Popular Science Monthly/Volume 2/December 1872/Foul Air and Disease of the Heart
|FOUL AIR AND DISEASE OF THE HEART.|
By CORNELIUS BLACK, M. D. Lond., M. R. C. P.
IF the question were asked, "Which side of the heart is the more frequently affected by disease?" the answer, in perhaps nine cases out of ten, would be, the left. This answer would not, however, embrace the whole truth. It would be true of the aggregate of cases of cardiac disease without reference to age; but it would be untrue if the occurrence of cardiac disease were referred to the later periods of life. If a man lives to the age of forty years without having suffered from cardiac disease, and, if after that period the heart becomes affected, the mischief will, as a rule, be found to exist on the right side. If, on the contrary, cardiac disease should occur before that age, the disease will, almost invariably, be found to exist on the left side. Hence, it follows that the right side of the heart is the seat of cardiac disease occurring after middle age—the left side of the heart the seat of cardiac disease occurring before middle age.
As in time, so it is with respect to the nature of the diseases which affect the right and left sides of the heart respectively. Those of the right side are the result of tissue-degeneration, or of mere mechanical influences; those of the left side are almost invariably the product of inflammation. The former are diseases which tend to widen the valvular apertures, and to dilate the right side of the heart; the latter are diseases which tend to contract the valvular apertures, and to increase the size and bulk of the left side of the heart.
Disease of the right side of the heart is essentially passive and secondary in its character; disease of the left side of the heart is essentially active and primary in its character. I speak now of disease when it occurs, not when it has existed for some time. Active inflammation of the left chambers of the heart arises; it progresses to a certain extent; treatment subdues it; the patient recovers; but a certain amount of damage is left behind. Years pass on; the patient during this time appears none the worse for his previous illness; but at length pulmonary symptoms suddenly manifest themselves, and then it is that the physician discovers that the left side of the heart is permanently damaged, and that the present condition of the lungs is traceable to this cause.
In this instance the mischief in the heart inducing this condition of the lungs is not, strictly speaking, active. The first step of the cardiac disease was active; but the second step was chronic. Bit by bit—increment by increment—after the patient's apparent recovery from the primary attack, is the valvular lesion left by such attack added to, not perhaps constantly, but intermittingly, until at length the aggregate increments of addition so hamper, oppress, obstruct, and distort the mitral, or the mitral and aortic valves, that secondary consequences begin to follow.
Why are the affections of the two sides of the heart essentially different in their nature? Why do those of the left side of the heart point to an inflammatory origin; those of the right side of the heart, with but few exceptions, to a non-inflammatory origin? There must be some cause for this difference. What is it? The reason is found in the difference which exists between the constitution of the blood which reaches the left side of the heart from the lungs, and that which reaches the right side of the heart from the general system. The blood reaching the left side of the heart from the lungs has been replenished with all the elements necessary for the growth of the tissues; it has been purified, renovated, and vivified by its oxygenation in the lungs, and it is thus rendered in the highest degree stimulating to the left heart. The blood reaching the right side of the heart from the general system has been deprived, by the requirements of growth, of the chief portion of its nutrient materials; it has been fouled by the débris of tissue-waste; it has been further poisoned by its impregnation with carbonic-acid gas: it is therefore a depressant, rather than a healthy excitant, to the right heart. True, it brings with it to the chambers of the right heart the products of the digestion of food; but what are they, either as nutrients or excitants, when they reach that point? They are no more than inert, unusable, passive elements. Not until they have passed to the lungs, and have there received the vivifying influence of oxygen, can they enter into the real composition of the blood, and thus become active, exciting, disposable constituents of it.
"Like begets like" in very many instances. This axiom is true in relation to diseases of the heart. The rich, stimulating blood of the left ventricle urges, feeds, and actively supports any disease which may arise at that point; while the poor, impoverished, fouled, tainted, and attenuated blood which flows through the cavities of the right heart favors disease of a correspondingly low and degenerate character.
So long as the body is rapidly built up and as rapidly pulled down, disease of the left heart maintains an active character; but when the balance between nutrition and waste is destroyed—when nutrition becomes less active, while waste remains the same, or is more active than before—disease of the left heart loses more and more of its active character, and approximates more and more in its nature to disease of the right heart. In many this change begins at the age of forty; in others, not until five or ten years after that period. Thenceforward the tendency to inflammatory disease of the left heart declines—the tendency to degeneration increases. With the gradual declination of the one tendency and the gradual increase of the other, a period is at length reached when active inflammatory disease ceases, as a rule, to affect the left heart. At this juncture the left and right sides of the heart, hitherto dissimilar in their tendencies, are in this respect almost as one. The active tendency of early life has given place to the passive tendency of advancing years inflammation to degeneration.
Acute rheumatism—a fruitful cause of cardiac disease in the earlier periods of life—is seldom seen beyond the age of fifty. I have, however, attended a case of acute articular rheumatism at the age of seventy-five; but such an instance was an exception to the rule. After fifty, acute rheumatism gives place to a form of rheumatism which slowly produces rigidity of the coats of the blood-vessels, hardens and contracts the tendons, thickens and renders stiff and rigid the ligaments of the joints, hardens and lessens the articular cartilages.
Thus, then, according to a law of Nature, the ultima linea of life ends in—degeneration.
Apart from the influence of this law, can any accidental, casual, or avoidable circumstance favor this immutable tendency to degeneration, speaking more particularly in reference to the heart? Yes; many circumstances are daily, hourly, momentarily doing this. Thousands annually perish from heart-disease, whose lives might and would have been prolonged had but proper attention been given to the simple laws of Nature. These laws demand attention to the three great vital functions-the action of the brain and nervous system, respiration, and circulation.
None of these functions must be overworked, as none of them must fall short of their proper duty. Healthy, regular, daily action is their law of life. If the brain and nervous system are overworked, vitality is lowered, the resisting power of the body is diminished, disease is easily produced. If the brain and nervous system are underworked, the generation of nervous power is low and deficient, the vitality of the tissues becomes low in proportion, and disease is easily excited. Overwork exhausts, ruins, kills the body, just as the continued generation of the galvanic current exhausts the acid and wears out the zinc plate. The weakest point of the body has to bear the result of this violation of Nature's laws. If the heart is that point, disease falls upon it, and death before the legitimate term of man's existence is the consequence.
To keep the body in perfect health it must be duly oxygenated. There must be free and ample interchange between the blood in the lungs and the air entering the pulmonary cells. The life-stream must be purified by its elimination of carbonic acid; it must be vivified by the absorption of oxygen. The fulfilment of these conditions demands a full, free, and constant admission of pure air into the lungs. This full, free, and constant admission of pure air cannot be obtained in badly-ventilated houses, crowded buildings, schools as at present constructed, theatres, manufactories, pits, underground railways, and the like.
When the body has reached that age at which natural decay or degeneration has begun, the absence of pure air hastens and increases the degenerative tendency. Where the heart is more prone than other organs to disease, the want of pure air falls with powerful effect upon the tissues of the right heart. Their nutrition is defective by reason of the impurity of the blood with which they are fed, their vital force is lowered, their muscular fibre loses its tonicity, degeneration and debility take the place of active nutrition and power. If in this condition any stress is thrown upon the heart by hurried walking, by lifting, climbing, violent declamation, passional expression, singing, laughing, or by any unusual exercise of the voice, the tricuspid valve gives way, it henceforth fails to close its aperture, and the results of a back-flooding of blood upon the venous system of the body begin to follow. If none of these exciting causes occur, the continued breathing of impure air is followed by constantly-progressing degeneration of the tissues of the valves and muscular structure of the right heart; they become soft and feeble, their atoms shrink; the segments of the tricuspid are at length unable to meet in their attempt to close their aperture; a small chink or slit is left between them; through this the blood finds its way into the auricle above at every contraction of the heart; and soon regurgitation is followed by the secondary consequences produced in the general system—congestion of the liver, stomach, spleen, kidneys, bowels—by hæmorrhoids, general dropsy, and occasionally by cerebral mischief.
I hold that the breathing of impure air is a fruitful source of disease of the right heart occurring after middle age. How many people ignorantly favor its occurrence by confining themselves to closely-shut, non-ventilated, hot, stifling rooms, in which the carbonic acid has accumulated to 2 or 3 per cent. of the air they respire! How many are thus destroyed by being compelled, through the exigencies of life, to pass the greater part of their time in pits and manufactories where ventilation is defective, or in which the air respired is poisoned by noxious fumes and offensive emanations from the materials undergoing the process of manufacture! How many are falling victims to the poisonous influence upon the heart of the atmosphere of an underground railway! What do these facts suggest? How are these evil results to be prevented? The simple answer is—Let the rooms in which you live be effectually ventilated by an incoming current of air filtered from all adventitious impurities, and so divided that no draught shall be felt; and by an outgoing current which shall remove from the apartments the carbonic acid, carbonic oxide, sulphurous-acid gas, sulphuretted hydrogen, and other noxious compounds, as rapidly as they are generated. Apply the same principle to public buildings, theatres, schools, manufactories, pits, and to all places in which people are accustomed to congregate.
As to underground railways, the best plan is to avoid them. True, the time passed in their polluted atmosphere is usually very short; but it is, nevertheless, sufficiently long to paralyze occasionally the heart's action, and always, by its pollution of the blood and by its direct effect upon the nervous system, to favor degeneration of the structures of the heart.
It often occurs to a medical man to visit a patient for the first time, and to find him suffering from a dilated right heart. He may for some short time have been sensible of a change in his breathing on walking rather quickly, or in mounting the stairs, or he may never have felt, or at least recognized, any such sensations. His attention was first arrested by observing that his feet and ankles were swollen, especially at night on going to bed. This sign it is which gives him the first alarm, and which causes him to seek the aid of his physician. An examination of his case detects a dilated right heart, with incompetency of the tricuspid valve. How has this condition of the heart been brought about? There is no history of previous cardiac disease; there has been no illness ushering in the present condition of things; there has never been, nor is there now, any affection of the lungs, and yet the right heart has suffered a lesion fatal to life! The answer is, that every such case has passed the age of forty, that the tissues of the right heart have entered upon the period of degeneration, and that this degeneration has, with very few exceptions, been hastened by the breathing of an impure air, either during the pursuit of the ordinary occupations of life, or in the patient's own dwelling.
When the degeneration of the right heart has progressed to a certain extent, incompetency of the tricuspid valve follows either with or without the aid of an exciting cause. Hence it is easy to understand why dilatation of the right heart and tricuspid incompetency are often found to exist apart from any previous history of cardiac disease.
The third great vital function which influences the degenerative tendency of the heart is that of the circulation of the blood. To preserve the health of the tissues, the blood must not only be pure and rich in the materials of growth, but it must flow with a certain speed through all the blood-vessels. If the speed with which the blood moves is on the side of either plus or minus of the standard of health, disease will shortly arise. If it is on the side of plus, active disease of the heart, where that organ is the one to suffer, will follow. If on the side of minus, tissue degeneration will ensue. Active disease will be the consequence before middle age; degeneration after that period.
These facts teach that all violent and long-continued efforts of the body should be avoided. They hurry the heart's action to an inordinate degree, they cause it to throw the blood with great force into the extreme vessels, and, as there is almost always one organ of the body weaker than the others, the vessels of this organ become distended, and, remaining distended, the organ itself becomes diseased. Running, rowing, lifting, jumping, wrestling, severe horse-exercise, cricket, football, are fruitful causes of heart-disease. Those which require the breath to be suspended during their accomplishment are more fruitful causes in this respect than those which require no such suspension of the breathing. Rowing, lifting heavy weights, wrestling, and jumping, do this; and, of these, rowing is the most powerful for evil. At every effort made with the hands and feet, the muscles are strained to their utmost; the chest is violently fixed; no air is admitted into the lungs; blood is thrown by the goaded heart with great force into the pulmonary vessels; they become distended; they at length cannot find space for more blood; the onward current is now driven back upon the right heart; its cavities and the blood-vessels of its walls become in like manner distended; the foundation of disease is laid. Hypertrophy, hæmoptysis, inflammatory affections of the heart and lungs, are the consequences in the young; valvular incompetency, rupture of the valves or of the muscular fibres of the heart, pulmonary apoplexy, and cerebral hæmorrhage, are too frequently the immediate consequences in those of more mature years.
If the flow of blood is minus the standard of health, the heart's walls are imperfectly nourished, by reason of a deficient supply of food within a given time; the blood itself, receiving less aeration, is, in consequence, more impure; degeneration of the heart's walls is thus induced, if it does not already exist—hastened, if it is present.
I propose now to consider the influence of an increasng quantity of carbonic acid in the air respired upon the contractility of the muscular fibres of the heart.
I take for my example the newly-hatched trout. During the winters of 1869–'70 and 1870–'71, I hatched some thousands of this fish, many of which I daily submitted to microscopical examination. The result of my investigations, in reference to the action of the heart and to the influence upon it of a decreasing quantity of oxygen and an increasing quantity of carbonic acid in the water in which the fish was confined, shows—
That, on placing the fish in a glass trough containing a quantity of water, the heart is seen, under the microscope, to be affected in the following manner:
In the first few moments of examination the venous blood, collected by the veins from the head, back, and yelk-bag (the first two of which unite to form a bulbous vessel into which the third opens), is seen to be projected with considerable force and rapidity into the upper (auricle) of the two cavities of which the heart is composed, and thence as instantaneously into the lower (ventricle) cavity, which contracts with equal rapidity, and forces the blood into the branchial artery, which conveys it to the gills. The projection of the blood into the auricle, its passage into the ventricle, and its expulsion therefrom, are but the work of an instant. As the blood enters the auricle, both it and the ventricle seem to anticipate the charge of blood; but especially is this the case with the ventricle. Before the blood well touches the valve which guards the entrance from auricle to ventricle, the latter is observed to shorten its longitudinal diameter, to visibly meet, as it were, the coming charge of blood from the auricle, and to force it instantly into the branchial artery. There is no delay whatever of the blood in the auricle or ventricle. It is shot in a straight line from the vena cava through the auricle and the auriculo-ventricular valve, caught by the contracting ventricle, and deflected and forced, without a moment's delay, into the branchial artery.
From these observations it was evident that the contraction of the heart was not excited by the distention of its cavities, but that it was induced by the mere impingement of the blood upon its lining membrane. In contracting, the ventricle was seen to roll about one-third upon its axis, by which a portion of that part of it which was previously out of sight was brought into view. As soon as it had delivered its blood into the branchial artery, it relaxed, and increased again its longitudinal diameter, recoiling from systole with an energy and a rapidity equal to those of its contraction.
In three or four minutes the heart is observed to contract both less quickly and less energetically. A very short time after this the blood can be seen gently pouring into the auricle, and thence into the ventricle, which latter now allows itself to be about one-fourth filled before it contracts. It now expels its blood, and again dilates; but its dilatation, like its contraction, is not so instantaneous as it was when first observed under the microscope. In a short time longer the sensibility of the heart is greatly diminished, for the blood is seen to be accumulating in both the auricle and ventricle, but especially in the former, from both of which cavities it is now only partly expelled by the contraction of the heart.
At length, just before death, the blood is seen to flow from the auricle into the ventricle, thence into the branchial artery and along it, the heart being passive during this time, and only now and then at long intervals manifesting a very slight and partial contraction. During the whole of this time the blood is coagulating more and more in the auricle and ventricle, but especially in the former; and, when at length the heart has ceased to beat, the auricle and the vena cava opening into it are fully distended, while the ventricle is only partly distended with black-red blood. In the last moments of life, after the heart has ceased to beat, the branchial artery is seen to be pushing forward its slender current of blood, and to become at length quite empty and transparent.
Here, then, as the oxygen dissolved in the water in which the fish is confined becomes exhausted, and as the carbonic acid increases, the sensibility and contractility of the heart are diminished, and at length entirely destroyed. The negation of oxygen, and the increase of carbonic acid, have culminated in the death of the fish.
Precisely the same effect is produced upon the human heart by an accumulation of carbonic acid in the air respired.
In the ordinary condition of the atmosphere, in which carbonic acid does not exceed one part in a thousand parts of that medium, its effects upon the heart are inappreciable. When, however, the carbonic acid has accumulated to the extent of 1 per cent. of the air respired, it begins to produce a slight feeling of faintness, and some degree of uneasiness across the brow. At 2 per cent. the heart's action is quickened, the sense of faintness is greater, there is slight giddiness, with heaviness and constriction of the head, together with nausea. At 3 per cent. all these symptoms are increased. There are vertigo, fluttering of the heart, nausea and sickness, followed by an overwhelming sense of muscular prostration. At this moment the contractions of the heart become very feeble, the skin relaxes, and is bedewed with a cool, clammy perspiration. These symptoms deepen with the increasing quantity of carbonic acid in the air respired until the utmost limit of toleration is reached, beyond which life can no longer be maintained. At this stage lethargy supervenes; and, at the moment of its occurrence, the heart begins to beat less frequently and much less powerfully than before. This condition is the parallel of that observed in the young trout, when the blood begins to accumulate and to coagulate in the auricle and ventricle, and when the heart's sensibility and contractility are reduced in the greatest degree.
From these effects it is certain that confinement to an atmosphere impregnated with carbonic acid, even to the extent of one per cent. only, quickly deranges the function of the heart, and ultimately deteriorates the tissues themselves of that organ.
The greater the percentage of carbonic acid in the air respired, the more quickly and the more profoundly are these effects produced. The constant breathing of air containing one per cent. only of carbonic acid proves fatal to life; but, if it is respired for a short time only, functional disturbance alone is then and there produced. It is, however, certain that in this functional disturbance lie the germs of organic mischief, and that frequent repetition of the cause will undoubtedly end in organic disease. Hence the impure atmosphere of the bedrooms of the poor, and, indeed, of many of the middle class, proves a sharp spur to the degenerative tendency manifested by the heart, and especially by the right side of the heart, after the age of forty. Such bedrooms are generally small in their superficial area, low-pitched, and often lighted by a diminutive window, which at night is kept constantly closed; and having a door which opens to the interior of the house, but which is also closed during the occupation of the rooms. Nay, to prevent the slightest admission of fresh air, the crevices of both window and door are most carefully stopped; and, to render the matter still worse, a fire is not unfrequently kept burning during the winter nights.
What must be the effect produced upon the air of such rooms under the conditions named? I take, for example, an average-sized bedroom in the cottages of the poor—say, a room twelve feet long, ten feet wide, and eight feet high. This gives a cubical space of 960 feet, which is not more than half the cubical space allowed each patient in our best-arranged hospitals. In this room, with its diminutive window and door constantly closed, three, four, and frequently a greater number of persons pass the night of eight or ten hours' duration. No provision has been made for the admission of fresh air—none for the escape of the carbonic acid exhaled during respiration. What little provision did exist in the crevices formed by the badly-fitting door and window has been carefully abrogated by sand-bags, rolls of rags, and stuffing of every description. Thus the air of the room becomes poisoned with carbonic acid, and in this condition it is breathed and rebreathed, to the manifest injury of the heart.
A simple calculation will enable us, if not to determine with exactitude, at least to approximate to the amount of carbonic acid exhaled by each sleeper, and consequently to the degree of vitiation which the air of the apartment undergoes. I fix the number of respirations at its minimum—14 per minute; the quantity of air exhaled at each expiration at 20 cubic inches; the quantity of carbonic acid contained in the expired air at 4 per cent.; and the duration of the night at 8 hours. Hence, 14×20×8×60=134,400 cubic inches, or 77.77 cubic feet, of air expired by each sleeper during the night of eight hours. This expired air contains 4 per cent. of carbonic acid. .·.100:77.77::4=3.11 cubic feet of carbonic acid exhaled by each sleeper during the night. Suppose the number of sleepers occupying the bedroom to be four, this will give 3.11×4=12.44 cubic feet as the quantity of carbonic acid which is exhaled by the four sleepers during the eight hours of night. The room itself contains 960 cubic feet of air, and through this 12.44 cubic feet of carbonic acid would have been diffused by the termination of the night. It therefore follows that, if no fresh air entered the room, and if in consequence the carbonic acid had no means of escape, the air of the apartment would, at the end of the eight hours of night, contain 1.29 per cent. of this gas: a quantity sufficient to produce serious results.
This statement, however, does not represent all the facts of the case. It must be remembered that the oxygen contained in the air of the room would be constantly undergoing reduction by respiration during the night. If the quantity thus consumed were determined from the quantity of carbonic acid exhaled, allowing for the fact that 15 per cent. more oxygen is taken into the blood than is contained in the carbonic acid of the air expired, it will be found that from one-third to one-half of the oxygen originally contained in the air of the room would have been consumed by the end of the night. This reduction in the quantity of oxygen, and the great increase of carbonic acid, would affect the body in two ways: firstly, by a deficiency of oxygen; and, secondly, by an excess of carbonic acid, in the air respired. Hence the reduction of the one and the increase of the other would render the air far more injurious than if only one of these changes in its constitution had taken place.
The actual result is not, however, in strict accordance with this calculation, because fresh air, although in limited quantity, does find its way into the room, and carbonic acid does, to a limited extent, find its way out. These, therefore, would modify the constitution of the air of the room at the close of night; but they would still leave it with an excess of carbonic acid injurious to life.
It is found that when air moderately impregnated with carbonic acid is inspired it greatly impedes the exhalation of more from the lungs; and that the greatest quantity of carbonic acid which exists in prebreathed air never exceeds 10 per cent. It is much to be feared that to this degree of vitiation the air of the bedrooms of the poor and of others not unfrequently rises by the too prevalent system of excluding fresh air, and by the frequent absence of provision for the escape of that which has already passed through the lungs.
Can it then be a matter of surprise that death from diseased heart should so often occur during the night?
In thousands of instances of cardiac disease life is thus sacrificed, where, had but proper ventilation of the bedrooms been observed, the subjects of such disease might, despite the cardiac mischief, have continued to live for an indefinite time.
It has frequently been my duty, during a practice of nearly thirty years in the midst of a large community prone by the habits and particular avocations of the people to heart-disease, to investigate cases of "found dead" in bed, and I have often been compelled to refer the immediate cause of death to the effect of carbonic acid liberated by respiration and confined to the apartment, in destroying the sensibility and contractility of the heart, rather than to the direct influence of the diseased heart itself.
I remember that on one occasion I was summoned to a case which had occurred in a bedroom fifteen feet long, twelve feet wide, and eight feet high. In this room, with the door and window closed, no fewer than twenty persons slept night after night! Can any one doubt that the air of such a room would be charged to excess with carbonic acid exhaled by respiration? Those who perished in this manner were beyond the age of forty; and, in every instance examined, the right side of the heart was either primarily affected by tissue-degeneration, or by disease consecutive to mischief in the left side of the heart and lungs.
Often indeed in the dwellings of the middle and higher classes of society the provisions for ventilating both their bedrooms and their day-rooms are miserably inadequate to preserve health. The consequence is, that cardiac disease is promoted to an inconceivable extent. There is no other disease in which the demand for cold, fresh air is so urgently pressed by the patient as in cardiac disease. There is none in which a constant supply of pure air is more needed—none in which it is more grateful to the patient, or in which it has a more immediately beneficial effect. At all times and seasons—in the depth of winter—by day and by night—a patient suffering from a paroxysm of cardiac asthma will hurry to the open door or window, and there, with his body hanging half out, will remain, with scarcely any vestments upon him, breathing the cold air until the paroxysm has ceased. Ought not this urgent, this powerful supplication of Nature to teach us the importance of ventilation, and of a full supply of fresh air in the treatment of heart-disease?
I hesitate not to say that free ventilation—the free admission of pure air into the apartment by day and by night—is one of the most important remedial measures which can be adopted in the treatment of this disease.
Where this means is defective, but where, nevertheless, the vitiation of the air of the bedroom does not exceed 1 per cent. of carbonic acid, a sensible effect is produced upon those who have slept within its influence. They complain, on leaving their bed, of weakness; their limbs tremble; they feel somewhat giddy, and their head feels heavy, or it aches. The least effort disturbs the heart's action, which is somewhat quick and feeble; their countenance is pale; the lips are not unfrequently somewhat blue; and the tongue is covered with a thin, whitish, and somewhat slimy fur. The appetite is in abeyance; there is a feeling of nausea; and the first evacuation is generally dark in color.
What is the pathological condition of such patients at this moment? Simply this: The blood contains an excess of carbonic acid, which, circulating with the blood through every organ, disturbs the natural action of every organ, blunting its sensibility, vitiating its particular function, and interfering with those molecular changes which constitute healthy nutrition.
A person thus affected does not usually die. The body, removed to a pure atmosphere, begins at once to excrete the carbonic acid by the lungs, the liver, the skin, the kidneys, and the bowels, and in the course of a few hours the more visible manifestations of its baneful effects have passed away. It, however, often happens that a sense of weariness and muscular debility is felt for days afterward. Night, too, frequently places such subjects in the same condition as before. The same bedroom is occupied; the same inadequate means of ventilation continue; the same accumulation of carbonic acid takes place; and the same effects upon the bodily organs are repeated. Blood charged with an excess of carbonic acid again pervades every tissue of the heart, diminishing its vitality, lowering its sensibility, and assimilating its nutrition to that of the reptilian heart. But the low character of the nutrition of the reptilian heart does not accord with the comparatively quick circulation, rapid nutrition, vital power, and energy of action required by the human heart. The one cannot be substituted for the other. In man the change results in disease where disease does not exist—aggravates disease where it is already present.—Lancet.