condition of the heart, but from fatty deposit on the borders of the lungs, and from the general deposit which is burdensome to the muscles, particularly to those concerned in inspiration, which naturally tire and eventually weaken from lifting eighteen to twenty times every minute the several pounds of fat deposited on and in the parietes of the thorax. Another factor partially concerned in the causing of this shortness of breath is probably a lithæmic condition resulting from overeating, drinking, and lack of exercise.

I would not have it understood that I do not realize the gravity of the fatty heart as a cause of serious functional, and finally organic, disturbances. Very fat men and women are not long lived, and frequently die of fatty degeneration of the heart, resulting not directly from the fatty deposit which has been carried so long, but from the changes which the sedentary habits of the obese generate in the arteries and capillaries of the body. Obesity, too, diminishes the natural resisting power which the healthy body possesses against disease influences. Let a fat man be stricken with pneumonia or typhoid fever, the chances of recovery are much less than in a man carrying the normal amount of adipose tissue.

By comparing the above case with those of fatty degeneration, which I shall now relate, the difference between the two becomes apparent. CASE 1. The first case which I shall cite was a hospital patient. Mr. A. T., age 50, occupation tailor, has taken but little exercise, and has been a free drinker of lager beer through life. His food has been largely farinaceous, his circumstances not permitting him to indulge in meat. Height 5 feet 8 inches. Weight 250 lbs. shortly before date of examination. Family history good. Complained on admission of great shortness of breath on exertion, swelling of the feet and legs, loss of appetite, constipation, sleepless nights, being unable to rest in the recumbent posture. Has had occasional attacks of vertigo, with loss of consciousness and falling, (pseudo apoplexy).

PHYSICAL EXAMINATION.-Evidences of general anasarca, and of a dropsical condition of the peritoneal, pleural and pericardial cavities; and crepitant and subcrepitant rales at the base of the lungs demonstrated the existence of oedema of these organs. The vital capacity of the lungs was but 50 cubic inches, while that of health in a man of his stature should be 229. There was a well marked arcus senilis, the degeneration of the cornea being not of the calcareous form so common in apparently hale old men and women, but of the yellowish fatty form, which latter is a common accompaniment of

fatty degeneration of the heart. The pulse was rapid, irregular, compressible and scarcely perceptible, the heart sounds feeble, the valvular element of the first sound predominating, making the first sound to resemble the second, but no murmur was heard at any of the orifices. The patient grew weaker, the dyspnoea and dropsy increased, the urine became highly albuminous, and one day while straining at stool he fell forward and died. Previous to death he suffered from the condition known as Cheyne-Stokes's respiration, which consists in the occurrence of a series of inspirations increasing to a maximum, and then declining in force and length, until the breathing ceases and the patient is apparently dead, when there is a feeble inspiration followed by a more forcible one, which marks the commencement of a new series of ascending and descending inspirations.

At the autopsy the lungs were found to be oedematous, the heart walls thickened, and the cavities all distended with blood. Atheromatous patches were found at the root of the aorta, the process extending to and involving the coronary arteries, the orifices of which were narrowed; the aortic valve cusps were thickened from a development of fibrous tissue. The same state of chronic valvulitis involved the mitral valve, but in neither valve was the deformity so great as to impair its function. There was a deposit of fat beneath the pericardium at the base of the right ventricle, and the walls of the heart were pale and flabby, the finger being readily thrust through the thickened walls of the left ventricle. The microscope showed those walls to be in a state of extensive fatty degeneration with infiltration of fat between the muscular fibers.

The liver was enlarged, fatty, and presented the peculiar mottled appearance on section which characterizes the condition known as nutmeg liver."

The kidneys were found to have undergone fibroid changes, but did not appear to be contracted; on the contrary, owing to intense venous engorgement, they were both larger than normal.

The walls of the stomach and intestinal canal were swollen and hyperemic.

CASE II.—Mr. A. L., age 56, an Englishman, formerly a member of the British Parliament, was sent to me by Dr. Robinson, of Staten Island, N. Y., for examination.

Patient was 4 feet 5 inches in height, and weighed 190 pounds. Had always been a free liver. Complained at his visit of great dyspnoea on exertion; could not walk across the room without getting out of

breath. Great nervousness in walking, fear of falling into any opening he may be passing so that he gives it as wide a berth as possible, though he feels that his action is absurd. Easily annoyed at trifles. Exceedingly irritable. Bowels regular, appetite moderately good, complains of "bloating of the stomach and bowels with gas"-" is full of wind." His main troubles are the shortness of breath and the nervous fear and unnatural irritability.

PHYSICAL EXAMINATION showed a well-marked fatty arcussenilis, tortuous temporal arteries, and small dilated blood-vessels on the cheeks, nose and ears. The feet were slightly oedematous. The heart hypertrophied, and the sounds indistinct; the muscular element of the first sound being entirely lacking. There were no cardiac murmurs. The lungs were oedematous at the base, and the urine slightly albuminous. Pulse feeble and irregular. A diagnosis of fatty degeneration of the heart resulting from artero-capillary fibrosis brought about by lithæmia was given. A rational diet with rest was ordered, and Phosphorus prescribed. Under treatment the patient improved, but one day after visiting me, he met on the Staten Island ferry-boat an old school physician, who, ignorant of the patient's real condition, advised exercise; telling him he was too fat; he must walk it off. So impressed was our patient. with this advice, that on reaching the landing he dismissed his carriage and walked to his home, a distance of half a mile. On reaching his house he ascended the stairs when he fell unconscious to the floor. In response to a telegram, I visited him and found him in a

From this con

state of coma, with one side of the body paralyzed. dition he did not rally, and died the next day. Although his heart was weak and fatty, there was enough strength left during extra impulse to rupture an atheromatous vessel in the brain. An autopsy was not permitted.

CASE III.-Mr. D. R., age 57, consulted me five years ago for some trifling gastric disturbance from which he readily recovered. At his first visit I was struck with the remarkably tortuous and prominent condition of the temporal arteries. I learned the history of his life and made a careful physical examination. The fact of my having an opportunity of watching this patient since the date of my first examination, and noting changes which I knew would be inevitable, renders the case one of great interest to me.

The following is from my record of his examination made five years ago: Family history good. As a child the patient enjoyed good health, and aside from the ordinary diseases of childhood had

no sickness until he was 33 years of age, when he suffered from a bilious attack which lasted for five months. During this time he was jaundiced, his urine was dark and his stools clay colored; had occasional attacks of "biliousness" during the six years subsequent to this illness; had measles at forty, and since then has had no serious liver disturbances, and remained in what he considered a superlative degree of health till he consulted me at the age of 57. Had always been possessed of remarkable mental and physical vitality. When others rode, he walked. When others tired from the mental work of the day, he worked far into the night. Commenced the study of law at 20, and at the age of 23 was admitted to the bar. ing his student days he wrote a law book which was published. This is mentioned to show that even at that early age he was an indomitable brain worker. This he has kept up to the present time and is now one of the leading lawyers of New York City.

Dur

Habits of life: Says he has always been temperate. "Never was intoxicated in his life," although for some years during his early life he was in the habit of drinking a bottle of ale at his dinner; occasionally this was varied with claret or champagne; rarely took brandy or whiskey. Of late years has been very moderate in the use of wines, etc. It has been his custom since he became a man to smoke two or three cigars a day. Has always eaten meat twice a day. Of late years the quantity of urine has been large, the patient always rising once or twice during the night to urinate.

PHYSICAL EXAMINATION: Height, 5 feet, 8 inches; vital capacity, 220 cubic inches (nearly normal); weight, 135 pounds.

Conformation of thorax perfect, cardiac impulse perceptible on inspection. Temporal arteries remarkably prominent, tortuous and full, and after exertion can be seen to pulsate. Dilated and atheromatous vessels visible on the cheeks, lobes of the ears and nose. Lungs, liver and spleen normal.

To me the interest of the case naturally concentrated on the result of my examination of the heart. The left ventricle was hypertrophied, the apex being found in the sixth intercostal space in the nipple line, with a normal area of lateral cardiac dullness. The impulse was heaving and very pronounced. The sounds pure but much intensified.

The pulse at the wrist was full, strong, the artery tense and resisting; and could be rolled beneath the finger without compressing it in the least.

Urine large in quantity, pale, specific gravity 1010, free from albumen and other abnormal ingredients.

The physical signs of the heart and blood-vessels demonstrated conclusively the existence of left-sided hypertrophy, with fibroid and atheromatous changes in the walls of the arteries and capillaries throughout the body; for the changes in the temporal and radial arteries and in the small superficial vessels in the cheeks, ears and nose, were positive evidence of similar changes in other portions of the body hidden from inspection.

It is evident with thickened walls of the left heart and weakened blood-vessels, that the danger at this time was apoplexy from the rupture of a cerebral vessel. In this case, the danger was peculiarly great, for the patient's delight in summer was in climbing mountains and in other hazardous feats of strength.

He was cautioned to avoid extra and sudden exertion, and advised to keep his passions under control, and to abstain religiously from alcoholic beverages and to moderate his diet, particularly in regard to meat.

year

Five years have now passed, during which time the patient has enjoyed good health, scarcely missing a day from business. But for the last he has noticed a diminution of strength and failing appetite, with occasional attacks of gastro-intestinal catarrh and vertigo with musca volitantes. The quantity of urine is but about one-half of that of five years ago. Recently I made another careful physical examination. The temporal arteries, still tortuous, are no longer full; in fact, at times they are scarcely perceptible on inspection. The pulse at the wrist is no longer strong and incompressible, and the artery is not well filled with blood. The heart shows the same physical signs as regards size, but the impulse is feeble and the sounds have lost their booming character. The first is lacking in the muscular element, and the second sounds are flapping in character. The vital capacity of the lungs has fallen from 220—which it was five years ago-to 175 cubic inches. The number of atheromatous vessels on the cheeks, ears and nose has increased and they are more prominent. There is no degeneration of the upper border of the cornea, and possibly may never be, for not all cases of fatty degeneration of the heart have this arcus senilis.

From the change in his condition as regards vitality and strength, and from the changes (deteriorating changes) in the condition of the circulation, and from the diminished secretion of urine, I am satisfied that degenerative changes are taking place in the walls of the heart.

The danger is not now of apoplexy from the rupture of a cerebral vessel, although such an accident is possible, as occurred in Case II, but lies in sudden stoppage of the heart from over distension,