Hypertrophy of the Heart.
Definition.—Hypertrophy of the heart is an enlargement of the organ, due to an increase in the volume of its muscular fibers, and usually also to dilatation of its cavities.
Etiology.—Hypertrophy of the heart is governed by the same law that applies to all development; namely, that size, strength, and activity of an organ depend upon its power and continued use. Increased activity gives increased development, whether of the biceps, the lung, or the heart.
The causes giving rise to the necessity for increased work are many, but may be divided into three classes: (a) Those that give rise to idiopathic hypertrophy; (b) those due to changes in the heart itself; (c) abnormal condition of the arteries.
Primary Idiopathic Hypertrophy.—This may occur from prolonged or prodigious physical exertion, as witnessed in athletes, bridge-builders, iron-workers, blacksmiths, etc. Mental excitation, where it is continued for a long time, as in some forms of hysteria, or the mental strain that keeps the patient keyed up to the highest tension, as in some forms of business, calls for over-activity of the heart and favors hypertrophy.
The excitation of the heart induced by drinking tea, coffee, and alcohol, also favors this condition. The increased expenditure of force from an overdistention of the blood-vessels by drinking large quantities of fluids, notably beer, is not to be overlooked as an exciting cause.
Lesions of the Heart.—By far the greater number of cases of cardiac hypertrophies, however, are due to endocardial changes affecting the valves or orifices of the heart. Just in proportion to the obstruction, is the heart called upon to do increased work, and the increased development is nature's method of prolonging the life of the individual.
Hypertrophy of the left ventricle is due to aortic insufficiency or aortic stenosis, also mitral insufficiency; while hypertrophy of the right ventricle is due to mitral stenosis and pulmonary obstruction. Hypertrophy of the left auricle follows mitral stenosis, and the right auricle will hypertrophy when there is tricuspid insufficiency.
Pericardial adhesions may give rise to hypertrophy as well as myocarditis. Bronchitis, empyemia, pleural adhesions, and, in fact, any respiratory disease that gives to obstructed pulmonary circulation, will cause hypertrophy of the right heart.
Disease of the Blood-Vessels.—General arteriosclerosis, or sclerosis of the aorta, would give rise to hypertrophy, likewise all conditions of increased arterial tension, induced by contraction of the smaller arteries caused by irritating substances, chemical or infectious, such as syphilis, Bright's disease, etc. In fact, anything that increases the blood pressure in the larger or smaller vessels necessitates increased heart-action, and therefore acts as a causal factor in hypertrophy.
Pathology.—Hypertrophy of the heart exists in two forms, with and without dilatation of its cavities, the first being far more frequent. The morbid anatomy of the heart will therefore depend upon the form. The normal heart in the male weighs from nine to twelve ounces; in the female, from eight to ten ounces. In moderate hypertrophy it will vary from fifteen to thirty, and in exaggerated cases has been known to reach the enormous weight of sixty ounces, and is then known as the "cor bovinum"—ox-heart.
Simple hypertrophy exists where the cavities remain normal, and is usually confined to the left heart, though occasionally seen in the right ventricle where there is pulmonary obstruction. The ventricle walls may measure from one to two inches in thickness. It is doubtful if there is ever simple hypertrophy of the auricles, dilatation always accompanying the enlargement. The auricles never reach the thickness of the ventricles, there being less muscular structure to undergo change.
The altered shape of the heart depends upon the part or parts involved, and also the degree of enlargement. Thus, where the left ventricle alone is involved, the pear-shaped form is maintained, the heart being elongated. Where the right ventricle is hypertrophied, as in mitral stenosis, the apex will be more blunt and composed largely of the right heart. Where both ventricles are involved, there is a marked broadening of the apex. Where greatly enlarged, the heart takes a lower position in the chest owing to increased weight.
When dilatation occurs, there may be a thinning of the hypertrophied walls. The papillary muscles and columnae carnae are often very much thickened. The color is dark red.
Symptoms.—It is quite difficult to separate the symptoms of hypertrophy from other lesions with which it is associated. In fact, during the period of compensation there may be an entire absence of subjective symptoms, especially when the hypertrophy is due to valvular lesions.
The compensatory changes take place so gradually that the stenosis or insufficiency is overcome by so delicate an adjustment of power that, unless some unusual strain is brought to bear upon the heart, the, patient may be unconscious for months or years of any heart trouble.
As progressive changes occur, however, unpleasant sensations are experienced in the precordial region. Not a pain, but a sense of weight and oppression, especially when lying on the left side.
Overloading the stomach, active exercise, sexual excesses, or severe mental exertion bring on these symptoms in an exaggerated form, and the patient's attention is directed to the heart. Palpitation is not often present, though, if the patient be of a nervous temperament, he may complain of the "pounding of the heart against the chest wall." This may be quite noticeable if he has an irritable tobacco heart. Pain may be experienced following the excessive use of tobacco, alcohol, or coffee.
When the hypertrophy is excessive and the cerebral circulation is disturbed, the patient complains of dizziness, ringing in the ears, headache, flashing of lights before the eyes, uncomfortable flushing of the face, and a sensation as though the eyeballs were too prominent. This excessive hypertrophy may cause arteriosclerosis, and the heightened blood-pressure may result in rupture of the vessels, giving rise to apoplexy if in the brain, or to cough and hemorrhage if in the lungs (pulmonary apoplexy).
When dilatation takes place, the period of compensation gives way, and the symptoms are the same as in the last stage of valvular disease; namely, venous congestion; dyspnea now becomes a marked feature, the skin becomes cyanotic, and undulation of the cervical veins is noticeable. Engorgement of the liver, with gastric disturbance, follows, and the secretion of urine becomes scanty, albuminous, and high-colored, owing to congestion of the kidneys. Finally, dropsy makes its appearance, first in the extremities, but gradually extending to the body, till general anasarca is established.
Physical Signs.—Inspection.—In children there is a widening of the intercostal spaces, and quite a perceptible bulging of the precordia. The apex-beat is often visible, and extends as low as the seventh or eighth interspace and to the axillary line. If the right heart be enlarged, there will be bulging of the lower part of the sternum. An impulse may be seen to the left of the ensiform cartilage, and especially in the sixth interspace. It may also be seen to the right of the sternum in the third and fourth interspace.
Palpation.—In simple hypertrophy, the impulse of the apex-beat may be felt at the sixth intercostal space and to the left axillary line. When the enlargement is excessive, it may be felt as low as the seventh or eighth interspace and to the left axillary line. The impulse is slow and heaving, and lifts the fingers when lightly placed. If dilatation be present, the impulse is more sudden or abrupt.
Percussion.—Increased dullness is observed in every direction, as high as the second interspace and as low as the eighth; to the left, to the axillary line; and if the right heart is involved, to an inch or more to the right of the sternum, giving a transverse area of dullness seven or eight inches in extent.
Auscultation.—In hypertrophy without dilatation, the first sound is often prolonged and dull, becoming clear, sharp, and more sudden as dilatation takes place. In young persons this first sound is accompanied by a peculiar clinking sound, which Laennec designates as the "cliquetis metalique." There is accentuation of the second sound, and in the aortic region is often reduplicated.
When the right is enlarged with dilatation, the first sound is loud, clear, sharp, and well denned. The second sound is sharply accentuated, and may be reduplicated in the second left intercostal space. A systolic murmur of tricuspid insufficiency may be heard over the lower part of the sternum.
Diagnosis.—The increased area of cardiac dullness, the heaving impulse, and the character of the cardiac sounds, would suggest hypertrophy of the heart. We are to remember, however, that there are a variety of causes that give rise to increased dullness, notably pericardial effusion, retraction of the lungs, with consequent exposure of the heart, mediastinal tumors, and aneurisms, and a careful examination should be made that we may eliminate the aforesaid conditions.
If we remember that in pericardial effusion, palpation reveals a diminution and finally obliteration of the cardiac shock, while in hypertrophy the heaving impulse is characteristic, we will avoid confusion. The dullness due to an aneurism is upward and to the right or left.
Pleural effusions will be recognized by previous history and by the absence of the heaving impulse. The same may be said of mediastinal tumors. Retraction of the lungs, exposing the heart to the chest-walls, may be due to tuberculosis or cirrhosis of the lungs. The history, a careful study of the symptoms, and auscultation would reveal the diagnostic difference.
Not infrequently we meet hysterical patients and neurasthenics who suffer from exaggerated palpitation, but if we note the character of the beat, we note the absence of the heaving impulse, and repeated examinations will soon remove any doubt as to its true nature.
Prognosis.—The prognosis depends largely upon the conditions present and the stage of development. It is generally unfavorable as to a permanent cure, but where the exciting cause can be overcome or controlled, the patient may enjoy a good degree of health and live his or her allotted time of life. The prognosis is more favorable when it occurs in early life than when it comes on in later years. If the general health is good and the patient refrains from severe physical exertion, it may never be detected during the lifetime of the patient.
Where the patient is delicate and anemic, degeneration sooner or later takes place owing to deficient nutrition, and the patient dies early. When due to valvular troubles, and the excitation continues calling for increased work of the valves, compensation finally gives way, dilatation occurs, and death terminates the disease.
Should the patient contract any of the infectious diseases, the heart would feel the force of the toxins, and to that extent be weakened, dilatation naturally following, when there may be a sudden termination of life. When the disease is idiopathic in the young, as in athletes, proper care, good hygiene, moderate exercise, and proper medication may result in a permanent cure.
If the physician can, by advice as to right methods of living and proper medication, maintain the period of compensation, the prognosis is favorable; but when this fails, the outlook is unfavorable.
Treatment.—The treatment of cardiac hypertrophy needs a careful study of each case, and will depend altogether upon the conditions present. When compensation is properly maintained, the treatment will be largely dietetic and hygienic. The diet should be plain, wholesome, and easily digested, and only as much as is consistent with health.
Coffee and tea should be used very sparingly, while alcohol and tobacco are to be absolutely prohibited. A quiet life should be enjoined, though moderate exercise in the open air is beneficial. All heavy work must be abandoned, and severe mental labor prohibited.
Regular habits are very essential, and eight, ten, or twelve hours' sleep encouraged. Sexual excesses must be prohibited.
The indication for remedies will depend upon several factors: thus respiratory wrongs would need remedies to control this phase of the disease. It may be bryonia for pain. lobelia for dyspnea, etc. Should dropsy be present, apocynum, digitalis, and like remedies, will be needed. Rheumatism would suggest the proper anti-rheumatics.
Where the hypertrophy is excessive, or rather where there is excessive power or force, veratrum may be used successfully, the indication being the full, bounding pulse. Its effects, however, should be watched carefully, and its depressing effects avoided.
Aconite adds tone to the heart, and encourages normal muscular action by removing irritation, and the small, frequent, hard pulse will be the symptoms calling for it. As the pulse is diminished in frequency, it gains in power.
Cactus encourages nutrition, adds tone to the organ, and is one of the best remedies in maintaining a stage of compensation. If it does not restore—and I am not sure but that it does to a certain extent—it at least retards for a long time further change, not only in the heart but in the blood-vessels as well. Of the specific tincture add ten to twenty drops to a half a glass of water, and give a teaspoonful every three hours. This should be taken for months.
One mistake in the treatment of these cases is in not continuing our remedies a sufficient length of time. Having selected the right remedy, patiently hold on to it till you get results; for in chronic heart troubles, beneficial effects are not seen in a few days.
Macrotys is an old and well-tried remedy where there is soreness and pain in the precordial region. The patient often complains of a bruised feeling; here macrotys will be found useful. If rheumatism be present, there will be additional reasons for its use. Crataegus has a similar action, and will often prove of great value.
Where dilatation occurs and compensation fails, quiet in bed must be strictly enjoined and nux vomica or strychnia given. Where the heart is feeble and dropsy appears, digitalis must not be overlooked. Apocynum will be indicated where there is general anasarca with feebleness; a decoction of the fresh root will increase the secretions from the kidneys and bowels, and at the same time add tone to the heart.
Lobelia will be called for to relieve asthmatic conditions where there is a sense of oppression, weight, and fullness in the precordial region, and where the pulse is of the same character.
Rhus Tox.—Frequently an irritation of the cerebro-spinal centers gives rise to irritation of the heart, which will be shown in the small, frequent pulse, with a sharp stroke. The patient is restless and starts in his sleep; in these cases, ten drops of rhus tox. to a half glass of water, a teaspoonful every one, two, or three hours, gives good results.
Echinacea.—Where there is septic infection, echinacea must not be forgotten.