Heart

Heart, in anatomy.—The heart1 is a four-chambered muscular bag, which lies in the cavity of the thorax between the two lungs. It is surrounded by another bag, the pericardium, for protective and lubricating purposes (see Coelom and Serous Membranes). Externally the heart is somewhat conical, its base being directed upward, backward and to the right, its apex downward, forward and to the left. In transverse section the cone is flattened, so that there is an anterior and a posterior surface and a superior and inferior border. The superior border, running obliquely downward and to the left, is very thick, and so gains the name of margo obtusus, while the inferior border is horizontal and sharp and is called margo acutus (see fig. 1). The divisions between the four chambers of the heart (namely, the two auricles and two ventricles) are indicated on the surface by grooves, and when these are followed it will be seen that the right auricle and ventricle lie on the front and right side, while the left auricle and ventricle are behind and on the left.

Fig. 1. The Thoracic Viscera.—In this diagram the lungs are turned to the side, and the pericardium removed to display the heart, a, upper, a′, lower lobe of left lung; b, upper, b′, middle, b″, lower lobe of right lung; c, trachea; d, arch of aorta; e, superior vena cava; f, pulmonary artery; g, left, and h, right auricle; k, right, and l, left ventricle; m, inferior vena cava; n, descending aorta; 1, innominate artery; 2, right, and 4, left common carotid artery; 3, right, and 5, left subclavian artery; 6, 6, right and left innominate vein; 7 and 9, left and right internal jugular veins; 8 and 10, left and right subclavian veins; 11, 12, 13, left pulmonary artery, bronchus and vein; 14, 15, 16, right pulmonary bronchus, artery and vein; 17 and 18, left and right coronary arteries.

Fig. 2. Cavities of the Right Side of the Heart.—a, superior, and b, inferior vena cava; c, arch of aorta; d, pulmonary artery; e, right, and f, left auricular appendage; g, fossa ovalis; h, Eustachian valve; k, mouth of coronary vein; l, m, n, cusps of the tricuspid valve; o, o, papillary muscles; p, semilunar valve; q, corpus Arantii; r, lunula.

The right auricle is situated at the base of the heart, and its outline is seen on looking at the organ from in front. Into the posterior part of it open the two venae cavae (see fig. 2), the superior (a) above and the inferior (b) below. In front and to the left of the superior vena cava is the right auricular appendage (e) which overlaps the front of the root of the aorta, while running obliquely from the front of one vena cava to the other is a shallow groove called the sulcus terminalis, which indicates the original separation between the true auricle in front and the sinus venosus behind. When the auricle is opened by turning the front wall to the right as a flap the following structures are exposed:

1. A muscular ridge, called the crista terminalis, corresponding to the sulcus terminalis on the exterior.

2. A series of ridges on the anterior wall and in the appendage, running downward from the last and at right angles to it, like the teeth of a comb; these are known as Musculi pectinati.

3. The orifice of the superior vena cava (fig. 2, a) at the upper and back part of the chamber.

4. The orifice of the inferior vena cava (fig. 2, b) at the lower and back part.

5. Attached to the right and lower margins of this opening are the remains of the Eustachian valve (fig. 2, h), which in the foetus directs the blood from the inferior vena cava, through the foramen ovale, into the left auricle.

6. Below and to the left of this is the opening of the coronary sinus (fig. 2, k), which collects most of the veins returning blood from the substance of the heart.

7. Guarding this opening is the coronary valve or valve of Thebesius.

8. On the posterior or septal wall, between the two auricles, is an oval depression, called the fossa ovalis (fig. 2, g), the remains of the original communication between the two auricles. In about a quarter of all normal hearts there is a small valvular communication between the two auricles in the left margin of this depression (see “7th Report of the Committee of Collective Investigation,” J. Anat. and Phys. vol. xxxii. p. 164).

9. The annulus ovalis is the raised margin surrounding this depression.

10. On the left side, opening into the right ventricle, is the right auriculo-ventricular opening.

11. On the right wall, between the two caval openings, may occasionally be seen a slight eminence, the tubercle of Lower, which is supposed to separate the two streams of blood in the embryo.

12. Scattered all over the auricular wall are minute depressions, the foramina Thebesii, some of which receive small veins from the substance of the heart.

The right ventricle is a triangular cavity (see fig. 2) the base of which is largely formed by the auriculo-ventricular orifice. To the left of this it is continued up into the root of the pulmonary artery, and this part is known as the infundibulum. Its anterior wall forms part of the anterior surface of the heart, while its posterior wall is chiefly formed by the septum ventriculorum, between it and the left ventricle. Its lower border is the margo acutus already mentioned. In transverse section it is crescentic, since the septal wall bulges into its cavity. In its interior the following structures are seen:

1. The tricuspid valve (fig. 2, l, m, n) guarding against reflux of blood into the right auricle. This consists of a short cylindrical curtain of fibrous tissue, which projects into the ventricle from the margin of the auriculo-ventricular aperture, while from its free edge three triangular flaps hang down, the bases of which touch one another. These cusps are spoken of as septal, marginal and infundibular, from their position.

2. The chordae tendineae are fine fibrous cords which fasten the cusps to the musculi papillares and ventricular wall, and prevent the valve being turned inside out when the ventricle contracts.

3. The columnae carneae are fleshy columns, and are of three kinds. The first are attached to the wall of the ventricle in their whole length and are merely sculptured in relief, as it were; the second are attached by both ends and are free in the middle; while the third are known as the musculi papillares and are attached by one end to the ventricular wall, the other end giving attachment to the chordae tendineae. These musculi papillares are grouped into three bundles (fig. 2, o).

4. The moderator band is really one of the second kind of columnae carneae which stretches from the septal to the anterior wall of the ventricle.

5. The pulmonary valve (fig. 2, p) at the opening of the pulmonary artery has three crescentic, pocket-like cusps, which, when the ventricle is filling, completely close the aperture, but during the contraction of the ventricle fit into three small niches known as the sinuses of Valsalva, and so are quite out of the way of the escaping blood. In the middle of the free margin of each is a small knob called the corpus Arantii (fig. 2, q), and on each side of this a thin crescent-shaped flap, the lunula (fig. 2, r), which is only made of two layers of endocardium, whereas in the rest of the cusp there is a fibrous backing between these two layers.

The left auricle is situated at the back of the base of the heart, behind and to the left of the right auricle. Running down behind it are the oesophagus and the thoracic aorta. When it is opened it is seen to have a much lighter colour than the other cavities, owing to the greater thickness of its endocardium obscuring the red muscle beneath. There are no musculi pectinati except in the auricular appendage. The openings of the four pulmonary veins are placed two on each side of the posterior wall, but sometimes there may be three on the right side, and only one on the left. On the septal wall is a small depression like the mark of a finger-nail, which corresponds to the anterior part of the fossa ovalis and often forms a valvular communication with the right auricle. The auriculo-ventricular orifice is large and oval, and is directed downward and to the left. Foramina Thebesii and venae minimae cordis are found in this auricle, as in the right, although the chamber is one for arterial or oxidized blood.

At the lower part of the posterior surface of the unopened auricle, lying in the left auriculo-ventricular furrow, is the coronary sinus, which receives most of the veins returning the blood from the heart substance; these are the right and left coronary veins at each extremity and the posterior and left cardiac veins from below. One small vein, called the oblique vein of Marshall, runs down into it across the posterior surface of the auricle, from below the left lower pulmonary vein, and is of morphological interest.

The left ventricle is conical, the base being above, behind and to the right, while the apex corresponds to the apex of the heart and lies opposite the fifth intercostal space, 3½ in. from the mid line. The following structures are seen inside it:—

1. The mitral valve guarding the auriculo-ventricular opening has the same arrangement as the tricuspid, already described, save that there are only two cusps, named marginal and aortic, the latter of which is the larger.

2. The chordae tendineae and columnae carneae resemble those of the right ventricle, though there are only two bundles of musculi papillares instead of three. These are very large. A moderator band has been found as an abnormality (see J. Anat. and Phys. vol. xxx. p. 568).

3. The aortic valve has the same structure as the pulmonary, though the cusps are more massive. From the anterior and left posterior sinuses of Valsalva the coronary arteries arise. That part of the ventricle just below the aortic valve, corresponding to the infundibulum on the right, is known as the aortic vestibule.

The walls of the left ventricle are three times as thick as those of the right, except at the apex, where they are thinner. The septum ventriculorum is concave towards the left ventricle, so that a transverse section of that cavity is nearly circular. The greater part of it has nearly the same thickness as the rest of the left ventricular wall and is muscular, but a small portion of the upper part is membranous and thin, and is called the pars membranacea septi; it lies between the aortic and pulmonary orifices.

Structure of the Heart.—The arrangement of the muscular fibres of the heart is very complicated and only imperfectly known. For details one of the larger manuals, such as Cunningham’s Anatomy (London, 1910), or Gray’s Anatomy (London, 1909), should be consulted. The general scheme is that there are superficial fibres common to the two auricles and two ventricles and deeper fibres for each cavity. Until recently no fibres had been traced from the auricles to the ventricles, though Gaskell predicted that these would be found, and the credit for first demonstrating them is due to Stanley Kent, their details having subsequently been worked out by W. His, Junr., and S. Tawara. The fibres of this auriculo-ventricular bundle begin, in the right auricle, below the opening of the coronary sinus, and run forward on the right side of the auricular septum, below the fossa ovalis, and close to the auriculo-ventricular septum. Above the septal flap of the tricuspid valve they thicken and divide into two main branches, one on either side of the ventricular septum, which run down to the bases of the anterior and posterior papillary muscles, and so reach the walls of the ventricle, where their secondary branches form the fibres of Purkinje. The bundle is best seen in the hearts of young Ruminants, and it is presumably through it that the wave of contraction passes from the auricles to the ventricles (see article by A. Keith and M. Flack, Lancet, 11th of August 1906, p. 359).

The central fibrous body is a triangular mass of fibro-cartilage, situated between the two auriculo-ventricular and the aortic orifices. The upper part of the septum ventriculorum blends with it. The endocardium is a delicate layer of endothelial cells backed by a very thin layer of fibro-elastic tissue; it is continuous with the endothelium of the great vessels and lines the whole of the cavities of the heart.

The heart is roughly about the size of the closed fist and weighs from 8 to 12 oz.; it continues to increase in size up to about fifty years of age, but the increase is more marked in the male than in the female. Each ventricle holds about 4 f. oz. of blood, and each auricle rather less. The nerves of the heart are derived from the vagus, spinal accessory and sympathetic, through the superficial and deep cardiac plexuses.

Embryology.

Fig. 3.—Formation of Septa. Diagram of the formation of some of the septa of the heart (viewed from the right side).

S.V. Sinus venosus. Au. Auricle. E.C. Endocardial cushions forming septum intermedium. V. Septum ventriculorum. T. Ar. Septum aorticum intruncus arteriosus. V.A. Ventral aorta.

In the article on the arteries (q.v.) the formation and coalescence of the two primitive ventral aortae to form the heart are noticed, so that we may here start with a straight median tube lying ventral to the pharynx and being prolonged cephalad into the ventral aortae and caudad into the vitelline veins. This soon shows four dilatations, which, from the tail towards the head end, are called the sinus venosus, the auricle, the ventricle and the truncus2 arteriosus. As the tubular heart grows more rapidly than the pericardium which contains it, it becomes bent into the form of an S laid on its side (∾), the ventral convexity being the ventricle and the dorsal the auricle. The passage from the auricle to the ventricle is known as the auricular canal, and in the dorsal and ventral parts of this appear two thickenings known as endocardial cushions, which approach one another and leave a transverse slit between them (fig. 3, E.C.). Eventually these two cushions fuse in the middle line, obliterating the central part of the slit, while the lateral parts remain as the two auriculo-ventricular orifices; this fusion is known as the septum intermedium. From the bottom (ventral convexity) of the ventricle an antero-posterior median septum grows up, which is the septum inferius or septum ventriculorum (fig. 3, V). Posteriorly (caudally) this septum fuses with the septum intermedium, but anteriorly it is free at the lower part of the truncus arteriosus. On referring to the development of the arteries (see Arteries) it will be seen that another septum starts between the last two pairs of aortic arches and grows downward (caudad) until it reaches and joins with the septum inferius just mentioned. This septum aorticum (formed by two ingrowths from the wall of the vessel which fuse later) becomes twisted in such a way that the right ventricle is continuous with the last pair of aortic arches (pulmonary artery), while the left ventricle communicates with the other arches (the permanent ventral aorta and its branches); it joins the septum ventriculorum in the upper part of the ventricular cavity and so forms the pars membranacea septi (fig. 3, T. Ar).

The fate of the sinus venosus and auricle must now be followed. Into the former, at first, only the two vitelline veins open, but later, as they develop, the ducts of Cuvier and the umbilical veins join in (see Veins). As the ducts of Cuvier come from each side the sinus spreads out to meet them and becomes transversely elongated. The slight constriction, which at first is the only separation between the sinus and the auricle, becomes more marked, and later the opening is into the right part of the auricle, and is guarded by two valvular folds of endocardium (the venous valves) which project into that cavity, and are continuous above with a temporary downgrowth from the roof, known as the septum spurium. Later the right side of the sinus enlarges, and so does the right part of the aperture, until the back part of the right side of the auricle and the right part of the sinus venosus are thrown into one, and the only remnants of the partition are the crista terminalis and the Eustachian and Thebesian Valves. The left part of the sinus venosus, which does not enlarge at the same rate as the right part, remains as the coronary sinus. It will now be seen why, in the adult heart, all the veins which open into the right auricle open into its posterior part, behind the crista terminalis. The septum spurium has been referred to as a temporary structure; the real division between the two auricles occurs at a later date than that between the ventricles and to the left of the septum spurium. It is formed by two partitions, the first of which, called the septum primum, grows down from the auricular roof. At first it does not quite reach the endocardial cushions in the auricular canal, already mentioned, but leaves a gap, called the ostium primum, between. This has nothing to do with the foramen ovale, which occurs as an independent perforation higher up, and at first is known as the ostium secundum. When it is established the septum primum grows down and meets the endocardial cushions, and so the ostium primum is obliterated. The septum secundum grows down on the right of the septum primum and is never complete; it grows round and largely overlaps the foramen ovale and its edges form the annulus ovalis, so that, in the later months of foetal life, the foramen ovale is a valvular opening, the floor of which is formed by the septum primum and the margins by the septum secundum. The closure of the foramen is brought about by adhesion of the two septa.

The pulmonary veins of the two sides at first join one another, dorsal to the left auricle, and open into that cavity by a single median trunk, but, as the auricle grows, this trunk and part of the right and left veins are absorbed into its cavity.

The mitral and tricuspid valves are formed by the shortening of the auricular canal which becomes telescoped into the ventricle, and the cusps are the remnants of this telescoping process.

The columnae carneae and chordae tendineae are the remains of a spongy network which originally filled the cavity of the primary ventricle.

The aortic and pulmonary valves are laid down in the ventral aorta, before it is divided into aorta and pulmonary artery, as four endocardial cushions; anterior, posterior and two lateral. The septum aorticum cuts the latter two into two, so that each artery has the rudiments of three cusps.

Abnormalities of the heart are very numerous, and can usually be explained by a knowledge of its development. They often cause grave clinical symptoms. A clear and well-illustrated review of the most important of them will be found in the chapter on congenital disease of the heart in Clinical Applied Anatomy, by C. R. Box and W. McAdam Eccles, London, 1906.

Comparative Anatomy.

In the Acrania (e.g. lancelet) there is no heart, though the vessels are specially contractile in the ventral part of the pharynx.

In the Cyclostomata (lamprey and hag), and Fishes, the heart has the same arrangement which has been noticed in the human embryo. There is a smooth, thin-walled sinus venosus, a thin reticulate-walled auricle, produced laterally into two appendages, a thick-walled ventricle, and a conus arteriosus containing valves. In addition to these the beginning of the ventral aorta is often thickened and expanded to form a bulbus arteriosus, which is non-contractile, and, strictly speaking, should rather be described with the arteries than with the heart. In relation to human embryology the smooth sinus venosus and reticulated auricle are interesting. Between the auricle and ventricle is the auriculo-ventricular valve, which primarily consists of two cusps, comparable to the two endocardial cushions of the human embryo, though in some forms they may be subdivided. In the interior of the ventricle is a network of muscular trabeculae. The conus arteriosus in the Elasmobranchs (sharks and rays) and Ganoids (sturgeon) is large and provided with several rows of semilunar valves, but in the Cyclostomes (lamprey) and Teleosts (bony fishes) the conus is reduced and only the anterior (cephalic) row of valves retained. With the reduction of the conus the bulbus arteriosus is enlarged. So far the heart is a single tubular organ expanded into various cavities and having the characteristic ∾-shaped form seen in the human embryo; it contains only venous blood which is forced through the gills to be oxidized on its way to the tissues. In the Dipnoi (mud fish), in which rudimentary lungs, as well as gills, are developed, the auricle is divided into two, and the sinus venosus opens into the right auricle. The conus arteriosus too begins to be divided into two chambers, and in Protopterus this division is complete. This division of the heart is one instance in which mammalian ontogeny does not repeat the processes of phylogeny, because, in the human embryo, it has been shown that the ventricular septum appears before the auricular. This want of harmony is sometimes spoken of as the “falsification of the embryological record.”

In the Amphibia there are also two auricles and one ventricle, though in the Urodela (tailed amphibians) the auricular septum is often fenestrated. The sinus venosus is still a separate chamber, and the conus arteriosus, which may contain many or few valves, is usually divided into two by a spiral fold. Structurally the amphibian heart closely resembles the dipnoan, though the increased size of the left auricle is an advance. In the Anura (frogs and toads) the whole ventricle is filled with a spongy network which prevents the arterial and venous blood from the two auricles mixing to any great extent. (For the anatomy and physiology of the frog’s heart, see The Frog, by Milnes Marshall.)

In the Reptiles the ventricular septum begins to appear; this in the lizards is quite incomplete, but in the crocodiles, which are usually regarded as the highest order of living reptiles, the partition has nearly reached the top of the ventricle, and the condition resembles that of the human embryo before the pars membranacea septi is formed. The conus arteriosus becomes included in the ventricular cavity, but the sinus venosus still remains distinct, and its opening into the right ventricle is guarded by two valves which closely resemble the two venous valves in the auricle of the human embryo already referred to.

In the Birds the auricular and ventricular septa are complete; the right ventricle is thin-walled and crescentic in section, as in Man, and the musculi papillares are developed. The left auriculo-ventricular valve has three membranous cusps with chordae tendineae attached to them, but the right auriculo-ventricular valve has a large fleshy cusp without chordae tendineae. The sinus venosus is largely included in the right auricle, but remains of the two venous valves are seen on each side of the orifice of the inferior vena cava.

In the Mammals the structure of the heart corresponds closely with the description of that of Man already given. In the Ornithorynchus, among the Monotremes, the right auriculo-ventricular valve has two fleshy and two membranous cusps, thus showing a resemblance to that of the bird. In the Echidna, the other member of the order, however, both auriculo-ventricular valves are membranous. In the Edentates the remains of the venous valves at the opening of the inferior vena cava are better marked than in other orders. In the Ungulates the moderator band in the right ventricle is especially well developed, and the central fibrous body at the base of the heart is often ossified, forming the os cordis so well known in the heart of the ox.

The position of the heart in the lower mammals is not so oblique as it is in Man.

Heart Disease.—In the early ages of medicine, the absence of correct anatomical, physiological and pathological knowledge prevented diseases of the heart from being recognized with any certainty during life, and almost entirely precluded them from becoming the object of medical treatment. But no sooner did Harvey (1628) publish his discovery of the circulation of the blood, and its dependence on the heart as its central organ, than derangements of the circulation began to be recognized as signs of disease of that central organ. (See also under Vascular System.)

Among the earliest to profit by this discovery and to make important contributions to the literature of diseases of the heart and circulation were, R. Lower (1631-1691), R. Vieussens (1641-1716). H. Boerhave (1668-1738) and the great pathologists at the beginning of the 18th century, G. M. Lancisi (1654-1720), G. B. Morgagni (1682-1771) and J. B. Senac (1693-1770). The works of these writers form very interesting reading, and it is remarkable how careful were the observations made, and how sound the conclusions drawn, by these pioneers of scientific medicine. J. N. Corvisart (1755-1821) was one of the earliest to make practical use of R. T. Auenbrugger’s (1722-1809) invention of percussion to determine the size of the heart. R. T. H. Laennec (1781-1826) was the first to make a scientific application of mediate auscultation to the diagnosis of disease of the chest, by the invention of the stethoscope. J. Bouillaud (1796-1881) extended its use to the diagnosis of disease of the heart. To James Hope (1801-1841) we owe much of the precision we have now attained in diagnosis of valvular disease from abnormalities in the sounds produced during cardiac movements. This short list by no means exhausts the earlier literature on the subject, but each of these names marks an era in the progress of the diagnosis of cardiac disease. In later years the literature on this subject has become very copious.

The heart and great vessels occupy a position immediately to the left of the centre of the thoracic cavity. The anterior surface of the heart is projected against the chest wall and is surrounded on either side by the lungs, which are resonant organs, so that any increase in the size of the heart, “dilatation,” can be detected by percussion. By placing the hand on the chest, palpation, the impulse of the left ventricle, or apex beat, can normally be felt just below and internal to the nipple. Deviations from the normal in the position or force of the apex beat will afford important information as to the nature of the pathological changes in the heart. Thus, displacement downwards and outwards of the apex beat, with a forcible thrusting impulse, will indicate hypertrophy, or increase of the muscular wall and increased driving power of the left ventricle, whereas a similar displacement with a feeble diffuse impulse will indicate dilatation, or over-distension of its cavity from stretching of the walls.

By auscultation, or listening with a suitable instrument named a stethoscope over appropriate areas, we can detect any abnormality in the sounds of the heart, and the presence of murmurs indicative of disease of one or other of the valves of the heart.

The pericardium is a fibro-serous sac which loosely envelops the heart and the origin of the great vessels. Inflammation of this sac, or pericarditis, is apt to occur as a result of rheumatism, more especially in children. It may also occur as a complication of pneumonia. It is a serious affection associated with pain over the heart, fever, shortness of breath, rapid pulse and dilatation of the heart. As a result of the inflammation, fluid may accumulate in the pericardial sac, or the walls of the sac may become adherent to the heart and tend to embarrass its action. In favourable cases, however, recovery may take place without any untoward sequelae.

Diseases of the heart may be classified in two main groups, (1) Disease of the valves, and (2) Disease of the walls of the heart.

1. Valvular Disease.—Inflammation of the valves of the heart, or endocarditis, is one of the most common complications of rheumatism in children and young adults. More severe types, which are apt to prove fatal from a form of blood poisoning, may result when the valves of the heart are attacked by certain micro-organisms, such as the pneumococcus, which is responsible for pneumonia, the streptococcus and the staphylococcus pyogenes, the gonococcus and the influenza bacillus.

As a result of endocarditis, one or more of the valves may be seriously damaged, so that it leaks or becomes incompetent. The valves of the left side of the heart, the aortic and mitral valves, are affected far more commonly than those of the right side. It is indeed comparatively rarely that the latter are attacked. In the process of healing of a damaged valve, scar tissue is formed which has a tendency to contract, so that in some cases the orifice of the valve becomes narrowed, and the resulting stenosis or narrowing gives rise to obstruction of the blood stream. We may thus have incompetence or stenosis of a valve or both combined.

Valvular lesions are detected on auscultation over appropriate areas by the blowing sounds or murmurs to which they give rise, which modify or replace the normal heart sounds. Thus, lesions of the mitral valve give rise to murmurs which are heard at the apex beat of the heart, and lesions of the aortic valves to murmurs which are heard over the aortic area, in the second right intercostal space. Accurate timing of the murmurs in relation to the heart sounds enables us to judge whether the murmur is due to stenosis or incompetence of the valve affected.

If the valvular lesion is severe, it is essential for the proper maintenance of the circulation that certain changes should take place in the heart to compensate for or neutralize the effects of the regurgitation or obstruction, as the case may be. In affections of the aortic valve, the extra work falls on the left ventricle, which enlarges proportionately and undergoes hypertrophy. In affections of the mitral valve the effect is felt primarily by the left auricle, which is a thin walled structure incapable of undergoing the requisite increase in power to resist the backward flow through the mitral orifice in case of leakage, or to overcome the effects of obstruction in case of stenosis. The back pressure is therefore transmitted to the pulmonary circulation, and as the right ventricle is responsible for maintaining the flow of blood through the lungs, the strain and extra work fall on the right ventricle, which in turn enlarges and undergoes hypertrophy. The degree of hypertrophy of the left or right ventricle is thus, up to a certain point, a measure of the extent of the lesion of the aortic or mitral valve respectively. When the effects of the valvular lesion are so neutralized by these structural changes in the heart that the circulation is equably maintained, “compensation” is said to be efficient.

When the heart gives way under the strain, compensation is said to break down, and dropsy, shortness of breath, cough and cyanosis, are among the distressing symptoms which may set in. The mere existence of a valvular lesion does not call for any special treatment so long as compensation is efficient, and a large number of people with slight valvular lesions are living lives indistinguishable from those of their neighbours. It will, however, be readily understood that in the case of the more serious lesions certain precautions should be observed in regard to over-exertion, excitement, over-indulgence in tobacco or alcohol, &c., as the balance is more readily upset and any undue strain on the heart may cause a breakdown of compensation. When this occurs treatment is required. A period of rest in bed is often sufficient to enable the heart to recover, and this may be supplemented as required by the administration of mercurial and saline purgatives to relieve the embarrassed circulation, and of suitable cardiac tonics, such as digitalis and strychnin, to reinforce and strengthen the heart’s action.

2. Affections of the Muscular Wall of the Heart.—Dilatation of the heart, or stretching of the walls of the heart, is an incident, as has already been stated, in pericarditis and in the earlier stages of valvular disease antecedent to hypertrophy. Temporary over-distension or dilatation of the cavities of the heart occurs in violent and protracted exertion, but rapidly subsides and is in no wise harmful to the sound and vigorous heart of the young. It is otherwise if the heart is weak and flabby from a too sedentary life or degenerative changes in its walls or during convalescence from a severe illness, when the same circumstances which will not injure a healthy heart, may give rise to serious dilatation from which recovery may be very protracted.

Influenza is a common cause of cardiac dilatation, and is liable to be a source of trouble after the acute illness has subsided, if the patient goes about and resumes his ordinary avocations too soon.

Fatty or fibroid degeneration of the heart wall may occur in later life from impaired nutrition of the muscle, due to partial obstruction of the blood-vessels supplying it, when they are the seat of the degenerative changes known as arteriosclerosis or atheroma. The affection known as angina pectoris (q.v.) may be a further consequence of this defective blood-supply.

The treatment will vary according to the nature of the case. In serious cases of dilatation, rest in bed, purgatives and cardiac tonics may be required.

In commencing degenerative change the Oertel treatment, consisting of graduated exercise up a gentle slope, limitation of fluids and a special diet, may be indicated.

In cases of slight dilatation after influenza or recent illness, the Schott treatment by baths and exercises as carried out at Nauheim may be sometimes beneficial. The change of air and scene, the enforced rest, the placid life, together with freedom from excitement and worry, are among the most important factors which contribute to success in this class of case.

Disorders of Rhythm of the Heart’s Action.—Under this heading may be grouped a number of conditions to which the name “functional affections of the heart” has sometimes been applied, inasmuch as the disturbances in question cannot usually be attributed to definite organic disease of the heart. We must, of course, exclude from this category the irregularity in the force and frequency of the pulse, which is commonly associated with incompetence of the mitral valve.

The heart is a muscular organ possessing certain properties, rhythmicity, excitability, contractility, conductivity and tonicity, as pointed out by Gaskell, in virtue of which it is able to maintain a regular automatic beat independently of nerve stimulation. It is, however, intimately connected with the brain, blood-vessels and the abdominal and thoracic viscera, by innumerable nerves, through which impulses or messages are being constantly sent to and received from these various portions of the body. Such messages may give rise to disturbances of rhythm with which we are all familiar. For instance, sudden fright or emotion may cause a momentary arrest of the heart’s action, and excitement or apprehension may set up a rapid action of the heart or palpitation. Palpitation, again, is often the result of digestive disorders, the message in this case being received from the stomach, instead of the brain as in emotional disturbances. It may also result from over-indulgence in tobacco and alcohol.

Tachycardia is the name applied to a more or less permanent increase in the rate of the heart-beat. It is usually a prominent feature in the affection known as Graves’ disease or exophthalmic goitre. It may also result from chronic alcoholism. In the condition known as paroxysmal tachycardia there appears to be no adequate explanation for its onset.

Bradycardia or abnormal slowness of the heart-beat, is the converse of tachycardia. An abnormally slow pulse is met with in melancholia, cerebral tumour, jaundice and certain toxic conditions, or may follow an attack of influenza. There is, however, a peculiar affection characterized by abnormal slowness of pulse (often ranging as low as 30), and the onset, from time to time, of epileptiform or syncopal attacks. To this the name “Stokes-Adams disease” has been applied, as it was first called attention to by Adams in 1827, and subsequently fully described by Stokes in 1836. It is usually associated with senile degenerative change of the heart and vascular system, and is held to be due to impairment of conductivity in the muscular fibres (bundle of His) which transmit the wave of contraction from the auricle to the ventricle. It is of serious significance in view of the symptoms associated with it.

Intermittency of the Pulse.—By this is understood a pulse in which a beat is dropped from time to time. The dropping of a beat may occur at regular intervals every two, four or six beats, &c., or occasionally at irregular intervals after a series of normal beats. On examining the heart, it is found, as a rule, that the cause of the intermission at the wrist is not actual omission of a heart-beat, but the occurrence of a hurried imperfect cardiac contraction which does not transmit a pulse-wave to the wrist. It is not characteristic of any special form of heart affection, and is rarely of serious import. It may be due to reflex digestive disturbances, or be associated with conditions of nervous breakdown and irritability, or with an atonic and relaxed condition of the heart muscle. The treatment of these disorders of rhythm of the heart will vary greatly according to the cause and is often a matter of considerable difficulty.

Surgery of Heart and Pericardium.—As the result of acute or chronic inflammation of the lining membrane of the fibrous sac which surrounds the heart and the neighbouring parts of the large blood-vessels, a dropsical or a purulent collection may form in it, or the sac may be quietly distended by a thin watery fluid. In either case, but especially in the latter, the heart may be so embarrassed in its work that death seems imminent. The condition is generally due to the cultivation in the pericardium of the germs of rheumatism, influenza or gonorrhoea, or of those of ordinary suppuration. Respiration as well as circulation is embarrassed, and there is a marked fulness and dulness of the front wall of the chest to the left of the breast-bone. In that region also pain and tenderness are complained of. By using the slender, hollow needle of an aspirator great relief may be afforded, but the tapping may have to be repeated from time to time. If the fluid drawn off is found to be purulent, it may be necessary to make a trap-door opening into the chest by cutting across the 4th and 5th ribs, incising and evacuating the pericardium and providing for drainage. In short, an abscess in the pericardium must be treated like an abscess in the pleura.

Wounds of the heart are apt to be quickly fatal. If the probability is that the enfeebled action of the heart is due to pressure from blood which is leaking into, and is locked up in the pericardium, the proper treatment will be to open the pericardium, as described above, and, if possible, to close the opening in the auricle, ventricle or large vessel, by sutures.

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