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general rule, the lungs are free from any serious disorganisation or change. Turning to the heart, he notices next, in a vast majority of cases, that there is no murmur, and no evidence of valvular obstruction. In place of indications of valvular mischief, there is, however, a sign which is specially symptomatic. This is irregularity of action. In instances where this irregularity admits of analysis, the hesitation observed is found to occur in the systole. There are a few strokes of perfect rhythm, lub-dup-pause; then lub-dup-dup-pause-dup-dup; and now again in rhythm, lub-dup-pause. The patient himself is not conscious of this irregularity of the stroke as a particular fact; for there is always a column of blood in the arteries waiting to be pushed on by the systole, and hence one hesitation during a fair interval of naturally repeated strokes is not specially felt. In one patient, who was a long time under my care, the systolic sound was sometimes suspended for such a long period, that it seemed to me impossible that some effect of which the sufferer was sensible, should not be felt. But I was wrong for, on listening, I would arrange that on a stamp of my foot the patient should note his sensations at that moment; and, although I invariably gave the indicated sign at periods when the intermission was longest, yet I never gained any fact of a peculiarity of sensation, nor observed any obvious indication of failure of power on his part.

And yet persons affected with this cardiac irregularity often tell the physician that they feel, at particular times, a symptom which they attribute to irre

gularity of the heart: this symptom is a creeping, rising sensation, commencing in the cardiac region, and ascending sharply into the pharynx; it occurs often after food, or at the moment of falling to sleep; it is very oppressive, and a source of great alarm to nervous people. It is always present in persons who are predisposed to cardiac apnæa, but it may be present in others; and it does not depend on an intermittent systole of the heart. It is, I believe, a temporary spasmodic twitch, commencing in the diaphragm, and communicated to the œsophagus: or else it is a reflex act from the terminal branches of the vagus to the branches supplying the pharynx. Any way, it is not cardiac; for during its presence the heart may be beating in the most perfect time and tune. I have said that persons predisposed to cardiac apnoea always experience the sensation just delineated; this depends on the circumstance that such person are inevitably sufferers from dyspepsia. The dyspepsia, I believe, always precedes the cardiac malady, and is, indeed, the basis of it, and a continual attendant.

Together with this dyspepsia, there are soon established an irregularity of the cerebral circulation, attended with frequent giddiness, occasional pains in the head, whistling sounds in the ears, and now and then with dimness of sight: these symptoms all contribute to render the person subject to them immeasureably unhappy; and hence, even in early stages, such persons become melancholic and utterly despondent. In two such examples, which came before

my notice, the patients committed suicide; and in a third instance an attempt at suicide, nearly fatal, was made. The cases, in fact, of this kind constitute an almost distinct series of themselves; the subjects of them running the round of the whole Esculapian fraternity, satisfied with nobody, and responding to no treatment, however rationally devised.

PATHOLOGY OF CARDIAC APNEA.

In studying the pathology of cardiac apnoea, we are led naturally in all cases to the heart or the great blood-vessels, as the seats of the morbid changes upon which the symptoms depend. In our previous survey, we have seen, incidentally, a variety of morbid phenomena as attendant on cases of the kind named; so that in this place it is unnecessary to do more than recall attention rather more systematically to these morbid conditions.

The most common lesions in the circulatory system by which cardiac apnoea is produced, are thinning and degeneration of the cardiac walls. These changes may present at least three general types. First, a change in which the muscular structure seems to have undergone a general atrophy and softening, without any actual intramuscular fatty deposit. The muscular tissue in these cases may indeed retain, to a large extent, its natural structural elements; but it has undergone waste, and the fibre is consequently thinned and flabby. This form of degeneration commences, I believe, most frequently on the right side of the heart, giving rise in the first stages of change

of blood in the ventricles in the course of an attack there is allowed opportunity for coagulation of a portion of the fibrine: as the heart recovers, the filaments of fibrine thus separated interlace themselves with the chordæ tendineæ, the curtains of the valves are brought into approximation, and the results are, complete arrest of the current of blood through the heart, and death.

While yet this sheet has been in hand, I have had a singularly good illustration of the termination of life in the way here described.

A patient of my friend Dr. Marshall, of Norwood, 74 years of age, had suffered for a long time from cardiac apnoea. The paroxysms usually occurred in the night, often preventing sleep, and offering those characteristic symptoms which I have described in previous pages. On the evening of Friday, the 25th of October, this gentleman went to bed dreading somewhat the possibility of a disturbed night, and a return of thoracic spasm. On the following morning, he was found by his attendant sitting up in bed lifeless. He had put on his dressing-gown, and propped himself with pillows, having, as the evidence seemed to show, risen (as was his custom when a paroxysm was coming on), walked the room, and returned to his couch. On making a post mortem examination, we found the heart disorganised in the way named in the third division given above. The organ was loaded with fat; the walls were thin and flabby; the right cavities were full of blood, the left empty; there was atheroma of the mitral valve, and also atheroma

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