Hypertrophy of the heart, not consecutive to either valvular or aortic lesions, and not an effect of either emphysema or any other pulmonary disease, constitutes always presumptive evidence of the existence of renal disease.
SUMMARY OF THE PHYSICAL SIGNS OF ENLARGEMENT OF THE HEART.
I cannot do better, in order to bring to your observation in a practical way, the prominent physical signs of enlargement, than to quote from Flint on Diseases of the Heart.
1. Percussion. – The area of the superficial cardiac region extended beyond the range of healthy variation. The degree of dullness within this area greater than in health, and the sense of resistance more marked. The limits of the deep cardiac region – in other words, the boundaries of the heart – generally defined by careful percussion; the dimensions of the space which the heart occupies being thus ascertained with precision, and the form of the organ delineated on the chest. Enlargement of the right or left auricle, sometimes determined by the extent of the area of dullness at the base of the heart, on the right or left side of the sternum.
2. Palpation. – the apex-beat moved to the left of its normal position, and lowered; the extent of variation, in either respect, being proportionate to the degree of enlargement, provided extrinsic causes be excluded. The area within which the apex-beat is felt extended beyond the range of health. Abnormal impulses felt in two, three, or more intercostal spaces, the additional impulses either synchronous or alternating with the apex-beat, in some instances referable to the auricles, although due to the ventricular systole; and, when felt in the epigastrium, due to the action of the right ventricle.
3. Auscultation. – The respiratory murmur not appreciable within the superficial cardiac region in tranquil breathing, and sometimes wanting when the breathing is forced; feeble over a large area within the praecordia than in health. The boundaries of the heart defined by abrupt cessation or notable diminution of vocal resonance, and the augmented space which the organ occupies, in this way determinable in corroboration of the evidence afforded by percussion.
4. Inspection. – Abnormal projection of the praecordial region in some cases; the projection considerable if the enlargement take place in early life. The movements of impulsion determined, which are also ascertained by palpation; movements sometimes seen which are not perceptible to the touch, especially movements which commence by depression with the systole of the ventricles. Alternate movements of intercostal spaces often apparent to the eye, which are imperfectly ascertained by palpation.
5. Mensuration. – Prominence of the praecordia greater than the corresponding portion of the chest on the right side; in some cases apparent on inspection, but determined with precision by diametrical measurement. Mensuration also employed in determining with accuracy the dimensions of the superficial and deep cardiac regions, the position of the apex-beat relatively to the nipple, median line, etc.
SUMMARY OF PHYSICAL SIGNS DISTINCTIVE OF ENLARGEMENT BY HYPERTROPHY.
1. Palpation. – Abnormal force of the apex-beat, denoting not merely excited action of the heart, but augmented power of the systole of the left ventricle, the impulsion prolonged and strong. A strong impulse in the epigastrium in cases of hypertrophy of the right ventricle; the impulsions sometimes communicated to the lower part of the sternum, and extending more or less over the site of the liver. A strong, heaving movement of the praecordia, in distinction from the shock, more or less violent, due merely to augmented functional activity of the ventricles.
2. Auscultation. – Increased intensity of the aortic second sound, and especially of the element of impulsion of the first sound, in hypertrophy of the left ventricle, rendering the first sound dull and prolonged, as well as abnormally intense, Exaggerated intensity of the pulmonary second sound, in hypertrophy of the right ventricle, especially if associated with obstruction to the pulmonary circulation. Augmentation of the tricuspid valvular element of the first sound in some cases of hypertrophy of the right ventricle.
TREATMENT.
The treatment of hypertrophy of the heart, i.e., enlargement by hypertrophy, by the allopathic school, presents some of the strongest arguments against the wilful bigotry of that school, and their persistence in adhering to a routine treatment, even when the facts of pathology are against them.
Up to a recent date, the allopathic treatment universally adopted, was equalled only by that of Dr. Sangrado, as depicted in Gil Blas. Repeated venesections; a diet so low as to result in partial starvation, was insisted on, not only by Valsalva and Albertini, but more recently, by Hope Bouillard, and even Wood.
I do not know of any disease where the results of such treatment could be more destructive to the integrity of the general system, for by it the heart was weakened, and dilatation – a condition ten-fold worse than enlargement – was generally caused.
The very object of the allopathic treatment was an error. A diminution of the size of the heart was considered a desirable result, but, as Flint observes, “A better understanding of the pathological relations of hypertrophy leads to the conclusion, that therapeutical measures designed to diminish or prevent it, are likely to do harm, in so far as they have efficiency in promoting these ends.”
I am sorry to inform you, that the homoeopathic treatment of hypertrophy of the heart has been as erroneous in principle, although the results have not been nearly as disastrous as those produced by the opposite school. The same remedies, in the same potency, have been used for the two opposite conditions of enlargement and dilatation. Even Baehr, otherwise sound, gives no separate and distinctive treatment for the two diseases.
I propose to present you with the treatment of enlargement by hypertrophy, and in a future lecture give you the true treatment of dilatation.
At present, the best authorities of both schools agree on one vital point, namely, that, considered in connection with the antecedent morbid conditions which give rise to it, conditions involving impediment to the circulation, hypertrophy, so far from being an evil, is an important provision against the dangers incident to the accumulation of blood within the cavities of the heart, and against the evils of dilatation. Hypertrophy compensates for the disturbance of the circulation caused by valvular lesions, and so long as the enlargement consists of this compensating increase of muscular structure, and consequently of muscular power, the patient experiences little or no inconvenience, providing nothing occurs, like anaemia, for example, to weaken the force of the heart’s action. It is when hypertrophy has reached the limit of its progress, and dilatation has followed, that serious inconveniences, referable to the heart and circulation, begin to be felt.
The general indications for treatment which I will now give for your adoption are :
1. To prevent those impediments to the circulation, arising generally from valvular lesions, which give rise to hypertrophy.
2. To prevent dilatation, by keeping up, if possible, the normal tonicity of the muscular structure of the heart.
3. To quiet undue excitement and irregular action of the heart.
The rules in relation to the general management of the patient are so uniformly agreed upon by all writers, that nothing original can be said. Baehr and Flint, the two representative authorities, have nearly the same views.
It is obvious that all influences that might stimulate the already over-excited heart should be avoided. Coffee, spirits, strong spices, salt in excess, also fat food, should be avoided. Mental excitement, especially anger, should be guarded against by the patient.
Very large and hearty meals should be avoided; small and frequent meals should be advised, and on no account should heavy meals late at night be allowed. The occupation of the patient may sometimes be changed to advantage. A sedentary life, attended by much excitement of mind, should be changed to a more active one, with less mental irritation. As regards exercise, your own judgment will have to be depended on. In some cases, general exercise, unless moderate, must be prohibited; in others, the physical activity may be greater. Local coldness of the hands and feet must be met with such gymnastics as exercise the extremities alone, the body being quiet.
The circulation should be equalized as much as possible; especially should remote parts of the body be supplied with blood, in order that the heart may not be overburdened and excited. The extremities should be warmly clad, and the whole body protected by flannel underclothing.
All influences tending the debility, nervous prostration, anaemia, or blood-impoverishment, should be avoided. Remember that the main object of treatment is to prevent weakness of the heart. Losses of the fluids of the body in excess tend to such weakness. Excessive venery, undue lactation, diarrhoea, purgation, a too meagre diet, and the improper use of medicines, should be guarded against. Mental depression will have the same unhappy result, and you should strive to have your patients placed under those influences which conduce to a happy, pleasant state of mind.
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.