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either as the effect of chilling of the surface of the body,' or from sudden emotion or over-physical exertion or strain.

It emains now to return to our aphorisms and demonstrate the relationship existing between them and the etiology of fatty degeneration of the heart.

Each of the three cases of fatty degeneration of the heart, narrated above, has been characterized by cardiac hypertrophy, tortuous temporal arteries and dilated superficial blood-vessels and capillaries; in other words, general artero-capillary fibrosis with compensating enlargement of the left ventricle of the heart; general, for as has been before stated, if the vessels enumerated have undergone fibroid or atheromatous changes it is conclusive evidence that similar changes have taken place in other portions of the body; in fact in all parts; greater, perhaps, in some than in others, the vessels of the heart, however, rarely escaping. A tortuous or atheromatous blood-vessel is a damaged blood-vessel. Its carrying power is lessened. If this condition exists in the coronary arteries and their branches, the heart walls are not properly supplied with nutriment. If the fibrosis is general a greater amount of pumping force is required on the part of the heart to propel the blood, and, to compensate, new muscular fibers are formed, and the heart becomes larger and stronger; and for a series of years compensation will be apparently perfect. But if its own vessels are atheromatous, and it is obliged to overcome by extra labor obstructions in the systemic vessels—in other words, if the heart is poorly fed and at the same time overtaxed—eventually it weakens, and finally dies; the death process commencing, perhaps, by the gradual transformation of the protoplasm of a single cell into fat; the process extending till large areas of the heart-walls have become degenerated.

What is the cause of this fibroid or atheromatous change in the walls of the blood-vessels and capillaries ? Atheroma is a term applied to the various alterations in the walls of vessels, resulting from chronic inflammation. The process is slow in its development and is not recognizable in its earliest stages. As concerns the etiology, it is now established that there are two factors which give rise to the inflammation : overstrain of the vessel and the presence in excess of lithic acid in the blood. In the former case, where it arises from overstrain alone, the process may be a local one; and it is generally found in the ascending and transverse portions of the arch of the

During a very cold spell of weather lasting about forty-eight hours in the winter of 1884, four patients suffering from fatty degeneration of the heart, who had been under my personal observation, died from this cause.

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aorta, frequently resulting in aortic aneurism. If arising from the latter cause-lithæmia--the process is a general one. The two face tors, however, are usually combined in the etiology of artero-capillary fibrosis.

The cause of overstrain of the vessels is increased heart's action, This may arise from violent and prolonged muscular exertion, from alcoholic and other stimulants, and from over-eating. The cause of the excess of lithic acid in the blood is a functional disturbance of the liver, which interferes with proper oxidation of waste nitrogenous material in the blood, instead of the soluble substance known as urea, which is readily eliminated, being formed, uric or lithic acid is generated. This is comparatively insoluble, and is laryely retained. The causes of this functional disturbance of the liver are the habitual use of the various forms of alcoholic beverages, excess in eating, particularly of meat, and sedentary habits. Hereditary influences, it is claimed, are frequently a powerful factor. I think hereditary habits of life a more potent factor in the etiology. A leading symptom in all cases of cardiac degeneration is debility, with gastricdisturbance, &c. This is readily accounted for. If the action of the heart is feeble, the various organs of the body are poorly nourished, and in a state of venous engorgement, consequently their functions are impaired. Another prominent symptom is shortness of breath on exertion, and in the later stages of the disease, dyspnoea at all times. This arises from pulmonary engorgement, which diminishes the capacity of the air cells, combined with weakness of the inspiratory muscles. The overloading of the venous radicles and the diminished power of the absorbents, together with a deteriorated condition of the walls of the vessels, accounts for the dropsy, which usually commences in the feet, although in some cases, the ædema commences at the base of the lungs. Frequently the walls of the right ventricle are in a fair condition of health, while an extensive degenerative process exists in the walls of the left. Under such circumstances the pulmonary engorgement will be intense; the right heart being powerful enough to distend the pulmonary arteries, capillaries and veins, while the left is too feeble to send the blood onward into the aorta. It is in such cases that the cedema is first found in the lungs.

The albuminuria, which is always a symptom of advanced cases, arises from renal engorgement. I shall be touching on delicate and debatable ground, if I attempt to state in accordance with my own views, how renal engorgement can produce albuminuria. Kuss ad

vances the theory that albumen escapes from the blood with the urine, which percolates the walls of the glomeruli, and that the tubular epithelia are instrumental in returning it to the blood in the venous plexus. If this be true, it can readily be seen that with damaged tubular epithelia and a condition approaching to blood stasis in the venous plexus, the albumen cannot be absorbed, and consequently passes onward with the urine.

The autopsy in Case II. demonstrated the existence of changes in the liver. In advanced cases this “nutmeg liver” is a constant condition, and arises from long continued hepatic engorgement, the result of weakened propelling power on the part of the heart. The right ventricle cannot empty itself; the right auricle, the ascending vena cava and all of the vessels, whose contents finally empty into them, are distended. This will account for the liver changes, the succulent condition of the mucous membrane lining the stomach and intestinal canal, the peritoneal dropsy, and the renal engorgement. The various nervous symptoms are accounted for in the same way. The descending vena cava with all of the vessels which ultimately empty their blood into it are distended, and of course brain hyperæmia will result with its numerous and varied symptoms.

Aside from the causes of fatty degeneration of the heart, which have been already given, may be mentioned valvular disease, particularly aortic insufficiency. In this latter condition the heart is not properly nourished and is at the same time terribly over-taxed.

On the closure of the aortic valve, the blood in the aorta recoils and eddies in the sinuses of Valsalva and is forced into the open mouths of the coronary arteries, the heart being fed while its walls are relaxed. If the valve is insufficient the blood, or a portion of it, rushes back into the ventricle and the coronary arteries are not well filled, consequently the heart suffers from want of proper blood supply and finally degenerates, although a common cause of death in aortic insufficiency is cerebral hæmorrhage from the rupture of an atheromatous vessel.

It should be mentioned here, that in cases of fatty degeneration of the heart the cardiac changes are often but a part of a general process, the degenerative changes being found in many, sometimes in all, of the organs and tissues of the body.

There is a form of fatty degeneration of the heart and of the other organs and tissues, which accompanies typhoid fever and other prolonged febrile conditions ; eventually, however, the fat is absorbed

; and new and healthy cells take the place of those destroyed.

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So fatty metamorphosis of tissue is an accompaniment of pulmonary phthisis and other wasting diseases.

It is well known that the changes in artero-capillary fibrosis extend to and involve the blood-vessels of the kidneys, and that as a result there is hyperplasia of fibroid tissue cells with subsequent contraction and impairment of the functions of the kidney [chronic interstitial nephritis—chronic Bright's disease]. It will be seen that this condition is therefore a constant accompaniment of fatty degeneration of the heart arising from fibroid changes in the walls of the arteries.

PROGNOSIS AND TREATMENT.-In all cases of fatty degeneration of the heart, resulting from the changes described above, the prognosis is bad. If detected in the earlier stages, by a proper course of life the progress of the disease may sometimes be arrested and the life of the patient lengthened, but in the majority of cases the progress is steadily downward, the patient finally dying by the slow drowning process characteristic of general dropsy, or the heart may suddenly stop during an extra and unusual effort, such as rising suddenly from the recumbent posture, straining at stool, during a violent paroxysm of coughing or vomiting, while running to catch a train, or during a fit of passion. Under such circumstances the heart stops during diastole, with its cavities filled with blood, being unable to contract, the over-distention of the cavities probably paralyzing its weakened walls. In some cases, as in Case II, the weak heart is powerful enough to rupture an atheromatous vessel in the brain and the patient dies of apoplexy.

A tortuous temporal artery is always a suspicious physical sign, especially if accompanied by atheromatous changes in the walls of superficial vessels on the face and should prompt the physician to make a thorough physical examination and to inquire into the habits of the patient; all abuses should be corrected and the life, so far as physical and mental exertion is concerned, modified. Plenty of time, at least eight hours out of the twenty-four, should be spent in bed, and the patient should have recreation and rest during the day.

If there are evidences of a weak heart he should be cautioned against sudden or violent effort, against any kind of fatiguing exercise ; his diet should be nutritious and not over-taxing to either the stomach or liver. Symptoms, as they present themselves, should of course be treated with the properly selected homeophathic remedy, bearing in mind the fact that Phosphorus and Arsenicum are our main and most reliable drugs in the treatment of the disease.

BOROGLYCERIDE IN THE TREATMENT OF OTITIS MEDIA PURULENTA.

By E. H. LINNELL, M. D., NORWICH, Conn. My attention was first drawn to boroglyceride in the treatment of suppurative middle-ear diseases by an article by Dr. Richard C. Brandeis, of New York, published in Knapp's Archives in March, 1884. In common with this writer, I had used boracic acid with much satisfaction, but had sometimes been annoyed by the fact of its becoming caked in the meatus and tympanum, requiring prolonged syringing for its removal. This proceeding I found objectionable, interfering to some extent with the process of healing, while the hardened mass was an element of danger if not removed, increasing the liability to mastoid and septic complications. Dr. Brandies recommended boroglyceride as a substitute for the boracic acid powder, claiming that it was equally efficient in arresting the discharge, more efficient as a disinfecting agent and free from the above-mentioned disadvantages of the latter remedy. I therefore determined to give it a trial in my practice. I have seen almost no mention of it, other than the article above referred to, and the following cases are submitted as a contribution to our knowledge of this drug, with the hope that more extended use will lead to more accurate discrimination of the class of cases in which it is applicable. I regret that many of my cases are rendered much less valuable by the fact that internal remedies were employed in connection with the local treatment and thus it is only by comparison with cases treated with other local measures and under the same limitations that we can estimate the comparative merits of boroglyceride.

I. CASE 1st. was that of a delicate boy about twelve years old who had had disease of the left ear since infancy, a sequel of scarlet-fever. The left membrane was almost entirely destroyed and the tympanic cavity was nearly filled with granulations springing from the vicinity of the malleo-incudal articulation. The child was nervous and sensitive and the parents were unwilling to have the granulations removed by surgical means as was repeatedly advised. He had been under treatment two or three years and almost all the materia medica had been exhausted and a variety of mild local remedies had been used. By these means the disease was kept in check, sometimes getting better and as often relapsing, until both parents and doctor were well-nigh discouraged. Boroglyceride was more satisfactory in its effects than any previously used remedy. A 50 per cent. solution in glycerine was used, sometimes alone, sometimes diluted one-half with alcohol. Under this treatment the improvement was more permanent

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