CHAPTER IX. DISEASES OF THE VASCULAR SYSTEM. (Part 2)

is synchronous with the thrill felt on palpation. VALVULAR DISEASE OF THE HEART. 141 Tricuspid Insufficiency. Remember that tlie signs are those of retarded pulmonary circulation and visceral congestion. Eemember that the pulse wave is seen in the veins of the neck, more pronounced in the right jugular. Remember that often an expansile pulsation of the liver may be palpated. This may best be de- tected by bimanual palpation. One hand is placed over the fifth and sixth costal cartilages, the other over the lower border of the liver in the midaxillary line, when a rhythmical expansile pulsation may be felt. Remember that a low systolic murmur is heard best over the lower part of the sternum and propa- gated in the direction of the right axilla. Crural Vein Sound. A valve sound may be heard over the crural vein, either single or double. If double, it corresponds to the presystolic and systolic filling of the vein. Tricuspid Stenosis. Remember that this condition is almost invariably associated with tricuspid insufficiency. Eemember that there is a presystolic murmur, best heard at the base of the ensiform cartilage. Remember that this murmur is associated with a presystolic thrill. Cardiac dullness is increased toward the right. Remember that cyanosis of the face and lips is commonly seen, and becomes pronounced where dropsy occurs. 142 diseases of the yasculak system. Treatment of Valyular Lesions. Remember tliat a heart with a lesion does not need treatment so long as hypertrophy overcomes the ill effects of the lesion. There is as much wisdom in knowing when not to treat cardiac lesions as there is in knowing what to do when active treatment is called for; hence we may divide the treatment into stage of compensation and stage of broken compen- sation. Stage of Compensation. In this stage the treatment is wholly dietetic and mechanical. Diet. The food should be abundant and nutri- tious. Coffee may be allowed, especially in the elderly. Milk should form a good part of the diet, but meats of all kinds are allowable in moderation. Fruits of various kinds and vegetables, especially spinach, lettuce, carrots, cauliflower. The digestive tract must be watched, that gases do not form in the stomach and interfere with cardiac action. Cathartics should occasionally be used, and sa-- lines are best, unless the patient is greatly weak- ened. Fluids must be allowed in moderation. It is bet- ter if the patient takes less than the ordinary amount in health. More should be allowed in hot weather. VAIiVULAE, DISEASE OF THE HEAET. 143 Tobacco is allowable in old smokers, as it will have no injurious effects; otherwise it is best to forbid it. Salt should be eliminated as much as possible from the food. It should be rigidly withdrawn when dropsy appears. Rest after eating should always be insisted upon, the length of time depending upon the individual case. Exercise should be moderate and in the open air. Violent or long-exhausting undertakings must be prohibited. Worry and anxiety are never allowable, and the patient must lead a quiet, even life. Baths. The skin should be kept active and free by tepid baths or sponging. Hot or cold baths should not be used. Turkish baths must be pro- hibited. Clothing. Flannel next to the skin is best, but care not to dress the patient too warm is just as important. The skin must be protected from sud- den chilling, as this causes visceral congestion and increases cardiac work. Medica,tion is indicated only as designed to tone up the whole system. For anemia and as a general tonic and a stomachic, arsenic is excellent. Fow- ler's solution may be given, or combined as follows: 3 Liquoris potassii arsenitis, Tincturse Valerianae aa 3 ij Misce. Sig. : 4 drops in water three times daily. Increase 1 drop per day until 8 drops are taken. 144 DISEASES OF THE VASCULAR SYSTEM. Or: 3 Arseni trioxidi gr. iss Piperis gr. xv Acacise . . . gr. ii j Aquae q. s. Misce et fiant pilulse No. XX. Sig. : Pill three times daily. Quinin as a tonic may be used, but it is not so good. B Tincturas cinchonae compositae 5 iv Sig. : Teaspoonful in water three times daily before meals. Or: R Tincturse cinchonae compositae, Tincturae gentianse compositae . . aa § ij Misce. Sig. : Teaspoonful three times daily before meals. Stage of Broken Compensation. Rest should be complete. The patient should be confined to his bed. Diet. So long as digestion is good or hydrops is not present the diet should be liberal. When either condition appears, the diet must be restricted. Best — milk, two pints, and add well-cooked cereals, shredded wheat biscuits, zwieback, toasted bread, and unsalted butter. Later soft egg, chicken, quail, lamb, or veal chops, and potatoes. Odd, locally — either the ice bag, Leiter's coil, or cold compress — should be laid over the cardiac re- gion. The compress should be changed as soon as it gets the least warm. Cardiac Stimulants. The best is digitalis. It VALVULAR DISEASE OF THE HEART. 145 slows the rate and strengthens the beat. Don't for- get its cumulative action. The effect on the heart can be detected as long as nine days after its use. There are various forms and preparations in which it may be given. R Infusi digitalis (fresh leaves) ....§iv Sig. : Tablespoonful every two or three hours. Or: R Tincturas digitalis, Tincturae scillse aa 3 iv Misce. Sig.: 20 to 30 drops three times daily. Or: R Digitaloni Ill xv Sig. : May be given every four hours hypodermatically. Or: R Digitalini gr. ss Alcoholis TTL XV Aquae 3 i j Misce. Sig.: Inject 10 to 20 minims subcutaneously. Or: R Potassii acetatis gr. xx Tincturse digitalis TTL xv Tincturae scillae TIX xl Tincturse nucis vomicae TTt v Infusi senegae q. s. ad § j Misce et fiat haustus. Sig.: To be taken every four hours. Or: R Tincturse scillae 3 iv Tincturae digitalis 3 iij Aquae cassiae q. s. ad § vj Misce. Sig.: Tablespoonful every four hours. 146 DISEASES OF THE VASCULAR SYSTEM. Remember that there are some conditions that contraindicate digitalis, or that require the drug to be administered very cautiously or in combination with other drugs. In a diseased heart muscle, es- pecially in aortic incompetency, it should be given cautiously, and, no improvement following, it should be abandoned. Fatty degeneration of the cardiac muscle and an extensive myocarditis contraindicate digitalis. In an abnormally slow heart, to be determined by cardiac auscultation and not by the radial pulse, digitalis should be combined with atropin (Ortner), thus: IJ Atropini sulphatis gr. ^o~g^- Veo Syrupi rubi idsei 5 iv Infusi digitalis q. s. ad 3 vj Misce. Sig. : Tablespoonful every two or three hours. In cases of extensive arteriosclerosis, digitalis is dangerous, unless the peripheral constriction is counteracted. Nitroglycerin should be combined with it, thus: R Tinctur£e digitalis, Tincturse nucis vomicEe aa 3 ij Spiritus glonoini TTl xij Tincturse cardamomi comp. q. s. ad ^ iij Misce. Sig. : Dessertspoonful every three or four hours. Two other drugs are of value, either when digi- talis can not be used or to supplement its action. They are strophanthus and spartein. VALVULAR DISEASE OF THE HEART. 147 Strophanthus may be given alone, 10 to 15 drops of the tincture, or as : R Tincturae strophanti, Tincturse Valerianae aa o i j Misce. Sig. : 10 to 30 drops three times daily. Spartein may be exhibited in solution, powder, or pills, as: R Sparteinse sulphatis gr. iv Syrupi aurantii 3 vj Misce. Sig.: Tablespoonful three or four times daily. Or: R Sparteinse sulphatis gr- 'vj Glycyrrhizse q. s. Misce et fiant pilulse No. XX. Sig. : Pill three or four times daily. With sign of cardiac failure — pulse hardly palpa- ble, heart tones weak, and the extremities cold and livid — camphor should be given hypodermatically. R Camphorag 3 ss Olei olivae 3 ij Misce et fiat solutio. Sig. : Inject 5 minims as necessary. Venesection is life-saving when dilatation occurs. When signs of venous engorgement occur, and when there is orthopnea with cyanosis, the withdrawing of from 20 to 30 ounces of blood is urgently indi- cated. Dropsy is frequently relieved by rest and a course of digitalis, but at times it is necessary to resort to other measures. Diuretics are then indicated. 148 DISEASES OF THE VASCULAR SYSTEM. Diuretin, wliich is sodium salicylate of theobro- min, has the advantage of stimulating the renal epithelium without injury. It is insoluble in cold water and is best given in powder, as: IJ Diuretini gr. x Fiat pulvere No. I. Dentur tales doses iSTo. XXV. Sig. : Powder every three hours. Or it may be given in solution, as diuretin is soluble in hot water, as: I^ Diuretini 5 j-o iss Essentise pepsini (Fairehild) § ij Aquae 5 v Dissolve diuretin by slightly heating water. Misce et fiat solutio. Sig.: Tablespoonful every two hours. Theocin-sodium acetate gr. iij-gr. v four to six times daily, and should not be given on an empty stomach. Calomel in many cases produces marked diuresis. The effect usually begins three or four days after beginning treatment and continues four or five days after treatment stops. It should be given only for three or four days and then stopped for an equal length of time. When it causes diarrhea, this may be overcome by giving gtt. iij-gtt. v of deodorized tincture of opium with it. Hydrogen peroxid should be used as wash for the mouth during the adminis- tration. R Hydrargyri chloridi mitis gr. ii j Sacchari lactis gr. vj Misce et fiat pulvere No. I. Dentur tales doses No. X-XII. Sig.: Powder three times daily. VALVULAR DISEASE OF THE HEART. 149 If the pulse is weak, it is better to administer digi- talis three or four days before giving the calomel. Addison's or Niemeyer's pills are excellent, as they are a combination of digitalis, calomel, and squills aa gr. j. One pill should be given three or four times a day for four or five days. Care should be used because of salivation if continued for too long a time. Cathartics may be used to remove dropsy, and of these concentrated solutions of the salines are best. Strong purges, like colocynth, should be avoided. Multiple incisions or paracentesis is ' at times necessary to get rid of the dropsy, and should be resorted to when other measures fail. Insomnia. A cup of hot gruel at bedtime, a tepid bath, or a light evening meal will be all that is neces- sary in many instances. Sodium bromid may be used. IJ. Sodii bromidi 5 ij Syrupi rubi idsei 5 iss Aquae q. s. ad S iv Misce. Sig. : Tablespoonful in evening and repeat in hour if necessary. If salt is withheld from the food, better effect of the bromid will be obtained, as salt hastens elimi- nation; a good point, also, to remember in cases of bromism. Bromipin in from 2 to 4-dram doses in the after- noon and evening often acts better than bromids. 150 DISEASES OF THE VASCULAR SYSTEM. Veronal is a good, safe hypnotic. Best given in glass of milk. It may be given in 5-grain doses and repeated in one to two lionrs. Congh is almost always present. When it be- comes annoying, codein gr. ^ should be given. An excellent combination is a tablet put up by Abbott, of Chicago, and has the following formula: IJ Zinci sulpliocarbolatis gr. j Codeini sulphatis gr. 14 Hyoscyaminaj liydrobromatis gr. %5q Stryclminae sulphatis gr. ^,{34 Misce et fiat tabella No. I. Sig. : Tablet every one or two hours. The SchoU Movements. The Schott or Nauheim system of treatment of cardiac affections consists in the proper resistance exercise. The exercise is such that different groups of muscles work against a gentle resistance of the physician or attendant. Careful watch must be kept during the movements, and on any sign of circula- tory or respiratory trouble the movements are at once suspended. The following are some of the movements used, each exercise being made against slight resistance applied by the physician: 1. The arms are extended in front of the body at the level of the shoulder, with the palms touching. The arms are then moved slowly outward until they are in a line with each other, and are then brought forward to the original position. VALVULAR DISEASE OF THE HEART. 151 2. The arms and hands hang at the side, with the palms forward. The forearm is flexed upon the arm until the fingers touch the shoulder. The fore- arm is then extended to its original position. This exercise is first done with one arm and then with the other. 3. The arms and hands in position as in No. 2. The arms are raised until the tliumbs meet over the head and then return to original position. 4. Same as No. 3, except fingers are flexed at first phalangeal joint. 5. Arms, hanging in position of ^'attention," are brought forward parallel to each other until they are elevated to a vertical position, and then re- turned to original. 6. Same as No. 1, except with fists clenched. 7. Same as No. 2, except with fists clenched. 8. The arms, starting from the position of "atten- tion," describe a circle by moving forward and up- ward until they are raised vertically; then each palm is turned outward and the arms descend back- ward to their original position. 9. The body is bent forward and then brought back to the erect position, the knees not being moved. 10. The body is rotated first to the right and then to the left without any movement of the feet. 11. The body is flexed first to the right and then to the left as far as possible without moving the feet. 152 DISEASES OF THE VASCULAK SYSTEM. 12. The patient in the erect posture, feet close to- gether, and one hand resting on a support, the oppo- site thigh is flexed as far as possible, then extended, and foot brought into its original position. The other hand is placed on a support and the opposite thigh is flexed the same as the other. Palpitation. Remember that this is more frequently found in women, and hysteria is often the causative factor. Remember that dyspepsia, especially if associ- ated with neurasthenia, is often the cause. Remember that the symptoms vary from a mild form, as seen in dyspeptic attacks, when there is slight fluttering of the heart, to the severe forms, when cardiac action is violent and the arteries throb forcibly. Remember that the pulse rate may be high — 150 to 160 — with diffuse flushing of the skin. A large quantity of pale urine may be passed after such an attack. Remember that the presence of a diastolic mur- mur excludes nervous palpitation. Remember that the area of cardiac dullness is not enlarged, thus excluding hypertrophy. Remember that the fact of intervals between at- tacks, when the patient is free of palpitation, is strongly suggestive of neurosis. Remember that if the patient is anemic, murmurs will be heard — systolic, soft, blowing — but the valve PALPITATION. 153 sounds will be normal and there will be no hyper- trophy of the heart. Treatment. First, quiet the patient's fears by assuring him that there is no actual danger. Second, seek out the cause, and inaugurate the proper hygienic and dietetic regimen. Regular hours should be kept, and ten hours of sleep insisted upon. Tepid bath, at night if nervous, or in the morning on arising. The evening meal must be light — mainly soups. Sexual excitement is particularly prone to keep up the trouble and patients should be specially warned. A Weir-Mitchell course of treatment is best where neurasthenia is the causative factor in women. Anemia demands iron. The following formulae are good : IJ Ferri et quiniiiEe citratis gr. xl-gr. Ix Liquoris strychninse TT], xl Spiritus chlorof ormi 3 i j Acidi hydrobromici TTL Ixx Aquse q. s. ad 3 iv Misce. Sig. : Tablespoonful three times a day before meals. Or: 3 Ferri et ammonii citratis gr. Ixx Tincturae nucis vomicae 3 iss Sodii bromidi 9 iv Spiritus ammonii aromatici 3 iv Aquse q. s. ad 3 iv Misce. Sig.: Tablespoonful three times daily. 154 DISEASES OF THE VASCULAE SYSTEM. When gastric disturbances are the cause, as seen in distention of the stomach by gas formed by the decomposition of food, medication directed toward the prevention of the gas formation is indicated. IJ Bismuthi carbonatis gr. x Magnesii carbonatis gr. v Sodii bicarbonatis gi"- x Aquae laurocerasi 3 j Aquse caryopliilli q. s. ad § j Misce et fiat haustus. Sig. : To be taken two times a day an hour before meals. (Yeo.) Or: IJ, Phenolis gr. xv Glycerini 3 v Bismuthi carbonatis 3 iiss Lactis magnesii q. s. ad § iv Misce. Sig. : Two teaspoonfuls after meals. Aconite or veratrum viride may be used where there is great rapidity of cardiac action. Digitalis is seldom indicated, but in obstinate cases it may be given in combination with nux vomica. Eemember that strychnin, in the form of tincture of nux vomica, and given in large doses, 20 drops three times daily, gives the best results in most cases. Angina Pectoris. E,emember that this condition occurs almost ex- clusively in men, and, when occurring under thirty- five, syphilitic aortitis is an important factor. ANGINA PECTORIS. 155 Remember that gout and diabetes are important etiologic factors, and angina pectoris has been known to follow influenza. Remember that arteriosclerosis is present in practically all the cases, but the degree of sclerosis of the palpable arteries is no criterion of the degree of degeneration of the coronary vessels. Remember that in angina an attack is usually caused by sudden exertion, mental worry, exposure to cold, or a hearty meal. Remember that