which is often excessive, in consequence of the impediment to the circulation created by the atheromatous condition of the vessels.

The statistics of spontaneous rupture of the heart are too limited to admit of any trustworthy generalisations. It appears, however, from the few cases on record,* that it occurs more frequently in males than in females, and is almost confined to the more advanced periods of life -a fact which might have been anticipated by reference to the nature of the structural causes in which it originates. The rent may be small or large, smooth or jagged at its edges, or may run directly, obliquely, or sinuously through the walls of the heart. If it takes place suddenly, as is commonly the case, the rent will probably be nearly direct; whereas, if it occur slowly, the blood may insinuate itself between the muscular fibres, and thus may work its way tortuously to the surface. Sometimes, as below stated,* the laceration takes place in the right ventricle, sometimes through the septum of the ventricles, in others through the walls of both ventricles, but most frequently it occurs in the left ventricle, about the middle of its anterior wall, or parallel to the septum, though in some rare instances, instead of being parallel, or nearly so, to the septum, it may run transversely across the muscular fasciculi.†

Death may occur suddenly as the result of the rupture, and usually does so; but sometimes the rent may be blocked with coagula, and the patient may survive for some hours, or even, as in a case related by Corvisart, may linger on for twenty-three days. One case, indeed, is on record in which, near a recent laceration of the heart, an older one * In a paper published in vol. i of the Dublin Jour. of Med. Science,' Dr. Townsend refers to twenty-five cases collected by himself and to nineteen collected by Bayle; sixteen are recorded in the twelve volumes at present issued by the Pathological Society of London, and a few cases are to be found scattered through the various periodicals. Out of the sixty cases above referred to, eight were instances of rupture in the right ventricle, and fifty of rupture in the left ventricle, and two of rupture of both ventricles. The rupture in one of the two last-named instances was through the septum of the ventricles, in the other through the edge of the septum and across the right ventricle. Dr. Walshe refers to fifty-two mixed idiopathic and traumatic cases referred to by Gluge in his 'Pathological Anatomy,' and of these thirtyseven were examples of rupture of the left ventricle, eight of the right ventricle, two of both ventricles, two of the right auricle, and three of the left auricle. Dr. Stokes states (loc. cit., p. 466) that spontaneous rupture of the auricles may take place, but I can find no record of rupture of the auricles, except as the result of external violence, and if it ever occurs it must be exceedingly rare.

† A case in point is recorded by Dr. Wilks in vol. viii, p. 156, of Trans. Path. Soc. Lond.'

See Rostan's "Mémoire sur les Ruptures du Cœur," Journ. de Médecine,' Juillet, 1820.

was found, firmly plugged with fibrin; but this solitary instance, which admits of easier explanation, scarcely justifies a presumption that recovery is possible.

The immediate cause of death is not mere loss of blood, which, in consequence of the inelastic, unyielding nature of the pericardium, is often small in quantity; but it is due, probably, in part to the loss of blood, partly to the shock occasioned by the rupture, and partly also to the pressure exerted upon the heart by the blood which has escaped into the pericardial sac.

There are no recognised physical signs of rupture of the heart, and even the general symptoms are not very characteristic; for they are such as may result from the rupture of an aneurism, and from other diseases of the heart and great vessels. In some instances a sudden agonising pain is felt in the region of the heart; the patient utters a piercing scream, puts his hand to his left breast, and dies. In others, in which life is not arrested so suddenly, acute pain occurs at the heart, and is followed by collapse, marked by extreme anxiety of countenance, pallor, cold clammy sweats, a fluttering pulse and faintness. At length insensibility supervenes, a few convulsive twitches of the muscles take place, and death speedily follows. In some instances on record, the same suddenly occurring and agonising pain has been felt in the region of the heart, followed by collapse, with its attendant symptoms; but after a time a remission has occurred, and the patient's recovery has not seemed hopeless until another similar paroxysm has ensued. When these symptoms recur, life is seldom prolonged beyond a few minutes, and death very commonly takes place suddenly.

The indications for treatment in cases of rupture of the heart are, to counteract collapse and sustain the circulation, and with this view, the patient should be placed in a recumbent posture, and stimulants and slight sedatives should be administered internally, and warmth applied to the surface of the body. But practically, in the great majority of cases, life is extinct before medical aid can be obtained, and even if it happen otherwise, the physician can do little towards averting the catastrophe. The damage which the heart has sustained is of a nature which does not admit of removal, and, under the circumstances, it is generally found impossible to rally the patient from the shock and to maintain the circulation.

Rupture of the valvular apparatus of the heart, which is not very uncommon as a result of straining efforts or violence, is still less so as a consequence of endocarditis. In the one case the aortic valves are those which usually give way; in the other the auriculo-ventricular valves, with their tendinous chords and the papillary muscles. And inasmuch as inflammatory and other changes, from which rupture of the valves and of the tendinous chords arises, are most common on the left side of the heart, it follows that, practically, rupture may be regarded as almost confined to the valvular apparatus of the left cavities of the heart.* For the same reason it is observed more frequently in the mitral valves and their apparatus than it is in the aortic valves.

The symptoms attendant upon rupture of a valve or a tendinous chord are extremely variable. Not unfrequently after death we find rupture of the valves or of the apparatus connected with them in persons who, during life, have never presented any symptoms characteristic of such a formidable lesion; whilst in others, again, the symptoms of rupture are well marked and characteristic. The patient is suddenly seized with acute pain in the heart, followed by excessive palpitation, irregular action of the heart, and dyspnoea; his countenance is deadly pale and expressive of extreme anxiety, the skin cold and clammy, the pulse weak and fluttering.

This variation in the symptoms which accompany rupture of the valves is strictly in keeping with what is observed in rupture of other internal viscera, and does not admit of satisfactory explanation; but in the cases under consideration there is reason to believe that the difference is partly referable to the circumstances under which the rupture takes place. If it occurs suddenly, whilst the heart's action is regular, and the patient is in his normal condition, it can scarcely fail to induce a sudden accession of alarming symptoms; whereas, if it occurs during an attack of endocarditis, by which the heart's action is greatly embarrassed and the patient is seriously distressed, the additional pain at, and disturbance of the heart may not be such as would excite attention under the existing excitement of the vascular and nervous system. Increased cardiac pain there probably would be, attended by tumultuous action of the heart and extreme irregularity of the pulse; but in a

* It may be remarked that rupture of the valvular apparatus which guards the right cavities of the heart occurs sometimes, though rarely. The late Dr. Todd has recorded an interesting example of spontaneous rupture of the chordæ tendineæ of the tricuspid valve in the ‹ Dublin Quarterly Journ. Med. Science,' new series, vol. v.

large proportion of cases there is none of the intense cardiac anguish, and suddenly occurring dyspnoea and collapse, which are commonly observed when rupture occurs independently of acute disease of the heart.

The diagnosis of rupture of the internal portions of the heart is by no means satisfactory. Not only are the general symptoms extremely variable, but even when most marked and most severe they are such as may arise in rupture of the heart, and in various forms of disease of the heart and great vessels. The same uncertainty attaches to the indications derivable from the general symptoms. Nevertheless, if the general symptoms and physical signs are viewed together, and thus made to illustrate each other, a tolerably correct conclusion may be arrived at in many instances. Thus, for instance, if, in a person previously in good health, a loud diastolic murmur arises suddenly at the base of the heart coincidently with the setting up of the acute cardiac and general symptoms above described, there can be little doubt as to the occurrence of rupture of the valvular apparatus. Even in a person known to have old-standing mitral disease, but in whom no acute disease is present, a sudden accession of cardiac anguish and other serious heart symptoms occurring coincidently with intensification or marked alteration in the character of the mitral murmur would be strongly in favour of rupture of some portion of the valvular apparatus, and so also would the fact of a murmur which before was systolic only becoming suddenly diastolic as well as systolic. But in cases accompanied by acute endocarditis, the character of the symptoms which accompany the disease, and the existence of loud endocardial murmurs, so complicate the diagnosis, that there are seldom sufficient grounds for a positive opinion as to the occurrence of rupture.

The treatment in these cases can only be palliative. The laceration or giving way of the valvular apparatus results, in most instances, from old-standing disease which does not admit of removal, and the rupture itself is equally beyond the scope of remedies. The only objects to be attained, therefore, are to sustain the patient under the shock he has received, and, at the same time, to relieve pain and tranquillise the nervous system. Diffusible stimulants and sedatives in full doses are the principal means by which these ends are to be accomplished, and to these may be added the local application of sinapisms or turpentine stupes, or of linseed poultices sprinkled with morphia, or smeared with hemlock or belladonna.

In connection with rupture of the internal portions of the heart, may be mentioned the pouching or circumscribed dilatation of the walls, which has been termed aneurism of the heart. Primarily referable in most instances, if not in all, to chronic disease of the endocardium, and of the muscular tissue of the heart, the immediate cause of its occurrence may be the giving way of the endocardial membrane, consequent on ulceration or external injury, but more commonly it appears to be produced by the sudden and extreme tension to which the enfeebled or damaged walls of the heart are subjected during violent straining efforts. It is rarely observed, except in the left ventricle,* and even then is a rare and exceptional occurrence, so exceptional indeed, that it was met with only four times amongst the 2161 patients examined in the dead-house of St. George's Hospital during the ten years ending December 31st, 1850.

Its symptoms are extremely variable, their precise character probably being dependent on the extent of the pouching and the rapidity with which it takes place. If it takes place slowly and is not excessive in degree, the general symptoms are simply those of dilatation, combined or not, as the case may be, with symptoms of hypertrophy. If it takes place suddenly, as the result of the giving way of the endocardium, consequent on ulceration or external violence, the symptoms are severe, and resemble those already described as accompanying rupture of the valves or of the tendinous cords.

Of the physical signs nothing definite can be stated, beyond the fact that they are sometimes those of dilatation and hypertrophy alone, sometimes of dilatation and hypertrophy combined with valvular disease. In neither case is there any sign by which to recognise the existence of the disease under consideration.

Death may occur suddenly, either from sudden failure of the heart's action, as in certain cases of dilatation, or from rupture of the aneurismal sac, or the patient may sink gradually from exhaustion, with all the symptoms heretofore described of dilatation of the heart.

*Nevertheless it does sometimes occur in other parts of the heart. In the year 1848 a case of aneurism of the right auricle of the heart occurred in St. George's Hospital. The case is recorded at p. 57 of the Post-mortem and Case-book' for that year, and the preparation is preserved in the museum.