صور الصفحة
PDF
النشر الإلكتروني

been carefully prepared. It is cut from the pelt or skin by a beautiful machine adverted to in the article FURRIERY, and shown in fig. 2;

Fig. 2.-Fur shearing machine.

after which it is sorted by the machine shown in fig. 3, described in the same article. When ready, the fur is bowed and imperfectly felted

Fig. 3.-Fur separating machine.

in the manner already described, and shaped the same as the body to which it is to be applied, but a little larger. The body is softened by immersing it in the boiler; after this the nap is applied and worked as in felting, until the required union is effected between the two bodies. A narrow strip of beaver is felted round the inside of the cap, to form the underside of the brim. During the felting, the fibres of fur become driven in between the fibres of the felt body, and firmly interlocked.

The felt thus covered is in the form of a cone, and must be brought to the cylindrical shape in which it is worn by means of a wooden block of the requisite form. This operation, which is called blocking, is performed by working it with the hand on the block to which it is tied. The hat is then combed and sheared; after which it is dyed in a bath composed of water, logwood, sulphate of iron, verdigris, and gall-nuts, in which the hat is boiled during some hours; it is then drained and dried. After this it is softened by steam, the crown is strengthened by placing in it a disc of scale-board, and linen is pasted over this. The nap is raised, and a uniform direction given to its fibres by means of warm irons and hair brushes. lining; when the hat is ready to be worn. The last processes are binding and through the hands of not fewer than twenty or twenty-five workmen A good beaver hat passes during the process of manufacture.

Plaited and Felt Hats.-The beaver hats, just described, although the best results of the hatter's art, are very little worn at the present day; their commercial importance is therefore small. of them has lessened. Originally the foundation, as well as the napping, In every way the use was made of beaver fur; then there was a substitution of fine wool

[blocks in formation]

and coarse fur for the foundation; then a mixture of cheek beaver and common beaver for the best fur, as a napping; and lastly, a combination of a very small portion of beaver with neutria, musquash, hare's fur, and wool. About the year 1830 it was estimated that a million beavers were annually killed to supply the hat-trade in Europe; but in 1860 it is believed that little more than one-twentieth of this quantity is thus used. The plaited hats, in which coarse and cheap fur are employed instead of costly beaver, are made nearly in the same way, and have been equally affected by change of fashion. The revival of the old felt hats, or the use of such hats by persons who would formerly have scorned to wear them, has given a great impetus to this particular branch of the manufacture. Here no fur is employed. Wool, of a greater or less degree of fineness, according to the price to be charged, is felted into a compact body; and this body is either blocked into the regular hat shape, or is made to assume one of the many varieties or slouch or wide-awake' forms. It may be mentioned here that in America felt hats are now made by machinery.

Silk Hats.-These have become by far the most important article in the manufacture, so far as concerns extent of production. Silk is wholly incapable of felting, and therefore cannot be applied to a hat in the same way as wool or fur. A silk hat consists of a non-felted body covered with a non-felted hood of silk plush. Willow, cane, chip, stiffened cambric, horsehair, mohair, and many other substances are employed for the body or foundation. The body is made by shaping round a block, and using a substance of extra thickness for the brim. A varnish cement is used to join the various parts; and a resinous stiffening composition is laid over the outer surface. To aid the adhesion of the silk plush to the body, the latter is coated with a peculiar varnish, which, being softened by a heated iron after the plush is laid on, causes the two to adhere closely. The fixing of the plush is the most difficult part of the manufacture. The silken fabric must not only be made to adhere in every part, but the seam or joining up the side of the hat must be rendered as imperceptible as possible. The plush is in the first instance sewn by women into the form of a hood or covering for the hat; but there is no sewing at the meeting-edges up the side; they are brought together, pressed down with a heated iron, and the silk shag brushed over the joint. Their junction can always be seen in a silk hat, however cleverly made. The large increase in the manufacture of silk hats within the last few years, has resulted chiefly from the use of a waterproofing composition previous to the application of the plush; the elastic gums, when dissolved in naphtha, impart a body or substance to the foundation, which enables the makers greatly to reduce the quantity of material employed in making it, thus at once cheapening the hat and making it more light and elastic. The same quantity will now work up into more than twice as many hat-bodies as were producible by it twenty years ago. Plush is largely made in England for covering silk hats; but the best, for the so-called 'Paris hats,' comes from France, whence nearly 200,000 lbs. of black silk plush are yearly imported for this purpose.

Cork Hats, &c.-The novelties introduced or proposed within the
last few years in the hat-manufacture are very numerous; but we can
only glance slightly at some of them. The lightest hats made are those
in which the foundation is of cork, cut into very thin sheets by a sort
of veneer-cutting machine; but though light, they are not yielding,
and not well suited to maintain their shape. One novelty in felt hats
consists in producing the shape by a kind of die and counter-die, one of
which forms the convex and the other the concave side; the dies are
heated by steam, and the combined heat and pressure force the felt to
assume the desired form. A somewhat similar method is that of
forming a hat in one piece without joining; the felt, cloth, or other
material, after being dressed with an adhesive solution, is stamped into
even receive a pattern or device on its surface, if the mould were
form between a heated mould and a heated plunger; the hat might
engraved or embossed; and a waterproofing solution might be applied
either before or after the stamping. One inventor proposes to employ
trough containing wool or hair; a revolving fan sucks the air out of
a former or core of perforated metal; this former rotates in front of a
the former, and draws the fibres from the trough until they are
cesses cause them to felt together into a hat-body. Some hats are
deposited in a layer on the perforated metal, where subsequent pro-
made with a complicated system of springs in the foundation, to facili-
tate the folding up of the hat into a flat form for placing under the
arm or on a seat. A contrivance having a similar object in view has
been introduced, consisting in cutting the body quite through, at the
lines intended for the creasing; the edges are then cemented by cover-
ing them with a thin strip of India-rubber, leaving the edges a little
way apart. A suggestion has been made for using palm-leaf, or the
Brazilian grass-plait, as the foundation for a hat; the material to be
plaited to something like the necessary form, then shaped on a block
while moistened by hot water, then strengthened with tapes at the
such a hat, coated with silk plush, would be light, soft, easy, and
edges, and then stiffened and rendered waterproof; it is conceived that
hole in the foundation, and hiding it with the silk plush; while others
durable. Some hats are rendered ventilating' by cutting a circular
exhibit a complicated structure of the brim and sides for the attainment
of this end.

nearly all to the British colonies.
The export of hats now amounts to about 130,000 dozens annually,

HATCHETIN. A fossil resin found in the lignite of Wales. It is colourless, fusible, and volatile; and is probably identical with ozokerite. It has the same per-centage composition as olefiant gas, but is doubt. less a mixture of several chemical compounds. HAUTBOIS. [OBOE.] HAWKER. [PEDLAR.] HAWKING. [FALCONRY.]

HAZEL. Economical Uses. The hazel is best known for its nuts, which are consumed in enormous quantities. From Spain alone there are usually exported 30,000 or 40,000 bags in a year, of four bags to the ton. Besides being eaten simply as a fruit, the nuts are sometimes peeled in warm water, and used as a component in dishes like blanched almonds; or converted into a kind of chocolate; or inade into bread; or pressed to yield an oil little inferior to almond oil. The wood of the tree is not large enough for building purposes; but it is used in cabinet-making, and in the manufacture of a number of small articles; it is close, even, and pliant, but does not take a good polish. Some of the roots yield curiously-veined pieces, eagerly sought after for ornamental purposes. The smaller branches and twigs of the hazel are more useful than the main trunk, on account of their toughness and flexibility; they are largely employed for crates, hurdles, props, wattles, walking-sticks, fishing-rods, whip-handles, ties for faggots, springes for birds, thatch-fastenings, &c. Evelyn, among other mention of the uses of this tree, said: "The use of the hazel is for poles, spars, hoops, forks, angling-rods, faggots, cudgels, coals [charcoal], and sprynges to catch birds; and it makes one of the best coals, once used for gunpowder, being very fine and light, till they found alder to be more fit. There is no wood which purifies wine sooner than the chips of hazel. Also, for withes and bands; upon which, I remember, Pliny thinks it a pretty speculation that a wood should be stronger to bind withal, being bruised and divided, than when whole and entire." Hazel-rods, cut of equal size and varnished, form good materials for rustic gardenseats and flower-baskets; and many ornamental devices may be produced by using some peeled, and the rest unpeeled. A laborious but uncommendable attempt has been made to produce a kind of mosaic picture, by interlacing differently-coloured hazel-rods.

A peculiar abuse, rather than a use, of the hazel, is described under DIVINING-ROD. The old herbalists, too, had singular notions about this plant, which modern medicine has by no means confirmed.

HEAD, INJURIES OF THE. From the many peculiar and important features which they present, injuries of the head have properly received a separate consideration in all systems of surgery. For not only is the brain so essential to life that even its least injury must be regarded as serious, but the parts around and guarding it have many peculiarities. The skull, composed of two thin layers of bone, much exposed to external violence, and protected from it by only slight coverings, is extremely liable to fracture, and it is covered by a very dense and tightly applied membrane, the pericranium, of which the injuries and diseases exhibit all the peculiarities of those of other fibrous membranes. By the free communications of its vessels with those of the similar membrane (the dura mater) lining the interior of the skull, and less directly with those of the brain, disease is very liable to spread from the pericranium to these more important parts; and it is itself covered by firm unyielding muscles and tendons, under which disease is always prone to extend widely. The injuries of the head are best considered as they affect the parts enclosing the brain or the brain itself.

In mere bruises of the scalp two circumstances are worthy of notice. A vessel of some size may be burst without the skin over it being wounded, in which case a most copious effusion of blood takes place, raising up the scalp from the skull, and producing rapid swelling of the whole of the upper part of the head. It needs however no particular treatment; no incision should be made into it, for if cold wet cloths be diligently applied, the blood will be again rapidly absorbed. If the effusion of blood from the bruise takes place between the pericranium and the skull, the former is raised into a tumour, with sharp defined edges, and yielding to pressure in a manner so similar to that of fracture with depression of the skull, that the most experienced surgeon might be deceived and induced to apply the trephine, but for the rule that it should never be employed except in cases in which the brain itself is implicated.

A common superficial wound of the scalp needs no particular treatment. It should be closed with sticking-plaster after the hair around it has been shaved off, and it should be kept cool; but to guard against mischief to the adjacent parts, the patient should avoid all stimuli, and all exertion of either body or mind, till it is completely well. Not unfrequently a violent oblique blow will strip off a large flap of the scalp so as even to denude the bone. In cases of this kind, the part, after being carefully cleaned, should be accurately replaced: if absolutely necessary, a suture may be inserted to ensure more exact adaptation, and the rest should be closed by adhesive-plaster; the head around, being shaved, must be kept perfectly cool; the patient must be placed on low diet, take aperient medicine, and remain quiet; on the first appearance of general excitement blood must be taken from the arm, and by leeches applied round the wound; under this treatment many cases get well with almost singular rapidity; but if irregularities be permitted, serious consequences may ensue even from the slighter injuries.

ARTS AND SCI. DIV. VOL. IV.

One of the most common of these sequels of injuries of the scalp is erysipelas of the head and face. It generally occurs in persons of an unhealthy habit, in hard drinkers, and in the full and plethoric. It commences about the third or fourth day after the injury; the patient begins to complain of headache and a feeling of general illness; he has a shivering fit, followed by nausea, thirst, and restlessness; a quick and hard pulse, and a thickly-coated tongue; he cannot sleep, and is perhaps slightly delirious. Soon after these symptoms have commenced the head and face feel very hot, and become red and swollen, appearances which increase, and after a day or two are accompanied with an eruption of small blisters, full of yellow fluid. There is no pain on touching the parts; but by the great swelling the eyes are often closed, and the features almost obliterated. Active reducing measures should, as a general rule, be early employed, and continued, if the disease does not yield, as far as the patient's strength will permit; and purgatives, with small doses of mercury, should be given, for the liver is very generally affected. After a period of from five to eight days the inflammation in most cases subsides, the cuticle scales off, and the wound, which had assumed an indolent unhealthy appearance, acquires a vigorous aspect, and rapidly heals. But in some cases the cellular tissue thus affected suppurates and sloughs, the scalp is separated, and there is profuse discharge from the wound. One or two incisions should in such case be made into the sloughing part, to admit of the free separation of the sloughs; but even with this the disease will sometimes spread and prove fatal.

Another affection which sometimes follows injuries (and especially punctured wounds) of the external coverings of the skull is inflammation and consequent extensive suppuration in the loose tissue connecting the tendon of the muscle covering the top of the head with the pericranium. The general symptoms of fever are in these cases less severe than in erysipelas; the scalp is less hot and swollen, but more painful and very tender; the face is never affected. After a few days of general illness, a feeling indicating a collection of fluid may be perceived over some part of the head; and on making an opening into the swelling which has formed there, a quantity of matter may be pressed out of it from beneath a large portion of the scalp. When this affection is suspected to be coming on, leeches should be put on the head in large numbers about the wound, and cold diligently applied; but if matter should form, one or more free incisions should be made through the scalp to let it out, and the part afterwards treated like a common abscess.

In cases in which the bone has been exposed, the same general and local treatment should be employed. The scalp when replaced may at once unite to the bone; or if it do not, granulations may spring up from the surface of the bone and close the wound: in worse cases, the outermost layer of the skull may die, and require a tedious process for its exfoliation and healing; in the worst, the whole thickness of the skull may perish, and the dura mater be exposed. In all these cases the mildest treatment is requisite, but as the disease is extremely liable to spread to the interior of the skull, the general health should be carefully watched, and if any indications of mischief arise, general or local bleeding should be at once employed.

When the bone itself is injured, no active treatment should ever be adopted, unless there are evident signs that the brain is suffering from compression or any injury that may be mitigated. These fractures of the skull get well even more rapidly than those of other bone; and in some cases, especially in children, the skull may be forced in to some extent, but when it does not produce any derangement of the functions of the brain the injury will be repaired, and health perfectly restored. Cases of fracture of the skull in which the brain is not at first injured may be amongst either the most simple or the most dangerous in surgical practice-for the least intemperance or irregularity committed within some time after their reception may produce irreparable inflammation of the brain or its membranes.

Injuries of the dura mater (the membrane lining the interior of the skull) are of yet more importance, because they more immediately affect the brain. The dura mater is connected with the skull by a tissue in which numerous vessels ramify, and these may be ruptured by the jar from a blow which does not even break the skin. The blood that flows from them, accumulating between the dura mater and the skull, produces compression of the brain. The chief indication of this very dangerous accident having occurred is that the patient, who for some time after the blow had seemed only stunned, or had been even quite sensible, gradually becomes dull, sleepy, comatose, and at last totally insensible, just like one suffering from apoplexy. These symptoms supervene with a rapidity corresponding to the size and number of the vessels ruptured; the most rapid are those in which, by a blow on the side of the head, the main artery, supplying the dura mater and upper part of the skull, and which ascends just before the ear, is wounded. The only hope in these cases is to bleed the patient largely, to check the flow of blood in the head, and if that be not evidently beneficial, to apply the trephine wherever it is most probable that the blood may be found and removed. It must be confessed, however, that there is little prospect of doing good by trephining in these cases; it is seldom possible to decide at what part of the skull the blood is effused, or whether it may not be between the dura mater and the brain, or even in that organ itself. The symptoms in each case are the same, but the mechanical removal of the blood is possible

SS

only when the blood is immediately beneath the upper parts of the skull.

produces healthy granulations, which unite to the surrounding parts and skin over; in others the fungous mass sloughs and the remaining parts heal; but in the large majority the exposure of the brain and its irritation by surrounding parts produce such continued inflammation of it as proves fatal.

Instead of blood, purulent matter may collect between the dura mater and skull, and produce equally fatal results. This is indicated by the patient (usually some considerable time after the accident) complaining of headache, restlessness, and extreme languor; he has The last injury of the brain that needs particular notice is that frequent irregular shiverings, his pulse is quick and hard, and he called concussion or commotion. The exact nature of it is totally cannot sleep: if unrelieved by treatment, all these symptoms increase, unknown; the name indicates only that which has been supposed, and are shortly followed by delirium, convulsions, insensibility, or namely, a shaking or general disturbance of the minute parts of the paralysis, which are no distant precursors of death. Early after their brain. In its slightest degree it is merely a stunning, from which first appearance, a puffy, soft, but not very hot nor painful tumour, perfect recovery takes place in a few minutes; in its most severe, it is forms over the part struck. If this be opened, the pericranium will rapidly fatal; but even in these, a post-mortem examination discovers be found detached for some extent from the skull, which when exposed no alteration whatever in the structure of the brain. One of the most is seen to be dead, of a dull yellow colour, and covered by purulent interesting points in surgery is the diagnosis of concussion from comfluid. In this case it may be expected that the dura mater is separated pression of the brain. As the latter seldom occurs without the former from the interior of the skull to the same extent that the pericranium (for of course a blow which would fracture or indent the skull would is from its exterior, and the only hope of relieving the patient is to violently shake the brain), compression has the symptoms of conperforate the dead portion of bone with the trephine, and let out the cussion, with the addition of some of the most severe which we have matter collected between it and the dura mater, and which compressed already mentioned. In concussion the patient is insensible only to the brain. slight impressions, for if he be loudly called to, he will wake up, The brain itself may suffer injury either from blood effused in it by answer a word or two, perhaps even rationally, and then relapse into rupture of its vessels, from compression by fractured portions of bone the same state. If he be severely pinched or otherwise irritated he being forced down upon it, from wounds, from concussion, or from will withdraw the part so injured: he occasionally moves his limbs; inflammation, and its various effects following any of these injuries. he appears, in short, as if in a sound heavy sleep, like that of a drunken The first need not here be particularly treated of; it does not differ in man. The breathing is not stertorous, but generally quite natural; its symptoms from the cases of common apoplexy with effusion of the pupil is contracted and irritable; the pulse is sometimes unaffected, blood [APOPLEXY], and admits of no mechanical treatment. The but in severe cases small and weak; there is nausea or vomiting, and second class comprehends the most important injuries of the head; the extremities feel cold. If the case is about to terminate fatally, the those of "fracture with depression," as they are called, and those whole body grows rapidly cold, the pulse becomes irregular and weaker, which occasionally happen in children, in which the skull is indented the breathing short and interrupted, and the insensibility increases. without being broken. The symptoms of such an injury are insen- In treating cases of concussion much caution is needed: it has not sibility, generally in direct proportion to the degree of pressure; the appeared that bleeding, which is the remedy popularly expected for all breathing is slow, laboured, and snoring, and at every expiration the such accidents, has at all diminished its primary symptoms, nor has cheeks are puffed out and elevated; the pulse is slow and irregular; the contrary treatment by stimulants been more successful. The the pupil widely dilated and insensible to light; the patient neither patient, while suffering from the immediate stunning consequences of feels nor moves, and lies as if in a fatal state of apoplexy. The part the blow, should merely be kept quite warm in bed, and carefully struck may of course present most varied characters: it may be starred watched; if the pulse grow weaker, the extremities colder, and the from the centre of the blow, so as to have a shallow conical depression; other symptoms of sinking seem increasing, stimulants are first called it may be fissured, and one edge have passed under the other; or it for, and should be given till he is completely roused to his former and the scalp may be broken up confusedly, and the brain be pro- state; but if, instead of being depressed, he remain stationary, no truding through the openings in them. It is worth remembering that active means of any kind should be employed. Cases are not rare in the inner part of the skull may, in consequence of its brittleness, be which, after remaining in a nearly insensible state, as if in a sound much more widely fractured than the external, so that the degree of sleep, for four, six, or eight weeks, with only very slight temporary pressure on the brain is not always indicated by the depth of the alterations, the patient wakes, complaining of but little inconvenience, indentation felt in the scalp. If unrelieved by treatment, the patient and rapidly recovers. If instead of waking nearly well, he is observed from the time of the accident grows more and more insensible; his to grow restless, to seem suffering from headache, or should he be pulse becomes more irregular, and he rapidly dies. The evident and delirious or convulsed-if his pulse becomes quick and hard, and his indeed the only mode of affording relief is to remove the pressure from eyes are hurt by strong light--he has in all probability inflammation the brain, by exposing the fractured part of the skull by enlarging the of the brain, which is the most frequent consequence of concussion, wound in the scalp, or making a fresh one, and taking away or and must be at once met by the active depleting and reducing elevating all the portions of bone that are depressed. The mode of measures necessary for its cure, from whatever cause it may arise. In doing this will be determined in each case by the form of the fracture some cases the symptoms of concussion gradually change into those and other circumstances; in some it may be sufficient to remove the of compression, which may then be suspected to arise from effusion of loose pieces with forceps; in others, to saw off portions with a Hey's blood into or on the brain, as in the cases already mentioned. saw, or to apply the trephine and raise the other depressed parts to their proper level with an elevator. These proceedings however must of course be limited to the cases in which the fracture is in a part within view; when it extends across the base of the skull no mechanical means are applicable, and recovery is therefore extremely rare. Such cases, and all others in which compression cannot be mechanically relieved, can only be treated like common apoplexy, by bleeding the patient, by cold sedulously applied, and by rigorous reducing measures. The after-treatment of cases in which the trephine or analogous means have been used is nearly the same as in wounds of the skull and soft parts; the edges should be brought gently together, and slight pressure employed to support the dura mater where it is exposed by the aperture in the skull and the other usual precautionary and curative measures, as cold, local bleeding, &c., resorted to.

The immediate consequences of wounds of the brain vary greatly, and indeed unaccountably in some cases a very slight injury is rapidly fatal, as in those (of which many are now recorded) in which a pointed instrument has passed in through the orbit, and produced almost instant death; whilst in others severe and extensive injuries, as from gun-shots, have been followed by serious symptoms at only a late period from their reception. In most of the cases where the dura mater is perforated, whether by wound or by ulceration, the wounded or exposed brain protrudes through the aperture in the form of a darkish dirty-looking fungous mass, called "Hernia Cerebri." Its surface discharges purulent matter abundantly, and often bleeds slightly pressure on it, as on the brain itself, produces immediate insensibility; but the whole mass may be cut off without producing any pain or ill consequences. This is indeed the best treatment of it. If after having protruded to some distance it shows no disposition to decrease or to slough, it should be cut down to the level of the skull, and gentle pressure by compresses covered with the mildest ointment applied, so as to compensate, if possible, for the deficiency in the dura mater. Should the mass again sprout forth, the same treatment may be repeated. In a few cases the growth is checked, and the brain

The account here given is only a sketch of the most prominent and constant symptoms, progress, and treatment of the effects of injuries of the head. There are other symptoms that occur occasionally, and as it were accidentally, which it is necessary briefly to advert to. Furious delirium, lasting for some days and requiring active depletion, sometimes immediately follows concussion; violent convulsions also ensue, either on slight compression or on concussion; paralysis or hemiplegia is not unfrequently produced directly by compression, and they still more commonly occur as its sequels. Loss of memory, sometimes most singularly limited to particular classes of events or things; impairment of individual sensations, and various forms of insanity, are all the occasional consequences of these injuries, or of the inflammation and disorganisation of the brain which follow them, and to the prevention or cure of which the chief attention is, in the majority of cases, to be directed.

HEADBOROUGH. [CONSTABLE.]
HEALTH. [PUBLIC HEALTH.]

HEARING TRUMPET. [EAR-TRUMPET; SPEAKING-TRUMPET.]
HEARSAY. [EVIDENCE.]

HEART, DISEASES OF THE. The heart, like the other viscera, is concealed from the eye, hence little knowledge of its healthy or diseased conditions can be obtained by mere inspection. Even the touch fails to ascertain much, on account of the bony case in which it is enclosed. Its impulse may, however, be detected by grasping the chest with the hand. The arterial pulse may be also felt by the finger, but these means of examination give but little information of the nature of diseases of the heart, compared with the use of the ear. Disease of the heart can be detected both by the aid of auscultation and percussion.

When the ear is applied to the left side of the chest, either directly or with the aid of the stethoscope, two sounds are heard, called the first and second sounds of the heart. [HEART, in NAT. HIST. DIV.] The two sounds differ from each other, and the period of silence between the two sounds also differs. The first sound is longer than the

second, and the two have been compared to the syllables lupp and dupp. It is heard most distinctly below and outside the left nipple, and with the systole of the ventricles, and on these accounts is called the systolic or inferior sound. The second sound is heard above and inside the left nipple, and is called the superior sound. It occurs with the diastole of the ventricles, and is called the diastolic sound.

The pause between these two sounds differs in the length of time it occupies: after the first sound and before the second it is shorter than between the second and the first.

These sounds present different characters in different individuals in health, and even in the same individuals at different times. They, however, indicate disease when they are permanently altered from their normal character. Thus they may be lower or higher, clearer or duller, muffled, rough, regular, irregular, intermittent, increased or decreased in number. Their quality may be altered, and they may be accompanied by friction sounds from disease of the pericardium, or murmurs may ensue from disease of the valves, as bellows, grating, filing, rasping, cooing, or whistling murmurs. There is also a relation between the sounds of the heart and the pulse. The first sound in health anticipates very shortly, but still very distinctly, the pulse at the wrist, hence any prolongation of this period is indicative of some obstruction to the course of the blood.

A knowledge of the nature and causes of the murmurs and abnormal sounds produced in the heart is essential to a correct diagnosis of diseases of the heart. These murmurs or morbid sounds may arise from disease within the heart, when they are called endocardial; or between the heart and its lining membrane, the pericardium, when they are called exocardial. The two classes of murmurs may co-exist. The endocardial murmurs arise either from an unnatural contraction or an unnatural widening of the orifices between the vessels and cavities of the heart. They may also arise from states of the blood. When caused by the latter they are called functional or inorganic, but when from the former organic. The exocardial murmurs arise from the roughening of the surfaces of the heart and pericardium. Each of the orifices of the heart may be the seat of two different kinds of murmurs, the one constrictive, the other regurgitant; the one occurring with the current of the blood, the other against the current. In this way eight different kinds of murmurs are recognised. It should, however, be remembered that the murmurs on the left side more frequently occur than murmurs on the right side. The following account of these murmurs, given in the order of their frequency, will give an idea of their character and the means of distinguishing them.

In giving some account of the disorders to which the heart is liable, it would perhaps be best to arrange them according to their causes; but as it is much easier to obtain a knowledge of the structure of this organ than of the remote causes of its several diseases, we shall here enumerate and describe, first, those lesions which occur in its investing membrane; secondly, those which affect it as a whole; and thirdly, those met with in its internal membranes. Those who desire to be further acquainted with this subject are referred to the works of MM. Corvisart, Laennec, Cruveilhier, Bouillaud, Bertin, and Drs. Elliotson, Hope, Watson, Latham, Taylor, Walshe, Williams, Billing, and Aitken.

I. Diseases of the Investing Membrane of the Heart. Pericarditis, Inflammation of the Pericardium, resembles much, in its pathological conditions, inflammation of other serous membranes, and is induced by similar causes, as exposure to damp and cold. It of course presents peculiar symptoms, arising from the situation and nature of the individual organ: thus the patient will complain of tenderness over the region of the heart, amounting, when pressure is made, to acute lancinating pain, which prevents him from lying on the left side, and is much increased by drawing deep inspirations or coughing, this latter symptom frequently depending on the pleura being involved in the inflammatory attack. This pain, however, is not always so severe; frequently only a sense of oppression is felt. The pulsations of the heart are frequent, sometimes regular, but at other times intermittent, and so strong as to constitute palpitations; but still, if much effusion has taken place into the pericardium, the hand when applied to the chest will have difficulty in perceiving them. The præcordial portion of the thorax is often bulged out by the forcible action of the heart and the quantity of fluid effused into the cavity of the pericardium. This effusion varies much in quantity and consistence at different periods of the disease: thus, in many cases, only a little bloody serum will be found; in others, pus in large quantities, coagulated lymph, bands of fibrinous matter uniting the two layers of the serous membrane, and even cartilaginous or osseous deposits. The dull sound discovered by percussion in the præcordial region of a person in health is always, in this disease, increased in proportion to the quantity of fluid in the pericardium. In proportion as this fluid becomes organised sounds will be heard by the application of the stethoscope, and often of the unassisted ear, varying in their nature according to the state of the organising process, and resembling at one time the creaking of new leather, at another the rubbing together of paper or parchment, the noise made by a file, &c. Other sounds also are frequently heard, which depend upon endocardial disease. Although at the commencement of the disease the patient may have symptoms of acute inflammation, the accompanying fever having a type sufficiently tonic, this state does not endure long; the effusions into the pericardium hinder the heart's action; the free passage of the blood of the organ sharing in the inflammation; and, the circulation being no longer vigorously and equally carried on, a crowd of distressing symptoms, such as inability to sleep, startings, faintness, shortness of breath amounting to suffocation, dropsies, &c., render life almost insupportable, and, if not speedily relieved, soon put an end to existence. This disease mostly accompanies acute rheumatism, particularly of the joints; and patients, when apparently recovering from acute rheumatism, are sometimes suddenly attacked and carried off by inflammation of the pericardium.

1. Mitral regurgitant murmur.—This arises from inefficiency of the mitral valve by changes in its structure, roughness at its edges, from vegetatious shortening of the chorde tendinece, or fibrinious clots entangled in them. It is a systolic murmur, and is heard best immediately above or to the outside of the left apex. It is faintly or wholly inaudible at the right apex. It is generally permanent. 2. The Aortic constrictive murmur is the next most frequent abnor-through its cavities becomes further impeded by various internal parts mal sound in diseases of the heart. It indicates a rough constriction of the aortic orifice. It is a systolic murmur, and is heard best at mid-sternum opposite the interspace, between the third and fourth ribs, or the upper part of the fourth rib. It has a high pitch, and is a harsh, loud, and prolonged murmur.

3. Aortic regurgitant murmur.—It differs from the last in being heard almost as distinctly at the ensiform cartilage as at the third costal interspace. It is a diastolic murmur, and is of a blowing or hissing

character.

4. Mitral constrictive murmur.-It is diastolic, and heard best immediately above and about the left apex.

5. Tricuspid regurgitant murmur.-It is due to regurgitation, or to the collision of the blood amongst the chorda tendinea. It is a systolic murmur, and is heard best immediately above or at the ensiform cartilage. It is inaudible, or nearly so, at the left apex. It originates in the right ventricle, and is generally a soft murmur of low pitch. It is a rare murmur, and may be often undiscovered when accompanied by a powerful mitral murmur.

6. Pulmonary constrictive murmur.—It indicates roughness, or obstruction from pressure in the pulmonary orifice. It is a systolic murmur, and is heard best at the sternal edge of the third left cartilage. It is rarely heard.

7. Pulmonary regurgitant murmur.-This indication of insufficiency of the pulmonary valves is very rare.

8. Tricuspid constrictive murmur.-It is the rarest of murmurs, is diastolic, and when heard is found at the ensiform cartilage.

The exocardial murmurs are produced by the rubbing of the surface of the pericardum against the heart, when these surfaces are roughened by the effusion of fibrine from inflammatory disease. They are more or less rough according to circumstances, and may entirely cease by the effusion of serum or fluid between the pericardium and

the heart.

Percussion may be employed in distinguishing enlargement of the heart. It is employed either mediately or directly. [PERCUSSION.] In the normal condition of the thorax, the situation of the heart is easily distinguished by the dull sound given out on percussion. When this dull sound extends unnaturally in any direction over the region of the heart it is indicative of an enlargement of that organ, a condition which will be made evident by other signs of disease.

The serious nature of this disease, and the rapidity of its progress, demand, apparently, prompt antiphlogistic treatment; but, on the contrary, some physicians exhibit tonic medicines. Dr. Watson says, "In a large proportion of cases, whether they be treated well or ill, or not treated at all, the patients will seem to recover."

The great guide to treatment is the pressure of the symptoms. At the commencement of the disease, if there is dyspnoea and tumultuous action of the heart, bleeding will immediately relieve. Towards the termination of the disease such symptoms are relieved by wine and stimulants; otherwise the general treatment for rheumatism is admissible in cases of pericarditis.

II. Diseases of the Heart itself.

Carditis; Inflammation of the Heart.-The proper muscular structure of the heart is not free from the attacks of inflammation, though whether the morbid action commences in this structure, or in the membranes, is difficult to determine. This, however, is certain, that when inflammation of the muscular structure exists, there will also be found traces of it in the pericardium, or in the lining membrane of the heart, or in both; and we cannot point out symptoms which distinguish the one from those of the other disease: the treatment consequently, will be similar in both.

Hypertrophy of the Heart.-Independently of any morbid process existing in itself, the muscular structure of the heart is often greatly increased in bulk, as if the nutritive process were too active in proportion to the absorbent, and new matter were deposited more rapidly than the old could be removed. From the peculiar nature of the functions of the heart, this disease becomes very important, and its effects not less dangerous than manifold. It is usually divided into three kinds; namely, simple hypertrophy, the least common, in which

the parietes are thickened without any change of capacity in the cavity; excentric or aneurismal hypertrophy, the form most frequently met with, in which the parietes are thickened and the inclosed cavity or cavities proportionally enlarged; and concentric hypertrophy, where the cavity is diminished in proportion to the thickness of the parietes. Any one of these kinds of hypertrophy may affect the parietes of either cavity of the heart, or of the whole organ. The extent to which this increase of size may proceed is enormous; hearts have been found weighing upwards of twenty ounces, whereas the average weight of a healthy heart is from seven to nine ounces. In hypertrophy, the shape of the heart is also much altered, the transverse often exceeding the vertical diameter; but these changes must depend upon whether the whole organ, or only a part, be implicated in the disease. The chest is often bulged out towards the left side, the sound produced by percussion more dull than in the healthy state, and the pulsations very strong; indeed, the bed-clothes are often visibly raised, and the head or hand of the observer when applied to the chest forcibly repulsed, yet the pulsations are for the most part regular, unless palpitations be induced by over-exertion. The sounds perceived by auscultation will be found very loud, but not otherwise unnatural, if the disease be not combined with some obstruction to the passage of the blood; and unless some obstruction exists, the functions of other organs will not be much deranged, provided that the hypertrophy be not of great extent; but it seldom does exist to considerable extent without the simultaneous occurrence of some impediment to the passage of the blood, already circulating with extraordinary force.

The accidents referrible to hypertrophy of the left ventricle of the heart are apoplexy and hæmorrhages; it will also contribute to the production of aneurism of the aorta. It frequently happens that the rupture of vessels in the brain by the too forcible expulsion of blood from an hypertrophied left ventricle is materially facilitated by an earthy or osseous state of the coats of those vessels. When the right ventricle, being hypertrophied, sends its blood too forcibly through the lungs, there will be a disposition to congestion of those organs. These effects will be combined when the whole heart is hypertrophied. This is a disease in which great perseverance is required on the part of the patient and the practitioner, but with proper care it frequently admits of much alleviation. Rest, abstinence, sedative medicines, and more or less depletion, according to the circumstances of the case, are the most efficacious plan of treatment.

Atrophy of the Heart is a wasting of the heart's structure, dependent on deficiency of the nutritive process. This disease is the reverse of hypertrophy, and, like it, may affect the whole organ or only parts of it; its extent is often such that the heart does not exhibit more than half its ordinary weight. Like hypertrophy, it has been divided into simple atrophy, when the walls of one or more cavities are thinned without any change of capacity in the cavity itself; excentric or aneurismal atrophy, when the enlargement of the cavity keeps pace with the thinness of the walls; and concentric atrophy, where the cavity is diminished, but the walls maintain their usual thickness. This state of the heart is usually accompanied by general emaciation, and the pulsations and sounds of the organ will be found feeble in proportion to the extent of the atrophy. In concentric atrophy, however, the pulse will be firm and resistant, though small, whilst in the excentric form of the disease it will be proportionally soft, feeble, and large.

When the heart is examined after death from atrophy, it is found that its tissues have undergone a change which has been called "fatty degeneration." The muscular fibre, instead of presenting the striped character found in health, loses the stripes, and presents a homogeneous appearance. In the interior of the fibrille will be found also fat globules, and the central portion of the muscle-cells, consisting naturally of fibrine, is converted into adipocire or cholesterine. It is in this state of the heart that rupture of its membranes so frequently occurs. (Quain, Fatty Diseases of the Heart.')

In atrophy the powers of the patient are all below par, and the proper treatment will be to support the system by wholesome, generous, but unexciting diet, and a salubrious atmosphere. Medicines, as quinine and iron, may be prescribed as auxiliaries, when any additional symptoms appear indicating obstruction to the nutritive functions.

any pre-existing impediment to the circulation, is most frequently the consequence of some obstruction to the free passage of the blood from the dilated cavity, and is the natural effect of distension from within. It however not unfrequently happens, that when the obstruction occurs at the orifice situated between the ventricle and artery the corresponding auricle will be the cavity dilated, its parietes being so much less strong than those of the ventricle. When the orifice of either of the cavities of the heart is dilated to such extent as to preclude its proper closure by the valves, a reflux of blood will be the result, causing the anormal bellows sound, and a sensation of purring, or of vibration such as would be produced by putting a chord in motion; and should this defective closure exist in the right auriculoventricular opening, it will give rise to a fluctuating motion in the jugular vein, called "venous pulse." Excessive exertions and strong passions seem to be exciting causes of this disease, and from the influence of these causes the patient should be sedulously guarded, and at the same time every remedy must be adopted which may contribute to equalise the circulation.

The preceding diseases are most frequently the result of disease of the lining membrane of the heart, and are often accompanied by the signs of valvular derangement.

III. Diseases of the Internal Membranes.

Endocarditis; Inflammation of the interior lining membrane of the Heart. The symptoms of endocarditis are more or less fever and anxiety; some bulging of the præcordial region, if accompanied by pericarditis; an extension of the dull sound heard on percussion in the healthy state; the pulsations of the heart unusually strong, and sometimes very rapid and intermittent, repulsing the hand when applied to the chest, and producing a peculiar vibratory sensation. Upon auscul tation the bellows sound will be heard, masking one or both of the normal sounds, and sometimes, during the ventricular contraction, a metallic tingling is heard, resembling the sound produced by dropping sand into a bell of metal. The pulse as felt at the wrist will not always accord with the beatings of the heart; often whilst the latter are very forcible, the former will be found small and weak, and sometimes less frequent: this indicates some obstruction to the free passage of the blood from the heart, notwithstanding the forcible contractions of that organ to propel it, and the patient will exhibit symptoms of much distress, as great anxiety of countenance, restless tossings of the body, dazzlings of the sight, and faintings; if the obstructions in the right side of the heart are extensive, as they often are from fibrinous concretions, thickenings, and other morbid growths of the valves, the venous circulation will be affected, as indicated by the livid bloated state of the countenance, and serous effusions into the extremities; various apoplectic symptoms seem to be sometimes induced by the same cause. The breathing is not affected generally beyond a sense of oppres sion, unless a considerable impediment is experienced by the circulation, but then the distress and restlessness of the sufferer is often extreme, accompanied by an inability to lie down, and a state of alarm and wandering amounting almost to delirium.

The causes of this serious malady are similar to the causes of pericarditis, and the treatment should be conducted on the same principles. It frequently arises in the course of an attack of rheumatism, and may or may not be accompanied by pericarditis.

Valvular disease of the Heart.-Upon examination after death from endocarditis, there will often be found, particularly in the right cavities of the heart, and entangled in the muscular fibres, clots or concretions of fibrinous matter, which are not only caused by stagnation of the blood at the time of death, but also by inflammation of the internal lining membrane. This membrane is also often thickened, especially at the valves; and after repeated attacks, or a long chronic attack of endocarditis, the valves will not merely be thickened, but will become the seat of a variety of warty excrescences, or even cartilagi nous and osseous formations of considerable size, extending into the cavities of the heart. This ossification is most frequently met with in old persons, and especially those who have been addicted to a too generous mode of living. The morbid sounds produced by these obstructions at the various orifices will resemble those of the bellows, file, or saw, according to the degree of obstruction; and sometimes a triple or quadruple sound will be perceived instead of the two normal sounds. The effects of these obstructions will be sanguineous and serous congestions, oppressions of the breath, apoplectic seizures, and

The treatment of such cases must depend on the nature of the symptoms present. Where anasarca is present, the water may be got rid of by rest and by acting on the bowels and kidneys. Asthma is frequently the result of valvular disease of the heart, and remedies must be applied to facilitate the passage of the blood through the obstructed lungs. Hæmorrhage from the lungs and extravasation of blood are produced by disease of the heart. Congestion of the brain and apoplexy are also the result of disease of the heart, and it is of the greatest consequence to detect the cause of these attacks in the state of the heart, and adopt treatment accordingly.

Dilatation of the Heart.-It has been shown that the heart may be increased or diminished in substance, or, in other words, may be other symptoms of embarrassed circulation. hypertrophied or atrophied; it is also found that the whole organ, or either of its cavities singly, or the orifices of these cavities, may be dilated, the solid parietes being merely extended, without any increase of substance, and the contained cavities proportionally enlarged. As in hypertrophy, so in this disease, according to its extent, the shape of the heart will be much changed. The muscular parietes being thinned and feeble, the circulation of the blood will not be carried on with vigour, and the patient will be weak and unfit for exertion, easily exhausted by small losses of blood, and sometimes carried off by what under ordinary circumstances would be deemed a trifling hæmorrhage. Partial dilatations sometimes occur after carditis; the muscular structure being thinned at some spot by ulceration, the parietes give way, and form a dilated aneurismal pouch. This disease, though it doubtless does sometimes occur in persons of relaxed muscular fibre without

Nervous Diseases of the Heart.-The last class of diseases affecting the heart which remains to be noticed differs from all the preceding in not presenting any organic changes. They are met with chiefly in women suffering from anæmia, chlorosis, hysteria, and other nervous

« السابقةمتابعة »