629 



HEABT, DISEASES OF THE. 



HEART, DISEASES OF THE. 



second, and the two have been compared to the syllables lupp and 

 dupp. It is heard most distinctly below and outside the left nipple, 

 and with the systole of the ventricles, and on these accounts is called 

 the syatolic or inferior sound. The second sound is heard above and 

 inside the left nipple, and is called the superior sound. It occurs with 

 the diastole of the ventricles, and is called the diastolic sound. 



The pause between these two sounds differs in the length of time it 

 occupies : after the first sound and before the second it is shorter than 

 between the second and the first. 



These sounds present different characters in different individuals in 

 health, and even in the same individuals at different times. They, 

 however, indicate disease when they are permanently altered from 

 their normal character. Thus they may be lower or higher, clearer 

 or duller, muffled, rough, regular, irregular, intermittent, increased 

 or decreased in number. Their quality may be altered, and they 

 may be accompanied by friction sounds from disease of the peri- 

 cardium, or murmurs may ensue from disease of the valves, as bellows, 

 grating, filing, rasping, cooing, or whistling murmurs. There is also a 

 relation between the sounds of the heart and the pulse. The first 

 sound in health anticipates very shortly, but still very distinctly, the 

 pulse at the wrist, hence any prolongation of this period is indicative 

 of some obstruction to the course of the blood. 



A knowledge of the nature and causes of the murmurs and abnormal 

 sounds produced in the heart is essential to a correct diagnosis of 

 diseases of the heart. These murmurs or morbid sounds may arise from 

 disease within the heart, when they are called endocarditil ; or between 

 the heart and its lining membrane, the pericardium, when they are called 

 exornrdiul. The two classes of murmurs may co-exist. The endo- 

 cardial murmurs arise either from an unnatural contraction or an 

 unnatural widening of the orifices between the vessels and cavities of 

 the heart. They may also arise from states of the blood. When 

 caused by the latter they are called functional or inorganic, but when 

 from the former organic. The exocardial murmurs arise from the 

 roughening of the surfaces of the heart and pericardium. 



Each of the orifices of the heart may be the seat of two different 

 kinds of murmurs, the one constrictive, the other regurgitant ; the one 

 occurring with the current of the blood, the other against the current. 

 In this way eight different kinds of murmurs are recognised. It should, 

 however, be remembered that the murmurs on the left side more fre- 

 quently occur than murmurs on the right side. The following account 

 of these murmurs, given in the order of their frequency, will give an 

 idea of their character and the means of distinguishing them. 



1. Mitral reyurgitant murmur. This arises from inefficiency of the 

 mitral valve by changes in its structure, roughness at its edges, from 

 vegetatious shortening of the </< .-en?, or fibrinious clots 

 entangled in them. It is a systolic murmur, and is heard best imme- 

 diately above or to the outside of the left apex. It is faintly or 

 wholly inaudible at the right apex. It is generally permanent. 



2. The Aortic constrict he murmur is the next most frequent abnor- 

 mal sound in diseases of the heart. It indii-ate-< ;i rough constriction 

 of the aortic orifice. It is a systojic murmur, and is heard best at 

 mid-sternum opposite the interspace, between the third and fourth ribs, 

 or the upper part of the fourth rib. It has a high pitch, and is a 

 harsh, loud, and prolonged murmur. 



3. Aortic reyurgilant murmur. It differ* from the last in being heard 

 almost as distinctly at the ensiform cartilage as at the third costal 

 interspace. It is a diastolic murmur, and in of a blowing or hissing 

 character. 



I. Mitral coiislrirlli-r mi'rmur. It is diastolic, and heard best 

 immediately above and about the left apex. 



5. Trictapid rrgurgitant murmur. It is due to regurgitation, or to 

 the collision of the blood amongst the cnordte tcndinerr. i It is a systolic 

 murmur, and is heard best immediately above or at the ensiform 

 cartilage. It is inaudible, or nearly so, at the left apex. It originates 

 in the right ventricle, and is generally a soft murmur of low pitch. It 

 is a rare murmur, and may be often undiscovered when accompanied 

 by a powerful mitral murmur. 



6. Pulmonary crjmtrictire murmur. It indicates roughness, or ob- 

 struction from pressure in the pulmonary orifice. It is a systolic 

 murmur, and is heard best at the sternal edge of the third left cartilage. 

 It is rarely heard. 



7. Pulmonary rfjHrgitant murmur. This indication of insufficiency 

 of the pulmonary valves is very rare. 



8. Tricuspid comtrictiee murmur. It is the rarest of murmurs, is 

 diastolic, and when heard is found at the ensiform cartilage. 



The exocardial murmurs are produced by the rubbing of the surface 

 of the pericardum against the heart, when these surfaces are 

 roughened by the effusion of fibrine from inflammatory disease. They 

 are more or les-s rough according to circumstances, and may entirely 

 cease by the effusion of serum or fluid between the pericardium and 

 the heart. 



Percussion may be employed in distinguishing enlargement of the 

 heart. It is employed either mediately or directly. [PEBCCSSION.] 

 In the normal condition of the thorax, the situation of the heart is 

 easily distinguished by the dull sound given out on percussion. When 

 this dull sound extend* unnaturally in any direction over the region 

 of the heart it is indicative of an enlargement of that organ, a condition 

 which will be made evident by other signs of disease. 



In giving some account of the disorders to which the heart is liable, 

 it would perhaps be best to arrange them according to their causes ; 

 but as it is much easier to obtain a knowledge of the structure of this 

 organ than of the remote causes of its several diseases, we shall here 

 enumerate and describe, first, those lesions which occur in its investing 

 membrane ; secondly, those which affect it as a whole ; and thirdly, 

 those met with in its internal membranes. Those who desire to be 

 further acquainted with this subject are referred to the works of 

 MM. Corvisart, Laennec, Cruveilhier, Bouillaud, Bertin, and Drs. 

 Elliotson, Hope, Watson, Latham, Taylor, Walshe, Williams, Billing, 

 and Aitken. 



I. Diseases of the Investing Membrane of the Heart. 



Pericarditis, Inflammation of the Pericardium, resembles much, in 

 its pathological conditions, inflammation of other serous membranes, 

 and is induced by similar causes, as exposure to damp and cold. It of 

 course presents peculiar symptoms, arising from the situation and 

 nature of the individual organ : thus the patient, will complain of ten- 

 derness over the region of the heart, amounting, when pressure is 

 made, to acute lancinating pain, which prevents him from lying on the 

 left side, and is much increased by drawing deep inspirations or cough- 

 ing, this latter symptom frequently depending on the pleura being 

 involved in the inflammatory attack. This pain, however, is not 

 always so severe ; frequently only a sense of oppression is felt. The 

 pulsations of the heart are frequent, sometimes regular, but at other 

 times intermittent, and so strong as to constitute palpitations ; but 

 still, if much effusion has taken place into the pericardium, the hand 

 when applied to the chest will have difficulty in perceiving them. The 

 praecordial portion of the thorax is often bulged out by the forcible 

 action of the heart and the quantity of fluid effused into the cavity of 

 the pericardium. This effusion varies much in quantity and con- 

 sistence at different periods of the disease : thus, in many cases, only a 

 little bloody serum will be found ; in others, pus in large quantities, 

 coagulated lymph, bands of fibrinous matter uniting the two layers of 

 the serous membrane, and even cartilaginous or osseous deposits. The 

 dull sound discovered by percussion in the priecordial region of a person 

 in health is always, in this disease, increased in proportion to the quan- 

 tity of fluid in the pericardium. In proportion as this fluid becomes 

 organised sounds will be heard by the application of the stethoscope, 

 and often of the unassisted ear, varying in their nature according to 

 the state of the organising process, and resembling at one time the 

 creaking of new leather, at another the rubbing together of paper or 

 parchment, the noise made by a file, &c. Other sounds also are 

 frequently heard, which depend upon endocardial disease. Although 

 at the commencement of the disease the patient may have symptoms 

 of acute inflammation, the accompanying fever having a type suffi- 

 ciently tonic, this state does not endure long; the effusions into the 

 pericardium hinder the heart's action ; the free passage of the blood 

 through its cavities becomes further impeded by various internal parts 

 of the organ sharing in the inflammation ; and, the circulation being no 

 longer vigorously and equally carried on, a crowd of distressing sym- 

 ptoms, such as inability to sleep, startings, faintness, shortness of breath 

 amounting to suffocation, dropsies, &c., render life almost insupport- 

 able, and, if not speedily relieved, soon put an end to existence. This 

 disease mostly accompanies acute rheumatism, particularly of the 

 joints ; and patients, when apparently recovering from acute rheuma- 

 tism, are sometimes suddenly attacked and carried off by inflammation 

 of the pericardium. 



The serious nature of this disease, and the rapidity of its progress, 

 demand, apparently, prompt antiphlogistic treatment ; but, on the 

 contrary, some physicians exhibit tonic medicines. Dr. Watson says, 

 " In a large proportion of cases, whether they be treated well or ill, or 

 not treated at all, the patients will seem to recover." 



The great guide to treatment is the pressure of the symptoms. At 

 the commencement of the disease, if there is dyspnoea and tumultuous 

 action of the heart, bleeding will immediately relieve. Towards the 

 termination of the disease such symptoms are relieved by wine and 

 stimulants ; otherwise the general treatment for rheumatism is admis- 

 sible in cases of pericarditis. 



II. Diseases nf tke Heart itself. 



Carditli; Inflammation of the If cart. The proper muscular structure 

 of the heart is not free from the attacks of inflammation, though 

 whether the morbid action commences in this structure, or in the 

 membranes, is difficult to determine. This, however, is certain, th;tt 

 when inflammation of the muscular structure exists, there will also bu 

 found traces of it in the pericardium, or in the lining membrane of the 

 heart, or in both ; and wo cannot point out symptoms which distin- 

 guish the one from those of the other disease : the treatment con- 

 sequently, will be similar in both. 



/////" ftrnfihij nf the Heart. Independently of any morbid process 

 existing in itself, the muscular structure of the heart is often greatly 

 increased in bulk, as if the nutritive process were too active in pro- 

 portion to the absorbent, and new matter were deposited more rapidly 

 than the old could be removed. From the peculiar nature of the 

 functions of the heart, this disease becomes very important, and its 

 effects not less dangerous than manifold. It is usually divided into 

 three kinds ; namely, simple hypertrophy, the least common, in which 



