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merely to an irregularity of pulse, and occasional breathlessness; in time the change extends to the left ventricular wall, upon which symptoms of direct failure of circulation occur, and therewith the earlier symptoms of cardiac apnoea are established.

The second description of change in the cardiac structure consists in deposition of fat within the muscle; and, in fact, in that ordinary modification of muscular fibre, which has been so ably described by Dr. Quain and others as fatty degeneration. I believe that, in most of these cases, the first symptom of debility is shewn in the right side, and that the first general symptoms are identical with those which mark simple atrophy. If there be a distinction, it consists in this; that, in the earlier stages of fatty deposit, the affected structure is increased rather than reduced in dimension, and that the physical signs, consequently, give. the idea of hypertrophy of the cardiac wall.

The third description of change may be considered as a mixture of the two preceding : it is very common in aged people, and consists of a thinning of the muscular wall, of large deposition of fat externally, so as almost to enclose the heart in fatty matter, and sometimes of partial destruction of the muscular elements of the organ itself.

Together with these changes, there may now and then be met atheromatous degeneration ; as atheromatous deposit on the valves, or atheroma of the coronary artery and aorta. Some of the older writers were of opinion that cardiac apnea (which they, selecting one symptom alone as the type, were wont

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 apnea. 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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[graphic][subsumed]

Fig. 1.-C Cc. Concretions; Centre Concretion looping up the Cords of Tricuspid Valve.

[graphic]

FIG. 2.-Concretion filling Right Auricle and Ventricle, and fixing Tricuspid Valve.

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