by acute pains in the region of the heart, we may suspect that the fleshy fibres are affected. If a rheumatic inflammation precedes or accompanies the attack, the pericardium, or, less probably, the endocardium, or even both, will be the seat of the disease. If pleurodynia with hemoptysis has preceded the cardiac attack, the right side of the heart is affected in consequence, of the pulmonary circulation being disturbed. Again, if the onset of the disease has been marked with slight symptoms, which have slowly and gradually increased, there is reason for apprehending the existence of some organic lesion, which will become more certain if the symptoms go on uninterruptedly, if they steadily increase in severity, and if they give rise to those general constitutional disturbances previously noticed.

Lastly, as regards the seat of the disease, it should be borne in mind, as I have already so strongly insisted on, that the left side of the heart is much more obnoxious to morbid changes than the right; and that when both sides are implicated, the alteration will be more decided in the left than in the right chambers. In nineteen cases out of twenty of valvular disease, the valves of the left ventricle-the mitral or aortic -will prove to be those affected; disease of the tricuspid valves guarding the right auriculo-ventricular orifice is rare, and of the semilunar valves of the pulmonary artery exceedingly uncommon.

ATROPHY OF THE HEART.

There are two forms of atrophy of the heart: one in which the organ simply wastes, and dwindles in all its parts; the other, in which the texture of the muscle suffers a sort of conversion into fat-becomes affected with fatty degeneration.

Fatty degeneration of the heart is a most interesting disease, for a full knowledge of which the student must refer to the writings of Drs. Quain and Ormerod, and Messrs. Paget and Barlow. It occurs under two circumstances; either alone, or in conjunction with fatty diseases of the other organs, as the kidneys, liver, cornea, &c. Its diagnosis is beset with difficulties, and when existing alone it is frequently not suspected until after death, and after a microscopic examination of some of the muscular fibres of the heart. The most prominent symptoms are feeble action of the heart, remarkably slow pulse-sometimes as low as fifty or forty-five, general debility, and a feeling of nervous exhaustion, loss of tone, &c.

It is not an uncommon cause of sudden death. "On opening a heart thus affected," says Dr. Ormerod, "the interior of the ventricles appears to be mottled over with buff-colored spots of a singular zigzag form. The same may be noticed beneath the pericardium also; and in extreme cases the same appearance is found, on section, to pervade the whole of the thickness of the walls of the ventricle and of the carnes columnæ." On microscopically examining these spots, their nature is revealed; they are not deposits, but degenerated muscular fibres. Instead of seeing transverse striæ and nuclei, the evidences of a healthy state-little can be distinguished but a congeries of oil-globules. The muscular fibres are also found to be short and brittle; and Dr. Quain has pointed out that the coronary arteries are often obstructed. Mr. Paget well remarks that "the principal characters which all these cases seem to present is, that they who labor under this disease are fit enough for all the ordinary events of calm and quiet life, but are wholly unable to resist the storm of a sickness, an accident, or an operation."

HYPERTROPHY OF THE HEART.

The heart is stated roughly to be about the same size as the closed fist; its mean weight is between eight and nine ounces. The muscular walls of one or more of the cavities of the heart may become thickened without any diminution in the size of the chamber; this is called simple hypertrophy. Or, as most frequently happens, the walls may be thickened and the chamber become larger than natural; this is eccentric hypertrophy. On the other hand, the increase in thickness may be accompanied with diminution in the size of the cavity; this is known as concentric hypertrophy.

The cause of the hypertrophy is usually some obstruction either to the flow of blood through the heart, or to the free play of this organ; the symptoms are palpitation, dyspnoea, difficulty of walking quickly, uneasiness and pain in the cardiac region, headache, and frequent attacks of vertigo. If we listen to the heart's movements we shall merely find the systolic sound less distinct than in health; but we shall also feel that the extent of the pulsation beyond the præcordial region, and especially the degree of impulse against the walls of the chest, are both much increased.

Simple Hypertrophy of the Left Ventricle with no Obstruction to the Flow of Blood.-This condition is rare. On ausculting the heart the systolic sound is less loud and

clear than natural, but no bellows murmur is heard. On placing the hand over the præcordial region the impulse of the heart will be found increased.

Hypertrophy of Left Ventricle with Valvular Disease. A systolic bellows-murmur will generally be heard, and the heart's impulse will be much increased. The hypertrophy in this case is often an endeavor towards health, the increased power compensating for the obstruction to the flow of blood caused by the valvular disease.

CYANOSIS.

Cyanosis, morbus cæruleus, or blue disease, are terms applied to a condition characterized by blue or purplish discoloration of the skin, arising generally from some malformation of the heart, permitting direct communication between the right and left cavities.

The chief malformations are, permanence of the foramen ovale; abnormal apertures in some part of the septum of the auricles or of the ventricles; origin of the aorta and pulmonary artery from both ventricles simultaneously; extreme contraction of the pulmonary artery; or, lastly, continued patescence of the ductus arteriosus.

In addition to the discoloration of the skin, the patients who survive their birth suffer from coldness of the body, palpitation, fits of dyspnoea, or syncope on the least excitement, and dropsical effusions.

ANEURISM OF THE AORTA.

Three forms of aneurism are usually described; true aneurism, in which all the coats of the artery dilate and unite in forming the walls of the pouch; false aneurism, in which the inner and middle arterial tunics being ruptured, the walls are formed by the cellular coat and contiguons parts; and mixed or consecutive false aneurism, in which the three coats having at first dilated, the inner and middle ones subsequently rupture as the distension increases.

Aneurism of the Thoracic Aorta is chiefly met with in the ascending portion, or in the arch. Its general symptoms are very obscure, partly in consequence of their similarity to those arising from disease of the heart. When the aneurismal tumor is large and pulsating, and rises out of the chest, producing protrusion or absorption of the sternum and ribs, then the diagnosis is altogether as easy as it was before

difficult. When the sac presses upon the trachea, there will be dyspnoea; when on the recurrent laryngeal nerves, aphonia, and occasionally a mimicry of laryngitis; when on the sophagus, dysphagia and symptoms of stricture; and when on the thoracic duct, inanition, and engorgement of the absorbent vessels and glands.

Aortic aneurism is sometimes accompanied by a bellowssound, sometimes not. In false aneurism there is generally a murmur both with the entrance and exit of blood into the sac; or there may be one loud, prolonged, rasping bruit, from the passage of the blood over the roughened inner surface of the vessel. In true aneurism or mere dilatation of a part of the wall of the artery, murmurs are seldom audible. A small but free opening from the canal of the artery into the aneurismal sac, and a roughened state of the arterial tunics, from degeneration or from atheromatous deposit, are, however, two conditions which will give rise to a bruit. In both forms, when a murmur exists, a peculiar thrilling or purring tremor will be felt on applying the hand over the sternum.

Aneurism of the Abdominal Aorta often gives rise to acute pain in the lumbar region, occasionally shooting into either hypochondrium, and downwards into the thighs and scrotum; constipation aggravates the pain. By careful examination, a tumor may generally be felt, which communicates a constant and powerful pulsation to the hand. On applying the stethoscope, a short, loud, abrupt bellows-sound will be heard.

Aneurism of the Heart occurs in two forms; either there is simple dilatation of the wall of a ventricle, forming the improperly called passive aneurism of Corvisart; or a pouched fulness arises abruptly from the ventricle, constituting a tumor on the heart's surface. The sac often contains laminated coagula of blood, especially when its mouth is constricted. The symptoms are uncertain and obscure. Death may result from rupture into the pericardium, or, if the pericardium be adherent to the heart-as it mostly is in these cases -into the pleura.

Aneurisms of the coronary arteries sometimes occur. I know of no signs on which the physician can rely for their detection.

17*

CHAPTER IX.

ON THE DIAGNOSIS OF DISEASES OF THE SKIN.

It is a very generally entertained opinion that the diagnosis of cutaneous diseases is extremely difficult, that the treatment of these affections requires special study, and that the subject of cutaneous pathology should be viewed as a distinct branch of medicine. I believe that such ideas are very erroneous and mischievous; the various phenomena presented by each class of these disorders being generally very characteristic, always appreciable by the eye, and their treatment being by no means difficult, but often remarkably simple. Since, moreover, the majority of cutaneous affections are merely symptomatic of other diseases affecting different organs, I hold that no man can pretend to be a sound practitioner of medicine who is not fully acquainted with them all in their bearings.

In treating of the diagnosis of the various skin diseases I shall adopt the classification of Willan, as modified by Biett; which is, however, like the Linnæan_classification of the vegetable kingdom, entirely artificial. I am of course conscious that in a work like the present only a faint outline of this important and interesting subject can be presented; and I therefore take the opportunity of referring those who wish to study the subject of cutaneous pathology thoroughly to the excellent translation of Cazenave's "Manual on Disease of the Skin," by Dr. Burgess, to which I am myself indebted for much very valuable information.

Willan's Classification, modified by Biett.

ORDER I. Exanthemata.-Erythema; erysipelas; roseola ; rubeola; scarlatina; urticaria.

ORDER II. Vesicula.-Miliaria; varicella; eczema herpes; scabies.

ORDER III. Bulla-Pemphigus; rupia; button scurvy. ORDER IV. Pustulæ.-Variola ; vaccinia; ecthyma; impetigo; acne; mentagra; porrigo; plica polonica; equinia or glanders.

ORDER V. Papula.-Lichen; prurigo.

ORDER VI. Squamæ. - Lepra; psoriasis; pityriasis; ichthyosis.