HEART AFFECTIONS THEIR RECOGNITION AND TREATMENT S.CALVIN SMITH CORNELL UNIVERSITY THE Sflotupr Veterinary ffitbrary FOUNDED BY ROSWELL P. FLOWER for the use of the N. Y. State Veterinary College 1897 This Volume is the Gift of ~^r. ..L.eojn..,..S.,. !3.e'?.rrL«l?.y.. Cornell University Library RC 681.C65 Heart affections; their recognition and 3 1924 000 360 226 Date Due Library Bureau Cat, No, 1137 Cornell University Library The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000360226 Heart Affections Their Recognition and Treatment BY S. CALVIN SMITH, M.S., M.D. Instructor in Medicine, University of Pennsylvania Graduate School OF Medici.ne; Visiting Physician to the Philadelphia General Hosi'ital; Visiting Physician fob the Study of Cardiovas- cular Affections, Philadelphia Hospital for Contagious Diseases; Formerly Instructor in Medicine, Jeffer- son Medical College; Formerly Special Cardio- vascular Examiner, United States Army. ILLUSTRATED Military References with the Permission of THE Surgeon General^ PHILADELPHIA F. A. DAVIS COMPANY, Publishers 1921 ^.^y^s-.-t:^ .• ««_. yy^ /y c^- /,V r ^ ^. COPYRIGHT, November, 1920 BY F. A. DAVIS COMPANY Copyright, Great Britain. All Rights Reserved SL5 PRESS OF F. A. DAVIS COMPANY PHILADELPHIA. U.S.A. TO MY BROTHER s. macCUen smith, m.d. ACKNOWLEDGMENTS To Dr. Wm. L. Coplin, Director of the Jefferson Medical College Museum, for permission to photograph specimens; To Dr. Allen J. Smith, of the University of Pennsylvania Medical School, for generous assistance in the selection of pathologic illus- trations. The v^friter expresses his indebtedness. PREFACE This is a treatise that deals with the heart and its affections — a book that does not presuppose a knowl- edge of the subject and that strives to encompass in small volume sufficient fundamentals of anatomy, physiology, pathology, diagnosis and treatment to give the busy physician a working knowledge of the more recent advances in studies of the heart. Contact with medical men in civil life has taught me the need of a fundamental volume on the heart, as have also requests of medical students. Physicians engaged in military work at American training camps and abroad have voiced a similar sentiment. Let that, then, be the raison d'etre for this book, which is undertaken in the hope that it may fill a need. Perhaps a desire to be brief has caused me to pass rather hurriedly over chapters, the importance of which warrants more elaborate treatment. If this be so, let the brevity stimulate my readers to follow the studies and researches to be found in larger volumes. S. C. S. 323 South Eighteenth Street, Philadelphia, Pa. (v) CONTENTS CHAPTER I. Introduction. _ . ,_ FAG l*- Thc present day eoneeption of heart affections — The place of aus- cultation in cardiac diagnosis — Instrumental methods of diag- nosis — Their contribution to cardiology — Four preliminary postulates for students — Cardiac aphorism 1-3 CHAPTER 11. Anatomy and Physiology of the Heart. Evolution of the heart — Size, weight and shape — Chambers of the heart — Valves of the heart — ^Circulation of the blood — The conduction system — Properties of heart muscle — The cardiac cycle — The cardiac nerves 4-20 CHAPTER III. Examination of the Patient : General Considerations. Extreme cardiac types — Diagnostic points — The presenting symp- toms of heart affections — The attitude of the patient — The attitude of the physician — The keeping of records 21-33 CHAPTER IV. Examination of the Patient (Continued) Previous History. Acute infections of childhood — Infections of adolescence — Chronic systemic diseases — Septic absorption — ^ Physical strain and emotional stress^ — Habits — "Inherited" heart disease 34-40 CHAPTER V. Examination of the Patient (Continued) : Inspection AND Palpation. Preparation of the patient — Inspection — Palpation 41-46 (vii) viii CONTENTS. CHAPTER VI. Examination of the Patient (Continued) : Palpation OF THE Pulse. p^^^g Reason for feeling the pulse^Technique — bimanual estimates- Rate — Importance of rate-response to exercise — What con- stitutes a natural rate-response— Rhythm — Volume 47-57 CHAPTER VII. Examination of the Patient (Continued) : Cardiac Percussion and Mensuration. Forms of percussion — Purpose of percussion — Malposition of the heart — Mensuration ■. 58-69 CHAPTER VIII. Examination of the Patient (Coitinued) : Auscultation of the Heart; Murmurs. Purpose of auscultation — Technique — Stethoscopes — Natural heart sounds — The puncta maxima — Cardiac murmurs — Tonal Properties of Murmurs — Transmission of murmurs — Accen- tuations — Reduplications — Friction rubs — Influence of exer- cise on murmurs — Murmurs without significance — Febrile murmurs — Murmurs of diagnostic import — Differentiation of Murmurs, French Method — How to regard a murmur 70-81 CHAPTER IX. Laboratory Aids in Diagnosis. Urinalysis — Renal function test — Ophthalmoscopy — Serologic reactions — Differential blood counts — Blood cultures — The fluoroscope — The orthodiascope *, 82-88 CHAPTER X. Graphic Methods of Examination : The Polygram and its Interpretation. Advantages of the polygraph — The apparatus — Component parts of the tracing — Technique — The normal arteriogram — The normal phlebogram — Interpreting the polygram — The inter- pretation of arteriograms — Dominant rhythm — Brief sug- gestions in analysis — Abuse of the poly^am 89-101 CONTENTS. ix CHAPTER XI. Graphic Methods of Examination {Continued) The Electro- cardiogram AND ITS Interpretation, PAGE Definition — The principle — The apparatus — Questions the physi- cian asks — Investigations that estabhshed electrocardiography — Clinical diagnoses confirmed — Diagnoses otherwise not pos- sible — How to read the normal electrocardiogram — Interpret- ing the curves — Pathologic records — Brief suggestions in analyzing electrocardiograms — The use and abuse of electro- cardiography 102-125 CHAPTER XII. The Significance of Blood-pressure Estimates. Definition — Importance of comparative readings — The apparatus — Technique — Terms employed — Usual standards — Blood- pressure aids — Blood-pressure "Don'ts" — ^Treatment of hy- pertension 126-133 CHAPTER XIII. The Irregular Pulse. General considerations — Sinus arrhythmia — Premature contrac- tions — Paroxysmal tachycardia — Auricular flutter — Auricular fibrillation — Etiology — Prognosis — Treatment — Heart - block — Diagnosis — Prognosis — Treatment — Pulsus altcriians — The general significance of pulse irregularities 134-163 CHAPTER XIV. Pericarditis. The physiologic function of the pericardium — Classification of peri- carditis — Etiology of acute pericarditis — ^Diagnosis of acute pericarditis — Pericarditis with effusion — Pericarditis with adhesions — Adherent pericardium — Treatment 164-188 CHAPTER XV. Myocardial Affections. Terms employed — Etiology — The induction of chronic myocardial change — Diagnosis of acute myocarditis — The recognition of chronic myocardial change — ^ Treatment 189-214 X CONTENTS. CHAPTER XVI. Endocarditis. p^jjj. The defining of endocarditis — Morbid anatomy — Etiology of acute endocarditis — Etiology of malignant endocarditis — Symp- tomatology — Physical signs — Diagnosis — Prognosis — Treat- ment 215-241 CHAPTER XVn. Chronic Valvular Disease of the Heart. General considerations — Etiology — Morbid anatomy — Varieties of valvular disease — Incidence — Mitral insufficiency — Mitral ste- nosis — Aortic insufficiency — Aortic stenOsis — Tricuspid valve lesions — Pulmonary valve lesions — Treatment 242-269 CHAPTER XVIII. Congenital He.'vrt Affections. Varieties — Patulous foramen ovale — Perforate interventricular septum — Persistent ductus arteriosus — Valve defects — Dex- trocardia — Congenital valvular disease — Conclusion .... 270-277 CHAPTER XIX. Arteriosclerosis. Definition and terms — Circulatory effects — Etiology — Clinical recognition — Blood-pressure — Kidneys — Heart — Pulse — Eye — Prognosis— Treatment 278-306 CHAPTER XX. Aneurism. Definition and varieties — Etiology — Acute aortitis: Symptoms — Physical signs — Diagnosis — Preaneurismal stage— Thoracic aneurism — General symptoms — Symptoms relative to site — Physical signs — Diagnosis — Prognosis — Treatment 307-336 CHAPTER XXI. Angina Pectoris. The condition defined — Objectionable terms — Etiology — Morbid anatomy— Symptoms — Physical signs — IJiagnosis — Prognosis — Treatment 337-351 CONTENTS. xi CHAPTER XXII. Neuro-circulatory Asthenia. PAGE The name — The syndrome in civil life — The syndrome in train- ing camps — The syndrome in war — Predisposing conditions — Typical case record — Further points in analysis — Treatment — Conclusion 352-360 CHAPTER XXIII. "What can be done for HEARt Disease?" A false impression — The early recognition of heart disease — What cannot be done — What may be done — Prophylaxis — The pa- tient's daily life — Correction — Conservation — Cardiac therapy — Rest — Exercise — Diet — Massage — Sanatorium treatment — Operation on septic foci — Balneotherapy — Drugs 361-392 CHAPTER XXIV. Cardiac Drugs. Digitalis — Strophanthus — Epinephrin — The nitrites — Atropine — Morphine — Antisyphilitics — Iodides — Strychnine — Caffein — Alcohol — Camphorated oil — Anesthetics in heart affections — Chloroform — Ether — Nitrous oxide 393-411 CHAPTER XXV. Cardiac Camouflage. Artificially induced disorders — The reason — The means employed — Simpler forms — Acetanilid — Atropine — Digitalis — Suspici- ous atttitudes of mind — Genuine mental atmospheres .... 412-417 Index 419 ILLUSTRATIONS I'IG. PAGE The Heart (Frontispiece). 1. Relation of Heart to Anterior Chest Wall 6 2. Right Auricle and Ventricle 8 3. Left Auricle and Ventricle 9 4. Lateral View of the Heart 10 5. The Valves of the Heart 13 6. The Excitation Wave 16 7. The Conduction System of the Heart 17 8. Form for Cardiovascular Record 31 9. Reverse Side of Cardiovascular Record, 32 10. Rate Response to Exercise 52 11. Cardiac Displacement (A) 63 12. Cardiac Displacement (B) 64 13. Cardiac Displacement (C) 65 14. Cardiac Mensuration 67 15. The Ford Stethoscope 71 16. The Puncta Maxima 74 17. The Usual Outline of the Heart 84 18. Cardiac Enlargement SS 19. Effect of Respiration on the Heart 86 20. Groedel Orthodiascope 87 21. Mackenzie's Ink Polygraph 90 22. Polygram of an Apparently Normal Heart 90 23. The Jugular Bulb 91 24. Sinus Arrhythmia 98 25. Auricular Fibrillation 98 26. Dropped Beats 99 27. Complete Heart-block 99 28. Pulsus Altemans , 100 29 The American Electrocardiographic Equipment 104 30. The Galvanometer and String-house 105 31. The Camera 107 32. The Three Leads 110 33. Component Parts of the Record Ill 34. Normal Electrocardiogram Ill 35. Sinus Arrhythmia 112 36. Right Ventricular Premature Contractions 113 37. Paroxysmal Tachycardia 113 38. Auricular Flutter 114 39. Auricular Fibrillation US (xiii) xiv ILLUSTRATIOiXS.. FIG. PAGE 40. Delayed Conduction 115 41. Dropped Beat , 116 42. High-grade Heart-block 117 43. Arborization Block 118 44. From a Case of Mitral Stenosis 119 45. Auricular Enlargement 119 46. Left Ventricular Preponderance in a Case of Aortic Regur- gitation s 120 47. Vagus Nerve Compressed by Lymph X^odes 143 48. Ilemopericardiunx 165 49. Acute (Villous) Pericarditis 169 50. Pericarditis with - Effusion 173 51. The Cardiohepatic Angle 175 52. Probable Pericardial Effusion 177 53. Pericardial Adhesive Bands 181 54. Adherent Pericardium 183 55. Polyserositis — Pick's Disease 185 56. Cicatricial Myocarditis 195 57. Fibrous Myocarditis 202 58. Verrucose Valvulitis 218 59. Vegetative Mural and Valvular Endocarditis 219 60. Mitral Valve Vegetations 220 61. Aortic Valve Vegetations 221 62. Fibrous Fusion of Valves 222 63. Aortic Valve Leaflet Distorted by Vegetations 223 64. Fenestration of Aortic Leaflets 224 65. Perforation of an Aortic Leaflet 225 66. Apical Abscess 226 67. The Funnel-shaped Mitral 245 68. The Buttonhole Mitral 247 69. Fusion of Aortic Leaflets ,* 255 70. Patulous Foramen Ovale 271 71. Imperfect Aortic Valve 275 72. Medial Calcification 284 73. Beginning Arterial Change .• 285 74. Arteriosclerotic Gangrene of Leg 287 75. The Arch of the Aorta 313 76. Aneurism of the Aorta 317 77. Aneurism 320 78. X-ray Photograph of Fig. 77 321 79. Aneurismal "Erosion" ^26 80. Aneurismal "Erosion." Side view Fig. 79 327 81. Rupture of an Aneurism into the Esophagus 329 82,- Foreign Body in the Heart 365 83. Influence of Digitalis on the Electrocardiogram 397 CHAPTER I. Introduction. Heart affections are being rewritten in that new nomenclature and broader understanding which has followed the investigations of the physicist, the physiologist, the pathologist and the anatomist, in their recent laboratory inc[uiries of the heart. The clinician has applied these investigations and advances at the bedside, and as a result many disorders of the cardiac mechanism, heretofore undiagnosed, can now be clinically recognized and classified for treatment. The day has passed when heart disease and prog- nosis are determined by the detection of cardiac mur- murs alone. The wisdom of an oracle is no longer believed to dwell in the mouth of a stethoscope. Aus- cultation of the precordium and the timing of adven- titious sounds within the chest do not now hold first place in the determination of heart disease. Auscul- tation should hold sixth place in our methods of physical diagnosis, being preceded in importance by the logical order of investigation which is systemati- cally employed in all modern medical examinations, z'is: history-taking, inspection, palpation, percussion, mensuration. Then should auscultation be employed, to confirm observations made by these five methods and, perhaps, to adduce additional testimony of cardiac disease. Supplementing the information thus elicited by the natural gifts of sight, touch and hearing, there (1) 2 HEART AFFECTIONS. are now available for further investigation of the heart, if need be, other diagnostic methods. The sphygmomanomeier records, in figures, changes in the blood-pressure of our patients — changes which are sometimes of pathologic significance. The poly- graph records, in ink, the events, transpiring in the right and in the left sides of the heart. The electro- cardiograph records, in photograf)h, alterations that may occur in the course of the excitation wa^■e which precedes the contraction of the various heart cham- bers. The orthodiagraph is an adaptation of the Rontgen rays \\'hich accurately determines an}- in- crease in the diameters of the heatt or of the greater vessels. However, these instruments of clinical precision are not to be considered absolutely necessary for the establishment of a clinically satisfactory diagnosis. In doubtful cases, or where there is a desire for fur- ther investigation, the newer diagnostic apparatus will of course be employed. The invaluable contri- bution which the electrocardiograph and the poly- graph have made to science has tfeen in the aid they afford in the clinical recognition of disturbances of the cardiac mechanism ; they have classified such dis- turbances and ha\-e taught the physician to differen- tiate serious pulse irregularities from those which are quite harmless. Instrumental methods are not in- tended to entirely supplant the trained finger, the alert eye and the discriminating ear in the recog- nition of heart disease. Nor can their use supply to him who lacks it the finely-balanced qualitv of clinical jitdgnient, which is the logical end result of care- fully weighing the evidence obtained by historv- INTRODUCTION. 3 taking, inspe'ction, palpation, percussion, mensuration and auscultation. The points, then, to be impressed on the reader ere he peruses the successive chapters of this book are as follows : 1. Adopt a systematic method of heart examina- tion, in which auscultation is to be the last, not the first, of the physical methods employed. 2. Attach little significance to the presence of systolic murmurs unless accompanied by other signs which indicate cardiac damage. One cannot estimate the degree of heart damage by adventitious sounds; nor is it wise, on'the other hand, to assume that the heart is normal because it is free from murmurs. 3. It is the condition of the all-essential heart mus- cle and not the presence of an incidental heart sound, which determines the cardiac efficiency of an individ- ual and which guides the physician in prognosis and treatment. 4. He who practices systematic routine in the ex- amination of cardiac patients will arrive at a clinic- ally-satisfactory diagnosis in the majority of in- stances, without the additional employment of modern instruments of clinical precision. And no matter what facilities may be at hand, he who lacks system in his examinations will have slip-shod and uncertain results. In conclusion, let us pursue our investigation of the heart and its affections by disabusing our minds of such earlier teachings as gave us the impression that a "murmur" is the indispensable factor in cardiac diagnosis, and in its place keep before us a sentence which might well be called today's Cardiac Aphorism : The muscle is of more importance than the murmur: The rhythm is of more importance than the rate. CHAPTER 11. Anatomy and Physiology of the Heart. "The heart is a hollow muscular organ, situated anteriorly within the thoracic cavity, lying between the second and fifth interspaces.: It extends eight centimeters to the left of the median line of the thorax and two centimeters to the right thereof. Its func- tion is to propel the blood through the greater and lesser circulations of the body." In some such stereotyped phrase as this do texts on anatomy define the marvellous combination of muscle, nerve, membrane and chambers which evolved itself, embryonically, from a redvtplication of curves in the primitive embryonic cardiac tube. If one thinks of the heart as thus derived, from that point in a blood-vessel where the deposit of an excess of nodal tissue gave rise to impulse; and if he continues to think of it as an architecturally-elaborate, highly- specialized evolution of an arter} , he will better under- stand why pathologic conditions ^^•hich affect the arteries so often affect the heart, and why maladies of the heart are not confined to that organ alone but may also involve the vessels of which it is a highly- elaborate structural part. SIZE, WEIGHT AND SHAPE. There are many circumstances which cause the heart to xary in size, in weight and in shape. Hence it is quite impossible to state that a heart, norinal for ail individual, shall have a specified weight, or that it shall conform to definite measurements, or that it (4) ANATOMY AND PHYSIOLOGY. 5 shall correspond to a given shape. Sex causes var- iations in the heart ; it is larger in men than in women. Stature also causes variations. Short, stocky individ- uals have as a usual thing a broader heart than that which is found in the tall, thin person. In the latter the heart may be of a length which causes it to extend to the sixth interspace and be correspondingly nar- row; to such an organ the term "dropped heart" has been applied. Occupation^ in the demands which it may make upon the heart, has an influence on its size ; the person who has never been accustomed to marked or continued physical exertion — the bookkeeper, for example — may be expected to have a heart which is smaller than that found in those accustomed to vigor- ous physical exercise. Those who are habitually en- gaged in arduous employments usually have efficient hearts ; but if they suddenly abandon physical activity and lead a life of comparative ease, the heart may lose its quality of tone and seem to be increased in width. Previous disease often has an effect on the size of the organ. General nutrition if below par, may cause the heart to respond unnaturally to the demands thrown upon it, and the organ be larger than one would expect to find. \A"hcn one considers that a multiplicity of factors such as these may alter the size, weight and shape of a normally acting heart, one sees that allowance must be made for departures from the average figures. The total transverse diameter of the heart averages 12 centimeters.* The average weight is 10 ounces. The average capacity of the left ventricle is 4 ounces. The usual position of the heart is well within the tradi- * ZYz centimeters ^= 1 inch. HEART AFFECTIONS. tional confines of the second and fifth interspaces (Fig. i) — although it may extend quite beyond them in one direction or the other, as* in "dropped heart," and be in no wise considered pathologic. Fig. 1. — RELATio>f of Heakt to Anterior Chest \\"all. The cardiac outlines were obtained by orthodiascopic projec- tion. The right border of the heart is fornied by the right auricle. (From Mackenzie.) One must investigate the history, the habits and occupation of a patient — must employ inspection, pal- pation, percussion, exercise tests and the sense of comparatk'c values — if one is to elicit definite infor- mation concerning each individual case. It is absurd ANATOMY AND PHYSIOLOGY. 7 to attempt to appraise a heart simply by auscultation and, with a flourish of stethoscope, proclaim that the brawny day laborer has an "enlarged heart" or that the slender, slim young girl needs strenuous exercise to bring her heart to "normal" standards! CHAMBERS OF THE HEART. The interauricular and the interventricular septa which divide the organ in a longitudinal plane afford an anatomic basis for speaking of the "right heart" and the "left heart" — convenient phrases for memory, as we recall that the right heart is concerned with the venous blood of the lesser or pulmonary circulation, while the left heart receives and distributes the arterial blood of the greater or systemic circulation. It has been customary to speak of the upper chambers of either side as the "auricular reservoirs" (most elaborately designed, indeed, for mere "reservoir" purposes!); these communicate with the ventricles below throtigh orifices called valves. The distribution, direction and extent of the muscle fibers show many interesting modifications in the various chambers. The "internal architecture" ■ — if one might thus refer to such structures as the columnae carnae, musculi ]Dapillares and chordae tendineae, for example, which unite to form the operat- ing mechanism of the mitral and tricuspid valves — is also subject to marked modification in the various chambers. Much of this can be learned at the dis- secting table; little of it can be learned from printed words. Study of the illustrations (Figs. 2, 3 and 4) will refresh the memory on the relative size, thickness and structure of the various heart chambers. HEART AFFECTIONS. Fig. 2. — Right Auricle and A'entricle. Both chambers laid open, the anterior wall of each having been removed. (From Chart of Dr. G. H. Michael.) ANATOMY AND PHYSIOLOGY. Fig. 3. — The Left Auricle and Ventricle. The arrows indicate the course of the blood. (From Chart of Dr. C. H. Michael.) HEART AFFECTIONS. Fig. 4.— Lateral View of the Heart. Obtained from section of a frozen specinien. Note position of the left auricle which is sometimes called "The posterior auricle." (From Alorns and Landis.) ANATOMY AND PHYSJOLOGY. 11 VALVES OF THE HEART. That orifice situated in the right atrio-ventricular septum is closed by the tricuspid valve, which consists of three segments or "cusps" of triangular shape (Fig- 5). Its fellow of the opposite side is known as the mitral or bicuspid valve. It is larger and thicker than the tricuspid and consists of two segments. The membranous leaflets of these valves are evolved from reduplications of the endocardium — the thin, translucent membrane which lines the cavities of the heart; they contain a few muscle fibers. The valves are reinforced by fibrous rings of comparative density where the leaflets join the heart muscle. It is interesting to note in passing that nature has paid particular attention to the reinforcement of the aortic valve of the ox, sheep and deer, to the extent of pro- viding a crescent of bone around the anterior aortic cusp. The aortic or semilunar valve guards the orifice between the left ventricle and the aorta. It has three leaflets. The pulmonary valve also consists of three leaflets, and is located at the junction of the right ventricle with the pulmonary artery. "Mitral disease" is a term freely used to describe an affection of this valve, which is of a size sufficient to usually admit the tip of three fingers. It is said that the mitral valve is damaged ^five times as often as are other valves of the heart, the averred reason for this being that it is subject to heavy "back-pres- sure" when the powerful and forcibly-acting left ventricle drives its content of blood into the circula- tion, thus tending to weaken the valve. The state- ment is quite at variance with physical laws in other 12 HEART AFFECTIONS. parts of the body, where the natural use of a struc- ture develops and strengthens it. Nor can the state- ment be reconciled with investigations^ A\'hich indicate that undamaged heart-structure is capable of putting forth 13 times the effort required in one day's life and yet emerge from the test apparently unaffected. It might be more nearly right to adopt the premise that mitral-valve damage is coincident with heart muscle affection — a local manifestation, in a valve, of a more widely spread condition — either from acute in- fections, absorption of toxins from chronic processes, or from long-sustained physical effort. For it is in- conceivable that disease could invade the myocardium and fail to aft'ect the overlying endocardium as well ; and it is equally as improbable that infection would confine its ravages to the delicate valve-membrane alone and leave the contiguous myocardium uninvaded. In speaking of the septum between the right and the left auricle the impression was perhaps conveyed that it is an imperforate dividing wall. Such is not always the case. The foramen ovale, A\hich is patu- lous in the fetal circulation, may fail to close at birth and persist as an opening between the right and the left auricle. In the frankly patent cases, we see the phenomenon of "blue babies," a rare one of which may live to maturity and indeed to old age. Or, in other instances, the foramen ovale may close onlv imper- fectly, remaining partly patulous through an appar- ently healthy life. Recent anatomic investigations indicate that this condition is found much more fre- quently than one would expect (see page 272). Under Levy: Ztschr. f. klin. Med., 1896-97, xxxi, 320. ANATOMY AND PHYSIOLOGY. 13 J3 bo < •a c > W H o Id 5 > 14 HEART AFFECTIONS. physical strain or excessive emotion, or in a heart of relaxed tonicity, this imperfect closure may permit the admixture of venous with arterial blood, with attendant symptoms of cyanosis or dyspnea. Such instances may produce marked alterations in the usual heart sounds ■which are suggestive of murmurs — an observation which emphasizes the< fatuity of building a diagnosis of heart disease solely upon the shifting sands of murmurs. CIRCULATION OF THE BLOOD. William Harvey, the London physiologist of the seventeenth century, published in 1628 his revolution- izing observation on the circulation of the blood. Arthur Keith, another London physiologist of the twentieth century, discovered in 1907 the sino-auric- ular node which initiates the contraction of the normal heart. One must review the old and new discoveries of these and other celebrated physiologists and anatomists, linking together sviccessive revela- tions in their logical entirety, if one is to clearly under- stand the functionating heart. Venous blood, be it remembered, is returned from the body to the right auricle by the ascending and descending venae cavae. It passes through the tri- cuspid \'alve into the right ventricle, through the pul- monary valve into the pulmonary artery, which carries the blood to the lungs for aeration. The oxygenated blood returns to the left auricle by wav of the pul- monary veins. (The pulmonary "artery"' carries venous blood and the pulmonary "Vein" carries arter- ial blood — misnomers applied by the earh^ anatom- ists). From the left auricle the i^'yid ])asses through ANATOMY AND PHYSIOLOGY. 15 the mitral valve to the left ventricle, then through the aortic valve into the aorta and is thence distributed through the body. The propulsion of the blood into the arteries is accomplished by simultaneous contraction of the ven- tricular chambers of the heart, the contraction being termed systole. The auricles of course also have a systole, and both auricles contract at the same time. It is a fraction of a second later — between 0.12 and 0.18 of a second — that both ventricles are in systole. Ventricular systole, in a heart which contracts at the rate of 75 beats per minute, occupies 0.3 of a second. Then follows a period of cardiac rest, known as dias- tole, which occupies 0.5 of a second (during the last one-tenth second of which the auricles contract). From this the rather interesting deduction can be made, inasmuch as the ratio of work to rest is as 3 to 5, that the heart is in contraction nine hours a day and in its rest period fifteen hours out of the twenty- four. THE CONDUCTION SYSTEM. But what mechanism regulates this rhythmical and synchronous contraction of the cardiac chambers? It is regulated by an excitation wave, which is trans- mitted to the chambers of the heart along a definite, established pathway, the conduction system. The impulse for contraction originates in the sino-auric- ular node, graphically named by the brilliant Lewis of London, the "pacemaker" of the heart. It is situated at the junction of the superior vena cava and the right auricle. From there the excitation wave spreads over the auricular wall in much the same 16 HEART AFFECTIONS. manner that concentric rings, from a pebble thrown in a brook, would spread to the banks on either side (see Fig. 6). Thus it reaches tlie node of Tazvara (described in 1906 by the Japanese investigator whose name it bears), which is situated in the junctional tissues between the right auricle and ventricle (see Fig. 7). This node is the head of a neuro-muscular bundle of tissue of perhaps half an inch in length; from its location it is sometimes called the atrio- Inferior vena cava - Superior vena cava Slnoaurlcular node Appendix auricularis Fig. 6. — The Excitation Wave. A diagram illustrating the spread of the excitation wave over the surface of the right auricle. The spread is almost uniform and follows the chief muscle bands. (After Lcn'ii.) ventricular bundle, although it is better known by the name of the anatomist Avho desct-ibed it, the bundle of His. The bundle soon divides into right and left branches, the flat left branch piercings the interven- tricular septum to reach the left ventricle, while the round right branch conducts the stimulus for con- traction to the right ventricle. The right and left branches of the bundle ter- minate in fine arborizations known as the -fibers of Piirkinje, concerning which the anatomist of that ANATOMY AND PHYSIOLOGY. 17 name wrote in 1845. Tawara showed us, in igo8, that these fibers are part of the conduction system and that they gradually fade into the ventricular muscle, where they discharge the impulse which now finally results in the contraction of the ventricles. The stimulus for contraction varies in speed. It travels four times as fast in the ventricles, over neuro- muscular tissue, as in the auricles; for in the latter situation it is conducted I'la muscular tissue alone. -^ ... Aorta V>n. ._ Pulmonary artery ^ Jr . . Node of Tawata ^ <^/\ .. Bundle of His W - - Left branch of hundle ■- Right branch ^ of bundle ^'1 '"""' \ A Fibers of 1 Purkinje ' L 'S -7- Left ventricle ___— -^ Superior vena cava • Slno-aurlcular node ("Pacemaker") Atrio- ventricular junctional tissue- Right auricle - Right ventricle - Inferior vena cava - Ftg. 7. — The Conduction System of the Heart. Showing in red the approximate relation of the more recently discovered structures to faniihar anatomical divisions of the heart. This is the pathway of conduction for a normal heart. It may be interfered with by disease. For example, it will be shown under auricular fibrillation, that in this condition the sino-auricular node is no longer the pacemaker of the heart and that the auric- ular rate is disordered by diseased foci situated in the muscular wall. There is another disturbance of con- duction to be considered under its proper head, called complete heart-block, in which the bundle of His is afifected and cannot conduct the impulse-for-contrac- tion from auricle to ventricle. Under such a circum- 18 HEART AFFECTIONS. Stance the unaffected portion of the bundle or even the ventricles themselves may initiate a rhythm of their own, and not depend on the pacemaker at all. In such an event the rates initiated by the lower part of the bundle are in the neig-hborhood of 45, while those originated by the ventricle are 30 or perhaps less. THE PROPERTIES OF HEART MUSCLE. We have seen in the foregoing paragraphs that heart muscle possesses the properties of : ( i ) Stimulus production: (2) Conductivity; (3) Contractility; (4) Excitability. To these we should add a fifth, the property of (5) Tonicity, by which heart muscle re- tains its tone and does not utterly relax during the rest period of the cardiac chambers. A loss in tonicity causes relaxation of muscle tissue; this in turn per- mits relaxation of the valve rings and prevents per- fect closure of an orifice; thus the're arise murmurs which are present when the patient is at ease, but which disappear on exercise. This is one of the phe- nomena produced by a loss in tonicity. These five properties are referred to coUectivelv vmder the term of tlic niyogcjiic theory of heart muscle. It is of clinical importance to bear in mind at this point that these five functions may be disturbed either singlv or in combination, giving rise to the disorders discussed under, "The Irregular Pulse" (Chapter XIII). THE CARDIAC CYC'LE. The cardiac cycle is that period which extends from the beginning of one contraction of the heart to the beginning of the next. It is well to commit to memory the paragraph which follows, for it is useful ANATOMY AND PHYSIOLOGY. 19 when analyzing polygraphic tracings and electro- cardiographic curves. It is valuable, too, to have in mind when studying patients at the bedside. The cardiac cycle begins with the stimulus for contraction, which arises in the pacemaker and which is conducted along the auricular wall to the atrio- ventricular node and over the branches of the bundle of His. The mitral and the tricuspid valves now stand open, and the auricles contract. Next, the ven- tricles receive the stimulus from the fibers of Purkinje and contract, the contraction starting at the apex. Then the mitral and the tricuspid valves close. When the tension in the ventricles exceeds that in the aorta and in the pulmonary artery, the aortic and pulmonary valves open, and the pulse period begins. Ventricular systole is then completed. Comparative relaxation of the ventricles occurs, and when the pressure within them is lower than the pressure in the aorta and the pulmonary artery, the aortic and the pulmonary valves close and the pulse (sphygmic) period ends. The ventricles further relax, the mitral and the tricuspid valves open, and a new cycle begins. THE CARDIAC NERVES. The right and the left pneumogastric are the in- hibitory nerves of the heart. It has been demonstrated recently that the right pneumogastric nerve sends the greater part of its fibers to the sino-auricular node. It is a distribution of much clinical signifi- cance; for inasmuch as the sino-auricular node gov- erns the rate of the heart, pressure on the right pneumogastric nerve, which supplies the node, may cut short a paroxysm of tachycardia (page 141 ). The 20 HEART AFFECTIONS. left pneumogastric nerve sends a greater part of its fibers to the node of Tawara, thus particularly in- fluencing" conduction. The action of these inhibitory nerves of the heart is much referred to under the term "vagal influence." The accelerator nerves of the heart are supplied by the SA'mpathetic S3'stem, of which there are two plex- uses. The superficial plexus lies beneath the arch of the aorta. The deep or great Cardiac plexus lies behind the aortic arch, in front of the tracheal bifurcation. The t\\-o coronary arteries, which arise from the aorta immediately above the aortic'valve, nourish the heart ( Fig. 68 ) . They are about the size of a crow- quill. Partial occlusion, narrowing of the lumen, or arterial spasm of a coronary artery have been believed to be the exciting factors in angina pectoris. CHAPTER III. Examination of the Patient. GENERAL CONSIDERATIONS. EXTREME CARDIAC TYPES. From the moment a patient enters the office, the alert physician may begin to make observations which will aid him in eventually determining the presence of heart affections. For instance, in the case of an elderly person, he may observe that the step is measured and deliberate, as though in avoidance of rapid movements which, bv disturbing" the circulatory equilibrium, would cause giddiness and distress. The face may be either flushed or cyanosed, and bags hang under the lustreless eyes, as is frequently the case in patients with combined heart and kidney lesions. The respirations may be forced and shallow, and in s'tting the patient may bend slightly forward, as though in studied protec- tion of some malady within the chest. Pulsations may be \isible in tortuous temporal arteries, and waves be present in the vessels of the neck.^ Or as another' example, take the young woman with the "neurotic" heart, who comes to consult the physician because of fainting attacks, faraway sensa- tions, etc. She will present none of the signs ]:)y which the elderly cardiopath may be recognized. Her car- riage will likely be erect, and her color natural. Put the observant physician may notice that her niove- (21) 22 HEART AFFECTIONS. ments are quick, as though in response to a highly emotional state; her respirations hurried; her thyroid gland quite apparent and fine tremors present in her finger tips — all suggestive of the tachycardia which is associated with thyrotoxicosis. Thus by careful observation of gait, bearing, atti- tude and superficial physical signs, one may classify the malady which brings the patient to the consulting office, and be on the alert for more definite symptoms which may be elicited as the examination proceeds. DIAGNOSTIC POINTS. One may observe other points while the patient relates his symptoms — points quite suggestive of defi- nite heart lesions. The head may nod with each pul- sation of the heart in aortic insufficiency; this affec- tion, too, gives more pallor than does anv other valvular disease of the heart. Radial arteries that are prominent or of a tortuous course will suggest arteriosclerosis, as they move laterally in the direction of the tilna with each impulse. A husky voice should cause one to think of the distended auricle of auricular fibrillation or of an aneurism, either of which some- times press upon the recurrent laryngeal nerxe, pro- ducing this symptom. Should four or five wa^-es be counted in the jugular vein to one in a slowly-pul- sating carotid, it will be interesting to determine whether this be a sign of heart-block. A brassy cough, with evidence of congestion, should remind the physi- cian of a mitral lesion. Thyroid enlargement and protruding eyes at once suggest hyperthvroidism, with its attendant rapid heart. The widened space between the eyelids, the prominent cheek bones, the EXAMINATION OF THE PATIENT. 23 transparent skin and the hectic flush of tuberculosis should lead the physician to anticipate the overacting heart of this condition. Should attention be arrested by characteristic scars or copper colored spots, search should be made for evidence that will convict syphilis of adding still another victim to its growing list of heart wrecks. PRESENTING SYMPTOMS OF HEART AFFECTIONS. The foregoing observations are simply diagnostic straws, which serve perhaps no other purpose than that of adding to the interest in a case. The best indication, before physical examination, that the pa- tient actually sufl:ers from a heart riialady will be found in the present i it g syiiiptoiiis — those syiuptoiiis of zvhich the patient actively complains. As indicative of the order of frequency and the relative importance of the earlier presenting symp- toms of heart affections, the following table is pre- sented : Incidence of Presenting Symptoms in SOO Consecutive Rejections fkom Military Service. Per cent. Precordial pain 68.2 Giddiness 66.6 Palpitation 66.4 Cough 34.4 Dyspnea 31.4 Fainting 29.5 Edema 7.8 These figures I gathered from a group of young men but recently drafted from civil life, who had physical breakdowns of varying degree during their first few weeks of training at a military camp. It is significant that precordial pain, giddiness and 24 HEART AFFECTIOKIS. palpitation were present in two out of three, of these recruits ; cough, dyspnea and fainting were symptoms in one out of three. Only one out of every fourteen had edema, for the reason that edema is one of the later symptoms of heart affections, and these were early cases. We may now briefly discuss the above and other presenting symptoms. (i) Inability to perforin customary tasks zvithont distress was the dominant symptom in this group of men. It was the reason for the xast majority of them being referred to the cardiovascular board — and hence it is above all the most important presenting symptom. The men ''broke" under drills, marches and double time: they were unable to withstand a degree of physical effort which imposed no hardship on hundreds of others. The routine of military life uncovered heart affections which were not revealed when the man was first recruited from civil life. After the first cardiac break, a few were unable to perform even the simple act of climbing stairs or bending' to lace shoes, without symptoms of distress. (2) Precordial oppression and pain were present in 76 per cent, of the men with mitral lesions : in /'2 per cent of those with cardiac enlargement (the cause of which was not always demonstrable) ; 52 per cent, of early aortic lesions complained of pain. Hence precordial oppression or pain is an earlv and impor- tant sjaiiptom of heart affections, and should never be lightly passed over without a thorough search for its cause. It may be due to pulmonary conditions or to pleural irritations ; still less frequently it is caused by fatigue of the breast muscles ; rarclv indeed can the diagnosis of "intercostal neuralgia" and "gastric EXAMINATION OF THE PATIENT. 25 flatulence" be made an excuse for neglect in searching for the probable cardiac origin of precordial pain. Precordial hyperesthesia — tenderness of the pec- toral muscles — might be mentioned in this connection. It is a sign that is not unusual in cardiac conditions, and is elicited by grasping the upper border of the pectoralis major muscle. It is often found in cardiac neuroses. (3) Giddiness — vertigo or dizziness — was present in 71.5 per cent, of the men with mitral lesions ; in 66.9 per cent, of those with cardiac enlargement and in 58.8 per cent, of early aortic lesions. Any of these afl:'ections will interfere with circulatory efficiency and giddiness arise as a result of sudden change of posture, or muscular exertion. This disturbance of the sense of stability also occurs in Meniere's disease, — a rare affection — and as a result of gastric, ocular or nerve disorders ; but in the latter conditions it is not as constant a symptom as it is in cardiac affec- tions. (4) Palpitation — by which I mean a periodic rapidity of heart-rate of which the patient is uncom- fortably conscious — was present in 67.5 per cent, of mitral lesions; in 69.1 per cent, of cases of cardiac enlargement and in 47 per cent, of the aortic lesions in the series. To be of significance, periods of pal- pitation should arise in the absence of muscular exer- tion and emotion. It is of passing interest to note that Darwin, in speaking of the influence of fear in his essay on "The Origin of the Emotions," refers to palpitation as follows: "the heart beats quickly and violently, so that it palpitates or knocks against the ribs; but it is doubtful if it then works more 26 HEART AFFECTIONS. efficiently than usual, for the skin becomes pale as during incipient faintness." (5) Cough arises as the result of so many condi- tions that one must rule out of consideration the more common causes before attributing any cardiac signi- ficance to cough. Pharyngitis, laryngitis, bronchitis, pleuritis and other acute and chronic pulmonary con- ditions are the most frequent factors. Unusual causes are a relaxed uvula which irritates the pharyngeal wall, and impacted wax in the external ear which, by stimulation of the auditory branch of the pneumo- gastric nerve, produces cough. Caseous material in the follicles of tonsils not infrequently causes cough. The smoking of tobacco and the habit of mouth breathing obviously induce cough. When such ap- parent causes are ruled out of consideration, cough is probably an evidence of heart affections and is fre- quently associated with rales at the base of the lungs posteriorly — an early and valuable sign of beginning circulatory failure. Of the mitral lesions found among the 500 cases which form the bases of this discussion, 35.7 per cent, had cough not due to obvious cause; 38.3 per cent, of the cases of cardiac enlargement presented the symptom, as did also 23.5 per cent, of the aortic lesions. (6) Dyspnea, as an early symptom of heart affec- tions, is usually transitory and is precipitated by some trivial exertion ; this differentiates it from the labored breathing of bronchitis, pulmonary edema, toxemia and acute lung infections in which effort is not re- quired to produce the symptom. An enlarged liver, ascites or other intra-abdominal enlargements may EXAMINATION OF THE PATIENT. 27 cause dyspnea. In the absence of such demonstrable causes, dyspnea was present in 3^7.7 per cent, of the mitral lesions, in 26.3 per cent, of the cases of cardiac enlargement and in 35.2 per cent, of the aortic lesions in this series. "Cardiac sleep-start" might here be mentioned, as it is caused by a paroxysm of dyspnea. It cannot be catalogued as an early symptom, however. The patient is suddenly awakened from sound sleep and, with a start, sits upright in bed. The period of apnea terminates after a short interval. Such experiences often cause the patient to elect to sleep in the sitting posture, rather than the recumbent. Cardiac sleep- start should not be confused with the sense of heart oppression which many people experience when they turn on their left side during sleep. This oppression is often accompanied by dreams of falling through space — and the sleeper awakens suddenly to change position, or may forcibly throw himself on the other side without fully awakening. But here the urgent absence of breath, which characterizes the genuine cardiac sleep-start, is lacking. (7) Fainting, as a presenting symptom, in the pre- ceding table (page 23) shows an interesting discrep- ancy between a mitral lesion incidence of 27.1 per cent, and an aortic incidence of 5.8 per cent. Fainting is a frequent symptom in the emotionally high-strung, in the constitutionally inferior and in persons who suffer from gastro-intestinal conditions. The fainting which is due to early circulatory disturbance is not to be confused with the periods of unconsciousness which arise, often without apparent cause, in far-advanced heart affections, in which unconsciousness is the re- 28 HEART AFKECTIONS. suit of coincident damage to the bifndle of His and to the cerebral vessels. (8) Edema of the feet or ankles, which appears at the close of the day and which has^ a tendencA' to dis- appear when the patient is at rest in bed, is character- istic of moderately-ach-anced and advanced heart afifections. Scrotal edema, ascites and anasarca are deepening degrees of extravasation of fluid in tissues. (9) Cyanosis is not an early symptom of heart affections. J^^xcluding neurocirculatory asthenia, in which moderate cyanosis is a part of the symptom- complex, cyanosis usually occurs in association with other w ell-marked physical signs which leaA'e no doubt as to the cardiovascular cause of the malady. One must of course bear in mind that c}-anosis is not always of cardiac significance, and that it may occur in pulmonary affections; as a result of intracranial conditions; as a manifestation of toxic absorption; and also in the primitive emotion of rage. Cvanosis may be extreme in congenital malformations of the heart and in lesions of the pulmonary and tricuspid valves. An increase in the number of red cells — polycythemia — is an occasional cause of a puzzling and symptom-free cvanosis. (10) "Dropped Beats" (actual dropped beats are rare), or a sensation of the "heart turning o\-er," or of its "suddenly stopping,'" are very frequent' words by which patients seek to express the ]:)henomena of premature contractions. A premature contraction is one of manv forms of pulse irregularities (sec Chap- ter XIII). K\ery pulse irregularity should lie thor- oughly studied in order to deternihie its nature and to determine whether it is progressive. The electro- EXAMINATION OF THE PATIENT, 29 cardiograph or polygraph may be rfequiredto elucidate confusing pulse irregularities. (11) Chcyiic-Sfokes brcalhing, as a symptom of cardiac affections, occurs in advanced cases. It is a late — often a terminal — symptom ifi patients suft'ering fl-om heart damage. In this condition periods of paroxysmal dyspnea alternate with apnea. There is a respiratory cycle — at first the breaths are faint, shallow- and inf recjuent ; gradually they increase in intensit}- and frecjuency, then as gradually decline to a period of respiratory silence which may last from 5 to 40 seconds, after which the cycle is repeated. Che_\ ne-Stokes respiration, in cardiac conditions, oc- curs usually at night, but may be continuous. It is also seen in coma which arises from affections of the nerve centers, uremia, narcotic poisons, acute infec- tionSi etc. (12) Other presenting symptoms of cardiac sig- nificance referable to the brain or to the nervous, gastro-intestinal and gehito-urinary systenis, are dis- cussed elsewhere in these pages under the affection to which they more especially apply. THE ATTITUDE OF THE PATIENT. The patient goes to the physician for the purpose of learning what bearing his presenting symptoms have upon, his future. He wishes to know whether or not they mean heart disease — a term of terror to the layman, in whose mind it conjures the picture of sudden death while in the midst of the pleasures or vocations of life. Perhaps he has been alarmed by the illness of a friend with similar symptoms, or he may have been thrown into a panic by life-insurance 30 HEART AFFECTIONS. rejection. Whether his frame of mind reveals it or not, he stands as a prisoner at the bar, awaiting verdict. What should be the attitude of his counsel, judge and jury — the physician? THE ATTITUDE OF THE PHYSICIAN. The physician's attitude should be one of quiet reassurance. One cannot hope to succeed in heart work if one has an abrupt manner, disinterested atti- tude, overbearing voice or that unfortunate air of diagnostic finality. He who would get the most in- formation out of a heart examination must take pains that his manner in no way alters the rate, rhythm or volume of the patient's heart. The cardiovascular examiner should be a physician whose quiet bearing and genuine interest inspire confidence, trust and hope. To avoid alarming his patient he should never employ the enigmatic shake of the head; he should not prolong auscultation ; he should regard his patient with human interest and not as a pathologic speci- men; and he should never use the alarming term "heart disease" in discussing a patient's condition with the patient. THE KEEPING OF RECORDS. It is desirable to keep a case-record of cardiac examinations. A record is necessary for future refer- ence in further consultations and also for the purpose of definitely noting progress. It mav save humilia- tion in medico-legal cases. It leaches system and en- courages order. The record may be kept in an ordin- ary blank book, or a card-index system may be used. THIS SPACE FOR POLYGBAPHIO TRACINGS OR BLECTRO-OARDIOGRAPHIO ODRVBS Date Graphic Record by NAME No. CAMP DATE ... Cardiovascular Examination Original Record for Military Files of Dr. S. Calvin Smith, PHILADELPHIA Regimeut Rauk Co .. Home Address Age R^ace Nativi ty . . Usiual Civil Height Weight Occupation I Bulisted. Date Entered Service I Drafted 1 Form S8 Referred by ] S. C. D. ( Plospital Case Referred for DIAGNOSIS:— Authority: Manual Page Par RECOMMENDATION:— In Line of Duty? Recruiting Officer Blamable? HOSPITAL CASE:— Ward Bed Entered Ho^ital Admission Diagnosis Decision of S. C. D. Board: . „ ,. T> j-tonf Return to Duty . . . . Pending Receipt of S. C. 1 Rgn^ain in Qts . . D. Papers (. Retain in Ward .. . Recording Clerk Reviewed and Approved by .. Special Cardiovascular Examiner. Yic, 8.— Form for Cardiovasculab Record. The form is folded in the center for filing, after being filled out on both sides. (31) Ever Rejected ? When? By Whoim?.' What for ? PREVIOUS HISTORY. (Put Down A^-e at Which Illness Occurred) 1. Absceased Ears..., 2. AiiSL-essed Teeth.. 3. Chorea 4. Diphtheria 5. Gonorrhea 6. JNIeaslea. 7. Mumps 8. PertiiHsia 9. Pneumonia ...- 10. Rheumatic Fi^ver . 11. Scarlatina 12. Syphilis , 13. Tonsilitis , 11. Typhoid Fever HABITS ti ^ f Tobacco. Alcohol.. (.Drugs Sleep Complains of. Duration StopF'f^'I Work Took to Bed. .„...,. Palpitation. J^. Pain Dyspnea Cough- Fainting Giddiness Flushing... ......Edema ..„. Withstand Drills ? Double Time ? Marches ? ., r. . A S Healthy, Pallid. n i . f Muscular. Robust. General Appearance < -^ Development / i Florid. Cyanotic. { Slender, Frail. „ . f Intylligent, Alert, Expression J ° ( Apathetic, Anxioug. Thyroid Gland :— Tumor Tremoi /Regular \IiTegular Relaxed. Infil trated PalBe (SSil^;! J Volume. ...Exophthalmo; A'lviMe Pulsations "'■* Arteries -( I Elastic. Indurated. r.?,?,'????^^^ I Circumscribed-^ Thn>sti„s { Normal Impact r None Disappears on Exereiso Arrhythmia ^ i^^^^^^^^ on Exer.-ise -^ Following Return from Exercise - ll'.-aving Impact Diffuse J Thrusting Slapping ^ Faint Femoral Thrills rBasal. Systnlio \ Apical , Presystolic ( SystoHo Blood Pressure 4 Diastolic I Pulse Pressure.. Maximum Cardiac Impulse int. ;-.C. M. to L. of M. S. Line. Transverse Diameter of Arch Cardiac Bnrdera - (4).. Cardio-Hepatic Angle .. ..(5) Murmurs ; Apical [Systolic. Presystoli. itolic. Transmissions S fOver Precordia ; To Axilla : To Back : ' ^^^^^ [Diastolic. Systolic (^ Along Heart Border : To Vessels of Neck Accentuations-— A ; T , P M Rates Standing Recumbent Immediately After Exercise Dyspnea ' Immediately' After Exercise None Five Sei.ijud Rate Return Twm Minutes Later (Recumbent) Respiratory 1 in 15 1 20 25 _3U_ 45 Ventricular Moderate Ur-«nt Radial 1 1 ~ ' Deficit V Lasted ....min. CLINICAL TESTS:— Wassermann Urinalysis X-Ray Renal Function Graphic Record REMARKS : DIAGNOSIS: (32) Fig. 9. — Reverse Side of Cardiovascular Record. EXAMINATION OF THE PATIENT. 33 The loose-leaf system, cross-indexed for "patients" and "diseases," and further indexed for "open ac- counts" and "closed accounts" is perhaps the most convenient of all. When it is desired to standardize examinations for the purpose of gathing statistics for the compilation of clinical data, it is useful to use a blank form. When doing much cardiovascular work the blank form saves time, as on it the secretary can record the findings of the physician with a few strokes of the pen when the observations are called off by the examiner. Military necessity caused the writer to devise such a blank (Figs. 8 and 9) which proved satisfactory in thousands of army examinations. With a few changes and the addition of space in which to outline treatment, progress, etc., it can readily be adapted to a loose-leaf system for private and hospital work. CHAPTER IV. Examination of the Patient (Continued). PREVIOUS HISTORY. ACUTE INFECTIONS OF CHILDHOOD. The term heart disease, as usually employed implies a chronic affection of either the valves or muscle of the organ. Being chronic, by the time it presents at the physician's office, it is the more or less remote result of antecedent damage. Hence it is important to know the previous history of a patient and to supplement this information with a knowledge of the manner in which previous diseases have been found to commonly affect the heart. Cardiac damage may have had its inception in the acute diseases of childhood, such as scarlet fever, chorea, diphtheria, measles, etc., or it may have aris'en during acute in- fectious processes of adolescence. The heart, wearied by the demands thrown upon it during the progress of these diseases, and perhaps infected itself at the same time, had two other circumstances with which to contend — the first being an insufficient period of convalescence in which to recover itself; the second, the labor imposed on a weakened organ by the sys- temic demands of the growing child and by the un- restrained activities of childhood. Consequently, such a heart comes to adult life more or less impaired. In analyzing my military records I have concluded (34) EXAMINATION OF THE PATIENT. 35 that the remote infections of childhood have been responsible for heart symptoms sufficient to reject the applicant from active military service in 1.5 per cent, of the total number examined, or about 50 per cent, of the total number rejected. The infections of childhood are further discussed on page 190. INFECTIONS OF ADOLESCENCE. Among what might be called infections of adoles- cence, rheumatic fever looms large as a provocative cause of heart damage. It has been estimated that 20 per cent, of those who suffer from rheumatic fever develop heart affections. Rheumatic fever is not to be confounded w ith the hybrid term "rheuma- tism," which is often a cloak that covers chronic septic absorption, with its attendant muscular aches and pains, from some focus within the body. The ph3'sician will do well, when he encounters the term "rheumatism" in previous history, to ascertain the number of weeks the patient was in bed with the affliction and inquire as to fever, <:ondition of joints, etc., at that time in order to determine the history of acute rheumatic fever. Tonsillitis, the frequent pre- cursor of rheumatic fever, is also provocative of heart lesions. Influenza is an increasingly common cause of cardiac damage. It has been stated that pneumonia induces auricular fibrillation in ip per cent, of its victims. Typhoid fever frequently involves the myo- cardium, as also does chorea. The incidence of gon- orrheal endocarditis is sufficient to warrant heart care during the progress of the more virulent instances of specific urethritis. 36 HEART AFFECTIONS. CHRONIC SYSTEMIC DISEASES. Syphilis directs much of its attack against the cardiovascular system, as is witnessed by the fre- ciuency of its history in aneurism and heart-block and, less often, in arteriosclerosis arid angina pectoris. Considerable time elapses between the initial lesion and the detection of cardiovascular syphilis, believed by many clinicians to be perhaps fifteen years. Exoph- thalmic goiter affects the heart, it is held, through the toxicity of the thyroid hypersecretion. The wasting disease tuberculosis is incessant in its demands on heart muscle and thus induces cardiac enlargement, often associated with valve-leakage, in the effort which the heart makes to supply the starving bodily tissues. Tuberculous patients may occasionally pre- sent what is apparently a displacement of the heart toward the affected lung; this is due to retractive changes in lung tissue. The toxins of gout may be reflected in cardiac disturbances. The association between nephritis and cardiac affections is shown by the classical hyphenated term ''cardiovascular-renal disease.' Mineral poisons, such as arsenic and lead, frequently induce permanent cardiac damage, the latter quite often delaying conduction. SEPTIC ABSORPTION. Foci of suppuration should be sought for in all obscure derangements of the heart. Chronically dis- eased tonsils may harbor the focus. Much more fre- quently than is supposed, the trouble lies in an unsus- pected abscess at the apex of a symptom-free tooth or teeth. Faulty dentistry is an especially unfortunate EXAMINATION OF THE PATIENT. 37 cause, inasmuch as recent dental work may give a patient a sense of security in worl<; improperly done. Crowned teeth should be regarded with suspicion and examined by the A--ray. Even in the absence of defi- nite abscess formation, one should bear in mind that the peridental membrane may harbor the Streptococcus heiiiolyficiis or Streptococcus viridans — and not ex- clude from suspicion teeth which are devitalized or "pulpless." Pyorrhea furnishes a focus for absorp- tion that may be reflected in the heart. So may ab- scesses and chronic joint diseases. Cardiac distur- bances are repeatedly seen to re-adjust themselves following operative procedures on a discharging ear, a septic gall-bladder or chronically inflamed appendix. PHYSICAL STRAIN AND EMOTIONAL STRESS. Continued physical strain, in excess of eflfort which a given heart has been taught to endure, is un- doubtedly a cause of heart maladies. The recent war is replete with instances, both at home and abroad, of men of sedentary habits who were suddenly whirled into lives of military activity, with the result that they had cardiac breaks under the strain of the new and unaccvtstomed life ( see Chap. XXII). Nor should there be any question of the part taken by emotional stress in the production of disordered action of the heart — such stress as exists, for example, in domestic calamities, shocking news, profound anxiety or dis- tressing loneliness. Whether these maladies be desig- nated by the newer term of "eflfort syndrome" or "neuro-circulatory asthenia," or whether they be included under the older phrases of "neurotic heart" 38 HEART AFFECTIONS. or "adolescent heart," the provocative factors remain the same, vis; physical strain and emotional stress. HABITS. Certain habits have a pernicious action on the heart; others, through the medical usage of years, have a blame attached to them which investigation scarcely sustains. Alcohol primarily increases the heart-rate and later induces a loss in the force of the ventricular contraction. Long continued use makes it a contrib- utory cause of arteriosclerosis. Tobacco aggravates premature contractions in hearts already affected from other causes; it also in- creases the pulse-rate in already affected hearts. In those unaccustomed to its use it raises pulse-rate, until systemic tolerance is established. There is no proof yet adduced that it adversely affects a normal heart unless used immoderately. 1 enc[uired concerning tobacco smoking among one thousand recruits, recently drafted to one of the military camps from all conditions of civil life, and elicited the following information. Eighty-seven per cent, of them smoked, on an average of 1 1 times a day. The average pulse rate of abstainers was 82 per minute; of tobacco users, 85 per minute. The incidence of heart affections was found to be con- siderably higher among" abstainers. This paradox, however, is explained by the fact that many abstainers had stopped using tobacco when it seemed to affect their hearts unfavorably, causing pulse irregularity or periods of rapid heart action. EXAMINATION OF THE PATIENT. 39 The hearts of heavy smokers have heen examined after death, and the only finding which w^as at all constant and otherwise unaccounted for was a short- ening of the papillary muscles-^a change the degree of which is certainly difficult to estimate after death. Until more definite evidence is forthcoming, a safe rule would be to interdict tobacco if its use produces un- pleasant sensations or manifestations of nerve disorder in a patient ; and it is equally safe to adopt the premise that one should not arbitrarily interdict the accus- tomed habit of years unless there be evidence that it provokes additional symptoms or signs in that partic- ular patient. One should be able to determine this by a temporary abandonment of the habit for a fortnight. Excessive physical exercise might here be men- tioned as a pernicious habit, especially in these days of the too strenuous life. If exercise be judiciously indulged in, it works benefit and health to the majority of people; but to force oneself, when wearied or in- disposed, into strenuous games is certainly ill advised. Athletic contests, in which physical effort must often be continued far beyond the point of fatigue and ex- haustion, are responsible for the occurrence of "athlete's heart." The heart of an athlete is one in which sustained physical effort has so increased the demands on heart muscle that the muscle property of tonicity is impaired. In consequence of this myo- cardial relaxation, the heart is incapable of meeting even the demands of moderate exercise. Systolic murmurs are often heard at the apex of the heart, and pulse irregularities may arise. The over-strained cardiac tissue is often an easy prey for infections which manifest themselves in actual heart damage. 40 HEART AFFECTIONS. Habit-forming drugs which are extensively used include analgesics, the cardiac-depressant coal tar derivatives such as acetanilid (see Chapter XXV), phenacetin, antipyrin, etc., and opium preparations, which also act in slowing heart-rate. Cocaine and cafifein are stimulants, increasing the pulse-rate. "INHERITED" HEART DISEASE. It is rather the rule for patients to state that "heart disease runs in their family" and conclude from this premise that they have inherited a cardiac malady. Their minds should be disabused of the idea. With the debatable exception of congenital syphilis, heart affections are not inherited. Valvular disease of the right heart, which may sometimes exist at birth, may on first thought seem to be an exception to this state- ment : but it is a congenital result of fetal endocarditis and does not at all imply the existence of the same malady on the part of the mother. Certainly, one may inherit the family characteristic of inefficient heart muscle, just as one may inherit slender and delicate muscular structures in other parts of the body; one may exhibit the heritage of weak cardiac nerves, just as one may present the family tic. One may go through life with this cardiac embarrassment, or may reconstruct one's inheritance and make it into cardiac sufficiency. But in its final analysis heart disease is not inherited, it is acquired. CHAPTER V. Examination of the Patient (Continued). INSPECTION AND PALPATION. PREPARATION OF THE PATIENT. It is folly to attempt a cardiac examination when the patient has his clothes on. It not only utterly deprives the physician of the valuable information to be gained from inspection, but it also interferes with the clearness of the percussion-note and with the ap- preciation of resistance to attempt percussion through intervening layers of clothing. If the physician has neither time nor inclination to properly prepare the patient for examination, it is better that he content himself with obtaining what information the pulse affords and postpone the complete cardiac examin- ation until time and opportunty permit him to be just to the patient and fair to himself. All clothing should be removed to the waist line. Considerations of delicacy will suggest that patients of the gentler sex be permitted to wear a dressing gown or an examining cape, which can be drawn to the side as examination demands. The patient should stand before the physician with direct light falling upon his chest, He should stand at ease, with arms at side, and not attempt assistance in the examination by twisting to one side or the other, for he thus distorts anatomic landmarks and (41) 42; HEART AFFECTIONS. increases the muscular resistance of the chest. If unable to stand, the patient should sit relaxed, on a straight, armless chair ; if he sits on the side of a bed he should not be permitted to support himself with either arm, for the reasons just stated. It is quite necessary for the physician to get his first impressions while the patient is in the erect or sitting posture, if at all possible; it is an essential part of systematic, routine examination. Observa- tions thus made will of course be supplemented later on with the patient recumbent. For it is to be remem- bered that the heart is subject to postural shift, and that, therefore, information obtained solely when the patient is in the reclining position is unreliable and may lead to erroneous conclusions. INSPECTION. In gathering cardiac evidence from inspection it is well to proceed from above downward. The head may nod with each pulsation of the heart. The pa- tient's general appearance may be pallid or cyanosed. The eyes may show the arcus senilis, or there may be sluggish or irregular pupils suggesting a systemic in- fection which would have an influence upon the heart. The mouth frequently gives evidence of pyorrhea, and the condition of the teeth may excite suspicion. The appearance of the mucous membrane and of the tonsils should next be noted. There may be visible pulsations of the vessels of the neck. If the caro- tids be forcible and quickly rising they suggest an aortic lesion; should the waves vary in volume or if there be an apparent deficit between the carotid and ventricular pulsations, mental note should be made EXAMINATION OF THE PATIENT. 43 that auricular fibrillation is a possibility in the case. The shape of the chest should now be noted in re- gard to any change that malformations might make in the normal relations of the heart. Should the thyroid gland be even slightly enlarged, look for widening of the palpebral orifice, for a tremor in the protruded tongue and for a tremor in the finger-tips of the out- stretched hands. In addition, seek for von Graefe's sign of exophthalmic goiter, in which the eyes, directed towards the ceiling, will follow the finger more rapidly in a downward course than will the upper lid. The sitpra-sternal notch may pulsate, as may also the 2d interspaces to the right and to the left of the sternum, when viewed laterally — evidence of aortic dilatation or of aneurism of the arch; (Lateral inspection of this area is also to be performed when the patient is later recumbent, as the information may then be more clearly elicited). The precordial impulse should next be noted, whether it be circumscribed and of the usual impact or whether it be diJ^use and striking. 'Trra- diation" is a term describing a precordial impulse that spreads over the left chest quite beyond the confines of the overacting heart beneath. Note the inaxiiinim car- diac impulse; it is usually in the fifth interspace, 8 cen- timeters or so to the left of the midsternal line, and may be displaced by malformations of the chest, by cardiac afi^ections or by extracardiac conditions (as further noted under percussion). Epigastric ptdsa- tions and pulsations of the hepatic region come in for mental note; the former might be caused by an en- larged right ventricle, although not often so. The 44 HEART AFFECTIONS. latter may occur as a result of visceral engorgement, further reflected in distended and tortuous veins. Reverse the patient; aneurisms occasionally show pul- sations only in the back. Glance at the loth and nth interspaces on the left side posterior for systolic re- traction — Broadbent's sign of adhesive pericarditis, present when there are extensive adhesions to the diaphragm. PALPATION. The palpating hand should be warm. The sense of touch is employed for several purposes, the first of which is the detection of thrills. Thrills give a sensa- tion similar to that imparted when the hand is laid on a purring cat. They may be noted ( i ) in the carotids, one of the signs of aortic stenosis ; (2 ) in the enlarged thyroid, associated with exopthalmic goiter; (3) in the suprasternal notch, due perhaps to an aneurism of the arch, in which event it may also be felt in the second interspace anteriorly, or in the back; (4) and at the apex one may note the presystolic thrill of mitral stenosis or at the base detect the systolic thrill of aortic stenosis. Hard pressure may obliterate a thrill. The palm of the hand will more often detect it than will the finger-tips. Precordial thrills are not always significant of heart lesions. Hearts which are overacting either because the patient is of a neurasthenic temperament or as a result of the excitement or emotion inci- dent to examination, may exhibit a forcible precordial impulse which has all the vibratory characteristics of a coarse thrill. Systolic thrills at the apex of the heart arc very rarely of pathologic significance. EXAMINATION OF THE PATIENT. 45 Palpate the thyroid to determine that it is an actual enlargement of this gland that rises between the fingers when the patient is told to swallow. The physician may be misled by possible lymphatic en- largements in the neighborhood of the thyroid or by thickly-developed sternocleidomastoid mv^scles that confuse the picture. Accessory thyroid tissue may oc- casionally be felt in the suprasternal notch. This is an opportune time to develop the tracheal tug (Oliver's sign), by slightly elexating the head and gently grasp- ing the trachea between thumb and finger to note a faint, gentle pull as the heart pulsates — due to aneu- rism of the arch of the aorta. Cutaneous hyper- esthesia or tenderness of the pectoral muscles may now be sought for — a symptom quite frequently pre- sent in neurocirculatory asthenia" — by gently grasp- ing the border of the pectoralis major muscle, the patient's attention being distracted by engaging him in conversation. At this time apical tenderness which is sometimes present in mitral stenosis, may be noted. To locate the lua.viniuin cardiac impulse, (some- times called the point of maximum intensity), is often difficult in a heart with a diffuse, irradiant impulse. It is desirable to locate it for purposes of mensuration and auscultation, and also because the furthest point at which the maximum impulse can be felt from the midsternal line is a point that defines the left cardiac border. In some instances I have found it helpful to place the palm of the right hand over the nipple and then bend the second finger under the palm, to touch the chest at that point where the palm feels the impulse at its maximuin. This point should then be dotted with a blue skin pencil. 46 HEART AFFECTIONS. The sense of touch further notes, on rare occa- sions, a pulsating Hver. It eHcits the presence of abdominal aneurism by a maneuver in which the patient is placed in the genupectoral position and the abdomen palpated; other abdominal tumors change their position, but aneurisms of the aorta remain stationary. Palpation can be made to yield a wealth of cardio- vascular information when it is directed to the pulse — a subject of sufficient importance to warrant its consideration in a separate chapter. CHAPTER VI. Examination of the Patient (Continued). PALPATION OF THE PULSE. An Iconoclast once remarked to the writer that there were five cardinal points to be observed when visiting the sick; ask where the pain is, how the bowels are, whether the patient slept, look at the tongue — and then feel the pulse long enough to make up your mind what might be the next best question to ask. REASONS FOR FEELING THE PULSE. Nowadays, thanks to the revelations of graphic records as interpreted by Sir James Mackenzie and Thomas Lewis, the pulse is felt for many other rea- sons than sparring for time. It tells the physician whether the heart be regular as to rate, rhythm and volume and permits him to estimate the condition of the arteries. Departures from natural standards put him at once on the track of several cardiovascular conditions, as set forth in Chapter XIII, under "The Irregular Pulse." TECHNIQUE. Three fingers may be conveniently employed in examining the radial artery. The purpose of that finger nearest the patient's hand is to compress the artery in event of a possible impulse reaching the middle finger through anastomosis or deep palmar arch. The middle finger is really the palpating finger ; (47) 48 HEART AFFECTIONS. while the third — that farthest up the wrist — is used in making the gradually increasing pressure which obliterates the pulse-wave and thus permits the esti- mate of pulse volume. BIMANUAL ESTIMATES. In studying the pulse it is well to acquire a set method of examination, so as not to miss information that lies at the fingertips. Therefore the first man- euver is to palpate both radials at the same time, in order to thus appreciate delay or retardation of one pulse when compared with the other. This happens, for example, in certain aneurisms of the aorta, or in aneurism of the innominate artery, where the right radial pulse is feeble or absent. Incidentally, the ex- aminer may discover that one radial is a much better pulse to study than is the other, which may lie so deep that its impulse is very faint*, or which may be quite absent owing to old injuries of the arm or wrist. Refore leaving the wrist, run the finger along each radial to ascertain whether the arterial walls be straight and of the usual elasticity of health, or whether they be resistent, infiltrated, thickened, sclerosed or "beaded" — all of which are degrees of arterial change. Now place the palm of one hand over the heart, with the other still at the wrist. It will of course be noticed that the radial wave rises one-tenth of a second later than the ventricular contraction, but the dom- inant question should be: 'Ts every beat of the ven- tricle accounted for by a pulsation at the wrist?" If not, there is a pulse-dciicit, caused by ( i ) premature contractions which rapidly succeed upon the previous EXAMINATION OF THE PATIENT. 49 normal cardiac cycle and which, therefore, contract on too small a volume of blood to lift the aortic cusps. These can be recognized by the compensatory pause which follows the premature beat ; also by the fact that they will disappear when the heart is accelerated. (2) Or the pulse deficit may be caused by auricular fibril- lation, in which event the deficit will become more marked following exercise. The pulse never gives more pulsations at the wrist than occur at the ven- tricle, although the two waves of a dicrotic pulse may suggest such an event to the uninitiated. There is still another observation to be made while feeling precordium and wrist. Do any beats seem to completely drop out of their anticipated place in the rhythm of the pulse — and are the identical beats dropped at the heart? If so, an unusual condition has been detected, ■z'/r.- the actual dropped beat. This is a low-grade heart-block, and is capable of eventuat- ing into block of higher grade. Dropped beats must not be confused with premature contractions ; the latter occur in advance of the anticipated interval. PULSE-RATE. There are two extremes of circumstance under which the usual pulse-rate of an individual cannot be obtained. One is when the pulse is quickened by emotion, exercise or excitement ; the other is when the individual is in bed, relaxed in body and at mental ease. There is middle ground between these extremes when an average should be drawn. In a previous article 1 I ventured the opinion, based on an analysis 1 Smith, S. Calvin : An Analysis of Government Cardiovascular Examinations; Jour. Am. Med. Assn., Mar. 30, 1918; vol. Ixx, pp. 911-914. 4 $0 HEART AFFECTIONS. of records, that the natural pulse-rate of active youths between twenty and thirty years of age was higher by ten or more beats than the traditional average of y2 beats per minute. I have since further satisfied my- self of this fact by estimating the pulse-rate of 400 young men enlisted in the medical corps of a base hospital. These men had easily passed entrance physi- cal examinations and were youths of normal activities, splendid physique and apparent health. They were examined a half-hour before their breakfast. The average pulse-rate while standing was 84. Conse- quently, I cannot see that there is any significance in a rather rapid initial pulse-rate, even though it be ninety, providing there be a well-balanced response to the exercise test. There is, however, much signifi- cance in a pulse-rate of 50; it should arouse the sus- picion of heart-block, which suspicion may deepen into conviction with a persistent rate of 40, and quite into assurance when the rate is 35 or less. Bradycardia is also encountered in brain tumor, meningitis, jaim- dige, in convalescence from typhoid fever and in aortic stenosis. It is convenient to estimate rate in 5-second counts for a period of 20 seconds. In the presence of any irregularity use full minute counts. The 5-second grouping permits one yet unfamiliar with variation in rate to appreciate it in figures ; if there be 6 beats in the first five seconds and 8 in the third, for example, manifestly it is a condition that calls for detailed study. Five-second grouping is also a convenience in estimating the return of rate from exercise (see chart, Fig. 9). EXAMINATION OF THE PATIENT. 51 IMPORTANCE OF RATE-RESPONSE TO EXERCISE. There is one fundamental purpose in examining a heart. That purpose is to arrive at an estimate of the heart's capacity for zuork. This capacity is deter- mined by the eihciency of the all-essential heart muscle. The best test yet available for heart-muscle efficiency is its response to exercise. This response is expressed in cardiac and respiratory rates following" exercise. With the above postulate in mind, no heart ex- amination can be considered complete without an exercise test. (Effort will of course be interdicted in the presence of acute heart conditions). Many tests have been proposed ; none are perfect, for it is difficult to standardize an exercise test. Dumb-bell gymnas- tics may impose slight effort on a person accustomed to using his shoulder muscles and yet induce prompt fatigue in one who uses his arms but little. Stair climbing is open to the same objection. Hopping on one foot is a form of exercise which is not usually an accustomed practice, and hence is perhaps the least objectionable of exercise tests; but the speed of hopping and the height of each hop should be regu- lated (see Fig. lo). The physician may overcome these objections to a degree and attempt to standardize, for his own pur- poses of comparison, the hopping test, if he will direct that the patient hops on one foot loo times, with knees slightly flexed at an established angle, keeping count and clearing the floor by about one inch at each hop. It will be necessary to "coach" the pa- tient as he proceeds by saying "A little higher — not D^ HEART AFFECTIONS. quite so fast — speed up a bit" etc., as the experience of the examiner dictates; for the object is to have pp^i^f^ :| -^1 M^t i^^CT^qgi Electrocardiogram from an apparently normal heart before "hopping 100 times on one foot": ventricular rate, 75; respiratory rate, 16 (Lead II, in this and following iigures). Curve from same heart immediately following 100 hops: ventricular rate, 120; respiratory, 30. One minute later: ventricular rate, 105. -TttL TOnarip iJf ■ -^1 - i^ ^^il^d^is^^ Two minutes later: ventricular rate, 75; respiratory, 16; both fallen to normal. Fig. 10. — Rate Response to Exercise. The exercise test employed is that of hopping one hundred times on one foot. this particular patient take just about as much exer- cise as did the previous patient, in order that the exercise test may more nearly conform to the standard EXAMINATION OF THE PATIENT. 53 which the individual physician has adopted as a basis upon which to form his judgment. WHAT CONSTITUTES A NATURAL RATE RESPONSE? I have analyzed the pulse-rates of a group of 2215 individuals who were referred for heart examination. Fifty-six per cent, were accepted as having appar- ently normal hearts. In these the rates per minute were as follows: Accepted. Pulse-rate before exercise Immediately after 100 hops Two minutes after 91.54 130.13 93.24 Contrast these rates with the rates of the forty- four per cent, who were subsequently rejected on ac- count of valvular diseases, cardiac enlargement, neuro-circulatory asthenia, etc. Rejected. Pulse-rate before exercise Immediately after 100 hops Two minutes after 109.16 1S1.8S 121.20 1'he "accepted" table expresses in an aggregate rates which experience has led me to adopt as quite the usual limits. Following exercise the rate is well-balanced and within 2 minutes approximates the initial rate. Indeed, it often returns within the first 20 or 30 seconds — now for a fleeting interval faster, again slower, then after a few such gradually declin- ing oscillations definitely returning to the pre-exercise rate well within a two-minute time limit. The "re- 54 HEART AFFECTIONS. jected" table is significant in the pulse-rapidity im- mediately following exercise and in the fact that it remains persistently elevated for several minutes afterward. Hurried, panting respirations and an unwarranted degree of physical exhaustion are also the rule in affected hearts. The unaffected hearts of six-year-old children and the heart's of men who are healthy at fifty, respond to the hopping test with a rate-response as natural as that just outlined for young adult life. The child, however, may exhibit a sinus arrhythmia following exercise which was not distinctly noticeable before the test. There are occasions when it is not wise to submit a patient to the effort of completing lOO hops on one foot. If marked dyspnea be present before exercise or if the initial rate be 140 or over the physician should instruct the patient to exercise only to a point of fatigue, and enter on his records some such obser- vation as "40 hops exhausted patient." In those un- able to use their legs or in those of advancing years, resistance exercises of the arms may be substituted to raise the pulse-rate perhaps forty beats higher than the pre-exercise rate, and calculations be thus deduced. An acceleration of approximately forty beats, where obtainable, seems to give the best basis on \\hich to study rate-response. In private practice, many of the patients who consult the physician are persons who have arrived at the meridian of life and who are frank cardiopaths. In such persons it is often policy to substitute for the more vigorous exercise tests a series of simple bend- ing movements, such as raising the arms over the head and touching the floor ten or fifteen times. The EXAMINATION OF THE PATIENT. 55 person accustomed to calisthenics will require many more bending movements than will the one to whom such exercise is a novelty, if the heart rate is to be appreciably raised. Possible sources of error in rate-response may arise in robust persons, or in others with heart-muscle weariness. A robust person may be so accustomed to vigorous exercise that exercise tests impose no ef- fort whatever on the heart and fails to modify either the pulse-rate or the force of the ventricular contrac- tion. It may be necessary to double the customary exercise when examining such an individual. Again, there are other persons with sluggish or wearied heart muscle — and these are usually individuals of greater weight than one would expect for their height and years — whose pulse-rate is little if any altered by a customary exercise test. In such persons, however, it will be noticed that exercise increases the force of the ventricular contraction, and it is not judicious to exercise them further as heart pain may be thus produced. It does not minimize the value of an exercise test to remark that it is only one of many signs upon which' to base final judgment of a heart. It is to be con- sidered only in its relation to the composite picture of heart affections painted by other carefully elicited symptoms and physical signs. RHYTHM. Rhythm is a word that expresses the sense of time. It is measured motion. The healthy heart has a regularity of pulsation whereby the sense of time can anticipate each beat, just as it can anticipate each 56 HEART AFFECTIONS. tick of a pendulum. Under "Bimanual Estimates" allusion has already been made to the alterations in rhythm occasioned by premature contractions, auric- ular fibrillation and dropped beats. Siiuis arrliythiiiia is perhaps the only variation in pulse-rhythm which is not pathologic; it is quite common in youth and adolescence and is a condition in which the pulse-rate increases on inspiration and decreases on expiration; it is altogether compatible with health. Coupled or tripled beats, in which the pulse-wave runs along in sets of 2 or 3, disturb the rhythm of the heart and may be due to multiple premature contractions or to an excess of digitalis drugging. In the latter event their occurrence is a signal for withdrawal of the drug. The "5-second count" mentioned under rate as a commendable habit to acc[uire in pulse examina- tions, is of splendid service in the study of rhythm. Rate, rhythm and volume should be estimated before and again after exercise. VOLUME. Volume is that quality of the pulse by which is sensed its fullness or quantity. It is not to be con- fused with arterial resistance. One speaks of a pulse of "bounding volume" in sthenic fevers; of the "trickling, low-volume" pulse of mitral lesions ; of the "thready volume" pulse of exhausting diseases. Un- der "Pulse Technique" was learned the manner of estimating volume, and finger-tips can usually note any marked deviations in volume that call for the figure-expressed estimates atTorded by the blood- pressure apparatus, the sphygmomanometer. EXAMINATION OF THE PATIENT. 57 The regularity of volume is much disturbed in auricular fibrillation; successive beats do not strike the finger with the same impact; the volume of blood is irregular in its force. There is an interesting observation to be made on volume before finally leaving the consideration of the pulse. In instances of heart-muscle exhaustion, where the function of contractility is interfered with, each alternate pulsation is of lower volume than its pre- decessor — pulsus altcrnans. It is usually a sign of grave diagnostic import. A convenient bedside man- euver that develops the pulsus alternans is accom- plished by making gentle pressure on the brachial artery with the disengaged fingers. Gradually in- crease the pressure to a degree where the weaker of the alternating beats are obliterated and do not there- fore reach the wrist. Thus, such brachial pressure produces a sudden cutting in half of the pulse-rate at the radial, a condition obtainable only in pulsus alternans. CHAPTER VII. Examination of the Patient (Continued). CARDIAC PERCUSSION AND MENSURATION. Percussion is a term derived from Latin roots and means to strike through. It is a method of physical diagnosis devised by R. T. Auenbrugger (1722-1809). There are two forms of percussion, immediate and mediate. Immediate is direct striking of the thoracic wall. Mediate or indirect percussion is the employment of a mediating or intervening sub- stance, usually the finger of a hand, between the chest wall and the percussing finger. Mediate percussion is employed almost exclusively in cardiac examinations; for direct blows over the heart, however gently they may be intended, are not only unwarranted but, as a matter of fact, elicit little information of practical value. Cardiac percussion is practised to determine the position and diameters of the heart; to establish pul- monary and abdominal conditions which might alter the position of the heart ; to ascertain the presence of pericardial effusions ; and to elicit any increase in the diameter of the aortic arch. The fact that cardiac percussion is liable to error — principally because many physicians place too much dependence on the sound of the percussion-note rather than upon the sense of resistance and the actual feel of the pulsating organ — should not preclude its thoughtful, systematic employ- (58) EXAMINATION OF THE PATIENT. 59 ment in routine examination. The intervening finger should be placed firmly on the chest, in a direction parallel with the edge of the organ being percussed; as one acquires experience in cardiac percussion one may prefer to employ the mediate finger in a direction parallel with the ribs. Heavy percussion should never be used. The hammer finger should strike a cpick, light, elastic blow, not to be often re- peated in one spot. Repeated percussion of a given spot only results in confusing the impression gained by two or three well-directed strokes. Dctenniiiijig the Left Border of the Heart. — Begin at a point on the chest far away from the heart and come toward it. It is well to begin in the axillary line and come forward in the 5th interspace towards the midsternal line, not varying the pleximiter-finger pressure nor altering the percussion stroke. That point at which the note first changes determines deep cardiac dnlljicss. As the examiner progresses he will soon elicit superficial cardiac dullness, where the air content of intervening lung tissue between the heart and chest wall is considerably less; the pitch of the note, and especially the sense of resistance, is dis- tinctly increased. This point is usually at the outer limit of the maximum cardiac impulse (the "apex beat," if one chooses to use that term) and is the point which should be marked with a skin pencil as deter- mining the left cardiac border. Near the junction of the 3d interspace with the left costal cartilage cardiac flatness will be elicited; for it is at this point that the heart comes in closest contact with the thoracic wall, without the interven- tion of lung tissue. This anatomic fact also explains 60 HEART AFFECTIONS. why a pericardial friction rub is best heard at this area. The Right Cardiac Border. — Selecting the 4th in- terspace to the right of the sternum, seek to deter- mine the right cardiac border. Beginning well to the right, approach a point perhaps 3 centimeters from the midsternal line, where dullness may again appear and the sense of resistance be increased. This point determines the right border of the heart — when it can be determined by percussion. It should be routinely sought for, as by the maneuver one may detect mal- position of the heart, although it is not ah^'ays possible to definitely determine the right border. Adding the distances thus obtained from the left and right of the sternum gives the total transverse diameter of the heart. If one desires, one may, by percussion in various interspaces, thus outline the heart vipon the chest wall. Completely otitlining the heart by percussion may be an interesting employment but not one of especial clinical importance; whether the outline thus obtained would be supposed to represent the heart in systole, when it is much smaller, or in diastole, when it is much larger, would be hard to sav (see Fig. 5). The Rontgen ray is more accurate. The Transverse Arch. — Percussion in the 2d in- terspace to the right and left of the sternum may elicit an increase in the transverse diameter of the aortic arch, in which situation transverse dullness usually averages 4 1^2 (women) to 5^ (men) centi- meters in diameter. Percussion of this area aids in eliminating aneurism, and should therefore be rou- tinely practised. In event of noting by percussion an EXAMINATION OF THE PATIENT. 61 increase over the usual diameter, record the findings but suspend definite opinion until confirmed by ;f-ray. MALPOSITION OF THE HEART. There are extra-cardiac conditions which may alter' the usual position of the heart within the chest. Their possible presence should always be borne in mind when appraising the heart. Such conditions include : 1. Malposition of the patient. 2. Malformation of the chest. 3. Spinal deformities. 4. Subdiaphragmatic growths or visceral dis- placements. 5. Pleural efi^usions. 6. Extra-pericardial adhesions. 7. Retractive changes in lung tissue. 8. Mediastinal tumors. 9. Dextrocardia. 10. Pericardial effusions. (i) Malposition of the Patient. — It is important that the patient be placed in a correct position for ex- amination. W'hether he be sitting or standing, he may hold the muscles of the chest rigid, perhaps through nervousness or apprehension, and thus interfere with the percussion-note and with the sense of resistance. By a slouchy or twisted posture he may so depress or rotate the left chest as to change its relation to the underlying viscus. The correct erect position when standing or sitting is with muscles relaxed and arms hanging loosely at sides. If the patient is examined in bed the correct position for the body is flat on the 62 HEART AFFECTIONS. back ; the head may be sHghtly elevated. It is always inconvenient and sometimes impossible to accurately examine the heart when the patient is twisted to one side or when the chest is flexed from being propped on pillows. (2) Malformations of the chest may alter the rela- tion of the heart to the chest wall. Allowances should be made for any alterations which might be induced by such abnormal chest conformations as the rachitic chest, "pigeon breast," "funnel breast," or "barrel chest," any one of which permits of marked deviations from the position normally occupied by the heart. (3) Spinal deformities have the same efifect as have malformations of the chest in displacing the heart. Scoliosis and kypho-scoliosis are more likely to alter the usual position of the heart than are either kyphosis or lordosis. (4) Subdiaphragmatic growths or visceral dis- placements, such as carcinoma of the stomach, en- largement of the spleen or liver, or an accumulation of fluid in the peritoneum may produce pressure- effects upon the heart's position. Visceroptosis may permit the heart to fall below its customary level. In this connection it may be remarked in passing that the heart has been found altogether below the level of the ribs and occupying the abdominal cavity — ectopia cordis abdominalis. (5) Pleural effusions, when left sided, may cause the heart to be pushed far to the right. (See Figs. II, 12 and 13). An eft'usion in the right chest may be so extensive as to transmit pressure on the heart and force it to the left, thus giving the impression of cardiac enlargement. EXAMINATION OF THE PATIENT. 63 Fig. 11, — Cardiac Displacement (A), The anterior chest wall has been removed. The heart, with its pericardial investment intact, is seen to the right of the midsternal (M-8) line. Compare with the two figures which follow. 64 HEART AFFECTIONS. Fig. 12. — Cardiac Displacem£,xt (5). The pericardial sac has been removed. During^ life the maximum cardiac impulse was in the 5th interspace to the riffht, 8 cm. from the midsternal line, giving rise to the impression that the heart was completely transposed; for in true dextrocardia one expects to find the impulse as far to the right of mid- sternal line as it is to the left of the line in perst)ns who are )iatiira11i/ con- structed. Aa a matter of post-mortem fact. ho*wever, in this instajice the impulse was caused by the canus arteriosus (marked ./) — that conical pouch at the upper and left angle of the right ventricle which communicates with the pulmonary artery. The portion of the left lung which, in the photograph, assumes the position usually occupied by the heart, was hyperresonant on percussion. EXAMINATION OF THE PATIENT. 65 Fig. 13. — Cardiac Displacement (C). The exploring hand of the pathologist detected a resistant mass within the left lung, disposed in an interlobar direction (i.e., upward aud backward from the 5th interspace anteriorly). The resistance collapsed under pressure of the hand and 1500 c.c. OV2 quarts) of pus poured from the left chest. The heart then gravitated toward its usual position, crossing the midsterual line to the degree shown in this illustration. Note the occluding tortuosity of the aorta after the heart has receded, lending color to the ante-mortem statement of the life-long invalid that his heart had "been dislocated ever since an attack of pneumonia thirty years ago." Note also the opaque plaque on the epicardium, ■which the midsterual line bisects. Such opacities have been called "soldier'a spots," for the reason that they are frequently found on the hearts of Civil War veterans; they are probably an evidence of cardio-sclerotic change and are not especially incident to the occupation of soldiering, for they were not observed at necropsies which the writer attended in France. 5 66 HEART AFFECTIOXTS. (6) Extra-pericardial Adhesions. — The adhesions which form in pericarditis may be between the parietal and \'isceral layers; such ;nfrfl-pericardial adhesions do not appreciably affect the position of the heart. When, however, adhesions are cxfra-perkardial, the attachments formed with rither structures may so limit the customary excursion Of the heart as to con- stitute a malposition. The heart may thus be attached to the sternum, lungs, diaphragm, ribs or vertebral column. (7) Retractive changes in lung tissue, such as occur in fibroid phthisis, in the right lung may draw the mediastinal structures to the right thus displacing the heart. Or a shrunken left lung may increase the extent of the heart to the left. (8) Mediastinal tumors are among the frequent causes of malposition of the heart. Thoracic aneu- risms are quite likely to deflect the organ to some degree, albeit the degree is usually moderate. Can- cers or other new growths in the mediastinum may also produce pressure changes in the heart's position. (g) Dextrocardia means a coniplete transposition of the heart from the left side to the right. It is not to be confused with malpositions which result from left sided pleural ettusions nor with retractive changes in lung tissue which displace the 'heart to the right. Although most medical schools ha\e a case of dextro- cardia ^^"hich can be brought in for exhibition to students, the condition is a rare one. I encountered hui three instances of it in two years militarv exper- ience with hearts, two of the recruits being recognized as medical school specimens. Incidentally, these anomalous men made good soldiers. EXAMINATION OF THE PATIENT. 07 (lo) Pericardial effusions may at times be suffi- cient to alter the position of the heart, aUhough they more often obscure than alter its position. MENSURATION. The heart borders, as determined in the erect posture and before exercise, should be measured and expressed in centimeters from a definite and Fig. 14. — Cardiac Mensueatiox. MS is the midsternal line, z represents the second interspace, upon which line is recorded aortic percussion dullness. 4 is the fourth interspace to the right, used for noting any increase in the right cardiac border. .5 is the iifth interspace to the left, upon wliich is recorded the diameter of the left cardiac border B-E be- fore exercise and A-E after exercise, as said diameter may then be found to be increased ; a healthy heart actually decreases in size following exercise. The dot below line 5, also designated by the letter A, represents the distance of the maximum apical im- pulse from the midsternal line. always determinable point on the chest wall, virj: the midsternal line. This can be marked on the chest with the blued end of a celluoid centimeter rule, draw- ing it from the base of the suprasternal notch to the 68 HEART AFFECTIOMS. tip of the ensiform cartilage. Such terms as "mid- clavicular line" or "anterior axillary line" or "the nipple line" denote points which are subject to ana- tomic change or to postural shift. They are indefinite and not always constant, and in cardiac mensuration can well be superseded by the more dependable mid- sternal line. Its convenience, for purposes of case- histories, is illustrated in the diagram superimposed on Fig. 14. When measuring heart borders, if a flexible rule or tape be employed, it should never be curved in con- formity with the chest wall; the reading will be erroneous. The measure should be held straight across the chest for accuracy. The usual measurements which one would expect to find in health can be set forth as follows — always remembering that the heart diameters which are usual for a robust youth of 150 pounds or more weight, would be most unusual and constitute en- largement in a slender girl of the same age. The figures are the average result obtained from analyzing 1500 cardiac records: — M (2nd int.) sH (4th int.) 3 cm. ^ 8^2 cm. (5th int.) EXAMINATION OF THE PATIENT. 69 Healthy children of five years of age or there- abouts have heart diameters which bear a surprisingly constant relation to the above, averaging a little over half of the measurements just given, as follows : — M (2nd int.) 3 {4th int.) iy» g"" ■ i% cm. (4th or 5th int.) < > CHAPTER VIII. Examination of the Patient (Contiiiucd). AUSCULTATION OF THE HEART: MURMURS. Auscultation of the heart is performed with three purposes in view. First, for the detection of unnatural sounds within the heart or pericardium and to ascertain their relation to the events of the cardiac cycle. Second, to determine the transmission of said adventitious sounds — A\'hether they be propagated along traditional pathway's. Third, to elicit alter- ations in the intensity or duratioil of other unaltered sounds. TECHNIQUE. One may listen to the heart cither h\ applying the ear directly to the chest wall or through the mediation of a stethoscope, an instrument devised by R. H. T. Laennec in the vear 1S19, for the conduction of sound. Both phvsician and patient will prefer the stethoscope to the more intimate method. Placing the ear directly on the chest can be excused in emergency, or when it is desired to estimate auricular activity in a slow heart sug'gestive of heart-block — for in this condition I have observed that thC: combined senses of touch and hearing may giAe information that is not transmitted through the stethog'cope alone. The diastolic murmur of aortic insufficiency is also best appreciated with the ear directlv on the chest. (70) EXAMINATION OF THE PATIENT. 71 As to a choice of instru- ments, there are many tvpes and each type has its dev- otees. The writer prefers the instrument known as the "Ford" stethoscope, as simple as it is old, and the property of the medical profession (see Fig. 15). it should be equipped with tubing of sufificient thick- ness to prevent collapse, of sufficient length to cover the prccordium without the assumption of awkward at- titudes, and of sufficient pliability to prevent the an- noying little cracks in rub- ber that may admit extran- eous sounds. Those who are hard of hearing may choose a make of stetho- scope equipped with a dia- phragm to intensify sound. Satisfactory auscultation is not so much a matter of stethoscope as it is a matter of concentration on the part of the physician, who may have no little difficulty in learning to shut from mind all other sounds than the particular one upon which Fig. 15. — The Ford Stetho- scope, ■ 72 HEART AFFECTIONS. he is then intent. Grading up from these simpler in- struments, there are ponderous contraptions of com- plex design and vaunted theoretical value to place on the precordium, but the choice of instrument resolves itself into a selection to be made between the two types above mentioned. The hard rubber ear pieces should be snugly fitted and comfortable. The best way to secure satisfaction in this matter is to order a selection of various sized tips and try them out until one finds the particular size that makes for clearness of sound, perfect fit and comfort. The stethoscope should be applied firmly to the chest, and it should be evenly applied. Large bells that by their size prevent the entire circumference from snugly fitting in an inter- space should be avoided. NATURAL HEART SOUNDS. Before taking up the subject of murmurs it will be well to review natural heart sounds and their man- ner of production. There are two distinct sounds produced at each systole of the heart. Bofli the first sound and tJie second sound can usually be Jicard at almost any point on the left anterior chest zvall. This sentence is italicized for the reason that an occasional student will imagine that the hrst sound is heard only at the apex, and the second sound only at the base of the heart ; as a result, cardiac auscultation is to him confusion worse confounded. There are classical points where the first sound attains greatest intensity and points where the second sovmd is best heard — to be described further on under puncta maxima. EXAMINATION OF THE PATIENT. 73 The first sound is loiv. pitched, deep seated and prolonged, in contrast with the second sound which is higher in pitch, more superficial and short. The first sound has been compared to that produced by taking the corner of a silk handkerchief in each hand and quickly "snapping" the border taut: this imitates the first sound. Now grasp the border at its middle, and snap only half the length: this imitates the second sound. The first sound of the heart is believed to be pro- duced by two factors; (a) the action of the ventricular muscle, and (b) the tautening of the mitral valve cur- tains, the synchronous action of the tricuspid valve curtains playing" a lesser part in the production of the sound. The second sound is believed to result from the closing of the aortic and pulmonary valves. THE PUNCTA MAXIMA. There are four classical points (see Fig. 16) on the chest wall where one may hear, with maximum inten- sity, the natural sounds of the heart. The aortic area is at the 2d interspace to the right of the sternum; here the second sound of the heart is distinct. The tricuspid area is at the junction of the 5th rib with the sternum on the right, and the louder of the sounds heard here is the first. The pulmonic punctum maxi- mum is at the 2d interspace to the left of the sternum; here the second sound is best heard. The viitral area is at the 5th interspace to the left of the sternum, and it is at this point that the first sound of the heart is more clearly heard. While it should be routine practice to listen at these areas, note should be madp that adventitious 74 HEART AFFECTIONS. sounds are not necessarily limited to these traditional confines. For example, the diastolic murmur of aortic insufficiency, which is classically located at the aortic area, frequently attains its greatest intensity at the pulmonic area; mitral murmurs often invade the tri- cuspid area; the systolic bruits incident to intimal roughening of the aorta may sometimes be heard quite generally over the anterior chest wall. Fig. 16. — The Puncta Maxim.a. Showing the areas on the anterior chest wall at which the natural valve-sounds are best heard. A, aortic area ; T, tricuspid area; P, pulmonic area; M, mitral area. CARDIAC MURMURS. Definition — A murmur is an adventitious sound which precedes, which takes the place of, or which follows one of the natural sounds of the heart. James Hope, who lived 1801-1841, first- interpreted many of the adventitious sounds of the heart. The term "bruit" is used interchangeably with the term "murmur." EXAMINATION OF THE PATIENT. 75 Cardiac murmurs are desigifated first, by their lecation, whether they be apical or basal; second, by their "time," or place of occurrence in the events of the cardiac cycle. If a murmur occurs during systole (with the lift of the heart ) it is a systolic murmur ; if it occurs after the second sound (during the rest period of the heart) it is a diastolic murmur; if it oc- curs towards the close of this period, just before the systole of the heart, it is a presystolic murmur. It is unwise and confusing ta time a murmur by feeling a radial pulse, as the radial pulsation occurs one-tenth of a second later than does the systole of the heart. One may make more intelligent use of the carotid artery or, better still, place the disengaged hand over the precordium to time a doubtful murmur. TONAL PROPERTIES OF MURMURS. Murmurs may vary in intensity, in quality, in pitch and in duration. Thus the murmur of mitral stenosis varies in intensity by gradually increasing in volume of sound as it progresses — this is the "crescendo" element of the sound ; the bruit of aortic insufficiency is called "diminuendo,"" for it decreases in volume of sound as it progresses. Quality in a murmur is illus- trated by the term "blowing" which is applied to the sound of aortic insufficiency, and by the term "harsh"' as applied to the bruit of aortic stenosis. Pitch is described by the adjectives "faint"' and "loud" as ap- plied to the murmurs of aortic insufficiency and sten- osis respectively. The duration of a murmur is shown by comparing the short bruit of mitral stenosis with the prolonged abnormal sound of aortic insufficiency. 76 HEART AFFECTIONS. The tonal qualities of a murmur — either intensity, quality, pitch or duration — are not safe criterions by which to judge the severity of a valvular lesion. TRANSMISSION OF MURMURS. Certain murmurs have classical lines of transmis- sion. The apical systolic murmur of mitral insttffi- ciency is often heard in the axilla or in the left scap- ular region. Aortic insufficiency, which produces a basal diastolic murmur is frequently accompanied by a Flint murmur at the apex. The basal systolic mur- mur of aortic stenosis is transmitted to the vessels of the neck. When listening for sound in an artery, undue pressure should not be made with the stetho- scope ; one thus narrows the lumen of the artery and murmurs may be produced by the onrushing cur- rent of blood beneath the point of pressure. ACCENTUATIONS. In the presence of valvular disease additional bur- dens may possibly be thrown on other valves — al- though it is more probable that the same cause which damaged one valve severely, damaged another to per- haps a lesser degree — and the result is an exaggera- tion of their usual action and sound, as afifected heart structure tries to make up in force what it lacks in efficiency. These exaggerated actions in other valves are called accentuations. In mitral stenosis, for ex- ample, the second sound, as best heard at the pulmonic area, is accented; the pulmonic second sound is plus, and is expressed by the symbol "P- ,+." In the overacting heart of neurasthenia the first sound, as heard at the mitral area, is accented — expressed by EXAMINATION OF THE PATIENT. JJ the symbol "M^ ,+." In childhood, the second sound of the heart, as heard at the pulmonic area, is usually louder than any other sounds heard at any other areas on the anterior chest wall. This ac- cented pulmonic second sound in children is not of pathologic significance. REDUPLICATIONS. One may occasionally notice a tripling of the heart sovmds, — a gallop rhythm as it is sometimes called, lliis is not a murmur; when analyzed, the phenom- enon is found to be a split first-sound of the heart. It is believed to be caused by the fractionally delayed contraction of one ^'entricle, which receives the im- pulse for contraction a fraction of a second later than does its fellow. Clinically, it suggests a blocking of the impulse for contraction in one of the branches of the bundle of His — hence, bundle branch block. FRICTION RUBS. Friction rubs are occasionally confused with mur- murs. The "leathery squeaks" due to pleural inflam- mations can be ruled out of consideration by in- structing the patient to hold his breath, when they will disappear. Pericardial friction rubs are not at all constant ; they can be made to alter in intensity and at times even made to disappear by shifting the posi- tion of the patient. INFLUENCE OF EXERCISE ON MURMURS. A moderate degree of exercise will intensify mur- murs that are due to structural valve changes. Ex- cessive exercise may "blur out" murmurs that are 78 HEART AFFECTIONS. faint in 'pitch or short in duration, by increasing the heart-rate to such a degree that the murmur is blended with a heart sound and cannot be disting- uished from it. A moderate degree of exercise will often cause the disappearance of murmurs that are due to relaxed tonicity of heart muscle. So too, a murmur which requires exercise to produce it, and which disappears completely when the heart-rate quiets down, rarely signiiies structural valve damage. It is well to make a practice of listening to the heart sounds immediately following the routine exer- cise test, and at short intervals thereafter. In this way one may hear sounds that were inaudible before exercise on account of a thick chest wall or a deep chest. MURMURS WITHOUT SIGNIFICANCE. There are many murmurs wilhoiit significance. Perhaps eight people out of a hundred have them. I kept records of a group of 1940 individuals referred for heart murmurs. Of this number 45.2S) is grasped by the finger of the right hand in a small ring (R). The bar J3' carrying the screen ^ is connected by the hollow crossbar (OB) with the bar B"; the latter carries *the A'-ray tube so that any motion imparted to the fluoroscopic screen by the observer moves the ^ -ray tube as well. By loosening the nut (.A^) the bar (B') may be slid along the cross- bar and the screen may be placed any convenient distance from the patient's chest. RB, rubber bulb used for marking purposes; >S'f', sliding counterweights) so that the screen and -X-ray bars may be properly counterpoised; C, cranks used to place the table in the horizontal position if necessary; LaS', leveling screws; F8w, the electrical foot switch. (Ncuhoft.) (87) 88 HEART AFFECTIONS. accurate. Manipulation of this apparatus is highly technical, and while some clinicians have acquired skill in orthodiagraphy, more satisfactory results can be secured if operation be left to the skilled Rontgen- ologist. CHAPTER X. Graphic Methods of Examination. THE POLYGRAM AND ITS INTER- PRETATION. The polygraph — from the Greek, meaning- many writings — is an instrnment which records upon a strip of paper the events transpiring in the "right heart" and in the "left heart." It is of infmite value in the study of pulse irregularities and sheds light upon cardiac conditions otherwise obscure. It is second only to the electrocardiograph in the information which it reveals, and possesses the advantages over that complex apparatus of (i) portability; (2) bed- side convenience ; (3) initial low cost (comparatively) with no maintenance expense. Further, it recjuires no special training for its successful manipulation, other than the native gifts of patience, continuity and attention to small details. Polyography is a fascinat- ing as well as a most instructive study. THE APPARATUS. The Mackenzie ink polygraph is the apparatus described and referred to throughout this article. It consists of a clock-work mechanism, which operates a time marker and feeds a strip of paper at chosen speeds; of tambors, which permit excursions of the recording inked pens; of a wrist appliance and tam- bor, of a precordial tambor, and of a jugular cup, (89) 90 HEART AFFECTIONS. the three last mentioned being connected with the recording apparatus by rubber tubing (see Fig. 21). Fig. 21. — Mackenzie's Ink Polygraph. A, Clock mechanism. B, Pen tambors. C, \\'rist tambor. Ci, Wrist appliance. D, Paper roll and holder. E, Receiving cup. F, Writing pens. iiiiiiiiiiiiiiiiiiir m i ii iiiiiiiiiiii i ii i i i iiTi ii i ii ii ii i i ii iii i i i i rii i iii i iiiirTti n rit f i n r LWS Fig. 22. — Polygram of an AppAREXTLi- Xorm.^l Heart. Heart was beating tranquilly, uninfluenced by emotion or dis- ease. The vertical lines at the end of the, record are ordinates. The top record is made by the time-marker, each interval meas- uring 0.2 of a second. The middle record is the phlebogram, made from the jugular bulb. The lowest line is the arteriogram made from the radial artery. COMPONENT PARTS OF THE TRACING. The tracing made by the poh'graph is called a polygram (see Fig. 22). The component parts of a GRAPHIC METHODS OF EXAMINATION. 91 polygram are: (i) a time-record, which is spaced at intervals of two-tenths of a second, essential in analy- sis and when comparing the events transpiring in right and left heart; (2) the arteriogram, which records the events of the left heart. It is most conveniently recorded from the wrist, and is sometimes called a R^ inf\ominat« vein. Fig. 23. — The Jugular Bulb. The circle indicates the position for the jugular receiving cup. The spot o is one inch from the sterno-clavicular articulation. (Keith.) sphvgmogram. If one obtains this record from the tip of the left ventricle it is called a cardiogram; (3) the phlebogram, which records the events of the right heart. It is most conveniently recorded from the jugular bulb, which is one inch from the sterno- clavicular articulation (Fig. 23). On rare occasions one may obtain it by placing the receiving-cup over a pulsating liver. (4) The ordinates from which to 92 HEART AFFECTIONS. measure. Ordinates should be routinely put in all tracings at 4- or 6-inch intervals by stopping the mechanism and flicking the recording pens with the finger tip. TECHNIQUE. If one would be spared annoyance and irritation, one must acquire system in the technique of pulse tracings. Habitual practice of the following points will save time, trouble and embarrassment, as one sits by the recumbent patient and apens the carrying- case ( Figures refer to those on illustration No. 21 ) : — 1. Wind clockwork of paper-feed and of time-marker (A, i and 2). 2. Release starting lever (6) to see that feed-roll revolves and that the speed-control knurl (j) has not locked itself. 3. See that the time-marker (-) has its customary excursion. 4. Adjust paper-bracket snugly m clock-case (9). Paper is to feed from top of the roll and run parallel in feed-guides. 5. Test tubings (^^). Close one end, blow in the other, to see if they are airtight. 6. Insert tambor arm snugly in clock-case {S). 7. Use tubing to test all three tambors {B, D and C) to see if tambors are air tight. 8. Place time-pen on time-marker (/). Insert the two tambor pens (F, F) and ink all three. Raise tambor pens slightly from paper. 9. Attach tubing to tambors. Insert jugular cup (^^*) in distal end of that tubing which supplies tambor nearest time-marker. 10. Apply the wrist-piece (C i) and attach wrist-tambor (C). The JVrist Piece. — One is well repaid for a little care in applying the wrist piece. The patient should be recumbent, with arm comfortably extended along his body, palm upwards. The wrist should be sup- ported by a Turkish towel, folded se\cral times and placed under the wrist, permitting the hand to fall back and thus bring the artery into prominence. The patient should be instructed to comfortalily relax his wrist and not disturb its position or twist his fingers GRAPHIC METHODS OF EXAMINATION. 93 throughout the seance, as he would thus distort the tracing. The tip of the tambor should now be placed directly over the artery at that point where the radial pulsations are strong and superficial. If it be faultily placed to either side of the artery the arteriogram will be distorted. Adjust the tip so that it presses lightly on the artery ; heavy pressure destroys the marking of the pulse-wave — as also does insufficient pressure. No\\- attach the tubing to the A\rist piece, making sure that the "fling" of the pen is of sufficient excursion. Experience will teach what is meant by the "fling" of the pen ; it should write in waves of sufficient height, instead of in miserable little points that scarcely leave the base-line. The Jugular Cup. — The jugular pulsation is ob- tained by placing the metallic cup over the jugular bulb (one inch from the sterno-clavicular junction and directly above the clavicle) with a moderate degree of pressure, which should be varie'd until one sees the recording pen fling actively — three times as often as does the radial pen and with greater excursions, usu- ally. Or, the excursions may be small and the waves still be capable of analysis. Any movement of the jugular pen \\'hich but imitates the radial pulsation is an indication that the metallic cup is more on the carotid artery than on the jugular brtlb (see Fig. 22). In some patients it may be most difficult to find the jugular pulsation. Especially is this so in the indi- vidual who cannot relax, and who keeps his sterno- cleidomastoid muscles tense, thus holding the cup away from the bulb. It may take several minutes to tire out this resistance of the neck muscles. Even in the docile type of person it occasionally requires 94 HEART AFFECTIONS. much patient search and the adoption of such tactics as the shifting of the patient's head to one side or the other, the bending of it a httle forward or backward, or even the placing of a small pillow between the shoulder-blades, in order to bring the bulb more prom- inently from behind the clavicle. Or, having tried these maneuvers on the right side of the neck, it may be necessary to try them on the left side, in the search for a satisfactory jugular pulse. One should not be disgruntled if, in spite of efforts, the jugular bulb still eludes him; persistence will bring its reward. Making the Tracings. — All is now in readiness for the final step in preparation, — the putting of the pen- points on the paper strip. Adjust them by manipulat- ing the tambor-heads so that the tracings are properly spaced on the strip and do not fling into each other. The points should press lightly on the paper; heavy pressure makes them drag and shortens their excur- sion. The tracing is begun by operating the starting- lever. It is a good habit to make two 6-inch tracings at slow motor-speed — in a slow record alternation of the pulse can be more easily identified. Stop the clockwork, adjust the speed-control and make two at moderate motor speed; repeat the operation at high motor speed — not forgetting that in each 4 or 6 inches of tracing ordinates are to be artificially inserted. There are of course occasions when one will not care to stop the motor to vary its speed — information can sometimes be better obtained from an uninter- rupted tracing — as, for example, when searching for a pulse-irregularity which occurs only at exceptional intervals or when studying grades of heart-block. Graphic methods of examination. 95 the normal arteriogram. Each radial impulse, as recorded in the arterio- gram, consists of the percussion zvave (/>), followed by the dicrotic notch (d) after which occurs the tidal zva-c'e (t). From the beginning of p to the base of the dicrotic notch, represents the systole of the heart. Diastole occupies the time represented between the base of the dicrotic notch and the rise of the percussion wave of the following cycle. The intervals between beats are evenly spaced; the percussion-waves are of the same height; the base-line of the tracing is un- interrupted. This constitutes a normal arteriogram. THE NORMAL PHLEBOGRAM. The jugular pulsations, as recorded in the phlebo- gram, consist of first, the a wave, which is due to auricular contraction. Second, the c wave, which is produced by carotid pulsation and by ventricular sys- tole; it might really be called a„ ventricular wave. Third, the z' wave (it is in fact a stasis-wave), pro- duced by a filled-up auricle during ventricular systole. Identifying the a-c-z' Waves. — From the ordinate on the right of the radial tracing measure with dividers to the beginning of any percussion-stroke. Carry this distance to the time-marker and reduce it by one-tenth second. Carry said reduction to the jugular tracing; place one point of the dividers on the jugular ordinate. The point of the other divider will now denote the c wave. Mark it c on the tracing. Return to the same percussion-stroke in the radial tracing. Measure from its rise to the base of the dicrotic notch. Carry this distance to the jugular 96 HEART AFFECTIONS. tracing, placing the left point of the dividers where the c wave begins. The other divider now points to the V wave. Mark it v on the tracing. Return a second time to the first selected percus- sion-stroke of the radial tracing. Measure the dis- tance to the following percussion-stroke. Carry this distance to the jugular tracing. Place left point of dividers on beginning of c wave; the right point now rests on the c wave of the following cardiac cycle, which is marked c. Place the same distance on the beginning of the v wave ; the right point will then rest on the ■?; wave of the same following cycle. Return to the arteriogram, select the following cycle, and repeat the above performance until several c and v waves are thus identified. There will now be noticed between the c and v waves of the jugular tracing which has been marked, another wave immediately preceding the c, as yet un- accounted for. It is the a wave and occurs at regular intervals. It is to be marked a. The jugular tracing should now show a succession of regularly recurring a-c-v waves. Variations in Jugular Waves. — Confusion in the jugular waves may arise ( i ) through the interpola- tion of a wave, especially in slow pulses, just before the a wave. It is the /; wave, described by and named after Hirshf elder. (2) Through split waves; a, c and I' may exceptionally, each or all, be split. So it would be possible (though not at all probable) to find seven waves in a jugular tracing — three double-splits and ^'^ ^"^^ (3) Quite frequently the a wave is piled on the c, and may appear as a scarcely-perceptible notch. Here the value of a tracing made at fast motor speed GRAPHIC METHODS OF EXAMINATION. 97 is manifest; to some extent it spreads out the waves, facilitating their identification. INTERPRETING THE POLYGRAM. By the radial tracing can be identified sinus ar- rhythmia, premature contractions, alternation of the pulse and auricular fibrillation (Figs. 24, 25, etc.). With the aid of the jugular tracing coincidently consid- ered can be confirmed : ( i ) auricular fibrillation, by the absence of the a wave (in gross fibrillation there may occur fine, fibrillary waves in the jugular) ; (2) heart-block is established, through the presence of an excess of a waves regularly recurring (Fig. 27). Considering the jugular tracing by itself, it shows us delayed conduction, as manifested in the length of the a-c interval. This interval, normally between 0.12 and 0.18 of a second, is estimated from the beginning of the a to the beginning of the c wave. If over 0.2 of a second, conduction is delayed. THE INTERPRETATION OF ARTERIOGRAMS. The following systematic steps are good routine to follow when one is ready to analyze the tracing : 1. Look for artefacts in the record, as produced by changes in motor speed, by interruption of the instrument or by the patient moving or coughing. Check-mark and disregard any such artefacts found. 2. Determine pulse-rate by measuring 30 intervals on the time-marker. These equal 6 seconds. Multiply the number of beats occurring in this distance by ten to get the rate per minute. 3. Note the general shape of the pulse-wave. If the patient is highly nervous it may be full of fine 98 HEART AFFECTIONS. fibrillary waves ; if the bed has shaken or if the table upon which the polygraph rests is unsteady, the waves will be altered in shape. The directness with which the percussion-wave rises may suggest aortic lesions; Fig. 24. — Sinus Arrhythmia. The waves in this and the following polygrams are purposely not lettered, in order that the reader interested in the subject may make his own analyses. if it has a broad, sustained plateau one thinks of aortic stenosis. The height of the pulse-wave is sometimes an index of pulse-tension. Fig. 25. — Auriculae Fibrillation. In analyzing this tracing it should be remembered that the a wave of the jugular tracing is absent in auricular fibrillation, des- pite the intrusion of an occasional wave suggestive of "a" in the phlebogram above. (Courtesy of Dr. Paul D. White.) 4- Determine the presence of a dominant rhythm, the rules of which were worked out by Wenckebach. A dominant rJixthni is a fundamental rhythm zvhich governs, more or less, the disordered ventric- idar movements. GRAPHIC METHODS OF EXAMINATION. 99 The presence of a dominant rhythm indicates either ventricular premature contractions or heart- block. A^entricular premature contractions are recog- nized by the fact that the distance from the beginning Fig. 26. — Dropped Beats. of the immediately preceding normal cycle, plus the period of disturbance and including its compensatory pause, is equal to the distance of two normal beats. Heart-block is recognized by regularly recurring a I iv * r * * r 7w\ AAV//v\ji/vAvvAn^>A4j\ Fig. 27. — Complete Heart-Block. waves in the phlebogram during the steady fall of protracted radial intervals. The absence of a dominant rhythm indicates auricular premature contractions or else auricular fibrillation. The former condition is measured just as for ventricular premature contractions; but the dis- tance is not equal to two normal beats. Auricular fibrillation is recognized by waves that are persis- tently irregular as to spacing and volume. 100 HEART AFFECTIONS. Sinus arrhythmia is recognized by the gradual in- crease of rate during inspiration and an equally grad- ual decrease during expiration. Inspiration and ex- piration can often be determined from the general contour of the jugular tracing. 5. When a premature contraction is found, look for alternation of the pulse following it. In alterna- tion each alternate beat is of less volume than its predecessor. Alternation must alternate, — that is, every other beat must be smaller than its predecessor -i-rrT^ '^ II I I I I ■ I Fig. 28. — Pulsus Alternans. The alternation follows the occurrence of a premature contrac- tion, and can be more clearly seen if a card is laid over the lower two-thirds of the tracing so as to show only the ends of the per- cussion waves. (Courtesy of Dr. Paul D. White.) in the radial tracing. There is nb such thing as an alternation every third or fourth beat (see Fig. 28). 6. Look for coupling or tripling of the radial waves. 7. Mark the tracing with name and address of patient, date, clinical diagnosis, cardiac diagnosis, polygraphic conclusions. BRIEF SUGGESTIONS IN ANALYZING POLYGRAMS. (a) The a wave is absent in any weak auricular action — as in auricular flutter or auricular standstill. GRAPHIC METHODS OF EXAMINATION. 101 (b) Expect to find a split a in heart-block. (c) Sometimes an a wave may be seen in the radial tracing of heart-block: it is due to the impact of a dilated auricle on the aorta. (d) A heart-block is called complete when the a-c interval varies disproportionately in length — as 0.-2 then 0.3 then 0.25 of a second, etc. (e) Any wave that persistently goes below the base-line of the radial tracing is a deep dicrotic notch, and the following wave is a part oi the preceding con- traction, despite its deceptive height. (/) Bigeminy is most often due to ventricular premature contractions. is) To differentiate bigeminy and alternation: alternation is always late or evenly spaced, — never premature; bigeminy, however, is premature. (h) When a run of regular beats occurs in a grossly irregular polygraphic tracing, think of auric- ular flutter, but confirm the thought by electrocardiog- raphy. Finally, do not try to read too much into a poly- gram. While it has a splendid clinical use, it is ca- pable of abuse and misinterpretation. This was shown with the first sphygmograph brought to America in 1865, which was discredited because such startling diagnoses as thoracic aneurism were made from radial tracings. Needless to say, the alleged aneurisms failed to appear at necropsies. CHAPTER XI. Graphic Methods of Examination (Continued). THE ELECTROCARDIOGRAM AND ITS INTERPRETATION. One frequently finds in the medical literature of today, illustrations which somewhat resemble the graining in oak, and which are called "Electrocardio- grams." The legends which accompany such illus- trations are often confusing, for they are written in a language wath which many physicians are not yet familiar. It is the intention of this article to explain the principle by which electrocardiograms can be in- terpreted and their valuable clinical information thus made available to the busy practitioner, who mav ha^-e had neither time nor opportunity to follow the de- velopment of this important subject. Physicians ha^e studied microscopy, urinology, hematology, rontgen- ology and serology, and considered the time well spent. Electrocardiography, the infant of the labor- atory group, is no less worthy of adoption than are its older brothers. And the thorough practitioner should proceed to acquire a working knowledge of this subject, records of \\hich at first glance seem to be only an intricate and unintelligible series of peaks, summits and depressions, but which are, in literal truth, messages from the heart. (102) GRAPHIC METHODS OF EXAMINATION. 103 DEFINITION. An electrocardiogram is the product of a modern graphic method of heart examination by which may be differentiated, accurately diagnosed and thus more intelHgently treated, various defects of the cardiac mechanism. The first American papers on electro- cardiography were not written until 19 lo, but already the subject has passed the stag:e of experiment in physiologic laboratories and has become of profound significance to the clinician. THE PRINCIPLE. An excitation wave precedes the contraction of the various heart chambers. Kolloker and Miiller told us of this in 1856. In discussing the physiology of the heart (page 16) it was stated that this wave normally takes a definite, established route from the pacemaker, where it originates, to its eventual distri- bution in muscle fibers, which it then excites to con- traction. This route is called the conduction system. Now, when disease or its toxins interfere with con- duction — when disease disturbs either the rhythm or sequential contraction of the heart ; when it enlarges some chamber or renders certain cardiac areas either too highly responsive or too apathetic to the contrac- tion-impulse, the excitation wave will take many devious pathways. By animal experimentation and by clinical experience it has become possible to inter- pret these deviations in terms of heart affections. The apparatus which records the course of the excita- tion wave is called an electro-cardio- graph. 104 HEART AFFECTIONS. THE APPARATUS. Einthoven, a Dutch physiologist, devised in 1903 the instrument by which the action currents of the heart can be led oiT the surface of the body and made to deflect a very fine gold covered quartz string — a string so fine that the unaided eye can scarcely see it. This wire moves between the poles of a very powerful electromagnet, and is protected from the action of out- FiG. 29. — The American Electrocardiographic Equipment. A is the lamp-hood which encloses the Cunningham arc light; the rays then pass through the condensing: chamber at B. C is a target by which the beam of light is directed on the anterior microscope D. E is the electromagnet, in the center of which is the string-housing F, which protects the delicate string which is actuated by heart-currents. G is another microscope for further magnification of the string shadow. H is the resistance box which controls the current passing through the string and which pro- tects against outside currents. K is the turfing-fork which marks the abscissK on the electrocardiogram. side currents by ingenious electrical contrivances. When the string (hence the term "string galvan- ometer," which is used as often as is the term "electro- cardiograph") is actuated by the excitation wave, its motions are magnified by microscopes, illuminated by an intense light and the shadow of the oscillating GRAPHIC METHODS OF EXAMINATION. 105 String is photographed on a moving photographic film. (See illustrations of apparatus, Figs. 29, 30, 31). This procedure is termed electro-cardi-op-- raphy; the record or curve thus made is an electro- cardio-gram. Fig. 30. — The Galvanometer and String-house. Closer range, showing how ingeniously the string is protected from particles of dust. The mounting of the microscopes is rigid, yet adjustable. QUESTIONS THE PHYSICIAN ASKS. It would burden this chapter to explain at length the elaborate technique incident to the manip- ulation of the electrocardiograph. Such details may well be left in the hands of technically trained physi- cians. The clinician is not interested in details of 106 HEART AFFECTIONS. Operation ; he is interested in results. In order to ap- praise these results, four questions in connection with this recently introduced clinical kid should be con- sidered, as follows: — (A) What credentials have established the truths of electrocardiography? (B) What information of definite clinical value can one expect to receive from the subject? (C) What constitutes a "normal" electrocardio- gram, and how is it read? (D) What are the more frequently encountered pathologic records with which one should be familiar ? {Answer A.) Investigations that Established Electrocardiography, The record from a healthy dog's heart is quite like the record from a healthy human heart; the difference is negligible. In experirnents with the dog the conduction system was interfered with at various points by pressure with forceps; it gave abnormal curves. Records similar to these were found in trac- ings from human hearts ; at necropsy in these cases it was discovered that disease had produced the same changes in the human heart that had been experi- mentally induced in the dog. Another experiment was to produce enlargement of the various chambers in the animal heart ; again was obtained a type of curve which had been observed in human tracings; and again did eventual necropsy establish the truth of the electrocardiogram. It was also demonstrated that when infectious disease, such as pneumonia, changed the human records it would alter the records in a similarly diseased dog in like manner. Drugs, such GRAPHIC METHODS OF EXAMINATION. 107 Fig. 31. — The Camera. L is the film-roll box; the motor M feeds the film past the camera lens O at a selected speed, usually at 25 R.P.M. for clin- ical work. P, is a knife which cuts the completed film, i? is a removable box in which the exposed film drops. 108 HEART AFFECTIONS. as digitalis, atropine, lead, etc., were administered to canines in the laboratory ; the cardiograms were modified. The same alterations in the records were found in patients taking these drugs. A\''ith such credentials has electrocardiography introduced itself to the medical profession. (Aiiszver B-i.) Clinical Diagnoses Confirmed by Electrocardiography. This method of examination has not only ac- quainted the physician with heart conditions which were not known to exist before its advent, but it has also confirmed many clinical diagnoses which he has been accustomed to make. For example, it tells which chamber of the heart preponderates in cardiac en- largement. It frequently substantiates the clinical diagnosis of mitral stenosis; it furnishes corrobora- tive written testimony of aortic valvular disease. It guides in the selection of cardiac drugs; it warns of their beginning toxic effects. It not only records the efficiency of chosen methods of treatment, thus often indicating a change of remedies, but it also signals the approach of danger in the overadministration of certain drugs. To illustrate : it tells when the cardiac tolerance of digitalis has been reached long before the physiologic limit manifests itself. It heralds, at times, the approach of some diseases which affect the heart — such as acute rheumatic fever — before the clinical evidences of fever, joint swellings, etc., make their appearance; and at the furtiier extreme of an illness, graphic records may indicate the approaching end of life long before Cheyne-Stokes respiration and GRAPHIC METHODS OF EXAMINATION. 109 Other traditional symptoms of dissolution ensue. In addition, the study of an extended series of curves, which have been taken under varying conditions of rest and exercise, may afford written evidence of the functional activity of the heart muscle. Structural myocardial change, which is a diagnosis often diffi- cult of clinical determination, can now be recognized by electrocardiography. (See Fig. 43). (Auszver B-2.) Diagnoses Not Possible by Usual Clinical Methods. Electrocardiography does more than confirm diagnoses at which one has clinically arrived ; it gives minute information concerning irregularities of the heart which are clinically suspected but which cannot be certainly sustained without graphic record. Among these are exaggerated sinus arrhythmias, multiple premature contractions, paroxysmal tachycardia of auricular or ventricular origin, atypical auricular fibrillations, auricular flutter, ventricular flutter, vary- ing grades of heart-block, etc. Such conditions give curves that can be better illustrated than described. Pathologic records are shown on subsecjuent pages. Now, however, the normal electrocardiogram should be first consid- ered ; then one can intelligently study departures from the normal which are induced by disease. It is suffi- cient to bear in mind, at this stage of the discussion, that disease changes the normal waves of the electro- cardiogram in sequence, in amplitude, in direction and in duration. 110 HEART AFFECTIOflS. (Answer C-i.) The Normal Electrocardiogram and How to Read It. Three curves compose the record; they are the three Leads, expressed in Roman numerals (see Fig. Fig. 32. — The Three Leads. The heart is represented as within a triangle composed of Leads 1, H, and IIL The arrow within indicates the electric axis of the heart ; the dotted lines represent the direction of the con- traction waves from this electric axis. In Ihe normal heart, Lead 11 registers the greatest value of these contraction waves, for the reason that it is more nearly parallel with said axis, and thus reflects more of the heart's surface. 32). They are called "Leads'" because they lead the current from certain surfaces of the heart. Lead 1 registers the electric potential of that part of the heart which comes nearest to a line- drawn from right GRAPHIC METHODS OF EXAMINATION. Ill Fig. 33. — Component Parts of the Record. A shows the ordinates, or horizontal lines, which are engraved on the camera lens. They are used to express in millivolts the amplitude of the various waves. B shows the abscissK, or vertical lines, put on the record by a time-marker ; their purpose is to time the various events of the cardiac cycle. C shows the shadow of the string when at rest, not activated by heart currents. '?^A-^4 X S^^' A '■■■ ^^...^ ^ j ^„ t..^ a I' I I i !l-l ' Fig. 34. — Normal Electrocakdiogram. P is the representative of auricular contraction. Q-R-S-T rep- resents the ventricular complex. The normal limits of the vari- ous waves are explained in the text. As Lead II expresses the greatest values of the individual waves, said lead will be used in the Ijathologic illustrations which follow as a normal standard for comparison. 112 HEART AFFECTIONS. arm to left arm. Lead II, of a line drawn from right arm to left leg; Lead III, of a line drawn from left arm to left leg. Insulated wire carries the heart cur- rent from patient to the string galvanometer. The connection or electrodes for the patient are simply pieces of German silver curved to fit right arm, left arm and left leg, and are held in place with bandages soaked in a 20 per cent, hot salt solution. Fig. 3S. — Sinus Arrhythmia. This curve strikingly illustrates the variations in rate which characterize the "youthful type" of cardfac irregularity. The sequence of events is a normal P-i?-5'- T^ -complex, but the rate varies with each contraction. The conditipn is not of pathologic significance. The fine horizontal screen lines (see Fig. 33-a) are called ordinafcs; they are permanently drawn on the lens of the camera and are used to measure the height of the individual waves, each space being equal to lO"' millivolts. The vertical screen lines (see Fig. 33-& ) are called abscisscr and are used .to time the events of the cardiac cycle, each division representing 0.04 of a second. The abscissae are photographed on the record as shadows of accurately revolving spokes which are regulated by the vibrations of a tuning- GRAPHIC METHODS OF EXAMINATION. 113 Fig. 36. — Right Ventricular Premature Contractions. Right ventricular premature contractions produced a bigeminal pulse. The premature contractions in this instance are identified by the tall R spikes which follow closely on the preceding T wave, during what should be the diastolic period of the heart. T t I , NOMiAL ELECTRuCAKDI0GiiAl4.j J | win^ F^=^ %1 ^ — 1^^ rr-: :=J^ 1 -=^3:: ■={ i i ^ = ^J-^fe-t^ P:!^ FpK|||P i^^ ^ bi£J -I^fJ^ H^ ^^ -E^ H B Fig. 37.— Paroxysmal Tachycardia. The ventricles respond to each auricular impulse, both chambers contracting at the rate of 210 per mmute. 114 HEART AFFECTIONS. fork, and called a time marker. Figure 33-c shows the shadow of the string when at rest, not activated by heart currents. The Symbols of the Electrocardiogram. — Ein- thoven applied certain symbols (purely arbitrary, with no interpretation to be put on the letters, as would be the case if he had chosen "a" to represent auricular contraction, "v" for ventricular contraction, "d" for ;, , ' ■,■! ■ I i T? ■ L '!' 1, ; M.. i. ■ : ■ 1 ;:i NORMAL ELKCTROCARCIOOiy* ' 1 ■ -.-...:■]. I 'i :. !■ ^gt^ __:;. — --. —1,-: — .V ~ i ==^3 ^ w _3 _iS ^^ ^!^(? ^ ™¥!rpE# ¥ ^ i 1 M W ll ^ii^l ::-" i; v .- ~ '^'t = r-jz: :;. £7 ; _7. -- ■ -- -r v-"'? - -F- = ~z ... _ ^ :-T- --- ; ---- - — — J,= ,=-- Fig. 38. — Auricular Flutter. The auricles are contracting at an average rate of 270 times per minute. The ventricular rate averages 60 per minute. The im- possibility of arriving at a clinical diagnosis under such circum- stances is quite apparent. Graphic records such as this, however, clearly establish the diagnosis and thus point the way to efficient treatment. diastole, etc.) to the various peaks, elevations and depressions of the electrocardiogram, which are uni- versally used. Thus the representartive of the auric- ular contraction is called the P wave (Fig. 34). It is a small, blunt pointed or rounded elevation, not normally o^'er 2 mm. high nor n\-er 0.02 of a second wide, and is directed upward. If it is more than 3 mm. in amplitude or if it is wider than G.12 of a second, GRAPHIC METHODS OF EXAMINATION. US KCRJ2AL ELSCTROCARCIOGBAM. Fig. 39. — Auricular Fibrillation. The P wave, the representative of auricular contraction, is ab- sent in all three leads. Fine fibrillary ("/") waves fill diastole in Lead III. Note the absolute irregularity of ventricular contrac- tion, as expressed in the uneven spacing of the R wave. ir ' ' ' ' 1 ' ' "i ' T P-R Interval - 1 (.optHi, ELECTROCARCIlXIPJiM. ' ' ' 1. .18 ecz^.A. IOCRAU. Fig. 41. — Dropped Beat. In the second curve it will be noticed that P-3 is not followed by a ventricular contraction. Dropped beat is in reality a low- grade heart-block, and is not to be confused, as is frequently done clinically, with ventricular premature contractions which fail to reach the wrist. (Fig, 40). The P-R interval in the electrocardiogram represents the same event as does the a-c interval in the polygram. Tlie Q-R-S-T complex denotes ventricular con- traction. Q-R-S indicate the spread of the contraction wave in the fibers of Purkinje. is the first evidence of activity at the apex of the ventricle; it is directed downward, usually not over 2 mni:.,and may be entirely lacking, being submerged by stronger contraction GRAPHIC METHODS OF EXAMINATION. 117 o ■* EQ •^.2 H J3 „ <: '' a w . ~ 1-1 m w p C ^ fc 3 w > nl tl ■^ u 1 rtH 1 (O 'C-C o ^-^ X! ^ +-• •-i-i M-< O o +J c c .2^ sS u a O "l^ tn -o .^ c •c" o,-^ G O o^ O rf Crt J,) should it extend from the anterior to the posterior chest wall. In pleural effusion there is not the diminution in the normal sounds of the heart which are to be expected in peri- cardial effusion, nor does the percussion note change so abruptly from dullness to resonance as when out- lining the intrapericardial accumulation. To diff'eren- tiate pericardial effusion from cardiac eidargcnienf, it is of assistance to remember, after one has con- sidered the difference in histories, that in cardiac en- largement the maximum cardiac impulse can usually be located without much difficulty and that the outer limit of the maximum cardiac impulse well defines the PERICARDITIS. 177 ^1^ ^ A 4k IP ll ^ fl^Hl 1 1 1 9ff-- -;:•' wl^ ^ J ^^^'-■*^P 1 pp »"^ v^ ^^^Bfe' -^^ ^H ^^ Mdjjm ^^^Hk ^H ^'" >f^<«f •- Wm ^^^v "■'"'' '■■-■^.v. H m ¥ '^ i ■1 ^ * ■'''-■■ "^i 1 '4 1 1 1 Wm^^'y' wBI^^^ j Fig. 52. — Pkobable Pemcardial Effusion. (Courtesy of Dr. Willis F. Manges.) 11 l^g HEART AFFECTIONS. point at which cardiac dullness disappears. In border Hne cases the fluoroscope or skiagraph may estabhsh the diagnosis. Exploratory puncture of the pericardium has Httle justification. To introduce a hollow needle for the sole purpose of determining whether or not fluid be present is a confession of weakness in the art of diag- nosis. On the other hand, to introduce a needle for the purpose of differentiating between a serous and a purulent effusion may be a justifiable procedure. Purulent effusions are frequently of such small quantity that one fails to attribute to their presence the prostration, repeated chills, septic temperature, leukocytosis and emaciation of a patient ; especially is this so if a previously large effusion has decreased in size through partial absorption of its more liquid constituents, permitting pus of a creamy consistency to remain. Under such circumstances one is war- ranted in employing the hypodermic needle for diag- nosis. The pericardium may be entered at the sites mentioned under "Paracentesis" in the paragraph on treatment which follows. ,;,^' DIAGNOSIS OF PERICARDITIS WITH '*" * ADHESIONS. Pericardial inflammation frequently terminates in the formation of adhesions. \Mien these adhesions form between the parietal and the visceral pericar- dium they are known as (i) Intrapcricardial adhes- ions. When they form between the parietal peri- cardium and adjacent structures they are (2) Extra- pericardial adhesions, and the coiidition is then called inediastino-pcricarditis. It will sometimes be found PERICARDITIS. 179 at necropsy that the visceral and the parietal peri- cardium are bound closely together, forming a dense and inseparable structure, and only to such a condi- tion is the term adherent pericardium properly ap- plied. (i) Intrapcricardial adhesions have a tendency to dispose themselves over those areas of the heart v^here the visceral and pericardial layers come in closest apposition to each other. For this reason ad- hesions will be found near the apex of the heart, in which situation they may be rather dense and fibrous owing to the tug exerted upon them by the apex. They also form along the outer border of the left ventricle and over the left auricle, and at the base of the great vessels. A network of adhesions may form around the left auricle or around the ventricle or at the base of the great vessels, enmeshing these parts; or the adhesions may be slender and not sufficiently extensive to be of any clinical significance. (2) Extrapericardial adhesions may be attached to the lungs, to the diaphragm, to the sternum, to the ribs and even to the vertebrje. Such adhesions are believed to be the result of distension of the pericardial sac with fluid which has accumulated during the prog- ress of a severe pericardial inflammation, at which time the attachments took place (Fig. 53). Statistics of 80 cases of mediastino-pericarditis revealed the fact that 49 of the hearts thus afifected had also co-existent valvular lesions. Whether the valvular lesions under such circumstances are the result of a probable pan- carditis which damaged all the cardiac structures at the same time, or whether the valvular lesions re- sulted from the extracardial adhesions which deprived 180 HEART AFFECTIONS. the heart of the support normally afforded by its non- elastic membrane, is a debatable point which the clinical history of a given case might decide. Physical Signs. — Intrapericardial adhesions do not yield any definite symptoms or signs which would lead to their recognition. Mediastino-pericarditis, on the other hand, affords symptoms and signs which depend for their severity upon the extent of the at- tachments between the pericardium and other struc- tures. Significant symptoms are found in a history suggestive of previous pericardial inflammation; in irregularity of the heart, in dyspnea upon slight ex- ertion, in precordial distress or in moderate anasarca. A physical sign of importance is a limitation in move- ment of the apex : in a normal heart or even in an en- larged heart the apex will move one and one half or two inches to the left when the patient is placed upon the left side. In mediastino-pericarditis the apex will not shift but will remain stationary during this man- euver. Some significance might perhaps be attached to the character of the maximum cardiac impulse which is often strong, sharp and Cjuick. Should the adhesions be formed between the heart and lungs, it is sometimes possible to notice the maximvnn cardiac impulse ascending when the patient's left arm is raised over his head. Adhesions that form posteriorly will give us the sign described by Broadbent, in which there is systolic retraction of the loth and nth inter- spaces, visible in back. When the pericardium is ad- herent to the diaphragm there is a limit to the respiratory motion, which reduction in motion can be appreciated by the eye or felt with the hand when compared with the respiratory movement of the other PERICARDITIS. 181 Fig. 53. — Pertcaedial Adhesive Bands. (University of Pennsylvania Medical School Museum.) 182 HEART AFFECTIONS. side. Adhesions to the sternum may show that the normal respiratory increase, amounting to an inch in the anterior-posterior diameter of the chest, is hmited in extent. CaHpers may be used to determine the extent of such hmitation. The term pulsus paradoxus defines a pulse which varies in volume with the respirations of the patient. It becomes larger and stronger during expiration; this is exactly opposite to a normal pulse, and hence the term paradoxical is employed to define it. For many years it has been taught that the pulsus para- doxus is symptomatic of pericarditis with adhesions. It is no longer considered of diagnostic significance in pericarditis, for it occurs in conditions which are associated with heart muscle damage and in which pericardial adhesions have not been found. Despite the above mentioned dia**gnostic clues, there are many cases of adhesive pericarditis which afiford no evidence whatever of their existence and are dis- covered only at necropsy. Especially is this so when the condition co-exists with valvular defects, for to the leaking valve is credited the occurrence of symp- toms and signs which might otherwise be attributed to pericardial fault. Again, the cardiac disturbances incident to a valvular defect may overshadow any evidence of pericardial inflammation. DIAGNOSIS OF ADHERENT PERICARDIUM. Adherent pericardium does not afTord any definite symptoms or signs by which it can be clinically recog- nized (Fig. 54). Its presence is often suspected if there be marked enlargement of the heart which can- not be attributed to valvular defects, to affections of PERICARDITIS. 183 the vessels or to cardio-renal disease. If in addition to this there be a history of rheumatic fever or of other acute inflammation, with the history of acute Fig. S4. — Adherent Pekicakdium. The pericardial sac is intimately adherent to the heart. (Uni- versity of Pennsylvania Medical School Museum, collection of Dr. R. S. Wilhon.) pericarditis or endocarditis at that time the suspicion becomes of more value. Kussmaul drew attention to systolic filling of the cervical veins as a suggestive sign upon inspection. Broadbent described a diastolic shock due to aortic 184 HEART AFFECTIONS. closure, which, however, also occurs in hypertension and in aortic dilatation. The pulse exhibits nothing of any significance, and may take on the character of a co-existing valvular lesion; for example, if there be an associated aortic insufficiency, the pulse may be of the quickly collapsing character described by Dominic Corrigan. Auscultation affords nothing dis- tinctive by which adhesive ])ericarditis can be recog- nized. The fluoroscope may be of diagnostic aid when it shows a limit in the normal up and down movement of the heart during forced inspiration and expiration. Pick's syndrome occurs in ihose cases of peri- cardial adhesions in which other serous membranes, the pleura and peritoneum, are also involved with inflammatory exudate (Fig. 55). To this polyserositis the term "pericarditic pseudocirrhosis of the liver" has been applied. The syndrome as defined by Pick consists of (i j a previous history 'of pericarditis; (2) enlargement of the liver; (3) obstinately recurring ascites; (4) absence of jaundice; (5) absence of signs of cardiac abnormality. TREATMENT OF PERICARDITIS. It should be distinctly borne in mind that the majority of cases of pericarditis, whether acute or with effusion, are self resolved under rest. AMien absolute rest is strictly enjoined upon the patient suffering from pericarditis but little other treatment is recjuired for the condition. Puncturing of the peri- cardium (paracentesis pericardii) for the withdrawal of fluid is necessary only in the exceptional case. Inasmuch as rest is the principal therapeutic re- quirement, drugs find little employment in the treat- PERICARDITIS, 185 Fig. 55. — Polyserositis — Pick's Disease. Adjacent serous membranes are involved in the inflammatory process of the pericardium. (Jefferson Medical College Museum.) 186 HEART AFFECTIONS. ment of pericarditis ; they may of course be indicated in the treatment of the primary infection to which the pericardial inflammation is secondary. For example, if acute rheumatic fever be the causative condition, the use of the salicylates in divided doses which may range between 60 and 120 grains a day, would be indicated. Should tuberculosis be the cause of the pericardial effusion the treatment for tuberculosis is indicated. For precordial discomfort incident to peri- carditis, an ice bag may be applied ; it is not to be left continuously in place, but removed from the chest wall at frequent intervals. Pain, which is believed to be present only when the myocardium is involved, may require the sulphate of morphine hypodermically in cjuarter grain doses; the drug may also be necessary if the patient be anxious or restless. In the peri- carditis arising during acute rheumatic fever, atten- tion has been drawn by Billings to the almost specific action of cacodylate of sodium. :Under its employ- ment the exudate often rapidly disappears. The drug is administered hypodermically in doses of I to 5 grains which may be given from one to four times a day. To children a grain of the drug is ad- ministered every six hours. It has been recommended in some quarters that a limited amount of exercise be given a patient suffer- ing from pericarditis, in the belief that the exercise, by increasing the heart action, may prevent the for- mation of adhesions. This theory is mentioned here only to condemn it. In pericarditis the pericardium is relaxed as a result of inflammation and is not at the time capable of acting in its normal capacity — i.e., as a supporting membrane for the heart. It is PERICARDITIS. 187 obvious, then, that to impose upon the inflamed mem- brane the burden of increased heart action such as would result from exercise is only to pile Pelion upon Ossa. Rest, absolute rest in bed, is the prime requisite in the treatment of pericarditis. It is to be continued not only during the activity of the condition, but also to be protracted beyond the period of convalescence. It is a matter of general observation that those pa- tients who have had a long convalescence from dis- eases which induced pericarditis, are the patients who subsequently present the fewest number of symptoms suggestive of pericarditis with adhesions. When ad- hesions once form there is of course no drug or treat- ment which can in any way affect their presence. The time for treating adhesions is past long before they form. Should they form despite absolute rest long continued, the burden of their occurrence can then be laid upon the extent of the inflammatory process and not upon the shoulders of the attending physician. Paracentesis of the pericardium, a procedure never to be lightly undertaken, may suggest itself in the presence of an effusion which is sufficient to embar- rass the heart's action or to interfere markedly with respiration. Should such an efTusion fail to improve from visit to visit and, on the contrary, increase, paracentesis should be performed. Large purulent effusions are of course to be evacuated; smaller puru- lent efl^usions that do not produce marked constitu- tional or mechanical pressure symptoms may present a fine question in treatment, as to whether they are better evacuated or better left alone in the hope of gradual and eventual reabsorption. The statistics of 188 HEART AFFECTIONS. operative interference in purulent pericarditis are not especially encouraging; Dolorme and Mignon have reported that in 80 instances in which para- centesis was performed, death resulted in 65 per cent, of the cases. Other statistics report a mortality of 46 per cent, as a result of the operation in purulent cases. It may not seem altogether fair to attribute such a mortality rate to operative interference, yet the figures indicate the seriousness of the under- taking. When paracentesis of the pericardium is per- formed, the trocar may be introduced at any one of several areas, the site of election being in the 5th interspace, to the left of the sternum; the cardio- hepatic angle may, however, be the site selected. The skin of the patient is prepared as for any surgical operation, cocainized, and slightly incised: through the incision the trocar, guarded as to depth by the thumb and forefinger, is inserted with a deliberate thrust. If the patient can be propped upright in bed the position will facilitate the removal of fluid, which should be allowed to escape slowly. Should signs of collapse intervene the operative procedure will be stopped at once and treatment for shock instituted. The possibility that the fluid may be loculated is to be borne in mind : for this reason it may be necessary to enter the pericardial sac from more than one point in order to drain various areas to which laminje of adhesions have confined the fluid. The wound is to be aseptically closed. CHAPTER XV. Myocardial Affections. TERMS EMPLOYED. The musculature of the heart may exhibit either acute inflammation or chronic structural tissue change. To acute inflammatory processes in heart muscle which are quite constantly secondary to infections elsewhere in the body, the term acute myocarditis is applied. After the acute process has subsided the heart may be found to be permanently damaged as a result of the strain and infection to which it was then subjected. To such a circumstance the term chronic myocarditis is applied. Strictly speaking, the term is a poorly chosen one, for the heart muscle is not chronically inflamed; it is structurally altered. The damage usually takes the form of degenerative change or of fibrous tissue increase. The term chronic myo- carditis also covers changes in heart tissue which result from long continued chemical poisoning or from degenerative change which results from long standing infections ; but here again there is structural alteration, not inflammation of heart muscle in the strict acceptance of the term. ETIOLOGY. Acute Myocarditis. — Acute inflammation of the heart muscle is secondary to bacterial invasions else- where within the body. The Diplococcus rheumaticus (189) 190 HEART AFFECTIONS. of Poynton and Payne, which is beheved to be the cause of acute rheumatic fever is considered one of the most active agents in the production of acute myocarditis. Staphylococci and streptococci, partic- ularly the Streptococcfis viridans, are prominent etio- logic factors. The frequency with which the Klebs- Loeffler bacillus induces heart muscle change during the progress of or subsequent to diphtheria is a matter of general observation.* The sino-auricular block and higher grades of heart-block which burst from a clear sky and cloud the convalescence of diphtheria are evidence that the conduction system has shared in a more widely spread involvement of heart muscle. Iniiucn.za is an increasingly common cause of acute or sub-acute myocarditis and a particularly serious one, inasmuch as the damage to the heart muscle in sub-acute cases does not usually reveal itself until a considerable time has elapsed following the acute in- fection. Typhoid fever, scarlet fever and pneumonia are frequently attended with acute myocarditis, or it may arise during convalescence from these aiifections. Measles, despite the fact that it has been lightly regarded as a "harmless" disease of childhood, in- trudes itself with a persistence unusual to children's diseases, in the previous history of patients with myo- cardial damage. In writing of this subject from one of the early military camps in 191 7 I presented the following: "Measles, in these figures, assumes a percentage * So far, my incompleted studies at the Philadelphia Municipal Hospital indicate that diphtheria may be expected to involve the heart muscle in varying degrees of severity, in 22 per cent, of all diphtheria patients. MYOCARDIAL AFFECTIONS. 191 importance far in excess of all the other acute, infec- tious, contagious diseases of childhood combined. Previous History — Diseases of Childhood Per cent. Measles 52.60 Diphtheria 9.79 Scarlet fever t IS.UO Whooping cough , 673 Total of other diseases of childhood 31.52 "It would be reading entirely too much into these figures to assume from them that measles plays an important etiologic part in the cardiac changes of later life; it is, however, quite permissible to call atten- tion to the earlier incidence of measles in over 52 per cent, of the patients with cardiac affections. That this traditionally "harmless" disease of childhood may be the precursor of eventual heart damage suggests itself in a plausible light when one reflects that the complications and sequelae of measles, such as middle ear involvements, pulmonic invasions and chronic catarrhal conditions of the upper respiratory tract, are freciuently suppurative in character and hence as fully capable of aiTecting the heart as are other septic processes within the economy." In this connection the question naturally arises "What is the usual percentage incidence of the dis- eases of childhood?" Their usual incidence can be approximated, but not accurately determined. There are insurmountable difficulties which rob any con- tagious disease statistics of their accuracy, such as a failure to recognize, a failure to report, or a desire to conceal ; again, changes in population will alter the accuracy of figures. Admitting these and other 192 HEART AFFECTIONS. sources of error, an approximate incidence might be stated as follows:* Usual Incidence of the Diseases of Childhood (Approximate). Per cent. Measles 18.1 Diphtheria 8.3 Scarlet fever .- 7.3 Whooping cough 3.3 In other words, it is probable that i8 out of a hundred people now alive have had measles, while the figures of those who had measles a,nd who were later found to have heart aflfections are higher than this usual incidence by nearly three to one. Further observations made in other camps con- firmed the above figures. At Camp Custer, Michigan, measles appeared in the previous history of 88 per cent, of a group rejected on account of chronic myo- cardial change. In presenting these figures, it is not my intention at the present time to make any deduc- tion or comment other than that they are snggcstk'e. "Rheumatism," in the present-day statistics of myocarditis does not loom so large as it did in the statistics of years gone by. The* reason for this is, probably, that a cHstinction is now more generally drawn between acute rheumatic fever, A\hich is a dis- * Basis for above percentages. These calculations are based upon statistics that show the number of reported cases in Pennsjlvania for a 3-ycaJ" period to be as follows : Measles 73,486 Diphtheria 33,889 Scarlet fever .^ 29,782 Whooping cough ., 13,341 During these years, the population of the State averaged seven million. The average length of human life has been figured herein as being 52 years. MYOCARDIAL AFFECTIONS. 193 tinct clinical entity, and the vague indefinite muscular pains and joint involvements which were hitherto in- cluded vmder the hybrid term "rheumatism" — condi- tions which are now believed to be the result of ab- sorption from foci of suppuration — focal infection. Chronic Myocardial Affections. — As previously stated, chronic myocardial change may ensue as a result of acute infections which involve the heart mus- cle. There are conditions other than acute infections, however, which induce structural alteration in the myocardium. Chemical poisons, such as lead, arsenic and mercury may, when absorbed over a period of time, produce myocardial change. Obesity has long been believed to be productive of chronic heart muscle alteration. Syphilis provokes changes of such a con- stant nature in heart muscle when seen at autopsy that the terms "syphilitic myocarditis" and "syphilitic heart disease" have come into existence as though to de- scribe a clinical entity. Recent statistics indicate that syphilis was responsible for chronic myocardial change in only 9.7 per cent, of a group of cases studied. This, however, does not cover all of the instances in which syphilis might be an etiologic fac- tor; for example, it is generally admitted that the Treponema pallidum is responsible for much oi the damage that is done in diseases of the aorta. With this fact in mind, it is not difficult to understand how specific inflammation of the aorta might inflame the coronary arteries at their point of origin in the great vessel (see Fig. 75) and thus reduce the blood sup- ply to the heart muscle itself, thereby bringing on chronic myocardial change; or by the extension of the aortic inflammation, through continuity of struc- 13 194 HEART AFFECTIONS. ture, to the coronary arteries these vessels themselves could readily become reduced in lumen and insufficient for the proper nourishing of the heart. An embolism or thrombus of the coronary ves,sels will also cause damage to heart muscle; should such an accident oc- cur during the course of an acute infection it may produce sudden and unexpected death, or by a partial blocking of the blood supply, give rise to areas of de- generation in the heart walls. Exophthalmic goiter, while an infrequent cause of myocardial change, at times aifects the heart muscle, probably by the long-continued rapid action and stim- ulation of the myocardium ^\'hich the elaboration of excessive glandular secretion may induce. THE INDUCTION OF CHRONIC MYOCAR- DIAL CHANGE. In tracing permanent heart muscle affections from their inception in acute myocarditis to their eventual development in chronic myocardial change, it is well to remember first of all that there are cases of acute myocarditis which to all appearances recover, either as a result of ( i ) cardiac resistance, (2) infections of a limited degree, or (3) through early recognition and skillful treatment. Aside from these instances, acute myocarditis induces permanent structural tissue change. Rest, so necessary to a restoration of normal physical function, is a therapeutic measure obtainable only to a limited degree for affected hearts ; and so, as the heart lal:)ors on, cloudy swelling and granular degeneration may affect its musculature; implication of the coronary arteries may starve the cardiac muscle MYOCARDIAL AFFECTIONS. 195 to an extent where ischemic atrophy ensues. HyaHne and fatty degeneration are unusual sequels to acute myocarditis, and yet they are found in post-mortem studies. In tissue under the microscope it has been Fig. S6. — Cicatricial Myocarditis. The photomicrograph illustrates the forriiation of scar tissue in heart muscle. Practically the entire field is scar tissue; here and there appear muscle bands, marked "M.'' The dark spots are blood-spaces "B," (Courtesy of Dr. Allen J. Smith.) found that one muscle cell can be dissociated from its neighbor, each lying separate from the other. Fibrous increase of the connective tissue, usually distributed 196 HEART AFFECTION.S. irregularly through the heart, is a very frequent find- ing at necropsy (Fig. 56). Fatty infiltration of the sub-pericardial connective tissue is often observed at necropsy. The thick fat is deposited not alone on the outside of the heart but also in the connective tissue between the muscle fibers. Fatty infiltration is to be distinguished from fatty de- generation, in which latter condition the fat is found in the muscle cell itself, which is a comparatively rare condition. Fatty infiltration is often suspected dur- ing life in cardiac patients who exhibit a general tendency to obesity. If there be an excessive deposit of fat in their bodily tissues it is f)erhaps a safe haz- ard to diagnose "fatty heart ;" but there is no definite symptomatology nor are there any definite clinical signs by which such a condition can be recognized during life. Dyspnea and palpitation are symptoms of cardiac embarrassment in the obese but they are also symptoms of cardiac embarrassment in patients of slender build. Increase in the transverse diameter of the heart exists when it is subject to fatty in- filtration, and it also exists when there is no evidence of fat deposit in heart tissue. Faint and muffled heart sounds occur in obese patients who might be suspected of "fatty" heart ; and they occur with equal frequency in patients emaciated and exhausted bv disease. There is no constructive evidence during the life of the patient upon which to base- the once popular diagnosis of "fatty heart." The pathology of myocarditis as outlined above, shows that such a possible varjety of myocardial changes may give a \-ariety of s}'mptoms. It explains why acute mvocarditis has no definite s^^nptom-com- MYOCARDIAL AFFECTIONS. 197 plex. It explains why the diagno.'iis is more a matter of deduction than it is a question of physical signs. Many of the conditions just enumerated, such as cloudy swelling, ischemic atrophy, fatty infiltration, etc., cannot be recognized clinically, nor are they im- mediately incompatible with a fair degree of health. When they eventuate in chronic myocardial change, muscular weakness may not show itself until years after, when the reserve strength of the heart has been expended and cardiac bankruptcy is impending: then symptoms of heart failure are precipitated by some trivial incident or illness. Cardiosclerosis is a term applied to ■ sclerotic changes •which take place in the musculature of the heart. There is no symptomatology or physical sign by which cardiosclerosis can be recognized during life; its presence can often be surmised when cardiac symptoms predominate in an arteriosclerotic process that is generally distributed. Cardiosclerosis is but another evidence of chronic myocardial change. It is produced by the same etiologic factors, it induces the same general symptoms of circulatory disturb- ance, and the symptoms may be benefited by the same methods of treatment, as any other chronic chang'e in the heart musculature. DIAGNOSIS OF ACUTE MYOCARDITIS. Acute myocarditis is often difficult of recognition. It may be suspected when, in the course of a febrile condition due to bacterial invasion, there is detected an irregularity of the pulse which heretofore had shown no unusual change, especially if there be added to this a sense of exhaustion, out of all pro- 198 HEART AFFECTIONS. portion to the severity of the infection, which is other- zvise unexplained. Hurried breathing, rapid pulse, cyanosis, pallor, coldness, fatigue or prostration in- duced by such trivial exertion as that of sitting up in bed, are further reasons for myocardial suspicion. The detection of fine rales at the base of a lung posteriorly, particularly at the base of the left lung, which rales are not associated with other evidence of respiratory involvement, is often an early and always a valuable sign of myocardial affections. Such signifi- cant rales are not constantly present — the\ are evan- escent in character, appearing with more frequency when the patient has been lying .on the back for a few hours. Usually there are associated percussion phenomena, which consist of a deeper pitch to the percussion note, diminished resonance and an in- creased sense of resistance in an area which approxi- mates that of the sixth, seventh or eighth dorsal -^-erte- bra, to the left of the spinal column. I am of the opinion that such percussion phenomena are occa- sioned by a left auricle that may be either relaxed in tone or increased in size. This chamber, it will be remembered, chiefly forms the posterior surface of the heart, and the pressure which it could exert, when for any cause expanded, upon lung tissue that offered little resistance on account of shallow breathing, would account for the production bi rales at the base of the left lung in cardiac conditions. Precordial oppression or precordial pain is of much significance. These symptoms maj- arise during the course of an acute illness, nr they may arise late in convalescence; whenever precordial pain occurs a thorough search should be instituted for its cause. MYOCARDIAL AFFECTIONS. 199 whether the patient be bedfast ©r ambulant. Pre- cordial distress that may deepen into actual pain, is a symptom of heart affection that has not been ac- corded the degree of significance which its importance warrants ; it may be of arterial or it may be of cardiac origin. I found it to have an average incidence of jy per cent, in young men whom it was necessary to reject from military service on account of symptoms of chronic myocardial change. The physician should not lose sight of the fact that heart pain is also fre- quently referred to the neck or between the shoulder- blades and may be complained of iiiore in these situa- tions than at the precordium. An anatomic basis for heart pain as referred to the base of the neck may exist in the fact that it is from the first and second dorsal vertebrae that the heart receives its innerva- tion during its embryotic development. Clinically, at least, the heart can so modify the irritability of the spinal segments of this area, perhaps reflexly, that heart pain is often referred to the lower cervical and upper thoracic nerves. Palpitation and tachycardia may first direct atten- tion to the heart in an acute infection with beginning myocardial involvement. AA^eak and irregular heart smmds may arise during the course of continued fevers, such as those which ensue during typhoid fever. In typhoid infection a gradual change takes place in the quality of the apical first sound which is best described by the term "snappy." It is due to the tautening of the mitral curtains, their action being more in evidence because, on account of muscular weakness, the "booming" quality of the first sound is faint or absent. If there be occasional reduplica- 200 HEART AFFECTIONS. tion of the first sound it is due to the fact that the impulse for contraction is delayed for a fraction of a second in reaching one ventricle or the other, prob- ably owing to some inflammatory change involving the bundle of His. Systolic murmurs may be present at the base of the heart or they may be heard at the apex, in which latter situation they can be produced either by the stretching or the relaxing of the mitral ring (see Fig. 5, "Annulus fibrosus" or fibrous rings j. It is quite likely, however, that murmurs which arise in acute myocarditis are for the most part produced by inflammatory changes in the endocar- dium, reflections of which help form the valves of the heart; for it is inconceivable that an inflammatory process could invade the musculature of the heart and not to some degree extend to the delicate and inti- mately adherent endocardium which lines the inner muscular wall. The physician who fails to diagnose acute myo- carditis should not censure himself too severely for a lack of diagnostic acumen. The indefinite and var- iable clinical picture, so often obscured or over- shadowed by symptoms which are due to the primary infection, may readily cause one to overlook acute myocardial involvement. Electrocardio graphic Recognition. — ]Mvocardial involvement may be suspected when an electrocardio- graphic curve reveals disturbances in the conduction system of the heart, as set forth in the concluding paragraph of Chapter XIIL Again, there are cer- tain alterations in the waves of the electrocardiogram which indicate involvement of the fibers of Purkinje, (Fig. 43), and such disturbances have been subse- MYOCARDIAL AFFECTIONS. 201 quently found, at necropsies, to be definitely associated with hyaline, fibrous and other degenerative changes in heart muscle. THE RECOGNITION OF CHRONIC MYO- CARDIAL CHANGE. Chronic myocardial change is usually the after- math of acute myocarditis. The bacterial invasion which produced the acute conditidn is now no longer active; it has ceased to work acute inflammatory changes in heart tissue and has left as an aftermath degenerated areas of heart muscle, or has impaired the efficiency of the organ with an increase of inter- stitial connective tissue (Fig. 57). There may be just enough efficiency remaining in the damaged cardiac tissue to maintain the daily demands of a moderately active life. Sooner or later some extra burden is imposed upon heart structure that has no reserve force. It may be the extra burden of unaccustomed effort, or it may be a gradual reduction in the efficiency of one muscle fiber after another as the changes incident to increased labor or to the advance of years inter- vene, as in arterio- or cardio- sclerosis. It is then that chronic myocardial change becomes manifest. Often, too, this condition is first suspected when there arises some enforced curtailment in the usual activities of the patient. Perhaps one in middle life becomes aware that he is no longer able to mount the staircase with his accustomed agility. He may notice that he is short of breath and that there is a sense of constriction about his chest as he hurries to his office. Faintness or dizziness may interrupt his game of golf or an unwonted feeling of exhaustion 202 HEART AFFECTIONS. and perhaps palpitation of the heart may follow the stimulation produced by motoring. With such mild limitations of accustomed heart response does early myocardial change announce itself. Fig. 57. — Fibrous Myocakditis. Areas of fibrous degeneration are extellently shown in the grayish patches of the heart muscle. (Jefferson Medical Col- lege Museum.) Advanced luvocardial damage is evidenced by the occurrence of the classical symptoms and signs of heart failure, in either moderate or pronounced de- gree. The symptoms of heart-muscle failure can be conveniently grouped under four heads, as follows: (a) Early exhaustion attending trivial physical effort. MYOCARDIAL AFFECTIONS. 203 (&) Cyanosis and venous distension. (c) Congestion of various viscera. Visceral congestion produces a chain of symptoms and signs, depending upon the viscus involved, which are numerically set forth in the following paragraph. Pulmonary congestion produces: changes in the respiration, varying from (l) hurried and shallow breathing to (2) dyspnea and (3) orthopnea; the presence of (4) moist rales in the lungs and other evidences of (5) chronic bronchitis; occasional (6) spitting of blood; sputum in which (7) "heart failure cells" may be found by the microscope. These are large, oval epithelial cells, presumably from the pulmonary alveoli; owing to long-continued pas- sive congestion they contain blood-pigment granules of a brownish hue. They are also found in the sputum following pulmonary hemorrhage. Renal congestion produces: (8) edema; (9) ascites; (10) anasarca; (11) toxemia, deepening from mild uremic symptoms to (12) uremic coma; (13) ocular disturbances ; (14) chemic and microscopic changes on urinalysis. There may also be present: (15) an enlarged and pulsating liver, or from this same cause (t6) turgescent super- ficial veins; (17) painful engorgement of the spleen; (18) digestive disturbances. The heart is usually increased in size. The pre- cordial impulse is often diffiuse, and yet the ventricular impact is surprisingly lacking in the degree of force which one would expect to find. Basal systolic mur- murs of varying degrees of intensity are frequently present. {d) The pulse irregularities of heart failure may be nothing more than occasional and isolated prema- 204 HEART AFFECTIONS. ture contractions, although they are more often o£ the multiple and rapidly-recurring type. Actual dropped heats also occur and may be the precursors of deep- ening degrees of heart-block, with the bradycardia which usually (but by no means always) attends it. Auricidar fibrillation frequently sets in, more often as a permanent than as a transitory condition. Brief periods of tachycardia are not at all uncommon. Pidsus alternans may be observed over a period of months, although its occurrence is generally premoni- tory of the approaching end of life in chronic myo- cardial degeneration. In short, any of the pulse ir- regularities mentioned in Chapter XIII may be present in myocarditis, for such irregularities are, for the greater part, simply evidences that the conduction- system of the heart has shared in the process which affected the heart muscle. TREATMENT OF ACUTE MroCARDITIS. The treatment of acute myocarditis is absolute rest in bed. Acute myocarditis continues acute as long as the causative factors are active. The best hope of lessening the degree of cardiac damage which is induced by the causative bacterial invasion, toxin or chemical poison lies in relieving the heart of as much eifort as is possible in order to increase its rest period; hence the dictum, absolute physical rest. The value of rest cannot be over emphasized: if by absolute rest in bed the physician can secure a re- duction of twelve beats per minute from a heart-rate of 1 20 in acute myocarditis, in 24 hours he has saved the laboring organ 17,280 cycles. In other words he MYOCARDIAL AFFECTIONS. 205 has given to the heart over 4 hours of additional rest out of the twenty-four by the prolongation of diastole, at the expense of which rapid rates are maintained. In addition such measures may be employed as are detailed under the treatment of acute endocarditis in the following Chapter XVL Treatment for the one acute condition is quite the treatment for the other, for one cannot suppose the existence of an acute myo- carditis Avhich has been induced by infections, with- out presupposing the co-existence of endocarditis to some degree, owing to the intimate association of these two structures. TREATMENT OF CHRONIC MYOCARDIAL CHANGE. The physician does not see chronic myocardial change at its inception; he sees it after it has been established for a period of time and become distinctly noticeable as the immediate consequence of an extra burden recently placed upon the heart. Logically the endeavor of treatment should be to first remove the extra load, and this includes an unremitting search for a focus of infection (page 224) that may be aggravat- ing the heart's distress: next, to compensate for the extra burden by relieving the heart from even its ac- customed daily effort for a period of time and finally, to guard against future strains on the myocardium by proper instruction of the patient (see The Patient's Daily Life, page 370). The first two indications are met by rest and other appropriate treatment which can be set forth as follows : 206 HEART AFFECTIONS. Indicated Treatment. 1. Rest — physical. 2. Rest — mental. 3. Rest — emotional. 4. Elimination. 5. Improvement of heart nutrition. 6. Alleviation of incidental distress. 7. Sustaining of the heart with drugs. ( I ) Physical Rest. — At the beginning of treat- ment it is a good rule to put the patient to bed. While this may seem too arbitrar}- a procedure to some pa- tients, it is much easier for the physician to lessen restrictions as circumstances may permit rather than to later impose added restrictions upon a patient who has been allowed to be ambulant. As the S}'mptoms which catised the patient to seek medical advice im- prove, the liberty of the room or house may be al- lowed. The period of confinement to bed is a variable one and can be determined only by the disappearance of cardiac symptoms with no unfavorable signs mani- festing themselves on attempted .effort; the patient may then be permitted to undertake simple physical efifort. If the pulse shows a marked change in rate when the patient is first permitted to be out of bed it is an indication that the period of rest has not been sufficiently long continued. A change in rh}-thm ma}' not be of the same significance as a marked change in rate, for an alteration in rhvthm is frequentlv en- countered as a previously-established condition in pa- tients of advancing years who have chronic myo- cardial change. .Vgain, such alteration in rhythm may have just had its inception during the recent collapse, threatened or actual, which caused the physician to put the patient to bed and be, from this MYOCARDIAL AFFECTIONS. 207 time on, permanently established. But if a change in rhythm or an alteration in volume is brought on by a change in posture or by the trifling effort of attemp- ted locomotion, the patient should be remanded to bed. Judgment dictates, of course, that the aged and the infirm who bear bed confinement very poorly as a rule, should be permitted a limited amount of liberty, of which liberty they are very often the best judges, rather than to be fretted and annoyed by a too arbi- trary change in their accustomed mode of life. (2) Mental rest is of but little less importance than is physical rest. This is frequently demonstrated by the beneficial results which follow institutional treat- ment in sanitarium or in hospital. There, for ex- ample, the head of a household is free from the worry of conducting or superintending a home, rid of the vexation of servants, away from the intrusions of over solicitous friends, and is amid cjuiet rest-inducing surroundings where the ear is not strained to catch every unusual sound nor the mind kept busy interpret- ing them, as would be the case were the patient abed at home. To many patients, particularly those of an anxious turn of mind, there is much mental ease afiForded by the thought that in a sanitarium a physi- cian is always wdthin easy call ; and from the point of view of the family doctor there is much advantage in the medical and nursing supervision, in the scien- tific preparation of meals, in the regulation of rest and in the other many attentions which spell efficiency in modern institutional management. However, treatment at an institution is not ad- visable for every case of cardiac disease. Patients with marked edema, cyanosis and dyspnea are often 208 HEART AFFECTIONS. better treated at home, particularly if the institution be a long distance away and imposes the effort and fatigue of a protracted journey upon the heart which is already showing symptoms of exhaustion. (3) Emotional disturbances are difficult to elim- inate in the home management of a cardiac patient, but they should be guarded against in every possible way, for at times they have a profound influence upon the affected heart. The attentions of home nurses may irritate ; the sympathetic eye of a friend who has been permitted to see the patient may cause depression of spirits; a whispered voice may be interpreted as ominous by the invalid whose sole 'thought is on her physical condition, or a laugh may be mistaken for an utter lack of sympathy. In such ways may the emo- tions of a patient be played upon and, through the sympathetic nerves, actually play upon the heart. (4) Elimination will need to be practised with more or less constancy in the treatment of the patient who is confined to bed. When the bowels are to be stimulated over a period of time it is better to use the milder laxatives in daily dose,, rather than to em- ploy drastic cathartics at intervals; for the latter, by depleting the system through excessive action, may add the burden of physical exhaustion to a laboring heart. The mild laxatives such as cascara sagrada, senna, compound licorice powder or the saturated solution of magnesium sulphate in small daily dose are therefore the evacuants of choice. Tlic skill can be kept sufficientlyactive by the daily tepid bath followed by witch hazel rubs, and aided by the employment of massage. The induction of free perspiration is to be avoided for it may prove very MYOCARDIAL AFFECTIONS. 209 eJchausting to the patient with heart muscle damage. Of course the urgent incidence of uremia may de- mand hot packs; or the occurrence of apoplexy may necessitate prompt and vigorous catharsis ; but these are exceptional instances in the treatment of mod- erately advanced myocardial aiTections and are, in- deed, two of the many possible occurrences which the physician hopes to avoid when he puts the failing patient to bed. The kidneys can be kept in a freely eliminating state by the drinking of water in liberal quantities. As concerns the use of various mineral waters which are supposed to be active renal eliminants ; they seem to possess little virtue other than that which could be ascribed to mechanical flushing. However, if the pa- tient, urged by a friend's advice feels that these waters have some curative virtue, the physician has nothing to lose in permitting their employment; patients fre- quently drink such waters with more regularity and faithfulness than they accord to ordinary unheralded and unlabelled water, and the physician's purpose of renal flushing is thus secured. Infusion of digitalis may be used where a more active renal stimulant than plain water is desired. The infusion of digitalis should be prepared by the pharmacist; in order to extract the active principles of fox-glove leaves it is necessary that a small amount of alcohol be used in preparing the infusion. Cer- tain glucosides upon which the activity of digitalis principally depends, vis: digitoxin and digitalin, are freely soluble only in the presence of alcohol. The usual aqueous preparation made by pouring boiling water on the leaves is inert so far as definite digitalis 210 HEART AFFECTIO}?S. effect is concerned. The only really active one of the five digitalis glucosides which suqh an aqueous solu- tion contains is digitalain. (5) Improvement of heart nutrition may be ac- complished in an indirect manner by easing the load and by increasing the period of cardiac rest through lessened physical effort. As to t;he direct effect of foods upon heart muscle, much yet remains to be dis- covered. A cardiac patient who is at rest in bed or confined to his room manifestl\- requires less nourish- ment than when he is up and around; consequently he must reduce the intake of food if he would avoid overloading kidneys, bowels and liver and by remote effect on these organs indirectly aggravate the con- dition of the heart and circulation. Small quantities of nutritious foods prepared in their most easily assimilable form, together with the limiting of pro- tein intake, and with the elimination of foods which are known to be productive of intestinal fermentation in a given case, are more desiraijle rules to follow than is the blind adoption of one of the many "cardiac diets" \\hich appear from time to time. A standard diet is given for reference in Chapter XXII. One notable exception to the general impracti- cability of rigid food regulation in cardiac patients is the diet suggested by Karell, to be used when it is desired to limit the zcater intake. There are instances where unlimited water intake might add to an existing edema, ascites or other effusion and thus add to the embarrassment of the heart. In Karell's diet fluid intake is limited to milk ; the free Use of salt is inter- dicted, on the iheor)- that it accumulates in the tis- sues and attracts fluids to the parts. Even sufficient MYOCARDIAL AFFECTIONS. 211 salt to maintain the normal individual demand of 15 grains per day is prohibited at first, until the excess previously stored in the tissues may be considered exhausted. The regime is as follows: The Karell Diet. — For the first seven days, 8 ounces of milk at 12 a.m., 4 and 8 p.m. No other fluid. Eighth day, milk as above, and at 10 a.m. one soft boiled egg; at 6 p.m., two pieces of dry toast. Ninth day, milk as above, and at 10 a.m. and 6 P.M. one soft boiled &gg and two pieces of dry toast. Tenth, eleventh and twelfth days, milk as above and at 12 noon chopped meat, rice boiled in milk, and vegetables; at 6 p.m., one soft boiled tgg. No salt is used throug^hout the course. Toast and butter are to be salt-free. A small amount of cracked ice is allowable. All meat is advantageously omitted. When the desired effect has been attained by this dietetic regime, the effect is maintained by an occa- sional "Karell day," in which the strict food regula- tion of the first seven days is adhered to for 24 hours. Cane-sugar in Heart Affections. — The classic ex- periment of F. S. Locke, ^ in which he demonstrated that the excised heart of a rabbit could be kept pulsat- ing for four days by pouring through it a solution containing dextrose, has stimulated much interest in the clinical value of sugar as a means of nourishing depraved heart-muscle. Physiologists have announced that the sinoauricular node, the bundle of His, and its arborizations, contain a remarkable amount of gly- cogen. Prof. Dr. Adamkiewiez- states that the heart requires its own weight of sugar each day for its 1 Locke : Zcntralbl. f. Physiol., No. 20. 2 Adamkiewiez : Prag. med. Wchnschr., No. 43, p. 601. 212 HEART AFFECTIONS. nourishment (9 to 11 ounces). These observations have been utihzed by Sir Arthur Goulston, of Exeter, in the treatment of heart affections with cane-sugar, carefully avoiding the employment of beet and any sugars other than cane. He begins with the admin- istration of 2 ounces a day, pushing the administra- tion rapidly to 4 ounces a day, or even to 10 ounces in some instances. The likelihood of digestive distur- bances and intestinal fermentation is disposed of by the observation of Abderhalden^ that the lactic acid ferment of the intestines does not attack cane-sugar or milk sugar. Sir Arthur reports brilliant results following this plan of treatment. Breathing exercises seem to have a beneficial effect in improving the nutrition of the heart in some patients. Their employment is based upon the theory that slow and deep expiration will so decrease intra- thoracic pressure upon the heart that the heart muscle itself will receive a greater blood supply under such a circumstance than during ordinary quiet breathing. Ey the same reasoning, slow and deep inspiration will decrease the intrathoracic area occupied by the heart and thus by compression more completelv empty the heart muscle of venous blood and permit the ingress of oxygenated blood with the ensuing inspiration. \A'hether the theory appears chimerical or not, the fact remains that some patients have an increased sense of well-being and seem benefited as a result of the prac- tice, which certainly has to commend it a more liberal aeration of the blood than is secured in ordinary quiet breathing. There are foreign physicians who employ a device to stimulate deep breathing in their 1 Abderhalden: Physiological Chemistry, Lecture XX. MYOCARDIAL AFFECTIONS. 213 patients who suffer from chronic myocardial change, the device consisting of two bottles connected to one another by a piece of glass tubing, one of the bottles being perhaps half filled with water ; a length of rub- ber tubing is attachable to a glass' tube which is in- serted through the cork of both bottles. The exercise consist in the patient blowing through the rubber tubing and attempting to force the water from one bottle into the other, with as few breaths as possible. Add water as capacity of the patient's lungs increases; interest in the procedure is thereby maintained. (6) Alleviation of Incidental Distress. — Distress- ing circumstances which add to the heart load and which the physician may have to ameliorate, are: anasarca, pain, sleeplessness, constipation, hepatic tor- por, dyspnea, bronchitis, and vomiting. Where pos- sible, remedial measures other than drugs should be employed. Dropsical effusions may be relieved by the trocar and cannula; painful engorgement of the ex- tremities by Southey's tubes or multiple punctures (^ inch deep) of the tense and edematous skin, always under antiseptic precautions and with subse- quent aseptic dressing; pain may be amenable to the ice-bag' or hot fomentations ; sleep may be induced by hot drinks, by massage or friction rubs; constipation and hepatic torpor frequently yield to a diet of laxa- tive foods or enemata; dyspnea, to a change in posi- tion, or the use of oxygen; bronchitis, to the gradual improvement of the cardiac condition; and vomiting, to a temporary withdrawal of all foods by the mouth, save the sipping of ice-water, and to the counterirri- tant effect of mustard plasters (i part mustard, 5 parts flour) applied to the epigastrium. 21-4 HEART AFFECTIONS. (7) Sustaining the heart zvith Drugs. — There is no specific drug treatment for chronic myocardial change, drugs being employed only for the treatment of symptoms as they arise and only when the simpler measures just described are not effective. Digitalis is a remedy very often abused by being promiscuously administered. In many quarters it seems to be the first thought when a cardiac or circulatory distur- bance is detected. Digitalis is by no means a panacea for all cardiac ills. There are some cardiac conditions which are made distinctly worse by its indiscriminate employment. By calling forth all of the scanty stock of residvial effort that yet remains in a seriously- damaged heart, digitalis can bring, on death l)y utter myocardial exhaustion. In chronic myocardial af- fections there are two indications which warrant the use of tincture of digitalis: either a failure of the heart muscle to improve in tone under rest and other effort conserving methods, or else (i progrcssiz'e zveak- ening of the heart muscle despite rest and other effort conserving methods. Un-der these circum- stances the "average dose" of 8 minims of the tincture, repeated 3 times a day, is quite often sufficient. The drug should be withdrawn when the desired effect is produced. (See Untoward Effects of Digitalis, Chap- ter XXIV). The ;r-ray may have a therapeutic value in myo- carditis in those rare instances where the disease can be attributed to no other cause than excessive gland- ular activity, as exemplified in thvroid disturbances. A Rontgen light over the thyroid may reduce actiAdty of the gland and, by lessening the excessive elabora- tion of secretions, lessen their effect upon the heart. CHAPTER XVI. Endocarditis. THE DEFINING OF ENDOCARDITIS. The term endocarditis in its customary acceptance implies acute or chronic disease of a heart valve. If one does not amplify this limited use of the term one may not secure a clear picture of the damage which is wrought in the lining membrane of the heart during the progress of or subsec[uent to acute infections else- where within the body. It should be remembered that while acute inflammation of the lining membrane, from the standpoint of gross pathology, is usually located on the valves, yet such is not always the case. It may be mural and distributed quite generally over the interventricular septum and even involve the chordae tendinse and the musculi papillares. It is questionable whether acute endocarditis ever confines itself to the valves and the mural endocardium alone. One of the symptoms of the condition and one which often first draws attention to the heart, is ir- regularity of the pulse. Irregularities of the pulse, for the greater part, reflect disturbances of the conduc- tion system. The conduction system of the heart is distributed in the muscular tissue of the heart walls; hence it is reasonable to assume that any inflamma- tion of the endocardium which produces an irregular pulse must have penetrated that thin translucent mem- brane and have reached to the heart muscle itself. (215) 216 HEART AFFECTIONS. Acute endocarditis is quite invariably a secondary process. The degree and extent of the cardiac inflam- mation depends upon several factors. For example, certain bacteria are more virulent than others and can be expected to set up a greater inflammation in the lining membrane of the heart; as the infec- tion is probably from the blood stream, the numbers of bacteria which might be present would also have an effect upon the degree of inflammation; and, if the cardiac tissues have been lowered in resistance through an exhausting primary illness or have been weakened by previous attacks of disease, an added endocardial inflammation will be the more serious in consequence. Tlie varieties of endocarditis are for the most part arbitrary distinctions, which are justified in that they enable easier descriptions of the various proc- esses. But it should be remembered that when inflam- mation of the lining membrane of the heart sets in during an acute infection there is no way of telling whether it will be "simple" or malignant, whether its course will be acute or chronic. The acute may sud- denly become malignant; and the malignant, which at first threatens to overwhelm,, may as suddenly modify its form and become the protracted variety of malignant endocarditis, — that type of slow evolution, the principal cause of which is now believed to be the Streptococcus z'iridans. M'e have then, for convenience of description: (i) acute ''simple" endocarditis; (2) acute malignant en- docarditis and (3) chronic malignant endocarditis. In any of these three forms the causatiA-e agent, bac- terial infection (perhaps rarely a chemical poison), is ENDOCARDITIS. 217 actively present ; not until that activity has ceased and the cause become quiescent, does (4) chronic endo- carditis ensue. Strictly speaking, ''chronic" endo- carditis is a poorly chosen term, for there is no actual inflammation present in the endocardium ; a previous inflammation has terminated in structural tissue change and the resultant permanent damage in valve structure is better known as chronic valvular disease of the heart, a subject which is discussed in the chap- ter which follows. Endocarditis, on account of its frequent associa- tion with acute rheumatic fever, is sometimes spoken of under the misleading term of "rheumatism of the heart." The term should be discarded; it gives no clear conception of the condition and may utterly misdirect the treatment of the physician who relies upon "antirheumatic" drugs alone to correct the per- verted cardiac condition, MORBID ANATOMY. Acute Endocarditis. — Early cases of endocarditis which come to post-mortem exhibit on the valves small, light colored beads which are arranged in a crescentic form, a line or two from the free edge of the valve, at that point where the leaflets touch each other when closed. These small beads are composed principally of fibrin in which micro-organisms can be found. To the unaided eye the walls are not as yet involved. Later on, as the inflammation progresses, these beads assume the shape of cauliflower-like ex- crescences and to this form the term "verrucose endo- carditis" is applied by the pathologist (Fig. 58). Eventually the process involves the deeper tissue of ns HEART AFFECTION'S. the valve, then spreads to the valve-bases and from there to the heart wall itself (Fig. 59). It has been observed that \\'hen the aortic valve is seriously in- vaded the infection has a tendency to spread in the Fig. 58. — Verrucose X'alvulitis. Close inspection of the leaflets will reveal the grayish, pin- point deposits which are the first macroscopic evidence of valvular disease. (University of Pennsylvania Medical School Museum, collection of Dr. R. S. Jl'iUson.) direction of the aorta ; profound infection of the mitral vah'C spreads upward to the auricle and down in the ventricle to the chordcC tendine^e, and to the musculi papillares. ENDOCARDITIS. 119 Acute endocarditis is much more common on the left side of the heart than on the right. For this reason the mitral and aortic valves are found at necropsy to be the ones most fre„quently affected; it is unusual for all four of the valves to be involved. Endocarditis may occur during intrauterine life in Fig. 59. — Vegetative Mukal anu Valvular Endocakditis. The black arrow points to the inflammatory process which in- volves the heart muscle wall as well as the valve above. The white arrow indicates further mural endocarditis. (University of Pennsylvania Medical School Museum.) which event the valves of the right side are those which are the most often affected. From this cause some forms of congenital heart disease arise. Malignant endocarditis presents a picture of roughened valve surfaces which become the seats of fibrin deposits whipped from the blood stream; these 220 HEART AFFECTIONS. deposits become infected and may be dislodged and swept as eiiiboU to other parts of the body (Figs. 60, 61 and 62). Retraction of the leaflets may occur and necrosis, ulceration and perforation of the valves be a part of the necropsy findings (Figs. 63, 64 and 65). It has been observed that two or more valves are in- f ■""SSf** 'N"^, '■J- '^r^^^S^J- aa* ^^ ~ ,5,,' Fig. 60. — Mitral Valve Vegetations. (University of Pennsylvania Medical School Museum.) volved in less than half of the cases of malignant en- docarditis which come to necropsy and that the mural endocardium is invaded by the process in over one- fourth of the cases so studied. The myocardium and pericardium may also be affected^ constituting a pan- carditis. Especially is this true of the streptococcic heart affections of children. ENDOCARDITIS. 221 ETIOLOGY OF ACUTE ENDOCARDITIS. The affection occurs for the most part in child- hood and in adolescence, although it is not confined to early life. Its frequency in youth is explained by the frecjuency of acute rheumatic fever during that period of existence. In a series of 173 cases of acute Fig. 61. — Aortic Valve Vegetations. (University of Pennsylvania Medical School Museum.) rheumatic fever it was found that 53 per cent, of the patients had acute endocarditis. In this connection it is well to recall that the "growing" pains of children are very often a manifestation of rheumatic fever or of absorption from a septic focus. In a series of cases of acute rheumatic fever associated with endocarditis which came to the post-mortem table, it was found 222 HEART AFFECTIONS. tliat the mitral valve alone was affected in 85 per cent, of the cases ; the aortic alone in 3 per cent. ; and that both mitral and aortic valves were involved in the remaining 12 per cent, of autopsies. Tonsillitis is so frequently followed by acute rheu- matic fever or by arthritic involvement that it is per- FiG. 62. — Fibrous Fusion of Valves. The black arrow points to the fibrous fusion of two aortic leaf- lets. The white arrow indicates- sclerotic and calcified vegetations within an aortic cusp. (University of Pennsylvania Medical School Museum.) haps the second most frequent cause of acute endo- carditis. Chorea is very frequently accompanied with or followed by endocardial infection. Of 171 cases of chorea \\'hich came to autopsv endocarditis was found in 90 per cent, of the total number. Pitetimonia was endocarditis: 223 found by Osier to be accompanied by endocarditis in 1 6 per cent, of the cases of pulmonary disease which came to necropsy. Typhoid fever gives an incidence Fig. 63;.^Aoetic Valve Leaflet Distorted by Vegetations. (University of Pennsylvania Medical School Museum, col- lection of Dr. R. S, WillsoH.) of 12 per cent, of endocardial infection; scarlet fever, according to my observations, less than 3 per cent. Erysipelas, osteomyelitis, infected zvounds and puer- peral fever have been,: found to be associated with endocarditis. 224 HEART AFFECTIONS. Focal Infections. — The percentage of endocardial inflammations which arise as a result of focal infec- tions is a difficult one to calculate. It not infrequently happens that no other cause can be found for endo- carditis than a focal infection which, although it may Fig. 64. — Fenestration of Aortic Le.^flets. The black arrow "A" indicates the fenestration. Despite this opening, the valve probably was not insufficient, for the fenestra- tion occurs along the free edge of the valve, beyond the line of closure, as indicated by the arrow "B." Arrow "C" points to an aberrant chorda tendinea. (University of Pennsylvania Medical School Museum.) have been comparatively quiescent for some length of time, becomes active when the powers of resistance of the individual are for some reason reduced; bacterial infection then gains ingress to the circulation and ENDOCARDITIS. 225 affects the lining of the heart. For that reason the physician should institute a thorough search for foci of suppuration which may arise from dental sepsis, infective tonsils, occasionally in chronic forms of ear Fig. GS. — Perforation of an Aortic Leaflet. (University of Pennsylvania Medical School Museum, col- lection of Dr. R. S. Willson.) disease, and less often in gall-bladder infections, peri- renal abscesses, pyelitis, prostatitis and chronic in- flammations of bones or joints. Foci of suppuration which are often overlooked may be found in apical abscesses of the teeth (Fig. 66). The physician should not be satisfied with the 15 226 HEART AFFECTIONS. Statement of the patient that his teeth were recently pronounced to be in a heaUhy condition. A negative report from the dentist should not disarm the sus- picion of a dental cause when the conviction has been once established; only upon the receipt of a negative .r-ray examination, in which the entire denture has been photographed, should abscessed teeth be ruled from consideration. The teeth should not be excluded as possible foci of suppuration simply because there is an absence of pus-pocket shadows on the film. Bliss ^ Fig. 66. — Apical Abscess. The abscess at the apex of the tooth gave no sensations what- ever of pain, elongation or tenderness. It finally ruptured through the skin below the chin, and the discharge of purulent material was believed by the patient to be due to a "wild hair," for he had been assured repeatedly that his teeth were in excellent condition. informs us that at the first examination the Rontgen- ologist may find only some thickening or irregularity of the peridental membrane, but that an exposure made at a later date may show a slightly darker area around the apex of the tooth, indicating that absorp- tion has taken place. Capped teeth are to be regarded with suspicion, whether or not they give sensations of elongation, pain or tenderness. Of tonsillar conditions it may be said that the chronically inflamed tonsil is the one likely to cause 1 Bliss, Gerald D. : Pcnna. Journal of Rontgenology, Jan., 1917, p. 9. ENDOCARDITIS, 227 endocarditis. Whether this be a catarrhal inflam- mation or whether the crypts of the tonsil present caseous patches — follicular tonsillitis — makes little difference; whether the tonsils be= hypertrophied or submerged makes little diiference; if the tonsils are chronically inflamed or frankly diseased they should be removed. A diseased tonsil is always a potential, and sometimes an actual cause of endocarditis, and the mere fact that it is not a normal gland and that it is subject to occasional or to repeated attacks of acute inflammation is sufficient cause for its enuclea- tion. Removal of part of the gland by clipping it — unsympathetically referred to as "massacre of the tonsil" — is worse than useless, in that it creates a false sense of security against future inflammatory processes. A^^hen tonsillectomy is indicated, the indi- cation is for complete enucleation, not a vestige of the gland being permitted to remain. ETIOLOGY OF MALIGNANT ENDOCARDITIS. While it is quite possible for malignant endo- carditis to be caused by the same factors which pro- duce the acute form, yet as a matter of clinical obser- vation, the malignant type has an added etiology quite its own. It arises for the most part in individuals who have had previous inflammation of the heart valves which permanently damaged the leaflets, anteceding by perhaps many years the occurrence of malignant endocarditis. For this reason malignant endocarditis is much more frequent in adults than it is in children, it having been shown that in patients suffering from the disease 65 per cent, are 25 years of age or older. 228 HEART AFFECTIONS. Septic mouth conditions are believed to be factors of no small moment in the production of malignant endocarditis. Dental caries, apical abscesses, pyorrhea or other foul conditions of the mouth very often har- bor the Streptococcus viridans. This is the strepto- coccus which is most frequently found in subacute or chronic malignant endocarditis, and it has been cul- tured post niortein from vegetations which have been found on the heart valves Other staphylococci and streptococci have also been found to be etiologic fac- tors in malignant endocarditis. The essential point to remember is that the condition is usuall}' the result of a bacteremia; the blood infection finds a point of less resistance on valves which have been previously dam- aged, either as a result of inflammation many years gone by, or as a result of recent acute infections; or still again, bacteria may find the endocardium lowered in resistance by long continued septic absorption and hence a vulnerable point for attack. It is unfortunate for the bacteremic point of view that blood cultures are so often sterile in malignant endocarditis. Certainly they seem to be more uni- formly negative in the early period of the disease, at the very time when they could be of the most value in diagnosis and in treatment, than they are later in the condition when the patient is desperately ill. There are some bacteriologists who have a peculiar aptness in finding bacteria in the blood and it is a point of repeated observation that one with this aptitude can find the bacterium when othefs have failed. One such who had the happy faculty of demonstrating the organism with remarkable ease, fold the writer that the blood cultures were more likdy to be positive if ENDOCARDITIS. 229 the blood were taken just before the anticipated ad- vent of a septic chill or immediately following symp- toms suggestive of an embolism having lodged. The statement is given here for what it may be worth; if it aids in one single instance in the early recogni- tion of the organism and thus facilitates the early preparation of an autogenous vaccine, it will have been well worth repeating-. SYMPTOMS OF ACUTE ENDOCARDITIS. The symptoms of acute endocarditis may be over- shadowed by the severity of the primary infection or they may be overshadowed by the pain of a primary arthritis. Fc-rcr is usually present, but it is of no particular type and is difficult to distinguish from the fever that is due to the primary condition. The physician should take pains to routinely examine the heart of a patient who is ill with an acute infection, for attention may thus be early drawn to changes in the heart sounds which take place from visit to visit. These changes may gradually develop into murinurs. Such murmurs are usually at the apex of the heart, although they may be basal ; they are systolic in time ; in quality they are at first soft, but eventually become loud and gross, although during the period of valve roughening they are often of musical quality. The musical note may be observed to recur from time to time, probably due to a vegetation which has formed on a valve and projected itself into the blood stream at an angle sufficient to produce a sound of musical timbre. The murmurs of acute endocarditis are at times evanescent in character and a murmur distinctly audible at one examination may not be heard 230 HEART AFFECTIONS. at all at the next. The pulse often has a rate out of all proportion to the fever and to the discomfort of the patient. This increased pulse rate may continue throughout convalescence from the initial illness. The occurrence of an irregular pulse announces some dis- turbance of the cardiac mechanism which for the most part takes the form of premature contractions or of auricular fibrillation. Dropped beats or higher grades of heart-block may occur, although such blocks are usually of a transitory nature. In this connection it might be well to state the self evident truths that murmurs are qidte invariably the result of endo- cardial conditions. Pulse irregidarities are quite in- variably the result of MYO-cardial conditions. PHYSICAL SIGNS OF ACUTE ENDOCARDITIS. On inspection one may note a degree of respiratory embarrassment in acute endocarditis. It may further be observed that the apex gradually moves toward the left as the days pass. An over-acting heart often exhibits a precordial impulse which is widely dis- tributed over the left chest. To an impulse of such extent the term irradiation is applied- Palpation will confirm the latter observations. The pulse is often rapid and irregular and may show wide variations in rate due to change of posture of the patient. The mere act of turning over in bed may cause an acceleration of perhaps ten beats a minute and the patient seem exhatisted as the result of the trivial physical effort. Percussion is of little value in acute endocarditis. If one has made a careful record of the transverse diameter of the heart on the occasion of one's first ENDOCARDITIS, 231 visit one may, by comparing this record with the ob- servations of subsequent days, detect an increase in the transverse diameter of the lieart. Percussion is also of service in drawing the attention of the ex- aminer to a pericardial effusion which may compli- cate acute endocarditis ; especially is this likely to happen in the streptococcic infections of children. Auscultation. — By auscultation may be frequently noted a gradual change in the character of the heart sounds. The first sound at the apex alters in quality and intensity; it may be "blurred," "muffled" or "prolonged," and from these varying degrees of change eventuate into a murmur, usually located at the apex, always systolic in time. At first the mur- mur is soft and blowing, and the second sound of the heart as heard at the pulmonic area is accented; later on the murmur may take on the rough, loud or occasional musical quality previously mentioned. It is neither the presence of a murmur nor its pitch nor its intonation that forms the suggestive diagnostic feature in acute endocarditis. It is the sequence in the alteration of lieart sounds — the grad- ual evolution of normal sounds into a murmur — that is of diagnostic significance. It should be remembered that systolic murmurs can be variously produced (page 78) and that those found to be present at one visit are absent perhaps at the next. Such murmurs of course do not have the significance attached to them which can be attached to a murmur which gradually evolves and which is the direct result of valve invasion. We have seen under morbid anatomy that the mitral valve is the valve which is affected in 50 per cent, of the cases of acute endocarditis which have 232 HEART AFFECTIONS. come to autopsy. While lesions of the mitral valve may produce either a systolic or a presystolic mur- mur, one should not lose sight of the fact that an apical /re-systolic murmur occurs only in mitral stenosis. Mitral stenosis is the result of long continued valve change, and therefore one would not at all expect to hear a /r^-systolic murmur in acute endocarditis, where the murmur develops in a few days and where the valve damage has not lasted sufficiently long to produce a narrowing of the mitral orifice. Pericardial friction rubs may occur during the progress of acute endocarditis and are of value in shoM'ing that the inflammatory processes are still ac- tively acute. A pericardial friction rub which may have existed before the onset of the acute endocarditis is of course not of the same significance. Sufficient has been said upon the character of the auscultatory findings in acute endocarditis to impress upon the reader the necessity of making frequent and repeated examinations of the hearty at each visit to a patient who is suffering from acute rheumatic fever, from chorea or from the more severe and more highly toxic forms of tonsillar infection. Indeed, heart ex- amination is a routine procedure not to be neglected in any acute infection. DIAGNOSIS OF ACUTE ENDOCARDITIS. The diagnosis is based, first, upon the history of a recent infection, particularly upon the history of acute rheumatic fever, chorea or tonsillar inflammation that has been unusually severe or protracted. Of the physical findings, the most significant is an alteration in the heart sounds, which alteration gradually pro- ENDOCARDITIS. 233 gresses in sequence and eventuates in a systolic mur- mur located at the apex. Cardiac weakness is also progressive in acute endocarditis. The continuance of fever after an arthritis or other acute symptoms have disappeared is a valuable diagnostic point. Further evidence that the process is still active in the body would be the recurrence of joint pains, chorea, ton- sillar inflammations or of the ervthema which is often present in acute rheumatic fever or arthritides. There is sig'nificance, too, in a leukocytosis which persists after the arthritis, tonsillitis or chorea have disap- peared. Emboli are not as frequent in acute endo- carditis as in that malignant form where an acute inflammation is engrafted upon previously established valve damage. SYMPTOMS OF MALIGNANT ENDOCARDITIS. As a rule this gravely serious condition is pre- cipitate in its onset. There are instances in which it may develop slowly as the result Of a low-grade bac- teremia which persists after an acute systemic disease has subsided. Malignant inflammation of the lining membrane may also be merely a part of a general pyemic invasion of many organs. Or it may arise as a result of metastasis from any original septic focus, in which event there may be a "typhoid" form or a "cerebral" form. The condition may sometimes resemble malaria or even a kidney autointoxication. So, the symptoms may be referable to any organ and the clinical picture not at all dominated by symptoms which are clearly referable to the heart. Emholism. — Emboli are to be expected in malig- nant endocarditis. They may be the cause of a renal 234 HEART AFFECTIONS. infarct, and a gross hematuria be the consequence. The spleen is often enlarged and painful as the result of an embolus. There may be fever which is of the septic or pump handle type, delirium, paroxysmal chills followed by sweating, loss of w^eight and cutaneous conditions; but these manifestations, after all may be grouped as but part of the picture which is furnished by septicemia ivitli einbolism. Infective aneurism may also form in various portions of the body. Hemiplegia and aphasia may result from cere- bral embolism as may also insomnia and hallucina- tions. Visceral emboli may cause sudden violent pains, diarrhea and other gastro-intestinal symptoms. The cutaneous manifestations may take the form of erythema, urticaria or subcutaneous nodules. The latter are often called "rheumatic nodules" and Brenneman interprets their presence as nearly always meaning endocarditis. PJiysical Signs. — Cardiac enlargement is more likely to occur in malignant than in acute endocarditis and may be confirmed by percussion. Auscultation reveals the same changes in heart sounds as were mentioned under acute endocarditis ; but multiple mur- murs are more frequent in the mp-lignant form, and to this an aortic murmur may be added. Pericardial friction sounds or pleural friction rubs may arise if either of these structures are coincidentally affected. DIAGNOSIS OF MALIGNANT ENDOCARDITIS. The knowledge of a \'alvular lesion having existed prior to the present acute illness is of importance when considering the possibility of malignant endo- carditis being present. Embolic features, such as ENDOCARDITIS-. 235 sudden swelling of the spleen, sudden hematuria, hemiplegia, coldness or numbness in legs or arms are among the most significant signs. A septic fever which arises during the course of an acute infection which does not usually have such extensive tempera- ture fluctuations is a suspicious circumstance. The occurrence of purpuric and painful cutaneous nodules has much diagnostic importance attached to it by various observers. Progressive cardiac changes, such as an increase in the transverse diameter of the heart, alterations in heart sounds which eventuate in mur- murs or the occurrence of an aortic murmur, are signs of much significance. Blood cultures may re- veal a causative organism which .may also be found in the urine. Malignant endocarditis is sometimes confused with typhoid fever, but the differentiation can be made by the sequence of typhoid fever symptoms and signs at the beginning of the second week of the fever. Widal reactions are of little value in these days of anti- typhoid inoculation, for inoculations negate the test; blood cultures may reveal the typhoid bacillus. Malig- nant endocarditis may at times be confused with malaria but a blood examination for the plasmodium of this latter condition will establish the diiTerential diagnosis. PROGNOSES OF VARIOUS TYPES OF ENDOCARDITIS. Aaitc Endocarditis. — Those patients who suffer from acute endocarditis which has its origin in acute rheumatic fever or chorea usually recover but a de- gree of valve damage often persists. Those cases in 236 HEART AFFECTldNS. which positive blood cultures are eventually found frequently die. If the general nutrition of the patient can be main- tained during the progress of the inflammation and until the infection has spent itself, the patient is likely to recover; but if in spite of all efiforts the general nutrition of the patient becomes more and more de- praved, the outlook is ominous. The appearance of embolic symptoms and of eruptions are very serious signs. It should be remembered that acute endocar- ditis may either terminate in or undergo transition into the malignant form at any time during the progress of the condition. Acute malignant endocarditis usually terminates in death. The duration of the disease is variable but short, the patient rarely surviving over a month or six weeks. The amount of emaciation during the disease is excessive; one patient \tl six weeks dropped from her usual weight of i8o pounds to 90 pounds at the termination of her illness. If recovery from acute malignant endocarditis takes place it is never complete and death may be the happier termination of the disease. Chronic malignant endocarditis, on the other hand, may eventuate in recovery after an illness which is rarely less than four months and may cover a period of a year or more. Here, too, permanent damage to the valves of the heart quite constantly results. TREATMENT OF ENDOCARDITIS. Absolute and complete physical rest is of more vital importance in endocarditis than is any other con- ceivable therapeutic measure. Apsohitc rest is of ENDOCARDITIS. 237 more importance in endocarditis than in any other disease to which the fiesh is heir. The patient with either acute or mahgnant endo- carditis should not be permitted to even turn himself in bed, so necessary is it to conserve every particle of physical effort and cardiac strength. When one re- calls that an affected heart which makes 12 extra beats a minute makes 17,280 cycles a day more than are required in health, one can then appreciate the necessity of sparing the organ even such a demand as would be occasioned by the simple effort of ex- tending the hands. The rise in pulse-rate which so often follows attempted effort on the part of the patient does not usually cease when the effort ceases. The increase in rate will continue for a considerable time afterward. Hence, attempted effort means more exhaustion; more exhaustion means less resistance of diseased cardiac tissue; and lessened resistance of cardiac tissue may mean cardiac failure and death. It is not the part of wisdom for the physician to attempt to impress the patient with the necessity for absolute rest ; to do so may alarm him unnecessarily and cause him an anxiety \\'hich he might well be spared. The knowledge that someone is at hand to carry out his every wish is often sufficient information for the sufferer. Instructions should be given to the nurse or attendant, thus sparing the patient the added burdens of anxiety, alarm or depression. Gentle re- straint is a much better method of controlling the invalid than is the employment of either force or argument. Attention should be directed to combating the underlying cause. Focal infections (page 224), if 238 HEART AFFECTIONS. demonstrated in a patient acutely ill with endocarditis, present a fine question for decision as to what period of the disease their correction can be more safely attempted. Should acute rheumatic fever be the provocative infection, the salicylates should be employed in lo to 30 grain doses at 3 or 4 hour intervals — always suffi- ciently diluted, and, always combined with sodium bi- carbonate. The sodium bicarbonate is added for the purpose of counteracting gastric irritation and in the hope of preventing the possible occurrence of salicy- late-poisoning by thus rendering the urine alkaline. Chorea should be treated by the administration of liquor potassii arson it is (J^^owler'-s solution), begin- ning with 3 minim doses well diluted in water, t.i.d., p.c. The dose is increased one minim at each admin- istration until the physiologic limits of arsenical tol- erance become manifest by slight puffiness under the eyes, looseness of the bowels and griping. When these symptoms occur the drug should be withdrawn for a day or two, and its administration again begun in a daily decrease of dose until a minimum of 5 minims t.i.d. is reached and then increased as before. The hygienic indications of elimination should be met as required. Gentle catharsis; is secured by fluid extract of cascara sagrada in 10 to 30 minim doses, which meets the indication of peristaltic stimulation. The nurse should keep the skin in active condition by tepid baths, followed by witch hazel applications. Diet should be of the form most readily assimilable and be free from any substance which, by provoking indigestion or fermentation, might add one iota to the load of the heart. Heat may be employed to relieve ENDOCARDITIS. 239 the sensory disturbances caused by an embolus ; opiates may be required for pain. Insomnia, which may be the bitterest antagonist of much-desired rest, should be controlled by quiet surroundings, well ventilated room and by the employment of opiates in sufficient dosage to secure the result desired. The question of sufficient dosage will have to be decided in each individual case. There is no way of telling how a given individual will react to opiates. To set an arbitrary limit on the amount of morphine to be used is to have the drug often fail of its purpose. Rest despite pain and rest despite insomnia is an ab- solute essential in endocarditis ; if rest is best secured by morphine, it is better to err in having given a little too much of the hypnotic rather than to have the pa- tient continuously wracked with pain or tossed about by insomnia through having given too little of the drug. Repeated doses are usually not so effective as is sufficient initial dose ; but repeated doses may have to be used until one learns what constitutes sufficient dose for the individual patient. He who hesitates to con- tinue the use of morphine when its continuance is warranted through the fear that a drug habit may be induced, can reassure himself with the fact that the morphine habit is very rarely acquired in several days of legitimate employment of the drug; the habit is engendered through use of morphine over a period of many weeks or months. Vaccine Therapy. — Much has been expected of the use of autogenous vaccines in endocarditis of the more severe types. An autogenous vaccine is one which is derived from a laboratory culture of those particular varieties of germs which are present in a 240 HEART AFFECTIONS. given case, as determined by bacteriologic examina- tion and by cultures from the blood. When used at all vaccines should be used early. To employ them as a last resort in malignant endocarditis is to de- prive the patient of a possible benefit in his battle with this desperate condition. Unfortunately, there may be a delay of several days in securing the autogenous vaccine and during that interval a. "stock" vaccine (one already prepared and marketed) may be em- ployed until the more desirable autogenous vaccine is prepared. As to the efficacy of this form of treatment much doubt exists — a doubt which entitles the pa- tient to the benefit occasionally reported from the em- ployment of vaccine in the more severe types of endocarditis. Digitalis. — It may be necessary to support a heart, which is threatened with failure, by the use of tinc- ture of digitalis in 8 or lo minim doses at 4 or 5 hour intervals. The drug is not to be used as a routine but only to meet the indications of progressive cardiac weakness or threatened circulatory failure. One of the foremost therapeutists of the day aptly refers to digitalis as "a lash to the lagging heart." To apply the lash to a heart which is already putting forth its supreme effort in combating its infection may result in the unloading of the last atom of re- serve force of which that diseased heart is capable. Hence the thoughtless, routine employment of digi- talis may precipitate death. Convalescence. — The duration of the absolute rest period in those patients who have weathered the storms of acute or malignant endocarditis is a matter of much importance. There is no disease of ENDOCARDITIS. 241 the heart which requires a longer convalescent period or a more careful guarding of the patient as he nears the shores of health. The absolute rest period should be continued until long after the fever has subsided and the rhythm of the pulse has become normal ; only then should the patient be permitted to sit up for brief intervals. These intervals may be gradually length- ened as the days pass, provided no unfavorable change in the rate and rhythm of the pulse ensues. 1"his usually means six or eight weeks in bed and another month on the couch before any activity is resumed. Even then, six months or more may elapse before the patient is permitted to busy himself in his former accustomed manner. It may be observed during the convalescent period that the heart has acquired a change in rhythm, such as premature contractions, or auricular fibrillation, which may have set in during the course of the acute disease and from now on be permanently established. If such a permanent irregularity has occurred, it is not an indication for keeping the patient at absolute rest so long as the pulse rate is not markedly altered by postural change or by exercise. Despite the efforts of the physician and despite whatever care he may take in treatment, acute in- flammation of the valves of the heart is quite likely to result in structural alteration of the orifices. The more thoroughly the likelihood of such structural alteration is appreciated the more care will the con- scientious physician exercise in order that he be in no v\ay responsible for the permanent damage that would ensue in consequence of disregarding the ab- solutely essential element in treatment — rest. 16 CHAPTER XVII. Chronic Valvular Disease of the Heart. GENERAL CONSIDERATIONS. Chronic valvular disease of the heart is a term which is applied to permanent structural alteration of the cardiac orifice leaflets. Chronic valvular disease is of clinical significance only in so far as it is an expression of co-existing heart nuiscle involvement. It is heart muscle failure and not a "leaking valve" that gives the classical symptoms of dyspnea, cyanosis, visceral congestions, etc. The part which an affected valve alone might play in weakening cardiac muscle to such an extent, is a part that is certainly overshadowed by the cardiac infection which, in all probability, attacked both muscle and membrane simultaneously, damaging muscle as well as valve. Therefore, to attempt to appraise a heart lesion by auscultatory findings alone, without obtaining infor- mation as to the condition of the heart muscle, is to render oneself liable to grave errors in judgment. History, inspection, palpation, percussion, mensura- tion and rate-response-to-exercise should all be con- sidered in their relation to the auscultatory phenom- ena dwelt upon in this chapter, for only with such complete information before us can we hope to cor- rectly appraise a heart. Only by a careful weighing of the evidence obtained by all of these methods of (242) CHRONIC VALVULAR DISEASE. 243 diagnosis can the physician intelHgently answer the question which is of paramount importance to the patient, namely; "Is this heart condition serious — does it necessitate a complete change in my manner of life?'' ETIOLOGY OF CHRONIC VALVULAR DISEASE. As chronic valvular disease is so often the ulti- mate result of a previous acute endocarditis it is evi- dent that the same causes are productive of both con- ditions, it is also likely that another cause of chronic valvular disease exists, namely, an insufficient rest period following acute affections of the heart. The value of rest in the prevention of chronic disease of the muscle and of the endocardium has been dwelt upon exhaustively in the chapters preceding, but its importance might well be here again emphasized by drawing attention to the fact that an insufficient rest pci'iod following the cardio-circulatory demands of any acute infection is a most likely cause of permanent structural alteration of heart tissnc. There is no particular cause for a particular valve lesion. While it is of course generally recognized that acute rheumatic fever affects, for the greater part, the mitral valve; and that syphilis, for the greater part, invades the aortic region and the aortic valve; yet either one of these infections may involve any valve or every valve of the heart. The broader concept of heart ai¥ections requires one to adopt the view that any infection, acute or chronic — whether it be local, focal or general — may be reflected in dis- turbances of the heart. The heart leaflets may also be damaged as a result of the same sclerotic changes in heart tissue which take place in the walls of the 244 HEART AFFECTIONS. arteries. Chemical poisons, defective elimination or autointoxication, when long continued, may damage the vah-es of the heart. In considering the etiology of acute and malignant endocarditis it was stated that in those conditions the causative bacterial invasion was still active. When acute endocarditis terminates in chronic valvular dis- ease the bacterial invasion has become quiescent; it is no longer active. It is of course possible for an acute infection to be engrafted on an old valvular lesion, but as a usual thing chronic valvular disease when once established is not actively progressive in nature. It may seem to increase in severity as the years go by, and become more and more incapacitating with the passing of time; but these are changes in- duced by the gradual wearing out of cardiac structure or by the eventual exhaustion of damaged muscle which has for years been working under load and strain. MORBID ANATOMY. Chronic valvular disease exhibits many varieties of pathologic change. There may be simple thicken- ing and induration of the valve leaflets or the leaflets may be retracted or curled upon thfemselves; atheroma and calcification may render the valve totallv unfit as a functionating structure. The term "funnel shaped mitral" describes an atheromatous valve which has been drawn down into the cavity of the ventricle by contractions and thickening of the chorda tendineae and musculi papillares, giving the valve the funnel shaped appearance from which it derives its name (Fig. 67). "The button hole mitral" is a term that was employed b}' Corrigan to describe adhesions and CHRONIC VALVULAR DISEASE. 245 atheroma of the mitral valve. Normally, the mitral valve will admit the tips of three fingers ; in the "but- ton hole mitral" the orifice is barely sufficient to per- mit the entrance of a button (Fig. 68). Fig. 67. — The Funnel-shaped Miteal. The mitral valve has been drawn into the cavity of the left ven- tricle. A glass rod passes through the stenosed mitral valve. The black arrow points to thickened and foreshortened tendinous chords, which certainly acted in holding the valve open throughout the cardiac cycle, causing insufficiency as well as stenosis of the orifice during life. (Jefferson Medical College Museum.) VARIETIES OF VALVULAR DISEASE. A valve may fail to close properly; in such a circumstance blood regurgitates through the imper- 246 HEART AFFECTIONS. feet opening when the heart contracts. The valve is instiificient . Or a valve may be shrunken, narrowed and thus obstructed as a result of disease. The word which is used to express narrowirig is stenosis. Any valve may be insufficient or it may be sten- osed, or it may be both. There are many logicians who believe that stenosis cannot be present without insufficiency co-existing. Insufficiency is often fol- lowed by stenosis — a progressive step, as it were, from one condition to another. A variety of valve lesions may exist in the same heart, as shown in the following paragraph. INCIDENCE OF VALVULAR DISEASES. The left side of the heart is more often affected than is the right side. Coitgciiifai valvular defects, however, form an exception to this rule as they are in the great majority of cases right sided. The order of frequency of valve lesions in the left heart is : ( i ) mitral insufficiency; (2) mitral stenosis; (3) aortic insufficiency; (4) aortic stenosis. The relative inci- dence of right sided lesions, whifih are infrequently found and still less frequently diagnosed, are: (l ) tri- cuspid insufficiency; (2) tricuspid' stenosis; (3) pul- monary stenosis; (4) pulmonary insufficiency. It has been estimated that right sided lesions constitute a fraction less than one one-hundredth of the total num- ber of cases. In combined lesions-,, double aortic and mitral insufficiency predominate, with aortic stenosis and mitral stenosis occupying" second place: aortic and mitral insufficiency are third in frequency; while double aortic and double mitral lesions are the least frecjuent of all the combined ^'alvular affections. CHRONIC VALVULAR DISEASE, 247 Fig. 68. — The Buttonhole Mitral, Near the center of the photograph is a depression which in a healthy heart is a valve opening which admits the tips of 3 fingers. The valve here shown is so stenosed that only the small, semilunar slit at the upper part of the depression remains open. (Jefferson Medical College Museum.) 248 HEART AFFECTIONS. Statistics have been gathered tJy Gillespie in refer- ence to the percentage of valve lesions which he found. The mitral valve was affected in 58 per cent, of the cases, the aortic in 21 per cent. Mitral and aortic lesions co-existed in 19 per cent., while pulmonary and tricuspid lesions were found in only 0.8 per cent, of the group. More than % of all valvular lesions in women occur at the mitral orifice. Aortic disease is three times as common in men as in women. Double lesions occur with twice the f recjuency in males. MITRAL INSUFFICIENCY. This is considered a very common valvular lesion and also the least harmful. My records show it to have been the most frequent diagnosis which was made in cases which were referred for murmurs, which murmurs were later found on extended study to be without significance (see page 78). In other words, the diagnosis had been based solely upon a systolic murmur, or upon some other isolated and un- associated sign, rather than upon a definite group of symptoms and signs. It is believed by some physi- cians that mitral insufficiency is diagnosed far more frequently than necropsy findings warrant. Such an opinion' is probably true when one remembers that mitral insufficiency may be of th^ muscular type; it is quite possilgrk for the atrio-ventricular orifice to fail to close oh Account of defective muscular action, and a murmur arise in consequence. There are also febrile conditions which induce transitory alterations in muscular tone; anemia, too, may interfere with cardiac nutrition; under such circumstances a mitral valve may fail to properly close and a murmur be CHRONIC VALVULAR DISEASE. 249 heard. Manifestly, a diagnosis of mitral insufficiency made under such conditions as these will not be re- vealed at necropsy; there is no way of estimating muscle-tone or of estimating the changes due to muscle-anemia at the post-mortem table. But to flatly assert that such a condition as mitral insuffi- ciency cannot exist is to deny the evidence of con- tracted mitral leaflets, inversion of their edges, vegetations, calcareous plates, and shortness and degeneration of the tendinous cords which are so frequently seen at autopsy, and which must have rendered the valve as patulous and as insufficient during life as it was found to be after death. The diagnosis of mitral insufficiency is based on the following group of physical signs: (i) an apical systolic murmur; (2) its transmission to the left axilla or even to the angle of the scapula in the back (this latter region sometimes being called the "mitral area" for the reason that a mitral systolic murmur can there be heard); (3) accentuation of the pul- monic second sound; (4) increase in the transverse diameter of the heart. To these physical signs are to be added in varying degree the symptoms of cyanosis, shortness of breath, edema, limited response to effort, etc. These latter symptoms are not charac- teristic of mitral disease; they are not characteristic of any valvular disease; they are evidence of heart muscle involvement. MITRAL STENOSIS. Mitral stenosis should be carefully studied. It is not a diagnosis which readily lends itself to snap judgment. Necropsies often fail to confirm the diag- 250 HEART AFFECTIONS. nosis of mitral valve narrowing, for the reason that it is frequently confused with the overacting heart of emotional persons or neurasthenic individuals. The diagnosis should be based upon the presence of the following group of physical signs. ( I ) An apical presystolic murmur, sharply local- ized at that point on the chest wall which corresponds to the clinical apex of the particular heart being ex- amined; (2) an apical presystolic thrill; (3) a "snappy" first sound as heard at the apex; (4) an accented pulmonic second sound; (5) an increase in the right diameter of the heart. To these are fre- quently added the following associated physical signs : (A) an enlarged left auricle which is often present in this condition and which may press on the recurrent laryngeal nerve, thus producing a husky voice or a "brassy" cough. (B) Pulmonary congestion may in- duce a bloody sputum which is more often encoun- tered in mitral stenosis than in any other valvular disease. This is the lesion in which the "heart failure cells" which are referred to under myocarditis (page 203) are often found. (C) Jugular pulsations are a very frecjuent part of the clinical picture. (D) Auricular Hbrillation was accompanied by mitral stenosis in 52 per cent, of a group of cases which Lewis studied. Hence the characteristic pulse changes of auricular fibrillation are noted more in this than in any other chronic valvular disease. Here- tofore the name "pulse irregularis perpetuus" was applied to the pulse which older writers found so often in mitral stenosis. This pulse is recognized by the fact that it is continuously, persistently and ab- solutely irregular as to rate, as to rhythm and as to CHRONIC VALVULAR l5lSEASE. 251 volume; and by the further fact that the irregularity in all three of these respects increases when the heart- rate is increased by effort. (See Auricular fibrilla- tion, page 253.) "Clubbing of the finger tips" is a time-worn sign of mitral stenosis, believed to be present when the lesion is of long standing; the sign is mentioned here to accord it the respect which should be paid its age, — not because it is of clinical significance or of diag- nostic value in heart affections. Discussion of Essential Physical Signs in Mitral Stenosis. In order to understand the phenomena of mitral obstruction, it is necessary to apply some of the state- ments which were made under the physiology of the heart. One should first remember that in a heart beating at the rate of 75 contractions a minute, systole occupies 0.5 of a second and diastole occupies 0.3 of a second; in the last o. i of a second of diastole, atiricular contraction occurs. Secondly; the first sound of the heart is produced by ventricular mus- cular action and by the tautening of the mitral and tricuspid valve curtains. The duration of the nmnmir in mitral narrowing is probably dependent upon the degree of the valve damage. Early in the condition the murmur may be very short and be heard only during that period when the auricle is actively contracting, via: at the end of the rest period of the heart. It is in the last o.i of a second of diastole that the auricle contracts. Hence the presystolic murmur in early cases may be only 0.1 of a second in duration. As the narrowing and 252 HEART AFFECTIONS. shrinking of the leaflets progresses to a degree where they exert no restraining influence whatever on the blood which is accumulating in the auricle previous to contraction of that chamber, the murmur may occupy all of the diastolic period — perhaps the full ^0 of a second which diastole occupies in a heart contracting at the rate of 75 beats a minute. Under such a circumstance the crescendo quality of the mur- mur is more apparent, — low and rumbling it may be at first, then increasing in intensity as the inception of auricular contraction forces blood through the nar- rowed orifice with greater impetus than that which was given the fluid by gravity and by the "aspirating" action of the ventricle. Instantly the first sound of the heart occurs : it is likely that the ventricle attempts to overcome the valve defect by increased muscular action; this in turn increases the closure-force of the tricuspid, the fellow-valve of the opposite side; both factors produce the "snappy" first sound. The Effect of Auricular Fibrillation. — The pre- systolic murmur of mitral stenosis undergoes marked alteration in the presence of auricular fibrillation. In this condition the auricle stands in trembling diastole. There is no aurictilar contraction. Hence there is no presystolic murmur. However, an early diastolic murmur due to ventricular filling, may be heard if the heart-rate be deliberate. An apical presystolic nuinnur is essential if one is to make a diagnosis of mitral stenosis It is not the only sign which is necessary for the diagnosis, but it is the prime requisite to which the other signs should be attached. The presystolic murmur should be con- stantly present ; it is louder when the patient lies on his CHRONIC VALVULAR DISEASE. 253 left side, and while it may thus alter in intensity, it should be so definitely present at repeated examina- tions as to cause neither doubt nor vacillation in the mind of the examiner. Moderate exercise may in- tensify the murmur: violent exertion may obscure it completely, for the reason that violent exertion pro- duces increased heart-rate; increase in heart-rate is quite invariably at the expense of and shortens dias- tole; and the shortening- of diastole by a marked increase in rate may blur out the presystolic — really a late diastolic — murmur. A Flint murmur, first described by the elder Flint whose name it bears, may be confused with the mur- mur of mitral stenosis. This murmur, also, is pre- systolic in time and is heard at that point on the chest wall which corresponds to the clinical apex of the heart; it may also be accompanied by a thrill: hence the confusion. The Flint murmur, however, arises only in aortic insiffficiency. It is produced by the anterior cusp of the mitral valve interposing it- self from its usual position along the heart wall dur- ing diastole, into the ventricular blood-stream; thus the leaflet is made to vibrate, first, by the blood which falls back from the imperfect aortic valve; second, by the blood which passes through the orifice during ven- tricular filling. Hence there is a late diastolic (which is of course a /re-systolic) murmur and thrill at the apex. The differential diagnosis is made by searching for the Corrigan pulse, arterial throbbing, increased transverse diameter of the heart and other phenomena of aortic insufficiency. The Presystolic Thrill. — This thrill may not be present in early cases where the murmur is slight; 254 HEART AFFECTIONS. the same factor that produces a murmur produces a thrill, via: — a narrowed orifice. If the opening be only a little narrowed but little thrill ensues. It is very easy to confuse the systolic vibration of an over- acting heart such as is often seen in the cardiac neuroses, with this thrill. TJie Right Transverse Diameter of the Heart. The right border of the heart is formed by the right auricle; the auricle is not usually enlarged to per- cussion in the early stages of mitral stenosis, but later the auricle may attain a size equal to all the other chambers of the heart. In such an event the right border of the heart, as measured in the 4th inter- space, will be much greater than the customary dis- tance of 3 cm. from the midsternal line. One would probably be correct in assuming that marked increase in the right border of the heart in mitral stenosis is a sign that the stenosis is well advanced. Evidence of mitral insuificiency frequently co- exists with mitral stenosis, such evidence being afforded by a distinct, harsh a-nd blowing apical systolic murmur, transmitted to fhe left. To be of significance this systolic murmur should be attended with increase in the left transverse diameter of the heart. AORTIC INSUFFICIENCY. The astute Irish physician Dominic Corrigan, (1802-1880) writing in 1832, first described this con- dition in a masterly manner which has caused it to be since referred to as "Corrigan's disease." He spoke of it as "a permanent patency of the mouth of the aorta." Chronic valvular disease. 255 This is that form of valvular disease so often found at necropsy in cases of sudden death occurring in those who are active and apparently robust. The incidence of syphilis in cases of aortic insufficiency Fig. 69. — Fusion of Aortic Leaflets. (University of Pennsylvania Medical School Museum, col- lection of Dr. R. S. Wilhon.) has caused many writers to classify this valvular dis- ease under the caption of cardiovascular syphilis. The frequency with which syphilis invades the aorta was shown in the statistics of Warthin of Ann Arbor, 256 HEART AFFECTIONS. who was able to demonstrate the Spirocheta pallida in the aorta of virtually 80 per cent, of successive and unselected autopsies. This is proof sufficient that syphilis may be a large factor iii producing inflam- mation of the aorta and of the contiguous aortic valves, but to assume that syphilis is the only etiologic factor in the production of aortic valve involvement is to deny a mass of clinical evidence which shows that there are many non-venereal factors which enter into its production. A lesion of the aortic valve may be a heritage from endocarditis which has been produced by any bacterial invasion. The valve may also be insufficient because it is congenitally malformed. It may be sclerosed — and be the only valve thus affected — by the processes which produce atheroma of the arteries in arteriosclerosis. Lesions of the aortic valve are not as a general thing the result of an active, fulminating infection. They are more the result of a change which is of slow development (Fig. 69), such as would be brought about by a long continued systemic infection or by atheromatous changes in and about the valve, as in cardiosclerosis. Physical Signs: Inspection. — The appearance of the patient with aortic insufficiency is usually striking. Arterial throbbing which is systolic in time may be seen in the temporal arteries or in- the vessels of the neck. The head may nod with each pulsation of the heart. The precordial impulse is diffuse and forceful. The heart, even upon inspection, is manifestly en- larged downward and obliquely toward the left. De- spite the fact that the precordial impulse is often CHRONIC VALVULAR DISEASE. 257 diffuse one may at times be able to locate two impulses at the apex of the heart. This is due to the fact that the "clinical" apical impulse is caused by contraction of the right ventricle; the "anatomical" apex of the heart is at the tip of the left ventricle: In enlargement of the left ventricle that chamber may be so distended that the anatomical apex comes in contact with the chest wall and presents the second impulse. Quincke described a capillary pulse in aortic in- sufificiency which can be elicited by making gentle pressure on the end of the patient's finger nail, or it may be better seen if a microscope slide or other con- venient piece of glass be placed upon the lips. The color deepens with each pulsation of the heart and fades between beats. The phenomenon is of little value as a diagnostic point in aortic insufficiency, for it is seen as well in exophthalmic goiter, in occasional forms of anemia, in neurasthenia and in other condi- tions of vasomotor instability. Dermographia, a con- dition in which designs can be traced with a blunt instrument or with the finger nail upon the flesh of the patient, and the design promptly be outlined in red and raised upon the surface of the skin, is fre- Cjuently present in aortic insufficiency. Dermogra- phia, however, is of no diagnostic importance. Aortic insufficiency is more frequently accom- panied by a pallor which is suggestive of anemia than is an)'' other valve lesion. This valve lesion also frequently co-exists with angina pectoris, probably because syphilis, an infection which is a frequent cause of the one condition quite as frequently causes the other. Syphilitic invasion is also a very probable explanation for the pallor which accompanies many 17 258 HEART AFFECTIONS. cases of aortic insufficiency: this would indeed seem to be the logical explanation of the pallor when one recalls cases of aortic insufficiency in children, where there is no evidence whatever of syphilis, and in whom there is usually a florid face and a heightened natural color. Palpation. — By palpation one may confirm the heavy tumultuous impulse and note the presence of systolic shock at the precordium. There is an in- crease in the transverse diameter of the heart, an in- crease which may be so marked as to suggest a collo- quial term by which aortic insufficiency is known, namel}^ "ox heart." The pulse is perhaps the most characteristic and most constant phenomenon of aortic insufficiency. It is a jerky pulse of full expansion; the waves rise suddenly and with extraordinary force, then instantly collapse, the artery seeming to be quite empty of blood between beats. Various names have been used to describe this pulse. It is the "pulsus cclcrrimus" of the older writers; it is the "\\-qter hammer pulse" of more recent authors, it is the "pistol shot pulse" of others, and it also bears the name of Corrigan, the one who first descril^ed it. The collapsing character of the pulsus celerrimus is intenjSified if the radial artery be felt when the wrist is held over the patient's head. Its characteristics may be masked by arterio- sclerosis. Percussion. — Percussion will 'confirm the down- ward and outward increase in the left border of the heart. It may when practised in the second interspace to the right and td the left of the sternum, show an increase over the usual distance of 5^ cm. which CHRONIC VALVULAR DISEASE. 259 demarks the usual extent of dullness of the aortic arch in men, and thus indicate dilatation of the trans- verse arch of the aorta — which is frequently asso- ciated with aortic valve lesions. Auscultation. — There is a basal diastolic murmur which is faint, prolonged, blowing and which has a diminuendo characteristic. The diminuendo of the murmur is in contrast to the crescendo of the bruit of mitral stenosis, in which latter condition the sound increases in intensity from its beginning; but the diastolic niurnmr of aortic insufficiency decreases in intensity from its beginning. The murmur is best heard with the patient in the sitting posture, the body bent a trifle for\\'ard. Classically, the murmur should be heard at the aortic pimctum maximum — in the 2d interspace to the right of the sternum — but as a matter of clinical fact, it is indeed oftener heard at the pulmonic area in the 2d interspace to the left of the sternum; even lower, in the 3d and 4th inter- spaces to the left of the sternum, it may attain its greatest intensity. When this murmur is listened for with the stethoscope it often escapes detection; its faint and high pitched note can be best appreciated when the ear is laid directly upon the chest. It begins just after the second sound of the heart at the aortic area and may muffle, prolong, or even replace the second aortic sound. The first heart sound at the base is often obscured by a systolic bruit which may be caused by ( i ) roughened aorta leaflets, (2) by atheroma, (3) by dilatation of the aorta, or (4) by stenosis of the aortic orifice. Thus we have two murmurs, — the "to and fro" basal murmur of double aortic lesions — which is 260 HEART AFFECTIONS. by no means always produced, by the co-existence of aortic insufficiency and aortic stenosis. The Flint murmur (see page 253) is frequently audible at the apex. Its presence was noted in 57 per cent, of my records of aortic insufficiency. Arterial Sounds: The "Pistol-shot Femoral." — The normal femoral artery is deVoid of sound. In aortic insufficiency, auscultation over the femoral artery may reveal the presence of sound therein, to which phenomenon the term "pistol-shot femoral" has been applied. The term is a poorly chosen one— it suggests a volume of noise and it suggests the ele- ment of surprise, neither of which is marked except in advanced cases. The sound varies in intensity — it more often resembles the click of a misfire, rather than a shot from a pistol. Diiroziez described a sound which may be present in aortic insufficiency. It is evoked by making slight pressure over an artery with the bell of a stethoscope. While heavy pressure may narrow the lumen of any artery and thus cause the production of sound, the phenomenon to which Duroziez drew attention is the second murmur, which occurs dufing collapse of the artery. It is this second murmur then, which is due to arterial collapse, and not the first murmur which occurs during filling of the vessels, which is essential to the establishment of Duroziez's sound. The phen- omenon is not at all a constant one and is more fre- quently absent than present. Blood-Pressure Estimates. — Blood-pressure esti- mates should be made in every suspected instance of aortic insufficiency. They may yield two important bits of testimony. The first point is one to which CHRONIC VALVULAR DISEASE. 261 Leonard Hill drew attention and is evolved by apply- ing the cuff of the blood-pressure apparatus to the leg of the recumbent patient. It is found by this man- euver that the systolic pressure in the femoral artery may be 30 or 60 millimeters higher than it is in the brachial; indeed it may transcend these figures to a surprising degree. It is essential that the patient be in the recumbent position if Hill's sign is to be of any value; a difference between the brachial and femoral pressure naturally exists in a healthy person should the cuff be applied to the leg when he is standing or sitting. The second obser^-ation which may be made during blood-pressure estimates is noted on auscultation of the brachial artery below the compression cuff. This maneuver shows in many instances, but not in all, that the loud systolic rap does not disappear at the usual and expected point; the sound persists as the needle approaches zero on the dial. Both Hill's sound and the one just mentioned are more frequently present than absent. As to the systolic pressure in aortic insufficiency; while it is usually elevated, it may quite as often show no degree of elevation over what would be expected for the age of the patient. The pulse pressure, how- ever, is Cjuite constantly high. Diagnosis. — The group of five cardial points upon which the diagnosis of aortic insufficiency should be based are : ( i ) A basal diastolic murmur, best heard when the patient is sitting and bending a trifle for- ward; (2) an increase to the left of the transverse diameter of the heart; (3) a characteristic jerky pulse of full expansion which is followed by a sudden col- 262 HEART AFFECTIONS. lapse; (4) the presence of arterial sounds; (5) arterial throbbing. "Heart Disease Delirium." — This term has been applied to the mental symptoms which frecjuently are found in persons who are suffering' from aortic lesions. The symptoms consist of insomnia, melancholia, suicidal mania and delirium. Manifestly their oc- currence is simply a coincidence and they are in no wise a result of any lesion of the aortic valve. It is highly probable that if syphilis be the responsible factor for an aortic lesion, it can also be the responsible factor for changes in the mental condition and in the nerve stability of the same patient. AORTIC STENOSIS. Aortic stenosis is the rarest uncomplicated valve lesion of the left heart. In 250 necropsies at the Massachusetts General Hospital there was not one of uncomplicated aortic stenosis. It nearly always co- exists with insufficiency of the aortic valve. It is a process of slow development and the leaflets do not present the changes which one sees in tissue as a result of frank inflammation. Aortic stenosis is more often seen in those of advanced years, although there are rare instances where it may be congenital. Inspection and palpation reveal a forcible impulse which is produced by the enlarged heart. This im- pulse which is a slow, deliberate push, is charac- teristic of aortic stenosis. Palpation of the pulse confirms the deliberate ventricular action ; the pulse in narrowing of the aortic valve is small and late and has a sustained plateau — in contradistinction to the quickly collapsing pulse of aortic insufficiency. To CHRONIC VALVULAR DISEASE. 263 this pulse the name pulsus parvis cf tardus is given by the older writers. Percussion shows an increase in the left trans- verse diameter of the heart. The increase is not so pronounced as is that of aortic insufficiency. Auscul- tation reveals a basal systolic murmur at the aortic area which is conducted into the carotids. The mur- mur is usually harsh and loud but in exceptional in- stances may be soft and musicaL While it is gen- erally best heard at the aortic punctum maximum, there are instances in which it may be heard at the left border of the vertebral column at about the level of the fourth dorsal vertebra. This is the point at which the aorta first comes close to the spine. A basal systolic thrill rougher than that which occurs in mitral stenosis is present and is conducted to the vessels of the neck. The second sound of the heart as heard at the aortic area is weakened. The reason for this is clear when one recalls that the second sound of the heart is produced by the closing of the aortic and pulmonary valves ; if the aortic valve be stenosed, manifestly it cannot close, and that part of the second sound which is due to the normal action of this valve is absent ; hence the second sound is feeble. Diagjwsis. — Basal systolic murmurs frequently occur and may be caused by inttmal roughening of the aorta or by change in the caliber of the vessels, no matter whether that change be produced by dila- tation of the aorta, by atheroma, by narrowing of the lumen or by any other factor which would alter its caliber. Hence a basal systolic murmur at the aortic area, if one is to interpret it as a sign of aortic sten- osis, must have as its accompaniment a basal systolic 264 HEART AFFECTIONS. thrill, weakening of the second sound of the heart at the aortic area, and the slow, deliberate well sustained pulse which is characteristic of the valvular lesion under discussion. TRICUSPID INSUFFICIENCY. As with all valvular diseases *of the right heart, tricuspid insufficiency is of rare occurrence and yet it is of greater comparative frequency than is insuffi- ciency of the pulmonary valves. This observation ap- phes only to the tricuspid insufficiency of structural change for insufficiency may also be due to a muscu- lar cause which occurs when the right ventricle is relaxed or enlarged. Muscular insufficiency of this valve is of frequent occurrence, being found in acute conditions of the lung which obstruct the lesser cir- culation, or associated with such chronic pulmonary diseases as emphysema or fibroid phthisis. When pulmonary conditions throw a load on the right ven- tricle the caliber of that chamber increases, and the valve leaflets stretch in response to the muscular pull. This is the traditional "safety valve regurgitation" of the tricuspid valve. The muscular "safety valve" type of tricuspid in- competency may afford no physical signs, usually none other than a soft systolic blow. Structural lesions of this vah'e, on the other hand, may produce marked symptoms. There is often edema, first of the feet, then of the ankles, and then ascites ; there is disten- sion of the jugular vein; by pressing a length of this vein between the fingers one will notice, upon releas- ing the lower finger, that the vein fills from helozv. Both this sign and visible pulsation of the jugular CHRONIC VALVULAR DISEASE. 265 may be more noticeable on the right than on the left side. There is cyanosis, pulmonary distress, dyspnea and cough. Physical Signs. — There is usually pulsation at the lower end of the sternum. The apical impulse is not displaced. A thrill is more often absent than present. The transverse diameter of the heart is sometimes increased to the right. The liver may be definitely pulsating; hepatic pulsation should not be confused with the impact which an enlarged heart might con- vey to the liver, nor should it be confused with ab- dominal movements. The edge of the liver may ex- tend considerably below the level of the ribs. Auscultation. — There is a soft, blowing systolic murmur best heard at the tricuspid area or at the xiphoid cartilage, which takes the place of the first sound of the heart at these areas. The murmur is conducted in the direction of the apex of the heart. The pulmonic second sound is faint. TRICUSPID STENOSIS. The rarity of tricuspid stenosis may be shown by the statistics of Herrick who was able to collect only 154 cases from the medical literature of the world. Of these 154 cases 90 per cent, were combined with mitral stenosis and only 12 times did tricuspid stenosis exist alone. Tricuspid stenosis may be masked by the co-exist- ing mitral lesion. Indeed it almost invariably exists in conjunction with a lesion of the mitral valve. Broadbent believes that tricuspid stenosis may be as- sumed when mitral stenosis, contrary to its usual rule, develops pronounced anasarca. 266 HEART AFFECTIONS. The physical signs consist of cyanosis, turgescent veins of the skin and dropsy. There is a short, rough, presystoHc murmur at the xiphoid cartilage; the mur- mur is not transmitted and increases in intensity from its beginning. A rough presystolic thrill is present. PULMONARY STENOSIS. This condition is usually congenital. Of a group of cases which were studied, 96 per; cent, were believed to have been the result of endoca'rditis during intra- uterine life. When the condition is acc[uired during adult life there is present a basal systolic murmur, which is loud and harsh and which replaces the first sound at the pulmonic area. This" murmur is trans- mitted to the left clavicle but not into the vessels of the neck. The pulmonic second sound is feeble. There may be increase in the right transverse diamr eter of the heart. In the congenital type the same physical signs are present in a modified degree, and in addition there is more cyanosis, more urgent dyspnea and more marked venous turgescence than in the acquired type. A basal systolic thrill is present. Simulating Sounds. Systolic murmurs at the base of the heart, partic- ularly to the left of the sternum, may be caused by several conditions with which we are familiar, and they may owe their origin to other circumstances with which we are not yet acquainted; their presence gives rise to erroneous diagnoses of pulmonarv stenosis, unless one demands associated physical signs of the systolic murmur. CHRONIC VALVULAR DISEASE. 267 Balfour has called this area the "region of cardiac romance." Here may be heard cardiorespiratory murmurs, or the "hemic" murmur which accompanies anemia, or murmurs due to atheroma or to aneurism of the arch. In this situation may also be heard a murmur which may be produced when the edge of the left lung is retracted, thus permitting the conus arter- iosus of the right ventricle to come in contact with the chest wall. Under such circumstances a murmur may arise due to pressure of the chest wall on this part of the right ventricle ; and it may at times be intensified when pressure is made with the stethoscope, the pa- tient being" in the erect position. PULMONARY INSUFFICIENCY. As a structural defect this is the rarest of un- complicated valvular lesions. It is the result of acute endocarditis which is secondary to acute infections. Congenital instances of the lesion are found at necropsy to be due to the fusion of two valve leaflets. Cough, dyspnea and cyanosis are the logical se- quence of pulmonary valve leakage. A soft thrill, diastolic in time, may be felt at the base of the heart. The right transverse cardiac diameter is traditionally increased. A basal diastolic murmur, soft and blow- ing in character, replaces or follows the second sound of the heart at the pulmonic area. The second pul- monic sound is feeble or absent. Basal diastolic murmurs of aortic valve origin need cause little confusion when it is remembered that those due to aortic insufficiency are accompanied by the other confirmatory signs so diagnostic of Corri- gan's disease. 268 HEART AFFECTIONS. CONCLUSIONS. In the final analysis, to definitely name the valve affected and to definitely time the particular abnormal sound which occurs within the heart is simply to tie a diagnostic tag to the auscultatory phenomena inci- dent to a heart lesion. It is of far more practical clinical importance to know to zvhat degree the heart muscle has been involved in the process zvhich dis^ eased the valve. Murmurs do not tell us this. This information we obtain from the history, from the response of the heart to exercise, from changes in its rate upon moderate exertion, and from such physical signs as cardiac enlargement, pulse irregularities, etc. History, inspection, palpation, percussion, mensura- tion and rate-response to exercise, point far more definitely than do the revelations of a stethoscope, to the ultimate purpose of clinical cardiac diagnosis vis: intelligent, corrective, constructiz^'e treatment. TREATMENT OF CHRONIC VALVULAR LESIONS. There is no direct treatment for chronic valvular lesions. The disabling symptoms which arise in val- vular disease of the heart are the result of myocardial insufficiency and not the result of tocal pathology in a valve. Valve lesions may improve to some degree as the condition of the heart muscle improves under treatment. Therefore the treatment of valvular dis- ease is the same treatment as that for chronic myo- cardial change (Chapter X\"). The treatment of chronic valvular disease which was once in vogue and which was known as the method of Oertel, consisted CHRONIC VALVULAR DISEASE. 269 in a series of graded exercises which increased the nutrition and muscular tone of the heart by judi- ciously combining periods of rest with frequent short excursions in hill climbing. The method is the equivalent of that suggested in Chapter XXIII under the caption of graded exercises. CHAPTER XVIII. Congenital Heart Affections. Congenital heart affections are of interest more from a pathologic than from a chnical standpoint, for the greater number of infants who are born with frank evidences of circulatory defects rarely survive. Evidence of congenital heart affections is rare in adult life. VARIETIES. Developmentalmalformations may be due to: (t) openings in the interauricular or (2) interventricular septum; (3) to a patent ductus arteriosus; (4) to mal- formations of the valves or deformities of the valve orifice. There may be (5) congenital mal- position of the heart, such as dextrocardia. And there may exist (6) congenital valyular disease. (i) Defects of the Interauricular Septum. — The foramen ovale may persist as an opening in the inter- auricular septum, or may continue into adult life only partially closed (Fig. 70). The foramen ovale is essential to the circulation of the fetus and is believed to completely close at birth. AA'hen it remains per- sistently open the phenomenon of "blue babies" is seen, probably due to admixture of venous with arter- ial blood in the greater circulation. There are those who contend that the cyanosis is produced by con- gestion incident to the al^normal 'opening, albeit evi- dence ()f congestion other than cyanosis is usually lacking. (270) CONGENITAL HEART AFFECTIONS. 271 Semi-patulous foramen ovale is more frequent in adults than is generally believed. Post-mortem studies which W. F. R. Phillips, i of Charleston, has conducted in this direction are of such interest that no better presentation of the subject can be made than Fig. 70. — Patulous Foramen Ovale. (University of Pennsylvania Medical School Museum, col- lection of Dr. R. S. WilUoii.) to abstract a monograph^ by Phillips, as is done in the following paragraphs. The fact that such patulency was frequent has been remarked by anatomists and by pathologists 1 Professor of Anatomy, Medical College of the State of South Carolina. 2 Phillips : "Patent Foramen Ovale and its Relation to Certain Car- diac Murmurs;" Medical Record, Sept. 7, 1918. 272 HEART AFFECTIONS. from time to time with more or less emphasis; it has been commented on also by clinicians, but with less frequency and decidedly less emphasis than the prevalence of the condition deserves, at least such is the impression given by an examination of some of the current text and reference works. The series of hearts here reported ( by Phillips ) shows a ratio of persistency as against complete closure of the foramen ovale of i8 to 5, or 78 per cent, persistency to 22 per cent, closure. This is a ratio greater than any other so far within my knowledge. There ap- pears to be wide variability in the observed frequency of unclosed foramen OAale in adult life. Quoting but a few among the relatively recent writers referring to the subject: Cunningham^ gives the ratio of patency to closure as about i to 5, that is about 20 per cent. ; Parsons and Keith- as over 26 per cent., as determined from a collective investigation of 399 hearts; according to AA'elch and Rolleston,-^' Firket reported the foramen vmclosed in 34 per cent, of his cases ; Kolb and AA^allman found' the foramen per- sisting in no less than 44 per cent.- In length the passageways which Phillips ob- served varied from oblic|ue slits to channels of some length, several being about three-quarters of an inch from orifice to orifice. Some of the long channels showed ciils-de-sac extending from them. The caliber of the communicating openings varied from pin-hole to pencil-size or larger in diameter, one being large enough to admit the passage of the tip of the little 1 Cunningham's Text-book of Anatomy, 4th ed., 1913, p. 875. - Parsons and Keith : Jour. Anat. and Phys,, London, 1897-8, p. 164. 3 Welch and RoUeston : Allbutt and RoJleston's System of Medi- cine, vol. vi, p. 7o2. CONGENITAL HEART AFFECTIONS. 273 finger. The shape of the openings on the right was equally as variable as the locations; some were mere slits with slightly rounded margins, others dimple- like to funnel-like depressions, and others of irregular shapes. The frequency of the occurrence of these openings through the fossa ovalis in adults of all ages and their almost invariable valvular nature, indicates that they are not inconsistent with perfect cardiac function, and that so far as constituting a pathologic condition they are virtually, as Humphry designates them, "without clinical significance." However, as factors that may and do cause unquestionably now and then signs that may be mistaken for those of pathologic changes in the heart, they are worthy of consideration. They invest the significance of cardiac murmurs and their accurate determination and discrimination with a great degree of importance and responsibility. In the light of the probability of openings of the kind herein described, cardiac murmurs, especially systolic ones, unaccompanied by other corroborative evidence of functional impairment, become less indicative of real cardiac incapacity. How many healthy hearts have been doomed because of murmurs caused by open foramen ovales no one can say; one may guess. Apart, however, from any relation to cardiac mur- murs, the frequency of openings in the fossa ovalis has a clinical importance not lightly to be passed by, because these openings are potential avenues for the passage of emboli from the venous circulation directly into the arterial circulation, the "paradoxical em- bolism" of Zahn."i 1 Phillips : Loc. cit. 18 2^4 HEART AFFECTIONS. (2) Perforate Interventricular Septum. — At no time in life is it natural for an opening to exist in this structure. It is a pure developmental malfor- mation. It produces an intense cyanosis and the "bruit de Roger," which is a loud, harsh systolic murmur at the xiphoid cartilage, beginning early in systole and lasting through diastole. It is as amazing a sound as can come through a stethoscope, and is well compared with the grinding, scraping noise produced by drawing a knife over a whetstone. One instinc- tively feels that such a sound cannot originate at a valve; it must come from sonie unnatural com- munication between the chambers of the heart. (3) Persistent Ductus Arteriosus (The ductus Botalli). — In the fetal circulation the ductus arterio- sus is a communication between the left branch of the pulmonary artery and the aorta., It enables blood from the upper portion of the fetus to reach the pla- centa by way of the aorta. This vessel should close completely a few days after birth ; it then becomes the ligamentum arteriosum. However, if the pulmonary artery be stenosed or if the aortic opening be nar- rowed, the ductus arteriosus may persist, thus be- coming a congenital malformation. Under these cir- cumstances it produces a loud and harsh basal systolic murmur which lasts into diastole. It is best heard at the second interspace. It has a diminuendo charac- teristic. This murmur may also be heard over the scapula. A long, rough thrill may be felt over the base of the heart. (4) J^alvc Defects. — The heart valves are subject to a variety of structural changes. There may be more leaflets in a valve than is normal, or there may be CONGENITAL HEART AFFECTIONS. 275 Fig. 71. — Imperfect Aortic Valve. Two leaflets of the aortic valve, instead of the customary three are not incompatible with longevity and are detected only at necropsy. One of the valves here shown is the seat of a healed ulcerative defect. (University of Pennsylvania Medical School Museum, collection of Dr. K. S. IVillsoii.) 276 HEART AFFECTIONS. less (Fig. 71). The valve leaflets may be perforated. Occasionally there may be no attempt whatever made at the formation of leaflets, and the valve be a mere diaphragm which stretches over the natural open- ing of the heart. Congenital valve defects may also assmne the shape of a funnel. Defective or malformed valves are the easy prey of endocardial inflammations. (5) Dextrocardia. — Dextrocardia means complete transposition of the heart from the left to the right side of the chest. It is usually associated with a transposition of the abdominal viscera and is usually discovered accidentally, although attention may be drawn to it by cardiac symptoms which arise when general visceral transposition is not complete, as when the heart is on the right side and subject to pressure- symptoms from the liver below. Dextrocardia may not be complete ; the heart may be in neither right nor left chest, but occupy a medial position. Under such circumstances a distinction must be made between transposition and malposition, for the heart may be misplaced to the right as the result of a left sided pleural effusion which pushes it into an unnatural situation (see Figs. 11, 12 and 13) ; or a fibroid right lung may, in its shrinking, so retract the mediastinum that the heart is pulled toward the right. (6) Congenital Valvular Disease. — Congenital valvular disease is confined, for the most part, to the right side of the heart. Of the lesions which may occur on the right side, 69 per cent, of them are caused by pulmonary stenosis. It is the result of endocarditis during uterine life. Cyanosis is the most striking and the most common evidence of congenital CONGENITAL HEART AFFECTIONS. 277 pulmonary stenosis. The physical signs in the con- genital form are the same as those which arise dur- ing extra-uterine life. There is a harsh, basal sys- tolic murmur which is transmitted to the clavicle; there is a thrill at the base of the heart ; the pulmonic second sound is weak; and there is an increase in the right transverse diameter of the heart. Congenital pulmonary stenosis is usually combined with an opening in the ventricular septum; hence the diagnosis of this valvular disease is not always pos- sible, for multiple signs due to developmental defects may overshadow or confuse the picture. CONCLUSION. The six abnormalities briefly discussed herein by no means constitute the full extent of malformations that may occur in the heart ; absence of the pulmonary artery or an extra pulmonary artery or even absence of one or the other of the heart chambers are ex- amples of the infinite variety of developmental de- fects which are found post-mortem. The six varieties enumerated, however, constitute the more frequent defects — comparatively speaking — which live long enough to present problems in physical diagnosis. Even though one establish such a diagnosis to one's satisfaction, there yet remains the problem of treating a patient who has a congenital heart affec- tion — a problem upon which but little light is thrown in medical literature and one that is sooner or later solved by the termination of life. A few persons so afflicted may live through years of a comfortable adult existence — but they live, it seems, regardless of treat- ment rather than as a result of it. CHAPTER XIX. Arteriosclerosis. DEFINITION AND TERMS. Arteriosclerosis is a progressive degenerative change in an artery which results in a loss of elas- ticity and in a thickening of the vessel wall, with resultant disordered function of the structures nour- ished by the affected vessel. While all three coats of the vessel are involved more or less in the process, the media is that coat which is believed to be the first involved. Those parts of the body with the smallest blood supply show the earliest effect of sclerosis, as is seen in the frequency of early retinal changes. Atheromatous plaques is a term applied to the sclerosed patches which are found at necropsy in the aorta and in the other large vessels. Endarteritis obliterans defines an obliteration, more or less com- plete, which occurs in smaller arteries and arterioles. The process involves as a usual thing only a short length of vessel, but inasmuch as it narrows the lumen or blocks the vessel completely, it is of clinical importance. The condition is not always pathologic, for it is the process which occurs in the umbilical vessels after they have ceased functioning ; it also oc- curs in the terminal portion of remaining vessels after a part has been amputated. Endarteritis obliterans is not an infrequent occurrence during the course of (278) ARTERIOSCLEROSIS. 279 acute infections. Capillary fibrosis is a term applied to such smaller arterial changes as produce the dry and wrinkled skin, the loss of hair, the arcits senilis, the disturbances of sensation and of touch, which are seen in persons of advancing- years. CIRCULATORY EFFECTS. Before considering the effects on the circulation which are brought about by scler'gtic changes in the arteries, it is well to pause long enough to recall to mind the varieties of tissue which constitute the three arterial coats. The advent it ia, or outer coat of an artery, consists of connective tissue in which elastic fibers predominate. The adventitia is thicker in ex- posed arteries, such as the brachial; it is of com- paratively little thickness in arteries which are in a protected situation, as is the abdominal aorta. In the media or middle coat there is also elastic tissue, bat here transverse muscle fibers occur in greatest abun- dance. It is in the media that the vasa vasorum are distributed — these being the small nutrient vessels in the walls of the larger supply vessels. The smaller vessels are believed to receive their nourishment from the blood circulating within them, as the vasa vasorum are not to be found in the media of the smaller vessels. The intinia or internal coat consists of endothelial cells surrounded by longitudinal elastic fibers and connective tissue. The distribution of elastic tissue and of muscle fibers further varies with the ( i ) loca- tion and with the (2) mechanical function of an ar- ter}^ For example, the media of the renal arteries contains more muscle fiber than does the carotid, even though the vessels are of approximately the same size. 280 HEART AFFECTIONS. Arteries are classed as distributing and peripheral ves- sels. The larger distributing vessels which have the greater mechanical function to perform, are known as "mains,"' z'i^: the aorta, carotid,- brachial, femoral, etc., they are also known as the xeini-elastic arteries for in them elastic fibers predominate. The per- ipheral arteries are known as "supply" vessels; in them and in the arterioles, muscle fibers predominate. The circulatory phenomena arising in sclerosis of either the distributing or the supply vessels are de- fined by Wiggers^ as follows: The more nearly the semi-elastic vessels approach the colidition of inelastic tubes the more rapidly the pulse is propagated to the periphery. As a consequence of the reduced disten- sibility, the quantity of ejected blood cannot be accom- modated in the aorta and, hencc', a larger onward displacement occurs during systole. During the sub- sequent diastole, howexer, less elastic or potential energy is available to mox-e the blood onward, hence the flow and pressure both diminish rapidlv. The result is a tendency toward an intermittent flow at the periphery and a rapid drop of the pulse w ave in diastole. We may now inquire what effect peripheral scler- osis has on the arterial circulation. Inasmuch as the endarteritis causes a reduction in the lumen of the peripheral arterioles, and resembles an increase in peripheral resistance, the decreased peripheral flow from the arteries to the capillaries causes an accumu- lation of blood in the arterial circuit and so elevates both systolic and diastolic pressures. I Wiggers, Carl J. : "Circulation in Health and Disease,'' Lea and Febiger, Philadelphia, 1915. ARTERIOSCLEROSIS. 281 The dynamic effect of sclerosis limited to the large distributing arteries and to the terminal arteries and arterioles is summarized in the following tabu- lation:^ Sclerosis of Distributing Vessels. Sclerosis of Peripheral Vessels. Systolic pressure .... Diastolic pressure . . . Increased. Unaltered or de- Increased. creased. Increased. Pulse pressure Increased. Decreased. Pulse amplitude Pulse shape Blood flow from ar- Decreased, unaltered, or increased. More rapid descent. Increased. More gradual ascent and descent. teries to capillaries Increased in systole. Decreased in diastole. Decreased in systole. Decreased in diastole. ETIOLOGY. Arteriosclerosis, it may be generally stated, oc- curs in persons of advancing years. Many of the earlier manifestations of the condition are seen as the meridian of life is approached, often in persons whose history of previous diseases is negative and whose lives have been clean and well ordered, Ad- vancing years so often manifest themselves in arterial change, and arterial change so often accompanies ad- vancing years, that there has arisen as a consequence of this general observation, the trite truism "A man is as old as his arteries." The condition, however, is not at all confined to advancing years, and may frequently be observed in young adults. Males are more often affected than are females, due perhaps to the more rigorous and more exposed life of men. Occupation has a bearing on the develop- 1 Wiggers : Loc. cit. 282 HEART AFFECTIONS. ment of the condition, for its greater manifestations are in persons of the high-strung type, such as might be represented by the man of large business aflfairs, by the l^anker or indeed by physicians, many of whom spend their days in high-tension response to the de- mands made upon them. The man of brawn, who earns his Hving with hammer or with shovel, is also a frequent victim of arteriosclerosis. The worker in iron mills, or the lumberman, in whom strenuous physical exertion brings old age prematurely, are further examples of arteriosclerosis resulting from long-continued physical strain. Klotz has stated that medial calcification is more common in the vessels on the right side of right-handed people. Habits. — It is a frequent clinical observation that abuse of tobacco, which produces tabagisin, tends to induce arteriosclerosis. This observation must be given weight, despite the fact that there is little ex- perimental evidence to set forth the exact manner in which tobacco acts in producing the condition. Alcohol, on the other hand, readily lends itself to logical explanation as a productive factor; if the tem- porary acceleration of heart rate which follows the ingestion of alcoholic beverages be multiplied several times a day for the period of several years, it can readily be seen that the extra and unnecessary load thus thrown on the circulatory system would result in premature aging of the blood vessels. Another fac- tor of no small moment is lack of siifUcient rest. The rack and ruin which results from driving a motor continually on high speed, despite the load and despite the road, finds a parallel in the racked and ruined vic- tims of modern high tension living. When the hours ARTERIOSCLEROSIS. 283 of activity are prolonged far into the night, or when theatre or card parties sustain the interest of a mind that is wearied with the duties of the day, or when dancing sustains the muscular effort in hours which should be devoted to rest, unnecessary wear and tear on the arteries ensues. Overeating, with its attend- ant gastric disturbances and with the additional load thus thrown upon the kidneys in aiding to eliminate the toxins resultant from partially-digested food, is also an etiologic factor. "One of the worst cases of arteriosclerosis I have seen was that of a man aged forty, whose vessels, heart and kidneys were all gravely involved, and whose condition was the direct result of his occupation. He was for years on board a large liner, and it had been his duty to taste all the dishes of the various dinners before they were dis- tributed to the passengers and the crew."^ Mechanical irritation of a blood-vessel may be a possible cause of arteriosclerosis. The arteries in the arms of a blacksmith or in the legs of a letter- carrier are more apt to be thickened than are the arteries elsewhere in their bodies (Fig. y2). The coronaries, which are frequently invaded by sclerotic changes, may owe their degeneration in some degree to the mechanical irritation to \\'=hich they are sub- jected with each contraction of the heart; certainly they are more subject to sclerotic change and more subjected to mechanical irritation than are the vessels in more deeply situated, less mobile organs. Toxic conditions such as chronic lead poisoning induce arterial change. The acute infections (Fig. 73) of 1 John Hay, Liverpool: "Some Aspects of the Senile Heart," 284 HEART AFFECTIONS. rheumatic fever, gout, arthritis and typhoid fever produce at times marked arterial degeneration. Theo- dore Janeway found plaques of ath-eroma in the blood- vessels of 21 people out of 52 who died from typhoid fever, and typhoid fever, be it remembered, is more a disease of adolescence than of advanced life. Focal Fig. 72. — Medial Calcification. The X-ray reveals calcification of the arteries of the leg {Cowan.) infections, such as dental apical abscesses or other foci of suppuration, may be factors in bringing about early arterial symptoms. Among the chronic infec- tions, syphilis is the one most persistent in its attacks upon the integrity of the cardiovascular system. Several years are believed to elapse between the initial lesion and the advent of circulatory symptoms ; bvit when luetic infection once manifests itself in arterial ARTERIOSCLEROSIS. 285 degeneration the clinical symptoms seem to progress more definitely and with more rapidity than when vessel damage arises from other causes. Fig. 1Z. — Beginning Arterial Change. The photomicrograph shows, in its center, beginning arterial change in a patient who died of influenza in the 1918 epidemic. The thickening of the intima at A; the loose elastic tissue at B : the condensation of elastic tissue at C, all constitute a microscopic arterial plaque. (Courtesy of Dr. Allen J. Smith.) The Ductless Glands. — Sajous,^ in considering the role of the ductless glands in arteriosclerosis, draws attention to the effect produced by toxemia upon the 1 Sajous, Charles E. de M. ; "The Ductless Glands in Cardiovas- cular Diseases"; New York Medical Journal, May 26, 1917. 286 HEART AFFECTIONS. internal secretion of the thyroid and adrenahn glands. In response to the demands thrown upon them by the toxemia, these glands respond with increased activity and "we witness the phenomena of stimulation — flushed face, brilliant eyes, with perhaps slight pre- cordial pain after an unusually co.pious meal or un- usual exertion, and general vivacity; but it is impor- tant to note that this stage of primary exuberance corresponds with the febrile period of an infection, which may, though relatively very short, do as much damage to the blood-vessels as years of overeating, hard labor, etc." Sajous questions the advisability of administering the iodides, or indeed any drug, at this stage, as the addition of the iodides to the thyro- iodine which already burdens the organism as a result of thyroid over-activity, may aggravate the malady. "No remedies until the toxic factor, whatever that may be, dietetic, intestinal, bacterial, etc. is eliminated prophylactically." Few indeed are the observing clini- cians who cannot subscribe to these truths since Sajous has so originally expressed them; they open a broad field for future clinical research into the etiologic fac- tors of arteriosclerosis. CLINICAL RECOGNITION. Arteriosclerosis depends to a great extent for its symptoms on the effect produced in the part or in the organ whose blood-vessels are thickened and whose blood supply is thus diminished, and such symptoms are the symptoms of disordered function of that part. If the vessels of the brain are* sclerosed, mental fatigue, drowsiness, loss of memory, confusion and syncopal attacks may precede the rupture of a vessel ARTERIOSCLEROSIS. 287 in the brain with its consequent symptoms of apo- plexy. Should the abdominal viscera be partly robbed Pjg. 74.— Artewosclerotic Gangrene of Leg. Showing the nutritional disturbances that arise from arterio- sclerotic occlusion of the vessels. (Jefferson Medical College Museum.) 288 HEART AFFECTIONS. of their nourishment through arterial degeneration, gastro-intestinal symptoms dominate the picture. When the vessels of an extremity are sclerotic (see Fig. 74), attention is attracted by sensory and ther- mal changes in the part affected, often with limita- tions of normal muscular movement and early mus- cular exhaustion produced by moderate effort. If the kidneys are the organs especially affected, the usual clinical evidences of lack of elimination, absorption of toxins and genito-urinary syndromes come to the fore. Any organ or any combination of organs may be involved ; and the more generally the arterial thick- ening is distributed, the more general are the symp- toms. Frequent Earlv Symptoms. — A person at the meridian of life may be vaguely conscious that his physique is below par. Instinctively his hours of rest from business become more frecjuent and his vaca- tions closer together; he also now exercises a care which he was not wont to take in his habits of eating. More attention is paid to exercise and more attention given to elimination than was his* custom. He com- plains, perhaps, of substernal distress following exer- tion, of slight attacks of indigestion, of an occasional feeling of faintness or of headaches. ]\Ieniory defects appear at times when he is weary; the speech may halt at intervals and vertigo, transitory numbness and slight ocular disturbances be the symptoms which cause the person with beginning arteriosclerosis to first consult a physician. The pre-sclerotic stage is a condition of elevated blood-pressure which is believed to exist before the advent of arterial thickening. That it is by no means ARTERIOSCLEROSIS. 289 always present is quite evident from the clinical ex- perience of many physicians. When it does occur the elevation is often found to be due to toxins or to de- fective elimination, and generally subsides when ap- propriate treatment is instituted. As intimated in a preceding paragraph the onset of arteriosclerotic symptoms is usually insidious. Damage to the artery has already taken place before the advent of symptoms, and it reveals itself in con- sequence of some physical effort, some sustained men- tal or emotional stress, some strain imposed upon an organ or set of organs — a demand in excess of that to which the physique has been accustomed. For ex- ample, overeating might provoke gastro-intestinal symptoms in a person who is bordering upon arterio- sclerotic change ; the indigestion itself may be of little moment ; but occurring at a time in life when thicken- ing arteries are unable to withstand any added strain, symptoms of arteriosclerosis may then manifest them- selves and remain established long after the provo- cative gastro-intestinal symptom has disappeared. Interniitteut claudication may be an early symp- tom. The term is applied to a sensation of weight or of pain in the leg which is brought about by walking and which produces sudden lameness. It is not pro- voked by the rapidity with which one walks nor does the distance travelled have any bearing in provoking the symptom. It is believed to arise as a result of the blood-supply to the leg muscles being insufficient for their nourishment, on account of spasm or sclerotic changes in the smaller of the vessels. To the pain, sensation of weight and lameness, there may be added sensory disturbances which the patient describes 19 290 HEART AFFECTIONS. with the words "tinghng," "nuilib," "dead." The pain of intermittent claudication is sometimes reheved by placing a rubber band or tourniquet about the upper third of the thigh ; by leaving it in place for an hour or two the pain is less likely to recur on further attempted effort. Blood-pressure. The systolic pressure in arteriosclerosis is for the most part elevated, although there are types of the condition, such as Albutt's "decrescent" type, to which this observation does not apply. But it is to be re- membered that hyperpiesia (high pressure) may be a compensatory process and, that in many instances it may be safely regarded as an expression on the part of nature of an attempt to maintain the circulatory balance necessary for the nourishment of a structure. Elevated systolic pressure is not always an evidence of arteriosclerosis, despite the fact that the two are so often associated; h_\perpiesia may arise as a result of temporary causes such as emotion or excitement, and is present in some forms of valvular disease, as well as in many conditions other than arteriosclerosis (see page 131). Isolated blood-pressure readings are worthless; they are worse than worthless, for they may be mis- leading. Temporary rises due to emotion, excitement or other causes may occur in the arteriosclerotic sub- ject as well as in a normal person. Therefore, if blood-pressure estimates are to be of significance to the physician, they should be frequentlv repeated and continued over a period of time. Then they may at times be an index to the value of treatment. The ARTERIOSCLEROSIS. 291 degree of blood-pressure elevation is no more an esti- mate of the extent or severity of an arteriosclerotic process than the number of bacilli in sputum is an estimate of the extent of lung involvement in pul- monary tuberculosis. Kidneys. One expects to find the kidneys involved to some degree when there is clinical evidence of arterio- sclerosis. The frequency of this association has given rise to much, academic debate as to which is cause and which is effect — as to whether the kidneys are pri- marily at fault, or whether the kidneys respond with inflammatory changes to the extra burden imposed by thickening of the renal vessels. It is certain that one sees what one believes to be beginning arterio- sclerosis, in which urinalysis affords no evidence of renal damage; and, on the other hand, one sees well-marked laboratory reactions in the urine of eld- erly people who give little clinical manifestation of arterial thickening. It is possible for kidney disease to induce arteriosclerosis, but it is more probable that arteriosclerosis induces kidney change. This seems the more likely view when one reflects that infections, intoxications, defective elimination and overeating are among the predisposing causes of arteriosclerosis ; the kidneys actively concern themselves with elimina- tion of such exciting causes, and consequent damage of kidney structure, with diminished function and damage to the renal vessels would indeed seem a logical course of events. Uremic manifestations are frequent. They may not occur until some dietetic or other indiscretion has 292 HEART AFFECTIONS. overtaxed kidneys in which the margin of health has been gradually reduced. It is after such an error in living that an unrecognized kidney affection may re- veal itself and uremic symptoms of minor or major degree become a part of the clinical picture. " C ardio-vascular renal disease" is a blanket term which does not describe any definite clinical picture. Cardiac symptoms may predominate, vascular symp- toms may predominate or kidney ilianifestations may rule the situation. It is a co-existence of conditions which is often encountered in advancing cases of arteriosclerosis, and can be brought about by degen- erative changes in the smaller arterioles, especially those of the heart and kidneys. The Heart. While the heart may be symptom-free in arterio- sclerosis, in the majority of cases it will yield some evidence of participation in the sclerotic process of the arteries. Often there are abnormal sensations referable to the precordium, varying from slight pre- cordial uneasiness to the agonizing pains of angina pectoris. Frequently there are disturbances of the cardiac mechanism, such as premature contractions, etc., which are described in the following paragraph under "Pulse." When the splanchnic vessels are af- fected or when there be extensive sclerosis of the thoracic aorta, the heart enlarges., Should the heart be increased in size, the cardiac impulse is often sharply defined and more toward the left side than usual; the first sound heard at the apex is prolonged; both first and second sounds at any of the four puncta maxima are usually loud and clear ; the second sound ARTERIOSCLEROSIS. 293 at the aortic area is often accented. There are no murmurs characteristic of arteriqsclerosis. As a re- sult of cardiac enlargement apical systolic murmurs may be heard. There is frequently, too, a basal sys- tolic murmur clue to intimal roughening- of the aorta. Such murmurs lack the associated phenomena which enable one to translate them as valvular disease. Pulse. The pulse affords information first, as to the con- dition of the arterial wall and second, as to any dis- turbance of rate, rhythm or volume in the cardiac contraction. Estimation of arterial thickening is usually made from the degree of resistance which the examiner finds in the radial or in the brachial arteries ; and it is helpful to accquire the habit of palpating the temporal, carotid, femoral, dorsalis pedis and other available arteries as well. AA'hat may seem to be increased re- sistance in a radial may be a pilirely local process confined to that artery alone, and thus lead to false conclusions if one is not thorough in the search for information which literally lies at the finger tips. Even though all of the superficial vessels should be found to be infiltrated, their area must indeed be small when compared with the total blood-distributing area in the large splanchnic (visceral) region; with this thought in mind one would not be surprised at the absence of symptoms in such a case, nor would one expect the systolic pressure to be materially raised so long as the splanchnic region remained unaffected. Various terms are used to define the degrees of infiltration which are found in sclerosed radial or other 294 HEART AFFECTIONS. superficial arteries, varying from the term infiltrated, which is apphed to beginning arterial change, up to the term calcification, which is used to describe an artery utterly lacking in resiliency on account of a deposit of calcium salts in its substance. A "loco- motor" artery is one that moves from side to side at each pulsation, as may be seen in a sclerosed brachial when the elbow is slightly fiexed and the forearm pronated. The term "goose-neck" artery describes the highly tortuous and thickened vessel of superficial situations. A"zvhip-cord" or "pipe-stem" artery is one which rolls under the finger cjuite in the manner that either one of these materials might do if under a thin investment of skin. "Beading" of an artery is the irregular recurrence of hard nodular deposits of calcium salts which greet the finger as it is run along the course of a vessel. Disturbances of rate in the pulse of arterioscler- otics are manifested in periods of tachycardia which may arise in the absence of any exciting cause. The increased rate is usually transitory and produces but little discomfort. Disturbances of rhytlnn are shown in premature contractions, which may be trivial and cause only a slight disturbance in the rhA'thm of the pulse during a day, or which may be so freely inter- spersed in the cardiac contractions as to suggest auricular fibrillation upon casual examination at the wrist. Disturbances of rhythm and of volume mani- fest themselves in auricular fibrillation which may oc- cur in transient periods or which mav become per- manently established. It is often a terminal event in arteriosclerosis. Disturbances of conductivitv are revealed in heart-block, usually of the lesser degrees. ARTERIOSCLEROSIS. 2'J5 although complete heart-block may be an added com- plication to the senile heart. Disturbances of con- tractility are evidenced in the pulsus alternans ; while it may occasionally persist for a period of months, it is usually premonitory of the approaching end of life in arteriosclerosis. It should be borne in mind that the disorders of the cardiac mechanism just envmierated are neither symptomatic nor chagnostic of arteriosclerosis. When they are encountered for the first time in this con- dition, they are of significance in that they indicate that the heart structure is manifesting the burden of extra labor or of toxins that are being imposed upon it; or they may indicate that heart tissue has been damaged by the same degenerative process which sclerosed the arteries. The Eye. Arcus senilis does not now have the same signifi- cance which \\'as at one time attached to it as a sign of arteriosclerosis. This greyish ring, whch forms at the periphery of the cornea, is the result of a colloid degeneration of some of the corneal layers. It is observed at times in persons who are apparently nor- mal, as well as in elderly persons \Vith arterial change. The retina does not always show changes in its arteries, but it shows them sufficiently often and with sufficient constancy to be considered of value as an early diagnostic sign in arteriosclerosis; in some in- stances these changes are the fore-runners of other clinical manifestations. Physicians who are not within easy call of an eye consultant would do well to familiarize themselves wdth the simple technique of 296 HEART AFFECTIONS. the ophthalmoscope, and to employ it in the vague complaints which so often herald the approach of sclerotic changes in the arteries. The usual findings are that the vessels of the retina are irregular in caliber and the veins are contracted at those points where they are crossed by infiltrated arteries. The retinal arteries may be more tortttous than usual and the central light streak is often very bright, giving the arteries a luminous appearance to which the apt term "silver wire arteries" has been applied. Ob- struction of the central artery or vein may also be observed and progressive optic atrophy may be re- vealed by the employment of the ophthalmoscope. To tersely suininarise the preceding pages on the clinical recognition of arteriosclerosis, one may con- clude as follows. In a patient past the meridian of life, who complains of fatigue on moderate exertion, dizziness, confusion, precordial distress, palpitation, cold extremities, insomnia, bronchitis, anginal symp- toms, slight edema, and in whom the svstolic pres- sure be found to be constantly from 30 to 60 mm. higher than the average pressure for a given age, arteriosclerosis is the probable diagnosis; but further inquiry should be conducted along the lines outlined on the preceding pages, to arrive at a definite opinion. The x-ray finds some diagnostic employment in the condition when requisitioned to establish the cause of such symptoms as would arise from medial calcifica- tion of certain arteries (Fig. 72). PROGNOSIS. Arteriosclerosis is not a condition in which patho- logic tissue change can be restored to normal; nor is ARTERIOSCLEROSIS. 297 it a condition the progress of wlii'ch can be arrested, except in unusual instances, for it is essentially pro- gressive in nature. The physician may, by the insti- tution of a proper therapeutic and dietetic regime, so relieve the burden imposed upon the circulation and upon the organs of elimination that the patient is kept comfortably unconscious of the progress of his condition. Indeed, such measures have been credited with adding years to the expected tenure of life. The prognosis in arteriosclerosis is to a consider- able extent based upon the etiologic factors in the con- dition. If the symptoms be mild in character and are those attributable only to the advance of years, the outlook as to relief of symptoms and additional years is of course more hopeful than if the arterial degen- eration were the result of toxic influences, or due to degenerative changes induced by long continued infections. The prognosis is also dependent upon the response to treatment which the patient exhibits un- der rest and elimination. If under proper manage- ment annoying symptoms disappe'ar and the general tone of the patient improves, the prognosis as to years is again more favorable than if treatment were un- attended with results. When the condition is the result of absorption from some long-unrecognized focus of suppuration, the institution of operative procedures for the evacua- tion of pus or destruction of pyogenic membrane may arrest what would otherwise be progressive arterial change. If it be found to be due to a definite systemic infection such as syphilis, appropriate treatment may succeed in checking the progress of sclerosis. 298 HEART AFFECTIONS. Should advanced arteriosclerosis be announced by the occurrence of cardiac dyspnea, apoplexy, pulsus alternans, Cheyne-Stokes' respiration and other ser- ious symptoms, the prognosis is ominous. TREATMENT. The first step in the treatment of arteriosclerosis, as in the treatment of any condition, is to seek for and if possible remove flic cause. Underlying infections (see Etiology), either constitutional or focal, are to be appropriately treated with the indicated remedies or by operative procedures. For example, a luetic history or more than one positive ^^'assermann reac- tion, point the way to specific treatment; or pyuria may be an indication of a long-standii.Tg kidney affection which the a--ray may suggest is l::e*st relieved by neph- rolithotomy. Other focal infections have already been mentioned on page 224. The constitutional con- ditions enumerated on page 36 should likewise be sought for. Tn such a thorough riianner should the physician continue the search for a cause, possibly remediable, which is aggravating the arterial condi- tion. The early symptoms of arteriosclerosis, if they be considered one by one, are of little moment ; taken in the aggregate however, they so reduce the physical and perhaps the mental efficiency of the patient that it is necessary to change the manner of living or risk a shortening of life. There is a border-line between the life of activity and the life of re'tirement which all must sooner or later reach. Such minor svmptoms as an enforced curtailment of accustomed exercise, shortness of breath on slight exertion, dizziness, con- ARTERIOSCLEROSIS. 299 fusion, mild digestive disturbances, ocular defects, irascibility, or lack of interest in the activities of life which have heretofore proved engrossing, are fre- quent manifestations of early arteriosclerosis and they mark the border-line between the life of activity and the life of partial retirement from business. It has well been said that the person so afi^icted is con- fronted with the same problem as that \\-hich presents itself to the teamster who is taking a load up a hill, the grade of which is ever increasing: the problem is whether to apply the lash or lighten the load. While it may be necessary at times to employ both exped- ients, manifestly the first choice is to lighten the load when the end of the road is not yet in sight. In treating a patient with arteriosclerosis the load is lightened by relaxation, by rest and by elimination. Relaxation. — The gospel of relaxation is perhaps the most difficult subject which the physician is called upon to teach. It is no easy task to persuade an active man whose strong, aggressive personality has long dominated his field of business that his symptoms, trivial as they may seem to him, necessitate a change in his method of living' — a relaxation from activities and cares, and the devoting of many hours to physical and mental rest. Such men rarely acknowledge that they have physical limitations, and never admit to the confusion of thought or slowing- of mental processes which may be quite apparent to business associates. Hence it is only by persistence, by insistence and by constant repetition that the physician can hope to im- press the active man of affairs with the degree of care necessary for his well-being and for the lengthening of life. 300 HEART AFFECTIONS. Short vacations or occasional Holidays may bring marked benefits which, however, soon are lost when the patient returns to his accustomed manner of liv- ing. Hence, the hours spent in business activities should be shortened ; more time shbuld be spent at the table; more hours should be given to moderate exer- cise in the open air; sufficient time for personal hy- giene should be taken in the mornings, supplanting the hurried rush to the office; more hours should be devoted to sleep. Physical and mental relaxation are the best preventives of possible rupture of a vessel at the base of the brain, with its attendant stroke of apoplexy. Rest. — There are instances in which the physician will desire to put the patient at complete rest in bed in order that he may more fully study the symptoms ; he may also thus anticipate possible emergencies which might arise should the patient ■ continue active and busy with his affairs. Further, with the patient ab- solutely under control in bed, the physician will be better able to estimate the beneficial results of treat- ment and thus arrive at a more diefinite prognosis. It is the part of discretion, when the severity of the symptoms warrant, to put the patient to bed at the beginning of a course of treatment and, as his improvement progresses, allow him to be up and around the house, rather than to later attempt to im- pose bed restrictions on a patient who has once been permitted to be ambulant. The patient who has been confined to bed for a period ^'arying from a few days to a few weeks will certainly be spared the strain that physical activity would throw upon his damaged cir- culatory system. His diet will receive more regu- ARTERIOSCLEROSIS. 301 lating than if he were tempted by the foods served at the family table. Furthermore, elimination, which is so essential to proper treatment, will receive the attention which its importance warrants if a nurse or skilled attendant carries out the physician's instructions for the patient who is being treated in bed. Elhnination. — When one recalls that the kidneys are frequently involved to a greater or less degree in arteriosclerosis and that the retention of toxins due to this cause may aggravate the symptoms the signifi- cance of elimination becomes at once apparent. The curious theory has been advanced in some quarters that increased fluid intake in arteriosclerosis adds to the volume of fluid within the body and thus increases the work of a damaged circulatory system. What- ever theoretical foundation there may be for such an idea, the fact remains that patients are quite invariably benefited by an increase in the fluid intake. When drinking water is used for the purpose of flushing it should of course be thoughtfully administered, and taken in quantities of one or two glassfuls, at a time when the stomach is empty, vis: on arising, half an hour before meals, three hours after, and on retiring. There may be instances in which the infusion of digi- talis is indicated as a diuretic; it should be prepared with the precautions suggested on page 209. Such an instance exists when it is desired to remove drop- sical efi^usions which have accumulated in the body by increasing the urinary output. Under such circum- stances the Karrel diet (page 211) should also be employed and the water intake for the time limited. Sweet spirit of niter and potassium citrate may be 302 HEART AFFECTIONS. employed as a diuretic in the proportions of the follow- ing prescription: ^ Spiritus setheris nitrpsi f^ss. Potassii citratis 3ij- Aquffi destillate .• q. s. ad i^iv. M. Sig. : Two teaspoonfuls in >^ glass of water at 4-hour intervals. The bozvels are best regulated, not by the use of hydragogues which by their excessive action may in- duce exhaustion, but by salines in moderate daily dose. The milder laxatives such as senna, compound liquor- ice powder, cascara sagrada, etc., may be preferred when it is desirable to stimulate peristalsis over a con- siderable length of time. The skin is kept active by the use of the daily tepid bath which may be followed by witch hazel rubs. Massage may also be employed in order to stimulate elimination by the skin. Hot baths or 1\irkish baths, if used at all, are to be cautiously employed and only under the direct supervision of the physician. As has already been stated, there are cases of arteriosclerosis in which milder uremic symptoms are manifest. For the emergency of uremic convulsions or uremic coma which may arise the usual treatment, consisting of purgation, hot packs, free elimination and support for the heart if failing, are of course indicated. Diet. — Food should be regulated, both as to its quantity and as to its constituents. As a general prop- osition, the protein intake should be limited and meats, condiments, sugars, fats and stimulants inter- dicted. No hard and fast dietary' rule can be formu- lated that is adaptable to every case. It is well to re- ARTERIOSCLEROSIS. 303 member in this connection that there are persons who ha\'e learned from years of experience to avoid certain foodstuffs to a degree that would seem to deprive them of necessary elements, and to use other food- stuffs to a degree which might seem excessive. Yet they have thrived on their continued dietetic vagaries. Therefore, when the physician arbitrarily insists on a patient eating certain foods to which the patient has a natural repugnance or \\'hich he confidently be- lieves will do him harm, the physician by such insis- tence commits an error in judgment in many instances. It is also no less an error in judgment to insist that the patient abandon certain foodstuffs which, while questionable, are not definitely harmful and upon which he has subsisted for years. For the first few days in bed liquid or semi-liquid diet may be advan- tageously employed in order to avoid overtaxing the system and to encourage elimination ; afterwards a more liberal diet may be permitted. Foods which contain a high percentage of protein should be avoided, (as far as it is feasible to avoid them), familiar ex- amples of which are red meats, eggs, fish, cheese, peas and beans. Perhaps the physician will desire to em- ploy, for a time, the diet for the "Senile Heart," as given on page 386. DRUGS. It should be remembered that relaxation, rest, elimination and diet regulation are the four cardinal principles of treatment which reduce high blood-pres- sure in the great majority of instances, and they re- duce it naturally and safely. In arteriosclerosis ele- vated systolic pressure (hyperpiesia) is often com- 304 HEART AFFECTIONS. pensatory; indeed it is probably nature's only method of getting sufficient nourishment to some organ or tissue of the body which might otherwise be more or less ischemic, owing to capillary fibrosis in the part. If this view be tenable, then the administration of "circulatory sedatives," such as veratrum, might well be referred to as meddlesome therapeutics. Vaso- dilator drugs, on the other hand, may be demanded in an emergency, as when apoplexy threatens, but it is not wise to employ them as a rule unless elimina- tion is being coincidentally practised. Drugs of the nitrite group are the vasodilators which are employed in the reduction of high pressure by drugs. Urgent symptoms may demand amyl nitrite in 2 minim pearls, crushed in the handkerchief and inhaled. The spiritus glycerylis nitratis is a i per cent, aqueous solution of nitroglycerine and is given in i or 2 minim doses, sometimes gradually ascended. Tablets of nitro- glycerine each contain o.oi of a grain. In adminis- tering the nitrites it is well to remember that their action is fleeting in character, the reaction not being sustained, and that for this reason they should be administered at three- or four-hour intervals. Digitalis. — This drug has no place in the routine treatment of arteriosclerosis. Its loose administra- tion as a universal panacea for anv affliction of the heart or circulation cannot be too strongly protested against. In arteriosclerosis there are two exceptional conditions under which it may be indicated; the first indication is as a support for the heart when cardiac failure threatens as a result of myocardial exhaus- tion. The second is in those instances where the physician is unable to relieve peripheral resistance ARTERIOSCLEROSIS. 305 and feels that the resultant strain vipon the heart muscle may result in failure of that organ; digitalis is then used to fortify against such a contingency. Potassiiuii iodide has for years been the sheet- anchor in the drug-treatment of arteriosclerosis. The action of the drug is in doubt, but its effects are not in doubt. It produces beneficial results which are not at all to be explained on the assumption that the drug benefits only syphilitics. One would do well indeed to bear in mind, especially in these days when the pendulum of etiology has swung too far to the side of syphilitic infection, that not every patient zvho is benefited by potassium iodide is a syphilitic. Balfour thought that the iodides dilated the arterioles; Burnett claimed that they increased elim- ination; either physiologic action would lower arterial pressure. Modern laboratory experiments have so far neither affirmed nor denied either of these opinions. The administration of the drug today is empirical, just as it has been for generations past. The usual dose of iodide of potassium for long-con- tinued administration is 5 to lo grains, held in solu- tion in a pleasant vehicle such as compound syrup of sarsaparilla to disguise its objectionable taste, or well diluted in water, taken 3 or 4 times daily, preferably after meals. The administration over a long period of time may bring on the symptoms of iodism, the early manifestations of which are coryza, a metallic taste in the mouth, moderate increase in salivary se- cretion, tenderness of the gums ©r of the teeth and slight nausea. The appearance of such symptoms is an indication for the withdrawal of the drug. In this connection the warning of Sajous on the subject 306 HEART AFFECTIONS. of "The Ductless Glands" (page 286), should also be borne in mind. Electricity in the form of high' frequency currents often lowers peripheral resistance and thus lowers the pressure in early and selected cases of arteriosclerosis. Its employment is better left in the hands of the elec- trotherapeutist. ] ^cncsection may be of value in warding ofif such a crisis as apoplexy or heart failure in arteriosclerosis. It is contraindicated in anemic patients and also where there is marked renal involvement. CHAPTER XX. Aneurism, DEFINITION AND VARIETIES. An aneurism is a circumscribed dilatation of a blood conducting structure. While aneurisms more often occur in the large arterial trunks, such as the aorta, subclavian, carotid, etc., they may arise along the course of any of the 468 arteries in the body ; they may involve the capillaries and, as in the case of a nevus vasculosis, involve both capillaries and veins. Aneurisms of the heart have been found at necropsy, as have also aneurisms of valve-leaflets. Aneurisms are subject to many classifications. They are said to be primary at the time of their first appearance; should they recur, as in the case of a femoral aneurism which has disappeared under com- pression treatment, the)^ are termed secondary. A true aneurism is one in which the sac is formed by the arterial walls, at least one coat of which remains un- broken; a false aneurism is one in which the wall is formed by surrounding structure, the coats of the artery having given completely away. Further classification is made according to shape. A sacculated aneurism is one whose opening into an artery is smaller than the diameter .of the sac — a very frecjuent clinical type. The fusiform variety is of spindle shape. A dissecting aneurism is one which burrows between the coats of the vessel. (307) 308 HEART AFFECTIONS. Aneurisms may be simple or combined; a com- bined aneurism is one in which some coats are rup- tured and other coats are dilated. A diffuse aneurism is one in which all the arterial coats are ruptured. A surgical aneurism is one in which there is a possibility of surgical intervention for its relief. The term traumatic is applied to those tumors of blood vessels which arise as the result of trauma or exer- tion. Embolic aneurism forms ag the result of dila- tation occasioned by the lodging 6f an embolus. Further subdivisions are made according to the names of the observers who first described them. No less than seven men have their names attached to tumors of blood-vessels which are known as Potts' aneurism, Rodrigues' aneurism, etc. Classifications can be multiplied almost indefinitely. This discussion will be confined to the most common clinical variety of aneurism, which is most frequently accompanied by disturbances of the heart and cir- culation, 7'/'r: aneurism of tlic thoracic aorta. ETIOLOGY. The patient and laborious researches of ^^^arthinl were of much etiologic significance in establishing syphilis as a probable cause of the majority of aneu- risms of the thoracic aorta, yet syphilis is by no means the solitary cause of aneurism. It should be remem- bered that there are many instances in which aneurism has arisen as a result of acute rheumatic fever, alco- holism, injuries and as the remote result of acute in- fections. The presence of aneurism is no warrant for fastening the stigma of syphilis upon the sufl'erer. 1 Warthin : Loc. cit. ANEURISM. 309 Aneurisms are more frequently encountered dur- ing early middle life. They are six times more com- mon in men than in ^^•omen. Occupation does not predispose to their occurrence, although violent ex- ertion or long continued strain may rupture a vessel coat and precipitate urgent symptoms in a hitherto unsuspected case. In considering the etiology of aortic aneurism, it is well to trace the condition from the period of initial inflammation to that point where the infection has so weakened the arterial coats that their dilatation or rupture results from the force exerted by the blood- stream on the weakened \'essel \\'alk While aneurisms may develop suddenl}- as the result of muscular ei¥ort, severe paroxysms of coughing, physical strain, etc., careful questioning of such patients will often elicit a previous history which is suggestive of aortitis or of aneurismal dilatation. If the physician is to be of the greatest service to his patient it is necessary for him to recognize that there is such a condition as a "pre-aneurismal stage" of aneurism and that this formatiA'e stage may give symptoms of acute aortitis or symptoms of dilatation of the arch, by the early recognition of which one may hope to prevent eventual rupture of the blood-vessel walls with well-nigh hope- less aneurism formation. ACUTE AORTITIS; THE PRE-ANEU- RISMAL STAGE. Those acute infections which so often induce myo- carditis and endocarditis are factors in the production of acute aortitis, namely, scarlet fever, typhoid fever, pneumonia, acute rheumatic fever, severe or long- 310 HEART AFFECTIONS. continued tonsillar infections, septicemia, and even influenza (Fig. 73). Necropsies on patients who have died of these conditions show areas of degener- ative change in the aorta. They may not be recog- nized by the unaided eye, but they can be recognized by the use of various stains which bring out the tissue degeneration under the microscope. Thus it is proven that the aorta may share in the damage which is wrought in heart tissues by these infections, and as a consequence an initial aortic damage arises which be- comes the vulnerable point in the integrity of the aortic wall in future years. In this connection one might again refer to the statistics of Thayer ^ who found plaques of atheroma in the aorta of 40 per cent, of 52 cases of t3rphoid fever. In considering the etiology of subacute forms of aortitis one should not lose sight of the frequency with which the treponema of syphilis invades the aortic arch — a frequency so marked that the aorta should be carefully studied for symptoms* and signs in any patient who presents evidence of syphilis elsewhere in the body. As a result of the close association be- tween acute aortitis and syphilitic manifestations, there has arisen the term aortitis syphilitica. SYMPTOMS OF AORTITIS. ( I ) Pain under the sternum is the most suggestive symptom; with it may be associated a sense of sub- sternal oppression. (2) Dyspnea, which need not especially follow physical effort, is often complained of. (3) Tcrf/'^o may be present in.a moderate degree. (4) One or both arms may present symptoms of sen- 1 Thayer : Loc. cH. ANEURISM. 311 sory disturbance or of pain. (5) Fezrr due solely to aortitis, if present at all, amounts to only a slight rise. (6) Cough may be added to the clinical picture. PHYSICAL SIGNS OF AORTITIS. The force exerted by the column of blood which is ejected from the heart at each systole of that or- gan increases the strain which infllammation has thrown upon the aortic wall; as a consequence, dila- tation of the aorta is likely to arise. Carotid pulsa- tion is one of the manifestations of aortic dilatation under such circumstances, but a more valuable sign is the one described by Potain which consists in up- ward displacement of the subclavian arteries so that they are seen to pulsate directly above the clavicles. These vessels are raised from their normal situation into the position where their pulsations can be seen as a result of the aortic dilatation, which lifts them from their usual position. If one hand be placed at the upper part of the sternum and the other hand be laid on the back between the scapulae, pulsations may be noticed which would otherwise have escaped detection on inspection. Again, if the ear be laid upon the chest wall at either of these points the systolic pulsation may be detected by thus combining the sense of touch and hearing. There may be an increase in the area of aortic dullness noted upon percussion. The total transverse arch of the aofta in health usually measures 5.5 centimeters in the second interspace to the right and left of the stermmi, but if aortic dilata- tion be present that distance is often found to be increased on percussion. 312 HEART AFFECTIONS. The aortic second sound is likely to be ringing in character. An aortic systolic murmur may be pres- ent should the aortic valve be involved; or the sys- tolic murmur may arise as the result of roughening of the internal arterial coat. A systolic murmur is of no diagnostic value in acute aortitis, aortic dilatation or aortic aneurism, except in so far as it co-exists with and is confirmatory of other signs. A diastolic im- pact may be felt in the second interspace to the right or left of the sternum. DIAGNOSIS OF AORTITIS. The occurrence of the above mentioned symptoms during the course of or subsequent to an acute infec- tion is cause sufficient to make the provisional diag- nosis of acute aortitis. There is no way of definitely determining the condition by physical signs unless aortic dilatation be present. In any event, the .:r-ray should be employed to confirm the suspicion of aorti- tis or aortic dilatation, and may reveal an increase in the diameters of some portion of the aortic arch where physical signs gave no information. Clinical evidence of syphilis or a positive Wassermann reaction in a given case is always cause for suspecting either aor- titis or aortic dilatation or both. Treatment is under- taken for the purpose of minimizing the inflammation by rest in bed, and the employment of such measures as may be appropriately selected from those detailed in the consideration of myocarditis, page 206. THORACIC ANEURISM. For the convenience of clinical description of aneurisms which might arise therein, the thoracic ANEURISM. 313 RIGHT COMMON CAROTID '% 0» ^- T V ID If) TRANSVERSE PORTIOM o 73 O z > ASCENDIMG PORTION LEFT .COROMARY Fig. 7S. — The Aech of the Aorta. (Natural size.) Showing areas at which aneurisms may arise and occasion special pressure symptoms on arterial trunks. 314 HEA*RT AFFECTIONS. aorta is divided into four parts, vis : ( i ) the ascend- ing arch, which is that portion extending from the left ventricle to the innominate artery (see Fig. 75) ; (2) tlie transverse arch, which extends from the in- nominate to the left subclavian artery; (3) the de- scending arch, which extends from the left subclavian artery to the level of the fourth thoracic vertebra; (4) the descending thoracic aorta, which is that por- tion of the vessel between the fourth vertebra and the diaphragm. Aortic aneurism occurs in order of frequency with the clinical divisions just mentioned. Aneurisms of the ascending arch are far more frequent than are those of the transverse arch, whik less in respective frequency are those of the descending arch and the descending thoracic aorta. GENERAL SYMPTOMS OF THORACIC ANEURISM. Aneurisms have many symptoms in common, ir- respective of that portion of the thoracic aorta which may be involved. There are other symptoms es- pecially referable to each of the four clinical divis- ions of the vessel. First to be considered are those symptoms and signs which are applicable to thoracic aneurism in general. ( 1 ) Pain. — The pain is sharp and acute if a nerve be pressed upon and is boring in character if a bone be implicated. Paroxysmal attacks simulating angina pectoris may occur. (2) Dyspnea on slight exertion. (3) Abnormal Pulsations. — These may be found in the second interspace, in the suprasternal notch, along the right border of the sterniim, or in the back ANEURISM. 315 between the scapulae. Such pulsations are not to be confused with the abnormal precordial pulsations or with the arterial throbbing- which are often observed in emotional or neurasthenic persons. Protrusion may be noted in any one of the situations just men- tioned. Aneurismal swellings exhibit, as a differential characteristic from tumors due to other causes which might be in the same location, the phenomenon of pulsation, usually laterally expansile. Pulsations not noticed on inspection may be detected upon palpation. (4) Systolic Thrill. — The systolic thrill of an aneurism is occasioned by the swirling of blood which takes place when the fluid enters the dilated portion of the vessel from an opening of smaller caliber. (5) Diastolic Shock. — The diastolic shock often present in aneurism is probably caused by the elastic recoil of the aneurism walls following systolic dilata- tion. A loss of elasticity of the vessel wall or the formation of a laminated blood ciot, often miscalled "a mattress of fibrin," ^ in a portion of a sac may ac- count for the absence of diastolic shock in some instances. (6) Other general symptoms which may be present include : inequality of pupils, due to irritation of the sympathetic nerves; engorged veins of chest, due to intramediastinal pressure; dysphagia, the re- sult of pressure on the esophagus; occlusion of a bronchus, causing an atelectatic lung ; noisy breathing, in consequence of a partial paralysis of the recurrent 1 Following recent studies, Dr. Allen J. Smith is of the opinion that the formation which may occur along the wall of an aneurism can in no wise be considered fibrous tissue ; it is a laminated blood clot, con- taining lime, fat, red cells, fibrin, and a substance resembling amyloid material. 316 HEART AFFECTIONS. laryngeal nerve; tubular breathing, the result of the conduction of sound from a bronchus by an aneurism. Enlargement of the heart, long considered a classic sign of aneurism, is found in less than i per cent, of cases, according to Howard's autopsy statistics.^ The heart may of course be pressed downward and to the left to accommodate the new growth within the chest. EFFECT OF THORACIC ANEURISMS ON PER- IPHERAL CIRCULATION. If the heart has not been affected by the same condition which diseased the artery, the peripheral cir- culation is not affected by the interposition of an aneurism in the course of an artery. The output of the heart is unaltered; hence the peripheral flow is unchanged, as was shown by the experiments of Stewart, who observed that when the pulse is smaller on the left side, the blood flow is nevertheless almost equal in the hands. PRESSURE SYMPTOMS RELATIVE TO SITE. An aneurism makes pressure on certain structures during its growth, and such pressure symptoms vary with the site of the tumor, thus often enabling one to locate the site of an aneurism by symptoms specially referable to some portion of the aorta (see Fig. 75). (i) Ascending Arch. — This is the aneurism which Broadbent designated "the aneurism of physical signs." It produces more displacement of the heart to the left than would a swelling* of similar size sit- uated on any other portion of the aorta. On account 1 Howard : Johns Hopkins Bulletin, HI, 266. ANEURISM. 317 Fig. 76. — Aneurism of the Aorta. The usual diameter of the aorta is seen in the descending portion on the right. It opens into a large aneurism, which in turn com- municates with the heart, (Jefferson Medical College Museum.) 318 HEART AFFECTIONS. of its proximity to the valve it is frequently accom- panied by signs of aortic valve leakage. By the pres- sure which it makes upon the recurrent laryngeal nerve it may produce alterations in the voice varying from a brassy cough and hoarseness to complete aphonia. If an aneurism of the ascending arch be on that portion of the vessel which is within the pericardial sac (Fig. ^(y), attacks of dyspnea and anginoid pains are marked, the reason for this being that the per- icardial space is lessened by the interposition of the aneurism and the heart action thus interfered with. If the tumor be large within the pericardium, it im- pedes the entrance of venous blood into the heart and as a consec[uence ^'enous engorgement is present in the neck and arms. If the aneurism is situated on that portion of the ascending arch which is external to the pericardial sac, the superior vena cava may be compressed with resultant engorgement of the neck, face and arm on the right side. (2) Transverse Portion of the Arch. — This is the aneurism which Broadbent called "the aneurism of symptoms," for with an aneurism so situated the symptoms are often more marked than are the physi- cal signs. This tvtmor frequently points backward. It presses the trachea and the esophagus, thereby giv- ing rise to respiratory symptoms, to alterations in the voice and to difficulty in swallowing — which will vary in degree in accordance with the size of the tumor. Dyspnea and dysphagia may be due to direct pressure on the structures concerned ; or they may result from pressure upon the left recurrent laryn- ANEURISM. 319 geal nerve, which is subject to pressure by an aneu- rism in this situation. The pulse exhibits more alterations in an aneurism of the transverse arch than in one in any other sit- uation along the aorta. If it presses upon or involves the innominate artery (see Fig. 75), the left common carotid or the left subclavian artery, changes appear in the carotid or radial pulse. If the innominate artery is involved the right carotid pulse is often lowered in volume or delayed, as is also that of the right radial artery. If the left subclavian or adjacent common carotid artery is pressed upon or involved, the left carotid pulse is lowered in volume or delayed, as may also be the pulse in the left radial artery. In estimating delay or retardation of the radial pulse it is wrong to time it by the precordial impulse, for the ventricular contraction naturally occurs o.i of a second earlier than the radial pulse. The delay in radial pulsations is estimated by grasping both the right and left wrists at the same time. Manifestly delayed pulsation is a sign that is not constantly pres- ent, for it depends upon the location and size of the tumor of the transverse arch; if the aneurism be small and situated on the concave portion of the arch it would not be expected to press upon the vessels which arise from the convex surface of the arch. Even though a radial pulse is found retarded, one should satisfy oneself that other symptoms of aneu- rism are present and not depend on this sign alone, for reasons enumerated in the following paragraph. Local Factors in Radial Pulse Obliteration. — The pulse is not infrequently absent in the right wrist of well muscled men who earn their living with their 320 HEART AFFECTIONS. Fig. n . — Aneurism, (Courtesy of Dr. Elmer H. Funk.) ANEURISM. 321 Fig. 78. — X-ray Photograph of Figuke 11. "Large aneurism of the first portion of the ascending arch. It points directly forward. Another aneurismal sac on the descending aorta, more posteriorly. There are large atheromatous plaques in the descending arch." (Courtesy of Dr. Willis P. Manges.) 21 322 HEART AFFECTIONS. arms. Persons in whom broken bones of the wrist have undergone repair, may possess a radial artery that is not palpable. Old inflammatory processes at the wrist joint may obscure the radial pulse. Oblit- erative change further up in the course of the artery may prevent a pulsation from reaching the wrist. There are many persons in whom the radial artery departs from its superficial locatioti and lies so deep as not to be perceptible at its usual situation along the styloid process. (3) Aneurism of the Descending Aortic Arch. — An aneurism in this situation, between the subclavian and fourth thoracic vertebra, is most frequently directed along the spine and may point in the back. Thus it may press on nerves of the spinal cord at their point of exit and cause pain in the part sup- plied by these nerves, such as the shoulders or the axillary lines. Enfeebled or delayed femoral pul- sations may be noted and perhaps there will be an absence of pulsation in the abdominal aorta. (4) Aneurism of the Descending Thoracic Arch. — The contact of such an aneurism with the spine may result in erosion of the lower thoracic vertebra. As a result pain of an excruciating character may be elicited if the vertebral column be pressed upon. PHYSICAL SIGNS OF THORACIC ANEURISM. Inspection. — Abnormal systolic pulsation may be noted between the clavicle and third rib; it may be suprasternal or it may be found in the interscapular region in the back. Feeble pulsations may be noticed, these occurring oftener to the right of the sternum. The pulsation may be lost altogether if the patient be ANEURISM. 323 examined in the erect posture alone. It is a good rule to routinely examine the anterior chest wall with the patient in the recumbent posture, a light falling di- rectly upon the chest and with the £yes of the examiner on the level of the chest wall. Palpation. — If the thoracic wall has been disinte- grated a definite pulsating tumor, brawny and indur- ated, will protrude (Fig. yy), and the maximum car- diac impulse may be displaced to the left by pressure of the new growth. Aneurismal "-erosion" should not be attributed to the mechanical effect of a pulsating tumor upon bone substance. It is due to an extension of inflammation from the walls of the sac, it having been shown by Smith ^ that in the case of an aneurism due to syphilis, the Treponema pallidum was the de- structive agent in sternal "erosion." Tracheal tugging may be eli-cited, especially in aneurism of the transverse arch. This sign, first de- scribed by Oliver, is not pathognomonic of aneurism, for it also occurs in aortic dilatation. It is elicited by having the patient, who is in the erect position, elevate his chin; the cricoid cartilage is then grasped between the finger and thumb and gently pressed upward. A tug will be felt at each pulsation of the heart, due to the fact that the arch of the aorta is crossed by the bronchus and, if the aorta be dilated, the bronchus moves with each systole of the heart. Resonance is diminished over the area occupied by the tumor. This may be noticed especially in reference to the ascending aorta, which is very acces- sible to percussion. Diminished resonance will change 1 Smith, Allen J. : New York Med. Jour., March 7, 1914. 324 HEART AFFECTIONS. into dullness and flatness as the aneurism increases in size. Auscultation reveals nothing distinctive in aneu- rism. A diastolic sound may be present on either side of the sternum and is co-existerit wth the diastolic shock previously mentioned. The systolic murmurs which are quite usually heard in aneurism are of no diagnostic significance. DIAGNOSIS OF THORACIC ANEURISM. When an aneurism has advanced to the stage where it presents as an external tumor, or even to the stage where it causes distinct pulsations in the inter- spaces, in the suprasternal notch or at other super- ficial locations, the diagnosis is evident. Should con- fusion arise with other tumors iii similar locations, the distinction can be made by remembering that an aneurism is a pulsating' tumor, the pulsations of which are synchronous with the systole of the heart, and the pulsations are laterally expansile in character. There is, however, little benefit to the patient in diag- nosing an aneurism after it has progressed to this stage (Figs, yy, 78, 79, 80). The diagnosis should be made long before such an unfortunate event oc- curs. Reliance should not be placed upon the pres- ence of physical signs, nor should the absence of any of the signs enumerated in this chapter disarm a sus- picion of present or future aneutism, \\'hich suspi- cion has arisen as the result of constant substernal pain, substernal oppression, dyspnea, cough and pal- pitation. There is only one way to make a definite diagnosis of early aneurismal formation. The x-ray ANEURISM. 325 should he employed as the only dependable means of early diagnosis. In employing the Rontgen light, fluoroscopic ex- amination is that form which is of special advantage in the diagnosing of aneurism. It permits of a search- ing examination of the mediastinum from all angles and directions. If an aneurism be detected, the fluoroscope permits one to estimate the degree of pul- sation in the sac; it shows the area of greatest pul- sation, thereby allowing one to anticipate the source of future pressure s}'mptoms should the aneurism progress. Later on, it furnishes some basis for an opinion as to the elasticity of the vessel at that point where diminished expansion might suggest the pos- sibility of early rupture of the elastic arterial coat. Early fluoroscopic recognition of an aneurism of- fers the best hope to the patient so afflicted. It means the early institution of treatment, such as the curtail- ment of activities, enforced periods of rest and treat- ment of the underlying cause, and thus holds out hope of preventing irreparable structural damage which may ensue if one depends for the recognition of aneurism upon the presence of clinical symptoms alone. PROGNOSIS OF THORACIC ANEURISM. Some beginning aneurisms which are recognized by fluoroscopy never reach a greater stage of develop- ment than that in which they are first seen, owing to the institution of proper treatment and change in the habits of life. Aneurisms which seem to progress in the absence of treatment have been observed by Vaquez and Vordet to actually reduce in size follow- 326 HEART AFFECTIONS. Fig. 79. — Aneurism.^l "Erosion." The upper part of the sternum has completely disappeared, as a result of extension of inflammation from the aneurism underneath. (Jefferson Medical College Museum.) ANEURISM. 327 Fig. 80. — Aneurismal "Erosion." Side view of Figure 79, A section has been cut from the aneurism, showing the thickness of its wall. (Jefiferson Medical College Museum.) 328 HEART AFFECTIONS. ing several arsphenamin injections which were di- rected to the cure of the causative infection, syphihs. These same observers report that the fluoroscope has shown, under such circumstances, an actual reduction in calcified areas in sacculated aneurisms of the as- cending and transverse portions of the aortic arch. As to the prognosis of aneurisms of considerable degree of development, it has been estimated that half of these cases terminate in rupture of the sac. The statistics of Lemann^ show that of 592 cases of thor- acic aneurism, rupture into nearby structures occurred in the following instances : Cases Pericardium (Fig. 48) 148 Left bronchus, pleura, or lung 160 Right bronchus, pleura, or lung , 62 Esophagus (Fig. 81) SO Trachea , 48 Through the skin , 35 Superior vena cava 31 Pulmonary artery 18 Other structures 40 592 Rupture of an aneurism max- be a most dramatic incident, especially if it suddenly i")erforates a bron- chus, or it may rupture into other structures and be quite free of symptoms other than, those of concealed hemorrhage. I ha^•e in mind a patient with clinical symptoms of aneurism of the transverse arch and with a very moderate degree ( )f external tumor forma- tion, who was comfortably propped in bed and pleas- antly engaged in conversatinn. Suddenly her features blanched and her expression became agonized ; she clutched at her throat, giving a shi int cough as though 1 Lemann : Amer. Jour. Aled. Sci., Aug., 1916. ANEURISM. 329 330 HEART AFFECTIONS. to clear it of some obstruction, and at that instant huge quantities of blood gushed from her mouth. Life was extinct a few moments afterward. In contrast with such an incident can be cited the tranquil termination of a patient with an aneurism which ruptured into the esophagus (Fig. 8i). "On the morning of his death he seemed in his usual con- dition, although he stated he felt disinclined to eat. He was sitting on the edge of his bed when he called for the nurse, stating that he felt faint. He was urged to lie down and in about fifteen minutes be- came quite pale. By the time the resident physician reached his bedside, ten or fifteen minutes later, he was dead."^ The case of a physician of 33 years who died as the result of rupture of an aortic aneurism into the left innominate vein, as reported by Herrick,- is a graphic description of the emergencies and complex symptoms which may result from aneurismal rupture. "On the evening of December 9, 1918, he returned late to his office. As he was ascending the stairs he experienced a feeling as of something giving way in his chest ; his neck and face felt flushed and full. The sense of choking and pressure was so urgent that as he entered the office he violently tore open his collar and the neckband of his shirt. \\^hile trying to turn on the electric light he lost consciousness. How long he lay in a swoon on the floor was not known; he thought about twenty minutes. After regaining his senses he turned on the light, looked in the mirror 1 From case history notes by Dr. Elmer H. Funk, to whom I am further indebted for Figxire No. 81, which illustrates the necropsy findings in the patient. 2 Herrick : Amer. Jour. Med. Sci., vol. clviii, No. 6, p. 782. ANEURISM. 331 and saw that his face and neck were greatly swollen and 'almost black in color.' Breathing was difficult. "The picture presented, as I saw this patient for the first time five weeks after his accident, was one of which I have never seen the duplicate. The neck and face as well as the wall of the chest were swollen as in the anasarca of chronic parenchymatous nephritis; the injected, bulging eyeballs could be seen through the narrow slits left between the swollen lids. But instead of the pasty pallor of the nephritic facies there was a purplish, almost black color, such as is seen only in the most extreme degrees of cyanosis. 1'he visible veins were distended and tortuous. But no feature was more remarkable than the sharp contrast between the bloated, dark, upper half of the body and the pale, emaciated lower portion. The legs were the spindle legs of one in the terminal stages of a wasting disease, with no swelling and no pitting on pressure. There was no sign of free fluid in the scrotal sac or in the abdominal cavity. The liver was just palpable. The abdominal wall itself was not edematous except slightly so above the umbilical level. The line of sep- aration between the non-swollen pale, flaccid abdom- inal wall and the swollen, purplish chest wall whose skin and subcutaneous tissue felt hard and brawny, pitting only on quite firm pressure, was almost as clear-cut as is the line of demarcation in a case of gangrene, being distinctly marked close to the costal margins. "Cardiac outlines were difficult to determine be- cause of the thick, edematous chest wall, but the heart was evidently located somewhat to the left. And it was plain that there was an increased area of dullness 332 HEART AFFECTIONS. at the base of the heart and ovfer the manubrium. Here also could be very clearly heard the murmur already described, which is referred to in the history sheet as follows : 'A systolic murmur which lasts into diastole is heard over the precordium in front and the interscapular region behind. At the aortic cartilage the murmur is particularly distinct and most in- tense. Here it is continuous, soft, blowing, some- what htimming in character. It is accentuated with the ventricular systole, so that at such times it becomes a loud, slightly roughened blow.' There were numerous rales, both moist and dry, over the lungs, particularly behind. At the bases was dullness with some obscuring of breath sounds as from pleural fluid." Death occurred 8 days afterward. The Wassermann test was strongly positive. Therefore it is evident, from* the statistics and from the instances cited, that the prognosis in an aneurism that is recognized by symptoms or recog- nized by physical signs is always graAC, and the patient's life in constant jeopardy. This statement must stand, despite the fact that we all know patients with well marked physical signs of aneurism who have led lives of semi-invalidism for years. TREATMENT OF THORACIC ANEURISM. Manifestly no treatment will restore the integrity of the vessel wall (Fig. So). Attention should be directed to the relief of symptoms and to the prolonga- tion of life. The time for treatment is well nigh past when the larger aneurisms have formed. The time to have treated the patient was when the symptoms of aortitis or of aneurismal dilatation of the arch of the ANEURISM. 333 aorta presented themselves in months or years gone by. Should the Wassermann serologic reaction be positive, antisyphilitics are indicated with the hope of minimizing- the active inflammation of the vessel wall. Pain is the most distressing and most persistent feature which one is called upon to combat in aneu- rism. The routine emplo)'ment of iodide of potassium in 5- to 20-grain doses three times a day is believed to have some eft'ect in the reduction, of pain. Morphine may be required in the dose of one quarter of a grain hypodermically, repeated when needed for further eft'ect. Venesection in the form *of occasional small bleedings frec[uently repeated, is of value in relieving pain and the effect is at times surprisingly long con- tinued. Six ounces of blood may suffice at one vene- section. Pain further yields to the introduction of wire in an aneurism, this method of treatment being discussed further on. Diet. — The dietetic treatment of an aneurism has for its object the thickening of the aiTected vessel wall by the deposit of coagulated fibrin from the blood. The coagulability of the blood may, to a limited extent, be affected by diet, as may also blood volume and density. For these purposes Tufnell, of Dublin, sug- gested a rigid diet in aneurism. It is spoken of as "only less rigid than the old method of Valsalva, who gave a half a pound of pudding morning and evening and nothing else — practically starvation !"i Tufnell's treatment and diet is as follows: Absolute rest is strictly enjoined upon the patient; he is not permitted to make exertion of any kind. He should be 1 Thompson: Practical Dietetics, 3d ed., Appleton, New York. 334 HEART AFFECTIONS. fed by a nurse. By rest alone the ra.it of the heart-beat is materially slowed, and this is favored also by the reduced diet; consequently the pressure within the afifected artery is lessened. Breakfast. — Two ounces of bread with a little butter and 2 ounces of milk. Dinner. — From 2 to 3 ounces of meat without salt and 4 ounces of milk ; for a por- tion of the milk an ounce or 2 of claret may be substituted. Supper. — ^The same as the breakfast. If the patient can be induced to submit to this rigid diet such improvement in the physical signs of an aneurism as diminished pulsation and lessened pain is often marked. Improvement may be looked for within the week. If too long enforced over a period of six weeks, an extreme degree of anemia may develop. THE WIRING OF AN ANEURISM. Thoracic aneurisms of the sacculated variety may lend themselves to the beneficial results attendant upon the introdtiction of a fine platinum-gold wire into the sac, when they are close enough to the chest wall to permit the introduction of the. cannula which di- rects the wire. The purpose of the operation is to prevent a rupture of the sac at that point where rup- ture is most likely to take place ; the wire is introduced into the sac — not into the caliber of the \-essel — with the hope that a clot ma\' form around the wire and thus retard a rupture of the aneufism wall. It is an operation not to be lightly undertaken. The intro- duction of the cannula may result in sudden rupture of the aneurism — a possibilit_\- that should invariably be explained to the relatives beforehand. ANEURISM. 335 The possibility that the wiring of an aneurism at one point may so deflect the blood stream as to cause a sacculation to appear at another and inaccessible point in the vessel wall, should not deter the physician if the procedure is indicated, the patient and relatives acquiescent, and the case a suitable one. Preliminary studies of the case are of course made by fluoroscope and by skiagraph. At the conclusion of the wiring the Rontgen light is again requisitioned to determine the position of the wire and establish the success of the procedure. In the method devised by Corradi, the skin over the aneurism is sterilized and protected from the ac- tion of the electric current. From lo to 15 feet of fine platinum gold wire is introduced through a small porcelain or lacquer-covered cannula. Some aneu- risms are of a capacity that will hold 45 feet of the wire. The end of the wire is now connected to the positive electrode of a galvanic battery, and a large wet electrode on the patient's back connected with the negative pole. The current is turned on to 5 milliam- peres and increased a like amount every 5 minutes until 50 milliamperes are being used. The acid re- action produced by electrolysis about the gold wire produces a firm clot, and by the end of half an hour pulsation in the sac is often notably diminished. No other alloy than platinum should be employed ; a cop- per alloy will be dissolved under the electric current. If there is an excess of platinum in the wire, it may be so springy as to push aside any fibrin already de- posited on the vessel wall, and by its resistance, push out the wall of the sac and thus defeat the purposes of the operation. At the end of an hour the electrodes 336 HEART AFFECTIONS. are disconnected and the free end of the wire pushed beneath the skin, the cannula withdrawn and the puncture sealed. The procedure has been successful in closing the sac in several instances. One of the most beneficial results is the marked relief from pain, which may occur within 5 minutes following the operation. After wiring an aneurism the patient should remain perfectly quiet in bed for two or three weeks to favor consolidation of the clot. CHAPTER XXL Angina Pectoris. THE CONDITION DEFINED. Angina pectoris, which hterally means "strang- ling of the breast," was cUnically described by Heber- den in 1772. The term is apphed to a symptom com- plex consisting- of: (i) paroxysmal attacks of pain, commonly substernal, often radiating down an arm; (2) a sense of constriction within the thorax; (3) a sense of impending death. It is necessary to enlarge upon the usual concep- tion of angina pectoris, both as to etiology and symp- tomatology, if one desires to recognize it in the early stages. This condition is capable of early recognition, provided one constantly bears in mind that any one of the three items enumerated in the symptom com- plex may be lacking — or may be so altered as not to come within the scope of the definition. The paroxysmal attacks of pain, for example, which have heretofore been spoken of as occurring at the precordium, are far more frequently located under the sternum : indeed they may have their origin along the course of distant arteries and not be felt in the upper region of the thorax at all. Again, while it is perhaps more usual for the pain of angina pec- toris to be referred to the left arm, it frequently hap- pens that it is referred to the shoulder, to the neck, to the right arm, to the back or even to the abdomen, 22 (337) 338 heArt affections. in which latter situation it may be mistaken for a gastric disturbance. In other instances, pain may be altogether absent, as has been recognized from the time of the earliest writers, who defined such a cir- cumstance by employing the term angina sine dolore. The sense of constriction is not invariably confined to the thorax, but may originate elsewhere and be referred to the pectoral region. The angor — a term which means great anxiety accompanied by painful constrictions and oppression- — is occasionally first felt in the abdomen or along the course of the larger arteries, such as the brachial. The sense of impending death, which has been usually described as due to fear, is not as a general thing accompanied by a feeling of fear. It has been repeatedly observed that sufferers with angina pec- toris are remarkably calm and self controlled when in the throes of an attack, despite the fact that many of them recognize the seriousness of their condition. It is clear, therefore, that unless one revises the usual conception of angina pectoris sufficiently to in- clude such broader interpretations of symptoms, one may fail to diagnose the condition in its earliest phases. OBJECTIONABLE TERMS. It is to be deplored that such- terms as "pseudo angina," "mock angina,"" "false angina," etc., have crept into medical literature. More extended obser- vation of such cases will frequently establish them as atypical instances of true angina pectoris. Time quite generally proves that the "mock"" anginas are mild attacks of the true condition, which have been dis- missed from consideration and proper treatment un- ANGINA PECTORIS. 339 der the reassuring diagnosis of "pseudo angina." Ingals^ who spoke of this subject with a depth of feehng born of intimate acquaintance, stated that the majority of patients with "false" angina die sooner than do those who suffer from diagnosed angina pec- toris — the palpable reason being that the former are neglected while the latter receive watchful care and proper treatment. Hysteria may of course simulate angina pectoris, just as hysteria may simulate any malady. But even though the symptoms prove to be due to an hysterical attack, it is far better for the physician to err on the side of the grave malady and to treat the patient ac- cordingly, rather than to fail to diagnose, or neglect, a condition which time may prove to be angina pectoris. ETIOLOGY. Angina pectoris is known as "The disease of doc- tors," for the reason that it figures so often as a cause of death among medical men, an illustrious example being the eminent John Hunter who suffered with the condition for twenty years and finally died in an at- tack. High tension livings is regarded as a very fre- quent factor in the production of angina pectoris ; this may explain its greater frequency among persons of the better class. It has a much higher incidence in men than in women. \Miile occurring with greatest frecjuency between the ages of 50 to 70 years, it is not confined to this period of life, but may be observed in young" adults and occasionally even in youth. The etiologic factors may be divided into three great classes; first, the neurotic class which includes 1 Ingals, E. Fletcher : Chicago Institute of Medicine, Mar. 28, 1918. 340 HEART AFFECTIONS. persons whose lives are spent under nerve tension and who are given to worry and anxiety. Second, those with a history of previous toxic diseases. Third, those of more advanced years who present other symp- toms of arterial degeneration. Among the infections to which angina pectoris can frequently be attributed are typhoid fever, gout, acute rheumatic fever, and blood impoverishments. The condition is often associated with aneurism, mitral stenosis, pericarditis, and thrombosis. It is probable that the primary infection which induces these cardio- vascular affections causes other initial damage which later develops into angina pectoris, Syphilis is not the all-inclusive factor which some syphilographers would lead us to believe. LeCount^ has noticed that syphilis is a likely cause in persons under 45 years of age — an opinion in which many observers concur ; but considering the comparative in- frequency of angina pectoris at this period of life, syphilis is robbed of much of its etiologic significance. Josue^ a French physician, believes that angina pec- toris is an almost certain sign of syphilis, but was able to secure a positive W'assermann reaction in only 33 per cent, of his cases. PATHOLOGY OF ANGINA PECTORIS AND ARTERIAL PAIN. The view that angina pectoris is caused by a spasm of, or by occlusion of, the coronary arteries, thereby depriving the heart of its nourishment, has never proved an altogether satisfactory explanation 1 Le Count : Jour. Am. Med. Assn., April 6, 1918. 2Josue: Paris Medical Journal, July 5, 1919, 9-27. ANGINA PECTORIS. 341 of this condition. It has been repeatedly observed at necropsies of persons who expired" during an attack of angina pectoris, that the coronary arteries were free from any macroscopic evidence of disease. It has further been observed that angina pectoris cannot be wholly attributed to degeneration of the heart muscle, for persons who have succumbed in attacks of angina pectoris have been found at necropsies to have apparently healthy heart muscle. No evidence of dis- ease could be found. Another hypothesis, which at- tributes the cause of angina pectoris to sclerotic changes in the walls of the blood-vessels, does not fur- nish a clinically satisfactory explanation, for the reason that some persons with the most advanced arterial degeneration have no evidence whatever of attacks which simulate angina pectoris. The views of the English school, which holds that angina pectoris is due to an affection of the walls of the aorta, are much in favor. This satisfactorily ex- plains the clinical phenomena of stibsternal pain and of constriction within the chest. It does not, however, satisfactorily explain the production of anginal symp- toms which begin in parts of the body distant from the thoracic aorta and which later localize, as it were, in the substernal region. It is well recognized, for example, that the first symptom of angina pectoris may be noticed in the left or in the right arm and, as the attack progresses, localize in the pectoral region. Likewise, attacks of pain of the same excruciating and transfixing character as those which characterize angina pectoris may arise in either arm, in the ab- domen or indeed in the leg, and the pain remain in these locations and not be referred to the pectoral 342. HEART AFFECTIONS. region at all. It is a repeated observation of many physicians that attacks of what subsequently proved to be angina pectoris had their locus in the abdomen, and were in the beginning confused with attacks of indigestion or other intra-abdominal conditions. In- deed, pain of this nature has been so generally ob- served that the term angina ahdominalis has been employed to designate the condition. What hypothesis, then, can we adopt which will furnish a universally satisfactory explanation for the production of angina pectoris, angina abdominalis or anginal pains which have their locus in any part of the body? If we adopt the premises that arteries are capable of producing pain, and that arterial pain is accompanied by a sense of constriction sufficient to inhibit voluntary movement and transfix the sufferer ^as any person to whom a tournicjuet has been too long applied can testify — a satisfactory hypothesis is forthcoming. It would account for anginal pains far distant from the pectoral region,; for "neuralgias" which are not iicri'c pains; for "hysterias" which eventuate in cardiovascular breakdowns ; even the pains of intermittent claudication might find an ex- planation were their etiology thus predicated. What changes could take place in an arterial wall to so per- vert its normal function? This subject oft'ers still further material for conjecture. Such a perversion of arterial function might arise from changes in the caliber of the vasa vasoruni which nourish the media; it might be due to changes in the unstriped muscle fibers which form the muscular coat of the arterial wall; again, it might be due to disturbances in the nerve supply of either the vasomotor apparatus or, ANGINA PECTORIS. 343 perhaps, to sympathetic nerve aifections. We have not yet begun to appreciate the perverted physiologic function which could arise from a disturbance of these delicate structures which enter into the construction of blood-vessels. Future investigation along these lines may reveal a definite explanation of the cause of arterial pain — or the cause may forever remain shrouded in doubt and leave us no firmer footing on which to base the production of angina pectoris, an- gina abdoniinalis and angina arteritis than the prem- ises that such anginas are the result of disturbances in a blood-vessel wall. SYMPTOMS. The pain and anguish of angina pectoris are suc- cinctly described in Seneca's description of his own case; "the attack is very short and like a storm. To have any other malady is only to be sick; to have this is to be dying." Pain has its seat in the region which underlies the sternum in those cases where the aorta is involved ; but it may be located in other arteries, or may begin in the vessels of the arm or neck and later be re- ferred to the substernal area. Pain is paroxysmal in character, the attacks lasting perhaps only for a few seconds, though they are usually of several minutes duration; they may last half an hour or longer. During the attack of pain there are often momentary intervals in which the pain increases — a waxing and waning of the angor, as it were, causing excruciating distress. In a few patients, dull pain may be con- stantly present for a period of days. In the majority of cases it radiates to the left arm, but it may also 344 HEART AFFECTIONS. radiate to the right, or involve hckh arms. It should be remembered that radiation of pain is not essen- tial to the diagnosis of angina pectoris; indeed, as previously stated, there are well marked instances of the condition where pain is not present at all — angina sine dolore. The sense of impending death transfixes the pa- tient to a greater or less degree and inhibits his move- ments. This sudden arrest oi motion which is induced by the angor and by the sense 6i impending death often results in the assumption of dramatic attitudes. For example, when a patient is raising himself from bed his movements may be suddenlv arrested by an attack of angina and he be transfixed, resting on one elboA\' with the other arm thrown out, the chest pro- truded, the head thrriwn back, with his gaze fixed on the ceiling. As the anguish lessens the patient slowly assumes a more natural position in bed. The sense of impending death is not due to fear. On the con- trary, should a patient attempt to- talk during an at- tack the tone of voice is usually quiet and well re- strained. Even though he at tinles cries out in his anguish, the response to questions^ between such cries is generally made in a well controlled ^•oice. Profuse perspiration is to be expected in this anguishing malady, beads of perspiration often stand- ing out upon the forehead. The face is usuallv blanched and colorless although it may at times be flushed. Dyspnea is not at all characteristic of the condition, but is often ])resent in thi)sc cases where the heart muscle is believed to be alTected. The pulse, except in the alarm of first attacks, is usually unaltered from its pre-existing condition. If it has exhibited ANGINA PECTORIS. 345 any irregularities before the attack it is not at all likely to show any alteration in such irregularities, nor even a change in rate, during the progress of the seizure. Any change in rate w'hich does occur is likely to be slowness of the pulse. It is unusual for the blood-pressure to be at all changed from its pre-existing condition, although in first attacks systolic readings may be elevated. The lungs may at times be acutely emphysematous during an attack of angina pectoris, as described by von Basch. PHYSICAL SIGNS. There are absolutely no physical signs character- istic of angina pectoris; those which are present are indicative onl_\' of associated conditions and are in no sense diagnostic of angina pectoris. The transverse diameter of the aortic arch may be found increased on percussion and the observation may be confirmed by fluoroscopic examination. An aortic murmur is often present; systolic pulsations due to a dilated aorta may be observed to the right and left of the sternum in the second interspace. The infiltrated blood-vessels of arteriosclerosis are often observed. All of these signs may be ;i.b,solutely lacking in a given case and, if present, it should be remembered that they are indicative only of associated conditions. DIAGNOSIS. The diagnosis of angina pectoris is based upon the symptoms previously described- and upon the his- tory of similar attacks. Inasmuch as it is possible for angina pectoris to be preceded by anginal seizures along the course of blood-vessels which are a dis- 346 HEART AFFECTIONS. tancc from the pectoral region, it is well to regard with suspicion the occurrence of arterial pain., as being possibly indicative of eventual angina pectoris. Therefore, if one is to be on the qui vive for early symptoms, a sense of constriction after such ordi- nary causes as fast walking or hill climbing should be regarded as of possible arterial origin. A pain recurring in the same location or under similar cir- cumstances is equally suggestive. Recurrent pain along- the course of an artery which is attendant upon the ordinary causes mentioned above, is most significant. Substernal pain radiating to the left arm or both arms with a feeling of constriction within the thorax and a sense of impending death are definitely diag- nostic of angina pectoris. PROGNOSIS. Guarded, not necessarily fatal, is the prognosis in angina pectoris. In young subjects or in those in whom it is induced by toxic agents, apparently complete recovery may ensue. Attacks which are brought about by overwork or which arise as a result of high tension living offer, of course, a more hope- ful prognosis as to relief than do those which result from degeneration of heart muscle or from arterio- sclerosis; under these latter circumstances the prog- nosis of associated angina pectoris is grave. Patients whose hearts exhibit a fair amount of cardiac reserve force may live through years of s-uccessive attacks; on the other hand, the weakened myocardium may succumb early after the establishment of the malady. ANGINA PECTORIS. 347 Herrick and Ntizumi give the average duration of life, in fifty patients who subsequently died with angina pectoris, as nearly three years following the onset of symptoms. It is believed'-fhat the immediate cause of death in angina pectoris \\'hich terminates suddenly is due to the inception of ventricular fibril- lation, although there is as yet no direct proof for this belief. TREATMENT. Prophylactic Treatment. — The patient who is sub- ject to attacks of angina pectoris should be cautioned to avoid those causes which precipitate a paroxysm. Attacks may be reduced in frequency in some patients by the avoidance of rapid walking. Walking against the wind is another provocative circumstance. At- tacks are invited in many subjects when they attempt to climb a hill or ascend a staircase without pausing" at f recjuent intervals in the ascent. The late James Honan believed that attacks were precipitated in those patients who walked immediately after meals and who were anxious to reach their destination — as for ex- ample the business man who hurries to his office im- mediately after breakfast. Sudden changes of pos- ture, or lifting, reaching or stooping, may also induce the condition. Sudden temperature changes are among the exciting causes. Exposure to cold air, as when the patient is greeted by a wintry blast as he steps from a well heated house, will bring on the symptom-complex in many persons who are subject to angina pectoris. Ingals^ expressed the opinion that meteorologic conditions bring on an attack, and 1 Herrick and Nuzum : Jour. Am. Med. Assn., Jan. 12, 1918. 2 Ingals: Loc. cit. 348 HEART AFFECTIONS. mentioned an instance in which a patient who was sit- ting in a warm railroad car was seized with an attack of angina pectoris when the train ran into a wind storm. Hurry and excitement undoubtedly favor the oc- currence of angina pectoris. Faulty habits of eating, or the ingestion of indigestible foods which cause flatulence, are exciting factors, as is also constipation. An ocean voyage benefits many patients who are subject to angina pectoris, probaJDly for the reason that they leave care and worry behind and, on board ship, are removed from their accustomed habits of life and find little occasion for the physical effort which, at home, would induce an attack. There are other persons, notably those who are not of the high strung type, in whom ocean voyages produce little benefit. A further step in the prophylactic treatment of the condition is to search for the cause of an under- lying anemia. This anemia may be due to blood dyscrasias, or to focal infections, or to systemic infec- tions, of which latter syphilis is an instance. Palliative Treatment. — Nitroglycerin is the remedy par excellence in relieving an attack of angina pectoris. When liberally employed it quite generally proves to be an efficient remedy, but when given timidly or in the usual dose of Vioo of a grain, but little result can be expected. Ingals stated that he received benefit and noted improvement of symp- toms within three minutes after a tablet of nitro- glycerin was dissolved on the tt»ngue. The effect of the drug is fleeting, however, arid it may be neces- sary to repeatedly dissolve on the tongue tablets of ANGINA PECTORIS. 349 the strength of Vioo of a grain tmtil the attack is relieved; in this way as much as V20 of a grain may be taken in the course of a day. A violent headache is often the result of administering the drug in un- usual dosage. It is, of course, the part of wisdom for the physician to begin with the usual dose of Yioo of a grain in a patient whom he sees for the first time, and to gradually increase the frequency of adminis- tration until the amount required by the individual patient and the degree of reaction is understood. Liquor trinitrini, i per cent, solution, given in 10 minim dose, is often efficacious, but requires the lapse of several minutes before its therapeutic action becomes manifest. Amyl nitrite is employed for relief of an attack by crushing- a pearl containing 5 minims in a hand- kerchief and inhaling the drug. It has an odor which to some persons is sweetish and sickening and is as often disappointing in its eiTect as it is at other times productive of good results. Morphine and atropine, in the usual hypodermic dose of % grain of the former drug and Viso of the latter, may be used to abate the severity of a pro- longed attack. Hot drinks may also be used with benefit in attacks of unusual duration, and external heat may be applied for the purpose of relaxing vaso- constriction. The use of chloroform to abate an attack of angina pectoris is a dangerous procedure, when there is no previous knowledge of the condition of the heart muscle or of the condition of the arteries (page 409). Potassium iodide is effective in relieving the anguishing pain of angina pectoris in some instances. 350 HEART AFFECTIONS. Even though its beneficial effects be not immediately manifest, it very frequently lessens the intensity of a paroxysm and retards the frequency of subsequent attacks. Potassium iodide is not a remedy to be re- served for exhibition in syphilitics alone; it proves effective in cases where there is no evidence of syphilis. Sodium nitrite in the dose of i to 2 grains may be tried in those instances where there be dull, con- tinuous pain. Opium in the dose of one grain morn- ing and evening may also be used under the same circumstances. Carminatives are employed for the relief of flatulence, it being frequently noted by pa- tients that an attack of angina pectoris ceases with belching. It is probable, however, that belching is more often occasioned by air which has been swal- lowed during the paroxysm, rather than by the flatu- lence of indigestion. If the pulse be slow atropine sulphate hypoder- mically in dose varying from Mi.^o to ^740 of a grain a day is approved therapeutics. Atropine paralyzes the peripheral ends of the vagus nerve, and if any part of the attack be due to vagal influence, atropine may correct such influence. Digitalis. — Digitalis is of very little use in the treatment of angina pectoris. It is more apt to pro- duce undesirable results than good effects, and in the opinion of many observers, distinctly aggravates the condition. There is little occasion for its vise unless auricular fibrillation coexists with angina pectoris, in which combination of conditions diaritalis benefits the heart delirium and improves the general circulatory condition of the patient. ANGINA PECTORIS. 351 Improvement may follow the employment of medi- cated baths, between paroxysms, in persons who are subject to angina pectoris. The employment of such baths is discussed under Balneotherapy, page 389. The condition of the heart muscle should be ex- haustively investigated in every patient who presents symptoms of angina. The electrocardiograph may at times reveal significant curves that indicate some form of heart muscle involvement. The possibility of Rontgen-ray examination of the mediastinum detect- ing pathologic conditions should also be borne in mind. CHAPTER XXII. Neuro-circulatory Asthenia. THE NAME. Da Costa, writing in 1871 of certain nerve and circulatory phenomena \vhich he encountered among mihtary men of the Civil War, employed the term "irritable heart of soldiers." Early in the recent World War such cases were referred to by military surgeons under the phrase "DiA.H." — disordered action of the heart. Inasmuch as the characteristic symptoms of the condition — hurried respirations, rapid heart rate, precordial pain, tremulous fingers and bluish hands were disproportionate to the slight aniottnt of physical effort required to call them forth, English writers later employed the terminology "effort syndrome" to describe the condition. A still further refinement of nomenclature, ncuro-circula- tory asthenia, seems to be an apt phrase to define the asthenic who is a potential cardiopath and a poten- tial neuropath as well. Perhaps the limit of termin- ology for the symptom-complex has not yet been reached; a generation later than ours may credit the one who first described it and give it such a name as "DaCosta's circulatory syndrome."" THE SYNDROME IN CIVIL LIFE. Neuro-circulatory asthenia is not at all peculiar to military life. It exists, active or quiescent, among (352) NEURO-CIRCULATORY ASTHENIA. 353 civilians of all classes of society. It is typified in the rather frail, neurotic, emotional person who collapses in psychic emergency or who breaks down under trifling physical strain. The hurried respirations, rapid heart-rate, precordial pain, tremulous fingers and bluish hands of this type have caused them to be referred to in the past as having an "excitable heart," a "nervous heart" an "adolescent heart;" the condi- tion has been designated "functional heart disease," and even referred to by the unpardonable term of "masturbator's heart." There are lesser degrees than this extreme type in civil life, found among people of sedentary existence — occasionally, too, among those of slothful habits — whose nervous and circulatory sys- tems are c|uite sufficient to the demands of their work- a-day life, and to any additional burdens incident thereto. THE SYNDROME IN TRAINING CAMPS. Now, let such an under-developed, yet self-con- tained and efficient individual, be thrown suddenly into the military whorl, with all its rigors and strains. Submit him to the unusual physical demands thus im- posed on undeveloped muscles; deny him his accus- tomed periods of rest; bend the individual's personal inclinations to the will of a distasteful or overbearing military superior; subject him to the constant fear of court-martial for some slight and unintentional in- fraction of army rule; surround him with the taunts of jibing comrades that prod him on when wearied nature demands rest for exhausted mind and body — it would seem that there could be nothing in the world that would more quickly make a neuro-circu- 23 354 HEART AFFECTIONS. latory weakling out of a constitutionally inferior per- son than the army gaff. Perhaps this is the reason more of these cases are observed in training camps than in civil life. At this stage the asthenic can still be saved to society if spared further effort ; he can be reconstructed, if painstakingly treated in development battalions. THE SYNDROME IN WAR. Take one with the above initial conditions and add the physical drain and the infections often attendant upon exposure, lack of sleep and poor nutrition on the battle-field; add, if you please, the shock of conflict and the carnage of war : and it is then found that one who was a perfectly efficient producer at home has become a quite useless waste-product of the front, fit to serve in neither civil nor military life. Such is the evolution of the neuro-circulatory asthenic in war. PREDISPOSING CONDITIONS. Although neuro-circulatory asthenia arises for the most part in individuals of the neurotic, neurasthenic or neuropathic type, who also haVe family histories along these lines, it is not necessarily confined to this group. Tuberculosis predisposes to the syndrome. So does goiter — so do low-grade infections, such as trench fever. It may arise if physical activities in- terrupt an insufificient convalescent period from pneu- monia, typhoid fever, or influenza. It may arise as a result of the inhalation of poisonous gases that affect the heart as well as lungs and bodily metabolism. In short, any condition that renders one constitutionallv inferior furnishes the canvas upon which the clinical picture of the cifort syndrome may be painted. NEURO-CIRCULATORY ASTHENIA. 355 TYPICAL CASE RECORD. For the purposes of this discussion I have analyzed a group of 100 consecutive cases of neuro-circulatory asthenia. From this analysis a typical case-history can be constructed, as follows : X. Y. Z., Age, 25 years. White. American. Clerk. 5 feet 6 inches. 135 pounds. General appearance: Healthy, frail. Hands bluish cast. Development : Slender. Skin : Pallid, fine texture. Family history: Mother subject to "nervous breakdowns"; had "spells with her heart." Rrother of slender build. Sister "nervous." Previous diseases : Irrelevant. Habits: Irrelevant. Personal history : Never indulged much in athletic games. Tires easily on physical effort. Has stopped work and taken to bed for brief intervals on occasions in past two years, on account of "having worked too hard" and being "nervous." Gave up job requiring physical effort and took clerking position. Presenting symptoms: Pain over heart, shortness of breath and palpitation following exercise. Easily excited. Physical examination : Thyroid gland palpable. Fine tremor of finger tips. Precordial hyperesthesia. Arteries elastic, pulse of usual volume, regular, rapid. Precordial impulse diffuse, striking, quick. Apical systolic thrill when erect. Cardiac borders : Transverse 12 cm., apparently not increased after exercise. Maximum cardiac impulse 7j4 cm. from mid-sternal line. Murmurs: Apical systolic, not transmitted; P2+. Rates J^*^^"^^ Exercise Immediately after 100 hops Two minutes later Respiratory 16 Ventricular 117 Radial 117 34 151 151 24 127 127 Deficit? Moderate dyspnea Diagnosis: Neuro-circulatory asthenia, moderately severe. 356 HEART AFFECTIONS. FURTHER POINTS IN ANALYSIS. It is interesting to carry the analysis of the hun- dred cases a bit further, as it gives one a more elastic picture of neuro-circulatory asthenia. Reasons Referred. — Forty per cent, were referred for tachycardia ; twenty-six per cent, for mitral dis- ease. The latter diagnosis \\-as probably based upon the detection of apical systolic murmurs, as they were present in 26 hearts. (Valvular disease did not exist in any of the patients). Twenty-two were referred with the sentence "Heart examination desired," showing that their hearts had been recognized as departing, in some indefinite manner, from usual standards. Previous Diseases. — Each man of the hundred had one or more of the following diseases earlier in life. Abscessed ears 7 Pertu'ssis S3 Abscessed teeth 12 Pneucnonia 17 Chorea 1 Rheumatic fever 3 Diphtheria 13 Scarlatina 9 Gonorrhea 18 Syphilis 3 Measles 74 Tonsillitis 24 Mumps SS Typhoid fever 11 Habits. — Seventy-one used tobacco five or more times a day; 32 smoked 5 to 10 times a day, 39 ten or more a day. Inasmuch as a previous investigation ( see page 38) had shown that 87 per cent, of a thousand American male adults smoked on an average of 11 times a day, there seems to be no fundamental con- nection between the tobacco habit and neuro-circula- tory asthenia. As to alcohol, 35 were accustomed to imbibing an ounce or more of spirits everv 24 hours. Presenting Symptoms. — Fifty-four of the hundred cases complained of precordial pain, especially after NEURO-CIRCULATORY ASTHENIA. 357 slight exertion. The following complaints had been present for an average period of 2^ years: Giddi- ness in 67; palpitation in 63; shortness of breath in 38 and fainting in 20 instances. Forty had, on various occasions during that time, found it necessary to stop work and take to bed as a result of these symptoms. General Appearance. — Forty-nine were of the usual healthy facial appearance: 27^ were pallid; 20 were florid. Fifty-four had cyanosis of their hands and forearms in varying degree, especially noticeable when the hands hung dependent. Fifty-four showed tremors of the finger tips of the outstretched hands before exercise, or else tremors of the lightly-closed eyelids. Concerning the mental attitude which these neuro- circulatory asthenics assumed toward their cardio- vascular examination: fifty-four displayed no more than the usual interest in the maneuvers; 25 were alert; 11 were anxious; to were apathetic. Thyroid Gland. — Of the hundred, 68 had palpable thyroid glands, varying in degree from those which had to be carefully sought for by palpation, to most apparent thyroid enlargements. Pulse and Pulsations. — The pulse in the greater number of cases was regular and of good volume. Sinus arrhythmia was present in 12 of the patients. The arteries, for the greater part, were of the usual elasticity found in health. Visible pulsations were not observed in the neck, in the brachials or at the base of the heart; at the apex a forcible impulse was present in 37 of the cases. The precordial impulse was dififuse — "irradiation" — in 60 of the hundred. 358 HEART AFFECTIONS. Blood-prcssurc Estimates. — The systolic estimates were quite what one would expect to find in neuras- thenia — never constant, often low — frequently ele- vated, perhaps 20 points over what is considered usual. Pulse Rates. — The average pulse-rate was 117 before exercise; it was 151 immediately after 100 hops, and 127 two minutes following. These figures do not represent the full excufsus of the neuro- circulatory asthenic pulse. In some the rate was 84 before exercise; in others it shot up to 204 inuned- iately after. An occasional patient was not exercised at all, as it was felt that an initial pulse-rate of 144 was sufficient warrant for not adding to the load of a tumultuous heart in seven of the lOO patients. Eight were unable to finish the test on account of urgent dyspnea arising. Two collapsed completely and fell to the floor with air hunger. Cardiac Borders. — The right border was believed to average 2.4 cm. from the midsternal line; the left border averaged 9.5 cm. The maximum cardiac im- pulse averaged y.y cm. from the midsternal line, in the fifth interspace. There is nothing unusual in the measurements. It was interesting" to note that in not one of the cases did palpation and; percussion reveal an increase in the left border following exercise. Heart Sounds. — Murmurs were present, prin- cipally at the apex, in 32 instances. An apical systolic murmur was heard in 26 cases and was transmitted to the axilla in seven of that number. The pulmonic second sound was accented in 45 of the hundred cases. The aortic second A\'as accented in 3. Among the 68 cases in which no definite murmur was heard at NEURO-CIRCULATORY ASTHENIA. 359 the mitral area, 34 had a marked aheration in the character of the mitral first sound, described as snappy in 13 of the hearts, as prolonged in 14 and as plus in 7. In other words, there were deviations in the auscultatory phenomena in every one of a hundred cases. TREATMENT. Going back in memory a few years, one can recall the "marvehous heart cures" that returned to Amer- ica, boasting of the wonderful results of treatment at German spas. Some patients had, unquestionably, been benefited — and now one asks one's self the ques- tion : were not these "cured" cardiopaths of that time similiar to the neuro-circulatory asthenics of today? Spa treatment certainly combines all of the essentials that contribute to the restoration of the neuro-circu- latory asthenic. Freedom from accustomed worries and from the routine cares of a too-familiar daily life; the avoidance of physical strain; cjuiet, peaceful sur- roundings; the interest of new acquaintances; regu- lated daily habits; personal hygiene; skilled nursing, but no others than the first few days spent in bed; dietetic regime; elimination; the soothing effects of baths; graduated exercises. Perhaps this treatment explains why more than one "aiormously dilated heart" — as many a neuro-circulatory asthenic be- lieves himself to have when he notices his diffuse pre- cordial impulse — returned to normal size! Be that as it may: the treatment which the "cured" cardio- path received is the ideal treatment for the neuro- circulatory asthenic of today. (The adaptation of graded exercises is discussed on page 383.) 360 HEART AFFECTIONS. CONCLUSION. The question is frequently asked — "Which sys- tem, nervous or circulatory, is primarily at fault in neuro-circulatory asthenia?" Neither is, necessarily, but cither uiav be. The syndrome arises as a result of continued or repeated emotional strain or physical stress in excess of the capabilities of a ivcakencd or constitutionally inferior person. He may be con- genitally weak, or he may be weakened by accident, by physical strain, by emotional stress or by disease; the weakness may be in nerves, or circulation, or lungs, or glands, or muscles, or bones. Wherever the weak- ness be, the nervous and circulatory systems endeavor to maintain the individual's physiologic balance. Their efforts in this direction may be no greater than those put forth by other bodily functions in the same common cause, the struggle for physiologic balance. But it happens that the nervous and circulatory sys- tems are noticed more than the others, for theirs is the louder voice of complaint. CHAPTER XXIII. "What Can be Done for Heart Disease?" There is a general impression, not altogether confined to the mind of the laity, that little can be done for heart conditions after once establishing the diagnosis. Indeed it is not unusual to hear the re- mark that all one can do for a person suffering from a heart affection is to put the patient at rest in bed and administer digitalis ! Consider the case of tuberculosis. Even the younger physicians of this generation will have no difficulty in recalling the time when a diagnosis of pulmonary tuberculosis was quite equivalent to the pronouncement of a death sentence upon the patient. Despite that gloomy prognosis, which was nurtured in the mind of the public by the skepticism of the physician, there were many excellent students of medicine who devoted their lives to the recognition of early signs and to the development of rational treatment for what was then called the "great white plagTie." The discovery by Koch, in 1882, of the causative bacillus gave an impetus to the studies of tuberculosis, and the results since achieved by the employment of proper feeding, elimination, hygienic and sanitary measures, are a triumphant vindication of those men of vision who insisted, in spite of popular opinion, that tuberculosis is a preventable and curable disease. The education of the pubhc to this belief has resulted in the building of vast sanatoria with public (361) 362 HEART AFFECTIONS. funds, where such patients can be segregated and skil- fully treated. He would be rash who, in the present day, would utter in the presence of even the most uneducated layman, a hopeless prognosis in every case of pulmonary tuberculosis. Such is the change that one generation has seen in the treatment of a chronic lung affection. The tuberculosis situation of a generation past finds a parallel in the study of heart disease today. From the time of Celsus and Galen there have been philosophers who believed that the treatment of heart disease could be put upon a rational basis. Despite the skepticism which surrounded them, investigators such as Morgagni, Corvisart, Laennec, Hope, Stokes, Corrigan, Quain, Balfour, and Babcock persisted in the study of cardiac conditions and evolved methods of treatment which bore fruit in their day, and which form the basis for modern therapeutic measures. Heart disease, it is true, has no specific bacillus for a present day Koch to discover; but Mackenzie, the Father of Modern Cardiology, has performed an equivalent service by devoting his life to the pioneer work of identifying by means of graphic records, early cardiac conditions which may be fore-runners of ex- tensive heart damage. It will probably never be necessary for the state to maintain institutions for the segregation of patients with heart affections, for heart disease, per se, is not communicable: but in the large centers of population cardiac clinics are already springing into existence at a gratifying rate and have for their purpose the treatment and instruction in self-care of persons so afflicted. The education of the public should be continued until the "WHAT CAN BE DONE?" 363 earlier symptoms of heart affections are so generally recognized that patients will, of their own accord, consult their physicians at a time when' beginning cardiac defects can be prevented from developing into the hopeless heart wrecks that stigmatize our profes- sion. Indeed, while it may seem Utopian, such in- struction should be carried to that point where a person who has suffered from any acute infection will appreciate the necessity of a thorough cardiovascular examination before venturing a return to his usual manner of living, and have the examination repeated a few weeks after he has entered thereon. This in- struction of the public must come from the physician ; and if the Doctor in Arte Medica is to be a true "Teacher in the Art of Medicine," he must forever abandon the skepticism which now belongs to the past and harmonize his mental attitude with the trend of the professional thought of today, which teaches that heart affections belong in the category of preventable and curable conditions ; but as in the case of tuber- culosis, both preventability and curability depend upon the recognition of early symptoms. THE EARLY RECOGNITION OF HEART DISEASE. Ten years ago, in many quarters, a diagnosis of heart disease was built upon gross physical signs. The symptoms of which the patient actively com- plained were accorded little significance, so long as his heart was free from murmurs, his legs free from swelling, his respirations free from labor and his features free from cyanosis. In those days, when an apparently healthy person 364 HEART AFFECTIONS. presented no symptoms other than shortness of breath following accustomed effort, pain in the chest, pal- pitation, or a feeling- of faintness, or when he as- serted that his heart "turned over" at times, it was customary to listen at the precofdium and reassure him with the statement that perhaps he had "a little digestive disturbance," or else that his heart trouble might be "functional, certainly not organic." Func- tional! A functional fault in a heart could be lightly dismissed — but suppose it had been his leg that was not functionating properly; would not a more thor- ough search have been made for the cause ? Today, however, the profession of medicine is awakening to the necessity of adopting finer diagnos- tic technique and newer methods whereby heart dis- ease can be recognized in its incipjency. Nowadays, when a healthy-looking patient complains of short- ness of breath, precordial pain, palpitation and a feel- ing of faintness he has, first of all, a thorough search made into his history, habits and occupation — for past or present diseases, past or present habits, past or present occupation, may influence the heart in divers ways which this volume has endeavored to set forth. The individual's pulse is carefully studied and any variations in rate, rhythm or volume noted. His heart borders are outlined to determine significant increases in diameters and, if need be, these clinical observations are supplemented by Rontgen ray ex- amination. He is put through an exercise test to determine the rate-response of the heart to efTort. A polygram may be required to elucidate a vague arrhythmia, or an electrocardiogram be demanded in order to clear up a doubtful diagnosis. By such an "WHAT CAN BE DONE?" 365 examination does the physician secure the testimony which enables him to diagnose an early heart affec- tion before it advances to the stage of cardiac bank- rnptcy. Fig. 82. — Foreign Body in the Heart. Sharp eyes will be able to discern the needle to which the arrow on the reader's left directly points. The arrow on the right points to the inflammation of the myocardium where the end of the needle impinged at each pulsation of the heart. This heart is from a former patient of the Norristown asylum. Supposed duration, over two years. (Courtesy of Dr. Allen J. Smith.) WHAT CANNOT BE DONE. The modern school of pulmonary teaching makes no claim that destroyed tissue can be replaced with healthy lung; nor does the modern school of cardi- ology assert that heart structure altered by disease is 366 HEART AFFECTIONS. capable of regeneration. Valve leaflets that are dis- torted by scar tissue can never again be made to approximate each other. Heart muscle structurally altered cannot be made to regenerate itself. There is no alchemist's art for the heart. Nothing can be hoped for as concerns the reconstruction of tissue. Surgery which has come so notabl}' to the relief of humanity in the early treatment of cancer, affords no hope in the treatment of heart conditions except in an indirect manner, as by operations on septic foci. Surgical manipulation of the heart itself is of such infrequent occurrence and so dependent upon the happy accidents of chance as to constitute surgical dramatics. The premises enumerated above are ob- vous, but it is fatuous to use them as a foundation for therapeutic nihilism, or for assertions that "noth- ing can be done for heart disease." Such specious utterances rob the cardiac sufferer of the hope that should be his, and paralyze constructive thought on the part of the medical attendant. WHAT MAY BE DONE. For convenience in studying, the treatment of heart affections can be divided into three general pro- cedures, namely: (A) prevention, |^B) correction and (C) conservation, which may now be considered in the order named. PREVENTION. The Infections of Childhood. — The prophylaxis of heart affections resolves itself, for the greater part, into watchful care of the heart du'ring the course of acute infections of childhood and adolescence. Chil- "WHAT CAN BE DONE?" 367 dren who suffer from "the usual diseases of child- hood" should be the subjects of careful heart- watch- ing- during the progress of such hitherto thought harmless, now believed pernicious, infections. For it is then that the initial damage, which perhaps does not openly reveal itself for years, may be imposed upon the heart. Little sufferers with even the milder forms of childhood diseases should not be permitted to play about the house during the progress of the in- fection ; they should be kept in bed in order that heart effort may be conserved. A cjuarantine period, as es- tablished by law, protects the heart to some degree by restraining the child's natural incentive to frolic with its comrades; but this period is usually not sufficient for thorough convalescence. The child may be fretful, restless and difficult to control during the period of enforced rest in bed or indoors; to restrain it without the employment of threats or an exhibition of force often calls for the greatest degree of tact on the part of the nurse and for sublime patience on the part of the mother. The purpose of restraint is to relieve the heart of un- necessary effort; fretfulness, or fear accelerate the heart rate and defeat this purpose. Many other little sufferers, however, seem to realize the seri- ousness of their situation and will submit to con- trol with a resignation that at times is pathetic. The tedious hours of convalescence should be whiled away with games, puzzle pictures, building blocks, picture books, drawing and painting materials; and when other entertainment palls, few indeed arc the children who are not content when an adult reads from a nur- sery book or tells a story. Other children should not 368 HEART AFFECTIONS. visit the little patient even though the danger of con- tagion be past; for playmates, by telling of their games or of their plans may sow the seeds of discon- tent and unrest in a mind that was perfectly satisfied with the attentions and diversions of care-taking elders. No time-limit can be set on the duration of convalescence from the acute infections of childhood; it is gauged by a study of the individual patient and by the child's return to a usual state of health. The word "convalescence" means "to grow strong," and it is infinitely better to err on the side of conserva- tism rather than to impose the burden of premature exertion upon a M'eakened heart that has not yet "grown strong-." During convalescence and in the activities follow- ing rettirn to play the little patient should be fre- quently examined to determine whether pulse, rate- response and early fatigue bespeak a myocardial aftermath. If electrocardiography be available it should be employed in the study of the child's heart ; and it should show normal curves before heart \igi- lance is relaxed, following the acute infections of childhood. Prophylaxis embraces the much-neglected point of sufficient period for conz'alcscencc, for adults as well as for children. An advilt ^^•ho has weathered the storms of acute rheumatic fe\'er, chorea, the more virulent attacks of tonsillitis, ]^TLierperal sepsis or other septicemia, should of course receive instruction from the physician that the convalescent period is to be not a matter of days but weeks. Yet even a greater danger to the heart lies in the neglect of heart care following minor infections, the cardiac "WHAT CAN BE DONE?" 369 significance of which is lately being recognized. For example, influenza is an increasingly common cause of heart maladies — not for the reason that the heart itself is affected during the short period of infection, but for the reason that patients who recover from in- fluenza frequently undertake their customary duties without a sufficient period of convalescence. The effort which ph)-sical fatigue entaijs upon the heart — the demands which the organism makes upon heart muscle in order that fatigued bodily tissues may be sustained — results in a depletion of cardiac reserve force and thus lays the foundation for cardiac ex- haustion, and perhaps for direct invasion of heart tissue by germs. It would be a safe rule for the fam- ily physician to insist that a patient who has had any acute infection should not be permitted to perman- ently leave bed until the rate and I'hythm of the pulse show no marked \'ariation on attempted effort; nor even after getting up should the jiatient be permitted to resume accustomed activities so long as a sense of ph3^sical exhaustion and an increased heart rate are manifest at the close of a convalescing day. Prophylaxis of heart disease finds a further em- ployment in the search for constitutional conditions such as occult tuberculosis, latent syphilis, thyrotoxi- cosis; or for focal infections, such as arthritides, car- ious denture, intestinal autointoxication — which may impair the efficiency of the individual and throw a load upon the circulatory apparatus. Especially should a search for a systemic condition, which may be causing a cardiovascular affection, be diligently prosecuted when the patient complains vaguely and indefinitely, perhaps, of substernal pain, precordial 24 370 HEART AFFECTIONS. distress, dyspnea on moderate exertion or an inability to perform accustomed tasks without distress. Under prophylaxis should alsb be considered the habits of the patient, many of which are known to be factors in cardiac derangement. Among these may be mentioned, driving the human machinery at high tension; the pursuit of business or pleasure far into the night; pernicious dietetic habits; over in- dulgence in physical exercise; hurry, worry, care and anxiety; and the habitual use of drugs. Here can be mentioned, too, the unnecessary and unwarranted ex- posure to infections which immoral habits engender; clean living in youth often brings as its reward a heart that is quite sufficient for ripe and mellow old age. The Patient's Daily Life. Patients who have recovered from acute infec- tions, especially if there was evidence of heart involve- ment at the time, often require elemental instruction as to the intimate details of their everyday life if they are to avoid the risk of subsequent heart strain. In briefly reviewing the subjects upon which patients seek advice, the remarks will be made to apply not only to the prevention of heart conditions, but also to the correction and conservation of hearts already afl^ected. Bathing. — The daily bath which is taken on aris- ing may be either a tepid sponge gr a tepid tub bath. The temperature of the water should be between 92" and 94° Fahrenheit. Prolonged immersion of the body is to be avoided. A warm towel should be used briskly for drying the body, and the bather "WHAT CAN BE DONE?" 371 should rest on bed or couch for a few minutes follow- ing a bath. Cold water baths, whether sponge, shower, tub or sea, entail a degree of shock and reaction to which only robust persons should be subjected. Hot baths are very relaxing and not advisable for cardiopaths. Superheated cabinets, Turkish or Russian baths are usually too exhausting to risk their employment. Bathing should, of course, be avoided immediately after eating or when digestion is in progress. Clothing. — Woolen underclothing may be re- quired in rigorous climates. As a general proposi- tion, however, it irritates the skin of the wearer and is a poor absorbent and distributor of bodily moisture. Cotton underwear is more desirable. There is a tendency on the part of semi-invalids to burden the body with clothing which by its bulk, hampers free bodily movements and imposes unneces- sary weight. There are other persons who, following the dictates of fashion, appear in unseasonable weather with neck and arms exposed, wearing stockings of thin silk with low cut shoes. One manner of dress is as extreme as the other. The purpose of clothing is to protect the body and keep it warm and comfortable according to season. Too much clothing, by hindering free muscular play and by keeping the body damp with perspiration that is perhaps^ barely perceptible, is as much to be condemned as is over-exposure of parts of the body where the cooling of the surface circulation cannot help but reduce the powers of resistance of the individual. Effort. — The rapid motmting of stairs should be avoided. It should be customary with physicians to 372 HEART AFFECTIONS. advise convalescent patients that they may chmb the stairs but once a day, pausing for a moment's rest in both ascent and descent. Hasty- movements of all kinds should be forbidden. The change from a re- cumbent to an erect position should always be deliber- ate and guarded. Shortness of breath following any attempted effort is a signal for the prompt cessation of effort. Stooping, as in caring for a furnace, and reaching, as in fumbling for an overhead light, fre- quently precipitate dizziness or vertigo. The lifting of articles such as chairs or coal pails, or the carry- ing of loads or bulky packages strains damaged heart muscle unnecessarily. Ploughing through snow or laboriously picking the way on slippery surfaces, have been responsible for many prostrations in cardio- paths. Bursts of speed are utter folly for the con- valescent and may retard such a person for weeks in his progress to strength. Affected arteries may respond to haste with sudden attacks of severe pain; while the result of bursts of speed upon af- fected heart muscle is too well illustrated bv sudden death in those who hurry for trains to recjuire further mention. Exercise^ including walking, is discussed farther on in this chapter as a therapeutic measure. Walking may be mentioned here in connection with the advice which the physician should give a convalescent pa- tient concerning walking in the wind, which imposes effort on even the strongest hearts. Talking when walking is also an effort that is poorlv borne by per- sons who are constitutionallv delicate. Exercise at times is distinctly contraindicatecL There are many people who have arrived at a time of life when the "WHAT CAN BE DONE?" 373 wear and tear of years is beginning to tell on the cir- culatory system ; and because they have always in- dulged in brisk walks they still insist on doing so, de- spite the fact that exhaustion, rather than the cus- tomary exhilaration, is the consequence. Absolute physical rest for a short period is the indication in such persons — after which short excursions of grad- ually increasing distances may be resumed. An afternoon rest of an hour or two is always advisable for those ^^■ho are returning to health. The siesta should be preferably taken after the mid-day meal and amid quiet, sleep-inducing surroundings. Clothing which interferes with perfect physical re- laxation should be removed and the room darkened, as far as is compatible with ventilation, before the person lies down to rest. Social affairs have an element of value in that they stimulate the desire of the patient to mingle with others and thus take the mind off of a recent illness and prevent the convalescent from cultivating a too- introspective frame of mind which in many borders upon hypochondriasis. The well mind concerns itself, for the most part, with three subjects — persons, things or ideas ; the minds of ailing persons are quite gener- ally concerned in a large degree, with their own physical condition. To be brought in contact with normally-acting minds is a therapeutic measure of no small benefit in the creation of a healthy mental atti- tude in the semi-invalid. Social affairs should of course not be continued into the hours intended for rest; receptions, card-parties or theatres that entail physical effort or that strain the endurance of the individual should not be attended. 374 HEART AFFECTIONS. Early to bed should be the rule of a convalescent. Individuals vary as to the number of hours of sleep required. It is said that Edison rarely spends over four of the 24 hours in bed; there are other persons who are fatigued for the day if they have less than nine hours sleep. Despite such individual variations, a person who wishes to exercise the greatest care of his circulatory system will relieve it of the effort of the erect posture for at least eight hours and for as many more as a sense of weariness or fatigue demands. Many people fall into pernicious habits of thought at bedtime by reviewing the day's events or by plan- ning the morrow. Others indulge in brain work until the mind is so alert that slumber is elusive. Still again there are those who devote the evening hours to exciting games or to forms of exercise that scatter repose — and there is also the unhappy class who discourage sleep by brooding over past or future fears. One should be mentally passive at bedtime. All forms of physical or mental employment should cease an hour before retiring. Sports. — Fishing, on first thought, would seem to be a form of sport of which even the infirm could freely partake — but it is to be remembered that the art of angling is divided into still and active fishing, fresh and salt water fishing. Still fishing from the shore or boat is an excellent pastime, with a day in the open, moderate exercise and the stimulating element of chance to commend it; the cautious and guarded movements in \\'hich an experienced disciple of AA^al- ton indulges rather than frighten a possible fish that might be in the neighborhood, are well within the "WHAT CAN BE DONE?" 375 range of physical effort of \\'hich damaged hearts are capable. Active fishing, however, svkIi as trudging along a trout stream, through underbrush and over boulders, with the constrained positions that are sometimes necessary in casting a fly with accuracy, impose a burden on easily exhausted hearts. I have seen more than one lawyer, stale from a winter in the court room, collapse after a happy day along a moun- tain stream. Salt water fishing is unobjectionable for those who enjoy this form of sport, providing a companion is along to relieve the cardiopath of the physical strain of landing a heavy fish which interposes a gamey resistance to the line. Rowing is healthful exercise 'for the cardiopath, providing it is iudiciousl}^ indulged in. The heading of a boat against the wind or pulling it in the face of a storm ; the loading of the boat with passengers whose weight adds to the effort of the stroke; rowing in contests or boating in a broiling sun should all, of course, be interdicted. Szvirnining should be advised against. It has the objectionable features of the initial cold plunge, the overcoming of the resistance of the water and the simultaneous employment of leg and shoulder muscles which precipitate sudden exhaustion. One may speculate as to how many drownings of "expert swimmers" are due to precipitate, cardiac exhaustion or arterial spasm. Skating is an exhilarating pastime whether it be on ice or floor. There is no reason why it should not be indulged in by a young person who is accustomed 376 HEART AFFECTIONS. to this form of sport and who has apparently re- covered from a heart afifection. Golf IS a form of outdoor sport particularly suited to the confirmed cardiopath and to those with the arterial changes of advancing years. However, mod- eration should be used and in some cases it is wise to play only a fe^v holes, rather than to force oneself around the entire course, thereby inducing exhaus- tion. Cycling at moderate speed, on level surfaces and along dustf ree highways is quite unobjectionable. Dancing once or twice in the course of an evening is permissible for an ex-cardiac patient, but dancing should not be carried to the point of physical exhaus- tion and should be discontinued upon the first ap- pearance of shortness of breath, dizziness or fatigue. Tennis, ball-playing, boxing and wrestling all have elements that make them undesirable forms of sport for any but the constitutionally robust. All are more or less violent; all necessitate stooping and reaching; the possibility of disabling accidents is always present in all but tennis ; and in each one there is the element of contest and desire for supremacy which so often tempt an otherwise thoughtful person beyond the point of fatigue into actual physical ex- haustion. When advising a patient as to permissible forms of exercise or of sports, it should be borne in mind that, as a general rule, solitary sports or games are likely to prove more beneficial and are certainly less fraught with undesirable possibilities than are those in which the clement of contest enters. Motori)ig imposes a strain upon the muscular and nervous systems of those who drive their own cars "WHAT CAN BE DONE?" 377 in city traffic or along unfamiliar highways. For those in the tonneau motoring has an exhilaration, but this can be pushed to extremes and a cardiopath be relaxed and distressed if the drive has been too long- continued. Horseback riding may Ije permissible for those patients who arc accustomed to it &,nd who do not ride furiously. Persons not accustomed to riding horse- back should not adopt it as a convalescent exercise. It recjuires skill and experience to manage a horse, which is often capricious and which interposes a brute resistance to the will of the rider, and thus makes a burden of what is otherwise a healthful form of exercise. Climate. — It is beyond the scope of this chapter to enter into a discussion of various climates and their indications, it may be generally stated that the desirable climate for a person with a cardiac condition is one that has a mild, dry, bracing atmosphere. Sud- den temperature changes should be avoided. Plenty of sunshine is conducive to outdoor exercise. Some people do well at sea level, other at elevations. There is no way of telling in advance which will give the patient greater benefit; the preference of the indi- vidual should be consulted when first making the choice between mountains and sea. Altitudes that are over three thousand feet are not to be advised for cardiac patients. Alarriage. — The physician is often consulted con- cerning the expediency of marriage of a person who has had a heart affection. The psychic value of com- panionship and of a renewed interest in living are not to be lightly passed over in considering the question. 378 HEART AFFECTIONS. Unquestionably those suffering from a chronic sys- temic disease or from a gradually progressive affec- tion of the heart muscle or arteries — as illustrated by a progressing myocardial lesion or by an aneurism — should be advised against entering into marriage. Valve lesions, per se, do not contraindicate matrimony, providing the associated myocardial change has been arrested. Persons who have recovered from an acute heart affection and who have enjoyed apparently nor- mal good health without any relapses for a period of a year or two can enter upon matrimony with the caution that any exhaustion of their physical reserve force may entail another cardiac siege. Those who have "nervous hearts,'" or the recovered neuro-circu- latory asthenics, are frequently distinctly benefited by marriage. Middle aged persons with chronic myo- cardial change may enter upon matrimony providing they are not subject to periods of circulatory failure; in such a case a physician will scarcely advise that the semi-invalid marry. A word of caution should be given those elderly persons with the arterial degenera- tion of advancing years ^^'ho contemplate marriage — especially if with one many years their junior. It is not indelicate to remark in this connection that persons who have had cardiac affections should enter cautiously upon the intimate relations of mar- riage. A lack of restraint or overindulgence in sex- ual gratification may precipitate acute heart symp- toms. Especially is this so in people who are subject to periods of tachycardia which is of vmdemonstrable cause, in chronic fibrillators and in persons with heart- block of any degree. A silver-haired roue of irre- pressible personal magnetism, who suffered from "WHAT CAN BE DONE?" 379 heart-block (Fig. ly, page 99, is his tracing), in- formed the writer that his amative procHvities were usually interrupted by a complete loss of conscious- ness, which was preceded by the sound of a pistol-shot in his brain — ^but his accustomed companion adminis- tered "restoratives" and bathed his head with ice water until returned consciousness and increased pulse-rate enabled him to complete the act, even though completion meant 2 or 3 weeks in a hospital recovering, to a degree, from symptoms of acute myocardial failure. Pregnancy is not fraught with danger to the one- time cardiopath who has apparently recovered from a heart condition and who has not been subject to periods of relapse. Even in persons with chronic val- vular lesions which are evidently not progressive, it is remarkable how the heart will sometimes meet the de- mands which pregnancy and childbirth throw upon it ; this heart response, however, is a. question of cardiac muscle reserve force, and heart patients should be carefully watched for symptoms of approaching myo- cardial failure as pregnancy progresses. CORRECTION OF PERVERTED FUNCTION. Under this head may be included minor affections and disturbances of the heart which can frequently be relieved by the removal of the cause, and thus be prevented from developing into more serious cardiac maladies. Among such causes which are capable of correction are irritable gastric conditions, which may pervert the action of the heart, thus disturbing its volume, rhythm or regularity; the heart becomes effi- cient again when the gastric condition yields to treat- 380 HEART AFFECTIONS. ment. Gall-bladder disease or chronic suppuration of the middle ear are examples of focal infections which may be reflected in cardiac embarrassment, which em- barrassment disappears upon removal of the cause (other focal infections are discussed on page 224). The irritable heart of neurasthenia is also capable of correction. Neuro-circulatory asthenia is a com- bination of nerve and circulatory phenomena, both of which are often relieved by correction of the under- lying systemic weakness. The brilliant results which can also be secured in the correction of such perver- sions of heart function as auricular fibrillation, auric- ular flutter, and paroxysmal tachycardia of ventric- ular origin, are examples of what one may accomplish in the correction of perverted function. CONSERVATIONl The conservation of heart or blood-vessels which have been irreparably damaged by disease or neglect includes a variety of measures which, employed either singly or in combination, will enable the physician to add to the physical comfort and perhaps to the tenure of life of the persons so afflicted, Among such therapeutic resources are : Rest. Exercise. Diet. Massag'e. Sanatorium treatment. Operative procedures. Balneotherapy. Cardiac drugs. These measures, however, are useful not onlv in the conservation of badly damaged hearts, but also in •■■WHAT CAN BE DONE?" 381 the correction of perverted function and as prophy- lactic measures. So, ^Yhen the subject of treatment presents itself as the logical conclusion of an examin- ation, the physician should ask himself which of these measures, alone or in combination, is indicated for the patient before him. The items of treatment may now be briefly discussed in the order enumerated, under the caption of cardiac therapy. Cardiac Therapy. I. Rest. — The value of absolute rest as a prime therapeutic measure has been mentioned under the treatment of endocarditis, myocarditis, pericarditis, etc., hence need not be repeated here. It is well, how- ever, to briefly draw attention to the physiology of rest. In the first place, rest lessens the demands upon the heart ; it requires far less effort on the part of that organ to maintain an adequate circulation when the body is supine than when it is erect. As efifort is lessened, the heart-rate is reduced. Simple changing of position from the erect to the supine posture may cause a physiologic reduction in the rate of an appar- ently normal heart, averaging perhaps ten beats a minute. Hence, rest in bed lessens the effort of the ventricular contraction and reduces the rate of the heart. It also lengthens diastole, the period of heart rest; it is during diastole that the coronary arteries pour their supply of nourishment into the tissues of the heart. Hence, the simple expedient of rest in the recumbent posture, by increasing the length of dias- tole, increases the nourishment of the heart. The benefit of such rest is also manifest in the general circulatory tone of the patient. When a per- 382 HEART AFFECTIONS. son is in the erect posture gravity has a tendency to displace the level of the blood column in the vena cava. Physiologically, this level must be maintained at the highest point of the tricuspid orifice; when it falls below this point, as in the erect posture, the bur- den of its maintenance is thrown upon the contractile power of the veins and capillaries, supported by the muscular resistance of the abdominal wall. Rest in the recumbent posture relieves the burden otherwise imposed upon a damaged circulatory system, and an improvement in general circulatory tone results. Mental rest has been mentioned under chronic myocardial change but emphasis might here be laid upon the actual benefit which accrues to the patient who has the reassurances of his medical attendant. The optimism, as well as the skill and common sense, of the physician has much to do with the success of treatment. In advising a patient as to his method of living and habits of life, the circumstances of the indi- vidual should be studied. It would be a lack of thought to advise a person of straitened circumstances to take an ocean voyage to secure physical rest or to avoid the cares of his occupation. It is often unwise to advise a patient who has earned his living by indoor em- ployment to seek some occupation which exposes him to the weather, and it is as frequently equally ill- advised for the outdoor worker to secure an indoor occupation. More harm than benefit may be g'ained from completely revolutionizing the environment of a patient; and the mental anxiety which is brought on by attempting to earn a livelihood in an occupation or trade to which the patient is not accustomed, may far offset the beneficial results which can otherwise be "WHAT CAN BE DONE?" 383 expected, and only add to the distress and unhap- piness of the patient. 2. Exercise. — In the treatment of heart affections, exercise will be of use during the period of transition from rest in bed to accustomed activities. After the acute symptoms have subsided, the patient is usually propped in bed at short intervals during the day; when neither dizziness, fatigue nor increased heart rate follow this change of posture he may on suc- ceeding days, be permitted to sit in a chair. Only by the adoption of such gradual change from the re- cumbent to the erect posture can the integrity of the circulatory balance be assured. Exercise may then be gxadually permitted, and should be limited to such simple excursions as walking" about the room or the house. The patient who has been in bed with an acute infection for a period of several days and who sud- denly leaves his bed to go about his usual employment, runs the risk of disturbing his circulatory balance, no matter whether the cardiovascular system was af- fected or not during his illness. Graded Exercise. — The application of graded ex- ercises can be illustrated in a patient who is being treated for neuro-circulatory asthenia. After a short period of rest in bed in order that heart rate, respira- tory rate and nerve balance may have an opportunity to re-adjust themselves to what is the usual range for the individual, graduated exercises may be begun. At first these should consist of a simple series of arm and leg movements, under the supervision of the physician or the nurse, and be carried up to but not beyond the point of early fatigue, as shown by in- creased heart response and respiratory rate. The 384 HEART AFFECTIONS. exercise should be gradvially increased at each day's treatment until it eventuates in drills, extended walks and a degree of physical endurance that spells re- construction for the individual. Graded exercises are the keynote in the treat- ment of heart disease by Oertel's method, which was at one time much in \-ogxie. This plan of treatment consisted in short excursions when the weather per- mitted, at first on the level, the distance to be grad- ually increased each day. As the endurance of the patient and as the tone of the heart improved, attempts at hill climbing were introduced as part of the treat- ment. Resistance exercises have enjoved much popularity in the treatment of chronc heart affections. This method, A^'hich is championed h\ Schott of Bad- Nauheim, consists in having a trained gymnastic in- structor impose resistance to the action of certain groups of the patient's muscles. The patient is later able to carry on the treatment without the aid of the instructor by resisting the action of one group of muscles with the opposition of another group. ^ In connection with both the Oertel and the Schott treat- ment, the diet of the patient is carefully regulated; certain hours of rest are insisted upon; and elimina- tion is stimulated by the employment of baths and by the drinking of "medicated" water 3. 3. Diet. — The diet of a patient who is in bed with an acute infection of the heart shows no modification from the diet \\'hich is employed in patients who are 1 Details can be secured from "The Gymnastic Treatment of Heart Disease," by Schott, published by P. Blakiston's Sou & Co., Piiiladelphia. "WHAT CAN BE DONE?" 385 otherwise ill with acute infections., Liquid diet is the rule in the treatment of such patients; raw eggs, broths and milk being the chief constituents. In the treatment of chronic heart affections the general rule is to avoid foods in quantity and to avoid foods which are rich or indigestible, for the reason that by deranging digestion they increase the burden of the heart. When a patient's circulation is disturbed the disturbance is reflected in the gastric juices which are likely to be reduced in quality and quantity. It should be remembered, too, that gastric derange- ments, acting through the vagus nerve, which sends branches to both heart and stomach, may disturb the action of the heart. Again, it is possible that disten- sion of the stomach with gas from vmdigested or fermenting- foods may exert pressure upon the heart, although as a matter of clinical observation it is only in the exceptional instance that the area of stomach distension can be outlined by percussion. It is more probable that the disturbances commonly due to the "pressure of gas" are induced by reflex action upon the vagus nerve. At times it is desirable to regulate the diet of patients who suffer from chronic heart affections, es- pecially for the first few days that they are under treatment. The standard diet mentioned below is an excellent one and much in favor. Balfour's Rules for Dieting for Weak Hearts. 1. There must never be less than five-hour intervals between meals. 2. No solid food is ever to be taken between meals. 3. All those with weak hearts should have their principal meal in the middle of the day. 4. All those with weak hearts should have their food as dry as possible. 386 HEART AFFECTIONS. Balfour's Diet for the Senile Heart. Breakfast, 8.30 a.m. — Dry toast, one small piece — one or one and a half ounces — with butter; one soft boiled egg, a small piece of white- fish ; three to five ounces of tea or coffee with cream and sugar, or an infusion of cocoa nibs, or milk and hot wafer, or cream and Seltzer. Sometimes oatmeal porridge is permissible, but not over three or four ounces should be taken. Principal meal, 1.30 or 2 p.m. — Fish (such as haddock or sole), or meat and pudding. Two courses only are allowed. No soups, pickles, pastry or cheese. Whitefish and short-fibred meat only are allowable. The fish may be boiled in milk. A little spinach or one potato may sometimes be eaten, or a half pound of fruit, such as pears, apples, or grapes. Four to five ounces of hot water may be drunk with each meal, but no more. S to 6 P.M. — Three to four ounces of tea (one teacupful) infused for four minutes may be drunk, but absolutely no solid food is to be taken with it. If desirable, teaspoonful of extract of meat may be stirred in with the tea. Supper, 7 p.m. — Whitefish and a potato or toast and pudding, or milk pudding, or bread and milk. Bedtime. — Four to five ounces of very hot water, sipped, helps the patient to fall asleep. 4. Massage. — Massage is often indicated in pa- tients who are convalescent from acute systemic infec- tions or convalescent from acute affections of the heart itself. In chronic affections of the heart and of the arteries, as when a patient is in bed from exhaustion of cardiac reserve force massage* is also beneficial. It is not advisable to manipulate the body during acute conditions, nor is it as a rule advisable to nrassage the thorax or the abdomen of patients suffering from cardiovascular conditions. There are two kinds of motion, namely, active and passive. Active motion originates with the patient either as a result of his own volition or in resisting the efforts of another, as in resistance exercises. Passive motion is not under the control of the patient ; it is under the control of another. Passive is the form which is most used in debilitated persons. "WHAT CAN BE DONE?" 387 The varieties of passive motion include rubbing, kneading, tapping, rocking and stroking. Stroking is the procedure of choice in cardiovascular patients. Efilleurage is a term which defines a stroking movement. It causes an increase in the flow of blood to the muscles and to other soft parts, thereby in- creasing the circulation and facilitating the removal of waste products. It also encourages the absorption of transudates and exudates and to some degree directly stimulates the sympathetic nervous system. EfBeurage stimulates the superficial muscles, produces a dilatation of the superficial vessels, stimulates elim- ination to a slight degree by causing an insensible perspiration, excites the skin reflexes and through the cutaneous nerves, increases rapidity of the cir- culation and the heart-beat in some persons. If a part be edematous and be massaged in the proper direc- tion, i.e, from the extremity toward the heart, the ab- sorption of the fluid is encouraged by such manipula- tion, the size of the swollen part decreased and its muscle power increased. Massage should not be employed beyond the powers of resistance of the patient. While to a cer- tain point it is beneficial and stimulating it may be practised to a degree where it causes fatigue, mark- edly increased respirations and a decided increase in heart rate. Massage in chronic cardiovascular con- ditions increases the general tone of the whole body and the heart shares in the improvement. It is also true that as a result of increased tone of the heart muscle, blood passes more easily through the lungs and the respirations become deeper and easier. But it should be borne in mind that massage is simply part 388 HEART AFFECTIONS. of the general management of a patient who is not acutely ill ; that it is but a substitute for exer- cise; and that it should never be employed so vigor- ously that it constitutes gymnastics for the patient who is in bed. 5. Saiiatoriiun Treatment. — The benefits to be received from sanatorium treatment are set forth on page 207, and it is therefore not necessary to dwell upon the subject here. In passing, however, mention might be made of a therapeutic measure which is of no small importance in the modern sanatorium, namely, the cheerful atmosphere, the diversions and the social intercourse at such an institution. Patients who are morbid or unduly sensitive, or given to un- warranted fears concerning their physical condition, will find that the atmosphere of the better sanatoria is calculated to create a brighter and more hopeful mental attitude, which pla}-s W) small part in the beneficial results of sanatorium treatment. Concerning treatment at German spas and similar resorts, it is not at all probable that such institutions can lay claim to an}^ other benefits than those which are found in any well conducted, properl}- regulated institution, nor would it seem necessarv for patients on this side of the water to journey across the seas for treatment w hich can be as uell secured at home. 6. Operative Procedures. — Cardiovascular opera- tions embrace the following measures : {A) paracen- tesis pericardii for the evacuation *of serous or puru- lent pericardial effusions ; ( S ) the Corradi method of wiring for the relief of symptoms, and with the hope of preventing early rupture, in fhoracic aneurisms; (C) venesection, when indicated in congestion or "WHAT CAN BE DONE?" 389 rupture of the cerebral \'essels; in patients with dan- gerously high systolic pressure; and in urgent cases of auricular fibrihation, where to wait for the action of drugs is to invite death; (D) for the removal of foci of suppuration, which may exist in diseased ton- sils or at the apices of teeth, as detailed on page 224. Other foci of suppuration, ^^'hich are much less fre- quently the cause of cardiovascular disturbances and \\hich may require surgical intervention, are found in discharging ears, sinus infections, gall bladder in- volvement, perirenal abscess, pyelitis and chronic appendicitis. 7. Balneotherapy. — The treatment of chronic heart affections by the employment of medicated baths has some ardent ad^'ocates. The baths are for the most part of benefit to patients of lowered vasomotor tone. It is said that the natural waters at Nauheim contain carbonic acid and that this substance slows the pulse rate and regulates the circulation of a person im- mersed therein, by dilating the capillaries and by indirectly stimulating the nerve centers. Under such treatment it is claimed that local congestions are dissipated, inflammatory deposits absorbed and the metabolism of the patient improved. At Nauheim the natural spring water which is heated to a tempera- ture of from 93° to 95" Fahrenheit, contains carbonic acid, sodium chloride and calcium chloride. Ilie treatment consists in baths A\'hich last from five to ten minutes and are usually given daily extending over a period of time varying from three to six weeks. The baths are contraindicated in acute conditions, in markedly weak or anemic patients, in those who chill easily and in those who fail to promptly react from 390 HEART AFFECTIONS. the initial chill upon being immersed. Thorne^ ad- vocates their use in angina pectoris. It is not necessary for patients who desire such baths to journey to Germany in order to procure them. They are now available in America at certain private establishments which are under the manage- ment of competent physicians. Schott^ of Bad-Nauheim gives the following directions for the preparation of the baths at the home of the patient. "It is now possible for those suffering from heart disease, who are not in a position to take the cure by means of the natural baths, to imitate these baths at home, to a certain extent. One- should employ for this purpose preferably the natural Nauheim bath salts, or, if these are not available at the moment, make use of the most important of their saline constit- uents, namely, sodium chloride and calcium chloride, in the correct proportions — 2 per cent, of the former, and I part per 1000 of the latter. These quantities may be increased when stronger baths are indicated. The carbonic acid is best obtained from sodium bi- carbonate and hydrochloric acid ; the chemical equiva- lents indicate in what proportion these ingredients are to be added to the bath, ^^'ith the strong solu- tion of hydrochloric acid (equivalent to 42.8 per cent.) equal quantities of hydrochloric acid and sodium bi- carbonate should be employed. AA^ith the dilute hydro- chloric acid a correspondingly larger quantity of this solution is necessary. The sodium bicarbonate, com- mencing with 3 ounces, and gradually increasing to 1 Thorne : Practitioner, Aug., 1917. - Schott : "Treatment of Chronic Heart Diseases" ; Blakiston, 1914. "WHAT CAN BE DONE?" 391 I5j 30j or even to 45 ounces, as the baths progress, should be dissolved in the bath-water simultaneously with the other salts (sodium chloride and calcium chloride), which must also be increased in proper pro- portions for these stronger baths. An excess of bi- carbonate of sodium is always advisable for the pro- tection of the bathtub. After the temperature of the water has been properly regulated, an amount of hydrochloric acid equivalent to the quantity of sodium bicarbonate already dissolved in the bath is poured directly on the surface of the water from a small- mouthed bottle and distributed well over it. One should avoid any additional agitation of the bath- water, as otherwise the carbon dioxide will readily escape into the air. The layer of carbonic acid gas which forms on the surface of the water during its preparation should be driven off with a towel before the bath is used, so that the patient will not breathe it. In this way the carbonic acid gas will continue to be evolved for a considerable time, probably a half- hour or more. "It is self-evident that even in the employment of artificial baths a constant supervision by the physi- cian is essential, if satisfactory results are to be ob- tained. And often a good result is only to be secured when it is practicable to remove the patient from business and family worries into pure air and new surroundings. Suitable nourishment also plays an important part in these cases. If properly used, favorable results can be obtained with artificial Nau- heim baths in a certain proportion of cases. Natur- ally, the number of caseg to be benefited must neces- sarily be limited by the circumstance that the strong- 392 HEART AFFECTIONS. est of these baths — the effervescing and the efferves- cing flowing baths — cannot be imitated artificially." 8. Cardiac Drugs. — The use of cardiac drugs is a therapeutic measure considered at length in the fol- lowing chapter. CHAPTER XXiV. Cardiac Drugs. The drugs which have been uSed in the treatment of cardiovascular affections are legion; those of proven efficiency are few. Remedies which affect the circulatory apparatus in an indirect manner by their eft'ect upon other organs cannot properly be classified as cardio-circulatory drugs ; yet many such are herein considered, for the reason that they are of definite value to the practitioner in his daily work. It is the purpose of this chapter to discuss those remedies which have been determined by lalxiratory research, by graphic records and by extensive clinical study to be drugs which have a definite cardiac effect. There are other preparations which have won their place in the affection of physicians through years of faithful service, which may not be mentioned in the following pages. This does not necessarily mean that such drugs are worthless; yet if they be of doubtful utility in the treatment of cardiac affections, it is bet- ter to urge the employment of dru^s which have been definitely studied, as illustrated by digitalis and epi- nephrin. Still other drugs, that seem to be absolutely without cardio-circulatory eft'ect, will be mentioned, not for the purpose of decrying a remedy in which many practitioners may have confidence, but more for the purpose that the physician may not in an emerg- ency lean upon a broken reed — as I believe that doctor does who administers camphorated oil in a cardio- circulatory crisis. (393) 394 HEART AFFECTIONS. DIGITALIS. This sovereign heart remedy was first brought to the attention of the profession by Withering who wrote "An Account of the Foxglove" in 1785.^ It is interesting to note the astute observations of this pioneer, who, in writing of the diuretic action of the drug, averred that "Digitahs seldom succeeds in men of great natural strength, of tense fiber, of warm skin, of florid complexion, or in those with a tight and cordy pulse. If the belly in ascites be tense, hard, and circumscribed, or the limbs in anasarca solid and re- sisting, we have but little hope. On the contrary, if the pulse be feeble and intermitting, the countenance pale, the lips livid, the skin cold, the swollen belly soft and fluctuating, or the anasarcous limbs readily pitting upon pressure of the finger, we may expect the diuretic efl:ects to follow in a kindly manner." \Mth what prophetic foresight are thus confirmed the ob- servations of today, when he allowed but little value to the drug in arteriosclerotics with high arterial pres- sure and associated dropsy, but admitted a beneficial action in the clinical picture of auricular fibrillation which he has so well painted! Controversial storms must have waged around AA'ithering's head, for in closing his preface he seeks the solace of saying: "After all, in spite of opinion, prejudice, or error, time will fix the real value upon the discovery, and determine whether I have imposed upon myself and others, or contributed to the ben.efit of science and mankind." 1 Withering, Wm. : "An Account of the Foxglove and Some of Its Medical Uses, with Practical Remarl