1847.]

Causes and Treatment of Hypertrophy.

347

observation, in 500 cases at least, have convinced me of the truth of this position, which may now, therefore, be regarded as an established general fact or law in cardiac pathology. It is not to be supposed from this that we dispute the agency of other causes in the production of this disease. Those enumerated by Corvisart contraction of the arteries, or loss of balance between the calibre of the vessels and the quality of blood to be sent through them; all the obstacles to the circulation of the blood, whether arising from a vice of organization, from any pathological condition, from the influence of moral emotions, or from corporeal offorts or exercises; perhaps, also, the more or less stimulant quality of the blood itself, exciting the organ to more or less energetic contraction-have unquestionably a morbific effect. One of the most curious and instructive illustrations of one of these agencies, enumerated by Corvisart, may be found in what is apt to take place in the right cavities of the heart in persons in whom the foramen Botalli remains open. The principal, if not the only, cause of the hypertrophy of the right ventricle (whose walls have been known to become nearly an inch and a half in thickness), under such circumstances, appears to be the admixture of a certain portion of arterial-which is more stimulating-with the venous blood within its cavity. This opinion seems to be confirmed by what we find to take place in a vein, between which and its adjacent artery a communication has been accidentally established; it becomes thickened, hypertrophied, and, if we may so say, arterialized. Now, the right ventricle of the heart may be fairly considered to be analogous to a vein adherent to a sort of artery, represented by the left ventricle. The venous heart, therefore, becomes hypertrophied or arterialized, just as a vein does where its contents communicate with those of an artery. So striking, indeed, is the resemblance of the right to the left ventricle in the cases alluded to, that several of the older writers, and Corvisart is among the number, have fancied that there was a sort of transposition of the ventricles. Morgagni, in his report of one such case, has expressly said :--ventriculus sinister forma erat quâ erat dexter, et dexter vicissim quâ sinister; et quanquam hoc latior, parietibus tamen crassioribus.

"If the explanation which we propose be just, the conjecture of Corvisart,' that the more or less stimulant qualities of the blood may perhaps be one of the exciting causes of hypertrophy of the heart,' would assume the importance of a demonstrated truth. We must not, however, omit to take into account other causes, which may act in concert with that one now suggested."

Supposing, now, that the nature of the cardiac disease has been clearly made out, and that no reasonable doubt can be entertained that an actual enlargement of the heart exists, the next questions for the physician come to be, what is the prognosis that he is to form of the case? and what is the amount or degree of benefit that he may justly expect from the resources of his art?

According to Dr. Latham's experience, genuine and absolute Hypertrophy of the heart-as ascertained in the manner which has been

tissue and the lymphatic glands usually become hypertrophied after chronic ulcerations of the skin and mucous membranes, that the fibrous textures of the joints and the articular extremities of the bones themselves become enlarged and thickened after long-continued inflammation of the synovial membrane," &c. &c.

M. Bouillaud had previously alluded to the influence of increased energetic action on the hypertrophic enlargement of muscular tissue, and had quoted with approbation the observation of Corvisart, that "exercise in the case of the external muscles, exercise and irritation in that of the heart, are the principal causes of the more active nutrition of these organs, and consequently of their unusual development."

explained in the present, as well as in the preceding article-is seldom, if ever, truly curable. Its effects may be mitigated, and its increase may be much retarded by wise treatment; but there is no satisfactory evidence, he thinks, to show that a really hypertrophied heart has ever been reduced to its natural dimensions. It would be important if we could determine this point with accuracy; but as yet we have not sufficient data for the purpose. Our own experience would lead us to adopt the same views with our author. But, whatever opinion may be entertained on the subject, no experienced physician will hesitate to give his ready assent to the wisdom of the remark that, in the treatment of actual Hypertrophy, we must be on our guard not to take the mere force of the pulse in determining the amount of blood to be taken by venæsection, when this is deemed requisite. The object is not to cure, but to relieve, the disease. From four to eight ounces will be amply enough. The operation may require to be repeated at intervals of some weeks or months, its effects on the general system, as well as on the aggravated actions of the heart, being all the while most attentively watched. But often, very often, the local detraction of blood from the cardiac region is decidedly to be preferred to bleeding from the arm. Dr. Latham very wisely recommends that the application of a few leeches should invariably precede the use of the lancet; it is often astonishing how much relief may thus be promptly given. When Hypertrophy is associated with Anæmia, the case is always a very serious and unmanageable one. Such a complication may have been induced by the injudicious depletion of blood. "Beware then," says our judicious author, with marked emphasis, "in the management of hypertrophy of the heart, beware, above all things, of bleeding your patients into paleness and poverty of blood."

The following passage, descriptive of the most frequent of all the complications of Hypertrophy, viz. with Valvular Disease, is so replete with interest in a physiological, as well as in a practical, point of view, that we shall give it entire.

"Here the diagnostic signs of both remain, so that there can never be the least doubt of the existence of either. The impulse within the chest, constantly augmented in degree and in extent, denotes the hypertrophy. The endocardial murmur, constantly present, denotes the injury of the valves.

"But, while the coincidence of the two is thus far without prejudice to the diagnostic signs of either, yet looking further to the actions of the heart itself, to the movements of the blood within the arteries, and to the deeper and more vital derangements, which naturally belong to each when they exist separately, we clearly discern the effects of the one wonderfully merged and lost in the effects of the other, now that they exist in combination; we see the effects of valvular injury merged and lost in those of hypertrophy.

"To valvular injury naturally belong an irregular contraction of the ventricle and an irregular pulse, and obstructions and delays to the course of blood through the arteries in various measures according to its degree. To hypertrophy naturally belong an excessive force of contraction in the ventricle and an excessive im pulse communicated to the current of blood in the arteries. And this force and impulse are naturally opposed to all that is irregular and eccentric in the action of the heart and arteries, and even counteractive of it, when it would otherwise arise. Thus, they are counteractive of their irregular action, when it otherwise would arise from valvular injury.

"Moreover this coincidence of hypertrophy of the left ventricle and of an in

1847.] Connection between Hypertrophy & Valvular Lesions. 349

jured valve exhibits the most beautiful example, in the whole range of pathology, of the checking, redressing and compensating powers which nature possesses and uses in furtherance of the great ends of mitigating distress and of protracting life, when some important structure is damaged beyond the possibility of rep

aration.

"In this coincidence there is nothing of accident; all is of design. The important structure, damaged beyond the possibility of reparation, is the valve. The unsoundness of the valve comes first, and then produces the hypertrophy, and produces with it the redress of its own injuries. While the valvular unsoundness is yet small, and still when it has become greater, and even still when it has become very great, the heart is often found from first to last maintaining its rhythm and the pulse its regularity. And no wonder. For it is accompanied at every stage of its increase by a proportionally increasing power of the ventricle.

"A loud systolic endocardial murmur and an excessive impulse of the heart and a larger space of præcordial dulness than natural, these are the sure and authentic signs of an injured valve and hypertrophy of the left ventricle. Yet often and often are these found to co-exist, when the order and sequence of the heart's contractions and the beats of the pulse are perfectly regular and rhythmical. And further, with this certain evidence of an injured valve and of hypertrophy of the left ventricle, not only will, the heart and the pulse beat regularly, but the blood will continue to be distributed freely and equably throughout the body. Often the complexion is still healthy, the lips florid and the body well nourished.

"Here it is the hypertrophy, which is the safety of the patient and enables life to go on as it does. Take away the hypertrophy and leave the injured valve, and the patient would be in a far worse state than he now is; worse with half his disease than he now is with the whole of it. The pulse would begin to flutter, the complexion would become dusky and the lips blue, and the surface of the body mottled and patched in consequence of the blood being here and there unequally distributed or partially detained. The ventricle reduced to its common bulk would want the power needed to impel the blood steadily onwards against an extraordinary obstacle."-P. 297.

Here then we have a striking illustration of the vis medicatrix (or conservatrix) Naturæ. The obstruction to the free exit of the blood from the heart is fixedly mechanical and altogether irremoveable. The only way, therefore, to meet the difficulty is to increase the force of the pump. This is what nature does. The remedy, it must be confessed, is the induction of a new disease: but this is rendered inevitable by the preexisting one.

In the treatment of Hypertrophy of the Heart, we are always to bear in mind that this morbid change seldom continues long without being accompanied with disease-usually of an inflammatory or of a hæmorrhagic character-in some other organ or part of the system. The Lungs, the Liver, the Kidneys, and the Brain are, each and all of them, exceedingly apt to become the seat of some irregular and morbid action. Perhaps, however, the general Arterial system itself is what most frequently and most severely suffers, and in which the most constant marks of structural change are discoverable upon dissection.

Dr. Latham has very wisely directed the attention of his readers to the very important fact, in the history of chronic cardiac disease, that not only the dynamic forces of the circulation, but that also the qualities of the circulating fluid itself become, in course of time, almost inevitably injured. No. 108

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Hence, unquestionably, the tendency to congestions, dropsical effusions, and hæmorrhages is vastly increased beyond what we may reasonably sup pose would be the case, if the blood itself remained in a completely healthy condition. To omit, therefore, from our consideration the most important element in the production and aggravation of so many maladies we mean that of humoral change-is at variance alike with the rational physiology of disease and with its scientific and truly successful treatment. The author says:

"The general mind of the profession is just now all alive in quest of the elements of disease in the blood. A good deal is in a hopeful way of investigation and some little is already made out. But let us beware of the common fault of physicians in all ages, and not make too much of our new knowledge and call upon it prematurely to explain every thing. Thus much, however, we cannot help seeing plainly enough, that the opposite states of plethora and anæmia have a vast pathological import both in themselves and in relation to all diseases, come from what source they may. They have it unquestionably, and they display it in relation to those secondary diseases which spring from an unsound heart.

"Plethora belongs essentially to the blood, and results from one of its ele ments, the globules, being in excess. Now think of what plethora is in its effects; how it modifies the functions of health, how it directly conduces to certain kinds of diseases, and how it stamps a peculiar character upon all.

"Think of great habitual force of the heart's action and great habitual fullness of the pulse; of blood carrying with it its visible colour of blood much further into the capillaries than natural; of rapid digestion and rapid nutrition, great con sciousness of strength and vitality, and great muscular development. Such is the health of the plethoric.

"Think of frequent vertigo and ringing in the ears, and frequent drowsiness; of spontaneous congestions and spontaneous hæmorrhages and feverish heat on slight provocations. Such are the proper ailments of the plethoric.

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Again, anæmia belongs essentially to the blood, and results from one of its ele ments, the globules, being in defect. Consider what anæmia is in its effects; how it, like plethora, modifies the functions of health but in a different way; how it too conduces to certain kinds of diseases, and how it stamps a peculiar character upon all.

"Habitual feebleness and frequency and occasional irregularity of the heart's action, habitual smallness of the pulse, the blood failing to give its colour to the skin and to the visible portions of the mucous surface; slow and painful diges tion, defective nutrition, cold extremities, nervous depression, mental irresolu tion, such are the ingredients which go to make up the health of the anæmic at best.

"Throbbing in the head, and vertigo and ringing in the ears as frequent as in the plethoric, and pain more frequent and more acute; also spontaneous hæmor rhage as in the plethoric, but now taking the shape of purpureous spots and blotches; and œdema of the ankles and feet, these are the proper ailments of the anæmic. "Then every accidental form of injury and disease putting on the character of weakness; inflammation itself failing to accomplish the proper work of inflammation for want of power, and not bearing the remedies of inflammation, yet still continuing pertinaciously, and often refusing to be cured; such is the character they have in the anæmic.

"Now anæmia, bare anæmia, is a thing formidable enough in itself. Without disease or injury of any solid structure whatever, the essential disorder of the blood alone may kill. It may give occasion to passive effusions, and to passive hæmor rhages, and to passive inflammation, which bring on death.

1847.] Atrophy and Softening of its Muscular Substance.

351

"As in plethora, so in anæmia, each unsoundness of the heart becomes conditionally a worse disease, but worse in a different way. As in plethora, so in anæmia, each unsoundness tends more rapidly to its evil consequences, but those consequences are apt to emerge in a different manner. Passive effusions, hæmorrhages, and inflammations, are rather wont to appear every where than in certain parts. Death seldom now arrives by oppression of the brain or the lungs singly, but oftener by oppression of many organs simultaneously."-P. 312.

So much for the important subject of Hypertrophy-simple and complex-of the Heart. We pass on to notice the opposite morbid condition, viz. Atrophy.

We find the following few remarks on its (supposed) causes in M. Bouillaud's work:

"The causes of this-by no means imaginary, as has been alleged by certain writers, and indeed tolerably frequent-disease are either local or general, direct or indirect, mechanical or vital. Among others may be enumerated, 1, long-continued compression of the heart from an effused fluid within the pericardium, or from some other mechanical cause; 2, a local impediment to the circulation on which its nutrition depends, by contraction or obliteration of the coronary arteries; 3, various hygienic and diseased conditions, the effect of which is to induce a state of general wasting or marasmus: the majority of the cases of Atrophy which we have met with have occurred in persons affected with some chronic, tuberculous, or cancerous, &c. disorganization of the chief viscera, or in whom inflammatory disease had proved fatal after two or three months' persistence; and 4, an anæmic state of the system."

The form of Atrophy of the Heart, which is by far the most frequently met with, is that where the muscular tissue of one or of both of the ventricles becomes attenuated, and (as is usually the case) softened at the same time. We briefly noticed, in our last article, the effects of active Carditis in giving rise to actual suppuration in the ventricular walls, and we shall again have occasion to revert to M. Bouillaud's description of this very rare lesion. At present, however, we have to do with a very different form of the disease; that, namely, where there has been a wasting or disorganizing absorption of the muscular fibres, so that the fleshy parietes of the heart often become so thin and softened as readily to give way under the pressure of the finger. In many cases, it is impossible to trace this most serious organic lesion to any probable cause. We have already alluded to instances where men, in seeming good health at the time, have been suddenly stricken with death, and in whose bodies the walls of one of the ventricles have been found reduced to the thickness of a line or two. In other cases, we are not without data for forming a reasonable conjecture, at least, upon the subject. For example: Softening of the substance of the Heart has been observed to occur in certain asthenic states of the system, in which there is a loss of tone or power in the entire muscular system; this atony originating from a diffluent, or otherwise depraved, condition of the blood itself. One of the most important varieties of this morbid lesion is that which so often occurs in Typhus and other low fevers.

"When, in fevers, the skin becomes dusky, and the impulse of the heart fails and fails, until it can be felt no more; and the systolic sound of the heart fails and fails, until it can be heard no more; and death follows; and after death the heart is found to yield and fall in pieces under pressure of the fingers; then surely we cannot be