Upon the incidence of the effusion the above treatment should be continued
and a good sized blister may be applied to the precordium; not only does
this act as a counter-irritant to the pain but in some cases it has a certain effect
upon causing absorption of the fluid. If the heart becomes weak and there
is venous stasis, strychnine and digitalis are indicated, or if there is tendency to
syncope and collapse, this is to be combated by the hypodermatic injection
of caffeine sodio-benzoate 2 to 5 grains (0.13 to 0.33) or of camphor dissolved
in sterile olive oil or aether. Dyspnoea due to congestion of the lungs may
be relieved by strychnine, which may be given, if necessary, in doses as large
as jQ of a grain (0.006). Acute cardiac dilatation with cyanosis may be
treated in the same fashion. Throughout the course of the affection the
bowels should be kept freely open and the activity of the kidneys, which may
aid in causing the disappearance of the effusion, should be insured by the
administration of alkaline diuretics and of the infusion of digitalis when
indicated.

When the quantity of the effusion is so large as to interfere with the heart's
action as evidenced by marked dyspnoea and cyanosis, weakness of the pulse,
an expression of anxiety, and coldness of the extremities, the pericardium should
be tapped and the pressure relieved. An effusion large enough to displace
the diaphragm and the underlying viscera may also be diminished to advantage
by paracentesis. Drawing off the fluid usually results in quick relief of the
pressure symptoms but may not be followed by quick recovery. Several
tappings may be necessary, especially if the inflammation is tuberculous. In
moderately large effusions the point of puncture may be in the fourth inter-
costal space about an inch to the left of the sternal margin or in the fifth space
I J inches from this edge. Dieulafoy advises puncture in the fourth or fifth space
2 to 2^ inches from the sternum. Others advise the insertion of the needle
outside the nipple line. In very large effusions a safe point is in the left
xiphocostal angle, the needle being directed upward and backward. It is
unwise to draw off all the fluid at once, 6 to 16 ounces (180.0 to 500.0) being
sufficient for one time; repetition may be necessary after a few days. If the
fluid is purulent simple tapping is insufficient; incision and drainage are
necessary. It is probable that recovery in pyopericarditis would be much
more frequent under early surgical treatment. It should be needless to
state that pericardial puncture should be performed under the strictest
asepsis.

The diet during the acuity of the course of a pericarditis should be of nour-
ishing fluids.



542 DISEASES OF THE HEART AND BLOOD-VESSELS.

CHRONIC ADHESIVE PERICARDITIS.

This condition often occurs in young persons as a result of a plastic peri-
carditis. Two forms are described: a. Simple adhesion of the peri- and
epicardial layers; this often causes no symptoms and its existence is unsus-
pected until revealed upon the autopsy table, h. Adherent pericardium
with chronic inflammation of the mediastinum and union of the parietal
layer of the pericardium to the pleura and thoracic wall. This type is espe-
ciaMy serious in children and may go on to extreme cardiac hypertrophy and
dilatation.

Symptoms. In type a the symptoms as stated are unnoticeable; in type
b they are those of cardiac hypertrophy and dilatation with subsequent
insufficiency. With the pericardial adhesions there may proliferative pleu-
ritis, peritonitis, perihepatitis and perisplenitis, in a word a panserositis,
with which there may be chronic ascites.

Physical Signs. Upon inspection a bulging of the precordium may be
noted. Friedreich's sign, a diastolic collapse of the cervical veins due to
their sudden emptying resulting from the expansion of the thorax, may be pres-
ent. Broadbent's sign, a systolic tug communicated through the adherent
diaphragm, may be noted; this is best observed between the eleventh and
twelfth ribs behind on the left side. Palpation reveals a diffuse apical impulse
extending in marked instances from the third to the sixth space in a
vertical direction and laterally from the right parasternal line to without the
left nipple. The apex beat may be variously displaced, is wavy in character
and with the systole there may be a retraction of the thoracic wall; the hand
may detect a quick rebound of the wall of the chest, the diastolic shock; these
two latter are the most typical signs of adherent pericardium.

The pulsus paradoxus may be present but is not pathognomonic. Upon
percussion the cardiac dulness is much increased. Adhesions of the peri-
cardium to the pleura prevent the lessening of the cardiac dulness upon deep
inspiration. The signs elicited by auscultation are neither constant nor charac-
teristic. Murmurs due to co-existent endocardial lesions are often present
and there may be a modified pericardial friction sound resembling the sound
caused by bending a piece of new leather. A ventriculo-systolic mtirmur
due to a relative mitral insufficiency or an auriculo-systolic murmur may be
heard. The course of chrome adhesive pericarditis is prone to be protracted,
the lesion being very likely to be permanent.

Treatment consists in improving the patient's general condition by the
administration of tonics and nourishing food. The symptoms should be
combated by appropriate measures and it may be possible to facilitate the
absorption of the connective tissue adhesions by the persistent inunction
over the cardiac region of a 6 percent, ointment of iodine vasogen and the



OTHER PERICARDIAL AFFECTIONS. 543

internal administration of the S}T:up of hydriodic acid in doses of i drachm
(4.0) in a wine glass of water one-half an hour before each meal.

OTHER PERICARDIAL AFFECTIONS.

Hydro pericardium, an increase of the normal amount of serous fluid con-
tained in the pericardium, occurs in cardiac or nephritic conditions associated
with a general anasarca. The amount is not often large and the presence
of the fluid may be overlooked. Large transudates cause interference with
the action of the heart. The physical signs are identical with those of peri-
carditis with effusion.

Hcemo pericardium. Blood is found in the pericardial sac as a result of
rupture of aneurysm of the aorta, of the coronary arteries, of the heart itself
or of wounds. Blood-tinged fluid may be found in the pericardium in tuber-
culosis or malignant growths of the membrane as weU as in the pericarditis
occurring with nephritis. The physical signs are those of any pericardial
effusion.

Pneumo-pericardium is rarely seen and is a condition in which the peri-
cardial sac contains gas and fluid, usually piirulent in character. It is most
often the result of traumatic or other perforation, from new gro\vth, for instance.
In the non-perforative cases the growth of the bacillus arogenes may be re-
sponsible. The symptoms consist of precordial pain and embarrassment of
the heart's action. The physical signs are tj^ical. The precordium may be
bulging and the apex beat obscured. The note below is dull due to the pres-
ence of fluid, above it is tympanitic. The extent of these areas may differ
upon change of the patient's position. Auscultation reveals a heart sound of
metallic, splashing or gurgling quality. The friction sound if present, is
also of metallic quality.

Calcification of the pericardium is rare but may occur subsequent to peri-
cardial inflammations, especially those of purulent or tuberculous type. It
sometimes occurs in panserositis.

Treatment of the above conditions is of little avail. If excessive fluid
causes cardiac embarrassment this may be relieved by tapping and surgical
measures may be useful if external wound is present.

DISEASES OF THE MYOCARDIUM.
CARDIAC HYPERTROPHY.

Definition. An enlargement of the heart characterized by increase in the
thickness of the waUs of the organ and with or without increase in the size of its
cavities. When the size of the cavities is not augmented the condition is



544 DISEASES OF THE HEART AND BLOOD-VESSELS.

termed simple hypertrophy; if the enlargement affects both the thickness of
the walls and the size of the cavities it is spoken of as eccentric hypertrophy.
The enlargement may involve the entire heart, one side alone or only one
ca\'ity.

etiology. The condition is an increased growth of muscular tissue and
is the result of a physiological effort to perform increased work. The left
ventricle becomes the seat of hypertrophy when there are such obstructions
to its action as are furnished by obstruction or insufficiency of the aortic valve,
by iasuf&ciency of the mitral valve, adhesions of the pericardium, interstitial
myocarditis, disorders of the innervation of the organ followed by increased
cardiac action such as occur in chronic palpitation, exophthalmic goitre, etc.,
and in disturbances of the vascular system such as arteriosclerosis, aneurysm,
contraction of the peripheral blood-vessels induced by the presence of toxic
substances in the blood as in nephritis; hypertrophy also occurs in muscular
over-exertion (the athlete's heart) and in congenital narrowing of the aorta.

Hypertrophy of the right ventricle is brought about by any condition which
increases the resistance to the pulmonary circulation such as disease of the
mitral valve; pulmonary emphysema or fibrosis; lesions of the valves of the
right side of the heart, which are often congenital; vahnilar lesions of the
left heart in the later stages result in pulmonary stasis and consequent obstruc-
tion to the pulmonary circulation causing hypertrophy of the right ventricle,
and adhesions of the pericardium may cause mechanical interference with
its free action and consequent hypertrophy.

Hypertrophy of the auricles is always associated with dilatation of these
cavities. The left auricle is hypertrophied as a result of mitral obstruction
and to a less extent it is caused by the regurgitation of the blood in mitral
insufficiency. Hypertrophy of the right auricle is less likely to result from
tricuspid disease since here there is much less resistance to the further back-
ward flow into the veins than upon the left side of the heart.

Pathology. The hypertrophied heart is heavier and larger than the nor-
mal organ and its shape is changed. With hi'pertrophy of the left ventricle
its shape is less conical than normal, its position is more horizontal and it
is elongated to the left. Hypertrophy of both ventricles results in a more
rounded shape and when the hypertrophy chiefly involves the right side, the
most bulky part of the organ is the right ventricle. The walls of the h}'per-
trophied ventricles are much thickened and the muscle fibres are darker in
color and more dense than normal.

Symptoms. Hypertrophy is primarily a condition of physiologic compensa-
tion and at first is unattended by symptoms, but as a result of its continuance
pathological changes take place and connective tissue over-growth occurs
producing sclerosis of the arteries of the heart muscle and fibrous degeneration
of the walls of the organ and the valves. These abnormalities are evidenced



CARDIAC HYPERTROPHY. 545

by symptoms which at their inception are not constantly present but are
induced by over-exertion, mental or physical, over-indulgence in stimulants,
tobacco, etc. The patient now complains of cardiac discomfort, increased
by lying upon the left side, consciousness of the heart's action, palpitation,
vertigo, tinnitus, visual disorders, flushing of the face and epistaxis.

Physical Signs. Inspection may reveal a bulging of the precordium,
especially in children, a displacement of the apex beat downward and toward
the left and a forcible and diffuse apical impulse; there may be visible pulsa-
tion of the carotids. Palpation confirms the displacement and over-action
at the apex; the radial pulse is regular, fuU and tense. Percussion in hyper-
trophy of the left ventricle shows enlargement of the area of cardiac dulness
to the left and downward; of the right ventricle increased dulness to the right
margin of the sternum and beyond. Auscultation reveals a first sound at the
apex prolonged, dull and perhaps reduplicated; the aortic second sound is ac-
centuated and it may be reduplicated in left ventricular hypertrophy, while in
right ventricular hypertrophy the pulmonic second sound is increased in in-
tensity. The apical impulse in hypertrophy of the right ventricle is displaced
to the left but not downward and when there is no accompanying left ven-
tricular hypertrophy the radial pulse is small.

The cardiac shadow, in left ventricular hypertrophy, as shown by the
Rontgen ray, is enlarged, principally downward and to the left; in hypertro-
phy of the right ventricle chiefly to the left and but little downward; in extreme
instances the cardiac shadow may be seen to the right of the sternum.

The diagnosis from neurotic palpitation is made upon the heaving character
of the apex beat, the increase in cardiac dulness and the presence of accen-
tuation of the second sounds. Retraction of the lung may uncover the heart so
that its area of dulness is much increased and hypertrophy may be obscured
by the interposition of an emphysematous lung. In pericardial effusion
the area of diilness is of characteristic triangular shape, the heart sounds
are obscured and the pulse is feeble. In hypertrophy with dilatation the pulse
is less strong and regiilar, murmurs are frequently present and there is less
likely to be accentuation of the second sounds at the base.

The prognosis in cardiac hypertrophy due to toxaemia is favorable until
permanent arterial changes take place. When it is the result of arterio-
sclerosis or aneurysm the prognosis is that of these conditions. Hypertrophy
with chronic valvular disease is a conservative physiological process and
lasts until for some reason, over-exertion, intercurrent illness, malnutrition
etc., dilatation supervenes.

Treatment. So long as no symptoms are present this consists in main-
taining the patient's nutrition, avoiding over-exertion and indulgence in
alcohol, tobacco, tea and coffee and in obtaining sufl&cient sleep. Simple
tonics may be prescribed if indicated. If arteriosclerosis is present we may
35



546 DISEASES OF THE HEART AND BLOOD-VESSELS.

administer the iodides preferably in the form of the syrup of hydriodic acid, i
drachm (4.0) in a wine glass (60.0) of water a half hoiir before each meal. For
the cardiac distress the fluid extract of cactus in doses of 10 to 20 minims
(0.66 to 1.33) three times daily may be given. If the palpitation is annoying
the following prescription may be found beneficial: I^ potassii bromidi, potassii
iodidi, aa gr. Ixxv (5.0); syrupi aurantii § vi (180.0). Misce et signa, two tea-
spoonsful night and morning. If the heart is laboring against excessive
arterial tension we may give glyceryl nitrate gr. y-^-g- to g-^ (0.0006 to 0.0012)
or erythrol tetranitrate gr. ^ to J (0.016 to 0.032) made up in pill form with
kaolin, three times a day.

CARDIAC DILATATION.

.Etiology. Acute cardiac dilatation of transitory type may occur as a
resiilt of pronounced muscular over-exertion. Chronic dilatation is associated
with hypertrophy and is due either to an increase of the endocardial pressure re-
sulting in over-filling of the chambers or to an obstruction to the outflow of blood
caused by valvular or vasciflar lesions. These causes may not at once lead
to dilatation but often first result in hypertrophy, the latter being always to
some extent present except in instances of very acute dilatation. In eccentric
hypertrophy, dilatation is a process of physiological compensation, going on
until failure of the nutrition of the heart supervenes when immediately the dila-
tation exceeds the hypertrophy to a marked extent (failure of compensation).
This condition may result in endocarditis, the infectious diseases, chronic
wasting diseases, and prolonged mental or physical over-exertion. Acute
dilatation may result from sudden excessive muscular effort as in mountain
climbing, rowing, bicycling, etc. Exercise within proper limits produces
hypertrophy with dilatation, not simple dilatation, i.e., enlargement of the
cavity with compensatory thickening of its walls. The harmful eft'ect of pro-
longed cardiac strain is held in check temporarily by the action of the tricuspid
valve in allowing a regurgitation of blood into the right auricle, but physiolog-
ical dilatation has passed beyond its limit when the cavity has become unable
to empty itself of blood. Here, although the reserve capacity of the heart
has been exceeded, the normal condition may be restored by rest.

A second factor which may resiflt in cardiac dilatation is a decreased resis-
tance of the cardiac walls; these may be weakened by fatty and fibrous degen-
eration, the degeneration which takes place during the acute infectious diseases,
in endocarditis and pericardiits, in disturbances of nutrition and in chronic
blood diseases. Idiopathic dilatation may occur.

Pathology. Dilatation involves the right heart more often than the left
and at least two chambers are usually affected; it is generally secondary to
valvular defects and is, in most instances, associated with hypertrophy. Ex-



CARDIAC DILATATION. 547

treme dilatation produces a relative insufi&ciency of the valves, these, although
being of normal size and condition are not able to close their respective orifices
on account of the great expansion of the valvular ring consequent upon the
dilatation or from the fact that the enlargement of the cardiac chambers
so draws upon the papillary muscles that these are insufficiently long to allow
the valve flaps to fall into place. The shape of the organ is changed depending
upon the situation and extent of the dilatation; when this involves the whole
heart iis shape becomes somewhat spherical. The endocardium may be
opaque and roughened; the myocardium is usually the seat of a fatty, fibrous
or parenchymatous degeneration; degeneration of the cardiac ganglia has
been observed.

Symptoms. Sudden acute dilatation is evidenced by cardiac or epigastric
distress or pain, sudden dyspnoea, rapid and feeble heart action and signs of
venous obstruction. In very acute instances sudden death without symptoms
may take place. In the milder forms of the affection the patient suffers from
palpitation, dyspnoea, faintness and feeble cardiac action; all these are much
relieved by rest, but return upon the least exertion.

In dilatation with compensatory hypertrophy there are no subjective symp-
toms but immediately upon the disturbance of the compensation the signs
of venous congestion are developed, dyspnoea, oedema, beginning in the feet
and extending upward, rapid, feeble and irregular heart action, cough, digestive
distiirbances, dizziness and headache and even delirium and coma; rarely
is the pulse rate slow. Palpitation and symptoms resembling those of angina
pectoris may occur. The urine is dark, of high specific gravity, scanty and
may contain hyaline casts and red blood cells.

Physical Signs. Upon inspection the apical impulse is seen to be weak,
irregular and diffused over a considerable area, there may be no point of
maximum intensity or this may be above and to the left of the normal position.
When the hypertrophy chiefly affects the right side of the heart the apex im-
pulse is absent but an impulse may be palpable below or to the right of the
xiphoid cartilage and there may be a diffuse wave in the fourth, fif.h and
sixth left spaces. There may be a visible pulsation, usually synchronous with
the systole, less frequently presystolic, in the second left space. When there
is dilatation of the right auricle a systolic impulse may be detected in the third
right space. Percussion reveals increased dulness to the right or left and
downward, unless the enlarged heart is overlapped by emphysematous pul-
monary tissue. Upon auscultation various sounds due to complications may
be audible. The characteris ic signs are present only in the idiopathic type
of dilatation; these are a weak but not impure first sound; at times it may be
almost inaudible or reduplicated as a result of lack of sjnachronous contrac-
tion of the right and left sides of the heart and the loud ventriculo-systolic
murmur of a relative mitral insufficiency may be present. The second pul-



548 DISEASES OF THE HEART AND BLOOD-VESSELS.

monic sound is distinct if only dilatation of the left ventricle with hypertrophy
of the right is present. It is weak if the dilatation affects the right ventricle.
The heart action is irregular, weak and intermittent. A gallop rhythm is typi-
cal of dilatation but is not constantly present.

The diagnosis from pericardial effusion (see p. 540) may be difficult; from
hypertrophy, dilatation may be distinguished by the indefinite, diffuse and
undulatory apex impulse, by the weakness and irregularity of the pulse and
the lack of accentuation of the second sounds at the base.

The prognosis while unfavorable as to final result, shoiild be guarded; proper
treatment often succeeds to a considerable extent in relieving symptoms and
prolonging life.

Treatment. The chief essential is complete rest in bed; under this alone
temporary recovery may be brought about in many instances. Cardiac
stimulants should be prescribed as in valvular disease with failing compen-
sation (see p. 578). In the acute type of dilatation, venesection may greatly
relieve the failing heart, especially if failure of the right heart is present as
evidenced by dyspnoea and cyanosis.

The employment of the so-called Nauheim baths and after the acute symp-
toms have disappeared, of the exercises originated by the Schott brothers
and modified by the resistance movements of the Lingg Swedish system of
exercises, is often fraught with excellent results. In connection with these
the patient's mode of life and diet should be regulated according to the strictest
principles and no measure calculated to prevent a recurrence of the dilatation
should be omitted.

The Nauheim treatment is, of course, most effectual when undertaken at
the springs but artificial imitations of the natiiral baths may be taken at home
and from these excellent results may be obtained. Artificial Nauheim salts
are now supplied by the manufacturing chemists or may be made up by any
pharmacist, the formula being supplied by the physician. They depend
chiefly for their action upon the evolution of carbonic acid gas and may be
employed in various strengths.

Bath No. I. Sodium chloride 4 lbs. (2,000); calcium chloride 6 oz. (180).

Bath No. 2. Sodium chloride 5 lbs. (2,500); calcium chloride 8 oz. (240).

Bath No. 3. Sodium chloride 6 lbs. (3,000); calcium chloride 10 oz. (300).

Bath No. 4. Sodium chloride 7 lbs. (3,500); calcium chloride 10 oz. (300);
sodium bicarbonate ^ lb. (250); 25 percent, hydrochloric acid 12 oz. (360).

Bath No. 5. Sodium chloride 9 lbs. (4,500); calcium chloride 11 oz. (330);
sodium bicarbonate i lb. (500); 25 percent, hydrochloric acid i^ lbs. (750).

Bath No. 6. Sodium chloride 10 lbs. (5,000); calcium chloride 12 oz. (360);
sodium bicarbonate 2 lbs. (1,000); 25 percent, hydrochloric acid 3 lbs. (1,500).
The amounts given are suitable for a bath of 40 gallons (160 litres).

A porcelain tub should be used or the salts should be dissolved in earthen



CARDIAC DILATATION. 549

bowls if the tub is of metal. When the salts have been dissolved the bottle
containing the hydrochloric acid is inverted and, with its mouth below the
surface of the water, the stopper is removed and the acid uniformly mixed with
the bath. The patient should now get in at once so as to get the fidl benefit
of the evolution of the carbonic acid gas. The numbers 5 and 6 are seldom
prescribed.

In addition to the carbonic acid other beneficial factors possessed by the
natural Nauheim baths are the warmth and the fact that it is natiural warmth;
the presence of alkaline salts and of metals in large quantities; the coincident
combination of the carbonic acid gas with the salts and other elements, and a
certain amount of electro-magnetism which the waters are considered to hold.

The temperatiure of the bath at the beginning should be from 92.3° to 95° F.
(33.5° to 35° C.) according to the condition of the patient, considering whether
he is stout or lean, young or old and whether he is accustomed to cool or warm
bathing. The temperature may be gradually lowered 4 to 6 degrees F.
(2 to 4 degrees C.) but in most instances rather less than these figures; with