regulation of the patient's mode of life. Excitement of all kinds must be systematically avoided, and so must active exercise, and whatever puts a strain upon the heart and induces the slightest palpitation or shortness of breath; the bowels must be regulated so that there may be no straining at stool; and care should be taken to avoid stooping and all other postures which may lead to mechanical interference with the heart's action, by inducing upward pressure of the abdominal viscera. The diet should be light and nutritious, but moderate in quantity, so as not to induce distension of the stomach, and wine and spirits may be taken in quantity sufficient to aid digestion, but not to accelerate the action of the heart.

After a time, however, the cardiac and general derangement will probably attain a point at which effusion of the watery parts of the blood will take place into the subcutaneous cellular tissue as a relief to the congested venous system, and dropsy will occur and will urgently claim attention. The fluid necessarily gravitates into the most dependent portions of the body, and thus oedema of the feet and ankles will take place before swelling is perceived in any other part of the body. So long as the swelling is slight, and confined to the feet and ankles, little heed need be taken of it. The remedies which are applicable to the relief of the other symptoms will probably, after a time, effect its removal. But, when anasarca shows a disposition to increase, and extends upwards into the legs and thighs, there is reason to apprehend that if the venous congestion be not speedily relieved, serous effusion will take place into the lungs, or into the pleura, the pericardium, or the peritoneal sac; or, that the skin of the legs, distended to an extreme degree, will crack and ulcerate, or even slough, and that thus very serious aggravation of the patient's sufferings and danger will occur. Under these circumstances the first consideration is how to get rid of the fluid accumulations which have already taken place, and to put a stop to their recurrence. Up to this time the treatment has been palliative, and the remedies which have been employed have been administered with a view to gentle and gradual action. But when dropsy has occurred to a considerable extent and effusion into the lungs or into the serous cavities is imminent, there is no time for dallying or for the exhibition of remedies which cannot be expected to effect their object for many days, or even weeks. Relief, if it is to be obtained at all, must be purchased by vigorous and immediate action. Pulmonary and renal congestion must be relieved by repeated dry cupping, aided, if the pulse

124 Chronic Disease of the Valves and Orifices of the Heart.

be forcible, by the local abstraction of a few ounces of blood; the various excretory organs must be stimulated to the utmost, and the strength of the patient husbanded by sleep, and supported by food and stimulants. Hydragogue cathartics, such as gamboge, elaterium podophylline, the bitartrate of potash, and the pulvis jalapæ compositus of the pharmacopoeia, should be given on alternate days, to ensure a copious watery flux from the bowels; and, if the liver be congested, and the kidneys healthy, a pill, containing squill, digitalis, and blue pill, should be administered twice or three times a day; the action of the kidneys should be solicited by diuretics, of which the nitrate of potash, acetate of potash, and acetate of ammonia, the iodide of potassium, digitalis, squills, cantharides, nitric æther, juniper, scoparium, erodium cicutarium, triticum repens, and chimaphila, are usually the most serviceable; and the skin's action may be cautiously stimulated by a vapour or hot air bath. At the same time, probably, stimulants will be needed to counteract the depressing influence of the watery flux which will be excited by this treatment, and nothing answers better than gin, hollands, and whiskey. Not only do they act as general stimulants, but, in many instances, they promote the action of the kidneys, and tend, I believe, to obviate the disposition to further serous effusion, by rousing the capillary circulation.

Sometimes, when anasarcous distension has reached a certain point, the tension of the venous system appears to be so great as not to admit of relief by internal remedies. In these cases, our utmost diligence will not avail to relieve the circulation and repress the continuance of effusion; the medicines fail utterly to induce diuresis, or to tranquillise the action of the heart; the breathing becomes exceedingly oppressed, inflammatory redness begins to show itself on the legs, and it becomes obvious that, unless relief be speedily afforded, the patient must succumb to his malady. In these cases scarification and acupuncturation of the legs have been proposed, and are often practised. But repeated observation at St. George's Hospital and elsewhere has taught me that they are dangerous expedients, especially when the kidneys are diseased, and should only be resorted to as a last resource. The former, especially, is almost certain under such circumstances to be followed by erysipelatous inflammation and sloughing; and in the majority of cases, unless the kidneys are sound, the same results ensue after the employment of acupuncturation. Further, I believe they are rarely necessary. Before distension has reached the point which justifies the adoption of mechanical

relief, the skin usually cracks, and an oozing of fluid at first glutinous, but afterwards watery, takes place; and if this spontaneous relief is judiciously promoted by warm flannels and other means, the fluid which has accumulated in the cellular tissue will be evacuated as surely, yet more gradually and more safely than by any artificial means. Nevertheless, if this weeping of the legs does not take place spontaneously, and mechanical relief is necessary, recourse may be had to acupuncturation. It is far preferable to scarification, and when the kidneys are sound, may be employed with a fair prospect of affording relief. If the punctures are made at a considerable distance from each other, there will not be any great risk of inflammation, and the serum which has collected in the cellular tissue will drain off in large quantities.

The congested condition of the stomach and intestines consequent on the obstruction to the portal circulation renders digestion weak, impedes nutrition, and deranges the biliary and intestinal secretions. The diet, therefore, should be light and nutritious; and, as the system is enfeebled by long-standing disease, stimulants in full doses are almost always needed.

CHAPTER IV.

HYPERTROPHY OF THE HEART.

THE term "hypertrophy," as applied to the heart, is meant to express augmentation in the bulk and weight of that organ-an increase in its muscular tissue. The increase which takes place is not in the thickness of the primative fasciculi of the muscular fibre, but in their number, which sometimes increases so prodigiously, that a heart which should weigh from nine to ten ounces, has been known to weigh upwards of forty ounces.

Hypertrophy may be either simple or eccentric. In the former case the walls of the affected cavities may become thickened, whilst the cavities themselves remain of their natural size; in the latter, both the walls and the cavities enlarge, but retain their normal relative proportions. When the hypertrophous tissue is of a weakly, unhealthy character, or has undergone partial degeneration, the walls often yield, and the cavities become dilated to an extent which is not otherwise observed;

and, in these cases, the disease is not simply hypertrophy, but rather a combination of hypertrophy and dilatation. And inasmuch as when the heart has long been diseased its nutrition is apt to be interfered with and its muscular structure to undergo degeneration, this combination of hypertrophy and dilatation is the form in which hypertrophy is most commonly met with in practice.

66

A very contracted state of heart is sometimes observed after deatha state, in which the walls appear to be thicker than natural, whilst, at the same time, the cavities are smaller. This was formerly termed concentric hypertrophy;" but, it is, in fact, a mere post-mortem appearance, resulting from the forcible contraction in articulo mortis of a healthy or a simply hypertrophied heart. Cruveilheir informs us that it is invariably met with in the bodies of criminals who have been guillotined, and it is also observed in persons who have been suddenly killed by accident, and occasionally in cases of phthisis and anæmia.

Whatever the form it assumes, hypertrophy may affect the entire heart, or may be confined to any portion of that organ. In most instances it is accompanied by dilatation, and involves both sides of the heart, the left side being that on which the hypertrophy is most apparent; but when it is local, its most common seat is the left ventricle, and after that the right ventricle; the left auricle is its next frequent seat, and then the right auricle. The aortic and pulmonary outlets increase in width, according as the right or left ventricle is affected, the semilunar valves enlarge in a corresponding degree, the mitral and tricuspid valves and the carneæ columnæ become hypertrophous, and the coronary arteries and nervous ganglia increase in size.* When hypertrophy exists in a marked degree, the form of the heart and its position in the chest are remarkably altered. Instead of being conical in shape, it becomes globular, or more or less imperfectly square; the natural projection of the apex disappears, and the entire organ is sometimes even broader than it is long. Its position undergoes a corresponding change; it lies more horizontally or transversely than natural in the chest, so that its apex pulsates considerably to the left, instead of to the right of the left nipple, and, in extreme cases, it may extend from the second intercostal space above, to the seventh, or even the eighth rib below. The precise form and position, however, which an hypertrophied heart assumes, in any particular case is regulated by * See the monogram on the 'Nerves of the Heart,' by my colleague, Dr. Robert Lee.

the extent and position of the hypertrophy; the enlargement taking place in one direction or another, according as the hypertrophy is general or is confined to either ventricle or auricle.

It is sometimes difficult to determine by mere inspection whether a heart is or is not hypertrophied; and, in order that a just estimate may be formed, it is necessary that some conclusion should be arrived at respecting its size and weight in health. From the nature of the case, it is impossible to fix a healthy standard; but for all practical purposes the weight of a healthy heart may be regarded as averaging rather more than nine ounces, or as varying in different cases from eight to ten ounces, the weight being less in women than in men, but in both sexes increasing gradually as age advances. Between the ages of thirty and forty-nine the thickness of the walls of the

Left ventricle, average at the base 0.43 inches 0.36 inches.

Nevertheless, these figures can only be regarded as giving approximate results, for not only do the relative size and weight of the heart vary in different persons, but the walls of a perfectly healthy heart vary considerably in thickness in different cases and at different ages.*

The causes of hypertrophy, whatever their precise nature, have one element in common: they all operate as incentives to increased cardiac action. This, in truth, is their essential character. Without an increased demand on the force of the heart's action, hypertrophy would never arise; whereas it is an intelligible and necessary result of any long-continued and abnormally forcible cardiac pulsation. Hence it is that, in the majority of cases, hypertrophy implies the existence of obstruction to the current of the blood; for in such cases the heart is stimulated to increased exertion, with a view to adapt itself to the altered mechanism of the circulation; and the result of that unwonted force of action is the same in the heart as in other muscles, viz., increased development of structure.

*The above are Bizot's admeasurements given in Dr. Stokes' work on 'Diseases of the Heart,' note, pp. 257-8.