with a regulated diet, arsenic, and iron, was sufficient to completely restore the heart to its normal condition.

Rest, in the majority of the cases of heart-failure in its early stages, is nothing more nor less than a specific, notwithstanding Oertel's opinion that exercise, especially climbing, forms an important element in the treatment, as he considers that severe exercise stimulates the heart-muscle and favors the restoration of hypertrophy. Osler considers his suggestion of a reduction in the amount of liquids ingested as a happy method of reducing the volume of blood to be circulated by the heart.

Digitalis becomes a true heart-food in these cases; by its exhibition we render the irregular, wavy, feeble, and frequent contractions regular, slower, and stronger, at the same time the overloaded, embarrassed circulation is markedly relieved. The medicinal substitutes for digitalis were considered in the last chapter.

In the final asystolism which will eventually arise, our sheet-anchor-digitalis-seems to have lost its most desired action, and we will be obliged to resort to alcoholic stimulation, together with hypodermic medication of rapid diffusible stimulants, as ether, carbonate of ammonia, or brandy.

ATROPHY OF THE HEART.

Cardiac atrophy occurs either congenitally or as an acquired affection; this condition was formerly termed phthisis of the heart. The heart is most usually decreased both in size and weight; in many of the degenerations of the heart-muscle there is localized atrophy of the fibres.

Congenital atrophy is almost entirely confined to the female sex, and is associated with anomalies or defective development of the arteries and the sexual organs.

Virchow has called attention to this condition of cardiac and circulatory atrophy in cases of chlorosis. Gowers† mentions a case seen by Allen Burns, in which an adult presented a heart corresponding in size to that of a child of six or seven years.

* Ziem. Handbuch der Allgemeine Therapie, Bd. iv.; Osler, American System of Med., p. 635.

† Osler, ibid.

Paul describes an atrophic sclerotic myocarditis which he states may occur during intra-uterine life. Phthisis seems to cause a marked and persistent atrophy of the heart. Quain has shown that in 54.4 per cent. cases of phthisis the heart is below the normal size in regard to weight; typhoid fever, marasmus, and diseases of a subacute character may lead to wasting of the heart. Locally, pressure by pericardial adhesions, by mediastinal growths or deformities, and interference with the circulation in the coronary arteries may cause atrophy.

Post-mortem examination in simple atrophy presents a general diminution in size and weight; in local atrophy one or more of the cavities or portions of the walls of the heart may be found below the ordinary standard. The atrophied heart may be normal in color, or it may be very pale; it has been noted of a deep reddish-brown. The pericardium presents a somewhat peculiar appearance, which Laennec has aptly styled a "withered-apple" aspect; it is due to the fact that the pericardium, not shrinking with the heart, presents a puckered, opaque, and oedematous appearance; the coronary arteries become prominent and tortuous for the same reasons. An important fact to remember in making these post-mortem examinations is that the acquired variety of atrophy alone presents the appearances just described; they are never seen in the congenital forms.

Symptoms.-These are not at all diagnostic; they are simply those that of necessity arise from diminished power of the heart; the sounds are feeble, the pulse is weak, and anæmia or chlorosis is generally present.

Diagnosis.-Atrophy of the heart is rarely diagnosed during the patient's life.

The treatment consists in combating the primary disease which has caused the atrophy.

CHAPTER IX.

CARDIAC NEUROSES.

FUNCTIONAL disorders of the heart's action, irrespective of inflammation or structural lesion of any kind whatever, constitute a frequent and an important class of cardiac diseases in

the growing child; they are usually paroxysmal in their manifestation, and may or may not be accompanied by pain.

Palpitation.-A violent or tumultuous action of the heart is a personal experience through which most of us have passed, excited by some intense mental emotion; we, however, have observed persons in whom the cardiac equilibrium could not be disarranged no matter what the provocation, either mental or physical. In these cases it has seemed to us that the heart possessed a peculiar organization, which maintained its rhythm under all and every condition; the pneumogastrics and the sympathetic ganglia in these individuals appear to be perfectly phlegmatic or callous, if we may so apply the term. Some children are undoubtedly endowed with pneumogastric and sympathetic nerves that are slow to carry impulses to the circulatory apparatus, while others have neurotic fibres which are always alert and active, responding but too readily to the slightest irritation. Da Costa has most happily expressed these thoughts in a terse manner by the term "irritable heart," which is peculiarly apt. This condition is met with under many diverse circumstances and conditions, and presents all degrees of severity, from the mildest disorder, often described by the patient as a "fluttering," to a most severe functional disorder accompanied by a fear of impending death.

Irritable heart in the young is generally a concomitant of neurasthenia, over-exertion, sexual excesses, and the abuse of certain articles, as tobacco, tea, coffee, or alcohol,-the so-called toxic cases. It is also seen in some anæmic and leukæmic cases and in malarial poisoning. The immediate cause is, of course, an undue excitability of the muscular wall of the heart, in all probability brought about by derangements in the cardiac ganglia, the vagus, and in the filaments of the ganglia of the great sympathetic, which are distributed to the heart. This condition is what is described by the parents as a nervous and excitable temperament in their child; Thomas Shapter considers early age a direct predisposing factor to this condition.

The irritable heart from over-exertion is met with in young lads who are gymnasts, runners, jumpers, etc.; the disorder is here sometimes styled heart-shock when due to a single great

and continued effort; in all probability, as Osler* states, there has been an acute dilatation caused by the sudden strain, and the heart possibly never returns to its normal condition. The other form induced by continued over-exertion is the condition to which Da Costa first called attention as met with in young soldiers during the war of the Rebellion, and now frequently seen in civil life in young persons exposed to occupations requiring strength beyond their years; some authorities have styled this form of palpitation as idiopathic dilated hypertrophy; Osler is of the opinion that syphilis may enter into its causation.

A fruitful source of palpitation or irritable heart in young boys is masturbation, or in older individuals excessive coitus; in many instances in which we have been consulted the cardiac symptoms speedily disappear, without other active treatment, when the youth was shown the moral and physical dangers of his habits.

Tobacco must often be considered when seeking the etiology of cases that desire our opinion.

James G., aged sixteen, presented himself at our service in the University Hospital; the boy worked in a cigar-manufactory, and stated that he habitually smoked eight to ten strong cigars a day, and desired our advice in regard to the condition of his heart. Examination showed a somewhat pale, anæmic boy, with an anxious expression, some dyspnoea, which he stated was greatly increased by exercise, marked palpitation, considerable cardiac distress or pain. The heart was acting at the rate of one hundred and eighty beats per minute, was very irregular, sometimes intermittent, but did not present any

Toronto Med. Soc, April 14, 1887.

The examination of one thousand workers in tobacco compared with a series of control experiments on animals resulted in finding among the workers dilatation of the pupils, cardiac neurosis, exaggerated tendon and vaso-motor reflexes, trembling hands, dyspnea. Headache, gastralgia, and nervous cough were also present. The respiratory organs were most frequently attacked after the nervous system. The same symptoms were produced by injecting one-fortieth to one-tenth drop of nicotine in rabbits, one-twentieth to one-third in dogs, and keeping them also in a tobacco-impregnated atmosphere. (Bull. Gén. de Thérap., July 15, 1887; Med. News, Oct. 8, 1887.)

evidences of increase in size either by dilatation or hypertrophy, -usually these cases present some slight enlargement. The patient was unable to assume the recumbent position but for a few minutes, was totally unable to lie upon the left side, for as soon as he assumed a left lateral decubitus a severe attack of angina would arise. This pain in many cases is very characteristic of the toxic action of tobacco upon the heart; we have notes of many cases in the young in which it was always present.

The pulse in irritable heart may be extremely irregular, varying from 75 or 80 to 150 or 200, depending much upon the patient's environment either before or during our examination; position will exert a decided influence upon the rate, usually slower when the patient is recumbent.

A peculiar flushing or lividity of the cutaneous surface, due to vaso-motor change or innervation, is sometimes noted.

Graves's disease and tachycardia, with pulsation at the rate of 180 to 200, are considered by Osler as forms of irritable heart.

Treatment. The removal of the cause is absolutely necessary to attain success; this, with perfect rest, preferably in the recumbent position, will often suffice to obtain a cure. In treating chronic tobacco-poisoning, in addition to the essential point of total abstinence, which, unfortunately, often cannot be obtained, Favarger* aptly advises that smoking be never indulged in on an empty stomach. Inasmuch as nicotine has been found in the perspiration and urine, he considers it not unreasonable that means to promote its elimination be used in treatment, such as packs, diuretics, and diaphoretics. Galvanism has been used by some authorities in cases of tobaccoheart with marked benefit; we have in a recent case obtained happy results from trinitrin, one one-hundredth-grain doses, increasing to full physiological tolerance, together with a regulated diet and absolute rest.

Palpitation, independent of the toxic causes, may often be relieved by bromide of potassium, or, in weak individuals, the bromide of sodium; strychnia is peculiarly efficacious in many

* Therap. Gaz., Oct. 15, 1887, p. 689.