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is also found in pathological hearts. Mackenzie, for example, points out that hearts with thin and dis- eased walls working against high arterial tension will not show any signs of dilatation and "on the other hand dilatation of the left ventricle may oc- cur, even when the diastolic force filling the ven- tricle is greatly diminished, e. g., in pure mitral stenosis." (2.) These marked differences in the cardiac muscular pumping power have been tentatively ascribed to differences in muscular tone (3, 4) ; that is, alter- ations m the amount of nerve energy transmitted to the heart account for alterations of tone or "ten- sive force." (Allbutt, 5.) This explanation, at present only partly based upon experiment, will probably be found to correspond with the result of further work and experimentation in this field. Clinical evidence also supports this theory for it, at least partly, accounts (as some of the cases de- scribed below will show) for the resumption of a practically normal "tone"' of hearts that have been subjected to extreme dilatation (61. It is not within the scope of thi.-- paper to dis- cuss endocardial or haemic mumurs, or the varie- ties and symptoms of cardiac dilatation. The writer wishes to describe particularly those Cheapest Generic Viagra Prices pa- tients with attacks of dilatation, whose course and symptoms he has been able to follow for years, and in whom he has been struck with the great differ- ence in the intensity of their heart symptoms pre- sented at various times. In some of the cases, the myocardial dilatation was secondary to valvular and arteriosclerotic changes. In others, there had been evidences of well marked and severe acute myocardial insufficiency and dilatation : after a va- rying period of days, months, or even years, the heart had regained its normal muscular strength and "tone" (7) and practically nothing had re- mained except the slight difference in the first sound at the apex (8, 9). A most careful examina- tion at this time will detect no alteration in the size of the heart from the normal : the heart's reserve force is again established, patients can again attend to their daily tasks, including laborious work (10). It is the alteration of the first sound as a sequel of an attack of dilatation upon which the writer places great significance as an indication of former cardiac mischief (11). This alteration may consist in nothing more than a diffuseness (slight or marked') of the 'natural sharpness and definition of the first apical sound (12) ; there may be a so called "split" first sound, i. e., a slight halt or break in its continuity ; there may be a bare impurity, a lack of distinctness of the first sound, or there may be a faint scarcely Cheapest Generic Viagra Prices dis- cernible soft blowing whiff or murmur accompa- nying or partly replacing the beginning of the api- cal systole. This murmur or whiff is not trans- mitted, is never Cheapest Generic Viagra Prices loud or rasping, and is at times only noticeable after sharp exercise (13, 14, 15). The following are a few case histories selected to illustrate the condition under discussion. Some of the patients had gone through several attacks of severe cardiac dilatation, accnnipauied by marked physical and auscultatory signs of decom- pensation. When improved, Cheapest Generic Viagra Prices however, nothing re- mained of the attack except an impure first sound. C.\SE I. K., male, age fifty years, had suffered from se\eral e.xceedingly dangerous attacks of acute pulmonary cedema; in each of these attacks the patient became very cyanotic the pulse very irregular, the heart sounds almost inaudible, and death seemed imminent. In each instance several days after the attack, the only noticeable change ni the heart was a muffied, impure first mitral sound. Case II. S., female age tifty-si.x years. Six years ago >he was first seen in an attack of malarial fever (tertian type) ; the heart was moderately Cheapest Generic Viagra Prices dilated with a loud sys- Cheapest Generic Viagra Prices tolic murmur at the apex and very irregular heart action ; the symptoms were those of moderate decompensation. .\iter a few days under the administration of quinine, the fever disappeared and with it the above cardiac symptoms and signs. During a period of two years thereafter, there were several such febrile attacks, each accompanied by a similar condition of the heart. There had been no attack since. At the present time the heart action shows only occasional intermittence and a faint murmur accompany- ing the first sound at the ape.x. C.'^SE III. B., female, age forty years, had had diabetes mellitus ; irregular "rheumatic" pains, refused to follow proper diabetic treatment for any Cheapest Generic Viagra Prices length of time. Under careful diet the sugar rapidly disappeared from the urine : when indiscreet in her diet, sugar soon reappeared (from 1.5 to two per cent.). In several of these attacks of glyco- suria, cardiac dilatation developed, accompanied by loud systolic murmurs at the aortic and mitral valves. In the intervals and since the last attack (one year ago) these marked e\idences of dilatation disappeared, leaving only a faint murmur accompanying the first sound at the apex. Case IV. F.. male, age forty-two years, alcoholic; three years ago he was first observed in an attack of severe car- diac dilatation (alcoholic myocarditis) with marked dys- pnoea and Cheapest Generic Viagra Prices a loud systolic murmur at the apex. His symp- toms lasted about four weeks, after which time the phy- sical signs and .symptoms Cheapest Generic Viagra Prices gradually improved. There had been no subsequent attacks. At present, the heart was slightly enlarged and there was a muffled sound accom- panying the first systolic at the apex ; compensation seemed perfectly established. Case V. E., female, age fifty years ; ten years ago had severe dyspncea lasting several days, and marked evidence of broken compensation. The heart was dilated, irregular in rhythm, there was a loud regurgitant mitral murmur present. Under treatment the heart gradually resumed its normal function. After several months the patient was again able to take up her duties and had Cheapest Generic Viagra Prices been at her work ever since. At the present time, the heart is normal ni size, beats regularly; Cheapest Generic Viagra Prices there is a slight whirring sound ac- companying the first sound at the apex. Case VI. M.. female, age forty-five years, suffered from severe alcoholic pseudotabes ; during convalescence, Cheapest Generic Viagra Prices myocardial dilatation developed. Cardiac examination showed loud systolic, aortic, and mitral murmurs. After several months the Cheapest Generic Viagra Prices cardiac condition cleared up; there now remained a faint murmur accompanying the mitral systolic at the apex. Case VII. Cheapest Generic Viagra Prices R., female, age forty years, was exceedingly neurotic; no rheumatic history; was a moderate beer and wine drinker. Four years ago during the course of an attack of alcoholic neuritis, toxic myocarditis developed.