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 (16J4–1720), 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 ofthe 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 out-wards 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 inter-costal 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 from excitement and worry, are among the most important 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 under-going 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 he sometimes beneficial .

The change of

air and scene, the enforced rest, the placid life, together with freedom 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 tile 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 abncrmally 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 . (J . F . H . B.) 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 . (E . 0.*) . HEART-BURIAL, the burial of the heart apart from the body . This is a very ancient practice, the special reverence shown towards the heart being doubtless due to its early association with the soul of man, his affections, courage and conscience . In medieval Europe heart-burial was fairly common . Some of the more notable cases are those of Richard I., whose heart, preserved in a casket, was placed in Rouen cathedral; Henry III., buried in Normandy; Eleanor, queen of Edward I., at Lincoln; Edward I., at Jerusalem; Louis IX., Philip III., Louis XIII. and Louis XIV,, in Paris . Since the 17th century the hearts of deceased members of the house of Habsburg have been buried apart from the body in the Loretto chapel in the Augustiner Kirche, Vienna . The most romantic story of heart-burial is that of Robert Bruce . He wished his heart to rest at Jerusalem in the church of the Holy Sepulchre, and on his deathbed entrusted the fulfilment of his wish to Douglas . The latter broke his journey to join the Spaniards in their war with the Moorish king of Granada, and was killed in battle, the heart of Bruce enclosed in a silver casket hanging round his neck .

Subsequently the heart was buried at

Melrose Abbey . The heart of James, marquess of Montrose, executed by the Scottish Covenanters in 165o, was recovered from his body, which had been buried by the roadside outside Edinburgh, and, enclosed in a steel box, was sent to the duke of Montrose, then in exile . It was lost on its journey, and years afterwards was discovered in a curiosity shop in Flanders . Taken by a member of the Montrose family to India, it was stolen as an amulet by a native chief, was once more regained, and finally lost in France during the Revolution . Of notable 17th-century cases there is that of James II., whose heart was buried in the church of the convent of the Visitation at Chaillot near Paris, and that of Sir William Temple, at Moor Park, Farnham . The last ceremonial burial of a heart in England was that of Paul Whitehead, secretary to the Monks of Medmenham club, in 1775, the interment taking place in the Le Despenser mausoleum at High Wycombe, Bucks . Of later cases the most notable are those of Daniel O'Connell, whose heart is at Rome . Shelley at Bournemouth, Louis XVII. at Venice, Kosciusko at the Polish museum at Rapperschwyll, Lake Zurich, and the marquess of Bute, taken by his widow to Jerusalem for burial in 1900 . Sometimes other parts of the body, removed in the process of embalming, are given separate and solemn burial . Thus the viscera of the popes from Sixtus V . (1590) onward have been preserved in the parish church of the Quirinal . The custom of heart-burial was forbidden by Pope Boniface VIII .

(1294-1303), but

Benedict XI. withdrew the prohibition . See Pettigrew, Chronicles of the Tombs (1857) .