The Practice and Applied
Therapeutics of Osteopathy
Charles Hazzard, D. O.
1905
CHAPTER XIV
DISEASES OF THE HEART AND CIRCULATORY SYSTEM
As in considering the diseases of the urinary system,
a number of cases are here noted for their value in showing various facts
in regard to the practice upon cases of this class, They show either important
lesion, the removal of which cured the disease; quickness of results gained
by osteopathic treatment in serious or long standing cases, unrelieved
by other methods of treatment; and something of the variety and range of
the practice in these cases. These reports as far as they go, are
typical of the practice. They are not, however, presented as model
case reports, nor as representing the whole field of practice in diseases
of this class.
(1) Fatty degeneration of the heart. The patient
was too weak to walk; the action of the heart was very weak; arrhythmia
was present; great dropsy of the lower limbs prevailed. The patient
could sleep only by kneeling over a couch with the chest supported by pillows.
This position relieved irritation from the lesion. Lesion was marked; there
was great contracture of the muscles from the atlas to the 6th dorsal,
especially marked in the upper dorsal region. The patient was very round
shouldered. These causes brought about a drawing together of the
sternal ends of the ribs, and lessened the cavity of the chest, allowing
of less room for the heart's action. For two weeks the patient was
treated daily, and could then lie down to sleep. After one month
he could walk a quarter of a mile to the office for treatment and return
unaided. At the end of a three month course of treatment he returned
home to work, and was well two years later.
(2) A case of palpitation of the heart, with goitre,
uterine disease, etc., presented contracture of the spinal muscles.
The clavicles were both down and backward at the sternal end; there was
lesion of the first right rib and of the second left rib; also a general
dropping of the ribs which narrowed the chest cavity. Lesion affected
the 1st and 2nd lumbar, and the pelvis was tilted. In six months
all lesions were corrected, and the case showed marked improvement.
(3) Palpitation of one years standing, attending
physical or mental exertion. Subluxation of the fifth rib was discovered.
It was removed in one treatment, and the patient suffered no further trouble.
(4) Palpitation and a complication of diseases;
lesion found at the atlas and in the upper dorsal spine. No Palpitation
occurred after the third treatment.
(5) Great palpitation of the heart, due to marked
spinal curvature in the upper dorsal and cervical regions, came upon the
patient frequently. Such an attack was usually treated medically
with digitalis and kept the patient in bed for several days. Osteopathic
treatment always relieved the patient of such an attack in a few minutes,
and the patient could go about her usual duties. It was a common
occurrence in this case to slow the heartbeat as much as twenty beats per
minute, this effect not being transient, but lasting for several days.
(6) Arrhythmia and a general bad condition
of the health; lesion of the 4th left rib; slight, lateral lesion of the
fifth lumbar vertebra. The latter was probably responsible for uterine
trouble present, which may have influenced the heart. After two months
treatment the heart beat was almost normal.
(7) Arrhythmia, in which the patient was very weak.
The left 5th was down upon the 6th and slightly inward. The cervical
and upper thoracic spinal muscles were very much contracted. The
treatment was directed to raising the rib and relaxing the contractured
muscles, and resulted in regulating the heartbeat in six weeks.
(8) Functional weakness; sinking spells occurred
upon any exertion, as in climbing stairs. The left thorax was found
depressed: the left clavicle was displaced downward at its sternal end,
while it was up and forward at its acromial end. All the ribs were
crowded together. Relief followed the first treatment, and the case
was cured in five weeks.
(9) Functional weakness of the heart, due to a downward
displacement of the right fifth rib affecting the intercostal nerve.
The case was cured in two months.
(10) Impeded heart action, resulting from a fall
causing spinal injury and nervous shock. The marked lesion was found
at the atlas.
(11) Valvular disease of 12 years standing in a
lady aged 40. Marked edema of limbs and abdomen were present.
She was suffering also from bronchial asthma. Lesions were contracture
of lower cervical and upper dorsal muscles; the upper ribs were all drawn
tight together, under treatment the asthma and dropsy were cured, and the
whole general health was made better than for years.
(12) Valvular lesion following acute rheumatism,
in a young man of 23. There was a twist in the spine at the 2nd dorsal
and at the 5th dorsal. Great benefit was gotten under the treatment.
(13) Enlargement of the heart, mitral and aortic
incompetence, and regurgitation; showed lesion in forward displacement
of the atlas, lesion of the left clavicle and upper two or three left ribs.
Three treatments produced much improvement, one months treatment corrected
the arrhythmia, and constant improvement went on under treatment.
(14) Angina pectoris after lagrippe; spinal muscles
contractured; the 3rd to 5th ribs displaced downward.
(15) Angina pectoris showing lesion of the 2nd to
5th left ribs. The left arm could not be raised above the head without
extreme pain. Under treatment the pains became gradually less severe,
until they had practically ceased at the end of two months.
(16) Angina pectoris, caused by downward displacement
of the left clavicle, and cured by its correction.
(17) Varicose veins and milk leg of fifteen years
standing. The tissues surrounding Hunter's canal and the saphenous
opening were tense, and the lumbar vertebra were anterior. An operation
had been advised, but the case had been practically cured under osteopathic
treatment at the time of the report.
(18) Varicose veins of eight years standing.
Three varicose veins were discharging when treatment began. Innominate
lesion was discovered. The case was cured in five weeks.
(19) Varicose veins, for which operations had been
made without success. The patient was compelled to sit with the limb
elevated, and had been thus for five months. The physicians found
they could do nothing more, and recommended continued elevation.
One month of osteopathic treatment cured the case.
(20) Varicose veins of two years standing.
Severe and continuous pain in the limb prevented sleep. The muscles
over the sacrum and the lower lumbar vertebra were rigid. In one
month of treatment the case showed great improvement.
(21) Varicose ulcers of ten years standing in a
man of 55. The ulcers extended from the middle of each leg down upon
the foot. The case was cured in three months by opening the venous
return from the limb.
(22) Disturbed circulation, in which the superficial
capillaries of one side of the body were flushed, reddening the skin, while
the other half of the body was pale. The line of demarcation between
the halves of the body was very prominent. This trouble had come
upon the patient as the direct result of a hard bicycle ride.
Lesion was found at the fifth lumbar, and its correction cured the case.
(23) Disturbed circulation. The patient had
accidentally received a hard blow upon the head, and intense pain developed
upon one side of the head. She was unable to turn her head without
turning the whole body. If she lay upon the injured side great pain
followed. This condition was of five years standing. Examination
showed a strong contractions of the muscles of the neck, which set up irritation
of the local sympathetic, affecting the vasoconstrictor fibres of the side
of the head in question, causing overcontraction of the vessels, setting
up the pain. Treatment was directed entirely to the contractured
muscles, and in five weeks time overcame the trouble entirely.
(24) Circumscribed ecchymosis upon left wrist, about
the diameter of a five cent piece, due to no bruise or injury, to the tissues
directly. The spot was dark, nearly black, and was accompanied by
slight numbness in the forearm. 'The lesion was a slight elevation
of the first left rib. The condition seemed to be a vaso-motor effect
from pressure upon the brachial plexus or by interference with the spinal
sympathetic connections. Reduction of the lesion was accomplished at one
treatment and had an immediate effect upon the ecchymosis. The area
began at once to grow lighter in color, and in ten minutes had materially
changed. In six hours it had disappeared.
(25) General Dropsy, ascites being quite marked,
in a lady of 38, and of 2 years standing.
Lesions occurred as a posterior condition of the third dorsal and a separation
between the fifth lumbar and the sacrum. The spinal muscles were
all very tender. The case was cured. The treatment was almost
entirely upon the lesions, with some general spinal, cervical and thoracic
treatment combined.
LESIONS: In seeking the lesion and in giving the
treatment in cardiac diseases, certain centers, prominently connected with
the normal activities and pathological manifestations of the heart, must
be specially examined for lesion. These centers, given below, do
not always relate to specific anatomical or physiological centers of the
texts, but in some cases refer to bony points become prominent in osteopathic
work as locations of lesion or of places where treatment produces special
results. These are: the first rib (heart failure); corpora striata;
1st, 2nd, 3rd, 4th, 5th dorsal vertebrae; 2nd to 4th dorsal (valves of
the heart); 3rd and 4th cervical (rhythm of the heart); superior cervical
ganglion (a sympathetic center); upper four or five dorsal nerves, especially
the 2nd and 3rd (accelerator center); medulla (general circulatory).
General vaso-motor centers which, with the special
vaso-motor motor innervation of a given viscus, suffer from lesion in circulatory
disturbances: superior cervical ganglion; 2nd dorsal, 5th lumbar, for general
superficial capillary circulation.
The lesions usually present in cardiac diseases
are: (1) of the atlas and axis; (2) the cervical region generally, both
muscular and bony lesion. Lesions of the atlas, axis and cervical
region affect the superior cervical ganglion and the other sympathetic
supply of the heart. (3) Lesions of the clavicle are found, as are
those, (4) of the 1st rib, (5) of the 2nd rib, (6) of the upper six ribs,
especially on the left side, (7) of the upper five dorsal vertebra, (8)
as a change in the general shape of the thorax, (9) of the fifth left rib
in particular, (10) of the diaphragm, i. e., of the lower six ribs, any
or all of them, and of certain portions of the spine.
Rib lesions are of prime importance in such diseases.
They seem to be relatively more frequent than other sorts, perhaps for
the reason that they affect the heart often mechanically, through alteration
of the chest cavity, as well as by interference with its nerve connections.
As to kind, the rib lesion is as important as any other lesion, while as
to frequency it is of greater importance. Many of the rib lesions
are of the 4th and 5th ribs, either or both, and usually of the left side.
Lesions of the fifth rib, significant with relation to the apex, also occur.
As a matter of fact, lesions of these two are the most important of the
rib lesions. They may affect both nerve connections and mechanical
relations of the heart. The fact that the apex beat (falling at the
fifth interspace) may be interfered with easily deranging the whole rhythm
of the organ, may account in part for the frequency with which such lesion
causes cardiac disease. In numerous cases the 1st and 2nd rib present
lesion, usually on the left side. While these lesions are not so
generally the cause of heart disease, they are frequent and important lesions
in these cases. Their main effect is through disturbance of the nerve
connections. The first rib may derange circulation through the subclavian
vessels, as may the clavicle. In some cases lesion of the clavicle
occurs. While not frequent, these lesions may be the cause of serious
trouble.
Spinal lesions, including both muscular and bony,
are of the greatest importance when it is considered that rib lesion contributes
to them by disturbance of the important nerve connections. They act
by producing derangement of the important nerve connections in the upper
dorsal region. From this point of view, bony and muscular lesions
in the cervical region become significant. While not so frequently
the sole cause of heart disease, they yet often occur and derange the important
sympathetic connections of the heart and this region. Lesions of the atlas,
axis, or of any of the first three or four cervical vertebrae also of the
rectus capitis anticus major muscle, may affect the superior cervical ganglion
as well as other cervical sympathetics.
It may be noted that practically all of the above
lesions affect the heart, in whole or in part, through its nerve connections.
This seems to be the most important avenue over which abnormal influences
travel from lesion to heart. By working directly upon nerve distribution
to the heart, irrespective of lesion, important changes are readily made
in its activities. Physiologically this organ is markedly affected
by nervous influences. It seems that a viscus whose nervous equilibrium
is so readily disturbed or influenced, should be peculiarly susceptible
to the influence of lesions to its regulative mechanism. Such lesions
as Osteopathy considers, affecting this mechanism directly as they do,
must be the true cause of many pathological states. Their removal
is therefore a rational means of cure.
The diaphragmatic lesion is of some importance in
heart diseases, as mentioned above. It is frequently associated with a
narrowed thorax, by reason of increased obliquity of the ribs, as well
as of various other lesions of them. These lesions prevent free rib
action, meaning also, practically, free thoracic play, free diaphragmatic
play, and free circulation. The various lesions which impede the free play
of these parts must unfavorably affect circulation.
In the cases of varicose veins reported the importance
of lumbar, sacral, and innominate lesion becomes apparent, also of the
stoppage of venous return. Lesions of the tissues about the saphenous
opening, and along Hunter's canal, are important in this connection.
Two cases of vascular disturbance showed lesion of the cervical region
and of the 5th lumbar vertebra, it being noticeable that each came at a
place at which it could affect the center for superficial circulation.
(Superior cervical and 5th lumbar).
In periods from one or a few treatments to three
months results are attained in long standing or serious cases that well
demonstrate the superiority of osteopathic therapeutics. In one case the
pulse was reduced from 140 to 110 at the first treatment, and was kept
down and constantly improved thereafter. In case 4 it is pointed
out that the pulse could be slowed as much as twenty beats per minute.
Considering the fact that a cardiac medicine that reduces the heart beat
one per minute is a successful one, it is readily seen that osteopathic
control of the heart is most successful.
The ANATOMICAL RELATIONS between the lesion and
the heart disease are made clear by the following facts. In view
of them it seems that the science of Osteopathy, by its methods of diagnosis,
arrives at the real cause of the disease. This is true also with
reference to diseases in general.
The pneumogastric nerves and the sympathetics are
the cardiac nerves. The pneumogastric is the heart inhibitor, and
its center has been definitely located in the medulla. It is a well
known osteopathic fact that lesion in the superior cervical region, acting
through the superior cervical ganglion, may disturb the centers contained
in the medulla. In such case the heart may be affected by disturbance
of the center of cardiac inhibition.
Special details of the action of the vagus in inhibiting
the heart have been observed. Strong stimulation of the nerve lengthens
both systole and diastole, i. e., slows the beat. It also lessens
the force of contraction, and causes the heart to beat not only more slowly,
but more weakly. At the same time this stimulation results in the
heart handling less blood, as the output and the input of the ventricle
are both diminished. The ventricular tonus is diminished, and the
heart dilates further by vagus stimulation, while at the same time the
walls of the ventricle have been found to be softer.
Osteopathic lesion to the vagi is a demonstrated fact. In view
of the above functions of these nerves, it becomes at once apparent that
lesion to them might cause serious disturbance. An irritative lesion,
keeping up stimulation of the nerve, would permanently slow the beat, lessen
force, retard circulation, and possibly lead to dilated and flaccid heart.
On the other hand, should the lesion be of a nature to cut off or to inhibit
to a degree the vagal impulse normally retarding the heart within limits,
the accelerator sympathetics would be left free to run the heart too fast.
In either case the removal of the lesion to the pneumogastric would be
of prime importance in curing the condition. Aside from removal of
lesion, osteopathic treatment of the vagi has been demonstrated to influence
heart action. The after effect of vagal stimulation Gaskell notes
to be increased force of cardiac contraction. This is an indication
that upon removal of lesion Nature would make special effort to repair
the former deficiency of function. As it is known that section of
the vagus is followed by atrophy of the cardiac muscle, it would
be possible that serious lesion might approximate such a result.
The vagus supplies the heart by its upper and lower
cervical and thoracic cardiac branches, which join with the sympathetic
and go to the cardiac plexus. It also has connection with the superior
cervical ganglion. As this nerve is known to be amenable to osteopathic
treatment at many points, likewise susceptible of lesion at various places,
as at the atlas, axis, and upper dorsal via its sympathetic connections,
along the stemo-mastoid muscle and at the clavicle, its importance in relation
to the cause and cure of heart disease is apparent.
The cardiac depressor nerve, whose presence has
been demonstrated in man, as well as in various other mammals, retards
heart action in a manner different from that of the vagus. Its stimulative
impulses come from the heart and act upon its sympathetic connections with
the splanchnics to produce reflex vasodilatation in the abdominal vessels.
They dilate and receive a large amount of blood from the general system,
the general blood pressure is lessened, arterial tension falls, and the
heart is thus quieted.
It is thus apparent that a bony lesion in the splanchnic
area might affect the spinal connections of the splanchnics, producing
an inhibitor effect that would likewise dilate the abdominal vessels, and
slow the heart by a process similar to that by which the heart depressor
nerves function.
On the other hand, lesion in the splanchnic area
might be of a nature to irritate or overstimulate the sympathetic connections,
thus causing a constriction of the abdominal vessels, and combating the
normal dilator tendency of the depressor nerve, thus preventing the heart
from being retarded in its beat to a normal degree.
Hence splanchnic lesion may result in abnormal slowness
or rapidity of the heart, and this condition may lead to other cardiac
disease. These facts may explain why we so frequently meet digestive
disturbances and the like in heart disease.
A further fact becomes evident. The practical
Osteopath makes much use of the splanchnic and abdominal areas in his work
upon cardiac and circulatory disturbances. By inhibiting the splanchnics,
and by an inhibitive or relaxing treatment over the abdomen, he dilates
the vast area of abdominal vessels and calls the blood from other parts
of the body. Reflexly the general blood pressure is lessened, arterial
tension is decreased and the heart is quieted. On the other hand,
stimulative treatment to splanchnics and abdomen will, by the opposite
effect, increase arterial tension and strengthen cardiac action.
An important avenue to the heart is through the
cervical sympathetic ganglia, each of which sends a cardiac branch to the
cardiac plexus. Between these branches, the branches of the vagus,
and the thoracic sympathetic, there are numerous points of communication.
Each ganglion is so situated and so connected with the spinal nerves that
it is susceptible to lesions. The upper ganglion lies in front of the second
and third cervical vertebra and communicates with the upper four cervical
nerves. It may suffer from lesion of the upper three vertebrae.
Its branches of communication with the 3rd and 4th cervical nerves often
pierce the rectus capitis anticus major muscle, on the sheath of which
the ganglion lies. Contracture of this muscle may act as lesion to
them. The middle ganglion lies in front of the 6th and 7th cervical
vertebrae and connects with the 5th and 6th cervical nerves. The
lower ganglion lies in front of the 1st costovertebral articulation, and
connects with the 7th and 8th cervical nerves. They are susceptible
to lesion respectively of the 5th, 6th, and 7th cervical vertebrae and
the 1st rib. All three are liable to muscular lesion in cardiac disease.
The accelerator or augmentor nerves of the heart
are sympathetic. They are antagonistic to the vagi. That they
are liable to suffer from spinal lesion is at once apparent from their
anatomical relations. They are derived from the upper four or five
dorsal nerves, especially from the 2nd and 3rd. They join the sympathetic
at the middle and lower cervical, perhaps also first thoracic, ganglia.
(Quain). The most important treatments for cardiac stimulation or
inhibition are made in the upper dorsal region, at the origin of these
nerves, by stimulation or inhibition of them. Important heart lesions
occur in the upper dorsal region (spine or rib) and probably affect the
heart through these connections. The connection of these ganglia
with the middle and inferior cervical ganglia lends the latter added importance
in these matters.
When these accelerators are stimulated, they increase
the frequency of the heartbeat from 7 to 70 per cent, but a long stimulation
produces no greater acceleration than a short one. This marked increase
in the pulse is quickly apparent under osteopathic stimulation of the accelerators.
Further results of stimulating them are an increased force of the ventricular
beat, the ventricles are more completely filled by the auricles and their
volume is increased. The strength and volume of the auricular contractions
are also increased, Hence our treatment both quickens and invigorates the
heart muscle, and the organ consequently handles more blood at a beat.
Lesions of the lower cervical, upper dorsal, or
upper thoracic (rib) region might be of such a nature as to maintain continual
stimulation of the accelerators, lead to permanently quickened and strengthened
heartbeat, and produce such an affect as hypertrophy of the heart.
Or the lesion might out off or lessen the accelerator impulse, leading
to abnormally slow heartbeat, lack of strength of heart action, etc.
Hence the importance of correcting lesion in these regions.
Jacobson (in Hilton's "Rest and Pain") points out
that the cardiac plexus through the aortic plexus, is connected with the
4th, 5th and 6th spinal nerves. This fact may in part explain the
importance of lesion of the 4th and 5th ribs in heart disease. The
1st, 2nd and 3rd spinal nerves, through the sympathetic supply sensory
fibres to the heart. (Quain) The above facts explain why secondary
lesion as contractured muscles may occur along the upper dorsal spine as
far as the 6th in cardiac disease.
The cardiac plexus is made up of the cardiac branches
of the vagus and from the cervical ganglia, whose functions and relations
to cardiac disease were pointed out above. This plexus suffers from lesion
of those nerves, and is the medium through which lesion acts upon the heart.
The right and left coronary plexuses, derived from the cardiac, supply
the coronary arteries. Lesion to them, through the cardiac, would
influence nutrition and circulation in the heart substance.
The intercostal nerves may become important paths
of transmission of the effects of lesion to the heart. It is well
known that rib lesions are among the most frequent causes of heart disease.
Possibly much of their influence is by irritation to the intercostal nerves.
These nerves are the anterior primary branches of the spinal nerves, and
the ramus communicans from each thoracic sympathetic ganglion passes directly
to the intercostal nerve corresponding. As shown above, the heart
is in connection with the upper six dorsal nerves through its sympathetic
supply. The upper four or five give origin to the accelerators.
The 1st, 2nd and 3rd contribute sensory branches to the heart. The
4th, 5th and 6th connect with the cardiac plexus through the aortic.
Hence, on account of this direct connection between heart and the anterior
primary divisions of the upper six dorsal nerves the immediate effect of
lesion in this portion of the thorax might be upon the heart. Hence the
importance of luxated ribs, sore and contractured intercostal muscles,
a narrowed chest and changed shape of the thorax. These facts emphasize
the importance of free thoracic play in the maintenance of the health of
the thoracic viscera.
A general changed shape of the thorax may have its
bearing upon the etiology of cardiac trouble in other ways. The total
intercostal circulation represents a considerable portion of the general
circulation. If this circulation be obstructed, as may occur in those
conditions in which a general alteration in the shape of the thorax has
produced narrowing of the intercostal spaces, the heart must be put to
great exertion to force the blood through this area of obstructed vessels.
Furthermore, such a condition of narrowed thorax is just the one pointed
out as the cause of lesion to the diaphragm, which obstructs the flow of
blood through the aorta and still further embarrasses the heart.
Take these obstructions to intercostal and aortic circulation in conjunction
with rib lesions to intercostal nerves, a frequent occurrence, and it could
hardly result otherwise than that cardiac derangement must follow.
The phrenic nerve innervates both heart and diaphragm.
Lesion to it may affect this organ, or treatment of it may aid in cardiac
cases. It is joined by branches from the middle or lower cervical
sympathetic ganglia and from the thoracic sympathetic, both of which are
connected with the heart innervation. It perforates the diaphragm
and joins the abdominal sympathetic. It supplies the right pericardium,
the right auricle, and the inferior vena cava. Perhaps it, a motor
nerve, coordinates the activities of heart and diaphragm, so closely related
in function. Its inhibition is our common method of relaxing the
diaphragm in hiccough.
Its inhibition would be important in securing a
lax or quiet diaphragm, so desirable in the treatment of certain forms
of cardiac diseases, the more so as it may likely be suffering from the
irritation of the disease affecting the heart or its coverings.
Clavicular lesion may affect the subclavian vessels,
dam back the flow of blood through the artery, or, by preventing the return
flow through the vein, cause the periodic loss of a heartbeat through insufficient
filling of the organ.
The intimate relations between the cardiac nerves
and the general nervous system is seen in the fact that stimulation of
the sciatic increases the force and frequency of the heartbeat. These
facts are of value in treatment for the general circulation.
PERICARDITIS
Under osteopathic treatment the prognosis for cure
is good in the dry or plastic form and in that with serous effusion.
In the purulent form, and in chronic adhesive pericarditis the prognosis
must be unfavorable though much might be done to benefit the patient's
condition.
The LESIONS affect the blood supply by derangement
of the spinal sympathetics. Irritative rib lesions, bringing pressure directly
upon the heart, cause the disease by mechanical irritation of the pericardium.
This is especially likely to occur in lesion to the fourth and fifth left
ribs, they occurring at the site of apex beat, where the greater range
of motion is more likely to be interfered with by narrowing of the thoracic
cavity or by inward displacement of these ribs. Lesions to the subclavian
vein at the first rib or clavicle, and to the anterior intercostal vessels,
preventing venous drainage of the pericardium, may predispose to the condition.
A narrowed thorax and a deranged diaphragm may, by pressure or traction
upon the pericardium, allow special causes to set up irritation and inflammation
in the structure. These various lesions may have the foundation for
the disease, some special active cause, producing it directly. Thus
spinal and other lesion to the cardiac nerves weakens the tissues and lays
them liable to the effect of such disorders as rheumatism, gout, scarlatina,
influenza, etc., secondarily to which pericarditis occurs. In such
cases also attention must be given to the lesion accountable for the primary
disease.
In the TREATMENT the patient must be kept rest in
the recumbent position to aid in slowing the beat of the heart. This
object is directly accomplished by stimulation of the vagus and inhibition
of the accelerators. The former is treated by manipulation along
its course behind the sternomastoid muscle. Inhibition of the accelerators
is applied along the spine from the 6th cervical to the 5th dorsal.
With the patient lying upon his back the left aim is raised and held well
above and behind the head, while steady pressure is applied along the upper
dorsal region as far down as the fifth vertebra.
The lesion must be removed. The ribs may be
carefully raised to free the venous circulation through the internal mammary
veins, which drain the anterior intercostal veins. This aids in allaying
the inflammation, as does also the inhibitive abdominal treatment by drawing
the blood to the abdomen. The latter operation is assisted
by inhibition along the splanchnics at the spine. Calling the blood
to the abdomen not only aids in allaying the inflammation, but may slow
the heart by decreasing arterial tension. As this reflex dilatation
of the abdominal veins is a result the same as that produced by the heart
depressor nerve in functioning to quiet the heart, it is supposable that
treatment given to dilate these vessels produces a result similar to that
resulting from depressor nerve action.
As all the ribs are carefully raised to expand the
thorax and give freedom to the heart, the various intercostal muscles should
be gently manipulated and relaxed. On account of the close connection
pointed out above between the intercostal nerves and the sympathetics connected
with the heart, it is probable that reflex sensations are transmitted from
the diseased cardiac apparatus to the intercostal nerve, leading to a contractured
condition of the intercostal muscles generally.
The phrenic nerves should be inhibited to relax
the diaphragm (and pericardium (?) which it supplies). This treatment
is the more important in pericarditis, as the diaphragm is probably irritated
by the inflammation in the pericardium directly contiguous to it. Irritation
would mean contracture. This relaxation of
the diaphragm would aid in quieting the heart and in relieving the whole
local condition. The desirability of securing a lax state of diaphragm
and pericardium in the treatment of pericarditis is suggested by Hilton.
The pain about the heart is lessened 'by the whole
treatment. Direct treatment may be made for it by inhibition of the
1st, 2nd, and 3rd dorsal nerves (sensory to the heart), and the 4th, 5th,
and 6th dorsal nerves, which apparently convey sensory impressions from
the heart.
The dyspnea is relieved by the allaying of the inflammation,
quieting the heart, and raising of all the ribs. Effusion is prevented
or resorbed by keeping up free circulation, especially after the acute
stage for the latter object. If necessary, the icebag may be applied
to the precordial region to allay the inflammation. Its use may become
necessary in the intervals between treatment. The diet should be
of milk and broths during the acute stage. Later it should be light.
Treatment should be given daily. More than
one treatment per diem may be necessary, especially attention to various
phases.
Treatment for the various forms of pericarditis
would be upon the same plan, with due attention to the manifestation of
each condition. In the chronic form it would be proper to keep the
heart well stimulated, to increase its nutrition. The patient should
take plenty of rest lying down to avoid hypertrophy of the heart.
For the plastic form and for that with serous effusion, the treatment is
as above described. In the latter, during the stage of effusion one
must carefully watch the heart to prevent collapse. When the pulse
becomes weak, and cyanosis is present, the heart and lungs should both
be stimulated. In the purulent form the treatment should be applied
as above, but this condition calls for surgical treatment. The pericardial
sac should be drained.
HYDROPERICARDIUM is a condition in which a serous
fluid transudate occupies the pericardial sac, but no inflammatory condition
is present. It is commonly associated with renal or cardiac dropsy,
and its treatment is that indicated for them, q. v.
PNEUMOPERICARDIUM calls for palliative treatment
similar to that described for pericarditis with effusion. The heart
should be kept stimulated against collapse. The case calls for surgical
treatment.
PALPITATION
DEFINITION: A paroxysmal rapidity of heart
action, perceptible to the patient, and usually accompanied by increased
force, disturbed rhythm, precordial distress, anxiety, and dyspnea.
This condition is caused by special lesion, usually a bony, one that interferes
with the nerve mechanism or with the heart mechanically. This, and
the socalled neuroses of the heart, are, from the osteopathic standpoint,
neuroses mainly because of their being caused by disturbed nerve mechanism
of the organ. This is no more nor less true in such diseases than
in the general diseases of the heart.
LESIONS AND ANATOMICAL RELATIONS have been discussed
in a general way above. An examination of the several cases of palpitation
reported at the beginning of the chapter shows a wide range of lesion,
namely, from the atlas to the last rib, when considering as a lesion producing
this condition those changes in the shape of the thorax and those lesions
of the lower six ribs responsible for lesion of the diaphragm embarrassing
the heart. These lesions may act by disturbing the nerve connections
of the heart, by occluding certain vascular areas or single vessels, or
by direct mechanical pressure upon the heart. Lesions of the clavicle
and first rib are frequent, and they, by damming back the blood in the
subclavian artery may cause periods of labored beat of the heart to force
it through. Or by lessening venous flow from the subclavian vein
such lesion may cause a paroxysm of rapid beating of the heart in the endeavor
to fill itself. Cervical and upper dorsal lesions, curvatures of
the upper spine, lesions of the upper five ribs, and general contracture
of the spinal muscles may all act as irritant upon the accelerator sympathetics,
noted as rising from the upper four or five dorsal nerves and passing to
the middle and lower cervical sympathetic ganglia. Stimulation of
these accelerators thus caused could produce the rapid beating of the heart
found in palpitation. This class of lesion is most
frequent in these cases.
Atlas lesion may affect the heart through the superior
cervical ganglion and its upper cardiac branch. But through this
ganglion such lesion is able to affect the inhibitory center in the medulla,
or it may affect the vagus itself by way of its sympathetic connections
with the ganglion mentioned. The result is over activity of the inhibitor
function of the vagus, and the rapid beat thus allowed as the result of
unopposed activity of the accelerator. This style of lesion is not
a frequent cause of palpitation.
It may be argued that as bony lesions are by nature
continuous, the paroxysmal rapidity of the heart in palpitation could not
be thus caused, that the effect of this continuous lesion must itself be
continuous as opposed to paroxysmal. Such is not the case, however.
The lesion may not be so excessive in degree as to keep up continual irritation.
Its irritation may become active only in certain motions or postures of
the affected parts. It may be the neuropathic basis weakening the
nerve tissues and laying the heart liable to the effects of special emotions,
stimulants, etc. The lesion might even, per se, be of a nature to
cause continuous irritation and yet its effects not be continually apparent
as rapid heartbeat on account of the natural variation in the activity
of the accelerator centers and in the condition of the nervous system.
Luxation of the fifth left rib mechanically irritates
the heart and causes palpitation. Occurring as it does at the site
of the apexbeat, it is just as likely a cause of palpitation as is the
pressure from a stomach dilated with gas. Displacement, of this rib
and of the 4th is a common cause of palpitation. Rib lesions in general
are quite apt to be found in cases in which palpitation is brought on by
slight muscular exertion. The movable rib, being luxated, is readily
thrown into an exaggerated condition of lesion upon muscular effort. Cases
are continually met in which some special form of muscular activity, perhaps
necessitated by the patient's occupation, has first caused the displacement
and has then become the repeatedly acting cause of the various attacks
of palpation which have followed.
A frequent and serious cause of heart disease in
general, as well as of palpitation in particular, is found in a general
downward luxation of the ribs resulting in a narrowed thorax. Such
a condition becomes a threefold lesion. Looked at as the cause of
palpitation, it acts: (1) By partially occluding the caliber of the arteries
in the total intercostal area, aggregating a considerable vascular total.
(2) By causing lesion to the diaphragm of a nature allowing it to constrict
the aorta. As a result of all this arterial obstruction, the heart
labors (palpitation) to force the blood along its accustomed channels.
(3) By irritation to the intercostal nerves in the narrowed intercostal
spaces. The upper six of these nerves, as above explained, are in
direct sympathetic connection with the heart and convey to it the irritation
engendered in the intercostal spaces, causing it to palpitate.
It will be noted that chronic heart sufferers are
very often the possessors of flat chests and narrowed thoraxes.
Dyspepsia, flatulence and diseased abdominal organs
often reflexly set up palpitation. It may be that both effects are
the results of a common lesion, i. e., one to the splanchnic nerves (abdominally
or spinally). It has been explained that the depressor nerve of the
heart acts reflexly, through the splanchnics to produce vasodilatation
in the great abdominal vascular area, "bleeding the patient into his veins,"
and to cause a fall of blood pressure, with a quieting of the heart.
On the other hand, splanchnic lesion may set an intense vasoconstriction
in this area, oppose the circulation of the blood in this way, and cause
the labored beat or palpitation of the heart to force the blood through.
The common cause assigned for palpitation, such
as a strong emotion, the use of tea, coffee, tobacco, and alcohol; reflex
disturbances from the ovaries, uterus, and other pelvic organs, etc., seem
to be but incidental. There must be some cause determining the effects
of these agents upon the heart. Otherwise it is hard to explain why
these things effect one patient's heart and not that of another.
The real cause weakening the heart and allowing these incidental causes
to disturb it lies in the anatomical weak point affecting the organ or
its connections. A multitude of cases cured by replacement of a displaced
rib, or the like, leads to the conclusion that these socalled causes had
little to do with the real cause; as of case 6 above, in which three weeks
treatment cured palpitation of many years standing, and rendered the patient
immune to the effects of coffee and tobacco, which before he could not
use.
In cases where the palpitation is purely secondary,
as in anemia, from the changed state of the blood, and in acute infectious
diseases, from the irritation of toxic substances circulating in the blood,
the lesions belong to the primary disease.
The PROGNOSIS is good. The most marked and
long standing cases have yielded readily to treatment. The case is
generally relieved at once and soon cured.
The TREATMENT of the time of attack must look at
once to quieting the nerve irritation that is causing the trouble. (1)
Often the immediate removal of the lesion is practicable and is the sole
treatment necessary.
(2) Inhibition of the accelerators in the manner
described in detail in the previous pages is the most efficient method
of at once relieving the palpitation. Considerable pressure may be
applied to the accelerator area of the spine, the left arm meanwhile being
strongly held above the head (see Pericarditis). Steady pressure
at each point along these nerves for several minutes is necessary.
During this treatment one hand is slipped beneath the patient, the arm
may be held down above the head against the table by the pressure of the
practitioner's trunk against it, while with his hand he relaxes the intercostal
tissues all about the precordial region. This is to release contractions
in the intercostal muscles set up by the irritation carried from the cardiac
plexus to the upper intercostal nerves, with which it is closely connected.
(3) Stimulation of the pneumogastric nerves in the
neck aids inhibition of the heart action (IV, Chap. IV). "
Pressure upon the vagus" in the neck, or pressure upon special points in
the abdominal parieties, the ovarian region in particular) sometimes arrests
the attack promptly" (Anders).
(4) Stimulation of the abdominal sympathetics, by
a quick treatment, will aid in inhibiting the heart beat. A better
method, however, is to dilate the vast abdominal vascular system by the
deep, inhibitive abdominal treatment. This drains the blood into
the abdomen, decreases general arterial tension, and quiets the heart.
It is the exact process by which the depressor nerve quiets the heart,
and may possibly cause it to function. Strong inhibition of the spinal
splanchnics aids this process.
(5) All the ribs should be carefully elevated to
allow free play to respiration and heart. The dyspnea is a reflex
from the disturbed heart. It is relieved by this treatment, and by
the relieving of the heart.
(6) Other sources of irritation, as anemia, pelvic
disease, etc., call for special treatment.
(7) Upon the attack the patient should be laid upon
his back at once, and the clothing about the neck and chest should be loosened.
Treatment (2) should be at once applied. In case of necessity during
the practitioner’s absence, an icebag applied to the precordial region
is a good domestic remedy. The patient may swallow bits of ice or
drink plentifully of cold water. Hot and somewhat stimulating drinks
are recommended.
If the attacks are frequent or persistent the treatment
must be often given. In treatment to prevent the recurrence of attacks
a course of treatment may be carried out along the lines laid down.
Special attention would naturally be given the lesion. Heart action
and circulation would be built up, etc. Attention should be given
to the diet as certain articles of diet, may cause palpitation. An
overloaded stomach should be relieved by vomiting.
TACHYCARDIA,
BRACHYCARDIA AND ARRHYTHMIA
The first is a rapid beating of the heart in paroxysms
of marked subjective variable duration, unaccompanied by marked subjective
sensations. The second is an abnormal slowness of the heart, temporary
or permanent. The third is irregular beating of the heart, the irregularity
being manifest in volume, force or time, alone, or in various combinations,
presenting various peculiarities. The lesion and its mode of causing
disease, described for palpitation, are essentially the same for these
three manifestations of disturbance to the cardiac mechanism. The
treatment, also, would proceed along the same general lines there laid
down, being varied to suit the requirements of the disease and of the individual
case. As a matter of fact the lesions found as the actual causes
of these different diseases are practically the same in kind, affect the
same areas, nerve connections, and vascular relations, but differ in degree,
in concentration upon a particular region, e. g., chiefly upon the accelerators
in the upper region to produce tachycardia, and therefore in the particular
manifestation or results of their presence.
It is natural that those lesions producing palpitation
should be greater in degree and more continuous and severe in action, thus
producing tachycardia; that upper dorsal lesion should so excessively affect
the accelerators as to permanently inhibit their activity to a degree great
enough to cause brachycardia, or that the periodic or irregular manifestations
of the effects of such lesion should produce arrhythmia. The latter
is generally a feature of ordinary palpitation. In the same way arterial,
venous, or other nerve lesion might become the cause of either disease.
In other words, a purely osteopathic classification of diseases would regard
these conditions as essentially the same, both as to lesion and as to general
manner of treatment.
One must bear in mind the fact that these conditions
are frequently simply symptomatic, as, for example, the arrhythmia resulting
from reflexes from kidneys, lungs, liver or stomach, or from the toxic
effects of tea, coffee, tobacco, alcohol, or drugs. But they may
also be due to cardiac changes in the ganglia, or in the walls, such as
simple dilatation, fatty degeneration, or sclerosis.
The fact that tachycardia is looked upon as being
a manifestation of paralysis of the pneumogastric or stimulation of the
sympathetic is significant from the osteopathic viewpoint.
The prognosis for these conditions is ordinarily
good. The results attained are very satisfactory and cases are often
readily cured. The fact that they are frequently symptomatic of other
disease, or secondary , thereto, makes the prognosis and treatment depend
upon the primary condition. When, as is often the case, they are
found to depend upon specific removable lesion the progress is good.
It is not good when organic heart disease is present.
The treatment for these conditions must be primarily
the removal of lesion or irritating cause, or the treatment of the primary
disease to which either may be secondary or symptomatic. All causes
of reflex irritation, and the abuse of tea, coffee, and alcohol, etc.,
must be looked to. That for tachycardia and arrhythmia is practically
that for palpitation. The treatment for brachycardia is mainly stimulation
of the accelerators. In the treatment of brachycardia or the tachycardia
following acute infectious diseases, e. g., typhoid fever, the excretory
organs must be stimulated to free the system of poison, and the centers
controlling the activities of the heart must be built up, as they have
been invaded by the poison of the disease. In brachycardia the heart
and lungs must be kept stimulated against the occurrence of syncope or
physical prostration. Treatment in the intervals may be directed
to upbuilding the general health, mechanical correction of the body, etc.
Proper physical training to strengthen the heart muscle is valuable in
all cases, and is practically all that is necessary in some cases.
IRRITABLE HEART is another neurosis, and is to be
regarded in the same light as the above conditions. It will be found
to depend upon practically the same lesions, and readily yields to the
treatment. Thorough general system treatment for the nervous system
should be added to that given the heart. The digestive disturbances,
constipation, etc., yield readily to the treatment for those conditions.
The cardiac uneasiness is overcome by keeping the ribs raised, and by inhibition
of the heart’s action. The patient should avoid stimulants and overexertion.
ANGINA PECTORIS
DEFINITION: Paroxysms of violent pain in the precordial
region, extending to the neck, back and arms, and accompanied by a sense
of impending death. It is said to be largely symptomatic.
The lesions presented in the above cases were mainly the left ribs
over the heart. One case showed lesion to the left clavicle, affecting
the subclavian circulation. Another case is reported with the lesion
as a spreading of the sixth and seventh left ribs anteriorly. Lesions
to the ribs over the heart are very common in this disease. The upper
dorsal spine is often affected. The nature of the pain of angina
pectoris is not well understood. Upper dorsal lesion may irritate
the sensory nerves of the heart. (1st, 2nd, and 3rd dorsal) The irritation
of the lesion upon the heart may result in a neurosis of the sensory branches
of the vagi. Other lesion to the vagi through their sympathetic connections
may cause it.. Some writers advance the theory that an aortitis is present
and causes it. A deranged nerve mechanism as the result of spinal,
rib and other lesion, seems sufficient, from an osteopathic point of view,
to cause this disturbance. The fact that it is usually associated
with some form of organic heart lesion, arteriosclerosis, etc., is not
contrary to the idea that bony lesion is at bottom the cause of the whole
bad condition.
The prognosis must be guarded because of the frequent
presence of organic heart disease in cases manifesting angina pectoris.
The prognosis for relief is good, and cases are often entirely cured.
The treatment consists mainly in relieving the pain.
This may be best accomplished by raising the left lower ribs in the region
of the heart, especially in case of lesion here, by adopting the motion
described for inhibition of the accelerators, bringing pressure over the
upper three spinal nerves (cardiac sensory) at the same time, and also
relaxing the tissues of the precordial region, with additional inhibition
of the pneumogastric nerves.
Spinal inhibition may be carried down along the
spine as low as the 6th dorsal nerve. Inhibition should be made upon
the local nerves of the parts to which the pain has radiated, as to the
brachial plexus, the cervical and spinal nerves, etc.
A general course of treatment, should be given to
strengthen the patient's general health, to correct heart action, and to
remove all lesions. In this way much may be done to prevent the recurrence
of the attacks. The patient should lead a quiet life free from physical,
mental and emotional extremes. Rest of mind and of body, and a good
diet, are helpful. In case of emergency use of the icebag, or of
hot applications over the heart may be useful.
ENDOCARDITIS AND MYOCARDITIS
These are inflammation of the endocardium and of
the heart muscle, attended by various pathological and degenerative changes
in the part attacked. The extent to which the pathological changes
go in most of these cases renders a cure hopeless. All forms of these
diseases are apt to produce serious valvular lesions. Aside from
simple acute endocarditis, death is imminent in most of these cases, yet
much may be done in individual cases to alleviate conditions and to prolong
life.
The LESIONS AND ANATOMICAL RELATIONS as pointed
out at the opening of the chapter apply here. It is seldom that myocarditis
or any of the several forms of endocarditis seem to occur idiopathically.
How far the actual causes of these diseases may be shown, from the accumulation
of osteopathic data, to be specific osteopathic lesions to the heart remains
to the future to decide. The accepted cause of these conditions generally
is the irritation of the organ by the poisonous products of disease.
Acute articular rheumatism is made accountable for 40 per cent of simple
acute endocarditis. Rheumatism, malaria, scarlet fever, pulmonary
tuberculosis, syphilis, gout, poisoning, etc., are looked upon as the primary
diseases in which poisonous products are generated and cause endocarditis
or myocarditis as a secondary cause. Various other causes are assigned.
While poison in the system is admitted by the Osteopath to be sufficient
cause of disease, it seems likely that specific lesion to the cardiac apparatus
has much to do in weakening the heart and laying it liable to the invasion
of these diseases. Circulation to the substance of the heart is under
control of the coronary plexus, derived from the cardiac plexus.
Lesion to the latter through its spinal connections may affect the former
and disturb the nutrition of the organ. The same result may be produced
by lesion to the pneumogastrics, said to contain vaso-motor fibers to the
heart and to have charge of trophic condition. It is obvious that
the usual cardiac lesions may predispose the heart to these diseases.
The direct irritation of the left ribs upon the heart, when they are displaced,
may directly cause pericarditis and myocarditis. As medical etiology
lays most of these cases to the action of bacteria, it is reasonable to
conclude that direct lesion to the heart deteriorates the vitality of its
tissues and allows them to gain a foothold.
This conclusion is strengthened by the fact that
endocarditis sometimes follows chronic wasting diseases, such as diabetes
and gleet. The fact that chronic endocarditis may be due to mechanical
influences, may be caused by heavy muscular effort, straining, etc., and
the further fact that myocarditis is ascribed by Anders to injuries of
the anterolateral thoracic region emphasizes the idea that mechanical lesions
regarded as important by the Osteopath may directly cause these conditions.
The PROGNOSIS for simple acute endocarditis is good.
It depends some upon the primary disease. The prognosis for chronic
and ulcerative endocarditis and for myocarditis is grave. If specific
lesion is found and may be removed, perhaps much may be done for the case
- generally speaking, much may be done in all of these cases to limit the
disease and to prolong life. Chronic endocarditis is has been cured.
The TREATMENT is practically that described for
pericarditis, q. v. Knowledge of the nerve and blood supply and of
lesions gives one the key to the situation. The lesion and all cause
of irritation must be removed, and the patient, in the acute stages, is
kept in bed to keep the heart quiet. Inhibition of the accelerators
and stimulation of the vagi is done as directed. The ribs are raised
to give the best freedom, and the abdominal treatment may be applied to
draw the blood away front the heart and aid in keeping it quiet.
Strict attention must be given the primary disease.
In those generating toxins in the system the bowels, kidneys and liver
are stimulated to excrete the poisons. In the chronic forms the heart
and its connected nerves may be carefully stimulated to increase its tone
and nutrition. The vegetation in acute in endocarditis may be absorbed.
Prophylactic treatment in rheumatism and in those
diseases leading to these conditions consists in keeping the heart well
stimulated, and in maintaining free action of kidneys and bowels to excrete
the poison.
In acute endocarditis the precordial pain and dyspnea,
if present, are relieved by carefully elevating the ribs in the region
of the heart by elevating the arm and holding it up behind the head.
While the arm is held in this position the intercostal tissues about this
region should be manipulated and relaxed. The upper dorsal spinal region
should be inhibited, from the 1st to the 6th dorsal. This treatment
would likewise quiet palpitation.
The heart should be carefully sustained and kept
gently stimulated, especially if it show indications of failing.
In ulcerative endocarditis the whole progress of
the case must be carefully watched. If it accompany a septic disease,
especial attention must be given that condition, and the chief indication
is to keep the poison freely excreted from the system. Local symptoms
of this form of endocarditis, if present, are similar to those for which
the treatment has been described in the acute form.
Gastrointestinal disturbance, vomiting and diarrhea, calls for such treatment
as has been described for these conditions. The local circulation
to eyes and kidneys should be kept active to prevent retinal and renal
hemorrhages, evident as hematuria and dimness of vision. Kidneys
must be stimulated to increase the urine, which may become scanty and contain
albumen. A general spinal and cervical treatment is necessary to
quiet the general nervous system and to relieve headache, delirium, somnolence,
or coma, which may appear.
Chronic endocarditis necessitates such treatment
as is described for valvular lesions, q. v. Myoarditis should be
treated as are endocarditis and pericarditis, conditions which it frequently
accompanies as a complication. It is necessary to keep the heart
quiet. Enforce absolute rest, and attend to the general nutrition.
FATTY DEGENERATION OF
THE HEART
DEFINITION: A condition in which the fibres of the
cardiac muscle are converted into fat.
LESIONS such as have been pointed out affecting
the heart may be present. The fact that this condition is often secondary
to cardiac hypertrophy, q. v., would lead one to work for such lesions
as cause it. These lesions act in various ways to cause the heart
to overwork and hypertrophy, either by over stimulation of the accelerators,
obstruction to the arterial circulation, by causing valvular lesion, etc.
After hypertrophy when the centers and parts concerned become exhausted,
fatty degeneration occurs.
It is pointed out by Anders that lesions to the
coronary arteries are the most significant causes of fatty degeneration.
Narrowing of the lumen of those vessels must result in defective nutrition,
of the cardiac muscle, and fatty degeneration follows. It was pointed
out above, in considering the general anatomical relations of lesion to
heart disease, that these coronary arteries are regulated in their caliber
and activities by the coronary plexuses, right and left, which are derived
from the cardiac plexus. Hence it is seen that lesions to the vagus
and to the sympathetic nerves of the heart, acting through the cardiac
and coronary plexus, could so influence these vessels as to narrow their
lumen, and cause malnutrition of the heart leading to degeneration.
Where the condition is due to a cachetic condition
of the system, as in phthysical and anemic conditions, and when it is secondary
to some severe acute disease, lesion must be expected according to the
primary disease.
The PROGNOSIS must be guarded. Sudden death
may ensue. Yet, on the other hand, Much may be done to strengthen
the heart and build up its substance.
The TREATMENT must be according to the requirements
of the individual case. In each case the special cause of the condition
should be found out and treated. The lesion must be corrected.
Special attention should be given the dilatation. It may be treated
as described for that condition. The heart should be continuously
but judiciously stimulated, because of the weakness of the heart.
This should be by stimulation to the accelerators in the upper dorsal region,
and to the sympathetics in the neck. This increases the strength
of the beat; and the tone of the heart muscle. By the same process,
and by removal of lesion, the functions of the coronary plexuses are corrected,
free circulation to the heart muscle is brought about, and it is better
nourished.
The palpitation, dyspnea, small and irregular pulse,
and cool extremities are due to the cardiac dilatation, and are benefited
by treatment of that condition. Raising the ribs and stimulating
the heart will be helpful for these symptoms.
Pseudo-apoplectic attacks may occur, and should
be promptly met. The patient should be placed upon his back with
the head a little raised. The heart should be well stimulated, and
this treatment should be extended the whole length of the spine.
The cervical tissues should be relaxed, and strong inhibition should be
made in the suboccipital fossae for several minutes. Next the splanchnics
should be inhibited as well as the solar plexus, and the treatment should
be given, as described before, to call the blood to the abdominal vessels.
By this procedure systemic circulation is rendered active, the blood is
called from the head, and is distributed throughout the vascular system.
For cardiac asthma treat as in ordinary asthma. The ribs should
be occasionally elevated, and the lungs should be kept well stimulated,
to overcome breathlessness and the Cheyne-Stokes breathing which tends
to appear. Angina pectoris may be treated as directed for that condition.
In anemic and cachetic conditions responsible for
the fatty degeneration, the oxygen carrying power of the blood should be
increased by a thorough course of general treatment devoted to the upbuilding
of the general health. The spleen, bowels, kidneys, liver and gastrointestinal
tract should receive special stimulating treatment.
The patient should be kept upon a carefully regulated
diet. Light exercise invigorates the heart.
FATTY OVERGROWTH, or fatty infiltration, is a condition in which an
abnormal amount of fat is deposited in the auriculo-ventricular groove,
beneath the visceral layer of the pericardium, and even between the muscle
fibers of the heart. The disease is apt to occur in the obese, and
in those who overeat, or who lead sedentary lives.
Such LESIONS as before mentioned may be present,
interfering with the nerve mechanism of the heart and disposing it to this
condition, or causing the primary disease to which this is secondary.
The PROGNOSIS is good for cure.
The TREATMENT consists in removal of lesion and
in due Attention to the primary disease. The heart should be kept
well stimulated as it may suffer weakness by reason of atrophy of its fibers
and the liver. It tends to be dilated, and may then be treated as
described for dilatation of the heart. This treatment overcomes the
resultant vertigo, syncope, dyspnea, cyanosis, palpitation, each of which
may be especially treated as before indicated, as may also the asthma and
bronchitis which are apt to occur. In obese persons it is well to
keep the pancreas and the liver stimulated. (See Obesity). This will
aid in preventing the deposition of fat. Also one should administer
thorough general treatment, with the same object in. view. Careful
and continuous stimulation of the heart increases the tone of it muscles
and the strength of its beat. Exercise helps this.
In these conditions much may be accomplished by
diet and exercise. A special method is followed. It consists
in: (1) limiting the supply of fluids allowed the patient, (2) enforcing
a protein diet, (3) taking as much exercise of a special kind as will be
tolerated by the condition of the heart. The fluids are
limited to 36 oz. in twenty-four hours. The (diet consists of coffee,
tea, or water; a little bread; game, veal, or beef; salad, vegetables,
fruit and eggs. The exercise is walking up graduated inclines, to
invigorate the heart muscle. This is well accomplished by walking
up hills, varying from mild inclines, gradually, to steeper ones.
VALVULAR DISEASES
The prognosis in cases of this kind is not generally
favorable. As a rule, valvular disease is incurable. Yet some
cases may be cured, and a fair number have been cured by osteopathic treatment.
In cases not curable, much may be done to better the patient's condition,
and prolong his life. Cases caused by simple dilatation or diminished
contractile power may be cured. Also when occurring in simple acute
endocarditis the prognosis for cure is good.
LESIONS: In many cases of valvular lesion, in the
left heart especially, the lesions present would be as described for endocarditis,
to which disease these may be secondary. In tricuspid insufficiency due
to obstructed pulmonary circuit, lesion to the lung, as ascribed in the
chapter on lung disease, cause the valvular trouble.
In aortic stenosis from increased tension in the
aorta, the condition may be due to lesion to the diaphragm as explained,
impeding circulation through the aorta. The same result may follow
extensive arterial obstruction, as of all the intercostals, the subclavians,
the abdominals, etc., as explained under Anatomical Relations at the opening
of this chapter. Aortic valvular lesions following heavy muscular
strains, etc., may be due to the presence of some one of the various lesions
described as affecting the heart, which forms a predisposing cause.
Lesions to the vagus and to the sympathetic supply of the heart may lead
to lack of tone and diminished contractile power (see general anatomical
relations) which sometimes causes valvular disease. General lesions
to the cardiac mechanism, as of upper vertebra, ribs, diaphragm, vagi and
sympathetics, doubtless weaken the heart and act as predisposing causes
to the valvular lesion which so frequently follows other disease.
The TREATMENT in ordinary cases would be to sustain
the heart and to maintain compensation. It should look to the removal
of any lesion, or of any obstruction to the blood current, especially in
tricuspid insufficiency caused by obstructed pulmonary circulation, and
in aortic stenosis due to increased tension in the aorta. Diaphragmatic
lesion or important arterial obstruction may be present. In the obstructed
pulmonary circulation the lungs should be kept stimulated and any lesion
to the lung should be removed. In all cases the whole generate circulation
must be kept free and well stimulated, in order to aid the heart to carry
out its work, thus relieving it of much labor. In cases in athletes,
or due to heavy muscular strain, one should suspect the presence of definite
spinal or rib lesion due to such activities. The primary disease
which may be causing the trouble calls for treatment according to its kind.
In diminished contractile power or dilatation of the left ventricle causing
mitral insufficiency, the accelerators, should be stimulated, as this increases
cardiac tonus and strength of beat, and contracts the heart. In such
cases lesion should be suspected to the vagus, as lesion to this nerve
may diminish ventricular tonus, dilate the heart and weaken its walls.
In all such cases the patient should lead a quiet life, free from excitement
or exertion. He should be much out of doors, and live upon a light
nutritious diet. He should avoid straining at stool, the use of alcohol,
tobacco, etc. Bathing is recommended, with exception of Turkish baths.
HYPERTROPHY OF THE HEART
In these conditions the prognosis is fair.
Much may be done to maintain the patient in a state of comfortable health,
preventing dilatation. Cases may sometimes be cured by osteopathic
therapeutics. The prognosis depends upon that for the condition producing
the hypertrophy. In such forms of valvular diseases as are curable
it may be cured. In cases due to exopthalmic goiter it may be curable.
Such LESIONS as before described in cardiac disease
may affect the nerve connections, etc., of the cardiac mechanism, and cause
or predispose to the condition. A common cause is obstruction to
the circulation through the small arteries. In the light of such
fact, lesions before pointed out, causing obstructed pulmonary circulation,
obstructed aorta, intercostals, subclavians, abdominals, etc., are important.
As the heart hypertrophies in valvular disease frequently, lesions would
have to be sought according to primary conditions:
Lesion to the sympathetics, as in exophthalmic goitre,
causing hypertrophy are important. Lesion to vagi and accelerators,
resulting in over-activity of the heart, may cause, hypertrophy.
When such simple causes as the use of alcohol, coffee, tobacco, etc., and
lead poisoning, etc., are alleged, one is bound to suspect one of the ordinary
lesions present as the real cause allowing the heart to be affected by
such agents.
The TREATMENT looks to the lesion, obstruction to
the blood flow, etc. It is directed to the primary disease when the
hypertrophy, as is the rule, is a secondary condition. The circulation
through the lungs should be kept free. The patient should remain
quiet. Attention should be given the sympathetics to slow the beat
as much u possible.
The patient should lead a quiet life, free from
excitement. His diet should be chosen with care, and he should particularly
avoid overeating, alcohol, coffee, etc.
DILATATION OF THE HEART
DEFINITION: There may be simple dilatation of a cavity,
causing increase in its size and thinning of its walls. The dilatation
may be accompanied with hypertrophy, in which there is an increase in both
the size of the cavity and in the thickness of the muscular wall.
As to CAUSES, the lesions as discussed should be
sufficient. No specific lesion has been pointed out for this condition.
Lesions to the cardiac mechanism weaken the heart and thus are especially
apt to predispose to dilatation. Under such conditions overexertion
and great physical strain would be more likely to cause dilatation of the
right ventricle. As the vagus nerve has been shown to have a trophic
influence on the heart walls, also an influence upon their dilatation,
lack of tone and a softened condition of them, lesion to it would have
an important part in the production of dilatation. Obstructed circulation,
and any cause producing increased intra-cardiac pressure may result in
dilatation. This is seen in mitral diseases. Osteopathic lesion
causing obstruction to the intercostals, abdominals, pulmonary circulation,
etc., as before discussed, may become the direct cause of dilatation of
the heart.
The PROGNOSIS is not good. It depends upon
that for the primary condition often, as in valvular diseases where the
prognosis is bad. When due to specific removable lesion the prognosis
may become favorable.
The TREATMENT consists in righting of mechanical
relations and removal of lesion. Obstruction to the circulation must be
relieved, and heart and lungs must be kept well stimulated to empty the
chambers of the heart of the clotted blood that is retained in them. Stimulation
of the accelerators aids the process by steadying and strengthening the
heart beat, contracting it and adding tone.
When secondary to acute infections disease, valvular
disease, etc., the primary condition must be treated. The dropsy
and dyspepsia present depend upon the bad circulation and are treated
in usual ways. Stimulation of the lungs and raising the ribs relieve
the dyspnea. Stimulation to kidneys in creases the flow of urine,
which has been lessened, and aids in overcoming the dropsy.
In the acute form the patient should rest in bed.
In the chronic form he should avoid fatigue. General directions for
the care of the patient are as before given.
CARDIAC DROPSY should be treated upon the same plan
as renal dropsy, q. v. The kidneys should be kept thoroughly stimulated
to quicken their excretory action and to thus relieve vascular tension.
The heart and general circulation. should be kept gently stimulated in
order to lessen venous stasis, to help out cardiac compensation, and to
force the lymph into the circulation.
ARTERIO-SCLEROSIS calls chiefly for a general palliative
course of treatment, equalizing and aiding general circulation, and attending
to the special disease or cause that is responsible for the condition.
As the lack of elasticity in the blood vessels interferes with the propulsion
of blood through them, the heart should be kept well stimulated, and general
circulation should be aided by a general spinal and muscular treatments.
To this may be added the abdominal treatment, and the treatment which regularly
elevates and depresses the ribs, thus aspirating the venous blood and toning
general circulation. This treatment also meets the important indication
of increasing the blood supply to the viscera, as it has been lessened.
Keeping the heart well stimulated maintains the balance of the cardiovascular
forces, and this, with the aid given the general circulation by the above
treatment, renders less necessary the hypertrophy of the left ventricle,
that is, limits the progress of such hypertrophy.
By this plan of procedure, myocardial degenerations
and dilatation of the left ventricle, common in the latter stages, as well
as the dilatation of the aorta often present, are rendered less probable.
Palpitation, dyspnea, angina, and precordial constriction
are treated as before directed.
The cerebral type calls for cervical treatment to
remove any obstruction to the circulation, and to aid the blood flow to
the brain. Raising the clavicles, opening the mouth against resistance,
working along the course of the carotids, etc., may be useful. The
special effects in this type, such as tinnitus, syncope, headache, vertigo
and the like, are remedied by corrected circulation. They may be
treated in the usual ways.
Likewise lungs and kidneys should be vigorously
treated to prevent their involvement, and the circulation to the extremities
should be kept active to prevent starvation of the tissues, and resulting
gangrene.
Much may be done to retard the progress of the disease
by correcting any habit that favors the disease, such as the use of alcohol,
excessive eating and drinking, muscular overstrain, etc. The diet,
should be light and nonstimulating.
Rheumatism, gout, syphilis, Bright's disease, mitral
disease, emphysema, and other diseases which predispose to arteriosclerosis,
should be carefully looked after.
ANEURYSMS
The treatment of aneurysms must be largely palliative.
Under favorable conditions the danger to life from the aneurysm may be
greatly lessened, and the contents of the sac may be clotted, practically
curing the case.
The treatment must be with great care. Any
considerable handling of the patient in the way of strong treatments must
be avoided on account of the danger of rupture of the aneurysm.
It is probable that various lesions, affecting vaso-motor
and trophic nerves, weaken the vessels, and lay them liable to aneurysm
by action of various causes, such as sudden great strain, from physical
exertion, arteriosclerosis, etc. It is likely that spinal and rib
lesions, acting upon the innervation of the thoracic aorta, and often combined
with lesion to the diaphragm which allows it to obstruct the aorta, may
be the causes of weakness and strain upon this vessel that result in aneurysm.
With the Osteopath, as with other physicians, the
object of treatment must be to decrease the arterial contraction of the
walls of the sac.
It is necessary for the patient to remain
entirely quiet upon his back, thus diminishing the number of heart beats,
as well as their strength, and at the same time the pressure of the blood
in the sac. A most valuable aid in this process is a large amount
of inhibiting treatment applied to the accelerator innervation of the heart.
(2nd to 5th dorsal and lower cervical). As the patient lies upon
his back, the operating band may be slipped beneath the shoulder and inhibition
be applied. The free hand may press the shoulder down upon the inhibiting
fingers. If the left arm be raised above the head to aid in this
treatment, it should be done slowly and cautiously. This treatment
diminishes force and frequency of the heart beat.
It is also of the greatest importance to decrease
arterial tension by further inhibitive treatment applied to the anterior
cervical region to affect the general vaso-motor center in the medulla.
To this should be added the treatment for dilating the abdominal vessels
and calling the blood to them by inhibition of the splanchnic area of the
spine and by the inhibitive, relaxing treatment to solar plexus and abdomen,
as before described. This treatment locally upon the abdomen cannot
be applied in case of abdominal aneurysm, but the remainder of the treatment
may be safely used.
Any lesion or source of obstruction, to the vessels,
particularly to the aorta, should be removed. The diaphragm, if prolapsed,
should be raised, and it should be sustained by a belt about the lower
costal region. The palpitation of the heart may be quieted by the
inhibition applied to the accelerators; the dyspnea by very cautious and
gentle elevation of the ribs; the pain by inhibition of the local nerve
supply of the part affected; other symptoms, according to their kind, may
be met by the usual osteopathic procedures. While most of these symptoms
are due to pressure from the aneurysm, the treatment is employed to relieve
and to make the patient comfortable.
The methods employed to reduce blood pressure, etc.,
also favor contraction of the sac.
Tufnell's treatment by absolute rest in the recumbent
position, and a restricted, dry diet is highly recommended. The dietary
consists of 2 oz. of bread and butter and 2 oz. of milk for breakfast;
2 or 3 oz. of meat and 3 or 4 oz. of milk or claret for dinner; 2 oz. of
bread and 2 oz. of milk for supper. This regimen must be persisted
in for several months, in order to bring about sufficient diminution of
the blood volume.
Surgical methods are often necessary for reduction
of aneurysm.
The patient should avoid stimulating diet and drink,
and should avoid excitement.
VARICOSE VEINS, (ANEURYSM
OF VEINS)
DEFINITION: This is a condition in which the veins become
enlarged, elongated, tortuous, and distended with blood. It may occur
in various parts of the body, and is generally speaking due to obstruction to
the blood flow from the veins, by lesions of various kinds. The term "varicose
veins" is applied especially to this condition in the lower extremities, in
which the internal saphenous suffers most often.
The LESIONS are bony, muscular, tendinous, etc., or pressure
from adjacent organs or growths, obstructing the venous flow. The course
of the vessel, its surrounding anatomical parts, and sources of innervation,
must be carefully examined for sources of obstruction, the simple removal of
which constitutes the efficient treatment in these cases.
In the case of the internal saphenous vein there are numerous
lesions which may act to obstruct the flow of blood. One of the most common
of these is tension or thickening of the tissues about the saphenous opening,
impeding the outflow from the vein. Sometimes relaxed abdominal walls,
or ptosis of the abdominal viscera, may cause pressure upon the femoral vein
where is passes beneath Poupart's ligament. A displaced or pregnant uterus,
or a loaded caecum or sigmoid, may bring pressure on the iliac veins, and cause
varicoses in the extremities. It is also possible for a prolapsed diaphragm,
compressing the azygos veins and obstructing the ascending vena cava to produce
a like result.
The vaso-motor innervation to the lower limbs is from the
lower dorsal, lumbar, and sacral sympathetic ganglia, and lesion to lower dorsal
vertebrae, lower ribs, lumbar vertebra, innominate bones, sacrum, or pelvis
may act through the connected nerves to weaken the vaso-motor state of the arteries
of the lower limbs, cause weakness of the circulation, and allow such causes
as excessive standing to cause varicoses. Dislocations of the hip, partial
or total, tense the tissues and muscles, obstructing venous return, and causing
this condition.
When the condition is due to pressure from tumors in the
abdomen or pelvis, heart or lung disease, ascites, etc., the lesion must be
sought according to such primary condition.
The PROGNOSIS is good. Very severe and long standing
cases can be cured. Osteopathic treatment has cured very many cases in
which the enlarged veins had reached a large size. Ulcers and eczema resulting
from varicose veins heal up after the circulation is restored.
The TREATMENT is directed at once to the removal of the obstruction.
In case of obstruction at the saphenous opening one may employ such a treatment
as described in Chap. X. The intestines should be raised from the femoral
vein (III, IV, Chap. VIII); the prolapsed uterus should be replaced (Chap.
IX, E); the abdominal walls should be strengthened by local treatment and by
treatment to the spine; and in like manner tumors, a constipated bowel, ascites,
diseases of heart or lungs, etc., should be treated as necessary according to
directions given for those various conditions. Tight garters should not
be worn. Lesion to lower ribs, spine, pelvis, etc., should be corrected.
Special treatment is given in these cases to stimulate the vaso-motor innervation
of the limbs to aid in keeping the circulation active. Likewise, a muscular
treatment of the limbs, with flexion, circumduction, etc., and thorough abdominal
treatment, reaching the iliac veins, the ascending cava, the portal circulation,
etc., would be found helpful. The liver should be kept free, and the bowels
as well.
Care must be taken in the treatment that the thinned walls
of the veins do not rupture and cause serious hemorrhage. In case of varicose
ulcers, and of eczema, the part should be kept clean, and a healing dressing
may be applied, but the parts must not be kept irritated by too frequent washing.
Ulcers and eczema heal when the circulation is made free.
Thrombi may form in the varicosed veins, and care must be
taken to absorb them, not to break them down, on account of the danger of embolism.
Bandages, silk stockings, etc., are gradually removed and,
the vessels and circulation are strengthened to take care of themselves.
Elevation of the limb and recumbency help.
