to subdue all emotional feelings, and regulate the movements of the body. The least mental excitement, and the slightest bodily exertion, are so apt to be followed by an attack of angina, and the attacks are so severe, and so likely to prove fatal, that the patient must be taught as he values his life, to avoid whatever may be likely to induce them. Neglect of these rules will inevitably lead to speedy death; whereas, by careful management, the attacks may be staved off, and the fatal catastrophe averted for many years. It is now above six years since I had the pleasure of a consultation with my friend, Dr. Bence Jones, in the case of a gentleman who was suffering severely from angina pectoris in its purest form. The attacks at that time occurred on the least excitement, or after the slightest exercise; but our patient, whose mental and bodily powers were at that time overtaxed, very wisely consented to abide by our advice and withdraw from his multifarious engagements, and led a life of perfect repose for above twelve months. The result has been that he is still alive and apparently in perfect health, and is so far improved, that he now rarely experiences any pain in his heart, and can walk and take a considerable amount of gentle exercise with impunity. The heart's action is regular, the sounds clear, the first sound unusually short,

It should, perhaps, be added, that many of the attacks described under the title of "angina pectoris" are not true examples of that disorder, but should rather be entitled "cardiac asthma." They are accompanied from the first by palpitation, dyspnoea, and lividity of the face, and are often connected with great derangement of the stomach, liver and bowels. In these cases a brisk emetic of sulphate of zinc or mustard, followed by a purge of colocynth and calomel, will often render all other treatment unnecessary; and when subsequent treatment is needed, hydrocyanic acid, and belladonna both externally and internally, will be found useful adjuncts to antacids, stomatics, and diffusible stimulants.

CHAPTER XI.

CYANOSIS.

THE term cyanosis, or morbus cæruleus, is employed to denote a peculiarly blue discolouration of the skin, which experience has proved to be symptomatic of various malformations or derangements of the heart or great vessels.

Cyanosis was formerly ascribed to a direct admixture of arterial and venous blood, consequent on the existence of an abnormal communication between the two sides of the heart, or between the aorta and pulmonary artery. But dissection has shown that, provided there is constriction of the pulmonary artery, cyanosis may occur in cases in which no communication exists between the two sides of the heart, or between its great vessels; that in other cases patency of the foramen ovale, or a deficiency of some portion of the ventricular septum permits the admixture of venous and arterial blood, and that, nevertheless, if the pulmonary artery be of normal size and unobstructed, cyanosis is not thereby produced; and, further, that whatever malformation or disease of the heart exists, obstruction in or contraction of the pulmonary artery is almost always present when cyanosis is strongly marked. Hence it would appear that disease of the heart and great vessels, of whatever nature, calculated to impede the flow of blood through the pulmonary artery, and produce obstruction to the systemic venous circulation, may prove a predisposing cause of cyanosis, and that, in some instances at least, the existence of such obstruction is essential to its production.

It needs, however, little argument to prove that something more than a mere impediment to the flow of blood through the pulmonary artery and the existence of systemic venous engorgement is necessary to the production of well-marked cyanosis. Cases are of daily occurrence in which obstruction to the circulation through the right side of the heart gives rise to extreme venous congestion, and yet is not productive of cyanosis. The missing link in the chain of causation is furnished, I believe, by the condition of the skin and of the capillaries on the surface. In cases of cyanosis the skin is usually thin, and the capillaries abnormally

large; hence, when obstruction to the pulmonary and systemic venous circulation causes imperfectly aërated blood to flow throughout the system, and still more so when, in consequence of some congenital malformation, a small portion only of the blood is subjected to the aërating influence of respiration, a far darker hue is necessarily imparted to the surface than would be produced in persons whose integuments are much thicker and whose capillaries are less dilated.*

But, although cyanosis in its minor degrees is often found associated with the various forms of cardiac and pulmonary derangement, which have the effect of obstructing the onward flow of the blood, and so, of causing pulmonary and systemic venous congestion, yet, practically, its more thoroughly developed forms may be regarded as connected with malformation or disease or injury of the heart or great vessels, of a nature to admit of the admixture of venous and arterial blood, and cause the distribution of venous blood to the systemic capillaries. Amongst the pathological conditions productive of this result may be mentioned a patulous ductus arteriosus; an open foramen ovale; a deficiency, from whatever cause arising, of part of the septum of the ventricles, or of the divisions between either of the cavities on the two sides of the heart; a heart formed of one auricle and one ventricle only, in which case (the aorta and pulmonary artery often arising from a common trunk), the mixed arterial and venous blood contained in the ventricle is necessarily distributed throughout the system; transposition of the aorta, which vessel may arise from the right ventricle alone, or partly from the right ventricle, and partly from the left,† and possibly transposition of the great vessels-the aorta arising from the right ventricle, and the pulmonary artery from the left; the venæ cavæ, as usual, emptying themselves into the right auricle, and the pulmonary veins into the left.

Many of these conditions of the heart and great vessels necessarily lead to the distribution of venous blood to the systemic capillaries, and, therefore, are always associated with greater or less degrees of cyanosis; but, others, such as an open foramen ovale, and a partial deficiency in the septum of the ventricles, are not always productive of this result. This, probably, is referable to the fact, that when the

* For details on all these points see Dr. Peacock's admirable treatise on Malformations of the Heart,' where the subject is fully and carefully worked out. For case in point see' Med.-Chir. Trans.,' vols. xi, p. 296, and xxx, p. 131. For cases in point see Med.-Chir. Trans.,' vol. xxv, p. 1.

pressure on either side of the septum is equal, there is not a great tendency to intermixture of the two currents of the blood. In short, when the pathological conditions under consideration produce cyanosis, they do so, probably, in consequence, partly of the size of the opening through which the admixture of blood takes place, but chiefly in consequence of the existence of some obstruction to the passage of the blood through the pulmonary artery-a condition which leads to the forcing of venous blood through the abnormal opening into the left chambers of the heart, and thus renders it impossible that the circulation should be carried on without a large distribution of venous blood to the systemic capillaries.

In

Cyanosis is usually a congenital affection, but in a certain proportion of cases (about 20 per cent.), the symptoms first manifest themselves in early childhood, and in others are developed in adults.* the last-mentioned instances there is reason to believe that ulceration and perforation of the septum between the ventricles or auricles has taken place, or that the septum has been ruptured by external violence, or by some straining effort, or that some similar circumstance has led to the enlargement of an already patulous foramen ovale.

The physical signs attendant upon cyanosis must necessarily vary with the precise condition of the heart and arteries to which the cyanotic discolouration is due; and all that can be fairly stated is, that the action of the heart is usually as forcible, if not more so than in health, and that hypertrophy and dilatation of the right ventricle are almost always present.

Deficiency of animal heat is the only general symptom constantly present beyond the discolouration of the surface. The intellect is not impaired by the circulation of the imperfectly oxyginated blood, and the various functions are seldom much disturbed. The extremities of the fingers are usually clubbed, and the nails adunc. Bronchorrhoea and bronchial hæmorrhage are not uncommon symptoms, and exertion and excitement of any kind are apt to induce excessive palpitation, with dyspnoea, faintings, or even convulsions. The occurrence of pneumonia, or of any impediment to the respiration, aggravates the cyanotic discolouration and the symptoms associated with it.

*Of seventy-one cases reported by Stille (Amer. Journ. Med. Sci.,' No. 3, new series, viii; quoted by Dr. Walshe), forty were congenital; and of 101 cases analysed by Dr. Peacock (loc. cit., p. 118) seventy-four were instances in which the affection, if not actually congenital, appeared immediately after birth. In nineteen of the remainder the symptoms manifested themselves within two years after birth.

The prognosis in these cases is always unfavourable, though it necessarily varies, according to the precise nature of the abnormal pathological condition on which the symptoms depend. In some instances the mischief is of such a character, and the cyanosis so intense, that the functions of life cannot be sustained beyond a few months, or, possibly, a few years; but in others, in which the symptoms appear almost equally severe, life may be prolonged until middle age,* or even to an advanced period of life. I know of no special sign or general symptom by which the probable duration of any given case can be determined.

The treatment of cyanosis resolves itself into the prevention of dyspnoea and palpitation, and the maintenance, as far as may be, of the temperature of the body. Mental excitement and active bodily exercise, as in running or straining, almost invariably induce palpitation and dyspnoea, and, therefore, must be carefully avoided; warm clothing should be had resourse to, a generous and stimulating diet adopted, and a free action of the abdominal organs maintained. The conditions on which the cyanosis depends are of course irremediable.

CHAPTER XII.

MALPOSITIONS AND DISPLACEMENTS OF THE HEART.

THERE are two conditions under which the heart is found to occupy an abnormal position in the chest. The first of these is congenital malposition; the second displacement as a consequence of disease.

Congenital malposition is of little importance, except in so far as it may serve to mislead the unwary practitioner, and induce him to believe that the heart is displaced as a consequence of disease. But, in this point of view, it is very essential to be able to arrive at a correct diagnosis, and, fortunately, in most instances, we have the means of doing so; for when the heart is congenitally misplaced, the abdominal viscera are usually transposed, the spleen being on the right side of the abdomen, and the liver on the left. If no such transposition of the

* In a case reported by Dr. Spitta in the ́ Med.-Chir. Trans., vol. xxix, the patient, who had been intensely cyanotic from birth, survived in tolerable health unto the age of forty, when she was suddenly seized with faintness and convulsions and shortly expired.