According to Bezold, the nervous centre of the cardiac movements furnishing three-fourths of the entire propulsive power of the heart, occupies the cervical region of the cord, including the medulla oblongata, and extends as low as the fourth dorsal vertebra. Its fibres run through the cervical spinal cord, and pass out between the seventh cervical and fifth dorsal vertebral, probably passing through the lower cervical and upper dorsal sympathetic ganglia, and proceeding to the heart.
The innervation of the heart is derived, in part, from the ganglionic or sympathetic system, and partly from the pneumogastric nerves. For its active force the heart is dependent on the cardiac ganglion and the plexus of nerves with which they are connected. The function of the pneumogastrics is to regulate its action. The latter presides especially over the rhythm of the heart’s movements. Morbific agencies giving rise to functional disorder may affect separately these two sources of the innervation of the heart. Most of the causes of functional disorder probably act primarily upon the nervous centres, but in some cases, as when the disorder depends on dyspepsia, or uterine irritation, the morbid influence is transmitted to the nervous centre, and reflected upon the heart. Very many cases of functional disorder of the heart are doubtless reflex in character. If we could decide, by accurate investigation, the particular nerves upon which medicines act pathogenetically, our knowledge of the curative powers of remedies would be much more certain.
PHYSICAL SIGNS OF FUNCTIONAL DISORDER.
Physical exploration by means of auscultation, percussion, and palpitation, is of immense value in functional disorder of the heart, as showing the absence of the signs of inflammatory and organic affections. The information which it affords is not less positive than if there were certain signs peculiar to functional disorder.
In our examination of the heart in cases of supposed functional disorder, we have to decide, first, as to the absence of abnormal phenomena denoting structural changes; and second, as to the presence of the normal phenomena denoting soundness of the organ.
By percussion we can ascertain that the heart is not enlarged, and, if not enlarged, that the disorder is quite certain to be functional. but we cannot, on the other hand, decide that the disorder is not functional because the heart is enlarged, for functional disorder may supervene upon, or coincide with enlargement.
Palpitation enables us to ascertain the force of the heart’s action. The movements and the irregular action are readily appreciated by the hand. We can discriminate between the increased and disturbed action due to morbid excitement, and the augmented power due to hypertrophy. The impulse in hypertrophy denotes strength rather than force; it is not quick and violent, but sluggish and strong; it does not give the sensation of a shock or blow, but it causes a gradual and strong heaving of the praecordia.
Palpitation also shows that in functional disorder not attended by structural disease, the point of apex-beat is in its normal situation; not elevated, as in pericarditis with effusion, nor lowered and carried to the left, as in cases of enlargement of the left ventricle.
Auscultation is important in two ways, first, by showing the absence of abnormal sounds indicating valvular lesions; second, showing that the natural sounds preserve their essential character and normal sounds preserve their essential characters and normal relations to each other.
Endocardial murmurs are very rarely heard, if ever, in purely functional disorder. A venous murmur, or hum, in the veins of the neck may be heard in persons in health, and the anaemic murmur may be diagnosed by the general condition of the patient. Aside from these two murmurs, it is not of practical importance whether a murmur be organic or inorganic, so far as relates to the treatment of functional disorder. Valvular lesions do not cause notable disturbance of the heart’s action prior to enlargement. If therefore enlargement is not present, the disturbed action of the heart may be considered as functional.
It must be borne in mind that all the normal heart sounds are intensified by the increased action present in functional disorder. So distinct do they become, that they may be perceived by the patient, especially at night. But if their sounds are only intensified, and not changed, we may know that functional disorder only exists.
DIAGNOSIS.
In order to make a correct diagnosis, we must first determine whether organic disease be or be not present; second, if organic disease be present, to determine whether super-added functional disorder be not the source of more or less of the symptoms referable to the heart.
It is in this case as in tubercular phthisis, that we can sometimes decide from the mental condition of the patient. It is well known that persons affected with tuberculosis are cheerful, and do not appreciate the gravity of the disease, while in those pulmonary disorders not dangerous they are despondent and foreboding.
In functional cardiac disorder, the patient is very anxious and apprehensive, while in purely organic disease no such degree of anxiety is manifested; on the contrary, they are often apathetic on the subject.
Again, the same or a greater amount of disturbance, when present in organic disease of the heart, causes much less anxiety than when arising from functional disorder.
The paroxysmal character of functional disorder is quite in contrast with the continued persistency of the symptoms of organic lesions.
In functional disorder active exercise does not generally aggravate the symptoms, it sometimes alleviates them, while in organic disease the contrary obtains.
There are certain symptomatic conditions belonging especially to organic disease, that are absent in pure functional disorder. Among these are general dropsy, lividity, haemoptysis, paralysis from embolism. They may coexist with functional disorder, but are not caused by it.
Cardiac disturbance is probably functional if it be connected with plethora, anaemia, derangement of the nervous system from excessive venery, mental anxiety, the abuse of tobacco, tea, coffee, or with gout.
Organic disease, on the other hand, in the majority of cases originates in acute rheumatism. If the patient has never had the latter affection, the probability is that the disorder is functional.
Functional disorder occurs especially in the young, between puberty and middle life.
Organic disease is oftener present in persons past the meridian.
Functional disorder is oftener present in females than males, while the reverse occurs in organic disease.
Functional disorder is worse at night; organic disease during the day.
We should not, however, venture an opinion as to the presence or absence of functional disorder, until we have made a physical examination. This, and this only, should decide us in forming a diagnosis.
PROGNOSIS.
The prognosis in cases of uncomplicated functional disorder is always favorable. The opinion that it may lead to organic lesions has been disproved. We may safely assure our patients that if a recovery does not occur, no organic disease need be apprehended.
TREATMENT OF FUNCTIONAL DISORDER OF THE HEART.
The therapeutics of functional disorder of the heart include:
I. Relief of disturbed action when present, or palliative measures.
II. Removal of the morbid irritability of the heart, or the causes of such irritability. These are the true curative measures.
Palliative measures are those which will allay any temporary excitement or disturbed action.
The mildest form of the disorder, when it arises from a fright, or undue exercise, usually need only rest of mind and body to allay it. A single dose of aconite may be of service.
For the attacks of palpitation, irregular and intermitting action, weakness or syncope, the following remedies will be found appropriate:
For paroxysms of palpitation from physical excitement, mental emotion, etc., a single dose of aconite will suffice if it has been caused by fright; coffea if from excessive joy; ignatia if from sudden grief; and scutellaria if from inordinate excitement of other kinds.
For paroxysms of tumultuous and irregular beating of the heart, with violent impulse, the chief remedy is veratrum viride, in doses of one drop of the tincture every hour, or oftener; a few doses will quiet the excitement. Such paroxysms usually occur in plethoric subjects. In similar cases cactus is often indicated, also aconite, arsenicum, belladonna, cocculus, lachesis, naja, and spigelia.
For paroxysms characterized by irregularity and intermissions, with feeble action or impulse, another class of remedies is indicated, namely: digitalis, cannabis ind., laurocerasus, acidum hydrocyanicum, arsenicum, veratrum album, and aconite.
Paroxysms of tremulous agitation of the heart call for nearly the same remedies, but the attacks are generally of such brief duration, that there is no time for the administration of medicines.
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.