A Treatise on the diseases of the heart and great vessels : and on the affections which may be mistaken for them, comprising the author's view of the physiology of the heart's action

Front matter

7^?

THE

ABNER WELLBORN CALHOUN

Preface

TO THE THIRD EDITION

The addition of one third of new matter to the present volume, and the care with which the whole has been revised and corrected, will, I trust, sufficiently prove my respect for the favourable opinion of my professional brethren, as evinced, not in this country only, but also on the European and American Continents, by the sale of no less than six or seven editions and translations in as many years.

The additions, including, I hope, some useful original matter, though they pervade every part of the work, will be found principally under the following heads : —

1. The natural sounds of the heart.* 2. The sound of costal percussion, with or without tinnitus (Laennec's Cliquetis.) 3. Murmurs from valvular disease, and the whole subject of particular valvular diagnosis, which will now, I confidently hope, be found one of the most simple and easy departments of auscultation. 4. Murmurs of the heart and arteries independent of organic disease. 5. Venous murmuis. 6. Musical murmurs. 7. Abdominal murmurs, both connected with pregnancy, and otherwise. 8. Tremour or thrill of the heart, arteries, and veins. 9. Signs, general and physical, of pericarditis and endo-pericarditis. 10. Connection of diseases of the heart with apoplexy, palsy, &c. 11. Partial dilatation or real aneurism of the heart. 12. The signs, physical and general, and the pulse of softening. 13. Signs of adipose disease of the heart. 14. Aneurisms of the aorta bursting into the pulmonary artery and the right ventricle. 15. Abdominal aneurisms. 16. Anaemic, nervous, dyspeptic, plethoric, bilious, and other sympathetic affections of the heart, with their diagnosis. 17. Displacements. 18. The pulses of disease of the heart.

To the complaints made by some, that additions and alterations so considera-

* My labours on this subject have been appropriated by a certain gentleman, who, however, has not the most remote pretensions to them. He says, in the Med Gaz. for September, 1835, p. 818, " In the last number of the Med. Gaz. there is an account of my experiments on the sounds of the heart, extracted from an appendix to Dr. Hope's work on the Diseases of the Heart. The statement of the experiments is correct, as Dr. Hope was present at the greater part (the whole) of them, and J also sent him the original notes." For the facts, see p. 52, and the foot-note.

Several writers and reviewers have been led into the error of ascribing these experiments to the individual alluded to: e. g. Professor Midler, in the translation of his Physiology, part iv. p. 176, and Appendix, p. 1: Dr. Alison, in his Supplement to his Outlines of Physiology, p. 18, 1836, &c.

6 PREFACE.

ble have been so tardily published,* though I have habitually taught most of them to my class and in the hospital for several years, I can only reply by pleading my utter inability, even if there had been the inclination, to devote more than an average share of attention to any one subject ; — an inability which rests upon all those who, to the private distractions of a laborious profession, add the onerous duties of hospital physicians and teachers of the practice of medicine. I can, indeed, truly say, with Senac and others, that I have worked slowly and painfully, inter " ta^dia et labores," in fragments of time hardly redeemed from excessive professional engagements.

I have studied brevity to the utmost, my object always having been, to offer the pith of the whole subject in the smallest possible compass. For this reason, I have avoided the multiplication of prolix cases, — offering no new ones, except for the illustration of new points of doctrines. As, however, I have sometimes referred to numbers so large as might seem incredible without explanation, it may be proper to state, once for all, that, out of upwards of 15,000 hospital in and out patients, whom I have treated during the last eight, years, about seven per cent., as near as lean judge from a rough calculation,! ^iave laboured under organic disease of the heart, — making a total of 1050 cases, exclusive of those occurring in private practice.

I have in several instances transferred to their proper sources discoveries which, in the first edition, I imagined to have belonged to myself. Any similar oversights in the present edition I shall be happy to rectify, if the authors will oblige me with the information.

I have, on the same principle, and, I trust, with perfect good feeling, ventured to reclaim for my countrymen and self a number of discoveries, which an eminent French writer, probably from unacquaintance with the English language and medical literature, has imagined to have emanated from himself.

Finally, I have added a few plates, which I trust will be found convenient.

I have to express my obligations to Mr. James Freeman for the excellent Alphabetical Index. J

J. H.

* Except the experiments on the sounds, published in the Appendix to the previous edition, in April, 1835.

t If I have leisure hereafter to sort these cases, I trust to give the exact per centage.

X In an Appendix prefixed to this Index will be found the important autopsies of the cases of V ... ., Esq., and GofT.

PREFACE

BY THE AMERICAN EDITOR.

In complying with the request to add notes to the first American Edition of Dr. Hope's work on the Diseases of the Heart, the object of the Editor has been twofold; — First, to present such views as were regarded by him as being important, in order more fully to elucidate the present state of knowledge respecting the pathology of the central organ of the circulation; and, secondly, whilst endeavouring to supply what he might regard as deficiencies, not to give superfluous or redundant matter, and thus render the work inconveniently voluminous.

In carrying out these views, it will be seen that the Editor has not restricted himself to the introduction of purely original matter, but, as he was anxious to do full justice to the eminent pathologists with whom any ingenious or valuable views may have originated, he has preferred using their own language, rather than incur the risk of conveying wrong impressions, either by condensing it, or by clothing their thoughts in other words. Hence, it will be found, that copious extracts from the writings of that most talented and ingenious pathologist, Dr. C. J. B. Williams, are not unfrequent. The valuable investigations of M. Bizot, respecting the dimensions of the heart, have been given in detail. Views respecting certain pathological facts derived from the Editor's observations have also been introduced, and a previously undescribed form of Dissecting Aneurism has been illustrated by several cases. It has also been thought proper to present the result of " the Experiments on the Heart's Action" which have been instituted since the death of the lamented Author; and as it

8 PREFACE.

was supposed that some interest might be had in those performed in this country, the Experiments which were made by the Editor and his friend Dr. E. M. Moore, of Rochester, N. Y., have been introduced. The additional matter presented in this edition is in small type within brackets, and bears the initial of the name

of the Editor.

C. W. P.

Philadelphia, July 1st, 1842.

CHAPTER II. On the Action and Sounds of the

Sect. I. Experimental Researches

on the Action of the Heart . 35 Experiments performed on Rabbits

and frogs, July 31, 1839 . . 36 Experiments, Aug. 21, 1830 . . 38 Couclusions on the motions of the

Conclusions on the sounds . . 43 Conclusions on the rythm . . 43 Experiments repeated, Aug. 10,

1831 44

Sect. II. Experimental, Physiological and Pathological Researches on the Sounds of the Heart . . 48 Experiments, Series i . . .53

, Series ii . . .55

, Series iii . . . 56

Conclusions from the whole of the experiments on the sounds . .71

a. Conclusions on the first sound . 71 How far it is caused by muscular

extension . . . . .73 How far it is caused by bruit mus-

culaire . . . . .75 How far it is caused by extension of

the auricular valves . . .76

b. Conclusions on the second sound . 79

c. Conclusions on murmurs artificial-

ly produced . . . . 80 Erroneous or defective Theories, of the Sounds of the Heart . . 80

CHAPTER III. Page

Physiological, phenomena of the Heart's Action and Sounds founded on the foregoing researches . . . . .83

1. The phenomena of the heart's action in the order of their occurrence . .....

2. Causes, mechanism and objects of the motions .....

3. Causes and mechanism of the

sounds .....

First principle of the heart's motion ...

83 84 89 91

Chapter IV

Pathological Phenomena of thb Heart's Action and Sounds 92 Sect. I. Modifications of the Motions and Sounds by Hypertrophy and Dilatation . ... 92 Simple hypertrophy . . .92 Simple dilatation . . . .93 Hypertrophy with dilatation . . 94 Sect. II. Murmurs produced by Valvular Disease. . . . .95 Aortic valves ; 1. Systolic murmur . 96 2. Diastolic murmur . 98 Pulmonic valves; 1 Systolic murmur . . . . .100 ; 2. Diastolic murmur ]oi

Mitral valve; 1. Systolic murmur . 101

; 2. Diastolic murmur 103

Tricuspid valve; 1. Systolic murmur 104

; 2. Diastolic murmur 104

Mec hanism and varieties of valvular murmurs . . . .105 Continuous murmur in the heart . 108 Pitch or key of valvular murmurs 109 Musical murmurs in the heart . 110 Summary of conclusions on murmurs in the heart . . .112 Situations in which murmurs of the respective valves are most audible . . 1 . .114

CONTENTS.

Page Sect. III. Murmur from Hypertrophy with Dilatation and its Mechanism . • • • .117 Sect. IV. Murmurs in the Heart and Arteries independent of Organic

Disease 1J^

Laennec's views incorrect . .118 Author's views, with proofs . • 120 Experiments on Dogs . . .122

Recapitulaton of causes . . • 124 Author's views applied to murmurs, a, from compression of arb, From loss of blood . . . 127

c, From anaemia, &c. . . • 127

d, From arterial varix . • .128 Musical murmurs not arterial, but

venous . 129

Sect. V. Venous or Continuous Murmur, Hum, and Musical Notes. 129 Venous murmur .... 129 Musical venous murmnr . . 136 Constitutional causes of venous murmurs ..... 140 Sect VI. Purring, Tremor or Thrill of the Heart and Arteries . . 141

1. In the heart . . . .141

2. In the arteries .... 142

3. Inorganic tremors in the arteries 142 Inorganic tremor in the veins . 539

Chapter V

1. The double beat of the foetal heart 143

2. The murmur usually called utero-

placental ..... 146 Cases illustrative of murmurs occurring in pregnancy, &c . . 148 Seat of the murmur of pregnancy . 153 Practical conclusions . . . 155

Part II

Inflammatory Affections of the Heart and Great Vessels 156 CHAPTER I.

On Pericarditis . . . 156 Sect. I. Anatomical Characters of

acute Pericarditis . . . 156

1. Preternatural redness of the peri-

2. Coagulable lymph adhering to the

surface of the pericardium . . 158 Object of adhesion . . . 159 Process of adhesion . . . 160 Opake white spots on the surface

of the heart .... 161 Analogous transformations of false

membrane . . . .162

Page 3. Fluid effused within the cavity of

the pericardium . . . 162

Anatomical characters of chronic

Sect. II. Signs and Diagnosis of acute

1. General signs .... 165 feigns of amelioration . . . 172

2. Physical signs. Percussion . . 173 Impulse. Sounds. . . . 174 Attrition-murmurs .... 175 Murmurs of coexistent endocarditis 180

Diagnosis of valvular from attrition-murmurs ..... 182 Signs and diagnosis of chronic pericarditis ..... 182 General signs .... 182 Physical signs .... 183 Sect. III. Causes of Pericarditis . 184 Sect. IV. Progress and Duration, Terminations and Prognosis of Pericarditis . . . .187 Progress and duration . . .187 Terminations .... 188

Prognosis 188

Sect. V. Treatment of Pericarditis 190 Treatment of acute pericarditis . 190 Treatment of chronic pericarditis . 195 Sect. VI. Adhesion of the Pericardium . . . . .196 Diagnosis of adhesion . . . 198

CHAPTER II.

Carditis, or inflammation of The Muscular Substance . 200

1. Universal carditis . . . 200

2. Partial carditis, abscess, ulcer, rup-

ture of walls, valves, aorta, &c. 201

CHAPTER III.

Endocarditis, or Inflammation of the Internal Membrane of the Heart .... 203

Sect. I. Anatomical Characters of

acute Endocarditis . . . 206

A. Redness of the internal membrane of the heart and arteries . 206

1. Non-inflammatory redness . . 206

2. Inflammatory redness . . . 210

B. Effusion of lymph on the internal membrane, with thickening

of its substance .... 210 Concretions of blood from endocarditis ..... 212 Sect II. Signs and Diagnosis of Endocarditis . 213 General signs . 214 Physical signs . , 216 Sect. III. Causes, Progress, and Duration, Terminations, Prognosis and Treatment of Endocarditis ' 21S

CONTENTS.

Page Causes, progress, duration, and terminations . . . .218 Prognosis, treatment . . . 220

CHAPTER IV.

Acute and Chronic Arteritis,

and Organic Diseases of the

Coats of Arteries . . 221

Acute arteritis .... 221

Chronic arteritis .... 222

Morbid alterations in the coats of

arteries, and especially the aorta 222 Causes of morbid depositions in the coats of arteries . . . 225

Chapter I

Hypertrophy of the Heart 230 Sect, I. Anatomical Characters, with Classification and Nomenclature of Hypertrophy . . 230

Classification, and Nomenclature . 231

Natural dimensions and weight of the heart , 233

Anatomical characters of hypertrophy .... 240 Sect. II. Mode of formation, with the predisposing and exciting causes of Hypertrophy . .244

Mode of formation and predisposing causes ..... 244

Exciting causes .... 247 Sect. III. Order of Succession in which the several Compartments of the Heart are rendered Hypertrophous by an obstacle before them in the course of the Circulation .... 250

Comparative frequency of the forms and combinations of hypertrophy 253

Sect. IV. Pathological effects of

Effects of hypertrophy of the left ventricle, and of organic diseases of the heart in general, on the

brain 256

Sect. V. Signs and Diagnosis of Hypertrophy

General signs

1. Palpitation

2. Dyspnoea .

3. Cough

4. Haemoptysis

5. Pulse

6. Affections of the bead

Page

7. Complexion .... 266

8. Serous infiltration . . . 267

9. Angina cordis .... 267 General signs of hypertrophy of

the right ventricle . . . 268 General signs of hypertrophy of the

auricles ..... 269 Physical signs. Impulse . . 269 Sounds . . 273 Dullness on percussion . . 274 Prominence of the prsecordial region . . 275 Sect. VI. Progress, Terminations,

and Prognosis of Hypertrophy 275 Progress and termination . . 275

Prognosis 278

Sect. VII. Treatment of Hypertrophy 278 Appendix to hypertrophy . . 287

CHAPTER II. Dilatation of the Heart . 288

Sect. I. Anatomical characters with Classification and Nomenclature of Dilatation . . 288

Sect. II. Mode of formation, with predisposing and exciting Causes of Dilatation . . . 293

Sect. III. Pathological effects of Dilatation and Mode of their Production .... 295

Sect. IV. Signs and Diagnosis of

Dilatation .... 300 General signs .... 300

1. Serous infiltration . . . 301

2. Discoloration of the face . . 301

3. Congestion of the brain . .301

4. Injection of the mucous mem-

5. Passive hemorrhage . . .301

6. Congestion and enlargement of the

liver 301

7. Angina of the heart . . . 302 General signs of dilatation of the

General signs of dilatation of the

auricles 303

Physical signs .... 303 Impulse .... 303

Resonance on percussion . 307 Physical signs of dilatation of the auricles .... 308 Sect. V. Progress, Terminations,

and Prognosis of Dilatation . 309 Sect. VI. Treatment of Dilatation 315

Chapter VI

Adipose and Greasy Degenerations of the Heart . 333 Excess of fat . . . . 333

Greasy degeneration . . . 334 Atrophy and oedema of the adipose

tissue ..... 335 Cases of fatty heart, illustrating the

signs 335

Chapter VII

Osseous, Cartilaginous, and other accidental, Productions connected with the Muscular Substance of the Heart, and with the Pericardium . . 338

CHAPTER IX. Diseases or the Valves and

Orifices of the Heart . 341 Sect. I. Anatomical Characters, with predisposing and exciting causes, of diseases of the Valves 341 Induration of the mitral valve . 344

Induration of the aortic valves . 347

Induration of the valves at the right

side of the heart . . . 348

Predisposing causes of valvular disease ...... 348

Exciting causes .... 348

Sect. II. Anatomical characters and causes of Warty Vegetations of the Valves . . 349 Sect- III. Pathological effects of

Page

Disease of the Valves, and mode

of their Production . . 354

Sect. IV. Signs, Diagnosis, Prognosis, and Terminations of Disease of the Valves . . . 357

General signs of disease of the

Pulse in valvular disease. . . 358

in disease of the mitral valve 359

in contraction of the aortic in regurgitation through the

aortic valves .... 362

in valvular disease of the right

side 362

Pain in valvular disease . . . 363 Progress, Terminations, and Prognosis ... . 363 Physical signs .... 364 Signs of disease of the aortic valves 365 of the pulmonic valve of the mitral valve of the tricuspid

368 369 of the arterial and

auricular valves conjointly . 372

Diagnosis of valvular from inorganic

murmurs .... 372

Unusual and curious sources of

murmurs .... 375

Sect. V. Cardiac Asthma . . 376

General doctrine of asthma . . 376

1. Asthma from chronic dry catarrh 377

2. Asthma from pituitary catarrh . 377

3. Asthma from mucous catarrh . 377

4. Asthma from disease of the heart 378

5. Asthma from spasmodic constric-

tion of the bronchial tubes . 378 Cardiac asthma described . . 379 Asthmatic fit described . . . 381 Sect. VI. Treatment of Valvular

Disease Bloodletting Diuretics Purgatives Diaphoretics Emetics .

Puncturing Setons, Issues and Blisters Expectorants .

Gases

Antispasmodics Stomachics Tonics .

Diet

Chapter X

Aneurism of the Aorta . 393 Sect. I. Classification, JVomenclature, Anatomical Characters, and Formation of Aneurism, of the Aorta .... 394 Classification .... 394

CONTENTS.

Page

1. Dilatation or enlargement of the

whole circumference of the aorta 394

2. True aneurism, or lateral, partial,

dilatation of the aorta . . 396

3. False aneurism, or aneurism by ul-

ceration of the interal and middle coats .... 398

4. Mixed aneurism, or false aneu-

rism surmounting true . . 399 General observations on aneurism of the aorta . . . .399 Sect. II. Pathological Effects of Aneurism of the Aorta on Contiguous Parts . . . 408

1. Compression of contiguous parts 409

2. Destruction of contiguous parts 409 Sect. III. Signs and Diagnosis of

Aneurism of the Aorta . . 413 General signs .... 413 Physical signs . . . .418

Purring tremor .... 422

Pulsation 422

Case of aneurism immediately behind the heart .... 423 Strong and double jogging impulse from this cause . . . 424 Sect. IV. Synopsis of the Physical, in conjunction with the General Signs, in reference to the several varieties of Aneurism of the Aorta . . . 425

1. Simple dilatation of the arch, and

ascending aorta . . . 425 Fallacies, and methods of detecting them 426

2. Dilatation'of the pulmonary artery 427 Diagnosis from dilatation and aneurism of the aorta . . .427

3. Sacculated aneurism of the thora-

cic aorta .... 427 Fallacies, and methods of detecting them 428

4. Sacculated aneurism of the abdo-

minal aorta .... 430 Fallacies, and methods of detecting them ..... 432 Case of aneurism of the abdominal

aorta 434

Ancemic and nervous Pulsation

of the Abdominal Aorta . . 435 Its physical signs . . . 436

Its general signs .... 436 Aortic Pulsation from Enteric

Inflammation .... 436 Appendix! to Aneurism of

the Aorta . . . 437 Case of aneurismal pouch of the aorta bursting into the right ventricle 437

Case of rupture of a dilated aorta into the pulmonary artery . 439

Page Signs of aneurism of the origin of the aorta opening into the right ventricle ..... 440 Signs of aneurism of the aorta opening into the pulmonary artery ..... 441 Diagnosis of aneurism of the aorta opening into the right ventricle, or the pulmonary artery from other diseases .... 441 Sect. V. Spontaneous Cure and Medical Treatment of Aneurism of the Aorta, and Treatment of JYervous Pulsation . 442 Spontaneous cure . . . 442 Medical treatment . . . 443 Treatment of anaemic and nervous pulsation 448

CHAPTER XI. Malformations of the Heart 449 Communication between the two

sides of the heart . . . 453 General signs of communication

between the sides of the heart . 455 Physical signs .... 457 Cases of communication between

the two sides of the heart . 458

PART IV. Nervous Affections of the

Spasms, convulsions, and Paraly-

. 461

CHPTER I.

Neuralgia of the Heart, or

Angina Pectoris . . 461 Causes of angina pectoris . . 463 Nerves affected in angina . . 464 Diagnosis ..... 465 Treatment 465

CHAPTER II.

Palpitation, particularly

nervous .... 467 Palpitation from inorganic causes, usually called nervous, imitating disease of the heart . . . 468

1. From dyspepsia, hysteria, &c. . 468

2. From anaemia .... 470 General symptoms of anaemia . 470 Physical signs .... 471 Treatment of anaemia . . . 472

3. From too stimulant diet . . 472

4. From plethora .... 473 Cases illustrative of palpitation . 473

CONTENTS.

Page

Case 1. Dilatation with hypertrophy; overfeeding; simple apoplexy 473

Case 2. Dyspeptic and nervous palpitation, with dilatation and cerebral congestion . . . 474

Case 3. Dyspeptic, hypochondriacal and nervous palpitation . 475

Case 4. Plethoric dyspepsia, with palpitation .... 475

Case 5. Plethoric congestion of the heart, with palpitation and slight dyspepsia .... 476

Case 6. Plethora; dyspepsia; hepatic enlargement; jaundice; intermission ; palpitation ; "fulness" of the heart; and fainting

Case 7. Plethora; bilious engorgement; intermission of the pulse; occasional fainting; great oppression and debility

Case 8. Derangement of the stomach, bowels, and liver; paroxysm of palpitation with orthopnoea

CHAPTER III.

Syncope

Treatment

480 481

CHAPTER I. Polypus of the Heart . . 482

Anatomical characters . . 483

1. Unorganized polypi . . . 483

2. Slightly organized polypi . . 483

3. More completely organized polypi 485 Causes and formation of polypous

concretions .... 485

1. From mechanical retardation of

the circulation . . . 485

2. From inflammation . . 485 Signs and diagnosis of polypi . 486 Physical signs .... 487 General signs . 4S7

Treatment 488

Solubility of polypous concretions 490

Part VI

Description of the plates . . 545 Plates (Figs. 2 to 22, inclusive) . 552 Plates 1 and 2 of dissecting aneurism 552

Table of pulses of disease of the

Appendix of the autopsies of V . . . ., Esq., and Goff . . 557

Index of cases .... 560 Alphabetical index . . .561

OF

ADDITIONAL MATTER BY THE AMERICAN EDITOR.

Position of the heart

The heart has no fixed relation to the thorax ....

Relative situation of the valves of the heart with the thoracic parietes Experiments of Drs. Pennock and Moore . . . . .

Auricular systolic sound ........

The second cardiac sound not diminished in simple hypertrophy Valvular extension insufficient for the production of the first sound Congestion of the heart affects its sounds .....

The morbid conditions of the aorta sometimes prevent the formation of the second sound ..........

Cardiac sounds influenced by the state of the circulation Thickening of the aortic valves causes patescence and abnormal murmurs Regurgitant murmur at the mitral valve heard near the left nipple Regurgitation through the mitral valve arises sometimes from mental causes Tricuspid valve does not produce sound from regurgitation, unless diseased Murjnur at the tricuspid, where heard . . . .

Roughness of the aorta affects the heart's sound ....

Ambiguity of the terms used to express the cardiac sounds .

Lesions causing different murmurs .......

The flexible stethoscope . . . . .

Feeble pulse caused by regurgitation of blood .....

Dr. Williams's idea of murmurs ......

Cause of the utero-placental murmur ......

Case of utero-placental murmur caused by a tumor ....

Pericarditis may be local .........

Louis on the lesions in pericarditis .......

Hypertrophy and dilatation in consequence of effusion in pericarditis . Pain sometimes referred to epigastrium in pericarditis ....

Pericarditis often latent .........

Valve of the sign of dulness on purcussion in pericarditis . Outline of the space which is dull on percussion in pericarditis, is similar to shape of the pericardium .......

Respiration absent over the precordial space when much effusion exists in pericardium ..........

Friction sound of pericarditis .......

Friction sound of pericarditis, double .....

Dr. Williams's idea of the "jogging motion" in pericarditis

M. Bouillaud's views, respecting the connection of auricular rheumatism

with peri- and endo-carditis, adopted by the American auscultators Prognosis favorable in uncomplicated pericarditis Topical depletion in mild cases of pericarditis ....

Dr. Hallowell, on rupture of the heart ....

Evidences of inflammation of the endocardium ....

Endocarditis associated with acute rheumatism its signs

To produce abnormal murmurs, greater lesions requisite at the aortic than at the mitral valves .........

Normal weight of the heart .......

M. Bizot's researches on the dimensions of the heart Dimensions of the heart, in reference to age ....

173 175 177 179

185 190 195 202 212 317

219 233 234 235

CONTENTS.

Combined obstructive and regurgitant lesions of the aortic orifice

General symptoms of disease of the aortic valves

Regurgitant lesions of the mitral valve

General symptoms of disease of the mitral valve

Inorganic murmurs often heard over the apex of the heart

Dissecting aueurism > > > > >

Cases of dissecting aneurism , , , ,

Dulness of percussion along the margin of the sternum in aneurism of the

Dr. Worthington's case of cyanosis , ,

Professor Dumglison's remarks on cyanosis Case of angina pectoris , ,

The heart increases in size in proportion to age ....

Dimensions of the heart, relatively to the height of the individual

— breadth of the shoulders

capacity of the ventricles

thickness of the left ventricle

to the thickness of the inter-ventricular septum ........... 239

Thickness of the walls of the right ventricle ...... 239

Comparative thickness of the walls of the right and left ventricle in the two

Professor Andral's views of the size of the infantile heart, erroneous 240

The measure of the right ventricle which indicates hypertrophy . . 240

The character of the muscular tissue of the heart changed in hypertrophy 240

Elongated hypertrophy of the heart ........ 242

Hypertrophy and dilatation often arise from the same causes . . . 247 Hypertrophy, not necessarily connected with valvular disease . . . 250 Dilated hypertrophy of the right ventricle connected with contracted hypertrophy of the left 252

Pathological effects of hypertrophy upon the general system '. . . 262

Character of the dulness on percussion, variable as regards the space, and

Impulse of the heart, influenced by the compartment affected . . . 272

Respiration exists over the precordial region, even when that space may

Treatment of hypertrophy ......... 286

Measurement of the cardiac orifices ....... 290

by M Bouillatjd .... 290

Measurement of cardiac orifices according to the age and sex . . . 290

the right cardiac orifices ...... 291

circumference of the aortic orifice .... 291

pulmonary artery . . . 291

Tissue of the heart changed in dilatation ...... 295

Regurgitation through the right auriculo-ventricular orifice in dilatation . 302

Articulate symbols for the sounds of the heart , 307

Extent of dulness on percussion, and seat of impulse changed in hypertrophy, &c. ... ........

Double pulsation accompanying dilated auricles ....

Apoplexy of the heart . . .

Aneurism of the valves of the heart ......

Softening of the heart ........

Induration of the heart : Bertin and Bottillatjd's views

Heart, overloaded with fat ........

CEdema of the heart .........

Symptoms of abnormal cardiac productions .....

Obstructive and regurgitant lesions of the valves ....

Disease of the valves of the left portion of the heart, most frequent

The period of the heart's action in which the morbid sounds are generated

Obstructive disease of the aortic orifice

Duration of murmur in the second sound

333, 335

351. 354

426 451 451 462

INTRODUCTION

TO THE FIRST EDITION

Preceded by names so distinguished as those of Corvisart, Kreysig, Burns, Laennec, and Bertin, I am sensible that I expose myself to the imputation of presumption, in offering to the profession a new treatise on the diseases of the heart and great vessels. I feel called upon, therefore, to explain, in a more circumstantial manner than I should otherwise have wished, the motives which have induced me to undertake this work, and the plan which I have pursued in its execution. Whether I am justified in the attempt I can scarcely form an opinion. Every author contrives, I believe, to persuade himself that the work which consumes his own midnight oil, is precisely the one that is wanted. It is for the reader to determine whether I labour under the delusion common to my brethren.

Notwithstanding the strong light diffused over the diseases of the heart by the researches of the above mentioned authors, — notwithstanding the brilliant sunshine emanating from the discovery of auscultation by Laennec, — a discovery, which, according to M. Bertin, " has, in a few years, more completely illumined the diagnosis of the diseases in question, than all the other modes of exploration had done for two centuries" the great body of the profession still deny that the piercing ray has reached its destination, still doubt the utility of ausculation in reference to the primary organ of the circulation, still find the ordinary symptoms beset with their accustomed difficulties, still complain, in short, that the obscurity which involves the diseases of which we speak, is scarcely less profound than ever;* and, while conflicting opinions are embar-