CHAPTER IX. DISEASES OF THE VASCULAR SYSTEM. (Part 1)

CHAPTER IX. DISEASES OF THE VASCULAR SYSTEM. Pericarditis. Remember that many of the idiopathic varieties are tubercular in origin, and that rheumatism is the most frequent cause of the secondary variety. Remember that the acute fibrinous stage may or may not be followed by an effusion into the peri- cardium. Remember that in the early, or fibrinous, stage auscultation furnishes the only conclusive evidence, and that the friction sound thus heard possesses the following characteristics : 1. It is double, and corresponds to the systole and diastole of the heart. 2. It is a to-and-fro murmur, and outlasts the first and second sounds of the heart. 3. The sound has a peculiar rubbing or grating quality, or it may be comiDared to creaking of new leather. 4. It is best heard over the right ventricle — the fourth and fifth interspace, at the left sternal mar- gin— and appears to be superficial or close to the stethoscope. 5. Variability. It may be heard at one time and not at another. 6. The murmur may be intensified by pressure upon the stethoscope. 127 128 DISEASES OF THE VASCULAE SYSTEM. 7. There are no definite lines of transmission, as in endocardial murmurs, and is usually heard over a limited area at the border of the sternum. Remember that when effusion occurs, the friction sound disappears over the body of the heart, but may be heard at the base. There is an accentuation of the second pulmonic sound, while the first is ob- scure. The cardiac action is rapid and frequently arhythmic. Remember that in well-developed cases of effu- sion the symptoms may be grouped as constitu- tional and local. Constitutional Signs. Fever, restlessness, dysp- nea, anorexia, pallor, insomnia, melancholia, with suicidal tendencies. Pain varies from sharp, lancinating to dull, ach- ing, and is made worse by pressure over the area with the stethoscope. The dyspnea varies with the amount of effusion — from breathlessness, when the patient prefers to lie on the left side ; to air hunger and extreme dyspnea, when he is obliged to be propped up in bed. The pulse is rapid, small, and may be arhythmic. It may be obliterated during inspiration in large ef- fusion— pulsus paridoxicus. It may be smaller in the left than right radial artery. Physical Signs. Inspection shows precordial prominence, and widening and bulging of the lower intercostal spaces. Palpation shows feeble cardiac impulse. PERICARDITIS. 129 First rib sign is found where there is a large amount of effusion. It produces an elevation of the clavicle, with a bulging of the left retro clavicular space, so that the first rib can be easily palpated to the sternum. Percussion yields the most important sign, but a certain amount of effusion is necessary before it can be detected. Botch's Sign. With a normal or dilated heart the vertical border of the heart forms a right angle with the upper transverse hepatic dullness. When elfusion occurs, this angle is replaced by a more or less curved line. Triangle Sign. When effusion takes place into the pericardium, it collects in the most dependent j)ortion of the sac, and as it increases it widens the area of dullness. This forms a triangle, with the base downward and apex up in the precordial region. The right leg of the triangular dullness may reach to or beyond the right border of the sternum, while the left leg may extend to the left anterior axillary line. It is important to remember that cardiac dullness, particularly the left leg of the triangle, extends be- yond the apex beat, which is also pulled downward and to the left. Remember that the pressure of the effusion pro- duces symptoms in other organs, but the most im- portant ones are dysphagia, paralysis of the vocal cords, vomiting, and singultus. 130 DISEASES OF THE VASCULAR SYSTEM. Remember that, in differentiating between cardiac effusion and cardiac dilatation, an undulatory im- pulse seen or felt in two or more interspaces; dis- tinct, though feeble, heart sounds, valvular in char- acter, but having the fetal rhythm; and changes in the upper border of dullness by postural changes, are strongly suggestive of effusion. Remember that in left-sided pleural effusion the heart is displaced to the right, the cardiac impulse and valvular sounds are distinct, and the area of flatness extends around the base of the chest. Treatment. Remember that rest in bed is imperative, so that the work of the heart may be lessened. Diet should be liquid and principally milk. If the case extends over a period of two weeks, it is better then to add to the diet, so that the nutrition of the cardiac muscle will be maintained. Medicinal. If the pericarditis is of rheumatic origin, sodium salicylate is indicated. It should be given with potassium bicarbonate. Ice bag should be applied over the cardiac region to quiet the heart. Morphin, given hypodermatically, is often beneficial to relieve dyspnea. Tincture of aconite ttl iij-trt v m.ay be given for the same purpose. Amorphous aconitin gr. %3o, given every half to one hour to effect, is much better. Digitalis is the best aid in this as in other cardiac affections. It may be given combined as follows : PERICARDITIS. 131 I^. Potassii acetatis 3 ij Spiritus setheris nitrosi 3 ij Tincturse digitalis 5 j Aquae mentlise piperitae ... q. s. ad § ij Misce. Sig. : Teaspoonful every four hours. Or: R Potassii citratis 5 ij Infusi digitalis ( fresh leaves ) . . . . 3 ij Aquae menthse piperitae .... q. s. ad § vj Misce. Sig.: Tablespoonful every four hours. Or: R Tineturae digitalis, Tincturse scillse aa 3 ij Misce. Sig. : 20 to 30 drops three times daily. If constipation exists, mild laxatives should be used. Should the fluid persist, it then becomes nec- essary to tap the pericardium and draw it off. The technic, according to Curschmann, is as fol- lows: The place chosen is the fifth intercostal space in the left mammary line, a point midway between the apex beat and left border of absolute dullness; or Bristow's choice, immediately to the left of the sternum in the fourth or fifth space, which latter location avoids wounding the artery and pleura. The skin is properly cleansed and may be anesthetized, and a small trocar and cannula pushed through the chest wall and pericardium. When the point passes through the pericardium, the sense of resistance ceases. A Potain aspirator 132 DISEASES OF THE VASCULAR SYSTEM. may be used. The fluid sliould be allowed to flow out very slowly and the patient watched carefully, as sudden death sometimes occurs. After the fluid is all withdrawn, a collodion dressing is applied. To lessen the troublesome adhesions that so often occur after withdrawing the fluid, it is well to give digitalis at intervals until recovery. Acute Endocarditis. Remember that this condition is most always, if not always, due to some infectious process, and that rheumatism, chorea, pneumonia, and scarlatina are exceedingly apt to produce it. Remember that in simple endocarditis two things should be watched for, announcing its onset. In or- der of importance, they are pulse rate and tempera- ture. The rapid pulse may be irregular and palpi- tation be complained of. Remember that the earliest sign that ausculta- tion reveals is a slight roughening of the "first sound." Later there may or may not be a murmur — systolic, or diastolic in time. Remember that reduplication and accentuation of the pulmonic second sound is frequent. Remember the more pronounced general symp- toms— as irregular, rapid, feeble pulse; faintness, oppression, pallor, perspiration, and precordial pain. Malignant Endocarditis. Remember that the history of the case is all-im- portant in the diagnosis. MALIGIS^ANT EOT)OCARDITTS. 133 Remember that we have two groups of symptoms — those of the primary disease and those of the endocarditis — and the clinical picture varies ac- cording to the domination of the one or the other group. To the first group belong the irregular fever, sweating, anemia, delirium, and loss of strength. To the second belong the air hunger symptoms, as dyspnea, orthopnea, palpitation, and irregular, but frequent, cardiac action. Remember that emboli are common, and the signs vary with their location. Remember that chills, fever, and sweat may occur periodically in some cases, and strongly suggest malaria, but the absence from the blood of the malarial parasite is conclusive. Treatment. Rest in bed, free from worry, in all infectious dis- ease likely to be complicated by endocarditis, is the best prophylaxis and becomes imperative after its onset. • Cold over the cardiac area or a mustard plaster is good to quiet the rapid heart action. The diet should be liquid and nutritious. If rheumatism be the cause, salicylate and alkalies should be given; this is extremely important in children, as the joint symptoms are so mild. With rapid, weak heart, digitalis should be used. If there is cardiac irrita- tion manifested by tachycardia and pain in the pre- cordial region, it is well to combine aconite with it, as: 134 DISEASES OF THE VASCULAR SYSTEM. R Tincturae digitalis 3 iiias Tineturae aconiti 3 iss Misce. Sig. : 15 drops three or four times daily. Eicliorst claims to have cured a case by a com- bined use of quinin and bichlorid of mercury, as follows : IJ. Quininae hydrochloridi gr. Ixxv Hydrargyri cliloridi corrosivi ..... gr. ii j Pulveris glycyrrhizge 3 ss Extract! gentianse q. s. Misce et fiat massa. Divide in pilulae No. XX, Sig.: 3 pills daily after eating. Oollargol (Crede) is claimed by Ortner to be tbe best remedy in all cases of sepsis, pyemia, and bac- teremia. If tlie ointment be used, the skin over the area to be rubbed is cleansed with alcohol and dried. Then 45 grains of 15-percent unguenti col- largoli rubbed in carefully until the skin shows a grayish-brown tinge. Rectal Use. IJ. Collargoli gr. xv Aquse destillatse 3 vj Sig.: The bowel is first irrigated with a cleansing enema in the morning and half of the above amount is run into the rectum slowly, and the balance is given in the evening. Potassium iodid is recommended to stimulate ab- sorption of the inflammatory product on the valves and prevent its conversion into fibrous tissue. It should not be given until subsidence of the inflam- matory condition, and then administered cautiously and alternated with digitalis. VALVULAR DISEASE OF THE HEAET. 135 A saturated solution may be used, or the follow- ing: IJ Potassii iodidi gr. xs Potassii bicarbonatis 3 ij Spiritus anunonii aromatici o ij Tincturae cinchonae compositse 3 v Aquse q. s. ad § iv Misce. Sig. : Tablespoonful three times daily. Valvular Disease of the Heart. Aortic Incompetency. Remember that this is the lesion of the athlete and occurs in able-bodied, vigorous men. Remember that, etiologicall}^, there are three groups: 1. Those of congenital malformation. 2. Those due to endocarditis. 3. Those caused by arteriosclerosis. The last is by far the most common, and is usually associated with a history of prolonged muscular strain. Remember that the earliest signs are usually those due to arterial anemia, as headache, dizziness, flashes of light, and a feeling of faintness on sudden rising. Remember that pain in the precordial region may be severe, and is often transmitted up the neck and down the arm. Further failure of compensation jiroduces dysp- nea, but rarely cyanosis, hemoptysis, and edema of the feet. 136 DISEASES OF THE VASCULAR SYSTEM. Remember tliat mental disturbances are very com- mon in tliis lesion, such, as delirium, hallucinations,, and morbid impulses, with suicidal tendencies. Eemember that anasarca is rare, while sudden death is more common than in the other valvular lesions. Remember the value of examining the arteries in this condition. The following signs are more or less distinctly characteristic of aortic incompe- tency : 1. The visible pulsations in the peripheral vessels. 2. The pulsation is accompanied by a character- istic jerking. The aorta may lift the epigastrium with each pulsation. 3. Corrigan 's, or water-hammer, pulse. The pulse wave strikes the finger with a quick, jerking im- pulse and immediately collapses. The peculiarities of the pulse may be emphasized by grasping the arm above the wrist and holding it up. 4. Retardation of the pulse. There is an appre- ciable interval between the heart beat and the radial pulse. 5. Capillary pulse, seen in the finger nails; or, by drawing a line upon the forehead, the margins of the hyperemia alternately blush and pale. It is important that you auscultate over the carotid artery, because the second sound can be heard here when absent at the aortic cartilage; when the second sound is audible over the carotid, it indicates the regurgitation is small in amount, and hence a favorable prognostic element. VALVULAR DISEASE OF THE HEART. 137 Remember tliat the murmur heard has a soft, blowing quality, and is loudest at midsternum, oppo- site the third costal cartilage, or along the left bor- der of the sternum. It is heard during ventricular diastole, and is produced by back-flow of blood from the aorta. The Austin Flint murmur is a second murmur limited to the apex, and is of a ''rumbling, echoing" character. It is presystolic in time and occurs in the latter half of diastole. It is often associated with a palpable thrill. Remember that this is the lesion associated with massive hypertrophy, and the apex beat may be seen in the seventh or eighth interspace on the anterior axillary line. Aortic Stenosis. Remember that arterial changes, which are so prone to occur in old men, lay the foundation for stenosis. Remember that no symptoms appear until a break in compensation occurs, when the earliest are those of cerebral anemia — viz., syncope, dizziness, head- ache. Remember that, while the high degree of muscu- lar hypertrophy is present, yet the apex beat may not be easily seen because of coexisting pulmonary emphysema. Remember that a marked, systolic thrill, most in- tense in the aortic region, is very characteristic of this lesion. 138 DISEASES OF THE VASCULAR SYSTEM. Remember that the murmur is a harsh systolic, and loudest over the second right costal cartilage. Remember that the murmur is transmitted into the carotids, and it often has a musical quality. Remember that not every murmur heard in this region is due to aortic stenosis. Calcareous plates in the aorta or on the cusp produce a very similar sound. Anemia causes hemic murmurs that are often best heard in the aortic area, but this soft bruit is very different from the loud, harsh murmur of stenosis. Remember that in both the sclerosis and the anemia the aortic second sound is heard, and in the former it is accentuated. Remember that the pulse is small and slow — pulsus tardus — and is somewhat characteristic of stenosis. Mitral Incompetency. Remember that so long as muscular hypertrophy is able to overcome the valvular defect, the patient will suffer no inconvenience from the lesion, except perhaps a little shortness of breath on sudden ex- ertion, as running up a flight of stairs. Symptoms are not a sign of the beginning of the lesion, but of the beginning of inequality between the lesion and the hypertrophy. Remember that this is the lesion which, in long- standing cases, particularly in children, produces clubbing of the fingers. VALVULAR DISEASE OF THE HEART. 139 Remember that attacks of bronchitis and hemo- ptysis are quite frequent, due to the pulmonic con- gestion. Remember that we have persistent cough, with blood-stained sputa, containing alveolar cells and pigment granules. Remember that the cardiac "sleep start" is a dis- tressing symptom. Just as the patient falls asleep he wakes, gasping for breath and feeling as though the heart were stopping. Remember the peculiarity of the pulse. It is ir- regular, with no two beats of equal force or volume, and persists even though compensation be re-estab- lished. Remember that the apex beat will be found dis- placed downward and to the left, and is seen in the sixth costal space to the left of the nipple line. Remember that the murmur is systolic, and loud- est at the apex. It is a blowing sound, and may entirely replace the valvular sound. Remember that this murmur may be heard also in the axillary space and beneath the angle of the scapula posteriorly. Remember the peculiar phenomenon that the re- cumbent position makes it plainer, and often a mur- mur can be heard in the recumbent posture that is inaudible in the upright position. Remember that percussion shows decided lateral increase of the heart, due to hypertrophy. Remember that the three important physical signs of mitral regurgitation are : 140 DISEASES OF THE VASCULAR SYSTEM. 1. A systolic murmur, loudest at the apex and propagated to the axilla and heard at the angle of the scapula. 2. Accentuation of the second pulmonic sound. 3. Increase in the transverse diameter of cardiac dullness, due to hypertrophy of both ventricles. Mitral Stenosis. Eemember that this is much more common in females. Remember that this is the only valvular lesion that has a characteristic thrill on palpation. Eemember that the hypertrophy is all in the right heart and increase of dullness is to right of sternum. Eemember that the thrill is felt best in the fourth or fifth space within the nipple line, limited in area and best felt during expiration. It is rough, grating in quality, and can be felt to terminate in a sharp, sudden shock, synchronous with the im- pulse. Eemember that the enlarged auricle may press upon the left recurrent laryngeal nerve, and cause paralysis of the vocal cords on the same side. Eemember that the murmur is heard to the inner side of apex beat or along the left sternal border, and sometimes can be heard only when the breath is held. It is a rough, vibratory, or purring sound, and gradually becomes louder until it terminates in the first sound. This murmur