Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

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Therapeutic Hints. — Compare Hydrothorax.
II, Diseases of the Endocardium.

Endocarditis, Infla7nmation of the Endocardium,

When anatomically examined, this affection exhibits the lining
membrane of the heart reddened, injected, swollen and covered with
fine fringes, which gradually change into papilla and wart-like excres-
cences, which consist of the softened lining membrane. In conse-
quence of this softening of the membrane, it is of frequent occurrence
that the chordee tendinese, or the valves themselves, are torn. In rare
cases, when the endocardium is torn at a place where it covers the
heart muscle, it causes the blood to rush into it, and to distend and
soften the heart muscle itself, constituting in this way what is termed
an acute aneurisma of the heart.

Other consequences of such inflammation are: adhesion of the
chordge tendine^ and points of the valves, either between themselves
or with the walls of the heart; extension of the inflammation to the
heart muscle or myocarditis; coagulations of fibrinous exudation
which cover the papilla, and wart-like excrescences about the valves,
and which are often driven into the arteries by the stream of blood.


Sucli pieces or lumps of coagulated fibrin are called emboli^ and tliey
may become the cause of hemorrhagic infarcts or abscesses, apoplectic
clots, or, if they obstruct the larger vessels of the lower extremities,
they may cause gangrene of the toes.

Endocarditis is almost always a secondary affection ; primarily (in
consequence of taking cold, or from traumatic causes) it is of very
rare occurrence. Grenerally it is found in the left ventricle in conse-
quence of metastasis during acute rheumatism of the joints, especially
when a great many joints are attacked or where the disease jumps
from one joint into another. It is also found associated with peri-
carditis, myocarditis, and the acute form of morbus Brightii, after
scarlet fever ; it also has been observed in the course of puerperal
fever, typhus, and measles.

Its invasion, during these different affections, generally takes place
. unnoticed ; because it is quite seldom that the patient complains of
pain in the region of the heart when attacked in this way. But once
established, we observe the following symptoms :

1. Palpitation of the heart, and soft, easily compressible, and small

2. Dyspnoza^ which is the greater the more the respiratory organs
become involved in the morbid process, causing quick and unequal
respiration, fainting, or congestion of the brain, with headache, delir-
ium, sleeplessness, sopor.

8. Higher degrees of endocarditis are frequently attended by

Its physical signs are the following :

1. The normal sounds of the heart are stronger, and audible over
a larger space than natural — in the beginning of the disease ,

2. In place of the first tick we hear, at the apex of the heart, a
noise, which shows that the mitral valves have become diseased; and,

3. The second tick of the pulmonary artery is increased in conse-
quence of the insufficiency of the mitral valves, causing an overflow
in that artery.

4. Percussion at first reveals nothing, but at a later period yields
a dull sound over a greater space than natural, because of the dilata-
tion of the right ventricle in consequence of impeded circulation.

Endocarditis may pass over into a perfectly healthy state ; but it
generally leaves diseases of the valves ; either thickening, adhesion,
or perforation of them; and in consequence of this, dilatation and
hypertrophy of the heart.


Therapeutic Hints,

Compare what has been said under Pericarditis. The characteris-
tics of the remedies acting npon the heart must be applied here too.
In addition, I shall mention only —

Spigelia, the most important ; waving palpitation, not synchronous
with the pulse; pulsating and trembling carotids ; purring feel over
the heart ; rheumatism.

Aurum, rheumatic pains, previously wandering from joint to joint,
become fixed in the region of the heart and cause great anxiety ; the
patient has to sit perfectly quiet in an upright position ; palpitation,
with irregular, intermitting pulse and short breath, feeling as though
the heart ceased beating for a while, and then at once one hard thump
is felt.

Bismuthum has not yet been tested in practice, but its pathological
eftects seem strongly to indicate it ; they are inflamed spots in the
endocardium, black coagulum in the heart.

Iodine, according to Kafka, if Spigelia has failed to act favorably
during; 24-36 hours.

Kali carb., where, in place of the first tick, a blowing noise and a
louder second tick of the pulmonary artery is heard, (Kafka ;) where
there consequently exists already a stagnation in the pulmonary cir-

In consequence of Endocarditis originate diseases of the valves ;
which consist either in —

1. Insufficiency of the valves; or in —

2. Go7istriciion of the valvular openings.

I. InsuflBeieney of the Mitral or Bicuspid Valve.

In consequence of this deficiency the blood regurgitates during the
systole into the left auricle, thus checking the normal flow of the
blood through the pulmonary vein. This causes an accumulation of
blood in the lungs, in consequence of which the blood is pressed
backwards into the pulmonary artery, causing here a widening of its
volume, and, in consequence, a louder second tick. This increased
second tick of the pulmonary artery is the most characteristic sign of
insuf&ciency of the mitral valves.

The check of circulation in the lungs causes further dilatation and
hypertrophy of the right ventricle, because it requires greater power
to force on the accumulated and obstructed blood. By-and-by, how-
ever, this increase of power in the right ventricle diminishes again,


and thus tlie veins of the kings become permanently overcharged
with blood ; the same result takes place in the vense cavge, and, in con-
sequence, the liver, spleen, and kidneys grow hypersemic, which
finally end in dropsy. This stagnation of blood in the lungs causes
also dyspnoea, bronchial catarrhs, periodical hemorrhages from the
lungs, passive hyperasmia of the brain, an undulation of the jugular
veins, cyanosis.

The characteristic physical signs are the following :

1. In place of the systolic sound we hear a noise at the point
where the apex strikes at the thoracic wall.

2. The diastolic of the pulmonary artery is much increased.

3. The dull percussion sound of the heart extends further in
breadth, on account of the dilatation of the right ventricle.

2. Constriction of the left Auriculo -Ventricular Opening:

As in this case the narrowed and roughened orifice does not allow
the blood to enter freely into the left ventricle, its passage through
this opening is also perceptible to the ear, and thus we hear during the
diastole a noise at the apex of heart. At the same time the narrowed
opening prevents the normal quantity of blood from passing through
into the left ventricle, which causes an accumulation of blood in the
left auricle ; hence, a check of flow in the pulmonary vein ; hence, an
overfilling of the lungs ; hence, a greater backward pressure into the
pulmonary artery ; and thus all the necessary consequences which I
have detailed under the head of defective mitral valves, only much
more rapid and much more intense.

In addition it causes the left ventricle to grow smaller and the
aorta to grow narrower, on account of the deficient quantity of blood
which enters into them.

Its characteristic physical signs are the following :

1. We hear at heart's apex instead of the diastolic sound a noise.
This noise is sometimes similar to the purring of a cat, so that it even
may be felt;

2. The diastolic sound of the pulmonary artery is louder ; and

8. The dull percussion sound of the heart extends further to the
right, on account of dilatation and hypertrophy of the right ventricle.

In cases where the mitral valve is defective and the left auriculo-
ventricular opening constricted at the same time, then we hear a noise
during the systole as well as during the diastole. The sound of the
aorta is mostl}^ weak. The pulse is in most cases weak, not corre-
sponding to the violent palpitation of the heart.


3. Defective Aortic Valves.

As soon as fhese valves do not shut tight, the blood which has
been driven during the heart's systole into the aorta, rushes, during
its diastole, back into the left ventricle, causing an abnormal quantity
of blood to collect there. To get rid of this the left ventricle has to
make greater efforts to rid itself of it ; and, in this way, it gradually
grows wider and thicker — eccentric hypertro2:)hy of the left ventricle.
By this increased capacity of the left ventricle the consequences of the
defective aortic valves become, so to speak, counterbalanced. For a
good while it prevents an overfilling with blood in the pulmonary
veins ; we observe no slowness of pulse, no decrease of arterial blood,
no cyanosis or dropsy. For, although the defective valves retard the
circulation and make the blood venous, the hypertrophy of the left
ventricle hastens the circulation and makes the blood arterial again.

Therefore, we find that patients thus affected suffer comparatively
little ; the most frequent signs are, congestion of the brain, which
manifests itself as dizziness, noise in the ears, flickering before the
eyes, headache, hallucinations, red face, &c.

Later, however, the increased capacity of the left ventricle is not suf-
ficient longer to overcome the consequences of the defective valves,
and thus all the symptoms of impeded circulation, as described above,
commence to set in. The characteristic physical signs of defective
aortic valves are the following :

1. Diastolic noise of the aorta, in consequence of the regurgitation
of blood into the left ventricle during the heart's diastole ;

2. Greater extension of the dull percussion sound in the heart's
long axis, on account of the hypertrophy of the left ventricle ;

3. Arched appearance of the region of the heart for the same
reason ;

4. The impu.lse of the heart's apex is felt lower down and outside
of the nipple line ;

5. Strong, jumping pulsation of the carotid arteries; and,

6. Short, jerking, wiry pulse.

4. Constriction of the Aortic Opening.

The disturbance of circulation is, in such a case, of course, still
greater than by mere defect of the valves ; and, therefore, the patient
soon shows symptoms of deficient circulation ; such as paleness, small,
thread-like pulse ; fits of fainting ; coolness of the extremities ; ansemia
of the brain. At a later period the veins become overcharged with


blood, and in consequence we find the patient suffer witli dyspnoea,
cyanosis, and all the other symptoms of heart disease.
Its characteristic physical symptoms are :

1. Systolic noise, which is often heard in the carotid.

2. Dull percussion sound, somewhat extended in the direction of
the longitudinal axis of the heart. In consequence, dilatation and
hypertrophy of the left ventricle.

3. Apex lower down and outside of the nipple line.

4. Pulse small, wiry, irregular and thread-like.

In case there also exists at the same time a defect in the aortic
valves, we may also hear a diastolic noise.

5. Defective Tricuspid Valves.

This defect allows the blood to regurgitate into the right auricle,
when the heart contracts. Thence the retrograde stream of blood goes
into the vense cavse and the jugular veins ; hence we feel a pulsation of
the jugular vein, synchronous with the arterial pulse. This retro-
grade motion of the blood causes over-filling of all the veins, and its
consequent results, hypereemia, cyanosis, hydrops, &c.

Its characteristic physical signs are :

1. Systolic noise in the right ventricle.

2. Sioelling and pulsation of the jugular veins.

3. More extended dull percussion sound in the direction of the breadth
of the heart on account of its right auricle having become enlarged
and hypertrophied.

This complaint is generally a secondary affection, in consequence of
diseases of other valves ; and then, of course, it is attended by all the
above-mentioned disturbances and signs.

The constriction of the right auriculo- ventricular opening^ the defect of
the valves of the 'pulmonary artery^ and the constriction of the pulmonary
opening^ are of such rare occurrence, that even Skoda did not observe
them on the living. Skoda, p. 371.

The treatment of all these difl'erent valvular affections has to be
adapted to each single case, and it is not the diseased valve which
points out a particular remedy, but the individual symptoms by which
the whole morbid process manifests itself.

Still I might give some general dietetic'rules, which are of great
importance for the treatment of these different affections.

Patients in whom we find symptoms of congestion of the brain or
chest, ought not to eat much animal food ; must avoid all sorts of
stimulants, and especially coffee, and all kinds of spices. Mental ex-


citements and depressions are alike "hurtful to them ; and neither a too
high nor a too low degree of temperature is advisable.

Patients, however, in whom anaemia and debility prevail, ought to
eat animal food and drink beer or wine ; ought not to over-exert them-
selves, and ought to have all the fresh, pure air they can get.

Amongst the most important remedies used in such complaints, I
find Ars., Calc. c. Digit., Ferrum, Iodine, Kali c, Lach,, Natr. m,, Phos.,
Plumb., Puis., Sepia, Spongia, Sulph.

Therapeutic Hints*

Calc. c, trembling pulsation of the heart, worse after eating, at
night with anguish ; menses too early and too profuse.

Ferr., chlorotic symptoms ; congestion of the head ; spitting of
blood ; palpitation, better from slowly moving about.

Kali hydroj., darts in the region of the heart when walking ; after
mercurial poisoning; after repeated attacks of inflammation of the

Natr. mur., irregularly intermitting pulsation ; fluttering of the heart
with weak, faint feeling, necessity to lie down ; coldness of hands and
feet ; numbness of the hands, better from rubbing ; cutting pain in
urethra after micturition ; menses scanty

Phosph., congestions of the lungs ; tightness across the chest and
tight cough ; spitting of blood , palpitation worse after eating, or any
mental emotion ; yellow spots on the chest ; painless diarrhoea.

Rhus t., palpitation worse during rest; pain from the region of the
heart into the left arm, with numbness ; rheumatism.

Spongia, violent palpitation, awakens after midnight with a sense
of suffocation ; loud cough, great alarm, agitation, anxiety and diflS-
cult respiration ; violent gasping respiration ; pain in the heart.

III. Diseases of the Heart-musele.

Myocarditis, Carditis, Inflammation of the Heart-muscle^

Is found always in connection with peri or endocarditis ; and then, its
seat is generally the left ventricle. The substance of the muscle ap-
pears yellowish; sometimes fatty degenerated. Its most frequent
occasion is acute rheumatism of the joints, but it has also been ob-
served in the course of puerperal and exanthematic fevers.

There are no characteristic signs of this complaint, because it is
alrnost always mixed up with peri or endocarditis. Mild forms
pass over without any consequences ; but if it extends to the form-


ation of abscesses, it may cause widening of the heart-niuscle, (partial
aneurism,) or bursting of the heart-muscle, and consequent sudden
death. When the abscess discharges into the ventricle, it causes the
formation of emboli, with their consequences.

Hypertrophy and Dilatation of the Heart.

Hypertrophy consists in an increase of mass of the muscle of the
heart, or a thickening of its walls, whereby the inner cavity becomes
narrower: this is the so-called concentric hypertrophy ; or the heart-
muscle is increased in thickness, and the inner cavity widened at the
same time; this is the so-called eccentric hyi^ertroj^hy .

When, however, the inner cavity is widened, and the heart-muscle at
the same time has grown thinner, then it is called dilatation of the heart.

The most frequent of these three forms of altered, conditions of the
heart-muscle is the eccentric hypertrophy.

But it is not always the whole heart that is enlarged or dilated ; it
is generally only one-half of it that is thus affected. A hyper-
trophied left ventricle makes the heart longer, reaching further doAvn
in the left thorax, whilst an eccentric hypertrophy of the right ven-
tricle makes the heart broader, so that it reaches further over into the
right thorax.

Both hypertrophy and dilatation have, as their most frequent cause, a
disturbed circulation, in consequence either of diseases of the valves
or diseases of the arteries, like aneurism, or in obstacles in the capil-
laries in the lungs. Also pericarditis and myocarditis, mental excite-
ments, strong coffee, tea, and spirituous liquors have been found
exciting causes of this complaint.

Total hypertrophy shows, on percussion, dulness of sound, increased
in all directions ; the impulse of the heart much increased, shaking
the whole thorax.

The apex strikes much lower and towards the left of the nipple-line.
Hypertrophy and dilatation of the left ventricle gives nearly the same
results. The difference between it and the total hypertrophy is, that the
dull percussion sound does not extend so far towards the right thorax.

In hypertrop)hy and dilatation of the right ventricle, we find the
dull percussion sound further towards the right side.

The impulse is not so strong and not so shaking, and the apex
strikes towards the lower part of the sternum, and over to the right
side. The jugular veins swell and undulate, and very soon associate
with it cyanosis, dropsy, and aftections of the lungs, (blood-spitting.)


Tlierapeiitic Mints — Compare wliat has been said of tlie dif-
ferent affections of the heart. As hypertrophy is more or less a con-
sequence of the one or the other, the characteristic indications of the
different remedies there described must also fit here. I have only to
add ;

Plumb, ac, stitch in the region of the heart during an inspiration,
with anxiety; heat and redness of the face; rushing of blood in the
region of the heart during a rapid walk ; anguish about the heart,
with cold sweat; palpitation of the heart.

Post-mortem, after poisoning, has shown that the serous coat of the
pericardium is lined with a layer of reddish- gray, fine villous, meshy,
firm, exuded lymph. The heart is more than double its natural size.
The wall of the left ventricle is more than an inch thick.

Kalmia lat., after rheumatism.

Fatty Degeneration of the Heart.

This consists either in a deposition of fat all around the heart-muscle,
or in deposits of fat corpuscles between the primitive fibres of the
muscle. In the latter case the muscle has a pale-yellowish color, and
its substance is easily torn.

It is generally found in persons in whom all the nourishment seems
to be converted into fat ; likewise in consequence of general disturb-
ance of nutrition, as in old people ; in tuberculosis, cancer, Bright's
disease ; and, finally, it has been observed as the results of hypertrophy
and diseases of the valves, and of myocarditis.


Contrary to hypertrophy, the more marked the fatty degeneration
of the heart becomes, the weaker becomes the impulse of the heart,
and the softer and smaller the pulse.

In its later course we observe cyanotic and dropsical symptoms ;
and death may suddenly occur in consequence of rupture or paralysis
of the heart, or in consequence of disturbed circulation through the
brain, in the form of apoplexy.

These symptoms offer no therapeutic indications. Persons inclined
to growing fat ought not to drink malt liquors; ought to exercise
much in the open air. Wine and water would be much better
adapted to them.


IV. Nervous AfFections of the Heart.

Nervous Palpitation of the Heart.

This affection occurs in spells, and is generally more distinctly felt
by the patients themselves than by the examining hand of the phy-
sician. When, during the attack, the patient's face is red, then the
pulse is generally full and large ; whilst, when the patient looks pale,
the pulse is small and intermittent. We often find it accompanied
with dizziness; roaring noises in the head; headache; flickering
before the eyes; trembling; fainting fits; and pressure and choking
sensation in the throat ; the patients complain of a sensation as though
the heart were jumping up into the throat.

Its causes are various. It is found most frequently in ansemic and
chlorotic individuals ; also in women during their climacteric period ;
in hysteric women, and in diseases of the womb ; during the time of
puberty ; after sexual excesses. Spinal irritations may also cause it ;
and we find it in children who grow very fast, or whose intestines are
irritated by worms. Very often it is brought on by mental emotions;
and sometimes we do not know any cause whatever.

The physical examination during a spell often discovers abnormal
noises in the heart, which might easily give rise to diagnostical errors.
The heart must then be examined at some other time ; and if we
then hear the normal sounds, we may be pretty sure that we have to
deal with nervous palpitation.

TJiercipeutic Hints^

Aeon., in young subjects; after fright; after wine.

Arsen., after suppressed herpes circinatus and suppressed perspira-
tion of the feet.

Asa feet., in women, after suppressed discharges or bodily exertions,
Avith small pulse ; breathing not oppressed.

Bell., with congestion of the head.

Calc. c, after suppressed eruptions and pimples on the face ; onan-

Camph., when attended with coldness of the skin; cold extremities;
pale face ; and sudden oppression of breathing.

China, great weakness from loss of vital fluids ; long-continued

Cocc, tremulous palpitation from quick motion and mental excite-
ment, with dizziness and faintness.



Coffea, after excessive exaltation.

Ferr., anemia; throbbing in all the blood-vessels; soft bellows-
sound at the apex.

Graph., amenorrhcsa ; pimples on the face about the menstrual

Moschus, when combined with hysterical symptoms.

IMux v., after coffee, wine, liquors, spices.

Natr. mur., fluttering, long-standing chlorosis, with torpid skin and
suppressed menses.

Nitr. ac, when caused by the slightest mental excitement.

Opium, after alarming events, causing fright, grief, sorrow, &g.

Phos., dyspnoea, tightness across the chest, great weakness, and after
any little mental excitement.

Phos. ac, in children and young persons who grow too fast; after
self-abuse ; long grieving.

Puis., young girls during the time of puberty ; from suppressed

Rhus, t., always worse when being quiet.

Secale, with profuse menstruation of a watery discharge.

Sepia, tremulous, intermitting pulsation ; suppressed menstru-

Thea, after exciting talking and mental exertions, with sleep-

Angina Pectoris.

Without any premonitory signs the patient feels a pressing, aching
pain in the middle of the sternum which takes his breath away, and
obliges him to keep perfectly still. Gradually increasing in violence
the pain spreads, in most cases, from the middle of the sternum
towards the left plexus-brachialis, and thence down into the hands and
lingers, seldom spreading over to the right side and arm. This pain
is attended with the greatest agony and dyspnoea ; the patient's face
looks pale and collapsed ; the front part of his head covers with cold
perspiration, and his limbs grow cold. He groans and moans, and
perhaps in a few minutes the attack is over, sometimes lasting, how-
ever, from a quarter to half an hoar, generally ending with eructa-
tions of wind.

During the paroxysm the action of the heart is increased, whilst,
in some cases, it is found to be weaker. Consciousness is never lost.
Such spells are rare in the commencement of the disease, but they
gradually grow more frequent, so that in bad cases they occur daily.


After an attack the patient feels weak, and the aching in the chest
and the left arm leaves behind for some time a feeling of numbness.

Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 23 of 65)