Complete Text (Part 1)

UC-NRLF ii SMITH HALLIDIE: Digitized by the Internet Archive in 2007 with funding from Microsoft Corporation” __ http://www.archive.org/details/diseasesofheartt0Owoosrich a ee ee ee me TT ee See Se ee ee ee DISEASES OF THE HEART: ‘THEIR DIAGNOSIS AND TREATMEN’. BY DAVID WOOSTER, M. D. MEMBER OF TH ROYAL ACADEMY OF MEDICINE AND SURGERY oF TURIN, Assigtant Surgeon in tho, Mexlean War,” Surgeon (Major Su the late Civil War, Author of “Diphtheria and Co: ital Asphyxia” 18%0), Founder md’ fore of The Bacific Medical and Me Sengeal Journ" obey os SAN FRANCISCO! H, H. BANCROFT AND COMPANY. 1867. Entered according to Act of Congress, by David Wooster, in the Clerk's Office of the District Court of the United States for the Northern District of the State of California, in the year 1867. PRINTED By THOMPSON & Co., No, 536 Market Street, opposite Second, BAN FRANCISCO. 0 Wrri1am Henry PAatTersoy, Esq, of San Francisco, I dedicate this volume, as a token of admiration and long personal friendship. Davip Wooster. 14 Geary street, San Francisco, ‘September, 1861. PREFACE. In writing the following pages, I have been scrupulously careful not to place my own unsustained assertions in oppo- sition to the results of clinical demonstrations or extreme probabilities. I have also endeavored to give the anatomy, or topography, of the structures under consideration, with as much accuracy as possible. ‘There are no such obstacles now, in the way of writing intelligibly on diagnosis of diseases of the heart, as there were even twenty-five years ago.’ If medicine has not yet become a science, it has, at least, so far advanced as to recognize its own defects, and to be conscious of its absolute knowledge. Physicians now know where their knowledge ends and their theories begin ; and in this they are far in advance of their forefathers. My aim has been to limit myself, as closely as possible, to known facts, and to indulge in no idle speculations, for the purpose of introducing some favorite theory of my own, in order to make myself seem original. I need not tell my in telligent readers that this treatise is merely an abstract ; but it is hoped that they will find it what the author designed it to be, a careful and conscientious epitome of the knowledge now possessed by the profession on the subject of which it treats. My only claim to their commendation will consist in having placed.the knowledge already possessed in a more accessible form, of having made the facts we daily need to use more tangible, by stripping them of some of their garni ture, and grouping them in closer and more obvious relations to each other. ii PREFACE. Ihave endeavored to condense the statement of facts into a much smaller compass than they appear in the standard authors, without omitting anything necessary to a clear un- derstanding of the subject treated. In the process of con- densation, I have frequently used several successive words, just as they occurred in the authority consulted, and perhaps occasionally a full sentence, without quotation marks. But, while I make no pretence to having written a work original in material, I have endeavored to avoid the crime of plagi- arism. +I have ventured to make some suggestions in diagnosis, not of a radical kind, but merely as to applicability and im- port of certain signs, and also to indicate additional treatment in some forms of heart disease to that which authors generally recommend; but, as I have at the same time pointed out wherein I have ventured to differ with the mas- ters, the reader will not be beguiled into mistaking my treatment for that of authors whom he may with just reason hold in higher estimation. I have insisted with some perti- nacity on the reflex treatment of unsoundness of the heart, but for my opinions on the value of this kind of treatment, Tam indebted to Radcliffe, Brown-Soquard, and others who have investigated the more recondite departments of human physiology. I have had much less to say of treatment than of diagnosis, because in reality much less is known of the former than of the latter. We are yet entirely ignorant of the manner in which, or of the prime cause why the heart becomes unsound by the deposition of analogous tissues, in most cases, and until we have acquired this knowledge, we cannot do much more than treat certain symptoms, which are common to cither acute or chronic inflammations. But thanks to our almost exact knowledge of the beginning and process of acute inflammations, derived from a multitude of clinical PREFACE. iii cases, carefully observed in all countries, by eminent and conscientious physicians, we are now able to treat symptoms with a degree of rationality which will accomplish a purpose predetermined on the part of the physician, and which will generally result in success in curable cases, and in the alleviation of the most hopeless. Cases of heart disease are of alarming frequency in Cali- fornia, yet, in the absence of statistics, it would be improper to say categorically that this affection is excessively frequent here ; still I feel convinced that it is, and were its etiology within the scope of this treatise, I think it could be satisfac- torily shown why disease of the heart is more likely to be prevalent in newer than in older civilizations, and in this climate than in many others ; and under the special, moral, mental and hygienic influences which characterize us, than under those which predominate in other centres of popula- tion. For example: the physical aspect of the country and metropolis—mountainous and hilly—reverse of fortune and the vital depression consequent upon it; family ties rudely sundered, and the despair resulting ; the insatiable thirst for riches, and the unusnal energy employed in acquiring them, to the deprivation of mind and body of essential rest ; the exposure, night and day, to which our mining popula- tion is subject ; the tunnel and deep drift work of the quartz miner; the excessive intemperance in drink—the thousand disappointments, and misfortunes, and endless unrest to which a population anxidus to become rapidly rich, like ours, must ever suffer, are so many teasons why the heart should be- come diseased and exhausted under the great labor of pro- viding for such extravagant use of all the functions of life. It is on account of my opportunities for observation during the seventeon years I have been practising medicine in Cali- fornia, and the hope that I might add some little to the facility of diagnosis, and the success in the treatment of iv PREFACE. affections of the heart, and that I might materially diminish the labor of finding the knowledge that has already been published, that I determined to make this slight addition to medical literature, ‘This small work has been prepared during the intervals of daily toil, and hence it Incks that unity of design and unin- terrupted sequence of subjects and sentences which are desira- ble in a strictly systematic treatise; but inasmuch as it does not aspire to that category, I trust it will be con- sidered with some indulgence in this respect. Those who desire a complete, systematic and exhaustive treatise, written with the most logical clearness, will find that of Walshe on “ Diseases of the Heart” unsurpassed in any language. I have freely consulted Walshe, Hope, Latham, Stokes, Bennett, Markham, Skoda, Rokitansky, Radcliffe, Brown- Sequard, See, Virchow, Claude Bernard, Flint, Piorry, and numerous other authors ; also, current medical literature of standard authority. Tam under many obligations to my friend Dr. J. N. Brown, of San Jos, one of the most learned and successful physi- cians in California, for valuable suggestions and criticisms during the compilation of this epitome. I am conscious of many imperfections in it, both in diction and manner of arrangement. With many misgivings, I offer it to the pro- fession, asking for it merely the indulgence which a con scientious author has a reasonable right to expect of a conscientious reader. DAVID WOOSTER. San Francisco, September, 1867. CONTENTS. DEDICATION. PAGE. PREFACE. CoNTENTS. Cmarrer I. Introduction, Causes of Discrepancies of Opinion in Cases where Exactness is possible. ........ 5 Carer IL. Anatomical and Physiological Facts concerning the Location of Valves, and Origin of Heart’s Sounds. 10 Carter III. Diagnostic Signs of Endocarditis Pericarditis, and Insufficiency of the Mitral Valve. Cases and Treatment, 19 Carrer IV. Disease of the Semilunar Valves of the Aorta, Direct and Regurgitant Murmurs—Differential Diagnosis of. Treatment of Disease of the Aortic Valves, and its Complications. ........2.s0000e0eee 48 Carrer V. Valves of the Pulmonary Artery. Constriction of the Mitral Orifice. Constriction of the Right Auriculo- Ventricular Orifice........s0eeseeeeeeseees . 86 Carrer VI. Inorganic Murmurs—How Distinguishable from Or- ganic. Dinstolic Inorganic Murmur............ 96 Cuaprer VIT. Pericarditis and Endocarditis. Endo-pericarditis. Car- ii CONTENTS. Cuapter VII. PAGE. Hypertrophy. Dilatation... CHaprer IX. Fatty Metamorphosis or Degeneration, or Fatty Sub- stitution of the Heart. Rupture of the Heart. . wecicneee cone ABO Thoracic Aneurisms: Diagnosis and ‘Treatment. Cyanosis and Atelectasis. Appreciation of the true cause of Cyanosis......00.60e000 sesenee 172 Cuarren XI. General Rules for Diagnosis and ‘Treatment of Dis- eases,of the Heart Cuaprer XI. General Reflections as to Prognosis in Organic Dis- eases of the Heart. AprenpIx A.—First Sound of the Heart 6 B—Intermittent Pulse. “ — G—Causes of Drops “ D.—Mode of Death in Mitral Disease. Cause of Pain. “-E.—Pericardial Effasion. “ B—Absence of First Sound in Softening and Pericardial Effusion. ..... “ @—Saline Evacuants. .. . “ H—Embolism, how developed. Cause of Coagulation of the Blood . “ [Tables of the Thickness of Ventricles. Order of Valvular Diseases ....... 209 187 ~ 201 206 206 ERRATA. DIAGRAM, exhibiting the relationship of the heart and great vessels to the lungs, (in moderate inspira- tion,) and to the regions of the chest - 210 INDEX. CHAPTER I. Ixtropvctioy. Causes oF DiscREPANCIES OF OPINION ay CASES WHERE EXACTNESS Is PossipLE. 1. Many works have been written on diseases of the heart, and its affections have been de- scribed and treatment recommended in all stand- ard works on the practice of medicine; but it has occurred to me that the matter might be much condensed, without detriment to scien- tific exactness and with great benefit to actual sufferers. 2. Physicians well know in their own minds that a very small proportion of the practitioners of medicine are able to diagnose an affection of the heart with even tolerable exactness ; not only are they unable to say what valve is affec- ted, but they do not distinguish the side of the heart ; still worse, many who listen cannot dis- tinguish normal from abnormal sounds, the beat of a healthy from the throb of a diseased heart. This inability of discriminating sounds, with some is a natural defect, a physiological defi- 6 DISEASES OF THE HEART: ciency in the ability to compare small discrep- ancies. But the inability generally is less seri- ous ; it isa lack of the acquirement and recol- “lection of facts which may be acquired and re- membered by most persons of intelligence. These facts can be acquired only by diligent study, and numerous examples, carefully and rigidly observed. For example: a person who has acquired the elements of Latin, when he attempts to trarislate a sentence of Latin into English, if he is really acquainted with the structure of the original, is altogether sure when he has rendered its true meaning. If he hhave less or more than the true meaning, he will be conscious of the deficiency or redundancy; or if different from the true he will know wherein the difference consists. But one who Jacks this knowledge of the principles of the original language, will never be quite sure of his translation ; there will always remain some doubt in his own mind about the exactness of his rendering. No-amount of labor, without a knowledge of the fundamental facts, will be of any avail. So he who practices physical diag- nosis, must first of all, be well grounded in the ineaning of natural sounds and signs, and in THEIR DIAGNOSIS AND TREATMENT. 7 their topography on and in the body. Of what use is it to recognize crepitus if we do not know what crepitus indicates. Of what use to recog- nize murmurs if we know not from whence they proceed, their cause and significance? Two physicians, with diplomas from respectable med- ical colleges, will examine a chest the same day. One will say there are softened tubercles in a lobe of the right lung, but that the left lung is natural; the other will say the right lung is not affected at all, but he finds one or more cavities in the left lung. Now, if the patient goes on to other physcians, perhaps the next will tell him he has a bronchitis or a catarrh ; the third will tell him his “lungs are more than half gone,” while a fourth will tell him categor- ically, his lungs are perfectly sound, but that he has disease of the heart. All physicians recognize this gamut of opin- ions on the same case, examined the same week. Whence do such discrepancies arise? They do not always arise from inability on the part of the examiner, less frequently from lack of frank- ness. Yet the result is the same on the mind of the patient and his friends and of the com- munity, as if the disagreement in opinion were 8 DISEASES OF THE HEART: the result of ignorance, In some cases, doubt- less in most, when the discrepancy is so irrecon+ cilable, the doctors have examined superficially, and the ear of each has been placed over a dif- ferent portion of lung, and the examination has not been minute and exhaustive. One listened, perhaps, at a lower lobe, the other at an upper, one placed his ear just below a clavicle, the other placed his just behind a scapula; one listened carefull on one and carelessly on the other side, while the other observed closely both sides of the chest; and finally one knew not the meaning of the sounds elicited, or heard with the ear, while the other appreciated their precise significance. But until professional opinions shall more nearly harmonize on matters of simple fact in physical diagnosis, the people. will not have implicit confidence in the opinion of any one of us, however excellent. If a patient with aortic insufficiency, or tuber- cular cavity under the right clavicle, should be examined by twenty physicians in succession, and the whole twenty should verify the insuffi- ciency in the same place, or the cavity in’ the same portion of lung, and if similar harmony THEIR DIAGNOSIS AND TREATMENT. 9 of opinion on matters within the reach of exact diagnosis, should prevail even with twenty phy- sicians in one large city, where there are five hundred doctors, as there are in San Francisco, I say, if twenty would agree. on ascertainable facts, the profession would very soon possess the entire confidence of the people. The fault is in our own carelessness or inability ; and whether we are careless or ignorant, the result ist much the same. 4. I purpose in the following pages to give a brief summary of what is known about diag- nosis and treatment of diseases of the heart, and to show how simple it is for all educated physi- cians to say positively what portion of the heart is affected in most cases, and to show in the few cases in-which positive diagnosis is unattainable that an extremely probable diagnosis may be given, sufficiently exact at least to form the basis of rational treatment. 10 DISEASES OF THE HEART? OHAPTER I. ANATOMICAT, AND PrystonoGicat, Facts CONCERNING Location or VALVES, AND ORIGIN oF Hxant’s SouNDS. 1. No two hearts are the same size. No two persons’ hearts beat precisely alike, or so nearly alike, but that a practiced ear would distinguish the difference in the dark. Yet the healthy beat of the heart is so different from the un- healthy, that the practiced listener would be able to say without seeing the patient’s face, whether the heart was healthy or affected. 2. The heart has a more or less conical form, and is suspended obliquely in the chest; its base corresponds with the median line of the breast bone, but is directed upwards and backwards towards the backbone, while its apex is directed downwards and forwards and to the left, so that when the heart contracts the apex is felt and seen to strike the chest between the fifth and sixth ribs, below and a little to the right of the left nipple, when the person stands erect. If he lean forward the beat strikes not only the fifth intercostal space, but the fifth rib and a little farther towards the breastbone. If he lie down THEIR DIAGNOSIS AND TREATMENT. i on his back, the apex beat is imperceptible any- where. If he turn on his left side he renders it more perceptible than in the erect position, but in a larger space more towards the nipple than the sternum. And, finally, if he turn on his right side, the heart’s impulse against the chest is scarcely, or not at all perceptible. These are obvious facts, but well worth re- membering. 8. Aside from all nice distinctions, the ear recognizes ¢wo natural sounds of the heart. These are known as the /irst and second sounds of the heart. 4. The first sound is heard most distinctly over the anterior surface of the heart, on the fifth costal cartilage, left side, at a point midway between its junction with the sternum and its junction with the rib. “Tt is long, dull, and smothered in tone, and occupies one-half the duration of a single beat.” It corresponds in time with the mpage: ¢ of the heart in the precordial region. 5. The precordial region is certainly