Diseases of the heart

Front matter

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Preface

In presenting this work to the profession the author does it conscious of two facts: first, that its contents have merit, for more than a dozen years, guided by the precepts laid down in it, patients both private and clinical have been benefited; and second, that there are imperfections in it; for perfection is a quality that few attain.

An attempt has been made to present the different phases of this subject in as brief, concise and practical a manner as possible. Controversial topics have been avoided and doubtful subjects omitted. Much attention has been devoted to the general treatment, to make it as complete as possible, believing this to be the weak point in the practice of many physicians. In order that there may be but few repetitions, at different places in the book the reader has been referred to other articles for the indications for certain remedies.

In presenting the remedies called for in a disease but little attention has been given to their alphabetical order; on the contrary, they have been presented in the order of their importance as observed by the writer.

In preparing the work, the assistance has been derived from the standard works, current literature, private and clinical practice, to all of which the author extends thanks, as well as to the many kind friends who have spoken words of encouragement.

CONTEXTS.

Chapter I

The Relation of the Heart to the Chest Wall and Surrounding Organs.

Chapter II

Clinical Examination of the Patient and Semeiology: Inspection — Apex Beat — Epigastric Pulsation — Palpation — Percussion — Auscultation — Cardiac Murmurs — The Arterial Pulse — Inspection and Palpation — Sphygmograph — Tracing — High Tensioned Pulse — Low Tension Pulse. Symptoms of the Digestive System— Blood and Glands— Respiratory System — Skin — Kidney — Reproductive System — Nervous System.

Chapter III

Cardiac Pathology: Etiology — Palpation — Rheumatic Poison — Gout — Acute Infectious Diseases — Cloudy Swelling — Fatty Heart — Senile Changes — Reaction of Tissue to Irritation — Hypertrophy.

CHAPTER TV.

Therapeutics : General Statement — Rest — Change of Temperature — Diet — Stimulants — Movement of the Bowels — Anemia — Sleep — Mental Condition — Scarification of the Skin — Exercise — Oertel's- Schott's Baths — Exercise.

Chapter V

Pericarditis: Definition — Varieties — Etiology — Pathology — Symptoms. Fibrinous : — Inspection — Palpation — Percussion — Auscultation. Serous Form: Inspection — Palpation — Percussion — Auscultation. Purulent — Hemorrhagic — Chronic Forms : Diagnosis — Differential Diagnosis — Prognosis — Treatment.

Chapter VI

Mediastino-Pericarditis : Etiology — Pathology — Symptoms — Diagnosis — Prognosis — Treatment. Adherent Pericarditis: Etiology — Pathology — Symptoms — Diagnosis — Prognosis — Treatment. Hemopericardium : Etiology — Pathology — Symptoms — Diagnosis

— Prognosis — Treatment. Pneumopericardium : Etiology — Pathology — Symptoms — Diagnosis— Prognosis— Treatment. Hydropericardium : Etiology — Pathology — Symptoms — Diagnosis — Prognosis

— Treatment. Pericardial Tuberculosis : Etiology — Pathology — Symptoms — Diagnosis — Prognosis — Treatment. Pericardial Syphilis — Neoplasms — Actinomycosis — Hydatid Cysts.

Chapter XI

Spontaneous Rupture of the Heart : Etiology — Pathology — Symptoms — Diagnosis — Prognosis — Treatment. Aneurysm of the Heart : Etiology — Pathology — Symptoms — Diagnosis — Prognosis — Treatment. New Formations: Tuberculosis — Cardiac Atrophy : Etiology — Pathology — Symptoms — Diagnosis — Prognosis — Treatment. Syphilis of the Heart : Etiology — Pathology — Symptoms — Diagnosis — Prognosis — Treatment. Wounds of the Heart: Symptoms — Physical Signs — Diagnosis — Prognosis — Treatment. Amyloid Disease — Calcareous Degeneration.

Chapter XXXIII

Acute Arteritis : Definition — Etiology — Pathology — Symptoms — Diagnosis — Prognosis — Treatment. Arterio-sclerosis : Definition — Etiol ogy — Pathology — Diagnosis — Prognosis — Treatment . Arterial Degeneration, — Fatty — Hyaline. Arterial Infiltration,— Calcareous — Amyloid. Coronary Arteries.

Chapter I. The Heart

Its relation to the Chest Walls and Surrounding Organs.

The heart occupies a central oblique position in the thoracic cavity, its base being upward, backward and to the right; while its apex is downward, forward and to the left. From an anterior view the right auricle and ventricle are all that can be seen, with the exception of a small portion of the left ventricle to the left.

The right auricle is behind the sternum, extending from a point one inch to the right of the right border of the sternum to the left border, and from a level with the third costal cartilage it extends downward to a point on a level with the seventh right costal cartilage.

The right ventricle is pyramidal in shape, its lower boundary resting upon the central tendon of the diaphragm; at the apex of this pyramid is the pulmonary artery, at its left border is a furrow where it unites with the left ventricle, while on the right side there is a furrow where it unites with the right auricle.

The left ventricle forms the left border of the heart as seen anteriorly, extending from the third left intercostal space down to the fifth intercostal space, where it terminates in the apex.

The appendix of the left ventricle lies directly behind the third left costal cartilage, close to its junction with the third rib.

1 4 THE HEART.

The area that would be mapped out on the chest as indicating the position of the heart is spoken of as the area of deep cardiac dullness.

The only portion of the heart not covered by lung tissue is a part of the right ventricle. This is spoken of as the area of superficial cardiac dullness: and is indicated by a line extending downward to the left of the middle of the sternum, from the level of the fourth costal cartilage to that of the sixth; its left border is indicated by a line started from the first point and extending along the fourth cartilage to its junction with the rib, and then dipping downward and curving outward to the apex. The base is indicated by a line extending from the sixth right costal cartilage to the apex.

The heart is surrounded by the fibro-serous membrane, the pericardium; its base is held in position by the great vessels with which it is connected. Its posterior surface is flat, is formed by the left ventricle, rests upon the diaphragm, and extends from a level of the fifth to the eighth dorsal vertebra.

Chapter II. Clinical Examination

Of the Patient and Semeiology.

The examination should be made systematically by inspection, palpation, percussion and auscultation. During this time the patient should occupy such a position that the light falls directly on the front of the chest, from which the clothing has been removed. It should be made when there has been quiet for some time, that all the organs may be observed in a condition as near normal as possible. The patient may occupy the standing, sitting or reclining position.

Inspection : — In a normal condition the two sides of the chest are symmetrical, and any departure from this should be examined. A bulging of the precordial space or deformity about the chest wall might cause a displacement of the heart; or a fixation of the thorax that might result from pleural adhesion or fibroid disease of the lungs. Any retraction of the intercostal spaces during cardiac systole should be noted as indicative of pericardial adhesions or cardiac hypertrophy with dilatation.

Apex Beat: — In the adult this is in the fifth intercostal space, just within the mammillary line. It is most apparent in children and in those with thin thoracic walls, while in those with an excess of adipose tissue and of short thorax it may not be evident; in a few cases it is directly behind the sixth rib and as a result is hidden. The position of the apex beat varies in health according to the position of the patient, moving to the right or left as the patient chooses one or the other side in repose. It also follows the movement of the diaphragm in respiration. Protrusion of the thorax from the third to the seventh ribs and from the sternum to the nipple is present at times; the result of enlargement of the heart, which is due to hypertrophy, dilatation or a distention of the pericardium due to an exudate. If the exudate is very large there will be bulging of the intercostal spaces.

Increased force to the apex beat is noticed in the cardiac activity due to psychic conditions; in certain neurosis as Grave's disease; at the beginning of endocarditis; during early stages of fevers and hypertrophy of the heart. It is displaced to the outside of the mammillary line in right sided pleural exudate, the displacement being in proportion to the exudate; when marked, the apex beat may be in the fourth intercostal space and at the axillary line, This tilting of the apex beat upward is due to the inferior vena cava being drawn downward by the depression of the diaphragm. In cases of left sided pleural exudates and pneumo-thorax the apex is either hidden altogether or displaced to the right. In many of these cases a cardiac impulse will be seen to the right of the sternum from the third to the fifth spaces and corresponds to the base of the heart. A displacement of the apex beat is noticed to the right or left when the corresponding lung is retracted. Any displacement of the diaphragm upward or downward will produce a corresponding displacement of the heart. At times there is a complete inversion of the viscera, and in these cases the apex beat is found upon the right side. The cardiac impulse is diffused where there is retraction of the border of the lungs, due to superficial breathing, contraction of the lungs or enlarged heart. In cases of hypertrophy of the left ventricle, the apex beat may be outside of the mammillary line, and if the ribs and cartilage are elastic they are lifted with each pulsation.

Epigastric pulsation is observed in thin individuals as a result of the pulsations of the abdominal aorta, and is most pronounced when the heart's action is vigorous as in certain neurosis; when the stomach is distended as after a meal or when some new formation develops anterior to the aorta. Pulsation in the hepatic veins and hypertrophy of the right ventricle also produces it. An aneurysm of the ascending aorta will produce a pulsation in the first and second intercostal spaces to the right of the sternum. While a pulsation in the first intercostal space on the left side, indicates an aneurysm of the arch of the aorta. A pleuritic effusion may participate in the cardiac movements, and a pulsation be noticed as a result. A pre-systolic or systolic pulse may be noticed in the cervical veins, indicative of tricuspid incompetency.

Palpation: — This assists and confirms inspection, and is best accomplished by placing the hand over the precordial region in such a manner that the tips of the fingers locate the apex beat, and the palm of the hand is over the heart. In this method -not only the apex beat, but also any friction rubs and thrills are at once conveyed to the hand. In the normal heart a slight impulse is felt which may be confined to the apex or extend over a larger area,

CLINICAL EXAMINATION.

depending upon the extent to which the lungs cover the apex. At times, on account of pericardial exudates or adipose tissue, the apex beat may not be palpable. Hypertrophy of the heart is attended with an increased impulse; and a degeneration, with a diminished impulse. The hand detects thrills which may be either exocardial or endocardial. If connected with the pericardium it will be rubbing, scraping and intermittent in character. While the endocardial thrill is continuous and purring in character, and either pre-systolic, systolic or diastolic in time; exocardial thrills are irregular.

The exocardial murmurs may not be developed until the ringers are pressed into the intercostal spaces, and are often obliterated by the patient taking a long breath. A thrill at the apex is usually felt just before the first sound ( presystolic ) and indicates a mitral stenosis; a distinct systolic thrill felt at the second intercostal space on the right side of the sternum indicates stenosis of the aortic valve. Thrills are not common with insufficiency nor in disease of the valves of the right side of the heart. But a communication between the two sides of the heart often gives rise to a pronounced thrill. The gravity of the disease must not be judged by the loudness of the murmur or the clearness of the thrill.

Percussion : — This is of no service apart from defining the size of the organ and its relation to surrounding structures. The area of flatness or absolute dullness of the heart corresponds to that portion of the right ventricle which is not covered by the lungs, and is triangular in shape; when the lungs are at rest its right border is at the middle of the sternum, while the left border begins at the upper border of the fourth costal cartilage, from which point it curves outward and downward, crossing the fourth intercostal space and the fifth rib until it reaches the fifth intercostal space, at which point it curves slightly inward until the cardiac dullness blends with the hepatic dullness. This makes an area of about two inches in the vertical by one and one-half inches in breadth, which varies slightly during inspiration and expiration. The size of the area of deep or relative cardiac dullness varies with all the changes in the size of the heart. In hypertrophy and dilatation the relative dullness is increased in certain directions; in case of the right side the transverse diameter is mostly increased, while in those of the left side, it is the vertical diameter that is mostly increased. The area of superficial dullness is increased as a result of pericarditis, hypertrophy and dilatation. To find the upper border of absolute cardiac flatness one should commence at about the second costal cartilage and percuss downward: usually, at about the middle of the fourth costal, the pulmonary resonance gives way to cardiac dullness. To find the left border we begin at the mammillary line and the fourth rib, and percuss in parallel lines from this to the apex. The left border is curved. At the lower border the cardiac dullness is continuous with that of the liver.

Absolute cardiac flatness changes with respiration, becoming smaller during inspiration and larger during expiration. The area of cardiac flatness is increased in those who have breathed superficially for a long time, and in cases of large accumulations of fat in the anterior mediastinum and pathological condition of the lungs. The area of flatness is diminished in deep inspiration, emphysema, collections of fluid and gas in the plural sac, pneumothorax.

Auscultation: — By auscultation we become famil iar with the normal and abnormal cardiac sounds. The first sound of the heart is produced by the closure of the auriculo-ventricular valves, the contraction of the ventricle and the impulse of the apex of the heart against the chest wall. The portion of the first sound produced by the mitral valve is heard best at the apex of the heart; while that produced by the tricuspid valve is heard best at a little to the left of the lower end of the sternum. It is low in pitch, of long duration and booming in quality. It is systolic in rhythm, being synchronous with systole of the ventricle, the apex beat and carotid pulse. It is preceded by a long pause and followed by a shorter one, after which the second sound occurs. This is produced by the closure of the aortic and pulmonary valves, (semilunar) and vibration of the surrounding structures.

The sound produced b}^ the aortic valve is heard best in the second intercostal space, to the right of the sternum; while that produced by the pulmonary is heard best in the corresponding space to the left of the sternum. The second sound is loudest at the points just mentioned and is it heard all over and beyond the cardiac area. The quality of the second sound is sharp and the pitch higher than that of the first sound, while its duration is shorter. The relation of the sounds with their intervening pauses have been represented as l 'lubb" — "dubb"— . The loudness of the sounds are modified by exercise, rest and the thickness of the chest walls.

The sounds are strengthened by such pathological conditions as Basedow's disease and febrile conditions. They are weakened from enfeebled conditions of the heart, great loss of blood and feeble condition of the patient. It should be remembered that adipose tissue or other developments might intervene between the heart and chest wall and muffle the sound. Arrhythmia is often the result of the degeneration of the cardiac muscle.

When a single sound is increased, the others being normal or weakened, the increased sound is said to be accentuated. This is usually caused by the closure of the valves under an increased blood tension. Reduplication of either sound may take place when the valves producing the sound do not receive their greatest tension at the same time. The diastolic sound is more frequently duplicated than the first, or systolic. It is usually temporary but may be permanent and it is not peculiar to any particular lesion. A metallic ring to the first sound at the apex is usually indicative of cardiac hypertrophy, or increased cardiac activity in a normal heart; with the second aortic sound it usually indicates atheromatous conditions of the arteries. Pneumo-pericardium, pneumothorax, a large cavity in the lung with smooth walls close to the heart and a gaseous distension of the stomach may give a metallic ring to both sounds at the apex.

Cardiac Murmurs : — Those having origin within the heart are said to be endocardial, and are divided into organic and inorganic. The former are due to anatomical changes of the valves: the latter to changes in the cardiac muscle, anomalies of the blood and general diseases. The organic endocardial murmurs may be systolic or diastolic, and may be upon the right or left side of the heart. When systolic and upon the left side of the heart they are heard with the first sound. When heard best at the apex it indicates mitral regurgitation. With it there are indications of pulmonary, renal and hepatic congestion, and often edema of the feet and ankles. The left heart is enlarged and there is accentuation of the second pulmonic sound; the murmur is apt to be soft and blowing in quality. Its intensity does not indicate the severity of the lesion. Its area of greatest intensity is at the apex. It is propagated to the left of the apex and is often heard at the lower angle of the scapula; but it is not transmitted to the carotids, and seldom to the base of the heart. This is the most frequently met with of all cardiac murmurs.

An aortic systolic murmur is due to obstruction at the aortic orifice, or a marked dilatation of the aorta just beyond the orifice. The pulse is small and wiry but regular, unless there is great cardiac embarrassment. A thrill is often present over the aortic area. Both the aortic and pulmonic second sounds are feeble. The murmur is harsh in quality with the first sound and its area of maximum intensity is in the second intercostal space to the right of the sternum; sometimes it is in the left; it is propagated to the vessels of the neck and towards the apex, and may be heard at the fourth dorsal vertebra.

A systolic murmur on the right side of the

CLINICAL EXAMINATION.

heart is due either to tricuspid regurgitation or pulmonary obstruction. With tricuspid regurgitation there is apt to be pulmonary disease or some disease of the left side of the heart, and congestion of the brain and abdominal organs; pulsation of the jugular and hepatic veins are observed as a result. The murmur is blowing in quality, replaces the first sound of the heart, has its area of maximum intensity over the tricuspid area at the end of the sternum and has but a limited area of propagation.

The pulmonic systolic murmur is due to obstruction of the pulmonic orifice. Accompanying it there is evidence of venous engorgement and enlargement of the right heart; the pulmonic second sound is weak. The quality of the murmur varies, but is" usually harsh; it accompanies the first sound, its area of maximum intensity is in the second intercostal space to the left of the sternum. It may be propagated towards the left shoulder but not in the direction of the similar lesions at the aortic orifice.

A diastolic murmur on the left side of the heart is due either to a mitral stenosis or an aortic regurgitation. With the mitral diastolic murmur the pulse is small and there is a purring presystolic thrill which is most distinct at the apex. There is pulmonary congestion, enlargement of the left auricle, and accentuation of the second pulmonic sound if the right ventricle is hypertrophied. The murmur is harsh and grinding in quality, long in duration, occurs before, and terminates with the first sound, and has its area of maximum intensity one-half an inch above the apex beat. It has a limited area of propagation, not heard to the left of the apex nor in the vessels of the neck.

With the aortic diastolic murmur the pulse is full, strong and drops away from the finger, " Corrigan's pulse." There is a marked pulsation of the carotids, extending to the angle of the inferior maxillary and capillary pulse is often noticed. The left heart is hypertrophied. The murmur is soft, blowing and often musical in quality. In rhythm it accompanies, replaces or follows the second aortic sound. Its area of maximum itensity is in the second intercostal space to the right of the sternum; it may be in the second intercostal to the left of the sternum or at the xiphoid cartilage. Is has a wide area of propagation down the sternum: to the epigastrium; to the apex; to the carotids; radial and femoral arteries; and at times, down the spine.

A diastolic murmur on the right side of the heart may be due to tricuspid obstruction or pulmonary regurgitation. With the tricuspid diastolic murmur there are symptoms of venous engorgement. The murmur is harsh in quality and presystolic in rythm. It is heard over the lower part of the sternum and is not propagated, except slightly toward the base.

With the pulmonic diastolic murmur there is evidence of venous engorgement and pulmonary disease. The murmur is soft and blowing in quality, it accompanies or replaces the second sound, has its area of greatest intensity in the second intercostal space to the left of the sternum, and is propagated towards the xiphoid cartilage. Functional cardiac murmurs are not constant, have no definite line of propagation and are always limited to the cardiac area and are not attended with enlargement of the heart. The anemic murmur is attended with symptoms of anemia, has the venous "hum" in the cervical veins. Pericardial friction sounds to and fro are superficial and are heard over but a limited area. Pleural friction sound ceases when the breath is held.

The Pulse: — The arterial pulse is a wave of increased pressure passing from the center to the periphery of the arterial system during cardiac systole, and is dependent upon the amount of blood, the energy of the heart and the resistance of the blood vessels.

Inspection : — In children the pulse is ,only visible in the carotids and possibly the temporal and radial arteries; while in the adults it may be seen at different points. In arterial sclerosis, the temporal and some of the superficial arteries of the extremities may be seen pursuing a tortuous course. In cases of aortic incompetency, the excessive pulsation of the carotids and superficial arteries are easily recognized.

Palpation : — The arterial pulse is most satisfactorily papated in the radial artery, immediately above the wrist and between the flexor tendons and the prominent ridge of the radius. The patient should be sitting or reclining and the arm supported at. the time. The observer should use three fingers in such a position that the index finger is nearest the heart, by this method the condition of the artery, the arterial tension and other points may be ascertained readily. When atheromatous changes or aneurysm are suspected, it will be necessary to examine both radial arteries at the same time.

Sphygmograph : — This will be found of service in supplementing the ringer of the observer, and will bring into prominence and demonstrate certain qualities and points of the pulse not clear before,

It should never be taken as a substitute for palpation, as tracings taken by different instruments, or even by the same instrument, but by different operators, differ wholly in their appearance.

In using this instrument the patient should be in an easy position, either reclining or sitting; the arm should rest easily, being supinated; the wrist bent backward, and the fingers partially flexed. The line of the radial artery should be indicated by a pencil. The clock work having been wound up it is then applied to the wrist in such a way that the button is over the radial artery. The paper having been cut to proper dimensions is then blackened b}^ holding it in the smoke of burning camphor. It is then introduced and the pressure

Fig 2. — Typical Pulse Wave. (After Sansom.)

adjusted to bring out the greatest amplitude of movement; the works are then started. To preserve the tracing it should be dipped into a saturated solution of gum dammar in equal parts of gasoline and benzine.

CLINICAL EXAMINATION.

The sphygmograph tracing of the normal pulse is indicated by a sudden line of ascent, which is followed by a more gradual line of descent, the latter being interrupted by two undulations.

Fig. 3.— Normal Pulse Tracing.

The line of ascent or percussion wave is the result of the entrance of the blood from the left ventricle into the artery, where it produces a wave of increased pressure. The line of descent indicates the gradual lessening of the arterial pressure following the cardiac systole. The first interruption is believed to be due to the current of blood passing along the artery. The second interruption is due to an outward wave of increased pressure resulting from a recoil of blood against the aortic cusps.

When palpating the pulse the condition of the artery should be recognized. While in health it gives a sensation of being yielding and elastic under the finger, in febrile conditions it does not give this sensation, but is too yielding. Again it is hard, and rolls under the finger in advancing years; in arterio-sclerosis ; in chronic nephritis and cardiac disease. In these cases the artery is not only hard, but by passing the finger along the course of the artery it will be found to be tortuous. The fullness of the artery should be noticed.

The pulse rate varies in health, being more frequent under the following conditions: in the female;

in infancy; during childhood; in the upright attitude; in high temperature; during the latter part of the day; often from eating or drinking, and during mental or physical exertion. It is also increased from fevers, nervous diseases, and in almost all the organic heart diseases. It is slower than normal during the latter stages of fevers, jaundice, renal disease, in affections of the myocardium and

Fig. 4— Pulse of Aortic Regurgitation.

A high tensioned pulse should always be investigated carefully, as it is often indicative of conditions that shorten life. It is a relative term and is indicated by degrees of fullness of the arteries between the beats. In investigating it three fingers should be used, and by pressure, first with the one nearest the heart, then the second and third, see how many fingers it requires to flatten the artery and control the wave. Being satisfied that such a condition exists, careful search should be made for the cause or causes, which is often found among the following: plethora, capillary contraction, resistance, old age, gout, diabetes, renal diseases, alcohol, sedentary habits and constipation.

A low tensioned pulse is one where the artery can be easily effaced between beats and starts into existence by the pulse wave. The pulse may be large and sudden or small and easily suppressed.

2 9

It is found as a result of fatty degeneration of the heart, obesity, warmth with moisture, warm food and drinks, fatigue, anxiety and debility. In cases where atheroma and aneurysm are anticipated, the radial pulses should be palpated and compared simultaneously. In aortic stenosis the initial percussion wave is slight and gradual while the pulse wave is prolonged. The artery is small and full between the beats. In aortic incompetence the

Fig. 5— Pulse of Aortic Stenosis.

pulse wave is sudden and forcible, but short and not sustained, its cessation being abrupt, giving what is known as the "water hammer" or "Corrigan's pulse." The artery is large but empty between the beats. In mitral stenosis the pulse wave is long, the artery is small and full between beats; the tension being higher than would be expected. In these three the pulse is regular until compensation fails. In mitral regurgitation the pulse is usually irregular both in force and frequency.

The dicrotic pulse is a common feature of a low arterial tension. Usually upon palpation of the radial artery but one pulsation is felt to each cardiac systole; but when dicrotism is present a second pulsation is felt immediately following the first. In this condition the tidal wave is absent while the dicrotic notch is exaggerated. When, in a sphygmographic tracing, the dicrotic notch touches the base line, it is said to be fully dicrotic; but when the notch sinks below the base line it is said to be hyperdicrotic. This condition may be produced by a hot bath and it is a clinical feature during the later stages of acute febrile diseases.