Lecture IX.
Atrophy of the Heart – Fatty Growth – Symptoms of Fatty Growth – Fatty Degeneration – Symptoms of – pathological Effects – Treatment – Softening of the Heart – Induration of – Rupture of the Heart – Treatment of the Various Lesions.
GENTLEMEN: The walls of the heart are liable to various lesions, other than hypertrophy. In this lecture I shall briefly consider these organic affections and their treatment.
ATROPHY OF THE HEART
is a condition in which the muscular substance is diminished, the cavities not enlarged, but actually lessened. The whole heart is smaller than the normal size. Its weight is diminished in proportion to its size, but the organ does not change its appearance in any other respect.
Causes. It generally attends chronic diseases where there is gradual progressive emaciation. It has been observed in tubercular phthisis, pericardial adhesions, calcification of the coronary arteries, and an excess of fat on the exterior of the heart. The heart wastes like other muscular when badly nourished.
The symptoms are those which denote feebleness of the circulation, but the feebleness of the circulation may have existed prior to the atrophy. The physical signs suffice for the diagnosis. The boundaries of the superficial cardiac regions are within the limits of health, the apex-beat is indistinct or wanting, and the heart-sounds are abnormally feeble, and may be inappreciable.
The treatment of atrophy, when due to impaired nutrition, is the same as that adopted for enlargement by dilatation. The remedies in Class III., together with a highly nutritious diet, to which may be added cod liver oil in doses of 20 or 30 drops three times a day.
FATTY GROWTH AND DEGENERATION.
Fatty growth. More or less fat is generally present in health, on the outer surface of the heart, after early infancy, especially on the right ventricle, at and near the base of the organ. It is most abundant between the ventricle and auricle, and around the coronary vessels. A small amount of over-accumulation is sometimes found in post-mortem examinations, where there had been no symptoms of disease of the heart during life. When the accumulation is excessive it leads to enfeebled muscular action, and consequent weakness of the circulation. It may induce atrophy of the heart. Fatty growth usually occurs after the middle period of life, and in persons of adipose diathesis. It may, however, occur in persons who are not corpulent. You will most frequently find it in persons who are growing fat rather rapidly. The heart has been known to become completely encased in a thick layer of adipose tissue.
Fatty infiltration is another and more serious form. In this disease there is an accumulation of fat between the muscular fibres. The pressure upon the fibres causes functional weakness and atrophy, and leads to dilatation.
Fatty degeneration is much more serious, and differs essentially from the two varieties I have just mentioned. The fat, in the form of oil drops or granules, replaces the muscular substance, and constitutes a form of fatty atrophy. It may be associated with fatty growth of the heart, but it occurs independently of the latter. It affects more especially the left ventricle, while fatty deposits on the heart affects the right. It may be uniformly diffused, but is oftener confined to circumscribed patches or strips. The portions affected assume a yellowish or fawn color, and if it occurs in patches, gives the heart a mottled appearance. Examined with the microscope, the striae, or transverse markings of the fibres are indistinct or wanting, and in place of the proper constituents of the muscular fibre, there are oil globules and granules, in more or less abundance, according to the amount of degeneration.
In this disease, fat replaces the muscular substance, and in proportion as this result obtains, the propulsive power of the heart is diminished; it yields more readily to distension, and dilatation occurs. Authorities differ as to the real condition, for while some believe that the muscular substance is changed into fat, others believe that the fat is substituted for the normal muscular substance. Others teach that it is a chemical, not a vital process.
Causes. As I have before stated, you will not always find either variety in adipose persons. It often occurs in persons who have fatty deposits or fatty degeneration elsewhere, as in the liver or spleen. The etiology may involve both general and local causes. Among the local causes is impairment of nutrition from obstruction of the coronary arteries, from atheromatous or calcareous disease. It may occur from hypertrophy, valvular lesions, emphysema, or Bright’s disease. It occurs in connection with the tuberculous and carcinomatous cachexia, also in cases of pyaemia or septicaemia. It may be caused by the poisonous effects of phosphorus, arsenic, and some other poisons. Alcohol, in excess, undoubtedly has a causative influence. In old habitual drunkards this condition is generally found after death.
SYMPTOMS AND PATHOLOGICAL EFFECTS.
Although the different forms of fatty disease differ pathologically, their general effects are similar. Both cause weakness of the heart and enfeebled circulation, but not in an equal degree. I have told you which produces the most serious results. Fatty growth, and even degeneration may be present in a large degree, and not suspected up to the moment of death; and rupture of the heart has been known to occur from fatty degeneration, and the patient show no symptoms of the disease during life.
The pulse may be very slow, down to 20 or 30, and even 8 or 10, per minute. It will always be deficient in force.
It may be intermittent, irregular, very frequent and feeble. A sense of oppression at the praecordia, palpitation, and a tendency to syncope, are commonly observed. Flint has observed, and so have I, a notable degree of capillary congestion of the extremities. In one case which came under my observation, the hands and feet would become intensely red, especially after meals. Dyspnoea is present in this, as in other heart affections.
Certain symptoms referable to the nervous and respiratory system, are supposed to be highly significant of fatty degeneration: (1) The occurrence of seizures resembling apoplexy, but not followed by paralysis. After death no morbid appearances are observable in the brain; (2) A peculiar aberration of the respiratory movements was observed by Cheyne, and Stokes, “It consists in the occurrence of a series of inspirations increasing to a maximum, and the declining in force and length until a state of apparent apnoea is established. In this condition, the patient may remain for such a length of time as to make his attendants believe he is dead, when a low inspiration, followed by one or more decided, marks the commencement of a new ascending and then descending series of inspirations.” This is said only to occur a few weeks before the death of the patient. But this symptom has been known to occur from hypertrophy of the left ventricle, without fatty degeneration; (3) Fatty degeneration of the cornea, giving rise to that appearance known as arcus senilis, has been observed, but I have observed it when no symptoms of heart disease were present.
PHYSICAL SIGNS AND DIAGNOSIS.
You will not find it very easy to diagnose fatty disease of the heart from the physical signs; but if no valvular disease is present, and hypertrophy is not found, and the heart’s action is feeble, and the patient is adipose, you may safely infer the presence of fatty heart.
If you suspect fatty degeneration, and find that percussion shows moderate or no increase of the volume of the heart, you have a negative point. If you find that the apex-beat is not removed from its normal position, and its beat feeble, or inappreciable – and no impulse elsewhere than over the apex; and if by auscultation you find the sounds of the heart weakened, the first more than the second, and that is short and valvular; and, finally, if you find both sounds extinct, you may safely consider the case of fatty degeneration.
TREATMENT.
In the treatment of fatty growth and degeneration, you must have three objects in view, namely:
I. To obviate and relieve the immediate effects of weakness of the heart.
II. To increase permanently the muscular power of the organ.
III. To arrest or limit the accumulation of fat.
I. The immediate effects of the cardiac weakness are, palpitation and praecordial distress, syncope, dyspnoea, and perhaps apoplectiform attacks. These occur in paroxysms, excited by over-exertion, mental excitement etc. The combat these symptoms, you should use as palliatives, in severe attacks wine, spirits, ether, or ammonia, and continue their administration until the urgent symptoms disappear or are much relieved. The specific remedies for these symptoms you will find in Classes I. and II., in the treatment of dilatation, with the indications for their use, to which I refer you. In the apoplectiform seizures, especially, you will find Gelsemium 6th, or Acidum hydrocyanicum 3rd, particularly indicated – the former if the attack was rather slow in coming on, the latter if it was very sudden in its invasion. In general, the two best remedies are undoubtedly Aconite and Digitalis – the former in the 3rd dilution, the latter in the 1st or mother tincture. Whichever remedy you select, give it as frequently as the urgency of the case demands, until the pulse becomes full and regular, and the condition of the patient has much improved. If the extremities are cold, advise the mustard foot and hand bath, to divert the blood from the heart.
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.