Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

. (page 22 of 65)
Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 22 of 65)
Font size
QR-code for this ebook


ascertained ; it lies mostly under the lower part of the sternum.

The valves of the pulmonary artery are situated under the cartilage
of the third rib to the left of the sternum.

The following diagram shows the. exact position of these parts:




Now, if we remember all this, we shall hear those sounds which
originate in the left ventricle, in the mitral valves, most distinctly at that
part of the thorax against which the apex of the heart strikes ; those
sounds which originate in the ascending aorta we shall hear best a little
to the right of the centre of the sternum, and from thence upwards ; those



AUSCULTATION". 207

sounds luliich originate in the pulmonary artery we sLall hear lest a
little to the left of the centre of the sternum ; those sounds which originate
in the tricuspid valves we shall hear loudest over the central and lower
part of the sternum.

If we now consider that diseases of the pulmonary valves and the
tricuspid valves are of very rare occurrence, we may centre our atten-
tion upon only these two points :

1. Upon the sounds of the mitral valves ; heard best at that part of
the thorax against which the apex of the heart strikes ; and,

2. Upon the sounds of the aortal valves ; heard best a little to the
right of the centre of the sternum, and thence upwards.

Third Step: Of the different morbid sounds or murmurs
of the heart,

1. The left chamber during its systole.

The first sound, heard clearest at the apex, is proof,

1. That the mitral valves shut perfectly ; not allowing any blood to
regurgitate into the auricle ; and,

2. That the aortic valves and orifice offer no obstacle to the direct pas-
sage of the blood out of the left ventricle.

But, suppose the mitral valves be deficient^ so that they would not
shut perfectly during the rush of blood against them, what would be
the consequence of this deficiency ? Simply, the stream of blood
would not be stopped there, but would re-enter the auricle and thus
cause a noise, but no tic.

Or, suppose the aortic valves be stiffened or roughened, or the aortic
opening constricted, so that the stream of blood in its course onward
would be interfered with, what would be the consequence of such
obstruction ? The stream of blood would rub against the obstacle
and cause a noise or murmur at the same time when the closure of
the mitral valves would give the first tic.

Or, suppose the mitral valves be deficient, and, at the same time, the
aortic valves stiffened and roughened, or the aortal opening constricted,
what would be the consequence of this deficiency and obstruction ?
Well, the stream of blood would regurgitate through the auriculo- ven-
tricular opening, and also rub against the obstacles in the aortic open-
ing, and thus cause a noise but no tic.

How then can we distinguish between these three different affec-
tions? In case of insufficiency of the mitral valves, the blood regur-
gitates at each contraction of the heart into the left auricle; and thus
it becomes retarded in the whole lesser circuit. In consequence of
which the right ventricle must make stronger efforts to drive it



208 THE HEAKT.

onward, and the pulmonary artery, becoming largely distended, con-
tracts the more, thus causing a more violent shock backwards against
its semilunar valves, and consequently a louder diastolic sound of the
pulmonary artery. An increase of the second or diastolic sound of
the pulmonary artery is, therefore, almost invariably attending an
insufficiency of the mitral valves. We must, then, when we hear a
noise instead of the diastolic sound at the heart's apex, make sure
whether there is also an increased second sound of the pulmonary
artery. The valves of this artery are situated under the cartilage of
the third rib to the left of the sternum — there we put the stethoscope,
and if it turns out so, we may be sure that the noise which we hear
at the apex, instead of the systolic sound, is caused by an insufficiency
of the mitral valves.

In case of constriction of the aortic opening we hear the systolic
sound and a noise besides. If we put our ear over the aorta, towards
the right of the centre of the sternum, we hear the noise there even
plainer than at the apex.

In case of insufficiency of the mitral valves and constriction of the aortic
orifice combined, we shall find these features united : an increased second
sound of the pulmonary artery, and an increased noise over the aorta.

2. The left ventricle during its diastole.

The diastolic or second sound of the hearty is proof — 1, That the aortic
valves shut well, not allowing any blood to regurgitate into the left
ventricle ; and 2, That the mitral valves or the auriculo -ventricular
opening offer no obstacle to the passage of blood out of the left auricle
into the left ventricle.

But, suppose the aortic valves he insufficient^ so that they would not
close tightly after the blood had been driven through them ; what
would be the consequence of this insufficiency ? The contraction of
the aorta would drive some of the blood back again into the left ven-
tricle, and cause thus a noise or murmur instead of the second sound.

Or, suppose the mitral valves he stiffened, roughened, or the auriculo-
ventriculccr opening constricted, so that the passage of the blood into
the ventricle were interfered with, what would be the consequence of
such obstruction ? The stream of blood would rub against the ex-
isting obstacle and cause a noise or murmur during the diastole of
the ventricle at the same time when the closure of the aortic valves
would give the diastolic sound.

Or, suppose the aortic valves be insufficient, and, at the same time,
the mitral valves or auriculo-ventricular openi7ig obstructed, what would
be the consequence of this insufficiency and obstruction? Surely



AUSCULTATIOISr. 209

the stream of blood would regurgitate tlirougli the aortic valves
into the left ventricle, and also rub against the obstacles in the
mitral valves and auriculo-ventricular opening, and thus cause a
noise or murmur, but no diastolic sounds

And how can we distinguish between these different affections ?
In case of insufficiency of the aortic valves, we shall hear a noise or
murmur instead of the second sound most distinctly over the aorta
to the riarht of the centre of the sternum.

In case of thickening of the mitral valves, or contraction of the
auriculo-ventricular opening, the blood accumulates in the lesser cir-
cuit, produces hypertrophy, with dilatation of the right ventricle,
and an increased diastolic sound of the pulmonary artery much more
readily than mere deficiency of the mitral valves. The more con-
stricted the mitral orifice is the longer will be the time necessary for
the flow of the blood into the ventricle, and the more prolonged and
louder the murmur. In cases of this kind the vibrations may even be
felt and seen.

In case of insufficiency of the aortic valves and constriction of the
mitral orifice combined, we shall, of course, find both features united
— a noise> instead of the second sound over the aorta and a murmur
over the mitral valve, with an increase of the diastolic sound of the
pulmonary artery.

8. The left ventricle during its systole and diastole.

The clear systolic sound indicates that the mitral valves close
perfectly,. and that the aortic valves are not constricted. The clear
diastolic sound indicates that the aortic valves shut well, and that the
mitral orifice is not constricted. But suppose the mitral valves be
insufficient, and, at the same time, the auriculo-ventricular opening
constricted, what would be the consequence of such insufficiency and
constriction at the same time ? The systole would cause a regurgita-
tion of the blood into the auricle, and the diastole a friction of the
blood during its passage through the constricted mitral opening, and
thus we would hear a see-saw, a noise instead of the first, and a noise
accompanying the second sound.

Or, suppose the aortic valves he insufficient, and, at the same time, the
aortic orifice constricted, what will be the consequence of such a state ?

Undoubtedly the contraction of the heart would cause a noise by
driving the blood through the constricted orifice, and during the
dilatation of the heart the blood would regurwitate and cause a mur-
mur instead of the second sound.

14



210 THE HEART.

And how are we to distinguish between these two different affec-
tions ?

When the mitral valves are insufficient, and the auriculo-ventricu-
lar opening is at the same time constricted, we must find also an
increased second sound of the pulmonary artery. When, however,
insufficiency of the aortic valves and constriction exist in the aortic
opening, we hear the murmur most distinctly over the aorta.

A comparison of the diagram on circulation, page 205, will help
much in elucidating these complicated states.

All that I have here said of the left ventricle and its valves during
its systole and diastole is almost verbally applicable to the right ven-
tricle and its valves. As, however, valvular diseases on the right side
of the heart are exceedingly rare compared with those of the left side,
and even when present on the right side, they almost always exist to
a greater extent upon the left than upon the right side — (Hughes) —
I think it best to break off here, so that I may not bring confusion
upon, instead of elucidation to, this subject ; and I shall at once
proceed to speak of those morhid sounds, resembling murmurs, but
which have nothing to do with the valves of the heart.

1. Anaemic murmcjrs. " They are ordinarily of the softer kind, and
resemble the blowing of a pair of bellows, but are sometimes harsh
and resemble the rougher morbid sounds, as that of filing or sawing."
(Hughes.) They are generally confined to the situation of the aortic
or pulmonary valves, or both. They do not follow th^ course of the
large vessels so fully or frequently as do the murmurs arising from
disease of the valves. They occur only during the systole of the ven-
tricles ; they are not generally heard below the left nipple, as they do
not arise from regurgitation through the mitral valve. They are almost
always accompanied with a smart, smacking impulse. They generally
disappear for a time, while the individual is quiet mentally as well as
bodily, if by that quiet the heart assume a natural impulse ; and they
are always diminished and generally disappear entirely under suitable
treatment. Hughes.

The origin of these anaemic murmurs have been attributed : 1, to
a watery condition, or a diminution of ordinary viscidity of the blood,
in consequence of which the particles of the fluid are more easily
agitated and thus give rise to the vibrations which produce the
murmur ; 2, to the remarkably quick and sudden contraction of the ven-
tricles, in consequence of which the fluid contents of the cavities are
propelled quicker through the arterial openings than in health, and



AUSCULTATION". 211

tlius give rise to greater friction, which produces the murmur, although
no actual constriction exists there. Hughes.

2. Yenous muemurs (nun's murmur, top-murmur) are heard in
many young persons in the anterior triangular space in which the
external jugular vein descends. It is a continuous murmur, and is
generally more audible on the right than on the left side. This mur-
mur disappears when the current of blood is interrupted by pressure
upon the jugular vein, by a deep expiration, or by any position of
the body in which the head lies lower than the thorax.

It is heard loudest in an erect position, and during inspiration.

It is thought to be in connection with anajmia, but Skoda says that
he has found it also in young and quite healthy individuals.

8. Pericardial murmurs. As long as the inner surface of the
pericardium is in its natural condition, slippery and glistening, the
heart moves within it without any sound; just as the two blades of
the pleura glide over each other inaudibly, as long as they are in a
natural condition. Not so, however, when this slippery and glisten-
ing surface becomes roughened in consequence of inflammation and
subsequent fibrinous exudation. Then we hear at once a friction
sound, which, according to Skoda, may resemble perfectly an endo-
cardial murmur.

How are we then to distins-uish between a friction sound caused in
the pericardium, and a sound caused within the heart?

Skoda says : " I know no sign by which the friction sounds of the
pericardium can be distinguished from the internal murmurs of the
heart, excepting this — that the internal murmurs correspond pretty
exactly to the rhythm and to the natural sounds of the heart ; whilst
the pericardial friction sounds seem lo follow upon the movements of
the heart. This distinctive sign is only available when the murmur
is somewhat prolonged ; if it be of short duration, we cannot deter-
mine whether it is endocardial or pericardial." Skoda, p. 253.

To this diflS.culty still another may be added, viz. : the friction sound
may also arise from a roughened condition of that portion of the
pleura which covers the unattached parts of the pericardium. The
sound is produced by the rubbing of the pleura which covers this
free portion of the pericardium, either against the thoracic walls or
against the surface of the lungs. Being caused by the action of the
heart, it coincides with its movements as completely as though it had
been produced within the pericardium. The murmur thus arising
external to the pericardium exactly resembles the murmur arising
within it, and here we have no means of distinguishing.



212 DISEASES OF THE PERICAEDIUM.

The special diseases of the heart I shall arrange under the follow-
ing heads :

1. Diseases of the pericardium. 2. Diseases of the endocardium
and its valves. 8. Diseases of the heart-muscle itself. 4. Nervous
diseases of the heart.

I. Diseases of the Pericardium.

Pericarditis, Inflammation of the Pericardium.

The internal layer of the pericardium being a serous membrane,
like the pleura, its inflammation presents precisely the same
anatomical character as that of pleurisy. We find injection,
swelling, and exudation of either a serous or sero- fibrinous, or to
the most part fibrinous fluid. In this latter case the fibrin is pre-
cipitated upon the walls of the pericardium, and forms network-like,
villous masses, which have given rise to the name of cor villosum or
Mrsuium. During the process of inflammation, sometimes the injected
capillaries burst, and thus cause a bloody exudation.

When pus globules form in great abundance the exudation be-
comes purulent, and, if it undergoes decomposition, it becomes a
fetid, discolored, ichorous fluid, as in empyema.

The mere serous exudation is most thoroughly absorbed again,
whilst the fibrinous fluid gives rise to adhesions between the heart
and the pericardium.

A large quantity of this fluid hinders the heart in its movements
and pushes it back from the thoracic walls ; at the same time it may
conipress part of the lung and the large vessels.

It causes also congestion of the lungs, the brain, and the liver,
serous exudation into the lower lobes of the lungs, the pleura, and the
membranes of the brain and oedema of the lower extremities.

Pericarditis may set in primarily in consequence of external in-
juries or taking cold ; or, secondarily, during the progress of acute
rheumatism, which is its most frequent occasion. But it may result
also from pleurisy, pneumonia, or ulcerative processes of the ribs,
vertebra, oesophagus, stomach, liver, &c.; or it may accompany mor-
bus Brightii, tuberculosis, diseases of the valves, cancer, intermittent
fevers, &c. It occurs, too, in typhus, variola, pyaemia, puerperal and
exanthematic fevers.

Chronic forms of pericarditis are caused by long-continued mental
depressions, abuse of spirituous liquors, violent exertion of the body,_
and chronic, gouty affections.



PEEICAEDITIS. 213

Its symptoms, if it is a primary affection, or in combination with
acute rheumatism, are — •

1. More or less violent fever, sometimes commencing with chills,
followed by heat and great acceleration of pulse.

2. As in pleurisy, we must consider the stitch or sharp cutting pain
in the region of the heart as a characteristic, subjective sign, which is
increased by motion, deep inspiration, and external pressure.

3. Dyspnoea is present in almost all cases ; sometimes to such a
degree that the patient is incapable of lying down at all.

4. Cough is sometimes wanting, but in most cases we find a short,
dry, hacking cough.

5. The position of those patients who can lie down is on their left
side or on their back.

Physical Signs.
■ The first which appears (although seldom during the first two or
three days of the disease) is the friction sound, wnich takes place as
soon as fibrinous deposits are formed within the pericardium. These
roughen its smooth surface, which rub together in consequence of the
motion of the heart and the respiratory motion of the thoracic walls.
This friction sound is scarcely ever synchronous with the sounds of
the heart, but is either in advance of them or follows them.

Inspection shows in young persons a swelling or bulging out of the
precordial region in advanced cases, with a large quantity of exuda-
tion. In older persons, where the cartilages of the ribs have become
ossified, such enlargement cannot take place.

Palpation discovers in the beginning of the disease a stronger im-
pulse of the heart at its normal place ; but later this impulse becomes
weaker and finally ceases altogether, when the collection of fluid
pushes the heart back from off the thoracic walls.

When there is a loud friction sound, this becomes noticeable also
to the sense of touch, and feels like the purring of a cat.

Percussion at first reveals nothing. There must be already a con-
siderable quantity of fluid exudation before we perceive the natural
dull percussion sound of the heart spread in a larger circumference ;
and if the lung happens to be in a position that it covers the filled
pericardium, we cannot get a dull sound in spite of even a very large
quantity of fluid.

At first the exudation is confined to the base of the heart and the
origin of the arteries. Here then we have at first to look for an in-
crease of dulness of the percussion sound. Later, the dull percus-
sion sound may increase in the long diameter, down the heart ; and if



214 DISEASES OF THE PERICAKDIUM.

the effusion is very considerable, also in its transverse diameter, so
that if, according to Skoda, the pericardium contain as much as two
pounds of fluid, the percussion sound becomes completely dull from
the second left costal cartilage to the lower border of the thorax, and
from the right edge of the sternum to the middle of the left lateral
region.

Secondary pericarditis of course develops itself differently. It
being a mere additional symptom or consequence of, or complication
with, some other disease, its first onset is hidden by the symptoms of
that disease. But, when once developed, its presence must of neces-
sity be indicated by the same physical signs which I have detailed
above.

Uncomplicated pericarditis is, of course, much more easily cured
than when complicated. In the latter case our prognosis has to be
based altogether upon the nature of that complaint with which it is
combined.

Therapeutic Mints,

Aeon., chill at the commencement, followed by fever-heat ; stitching
pain in the region of the heart ; impossibility to lie on the right side ;
great restlessness ; frequent sighing and taking a deep breath; feel-
ing of fulness in the chest, dyspnoea ; fainting.

Arsen., in consequence of suppressed measles or scarlet fever ; inex-
pressible anguish and restlessness ; worse at night ; the patient finds
no ease in any position ; flushed face ; paralytic feeling in the upper
extremities ; tingling in the fingers ; cold perspiration.

Bryon., stitching pain in the region of the heart, preventing motion
and even breathing ; wants to lie perfectly quiet.

Cactus grand., sensation of constriction in the heart, as if an iron
hand prevented its normal movement ; acute pains and stitches in the
heart; difficulty of breathing; attacks of suftbcation, with fainting;
cold perspiration in the face, and loss of pulse ; palpitation when
walking, and at night when lying on the left side.

Digitalis, copious serous exudation, rheumatism; irregular, inter-
mitting pulse ; brick-dust sediment in the urine.

Iodine, in complication with croupous pneumonia; purring feeling
in the region of the heart ; violent palpitation, increased from the
slightest motion, better while lying perfectly quiet on the back ; faint-
ing spells.

Kali e., stitching pain in the region of the heart; swelling between the
eyebrows and the upper lids, like little bugs; jerking up of the limbs,



DROPSY OF THE PERICAEDIUM:. 215

much friglitened -wlien having the feet touched ; every thing worse
about three o'clock in the morning.

Lachesis, restless and trembling; hasty talking ; great oppression;
anguish about the heart in rheumatism ; irregularity in the beats of
the heart.

Psopin., psoric nature; better while lying quietly.

Puis., the patient weeps easily -, is thirstless ; often changes position ;
has a loose, rattling cough, worse on first going to bed ; rheumatic
pains, which quickly change locality ; inclination to looseness of the
bowels ; suppressed menstruation.

Rumex, during rheumatism ; burning, stinging pain in the left side
of the chest near the heart when taking a deep inspiration, when lying
down in bed at night.

Spigelia, when, notwithstanding the use of Aconite, the fever con-
tinues and the rubbing sound commences ; stitching pain in the chest
from the very slightest motion.

Sulphur, palpitation after going up stairs, with shortness of breath ;
steady pain in the left side through to the shoulders ; red lips ; sleep-
lessness ; after suppressed itch.

Tart, em., in complication with pleuro-pneumonia.

Veratr. vir., faintness after rising from a recumbent position - syn-
cope when walking ; relieved only by lying down.

Hydropericardium, Dropsy of the Pericardium.

The pathological character of this disease consists of a collection of
serum, toithout fibrin. A fibrinous exudation never takes place with-
out an inflammatory process. The serum is a yellowish, clear fluid ;
sometimes, if mixed with blood, it is brownish or reddish, and of alka-
line reaction. A small quantity of such fluid is found in all post-mor-
tem examinations. To constitute dropsy of the pericardium, this sac
must contain at least several ounces of serum, and it amounts in some
cases even to over one pound. When such is the case, the pericardium
is distended, is of a dull whitish color, without lustre ; the fat upon the
heart is gone, and the cellular tissue appears cedematous ; the lung
becomes compressed and the thorax enlarged.

Dropsy of the pericardium is generally the consequence of a hydras-
mic condition of the blood, or of diseases which cause dropsical aflec-
tions also in other parts, such as chronic affections of the spleen, morbus
Brightii, cancer, anasmia, dilatation of the right ventricle, &c. It is
also found in consequence of conditions which prevent the necessary



216 DISEASES OP THE ENDOCARDIUM.

oxygenation and free circulation of the blood, as in empliysema, in
cirrhosed lungs, in defects of the valves of the heart ; also in atrophy
of the heart, as likewise in atrophy of the lungs after chronic pleurisy
or pneumonia.

Hydropericardium is, therefore, altogether a disease of secondary
nature, and its symptoms do not become very prominent, unless a
very considerable quantity of fluid collects within the pericardium.
Then we observe great dyspnoea^ which prevents the patients from
lying down ; any effort to do so at once causes an attack of suffoca-
tion ; they have to sit up day and night with their bodies bent for-
wards. The jugular veins swell and dropsical affections appear also
on other parts of the body ; first in the lower extremities ; then in the
genitals; later, within the peritoneum and the pleurae; finally, the
dropsical swelling invades the whole body, and the impeded respira-
tion and circulation cause stupor and death.

The physical signs are : no friction sound ; distension of the pre-
/? cordial region in young subjects; impulse of the heart either absent

(yyyiAyOG0<^ ^^ weak ; weak sounds of the heart ; and dull percussion sound in a
wider circumference than the heart alone would give rise to.



Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 22 of 65)