heart's action are indicated in cases of dilatation, as well as in cases of hypertrophy. The same remedies are indicated in both forms of enlargement; but they are to be employed with more caution in the former than in the latter. The danger of weakening or retarding too much the muscular action of the heart is far greater in cases of dilatation. Anodynes, digitalis, aconite, etc., are serviceable, but must not be pushed beyond the effect of tranquillizing the action of the heart, incurring risk of weakening the muscular power of the organ.

The paroxysms of dyspnoea or orthopnoea, sometimes the source of great distress in cases of dilatation, are to be palliated by antispasmodic remedies and revulsive applications. Of the former, the ethers, and of the latter, sinapisms, dry cupping, and stimulating pediluvia are the most efficient.

The treatment of dropsy dependent on cardiac disease is deferred till after the consideration of valvular lesions.

CHAPTER II.

LESIONS, EXCLUSIVE OF ENLARGEMENT, AFFECT. ING THE WALLS OF THE HEART.

Atrophy, with diminished bulk of heart-Fatty growth and degeneration-Symptoms and pathological effects of fatty growth and degeneration-Physical signs and diagnosis of fatty growth and degeneration-Treatment of fatty growth and degeneration-Softening of the heart in typhus and typhoid fever and other affections-Treatment of softening of the heart-Induration of the heart-Cardiac aneurism-Rupture of the heart-Carcinoma, tuberculosis, extravasation of blood and cysts.

EXCLUSIVE of enlargement, the heart is liable to various lesions affecting the walls of the organ, to some of which allusion has been already made, as standing in a causative relation to dilatation. Atrophy, with diminished bulk of the heart, is one of these; fatty growth and degeneration constitute others; other lesions are, softening and induration, and in this category may be included aneurism of the heart and rupture. This chapter will be devoted to the consideration of these different organic affections, taken up in the order in which they have just been mentioned.

ATROPHY WITH DIMINISHED BULK OF THE HEART.

The muscular substance of the heart is sometimes diminished, the cavities not being enlarged, but, on the contrary, their capacity lessened. The organ is reduced in size below the normal limits. In the adult subject it may resemble in bulk the heart of a child. The weight corresponds to the diminution in size. This reduction in size and weight does not involve necessarily any notable change in the appearance of the organ in other respects, the only obvious deviation from the normal condition being the diminution in volume and in the thickness of the ventricular walls.

This is undoubtedly to be considered as an organic affection of the heart, but it very rarely, if ever, occurs except in harmony, so to speak, with other morbid conditions, and under circumstances in which it neither occasions unpleasant consequences, nor claims attention in a therapeutical point of view. It is incidental to chronic diseases of long duration, characterized by gradual, progressive emaciation. It is observed in some cases of pulmonary tuberculosis, and more especially in cases of carcinoma. It is said to follow, in some instances, pericardial adhesions and calcification. of the coronary arteries; but its dependence on these lesions does not appear to be established. It is observed, in some instances, in connection with a superabundance of fat on the exterior of the heart, and may be due, in these instances, as in cases of pericardial adhesions, to mechanical pressure of the organ continued for a long period. The conditions generally giving rise to it are diminution of the mass of blood, and of its nutritive materials-conditions involving diminished exertion of the muscular power of the organ. The heart wastes like other muscles when badly nourished and insufficiently exercised. But, under the circumstances, that is, in view of coexisting tuberculosis, or carcinoma, or some other affection, which, like these, terminates fatally after slowly progressive emaciation, the cardiac atrophy, so far from being an evil, may perhaps belong among the conservative provisions of which the pathological history of even the most fatal forms of disease furnishes illustrations.

The symptoms of atrophy of the heart, it is sufficiently clear, must be those which denote feebleness of the circulation; but inasmuch as an enfeebled circulation due to other morbid conditions, precedes and gives rise to the atrophy, it must be difficult to decide to what extent the symptoms are dependent on the latter. Nor are the symptoms denoting feebleness of the circulation distinctive of this particular lesion of the heart. They are incident alike to dilatation, fatty degeneration, softening, &c. The physical signs are much more distinctive, and, in fact, suffice for the diagnosis. The boundaries of the superficial and deep cardiac regions are within the extreme limits of health; the apex-beat is indistinct or wanting, and the heart-sounds are abnormally feeble, and may be inappreciable. In a patient under observation at the time I am writing, a clear, vesicular resonance on percussion is elicited over the entire præcordia. The respiratory murmur is quite intense and normal over the whole præcordial space, a fact which excludes

emphysema of the portion of lung overlapping the heart. There is in this case no superficial cardiac region; the anterior borders of the heart appear to meet. The left boundary of the deep cardiac region is sufficiently defined by the percussion-sound, and falls half an inch within the nipple. The apex-beat is not felt, and the heartsounds are nowhere discoverable. There is evidently considerable atrophy in this case, yet there are no symptoms pointing to cardiac disease. The patient has for several years been affected with pulmonary tuberculosis, which is either non-progressive, or advancing very slowly.'

As already stated, atrophy of the heart does not call for medical

treatment.

FATTY GROWTH AND DEGENERATION.

With the undue accumulation of fat are connected lesions quite different in character and importance, according to the difference of situation in which the fat accumulates. More or less fat is generally present in health on the outer surface of the heart after early infancy, especially on the right ventricle, at and near the base of the organ. It accumulates in this situation to an abnormal extent in some cases. A moderate amount of over-accumulation is frequently met with in post-mortem examinations, when there had been during life no symptoms of heart disease. If the quantity do not considerably exceed the normal average, although it must in some measure embarrass the movements of the organ, it does not occasion any serious results or appreciable inconvenience. When the accumulation is excessive, however, from its weight it leads to enfeebled muscular action and consequent weakness of the circulation. It may also favor dilatation if, from other causes, the blood accumulate unduly within the cavities of the heart. Without these concurrent causes, it may induce atrophy with diminished size of the muscular portion of the heart. This variety of fatty heart occurs after the middle period of life, in persons who present evidence of an "adipose diathesis," viz: accumulation of fat in

I Case of Thos. Carr, Hospital Records, vol. xiii. page 87.

2 This term is borrowed from my friend, Prof. Gross. Elements of Pathological Anatomy, third edition, 1857. Dr. Bellingham also makes use of the term "fatty diathesis." Treatise on Heart, part ii., 1857.

different organs and beneath the integument, constituting corpulency. Not unfrequently, however, it occurs in persons who are not corpulent.' The heart is sometimes completely encased in a thick layer of adipose substance, which alters, in a marked degree, the external appearance and form of the organ. The volume of the heart is often increased not alone by the fatty deposit, but by more or less dilatation. Beneath the fatty layer the muscular substance may not present any structural change. It is, however, generally unusually pale, and the texture softened.

The extension of fatty growth between the muscular fibres is followed by more serious consequences than when the deposit is limited to the surface of the organ. The pressure upon the fibres induces greater functional weakness, and, at length, atrophy. The power of the heart in propelling the currents of blood and in resisting the force of distension from accumulation within the cavities is proportionately lessened. Hence, feebleness of the circulation and proneness to dilatation in proportion to the amount of deposit in this situation. The deposit in this situation may be in the form of adipose vesicles and infiltrated oily matter.

Another variety, much more serious, and differing essentially in character, is that commonly known as fatty degeneration. The fat is deposited in the form of oil-globules within the sarcolemma. It replaces the muscular substance and constitutes another form of fatty atrophy. This variety may be associated with the preceding varieties of fatty heart, but it occurs independently of the latter. It affects more especially the left ventricle, while the varieties consisting of abnormal growth of the adipose vesicles are most abundant on and within the right ventricles. It may be pretty uniformly diffused over the left ventricle or the whole heart, but it is oftener confined to circumscribed patches or strips. The portions affected assume a yellowish or fawn color, which is somewhat characteristic, and if the heart be affected in disseminated patches it presents a mottled aspect. Examined with the microscope, the striae or transverse markings of the fibres are indistinct or wanting, and in place of the proper contents of the sarcolemma, it contains oil-globules in more or less abundance according to the amount of degeneration. It is evident that in proportion to the degree and extent of this

Of 49 cases analyzed by Dr. T. K. Chambers (Decennium Pathologicum), it was associated with general corpulence in 20, and occurred in persons not corpulent in 29. Vide Bellingham, op. cit. part ii.