237

the veins returning the blood from thebrain, as well as other parts of thebody, become finally congested ; andthus, between the Inngs, brain, heart,and blood, death takes place, ratherfrom the remote than the immediateeffects of inflammation.Having said thus much upon inflam-

mation, possibly you might expect meto give a general Lecture on its treat- ,

2ne2it; but such a method of proceed-ing I hold to be absurd and hazard-ous, because in practice we have notto deal with general disorders, butwith particular facts, -which, varying,require a correspondent change oftreatment.

It is commonly said, that bleeding,blistering, purging, and a spare diet,are to be employed for the removalof inflammation; but the treatmentfitted to one case of inflammation isdifferent from that fitted to another.There are, in truth, various circum-stances which modifv the treatment;the structures attacked; the degree ofinflammation ; its duration also; theremote causes, common and peculiar ;the age, sex, and habits of the parties,all demand a deliberate consideration.For these, and other reasons whichmight be added, I shall, in my nextLecture, commence the illustration ofparticular inflammations, with the ap-propriate treatment of each.

REVIEW.

Traite des MALADIES du CŒUR et des

GROS VAISSEUX, par R. J. BERTIN,Professeur a la Faculté de Paris, -c.Redige par J. BOUILLAUD, Docteur enMédecine de la Faculté de Paris, &c.avec sixplane7tes. Paris, 1824.

Treatise on DISEASES of the HEART andthe LARGE VESSELS, by R. J. BERTIN,Professor to the Faeulte of Paris, &c.Edited by J. BOUILLAUD, Doctor in

Medicine, &c. with six plates. Paris,1824.

As long ago as the year 1811, the vo-lume before us first made its appear-

ance, and notwithstanding the cele-brated works of MORGAGNI, Larcrsr,SENAC, and CoRVISART,onthe diseasesof the heart, M. BERTi-4’s work con-tained some discoveries in the patho-logy of these affections that had en-

tirely escaped the observation of thosewho preceded him. The copy before

us is an edition just published, and isedited by the friend and pupil of theauthor, M. BOUILLAUD. The points inwhich BERTIN’S book differed from

those of his predecessors on the samesubject, related principally to the dis-eases affecting the muscular substanceof the heart. CORVISART, who hadwritten on the diseases of the heart,a short time only before the appear-ance of M. BERTIN’S work, adopted aclassification, respecting the particu-lar affection to which we have alluded,founded on the generally received,though erroneous opinion, that a dilata-tion of the cavities of the heart alwaysco-existed with an augmentation of itssize. In 1811, our author read a paperbefore the IN3TITUTE of France, mwhich he demonstrated, by numerousfacts, that dilatation does not alwaysaccompany thickening of the parietesof the heart, that this thickening maytake place, and the cavity preserve itsnatural size ; and that even hypertro-phia may co-exist with a diminution ofone or more of the cavities. HYPER-

TlWPHIA is the modern term, which

corresponds to that of ANEURISM of

the heart, made use of by CORVISART.We will state in CORVISART’S own

words the sense in which lie uses this

term, and then our readers will beable better to understand its misap-plication.

238

41 Of Aneurisms of the Heart ingeneral.

" I wish to make a few prefatoryremarks before I enter materialty onthe disease in question. In every caseof aneurism of the heart, I state thatthat organ is increased in volume ; Ishall also have occasion to say, that insuch and such a case, it had acquireddouble its natural size, &c. Everyreader will readily see, that this cal-culation must always be merely ap-proximative. Vre well know that itssize varies according to age, sex, tem-perament, manner of living, &c., butwe want, and ever shall want, a per-fectly exact standard by which toascertain the weight, the volume ofa dilated heart thickened in its pa-rietes. This, then, is a mode notstrictly correct; but every practitioner;in adopting it, is aware of its want ofexactness, as ’well as of the difficultyof -obtaininz a better." In medical language the word

Aneurism is used to express a dilata-tion of the heart, or of an artery.Thus; to avoid mistake in the meaningwhich may be affixed to this term, Ialways use it as a word expressive -ofan. unnatural dilatation, either activeor passive, of one or more of the cavi-ties of the heart. When I shall haveexplained the difference between thesevarious aneurisms, the propriety ofnot attaching any other meaning to

the word than the one I have givenwill be better understood. Once forall, then, I shall use the words Aneurismand Dilatation in a sense perfectly sy-nonymous.

We must admit two kinds of dila-tation of the heart, the one active, theother passive. The real existence ofthese’two species is proved to the phy-sician, by the different and proper rsymptoms of each; to the anatomist,by the uniform and frequent observa-tion of the two very distinct states, inwhich the heart is found when it has

been the seat of disease.,

" In the first species (active dilata-tion) the heart i dilated, its parietesare thickened, and the force of its ac-tion is increased. ’

94 In the second (passive dilatation)there is evidently also dilatation, butwith diminished thickness of the pa-rietes, and a diminution in the force ofthe action of the organ." CORVISART

on the Heurt. HEBB’S Translation,P. 57.

From the observations of BERTIN

it will be seen that the term active an-eunisnz, whilst it indicates increase of

t nutrition, hypertrophia of the heart, is

incorrect, since it carries with it the

idea of dilatation; and as hypertrophymay exist, not only without dilatation,but even with a diminution of the

cavities of the. heart. BERTIN, there-

fore, renounces CORVISART’S division,and classes all the cases of hyper-trophia under three forms. 1. When

the parietes of one or more of the

cavities are thickened, without an

increase or diminution of their size,he calls it H .ype2-t,i-ophia Simple.—2d. When the parietes are thickenedand cavities enlarged, Hypert?,ophi(6Excentrique. 3d. In cases where the

cavities are contracted, at the same

time as the parietes are thickened,it is named Hypertroplaia Concentrique.The manner iri -which the cavities

of the heart are affected with thls-

disease is very various; both ven.

triciss are sometimes affected at the

same time, and sometimes one only.The auricles are also subject to thethree forms of hypertrophia, but mostcommonly to the second form ; in fact,it occasionally happens that the wholeheart is attacked with this complaint,and in these cases the size which it

attains is enormous. The symptomswhich hypertrophy of the various

cavities exhibits vary according to,thecavity or cavities affected, which

makes the study of this complaintsome what diffi-cult, indeed we believe’that the diseases afao organ require :more time and attention to be tho-

239

roughly studied than those of the iheart. There are, however, some Isymptoms belonging to all forms oflhypertrophia in common, and which, Iwe think, cannot be better classedthan according to the senses throughwhich they are communicated.

1. Signs furnished by the sight.The movements of the heart are vi-

sible in a greater or less extent of the

chest, according to the size of the

hypertrophia. The chest is sometimesagitated by- these, even as far as theleft clavicle, the epigastric -region isshaken, and the clothes or covering ofthe patient raised by them.

2. Signs furnished by the feel, whe-ther immediate or mediate, If the hand

be applied on the prsecordia, it is

struck, and, to use the expression,forcibly repulsed by strong, hard, andextensive pulsations, which are some-times slow and superficial at othersmore deep and rapid. It feels, in cer-tain cases, as if the heart struck the

hand with its whole mass, in others

with the point only. By the touch themovement of the chest, to a very con-sidetable extent, and even to its pos-terior part, may be recognized:

3. Signs furnished by the hearing.These may be distinguished into thosefurnished by percussion, and those byauscultation, either immediately onthe naked ear, or mediately throughthe stethoscope.

If percussion be performed in the

cardiac region, it gives an obscure

or dull sound to an extent proper-tioned to that of the hypertrophy;and as for the sounds communicated

by the stethoscope, we gave a full

acconnt of them in a late Number.

Vide LANCET, No. 4. of this volume, .p.158. _

Before we proceed to- give an ac-count of the symptoms which mark

hypertrophia of any particular cavity,we shall make a few observations onthe state of the circulation, respira-tion, and nervous power in this disease.With respect to the circulation, we

have already said that the palpitationsof the heart in hypertrophia are, atintervals, violent and prolonged. The: =

pulse also presents several modifica-

tions, according to the form, degree,and complications of the hypertrophia.In hypertrophia, only, the pulse is ingeneral regular, harder, and softer,-than in the natural state. In simple -hypertrophia, without dilatation, or ifthere be any, not sufficient to have

weakened the muscular fibres, thepulse is slow; tense, hard.’and vibratesnnder the fingers. In hypertrophia,with contraction of the cavity, thepnise preserves its hardness, but it iswhat may be designated a labouringpulse. It is scarcely necessary to saythat the state of the pulse is only ofassistance in ascertaining the state ofthe left ventricle, and of no use in the

diagnosis of that of the right. In

general, the respiration is very littledistnrbeâ in hypertrophia, when theheart is of a moderate size ; but=whenthis organ becomes much enlarged, itis considerably impeded. With respectto the nervous power, in the com-

mencement of this complaint, it is notin the slightest degree affected, but assoon as the respiration becomes affect-ed, it is very much depressed. Wewill now give the-distipetive signs of

240

bypertroplxia of each of the cavities ofthe heart.

Signs of Hypertrophy of the Left_ Ventricle.

The pulsations of which we have

spoken a little higher up are par-

ticularly distinct through the stetho-

scope, in the region of the cartilagesof the fifth and sixth ribs. Here theyare most intense ; in the other partsof the left side they are more weak, butstill stronger than on the right side.To this symptom must be added thosefurnished by the genera! circulation-the patients have the colour of thecountenance changed to a red or ver-tmUoa; the eyes bright ; the pulsestrong, full, hard, vibrating, and

large; at least, if the cavity be notcontracted, they are stibjecttolioerior-rhages ; epistaxia, in particular; to stn-por, and other symptoms of cerebral

congestion, of which they frequentlydie.

Symptoms of Hypertrophia of theRight Ventricle.

The contractions with the characters

stated above, instead of being felt inthe space between the fifth and sixth,are much more marked in the inferior

part of the sternum, and, in general, I

more distinct in the right than in theleft side of the chest. Frequently, ex-

pectoration of bloody matter.Having given the symptoms of each

of the forms of hypertrophy, whenthey attack the left ventricle or the

right, it will not be difficult to i-eco,,-nise combinations of these different

forms, when they occur in any inùi-

vidual. For instance, let a patientbe affected at the same time with

simple hypertrophia of the right ven-

tricle, and with simple hypertrophia,or even a certain degree of contrac-tion, of the left; in this case, the firstwill be recognized by the strong, dis-tinct, and sonorous pulsations whichare to be heard on the inferior part of

the sternum ; and the second by con.tractions equally strong, but dull andconcentrated, which are to be ascer-tained in the space between the car.

tilages of the fifth and sixth ribs.As for hypertrophia of the auricles,

it will be distinguished by a stifled

sound which accompanies their con-

tractions. As, moreover, this lesionis nearly always consequent on a le-sion of the valves, an impediment ofthe circulation, it will be quite suffi-

cient in announcing this to have dis-covered the existence of this hnpedi-ment. The hypertrophia, besides, isof little importance to discover, andmuch less dangerous by itself than thecause which has produced it.In concluding what belongs to the

symptoms ofhypertrophiaofthe heart,we wish particularly to state, that

auscultation mediate is in general pre-ferable to auscultation immediate, in

exploring this disease. In the disease

of the heart, in general, the stetho-

scope will be found of the greatestservice ; but to arrive at certainty inthe diagnosis of these diseases re-

quires greater attention and studythan of those of the chest. Havingstated generally and particularly the

symptoms of hypertrophia, which wehave taken in part from the work be-fore us, but many of which we have

had frequent opportunities of observ-ing ourselves, we shall now proceed to

give some of the author’s cases, to il-

241

lustrate the different forms of hyper-tropliia, in the different cavities of theheart.

CASE.

Simple Hypertrophia of the left ven-tricle,—Apoplexy.

- MADELINE RlQUET, æt. 65, of a

strong constitution, but worn down bypoverty, was admitted on the llth ofMarch into the Hôpital Cochin. Shehad slight diarrhoea and colic, but wasvery much subject to frequent pains inthe head, vertigo, and stupor. Thepulse was strong and remarkably vi-brating ; the pulsations of the heartwere very strong, but not to be felt toa very great distance. The patient,however, did not complain of havinghad any palpitations before her entryinto the hospital. Blood-letting, bothlocal and general, was ordered.The patient began to recover under

this treatment, when one day she wassuddenly seized with an attack of apo-plexy and died.

’

Inspectio cadaveris.—The lungs werehealthy ; the heart was rather large ;the parietes of the let’t ventricle werean inch thick throughout, except to-wards the point of the heart ; its cavitywas in the natural state, the carnsecolumnæ were very large. The rightside of the heart presented nothingparticular, nor did the left auricle, thevalves, or the large vessels. All thevessels of the brain were gorged withblood. We observed some coagula inthe line which separates the tuberannulare from the medulia oblongata :these clots or coagilla extended fromboth sides into the fourth ventricle,which they filied, and penetrated eveninto the substance of the cerebellum.The other ventricles were full of a

bloody serum.The abdominal viscera presented

nothing remarkable.-p. 295.CASE.

Siniple Hypertrophia of the right ven-tricle,—Simple dilatation of the leftventricle.

HUBERT, setat. 64, had experienced,from the age of forty-five, when hermenses stopped, palpitations, sense oisuffocation, and great anxiety. These

symptoms were relieved for a time bythe application of leeches. On hei

admission into the hospital, the patient; was very weak, the pulse scarcelyperceptible, whilst the pulsations ofthe heart were strong and quick, andmight be felt or even seen in a greatextent of the chest; the skin was paleand livid, the countenance fallen, thepatient complained of a general cold-ness, and the extremities were swol-len. The patient was quite unable toremain in the horizontal position. Per-cussion of the chest gave a dull sound.The respiration became more and moreimpeded, and intermpted by frequentsiglis ; on the slightest exercise a

sense of stiffocation came on. Infour days after her admission the pa-tient died, without having had anyfresh symptom which could lead to anexplanation of the cause of her suddendeath.

Inspectio cadaveris.—The respira-tory organs were in the natural state.The pericardium was large, and dis-tended by a pint of a limpid serum.The heart was of a good size, and pre-sented nothing remarkable but a dila-tation of the left auricle, without itsparietes being at all changed, aud athickening of the parietes of the rightventricle, sufficiently large to renderthem equal to those of the left ventri-cle, without any alteration in the sizeof the cavity. The hypertrophia wasrather equal and uniform in the wholeof the parietes of this ventricle. Theleft ventricle was more thin and softthan in the natural state. The valvesof the heart and the large vesselswere healthy.—p. 317.

CASE.

Pulsations of the heart very similar tothe bloitys of a hummer,—paralysis ofthe left side with stiffiness of the leftarm,—hypertrophia with slight dila-tation of the left ventrir.le,-aruchni-tis,—softening of the right hemisphereof the brain.

JEANNE BOSSUERT, ætat. 76, servant,of tall stature, thin, pale, and ner-vous, was brought to the HôpitalCochin, on the 12th of June, 1822.The persons who brought her couldgive no other information respectingher, than that she had suddenly lost

all recollection about a fortnight ago ;that the intellectual faculties returned

in part, but paralysis of the left side

242

had remained ever since. The follow-ing are the symptoms which the pa-tient presented on her admission.Head inclined to the right side, mouthturned in the same direction ; pupilsfixed, countenance expressing a sortof stupid gaze ; paralysis of the leftextremities ; cries, agitation, disposi-tion to talk, low delirium. In all the

arteries, but especially the carotids,there is a strong pulsation, and thepulse is rather quick. The pulsationsof the heart raise the clothes of the pa-tient ; they are strong, distinct, andquickly heave off the hand when ap-plied to the prsecordia. With the ste-thoscope they nearly resemble blowswith a hammer, and give a rather clearsound.Diagnosis Hypertrophia of the

heart, cerebral inflammation. Suchsevere maladies, joined to the very ad-vanced age of the subject, left no hopeof amelioration, and in five days thepatient died.

Inspectio cadaveris, thirty hours afterdeath.-Both lungs crepitate freely,adhesions of the right. The pericar-dium is injected, and the heart verylarge. The right ventricle surround-ed with a great quantity of fat, withthis exception, in the natural state. Itwas empty, as well as the correspond-ing auricle, whose carneae columnse arevery strong. The left ventricle affect-ed with hypertrophy. Its parietes,at the base, are about eleven lines inthickness, the partition between theventricles seven. The parietes of theleft auricle thickened. The tissue ofthe ventricles red and firm. The co

ronary arteries formed a kind of reliefon the surface of the heart, their pa-rietes hard and ossified in all their ex-tent. Yellow points in all the valvesof the heart, the semilunar valves, inparticular, covered with osseous or cal-careptts deposits. The origin of theaorta dilated, through its whole extent;unequal on the internal surface, linedwith yellow earthy flaques, like theshell of an egg.There was a great quantity of serum

in the base of the cranium, and theventricles; softening of the posteriorlobe of the right hemisphere, and in-flammation of the arachnoid.-p. 300.We have not space for any more

cases, but must speak of the ge-

neral result of these cases, and thetreatment which they require. Hy-pertrophia, in itself, is rarely dan-

gerous, and perhaps never mortal ;but its influence on the several organs,particulady on the brain and Itingsare of a very severe, and frequentlyfatal kind. The influence which the

left ventricle has on the circulation of

the brain, is at present well known toall, and therefore it is not at all sur.

prising that hypertrophia of this ca.vity should predispose to affections ofthis organ. In most cases of hyper.trophia of the left ventricle, the pa-tient is carried off by an attack ofapoplexy, and it is a singular fact,’that those illustrious physicians, Maa.

PIGHI, CABANIS, and RAMAZZINI, whodied of apoplexy, had hypei-tropliia ofthe left ventricle. In hypertrophia ofthe right ventricle, the lungs suffer—just as the brain, when the left is af-

fected with this complaint. The eoiirs6which this complaint takes varies verymuch, according to the causes which

produce it, the state of the patieptythe means which are taken to remove

them, &c.

The causes which produce this com-plaint may be divided into p1’eclispo.sing and exciting. The first include-

the predisposition of the patient; forindividuals of a plethorie sanguineoustemperaniont are very much predis=posed to this disease. All affections ofthe respiratory organs, whether acuteor chronic ; pneumonia, tubercles, hy-drothorax ; all those, indeed, which are

capable of opposing an impedimenttothe intermediate circulation betweenthat of the right and left cavities; in-

durations of the -valves of the aorta;

243

and all the eomplaints which diminishthe capacity of the chest also pre-

dispose to it. The predisposing causes

may, then, be properly divided into

hereditary, and those which are not

hereditary.The exciting causes may be divided

into moral and physical. The influence

Qf the passions on the heart and circu-lation is very powerful; and there arefew who have not felt, in their ownpersons, the effects of hope and fear inthe action of the heart. The extremes

of hope and fear not unfrequentlycause sudden death; and, although inthese cases the seat of mischief is ge-

nerally found in the brain, it is more

than probable that the cause of themischief, in many cases, originated inthe heart, either from a momentaryderangement of its function, or or-

ganic disease in the organ. The facts

on this subject, however, are not suffi-

ciently numerous to enable us to speakwith certainty. The physical causesconsist of all violent exercises and

efforts, thereby increasing to an un-natural degree the action of the heart.These are the causes which have an

immediate or direct influence on the

heart, but there are others which

have a mediate or indirect influence,as through the stomach or other partsof the body ; and, on this account, the

patient should take great care to avoid

every kind of food which deranges thestomach, or those causes which he

knows will disorder his health. Per.

sons with deformed chests or spines,and women at the time of the sup-

pression of the menses, are predis-posed to affections of the heart, andtherefore should be;particularin avoid-

ing those causes which are likely toproduce them.We have dwelt at length on the

causes of this complaint, because, if

these are distinctly stated and under-stood, all persons endowed with com-mon sense and a little self-denial, whoare predisposed to affections of theheart, may prolong, to a considerableextent, their own existence, and savethemselves from a premature grave.Let those who think that it is wrongfor the public to possess informationon professional subjects, reflect for aninstant, on the mass of human miserythat might be prevented, if medicalknowledge were more generally dif-fused. A writer in the Westminster

Review (No. III.) has stated in a veryable article on the " Use of the Dead to

the Living," * some of the advantageswhich would result from the diffusion

of medical knowledge among the

people, but has overlooked the one

that we have just mentioned. The

treatment found most successful in hy-pertrophia, where it is unconnected

with any other disease, is blood-letting.We will give M. BERTiN’S observationon the treatment of this disease, andconclude with a few remarks on the

modifications with which it must be

adopted.Treatment of Hypertrophia of

the Heart.It is evident that where hypertro-

phia is merely an effect of some otherdisease, all our therapeutic measures

* This article has been just reprintedin the form of a pamphlet (Is.), underthe title of "Bondy SNATCHING, " andwe recommend it to the attentive pe-rusal, not only of all professional men,but of all those who take any interestin the advancement of science genfi-rally.

244

must be directed towards the cause onwhich it depends. tt is equally clear,that, in every case, we must begin byremoving all known causes of this com-plaint. As for the agents that shouldbe employed against hypertrophia it-self, they ought almost exclusively toconsist of an antiphlogistic kind. Havewe not proved, indeed, that hypertro-phia of the heart necessarily commu-nicates to the sanguineous system avety strong impetus, and frequentlyterminates by active haemorrhages ?Consequently, the sedative mode oftreatment, and the employment ofleeches, naturally present themselvesas the only means really fit to oppose

-

this disease; we have stated our viewsso often throughout the work, thatwe will merely add that it should becarried to greater lengths than hasbeen done by VALSALVA and ALBER-TINI. It has been shown by severalcases, that hypertrophia has been

- cured by it when in the first or secondstage.—P. 366.

We firmly believe that the antiphlo-gistic plan will be found the only snc-cessful treatment in hypertrophia ;but we have not found it answer when

carried to extremes, as is so fre-

quently done. Moderate and fre-

quent blood-lettings appear to re-

lieve better than when a large quan-tity is taken ata time ; and, in general,a very low diet does not agree with

patients as well as one which is slightlynutritious, but not at all stimulating.We have seen both these plans of

treatment adopted in cases which

presented no difference that we coulddetect in any respect, and have ar-

rived at the conclusion we have men-tioned, from the different effects whichwere produced. The use of the digi.talis and colchicum will be found

valuable assistants. In no complaint,scarcely, is the power ofself-denial of

- so much importance as in this ; for ifthe patient has been well off in the

world, he will be required to relinquishseveral of the comforts of life to which

he has been accustomed, and withoutwhich abstinence all treatment wilt be

unavailing.The work before us treats of most

of the diseases of the heart, but wehave confined ourselves to one only,for the good old reason, that one thingdone well is worth twenty done badly.We are far, however, from wishingto say that the article is a completetreatise on hypertrophia, but it con.

tains a summary view of most of the

circumstances connected with this

complaint. We regret that we havenot illustrated our observations bymore cases, space would not permit,and we must, therefore, refer our

readers to Dr. FonBEs’s work, whichwe so lately reviewed, to CORVISART’Sand LAENNEC’S, or to the work beforeus, the merit of which principally con.sists in the numerous valuable cases

which it contains.

FOREIGN DEPARTMENT.

ANALYSIS OF FOREIGN MEDICAL JOUR-NALS.

REVUE MEDICALE-SEPTEMBER.

The principal articles in this Num-ber are, an account of an amputationat the hip joint by Professor DELPECH,and some observations on a few fatal

cases of dyspncea, without any organicchange, by M. ANDRAL, jun.

Amputation at the Hip Joint siicre.5s-,f’ultp performed by Professor DEL-PECH, at the Hotel Dieu—SaintElois.

The subject of the following ope-

ration was admitted into onr hospital