Chapter XXXII: Introduction (17)

Thorough treatment to the genito-urinary center (lower dorsal and upper lumbar) will also be of aid. In males direct treatment of the prostate gland is occasionally important as is also the plexus of nerves at the trigone of the bladder. In =treating= the =prostate gland= introduce a finger into the rectum and work about the base of the gland to relax the tissues, and thus remove obstructions of the vascular, lymphatic and nervous structures to the gland. Do not work too much upon the gland itself (commonly once a week or ten days), as it may irritate, but release surrounding edema. Also treat the innervation at the eleventh and twelfth dorsals, fifth lumbar, and first, second and third sacrals. Spreading the ischii will occasionally be beneficial; this tends to release the anterior commissure where it is attached to the symphysis.

Follow the above with a “general treatment” in order to secure a general systemic reaction. This is of value in all infectious disorders.

It is important in =young boys= to examine the condition of the penis in bladder diseases. The prepuce may become adherent or other irritations may be found that are a source of disturbance to the bladder, or even to the kidneys, on account of the intimate connection of the sympathetic system in this region and the relation of one organ to another.

An =irritable bladder= is usually due to disorders of nearby tissues, especially the urethra, vagina, uterus and rectum.

=Enuresis=, exclusive of paralysis, is frequently due to some local mechanical disturbance. =Nocturnal enuresis= or =bed wetting= is caused by lower dorsal and lumbar lesions (especially the fifth lumbar), displacements of the innominate, or phimosis, hooded clitoris, contracted meatus, highly acid urine, worms, lack of discipline, etc. The patient is usually =neurotic=, which demands attention to the neuromuscular system of the entire body. Care of the general health and habits is important. Constipation may be present.

DISEASES OF THE CIRCULATORY SYSTEM

DISEASES OF THE PERICARDIUM

Pericarditis

=Pericarditis= is an inflammation of the serous membrane covering the heart and its reflection in front over the chest. Primary inflammation of the pericardium is rare. Such cases usually result from cold and exposure or injury or tuberculosis, and are most commonly met with in children.

The exciting causes of =secondary pericarditis= are rheumatism, Bright’s disease, tuberculosis, gout, diabetes, eruptive fevers, various septic conditions and dyscrasia. Pericarditis may result by extension of inflammation from contiguous organs, as the disease may occur in pneumonia, pleuropneumonia, chronic valvular diseases, and ulcerative diseases of the esophagus, bronchi, vertebræ, ribs, stomach, etc.

Displacement of the ribs over the heart and involvement of the corresponding vertebræ predispose to pericarditis, by weakening the innervation of the pericardium and thus disturbing the circulation. Lesions of the cervical region affecting the left phrenic are to be considered. Upper rib lesions may disturb the internal mammary artery and the lymphatics, which have important relationship with the pericardium. The disease may occur at any age. Males are more frequently attacked than females.

The morbid conditions vary with the stage. The stages are (1) acute, plastic, or dry pericarditis; (2) pericarditis with effusion, serofibrinous, hemorrhagic or purulent; (3) absorption or adhesive pericarditis. These different stages or varieties commonly succeed one another, although medical writers place so much importance in them that each is described separately. =Acute pericarditis= is by far the most common and often the inflammation subsides at this point instead of going on to more serious involvement. There is a possibility that in some cases the forms are independent of each other.

The changes are the same as in various serous membranes. Hyperemia and alteration of the epithelium is most marked on the visceral layer. This is followed by an exudation from the hyperemic vessels. There is roughening and loosening of the epithelium and the fibrin is precipitated upon the walls of the pericardium. More or less lymph is exuded and sometimes injected capillaries burst and cause a bloody exudation. From this stage the morbid appearances vary according to the progress of the disease. The disease may undergo resolution and fatty degeneration and absorption of the products in point take place. As the stage of effusion occurs, the parietal and visceral layers of the pericardium are separated by a serofibrinous exudate. This condition may increase until the quantity of the exudation is considerable, or the effusion may become absorbed. Rarely does the exudate become purulent.

Adhesions may be formed between the layers of the pericardium, during the last stage, by bands of various lengths or the layers are more or less separable.

=Symptoms.=—Simple cases may not present any symptoms. Usually a chill or cold feeling at the heart, followed by pains in the cardiac region, ushers in the attack. Fever is commonly present, rarely exceeding 103 degrees F. Tenderness over the heart is noticeable. There is dyspnea and the patient is restless.

In the =effusive stage= the symptoms depend largely upon the amount of diffusion. The pain is sharp and stitch-like. Nausea, vomiting and hiccough sometimes occur. The pulse is irregular and feeble. Insomnia, headache and even delirium may occur. Distention of the veins of the neck may cause dysphagia and a cough may be present, owing to the irritation of the trachea. The recurrent laryngeal nerve may be compressed as it winds about the aorta and thus cause aphonia.

The friction sound is a characteristic physical sign of the first stage. In the effusive stage there may be precordial bulging. The area of dullness is enlarged, the diaphragm and liver may be crowded downward, causing an epigastric bulging. As the effusion increases, the heart sounds become less distinct; the friction is not heard. In the =third stage= there is usually a return to normal, although =adhesions= may form and cause precordial retraction and permanently embarrass the heart’s movements. The young are more subject to permanent disability. Extension of heart impulse, which is undulatory; diastolic shock to hand placed over heart; increased area of dullness; prominent precordia; position of patient does not change apex beat; and when pericardium is adherent to diaphragm a systolic tug is noted over points of attachment, are essential signs and symptoms.

=Diagnosis.=—Pericarditis is frequently overlooked. It is a serious disease and one should be especially careful. In cases of rheumatism the osteopath must always be on his guard. Tonsillitis may be the origin of the infection. Care has to be taken in distinguishing between dilatation and cardiac hypertrophy and pericardial effusion. Hydro-pericardium may be mistaken for pericardial effusion.

To distinguish between endocarditis and pericarditis should not be a difficult task if one understands thoroughly the nature of each disease. A large pericardial effusion may be confounded with a pleural effusion. In doubtful cases utilize the X-ray.

=Prognosis.=—In mild cases of pericarditis the large majority rapidly recover in two to three weeks. In cachectic subjects and where adhesions have formed, the duration is longer. Relapses may occur. The purulent effusions are always serious.

=Treatment.=—Demands prompt and effective measures. Absolute rest mentally and physically, is necessary. Too much stress cannot be laid upon this point, as death has occurred from neglect of this. To quiet the heart’s action is the first necessary requisite, and then give treatment to limit the inflammation. In the early stage relaxing the upper dorsal musculature to control innervation, and raising and freeing all the upper ribs and clavicles to promote lymphatic drainage is effective. In the second stage prevention of cardiac failure and promotion of absorption are the indications to be met. Too much importance cannot be placed upon the point that general strength, good nursing, dieting and free elimination are essential, not only in securing a rapid subsidence of the inflammation, but to prevent further complications.

Raising and separating the ribs over the heart will be of great aid in lessening the inflammation and promoting absorption. In many cases lesions to the ribs on the left side and subdislocations of the vertebræ affecting the vasomotor nerves, the lymphatics and nerves to the heart will be found. The first five ribs and corresponding vertebræ is the region where one may expect to find the lesions. In addition to absolute rest, an inhibiting treatment in the dorsal region between the scapulæ will aid in slowing the heart’s action. Correcting any lesion that may be found to the vagi nerves will also be a help in controlling the heart’s action; besides, most of the vasomotor fibers to the heart are in the vagi. These lesions are usually found at the atlas. One should also examine carefully all the cervical vertebræ for derangements that might affect the cervical sympathetic, especially the superior and middle cervical ganglia. These ganglia are primarily affected from the fifth cervical to the first dorsal. Inhibition for a few minutes between the transverse process of the atlas and the occipital bone to the posterior occipital nerves will be of great aid in controlling the tumultuous action of the heart; also, inhibit in the upper dorsal. The warm bath will quiet the heart, but care should be taken not to weaken the patient. The general treatment has the effect of lessening nervousness and quieting the heart.

The function of the phrenic nerve must be borne in mind when regarding the pericardium. The phrenic is usually primarily affected at the third, fourth and fifth cervicals, and occasionally there are connecting fibers as low as the fourth and fifth dorsals. Ice-bags may be found of value in retarding the progress of the effusion and in lessening the heart’s action. Liquid food, as milk and broths, should be given throughout the disease. If the effusion is very large the services of a surgeon should be secured and tapping performed. If the effusion is of a purulent nature, a free incision should be made with antiseptic precautions.

In chronic cases carefully graduated breathing exercises and moderate stretching of the adherent regions, if pathology permits, should be considered.

Endocarditis

=Endocarditis= is an inflammation of the lining membrane of the heart. The process is usually confined to the valves; the lining of the cavity of the heart may also be affected, especially in severe cases. Three forms are recognized: simple acute endocarditis, ulcerative endocarditis, and chronic endocarditis.

=Simple Acute Endocarditis.=—This form usually results from acute articular rheumatism. Tonsillitis may be associated with endocarditis. It may also be caused by other infectious diseases, especially scarlet fever, but rarely, by typhoid fever, measles, chicken-pox, diphtheria, smallpox and erysipelas. Acute endocarditis is frequently found in chorea. It is also met with in diseases attended with emaciation and general weakness, as cancer, gout, Bright’s disease and diabetes. It is not uncommon in phthisis. Micro-organisms play an exciting part, but back of this the osteopath finds lesions of the heart innervation important predisposing features. Prophylactic osteopathic treatment is a potent factor in preventing endocardial changes in the above diseases. Keeping the muscles relaxed and the osseous tissues intact is of great value.

=Pathologically=, the left side of the heart is most commonly involved. The disease is characterized by the presence of small vegetations on the segments or on the lining membrane of the chambers, although in mild cases there is simply swelling of the valves. The mitral valves are more often affected than the aortic. The vegetations appear, usually, on the auricular surface of the mitral and the ventricular surface of the aortic valves, a little back of the valve edge. Their seat corresponds to the point of maximum contact (Sibson). These growths are liable to be broken off at any time and carried as emboli by the blood current to distant organs, particularly the brain, spleen and kidneys. This is not uncommon in acute endocarditis or chronic valvulitis. In favorable cases the vegetation is ultimately absorbed and the valve is but slightly altered beyond a simple sclerotic thickening. This is often the starting point of sclerotic valvulitis. Osteopathic measures undoubtedly lessen the liability of cardiac involvement, prevent extensive changes and promote absorption of disease products, by lowering heart tension and improving the cardiac nutrition, as well as increasing free elimination of the toxins in the blood.

During the fetal life, the right side of the heart is most commonly involved. The chorda tendinæ are sometimes affected, but rarely alone.

The vegetations are composed of proliferated connective tissue cells. The superficial elements undergo a coagulation-necrosis and fibrin is deposited from the blood. Micro-organisms are found and are the specific agent in causing acute endocarditis.

=Symptoms.=—A large number of cases are latent, the autopsy first disclosing the lesion. In many cases there are slight fever, a frequent, sometimes irregular, pulse, palpitation and dyspnea. There is seldom any pain.

=Physical signs= are very uncertain. They may not be present in mild cases and in those in which the valves are not affected. Usually auscultation furnishes the only indication of endocarditis—a soft, blowing, systolic murmur which is heard most frequently at the apex, as the mitral valves are the ones generally involved. When the aortic valves are affected, the murmur is heard at the second interspace at the right edge of the sternum.

=Diagnosis.=—This depends entirely upon the etiology and physical signs. The greatest danger is in the disease becoming chronic.

=Treatment.=—The patient should be kept as quiet as possible, so that the work required of the heart may be reduced to a minimum. The disturbed circulation can be controlled by careful attention to the vasomotor nerves at the various centers along the spine. Attention should be given the disease that is causing the endocarditis. Keep the patient well protected by flannels and beware of damp rooms and sudden changes of temperature.

Treatment should be given to correct any lesion found in the upper five dorsal vertebræ or ribs and to raise and spread all of these ribs so that the heart’s action will not be unduly disturbed by interferences with its innervation. The vasomotor nerves to the heart’s vessels are found in the vagi nerves, consequently care should be taken that lesions to these nerves do not exist. An inhibitory treatment to the suboccipital nerves acts reflexly on the vasomotor nerves and tends to equalize the general vascular system. This treatment quiets the heart’s action. Ice applied locally is advocated by many practitioners. Flannels should be placed next to the skin and the ice-bag placed over the flannel. This reduces the fever, lessens the pulse-rate and quiets the heart action. The same points are obtained by the inhibitory treatment at the suboccipital region. The ice-bag also relieves pain and oppression. Be very careful in the use of ice when there is much cardiac dilatation. Treatment of the middle and inferior cervical regions may have some effect in controlling the heart’s action. A general treatment to quiet the patient is effective. Do not allow any overexertion. The patient should have nourishing liquid food.

Emery[100] says: “Many of us have been in the habit of saying, just because we hear a decided murmur in the heart region, that the patient has valvular heart trouble; that the patient has organic heart trouble. This is a common error... When there is an anemic condition of the body, apparently the cusps of the valve will be so weakened, and the attachment will be so weakened that the blood will force its way between the valves and back into the heart, causing regurgitation murmur, when as an actual fact there is no deformity and no real disease of the valves, and as soon as the general condition of the anemia is improved, the valve will do its work fully and the murmur entirely cease. So if you have the murmur without the hypertrophied condition, which at once follows such a valvular lesion, you must be guarded in your statements, for if an actual valvular lesion existed, compensation would take place, and it would be the means of corroborating such a valvular condition; if no hypertrophy is found, then we are not justified in definitely stating that a valvular or organic lesion exists, for such a weakened condition as has been mentioned might be the only pathology present, and be the cause of the murmur.”

=Ulcerative or malignant endocarditis.=—This is an acute, infectious or septic disease, characterized locally by necrosis or ulceration of the valve. It is generally a secondary affection to septicemia, pneumonia, erysipelas, scarlet fever and acute rheumatism. Acute endocarditis often precedes the ulcerative variety, the latter being simply an increase in severity of the former.

=Etiology and Pathology.=—It is doubtful if there can be a primary form of ulcerative endocarditis. Chronic valvular defects are the most important predisposing causes. Pneumonia is most frequently, of all the acute diseases, associated with severe endocarditis. It is rare in tuberculosis, diphtheria, typhoid fever and chorea. It occurs in association with erysipelas, gonorrhea and rheumatism. Septicemia, pleurisy, meningitis and puerperal fever are other possible causes of ulcerative endocarditis.

Deep seated lesions, which means firmly anchored lateral flexions and rotations due to fibrotic changes, are important predisposing local factors, while other lesions that disturb blood elaboration and resistance and lessen elimination, are predisposing systemic causes.

=Pathologically=, the lesions are either vegetative, ulcerative or suppurative. The vegetations are composed of granulation tissue, granular and fibrillated fibrin, and colonies of micro-organisms. They become necrotic and break down into ulcers. The ulcerative changes may lead to perforations or produce valvular aneurisms. Of the valves the mitral is the most frequently affected; then the aortic; then the mitral and the aortic together; then the heart walls; then the tricuspid; then the pulmonary. In a few cases the right heart alone is involved. The lesion is not always confined to the valves, but may involve the mural endocardium. The most common organisms found are the pneumococcus, streptococci and staphylococci. The bacillus diphtheriæ, bacillus coli, gonococcus, bacillus anthracis and other organisms have been found. Associated pathological changes include the lesions of the primary disease and the changes due to embolism. The spleen, kidneys, brain, intestines and skin may be the seat of embolism. When found in the lungs, they originate in the right heart.

=Symptoms.=—If in the course of any of the diseases previously named under etiology, chills followed by fever and sweats occur, ulcerative endocarditis should at once be suspected and a thorough examination be made. The general symptoms are high, irregular fever, delirium, sweating, great prostration, rapid pulse, hurried breathing and sometimes jaundice and diarrhea occur.

The occurrence of delirium, coma or hemiplegia points to involvement of the brain; pain in the region of the spleen, with increased dullness on percussion, point to trouble in that organ; hematuria may occur from involvement of the kidneys. More rarely there will be impaired vision from retinal hemorrhage; and there may be suppuration and sometimes gangrene in various locations, depending upon the position of the embolism.

The =septic type= is secondary to suppurating external wounds, puerperal sepsis or acute necrosis. Occasionally gonorrhea is the cause. The symptoms presented are rigors, irregular fever, sweats and exhaustion—the signs of septic infection. The symptoms may resemble a quotidian or a tertian ague. The =typhoid type= is the most common. The characteristic symptoms are irregular temperature, sweating, prostration, delirium, drowsiness, diarrhea, petechial and other rashes, distention of the abdomen and pain in the right iliac region. The heart symptoms may be overlooked, as in the septic type. The =cardiac type= are cases of chronic valvular diseases in which fever, rigors and sweats, and the symptoms of embolism may develop. In the =cerebral= cases the symptoms may simulate meningitis. Acute delirium may be the distinctive symptom. Heart symptoms may be overlooked.

=Physical Signs.=—The heart symptoms may be latent. Even after a careful examination, there may be no murmur present. When murmurs are present it is often difficult to locate them.

=Diagnosis.=—The previous history should be considered and this, together with the symptoms, makes a correct diagnosis possible, even though physical signs are absent. The duration is from a few days to several weeks.

=Treatment.=—The treatment of this form of endocarditis is likely to be of little avail, although in a few cases where the source of infection can be eradicated the condition may be considerably improved and life prolonged. About the same treatment as in simple endocarditis should be followed. Absolute rest is essential and this, coupled with the local treatment of simple endocarditis and a nourishing liquid diet, constitutes the principal treatment.

Chronic Endocarditis

This condition may begin as a chronic inflammation or follow the acute form, which is more often the case. There is a =sclerosis= of the valves which causes deformity, owing to the contractions. The onset is usually insidious.

It is well known that the larger percentage of valvular lesions are the result of either acute or chronic endocarditis. Thus rheumatism stands foremost as a cause of valvular defects. Alcoholism and overeating (through introducing irritating influences into the blood, or by causing rheumatism, gout and allied diseases) are important etiological considerations. Nephritis and syphilis are considered among the causative factors. Infections and senility, when associated with high blood pressure, is a phase not to be overlooked. Chronic endarteritis extending from the aorta to the valves, resulting in thickening and degeneration of the tissue, may be an insidious source of valve disease. This is probably often of syphilitic origin.

A potent cause of special interest to the osteopath (for the reason that his treatment is so effective), is continued =muscular strain= as seen in athletes and laborers. The heart muscle itself may be strained, particularly the valve leaflets and the tissues about the valve, which effect often terminates in valvular leakage. In addition, the orifice of the valve openings may become stretched and distorted through strain superinduced by prolonged exertion, by flabbiness of heart tissue, and by dilatation of the ventricles. In these latter cases it is seen that the leaflets of the valves may remain intact, but still they are unable to stretch completely across the opening.

With the above condition it is readily noted that thickening, curling and adhesions will take place when inflammation attacks the valves and contiguous tissues, and following these, limy infiltration and fatty degeneration may be a consequence.

Predisposing osteopathic lesions as noted in acute endocarditis, are not to be neglected.

=Thickening and hyperplasia= are immediate consequents of connective tissue overgrowth; and especially is chronic endarteritis accompanied with atheromatous and calcareous degeneration. Thickening, at times, is only slight and the function of valves is not impaired.

In curling or =retraction=, there occurs a shrinkage of the hypertrophic or hyperplastic tissues. This condition is very apt to become permanent.

=Adhesions= of the valve leaflets is a self-evident condition. It is well to note here that in acute and chronic endocarditis some part of the fibrous valve ruptures or is lacerated or eroded from strong and rapid heart action; the =laceration= or rupture or erosion always occurs at the point of maximum contact. Thus the eroded surface allows an opportunity for the rheumatic or septic micro-organisms to lodge, multiply and grow, and adhesions result. Carefully applied osteopathic methods are very efficacious in impending acute heart disturbances, and this without doubt is the reason why so many of our rheumatic cases get well without any heart affections. Keeping the heart quieted and slowed prevents the strong and rapid action and thus lessens the probability of lacerations, ruptures and erosions of the valve tissues. General resistance is increased and elimination improved, which have a decided effect in preventing complications.

=Calcification and atheroma=, as has been mentioned, may follow the above diseased processes. The calcification is sometimes so marked as to be of the character of a bony ring.

The question arises here, What effect have =osteopathic lesions= as direct =causative factors= in valvulitis? It appears reasonable that the heart is not exempt from the influences of the vertebral and rib maladjustments. Furthermore, clinical experience has abundantly proven that the heart tissues are affected by these lesions in the same manner as any tissue or organ is affected. Again, osteopathic dissection reveals direct nervous connection from the upper dorsal spinal ganglia to the heart ganglia.

No one will question that the integrity of heart function and life are dependent upon normal coronary artery supply, upon vasomotor equilibrium, and upon motor control. All of these functions are influenced by the status of cervical vertebræ, upper dorsal vertebræ, and rib relations. Just what the pathological affection is when these anatomical parts are disturbed is beyond us until more careful dissection and experimentation have taken place. How cervical and dorsal sympathetics, vasomotor and motor nerves with their spinal connections, vagi and phrenic, are so disturbed as to involve valvular parts and induce inflammation, is a problem for us to investigate. Through analogous reasoning from other organic ailments and through the fact that osteopathic therapeutics corrects heart lesions, we know in a general way that the correction of osteopathic lesions decidedly influences the heart.

Two well known =physiological facts= relative to the heart are: first, the heart increases in size up to adult life, and, second, the heart muscle can actually be increased in size. This latter fact occurs in physical development and training. A heart that is weak and flabby can be increased in strength, tone and size. This helps us to understand how certain strains and distortions of the heart, with consequent valvular lesions, may be corrected through rest, exercise and treatment; somewhat analogous to the correction of an atonic, prolapsed and dilated stomach. Then it also seems probable that disturbed innervation and blood supply to heart areas or to the heart as a whole would predispose to congestions, inflammations and degenerations whereby rheumatism, septic states, etc., and muscular strains would act only as exciting causes, not true causes.

No one is going to expect that thickened, retracted, adhered, or ruptured valves are to be made anatomically correct; but the right treatment will certainly reduce the morbid state to the minimum. Then there are cases where osteopaths have eliminated all murmurs when specialists stated the disease was incurable; showing that it is impossible by signs and symptoms to always diagnose the morbid tissue state. Only the resulting effects of size and of leakage are definitely revealed by auscultation and percussion. Hence there is a class of valvular diseases that can be successfully treated by osteopathic measures, which, if left to terminate under drug medication, will reveal (at post-mortem) the pathological signs of valvular heart disease.

Downward displacement of the =first rib= may interfere directly with the subclavian artery and thus cause constriction of that vessel and a consequent regurgitation; also, cardiac fibers of the recurrent laryngeal nerves may be impinged by a dislocation of this rib. Many lesions which interfere with the right side of the heart occur at the =second= and =third ribs= and lesions of the =third=, =fourth= and =fifth ribs= may interfere with the valves. Lesions of the =corresponding vertebræ= produce the same results as the ribs. These lesions are probably to the sympathetic nerves along the dorsal region. Lesions may be found anywhere along the cervical vertebræ which may involve inhibitory (vagi) fibers or accelerator (sympathetic) fibers to the heart. Also, in some cases the =floating ribs= are dislocated downward and cause a prolapse of the diaphragm, and thus a constriction of the aorta, which may result in regurgitation and valvular disorder.

=Mitral Regurgitation.=—Mitral regurgitation is a leakage of blood from the left ventricle, through the mitral valves, into the left auricle. The opening of the valve may be distorted, or the valve leaflets thickened, rigid, or retracted, thus allowing an escape or reflux of blood from ventricle into auricle. The tendinous cords may also be thickened and adhered, with consequent prevention of free action.

By a forcing back of a portion of the blood from ventricle to auricle at the same time the pulmonic veins are emptying into the auricle, an overdistention of the auricle takes place. The auricle, then, from the extra amount of work required, becomes hypertrophied and dilated. There may be no noticeable symptoms at first. Later on shortness of breath, cough, irregularity of heart’s action, indigestion, liver congestion, and so on, occur.

The =apex beat= is forcible and downward to the left. Of course the area of dullness is to the right and left. There is a =systolic murmur= in the mitral area, which is transmitted to the left axilla.

Every osteopath should understand the mechanism of this most frequent valvular lesion. Following hypertrophy and dilatation of the left auricle, the reflux may be so excessive that a residue remains. The auricle not being able to handle all the =blood=, stasis of the pulmonary vessels takes place, and pulmonary edema and hydrothorax are sequelæ. Then comes dilatation of the right ventricle and back pressure on tricuspid valves and right auricle. The =veins= throughout the body become turgescent, and the liver is apt to be indurated. It should be emphasized, however, that “back pressure” is only an effect commonly due to myocardial degeneration, caused by some infection, of which auricular fibrillation is an important part of the pathology.

Before the breaking down of the left heart compensation, osteopathic methods, as all know, are effective in maintaining balance. Even after the lungs begin to be affected, careful and thorough treatment will result in good, and in cases of general venous sluggishness treatment, particularly to liver, diaphragm, bowels and limbs, will generally materially help in slowing the downward course of the disease.

=Mitral Stenosis.=—In stenosis there is narrowing or constriction of the valve opening. Thus in mitral stenosis the free flow of the blood from left auricle to ventricle is hindered.

The =cusps= are usually thickened, rigid and adhered. The valve opening may be so stenosed as to be but a narrow slit. In all cases stenosis is a =structural defect=. It can occur by strains, as regurgitative effects sometimes result.

The =symptoms= of mitral stenosis are practically the same as those of mitral regurgitation, owing to similar effects upon the circulation.

Under =physical signs= we find the apex-beat is only slightly displaced. Palpation will reveal, near the apex, a rough presystolic thrill. The increased area of dullness is to the right. There is an abruptly terminating, rough, presystolic murmur.

=Aortic Regurgitation.=—Aortic regurgitation is a reflux of blood from aorta to left ventricle, following ventricular systole. This is considered the =most serious= of the valvular diseases. The valve opening is either too large, so the valve leaflets do not fit tightly, or the segments themselves are thickened and retracted. Structural defects of the aortic valves are largely of the same character as in diseases of the mitral valves.

The =regurgitation= first causes dilatation of the left ventricle. This is followed by hypertrophy. If the mitral valve holds intact, no further effects result. But if the mitral valve is diseased or becomes incompetent from the dilated ventricle, the same morbid states follow as was noted under mitral regurgitation.

There is a forcible apex-beat, displaced downward to the left. The increased dullness is to the left. There is a long, loud =diastolic murmur=. The well known “water-hammer” pulse is felt.

=Aortic Stenosis.=—Aortic stenosis indicates a narrowing of the aortic orifice. It is a structural defect. The free flow of blood is obstructed from the left ventricle into the aorta.

Aortic stenosis is much less frequent than regurgitation. Aortic stenosis and regurgitation are very apt to be associated. The beat is commonly forcible, and the increased area of dullness is to the left. There is a systolic murmur, heard best at the right second interspace, which is conducted into both carotid arteries.

=Tricuspid Regurgitation.=—Tricuspid regurgitation is the most common valvular lesion affecting the right heart. It is rare as a primary lesion. The affection may be of a structural character, or functional.

Hypertrophy of the right ventricle occurs after the manner of left ventricle hypertrophy in mitral regurgitation. The sequelæ of venous turgescence follow, also, in the same way as was given under the mitral lesions. Tricuspid regurgitation rarely exists independent of some other cardiac or pulmonary ailments.

The apex-beat is diffused toward the epigastrium. Increased cardiac dullness is toward the right. There is a systolic murmur, which is heard best just above the xiphoid cartilage. The jugular vein pulsates; in severe cases there is pulsation of the liver.

Osteopathic treatment is usually effective in relieving the engorgement of the veins, and particularly in reducing liver congestion.

=Tricuspid Stenosis.=—This affection is said to be the =most rare= of valvular lesions. Thickening, obstruction and adhesions from endocarditis cause the stenosis. As in other lesions of the heart, there is a congenital form. There is presystolic murmur, heard best at the xiphoid cartilage. The pulse is small and weak.

=Pulmonary Regurgitation.=—This is another rare lesion, and is seldom met with in a simple form.

There is forcible pulsation in the epigastrium. Increased cardiac dullness is downward. There is a diastolic murmur, heard most distinctly at the left second intercostal space.

=Pulmonary Stenosis.=—Another rare lesion. The effect of this lesion on the right ventricle is the same as that of aortic stenosis on the left. The congenital lesion is apt to occur with a patulous foramen ovale.

There is a systolic murmur, heard best at the second intercostal space on the left. =Many systolic murmurs= heard over the pulmonary opening =are functional=.

=Combined Valvular Lesions.=—When two or more lesions occur at the same time the terms, combined or associated, are employed. This is a very common occurrence. Two, three or all of the valves may be affected at the same time. =Stenosis= and =regurgitation= at the same orifice is the most common association of any two valvular lesions. When there is a joint affection of two or more valves, the =aortic= and =mitral= are most commonly associated; then mitral and tricuspid; then aortic, mitral and tricuspid.

=Prognosis and Treatment of Valvular Diseases.=—It is impossible to outline with exactness either prognosis or treatment of heart lesions. All will agree that the character of the lesion is the first consideration, and before records of these cases can be of any scientific benefit, we must look well to the nature of the valvular leakage or obstruction and note precisely what effect our therapeutics has. Perhaps of greatest consideration in the matter of prognosis is, to what extent =compensation= has been maintained. We know that compensation may be perfect; that hypertrophy and dilatation may balance the valvular defect so thoroughly that even the patient is not aware of a heart lesion. As soon as compensation begins to fail, when palpitation, irregularity of pulse, dyspnea, edema, etc., appear, we know that our treatment should pass from the realm of the defensive to that of the offensive. Then when compensation fails still more, prognosis and treatment must necessarily be changed according to the increasing gravity.

In our osteopathic work we should never forget that the condition of the lesion may be greatly influenced by environment. Habits, occupation and general daily life may affect the heart ailment for good or bad. Thus in =prognosis= we have =three features= in particular to note: character of heart lesion, extent of systemic involvement, and environment. In the immediate prognosis, the extent of general venous stasis, if any, is of great importance. In other words, the gravity of the complications is of first consideration.

Aortic regurgitation is ranked by heart specialists as the most serious lesion. Aortic stenosis is a grave lesion, but not so serious as aortic regurgitation. It is often stated that the character of the lesion is not of so much consequence as the extent of involvement the lesion has engendered. Mitral stenosis is more grave than mitral regurgitation. Right side heart lesions are usually relative, and, naturally, when the right heart is diseased from extension of the ailment from the left side, the situation is serious.

It should be remembered that a heart normal in size and beating regularly is usually in a fairly healthy condition even if a murmur is present.

In our =treatment= the first point indicated is to improve, if possible, the =integrity= of =heart muscle= and lessen the =valvular defects=, if such can be done. Owing to a dearth of statistics, it is impossible to state to what extent improvement in organic lesions has been accomplished. Very likely if we had statistics and no post-mortem findings, we would still be in the dark as to much of our work. This much is positive: osteopaths have time and again apparently cured grave valvular lesions; cases that eminent specialists diagnosed as absolutely organic lesions. Our practitioners have eliminated the murmurs, reduced the size of the heart, and removed any and all systemic symptoms. These patients are well, have been well for years, and are leading active lives. But were these cases suffering from organic lesions? No doubt there was valvular leakage, hypertrophy and dilatation, but was the valve defect a functional one? In other words, was it due to strain and distortion? In all probability the patients’ days were numbered and post-mortems would have shown grave lesions and quite likely more or less organic changes.

Does it not seem likely that some functional lesions may terminate in organic lesions? Through continued stretching of the valves and their immediate tissues, fatty degeneration may take place; the same as fatty degeneration of the heart muscle, occurring in dilatation of the chambers. If we can remedy functional lesions through specific work upon nerve centers and fibers, why cannot we influence organic lesions and at least reduce the gravity to a minimum? We know functional diseases of the heart, as palpitation, rapid heart, slow heart, etc., can be corrected, and from all indications, functional valvular leakages are generally easily and quickly remedied; it is only a step farther to affect truly organic lesions. The same valves, the same nerves, and the same osteopathic lesions are noted. Then it is only a continuation of the same process from functional disease to organic disease. Indeed, no one is able to draw a line between the two. Probably, as was intimated before, careful osteopathic treatment in rheumatism and other diseases that are apt to predispose to heart affections, will keep the heart so strong functionally and organically that resulting valvular lesions are not nearly so likely to develop. The heart can be treated and controlled as can any tissue or organ. It certainly stands to reason that osteopathic therapeutics is rational in both preventing and curing valvular lesions. The M. D. gives his drugs with the hope of maintaining heart muscle integrity, of lessening a too forceful beat, of increasing waning power, of promoting general circulation, of preventing and lessening complications. We can do the same thing with our methods, even more effectually, and with no probability of harmful effects.

It would appear there are at least two ways in which organic lesions may develop. =First=, as stated above, through =functional distortion=, the normal heart muscle being strained from severe exercise, or a weak, flabby, or disused heart muscle being overtaxed by ordinary exercise. Here it will be seen that in the first instance immediate rest will probably correct the weakness; in the second, rest and general building up of the body if the atonic heart muscle resulted from some debilitating disease. If from local causes correction of the specific osteopathic lesion should be effective.

=Secondly=, through strong and rapid heart action the =valves= are =ruptured= or =lacerated=, always at the point of =maximum contact=, and thus present a favorable surface to micro-organisms.

Owing to the valves being a reduplication of the endocardium, they have no muscles or blood-vessels, so that in =functional leakages=, inflammation does not play a part, hence, a possibility of degeneration occurring from excessive stretching.

The large majority of =osteopathic lesions= are unquestionably found in the upper five dorsal vertebræ and the first five or six ribs on the left side, although cervical lesions, in many instances, play an important secondary, if not the primary, role. These maladjustments affect vasomotor nerves to the heart, that is, to coronary vessels, the dorsal and cervical sympathetics, the vagi, and the phrenic. We are unable to state just how these lesions disturb nerve conductivity; what present anatomy and physiology teach us does not fully explain. Osteopathic dissection must be the means to the end of the explanation. We have many clinical results, but not the physiological knowledge, as yet, to support it.

The dropping down of the first rib, as well as the clavicle, interferes with the large blood-vessels, especially the subclavian, and causes increased resistance of the heart’s action and probably a certain regurgitative effect. This regurgitative effect would also occur in cases of obstruction to the aorta by constriction of the diaphragm from dropping of the floating ribs. To what extent this latter feature has been demonstrated is not known. In valvular diseases it is practical to divide them for treatment into, =first=, where the =lesion= is =compensated=; =second=, where =compensation= is =incomplete=; =third=, where =compensation= is =lost=. With all cases we should give consideration to environment, temperament, habits, food, clothing, exercise, etc. Often these secondary matters are of vital importance, especially when compensation is failing. The Schott method of treatment may be of some avail; this treatment, which is composed of a series of resistant exercises, tends to lessen peripheral resistance, develop heart muscle, and remove heart stasis.

Speaking in general, =hypertrophy= and =dilatation= follow valvular leakage, as a =secondary effect=. It is a compensatory condition, and whenever compensation is failing, there is naturally a breaking down of the structural tissues of the heart; that is, the muscular hypertrophy is losing in integrity. Our primary aim, then, should be to keep up the compensation, which is represented in the hypertrophy, although there are cases that fail rapidly, especially in emphysema and cirrhosis of the lungs. Generally, in hypertrophy and dilatation, there is a =disproportion between= the =amount of work the heart has to do= and its =ability= to do it. One of two things has occurred; there is an increase in peripheral resistance or the volume of blood through the heart is abnormal in quantity[101]. Loudon[102] says: “The treatment of chronic disease of the heart requires a longer time, as a rule, than the same disorder in the acute stage. Some cases cannot be materially helped; a vast majority may be greatly benefited after a thorough trial; while more than we might at first suppose, can be entirely cured. We desire to quote at length from Hare relating to this point. He says: ‘A chronic structural change in the heart resulting from an acute process is not always synonymous with chronic heart disease. Thus, acute endocarditis occasions a variety of changes of the mitral and aortic valves which long may indicate their presence by their characteristic murmurs, and yet in time these may wholly disappear. That many such cases outgrow the valvular trouble, especially mitral lesions, there can now be no doubt. The majority, even of those in whom valvular murmurs permanently continue, do not have their health unfavorably affected for years, and in many of these, the duration of life is not appreciably shortened.’” This statement, from such an author, gives the osteopath great encouragement; for add to those above referred to, which recover in time from all valvular trouble, the many cases of valvular insufficiency, due to dilatation, owing to osteopathic lesions to the trophic nerves, and which may be cured by removing such lesions, we find that quite a percentage of cases are thus disposed of.

“It is doubtless true, also, that the cases above mentioned having valvular thickening and vegetations, could have been cured in quicker time and greater number had osteopathic treatment been given to tone the heart, upbuild the general circulation and increase the activities of the excretory organs. The importance of the lungs is often overlooked in the treatment of cardiac diseases. The osteopath’s ability to expand the chest and increase the capacity of the thorax should be demonstrated in both cardiac and pulmonary troubles. It is said to be a universal law throughout the animal kingdom ‘that muscular power is directly proportional to the amount of oxygen consumed.’ Hence give the power, and have your patient live as much out of doors as practicable. =Exercise= should be =moderate= and always =stopped= short of =fatigue=.”

Treatment of the abdominal organs should not be neglected, for improved circulation here and thorough removal of effete products will influence the heart. Freedom from worry, strains, etc. are essential. Tepid baths are best.

A person may have a valvular leakage and not be aware of it. Probably it is best to inform them, except in certain neurotic individuals. For then they can take special care of themselves, as to overwork, strains and intercurrent infections, and their life and usefulness be greatly prolonged.

When compensation begins to break, certain symptoms are noticed, as heart irregularity, difficult breathing, particularly at night, shortness of breath, and more or less anemia. Later there is disturbance of rhythm, cyanosis, dilatation of heart and dropsy. Frequently, considerable can be accomplished through the upper dorsal treatment, attention to the chest mobility, manipulation of the abdominal organs and diaphragm, and special attention to the diet, rest and some exercise. A light general treatment will assist the labored circulation and improve assimilation, and a change of climate may be of benefit.

Hypertrophy of the Heart

=Hypertrophy= of the heart is an enlargement of the heart, due to an increase in the muscular tissue. It is usually associated with dilatation. The ventricles are more often involved than the auricles, and the left ventricle is more likely to be affected.

=Etiology.=—Valvular disease of the heart causing an obstruction to the outflow of blood, as mitral insufficiency, diseases of the aortic valve; increased intra-vascular pressure, caused by sclerotic changes in the walls of the vessels; contraction of smaller arteries, due to irritation of toxic substances in the blood, as in Bright’s disease. Overeating or drinking and excessive physical exercise would also induce hypertrophy of the left ventricle. Hypertrophy of the right ventricle is caused by valvular lesions on the right side. Lesions of the mitral valve causing an increased resistance in the pulmonary vessels are etiologic factors; also diseases of the pulmonary vessels in the lungs, as in cirrhosis and emphysema. There are conditions affecting the heart, as the use of tea, alcohol and tobacco. Disturbed innervation, as in exophthalmic goiter; derangements of the vertebræ, and ribs corresponding to the upper five dorsals; downward displacements of the floating ribs, causing a prolapse of the diaphragm and a consequent retardation of blood through it to and from the heart, will affect the heart’s action. Simple hypertrophy never occurs in the auricles; it is always accompanied with dilatation. The condition develops in the left auricle in mitral lesions; in the right auricle when there are disturbances of the pulmonary circulation. The tricuspid is rarely affected primarily.

=Pathologically=, the left side of the heart is more commonly enlarged than the right; the ventricles than the auricles. The shape of the heart varies when the left ventricle is hypertrophied, the conical shape being more or less lost; it lies more horizontally and is elongated. When both ventricles are enlarged the heart is round. When the right ventricle is affected, it occupies the largest part of the apex. The increase in the size of the heart is probably due to a numerical increase in the muscle cells. The muscle is firm, of deep red color and cuts with considerable resistance. Normally, the heart weighs from eight to nine ounces. In general hypertrophy it may weigh from fifteen to thirty ounces.

=Symptoms.=—Hypertrophy, being a conservative process or an act of =compensation=, does not necessarily present any symptoms at first. At the beginning there is rarely any pain, but a sense of fullness and discomfort is present. As the hypertrophy increases, the arteries become fuller, the veins less full and the circulation accelerated. In hypertrophy associated with arteriosclerosis the blood pressure is increased, and the pulse full and firm. Epistaxis may be of frequent occurrence and the face congested. Pains occur in the precordial region. There are nervousness, headache, hot flushes, palpitation, cough and vertigo. In hypertrophy of the =left ventricle=, the apex is lower and to the left. The carotids pulsate visibly and the radial pulse is strong and tense. Percussion reveals enlargement to the left and downward. The first sound is louder and prolonged. The aortic second sound is intensified. In hypertrophy of the =right ventricle= the enlargement is to the right edge of the sternum. The second sound in the pulmonary area is increased. The apex-beat is displaced outward. The pulse at the wrist is usually small. Hypertrophy of the =auricles= always occurs with dilatation, which is most common in the left auricle. The physical signs are characteristic. They are caused by diseases of the mitral and tricuspid valves and diseases of the lungs, as emphysema and cirrhosis.

=Diagnosis.=—If a careful examination is made, hypertrophy can hardly be mistaken for any other condition. There may be a resemblance to pericardial effusion, pleuritic effusion, aneurism or mediastinal tumor, when near the heart. The X-ray will be of assistance.

=Prognosis.=—Depends largely upon the cause producing the hypertrophy. Remember that hypertrophy is a compensatory act. The prognosis is more or less unfavorable if resulting from emphysema, Bright’s disease or in old age; also in degeneration of the vessels. In most cases of functional overaction, persistent treatment can usually accomplish considerable.

=Treatment.=—The treatment must be according to the cause of the hypertrophy. There are many etiological factors, consequently the treatment depends upon the influence of these factors. The principal treatment will be found under endocarditis, as valvular diseases are usually caused by endocarditis, and hypertrophy of the heart is a conservative process of nature—an act of compensation secondary to valvular and arterial lesions. The indications are to lessen the force and number of pulsations of the heart and remove the cause if possible.

Dilatation of the Heart

There may be =dilatation= with thickening of the walls, and dilatation with thinning of the walls, or they may be normal. It may be produced by impaired nutrition of the cardiac muscle or increased endocardial tension. More frequently the two conditions act jointly, although they may act singly. Impaired nutrition of the cardiac muscle may diminish the resisting power and thus cause dilatation. Weakening of the cardiac walls may occur in scarlatina, typhoid, typhus, rheumatic fever, etc. It is met with in chlorosis, anemia and leukemia. Increased endocardial tension occurs in sudden, extreme exertions and in valvular diseases. A normal heart through excessive exertion is rarely if ever dilated. The important causes are considered under hypertrophy. Both impaired nutrition and increased endocardial tension are influenced directly by the extent and severity of the osteopathic lesion. This point has been considered under chronic endocarditis.

=Pathologically=, the right side is more commonly affected than the left. In advanced aortic incompetency, all the divisions may be dilated. When one ventricle alone is dilated the septum may be seen to bulge. In extensive dilatation, the auriculo-ventricular rings are often dilated. Other orifices may also be dilated. The condition is often associated with =hypertrophy= and =fatty degeneration=. The muscle may be normal in appearance. The endocardium is often opaque, and roughened in patches. There is degeneration of the ganglia of the heart.

=Symptoms.=—Dilatation causes weakness of the walls of the heart, but as long as the hypertrophied walls can compensate, no symptoms result. When the hypertrophy weakens, greater dilatation occurs and symptoms of venous stasis appear, as dropsy, feeble irregular pulse, dyspnea, cough and scanty urine. In some instances there may be brief precordial distress, faintness or palpitation.

=Physical Signs.=—On =inspection= the apex-beat is diffuse and feeble, or it may not exist. As observed by Walsh, the impulse may be visible and yet not palpable. =Palpation=—the impulse is diffuse, feeble and fluttering. The pulse is small, rapid and irregular, rarely is it slow. =Percussion=—the area of lateral dullness is increased to the right. There is increase in the dullness downward to the sixth interspace and upward to the second rib in many cases. =Auscultation=—the sounds are weak and sharp. The first sound is shorter, lacks its muscular element and becomes more like the second. The sounds are obscured, the cardiac murmurs are present. In many cases the characteristic gallop rhythm is present. When the right heart is chiefly dilated, the true apex-beat cannot be felt, while an impulse may be felt below the xiphoid cartilage, and a wavy impulse is seen in the fourth, fifth and sixth interspaces to the left of the sternum.

=Diagnosis.=—When a clear history can be obtained, together with the characteristic features, the diagnosis can be readily made. =Prognosis= depends upon the cause.

=Treatment.=—The treatment of dilatation is that of valvular heart disease. It is important that the patient should have plenty of rest, suitable food and regulated exercises.

In acute dilatation absolute rest is necessary. Limit the fluid intake, and open the bowels thoroughly. In serious cases, bleeding, a pint or more, should be considered.

Myocarditis

=Myocarditis= is an acute or chronic inflammation of the heart muscle. In many cases where the muscle substance of the heart is diseased, there is no doubt that =osteopathic lesions= are potent underlying factors. The lesions lessen nervous integrity and thus have a direct bearing upon the muscular strength and the likelihood of inflammatory invasion.

=Acute Interstitial Myocarditis.=—This affection is met with in fevers, in connection with endocarditis and pericarditis. Of the infections diphtheria and typhoid are the most frequent. Septic emboli may block the coronary arteries in pyemia, septicemia and malignant endocarditis and cause infarcts in the myocardium with abscess formation. It may be a complication of gonorrhea. Males are affected more often than females.