'-...^.-.•si. :-y;!^y: 3d (Clarence WMlarb Antler. NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Gift of The National Center for Homeopathy Tl W* gfit //Maesimund Ibanninq panes lubrary 19- o^L-^ ^OmqeO' Ml 61 / A DIAGRAM OF THE HEART. (After Ewart.) 1. Relative position of the heart, especially to the liver. The dotted line is the posterior border of liver behind heart. Only a small portion of the left ventricle L. V. is shown behind the right ventricle R. V. The dashes marked t. v., m. v., a. v., and p. v., locate approximately the valve regions. The circle" M" site of loudness of mitral (first) sound. " T " site of tri- cuspid (first) sound. "A" location of aortic or (second) sound. "P" site of loud- ness of pulmonary (second) sound. The arrows are explained in the text—see p. 15. HAND BOOK Diseases of the Heart AND THEIR HOMEOPATHIC TREATMENT. Thomas C. Duncan, M. D., Ph. D., LL. D., PROFESSOR OF GENERAL MEDICINE AND DISEASES OF THE CHEST, NATIONAL MEDICAL COLLEGE, CHICAGO; AUTHOR OF 'DISEASES OF CHILDREN AND THEIR HOMOEOPATHIC TREATMENT, '• P.EDOHYGEA," "HOW TO BE PLUMP," ETC., ETC. PUBLISHER: HALSEY BROS. CO., CHICAGO. COPYRIGHTED BY T. C. DUNCAN, M. D. 1898 DISEASES OF THE HEART. A CLINICAL OUTLINE. Diseases of the heart are most serious, often the most insid- ious and least understood of all the disorders that the practi- tioner may encounter. Hence the great necessity for clear and concise instruction upon this branch (and it is believed for an elementary work, plain and practical). Those who would master diseases of this vital organ must make careful reviews of its peculiar anatomy (and dissect many hearts), comprehend its histology, understand the workings of its mechanism and the effect of various disorders of remote organs upon the heart as well as the etiological factors of occu- pations, habits, foods and drugs especially as revealed by toxi- cology and the provings found in our materia medica — as taught today in all thorough medical colleges. The effects of stimulants, including whisky, beer, wine, tobacco, tea, coffee, etc., and all drugs as well as various waters and localities upon the heart should be familiar to the cardiolo- gist. The principal diseases of the heart should be easily diag- nosticated by every physician. The salient points in physical diagnosis should be emphasized by constant drill. Life insur- ance societies find difficulty today in obtaining reliable exam- iners. The family physician should know about all the hearts in his field of labor. He would, if he could read the pulse aright. Many people will not submit to a physical examination of the chest for fear serious disease of the heart will be discovered. 6 DISEASES OP THE HEART. To capture the confidence of these people, especially ladies, demands both tact and the evidence of much general knowl- edge of the relations of the heart to other organs of the body. Here "a, little knowledge is a dangerous thing" all around. People know that sudden death is often caused by disease of the heart and they infer that those who may have disease of this vital organ are liable to die suddenly, therefore the result of the examination should not leave them in doubt—"to live in fear and trembling all their days." [See "Diseases of heart caus- ing sudden death," p. 54.] The physician can explain that there are many slight diseases of the heart as well as serious ones—functional as well as structural. He should explain that fear shocks the heart, stops it for a moment, during that time the blood leaves the brain and faintness is felt. We lay the person down so that the blood can get back more easily to the brain. Water dashed into the face shocks the nerves and starts the heart to more vigorous action. All should know that excitement and overwork are the chief causes of serious diseases of this organ; also that rheumatism is an accidental cause that all may be liable to. Digestive disorders may give rise to car- diac disturbances and vice versa. Functional disturbances when long lasting may bring about structural change. Physiology (Carpenter) tells us that "concentrated attention will disturb and derange any organ," so that great tact is often neces- sary in the diagnosis and subsequent management of cases with disease of the heart. Diverting the attention (as practiced by Christian Scientists so-called) may benefit some cases, while in others the strong will of the patient may be necessary to assist the work of a feeble heart and so prolong life. The anatomical relations of the heart should receive the first diagnostic attention. Is the chest capacious? or is there con- striction of the bony environment and organs? The heart occupies much lung space in the left chest, you know, and its function can be impeded or accelerated by the condition of the A CLINICAL OUTLINE. 7 lungs. A new motion of the heart has been discovered which is that of "lateral expansion," that takes place during expira- tion. When respiration is retarded as in asthma, emphysema, etc., the heart labors with difficulty. The heart lies upon the diaphragm and when the action of this septum is impeded, in any way, the function of the heart will also be disturbed. The left lobe of the liver it will be seen extends well under the heart, even to the left nipple line and when enlarged, or ele- vated by the organs below, must crowd the heart. [In one case of tumor involving the liver that came under the notice of the author, the heart was crowded up to the fourth interspace and well to the left. The person was young.]. The cardiac end of the stomach extends up behind and to the left of the heart and when distended with gas from tardy digestion, especially in cases of hypertrophy and dilatation the heart may be so crowded as to interfere with its function. Palpitation and arrhythmia are often due to indigestion. The pancreas beneath and the spleen to the left when enlarged especially, may, in cases of stomach indigestion, crowd upon the heart and thus interfere with its function. In many a case of a weak and failing heart indigestion is the first persistent and alarming complication. In spare people the visceral organs may be dislocated and brachycardia or tachycardia be the result, aggravated by a droop of the shoulders. In fleshy subjects the colon, instead of crossing the body just above the navel, as in the spare subject, will be distended and pushed high up. When severely dis- tended with gas may crowd up and impede cardiac action. The chief cause of short breath in fleshy people, you know, is due to the disturbed abdominal viscera crowding upon the thor- acic. Superficial respiration tends to increase the venosity of the system and weakens the heart. This condition is aggra- vated if there is also a stoop of the shoulders, perhaps due to hard work or injury to the back. In cases of hypertrophy of the heart especially of long standing in young, growing people, 8 DISEASES OF THE HEART. there may be an elevation of the left shoulder and a droop to the right with a slight rotation of the thorax forward and out- ward. This often explains the "precordial bulging." The object of this change of shape is to give the heart more room. Malformations of the heart are not as frequently met with as are those of other organs of the body. In examining every case we locate the apex beat as the next step in diagnosis. * Sometimes the visceras are reversed, as in one instance that came before us. An x-ray picture brought out the cardiac and liver outlines, proving conclusively that the organs were reversed. Cases of infantile heart, with the right ventricle the best developed, are so.metimes met in practice. There are usu- ally other evidences of lack of development. The systemic cir- culation is deficient and cold hands and feet and anaemic head- aches should direct the attention to the probable cause. Proper nourishing food and exercise can do much if the subject is young, to reinforce the heart and circulatory system. The for- amen-ovale may be patulous giving rise to cyanosis. In in- fancy we will have a "blue baby." Plumping the r.ew born baby down on its right side assists materially in closing this fcetal inter-auricular opening. The right side position should be maintained for some time after birth. [This the author always advises; also on account of the large liver filling one- third of the abdominal cavity.] This position also helps to develope the left ventricle. Ihe physician should carefully watch the development of this vital organ during the growing period. The attachments and position of the heart are peculiar, and should next engage our attention. It is located as high up in the thorax as possible, so as to enable the aorta to arch properly. In fact, the base is well to the right, so that the aorta can describe a graceful curve and pass backward, downward and to the left of the vertebral column, to which it is firmly anchored The heart is supported by the aorta and other vessels at its A CLINICAL OUTLINE. 9 base and fascia. The next question now before us is: Is the heart dragging her anchors? Lack of integrity of the ligaments has much to do in developing anaeurism (see p. 50) and serious systemic symptoms. It should be remembered that "when the blood is discharged into the aorta and pulmonary artery, these vessels are slightly elongated, owing to the increased blood pressure (Senac)." Marked depression at the throat pit sug- gests a possibly displaced heart. The cardiac outline should now be ascertained by careful percussion. The pleximeter and hammer should be used, although the fingers are often all-sufficient, but for deep percus- sion the instruments will outline the dullness better. Have the patient hold the breath or percuss only during expi- ration, while sitting. A practical point here should not be overlooked. In comparative anatomy the heart is met as a double organ, with two cavities each, while in the human heart these four cavities should be tightly bound together with a firm, fibrous band. Lax fibre may account for a flabby, large heart. In the adult the left ventricle is the best developed, because it has most work to do to pump the blood around the whole body. It lies behind the right ventricle, but during contraction the heart elongates and rotates slightly to the right, if there is defective development of the right ventricle. Two points of practical value should be ascertained. 1st. Is the heart firmly bound together; and 2d, Is the muscular development normal or abnormal? In a rough way the heart should correspond to the fist clenched about the extended thumb. [This the author has verified repeatedly, even in children, at the Chicago Found- 10 DISEASES OF THE HEART. ling's Home.] The heart increases in size during growth, and "even to advanced age" we are told. The cardiac envelope should next be carefully investigated. "Precordial retraction" will suggest pericardial inflammation, involving the mediastinum and producing sinking in of the sternum. Inflammation here may leave a roughened surface and adhesions. These will be apparent by friction at the ajex on stooping or irregular erratic cardiac action on lying dcwn. Palpitation and auscultation will usually solve the problem. It is well to remember that the pericardium is a dense, serous membrane, but when swollen by inflammation the meshes allow corpuscles to pass so that fibrous bands may be left to retard the heart—just as after pleurisy with sero-fibrous exudation we may have adhesions. Left side pleurisy may also involve the peri- cardia m, so in all cases with a history of sharp pain in the left side the condition of the pericardium should be ascertained by careful and repeated examinations. The heart function deserves a close clinical study. It is a principle in physics that the motive power should be placed at the point of least resistance—nearest the centre of its work. Perhaps if the convolutions of the brain were unraveled the heart would really be at the centre of the body. The head is the chief end of man, therefore this thinking machine must receive a large share of blood—one-fourth or one-third. The stooped position of the student doubtless favors a still larger supply as evinced by the cold hands and feet. This position taxes the heart as we shall see. Walking, the erect posture and deep breathing are the best correctives; as the increased muscular tone assists cardiac action. The heart is a muscular pump of enormous power. It is the function of muscle to contract. From your histology you learned that although made up of involuntary muscular fibres there is here no fibrous sar- colemma, so that muscular stiffness, rigidity and fibrous degen- A CLINICAL OUTLINE. 11 eration does not take place in the heart muscle itself. Its fibres are stripped for work and work as no other muscles in the body can work. When the artery at the wrist or temple is hard and tortuous we may expect sclerosis (fibrous thickening and degeneration) not only of the arteries but of the valves and cordae tendinae. We look for this in large jointed rheumatic subjects. A careful study of the cavities of this organ will help to mas- ter its diseases. It is lined throughout with dense serous mem- brane, thrown into rugas by the peculiar anatomy. In the ven- tricles strong, muscular columns stand out, joined to fibrous bands, going to make up the bars that form the two-fold gate (mitral valve) and the triple one (tricuspid valve). You should know that at post-mortem three fingers may be passed into the right auricular opening, but only two will be admitted into the mitral opening. Inflammation here roughens this smooth sur- face and draws these valves out of shape, giving rise to cardiac murmurs and complications. When the ventricles contract these valves close, so as to prevent the blood going back into the auricular vestibules. The valves at the ventricular outlets are moon-shaped (semi-lunar), and it takes three of them to close the circular aortic and pulmonary openings. These valve seg- ments are saucer-shaped and, as might be inferred, contain dense fibrous tissue. The outer lip has a firm border, corpus arantii, that often is the seat of disease, calcareous and fibrous. (See Valvular Diseases.) Although the heart handles so much blood it has a liberal supply of its own. The coronary arteries that run along the ventricular septum arise, you know, from the vestibule behind the aortic valves. This eddy current ensures a good cardiac supply, but like all eddies the tendency to deposit calcareous salts or fibrinous clots in the coronary arteries is very much facilitated thereby. Its nervous connections. The heart is termed the emotional 12 DISEASES OF THE HEART. centre, and the review of its anatomy will not be complete until we see how it is wired to the nervous system. Besides, the deep cardiac ganglia that are a part of the great sympathetic sys- tem, this is reinforced from the spinal. It also has branches from the pneumogastric, and besides there are superficial ganglia, and each ventricle is also well supplied with a separate ganglion. This vital organ must not fail from lack of nervous stimulus. Some of its functional disorders are due to this nervous arrange- ment, as we shall see. [Vide Palpitation.] It has been ascertained that "The cardiac ganglia cause the rhythmic movements of the heart, while the fibres of the spinal accessory nerve, conveyed to the heart in the trunk of the vagus, restrain and inhibit its movements, even to the arrest of the heart's action." We infer that in tachycardia that the gang- lia are irritated, while in arrhythmia the spinal nerves are doubtless involved. More decided involvement doubtless ex- plains the spasm of angina pectoris. The heart in action. The heart is likened to a pump. It is a most vigorous muscular accelerator of the circulation. It is believed that the blood is partly driven and partly drawn into the right vestibule from above and below. The valves in the veins and the valvular shape of the auricle prevent regurgita- tion or back flow. If there is obstruction anywhere in the portal circulation, especially in the liver, the function of the heart will be disturbed. Let us study its workings. This right ante chamber is filling with blood while the ventricles are con- tracting. After a brief pause the tricuspid valve opens and the blood is drawn into the ventricle, a short pause ensues, then comes the contraction and the blood rushes into the pulmonary artery, while the valve here closes as the ventricle relaxes. At the same time the blood from the lungs returns by four vessels and fills the left auricle or antechamber. With the ventricular relaxation the blood is drawn in and forced into the powerful A CLINICAL OUTLINE. 13 left ventricle which soon forces it out and into the aorta and all over the body by its tremendous contraction. The double action of the heart is really eccentric, for with every ventricular elongation the apex is lifted, and drops down and back with each relaxation. It is well to place the patient in various positions while examining its action. Examine it also at various times a day. The systole corresponds, yon know, with the first sound of the heart. The second sound is diastolic. They have been likened to the expressions "Lubb-dup—lubb-dup." The first sound is therefore prolonged while the second is short and sharp. Many theories have been presented to explain these sounds, but the most recent one is that advanced by Sir Richard Quain who believes that the first sound is produced by the blood being forced against the aortic and pulmonary semi-lunar valves; while their closing produces the second sound. If this is true it will help to simplify the heart sounds and assist in reaching a ready diagnosis in endocardial diseases. Taking the pulse. The first usual step in heart diagnosis is " to take the pulse. The Chinese, who are reported to diagnose most diseases by the pulse, place three fingers on the radial artery and sometimes both hands. The character of the (1) blood- flow, (2) its conduits and (3) the condition of the heart-pump are the three points of inquiry. Rapid flow goes with fever or palpitation. When the thermometer is in the mouth to take the temperature, then is a good time to take the pulse. The mind of the patient will be centred upon holding the thermome- ter and leaving the pulse uninfluenced. Put the arm at rest as in the lap and grasp the pulse with the fingers, while the thumb rests upon the unfeeling radius. Hold the pulse for a full minute, so that the blood will have gone at least twice around the body. The character of the artery under the finger is the first point to note. It should be smooth, soft, compressible. If 14 DISEASES OF THE HEART. hard and tortuous it speaks of a diseased condition. (See Atheroma.) If the flow is "shot-like" ("a water hammer pulse") it tells of aortic disease, described elsewhere. If the flow is irregular, now rapid and full, now slow and feeble, the cause may be remote. A slow pulse (brachycardia) may be con- stitutional or muscular, the same is true of arrhythmia. The frequency of the intermissions should be noted by repeated examinations. They may be stomachic or muscular. If increased by walking the condition may be serious. (See case reported.) It is sometimes a result of disease. Several drugs cause an intermittent heart. The condition of the blood-stream should be read in the pulse. In anaemia or hydraemia the action is usually rapid, and the artery is not full, and therefore easily compressible. If the artery is full and tense, without fever or nervous excitement, we may expect to find hypertrophy. With the micro-stethoscope the pulse may be auscultated, but the fing- ers should be the tactus eruditus. Now the radial and temporal arteries may be read together. The pulse of both wrists should also be compared. The carotids may be interrogated. The pneumogastric nerve passes down here, you remember, so that slight pressure may shock the system, as well as frighten the patient. In auscultation of the heart, as we have four sets of valves, we are obliged to listen at four different points Remember that the blood carries the sound along, therefore we listen for the closing of the valves at the points indicated on the diagram. (See frontispiece.) It will be found to be the most satisfactory to take the left side of the heart first, beginning with the mitral valve. If this valve is normal the two heart sounds should be clear and distinct. We presume also that the other valves are in a normal condition. The next set examined should be the aortic. Then the pulmonary, best heard at the second in- terspace, may be interrogated; and, last of all, the tricuspid, over the ensiform cartilage. If there is any suspicions that the A CLINICAL OUTLINE. 15 ventricles do not contract fully or synchronously, the tricuspid valves should be auscultated after the mitral, and in rapid suc- cession. The same plan may be followed in auscultating the aortic and pulmonary in a diastolic murmur. All abnormal heart sounds are termed "murmurs." It is well to place the person examined in various positions, as sitting and lying* as well as standing. It should be remembered that a ventricular murmur may disappear when laying the patient down. One disagreeable feature about heart examination is the ne- cessity of disrobing. Fortunately the new stethoscope makes the heart sounds so distinct that many cases can be examined outside of light covering. It is always well, if the patient is at all nervous, to begin in that manner. To oblige you the chest will be gradually exposed. The flat hand may be passed under the clothing and the apex beat located by the finger tips. If found at the normal point we may usually exclude both hyper- trophy and dilatation. If the lower part of the micro-stetho- scope is removed, the flat surface (warmed, if the day is cold) may be placed over the various valve regions even under the clothing. If the ear is used, ask for a linen handkerchief to cover the chest. At the mitral region we listen for the normal heart beats, also over the ensiform cartilage. At the aortic region (second interspace) we hear best the sharp click of the closing valve; the same is true when we listen over the pul- monary valve region. If the sounds are not normal then we go over the regions again and again, to differentiate. Now study and compare the chart given as frontispiece. The arrows are intended to show the character of the murmur. Commencing at the apex (just outside and above) we may have a "thrill," limited to the apex and well to the left. That indicates mitral obstruction or stenosis, sometimes called an onward mitral murmur, and is presystolic in time. The arrow points downward. This disease is a rare one. The other arrow 16 DISEASES OF THE HEART. here represents an insufficiency—a regurgitant mitral murmur. That is systolic. Coming now to the right ventricular region a tricuspid regurgitant murmur is indicated by the arrow. That is sys- tolic occurring during the severe ventricular contraction. Now the aortic valve should be carefully examined. If there is obstruction or stenosis here (as may be found if there is also mitral regurgitation or insufficiency), then we will find the murmur transmitted outward. The outward arrow indicates an outward obstructive aortic murmur. If we have a regurgitation or backward flow then the sound will also be conveyed back- ward. The downward arrow indicates a regurgitant aortic murmur—aortic insufficiency. When we have both as well as- defective mitral valve the diagnosis is difficult and confusing. (See Clinical Illustrations, whistling heart.) The pulmonary valve is not often diseased except as in dis- turbed respiration. The murmur most frequently heard here is haemic and in the diagram is represented by a two-headed arrow with a small p on the stem. It indicates an outward pul- monary murmur. Regurgitation is so rare that the downward arrow is omitted. The next problem to solve is whether the murmurs are endo- cardial, (inflammatory or degenerative) or muscular. To determine that we proceed by exclusion. The prominent physical signs of diseases of the heart should be recalled with every case examined. It takes constant prac- tice to become an expert cardiologist and often repeated exam- inations to settle obscure points. The duties of life insurance examiner give experience along a certain line of cases, but none has a finer or more varied field than the family physician. Children are willing subjects and their record should be taken at least twice a year; four times -would be better. No heart should go wrong under proper attention. In these days of athletics muscular and nervous strain s! ould be prevented by close attention and proper management. More people would live longer if this vital organ received intelligent attention. DISEASES OF THE HEART. REVIEW QUESTIONS. 9 PHYSICAL SIGNS OF HEART DISEASES. 1. Precordial retraction is diagnostic of what? 2. What causes precordial bulging? 3. When is the apex beat found well to the left? 4. When to the left and downward? 5. When displaced to the right? 6. When is the heart impulse almost imperceptible? 7. Signification of excessive heart impulse? S. Signification of a purring sensation? d. Cause of grating sound ? 10. Pulsation in right second intercostal space? 11. Pulsation apparent in jugular veins? 12. What does hardness, loss of elasticity and tortuousnesa of the arteries signify? 13. Intermittent or irregular pulse is diagnostic of what? 14. When is the pulse beat slow, firm and prolonged? 15. When is the pulse shot like? 16. The paradoxical pulse—what is the cause? 17. Intermittent action of heart signifies what? 18. Cause of irregularity of rythm? 19. Signification of palpitation? 20. Increased area of dullness is diagnostic of what? 21. Describe difference of heart sounds in the fleshy and spare ? 18 DISEASES OF THE HEART. 22. Increase of first sound over ensiform cartilage denotea what? 23. Exaggeration of second sound at same spot means what? 24. Suppression of first sound what? 25. When is second sound suppressed? 26. When doubling of heart sounds? 27. Describe murmurs and varieties. 28. Define precardial murmur. 29. Varieties of endocardial murmurs as to caii3e? 30. A systolic murmur heard loudest at apex, what? 31. Systolic murmur over ensiform cartilage? 32. Harsh systolic murmur at second intercostal space on right side of sternum? 33. A whistling or musical murmur signifies what? 34. Diastolic murmur heard over aorta? 35. A systolic murmur over pulmonary valves? 36. A presystolic murmur at apex? 37. What order in frequency of endocardial mnrmnrs? 38. What combinations of murmurs are met? 39. Character of haemic murmurs, where detected? 40. Venous murmurs and where heard? 41. Describe dynamic murmurs, where and when heard? 42. Differentiate pleuritic sound from heart murmurs? FUNCTIONAL HEART DISEASES. 1. How may heart disorders be classified? 2. Name the chief functional diseases? 3. What other name is given them? 4. Define Palpitation of the heart—functional? 5. Give the principal causes? 6. What conditions give rise to nervous palpitation? 7. Causes of dyspeptic palpitation? 8. How does rheumatism cause palpitation? 9. Differentiate functional palpitation from structural? REVIEW QUESTIONS. 19 10. What are the alarming symptoms? 11. Give outline of treatment of palpitation? 12. Name the chief remedies and indications. 13. Give symptoms of Weak heart. 14. What are the chief causes? 15. What pathological condition may be present? 16. Give outline of treatment. 17. Name the principal remedies for weak heart. 18. Give diagnostic signs of Exophthalmic goitre? 19. Nature and pathology of this disease. 20. Describe its course and effect upon heart. 21. Give prognosis. 22. Enumerate the supposed causes. 23. Give management and remedy indications. 24. Diagnose Angina Pectoris. 25. What is its etiology? 26. Describe an attack. 27. What is its pathology? 28. What is the prognosis? 29. Describe management of an attack. 30. Give remedies that may be indicated. STRUCTURAL DISEASES OF THE HEART. 1. Enumerate the structural diseases of the heart. 2. Describe Hypertrophy of the heart and forms. 3. Give the diagnostic symptoms. 4. Give the causes of this disease. 5. Course and sequale of this disease. 6. Give management of a case. 7. What remedies may be indicated? 8. Diagnose Dilation of heart. 9. Give the usual causes and forms. 10. Give physical signs. 20 DISEASES OF THE HEART. 11. What complications may be met? 12. Give management and remedies. 13. Describe Atrophy of the heart. 14. Give the causes. 15. Diagnostic signs. 16. Give management and indications for remedies. 17. Define a Fatty heart. 18. What are the principal symptoms? 19. Give the prognosis. 20. Describe the management of a case. 21. Give chief remedies and indications. INFLAMMATORY DISEASES OF THE HEART. 1. What is Pericarditis? 2. Enumerate the chief causes. 3. Is the inflammation usually general or circumscribed? 4. Describe an attack giving the prominent symptoms. 5. Give the stages of this disease. 6. Give the serious symptoms. 7. Give the physical signs. 8. Give the prognosis. 9. Describe the management. 10. Give remedies, order and symptoms. 11. What is Hydropericardium? 12. Give its principal symptoms. 13. Outline the treatment and give remedies. 14. Define Carditis or Myocarditis. 1£. Give diagnostic symptoms. 16. State the complications. 17. Give treatment and remedies. 18. Define Endocarditis. 19. Is it a primary or secondary disease? REVIEW QUESTIONS. 21 20. Causes for each. 21. Give the chief symptoms. ,22. Differentiate endocarditis from pericarditis. 23. Enumerate the complications that may arise. 24. Give sequale that may follow an attack. 25. Describe management of an attack. 26. Outline remedies that may be indicated. VALVULAR DISEASES OF THE HEART. 1. Enumerate the valvular diseases. 2. Causes of valvular lesions. 3. Pathology of valvular changes. 4. Which valve chiefly affected in young people? 5. Describe Mitral Insufficiency. 6. What are the chief causes and pathology. 7. Give diagnostic signs. 8. What is Mitral Stenosis. 9. What are the principal causes? 10. Give its diagnostic signs. 11. Which valve is most often affected in the aged? 12. Describe Aortic Insufficiency. 13. Give the causes therefor and sequence. 14. Give the diagnostic symptoms. 15. Describe Aortic Stenosis or obstruction. 16. Give the causes and complications. 17. Enumerate the diagnostic signs and symptoms. 18. Sequale of advanced mitral and aortic valvular disease. 19. Describe Tricuspid Insufficiency. 20. Give the causes producing it. 21. Give the diagnostic signs. 22. Complications and sequale. 23. Describe Tricuspid Obstruction. 24. Give the causes thereof. 22 DISEASES OF THE HEART. 25. Diagnostic signs. 26. What is cause of Pulmonary Obstruction? 27. Give diagnostic signs. 28. Give signs of Pulmonary Insufficiency. 29. Give order of valvular involvment. 30. What results when compensation ceases? 31. Give management of cases of valvular lesions. 32. Give principal remedies and indications. 33. What is meant by atheroma? 34. Describe aneurism. 35. What remedies have arrested aneurism? 36. What is varicosis? 37. What is embolism? 38. Give curative remedies. 39. Give diseases of the heart that cause sudden death. HEART REMEDIES. 1. How would you classify the heart remedies? 2. Enumerate the inflammatory medicines. 3. Enumerate the drugs for structural change. 4. Give the chief functional heart remedies. 5. Give the ones where pain guides in the selection. 6. Outline the Aconite heart attack. 7. Describe the Veratrum Viride heart. 8. Give the emphatic heart symptoms of Bryonia. 9. Outline a case where Spigelia is the remedy. 10. When would you give Belladonna1? 11. Give conditions and symptoms calling for Digitalis. 12. Symptoms calling for Kali carb. 13. When and why would Colchicum be indicated? 14. What are the symptoms for Arsenicum? 15. Combination of symptoms Cimicifuga would relieve. 16. Outline a Kalmia case. REVIEW QUESTIONS. 17. Give symptoms calling for Squilla. 18. What are the conditions demanding Msculus'i 19. Outline the Cactus cyclone. 20. Describe the Apis heart case. 21. When is Apocynum called for. 22. Combination of symptoms met by Hellebore. 23. When is Lycopodium indicated? 24. Describe the Mercurius heart case. 25. When would you call Sulphur into action? 26. When would Arnica meet the shock of battle? 27. Where has Plumbum done good service? 28. What symptoms call for Naja. 29. When would you think of lachesis? 30. Where would China come in? 31. Describe a Phosphorus heart. 32. When could you depend upon Ferrum? 33. Give the sphere of Xux Vomica. 34. When may Ipecac be relied upon? 35. What class of cases are benefited by Hydrastisf 36. When and why would you call on Ignatiaf 37. In what cases does Crataegus promise to be helpful? 38. Describe Moschus heart effects. 39. What heart symptoms are relieved by Gelsemiumf 40. Effect of Bromine on the heart. 41. Symptoms cured by Spongia. 42. Cases cured by Iodine. 43. Effect of Lycopus on the heart. 44. Cases and symptoms calling for Veratrum alb. 45. Symptoms and conditions met by Aurum. 46. When would you think of Kumexf 47. Symptoms calling for Tartar emetic. 48. When would Lilium be indicated? 49. The heart of Lithium. The Tobacco heart, describe it. 24 DISEASES OF THE HEART. 51. What cases call for Calcarea? 52. , How does Cuprum affect the heart? 53. What is the effect of Phytolacca? 54. What conditions call for Baptisiaf 55. When would you use Amyl Nitrate? 56. Give the heart symptoms of Camphor. 57. Describe the Agaricus heart. 58. When might Pulsatilla be called for? 59. What heart symptoms does Sepia cause? 60. Symptoms calling for Cocculus. 61. The heart effects of Badiaga. 62. What heart effect has Laurocerasus? 63. What symptoms call for Rhus? 64. The range of Natrum in heart cases. 65. Outline the effect of Baryta on the heart. 66. When might Dioscorea be indicated? 67. Form of heart effect of Tarantula. 68. Conditions calling for Carbo veg. 69. Give the action of Causticum. 70. What symptoms call for Graphites? 71. Effect of Amber on the heart. 72. When would Ammonia relieve? 73. Outline the heart action of Anacardium. 74. What is the effect of Argentum on the heart? 75. Conditions calling for Asafcetida. 76. Action of Benzoic acid on the heart. 77. Heart symptoms of Physostigma. 78. Describe the effect of Cannabis on the heart. 79. Action of Carbolic acid on cardia. 80. What is the effect of Glonoine? 81. Describe the Cicuta heart. 82. Does Clematis produce heart symptoms? 83. Give the effect of Eupatorium on heart. 84. When does Lachnanthes come in? REVIEW QUESTIONS. 85. Has Lobelia heart symptoms? 86. Action of Nux Moschata on the heart. '87. When might Petroleum come to the front? 88. Describe the Podophyllum heart symptoms. 89. What will Silicia do? 90. Does Psorium affect the heart. 91. Give the Scutillaria heart effects. 92. What conditions has Secale cured? 93. Describe the heart of Stramonium. 94. Give the neart symptoms of Sumbul. 95. Where in heart diseases do you call for Zinc? 26 DISEASES OF THE HEART. PHYSICAL SIGNS OF HEART DISEASES. 1. Precordial retraction is a sinking of the chest involving the ends of the ribs, left side, and sternum. It signifies peri- cardial adhesion, as a result of inflammation, unless congenital or due to rickets. In the young with elastic walls the depress- ion will be increased with each diastole. 2. Precordial bulging is found in Hypertrophy, if decided and involving the whole heart, or it may be due to Pericardial effusion, i. e. Hydropericardium. o. The Apex beat is found to the left of the normal location in Cardiac enlargement, generally Dilatation and from valvular disease, or it may be due to an elevated diaphragm. 4. When the apex strikes the chest wall below the normal point it indicates Hypertrophy. 5. The heart is displaced to the right in cases of extensive pleuritic effusion in the left side. 6. The impulse of the heart is almost imperceptible in Car- diac debility or Weak heart, Atrophy, Fatty heart, or in Hydro- pericardium. 7. The impulse is excessive in Palpitation, Hypertrophy and in the first stage of inflammation. 8. A purring sensation is present irt endocardial involvement or in anaemia. 9. A grating sound is detected as a result of Pericardial inflammation. 10. Pulsation at the first and second intercostal space, right side, close to sternum is diagnostic of Aortic dilatation. If at second alone in a spare person it may be a normal condition. PHYSICAL SIGNS OF HEART DISEASES. 27 11. Pulsation in jugular veins signifies tricuspid regugita- tion. If there is also giving way of venous valves, will have pulsation in the liver. 12. Hardness, loss of elasticity and tortuousness of the arter- ies signify that there has been inflammation of their coats. 13. Pulse intermittent or irregular is indicative of weak, failing heart, especially if worse after exertion of any kind. 14. Pulse slow, firm and prolonged signifies obstruction of the aortic orifice. 15. When the pulse is like shot it signifies regurgitation at the aortic opening. 16. The "paradoxical" pulse intermits partially or entirely with each respiration. Fibrous bands from a previous pericar- ditis binding the heart may be the cause. 17. Intermittent action of the heart indicates that the ven- tricles do not contract, from fatty degeneration, atrophy, dilata- tion, hypertrophy or obstruction if aggravated by exercise. It may also be due to nervousness. 18. Irregularity of rhythm is a halting during a portion of the systole and may be due to nervousness, muscular weakness or obstruction of circulation or both. 19. Palpitation is a tumultuous action of the heart and is caused by cardiac debility, hypertrophy or nervous excitement. It is also an early symptom of inflammation. 20. Increase of the area of dullness to the left and down- ward is diagnostic of Hypertrophy and Dilatation. If also up- ward, Hydropericardium. 21. In fleshy people the heart sounds are muffled. In spare people and children the sounds seem to be exaggerated. 28 DISEASES OF THE HEART. 22. An increase of first sound over the ensiform cartilage denotes pulmonary obstruction. 23. Skoda considered an exaggeration of the second sound pathognomonic of mitral obstruction. 24. The first sound may be suppressed in typhoid fever, or in the later stages of fatty degeneration. 25. The second may be suppressed at both aortic and pul- monary orifices in Asiatic cholera. 26. Doubling of heart sounds. Doubling of first sound is not often met with and is due to irregular muscular contraction. Doubling of the second sound is found in mitral obstruction and irregular closing of the semilunar valves. 27. All abnormal heart sounds are called murmurs and may be pericardial or endocardial. 28. The pericardial murmur is a friction sound and the result of inflammatory roughening of the pericardial surfaces. Sometimes heard at the base, but often best heard when the person bends forward. 29. Endocardial murmurs are (1) obstructive, (2) regurg- itant or (3) bcemic. 30. A systolic murmur heard loudest at the apex is due to mitral regurgitation. 31. Systolic murmur heard loudest over the ensiform carti- lage is diagnostic of tricuspid regurgitation. 32. A harsh systolic murmur heard at second intercostal space, right side, close to sternum tells of aortic stenosis or in other words constriction of the aortic opening. 33. A whistling or musical murmur heard best at this point is met when there is ossification or cartilagenous thickening of the aortic valves so as to produce a circular opening. PHYSICAL SIGNS OF HEART DISEASES. 29 34. A diastolic murmur is heard best over the aorta in insufficiency, or openness of the aortic valves. 35. A systolic murmur of pulmonary valves heard best at second and third intercostal space left side of sternum indicates valvular insufficiency. It may be haemic-anaemic. 36. A presystolic murmur at apex is mitral and the cause is obstruction. Its character is rasping. 37. The order of frequency of endocardial murmurs are 1. Mitral regurgitant; 2. Aortic obstructive; 3. Aortic regurg- itant; 4. Mitral obstructive; 5. Tricuspid regurgitant; 6. Pul- monary obstructive; 7. Pulmonary regurgitant; 8. Tricuspid obstructive. The two latter are very rare. 38. The combinations of these murmurs encountered in practice are: 1. Aortic obstructive and regurgitant; 2. Mitral obstructive and regurgitant; 3. Aortic obstructive and mitral regurgitant; 4. Mitral regurgitant and tricuspid regurgitant; 5. Aortic and mitral regurgitant. 39. Hcemic murmurs are anaemic or hydremic and are of a blowing quality and systolic. Heard best at aortic orifice. 40. Venous murmurs are also anaemic or hydraemic but are best heard over the jugular veins. 41. Dynamic murmurs. The left ventricle may contract irregularly giving a mitral insufficiency and murmur. This is nervous. An apex murmur may be met with in typhus or severe typhoid. 42. To differentiate a pleuritic friction sound from a heart murmur, remember that the pleuritic sound occurs with the res- piration and is absent when the patient suspends respiration. Pleurisy that extends well to the left may confuse. 30 DISEASES OF THE HEART. FUNCTIONAL HEART DLSEASES. 1. Diseases of the heart may be classified as Functional diseases, Structural diseases, Inflammatory diseases and results 2. The principal functional disturbances of the heart are due to (1) palpitation, (2) weak heart, (3) angina pectoris, and (4) exophthalmic goitre. The first two are really the only strictly functional disorders of the heart. 3. They are also termed Cardiac neuroses. PALPITATION OF THE HEART. 4. Palpitation is a forcible, disturbed and rapid action of the heart. 5. The principal causes of palpitation are Nervousness, Dyspepsia, Rheumatism, and Hypertrophy. It is also a symptom of disease of this organ (e. g. inflammation) and also is met in connection with disease of remote organs. 6. Nervous Palpitation is encountered in Anaamia persons and especially in Hysterical women, also in Chlorosis and at the Climacteric. Spinal Anaemia is also a cause as well as sexual excitement and excess. The hurry and worry of life may cause attacks of palpitation. 7. Dyspeptic Palpitation is met in coffee and tea lovers, tobacco users, liquor drinkers and high livers generally, also in those who bolt their food. Certain occupations that inter- fere with the digestive function also produce palpitation. 8. Rheumatism develops palpitation by the fever, as well as the acidity of the blood. Lithiasis. FUNCTIONAL HEART DISEASES. 31 9. We may know that the disorder is functional and not structural when the palpitation is not increased by moderate exercise. If increased it may be inferred that it is due to hypertrophy with possible valvular lesion. 10. The alarming symptoms in a case of palpitation of the heart are dizziness, headache, trembling, choking and faintness. 11. An outline of treatment includes, (1) rest in the recum- bent posture (2) diversion of mind, (3) drink of water or something warm, and (4) give the indicated similar remedy. 12. The principal remedies that may be indicated are: Aconite, if the attack is due to fright or wine; Ignatia, if hysterical case with left sided headache; Moschus, if from mental or sexual excitement with great anxiety; Belladonna, if there is a flushed face with throbbing or bursting headache; Lachesis, if from climacteric with hot flushes; Phosphorus, in cases with rush of blood to the chest, tall spare growing per- sons; Arsenicum, if from«Buppressed eruptions and attacks of palpitation are worse at night and aggravated by drinking cold water. For further indications and remedies see Heart Thera- peutics. WEAK HEART. 13. The chief symptoms of weak or irritable heart are faint- ness and vertigo on extra exertion or excitement There may be also headache with cardiac pain or distress. 14. The chief causes of weak heart are, over exertion, over work, mental excitement and severe illness. 15. The real pathological condition may be spinal or nerve centre hyperaemia unless dependent upon local diseases else- where. Weak heart is an inheritance of old age. 32 DISEASES OF THE HEART. 16. The outline of management of a case of weak heart will depend something upon the history. Rest is of the first impor- tance. A supporting diet must be carefully selected. The mind should be diverted, a country or seaside resort should be selected when possible. A visit to the mountains or a European trip should be discountenanced. A diffusive stimulant should be at hand to ward off attacks of heart failure. 17. The remedies that may be indicated are many. Arnica, if the result of muscular overwork, as in athletes, may be the remedy; if mental excitement or work, NuxVomica, (men); if from mental worry, Ignatia, especially in women. If the cardiac myalgia is decidedly worse on motion, Bryonia would be thought of. If joy or grief starts the bowels, consider Gelsemium. If there is a constant weak pulse with faintness and vertigo, use Digitalis. If from losses, China may be indi- cated. Crataegus may be helpful here. For further indica- tions and remedies see Heart Therapeutics. « AN EXOPHTHALMIC HEART. 18. Rapid action of the heart with enlarged thyroid and prominent eyes are the diagnostic signs of exophthalmic goitre. 19. This disease may be classed as a neurosis of the cardiac plexus of the sympathetic and its connections. 20. This disease is usually slow in making its appearance. It may be remittent, as during and after pregnancy, and disap- pear, but unless arrested it usually grows worse. It produces, or is attended with, rapid action of the heart. 21. The prognosis should be guarded. While it may disap- pear the usual course is to produce hypertrophy and dilatation of the heart with valvular insufficiency, aneurism of the FUNCTIONAL HEART DISEASES. 33 thyroidal vessels and inflammation and ulceration of the cornea of the eyes. 22. The supposed causes of this disease are cardiac neuroses, mechanical obstruction in the gland, delayed menstruation, mental excitement, and calcareous water. 23. The treatment and remedy indications are—Remove the cause if possible, select a proper diet, control the life, apply galvanism to the thyroid driving the blood away from the gland to the cord and select the similar remedy. Arsenicum has cured many cases. Bromine in one case produced a con- strictive cough that developed the characteristic symptoms of this disease. Spongia, so useful in goitre, may be indicated here, also Iodine high. The remedy may be Belladonna or Cimicifuga if worse at the menstrual epoch. Lycopus has cured cases. Lachesis should be consulted if at the climacteric. Consult Heart Therapeutics for indications and other remedies. ANGINA PECTORIS. 24. Angina Pectoris or Stenocardia is an irregular paroxy- Bonal attack of cardiac pain, with a feeling of impending death. 25. It is supposed to be of nervous origin (spinal hyper- emia) with or without cardiac lesions, e. g. ossification of the coronary arteries, hypertrophy and valvular lesions. 26. The attacks are ushered in suddenly with a feeling of constriction and severe pain at the heart as if held by a hand. He imagines he cannot breathe but gets a deep breath now and then. Sometimes the pains radiate down the left arm. Extremities are cold, face pale at first but becomes finally flushed with anxious expression as of impending death. The 3 $ 34 DISEASES OF THE HEART. paroxysm3 are usually short and when severe simulate epilepsy. Extra mental or physical exertion or fright may precipitate an attack. Men are more frequently sufferers from this disease than women. 27. The pathology seems to be a spinal and cardiac hyper- aemia, with, in some cases, cardiac lesions, as hypertrophy, ossi- fication of the coronary arteries, valvular obstruction or insuf- ficiency, atheromatous arteries or fatty heart. 28. The prognosis should be guarded. The attacks are dangerous, but patient often lives for years in fear and alarm. 29. The treatment of an attack is as follows:—Place the patient in a comfortable position and while attendants are loosening the clothing, chloroform may be applied, while the indicated remedy is getting control of the disease. The allo- pathic treatment is to inject morphine at once and give chloro- form, but even this does not arrest the attack. Nitrite of Amyl is sometimes used. Between the attacks regulate the habits and diet of the patient. 30. The remedies indicated for the attack may be either Cactus, Belladonna, Gelsemium, Veratrum, Glonoine, Arsenicum, Spongia, or Spigelia. To prevent a return of an attack the indicated remedy should be continued. In addition to the foregoing Aurum and Agaricus have been curative. Select carefully and adhere to the remedy for several months. For indications, etc., see Heart Therapeutics. INFLAMMATORY DISEASES OF THE HEART. 35 INFLAMMATORY DISEASES OF THE HEART. PERICARDITIS. 1. This is an inflammation 6f the serous membrane which covers and surrounds the heart, and is reflected in front over the chest wall. 2. The chief causes of pericarditis may be enumerated as: rheumatic, traumatic, pleuritic, pulmonic, or as diseases of the rib3, vertebrae, aesophagus, stomach or liver. 3. The inflammation may be primary or secondary. It may be circumscribed or general involving the whole pericardium, acute or chronic.—See hydropericardium. 4. The prominent symptoms of an attack are usually a chill or cold feeling at the heart followed by fever with stitch-like pains at the precordial region or radiating from it; tenderness on pressure, praecordial anxiety; dyspnea, preventing lying down. There may be nausea and vomiting at times. A short dry cough may be present. There is an expression of anguish on the face that is most distressing in severe cases. 5. There are three stages recognized: (1) inflammation; (2) effusion and adhesion and (3) absorption or pressure and death. 6. The serious symptoms looked for are from two causes: (1) extension of the inflammation involving the heart muscle and (2) rapid and extensive pericardial effusion and adhesions. In the first instance the heart anguish will be increased with cold- ness of the extremities, heart action tumultuous, insensibility, delirium, sudden death. In the second stage the heart's action is labored, dyspnea marked, oedema appears, loss of pulse, coma or faintness and death. 36 DISEASES OF THE HEART. 7. The physical signs are the friction sound, likened to the purring of a cat, and increased action of heart, sometimes inter- mittent. As the effusion increases the heart sounds become muffled and the area of dullness is increased. In cases of ad- hesions the action of the heart may be paradoxical. 8. The prognosis should be guarded, Death may occur in 30 hours. The heart may be paralyzed by the effusion. Ad- hesions may form. The disease may become subacute or chronic and continue for weeks and complete resolution event- ually take place. The serous membrane is apt to become contracted, roughened and adherent by fibrous bands prodacing retraction of the ensiform cartilage and ribs. In young persons this may be very decided. 9. The treatment demands prompt and effective measures. The patient must be quieted and placed in the most comfort- able position, and if possible have a trained nurse. The food should be light and nourishing, stimulants are to be avoided, especially in the first stage. The carefully selected remedy should be administered to allay the inflammation and prevent effusion, adhesions, paralysis or complications in remote organs. Even if it is secondary upon some other disease, the pericarditis should receive the first at- tention. 10. Remedies that may be indicated are as follows: If trau- matic, Arnica. For the inflammatory outset, Aconite or Vera- trum viride. The anguish of Aconite distinguishes its inflam- mation from that attending the stupor of Veratrum. For the pain Bryonia or Spigelia. They may be indicated in this order, Bryonia for the first stage and Spigelia for the subsequent myalgia. In these cases there may be met with indications for Belladonna (its flushed face), Arsenicum (dyspnoea on lying down), Digitalis (its weak pulse), Cactus (severe myalgia) or Kali carb (stitching pains). General symptoms may call for INFLAMMATORY DISEASES OF THE HEART. 37 Oolchicum, ^Esculus, Kali iod., Cimicifuga, Kalmia, Squilla. For special indications see Heart Therapeutics. HYDROPERICARDIUM. 11. This is an effusion in the pericardium or heart sac, that may occur without active local inflammation. It may be a primary as well as a secondary disease. 12. The Symptoms are not prominent unless the amount of fluid is large. Dyspnoea on lying down, general dropsy, feeble heart sounds and increased area ,of dullness in all directions, especially in a pypmidal shape are diagnostic. 13. The treatment calls for great care in the nourishment of the patient. Enjoin rest and remove any exciting cause if possible. Aspirate if the effusion threatens life. The prin- cipal remedies that have proven serviceable are Arsenicum, Apis, Apocynum, Hellebore, Lycopodium, Mercurius or Sul- phur. See also Pericarditis and consult general Heart Thera- peutics. Hcemopericardium is caused by blood in the pericardial sac from rupture of an aneurism, rupture of the heart, traumatism and cancerous and tuberculous pericarditis. The local signs are the same as in hydropericardium with the general one of rapid prostration and speedy death, as in one of my own cases. In traumatism control the inflammation with Arnica and aspir- ate if the conditions favor. Pneumopericardium. Air in the pericardium is a rare con- dition and results from external wounds, or the perforation of a pyo-pneumothorax into the pericardial sac with the formation of pus. Percussion yields a tympanitic sound, and on auscultation splashing and metallic sounds are detected. An anxious, pain- 38 DISEASES OF THE HEART. ful expression with dyspnoea, cyanosis and sudden collapse are the chief and alarming symptoms. The remedies indicated are Arnica for traumatism, Arseni- cum, or Sulphur for formation of pus (see Pericarditis and Hydropericardium). MYOCARDITIS. 14. Myocarditis or carditis is an inflammation of the heart muscle itself. It may be a primary disease as the result of heart strain or rheumatism, but is usually a complication of either pericarditis or severe endocarditis. 15. The diagnostic sig?is given are extreme cardiac anguish and pain. The heart is unusually excited with high fever. 16. The Symptoms may appear gradually as after severe exercise. During an attack of peri or endocardial inflamma- tion the carditis may appear as a second "storm. 17. The indications for treatment are to keep the patient quiet and comfortable and select the indicated remedy which may be either a myalgic or inflammatory one, e. g., Arnica, Rhus, Aconite, Bryonia. See Heart Therapeutics as well as Peri- carditis and Endocarditis. ENDOCARDITIS. 18. Endocarditis is an expressive term for inflammation within the heart envolving the serous membrane covering the walls, columns and valves. 19. It is usually a secondary disease, but may be primary as from cold or traumatism. It is most severe in its results. 20. When secondary it appears as a result of (1) rheumatic, acid irritation of the endocardium and usually of the heart muscle, (2) vitiated state of the blood as from Pyaemia or Bright's disease. INFLAMMATORY DISEASES OF THE HEART. 39 21. The diagnostic symptoms may be few. In fact the in- vasion may be unnoticed. Usually pain, palpitation of heart, sounds stronger and audible over more space, pulse rapid and small, dyspnaea, delirium, finally icterus may appear. The appearance of a valvular murmur locates the seat of lesion. 22. To differentiate inflammation within the heart from that without, note the following points: The endocardial murmur is constant in situation, rhythm and character. Position has no effect, neither does respiration nor pressure change the murmur. Generally more widely diffused. Pericardial friction sound, change of position increases, di- minishes or suppresses the friction sound. Pressure increases it. More local. 23. In endocarditis we expect serious valvulitis and as a result lesions of one or more sets of valves. Fibrillae from adherent valves may be carried into remote organs and produce throm- bosis. 24. The sequale of an attack of endocarditis are valvular insufficiency or stenosis and consequent hypertrophy and dilata- tion. 25. The management of an attack of endocarditis involves (1) control of the inflammation and (2) repair of the lesion. The primary disease must also receive due attention that a sub- sequent attack may not occur. Prompt action is demanded. 26. The remedies that have proven serviceable here are few. Aconite for the iniatiatory chill and fever (cold). Arnica if trau- matic. Bryonia if rheumatic with stitching pains. Then may come Spigelia, Cactus, Digitalis, Lachesis or Lycopus. If the acid or septic cause remains other remedies may be indicated as Arsenicum. See valvular remedies and Heart Therapeutics. 40 DISEASES OF THE HEART. STRUCTURAL DISEASES OF THE HEART. 1. The four principal structural or organic diseases of the heart are: (1) Hypertrophy, (2) Dilatation, (3) Atrophy, and (4) Fatty heart. HYPERTROPHY OF THE HEART. 2. This is an enlargement of the walls of the heart. Three forms are recognized: (I) Simple hypertrophy where the mus- cular walls are thickened while the cavities remain of normal size; (2) eccentric hypertrophy where the walls are thickened and the cavities are dilated; (3) concentric hypertrophy in which the walls are thickened while the cavities are diminished in size. This form is always congenital. The left ventricle is the one most frequently enlarged. 3. The diagnostic symptoms are: Increased area of dullness downward, and sometimes also to the left; very forcible beating of the heart, constant; sounds dull and loud. 4. The causes of this structural disease of the heart are many. It may be congenital. Rheumatism, with valvular insufficiency and stenosis, is a frequent cause. Overwork while young, athletic feats, early and constant excitement, typhoid fever, overwork (where the respiration is impeded, as in carpenters, blacksmiths), emphysema, Bright's disease, and certain drugs like tobacco, may be exciting causes. 5. The usual course of hypertrophy, if not arrested, is to pro- duce dilatation, also valvular disease, arterial degeneration, fatty degeneration of the heart and apoplexy. 6. The management of a case of hypertrophy should include a control of diet and habits, compel a quiet life, avoiding stim- ulants, excitement and tobacco. Enjoin plenty of sleep after STRUCTURAL DISEASES OF THE HEART. 41 a light supper. The exciting cause should be removed if pos- sible. Select the remedy to meet all the conditions and to cover all of the symptoms. 7. The remedies to be thought of are: Arnica in a traumatic athletic case; Kalmia if the hypertrophy is markedly left ven- tricular; Plumbum if general and eccentric; Arsenicum, Lyco- vodium, Naja or Spigelia may be called for as well as other remedies. If the hypertrophy is a sequence of disease of some remote organ the selection of the remedy must be affected thereby. See for further information Heart Therapeutics. DILATATION OF THE HEART. 8. In dilatation of the heart the walls become thin. A marked area of dullness is detected, especially to the left. 9. The causes of dilatation of the heart enumerated are: Debility following wasting disease, valvular lesions, impaired heart nutrition, destruction beginning in organs remote from the heart, and severe disease in those who suffer with hyper- trophy. The chief cause is hypertrophy. 10. The diagnostic signs are increased area of dullness, es- pecially to the left. The heart sounds are never loud but may be clear, especially on excitement. When dilatation reaches the stage to produce valvular insufficiency, then we may have dyspnoea, cough, dyspepsia, scanty urine, dropsy, with a feeble, irregular pulse. When the right heart is involved an impulse may be noted below the sternal cartilage. 11. Dilatation may be complicated with fatty degeneration. Hypertrophy of one ventrical wall may exist with dilatation of the other cavity giving rise to irregular contraction. Atherom- atous arteries exist as a complication in many cases. 12. The remedies that may be helpful are the same as those mentioned under hypertrophy, weak heart and fatty heart. 42 DISEASES OF THE HEART. Aconite may be called for. Cactus may be indicated. Nux vomica may be needed. Gelsemium, dilatation of the left ven- tricle. Tartar emetic, dilatation of the right ventricle with asthma. Digitalis, Cuprum, Muriatic acid, Hydrocyanic acid, Hydrastis and other remedies should be consulted. See Heart Therapeutics for indications. ATROPHY OF THE HEART. 13. In atrophy the heart is smaller than normal. The'walls are thin but the cavities may be of normal size. 14. This condition may be congenital or it,may be caused by . pressure from pericardial effusion, pericardial adhesions, and marasmus. 15. The diagnostic signs are few, the area of dullness is diminished, the sounds are distinct and regular but not loud. The pulse is usually regular but feeble and quick. 16. In the treatment of atrophy of the heart, proper food and exercise should be insisted on so that the weakened muscle may be developed. If there exists pericardial effusion it must be removed (see hydropericardium). The remedies are usually the nutritious ones' unless the local symptoms point out differ- ently. Arsenicum would be indicated where effusion and the other symptoms suggest it; Phosphorus, if the result of fatty degeneration; Sulphur, if complicated with hydrothorax; China, if the digestive symptoms correspond; Ferrum may be indicated or Nux. The general condition and symptoms must decide in the selection of these or some other remedy. STRUCTURAL DISEASES OF THE HEART. 43 FATTY HEART. 17. The pathology of fatty heart includes, (1) a deposit of fat about the heart muscle, (2) where the muscle fibre is dis- placed by fat. 18. The principal diagnostic symptoms are few.—Feeble irregular heart beat, exhaustion and dyspnoea on exertion, pulse slow, 30-40 when at rest while the heart may be 50-60. Attacks of apoplectic syncope, at first more like syncope, then becoming apoplectic. In the earlier stages those symptoms may not be so prominent as to direct attention to the heart. 19. The prognosis is always grave, although life may be prolonged many years. In fatty infiltration it is less grave than in fatty degeneration of the muscular fibers. 20. In the management of these cases the best judgment must be exercised in the selection of nourishing diet and pure air. A quiet life, light occupation, the avoidance of all vio- lent efforts, physical or mental, and regular exercise should be insisted on, in a mild climate. Malt liquors are to be avoided. 21. Select carefully the indicated remedy and give it time to do its work. The selection may lie between Phytolacca, Nux vomica, Belladonna, Ipecac, China, Arsenicum, Kali, Phosphorus, Hydrastis, Crataegus, or some other remedy. See Heart Therapeutics. 44 DISEASES OF THE HEART. VALVULAR DISEASES OF THE HEART. MITRAL, AORTIC, TRICUSPID AND PULMONARY. 1. The valvular lesio?is of the heart are: Mitral insuffici- ency, aortic insufficiency, tricuspid insufficiency, pulmonary insufficiency, mitral stenosis, aortic stenosis, tricuspid stenosis and pulmonary stenosis. 2. The causes of valvular disease may be inflammation; cal- careous, cartilaginous or ulcerous degeneration. Change in the walls, as from hypertrophy and dilatation may also give rise to valvular lesions. 3. The pathological changes that occur are contraction, thickening, calcareous infiltration and fibrous sclerosis. Rup- ture sometimes occurs. MITRAL LESIONS. 4. The mitral valve is the one most frequently diseased in young people. The activity at this time of life taxes the left heart. 5. In mitral insufficiency the two segments of the valve do not close properly, from rupture, inflammatory contraction of the columns, from dilatation or weakening of the left ventricle. 6. The chief causes of mitral valvular lesions are (1) a viti- ated state of the blood, from rheumatism, pyaemia, Bright's disease, syphilis, alcoholism, etc.; (2) sudden muscular strain; (3) fevers; (4) occasionally congenital defects. The pathological changes in the valve are contraction of the fibres or tendons and sometimes rupture of the muscular col- umns. Insufficiency of this valve causes dilatation of the left auricle and eventually hypertrophy of the left ventricle. 7. The diagnostic sign of mitral insufficiency is a murmur VELVULAR DISEASES OF THE HEART. 45 or blowing sound heard best at the apex, synchronous with the first sound of the heart. The other valve sounds may be normal. 8. Mitral stenosis is a condition where the left auricular- ventricular opening is imperfect so that the flow of blood from the left auricle is impeded. 9. The causes are the same as those already noted being chiefly inflammatory, resulting in thickening, contraction and adhesion of the mitral segments. 10. A rough presystolic thrill is felt near the apex. The area of dullness is increased to the right. A prolonged, rough, churning murmur, presystolic in time, is heard a little above and to the left of the apex. The second sound is usually increased. A sequence is tricuspid regurgitation from consequent hyper- trophy and dilatation of the left auricle. The face is pale. AORTIC LESIONS. 11. In the aged the aortic semilunar valves are most fre- quently affected. 12. Aortic insufficiency is due to a failure of the valve seg- ments to close properly so that there is a regurgitation of blood back into the left ventricle at every dilatation of the ventricle. 13. The special pathological causes are rupture or inflamma- tory contraction of the segments or from dilatation of the ori- fice from hypertrophy of the left ventricle. 14. The diagnostic signs are: (1) A shot like or "water hammer" pulse; (2) The arteries pulsate visibly; (3) There may be praecordial bulging; (4) The apex beat is forcible and located downward and to the left; (5) Area of dullness in- creased; (6) At right second intercostal space maximum in- tensely of a diastolic murmur. 46 DISEASES OF THE HEART. 15. Aortic stenosis or obstruction is a thickening of the seg- ments of the valve, by inflammatory action or calcareous infil- tration or from adhesions, so that the onward flow of the vital current is impeded. 16. The cause in the majority of cases is rheumatism. In- flammation or degeneration produces changes in the segments. Calcareous thickening is met with in old people who live in limestone sections. 17. The heart-beat if strong is found downward and to the left. Increased area of dullness especially to the left. At the right second intercostal space a strong systolic murmur and is transmitted, to both carotids. The pulse, when the heart becomes weak is small and slow. 18. The sequela} of mitral insufficiency and stenosis are tri- cuspid insufficiency and regurgitation. The result of aortic insufficiency and obstruction is mitral regurgitation. TRICUSPID LESIONS. 19. Tricuspid Insufficiency or regurgitation is caused by an imperfect closure of the right auricular ventricular valve. 20. Inflammation produces shortening of the valve columns or more frequently dilatation of the right ventricle. Secondary to mitral disease or to chronic lung disease. 21. The physical signs are enlargement of the heart, a sys- tolic murmur soft and blowing, heard most distinctly just above ensiform cartilage with pulsation of jugular veins and in some advanced cases pulsation of the liver. 22. The consequences are that the whole venous system be- comes engorged, and we have enlargement of the liver and spleen with blue skin, anasarca and finally effusion into the serous cavities and death. If the regurgitation is slight such serious results may not follow. VALVULAR DISEASES OF THE HEART. 47 23. Tricuspid Stenosis or obstruction is due to adhesion of the columns or growths thereon; that interfere with the flow of the blood through the right auricular-ventricular opening. 24. This is an exceedingly rare lesion and is usually of foetal origin. It may result from inflammation. 25. The chief symptom is a presystolic murmur located over the ensiform cartilage very feeble and not transmitted. Hyper- trophy of the right ventricle is detected. PULMONARY VALVE LESIONS. 26. Pulmonarg Obstruction or Stenosis is a very rare lesion and a defect of the pulmonary valve interfering with the systolic current from the right ventricle. It is usually congen- ital. 27. A systolic murmur at the second left interspace is diag- nostic. Enlarged right ventricle extending well to the right of the sternum. Pulse weak, surface, especially of the extrem- ities, cold. Cyanosis, often extreme. Finger ends clubbed, blue; nails curved and thick. Dyspnea. 28. Pulmonary insufficiency causes regurgitation of the blood (being forced into the lungs) back into the right ventri- cle. This also is a rare lesion and is usually congenital. It produces a diastolic murmur or thrill heard best at the left second interspace. The apex beat on account of right ven- tricular hypertrophy, becomes displaced to the left. Tricuspid systolic murmur or thrill from dilation and, insufficiency is apt to occur. ORDER AND RESULTS. 29. The order of frequency of valve lesions are given as, (1) Mitral insufficiency, (2) Aortic stenosis, (3) Aortic insufficiency, (4) Mitral stenosis, (5) Tricuspid insufficiency, (6) Pulmonic stenosis, (7) Tricuspid stenosis, and (8) Pulmonic insufficiency. 48 DISEASES OF THE HEART. The effect of mitral lesions is to bring about tricuspid regurg- itation. Aortic lesions are followed by mitral incompetency. The order of gravity of the various forms of valvular lesions is, (1) Tricuspid regurgitation, (2) Aortic insufficiency (often ending in sudden death), (3) Aortic stenosis, (4) Mitral steno- sis, and (5) Mitral insufficiency. The general unfavorable conditions are early life, advanced years, great cardiac enlargement, irregular heart action, recur- rent attacks of rheumatism, bad hygienic surroundings and symptoms of venous congestion of the lungs, kidneys and digestive tract. 30. Compensation offsets for a time the serious effects of valvular lesions. This is brought about by an increase in the size and strength of the cardiac chambers sufficient to enable the heart to furnish the outflow of blood to properly nourish all parts of the body. When the walls become weakened compen- sation ceases and pari passu venous congestions of the organs occur. Pulmonary congestion produces dyspnea, asthma, haemoptysis and chronic bronchial catarrh (mitral). Hepatic, stomachic and intestinal congestion produces dyspepsia. Renal congestion produces albuminuria and nephritis". Cerebral con- gestion produces headache, vertigo and syncopal attacks (aortic). General venous congestion produces cyanosis and dropsy, from the feet upward. TREATMENT OF VALVULAR LESIONS. 31. The management of cases of valvular lesion depends upon the condition of the heart walls and remote organs. If compensation is well maintained the complicating disorder should secure the first attention. The effort should be by proper exercise, diet and remedies to secure the best heart action under the circumstances. When there are symptoms of heart failure as manifest by VALVULAR DISEASES OF THE HEART. 49 orthopnea and cyanosis, rest should be absolute. Light, nutritious, supporting diet should be given. 32. The remedies indicated may take a wide range during the development of serious valvular lesions. In aortic disease to prevent further distortion of the valve flaps Arnica may be given if worse on severe exertion; if worse while at rest, Rhus. If there is a lingering rheumatic inflammation Bryonia. In mitral involvment Bryonia, Kalmia, Sulphur, Cactus, Dig- italis, Arsenicum, Lachesis, Spongia, Naja, China, Spigelia, Plumbum. For valvular affections in general in addition to the foregoing Aurum, Kali curb., Bismuth, Cannabis, Crotalis, Laurocerasus, Natrum mur., Tabicum, Sepia, are mentioned. To control the attending hypertrophy and dilatation, Digitalis, Aurum, Lachesis, Lycopus, Nux vom., Spigelia, or Spongia may be in- dicated. For functional anemic murmur China, Nux vomica, Ignatia or Sulphur may be needed. For hydremic murmur venous and functional the chief remedy may be Arsenicum, China or Hydrastis. For the asthma from pulmonary conges- tion Spongia, Nux vom., Arsenicum, Veratrum vir. In each case the general as well as the local symptoms should be covered by the selected remedy. For further indications and remedies see Heart Therapeutics. i 50 DISEASES OF THE HEART. DISEASES OF THE BLOOD VESSELS, ETC. ATHEROMA. 33. Atheroma is a thickening of the arteries due to an in- flammatory increase of the connective tissue, associated with more or less fatty degeneration and calcification. The arteries are thickened, tortuous and rigid from chronic endarthritis. If located in the lower extremities gangrene may supervene. Atheroma of the coronary arteries may produce serious heart symptoms, as angina, etc. Old age, gout, rheumatism, alcohol- ism, syphilis, lead poisoning, nephritis, calcareous water and laborious work, are the usual etiological factors. The symptoms of atheroma are usually a sluggish high tension pulse, accentuation of the second aortic sound, palpitation, dysp- nea, anginoid pains and hypertrophy of the left ventricle, urine increased and at times albuminous, headache, vertigo, dis- turbed sleep, failure of memory and ringing in the ears. As sequelce there may be cerebral congestion, apoplexy, fatty heart, dilatation, angina pectoris, aneurism, interstitial nephritis and gangrene of extremities. The treatment should include a careful diet, no stimulants, and a regulation of the habits. The remedies indicated may be Bryonia, Secale, Lachesis, Arsenicum, Carbo veg., Lycopodium, Carbolic acid. See hypertrophy, angina pectoris and general heart therapeutics. In gangrene of the extremities operate high up and early. ANEURISM. 34. Aneurism is a circumscribed dilatation of an artery. This may occur in any artery but is found most frequently in the aorta as a result of arterial degeneration. The sign of an aneurism is a murmur or bruit loud and DISEASES OF THE BLOOD VESSELS, ETC. 51 booming in character, systolic in time, heard best over the aorta or base of the heart with an abnormal area of dullness and pulsation and symptoms of pressure. Dyspnea, cough, pain or distress serve to locate the aneurismal tumor. The conditions of life which lead to arterial degeneration, i. e. rheumatism, gout, alcoholism, syphilis, cancer, drugs, labori- ous work, are predisposing causes. The male sex at middle life suffer most, as sudden exertion is the most common exciting cause. Aneurisms are divided into true and false. When the internal coat of the artery alone gives way, allowing the blood to escape between the layers it is termed false. When all the coats yield it is a true aneurism and may be fusiform, saccular and cylin- drical. The prognosis is always grave. The average duration is from one to two years. Death takes place from rupture, exhaustion or heart failure. 35. In the treatment where it is possible to reach the artery as in abdominal aortal aneurism, compression has been resorted to with good results. Electricity is a valuable adjuvant where the vessel can be reached. The predisposing cause should receive attention. Rest in bed for two or three months should be insisted on, a nourishing milk or meat diet should be given, avoid stimulants and excitants. Warm milk makes an excellent stimulant as well as food. Select the remedy carefully. Lycopodium 12 has cured aneur- ism of the carotid (Hughes). If the attack is due to a sudden strain or injury, Arnica; if from fear or fright, Aconite; if from syphilis, Mercurius, Kali hydro or Nitric acid; if from alconolism, Arsenicum or Nux vomica; if from fatty degenera- tion, Phosphorus; if from fibrous inflammation and degenera- tion, Bryonia; if there is great arterial excitement and delirium, 52 DISEASES OF THE HEART. Veratrum viride; if circulation sluggish, Digitalis. S'ecale has cured aneurism. Consult Carbo veg., Spigelia. See Heart Therapeutics. EMBOLISM AND THROMBOSIS. 36. Embolism is an occlusion of an artery from a fibrinous clot, as the result of a valvular disease. A calcarous deposit on the valve as well as fibrin may be washed off and occlude an artery in the kidneys, spleen, brain or in an extremity. Local inflammation is a prominent symptom and the seat of pain assists in the diagnosis. The part becomes blue, swollen and insensible. Rest is of first importance in treatment. The remedies indi- cated will depend upon the location and severity of the symp- toms. Aconite for fever and restlessness. I ycopodium, Calcarea, Phosphorus, Graphites, Silicea, Sulphur have been suggested. Thrombosis is a blocking of the local circulation either spon- taneously, after injuries or from slow and imperfect circulation forming a clot. In thrombosis the part becomes pale and oedematous. The remedies are Aconite for first stage, Hamamelis, Lachesis or Lycopodium may be indicated. If suppuration threatens Sulphur or Hepar. Rest and a supporting diet. VARICOSIS. 37. This is an inflammation of the veins, usually those of the lower extremities, but may be in those of any part of the body. Positions and conditions that interfere with the venous current are the causes. Varicosis causes dropsy in old people. 38. The curative remedies are few. The most prominent are Hamamelis, Pulsatilla, Carbo veg. or Sulphur. If the varices ulcerate then Arsenicum, Lachesis or Hepar should be consulted. To prevent rupture and assist the venous circulation of the DISEASES OF THE BLOOD VESSELS, ETC. 53 extremities an elastic stocking should be worn. Posture and bathing with Hamamelis, rubbing at night so as to assist the circulation, are helpful. DROPSY—CARDIAC. Dropsy is the unnatural accumulation of serous fluid in the tissues or cavities of the body. It is usually a symptom. The causes are (1) venous stasis from heart, liver and lung diseases and from local obstructions to the circulation, e. g., pregnancy, tumors, constricting clothing, occupations, etc.; (2) changes in the blood, e. g., anemia, inflammation, Bright's dis- ease, etc. Cardiac dropsy usually begins in the feet and ascends. Dropsy is not always fatal at first; but subsequent attacks finally result in death. The remedies that have been of service in dropsy, dependent upon heart disease, are Arsenicum, Lycopodium., Spigelia, Car- bo veg., Digit