To these belong: a. First, and most prominently, inflammations, as for instance of the pericardium, the muscular substance of the heart and the endocardium, both in their primary and secondary character. By paralyzing the substance of the heart, inflammations occasion dilatations, which are maintained by their own secondary conditions, which mechanically augment them, and gradually superinduce hypertrophy.

An important place must be assigned to dilatations arising from chronic pericarditis, especially when associated with purulent exudation, or when investing the heart with a pseudo-membrane incapable of contraction, or lastly, when there is firm adhesion of the heart to the pericardium consequent on these new structures. Inflammation, in proportion to its intensity, and the quantity and purulent character of its effusion, tends to promote paralysis of the muscular substance of the heart, accompanied by decoloration and diminished cohesion, and hence furthers the development of passive dilatation. The longer the inflammation has continued, the more permanent will be the character of the cardiac affection, and if at length the heart adheres to the pericardium, a mechanical obstruction is opposed to the contraction of the former by the pseudo-membrane, which agglutinates the pericardium to the heart. This form of dilatation commonly affects the whole heart.

The dilatations induced in the same way by the endocarditic process, are similar to the former, but are usually less important; and when it gives rise to anomalies of the valves, they may gradually assume the active form by the association of hypertrophy. The left side of the heart, especially the left ventricle, is incomparably the most frequent seat of these affections.

It must be evident that the importance of the dilatation induced by the inflammation of the muscular tissue of the heart, will be in proportion to the frequency of inflammation, and the number and extent of its starting-points. This form of dilatation, excepting in very rare cases, invariably affects the left ventricle.

B. Adiposity Of The Heart

An excessive accumulation and formation of adipose tissue in the heart promotes dilatation of a passive character, in consequence of the simultaneous attenuation of the muscular walls of the heart.

The form which we regarded as consecutive, in speaking of the condition of the texture of the hypertrophied and dilated heart, appears to favor further dilatation.

3. Finally, in all those cases in which cardiac disease cannot he referred to any of the above-enumerated causes, it may originate in excessive innervation of the heart. Under this head we may include a considerable number of cases of hypertrophy and dilatation of the left side of the heart, which Bouillaud has termed primary, in order to distinguish them from consecutive forms arising from the causes already indicated.

Many of these causes, more especially endocarditis and its secondary conditions, are occasionally observed in the foetus, and the diseases to which they give rise under these circumstances are then congenital. Other cardiac diseases belonging to this category depend on original malformation of the heart, its ostia and vascular trunks, and constitute a special series, of which we purpose treating subsequently under the head of cyanosis.

Independently of these causes, the consecutive diseases, arising from affections of the heart, are alike important and numerous. The following are the most worthy of notice:

Excessive Fulness And Dilatation. Stasis In The Whole Venous System

This condition is most strikingly manifested in the great venous trunks, the venae cavae, and the trunk of the portal vein, - from whence it extends along their branches into the capillaries, and is then characterized by distension and cyanosis.

Hemorrhages, resulting from the excessive fulness of the capillary system, manifested in discharges of blood from the mucous membrane of the nose, excessive menstrual uterine discharge, bleeding from the bronchial and pulmonary mucous membrane (haemoptysis and haeemoptoic in-farctus), hemorrhage from the intestinal mucous membrane, from the liver (apoplexy of the liver), and into the brain. The most frequent and important of these, are bleeding from the bronchial and pulmonary mucous membrane, and cerebral hemorrhage; and we will, therefore, treat of them specially, together with other subjects, in a future page.

Hypertrophies, more especially affecting the parenchymatous abdominal viscera, as the liver, spleen, and kidneys, although more particularly the two former. These affections are frequently marked by a visible increase in the volume of the organs, by a persistent tumor, and more commonly - either with or without the former, - by a striking increase of consistence depending on a compression of the elementary structure induced by hypertrophy.

To these we must add hypertrophies of the mucous membranes and the chronic catarrhal inflammatory conditions - the forms of blennor-rhoea - to which they give rise. Those which are most remarkable for their intensity and extent are bronchial catarrh, and a catarrhal condition of the whole of the intestinal mucous membrane.

Dropsy which usually manifests itself first as anasarca of the lower extremities, and is then converted into general dropsy by the addition of serous effusions into the large serous sacs, is the result of the above-named venosity and mechanical hyperaemia. (Edema of the lungs is highly important, whether it be slowly established, and as a result of dropsy in other parts, or whether it show itself among the earliest symptoms of dropsy, and speedily attains a high degree of intensity, when it not unfrequently proves rapidly fatal.

Besides these secondary conditions, there are others which, from their importance, merit special consideration: these are certain diseases of the liver.

The diseases of the liver, of which we are about to speak, have frequently been regarded as causes of disease of the heart, but it is not very clear in what manner they can be supposed capable of bringing about such a result. Facts as well as theory tend rather to show, that the morbid condition of the liver is a consequence of heart-diseases, and is developed by the constant mechanical hyperemia induced by the latter. To this class belong, besides the hypertrophy already described, the condition known as nutmeg liver, which is generally developed in a very intense form, that is to say, as a sharply-defined saturated yellow substance, very rich in blood, and marked with well-defined red patches; and, finally, that granular condition of the liver which is gradually developed from the latter, either with or without inflammation.

In our observations on hemorrhages, we spoke of those of the bronchial and pulmonary mucous membranes, and of cerebral hemorrhage as among the most important results of the cardiac diseases under consideration. Cerebral hemorrhage (apoplexia gravis) occurs in so large a majority of cases in conjunction with disease of the heart, that the latter has, with much reason, been regarded as a predisposing cause of cerebral apoplexy. The disease of the heart consists here in simple hypertrophy of the left ventricle, or what is much more frequently the case, in its dilatation, associated with highly developed hypertrophy. Cerebral apoplexy is undoubtedly induced by laceration of the cerebral vessels, occasioned by the augmented impulse propagated from the left ventricle; and this is the more easily effected the more the arterial coats in advanced life have lost their normal texture and cohesion, their power of resistance, and elasticity, or have become ossified, etc. A similar or even identical relation has been supposed to exist between hemorrhages of the bronchial and pulmonary mucous membrane and active dilatation of the right side of the heart. It must, however, be observed in reference to this point, that hemorrhages of this kind very frequently occur in dilatation and hypertrophies of the most different portions of the heart, in the form of haemoptysis and haemoptoic infarctus (pulmonary apoplexy). The cases in which they are found to exist, are very rare in comparison with the frequency of active dilatation of the right ventricle, and their coincidence bears a very secondary relation to the frequency of the coexistence of active dilatation of the left ventricle and cerebral apoplexy. Whether this depends on the absence of that diseased condition of the coats of the vessels in the branches of the pulmonary artery which is found to exist in the cerebral vessels, is a point that has not been determined, since, on the one hand, cerebral apoplexy, when associated with the above-named heart-disease (viz., hypertrophy of the left ventricle), is found to occur without any recognizable anomaly of the cerebral vessels; and on the other, because bronchial and pulmonary hemorrhage, are frequent in the cardiac diseases referred to. It follows, therefore, that these affections are only in very rare cases to be referred to an increased impulse propagated from the hypertrophied right ventricle, and that in the most numerous cases they are the result of an excessive fulness of the whole vascular apparatus of the lungs, induced by the obstruction opposed to the emptying of the pulmonary veins into the left side of the heart.

These diseases of the heart attack individuals of every age, not even excepting the foetus, but they occur more frequently in advanced life than in childhood and adolescence, simply because the different causes favorable to their active development have been for a longer time in operation, and the system is no longer equally able to resist disease.

They frequently prove fatal in consequence of the secondary diseases to which they give rise, and often produce sudden death, especially by paralysis of the hypertrophied organ, hyperaemia of the lungs, rapidly developed pulmonary oedema, or cerebral hemorrhage.

They are further worthy of notice on account of the immunity from tuberculosis, which they insure to those affected by them; and it may be generally remarked, that the immunity which is yielded by the most various anomalies is always dependent on this class of diseases of the heart.