degree in which dilatation of the chambers of the heart exceeds the hypertrophic thickening of their walls. In like manner, the coexistence of hypertrophy with dilatation lessens the immediate danger of the latter form of disease, by rendering the heart more able to fulfil its functions. In its active or complicated form, or even in its simple or attenuated form, dilatation may continue for many years without producing fatal consequences, provided due attention be paid to the medical treatment of the patient, and to the careful regulation of his mode of life; but if his habits are not placed under proper control, the character of the blood improved, and the tone of the system upheld, the patient may have a brief and miserable existence. Death sometimes occurs suddenly in a paroxysm of angina, or from syncope, the result of failure of the heart's action; but more commonly it takes place slowly, with dropsical effusion and congestion of the pulmonary and systemic capillaries. When once dropsy has supervened, relief will be only temporary, and life can seldom be prolonged beyond one or two years.

The only satisfactory treatment of dilatation in its earlier stages consists of measures calculated to regulate the chylopoietic viscera, to improve the condition of the blood, and of the system generally, and so indirectly to impart tone to the heart without exciting its irritability. In the later stages, when dropsy has supervened, our aim must be to relieve the capillary circulation, and to obviate mischief which would render all other treatment useless.

In the first instance, quinine and other vegetable bitters may be needed, in combination with taraxacum and the mineral acids, or small doses of the alkalies, to promote digestion and ensure a proper action of the liver; and if further assistance in this direction is desirable, occasional doses of blue pill, podophyllin, and ox-gall may be given at night, and followed by a warm aloetic draught in the morning. But of all remedies, iron, digitalis, and belladonna are those which exert the most remarkable effect on a dilated heart, and contribute most surely to a successful issue. Aconite, which is so useful in cases of hypertrophy, and has been often recommended in dilatation, is dangerously depressing in its action, and if given at all, must be closely watched. The administration of iron is so manifestly indicated by the aspect and general symptoms of the patient, and is so universally acknowledged as an essential element of treatment, that it is unnecessary to do more than urge the expediency of persevering in its exhibition for a lengthened period—not for a few weeks or even months, but, with

trifling intervals, for several years. In many instanses, I have known the physical signs of dilatation improve materially, and the general symptoms almost wholly disappear after a course of iron has been steadily persisted in for the space of three or four years. Belladonna, again, administered internally, and applied externally, is so generally recognised as a remedy on which reliance can be placed for quieting the irritability of the heart and checking palpitation, that lengthened laudation of its virtues would be superfluous. But it is otherwise in respect to the use of digitalis. Most authorities concur in speaking of this drug as valuable in the treatment of hypertrophy of the heart, but most dangerous, and therefore only to be employed with extreme caution, in the management of dilatation, their views being founded on the commonly received but erroneous impression that digitalis exercises a depressing influence over the action of the heart, and therefore leads to accumulation or coagulation of blood in its cavities, if not to actual paralysis of its muscular structure.* But these views are based on an imperfect knowledge of its action, and are utterly inconsistent with fact. Experiment and observation may be alike appealed to in proof that digitalis stimulates the muscular fibre of the heart, and augments the contractility of the capillaries. When it kills, it does so not by producing paralysis of the heart, but by giving rise to tonic contraction and spasm of that organ. Such being the case, it is a most valuable remedy in the treatment of dilatation, and is dangerous only when administered in hypertrophy. Whenever the pulse is feeble and irregular, and more especially when, from any cause, its feebleness and irritability are temporarily increased, digitalis is of all known remedies the most useful. By stimulating the muscular tissue of the heart, it allays the irritability of that organ and moderates its action, whilst at the same time it augments the tone and contractility of the vessels, increases the flow of urine, and exerts a restorative and calming influence over the system, which is not attainable by any other means.†

*For instance, Dr. Walshe, when speaking of the treatment of dilatation, says:— "The exhibition of digitalis requires the utmost caution: slackening the circulation, as it does, it promotes either coagulation within the heart, or, in a less degree of its action, accumulation of blood in the cavities, whereby they may be still further passively dilated. If the power of the ventricles be seriously impaired, digitalis cannot be given without excessive risk, and had much better be altogether avoided." (Loc. cit., p. 664.)

†The grounds for the opinion above given respecting the action of digitalis may be briefly stated:-1st. During many years I have observed that the cases of heart disease most benefited by digitalis have been those in which the heart has been weak and

In the later stages of the disorder, when cough, dyspnoea, and dropsy have resulted from the stagnation of the pulmonary and systemic capillary circulation, recourse must be had to the remedies which experience has shown to be most serviceable in removing these several symptoms. These have been discussed in the sections devoted to valvular disease of the heart, and it is needless to recapitulate them here. Suffice it to say, that dry cupping between the shoulders and across the loins, and the use of mustard poultices and turpentine stupes, should never be neglected when the lungs are congested; that squill, senega, nitric æther, and ammonia, usually prove the most serviceable expectorants; that hyoscyamus, belladonna, hydrocyanic acid, and æther, lobelia, and the liquor opii sedativus, are the remedies which can be most relied on for controlling the frightful paroxysms of dyspnoea and pain in the cardiac region which are sometimes attendant on this form of disease, and that hydragogue purgatives and diuretics are necessary to drain off superfluous fluid, relieve the congested capillaries, and get rid of the dropsical swelling.

dilated, and the pulse feeble and irregular. In these the pulse has become stronger and steadier, and less frequent under its action. 2ndly. In the only cases in which I have known death to occur suddenly during the administration of digitalis, the heart has been hypertrophied and firmly contracted. This may have been a coincidence, but, viewed in connection with the results of experiments to which I shall presently refer, it is, at least, a suspicious fact. 3rdly. Dr. Dickenson has pointed out (‘Med.-Chir. Trans.,' vol. xxxix), and I have repeatedly verified his observation, that digitalis, if given in full doses, induces violent uterine contraction, and checks uterine hæmorrhage; and, inasmuch as its action in staying menorrhagia and uterine hæmorrhage is permanent, it seems fair to conclude that it gives tone to the capillaries and increases their contractility. 4thly. This view is borne out by what I have long since observed relative to its action in arresting hæmoptysis, viz., that whilst effecting the object required, it does not weaken but rather increases the force of the pulse though it lessens its frequency. 5thly. When patients die of delirium tremens, the pulse is usually rapid and fluttering before death, and the heart is found weak, flaccid, and distended with blood afterwards. These are just the cases in which, on the commonly received doctrine as to the action of digitalis, the drug ought necessarily to prove fatal, and yet modern experience has shown that in these cases it is tolerated even in excessive doses. My impression is that its remedial action in these cases depends on its stimulating the heart, subduing its irritability, and increasing the tonicity and contractility of the heart and the capillaries, so that the brain is better supplied with blood, and the effusion of its more fluid parts, which gives rise to the "wet brains" of habitual drunkards is avoided. 6thly. It has been proved by experiments on animals (Dr. H. Jones) that when death is induced by digitalis the heart is not flaccid and distended with blood, as is commonly supposed, but, on the contrary, empty, contracted to the utmost, and in a state of tonic spasm. All these facts confirm my view as to the action of digitalis, and if it is correct its practical importance in relation to the treatment of cardiac dilatation can hardly be over estimated.

From the earliest period of the disease the patient should be encased in flannel, and be otherwise kept warm, and should lead a tranquil life, avoiding fatigue and all active exertion. Cheerful society, frequent change of scene, and regular but moderate exercise in the open air, are important elements in the treatment. The diet should be light, nourishing, and easy of digestion, and soups and liquids should be avoided as much as possible, as calculated to excite flatulence and distension of the stomach, and so to interfere mechanically with the action of the heart. Diffusable stimulants are always needed. A glass or two of wine, or brandy and water may be taken at luncheon and dinner, so long as the legs are not oedematous; but, as soon as anasarca supervenes, whisky, hollands, or gin, may be advantageously substituted, as stimulating increased action of the kidneys.

CHAPTER VI.

ATROPHY OF THE HEART.

ATROPHY of the heart, as its name implies, is the reverse of hypertrophy, and results in the diminution of the muscular tissue of the heart, and of the nerves and vessels which supply it. Every part of the organ decreases in size, its walls become thinner, its cavities contract, its valves become smaller and more attenuated, and the entire bulk of the organ may be so reduced that the atrophied heart of an adult may weigh only four and a half or five ounces, instead of nine or ten.

The structure of an atrophied heart is not necessarily diseased; indeed, in simple atrophy the fibre is not diseased; the transverse striæ of the muscular tissue are clearly marked, and the only perceptible difference between an atrophied and a healthy fibre is, that the former is paler than natural, and of lessened tonicity. Not unfrequently, however, the muscular fibre of the heart, when atrophous, becomes markedly fatty, and the transverse striæ disappear. Under these circumstances, the muscular tissue is soft and inelastic, and the case comes under the category of a softened or fatty heart, which will be described in a future chapter.

Atrophy of the heart, when simple and uncomplicated, may be the

result of a deficiency in the supply of blood to its tissue, consequent on the tight embrace of an adherent pericardium, or on narrowing or obstruction of the coronary arteries, or else of the comparative inactivity of the organ consequent on the lessened amount of work it has to perform. Just as the voluntary muscles, when little used, dwindle and become weak, so the muscular tissue of the heart under the same conditions wastes, and the bulk of the organ shrinks. This is mostly observed in connection with cancer and other wasting disorders which do not create any serious impediment to the circulation. By leading to a diminution in the bulk of the body, and in the quantity of blood in circulation; by impoverishing the quality of that blood, and by necessitating repose and freedom from exertion, they not only render the nutrition of the heart imperfect, but necessarily produce a decrease in the energy of its action, and a corresponding diminution in its bulk. This condition of the heart is not characterised by any pathognomonic physical signs or general symptoms. The pulse of course is small, the impulse weak and of small extent—often imperceptible—and the area of percussion dulness lessened. The sounds of the heart are clear, and, unless the muscular tissue be fatty, are not remarkably altered in rhythm. Palpitation is seldom observed, and when it occurs, it is of temporary duration and attributable to accidental causes, rather than to the structural condition of the heart.

Atrophy of the heart can hardly be regarded as an idiopathic disease, but rather as a consequence of another disorder. The treatment is necessarily that of the general malnutrition out of which the atrophy has arisen. When it has occurred in connection with the tight embrace of an adherent pericardium, with obstruction of the coronary arteries, or with cancer or other malignant disease, its cause is persistent, and its treatment hopeless; but when it has taken its origin in a cause of protracted yet temporary waste and bodily inaction, its cause is removable, and whatever will tend to rectify the constitutional derangement, and restore tone and vigour to the body, will tend also to stimulate the nutrition of the heart, and cause it to be effected more perfectly. In one case which I had under observation for the space of three years after the patient's comparative restoration to health, the alteration produced in an atrophied heart was most remarkable.