Complete Text (Part 1)

72> 4 CSUs 4 Po Columbia Cniversitn * inthe City of a ark Reference Library Given by Ves Rein, oS rerio’ DIAGNOSIS AND TREATMENT OF HEART DISEASE THE DIAGNOSIS AND TREATMENT OF HEART DISEASE PRACTICAL POINTS FOR STUDENTS AND PRACTITIONERS BY E. M. BROCKBANK M.D, (Vict.), F.R.C.P. HON. PHYSICIAN, ROVAL INFIRMARY, MANCHESTER CLINICAL LECTURER ON DISEASES OF THE HEART, DEAN OF CLINICAL INSTRUCTION, . UNIVERSITY OF MANCHESTER SECOND EDITION WITH ILLUSTRATIONS PAUL B. HOEBER 67-69 EAST FIFTY-NINTH STREET NEW YORK 1916 [Printed in England] PREFACE TO SECOND EDITION Tue demand for a second edition of this small work has enabled me to alter and add to it considerably. I hope it will prove even more useful now to students and practitioners than it did in its original form. It could have been improved further had not National affairs distracted attention from teaching matters. E. M. B. PREFACE TO FIRST EDITION (Enrirnep ‘Heart Sounps anp Murmurs, THEIR Causation anD DIFFERENTIATION.”’) In this small work I have attempted to put simply, clearly and in convenient pocket-book form for clinical reference the elements of cardiac auscultation for the use of students. I have repeated myself a good deal with the object of making an argument or explanation as complete as possible in the one place and thereby of avoiding turning backwards and forwards. E. M. B. Mancuester, 1911. SECTION I. IL. Ill. IV. Vv. PRiLIMINARY CONSIDERATIONS - * RoutINE EXAMINATION - = - THE Heart Murmurs - - CONTENTS Anatomy and Physiology. What patients complain of—The arterial pulse: how to feel it: varieties: tension: wall of artery—Venous pulse—Inspection of patient: general : the neck: the pracordia—Palpation : cardiac impulse and apex-beat—Percussion : routine method : cardiac dulness—Auscultation. Heart Sounps” - + = The first sound and its variations—The second sound and its variations—Rhythm of sounds: tic-tac rhythm: cantering rhythm, bruit de galop. Timing — Changes in the valves which lead to murmurs: obstruction: incompetence — Physical causes : fluid veins: vibration of cur- tains: blood changes, hemic murmurs—Changes in the different valves which cause murmurs: auriculo-ventricular valves, stenosis, dilatation, ulceration: semilunar valves—Crescendo mur- mnur—Murmurs with heart sounds— Absence of heart sounds with normal valves—Influence of mobility of curtains on sounds, AREAS OF AUDIBILITY OF HEART Murmurs - Situation of valves—Influence of change of position on murmurs. VI. ConpucTIon AND TRANSMISSION OF MuRMURS Conduction—Transmission. vii PAGE 6 48 65 68 viii CONTENTS secTION PAGE VII. SpectAL CHARACTERISTICS OF THE DIFFERENT VALVULAR MURMURS - - s 8 Mitral murmurs—Rheumatism in childhood : nodules—Crescendo murmur—Tricuspid mur- murs—Aortic murmurs—Posture murmur— Pulmonary murmurs. VILL. Hamic Murmurs - - - - 89 Cardiac—Vascular : bruit de diable. IX. Exocarpiat Sounps” - - - - 91 Pericardial—Cardio-respiratory. X. Sepric ENDOCARDITIS, PERICARDITIS, ANGINA PECTORIS - = < 3 - 98 Septic, malignant, or ulcerative endocarditis— Pericarditis, simple, serous, purulent—Adherent pericardium—Angina pectoris. XI. Carpiac IRREGULARITY RESULTING FROM Dis- TURBANCES OF STIMULATION - - 98 Electrocardiogram — Tachycardia: apprehen- sive heart: paroxysmal tachycardia — Slow pulse: bradycardia —Heart-block—lIrregular or intermittent pulse: premature systole, extra- systole—Sinus arrhythmia—Auricular fibrilla- tion—Auricular flutter. XIL. Treatment or Carpiac DiszAse - - 107 Before muscle failure: general: diet: exercise: drugs—Cardiac muscle failure: rest in bed: diet : sleep: drugs—Drugs acting on the heart muscle: digitalis : strophanthus: caffein : strychnine — Vessel dilators — Treatment of special forms of heart disease: mitral valve: aortic valve: alcoholic heart failure: angina pectoris. INDEX - - - - - - 118 PRACTICAL POINTS IN THE DIAGNOSIS AND TREATMENT OF HEART DISEASE I PRELIMINARY CONSIDERATIONS Anatomy aNpD Paysronocy. Anatomy.—The heart is a conical-shaped organ with the great y s attached to its base; it is about the size of its owner’s clenched fist, and lies obliquely in the thorax, inclined from above downwards, forwards, and to the left, with one-third (the base) to the right and two-thirds to the left of the mid-sternal line. The anterior aspect of the heart is formed almost entirely by the right ventricle, right auricle, and infun- dibulum or conus arteriosus; only a small part of it, namely, the apex and about half an inch along its left margin, is formed by the left ventricle. The tip of the left auricle just comes to the surface behind the second interspace. It is covered by lung all over except in the mid-sternal line, and a triangular space formed by the mid-sternal line, a line from the fourth chondro- sternal articulation to the junction of the fifth costal cartilage with its rib, and the line of liver dulness, the so- called area of superficial cardiac dulness (see p. 26). 2 HEART DISEASE Surface anatomy.—The upper limit is behind the second costal cartilage. Its right side extends half an inch beyond the right edge of sternum. Its apex or its limit to the left is in the fifth intercostal space two and a half inches beyond the left edge of the sternum; in adult males this is about one inch below and three-quarters of an inch to the sternal side of the nipple. Its lower limit is about the sixth rib, where the heart lies in con- A,, Aorta; A.V, aortic valve; M., mitral valve; P.4., pulmonary artery ; P.V., pul- vightaw . ¥., septum ventriculorum ; S, ¥.C,, superior ‘V., tricuspid velve, (Cunningham) tact with the diaphragm. In children the heart may be rather higher and its apex farther out in the chest. N.B.—The nipple in men, normally situated about 4 inches from the mid-sternal line, may be nearer than this to the sternum if the chest is not well developed. An apex-beat outside the vertical nipple line, therefore, need not necessarily indicate disease. In children the ANATOMY 3 apex-beat may be farther out and up in relation to the nipple than it is in man. The nipple in women is use- less as a point which has definite position. The surface lines or landmarks which are of use in the examination and note-taking of thoracic affections are: The mid- sternal line down the middle of the sternum, The lateral sternal lines down the right and left edges of the sternuin. The parasternal lines midway between the lateral sternal lines and The mid-clavicular lines, which are lines drawn per- pendicularly from the middle of the collar-bones or midway between the middle of the suprasternal notch and the top of the acromion. The nipple line in the normal adult male is practically the same as the mid-clavicular line, the nipple being situated about four inches from the mid-sternal line. The awillary lines, anterior, mid, and posterior, running perpendicularly downwards through the anterior, mid, and posterior regions of the axilla. The scapular lines, through the angles of the scapule. Nervous mechanism of the heart-beat.—The stimu- lation of the heart for its beating is carried on by means of a special form of tissue, partly nervous and partly heart muscle in structure, which occurs in aggre- gations or nodes, and connecting or end fibres. (1) The sino-auricular node is in the subepicardial tissue at the junction of the superior vena cava and the tight auricular appendix. This node is the most highly developed aggregation of the neure-muscular tissue, and it initiates the stimulus and sets the pace and rhythm of 4 HEART DISEASE the heart. It is believed to receive fibres from the vagus and sympathetic nerves. From it the stimulus passes, in some way not fully understood, through S.A. node AV. node AV. bundle Fic, 2.—Tur Carpiac Nervous MEcuanism. S.A, node, Sino-auricular node; A.V. node, auriculo-ventricular node (Tawara) A.V. buadle, auriculo-ventricular bundle. The connection between the S.A. node and the A.V. node is indefinite. It may be through the contracting auricular muscle, (2) The auricular walls to the awriculo-ventricular node, which lies in the right side of the auricular septum. From this a.v. node the stimulus is carried by (8) The auriculo-centricular bundle (a.v. bundle) to the ventricles. ‘This bundle divides in the interventricular NERVOUS MECHANISM oO septum into two branches, which ultimately spread out in the subendocardial tissue of right and left ventricles as Purkinje’s fibres. The papillary muscles are said to be the first part of the ventricles to receive the stimulus to contract. It is not known how the stimulus from the sino-auri- cular node traverses the auricles. It is probably carried by the muscle fibres, regular and complete contraction of which is essential for the regular contraction of the ventricles. At any rate, irregular and incomplete con- traction of the auricles results in irregular contraction of the ventricles. In a marked condition of auricular disease, in which the wall is dilated, and in which the muscle is in a state of over-excitability and is making constant incomplete attempts to contract (see Auricular fibrillation and Flutter), there is an extreme degree of irregularity in the ventricular rhythm. Whilst the stimulus for the heart beat arises normally in the sino auricular node, and is rhythmic or regular in origin, in abnormal conditions, functional or organic, it may arise in other parts of the nervous mechanism, or be arrhythmic or irregular in origin. Thus it not un- commonly starts in the auricle or ventricle causing the condition known as premature systole (q.v.), or pre- mature stimuli may leave the sino-auricular node with the same result. If the nervous tissue of the heart be changed struc- turally by disease, or become unduly irritable, irregu- larity in the action of the heart results, giving rise to conditions (q.v.) known as premature systole, heart-block, auricular fibrillation, and paroxysmal tachycardia. II ROUTINE EXAMINATION Wuar Patients with Harr Diseask COMPLAIN OF. Patients suffering from the worst forms of heart disease may feel perfectly well, and have no complaint of any sort. Their cardiac weakness may only be discovered during the course of an examination for life insurance, or for some illness not connected with the heart. As a rule, however, they do complain of one or more subjective symptoms, chiefly shortness of breath, palpitation, and pain. 1, Shortness of breath, especially after only slight exertion, as on going up a flight of household stairs or up a short hill, In more severe conditions the patient may be awakened from his sleep with a sensation of breathlessness and tumultuous action of the heart—a very distressing condition. 2. Palpitation, or unusual action of the heart, which attracts its subject’s attention. ‘The quick action with a “throbbing” sensation in the neck resulting from emotional or muscular overaction is commonly met witb, and generally described as palpitation. It may be met with in normal as well as diseased hearts. A “ flutter- ing” or “tumbling ” sensation is often felt. This, how- 6 ROUTINE EXAMINATION 7 ever, in its slighter forms may be present when the heart is quite sound, and be due to functional disturbance of the regular stimulation of the heart. In disease, when the heart is enlarged and its action forcible, this symptom is often most distressing, especially when it wakens the patient up out of his sleep with a smothering feeling. 3. Pain (1) over the precordia, made worse by exer- tion or increased quickness of beat, is met with chiefly in cardiac enlargement due to valvular disease or adherent pericardium. There is much tenderness to the touch in these cases. Or (2) shooting down the arms, especially the left arm, or in the shoulder or up the neck, in aneurysm or angina pectoris. There is often also a sense of suffoca- tion or of gripping of the heart, with apprehension of impending death, in anginal cases while the pain is present. N.B.—Pain in the wpper arms, especially in the left arm, or wp the back of the neck, may be the first indication of aneurysm of the arch of the aorta. The Cause of the Cardiac Pain.—The pain is one form of referred pain. The heart, developmentally, is asso- ciated with the first eight dorsal segments and nerves, and painful impressions arising in it are usually referred to the first and second dorsal nerves. The cutaneous distribution of these nerves is the inner aspect of the arm as far down as the elbow, and anginal pains which arise from disease at the base of the ventricles, or first part of the arch of the aorta, are referred to ene shoulder and down the arm. Hemorrhage front mucous surfaces may be com- plained of by patients with mitral disease, especially 8 HEART DISEASE mitral stenosis. Epistaxis, hemoptysis, hamatemesis, and bleeding from the ears, have been present in cases under my care. he heart must therefore always be carefully examined in all cases of mucous membrane hemorrhages. Dropsy.—In heart disease dropsy affects the legs in the first place, and is improved by rest in bed. In looking for cedema pressure should be applied deliber- ately, for about five seconds, over the face of the tibia near the ankle, and also over the sacrum. Slight degree: ees of it Eallsbe overlooked unless this care be taken. Cough from congestion of the pulmonary mucous membrane is a frequent consequence of disease of the mitral or tricuspid valves. Tue Arrertan Purse. N.B.—The pulse should be examined at the com- mencement of the investigation of any heart affection. Much valuable information can be obtained in heart affections by an intelligent feeling of the radial pulse with the fingers. The sphygmograph is an interesting instrument, and gives instructive information when you know the kind of tracing you ought to get and the proper way to get it. But even to one experienced in its use it gives but little information which escapes the practised fingers. The best way to feel the radial pulse is to use two hands for the purpose. One hand is to steady the patient’s wrist, by holding his hand so as to allow the delicate application of three fingers of the other hand to the artery, as it runs over the end of the radius. The thumb, to further steady matters, should be placed behind the patient’s wrist. All three fingers should be THE PULSE 9 placed closely together over the end of the radius, so that the artery can be pressed against it, and not against the less res oe soft tissues. ‘The index finger should be applied fir mly as close to the base of the metacarpal hone of the thumb as possible to obliterate the junction of the radial artery with the palmar arch, and prevent any wave coming round that way. The ring finger is used to tell when the-pulse in the artery is beating or not, and the fourth finger to apply pressure over the artery and estimate the amount of force necessary to obliterate the pulse in the radial artery. In this way changes in the tension of the bloodvessel can be very accurately estimated with a little practice and knowledge of the normal condition of affairs. Another useful way of feeling the pulse is to grip the lower end of the radius between the forefinger and thumb of one hand, with the finger applied firmly over the artery close up to the base of the metacarpal bone of the thumb to cut off the palmar arch anastomosis pulse, and then to apply the first and second fingers of the other hand to the radial artery as before. In either method all three fingers must occupy as little space as possible, so that they can manipulate the artery as it runs in front over the end of the bone. It is sometimes instructive to feel the pulse by gripping the wrist with the hand in such a way that the palm of the observer will lie over both radial and ulnar arteries and feel their pulsation, at the same time elevating the patient’s forearm so that there is a considerable stretch of perpendicular artery. In this way the water-hammer or Corrigan’s pulse is best developed, both arteries slap- ping their pulse wave against the palm of the hand, and its simulation by a low tension pulse of cardiac dilata- tion reduced to a minimum, 10 HEART DISEASE No apology need be made for giving such details of good methods of feeling the pulse, for by their adoption an accurate estimate of changes in the pulse tension may be more easily made, and variations from the normal in other ways more easily recognized than if less deliberate methods be adopted. Congenital abnormalities in the anatomy of the radial arteries may occur, and must be allowed for. Thus the radial artery may be of smaller size than normal in one or both wrists, and make pulse-feeling rather difficult. Comparison of the two radial arteries.— Inequality in the pulse wave of the two radial arteries may occur, and be due to— 1. Congenital causes. 2. Pressure on the artery somewhere on the proximal side of the wrist (with a thoracic aneurysm or new growth). : 3. Changes in the wall of the artery (atheroma). 4. Obstruction in the lumen of the vessel (embolism or thrombosis). The points to be noticed in feeling the radial pulse are, the rate, volume, regularity, tension, condition of the vessel wall, aud the comparison between the two radial pulses. Pulse-rate.—In counting a pulse-rate, it is to be remembered that the result does not always indicate the rate the heart is beating at. It generally does, but in one form of heart disease—namely, auricular fibrillation—in which the rhythm and force of the ventricular systole is extremely irregular and uneven, THE PULSE ll many of the ventricular beats, which are considerably increased in number, are so feeble that they do not transmit a pulse wave to the radial artery. Therefore, when the radial pulse is irregular in rhythm and size of wave, and increased in frequency above the normal, the stethoscope should be applied to the heart whilst the pulse is being counted. A quick pulse in heart disease practically always means either 1. Some debility of the heart muscle—that is, inability to do the extra work thrown on it by the abnormal condition by its usual number of beats. It often