>> $< Diseases of the Heart: Their Diagnosis and Treatment. By ALBERT ABRAMS, A. M., M. D., (Heidelberg), F. R. M. S., rONSULTING PHYSICIAN FOR DISEASES OF THE CHEST, MT. ZION HOSPITAL AND THE FRENCH HOSPITAL, SAN FRANCISCO. CHICAGO : G. P. ENGELHARD & COMPANY, 1900. THF LiBRAftY OP CONGRESS, Two COPHi^ RE06IVCD CLAS«(X OOCa No. corr b. Copyright 1900 By G. P. ENGELHARD & COMPANY. CONTENTS. Chapter. Page. I. Introduction to Diseases of the Heart . 11 II. The Diagnosis of Diseases of the Heart 30 III. General Treatment of Diseases of the Heart'. 65 IV. Affections of the Pericardium 92 V. Endocarditis and Chronic Valvular Disease 109 VI. Neuroses of the Heart 128 VII. Affections of the Arteries ; . . . 144 VIII. Addendum 155 PREFACE. This little book was never intended to aspire to the dignity of a treatise on diseases of the heart. The primary object was to make it useful to the practical physician in the diagnosis of cardiac diseases. The cardiac diagnostician is often like the veterinarian, for his diagnosis is based essen- tially on objective signs. He must depend largely on the Baconian or inductive method of ratiocina- tion, in contradistinction to the deductive method. The former analytic method of diagnosis is a conclusion drawn from concrete facts. Mistakes in diagnosis may be attributed to the following causes: 1. Incomplete or careless examination. 2. Misinterpretation of symptoms, due to errors in judgment. 3. Ignorance of the methods of examination. 4. Prejudiced preconception. 5. Incompleteness of medical diagnosis. 6. Placing too much reliance on the results of treatment. 7. Incomplete history of the case, and the incom- plete development of symptoms. 8. Simulation or dissimulation on the part of the patient. 1. Errors in diagnosis are not so much due to ignorance as carelessness. Sir William Savory tritely remarks, "Consciousness of one's ignorance may do much to avert the errors of carelessness, and he who has confidence in his own judgment should of all men be most careful in inquiry." Unfortunately, we of to-day treat the disease, but not the patient. "And I said of medicine, that this is an art which considers the constitution of the patient, and has principles of reason and action in each case." It is but a few years ago, that a physician punctured a pregnant uterus with a tro- car, believing that he was dealing with a case of ascites. We recall the grave error occurring in the practice of a famous English surgeon who mistook a swelling in the neck for an abscess, who, with more precipitation than reflection, plunged his lance into the tumor and death from hemorrhage resulted. 2. Under the caption of misinterpretation of symptoms due to errors in judgment, mistakes may arise from (a) placing too much reliance on the subjective symptomatology; (b) giving undue prominence to one symptom to the exclusion of others; (c) grouping symptoms which are the effect of disease, and not the disease itself. When the pathologist makes an autopsy he records many of the pathological conditions found, as anatomic diagnoses. The clinician should be similarly guided. It would appear at times as if, in our struggle to establish a diagnosis, it would be better to make none at all, rather than group symptoms under such equivocal expressions as pseudoangina, arrythmia, cardiac palpitation, etc. Such expres- sions mean practically nothing in etiologic diag- nosis. 3. Ignorance of the methods of examination is responsible for many unfortunate mistakes. The rejected applicants of insurance companies furnish a large contingent. Nephritis is diagnosed because albumin is present in the urine, diabetes, because sugar is found, and heart disease because murmurs are heard. An unprincipled physician could reap a harvest, by putting in condition for re-examina- tion many rejected applicants, diseased or other- wise, for life insurance. 4. Prejudiced preconception arises from two causes: (a) Placing too much reliance on the history of the patient; (b) being misled by first appearances. Like the critic who never read a book before he received it because he might be prejudiced, so it should be with the physician — he should not learn the history of his patient be- fore he examines him. Diseases present such vari- ous pictures, that with our mental astigmatism, we can see anything we want. The personal his- tory of the patient should only be used in confirm- ing the objective examination. 5. When a disease runs a typic course diagnosis is, as a rule, easy ; but when the affection is a typic, one is frequently led into error. The physician is too often inclined to misinterpret the limitations of his art, mistaking the latter for his own delii^ quencies. Myocarditis is more often an anatomic than a clinic diagnosis. Differentiation between cardiac dilatation and pericardial effusion is ex- ceedingly difficult at times and to puncture the dilated heart with the idea that the latter condition is present is a gross error. Treatment should never be attempted before a diagnosis »is made. Better no treatment than meddlesome therapy. Qui bene dignoseit, bene curat. It is related of Frerichs, that after examining a patient, he was in doubt about the diagnosis. The patient insisting about knowing the nature of his trouble, Frerichs comforted him with the assurance that the diag- nosis would be determined at the autopsy. 6. We are frequently led into error by mistak- ing recovery for cure, thereby ignoring the vis medicatriz naturae. I have seen many patients with organic cardiac murmurs, the latter becom- ing less intense after the administration of chalyb- eates. Under the circumstances, one would be inclined to regard the murmurs as anemic. Upon more mature consideration, this view would be dispelled. Impoverishment of the blood attends nearly all organic cardiac affections and only suc- ceeds in intensifying the murmurs, hence iron only removes the factor in intensification. 7. Diagnosis must be held in abeyance in many cases owing to undeveloped symptoms and incom- plete history of the case. Problematic diagnoses are elusive, and a diagnosis altered to correspond with each stage of the patient's illness is no diag- nosis at all. 8. Disease is expressed in a manner peculiarly its own. The interpretation of the signs consti- tutes diagnosis. The translation may be correct, partially correct, or wrong. In all three instances the result, as far as the patient is concerned, will, as a rule, be the same, provided no treatment is instituted. To treat a disease, other than by ex- pectant methods, where the diagnosis is wrong, is adding insult to injury. S. W. cor. Van Ness Avenue and California St. December, 1900. San Francisco. CHAPTER I. INTRODUCTION. The heart with its valvular apparatus acts like a pump with a suction and pressure valve. Dur- ing diastole, it sucks the blood from the veins, and during systole drives it into the arteries. There- fore during diastole the pressure in the veins sinks and rises in the arterial system during di- astole. This difference in pressure causes the blood to circulate. COMPENSATION. All heart affections, whether of the valves, muscle or pericardium, result in circulatory dis- turbances and are characterized by diminished pressure in the arteries and increased pres* sure in the veins, with retardation of the blood current in the capillaries. When the heart by in- crease of power and volume opposes the local and general disturbances, the lesion is said to be com- pensated, and a well compensated valvular lesion may be unattended by subjective symptoms. Compensation fails when the heart muscle (myocardium), in consequence of nutritive dis- turbances, degenerates. A valvular heart trouble, especially in children, retards development and 12 DISEASES OF THE HEART. nutrition, leading to cardiac cachexia. The not- able tissue changes are thickening of the nose and lips and clubbing of the finger ends. Overloading of the veins leads to the accumu- lation of fluid in the tissues ; beginning first in the feet, it gradually invades the rest of the body. Fluid also accumulates in the serous cavities (pleura, pericardium, brain ventricles). As a rule, the peritoneum is the first serous cavity in- vaded (ascites). The chief cause of cardiac dropsy is disease of the mitral valve, and especially mitral stenosis. Cyanosis of the skin is an early sign and ap- pears as soon as the pulmonic circulation is dis- turbed, therefore cyanosis is more evident in mitral than in aortic lesions. The cutaneous veins are filled with blood and may become varicosed. Jaundice, due to catarrh of the bile passages, is not uncommon. Cutaneous hemorrhages from rup- ture of the capillaries or caused by emboli may develop. The temperature of the body may be normal or lowered, owing to the retarded circulation. Inter- current elevations of temperature may be caused by emboli in the viscera or lung infarcts. PULSE. The pulse has a specific character in nearly every valvular lesion. Disturbance of compensation gives a frequent, irregular, soft and feeble pulse. An INTRODUCTION. 13 intermittent pulse is caused by feeble heart con- tractions which are not strong enough to drive the blood to the radial artery. In such instances, if the heart is auscultated synchronously with pal- pation of the pulse, there are more heart tones than pulse beats. Palpitation of the heart, a frequent symptom, may be subjective, objective, or both. Pain in the precordia radiating to the left arm, neck or um- bilicus, gives rise to symptoms not unlike angina pectoris. This precordial pain is especially fre- quent in aortic incompetency and has been at- tributed to irritation of the cardiac plexus by the dilated aorta. BLOOD-VESSELS. Emboli and thromboses occur. Emboli from the right ventricle pass into the pulmonary arteries and cause hemorrhagic infarctions. Emboli origi- nating from the left ventricle go to the extremi- ties, skin, retina or the viscera. Embolism of the spleen is manifested by a sudden chill, fever, per- spiration, pain in the splenic region and enlarge- ment of that viscus. To the foregoing symptoms, hematuria is added when the embolus attains the kidney. An embolus of the brain reaches that organ usually through the left carotid artery. LUNGS. Dyspnea, especially on exertion, is frequent. The dyspnea of heart disease is out of all propor- DISEASES OF THE HEART. tion to the physical changes in the lungs. Diffi- cult breathing is usually caused by pressure of the enlarged heart on the lungs, disturbed pulmonic circulation, hydrothorax, ascites or bronchial catarrh. Hemoptysis occurs frequently in mitral disease. Hemorrhage may be due to congestion, rupture of vessels or hemorrhagic infarcts. Hemoptysis is most frequently the result of infarcts, and the latter are frequent in aortic disease. Lung in- farcts lead to a brownish red sputum not unlike that of pneumonia. Stress has been laid on the fact that in hemoptysis of cardiac origin, the blood is clotty and blackish blue in color. Edema of the lungs is a frequent cause of death. It gives rise to diffuse crepitant rales and serous expectoration. Valvular heart troubles predispose to inflammatory lung affections. Glottis edema may complicate heart lesions. Epistaxis is not infrequent. GASTEECTATIC DYSPNEA. A frequent cause of dyspnea in heart disease is acute dilatation of the stomach. After meals patients complain of difficult breathing and dis- tress in the precordia, and death has not unfre- quently followed an indigestible meal. I have called this condition gastrectatic dyspnea, because it is always associated with a dilated stomach. In some instances dyspnea is associated with symp- INTRODUCTION. 15 toms of angina pectoris. Many patients make- no mention of dyspeptic symptoms. They com- plain of pressure or weight in the sternal or pre- cordial region, and often add that eructation will relieve the pressure. This symptom, as I have assured myself after examination of a number of cases, is dislocation of the heart upwards by an acute or chronically dilated stomach. Some years ago I reported a case of gastroptosis and merycis- mus, with voluntary dislocation of the stomach and kidneys.* This phenomenal case taught me one fact in particular, how easily the heart could be displaced by dilatation of the stomach. The in- dividual in question could, by buccal insufflation of the stomach, cause his heart to disappear be- hind the lungs, so that percussion of the pre- cordial region yielded no dullness on percussion. This case directed my attention to a correct investigation of all individuals presenting them- selves for the treatment of slight dyspeptic symp- toms in whom sternal pressure was the chief subjective symptom. In all such cases the diminished area of cardiac dullness bears a distinct relation to the severity of the pressure symptoms. The removal of ingesta and gases from the stomach restores the heart to its normal position and feeble heart tones become strong. *Medical News, April 13, 1895. 16 DISEASES OF THE HEART. Not infrequently true asthmatic attacks, asthma dyspepticum, v/ere present. . The patient is unable to get rid of the gases owing to a spasm of the Fig. I — Skiascopic picture of the outline of the heart and stomach before swallowing the seidlitz powder. sphincters of the stomach; the distended stomach pushes the diaphragm upward, dislocating the heart, and induces typical attacks of asthma. INTRODUCTION. 17 To quickly detect a dilated stomach encroach- ing on the chest organs, the following percussion method will be found practical. The circular tympanitic stomach-lung region formed by the stomach beneath the lower lobe of the left lung gradually disappears behind the axillary line if the stomach is normal, but if dilated, the tympan- itic sound may be traced to the vertebral column. Sometimes in dyspeptic asthma relief is quickly obtained by introduction of the stomach tube and allowing the gases to escape. The following il- lustrations describe more fully than words the influence of a dilated stomach on the position of the heart. They are rough reproductions from the fluoroscopic picture with the use of the X-rays. In the average examination of the chest by the X-rays, the portion of the stomach which is in direct contact with the chest wall is obscured by the shadow cast by the spleen, but in this patient no spleen shadow being present and the contour of the stomach being clearly defined, opportunity was afforded to test the influence of a stomach distended by a seidlitz powder on the position of the heart.* Every phase of the stomach distention was followed in the fluoroscopic picture. *Later a similar case came under my observation. See "Note on a Case of Nervous Eructations Studied by Skiagrams," Philadelphia Med. Journal, Aug. 12, 1899. 18 DISEASES OF THE HEART. CARDIAC ASTHMA. Cardiac Asthma closely simulates bronchial asthma, but the former is associated with some anomaly of the heart or arterial system. If such Fig. 2 — Shows the same organs after distention of the stomach by gas. anomalies exist, asthmatic paroxysms may result, whenever the pressure in the capillaries of the lungs rises. Such rise in pressure may follow an INTRODUCTION. 19 increased or diminished blood pressure in the aorta. In either instance, the capillaries of the lung alveoli become surcharged with blood, which in turn make the alveolar walls rigid and incapable of distension, thus diminishing the respiratory area. The following table may assist in differential diag- nosis : BRONCHIAL ASTHMA. Usually absent. CARDIAC ASTHMA. Signs of cardiac disease (valvular lesion, arterio sclerosis, fatty heart). Dyspnea is equally in- spiratory and expira- tory. Pulse in the early stage of paroxysm may be strong, but it soon be- comes soft and small. Percussion shows an ex- tension of the borders, of the lungs and oblit- eration of the area of superficial cardiac dull- ness. Auscultation shows an ab- scence of rales unless complicated by edema of the lungs. DIGESTIVE APPARATUS. Yenous stagnation conduces to chronic catarrh of the gastro-intestinal mucous membrane, re- sulting in dyspepsia, constipation, diarrhea and Dyspnea is expiratory. The pulse is usually one of increased tension throughout the par- oxysm. The extension of the lung borders is more pro- nounced than in cardiac asthma. Sonorous and sibilant rales are always heard, louder during expira- tion than inspiration. 20 DISEASES OF THE HEART. hemorrhoids. Gastralgia occurring in cardiac lesions may mislead the physician if the diagnosis is of a stomach trouble. LIVER AND SPLEEN. The liver participates early in the circulatory disturbances. Owing to the venous engorgement of the inferior cava, the hepatic veins cannot un- load, and the liver in consequence swells and may be felt below the border of the ribs as a hard and painless mass. Later in the disease, owing to atrophy of the liver cells, the organ may become reduced in size. Not infrequently the enlarged liver may pulsate owing to transmitted pulsations from the aorta. It is well to remember that the knee-elbow position will usually cause the disap- pearance of transmitted pulsations. Stagnation of blood in the portal circulation leads to venous en- gorgement of the spleen, stomach and intestines, with enlargement of the first mentioned viscus. From the quantity and constituents of the urine the severity of the compensation failure may be gauged. The lower the blood pressure in the aorta and the higher the blood pressure in the venae cavse, the more the urine partakes of the charac- teristics of passive congestion of the kidneys. The urine is reduced, of high specific gravity, contains albumin, casts, and often blood corpuscles. Uric INTRODUCTION. 21 acid is increased and is deposited as a brick dust sediment. NERVOUS SYSTEM. Aortic lesions, particularly owing to brain anemia, are often complicated by syncopal attacks. Brain hyperemia complicating heart lesions is characterized by attacks of fainting, fullness in the head, ringing in the ears, etc. Nitrite of amyl inhalations are of signal advantage in diagnosis. This drug will ameliorate symptoms of brain anemia and intensify those of hyperemic origin. An embolus in the left arteria fossae sylvii will cause hemiplegia on the right side, associated with aphasia. Temporary aphasia may occur without an embolus and must often be attributed to mere circulatory disturbances. Mental diseases are not frequent in heart lesions. In some cases a real intellectual disturbance exists. Observations are recorded of maniacal delirium in patients with mitral lesions. Such cerebral troubles may be remedied by treatment directed exclusively to the heart. RELATION OE DISEASES OF THE HEART TO OTHER DISEASES. An individual with a heart lesion assumes a grave risk when attacked by other diseases. This is notably the case in febrile affections. In fever, the organs show cloudy swelling; a like change occurs in the muscles, and the heart manifests the DISEASES OF THE HEART. granular alteration of its fibres to the highest de- gree. These tissue changes arise from contact with the poisons circulating in the blood and from the accompanying rise of temperature associated with disturbances of nutrition. A febrile affection therefore may seriously implicate the functions of the heart in valvular lesions. Intercurrent diseases of the lungs tax the func- tions of the right heart to the utmost. Pregnancy always causes hypertrophy of the heart, but this recedes in the healthy woman after delivery. Cardiopathic patients are predisposed to acute exacerbations of endocarditis, and a large number are always in danger of miscarriage. Du- rosier noted that out of forty children born of cardiopathic mothers, thirty-seven died before at- taining the age of six years. The most unfavor- able lesion to the mother from the point of prog- nosis is mitral insufficiency, the mildest, aortic insufficiency. The most serious complications, and the greatest danger of death for the mother, ap- pear about the seventh and a half, or the eighth month. Cardiopathic mothers should not nurse their infants because lactation augments heart hypertrophy. Endocarditis is regarded by some as the cause of chorea; particles of fibrin are supposed to pass from the valves as emboli to the cerebral vessels. At any rate, endocarditis is very common as a INTRODUCTION. 23 complication, although many of the heart mur- murs in chorea may be caused by anemia or the rapidly acting heart. The belief was at one time current that an in- dividual with heart disease was in no danger of contracting phthisis. As a rule (pulmonary ste- nosis the exception), pulmonary tuberculosis rarely develops in an individual with a valvular heart lesion. In 277 autopsies on individuals who dur- ing life suffered from valvular trouble, Frommalt found phthisical lung changes in 8 per cent of the cases. These statistics show the infrequency of phthisis complicating valvular lesions, since Biggs reports that more than 60 per cent of his autopsies showed lesions of pulmonary tuberculosis. ETIOLOGY OF DISEASES OF THE HEART. Endocarditis is the usual cause of valvular heart lesions. That part of the endocardium performing the most work is the first to become involved and suffer most. This explains the rarity of endo- carditis on the right side in adults and the infre- quencv of congenital lesions on the left side of the heart. The process usually implicates the valvular endocardium and is therefore known as valvular endocarditis. In adult life, about one-half the cases of endocarditis occur on the mitral valves; of the remaining 50 per cent, about 94 per cent occur on the aortic valves ; the remaining cases are divided between the valves of the right side, the 24 DISEASES OF THE HEART. tricuspid valve being in the ascendency. It is customary to speak of the following forms of endo- carditis : (a) Acute \ S ™? e ' , ( malignant. (b) Chronic or indurative. (a) The acute simple endocarditis is caused by acute articular rheumatism in 20 per cent of the cases. Among the other causes are : the infectious diseases of children, tonsillitis (by many regarded as the avenue of rheumatic infection), pneumonia, and diseases associated with blood intoxications, like diabetes, gout, cancer, and nephritis, especially the interstitial form. Various organisms, like strepto- and staphylococci, gonococcus, and even the bacillus tuberculosis, have been found in and on the affected valves, but their casual relationship has not been demonstrated. The malignant form is of microbic origin and is secondary to some infectious disease. The ma- jority of cases develop during an attack of croupous pneumonia. The other diseases associated with the infectious process are: pyemia, septicemia, puerperal fever, gonorrhea, erysipelas, puerperal fever, diphtheria and rheumatism. (b) Chronic endocarditis results from the acute forms and from syphilis, alcoholism, gout and ex- cessive work for any one valve, INTRODUCTION. 25 RESULTS OF ENDOCARDITIS. When restitution of the valve does not take place (rare), one of two conditions of clinical import- ance occurs, narrowing, obstruction or stenosis, or insufficiency or incompetency of the valves. In either instance, murmurs are heard resulting from obstruction to the onward flow of the blood or from leakage backwards through a closed but incompe- tent valve. The former are known as obstructive, the latter as regurgitant murmurs. RESULTS TO THE HEART. The inevitable consequence to the heart in a valvular lesion is increased work, leading to hyper- trophy or dilatation. Hypertrophy is muscular thickening of the walls of one or more cavities of the heart, and rarely occurs without some dilatation of the cavities. Increased work of the heart, when nutrition is plentiful, is followed by hypertrophy. Overwork, beyond the nutrition and muscular power of the heart, results in dilatation. Hypertrophy is a favorable compensatory condition in cardiac les- ions ; it is the response of the cardiac muscle to an increased demand for power. It can only develop when the health of the organism is maintained at the proper standard, and when this fails the com- pensation attempted by nature must fail, and then hypertrophy passes into dilatation. Heart strain is a prolific etiologic factor in dis- ^O DISEASES OF THE HEART. eases of this organ and of the aorta. The initial effect of prolonged exertion is dilatation of the right side of the heart. The effect of sudden strain is on the aortic area. Peacock found, in 17 cases of rupture of the heart valves after sudden strain, that the aortic valves were implicated ten times, mitral valves four times, and the tricuspid valves three times. Schott* has demonstrated in a series of skiagraphs that dilatation of the heart after wrestling can be demonstrated by the Eoentgen rays. In recent years, heart disease, resulting from overstrain after bicycling, has been frequently ob- served. I have examined a few individuals with the X-rays who have done "century runs," and have demonstrated dilatation of the right heart following such foolhardy attempts. I have per- sonal knowledge of five individuals who have be- come heart cripples from excessive bicycling. The size of the heart chambers varies in health. In severe exertion the chambers dilate, especially those of the right side, to accommodate themselves to the increased quantity of blood; this compen- sation on the part of the heart is "the getting of wind," as it is called in training. When an indi- vidual in poor condition subjects himself to heart strain he suffers from rapid and feeble pulse, car- diac dyspnea and precordial pain, and for months *Medical Record, March 26, li INTRODUCTION. 27 after he may be unfitted for severe exertion or be- came permanently crippled. Systematic and judicious muscular exercise develops heart hyper- trophy, a propitious condition when great en- durance is demanded. Injudicious exercise weak- ens the heart. Relative valvular insufficiency (i. e., normal valves which are no longer capable of completely closing the orifices of the heart), especially of the tricuspid valves, frequently follows heart strain. In men the aortic valves are more frequently impli- cated than in women. This is owing, no doubt, to the fact that bodily exertion predisposes to arterial disease. Among the laboring classes valv- ular lesions are most frequent. FREQUENCY OF INDIVIDUAL VALVULAR LESIONS. In extra-uterine life the most frequent valvular lesion is mitral insufficiency, then follows mitral stenosis, combined with mitral insufficiency, then aortic insufficiency, then aortic stenosis, and finally aortic stenosis combined with aortic insufficiency. Combined lesions are not infrequent. Mitral and aortic lesions may coexist and less often mitral and tricuspid lesions. In children, the most com- mon combination is aortic and mitral insufficiency. PROGNOSIS OF DISEASES OF THE HEART. The prognosis in valvular lesions is unfavorable. Cure may be spontaneous, but is never attained by «8 DISEASES OF THE HEART. medication. Aortic are more favorable than other lesions, owing to the ability of the voluminous left ventricle to compensate the defect. Pulmo- nary lesions are especially unfavorable, owing to the frequency of phthisis complicating such lesions. Combined lesions of different valves are more unfavorable than lesions of individual valves, owing to the increased work thrown on the heart. The social position of the patient influences the prognosis. Occupation which demands little mus- cular effort and permits a sedentary life favors longevity. The stronger the constitution the greater the likelihood of the heart being able to meet the increased demands made on its power. Valvular lesions acquired in childhood soon result in compensatory disturbances. Mechanical troubles of circulation when the heart muscle is inadequate to perform its task furnish an unfavorable prognosis and lead to a lingering illness, death resulting eventually from paralysis of the heart, blocking of one of the branches of the coronary arteries, lung edema or debility. In other instances death is sudden from heart rupture or cerebral complications. So long as an efficient compensation is maintained in val- vular disease, even the most serious valve lesion is unattended by inconvenience to the patient. Sir Andrew Clark summarized the following condi- tions which justified a favorable prognosis : Good INTRODUCTION. 29 general health; just habits of living; no excep- tional liability to rheumatic or catarrhal affec- tions; origin of the valvular lesion independently of degeneration; existence of the valvular lesion without change for over three years; sound ventricles, of moderate frequency and general reg- ularity of action; sound arteries, with a normal amount of blood and tension in the smaller ves- sels; free course of blood through the cervical veins; and lastly, freedom from pulmonary hepatic and renal congestion. CHAPTER II. THE DIAGNOSIS OF DISEASES OF THE HEART. SIGNIFICANCE OF MURMURS. No fallacy in medicine has been more carefully nourished than the belief that a cardiac murmur is always indicative of heart disease. Some of the most serious heart affections are unaccom- panied by murmurs. "The idea that a murmur in itself and by itself is a serious thing dies hard" (Shattuck). Sir Andrew Clark gave utter- ance to the truism "that a murmur in itself is of little or no moment in determining the prognosis of any given case. Osier voices the opinion of the skilled cardiac diagnostician as follows: "Prac- titioners who are not adepts in auscultation and feel unable to estimate the value of the various heart murmurs should remember that the best judgment of the conditions may be gathered from inspection and palpation. With an apex beat in the normal situation and regular in rhythm, the auscultatory phenomena may be practically disre- garded." THE APEX BEAT. We must always remember that disease of the heart valves of any consequence to the patient, DIAGNOSIS OF DISEASES OF THE HEART. 31 always leads to functional and structural heart changes and unless the latter can be demonstrated, the diagnosis of valvular disease should be held in abeyance. Fowler is responsible for the epi- gram: "That the position of the cardiac apex is the key to the diagnosis of nearly all affections of the chest and heart." The normal location of the apex beat excludes dilatation, hypertrophy, pericardial effusion and heart dislocation. CARDIAC MURMURS. Adventitious sounds originating in the peri- cardium heart and blood vessels are known as murmurs. The auscultation of a murmur sug- gests many problems in diagnosis. Having de- termined the presence of a murmur the first prob- lem to unravel is its origin. The most frequent murmurs are endocardial in origin and they are divided into organic (if caused by anatomic changes of the heart or blood vessels) and inor- ganic or functional murmurs (caused by changes in the quality of the blood. An organic murmur may be obstructive or regurgitant. Two prob- lems await solution: First, the seat of the mur- mur; second, the nature of the murmur. The seat of the murmur is determined by noting its position of maximum intensity and the direc- tion of its transmission. These facts apprise us of the valve orifice affected. 32 DISEASES OF THE HEART. THE ORIFICE AFFECTED. The position of maximum intensity of a mur- mur usually occurs at the point where the normal valve sound is best heard in health. We must not forget that the heart orifices are closely situated and therefore murmurs are created within a lim- ited area; if it were not for the fact that mur- murs have directions of selective propagation it would be impossible to determine at which valve orifice the murmur was generated. DIRECTION OF TRANSMISSION", NATURE AND TIME. In general, systolic murmurs of aortic origin are transmitted upwards from the base. Systolic mur- murs of mitral origin are transmitted toward the axilla. The transmission of a murmur is in the direction of the currents which produce them. Our next duty is to determine the nature of the murmur, which is ascertained by noting the time of the murmur and the direction of its propaga- tion. Organic endocardial murmurs may be ob- structive when there is obstruction to the onward flow of blood, the nature of the lesion being a stenosis and regurgitant murmurs when there is leakage backwards through a closed but incompe- tent valve, the nature of the lesion being an in- sufficiency. Organic heart murmurs have a definite relation to the cardiac cycle and we distinguish systolic, diastolic and 'presystolic murmurs. DIAGNOSIS OF DISEASES OF THE HEART. 66 SYSTOLIC MURMURS. The systolic murmurs arise from aortic ob- struction, and mitral and tricuspid regurgitation. Systolic murmurs are synchronous with the caro- tid pulse, therefore in a rapidly acting heart, the time of the murmur may be determined by pal- pation of the carotid pulse during auscultation. The radial pulse should not be selected because it is felt too long a time after systole. The diastolic murmurs are aortic regurgitation, and mitral obstruction. The so-called presystolic murmur is associated with mitral stenosis : it occurs at the end of systole, or, in case it is pres- ent at the beginning of diastole, it becomes stronger toward the end. CHARACTER OF MURMURS. Eegurgitant murmurs as a rule are soft and blowing. The murmur of aortic regurgitation is characterized by length and softness, while the murmur of mitral regurgitation is louder, but not so long. Murmurs that are rough and high in pitch are usually generated by valves which are thickened and rigid, a common condition in chronic endocarditis. Murmurs soft and low in pitch are associated with soft exudations on the valves and are heard in endocarditis of rheumatic origin. The murmur of mitral obstruction is the only murmur which has a specific character. It 34 DISEASES OF THE HEART. is a prolonged murmur of a churning or grinding character as if fluid were being forced with great effort through a narrow channel. Murmurs may sometimes be felt in the heart region. The sensation is similar to that perceived upon stroking the back of a purring cat ; for this reason, they are called purring tremors. Like mur- murs, they may be presystolic, systolic, or diastolic in time. They are nearly always indicative of a valvular lesion. SECONDAEY EFFECT OF VALVE LESIONS. Having ascertained the endocardial character of the murmur and the seat of the lesion our next endeavor is to confirm our diagnosis by determin- ing the all important fact, viz. : the secondary effect of the lesion on the heart. Without this corroboration the detection of a murmur is with- out diagnostic or prognostic importance. Aortic Obstruction. — Owing to the obstruction of blood from the left ventricle, the latter must work with increased force, therefore it hyper- trophies. Less blood on account of the stenosis is thrown into the arterial system, hence the pulse is small and of high tension owing to the hyper- trophied left ventricle. Aortic Regurgitation. — The blood flowing back into the left ventricle dur- ing diastole, causes this chamber of the heart to enlarge (dilatation), but compensation occurring, the dilatation is overcome by hypertrophy of the DIAGNOSIS OF DISEASES OF THE HEART. 35 ventricle. The pulse of aortic regurgitation is pathognomonic. It is called the Corrigan or "wa- ter hammer pulse." The impression received by the finger on the radial artery is one of recedence Fig. 3 — Auscultatory areas of the valves and points of maximum intensity of the murmurs: M, mitral valve; T, tricuspid; P, pulmonary; A, aortic. Ana- tomic position of the cardiac valves: t, tricuspid; m, mitral; a, aortic; p, pulmonary. of the pulse wave as soon as it strikes the finger. The phenomenon is accentuated if the arm is raised. 36 DISEASES OF THE HEART. Mitral Regurgitation. — In this lesion the brunt of the work is thrown on the right ventricle, which dilates and hypertrophies. The increased tension of the pulmonary artery is evidenced by accentu- ation of the second pulmonic tone. The arterial system receives less blood leading to insufficient nourishment of the heart through the coronary arteries, hence degeneration of the organ must ensue. In Mitral Obstruction it is the left auricle which primarily hypertrophies to overcome the narrowed mitral orifice. Later, the right ventricle hypertrophies. ACCIDENTAL HEART MUEMURS. There are a number of accidental heart mur- murs, functional in their nature, which admit of no definite classification. As a rule, they are unattended by any palpable changes in the heart or pulse. They are almost invariably systolic in time. In my experience, they are frequent before operations and in gastric disturbances. There are many individuals, chiefly women in whom func- tional murmurs appear just before an expected operation and disappear with equal readiness a few days after the operation. They might correct- ly be called "murmurs of apprehension." The other class of murmurs associated with stomach disturbances, which for purposes of con- DIAGNOSIS OF DISEASES OF THE HEART. 37 venience I will designate as "murmurs of gastric origin," I have encountered frequently. They usually coexist with digestive disturbances and are sometimes of great intensity. Such individuals complain of precardial pain and pressure and the disappearance of the latter symptoms mark the evanescence of the heart murmurs. The mur- murs are in no wise associated with the pressure of a dilated stomach on the heart as would be primarily surmised, for I have never been able in such individuals after disappearance of the mur- murs to recreate them by artificial insufflation of the stomach. Other causes must exist and the most likely cause is reflex irritation of the cardiac nerves superinduced by the toxic products of gastric in- digestion. While stress has been laid on the fact that functional murmurs are in the great majority of instances systolic in time, we must not forget that they may also be diastolic. In my experience I have encountered such murmurs in anemia, with their maximum intensity over the auscultatory situation of the aortic orifice and they may be traced to the jugular veins in the neck, their un- doubted point of origin. Care must be exercised in distinguishing such murmurs from those oc- curring in aortic incompetency, an error which is hardly possible, if all the facts in this chapter are carefully considered. The foregoing facts prompt us to hold in reserve the diagnosis, "or- OO DISEASES OF THE HEART. ganic heart murmur," without repeated examina- tions of the heart, for it is evident that, if at one examination, we note, let us say, a systolic murmur at the mitral area and at a subsequent examination a systolic tone, as a rule there can exist no organic disease of the valve. ANALECTIC REVIEW OF CARDIAC VALVULAR MUR- MURS. 1. The character or intensity of a murmur is no index to the gravity of the lesion producing it. The loudest murmur may be produced by the smallest lesion and vice versa. 2. The loudness of a murmur is largely de- pendent on the activity of the heart. Loud mur- murs may become weak, and this change is an ominous sign indicating heart weakness. For the same reason they may disappear in febrile dis- eases and in the dying state. Faint may often be converted into loud murmurs after increasing cardiac activity by exercise and cardio-tonic medication. Complete compensation may often cause the temporary disappearance of a murmur. 3. In some individuals murmurs are louder in the recumbent than in the erect posture, especially murmurs of tricuspid and mitral origin. Mur- murs should be auscultated with the patient in different postures. DIAGNOSIS OF DISEASES OF THE HEART. 39 4. Murmurs are less loud in inspiration than expiration. 5. Strong pressure on the chest, especially in children, may cause the disappearance of mur- murs, the pressure inhibiting cardiac action. 6. When the heart is rapid or irregular in action, it is difficult to determine the time of a murmur. Remember that systolic murmurs are synchronous with the carotid pulse. Also regu- late the action of the heart with digitalis. 7. Systolic are usually louder though less pro- longed than diastolic murmurs. 8. When murmurs are faint, have the patient suspend respiration during auscultation. 9. Murmurs are most intense at their point of origin and they are propagated in the direction of the blood current by which they are developed. 10. Murmurs of extra-uterine origin are oftener found to proceed from the valves of the left heart, and in adults, murmurs at the tri- cuspid and pulmonary areas are rare. 11. In rare cases the murmur may be heard at a distance without laying the ear over the chest and they may be perceived by the patient. Only those arising at the aortic opening have this pe- culiarity. 12. When two murmurs co-exist at systole or diastole they may be transmitted or be due to dis- ease at different orifices. Thus two murmurs oc- 40 DISEASES OF THE HEART. utl ™ ^ .- P 2 ;5 erf H » w Q _ Q, „ fl R 3J ° - w iJ«5 c o "OS a) ."©£>, a) bo t>>~ ssjoifjsiiil^&i pa ilia* pis T-ic4cot> H Eh fa j d 2© S £,© d+J , £ es S 'Sag .-s»2 O fc =-| »> - «. §s?a&sj.3 g-s£S G w mm cj OS :».d S3 d 5? 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Unlike endocardial murmurs which are limited to a certain phase of the heart's action, they might be systolic, diastolic, or both, or even presystolic. 2. They are increased in intensity upon pres- sure with the stethoscope, which maneuver fa- cilitates the friction between the pericardial layers. 3. During inspiration the lung approximates the layers of the pericardium, thus increasing dur- ing this phase of respiration, pericardial mur- murs. Endocardial murmurs by the same act are diminished in intensity, because the interposed lung offers a poor medium of conduction to the chest wall. 4. The closer the two layers of the pericardi- um are approximated, the louder the murmur. To facilitate this approximation I would suggest pressure being made in the intercostal spaces and not on the ribs, as is the conventional practice. The same maneuver is applicable in the elicitation of pleural friction sounds. To make pressure with the stethoscope in the intercostal space, a phonendoscopic attachment may be fitted to the chest piece of any stethoscope according to the illustration. A piece of tin may be easily fitted by anv tinsmith. In the center of the tin a rod termi- nating in a small button is screwed, 44 DISEASES OF THE HEART. Fig. 4 — Dr. Abrams' Modified Stethoscope. 5. They are circumscribed and are not trans- mitted beyond the area of cardiac dulness. 6. Change of position exerts a greater influence on the character of pericardial than endocardial murmurs. The former are especially distinct when the patient is in the sitting posture, with the body inclined to the left side. 7. They give the impression of being superficial in origin. 8. They frequently change their character, whereas the character of endocardial murmurs is almost constant. 9. They are rough, grating to and fro, or rub- bing and scratching sounds. 10. When doubt arises whether a murmur is peri or endocardial in origin always remember that organic endocardial murmurs modify the DIAGNOSIS OF DISEASES OF THE HEART. 45 pulse and induce secondary effects upon the muscle of the heart. PLEUEO-PEEICAEDIAL MUEMUES. 1 These murmurs often simulate pericardial mur- murs. They arise when the pleura or peritoneum adjacent to the heart is roughened. They are modified by respiratory movement, disappearing or diminishing when the breathing is suspended or disappearing after forced expiration. Deep in- spiration will usually accentuate them. CAEDIO-EESPIEATOET MUEMUES. These are sounds synchronous with the heart's action, produced outside this organ and heard usu- ally to the left of the apex beat. Two factors enter into the production of these murmurs. 1. Forcible expulsion of air from the lungs by the heart strik- ing against it. 2. With each cardiac contraction the bulk of the heart is reduced in size and a cor- responding vacuum produced in the chest, which the lung compensates by expanding, thus produc- ing a murmur. AXEMIC MUEMUES. In anemia murmurs are frequently heard over the heart and vessels. They are endowed with certain characteristics : 1. They are soft and blowing in character and not prolonged. 2. They are systolic in time. 3. Generally loudest at the base of the heart and especially over the pulmonary orifice, a point where organic systolic murmurs are 46 DISEASES OF THE HEART. often heard. The chief means of differentiation between the two lies in the fact that with organic we find dilatation and hypertrophy of the heart which are usually absent in anemic murmurs. 4. They are unaccompanied by changes in the size of the heart. 5. They frequently change their character. 6. They are accompanied by anemic symptoms and murmurs in the veins of the neck. 7. They are louder in the recumbent than in the upright position. 8. They are not transmitted away from the heart. 9. Under appropriate treat- ment with chalybeates they can be made to dis- appear. PULMONARY ANEMIA, I have described (Medical Standard, Jan. 1900) an anemia of pulmonary origin, in which anemic murmurs are frequent. In this form of anemia the ferruginous preparations are without effect on the murmurs which only yield to systematic lung development, inasmuch as the cause of pulmo- nary anemia is dependent on collapsed areas of lung. HEMIC MURMURS IN THE LARGER ARTERIES. The normal systolic and diastolic heart sounds are heard in the carotid and subclavian arteries. Pressure with the stethoscope over one of the large arteries will create a systolic murmur. Murmurs from the heart are often propagated to the large arteries. Of all the arterial murmurs likely to DIAGNOSIS OF DISEASES OF THE HEART. 47 perplex the physician, the subclavian murmur is the most frequent. It is regarded by many clin- icians as a sign of phthisis. From an investiga- tion of more than 300 cases (Vide my paper Medical Standard, Oct., 1899), I am able to formulate the following conclusions : SUBCLAVIAN MURMUR. 1. The subclavian arterial murmur is an inde- pendent and rarely a transmitted murmur. 2. Its point of maximum intensity is the fossa of Mohrenheim, with feeble tendency to propa- gation. (The fossa is a depression under the clavicle in the outer part of the infraclavicular region between the pectoralis major and deltoid muscles. ) 3. It is heard most often on the left side, less frequently on both sides and least frequently on the right side. In order of frequency it is heard at the height of inspiration, at the end of expiration and after momentary suspension of respiration. 4. It is usually a succession of. murmurs uni- form in character and intensified by certain maneuvers, notably deep inspiration, suspension of respiration and voluntary stretching of the neck. 5. One of its chief characteristics is its mo- mentary duration, disappearing usually after a few deep inspirations. 48 DISEASES OF THE HEART. 6. Its dependence on the phases of respiration distinguishes it from all transmitted murmurs. 7. It may be present at one and absent at a subsequent examination, and neither its character nor duration is ever uniform from one examina- tion to another. 8. The position of the patient may influence its genesis, but this is never sufficiently uniform to be of practical value. 9. A phthisical lung is not specially propitious to its occurrence, as it is found nearly as often in healthy as in phthisical persons. 10. It was present in thirty-six per cent of all healthy persons examined, advantage being taken in this enumeration or re-examination and those propitious factors which determine its occurrence, viz. : respiration and decubitus. 11. The venous subclavian murmur was only heard in six individuals with a preponderance of its occurrence on the right side. 12. The arterial subclavian murmur could be artificially induced on the left side in nearly 80 per cent of all individuals examined, and on the right side in about 65 per cent of the cases by a simple maneuver, viz., raising the arm gradually until it assumes a vertical position, while auscul- tating the Mohrenheim fossa during the time that the arm is brought to the latter position, the mur- DIAGNOSIS OF DISEASES OF THE HEART. 49 mur suddenly appearing at some time during the execution of the movement. 13. By the foregoing maneuver the subclavian venous murmur could be induced on the right side in 43 per cent of all persons examined. DIAGNOSIS OF ENLARGEMENT OF THE HEART. Thickening of the muscular walls of the heart is known as hypertrophy, while enlargement of one or more chambers of the organ is known as dilatation. HYPERTROPHY OF THE HEART. In hypertrophy, the left ventricle is most fre- quently involved owing, to the increased work put on it by valvular lesions, diseases of the blood vessels, muscular exertion, etc. Its fellow ventricle on the right side hypertrophies in valvular lesions and in lung diseases whenever there is obstruction to the blood flow through the pulmonary organs, or, as we often say, increased resistance in the pulmonary circulation. The symptoms of hypertrophy of the left ven- tricle are those of increased tension in the arterial system, viz. : congestive headaches, noises in the ears, and flushing of the face. The physical signs of the increased tension are: forcible and heavy heart impulse, the first sound at the apex is dull and prolonged while the second aortic tone is accentuated. The sounds are of course modified if valvular lesions are present. The pulse is reg- 50 DISEASES OF THE HEART. ular, full, strong and of high tension. In hyper- trophy of the right ventricle, increased tension may be manifested by hemoptysis owing to rup- ture of the blood vessels. Eeliance, however, must be made on the objective examination. Over the tricuspid area, the first tone is louder and more prolonged than normal, while the second pulmonic tone is accentuated. Hypertrophy is usually attended by dilatation, hence in left ventricle hypertrophy, the apex beat instead of being felt in the fifth interspace, two inches below and one inch to the right of the left nipple, is felt in the sixth, seventh or eight inter- space, from one to three inches outside the nipple. Percussion shows increased dulness upward and transversely. If dilatation attends an hyper- trophied right ventricle we find, bulging of the lower part of sternum, dislocation of the apex beat to the left, but rarely displaced downward. A marked epigastric impulse is noted in the angle between the ensiform cartilage and the seventh rib. The percussional area of dulness is increased transversely toward the right. DILATATION" OF THE HEART. Dilatation of the heart is an evidence of weak- ness of the organ and it usually follows hyper- trophy. It is the very earliest evidence of com- pensation failure. The symptoms are the reverse of hypertrophy, because the ventricles are ineap- Diagnosis of diseases of the heart. 51 able of emptying themselves at each systole. The apex beat is of course dislocated when the left side is involved, but it is very feeble and not punctu- ated, as in hypertrophy, but diffused. When the right ventricle is dilated, the impulse is seen and felt to the right of the ensiform cartilage. The action of the heart is irregular and inter- mittent. The heart tones are feeble and assume a fetal heart rhythm (embryocardia), i. e., the first and second heart sounds are alike and the long pause is shortened. THE PULSE IN HEART DISEASE. In palpating the pulse we must take into con- sideration: 1. Condition of the arterial wall. 2. Tension or blood pressure. 3. Volume. 4. Ehythm. 5. Frequency. CONDITION OF ARTERIAL WALL. 1. In health the radial artery can easily be com- pressed and distinguished from other tissues. In atheroma of the arterial system, it is with diffi- culty compressed and may be rolled like a cord or pipe stem. Atheroma or arterio-sclerosis is a senile phenomenon and illustrates the fact, that the duration of life is decided by the condition of the arteries or, axiomatically expressed, "A man is only as old as his arteries." Alcohol, lead, gout, syphilis and other intoxications are common causes. Atheroma by increasing the blood pres- sure results in hypertrophy of the left ventricle DISEASES OF THE HEART. and the latter sign associated with a high tension Fig. 5- Diagram to illustrate the effect of dilatation of the right and left sides of heart respectively (Gee after v. Dusch). Continuous heavy outline, normal heart; dot- ted line, dilatation of right side; thin double line, dila- tion of left side. DIAGNOSIS OF DISEASES OF THE HEART. 53 pulse and accentuation of the second aortic sound are pathognomic of arteriosclerosis. Angina pectoris owing to atheromatous involvement of the coronary arteries is common in arterio-sclerosis. TENSION" OF THE PULSE. 2. The pressure with which the blood flows in the arteries depends upon the degree of peripheral resistance and the force of the ventricular contrac- tion. Normally, the pulse almost subsides between the beats, but little pressure being required to ob- literate it. When the tension is increased, the artery remains continuously full between the beats. A pulse of low tension is soft and very compress- ible. It is indicative of heart weakness. VOLUME OF THE PULSE. 3. This is dependent on the amount of blood in the artery; therefore in aortic and mitral stenosis the volume is small. PULSE RHYTHM. 4. Disturbance of rhythm is manifested by inter- mission or irregularity of the pulse beats. Inter- mission means a dropping of a pulse beat and may occur at regular or irregular intervals. An inter- mittent pulse is characteristic of a fatty heart, if associated with a weakened first heart sound and evidence of failing circulation (edema of the feet). It is a symptom of coffee, tobacco, tea or digitalis intoxication. An irregular pulse is evidenced by 54 DISEASES OF THE HEART. differences in time, force or volume of successive pulse beats and is of more, serious import than an intermittent pulse. It occurs in mitral lesions and cardiac degeneration. FREQUENCY OF THE PULSE. 5. In nearly all valvular heart lesions, except- ing aortic obstruction with failing compensation, the pulse may be increased in frequency. Vagus disease and heart weakness are associated with an increased pulse rate. Diminished frequency of the pulse rate (bradycardia) may be associated with certain forms of cardiac disease, especially aortic obstruction. Appearing late in valvular lesions, it is usually an ominous sign. The sphygmo graph is an instrument of refine- ment to the practical physician in as much as pal- pation alone will detect all the variations in the pulse. RECAPITULATION. Mitral Insufficiency. — Pulse is small and feeble because the arterial system is devoid of blood. Mitral Stenosis.* — Pulse small and irregular with increased frequency. Aortic Insufficiency. — Rapid recedenee of the pulse as it strikes the finger (Corrigan's Pulse), especially if arm is elevated. Aortic Stenosis. — On account of obstruction to the flow of blood, the left ventricle is hypertro- DIAGNOSIS OF DISEASES OF THE HEART. 55 phied, hence the pulse is one of high tension but lessened in volume. Myocarditis. — Pulse small, soft and irregular; frequency, normal, diminished or increased. A comparatively strong pulse, with feeble apex beat and heart tones is of great value in the diag- nosis of exudative pericarditis. The strength of the right ventricle should never be gauged by the pulse, the loudness of the second pulmonic tone should be the index of its vigor. Measuring the Intensity op the Heart Tones. We are unfortunately in possession of no accu- rate means of registering the heart tones to facili- tate accuracy in determining the progress of patients with heart lesions, or the action of cardio- tonics. I have already reported (Medical News, July 8, 1899) the following method, which is only relatively accurate: It is based on the simple physical principle that the intensity of sound varies inversely as the square of the distance from the sounding body, hence the distance to which a heart sound may be heard depends upon its intensity, ignoring of course those adventitious causes of propitious con- ductivity. Between the area auscultated and the stethoscope a medium is interposed. Experiment has taught me that one of the best media is par- tially vulcanized rubber in the form of a rod, and 56 DISEASES OF THE HEART. just sufficiently soft as not to interfere with con- venient manipulation. Such rods may be pur- chased in any store where rubber goods are sold. The circumference of the rods must equal the cali- ber of the pectoral end of the stethoscope in which they are to be inserted. The degree of insertion must be regulated by a notch cut into the rubber. The object of this regulation is to insure uni- formity of results in the examination of individual patients. The rods may be of different sizes, vary- ing in length from 6 to 26 centimeters, or even of greater length. Before auscultating the heart tones by this method, we must first mark on the chest the dif- ferent points in the precordial region, where the Fig. 6. Rod inserted into the pectoral extremity of the stethoscope for measuring the intensity of the heart tones. heart tones are heard with the maximum degree of intensity. Over each ostium we auscultate with the rod inserted into the end of the stethoscope, beginning with a rod of medium length and grad- ually increasing the length of the rod until one is DIAGNOSIS OF DISEASES OF THE HEART. 57 attained through which the heart tones are no longer conducted. The tubes are numbered, and a record may be made in our case book after the fol- lowing formula. Mitral, I tone 6 Mitral, II tone 5 Aortic, I tone 4 Aortic, II tone 5 Tricuspid, I tone 6 Tricuspid, II tone 4 Pulmonary, I tone 4 Pulmonary, II tone 5 According to the foregoing formula we conclude the following: That with a rod (No. 6) which is 26 centimeters in length we may still be able to hear the following tones : Mitral systolic and tri- cuspid systolic tones. A similar interpretation may be deduced from the other numbers. These figures possess no value for general application as the degree of transmission is dependent on the character of the stethoscope as well as the length of the rod employed. Each observer must cut his own rods of different lengths. With some kinds of stethoscopes the first mitral and tricuspid tones are still heard with rods fully 30 centimeters in length, whereas with other kinds a rod of half the length will no longer transmit the same tones. In some instances another method may be adopted. It is less reliable than the former method, especially in thin persons, owing to the 08 DISEASES OF THE HEART. increased conductivity, of the thoracic tissues. As before, one marks on the chest wall the different situations where the heart tones, corresponding to each ostium, are heard loudest, and then proceeds in different directions until the sounds are no longer audible. The distance to which the sounds are propagated is marked and measured. The directions in which the sounds are auscultated have been determined empirically as follows : Miteal Tones. — Auscultate along a line on a level with the apex-beat to the left axillary region. Teicuspid Tones. — Auscultate along a line ex- tending from the point of auscultation to the right axillary region. Aoktic Tones. — Along a line on a level with the point of auscultation to the right axillary region. Pulmonic Tones. — From the point of auscul- tation to the left axillary region. The tricuspid and mitral tones are best conducted downward by the liver, but as a differentiation of the mitral and tricuspid tones over the hepatic region is im- possible this direction cannot be employed. I will mention, parenthetically, that the liver is an ex- cellent conductor of the heart tones, and when they are no longer audible by auscultation we can safely conclude that the lower border of the liver has been reached. DIAGNOSIS OF DISEASES OF THE HEART. 59 Inhibition of the Heart as an Aid in Diag- nosis. The inhibitory nerve of the heart is the vagus, stimulation of which stops the heart in diastole. Czermak was able to press his vagus nerve against a little bony tumor in the neck, and by thus sub- jecting the nerve to mechanical stimulation was able to slow or even stop the beating of his own heart. If, in almost any healthy person, the caro- tid artery, or a point immediately adjacent to it in the neck, is compressed, slowing or complete inhibition of the heart and pulse ensues. This phenomenon is explained by compression of the vagus lying alongside the carotid artery. Friedreich, and subsequently Sewell of Denver, observed that strong pressure with the stethoscope on the chest could cause the disappearance of murmurs, especially in individuals with an elastic thorax, which was attributed to inhibition of the heart movements. I have endeavored to employ the phenomenon of cardiac inhibition as an aid in diagnosis. Ob- servation has taught me that, for clinical purposes, inhibition of the heart is best attained by forcible voluntary contraction of the muscles of the neck. In some instances, the inhibitory effect on the heart is best observed when the head is stretched backward, and, when in this position, contraction of the neck muscles is attempted. With some per- 60 DISEASES OF THE HEART. sons, to whom no instructions are intelligible, I place a long narrow cushion on the front of the neck and then ask them to press with all their might on the cushion with their chin. If too much violence is used in any of these maneuvers, the primary effect will be to increase the rapidity of the heart. If the maneuver is properly executed, we dimin- ish the intensity of cardiac tones and murmurs, and it is this fact that determines the real value of cardiac inhibition in diagnosis. A few seconds Fig. i — Normal pulse. Fig. 2 — Pulse during cardiac .inhibition, usually elapse before the effect on the heart be- comes manifest, then, while the subject is still forcibly contracting the muscles of the neck, the heart tones become less and less evident, assuming an embryocardial character, until finally they are no longer audible. The accompanying sphygmo- gram was obtained from an individual on whom the method was tried for the first time. We note almost total annihilation of the pulse DIAGNOSIS OF DISEASES OF THE HEART. 61 after irritation of the vagus by the contracted neck muscles. My investigations with this maneu- ver may in brief be summarized as follows : 1. Organic heart murmurs will become faint and often inaudible. 2. Transmitted murmurs are more amenable to the maneuver. 3. The fainter the murmur, the more easily it is suppressed. 4. When a transmitted murmur can be in- hibited, the tone which it masks can be auscul- tated. 5. Heart tones are less amenable than mur- murs to inhibition. 6. Hemic murmurs are more readily inhibited than organic murmurs. 7. When the murmurs of anemia are inhibited, they are replaced by tones. 8. Incorrect execution of the maneuver will intensify rather than diminish murmurs. 9. The inhibition maneuver when too often re- peated is futile in its results owing to over stimu- lation of the vagi. 10. The maneuver enables us to determine the condition of the vagi as inhibitors of the heart and guides us in the administration of cardio- tonics. 0« DISEASES OF THE HEART. ILLUSTRATIVE CASES. The value of the method is illustrated by the following cases : 1. Murmur audible during diastole in the second right interspace. At apex, systolic tone and diastolic murmur. During inhibition, the murmur in the second right interspace becomes fainter, while the diastolic murmur at the apex disappears and is replaced by a tone. Diagnosis : Aortic incompetency. The diastolic murmur at the apex is a transmitted murmur. 2. Loud murmur audible during diastole in the second right interspace. At the apex, systolic murmur and diastolic tone. During inhibition: Murmurs over aorta and apex persist but are less loud. Diagnosis: Aortic and mitral incompe- tency. The systolic murmur at the apex is not transmitted but is dependent on mitral incompe- tency. 3. Systolic murmurs over all the ostia anc? not transmitted away from the heart. Blood evidence of anemia. Inhibition: Systolic mur- murs replaced by systolic tones. Diagnosis : Mur- murs of anemia. 4. Systolic and diastolic murmurs at base of heart, modified by pressure with stethoscope and position of patient. Anemia not present. Inhi- bition : Murmurs disappear and replaced by tones. Diagnosis : Pericardial murmurs. DIAGNOSIS OF DISEASES OF THE HEART. 63 5. Murmur at fourth left interspace. Heart irregular, and rapid. No anemia nor sign of peri- carditis. Inhibition: Murmur disappears to be replaced by a tone. Diagnosis : Cardio-muscular murmur. The X-Eay in Cakdiac Diagnosis. A few years ago I exhibited before the Califor- nia State Medical Society a series of lantern slides illustrating cardiac lesions diagnosed by the aid of the Eoentgen rays. Many of my auditors no doubt regarded my exhibit as manufactured evidence, whereas others, less captious, were inclined to re- gard the demonstration as a joke. The vast amount of literature that has since accumulated has convinced the most skeptical that the Eoentgen rays are invaluable in cardiac diagnosis. With the rays, we can accurately determine the size of the heart and learn in what part the organ is en- larged, and all this with more certainty than by any other method of examination. Aneurism of the heart may be accurately diagnosed, an impos- sible feat with other physical methods; aortic aneurism may be demonstrated even before sub- jective symptoms are experienced. By means of the Eoentgen rays, we are enabled to gauge the action of digitalis and the Schott method of treatment on the heart with perfect ease. Pericardial effu- sion, dislocated, transposed and congenital mal- formations of the heart may be accurately de- 64 DISEASES OF THE HEART. termined. For all this, two things are essential: Good apparatus and the services of an expert in- terpreter of skiascopic pictures. "Without a Roent- gen ray apparatus no physician can lay claims to scientific refinement in cardiac diagnosis. CHAPTER III. GENERAL TREATMENT OF THE DIS- EASES OF THE HEART. I. Prevention. II. Treatment during compen- sation. III. Treatment during broken compensation. IV. Treatment of individ- ual symptoms. Peevention. Acute articular rheumatism is one of the chief predisposing factors in the etiology of valvular les- ions. We are constrained to heed the wise injunction of Sibson, that complete rest, during and after an attack of rheumatism lessens the average percent- age of cases in which cardiac complications de- velop. We may profit by the experience of Cham- bers, who tells us, that during an attack of rheu- matism, cardiac complications develop less often, when patients sleep in blankets and not between sheets. Sheets become wet with the acid per- spiration and conduce to relapses from chilling of the skin. The salicylates are almost specific for the arthritis, but they are not prophylactic against cardiac inflammation. The alkaline treatment ac- cording to Garrod, viz. : 40 grains of the bicarbon- DO DISEASES OF THE HEART. ate of potassium and 5 grains of citric acid, every 2 hours continuously until the urine becomes and remains alkaline and smaller doses thereafter, is the most certain means we possess for preventing and arresting heart complications. With the alkaline treatment the use of salicylates may be employed. The gouty tendency is often associated with high blood tension, arterial degeneration and cardiac hypertrophy. Individuals showing this tendency must guard against over-feeding, in- dulgence in alcohol and live an open air life with an abundance of well regulated exercise. The in- ordinate use of alcohol is an important factor in etiology. Arterial degeneration and heart failure associated with dilatation of the organ are well recognized conditions in the inebriate. Tobacco, like alcohol, must be interdicted in those who show a tendency to cardiac dis- ease. Tobacco augments the cardiac contractions and induces intermittences and irregularities (arrythmia) of the heart. In the etiology of spurious angina pectoris, nicotine poisoning is paramount. An effective argument to induce to- bacco habitues to discontinue their habit, is to in- struct them to count the pulse before and after smoking, when they will invariably note an in- crease of from 4 to 11 beats a minute. Coffee and tea are not without influence in the etiology of GENERAL TREATMENT OF DISEASES OF THE HEART. 67 affections of the heart, notably, functional dis- turbances. Syphilis is frequently concerned in endo-peri and myocardial lesions. Arterial syphilis is of common occurrence. Syphilitics, therefore, must be vigorously treated by inunctions or intravenous injections upon the advent of cardiac complica- tions. Gonorrhea is frequently a factor in the etiology of endocarditis, gonococci having been frequently demonstrated on the implicated en- docardium. Moral hygiene is of importance in those predis- posed to or suffering from heart disease. All emotions directly influence the heart and the epigram of Peter is worth repetition, "The physical heart is the counterpart of a moral heart." Diet is of great moment in many functional heart affections. Food must be eaten in small quantities and be easy of digestion. Overloading the stomach, especially at night, must be avoided. Carbo-hydrates, owing to their tendency to form gases, must be used sparingly. Laxatives must be given to aid the abdominal functions. Digestive reflex neuroses of the heart are not infrequent af- ter errors in diet. Dyspnea, palpitation and ir- regular heart, epigastric pulsation and psychic depression are a few of the symptoms following in- digestion in some persons. The effects of muscular strain on the heart 68 DISEASES OF THE HEART. must not be forgotten, and occupations must be recommended which, demand no excessive nor sud- den muscular work nor exposure to cold and wet. Badly fed laborers often suffer from dilatation of the heart without valvular disease. In lifting heavy weights, such individuals, first take a deep inspiration and then suddenly stop expiration dur- ing the time severe exertion is made. The effect would be to empty the veins into the chambers of the heart leading to dilatation of the cavities. Prolonged rest should always follow heart strain, otherwise chronic irritability of the heart with dilatation ensues. Treatment During the Stage of Compensa- tion. In the early history of medicine, patients with cardiac hypertrophy were made the subjects of a depleting treatment and they were placed on a low diet. Luckily for the patients, this error in therapeutics is no longer perpetrated. The prov- ince of the physician, during the stage, is strictly limited in maintaining the vigor of the heart muscle. The great majority of those afflicted with com- pensated valvular lesions, suffer no inconvenience for years nor is the duration of their existence ap- preciably abridged. Clark, in 684 chronic val- vular lesions which had been kept under observa- tion for 5 years, noted no physical inconvenience GENERAL TREATMENT OF DISEASES OF THE HEART. 6SJ in any of the patients. Unfortunately, the belief yet survives, that the demonstration of a cardiac murmur, is the signal for digitalis, notwithstand- ing compensation is present. Hypertrophy of the -heart, which is practically compensation, is an ef- fort on the part of nature to overcome the cir- culatory disturbances resultant on valvular lesions. Our efforts must be directed toward inviting hypertrophy and when present to encourage its ex- istence. We must "make the heart equal to its task" (Beau). To maintain compensation the pre- ceding remarks on prevention are germane. The rules of prophylaxis can only be executed with the intelligent co-operation of the patient, who must be informed in a judicious way of the nature of his trouble. My almost invariable rule is to tell the patient that his trouble is purely a functional one, that unless certain laws of health are observed, it may become organic. The apothegm, "Ignorance is bliss," is especially ap- plicable in the case of the cardiopath. "Hope springs eternal in the human breast" may refer to the phthisical, but never to the cardiac patient. Systematic exercise must not be inhibited, on the contrary, it is now regarded as an invaluable aid in maintaining the muscular power of the heart and increasing it. The character of the ex- ercise taken is of little moment, provided no dyspnea, heart distress or palpitation follows, The 70 DISEASES OF THE HEART. slightest evidence of such symptoms is a signal of danger. Provision by the usual preventive measures must be taken against catching cold. Every at- tack of bronchitis throws an additional burden on the heart. Climate is a valuable adjunct in treat- ment. Extremes in climate must be avoided. Mild temperate climates with cool weather are to be favored. High altitudes in general must be avoided. Observations teach us that it is the right heart which is first overtaxed by a sojourn in high altitudes and this observation applies with equal cogency to the healthy heart. Treatment During Failure of Compensation. Broken compensation asserts itself slowly. Among the earliest subjective symptoms are dyspnea on exertion, nocturnal paroxysms of dyspnea and cardiac distress. Objectively, small, irregular and feeble pulse and localized edema are characteristic. The chief object of treatment is to restore the enfeebled heart muscle which is at- tained by rest, the use of agents which stimulate the heart's action and by methods which relieve the embarrassed circulation, viz. : Venesection and depletion by purgation. The heart receives two sets of nerves, the ex- citary from the sympathetic system and the mod- erator nerves derived from the pneumogastric. While the excitatory nerves put the heart muscle in GENERAL TREATMENT OF DISEASES OF THE HEART. 71 action, the moderator nerves inhibit the move- ments, but, by harmonious action of these opposite nerve influences, the regularity of the heart con- tractions is due. Absolute rest in bed is one of the supreme tri- umphs of cardiac therapeutics. By this method alone, the relief of the symptoms of failing com- pensation is oftentimes phenomenal and but two or three weeks' rest usually suffice to attain the object. The rest must, however, be as absolute as in the rest cure method of Weir-Mitchell and the nourishment must be equally exacting. If anemia is present, the liberal use of some assimil- able chalybeate is indicated. In addition, we must remember the great value of fresh air, sun- shine and a cheerful environment. When rest in bed alone fails to restore the circulatory equilib- rium, the recourse must be had to cardiac stimulants and tonics. CARDIAC TOXICS. The sovereign heart tonic is digitalis, the quinine of the heart. Digitalis slows the action of the heart and increases the force of its beats; the blood pressure in the arterial system rises with contraction of the peripheral arteries. The physi- cian is frequently bewildered in encountering in the text books, prolix and elaborate indications and contraindications for its use. An invariable indication for its use is dilatation of the heart, 72 DISEASES OF THE HEART. stationary or progressive, irrespective of the na- ture of the valvular lesion. The physician un- skilled in methods of cardiac percussion is justified in its use, in all cases of compensation failure. There are some authorities who declare that its use is dangerous in aortic incompetency, because by prolonging diastole it promotes the regurgitation of blood into the left ventricle. This objection is purely theoretic. Some contraindications against its use are ex- cessive slowing of the pulse present in some cases of idiopathic myocardial disease as well as in stenosis of the aortic and mitral orifices. The danger of arterial rupture, owing to the increased blood pressure which attends its physiologic ac- tion, I believe to be theoretical. Of one contra- indication one can speak absolutely and that is, it should never be used when compensation is prop- erly balanced. When digitalis acts favorably, we note the fol- lowing: Pulse becomes slower, regular and in- creased in tension. Dyspnea and dropsy disappear. The urine formerly scanty, high colored and de- positing urates becomes light colored with dimin- ished specific gravity and is very much increased in quantity. In the use of the drug we must al- ways anticipate toxic symptoms which are gradual in their appearance, viz.: Nausea, vomiting, small irregular pulse and diminished excretion of urine. GENERAL TREATMENT OF DISEASES OF THE HEART. 73 These symptoms usually disappear when the drug is withdrawn and are rarely serious. Digitalis must be continued until compensation has been re- stored. During the course of its administration, it is well to suspend its use for a day or so in antici- pation of its cumulative action. When nausea at- tends its use, it may be given by the rectum, pre- ferably in the form of the infusion. Digitalis has often been unjustly discredited as a drug, owing to many inert preparations found in the shops. The most reliable preparations are those secured from trustworthy eclectic and homeopathic pharmacists as they are in honor bound to use the fresh leaves. After curing, digitalis leaves rapidly deteriorate. Authorities are not in accord on the preparation to be em- ployed. Some prefer the watery, others the alcoholic preparation. The two preparations are by no means identical in action, the glucosides (digitalin, digitoxin, etc.) vary in solubility in alcohol and water. The watery preparation, the infusion, is more effectually diuretic whereas the tincture has a more direct influence on the heart. The glucosides ought not to be employed, as our present knowledge of their composition and phy- siologic action is very uncertain. The tincture of digitalis is administered in 10 to 15 minim doses every 3 or 4 hours, the infusion in | ounce doses at the same intervals. To secure 74 DISEASES OF THE HEART. the best results with digitalis, I am in the habit of giving the tincture before and the infusion after meals. Osier voices the opinion of careful observers when he expresses the belief that there are no substitutes for digitalis. Strophanthus. This is the only cardiac tonic which possesses any action similar to digitalis, but unlike the latter it is less reliable and energetic. Strophanthus increases arterial pressure by in- creasing the work of the heart, but unlike digitalis, it does not contract the blood vessels. It may be given continuously without fear of toxic manifestations, in fact, its action is only apparent after long continued use. In many instances the tonic effects on the heart initiated by digitalis may be continued with strophanthus which is usually given in from 5 to 10 drop doses 3 or 4 times a day. Caffeine is regarded by some as almost equal to that of digitalis in diseases of the heart. It causes the beats of the heart to become stronger and oc- casionally more rhythmical. Unlike digitalis and strophanthus it has no specific action on the in- hibitory nerves of the heart. Caffeine is frequent- ly of service in cardiac disease when other cardiac tonics have failed to give relief and it is of especial value in cardiac dropsy alone or combined with digitalis. Caffeine is given in doses of from 3 to 5 grains, 3 or 4 times daily as the natrobenzoate GENERAL TREATMENT OF DISEASES OF THE HEART. 75 or natrosalicylate owing to their increased solu- bility and more rapid action. Strychnin is a most efficient heart stimulant in sudden heart failure. By the mouth, in the doses usually recommended, I have seen very little effect. It must be given hypodermically in doses varying from 1-30 to 1-15 of a grain and frequently re- peated. Lately other cardiac tonics have been recommended, but they are of subordinate value. They may be briefly referred to: Spartein. Serviceable in valvular disease when dropsy is present. Dose, gr. 1-6 to £ every 4 to 6 hours. Convallaria Majalis (lily of the valley) . Effects on the circulation like that of digitalis, but less powerful and decidedly more uncertain. The best preparation is the infusion, in doses of from 2 to 8 drachms. Adonis. An uncertain cardiac stimulant with marked diuretic powers giving it a supposed value in dropsy and fatty heart. Dose of the infusion, a tablespoonful, 3 or 4 times a day, Nitro-glycerine. Cardiac stimulant and arterial relaxant. Useful in aortic valvular lesions when the object is to give relief to the violently acting left ventricle by dilating the peripheral blood ves- sels. Dose, one minim three times a day of the one per cent solution and increasing the dose one 76 DISEASES OF THE HEART. minim each day until flushing or headache is ex- perienced. Cocain. Similar in action to strychnin. Dose, \ grain every 4 hours. The following tabular re- view will recall the essential facts necessary in the administration of cardiac tonics. THE SCHOTT METHODS BY SALINE BATHS AND EESISTED MOVEMENTS. These methods produce phenomenal results in overcoming the symptoms of disturbed compensa- tion even after rest, digitalis and other cardiac tonics have failed. By these methods, the results achieved are due practically to, (1,) the removal of peripheral resistance which increases the arterial circulation; (2,) relief of venous conges- tion owing to the increased quantity of blood in the arteries; (3,) diminished work of the heart owing to free circulation of blood in the arterial system. The Schott treatment is indicated in all func- tional disturbances of the heart and in valvular lesions complicated by incompensation. It is con- traindicated in aneurism, chronic myocarditis and marked arterio-sclerosis. For more than 40 years the brothers Schott in Nauheim, Germany, have been active in the treatment of cardiac diseases by gymnastics and baths, but it is only in recent years that the Schott treatment has been revived GENERAL TREATMENT OF DISEASES OF THE HEART. 77 " a> • A < tb n ,\ m'O A * -L J. M A .' 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