allay the symptoms. The extract of belladonna applied in this manner, reduces the violence of the action of the organ.

Digitalis according to Dr. Stokes, is most useful in active hypertrophy, attended with a clean tongue, and an absence of fever. Other palliative remedies are sometimes used. Opium, hyoscyamus, and indian hemp, particularly the latter are admissible, when the case is beyond the reach of curative agents.

These palliative agents it should be recollected, are not to be used except in the last stages, when all that can be done must consist in the removal of distressing symptoms.

CHAPTER VI.

DILATATION OF THE HEART.

The term dilatation is applied to an enlargement of the cavities of the heart. This sometimes occurs as a distinct lesion, and sometimes in connection with hypertrophy. When it occurs as an isolated affection, the parietes of the heart are rather thinner than natural, and are free from any appearance of thickening.

Dilatation is attendant upon three states of the ventricular parietes, as to thickness; the thickened, the natural, and the attenuated. There are, therefore, three varieties, dilatation with hypertrophy, simple dilatation, and dilatation with attenuation.

The first variety is identical in nature with that variety of hypertrophy called hypertrophy with dilatation. And all the difference there is consists in the predominance of the one condition over the other. This is expressed by the precedence of the term hypertrophy in the one, and dilatation in the other. Thus, hypertrophy with dilatation denotes the predominance of hypertrophy; whereas dilatation with hypertrophy, that of dilatation. These two conditions are very nearly associated, and whether the one or the other will predominate, depends very much upon the constitution of the patient. Similar causes acting upon different persons, or upon the same individual under different circumstances, give rise to one or the other of these affections, according to the variable state of the nutritive functions.

When hypertrophy is most predominant, the causes have probably acted upon a more vigorous constitution, one more disposed. to active nutrition of a semi-inflammatory kind; when dilatation is predominant, those causes have so overcome the resisting force of the heart on account of a want of constitutional vigor, as to partly destroy its contractile power. The organ then becomes larger, its walls thinner and more attenuated.

This condition of the muscular parietes of the heart is, as we would naturally expect, most common in anæmic individuals, especially in chlorotic girls, while the converse affection, hypertrophy, is most common in males.

The dilatation is more common and greater in the direction of the transverse, than in the longitudinal diameter of the heart. This changes the heart to a spherical form, and tends to round off the apex to such an extent that in some cases it is scarcely discernable.

PATHOLOGY.-Sometimes the muscular tissue presents a healthy appearance; more often however, it is flaccid, paler than natural or of a deeper red, resulting from venous congestion, or from stagnation of blood in the muscular texture. The paleness results. from general muscular paleness. Softening sometimes occurs to such an extent, as to cause the substance of the heart to readily break down under the fingers. The attenuation, too, sometimes. proceeds to a great extent, even reducing the most substantial part of the left ventricle, to two lines in thickness, and the apex to a mere membrane. From this extreme tenuity, or from the effects of ulcers penetrating the parietes of the heart, a rupture sometimes takes place, in which case Dr. Watson remarks, "the patient dies suddenly, the motion of the organ being stopped and strangled by the effusion of blood into the pericardium; so that to die of a broken heart, is not a mere metaphor." Dilatation sometimes accompanies a deposit of fat about the organ, and the fatty degeneration may be of that kind in which the fat globules are interstitially deposited in its fibre.

The complication of dilatation with pericarditis or endocarditis, seldom exists. In the simple form of the disease, the dilatation seldom reaches that degree often observable in cases complicated

with hypertrophy. And the cause of this is found in the existence of the natural law in the economy, that a dilated hollow organ tends to hypertrophy.

Patescence is often observable; and in some cases, dilatation comes on so suddenly as to lead to the conclusion, that the chordæ fendineæ, are stretched, or ruptured.

DIAGNOSIS.-General symptoms.-The feebleness of the heart's contraction gives rise to deficient arterial circulation; and hence the venous blood presses upon the brain, lungs and liver, as well as upon other organs, giving rise to coldness of the extremities, great debility, syncope, a distension of the veins and dropsical effusions. The tension of the external jugulars is the most distinctive symptom between dilatation of the right and left side of the heart.

Hysteria and neuralgic affections may be associated with dilatation. These complications make the diagnosis so difficult that repeated examinations are necessary, in order to determine with certainty the nature of the case.

Physical signs.-The cardiac contractions are abrupt and quick, the impulse feeble, dullness extends over a larger space than normal, the sounds are louder and clearer, both of the sounds resembling the words lup tup instead of lubb tuk. The bellows murmur is sometimes heard, as a consequence of regurgitation through the mitral valve.

PROGNOSIS. The termination is in very many instances unfavorable. In most instances an effect of an antecedent cause, its prognosis must for the most part, depend upon the nature of that cause, and the possibility of its removal.

TREATMENT.-The treatment of this disease should be very similar to that of hypertrophy. There is, however, need of more tonic medicine, of more dietetic care in order to add nutrition to the blood, and strength to the general system. The action of the heart should be kept tranquil, the pain removed, not by agents which debilitate, but by nervines combined with tonics. The use of tobacco, tea and coffee must be rigidly prohibited. Pure,

permanent stimulants are of use, such as capsicum. Every nervous excitant should be avoided, the free use of narcotic remedies is inadmissible. Excesses which disturb cardiac action, the indulgence of passion, in short, every thing which can debilitate, is decidedly injurious in this disease.

If anæmia complicates dilatation, the continued use of tonics, constitutes the best course of treatment. The free administration of the prunus virginiana in connection with the preparations of iron, the judicious application of cold bathing or sea bathing are perhaps means as efficacious as any other.

In the latter stage of the disease when all curative agents are ineffectual all that the physician can do is to palliate symptoms. For this purpose the same, or similar means should be used that are recommended in the article on hypertrophy.

The curative treatment in order to prove beneficial must be long continued. Dr. Hope remarks that the great majority of recoveries take place between one and two years from the beginning of treatment. The dietetic and remedial means of cure should be continued some time after all the symptoms subside.

CHAPTER VII.

DISEASE OF THE VALVES OF THE HEART.

The valves of the heart are subject to various morbid changes from the direct effect of inflammation, or from its more secondary effects. Those of the left side are much more often affected than those of the right. Dr. Hope considers the proportion as one to twenty; Dr. Clendinning as one to sixteen. The cause of this great frequency of the disease in the left side of the heart is the increased strain and the more frequent occurrence of endocarditis in the left ventricle, arising from the more stimulating character of the arterial blood.

PATHOLOGY.-The pathological changes of the valves are substantially those of endocarditis. A deposition of lymph upon the endocardium under the various forms of vegetations or granula

tion is seen. The chordæ tendineæ, and columnæ carneæ sometimes become shortened, and thickened, and sometimes elongated. In either case the effect is an imperfect closure of the valvular orifice. The exuded lymph assumes various forms; sometimes appearing like points or granulations, at other times, like excrescences, similar to venereal warts.

The matter is effused between the lamina of the valves, sometimes inducing ulceration. Usually there is a series of progressive changes. At first thickening and induration, then fibro-cartilage, and lastly bony deposition, take place. They cause stiffness of the valves so that they cannot readily open and shut, and conse.quently the various sounds of obstruction from contraction of the orifice and regurgitation may be produced by a very few simple organic changes.

DIAGNOSIS.-General Symptoms.-Pain, dyspnea, palpitation, are occasional effects of almost every variety of cardiac disease. The character of the pulse, according to Dr. Hope varies much with the valves affected. According to that author in disease of the mitral valve, whether it impedes the flow of blood by contraction, or allows of regurgitation the pulse is in various degrees small, weak, irregular, intermittent, and unequal. "In very great contraction of the aortic valves, the pulse is often small, weak, and irregular; but generally continues full, regular and of due strength in this affection." Regurgitation at the aortic valves is attended with a peculiar jerking pulse, the stroke being at first quick and strong, but rapidly receding from the fingers in consequence of the backward movement consequent on regurgitation.

Dr. Corrigan observes "that the pulse in aortic regurgitation, may sometimes be seen beating in various parts of the body." Dr. Williams considers this phenomenon as in the highest degree characteristic of this disease.

Valvular lesions on the right side of the heart, rarely affect the pulse. They soon become associated with dilatation, and hypertrophy, their direct effects,-at which time they cease to be exclusively valvular.

Valvular disease often causes serous effusions in various parts