over the actions of the heart; and palpitation from this source is very frequent. Dr. Cullen entertained the idea that it arose from the too rapid influx of nervous power into the muscular fibres of the heart; but this notion is too hypothetical to require discussion. Palpitation is frequently observed in persons of irritable habit, and is often connected with amenorrhoea, chlorosis, and hysteria, of which latter disease the animus varius et mutabilis constitutes so striking a feature. 2. Palpitation is owing, secondly, to a plethoric state of the body, the heart labouring in its functions from over-distension of its cavities; and sometimes to preternatural increase in the velocity of the blood, without augmented bulk, as where it is brought on by violent exercise. 3. It arises thirdly, from sympathy of the heart with a deranged condition of the abdominal viscera, and consequently is a frequent symptom of dyspepsia, constipation, and diseased liver. It is hardly consistent with sound pathology to attempt any more precise explanation of this phenomenon, than what the term nervous sympathy suggests. 4. The last proximate cause of palpitation to which I shall allude is weakness of the heart's action. It frequently occurs in young men of studious habits, who have impaired their general health by want of due exercise, by mental anxiety, and by continuing their exertions of thought so far as to break in upon their natural hours of rest and recreation. It seems to be a law of the human economy, that debility in the exercise of any function often produces temporary efforts at more vigorous exertion, and commonly in a convulsive manner. Hence it is that syncope and palpitation are so often associated together. Diagnosis. Nothing is more necessary in actual practice than to distinguish carefully between simple nervous palpitation and the organic lesion of the heart (hypertrophy), for which the anxious mind of the patient so often and so causelessly mistakes it. In both affections the heart is felt tumbling irregularly in the chest, and a violent impetus is given to its parietes. But in the nervous palpitation, the impulse is confined to the proper region of the heart. It neither extends to the back, nor to the right side. It is unaccompanied with swelled legs, dropsy, or lividity of lips. If the complaint occur in young women, the pale, bloodless chlorotic aspect of the countenance will contribute to fix the nature of the disease. An accurate diagnosis in this case not only relieves the mind from much painful anxiety, but it prevents the adoption of measures which might have added fuel to the flame. In hypertrophied heart the patient is to be put on a restricted diet, and to be debarred from severe exercise. In the palpitations of irritable females and anxious students, horse exercise and an allowance of wine are measures of the first importance. Treatment.-An affection arising from such various and even opposite causes must be met by measures adapted to the particular circumstances of each case. When plethora is present, and the heart labours in its functions from excess of duty, the loss of a moderate quantity of blood will give temporary relief, and form a fit prelude for other and more lasting depletory measures, especially low diet, purgatives, and nauseants. In by far the larger proportion of cases, however, the habit of body in which palpitation occurs is that of weakness, atony, and irritability. The system of management, therefore, here must be essentially tonic. The diet should be nourishing without being stimulating. Moderate exercise in the open air should be directed. The bowels are to be relieved by warm aperients, such as the compound decoction of aloes. Long continued study is to be exchanged for cheerful amusement. The general habit is to be strengthened by quinine and chalybeates. Such measures, steadily pursued, may effect a cure, even in cases of great obstinacy, but they must often be continued for one or two years before the heart completely regains its tone. CHAP. V. ORGANIC DISEASES OF THE HEART. Chronic diseases of the Heart connected with alteration of its structure. Angina Pectoris. Its symptoms, progress, and termination. Morbid appearances. Pathology. Treatment. Enlargement of the Heart. Simple Dilatation. Its general and external signs. Hypertrophy. Its general and external signs. Diagnosis of its several species. Prognosis. Causes of enlarged heart. Treatment. Of Valvular disease of the heart. Diagnosis of the several varieties of valvular disease. Prognosis. Pathology of valvular disease. Treatment. Congenital malformations of the heart. Symptoms occasioned by them. Cyanosis, or blue disease. Aneurism of the thoracic Aorta. IN a preceding chapter (page 265) an attempt was made to arrange the several diseases of the heart which are connected with alteration in its complicated structure. On that occasion the inflammatory affection of its surface was considered, together with its consequence, adhesion of the heart to the pericardium. I now proceed to describe those organic diseases of the heart which are not usually associated with fever. They may be thus enumerated. 1. Affections of the Parietes of the heart; viz. Ossification, leading to Angina Pectoris, Dilatation, and Hypertrophy. 2. Affections of the interior of the heartPolypi, Valvular Diseases, and Malformations. A few obser vations may follow on Aneurism of the Thoracic Aorta. ANGINA PECTORIS. To a disease exhibiting many uniform and characteristic symptoms, and usually considered as depending on some chronic structural derangement in the heart, Dr. Heberden, in 1768, gave the name of angina pectoris.* Dr. Parry, of Bath, has treated of it fully, under the title of syncope anginosa.† In Dr. Cullen's nosology it has received no place, although it might readily have found one next to asthma, to which, in many of its characters, it bears a strong analogy. Modern writers Transactions of the London College of Physicians, vol. ii. page 59. Account of a Disorder of the Breast." By Dr. Heberden. "Some + Inquiry into the Symptoms and Causes of the Syncope Anginosa. 1799. have added but little to the observations of the distinguished author who first described this disease. Symptoms.-Angina pectoris, or neuralgia pectoris, as it might more properly be called, consists of repeated paroxysms of violent pain or uneasiness about the chest, occurring principally when the patient is walking up hill, or against the wind. The feeling of pain is so acute as to make him instantly stand still, and even to give the apprehension of immediate death. It is referred to the sternum a little inclined to the left side, from which point it shoots across the breast to the left arm, and appears to terminate at the elbow. In some cases it extends to the right breast, and passes down the right arm in a similar manner. At first the paroxysms do not last more than a few minutes, and occur only at long intervals. Gradually they lengthen, and recur with increased frequency; being brought on, not only when the patient is walking, but when sitting or lying down, and by the slightest bodily exertions, or even anxiety of mind. In many cases they are brought on by taking food, or the accidental distension of the stomach by wind. The duration of the paroxysm has been, in some very severe cases, protracted to half an hour or more, the face and extremities becoming pale and bathed in a cold sweat, and the patient, for a while perhaps, deprived of the power of sense and voluntary motion. The character of the pulse during the fit is apparently subject to considerable variety. Dr. Heberden found it sometimes, though far from uniformly, affected. Dr. Fothergill reports, that in his cases it was commonly intermitting or irregular. There is always some difficulty of breathing, or at least a distressing sense of suffocation, present at the same time; and in the advanced periods of the disease the stomach becomes unusually irritable. Prognosis and Diagnosis.—Angina pectoris has been known to last for many years; yet the prognosis is very unfavourable. In the larger proportion of cases it proves fatal suddenly, giving rise to the suspicion that apoplexy has taken place, or that the heart itself has given way, but which upon dissection nothing will appear to corroborate. The diagnosis has often been looked upon as a matter of considerable difficulty, but I think without sufficient reason. Angina pectoris derives its character from a remarkable group of symptoms present during life, and not from any appearances found after death; and if the former are observed, the discase is at once entitled to such a denomination. Morbid anatomy.-Dr. Parry has the merit of first connecting the symptoms usually known by the name of angina pectoris, with an ossified state of the coronary arteries of the heart. Subsequent experience has shown that this important principle in pathology is fairly admissible, though subject to modifications and exceptions. In some cases the aorta has been found ossified or dilated; in others the valvular structures of the heart have been implicated in the disease. Nothing, however, tends to obscure this subject more than observing that in many cases (and very remarkably in that described by Mr. H. Watson*) a most extensive ossification of the coronary arteries existed, without giving rise to a single symptom of thoracic disease. Dr. Latham, in an interesting communication to the London College of Physicians,† has described two cases of enlarged liver, in which all the genuine symptoms of angina pectoris were observed. Both patients died suddenly. But further, this disease has proved fatal where the most accurate anatomists have failed in detecting any morbid alteration of structure; and it has been observed, during life, in combination with certain other symptoms denoting general constitutional disturbancesuch as are sometimes designated by the title of flying gout. Upon the whole, therefore, we must conclude, that angina pectoris, though associated in so large a proportion of cases with structural disease, especially ossification of the parietes, of the heart, as fairly to claim for itself the title of a disease of the heart, may still arise from other sources, and possibly may have for its proximate cause some condition of the thoracic nerves which has hitherto eluded observation. Causes. Angina pectoris prevails more frequently in men. than women. It is met with exclusively in the middle and advanced periods of life. It is more frequent among persons in easy circumstances than in the labouring classes. It seems to have some ill-defined connexion with the gouty diathesis. The nature of that action of the vessels which precedes the ossific * Medical Communications, vol. i. page 234. + College Transactions, vol. iv. page 278. Pectoris notha." "Observations on the Angina |