Manual of the physical diagnosis of the diseases of the heart : including the use of the sphygmograph and cardiograph

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DISEASES OF THE HEART

NOTE.

Section I.— The normal heart-sounds are modified in degree. A. At the base of the heart

(a.) The aortic second sound is intensified. There is Hypertrophy of the Left Ventricle.

(b.) The pulmonary second sound is intensified. There is heightened tension in the pulmonic circulation.

Note. — A strong pulmonary, associated with a weak aortic second sound, is presumptive evidence of mitral obstruction or insufficiency.

B. At the apex of the heart : —

(a.) The first soimd is increased in duration. There is Hypertrophy of Left Ventricle.

Note. — When there are signs of Hypertrophy of Left Ventricle without other cardiac signs to account for it, suspect Chronic Renal Disease.

(b.) The first sound is short, resembling the second sound. There is feebleness, dilatation or degeneration of left ventricle.

Note. — Reduplication of heart-sounds occasionally occurs in health ; when associated with fever or with grave debility, indicates myocarditis or cardiac degeneration ; if reduplication of second sound, suspect mitred stenosis.

Section II. Abnormal sounds are heard over the heart-region

A. Generally over the precordial area.

(a.) Friction sound indicates Acute Pericarditis — or Pericardial roughening, the result of a remote pericarditis.

B. Localized in definite relation with the situations of the valves.

(a.) First-sound murmur over site of aortic valves (anremia excluded) indicates aortic obstruction.

Note.— The murmur may be localized or propagated in the course of the great arteries.

(6.) Second-sound murmur over site of aortic valves indicates aortic regurgitation.

Note. — This murmur may be localized, or propagated downwards in the line of the sternum.

(c.) Double (first and second sound) murmur (a and b) denotes combined aortic obstruction and insufficiency.

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(cZ.) First-sound murmur over site of valves of pulmonary artery denotes (anaemia and pressure upon trunk of pulmonary artery excluded) obstruction of pulmonary artery.

Note.— Pulmonary obstruction is nearly always congenital.

(e.) First-sound murmur at base of ensiform cartilage indi. cates tricuspid regurgitation.

Note. — This is most commonly found as secondary result of mitral disease.

(/.) Before first-sound murmur- at base of ensiform cartilage denotes tricuspid stenosis.

(g.) First-sound murmur heard over situation of right ventricle may be due to myocarditis or anosmia with cardiac debility.

Note. — These murmurs are not persistent.

(/i.) First-sound murmur localized in mitral area denotes mitral regurgitation.

(i.) Before-first-sound murmur localized at apex, or just internal thereto, denotes mitral stenosis— i.e., obstruction.

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PAET I.

THE ORDINARY METHODS OF PHYSICAL DIAGNOSIS.

LECTURE I.

IN TRODDCTORY.

Symptomatology — Importance of subjective symptoms in regard to treatment : of objective in diagnosis — Pain — Angina pectoris — Cardiac symptoms — Disturbances of circulation — Pulmonary symptoms — Cerebral phenomena — Embolism— Gastric symptoms — Signs referred to the throat — Renal symptoms — Etiology — Rheumatism — Other causes of heart disease.

A few words on the threshold of the subject — advice pertinent to investigation of disease in any form, but yet I think rather particularly so to the class of diseases which we shall presently examine. When a sufferingpatient comes to you for examination, do not permit a diversity of purpose of intent to exist between your mind and his. His chief object is to g-et relief from his aches and pains ; yours, perhaps, is to find out — by a process similar to that employed by botanists to discover the name of a newly found flower — the name of the disease which he suffers from. Remember that your duty is not chiefly to find out what disease he is the subject of, but what his sufferings are, what his deviations from sound health. The plane of unhealth

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is divided into definite squares, which are called Diseases, and the nomenclature of these is very important, because the mention of one of them displays before the medical mind a large picture, and a moving panorama of phenomena ; but your sole object is not to find out into what particular square your patient's aggregate of symptoms will fit. You must investigate his ailments as well as his diseases if you would do him good. I am very far from wishing to be a censor, but I do think that in these days of great and increasing precision in physical diagnosis, there is a real clanger of students thinking too lightly of the uttered complaints of patients. It has been said that one objective sign is worth a dozen subjective symptoms, and this, so far as regards diagnosis, has a large amount of truth ; but we must recollect that perturbations, which greatly distress our patient, may exist independently of his chief disease, and it is the patient, not the disease, that we have to treat. Let me instance a hypothetical case. A. B. comes to you, and, under fire of cross-examination discloses that he has had rheumatic fever some years ago. You examine his heart and find something wrong with the mitral valve. You dose him, probably help his heart over its presumed difficulties with digitalis, and order the inevitable belladonna plaster to be applied. But your patient at his next visit is not a whit better. It was not his heart which troubled him — that was neither better nor worse than it had been for many years past, and was likely to be for many years to come ; but he suffered from a trigeminal neuralgia, and would have showered blessings upon you had you relieved him.

The moral I would point, then, is this : Always

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s commence your interrogatory of a patient by asking what lie complains of, what are his troubles and distresses, and if you record his case, write on the first line, complaint, and give his expressions, as nearly as possible, with the necessary abbreviations, in his own words.

Now we come more closely to our subject. The comprehensive view of what disturbs the equanimity of a patient, with a view to the alleviation of his troubles is one thing-, the particular determination of the physical significance of his ailments, and the precise diagnosis of his diseases is another. For this latter purpose, the details of pains and aches, though all due weight must be given to them, are very deceptive. How very common it is for a patient to fancy that he has disease of the heart because he experiences discomfort or pain in the heart-region, and to insist on being " sounded," so that his doubts may be set at rest. How rarely do we find that he really has organic heart disease ? Oftentimes the patient goes away apparently with a look of disappointment that his fears are not confirmed, and with a doubt probably of our skill, because his aches are so precise.

In looking over the notes of a hundred cases of the coarse and decided forms of disease of the heart which have been under my own immediate care, I find that in just half the number, there was no complaint whatever of any pain referred to any part of the chest. Seventeen referred the pain generally to the front of the chest, fifteen to the back of the chest, and especially between the scapula?. Twelve referred the pain to the epigastrium ; eleven suffered pain on the left side of the chest ; whilst two referred their sufferings to the right side. Those who localised their suffer-

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mg-s to the exact area of the heart were hut eight; and of these, two complained of it only on exertion • one referred it to the base of the heart ; one described it as a sense of extreme soreness at the apex ; and in one, it partook of the character of neuralgia of the left breast. So far as the evidence derived from the above cases— which are, I believe, fair specimens of those presenting- themselves at the public or the private consulting- room— teaches only eight per cent., or less than one in a dozen, complain of pain directly referred to the situation of the organ which is diseased. This though strange to the non-medical mind, can scarcely be surprising when we consider that the heart possesses very little common sensation, and that its structure can be punctured, torn, or lacerated, without the direct infliction of pain. When we consider the vast number of patients who present themselves with symptoms referred to the region of the heart, but really caused by dyspepsia or pleurodynia, and then take into account the very small proportion of real undoubted heart cases presenting signs of local pain, we must estimate at a very low figure the value, in a diagnostic point of view, of pain in relation to heart disease.

Looking on diseases of the heart in general from the point of view of symptomatology, we find that their origin and progress are oftentimes very insidious and obscure. Even* the most pronounced and dangerous forms of the disease may, in some cases, go through their stages without betraying themselves by marked symptoms of distress. This fact was strongly impressed upon my mind by a case which was under my care at the North-Eastern Hospital for Children. A little girl, who had been treated pre-

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viously for a valvular affection, was brought to me because the mother thought she seemed a little languid, though the child complained of no distress On examination, I found that there was effusion into the pericardium. She was admitted, and went through all the stages of pericarditis with extreme distension of the pericardium, exhibiting one of the most pronounced instances of pericardial friction that I have ever beard and an accompanying endocardial change, and yet throughout her whole illness the child complained neither of pain nor distress, and it was impossible to keep her in bed.

There is one form of pain in heart disease, however, which is of terrible significance — I mean Angina Pectoris. It has the character of a grip : it shoots down the left arm and occasionally involves both arms, or radiates to the back.* This is the pain, mi generis, of cardiac origin, and if you have once seen a pronounced example of it, you will never forget it. The patient suddenly sits up in his bed, and with a cry of horror indicates his sense of pain at the pragcordium. It has great intensity, but is of a cold and

* " The pain of angiua is distinctly located in or about the midsternum, whence it radiates. Eulenberg says this is due to the connection between the superior cardiac nerve and the anterior branches of the four upper cervical nerves ; while the middle and inferior cardiac nerves are connected with the four lower cervical nerves, uniting in the brachial plexus aud first dorsal nerve. The paiu usually runs out at the peripheral endings of the ulnar nerve, especially the little finger. It is almost invariably found on the left side only, in a case where it was on the right side, the pulmonary artery was the seat of disease."— " Path. Soc. Trans.," 1878. "The Diseases of the Heart," Dr. Milner Fothergill. Second edition, London, 1879, p. 285.

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sickening character ; the chest is fixed, the breathing not quickened, and your hand, placed over the epigastrium, finds that the heart's action is slow and laboured. The face wears a look of horror, the hue is pale or slightly leaden, and a cold sweat breaks out upon the forehead. Worse than the pain is the feeling- of fearful sinking and depression ; the poor patient gasps, I shall die !" and, sometimes, as in a case which it was once my lot to witness, his short, but concentrated sufferings in a few minutes end in death. From such a typical case of high diagnostic and prognostic import, there are many gradations of intensity, until, in some cases, it is difficult to differentiate the symptoms from those of dyspepsia or hysteria. In some cases the pain is absent though the other symptoms are present; such is the "angina sine dolore" of Gairdner. The points to be remembered are: — (1) The attacks are paroxysmal with long or short intervals. (2) There is always a sense of coldness experienced, and frequently a cold sweat. (3) The heart's action is not increased, and (4) The chest is fixed, the breathing slow.

Few questions in the domain of medicine Wo presented greater difficulties than that 'of the nature and pathological significance of angina pectoris. Latham said of it : " We are sure of what it is as an assemblage of symptoms. We are not sure of what it is as a disease." In the fatal cases, the lesions which have been discovered have been various, and in some no morbid appearances have been demonstrated at all. The most commonly discovered conditions have been (a) degeneration and calcification of the coronary arteries ; (b) atheromatous disease of the aorta ; (e) disease of the aortic valves; (rf) fatt3' degeneration of the muscle of the heart. The affection is rare, though by no means unexampled, be foremiddle age, and is much more common in the male than in the female sex. It has proved fatal even in a tirst attack ; Dr. Arnold, of

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Rugby, died within three hours of the onset of an attack of angina pectoris. In the case of a young man, aged twenty-three (recorded by Dr. John Wilson, Edinburgh Medical Journal, September, 1874), who died the day after he had manifested heart-pang, no disease was found at the post-mortem examination. The heart was flaccid, the cavities empty, and the valves all healthy. The young man had been in perfect health until a sudden exposure to cold led up to the fatal attack. It is obvious, therefore, that we must not look alone to the post-mortem table for a solution of the difficulties which beset the pathology of angina pectoris. Fortunately, cbnical investigation has succeeded in a large measure in dissipating those difficulties. Dr. Lauder Brunton demonstrated, in 1866, by means of the sphygmograph, that the arterial tendon during an attack of angina pectoris is increased. Dr. Brunton, knowing that the effect of nitrite of amyl was to relax the arterioles and thus to relieve the tension, administered this drug by inhalation during the paroxysm of angina, with complete success ; the symptoms were immediately alleviated. Dr. L. Brunton' s observations have been conclusively confirmed. More recently, Dr. Murrell has introduced for the treatment of angina pectoris another agent, which, like amyl nitrite, has the power of relaxing the arterioles— nitro-glycerine. The use of this drug, which is administered by the stomach, is also attended by.most obvious relief of the symptoms. It may, therefore, be taken as proved, I consider, that angina pectoris is essentially a condition in which the arterioles are contracted, and in which there is high pressure in the arterial system, and that when the arterioles are made to dilate, and the intra-vascular pressure is rebeved, the symptoms abate. You should remember that angina pectoris is by no means a common affection. Dr. Hayden, in his large experience, states that he has met with only six genuine examples ("Diseases of Heart and Aorta," p. 1043). It follows, therefore, that you must be careful, in any case which appears to you to present tlie characteristic symptoms, to discriminate between true angina and the many forms of pain which are sometimes called false angina, and which may be neuralgia, intercostal rheumatism, the consequences of dyspepsia, &c. You will make the diagnosis by observing whether the symptoms correspond

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with those I have before described, and especially also by ascertaining, ,f you have an opportunity of witnessing the phenomena of an attack, whether the arterial tension during the paroxysm is increased. On this point you should obtain the evidence of the sphygmograph if possible. Having recognized your case as one of true angina, supposing that you have opportunities of further investigation, you will find it in my opinion, most practically useful to place it under one of two categories. A, in which the arterial tension is not increased m the intervals of attacks. B, in which there is persistently high arterial tension. The cases [A) in which normal tension is moderate or low, constitute the minority, and for the most part comprise the exceptional cases occurring in the earlier periods of life. In such there is an acute supervention of high pressure, the arterioles become contracted (perhaps in obedience to a direct external cause, such as exposure), the left ventricle struggles against the difficulty so imposed, and becomes overdistended. As I have said, such acute angina may be fatal On the other hand, the paroxysm being relieved, the patient may go an unlimited time without recurrence. In such cases there may be no antecedent cardiac disease ; it is not common to meet with angina in the valvular diseases consequent on rheumatic endocarditis. I have seen, however, a single severe attack in a lady aged thirty-one, who presented the marked signs of mitral regurgitation ; in this case, however, the sphygmograph demonstrated high tension a condition quite different to that usually obtaining in such pronounced mitral regurgitation. In resume, therefore, in Class A, the angina attack is a neurosis, the essential of which is the acute supervention of a contraction of the arterioles, with rise of blood pressure throughout the arterial system,' and distension of the left ventricle from accumulation of blood therein. In Class B, which includes the majority of cases of angina pectoris, the arterial tension is persistently high, though it is still higher during the paroxysms. In these there is a special cause for the recurrence of attacks ; such cause is disease of the coats of the aorta (aortitis deformans) or disease of the systemic arteries (arteritis) and especially of the coronary arteries. In such cases you will find the arterial pulse hard and incompressible, and there will be signs of hypertrophy of the left ventricle, and probably valvular disease,

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which is usually aortic. When from any cause the already high arterial tension is increased, and the left ventricle is overtaxed in its struggle to propel the blood, angina may ensue. Undue exertion or effort are frequent exciting causes of an attack. In some cases, however, paroxysms occur without obvious disposing causes, and in such it seems highly probable that there is a direct interference with the nervous mechanism. Lancereaux has described a case which manifested attacks of angina pectoris wherein, at the autopsy, there was found aortitis, with a direct involvement, by the disease of some of the fibrils of the aortic and cardiac plexuses (Cf. Lancereaux, "Anatomie Pathologique," Paris, 1871, p. 257, and Gazette Medicate, 1867, p, 432). Seeing the common association of the cases of angina which fall under this section, with disease of the arterial coats, it seems very reasonable to link the nerve-phenomena with an affection of the sympathetic filaments which are in such close relation to the coats of the vessel. If we accept this view, the calcification of the coronary arteries— heretofore supposed to induce the symptoms through the degeneration of the heart muscle, which, by impairing the blood-supply, it occasions — is the cause of the pain rather by the direct implication of the cardiac plexus. It is quite true that cardiac degeneration follows coronary obstruction ; but this is a cause, not of the pain, but rather of the fatal issue. In a case recorded by Romberg, it was proved that not only the cardiac nerves were involved, but also the vagus. In his attacks, the patient, a man aged thirty-six, after a prodroma of apprehension and terror, felt his heart stand still — there was an intermission of from five to six beats— at the same time he experienced violent pain on both sides of the chest, extending to the neck and head. Here was a complex form of angina, the peculiarity of which was a long arrest of the heart's action. At the post-mortem examination the great cardiac nerve was found very distinctly diseased, and the left vagus as well as the phrenic were involved in diseased glands. The vagus is the inhibitory nerve of the heart, and there could be no doubt that an irritation of its inhibitory fibres produced the long intermissions of the heart's action witnessed in the case. The high tension observed in these cases is not necessarily associated with hypertrophy of the left ventricle. In the case of Dr. Arnold, the walls of the left ventricle were much thinner aad softer

atLte? J°Ln ^ed after attlf

ang m pectoris and the heart in his case was found to be very smaU and its tlssue pale. Dr. W. T. Gairdner says : « ±>0Z

mortem ex^nnnations have generally shown that the heart is ound fl d ratt rig.dly contractedi andtheIes.ona

found m the muscular substance of the heart itself are usually such as would confirm the idea of decidedly and permanently I?}™ , e^'^.rfhert^^ disposition to abnormal contraction." The high tension, then, is due to vascular rather than to cardiac causes ; the left ventricle labours against the obstacle imposed by the firm contraction of the arterioles. In the large class of cases of angina pectoris associated with atheromatous disease of the great arteries, I consider that a strict analogy is established with those cases of epilepsy which are found to depend on local irritation of the nerve centres in the former, owing to irritation of the nerve fibrils involved ' m the wall of the diseased artery, there are periodic explosions expressed by the tight contraction of the arterioles and the consecutive heart-struggles, whilst in the latter the expression ot the maximum of central irritation is an epileptic fit In any case manifesting angina pectoris, I counsel you strongly to obtain, by means of the sphygmograph, evidence of the condition of the vessels. I may mention a case in point. I saw in conjunction with my friend Dr. John Bruntou, an old lady of sixty-nine, who suffered from severe pain, referred to the epigastrium and abdomen. This pain might very easily be referred to visceral congestion, but it was to a considerable extent paroxysmal, and there was a marked look of anxiety upon the face with tendency to cold perspiration. The heart sounds betrayed nothing abnormal, but a tracing of the radial gave very important evidence. Not only was there extremely high tension, but the trace bore strongly the characters of aortic obstruction (see tracing of Aortic Obstruction in Part II.). I had no hesitation in concluding that the vessels were extensively diseased, and it seemed to me very probable that the great suffering referred to the epigastric and umbilical regions might be ascribed to disease of the coats of the abdominal aorta. Nitro-glycerine gave relief, and the subsequent history of the case confirmed the diagnosis. Dr. Brunton wrote me : " The old lady has gone on tolerably well

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till two days ago, when failure of pulse came on, only one decent beat in ten, but over the heart the sounds were quite normal in strength, rhythm, and note. ... You will find the case a most interesting witness of the power of the sphygmograph." It is very probable that some of the recognized forms of abdominal pain are but varieties of angina. Whilst ascribing, however, to direct disease of the arterial tissues the causation of a large proportion of those cases of angina which are accompanied by persistently high vascular tension, I do not mean to assert that in some instances the attack may not be initiated by visceral causes. Bergson has narrated a case of angina, in which there was enlargement of the liver, the attacks ceasing after treatment directed to the hepatic disease. (On this as well as many points of interest as regards angina pectoris, see Dr. Milner Fothergill, "The Heart and its Diseases." Second edition, chap. xi. London : Lewis.)

You have seen, then, that a large numher of heart cases occur without the manifestation of any painthat the special pain of heart disease, though of great diagnostic importance, is of comparatively rare occurrence. You may he led to inquire what are the other symptoms that lead up to the suspicion of heart disease ; and although we cannot enter at all deeply into symptomatology, we may endeavour to give a brief answer to the question.

In this review of symptoms, in order to give a rough idea of the relative frequency, I shall place between brackets the number of instances in which each has been observed in the hundred cases which I have taken as typical. The first class of symptoms (A), excluding pain which we have already considered, includes palpitation and disturbances of the muscular structure of the heart. Palpitation is far from being a pathognomonic sign of heart disease. Its first cause resides often in the nervous system. It is not by any means a sign of heightened functional

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activity but is rather the "spurt" of overtaxed and weaned muscle. Though occurring verv often in cond.tions in which the heart is not •structurally diseased, palpitation is a frequent sig-n and source of trouble m organic heart affections (28) It is specially called forth on exertion, often of the slightest degree, and it occasions much distress- in some cases, especially where the aortic valves cannot close perfectly, the patients complain that the heart beats like a hammer. Another sign of imperfect action of the muscle of the heart is Intermission. After a number of pulsations at regular intervals, the heart waits over the whole period necessary for a contraction, and then resumes, to wait again after another interval. Intermittency, like palpitation, may be no sign of structural heart disease ; it is in many cases due to an incoordination of nervous actions, and is to be ascribed, not to cardiac, but to cerebro-spmal causes. When it does occur, however m ascertained organic disease, it is of serious import! It often means that the contraction of the auricles is at certain times so imperfect that they do not fill the ventricles. The necessary stimulus to the ventricular contraction is a sufficient repletion of the cavities. Hence the ventricles wait until the auricles supply them with enough blood. A third trouble of heart-muscle is Irregularity. This, also, is due to a want of action, in accord, of the layers of muscular fibre of which the heart consists. The heart does not wait for a whole beat as in intermission, but alters its rhythm irregularly. Sometimes the left and right sides do not contract, or do not complete their contraction, at one and the same moment; then the action may be reduplicate. Sometimes there is so much

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disturbance that the periods of action and rest cannot be discriminated ; the beats are tumultuous. Irregularity may, like the other disturbances of heart-muscle, exist independently of organic disease ; but when it reaches a high degree, it is one of the strongest evidences of such disease. Patients sometimes describe the irregular action as like the fluttering of birds. One complained to me of a fluttering in his heart " like two pigeons." Such signs are of dangerous import.

The symptoms, however, may be referred, not to the heart itself, but to the next portion of the system of blood-distribution— to the arteries. Patients complain of (B) Pulsation. This, we shall see, is very pronounced in the general arterial system when the aortic valves are incompetent to close. It was complained of in my patients as a symptom of distress (3) in the ear whilst lying on the pillow, in the right temple, in the occipital region. Pulsation is, of course, a characteristic sign of aneurism, but this condition we do not intend to discuss. Another arterial symptom in connection with heart disease, but rare and of no considerable diagnostic importance, is Flushing. A very important consequence is (C) Hemorrhage (22). This may occur from the lungs (12), when it must be remembered that it has not the dangerous significance of the haemoptysis of pulmonary phthisis. Considerable cpiantities of pure blood can be expectorated with the result of relieving the venous engorgement of the lung which is the result of some forms of heart disease. Of worse omen, in my opinion, is the frecpient voiding of blood-stained sputa; this occurs usually when the right side of the heart is dilated, and is one of the late consequences of valvular disease.

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Bleeding' from the nose (5) is far from uncommon in heart disease ; haemorrhage may occur also from the stomach (3), or from the uterus (metrorrhagia) (2). In all these cases the haemorrhage may occur from the direct rupture of capillaries by the shock of an unduly contracting left ventricle, but much more commonly it occurs from superinduced venous congestion. Occasionally the haemorrhage is not manifest outwardly, but occurs in the interior of organs.

Other signs are referable to plethora of the venous system. The veins may sometimes be seen to be obviously distended, and in some cases, as we shall describe, the large veins pulsate. Patients with certain malformations of the heart exhibit a blueness of surface (D), Cyanosis, from the distribution of venous blood by the arterial channels or from venous congestion. A like blueness obtains intermittingly, on account of venous congestion, in the paroxysms of dyspnoea from which patients with heart disease occasionally suffer. A consecpience of habitual venous plethora may be (E) Dropsy, of which it is well known that cardiac disease is one of the great inducing causes.

Next in order to the obvious disturbances of the heart itself and the channels of blood-distribution, we come to consider the symptoms of disturbance of the functions of the lungs in heart diseases. These symptoms are far more frequent than those referred to the heart itself. Nearly half the cases (45) complain of difficulty of breathing. Some (8) are obliged to sit upright (orthopncea) in order to breathe. A very large proportion of patients with heart disease suffer from cough (45).