ENLARGEMENT BY DILATATION



SYMPTOMS AND PATHOLOGICAL EFFECTS OF DILATATION.

“The symptoms due to dilatation, like those of hypertrophy, are generally involved with those incident of valvular or other concomitant lesions. In proportion to the amount of dilatation, the muscular power of the heart is impaired. The symptoms distinctive of dilatation proceed from feebleness and incompleteness of the heart’s action. The action of the heart is often irregular, as represented by irregularity of the pulse and of the apex-beats. Both are abnormally feeble. The pulse may be unequal as well as irregular. These symptoms are in relation to dilatation of the left ventricle. The patient experiences more or less uneasiness and undefinable distress, referable to the praecordia, but he is not conscious of that powerful action of the heart which characterizes hypertrophy. The extremities and surface of the body are cool. Lividity may be apparent on the prolabia, the tongue, face, and extremities. the veins, especially those of the neck, may be distended. These symptoms are more or less marked, in proportion as the dilatation affects the right ventricle. Dyspnoea will be prominent in proportion as the right ventricle is the seat of dilatation. The recumbent posture, with the head low, may be insupportable, and, in an advanced stage, the suffering from defective haematosis may amount of orthopnoea. Occurring in paroxysms, this difficulty of respiration has been called cardiac asthma. Exercise and mental excitement augment the symptoms, particularly the dyspnoea. More or less cough is usually present, with serous and sometimes sanguinolent expectoration. The abdominal viscera as well as the lungs, are in a state of passive congestion. Owing to this state, the liver may become more or less enlarged, and may be found to augment rapidly in size when, from any cause, the circulation is temporarily embarrassed in an unusual degree, resuming it former dimensions when the paroxysm ends and the heart recovers its habitual strength.* * Strokes on the Heart and Aorta. The digestive functions are weakened, but nutrition may be sufficiently active; patients do not always emaciate. The urine is not abundant, and may be found slightly albuminous, which is due to renal congestion, and is not necessarily indicative of structural disease of the kidneys. Renal disease is, however, associated, in a certain proportion of cases, with dilatation as with hypertrophy. Finally, oedema occurs, first manifested in the lower extremities, thence extending over the body, and effusion into the serous cavities, succeeds, constituting general dropsy.

“This is an enumeration of the more important of the symptoms belonging to cases of enlargement in which dilatation predominates, but it is to be borne in mind that, in general, valvular or other lesions co-exist, which, after inducing more or less hypertrophy, have at length led to dilatation; and, under these circumstances, it is difficult to say to what extent the symptoms distinctive of this stage of the disease may not be due to the causes of the dilatation, in other words, to the concomitant lesions. But it is certain that much, if not chief importance is to be attached to the dilatation in the production of the symptomatic phenomena which have been mentioned.

“The pathological effects of dilatation are, in a great measure, embraced in the foregoing account of the symptoms. The dilatation is the result of weakness of the cardiac walls, together with an accumulation of blood within the cavities; and, on the other hand, it is the cause of further diminution of the power of the heart’s action, and consequent over-repletion. It has, therefore, an intrinsic tendency to increase. The evils incident to enlargement are mostly referable to dilatation. Little or no inconvenience is felt so long as the heart is hypertrophied, and the capacity of its cavities not increased. But in proportion as the latter takes place, the quantity of blood to be propelled from the cavities is greater, and the ability of the muscular walls to contract sufficiently is lessened; hence, inadequacy of the motive power of the central organ to carry on the circulation. This inadequacy increases in more than an arithmetical ratio as the dilatation progresses. The immediate effect on the vascular system is passive congestion, arising, not alone from the defective propelling power of the heart, but from the obstacle presented to the return of blood to this organ by the accumulation within its cavities. The ulterior effects dependent on congestion are: embarrassment of the functions of the important organs of the body; serous transudation, or dropsy; and, occasionally, haemorrhage. An occasional effect of great dilatation, conjoined with extreme feebleness of the heart’s action, is the formation of coagula within the cavities of the heart. There is reason to believe, that in some instances in which the accumulation is excessive, and the contraction of the walls extremely feeble, the blood coagulates during life, and proves the immediate cause of a fatal termination. An unusual accumulation of blood, from any cause, in either the right or the left ventricle, when it is much weakened by dilatation, may occasion paralysis of the walls by distension, and thus produce sudden death.

PHYSICAL SIGNS DISTINCTIVE OF ENLARGEMENT BY DILATATION.

“The physical signs of enlargement of the heart have been already fully considered. The signs distinctive of dilatation are now to be noticed. The several methods of exploration which furnish evidence of enlargement, contribute signs pointing to dilatation in distinction from hypertrophy. The evidence obtained from percussion relates to the form of the area of deep dullness. If the boundaries of the heart be delineated on the chest by means of percussion, the transverse dimension of the area exceeds the vertical in proportion as dilatation predominates over hypertrophy. This corresponds to the difference as regards the form of the heart, which has been stated. The outline which the heart presents is wedge-shaped or nearly square if the dilatation be excessive. Palpation furnishes negative characters more readily available and striking. The powerful apex-beat of hypertrophy is wanting; also the elevation of the ribs and the heaving of the praecordia. The impulse of the apex is feeble, and may be suppressed. The movements of the organ, owing to the extended space in which it is in contact with the thoracic walls, are sometimes obscurely felt, and oftener visible in two, three, four, or even more intercostal spaces, which together present an appearance of fluctuation, or, as called by Walshe, quasi undulation. In some cases, in which the thoracic walls are thin, and the intercostal spaces wide, the heart seems to be almost exposed to the vision and touch. Auscultation furnishes certain distinctive points pertaining to the heart-sounds. Both sounds are feeble in comparison with their augmented intensity in cases of hypertrophy, but the first sound is disproportionately wakened. The first sound is also altered in character; it becomes short and valvular, resembling in these respects the second sound. The latter alterations, although distinctive of dilatation as contrasted with hypertrophy, are not peculiar to the former, and their true explanation has not been understood. They are due to the impairment or absence of the element of impulsion in the first sound. This element is deficient or wanting whenever the left ventricle lacks the muscular power necessary for its production. In hypertrophy this element is intensified, owing to the increased force of the ventricular contractions; and in dilatation it is feeble or absent, owing to the feebleness which, at the same time, renders the apex-beat weak or inappreciable. But this element is also impaired or absent when, from other causes than dilatation, the muscular power of the heart is weakened. The intensity of the first sound is diminished disproportionately to that of the second sound, in cases of fatty degeneration, and of softening in typhus fever, and of pericarditis with effusion. The valvular element predominates, or is alone present in consequence of the feebleness or absence of the element of impulsion. But the intensity of the valvular element is also more or less diminished, in the first place, in consequence of the weakness of the ventricular contractions, and in the second place, because at the time when the ventricular contractions take place, the quantity of blood within the ventricle is large, causing closure of the auriculo-ventricular valves.

“In the diagnosis of enlargement by dilatation, assuming the fact of enlargement to have been ascertained, symptoms (as distinguished from signs) have considerable weight. Passive congestions, lividity, feeble pulse, and dropsical effusion, in fact, constitute evidence almost, if not quite conclusive. The obstruction due to the valvular lesions which are so generally associated with enlargement, it is true, contributes toward the production of these symptoms; but, as will be seen when valvular lesions are considered, the obstruction due to these rarely, if ever, gives rise to the effects just mentioned until dilatation of the cavities of the heart has taken place. With the aid of the physical signs, the discrimination between predominant dilatation and predominant hypertrophy may generally be made with reference to prognosis and treatment. The prospect of life and tolerable health is less in proportion as dilatation predominates, and the management involves attention to incidental events which do not occur as long as hypertrophy predominates. For the convenience of comparison with the physical signs distinctive of hypertrophy (see page 149), the signs distinctive of dilatation are embraced in the following summary:

Edwin Hale
Edwin Moses Hale 1829 – 1899 was an orthodox doctor who converted to homeopathy graduated at the Cleveland Homoeopathic Medical College to become Professor Emeritus of Materia Medica and Therapeutics at Hahnemann Medical College, editor of the North American Journal of Homeopathy and The American Homeopathic Observer and a member of the American Institute of Homeopathy. Hale was also a member of The Chicago Literary Club.

Hale wrote Lectures On Diseases Of The Heart, Materia medica and special therapeutics of the new remedies Volume 1, Materia Medica And Special Therapeutics Of The New Remedies Volume 2, Saw Palmetto: (Sabal Serrulata. Serenoa Serrulata), The Medical, Surgical, and Hygienic Treatment of Diseases of Women, New Remedies: Their Pathogenetic Effects and Therapeutic Application, Ilex Cassine : the aboriginal North American tea, Repertory to the New Remedies with Charles Porter Hart, The Characteristics of the New Remedies, Materia Medica and Special Therapeutics of the New Remedies, The Practice of Medicine, Homoeopathic Materia Medica of the New Remedies: Their Botanical Description etc.