended by a feeling of numbness, or as if the limb were paralyzed. Numbness referred to the testes. is mentioned by Dr. Walshe as a rare concomitant. Tenderness to the touch, or hyperesthesia of the integument over the situations in which the pain is felt, has been observed in some cases, especially in females.

The affection is essentially paroxysmal. The patient is seized suddenly, often when in motion, and the paroxysm has been repeatedly noticed to occur in walking up an acclivity, after a meal, and especially against a strong current of air. Instant and complete rest is imperative. He seizes hold of some firm support, if any be at hand, or he finds it necessary to take a sitting or recumbent posture, which he does with great caution, and remains as immovable as possible until the paroxysm passes off. The pain is by no means the sole element of the distress. The sense of suffocation and of impending dissolution occasions hardly less suffering.. There is, in addition, often a feeling of anguish which patients find it impossible to describe. Dyspnoea is not a constant element of the paroxysms. It may be present, but is frequently wanting. The respiratory movements are often momentarily suspended or restrained by an act of the will, from fear of increasing the pain and distress, but the ability to expand the chest and breathe regularly is not necessarily impaired. An intelligent patient recently

1 Guide de Médecine pratique.

under my observation, who was subject both to angina and paroxysms of dyspnoea, described them as clearly distinct from each other, nor were the two liable to occur at the same time. Not infrequently the respirations continue unaffected during the paroxysms of angina, and they are rarely more than moderately accelerated. Palpitation is often present. It is rare for the action of the heart to be undisturbed, certainly if the paroxysms are severe. Often the heart acts with great violence, seeming, to quote the language of a patient, "as if it would leap out of the mouth." It is frequently irregular and intermitting, the pulse sometimes indicating vigor, and in other instances feebleness, of the ventricular contractions. The pulse, however, has been observed to be unnaturally slow during the paroxysms. The countenance is pallid, and expresses great anxiety and distress. The change in this respect may be very striking, a deathlike complexion, with great haggardness of the features, suddenly taking the place of an appearance of health. Lividity is occasionally observed. The surface is cold, and frequently bathed in perspiration. The faculties of the mind remain unaffected. A free secretion of limpid urine takes place in some cases. The reader who has not witnessed a severe paroxysm, may form from the foregoing account some idea of the distressing nature of this affection. There are few, if any, diseases which give rise to greater suffering. A patient who experienced the excruciating torture of daily attacks for several months before he found relief in death, made a dying request that I should examine his body post-mortem, in the hope that something might be thereby ascertained which would lead to the means of relieving others in like manner afflicted; a request with which I did not fail to comply.

The paroxysms of angina, in different cases, differ much, not only in severity, but in their frequency of recurrence, their duration, etc. They do not always have the severe character which has been por trayed in the foregoing sketch. They are sometimes comparatively mild. The affection in some cases commences with mild paroxysms, which may progressively become more severe; but in other cases the first attack is intensely distressing. Their duration is extremely variable. Often they last only for a few moments, but in some of the instances which have fallen under my observation, the suffering has continued for several hours. The cessation of the paroxysm is frequently as abrupt as the commencement. I have known a laborer to be attacked repeatedly while at work, and, resting for a few moments till the paroxysm ceased, at once resume his labor.