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 practitionerís 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 heartís 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.