Breathlessness on exertion, even though slight, and syncopal attacks are sometimes troublesome. There may be frequent attacks of cardiac asthma in the morning, and these may be accompanied at intervals with pains, anginoid in char acter and assuming the severity of pec toris even. The latter complication may, however, occur independently of the asthmatic seizures. The pulse, in conse quence of the irritation of the inhibitory centre in the medulla, frequently be comes much retarded, declining from the normal rate to thirty or forty beats per minute, and in rare cases from ten to twelve beats. Disturbances of the intel lect, at times assuming the form of mani acal delusions, may come on and persist for weeks and even months. The fatty arcus senilis possesses no diagnostic value. Two symptoms of considerable value, particularly when combined in the same case, are pseudo-apoplectic attacks, due to disturbance of the cerebral circu lation, and Cheyne-Stokes respiration, the latter being among the later mani festations. When Cheyne-Stokes breath ing is in association with pseudo-apoplec tic seizures, they are more apt to be due to a urcemic toxaemia perhaps than to fatty degeneration of the heart. Ac cording to Broadbent, a noteworthy point is that well-marked dropsy is rare, and probably never occurs in uncompli cated degeneration. The significance of this is that the special effect of the dis ease is defective pressure in the venous system, and it is to this that the syncopal, apoplectic, and epileptiform attacks are due, which, together with angina pec toris, are the most characteristic later effects of fatty degeneration. The syn copal attacks vary greatly in intensity, and are marked rather by duration than intensity, and are not attended with com plete loss of consciousness. He also speaks of attacks resembling petit mal, attended with slow pulse, sometimes less than twenty in the minute.
Interesting case of thrombosis and embolism in fatty heart observed. On setting the patient up in bed on one occasion, to examine his back, the writer did not hear him breathe, and on looking at the patient he was to all appearances dead. There was no pulse, no sound over his heart, no respiration, his eyes were glassy and fixed, he could not swallow, and severe slapping of the epigastrium had no effect. After ex hausting all available stimulants with out good effect, the writer applied a lump of hot coal over the xiphoid car tilage and along the insertion of the diaphragm with tongs. This produced powerful contractions of the inspiratory muscle. Finally, by degrees respiration returned, eyes opened, heart beat, and color came to the face. He then ad ministered some brandy, and at last.the patient rallied. W. L. Symes (Dublin Jour. Med. Science, '92).
As to physical signs, there is a weak, irregular impulse that often can neither be seen nor felt; later dilatation super venes. After the latter event the im pulse is apt to be diffuse. The most con stant and significant feature of the pulse is that it is short and unsustained (Broadbent). The area of cardiac dull
ness increases, and a- soft systolic mur mur is often audible at the apex (relative insufficiency). When fatty degeneration is associated with marked obesity, it is difficult to delimit the area of dullness, for obvious reasons, and the cardiac sounds on auscultation are apt to be weak, distant, and muffled. On the other hand, in thin subjects and in the fatty degeneration of grave ancemias, the first sound of the heart is often short, sharp (flapping in character), simulating the second sound.
Diagnosis.—It is to be emphasized that in a large number of cases the pa tient has not consulted his physician when sudden death supervenes from rupture, usually during active exertion or excitement; less frequently the termin ation in death follows the administration of an anaesthetic or a full meal. Rarely, death follows the action of the exciting cause after the lapse of several hours.
[In a large proportion of the cases there has been no ailment which has led the patient to consult a physician when he is overtaken by sudden death during exertion or excitement, or the adminis tration of chloroform, or after a full meal; or the exertion or excitement may be passed through safely, and death follow some hours later, or even next day. Rupture of the heart is one mode of termination, and this may take place on very slight provocation. When the course of the disease has been suffi ciently chronic to permit of the recog nition of symptoms (which is chiefly when the degeneration is secondary to changes in the coronary arteries or to old-standing hypertrophy, with or with out dilatation), they will be such as are produced by a slackening circulation, and they are not so different from those attending dilatation as to permit of any distinction being drawn between the two conditions in an early stage with out physical examination. In advanced stages characteristic differences appear. Marked dropsy is rare. The special effect of the disease is defective press ure in the venous system, and it is to this that the syncopal, apoplectic, and epileptiform attacks are due, which, to gether with angina pectoris, are the most characteristic later effects of fatty degeneration.
The pulse is short and unsustained. The rate may be regular or extremely irregular, and it may be frequent or slow. The physical signs are largely negative. If the fatty change is at all advanced, the impulse can be neither seen nor felt. The sounds are weak, and sometimes almost inaudible. WHIT TIER, VICKERY, and GREKSE, Assoc. Eds., Annual, '921 I believe that while fatty degeneration may be a sequel of coronary disease, den death in the latter is in the majority of instances to be ascribed to changes in the arterial coats and not fatty tion of the heart-walls, with ensuing rupture. Corroborative post-mortem evidence is not wanting. Key Aberg found extensive areas of fatty tion only in two instances out of thirteen autopsies of sudden death from cardiac paralysis, brought about by sclerosis of the coronary arteries.