DILATATION OF THE HEART. 337 



Hon. It is aggravated upon ascending stairs, walking Tip-hill, and 

 similar causes, and at first is scarcely perceptible when the body is at 

 rest. The aspect of the patient at this period is pale, owing to the 

 lack of blood in his arteries ; but the overloaded state of the veins is 

 not at first sufficient to produce cyanosis and dropsy, although the lips 

 may be somewhat livid. Besides this, there are a certain languor and 

 apathy, with liability to fatigue upon slight exertion, symptoms which, 

 as we have repeatedly said, indicate a venous condition of the blood. 

 If the disease advance, the palpitation and dyspnoea become more dis- 

 tressing, the patient fears to make any exertion, because it " puts 

 him out of breath." The lips and cheeks assume a distinctly blue 

 tinge, the liver begins to swell, from the venous engorgement, and a 

 slight oedema of the extremities begins to appear toward evening. In 

 the most aggravated stage of the disease the patient complains of 

 great shortness of breath, even when in a state of complete repose, 

 winch becomes almost intolerable upon his making the slightest effort. 

 The pulse is small, and often is irregular and intermittent. The 

 urine, which is extremely scanty and concentrated, deposits a copious 

 sediment of urate of soda upon cooling, the small amount of water 

 which it contains being insufficient to retain the salts in solution at a 

 reduced temperature. At this period more or less albumen usually 

 appears in the urine, and both lips and cheeks are decidedly cyanotic. 

 The dropsy spreads from the ankles to the legs, thighs, scrotum, 

 and abdominal integument. The upper extremities and face become 

 cedematous, dropsical effusions also forming in the cavity of the abdo- 

 men and the serous sacs of the chest. At length the patient suc- 

 cumbs to the symptoms of bronchial palsy and oedema of the lungs. 

 Every busy practitioner has repeated opportunities to witness cases 

 where old people die of this malady with precisely such symptoms, or 

 with symptoms but slightly different. The smallness of the pulse 

 and the diminution of the urine are the result of the constant de- 

 crease of the arterial contents; the cyanosis, dropsy, and albumin- 

 uria are necessary consequences of the ever-increasing venous engorge- 

 ment. 



The symptoms of dilatation supervening upon an excentric hyper- 

 trophy, arising from endarteritis deformans, are essentially the same as 

 those described above. It is often impossible to determine with which 

 of these two forms we have to deal. This will not seem strange, when 

 we consider that endarteritis deformans does not occasion any derange- 

 ment of the circulation as long as the heart remains in a state of excen- 

 tric hypertrophy, and that the evidence of disease only becomes appar- 

 ent after the hypertrophy has become spurious by secondary degener- 

 ation, and after its coniDensatory action has become imperfect. When 

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