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LECTURES
ON
DISEASES  OF THE HEART.
BY
       EDWIN M. HALE, M.D.,

SPECIAL LECTURER ON DISEASES OF THE HEART, AND PROFESSOR OF MATERIA MEDICA
  AND THERAPEUTICS OF NEW REMEDIES, IN HAHNEMANN MEDICAL COLLEGE,
       CHICAGO; AUTHOR OF "NEW REMEDIES," ETC.
SECOND EDITION—ENLARGED.
      BOERICKE & TAFEL:
NEW YORK: 145 GRAND ST.  PHILADELPHIA: 635 ARCH ST.

            18 77. 
H l(pf  L
1211
             Entered, according tc Act ot V/ongress,
                    By EDWIN M.  HALE,
In the year 1871, in the office of the Librarian of Congress, at Washington. 
                       TO

        jBnvid  M. Smith, Ml. ?3.
                     OF CHICAGO,

    THE FIRST HOMCEOPATHIC PHYSICIAN
                  IN THE NORTHWEST ;

 THE FIRST PRESIDENT OF HAHNEMANN MEDICAL COLLEGE OF
                     CHICAGO ;

THE FIRST PRESIDENT OF THE  ILLINOIS STATE HOMOEOPATHIC
                 MEDICAL  SOCIETY;

                    THIS VOLUME IS

            RESPECTFULLY DEDICATED. 
 
           PREFACE
TO  THE SECOND  EDITION.
  The Lectures contained in  this volume were delivered  before
the Class  of Hahnemann Medical College, Chicago, during the
winter of 1870-71.   I was appointed by the Faculty of the Col-
lege to give a special course of Lectures on Diseases of the Heart
and their homoeopathic treatment.   The  satisfaction manifested
by the class  emboldened me to publish them.  The reception of
the first edition by the profession was so favorable, that  a second
has been  demanded.  To the  original  volume I  have  added an
Appendix containing several papers on Cardiac  Disorders, read
before the Illinois State Homoeopathic Medical  Society;  also a
copious  Index, which may be of value to  the  student and prac-
titioner.
  As  it is manifest that but little that is new or original relating
to the Etiology and Diagnosis of diseases of the heart can be  pre-
sented, I cannot be criticized for quoting  largely from standard
authorities on that subject.  The treatment, however, is in ac-
cordance with  the doctrines first promulgated by Hahnemann.
The therapeutics is  enlarged  by addition of new remedies  not
recommended  by other  authorities.   While I  accord the largest
liberty in  the  matter of dose, I  have advised  the quantities and
attenuations which  have  been most successful in my  hands, or
that are  indicated by my  law of dose, which I  have fully ex-
plained herein.
    Chicago,  April, 1875. 
 
TABLE
OF  CONTENTS.
                          PART   I.

             Functional Disorders  of the  Heart.


                    INTRODUCTORY LECTURE.
                                                            PAGK
The Wonders of the Heart—Its Functions — Increased Frequency
    of its Diseases — Its Anatomical Peculiarities—Its Circulation —
    Its Innervation — Its Nervous  System — When it Begins to Beat
    —Pathological Deductions, .    .......   19-32

                           LECTURE II.
Circulation of Blood through the  Heart—Location of the Heart —
    Space  over which  Normal Dullness is found — Sounds of the
    Normal Heart — Sounds of the Abnormal Heart,   .    .    .   33-41

                          LECTURE III.
                FUNCTIONAL  DISORDERS OF THE HEART.
Definition and various Forms  of Disorder — Pathological Relations
    and  Causes—Association  with other Diseases — Symptoms,
    Physical Signs of— Diagnosis — Prognosis — Treatment—Cases,   42-5£

                          LECTURE IV.
                         ANGINA PECTORIS.
Nature of She Disease — Symptoms—Pathology—Pathological Rela-
    tions— its Frequency — Prognosis—Cause of Sudden  Death in
    — Diagnosis — Treatment,  ....         .        .   56-64 
VTII                   TABLE OF CONTENTS.
                                                               PA OK.
                          PART  II.

           Inflammatory Affections of the Heart.


                           LECTURE V.
                           PERICARDITIS.
Acute Pericarditis — Anatomical Characters — Morbid Changes —
    Causes  and Pathology — Connection with Rheumatism — With
    Albuminuria —With Bright's Disease, Pyaemia, etc.— Jymptoms:
    — Of  the  Heart—Of the Circulation —Of the  Respiratory
    Organs — Digestive Organs — Brain and  Spinal  Cord — Phys-
    ical Signs  of  Pericarditis — Signs  furnished by Auscultation,
    Percussion, Palpation, Inspection, and Mensuration — Summary
    — Diagnosis—Prognosis — Treatment,   .....   67-95

                           LECTURE VI.
                   ENDOCARDITIS AND  MYOCARDITIS.
Definition — Anatomical  Characters — Causes and Pathology — Symp-
    toms— Physical Signs — Diagnosis—Prognosis — Treatment, .  96-113
                          PART  III.

                Organic Diseases of the Heart.

                           LECTURE VII.
                           HYPERTROPHY.
Definition and Varieties of Hypertrophy — Enlargement by Hyper-
    trophy— Concentric Hypertrophy — Symptoms and Pathological
    Effects—Physical  Signs and  Diagnosis  of Enlargement by
    Hypertrophy—Summary of the Physical Signs of Hypertrophy
    with Enlargement of the Heart — Treatment.....115-141

                           LECTURE VIII.
                     ENLARGEMENT BY DILATATION.
Definition of Enlargement by Dilatation — Symptoms — Pathological
    Effects—Physical Signs and Diagnosis—Summary—Treatment,  142-1C4 
TABLE  OF  CONTENTS.
IX
                                                                  PACF
                            LECTURE  IX.
                 LESIONS OF THE  WALLS OF THE  HEART.
\trophy of the Heart — Fatty Growth—Symptoms of Fatty Growth
    — Fatty  Degeneration — Symptoms of—Pathological  Effects —
    Treatment —Softening of the Heart — Induration of—Rupture of
    the  Heart — Treatment  of the  Various  Lesions,    .    .    .  165-174

                             LECTURE  X.
                   VALVULAR  DISEASES OF THE HEART.
Aortic Lesions — Mitral Lesions — Primary Effects of Valvular Lesions
    on the Circulation — Symptoms and Pathological Effects of Valv-
    ular Lesions — Secondary  Effects of Valvular Lesions—Pain —
    Palpitation — Cardiac  Dropsy — Symptoms  of the  Respiratory
    Svstem — Symptoms of the  Nervous System — Symptoms of the
    Digestive System—Symptoms of the Genito-Urinary System —
    General Symptoms,.........  175-193

                             LECTURE XI.
                    VALVI'LAR DISEASES OF  THE HEART.
Physical Signs  and Diagnosis  of Valvular  Diseases of the Heart —
    Endocardial or Valvular Murmurs — Mitral Direct Murmurs —
    Mitral Regurgitant Murmurs — Aortic Direct  Murmurs—Aortic
    Regurgitant Murmurs — Recapitulation of  Murmurs — Purring
    Tremors—Diagnostic Characters of Mitral Lesions — Diagnostic
    Characters of Aortic Lesions — Of Tricuspid  Lesions-—Of Pul-
    monic Lesions — Treatment of Disorders Resulting from Valvular
    Lesions,...........194-206

                          APPEXDIX.

The Influence of the Mind over the Heart — The Pathology and Treat-
    ment of Diseases of the Heart caused by Emotional Influences — On
    the Relation of Sudden Death to Cardiac Disease — Collinsonia in Irri-
    tation of  the Cardiac Nerve,.........207-243 
 
PART I.
FUNCTIONAL DISORDERS OF THE HEART. 
 
 

S^-""M%.
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\
 
            LECTURES  OX

DISEASESOF  THE  HEAET.
             INTRODUCTORY LECTURE.

The Wonders of the Heart — Its Functions — Increased Frequency of its
  Diseases — Its Anatomical Peculiarities —Its Circulation—Its Innervation
  —Its Nervous System — When it Begins to Beat — Pathological Deductions.

  Gentlemen :   I approach the subject upon which I have
been appointed to lecture with the fullest and deepest sense
of its importance.  Diseases of the  heart, from  their very
nature,  and the paramount importance of the organ affected,
should  claim the interest  and profound attention  of all
thinking  and conscientious physicians.   I  do  not wish to
exaggerate  the importance of cardiac  diseases,  or give a
false estimate of their frequency, but I have no  hesitation in
asserting, that my observations in a large practice of twenty
years have  convinced  me that diseases of the heart, and
especially functional disorders of that organ,  have largely
increased within the last decade.   It may be owing to the
fact  that the latter half of my years of practice  have been
spent in a great city, that I have come to this conclusion.
The intense strain upon the nervous  energies incident to the
business and pleasures of a city life,  do certainly have much
to do in the causation  of certain   heart diseases.  In the
country, life is  calmer, and its tide flows slower, and the
vital energies are less subjected to violent aberrations.
  In view of these facts, it becomes us  to study well this
organ—the  heart—in all its relations, not  only anatomically,
physiologically,  but psychologically. And in  order to do 
20
DISEASES  OF THE HEART.
this, we must first inquire into the character of this organ.
Is it merely an appendage to the body—an organ of elimina-
tion or secretion?  Or is it the centre of the blood-system,
just as the spinal cord is the grand centre of the nerve-
system, and the brain the centre of the mental forces ?
   As the brain animates the body with intention and pur-
pose, and the lungs give it corresponding motion, the heart,
as the blood's executive power, gives corporeal substance
to the frame, inasmuch as the body itself arises from the
blood.  The existence of the human machine depends upon
the heart, but its usage upon  the  lungs and brains.  The
heart is the source whence the finished  blood descends to
the organs throughout the system, and, as the life  is in the
blood, the heart is the agent for bestowing that life upon the
organization.  In a word, the heart, or blood, determines
the fleshly tenement.

              ITS ANATOMICAL PECULIARITIES.

  Anatomically  the   heart is  a  conical, hollow muscular
organ, lying obliquely in the chest,  between the two lungs,
the base of the cone pointing upward in the direction of the
right shoulder, the apex pointing to the  space between the
fifth and  sixth ribs.   It rests upon the tendinous portion of
the diaphragm, which is the partition between the chest and
the abdomen, and it is encased in a peculiar bag or capsule,
the pericardium,  which  consists of two  layers; the outer,
fibrous, by which the  pericardium is attached to the great
vessels at the root of the heart; the inner, a serous layer,
continuous with the serous membrane which covers the outer
surface of the  heart.  The cavity  between  the heart and
pericardium, thus lined  by a serous covering, generally con-
tains more or less fluid, whereby the heart is  lubricated  on
the outside,  and its local motions are rendered easy.
  The heart comprises  four  cavities, two auricles, and two
ventricles; one auricle and one ventricle being on each side
and the right pair of cavities being devoted to the circulation
of the venous blood,  the left  pair to that  of the arterial
blood.   The auricles are  at the top, constituting the base of
the heart; the ventricles  form the apex; the latter are much 
CIRCULATION IN THE  HEART.
21
stronger than the auricles, consisting of very thick muscular
walls, the reason of which  we shall see presently.

             THE CIRCULATION OF THE BLOOD.

  The heart is a peculiar muscle, and when any of its four
cavities contract,  they have  the power of expelling their
contents,  the force of the  expulsion being  the prime mover
of the circulation of the blood.  We may begin the circle
where we please and we shall find that it returns into itself.
Starting, for instance, from the left ventricle, we see that the
blood is driven, by the contraction of that cavity, into the
aorta—the highway which leads into all the arteries of the
body; through these the blood  is discharged into the veins,
which unite to form at last only two great trunks the venae
cavse, which are  again the  thresholds  of the heart,  and
debouch into the right auricle.   The  blood which has now
passed from the left ventricle to the right auricle, has  still a
journey to make before it completes its course.  Accordingly,
from the right  auricle it  is forced into the right ventricle,
and by the right ventricle into the pulmonary artery,  which
conveys it to the lungs, where it ramifies through the mul-
tiple branches  of that artery, and whence it is brought back
by  the  pulmonary  veins, forming  ultimately four  large
trunks,  which empty into the heart's  left auricle, by the
 contraction of which the blood is next  forced  into the left
ventricle, to the place from which we began.
   "Without entering  into  a description of the  complete cir-
 culation of the blood throughout the body, with which you
 are all doubtless familiar,  we will consider a more important
 and interesting subject, namely: the circulation of the blood
 in the heart itself.

              THE  CIRCULATION  IN THE HEART.

   That there must be a circulation in  and through the heart
 is evident; for how else could the heart be nourished?  The
 heart is supposed to be nourished by the  coronary vessels;
 they are called coronary from corona, a crown, because they
 run  in crowns or coronal  circles around the heart.  They 
22
DISEASES OF THE HEART.
arise from the aorta, close beside the semi-lunar valves, and
running around the base of the heart, and sending branches
down the  lines of partition between the four-fold chambers,
they form a kind of vascular cage-work in which it is  con-
tained.  The coronary veins, said to begin from the minutest
twigs of the coronary arteries, by their considerable branches
for the most part accompany those of the arteries,  and dis-
charge themselves  by one, two, or  three orifices,  into the
right auricle.  The interior of the four cavities of the heart
is not a smooth, even  surface,  but is rendered extremely
irregular  by muscular columns, projections, and  partitions;
it is scooped, channelled, and caverned, besides which, on the
walls of the cavities there are minute openings, the foramina
of Thebesius, which are supposed to be the mouths of little
veins.
   It is a curious fact that nearly all the  old anatomists, and
some also of the moderns,  have suspected a puzzle in these
coronary vessels.  They come from the aorta, and run back-
ward  to  the heart.   In  a  certain  proportion of  cases,
estimated as 5 in 20, one or more of their orifices lies behind
the  semi-lunar valves, and such orifices,  it is clear,  cannot
receive the streams propelled from the heart,  because it lays
down the valve  flat upon  them, and effectually closes them.
As,  therefore, nature's  law must be constant, it was  argued
that what holds of one  orifice must hold of all, and that the
blood runs back  into  the coronaries from  the  aorta when
the   heart's   contraction   ceases.   This  was  Boerhaave's
opinion.
   Sweclenborg,  however, one of the profoundest anatomiste
 and physiologists of any age, propounded another view.  He
 argued that  the raising up  of the semilunar valves during
 the  contraction  of  the heart, when'the blood is expelled into
 the  aorta, precludes its passage then into the  coronaries, and
 that the stretching of the  coronaries, and their pressure by
 the full aorta, contributes to the same preclusion.  He held
 that the coronary arteries do not  arise  from, but terminate
 in the aorta; that they are veins relatively to the heart,
 although running  into the beginning of the arteries  of the
 body.  The doctrine, in brief, is this: that the heart, as the
 head of  the  vessels and the fountain  of the  blood,  itself 
CIRCULATION IN THE HEART.
23
requires  the firstling  blood  for the  exercise of  its noble
offices, and cannot hold  its life by tenure  from one of its
own arteries, which would be to invert all ideas of the order
of nature.
  The heart is already full of blood,  and if fluids, or fluid
persons,  like solid persons, move with  greater velocity in
proportion to their life, the best blood  in this race will con-
tinually outrun the rest, and  always first  in the heart,  will
skirt along its porous walls.  Xow, what structure do  we
find upon  these walls, but caverns, jagged cavities,  and at
the  bottom of these a number of little holes, the foramina
of Thebesius.  Into these caverns, then, miniature ventricles
in the great ventricle,  hearts of the heart, the quickest blood
is received, and the pores open with all their hearts to take
it in.   And  when the heart contracts,  it drives out the
general blood of the body into the grand aorta, but its own
particular  blood,  detained  in  the  cavernous  lacunse,  it
squeezes, slippery with  spirit,  through  its walls, into its
muscular substance, and  thence  onward and outward to the
surface,  into the coronary arteries  and  the coronary veins,
from which there is a  reflux,  when necessary, into the
auricles and ventricles.*
  According to this  explanation, which  we cannot hesitate'
to accept, the heart has a circulation of its own,  which gives
it a power to maintain its own constancy in  the midst of the
fluctuations of the blood, and to make it the head, ratio, or
balance, as well as the heart, of  the too-mobile circulation.
  Again, according to this view, the varying quantities of
the  blood  returned upon the heart, find  an outlet through
the  walls of the heart itself, and equilibrium is thus main-
tained by  the coronary vessels;  so that  the heart, plus the
coronaries, equals all the forces of the circulation;  while the
heart, minus the coronaries, is a comparatively regular force
uninfluenced by the general state  of the system.   Were it
not for such provision, the heart would  be at the mercy ot
extraneous influences;  the most  important organ of  the
trunk would have no  stability, would in  the end yield, and
* Dr. Wilkinson—"The Human Body and its Connection with Man." 
24
DISEASES OF THE HEART.
be distended into a bladder or membrane, incapable of any-
thing but the most passive recipiency.
  Next to the consideration of the circulation of and in the
heart, and its nutrition, the next in importance is

             THE  INNERVATION OF THE HEART,

Or, the nervous circulation or nervous forces which  impel
and regulate the motion of this wonderful organ.  The heart
is endowed, above all other organs, with a property which
has been termed irritability, by which is meant the capability
of being easily excited to movements of contraction alter-
nately with relaxation.
  After the heart has been removed from the  body, and has
ceased to contract, a slight irritation will cause it to execute,
not one movement only, but a series of alternate  contractions
and  dilatations, gradually diminishing in vigor until they
cease.  The contraction begins in the part irritated, and then
extends to the rest.  And it appears that it is the muscular
tissue  alone that possesses this peculiar property, for  if the
parts of  the heart experimented upon are connected by ten-
dons the irritation will not extend through such connection.
This irritability is less speedily lost in cold-blooded  than in
warm-blooded  animals.   The heart  of a frog  will go  on
pulsating for many hours after its removal  from  the  body;
and the  heart  of a sturgeon when inflated  with air, con-
tinues to beat until the auricle absolutely becomes so  dry as
to rustle during its movements.
   Not only  wTill  the whole  heart continue  to beat wdien
removed from the body, but even small and isolated portions
will contract and relax with great regularity.  Cut the heart
lengthwise into two halves,  and  each half will continue
beating.   Cut it across, through both auricles and ventricles,
and both  sections will beat as before.  The  auricles will
persist in their rhythmical  action when cut oft* above  the
auriculo-ventricular rings, and the apex of  the heart will do
the  same when separated from the rest of the ventricles.
   This is one of the spectacles which assail the mind of  the
student  with somewhat of a  tremulous awe.   The beating
of the heart, which  from his childhood he  has learned to 
          WHEN DOES THE  HEART BEGIN TO  BEAT?        25

associate, in some mysterious manner, with life and emotion,
he here sees occurring under circumstances removed from
all possible suggestions of emotion or life.   All connection
with the spinal cord is severed.  The brain cannot send to
it  any voluntary influence.  The blood  no longer courses
through  it,  to  give it  motion  by  contact or otherwise.
What then causes the heart and each separated portion to
continue their rhythmical pulsations?  This irritability does
not depend upon the cerebro-spinal system, for it has been
proved that the heart's action will continue in the body after
the brain and  spinal cord have  been removed.  For many
years no explanation could be given of this wonderful self-
life of the heart. We now know that the heart has a nervous
system of its own, as well  as a circulation within itself.
  In the substance of the heart is a complete little  nervous
system, consisting of ganglia and nerves, and is not  made
up of the nerve filaments which come from the pneumogastric
nerves.  From  these ganglia nerves are distributed  through
its muscular substance.  It is to this nervous apparatus that
we must ascribe the spontaneous action of the heart;  for if
any part be severed form all connection with the ganglia the
pulsations will  cease  at once, but if the  smallest severed
portion of a heart  contains a ganglion  the pulsations will
continue.  In  other words, it retains its irritability.  The
movements during  life  or death are due to these ganglia.
No other ganglia in  other parts of the body retain their
power after the circulation has been destroyed.  In view of
this, we  might almost believe  the  fanciful notion  that  the
heart was a sentient organism—a being within a being!
  But the most wonderful thing about the heart remains to
be told.   It pulsates in the embryo long before it contains blood,
and long before any nerves  have been developed in it—when, indeed,
it is nothing but a mass of cells!  What is the essential nature
of these cells?  Does each one possess the property  of spon-
taneous movement?  Do we know the nature of the stimuli
which cause this movement ?   And when does this  move-
ment begin ? 
26
DISEASES  OF THE HEART.
          WHEN  DOES THE HEART BEGIN TO BEAT ?

  In discussing this question, a certain eloquent writer says;
  " The essential unity of the  rhythmic beat of the heart,
and the amoeboid movement of protoplasm, are well shown
by the history of the new-born  heart,   In the chick growing
within the egg the heart begins to beat very early, while as
yet it is  built up of nothing but protoplasmic cells.  Many
authors, over-jealous, as it seems to me, for the prerogative
of nerve-cells, find satisfaction  in affirming that these con-
stituent cells of the young heart, though apparently alike in
structure, are various,  some being  potentially nerve-cells,
others potentially muscle.  To my  mind,  each  and every
cell is not only potentially, but actually,  both  nerve and
muscle.   So long  as they are still  cells,  that is, still  tiny
masses of untransformed protoplasm,  each enjoys all  the
powers of life.   What befalls them afterwards is  not gain,
but limitation  and loss.   Some  cells lose the power to move,
and so become nerve-cells; other cells lose (to a great extent,
at least) the power to originate impulses, and so become
muscular.  Very interesting is it to watch how the slow,
irregular,  drawling movements  of the primordial protoplasm
are gradually transformed and  gathered up into the sharp,
short  stroke of  the  heart's beat.   We speak, in  common
language, of the heart of  the chick as beginning to beat on
the second or third day of incubation.  It is  then that its
beat becomes obvious  to our senses as  a beat.  But,  in
reality, it never does begin to beat.   There is no sharp line
of demarcation between the protoplasmic crawl and the true
rhythmic spasm; the  one, little by little,  merges  into  the
other.   To  borrow  an illustration  from  music,  it might
naturally be imagined that the  matter took  place in this
wise:  We might fancy that the tiny cells were marshalled
in their places round the cavity of the heart, as musicians
are marshalled in an orchestra, fully equipped with powers
of rhythmic pulsation,  but quiet and  inactive;  and then,
that at a  wave of the wand of the great  conductor, at  the
moment  when fuller life was  breathed into  every cell, all
struck up in unison with the heart-beat.  We might fancy,
I say, that this was how the first stroke was wrought.  But 
PATHOLOGICAL DEDUCTIONS.
27
it is not so.  To gain a truer image of the process, we must
think of ourselves as listening with eagerness, a long way
off, to a multitude of performers assembling together, each
playing on the same instrument, but playing  in a different
way,  though all  trying to learn the same tune,  and  all
gradually  drawing near to us.   As we  listen to them with
stretched  ear, coming nearer and  nearer, and as,  at eac-h
moment, more and more performers fall into the one proper
time, the  initial discordant noise, as it gathers in intensity,
also gradually puts  on a definite form,  and  at last  there
comes a moment when we say, ' Now I hear them !  now  I
have the tune!'   So it is with the growing heart.   Looking
at it  earnestly with  the microscope, we may fancy ourselves
witnesses  of how the cells, as they assemble together, little by.
little exchange the all-sided flow of protoplasm for the limited
throb of a muscular  contraction, gaining in force what they
lose in  form.  And so there will come a time  when we  can
say, ' Now I can see it beat;' though in reality it has been
beating a  long time before." *

                PATHOLOGICAL DEDUCTIONS.

  From a pathological point of view, this peculiar nervous
structure  of the  heart  is  important.  It teaches  us that
certain diseases of the heart may originate within itself—i. e.,
are idiopathic.  Especially may this be the case with the disor-
ders known as functional or nervous.  Thus, in some cases  the
functions  of the body may be perfectly healthy, while  the
heart is disordered.   Its nervous system may be deranged,
while that of the body may be in perfect health.
  We are also taught, by the fact  of the heart's  peculiar
irritability, that we  cannot always decide on the existence
of life or  death from the presence or subsidence of its move-
ments.  The heart may be still  beating in the body while
the body has been dead for hours;  and the heart may cease
to beat while the body lives.  The hearts  of decapitated
criminals  have been observed to beat two, four, and even
seven and twenty hours after the operation!   On the other
* Dr. S. Foster—" Wonders of the Heart." 
28
DISEASES OF THE HEART.
 hand, many instances have  been known where the heart's
 action could not be  discovered  for  hours, yet  the patients
 recovered.  In those  morbid conditions known as trance and
 catalepsy, the heart's action  may appear to be suspended for
 hours, clays, and even weeks—the patient meanwhile retain-
 ing consciousness.  In this condition of apparent death many
 persons have been  buried,  and some remarkable cases  of
 burial and  resuscitation are  on record.  In syncope or faint-
 ing the consciousness is lost, no action in  the heart can be
 perceived,  even  by auscultation,  for many minutes, yet by
 the proper use of stimuli the patients recover.  M. Bouchat
 says if the heart's action ceases beyond five minutes death
 is certain, and he declares that the circulation can be heard,
. when it can be detected by no other means, but this assertion
 is open to much doubt.
   But aside from this self-life which  the heart  possesses,  it
 has a  life imparted  to  it from  the brain and spinal cord.
 The heart  receives nerves from the cerebro-spinal system,
 and also from the  sympathetic.  From  the former  it  is
 supplied  by the cardiac branches of  the pneumogastric and
 the lately-discovered motor  and sensory nerves, which  go
 to the heart directly  from the spinal  cord; but the pneumo-
 gastrics  may be  severed  at their   origin,  and  the heart
 continue  to act;  and, what is more astonishing, the cerebro-
 spinal centres may be  removed  from an animal  without
 arresting the heart's action.  In  those  monstrosities some-
 times called into being, no brain or spinal cord exists, but
 they nevertheless  possess a regularly pulsating heart.  The
 heart may be isolated from  all  connection with the sympa-
 thetic system, and yet continue to pulsate.
   These  are  important  facts  for   you  to  remember,  in
 connection  with the  use of the  medicines for the relief of
 cardiac diseases.  A remedy may act  upon the cerebro-spinal
 or  the sympathetic systems; but  if  these systems refuse to
 respond to the medicinal stimuli, the heart will not feel the
 action of the curative agent.  On the other hand,  a remedy
 may act on the heart, even  if the nerves leading  from the
 great centres of the  two systems are severed or paralyzed,
 for it may act by being carried in the blood  directly to the
 heart, there to act upon the ganglia which lie in its structure. 
PHYSICAL POWER.
29
           THE PHYSICAL POWER OF THE  HEART.

  Another wonderful thing about the heart is its  immense
physical power.   It is built up of muscular fibres  in such a
way as to give it a strength possessed by few other  muscular
structures.   Every time it  pumps blood  into the arteries  it
exerts  a force which is estimated  at thirteen pounds.  The
usual force constantly exerted by the  healthy human  heart,
it  is estimated,  would  sustain a column of blood 7|  feet
high, the weight of which would be about 41bs. 6oz.  Imagine,
if  you will, an organ exerting this immense force — hour
after hour — day after day — year after year — and you can
form some idea of the aggregate power of the heart during
the life of a man.   Not only is the power of the heart won-
derful, but its  sensitiveness  is peculiar and unparalleled.
As the blood courses through its  substance,  even into its
innermost recesses,  it feels  the presence, in  some way  or
other, of everything which has found its way into the blood.
All poisons, the elements of maladies, the essential portions
of all nutritive material, and even the emotions of the mind,
influence  the heart's motion, and the beat is altered by such
influences.  Disease may accelerate its pulsations  to 140  or
150  per minute,  or cause  them  to sink as low as 25 or 30.
 So is  it with  certain medicinal agents.  By their use we can
 alter the  heart's force, the frequency of its beats, its regu-
larity  of rhythm, and other qualities.
   The heart is influenced by all the forces in nature; by  all
mental and physical influences.  " Hence, also, it is that it
 never wearies.  Let  me remind you  of the work done  by
 our hearts in a day.  A man's total outward work, his whole
 effect  upon the world in  twenty-four  hours,  has  been
 reckoned at about three hundred  and fifty foot-tons.   That
 may be taken as a good  'hard day's work.'   During the
 same  time, the heart  has  been working at the rate of one
 hundred  and twenty foot-tons.  That is to say,  if  all the
 pulses of a day and night  could be concentrated and welded
 into one  great  throb, that throb would  be enough to throw
 a ton  of iron one hundred and twenty feet into the air.  And
 yet the heart is never weary.   Many of us are  tired after
 but feeble labors;  few of us can  hold a poker out at arm's 
30               DISEASES  OF THE HEART.

length without, after  a  few minutes,  dropping it.  But  a
healthy heart,  and many  an unsound heart too—though
sometimes you can tell in the evening, by its stroke, that it
has been vexed  during the day, that it has been thrown oft'
its  balance  by the turmoils- and  worries  of life — goes on
beating through the  night while we are asleep, and, when
we awake in the morning,  we find it at work, fresh as if it
had only just begun to beat.  It does this because upon each
stroke of work  there  follows a period, a brief but a real
period, of rest, because the next stroke which comes is  but
the natural sequence of that rest, and made to match it;
because,  in fact, each  beat is, in force, in scope, in character,
in everything,  the simple  expression  of the  heart's own
energy and state." *
  We will now consider  the heart psychologically,  or the

      RELATIONS BETWEEN  THE MIND AND THE HEART.

  The heart is one of the so-called involuntary muscles, an
organ which is supposed to be beyond the influence of the
will,  if not  of the mental  sphere.  But this view of the
nature of the heart's  relation  to  the  mind is  not entirely
correct, for, as Dr. Holland has remarked, "the action of the
heart is  often  quickened, or  otherwise  disturbed, by the
mere centreing the consciousness upon it, without  any emo-
tion or anxiety.  On  occasions where the beats are audible,
observation will  give  proofs of  this, or  the physician can
very often infer it while  feeling the pulse, and when there is
liability  to irregular  pulsation, such  action  is seeming]}
brought  on, or  increased,  by the effort  of attention,  even
though no obvious emotion is present."
  Dr. Murray,  writing  of  "Emotional Disorders,"  says,
"The heart is  an organ  highly susceptible of emotional
excitement, and even  the strongest volition and  coolest tem-
perament will not give  immunity from  this susceptibility.
Thus easily excited,  in  those  of  nervous temperament the
organ is  ever been disturbed by emotion.  Note, for instance
the palpitation  or paralysis of fear, and the  intermittent
* " Wonders or the Heart," by Stephen Foster. 
      RELATIONS  BETWEEN THE MIND AND THE HEART.    31

action of a weak  or unhealthy organ when it is under  the
influence of emotional excitement.  Further, we have more
than once noticed, that long-continued anxiety will lead to
a wreak  and slow action of the heart,  causing the  pulse at
the wrist to fall below its normal standard, both in frequency
and force,  and at the same time rendering the organ liable
to become excited and turbulent on the slightest accession
of new  emotional feelings."
  Indeed, such is the  influence of emotions  on  the heart,
that a sudden and  painful shock  to the feelings has been
known  to  arrest its action, or to excite it to an  action so
turbulent as to  injure its valves  or their  tendinous cords.
The phrase " died of a broken heart" is  is  not purely
figurative,   for  the heart  has  been ruptured  by  violent
emotions, resulting in sudden death.
   Terror may paralyze the heart,  and so  may joy when it
suddenly seizes  upon  a  person  already overpowered  by
despair. The Roman matrons, after the battle of Cannae, on
seeing their sons, whom they supposed to have been killed,
dropped down dead on the spot.   Fear, the chronic form of
fright,  occasions a tremulous palpitation,  not  the  full,
bounding  beat of  energy or courage.   Rage  produces pre-
cordial  oppression,  and has  been known to bring on an
attack  of angina pectoris.  I  have known excessive grief,
from disappointed affection,  to  cause not only functional
disorder, with irregular and feeble pulse, but those abnormal
sounds  in  the heart which  indicate  deranged action of its
valves,  while, at  the same time, the patient  grew pale  and
anaemic.  As a rule, hope will excite and sustain the organ;
despair  and anxiety will  depress  it;  and contentment  and
peace of mind wTill give it healthy action.
   It is  my conviction that but few physicians have realized
the importance of  the subtle relations of the  brain or mind
with the heart;  or appreciate the connection between  the
soul and that centre of physical life.  We might go so  far
as to assert, that as there is a corporeal  heart, which is  the
life-giving  centre of the body, so  there must be a spiritual
heart, which is  the centre  of soul-life.   Else,  why do we
continually use the word " heart," as applied to the feelings,
impulses, and emotions?  We say, a man "has a heart," or 
32
DISEASES OF THE  HEART.
" no heart," that such an emotion " comes from the heart,"
or "comes from the head," indicating thereby that one kind
of feeling or impulse  may be  from  the soul, and  another
from  a more  "calculating" origin.  All the grand, noble,
loving, and impassioned impulses of our nature are said to
come from the "heart;" while  the cold, unemotional,  and
more practical  acts are said  to  emanate from the brain.  As
a rule, what is deeply rooted in the natural convictions and
expressions of  the people, has its origin in  truth, and  so  is
this accepted  correspondence between  the feelings  and the
passions of the soul,  and  the physical heart, based upon
a correspondence between  the heart, which is the central
life of the body, and love, which is the central life of the
soul.
   But the will, as well as the emotions, may affect the heart.
Many cases illustrative of this assertion are on record.   The
best authenticated case is  that of a Col. Townsend, of Bal-
timore,  which was  described  by Dr. George Cheyne,  who
 was a witness of the fact.  The case was that of a gentleman
 in apparent health, who by an effort of the will could at any
 time cause an  apparent cessation of all  the vital functions, so
 that the heart's action could not be perceived, nor any respiratory
 movements be observed.
    It is a fact well known to anatomists, that animals possess
 the power to move and govern certain muscular organs and
 muscles, while man, possessing the same muscular structures,
 has no apparent influence on  them.  How far this  influence
  extends to the heart is a problem wmich may well attract our
  attention.  We should not  overlook this sympathy between
  the mind and the heart.   A full appreciation of it may lead
  us to form opinions and diagnoses, which could not  otherwise
  be correctly made.   A physician may be treating  the  heart
  with medicines, when his efforts  should be  directed to a
  "mind  diseased."    We  should  never  lose  sight  of  the
  psvchological relations of the heart, as well as its anatomical,
  physiological, and pathological  history.
* Treatise on Nervous Diseases, p. 307. 
LECTURE  II.
Circulation of Blood through the Heart — Location of the Heart—Space over
  which Normal Dullness is found—Sounds of the Normal Heart — Sounds
  of the Abnormal Heart.

  Gentlemen :  Before I proceed to describe the Diseases of
the Heart, it  is.proper that we inquire into the method of
the circulation of the blood in and through that organ.
  The venous  blood which is returned by the ascending and
descending  vena cava, enters the  right auricle  during  its
diastole.
  Part of it flows on into the right ventricle during the earlier
part of its  diastole; but the  auricle being  filled before the
ventricle, then contracts, and discharges its contents through
the tricuspid valves into the ventricle, which it thus completely
distends.
  The reflux  of blood into  the veins during the  auricular
systole, is impeded by the contraction of their  own walls,
and by the valves with which they are furnished; but these
valves are  so formed  as  not to close accurately, especially
when  the tubes  are distended; so  that  a small*amount of
reflux usually takes place, and this is much increased when
there is any obstruction to the pulmonary circulation.
  Whilst the right ventricle  is contracting upon the blood
that has entered it, the cameos, columnce, which contract simul-
taneously with its  proper walls, put  the chorda tendinis upon
the stretch, and  these draw the  flaps of the tricuspid  valve
into the auriculo-ventricular axis.
  The blood then getting behind them, and then being com-
2 
84
DISEASES OF THE  HEART.
pressed by the contraction of the ventricle, forces the flaps
together in  such a manner as to close the orifice;  but they
do not fall suddenly against each other,  as is the  case with
the semi-lunar valves, since they are restrained by the chordae
tendinae, whence it is that no sound is  produced by  their
closure.
  The blood is expelled by the ventricular systole into the
pulmonary artery, which it distends, passing freely through
its semi-lunar valves; but as soon as the vis a tergo ceases, a
reflux might take place by the contraction of the arterial
walls.   The valves-are filled out by the backward  tendency
of the blood, and completely check the return of any portion
of it into the ventricle.
  The blood  after having circulated  through  the lungs,
returns  as arterial blood by the pulmonary veins to the left
auricle;  whence it passes through the mitral valve into the
left ventricle, and thence  into the aorta through  its  semi-
lunar valves, in the same manner as that on the other side.
  We will now proceed to describe and  determine the

                 LOCATION OF THE HEART,

and the space in which normal dulness is found.
  The heart is situated between the cartilages of  the third
and  sixth ribs.   The  upper extremity,  or  base, is defined
with  sufficient precision by the upper margin of  the third
rib.   The point or apex generally extends to  the fifth  inter-
costal space, near  the junction of the rib to  its cartilage.
The  organ  is situated obliquely  within the  chest, a line
passing through the longitudinal  axis, intersects obliquely
the clavicle near  its  acromial  extremity.   The medial line
and the linea mammalia, are convenient landmarks for indi-
cating the space which the heart occupies transversely.   The
median  line divides the heart, leaving  about one-third  on
the right, and two-thirds on the left side.  The left margiu
of the heart, in  the male,  extends to a point just within the
nipple, which is situated on the fourth rib, near the junction
of its rib with the cartilage.  The apex is about three inches
to the left of the median line, and about an inch within the
linea mammalis.  The right  margin extends from half an
inch  to  an inch  beyond  the  sternum, on the right side. 
    RELATIONS  OF  THE HEART TO THE ADJACENT ORGANS.  35

Viewing the several portions of the  heart  in relation to
the median line, on the right are situated  the  right auricle,
and about a third of the right ventricle;  on the left of this
line are situated two-thirds of the right ventricle and the left
auricle.
   The relations of the heart to the adjacent organs  are important
with reference  to the signs furnished by percussion, also by
the other methods  of exploration.  At  the  base are the
large arteries connected with the ventricles, viz.,  the aorta
and pulmonary artery, which  extend  up beneath the sternum
— the latter to the level of the upper  margin of the second,
and the former nearly as high as the first  rib.   The portion
of the heart situated on the right of the median line is covered
by the right  lung.   The  lower border of the heart, to the
left of the median line, lies on  the diaphragm which sepa-
rates it from the left lobe of the liver, and, towards the apex,
from the  stomach.  The portion of the heart lying  to the
left of the median line, is  only  partially covered by the left
lung—a part is in contact (the pericardium only intervening)
with  the thoracic walls.
   The space on the chest within which the heart is not cov-
ered by lung, is called the superficial cardiac region.
   The praecordial space within which the heart is covered by
lung is called the deep cardiac region.
   These names should be remembered,  for they will fre-
quently occur.
   The  boundaries of the  superficial cardiac region are thus
given:  It is bounded on its sides by lung, and on the greater
part of one side, viz., the lower, b}r the liver  and stomach,
with the diaphragm intervening.  The portion of the heart's
surface exposed, is an irregular quadrangle.  This space may
be embraced within  a right angled triangle delineated as fol-
lows :  The oblique  line, or hypothenuse, is drawn by con-
necting a point at the centre of the  sternum on a level with
the junction of the fourth  costal cartilage, wTith  the  point
where  the apex of the heart  comes  in  contact  with the
thoracic walls, the latter being usually in the fifth intercostal
space, about an inch within the linea  mammalis, or about 
36
DISEASES OF THE HEART.
three inches to  the  left of the median  line.  The median
line extending from  the same  point  on  the sternum, and a
line extending transversely from the  point of the apex-beat
to meet the median line, will form the two other sides of the
triangle.
  The limits to which  the deep cardiac  region extends have
been already defined in  giving the boundaries of the space
which the heart occupies within the chest.
  The dulness  over  the superficial  cardiac  region is more
decided than over the deep-sealed cardiac region, owing to the
fact  that it is  not covered by lung. This dulness can be
recognized by light percussion.  It requires forcible percussion
to mark out the dulness over the deep cardiac region.
  [For full and minute directions to  examine by percussion,
consult Walshe  or Flint on Diseases  of the Heart.]
  If the dulness, found on examination of a patient, exceeds
the limits given above,  we may conclude  that  some kind of
enlargement exists.  The heart, in proportion to its increase
in volume, pushes aside the anterior border of the left lung,
leaving a large portion  of its anterior surface uncovered and
in contact with  the  thoracic walls.  The degree of  dulness
writhin the superficial cardiac region is greater than in health
in proportion  to  the  enlargement.  Increased  extent  and
degree of superficial dulness are signs of enlargement of the
heart, provided the adjacent organs are healthy.  The pres-
ence of phthisis, chronic pleurisy, enlargement of the liver,
dilatation of the  stomach, aneurism of the aorta, enlarged
spleen, ascites, pregnancy, may cause difficulty in making a
correct diagnosis by means of percussion.
   The limits of this wTork  will not  permit us to go further
into this subject.  For  full and exact knowledge relating  to
the physical diagnosis of abnormal conditions discernable by
percussion, reference must be had to the wTorks previously
alluded to.

             THE SOUNDS OF THE NORMAL  HEART.
   When the ear is applied over the cardiac region, during
 the  natural movements of the heart, two successive sounds
 are  heard, each pair of which corresponds  with one pulsa-
 tion; there is also an interval of silence between each recur- 
NORMAL SOUNDS OF THE  HEART.
37
rence, and the sound that immediately follows this interval
is known  as the first sound, the other as the second.
  The first sound of the heart is caused by the contraction or
systole of the ventricles, and is called the systolic sound.  The
second sound is caused by the dilation or diastole of the ventri-
cles, and is called the diastolic sound.
  The first sound is heard plain,  over the apex of the heart;
or where  the apex-beat is felt.
  The second sound  is best heard just above the base of the
heart, in the intercostal  space between the second and third
ribs, close to the sternum.
  The first sound, over the apex, is longer, lower, and has a
"blowing" quality.
  The second sound, in the second intercostal space on either
side, is shorter, more acute, and has a clicking or valvular
quality.
  In order  to  get a clear idea of the  heart-sounds, the
stethescope should  be used.  The  bin-aural stethescope is
considered superior to all others  for this purpose.
  If the  ear is applied to the praecordia, the sounds  from
different  sources are  commingled, and they  cannot be so
well studied separately.
  The second sound  of the  heart varies, as we  study it on
different  sides of  the  sternum,  in the space between the
second and third ribs.
   On the right side  the  sound is more acute, more abrupt,
louder, and apparently nearer the ear,  and is  said  to be
caused by the movements of the  semi-lunar valves of the
aorta.
   On the left side the sound is less acute, and emanates from
the valves of the pulmonary artery, and due to their expan-
sion succeeding the ventricular systole.
   This second sound of the heart consists of a single element
only _ a valvular element —in this respect differing from the
 first sound.
   The first sound of the heart, as heard over the apex of the
 organ, is a mixed sound.  It is composed chiefly ot two dis-
 tinct elements.  One of these elements consists of a clicking
 souucl, emanating from the mitral and tricuspid  valves; the
 other proceeds from the  movements of the apex of the 
38
DISEASES  OF THE HEART.
heart against the thoracic walls.   The latter is called the
element of impulse, or  the impulse-sound;  the  former, the
valvular element, or valvular sound.

           THE ABNORMAL SOUNDS OF THE  HEART.

   There are certain morbid sounds  or murmurs  of the heart
which occur in disordered conditions of that organ.  They
mingle with,  follow, or  quite supersede the healthy sounds.
   These "murmurs," as they are generally called, with one
or two exceptions may be considered as modifications of the
bellows murmur, or bruit de souffle.
   This, in its  purest form,  is a smooth, blowing  sound,
named from its resemblance  to that made by a pair of bel-
lows.  It may be single or double,  soft or loud,  of a low or
high key; short, so as to merely prolong one of the natural
sounds, or continuous, so  as  to fill up more or less  com-
pletely the space between the impulses.   Sometimes it wholly
supersedes the healthy sound, and nothing is heard but one
continuous bellows-murmur;  but such cases are  rare.
  Not unfrequently it becomes, in various degrees, rough or
broken ; and attempts have been made to designate the mod-
ifications thus produced by the terms filing, rasping, sawdng,
etc.   The sawing sound being a double sound, should only be
applied  to the double murmurs  produced by the alternate
motion of the heart.  In some instances the murmur is of a
musical  or whistling character, and has been compared to
the chirping of young birds.
  The pure bellows  murmur may exist without any organic
disease of the heart.   It  may be produced  artificially,  by
alterations in the diameter of one of the larger arteries, even
in health, as by the pressure of the stethescope upon the artery.
The most frequent cause of the sound is probably an abrupt
contraction at one  of the orifices, or  in  one of the tubes
through which  the  blood  passes.  It will be readily under-
stood that the fluid, as it emerges  from the stricture, and
spreads out to fill the larger space beyond it, breaks into
currents, which set against the sides of the tube, and,, being
thence reflected, occasion vibrations which result in sound.
Thus the sound may result from contraction of any of the 
ABNORMAL SOUNDS  OF THE HEART.
39
orifices of the heart, or  the expansion of one  of the great
arteries immediately beyond them, and, in the  former case,
may be produced either  by organic or by functional disease
or spasmodic contraction.  The bellows murmur is not always
produced by changes in  the heart and arteries.  It may be
produced by a  watery state of the  blood,  such as occurs in
chlorosis or anaemia.  The liquid in these states being more
movable, currents are more easily formed by whatever affects
the regular movements  of the  blood.  In  such conditions,
anything which  excites  the circulation  will generate  the
murmur.  It may also be induced  by bleeding, and  arises
from any profuse haemorrhage.
   The rough murmurs, as they are called, to distinguish them
from smooth murmurs, may be produced by inequalities in the
surface over which the blood flows, especially in the orifices
of  the  great  vessels, produced by  depositions of lymph,
excrescences of  various  kinds, osseous or cartilagenous pro-
ductions, etc.   These rough sounds, like rasping, filing,  and
the  like, are supposed  to indicate organic disease in  the
valves or the valvular openings.
   Another  species of  murmur  is  called  the regurgitant.
These regurgitant  murmurs are caused by some defect in
the  valves — either loss  of substance, irregular  thickening,
dilatation of the orifice, or  something else which prevents
their accurate closure, and thus allows a regurgitation  of the
blood.  It may be supposed that in these cases the  sound is
ascribable not only to the irregularity given  to its backward
movement  through the  insufficient valve, but  also in some
measure to the  conflict of the reverted  with the regular
current  of  blood;  as, for  example, when the blood of the
contracting ventricle is sent through the insufficient auriculo
ventricular valve against the current entering the auricle.
   All  these murmurs are  heard  most distinctly when the
heart is in an excited condition.  They are influenced by the
less or greater force of the moving  cause.  The systolic ven-
tricular murmurs are louder than the diastolic, because the
former is caused by  the more  powerful  contraction of the
ventricles;  the latter, on the feebler elastic pressure of the
great arteries.
   Roughness of  sound is proportionate  to irregularity  in the 
40
DISEASES OF THE HEART.
surface producing it, and it most frequently attends regurgi-
tation.
  The tone of the murmur depends somewhat  on the depth
at which the sound is generated.
  By close examination, the following two important points
can be ascertained:
   I.  In which of the valvular orifices the murmur originated.
  II.  Whether it  depends on obstructions, or upon deficiency of
the valves, and consequent regurgitation.
  When the sound is loudest  on  the sternum immediately
below the insertion  of the third rib,  and thence  extends
upwards for about two inches along the course of the great
vessels,  it  may be considered as having  its source in the
semi-lunar valves.
  If the sound be perceived most distinctly along the course
of the ascending aorta, upon the right, it is probably seated
in the aortic valves; if along the pulmonary artery, on the
left, it is in the pulmonic valves.
  When the murmur is most distinct over that part of the
chest on which percussion is dull — that is, where the ventri-
cles are  in contact with the walls—it may be inferred that
it is generated  either in the mitral or tricuspid,  valve; in the
former, when the point of  greatest loudness is  a little to the
right of the left nipple, and an inch  or so below it; in ihe
latter, when the  analagous point is on or  near the sternum,
in the same horizontal line.
   There are other morbid sounds, resembling murmurs, which
have nothing to do with the valves of the  heart.
   Among these  are  the anozmic murmurs,  mentioned above.
They do not follow  the course of the large vessels so fully
or  frequently as  do valvular  murmurs.   They occur only
during  the systole of the ventricles — are not generally heard
below the left nipple, as they do not arise from regurgitation
through the mitral valve.  They are almost always accom-
panied   by a  smart, smacking impulse.   They disappear
during  mental or  physical quiet.  They  are always dimin-
ished, and generally disappear under appropriate  medical
treatment, which is not ordinarily the case with true valvular
murmurs.
   Venous murmurs (nun's murmur, top murmur,) are heard 
ABNORMAL SOUNDS OF  THE HEART.
41
in many young persons, in the anterior triangular space, in
which the external jugular vein descends.  It is a continuous
murmur, and is-generally more audible on the right than on
th^ left side.   This murmur disappears when the current of
blood is interrupted by  pressure upon  the  jugular vein, or
by any position  of the body in which the  head lies lower
than the thorax.  It is heard loudest in  an erect position,
and  during inspiration.   It was thought to  be connected
with anaemia, but has been  found as often in young and
healthy persons.
  Pericardial murmurs.   The inner surface of the pericardium
is normally smooth, and  the  heart moves within it without
causing any sound.  But when this surface becomes rough-
ened in consequence of inflammation and exudation,  we
hear friction-sound, wThich may closely resemble an endocar-
dial murmur.  We can generally distinguish between these
murmurs, for the internal murmurs correspond almost exactly
to the rhythm and the natural sounds of the heart, whilst
the friction-sounds seem to follow upon the movements of the
heart.   Should the friction-sound be short, we cannot dis-
tinguish it from an endocardial murmur.
  There is another friction-sound, caused  by a  roughened
condition of that portion of the pleura  which  covers  the
unattached portion of the pericardium.  It is produced by
the rubbing of this portion of the pleura against the lungs
or thoracic walls.  Being caused by the action of the heart,
it exactly coincides with its  rhythm, and cannot be distin-
guished from endocardial murmurs.   The  previous history
of the disease and the result  of appropriate  treatment can
only settle the question. 
LECTURE  III.
           FUNCTIONAL DISORDERS OF THE HEART.

Definition and various  Forms  of Disorder — Pathological Relations and
  Causes — Association with other Diseases — Symptoms, Physical Signs of—
  Diagnosis — Prognosis — Treatment — Cases.

  Gentlemen :  I propose to take up the  Diseases of the
Heart in the following order : (1)  Functional.  (2) Inflam-
matory.  (3) Organic.   This lecture will treat of Functional
Disorders of the Heart.
  A purely functional disorder of the heart is any disturbed
action  occurring independently  of either inflammatory  or
organic affection.    These affections may  be  attended by
more or less functional  disorder, but there are many cases
where the  latter are unattended by any lesion or inflamma-
tion.
  In most cases, the  disturbed action of the heart is evidently
due  to  morbid  conditions seated  elsewhere, but it may  be
symptomatic of either  blood-changes,  or affections  of the
nervous system, or of both.
  It must be borne in mind that disordered function of the
heart, in cases of inflammatory or organic affections, involves
the same morbid conditions which often exist independently
of these affections.
  The subject of functional disorder of the heart is of great
practical importance, on account of the frequency of  its
occurrence, the anxiety which it occasions, and the liability
of confounding it with organic disease.
  The majority of persons who complain of symptoms refer-
able to the heart, suffer  from functional disease only.  But
the discrimination of functional from organic affections can
only be made by one who is thoroughly acquainted with the
subject.  The  great importance  of a  correct diagnosis is
obvious, when we  consider that  structural  lesions involve
more or less danger, while  functional  disorder,  although
very distressing, very rarely, if ever, proves serious. 
FUNCTIONAL  DISORDER OF THE  HEART.
43
  There are several varieties of functional disorder.  In the
mildest form the action of the heart is simply increased by
transient  exciting causes, such as mental emotions, unusual
exertions, etc., but this excited action is only transient.
  Persisting inordinate action is another form.  The heart may
act with  regular rhythm, but with abnormal rapidity and
force, not greatly influenced by exciting causes; and this
action may continue  for weeks and months.  The pulse, in
such  cases, ranges from  120  to  130 per minute,  and the
patient is in  a state of constant  anxiety,  fearing organic
heart disease.
  Paroxysms of irregular and tumultuous action is another form
of this disorder.   Such paroxysms often occur without any
obvious exciting cause, and the patient is attacked suddenly
with  violent beating of the heart, with  disturbed  rhythm.
A feeling of impending death is experienced,  with  great
terror and anxiety, which  increases the intensity of the
paroxysm.   The slightest  motion  increases  the anxiety
and palpitation.  {Digitalis.)
  The  attacks may occur at short intervals,  or only once in
a few wreeks; they may last but a few moments, or several
hours.  Such cases are frequently met  with  in hysterical
women, and are accompanied by various attendant symptoms.
Boullard calls this affection an " insanity of the heart," but it
has appeared to me to act more like a choreic affection, such
as we observe in muscles elsewhere.
  Another species of paroxysm is irregularity and  intermis-
sions,  without  increased force of the  heart's  action;   on the
contrary,  the action of the heart may be quite feeble.   Such
paroxysms inspire great terror.   The patient feels  as if the
slightest movement would cause death, from stoppage of the
heart's motion, or from syncope.  (Gelseminum.)
  It  must be  remembered  that some cases of mere inter-
mittency are  congenital,  and  are  of no importance  as a
symptom.
  In  other cases the pulse may intermit, but not the heart's
action.  This is termed a false intermission.  The  force of
the ventricular contraction is not  sufficient to  produce a
radical pulsation. 
44
DISEASES OF THE HEART.
    CAUSES AND  PATHOLOGICAL RELATIONS OF FUNCTIONAL
                 DISORDER OF THE  HEART.

  These may be enumerated  as  follows:  plethora, anaemia,
derangement of the nervous system, dyspepsia, and the gout?/
diathesis.
  Plethora is that condition in which the blood is abnormally
rich in red globules, and, perhaps, in excess as regards quan-
tity.   The  heart becomes  overtaxed and overstimulated,
and becomes morbidly irritable.   There is much violence
of action without much disturbance of rythm.  Palpitation
may be the first symptom that awakens the anxiety of the
patient, and concentrates his attention  on the heart.   He
becomes fearful of organic disease,  and  taxes the patience
of his medical  attendant to  a high  degree.   Those  who
suffer most  from this affection are men who leave the farm
or workshop, and men of previously active business pursuits,
who change their mode of  life  and become   luxurious,
indolent,  or lead sedentary lives.  Women who tend  to
obesity and live much indoors  are liable to this form  of
heart  disorder.
  Anazmia, or an opposite condition to the above, is more
frequently met with, and rarely occurs without more or less
disturbance of the heart's action.  Women are more subject
to this variety than men. Anaemia being produced  by excess-
ive loss of blood, or of any of the fluids of the body, the first
cause  may generally be located in some particular organ or
tissue.  It must be borne in mind that the heart disorder is
not always proportionate  to  the anaemia.  It may be slight
in cases of marked anaemia, and severe when that condition
is hardly appreciable.
  With the  anaemia, besides the  functional heart disorder,
we shall find coldness of the extremities, headache, neural-
gia, melancholy, irritability of temper, etc.  Anaemic patients,
with heart  symptoms,  live in  constant  dread of  organic
disease, and fear  of fatal results.  If the physician trusts
altogether  to symptomatic phenomena,  he may  have  the
same fear of serious results in his patient, for  in these cases
palpitation is excited by the slightest exertion ;  dyspnoea is
experienced, the countenance is morbid, and occasionally 
CAUSES OF FUNCTIONAL DISORDER.           45
dropsy sets in, which may be mistaken for the dropsy caused
by organic disease.
  Derangements of the nervous system may be a cause of func-
tional disorder of the heart, without the presence of anaemia.
Cases of hysterical  palpitation come under this  head,  foi
hysteria often occurs without anaemia, but with plethora.
  A condition of the nervous system favorable to functional
disorder is said  to be caused by masturbation and  venereal
excesses.   Uterine disorders  are a prolific cause.   The  ex-
cessive  use of tobacco,  green  tea, and  coffee often induce
a condition giving rise to functional  disorder of the heart.
  Whatever may be  the causes  of  this  condition, mental
depression is a constant attendant (in marked contrast  to
chronic pulmonary affection).   The patient persists in believ-
ing that he has  organic disease, in spite of our most earnest
assurances.  He watches the action  of the  heart with con-
stant anxiety, and habitually counts his pulse, and  feels  for
the  beating  of  the  heart, and lives  in such a morbid state,
mentally, that the condition of the heart is  actually aggra-
vated by his constant dread and apprehension.
  Dyspepsia, in  its various forms, tends directly to cause this
disorder,  but as  many  dyspeptic  ailments proceed  from
derangement of the nervous system—and this often induced
by mental  distress or anxiety—it is often  difficult to separate
this cause from those  gastric affections proceeding from
indigestion or hepatic derangement.
  Dyspeptic patients with  heart disorder are equally prone
to magnify it into a dangerous complaint.  They watch the
pulse and the beating  of the heart, and are  in  dread of
sudden death, such as they have heard of in organic disease.
It is notorious that this morbid watching for heart-symptoms,
and the anxious  expectations of finding heart disease,  is
actually sufficient, in some cases, to  produce the functional
variety.   The presence of gas in  the stomach, even when
dyspeptic  symptoms are not  present, often causes  severe
attacks of palpitation.  In such  cases,  the  expulsion of a
quantity of  wind  by  belching often  puts an end to the
distressing paroxysm.
   The gouty diathesis gives a liability to  functional  derange-
ment of the  heart's  action.  Attacks of palpitation occur in 
4(3
DISEASES OF THE  HEART.
such persons before the joints are affected, and cease when
tumefaction is present.  The presence of an undue quantity
of lithic acid in the blood is  supposed to be a cause—acting
as an irritant to the nerves which control cardiac action.
  Other causes of functional disorders have been noticed by
clinical observers.   It occurs during convalescence from
fevers.   Deformities of the chest seem to favor it.   Young
persons whose growth is rapid are liable to it.  Excess in
muscular exercise induces it.  Soldiers in the late civil  war
were affected with it, probably caused by the excitement  and
muscular exhaustion incident to their life.

        FROM WHENCE  COMES  CARDIAC INNERVATION?

  This  is an interesting question, both in its pathological
and therapeutic relations.  Barthez* says wTe  must make a
distinction between the  radical and the  acting forces gov-
erning  the heart.   The former may be nearly  exhausted,
while the latter are in  full play;  and, vice versa, the latter
may be but slightly manifested, while the former are  power-
ful.  The  amount  of radical forces  represents a  person's
capacity of vital  resistance  to  disease and  fatigue.  The
acting forces have their  origin in the radical.  In cases of
functional disorder wTe have  hyperaesthesia  from debility, or
a morbid stimulus may be reflected from the nervous centres
on the cardiac nerves.
  According to Bezold, the nervous centre of the cardiac
movements furnishing three-fourths of the entire propulsive
power of the heart, occupies the cervical region of the cord,
including the medulla oblongata, and extends as low as the fourth
dorsal vertebra.  Its fibres  run through  the cervical  spinal
cord, and pass out between  the seventh cervical and fifth
dorsal vertebra, probably passing through the lower cervical
and upper dorsal sympathetic ganglia, and proceeding to  the
heart.
  The innervation of the heart is derived, in part, from  the
ganglionic or sympathetic  system,  and  partly from  the
pneumogastric  nerves.  For its  active force  the  heart is
dependent on the cardiac ganglions and the plexus of nerves
* Traits de Therapeut., vol. 1, p. 43, par Trousseau and Pidoux. 
         PHYSICAL SIGNS OF FUNCTIONAL  DISORDER.       47

with which they are connected.   The  function of the pneu-
mogastrics is to  regulate  its  action.   The  latter presides
especially over the rhythm of the heart's movements.  Mor-
bific agencies giving  rise to functional  disorder may affect
separately these  two sources of the innervation of the heart.
Most of the causes of functional disorder probably act pri-
marily upon the nervous centres, but in some cases, as when
the disorder depends  on dyspepsia, or  uterine irritation, the
morbid influence is transmitted to the nervous centre, and
reflected upon the  heart.   Very  many  cases  of functional
disorder of the heart are doubtless reflex in character. If we
could decide, by accurate investigation, the particular nerves
upon which medicines act  pathogenetically,  our  knowledge
of the curative  powers of remedies would  be much more
certain.

         PHYSICAL SIGNS OF FUNCTIONAL DISORDER.

  Physical exploration by means of auscultation, percussion,
and palpation,  is of  immense value in  functional disorder
of the heart,  as showing the absence of  the  signs of  inflam-
matory and organic affections.   The  information  which it
affords  is not less positive than if  there were certain signs
peculiar to functional disorder.
  In our examination of the  heart  in cases of  supposed
functional disorder, we have to decide, first, as to the absence
of abnormal phenomena denoting structural changes; and
second, as to the presence of the  normal phenomena denoting
soundness of the organ.
  By percussion Ave  can  ascertain  that the  heart  is  not
enlarged, and, if not enlarged, that  the  disorder is quite
certain to be functional.  But we cannot, on  the other hand,
decide that the disorder is not functional because the heart is
enlarged, for functional disorder may supervene  upon,  or
coincide with enlargement.
  Palpation  enables us  to ascertain the  force of  the  heart's
action.   The movements and the irregular action are readily
appreciated by the hand.   We can discriminate between the
increased and disturbed action due to morbid  excitement, and
the augmented  power due to hypertrophy.  The  impulse in 
48
DISEASES OF THE HEART.
hypertrophy denotes strength rather than force; it is  not
quick and violent, but sluggish and strong; it does not give
the sensation of a shock  or blow, but it causes a  gradual
and strong heaving of the praecordia.
  Palpation  also  shows  that  in  functional  disorder  not
attended by structural disease, the point  of apex-beat is in
its normal  situation;  not  elevated, as  in pericarditis with
effusion, nor lowered and carried to the left, as in  cases of
enlargement of the left ventricle.
  Auscultation is  important  in two  wTays, first, by showing
the absence  of abnormal sounds indicating valvular  lesions;
second,  showing  that the  natural  sounds  preserve their
essential characters and normal relations to each other.
  Endocordial  murmurs  are very rarely heard, if  ever, in
purely functional disorder.  A venous murmur, or hum, in
the veins of the  neck may be heard  in  persons in health,
and the anaemic  murmur may be diagnosed by the general
condition of the patient.  Aside from  these  two murmurs,
it  is not of practical  importance whether  a  murmur  be
organic or  inorganic, so far  as  relates  to  the treatment  of
functional  disorder.   Valvular lesions  do not cause notable
disturbance of the heart's action prior to enlargement.   If
therefore enlargement is  not present,  the disturbed action
of the heart may be considered as functional.
  It must be borne in mind  that all the normal heart sounds
are intensified by the increased action present in functional
disorder.  So  distinct do they become,  that they  may  be
perceived by the patient, especially at night.   But  if their
sounds are  only intensified, and not changed, we may know
that functional  disorder only exists.

                       DIAGNOSIS.

  In order  to make a correct diagnosis, we must first deter-
mine whether organic disease be or  be not present; second
if organic disease be present,  to  determine  whether super-
added functional  disorder be not  the source of more or less
of the  symptoms  referable to the heart.
  It is  in  this case as in tubercular  phthisis, that we  can
sometimes  decide from the mental condition  of the  patient. 
DIAGNOSIS.
49
It is well known that persons affected with tuberculosis are
cheerful, and do not appreciate the gravity of the disease,
while in those pulmonary disorders not dangerous they are
despondent and foreboding.
  In functional cardiac disorder, the patient is very anxious
and apprehensive, while in  purely organic disease  no such
degree of anxiety is manifested; on the  contrary, they are
often  apathetic on the subject.
  Again, the same or a greater amount of disturbance, when
present in  organic  disease of the heart,  causes much less
anxiety than when arising from functional disorder.
  The paroxysmal character of functional disorder is quite
in contrast writh the continued  persistency of the  symptoms
of organic  lesions.
  In  functional disorder active exercise  does  not generally
aggravate the symptoms, it sometimes alleviates them, while
in organic  disease the contrary obtains.
  There are certain symptomatic conditions belonging espe-
cially to organic disease, that are absent  in  pure  functional
disorder.  Among these are general dropsy, lividity, haemop-
tysis,  paralysis from  embolism. They  may  coexist  with
functional  disorder, but are not caused by it.
  Cardiac  disturbance  is probably functional  if it be con-
nected with plethora, anaemia, derangement of the nervous
system from excessive venery, mental anxiety, the abuse  of
tobacco, tea, coffee, or with gout.
  Organic  disease, on the other hand, in  the majority of
cases originates in acute  rheumatism.   If the patient has
never had the  latter affection, the probability is that the
disorder is functional.
  Functional  disorder  occurs  especially  in  the  young,
between puberty and middle life.
  Organic  disease is oftener  present in persons past the
meridian.
  Functional disorder is  oftener present  in  females than
males, while the reverse occurs in organic disease.
  Functional disorder  is worse at night;  organic disease
during the day.
  We should not, however, venture an opinion as to the
presence or  absence  of functional disorder, until wre have 
50
DISEASES OF THE  HEART.
made a physical examination.  This, and  this only, should
decide us in forming a diagnosis.

                        PROGNOSIS.

  The  prognosis  in  cases  of uncomplicated  functional
disorder is always favorable.  The  opinion  that it may lead
to organic  lesions  has  been  disproved.   We  may  safely
assure our patients that if a recovery does  not occur, no
organic disease need be apprehended.

    TREATMENT OF FUNCTIONAL DISORDER OF THE HEART.

  The therapeutics of  functional disorder  of  the  heart
include:
  I.   Relief of disturbed action when present,  or palliative
measures.
  II.   Removal of the  morbid  irritability of the  heart, or
the causes of such irritability.  These are  the true curative
measures
  Palliative measures are those which will allay any temporary
excitement or disturbed action.
  The mildest form of the disorder, when it arises from a
fright, or  undue exercise, usually need only rest of mind and
body to allay it.  A single dose of aconite may be of service.
  For  the attacks of palpitation, irregular  and intermitting
action, weakness  or  syncope, the following  remedies will be
found appropriate:
  For  paroxysms of palpitation from physical  excitement,
mental emotion,  etc., a single dose of aconite will  suffice if
it has  been caused  by fright; coffea if from  excessive joy;
ignatia  if  from sudden grief;  and Scutellaria if from inordi-
nate excitement of other kinds.
  For paroxysms of tumultuous and irregular beating of the
heart,  with violent  impulse, the chief  remedy is  veratrum
viride, in doses .of one drop of  the tincture every hour or
oftener; a few doses will quiet  the excitement.  Such par-
oxysms usually occur in plethoric subjects.  In similar cases
cactus is often  indicated, also aconite, arsenicum,  belladonna
cocculus, lachesis, naja, and spigelia.
  For  paroxysms characterized by irregularity and inter- 
TREATMENT.                      51
missions, with feeble  action or  impulse, another  class of
remedies  is  indicated,  namely:  digitalis,  cannabis  ind.,
laurocerasus, acidum hydrocyanic urn, arsenicum, veratrum album,
and aconite.
  Paroxysms  of  tremulous agitation  of the  heart call  for
nearly the same remedies, but the attacks are  generally of
such brief duration, that there is no time for the administra-
tion of medicines.
  Hysterical palpitations or disturbed  action, require the
use  of ambra, assafcetida, camphor, castoreum, crocus, ignatia,
lilium, sumhul, Scutellaria, and Valeriana.
  In actual cardiac syncope, the use of  active stimulation is
necessary.  Brandj,  or any alcholic liquor may be used, or
camphor, xanihoxylum  and  ammonia,  aided by the mustard
foot bath.  The  recumbent posture is  absolutely  necessary
until the attack is over.
  [For special or characteristic  indications for  the selection
of remedies consult the symptomatology given in this work.]

             RADICAL  OR  CURATIVE TREATMENT.

  Plethora should  be treated by means of appropriate diet,
namely:  the abstinence from  rich  and  stimulating food,
coffee, pastry, and  the avoidance of a sedentary life.  Small
meals and a large amount of active exercise are the principal
curative agents.
  The administration of veratrum viride in doses of five drops
of the first decimal dilution three times a day,  will  aid in
effecting a removal  of  the  plethoric  condition.  Equally
efficacious is  the bromide of ammonium  in five  or ten grain
doses of the first decimal trituration, taken after each meal.
  Ancemia should be  met by such remedies as will increase
the proportion of red globules in the blood,  and the use of
such articles of  diet  as will  bring about  the  same  result.
Active exercise  in the open air, and  a  residence in  non-
malarious localities, should be advised.
  Ferrum, in  some form, is here the principal remedy; but
it must  be borne  in mind that iron is not the remedy in all
cases  of anaemia.  It  will not remove anaemia  caused by
distressing emotions,  nor the anaemia growing out of some 
52
DISEASES OF THE  HEART.
morbid dyspasia.  It is  only useful in  cases  arising  from
some fault in assimilation  or abnormal  condition of the
vegetative system.  Various preparations of iron have  been
found useful.   Fcrrum met. in the lowest triturations is gen-
erally useful;  but if  this does not have  the desired result,
and iron seems to be  strongly indicated,  select the lactate of
iron, murialed tincture  of iron, phosphate of iron,  iodide of iron,
or the  citrate of iron and strychnia.
   The  hypophosphites of lime, soda, or potassa,  phosphoric, or
hypophosphoric  acid, act promptly if the  anaemia arise  from
nervous prostration or prolonged nervous excitement.
   China is indispensable if the anaemia  is  the result of
haemorrhages,  or loss of  any of the  vital  secretions of the
body.  Helonias, hydrastis, phosphoric acid, and arsenicum are
indicated in similar conditions.
   Cuprum is, according to Grauvogl, superior to iron in many
cases of anaemia.
   Nux  vomica, ignatia, and  strychnia  are  indispensable  in
certain anaemic conditions, when the blood is  impoverished
from deficient  vitality of  the nervous centres.
   When derangement of the nervous  system  causes  func-
tional heart-disorder, nux, ignatia, secale,  phosphorus, cuprum,
digitalis, phosphoric acid,  and similarly acting medicines are
to be used.  The bromide of potassa and zinc will be  found
useful  in many cases.
   When the cardiac  irritation is reflex, wTe must select:
   For   gastric  disturbance — nux  vomica,  pidsatilla,  ignatia,
collinsonia, lycopodium, iris ver., hydrastis,  etc.
   Collinsonia is very highly recommended by many promi-
nent physicians  of  the  eclectic  school  of medicine,  as an
excellent remedy in purely functional disorder of the heart,
when  its action is  persistently rapid, but  weak, or when  there
is excessive action with  deficient force.  It has been  given
successfully in doses  of 5 to 15 drops of the tincture several
times  a day.  The  pathological conditions to  which it is
homoeopathic cannot be clearly defined because the  provings
do not yet indicate its specific action on the heart.  But from
its known curative action  in cough, hcemoptysis, haemorrhoids
and constipation, we may consider its action on the heart as 
TREATMENT.
53
reflex.  My experience confirms the recommendation of its
use in some cases of functional disorder.
  For uterine disturbance—cimicifuga, pnlsatilla, plalina, lilium,
sepia, gelsennnum, nux moschata, sanguinaria, etc.
  The  following is one  of the many notable cases of func-
tional disorder of the heart resulting from uterine disease,
which have come under my observation:
  Case.—A lady, mother of two children, had suffered for
several years from retroversion, abrasion of the os uteri, and
a great variety of anomalous pelvic pains peculiar  to  such
cases.  About a year ago the uterus was replaced, and a
ring pessary  inserted,  which  kept the  uterus  in  normal
position, and soon after the leucorrhoea and  uterine pains
disappeared.   But she soon began to complain of rapid and
persisting beating  of the heart—worse  at the menstrual
period—which increased to  such  a degree that I was con-
sulted.  Neither auscultation nor percussion  revealed  any-
thing abnormal, except an  increased clearness of the sounds
of the heart.  The force of the heart's action was decidedly
increased.  The  pulse was generally regular—120 to 130—
but  sometimes  irregular and  intermitting.   The menses,
heretofore normal in amount, became scanty, and a condition
of prostration set in, accompanied  by emaciation.   All the
cardiac remedies in our materia medica were consulted  and
tried,  but without other   than palliative  benefit.  (Nux
moschata  helped her most.)  The  bromide of potassa and
hydrate of chloral gave no permanent relief.  A few weeks
ago she was attacked by the prevailing influenza, and came
near having pneumonia, but it was  arrested by the free use
of veratrum vir.   A severe  cough, which called for sanguin-
aria, led me to give that  remedy.  On the day after,  she
said, "Doctor, something has stopped  my heart for the first
time in a year."   To  my surprise,  I found it beating regu-
larly, quietly, at  72 per minute.  Did the sanguinaria cause
this curative action ?  I do  not know.   Her menses came on
the day I gave the sanguinaria, and more profuse than usual,
and she now began to complain of her old uterine symptoms.
On examination  the uterus was found retroverted—the  ring
pessary appearing too small to support it in proper position
—and  the presence of cervical inflammation was detected. 
54
DISEASES OF THE  HEART.
A larger ring was introduced, lilium and sepia given>  but
the heart still beats normally.  I  think the irritation was
transferred  or reflected from  the  uterus to the  heart and
has now returned  to  the former  organ.  What part  the
sanguinaria played in  this case  I do not know, but imagine
it may have assisted in the transferrence.

  Among the palliative  remedies in this cardiac disorder,
the chloral hydrate bids fair to become useful.  Physicians of
other schools speak highly  of it  in such cases.   Its well-
known  power  over nervous aberrations, whether  local  or
reflex, appears to recommend it as  a valuable agent.  One of
my patients, whose heart kept her awake, night after night,
for months,  got no  sleep from any remedy until she took the
chloral —15 grains at bedtime.   Under  this  remedy  she
improved decidedly in strength and appetite,  and  specific
remedies appeared  to have a better and more lasting effect
in bringing  about a cure.

  Nux moschata has had  a reputation for centuries in heart
disorders of a nervous character.   The  symptoms given in
Dr. Hering's very complete pathogenesis, prove it to have a
decided  influence on  that organ.   Among the most prom-
inent symptoms are—quivering, trembling, fluttering, and violent
palpitation, labored beating of the  heart,—" a fearful embarrass-
meiit.'"  It is  asserted  to be curative in cases arising from
fear, fright, grief, stoppage of urine, ucerine troubles, men-
strual difficulties.  I do  not  hesitate to advise it in cardiac
debility,  with the symptoms above enumerated, especially in
delicate, nervous women given to fainting, or  sensitive to
the slightest emotion,  and when the cardiac irritation alter-
nates with  uterine or vesical disorder,  or  even  gastric
troubles.  Give the 3rd or 6th trituration.
  Primus virginiana (wild cherry) has long held a high repu-
tation in abnormal  conditions of the heart characterised  by
irregular, intermitting, and feeble  action.  It will be found most
useful when the disorder is purely functional, but it has been
used with excellent  results as a palliative in structural disease.
The usual method  of administration is  in  the .form of cold
infusion.  One ounce of the inner bark (fresh, if procurable) 
TREATMENT.
55
in a quart of cold water.   After standing six hours, it may
be  prescribed  in wine-glassful doses every  three  or four
hours, until there is a decided improvement.   It is  a safe
and simple remedy,  giving tone to  the general system, and
improving the condition  of the circulation.  It is  a  feeble
analogue of digitalis.
   Lycopus virginicus*  has some reputation  for conditions
similar to those for which primus is recommended, but from
the testimony adduced for it I think it resembles aconite rather
than digitalis, and is better indicated where  the pulse and
heart's action  is rapid, but  rather  hard, with  or without
irregularity.   From some of the symptoms of the proving, as
well as the results of clinical experience, it promises to  be
useful  in that  disorder known   as  " exophthalmos," —
"Basedow's Disease "— " Grave's disease," etc.  According
to Flint, functional disorder may end in this condition.  The
lycopus may have  the power  of  warding off such  result.
Prescribe it in lowest dilutions or mother tincture.
*New Remedies, p. 705. 
LECTURE  IV.
                    ANGINA  PECTORIS.

Nature of the Disease —Symptoms —Pathology — Pathological Relations —
  Its  Frequency —Prognosis—Cause  of sudden  death in — Diagnosis—
  Treatment.

  Gentlemen:  Of all affections of  the heart this is  the
most painful  and distressing.  While some authorities —
among  whom  is  Dr. Watson—would  place this disorder
among the organic diseases, the majority consider it  a func-
tional disease.  Watson thinks it is not a neuralgia, because
the  paroxysms are excited by bodily exertion  and  mental
emotion, and  because it is so frequently and suddenly fatal.
But Dr. C. Handheld Jones  disposes of this by citing the
commonly observed  fact  that  many  of the neuralgiae are
excited and aggravated  oy similar  causes.  Dr. Jones, after
summing up the opinions of various authors, expresses him-
self in these words, " It is thus  invariably a  neuralgia,
whose sole and constant seat is  in the cardiac plexus."*
  This affection is  characterized  by paroxysms  of intense
pain, emanating from the region of the heart, and extending
in various directions, often into the left shoulder and down
the  arm,  accompanied by indescribable anguish, a sense of
suffocation, and a feeling of impending death.   The pain
radiates into  both sides of the chest, into the back, upper
extremities—generally the left—and sometimes extends into
the  lower extremities.  The pain in the  upper  extremity
does not always extend to the hand, sometimes  it  ends  at
the  shoulder,  at other times in the elbow, and the pain is
occasionally felt  only in the forearm.   It  commonly seems
to follow the course  of the nerves, and is  felt all over the
affected extremity, even to the ends of the  fingers.
   The pain is attended by a  feeling of numbness,  or as if the
* On Nervous Disorders, p. 212. 
ANGINA  PECTORIS.
57
limb was paralyzed.  A rare symptom is pain and numbnew
in the testicles.  Hyperaesthesia, or  tenderness, where the
pain is felt, has been observed.
  This is one of the affections  that are purely paroxysmal,
a strong proof of its neuralgic nature.  The patient is seized
suddenly, often  during  motion,  as walking  up-hill,  or
against a strong wind, or when quickly turning in bed.
  From the first instant of attack all  motion seems impos-
sible. He seizes hold of some firm support, or fixes himself
in some way immovable, until the paroxysm passes off.
  Besides the  pain, the  feeling of suffocation  alarms the
patient, and he  feels as if death was impending.  Dyspnoea
is not always present, but the breathing is often suspended
for an instant, or restrained by an act of the will, for fear of
increasing the pain, but  the ability to expand the chest and
breathe regularly is not impaired.   Speaking is often impos-
sible, or difficult, as it seems to aggravate the pain.
  Palpitation is often present;  the action  of the heart, in
some instances, intermitting and irregular;  the pulse strong
or feeble, and sometimes very slow.  The countenance is pale
and expresses terror, anxiety, and distress;  a death-like com-
plexion and haggard  features suddenly taking the  place of
an appearance  of health.  Lividity is sometimes  observed.
The  surface is cold and bathed in cold sweat.  The faculties
of the mind remain unaffected or nearly so.  After an attack
a sense of prostration is  present, and sometimes, as after
other nervous attacks, a free secretion  of pale limpid urine.
  The paroxysms differ in the frequency of their occurrence,
duration, severity, etc.
  They may recur every few hours,  days, or weeks, and often
years may elapse between them.  They are sometimes very
mild at first, and afterwards increase in severity; or the first
may be very severe.   They  may last for a  few moments or
seconds, or continue several hours.  They will often subside
as suddenly as they commenced;  at other times  the relief is
gradual.
  You must not get the idea that they only occur after some
physical or mental excitement, for they often occur at night,
during sleep.   I have known persons who were thus affected,
rendered so fearful of going to sleep  as to  make life almost 
58
DISEASES OF THE  HEART.
insupportable.   In one case a fearful dream  seemed  to the
patient to be the- exciting cause.
  You will naturally inquire what is the pathological character
of this affection, also its pathological relations.  As I  have
said,  I believe the affection is generally a form of neuralgia.
The  character  of  the pain   proves  this.   It has   been
ascribed to spasm, but a spasm  of the heart,  lasting as  long
as  an ordinary paroxysm  of  angina, would destroy  life;
besides, the heart's action is seldom, if ever, arrested.
  The pathological relations of angina are interesting.  Flint
says,  "It involves, in a large proportion of cases, the exist-
ence of some organic affection of the heart and  aorta," and
adds that the lesions found  " do not agree invariably in any
appreciable morbid alterations." Valvular lesions may  be
present or  wanting.   Calcification of the coronary arteries is
sometimes present.  Fatty degeneration has  been observed.
It has been asserted that a " weakened heart" is essential to
the presence of  the disorder, but this theory is disputed  by
both Flint and  Jones.   While  I do not believe that a weak
heart is a necessary condition,  it is  more than probable that
a condition is often present which  is similar  to myalgia else-
where in the body.   In other  words,  cardiac myalgia may
simulate, or coexist with, angina.
  As before remarked, angina pectoris is a  very rare affec-
tion.   In 338 cases of organic  disease of the heart, Flint
found it to exist in 15 only.  That it occurs more frequently
with than without organic disease seems proven.
  The causes of this disorder  are  at best obscure.   It has
been  supposed to arise from the rheumatic or gouty diathesis,
but this supposition is not tenable.   Nor  can it  be said to
■arise  from  dyspepsia.  Trousseau  considers  angina a form
•of epilepsy, but this seems to me only a fanciful idea.
  It occurs much oftener in males than in females, and in
the majority of cases  occurs  after the age of fifty.  But
cases have been observed in youth, and even in infancy.

                        PROGNOSIS.

  The prognosis will depend largely on the condition  of the
heart.  If  that organ, or the aorta,  is in a state of structural 
TREATMENT.
59
disease, the prognosis is far  more unfavorable than if the
disorder is purely functional in character.  If organic disease
is present, you cannot assure the patient of exemption  from
their recurrence, while, if  not connected with  lesions, years
may elapse before another paroxysm occurs.
  Paroxysms of angina  sometimes cause  sudden death.  In
such instances,  " the action of the heart is  arrested  by a
morbid  agency affecting   it through the pneumogastric
nerves, in the manner  in which irritation of these nerves,
or the electrical currents, produces this effect in experimental
observations."   (Flint.)
  The danger is in proportion as the action of the  heart is
feeble, irregular, or retarded  during the paroxysm.  But if the
action of  the heart  be  but little, or not at  all disturbed
during the paroxysm,  there will  be but small danger of
sudden death.  Sudden death will oftener occur when organic
disease is  present,  than  when  the disorder  is purely
functional.  Even if organic disease  is  present, judicious
homoeopathic treatment  often cures, and generally cures the
purely neuralgic.
  The diagnosis of this  disease is generally easy.   I do not
see how the paroxysms can  be  confounded with attacks of
dyspnoea, or so-called  cardiac  asthma,  for with the  latter
motion is  not incompatible, pain is rarely present, they do
not occur abruptly, and there is not the same fear of  impend-
ing death.
  There is a pseudo angina occurring in hysterical, anaemic,
or dyspeptic persons.  The misnamed cardialgia may some-
times simulate angina, and I have known  the  pain  under the
left breast, occurring in women, to be so severe as to resemble
that  disorder.   Intercostal  neuralgia  and   myalgia  may
closely imitate it; but the tenderness on pressure, which is so
diagnostic of the former, is rarely present in angina  pectoris.

                        TREATMENT.

  The  treatment of this distressing disorder embraces:
  1. Remedies which will  diminish the severity and shorten
the duration of the paroxysms. 
60
DISEASES OF THE HEART.
  2. Such  treatment in the intervals  as  will  postpone or
prevent the recurrence of the paroxysms.
  It is  a difficult matter, as you will  find, to treat a single
paroxysm.   It  is  generally of such short duration  that no
remedy can be selected and given before the brief "reign of
terror" is over.
  But in those instances in which the paroxysm is of longer
duration,  you  should do your best  to allay  the  terrible
distress.   A firm and reliant demeanor on  your part—assur-
ing the patient  that he will not die—is of much service, for
the deadly  fear,  added  to  the pain,  may be  a source of
danger  to  the  patient.  There is some reliable testimony
that a dose of arsenicum, 30th,  has shortened the paroxysm.
The same has been asserted of lachesis, 30th.
  Certainly these  remedies,  if any, will act with sufficient
rapidity, and are generally indicated in the severer forms.
  If the action of the heart is very irregular and feeble, and
there is a tendency to, or actual fainting, you should resort
to the diffusible stimulants, such as brandy, or any  kind of
spirits which you can  immediately procure,  or, what is
sometimes  better, ammonium carb., a few  grains, dissolved
in milk and water. A prompt  resort to stimulants may save
the patient's life, and ward off sudden and fatal syncope and
cardiac paralysis.
  If, however, the tendency to faint continues,  and the pulse
is very feeble,  slow, irregular, or  intermitting, digitalis is
the appropriate remedy, and should be  given  in doses of 5
or 10 drops of the first dilution, repeated every 15 minutes.
Watch  the pulse,  and suspend the medicine so soon  as it
becomes normal   in  force  and frequency.  Digitaline,  3rd
trituration, may be substituted for the tincture.
  If, with the general prostration, the skin becomes suddenly
very cold and clammy, and cramps of the extremities set in,
give veratrum album in the 6th dilution, frequently repeated.
  If the pain is so severe as to predominate over all the
other symptoms, and  the action of the heart is  not  notably
depressed, you  may resort to the inhalation of ether.   In a
case which occurred in my practice several years ago, ether
always gave relief in  a  few minutes.   Chloroform  may be
used if more readily obtainable.  It has one advantage,  that 
TREATMENT.
61
it acts more quickly,  but it  should be used with  extreme
caution.  If half a drachm or a drachm does not give relief
it should not  be tried further.   The hydrate of chloral acts
very quickly,  and a dose of ten or fifteen grains may prove
a safe and efficient palliative remedy, used for the same con-
ditions as ether and chloroform.  Never give opium, or any
of its alkaloids; they do not act quickly enough  to palliate,
and are useless as curative agents.
  It has been found that electrization of the skin in  the prae-
cordial region is remarkably  effective, both in arresting the
paroxysms and postponing their occurrence.  It is probable
that with  the  great  advancements  made  in electro-thera-
peutics, some method of application will be discovered that
will result in a more certain curative treatment than we now
possess.

  Swallowing  pieces of ice  has been  found an  effective
measure by Romberg. The application of mustard over the
region of the  heart may be  of benefit.   Dry  cupping and
the hot foot-bath should  not be forgotten.
  You should  never be at  a  loss for expedients in the treat-
ment of such  disorders.  Anxious friends are too impatient
to wait until  you have  tried to  question the sufferer, for
every moment seems an  hour to both, and  unless  you do
something very quickly,  their criticisms will be anything but
complimentary.  Not only should you be quick  to act, but
you should inform  the  attendants just what to do if the
paroxysms return, and  supply  them with  the appropriate
remedy for such emergencies.  It is seldom that a physician
can be procured before  the  paroxysm  has  passed; for this
reason it is  your duty to anticipate the treatment.  I will
add that you will  find  it  difficult  to decide whether your
treatment  has really mitigated or shortened  the paroxysms,
for they vary so much as to intensity and duration.  Finally,
you must  caution them against exciting causes,  namely:
strong mental excitement, violent muscular exercise, excesses
in  eating  and  drinking,  walking against  the wind, or
climbing heights. 
62
DISEASES OF THE  HEART.
   For  the radical  treatment of angina pectoris  the  best
 remedies are arsenicum, digitalis, lachesis, naja, rhus, aconite,
 spigela, cimicifuga, and phytolacca.
   Arsenicum is probably the most  reliable remedy for the
 eradication of  the disorder.   Hartman says,  "Not only the
 actual  paroxysms,   but the  disease,  generally  finds  in
 arsenicum its  appropriate remedy, provided  the disorder is
 not complicated with  structural changes  of the heart and
 the large  arteries, or other extensive disorganizations.  It
 is indicated if the patient can only breathe very gently, with
 his chest stooping forward, and if the least motion causes a
 complete loss  of breath; if oppression and  stitches in the
 praecordial  region are associated with anxiety and a fainting
 sort of weakness; if the breath gives  out even while the
 patient is getting out of bed, and it takes him a long  time
 to recover his  breath; or if the paroxysm is excited  by  a
 simple change  of position  in bed."   To these indications  I
 will add, that arsenicum is  especially indicated in angina
 with regularly recurring paroxysms,  as sometimes occurs in
 malarious  districts.    In these cases, if  the  30th does not
 prevent  the recurrence of  the  paroxysms,  use the lower
 dilutions.  The dose should be repeated two or three times
 a day.
   Digitalis and digitaline come next  in importance. Baehr
 asserts  that he  cured  a case with digitaline, 2nd  and  3rd
 trituration, " not very often  repeated."   The symptoms and
 therapeutic range of the drug correspond with the disease,
 whether it be  a pure neurosis or  accompanying organic
 disease of the heart.  In cases of angina pectoris indicating
 digitalis,  abnormal action and  a sense of  oppression,  with
 tendency of syncope, are predominant.   The  pulsations are
 irregular and feeble, or spasmodic,  and cause anguish and
 pains under the sternum and below the ribs of the right
 side.  The pain extends to the head  and left  arm.  Vertigo
 and fainting,  and   feeble,  irregular  pulse   are  generally
 present.
  I advise you  to use the 1st dilution, or  a  few drops of the
 tincture of digitalis, in a half-glass of water, and  repeat the
 dose as often as every six hours between the paroxysms.  If
you  use  digitalin use the pure alkaloid (not Keith's or  any 
TREATMENT.
63
other inefficient article),  in  the 1st centesimal or the  3rd
decimal trituration.
  You will find lachesis and naja useful when the pain and
dyspnoea are  concomitants of organic disease of the heart,
and  are attended  by  irritation  of the  glosso-pharyngeal
nerves,  causing distressing sensation of choking, constric-
tion, or " rising " in the throat, and inability to speak.  Use
the 200th, and repeat not oftener than every 12 hours.
  Aconite will prove an excellent remedy in your hands if
your  cases are  marked by intense anxiety, fear of death,
coldness, and  cold sweat,  feeble pulse,  and  intense pain  in
all directions, and general or local  numbness and tingling.
It is indicated  in pure neuralgic cases, and should be used
in the lower dilutions.
  Spigelia has been used with good results, when there are
severe stabbing stitches in the heart at every beat; pain and
palpitation, aggravated by bending forward,  touchiug  the
stomach, lifting the arms, or any other motion.   It is useful
in the purely neuralgic,  and  also cases of  organic disease.
The 6th dilution is to be preferred.
  Rhus tox. is indicated in patients of a rheumatic diathesis
—when the symptoms occur with or without organic disease.
The characteristic indications for its use are, stitches in the heart,
with painful  lameness and stiffness of the whole  body and
extremities, and pain extending down the  left arm.   A  case
having these  symptoms, also  " hypertrophy with dilatation,
paleness, and  weakness;  pulse soft, slow—48 per minute ;
coldness and numbness of left  arm; pain worse every morn-
ing at 4 o'clock; a faint, fluttering sensation in stomach and
left chest;  gurgling in  region of heart;  soreness throughout
left side; lying  on left  side brings on severe palpitation and
pain in region  of the  heart," is reported as cured  by the
200th of this remedy.
  Phytolacca will be indicated in those cases where the pain
extends to the right arm.
  I once cured  a  case with cimicifuga,*  1st dil.   The pains
were sharp, lancinating, and extended all over the left chest,
* See New Remedies, p. 234. 
64               DISEASES OF THE  HEART.

down the left arm, and into the back, with dyspnaea, uncon-
sciousness, etc.
  If the remedies I have mentioned fail  to cure, do not be
discouraged, but  try the valerianate of  zinc, laurocerasus,
cuprum, crotalus, arnica, and cactus,  which last may prove to
be an  excellent remedy in this disorder, when  its peculiar
characteristic symptoms are present.*
* Seo New Remedies. 
PART IT.
INFLAMMATORY AFFECTIONS OF THE HEART 
 
LECTURE  V.
  Gentlemen :  I shall call your attention in this and follow-
ing lectures to the

        INFLAMMATORY AFFECTIONS OF THE HEART.

  Inflammation of the heart may affect  one or more of the
structures which compose that organ.  The investing serous
membrane may be alone inflamed, constituting the disease
known  as  pericarditis.   When  the  membrane  lining the
cavities, or the endocardium, is the seat of inflammation, the
affection is called endocarditis.  Inflammation of the muscular
tissue, or substance of the heart, is designated myocarditis or
carditis.
  Although these different inflammatory affections may exist
each  independent of the others, they are often associated.
In many cases of pericarditis,  carditis co-exists.  Myocarditis
very rarely  occurs except  in  connection with inflammation
of either the investing or lining membrane of the heart.
  The importance of these diseases cannot be overrated, and
their  study is of the highest  importance. They  are seated
in the great vital organ of the body.   They involve great
suffering and danger to life.   Their remote consequences are
very grave.  All organic affections of the heart have  their
origin in  the inflammatory.  Too many physicians neglect
to study this class of affections, greatly to  their  own detri-
ment and  that  of  their  patients.   The homoeopathic
treatment  of inflammatory  cardiac  affections,  if skillfully
applied, is vastly superior to the ordinary  methods.   The
late improvements in physical examination greatly facilitate
correct  diagnosis, and  enable us  to  combat these diseases
with the happiest results. 
68
DISEASES OF THE HEART.
                       PERICARDITIS.
Acute pericarditis — Anatomical characters — Morbid changes — Causes and
  pathology — Connection with   rheumatism—With albuminuria — With
  Bright's Disease, pyaemia, etc. — Symptoms — Of the heart —Of the circu-
  lation — Of the respiratory symptoms — Digestive organs — Brain and spinal
  cord — Physical signs of pericarditis — Signs  furnished  by auscultation,
  percussion, palpation, inspection, and mensuration — Summary — Diagnosis
  — Prognosis — Treatment.

  Inflammation of the investing membrane of the heart is less
common than endocarditis,  but it is a more serious affection
as regards immediate danger.
  This membrane is like the serous tissues in other portions
of the body, and inflammation results in the same changes in
this, as in the pleural and peritoneal membranes.  It is more
dangerous than the other  serous inflammations, because of
the small  size of the pericardial  sac, and  the  fact that the
heart-substance consists of muscular tissue, also because of
the important function of the organ  and its physiological
relations.
  In treating of pericarditis the following points  will be con-
sidered:  1.  The morbid  changes incident to  the  disease.
2. Its causes and pathological relations.  3.  The symptoms,
signs, diagnosis, prognosis, and treatment.
  Like other inflammatory affections, this has an acute, sub-
acute, and chronic form.

                   THE  MORBID CHANGES.

  The  inflammation  is seldom diffuse,  and  is  generally
limited to single spots.  The membrane at first looks injected,
opaque, sometimes spotted, in consequence of slight extrav-
asations.  Acute  inflammation speedily leads to exudation
of  lymph.   This exudation   takes  place,  in  most  cases,
probably within a few hours from the  commencement  of the
inflammation.  It is at first of a jelly-like consistence, and
adheres slightly to the membrane, forming  a thin  layer,
either limited to the base of the organ and  about the roots
of the large  vessels, or extending more or less over the peri-
cardial  surface.  The heart, at this stage, is said to present 
          CAUSES, AND PATHOLOGICAL  RELATIONS.          69

an appearance like that of hoar frost, or to a "layer of liquid
gelatine spread upon the parts with  a camel's hair pencil."
The exudation goes on, and  generally, but not invariably,
more or less liquid effusion accumulates w7ithin  the pericar-
dial  sac.  This effusion  varies in quality  and quantity.  It
may amount to a few ounces or to several pints.  The exu-
dation either consists of plastic  lymph, mixed  or not with
serum, or blood, very seldom  of serum  alone.
  The first stage extends to the time  when the accumulation
of lymph  is sufficient to  be determined  during life by symp-
toms and  physical signs.
  The second stage embraces the period during which an
appreciable amount of liquid  continues.
  The third stage comprises the duration of the disease after
the resorption of the liquid.
  These stages  have  been called stages  of exudation, of
liquid effusion, and of adhesion.
  If the disease do not  prove fiftal, the liquid  is gradually
absorbed, and adhesion follows; or absorption occurs without
adhesions;  or a membrane may be formed from the plastic
exudation;  or the effused fluid  may  be  changed to pus.
The adhesions may be firm and  extensive, or  delicate  and
thread-like.
  A liquid  effusion sufficient  to  be manifested  by physical
signs may take place at a period of the  disease, varying from
one to four days from the date of the attack.
  Death usually occurs during the period of liquid effusion.
  The effusion is sometimes absorbed quite rapidly, in other
cases slowly.   In the latter  instance, a  condition obtains
which has been called dropsy of the heart.

           CAUSES, AND PATHOLOGICAL RELATIONS.

  Acute  pericarditis  is  rarely  an  idiopathic  or primary
disease.   In the  great majority  of cases  it is  a secondary
affection.   There are many cases of which  it is an occasional
concomitant, but in  the larger  proportion of  instances it
occurs either in  the course of acute articular rheumatism, or
the renal  affection known as BrigMs  disease.
  Of 847  cases of  rheumatism, collected from  various 
70
DISEASES OF THE  HEART.
sources, and  analyzed by Dr. Fuller, it existed in 142, or
about one to  every six cases.
  Of  50 cases  collected by  Dr.  Flint, it  existed in 19, or
more than one-third.
  Rheumatism  is more likely to become  complicated  with
pericarditis  in  the young than in  the  aged, and occurs
oftener in females than in males.
  The more  acute  the  rheumatic affection, the greater the
liability to pericarditis; and  it occurs oftener during first
attacks than  in subsequent.
  That  there is an intimate relation  between acute rheuma-
tism and  pericarditis admits of no doubt, but  the  common
notion that there is a metastasis from the joints to the heart
is erroneous, although  some cases appear  to  support the
supposition.  The facts are that pericarditis often  precedes
the affection of  the  joints,  and  the inflammation of the
joints does not usually subside when  the heart is affected.
  The true  explanation  of  the  apparent  transfer of the
disease, and  of the relation existing,  is, that the pericarditis
and affection of the joints depend upon the same condition
of the blood.  The analogy of structure between the peri-
cardium and the synovial membranes will account for the
liability of the former to become inflamed when the latter
are affected.
  The connection between pericarditis and albuminuria and
uraemic phenomena is now quite definitely ascertained.
  Of  35  cases of pericarditis  analyzed, with  respect to
causation, by Dr. Taylor, renal disease existed in 13.
  Of  50  cases collected by Dr. Flint,  renal disease was
present in 7.  Of  292 cases of renal disease  analyzed by
Frerichs, pericarditis  occurred in  13.  Of 135 fatal cases of
pericarditis  analyzed by Dr. Chambers, the  kidneys were
diseased in 36.
  Renal disease exists in a larger proportion of the cases of
pericarditis  which end fatally  than of  those  ending in
recovery.   The explanation of this is, pericarditis developed
in  connection  with Bright's disease usually ends fatally;
whilst in connection  with acute rheumatism recovery takes
place in a large proportion of instances.
  What is the  relation between pericarditis and certain renal 
SYMPTOMS OF ACUTE PEICARDITIS.
71
affections ?  It .is well known that serous inflammations are
apt to become developed in connection with Bright's disease.
These  inflammations are attributed  to  the  accumulation of
urinary principles in the blood, from  faulty excretory func-
tion in the kidneys.  The excess of urea, or the decomposition
of its products in the blood, act as poisonous agents, giving
rise to inflammation  of the  pericardial and other serous
membranes.
  Pericarditis may be associated with pleurisy or pneumonia,
It must not be supposed, however, that it obtains by means
of extension, but results from the same pathological cause.
  Pyaemia frequently  co-exists with pericarditis.  Wounds,
and surgical operations, in tissues remote  from the heart,
sometimes give rise to pericarditis.  The explanation is, the
blood becomes poisoned so as to cause serous inflammations.

             SYMPTOMS OF ACUTE PERICARDITIS.

  The symptoms of pericarditis vary with the three periods
of the disease.   They are modified by the amount of fluid
effused during the second  period, and again during the
absorption of the fluid in the third stage.   The intensity of
the inflammation may be in ratio to the severity of the  pain.
  In  some  cases, however,  pericarditis may run  its course
with  but little pain or febrile movement attendant,  But
this is equally true of inflammation in any  organ, especially
in the serous tissues.
  The symptomatology of pericarditis  is best treated of by
taking it up in the following order, namely:  The symptoms
relating to the heart, and afterwards those referable to the
circulatory, respiratory, and nervous system.

  Symptoms  referable  to the heart,  (1) pain,  (2)  tenderness,
(3) palpitation.
  Pain referred to the praecordia is a prominent symptom in
some cases.  It is generally burning, lancinating, and  often
accompanied by a sense of constriction.  It is aggravated by
inspiration  and the  movements of the body.  The  pain is
sometimes felt in the epigastrium, or to the  right side, or the
centre of the sternum.  It  may extend to  the back, to the 
72               DISEASES OF THE  HEART.

left shoulder, and down the  left arm, as  in angina pectoris.
The pain much resembles the pain of pleurisy, with which
pericarditis may be  confounded.  The  two diseases may,
however, exist at the same  time;  so also may pleurodynia
and  intercostal  neuralgia.  But pain in  pericarditis may be
very slight, or altogether wanting.  Dr. Flint says, in  the
larger number of cases observed by him, the pain was very
slight.
  It is  a  disputed question  on what the  pain depends.
Bouilland attributes it to co-existing pleuritis.  Flint  refers
it to the nerves of the heart.   Inman says it is a myalgia of
the thoracic muscles.
  When pain is present  it belongs to the early part of  the
disease.  When  the  inflamed   surfaces  are covered with
lymph, or are separated  by  liquid effusion, it diminishes or
disappears,  leaving  only a sense  of uneasiness  in  the
praecordia.
  Tenderness on pressure  is generally present, but, like pain,
varies  in degree, and is  rarely very marked.   Hope says it
may be discovered by pressing on the epigastrium beneath
the cartilages of the ribs, in a  direction towTard  the heart,
when  it is not  apparent directly over the  heart.   Flint
asserts that in order to constitute a symptom  of pericarditis
it must be limited to the region of the heart.  If tenderness is
diffused, it indicates the presence of pleurisy, or pleurodynia.
It  is only when taken in connection -with other symptoms,
that tenderness is of positive value.  It is well  known that
in peritonitis tenderness  is sometimes absent; so  in pericar-
ditis.   Why this is so has not been explained.
  Increased  action of the heart  occurs in  pericarditis in the
early part of the disease.  The contractions are violent, and
sometimes  irregular, and the  patient is conscious  of  an
unnatural beating of the heart.   This symptom, however, is
by no means constant, and of itself is of little value, because
it is found in functional disorder and organic disease.
  If,'during the occurrence of rheumatism, tumultuous action
of  the  heart is  noticed,  it  should  lead  to   a  careful
examination.
  In the stage of liquid effusion, palpitation cannot occur to
any  degree, and if the  effusion is absent the  heart is so 
RESPIRATORY  SYMPTOMS.
73
weakened in the second stage as to make palpitation almost
impossible.
              SYMPTOMS  OF THE CIRCULATION.

  The pulse alone, in this disease, does not furnish positive
diagnostic information, but when the diagnosis  is made, it
aids us in judging of the condition of the  heart.  At the
outset of the  disease it  corresponds to the  increased  mus-
cular action of the organ, and is strong, quick, and vibratory,
more or less frequent, and  sometimes irregular.
  As  the  heart  becomes weakened  the  pulse  becomes
enfeebled;  and  when, together with  a certain  amount of
paralysis, there occurs  liquid  effusion, the pulse becomes
weak and small, with greater disturbance of rythm.
  Walshe says  that  the frequency of the pulse " is subject
to more sudden variations from the influence of emotional
excitement and effort in  this  than  in any other disease."
He adds, that he has known a gentle movement of the trunk
to raise the pulse from 80  or 90 to 130 or 140.
  But  to the above statements there are many exceptions.
Even in the first stage it may not be more frequent than in
health.  Graves says it is often " less frequent."  It may
even continue regular, and in no way abnormal.
   Lividity of the lips, face,  etc., may be due to a weakness of
the heart,  and  belongs  to the second stage of  the  disease,
when it  denotes  serious  obstruction.   It is attended with
feeble and  irregular pulse.
   Lividity is caused by congestion of the venous radicles, but
generally involves some affection  of the pulmonary system
co-existing with pericarditis.  The deficient aeration of the
blood by the lungs may in such cases cause lividity.  This
symptom is not  therefore very important as  a diagnostic
 sign of pericarditis.

                  RESPIRATORY SYMPTOMS.

   Respiration is  sometimes  accelerated in pericarditis  in
 consequence  of the  inspiratory acts being shortened by the
 praecordial pain, and, in  such cases, dilatation of the dial nasi
 may be observed, the dyspnoea  may be dependent on conges- 
74               DISEASES OF THE HEART.
tion  of the lungs, incident to compression of the  heart b\
liquid effusion, but it may be absent even when the pericar-
dial  sac  is  largely  distended.  But this symptom is not
always present, for  the respiration may  be  unaffected, or
only accelerated by the febrile movement.
  Cough, dry,  hacking, or  spasmodic, is common, and may
exist independent of any pulmonary disease.   It may, how-
ever, be absent in all  stages.  When a dry,  short cough is
associated with orthopnoea, a frequent and feeble pulse, and
lividity of lips and face, it denotes imminent danger.
  The voice may be very weak, the patient being unable to
speak, except  in  feeble tones and with great effort.  This
symptom seems to be connected with copious effusion.

                    GASTRIC  SYMPTOMS.

   Vomiting is sometimes present and  persistent,  and may
lead us to a  faulty diagnosis in mistaking  the attack for
gastritis.
  Dysphagia  occasionally occurs,  and was first noticed by
Testa, an  Italian author.  It may be a  spasmodic affection,
or due to pressure of the distended  pericardial sac upon the
oesophagus.

       SYMPTOMS  OF  THE COUNTENANCE,  POSITION, ETC.

  An  expression of anxiety, or  apprehension, is  often  a
prominent  symptom.    The  risus  sardonicus  has  been
observed  in  seven  cases  which terminated  fatally.   The
position of the patient is generally on  the  back,  or diag-
onally, between that on the back  and on the  side.  It is
rarely on  the  left side, the liver in this  position pressing on
the heart.  In some cases the patient can  lie  comfortably on
the right side.  Generally, the patient  desires to have the
head and shoulders  raised.  But whatever position  the
patient selects he is  very reluctant to change it, owing to the
great increase of the  pain or distress, and the excitement
of  the  heart, which  gives  rise  to a  feeling of  syncope,
especially when the sac is filled with fluid.  Fatal syncope
has  been  induced  by change  of  position.   Flint refers to
several cases,  and I have observed it to occur  in one case of 
SYMPTOMS OF THE NERVOUS SYSTEM.
75
rheumatic  pericarditis, and  in  several cases where cardiac
disease was complicated with diphtheria.

            SYMPTOMS OF THE NERVOUS SYSTEM.

  In addition to the mental  anxiety, depression, and fear of
death observed in cases of pericarditis, actual delirium may
exist.  It has not been considered an element of the disease.
  There are, however, cases  of pericarditis  in which the
cerebral symptoms are so marked  that they may mask the
cardiac inflammation.  These cerebral symptoms may simu-
late meningitis,  mania, dementia,  coma, epilepsy, tetanus,
and chorea.  In  many cases of supposed  cerebral disease
terminating fatally, autopsy shows no  appreciable  lesion of
the brain  and spinal  cord.  But  if the  examination had
included the heart, pericarditis would have been  found to
have existed.
  Dr. Burrows* was the first to call special attention to this
connection of cerebral  symptoms with cardiac disease.   Dr.
Flint alludes to several interesting cases of a similar charac-
ter which  came under  his observation.  These  two authors
show  conclusively  that  the  physician  may  mistake  an
inflammation of  the pericardium for an inflammation of the
brain.   In the 16 cases detailed by Burrows there occurred
delirium,  convulsions,  agitation of the  limbs  resembling
chorea,  dementia, coma, and  seizures resembling  apoplexy
and tetanic spasms.  Flint's cases  had delirium, with wild,
staring expression, inability to protrude the tongue, shouting
as  if from danger, coma, great agitation,  blindness  of one
eye, etc.  One patient " ejected saliva wTith great force, and
in all directions."
   Several  cases have come under my own observation.  One
very notable case, in  a girl  eight years of age.   The symp-
toms all simulated meningitis, and it  was only when my
attention  was called  to  the heart by  the full and  very
irregular  pulse,  that  physical examination  disclosed the
presence of pericarditis.
  * "On Disorders of the Cerebral  Circulation and on  the Connection
between Affections of the Brain and Diseases of the Heart." 
76
DISEASES OF THE HEART.
  Flint says the delirium is peculiar, " the patient lying in
a species  of  coma vigil, the eyes open  and fixed in  one
direction,  not replying to questions, and incapable of being
roused ; this state was followed by maniacal excitement, the
patient shouting,  and apparently laboring  under fear of
harm, with occasional ebullitions of hilarity.  A fixed delu-
sion of having committed  some crime  appears to be  a
distinguishing feature."
  From the above symptoms — and this  peculiar delirium
does not occur  in meningitis—and also the absence of acute
pain in the head, throbbing of the carotids, injection of the
eyes and face, we may know that the disease is not cerebral.
The delirium resembles somewhat delirium tremens, in  which
condition  the heart is often much disordered.  This fact may
lead us to understand the curative action of digitalis in mania
a potu.
  I wash to call attention to a fact which Flint has not men-
tioned, namely, the disordered action of the heart in idiopathic
brain affections.   In some cases  of meningitis, and nearly
all  cases  of tubercular meningitis, the pulse  is at first full
and irregular, afterwards  soft and fluttering,  then  inter-
mitting, irregular, full, slow and labored, easily quickened
by  motion or  mental disturbance  to double  its previous
amount of pulsations.
  When  we reflect that  these  symptoms  also  occur  in
pericarditis, we shall admit that  it may be possible  for the
physician who neglects physical examinations to make  a
wrong diagnosis.  I have seen cases of tubercular meningitis
in which  the beating of  the heart  and the character  of the
pulse simulated pericarditis.  The physical signs on percus-
sion were, however, wanting.  In such cases  the disorder of
the heart was functional, or reflex, the  nervous irritation
being transmitted  through the phrenic and  pneumogastric
nerves, just as in reflex disorder  of the brain from pericar-
ditis, but in a  contrary direction.  I will here remark, that
for  brain symptoms arising from  diseases of  the  heart,
digitalis is generally specific; but if the contrary  obtains, it
is not indicated. 
PERCUSSION.                     77
             PHYSICAL  SIGNS  OF  PERICARDITIS.

  The symptoms of acute pericarditis above enumerated are
not alone sufficient to  enable us to diagnose with certainty
the presence of that disease.  But by means of the physical
signs obtained by percussion, auscultation, palpation, inspec-
tion,  and mensuration, the disease may now be  generally
recognized  with  a  degree of  positiveness which  clinical
observers, not many years ago, regarded as unattainable.
  Instead of entering into a profuse  description of these
signs occurring in pericarditis,  I  shall take the  liberty to
present the admirable  summary given by Dr. Flint, in his
work on Diseases of the Heart:

                       PERCUSSION.

  "Enlarged area of praecordial dullness; the extent of  this
area greater in a vertical than in a transverse direction; its
shape corresponding to the pyramidal form of the pericar-
dial sac when distended; the dullness within this  area,  and
the sense of resistance on percussion greater than over  the
praecordial region in health,  or  in cases of enlargement of
the heart.   These signs denote an abundant effusion within
the pericardial sac.
  " Moderate or  small  effusion denoted by increased width
of the area  of dullness at the lower and middle portions of
the praecordial region.  The increase of the area of dullness
taking place within a  few days or hours,  and progressing
rapidly;  its extent varying  on  different  days during  the
course of the disease.  Dullness from  the presence of liquid
below the point of the apex-beat of the heart.  Diminution
of the area of dullness, with more or less rapidity in the
progress of  the disease toward convalescence, and its  final
reduction to its normal  limits;  when  convalescence  is
established." 
78
DISEASES OF THE HEART.
                      AUSCULTATION.

  " A friction  sound developed,  usually,  soon after the
commencement of the inflammation, depending on the exu-
dation of lymph ;  rarely wanting during the  period of the
disease which precedes that of liquid effusion ;  frequently,
not invariably, disappearing during the period of effusion ;
often returning  after the absorption of liquid, and sometimes
persisting after adhesion of the pericardial surfaces has taken
place.  Intensification of the heart sounds at the  commence-
ment of the disease, or prior to  liquid effusion;  during the
period of effusion, both sounds weakened, but  especially the
first sound;  the element of  impulsion  in  the  first sound
notably impaired or lost, and this sound, therefore, consisting
of the valvular element alone, resembling the second sound
as regards quality and  duration;   the  sounds  apparently
distant, and the apparent distance greater when  the patient
is recumbent on the back.
  " Cessation of respiratory murmur  and vocal  resonance,
concurring with the results of percussion, in determining the
enlarged area of praecordial  dullness dependent on distension
of the pericardial sac."

                       PALPATION.

  " Prior to  the period of effusion, the cardiac impulse
abnormally forcible, violent, extending over a larger  space
than in health,  and sometimes  tumultuous  beating  of the
heart.  After effusion, the  point of apex-beat raised, and
carried to the  left of its normal position.   Suppression of
the apex-beat,  if the quantity of liquid be  large.  Return
of the beat when  the liquid diminishes.  Vibration of the
thoracic walls  in the praecordia  before, and sometimes after
the period of effusion, constituting tactile friction—fremitus.
Retardation of  the  apex-beat  in some cases, after a certain
amount of effusion, so that  the first sound precedes it by a
distinct interval." 
DIAGNOSIS.                      79
                        INSPECTION

  " Prominence or arching of the praecordial region in some
csases during the period of effusion, if the pericardial sac be
distended,  observed  chiefly in young subjects; the promi-
nence presenting an indistinct outline of the pyriform shape
of the pericardial  sac.  Restraint of the respiratory move-
ments of the left side, if the quantity of liquid be large, and
also, prior  to  effusion, in some cases, from pain felt in the
act of inspiration.  Undulatory movements in the intercostal
spaces over the pericardium distended with liquid, in a very
small proportion  of cases.  Depression of the praecordial
region in some cases, after the absorption of liquid."

                      MENSURATION.

  "Prominence of the praecordia in some cases, produced by
liquid  accumulation  in  the pericardia] sac, determined by
callipers.   Sudden development, or  increase of prominence,
and its sudden or rapid disappearance."

                        DIAGNOSIS.

  If the physician  depends altogether upon  the symptoms
supposed  to indicate pericarditis, he wrill find the diagnosis
of the disease to be difficult, and often impossible.   It has
been shown that cases may occur which do not show symp-
toms of a positive character.   It is only since the discovery
of  physical exploration, that the diagnosis is made com-
paratively easy.   But since this method  is still neglected  to
much extent, pericarditis is habitually overlooked by many
medical practitioners.
  There are many diseases  having pathological relations  to
pericarditis, and  during the progress of those diseases we
should  be  on the watch  for  the earliest evidence of its
development.   During the progress of  acute rheumatism the
praecordial region should be daily explored with reference to
the signs of pericarditis, as well as  endocarditis.  We may,
in such cases, discover the friction-murmur before the patient 
80
DISEASES OF THE HEART.
makes any complaint of pain or other symptoms denoting
that the pericardium has become involved.
  In view^ of the fact that inflammation of the pericardium
as w^ell as other serous structures, is  liable to be developed
in patients affected with disease of the kidneys, we should not
neglect to examine the chest from time to time.
  The diagnosis of pericarditis from  pleuritis or pneumonia
is sometimes difficult.   In such instances the heart should
be closely interrogated.
  We  may  hear a  friction-murmur  in pleuritis, produced
outside the pericardial sac.   It will  be found difficult to dis-
cover  the  presence of liquid  effusion in  the pericardium
when,  at the  same  time, it exists in the  left pleural sac;
while,  if the effusion is in  the right pleural cavity, we can
readily distinguish it from pericardial  effusion.
  Flint says that he has known acute uncomplicated pericar-
ditis to be considered and treated, throughout the disease, as
pleurisy, when the diagnosis was based on symptoms alone,
and I have  no doubt but such instances are very numerous,
too numerous in fact for the dignity  and honor of medical
science.
  Dropsy of the pericardium, may be mistaken for the  stage
of pericarditis with effusion.  But  the former rarely occurs
except in connection with general  dropsy, and then not to
the same extent as in  pericarditis.  Moreover, hydro-peri-
cardium is not preceded by pain, tenderness, fever, etc., nor
is it attended by the friction-murmur.

                       PROGNOSIS.

  Pericarditis is always a serious affection, and its progress
should be  watched with great  solicitude.   In no  disease
must we  attend so closely to the development of the various
stages.
  Different  observers  vary  in  their  testimony  as  to the
fatality of the disease.   Dr. Hope declared  that in ten  years
he did not  lose a case.  Of 106 cases analyzed  by Louis, 36
died.   In 84 cases reported by Latham, only 8 died.  Of Dr.
Flint's 50  cases,  27 died;   but  these were  unusually bad
•^ases variously complicated. 
TREATMENT.
81
  According  to Flint, pericarditis  is  least  fatal  when
rheumatic;  more dangerous wdien  occurring during renal
affections,  eruptive  and  continued  fevers,  pyaemia;  and
generally fatal when associated with marked disorder of the
nervous  system, giving rise to mania, tetanus, chorea, etc.
Under judicious homoeopathic  treatment this  rate of mor-
tality would probably have been less.   Dr. Russell's success
in the London Hospital was certainly very satisfactory.
  The duration of the disease is variable.  It may prove so
rapidly fatal as to kill in 24 hours.   It lasts usually from one
to two weeks, and, if not ending fatally in this  time, ends in
recovery, or the chronic form.
  The termination, in favorable cases, is more or less adhe-
sion of the pericardial surfaces.  Flint considers it doubtful
if the exudation is  ever  completely removed by absorption
—leaving the surfaces unattached and  free from disease. He
also considers it the rule that the pericardial sac is obliterated,
from adhesion throughout  its entire surface.   Of 156 cases
of pericardial adhesions  analyzed by Louis and Chambers,
111 were universal.
  Death occurs  in pericarditis from arrest of  the circulation,
from paralysis of the heart, from the combined effects of the
pressure of  the liquid effusion and  the proximity of the
inflamed membrane to the muscular fibres of the organ.   It
must be remembered  that death from  the  slightest over-
exertion may occur during the stage of effusion.

                       TREATMENT.

   The treatment of inflammatory cardiac affections has not
yet  received  that careful study in  our school which their
importance demands.  Notwithstanding this, we can safely
assert that our treatment is far  more successful than that of
the allopathic school; or, with greater propriety it might be
said, than  the former treatment by that school, which con-
sisted of blood-letting, calomel, blisters, opium,  etc.  The
allopathic  treatment,  as  at present adopted by its  best
practitioners  is  far  more  rational  than ever before — it is
even homoeopathic—as witness  the treatment advised by Dr.
Flint, who discards blood-letting altogether,  and says of
         6 
82
DISEASES OF THE HEART.
mercury, that it should not be used in Bright's disease, anae-
mia, or any cachectic state; and other authors deny its efficacy
in idiopathic or rheumatic pericarditis.  Flint says of opium,
that it is a very important and valuable remedy, but he relies
more  upon  aconite and digitalis than any other agents, and
these  he uses in a strictly homoeopathic manner.
  If the homoeopathic school is limited to a few remedies, it
is because our pro vers have not paid sufficient attention  to
objective symptoms.   In but few of our provings  has any
proper record been made of the cardiac symptoms developed.
The objective  symptoms  have  been neglected, and the
subjective  only vaguely recorded.   Not  only  this, but
even in the few reported clinical cases of heart-disease found
in our literature, no physical exploration of  the chest was
made,  to confirm the diagnosis, and in many cases we are
in doubt whether they were really cases of  disease of the
heart.
  The following are  the chief  remedies to be selected  in
pericarditis:
  Aconite.  The symptoms  of the aconite-heart-disease are
prominent and  unmistakable.   It is  indicated in  the first
stage  of the disease, or until the exudative process is com-
pleted.  It is not so often indicated in the second stage—or
stage  of liquid effusion—and rarely in the third stage.   The
action of aconite is  twofold.  Primarily, in  large  doses  it
depresses  the vitality of the heart  even to the point  of
paralysis.   But  the  reaction which  occurs is a secondary
effect, and  results in hyperaemia and inflammation;  but this
inflammation does not go to the extent of causing liquid
effusion, nor does  it  cause organized exudation of lymph.
The following are the symptoms for  which it  is indicated in
the first stage:
  The beats of the  heart are  more violent  and  rapid; the
pulse  hard, strong, and contracted (not full  and  bounding).
The pain,  if any is felt in  the cardiac  region, is burning,
lancinating, and constrictive, or stitching.   There  may  be
tenderness  on pressure over the cardiac region, or in the
epigastrium under the ribs.  The  skin  is very hot,  with
burning and intense thirst.  The urine scanty and red.  The
countenance  expresses  great anxiety, and  there is always 
TREATMENT.
83
present a fear of death.  The position of the patient is  on
the back, with the  head and  shoulders raised.  Any move-
ment aggravates the pain, if any.  But cases of pericarditis
occur without pain, and here we must depend on physical
signs.  If fever is present, and the heart's action is hard and
rapid, and pulse hard, and percussion and auscultation shows
the first stage, then is aconite still indicated.  It is not  indi-
cated in  the  first  stage of pericarditis, when the cause is
Bright's disease, or pyaemia, but only in idiopathic, traumatic,
or rheumatic cases.
  If wTe  expect  aconite  to act well  in this stage, wre must
give the lower dilutions, 1st  to 3rd, or even a few drops of
the mother tincture  in half a  glass of water, a spoonful
repeated  every hour  or two.  Nor shall we find it useful
after  the  first 12  or  36 hours.   So soon as we discover the
pulse to grow weaker, and the action of the heart less violent,
the size of the dose must be changed, or some other remedy
must be selected.  Baehr says, "Aconite is not only indicated
at the commencement  of the disease, but, in  many cases,
during its wdiole course, more especially in rheumatic  cardiac
inflammations, so  long as  the  organic alterations  do not
result in paralytic or cyanotic symptoms."
  I cannot support these assertions.  Aconite  is indicated
in the second and  third stages,  but not  on account of any
inflammatory action supposed to be existing, but  because it
is homoeopathic  to threatened  paralysis.   Baehr  himself
admits this, virtually, when he says aconite is also indicated
when the  " beats of the heart become slower, or else  they
remain quick, and grow feeble or irregular;  or a  feeble and
small pulse, not synochrous  with  the beats of the heart,
intermitting or unequal, the temperature is lower, and the
number of respirations  increase rather than decrease."  But
Baehr says nothing about changing the size of the  dose when
the symptoms change.  The physician who gives the same
dilution of aconite  in the second  as  in the first stage will  be
disappointed, and do injury to his patient.
  The dose in the second and third  stages  should never  be
lower than the third dilution, unless the powers of absorption
are very feeble.  These stages are similar to the primary
stages of  aconite-poisoning,  when  the cardiac nerves are 
84
DISEASES OF THE  HEART.
brought  to the verge of paralysis.   The 30th or 10th is  the
proper attenuation to use when we give it  for  feeble and
irregular cardiac action.
 . Asclepias tuberosa will be  found  useful in some cases of
pericarditis.   Its action is quite analogous to bryonia.   The
symptoms point rather  to a sub-acute  than an acute condi-
tion.  I have used it in one such case with excellent results.
The asclepias-fever is not intense, the  pain  in the cardiac
region is pricking, there is shooting pain near the left nipple
extending to left shoulder, with a  feeling of constriction in
the region  of the heart.  A dry, spasmodic  cough, with
some  dyspnoea, is generally present.  The pain in the chest
is relieved by bending forward.  There is palpitation of the
heart, with pulse 88 and small. It is indicated in sub-acute
cases, with   liquid  effusion,  the  absorption  of  which it
hastens, and  should  be used in the lowest dilutions.  The
asclepias  syriaca  is indicated in similar conditions, namely,
the second stage, when the disease is connected with uraemia,
with  copious  liquid effusion.  Its  action on the  kidneys is
similar to colchicum.
  Bryonia  alba  is  doubtless  one  of  our  most  valuable
remedies in the first and second stages of pericarditis.  Its
action begins when the exudation of plastic lymph appears,
and as this often occurs very soon, it is best to alternate it with
aconite, or follow closely after  that remedy.  It is indicated
in  those cases of idiopathic  or rheumatic pericarditis, with
or  without   pleurisy,  with  intense fever, frontal  or occi-
pital  headache, and acute stitching pains aggravated by the
slightest movement.  I do not consider it the best remedy
in cases of liquid effusion, nor does it  do any good  in cases
of  feeble, irregular,  or  intermittent cardiac  action.  The
heart's action is not violent or tumultuous, but the friction-
murmur is always heard, dulness  on percussion  is  present,
the point of  apex-beat raised and carried to the left, and the
heart's sounds intensified (at first), then both sounds weak-
ened. It is of no value in pericarditis from Bright's disease
or pyaemia, nor when  the effusion  is copious, and  aeration
of  blood deficient.
   Arsenic.  The testimony relating to the efficacy and appli-
 cability of arsenic in pericarditis is quite conflicting.  Baehr 
TREATMENT.
85
says, " w~e have never seen any good effects from it in acute
conditions.  It  is a  remarkable fact that among the large
number of cases of poisoning by arsenic, post-mortem exami-
nations have never yet revealed a single symptom that might
lead  us to infer that  arsenic  exerts a  specific  action upon
the heart."
   Dr. Russell, on the contrary, asserts  that arsenic  exerts a
powerful  influence  on the heart and lining membranes, both
internal and external.  He quotes  Orfila, who found " small
spots of a bright crimson color in the left ventricle and on
the columnae carneae, and this color penetrated deeply into
the substance.   The right cavities presented spots of much
deeper red—almost black color."  But  he did not find  the
serous membrane inflamed.
   If  arsenic is  homoeopathic  to  pericarditis, it is  to  that
variety caused by uraemia or pyaemia, in wThich conditions the
nervous life of the organ is poisoned.  It may be homoeo-
pathic to  carditis, and  also to  the  second  stage of sub-acute
or chronic pericarditis,  with serous  or liquid  effusion,
associated with great irritability and tendency to paralysis.
   The  symptoms indicating arsenic are:  great anxiety in
the region of the heart, with fear of death;  tightness in the
praecordia ; cannot lie down ;  dyspnoea and palpitation after
the  slightest motion;  great   thirst;  violent,  tumultuous
action of  the heart, alternating with feeble, irregular beating;
tendency  to fainting;  pulse strong  and jerking, or  feeble,
fluttering, and irregular; cold skin, hands, and feet.  The
pain is piercing, burning, and  a sensation of  soreness in the
region of the heart.
   The physical signs on percussion and auscultation  are:
dullness over a greater  extent than usual in  the  cardiac
region, especially in a vertical direction; the  element of
impulsion in the first sound is impaired or lost, the sounds
apparently distant.
   The iodide of arsenic will doubtless prove a superior remedy
in such cases.  Dose, the 3rd or 6th trituration.
   Digitalis is one of the most useful remedies  in pericarditis,
but in order to use  it successfully you must fully understand
its sphere of action.  Not only this, but you must know how
to graduate the dose to suit the varying phases of the disease. 
86
DISEASES OF THE  HEART.
  I will first give you the opinion of Baehr, and then  my
own.   He  says,  " Since  I  have  devoted,  for  years past,
special  attention to the use of this drug, I have found it
much more frequently applicable in the treatment of diseases
than in former times;  and I am now prepared to assert most
positively, what I was then only able to announce in rather
dubious language, that digitalis  is  an excellent remedy in
acute diseases of the  heart, more  particularly in pericarditis.
Digitalis is not so much adapted  to  inflammations setting in
with very violent symptoms, but to inflammations approach-
ing: in an insidious and  scarcely observable  manner, more
especially  without  any  local  pain, but  with  a  rapidly
increasing embarrassment of  the  respiration.  We should
take a very one-sided  view of the action  of  this drug, if we
were to regard the irregularity and slowness of the pulse as
the chief criterion for its  application, since a rapid and very
weak pulse constitutes an equally reliable indication.  Even
a violent  excitement of the functional  activity of the heart,
as generally occurs at the commencement of cardiac  inflam-
mation, is in  characteristic accord  with  the first symptoms
of poisoning by digitalis.  Among  all the various  forms  of
cardiac inflammation, we  consider  the rheumatic form  the
best adapted to digitalis, and  likewise if it is associated with
a copious  effusion  of serum;  less, however, in pericarditis,
if the friction murmurs continue unchanged from the begin-
ning of the disease.  The sooner  these murmurs disappear,
the better  is digitalis adapted to the case.  *   *  Among  the
general  symptoms, the  following  invite more  particular
attention to the use of digitalis : Rapidly increasing dyspnoea,
with occasional symptoms of acute congestion of the chest;
inflammation  of the pleura or lungs; bronchitis;  chronic
catarrh of the bronchia; expectoration mixed (not streaked)
with blood; spasmodic cough; livid, turgescent face, with blue
lips, headache,  vertigo, delirium,  sopor,  vomiting,  at  the
commencement or  during the  course of the  disease; hyper-
emia of the liver; slight  icterus; catarrh  of the  kidneys;
excessive   feeling of  illness, not  corresponding  with  the
perceptible symptoms; great anxiety, but without any con-
tinual restlessness; aggravation by the slightest motion; a
drawing, tearing pain in left  shoulder." 
TREATMENT.
87
  Dr. Baehr's  experience coincides with my own.   In my
several  papers  on the action of digitalis T have  always con-
tended  for the  double action of this drug, and unless such
action is fully understood, you cannot prescribe it successfully.
In its primary  action, i. e., its  pathogenetic effect in large
doses, it  first  causes a  hyper-stimulation of  the  cardiac
tissues, manifested  by increased force,  and sometimes, not
always, frequency of the  heart's action; and this may go on
to the very verge of acute inflammation, or to  a condition
of the  heart  culminating in tetanic spasm of that organ.
Digitalis is not so  much indicated  in  acute   as sub-acate
pericarditis,  in its first  stages.  It is   not indicated for
plastic exudation, but only for  serous effusion; and not so
much for the inflammation itself, as  its results, and the exces-
sive irritation  of the cardiac  nerves wdiich attends it.  If
given in the first stages the closes must be made very small,
not lower than the third decimal dilution.   It is  very import-
ant to  understand  the secondary action  of digitalis.  After
it has exhausted the nervous and vascular irritability of the
heart by its primary action, a contrary condition  sets in.  The
heart's vitality is  lowered, its  pulsations decrease in force,
but  increase  in frequency,  or become  very irregular  and
intermittent; the slightest motion  or excitement increases
the heart's action in a very distressing  manner, and death
may  occur from cardiac paralysis.
  You will  observe that Baehr mixes the  primary  and
secondary symptoms and conditions in his indications.  This
is unfortunate, for if the  practitioner does  not  separate the
two states, he wTill forever be in the dark regarding the true
action of the drug, and never  be able to prescribe  it with
safety and benefit to his patient.
  I have given you the symptoms and conditions indicating
digitalis in the  first stage of pericarditis, and the dose
required.  Its  most useful sphere, however, is  in the second
and  third stages, or those conditions characterized by liquid
effusion, failure of the nervous and muscular power of the
heart, from pariesis or over-distension, and accompanied by
excessive  irritability.  The physical signs  in this condition
are:  absence  or  decrease of the friction-murmur;   rapidly
increasing dullness over a large area; heart-sounds weakened. 
88
DISEASES OF THE  HEART.
especially the first, the element of impulsion in the  first
sound  nearly or entirely lost, the sounds apparently distant.
The posture is generally with the head and shoulders raised.
The patient cannot lie  on the left side, the slightest  move-
ment increases  the distressing  dyspnoea.   Sometimes the
urinary organs are affected, and urination becomes frequent
and  painful—the secretion scanty, but of  nearly normal
color.  An excessively faint " empty " feeling at the pit of the
stomach is a notable  indication for digitalis.  Under  its use
the effusion  rapidly  diminishes;  the heart's action soon
improves in force; its irritability diminishes with the increased
tonicity; the lividity of the face and lips disappears, as  does
the dyspnoea, vertigo, and imperfect circulation everywhere.
But in order to effect this  curative action, you must know
the requisite dose.  Any attenuation above the third decimal
is useless.  The tincture, or first decimal, is usually required,
and must be given in doses of one to five drops every hour
or two until decided improvement sets in, when the intervals
between the  doses  may be  lengthened,  or the quantity
decreased.   I have  frequently found the patient so  near
cardiac syncope, that  I  have without hesitation  given ten
drops  of the strongest tincture, and,  with my finger on the
pulse,  watched  its effects.  If the pulse  did not rise,  or
increase in force in  fifteen minutes,  the dose was repeated,
and this was continued until  I was satisfied the dangerous
exhaustion wTas over.   In such cases of threatened or actual
collapse, you may think  veratrum album or arsenicum better
indicated, but neither are as reliable as digitalis.   After you
have warded off the immediate danger, prescribe the digitalis
in smaller doses, and place  the  patient under the influence
of  wine-whey, egg-nogg, beef-tea, cocoa, and other  highly
nutritious articles.
   Spigelia  is an  important  remedy in  pericarditis, but the
provings were conducted with such disregard for physical or
 objective symptoms, or  even correct subjective symptoms,
 that it is difficult to define clearly its  curative sphere.
   Baehr says the symptoms given by him are not pathogenetic
 but clinical, and even  these " do not contain the symptoms
 of sero-plastic or serous pericarditis.  On the other hand we
 distinctly  recognize in this complex  of symptoms, both the 
TREATMENT.                      89
purely plastic, as well as incipient endocarditis."  He further
adds  that  " according to  practical  experience,  spigelia  is
particularly adapted  to  rheumatic pericarditis, likewise  to
sero-plastic pericarditis during its whole course, especially
if the patient complains of internal local  pain;"  but he
asks  " upon what basis are w7e to prescribe spigelia in cases
where  the  disease   is  painless  and   has  scarcely  any
symptoms ? "
   He  gives  the  following  symptomatic indications  from
Hartmann ; indications which  are based  on  curative results
on the sick,  namely: "Undulating  motion of the heart;
indistinct  beats  of the  heart running  into  one another;
when laying the  hand upon the  heart, tumultuous  beating
of the heart, in a recumbent as well as in a sitting posture,
not synchronous with the radial pulse; spasms of the chest;
suffocative complaints; tremulous sensation  in the chest and
temples, increased by motion ; tearing sensation in the chest
when raising the arms over the  head, and wThen touching
the pit of the stoinaeh;  purring murmur during  the  beats
of the heart; stitches in  the region of the heart; pulsations
of the carotids with a tremulous motion; great dyspnoea at
every change of  position;  bright redness  of the lips and
cheeks, changing  to pallor dnring every motion; the impulse
of the heart raises the four last true ribs, the sternum and
xiphoid cartilage, and displaces the dorsal vertebrae;  audible
beating of the heart, causing a pain that is felt through to
the back;  cutting pains from  the heart to the shoulders, as
far as the head and arms; excessive dyspnoea, with a pressing,
cutting pain in  the abdomen, at the insertion of the ribs;
arthritic  pains and  stiffness  of the joints;   dull  stitches
where the beats of the heart are felt, and recurring with the
measured  regularity  of  the pulse;  the  beats  of  the  heart
can be felt  through the  clothes, with anxious oppression of
the chest; scraping  in the  throat, affection of the tracheal
and  bronchial mucous membranes;  the  beats  of  the  heart
are  not synchronous with the pulse;  purring  murmur."
(Dose, 3rd to 12th dilutions.)
   Niirum  (kali nitricum) ought to prove curative in  some
cases of pericarditis, especially if it appears as a complication 
90               DISEASES  OF  THE HEART.

of  acute  rheumatism or  33right'8  disease.   It has  man}
svmptoms which indicate its use in cardiac inflammation.
 " Gelsemhmm is rarely indicated in  acute  inflammations of
the heart.   It may  be  useful in the first stage, and for a
very short time.  It is  useful  in cases having a  catarrhal
orioin; rarely, if ever, in rheumatic pericarditis; and never
when from diseases of the kidneys.
  The symptoms calling for its administration are: chilliness,
then fever,  with feeling  of  dullness, heaviness and  swim-
ming in the head (occiput); stitching sensation in the region
of the heart;  constrictive pain around the lower part of the
chest;  sudden  attacks of  suffocation;  inspiration  of a
sighing  and  catching  character;  expirations sudden and
forcible; heart's sounds intensified; pulse full, rapid,  soft.
   For these symptoms the proper  dose  lies below the 2nd
 dilution.  No result will  be gained in inflammatory affec-
 tions if the higher  attenuations are used.  Its administra-
 tion should not be continued after the pulse becomes slower
 and softer, unless we change the dilution to the 6th or 12th,
 for if  indicated in the third stage, it is for  the tendency to
 paralysis of  the heart, which is a primary effect  of the
 medicine.
    Veratrum viride.   The same remarks are applicable to this
 medicine that have been applied  to  gelseminum.  It may,
 however, be given in those cases of idiopathic or  rheumatic
 pericarditis that are ushered in by violent  fever,-full, hard,
 bounding pulse, with congestion  to  the  head,  throbbing
 carotids, etc.  The pain is burning, constant, with oppression
 of the chest;  sensation  as  of a heavy load  on the chest;
 heart's action violent  and tumultuous;  respirations rapid,
 labored, and sighing.  Dose, 1 drop of the  tincture, or first
 decimal dilution, repeated every two hours.
   Unlike the veratrum alb., it cannot be used  in the second
 or third stages,  unless  we  have  the  rare phenomena of
 vomiting, cold  skin, pulse 20 or 30, and  here it must be
 given in the 6th dil.
    In  cases of poisoning by verat. v. (in  cats)  serum to the
 amount of 15 to \% was found in the pericardium.
    Colchicum has been recommended for pericarditis,  espe-
 cially  rheumatic.   Baehr says, " it seems  to  us  to  be 
TREATMENT.
91
improperly ranked among cardiac remedies."   In cases of
poisoning, no pericardial lesions were observed; in fact the
pericardial sac was found empty.  Muller, however, says that
colchicum  is more suitable for  pericarditis than endocarditis.
Baehr asserts that all the heart-symptoms  are secondary
from  loss of  fluids.   In Laurie's Practice a case is reported
where colchicum  removed the following  symptoms (after
laeh. and  ars.): dullness on percussion  over a larger space;
friction-noise at the sternum  stronger  than before, impulse
more powerful, but the natural heart-sounds  impaired  and
distant; great dyspnoea and faintness on the slightest move-
ment; oppression after eating or drinking ever so little; no
cardiac pain; position on the  back, with head and shoulders
raised."   This would seem to prove that it wras useful in the
second stage.  It is probable that  the best  indication for
colchicum  in  pericarditis is the  co-existence  of  rheumatic
inflammation elsewhere, and the urinary symptoms indicating
that medicine.
   Dose:   The dilutions from  the 1st to the 6th
   Tartar  emetic, according to  Russell, is  a good remedy in
some cases of  rheumatic pericarditis, and for the following
urgent symptoms: " Great dyspnoea, and violent  pain at the
heart, with cough."  But  he  evidently does not believe it to
be a specific  remedy, but removes this dyspnoea, etc., by its
action on the lungs,  and its effect  on  "the pulmonary
branches  of  the pneumogastric nerve, by sympathy with the
cardiac."
   Dose:   Grain doses of the  2nd or 3rd dec.  trituration.
   Kalmia latifolia.  Of this remedy Hering says, "No remedy
in the whole  materia medica has such control  over the pulse,
except digitalis."   "In diseases of the heart which alternate
with  rheumatism, or have originated in rheumatic attacks,
kalmia must become important."  No clinical reports  have
been  made to  substantiate this statement, nor do we know
of any reliable symptoms of the medicine indicating its use.
If useful at all, it is in the first stage.
   Cactus  grandifiorus  was  strongly  recommended  by  Dr.
Rubini for " all inflammatory affections of the heart."  He
does not,  however, mention pericarditis among his clinical
observations, but  says  it  cures pleurisy and  inflammations 
92               DISEASES  OF  THE HEART.

of serous membranes.  If homoeopathic to pleurisy, it is
probably also to pericarditis.  The symptoms seem to indi-
cate   its  tendency  in   that  direction :   " Sensation  of
constriction of the heart.  Dull, heavy pains in region of the
heart, increased by external pressure.  Pricking pain in the
heart, impeding respiration and motion of the body.   Very
acute pain, and  such painful  stitches in the region of the
heart as to cause him  to w^eep  and cry out loudly, with
obstruction  of respiration.  Palpitation  of the heart  con-
tinues day and night.  Fever, with great heat, violent pain in
the head," etc.  It is to  be greatly regretted that Dr. Rubini
made no observation of the pulse, or examined the condition
of the heart by physical exploration.  Such neglect is a loss
to science, and  utterly unpardonable.  Cactus may be indi-
cated in any stage of pericarditis, and the best effects have
been obtained from the  lowest dilutions.
   Cannabis.   Baehr  seems to  confound  the cannabis  indica
(haschisch) with  cannabis saliva,  which  latter possesses, in
no degree, the cerebral  symptoms of the former.   Cannabis
saliva has been recommended  in pericarditis, but upon very
unreliable data.  Baehr gives the following symptoms  of
cannabis  indica:   "Violent palpitation of the heart,  some-
times without any anguish, sometimes attended with perfect
agony."   It is indicated in cases of pericarditis with cerebral
symptoms.. Dose, 1st to 3rd dilution.
  Sulphur  has  not usually been  mentioned  in  connection
with pericarditis, but its  pathogenesis contains many symp-
toms relating to the heart.  From analogy, however, I claim
that it ought to receive  more attention as a cardiac remedy.
  You have been taught  how useful it  is as a remedy in
pleurisy,  in  the  stage  of exudation, also its power over
obstinate inflammations.
  Its  action on the pericardium is doubtless  the same as on
the pleura,  If it will cause absorption of plastic lymph in
one serous membrane it will in any other.  Baehr mentions
" a case of pericarditis where  uncommonly loud friction-
murmurs and a  rubbing of the  pericardial surfaces against
each  other, that  could  even be  felt by the hand, and had
already  existed  for  upward of  three months, disappeared
entirely after sulphur had been given for a fortnight,"  You 
TREATMENT.
93
   may give  sulphur with  great  confidence  where  there is
   plastic exudation, if the  inflammation seems to linger, not-
   withstanding the free use of bryonia,  (Dose, 1st to 30th.)
     Iodine, or iodide  of potassa—I  prefer the  latter—will  be
   found useful in cases quite similar to those for which I have
   recommended sulphur.  Iodide of potassa has great power
*   in causing  absorption of morbid products.   It removes the
   plastic and serous exudation in pleurisy and  pericarditis.
   The pathogenetic symptoms  recorded  in   the  Symptomen
   Codex  are  very  suggestive, and  closely  simulate the pains
   of pericardial inflammation.  (Dose, one-half to two grains
   in an ounce of pure soft water every four hours.)
      The alkaline treatment, although not dynamic, but  chemical
   in its  nature, has  some claims  upon your  attention.  The
   theory advanced in its support is this: alkalies are  supposed
   to exert their effect by neutralizing the materies morbi in the
   blood, and also to eliminate them from  the  body.  The
   bicarbonate of potassa or soda are the alkalies preferred, and
   it is considered necessary to give as much as  three or four
   drams daily, until  the urine becomes alkaline.  It is claimed
   by Fuller,  that rheumatic pericarditis may be prevented if
   the  alkaline  treatment  is  carried to  this  extent.   Dr.
   Richarsdon's researches appear to substantiate this  assertion,
   for of 48 cases  in which the  " full alkaline treatment"  was
   employed,  the heart was affected in but one case.   He con-
   trasts these with 110 cases treated by  bleeding, nitre, mercury,
   etc., where the heart was affected in 35.   Flint,  however,
   says he  has known cases in which pericarditis  occurred
   during the " full  alkaline treatment," and  after  alkalinity
   of the urine had been produced.   Dr. Russell (honiceopathist),
   in  his Clinical  Lectures on  Rheumatism, approves  of  the
   alkaline treatment, and says that it cannot interfere with the
   action of specific remedies.  He believes that  we  ought to
   neutralize  and eliminate the lactic acid, and  thus remove the
   cause.  He also believes that both aconite  and bryonia  act
   by removing the  cause which develops  the lactic acid, and
   in this way, perhaps, act as curative agents  in rheumatic
   affections.
      I have  frequently tested  the  value of the alkaline treat-
   ment  and  believe acute rheumatic affections generally  run 
94
DISEASES OF THE HEART.
a shorter course under such  treatment,  You may give ten
or twenty  grains, or  more,  of the bicarbonate  of soda  or
potassa,  or  the  citrate of potassa, largely diluted with  gruel
or pure  water,  three  or four times  a clay, until  the  urine
becomes alkaline, which condition is  readily ascertained by
testing that secretion with litmus  paper.

                      RECAPITULATION.

  For pericarditis, as  a complication  of acute rheumatism,
the remedies are, aconite, gelseminum, veratrum viride, asclepias
tuberosa, bryonia, cimicifuga, colchicum, cactus, nitrate and  iodide
of potassa,  digitalis, spigelia, and sulphur.
  F'or pericarditis from Bright's disease, arsenicum, phosphorus,
kali nitric am, colchicum, asclepias syriaca, digitalis, and benzoate
of ammonia.
  For pericarditis  from  pyaemia, arsenicum,  baptisia,  phos-
phorus, carbolic acid, and the sulphite of soda.
  For threatened  cardiac paralysis, digitalis,  veratrum album,
lachesis, naja,gelseminum, aconite, veratrum viride, and arsenicum.
  For pericarditis, wTith pneumonic complication; phosphorus,
tartar emetic, kali nit., sanguinaria, bryonia, veratrum viride; with
pleurisy;  bryonia, asclepias tuberosa,  arnica, iodide  of potassa,
sulphur ; with cerebral irritation, cannabis ind., veratrum alb.,
cimicifuga, belladona, digitalis, and perhaps opium.
   For hydropericardium, or  copious  effusion of serous fluid,
digitalis, arsenicum,  colchicum, apocynum cann.,  benzoate  of
ammonia, nitrate and  iodide  of potassa, iodide of arsenic, and
perhaps apis mel.

             DIETETIC AND HYGIENIC  TREATMENT.

   During  the  first or  acute inflammatory stage,  the diet
 should consist of the lightest kind of food.  Cardiac inflamma-
 tions  do not exhaust the general system as much as other
 inflammations, and less  food will sustain the vital forces.
 All stimulating or highly  nutritious food and beverages
 should be prohibited.   Mental and bodily exertion must be
 avoided as much as possible.
   In the stage  of effusion, when the heart becomes weak and 
DIETETIC AND HYGIENIC TREATMENT.          95
irritable, the only change  in  diet and regimen  you should
advise, would be to permit light soups and broths, or weak
beef tea, if the patient desires them.   In this stage tea should
be  strictly prohibited, and  absolute mental and  physical
repose  insisted upon.   In threatened  paralysis  you  may
administer cautiously alcoholic stimulants, beef-tea, carbonate
of ammonia, and  even apply the  electro-galvanic current in
desperate cases.
  If I have not fully impressed upon you the importance of
insisting upon absolute quiet, and the recumbent posture, I
will here repeat, that you should insist that the patient must
not be raised  in bed to eat, drink, urinate or  defecate, nor
turn on his side unaided,  for any such movements in severe
cases may result in fatal syncope.
   External applications on  the chest, over the region of the
heart, may be  of benefit in some cases  by assisting in the
reduction of the inflammation, or palliating the pain.   Warm
poultices of flax-seed meal, medicated with tincture of aconite
or  verat. viride—or compresses of quite warm water, may be
applied during the first  stages.  In the latter stages, I
eannot recommend you to prescribe any external application. 
LECTURE  VI.
                      ENDOCARDITIS.
Definition — Anatomical Characters — Causes and Pathology—Symptoms —
  Physical  Signs — Diagnosis — Prognosis — Treatment.

  Gentlemen :   I  shall,  in this lecture, take up  one of the
most important of the inflammatory affections of the heart;
more  important than pericarditis,  because of  the serious
valvular lesions which it usually leaves.
  An inflammation of the membrane which lines the cavities
of the heart, and  is duplicated to cover the valves, is called
endocarditis.   It  is not more  than  fifty  years since  this
disease has been clearly described and recognized, but clinical
experience has demonstrated that it  is by no means infre-
quent.  In the  majority  of cases  it  occurs as a complication
of acute rheumatism.  The inflammation may be acute, sub-
acute, and chronic, but these distinctions are not of practical
value.

                 ANATOMICAL CHARACTERS.

  This inflammation  is  said  to  be  confined, in  the vast
majority  of  cases,  to the  membrane lining the cavities of the
left side of the  heart.  The  lining  membrane of the  right
auricle and ventricle is rarely inflamed, and when inflamed it
is also present on the left side.
  All portions  of  the endocardial membrane of the left side
are not equally subject to inflammation.   You must'bear in
mind  that  it generally attacks the  membrane covering the
valves and  lining the orifices, and that it  is in  these situa-
tions that it leaves the most troublesome results.   There are
two reasons for the tendency to attack these localities.   1st.
The membrane here is most exposed to the blood-currents •
the valvular portion  is  in constant motion, and  is almost
constantly in a  tense or strained condition.  2nd.  The mem- 
ANATOMICAL CHARACTERS.
97
brane is here underlaid by fibrous tissue, and not, as in other
situations, in close proximity to  the muscular walls  of the
heart.
  Flint believes  there are  grounds for believing that the
foetus in litero is subject to endocarditis, a.nd that the inflam-
mation is then limited to  the right side.   He believes the
malformations  found in  infants — cyanosis,  etc.—may thus
be accounted for.
  In  the  occasional instances  in which death has occurred
during the inflammation, there  has been  found (a) redness
from  vascular  injection,  (b) alterations in  the membrane
itself, and (c) the presence of inflammatory products.
  (a)   Redness,  due to endocarditis, is caused by injection of
the vessels which ramify  in the  areolar tissue  beneath the
membrane, but it is not always found,  and may disappear as
a post-mortem change.  But the  redness, when found, is not
always a  proof of inflammation, for it may be the effect of
the imbibition  of haematin dissolved out of the red globules
of the blood which the cavity contained after death.   This
redness from imbibition,  however, is distinguished from that
due to inflammation  by these  differences:  (1)  It is  not an
arborescent,  but'a uniform redness,  and when examined
with  a lens, injected vessels  are not visible;  (2) It has a
deeper and darker color than  inflammatory redness;  (3) It
is not  more likely to  be limited  to the left than the right
side, nor is it usually limited to  the valves and orifices, and
is more conspicuous in the arteries than in  the cavities of the
heart.  Moreover, in  redness from  imbibition, the  mem-
brane preserves its normally firm, polished appearance.
  (b) Alterations in the membrane itself are much more indica-
tive of inflammation  than redness.   These  changes  are:
"loss  of the   smooth,  polished appearance  which  the
membrane has in a  healthy  state;  instead of  which  it
becomes opaque, rough, velvety,  and felt-like ; more or less
swelling and softening;  and  brittleness  of the -subjacent
areolar tissue."  (Flint.)
  (c)   The presence of inflammatory products will prove to you
conclusively, if present, that endocarditis has existed.   You
remember that the endocardium, unlike other serous mem-
branes, is not  a  shut  sac,  wherein inflammatory products 
98
DISEASES OF THE HEART.
 may  be collected  and  retained.  Such products  may  be
 washed  awa\ by the  currents of blood  and carried  along
 with  the circulation,   Another difference  is that  the free
 surface of the endocardium  is  in contact with  the  blood
 itself, and  that while the fluid detaches and removes morbid
 products, it may also furnish deposits by yielding a portion
 of its fibrin, which undergoes coagulation.
   These products  of  inflammation,  then,  may be  derived
 from  two sources, namely:  the exudation of lymph, and the
 coagulation of fibrin from  the  blood.   The exuded lymph
 occurs on the free  surface of, as well  as beneath,  the  endo-
 cardium.   That on the free surface, if not washed  away,
 forms layers, as in pericarditis.  The roughness of the exuded
 lymph attracts—as  it  were—fibrin from the blood, as the
 threads did when passed through the  arteries in Dr.  Simon's
 well  known experiments.  When we consider that in acute
 rheumatism the fibrin of the blood is in excess, we can see
 how the tendency to fibrinous depositions is greatly increased
 in endocarditis from that cause.
  Various  morbid growths are to be enumerated as  the result
 of endocarditis.  They are  commonly called vegetations, and
 are found  either at the base or the  free extremities of the
 valves.   They occur in the  form of small granular masses,
 or beads, from  the size of a pin's  head to a millet  seed,
 studding the margins of the curtains  of the mitral valve,
 and fringing the crescentic extremity of the fibrous portion
 of the segments of  the valves of the aorta.
  Virchow denies the occurrence of the exudation  of lymph
 in  endocarditis.   He  charges   the formation of excres-
 cences and membraniform  layers wholly to proliferation
 or morbid growth, and the coagulation  of coagulated fibrin
 from  the blood within the cavities of the heart.  Flint,
 however, believes  that  morbid  growths may  have,  as  a
nucleus, the true vegetations or exuded  fibrin, to which may
be added the  coagulated fibrin from the blood.
  Other morbid changes may occur,  namely: loss of sub-
stance by ulceration and erosion; perforation of the valves;
lacerations; and even gangrene.  Among the rarer occur-
rences are  adhesions of the  valves to each other, or to the
walls  of the heart. 
CAUSES AND PATHOLOGICAL. RELATIONS.         99
  The remote  effects  of  endocarditis will  be considered in
future lectures, when we  come  to consider the  Organic
Diseases of the Heart.  I will  only say here, that in a very
large proportion of cases, valvular  lesions, involving either
obstruction or regurgitation, or both, owe their origin to the
anatomical changes which occur as a result of endocarditis.
It may be months or years before  serious structural  changes
obtain; but you should  carefully watch your patients who
have had this disease, and  be on  the look-out for the first
symptom of organic  affection, for it  is rare that they are
escaped altogether.

           CAUSES AND PATHOLOGICAL RELATIONS.

  Endocarditis  is rarely an  idiopathic  affection.   Like
pericarditis,  it  is usually  associated with acute articular
rheumatism.  It differs, however, from the former, in occur-
ring independently of that affection, and is a comparatively
rare affection as occurring in other pathological connections.
When the two diseases  occur together, the combined affec-
tions are designated endo-pericarditis.
   Of 474 cases of rheumatism, collected and  analyzed by
Fuller,  endocarditis  existed   in  214, the ratio being 1  to
every 2.25 cases.   Of 204 cases, endocarditis existed in 138,
pericarditis in 19, and endo-pericarditis in 38.  Bamberger
says endocarditis  occurs  in   20  per  cent,  of  all  cases  of
rheumatism.
   The connection of endocarditis with acute rheumatism is
'the same as  that  of pericarditis.   It  is not developed  as a
metastasis, but depends upon the same morbid condition
that causes the rheumatic affection.
   Endocarditis may become  developed in  connection  with
renal disease, owing  to the analogy of structure between the
endocardium and the serous membranes.  (See Pericarditis.)
   It is  said  that in non-rheumatic endocarditis the aortic
 valves are more likely to be  the seat of inflammation  than
 the mitral;  the  reverse being true, as has been seen,  of
 rheumatic endocarditis.
   Endocarditis and  pericarditis  are frequently associated.
 Fuller says that in 204 cases, analyzed by him, this combina- 
100
DISEASES OF THE  HEART.
tion.existed in 38.  Either affection may take precedence in
point of time.
   Endocarditis  is  sometimes associated  with  pleurisy  or
pneumonia.  It is less frequently associated with these affec-
tions than pericarditis. Endocarditis is occasionally develoiied
in connection with the eruptive and  continued fevers, and
with that  morbid  condition  known as  pysemia,  but its
occurrence  in  these connections is  rare.   It may  also be
produced by injuries of the  chest; but  cases of traumatic
endocarditis are rare.
   The  experiments of Richardson, made by injecting  into
the peritoneal cavity of a clog a solution  of lactic acid, con-
taining ten per cent, of the acid, seems to  show that lactic
acid, when  absorbed into the blood, will cause endocarditis.
   In about twelve hours after the operation, the symptoms
and  physical signs  of endocarditis appeared.   Richardson
regarded  his  experiment  as  proving  synthetically  that
rheumatic endocarditis is produced by a similar agent,  In
rheumatism the morbid conditions are supposed to be caused
by the presence of lactic acid in the blood.

         PATHOLOGICAL RESULTS  OF  ENDOCARDITIS.

   Endocarditis may give rise to immediate  pathological
results which are important, namely:  emboli, or plugs, con-
sisting  of  detached vegetations,  or  excrescences,  which,
propelled with the current of blood into  the arteries, "are at
length arrested in their course in trunks too small to permit
their further progress, giving rise to arterial obstruction and
diminished supply of blood to certain parts.  For a further
consideration of this subject, see Valvular Lesions.
   "The solidified products in  cases of endocarditis, namely:
fibrin and  lymph, are, to  a greater or less extent,  disinte-
grated by the blood-currents, and carried into the circulation,
either  in solution or  suspended in  the  form  of  minute
particles.  It is supposed that the comminuted solid deposits,
transported to  different organs, and  becoming  arrested in
the capillary vessels, may give rise to vascular  obstruction
and  secondary inflammation in these organs.  The  kidneys
and  spleen are most likely to be  the seat of disease thus 
SYMPTOMS OF ENDOCARDITIS.
101
induced.  These effects are primarily mechanical; but it is
highly probable that morbid changes in the blood itself are
sometimes induced by the admixture of the liquid products
of endocardial inflammation.   It can hardly be otherwise if,
as is not improbable,  purulent matter is occasionally formed
on  excoriated or  ulcerated surfaces,  which  are in some
instances observed after death  in  cases  of  endocarditis."
(Flint.)
  The formation of large masses of fibrinous coagula  in the
cavities of the heart  belongs to the  immediate pathological
effects  of endocarditis.   It is  supposed that these ante-
mortem clots are the  formations called  by the older writers,
polypi of the heart.

                SYMPTOMS OF ENDOCARDITIS.

   The  symptoms of endocarditis  are  less distinctive even
than those  of pericarditis.  Occurring  generally  in connec-
tion with acute rheumatism, its symptomatic indications are
merged in those of the latter affection.  In a large  proportion
of cases, there are no symptoms which attract attention to
the heart as the seat  of any disease.  Examination, however,
with a  view to  determine the  presence, or otherwise, of
phenomena which point to endocarditis, may elicit symptoms
which are of importance in the diagnosis.  These symptoms
consist of pain referable to the  heart, symptomatic fever,
and excited action of the organ, or palpitation.   Symptoms
arising from obstruction to the passage of blood through the
orifices  of the heart, do  not belong properly to  the symp-
tomatology  of endocarditis, but are due either  to lesions
resulting from endocardial inflammation, or to  accidental
events, such as the formation of coagula.  (Flint.)
   Pain is very rarely a prominent symptom, and,  as in other
serous inflammations, is sometimes altogether absent.  Even
when  it  is present it is not easy to refer it to endocarditis,
except by taking into account other symptoms, and especially
the physical signs.   The pain  is generally dull and obtuse,
rarely sharp or lancinating.  A feeling of uneasiness hardly
amounting to pain, is sometimes referred to the  praecordia.
The  suffering which patients endure from the  pain in 
102
DISEASES OF THE  HEART.
the  joints is so  much more  severe,  that  they will  not
be likely to mention the uneasiness in the heart unless you
question them closely. If the pain  in the region  of the heart
is so severe and acute as to cause complaint, the probabilities
are that pleurisy or pericarditis is present, rather than endo-
carditis.
  The/<r<r is not  of any importance, for it is not distinctive
of this disease.
  Palpitation  in endocarditis may arise indirectly from excita-
tion of the muscular  structure of the heart,   The action of
the heart  may be irregular, as well as unnaturally excited.
  The pulse  may  not correspond  with  the  action  of  the
heart, for while the latter  may be acting with increased
force, the  pulse may be weak.
  If  you  observe these  symptoms  occurring  during  the
course  of acute  rheumatism, you may safely  suspect  the
presence  of endocarditis, and you should resort to physical
examination  without delay.

             PHYSICAL SIGNS OF  ENDOCARDITIS.

  Increased extent and degree of dullness on percussion,  due
to  tumefaction  of the  heart,  and accumulation of  blood
within its cavities, is considered by Bouillard and others as
a  physical sign  of endocarditis.   Flint,  however,  doubts
whether the cardiac enlargement often, if ever, exceeds the
limit of healthy variations.  He thinks if the heart is found
enlarged, there must have been a previous hypertrophy.  He
says, "how  far the size of the heart undergoes alterations
during the progress of endocarditis, I am unable to say from
my own observations, but it is evident that percussion  can-
not afford very important  information with reference to this
disease, except in a negative point of view, that is, by aiding
in  the exclusion of other cardiac  affections, more especially
pericarditis."
   Palpation and  inspection will furnish  evidence of  excited
action of the heart.  The impulse  is seen and felt to be more
violent than  in health, or out  of  proportion to  the amount
of febrile movement which exists.  But the  signs furnished
you by these methods of exploration will be of little value 
PHYSICAL SIGNS OF ENDOCARDITIS.          103
to you except  as  associated with other evidences of endo-
cardial inflammation.
  Auscultation will furnish  you with the only positive proof
of the existence of endocarditis, and this proof is the devel-
opment of the endocardial  murmur.
  This assertion has been substantiated by clinical experience,
and you should  give particular attention to its study.  The
murmur  is usually soft, having the character of a bellows-
sound.  It is systolic, for it accompanies the first, or systolic
sound of the heart, but you will not find it always at the com-
mencement of the disease.  In fact, its existence is considered
rare in that stage.   I cannot give you any certain data as to
the period of inflammation in which this murmur occurs.
There are conflicting opinions on this point.  The time of its
appearance is,  however, in the  opinion  of  all authorities,
quite  variable.   The  endocardial  murmur is not, of itself,
absolute  proof of  existing  endocarditis.  Previous valvular
lesions may be  a  cause  of the murmur.   It  occurs in con-
sequence  of blood-changes, independently of inflammatory
or organic disease  of the heart.
  Under  what  circumstances  then,  you  will ask,  is the
presence of the murmur a diagnostic symptom of endocarditis ?
If you  find  an endocardial  murmur  in  connection with
symptoms denoting  cardiac  inflammation,   and  if  acute
rheumatism co-exists; and, further, if you  have made previ-
ous careful explorations, and failed to discover any murmur,
you may then conclude that the murmur you have detected
is a sign  of endocarditis.   If,  howrever, the murmur is dis-
covered  on first examination  the symptom  is of  doubtful
value.
  A murmur developed by endocarditis generally continues
not only throughout  the  duration of the disease, but even
afterward. There seem  to be some exceptions to this rule,
for Flint says  he has repeatedly known a mitral murmur to
disappear entirely  after recovery from rheumatism, when  it
was very marked during the disease.  This could only occur
in those  rare cases in which the swelling   of  the valves
diminishes, and the vegetations are  detached and  washed
away, leaving the endocardial surface smooth. 
104
DISEASES OF THE HEART.
  I need not  inform you of  the  cause  of tnc murmurs
alluded to.  It is doubtless due  to a roughness of the endo-
cardial  membrane  covering the  valves, produced  by  the
lymph, fibrin,  and vegetations; although some authors have
conjectured that the  murmurs were due  to a spasmodic
action of the papillary muscles,  preventing the.mitral valve
from  fulfilling its function—allowing regurgitation  to take
place.
  The heart-sounds may be abnormally modified during endo-
carditis.   Reduplications  have  been observed.   The first
sound, and sometimes the second, may be  less distinct than
in health, or the first sound may be wanting.

                       DIAGNOSIS.

  You will find  that  the diagnosis of endocarditis does not
depend  upon  symptoms,  but almost entirely on  evidence
developed by auscultation.  Those of you who attempt to rely
upon symptoms alone  will necessarily overlook  this import-
ant disease, and  allow your patients to lose the aid which
might be afforded in the prevention of organic disease.  Never
neglect this in cases of acute rheumatism.   Examine your
patient every day, and be on the watch  for the endocardial
murmur, which is the only sure evidence of this disease.
   But, as I stated a few  moments ago, you  cannot give a
positive  opinion unless you  have been  watching  for  this
murmur at a time before it existed, for if you heard it at the
first examination, it may have previously existed from some
valvular lesion of long standing.  You will  readily deduce
from this caution, that it will  be very difficult, if not impos-
sible, for you to detect endocarditis in a  patient who has
any organic disease of the heart.
   As idiopathic endocarditis is  the rarest of all diseases of
the heart, I will not  enter into discussion of its diagnosis.
I must  inform you, however, that pericarditis  is  so often
associated with  endocarditis,  that  you will rarely  find the
latter free from the former.  In  the  diagnosis  of endo-
pericarditis,  you will have to  compare  the signs  of both; 
PROGNOSIS.                     105
but,  happily,  the  treatment  of these  affections  is not
materially different.

                        PROGNOSIS.

  The prognosis  of endocarditis  is  generally favorable, so
far as any immediate  danger  to  life is concerned.   The
symptoms may continue, and the condition become chronic,
and cause great inconvenience, and exist  for a long  period.
Chronic endocarditis may be suspected if the  patient  con-
tinues to complain of uneasiness in the heart0 and that organ
continues unnaturally excited. But this disease, when chronic,
so  nearly simulates valvular disease, that  the prognosis
depends on the extent of the structural lesion.
  Certain accidental events may  occur during endocarditis
which may seriously endanger  life,  namely:  the formation
of fibrinous coagula; the detachment of vegetations or of
masses of fibrin or lymph, constituting emboli; the admix-
ture of disintegrated solid deposits;  and  purulent infection
of the blood.
  If we can judge of the prognosis  from recorded  clinical
experiences, wre can  believe that, in a large majority of cases
of endocarditis, recovery takes  place without serious acci-
dents.  The cardiac symptoms  gradually disappear.   The
patient, however, is generally left exposed to the evils arising
from  valvular  disease,  which may become developed at a
period  more  or  less  remote,  unless your treatment  has
prevented such a result.

               TREATMENT OF ENDOCARDITIS.

  The treatment  of endocarditis  cannot  be disposed of so
summarily  as some authors  have done,  by  asserting  that
there  is " no essential difference " in the treatment of endo-
carditis and pericarditis.  Xot only is the treatment not the
same,  but the objects  of treatment are  dissimilar.  Flint
very tersely observes, that in pericarditis the  compression
of the heart by the accumulation of liquid within the peri-
cardial sac is a source of distress and danger; and to prevent
this accumulation, and promote its removal, are  important 
106
DISEASES OF THE  HEART.
therapeutical ends.  In endocarditis, however, the action of
the heart is free from all mechanical  restraint.  In  pericar-
ditis the  inflammation  is more  generally  diffused, and a
greater effect is produced upon the muscular walls, first  by
excitation, and afterwards by paralysis.   In  endocarditis the
inflammation is seated especially in the membrane connected
with the valves and  orifices, when it  is not in contact with
the muscular walls,  and the latter are consequently affected
in a less  degree.  In pericarditis the aim of the practitioner
is often to avert impending death.  In endocarditis  there is
little fear of a fatal result.
   But although the two affections are so dissimilar  in many
respects, the general principles of management are in a great
measure alike applicable to both.
   The therapeutical indications  in the treatment of endo-
carditis relate mainly to the alterations to which  the mem-
brane is  exposed, and to the products of inflammation.
   Your objects must be to diminish as  much as possible the
local  effects of the inflammation;  then  to aid in restoration
from  these effects,  and  thus protect the  organ  from the
remote consequences arising from incurable and progressive
unsoundness.   In other words, you must accomplish, if pos-
sible, the following results :
   1.   Abate the intensity of the inflammation.
   2.   Abridge its duration.
   3.   Limit the exudation of lymph.
   4.   Diminish the  precipitation  of fibrin.
   5.   Effect the removal of solid deposits.

   The remedies to which you must resort to gain these ends
 are, mainly:  aconite, veratrum viride, digitalis, arsenicum, spige-
 lia, phosphorus, colchicum, bryonia, asclepias, lachesis, naja,
 sulphur,  belladonna, rhus.
   Aconite is useful in the first stage of the disease, when the
 pulse is  hard, small, and quick, and there is pain of a sharp,
 pricking description in the cardiac region, with anxiety, fear
 of death, faintness, oppression, and tumultuous action of the
 heart, (see also "Aconite " in Pericarditis.)
   Veratrum viride you will find  useful  in those cases which
 are ushered m by a more violent congestion, pain, and intense 
               TREATMENT OF ENDOCARDITIS.            107

force  of the  circulation.  The bounding pulse—full, hard,
and quick;  the intense throbbing headache, without delirium,
will indicate this remedy, in  the lowest dilutions.  With
these  two agents, aided by a low diet and absolute rest, you
will be able to abate the inflammation and shorten its dura-
tion.  But the disease is often so rapid in its course,  that
you will  be  obliged  to  anticipate the second  stage,  and
alternate with the above :
  Bryonia, if the  pains are  of the severe stitching  character
peculiar to the medicine.   This remedy is powerful  against
the exudation of lymph, and is equally useful in endocarditis
as in pericarditis.
  Asclepias  tuberosa,  as  I   remarked   when  speaking of
pericarditis, has nearly the same sphere of action as bryonia.
   Colchicum  is probably more suitable  to pericarditis than
endocarditis.  I am of opinion,  however, that it  is not so
much the local condition that indicates this remedy, as the
condition of  the blood.   Colchicum causes an  extraordinary
increase in the secretion of uric acid, and it  is this which
makes  it such an invaluable  remedy  in  6ardiac  affections
occurring during attacks of gout.  It  is, however,  equally
useful in rheumatic endocarditis.
  Belladonna  is   an  excellent   remedy  in  endocarditis,
especially when there  is secondary irritation and congestion
of the brain, and also where there occurs congestion of the
chest.   It is  best indicated when the first is passing into the
second stage, and we have the following symptoms:  aching
in the cardiac region, taking one's breath away and causing
anxiety; occasional intermittence of the pulse; irregular,
unequal contractions of the  heart; throbbing  pain beneath
the sternum, near the  epigastrium; violent heart-throbbing,
with jarring  of the head and neck.
  Digitalis, from  the very nature of its action,  cannot prove
of much value in endocarditis, unless  it be associated with
pericarditis.  As  Baehr very properly remarks, " In endo-
carditis it seems almost impossible to indicate  special heart
symptoms requiring the  use of digitalis ; in such cases, the
constitutional symptoms will have to determine our choice."
However, as  endocarditis rarely occurs unattended by some
pericardial inflammation, digitalis should always  be thought 
108              DISEASES OF THE  HEART.

of, and selected according to  the  indications  given under
pericarditis.
  Arsenicum will not control acute  endocarditis, but  will be
found useful in those severe paroxysms of palpitation, or the
attacks of cardiac syncope, which sometimes occur.  It will
be most indicated if Bright's disease or pyaemia be the cause
of the endocardial inflammation.
  In  direct contradiction to Baehr, Dr.  C.  Miiller asserts
that ''Arsenic  has been  found serviceable  in  palpitations,
carditis,  endocarditis,  rheumatic, and   organic  diseases,
especially of the  left side of the heart,"  and he adds  that
" Arsenic possesses the most perfect specific and homoeopathic
relation  to  endocarditis.  Tt is indicated not only in  the
commencement of the disease, but also when exudations and
vegetations have  formed  on the  endocardium and valves,
especially  of  the left ventricle.   It is  hence  the  main
remedy in Bouilland's so-called chronic endocarditis.   It is
indicated when the  following physical  signs  are present:
dullness over  a  greater extent than  usual in the cardiac
region, especially in a vertical direction;  violent and irregu-
lar action of the  heart, with feebleness  or almost  complete
extinction of pulse; indistinctness,  or roughness,  of  both
sounds of the heart, or a  bellows-murmur with  the  first
sound, heard on the left ventricle and  along the aorta, but
loudest over the aortic valves, viz., at the edge of the third
rib, near the left edge of the sternum."
   Spigelia, according to  Baehr, is only useful in  incipient
 endocarditis, or  to  endocarditis  generally  before  marked
valvular changes  have taken place.   For the special indica-
tions  for spigelia,  I refer you to your notes on pericarditis,
 and the remarks  I shall make in the future consideration of
 valvular diseases.
   Phosphorus  will undoubtedly be of use to you  in  some
 cases  of endocarditis.  I  can  do no better  than to  give you
 the indications  pointed  out  by  Baehr, which  I  consider
 reliable.   He  says  " Phosph.orus is clearly  suitable  for
 inflammation of the endocardium and the  muscular tissue,
 never for pericarditis.   The constitutional  symptoms would
 lead us to recommend phosphorus in endocarditis associated
 with  pneumonia,  against  the cardiac  inflammation, not 
TREATMENT OF ENDOCARDITIS.
109
against  the pneumonia,  for we  have already stated that
when pneumonia is complicated with cardiac inflammation,
the presence of the latter constitutes an absolute obstacle to
the absorption of the pneumonic exudation.  In  the next
place,  phosphorus takes  the  precedence  over  every other
medicine in cardiac inflammation, when  occurring as com-
plications of such processes as  lead  us to infer a dissolution
of  the  blood,   like  scurvy,  puerperal   fever,  malignant
exanthematous diseases,  typhus,  etc.   Finally, we possess
few  remedies  that embody in their pathogeneses as plain
a  picture   of  nephritic and  cardiac   inflammation  as
phosphorus."
   Baehr is of opinion  that  we  have often cured cardiac
inflammations with phosphorus without knowing it.  In the
conclusion  of his observations he says,  " Finally, we have
to point out  a  symptom which most  decidedly  indicates
phosphorus, we  mean the dilatation which develops itself
during   endocardial   inflammation with  such surprising
rapidity."
   I will add that  phosphorus appears to be  pathologically indi-
cated in this disease.   The post-mortem appearances observed
after poisoning by phosphorus are: the  muscular tissue is
flabby and easily torn;  opaque appearance  and intersticial
distension  of  the endocardium;  bloody  infiltration,  which
in certain circumscribed spots penetrates the whole thickness
of the muscular tissue.  If, in addition to  these appearances,
we consider the very feeble, small, and exceedingly frequent
pulse; the frequent observation that the sounds of the heart
either often  disappear  or  are replaced  by murmurs, we
cannot  deny that this remedy ought to  be  tried in severe
cases, especially those of a secondary character.
   Lachesis, as well as all the  serpent-poisons, exerts a pro-
found an a" specific action on the  heart, and more upon  the
endocardium than the pericardium.  In all cases we find an
unusual  increase of  the frequency  of   the pulse,  which
becomes feeble and small, or intermittent; there is pain in
the region  of  the heart, the  pain being sometimes intense;
palpitation of the heart;  fearful anguish; bloody expectora-
tion, with  constant hacking  cough; marked symptoms of
cyanosis; icy coldness Of jthe extremities,  with cold perspira- 
110
DISEASES OF THE  HEART.
tion; paralvtic sensation in the whole left side of the body,
or a violent pain in the left shoulder and left arm.   In my
opinion, lachesis  (also crotalus and naja.)  is indicated  in  the
second and third stages  of very acute  and severe cases of
endocarditis, when arising  from pyamiia, typhus, or  during
malignant eruptive fevers.  It is homoeopathic to the vegeta-
tions  and  structural changes  which  occur, for post-mortem
examinations after death from serpent-poisoning have  always
shown the heart more or  less affected.   The endocardium in
the region  of  the valves is   infiltrated and  easily  torn;
ecchymoses  cover  its internal and external surfaces;  and
exudations occur in the muscular tissues of the heart.  Take
these indications, together with the many symptoms recorded
in our materia  medica, and you will have no  difficulty in
selecting lachesis.   Dose: the dilutions from 6th to :^0th.
   Iodine and its combinations should not be  neglected by
you in endocarditis.  They are indicated in sub-acute cases,
and not  so  much for the inflammation as for the structural
changes occurring on the valves.
   Cuprum aceticum  has been reported  by a Dr. Kissell* as
 having cured three cases of rheumatic  endocarditis, but the
 testimony is based on the observation that " Auscultation
 revealed a  bellows-sound  at  every other beat  of the heart;
 feeble pulsation of the heart."  The symptoms of the  heart
 were: "pressure under  the lower part of the sternum, and
 oppression  of the chest; pulse, 85;  quick pulsation of the
 heart, and the  tone feeble and dull, as  if it came from great
 depth."
   Do*c: the tincture, or 3rd to 6th triturations.
   Apocynum androsemifof.ium.    In endocarditis-rheumatica,
 when the rheumatic affection  has been  confined to the  hands
 and feet, and there is present considerable gastric and hepatic
 irritation.f
   Dose: the first dilution has been found most useful.
   Asdepids syriaca, as you will observe from the provings,
 will  likely  prove of service in endocarditis from renal affec-
 tions, or from a retention of scarlatinal poison.
   Dose: the tincture, a few drops, in water.
* Marcy and Hunt's Practice.       f New Remedies, 2nd Ed. 
TREATMENT OF ENDOCARDITIS.
Ill
  Baptism will  prove in your hands an unrivalled remedy in
endocarditis during or following typhoid or other low fevers,
especially when you have present its well known character-
istic symptoms.
  Dose :  the first decimal dilution, in drop doses.
  Cactus grandiflorus will never fail you, in the severest cases
of the acute form, if that peculiar symptom, " Sensation of
constriction of  the  heart, as if from a band around it, pre-
venting movement," is present.  No other remedy equals it
in controlling the severe  nervous palpitations common to the
disease.  I get the  best effects from the 1st dil.
   Cimicifuga  must  not  be forgotten  in the treatment of
endocarditis rheumatica.   It may be better suited to peri-
carditis, but if the former affection have a rheumatic origin,
I see no reason  why this  remedy should be neglected.  If
the  endocardial  inflammation  occur in  a woman from sup-
pression of the menses, and there is also intense headache,
delirium, stitching  pain in the region of the  heart, in the
infra mammary region, and down the left arm, you can give
the cimicifuga with every prospect of success.
   Dose: the dilutions below the 4th.
   Hamamelis.  I have reason to believe that in certain cases of
phlebitis, the inflammation may be transferred or extend to
the  heart.   If such a condition does occur, this remedy will
be found useful.  In the  provings we find it to cause pricking
pain in  the  region of the heart, felt  also in the superficial
veins of both  arms, continuing  for  ten  days.  By referring
to the provings you will find  other  important symptoms of
cardiac inflammation. This medicine acts best in the lowest
dilutions.
   Lachnanthes  will  have to be  used  if cerebral  symptoms
occur, which indicate its use.   The cardiac symptoms of this
remedy  are also notable.
   Lobelia inflata  has been used  successfully in some cases
of  endocarditis.   The  characteristic  symptoms calling for
its administration  are very striking:  excessive  vomiting;
an intense sensation of sinking at the  stomach;  sighing;
great dyspnoea; deep seated pain in  the region of the heart;
and small, quick, and feeble pulse.
   Dose: the dilutions from 1st to 6th. 
112
DISEASES OF THE HEART.
  Phytolacca may prove useful in sub-acute or chronic endo-
carditis if the patient has rheumatic  symptoms, and  the
cardiac pain extends to the right shoulder and arm instead
of the left.
  Saiiguinaria.   The   sphere  of  action  of this medicine
resembles that of phosphorus, in so far as the complication
of endocarditis  with  pneumonia  may  occur.  If you meet
this  complication  in  practice, do  not  forget  to study  the
provings of sanguinaria, for you may find it  indicated when
phosphorus or  sulphur have been used  without the expected
curative results.  If the right  lung is the seat of the inflam-
mation, it is to be selected instead of phosphorus.
  You will remember that in my lecture on pericarditis I
mentioned the efficacy of the  alkaline treatment, as  a means
of combatting the existing pathologico-chemical cause of
rheumatism.   The same  observations will apply  to  that
treatment in endocarditis.  It may also prevent the formation
of the solid products incident to the latter, by depriving the
blood,  to  a  certain  extent, of  its excess  of fibrin.   The
carbonate of ammonia has been highly recommended for this
purpose, as being more powerful than  other alkalies, and it
is affirmed that its use will prevent the formation of large
fibrinous coagula.

  The  indications during convalescence and  subsequently
are:  to advise against undue exercise, the  abuse of stimu-
lants, the avoidance of agitating emotions, and  excesses of
any kind, which  might  bring  back  the inflammation, or
hasten  the development  of  structural  lesions.   But  you
must not go  so far as to alarm your  patient to exceeding
caution, for  an extreme  sedentary life  should  be equally
avoided.   An  amount  of physical  activity  necessary to
vigorous health is not unfavorable as regards the liability to
organic disease.  You  mu>t  not excite the  fears of your
patient, for the moral  effect of looking forward  to probable
organic disease is not favorable to mental or bodily  health.

                       MYOCARDITIS.

   A brief allusion to  myocarditis will  close  this lecture.
This is an inflammation  of  the muscular structure  of the 
MYOCARDITIS.
113
heart.   The muscular substance of the heart is the seat of
inflammation much  less frequently than  the investing and
lining  membranes of the  organ.  It rarely,  if ever, occurs
independently  of   endo-  and peri-carditis.    Either the
investing or lining  membranes,  or both, are  implicated.
The inflammation, probably, in most instances extends from
these membranes to the muscular substance.  Theoretically,
it ought to occur more frequently as a complication of mus-
cular than synovial  rheumatism.  Practically, however, we
do not  know that this is the case.  The inflammation  is
usually limited to certain portions of the  heart, and it occurs
much oftener in the left than in the right ventricle.  It may
be confined to the outer or inner layers of muscular fibres;
or it may extend throughout the walls and affect the columnce
carnce.   The septum  is less  likely to  be affected than the
ventricular walls.  The results of myocarditis are suppuration,
induration, and aneurismal dilatation.  Rupture of the  heart
may also occur.
   Where abscesses  exist, there is purulent infiltration of the
 surrounding parts.   The formation of abscesses destroys the
 muscular structure to a great extent.   They may discharge
 their contents into  the pericardial sac, giving rise to acute
 pericarditis;  or  they may  evacuate  into the  ventricular
 cavity, and give rise to purulent infection  of the blood.  In
 either case a fatal result is inevitable.
    The diagnosis of myocarditis is nearly impossible.   There
 are no symptoms   or signs which can warrant a positive
 opinion.
    The treatment does not  differ materially from that advised
 in the former diseases. I will suggest, however, that  where
 there  is reason  to  suspect myocarditis, aconite,  bryonia,
 belladonna, cimicifuga, and other medicines having a special
 affinity for muscular structure, would be chiefly indicated. 
 
PART III.
ORGANIC DISEASES  OF  THE HEART. 
 
LECTURE  VII.
  Gentlemen :  You  have  followed  me  with  excellent
attention through the lectures on Functional and Inflamma-
tory Diseases of the Heart.  It is now my duty to give you
the history  and treatment of those diseases  of the  heart
which are termed structural, for the reason that they all pre-
sent some lesion which changes  its normal structure, and I
will commence with the various forms of

                      HYPERTROPHY.

Definition and  Varieties of Hypertrophy — Enlargement by Hypertrophy —
  Concentric Hypertrophy—Symptoms and Pathological Effects — Physical
  Signs and Diagnosis of Enlargement by Hypertrophy—Summary of the
  Physical Signs of Hypertrophy with Enlargement of the Heart—Treatment.

  Enlargement of the heart is a term which embraces abnor-
mal  increase  of this organ, as  regards  either  volume  or
weight, or,  as is commonly the case, increase both in weight
and volume.   Increase of the  volume of the  heart, and
increase of its weight, are different forms  of enlargement,
either of which, although they  are usually associated, may
exist independently of the other.  The heart may  exceed
the limit of  health as regards  weight, from  an increased
thickness of  its  walls, the normal volume being  retained.
This is  a condition sometimes found  after death, although
in  the vast majority  of  the  cases in  which  the weight is
augmented  the volume exceeds the healthy limit.
   On the   other hand,  the volume of the heart may  be
abnormally  great, the  cavities  being  enlarged, while the
thickness of the walls is so far diminished  that  the normal
weight is retained.  The latter form of enlargement is also
of  very  rare  occurrence, the  organ generally  increasing in
weight when  its volume  is greater than in  health.  Abnor-
mal increase  of the heart in weight, due to morbid thickness
of  the muscular walls of the  organ, constitutes  the morbid 
118
DISEASES OF THE  HEART.
condition called Hypertrophy.  Abnormal increase of the
heart in volume, due to the morbid size of its cavities, con-
stitutes the morbid condition called Pilatation.  These names,
hypertrophy and dilatation, thus  denote different forms of
enlargement of the heart, wmich exist sometimes separately,
but usually together.  Hypertrophy and dilatation have been
subdivided by waiters into several varieties, the subdivisions
being based on well-marked distinctions.
  First.   Hypertrophy exists, in  some cases, without  any
alteration of the cavities, the  latter remaining normal.  This
has been called pure  or simple hypertrophy.
  Second.  The cavities are sometimes  found to be dimin-
ished in size below the limit  of health.   This has generally
been admitted  as  a  variety of  hypertrophy, although its
existence, as a morbid condition, is open to doubt.  It has
been distinguished as concentric hypertrophy, or hypertrophy
with contraction.
  Third.  The variety  occurring  much  more  frequently
than the others is characterized by the co-existence of dilata-
tion to a greater or less extent.
  This variety has  been  called  eccentric hypertrophy, or
hypertrophy with dilatation.  Dilatation, on the other hand,
differs in different cases, according to the thickness of the
walls of the heart.
  First.   It exists in some cases, the walls  retaining their
normal  thickness.   This  has been  called pure,  or simple
dilatation.  It is obvious, however, that in proportion to the
dilatation, the heart  is hypertrophied, assuming the wralls to
preserve their normal thickness, inasmuch as the quantity
of muscular structure  and the weight of the organ, under
these circumstances,  must be  increased.
  Second.  In other cases,  in which  the  capacity of the
cavities is increased,  the thickness of the walls is diminished.
In this variety, the weight of the heart  may not exceed, and
may even fall below, that of health.  This  has been dis-
tinguished as dilatation with  attenuated walls, or attenuated
dilatation.
  Third.  The variety of dilatation  which occurs with far
greater  frequency  than  either of the  other varieties,  is
characterized by increased thickness of the  walls, or well- 
HYPERTROPHY.
119
marked hypertrophy,  the dilatation,  however, being  pre-
dominant.  These subdi visi ons, although based on distinctions
which are valid, are embarrassing to the student.  They are
consistent with the different morbid conditions of the heart,
as determined by  examinations after death;  but they are
not accompanied by diagnostic criteria, by means of which
they may be discriminated at the bedside during life.  A
simpler arrangement is clinically more available, and  suffices
for all practical purposes.
  We may distribute  all cases of enlargement of the heart
into  two groups:   1st, Enlargement by hypertrophy;  and,
2nd, Enlargement by dilatation.  These groups will include,
respectively, cases in which the hypertrophy or  the dilatation
is either simple or predominant.
  In cases of  enlargement by hypertrophy, the cavities  may,
or may not, exceed  their normal capacity.  Cases in which
the cavities are diminished will also fall in this class.  If the
hypertrophy be neither simple nor concentric, it is included
in this class whenever it is greater than the co-existing dila-
tation.   The symptoms  and signs enable  the  diagnostician
to determine,  often with positiveness, the existence of hyper-
trophy, wThich may be either  simple, or predominant over a
co-existing dilatation;  but to  discriminate  between the  cases
in wdiich  the  hypertrophy is  simple, and  those in which it
predominates  over  co-existing dilation,  is  a problem  in
diagnosis by no means easily solved.
  So, in cases of enlargement by dilatation,  the quantity of
muscular structure  may, or  may not, exceed  the limit  of
health.   The  diagnostic  criteria of predominant  dilatation
are often sufficiently positive; but it is far less easy to decide
whether the dilatation be accompanied with  hypertroph}7 or
attenuation.   Moreover, as regards prognosis and treatment,
after the existence and degree of enlargement are ascertained,
it is enough to determine which form of enlargement pre-
dominates, namely, either hypertrophy or dilatation. 
120
DISEASES OF THE HEART.
              ENLARGEMENT BY HYPERTROPHY.

  Under this head, it is to be borne in mind, I include, not
only enlargement due exclusively to increased  thickness of
the muscular  walls, but enlargement  by hypertrophy  with
dilatation, provided the former predominate over the latter.
In examining  the heart, after  laying  open the cavities and
removing their contents, the predominance of  either hyper-
trophy or dilatation is generally obvious to  the eye.  The
two  forms of  enlargement are combined, in  different cases,
in every degree of relative proportion.
  In  determining,  then,  whether  the enlargement  be by
hypertrophy or  by dilatation, the question  is, which  con-
tributes most  to  the morbid size, increase of the  structure,
or increased  capacity  of  the  cavities.  Instances, however,
occur in which  these  two forms of enlargement  are about
evenly balanced.   On  measuring  and weighing the heart,
the excess of weight is greater than the abnormal dimen-
sions, in proportion as hypertrophy preponderates.
  The walls are  more solid and  resisting.  The  ventricles
retain their  rounded form when the heart is placed on its
posterior surface, not being flattened by the collapse of the
ventricular  wralls.  If the increased thickness of the wralls
of the ventricles be due purely to hypertrophy, they present
'externally, and on section, the appearances of  healthy mus-
cular structure, and the microscope shows the  characters of
the  normal tissue;  the  hypertrophy,  causing  abnormal
volume and weight,  is  due  to  increase of the  muscular
substance.
  The heart may be more or less enlarged by  an accumula-
tion of fat upon the surface and between the muscular fibres,
or by the presence of different morbid  products in these
situations.   Under these circumstances, notwithstanding the
-abnormal volume and weight, the muscular substance may
be diminished;  that  is,  instead of hypertrophy, there is
atrophy of the heart,
  The several  portions of the heart may collectively partici-
pate in the enlargement, or  it may be confined  to one or
more of the anatomical divisions, without extending to the
whole organ.  In the majority of cases, all  portions are 
ENLARGEMENT BY HYPERTROPHY.          121
 involved, but they are rarely affected equally;  the  enlarge-
 ment is more marked in some divisions than in  others.  The
 different portions may predominate in one part and dilatation
 in another.   If the enlargement be limited to,  or be seated
 chiefly in, the left ventricle, the vertical is more increased
 than  the transverse  diameter;  the heart  is elongated, and
 the conoidal form may be more marked than in health.   If
 the enlargement  be great, the right appears to be  merely an
 appendix of the left ventricle.   The apex is lowered, and is
 more or  less removed to the left of its normal situation.
   On the other hand, if the enlargement  be  limited to, or
 be seated chiefly  in the right ventricle, the width, more than
 the length, is  increased; the conoidal form is  less marked
 than in health; and the apex, formed in part or entirely by
 the right ventricle, is blunt instead of pointed.  The apex
 extends lower than in health, and more in a direction toward
 the epigastrium than when the enlargement is seated in the
 left ventricle.  If both ventricles be considerably enlarged,
 the organ  has a  globular form.   The papillary muscles are
 not infrequently more or less  increased  in size  when the
 ventricular walls  are thickened   The degree of hypertrophy
 varies greatly in  different eases.  The thickness of the left
 ventricle  may be increased to an inch,  an inch and a half,
 and even two inches.  The wralls of the other compartments
 may,  in  like manner, be doubled, tripled, and  quadrupled.
 The vertical and transverse dimensions may be five or six
 inches, or more.   The weight may exceed two, three, four,
 and even more than five times the normal average.
   Is enlargement by  hypertroplry due to an increase in size
 of the muscular fires,  or does it involve an abnormal multi-
 plication of the fibres ? If the term hypertrophy be applied
 exclusively to morbid growth, it implies that the enlargement
 is due to  the former, that is, to an increase  in  size of the
 muscular  fibres.  The term is  thus restricted  by Virchow
 and others.  The  multiplication of fibres, on the other hand,
 is called  hyperplasia, or hypergenesis.  Measurements in
 normal hearts, and in hearts more or less  hypertrophied,
 show an increase  of size of the muscular fibres, their diame-
ter in the latter sometimes being four times greater than in
the former.  The heart  may, therefore, be enlarged so that 
122
DISEASES OF THE HEART.
the volume will be  four  times greater than in health, by
hypertrophy, in the restriction sense of the term.   This,
however, will probably not account for the increase of the
muscular substance in all  cases;  and, if not, the multiplica-
tion of fibres must he admitted.  Enlargement of the heart
by  hypertrophy, therefore,  may be  due wholly to hyper-
nutrition, or increased  growth of the muscular fibres, and
hyperplasia may be superadded.
  What causes  the  pathological processes,  namely, hyper-
nutrition  and hyperplasia,  which increase the quantity of
the muscular substance of the heart ?
  Generally, if not invariably, enlargement  by hypertrophy
is the result  of prolonged abnormal force of the heart's
action.  It is difficult to account for this form of enlarge-
ment,  except as  caused  by augmented  muscular  power
continued for a long period; and generally there are present
obvious causes which account, in this way, for the enlarge-
ment.   The mechanism is the same  as in the familiar
examples of certain voluntary muscles becoming dispropor-
tionately   developed  when  inordinately  exercised.   The
muscles  of the arms of the blacksmith  are strikingly in
contrast with the muscles of the lower limbs; and the reverse
is true of pedestrians  and  dancers.  Involuntary muscles,
aside from the  heart, also present examples.  For  instance,
the muscular structure of the urinary bladder may become
enormously hypertrophied, when the powrer of contraction
of  this organ  has been for a long time increased  in  conse-
quence of obstruction  to  the expulsion   of  the   urine.
Clinical  observation shows, that in most cases of enlarge-
ment  of the heart by hypertrophy, there are prior morbid
conditions which stand to it in  a  causative relation.  The
practical  bearing of this pathological view of  hypertrophy
is  vastly  important.   It follows, that enlargement of the
heart  by hypertrophy, as a rule, is compensatory;   or, in
other words, a conservative provision to meet the difficulties
incident to the morbid conditions  upon  which the  hyper-
trophy depends.    This  truth cannot  be  too  strongly
impressed.
   In the great majority of cases, enlargement by hypertrophy
ir  consecutive to, and dependent  upon, morbid conditions 
ENLARGEMENT  BY HYPERTROPHY.
123
within the heart, namely, on valvular lesions.   These give
rise to hypertrophy when they involve over-repletion of the
cavities,  in consequence either  of  obstruction  to  the  free
passage of the blood through the orifices, or of regurgitation
due to valvular  insufficiency.  The organ being unduly dis-
tended  and  stimulated  by  the  accumulation of blood, its
action becomes  abnormally  forcible;  the causes of accumu-
lation being permanent, and often progressively increasing,
the increased powder of action continues and augments,  and
hypertrophy is the result.  The  hypertrophy commences  in
that portion  of the heart which is primarily affected, but the
several  portions sustain to each other, in  their anatomical
structure and functions, relations so close and  reciprocal,
that causes which at first are limited to one portion, affect,
ultimately, the  whole organ.  The enlargement, however,
preponderates in the portion which is first affected.
  Directing  attention, with  some  detail,  to  the mode  in
which valvular  lesions give rise to  enlargement, wre shall
be  led to consider  the development of the affection in the
different  anatomical  divisions   of  the  heart,  respectively,
taking them up in the order of their greater relative liability
to become hypertrophied.
  Of the  several portions,  the left  ventricle is  oftenest
enlarged ;   next  in  liability^ to enlargement, is  the left
auricle; next, the right ventricle; and, last, the right auricle.
  The valvular  lesions which especially lead to hypertrophy
of the left ventricle, are seated at the aortic orifice.  Lesions
in this situation may involve, as will be seen hereafter, either
contraction, and consequently obstruction; or incompetence
of  the  valves, and consequent  regurgitation of the blood
from  the aorta into the ventricular cavity.

  Obstruction seated  in the aorta, either near to or at some
distance  from  the  heart,  such as  is incident  to aortic
aneurism,  may  lead  to hypertrophy of  the left  ventricle
primarily, and subsequently  of the other portions.   Enlarge-
ment commences  in  the left ventricle, in  connection with
lesions  affecting  the  mitral orifice and valves, and involv-
ing  either  contraction  or  insufficiency,  or  both these
immediate effects. 
124
DISEASES OF THE HEART.
  Contraction and valvular insufficiency at the orifice of the
pulmonary artery occasion, primarily, enlargement of the
right ventricle, precisely  as  aortic  lesions  induce, first,
enlargement of the left ventricle.
  Lesions at the tricuspid orifice being extremely infrequent,
enlargement  of the right auricle rarely occurs, except con-
secutively to an affection of the right ventricle.
  Enlargement  of the heart,  not associated  with valvular
lesions, may be  due to obstruction at a  distance from the
centre of the  circulation.  Obstruction  to the pulmonary
circulation incident especially to emphysema of the lungs,
and  occasionally to chronic pleurisy, collapse, and dilated
bronchi, leads to enlargement.

  The researches  of  Larcher,  Ducrest,  and  others, show
that a certain amount of hypertrophy, limited to  the left
ventricle, is incident to pregnancy.   It would seem that the
hypertrophy, under these circumstances, is to be regarded
as normal, and that it disappears after confinement.
  The changes wdrich occur in the muscular structure of the
uterus, in connection  with gestation, are thus  represented,
on a small scale, in the heart.  The increase in weight of the
heart in pregnancy, it  is estimated, may amount to one-fifth
of the previous weight of the organ.  Doubtless this tem-
porary hypertrophy is  compensatory or conservative, as it is
when it occurs in other connections.
  It wras  formerly supposed,  that the prolonged  functional
disorder of the heart frequently eventuated in  the develop-
ment  of  hypertrophy.  This supposition does  not derive
much  support  from clinical experience.   At  first view, the
statement just made may appear inconsistent with  the fact
that the  abnormal  growth of  the muscular walls of the
heart is the result of abnormal muscular action of the organ.
The inconsistency disappears when it   is considered that
functional palpitation, even when intense, does not involve
the increase of power  or  strength of muscular action which
is incident to  the over-accumulation of blood  from  an
impediment to the circulation.
  (See " Functional Disorders," page 50,  where this opinion
is controverted.  Sale.) 
          PATHOLOGICAL EFFECTS OF HYPERTROPHY.       125

  Enlargement  by hypertrophy, as already stated, is almost
always a secondary affection.  In the great majority of cases
it  is consecutive to valvular or aortic lesions.   It is also an
effect of certain chronic pulmonary diseases, more especially
emphysema of  the  lungs.   It  occurs in certain  cases of
Blight's disease.  It  is a  physiological event in pregnancy.
It may be produced—but the  examples  are very rare—by
long-persisting functional disorder.  Its occurrence, when it
is  not evidently a secondary affection, is  so infrequent, that
there is room for doubting whether it ever  be a truly idio-
pathic affection.   (Flint.)

   SYMPTOMS  AND PATHOLOGICAL  EFFECTS OF HYPERTROPHY.

  The symptoms  of  hypertrophy, in  the  cases which come
under the cognizance of the physician, are generally inter-
mingled  with  those of  concomitant  cardiac or  other
affections, of which the hypertrophy is an effect.  Cases of
hypertrophy not associated with, and dependent upon, other
affections, are so rare, that its clinical history cannot be said
to have been established by observation.   The  symptomatic
phenomena which are described  as distinctive of it, are
determined inferentially,  rather than by facts observed in
well-authenticated  cases.   Rationally considered, it  is clear
that the symptoms would be those indicative  of abnormal
power of the heart's  action.  Undue determination of blood
to the head might be expected to occasion certain phenomena,
such as cephalalgia, flushing of the face, throbbing, epistaxis,
vertigo, etc.   These  symptoms  have  relation  especially to
hypertrophy affecting  the  left  ventricle.  Assuming the
absence of aortic and of mitral lesions involving obstruction
or regurgitation,  the pulse would represent by its force,
fullness, and incompressibility, the power of the ventricular
systole.  Dyspnoea, when, from  any cause, the action of the
heart is increased, as, for  example,  after exercise, would
denote that the hypertrophy affected the right ventricle.  Of
the powerful action of the heart the patient would be con-
scious when his  attention was directed to it, and it would be
apparent from the movements of parts of  the body and the
dress.   The digestive and assimilative functions would not 
126
DISEASES OF THE HEART.
be  expected  to offer  any marked  symptoms of disorder,
The muscular strength would not be diminished; nutrition
would not be  impaired; nor the functions of secretion and
excretion interrupted.   (Flint.)

  Hypertrophy  of the  heart,  not  consecutive  to either
valvular or aortic lesions, and not an effect of either emphy-
sema or any  other  pulmonary disease,  constitutes  always
presumptive evidence of the existence of renal disease.

     SUMMARY OF THE PHYSICAL  SIGNS OF ENLARGEMENT
                      OF THE HEART.

  I cannot do better, in order to bring to your observation
in a practical way, the prominent physical signs of enlarge-
ment, than to quote from Flint on Diseases of the Heart.

  1.  Percussion.—The area of the superficial cardiac region
extended beyond the range of healthy variation.  The degree
of dullness within this area greater than in health, and  the
sense of resistance more marked.   The limits of the deep
cardiac region—in other words,  the  boundaries of the heart
—generally defined by careful  percussion; the  dimensions
of the space which the heart occupies being thus ascertained
with precision, and the form of the organ delineated on the
chest.  Enlargement  of the right or left auricle, sometimes
determined by the extent of the area of dullness at the base
of the heart, on the right or left side of the sternum.

  2.  Palpation.—The  apex-beat  moved to  the left of its
normal position, and  lowered; the  extent of variation, in
either respect, being proportionate  to the degree of  enlarge-
ment, provided extrinsic causes be excluded. The area within
which the apex-beat  is felt extended  beyond the range of
health.   Abnormal  impulses felt  in  two, three, or more
intercostal spaces, the additional impulses either synchronous
ior alternating with the apex-beat, in some instances referable
to the auricles, although due to  the ventricular systole; and,
when felt in the epigastrium, due to the action of the right
ventricle. 
    PHYSICAL SIGNS OF ENLARGEMENT BY HYPERTROPHY.  127

  3.  Auscultation.—The respiratory murmur not appreci-
able within the superficial cardiac region in tranquil breathing,
and sometimes wanting when the breathing is forced;  feeble
over a larger area within the prsecorclia than in health.  The
boundaries  of  the heart defined by  abrupt cessation  or
notable diminution of vocal  resonance, and the  augmented
space which the organ occupies, in this way determinable in
corroboration of the evidence afforded by percussion.

  4.  Inspection.—Abnormal projection of the praecordial
region in  some  cases;  the  projection  considerable if the
enlargement take  place  in  early life.   The movements of
impulsion  determined, w-hich are  also ascertained by palpa-
tion ; movements sometimes seen which are not  perceptible
to  the  touch,  especially movements wdrich  commence  by
depression with the  systole of  the ventricles.   Alternate
movements of  intercostal spaces often apparent to the eye,
which are imperfectly ascertained by palpation.

  5.  Mensuration.—Prominence of the pnccordia greater
than the corresponding portion of the chest on the right side;
in some cases apparent on inspection, but determined with
precision  by diametrical  measurement.  Mensuration also
employed  in  determining with accuracy the dimensions of
the superficial  and deep cardiac regions, the position of the
apex-beat relatively to the nipple,  median line, etc.

 SUMMARY  OF PHYSICAL SIGNS DISTINCTIVE OF  ENLARGEMENT
                    BY  HYPERTROPHY.

  1.  Palpation.—Abnormal  force of the apex-beat, denoting
not merely excited action  of  the  heart,  but  augmented
power of the systole  of  the left ventricle, the impulsion
prolonged and  strong. A strong impulse in the epigastrium
in cases of hypertrophy of the right ventricle;  the impul-
sions sometimes communicated to  the lower part of the
sternum, and extending  more or  less over the site of  the
liver.  A  strong, heaving movement of the prsecordia,  in
distinction from the shock, more or  less violent, due merely
to augmented functional  activity of the ventricles. 
128
DISEASES OF THE HEART.
  2.   Auscultation.—Increased intensity of the aortic second
sound, and especially of the element of impulsion of the first
sound, in hypertrophy of the  left ventricle, rendering  the
first sound dull and prolonged, as well as abnormally intense,
Exaggerated intensity of the pulmonary second  sound, in
hypertrophy of the right ventricle, especially if  associated
with obstruction to the pulmonary circulation.  Augmenta-
tion of the tricuspid valvular element of the first sound in
some  cases of hypertrophy of the  right ventricle.

                       TREATMENT.

  The treatment of hypertrophy of the heart, i. e.,  enlarge-
ment by hypertrophy, by  the allopathic  school,  presents
some of  the strongest arguments  against the wilful bigotry
of that school, and their persistence in adhering to a routine
treatment, even when the facts  of pathology are against
them.
  Up to a recent date, the allopathic treatment universally
adopted,  was equalled only by that  of Dr.  Sangrado, as
depicted in  Gil Bias.   Repeated venesections;  a diet so  low
as to  result  in partial starvation, was insisted on, not only by
Yausalva and  Albertini,  but more  recently,  by Hope,
Bouillard, and even Wood.
  I do not know of any disease where the results of such
treatment could be more destructive to the integrity of the
general system, for by it the heart was weakened, and dilata-
tion— a  condition  ten-fold  worse  than  enlargement — was
generally caused.
  The very object of the allopathic treatment was an error.
A diminution of  the size of the heart  was  considered a
desirable result, but, as Flint observes, "A better understand-
ing of the pathological relations of hypertrophy leads to the
conclusion, that therapeutical measures designed to diminish
or prevent it, are likely to do harm, in so far as they  have
efficiency in promoting these ends."
  I am sorry to inform you, that the homoeopathic treat-
ment of  hypertrophy of the heart has been as erroneous in
principle, although  the results  have  not been nearly as
disastrous as those  produced  by the opposite school.  The 
                       TREATMENT.                    129

same remedies, in the same potency, have been used  for the
two  opposite conditions  of  enlargement  and   dilatation.
Even Baehr, otherwise sound, gives no separate and distinc-
tive treatment for the two diseases.
  I propose to present you with the treatment of enlargement
by hypertrophy, and in a future lecture give  you the true
treatment of dilatation.
  At present, the best authorities of both schools agree on
one vital point, namely, that, considered  in connection with
the antecedent morbid  conditions which give rise to  it, con-
ditions involving impediment to the circulation, hypertrophy,
so far  from being an evil, is an important  provision against
the dangers incident  to the accumulation of blood within
the cavities of the  heart, and against the evils of dilatation.
Hypertrophy compensates for the disturbance  of the  circula-
tion caused by valvular lesions, and  so long as the enlarge-
ment  consists of  this compensating increase of muscular
structure, and consequently of muscular power, the  patient
experiences  little  or  no  inconvenience, providing nothing
occurs,  like  anaemia,  for example,  to  weaken the  force
of  the heart's action.   It is when hypertrophy has  reached
the  limit of  its  progress,  and  dilatation   has  followed,
that serious inconveniences, referable to the heart and circu-
lation, begin to be felt.
   The general  indications for treatment  which I will  now
give for your adoption are :
   1.   To  prevent  those impediments  to the  circulation,
arising  generally from  valvular lesions, which give rise to
hypertrophy.
   2.   To prevent  dilatation, by keeping up, if possible, the
normal tonicity of the muscular structure of the heart.
   3.   To quiet undue excitement and irregular action of the
heart.

   The rules in relation to the general management of the
patient  are  so  uniformly agreed  upon by all writers, that
 nothing  original can  be said.  Baehr and  Flint, the two
representative authorities, have nearly the  same views.
   It is obvious that all influences that might stimulate the
 already over-excited heart should be  avoided.  Coffee, spirits, 
130              DISEASES  OF THE HEART.
         strong spices, salt in excess, also fat food, should be avoided.
         Mental excitement, especially  anger,  should  be guarded
         against by the patient.
           Very large and  hearty meals should be avoided;  small
         and  frequent  meals should be  advised, and  on no account
         should heavy meals late at night be allowed.  The occupation
         of the patient may sometimes be changed to advantage.   A
         sedentary life, attended by much excitement of mind, should
         be changed to a more active one, with less mental  irritation.
         As regards  exercise, your  own judgment will  have to be
         depended on.   In some  cases,  general   exercise, unless
         moderate, must be prohibited; in others, the physical activity
         may be greater.   Local coldness of the  hands and  feet must
         be met with such gymnastics as  exercise  the  extremities
»         alone, the body being quiet.
           The circulation should be equalized  as much  as possible;
         especially should remote parts of the body be supplied with
         blood, in order that the heart may not be overburdened and
         excited.  The extremities should be warmly clad, and the
         whole body protected by flannel underclothing.
           All  influences tending to  debility, nervous  prostration,
         anaemia,  or   blood-impoverishment,  should be   avoided.
         Remember that the main object of treatment is to  prevent
         weakness of the heart,  Losses of the fluids of  the  body  in
         excess tend to  such  weakness. Excessive  venery, undue
         lactation, diarrhoea, purgation, a too meagre diet, and the
         improper  use of  medicines,  should be guarded  against.
         Mental depression will have  the same unhappy result, and
         you should strive to have your patients placed under  those
         influences which  conduce  to a happy, pleasant state of
         mind.
           The medicines indicated for hypertrophy with enlargement
         are best  presented in four classes,  arranged according  to
         their peculiar spheres of  action,  thus:
           I.   Those medicines wmose primary  effect in  large doses
         is to depress the action of the heart and  weaken its muscular
         power, namely:
           Aconite, gelseminum, veratrum viride, veratrum album, kalmia,
         tartar emetic, colchicum, sanguinaria, lobelia, and tabacum.
           II.   Medicines whose  primary effect is  to increase the 
INDICATIONS FOR THE  REMEDIES.
131
strength of the muscular power of the heart, by stimulating
its  nervous life; and whose  secondary effect is to depress
and paralyze the nervous and  muscular power of that organ.
Among the most prominent of this class are:
  Digitcdis, cactus, lilium, hydrocyanic  acid,  primus virginiana,
amygdalus, and A. amara, persica, lycopus virginica, and lauroce-
rasus.
  HI.   Remedies wdiich  primarily  tend  to  increase the
nervous power and nutrition of the heart;  and secondarily,
to weaken and paralyze the same cardiac functions, namely:
  Nux vomica, ignatia, hydrastis, collinsonia,  cinchona, ferrum,
cimicifuga, helonias, phosphorus, and sulphuric acid.
  IV.   Certain  antipsoric or alterative  remedies, whose
effects cannot  be  classified  into  primary  and  secondary
sequences, namely:
  Spigelia, rhus,  iodine, graphites, natrum mur., bismuth, lycopo-
dium, and sulphur.

         INDICATIONS  FOR THE REMEDIES IN  CLASS I.
  In selecting a remedy for the symptomatic or pathological
results of this form of enlargement,  you should  first assure
yourself that  the force of  the  heart is actually increased.
Remember that  the heart may be in excessive action, without
having increased force.
  If the hypertrophy occur  in robust, strong, full-blooded
persons, with bright complexion, disposition to changes of
color of  the face, glistening eyes, injected conjunctiva, head-
ache, stinging pains in the region of the heart, aconite is the
remedy, and  should  be given in  the lowest dilutions, and
frequently repeated, until an  amelioration occurs, when the
medicine should  be  withdrawn.   Remember  that  these
symptoms are like the  secondary effects of aconite, and this
obliges,us to prescribe it  in  more material  doses.   All of
Class I. follow this law, and if indicated by the increased force
of the heart's action, and the general symptoms  correspond,
the dose should  be the same as aconite.
  Veratrum viride is indicated by the more forcible impulse
of the heart, the stronger pulse, and the greater congestion
of the head and chest.
  Gelseminum, by the same  symptoms, but in a  less degree, 
I
132              DISEASES OF THE  HEART.

and  an apparent torpor  of the functions of the  brain and
lungs, and a less active congestion.
  Veratrum album., according to Ch. Muller, causes  "Extreme
agony,  which  takes  away the breath;  palpitations, with
anxiety, and quick audible respirations; paroxysms of agony
about the heart, which beats very  violently, and feels as if it
were too warm; violent  beating of the heart, which  forces
up the ribs; the heart beats up very high and forcibly, so as
to force the  hand  aw7ay, without  pain."   He remarks that
" the entire absence of pain  about the heart, while it beats
so violently as to shake  the chest, elevate the ribs, and  lift
the  hand  of the auscultator,  deserves particular attention,
for this almost never occurs, except in hypertrophy with
dilatation." (?)  (He  should  have  said  with  enlargement,
for in dilatation no such forcible impulse  is present.)
  "Physical signs."   The percussion sound  may be dull over
a very large space,  (the apex of the heart may beat directly
beneath, outside of, or above the nipple,) bulging of the ribs
over the heart; action  of the heart visibly very violent;
sounds of the heart very loud  and clear,  or else one or both
sounds accompanied with abnormal murmurs."
   If veratrum  alb.  causes this array of  symptoms—and it
appears to me that the primary and secondary are mixed in
the  above—the  increased impulse or force of the  heart's
action must be a secondary effect, for the  immediate effects
of white hellebore are marked depression of the heart's action,
even to pulselessness.   If this medicine is given for concen-
tric hypertrophy, it must be given in  the same  doses as
advised for aconite and others of its class.
   Kalmia may be useful  in certain cases, but the indications
are not yet certain.
   Tartar emetic should be resorted to if pulmonary engorge-
ment is  feared, and there is at the same time hepatic
congestion, dyspnoea, cough, etc.
   Colchicum, if the urine is scanty, red, and deposits a brick-
dust sediment, and  the heart's  action   is  excessive  and
strong.
   Sanguinaria will prove a potent  remedy if the hypertrophy
is complicated with suppressed or scanty menses, congestion 
INDICATIONS FOR THE MEDICINES.
133
of the  lungs, cough,  dyspnoea, and sometimes  congestive
cephalalgia.
  Lobelia should  not be forgotten when there are asthmatic
symptoms with the enlargement.
  Tabacum. is secondarily homoeopathic to hypertrophy, and
Baehr advises smoking small  cigarettes for palliative relief
of the  excessive palpitations.   If  they are marked  by
increased impulse, tobacco may be used occasionally; if the
impulse is weak it should be prohibited.
  In regard to the administration of these remedies, I wish
to impress upon your  minds this  important fact, namely,
that if you wish to get permanent curative effects from any
remedy in  hypertrophy, you must continue its use for days
and even weeks.   If you  have selected aconite as the appro-
priate medicine, do not supplant it for some other in a few
days because you do not see an  improvement in the action
of the heart,  Our doses do not rapidly depress the excessive
cardiac action, therefore the physiological or normal action
which we wish to induce does not come suddenly.
  As a general  rule,  the  remedies  above named  may be
given every three or six hours, according to the severity of
the case, and always in the  lowest potencies, and sometimes
the mother tincture.

        INDICATIONS FOR THE MEDICINES IN CLASS II.

  Of all the medicines in this class, the digitalis purpurea is
the most important, but even to this day  its true method of
action is not understood by a portion of the profession, who
persist in believing it to be  a primarily depressing medicine.
Those of you who have read my paper on digitalis, published
in the United, Stales Medical and Surgical Jour tad, and reprinted
in pamphlet  form, need not be told  that many years ago  I
adopted the views of Prof.  Tullv, who was far ahead of his
time in his estimate of some medicines. Within  a fw years,
Handheld  Jones, Hammond,  and others have adopted the
same view of its action.
  Digitalis, when given in medicinal  doses, causes pathogen-
etically a condition similar in effect to  hypertrophy with
enlargement of the heart.   It does not cause actual enlarge- 
134
DISEASES OF THE  HEART.
ment,  but such  a hyper-stimulation of  the  heart  that  the
results are similar.
  When death occurs  from acute poisoning  by digitalis,  the
muscular substance is  hard and  firm ;  the heart is rigidly
contracted, and no blood  is found  in its cavities.  Now, if
death should  suddenly occur from  concentric hypertrophy
or enlargement, the heart would be found  in the same con-
dition as in digitalis-\)0\&o\\i\\g.
  It is obvious that if we accept this as the  true action of
digitalis,  namely, that  it is, in large doses, a  cardiac tonic,
you can readily understand how injurious, and  even danger-
ous, it w7ould  be to give  large  doses  in hypertrophy with
enlargement,  i. c., when the heart has already an excess of
muscular power.  It is in such cases that, when given by the
old school, dangerous and  alarming  symptoms occurred,
which led to the fears of its use which we find so prevalent.
It is as if an allopath were to  give  a massive  dose of bella-
donna in a case of cerebritis, or nux vomica in spinal congestion,
or arsenic in  gastritis.   In  such cases,  the  remedy being
intensely  homoeopathic, a severe or  fatal aggravation would
occur.
  The deduction I would have you draw from this is, that as
digitalis is primarily and intensely homoeopathic to a condition
similar to hypertrophy with enlargement, in which  the con-
tractile power and impulsive force of the heart is increased,
it should  be prescribed in  the smallest dose consistent with
reason.   I will explain what I mean:  the 3rd  of digitalis
may not  be stronger in reality than  the 30th  of lycopodium,
for while the former appears to lose its medicinal power after
the 3rd, the latter seems to gain  in power at every remove
upwards from the 3rd trituration.   This difference is due to
the fact  that certain medicines  have  different qualities of
inherent  power; and,  in the future, it should  be the aim of
our school to ascertain the  inherent medicinal power of each
drug, instead of quarreling about the dose.
  The  dose of digitalis, then, in this disease, should lie in  the
first three dilutions of the tincture, or  the  triturations of
digitaline from the 3rd to the 6th.  With these doses,  repeated
every few hours, or as often  as every hour, no aggravation,
but much benefit, will be derived. 
INDICATIONS FOR THE  MEDICINES.
135
  Cactus grandiflorus  is an analogue of digitalis, and  not of
aconite, as some suppose.  If you will  look at the provings
you will see that the evident primary symptoms are those of
hyper-stimulation of the heart, even to spasmodic contraction
of its muscular tissues.  What else can that characteristic
symptom, " constriction in the chest and in the heart, as if
from an iron hand," mean ?  The general symptoms of cactus
all tend in this direction, for it causes ' constriction ' every-
where.   I have carefully analyzed  the clinical cases wherein
cactus has proved curative, and am convinced  that in those
cases  where  the high dilutions were  beneficial, there was
present  a condition of increased tonicity of  the  heart; in
other words, the palpitations  and so-called congestions of the
heart were  due to cardiac lryper-stimulation.  In cases of
true hypertrophy, then, do not use cactus lower than  the 6th
decimal  dilution.   Lower  than  this  I have found  it to
aggravate all cases where the impulse  of the heart was too
strong.
  Lilium is,  according to its  recent provings, a very near
analogue of cactus.
  Acidum hydrocyanicum is another remedy closely allied to
digitalis.   In proof of this,  I have but to cite  you to Dr.
Handheld  Jones' experiments.   He  says,  " In  poisonous
doses it produces tetanic convulsions, preceded by faintness
and giddiness.  After death the heart is  well and firmly
contracted, its  tissue remarkably firm, the cavity of  the left
ventricle almost quite obliterated, that  of right small, but
little blood in  either, coagula in both auricles."  Stille says,
" the whole  venous system  is gorged and  distended with
dark uncoagulated blood," which implies that, owing to the
tetanic  contractions of the  heart,  the circulation was sus-
pended.  I consider this remedy useful in high potencies to
quell the excessively forcible action, pain like angina pectoris,
and for  other symptoms found in its pathogenesis.   Use the
6th or 30th centennial dilution.
  There are many  agents,  chemical  and vegetable, which
contain hydrocyanic acid in appreciable quantities.   These all
have, in a less degree, the same specific action on  the  heart
and its  nervous supply.  The most potent of  these is the 
136
DISEASES OF THE HEART.
  Cyanide of potassium, which  may be used  in  the 6th or
30th potency for similar symptoms and conditions.
  Laurocerasus is another which possesses many notable and
important heart symptoms.
  Prunus virginiana (wild cherry) and amygdalus persica (peach)
both contain acidum hydrocyanicum, and have long been used
to quiet and regulate abnormal action of the heart.  Their
use, in infusion of the bark, has doubtless been  injurious in
hypertrophy wuth enlargement, but in the 2nd or 3rd dilution
would no doubt be  beneficial.
  Lycopus virginicus*  possesses powers closely allied to the
above medicines.   In the dilutions below the 3rd  you will
find it beneficial in  hypertrophy with a tendency to, or actual
haemoptysis and cough.
  Amygdala  amara  (bitter almonds) contain hydrocyanic acid.
I have  known patients troubled with palpitations  from
hypertrophy get considerable relief from eating two or three
after each meal.
  Repetition of medicines.  If you have carefully selected one
of the above for the case you are treating, give it a fair trial.
Do not change the  medicine unless the symptoms materially
change, but  continue its use  for  days  and perhaps weeks.
The repetition of the dose will depend on the  amount of
cardiac disturbance.  Four doses a day, unless frequent pal-
pitations or severe congestions occur,  in  which cases the
medicine may be repeated every hour or two.
  The  remedies of  the  third class, namely:  nux vomica,
ignatia, cinchona,  ferrum,, hydrastis,  collinsonia, and  sulphuric
acid, do  not differ  very widely, in their ultimate effects on
the heart, from those of Class II.   Both classes primarily
increase the innervation and tonicity of the  heart, by acting
through different channels.   Nux vomica acts  through the
cerebro-spinal nerve-centres, while digitalis operates through
the great sympathetic.
  I will now give you the indications for this class:
  Nux vomica,  I  assure you, has  not  been   sufficiently
appreciated  in hypertrophy of the heart.  It is indicated  in
* New Remedies.  2nd Edition. 
INDICATIONS FOR THE MEDICINES.          137
the concentric and eccentric form.   But it is of the former
only that I will now speak.
  Dr. Ch. Miiller* says of this medicine,  "It causes palpita-
tion in frequent short paroxysms, with commotion of blood;
pulsating throbs in the direction of the heart; great anxiety,
with severe palpitation.  In the numerous and careful post-
mortem  examinations  which  have been  made in cases of
poisoning with nux,  no organic alterations about the heart
have  been found.   Its influence  on  the heart  must  be
referred to the nervous system.  It causes increased activity
and evident  irritation of the  ganglionic system, which may
be  propagated to the mind and  senses;  hence  the above-
mentioned heart-symptoms may  arise in consequence of
sympathy with the  ganglionic and mental affections.   For
this reason Hahnemann laid so much stress on the presence
of  vexability,  over-sensitiveness to  all impressions,  hypo-
chondriacal humor, passionate irritability  and sudden choler,
great  anxiousness,  starting  in  affright,  fearful, anxious
dreams, etc., as strong indications  for the  use of nux vomica.
Hence, nux cannot prove homoeopathic to any heart affection
dependent  upon  any  organic  or  material  change  of
structure."
  I cannot agree with  Dr. Miiller in his estimate of this
medicine.  Because no structural  change  wras  found in the
heart  from  acute  nux-poisoning,  it  does not  prove that
hypertrophy  may not be caused by  its long-continued patho-
genetic effects.   You  will remember that hypertrophy is
rarely a primary disease.  It  is generally brought on  from
obstructions  somewhere else, in the circulation, or in import-
ant organs.   That the  chronic poisonous effects of nux vomica
on  the liver, intestinal canal, and spinal cord, will  cause
Irypertrophy, I have no doubt.  It will not cause, directly,
the thickening  or  thinning of the heart-walls, but  it  will
cause disorders which  lead to  that result.
  The translator of Dr. Miiller's paper says,  " Nux vomica
acts predominantly and specifically  on the motor side of the
spinal marrow and  the muscular  system in  general, and
tends more particularly to cause tetanic spasms; as  the heart
.* Homoeopathic Examiner, Vol. V. 
138
GISEASES OF THE  HEART.
is  a very muscular organ  it  is probable  that  it  exerts a
similar  action on it;  in  fact, the  spasm of the heart may
become so complete and persistent, that this organ remains
tightly contracted for  some time, during which little or no
impulse is felt, the respiration being difficult and the  pulse
extinct.  If the spasm of the heart be  less  complete and
tonic, i. e., more  atonic, then  violent palpitation may ensue.
But nux vomica constantly tends to produce long-continued
spasmodic contraction of the  heart.  According to Sorben-
heimit often causes an asphyxiated condition, dependent upon
an  extremely violent contraction of the respiratory muscles
and heart.  Every one familiar with diseases of the heart
must be familiar with this state of  things: a patient with
organic disease of the heart  will  be suddenly taken with
what he calls spasms;  he sits  in speechless  agony, his hands
clasped over the cardiac region, his eyes protruded, his face
livid;  the  physician  attempts to  feel  the pulse and can
scarcely find it;  he places his hand or ear over the heart,
and finds everything  still  and motionless  as death itself;
after a while the spasm relaxes;  more or less palpitation
follows, and the patient recovers for  the time.   Such attacks
are often  mistaken  for paralysis, exhaustion,  or debility of
the heart, and treated with stimulants."
   This writer asserts  that nux is  homoeopathic to enlarge-
ment  of  the heart with thickening  of  its  w7alls, which
assertion  I  accept, but only as relates  to its primary effect,
for the  secondary effects of the above-described action of nux
will just  as certainly be  dilatation of the  heart, with atony
of its remaining muscular fibres, even to paralysis.
   You will doubtless read some  authorities, who, like  the
writer I have quoted, will assert that the  action of digitalis
is opposite to that of nux.  This is  not the case, unless the
statement is qualified.  The  primary action of both is very
similar, so is the resulting secondary effect.   It  might be
said that the secondary effect of digitalis was the opposite of
the primary action of nux; such an  assertion would be
correct.
   Nux vomica, therefore, is indicated  for simple hypertrophy,
i. e., when the  walls of the heart  are  thickened, the cavity
retaining its  natural dimensions; also  in that variety of 
INDICATIONS FOR THE MEDICINES.
139
hypertrophy in which the walls are considerably thickened,
and the cavity dilated; and in hypertrophy with contraction,
in which the walls are thickened and the cavity diminished
in size.   But, before you venture to prescribe nux vomica, be
sure of  your diagnosis, for if you give it in too large doses
in the above  conditions, you will surely get severe aggrava-
tions, and injure your  patient, because they are conditions
simulating the primary effects  of  nux, and calling for the
highest attenuations, namely, from the 12th to the 200th, or
even higher.
  Ignatia is indicated for the same pathological conditions as
nux vomica, but the selection must depend  on the mental
symptoms and the sex of the patient.  Ignatia is more suited
to women, or men with feminine  dispositions, to patients
who weep easily, or laugh and cry  alternately; in  other
words, persons of hysterical temperament; and for  hyper-
trophy when caused by the  remote effects of grief, care, or
other mental trouble.   Prescribe  the  higher attenuations,
not too often repeated.  (Nux  and ignatia  are also homoeo-
pathic to hypertrophy with dilatation and attenuation of the
heart-walls, but of this I will speak in my next lecture.)
   China, or cinchona, has not been used by the homoeopathic
school to any extent in diseases of the heart, yet I consider
its action analogous to that  of digitalis and nux, or as holding
an intermediate relation to them.  Hahnemann's observation
that in  cases of poisoning from digitalis, china  causes terrible
anxiety and  aggravation, is  one of the best proofs that, in
their primary action on the heart, they act similarly.
   The  following symptoms from the Materia Medica Pura
will remind you of the symptoms of nux and digitalis:
   " Palpitation of the heart, also with rush of blood to the
head, and heat and redness of the face, with cold hands."
  " Strong, violent beats  of the heart, also with anxiety,
also with feeble pulse and cold skin."
  " Pressure in the region of the chest (heart), particularly
when the trunk is  bent forward, when sitting or standing,
also with anguish and oppression of breathing."
  In the proving of quinine you will find similar symptoms,
to which I add the following: " distressing constriction about
the throat, and sense of fear about the heart; " and, if you 
140
DISEASES OF THE HEART.
should happen  to  practice in  malarious districts,  where
people are poisoned with quinine, you will  have excellent
opportunities of observing its effects, namely:  its primary
symptoms, like those I  have just quoted,  denoting over-
stimulation of the heart;  and its secondary  effects, namely,
weakness, irritability, and irregular action of the heart.  I
have no  hesitation in asserting, that many of the cases of
hypertrophic debility of the heart, supposed to  arise from
ague, have their origin in  the enormous quantities of  quinine
given to suppress that disease.
  I believe,  also, that  the free use of  quinine  Avill  cause
hypertrophy with enlargement, of a temporary character, and
as a large proportion of the cases of dilatation of the heart
is preceded by  this condition,  we have in  quinine a medicine
which is  homoeopathic to  that variety of cardiac disease.  I
shall refer to china again in the next lecture.
  Dose:  In  hypertrophy with  enlargement, having the
above symptoms, give the 6th or 30th dilution.
  Ferrum has an action not so  far removed from nux and
china as some have supposed.   All  the preparations of iron
cause pathogenetically a pseudo-plethora,  i. e., a plethora not
of a healthy physiological character.  I  do  not  look upon
iron merely as  a blood-enricher, acting in the same  way as
beef or other blood-food.   To suppose that it acts simply by
imparting iron to the blood is too crude a  notion.  The more
rational theory is that  it has a two-fold  action, namely, of
entering the blood and then stimulating the nerves of nutri-
tion until the  blood-making  process  goes  on in a normal
manner.   This  ferrum-plethora closely simulates that con-
dition which we sometimes see in cases of hypertrophy with
enlargement.   The symptoms indicating its use are: Rush of
blood  to  the  head, with puffiness around the eyes and
swelling of the veins;  vertigo, staggering,  hammering and
throbbing headache, and  roaring in the head; faint  feeling
in  walking,  with blackness before  the eyes; hard,  strong
beating of the  heart; pulse hard, large, and slow, or quick-
ened  by  exertion; heat,  with anxiety and   oppression,
proceeding from the pit of the stomach; tightness  in the
chest,  as  if  constricted, with difficult, anxious  breathing, 
INDICATIONS FOR THE  MEDICINES.
141
and  contractive spasm of the  heart.  For these  symptoms
give ferrum., but not lower than the 6th trituration.
  Hydrastis has no special heart-symptoms, but I recommend
it, on theoretical grounds, when the hypertrophy  is impend-
ing from obstructions in the liver, or chronic stagnation of the
portal circulation.  Podophyllum* leptandra, cesculus, and col-
linsonia  have the same action, and are especially indicated  if
the patient is subject to haemorrhoids, and when the cardiac
symptoms are worse when the piles are least troublesome.
  The  medicines of  the fourth  class,  namely:  belladonna,
glonoine, lachnanthes, stramonium, agaricus, cimicifuga, aurum,
and  solanumf  are all  excellent palliatives in hypertrophy,
when the impulse is so strong as to throw an undue amount
of blood to the head  and lungs, causing headache, vertigo,
frightful dreams, etc.   They have the best effects in the 3rd
to 6th dilution.
  Plumbum acelicum, according to Raue, is homoeopathic to
true hypertrophy with the symptoms:  "Stitch in the region
of the heart during inspiration, with anxiety;  heat and red-
ness of  the face; rush of blood to the  region of the heart
during  a rapid walk; anguish about the heart, with cold
sweat;  palpitation.  Post-mortem after poisoning has shown,
that the serous coat of the pericardium is lined with a layer of
reddish grey, fine, villous, meshy, firm, exuded lymph.   The
heart is more than double its natural size.   The wall of the left
ventricle is more than an inch thick." J
* See Symptoms of Podoph. in New Remedies.
f U. S. Jour, of Horn., 1870.
J Raue's Pathology. 
 
LECTURE  VIII.
              ENLARGEMENT  BY DILATATION.

Definition of Enlargement by Dilatation— Symptoms — Pathological Effects
  — Physical Signs and Diagnosis—Summary — Treatment.

  Gentlemen :  In  this lecture,  a condition  of the heart
nearly the opposite  of that described in the last, namely,
enlargement by dilatation, will be considered.  I shall quote
entire Flint's admirable description, because no words of
mine could make  it plainer.   The  treatment, however, is
purely  homoeopathic — not  theoretical,  but  based  on
experience.
  " Under this  head are embraced,  in addition  to  the rare
cases of pure or simple dilatation, that is, those in which the
capacity of the cavities is increased and the walls attenuated,
all cases in  which  dilatation co-exists  with,  but  predomi-
nates over hypertrophy-   Of the two kinds of enlargement,
this  is by far the most frequently found after death when
organic disease  of the heart  proves  fatal.   In the cases in
which the heart attains to a very large size, dilatation almost
invariably preponderates.  The cases in which  the organ,
from its immense  bulk, resembles  a bullock's heart (cor
bovinum) are  those  in which there exists great hypertrophy,
with still greater dilatation.   The degree of dilatation varies
greatly  in different  cases,  and the  hypertrophy combined
with  it is also variable.  The preponderance of dilatation,
when the heart is examined after death, is generally suffi-
ciently evident on inspection.   The abnormal increase in the
dimensions of the  organ exceeds that of the weight.   The
ventricular walls collapse, and the organ, resting on its  pos-
terior surface, is flattened, instead of preserving a  globular
form, as  when  hypertrophy predominates.  The greater
increase in width than in length, is marked in proportion 
144
DISEASES OF THE  HEART.
to the preponderance of  dilatation.   Owing to  this, the
organ becomes wedge-shaped, and sometimes presents nearly
a square form.
  "The mechanism of dilatation is quite different from that
of hypertrophy.  In the production of the latter the process
is vital, whereas in the former it is mechanical.  Hypertrophy
is a consequence  of over-nutrition;  dilatation is the result
of the yielding of the walls of the heart to a distending force,
the  condition, however,  which stands  immediately  in  a
causative relation to both  is the  same, viz., undue accumula-
tion of blood within  the  cavities of the  heart;  hence  it  is
that both take place either conjointly or in succession, so that
hypertrophy and  dilatation are very often associated.  Dila-
tation, thus, not less than hypertrophy, depends on antecedent
affections  which  occasion  impediment  to  the  circulation
through the vessels or the orifices of the heart, leading  to
over-accumulation of blood within the cavities.   These ante-
cedent  affections are the  same as in cases  of predominant
hypertrophy;  and the several portions  of the heart  become
affected singly and in succession, as fn  the  latter  form  of
enlargement.  It is not necessary, therefore, in this connec-
tion, to consider the dilatation of these.portions, respectively,
in relation to the particular lesions of the valves  and orifices
and vessels on  which  dilatation and  hypertrophy  alike
depend.   Moreover, both dilatation  and  hypertrophy of the
different portions of the  heart will be referred  to hereafter
in treating of valvular lesions.   It  will suffice to  inquire
into the circumstances which determine the occurrence  of
dilatation in the  place of, or,  as is generally the  case,  in
addition to, hypertrophy.
  " The first effect of an undue accumulation of blood in the
cavities of the heart, continued for a sufficient period,  is
increased  power of muscular action and  consequent hyper-
trophy in  the great majority of cases.   The hypertrophy is
more or less progressive, but it has its limit.   The abnormal
growth of the muscular tissue ceases after it has progressed
to a certain extent.  But the morbid conditions inducing
over-repletion of the cavities still remain, impeding  more
and more  the circulation.   The compensating  increase  of
the muscular tissue no longer taking place, the walls of the 
ENLARGEMENT  BY DILATATION.
145
cavities yield to the mechanical force of distension, and the
progressive enlargement  from this time onward is due to
dilatation.   The limit of hypertrophic enlargement varies in
different persons.  If the  hypertrophy progress  until the
muscular walls attain to a great thickness, and life continue
for a long period afterward, dilatation finally predominates,
and the result  is an enormous enlargement of the heart, a
cor bovinum..  But dilatation may commence after  moderate
or slight hypertrophy has taken place;  in other words, the
hypertrophy ceases after a  smaller amount of  muscular
growth, and dilatation  commences.  Dilatation may even
commence without any previous hypertrophy, and the result
is, then, enlargement with attenuated walls, or simple dilata-
tion,  a rare variety  of  enlargement  of the heart,  The
occurrence  of dilatation is determined  by the state  of the
muscular walls.  Functional debility of the organ, and, still
more,  changes  in the muscular fibres, prevent that vigorous
activity which  induces abnormal growth; and  yielding of
the wralls takes place early,  in proportion as the  vital  powder
of resistance is impaired.  Anaemia, the feebleness consequent
ou  pericarditis and adherent pericardium, fatty degeneration,
softening, and  any changes which compromise the muscular
power of the organ, tend to abridge hypertrophy and favor
dilatation.   The latter will  therefore predominate in propor-
tion as the condition of the walls is such that they early and
readily yield to the distension caused  by the accumulation
of blood within the cavities.  After this brief consideration
of the  circumstances  determining the  occurrence of dilata-
tion, in addition  to the  incidental remarks already made
under  the  head of enlargement by hypertrophy, the reader
will be able to trace  the relations of dilatation affecting the
different cavities of the heart, to lesions  of the mitral and
the aortic  orifice, involving either obstruction or regurgita-
tion, or both, and  to  obstructions affecting the pulmonary
and systemic arterial  systems at situations more  or less
remote from the heart, without recapitulation of  the account
already given in connection with hypertrophy.  The inquiry
arises, Does not the heart, in some instances, become dilated
in  consequence of inherent weakness, no antecedent  affec-
tions existing to occasion impediment to the circulation ?  It 
146
DISEASES OF THE HEART.
is  probable that  this sometimes occurs as an effect of fatty
degeneration,  pericardial adhesions, atrophy  or softening
of the muscular fibres, etc.  Examples are found of dilatation
associated with these structural changes, and without other
obvious sources of impediment to  the  circulation.  These
changes may be subsequent to dilatation, but it is reasonable
to suppose tl at in some instances they precede and give rise
to it.  Clinical observation, however, furnishes no evidence
that functional weakness alone leads to dilatation, irrespective
of structural changes of the walls of the heart, or lesions of
some kind  which occasion impediment to the  circulation.
Dr. W. T. Gairdner accounts  for  dilatation of the heart in
cases of pulmonary emphysema, in the same way that  he
accounts  for emphysema, namely, the  cavities of the heart
are  dilated by the force of  inspiration, as are the unob-
structed air-cells  in  consequence of collapse of more  or less
of the pulmonary lobules.  This author accounts in this way
for, not only  dilatation, but hypertrophy, the expansion of
the  thorax tending  constantly  to overload  the heart, and
thus occasioning  increased muscular foree.  Without adopt-
ing this explanation, it must be admitted that  Dr. Gairdner
bases  his explanation on  facts  which  have considerable
weight.   " Of 24 cases  of enlargement  without valvular
lesions, in 21 cases  there were manifest and  extensive old
atrophic lesions of the lungs, with or without accompanying
emphysema, which is recorded as  having existed  in 17 of the
cases.'* Dr. Gairdner  also shows, by an  analysis of fatal
cases,  that enlargement of  the   heart occurs  oftener  in
emphysematous cases than in mixed cases, the proportion
being as 15 to 23 per cent,; and that, of the cases occurring
with emphysema, valvular lesions are present  in a less pro-
portion than in the mixed cases, the whole number of cases
analyzed  being 84.   To show that  contraction of the capil-
laries of the lungs from any cause, or obstructed circulation
through these organs, will not give rise to enlargement of
the  heart, he analyzes 18 cases,  in which effusion into the
pleurae or  peritoneum, or other causes, occasioned compression
of the lungs for a considerable time, there being no valvular
lesions.   In only four of these cases did enlargement exist,
and in one case its existence was doubtful.   On these data 
           SYMPTOMS  AND PATHOLOGICAL EFFECTS.        147

he bases the  conclusion, that, while  diseases of the lungs
which merely obstruct or obliterate  the circulation in the
capillaries, have no well-marked tendency  to  be associated
with enlargement of the heart, those  which produce atrophy
of the pulmonary tissue, and secondarily emphysema, have
an obvious influence on  the  heart, and  frequently cause its
enlargement.

    SYMPTOMS AND PATHOLOGICAL EFFECTS OF DILATATION.

  " The symptoms due to dilatation, like those of hypertrophy,
are generally involved with  those incident to  valvular or
other concomitant lesions.   In proportion to the amount of
dilatation,  the muscular power  of the heart is impaired.
The symptoms distinctive of dilatation proceed from feeble-
ness and incompleteness of the  heart's action.  The action
of the heart is often irregular, as represented by  irregularity
of the pulse  and  of the apex-beats.   Both are  abnormally
feeble.   The pulse may be  unequal as well as irregular.
These symptoms are in relation to dilatation of the left ven-
tricle.  The patient experiences more or less uneasiness and
undefinable distress, referable to the praecordia, but he is not
conscious  of that  powerful  action  of the  heart  which
characterizes hypertrophy.   The extremities and surface of
the body are cool.  Lividity may be apparent on the prolabia,
the  tongue, face, and extremities.   The  veins, especially
those of the neck, may be distended.  These symptoms are
more or less marked, in proportion as the dilatation affects
the right ventricle.  Dyspnoea will  be prominent in propor-
tion as the right ventricle is the seat of dilatation.  The
recumbent posture, with the head low, may be insupportable,
and,  in an advanced stage,  the suffering  from  defective
haematosis  may amount to orthopnoea,   Occurring in parox-
ysms, this  difficulty of respiration  has  been  called cardiac
asthma.  Exercise  and  mental excitement  augment  the
symptoms, particularly the dyspnoea.   More or less cough is
usually present, with serous and .sometimes sanguinolent
expectoration.  The abdominal viscera, as well as the lungs,
are in a state of passive congestion.   Owing  to this  state,
the liver may become  more  or  less  enlarged, and may be 
148
DISEASES OF THE HEART.
found to augment rapidly in size when, from any cause, the
circulation is temporarily embarrassed in an unusual degree,
resumino- its former dimensions when the paroxysm  ends
and the heart recovers its habitual strength.*  The digestive
functions are weakened, but nutrition may be sufficiently
active; patients do  not always emaciate.  The urine is not
abundant, and may be found slightly albuminous, which is
due to renal congestion, and is not necessarily indicative of
structural disease of the kidneys. Renal disease is, however,
associated, in a certain  proportion of cases, with  dilatation
as  with hypertrophy.  Finally, oedema occurs, first mani-
fested in the low7er extremities, thence extending  over the
body, and effusion  into the serous cavities succeeds, consti-
tuting general dropsy.
   " This is  an enumeration of the more important of the
 symptoms belonging to cases of enlargement in which dila-
 tation predominates, but it is to be  borne in mind that, in
 general,  valvular  or other lesions  co-exist,  which,  after
 inducing more or  less hypertrophy,  have at  length led to
 dilatation; and, under these circumstances, it  is difficult to
 •say to what extent  the symptoms distinctive  of this  stage
 of the disease may not be  due to the causes of the dilatation,
. in other words, to the concomitant lesions.  But it is certain
 that much, if not chief importance is to be attached to the
 dilatation in the production of the symptomatic phenomena
 which have been mentioned.
    " The pathological effects of dilatation are, in a great measure,
 embraced in the foregoing account of the symptoms.   The
 dilatation is the result of weakness of the  cardiac walls,
 together with an accumulation of blood within the  cavities;
 and, on the other hand, it is the cause of further diminution
 •of the  power of the  heart's action, and  consequent  over-
 repletion.  It has, therefore, an intrinsic tendency to  increase.
 The evils  incident to enlargement  are mostly referable  to
 dilatation.  Little or no inconvenience is felt  so long  as the
 heart is hypertrophied, and the capacity of its  cavities not
 increased.  But in proportion as the latter takes place, the
 quantity of blood to be propelled from the cavities is greater,
* Stokes on the Heart and Aorta. 
       PHYSICAL SIGNS DISTINCTIVE OF ENLARGEMENT.    149

and the ability of the muscular walls to contract sufficiently
is lessened; hence, inadequacy of the motive power of the
central organ to carry on the circulation.   This inadequacy
increases in more than an arithmetical ratio as the dilatation
progresses.   The immediate effect on the vascular system is
passive  congestion,  arising, not  alone  from  the defective
propelling power  of the  heart, but from  the obstacle  pre-
sented to the return of blood to this organ  by the accumula-
tion within its  cavities.  The ulterior effects dependent on
congestion  are:   embarrassment of  the  functions  of the
important organs  of the  body;  serous  transudation,  or
dropsy;   and, occasionally,  haemorrhage.    An  occasional
effect of great dilatation, conjoined with extreme feebleness
of the heart's action, is  the formation of coagula within the
cavities of the heart.  There is  reason to believe, that  in
some instances  in which the accumulation is excessive, and
the contraction of  the  walls extremely  feeble, the blood
coagulates during life, and  proves the immediate cause of a
fatal termination.   An unusual accumulation of blood, from
any cause, in either  the right or the left ventricle, when it
is much  weakened  by dilatation, may occasion paralysis
of the walls by distension,  and thus produce sudden death.

 PHYSICAL SIGNS DISTINCTIVE OF ENLARGEMENT BY DILATATION.

   " The physical signs of enlargement of the heart have been
 already fully considered.  The signs distinctive of dilatation
 are now to be noticed.  The several  methods of exploration
 which  furnish  evidence of  enlargement, contribute signs
 pointing to dilatation in distinction from hypertrophy.  The
 evidence obtained from percussion relates to the form of the
 area  of deep dullness.   If the  boundaiies of  the  heart  be
 delineated on the chest by means of percussion, the trans-
 verse dimension of the area exceeds the vertical in proportion
 as dilatation  predominates over  hypertrophy.   This corres-
 ponds to  the difference as regards the form  of the heart,
 which has been  stated.   The outline which the heart pre-
 sents is wedge-shaped or nearly square if the dilatation  be
 excessive.  Palpation  furnishes negative characters more
 readily available and striking.   The powerful apex-beat of 
150
DISEASES  OF THE HEART.
hypertrophy is wanting; also the elevation  of the  ribs and
the heaving of the praecordia.  The impulse of the apex is
feeble, and  may be  suppressed.  The movements of  the
organ, owing to the extended  space in which it is in contact
with  the  thoracic walls, are sometimes obscurely felt, and
oftener visible in two, three, four, or even more intercostal
spaces, which together present an appearance of fluctuation,
or, as  called by Walshe, quasi undulation.   In  some  cases,
in which  the thoracic walls  are  thin, and the intercostal
spaces wide, the heart seems to be  almost exposed  to  the
vision and touch.  Auscultation furnishes certain distinctive
points pertaining to the  heart-sounds.  Both sounds  are
feeble in comparison with their augmented intensity in cases
of  hypertrophy, but  the  first sound is  disproportionately
weakened.  The first sound is also altered  in character; it
becomes short and valvular, resembling in these respects the
second sound.   The  latter alterations, although distinctive
of dilatation as contrasted with hypertrophy, are not peculiar
to  the former, and  their  true explanation  has  not been
understood.  They are due to the  impairment or absence
of the element of impulsion in the  first sound. This element
is deficient or wanting whenever the left ventricle  lacks the
muscular powrer necessary for its production.   In  hypertrophy
this element  is  intensified, owing to the  increased force of
the ventricular contractions; and in dilatation it is feeble or
absent, owing  to the feebleness which, at the same time,
renders the  apex-beat weak  or  inappreciable.   But this
element is also  impaired or absent when, from  other  causes
than dilatation, the muscular powrer of the heart is weakened.
The intensity of the first sound is diminished disproportion-
ately to that of the  second sound,  and it  is also short and
valvular like the second sound, in cases of fatty degeneration,
and of softening in  typhus fever, and of  pericarditis with
effusion.  The valvular  element predominates, or is alone
p -ent, in consequence of the feebleness or absence of the
element of impulsion.  But  the  intensity of  the valvular
element is also more or less diminished, in the first place, in
consequence of the weakness of the ventricular contractions,
and in the second place, because at  the time when the ven-
tricular contractions take place, the quantity of  blood  within 
SUMMARY OF THE PHYSICAL SIGNS.          151
the ventricles  is  large, causing  closure  of the  auriculo-
ventricular valves.
  " In the diagnosis of enlargement by dilatation, assuming
the fact of enlargement to have been ascertained, symptoms
(as  distinguished  from  signs) have considerable w7eight,
Passive  congestions, lividity, feeble pulse,  and  dropsical
effusion, in fact,  constitute evidence almost, if not  quite
conclusive.  The  obstruction  due to the valvular  lesions
which are so generally associated with enlargement, it is true,
contributes toward the production of these S37mptoms ;  but,
as will  be seen when  valvular lesions  are considered, the
obstruction due  to these rarely, if ever, gives  rise to the
effects just mentioned until dilatation of the cavities of the
heart has taken place.   With the aid of the physical signs,
the  discrimination  between  predominant  dilatation  and
predominant hypertrophy may generally be made with con-
fidence.   The  differential  diagnosis is  of importance  with
reference to prognosis and  treatment.   The prospect of life
and tolerable health is  less in proportion as dilatation pre-
dominates,  and   the  management  involves attention  to
incidental events which do not occur as  long as hypertrophy
predominates.   For the  convenience of  comparison  with
the physical signs distinctive of hypertrophy (see page 149),
the signs distinctive of  dilatation are  embraced  in the
following summary:

      SUMMARY OF THE PHYSICAL  SIGNS  DISTINCTIVE OF
               ENLARGEMENT BY DILATATION.

   "1.   Percussion.—The transverse dimensions of the space
 occupied by  the heart greatly  exceeding the vertical, the
 form of this space corresponding to the wedge-like or square
 form of the organ w7hen the dilatation is excessive.

   "2.   Palpation.—The apex-beat devoid  of abnormal forcer
 and  in  some  instances  suppressed.  Absence  of heaving;
 movement of the ribs and praecordia.

   " 3.   Auscultation.—The element of impulsion of the first
 sound deficient or absent, and the sound short and valvular;
 in these respects resembling the second sound." 
152
DISEASES OF THE HEART.
                TREATMENT OF DILATATION.

  The indications  for  the treatment  of enlargement  by
dilatation in some respects does not differ  from the treat-
ment of predominant hypertrophy.  In other and important
respects, however, the treatment materially differs.
  You  cannot remove the impediment to  the circulation
which co-exists in the great majority of cases, but the effects
may be  mitigated,  if  you have your  patients  avoid the
extrinsic causes which excite unduly the action of the heart.
  In  the dark days  of the history of medicine, incalculable
evil was done, under the  impression that the mass of blood
must be diminished.  Bloodletting was  resorted to, giving
temporary relief, but ending most  disastrously, by causing
anaemia and muscular  atony, accompanied with  excessive
cardiac  irritability.  The  same effect  wras  produced  by
drenching  patients with saline drugs, or the use of exhaust-
ing cathartics.  When these were abandoned, the allopathic
school  resorted  to large  doses  of aconite, antimony,  and
similar  exhausting remedies, which only made  the  disease
worse, by weakening the nervous and muscular power of the
Jieart.
  Before speaking of medicinal agents, I will give you the
general rules which you  should try to  make your patients
adopt.  Excessive muscular exercise, mental excitement, or
anything calculated to excite unduly the action of the heart,
should be avoided.
  The great end of the treatment,  remember, is to  increase
the  muscular power of the heart.   The diet, therefore, should
be as highly nutritious as possible, and the quantity of liquid
ingesta as  small  as  is compatible with comfort,  A  diet of
solid, easily-digestible, animal food, with a careful admixture
•of nutritious  vegetables,  should be advised.  At  the  same
time  advise the patient to avoid any articles that appear to
digest with difficulty.
  Indigestion, constipation, hepatic torpor,  or  inactivity of
the lungs,  must be removed as soon as discovered, and care-
fully guarded against.   The mental condition of your patient
will have  much to do with  his condition.  Depression of
Bpirits tend to aggravate the disease.  You  must encourage 
TREATMENT OF DILATATION.
153
as much as possibla, in order to prevent the gloomy forebod-
ings which  annoy and  depress.  You can do this  conscien-
tiously, for in the majority of cases under your care, you can
safely encourage hope, not of  a complete cure, perhaps., but
of tolerable  health  for an  indefinite period.   The common
notion  that  disease of the heart  ends  in sudden death  is
erroneous,  and  you should  strive  by  the  most positive
assurances to  remove  this  idea  from  the minds of  your
patients.
   The medicines most useful in the treatment of  dilatation
have already been enumerated under  the head of Enlarge-
ment by Hypertrophy.   This, at  first  thought, may  seem
strange ;  but wiien you remember  that all medicines have a
double  pathogenetic action, you  can  readily see that they
will prove curative in opposite, pathological conditions.  You
will observe this in the  provings of all  medicines, and also
from the fact that a medicine  is recommended for constipa-
tion  and  diarrhoea, spasm  and  paralysis,  irritation an-d
torpor.
   I will, therefore, recapitulate the same classes I  gave you
in  the  previous  lecture,  but with the apppropriate indica-
tions :
   Class I.  Includes medicines whose primary effect  is  to
depress and weaken the muscular and nervous power of the
heart, and give rise to conditions which would tend to  cause
dilatation;  but whose secondary effects  are similar to  those
conditions described in the last lecture.
   All the truly representative men  of the  allopathic and
eclectic schools now recognize the fact, that  small doses of
depressing medicines  act as  tonics to the  tissues they j)rimarily
depress.  In proof of this I refer you to the recent writings
of Dr.  J. R. Reynolds, Handfield Jones, Trousseau, Brown-
 Sequard, Flint, Scudder,  King,  and  others.   This  is an
affirmation of the theory promulgated  by Hahnemann, and
which  forms the basis  on which  rests our important and
universal Law of Cure.   The Law of Dose, which  I have
taught  you  in my lectures  when occupying the chair  of
 Materia Medica, is, however,  equally important, for without
 it, the  selection  of the dose is a matter of great uncertainty.
fc   The medicines of this class, then, which primarily depress 
154              DISEASES OF THE  HEART.
  the heart's vitality, are especially indicated in the treatment
  of dilatation, and its co-existing debility of the structure of
  the heart.  They are :
    Aconite, veratrum album, veratrum  viride, gelseminum, tartar
  emetic, colchicum, lobelia, and tabacum.
     While I advised you to use these remedies in the  lowest
  attenuations or mother tincture, in  concentric  hypertrophy
  when there is an abnormal  increase of power, I now advise
  you to use these medicines in high attenuations, for the reason
  heretofore given, that the smallest possible doses should be given
  when we  are treating symptoms similar to the primary effects of
  medicines.
     The two most prominent physicians* of the opposite schools
  almost recognize  this rule, for they  prescribe  the above
  medicines in  the  following manner, namely, ten  or twenty
  drops of the  tincture in  four  or eight ounces of water;  a
  teaspoonfull every three  or  four hours.
     Leaving you  to select each medicine  in accordance with
  its characteristic symptoms, I advise you to give the attenua-
  tions  from the 3rd to the  3000th.  After you have  chosen
  the appropriate  remedy, do not change too soon, but continue
  its use until you are satisfied with the improvement, or are
  sure it is not causing the wished for amendment,
     I am  not favorable to the  alternation  of remedies, as a
  general practice, but I have so often seen  beneficial  results
  follow the alternation of  remedies belonging to Class I. with
  those belonging to Class III., that I have no hesitation  in
,  advising the practice.
     I will only give a few of the most characteristic symptoms
  of these medicines:
     Aconite: pulse irregular,  quick, weak, thready, and small;
  feeble and incomplete action of the  heart; the pulse and
  heart-beats do not agree; coldness of the  extremities, numb-
  ness and tingling of the cold extremities;  great anxiety and
  fear of death accompany the attacks of palpitation (dilatation
  of left ventricle.)
     Veratrum album.: pulse very small, almost imperceptible;
  intermittent; heart's  action feeble, irritable; palpitations,
* J. Russell Reynolds and Scudder.
tf 
TREATMENT OF DILATATION.
155
with distressing dyspnoea;  cold  face, with cold sweat on the
face and  forehead;  cold and livid  hands  and  feet, with
tendency to cramps in extremities. No fear of death, or great
anxiety, as from aconite, although the patient may think death
is near (dilatation of right  ventricle).
   Veratrum viride: pulse soft, feeble, but very slow, hesitat-
ing, or intermittent; excessive irritability of the heart,  so
that the slightest motion in bed, or sitting up, causes  faint-
ness, vertigo, and blindness; pale face, but not the excessive
coldness of veral. alb.;  indifference, no fear of death.
   Gelseminum:  pulse soft, slow, almost absent; heart's action
very feeble, slow% almost imperceptible; fear of any movement,
lest the heart should stop beating;* veins of the neck  distended;
extremities not cold, but  apparently  swollen from venous
turgescence, slightly  livid ; indifference ;  obtuseness ; diffi-
culty of lifting the upper eyelids, dimness of sight; heaviness
and weariness of the limbs;  palpitations  feeble, (dilatation
of left ventricle.)
   Tartar  emetic:  pulse  small,  thready,  irregular,  feeble;
heart's action feeble and irregular; dyspnoea of a very severe
character, with cough and  frothy expectoration;  congestion
of the  lungs;  cannot lie down; enlargement of  the liver;
jaundice;   attacks of  vomiting;  (dilatation  of  right ven-
tricle,  with cardiac asthma,)
  Sanguinaria:  for  nearly  the game symptoms, except that
the expectoration is bloody,
   Colchicum:  pulse  and heart's  action  feeble; urine scanty
and albuminous; tendency to dropsy, beginning with oedema
of the feet, then extending upward.
  Lobelia:  pulse small, feeble, and irregular;  heart's action
irregular  and weak, aggravated by the slightest exertion;
distressing sinking  sensation  at  pit of stomach,  attended with
agonizing  attacks of dyspnoea;  anxiety, and  fear of death;
cold face and extremities; cough, with serous expectoration;
(dilatation of  right ventricle.)
  Tabacum : for nearly the same symptoms as  lobelia, but
with vertigo, and  sensation of shocks in the heart, with feeble
distressing palpitations.
*A very characteristic symptom, just the opposite of all other medicines. 
156               DISEASES  OF THE HEART.

   Class II. contains medicines which act in a manner directly
the reverse of Class I., i. e., their primary action is similar to
(not identical with) the secondary effects of the  latter.  I
have explained to you this primary action of digitalis  and its
analogues, and  described the condition  of the heart  from
their  ultimate primary action.  Their  secondary effects on
the heart are  weakness,  irritability,  and  even paralysis.  I
believe  their  long-continued  pathogenetic  effects would
result  in dilatation of the heart.   They are among our very
best remedies in that condition; but in order to get prompt,
palliative, and  curative  effects,  you  will  have  to   give
appreciable doses, not going higher than the third decimal
dilutions, even for infants.  You will  often get the best
effects from the mother tinctures, or the aqueous  infusions.
These medicines, you will remember, are:  digitalis, cactus,
hydrocyanic  acid, prunus vir., prunus laurocerasus,  amygdcdus
persica, and lycopus.
   Digitalis.   In the spring of 1867,  I read a paper on the
action of digitalis before the Illinois State Horn. Med. Society,
wiiich paper w7as  afterwards published in the third  volume
of the United States Medical and Surg. Journal.  To this  paper
I would refer you if you wish all  the necessary proofs as to
the tonic effects  of digitalis in cardiac debility.  The primary
action of digitalis is  quite  transient.  For this  reason you
will find its sphere of action in sthenic diseases much more
limited  than in  the  asthenic;   in a weak condition  of
the heart oftener  than in inflammations or concentric hyper-
trophy.   It is indicated  in all the varieties of hypertrophy
with dilatation, whatever  the  cause may be, or any condition
of the heart where its muscular power is especially deficient.
This  is  directly  contrary  to the teachings of  nearly all
authorities up to a few  years ago.   Prof. Tully, however,
was a notable exception.  He boldty placed it  among his
" antisbeslic," or exhaustion-opposing medicines, and asserts
that he  has given it for years to the same patient without
any other than  excellent effects.   He used  it freely in cases
of hypertrophy, but it is evident, from his description, that
they were cases of dilatation.  Of late years, the best  prac-
titioners  of  the  allopathic school  use  it  without fear  in
cases of dilatation, even in large doses.  I will quote to you 
TREATMENT OF DILATATION.
157
from Flint, wrho is evidently an unbiassed witness.  He says,
" As a remedy, with reference to irregularity of the heart's
action  incident  to  dilatation,  digitalis  often  manifests a
truly remarkable efficacy.   Of the different preparations the
tincture is to be preferred, on  account of its being  more
reliable  as regards  strength.  Digitaline,  however, has stilli
more this advantage, and is perhaps entitled to preference."
Alluding to the conflicting  opinions relative to  its action, he
says,  " Without discussing these different opinions, it may
be assumed that, given in small or moderate doses, for exam-
ple, from ten to thirty drops of the tincture, it cannot, under
any circumstances, have much potency to do  harm, and it
cannot prove a dangerous remedy.   That it renders the
action of the heart slower and  more regular is undeniable.
With reference to these effects, Bouillard calls it "the opium
of the heart.  That  it produces these effects without weak-
ening the heart may be assumed ;  and clinical observation
appears to show  that, under  its  use,  the heart,  already
weakened  by  dilatation,  acts  with  increased   strength.
With these  viewrs,  it  is a remedy useful in cases both of
hypertrophy and of dilatation."   Flint  does  not  say how
often his thirty-drop doses  should be repeated, but I assure
you that if they were repeated every twro  or three hours in a
case  of hypertrophy with enlargement,  they  would  cause
dangerous  cardiac  spasms,  while  in dilatation  no  such
dangerous results would  follow,  although  no such   large
doses are admissible, except in  sudden cardiac syncope, and
similar emergencies.   I have found that doses of one, two,
or five drops of the first dilution, repeated every two or three
hours,  acted well  in  children or sensitive  adults, but the
mother tincture in similar doses may  be required.  In cases
 of dilatation, give  the digitalis  until it causes the requisite
slowness, strength, and regularity, even if you have to increase
the dose to Flint's standard to bring about that result.
   I do not speak from mere theory in this matter, but from
 much practical  experience, which experience I have  found
to substantiate  my theory of dose.
   There is  another fact  relating to  the use  of digitalis in
 dilatation.   This condition will,  as you are  aware,  cause
 various pathological conditions  in other important organs - 
158
DISEASES OF THE  HEART.
the brain, lungs, liver,  and kidneys.   Dilatation causes
passive congestion, with consequent torpor of function in all
these  and other organs.  Therefore, in cerebral, pulmonary,
hepatic,  and renal troubles;  in vertigo,  apoplexy, cough,
haemoptysis, jaundice, enlargement of the  liver, dropsy, etc.,
you should always ascertain if cardiac debility is not at the
bottom  of the trouble.   If  you find this to be the ease,
digitalis  is the  chief  remedy  always.   As for characteristic
symptoms whereby to  select  this remedy, I  must  say that
they appear to me of less value  than a  knowledge of the
pathological condition of the heart and its consequences I
have just delineated.   If you consult any work for symptoms
go to  the Symptomen Codex, but even there you will  find the
indications unsatisfactory.  Neither Lippe nor  Gross give
any indications of value for digitalis in cardiac disease.  If I
were  to name any group of symptoms  indicating  its use in
dilatation, these  would have the  preference: quick, weak,
irregular, or intermittent pulse; increased or deficient action
of the heart, with deficient force or  impulse;  cough, haemop-
tysis, jaundice, alternate scanty and profuse urine, sometimes
albuminous;  oedema  of the feet,  legs,  face, and scrotum,
ending in general anasarca; sighing respiration, with sinking,
weak  feeling at pit of stomach;  and sometimes vertigo  and
amaurosis.
  I shall allude to digitalis again in  the treatment of valvular
diseases.
  Digitalin is sometimes more efficacious in  dilatation than
the tincture.   I allude to the digitalin of Quevenne,  the only
preparation of any value.  It occurs in pale straw-colored
scales, or a white powder, and is  inodorous  and extremely
bitter.   The triturations should  always  be made  on  the
centesimal scale.  You will get the best effects from the 1st
to 3rd triturations, of which a  grain may be given every
three  hours.
  Hydrocyanic acid is  the nearest analogue  of digitalis, but it
acts with greater intensity and rapidity.  The  primary action
of this poison  I have already given  you.  Its secondary
action does not materially differ from that of digitalis.  After
the primary  effects  have passed away, the  heart  becomes
weak, flaccid, and subject to irregular action  and  severe 
              I
                TREATMENT  OF  DILATATION.             159

pains, which I think are myalgic.  These symptoms make
it indicated in dilatation with asthmatic troubles, and attacks
of angina  pectoris.  The  provings have  " tightness of the
chest; feeling of suffocation, with torturing pains in the
chest; sticking in left  side of chest, and  pain and pressure
in the region  of the heart; irregularity, with feeble beating
of the heart."  You must be exceedingly cautious in  pre-
scribing the  dilutions.  The 1st decimal  dilution cannot be
taken  in doses of  one drop  frequently  repeated,  without
causing, in sensitive persons, unpleasant symptoms;  but you
can put 10 or 15 drops in  half a glass of  water, of which  a
teaspoonful may  be taken  every twTo  or  three hours.   Its
use should be suspended, or the doses given at longer inter-
vals, as soon  as  the action  of the heart  becomes stronger
and  more  regular.  The 3rd dilution may be given in  drop
doses.  But when this acid is indicated, there  are agents
which contain it and other additional medicinal constituents,
making them of greater value in the treatment  of cardiac
affections.   The best of these is the :
   Prunus virginiana (wild  cherry) w7hich contains a principle
which possesses tonic properties, similar to  china and hydrastis.
This  property is also  possessed, in a greater degree, by the
cerasus serotina (choke cherry).
   We have no provings of these remedies, but their success-
ful use for nearly a century, has given  us  clinical experience
sufficient to give us reliable  data.
   I can give you no better indications  than those of digitedis,
to which can be added "weakness, loss of appetite,  slow
digestion, cough, tightness and  constriction  of the  chest, and  a
fulness and pressure in the  head."  The sj-mptoms in italics I
have often observed to arise from large doses of the infusion
of the bark of these trees.   You can  use a hydro-alcoholic
tincture of the fresh bark in drop doses,  or the  lowest  dilu-
tions, or the syrup, or the cold infusion, made by digesting
or percolating one ounce of the fresh, or  dry inner bark  in
a quart of water, until  it  assumes a dark red color.   This
may  be given in  table-spoonful  or wine-glassful doses,
repeated every three or six  hours.  Those who are sticklers
for the high dilutions may object to this method of prescrib-
ing a medicine, but I cannot see the  necessity of adhering 
160
DISEASES OF THE  HEART.
to any one method of preparing our remedies.   If a medi-
cine is homoeopathic to the disease, it matters not in what
form we give it, if the doses are not large enough to cause
pathogenetic symptoms.   Your object  should  be  to cure
your patient in the quickest manner, regardless of peculiar
notions relating to arbitrary pharmaceutical preparations.
  The leaves, pits, or inner bark of the amygdalus persica
(peach) is much stronger in prussic acid, and may be used
in infusion  or  hydro-alcoholic tincture, but  in  one-half or
one-third  the quantity recommended for prunus.
  The amygdala amara (bitter almond) is still more powerful.
This  medicine, as  well  as the pit of the peach,  may be
prepared  in  triturations, and used  in the 1st.  In cases of
hypertrophy with  dilatation  I have known  a  few  bitter
almonds eaten before and after meals prevent the palpitations
which are apt to occur after eating.
  Lycopus virginicus  is  likely  to prove  one of our best
remedies  in dilatation.  If you will refer to the provings and
clinical experience recorded  in  " New Remedies," you will
see that  its  sphere of action is evidently that of a cardiac
sedative and tonic.   It is useful in dilatation associated with
and  causing  pulmonary  troubles,  such  as  congestion,
haemoptysis, cough, and dyspnoea,   You  can prescribe  it
in the tincture  or lowest dilutions, or an infusion of half an
ounce of  the leaves to eight ounces of hot water.  Of this
a teaspoonful may be given every two or four hours.
  Ferro-cyanuret of potash has  lately been introduced  into
practice as a remedy for hypertrophy, as  well as for  func-
tional disorders  of the heart.  This  double salt  is  of a
yellowish color, and quite innocuous when compared with
the cyanide of potash, with which you should be careful not
to confound it.
  Dr. Ray, in a recent paper, speaks very highly of its  use,
and gives several clinical cases in which he prescribed it with
excellent  results.   The symptoms which he removed with it
were: palpitation, ringing in the ears, vertigo, intermittent pulse,
waking with a sense of suffocation, palpitation disturbing sleep at
night, improvement  in the  open air.   Some  of the  cases were
doubtless purely functional, others apparently structural.
  You will doubtless find  it  especially useful in those cases 
TREATMENT OF DILATATION.
161
which  seem to require iron and  digitalis.  This  meets the
indication for both, and may be given in grain doses of the
1st decimal trituration, repeated  every few  hours.  It  is
peculiarly suitable in those cases of dilatation aggravated by
venereal excesses.   In doses of 10 or 15 grains every five
hours it soon destroys all sexual desire and power, (while its
use is continued) and arrests the cardiac irritation.

   We next come  to the remedies of  Class  III.,  namely:
nux vomica,  ignatia,  collinsonia, cimicifuga, china,  hydrastis,
ferrum,  cuprum, hypophosphite  of potassa,  phosphoric acid,
sulphuric acid, muriatic acid,  etc.
   Nux vomica, and its alkaloid, strychnia, are the most important
of this class.   By referring to your notes on  the treatment
of hypertrophy with enlargement, you will find nux vomica
recommended  for its primary symptoms.  Allusion was made
to its secondary effects, wilich are very profound and import-
ant.   The reaction from  the intense  stimulation (primary)
induces  a condition of nervous and muscular irritability in
proportion to  the  weakness wmich obtains  in  the nerve-
centres.   To make matters worse, all the important organs
of the body  partake of the prostration and  loss of tone.
The liver, stomach, intestinal canal, renal and sexual organs,
and even the brain, become the  seat of morbid irritability
and perverted  function.
   I will not attempt here to give you all the symptoms which
indicate its use in hypertrophy  with  dilatation.  They are
too numerous  for me to mention and for you to remember.
Suffice it to say, that the general mental and  physical con-
dition, the weakness and irritability of the heart, the aggra-
vations  after meals and from  emotions, and the dyspeptic
symptoms, must be  your guide.  First be  sure  of your
diagnosis, then consult the  Symptomen Codex, or the excellent
materia medica cards of Prof. Hoyne, and prescribe for  the
ensemble of the symptoms.
   The dose of nux vomica is quite important.  As a rule, the
lowest dilutions or triturations will give you the best results.
The 1st or 2nd  decimal dilution, or  trituration, one drop
or one grain every three or six  hours, wall, in a few days or
weeks, produce a notable curative result. 
162              DISEASES OF THE  HEART.

  Strychnia will sometimes give better satisfaction than the
nux  vomica, especially when  there is a preponderance of
symptoms denoting spinal exhaustion, and a general tendency
to paralysis  of muscular power  and torpor  of function.
Use  the centesimal  triturations, from the  1st to the 3rd.
  Ignatia, while it resembles nux vomica in some respects, has
important symptomatic differences.  It  is more suitable for
women ;  for the  hysterical  condition;  for  irregular mani-
festations of a  spasmodic character; and for the effects of
grief.  A characteristic  symptom which is a valuable guide
is the  " sensation of great weakness  and sinking in  the
stomach."  This feeling oftener proceeds from cardiac weak-
ness than any other cause.
  Dose: the same as  nux vomica.
   Collinsonia is certainly of considerable value in this disease.
While it does not appear to me to act on the nerve-centres
like nux vomica, it resembles that remedy closely in its action
on  the vegetative system,  and the various organs  of the
body.   Dr. Squire thinks* we  have no remedy superior to
it in chronic functional or structural diseases of the heart.
He  asserts that he has given it in nearly one hundred cases
of cardiac trouble, and that it has not failed to give relief in
a single case.   In one patient suffering with  hypertrophy,
the  irregular action of the heart ceased in a few days, and in
three months he was discharged  cured.  The doses used in
these cases wrere 15 drops of the fluid extract three or four
times  a day.  He remarks that, " larger doses did not  have
 the  desired  effect," wThich shows that pathogenetic aggrava-
 tions were present in some degree.
   The 1st  dilution,  or  drop doses of the tincture, may be
prescribed.  Consult the provings and  account of its cures
 in " New Remedies," for further indications.
   Xhnicifuga, from its  well-known action on  the muscular
 and nervous system, will  doubtless  often  aid you in the
 treatment of hypertrophy with dilatation.   It is the remedy,
 par excellence, for the palliation  and cure of myalgia.  It
 occupies  a place  between  nux and china, partaking of the
 characters of both.   It does not seem to affect  the functions
* Eclectic Medical Journal, Vol. 1871, page 267. 
TREATMENT OF DILATATION.
163
of the vegetative system so much as the nerves of motion
and  sensation.   All weakened muscles  become irritable,
painful, and  subject  to spasmodic movements.  Cinncifuga
controls this  condition, and restores  the normal tone of the
nerves which  supply the  muscles.   Chorea  is  sometimes
associated with cardiac debility; even the movements of the
heart  may partake of  that  character.  In such cases, no
remedy rivals cimicifuga.  If the disease is a sequel of mus-
cular rheumatism, this medicine is especially indicated.  In
dilatation during pregnancy, or at the critical age, no remedy
will  prove more useful.   If sympathetic cerebral symptoms
occur, cimicifuga will be finely indicated.
  Dose: the dilutions from 1st to 3rd, or the lowest tritura-
tions of cimicifugin (macrotin), its active principle.  Do  not
leave off its use too  soon, or  change the remedy until you
are sure it is not appropriate.
  Agaricus should be consulted if cimicifuga seems indicated
but does not give satisfaction.
   China, or its alkaloid, quinine, has  already been spoken of.
While you will  rarely  have  to use  it in enlargement, you
will  frequently  find  it invaluable  in  dilatation.  It  is
especially useful if the disease is associated with, or produced
by  malaria,  loss of  the vital  fluids, long-continued night
watching, or  deficient  food.   The action of the heart  may
be very tumultuous, while the real force is weak; the blood
is poor, and  deficient in quantity; the countenance sallow;
digestion impaired,  wTith tendency  to flatulence;  there is
ringing in the ears, vertigo, and night sweats.
  Hydrastis,  or the active principle,  hydrastin, ranks next in
importance.   As a restorer of the tone  of muscular tissue
it is not surpassed.   It  is indicated  in those cases which do
not  arise from malaria, but which appear to  indicate china;
also for those cases where the action of the heart is persist-
ently w7eak and excited, and where the patient  is emaciated,
is troubled with  indigestion,  and the liver is also deranged.
Its persevering use will  bring about permanent good results.
  Dose: the  lowest*dilutions of hydrastis, or triturations of
hydrastin.
  Ferrum..  All  the preparations of iron are indicated in
dilatation, especially if it co-exist with anaemia.  In selecting 
164
DISEASES OF THE  HEART.
the preparation, the idiosyncrasies of your patient must  be
taken  into account,  as  well  as  the  bodily  constitution.
Ferrum metallicum or ferrum. carb. are indicated  in uncompli-
cated cases.  If fatty degeneration  of the heart is suspected,
use ferrum iod.  If dyspeptic  symptoms predominate, try
the lactate of iron, or the double salt of iron and strychnine.
Certain cases wTill  require the  phosphate of iron, and others
improve rapidly under the tinct. ferr. muriaticum in the low
dilutions.   The dose  of the  ferruginous  preparations  may
range from the 1st to the 6th.
   Cuprum, according  to Grauvogl, will cure some  diseases
associated with anaemia wiien iron fails.  For dilatation  with
fatty degeneration it appears to be  decidedly indicated.
   The hypophosphite of potassa is a favorite remedy with me
in all heart affections  with muscular »tony or myalgia.  All
the potash salts appear to have an affinity for muscular tissue,
and none  more so than this.   If the patient has been pros-
trated by  excesses, loss of fluids, loss of sleep, mental labor,
and is  emaciated, use this salt in  doses  of \  to Y$th. grain
three times a day; alternate  with hydrastis, nux  vomica, or
collinsonia, and the results will be very satisfactory.
   The  mineral  acids  have  not been used  as  often or  as
thoroughly in cardiac  affections with debility, as their merits
demand.   The phosphoric acid is unrivalled  as  a remedy
when  indicated by the general symptoms of the patient.
Sulphuric acid has enabled me to relieve and prolong the life
of several patients suffering with dilatation, co-existing  with
Blight's disease.  Not only did the  heart's action improve
under its  use, but the  renal disease was decidedly benefitted,
the dropsical symptoms disappeared, and the appetite and
strength returned in a short time.
   Muriatic acid will prove a valuable remedy in your hands.
Study the provings well, and the clinical indications, and
select accordingly.  In prescribing these acids, insist on the
aqueous dilutions, from the 1st to 3rd, sufficient  to render
the water slightly acid, and repeat the dose four or five times
a  day.
   The  remedies of Class IV., pamely, belladonna,  solanum,
lachnanthes, glonoine,  stramonium,   agaricus, cethusa, conium,
etc., will  be found useful as palliatives when  paroxysms of 
TREATMENT OF DILATATION.
165
obstinate  palpitations, attended by local congestions, occur.
In the so-called cardiac apoplexy they are useful medicines.
  I cannot give you the indications for all these remedies.
You must be guided by their characteristic symptoms and
pathological effects.  You will find that the middle dilutions
(6th to 30th)  will give the best results.
  Do  not forget the  anti-psoric  remedies while  treating
dilatation, for they will  prove of service to you in combatting
lurking miasms, and arousing the dormant energies of the
organism.
  The stillingia and chimaphila are very important antipsoric
remedies, as  well as those introduced by Hahnemann.  All
this class should be used in the middle or higher attenuations. 
LECTURE  IX.
           LESIONS OF THE WALLS OF THE HEART.

 Atrophy  of the  Heart — Fatty Growth — Symptoms of Fatty  Growth —
  Fatty Degeneration — Symptoms of—Pathological Effects—Treatment —
  Softening of the Heart—Induration of — Rupture of  the Heart — Treat-
  ment of the Various Lesions.

   Gentlemen :  The walls of the heart are  liable to various
 lesions,  other  than hypertrophy.  In  this  lecture I  shall
 briefly consider these organic affections and their treatment.

                  ATROPHY OF  THE HEART

 is a condition in which the muscular substance is diminished,
 the cavities not enlarged, but actually lessened.   The  whole
 heart  is smaller than  the  normal  size.   Its  weight is
 diminished in proportion to  its size, but the organ does not
 change its appearance in any other respect.
   Causes.  It generally  attends chronic disease  where there
 is gradual progressive emaciation.  It has been observed in
 tubercular phthisis, pericardial adhesions, calcification of the
 coronary arteries, and an excess of fat on the exterior of the
 heart.   The heart wastes  like other  muscles  when  badly
 nourished.
  The symptoms are those  w7hich denote feebleness of the
 circulation, but the feebleness of the circulation may have
 existed prior to the atrophy.   The physical signs suffice for
 the diagnosis.   The  boundaries  of  the superficial cardiac
 regions are within the  limits  of health,  the  apex-beat is
indistinct or wanting,  and the  heart-sounds  are abnormally
feeble, and may be inappreciable.
  The treatment of atrophy, when due to impaired nutrition,
is the same as that  adopted for  enlargement by dilatation 
FATTY GROWTH AND DEGENERATION.          167
The remedies in Class III., together with a highly nutritious
diet, to which may be added  cod liver oil  in doses of 20 or
30 drops three'times a day.

            FATTY GROWTH AND  DEGENERATION.

  Fatty growth.   More or less  fat  is generally present in
health, on the outer surface of the heart, after early infancy,
especially on the right ventricle, at and near the base of  the
organ.  It is most  abundant  between  the ventricle and
auricle, and around the coronary vessels.   A small amount
of  over-accumulation  is  sometimes  found in  post-mortem
examinations, where  there had been no symptoms of disease
of the  heart during life.  When the accumulation is excessive
it leads to enfeebled muscular action, and consequent weak-
ness of the circulation.  It may induce atrophy of the heart.
Fatty growth usually occurs after the middle period of life,
and in persons of adipose diathesis.  It may, however, occur
in persons who are not corpulent. You will most frequently
find it in persons who ,are growing fat rather rapidly.   The
heart  has been known to become  completely encased in a
thick layer of adipose tissue.
  Fatty infiltration is another and more serious form.  In this
disease there is an accumulation of fat between the muscular
fibres.   The  pressure upon   the  fibres causes  functional
weakness and atrophy, and leads to dilatation.
   Fatty degeneration is much more serious, and differs essen-
tially from the  two varieties  I have just mentioned.   The
fat, in the form of oil drops or granules, replaces the muscu-
lar substance, and constitutes a form  of fatty atrophy.  It
may be  associated with fatty  growth of the heart, but it
occurs independently of the latter.   It affects more especially
the left ventricle, while fatty deposits on the heart affects the
right.  It may be uniformly diffused, but is oftener confined
to  circumscribed  patches or  strips.  The  portions affected
assume a yellowish or fawn color, and if it occurs in patches,
gives  the heart a mottled appearance.  Examined with  the
microscope, the  striae, or transverse markings of the  fibres
are indistinct or wanting, and in place of the proper con-
stituents of the  muscular fibre, there  are  oil globules and 
168
DISEASES OF THE  HEART.
granules,  in  more or  less abundance, according  to  the
amount of degeneration.
  In this disease, fat  replaces the muscular substance, and
in proportion as this result obtains, the propulsive power of
the heart is diminished; it yields more readily to distension,
and dilatation occurs.   Authorities differ as to the real con-
dition, for while some believe that the muscular substance
is changed into fat, others believe that the fat is substituted- for
the normal muscular substance.   Others  teach that it  is a
chemical, not a vital process.
  Causes.   As I have before stated, you will not always find
either variety in adipose persons.  It often occurs in persons
who have  fatty deposits or fatty degeneration elsewhere, as
in  the  liver  or spleen.   The etiology may  involve  both
general and local causes.  Among the local causes is impair-
ment of nutrition from obstruction of the coronary arteries,
from  atheromatous or calcareous disease.   It may  occur
from  hypertrophy, valvular lesions,  emphysema, or Blight's
disease.   It occurs in connection with the tuberculous and
carcinomatous  cachexia, also in  cases of p}78emia or septi-
caemia.   It may  be caused  by  the poisonous  effects of
phosphorus, arsenic, and some other poisons.   Alcohol, in
excess,  undoubtedly has  a  causative  influence.  In old
habitual drunkards this condition is generally found  after
death.

           SYMPTOMS  AND PATHOLOGICAL EFFECTS.

  Although the different forms of fatty disease differ patho
logically,   their general effects  are  similar.   Both  cause
weakness of  the heart and enfeebled circulation, but not in
an  equal degreee.   I have  told you which  produces the most
serious  results.   Fatty  growth, and  even  degeneration  may
be  present in a large degree, and not suspected up to the
moment of death;  and rupture of the heart has been known
to occur from  fatty degeneration, and the patient show no
symptoms of the disease during life.
  The pulse may be very slow, down to 20 or  30, and even  8
or 10, per  minute.   It will always be deficient in force.
  It may be intermittent, irregular, very freauent and feeble. 
               PHYSICAL SIGNS AND DIAGNOSIS.          169

 A sense  of oppression at the praecordia, palpitation, and a
 tendency to  syncope,  are commonly  observed.   Flint has
 observed, and so have I, a notable degree of capillary con-
 gestion of the  extremities.   In  one case which came under
 my observation, the hands and feet would become intensely
 red, especially after meals.  Dyspnoea  is present in this, as
 in other heart affections.
    Certain, symptoms referable to the nervous and respiratory
 system, are supposed to be highly significant of fatty degen-
 eration:  (1) The occurrence of seizures resembling apoplexy,
 but  not  followed by  paralysis.   After  death no  morbid
 appearances are  observable  in the  brain;   (2) A peculiar
 aberration of the respiratory movements was  observed by
 Cheyne,  and  Stokes, "It consists  in  the occurrence of  a
 series  of inspirations increasing  to  a  maximum,  and then
 declining in force and length until a state of apparent apncea
 is  established.   In this condition, the  patient may remain
 for such a length of time  as to make his attendants believe
 he is dead, when a  low inspiration, followed  by  one more
 decided, marks  the commencement of a new ascending and
 then descending series of inspirations."  This  is  said only
 to  occur a few weeks before  the death of the patient.   But
 this  symptom has been  known to occur from  hypertrophy
 of  the  left ventricle, without fatty degeneration;  (3) Fatty
 degeneration  of the  cornea, giving rise to that appearance
 known as arcus senilis, has been observed, but I have observed
 it when no symptoms of heart disease were present.

              PHYSICAL SIGNS AND DIAGNOSIS.

  You will not find it very easy to diagnose  fatty disease of
 the heart from the physical signs ; but if no valvular disease
 is present,  and  hypertrophy  is not found, and the heart's
 action is feeble, and the  patient is adipose, you may safely
 infer the presence of fatty heart.
  If you suspect  fatty degeneration, and  find that percussion
 shows moderate or no increase of the volume of the heart,
you have a negative point.  If you find that the apex-beat is
not removed from its  normal position, and its beat feeble, or
inappreciable—and no impulse elsewhere than over the apex; 
170
DISEASES OF THE HEART.
and  if by auscultation you  find the  sounds of the  heart
weakened, the first more than the second, and that is short
and valvular;  and, finally, if you'find both sounds extinct,
you may safely consider the case one of fatty degeneration.

                       TREATMENT.

  In the  treatment of fatty growth and degeneration, you
must have three objects in view, namely:
  I.   To obviate and relieve the immediate effects of weak-
ness of the heart.
  II.   To increase permanently the muscular power of the
organ.
  III.   To arrest or limit the accumulation of fat.

  I.   The immediate  effects  of the cardiac weakness are,
palpitation and praecordial distress, syncope, dyspnoea, and
perhaps apoplectiform attacks.  These occur in paroxysms,
excited by over-exertion, mental excitement, etc.   To combat
these symptoms,  you  should use  as  palliatives, in  severe
attacks, wine,  spirits, ether, or ammonia, and continue their
administration until the  urgent S37mptoms disappear or are
much relieved.  The specific remedies for these symptoms
you will  find in Classes I. and II., in the treatment of dilata-
tion, with the  indications for their use, to which I refer you.
In the apoplectiform seizures, especially, you will find Gel-
seminum  6th,  or  Acidum  hydrocyanicum   3rd,  particularly
indicated—the former if the attack was rather slow in coming
on, the latter if it was very sudden  in  its invasion.  In gen-
eral,  the  two  best  remedies are  undoubtedly  Aconite and
Digitalis—the former in the 3rd dilution, the latter in  the 1st
or mother tincture.  Whichever remedy you  select,  give it
as frequently as the  urgency of the case demands, until the
pulse becomes  full  and  regular, and  the  condition  of the
patient has much improved.  If  the  extremities are  cold,
advise the mustard foot and  hand bath, to divert the blood
from the heart.
  II.  The second object is to increase  permanently the
muscular power of the heart.   This is to be accomplished by
the judicious administration  of those remedies belonging to 
DIET.
171
Class III. mentioned under " Dilatation," namely :  Ferrum
and  its various preparations (the Iodide is the best in this
disease),  nux  vomica,  ignatia,  hydrasti*,  manganese,  aletris,
helonias,  china, ptelia,  cuprum, platinum, plumbum, the hypo-
phosphites, and the mineral acids.
  The anti-psorics may be useful  to combat the various
dyscrasia, and may be advantageously alternated with the
remedies just mentioned.
  You will find that the lowest attenuation of Class III. will
bring about the best results, while the high dilutions of the
anti-psorics are most appropriate.
  The diet of the patient is  of great  importance.   You
should aim  to produce  a  healthy nutrition of the affected
organ  by rendering the blood  rich in nutritive materials.
All  articles of diet allowed should be highly nutritious and
easily assimilable.  As large a portion of animal food as the
digestive powers  will permit should  be advised.  The meat
should, however, be lean, tender, and properly cooked.  The
quantity  of fluids should be restricted, in order not to make
the quantity of water in the blood excessive.   Warm clothing,
especially about  the  extremities, should  be  insisted on.
Excess of all kinds,  in eating, drinking,  venery,  mental
occupation or excitement,  late hours, etc., should  be prohib-
ited.  As physical indolence predisposes to this affection, a
judicious course of exercise in the open air should be advised.
But  while exercise is advised, it  should  not go to the point
of causing dyspnoea or palpitation.  In order to have exercise
do good there must be an interesting object.   For this reason,
hunting, fishing,  botanizing, horseback riding, etc., are the
best  methods.
  HI.  It is important that you  should try to arrest or limit
the accumulation of fat in  or upon the heart.  Although the
pathological  condition in  the  two forms differ, we do not
know that the dietetic  treatment should differ.   All fatty
and  saccharine substances  should   be  avoided.   Starchy
food is also inadmissible  except in  small  quantities.  The
diet  should  consist of  lean meat,  bread,  non-farinaceous
vegetables, and certain  kinds  of fruit, principally the acid
fruits.
  Of medicinal remedies, those which act chemically cannot 
172
DISEASES  OF THE HEART.
be used with  safety and they have  been abandoned.   The
bromide of ammonium, in doses of 5 or 10 grains, three times
a day, seems  to have the  power of  diminishing adiposis
without injuring the health.  I  have  found that graphites,
6th and 30th, used for a month or more, has the same effect,
Phytolacca appears  to have the power of diminishing the
amount of fat in the system, when given in the lowest dilu-
tions.  It is claimed that the iodide of potassa has the same
effect.  But these remedies should always be alternated with
the ferrum group.
  Baehr says, after recommending iodine and calcarea, " We
have two other remedies which w7e cannot  recommend with
sufficient  emphasis in  heart-disease generally, and more
especially in  fatty  degeneration, we  mean  cuprum  and
plumbum.  Both remedies act similarly, except that the action
of plumbum  is more persistent and penetrating."  He gives
the following indications taken from cases of poisoning:
  "Cuprum: pulse  irregular,  small,  easily  compressible,
intermitting, accompanied  by excessive  muscular debility;
the beats of the heart are scarcely, or not at all, perceptible;
the sounds of  the heart are indistinct;  dyspnoea; feeling of
anxiety;  disposition to faint.
  "Plumbum: the impulse of the heart is very feeble, or even
imperceptible; sounds of the heart indistinct; palpitations,
attended  with  excessive dyspnoea;  pulse  very soft, easily
compressible, intermitting, irregular, 50 to 60 in a minute,
less frequently over a hundred, after  which it is scarcely
perceptible; heart  flabby; sudden paralysis of the heart;
fainting fits  during every exertion, also, attended with slight
convulsions, extreme muscular debility, and oppression from
the least motion; despondency and  dread  of death;  night
mare ;  oedema of the skin."
  The  iodide of lead ought  to prove more valuable than the
pure lead for fatty degeneration of the  heart.
  Baehr thinks aurum will prove a good  remedy.
  Phosphorus  and  arsenicum are the twTo  medicines which
correspond  pathologically  to  fatty  degeneration.    Both
cause fatty heart, as well as fatty degeneration of the liver
and kidneys.  The pathogenetic symptoms also correspond,
and theoretically they ought  to cure  this malady, but w« 
SOFTENING OF THE  HEART.
173
have no clinical testimony to substantiate it.  I would advise
you to try them when indicated, in tne 3rd or 6th attenuation,
for a sufficient length of time to test their curative pow7ers.
  I have sent a few patients, whose adipose growth in general
was immense, to a most rigid hydropathic establishment,
where a few months'  residence removed a large quantity of
the abnormal deposit,

                 SOFTENING OF  THE HEART.

  I have already called your attention  to  this condition,
when speaking of  inflammation of the heart.  It has also
been considered as incident to fatty degeneration.  It occurs
during the course of essential fevers, especially typhoid fever
and typhus.  Sometimes the softening  is limited to the left
ventricle, and sometimes it  extends  all through the heart-
substance.
   When softening has taken place the wTalls are relaxed  and
feeble;  the structure easily torn with the finger;  the organ
is flaccid and collapses with its own weight, not preserving
its natural form, but retaining, like a wet cloth, any shape in
which it  is  placed.   When incised, the  cut surfaces are
dry and unpolished, and  the color of the cut surface is
purplish and livid.
   Symptoms and  physical signs.  These are the same as in
fatty  degeneration.  They proceed  from weakness of the
organ, and loss of muscular power.  Stokes gives  the best
indications for  the diagnosis of  this affection,  especially
when it  occurs during fever.
   Treatment. The sole indication for the treatment of soften-
ing from any cause, is  to  sustain  the failing  power of the
heart by  stimulants,  aliments,  and  restorative  remedies.
The use of  wine,  brandy,  egg-nogg,  beef-tea, wine-whey,
aided by china, hydrastis, ferrum, phosphorus, and the mineral
acids, should  be freely used, until  the action of the heart
denotes such an amount of force as to free the patient from
danger.  In severe cases the patient must not be allowed to
sit up, or make any sudden movements while the heart is
very weak.  Fatal  syncope has been known to occur from
such imprudence. 
174
DISEASES  OF THE HEART.
                INDURATION OF THE HEART.

  This lesion is so rare, and  so difficult of diagnosis, that I
will not speak of it at length, nor shall I treat at length of

                   CARDIAC  ANEURISM,

a condition rarely met with, but which the older pathologists
confounded  with hypertrophy with dilatation.   Although a
rare lesion,  Thierman has collected  seventy-four cases on
record.   The aneurismal  dilatation forms a  tumor,  varying
in size, in different cases, from that of a small nut  to a sac
as large as, or even larger than, the heart itself. It contains
layers of condensed fibrin, and various forms of coagula like
arterial aneurisms.   It is sometimes  lined  or  studded with
calcareous matter.  For a fuller consideration of this  subject,
I refer you to works on morbid anatomy.
  Flint gives  five  interesting cases  which came under his
personal observation.
   Treatment.   No cure can be effected;  but the same treat-
ment recommended for dilatation of the heart would be
appropriate, and perhaps palliate suffering and prolong life.
Some of the early homoeopathic writers recommended lachesis
and lycopodium, but we are in doubt whether  they  referred
to hypertrophy with dilatation or true aneurism.

                 RUPTURE OF THE HEART.

  It is believed that spontaneous rupture of the heart is of
rare occurrence; and Flint doubts if  it has  ever occurred as
a  result purely of muscular activity of  the organ.  He
believes it is  always dependent  on some prior morbid con-
dition of the  cardiac parieties.   I believe, however, that
eases are on record where rupture of the heart has occurred
from violent mental emotion, independent of cardiac disease.
A  singular  book has  lately been published  in  England,
treating of the  diagnosis of  the crucifixion of Christ.  The
authors  are the eminent London surgeons, William Stroud
and Sir J. Y. Simpson.   Dr. Stroud, after  citing  and com-
menting On  a  long series of  instances of bloody sweat, feels 
RUPTURE OF THE HEART.
175
warranted  in  the conclusion that, " owing to  the natural
constitution of the human frame, the exciting passions, when
violent, and especially when accompanied  with  agony  or
conflict, are capable of producing bloody sweat, and  when
still more  intense,  rupture  of  the heart."  Among  other
medical  authorities  he quotes the younger Gruener, to the
effect that it is common for a person whose heart is oppressed
by excessive congestion of blood, and who is threatened with
suffocation, to " cry out  with a loud voice; " and  also Dr.
Walshe, Professor of Medicine in University College, London,
who says, that in case of rupture  of the heart, the  hand is
suddenly carried to the front of  the chest  and a piercing
shriek uttered.   Sir James Y. Simpson, w7hose high rank in
the profession has won for him the title of Baronet, adds an
appendix to Dr. Stroud's treatise, in which he says, in sub-
stance, that usually death very rapidly ensues, in consequence
of the blood escaping from the interior of the heart into the
cavity of the large surrounding  heart-sac or pericardium,
and that  in such cases the sac will be found, on dissection,
to contain  two,  three, four, or more pounds  of blood accu-
mulated  within  it, and separated into red clot and limpid
serum, or " blood and water."  As dissection was not prac-
ticed in ancient times, the  nature of this rare disease was
not understood,  if indeed its existence was  even  suspected.
These surgeons  agree, therefore, that death wTas occasioned,
not by pain and physical  exhaustion, wThich, in a person in
the prime  of life, would require two or three days, but by a
literally broken heart.
   Rupture of the heart is almost  inevitably fatal, and death
occurs instantaneously.  Walshe, howTever, states that one
case  has been recorded  of  death from rupture, in wilich a
former rupture  was discovered firmly filled by a fibrinous
coagulum, adherent to the wall of the heart.

    Wounds of the heart belong to the domain of surgery, and
I will only  say to you,  that  they are  not as fatal  as is
generally supposed.  In the  " Surgical Memoir of the  War"
you will find several cases to substantiate this statement. 
LECTURE  X.
            VALVULAR DISEASES OF THE HEART.

Aortic Lesions—Mitral Lesions — Primary Effects of Valvular Disease on the
  Circulation—Symptoms and Pathological Effects of Valvular Lesions —
  Secondary  Effects of Valvular  Lesions — Pain — Palpitation — Cardiac
  Dropsy — Symptoms of the Respiratory System — Symptoms of the Nervous
  System — Symptoms of the  Digestive  System — Symptoms of the Genito-
  urinary System — General Symptoms.

  Gentlemen :  I now come to  those diseased conditions of
the  valves and  orifices of the  heart which go  under  the
general name  of Valvular  Diseases.  I have reserved  this
subject for my last lectures because these  lesions are con-
nected with, and are the results of the inflammatory affections
hitherto treated of.  Another and important reason is, that
many diseases  and functional disorders of various organs of
the body, which are often  considered idiopathic by unobserv-
ing  physicians, are really  the result of  valvular lesions.   If
the heart does  not work in a normal manner, the  circulation
all over the body is imperfect, and every other organ becomes
deranged.
  The clinical study of these lesions is of great interest, on
account  of  the w7onderful  precision  with  which  modern
diagnosis,  by means of  auscultation, enables us to locate the
situation and nature of the  lesion.
  In treating of valvular  lesions, my main object will  be to-
describe their  immediate  and remote effects, and the means
by which we can make  a  correct  diagnosis, and  finally, the
appropriate homoeopathic treatment for these effects.   The
cause can  rarely, if ever,  be removed.
  I  shall first take up for  your consideration the 
MITRAL LESIONS.
177
                     AORTIC LESIONS.

  Lesions affecting the aortic valves may be limited to one
or two of the semilunar segments;  but in most cases all are
more or less affected.   Thickening of the segments is one of
the most frequent of the morbid  changes.   This will not
specially impair the function of the valves, but their expan-
sion will be somewhat  sluggish, and  the  intensity of the
aortic second sound of the heart must be in some measure
diminished.
  The segments are often contracted  as w7ell as thickened.
Consequently a current  of blood is forced backward  from
the aorta into the ventricle, by the  recoil of the arterial
coats.  At the same time the aortic second sound of the heart
must be weakened by the diminished size of the valves as
well as by the thickening.
  Rigidity of  the valves from calcareous  deposit  is of
frequent occurrence.  The segments are sometimes expanded,
and being encrusted with calcareous salts, appear to be  com-
pletely petrified.   This wras formerly called ossification.
  Another variety of lesion consists in the presence of warty
excrescences or vegetations.  These  are generally attached
at or near the free border of the segments, on their ventricu-
lar aspect.
  These vegetations  may be loosely attached, and liable to
be  separated by the  force of  the  current  of blood  during
life, and become emboli, and obstruct the circulation in the
arteries.
  Attenuation  from  atrophy is  also a  lesion to w7hich the
valves are liable.  Rupture, under these circumstances, is
liable to occur.
  Perforations may occur  at any point where the valves are
softened, and perhaps at the same time thickened.
  Lesions in the  aorta, extending, to a greater or less extent,
above  the valves,  are, in  the  majority of cases, associated
with lesions of the aortic orifice.  The artery may be dilated
or contracted.
                     MITRAL LESIONS.

  Lesions at  the mitral  orifice are  essentially the same as
aortic  lesions, the points of difference relating chiefly to the 
178
DISEASES OF THE HEART.
differences, as regards form and arrangement, of the mitral
valves.  As a result of their insufficiency, a retrograde stream
or current, from the  ventricle into the auricle, takes place
with each systole of the ventricle, the quantity of blood thus
regurgitating, of course, being proportionate to the extent
of the mitral insufficiency.
  Rupture of the tendinous cords connecting the free mar-
gins  of  the valves  with the  papillary muscles occasion
insufficiency of the mitral valves.
  The deposit  of calcareous salts  at the base of the valves
gives rise to lesions, and reduces the the auriculo-ventricular
orifice to a small aperture.
  Vegetations and warty excrescences occur in this situation
as at the aortic orifice.  But the most frequent mode in
which contraction of  this orifice is produced is by the union
of the curtains at  their sides, leaving a narrow slit through
which the blood passes from  the auricle into the ventricle.
  Aneurism of the mitral, as well  as of the semilunar valves,
is another variety of  lesion.
  It is evident, that  in so far as the different lesions which
have been  noticed interfere with the play of the mitral
valves, the first sound of the heart must be weakened and
modified  by the diminution  or extinction of  the valvular
element of this sound.

         SYMPTOMS OF AORTIC AND  MITRAL LESIONS.

  As symptoms  referable  directly  to the  heart may be
noticed : pain, palpitation, abnormal changes of the pulse,
turgescence of the veins, and venous pulsation.

   Pain.   Absence of  pain  is  the  rule,  but  occasionally
patients complain of  painful sensations referred to the prae-
cordia.   A  sense  of  constriction,  uneasiness, or undefinable
distress, is oftener met with than actual pain.
   Palpitation.   Is due,  not  directly to  the  lesions of the
valves or  orifices,  but to the  hypertrophy to which they have
given rise.  When the patient complains of the beating of
the heart, the impulse is found, on applying the hand  over
the  praecordia, to be abnormally  forcible.   This  increased 
         SYMPTOMS OF AORTIC AND  MITRAL LESIONS.     179

force is observed when the patient is not aware of any such
palpitation.  Palpitation,  therefore, may  be present as an
objective, when it is wanting as a subjective symptom.
  Other things being equal, the increased  violence  of the
heart's action is proportionate to the amount of hypertrophy,
and especially hypertrophy of the left ventricle.
  Usually, if the  patient complain of undue violence or of
irregularity of  the heart's  action, exclusive of other circum-
stances,  the  presumption  is that  organic disease does not
exist.
  Palpitation from functional disorder always occasions great
uneasiness, and generally intense anxiety arid alarm.
  It is quite otherwise with palpitation incident to  organic
disease.   As a rule, then,  and you may  consider it a safe
one,  palpitation, when accompanied  with great uneasiness
and uncomplicated, indicates or will suggest to you the non-
existence of structural lesion.
  Palpitation due to organic disease is  less violent.  Func-
tional palpitation  occurs often when  it  cannot be traced  to
any exciting cause, and is  more likely to  occur when the
patient is at rest.
  Pulse.  You must accustom yourselves to the movements
as given by the pulse in heart affections, as well  as in other
disorders, and it is only by close observation at  the bed-side
that you will attain that peculiar sense of  touch  necessary to
aid you in your investigations.
  You will observe the size, strength, as compared with the
heart's impulse (which never overlook), rhythm, its quickness
or  slowness, the  duration of the  movement of the artery
under the finger,  etc.
  Frequency of the pulse, although important as  represent-
ing  the general condition of the  circulation, and the state
of  the  vital forces, has no special significance  as  regards
vavular disease.
  In mitral lesions  attended by regurgitation, the size and
strength of the pulse are diminished  in  proportion to the
quantity of blood  driven backward by the systolic contraction
of the  left ventricle, into  the  left auricle.  The weakness
and smallness  of  the pulse are in contrast with  the  impulse
of the heart, as felt by the hand applied over the prascordia, 
180
DISEASES OF THE  HEART.
provided the  left ventricle be hypertrophied and the action
of the heart vigorous.   The pulse may be regular, but often,
in an advanced stage of the affection, its rhythm is disturbed;
it becomes irregular or intermitting.  A^ariation of successive
beats  as  respects  size, force,  etc., is  frequently  observed,
although it is  less characteristic of mitral regurgitant lesions
than  of  those attended  by obstruction.   The  frequency of
the pulse in this, as in the other varieties of valvular lesions,
depends on the vital condition of the heart,
   In ca>:e of mitral regurgitation, the pulse is rendered small
and weak by the deduction of the blood which regurgitates
from the quantity which would otherwise be propelled into
the aorta with each systole.
   Mitral contraction,  when extreme,  renders the  pulse not
only small and weak, but  often  irregular, intermitting  and
unequal.  When  from any cause  the supply of blood pre-
ceding the ventricular systole  is less  than usual, the pulse,
which represents the systole of the left ventricle, is unusually
small and weak.   Under these circumstances the heart acts
with irregularity.  Intermittency of the pulse may represent
intermittency  of  the  heart's  action, but it  is  sometimes
observed where there  is not a corresponding interruption in
the heart's action.
   Intermittency of the pulse is a peculiarity of the circulation
in some persons.  It is not, therefore, intrinsically a symptom
of disease.  Weakness,  smallness,. and irregularity, as w7ell
as intermittency, and  even inequality, it  is to be  borne in
mind, are not distinctive of mitral or other valvular lesions.
All may occur in functional disorder of the heart.   A distin-
guishing point pertaining to  functional  disorders  is,  they
occur  only during paroxysms  of palpitation  presenting the
distinctive features of  palpitation from nervous  disorder,
whereas, occurring in  connection with valvular lesions, they
are either constant or frequently recurring, and unattended
by the features which  distinguish functional palpitation.
   Aortic lesions giving rise to  obstruction are not character-
ized by a pulse weakened in  proportion to the diminishing
quantity of blood propelled  from the  left ventricle.   In
cases  of aortic obstruction, when  great  enlargement of the
heart has ensued, and especially when the muscular powei 
TURGESCENCE OF THE VEINS.
181
of the  organ is  much diminished by  either dilatation  or
fatty degeneration, the pulse may become  irregular,  inter-
mitting, and unequal.   Irregularity and inequality are thus,
in some measure, diagnostic of lesions affecting the mitral
orifice,  as contrasted with those affecting  the aortic orifice;
but it  is  to be  borne in mind that  they occur  in cases of
dilatation, fatty degeneration, etc., uncomplicated with any
affection of the valves or orifices.
   Slowness  of the pulse, that is, the gradual expansion of the
artery,  as  distinguished  from  quickness (not frequency),
denotes the prolonged systole  of the left ventricle, and is
distinctive  of aortic obstruction.  In  cases of aortic lesions,
with  considerable  insufficiency,  the  jerking or collapsing
feature of the pulse is usually  strongly marked.   It is not,
however,  a  symptom of aortic obstruction.
   Prolongation of  the interval between the  pulsation of the
radial artery and the heart's impulse, is significant of aortic
regurgitation.

    TURGESCENCE OF THE VEINS  AND VENOUS PULSATION.

   Abnormal fullness of  the veins occurs  whenever there is
an obstacle to the free  entrance of blood into the right
auricle.   An obstacle exists when the right auricle is already
full, or distended with blood.  The most direct and efficient
causative  condition is contraction of the tricuspid orifice.
Obstruction to the pulmonary  circulation from emphysema
of the lungs  occasions  an undue accumulation of  blood
within the right  ventricle and auricle, leading after a time to
enlargement, and  a consequent  obstacle  to the  free trans-
mission of  blood to the systemic veins.   Pressure on the
vena  cava  by an  intra-thoracic tumor  produces obstruc-
tion and venous  turgescence.  Thus, marked fullness of the
veins of the head  and neck is  observed in some cases  of
aneurism of the arch of the aorta.   As  a  symptom,  then,
this is not distinctive in itself of cardiac  disease, nor, when
it proceeds  from the latter, does it point to the seat, or even
denote  the  existence of lesions of  the  valves or  orifices,
but rather  that  the right auricle is either  dilated or over-
distended. 
182
DISEASES OF THE HEART.
   Venous  turgescence is  usually most  conspicuous on the
neck, in the jugulars and  the  venous  branches communi-
cating with them.  In extreme cases the vessels present a
varicose appearance.
   If the obstruction at the right auricle be considerable, when
pressure is made on  a vein  high on  the neck, the vessel
remains distended below the  point of pressure,  and may be
refilled after the contents of the vessel have been  pressed
backward by the finger, showing not only a resistance to the
gravitation of the blood, but a reflex current.
   This symptom, taken in connection with the physical signs
which establish the nature and seat of organic lesions of the
heart, possesses considerable value.
   Venous  pulsation is a diastolic movement of the veins,
which is visible, and sometimes even  appreciable  by the
touch.  The movement is due  to a retrograde current or
impulse communicated to the blood contained in the veins.
It is to be  distinguished from the movements occasioned  by
respiration, with which every  one is familiar, and also from
those communicated by subjacent arteries.  With the latter
it is liable to  be confounded, unless care be taken  to avoid
this error.   The error may be avoided by making moderate
pressure over  the veins  at the  lower  part of  the neck.
Pressure here, not  sufficient  to stop the circulation in  the
arteries, will arrest pulsation of  the veins.  The  movements
due to respiration may be arrested by causing the patient to
suspend breathing for a few  seconds.   Pulsation is rarely
observed elsewhere than in the veins of the neck.  It is often
limited to  the veins just above  the clavicles.  It  is now
admitted that  venous pulsation, if marked or extensive, is,
in  a  certain  proportion of  cases,   evidence of tricuspid
degeneration.   (Flint.)
  The conditions most  favorable for the production of  the
venous  pulse,  are free tricuspid  regurgitation and hyper-
trophy of the right ventricle.
  The systolic contraction of  the right  auricle may cause a
movement  of the blood in a retrograde direction  sufficiently
to give rise to this  symptom.  Experimental observations
show that the auricular systole precedes the ventricular.   A 
CARDIAC DROPSY.
183
venous  pulse due to auricular contraction should  therefore
precede slightly the arterial pulse, or apex-beat of the heart.
  Placing the  finger over the apex of the heart,  the apex-
beat, if it be felt, will be found to follow the venous pulse in
the neck, provided the latter be produced by the contraction
of the auricle;  whereas if the venous pulse be  due to tri-
cuspid regurgitation, it will be either synchronous with, or
lagging a little behind the apex-beat.  By placing the finger
over the carotid, and the eye fixed upon a pulsating vein, it
is easy to determine whether the venous pulse  precedes or
occurs simultaneously with the beating of the artery.

    CARDIAC DROPSY  IN  RELATION TO VALVULAR LESIONS.

  General dropsy, when dependeut on disease of the heart, is
called cardiac dropsy.   It may be due  to other pathological
conditions, and especially to disease of the  kidney, when it
is distinguished as renal dropsy.   It  appears first,  as a rule,
in  the  form  of  oedema  of  the feet  and  ankles,  which
gradually extends over the low7er extremities.   (Edema of
the face follows, or  may  occur simultaneously with, or pre-
cede, the oedema of the feet,   So enormous is the swelling
sometimes,  that erythema and gangrene may  occur.  The
surface cracks  or ulcerates, and  allows the liquid to flow
away.   The surface assumes  a  dusky hue, due to venous
congestion, which distinguishes  this variety of dropsy from
renal dropsy, but both may be combined.  Effusion into all
the serous cavities may  occur.  The occurrence of dropsy
has reference to the situation, nature, and degree of valvular
lesions.  Tricuspid  contraction  is  the lesion  which  most
directly and efficiently tends to give rise to this effect; but
this lesion is exceedingly  infrequent.
  The  occurrence of dropsy,  other  things being  equal, in
cases of mitral  or aortic lesions, will depend, not immediately
on the nature and extent of these lesions, but on conditions
induced thereby which relate to  the right side of the heart.
Dilatation  of the right ventricle, or weakness from fatty
degeneration and other causes, precedes, in the great majority
of cases, the occurrence of dropsy.
  Dropsy, therefore, is an  event which usually belongs to 
184
DISEASES OF THE  HEART.
an advanced  period of organic disease, and it is  frequently
a precursor of fatal termination.   Enlargement of the right
side of the heart, especially if accompanied by degeneration
of structure or great muscular weakness, may induce dropsy
when valvular lesions are not present.  The occurrence thus,
when aortic or mitral lesions are present, is evidence  that
the effects of these lesions on  the right side of  the  heart,
which have been considered under another head, have taken
place.
  Embolism.   Arterial obstructions by vegetations or fibrin-
ous masses detached from the valves or orifices of the heart.
The obstruction is carried onward with the current in the
course of the circulation, until it reaches an arterial  trunk
smaller  than  its own  dimensions.   Here it is arrested,
obstructing the  passage of  blood in  the artery ■ and its
branches beyond the point at which they are lodged.
  Emboli from within the heart, in cases of chronic valvular
lesions, are derived, in  the vast majority of cases, from the
left ventricle, since lesions affecting the valves of the right
side of the heart are exceedingly infrequent.
  Emboli  derived from Avithin  the  heart are  sometimes
calcareous.   They may cause apoplexy, coma, paralysis, and
softening of the brain,  by obstructing the cerebral circula-
tion.  They may even cause typhoid symptoms and petechial
eruptions.

  SYMPTOMS AND  PATHOLOGICAL EFFECTS REFERABLE TO THE
                   RESPIRATORY  SYSTEM.

  The phenomena referable  to  the  lungs,  irrespective of
associated or intercurrent pulmonary affections, depend, for
the most part, on vascular engorgement  of these  organs.
Congestion of the lungs is an immediate result of  an impedi-
ment to the free admission into the left auricle, of blood from
the pulmonary veins.   An impediment  exists whenever the
left auricle is over-distended with  blood; and over-distension
of this auricle occurs as a consequence of anj7 interruption
of the blood-currents through the orifices of the  left side of
the heart.  Obstructive lesions at the mitral orifice especially
give rise to pulmonary congestion. Aortic lesions,  obstructive
and  regurgitant, also, sooner or later, are followed by over- 
           SYMPTOMS  AND PATHOLOGICAL  EFFECTS.        185

distension and  dilatation of the left auricle and  consequent
congestion of  the  lungs.  The engorgement of the  lungs
arising  from valvular lesions gives rise to  important pul
monary symptoms without any other superinduced aft'ectiou
of these organs.  The most  prominent  of these symptoms
are dyspnoea, cough, muco-serous expectoration, and haemop-
tysis.  Certain pulmonary affections appear in some cases to
be  dependent, directly and  exclusively, on  over-distension
of the vessels, namely, extravasation of blood, or apoplexy
of the lungs, and oedema.  The existence of  valvular lesions
thus involves a liability to bronchitis, pneumonitis, pleurisy,
and emphysema.
  Dyspnoea is a symptom more or less prominent in the great
majority of cases.  It occurs earlier and is more marked in
cases of .mitral than  aortic lesions, because the former tend
more directly, and in a greater degree, to engorgement of
the  pulmonary vessels.   In most  cases of  either  mitral
obstruction or regurgitation, dyspnoea is the first symptom
which occasions inconvenience.  The patient often complains
of  this symptom alone, or chiefly, for a  considerable period.
In  cases  of aortic lesions  it occurs later,  and is oftener
preceded by palpitation or other symptoms, referred  by the
patient to the  heart.
   The intensity of dyspnoea varies greatly  in  the  different
cases of valvular affections in which this symptom is present,
and in the same case  at different periods. It  consists, at first,
of  a slight  deficiency of breath on exertion.  This progres-
sively increases until active  exercise becomes insupportable.
 Other  cases  are  characterised  by  paroxysms of difficult
breathing when  not provoked  by exercise,  and by more or
less  difficulty which is constant.   Affections  of  the  pul-
monary organs, super-added  to  congestion,  contribute  to
increase the amount of dyspnoea.   This dyspnoea has been
 designated as orthopncea when  extreme, and also as  cardiac
asthma.
   Cough  and expectoration are usually present when valvular
 lesions have induced considerable pulmonary engorgement.
 The expectoration is muco-serous  in  its  character.   The
 prominence of the cough  and the charater which the expec-
 toration presents will serve to indicate, on the one hand, 
186
DISEASES OF THE HEART.
merely congestion of  the  bronchial  membrane, or, on the
other hand, a superinduced pulmonary affection.
  Haemoptysis  is a symptom which occurs in a pretty large
proportion of  cases  of valvular lesions attended with  a
marked degree of engorgement of the lungs.
  Haemorrhagic extravasation, pneumorrhagia, or pulmonary
apoplexy,  involves the  same  pathological  explanation as
haemoptysis, but occurs much more frequently than  the
latter. It is an occasional  effect of engorgement.   In most
of the cases in w7hich it  occurs there exists mitral  contrac-
tion.
  Haemoptysis and haemorrhagic extravasation  occasionally
co-exist.
  Pulmonary oedema is another pathological effect attributable
directly to  over-distension of the vessels  of the lungs.   This
event takes place much more frequently than extravasation
of  blood.   Occurring  alone,  or  irrespective of  dropsical
effusion elsewhere, it belongs among the  events incident to
an advanced stage of  valvular lesion.   As a rule, whenever
events of  importance referable to  the  respiratory system
become developed, valvular lesions have  existed for a consid-
erable length of time, and  have led to more or less enlarge-
ment of the heart.   Certain pulmonary  affections,  not  due
directly  or exclusively to the congestion proceeding from
valvular lesions, are more  apt to occur under these circum-
stances  than if the latter  did  not exist.  The lesions thus
indirectly predispose to the development  of these affections.
Emphysema of the lungs is one of these affections.
  The congested state of the bronchial  mucous membrane
renders it prone to inflammation.  Bronchitis is a frequent
complication of  valvular  lesions after  they have induced
pulmonary engorgement.   This complication developed when
the lungs are already  congested, in connection with cardiac
lesions,  dyspnoea becomes  more or  less prominent.    The
co-existence of bronchitis not only adds  to the distress inci-
dent to valvular lesions, which interfere  with the pulmonary
circulation, but,  if severe or extensive, often places the
patient in  immediate  danger—the accumulation of mucus
within the bronchial  tubes, together with the  diminished
calibre of the tubes from swelling of the membrane, inducing
suffocation. 
           SYMPTOMS AND  PATHOLOGICAL EFFECTS.       187

  Dropsical effusion  into  the pleural sacs rarely  occurs  to
much extent independently of general dropsy.  When it does
take place, the compression of the lungs by the effused liquid
abridges their functional capacity,  aggravates  the  dyspnoea,
and hastens a  fatal issue.

SYMPTOMS AND PATHOLOGICAL  EFFECTS   REFERABLE TO  THE
                     NERVOUS SYSTEM.

  It is a common impression that various symptoms denoting
cerebral disorder,  such   as  cephalalgia,  vertigo, tinnitus
aurium, muscae volitantes, etc., etc, are  usually  observed,
sooner  or  later,  during the progress  of  cardiac disease.
These symptoms  are  often observed in  persons  not affected
with  disease  of the  heart, and hence  would  possess  small
diagnostic  significance were  they  more frequently present;
but, the truth is, they occur in only a small proportion  of
cases, at least in a marked degree.
  A'alvular lesions, accompanied by enlargement  of the heart,
have been supposed to involve a strong liability to  apoplexy.
We may conclude that apoplexy is very rarely due, distinctly
or  exclusively, to the condition of the heart, but that the
changes which the cerebral vessels undergo, or other circum-
stances, generally play an  important part  in its  production.
And of the two conditions which tend  directly to  affect the
circulation in  the brain, namely, obstruction  at the  right side
of the heart, and  hypertrophy of the left ventricle, the former
must be considered as most likely to lead  to serious results.
  Apoplexy occurring  in  connection with  cardiac lesions,
generally depends on extravasation of  blood.  Under  these
circumstances, paralysis of course  ensues; if the apoplectic
attack do not  prove suddenly fatal, the patient  is found to  be
hemiplegic.   Vegetations, or masses of fibrin from within
the cavities of the left side of the heart, being detached, are
liable to become fixed in an artery  of the brain, and give rise
to apoplectic seizures with hemiplegia, or to the latter without
the former.
  Arterial obstruction  gives rise to apoplectic  phenomena
and paralysis, by lessening the supply of blood to  certain
portions of the cerebral substance. 
188
DISEASES OF THE HEART.
  Aside from  apoplexy  and paralysis,  various  symptoms
already mentioned, namely, pain, vertigo, tinnitus, etc., are
occasionally associated with valvular lesions.  Apoplexy and
paralysis, depending either on an extravasation which involves
a morbid condition of the cerebral vessels  or  an arterial
obstruction from emboli, are usually not preceded by premo-
nitions referable to the brain.   This is a practical point to be
borne in mind, in  order that  needless apprehension  be not
entertained on the part of physician or patient, and measures
employed with a view of  warding off an attack of apoplexy
or paralysis, which, being uncalled  for,  will be likely to be
not only unnecessary but injudicious.  In the cases in which
there is of necessity more  or less  cerebral congestion, the
superficial veins  of the  neck being swelled or  pulsating,
marked cerebral symptoms are by no means uniformly pres-
ent.   Headache, dullness of the intellect, listlessness, drowsi-
ness, etc., are  symptoms which, in a certain proportion of
cases of this description, are more or less marked, and are
probably due to  abnormal fullness of the  cerebral  veins.
These  symptoms  of  cerebral oppression  are  sometimes
marked in cases in which, either from obstruction of the
right side of the heart,  or imperfect  oxygenation of the
blood, the prolabia and surface of the  body present a livid
appearance.
  The sleep of  patients affected with cardiac disease is fre-
quently imperfect.  They  complain often of frightful dreams.
This is generally associated  with dyspnoea, and appears to be
ow7ing  to disturbed respiration rather  than to  disordered
cerebral  circulation.   Moaning  in sleep  is a  symptom
observed in  some cases  when  the patient  is not wakeful
nor conscious of any morbid sensations.
  A symptom which may be included among the events refer-
able either to the nervous or respiratory system, is noticed in
some cases, namely, a  choking sensation analagous  to that
experienced in painful emotions when  an effort is made to
refrain from weeping.   The  mental condition  of patients
affected with organic disease of the heart may be noticed in
this connection.   The  contrast presented,  in  this respect,
with patients  affected with merely functional disorder, has
been already referred to.   Persons  with  organic  disease 
SYMPTOMS.
189
which has given rise to grave symptoms, such as palpitation,
dyspnoea, dropsy, etc., are  generally  free from excitement
and   apprehension.   They  often  seem  to  be  remarkably
indifferent or apathetic.

  SYMPTOMS  AND  PATHOLOGICAL EFFECTS REFERABLE TO THE
            DIGESTIVE SYSTEM AND NUTRITION.
  The phenomena manifested in connection with the diges-
tive  apparatus,  in cases  of valvular  lesions, proceed from
congestion of the systemic venous system.   Assuming the
lesions to be either mitral  or  aortic, or both, congestion of
this  order of vessels depends on the effects of these lesions
on the right side of the heart.  It may  be stated that, as a
rule, the systemic congestion is not sufficient to give rise to
important symptoms or pathological effects until dilatation
of  the right ventricle has taken place, involving  over-
distension of the  right auricle, and, in certain cases, tricuspid
regurgitation.  The impediment  to the free  admission of
blood from the venae cavae  into the right auricle, occasions
cerebral congestion, as has  just been seen.  The congestion
throughout  the body thus induced, as has also been  seen,
gives rise to venous turgeseence and  general dropsy.   The
abdominal viscera indirectly participate in the effects of this
impediment at the right ventricle, owing to their vascular
relations to the  venae cavae being through the  intervention
of the portal system.  In view of the anatomical peculiarities
of the latter, it  is obvious  that,  of the  organs comprising
the  abdominal  viscera, the liver is  first affected by  an
obstruction  at the right side of the heart.  The pressure of
the portal  branches on the biliary tubes may occasion an
undue accumulation of bile in the latter.   (Flint.)
  I  have observed  obstinate cases of jaundice  in  several
cases of valvular disease of the heart.
  Sections of the organ then present that peculiar aspect
commonly known as the " nutmeg liver."
  Extending beyond the'liver to the portal vein  and its radi-
cles, the congestion affects finally the stomach and intestines,
the spleen and the pancreas.  Congestion of these organs is
a secondary effect due directly to the mechanical obstacle to'
the passage  of blood through the liver. 
190
DISEASES OF THE HEART.
  The successive  steps, then, in the  series of congestive
effects dependent  on valvular lesions  are:  obstruction  or
regurgitation at either the mitral or aortic orifice, or at both
situations;  dilatation  of  the  right  ventricle, following
engorgement of the pulmonary  vessels;  over-distension  of
the right auricle,  with  or without tricuspid regurgitation,
involving an impediment to the free transmission of blood
from  the vena cavae; congestion of  the  hepatic veins and
their  radicles,  the intralobular veins;   congestion  of the
terminal branches of the portal vein;  congestion  of the
vena portae and its radicles  in the abdominal viscera, these
vessels furnishing  the blood for the portal circulation.
  Enlargement of the  liver is an occasional effect incident
to valvular lesions, as well  as to enlargement of the heart
without these lesions.
  Cirrhosis is not a frequent  complication of valvular affec-
tions  of the heart,  The event denoting co-existing cirrhosis
is hydroperitoneum  in a degree  disproportionate  to the
general dropsy. -
  There are many other disorders in a measure incident and
common, such as  dyspepsia, haemorrhage from the bowels,
haemorrhoids, enlargement of the spleen,  etc., which you can
study at your leisure  in the various works on diseases of the
heart.

  SYMPTOMS AND PATHOLOGICAL EFFECTS REFERABLE TO THE
                  GENITO-URINARY SYSTEM.

  The renal or emulgent veins terminating in the vena cava
descendens, the kidneys must  participate in the congestion
of the systemic venous system arising from  an  impediment
at the right side  of  the heart.  These organs  are affected
more  directly than  the abdominal  viscera,  which are
tributary to  the  portal  vein.   So soon  as  valvular lesions
have  led to the anatomical  conditions involving an obstruc-
tion extending to  the vena cavae arid  their branches, renal
engorgement   necessarily  ensues.   Congestion of   these
organs  is generally observed  in  examinations after death in
valvular disease  accompanied by dilatation of the cavities
of the right side  of the heart.  Venous congestion, under 
SYMPTOMS.                     191
these circumstances, does not uniformly occasion a greater
flow of ufme than in health.  Indeed, the quantity of urine
is oftener diminished than increased, a fact  going to show
that the diuresis depends on the amount of blood conveyed
to  the  kidneys  by the arteries, or on conditions pertaining
to  the blood  itself, rather than on accumulation in the renal
veins.   The urine is frequently scanty, even when the venous
obstruction is sufficient to give rise to general  dropsy.  We
may have  albuminuria, owing to the  mechanical pressure
incident to venous  congestion.  It does not constitute evi-
dence  of  structural changes of  the  kidney,  or Blight's
disease, when it is  in small quantity, transient in duration,
and notably fluctuating.  (Flint.)
  Aloreover, hyaline casts are wanting when albuminuria is
only a  symptom of disease of the heart, and the  specific
gravity of the urine, instead of being diminished, is usually
increased.
  The degenerations of structure  included under the name
Blight's disease,  are  sometimes  associated with valvular
lesions of the heart.
  The co-existence of  structural degeneration of the kidney
is shown, as already intimated, by the degree and constancy
of the  albuminuria, and  by the different varieties  of casts
of the uriniferous tubes, which the sediment of the urine is
found to contain when subjected  to microscopical examina-
tion.   The tendency to general dropsy is augmented by this
complication; renal and cardiac dropsy are, in fact, combined.
As  regards the generative  functions,  Flint has observed,
that in  cases in which  lesions had existed for a considerable
period  before  puberty, the genital  organs, including,  in
females, the mammary gland, attained to a full development.

SYMPTOMS AND PATHOLOGICAL EFFECTS REFERABLE TO THE COUN-
      TENANCE AND EXTERNAL APPEARANCE OF  THE BODY.

  Lividity of  the prolabia and face, which may be apparent
over the whole surface of the body, denotes either venous
congestion or imperfect  oxygenation  of  the  blood.   The
latter is incident to the pathological effects taking place  in
the lungs; the former, to obstruction at the right side of the 
192              DISEASES OF THE  HEART.

heart.   But both  conditions may  be  conjoined.  A dusky
hue of the face, combined with oedema, is quite distinctive
of cardiac, as  contrasted with  renal, dropsy.  I need  not
mention the painful expression of the countenance in  a
patient  suffering  from what is  known as cardiac  asthma.
Dr. Hope gives a  graphic picture  of the terrible sufferings
of such patients.
  Some cases of valvular disease are characterized by pallor
of the complexion.  The co-existence of Blight's disease is
likely to  lead  to  this effect.  But it is observed in some
instances  when the  kidneys  are  not  affected.   It then
depends on alterations of the blood proceeding from other
causes.
  An anaemic condition  is incident, in a certain proportion
of cases, to cardiac disease  uncomplicated w7ith an affection
of the  kidneys.   Analysis  of  the  blood  shows  a  notable
deficiency  of  albumen,  together with a  reduction  in  the
relative proportion of blood corpuscles and fibrin.
  The accumulation of blood in the right chambers of the
heart induces, in addition to abnormal fullness of the super-
ficial  veins,  a  congestive  state of  the  capillary  vessels,
causing the surface of the  body to present an  appearance
like that produced  by exposure to cold.  -The redness  dis-
appears on pressure, and  returns, more or  less  slowly, after
the pressure is  removed.  The appearance  is not unlike that
observed in typhus and typhoid fever, although the rationale
is by no means the same.
  Erythema, affecting portions  of the surface, occurs in some
cases  not associated with oedema.  The  lower extremities
are most apt to be affected.  Flint met with  an instance in
which the extremities of the fingers and  a  portion of  the
palms presented permanently an erythematic redness.   On
the other hand, in a patient with considerable mitral regur-
gitation, the fingers at times were  bloodless, being as pallid
and cold as those of a corpse. 
LECTURE   XI.
             VALVULAR DISEASES OF THE HEART.
 Physical Signs and Diagnosis of Valvular Diseases of the Heart—Endocar-
  dial or Valvular Murmurs — Mitral Direct Murmurs — Mitral Regurgitant
  Murmurs—Aortic Direct Murmurs—Aortic Regurgitant Murmurs__Reca-
  pitulation of Murmurs — Purring Tremor —Diagnostic Characters of Mitral
  Lesions — Diagnostic Characters of Aortic Lesions — Of Tricuspid Lesions__
  Of Pulmonic Lesions — Treatment  of Disorders Resulting from Valvular
  Lesions.

   G-entlemen : We have thus far, in lecturing on  Diseases
 of the Heart, gathered from the latest  and standard works,
 together with our own observations, and have omitted  much
 that  might be said, while we  have  endeavored, by careful
 study, to give you, in few words, the prominent points which
 will aid you in the investigation of the diseases  of the heart.
 Our clinics do not yet furnish us with opportunities in this
 direction, and for this reason have  I taken special  pains  to
 treat the various affections in a plain and concise way.   But
 you must not stop here,  but investigate for yourselves.
  We will  devote  this hour to the consideration of the
    PHYSICAL SIGNS AND  DIAGNOSIS OF VALVULAR LESIONS
  Cardiac murmurs originate either within the heart,  or on
 the peripheral surface  of the organ.
  In treating of endocardial  murmurs, the practical points
 to be considered relate to the different character which they
 present, the  morbid  conditions  which they  denote,  their
 significance and value as signs of disease, and their applies,-
 tion to the diagnosis of valvular affections.   These murmurs
 may be  produced within  the cavities  of the  heart, at the
 auriculo-ventricular or  the ventriculo-arterial  orifices, and
 within the  aorta or  pulmonary artery, near  the junction of
 these vessels  with the ventricles.  It is practicable often, if
 not  generally,  to determine from which  of the  cavities,
 orifices, or  vessels mentioned, emanate  the murmurs heard
in individual  cases.
  The importance of this  localization,  as  pointing to the
seat of the lesions which  occasion the murmur, is obvious: to 
194
DISEASES OF THE  HEART.
determine the existence or non-existence of valvular disease;
to determine the particular situation  of structural lesions;
to determine the character of lesions, and certain  of their
effects on the blood-currents through the different orifices.
  Endocardial  murmurs  are  not always due to lesions of
structure or organic disease.   They  occur as a  result of
certain blood-changes and of  functional  disorder  of  the
heart.
  The latter are distinguished as inorganic murmurs, while
those  dependent on structural changes are  called organic
murmurs.
  Organic murmurs, in  the  majority of cases,  resemble a
bellows-sound.   Murmurs of  this kind  are said to be  soft
murmurs.   In  some instances they are so feeble as to be
just appreciable.  In other instances they  are so loud as to
be  heard over  the  whole chest, and they  are sometimes
perceived by the patient,  especially in  the night-time.
  Different varieties have been described  and named from
their resemblance to certain sounds.   Enough for practical
use is to consider them simply as presenting different modi-
fications and degrees of roughness, the latter  being the only
distinctive feature worthy of being noted.
   Murmurs  sometimes  have  a musical  intonation.   The
sounds have no special pathological or diagnostic significance,
except that they denote the existence of organic disease.
   The presence of  a  murmur involves only the fact  that
there  is something  abnormal.  The presence of a murmur
by no means warrants  the conclusion, in  all  cases,  that
lesions do exist, as will appear more fully after the inorganic
murmurs have been considered.  The  absence of murmur,
on the other hand, warrants  the conclusion  that lesions do
not exist, the probability of error  being exceedingly small,
provided the heart be not, from any cause, greatly enfeebled.
   After the systolic contraction of the ventricles,  the blood
passes through the auriculo-ventricular orifices  from the
auricles  into the ventricles.
   The current of blood  from the left  auricle, through the
mitral orifice, into the left ventricle, may  be  designated the
direct mitral current.
   The systolic ventricular contractions impel the blood from 
PHYSICAL SIGNS.
195
the cavity of the ventricle into the aorta.  The current  of
blood from the cavity of the  left ventricle into the  aorta may
be distinguished as the direct aortic current.  These are the
normal blood-currents.  If the mitral valves be insufficient,
more or less of the blood contained in the cavity of the left
ventricle is driven  backward by the ventricular systole into
the left auricle.  Here, then, is a regurgitant current which
does  not  exist  when the valves are  sufficient.  It may be
called a mitral  regurgitant  current.   So may we  have the
aortic  regurgitant  current.   Each of  these four currents
may give  rise to  a murmur.  A mitral direct murmur begins
after the diastolic, or second sound of the heart; or it takes
place during the long silence  or pause which separates the
diastolic and systolic sound, and may be called the mitral
diastolic murmur.
  A mitral regurgitant murmur being produced by the ven-
tricular systole, commences  with  the  systolic sound; it  is,
therefore, a systolic murmur, and may be called  the mitral
systolic murmur.
  An aortic direct murmur,  also produced by the ventricular
systole, is a systolic murmur; it commences with the systolic
sound, and may be called the aortic systolic murmur.
  An  aortic regurgitant murmur, on  the other hand, pro-
duced  by a  retrograde  current from the  aorta  into  the
ventricle after the systolic contraction, commences with the
second or the diastolic sound.
  Then w7e have the systolic  murmurs, commencing with
the systolic or first sound of the heart:
  1st.   A mitral regurgitant, or a mitral systolic murmur.
  2nd.  An aortic direct, or an aortic systolic murmur.
  Also the diastolic murmurs, commencing with or following
the diastolic  or second  sound  of the heart:  1st,  A mitral
direct, or  a mitral diastolic  murmur;  and, 2nd, An aortic
regurgitant, or an aortic diastolic murmur.

  The mitral direct, or the mitral diastolic murmur, generally
denotes a particular kind of lesion, namely, union of the
mitral curtains, leaving a slit-like and more or less contracted
aperture between the auricle and ventricle.  It may be dis-
tinguished  as a blubbering  sound when this quality  is 
196              DISEASES OF THE  HEART.
strongly marked.   The  mitral  direct murmur always ends
with the ventricular systole.  This murmur may be produced
—and it may be quite intense—when  the mitral valves are
not the seat of any lesion.  The fact that the mitral curtains
are floated out and brought into apposition to each other, by
simply  distending the  ventricular cavity  with liquid, is
sufficiently established and easily verified.
  Now, in cases of considerable aortic  insufficiency, the  left
ventricle is rapidly filled with blood flowing back from  the
aorta, as well as from the auricle, before  the auricular con-
traction  takes place.   The mitral  curtains, under these
circumstances, are  brought into co-aptation, and when  the
auricular contraction takes place, the mitral direct  current
passing between the curtains,  throws them into vibration,
and gives rise to the characteristic blubbering murmur.

  Mitral regurgitant, or systolic murmur, is  most frequently
met with in cases of organic disease of the heart.  Whenever
the mitral valve  is  insufficient,  a portion of  the  blood
contained in the left ventricle  is driven backward by  the
ventricular systole into the left auricle.
  The gravity of valvular lesions, as has been seen, depends
on the amount of obstruction and regurgitation resulting from
them; hence the  importance of  bearing in mind, that a
mitral systolic murmur is  not  always, strictly  speaking, a
regurgitant murmur, that is, the murmur may be produced
without regurgitation.

  Aortic  direct  or  systolic murmur.   In  proportion as
obstruction  to  the  aortic blood-current  is  involved, evils
ensue, namely,  accumulation of  blood in  the  ventricular
cavity,  enlargement  of the  left auricle,  followed  by pul-
monary congestion, and the more remote consequences which
are essentially those  resulting from obstruction  and regur-
gitant  lesions at the mitral  orifice.  There  are no constant
characters pertaining to the murmur itself which enable the
auscultator to determine whether the lesions do, or do not,
involve obstruction.   In a  large proportion of the cases of
obstructive  lesions  at  the  aortic  orifice,  the  valves   are
involved sufficiently to compromise,  to  a  greater  or  less 
PHYSICAL SIGNS.
197
extent, their function, and impair the intensity of the aortic
second  sound.   Aside from attention  to  the aortic sound,
the evidence of obstruction, and also of its degree and dura-
tion, must be derived from  the amount  of enlargement of
the  left ventricle,  and  the remote  effect  of the  heart
affection.

  Aortic regurgitant or diastolic murmur.  This ranks next
to a mitral direct murmur as regards infrequency.  The
gravity of the lesions represented by this murmur depends
on  the extent  of insufficiency or the amount of regurgita-
tion.   Absence of an aortic  regurgitant murmur, therefore,
is not positive proof that there is no regurgitation.  Rough-
ness of the inner surface  of the aorta above the aortic valves
may occasion a murmur writh the retrograde movement of
the column of blood within the vessel, although the aortic
valves  are sufficient.   An aortic non-regurgitant  diastolic
murmur is then characterized by its  ending abruptly with the
second sound of the heart; wmereas an  aortic regurgitant
murmur continues, more or  less, after the second sound.
  Localization of the systolic murmurs.   The first point is
to ascertain wdiether it be a systolic or a diastolic murmur.
If the  heart-sounds recur with great frequency, the difference
in duration between the two pauses or intervals  is scarcely
apparent.  AVhenever there  is doubt or difficulty in deter-
mining whether a murmur be systolic or diastolic, it is to be
remembered that the first or systolic sound of the heart is
synchronous with the apex-beat  and the  carotid  pulse.  If
the beginning of a  murmur be  coincident with the carotid
pulse,  it is either an aortic or a mitral  systolic murmur.  A
murmur  may be  inappreciable, owing to feebleness  of the
action  of  the  heart.   Before  deciding,  therefore,  on the
absence of murmur, it is sometimes advisable to excite the
heart's action by muscular  exertion.  If  the murmur be  a
mitral systolic, its maximum of  intensity is at or near the
apex of the heart.  This, is to be depended upon as a rule.
   If a systolic  murmur  be an aortic direct murmur,  its
maximum of intensity is at  or above the base of the heart.
The particular situation where it is most intense is usually
in the intercostal space nigh to the sternum.  From the base 
198
DISEASES OF THE HEART.
of the heart it is propogated upward for a greater or less
distance, usually more so on the right than on the left side
It is often pretty loud at the sternal notch.
  To  determine the presence of both these murmurs :   If a
murmur heard at the apex be transmitted over the left lateral
aspect of the chest, and if it be heard at the lower angle of
the scapula behind, a  mitral regurgitant murmur is present.
If, now, a murmur heard at the base  be  heard over the
oarotids, there is also present an aortic direct murmur.

  Localization  of  the diastolic murmur.  A mitral direct
murmur is  pre-systolic.   It occurs just, before  the  first or
systolic sound, and is almost always continued up  to  that
sound.  None  of  the other murmurs  occur in  the  same
relation to the first sound  of the heart, and hence, this alone
is distinctive.  Its  maximum of intensity is within a  circum-
scribed space around the apex of the heart. If the diastolic
murmur be an aortic regurgitant  murmur, it  commences
with, and follows, the second  sound of the heart.  As no
other of the four  murmurs under consideration commences
with the second sound of the heart, it suffices for its recogni-
tion to make out this point; and if it be difficult to determine
which of the heart-sounds is the first, and which the second
sound, the relation of the murmur  to the second sound is
shown by the interval between the murmur and the carotid
pulse. 
SYSTOLIC  MURMURS.                    199
Recapitulation of Point* involved in the Localization of the Systolic and Diastolic
            Murmurs referable to the Mitral and the Aortic  Orifice,*
systolic murmurs.
         Mitral Regurgitant.
Maximum of intensity at or near the
    apex of the  heart.
Comparatively feeble or wanting at
    the base.

Not propogated above the base of the
    heart.   Not  heard over carotids.
Often heard over left lateral surface of
    chest.
If heard  in the interscapular space,
    most intense near the lower aDgle
    of scapula,
Aortic  second   sound  weakened  in
    proportion   to   the  amount  of
    regurgitation, but distinct.
Pulmonic  second sound  often intensi-
    fied.
Mitral  valvular  element of  the first
    sound more or less impaired.
           Aortic Direct.
Maximum of  intensity at the base of
    the heart in the second intercostal
    space, near the sternum.  Inten-
    sity diminished over body of heart
    and at the apex.
Propogated above the base of the heart
    and generally heard over carotids.
Rarely heard  over left lateral surface
    of chest.
If heard in the interscapular space,
    most intense as high as the spinous
    ridge of scapula,
Aortic second sound often weakened,
    and more or less indistinct.

Pulmonic second sound less frequently
    intensified.
Mitral valvular element of  the  first
    sound not impaired.
diastolic murmurs.
           Mitral Direct.
Occurs just before the systolic or first
    sound, and ends with the occur-
    rence  of  this  sound.   Usually
    vibratory or blubbering in quality.
Maximum  of intensity  over  apex of
    heart.
Generally not appreciable at the base
    of the  heart.
Mitral valvular element of first  sound
    impaired.
Pulmonic second sound  often intensi-
    fied.
         Aortic Regurgitant.
Commences with and follows the dias-
    tolic or second sound. The quality
    usually soft.

Maximum of intensity over  body of
    heart, near the sternum.
Generally appreciable at the base of
    the heart.
Mitral valvular elememt of first sound
    not impaired.
Pulmonic second sound less frequently
    intensified.
   In connection with murmurs,  it may be safe  to say,  that
they show organic lesions  are  accompanied  by an  organic
murmur in the great majority of cases.
   Lesions which occasion neither obstruction  nor  regurgita-
tion may give rise to murmurs.
* From Flint, on Diseases of the Heart. 
200
DISEASES OF THE HEART.
  Purring tremor.  This  term is applied to a sense of vibra-
tion, or thrill, felt on placing the fingers or the hand on the
praecordia.  It resembles the sensation given to the hand by
the purring of a  cat,  It is  doubtless  due to  tremulous
movements of the heart.   A  well-marked purring  tremor
may be considered as a sign denoting valvular lesions asso-
ciated with hypertrophic enlargement  of the left ventricle.
It occurs when the mitral  orifice permits free regurgitation,
and may also occur in aortic lesions.

        DIAGNOSTIC CHARACTERS OF MITRAL LESIONS.

  Physical  signs: — An   endocardial   systolic  murmur  is
present in the majority  of  cases, with the traits  which
distinguish a mitral regurgitant murmur, viz.; its maximum
of intensity at or near the apex of the heart, the intensity
diminishing as the stethoscope  is carried  upwards over the
body of the heart; generally feeble or lost  above the base
of the organ; not  propagated into the carotids; often dif-
fused over the left lateral surface of the chest; and not
infrequently heard on the posterior  surface, at the lower
angle of the scapula, and  in  the interscapular space below
the level  of the spinous ridge of the  scapula; the murmur
more or less  intense; generally soft,  but sometimes rough,
and occasionally musical.  The aortic  second sound is weak-
ened;  the pulmonic second  sound   is  often  intensified.
Enlargement of the heart exists in the majority of the cases
•which come under observation.
  Pain  is  rarely present.  Abnormal force  of  the  heart's
;action and palpitation denote consecutive enlargement, but
the symptoms are often not prominent.
  The pulse is small  and weak, and,  in an advanced stage,
'it becomes irregular and  intermitting;  inequality  of the
pulse is,  in some measure,  characteristic  of  obstructive
lesions. Turgescence of the jugular and other veins, lividity,
•or cyanosis, and dropsy occur at an advanced period, when
dilatation of the right cavities of the heart has been induced.
Dyspnoea  is more  or  less marked.  Cough and muco-serous
expectoration  occur frequently.   Haemoptysis is of frequent
occurrence, and extravasation of blood in the lungs, or pul- 
DIAGNOSTIC CHARACTERS.
201
monary apoplexy, takes place occasionally.  (Edema of the
lungs is not infrequent.

         DIAGNOSTIC  CHARACTERS OF AORTIC LESIONS.

  Physical  signs. — An endocardial  systolic  murmur   ia
present  in  the majority  of  cases, wTith the  traits wiiich
distinguish  an aortic direct murmur,  viz.: its maximum of
intensity at  the base of the heart;  comparatively feeble and
often lost at the apex;  propagated upward in the direction
of the  aorta, and into the carotids; not diffused over the left
lateral surface of the chest; and if heard on the posterior
surface, either limited to, or most intense in,  the interscapu-
lar space on and  above the level of the spinous ridge of the
scapula,   Murmur more or less intense ; generally soft, but
sometimes rough.  The aortic second  sound  of the heart  is
often weakened and indistinct; the  pulmonic second sound
is  much less  frequently intensified  than in  cases of mitral
lesions.  Enlargement of the  heart exists in the majority of
cases.  An aortic regurgitant murmur is present in a certain
proportion of  cases.
  Pain is oftener present than in cases of mitral lesions, but
is  often  absent.  Abnormal force of  the heart's action and
palpitation,  as a rule, are more prominent symptoms than in
cases of mitral lesions.
  The pulse in cases of aortic regurgitation is quick, jerking,
collapsing, and a longer interval than natural is sometimes
observed  between the apex-beat or systolic sound  and the
pulsation in remote arteries.
  Visible pulsation  of superficial  arteries  is  frequently
marked.   Turgescence of  the jugular and other veins, and
dropsy, occur  at a later period than in  cases of mitral lesions,
and oftener wanting.
  Dyspnoea is less marked.  Cough and  muco-serous expec-
toration   and   haemoptysis are  comparatively  infrequent.
Pulmonary  apoplexy  rare.   (Edema  of the  lungs  less
frequent. 
202
DISEASES OF THE  HEART.
       DIAGNOSTIC CHARACTERS OF TRICUSPID LESIONS.

  Physical signs.—The rule, that a murmur is present in the
vast majority of cases, cannot be applied to tricuspid lesions;
and hence, absence of murmur is not proof that the latter
do not exist.   A  tricuspid  regurgitant murmur, however,  is
sometimes observed.  It is rarely intense or rough, and  is
usually low  in pitch.  Its  maximum  of intensity is at or
above the xiphoid cartilage.
  Tricuspid  lesions, not  congenital, are in most instances
associated with lesions of one or more of the valves of the
left side of the heart.  One case is reported of the diagnosis
being  based  on  the fact that the presystolic murmur was
heard, not only around the apex, but at, and to the right of,
the ensiform  cartilage.
  Regurgitant and obstructive lesions, situated at the tricus-
pid orifice, do not produce those immediate effects on the
respiratory system and the pulse which pertain to analogous
lesions seated at the mitral orifice.   Their immediate effects
are manifested in the systemic venous  system.   Congestion
of the systemic veins is  a direct result, tending to general
dropsy.  Cerebral apoplexy  is more liable than in mitral or
aortic lesions.

       DIAGNOSTIC CHARACTERS OF PULMONIC  LESIONS.

  Physical signs.—Lesions situated at  the pulmonic orifice
may give rise to a murmur with the first sound of the heart,
which may be called a pulmonic direct murmur.   This mur-
mur has its maximum of intensity  in the second intercostal
space on  the  left side of the  sternum, the situation where
the pulmonic second sound  of the heart  may  be isolated
from the aortic second sound.
  Pulmonic lesions, however, exclusive of congenital mal-
formations, are so rare, that the opportunities of an}7 clinical
observer,  however large  his experience,  for  studying  the
physical signs, are extremely limited.
  Hypertrophy of the right ventricle, wdiich is produced bv
obstructive or regurgitant lesions  of the  pulmonic orifice,
involves  augmented  intensity  of the tricuspid  valvular 
       DISEASES  RESULTING FROM  VALVULAR DISEASES.    203

element  of the  first sound, and  an impulse in the epigas-
trium.
  The primary  effect  of obstructive or regurgitant lesions
situated  at the pulmonic orifice, is enlargement of the right
ventricle.  The  secondary and remote effects, and the symp-
toms  thereon dependent,  are essentially those which  are
occasioned by tricuspid lesions, being due to  distension of
the right auricle, tricuspid regurgitation, and  congestion
of the systemic veins.

    TREATMENT  OF DISEASES RESULTING FROM VALVULAR
                 DISEASES  OF THE  HEART.

  It is evident that the anatomical  changes which the valves
and orifices of the heart have undergone, are not amenable
to any medical treatment.  The lesions existing must remain.
The most that can be  done is to retard their progress  and
control their primary effects.
  Cases  may, however, occur where suitable remedies may
set up such an  action  in  the system, as may  result in  the
partial or complete  removal of certain  morbid  products
deposited on or  about the valves.  A thorough trial of those
remedies known to us  as  antipsorics may give  you excellent
results.
  You need not feel discouraged in the treatment of valvu-
lar diseases, nor should you discourage your patients, for in
general  no  immediate danger is present, even when those
lesions exist  which  involve  more or less  obstruction  or
regurgitation.
  For the treatment  of  the  primary  effects of valvular
diseases, I refer  you to the treatment of enlargement of the
heart.
  The secondary effects of  valvular lesions do  not  generally
appear so long as the enlargement  of the heart is  by hyper-
trophy, unless, from fatty degeneration or some other cause,
weakness of the organ has been induced.  Flint  says that
obstruction and regurgitant lesions tend first, as  a rule, to
produce  hypertrophy, the muscular walls increase  in thick-
ness  up  to a certain limit. When  this  limit is reached,
dilation  of the   cavities  ensue,  and, finally,  predominates 
204
DISEASES OF THE  HEART.
over the hypertrophy.  So long as the hypertrophy lasts the
increased  power of the heart compensates for the immediate
consequences of the obstruction and regurgitation.
  But when dilatation takes place,  the real  danger appears.
It is then that  other organs become affected, and a train of
evils follow7 which will require your watchful care to relieve
and arrest.
  The main objects of treatment, before these resulting affec-
tions  have appeared are mainly preventive.   (1)  You must
seek to prevent or retard the progressive anatomical changes.
(2) You must  strive to  prevent  weakness  and consequent
dilatation of the heart. ■
  As I have just  now stated, you will  find this treatment
fully set forth in your notes on hypertrophy and dilatation.
  You must ever bear in mind, that in the treatment of the
secondary and  remote effects of these lesions, the condition of
the heart should not be forgotten.   You cannot successfully
treat the local  congestions in such cases by specific remedies
directed sole]}7  to the organ affected. For example, leptandra
will not as often remove a jaundice caused by cardiac disease
as will  digitalis, because the latter  has  a specific influence
over the heart.
  These  secondary  affections  are  mostly  dependent  on
passive  congestion, and  as they arise from  a weakened cir-
culation, those cardiac remedies which strengthen the force
of the circulation will give the most relief.   I have enume-
rated these in Classes I., II., and III. in "Dilatation."
  Dyspnoea, otherwise known as cardiac asthma, or breath-
lessness,  will  often  claim  your  special   attention.   In
advanced cases you can only palliate, but you  can  do much
with  such  medicines  as  digitalis,  hydrocyanic acid, arsenic,
lobelia, cuprum  aceticnm, phosphorus, and  tartar emetic.
   Cough can be alleviated by the  same remedies, aided by
hyoscyamus, conium, lycopus, etc.
   Expectoration in valvular  disease should  be encouraged
rather  than checked, for it often  relieves the congestion.
When  it becomes  too profuse, it may be lessened  by squilla,
tartar  emetic-, cubebs, copaira, ammonia,  ipecac, and similar
remedies.
   Intercurrent pulmonary  affections,  such  as  bronchitis, 
       DISEASES RESULTING  FROM VALVULAR  DISEASES.    205

pleurisy,  pneumonia, are  to  be  treated  in the  ordinary
manner.
  The disorders of digestion and hepatic affections are sometimes
quite obstinate.  If you will  study the  provings of digitalis,
you will observe the peculiar and  prominent derangement
of the gastric  and  hepatic functions  which  it  causes.  It
causes these disorders by deranging the action and  impulse
of the heart. Digitalis is our most  reliable remedy in similar
cases;  and next in value come  mix  vomica, ignatia,  china,
comus, cesculus, hydrastis, podophyllum, leptandra, lycopodium,
sulphur, and benzoic acid.
   Cerebral congestions are to be met with digitalis, nux vomica,
opium, glonoiue, agaric us,  arnica, solanum, aided by hot mus-
tard foot and  hand  baths.  The  extremities  must  be kept
warm and full  of blood.
  General  dropsy is  one  of the most  troublesome of  the
secondary effects, and will  tax your skill greatly.   Remem-
ber that  the  kidneys are  not  primarily  in  fault.   The
co-existence of Blight's disease gives the disease  a double
character.
  Any remedy  which will  aid   the  heart  by giving it
increased power will benefit the dropsy.  It is not necessary
that the remedy should  be  a kidney  remedy.  The  best
remedies for cardiac dropsy may be arranged in  two classes,
namely:
  I.  Those which act primarily on the heart:  digitalis and
its analogues;  nux vomica and  china and their analogues.
  II.   Those wirich act specifically on the kidneys : apocynum
conn.,  asparagus,  eupatorium  purp.,  benzoate of  ammonia,
colchicum, asclepias syriaca, squilla, potass nitras and acet, etc.
  In  cases of  co-existing Blight's disease,  I have found
sulphuric acid to act in a wonderfully efficient manner.
  It is a significant fact that allopathic  authorities are quite
unanimous  in  asserting, that from experience they find that
by combining a remedy of my Class I. with one  of Class  II.,
they are enabled to remove  cardiac; dropsy more rapidly than
in any other way.   A favorite combination with  them is
digitalis and squills.    Now, we  need not combine medicines
to get these good effects.   Better  results can be  gained by
alternation.  You  will,  according to  my  experience,  get 
206
DISEASES OF THE HEART.
prompt action from an alternation of digitalis and apocynum
conn., or china and asclepias, or nux and benzoate of ammonia.
  Obstinate cases have been reported  where the interna]
administration of remedies failed to remove  this form of
dropsy, but  in which  their  external application over tho
abdomen and kidneys wras successful.
  If your dropsical patient is anaemic, give him ferrum (the
iodide is the best,) and advise a strong nitrogenous diet.

  Finally, gentlemen;  do not always inform your patients
of the  presence of organic  disease of the heart.  Such an
announcement will militate against your best chosen  reme-
dies, by depressing your patient's spirits, and thus lowering
the vital energies.  Better is it to encourage; and only allude
to the heart in a vague or indirect manner. 
APPENDIX.
     THE INFLUENCE OF THE MIND OVER THE HEART.

   The object of this paper is twofold:
   First. To show the powerful influence which the mind can
 and does exert over the heart, and the manner in which such
 influence is exerted.
   Secondly. The results which may be brought about upon
 the normal conditions of the heart by such influence; and
 their value from a medico-legal and therapeutic point of view.
   We will first inquire how the  mind  can affect the heart;
 or, in other words, through what nerve-channels the intellect,
 the will, and the emotions can affect that important organ.
   The heart is supplied with nerves by the pneumogastric and
 the sympathetic ; but we find it impossible to make satisfac-
 tory experiments with the nerves in connection with the purely
 emotional influences.
   'We are obliged to depend mainly on negative testimony,
 viz., the effect produced upon the heart by irritation and by
 division  of these nerves.  Even here, unfortunately, we are
 met by so much contradictory evidence that it really seems
 hopeless  to arrive at any definite conclusion.
   Claude Bernard, "Weber, Yalentine, Schiff, and Lockhart
 Clark  disagree in many essential  particulars  relating to the
 effects of division or irritation of the pneumogastrics.
   The majority of evidence, however, is in favor of the con-
 clusion  that  the pneumogastrics, pure  and simple, contain
 motor  fibres, and that, through the cardiac  branches, they
 effect the motions of the heart.
  The  pneumogastric  may contain sensory fibres also,  and
may, therefore, be a compound nerve from its origin.
  Avith regard to the influence of the sympathetic, Carpenter
                           14 
208
APPENDIX.
found that pressure on the great cardiac sympathetic  nerve
checks the heart's  pulsations from four to six beats, causing
fearful anxiety and pain; while Weber  found that stimuli
conveyed  through this nerve accelerated the  movements of
the heart.
  These and other facts leave no room to doubt that the sym-
pathetic nerves are also concerned in the motions of the heart.
  Xow the  question is  w7hether the emotions act through
them or the pneumogastrics, or both, when  accelerating or
retarding; the movements of the heart.
  As to the sympathetic nerves of the heart, Moleschott's ex-
periments demonstrated that the same phenomena occurred
as in the case of the vagi, when excited mildly or strongly by
galvanism, and he concludes that these two sets of nerves
exercise the same influence upon this viscus.
  It appears fair, therefore, to conclude that the emotions act
upon the heart both through the vagi and the sympathetic.
Their modus operandi—now  accelerating, now retarding its
action—would  seem to derive  illustration from  these and
similar experiments.
  If we were  to substitute emotion for the stimulus applied
by Moleschott to the nerves proceeding  to the heart, we can
well understand how the former should produce the various
and opposite disturbances of this organ,  including spasm and
paralysis, with which we are familiar.  First, as a feeble or
moderate stimulus of the vagus (whether  electric  or other-
wise) causes a considerable  rise in  the pulse, so does an emo-
tion which is not excessive  in  character.  Secondly,  as an
increased stimulus gradually retards the  action of the heart,
wrhile a very powerful one immediately arrests  it  from  the
fatigue which succeeds stimulus, just so,  we can wTell con-
ceive, a violent emotion wTould act.  Thirdly, the fatigue may
be gradually recovered from and the heart's action restored
to its normal frequency and force.
  The ganglia of the heart appear to act in the way of com-
municating the condition of one of the four nerves supplying
the heart to the  other three.  In  regard  to the emotional
stimuli, however, it seems impossible to decide whether  one
is more influenced than  another, and, in view of Professor
Moleschott's experiments, it is evident that the emotions may 
        INFLUENCE OF THE MIND  OVER THE HEART.     209

act in precisely the same way through either the vagi or sym-
pathetic.
  We  may be allowed to surmise that the ganglia and the
fourfold supply of nerves to this organ are designed to lessen
its liability to fatal spasm and paralysis by emotion.
  " The heart," observes Moleschott,  " is  animated by four
very excitable nerves, which may be easily over-excited ; these
four nerves, two vagi and  two sympathetic, have a peculiar
consensus, which is no doubt clue to the action of the ganglia
of the heart, so that the state of irritation or over-excitement
of one is conveyed to the other three; but  it is impossible to
permanently exhaust the  other three by the over-excitation
of one nerve singly, as stimulants which w7ould be powerful
enough to effect this, w7oulcl soon kill the excited portion of
the one nerve, and therefore lose their effect upon  the other
three; such an effect being only possible as long as the nerve
acted upon retains part at least of its excitability."
  This conclusion accords with the opinion of Kirkes  and
Paget, that the cardiac branches  of the pneumogastric are
one, though not the sole channel through which the influence
of emotion is transmitted  to this organ, and with that of Dr.
Carpenter, already cited; and it does not contradict the judg-
ment expressed  by him elsewhere, that the sympathetic  con-
stitutes the  channel through  wThich  the  passions produce
palpitation  of the  heart,  or Dr. Baly's statement, that the
disturbed action of the heart during emotion is a remarkable
instance of the influence of the passions over movements of
organs supplied by the sympathetic.
  Since Moleschott's experiments, those of MM. Cyon  and
Ludwig  indicate the existence of accelerator and  depressor
nerves of the heart, the former emerging from  the cord with
the  third branch of the inferior cervical  ganglion, and the
latter arising, in rabbits, from the pneumogastric and superior
laryngeal nerves.
  Bernard, it is stated, adopted this view,  and  held that the
heart, with this sensory depressor nerve, is able to regulate
its volume according to circumstances, by exerting a reflex
action on the general circulation.
  If the inhibitory view of the pneumogastric nerve be estab-
lished, we must, in attempting  to explain the injurious mode 
210
APPENDIX.
 of action of certain emotional states upon the heart, suppose
 that the normal control which is being constantly exercised
 by this nerve is, under excessive emotion, so intensified under
 increased stimulation at its origin in the medulla oblongata,
 that the pulsations of the organ are partially or wholly arrest-
 ed.   A provision  by which  the heart is prevented  sending
 more blood to an  organ already too vascular from emotional
 excitement, may thus  cause death.
   It seems, however, that as long as physiologists differ so
 widely as to the functions of the nerves  supplying the heart,
 it is impossible  to determine the exact manner in which  the
 emotions influence this organ.
   The general conclusion is,  that  it is through the acknowl-
 edged sympathetic and probably through the pneumogastric
 by reflex action, when excited centrally by certain emotional
 states, just as it is alleged to do from the state of the heart
 at the periphery,  or, if  Moleschott's  views  be adopted,  di-
 rectly through the motor fibres of this nerve.
   In order to be methodical and give a more clear and com-
 prehensive understanding, we will take up the various func-
 tions of the mind,  as the intellect, the will, and the emotions.

                      THE INTELLECT.

   The influence of the intellect upon the heart is similar to
 that exercised over voluntary muscles.
   The direction of thought  to the heart has  very generally
 an embarrassing influence on  its regular action.
   Sir Henry Holland  says: " There is  cause  to  believe the
 action of the heart is often quickened or otherwise disturbed
 by the mere  centring  the  consciousness on it, without any
 emotion or anxiety."   On occasions where its beats are audi-
 ble, observation will give proof of this, or the physician can
 very often infer it while feeling the pulse; and where there
 is  liability  to irregular pulsation such  action is seemingly
 brought on or increased by the effort of attention, even though
 no obvious emotion be  present.
  I have observed this phenomenon, in  my own practice, in
hysterical women,  who imagine  they have heart disease.   In
these cases a morbid  attention to the action  of the heart 
        INFLUENCE OF THE MIND  OVER THE HEART.     211

would bring on palpitation  and irregular action.  Upon the
removal of all anxiety by a decided assertion from me, after a
careful physical examination, that  the heart was not diseased,
it would quickly resume its normal action.
  From the same cause medical students, when their thoughts
are directed by their studies to this organ, are frequently suf-
ferers from its disturbed action.  Anxiety, no doubt, comes in
here to aggravate the disorder, and will  be referred to again
under emotions.  Peter Frank himself, even in advanced life,
while devoting especial  attention  to the subject of heart dis-
ease, during the preparation of his  lectures, was attacked with
severe palpitations, accompanied by an intermittent pulse, and
felt certain that he was affected with an aneurism. The symp-
toms did not cease till  some time after the completion of his
labors, and after he had enjoyed the relaxation and diversion
of a journey.  In fact, it is quite a common remark that med-
ical  men  often die  from a disease that they have made a
special study during life.
  The question now naturally arises, is it possible for hysterical
or hypochondriac persons to bring on permanent structural dis-
ease of the heart by a morbid concentration of the mind on it ?
  It is the opinion of most medical waiters that it is not prob-
able such a result w7ould  occur.   They admit, however, that
it would be likely to aggravate any previous mischief and in-
duce irregular action, and  ultimately hypertrophy, or  some
other disease decidedly organic.  The physician should, there-
fore, in  treating such patients, exercise his influence  and in-
genuity to divert their  minds from the heart to some other
subject or organ.
  Numerous interesting cases are  recorded showing the  spe-
cific effects of the intellect over the heart's action, as one of a
medical student being initiated into the rites of  a Masonic
society; his eyes were bandaged, a ligature bound around his
arm, and the usual preparations made for bleeding. A pretence
of opening the vein was made, and a stream of water spurted
in a bowl to represent the sound of the flowing blood expected.
As a result the student soon became pale and fainted.
  Then there is the well-known case of the man being bled
by the prick  of a pin and warm water running down his arm,
who actually died as a result. 
212
APPENDIX.
  The daughter of Sir Charles Lee, at 2 o'clock on a certain
morning, saw between the curtains of her bed a little old wo-
man, who told her that at 12 o'clock the next day she would be
with her in the next world.  She immediately dressed herself
very carefully, went into her private closet, and did not come
out till 9 o'clock, when she went to her  aunt, handed  her a
letter directed to her father with the request it be sent to him
immediately on her death, telling her aunt about the appari-
tion.  A physician and a surgeon w7ere sent for, but could dis-
cover no disease, but on the urgent solicitation of  the aunt
bled her slightly.   She then took a chair and played on her
guitar and sang some favorite pieces, and a fewr minutes be-
fore 12 went to a large arm-chair, sat in  it, and at 12 raised
her hand toward her heart and was dead.
  Another case of a young lady who received a similar  warn-
ing, only it came  a year before the appointed time.   She be-
came  anaemic, lost flesh and  strength; nothing could appar-
ently  be done to save  life, although no organic or structural
disease could  be found by the closest examination by skilful
physicians. The day before the time set for her death a young
physician who had some tact gave her a very heavy anodyne,
and she slept under its  influence during the entire day of her
expected death.  When she  returned  to consciousness the
next day, and was making a few final  preparations, she was
assured that the time  had passed for her  to die and that the
oracle knew nothing of such matters and was an impostor.
She got up from her bed and  rapidly regained both flesh and
strength.
  To  be sure these are isolated and exceptional cases, and may
by many be accounted for on influences other than intellec-
tual, but in them we cannot help seeing a result comparing
with the natural reasoning and with ideas firmly fixed in the
minds of the  individuals.

                        THE WILL.

  Dr. Tuke says: " The direct action of the will  upon the
heart and nonstriated muscles, if it can ever be exerted, is al-
together exceptional,  although it may powerfully  influence
them  indirectly by directing the course of the emotions and 
        INFLUENCE OF THE MIND  OVER THE HEART.     213

ideas to them, and in this way it may, and probably does,
affect the organic functions."
  A distinguished Fellow of the Royal Society (set. 79)  told
him that he could by voluntary effort, increase the frequency
of his pulse from ten to twenty beats per  minute.  At the
Doctor's request the experiment  was made.   When  he sat
down his pulse was sixty-two ; in the course of  about tw7o
minutes it increased  to eighty-two.  On being requested to
describe the manner of accelerating it, he said it seemed to be
parti}7 due to " a sort of impulse," partly to an internal shiver,
and partly to an action on  the breathing.
  The increase in respiration was not apparent.
  It may be that the will  did not act directly on the muscu-
lar tissue of the heart, but indirectly by  concentrating the
attention on that particular object, on that particular organ.
  The case of Colonel Townsend, in which it is said  he pos-
sessed the remarkable faculty of thro wing himself into a trance
at pleasure.  The heart ceased apparently to throb at his bid-
ding, respiration seemed  at an end, his whole frame assumed
the icy  rigidity of death, while his face became colorless and
shrunk, and his eyes fixed, glazed, and  ghastly.   He would
remain  in this state for hours, entirely unconscious, when the
signs of life would gradually reappear.
  Dr. Darwin says: "There is an instance in the Philosophical
Transactions, of a man w7ho could for a time stop  the motion
of his heart when he pleased."

                      THE EMOTIONS.

  The heart may be so affected by the emotions, through the
nerves supplying it, as to produce  violent contractions—tonic
spasms  of the organ.  This occurring in such a vital organ
must of necessity cause death.
  It is  difficult to decide whether this results from muscular
irritability, is caused by the withdrawing of an antagonistic
nerve-force, or from the direct action of nerve-force upon the
muscles;  but it is  evident that, in cases of death like Hun-
ter's, a  condition of spasmodic contraction of the walls of the
heart is produced.   Let  me refer to the record of his death
and post-mortem. 
214                    APPENDIX.
   The governors of St. George's Hospital  decided  that  no
person should be admitted as a student without bringing cer-
tificates of being educated in the profession.
   Hunter advocated, at the board, the admission of twro young
men inadmissible  under the new rule.  His biographer, Mr.
Palmer, states that, before the meeting, he expressed his ap-
prehensions to a friend, " lest some unpleasant dispute might
occur, and his conviction that, if it did, it would certainly
prove fatal to him."   Arrived at the hospital he found the
board already assembled, and entering  the room, presented
the memorial of the young  men,  and proceeded to urge the
propriety  of their  being admitted.   In  the course of his re-
marks he  made some observations which one of his colleagues
thought it necessary instantly and flatly to contradict.  Hun-
ter immediately ceased speaking, retired from the table, and
struggling to suppress  the tumult of his  passion, hurried into
the adjoining room, which  he had scarcely reached when,
with a deep groan, he fell lifeless into the arms of Dr.  Robert-
son, one of the physicians of the hospital, who chanced to be
present.  Various attempts were made for upward of an hour
to restore animation, under  the hope that the attack might
prove to be a fainting fit, such as  he had before experienced,
but in vain ; life had fled and all their efforts proved useless.
The post-mortem showed the heart to be badly diseased;  it
was small, appeared  to have wasted, and was strongly  con-
tracted.  The viscera of the abdomen and head were loaded
wTith blood.
  As in such  cases death seems to  be caused  by the severe
and persistent spasm or contraction of the heart, it seems to
me that the opposite condition of dilatation may also occur
from emotional excitement.   The organ would, in that case,
cease to contract on its contents and become powerless, and
death ensue.   We see this  in voluntary muscles and from
emotional causes, as in the  hand.   In  one case it  will be
rigidly contracted, in another paralyzed, the only difference
in result  being that  the heart is  a  vital organ, the hand  is
not.
  Senac gives  a case of a person who was witness to a ship-
wreck, and became so affected by the distress around him and
terror that palpitation of the heart was succeeded  by sup- 
        INFLUENCE OF THE MIND OVER THE HEART.     215

pressed  breathing, syncope and  death.   Upon  examination
the heart was found enlarged.
  Bonnet, Morgagni, Tissot, and others assert that dilatation
of the heart has been caused by chagrin and anger.
  Dr. Richardson says:  "I have never met with a case of in-
termittent pulse in which the disorder was not sequential to
some anxiety, shock, fear, sorrow, or their similars."
  From statistics we learn that in the last twenty years deaths
from heart disease have increased about twenty-five per cent.,
and the percentage of the increase is entirely confined to men,
and to those between the ages of 21 and 45, which is the time
they are subject to the most trying emotional causes.
  It is not an uncommon occurrence to meet with syncope
produced by emotional  excitement, and in the case of a per-
fectly healthy heart w7e can readily understand why nothing
more serious should supervene, and I  think it equally clear
that it should  succumb when it is  already diseased, and of
course has less power of resistance.
  Here again we find that exactly similar results are produced
by  the opposite emotions of joy  and fear.
  Lord Eglinton informed John  Hunter " that when two sol-
diers were condemned to be shot, and one of them to receive
a pardon, the event being decided by their throwing dice, the
one who proved successful—thus securing a reprieve—usually
fainted, while the  other remained calm."
  The American poetess, Lucretia Davidson, who died at 17,
often fainted when listening to some of her favorite melodies
from Moore,  yet notwithstanding this, she would beg to have
them repeated.
   \Ve often see examples where fear prevents fainting so long
as it operates, and immediately it is withdrawn the system
yields to the reaction and fainting  takes place.  A lady sit-
ting up after the rest of the household had gone to bed saw a
servant enter the door with a pistol in his hand.  She imme-
diately blew  out  the candle, pushed the bed from the wall,
got behind it, and succeeded in evading him and getting out
of the door and locking it behind her.   She awoke the house
and then fainted away.
  The case of the  doorkeeper of Congress, an aged man, who
died suddenly on  hearing  the  news of the capture of Lord 
216
APPENDIX.
Cornwallis's army, is an instance of death from joy, and there
can be no  doubt that it w7as the result of cardiac and not
cerebral lesion.
  Sweetser reports a case of an Irishman, aged 36, of ungovern-
able passion.  Having experienced various misfortunes during
the Revolutionary war, at length, on the affairs of France as-
suming a more favorable aspect, received a pension, but which
was immediately taken away from him on  the death of the
patron by whom it had been procured.  Immediately on hear-
ing the news he felt a dreadful heavy weight in  his chest.
His respiration became fatiguing, and the action of the heart
assumed an irregularity  which had no interruption during
the tw7o and a half years that he survived his misfortune.
  On post-mortem the  heart w7as found pale and flaccid ; the
parietes of the cavities fell together.  There was an astonish-
ing contrast  between  the flesh of the heart and that  of the
rest of the body, showing conclusively that it wras the diseased
organ.
  It has been observed by African  travellers, among w7hom
are Livingston and Samuel Baker, that when the natives be-
longing to some  of the interior tribes were  taken from their
homes by force or bribes, that their sufferings from homesick-
ness were intense, and sometimes fatal.   Their sufferings wrere
not only mental  but physical, for when asked to point out the
seat  of  their evident suffering, they indicated correctly the
region of the heart.  These same authorities further assert
that those  w7ho died showed all the evidences of death from
cardiac disease.
  It is w7ell knowm that the Swiss soldiers sometimes  die of
homesickness, attended with  all the symptoms  of cardiac
failure.
  Dr. M. Ward  reports a case of death, which is so remarka-
ble I cannot  resist the temptation  to quote it in brief.  Dr.
Ward was  called on February 17th,  1870,  to  a Miss H.
He found she had been suffering for several days from fever;
had been out the day before.  She had recently returned from
the funeral of a sister who died from  typhoid  fever.  Her
symptoms became rapidly worse, and she died before morning.
  A Mr. Filby,  a butcher who lived next door to the  above
Miss  H., who had come  for the Doctor shortly  before her 
        INFLUENCE OF THE MIND OVER THE HEART.    217

death, appeared  perfectly healthy but  very much depressed.
He told the Doctor he had never seen any one dead before, and
hoped he never  should again.   He did not go to bed that
night, but remained sitting in a chair, and  apparently slept
well.  The next  morning he was found slipping down in the
chair, and, upon  trying to arouse and  get him up further in
the chair, it was found that he w7as dead.
  A post-mortem revealed a perfectly healthy man;  no mark
of disease could be found in any part of the body.  Dr. Ward
gave it as his opinion that it was  a sort of gradual cardiac
syncope.
  A distinguished  veterinary  surgeon, of cool wTell-balanced
nerves, consented to having an  operation of lithotomy per-
formed.  He had had a great aversion and dread of  this ope-
ration.   \Vhen the  preparations were  being made and the
usual  preliminary examinations, he show7ed  no signs of fear,
but when the catheter was being introduced  he was  observed
to become pale and faint, and notwithstanding  every effort
was made to restore the patient, he died in about ten minutes.
  Dr. Currie, of  Edinburgh, engaged to perform paracentesis
abdominalis in a case of ascites.  On  entering the room the
lady fainted, and on attempting  to restore her he found she
was dying.
  A station master  on one of the  Italian railways, 55 years
of age, in robust  health, was awakened one morning  w7ith the
news that his station had  been robbed. Although  perfectly
healthy the  night before, he  immediately became sick  and
died within twenty-four hours.  There was utter prostration,
spasmodic action of the stomach, with obstinate vomiting,
hollow voice, and failing pulse;  consciousness continued  to
the last.
  The case  coming before  the courts, it w7as decided, " that
sudden mental emotion may induce death within a brief space
of time, or even  immediately, and even in persons of robust
health, is a  fact  freely admitted in science." And  that the
fact of his not dying for twenty-four hours was no proof that
it was not caused solely by the mental emotion. 
218
APPENDIX.
                    A  BROKEN HEART

is no myth.  Dr. Murray says such is the influence of emo-
tions on  the heart that a sudden shock has  been known to
arrest its action or to excite it to an action so turbulent as to
injure its valves  or their tendinous  cords.  Those who have
read my Lectures on  the Heart will remember the cases there
reported of actual rupture of the heart  and sudden death in
cases of persons dying from some great and sudden calamity.
  A singular book has been published in England treating Of
the diagnosis of the crucifixion of Christ, by the eminent Lon-
don surgeons, William Stroud and Sir J. Y. Simpson.  In this
they claim  that Christ died from a literally broken heart.
  Walshe states  that a case is on record  and well authenti-
cated in  which a former rupture  firmly filled by a fibrinous
coagulum, adherent to the w7alls of the heart, was found.
  It is probable, says Brown Sequard, that in cases of death
from sudden  emotion an excitation  is  produced on the roots
of the par vagum, which appear to have their true origin in
the neighborhood of the calamus scriptorius, and  in conse-
quence the  bloodvessels  of  the heart contract and expel  the
blood they  contained, and with it the natural excitant which
causes the movements of the heart.
  Dr. Carpenter takes the  ground that the nerve-force is to
be regarded as a polar force, analogous in its mode of trans-
mission to electricity, and that death results from the reversal
of the usual direction of this current.
  Dr. Richardson says, in regard to cardiac paralysis, the bal-
ance between the heart and lungs is broken on the circulation
side, and gives several cases to illustrate his idea.
  I have brought forward but a small portion of the facts re-
corded in medical literature, illustrating the influence of  the
mind over the heart.  But  enough has been offered, I think,
to convince the most skeptical of the actual existence of such
influence.
  It only remains to us to inquire into the practical value of
such established facts.  I believe them to be of the greatest
importance to the physician, both in  the study of the etiology
of disease and in therapeutics. *
  Many  cases of cardiac disorder  are treated by remedies 
  PATHOLOGY OF EMOTIONAL DISEASES OF  THE HEART.  219

which only have an action on  the blood and nutrition  pro-
cesses, when, if the mental  origin was known, no medicine
would be prescribed, and the treatment directed to the minis-
tering to a mind diseased. The homoeopathic Materia Medica
is  rich in  remedies which have a profound curative  action
upon  a disordered  mind.  Such remedies, used  alone or in
conjunction wTith change of scene, diversion, or  properly di-
rected mental influences, will, in a majority of instances, re-
move  cardiac disturbances of an  apparently serious  nature.
But this portion of the subject must be deferred for consider-
ation in another paper.


 THE  PATHOLOGY  AND  TREATMENT OF DISEASES OF THE
       HEART, CAUSED BY EMOTIONAL INFLUENCES

  It will be remembered that I have read before  this Society
several papers relating to the effects of the will and the emo-
tions on the heart.   Without going over the same ground
again, I w7ill briefly allude to the manner  in which the emo-
tions do affect the heart.

             HOAV EMOTIONS  AFFECT THE HEART.
  The experiments of modern physiologists, Claude Bernard
iu particular, show that all  sensations  act primarily on the
nerve-centres, through the nerves reaching from the periphery
of the body to those centres.   The excitation thus determined
in the brain, or spinal cord, is then transferred to the nerve
filaments which  extend  to  the viscera  and  members,.and
hence the latter are affected only secondarily.
  Of all the organs, the  heart is  the one  which earliest and
most profoundly  experiences the influence  of the  sensitive ex-
citations produced in the nerve-centres.  So soon as any modi-
fication is produced in the central nerve-substance, the nerves
transmit  this vibration  to the heart, and  at once the move-
ments of the latter suffer a perturbation which is  expressed in
various ways.
  If the ordinary bodily sensations experienced from physical
influences thus affect the heart, through the brain and cord,
how much more intensely do  those mental sensations, caused 
220
APPENDIX.
by purely emotional influences affect that organ, for the emo-
tions affect the brain in a much  more direct and immediate
manner than the physical sensations.   Emotional influences
do not always affect the heart in the same  manner.  In fact,
their influence on the heart is as varied and diverse as their
influence on the mind.
  We say the mind is depressed by grief and excited by joy.
In the same manner emotions of sadness or grief  so  depress
the heart's action that it beats with great feebleness, or its
motion is almost arrested, causing  that condition known as
fainting.   Joyous emotions, on the other hand, so excite the
heart that the frequency of its beats is often doubled.
  The heart, says Fernand Papillon, is  no  more the  seat of
the sentiments than the hand is the seat of the will; but it is
a reactive, which is modified  by the sentiments, with the ut-
most nicety and with infallible certainty.
  Xot only does the heart betray by the very disturbance of
its normal rhythm the nature of the initial brain excitation,
but it also  produces  throughout  the whole organism dis-
ordered actions, the sum of which constitutes, as it were, the
physical  image, the palpable externals  of passion.   But it
produces this disordered action only by reacting on the brain,
which is  the organ of all the demonstrations and of all the
movements in the nerves, and consequently, of the muscles.
  It is disbelieved  by some, even at this day, that emotional
influences can cause long-lasting functional disorder of the
heart.  Much less is it thought that they may cause structu-
ral changes in that organ.
  In this connection,

                THE  STATISTICS OF  INSANITY

are suggestive, if nothing else.  Dr. Wilkie Burman, w7ho has
lately investigated the relations of heart disease with insanity,
says:  "Examination of the heart in the living and the dead
shows that diseases of the heart are very frequent in persons
suffering from mental diseases. In 500 cadavers, 36 per cent.
gave a diseased state of the valves and apertures of the heart
and aorta; 14 per cent, showed hypertrophy, without valvular
disease;  30  per cent, showed hypertrophy, fatty degenera- 
  PATHOLOGY OF EMOTIONAL DISEASES OF THE HEART.  221

tion, and other heart diseases of minor importance;  only 20
per cent, gave perfectly sound hearts.   Of 680 male patients,
44 per cent,  had heart disease.  The average weight of the
heart is, in both  sexes, when suffering from mental diseases,
heavier by one ounce than in persons of sound mind.   This
increase may be ascribed to  the valvular morbid states, or to
the hypertrophy which is seen in chronic and recurring mania,
and in consecutive dementia, often without valvular disease,
and most frequently attacking only the right ventricle."
  Heart  diseases are most  frequently observed  in  patients
with  hypochondriac melancholy ; with the so called  " melan-
choly with suspicion," causing a suspicious morose disposition,
and it appears that the heart disease has some relation to it,
whereby the subjective sensations offer  a prolific foundation
for illusions and delusions.   In chronic cases and for ad-
vanced mental disease it shows an essential asthenic type, also
feebleness in the circulation, cold livid extremities, and a weak,
small pulse.
                      THE CONCLUSIONS.

   If  these statistics show anything, they show (1) that the
presence of heart disease during mental disorder  is too com-
mon to be an accidental coincidence; (2) that, in a proportion
of  the cases, the heart disease must have been caused by the
mental; (3) that the coincidence of heart disease with melan-
choly is pretty conclusive that  mental depression causes car-
diac depression,—a condition w7hich leads to certain forms of
structural changes in the heart.  I admit, be it remembered,
that diseases of the heart may and do cause many cases of in-
sanity.  But I must affirm  my belief that emotional shocks,
or  mental influences, may and  do cause not only functional
but organic heart diseases.
   Take, for example, the influence of

                   FRIGHT,  SUDDEN GRIEF,
or other  sad and painful emotions.   They suddenly  diminish
the rapidity  of  the  heart's beating, and thus increase the
amount of blood discharged  from that organ at each  diastole ;
hence the contractions by which it drives the blood into the
vessels are very  laborious and protracted.  In some cases the 
990
APPENDIX.
 shock (as from fright, terror, or the sight of blood), may at
 once  stop the motion of the heart,  and as the blood is  no
 longer  discharged into the vessels, fainting  occurs.   This
 fainting may not only simulate death, but may actually cause
 it, by rupture of the heart or tetanic and persistent contrac-
 tion of its cavities.  But, if recovery  occurs, the heart has  re-
 ceived such a strain that it  may take that organ weeks and
 months to recover, or it may not recover  at all, but end  in
 structural disease, for it is admitted  now by all  the best au-
 thorities that many functional cardiac disorders may, if per-
 sistent for a long time, end in organic disease.
  Among the diseases of the heart which may be caused by
 mental emotions and psychical disorders may be enumerated:
 1. Cardiac irritability, angina pectoris, cardiac myalgia, pal-
 pitation, and weakened  heart; among the purely functional.
 2. Hypertrophy with dilatation, and with enlargement, cer-
 tain valvular diseases, rupture and aneurism; among the or-
 ganic.
                    HOW  EMOTIONS ACT.

  Right here it may be of interest to inquire, Through what
 media do emotions act upon the heart ?  The recent discove-
 ries of M. Cyon afford us a basis for the most probable ex-
 planation of the phenomena.  The following  embodies the
 results of his researches.
  The heart is provided with a  number of little, self-acting
 nerve-ganglia without  relations  to the brain, from which
 spring, under the influence of the blood, a certain number  of
 motor impulsions.  These ganglia govern  the  usual  normal
 action of the cardiac apparatus ; but the rhythm and force of
 the beatings are every instant modified by excitations having
 their  origin  in the brain.  The brain sends  out to the ganglia
 of the heart two sets of nerves;  the  retardator (pneumogas-
 tric) and accelerator nerves.   Excitation of the former dimin-
ishes  the frequency  and augments the force of  the  heart's
 movements.   Excitation of the latter produces the opposite
results, increasing the number and lessening the force of the
heart's contractions.
  Xow it is evident  that the emotions, according to  their 
   PATHOLOGY OF  EMOTIONAL DISEASES OF THE HEART.   223

quality and intensity, must affect these  two sets of nerves
either separately or together. Our next inquiry will be, then,

              CAN WE CLASSIFY THE EMOTIONS

and arrange them in such a way as to show those which af-
fect these sets of nerves in a special manner, either to excite
or depress ?
   After considerable study of the action  of the various emo-
tions,  and guided by such  authorities as Tuke, Winslow,
Carpenter, and Maudsley, I  have  ventured to arrange them
as follows: (1) Emotions  which excite mainly the retardator
nerves: Joy, rapture, ecstasy, hope (with faith), pride, cour-
age, love, adoration, wonder, and astonishment, to which we
may add anger, rage, and wrath.  (2)  Emotions which excite
mainly the accelerator  nerves:  Grief, sadness,  discontent,
disappointment, melancholy, despair,  remorse, fear,  fright,
horror, anxiety, and wonder.
   It may be said, in criticism of  this arrangement, that we
rarely find one emotion acting exclusively at one time.  This
is admitted, and it  is the one  chief element of uncertainty
that  prevents  a perfectly  satisfactory classification of  the
emotions.  Suppose, for example, that we have joy and anx-
iety acting at  the same  time upon the  brain.  The result
would be an excitation of both sets of nerves, causing an in-
creased force with accelerated action of the heart.  Again, as-
tonishment from pleasurable causes would act altogether on
the retardator nerves; but,  if from unpleasant causes, on  the
accelerators.
  Apparently, the most opposite emotions cause similar head-
symptoms, but, when w7e analyze  the nature of the effects,
they will be seen to be widely different.  Thus joy and terror
both cause palpitation, but the former causes increased  car-
diac action with augmented vital  force,—the latter produces
an  irritative frequency  with deficient power.  It  may be
asked, How can
                     JOY AND FRIGHT

both cause death ?   The action of an emotion is  like the  ac-
tion of a drug.  In small  and repeated doses, quinine causes
a continuous augmented action of the heart, not injurious uu-
                            15 
224
APPENDIX.
less too long continued :  while a massive dose acts suddenly,
causing cardiac spasm and fatal symptoms.  So joy, moderate
and continuous, increases the vital manifestations of physical
and  mental life,  but sudden  and great  joy kills by causing
persistent cardiac spasm.  Fright or terror may also kill sud-
denly, either by causing immediate cardiac  failure,  if the
emotion is overwhelming, or destroy life more slowly by pro-
ducing an irritative frequency which will end in gradual ces-
sation of the contractions of that organ.
  Enough  has been said to show  that  we must  study the
effects of the emotions as closely and in the same  manner as
wre study the effects of drugs on the human organism.  We
ought, some time, to have carefully arranged pathogeneses of
the emotions, not only that wre may recognize the peculiar
diseases which they cause, but that we may use their influ-
ence  as remedial agents for the removal of similar disorders.

                     THE TREATMENT.

  We come now to  the treatment of those disorders  of the
heart caused by  the emotions.   What is the first principle
which should guide us in selecting the medicine, after we
have  prescribed the proper  hygienic rules?   The tenets of
our school of practice give us the following laws, namely:
  (1)  The medicine chosen must  be one which is capable of
causing  in the healthy  a  condition and symptoms similar to
each special case.
  (2)  The origin and direction of the medicinal force must be
similar to  the origin and direction of the original  morbific
force.  This latter rule I  consider of the utmost importance.
Allow me to explain: In  a ease of irritable heart, when you
have  traced  the  cause  to be  excessive,  unexpected joy, the
emotion  first affected  the  brain through  the soul.   This
shock was transmitted  by the  pneumogastric nerve to the
heart, which it caused to  palpitate, violently, w7ith  increased
force, as well  as  increased frequency.  An irritation  of the
cardiac ganglia w7as set up, rendering that organ  more suscep-
tible to any and  all emotions.   This irritability may become
permanent and possibly end  in structural disease, unless it is
arrested.   In selecting the medicinal remedy we must select 
  TREATMENT OF EMOTIONAL DISEASES OF THE HEART.  225

one whose pathogenetic action  begins  in the brain, and in
that portion of the encephalon which presides over the trans-
mission of joyous  and all other exhilarating emotions.   The
medicinal or drug force, starting from that locality, when
transmitted to the heart, must  be capable of causing the pe-
culiar  kind of irritability w7hich w7e find in the patient we
are treating.  Hahnemann and all his most  scientific follow-
ers have  recognized this rule, and when strictly followed it
has  resulted in  some  brilliant  cures.  Those who  restrict
themselves to covering  the  totality of existing  symptoms
will find  the cure of their patients  tedious and  unsatisfac-
tory.
   Another rule I would add, of equal  importance with the
above, namely:  When the primary symptoms of the case re-
semble the primary symptoms of the medicine selected, pre-
scribe  that medicine in the  high attenuations.   When  the
secondary symptoms of both the medicine  and the disorder
are coincident!}7 present, the  dose should consist of apprecia-
ble, or material, quantities.

                       THE MEDICINES.

   We will now enumerate the medicines which will be found
useful in  cardiac affections from  emotional causes, but in
order to have a clear understanding of their action we shall
compare  the pathology of the  emotions with the pathology
of the medicines, namely :
   The emotions of joy, rapture, ecstasy, hope, pride, courage,
ano-er, rage, w7rath, love, adoration, wonder, and astonishment,
all stimulate and irritate the retardator nerve and increase
the force of the heart's action.  Excessive  and sudden joy,
anger, and rage over-stimulate the retardator nerve and cause
sudden death by cardiac  spasms.   Of medicines, Ammonia,
Agaricus, Cinchona,  Coft'ea, Crocus, Cactus, Camphor, Bella-
donna, Digitalis, Hydrocyanic  acid, Lycopus, Laurocerasus,
Ignatia, Xux vomica, and Cannabis  indica, all stimulate the
pneumogastric  or retardator nerve and augment the force of
the heart's contractions.  Of these, Cinchona (and Quinine),
Camphor,  Belladonna,  Digitalis,  Hydrocyanic acid,  Nux
vomica, and Ignatia, if taken in massive doses, are  capable 
226
APPENDIX.
of over-stimulating these nerves to such a  degree as to cause
sudden death by cardiac spasm.
  It follows, then, that among these medicines you will find
the remedies for the cardiac disorders consequent on the mor-
bific effect of those emotions which irritate and over-stimu-
late  the  retardator nerve.   In  our old repertories you will
find manv of these mentioned  as having been recommended
by Hahnemann and others.

                  AN ILLUSTRATIVE CASE.

  As an illustration of the proper method  of treating a case
of prolonged cardiac hyperesthesia  from the combined effects
of excessive joy and anxiety, I will  narrate  one that came
under my care a few months ago.
  A young married woman applied to me for the relief of an
unpleasant  nervous feeling in  the  chest,  not amounting to
pain, but an "uncertain, weak, weary sensation," as  she ex-
pressed it.   She was subject to alternate  feelings of depres-
sion and exhilaration; a strange sensation of sinking,  and
emptiness in the pit of the stomach ;  the heart's impulse was
feeble, its rhythm not disturbed, but  the pulse-beats were
small, soft, and averaged 100 to 110 per minute, even when
lying down.  Here were symptoms which appeared to  call
for  Collinsonia, Lycopus, Prunus, and  some others, but the
history of the case revealed the true similimum.   Mie  had
always been strong and  healthy, but, during  the  civil war,
her affianced was  in the army during its most perilous cam-
paigns.   On several occasions  rumors  of his death reached
her; on one occasion  she did not hear from him for several
months.  Meanwhile it was  supposed he was starving in the
prison-pen  of  Andersonville.  All  this time her heart  was
being irritated and weakened  by the  emotions of anxiety,
grief, and despondency.  How true  the  ancient adage, " Hope
deferred  maketh  the heart  sick."  At last, when she  had
nearly given him up for dead,  he  suddenly appeared before
her; but wan, and thin, and pale—a mere shadow7  of his
former self.   The shock wras sudden  and overwhelming, not
of joy alone, but mixed with astonishment, pain, and sorrow7.
  As w7e rarely find among the sick an  affection of  one organ 
  TREATMENT OF EMOTIONAL DISEASES OF  THE HEART.  227

and tissue alone, so do w7e rarely find cases where one emotion,
unmixed with others, exercises its specific, uncomplicated in-
fluence.  In this case, however, joy was the one predominant
emotion.  Her heart, already weakened and irritated by grief
and anxiety, succumbed to the excessive stimulation  of joy,
and cerebral congestion, throbbing temples, loud hysterical
laughter, followed by spasmodic weeping, and a sensation "as
if the heart was trying to beat painfully in a cage," as she ex-
pressed it, ended in a nervous erethism which  had never left
her, although she was happily married and situated pleasantly
in life.
  The remedy in this case proved to be Ignatia.  It covers all
the symptoms and conditions, and also simulates the history
of the disorder.  One dose of a high potency was given and
allowed to  act a w7eek.  This  was followed by doses of the
lower attenuations, three times a day, and she was cured in a
month.
                   IN ANOTHER INSTANCE,

occurring in a healthy woman, wrhere no previous anxiety had
weakened the heart, the unexpected news of great good for-
tune caused a condition of extreme nervousness, with strong,
quick  palpitation of the  heart, sleeplessness, and  cerebral
erethism.   Here the remedy was Coft'ea ; a few doses of a
low7er  attenuation promptly arrested  the  cardiac excitation
after  it had continued  a week, notwithstanding the  use of
morphine and other anodynes.
  The emotions of grief, sorrow7, anxiety, expectation, discon-
tent, melancholy, despair,  remorse,  fear, fright, horror, and
astonishment, all stimulate chiefly the accelerator nerve and
quicken the heart's action, while they decrease the force of its
contractions.  Of these, grief, fright, terror, expectation, anx-
iety, and fear have caused death, from cardiac paralysis.  The
heart  in such cases is found relaxed, flaccid, and its cavities
uncontracted. Of medicines, Aconite, Arsenic, Calabar, Chlo-
ral, Cimicifuga, Crotalus, Gelseminum, Iberis, Lachesis, Phos-
phoric acid, Platina, Veratrum album, and Veratrum viride
irritate the accelerator nerve, and weaken the heart.  Of
these  Aconite, Calabar, Chloral, Lachesis, and Crotalus, are
capable of causing sudden death from cardiac paralysis. 
228
APPENDIX.
  It Avould not be proper in a paper of this scope to give the
special indications f<s>r each remedy.   Such indications are to
be found in our text-books  on  materia medica.   I will, how-
ever, give

                 s   TWO TYPICAL CASES

as illustrative of the effect of medicines in the treatment of
cardiac weakness.
  A weakly young man, at the time of the great fire, awoke
suddenly to  find his  room in flames, and no apparent means
of escape.  He was  seized  with an  overwhelming terror,
which caused profound syncope, and he was taken from  the
floor of his room apparently more dead than alive.  It was
many hours  before he  rallied from  the  shock, and then  his
mind and body both appeared hopelessly enfeebled.  When I
first  saw him, it was several weeks  after that fearful night,
but his face still wore a look of settled fright, mingled wTith
terror.   His  skin w7as cold and clammy.  Any reference to
the fire caused a cold sweat to break out on his forehead and
hands.   His pulse was small, weak, and  quick, the heart's
action feeble, quick, and incomplete.  His appetite was quite
good, and there Avas  no particular abnormal condition of the
digestive system.  Here was a  case that called for Aconite,
and a few small doses restored him to  health in a very short
time.
  A young and blooming farmer's daughter met with a severe
disappointment in her affections.  Her lover left for parts  un-
known.  Weeks and months passed and no tidings.  She did
not weep, or make any outward demonstrations of grief, but
her color faded, her  plumpness disappeared, the  extremities
became cold, a dry, hacking cough  set in, her breathing be-
came shallow, dyspnoea occurred on the slightest exercise, and
her mind became obtuse.  She seemed all  the time brooding
over her  sorrow, but no sighs or tears escaped her.  She  ate
wrhen food was  set before her, but expressed no desire  for
anything but to be allowed to be alone.  The heart beat fee-
bly and quick, and the  pulse was almost imperceptible.
  You will all recognize this as a case calling for Phosphoric
acid, w7hose deepseated  and profound depressing effect on the
nervous life of the heart made  it  the specific remedy in  this 
  TREATMENT OF EMOTIONAL DISEASES OF THE HEART.   229

case.  A few drops of the  third attenuation in water, three
times a  day, removed all the physical symptoms in a  few
weeks, and even the mental condition became more hopeful.
After the medicine had nearly restored her, her recreant lover
returned and finished the cure.
  I ought to mention another class of remedial agents whose
action appears  to be soothing and  calming to both sets of
nerves above mentioned.  They are Ambra,  Castoreum, Asa-
fcetida, Cocoa,  Scutellaria,  Guarana, Cypripedium, Valerian,
and Zinc.
                 STRENGTH OF THE  HEART.
  Before we  pass to the  hygienic treatment of the disorders
herein mentioned, we may as well try and answer the  perti-
nent question,  AVhy is it  that the heart is affected abnor-
mally by the  emotions ?   The heart, in its normal  state,
should have the same relative strength possessed by the gen-
eral muscular system.  It is the systematic  use, and not the
irritation, of a  muscle, that gives it strength and endurance.
That  great muscle constituting the heart can, under proper
use, become one of the strongest in the human body.   But it
requires, to make it strong, plenty of fresh air, free from  car-
bonic acid;  regular, active exercise ; at least eight hoars of
good  sleep, and the avoidance of alcoholic stimulants, impure
tea and coffee, tobacco, narcotics, an abuse1 of the passions, all
the depressing  emotions, and even an excess of those w7hich
are exhilarating.   How many American  men and women in
this year of Our Lord live up to these requirements?
  Generally the foundation for cardiac debility is laid early.
Beginning in infancy the young child is  improperly dressed
and improperly fed.  It is allowed unnatural condiments  and
food before it should be weaned from  milk and bread.  It is
placed in schools, and its tender brain  crammed with the rub-
bish of dead languages, wdien it ought to be in the fields or
gardens gathering flowers; or romping in untrammelled free-
dom.  Of all persons

               THE  WOMEN OF THIS COUNTRY

grow  up with the weakest muscular structure, and consequently
the weakest hearts.   Place your finger on the pulse of the aver- 
230
APPENDIX.
age school-girl attending a fashionable seminary or academy, or
the ordinary woman of fashion, you will find her pulse small,
soft (or wiry) and very unequal.  Her heart beats in the same
manner, unless she is under the influence of some abnormal ex-
citement.  Her extremities are cold and blue, and a general lan-
guor pervades the w7hole body.  What has brought all this
about?  From childhood she has lived in  hot, close  rooms, in
an atmosphere containing a large percentage of carbonic acid.
She eats but little meat, milk, or bread, but largely of cake,
preserves,  confectionery, and other improper nick-nacks.  She
reads trashy  novels, every page of  which calls up  emotions
and  passions  which excite her mind and brain.  The heart
becomes weak and irritable, and in  time  it acts unfavorably
upon the brain, rendering it excitable and susceptible to the
very emotions most injurious to its  integrity and vitality.
  Compare this  picture with that of the robust and healthy
school-girl in  the country, or village, or a woman in any posi-
tion in life, whose physical training has had  in it some ele-
ment of common sense.  Or, wre will say, some servant girl of
Irish,  Scotch, or English descent, or an American farmer's
daughter  w7ho is not  too proud to work.  How firmly the
pulse of such a  person  beats  under the finger!  It seems to
lift and throb with a strong vitality, and its  rhythm is like
the steady step of a trained soldier.   We know that the heart
which thus sends the  blood into the arteries is strong, endur-
ing, and full of vitality.
  The above pictures are applicable to  men  and  women of
all ages and conditions in life.  The former class are suscep-
tible to the malign influence of emotions which would not
affect the  latter  abnormally.   The healthy heart, strong and
steady, is  not affected unpleasantly or provoked to disordered
or painful action any more than the trained pedestrian is af-
fected unpleasantly by a walk of a few squares.
  In conclusion, allow me to assert that we ought to teach
that the heart, as well as the brain, or the muscular system
in general, requires regular, systematic exercise and training,
in order that it may have ordinary  immunity  from abnormal
emotional influences. 
RELATION OF SUDDEN DEATH TO  CARDIAC DISEASES.  231
    ON THE RELATION OP SUDDEN  DEATH TO CARDIAC
                        DISEASES.

  Popular fallacies are not confined to the public.   Certain
fallacious ideas  concerning special  subjects become  popular
with and gain advantage in the various professions.
  For  example, there are certain  popular medical fallacies
which cling to the medical profession as well as to the people;
and, although the best authorities on medical topics announce
repeatedly the erroneousness of such belief, they retain their
hold on  the  popular and  professional  mind with a singular
pertinacity.  For this state of things a portion of the medical
profession is  to blame.  Some physicians are prone to pander
to popular and vulgar beliefs, however  groundless  they may
be. We all know how dangerous it is for the young physician,
or one w7ho has not gained for himself a position as an author-
ity, to set up his opinion against that of the  masses, or even
the dictum of an ignorant but dogmatic nurse.  For these, and
many other reasons, certain opinions relating to sudden death,
not supported by absolute  proof, are very prevalent, much to
the detriment of true science.
   It is my purpose in  this paper to allude to but one of these
popular  fallacies, and solely for the purpose of disabusing the
popular  mind of its supposed truth.   I refer to the prevalent
idea that sudden death is  generally caused by some form of
disease of the heart.
   It is the habit of the public, when a case of  sudden death
occurs, not directly traceable to some acute disease, and when
the immediate cause is not perceptible to the senses, to ascribe
such sudden dissolution to disease of the heart.   In the popu-
lar mind, but few other causes are sufficiently potent to pro-
duce rapid dissolution of  life in a man in apparent health, or
even during  the progress of known chronic  disease.  With
physicians, who should be peculiarly careful as to an opinion
in such grave cases, the same habit of ascribing to cardiac dis-
ease all sudden deaths which they cannot immediately account
for is altogether too prevalent. 
232                     APPENDIX.

  In fact, heart disease is too often made the scapegoat upon
which is loaded the results of ignorance and insufficient inves-
tigation.   Let a man fall dead in the crowded street, or at his
own table, or be found dead in his bed, and the physician w7ho
is called  in  seems to have no hesitation, in the majority of
cases, to  ascribe the cause of this sudden death to heart dis-
ease.  The alleged cause is then proclaimed in the papers, and
as such it is reported to the Board of Health, and thus placed
upon the records.
  What  grounds had the physician for giving such an opinion ?
Was he conversant with the history of the deceased?  Did he
make a post-mortem examination.
  In the great majority of instances  no adequate  inquiry is
made concerning  the history of the patient, and in but very
few cases is any post-mortem examination made. The  opinion
is given because it is the easiest made, is the most plausible,
and one with which the family are best satisfied.  I do not
hesitate to say that such an opinion, unless  based on positive
knowledge, is  a subterfuge of ignorance and indolence, and a
disgrace  and reproach to the medical profession.
  And it is more than this.  It is  a positive  injury to the
health and happiness of the people, especially those who are
connected with the victims of sudden  death ;  and actually
endangering the lives of those who suffer from cardiac diseases.
  To the former class the dread of a similar unheralded and
sudden death becomes  a nameless horror which haunts them
all through life, and nothing is more difficult for the physician
than to treat that class of sufferers.   A slight  illness is sure
to be accompanied by mental depression, attended  by such a
dread as to render their lives miserable in the extreme.
  I propose, in order to establish the above assertions, to take
up and consider briefly the principal diseases of the heart, and
their liability  to cause  the accident of sudden death.
  Beginning with the  inflammatory diseases, let us  inquire
into the  circumstances under which  death occurs.  Is it sud-
den?  On the contrary, dissolution is usually attended by pro-
longed suffering, a gradual failure of the heart's vitality, and
an unmistakable struggle.  Only in  rare instances, and those
readily avoidable, does a sudden death carry oft'the patient.
   In pericarditis,  paralysis of the heart may sometimes occur 
    RELATION  OF SUDDEN DEATH TO CARDIAC DISEASES.  233

suddenly, and to a certain extent, unexpectedly, as w7hen the
patient, through carelessness of orders, or the inattention of
attendants, makes some violent and sudden motion.
  In  endocarditis, the danger of sudden death is still less,
indeed, it  rarely occurs, unless  the  muscular  structure  is
involved,  when cardiac  syncope, w7ith sudden  arrest of cir-
culation, may occur from imprudent  exertion or ineffectual
treatment.
  Next in order are the functional disorders  of the heart, in
which it does  not seem possible, nor is it probable, that sud-
den death could occur through any fault of that organ.  Even
in angina pectoris, not due to organic disease, when the agony
is fearful  and  the collapse great,  sudden dissolution is the
rarest of incidents.
  Even granting that death may sometimes occur from the
shock, as it is  termed—for it is well known that in certain
debilitated constitutions  pain  alone, by its intensity and se-
verity, may destroy  vitality  very rapidly—how are we to
know  absolutely that the pain  in the  heart caused death?
There are other thoracic pains which are fully equal in  inten-
sity to cardiac neuralgia.  It has been supposed that there are
such conditions of functional disorder of the heart as choreic
convulsion, tetanic spasm, irregular contraction, and the like,
wiiich might  cause rapid dissolution.   But this is not fully
proven.  The  heart  is often  found rigidly contracted  after
death, but this is generally rigor mortis, and not a true patho-
logical state, occurring previous to death.
  Right here  I would like to demolish one of the most com-
mon of the popular  fallacies  relating to the heart, namely,
that it is a  delicate organ  whose  vitality is easily destroyed.  On
the contrary  the heart  is more tenacious  of life than aiiy
organ  in the  body.   It will go on w7ith its  work when all
other organs have lost their integrity,  or when its own integ-
rity is impaired to a  degree that  seems wholly incompatible
with its own vitality. It will even go  on beating w7hen  taken
out of the body, and  after it has  ceased to  beat for hours, it
may be irritated by electricity or galvanism, and commence
beating again, from a strange latent vitality.  The wonderful
tenacity of life possessed by the  heart is best seen in those 
234
APPENDIX.
organic or  structural diseases in which great and important
changes have taken place in its walls or valves.
  The walls of the heart may become so thick that the organ
becomes monstrous in weight, or so thin that they are atten-
uated to the last degree.  In  the former (hypertrophy from
enlargement), death rarely occurs suddenly from the immedi-
ate consequences of the enlargement.  If the patient should
be of apoplectic habit, the enlargement might aid in  bringing
about an attack, but the resulting death  could not  properly
be said to be due to the cardiac disease.
  In the latter (hypertrophy by dilatation) death  does some-
times occur suddenly, not unexpectedly  by any means, but
from sudden paralysis or rupture of the attenuated  muscles.
But nothing more astonishes the physician who sees much of
cardiac disease than  the length of time patients live with at-
tenuated hearts, and the exertions they will undergo, neces-
sary and unnecessary, without suddenly destroying  the mo-
tive power of this wonderful organ.
  It would seem that so long as  there exists sufficient muscu-
lar fibre to force the blood out of the ventricles, the heart will
go on beating  in spite of all our predictions to the  contrary.
   Valvular diseases of the heart are rarely the immediate cause
of death, and  still more rarely do they cause sudden death.
Prof. Tully likens the heart to  a force  pump, and  observes
that " it may be a very poor heart, but a pretty good pump."
In  other words, it will keep  up the  circulation of the blood
long after its machinery  is  greatly deranged.   Death  from
valvular disease occurs from  the arrest of function  in other
organs, namely, the kidneys, lungs or brain, or from the de-
posit of emboli in importaut arterial  trunks.  In  only one or
two instances can sudden death  result.   An embolus may
plug a cerebral artery, thus cutting off the supply of blood to
the brain and cause sudden and fatal coma and paralysis, or it
may obstruct one of the great arteries leading from the heart.
What are  sometimes called polypi of the heart  are of this
nature, large fibrinous masses, which sometimes  completely
fill one of the heart's cavities, causing sudden arrest of its con-
tractions.
  Prof. Meigs, in his treatise on obstetrics, mentions this lia-
bility to the formation of fibrinous clots within  the  heart, 
   RELATION OF SUDDEN DEATH  TO CARDIAC  DISEASES.  235

especially during the puerperal state, when from loss of blood
the circulation  becomes so enfeebled that the blood accumu-
lates and  stagnates in  the cavities.  This author accounts in
this way for the cases of sudden death after  childbirth, and
during syncope, induced by assuming suddenly the erect pos-
ture after profuse hemorrhages.
  One of the most common causes of sudden death is rupture
of the  heart, but this accident is of very rare occurrence.   It
usually  occurs  from softening, or fatty degeneration; from
abscesses or ulcerative perforation, or from aneurism or atten-
uation of the walls of the heart.  The immediate cause in such
cases  has  been  usually ascribed to great mental excitement,
anger, grief, or  to sudden physical exertion, but Dr. Hallowell
has collected thirty four cases of sudden death from  rupture of
the heart, and  it is a singular fact that in  the  large propor-
tion of  cases the patients were in a state of  repose when it
took place.
  Death generally follows the rupture almost instantaneously.
It is rare  that any struggle followrs the breakage of the walls.
  The common phrase, " died of a broken heart," is not a
mere  myth, as  some have asserted, for  rupture  of the heart-
walls, from sudden and overwhelming grief, has been known
to occur.
  In  fatty  degenerations, sudden death oftener occurs from
cardiac paralysis than from rupture. The muscular fibres are
so far replaced  by fat  that not enough  are left  to propel the
blood out of and contract the cavities.
  The fallacy of referring all cases of sudden death to disease
of the heart is well showm, if we consult any standard work
on pathology, where it will  be found that it may  be brought
about by  very many other conditions, namely, diseases of the
brain of  an apoplectic character; spinal and cerebro-spinal
congestion  and extravasation ; the  bursting  of internal ab-
scesses and aneurisms ; internal hemorrhages,  and even severe
mental shocks.  It may also be caused by the lightning-stroke,
excessive heat (sun-stroke, various injuries of an unknown
nature, the action of poisons like prussic acid, and the venom
of serpents.
   I will venture to  assert that if we could get trustworthy
statistics, the ratio of sudden deaths from heart disease, com- 
236                     APPENDIX.
pared with  those  arising from other causes, would  not  be
greater than three to ten!
  Xow, to briefly  recapitulate.  The causes of sudden death
from heart affections may be divided into three classes:
    I.  From paralysis of its muscular structure.
   II.  From rupture of its walls.
  III.  From mechanical  arrest of  its movements by clots,
polypi, etc.
  The instances of sudden and fatal cerebral or  pulmonary
apoplexy from  heart disease  are so  rare that we  may waive
their  consideration.   Sudden  paralysis can only occur from
excessive  attenuation of its walls, in debility from excessive
loss of blood, during convalescence  from typhus  or other en-
feebling diseases,  from  softening  or fatty degeneration,  or
during acute pericarditis.

                       TREATMENT.

  It comes properly  within the scope of this paper to suggest
the treatment of those cases where  the appearances indicate
that sudden death will  occur during the progress of cardiac
disease.   In cases of threatened paralysis,  from whatever
cause, the assistance must be prompt and energetic.   First of
all the patient must be placed in the  recumbent position, upon
a level bed or floor (the  head not elevated), and on the right
side, if on either.  Then we must immediately give the most
rapidly acting cardiac stimulant we possess.  Alcoholic spirits
will do, but I prefer the volatile Ammonia to all others.  The
aromatic spirits should be administered in suitable doses until
the pulse and heart-beats show that  the patient is out  of dan-
ger.   Xext to Ammonia, and more efficacious as a true reme-
dial agent, is Digitalis, in material doses.  If possible I gener-
ally give both remedies in rapid alternation.
  In such cases do not  be afraid of  Digitalis.  It is not the
depressing agent it was decreed to be by our predecessors, but
a true cardiac tonic, capable of saving life when all other med-
icines  are  useless.   Cases may occur, however, wThere Cam-
phor, Veratrum album, Veratrine, Gelseminium or Arsenicum
are the appropriate remedies.
  In rupture of the heart there is no time to use  medicinal 
           IRRITATION OF THE CARDIAC NERVES.        237

agents, even if they could be of value, for the death is as sud-
den as it is inevitable.   The same may be said of those me-
chanical impediments called polypi, heart-clots, and fibrinous
concretions.  The moment they form of sufficient size to block
up the great  arteries, or arrest  the cardiac contractions, no
human interference can save the victim.
  In conclusion, I feel called upon to declare that it is a duty
which physicians owe to themselves, to the profession, and to
the public, that they decline to give an opinion as to the cause
of sudden death, unless their previous knowledge of the patho-
logical condition of the deceased, or an actual post-mortem
examination of the body  enables them  to give a positive opin-
ion as to the cause of death.
  And it  is also the duty of the constituted authorities, the
members of the Board of Health, to refuse to receive reports
ascribing sudden death to heart disease,  or any other alleged
cause, unless they are fully satisfied that the physician has in-
vestigated  the condition  of the patient, before or after death,
in a competent and scientific manner.  The neglect of such an
evident duty, has often  resulted in the covering up of gross
ignorance or a terrible ciime


 COLLINSONIA IN IRRITATION OF THE  CARDIAC NERVES.

  Those physicians w7ho  are familiar with the  history of the
introduction of the Collinsonia  as a remedy, in the homoeo-
pathic school, are aware that  it was  first mentioned in the
first edition of New Remedies.  In the second  edition an ad-
ditional proving, by Dr.  Burt, w7as published, wdiich proving
verified many of the symptoms  previously given.  Mention
was also made of a discussion  before the Western Institute
of Homoeopathy, relative  to  its  use  in cardiac  affections.
Several physicians testified to its value  in disordered action
of the heart.
  On page 258 of New Remedies will be found a report of the
curative value of Collinsonia in a  case of pulmonary hemor-
rhage.  It is to be  regretted that the condition of the heart
and circulation was  not  mentioned, as it might have thrown
some light on its action in such cases.  Is it not probable that 
238
APPENDIX.
it assisted the hemorrhage by virtue of its homoeopa tin city to
irritation of the heart, with too great action ?
  Since the publication of New Remedies, in 18G7,much addi-
tional  experience with Collinsonia in cardiac  affections  has
been published, principally by the Eclectic  school, and some
valuable clinical observations by our own.
  The most valuable contribution to  the clinical history of
Collinsonia has  been from the pen of Dr.  M. M. Fenner, of
New York, and published in  the Proceedings of the New
York State Society (Eclectic).  He states that he has found
it most useful in that condition known as " irritation of the
cardiac nerves."
  " Every practitioner,"  he says, " is familiar with cases of
excited actions of the heart, that he  could not refer to  any
palpable cause.  It is common in  one's daily practice to meet
with perturbations in the rhythm of this great centre of the
circulation, but it is  usually not difficult  to find the offending
cause."
  The causes of this affection are derangements of the diges-
tive organs; abuse of stimulating liquors  and condiments;
derangements of the portal circulation ; excesses in  venery;
mental emotions; or any causes  which  impair the integrity
of nerve-tissue.
  The  Symptoms—Idiopathic cases of this  affection  may oc-
cur, in which the abnormally and  persistently increased action
of the heart may be all that may be discovered.
  But it is generally  a sympathetic affection, arising  from re-
flex irritation, transmitted from disorder of the stomach, lungs,
uterus, and other organs.
  The more common symptoms are  pressure in the praecordia,
a feeling of fulness in the chest or heart, or both.  Dr. Fen-
ner says it  is always—so far as he has observed it—periodical,
perhaps intermittingly so at first.  The pulse  beats  rapidly,
full, and strong, sometimes reaching as high as 140 beats  in a
minute, but more  often  about 120.   Generally, more or  less
of oppression and pain exists in  the chest,  sometimes with a
feeling of faintness.
  Any unusual stir,  or the appearance of strange faces,  will
usually increase the  rapidity of the pulse, and aggravate all
attendant symptoms  in  a marked manner.  So much is  this 
           IRRITATION OF THE CARDIAC NERVES.        239

the case that the patient will live in  constant dread of hear-
ing or seeing something new.  This condition is quite com-
mon in women suffering from spinal irritation or uterine dis-
order.
  After a full meal, the taking of stimulating drinks, or any
other circumstance calculated  to  excite vital action, all the
symptoms will become temporarily aggravated.   During sleep,
on the contrary, the patient  becomes  comparatively quiet,
with respect of cardiac  pulsations, until the  latter stages of
the disease, when even  in this state of repose he shows the
abnormal cardiac action.  The irregularly periodic action be-
comes a sustained effort.
  Thus the disease continues until the  sufferer is worn out
by the continued exalted action.   He becomes emaciated and
effeminate; distressingly sensitive to all external impressions.
There seems to be no tendency to spontaneous subsidence of
the symptoms, and recovery.   The disease once established,
from whatever cause, seems to  be self-sustaining, and contin-
ues, although the cause may disappear, until relief is obtained
by treatment, or  death claims  his victim from this  alone, or
the conjoined effects of this and some supervening disease.
  This affection  has yet hardly  a place in the established
nomenclature  of diseases.  Watson mentions  it  under the
head of " irregular action of the heart."  He says: " Besides
these over-strong or irregular movements, which are symptoms
of disorder of the stomach, there  are palpitations of a purely
nervous kind ; I mean they depend upon a peculiar and highly
sensitive condition of the nervous system."
  In Scudder's Practice (Eclectic) there is a section devoted
to " Excited Action of the Heart," and referred  to as a symp-
tom of: 1st. Derangement of  the circulation;  2d. Derange-
ments of contiguous viscera ; and 3d. Irritation of the cardiac
nerves.  Dr. Handfield Jones, in his excellent work on " Nerv-
ous Disorders," gives, under the head of "Cardiac Neurosis,"
a full  description of  this affection, illustrated by  numerous
cases.  He would call the disorder "Cardiac hyperesthesia."
He says:  "A common form of cardiac neurosis  is that when
the action of the heart is much accelerated, varying from 110
to 140 in the minute  in the standing position, and not falling
much below the former figure in the sitting.   The contrac-
                            16 
240
APPENDIX.
tions are abnormally sharp  and vivid; the organ  seems to
spring up with  a  quick, forcible leap against the ribs.  The
apparent excess  of action misleads the practitioner sometimes
to suppose that  there is hypertrophy.  Percussion,  however,
showrs that no enlargement exists, and auscultation detects no
vascular bruits,  nor derangement of the rhythm.  The feeble
stroke of the radial pulse often contrasts markedly with the
vivid action of the heart.  The general condition of the pa-
tient exhibits, more or less, indications of debility."  Dr. Jones
considers the excessive use of tea to be the principal cause of
this condition.
  My own experience in this  affection has satisfied me that it
often has its origin in spinal irritation, either reflex or idio-
pathic.   It may have a rheumatic origin, in  wrhich  case it
might be called  a " rheumatic neurosis."
  According to  Bezold,  the  nervous  centre of the cardiac
movements furnishing three-fourths of the entire propulsive
force of the heart, occupies  the cervical region of the cord,
including the  medulla oblongata, and extends  as low as the
fourth dorsal vertebra.   Its  fibres  run through the cervical
spinal  cord, and pass out between the seventh cervical and
fifth  dorsal vertebra, probably passing through  the  lower
cervical and upper dorsal sympathetic ganglia and proceeding
to the heart.   If we suppose a rheumatic disorder, assuming
the form of intercostal neuralgia, it is not difficult to under-
stand how, by extending backwards and involving the origins
of the upper dorsal nerves, it might induce  a rheumatic neu-
rosis of the cardiac nerves, resulting in hyperaesthesia.
  I have often found in cases of excited action of the heart a
tenderness of one or more of  the cervical or dorsal vertebrae,
or a tender spot  on one side or the other of the spine.

                       TREATMENT.
  Before proceeding to the examination of the value of Col-
linsonia in this affection, we  will make some inquiry into the
treatment usually adopted.
  Handfield Jones, who may be considered the best Allopathic
authority, says:  "The treatment of cardiac hyperaesthesia is
too often unsatisfactory, probably because  it is impossible to
obtain rest for the organ.  An irritable brain or stomach may 
           IRRITATION  OF THE  CARDIAC NERVES.        24l

be soothed by giving them timely repose, but we can do this
but very partially with the heart.  Belladonna  plasters  are
generally useful.   Internally, I  have seen  most benefit from
tinctura digitalis, fifteen  minims  a day, but I am  not alto-
gether satisfied how far it is  quite safe to give  this drug in
states of cardiac excitement.  In conditions of cardiac languor
I have no fear of it, but in the  opposite I think we must be
cautious."
  [Digitalis is doubtless homoeopathic to cardiac  hyperaesthe-
sia, but only when it depends on a secondary condition char-
acterized by loss of tonicity.   In  this condition it may be
given in the lower dilutions with success.]
  Dr. Jones also  suggests Opium,  Nitrate of Silver, Aconite,
and Hydrocyanic acid.   In  another place he says  all nerve-
tonics tend to decrease and strengthen the action of an excited
and weak  heart.  This is doubtless the case, owing  to  the
fact that primarily all tonics increase and excite the action
of the heart to an abnormal  degree, while  secondarily they
cause an irritable and weak condition of that organ.
  Various  remedies have been recommended and used success-
fully for this  condition.  Iron, especially the iodide of iron,
has been found useful.  The bark of the wild cherry {Prunus
v.) has a specific effect on the heart, especially when its action
is rapid, weak, and irregular.   Lycopus virginicus is useful
in moderating excessive action, and will probably be found
curative in cardiac diseases, with exophthalmia.
  Dr. Fenner, above quoted,  says the specific remedies for
this  condition are Cactus grandiflorus, in doses of 10 to  20
drops of the tincture three or four times a  day (he  acknowl-
edges that he gets his information from homoeopathic sources).
Pulsatilla,  Collinsonia, and Lobelia in  non-nauseating doses,
are also claimed to possess specific powers over cardiac irrita-
tion.
  The homoeopathic  treatment of irritation of  the cardiac
nerves has never been fully elucidated, nor the specific indi-
cations given for the use of  our remedies.  It is obvious that
we must be guided by the pathological condition, as well as
by the  totality of symptoms, modified  by those characteristic
indications which are sometimes so useful in practice.
  A careful study of the heart symptoms given in the Reper- 
242
APPENDIX.
lory to Jahr's Materia Jledica, will afford a comparative analy-
sis of the remedies we have at our command.
  It is probable that all those medicines included in the Aco-
nite  group, viz.: Gelseminum,  Veratrum  viride, Veratrum
alb., and Cactus grand., are in many cases homoeopathic to
this  malady.  Digitalis, Hydrocyanic acid, Kalmia, Lauroce-
rasus, Prunus, Thea, Tabacum, may  each be found useful  if
we select them with  a full knowledge of their  pathological
action.
  My experience leads me to  prefer Cactus, Digitalis, Lyco-
podium,and Collinsonia as being most generally useful in this
complaint.
  Digitalis has succeeded best in  my hands when the exces-
sive  excitement was  an idiopathic  affection consequent  on
nervous depression secondary to some excitement; or was the
result of previous inflammatory  action in the system  which
left the heart itself in a debilitated condition, or hypertrophy
with thinning of the walls ; or was caused by loss of fluids, or
was present in convalescence from acute disease.
  Cactus is most useful in affections of the motor and sensory
nerves; when the increased action alternates with spasms of
the tissues of the heart, and congestions of the head and chest
occur as complications or results.
  Collinsonia, although  it  has  been of great value to me in
this  disorder, has not been  sufficiently subjected to physio-
logical experiments on the healthy to enable us to explain its
method of action.  It is a little strange that Dr. Burt did not
observe any cardiac symptoms ;  nor  have those patients who
have been treated by  large  doses observed  any derangement
of the heart.  It may be that it should be proven in the higher
potencies in order to bring out these cardiac symptoms which
certainly appear to belong to it, if we can judge  by its cura-
tive action.
  Dr. Fenner says : " I have tried as  yet only the Collinsonia,
not having had occasion  to go beyond this agent for the re-
lief of this affection.   In every instance in which I have used
it improvement has followed its administration."  He gives it
in closes of 10 to 30 drops every three  or four hours, if the case
demands.  I have not found it necessary to use  more than 5 
           IRRITATION OF  THE CARDIAC NERVES.        243

or 10 drops  of  the  first  decimal dilution.  The  symptoms
cured by Dr. Fenner are these:
  Periodical  spells of faintness and oppression.
  Pulse 140 per  minute, steady and quick.
  Attacks of syncope, with fulness of the chest and difficulty
of breathing.
  The slightest emotion or excitement of any kind would ag-
gravate the symptoms.
  Pulse very strong, 128 per minute, and intermittent.
  Severe attacks of dyspnoea, with great weakness.
  We shall not venture  to theorize on the probable method
of action of this remedy, but  it will  do no harm to place be-
fore the physician some facts relating to its effects on disease.
  I.  It relieves headaches  consequent on suppressed haemor-
rhoidal discharges—at least under its action the hemorrhoids
return and the headache disappears.
  II.  In preliminary  hemorrhages the Collinsonia arrests the
bleeding, but brings back the  haemorrhoids which existed be-
fore the hemorrhage.
  III. In cardiac disorders, such as palpitation, irregular ac-
tion, and excessive action,  this remedy relieves ; but under its
action haemorrhoids appear, or  a  suppressed menstrual  flow7
returns.
  These three facts seem to show that the reflex action on
the nerves controlling the circulation are in  some way con-
trolled by Collinsonia in a  remarkable degree.
  The symptoms existing between congestion of the pelvic
viscera and the heart, are always worthy our attention.   Col-
linsonia is not inferior to any  remedy when this complication
obtains.   In  such cases it is the rival of Aloes, JEsculus, Nux
vomica, and Sulphur. 
 
INDEX.
Anatomical peculiarities of the heart, 20
Anxiety, effects of, 31
Anaemia, functional disorders from, 44
             treatment,  51
Angina pectoris, 56
        nature of, 56
        symptoms of,  56
        pathology, 58
        prognosis, 59
        diagnosis, 59
        treatment, 59
Atrophy of the heart,  166
             symptoms,  166
             treatment,  166
Aneurism of the heart, 174
Aortic valvular lesions,  176
             symptoms,  178
             pulse in,  179
             palpitation in, 178
Arsenicum in fatty degeneration, 172
     in endocarditis,  108
     in pericarditis, 84
     in angina pectoris, 62
Aconite in angina pectoris, 63
     in pericarditis, 82
     in endocarditis, 106
     in hypertrophy, 154, 131
Asthma, cardiac, 185
Asclepias in  pericarditis, 84
Apocynum andro. in pericarditis,  110
Alkaline treatment in  pericarditis, 93
Aortic valvular lesions, physical signs, 193
             diagnosis, 201
             treatment,  203
Apoplexy, from valvular disease, 188
Acids, mineral uses of, 164
Ammonia, in cardiac syncope, 51
         in angina pectoris, 60
         in endocarditis, 112
     benzoate of, 205
Blood, circulation in the heart, 21
Broken heart, 174, 31
Bright's disease, 191
        a cause of pericarditis, 70
Bronchitis, 186
Bromide of ammonia, 51
        in fatty heart,  172  _
Brain symptoms in pericarditis, 75
Bryonia in pericarditis, 84
        in endocarditis, 107
Baptisia in endocarditis, 111
Belladonna in endocarditis, 107
Circulation of the blood in the heart, 33, 21
Coronary vessels of the heart, 21
Coffee, functional disorders from, 45
Cardiac aneurism, 174
    asthma, 205
    dropsy, 183, 191
    murmurs, 193
    syncope, 51
    irritability, 52
Chloral hydrate, 61, 54
Chloroform, 60
Cough in heart disease, 74
Cactus in pericarditis, 91
    in endocarditis, 111
    in hypertrophy, 135
Cimicifuga in angina pectoris, 63
         in endocarditis, 111
         in hypertrophy, 162
         in functional disorder,  52
Collinsonia in cardiac irritation, 52
China in hypertrophy, 163,  139
Coronary vessels of the heart, 21
Camphor in cardiac syncope, 51
Cuprum met. in fatty heart,  172
         in anaemia, 52
    acet. in endocarditis, 110
Colchicum in pericarditis, 90
         in endocarditis, 107
Cannabis in endocarditis, 92
Concentric hypertrophy, 120
Calcareous deposits in valves, 177
Circulation in pericarditis, 73
Diseases of the heart, increased frequency,
  19
Disappointed love, effects of, 31
Despair, effects of, 31
Dyspepsia, functional disorders from, 45
             treatment. 53
Differential diagnosis of valvular lesions,
  199
Dropsy of the heart,  191, 68
    from heart disease, 183, 205, 190
Dyspnoea, 185
Digitalis in angina pectoris, 62, 60
    in pericarditis, 85
    in endocarditis,  107
    in hypertrophy,  156, 133
Diastolic murmurs, 199
Dose, law of, 101
Diet in pericarditis, 94
    fatty heart, 171
Diagnosis of angina  pectoris, 59 
246
INDEX.
Diagnosis of aortic valvular lesion, 201
    differential of valvular lesions, 199
    endocarditis, 104
    functional disorders, 48
    fatty degeneration, 169
    hypertrophy with  dilatation, 151
    mitral valvular lesions, 200
    myocarditis, 113
    pericarditis, 79
    aortic lesions, 201
Dilatation of the heart, 143
    mechanism of, 144
Emotions, effect of, on the heart, 31
Endocarditis, 96
    anatomical characters, 96
    definition,  96
    causes.  99
    pathological relations, 9D
        results, 100
        symptoms, 101
    physical signs,  102
    diagnosis, 104
    prognosis,  105
    treatment,  106-113
Embolism,  184
External applications in pericarditis, 95
Enlargement of the heart, 117
    by hypertrophy, 120
    by dilatation, 143
Electrization in  angina pectoris, 61
Expectoration in valvular disease, 204


Functions of the heart, 19
Fear,  effects of, 31
Functional disorders of, 42
        causes of, 44
        physical signs in, 47
        diagnosis of, 48
        prognosis,  50
        treatment, 50
        case of,  53
Fatty heart, 167
    degeneration of, 167
    causes of, 168
    symptoms of, 168
    pathological  effects of,. 168
    physical signs, 169
    diagnosis,  169
    treatment, 170
Ferrum in anaemia, 51
    in hypertrophy, 140
Ferrocyanuret, 160
Grief, effects of, 31
Gouty diathesis, 45
Gelseminum in pericarditis, 90
    in hypertrophy, 155, 131
Haemoptysis, 186
Headache from valvular diseases, 205, 188
Hepatic disease, 189
Hemorrhage from the lungs, 186
Heart, valvular diseases of, 176
    wounds of, 175
Heart, rupture of, 174
     wonders of, 19
    anatomical peculiarities of, 20
    functions of, 19
    increased frequency of diseases of, 19
    circulation of the blood in, 21
    innervation of, 24,
    nervous system of,  25
    coronary vessels of, 21
    irritability of, 24
    when does it begin to beat, 26
    physical power of, 29
    psychological relations of, 30
    relations of mind to, 30
    effect of emotions on,  31
    broken, 174,  31
    terrors, effects of, 31
    location of, 84
    normal sounds of, 36
    normal dulness, where found, 35
    sounds of, 37
    abnormal sounds of, 38
    its relations to adjacent organs,  35
    functional disorders of, 42
             causes of, 44
    inordinate action of, 43
    irregular and tumultuous action, 43
    intermittent  action, 43
    inflammatory affections of,  67
    walls, lesions of, 166
    fatty, 167
        degeneration of, 167
    atrophy of, 166
    softening of,  173
    induration of, 174
    aneurism of,  174
Hope, effects of,  31
Heart, effects of the will on, 32
Hypertrophy, with enlargement, 120
             pathology, 121
             symptoms, 125
             causes. 124
             pathological  effects, 125
             physical signs of, 126
             treatment, 128-141
      with dilatation, 144
             definition of, 144
             pathology, 144
             mechanism, 144
             symptoms, 147
             causes, 145
             pathological effects, 148
             physical signs, 149
             diagnosis,  151
             treatment, 152-165
Hydrocyanic acid in hypertrophy, 135, 158
Hypophosphites in functional disorders, 52
Hydrastis in hypertrophy, 162
Innervation of the heart, 24
Irritability of the heart, 24
Inflammatory affections of the heart, 67
Induration of the heart, 174
Iodide of potassium in pericarditis, 93
Ignatia in hypertrophy, 139-162
Irregular and tumultuous action, 43
Intermittent action, 43
Ice in angina pectoris, 61 
INDEX.
247
Joy, effects of, 31
Jaundice,  189
Kidney, diseases of. 191
Kalmia in pericarditis, 91
Love, effects of, 31
Lesions of walls of the heart. 166
    of the tricuspid valves, 202
    of the pulmonic valves, 202
Liver,  diseases of. 189
Lungs, disease of, 184
    hemorrhage  from, 186
    oedema of, 186
Lycopus,  160, 55
Lachesis in angina pectoris, 63
         endocarditis. 109
Lactic acid, a cause of endocarditis,'100
Lobelia in hypertrophy,  155, 133
Location of the heart, 33
Law of dose,  131
Mind and heart, relations of, 30
Mitral valvular lesions, 177
             symptoms, 178
             pulse in.  179
             physical signs, 200
             diagnosis. 200
             treatment, 203
Mineral acids in heart disease, 167
Murmurs, cardiac, 193
    systolic, 199
    diastolic, 199
Mechanism  of dilatation  of the heart, 144
Medicines, primary and secondary action
       of.  130
    repetition of, 136
Myocarditis. 112
    diagnosis. 113
    treatment, 113
Nervous system of the heart, 25
Nux moschata, 54
    vomica in hypertrophy, 161, 136
Normal sounds of the heart. 36
    dulness where found. 35
Nitrum in pericarditis. 89
Naja in angina pectoris.  63
Nutrition of the heart, 21
Organic diseases of the heart, 117
03dema,  pulmonary, 186


Pathology of angina pectoris, 58
    endocarditis, 99
    fatty heart. 168
    hypertrophy, with enlargement, 125
             dilatation,  144, 148
    pericarditis, 69
Prognosis in angina pectoris, 59
    in endocarditis, 105
    in functional disorders, 50
Prognosis in pericarditis, 80
Physical signs in aortic valvular lesions, 193
         in endocarditis, 102
         in functional disorders, 47
         in fatty heart,  169
         in  hypertrophy,  with  enlarge-
               ment, 126
             dilatation, 149
         in mitral valvular lesions,  200
         in pericarditis. 77
         in softening, 173
    power of the heart,  29
Psychological relation of the heart, 30
Plethora, functional disorder from,  44
             treatment  of, 51
Pericarditis.  68
    anatomical characters, 68
    morbid changes in,  68
    causes of, 69
    pathological relations of, 69
    symptoms of, 70
    pulse in, 73
    circulation in, 73
    respiratory symptoms, 73
    gastric symptoms, 74
    cough in, 74
    nervous symptoms in, 75
    physical signs, 77
    diagnosis, 79
    prognosis, 80
    treatment, 95, 81
Pulmonic valves, lesions of, 202
Palpitation of the heart, 50. 51
             treatment  of. 52
         hysterical, treatment of. 53
Prunus Virg., 159, 54
Phosphorus in endocarditis, 108
Plumbum in hypertrophy. 141
         in fatty degeneration,  172
Phytolacca in fatty degeneration, 172
         in endocarditis.  112
Phosphorus in endocarditis, 172
Palpitation in aortic valvular lesions,  178
Pyaemia a cause of pericarditis. 71
Pulmonary oedema in valvular disease, 186
Pulse in pericarditis, 73
    in aortic and mitral lesions. 179
Primary and secondary effects of drugs, 131
Purring tremor, 200
Position in pericarditis, 74
Rage, effects of, 31
Rupture of the heart, 174
         death of Christ from, 174
Rhus tox in angina pectoris, 63
Rheumatism a cause of pericarditis, 71
              endocarditis. 99
Recapitulation of the remedies in  pericar-
  ditis,  94
Repetition of medicines, 136
Simpson, J. Y , on rupture of the heart, 173
Swedenborg on the heart.  22
Softening of the heart. 173
        symptoms,  173
        physical signs. 173
        treatment,  173 
248
INDEX.
Sleep, in valvular disease,  188
Syncope, cardiac,  51
Sanguinaria in irritable heart, 58
    in endocarditis, 112
Spigelia in angina pectoris, 63
    in pericarditis, 88
    in endocarditis, 108
Squilla in cardiac dropsy, 205
Systolic murmurs, 199
Sulphuric acid in Bright's  disease, 205
Scutellaria in functional disorders, 50
Sudden death in angina pectoris, 59
Sulphur in pericarditis, 92
Secondary action of medicines, 131.
Structural diseases of,the heart, 118
Terror, effect of. 31
Tobacco, functional disorders from, 45
Tea, functional disorder from, 45
Tricuspid valves, lesions of,  202
Tartar emetic in pericarditis, 91
Tremor, purring, 200
Urine, treatment, 53
Uraemia a oause of pericarditis,  71
Valvular diseases of the heart, 176
             aortio, 177
             mitral, 177
        their differential  diagnosis, 199
        nervous  symptoms, 187
Venous pulsation, 182
    turgescence,  182
Veratrum viride in plethora, 51
        in perioarditis, 90
        in hypertrophy, 155, 131
        in functional disorder, 50
Veratrum album  in hypertrophy, 155, 132
Wonders of the heart,  19
Will, effeots of on the heart,  32
Walls of the heart, lesions of, 166
Wounds  of the heart, 175
Whence comes oardiac innervation, 46
Xanthoxyllura in cardiac syncope, 51
Uterine  disorders,   functional  disorders
  from, 45 
 
 
 
 
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