Columbia ^nibersiitp in tiic €itp of J^eto l^crfe CoUege of ^fjpsicians anb ^urgeong 3^ef erence Hibrarp DISEASES OF THE HEART BY THE SAME AUTHOR. THE SCIENCE AND ART OF PRESCRIBING BY E. H. COLBECK, M.D. F.R.C.P. (Lond.), D.P.H. (Cantab.), AND ARNOLD CHAPLIN, M.D. M.R.C.P. (Lond.) In one very handsome 12mo volume of 192 pages, bound in fill leather, gilt edges. Price 5s. net ; by Post Js. 3d. " Can be thoroughly recommended." — Medical Review, "This little volume should prove invaluable." — London Hospital Gazette. "Will be cordially welcomed both by students and practitioners." — British Medical Journal. " The book is full of useful information and excellent formula . . . is sure to be perused by many." — Canada Lancet. " Is a very good little book." — Lancet. "All that can be desired." — Hospital. LONDON: HENRY KIMPTON, 13 FURNIVAL STREET, E.G. Digitized by tine Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofheartcOOcolb SKIAGRAM OF THE CHEST SHOWING THE POSITION OF THE HEART (Hugh Walsham) The numbers i-6 arc placed on the posterior surface of the first six ribs in front. DISEASES OF THE HEART A CLINICAL TEXT-BOOK FOR THE USE OF STUDENTS AND PRACTITIONERS OF MEDICINE EDMUND HENRY COLBECK B.A., M.D., BC. (Cantab.); F.R.C.P. (London); D.P.H. (Cantab.) PHYSICIAN TO OUT-PATIENTS AT THE CITY OF LONEON HOSPITAL FOR DISEASES OF THE CHEST, VICTORIA PARK, E. PHYSICIAN TO THE METROPOLITAN DISPENSARY, E.G. LATE HOUSE PHYSICIAN AT ST. MARY's HOSPITAL ETC., ETC. WITH FORTY-THREE ILLUSTRATIONS SECOND EDITION. REVISED AND ENLARGED W. T. KEENER & Co., 90 WABASH AVENUE CHICAGO 1905 X-y^Y^ TO SIR WILLIAM H. BROADBENT, Bart. M.D. (LoND.), F.R.S., F.R.C.P. PHYSICIAN IN ORDINARY TO H.R.H. THE PRINCE OF WALES CONSULTING PHYSICIAN TO ST. MARY'S HOSPITAL, AND THE LONDON FEVER HOSPITAL LATE PRESIDENT OF CLINICAL, MEDICAL, NEUROLOGICAL, AND HARVEIAN SOCIETIES WHOSE TEACHING HAS DONE SO MUCH TO ADVANCE THE CLINICAL STUDY OF DISEASES OF THE HEART THIS BOOK IS RESPECTFULLY AND GRATEFULLY DEDICATED PREFACE TO THE SECOND EDITION. I HAVE taken advantage of the opportunity afforded by the demand for a Second Edition of " Diseases of the Heart " to make a few corrections in the text, and to add a little new- matter, without in any way interfering with the general arrangement and character of the work. A short account has been given of mechanical strain of the heart, and of the Stokes-Adams' syndrome ; and the description of the treatment of chronic valvular disease has been somewhat amplified. The instrumental determination of blood pressure which seems likely to occupy a prominent place in the clinical investigation of cardio-vascular disease has received but scant consideration ; but in the present state of our knowledge it appeared hardly profitable to enter into a detailed description of this method of procedure. The remaining additions that have been made do not call for comment, but it is hoped that they may enhance what- ever usefulness the work may possess as a clinical guide to diseases of the heart. E. H. C. November 1904. PREFACE My interest in Diseases of the Heart dates from the time that I was appointed House Physician to Sir William Broadbent. I should have profited more by the leaching of this great master of clinical medicine had I possessed a better knowledge of the elementary and fundamental bedside features of cardio-vascular disease. It seemed to me at this time, and it does so still, that a book dealing with the clinical side of the subject of Heart Disease in a form suitable to the requirements of the student and newly qualified practitioner of medicine, would prove of very great service. It has been my endeavour in the following pages to fulfil these conditions in as concise and systematic a manner as possible. In order to keep the size of the book within reasonable limits, compression of the subject-matter was unavoidable ; but it is hoped that this process has not been carried so far as to interfere with the intelligibility of the text. Controversial matter has to a large extent been avoided, and while this has entailed the exclusion of much new and interesting work, it has also permitted of much greater precision in the exposition of the subject, a feature of no small advantage to the student of clinical medicine. I have freely consulted and made use of the writings of the leading authorities on Diseases of the Heart, and more PREFACE ix particularly those of Walshe, Peacock, Gairdner, Balfour, Broadbent, Sansom, Byrom Bramwell, Gibson, and Allbutt. I am especially indebted to the masterly article on " Enlargement of the Heart " in Keating' s Encyclopcedia of the Diseases of Children, written by Dr. Mitchell Bruce, whose nomenclature with respect to the mode of production of dilatation of the heart I have adopted throughout the book. The illustrations are for the most part original, but I have to acknowledge the kindness of Messrs. Charles Griffin and Co., and Messrs. Longmans, Green, and Co. in permitting me to make use of electrotypes of illustrations appearing in works published by them. My thanks are due to Dr. J. G. Emmanuel, late Resident Medical Officer at the Chest Hospital, Victoria Park, for a large number of the pulse tracings. Dr. Hugh Walsham has kindly placed at my disposal the skiagram of the chest, which appears as a frontispiece. E. H. C. London, yaw2/«rj/ nth, 1901. TABLE OF CONTENTS CHAPTER I Anatomy pagh Position and shape of Heart and Pericardium — Size and weight of the Heart — Dimensions of the Auricles and Ventricles — Relative position of the Cardiac Orifices and Valves — Relative size of the Orifices of the Heart — Relation of the Heart and its Orifices to the Sternum and Ribs . . I CHAPTER H Physiology Cardiac Cycle — Time relations and sequence of the various events which comprise Cardiac Cycle — Cardiac Impulse — Its position and cause — Sounds of the Heart — Their cause and duration — Nervous Supply of the Heart . . . . . . . . g CHAFFER III Methods of Diagnosis Enumeration of Methods — Section I. Symptomatology — Section II. ^Etiology — Section III. The Physical Methods of Di-agtiosis — Sub-section I. In- spection ; general ; local — Sub-section II. Palpation ; Prsecordium ; great vessels ; other organs — Sub-section III. Percussion ; Heart ; Pericardium ; great vessels ; other organs — Sub-section IV. Auscultation; Heart Sounds and their Modifications; Adventitious Sounds; Vascular Sounds . . i6 CHAPTER IV The Pulse Definition — Method of Production — Physical Examination of Pulse — Inspec- tion — Palpation — Graphic Record or Sphygmogram — Instrumental Determination of the Blood Pressure . . . . -74 CHAPTER V The Cardiograph Its Sphere of Usefulness — The Normal Cardiogram — Cardiograms of the Chief Valvular Lesions .... . . 94 CHAPTER VI Congenital Affections of the Heart and Great Vessels .(Etiology and Pathology — Classification — Symptoms — Physical Signs — Diagnosis — Prognosis — Treatment . * . . •99 xii TABLE OF CONTENTS CHAPTER VII Diseases of the Pericardium page Classification — Section I. Acute Pericarditis — Section II. Pericardial Adhe- sion — Section III. Hydropericardium — Section IV. Haemopericardium — Section V. Pneumopericardium — Section VI. New Growths . .116 CHAPTER VIII Acute Endocarditis Classification — Section I. Acute Simple Endocarditis — Section II. Malignant or Infective Endocarditis . . . ... 138 CHAPTER IX Chronic Endocarditis Pathogenesis — Morbid Anatomy — Effects on the Functions of the Valves — Effects on the Heart and Circulation — Effects on other organs . . 160 CHAPTER X Chronic Valvular Lesions Pathogenesis of Chronic Valvular Disease . . « , . 165 CHAPTER XI Mitral Incompetence Pathogenesis — Morbid Anatomy — Compensation : its method of production and maintenance — Failure of Compensation, and its results — Symptoms — Complications — Physical Signs — Diagnosis — Estimation of the amount of Regurgitation . . . . . . . 167 CHAPTER XII Mitral Stenosis Pathogenesis — Morbid Anatomy — Pathological Effects on the Heart and Circulation — Symptoms — Complications — Physical Signs — Diagnosis — Estimation of the degree of Stenosis . . . . . 181 CHAPTER XIII Aortic Incompetence Pathogenesis — Morbid Anatomy — Effects on the Heart and Circulation — Compensation— Sudden Death — Symptoms — Complications — Physical Signs — Diagnosis — Estimation of the amount of Regurgitation . -195 CHAPTER XIV Aortic Stenosis Pathogenesis — Morbid Anatomy— Effects on the Heart and Circulation — Compensation : its duration and failure — Symptoms — Complications— Mode of Termination — Physical Signs — Diagnosis — Estimation of degree of Stenosis . . . . ... 207 TABLE OF CONTENTS xiii CHAPTER XV Tricuspid Incompetence page Pathogenesis — Morbid Anatomy — Effects on the Heart and Circulation — Symptoms — Physical Signs — Diagnosis — Estimation of the amount of Regurgitation . . . . . . . 212 CHAPTER XVI Tricuspid Stenosis Pathogenesis — Morbid Anatomy — Effects on the Heart and Circulation — Symptoms — Physical Signs — Diagnosis — Estimation of degree of Stenosis 217 CHAPTER XVII Pulmonary Incompetence Pathogenesis — Morbid Anatomy — Effects on the Heart and Circulation — Association with other Cardiac Developmental Anomalies — Symptoms — Physical Signs — Diagnosis — Estimation of the amount of Regurgitation . 221 CHAPTER XVIII Pulmonary Stenosis Pathogenesis — Morbid Anatomy — Effects on the Heart and Circulation — Symptoms — Physical Signs — Diagnosis — Estimation of the degree of Stenosis . . . . ... 225 CHAPTER XIX Combined Valvular Disease . . ... 229 CHAPTER XX Prognosis of Chronic Valvular Disease . ... 230 CHAPTER XXI The Treatment of Chronic Valvular Disease Prophylaxis — Treatment before Failure of Compensation — Treatment after Failure of Compensation — Removal of Cause — Treatment of Effects — Use of Cardiac Stimulants and Tonics . ... 234 CHAPTER XXII Diseases of the Myocardium Classification — Section I. Hypertrophy and Dilatation of the Heart ; Defini- tion ; Classification of Kinds of Cardiac Enlargement ; Morbid Anatomy ; Effects on other Organs ; Pathogenesis ; ^Etiology ; Symptoms ; Physical Signs; Diagnosis; Prognosis; Treatment — Section II. Acute Myocarditis ; ^Etiology ; Morbid Anatomy ; Effects on the Heart ; Symptoms ; Physical Signs; Diagnosis; Prognosis; Treatment — Section HI. Degenerative Diseases of the Myocardium; Definition; iEtiology; Morbid Anatomy; Pathogenesis ; Symptoms ; Physical Signs ; Diagnosis ; Prognosis ; Treat- ment — Section IV. Fatty Diseases of the Heart ; Fatty Infiltration ; Fatty Degeneration — Section V. Fibroid Disease of the Heart — Section VI. Growths in the Heart . . . ... 248 xiv TABLE OF CONTENTS CHAPTER XXIII Angina Pectoris page Etiology — Kinds of Angina — Morbid Anatomy — Pathogenesis — Symptonas —Physical Signs — Diagnosis — Prognosis —Treatment . . . 310 CHAPTER XXIV Functional Disorders of the Heart Definition — Etiology — Pathogenesis — Section I. Cardiac Pain ; Local and Referred — Section II. Palpitation ; Definition ; Causation ; Features of Paroxysm — Section III. Cardiac Asthenia — Section IV. Alterations in the Rhythm of the Heart's Action ; Arrhythmia ; Intermittence and Ir- regularity — Section V. Alterations in the rate of the Heart's Action — Section VI. Tachycardia — Section VII. Decrease in the rate of the Heart's Action — Section VIII. Diagnosis; Prognosis; Treatment . 322 Index » > j • ■. > • . 345 LIST OF ILLUSTRATIONS FIG. r Section through the base of the heart, showing the relations of the cardiac orifices and valves . . . . Relation of the heart and aorta to the ribs and sternum . The position of the valvular orifices, and their relation to the cardiac dulness . . . . . , 4. Diagrammatic representation of the cardiac cycle ^ 5. Normal Cardiogram (Sansom after Galabin) 6. Diagrammatic represeiUation of the cardiac sounds with reference to the cardiac cycle . . . . , 7- Diagrammatic representation of the diagnosis . 8. The areas in which the sounds produced at the various cardiac orifices are most distinctly heard . . . . 9. Diagrammatic representation of a systolic murmur 10. Diagrammatic representation of an entire diastolic murmur 11. Diagrammatic representation of a presystolic murmur 12. Diagrammatic representation of an early diastolic murmur 13. Diagrammatic representation of a mid-diastolic murmur . 14. Normal pulse tracing . . , . ' . 15. Mahomed's scheme of the tidal wave . . . 16. High-tension pulse tracing . . . . 17. Low-tension pulse tracing . . , . 18. Dicrotic pulse tracing . .... 19. Virtual-tension pulse tracing , . , . ■ 20. Pulse tracing from a case of dilatation of the heart showing respiratory curves ...... 21. Pulse tracing from a case of aortic regurgitation 22. Pulse tracing from a case of aortic stenosis 23. Anacrotic pulse tracing . . . , . 24. Pulsus Bisferiens . .... 25. Pulse tracing from a case of mitral regurgitation 26. Pulse tracing from a case of mitral stenosis 27. Pulse tracing taken from the left radial artery in a case of aneurism XV 3 5 7 10 12 13 17 44 S6 57 57 57 57 81 83 85 86 86 87 89 90 90 90 91 91 92 xvi LIST OF ILLUSTRATIONS FIG. PAGE 28. Pulse tracing taken from the right radial artery in the same case (Fig. 27) 93 29. Normal cardiogram (Sansom after Galabin) . . . . 94 30. Cardiogram from a case of mitral stenosis (Sansom) . . . 96 31. Cardiogram from a case of mitral stenosis (Sansom) . . . 97 32. Cardiogram from a case of mitral stenosis (Sansom after Galabin) 97 33. Cardiogram from a case of mitral regurgitation (Sansom) . . 97 34. Cardiogram from a case of aortic obstruction (Sansom after Galabin) . 98 35. Cardiogram and sphygmogram from a case of aortic regurgitation (Sansom) . . . . ... 98 36. The aortic arches, showing mode of transformation into permanent arterial trunks (after MacAlister, modified) . . . lOl 37. Diagrammatic outline of the organs of circulation in the foetus of six months (Thompson) . . . ... 103 38. Diagrammatic representation of an entire diastolic murmur . . 189 39. Diagrammatic representation ol a presystolic murmur . . . 189 40. Diagrammatic representation of an early aiastolic murmur - . 189 41. Diagrammatic representation of a mid-diastolic murmur . . 189 42. Bigeminal pulse tracing . . . ... 332 43. Trigeminal pulse tracing , , » » « . 332 DISEASES OF THE HEART CHAPTER I ANATOMY Position and shape of Heart and Pericardium^Size and weight of the Heart — Dimensions of the Auricles and Ventricles — Relative position of the Cardiac Orifices and Valves — Relative size of the Orifices of the Heart — Relation of the Heart and its Orifices to the Sternum and Ribs The heart is situated in that portion of the cavity of the chest which is known as the middle mediastinum. The Pericardium : its shape and connections, — The pericardium, wherein the heart is contained, is a cone-shaped membranous sac, which is attached by its base to the middle leaflet of the tendon of the diaphragm, and by its apex is continuous with the fibrous sheaths of the great vessels, and through them with the cervical fascia. This, the outer or fibrous layer of the pericardium, is lined by a serous coat, which is reflected along the great vessels on to the surface of the heart, and completely envelops the whole viscus. The space between the two layers of the serous covering is known as the cavity of the pericardium. Under normal conditions this space is potential rather than real, since the two layers of the sac are in close apposition. The general shape of the heart is that of a blunt, flattened cone, the anterior convex surface of which faces upwards and forwards, while the more flattened posterior looks downwards and backwards. The shape and position of the h;art. — The base of the organ is directed upwards, backwards, and to the right, extending from the level of the sixth to the eighth dorsal vertebra, and the apex points downwards, forwards, and to the left. During life the apex beat is palpable in the space between the cartilages of the fifth B 2 DISEASES OF THE HEART and sixth ribs, about 3-|- inches, or 9 cm., from the mid-sternal line. In the child the apex beat is situated in the fourth interspace. Of the two borders of the heart, which are formed by the junction of the anterior and posterior surfaces, the one {inargo acutus), longer and thinner, looks forwards and downwards, while the other {inargo obtusus), shorter and more rounded, is directed backwards and to the left. The axis of the heart is inclined to the horizon at an angle of 40°, and the greater portion of the organ is situated to the left of the median line. The position of the heart is affected to some extent by posture, and by the degree of distension of the lungs. Except at its base, where it is attached to the great vascular trunks, the heart lies entirely free within the pericardial sac. It will be observed that although the pericardium and heart are both conical in shape, the bases of the two cones do not coincide. Thus in the case of the pericardium the base of the cone looks downwards, while in that of the heart it is directed upwards, back- wards, and to the right. The relations of the heart. — The anterior surface of the heart is completely overlapped by the pleurae and lungs, except over its lower part, where a roughly triangular area, to the left of the median line, remains uncovered. This uncovered portion of the wall of the heart, which corresponds with the area of superficial cardiac dul- ness, will be more accurately defined in a subsequent paragraph. The size and weight of the organ, — The size and weight of the heart are liable to considerable variation, in accordance with the age, sex, stature, and muscular development of the subject, as well as with the method of removal that is adopted. The following figures, therefore, must be looked upon as representing average measurements only. The weight of the adult male heart averages 1 1 ounces, or about 310 grammes; the weight of the adult female heart 9 ounces, or about 255 grammes. As a general rule, the adult has about 5 grammes of heart weight for each kilo of body weight ; or, stated more exactly, the proportion of heart weight to body weight in the male is as i to 178, and in the female as i to 169 (Macalister). External markings. — The external surface of the heart is divided into auricular and ventricular portions by a deep transverse groove — the auriculo-ventricular furrow. The division between the ven- tricles is shown by two shallow interventricular grooves, which, running from and at right angles to the auriculo-ventricular furrow, become continuous with one another a little to the right of the apex. It will thus be seen that the apex of the heart is formed entirely by the left ventricle. Moreover, owing to the position of the organ, ANATOMY 3 the right ventricle forms the greater portion of the anterior surface of the heart, and the left of the posterior. Size and dimensions of tlie heart. — The capacity of each of the four cavities of which the heart is composed is approximately the same, and may be put at loo cc, or about 3I- ounces. The walls of the different chambers vary greatly in thickness. The '/ /-■A T M IG. I. SECTION THROUGH THE EASE OF THE HEART, SHOWING THE RELATIONS OF THE CARDIAC ORIFICES AND VALVES P= pulmonary orifice; A= aortic orifice ; M = mitral opening ; T = tricuspid opening average thickness of the auricular walls is about i mm., or J^ of an inch. The wall of the left auricle has a maximum thickness of 3 mm., or \ of an inch, and the wall of the right auricle 2*5 mm., or y\j- of an inch. The thickness of the wall of the left ventricle ranges between 4 mm. and i cm. (p to h, inch), and of the right ventricle between 2 mm. and 4 mm. \~^ to \ inch). 4 DISEASES OF THE HEART Relative position of the cardiac orifices and valves. — The relative position of the various orifices with their valves is most readily appreciated by means of a transverse section taken just above the ventricles, so that the structures exposed can be viewed from above. The accompanying diagram illustrates such a section (Fig. i). Pulmonic orifice. — It will be observed that the conus arteriosus crosses the aortic opening obliquely from right to left, whence it happens that the pulmonic orifice is carried in front of and slightly to the left of the aortic. Aortic orifice. — The orifice of the aorta lies in front of and between the two auriculo-ventricular openings. The aortic and pulmonic orifices are each guarded by a valve con- sisting of three semilunar flaps, which are differently arranged at the two openings. At the aortic orifice one flap is anterior and to the right, one anterior and to the left, and the other posterior and to the right ; while at the pulmonic opening one is anterior and to the left, one posterior and to the left, and the third posterior and to the right. Mitral opening. — The left auriculo-ventricular or mitral orifice is situated immediately behind and to the left of the aortic opening. It is guarded by a valve composed of a small posterior and a larger anterior curtain, the latter of which separates the mitral from the aortic orifice. The close proximity of the large anterior flap of the mitral valve to the orifice of the aorta is of some clinical importance, and will be again referred to. Tricuspid opening. — The right auriculo-ventricular or tricuspid opening is closed by a valve consisting of three segments, of which one is placed anterior and to the left, a second to the right, and the third posteriorly. It is worthy of notice that the dimensions of the aortic and pul- monic orifices are anatomically incapable of any alteration at the time of the closure of the semilunar valves. On the other hand, the size of the auriculo-ventricular openings is very much diminished during systole, in order to enable the valvular curtains to come into accurate apposition. This difference in the mechanism of closure of the two sets of openings has, as will be seen, important patho- logical and clinical bearings. The following measurements (taken from Macalister's Text Book of Human Anatoniy) are of some interest as showing the relative size of the orifices of the heart : — • Area of the tricuspid orifice in sq. mm. Area of the mitral orifice „ Area of the aortic opening „ Area of the pulmonic opening „ xMales. Females. I27"0 .. 105-0 96'o .. 86-8 7o"6 65*2 68-5 . •• 64-5 ANATOMY 5 Topography of the heart. — It has already been mentioned that nearly two-thirds of the bulk of the heart lie to the left of the median line of the body. The upward extent of the organ is repre- sented on the surface of the chest by a horizontal line drawn slightly below the level of the second costal cartilages. The heart hes to the left of a vertical line drawn downwards from the sternal end FIG. 2, RELATION OF THE HEART AND AORTA TO THE RIBS AND STERNUM L.V. = left ventricle ; R.V.=right ventricle; L.A. = left auricle ; R.A. = right auricle ; A.=aorta; P.A. = pulmonary artery ; V. C. = vena cava. of the right clavicle, and to the right of an oblique line considerably convex upwards and outwards, drawn from the second costal carti- lage about an inch from the left sternal border to the upper border of the sixth costal cartilage, 9 cm. or 3^^ inches from the mid-sternal line. It lies above a line, very slightly concave upwards, drawn from the upper border of the sixth rib, 9 cm. from the mid-sternal line, to the lower border of the cartilage of the right fifth rib, close to the sternal edge. The width of the heart at the level of the fourth costal cartilage is about 4^ inches, of which i|- inches lie to the right of the mid- sternal line, and^ 3 inches (nearly) to the left. 6 DISEASES OF THE HEART Area of deep cardiac dulness. — The whole of this area marks out what is known as the region of " deep cardiac dulness," and corresponds approximately with the absolute size of the heart so far as its anterior aspect is concerned. Area of superficial cardiac dulness. — By the term superficial cardiac dulness is meant the extent of the cardiac surface un- covered by the margins of the lungs, and in contact, through the pericardium, with the chest wall. This area is included in a triangle, which is bounded by the mid-sternal line, by a line drawn from a point on the mid-sternal line, opposite the level of the upper border of the fourth costal cartilages, to the lower border of the fifth left costal cartilage, at its junction with the rib, and by a line drawn hori- zontally inwards from this point to the mid-sternal line. For practical purposes the area of superficial cardiac dulness may also be defined by a circle 2 inches in diameter, drawn from a point midway between the left nipple and the end of the gladiolus (Latham). The relation of the different chambers and orifices of the heart to the area of deep cardiac dulness will now be described. Right auricle. — The right auricle lies behind the sternal end.s (about I J inches from the mid-sternal line) of the third, fourth, and fifth costal cartilages, the second, third, and fourth intercostal spaces, and the right sternal edge. The apex of the right auricular appendix is situated in the middle line opposite the level of the upper border of the third costal cartilages. Left auricle. — The only part of the left auricle that is visible from the front is its appendix, which is placed behind the second left interspace and upper part of the third costal cartilage about i|- inches from the left sternal edge. Eight ventricle. — The greater portion of the anterior surface of the heart consists of the wall of the right ventricle, which, measured along the left edge of the sternum, extends from just above the third rib to the lower border of the sixth costal cartilage. Its upper part is formed by the conus arteriosus, and is uncovered by lung. Left ventricle. — The left ventricle forms the left border of the heart as high as the upper border of the third rib, and also the apex of the organ. The apex of the heart in adults is situated in the fifth intercostal space, 9 cm. or 3J inches from the mid-sternal line. A diagrammatic representation of these relations is shown in the preceding figure. Tricuspid opening.— The right auriculo-ventricular or tricuspid opening is behind the middle of the sternum opposite the fourth costal cartilages. ANATOMY 7 Mitral opening. — The left auriculo-ventricular or mitral orifice lies behind the sternum, to the left of the middle line, on a level with the upper border of the fourth costal cartilages. Aortic orifice. — The aortic opening is situated behind the sternum to the left of the middle Hne on a level with the lower border of the third costal cartilages. The ascending portion of the aorta extends from this point to the level of the upper border of the second right costal cartilage at its junction with the sternum. Pulmonic orifice. — The pulmonic orifice lies behind the upper border of the third left costal cartilage at its junction with the FIG. 3. THE POSITION OF THE VALVULAR ORIFICES, AND THEIR RELATION TO THE CARDIAC DULNESS P = pulmonary orifice ; A = aortic orifice ; M = mitral orifice ; T = lricuspid orifice P (within circle) = pulmonary area ; A (within circle) = aortic area M (within circle)=mitral area ; T (within circle) = tricuspid area Sternum. The vessel ascends vertically from this point to the level of the second left costal cartilage, behind which it bifurcates. The auriculo-ventricular sulcus. — The auriculo-ventricular sulcus is represented by a line drawn from the upper border of the 8 DISEASES OF THE HEART cartilage of the sixth rib on the right side, at its junction with the sternum, to the upper edge of the third left costal cartilage close to the sternal border. The interventricular sulcus. — The anterior interventricular groove corresponds with an oblique line, slightly concave inwards, drawn from a point half an inch inside the apex, to the upper border of the third left costal cartilage, i^ inches from the left sternal edge. It must be borne in mind that the foregoing landmarks are subject to considerable variation in different individuals, according to age, muscular and bony development, etc. In children the apex of the heart is situated a space higher than in adults, i.e.. in the fourth intercostal space, and further to the left, so that it is often found in the nipple line, or even slightly outside this limit. Aorta. — The first or ascending portion of the aortic arch extends from the lower border of the third left costal cartilage to the upper border of the second right costal cartilage at its junction with the sternum. The transverse portion of the arch runs across the sternum below the level of a line drawn horizontally through the middle of the manubrium, to the upper border of the fourth dorsal vertebra. The third or descending portion of the arch lies to the left of the body of the fourth dorsal vertebra. CHAPTER II PHYSIOLOGY Cardiac Cycle — Time relations and sequence of the various events which com- prise Cardiac Cycle — Cardiac Impulse — Its position and cause — Sounds of the Heart — Their cause and duration — Nervous Supply of the Heart The term cardiac cycle is applied to that sequence of events which is included in each successive beat of the heart. It is com- posed of a contraction or systole of the auricles, a contraction or systole of the ventricles, and a pause or period during which all four chambers of the heart undergo relaxation, and then remain in a state of passivity {i.e. a condition in which the muscular walls neither contract nor relax) until the commencement of the succeed- ing cardiac cycle. This pause is called diastole. The phases of contraction and relaxation on the right and left sides of the heart are, under normal conditions, exactly synchronous in the corresponding chambers. The normal rate of the heart's action may be taken to be seventy- five beats per minute, so that each complete cardiac cycle is about eight-tenths (y^^) o^ ^ second in duration. The times occupied by the individual phases are approxi?jiately as follows : — Auricles. Ventricles Systole of the auricles Systole of the ventricles Diastole of the auricles : Relaxation Passive interval Diastole of the ventricles Relaxation Passive Interval . Total Cardiac Cycle 1 sec. TTT sec sec. sec. sec. It must be clearly understood that the clinical uses of the terms "systole" and "diastole" apply solely to these conditions in the ventricles. Consequently " systole," as applied to the phases of the cardiac cycle, includes the ventricular contraction, and part of 9 JO DISEASES OF THE HEART the auricular relaxation ; while "diastole" comprises the ventricular relaxation, part of the auricular relaxation ; the passive interval, and the whole of the auricular contraction (see diagram Fig. 4). ■eSecs. ■^Secs. FIG. 4. DIAGRAMMATIC REPRESENTATION OF THE CARDIAC CYCLE By the successive contractions of the auricles and ventricles the blood passes from the former into the latter, and from the latter into the arterial trunks. A reflux is prevented by the interposition of valves between the auricles and ventricles, and at the orifices of the aorta and pulmonary artery. The flaps of these valves come together and close the openings which they guard so soon as the blood pressure in front of them becomes greater than in the chamber immediately behind them. There is no valvular mechanism to prevent a reflux of blood from the auricles into the large veins during the auricular contraction, but immediately before and during the auricular systole there is a similar contraction of the muscular walls of those portions of the large veins which lie nearest the heart, and a consequent narrowing of their lumen, so that the blood takes the path of least resistance, and passes through the auriculo- ventricular openings into the ventricles. PHYSIOLOGY II Blood passes into the ventricles during the whole of the ventricular diastole largely in consequence of the positive pressure which prevails in the veins and auricles, but in some measure, no doubt, owing to the negative pressure which obtains in the ventricular chambers, by reason of the active dilatation of their walls. The final process of filling the ventricles is completed by the auricular systole. The time relations and sequence of the various events which comprise the cardiac cycle are illustrated by the preceding diagram. The outer and inner circles represent the movements of the auricles and ventricles respectively. The radial and circular lines between the circles represent the contraction and relaxation of the auricles and ventricles respectively. The passive interval is left blank, while each eighth part of the circumference of the circles represents one-tenth of a second. The most constant feature of the cardiac cycle, with different rates of heart beat, is the duration of the ventricular systole. Hence it follows that an increase in the rate of the heart's action is obtained chiefly by means of the shortening of the diastole. The cardiac impulse. — The cardiac impulse is the visible and palpable pulsation of the heart against the chest wall. It is syn- chronous with the systole of the ventricles, and can be most distinctly seen and felt in the fifth left intercostal space, about half to one inch on the sternal side of the vertical nipple line. The site and force of the cardiac impulse vary somewhat with the position of the body. The cause of the cardiac impulse is briefly as follows. In the state of rest, during diastole, the heart lies with its axis directed obliquely downwards, so that the apex of the organ (in the up- right position at all events) is in contact with the chest wall at the point mentioned above. During systole the heart, besides being tilted slightly upwards, moves forwards and to the right, whereby the apex is brought into closer contact with the thoracic parietes at a time when the wall of the ventricles suddenly becomes tense and hard. Furthermore, the antero-posterior diameter of the heart is increased during systole, and in this way the anterior surface of the ventricles is also brought nearer to the chest wall. The total effect of these changes is to bring the apex and adjacent portion of the cardiac wall, during systole, into somewhat violent contact with the thoracic parietes in the position of the apex beat. The cardiac impulse, therefore, is the local displacement of the thoracic parietes produced by the more or less forcible impact of the apex and adjacent portion of the hardened and rigid cardiac wall during the ventricular systole. A lengthening of the long axis of the heart is not concerned in the production of the apex beat, inasmuch as this diameter of the organ remains apparently unaltered during systole and diastole. If the heart's impulse be allowed to impinge on the end of a lever, or on the membrane of a tambour in one of the manv forms 12 DISEASES OF THE HEART of cardiograph, a tracing or impulse curve may be obtained, which will be considered more fully later (see p. 94). The following is a normal cardiogram : — 5. NORMAL CARDIOGRAM (Saiisom afi'ar Galabin) The sounds of the heart, — On listening over the region of the heart two sounds may be distinguished, which have been likened to the pronunciation of the syllables lubb-dup. The first sound, as indicated by the consonous syllable lubb, is comparatively dull, deliberate, and prolonged ; while the second sound, represented by diip, is sudden, sharp, and short. The interval between the first and second sounds is very short, while that between the second and succeeding first sound is relatively of considerable duration. By direct observation it has been proved that the first sound is synchronous with the ventricular systole, and the second sound with the closure of the semilunar valves. The first sound of the heart is caused partly by the tension vibration of the segments of the auriculo-ventricular valves, consequent on the sudden closure of their orifices ; partly by the so-called muscular sound, which is pro- duced by the vibration of the muscular wall of the ventricles, consequent on their contraction ; and partly by the vibration of the mass of blood in the ventricles and of the chordai tendine^. The second sound is due partly to the tension vibration of the semilunar cusps, consequent on the simultaneous and sudden closure of the aortic and pulmonic valves, and partly to the vibration of the column of blood in the aorta and pulmonary artery. The duration of the cardiac sounds, and more especially of the pauses between them, is subject to considerable variation, but the average times of these incidents, and their relation to the events comprising the cardiac cycle, are represented in the accompanying diagram. (Fig. 6.) The nerves of the heart. — The nervous supply of the heart is derived from two sources, namely, from the pneumogastric or vagi, and sympathetic nerves. PHYSIOLOGY 13 The pneumogastric branches are as follow : — 1. The superior cardiac branches, two or three in number, leave the vagus between the superior and inferior laryngeal branches. 2. The inferior cardiac branches arise partly from the superior laryngeal nerve and partly from the main vagus trunk as it enters the thorax. ^ -8 Sees ^ ■CSecs. I ZSecs. ■4 Sees. FIG. 6. DIAGRAMMATIC REPRESENTATION OF THE CARDIAC SOUNDS WITH REFERENCE TO THE CARDIAC CYCLE The sympathetic branches are as follow : — 1. The superior cardiac branch from the superior cervical ganglion. 2. The middle cardiac branches (composed of small strands) from the middle cervical ganglion. 3. The inferior cardiac branches derived from several small strands from the inferior cervical and first dorsal ganglia. Physiological experiment shows that in the dog, and presumably in man, the sympathetic fibres leave the spinal cord by the anterior roots of the second and third dorsal nerves, and then pass by the rami communicantes to the ganglia stellata (ist thoracic) and thence by the annulus of Vieussens to the inferior cervical ganglia, whence they are distributed to the heart via the cervical ganglia. 14 DISEASES OF THE HEART All three branches unite in the cardiac plexus, which may be described as consisting of a superficial and a deep portion. The former lies in front of the arch of the aorta on its concave border ; the latter lies behind the aorta at a higher level than the superficial portion of the cardiac plexus. From these two plexuses {i.e. superficial and deep) nerves pass directly to supply the auricular walls. The main distribution, how- ever, is by two separate strands which accompany the right and left coronary arteries, and are called the right and left coronary plexuses respectively. The right coronary plexus supplies chiefly the posterior surface of the heart, while the left coronary plexus is distributed mainly over the left ventricle. A large number of ganglion cells are interpolated along the course of the nerves composing these plexuses, more especially in the inter- ventricular and auriculo-ventricular grooves. From these ganglion cells a large number of fine nerve processes penetrate the substance of the heart to be distributed to the individual muscular fibres, as well as to the intermuscular, sub-endocardial, and sub-pericardial tissues. The nuclei of the pneumogastric nerves, or rather those parts of them which supply the heart, viz. the accessory portions, are situated in the medulla oblongata, in close proximity to the respiratory and vaso-motor centres. The sympathetic fibres have also a central connection with cells in the medulla and upper part of the spinal cord. The cells con- nected with the sympathetic fibres do not appear, however, to be aggregated into a definite centre, but seem rather to be distributed as a series of centres through the upper portion of the spinal cord, with, probably, a controUing centre in the medulla, situated near the pneumogastric nucleus. The regulation of the beat of the heart, so far as this is deter- mined by nervous influences, is effected for the most part, if not entirely, either directly or reflexly, through these centres. With regard to function the pneumogastric centres have been termed " cardio-inhibitory," and the sympathetic centres "cardio-accelerator" or "cardio-augmentor," inasmuch as those impulses which diminish the force and rate of the heart's action and prolong diastole, reach the heart by way of the pneumogastric nerves ; while those impulses which increase the force and rate of the heart's action and shorten diastole reach the organ by way of the sympathetic fibres. The action of the cardiac centres can be affected— 1. Directly, by the condition of the blood, by drugs, by altera- tions in blood pressure, etc. 2. Reflexly, by — (a) Afferent impulses reaching the centres from the heart. PHYSIOLOGY 15 (P) Afferent impulses from other organs, notably from the abdominal organs. (7) Afferent impulses from the higher nervous centres originat- ing in emotion, anxiety, grief, etc., or sensory impressions in the form of pain. (5) Vaso-motor, respiratory, and other influences. It must be borne in mind that, quite apart from nervous influences, the cardiac muscle has the power of independent rhythmical con- traction; a power which is, however, but feebly developed in the mammahan heart. Nevertheless the beat of the heart can be, and is, profoundly modified by influences acting directly on the cardiac muscle, and possibly on the cardiac ganglia. The function of the cardiac ganglia is not fully known, but their influence on the regula- tion or modification of the heart's action is probably quite subsidiary. The more important conditions which exert a direct influence on the cardiac muscle and thereby modify the beat of the heart are : — 1. Mechanical stimuli. — The heart is seldom exposed to mechanical stimuli; but the pressure that is not uncommonly exerted on the organ by a distended stomach, etc., may be classed under this head. 2. Alterations in the quantity and quality of the blood, both physiological and pathological ; drugs, etc. 3. The degree of distension of the cardiac chambers, as, for instance, may be affected by respiration, alterations in blood pressure, or by disease in the form of valvular incompetence or stenosis of an orifice, etc. Here the distension of one or other of the cardiac chambers increases the tension of its walls, and by this means gives rise, within certain limits, as in the case of skeletal muscle, to a more forcible contraction of the heart. CHAPTER III METHODS OF DIAGNOSIS Enumeration of Methods — Section 1. Symptomatology — Section II. Etiology — Section III. The Physical Methods of Diagnosis — Sub-section I. Inspection ; general ; local — Sub-section II. Palpation ; Prsecordium ; great vessels ; other organs — Sub-section III. Percussion ; Heart ; Pericardium ; great vessels ; other organs — Sub-section IV. Auscultation ; Heart Sounds and their Modifi- cations ; Adventitious Sounds ; Vascular Sounds. The diagnosis in cases of heart disease is based on — 1. The symptoms. 2. The causal conditions indicated by the age, sex, occupation, and history of the patient. 3. The physical examination of the patient, which consists in the use of certain modes of procedure, distinguished under the titles of Inspection, Palpation, Percussion, and Auscultation. These physical methods of diagnosis should always be em- ployed in the order in which they are named. Each element in the diagnosis will now be considered under the headings of Symptomatology, Etiology, and the Physical Methods of Diagnosis. A short account of the pulse and of the clinical uses of the sphygmograph and cardiograph will complete the chapter. SECTION I SYMPTOMATOLOGY Disease of the heart may exist for a long time without giving rise to symptoms of any kind. Thus it not very uncommonly happens that the presence of a cardiac lesion remains unsuspected until some accidental circumstance, such as a medical examination for life insurance or for one of the public services, reveals its existence. The symptoms of morbus cordis are sometimes referred mainly to the heart itself, but more often they are ascribed, for the most partj 16 METHODS OF DIAGNOSIS 17 to other organs, consequent on the disturbance of function that attends any mechanical derangement of their blood supply. A systemic arrangement of the symptoms will be adopted in the following brief account of the subject. Cardio-vascular system. ^ — Apart from pericarditis and angina pectoris, prsecordial pain is seldom a prominent feature of heart disease. A feeling of tightness, uneasiness, or pressure in the cardiac region, accompanied possibly by palpitation, or by the Palpation Percussion lnspecl"ron Symptomatology Auscultation Aetiology Diagnosis FIG. 7. DIAGRAMMATIC REPRESENTATION OF THE DIAGNOSIS consciousness of an irregular or intermittent action of the heart, is sometimes complained of. These symptoms are, however, more commonly due to nervous causes, or to digestive disorders, than to organic disease of the heart. Pulsation may be felt in various situations, more particularly in the region of the head and neck, and is occasionally a source of much discomfort. Noises in the ears are also experienced in connection with abnormal conditions of the circulation. Hemorrhage from the nose, lungs, stomach, uterus, etc., is by no means uncommon, and may lead to serious loss of blood. Defective supply of blood to the extremities is the cause of the i8 DISEASES OF THE HEART cold hands and feet so commonly complained of by the subjects of heart disease. Cyanosis and dropsy will be considered under the heading of physical methods of diagnosis {vide Inspection). Accidental symptoms, due to the emboHc plugging of an artery in the brain, spleen, kidneys, or elsewhere, may occur at any period of the disease. Bespiratory system. — Shortness of breath on exertion is one of the earliest indications of commencing failure of the muscular power of the heart. The dyspnoea, which is at first excited and increased by effort, gradually becomes more pronounced as the cardiac weakness progresses, and in the final stages of the disorder may culminate in orthopncea. In some instances the patient suffers from paroxysmal attacks of difficulty in breathing, which are known under the name of cardiac asthma. Rhythmic dyspnoea, in the form of Cheyne-Stokes' respiration, may precede the fatal event. The pathology of cardiac dyspnoea will be discussed subsequently. Cough, with a variable quantity and quality of expeetoration, is often a troublesome symptom. Haemoptysis may occur more especially in mitral disease, and epistaxis is not uncommon in association with aortic insufficiency. The subjects of heart disease are particularly Hable to attacks of bronchitis, and in a less degree to pneumonia. Digestive system. — It frequently happens that patients suffering from morbus cordis, notably in the form of mitral disease, seek medical advice in the first instance for the relief of dyspepsia. The derangement of digestion usually takes the form of epigastric pain, or weight after food, nausea, vomiting, pyrosis, flatulence, and constipation, or irregular action of the bowels. Flatulent distension of the stomach reacts unfavourably on the heart by directly interfer- ing with its free action, and in this way gives rise to palpitation and cardiac distress. Congestion of the portal circulation is commonly associated with a greater or less degree of gastro-intestinal catarrh, which seriously aggravates the pre-existing dyspepsia. Hsematemesis sometimes occurs, and hemorrhoids are frequently a cause of very great discomfort. Pressure on the oesophagus, with difficulty in swallowing, may be due to a large pericardial effusion. Hoarseness or aphonia occasion- ally depends on a like cause. Nervous system. — A feeling of depression and languor, dis- inclination for mental or bodily exertion, pain in the back and extremities, and weakness, twitching, and tremor of the muscles are among the early indications of a defective supply of blood to the central nervous system. METHODS OF DIAGNOSIS 19 Headache, giddiness, noises in the ears, flashes of hght before the eyes, and attacks of faintness or syncope are associated with disturbance of the cerebral circulation. Sleeplessness is frequently a most distressing feature of diseases of the heart. On the other hand, drowsiness may be complained of, and sleep is often attended by unpleasant dreams. DeUrium is occasionally observed, and is of serious import. Emotional disturbances, mental changes, failure of memory, hallucinations, melancholia, dementia, etc., are not infrequently found in association with the different forms of valvular disease. Hemiplegia, coma, and convulsions may be due to haemorrhage in the brain from rupture of a blood vessel, to embolism of a cerebral artery, or to thrombosis in the cerebral veins. The mode of onset of the symptoms considered in relation to the circulatory conditions at the time of their occurrence, the age of the patient, and the associated causal indications outside the nervous system, are the chief points in the differential diagnosis of these lesions. Genito-urinary system. — The urine of heart disease (after failure of the organ) is scanty, high coloured, and throws down on cooling a copious deposit of urates. It frequently contains albumen, hyaline or granular casts, bile, uric acid crystals, and occasionally blood. The characters of the urine of heart disease will be more fully considered under the heading of physical diagnosis {vide Inspection). SECTION II -STIOLOGY The influence of the age, sex, occupation, and history of the patient on the incidence of heart disease will be considered under their respective headings. Age. — Developmental malformations, and intra-uterine endo- carditis account for the large majority of cardiac affections that are found during infancy. In childhood, endocarditis, and pericarditis, of rheumatic origin, are comparatively common, and are apt to run a very insidious course. The rheumatic symptoms are usually slight, and unless great watchfulness is exercised may easily escape observation. The influence of chorea, a common disorder of childhood, in the production of endocarditis, is largely due to its rheumatic ancestry. Certain of the acute specific fevers, notably scarlet fever, diphtheria, influenza, pyaemia, sepiicsemia, and measles are some- times accompanied by inflammatory affections of the heart. The endocardial inflammation in childhood usually attacks the mitral valve, rarely the aortic. During adolescence and early adult life (15-30) the acute inflammatory affections of the heart, due to 20 DISEASES OF THE HEART rheumatism, are more prevalent than at any other time. Further- more, at this period the influence of anaemia in the production of cardiac disease is most marked, and at the same time functional disorders of the heart begin to make their appearance. The mitral valve is more commonly affected than the aortic, but the relative immunity of the latter is not so great during this stage as in childhood. Although the influences just mentioned are still operative, the middle period of adult life (30-45) introduces other important causes of cardiac disease, chief among which are physical overstrain, syphilis, and many other toxcemias, including the effects of excess in the use of alcohol and tobacco. Moreover, the effects on the heart and aorta of the high arterial tension that is associated with gout, contracted granular kidney, chronic lead poisoning, emphysema, etc., commonly begin to make their appearance during this and the succeeding decade of life. In later adult life and during old age (45 and upwards) degenera- tive diseases of the heart and aorta become increasingly prevalent. True angina pectoris rarely occurs before the age of 40, and may therefore be fairly included among the cardiac lesions of the period under consideration. Atheromatous affections of the endocardium may be primary, or they may be grafted on to pre-existing valvular disease. The myocardium is frequently the seat of parenchymatous, fatty, or fibroid changes, as well as of other nutritional disturbances of a less defined nature, which are closely concerned in the production of failure of the heart, and dilatation of its cavities. Sex. — Women suffer more frequently from chorea, anaemia, ex- ophthalmic goitre, and functional affections of the nervous system than men, and are consequently more liable to the cardiac lesions associated with these morbid conditions. On the other hand, the in- fluence of muscular overstrain, gout, syphilis, and alcoholism on the incidence of heart disease is more marked among males than females. Occupation. — Persons who are exposed to cold and wet, as for instance washerwomen, out-door labourers, cabmen, etc., are more liable to suff"er from the rheumatic manifestations of heart disease than other people. All occupations that are attended by severe muscular exertion, and more especially those that entail sudden effort, are productive of enlargement of the heart, and, if the cause persist, of aortic and arterial disease, in the form of arterio-sclerosis and atheroma. These conditions obtain principally among hammermen, miners, stokers, hill-climbers, puddlers, stonemasons, slaughterers, soldiers, and sailors, and to a less degree among athletes. In the case of soldiers, and possibly in other instances, it is probable that a nervous element co-operates with the muscular overstrain in the production of the cardiac hypertrophy. The enlargement of the heart, in the class of cases under con- METHODS OF DIAGNOSIS 2\ sideration, is due predominantly either to hypertrophy or to dilatation according as the state of cardiac nutrition is satisfactory or otherwise. Hypertrophy of the left ventricle is the condition usually found. Aortic valvular disease, arterio-sclerosis, and atheroma are due to the strain to which the whole arterial system is exposed in cases of prolonged muscular exertion. Persons of sedentary habits, who habitually eat and drink to excess, are frequently the subjects of atheromatous disease and of myocardial degeneration. History. — -A short account will be given under this heading of the various conditions of disease, and other morbid influences in the life-history of the patient that are causally related to affections of the heart. Rheumatism, in one or other of its manifold phases, is by far the most important cause of heart disease. In many instances it is possible, indeed probable, that the cardiac affection is the sole manifestation of the rheumatic state. The endocardium, pericardium, and myocardium may be separately or simultaneously the seat of acute or chronic inflammatory changes in rheumatic cases. Endo- carditis and pericarditis also arise in connection with certain of the specific fevers, notably with scarlet fever, less frequently with measles and erysipelas, and rarely with enteric fever and small- pox. Inflammation of the pericardium is a comparatively common complication of chronic Bright's disease, and it is occasionally observed in the course of pysemia and pneumonia. Malignant endocarditis, which in three-fourths of the cases is superimposed on previously existing valvular disease, occurs in asso- ciation with pneumonia, puerperal fever, osteomyelitis, the specific fevers, phlebitis, and with other forms of septicemia and pyjemia. Pysemia and phlebitis also account for a certain number of the cases of acute myocarditis. The so-called "parenchymatous myocarditis" appears in the course of many of the acute febrile and infective processes, as for instance enteric fever, diphtheria, scarlatina, small-pox, typhus, relapsing fevers, septicaemia, and pyaemia. Anaemia is a frequent cause of cardiac malnutrition and dilata- tion of the heart, which usually disappear with the restoration of a normal blood condition. The comparatively common occurrence of mitral stenosis among women in the absence of a history of rheumatism has led to the belief that chlorosis may, in some instances, be a cause of this form of organic valvular disease. Gout, chronic alcohoUsm, and syphilis are among the chief dis- posing causes of aortic valvular lesions, arteritis, and atheromatous affections of the arterial system. Degenerative changes in the myocardium, of a fatty and fibroid nature, are also frequently associated with alcoholism, syphilis, and other toxaemias. 22 DISEASES OF THE HEART Physical overstrain and protracted high arterial tension from any cause are productive of enlargement of the heart, and of arterial disease in the form of aortic valvular lesions, arterio-sclerosis, and atheromatous affections. Nervous disorders of the heart frequently owe their origin, in part at least, to physical overstrain. Worry, anxiety, grief, and long-continued mental strain of any kind are sometimes the exciting cause of cardiac disease, and their occur- rence adds greatly to the gravity of pre-existing affections of the heart. The influence of heredity on the incidence of heart disease has also to be taken into consideration. Cardiac affections are hereditary chiefly in so far as their causes are hereditary. Thus rheumatism and gout, on which the large majority of the cases of heart disease depend, show a remarkable tendency to be trans- mitted from one generation to another. An hereditary tendency to high arterial tension and atheroma is also observed in some cases. The functional derangements of the heart which depend on neuroses of various kinds are likewise prone to run in families. SECTION III THE PHYSICAL METHODS OF DIAGNOSIS So far as the examination of the heart is concerned, the physical methods of diagnosis range themselves under the four heads of Inspection, Palpation, Percussion, and Auscultation, which, as previously mentioned, should always be practised in this order. The data afforded by each of these methods will first be given in tabular form, and then discussed in detail. SUB-SECTION I INSPECTION No complete or accurate physical examination of the heart is possible unless the entire chest is fully exposed. The information afforded by inspection may be most conveniently classified under the two heads of A. General B. Local A. General. — This will be considered under the followin scheme : (^^-^ Appearance a?id attitude of the patient (b) Colour 1. Cyanosis or lividity 2. Pallor 3. Jaundice {c) Dyspncea (d) Dropsy (e) State of gefieral nutrition (/) Urifie METHODS OF DIAGNOSIS 23 B. Local. — This will be discussed under the following arrange- ment : — {a) Bulging or retraction of the prcecordial region as a whole, or in part (b) Position of the apex beat {c) Visible pulsation 1. Cardiac Prsecordium as a whole, or in part Epigastric Displaced 2, Vascular Arterial Venous Capillary Glandular A. GENERAL {a) Appearance and Attitude The aspect of the patient suffering from morbus cordis is often very characteristic, and it should be noted in all cases. The facial appearance commonly associated with the more important cardiac lesions will be fully described under their respective headings. The attitude of the patient is frequently peculiar to his condition, and may have considerable diagnostic significance. {b) Colour I. Cyanosis or lividity. — This phenomenon, with clubbing of the fingers and toes, and coldness of the extremities, is usually associated with congenital malformations of the heart. It is, however, also observed, though usually to a less marked extent, in chronic disease affecting the mitral and tricuspid valves, and in lesions of the cardiac walls. Cyanosis, to any great degree, is rarely found independently of some form of heart disease. The discolouration of the skin in any given case is seldom constant, and may vary within very wide limits. It is increased by excitement, exertion, and lung complications, and diminishes under the influence of rest, sleep, etc. Two theories have been advanced with the object of explaining the mode of production of the cyanosis. The one, proposed by Morgagni, attributes the blue tint to the general venous congestion caused by the obstruction to the free passage of blood through the right side of the heart; while the other, advanced by Hunter, ascribes it to the intermixture of venous and arterial blood. Both views have met with wide acceptance. There are, however, several very powerful arguments which favour the explanation afforded by Morgagni's theory. It has, in the first place, been clearly shown that no constant relation exists between the intensity of the cyanosis and the amount of intermixture of arterial and venous blood ; more- 24 DISEASES OF THE HEART over, extreme cyanosis may exist without any possibility of inter- mixture. Furthermore it is noteworthy that in all cases of well marked cyanosis the conditions under which great venous obstruction may occur are present. It would appear, therefore, that Morgagni's theory affords a fairly adequate explanation of the manner in which cyanosis is produced. At the same time it is probable that the intensity of the cutaneous discoloration is influenced by other factors, such as the amount of intermixture of arterial and venous blood ; an insufficient aeration of blood by the lungs ; dilatation of the cutaneous capillaries and an unusual transparency of the skin. 2. Pallor. — The frequent association of anaemia with morbus cordis is a matter of common observation, and its production, excluding accidental causes such as epistaxis, hsemoptysis, menor- rhagia, etc., is accounted for in two ways, viz : — 1. That the chief causes of heart disease, as, for instance, rheumatism, the specific fevers, gout, etc., site per se fruitful sources of ansemia. 2. That in consequence of the particular lesion which exists, the circulation is inadequately maintained, and the proper assimilation of food and elimination of waste products is more or less defective, and hence the anemia. The most intense form of anaemia resulting from organic disease of the heart is that associated with aortic incompetence. Children suffering from morbus cordis are frequently the subjects of severe anaemia induced by repeated attacks of rheumatism. The pallor affects the general surface of the skin, the conjunctivae, and mucous membranes. 3. Jaundice. — This sign, which is seldom well-marked or constant, is usually observed after failure of the heart, and most commonly with mitral and tricuspid lesions. During the early stages of cardiac failure the jaundice is due to catarrh of the bile ducts, while at a later period of the disease it depends on organic changes in the liver, the result of long-continued venous congestion. {c) Dyspnoea Dyspnoea, by which is meant increased action of the respiratory muscles, both as regards frequency and degree of contraction, may be either inspiratory or expiratory, or a combination of the two conditions. Speaking generally, cardiac dyspnoea is both inspiratory and . expiratory. With disease of the heart difficulty of breathing may be observed under several conditions : — I. It may appear on exertion only, or as the result of some other external influence. METHODS OF DIAGNOSIS 25 2. It may arise spontaneously, or without any obvious exciting cause. 3. It may be constant and postural, and it is then known as orthopncea. 4. It may be paroxysmal, or rhythmic, in the form of — (a) Cardiac asthma (d) Cheyne-Stokes' respiration. The value of dyspnoea as an indication of failure of the heart depends on the magnitude of the cause producing it. Dyspnoea which arises spontaneously, or as the result of very slight provoca- tion, argues a greater degree of cardiac insufficiency than that pro- duced by some definite and partially adequate cause. Orthopncea, often associated with dropsy, usually indicates a considerable amount of dilatation of the heart from failure. The occurrence of Cheyne-Stokes' respiration with organic disease of the heart is usually but not invariably of fatal import. The pathology of dyspnoea, though somewhat complicated, can be but briefly considered. The movements of respiration are regulated by the respiratory centre, the activity of which depends on the quantity and quality of blood supplied to it. An excess of carbon dioxide, or a deficiency of oxygen in the blood, excites the centre to greater activity, with the result that increased action of the respiratory muscles is produced, or, in other words, dyspnoea. Now, in disease at the mitral orifice there is always, owing to the position of the opening, more or less embarrassment of the pulmonary circulation, whereby the blood becomes insufficiently aerated, z'.e. it contains more carbon dioxide and less oxygen than normal, and the consequent stimulation of the respiratory centre gives rise to dyspnoea. This explanation, however, of the cause of cardiac dyspnoea is probably far from covering the whole of the ground. A venous condition of the blood produces, also, through its effect on the vaso-motor centre, a general rise of systemic blood pressure by virtue of the contraction of the arterioles throughout the body. Von Basch has shown that increased systemic tension is invariably followed by a rise of blood pressure in the pulmonary circulation. He also points out that the accompanying distension of the pulmonary capillaries causes, so to speak, a general erection of the lung tissue, with enlargement of the lumina of the alveoli, and increased rigidity of their walls. As a consequence of these changes, increased inspiratory force is required to properly inflate the lungs, and expiration is difficult owing to the impairment of the elasticity of the alveolar walls, hence dyspnoea follows in proportion to the difficulties to be overcome. It would therefore appear probable that in the production of cardiac dyspnoea, pulmonary engorgement acts in two ways : 26 DISEASES OF THE HEART (a) directly by a mechanical effect on the lungs, and (i) indirectly through the respiratory centre. Dyspnoea produced by cardiac insufficiency assists the circu- lation inasmuch as each respiration pumps the blood from the venous system through the lungs (Leonard Hill). The foregoing account, while offering a fairly adequate explana- tion of the causes of dyspnoea in disease at the mitral orifice, does not by any means exhaust the subject. In pulmonic and tricuspid valvular lesions the mechanical inter- ference with the circulation through the right heart and lungs will result in the insufficient aeration of the blood and the consequent stimulation of the respiratory centre with the production of dyspnoea. In disease at the aortic orifice shortness of breath is always a prominent feature. Its production probably depends on several factors, chief among which are (i) the anaemia that is commonly associated with these lesions, and (2) the interference with the proper supply of blood to the heart and medulla, owing to the degenerative changes (arterio- sclerosis and atheroma) in the walls of the arteries supplying these structures, which are affected in common with the other arteries of the body in cases of aortic valvular disease. In the production of cardiac dyspnoea an additional factor still remains to be mentioned, and that is the reflex disturbance of the nervous mechanism of respiration which must occur, to a greater or less degree, in all cases. Its influence is more obvious in the dyspnoea associated with disease of the aorta and its orifice and of the cardiac walls than of any other heart structure. The precise manner in which this reflex effect is produced and the circumstances under which its action is brought into play have not yet received an adequate explanation, but there can be no doubt that sensory nerves supplying the heart, great vessels, and lungs are involved in the morbid processes affecting these structures. A striking example of the reflex production of severe dyspnoea independently of pulmonary influences is seen in cases of acute inflammation of the aorta. Orthopnoea is the condition in which the patient is obliged to adopt a semi-erect or sitting position, since any attempt to lie down is followed by severe and insupportable dyspnoea. The attitude of the patient is often peculiar to this form of laboured breathing, and is such that he can bring into action the accessory muscles of respiration to the greatest possible advantage. The upright position also facilitates the movements of the diaphragm, by reason of the descent of the liver, and other abdominal organs under the influence of gravity, and the same force may also retard the flow of blood in the inferior vena cava, and by this means relieve the engorgement of the right heart and pulmonary circulation. The significance of orthopnoea has already been indicated. The cause of cardiac asthma has not yet been fully determined, though doubtless in many instances it is due to toxic influences, the result of defective eUmination by the kidneys. METHODS OF DIAGNOSIS 27 The pathology of Cheyne-Stokes' respiration is still uncertain, though speaking generally the phenomenon is attributable to exhaustion of the respiratory centre, and the consequent deterioration of functional activity finds expression in a less speciahzed form of energetical manifestation, which, as in the case of all vital phenomena under similar conditions, tends to assume a rhythmical or periodic type. {d) Dropsy- Dropsy of cardiac origin almost invariably begins in those portions of the body which are most distant from the heart. It commences, therefore, in the feet and legs and gradually spreads upwards. At an early period it invades parts like the scrotum and eyelids, where the subcutaneous tissues are looser, and the vessels less supported than elsewhere. Ultimately all the subcutaneous tissues may become infiltrated with fluid. Effusion into the peritoneal and pleural cavities is not uncommon, and may occur at a comparatively early stage of the cardiac failure. The pericardium is affected less frequently, and usually at a later period of the disease. Dropsy may be observed in almost any form of heart disease, but it is most commonly associated with mitral and tricuspid lesions, and with affections of the cardiac walls. The pathology of cardiac dropsy is briefly as follows : — In consequence of {a) the enfeeblement of the driving power of the ventricles and {b) the obstruction to the onward flow of blood through the right side of the heart, a condition of systemic venous engorgement is produced which leads to a general rise of intra- venous and capillary pressure. This state of the circulation favours an increased transudation of the fluid elements of the blood from the smaller vessels and capiUaries into the connective tissue and lymph spaces, and a diminished re-absorption from them into the venous radicles. The process is in all probability intensified by changes in the composition of the blood, and by the consequent interference with the nutrition of the Hning membrane of the capillaries and smaller vessels. Under physiological conditions the lymph channels alone would suffice to carry off the increased quantity of fluid exuded from the capillaries, but the lymph circulation is also impeded, owing to {a) the general muscular enfeeblement, {b) the diminished aspirating power of the thorax, {c) the diminished suction power of the ventricles, and (d) the positive intra-venous pressure in the great trunks of the neck and thorax. As the result, therefore, of the general venous engorgement, and the impeded lymphatic circulation, the fluid exuded by the capillajies and small vessels is unable to escape completely by either venous or lymphatic outlet, consequently it accumulates in the subcutaneous tissues and spaces, with the production of dropsy. 28 DISEASES OF THE HEART () its time relation with respect to the cardiac cycle, which is determined by placing a finger on the apex beat, or carotid pulse, while the other hand palpates the thrill. A thrill that is synchronous with the ventricular impulse is called systolic, while one that alternates with the impulse is termed diastolic. The diastolic thrill may be felt throughout the diastole of the ventricles, or it may be palpable during the early part only of the diastole, when it is called an early diastolic or post-systolic thrill, or during the late part only of the diastolic period, when it is known as a late diastolic or presystolic thrill. A systolic thrill felt over the apex beat indicates mitral incom- petence ; a presystolic or diastolic thrill in this situation is indicative of mitral obstruction, but, as will be shown later, it may be asso- ciated with aortic regurgitation. Thrills felt over the base of the heart; in the second right inter- costal space close to the sternal edge, or in the episternal notch, are indicative of disease at the aortic orifice. If systolic, the opening is obstructed, if diastolic, the valves are incompetent. DiastoHc thrills due to aortic insufficiency may also be felt along the right sternal edge as low as the fifth costal cartilage, and in the second, third, and fourth left intercostal spaces close to the sternum, as well as at the apex beat. Dilatation of the aorta just above the valve may give rise to a systolic thrill in the second right interspace. Thrills felt in the second left intercostal space or over the third left costal cartilage close to the edge of the sternum, indicate disease at the pulmonic opening. If systolic, the orifice is obstructed, if diastolic, the valve is incompetent. A presystolic thrill, palpable in the fourth and fifth intercostal spaces close to the sternum, or over the xiphoid cartilage, is in- dicative of tricuspid stenosis. Congenital disease of the heart not infrequently gives rise to a prsecordial thrill, which is more commonly felt over the base of the organ than at the apex. The intensity of a thrill is often markedly affected by alterations in the position of the patient. 38 DISEASES OF THE HEART 2. Exocardial. Friction fremitus. — This sign, which is the result of the rubbing together of roughened pericardial surfaces, is generally felt earliest over the base of the heart, or over the region of the fourth left costal cartilage. It is commonly systolic in time, but it may have a double rhythm, i.e. systolic and diastolic, and gives the sensation of a rubbing movement to the hand. Pleuro-pericardial friction fremitus is sometimes felt in the region of the apex beat and along the left border of the heart as high as the third rib. {£) Fluctuation Fluctuation is occasionally felt over the prsecordial region in cases of long-standing, large pericardial effusion. B. GREAT VESSELS (a) Aneurismal Pulsation It has already been stated that pulsation above the level of the third rib is generally aneurismal. The features to be observed on palpation are the rhythm, which will be systolic, and the character of the pulsation, which will be expansile. {b) Diastolic Back Shock It has already been mentioned that a diastohc back shock may be felt over the aortic cartilage (second right) in cases of high arterial tension. A similar phenomenon may be observed in aneurismal conditions of the aorta. {c) Thrills 1. Arterial. — A thrill, systolic or diastolic in time, may be felt over an aneurism. 2. Venous. — A venous thrill may often be felt in the jugular veins at the root of the neck in cases of chlorosis and annsmia. The proper appreciation of these thrills necessitates the gentlest palpation, {d) Tracheal Tugging This phenomenon, which is said to be indicative of aneurism of the first part of the aortic arch, is obtained, according to Dr. Ewart, as follows : The patient being seated, the operator, standing behind him, places the tips of the index fingers under the lower edge of the cricoid cartilage, and gently raises it. The patient's head rests on the chest of the operator. The sign consists in a downward traction of the trachea, felt with each systole of the heart. It is not present in all cases of aneurism of the first part of the arch, nor is it patho- gnomonic of this condition. C. OTHER ORGANS A feeble pulsation may sometimes be felt in the thyroid gland with each systole of the heart. Pulsation of the liver is best appreciated by means of palpation, and its expansile character should be carefully observed. The METHODS OF DIAGNOSIS 39 possibility of transmitted pulsation from the right heart should be excluded before the existence of true pulsation is admitted. The lower edge of the liver is frequently palpable in cases of hepatic enlargement. Cardiac disease, as Dr. Head's brilliant investigations have shown, is attended by referred pain and tenderness over certain well defined areas of the chest and scalp. Thus affections of the aortic area and ventricle give rise to reflected pain and tenderness over the upper areas of the chest (2, 3, 4, 5 dorsal) and the mid- orbital region of the scalp. Lesions of the mitral area and auricles are attended by referred pain and tenderness, in the lower part of the chest and upper part of the abdomen (5, 6, 7, 8, 9, dorsal areas) and in the temporal and fronto-temporal areas of the scalp. The tenderness in these areas can be elicited by picking up the superficial structures between the thumb and finger, or by means of the blunt end of a pin. SUI3-SECTI0N III. PERCUSSION Two signs are elicited by means of percussion : the first and more important being the sound emitted by the part percussed, and the second, the degree of resistance, or the density of the spot that is struck. Percussion is distinguished under the terms 'superficial' or 'deep,' according as the finger or pleximeter is struck gently or forcibly. Percussion of the cardiac area will be considered under the following arrangement : — A. Heart {a) Superficial cardiac dulness 1. Increase of 2. Diminution of (<^) Deep cardiac dulness 1. Lateral increase of 2. Upward increase of 3. Downward increase of B. Pericardium {a) Dulness dtie to effusion (l>) Dulness due to adhesions C. Great Vessels D. Other Organs A. HEART {a) Superficial Cardiac Dulness By superficial cardiac dulness is meant the extent of the heart's surface which is uncovered by the lung, and in contact with the chest wall. This area has already been marked out, under normal conditions, on the surface of the chest (see p. 6), and it is necessary only to add that light percussion should be used in defining its outline. 40 DISEASES OF THE HEART 1. Increase of: The area of superficial cardiac dulness is in- creased by (a) deep expiration, (i>) lying on the left side, (c) retraction of the lungs, (d) enlargement of the heart, and (e) pericardial effusion and pericardial adhesions. 2. Diminution of: The area of superficial cardiac dulness is diminished by (a) deep inspiration, {^) emphysema, (c) pneumo- pericardium, (d) displacement of the heart due to air in the pleural cavities, stomach, intestine, and abdominal cavity, or to pleuro- pericardial adhesions, which may drag the organ under the lungs, and possibly by (e) atrophy of the heart. The information obtained by the superficial method of cardiac percussion is, on the whole, more useful in the diagnosis of diseases of the lungs than of the heart. (d) Deep Cardiac Dulness The area of deep cardiac dulness corresponds approximately with the size of the heart. The outline of the organ on the surface of the chest under normal conditions has already been mapped out (see p. 5) and need not be described again. In order to trace out the area in question deep percussion should be employed and a definite mode of procedure adopted. Percussion, in all cases, whether superficial or deep, should be commenced well outside the normal limits of the dulness to be percussed, and the finger is then gradually advanced towards the line where resonance is impaired. In the case of deep cardiac dulness, for instance, the point where the lung resonance begins to be interfered with by the underlying heart should be marked on the chest wall, and the joining of the points, obtained by percussion from all sides, will represent the outline of the heart. I. Lateral increase of the area of deep cardiac dulness. Increase to the right : For clinical purposes the right limit of cardiac dulness, under normal conditions, is defined by the right edge of the sternum. Extension of dulness beyond this line means enlarge- ment of the right auricle and a priori of the right ventricle. It will be noticed that the right limit of cardiac dulness as obtained by precussion does not exactly correspond with the outline of the right auricle as marked out on the chest wall (see diagram, p. 5). This is due to the fact that the outline of the heart is drawn from measurements in the cadaver, whereas in life it is probable that, owing to the pressure of the inflated right lung, and the tone of the auricular wall, the right auricle is situated rather more to the left than is represented. Increase to the left : Extension of the cardiac dulness beyond the left vertical nipple line, which is the normal limit, indicates dilatation of the left ventricle. Increase to the right and left: A bilateral increase of the cardiac dulness is indicative of enlargement of both sides of the heart, and is the condition that is commonly found. METHODS OF DIAGNOSIS 41 2. Upward increase of the area of deep cardiac dulness. The upper limit of cardiac dulness, under normal conditions, is the level of the third rib. Extension of dulness above this line means, in the absence of pericardial effusion, enlargement of the infundibulum of the right ventricle, enlargement of the left auricle, aneurism of the aorta or mediastinal tumour. 3. Downward increase of the area of deep cardiac dulness. The downward extent of cardiac dulness is often difficult to define accurately, owing to the presence of the liver. The lower limit of the left-sided portion of the organ can gener- ally be made out, especially if the stomach is distended with gas, and the lower Hmit of the right- sided portion may often be ap- proximately determined by a shght increase in the intensity of the dulness, and a feeling of increased resistance on passing from the heart to the liver. When the lower limit of the heart cannot be determined by percussion, it may be nearly defined by drawing a line, slightly curved upwards, from the apex beat to the angle of junction of the upper limit of liver dulness with the right limit of cardiac dulness. Extension downwards of the cardiac dulness means, on the left side of the heart, hypertrophy of the left ventricle, and on the right side of the organ, enlargement of the right ventricle. An increase in the area of cardiac dulness downwards and to the left indicates hypertrophy and dilatation of the left ventricle. B. PERICARDIUM {a) Dulness due to Effusion Effusion into the pericardial cavity causes an increase upwards of the praecordial dulness, which may reach as high as the cartilage of the first rib. It may extend downwards as low as the sixth rib or space, while laterally it may, with a copious effusion, stretch from the right vertical nipple line to the left axillary line. The shape of the area of dulness is pyriform when the amount of effusion is slight, and pyramidal or triangular when it is extensive, with the base of the figure directed downwards in both cases. Owing to the pushing aside of the lungs by the enlarged pericardial sac, the line of dulness separating it from the pulmonary tissue is abrupt and well defined, and the finger experiences a sense of increased resistance over the effusion. The relation of the apex beat to the area of dulness must be carefully ascertained. With a copious pericardial effusion the apex beat lies well above and inside the area of dulness, that is to say the dulness due to the effusion extends below and outside the apex beat. 42 DISEASES OF THE HEART (b) Dulness due to Adhesions Pericardial adhesions are often associated with a permanent increase in the area of cardiac dulness, which depends on en- largement of the heart. C. GREAT VESSELS Dulness due to dilatation of the ascending aorta may often be percussed out over the second right intercostal space and adjacent portion of the sternum, and appears as an extension upwards and to the right of the cardiac dulness. Aneurism of the vessel gives rise to a larger area of dulness in this situation. Dulness over the upper sternal region and adjacent portion of the left side of the thorax is sometimes associated with aneurism of the transverse portion of the aortic arch. Dilatation of the pulmonary artery gives rise to dulness in the second left interspace close to the edge of the sternum. D. OTHER ORGANS The size of the liver should always be determined by means of palpation and percussion in cases of morbus cordis. Normally the upward extent of the organ in the right vertical nipple line is the level of the sixth rib, though the upper surface of the liver, owing to its dome-shaped conformation, corresponds, in easy breath- ing, with a horizontal line drawn at the level of the base of the ensiform cartilage, or middle of the eighth dorsal vertebra. The downward extent of the Hver in the nipple line is the costal margin, while in the median line it extends one and a half inches below the base of the xiphoid cartilage. Enlargement of the liver is one of the earliest indications of interference with passage of blood through the right heart and lungs, hence the importance of a systematic examination of the organ in all cases of heart disease. Indeed, so sensitive is the liver to disturbance of the blood current through the right heart and lungs that it might almost be called " the barometer of the circulation." SUB-SECTION IV AUSCULTATION Auscultation of the heart will be considered under the following scheme : — A. Heart Sounds and their Modifications {a) Position and direction of cofzdicction {b) Character {c) Rhythm {d) Reduplication METHODS OF DIAGNOSIS 43 B. Adventitious Sounds {a) Endocardial 1. Organic murmurs Physical causes of Site of production and direction of transmission Character Rhythm 2. H^mic murmurs Causes of Site of production and direction of transmission Character Rhythm ip) Exocardial 1. Friction sounds Pericardial Pleural Pleuro-pericardial 2. Murmurs Cardio-pulmonary C. Vascular Sounds 1. Normal sounds 2. Adventitious sounds Arterial Venous A. THE HEART SOUNDS AND THEIR MODIFICATIONS The normal sounds. — The method of production of the normal sounds of the heart has already been discussed (see p. 12), and does not require any further consideration. Before describing the position in which the sounds are heard, a brief account will be given of the mode of procedure that should be adopted in auscultating the heart. The chest piece of the stethoscope is placed firstly over the apex beat and the region of the chest wall immediately surrounding it, which may collectively be termed the '"mitral area." The instru- ment is then gradually advanced, obliquely upwards and outwards, into the left axilla, and thence as far as the angle of the left scapula. It is then placed upon successive points on the chest wall, in a line connecting the apex beat with the second right costal cartilage, at its junction with the sternum. The second right costal cartilage is known as the " aortic cartilage," and this region of the chest wall, with the adjacent portion of the second interspace, is called the "aortic area." From here the stethoscope is carried upwards to the episternal notch and right side of the neck over the carotid artery, 44 DISEASES OF THE HEART and downwards along the right sternal edge. It is then placed close to the sternum over the second left costal cartilage, ternaed the "pulmonary cartilage," which with the adjacent portion of the second interspace is known as the "pulmonary area." The instrument is now carried along the left sternal edge to the base of the ensiform cartilage. The fourth and fifth left intercostal spaces, for about an inch to the left of the sternum, and the region of the chest wall immediately surrounding the base of the ensiform cartilage, are collectively termed the " tricuspid area." FIG. 6. THE AREAS IN WHICH THE SOUNDS PRODUCED AT THE VARIOUS CARDIAC ORIFICES ARE MOST DISTINCTLY HEARD M (within circle) = mitral area ; A (within circle) = aortic area ; T (within circle) = tricuspid area P (within circle) = pulmonary area To distinguish between the two sounds of the heart, a finger should be put on the apex beat, or on the carotid artery in the neck, while the stethoscope is placed in the mitral area; the first sound is synchronous with the cardiac impulse or pulse wave, as the case may be. METHODS OF DIAGNOSIS 45 {a) Position and Direction of Conduction of the Normal Heart Sounds The left ventricle first sound. — The left ventricle first sound is most distinctly audible at and to the left of the apex beat. It is also heard with a variable degree of distinctness in the aortic area. The aortic second sound.- — -The aortic second sound is heard best in the aortic area, but it is distinctly audible over the carotid arteries in the neck, especially on the right side, and in this situation is not liable to be confused with the pulmonic second sound. The aortic second sound can also be well heard at and to the left of the apex beat. The puiniofiic second sound.— The. pulmonic second sound is heard most distinctly in the second left interspace close to the sternum. It is also plainly audible over the second left costal cartilage, and over the whole of the right ventricle. It is not normally audible at the apex of the heart. The right ventricle first sound. — The first sound of the right ventricle is heard over the whole of the organ in relation with the chest wall, but it is most distinctly audible in the tricuspid area. It will be noticed that the areas in which the various heart sounds are best heard do not necessarily correspond with the anatomical posi- tion of the structures producing them, and for the following reasons. It has already been explained that the first sound of the heart is composed of a muscular and a valvular element. The muscular element of the first sound gives rise to no difficulty, as it is naturally heard most distinctly where the ventricles are in closest contact with the chest wall, and hence, in the case of the left ventricle, is most plainly audible at the apex of the heart. The valvular element of the first sound of the left ventricle is not audible over the anatomical position of the mitral orifice, because here a considerable thickness of lung tissue, which is a bad con- ductor of sound, is interposed between the heart and chest wall. The valvular vibrations are, however, transmitted along the wall of the left ventricle, and are best heard at the apex of the heart, which, uncovered by lung, comes into close relation with the thoracic parietes. For similar reasons the first sound of the right ventricle is most distinctly audible in the tricuspid area, and not directly over the site of the tricuspid valve. The left ventricle first sound is heard in the aortic area, and is conducted thither by the walls of the aorta. With respect to the aortic second sound, it is heard most distinctly in the aortic area, where the vessel comes nearest to the surface. The vibrations due to the sudden tension of the semilunar valves are transmitted along the course of the aorta by means of the arterial wall and the contained column of blood. A similar mechanism explains the conduction of the aortic second sound into the neck, and it is transmitted to the apex of the heart by the wall of the left ventricle. 46 DISEASES OF THE HEART The reason that it is not heard over the site of the aortic orifice is that here the vessel is covered, not only by lung, but also by the infundibulum of the right ventricle, which interferes with the trans- mission of vibrations to the surface of the chest. The pulmonary second sound is heard most distinctly over the exact anatomical position of the orifice, viz. at the upper border of the third left costal cartilage close to the sternum. The sound is transmitted upwards along the course of the vessel, as high as the second costal cartilage, and downwards by the wall of the right ventricle, to the base of the ensiform cartilage, and to within an inch of the apex beat. {b) Character of the Normal Sounds of the Heart The sounds of the heart are usually represented by the familiar syllables " lubb-dup," which correspond to the first and second sounds respectively. They convey the idea of sudden tension, and can be imitated by the more or less rapid stretching of longer and shorter pieces of string or membrane. The border of an ordinary pocket- handkerchief answers the purpose perfectly well. The first sound is duller, longer, and louder than the second, which is short and sharp. Normally the left ventricle first sound is duller and longer than that of the right, which is relatively short and sharp. This difference is in all probability explained by the relative preponderance of the muscular element in the production of the left ventricle first sound. The pulmonary second sound at the base of the heart is under normal conditions louder than the aortic, but, according to some observers, this statement is open to doubt. The relative intensity of the two sounds is apparently determmed largely by the age of the individual (Cabot). {c) Rhythm of the Normal Sounds of the Heart The relative time duration of the events composing the cardiac cycle may be stated approximately as follows : — . The first sound occupies nearly three-tenths of a second. The in- terval between the first and second sounds one-twentieth of a second. The second sound occupies one-tenth of a second. The long silence, or in other. words the diastole of the ventricles, occupies five-tenths of a second. Under normal conditions the relative lengths of the interval between the first and second sounds, and second and first, are preserved, though the rate of the heart beats per minute may vary within very wide limits. Position and direction of conduction. — In order to avoid subse- quent repetition, it may be stated generally that the degree of distinctness with which the sounds of the heart are heard depends not only on the character of the sound, but also on the thickness of the thoracic wall, and the extent to which the organ is overlapped METHODS OF DIAGNOSIS 47 by lung tissue, or by other material, such as air, fluid, solid tumours, etc. For example, the first sound of the heart is more or less indistinct in cases of emphysema of the lungs, and of pericardial effusion or growths. On the other hand, the sounds of the heart become more distinct in those conditions in which the organ comes nearer to the chest wall, as in retraction of the lungs, etc. Thus the pulmonary second sound may appear to be accentuated in retraction of the left lung, and similar effects are observed as regards the other sounds of the heart, under like circumstances. These conditions are mentioned in order that due allowance may be made for them in estimating the character of the various cardiac sounds. The left ventricle first sound. — In hypertrophy of the left ventricle, and in cases of high systemic tension, the first sound of the heart becomes less distinct, and may be quite inaudible in the aortic area. On the other hand, it becomes more distinct in this situation, in conditions of low arterial tension and in dilatation of the left ventricle. Apparently the character of the left ventricle first sound largely influences the degree of its conduction along the aorta. The aortic secofid sound. — The aortic second sound becomes in- audible at and to the left of the apex beat, when, owing to enlarge- ment of the right heart, the left ventricle, and with it the apex, is displaced from its normal position. This occurs in cases of mitral stenosis, though probably in this disease the weakness of the second sound also affects its conduction. The absence of the aortic second sound over the carotid arteries in the neck depends on damage to the semilunar valves, the result of injury or disease, whereby these structures are unable to offer sufficient check to the backflow of blood towards the ventricle to produce vibrations of the aortic walls. It will be seen, therefore, that the absence of the second sound in the neck is indicative of a considerable amount of regurgitation into the left ventricle. The pulmonic second sound. — This sound, in cases of enlargement of the right heart, may be heard as far to the left as the normal position of the apex beat, and is transmitted there by the walls of the right ventricle, which has usurped the place of the left. In some instances of consohdation of the left upper lobe of the lung, the pulmonary second sound may be heard over a large area of the left chest. The right vejttricle first sound. — In cases of enlargement of the right ventricle, the first sound may be heard further to the left than usual. 48 DISEASES OF THE HEART Modifications in the character of the sounds of the heart. — Three distinct elements are to be distinguished in every tone, viz. : — 1. Intensity (loudness) 2. Pitch 3. Quality (timbre) The three elements taken together determine the character of a tone. With regard to the sounds of the heart, which are not true musical tones, it is often difficult to state with precision the exact modifications that they may undergo. This statement applies more particularly to changes in quality, but the attempt will be made to state, so far as possible, in technical language the variations to which the different sounds of the heart are liable. Left ventricle first sound. — Under normal conditions the variations in character of the left ventricle first sound are comparatively unim- portant, and consist mainly in alterations in duration and intensity. The first sound is short and loud when the ventricle is acting rapidly and the arterial tension is low, as may occur in nervous conditions, for instance in Graves' disease, or in the early stages of fever. Conversely, it is long and diminished in intensity when the ventricle is contracting slowly against increased systemic tension. In hypertrophy of the ventricle the muscular element becomes obtrusive, and the first sound is therefore prolonged and dull. Stated in technical language, the sound is characterised by increased duration, diminished intensity, and slightly altered quality. In dilatation of the ventricle the condition of affairs is reversed. Here the valvular element becomes prominent, and the sound is short, sharp, and loud. In other words, the sound is characterised by diminished duration, by heightened pitch, and by increased in- tensity. The quality of the sound also undergoes slight modification by reason of the change in the mechanism of its production. Shortness of the left ventricle first sound, with diminution of intensity, which may go on to complete extinction, is indicative of extreme weakness of the ventricular walls, and occurs in pro- longed febrile conditions, such as enteric fever and in other diseases productive of protracted malnutrition of the myocardium. In mitral stenosis the first sound of the left ventricle is remark- ably and characteristically short, sharp, and loud, and at the same time altered in quality. In cases of mitral regurgitation, the first sound may be partially or wholly replaced by the systolic murmur. The aortic second sound. — The most common variation affecting this sound is a change in intensity, which becomes either relatively or absolutely increased or diminished. An increase in the intensity of the sound produced at the aortic or pulmonic orifices is known under the name of accentuation. Accentuation of the aortic second sound occurs in high arterial tension with a forcibly acting left ventricle. It may also occur in METHODS OF DIAGNOSIS 49 association with low arterial tension, if the ventricular systole is vehement; but in such cases the accentuation is not relatively apparent, owing to the concurrent accentuation of the pulmonic second sound. Accentuation of the aortic second sound is almost invariably pro- duced by dilatation or aneurism of the ascending aorta, and in such conditions the sound is not only accentuated but is also of markedly lower pitch. A further modification of the second sound is observed when, in association with dilatation of the vessel, the walls of the aorta have undergone thinning, and more or less fusion of the three coats of the artery has taken place. In addition to an alteration in intensity and pitch, the sound now acquires a change of quality to a more musical tone, which is highly characteristic of the affection in question, though a similar modification may be produced by aneurism of one of the sinuses of Valsalva. Diminution in intensity, or feebleness of the aortic second sound, is associated with weakness of the left ventricle due to myocardial inflammation or degeneration. The second sound is enfeebled also in mitral stenosis and in nearly all forms of disease affecting the aortic valve. Weakness or disappearance of the aortic second sound in the neck in cases of aortic incompetence is significant of a considerable amount of valvular insufficiency. The pulmonic second soiuid. — The pulmonic second sound is accentuated in all conditions which give rise to obstruction to the passage of blood through the lungs. It occurs therefore in affec- tions of the lungs such as pneumonia, bronchitis, emphysema, pleural eifusion, etc., and sooner or later in all diseases of the left side of the heart. Weakness of the pulmonic second sound is of importance only when observed in conjunction with previous accentuation. With this sequence of events, enfeeblement of the sound is indicative of dilatation of the right ventricle with leakage through the tricuspid valve. The right ventricle first sound. — So long as the myocardium remains healthy, the right ventricle first sound is intensified in all conditions which interfere with the normal circulation of blood through the lungs. The circumstances under which pulmonary obstruction occurs have been referred to under the causes of accentuation of the pulmonic second sound. Enfeeblement of the right heart first sound occurs as the result of myocardial inflammation or degeneration, and in the later stages of dilatation of the ventricle from any cause. 50 DISEASES OF THE HEART Modifications in the rhythm of the sounds of the heart. — For clinical purposes alterations in the relative time duration of the various events composing the cardiac cycle may be considered to take place in two directions, with the result that the sounds of the heart are spaced (that is, separated by a longer interval than normal) or approximated. The first effect may be produced either by prolongation of the interval between the first and second sounds, or by the shortening of the diastole : the second, by the shortening of the interval between the first and second sounds, or by prolongation of the diastole. Spacing of the sounds of the heart may be carried to the point at which they become equidistant, and this condition has been termed embryocardia, or the tick-tack action of the heart, from its resemblance to the rhythm of the foetal heart sounds, or to the ticking of the pendulum of a clock, or of a watch. Equidistance of the two sounds of the heart, from prolongation of the interval between them, is found most commonly in associa- tion with high arterial tension, and is then indicative of impending failure of the left ventricle. Thus, in these cases, the ventricle, in spite of the increased resistance to the discharge of its contents, is still just able to empty itself, but it does so with much greater difficulty, and therefore more slowly than usual ; hence the spacing of the sounds. A similar phenomenon may be observed in enteric fever as the result of myocardial degeneration, and is then usually of fatal import. Equidistance of the sounds of the heart is sometimes associated with tachycardia, and in such instances is produced by the shortening of the diastole. Approximation of the first and second sounds of the heart usually indicates weakness of the left ventricle, consequent on myocardial disease, or high arterial tension. Here the ventricle does not com- plete its contraction by reason of the absolute or relative inability of its muscular walls to maintain the intra-ventricular pressure above that in the aorta throughout the systole. So soon, therefore, as the pressure in the aorta exceeds that in the ventricle the semilunar valves close, and the second sound occurs. This event may take place at any stage of the ventricular contraction, with a correspond- ing variation in the degree of approximation of the sounds. In some instances the second sound follows the first almost im- mediately. The phenomenon is observed vnth failure of the heart in diphtheria and other acute febrile conditions, and in the early and late stages of kidney disease. The approximation of the sounds, under these circumstances, is of very grave significance. Approximation of the sounds of the heart may also be heard in some cases of low arterial tension with a rapid action of the organ, METHODS OF DIAGNOSIS 51 such as occurs in febrile and emotional states, and is then of no prognostic value. {d) Reduplication of the Sounds of the Heart Either the first or second sound of the heart may be reduplicated. The reduplication usually implicates one sound at a time, but occasionally both are affected together. The two elements com- posing the double sound may be closely approximated, or they may be separated by an appreciable interval, producing, in the first event, an effect resembling the double beat upon a drum, and hence called the "Bruit de rappel," and in the second, a hkeness to the footfall of a horse at a canter, the " Bruit de galop." Thus in the case of the doubling of the first sound of the heart the result is heard as "lurrub-dup" or " lublub-dup," and of the second, as "lub-durrup" or " lub-dupdup," according to the degree of separation of the two elements of the double sound. There is no kind of agreement among writers on the subject, either as to the cause, significance, or even area of greatest audibility of the phenomena in question, and it will be possible to give but a brief outline of the views which have been advanced to explain them. Reduplication of the first sound of the heart. — Reduplication of the first sound is usually most distinctly audible just internal to the apex beat, and along the line of the interventricular septum, but it may also be heard in the tricuspid area, and along the left edge of the sternum as high as the third rib. It is rarely, if ever, well heard over the base of the heart. Reduplication of the first sound occurs most commonly in association with hypertrophy of the heart, the result of high arterial tension, such as obtains in some forms of kidney disease and in other disorders. It is also observed in cases of dilatation of the heart following myocardial disease, or pericardial adhesion, and it may occur in the absence of any appreciable cardiac lesion (Potain). Reduplication of the first sound is probably of little or no clinical significance, except when it is found in association with high arterial tension, particularly of nephritic origin, and it is then a sign of commencing dilatation of the left ventricle from failure. The doubling of the first sound of the heart has been ascribed to a want of synchronism in the contraction of the two ventricles. Under normal conditions the relation between the intra-ventricular pressure and the muscular power of the ventricles is so adjusted that the two sides of the heart contract simultaneously. It is sup- posed that an increase of intra-ventricular pressure occurring on either side of the heart might, if sufficiently great, upset the normal balance and cause asynchronism. Thus the ventricle work- 52 DISEASES OF THE HEART ing against the increased pressure might contract later (according to Dr. Barr earUer) than usual, and especially may this be the case if, as Sir William Broadbent supposes, the ventricle affected is beginning to dilate before the resistance that has to be over- come. Against this view has been advanced the fact that physiologists have never observed asynchronism in the contraction of the right and left sides of the heart. It is, however, extremely likely that under physiological conditions of the circulation this observation may hold good, but it is no argument against the view that asynchronism might occur under pathological influences. The reduplication of the sound is most distinctly audible along the course of the interventricular septum, and in some instances is palpable in this situation. Moreover, in cases where doubling of the first sound is observed, the two elements composing it can be heard when the cusps of a differential stethoscope are placed over the right and left ventricles, where on separate examination, but one sound is audible (Broadbent). It would therefore appear highly probable that a want of synchronism in the contraction of the two ventricles is a cause of reduplication of the first sound of the heart. The explanation that has Just been given may not, however, cover all the cases in which reduplication of the first sound of the heart is heard. The phenomenon was ascribed by Dr. G. Johnson to an audible contraction of the auricle immediately preceding the ventricular systole. It is a priori improbable that the auricular contraction could give rise to a sound, and further, the area of audibility of the double sound as described by Dr. Johnson, and on which his view was largely based, is contrary to the experience of most observers. Dr. Sansom attributes all forms of reduplication of the sounds of the heart to tension of the curtains of left auriculo-ventricular valve during some part of the diastole of the ventricle. Thus, in the present instance, he supposes that a forcible auricular contraction causes an impulse to the apex of the left ventricle, which by contre-coup gives rise to vibrations of the mitral curtains, and the sound thereby produced is heard just before the ventricular first sound. There is, however, no cause in most of the cases in which reduplication of the first sound occurs for a forcible contraction of the auricle, since the stress of the circulation falls on the ventricle ; hence the explanation given by Dr. Sansom cannot be regarded as of general application. Reduplication of the second sound of the heart. — Reduplication of the second sound is usually most distinctly heard over the base of the heart, and at the left edge of the sternum about the level of the third intercostal space. According to Dr. Sansom it is most plainly audible just inside the apex beat, and along the left edge METHODS OF DIAGNOSIS 53 of the sternum, at the level of the junction of the fourth and fifth costal cartilages. There is no doubt that an apparent doubling of the second sound of the heart is sometimes audible immediately to the inner side of the apex beat and not at the base, in cases in which a presystolic murmur subsequently appears, but the mechanism of its production differs from that of the reduplication previously mentioned. Reduplication of the second sound of the heart occurs most commonly in mitral stenosis, but it may be observed with pul- monary obstruction from any cause. It is also heard in pericarditis and myocarditis, and in high arterial tension with hypertrophy of the left ventricle. Except when it is heard at the apex of the heart and not at the base, reduplication of the second sound is of no clinical significance. It has been ascribed to a want of synchronism in the closure of the semilunar valves on the two sides of the heart. The asyn- chronism may be caused by increased systemic or pulmonic tension, which delays the completion of the systole of the corresponding ventricle, and consequently the closure of the semilunar valves. This explanation, while accounting for the reduplication of the second sound as heard at the base of the heart, does not elucidate the apparent doubling of the second sound audible at the apex only. This is probably due, as Dr. Sansom suggests, to tension of the segments of the left auriculo-ventricular valve, which is caused by a more rapid flow of blood than usual into the ventricle during the early part of the diastole consequent on increased pressure in the auricle. Apparent doubling of the second sound which is heard in the neighbourhood of the apex beat only is, therefore, a sign of con- siderable diagnostic importance, since it is almost invariably the precursor of a presystolic murmur, indicative of stenosis at the mitral orifice. B. ADVENTITIOUS SOUNDS {a) Endocardial • Audible vibrations, exclusive of the normal heart sounds and their modifications, accompanying the cardiac movements, and generated as the result of morbid conditions of the heart and pericardium, are known as murmurs. Such superadded or adventitious sounds may partially or wholly replace the normal sounds of the heart. For clinical purposes murmurs may be divided into — • {ci) Endocardial murmurs {b) Exocardial murmurs {c) Vascular murmurs 54 DISEASES OF THE HEART Endocardial murmurs may be further subdivided into— (a) Organic murmurs (d) Functional or Haemic murmurs I. Organic murmurs. — A murmur which is due to the presence of an appreciable morbid lesion is known as an organic murmur. Physical Causes of Organic Murmurs A murmur is the sound produced, under certain conditions, by the passage of gas or fluid along a tulDe. So long as the tube has a smooth internal surface, and does not alter in calibre, the circulation of fluid through it does not give rise to any audible vibrations. If, however, a constriction be introduced at any point along the course of the tube a "fluid vein" is formed immediately beyond the nar- rowed portion, which gives rise to sonorous vibrations that may be heard as a murmur. In the case of the heart the size of the various cavities and orifices is so adjusted that, under normal conditions, no sound is produced by the circulation of blood through them. Whenever a cavity or orifice is increased or diminished in size, either relatively or absolutely, the conditions for the production of a fluid vein are present, and consequently a murmur may be heard. So far as the clinical expression of a murmur is concerned, it must be borne in mind that the vibrations in the blood stream caused by the formation of a fluid vein, though sonorous, are in aU probability largely modified by the conducting properties of the surrounding soUd structures, by means of which they are transmitted to the surface of the chest, and hence to the ear. The presence of a fibrous cord or shred of membrane capable of free vibrations in the course of the blood stream may give rise to a musical murmur. Such conditions may exist in the heart when, in consequence of the improper adaptation of the margins of the valves guarding an orifice, the free edges of the valvular curtains can vibrate, or when a shred of fibrin, formed as the result of some morbid process, hangs loose in the blood stream. A musical murmur can also be produced, under certain conditions, by the vibrations of a fluid vein alone. The loudness of a murmur depends for the most part on the swiftness of the flow producing it, and this is determined by (a) the vis a tergo, (b) the quality of the circulating fluid, and {c) the degree of constriction of the tube. If the velocity of the flow falls below a certain rate no murmur is produced. A murmur is propagated in the direction of the flow, and is most distinctly heard immediately to the distal side of the site of its production. This statement holds good with respect to the heart, but the area of audibihty of a cardiac murmur is greatly modified by the various METHODS OF DIAGNOSIS 55 solid structures along which the sonorous vibrations are conducted to the surface of the chest wall. Cardiac murmurs are distinguished as {a) direct or obstructive, or {b) indirect or regurgitant, according as they are produced in the course of or against the natural direction of the blood stream. Obstructive murmurs are due to — 1. The narrowing of an orifice, the result of a local constrictive process ; or an impediment to the onward flow of blood through an opening by reason of an outgrowth or projection from its valve, or from adjacent structures. 2. The narrowing of an orifice relatively to the size of the channel situated immediately in front of or behind it. In such cases the dimensions of the orifice remain un- changed, while the cavity or lumen of the structure in immediate relation with it, either anteriorly or posteriorly, becomes dilated. Regurgitant murmurs are due to — 1. The defective closure of a normally closed orifice, the result of disease affecting the valve that guards it. 2. The dilatation of an orifice, such as the auriculo-ventricular, in consequence of the relaxation and stretching of its mus- cular girdle, so that the curtains of its valve are unable to come into complete apposition. 3. The dilatation of an orifice owing to its involvement in a like process affecting primarily the channel beyond it, with the result that the proper adaptation of the valvular segments becomes impossible. Murmurs are also distinguished, according to the period of their occurrence in the cardiac cycle, as (a) systolic or {b) diastolic. A murmur that is heard between the beginning of the first sound and the occurrence of the second is called "systolic," while one which appears between the- beginning of the second sound and com- mencement of the first is called "diastolic." Diastolic murmurs are subdivided into — 1. Murmurs occupying the whole diastole. 2. Murmurs occupying a portion only of the diastole, to wit — ■ {a) Early diastolic or post systolic {b) Mid-diastolic {c] Late diastolic or presystolic 56 DISEASES OF THE HEART The relation of murmurs to the different periods of the cardiac cycle may be diagrammatically represented as follows : — Systolic Murmurs FIG. 9. DIAGRAMMATIC REPRESENTATION OF A SYSTOLIC MURMUR It will appear, therefore, that systolic murmurs, due to organic disease, and produced at the arterial orifices of the heart, are indicative of obstruction to the blood stream, whereas at the auriculo-ventricular openings they are significant of regurgitation. Conversely, diastolic murmurs originating at the arterial orifices indicate regurgitation, and at the auriculo-ventricular openings, obstruction. Site of Production and Direction of Transmission of Organic Cardiac Murmurs As a general rule a murmur is most distinctly heard over that portion of the chest wall which is nearest to the site of its pro- duction. The relation of the cardiac orifices to the thoracic parietes has already been defined under the anatomical description of the heart. The deviations from the general rule just mentioned are numerous, and depend, for the most part, on the influence exerted by the conducting properties of {a) the solid structures interposed between the site of production of the murmur and the surface of the chest, and of (b) the blood current, or, as it usually termed, convection. The modifications in the area of audibility of a murmur, thus produced, will be illustrated in the following account of the subject. Mitral Orifice. — Murmurs which are due to lesions at the left auriculo-ventricular opening may be either systolic or diastolic, METHODS OF DIAGNOSIS 57 Diastolic Murmurs FIG. lO. DIAGRAMMATIC REPRESENTATION OF AN ENTIRE DIASTOLIC MURMUR FIG. II. DIAGRAMMATIC REPRESENTATION OF A PRESYSTOLIC MURMUR FIG-i 12 DIAGRAMMATIC REPRESENTATION OF AN EARLY DIASTOLIC MURMUR FIG. 13. DIAGRAMMATIC REPRESENTATION OF A MID-DIASTOLIC MURMUR 58 DISEASES OF THE HEART the former indicating regurgitation through, the latter obstruction at the orifice. Systolic 7nitral r?iurmurs. — These are most distinctly heard in the mitral area, inasmuch as they are conducted thither by the wall of the left ventricle. They are also transmitted (under the influence of convection) for a variable distance into the axilla, and may be audible as far outwards as the angle of the left scapula. Systolic mitral murmurs are occasionally heard as far inwards as the left sternal edge, in the tricuspid area, and more rarely they are conducted upwards as high as the third or second rib. In ex- ceptional instances systolic mitral murmurs are audible in the second and third left intercostal spaces, about two inches from the sternal border, and in this situation only. Diastolic mitral murmurs. — All the varieties of diastolic murmur that were previously enumerated may originate at the mitral orifice. Mitral murmurs which occupy the whole diastole (or, for that matter, any part of it), entire diastolic murmurs as they have been called by Dr. Bristowe, have this peculiarity that they invariably follow the second sound. It is in this particular that they differ from aortic diastolic murmurs, which, whether audible in the mitral area or elsewhere, accompany and partially or wholly replace the second sound. Mitral diastolic murmurs are usually most distinctly audible in the mitral area, and for the reason that they are conducted thither by the wall of the left ventricle. The presystolic murmur, which, for the sake of convenience and on account of its importance, will be considered first, is best heard immediately above and to the inner side of the apex beat, and its area of audibility is limited to this situation with remarkable con- stancy. It is occasionally audible as far to the right as the left sternal edge and upwards as high as the third rib. Rarely, too, it is conducted into the axilla, and outwards as far as the angle of the left scapula. The area of audibility of entire, early, and mid-diastolic murmurs corresponds, in the main, with that just described, though it is not usually so localized. Combined systolic and diastolic mitral murmurs. — Cases of pure mitral obstruction are comparatively rare, since, by reason of the altered condition of the orifice and its valve, the segments of the latter are seldom able to come into effective apposition, and con- sequently a variable, though small, amount of leakage takes place. The systolic murmur, produced by this means, is heard in the mitral area, but it is seldom well conducted into the axilla, and is rarely if ever audible at the angle of the left scapula. The area of audibility of the accompanying presystolic bruit does not dififer from that previously described for such murmurs. METHODS OF DIAGNOSIS 59 Aortic Orifice. — Murmurs originating here may be either systoHc or diastolic, the former indicating obstruction at the orifice, dilatation of the aorta, or roughening of its hning membrane or of the cusps of the valve, the latter, regurgitation through the opening. Systolic aortic murmurs. — Systolic murmurs due to obstruction at the orifice are heard best in the aortic area, and are well conducted upwards (under the influence of convection) into the neck, especially on the right side. They are also audible over the upper third of the sternum, since bone is a good conductor of sound. Murmurs occasioned by atheromatous disease of the valve or aorta are heard in the same situations, but they tend to spread laterally rather than upwards. Diastolic aortic murmurs. — The area over which these murmurs may be heard is a very large one. A diastolic aortic murmur is most distinctly audible at one time in the aortic area, at another in the mid-sternal region about the level of the fourth rib, in the mitral area, or over the base of the ensiform cartilage. It is usually well conducted downwards along the right and left edges of the sternum, and along an oblique line leading from the second right costal cartilage, at its junction with the sternum, to the apex beat. A diastolic aortic murmur is sometimes audible at the apex only, and in such cases may closely resemble the presystolic murmur that is associated with mitral stenosis. The reason for this will be con- sidered under the heading of the valvular lesion in question. An aortic diastolic murmur may also be heard in the neck over the carotid arteries, and most distinctly on the right side. Combined systolic and diastolic aortic murmurs. — The two mur- murs are observed over their respective areas of audibility, as above described. In those situations where the areas of audibility overlap a " to and fro " murmur is heard. Pulmonary Orifice. — Murmurs due to structural disease at this orifice, apart from congenital conditions, are rare. Nevertheless systoHc and diastoHc murmurs, indicating stenosis of the opening and incompetence of the valve respectively, are occasionally observed. Systolic pulmonary murmurs. — These are heard most distinctly in the second left interspace close to the sternum, and are transmitted upwards and to the left for a short distance. They may also extend to the right as far as the aortic area on a level with the second inter- space. They are inaudible in the neck. Diastolic pulmonary murmurs. — These are, as a rule, most plainly audible in the pulmonic area, and are conducted downwards along the left sternal edge as far as the base of the ensiform cartilage. They may be heard over any portion of the right ventricle. 6o DISEASES OF THE HEART Tricuspid Orifice. — Murmurs produced at this orifice may be either systolic or diastolic, and have, mutatis miita?idis, the same significance as those heard at the mitral opening. Systolic tricuspid murmurs. — These are heard most distinctly in the tricuspid area, and are conducted by the right ventricle to the right, and upwards along the sternal edge as high as the fourth interspace. Diastolic tricjispid murmurs. — A presystolic murmur, indicating tricuspid stenosis, is sometimes heard at the left sternal edge, about the level of the fourth and fifth costal cartilages, and over the base of the ensiform cartilage. Combined systolic and diastolic tricuspid murmurs. — A systolic and presystolic murmur are occasionally heard together in the tricuspid area. Associated murmurs. — It not infrequently happens that more than one orifice of the heart is the seat of disease at the same time, and in such an event murmurs with different sites of production may coexist. The most common association is that of systolic and diastolic aortic murmurs, with a systolic mitral bruit, and then either of the former with the latter. Combined systolic and diastoHc murmurs produced at the aortic and mitral openings may also coexist, and more rarely still combined or single aortic murmurs may be associated with a presystolic mitral bruit. A systolic or presystolic mitral murmur, or a combination of the two, is not uncommonly associated with a systolic murmur of tricuspid origin. Apart from congenital conditions, a presystolic tricuspid murmur is almost invariably associated with a mitral presystolic bruit. With respect to the association of murmurs which are produced on the left and right sides of the heart, it should be noted that the relation of the lesions giving rise to them is nearly always one of cause and effect. The Character of Organic Murmurs Cardiac murmurs are described as blowing, rasping, purring, rumbling, etc., according to the fancy of the observer. These terms apply, of course, to the quality of the sound, which is of little clinical importance. Systolic mitral murmurs are usually soft and blowing, and some- times possess a musical character, whereas systolic aortic murmurs are commonly rough and rasping. The presystolic bruit due to mitral obstruction is peculiarly and characteristically rough and rumbling, and increases in intensity up to the first sound, at which it abruptly terminates. Presystolic tricuspid murmurs exhibit similar qualities. Diastolic murmurs produced at the aortic orifice are usually soft and blowing, and they gradually diminish in intensity from their commencement with the second sound to their termination. They do METHODS OF DIAGNOSIS 6i not, however, always possess these characters, for, as has already been pointed out, a murmur due to aortic regurgitation is sometimes audible at the apex only, and may then be indistinguishable, so far as its character is concerned, from that associated with mitral obstruction. The distinctness with which a cardiac murmur is heard depends for the most part on posture, on the quantity and conducting quality of the material interposed between the site of production of the murmur and the ear, and on the loudness of the murmur. Unless considered in the light of previous observations, the loud- ness of a murmur is of Uttle or no diagnostic or prognostic value. It depends mainly on the swiftness of the blood current, and in the case of the heart this will be determined by the force of the auri- cular or ventricular contraction, as the case may be, and by the condition of arterial tension. Speaking generally, a loud murmur is of less import than a soft one, as it is an indication that the heart is acting forcibly. Gradual increase in the intensity of a murmur is a good prog- nostic sign, in so far as it is indicative of improving cardiac vigour. On the other hand, sudden or gradual decrease in the intensity of a murmur is often significant of serious failure of the power of the heart. A soft murmur is, however, compatible with very slight damage either to the myocardium or endocardium. The subject will be again referred to under the general account of the prognosis in valvular affections of the heart. The Rhythm of Organic Cardiac Murmurs It has already been pointed out that, with regard to their position in the cardiac cycle, murmurs may be either systolic or diastolic. Their time relations should be gauged clinically by reference to the sounds of the heart, to the impulse of the organ, and to the carotid pulse, which for all practical purposes is synchronous with the ventricular systole. It must be borne in mind that palpation of the apex beat does not always afford reliable information as to the time of the con- traction of the ventricles, as may be demonstrated in some cases of aortic regurgitation. With reference to the position of murmurs in the cardiac cycle, two additional points remain to be mentioned, viz. (i) the relation of the murmur to the sound of the heart with which it is associated, and (2) the duration of the murmur. Thus, by way of illustrating the first point, a systolic murmur produced at the mitral orifice may wholly or partially replace the first sound of the heart. If the murmur wholly obscures the first sound, the indication is that there is an excessive production of sonorous vibrations at the orifice, or that the valvular segments are unable to undergo sufficient tension to produce a sound. Under either supposition the inference 62 DISEASES OF THE .HEART is that the amount of regurgitation must be considerable. If, on the other hand, the murmur follows and only partially obscures the sound, it is obvious that the segments of the auriculo-ventricular valve are able to come together, but are unable to remain in apposi- tion, which argues but a slight amount of leakage through the opening. Again, a diastolic murmur produced at the aortic orifice may wholly or partially replace the second sound. If the second sound is inaudible it means that the valvular cusps fail to offer any effective check to the backflow of blood, and therefore that there must be a large amount of regurgitation. If, on the other hand, the murmur follows the second sound, or only slightly obscures it, the valve must still offer a hindrance to the regurgitant current, and consequently the leakage through the opening can be but slight. These considerations, while affording a valuable means of esti- mating the degree of incompetence of a valve, are not absolute, and they must be weighed in conjunction with the other indications of the extent of the valvular insufficiency. The duration of a murmur is of little clinical significance. A long murmur, which depends on valvular incompetence, fre- quently indicates slight disease and a forcible action of the heart. On the other hand, a short murmur is sometimes a sign of serious failure of the cardiac power. 2. Hsemic murmurs. — The method of production of hgemic or functional murmurs (as they are sometimes termed) has long been a subject of controversy, and still remains undetermined. There can be little doubt, however, that the production of a haemic murmur depends, as in the case of an organic murmur, on the formation of a fluid vein, which is sonorous. If the conditions under which a fluid vein may be formed can be shown to be present in anaemia, there is no necessity to endeavour to explain the occurrence of hjemic murmurs on other grounds. An attempt will be made to show that such conditions may exist, but it wall also be necessary to briefly review the other chief theories which have been advanced to explain the formation of these murmurs. The order in which hsemic murmurs appear in anaemia is usually as follows : — 1. The venous hum or "bruit de diable" in the neck, 2. A systolic murmur in the pulmonic area. 3. A systolic murmur in the mitral area. 4. A systolic murmur in the tricuspid area. 5. A systolic murmur in the aortic area. METHODS OF DIAGNOSIS 63 Site of Production and Direction of Transmission of Cardiac Murmurs due to Anaemia The venous hum which may be heard in the neck in cases of anaemia, will be considered under its appropriate heading. Cardiac murmurs of hsemic origin will be taken in the order of their usual appearance. Pulmonic orifice. — A systolic bruit, which is most distinctly audible in the second left intercostal space close to the sternum, or, in other words, in the pulmonic area, is the earliest and most constant of the cardiac murmurs that are found in association with ansemia. The area of audibility of the murmur as given here is not admitted by all writers on the subject, nevertheless the majority are agreed that the bruit appears soonest, and is heard best, in this situation. It is in all probability produced at the pulmonic orifice, and for the following reasons. In anemia, from whatever cause, there is present a general muscular malnutrition, and the heart suffers in common with the rest of the contractile tissues. Owing to the comparative thinness of its walls, the right ventricle feels the effect of this nutritional impairment at an early period of the disease, and a variable degree of dilatation of the ventricular cavity ensues. Consequently the orifice of the pulmonic artery, which by reason of its dense fibrous girdle remains unaltered in size, becomes relatively con- stricted as regards the cavity of the ventricle, and hence the conditions for the production of a fluid vein are present. This view, too, would explain the presence of a murmur, even if, as Duroziez asserts, the heart and its cavities are diminished in size in anemia, for then the pulmonic orifice would be relatively dilated. It is possible, indeed probable, that the alteration in the quality of the circulating fluid may also be a factor in the production of the fluid vein. A fall of blood pressure in the aorta or pulmonary artery as the case may be is also a contributory factor in the production of a functional systolic murmur at the orifices of these vessels. Balfour considers that the murmur under consideration is due to mitral regurgitation, which causes a vibration of the walls of the left auricular appendix, and therefore that the murmur is heard most distinctly over the position of the appendix, i.e. in the second left intercostal space one and a half to two inches outside the left sternal edge. Apart from the fact that the area in which the murmur is most plainly audible is not located by the majority of observers in the situation described by Balfour, it has been shown that in a large number of cases of ansemia the left auricular appendix does not come into contact with the chest wall. Moreover, it is difficult to suppose that the small amount of regurgitation which takes place could cause any audible vibration of the auricular walls, seeing that in structural disease of the mitral valve, with considerable leakage, systolic murmurs are rarely heard in the situation described by Balfour. 64 DISEASES OF THE HEART Russell's theory, which accounts for the murmur by the pressure of a dilated auricle on the pulmonary artery causing a local narrow- ing of the vessel and hence a fluid vein, is equally improbable. There is no proof that the auricle is distended in anaemia, and furthermore, there is direct evidence that when the auricle is dilated, as in mitral stenosis, no pressure is exerted on the pulmonary artery, or at all events not sufficient to produce a murmur. Chauveau supposes that in anaemia the total quantity of blood in the body is diminished, and this results in a partial collapse of the capillaries, small and medium-sized arteries and veins, and of the heart and its orifices. The aorta and pulmonic artery, owing to the anatomical structure of their walls, are unable to accommodate themselves to the altered circulatory conditions, and consequently they become relatively dilated as regards their respective orifices, and thus the conditions for the production of a fluid vein are produced. It has not been proved that the total quantity of blood is diminished in anaemia ; moreover, partial collapse of the orifices of the aorta and pulmonic artery would seem as difficult of accomplishment as of the vessels themselves. According to Hayden, two factors enter into the causation of haemic murmurs, viz. (i) friction of the blood corpuscles against one another and against the edges of the cardiac orifices and walls of the vessels, and (2) vibrations of the heart and walls of the vessels. It is by no means certain that increased friction between the blood corpuscles, etc., could give rise to sonorous vibrations. Moreover, if this were possible, the occurrence and intensity of the bruit thereby produced should be regulated by the degree of anaemia, which is not the case with respect to haemic murmurs. Explanations of the mode of formation of haemic murmurs based on neuro-muscular causes, such as those advanced by Dr. Sansom, can hardly be considered satisfactory in the present state of our knowledge of these conditions. Foxwell (Bradshaw Lecture, 1899) contends that the systolic murmur heard in the second and third intercostal spaces in cases of cardiac debility (due to anaemia and other causes) depends on a localized dilatation of. the conus arteriosus and pulmonary artery. He states that dilatation of the conus arteriosus and pulmonary artery is constantly found post mortem in patients who during life exhibited this functional pulmonary murmur, and he advances the following arguments with the object of showing that this association is one of cause and effect : — I. The pulmonary orifice is not increased in size, and therefore becomes relatively constricted as regards the enlarged conus, METHODS OF DIAGNOSIS 65 with the consequent production of the necessary conditions lor the formation of a fluid vein and hence of a murmur. 2. The dilatation of the conus carries the orifice of the pulmonary artery upwards, so that the valve comes to lie vertically over the bifurcation of the vessel, which is a fixed point. The shortening of the artery, produced by this means, renders its walls less taut, and thereby conduces to a bagging of the vessel with each systolic incursion of blood. This condition would result in the formation of eddies, and hence of a murmur. 3. The want of space necessary to accommodate the increased size of the pulmonary artery would lead to the compression of the lax arterial wall by the comparatively rigid parietes of the chest and also by the aortic arch, and this, acting as a partial constriction, would tend to the production of eddies and a murmur. 4. Owing to the greater extensibility of the anterior surface of the conus and the comparatively firm attachment of the posterior wall of the pulmonary artery to the aorta, the anterior wall of the pulmonary artery is carried up further than the posterior wall. As a consequence of this the plane of the valve ring is not perpendicular to the longi- tudinal axis of the artery, and the systolic incursion of blood would therefore tend to be directed against the wall of the vessel, and in this way eddies might be formed and consequently a murmur. Dr. Foxwell also brings forward direct experimental evidence in support of his contention. Indeed, in the face of the arguments and experiments advanced by him, it is difficult if not impossible to resist the conclusion that the pulmonary systolic murmur heard in cases of cardiac debility is due to the dilatation of the conus arteriosus and pulmonary artery. Mitral orifice. — The systolic murmur, which is audible at the apex of the heart in some cases of ansemia, is due to regurgitation through the mitral opening. It is heard most plainly in the mitral area, and is conducted with a variable degree of distinctness into the axilla, and is occasionally audible at the angle of the left scapula. Regurgitation through the mitral orifice consequent on anaemia may be the result of — I. Enfeeblement of the muscular fibres surrounding the opening, whereby the orifice is not sufficiently constricted to permit the proper adaptation of the valvular curtains. z. Dilatation of the left ventricle from failure of its muscular walls, which may be due to malnutrition of the myocardium, F 66 DISEASES OF THE HEART or to the high arterial tension that is sometimes associated with anaemia. 3. Enfeeblement of the rausculi papillares from similar causes. Under normal conditions the closure, or in other words the proper adaptation of the curtains of the auriculo-ventricular valves, {i.e. mitral and tricuspid) is effected, during systole, by means of (a) the constriction of the orifices by the contraction of their respective muscular sphincters and {^) the maintenance of the levels of the valvular segments, and thus the prevention of their retroversion into the auricles by the shortening of the musculi papillares. Failure in the proper performance of either of these functions may prevent the perfect apposition of the valvular flaps, and thus render the valve incompetent. Dilatation of the ventricles acts by increasing the size of the auriculo-ventricular openings, so that the contraction of the muscular sphincters cannot reduce their dimensions sufficiently to enable the curtains of the valves to come into complete apposition, and hence leakage takes place into the auricles. Tricuspid orifice. — A systolic murmur, indicative of tricuspid regurgitation and audible in the tricuspid area, is sometimes ob- served with anaemia. The mechanism of its production has already been explained. It is certainly not a little remarkable that, so far as the auscultatory evidence is concerned, mitral regurgitation always precedes leakage through the tricuspid valve in anaemia, since a pj'iori it would seem likely that the right ventricle, and with it the tricuspid opening, should undergo dilatation before the left. At the same time, in- competence of the tricuspid valve, more especially when this is slight, may exist without giving rise to any auscultatory signs, and it may be that herein lies the explanation of the late appearance of the murmur. Aortic orifice. — The systolic murmur, which may be audible in the aortic area in cases of anaemia, is in all probability due to relative stenosis of the aortic orifice, by reason of the dilatation of the left ventricle while the size of the opening remains unchanged. Speaking generally, the area of audibility of hasmic murmurs formed at any of the cardiac orifices corresponds with that of organic murmurs, of like rhythm, produced in the same situations, though the former are seldom so widely or so clearly conducted as the latter. Character of Haemic Murmurs Heemic murmurs have usually a soft and blowing character, though those produced at the pulmonic orifice are sometimes remarkably rough and loud. METHODS OF DIAGNOSIS ^7 Rhythm of Haemic Murmurs Cardiac murmurs due to anaemia are invariably systolic as regards their time relation to the cycle of the heart. {b) Exocardial Adventitious Sounds I. Friction sounds. Pericardial. — In health the movements of the parietal and visceral layers of the pericardium on each other give rise to no appreciable sound. When these normally smooth surfaces become roughened by disease, friction sounds coincident with the movements of the heart may be produced. Friction sound may be audible over any portion of the prsecordial area, but as a rule it appears earliest and is most distinct over the right ventricle and base of the heart. Unless it is very loud, friction sound can be heard over the site of production only, and consequently its area of audi- bihty is usually limited by the praecordial outline ; a point of some value in the differential diagnosis of pericardial from endocardial sounds, since the latter are audible outside this area. A peculiar form of friction sound is sometimes heard over the right ventricle at the level of the fifth and sixth intercostal spaces close to the left sternal edge and over the base of the ensiform car- tilage. It is possibly associated with the formation of the "white patch" which may be observed on the underlying portion of the pericardium covering the heart. The sound is systolic as regards its relation to the cardiac cycle, and may, at one time, roughly resemble a reduplication of the first sound, at another, an endocardial bruit. It may vary in character between a faint click and a definite rub, and as a rule the intensity of the sound is greatly modified by changes in the position of the body. The sound is most commonly observed in downward displacement of the heart due to emphysema, but it may be present under apparently normal conditions. Pericardial friction sound is described as scraping, rubbing, creaking, grating, rasping, etc., and it conveys to the observer the impression that it is produced close to the ear. The intensity of the sound is compara- tively uniform from beginning to end, thus differing from endocardial murmurs which usually have a crescendo or diminuendo character. Moreover, the loudness of a pericardial friction sound is commonly markedly modified by (a) pressure with the stethoscope, {b) deep inspiration or expiration, and ic) changes in position of the body. Furthermore, friction sound may change its site of maximum intensity from day to day — indeed it may do so while under observation — though, unlike reduplication of the heart sounds, it does not show- intermissions. Friction sound, as has already been stated, corresponds, not with the sounds of the heart, but with the movements of the organ. Consequently it usually has a "to and fro" rhythm, i.e. 68 DISEASES OF THE HEART systolic and diastolic, corresponding with the contraction and relaxa- tion of the ventricles. It may, however, exhibit a triple rhythm, owing to the systole of the auricles, and the sound thus produced is presystolic in its relation to the cardiac cycle. The presystolic friction sound is heard most distinctly in the second and third left intercostal spaces about one and a half to two inches from the sternal border. The relation of the friction sound to the cardiac cycle may vary from day to day. At one time it may be systolic and diastolic, at another presystolic, systolic, and diastolic, or again i,t may be systolic or diastolic only. A sound which is observed to vary thus in its relation to the cardiac cycle is almost certainly pericardial in point of the site of its production. It sometimes happens that both air and fluid are present at the same time in the pericardial sac. Under such conditions sounds corresponding with the movements of the heart, and having various characters, may be heard. Thus splashing or gurgling sounds are sometimes observed, and these have been compared to the noise produced by a water-wheel in motion, and hence have been called " water-wheel sounds." On other occasions an amphoric echo of the heart sounds or of pericardial friction sound is produced. These signs do not persist many days, and are invariably of the gravest import. Pleural. — A pleural friction sound has occasionally a "to and fro " character communicated to it by the movements of the heart. In such cases the sound, as a rule, ceases when a deep inspiration is made and the breath is held. Pleuro-perkai'dial. — Inflammation of the pleura over the heart may lead to the production of sounds very like those caused by pericardial friction. The differential diagnosis between the two may be difficult, but in the case of pleuro-pericardial friction sound, the site over which it is most distinctly heard is usually along the border of the left ventricle, and not over the base of the heart, or right ventricle, and further it is, as a rule, markedly modified by the respiratory movements. Thus pleuro-pericardial friction sound often disappears at the end of expiration, or when the breath is held ; whereas during inspiration, when the pleural surface is more closely applied to the pericardium, it is increased in intensity. Pericardial friction sound, on the other hand, is not annulled by holding the breath, and is loudest during expiration. 2. Murmurs. Cardio-pulmonary. — It will be most convenient to consider these under sounds of exocardial origin, though, as will be seen, they are endocardial as regards site of production in many cases. They have one feature in common, which is that they all depend in the first instance on changes outside the heart. METHODS OF DIAGNOSIS 69 Cardio-pulmonary murmurs are produced in a variety of ways, which may be arranged as follows : — 1. Displacements of the heart due to disease of — (a) The thorax (^) The pleurae (c) The lungs (d) The abdomen 2. Pressure on the heart due to disease of the left pleura. 3. Changes in the lung overlying the heart. I. Displacements of the Heart due to Disease of (a) The thorax. — In severe cases of deformity of the thorax the heart is always more or less displaced, and a systolic murmur may be heard over some portion of the altered prascordial area, and is produced most probably by the dislocation and consequent twisting of the great vessels at the base of the heart. {b) The pleurcB. — A systoUc bruit is occasionally heard in the pulmonic or aortic area in cases of extensive pleural effusion on either side. It is in all probability produced in the pulmonary artery or aorta, as the case may be, in consequence of the slight twisting of these vessels, which may accompany considerable dis- placement of the heart. The murmur disappears when the fluid has been removed and the heart has returned to its normal situation. {c) The lungs. — Displacement of the heart following pleuro- pericardial adhesions and the contraction of a cavity, or cirrhosis of either lung, may give rise to a systolic bruit, which is usually most distinctly heard in the second interspace to the right or left of the sternum, according as the right or left lung is affected. The murmur is also often distinctly audible over the pulmonary cavity and sometimes over the whole of the affected side. It is as a rule most intense during inspiration. The mechanism of its production is in all probability similar to that suggested in the preceding paragraph. {d) The abdomen. — A systolic murmur audible at the base or apex of the heart may be due to the displacement of the organ by a large fluid or gaseous effusion into the peritoneal cavity. Re- moval of the effusion is followed by disappearance of the bruit. 2. Pressure on the Heart due to Disease of the Left Pleura A systolic murmur audible over the heart and left side of the chest sometimes follows inflammation of the left pleura. In cases of this kind the lung becomes fixed over the pericardium by pleural adhesions, and the heart is more or less pressed upon by the thickened pleura. The murmur is supposed to be due to the 70 DISEASES OF THE HEART sudden displacement of air in the larger bronchi, as the result of the impact of ihe contracting ventricle on the surrounding lung tissue, which has undergone partial consolidation. The bruit is usually systolic in its relation to the cardiac cycle, but it may be diastolic, and it is heard most distinctly during inspiration. It usually disappears when the breath is held. 3. Changes in the Lung Overlying the Heart Pulsating crepitations or rales are sometimes heard at the apex of the heart in morbid conditions of the lung overlying the organ. They disappear when the breath is held after a deep expiration. A systolic murmur audible at the apex may be observed when the overlapping lung is partially consolidated, and its mode of production has already been explained. A systolic murmur audible in the pulmonic area is of fairly common occurrence in tubercular disease of the upper lobe of the left lung. The pulmonary artery is in all probability displaced or pressed upon by enlarged glands, or consolidated lung, and the local narrowing of the vessel thus produced results in the formation of a fluid vein, and hence the murmur. The Differential Diagnosis of Endocardial and Exocardial Murmurs The size of the various chambers composing the heart should first be ascertained in the manner described under " Physical Diagnosis," and any changes that obtain should be weighed in conjunction with the known effects of any particular valvular lesion or other morbid cardiac condition which may be indicated by the presence of a murmur. Furthermore, the condition of the pulse and the size of the liver should be ascertained. The absence of any abnormality in both of these respects would strongly contra-indicate disease of the heart. The site of production and direction of transmission of the murmur, together with its character and rhythm, would afford valu- able and, in many instances, unmistakable evidence in favour of its endocardial or exocardial origin. It is not necessary here to repeat the points which are of diagnostic value. The lungs should be examined in all cases in which a murmur of doubtful significance is heard, and the effect of the respiratory movements and of holding the breath on the abnormal sound should be carefully observed. A murmur of equivocal import in cases of tubercular disease of the upper lobe of the left lung would favour an exocardial origin, in view of the rarity with which endocardial changes occur in phthisis. Congestion of the bases of the lungs with a systolic apical murmur would strongly suggest a valvular lesion. METHODS OF DIAGNOSIS 71 The effect of changes in position on the murmur sometimes affords very valuable information. A bruit which disappears when the patient lies down is almost certainly produced outside the heart. C. VASCULAR SOUNDS 1. Normal sounds. — It has already been mentioned that under normal conditions the second sound of the heart is audible in the neck over the carotid and subclavian arteries. It is conducted thither by the walls of the vessels and the contained column ot blood which intervene between the heart and the site of audibility of the sound. If the stethoscope be placed lightly over the carotid, subclavian, or even femoral arteries a dull sound or thud may be heard corre- sponding with the ventricular systole. It has been thought that, at all events in the case of the carotid and subclavian arteries, this thud may be the first sound of the heart conducted along the walls of the intervening vessels. The sound is, however, in all proba- bility of local origin, and is caused by the pressure of the stethoscope, and this is still more likely in the case of the femoral arteries. Whatever be the explanation of the foregoing phenomenon, it is found that when a certain moderate degree of pressure is made with the stethoscope over the vessels in question, the sound just referred to is replaced by a murmur synchronous with the systole of the heart. It may be remarked, however, that this disposition of events is not always easy to obtain. The murmur is most probably due to a local narrowing of the vessel caused by the pressure of the stethoscope, whereby the conditions for the forma- tion of a fluid vein are produced. A continuous murmur, audible over the internal jugular vein at the root of the neck, is explained in a similar way, and is observed under perfectly healthy conditions. It is said that a " to and fro " murmur, i.e. systolic and diastolic, may be heard over the femoral artery under normal conditions, but the statement is open to serious doubt. The question will be referred to again under the next heading. 2. Adventitious sounds. Arterial. — Systolic and diastolic murmurs produced at the aortic orifice may be conducted some distance along the great arterial trunks, and are commonly to be heard in the neck. It is said that a shrill diastolic murmur of aortic origin may be audible over the radial artery at the wrist. In cases of aortic regurgitation a combined systolic and diastolic murmur may be heard over the femoral artery. The method of production of the systolic portion has already been considered. The diastolic moiety depends on a similar mechanism. Thus, in consequence of the incompetence of the aortic valve, there is a general reflux of blood towards the left J2 DISEASES OF THE HEART ventricle during diastole. As the current of blood flows backwards past the constriction in the femoral artery, produced by the pressure of the stethoscope, a fluid vein is formed, and hence a murmur. The diastolic part of the combined murmur is shorter and fainter than the systolic portion Under normal conditions the presence of a diastolic murmur over the femoral artery is explained by the supposition of a high degree of dicrotism of the pulse. A systolic murmur audible over the subclavian arteries above and below the clavicles, and most marked on the left side, still remains to be mentioned. The murmur is modified by the respiratory movements, and may be annulled or intensified by taking a deep breath. Its mode of production is still a matter of doubt. A systolic bruit is occasionally heard over the arteries in the neck in cases of anaemia. Aneu7-isvial. — The sounds which may be heard over an aneurismal sac in the neighbourhood of the heart are very variable. Most commonly two sounds, corresponding with those of the heart, are observed. The second sound is accentuated and of a lower pitch than normal, and it may be preceded by a systoHc murmur. The first sound may be absent, and a systolic bruit, followed by a second sound, may alone be audible. In other instances a systoHc and diastolic murmur are heard while the sounds of the heart are absent. The systolic murmur may be conducted from the aortic orifice, or it may be produced at the mouth of the aneurism. The diastolic murmur is probably always conducted from the aortic opening. Venous. — A continuous murmur, the " bruit de diable," may be heard over the internal jugular veins at the root of the neck in cases of anaemia. The bruit is, however, not peculiar to anaemia. It may occur under perfectly healthy conditions, and it has been observed in 50 per cent, of cases showing no signs of antemia. The murmur, which has a musical humming quality, is usually most distinct on the right side. The intensity of the murmur is increased by the upright position, by turning the head away from the side that is being auscultated, and by a deep inspiration. It is also greatly modified by the degree of pressure exercised by the stetho- scope over the vessel. The intensity of the murmur is also increased during inspiration and during auricular diastole. The murmur has been ascribed to the alteration in the calibre of the vein produced by the pressure of the stethoscope and the consequent production of a fluid vein. In many cases, how- ever, it may be heard when the instrument is placed over the sternoclavicular joint, where no pressure on the soft parts is possible. It is probable that the anatomical relations of the lower part of METHODS OF DIx^GNOSIS 73 the internal jugular veins exert an important influence on the production of the murmur. This portion of the vessel is intimately connected with the cervical fascia, so that its calibre remains constant. If, now, the dimensions of the vein above or below this site are diminished, or increased, respectively, the adherent portion of the vessel becomes relatively dilated, or constricted, as the case may be, and these are the conditions for the formation of a fluid vein. According to some writers a general contraction of the veins on a diminished quantity of blood in circulation is present in anaemia, while others suppose that these structures undergo relaxation from malnutrition and loss of tone. In either event the theory advanced above will explain the presence of a murmur over the internal jugular vein. In some instances the adherent portion of the vein is normally somewhat pouched, and it may be that an alteration in the quality of the blood would, under these conditions, be sufficient to deter- mine the formation of a fluid vein. It must be borne in mind, too, that diminished viscosity of the blood, and lessened peripheral resistance, play an important part in the production of hjemic murmurs. A venous hum is not present in all cases of ansemia, and the intensity of the murmur does not necessarily correspond with the degree of deterioration in the quality of the blood. A bruit may also be heard over the longitudinal and lateral sinuses, and over the subclavian and other veins in cases of anaemia. A continuous venous murmur, apart from ansmia, is occasionally heard on either side of the xiphoid cartilage, and has been ascribed to constriction of the inferior vena cava at its junction with the right auricle. The murmur resembles the fitful blowing of wind through the rigging of a ship under bare poles. In those exceedingly rare instances in which a communication is formed between the ascending aorta and superior vena cava, a murmur may be heard over the first or second right intercostal space an inch or more from the sternal edge, which bears a resemblance to the sound produced by a water-wheel in motion. The continuous murmur which attends the establishment of a communication between the aorta and pulmonary artery, a very rare event, is heard best close to the left sternal edge, about the level of the second costal cartilage. The murmur heard under these circumstances, though continuous, is not uniform in intensity, but varies rhythmically with the balance of pressure in the two vessels. CHAPTER IV THE PULSE Definition — Method of Production — Physical Examination of Pulse — Inspection — Palpation — Graphic Record or Sphygmogram — Instrumental Determination of the Blood Pressure. From a clinical point of view the pulse is the alteration in the shape of an artery which obtains during the time that each wave of increased pressure, due to the heart's systole, passes along the vessel. The perception of the pulse rests on the visible and palp- able displacement which the artery imparts to the media in con- tact with it, as each wave of increased pressure passes beneath the point of contact. The pulse depends on — 1. An alteration in the shape of the artery from the flattened to the cylindrical (Broadbent). 2. A shght expansion of the artery. An artery is usually flattened by the tissues which overlie it, and exercise pressure against some underlying and resistant medium. In the case of the radial artery it is the radius against which the vessel is pressed. The artery is still further flattened by the examining finger. All elastic tubes, however, tend to become circular when the fluid pressure w'ithin them is sufficient to over- come the resistances which conduce to alterations in their shape. Thus it is that as the pulse wave passes any particular point in the course of an artery, the vessel's shape is altered from the flattened to the circular, and a false impression of expansion is experienced. In addition to this factor in the production of the pulse the arterial wall does actually expand, but, in the case of the radial artery, to an extent which could scarcely be appreciated by the finger. The physical examination of the pulse includes — 1. Inspection 2. Palpation 3. Graphic record or sphygmogram 4. The instrumental determination of the blood pressure. 74 THE PULSE 75 INSPECTION. The information derived from inspection of the pulse is always checked by subsequent palpation. Nevertheless this method of investigation has its value as a means of rapid diagnosis. The vessels which lend themselves most readily to this mode of examina- tion are the temporal arteries, and occasionally the retinal arteries, since the course of these vessels can usually be seen in the adult by careful inspection. The degree of tortuosity of the artery, and the frequency, regularity, and to some extent the character of the pulse, as well as the bilateral symmetry of the pulsation, can be roughly gauged. Thus aortic regurgitation may be suspected in cases where the discursion of the pulse is extensive, the collapse of the pulse wave sudden, and the vessels tortuous. Heart failure, especially in mitral regurgitation, is suggested by inequalities in the force and rhythm of the visible pulse. Visible pulsation of the carotid arteries is frequently associated with aortic regurgitation, and also with ex- ophthalmic goitre and other nervous disorders of the heart. Other points, which may be observed on inspection, have their diagnostic value as described under palpation of the pulse. PALPATION Method of Feeling the Pulse The first three fingers should be placed lightly upon the radial artery at the wrist, with the forefinger nearest the heart and the thumb supporting the wrist. The vessel should be investigated, under varying degrees of pressure, both in its transverse and longitudinal aspects, and each feature of the pulse that requires attention should be appreciated by a distinct and well-defined manoeuvre of the examining fingers. The features of the pulse to which the observer's attention should be directed are the following :■ — • 1. The frequency. While counting the pulse rate, the regularity or irregularity of the force and rhythm of the pulse should also be observed. 2. The size of the artery. 3. The degree of fulness of the artery between the pulsations. 4. The character of the pulse wave. 5. The compressibility of the vessel. 6. The condition of the arterial wall. 7. The bilateral symmetry of the pulsations. I. The freoLuency of the pulse. — The rate of the pulse and of the heart beats usually correspond ; but this is not always the case, inas- much as the force of the cardiac systole may not be suflicient to propel the pulse wave as far as the radial artery. The average 76 DISEASES OF THE HEART rate of the pulse in the adult male is about seventy-two beats per minute. The conditions which give rise to physiological variations in the frequency of the pulse are : (i) Age, i.e. the pulse rate is quicker in children than in adults; (2) Sex, i.e. the pulse rate is quicker in women than men ; (3) Heredity ; (4) Nervous impressions ; (5) Emotional disturbance; (6) Exertion; (7) Position; (8) Food; (9) Temperature; (10) Time of day or night; (11) Alterations in blood pressure, etc. The pulse rate is also influenced by drugs, such as alcohol, tobacco, digitalis, and the like. The variations in the pulse rate produced by disease may be tabulated as follow : — A. Increased Frequency of the Pulse (i) Pyrexia. (2) Ansemia. (3) Pathological conditions which decrease blood pressure. (4) Pericarditis. (5) Myocarditis. (6) Valvular disease of the heart. (7) Dilatation of the heart. (8) Irritable heart (Da Costa). (9) Loss of vagus control, or irritation of the cervical sympathetic (accelerator) nerves as observed in cases of palpitation, ex-ophthalmic goitre, etc, (10) Tachycardia. (11) Hysteria. B. Diminished Frequency of the Pulse (i) Renal disease. (2) Pathological conditions which increase blood pressure. (3) Jaundice. (4) Fatty and occasionally fibroid disease of the heart (the pulse rate is, however, sometimes increased under these circumstances). (5) Epi- lepsy and other cerebral disorders. (6) Pain. (7) During convalescence from the acute fevers, such as pneumonia, typhoid, etc. The diminished frequency of the pulse that is found in association with the remarkable condition in which two beats of the heart occur to one of the pulse is of course not included in the present category. The condition is mentioned here with the object of emphasizing the necessity of controlling observations made with respect to the fre- quency of the pulse at the wrist by an examination of the heart. Rhythm The rhythm of the pulse and of the heart's action usually corre- spond, but, as in the condition just mentioned, this is not necessarily the case. Deviations from the normal rhythm give rise either to "inter- mittence" or to "irregularity" of the pulse, or to a combination of these conditions. Intermittence of the pulse means the omission of a beat, which may occur at regular or irregular intervals. The phenomenon is more commonly observed in old than in young people, and it is fre- THE PULSE 77 quently found independent of any other discoverable abnormality. It is habitual in some individuals, while in others it is readily pro- duced by emotional disturbance, indigestion, or the abuse of tea and tobacco. Intermittence of the pulse is also observed in association with gouty manifestations. It is sometimes found in connection with fatty disease of the heart, with cardiac failure, and with acute affections of the lungs, and is then of serious import. It is said that habitual intermittence of the pulse usually disappears during attacks of pyrexia. Irregularity of the pulse usually, but not necessarily, implies in- equalities in the force and volume of the pulsations, as well as the appearance of the beats at unequal intervals of time. It is asso- ciated with valvular disease of the heart, and more especially with mitral regurgitation. It is also commonly observed in connection with failure of the heart from any cause, and speaking generally, it is a sign of disturbance of myocardial metabohsm. Irregularity of the pulse sometimes depends on reflex disturbance of the heart from gastro-intestinal and uterine disorders. It also occurs in association with the abuse of tea, coffee, and tobacco. It is occasionally found apart from any other morbid manifestations. Certain peculiar modifications in the rhythm of the pulse are designated under the special titles of the pulsus bigeminus, the pulsus trigeminus, the pulsus alternans, and the pulsus paradoxus. Pulsus bigeminus. — In this variety of pulse the beats are grouped in pairs, with a pause between each group. The second beat is usually the weaker of the two. The heart beats correspond in rhythm with the pulse, so that a strong impulse is followed by a weak one. This variety of pulse is found most commonly in mitral stenosis, more especially when under the influence of digitalis. It is also observed in association with bodily and mental strain and with epileptiform attacks. Pulsus trigeminus. — In this variety of pulse the beats are arranged in groups of three. It occurs under conditions similar to those in which the pulsus bigeminus is observed. Pulsus alterfians — The regular succession of a strong and weak pulsation constitutes the pulsus alternans, which is observed in connection with Cheyne-Stokes' respiration, (Sansom) and with the other conditions of central nervous disturbance, and occasionally also with mitral affections. Pulsus paradoxus. — In this condition the pulse is markedly influenced by the respiratory movements. During inspiration the pulse wave is annulled, or becomes much diminished in force, while during expiration it may be of full amplitude. It can some- times be elicited under physiological conditions by holding the breath in extreme inspiration or expiration. In certain pathological conditions, however, it is more or less constantly present. It occurs in association with pericardial adhesions, mitral stenosis, emphy- sema, and with conditions of heart failure. y8 DISEASES OF THE HEART So far as the mechanism of production of this variety of pulse is concerned, it is probable that the increase of negative pressure in the thorax with each inspiration offers a greater resistance to the discharge of the ventricular contents than an enfeebled heart is able to cope with. The pulsus paradoxus is of small diagnostic value. 2. The size of the artery. — Observations on this head are of importance, inasmuch as the size of the artery appreciably affects the perception of the size and force of the pulse wave. Thus the pulse wave in a large artery will appear more forcible than in a small one, but, on the other hand, the pulsation is much more easily obliterated by pressure with the fingers in the former case than in the latter. The size of the artery, therefore, becomes one of the factors in the estimation of the strength or force of the pulse. The size of the artery depends for the most part on the condition of contraction or relaxation of the vessel, which is of course regulated by the tone of the arterial walls. The thickness of the arterial wall also effects to a slight extent the size of the vessel. The size (calibre) of the artery is most accurately determined by means of Oliver's arteriometer. The systematic use of this instrument is of very great service, inasmuch as it enables a record to be kept of the calibre of the artery for purposes of comparison and reference. 3. The degree of fulness of the artery between the pulsations. — The degree of fulness of the artery between the beats of the pulse is the measure of the mean intra-arterial pressure, or pulse tension, and is determined by (i) the force of the ventricular systole, (2) the peripheral resistance, and (3) the competency of the aortic valve. In order to determine the tension of the pulse the' fingers should be carried transversely to and fro across the artery, and an attempt made to roll the vessel beneath the fingers. When the artery can be felt distinctly during the passage of the pulse wave beneath the finger, and is, with care, distinguishable between the pulsations, the pulse may be regarded to be of average tension. When the artery cannot be clearly outlined by the fingers at any period of the passage of the pulse wave, or during the interval between the pulsations, the pulse is said to exhibit low tension. AVhen the artery can be rolled beneath the fingers during and between the pulsations the pulse is described as one of high tension. An artery that is empty between the beats of the pulse (low- tension pulse) depends on a general want of tone of the ventricular and arterial walls, and is occasioned by — (i; Pyrexia. (2) Hereditary influences. (3) General debility, due to anxiety or nervous strain of any kind, excesses of various kinds, bad hygienic surroundings, ansemia, and so forth. (4) Food. (5) Serious purgation. (6) Exhaustion or fatigue from any cause. (7) Fatty degeneration of the heart. (8) Dilatation of the heart. (9) Aortic regurgitation. (10) Mitral regurgitation, etc. THE PULSE 79 An artery that is full between the beats of the pulse (high-tension pulse) depends on (i) increase in the quantity of blood in the circulation, (2) forcible action of the heart, (3) increased arterial tone and arterio-capillary resistance, and is occasioned by — (i) Age. (2) Hereditary influences. (3) Renal disease. (4) Gout. (5) Pregnancy. (6) Lead poisoning. (7) Aneemia (in some cases). (8) Diabetes (in some cases). (9) An attack of angina pectoris. (10) Constipation. (11) Peritonitis. (12) Emphysema and chronic bronchitis. (13) Aortic and mitral stenosis, etc. 4. The character of the pulse wave. — The character of the pulse wave must be considered with regard to its rise, duration, and fall. The rise of the pulse wave may be sudden or gradual, of great or of small amplitude. It is sudden and of great amplitude when a comparatively large amount of blood is pumped into an empty arterial system, as in (r) aortic regurgitation with hypertrophy of the heart, (2) after hsemorrhage, (3) in most pulses of low tension. The rise of the pulse wave is gradual if the ventricle can empty itself slowly only into the aorta, as in (i) aortic stenosis, (2) aneurism of the aorta, (3) high-tension pulses. The rise of the pulse wave is of small amplitude (i) when the pulse tension is high, (2) when the amount of blood ejected into the aorta is small, as in mitral stenosis, mitral regurgitation, etc. The duration of the pulse wave is considerable when the pulse tension is high and the ventricular systole powerful, as in cases of high tension, aortic stenosis, etc. The duration of the pulse wave is short when the pulse tension is low or the ventricular systole is weak, as in low-tension pulses and failure of the heart, etc. The fall of the pulse wave may be sudden or gradual, with or without subsidiary pulsations. A sudden fall of the pulse wave is observed in cases of (i) aortic regurgitation, (2) pulses of low tension. A gradual fall of the pulse wave is observed in (i) aortic stenosis, (2) pulses of high tension, (3) aneurism. Seco7idary pulsations, etc.—Hh& dicrotic wave is practically the only secondary or subsidiary pulsation appreciable to the finger. It is most commonly observed when the pulse tension is low and the heart beat forcible. A fuller account of the dicrotic pulse and of the other subsidiary waves that may be observed will be given under the account of the sphygmogram. 5. The compressibility of the artery. — The strength of the pulse, and the degree of the constant or mean intra-arterial pressure or tension, is computed from the compressibility of the artery. The degree of pressure that is required to obliterate the pulse is the measure of its strength. The degree of intra-arterial pressure is 8o DISEASES OF THE HEART gauged by the amount of force that is required to flatten the artery between the pulsations. The method of estimating the compressibility of the artery and hence of the variable and constant pressure within the vessel is as follows : Three fingers are placed upon the radial artery in the manner previously described. The two fingers nearest the heart exercise pressure upon the artery until the pulsations are obliterated, that is, they cannot be felt by the third finger. The degree of pressure that is required to extinguish the pulse is the measure of its strength. The three fingers may be used to compress the vessel between the beats, and the degree of pressure that is required to flatten the artery is the guide to the estimation of the mean arterial tension. The artery is difficult to compress in (i) pulses of high tension, (2) when the vessel is rigid from degenerative changes in its walls. The artery is easy to compress in pulses of low tension. 6. The condition of the arterial wall. — In order to estimate the condition of the arterial wall, the fingers should carry the skin up and down along the course of the vessel with varying degrees of pressure. The healthy arterial wall is soft and elastic to the touch. On passing the fingers along the course of the artery and applying some pressure, no variations in consistency, or irregularity in outUne should be felt. If the vessel feels unnaturally rigid, with irregularities in thickness and density, especially when this is combined with tor- tuosity of outline, the arterial wall has undergone degeneration. Hardened patches are due to established or commencing cal- careous deposition, and the tortuosities depend on the loss of elasticity of the arterial coat in conjunction Avith strain on the vessel. In extreme cases the artery is found to be converted into a rigid calcareous tube. Atheroma is a frequent sequel of protracted high arterial tension. It is usually present to a greater or less degree in old age. 7. The bilateral symmetry of the pulsations. — In cases of doubtful nature it is well to make a practice of examining the pulse at each wrist simultaneously, with the object of disclosing any want of synchronism, or differences in the size or character of the two pulses that may obtain. Apart from an abnormal distribution of the arteries, a want of synchronism, or a marked difference in the size or character of the two radial pulses, is usually indicative of aneurism of one or other of the great arterial trunks. Recurrent pulse. This pulse, which is felt as a feeble and retarded beat on the distal side of the radial artery after this vessel has been completely blocked by pressure with the fingers, is due to the transmission of a THE PULSE 8i wave through the palmar arch by way of the ulnar artery. It is observed in cases of extremely low tension, with a vigorous ventricular contraction, as, for instance, in aortic regurgitation, and also in conditions where protracted high tension has led to failure of the muscular coats of the arteries, as, for example, may obtain in the terminal stages of chronic Bright's disease. GRAPHIC RECORD OR SPHYGMOGRAM For a description of the sphygmograph and its method of use the reader is referred to works on physiology. The sphygmogram is a tracing of the discursions of the pulse magnified by the lever mechanism of the sphygmograph, and registered on a recording surface. It consists of — 1. An ascending Umb {a-b) 2. An apex {b) 3. A descending limb {b-g), which is interrupted by one or more secondary waves and notches, viz. — I (a) The tidal or predicrotic wave {d) (b) The aortic notch (e) {c) The dicrotic wave (/) {d) Subsidiary or post-dicrotic waves FIG. 14. NORMAL PULSE TRACING I. The Ascending Limb In health this line is vertical, or nearly so. Its amplitude depends on — 1. The energy of the heart's beat 2. The intra-arterial tension 3. The magnifying power of the lever mechanism 4. The skill of the operator The energy of the heart's beat. — Ceteris paribus, the more energetic the beat of the heart the greater the amplitude of the G 82 DISEASES OF THE HEART ascending limb of the pulse trace, but owing to the correlslion between the cardiac and vascular mechanisms, it usually happens that when the heart's beat is forcible the arterial tension is high. Hence the effect of a powerful ventricular contraction on the ampli- tude of the ascending limb of the sphygmogram is largely neutralized. The intra-arterial tension. — When the arterial tension is high the artery is circular, not only during the passage of the pulse wave, but also during the interval between the pulsations, unless the vessel be subjected to great pressure. Hence the full effect of the change of shape in the artery, i.e. from the flattened to the circular, loses its due influence on the percussion stroke, which, in consequence, is of low amplitude. When, on the other hand, the tension is low the artery is flattened between the beats of the pulse by the pressure of the small arm of the lever of the sphygmograph ; and hence the discursion of the long arm of the lever, when the vessel becomes circular, is considerable or great as the case may be. The skill of the operator. — Unless the lever be accurately ad- justed over the artery, the displacement of the tissues surrounding the vessel, and not that of its walls, is imparted to the sphygmo- graph. There is for every degree of tension a degree of pressure which produces the maximum discursion of the lever. This can be found by experiment only, and by the skilled operator. The ascending limb of the sphygmogram is of great amplitude in — 1. Aortic regurgitation 2. Pulses of low tension with forcible heart beat 3. The pulse after haemorrhage The ascending limb is of small amplitude in — 1. Pulses of high tension 2. Mitral disease 3. Aortic stenosis 4. Aneurism 2. The Apex {b) The apex is the angle included between the ascending and descending Umbs of the sphygmogram. It is normally acute. Its arc, however, largely depends on the rate of movement of the recording surface. The angle is very acute under those conditions which produce an ascending Hmb of great ampUtude. It is obtuse when the arterial tension is high, or when the aorta is slowly filled, as in aortic stenosis, and aneurism of the arch of the aorta. Sometimes the tracing has a double apex {pulsus bisferietis) — a condition which sometimes obtains in aortic stenosis and in cases of senile degenera- THE PULSE 83 tion of the arteries. It is compounded of two distinct efforts on the part of the ventricle to empty itself. 3. The Descending Limb {b-g) The first part of this line (b-e) is due to the fall of the lever after its initial elevation by the pulse wave. Together with the ascending limb and the apex it forms the so-called percussion wave. Tidal Wave [D) The explanation of the cause and significance of the tidal wave is most succinctly and clearly given by Mahomed in the following words : — 1. 2. FIG. 15. MAHOMED S SCHEME OF THE TIDAL WAVE "The simplest pulsatile movement that can be conceived in an elastic tube is the mere passage of a wave of fluid through it, causing more or less sudden expansion and a gradual collapse of the tube as it passes through it; such a wave is the foundation of the pulse, and has been called the ' Tidal ' wave. If the impulse imparted to the fluid is more sudden, an element of percussion or shock will be introduced (Fig. 2), giving an abrupt and vertical up-stroke from the jerking of the lever by the sudden expansion of the artery [change of shape. — Author]. Owing to its acquired velocity, this movement of the lever is rather greater than the corre- sponding movement in the arterial wall which produced it, and on reaching its highest point, it falls suddenly by its own weight, till it 84 DISEASES OF THE HEART is again caught and perhaps slightly raised by the tidal wave B, which is now only reaching its maximum of distension. "... The tidal wave is the true pulse wave, and indicates the passage of a volume of blood through the arteries, pumped into them by each contraction of the heart. It resembles the passage of the tidal wave or ' bore ' up a river ; hence its name. It is transmitted more slowly than the percussion wave, or rather attains its maximum intensity more gradually ; hence their separation in the tracing. Though they usually commence to distend the artery together, the percussion wave necessarily attains its maximum intensity instantaneously, it being only a shock, while the tidal wave does so more gradually. Sometimes a considerable interval elapses between them. Frequently they are inseparable, the per- cussion wave not existing or else being merged into the tidal." The tidal wave has been explained on the assumption that it is a reflection of the primary wave from the periphery, but the view ad- vanced above is perhaps the one most commonly held. Aortic Notch and Dicrotic Wave {e and f) The recoil of the elastic arterial walls, which follows their dis- tension by the percussion and tidal waves, forces the blood back-, wards and forwards towards the aortic cusps and towards the periphery. The flow backwards closes the aortic valve (represented by the aortic notch), and the barrier thus thrown in the path of the blood stream gives rise to a reflected wave of increased pressure (the dicrotic wave). Other views are held with regard to the causation of the dicrotic wave, but the explanation given here is the one most commonly accepted. The subsidiary waves which sometimes appear on the descending limb of the sphygmogram below the dicrotic wave are echoes of the dicrotic wave. They are due to the vibrations set up in the elastic arterial walls consequent on the injection of the mass of blood into the aorta at each systole of the heart. As equilibrium is established they gradually die away. Irregular undulations on the descending limb of the pulse trace are sometimes due to vibra- tions of the sphygmographic lever, or of the tissues in the imme- diate neighbourhood of the pulse. The application of the foregoing methods of examination of the pulse will now be illustrated in the following brief description of the characteristic features of the pulse in — 1. High tension 2. Low tension 3. Virtual tension 4. Hypertrophy of the heart 5. Dilatation of the heart 6. Aortic regurgitation 7. Aortic stenosis THE PULSE 8s 8. Combined aortic regurgitation and stenosis 9. Mitral regurgitation 10. Mitral stenosis 11. Combined mitral regurgitation and stenosis 12. Combined aortic and mitral disease 13. Aneurism of the arch of the aorta I. High-tension Pulse Inspection. — Unless its walls are degenerated the vessel is usually small and contracted. If degenerated, the temporal arteries stand out as thick sinuous cords. The radial artery, under these circum- stances, is visible far up the arm, and the vessel is thrown into curves with each pulsation. The diameter of the artery does not appear to be appreciably altered during the passage of the pulse wave. Palpation. — The pulse is decreased in frequency, but regular in force and rhythm. The vessel is small if healthy; large if de- generated, full between the beats and not easily compressible. The pulse wave is of low amplitude, rises slowly, lasts long, falls slowly, FIG. 16. HIGH-TENSION PULSE TRACING and is difficult to compress. The arterial wall, usually more or less thickened, is sometimes extremely degenerated. Sphygmogram. — The ascending limb is of low amplitude, and shows a gradual, somewhat slanting ascent. The percussion wave is badly defined and often absent. The apex (tidal wave) is rounded. The dicrotic wave is small, and situated high up on the descending limb. The descending limb falls gradually, and is interrupted by numerous subsidiary waves. 2. Low-tension Pulse Inspection. — The pulse is often visible as an energetic throb. The vessel cannot be seen between the beats. Palpation. — The pulse is increased in frequency, but regular in force and rhythm. The artery, which may be large or small, cannot 86 DISEASES OF THE HEART be felt between the beats. The pulse wave, which may be of great or small amplitude, in accordance with the force of the ventricular contraction, rises quickly, is of brief duration, falls quickly, and is easily obliterated by pressure. Dicrotism is always well marked, so that in some instances two distinct pulsations can be felt with each beat of the heart. This variety of low-tension pulse has been termed the dicrotic pulse. The arterial wall is healthy. Sphygmogram. — The ascending limb rises quickly, and is of great or low amplitude according as the left ventricle is acting powerfully or feebly. The apex is acute and the tidal wave badly marked. FIG. 17. LOW-TENSION PULSE TRACING FIG. 18. DICROTIC PULSE TRACING The aortic notch and dicrotic wave are well marked and are situated low on the descending limb, which falls suddenly. 3. Virtual-tension Pulse This variety of pulse is observed when the element of forcible and energetic heart beat is wanting, but the other conditions are those productive of high tension. These conditions obtain in the terminal stages of Bright's disease, when the heart is failing, and in mitral stenosis, when the amount of blood discharged at each systole into the aorta is small. Inspection. — If the pulse is visible {i.e. in the last stages of Bright's disease) it rises and falls suddenly. The artery is large and its walls tortuous. THE PULSE ^7 Palpation. — The pulse may or may not be increased in frequency. It is usually regular in force and rhythm until the heart fails (mitral stenosis). The vessel is usually large, but it may be small, as in mitral stenosis. The artery is full between the beats and fairly easily compressible. The wave rises rather suddenly, is of short duration, and falls some- what less abruptly than it ascends. The wave is easily compressed, and the vessel wall is usually more or less degenerated. Sphygmogram. — The ascending limb is steep and of considerable amplitude, the apex is acute and the tidal wave short. The de- scending limb is somewhat steep and the dicrotic wave is fairly well marked, and is situated well above the base line. FIG. 19. VIRTUAL-TENSION PULSE TRACING 4- Hypertrophy of the Heart The pulse in cases of cardiac hypertrophy is that of the condition which has given rise to the enlargement of the organ. Simple hypertrophy of the heart from prolonged over-exertion is associated with the following pulse : — Inspection. — The arteries are often large, and show regular and forcible pulsation. Palpation. — The pulse is normal in frequency and regular in force and rhythm. The vessel is often large, and can usually be felt between the beats. The wave rises suddenly, falls rather rapidly, and is fairly easily compressible. The arterial wall is healthy. Sphygmogram. — Normal, but on rather a large scale. 5. Dilatation of the Heart As in the case of hypertrophy, dilatation of the heart is usually associated with conditions which modify the characters of the pulse. The pulse of dilatation of the heart due to over-exertion, or to weakness of the cardiac walls following pyrexia, the acute fevers, etc., needs a brief description. 88 DISEASES OF THE HEART Inspection. — Pulse not visible. Palpation. — The frequency of the pulse is increased. The pulsations are irregular in force and rhythm. The vessel is small and cannot be felt between the beats. The wave is small, and it rises and falls quickly. The arterial wall may or may not be degenerated. PULSE TRACING FROM A CASE OF DILATATION OF THE HEART SHOWING RESPIRATORY CURVES Sphygmograra. — The tracing is very irregular. The dicrotic wave is usually present. 6. Aortic regurgitation The collapsing pulse of Corrigan, or the water-hammer pulse. 1. In valvular disease 2. In atheroma I. IN VALVULAR DISEASE Inspection. — The arteries of the neck, the temporal, subclavian, brachial, and radial arteries, etc., show visible and often violent pulsation, which exhibits a rapid rise and fall. The arteries are usually tortuous and more or less thickened and degenerated. The tortuosity is increased and is associated with a pecuhar vermiform movement of the vessel as the pulse wave passes along it. Palpation. — The pulse is normal in frequency and regular in force and rhythm. The vessel is large and empty between the beats, a feature that is more readily appreciated by raising the wrist above the level of the shoulder. The wave rises very suddenly and falls with remarkable abruptness, and is of momentary duration only. It is easily compressible. The arterial wall is usually thickened and may be degenerated. It will be noted that there is an appreciable delay in the appear- ance of the pulse wave at the wrist after the systole of the heart. This loss of time between the systole of the ventricle and the appearance of the pulse wave is peculiar to low-tension pulses, and reaches its maximum development in cases of aortic incompetence. THE PULSE 89 Capillary and venous pulsation are other phenomena which may be seen in connection with a relaxed condition of the arterial system, such as obtains in cases of aortic regurgitation. In these conditions the relaxed arterial walls fail to obliterate the pulse wave, which is therefore carried on into the capillaries and thence into the veins. FIG. 21. PULSE TRACING FROM A CASE OF AORTIC REGURGITATION Sphygmogram. — The ascending Hmb is steep and of great ampli- tude. The apex is very acute, and the descending limb remarkably steep. The tidal and dicrotic waves are hardly marked on the tracing, or are altogether wanting. 2. AORTIC REGURGITATION DUE TO ATHEROMA The regurgitation in these cases is due for the most part to dilata- tion of the root of the aorta involving the aortic orifice. The degree of regurgitation is commensurate with the degree of dilatation of the orifice and is usually slight. Inspection. — The temporal and radial arteries may stand out prominently as tortuous cords. The pulsation, when visible, will appear to come and go quickly, and may be attended by loco- motion of the arteries. Palpation. — The pulse is normal in frequency and regular in force and rhythm. The artery is large and full between the beats. The wave rises and falls suddenly, and is easily compressible. The wall of the artery will show degenerative changes. The delay of the pulse at the wrist is very much less marked than in aortic regurgitation due to valvular disease. Sphygmogram. — The ascending limb is of moderate amplitude and somewhat steep. The descending limb is moderately steep and shows an ill-marked dicrotic wave. Inspection. - Palpation.- and rhythm. 7. Aortic Stenosis —The pulse is not usually visible. -The pulse is normal in frequency and regular in force The artery is small and can be felt between the beats. 90 DISEASES OF THE HEART The pulse wave rises slowly, falls slowly, and is of considerable duration. It is fairly easily compressible. The condition of the arterial wall is normal. FIG. 22. PULSE TRACING FROM A CASE OF AORTIC STENOSIS Sphygmogram. — Percussion wave absent. The tidal wave has an ascending limb of low amplitude, rising gradually. The apex is rounded or flattened. The descending limb falls gradually. The dicrotic wave is badly marked. In cases of aortic stenosis, and also in other forms of cardio- arterial disease, tracings with a double summit are sometimes FIG. 23. ANACROTIC PULSE TRACING FIG. 24. PULSUS BISFERIENS obtained. This is probably due to an ineffectual percussion wave followed by a tidal wave of greater amplitude. According to Broad- bent, the double summit is an example of the pulsus bisferiens, and is due to a reinforcement of the ventricular systole towards its close. THE PULSE 91 8. Combined Aortic Regurgitation and Stenosis The pulse is the summation of the effects produced by the two lesions, with the result that the characters proper to each disease are largely neutralized. Speaking generally, the pulse will reflect, for the most part, the characters peculiar to the predominating lesion. As a rule the pulse is visible, regular, and more or less collapsing. 9. Mitral Regurgitation Inspection. — The pulse is not usually visible. FIG. 25. PULSE TRACING FROM A CASE OF MITRAL REGURGITATION Palpation. — The pulse is increased in frequency and is irregular in force and rhythm. The artery is small and cannot be felt be- tween the beats. The wave rises and falls quickly, and is easily compressible. The arterial wall is healthy. Sphygmogram. — The tracing is often very irregular. The ascending limb is of low and irregular amplitude. It rises rapidly. The apex is usually sharp, and the ascending limb falls quickly. The dicrotic wave is fairly well marked, and usually appears low down on the descending limb. 10. Mitral Stenosis Inspection. — The pulse is not visible. Palpation. — The pulse is slightly increased in frequency, and is regular in force and rhythm until the heart fails. The artery is small and full between the beats. The wave is small and rises and falls gradually. It is easily compressed. The arterial wall is healthy. FIG. 26. PULSE TRACING FROM A CASE OF MITRAL STENOSIS 92 DISEASES OF THE HEART Sphygmogram. — The ascending limb rises gradually and is of small amplitude. The apex is usually rounded. The descending limb falls gradually and shows a badly marked aortic notch and dicrotic wave. In the later stages of mitral stenosis, with the establishment of tricuspid regurgitation, etc., the pulse becomes very irregular, owing partly to the fact that many abortive heart beats fail to propel the pulse wave as far as the wrist. II. Combined Mitral Stenosis and Regurgitation The pulse is very irregular and small. It combines the features peculiar to the two lesions, the influence of the predominant affection preponderating, 12. Combined Aortic and Mitral Disease The pulse differs greatly in different cases. The predominating lesion exercises the greater influence on the characters of the pulse. If aortic regurgitation predominates, the percussion wave is large and collapse of the pulse wave prominent. If mitral regurgitation, irregularity is the main feature. If aortic stenosis, the percussion wave is absent, the tidal wave taking its place. If mitral stenosis, the smallness of the pulse is its most distinguishing feature. 13. Pulse of Aneurism The radial pulses on the two sides may differ in time and character. Inspection. — A visible pulsation may occur over the seat of the aneurism. FIG. 27. PULSE TRACING TAKEN' FROM THE LEFT RADIAL ARTERY IN A CASE OF ANEURISM Palpation. — The pulse is normal in frequency and regular in force and rhythm. The artery is small and full between the beats. The wave is small, gradual, prolonged, and subsides gradually. It is easily compressible. THE PULSE 93 Simultaneous examination of the two radial arteries may show delay and altered character of the pulse on the affected side. FIG. 28. PULSE TRACING TAKEN FROM THE RIGHT RADIAL ARTERY IN THE SAME CASE (FIG. 27) Sphygmogram. — The percussion wave is absent. The ascending limb of the tidal wave is of low amplitude and rises slowly. The apex is rounded, and the descending limb falls gradually. The dicrotic and secondary waves are usually absent (Fig. 27). THE INSTRUMENTAL DETERMINATION OF THE BLOOD PRESSURE The digital estimation of the blood pressure obtained from a peripheral vessel like the radial artery is liable to several fallacies which may mislead even the well-trained finger (Oliver). In order to ensure accuracy of observation, and also to provide a record for the purposes of comparison and reference, it is necessary to employ other means of gauging the blood pressure. Instruments which fulfil these requirements have been devised by Hill and Barnard (the Sphygmometer); also by Oliver (the Hsemodynomometer), and by others. The estimation of the blood pressure by both instruments is obtained through a fluid medium, and herein lies the accuracy of the method. The sensitiveness and accuracy of these instruments have been thoroughly tested, and though the results obtained are not beyond dispute, it is not too much to say that a blood pressure gauge should form part of the equipment of every clinician. Both the arterial and venous blood pressures are capable of measurement. Oliver states that if the influence of gravitation be excluded the arterial blood pressure is practically uniform throughout the arterial system. The average mean arterial pressure varies between 90 and no c.mm. Hg. It is modified by the age, weight, and build of the individual. The average venous pressure in recumbency Oliver puts at 10-20 c.mm. Hg. CHAPTER V THE CARDIOGRAPH Its Sphere or Usefulness — The Normal Cardiogram — Cardiograms of the Chief Valvular Lesions. The value of the cardiograph as a means of diagnosis even in skilful hands is somewhat problematical, and in any case the results obtained are decidedly less trustworthy than those afforded by the sphygmograph. The apex beat is often difficult or im- possible to define, and unless the button of the instrument is accurately applied over the site of its manifestation, the tracing obtained is not that which is due to the actual impulse of the heart against the chest wall, but to movements in the neighbour- hood of the apex beat which give the so-called " inverted tracing." If the operator is not aware of this possibility his results may be quite unintelligible. Provided, however, that an accurate and reliable tracing can be FIG. 29. NORMAL CARDIOGRAM (Sansom after Galabin) F = Closure of semilunar valves and commencement of diastole K = Elevation due to sudden filling of ventricle by the active dilatation of its walls / = Period of passive filling of ventricle a, = Auricular systole and completion of the process of filling the ventricle a-d= Sudden rise of lever due to contraction of the ventricular wall at the commencement of systole d = Sudden opening of aortic valve r^ FIG. 43. TRIGEMINAL PULSE TRACING The alternate heart beat corresponding with the pulsus alternans is produced by repeated and successive strong and weak ventricular contractions. A duplicate or triplicate arrangement of the cardiac action may be observed, so that groups of two or three beats occur with a pause between each group. The pulsus bigeminus and pulsus trigeminus are respectively the peripheral expression of these two forms of cardiac arrhythmia. In the pulsus bigeminus the second beat is usually the weaker of the two. The weakness of the second beat may be carried to the point of extinction, so that two beats of the heart occur to one of the pulse. These varieties of arrhythmia occur most commonly in mitral stenosis, more especially when under the influence of digitalis. FUNCTIONAL DISORDERS OF THE HEART 333 The alteration in the rhythm of the heart's action which gives rise to the pulsus paradoxus is an illustration of the influence of respiration on a weak or hampered left ventricle. The most extreme disturbance of the cardiac rhythm is observed in the condition known as delirium cordis. The alterations in the rhythm of the heart's action associated with approximation, spacing and reduplication of the cardiac sounds, together with their significance, have been considered in previous sections (see pp. 50 and 51). The chief causes of disturbance of the cardiac rhythm, exclusive of structural lesions of the heart, are functional and occasionally organic affections of the brain, the acute specific fevers, and acute disease of all kinds, but more especially of the lungs and kidneys, flatulent dyspepsia, and reflex irritation from gastro-intestinal and hepatic derangements, sexual irregularities, and the like. Arrhythmia is also commonly due to the abuse of tobacco, tea, alcohol, etc., and to the action of certain drugs, notably of digitalis, belladonna, and aconite. Gout and allied disorders are also productive of intermittent and irregular action of the heart. It frequently happens that cardiac intermittence or irregularity lie outside the sphere of consciousness, and this is especially likely to be the case when the disturbance of rhythm is associated with organic disease of the heart, and is therefore more or less constant. On the other hand, intermittent action of the heart is not un- commonly attended by a fluttering or sinking sensation in the precordial area, followed by a thump or bump as the cardiac action is resumed with a somewhat more powerful contraction than usual. Apart from palpitation, irregular action of the heart is rarely perceptible to the patient. It is said that disturbance of the cardiac rhythm is of less moment when attended by subjective sensations than when it is not. Physical examination of the heart in cases of cardiac intermittence sometimes shows that the dropping of the beat is apparent rather than real, since there is evidence that the ventricular contraction occurs but is not sufficiently powerful to transmit the pulse wave as far as the wrist. In some instances, however, a real omission of the beat takes place, so far as the absence of auscultatory and other physical signs can demonstrate this occurrence. 334 DISEASES OF THE HEART SECTION V ALTERATIONS IN THE RATE OF THE HEART'S ACTION Alterations in the rate of the heart's action lead either to an increase or to a decrease of its frequency, and these are the aspects under which the subject will be considered. I. Increase in the Rate of the Heart's Action Increased frequency of the heart's action, which may amount to eighty, ninety, or even one hundred beats per minute, is a normal phenomenon in some individuals. Otherwise the causes of an increase in the rate of the heart's action are practically any of the conditions that were enumerated under the heading of "setiology" at the begin- ning of this chapter. Palpitation and rapid heart rate are very commonly associated, but they may and frequently do occur inde- pendently. An increase in the frequency of the heart's action is symptomatic of the affection known as ex-ophthalmic goitre, and it is found sooner or later in almost all forms of organic disease of the heart. It is also observed in connection with certain lesions of the vagus nerve and medulla oblongata. The effect of an increase in the rate of the heart's action on the time relations of the various events comprising the cardiac cycle is to shorten the diastole. The shortening of the diastole interferes with the proper filling of the heart with blood, so that not only is the output per ventricular contraction greatly reduced, but also the gross output per unit of time is not increased, and may be diminished. It is obvious, therefore, that rapid action of the heart does not per se add to the work of the organ, and herein may lie to a large extent the explanation of the absence of cardiac hypertrophy, even after long-continued increase in the rate of the heart's action. SECTION VI TACHYCARDIA Paroxysmal attacks of extremely rapid cardiac action, attended by palpitation and more or less prsecordial discomfort, are distinguished under the title of tachycardia, which may possibly represent a true neurosis of the heart. Tachycardia is found chiefly among neurotic subjects of either sex, and it may occur at almost any age. In some cases among women the attacks have appeared for the first time about the period FUNCTIONAL DISORDERS OF THE HEART 335 of the menopause. An hereditary influence has been remarked in occasional instances. The causation of tachycardia has not yet been satisfactorily deter- mined. The attacks, in some instances, have appeared to depend on emotional disturbance, gastric derangements, uterine displace- ments, pregnancy, floating kidney, over-exertion, and so forth. In other cases the abuse of tobacco, alcohol, etc., has appeared to exert a causal influence in the production of the disorder. In a case observed by the author, the attacks occurred apparently as a sequel of acute rheumatism. The pathogenesis of tachycardia is equally uncertain. The rapid action of the heart has been explained on the supposi- tion of loss of vagus control, or of discharging lesions affecting the " accelerating " centres, or of a combination of these causes. Lesions of the cardiac ganglia and vaso-motor changes have also been as- signed a share in the causation of the attacks. As a working hypothesis it may be supposed that in cases of tachycardia there is an unstable condition of the neuro-muscular mechanism concerned in the regulation of the heart's action, which would affect chiefly the controlling function of the vagi and cardio- inhibitory centre as well as of the vaso-motor centre. Under these circumstances reflex or centric irritation of the neuro-muscular apparatus of the heart might, through the accelerating mechanism, be capable of giving rise to the phenomena of the attacks. The paroxysms commence suddenly with a feeling of tightness, uneasiness, or oppression in the praecordial region, accompanied by a more or less distressing sensation of rapid cardiac action. The degree of discomfort experienced varies greatly in different cases. The pulse rate rapidly runs up to 150, 200, or even 250 beats a minute. In one of the reported cases a pulse rate of over 300 beats a minute was counted (Bristowe). The heart acts regularly, as a rule, throughout the attack, unless dilatation supervenes, but the pulse may become irregular owing to the failure of some of the beats to reach the wrist. The duration of the paroxysm varies greatly. It may continue for a few hours or a few days, and, it is stated, that in exceptional instances it has persisted for weeks. As a rule the attack ceases abruptly, and is followed by more or less exhaustion. A copious secretion of urine may accompany the terminal stages of the paroxysm. The attacks may recur at intervals of a few hours, days, or weeks, or, as is not infrequently the case, the period of immunity extends into months or even years. A physical examination of the heart during the attack usually reveals nothing abnormal beyond the modification in the rhythm of the sounds that is always associated with rapid cardiac action. The shortening of the diastole gives rise to the so-called foetal heart rhythm, or tick-tack action of the heart. 336 DISEASES OF THE HEART Recovery is usually complete, provided the interval between the attacks is sufficiently long to enable the heart to recuperate. In some instances the repeated occurrence of the attacks at short intervals exhausts the heart, and dilatation then supervenes together with its effects. Death, under these circumstances, may be due to gradual failure of the heart or, as is more often the case, to syncope. SECTION VII DECREASE IN THE RATE OF THE HEART'S ACTION The term " bradycardia " or brachycardia is used to denote slow action of the heart. It has no other significance. An infrequent action of the heart, by which is meant a rate below fifty beats a minute, is a normal condition in some individuals. A decrease in the rate of the heart's action is a physiological occurrence in parturition (Osier). It is also found in association with hunger. A slow action of the heart is sometimes observed in connection with fatty degeneration, less often with fibroid disease of the cardiac walls. The significance of the phenomenon in this respect is in- creased when it occurs in association with vertigo and syncopal attacks (Allbutt). A slow pulse does not necessarily imply an infrequent action of the heart, since some of the beats may fail to reach the periphery. Deductions drawn from the pulse rate with respect to slowing of the cardiac action should be checked, therefore, by an examination of the heart. Apart from the conditions mentioned above, a decrease in the rate of the heart's action is observed in association with — 1. A rise of blood pressure. 2. Pain. 3. Diseases of the nervous system. Apoplexy, and tumours of the brain. Lesions of the medulla. Diseases of the spinal cord {tabes dorsalis). Emotion. Hysteria, melancholia, mania (occasionally). 4. Reflex irritation from gastro-intestinal derangement, worms in the intestinal tract, ovarian and uterine disorders, etc. 5. Exhaustion during convalescence from fever or from over- fatigue, sexual excesses, etc. 6. Toxic influences, such as by poisons associated with the acute specific fevers, diphtheria, influenza, etc., or with lithsemia uraemia, jaundice, and so forth. The action of lead, tobacco, digitalis, and the like. 7. Stokes Adams' disease. FUNCTIONAL DISORDERS OF THE HEART 337 Slowing of the heart's action is for the most part effected by direct or reflex stimulation of the central or peripheral connections of the vagi. There is, however, both physiological and clinical evidence to show that a like result may possibly depend, to some extent at least, on direct stimulation of the cardiac muscle. The functions of the cardiac ganglia are not thoroughly under- stood, but so far as is known these structures exert no influence on the regulation of the heart's beat. Theoretically, diminished functional activity of the cardiac accelerating mechanism might be attended by a reduction in the rate of the heart's action, but the physiological and clinical evidence bearing on this point is not sufficiently convincing to admit of a definite statement. Syncope or fainting is the only symptom that will be considered in connection with slowing of the heart's action. This phenomenon, which is within the experience of most people at some period ot their lives, is most commonly observed in association with pain or emotional disturbance. As there are all degrees of syncope between death and so-called fainting attacks, so are there, no doubt, all degrees of infrequent cardiac action between complete arrest and the reduction in rate necessary to produce symptoms of cerebral anaemia, which is the proximate cause of the phenomena. In an ordinary fainting attack, due to reflex stimulation of the vagi by pain, emotion, etc., there is probably a reduction in the rate of the heart's action in association with ventricular contractions of so feeble a kind that they are not preceptible within the limits of a physical examination of the heart. There is an additional factor, frequently a potent one, in the production of fainting attacks of functional origin, viz. vaso-motor disturbance, which, by relaxing the vessels in the cutaneous and splanchnic areas gives rise to a fall of systemic blood pressure. STOKES ADAMS' DISEASE. This remarkable symptom-group or syndrome is characterised by the occurrence of bradycardia in association with symptoms that are referable to disturbances of the cardio-vascular, nervous and respira- tory symptoms. The aetiology and pathology of the Stokes Adams' syndrome is still obscure, but the conditions under which it may be observed are arranged by Osier in three categories, viz. : — 1. Post-febrile group. — In this class the attacks follow, rarely accompany, an acute infection such as enteric fever, scarlet fever pneumonia, diphtheria, influenza, etc. 2. Neurotic group. — In this group the syndrome is associated with a gross lesion of the medulla or some other portion of the central or peripheral nervous apparatus, or with functional disturbance of the nervous system. Z 338 DISEASES OF THE HEART 3. Arteriosclerotic group. — In this variety there are found structural changes in the heart or vascular system, or in both. The large majority of the cases belong to this group, and they are observed among men over the age of fifty. The central feature of the Stokes Adams' syndrome, in its clinical aspect is bradycardia, which may be observed in an acute, chronic, or intermittent form in different cases. The slowing of the heart is associated with vertigo, syncopal attacks, epileptiform seizures, pseudo-apoplexy, and respiratory disorders, which will now be briefly considered. The bradycardia or slowing of the heart beats, as reflected by the pulse, may be real or apparent only, inasmuch as it not infrequently happens that some of the cardiac systoles are abortive, and fail to transmit the pulse wave as far as the radial arteries, or even in some instances as far as the carotid trunks. A temporary arrest of the heart's action, and vaso-motor disturb- ances in the form of pallor, sweating, etc., are sometimes observed. Vertigo is a very constant symptom, and may precede by months or years the full development of the syndrome. Syncope with loss of consciousness is usually a prominent feature of the disease. The attacks of fainting come on suddenly, and seldom last more than a minute or two, and are apt to be associated with convulsive seizures of an epileptic type. The pseudo-apoplectic phenomena resemble the ordinary features of an apoplectic stroke, except that after lasting a few^ minutes, con- sciousness is restored and the patient is able to resume his usual avocations. The respiratory disturbances take the form of asthmatic seizures and Cheyne Stokes' breathing. The diagnosis of Stokes Adams' disease when fully developed presents little or no difficulty, but in its initial or slighter manifesta- tions the sj-ndrome is very easily overlooked. The occurrence of bradycardia in association with vertigo should in all cases suggest a careful examination of the patient in view of the possible existence of the symptom group under consideration. The prognosis is very grave, and in the present state of our knowledge of these cases treat- ment can be symptomatic only. SECTION VIII DIAGNOSIS The diagnosis of functional disorders of the heart rests on the presence, either alone or in combination, of the symptoms and signs which have been described. In practice the chief difficulty lies in the differential diagnosis of the cause of the cardiac disturbance. FUNCTIONAL DISORDERS OF THE HEART 339 more particularly with regard to the exclusion of organic disease of the heart. In purely functional affections of the heart there is an obvious disproportion between the intensity of the subjective symptoms and the degree of mechanical disturbance of the circulation. Moreover, palpitation and arrhythmia of functional origin are sometimes relieved by exertion, which exaggerates these symptoms when found in association with organic disease of the heart. This statement does not of course apply to the palpitation observed in connection with ansemia, but in this condition the cause of the cardiac disturb- ance is usually obvious. Physical examination of the heart in cases of functional disorder rarely demonstrates the presence of any serious degree of cardiac enlargement, though it is not uncommon to find a little dilatation of one or both ventricles. Moreov-er, the character of the sounds in functional cardiac affections is sometimes of service in excluding organic disease of the heart. Again, murmurs heard in association with functional disorders are practically always systohc in time, and they do not replace the sounds of the heart as in the case of bruits due to organic disease of the organ. Furthermore, the site of greatest audibility and the area of distribution of functional and organic apical systolic murmurs do not coincide. Apart from organic disease of the heart, the differential diagnosis of the causes of functional affections of the organ rests on the history of the case, on the character of the symptoms, and on the causal indications furnished by the cardio-vascular and other systems. Tachycardia is distinguished from rapid action of the heart due to other causes by its paroxysmal character. An increase in the rate of the heart's action not uncommonly precedes the development of the proptosis and th}Toid enlargement in Grave's disease, but in this disorder the persistent acceleration of the pulse would suffice to exclude tachycardia. Again, dilatation of the heart, mitral stenosis in its terminal stages, and bulbar paralysis also give rise to increased frequency of the pulse ; but in these conditions both the rate and rhythm of the cardiac action are more or less persistently altered, features which are incon- sistent with tachycardia. A paroxysmal increase in the rate of the heart's action is sometimes observ-ed in connection with the crises of locomotor ataxia. A correct diagnosis seldom presents much difficulty in these cases, inasmuch as the attacks are associated with disturbance of the cardiac rhythm and with the symptoms peculiar to the ner\"ous disorder. 340 DISEASES OF THE HEART PROGNOSIS The prognosis of functional disorders of the heart is, on the whole, favourable as regards the expectancy of life. The prospects of recovery, so far as the cure or prevention of the cardiac disturb- ance is concerned, depends, for the most part, on the extent to which the cause can be removed. In the absence of a discoverable cause, and in view of the difficulty which is so often experienced in excluding organic disease of the cardiac walls, it is advisable, before giving a favourable prognosis in a case of functional disorder of the heart, to make repeated and careful examinations of the patient both in the upright and supine positions. The outlook with respect to that variety of irritable heart known as "soldier's heart" (AUbutt) is not good, inasmuch as the cardiac disturbance leads ultimately to dilatation and hypertrophy of the heart. The prognosis of tachycardia depends largely on the duration of the attacks and the frequency of their incidence (Herringham). Long duration {i.e. more than four or five days) and frequent repetition {i.e. recurrence within a few months) of the paroxysms involve more or less cardiac strain, which sooner or later leads to dilatation of the heart and its disastrous effects. On the other hand, short attacks with protracted periods of immunity are com- patible with longevity. The prognosis of bradycardia is the prognosis of the cause of the cardiac disturbance. TREATMENT The treatment of functional disorders of the heart consists as much in the general management of the patient as in the employ- ment of drugs. It is obvious that in practice treatment should be directed, in the first instance, to the mitigation or relief of the paroxysms, and, secondly, to the prevention or removal of both the immediate and remote causes of the cardiac disturbance. Nevertheless, for descriptive purposes it is convenient to take the second object first, inasmuch as certain general hygienic, dietetic, and moral considerations are applicable in the treatment of all forms of functional disease of the heart, whereas special means are requisite for the relief of the individual symptoms. It is of the utmost importance in all cases of functional cardiac disorder to be able to convince the patient that there is no disease of the heart. While, on the one hand, a careful investigation of the condition of the heart should be made at the outset; on the other, too much attention should not be directed to the organ by subsequent examinations. Moreover, the patient's thoughts FUNCTIONAL DISORDERS OF THE HEART 341 should so far as possible be diverted from his ailment by change of air and scenery, by cheerful companionship, by the pursuit of some wholesome hobby, and by the avoidance of strain and excite- ment of all kinds. A moderate amount of exercise in the open air is nearly always beneficial, and any outdoor pursuit which does not involve excite- ment or fatigue may be safely encouraged. Cold bathing, more especially in the form of shower baths, is frequently of service, but should be used with caution. Sea bathing is sometimes attended by the happiest results. The adoption of an open-air life, and the cultivation of regular habits with respect to the taking of food, alcohol, sleep, and exercise, is often sufficient to effect a cure. Moderation with regard to the quantity of food, and a common - sense discrimination with respect to its quality are of the first importance. It is frequently advisable to altogether interdict the use of tobacco, alcohol, tea, and coffee. Sexual excesses are a prolific source of functional disorders of the heart ; hence it may become necessary to warn the patient against this form of over-indulgence. Inasmuch as functional affections of the heart are so frequently found in association with disturbance of the nervous system, an attempt should be made to remove such causes of mental strain as overwork, worry, anxiety, and so forth. Hysteria and conditions of general nervous irritability or excitement may be met by the use of bromides, valerian, hyoscyamus, and other sedatives. Gastro-intestinal derangements, which are perhaps the most common cause of functional disturbance of the heart, should be corrected by careful dieting, and the exhibition of the remedies appropriate to the relief of the particular kind of dyspepsia that obtains. In children the possible presence of intestinal worms should not be overlooked. The bowels must be regulated, and any source of intestinal irritation, as, for instance, piles, should receive attention. The correction of uterine displacements is some- times followed by the disappearance of the cardiac symptoms. Anaemia, gout or lithsemia, and other disordered conditions of the blood, should receive appropriate treatment. If a careful and systematic investigation of the case fails to reveal the cause of the cardiac disturbance, the drugs most likely to be of service are the bromides, salicylates, or iodides, with or without arsenic, strychnine, or digitalis. The treatment of cardiac pain depends for the most part on its cause. Digestive disorders, uterine derangements, emotional disturbance, and increased arterio-capillary resistance must be con- trolled and removed by appropriate means. The application of a belladonna plaster, or of a small blister, or, if the pain be very severe, of one or two leeches over the painful area, usually gives great relief. Belladonna may also be 342 DISEASES OF THE HEART given internally with advantage. In the absence of a discoverable cause, or when the pain resists other remedies, the administration of one-sixth of a grain of barium chloride in pill form three times a day sometimes gives excellent results. An attack of palpitation can sometimes be relieved by exercise or by the simple expedient of drawing a few deep breaths. In general, the treatment of the paroxysm consists in rest in the recumbent position and in the use of stimulants, such as ether, ammonia, valerian, ginger peppermint, camphor, and the like. The compound spirits of ether, in drachm doses, is an efficient remedy under these circumstances. The following prescription is an example of a very serviceable combination in the treatment of palpi- tation : — ^ Tincturas Valerianae Ammoniatse 5i- Tincturas Lavandulae Compositse 5ss. Spiritus Vini Rectificati Si- Aquae Chloroformi q.s. ad. §ss. Fiat Mistura. S. One tablespoonful to be taken every two or three hours. Alcohol, in some warm vehicle, is also of service, but its administration requires strict supervision. The vagi may also be stimulated through the nasal mucous membrane by means of smelling-salts, snuff, ammonia, etc. Hot or cold applications to the praecordial region usually afford relief, but cold, in the form of an ice-bag, must be employed with caution, more especially if the action of the heart be irregular. In the case of less acute and more protracted attacks of palpitation, the various measures just mentioned must be supplemented by treatment directed to the more remote causes of the cardiac disturbance. With this object the hygienic and dietetic regulations which were detailed at the beginning of this section should be put into operation. The exhibition of nerve sedatives, more especially of the bromide of sodium or ammonium, is usually of service in neurotic cases. Belladonna, given internally, or applied in the form of a plaster to the prsecordial region, is sometimes of service. The use of aconite is strongly recommended by AUbutt, but care must be observed in the employment of this remedy. Digitalis is seldom of much benefit, but the administration of cactus grandiflorus, as a tincture, is not infrequently attended by excellent results. Vaso- motor disturbances in connection with palpitation should be corrected and controlled by appropriate treatment. Tonics are frequently of service in the intervals between the attacks. The treatment of that form of irritable heart which occurs in young people consists in the careful regulation of the habits of the patient as regards the taking of food, exercise, sleep, etc., and the use of such substances as tobacco, tea, coffee, and alcohol. Medicinal treatment is seldom required. Complete rest for a time is sometimes of great benefit in these cases. FUNCTIONAL DISORDERS OF THE HEART 343 The treatment of so-called " soldier's heart " is very unsatisfactory. Absolute rest in bed, and the administration of digitalis and aconite appear to afford the best results. Cardiac asthenia should be treated, according to Da Costa, by rest in bed, followed by graduated shower baths, massage, and Swedish exercises. The diet should be nutritious and liberal as regards quantity. Alcohol is also of service. So far as medicinal treatment is concerned Da Costa strongly advocates the use of strychnine, and, failing this, of arsenic or of the cardiac tonics. Nerve sedatives are occasionally called for. Allbutt suggests that compression of the abdomen by a properly fitted binder or pad might be of use in view of the pathogenesis of this disorder, which he thinks may be a dilatation of the vessels in the splanchnic area. The treatment of arrhythmia does not require special considera- tion, inasmuch as it turns on the application of the general principles already indicated. In all cases treatment should be addressed to the cause of the cardiac disturbance, be this digestive disorder, uterine derangement, or the abuse of tea, alcohol, tobacco, coffee, etc. If the cause cannot be discovered, and provided the patient suffers no inconvenience from the abnormal cardiac action, inter- ference by means of drugs usually does more harm than good, and is therefore to be deprecated. Tachycardia does not offer much scope for treatment, since the conditions on which the attacks depend are not fully understood. The general health of the patient must be promoted by suitable hygienic and dietetic means, and any functional disturbance of other organs which might stand in causal relation to the attacks should so far as possible be remedied. DigitaHs exercises little or no influence on the paroxysms, but strophanthus has occasionally appeared to do good. The bromides are of service in some instances, and they may be given in combination with full doses of belladonna. The salicylates and iodides are also worthy of trial w^hen other measures fail. Treatment by electricity has not fulfilled expectations, but the application of the continuous current over the nerve trunks in the neck has sometimes appeared to mitigate the severity of the attacks. The treatment of bradycardia, when this is necessary, should be directed to the cause of the condition. In the absence of organic disease of the heart, the feeling of faintness which precedes the occurrence of actual syncope and loss of consciousness can usually be relieved by making the patient sit down and bend forwards with the head betw^een the legs. When fainting has occurred the patient should be placed flat on his back, with the head at a lower level than the rest of the body. The clothes round the neck, chest, and abdomen should be loosened, and a current of cold air allowed to play on the skin wath the object of producing contraction of the superficial vessels and of raising blood pressure. 344 DISEASES OF THE HEART Reflex stimulation of the heart and respiration is accomplished by flicking the face and chest with a wet towel and by the applica- tion of ammonia, smelling-salts, and other pungent substances to the nose. If these measures fail to restore consciousness, ammonia, ether, brandy, or strychnine may be injected subcutaneously, or per rectum. When the syncopal attack is due to hemorrhage the patient should be inverted, or the limbs bandaged from the feet upwards, with the object of driving blood towards the heart and brain. Meanwhile, hot applications may be made to the praecordial region. In urgent cases artificial respiration, galvanization of the phrenic nerves, or even transfusion of a saline solution may be required. After consciousness is restored the patient should remain in the recumbent position until all danger of a recurrence of the attack has passed away. INDEX Abscess of heart, 151, 290, 291 Accentuation of aortic second sound, 48, 205, 270 of pulmonic second sound, 49, 175, 187, 272 Aconite in treatment of functional dis- orders of heart, 343 Adherent pericardium, general account of, 129 Etiology, general account of, in cardiac disease, 19 Age, as affecting compensation, 232 prognosis, 232, 280 in aetiology of cardiac disease, 19 Alcohol, 115, 128, 149, 159, 236, 244, 282, 287, 289, 293, 303, 320, 342, AUbutt, 201, 328, 336, 340, 342 Ancemia, 20, 21, 24, 63, 146, 168, 177, 211 as a cause of fatty degeneration of heart, 299 as a cause of mitral incompetence, 168, 278 Anatomy of heart, general account of, i Aneurism of heart, 151, 291, 300, 306 Angina pectoris, general account of, 310 in aortic incompetence, 199 in fatty disease of heart, 301 in fibroid disease of heart, 306 pseudo-, 311 Aortic area, 43 incompetence, general account of, 195 notch, 81 orifice, position of, 4, 7 size of, 4 second sound, 45, 47 accentuation of, 48 stenosis, general account of, 207 Aortitis, 26 Aperients, 236, 283, 286, 298, 303 Apex beat, character of, 36 — — — displacement of, 34, 35 extent of, 35 position of, i, 6, 34 Apoplexy, pulmonary, 163 Arcus senilis, 301 Arrhythmia, 331 Arterial tension, 78 high, causes of, 79 description of, 85 in the production of hyper- trophy, 259 • treatment of, 239 low, causes of, 78 description of, 85 Asthenia, cardiac, 330 Asthma, cardiac, 18, 25, 301, 306 Asystole, 241, 266 Atheroma, 20, 21, 80, 89, 160, 161, 165, 204, 299, 312 Auricle, left, dilatation of, 266 hypertrophy of, 266 impulse of, 36 position of, 6 right, dilatation of, 266 hypertrophy of, 266 — impulse of, 36 position of, 6 Auriculo-ventricular sulcus, 7 Auscultation, general account of, 42 B Bacteria in simple endocarditis, 141 in malignant endocarditis, 151 in myocarditis, 290 Balfour 63, 318 Bamberger, 124 # 345 346 DISEASES OF THE HEART Barie, 221 Barr, 52 Basch, Von, 25 Baths, 285, 341 Bed, rest in, 127, 239, 241, 284, 287, 342 Bouley, 315 Bradycardia, 336 Breath, shortness of, 18, 24 Bristowe, 58, 335 Broadbent, Sir \V., 31, 52, 74, 132, 185, 188, 191, 193, 219, 243, 246, 247, 317 Dr John, 132 Bronchitis, 18, 163, 170, 172 Bruce, Mitchell, 249 Burns, 315 Byrom Bramwell, 140, 182, 212, 218 Cactus grandiflorus, 342 Caffeine, 243, 244, 287 Capillary pulsation, 32, 201 Cardiac asthenia, 330 asthma. 18, 25, 301, 306 cycle, 9 dulness, deep, 6, 40 superficial, 6, 39 impulse, 11 nerves, 12 pain, 17, 327 tonirs, 244 Cardiogram m aortic regurgitation, 98 stenosis, 98 mitral regurgitation, 97 • stenosis, 96 Cardiograph, general account of, 94 Chauveau, 64 Cheadle, 128, 144 Cheyne-Stokes' respiration, 18, 25, 172, 301 Chordee tendineas, rupture of, 142, 151, Circulation in foetus, 103 Climate, 236 Compensation, 169, 198 conditions affecting, 162 failure of, 170, 198 treatment before failure of, 234 after failure of, 238 Congenital affections of heart, general account of, 99 Convallaria majalis, 245, 287 Corrigan's pulse, 88 Cough, 18 Cyanosis, 23, no, 226 Ua Costa, 328, 330, 343 Death, sudden, 131, 136, 173, 198, 200, 209, 268, 298, 301, 306, 317 Degeneration, fatty, of heart, 298 fibroid, of heart, 303 parenchymatous, of heart, 294 Development of heart, 99 of great vessels, 100 Diagnosis, methods of, 16 physical methods of, 22 Diastolic murmurs, 55 back shock, 38 Dicrotic wave, 84 Diet, 236, 281, 288 Digitahs, 1 15, 245-7, 287 Dilatation of heart, general account of, 253 acute, 262 Displacement of heart and apex beat, 35 Diuretics, 242, 286, 288 Dreschfeld, 152 Dropsy, 27, 173, 268 Ductus arteriosus, 102, 104, 106, no Dulness, cardiac, deep, 6, 40 superficial, 6, 39 due to pericardial effusion, 41, 124 Duroziez, 63, 132 Dyspepsia, 18 Dyspnoea, causes of, 24 Eccentric hypertrophy, 249, 258 Effusion into pericardial cavity, 41, 122-4 Emaciation, 28, 185, 268 EmboHsm, 18, 145, 154-6, 185, 251 Endocardial murmurs, 53, 54 Endocarditis, acute, simple, 138 malignant, or infective, 149 chronic, 160 Endocardium, diseases of, 138 Epigastric pulsation, 30 Epileptiform attacks, 338 Epistaxis, 18, 172, 184, 199 Ewart, 38, 123 Exercise, 149, 235, 239, 281, 284, 285, 303, 321, 341 Exocardial murmurs, 68 Face, expression of, 23 Fatty degeneration of heart, 298 infiltration of heart, 296 Fibroid disease of heart, 303 DISEASES OF THE HEART 347 Fingers, clubbing of, 23, no, 174, 226 Flint, 203 Fluctuation, 38 Foetal circulation, 103 Foster, 324 Fox well, 64 Frankel and Saenger, 152 Friction sounds, pericardial, 67, 121 pleural, 68 pleuro-pericardial, 68 : fremitus, 37, 121 Functional diseases of heart, 322 Gairdner, 314 Galabin, 12, 97, 98 ■ Gibson, in Gilbert and Lyon, 151 Great vessels, development of, 102 H H^MATEMESIS, 1 8, 1 72 Hffimic murmurs, 62 Haemopericardium, 135 Hremoptysis, 18, 183, 184 Haemorrhoids, 19, 172 Hamilton, 163 Hayden, 64 Heberden, 310, 315 Head, 39, 327 Heart, abscess of, 151, 290, 291 aneurism of, 15 1, 291, 300, 306 dilatation of, 249 displacements of, 35 fatty degeneration of, 298 infiltration of, 296 fibroid disease of, 303 functional disorders of, 322 hypertrophy of, 249 malformation of, 108 misplacements of, 107 nerves of, 12 new growths in, 307 position of, i regulation of beat of, 14, 325 relation of, to chest wall, 5 .rupture of, 291, 297, 300, 301, 306 shape of, i size and weight of, 2 sounds of, 12, 43 topography of, 5 Heredity, influence of, in causation of cardiac disease, 22 Herringham, 340 History of patient in tetiology of heart disease, 21 Huchard, 311 Hydropericardium, 135 Hypertrophy, general account of, 249 I Ice bag, use of, 127, 148, 342 Impulse of auricles, 36 Impulse, cardiac, 1 1 diastolic, 36 of left ventricle, 34 of right ventricle, 36 Infective endocai'ditis, 149 Insomnia, 19 Inspection, general account of, 22 Interauricular septum, development of, 100 malformation of, 108 Intermittent action of heart, 331 Interventricular septum, development of, 100 malformation of, 108 rupture of, 1 51, 291, 306 sulcus, position of, 8 J Jaundice, 24 Jugular veins, distension of, 32, 175, 215, 219, 273 pulsation in, 32. 175, 215, 219, 273 Johnson, 52 Leeches, 115, 127, 148, 242, 286 Liver, enlargement of, 42, 172, 213, 215, 219, 252 examination of, 42 pulsation of, 38, 215, 220, 273 M Macalister, 4, 10 1 Mackenzie, 220 Maguire, 112, 124 Mahomed, 83 Malformation of heart, 108 of great vessels, 109 Massage, 115, 240, 244 348 DISEASES OF THE HEART Micro-organisms in acute simple endo- carditis, 141 malignant endocarditis, 151, myocarditis, 290 Milk spots, 129 Mitral area, 43 incompetence, general account of, 167 opening, position of, 4, 6 size of, 4 stenosis, general account of, 181 stages of, 193 valve, 4 Morgagni, 23 Morphia, 127, 243, 244, 288, 320 Murmurs, account of, 53 aortic, 59) 202, 210 cardio-pulmonary, 68 ■ character of, 60 diastolic, 55 differential diagnosis of endo- and exocardial, 70 endocardial, 53 exocardial, 53 hsemic, 62 mitral, 56, 175 ■ ■ mode of production of, 54 obstructive, 55 organic, 54 presystolic, 55, 58, 187, 203 ■ pulmonic, 59, 223, 227 regurgitant, 55 rhythm of, 61 • systolic, 55 tricuspid, 60, 215, 219 ■ vascular, 53 venous, 72 Myocardium, diseases of, 248 Myocarditis, acute, general account of, 289 N Nauheim, 240 Nervous supply of heart, 12 New growths in heart, 307 in pericardium, 137 Nitrites. See Vaso-dilators Nutrition, general state of, in cardiac disease, 28 Occupation, influence of, in setiology of cardiac disease, 20 GEdema, 27, 173, 268 CErtel, 285 Orthopnoea, 26 Osier, 150, 3I5>.337 Oxygen, inhalation of, 243, 288, 320 Pain, cardiac, 17, 327 Pallor, 24 Palpation, general account of, 33 Palpitation, general account of, 328 Paracentesis pericardii, 128 Paul, 211 Peacock, 105, 112, 228 Percussion, general account of, 39 Pericardial adhesion, general account of, 129 effusion, 41, 122-4 Pericarditis, acute, general account of, 116 Pericardium, diseases of, 116 shape of, i Petit, 185 Physical examination of heart, 22 Physiognomy, iii, 174, 185, 200, 209, 214, 218, 222, 270, 272, 301, 306 Pneumogastric nerve, 12, 325 Pneumopericardium, 136 Potain, 51 Prfficordium, bulging of, 28 retraction of, 29 Predicrotic wave, 81 Presystolic murmur, 55, 58, 187, 203 Prognosis in acute endocarditis, 147 infective endocarditis, 159 myocarditis, 292 in angina pectoris, 319 in chronic valvular affections, 230 in congenital affections of heart, 113 in dilatation of heart, 278 ■ in fatty degeneration of heart, 302 • infiltration of heart, 297 in fibroid disease of heart, 307 in functional disorders of heart, 340 in hypertrophy of heart, 279 ■ in pericardial adhesion, 134 Pulmonic area, 44 incompetence, general account of, 221 orifice, position of, 4, 7 . size of, 4 • second sound, 45, 47, 49 accentuation of, 49 stenosis, general account of, 225 Pulsation, general account of visible, 29 — of palpable, 34 Pulse, account of, 74 DISEASES OF THE HEART 349 Pulse, collapsing, 88, 201 Corrigan's, 88 • high tension, 78, 79, 85 in aneurism, 92 in aortic incompetence, 88, 201 stenosis, 89, 209 • • in dilatation of heart, 87, 271, 274 in hypertrophy of heart, 87, 269, 273 in mitral incompetence, 91, 174 stenosis, 91, 186 low tension, 78, 85 recurrent, 80 virtual tension, 86, 317 Pulsus alternans, 77, 332 bigeminus, 77, 332 bisferiens, 90, 202 paradoxus, 77, 133, 333 trigeminus, 77, 332 Purgatives, 115, 239, 242, 244, 283, 286 QUAIN, 289, 304 R Reduplication of heart sounds, 51 of first sound, 5 1 of second sound, 52 Relative incompetence of aortic valve, 196 of mitral valve, 168, 176, 278 Rest, 127, 240, 241, 284, 287, 343 Rheumatism, 21 Rhythm of heart sounds, 46 Rokitansky, 100 Rotch, 124, 128 Roy and Adami, 98 Rupture of heart, 291, 300, 301, 306 of valve, 195, 230 Russell, 64 Samways, 192 Sansom, 52, 53, 64, 190 Schott treatment, 240, 285 Semilunar valves, closure of, 36 developmental anomalies of, 109 Sex as affecting prognosis, 232 Sex, influence of, in setiology in cardiac affections, 20 Sibson, 121, 123, 129 Sleeplessness, 19, 120, 199, 243, 279,288 Sounds of heart, general account of, 43 Sphygmogram, general account of, 81 Stimulants, 128, 149, 159, 287, 293, 298, 307, 320, 342 Stoke-Adams' disease, 337 Strophanthus, 244, 245, 282, 287, 343 Sudden death, 131, 136, 173, 198, 200, 209, 268, 298, 300, 306, 317 Sympathetic nerves, 13, 325 Symptomatology in cardiac disease, 16 Syncopal attacks, 199, 209, 300, 301, 306, 318, 336, 337, 338 Syphilis, 21, 139, 195, 304, 308 Systolic murmurs, 55 Tachycardia, 334 Temperature, ill Thompson, 103 Thrills, general account of, 37 Tidal wave, 83 Tracheal tugging, 38 Treatment of acute infective endocar- ditis, 159 Treatment of acute myocarditis, 293 simple endocarditis, 148 of angina pectoris, 319 of chronic valvular disease, 234 of congenital affections of heart, "4 of dilatation of heart, 283 of fatty degeneration of heart, 302 infiltration of heart, 298 of fibroid disease of heart, 307 of functional disorders of heart, 340 of hypertrophy of heart, 281 ■ (Ertel 285 Schott, 240, 285 Tricuspid area, 44 incompetence, general account of, 212 orifice, position of, 4, 6 size of, 4 stenosis, general account of, 217 U Urine in cardiac disease, 19, 28 350 DISEASES OF THE HEART V Vagus nerve, 13, 325 Valvular lesions, acute, 138 chronic, 165 Vascular sounds, general account of, 71 Vaso-dilators, 239, 243, 287, 288, 320, 321 Veins, jugular, distension of, 32, 175, 215, 219, 273 pulsation in, 32, 175, 215, 219, 273 Venesection, 115, 128, 242, 286 ^^enous murmurs, 72 Ventricle, left, dilatation of, 261 first sound of, 45, 47 Ventricle, left hypertrophy of, 258 impulse of, 34 position of, 6 right, dilatation of, 265 first sound of, 45, 47, 49 hypertrophy of, 265 ■ ■ — impulse of, 36 position of, 6 Vomiting, 127, 199, 279 W Water-hammer pulse, 88, 201 Weichselbaum, 152 Wilks, 134 TRINTED AT THE EDINBUKGH PRESS, 9 AXU II YOUNG STREET SELECTIONS FROM HENRY KIMPTON'S CATALOGUE OF STANDARD MEDICAL PUBLICATIONS. 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