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·CLUES IN THE DIAGNOSIS AND TREATMENT OF HEART DISEASE

·Pabl I10 Iber 12
AMERIC LECTURE SERIES
V noget ph 1
TH RANNERSTOVE DIVISION
AAIERICAN LECTURES IN CIRCULATIOY
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Cleveland Cir
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·CLUES IN THE
DIAGNOSIS AND
TREATMENT OF
HEART DISEASE
By PAUL D WHITE, M.D
PUBLISHFR
U.S.A
CHARLES CTIO VIS
il nus
Springfield

·CHARL C TH04 PUBLISHER
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This monograph protected by copyright. A
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co chi 1953 by CLARE C TWOWA
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·PREFACE A LONG experience in the practice of medicine with purtxular attention to ando ocular disease has revealed the value of a search for diagnosus, prognosik and therapeutic duas often not listed 3 fach in the cur rent loubools or general arucio. Although such clue have frequently been dukused and analyzed in individual re Fearcha and published papera they have now been arktabled for ready reference Duning the last 10 years or more I have been in the habit of giving a lecture on the subject in graduate Cook in hort does The selulness of such preventauon has resulted in a request that I expand it for publication into a small volume The chapers in this book present clues obtained from general observation of the patient from fiu past and family bustorict from her symptotos from signs obtained by physi cal cumination aucultauon and phygmomanometry and the resulu of x ray and clearocardiographic studies Snce this volume u intended largely for the general prac nitionat I ha concluded very hule of the finding obtained by the more specialized laboratory procedures such a cardiac arhetenzation angiocardiography tallstocardı ography phonocardiographs and biochemical technia. For a discusion of the findings in such technio the reader u referred to the larger or special olums concerned ahert with Before completing the manustip I have collected from arlous medical collages in this country and abroad ad about some of their own pet cluss und thus, through their Lindner I have renforced my own experience with thieina. Fot this I am indebted to the following plys sans in ·11 DLACNOSIS AND TREATHLYT OF LAIT DULASE Hell us to many others, too numerous to name liete llose i titing I have read or those lecturo I have attended Drs H Alessandr Santiago Chile R. Arxala, Havana, Cuba E. Conila Andrus Baltimore vid R. Annar Griz Santiago Chile Arlie Bames, Rochester Minn D Eran Bedford London England Julien Benjanın Cincinnati Ohio Edward F Bland Boston, Mass. Geoffrey Bourne London, England George Burch Near Orleans, La C Sidney Burwell Boston Mass. Maunce Campbell Lon don England J H Cannon Carleston S C Pedro Canillo Havana Cuba Franas Chaniberlain San Fran Cisco Calif Ignacio Clarez, Alexico City L Condorelli Rome Italy Pedro Como Buenos Aires Argentina Clar ence de la Chapelle Net Forh, NY Ierus Dexter Bos. ton Vas. Eugene Drake Portland Ve Picrre Duchosal Geneva Switzerland Thonias Durant Philadelphia Pa Laurence Ellu, Boston M. Tulliam Evans, London England Harold Feil Closeland Ohio Mariliall Fulton Providence RI 1. Gallai ardın Lyon France George Coffith Paudena, Calif Burton Hamilton Boston, Mass. Tinsley Harrion Birminglam Ala. Jolin Hepbum Toronto Ontano George Herninann Calaton Teras T Duchett Jones Ver Tort II William J herr San Francisco Clif Robert Ling Seattle Vlash Carla Laubry Paru, France R. F Leinbach Charlotte VC J Lenegte Pan France Samuel Lone, Boston Vass. Robert L. Lay Vei York N Camille luan Tans, France David Littmann Boston Mass. R Bruce Logtie Emory G (renival Londres Rio de Janeiro Brazil Kempton Vaddo, Sydiky luuralia E Magalhaes-Gomes, Rio de Janeiro Branl I Alaluim Lauennc Srinesland Benedict Varsell Boston Moss. Fdkin P Vaynard Brooklyn AS Roberto Vencia de Olivein Rio de Janeiro Bruil Jolinson veruire Cincinnati Ohio Ilugh a lorgan Vashvilic Tenn GustaVylin, Stock ·MEACE holm Sweden joba Oille Toronto Canada Edward Orgain, Durham NCT Ortu Ramires Melco City Irvinc Page, Clercland Ohio John Palmer Manual Canada Harold E B Pardee New York NY Joha Pathinon London, England George Pickering, London, England Samuel Proger Boston Mast Vittono Puddu Rome laly F Rojas Villegas Santiago Chile Harold Rykert Toronto Ontario P Rylant, Bruurels Belgium John Sampson San Francisco Calif Roy Scott Cle cland, Ohto Harold Segall Blontreal Canada FH Smirk Dunedin New Zealand F Janney Smith Detroit Mkhi gan Hugh Smith Greenville S CH Snellen Leiden, Holland Paul Sorolo Helsinki Finland Howard & Spragike Boston Neo Eugene Stend, Durham C William D Stroud, Philadelphu P& Alberto Tagain Buenos Ara, Argentina Helen 1. Taussi8 Baltimore Md. William P Thompson Los Angeles, Calif Lonis E. Viko Salt Lake City Utah Bernard J Walsh, Wushing ion, DC Fomin Wheeler Bonton Man. Conger llal flamu Boston Vass. Charla C Hollerth Philadelphia Pa loun llo8 Boston Ala R 11 ottheim 11 urzburt Germany Paulllood, London, England. Some of the more epigrammate observations contained in the replies of these medical Inends I am including us dirait quotations generally verbatim I appreciate very much the perintion to do so. Also I would like to pre my appreciation the cditors of these olumo Da Inine Page and L c Cot CUTIN for asking me to write this book in the host pla c to my secretary Slix Helen Donwlan for prepanng the mantsript, u Vin louise Wheeler and Dr Allan Fried heh for assembling the illustrations and to the publishers Estheir nendly cospetation Pal. D lurt Bo ton lassachusetts

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·CONTENTS Page Y PREFACE LIST OF ILI USTRATIONS 3 3 Chapter INTRODUCTION 1 GEDAL CLUES 2 PAST HISTORY 22 30 3 FAMILY HISTORI 4 SYMPTOMS BREATING DIFFICULTTES 5 PAN 53 6 PALFITATION 6 80 7 OTHE Siarious 8 Sisus 88 9 HEART SOUNDS AND AILTURS 100 10 Bloop PRISURE 133 156 11 Ror\TUCNOLOGI 19 EISCTROCARDIOGRAPHY 171 1% TILFRAPEUTIC CLI> APPENDIX I DE

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·LIST OF ILLUSTRATIONS Ch ples II THE KA SHADOW OF TIE H IT AND Cu PHO 1 X ny pature dowlog dl marked left matricolor enlarge Mcht 102 2. Xny sovint elmarted rett entricular kergement 101 ZB Lalaul Kw 103 JA. Yty showing enlargementſ the left alom 106 SB, Lalenalky 107 Yny bowing a Led ardmc calargement 103 5 Ynay choulor cpuricolt aneurys 109 o x ay showing it t the audit pas 110 7L X - sbona ing large per cardul custoo 112 70 Kruy show 14 Lirge penardul of lo after pericardial up with 1 troduction li 115 1 X IItboltidal agiaton 1 Crne i chronk Opatrict perkardith 114 BB Lateral y 15 9 X-ray showing netry of the threat orta 116 101 \ y bowing the work arcb prior t doetunt neury of the marta 118 100 ray baken ten mo ths fter I she log corti ditaron 119 1 X-ca) uoming wxleomy and calculation in the scending sorud + Twerk portit! 120 12\ Yty showing parculum of the porta 11 In y soning cow station of the mu * th notchim of the rib 12? 1 \tayhon Pfull mpul deferı 124 14 x y toni s patent doce meroan 15 13 L \mchom ng large depold g* f the mediastwo 116 15R Yam of the unde che fict 12 year I Letal 177 161 \+1) boning en ate puposary edmath ddatalon of the wuperior icoana U of the are1 161 na taken at karlog of the ru pulmonary edema enlarged kit luto 199 17 Yay showing polmonary Arthu enou fwa 190 boy older patiOn thon ng ·DIAGNOSIS AND RATHIEYT OF FAIT DISFANY Cheplo 12 ELICTLOCHWOOLAMO CULTI I gure 1: Electrocardiogram koning vul dutier 1.16 19 Electrocardiogram of two cases thering 1) Right uh debation due to entkal beart poatlon J318 B) Right Exh deration with right cotricul renlargement 13.8 70 Elettrocardiogram fino cuxo showing 1) Left avis desution th horizonul beart posluon 1 10 D) Left ath der Gation * th left entricular enlargeoint 1 10 21 Elettrocardiograd shon er in cried T K un Lady ? and wochleith crucılbart poutlo 141 22 Elettroc neogr mm In casos tonis 1) Wide Pr o due to left atrlal eolaryerdent to tral Chow 1+2 D) High Pwa mociated with right catalar enlarge mont lo congeploa) heart disease 112 23. Electro rdrom showing acute mr pulimon 1 4) During maumum effect B) Ifter rerosary 145 24 Electrocardingram whoring chrob or pulmonal nd also dig lalu effect 14 23 Llect or rdiogram show my cut sterior myocardial i Garc 110 * Eelrox dropm sbow ng dui posterlo myocardul in tarctron 116 77 Electrowdrogram shoming effect of digitalis 147 70. Electrocardiogr mshoning wbacate upterosepul mo ardlal i farction 140 19 Electrocardiogram show and healed (to lateral mo ardial infarction 149 90 Electrocardiogram showing A brute posterior niynardial inlarcutoa 250 31 Electrocardiogro shon ng dl heaked posterior para ardbal mfrition 150 12 Electrocarlion showing the effet of a tem morarlbal deux of ualmen ongi 33 Electmandort mshening atfect of me perta del 15$ 4 Eketrocardingtam shrning h komurku perkardith 151 * Electrocardiogram shuning etect loy cha 111 tron ·CLUES IN THE DIAGNOSIS AND IREATMENT OF HEART DISEASE

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·INTRODUCTION THE PRACTICE of medicine has secta! attractive feature which render it one of the most fascinat ing adventures in the world. In the first place it deals with people an absorbing occupation in itself both because of its humanitarian role and because of the infinite vanety of personalities invol ed. One must individualve wrictly and study and treat the nliole man as well as the disease (10 thus case of his heart) In the second place it is a Kcientific discipline which has greatly advanced in factual knowledge dunog tlic last few decada and allows us now to bring hope to many particots who were doomed a genera tion ago And, finally it is very often a fine art of detection which requires for iu solution an assembly of revealing clua The nell rounded practicing plıysician needs there forc in his own person a fair Hare of all these three at tnbutes 1) the loc of humanity ") a scientiſic inlod and 5) an interest in the unraveling of mysteria 4 bumy doctor hardly needs to spend much umc reading detectie horlo tor I is entertainment for he is faced by many problems of this sont in hu daily life The diagnosis and treatment of heart disease lend tlıcın selves especially well to the gathering of clues for cluida: uon. E on what seem like straight forward laions may in their evolution develop anexpected complications which might have been foreseen had certain dua been looled for and noted along the way And not infrequently there are olmunia at the sety onset diat can be clared by a con- KIOUS search for clue In the past, althoughi suemauc questioning and examination of patients may liave been 3 ·1 PLAG YOUD AND TREATIENT OF HEART DISEASE the customary rule there has been on occuion little effort to separate the red herange from the important clua. There has tended to be a haphazard recording of facts without emphuis on certain sigruficant clues which an be Kentifically appraised. A further point of considerable im portance u that one cannot rely on the absence of symptoms or signs unless they have been specifically inquired into or looked for A doctor who cannot take a good liis tory and a patient who cannot give one are in danger of giving and receiving bad treatment. And finally In di agnosis one should seldom think of any angle case onc may have seen. Thu often warps the judgment as Robert Hutchison lius mentioned, and yet it is true that very rare cause of discas such as amyloidoou and neoplam should be thought of in very obxure cases. Do not, howener veld to the natural temptation to make a map diagnose ·CHAPTER 1 GENERAL CLUES Tu cha tho lumeell scos, ques ton and examina a pauent has a great adiantage over the one to simply reads or hean the patients record pre pared by Kancunc clse Mot, of course that he could baie necesurly prepared a better record, but there are some thiagt in dealing directly with a person that are luard to put down on paper le is the disadvantage that presents A completc plature of a case 10 a donkopathological conſer ence although that dificulty is counterlalanced by the fact that the detective on the case can usually count on the probability of a rare or unusual diagnosis Tire general appearance of the patient and hn or her menual attitude are of the greatest importance at the very vulst in the appraisal of a case and though quchis noted by the obserser are rarely recorded. They are clues for the correct interpretation of symptoms which they are described by the patient and hasca baning on prognosy 13 well as on diagnosis and treatment In only do they help centually in outlining framment but they stat quite early ethiet or 1904 it will be mass of diffcult to secure the confidence of she patient and the exists a full coviperation in carrying out treatment which often mist eiend for a good niany tats. 5 ·6 DLAL VONIS AND TREATIENT OF FAIT DISEASE The physiqun must himself of course sympathetically vecene the parent and listen to the story before enying to impose his own personality The very first lour of consul tation may male or mar all ſuture relationshups and render cusy or diſhcult the anablishment of a correct diagnorus and proper treatment In accompluhing thu there is a luppy mean Letteen 2 studied cold objective manner and 2 maudlin olet-soliacude though cach case must perforce be Judged and traated on individual meriti. Even the doctor s secteury who mala the fint appoint ment by telephone or direct conyctuation or a friend or a member of the family or another physkun ulo refers the paucit, may not infrequently be ablc to add comments of conuderablc importance about the plıysal or mental at titude of the patient before the doctor himself meets him these should not be ignored though they may need to be currated later on better acquaintance Is the patient impetuous or 01 cranxious or us he slot in seeking advice and tending to minimize his troubles! The first few minute of the consultation afford such in formation whide u of course essential in the clucidation as well as in the approval of the symptoms. Is he net ously sensitive u Ith a low thrashold and so more conscious of hus trouble whether pathological or plinologkal or a mix ture of both? Or is he calloiu about lumsell or otlien an 10 insensitise that come discare process may be fairly ad yanced before he is actually apare of it or willing to ac nonledge that lie u sichr It is sometimes difficult to define these attribute of the patient but euch more is it true that they are infrequently put down on the cake record although they are appreciated and actually subconsaously waken into consideration of the doctor himself Voredi et what is the client of the patient s knowledge and insiglit into hu medical Hatus? How much has the brent ·GEELAL CULES 7 told by other doctors by members of bu family and by friends. And how much of what he has been told us true or doos he belice? Is he e reader of medial columns in Denpapers or of medical articles for the layman in popular magazine? Does he rad medical books in the libraria or at hone? How nich is hu vocabulary in medial tertius? How much does he actually Loon of these terms and how much does he apply them in hu own case and how justifiably: Doa he admit that he thinks that he missed his alling and should have been a doctor? Or did he have a little medical education hunself at some tude or have there been doctors in bu famıly? Before completing a butory of the case it may be worth while for the doctor to ul a quation or to along these lina which may be itty revealing On more than one occanon I have encountered lay patients who were reading my own textbook, sometima however the Trong cluptm thiện. It also happens sometimes that the most difficult pa tient of all is the physician himself especially an internet, who imaging all the worst posibilities at the very begin ning. On the other hand some of my most cooperative patients have been doctors, con cardiologist, who have delivered themsela for dugrosu and treatment without prejudice or doubt. Before closing thu chapter on these clua in general the family and friends of the patient must be taken into con siderauon. Wat u their attitude about him or hus illness It s well to obtain word of it directly from them as well as from the patient. Such information can be glazed by letter by telephone or bost by personal conversation which need not arouse the patients wpicion. In obtain ing dila foformation the family and friends roubt be judged just as is the patient us to emotional attitude icraaty and details of the situation at home, at ndiool or at KOTL OL ·8 DIAGOSTS AND TREATIVT OF HEART DISEASE course much of this an le obtained host of all from the good old fashioned family doctor if there is one As in the care of the patient himself are the family associata in Kchool or at work and close friends OlcT-40Licitou or are they impatient and con inconsiderate? A gummary of all thu might well be incorporated confidentually in the pa tients record. Conscious malingering in my esperienre rare in routine prectice but, of course there are many instances of evaggeration of symptoms when dwability insurance or payments are concerned and much careful evaluation of the overall picture is essential with a many objectne data perluaps serially obtained as can readily Le Kcured. Since Injustice as possible both ways, by minimizing symptoms as well as in their cuaggeration The must always remeniler that a very neurotic perzon can be senoruly indeed even dangerously ill with coronary insuliciency hypertensive cardiovascular disease or rheumatic ialvular deformities and their effect One should be aspecially careful there ſore to eumine a patient more thoroughly than usual belore excluding organic hart disease and diagnoring instead cardiac neurosis. This is said to be particularly true in the ase of the full blooded Negro who may be seriously ill with only a little misery in bu chat the significance of which may at first be underestimated I vould add that it is in general nike to tale uie patient into one s confidence if he is of everage intelligence and can be trused. For him to look at u itong tends to nd lum of unnecessrs fears of both the unknown and the Inoin to enlist his cooperation in hu treatment and to uncoier further clue in the future : hich may prove to be of inestimable help in his prognosis and ſunlier panage ment. I have rarely if mer regretted such a slop but of course much tixiom tact and aperience are needed in ·GNERAL QUE 9 the proper presentation of his arduc status to the indi vidual pauent huuself In addiuon to what has been aid above there are set cral general duct that are more or les balen for granted in the apprawal of a patient but which deserve brief men ton. The first is age A baby with something wrong with its heart is naturally suspected of having some congenital defect a child over four may have either rheumatic or con genital heart disease a young adult may have also thyro toucosu, carly hypertension or even coronary heart du cak in middle age all these Linds of leart disease are por sible plus the syphilite and the cor pulmonale while in old age congenital defects and rheumatic valvular disease are much les I Lely coronary heart disease and the effects of hypertension predominating knility itself doo not carty with it any specific type of heart disease but often us beset by one of thoxe just mentioned-nately if ever does a perion dic of old age alone without adequate phyical cause discovered at autopsy Sex is an important clue in youth and middle age the more serious hypertensive cases and almost all patients with angina pectoris and coronary thrombosis are in those earlier decada malas Tlie female hormone seems to be protective Body build has at least one important correlation. IL B primarily tlie macromorph the wide stochy muscular male wllo 4 the typial carls candidate for coronary lieart discake And of course body build tends to be iolierited, de spicc vluch fact we are seardiling for some protective measures in the way of life for such andidata The state of nutrilion is often important. Obeslıç fasons the so-called degenerative type of lan discase, that is, the hyperienne and the coronary while loss of wight and malnutrition suggot tlıytolovicoais, chronic crippling by

·IO
DIAGNOSIS AND TEATTENT OF 4T DUEASE
ulaces such a heart failure or even a prolonged effect of
drug therapy as in the case of anorexia caused by digitalis.
The
presence of other congenial anomalies always
favors the diagnosu of congenital ardiovascular defects
when there is doubt au to the use of abnormalitia of the
heart or great retrels.

·CHITER 2 THE PATIENTS PAST HISTORY The Past history of the pauent v often full of clue and yet it is freqnently the most neglected pani of the entire examination Huse and lack of synematic en quiry are usually responsible for much beglect. On occasion however It a duc to a superionty compla as in the cax of a young Inapital interac who may viene fu newly admitted patients as if they had never been outuned bclore ignoring the findings opinion, and therapy of other doc tors who have daalt huh the pauent before him a forex imple in some small haspatal or in the practice of an IMD or family doctor Happly the custom u being scadily replaced by one of more rapeet for pretlous find ang, enpedited by the realiation of the young doctor that they two mill moon baone the LVDs of the future Someume the patient will lauraself supply imporani information about hus put but lic is likely to forget certain itens which are important so far the heart and blood promure are concerned, and which therefore should lx thed klout For intanet hane thac been enaminations for life in urance when were they and how ardully done? The amount of insurance applied (or has a beaning since for small policies us for five or ien thousand dollar the cumination may be very superficial white ſur large ·12 DIAGNOSIS AND DATIENT OF TILAIT DIFAST amounu it may be rery arefully came out an interest ing case of my own tras a man 48 years old who came to see me in a panic Laus know heart disease had just been ducovered by an insurance examiner It turned out that he had a slight to moderate degree of parency of the ductus arteriosus, present of course unce binh but drag posed for the first tirc at 48 when he apphed for a large insurance policy for business reasons. On thu Ocasion he was arefully cxamined for the fire time aod the base of the hean was listened to as well as the apex, thus revealing the characterutk conunuous Durmur Previous insurance examinations for small sum had been quite inadequate the stethoscope was lastily applied to the carduc aper Only Incidentally the man is sull alive and well carrying on a big businew and playing golf without difficulty at the age of 77 Other phyunal cumination should also be enquired about as in kchool or indwrial plant ut for sporu or mili tary service Of course the raulu slıould be taken with a grain of alt 21 told by the patient but they may nevertheles bore helpful and it may be possible sometimes to obtain the artual details of such examination by consulting the records if they are available. On occanon it u of the most importance to see former electrocardiograms or ray films for comparison with current one. It may be difficult 10 obtain them but it u wually worth the effort and the diagnous way actually leatablulied by such comparison The same thing is true about previous stays in other hospitals eiea in remote parts of the country or in foreign Land although of course the difficulties increase with distance and there may be considerablc delay Horres et a doctor : obueniations in sonie remote part of the world may hold the clue that clears some medical mystery and in would not be korned.

·TIE PATIENTS PAST HISTORY 13 To be more specific to far as the heart u concerned mur muns may date back to the first few weeks or months of life Indicating the probabiliy of a congenital defect of 10 the age of five of 11x folloiring rheumark for et karet fever or a severe sore throat Almost half of all case of rdcumatic heart disease present in adults gire no buzor) of having iad sute rheumace but th u norlikely to continue to be the station in the future s vlay of the it creasing frequency of routine criminations of young chil dren with the ducovery of ocwly appearing heart musmus by doctors in wchools and in priate practice specially on occuons when a chud feels 1) or appen to be x In very rare axs diphtheria may be the explanation for a y or bundle branch block rather than a congenital delect, Cor onary atherosclerosis or mayocarditu of onljotrn cause It 4*, however an interesting fact that almost all of my mwn young cireas of coronary heart disease leave had no ACTIOUS infection of any sort. One common condition that may be cul confirmed Ing clues in the past hwory u Ocurocirculatory anhena (cometimo called andety neurosis) of such is mispautech {cading questions are in order Has there been a story of Caloring at adolescence or of a net ou hear, or of netrou prostration in arly adult life? It us common for a vicum of neurocirculatory asthenia to have had a chechered hustory of recurrent prouble of the von Hon souch has the patient la cold about liis coadı uon by other doctors and has he interpreted correctly wltat He has been told? Has he descloped a fear of lus leare dos cax or of Smptoms which he thinks are due to heart do que but are actpally caused by rooicthing chet ( hahe Lecomte quite blast in his attitude or falaltic ut little fasth in heament or willingnes in undergo it? Hlas Uiere been a considerable difference of opintar a mi diagnon ·DIAL VOUS AND DIATUIT OT HEART DITAV. or treatment or both by various doctor whom he has con julted while shopping around? And if there has been has he become depressed or dullwoned? Hus he been driven to the new doctor who is yourself or to a new clinic by family or friends when he still has faith in hu old doctor or in none at all? 411 these point should be setuled at the very first opportunity if posrble since they are of fundamental importance Have there been operations of importance such as a drolecystectomy or prostatectomy or gutrectomy and low did the patient Hand them? Il as the liart considered normal at the aime or was there special care in preparation or in anadiosu or in surgical technic llere any of the operations designed to help the heart or other part of the arculatory apparatus, such as e perardual resection for constnctive pericarditis commidurotomy for mitnl steno- 54 shunt or other proredure for congenital defects or sym pucheaomy for hypertension? How succesful tra the pro cedure and low long ago was it donc? What were the de tails of blond gas and pressure analyze by ardiac dieteti quion before and after operation? If there luas been a sym pathectomy is there atill a relative postural hypotension wluch would be foued? How long did it last after the operation? Wiuat about the diet? Has alt been raincted hon much and for what (hypertension congestion)? How suc ccuful was that salt restriction How long was it carried Out? Havetlicere been any episode of collapse tefrictor! neus to diuretic tierapy due to sodium depletion Have the krum electrolytes been well studied and snally? Have the calories been senerely restrictel, or an Arginly in it therapy of obesity and hor successfully? If the calones were much limited has there ixen a danger of vitamin lad or HCC vitamines given as an adequate supplement? Ilave ·mit PAHIUXT'S PAST STORY 15 any bizate dicu been used and for what And finally what has been die custom us to alcoholic bercrages and tobacco? It is always wise to make specific mention of thek items because keseral highballs a day may explain a failure to lose weight when food calories have been adequately re duced and arrhythmia (preuature beats or pastryma! **claycardia) can be the renult of the effect of tobacco in a PTK whose heart sensitivt to it The amount of a and coffee should also be exertained for although no ar ous trouble come from them they can be responsible for Lothervome insomnia and palpitation. Net wat has been the actual drug treatment long ago and recent One should learn the details of thu from pa uent or family previous doctors and hospitalclinsa. Once in a while there u merely a numbered prekriprion (or pomc med one 19tbout details 1 to contenus thu porma rion can be applied by the pliarmacut ulio put it up if the doctor who wrote it annot be reached Somc mcdianei alter the finding apprecubly and so should be nown For mample digitalu in large dosage may depre con siderably the SS segments of the electrex ardiogram um lauing the effect of coronary insufK ICX) Quinidine can induce transient bundle branch black change atrial hbuslation into futter (Twin drugs such u the teratur alhaluids and heramaloninim can loet the blod pres sure in hypertenson Thyroid and atropine or belladonna ran raise the cart rate li u ofien important to know whether these medicine fave been used in the put in what douage and for the long and to ukolain whether they ee helpful harmful or aventually inert Fach one may x 4 tuc | xime present inding in some symptom ar sign ind of course it is alwayı impartant ison i{there has lucen any narcntk habituata n Finally o lar as past luxor 4 Loncerned it is well to ·16 DLAGRONS AND TREATSIENT OF IT AIT DUTATE know something about the past habits of nork and play indulgment in strenuous sports heavy raponsibiliuos in bwineus family are or community adequacy of sleep relaxation and vacations and other aspects of the way of life that may have a direct bearing on current symptoms or signs. Sorae recent lieavy strain, pliysical or mental may have precipitated auto trouble in a case of chronic heart trouble trell tolerated till nor Cluas may be angubere and need to be diligenug sought In the case of a troman the history should include questioning about the alta menia, which may aggravate congeunte sympionus and sigo and about the effect of childbirths. How many preg nancies have there been? Were they all well tolerated? Are all the children living? Hou old are they? And does the mother have adequate help at home?

·CHAPTER 3 THE FAMILY HISTORY Oor only lip Hero we us pead to the obla gation of enery phyıkcun to know as much as possible about the family littory of his particols. For the old time family doctor thus hoorledge wa w a rule rouuncly acquired in deal during a long lfetime and was invaluable in has practice in lieu of such a sale of affairs it u important for the physician who tala care of cardiac pauenu or of any sKk people as a matter of fit to record on his case his tona accurate details so far as they can be secured ol the uges whether sull living or at the ume of death of the car relatio of the patienı being audied These should in clude father mother brothers sisters and children and on occuton grandparents 100 and half brothers and half juters. Bado the information u Deurnal or death and the ages important illneues of these relatnia should be noted apetually if such titte the cause of inualidum or deach or if they involved Ure heart or blood iarel Someimos particularly in the case of young people family en els are important to know about for chample unusual factors causing special strains like divorca sui Ha, other volent deaths as in lantle atidenis or con comranon amps, bankruptcy and the dependency of ·16 PIAGYOSUS AXD TREATMENT OF HEART DISEASE knot something about the past habits of work and play indulgment in strenuow sporu haavy ropotuibihtio in business, family care or community adequacy of sleep. relaxation and vacations, and other aspects of the way of life that may have a direct beaning on current symptoms or signs. Some recent heavy strain phyucal or mental may have precipitated actite trouble in a case of chronic heart trouble well tolerated til nok Clues may be anythere and need to be diligently sought in the case of a woman, the hustory should include quchioning about the ata menu which may aggravate congestive symptoms and signu and about the effect of childbirtin How many preg nancies have there been. Il ere they all sell tolerated? Are all the children living? How old are they? And doc thie mother have adequarc help at homoc?

·THE TAMILY HLATORY 19 und uixe this is so und are some of these diseases start only in muddle age or later it behoova w in all cases, young and old, to record a clar family history us to these dus 4 to how they or the repubility thereto uc passed on we have only theories Rheumatic fever and rheumatic heart disease do often run in families and should always be uhed about. Is the tendency due to a family allergy to the Streptococcus hemolyticus? Hypertension (or the old Brights disease) is often a famıly complaint But some families are simply nervous hyperreacton and never get real hypertenson. The combinauon of inherited hypertension and netvou hypote activity is aspecially unfortunate. Corotury atherosclerosis of high degree awing angina pectoris coromary thrombosis myocardul infarction or nudden dath u notably commoner in the children of parents who gave such a bátory and especully if both par ou are so affected in youth or middle age Is that due to familial hypercholosterolemu of greater or lesket degree, to cuconne mesomorphic build which u certainly readily in herited, to an inherited inadequacy of a coronary arterial tree, to hormonal imbalance, to familial gluttony or to combinauons of these factor or others dot yet under fire? Neurocirculatory authonia and familial tendencia to develop ony about heart disease 1 hether such as present Or not, should always be enquired about since they are commonly found in both parents and children and an account for much of the symptomatolog, Happily they do not themselves predupoxe to heart disease or shorten life but they can make the line of gepentions of people rather monctable. One of my pauend with neurocirculatory asthenia who was discharged from m litan kuce in World War I because of disability due to that condition ·20 DIAGNOLIS AND TEATWENT OF HEAIT DDEAL had a son who was discharged from military service in World War Il for the same reason. Finally unwual longevity itself is family trait and should be carefully enquired about. It is well known that a person who has recent ancestors parents or grandparents or both who have lived to be very old that is beyond 80 years, is likcly to live to be old also and to survive illoesses, operations and accidents more readily than docs another person whose parents died rather young of ardiovascular disease The outlook u aspecially favorable if there haic been long lived ancators on both sides of the family Years ago many young persons died of infections that are now happily wiped out or sharply controlled. Such deaths in our family history recording should be noted but largely discounted For example my father s mother died of cholera before he was a year old and lius fatbei died not very long afterwards, also quite young, of phthuis. But much more important than their early deaths as current clue was the survival of bus fathers mother into her hundredth year she was born in 1800 and abe died in 1900 In prognosis aspecially is familial longevity a very important clue In closing thu chapter I should add a few words about the health specially that of the heart of the spouse. Ilony 01er this may aggravate or precipitate trouble duc to heart discase or there may be an anucty syndroide duc to the beginning of sympionu which may seem to mimic those that croppled or Lillel the husband or 1 lle. Occasional patients, mostly rromen with neurocirculatory asthenia someumes called anxiety neurosis hare consulted me because they ſcared that they too had the heart disease generally coronary in type that had affected their huslands, not infrequently and dramatically cwing their sudden daus. Or the husband or wife already a cardiac patient

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·CHAPTER 4 SYMPTOMS BREATH ING DIFFICULTIES More valuable cardiovascular clucs in diagnosis and treatment come from subjecuie evidence of the present illnes, that u from symptoms, than from any other category For this reason the most meticulous care should be directed to obtain the best possible history of the prescat illnas with the details of the syruptoms. More time is usually necesary for this part of the examination than for any other and it should be conducied by the physican himself or herself and not relegated to audent, wwwnt secretary or nurse Expencace cnliance the value of the Luustory but thoughtful consideruon of the importance of this part of the eumination will allow engi a relative beginner to do a good jab Of all the symptoms the difficulua in bratung are the most diffuse and important in diffcrential dugnasis and so they will be discused linse in the present chapter Important cardiovascular clues are related to breathing and yet the great majority of persons n ho have difficulpa of raperation have no heart disease at all Bronchial asthma, infections of the lungs or bronchi pleuruy nen oumas poor physical fienes and an extremne obesity are common auses of dypnica Leis common causa are periardaus poeumothorax intrathoracic cumon and dis 22 ·SYVETOVRETIUNT DIFY ULTIS orden of the bram or of u arculauon. These vanous con diuou may be muuten for beart failure and se treated wrongly u ruch parucularly if they happen to be present iu persons who happen to have some heart disease too. Especially is the true in the case of old men and old Omen with dyspner and sheering due to chronic bronchu {w and caphysema with no heart trouble at all but be cause they are old they are given digitalis without benefit Qua which help to rule out heart ducas a ause of dyspnoa arc 1) ray evidence of a small hart shados sot inbre quently veral in position with low poorly moving dr aphragm in the case of pulmonary emphysema. A normal electrocardiogram 3) Wheeting induced by certain foods pollens or dues and cleared by climbination of such factors or by epinepo runc. 1) Isthmatic attacks which are recurred for many years 5) Sighing rasprauon with a tendency to hyperventilic along with multiple other symptoms in particular heart ache palpitation fuinness, marked fatigability and nerv ounem in the case of neuroarculatory autheau. 6) Pain on breathing deep or superficial whether or not one hear a pleural or pericardual friction rub to the Cak of pleuruy or pericarditu. 7) Fever tachycardu, and leukocytosis in the case of respiratory infecusons and puissonary infarctions Then heart disease usello present along trith these clues ut becoma doubly importanti daiemmine so Lar s possille whether the licart disease is partly respaguble for dyspnea or whether it is best coincidental and ulent, One important kind of heart disease that may be serious and yet not ile Caux of dyspies us that due to coronary ailerosclerotic nasrundag no older man suosittelud engirur pectors for ·1 DIAGNOSIS AYD TREATMENT OF ILLAST DILASE yean but never myocardial infarction or other possible ause for Cardiac enlargement or left ventricular failure lading to dyspna therefore, some other than ardiac cause of the shortness of breath should be diligently sought. It is likely to be found as chronic bronchitis and emphy seni In rare cuo it is difficult to exonerate the heart completely and then it is not only permissiblc but in truth wise to test therapeutically If digitalis or a low sodium inuake or mercunal druresis, is quickly that is, within tho or three days followed by relief of dyspaca, one may with reason in doubtful core blame the heart for at least some of the difficult breathing if a coincidental improvement can be fairly well ruled out. In the case of the siglung dyspnea of neurocirculatory asthenia hypervenulation may induce faintness and other symptoms i hich alarm the pauent. It is helpful sometimes to dernonstrate to such cases the relause unimportance of these symptoms by asking these patients to hypen aulate in the presence of the physician at the lime of the first dater vicu The most duurcoing dyspnea of all which tends to come on cty suddenly often making a person up at night is that 250gated with pulmonary edema. There may or may not be whecaong with it if there is Krious liaart disease present such asthma us ordinarily called cardiac #thma. Howevet eien in the presence of serious heart disease pulmonary edema wide its intens dyspoca and onthopnes may be due to something else mot often to acute pulmonary embo lumn With no heart disease at all pulmonary edema with its distrasing dyspnes can be excited by pulmonary cm bolism and non and then by other couxs too, een a thoracentou. Cluss durch point to tlie diagnosis of acute pulmonary cmbolum should be always born in mind in differential ·SYRIOV. HLATHTHO DIFFICULTIUS 23 diagnoun A sudden attack of dyspna with or without cough or usthmatic breathing specially in a patient with chronic hart disease and congestive fulure or postopera tively attended by considerable tachycardua and often fol lotred by olight to moderate fever and leukocytosis u not infrequently due to pulmonary embolism with infarction. There may be no fevet unless there is infarction which us more likely to occur if there is uready congesave heart failure and a faulty pulmonary arculation. There may or may not be hemoptru copiow or slight, mith pulmonary infarction and there may or may not be signs of the acute cor pulmonale dependent on dilatation and anoxia of the right ventricle The electrocardiographic evidence of the acute cor pulmonale aluch we have found in about 10 per cent of our cases of pulmonary embolum (the ones with the larger emboli as a rule) consists of the appearance or accentuation of S waves in Lead 1 and of Q waves in Lad $ increased R waves in Leads and V and inserted T waves or an increase of their inversion in Lads 3 AVF V., and An important clue to the diagnosis of pulmonary embollim u recent unilateral swelling of a log due to venous thrombosis or usymmetrical edema if both legs are swollen Even cquality of leg edema may be a clue if no other cause Auch as congestire failure u found for it. Tu chuc should always be looked for but it is not infallible and there may be no swelling at all even in the presence of leg icio thrombosis, and of course, thrombosis and swelling may Le present in the legs wurout embolista and with other cause for the cute dyspaa The Homans sign (SOTNOS in alf when the foot u lered) is a useful clue also when it I present but, like tendemas on prossimC O CT the alves themselves it is not infallible. Onc other rather uncomon clue to a pulmonan infarct of large size In the presence of congoue heart fallure with ·DIAG YOW LD LATIQT OF HEART DISEASE engorgement of the Inc is jaundice due to inability to duspose quickly enough of the excessire blood pigment Other noncardiac causes of abrupt or rapidly developing dyspnea include spontaneous pneumothorax, acute pleur isy or pericarditis (here the breathing u usually painful as well as dificult) and dissection or rupture of the aorta. Further considerauon will be directed to these conditions in the chapter on Pain Cardiac causes of dyspnea whether acute or chronig, are essentually to failure of the left ventride and mitral stenosis, in the former due to nipocardial insuficiency and in the latter to valvular stenosu or regurgitation or both that is a mechanical factor The left ventriclc u much more often primarily under strain pathologically than is the right ventricle and 80 CTy pacient with chronic hypertension chronic Orlic valvular disease or myocardial infarction (acute or chronic) duc to coronary thrombosu should be carefully followed as to clua of beginning failure of the left ventrale there are dyspnea on ordinary effort of suddenly at rosi, apical gal Jop rhythm accentuauon of the pulmonary second sound, and alternation of the pulse If these cluas appear trot ment for heart failure should begin at once Failure of thc nghit ventrcle does not cause dyspnea until it is far advanced at which timc air space in the lungs us restricted by congestive hydrothorax or by a big liver and ascules rainag the diaphragin accept tluat a laully cerebral drculation doos favor Chieyne Stoles breathing or less marked periodkits and difficulty of respiration Sudden dyspnea in mitral Heriosus before the right ientricle fails may be due to extraniac causation of pul monary embolism but it is usually due to sudden pul monary edema secondary to the narroting of the niittal orifice which prevents the blood which is flooding the lungs from foring fast enough through the hart.

·UTION. PLEATHLYG DIFTICULTIP) 27 Although adden effort may cause the left ventricle to tail quảckly or the lungs to be congested in the presence of mitral stenosis and although some abrupt complication like acute myordual infarction or 2 pulmonary embolus may act similarly a common and important exciting factor precipitadng either condition, und thereby acute pul monary edema, is paroxymal tachycardia, ether itrul or ventricular or paroxysmal atrial fibrillation. A addan nie of 60 to 80 beats as from 80 to 150 u often too great a Itrain for the limited reserve of either left ventricular myo aardium or pulmonary drculation. Since usually measures are available to control ruch arrhythmias, or at least the ventricular rata, it u of the utmost importance to seck this clue as to heart rate by question or observation or electro cardiograma The position of the hart in the body has an important influence on breathing The commonat descriptive phrase applicable to thuis orthopnea which means literally brathing in the upright position This position u, of coure usumed by the victim of dyspna for comfort make It is found in a great variety of conditions and is not Atrialy dugnostic. It s almost always prosent whenever there 1 kevere shortness of breath on effort or moderate shortnem of breath at rost. It u, of course explained by the greater air space available for orygenation of the blood 10 the upright position An interesting vanant of orthopaea u the attitude anumed by certain indırduals, especially those with penardial effuson or rety large hearts, who are most comfortable when lanıng way forward often with chat rating on a few pillows or on a bed table. Some puenu who are unable to breath comfortably lying on their locks or sida do find that they an breath with fair comfort if thc, lie face down It is well to remember dis at the leginning to tat its effect and even periaps to use it therapeutally Finally the squatting posil on uumec ·DIVNO11) A.VD NU ATENT OF HEART PLEALL tant by children with congenital heart duease with the morbus caeruleus that u the cyanock type of congenital heart dis u well known. It is probably helpful because the individual affected us at rest in the upright position. For children, fair comfort in this poution is readily acquired but for adulu this position is uncomfortable and sitting in a chait is more suitable Onc other important type of dyspnea due moore to cerebral vascular insufficiency than to heart failure itself us the periodic apncic and hyperneic respiration of Cheyne Stoka combination of cerebral vascular ardiac, and renal insufficiency is particularly likely to lead to Chcync Stola breathing It u caused by the alternating simulus of CO ercou in the blood and depression of oxygen uatura uon and co lach. Thu is often as distresung for the ob- KTV Cr us it is for the pauent because of the long periods of no breathing at all It tends to be worse at night and is aggravated bę opiata or sedania but helped aspecully by intravenous or rectal aminopluylın Of all the technial methods those that give us the rich est clues in the elucidation of dificultia in breathing are Muoroscopy and the x tey film in the first place we can determine the presence or absence of serious pulmonary disease (ntrathoracic tumors, hydrothorar pneumothorax diffuse or localized pulmonary edema or infarcıs, and emphysema And secondly we aan study the heart as to its 3170 shape position and action and the presence or absence of extensive pericardial effusions or calification and the hllus shadowy nhich represent the main pulmonary arterias and reins Certain clua are quickly deused such as the following the first tio of which were mentioned carlier in the chapter 1) Dyspna cannot be ascribed to myocardial fallure sf the heart shadow is mall or normal in size 2) A very low diaphragm which moss little with rose ·SMITTOILS. ALATHINC DITTICULTIES 29 piration is a ugn of emphyta which can itkelf ause dyspna whether the baart u diseaxed or not 3) Excenive fulnen of pulmonary arc and lung bilas shadows in the absence of congenital defects, in particular atrul keptal defect and patent ductus arteriosus is evidence in favor of the diagnosis of left ventricular failure or of mitral stenosu us a cause of dyspnea. The differentiation between these two causes should be easy through physical examination and electrocardiography 4) Fluid limited to or prepondenntly in the left aide of the thorax indicata the probability of some factor other than heart failure (ef pulmonary infarction or infection) un cause of drpna. Measurement of the ute capacity is of interest in com paring the breathing capacity on different occurons in the ame individual but it u not diagnostic One may have sharp limitation of the vital capacity when there is disease of the lungi, when there is heart failure when there is fluid or air in the chat, and when there u neurocirculatory athenu Determination of the blood gases and blood pres uure in various parts of the circulation is also of general interest, again not very helpful in differential dugnosis excepe in the intricaco of the elucidation of the particular defect in congenital han descak. Here the data olxtained by cardiac atheteration are of much value and the reader u referred for discussion of this information to larger works that deal with details of analysn of congenital and aquired cardiac defects Thus, it u evident that despite the complexity of this symptom of difficulty of breathing there are many clues to help us decide the degree of roponsibility of the heart in iu production and to indicate the proper treatment ·CA APTER 5 PAIN ONE of the most important and intri gliing symptomy of ardiovaxular interest is pain Some times and in fact in the great majority of cases thu sympcom is casy to interpret but often it can be conſwing its proper analysis u of the greatest importance in differenual diagnorul. At tic very outset it should be recognized that one of the reasons for confugon is that there are in many coses not just onc pain which is thought to be caused by one condition or another but actually two or three different pains, often closely resembling each other in position or diaracter or circumstance but cach indicatric of soine spe. cal disease or disorder It is also very important to recognize that one of those pains may sir up another as an agytovat ing but not quative ſector The extra time needed for adequate query or text to untangle complicated problems related to pain us ume well spent on the occasion of the fire examination of a patient and may save wecks or montlus of uncertainty ubjection to much needless instigation loy xray and quiet proceduro, and useless therapy The definition of pain is actually very broad and is van ously interpreted by diferent Indu Iduals to that if neces Ary one should go into some deuils about definition with the patient at the very beginning Some person call almost any discomfort pain or at least painful while other limit ·PAN 31 their interpretation of pain to a sharp or cutting station while a dull discomfort u called an uche OT 1 BOTCNCH OT + mukty or a hurt A good many of my paucnus with typoal engina pectons have refused to call it a pain but have 10- rad alled it a prosaire, i choking (which is the literal translation of the Greek word angina) a banner or even a difficulty in breathing when actually there u no disorder of rapiragon pet se If a paucat complains of difficulty or heaviness in breathing for which there is no apparent reason, it u well to ask him where this difficulty . If he places hus hand over the hernum one should suspect that angina pectoris is raponible for the nymptom which he interprets as a breathing difficulty Since this is a fauly common experience it behoova the doctor to take plenty of time in obtaining the patients history if there seems to be any question about the presence or absence of pain. There a one other very important bass conuderation and that concerns the seasibility or nervous sensitivenes of the patient. It is, of course an axiom widely quoted that in the practice of medicine the host must be considered equally with the disease or injury itself Thu u parucularly true of the symproms of cardiovascular disease. A relatively insensitive person may be hard hit before he feels such while a very sensure patient may feel badly with relauvely little dwere present. A corollary of this is that a person, DO matter how knultire, an school hunxelf or herself to en dure pain or other symptoms with overmuch fortitude hiding his or her illnas from family and friends and, indeed, even from the doctor until it may luve become far advanced Thus matter of sensitiveness and codurance must be carefully waglied by the physkuan at tic time of the first examination. The acuindc of the patient while he tells the story his presentation of facts, the attitude and com meau of wlates et member of the family is praent or near ·32 DLACNOSO AND DEATHINT OF IFAIT DIILAJE at land and a few findings on plyscal examination are useful clua For erample, the patient may be obviously lety netow or apprehensive may sigh or tremble may perspire or shou a fou heart rate at the time, his reflexa especially the knee jords, may be hyperactic and he may on tously exaggerate or indeed minimize hus pain or other symptoms All thus season is fully us important in diagno. au and treatment as the details of the symptoms themselias Incidentally a point of much significance fometime over looked u that a very nerously ceruluve person can also become very ill with coronary heart disease for example but at finue the disease itself niay be underestimated or een ignored by family and doctor because of the fact that the person in quation has always been nervou and apprehen me and indeed not infrequently hypochondracal One must be on the outlook for thu. Coronary Insufficiency of all the pains and dingrecable Kensacions awed by heart trouble or related directly with the hean that due to coronary insultciency is the most important and wo will be discutid fint It should, how er be observed that coronary insuficiency an occur without pain Altliough this is true this fact has on occa sion been overemplasired There are to be sure some pa cienu kelio fail to present subjective aidence of acute or Hubaaite coronary insufficiency nhidu clearly evident by objective findings but these cases are relac ely very few in number in there there u citler a masling of the pain by the presence of a state of shock us for example in acute coronary thrombosis or postoperately or by anotheis induced cither for surgery or other therapy or indeed acn \ua alcohol or by a psychouc state or extensiic disease of the central crow System which can make interpretation of symptoms difficult or Imposible or finally and leau commonly of all by an extraordinary lack of sensibility It ·PATY 33 has been wid that 2 full blooded negro does not have the characteriac symptom of angina pectoris in the presence of coronary insulaecy le nea Hot Cle much more uccurate information than we have a ja to now the degree of correctner of thu obueniation. At any rate che chief reason I bave found for the statement that painlea coronary insucietky a relatively common is the faul ure of obserien to obtain adequate historia of the pauents concerted In the great majority of my patients wie dugmes of coronary insufficiency w cary based on the presence of the characteristic symptom of angina pectors. I would estimate Ulat in at least 90 per cent of patienu there is no diffically whatsoever and in them one docent need to reck for other Juo The typical story u of course that of vulsternal oppret svon high low or intermediate in position 17th or without ndiauon of a numbnes to both forearms but tugally pre ponderanuy in or even limited to the left side lasting a few minutos at a time induced characteristrally by cifort or excitement, and relieved by rest of nitroglyceride. The Jeer doesn i nord to be servere sa matter of fact it is often mild and kmeilma only a suspicion of a pain in mm perience it is rarely attended in the semise of impending doom or dosolution to often mentioned in past olier Auch apprehension of death I hasc ſound atually more often in netious persons without angina pectoru Itt mitt such a condition 24 neurocirculators athenia. A lielpful clue to the diagnous is the gesture of the parient in locating the position of the pain the practically never points to it with one linget but pluca a palm of een both palms olet the front of the olev The palra is mually laid met the SICTnum in the case of angina pectors if it is placed over the left breast the ache of neurocimulator ashew is more ·DIAGYOSIS AND TREATIENT OF ILAIT DISLASE likely to be the anser As already stated, one should 10 member that many patienus refuse to call the sensation pain but use other terms to designate the leasiness or drohing that they feel Heberden himself in coining the words angina pectoris in 1768 picked out the Greck nord for Hrangling to dustinguish it from other kinds of pain or dolor Onc of the most interesting and important variants of angina peaons or of pain due to coronary inullaency !! the discomfort that may be induced thereby outside the chat altogether or in the back Usually the pain starts chancteristially subternally and then radiata to or is followed or accompanied by pain in left arm wrist or brand most commonly right arm sometimes and neck jais teeth bach or upper abdomen less often. Radiation of sub sternal pain to the jaws or teerh strongly favor its intet pretation us angina pectoris I have never observed its radiation or occurence in the lots et abdomen or legs, but I have encountered it in the ranke. On occasion tie radia tion may be reicned in its direcuon Harting outside the chau but radiaung finally to the substernal area In cry rare instances the pain may be actually limited to one or more of these outlying poious and in such cases the diagno $19 may be very duricult It should be added that radiation of pain to the left arm docs not cutablish thic dugnosis of coronary insufficiency since there are other causes The most important chios are the production of uic pain by maling fast or uplull nuithout undue motion of the part allected sudi as nu arm shoukler or neck aud by sus quick relief by nitroglycerine Sloning the lan raic by caroud sinis pressare leas also been noted to clear the pala kuat more quickly If the pain is produced only on lo. al main and nx by walking fan one cannot escube it 10 coronary insufficiency The final chute to this unusual mani ·PALY fatation of coronary imufficiency is the presence of come previous or current injury to the area that is painful or other lesion of the part for euample, sprun or Hrun, displaced intervertebral dik, arthritu bursitis or severely Infected tooth root. Thus ruch a pain posluon might be ascribed to a sympathetic sensory dutnbution or ndiation. Two other observations about angina pectoru ue of special interest. One is that thu symptom u commonet at the beginning of the day (for example on walking to garage, bu or run after breakfast) and at the beginning of some CTCise such us gold, a physiological vasodilatation affording protection later The other is that in the ase of more knows coronary insufficiency angina pector may occur on fint lying down at night or later to awaken the patient this is called angina pectons decubitus and de mands respectful consideration and treatment and careful differentiation from the pain induced by a hutus hernua which does not cause pain on walking but is often relieved thereby Clues that are helpful in ruling out angina pectoris are Dumerous. Among them are the following 1) a sharp stabbing or needle like character of the pain, na throb blog pain 3) a very short duration of a few seconds only 4) a very long duration of a half hour or more unlos coronary thrombow or come continuing strain such as con tinuow effort, excitement or tachycardu (especially parox yamal in type) is in progress, 5) induction of the discom fort by cating or during rest rated and not by effort in the ame ase or retumbexy in the Alpine position 6) relief of dies paln by effort, 7) mduction of the pain by light or molente use of the 2ms apecially by raising an arm without any discomfort during fast walking 8) induc tion or aggravation of chese pain by deep breathing, and 9) condemas act the site of the pain.

·36 DIACNOS AD LIT OF BLAXT QUE LE I would add at this point that the particular auses roponsible for the cluo just mentioned are in particular conditions such as a) digesuie disorders, especially spasm of cophagus or ardua of the stomach (cardiospoon) that may not only mimic angina pectons due to coronary insuffciency but not uncommonly complicate it b) bruises sprains, arthntu bursitis and other such abnormalius in dick wall spiae shoulders and neck, c) neurocirculator asthenia, d) neuritis u in herpes zoster and c) pericardius Skullful and experienced questioning and piysical anamın ing usually sufice for the unravelling and proper applica won of the various clues i en before resorting to laboratory procedures in parucular of course to electrocardiography The commonert mistalas are of commission rather than of omission and in calling other troubles coronars insulli ciency Cardiospasm, caused by imtability of crophagnis and stomacb often produces substernal discomfort that simulates angina pectors in position character and dura un but not in the circumstanca of its occurrence The pains are apparently not however cuactly alike sunce a good many patients who llave both can tell them apart The digestive disorder often cuiends out mwh of the pericnte lifetime although in anying degree it may de crease or aon disappear when smoking B sopped or nenaus strain qubade. Sometima the discomfort Qused by cardiopum ends in the belching of gas and lien an attack of angina pectoris B accompanied by ardiospasm or us a cause thereof the coronan insulin un inay seen to be unusually prolonged and to be relied by a lekli Pain from a sleietal abnormality of some kind in lones pinta, muxla, and burse can be very confusing expecially if the pain therefmo ts sulsteal or in the left shouldet or arm There are ses eral dues to such an origin of pain As already noted above motion of the affected pan usualls ·PALY indures pain, u may certain positions in bed at night. Tenderna on pressure over the nte of the pain is hrung evidence in support of this diagnosis since that ngn u not an accompaniment of uncomplicated angina pectoris. There may be e solness of a joint or of the whole neck or of an arm. An important query concerns the origin of the lenon there may have been an accident or a muscle hrain, arthritis may have begun to appear in other parts of the body or there may have been prolonged inactivity u in the case of bed rat for renow Ils such as myocardul infarction. The called shoulder arm syndrome may arise in the way complicatiog the convalescence of some pa uents after coronury thrombosu but it has been a rare complication in my coronary heart disease call and u not, in my opinion to be related any more to the coronary disease itxelf than to any other cause of long invalidioma perhapu my long atablwhed custom of relatni cly short bed rest (not over three weeks) has helped to keep dorni such a condition Neurocirculatory asthenia is often wrongly interpreted 13 coronary insuficiency just as it is also wrongly treated u myocardial insufficiency The very mulnpliaty of the symptoms of thu condition Causes confusion even though it is perhaps the chief clue to the correct diagnosis. Here the prolonged heartache often accompanied by precordial tendernes on percussion or palpation 1 voty different from angina pectoris Hasty questioning may forever miss this easy differentution as to position, character and daration since die patent simply solunteers the informa tion that he has anterior client pain induced or aggravated by effort or catement This one conimon lond with angina pectoris is no reason for misluagnosis but fus promi nence in the are all picture of neurocircalatory authenla vrat responsible for its early label as the effort syndrome ·DIAGNOLIS AND NANDYT OF FAIT DISTALE In most cases of neurocirculatory asthenia the chat pain is les complained of than is the difficulty of breathing of the sighing type vludu was discussed in the chapter before this one True neuritis involving click or arms is far dayn tbc Just in differential diagnosis. Pressure on genc roou touc neunts and inflammatory disease give rise as a rule to symptoms easily distinguished from angina pectoris. The pain is rarely absternal it u sharp and more like a tooth ache and is of long duration although it may come and go rapidly as a throbbing sensation The very disagreeable left chest pain of herpes zoster may simulate the pain of coronary thrombosis in duration and severity but its post tion is different to that it tends much further posteriorly often follows a narrower bandlhe course and reveals tho abnomulity in the clectrocardiogram Also it is a very much ruret condition and when it is responuble for an obscure chest pain reveals iuself eventually in the crop of herpetic skin lesions which should altrays be looked frrin the follow up of a diagnostic problem Finally the tem intercostal neuralgia should be applied with great hen tation if et It coicni a mulutade of conduons some of which like muscle strain can be readily diagnosed with a lite are Generally the term means nothing except an admision of ignorance which u better cypressed in some other way such as chat pain of unknown ongin Earlier in this cliapter I llave referred to the pain of acute coronary thrombosis due to myocardial anoria or infarction us well as to the pain of angina pectoris is a matter of fact, they lase cwcly the amc diaracteristka except for the long duration of the fonnet and its greater tendency to cause collapse Iery rarely is there prostratiou with angina pctoris although there is such a condition as that described in 1799 by Parry uliich he labelled syncope ·PAN angina. Very infrequently a pauent may actually faint with angina pectoris apparently through a sudden abrupt drop in pressure and mcdentally it å poenble 10 luce nrope in a rusepuble person by an a crage dose of nitroglycerine (1/100 grain or 0 0006 gram) It us on the other hand quite common for a patient suffering from 10 coronary thrombosu to develop a sharp drop in blood pressure and state of shock The reverse is also possible ia fewer cxar of coronary thrombosis, that 1x, a rise of blood pressure to high levels remporarily dur ing the pain which apparently acts as a PTSLOT AGEDI. Reference should here be made to dues to distinguish three mac fulminating accidents to health froin the con dition of acute coronary i rotabases which they sonetimo resemble The firs of these is quite common and conuests of pulmo vary embolism Altbough there may be precordul pain with exch an episode etpetually wlien there is an in adequate coronary circulauon to Hart with there are dyr unguishing features slidi conut as a rule of a sharp Lim CTERS in heart and respiratory tatas us nell an (net when there B embolum lung signs inkluding localized tales or consondation 1177 esidence of alcletaus og karring in lung, in a low cases of the route ur pulmonale characters uc changes in the electrocardiogram and later pleura pain and a friction rub and sometimo tenderness are che site of a pulmonary infarct As a matter of 197 both condo tions may occur together pulmonary embullum aplicat ing a te myocardial infarction and see scrsa The Krond condition to be diferentiated us an scule abdominal emergency such as the passage of ontruction of 2 gall one rupture of a viscus (06 through a peptic ulcer) mesenteric from *it of eralulom a a rupturc of an arterioscleroux ancuiryam Since the symptomm and ngns of theke conditions are almost all subduphragmatx, ·10 DLAGNOSIS AND TRADITINT OF HLART DLLAST an error should rarely be made On occanon lioneler ve need all tests including electrocardiography to be sure and again we must remember but both conditiou are often zapoczated (without cual relationship) Thu u ospe cally true of gallbladder discase and myocardial infarc tion It should be noted that although there is comicumos Coronary insulhciency pain limited to an ann which there fore might lxe called angina brachialis there is no real entity such as angina abdominis due to coronary insufficiency of one excludes pain located in the cpigastrium which radiates neither up nor down Sometimo an arterio- <lcrouc aneurysm in the abdomen may ache and a marked scleroue or thrombotic narrowing of the meetitet IC arter 10s with severe reduction of blood supply to the 19tenines can ause sencre pain due to anoxia nhich has sometimo been called angina abdominis. Further evolution of this process may lead to intestinal infarction with or without complete thrombouc mesenteric occlusion Finally there is aordic wall dissection in the chest The abrupt onset of excrucuting pain often maximal at the start its radiation rule to the lack and often down the spine to tlic legs the involvement of vanous aorta brancha with interference of the blood how therein the absence of clectrocardiographic changes unless the coro nary ſon is interfered with by hanorthage in the coronary artery walls and the much lugher carly mortality in the case of the dissecting aneirysm of the conta are all clues pointing to the aorticlesion. Vext, ne come to inflammatory lexons in the thorax in particular pleurlu and penanditu. The former is com mon when uncombined with the latter and gros rise to pain that is es a rule not precordial but in the latenal or posterior portions of the chest. Icute pericarditis however dces often gite rise to precordial pain which is poinetime ·PAIY more 20d not infequently wooaed with pleunus (pleu topencarditis) Such pain, attended by face and lculocy tonu and be strual changes in the dectrocardiogram aan umulate cute myocardul infartuon and needs cudul craduation 4 helpful clue is the increax of the pain dur ing full deep respiration in the case of infcruow peri aardiu. Such agravation by breathing u mrc in acute myocardial infarction men when there w a periaardual frkuon rub due to isoleonent of the cplardium by the infarct. There are exception in ars of infarcuon with culoase percatdw when the parietal perioardium and adjacent pleun are also invul ed. Another clue - the carly appearance of ſever and traion rub immediately after the pan of pericardiau begim or indeed excoming corna donully Although tbe clatrocardiogram is bronal D most instance of acute periarto the pattern can be us a tule costly duunguuhed from that of acute aryocardial infarction. Up to now in this chapter the dmubuon of urdhon axu Lar pain tws been limual to that dependem on coronary insufficiency or chrombose to pericarditis and to disa Kution of the north wall and as a matter of fact there is httle cbe 10 present of importance concerning pain in the ican and great cokela Ton due to pressure from or rupture of an ortic WM arism in the thopal i lar les Omon non adays than 1t was a generation ago because of the sharp decrease of aorta philm. It can usually be easily identified in iu changer duration and especulls of course by x ray con brmation of the presence of the incunu The hanache of neuronat ilators a thonia has aſtra ly been referred to it it cornmon and readily diagnosed on the lasis ol is char acter of the type of person retet and of the concident 13mpxoms which always accompany at Pulmorary vascular ·12 DAGNOLS AND TEATANT OR FART DISEASE pain has been occasionally referred to as a basu for the so called angru In perowotica Sudden stretching of the pulmonary artery walls or of those of its main branches does occur acutely when there u a nagive pulmonary em bolius and may perhaps account for some of the ducomfort which accompanies the citieme dypne of such an episode but in such cues coronary nuufficiency at least in part duc to myocardul anoma or hypoll in an older person i ith limited coronary reserc can also cause dutress at such a ume Pressure from a rare pulmonary artery aneurysin u a very rare cause of chest pain In closing thus chuapter an important basis for typical angina pectoris not due to coronary atherosclerosu or obstruction should be mentioned. It is possible to have a beartache or almost uniquely even angina pectors when there is myocardial disease due to theumatic fever or other Cause I cry recently I encountered a case of toalled endo cardial or endomyocardul fibroclastosis *7th very haary heart whose as I had followed for 15 years before he died at the age of 71 of congottie failure. He had had absolutely characteristic angina pectory on cffort during all those years and had slowly developed left bundle branch bloch but at autopsy hu coronary arterios ucte capacious tiete was very little coronan atherosclerosis and the myo cardium showed no infarction In some cases there inay be to be sure, some coronary narrowing but far too lattic to explain the pain There us one thing in common in theke cases and in many of them a subsidiary factor Tech planation is probably to be found in die extra loud ini posed on a my cardium which is not strong enough to support the load with the available oygen supplied by 2 coronary circulation wludi should be adequate for a stronger muscle or for a lost land Thus one finds left venincular enlargement or ach total ventricular hyper ·PALY trophy insufficient to arry the burden of severe hyper tension of large myocardul kamng, or of zortic valve di cike (stenosu or regurgitation) without more oxygen. That happens before the myocardım actually fauls with cung congestion in lungi or sykemi arculation, Once myocardial insufficiency sets 11, the symptomatic evidence of coronary insufficiency rubsido although at the turn both may be present cien from day to day Thus particular sequence of eventi u true whether the angina pectoru u due to coronary arterial obstruction or to the much less common mechanism described above The subsidiary factor mentioned is the effect of a highly Kensitive nervous system which reacts suddenly to increase the hart load by nuing heart rate and blood pressure on excitement or effort. And there is one final factor behind angina pectons in some cases of little or no coronary ar terial narrowing and that w a high degree of corlic valoe stenons usually scquued and rheumatic in origin, which sharply reduces the stroke output of the heart and thereby limit the amount of blood which caters the coronary arteries An important ause of sudden death is high grade Loruc stenosis.

·CHAPTER 6 PALPITATION Purprration AIPITATION is the least important of the three common cardiac symptoms and yet it is often of great significance us a clue to explain the sudden onset of cather of the oder iso dyspnea and pain or to recal the callke of a cardiac ncurs. By definition palpitation is the consciousness usually disagreeable of the heart beat whether regular or irregular in rhythm and whether fast slow or of average rate It accun nether the heart is discussed or not and is in major degree dependent on the nervous sensibility of the pothon under consideration. Thus a scry sensitive individual may feel dugtecably cien a relatively slight increase of the normal heart rate (finus laclaycardia) hc may wince at or be terrified by a completely unimportant catrs solc or premature contraction or he may be completely prostrated bg a paroxysm of lachycardia which although annoying may be quite benign On the other luand an insensitive person may be quite unconscious of the Octurence of cursuolas and even hardly aware of considerable tadıy ardia whetliet paroyomal or not. Those are of course the cx TOTO most individuals fall into the large inter mediate group further basic comideration concern thic findings at tle time of cuminauon of a person who complains of ·PALMITATION 45 palpitation. The hart may then be regular and well within the normal range of rate, and yet the past or recent history of the pauent may clearly regal a diorder of rhythm at the ume of some episode of chat pain, shortnes of brath funtness or malaise lasting seconds, minutes, houn dayı or een reels Too hasty a questioning may ful to uncover thus important clue and the patient may be wrongly regarded us wholly neurotic or u baring auf fered from cenow heart attacks neither of which cutreme apprawals i correct. Two illustrative cases which I et countered during the second Ilorld llar are examples of 1 common failure to look for important clues or to inter pret them properly when they are found Both of these cases were hypersensitise young soldiers with carduc nettroca but no heart disease Both had had paroxysms of ruchycardu. In one case the doctor who made an examina tion a few hours after a paroxyım found nothing wrong and on erdid hus rezonance intimating that the heart at LACK was an imaginary one this attitude caused an anagonum and distrus which deepened a cardiac neuros already beginning Equally unfortunate was the atatudc of a phyucian who saw the second young man dunng a pa mnyam of tachycardia prolonged bed text and ranous medicina nete prescribed and conunued for monetime alter dc purosyan was over and the patient was left to believe that he had had a serious well nigh fatal heart at Lach cuablusung a cardiac neurosu of higb degree Some jaan ago an aspecally unfortunate case this sort me under my observation. A middle-aged woman otherwise in good health was admitted to the hospital for an addiction to morphine that had atended for many scan following the 01 Creatment of a les paroysms of tachycardia 10 IKT youth. Tliete 28 no evidence wharSociet of any heart dis ext or ornet ille rutept for the mutpunism and yet she ·16 DIAGYO AND DEATHINT OF FILAXT DBLARE had acquired such a sensitivity to an increase of her heart rate of only 10 to 20 beats us on the occasion of my own eximation of her that she would at jach umo cry out in anguish for more of het soothing radiane Ilich some difficulty she was restored to good halth with a cure of her opiate addiction The commonext type of palpitation is simply conscious nas of a forceful heart bear dunng pormal rhythm whether the rate u rapid, slow or ai crage There are many cause, including clfort, excitement, fever toxic stata, and trauma. Rarely however is this symptom itself bothermomc enough to be a specific complaint Next in frequency are extrasystoles or premature con Tractions The great majority of persons who show extra goles have no heart disease Suchi beaus are commoner in cardiac patienu than in nonarduo and also they are more numcrous with increasing age Vost persons are conscious of this disorder of rhythm when it fint occurs but they often become accustomed to it and after a while may not notice it at all aspecially if it como regularly every felv beat and indeed even as often as every other beat The arrhythina may be felt as the carly beat itself or us the pause following the premature beat or as the post-out systolic thump sometimes all three sensations are fcit I myself have noted a full smilion in the peck at about the tume of a prenature beat due doubtless to the waic of blood rear up from the annum hen it contracts at thic time that the choicle iuclt is still in contraction and thic trictosprd value is still closed. A fen luypersensitive persons may leel extrasshola u painful snations and be ſcariu that they man angina pectoris or other rise Indlatc licart diene buc reassurance relieves their anxiety although the disagreeablc Kisations may continue. In a care of 10) csily induced angina pectoris either the exirassole italf ·PALPITATION 47 or the forceful post atrasystolic beat may be felt u a tvinge of pain closely resembling angina pector of effort in character and location but not in duration. There i little or no difference in the Kratons of atrial premature beat u compared with ventricular premature beau which ve much MOTC common Pittuature beats induced by a Crake are more likely to be found in heart disease than are auch bets occurring at rest. The three more common abnormal mecharusms of the heart beat raponable for paroxysmal tachycardu are us follows atrial paroxysmal tachycardia, atral fibrillation, and atrual flutter Clinical dua to distinguish between them may be helpful but, of course the electrocardiogram is the best technic of all their differential diagnosla. Ainal paroxysmal tachycardia u the commonent and u often du. unguuhed by its brevity lasting frequently only a minute or two up to an hour or two it starts abruptly (a curcum Itance often well desenbed by the victim) and ends #1 suddenly although its terminauon may not be morrell Doted by the patient if sinus tachycardu follow it It may on occasion, be wopped abruptly by caroud nnu premure and it u almost invariably perfectly regular at rates be tween 130 and 180 per minute It most frequently occur in petons tith no heart disease. Atnel fibrillation is a real arrhythmia with grous irreguharlty of rate thich ranges in rate us a rule when untated between 130 and 180 it lasts generally for houn, day, weeks, or often permaneatly and is not stopped by any mejura except specific drugs in parucular qwnıdıne the leart rate in atrial fibrillation is horrect generally readily controlled by digitalis, in the absence of thy foko\ coas infection, or infarction but enough digitals needs to be guien to control the rate reasonably during mild cher like a well us at ral Atrial fibrillation is much more com ·48 DIAGNOSIS AXD TEATUINT OF ILFALT DLSLASE mon in patienu with heart disease than in persons without it 11 most frequent us a complication of mitral stenosis but it occurs in many other conditions, for example paroxys mally with pulmonary embolum, Atrial flutlet is more or low bettvext and beta con those other two atrial arrhythmias but like the others it starts suddenly it us wally attended by a regular rhythm and a rate of 150 the atria beaung at twice that speed but able as a rule to transmit their simulu to the ventrcles only C\Cry other beat because of tho to one hart block. On oc casion spontaneously or as the result of regal action via carotid sinus pressure or digitalis effect the degrec of bloch may be increased regularly or irregularly so that only en cty fourth sumulus is transmitted or alternately third fourth fifth or sixth When the block is thus increased consistently the tachycardia is controlled although the actual atrial futter mechanum may conunue indefinitely Arnal fatter ulas common than cither fibrillation or paroxysmal tachycardia it lasts as a rule for days but it may be brief as for hours, or prolonged cien for years A fourth type of paroxyımal tachycardia is that which onginates in tlie ventricles (ventricular parorysmal tachy cardia) but it is much rater and often much more serious prognostically than the other three types since it 11 morc often associated with important heart disease particularly coronary in uuture It is wually rather brief lasting mın utc to hours, but like Ulic other kinds of partyjamal tachycardia it may precipitate coronary or myocardial fail uire in a cardiac patient ius rate ranga mually from 140 to 180 and tends to be slightly irregular although generally an clectrocardiogram is necesary to differentiate it from atrial perortimal tachycardia The differentiation is of importance because of differences in therapy For example in the case of the sentricular arrhythmias digitalis is out ·PALITLATION 19 of order in fact digitalis intoxication us anc of the aux of this disorder of thythm quinidine and pronatyl art frequently effective. One other very rare type of paroxysmal tachycardia is that aruing in the atrioventricular node it is called nodal fachocardia but an be dutinguuhed only by electrocardio grum from atrial paroxyunal tachycardu which it resem bla clinically In contrast to the patients with carduc neuromus precipr wted by palpitation or by die wtong tretment thereof and to those with premature contractions and paroxykmal tachycardia without heart disease there are the very impor ont and often krious cases of heart disease whore pain or dyapnea or even death may be aused by disorders of haar rhythm whuch occur wually u tachycardia regular or ir regular and atrul or ventricular Qute often such patients do not complain and indeed may not even be aware of the duturbance of rhythm itself because of the abrupt kequence of the vwtly more diagreeable pala or dyspraa which masks it Since, however it u of the greatest impor tance for the physican in diagnosis, prognosu and treat ment to distinguish between coronary or myocardial in jufficiency indaced by overwork caused by effort, acte ment or paroxysmal achycardia of any type on the one band and such insuffidency occurring ewenually at rett on the other clues us to disorder of rhythm should be scrupulowly looked for The parorysm may be over by the unic tbc paucat is ken by the phyucian and thacfore careful inquiry should be made u to the detuls of the patients sensations at the onset or just before the onset of the pain or shortness of breath. Ilus there a raging of the heart first or simultancously? Or if the heart did not to beat fast duning the attack did that follow after a bit the beginoing of the pain darprea itself and rem. to be tevelt ·DIAGNOU AND TREATIUFT OF TART DUCAL rather than a cuse? And just how fust mu the heart beat? Urually the patient cannot tell the heart rate wur any degree of accuracy but he may recognize that it iras about double the usual rate sometimes it is impossible to anstret this question at all and then it u wike to ask the patient to all the dOCTOT at once at the onset of the next heart attack. The phyucian can then tell by observation or better sull by electrocardiogram whether or not there u a dus order of rhylum At umas even on the first occasion the doctor may note an arrhythmia of which the patient is not consciouh One of the most important clus in ordiovascular duag nosu and treatment u that of tachycardie whether atral or canicular responsible for prolonged angina pectoris or pulmonary edema In a person with much limitation of coronary reserie a sidus anginostus may be to induced and continged for hours, indeed so long that there us a close resern blance of the attack to one of acute coronary throm bosus hich it is of the greatest importance to rule out. In the care of the natus angious duc to an abnormal tachy cardia the treatment primarily consists of course in the treatment of the arrhythmia, to be follored wally by only a few houn of rest instead of wechs of rok us in the case of acute myocardial infarction. If the pain w CTC duning paroxymmal tachycardia morphinc or other opium denvase may be necessary u in the case of coronary thrombosis but one does not need of course, to begin anu coagulant therapy Although the electrocardiogram rorcals thic abnormal medianis it may not be very hcipful other wisc except as taken serially since the temporary niyo ardul anonia may awe temporary changes in S-T kg menu and T maics that annot always be disunguislied from the beginning changes of acute myocardial infarction. So soon as the lachycardia is over the electrocardiogram in ·PALYTTATIOY 01 the arrhythmia groap tends quite quickly (in hours of days) to return to its former state and, of course, the fever and leukocytosis of myocardul mfarcuon ue abrant Much the ame is true in the case of the paroxysmal dyspoca and pulmonary edemua indued by parorysmal tachyardia in two types of heart disease. One of these types is that of left ventricular myocardial sakness with low TOKITE secondary to hypertension zortic valve disease (stenons, regurgitation, or both) or infarction (old or new) The newly imposed uachyardu prove to be too much of a burden the left venuncle fals and the lungs become congested. Thus state of affairs wually lasts for boun and subodas slowly after the rachycardu has clared up which may happen spontaneously or by treatment vu quinidine, pronatyl digitale, or other specific drag or measure It may be simulated by acute maxiVe Orci en moderate-rized pulmonary embolum which usually induces a sinus tachy ardia of high degree even up to 140 to 160 per minute, thus resembling the heart rate in paroxysmal uchycardia It u obviously important to distinguuh between these two conditions some of the clues have been presented in Chapter 4 on Breathing Difficulties but it ba oln jou that clectrocardiography quickly distinguishes between the yenu trhycardia of pulmonary embolia and paroxyumal tachycardia u tuchi cicept in the rare cases in which pul monary embolom itself may actually induce a paroxysm. In any case no matter what causes the pulmonary edema morphinc us the drug of choice in addition to any other specific measures audi as quinidine and digicalu that are indicated. The other cry important basis for acute pulmonary edema induced bs paroxyunal tachycardia is mitral stenosis. Herc, of course, it u not myocardul wealoes and failure that are the underlying cause bu rochanial obstruction ·59 DIAGNOAS AVD TREATINT OF HEART DIILAL which prevents a free flow through the lungs and left heart chambers of the blood that is pumped on vigorously by the dill then unolatructed rapidly beaung right venin cle Mitral valve surgery may solve this problem after careful study following the paroxywm. Finally there is one other kind of palpitation due to a v heart block not assocated with rapid atrial rate There may be true dropped beats as the fault of which there is often consciousness of long pauses in the heart action folloned by unusually forceful beats due to the expulsion of a larger amount of blood from the entricla than usual thu blood having accumulated during the longer pauses Such pauses and hard thumps may ocrur after any second beat when the degree of block us three to two after every third beat when the grade is four to three after every fourth when five to four and so on. Or the grade of block may be very variable When tlic rythm is regular tlough slow hay at 40 due to two to one block or even slower at about 32 then there is complete block with independent ventric ular action there is wually no palpitation Indeed some relauicly insensitive persons are not even conscious of ulic arrhythmia in partial block If there is an interval of prolonged ardiac standsull in very higli grade block, Caint nes and then yocope (Adams Stokes syndrome) may en suc ties will be discussed in the next clapier A very rare variant of the consciousness of an irregular bradycardia in a s bloch is that due to so block that is, an irregular slow discliarge of impulse from the ta node itsele. It us to be differentiated from a y block by graphic records most readily electioardiograplıc li may ortur in thic toalled arotid sinus syndrome or other fore vagul or toxic depression of the sinoatrial pacemaker and is not prognostically wo important as anoventricular Lloch Bundle branch block products no symptoms per a ·CHAPIER 7 OTHER SYMPTONS Vali ABLE dua w ardiac diagnosis and ucatment are come una revealed by symptoms not so cuatomanly related to the leart as are the three that hare lyced dixuwed in the law three diapten namely dyspnea pain and pulptation. Occasionally autention is called to then in individual papers lnut it will be helpful to present the more important ones together in the present chapter Fainthou and actual syncope are common symptoms in general only rarely are they due to heart trouble How et on occanon they are very important and in the ab etxe of other oh sous cause should be investigated as a posible reult of cerebral anoxia due to an abnormal heart rlythm ut to faulty cerebral circulation aused lry cerebral anterosclerous with some superimposed strain. 17 CTC ase fic disorders of thrihm that may cause there iy mpcomi The conmonet is an extremely fast heart rate due lo atrial parorysmal sach cordia whuh may be in the form of an atopa atrial rhythm ather tlc usual type or rul Nuccer (with I tol rythm, for example). Much less common s a caur is the stond type oamely an ectopic peninculer Ayrhm. Ainal fibnllation rarely induct a rate ſau cough (that w Oct 180 or 300 per ninute) to use any propounced fatninou ade from actual uncope. As a matter of fact, loss of consciousnos is rare math any type ·DIAGNOMS AND TRIATUFYT OF FANT PDEASI of tachycardia though it doo occur Once in a great wbile fainine or een actual cope may occur briefly at dic end of a parovysm of cachycardia when the heart stands sull just before the normal shythm u reuined Syncope iuelf when of cardiac origin us more commonly duc to a chird disorder namely sentricular sandsull than to any other cause such as extreme tachycardia. The most common type ot ventricular standstill is that due to very high grade parlal heart block in which no atrial sumulus passes the ai node and bundle for an appreciable length of time (ininimum of about six to ciglu seconds) and in which there is no ready occurrence of ventricular excipe A vagal rellex, as from carotid sinus pressure may pre cipitate partial leart block with or witliout reakness and syn.cope Because of the possibility it is often Hike to cry to block this raçal reflex by belladonna or atropm itself luch mar tide over the rorst of the symptom. It us to be noted that ventricular Handsul] long enough to cause sytucope may occur paroxysmally and to the wrprise of the observer even though the electrocardiogram may show no a v block at all between syncopal atuad Anoilier point of considerable importance to remember is that some per konu mith paroxysmal a block which may an faint rivay with anhac sandsull upon the application of pressure over the carotid sinu The carotid sinus may not be undulf sensitie but the nototal reflex may uncover the a block and be wrongly diagnosed as an example of the aroud sinus sxdrome Electrocardiograplir sudy quickly corrects Urus error loanoul any aytmopal attack in the Adams-Stola disease can be fatal t u nse to the wa lat carotid slow pressure only with great caution in alder person who may luse either atual or potential induce syncope 2: block The fourth disorder of Hiythm which can cause falnties or syncope 4 standstill of the rho. hical that is high ·01HD STON 55 grade snostnal block long enough to induce parosyaal atral paralysu. This is very rare. Although it an be ding noved by careful auscultation at the left steal border to pick up the atrul contraction sounds or by arcful obser vauon of the jugular pulse with the subject Iylng supine (Do wird are noted at all during the cardiac rundstill in contrut to the regularly recurring e or atnal hares that are keen in cases of a v block) electrocardiography u the technic of choice to sublush thu duagnosis A hypersensitive carotid sous rerulung in the caroud sou syndrome be longs here. It u in diese rare cases that atropine L licly to be more helpful than in the patients with a v block. The fifth and last disorder of rhythm that may cause syncope and that 11 asily confused with the truc vcnincular standsdll of heart bloch u transient or paroxysmal ventric ulat fibrillation As a rule the onset of ventricular fibrilla tion means the death of the I cart and of the pauent but there are occasional casas one will never know how many who survire not only one but numerous attacks of that unually fatal arhythmia. It can be distinguished from the Ordinary Adams-Stoko syndrome due to a v blod by clec trocardiogram (or by the feel of the squirming not pulsat ing, ventncia ff the hand of the surgeon grasps the heart) and since the treatment of the two conditori es to com. pletely different it is most important to obtain an electrical record during a sncopal attack if at all possible When ventricular ſibnllation occur as a complication during anesthesia or a purgial operation life may be Aled by the quick application of a defibrillating electncal shock which should be avallable in as many operating roods as possible The old ume ux of epineplırıne by application to the heart directly inside or out, in tactgency may be helpful in the usual cases of ventncular Handstill but it is just the wtong therapy for senincular fibrillation which indeed it may indice ·DIAGNOOLS AND TRLATIENT OF HEART DISSUE If syncope due to ventricular or carduc standstill or to ventricular fibrillation u prolonged it may lead to convul nons. In fact the Adam Stokas stdrome is commonly defined a syncope and convulsons 28ociated with nurked slowing of the pulse. It is to be distinguished from cpi lepay by the very marked pulse slowing in the former and the earlier occurrence or sequence of the convulurons in the latter When fainmeu or syncope rcrulu (rom cither cachy cardia or cardiac (ventricular) sandsull it u important to review the drugs being used. Excessive digitale may induce a serious paroxyrm of ventricular tadıycardia and probably eien ventricular fibrillauon in susceptible herufire or discased hearts it may cause a v block or even atrial stand will although rarely the Adam-Stokos syndrome unio high grade panlal block is already present. Quindine sulphate on paralyze the ra and a poceinahen, Chlorofom and related anesthetics can cause ventricular lachy ardia nod ventricular Gbrillation Other drugs in poisonous dosa an alto produce arrhythmias, and therefore all therapy should be stutinized when falntness and sncope appear to be caused by faulty heart action. Related to Canines and spacope is a sale of shock about which to important comments are here in order In the first place shod may be induced by several snow cardiovascular acaden. The most common of these u acute coronary thrombosis Tnd other accident responsible for shock in occasional cases are aciile pulmonary edema duc to left scntricular failure or to an abnormal tachyardia in mitral stenosis and acuic usually manne pulmonary emo bolam Rere auses are dissection of the aortic wall and rupture of the in!ETI NITIUlar spum or of brant valve or papillary muscle. Tie differential diagnosis of these vario cuo is 3 a rule fairly cany once one thiol of ·OTHT TOUS 87 the varnou posibilita and makes the necesity tot by history physical oamination electroardiogram and Inay The other important comment about shock us a complı auon of cardiovascular disease 13 that it often mal other diagnostic symptoms such u pain palpitation and dyspnea md may therefore confuse the obsctiti considerably As 1 rule hou eie there - a short time, even if but a few minuta when the mitial symptoms were present before shock occurred, and someone, a relauve, a friend or a bystander roxy be able to tell the physician about this. I shall never forget to patients whom I aw in my arly day one with intense breathiouness due to pulmonary edema and the other with the excruciaung pain of massic myocardial infarction who in the course of an hour lost respectively their dyspnea and pain and quietly died in shock In contrast to faintness, syrxcope and shoch, tertigo 13 rarely related to heart disease. When intense it may be traced to the internal car u Ménières disease or to a cere bellar defect but it an be confused with a heart attack in a nr cax not adequately appraised A very helpful clue in a severe attack of acute Ménières disease is the desire of the patient to lie with his cte closed Continuou bun ing in the aan bould make one suspect an intramanial as COTO munication auscultation dict the skull may rhaal A ardia or arterial murmur mas be heard in a troublesome way in one car or both especially if the cars arc faulty also Insomnia and extreme ratlesness chief complaints are uncommonly due to heart disease As a rule they are to be ascribed to hypersensitive netics ander strain ore COINC sumulation from one cause or another but they can in rare and of heart disease mash other symptoms it.

·58 DLAC\OSIS AND PATIENT UF UZ AT DISLASE Iery careful detailed observation may be needed to unravel clues. I have seen patients ho sete sleepless because of dyspaca (orthopnea or Cliczne Stoka respiration) of which they did not specifically complain unul uted they would sit up or walk the floor at night to get relief. Hypnoua mould make them worse increasing Cheyne Stokes respira tion for example or inducing nightmare or hallucina uons Onc pauent of mine was about to be sent to a psycho pathic hospital because of these symptoms and reactions but fortunately was discovered to lure incipient mya cardial failure Digitalis and mercurial duurctics quickly cleared hu insomnia and halluanations and in a feu days he was perfectly comfortable Digitalis itself unlike the hypnotic and narcotias docs not cause lallucinations or psychoses although it has on occavon been Wamed for dis turbance of the mind duc to the airculatory failure for sluch it is prescribed nor has it in my experience met caused an allergic response although such bs concouably possible Annoying chest pain of coronary or aortic origin or duc to neuroarculatory asthienu and bothersomnc palpi cation can act in the same way with much benefit by traat ment of the specific conditions back of the insomnia ond restlessness. Headaches and other intracranial circulatory dihurbances soncura lumped under the term encephalopalin are not characterisically found with heart disease per se or failure of cidict the myocardium or the coronary arcu Lation Furthermore the vast majority of headaches are not associated 11th discuss citlicr of the heart or of the blood vesels. Ileadaches are lio TITT common with lyperien sion and cerebral arterioscleron15 and in advanced as MY cuage called little stroha consisting of transient paralyses, cien z panial or complete hemiplegla lasting a few lours to a day or ind and clearing wholly or in large ·OTHER SY IPTOV 59 part, only to be folloned by other attacks and often culmi rating in a massive stroke wluich may be terminal One should mention in passing the sudden encruciating head sche that often us followed by fatal bleeding in the case of rupture of a mall (+ congenital) ancuryum located in the Circle of Wills and called familuarly subanachnoid hemor thage wually victims of thus duese have no heart trouble but only the local cerebral vascular fault with or 1 ithout hypertension phasia word blinduess and loss of memory may be tranuent or permanent results of cerebral vascular disease which fius into the category of cithet hypertensive or ar teriosclerotic encephalopathy It is possible of course to have much the same effects of varying extent and of vary ing duration from cerebral em bolign secondary 13 in thic case of disorders of vision to intracardiac thrombosis I istal disturbances Sudden loss partial or complete of the night of once can roult from embolism due to intraardiac thrombosis based on a variety of causes auch us subacute bacterial endocardius involving enthet aortic or mitral valve nieumauc heart disease and large myo cardial infarcts or cien ardiac dilatation of any type wib failure aspecially if there is also atrul brillation Or there may be thrombosis or hemonhage with hypertension or arteriosclerosis. An cuietosive and charactersuc picture of reunal charges u found in malignant laypertension et en hith choled dist cleanng surprisingly noccasion with treatment of variolu sorts sympathectomy fiypotensic drug therapy and the ricc dicu. In fact the clamitation of the geamunis affords one of the text clues to the severity and prognosis of 1 ypertension and to che clicacy of its treatment. Finchering of the siglit and colored 1won may be duc in digitalis untoration and should alnars Le looled for ·DIAGNOSLS AND TRIATLIENT OF HEALT DISCAIS if there are other suggestive symptoms such as anorexia nausea, or irritation of the color or if unusually large doses of the drug are being adminutered Cough and hoarseness hare their ongin rarely in ducaset of the heart or great resseli but once in a tvbile they are useful clues thereto. The former cough may be the result of pulmonary vascular congestion and especially pulmonary edema with the raislag of frothy sometimes blood tinged sputum. Prosjure from a very large beant, left atrium peri cardial effusion, or aortic aneurysm can cause a bothersome chronic cough often brassy in character when an ancurym u responsible lo the vast majority of patienu nho com plain of a cough hotvever the heart and great vessels are not responsible even though they may be discard In such cases the cough is due to an acute or chronic inflammation of bronchi lung tissue trachea, laryny, or upper air pais. agos (with the dropping of secretions into the trachea) or to the irritation carued by tobacco In rare cases of mo cardial failure with pulmonary vasular congestion cough 1. mort bothetsome than dyspnca and may be induced by recumbency as on first lying down at night What has been uid about cough applia also to hoarsenou Very rare pauents show runilateral Laryngeal paralysis duc to pressure on the recurrent laryngeal neric from an Aortic aneuryın or from dilated pulmonary artery dis placed uprands by a sety large left arrium A good many years ago I lappened to come across several patients with mitral Heness and laryngeal paralysis but since then I have encountered very few more Gastrointestinal symptoms There are several such ymp toms that can be blamed in rare cases on arionakular disease but cluas are often mot sought Tic fint of these y dysplagia Only in the ratest cases is gross enlargement For drum of a nemu ke the oth pe 1) ·OTHO MOTO D 61 of the heart itself or a maurre pericardial effusion big enough serowly to duplace or to compress the esophagus which w a rery adjustable more or lets elastic tube. Much more responsible u displacement with compression by a sety abnormal aorta as in the case of a large ancun an or by a vakular ring due to a congenital anomaly in panicu lar a right subclavian artery ansing from the descending thoracic aorta The clad in analyzing thu symptom are two first, the realization and remembrance of the poor bility and second, x-ray Hudia with bariam in the crophagus, It is important to establish the diagnosis sace nowadays surgical therapy may be effective Cardiospasm with or without the belching of gas s not a ardac symptom but may umulate angina pectorus and may complicate heart disease of any type. It has been dis cused in Chapter 5 to which the reader n referred. In brief it u the discomfort cubaternal in location produced by spam of the esophagus and cardia of the stomach Its cautos are myriad. One of the exciting factors in cardiospam is angina pectoru. This has been so coofusing in the past chat on OcESSION esophageal spasm has been con sidered to be the reflex mechanism of the symptom of angina pectoris set off by myocardul anor Anoreria is not a cardiac symptom but it may be an important carly clue to digitalu or other drug intoxication. Of course advanced beart failure and the most acute suge of coronary thrombosis may be accompanied by anoreza Vauca and tomiling may be initiated by a heart attack of any sort especially by acute coronary thrombosis buit more commonly it is the mediation rather than the disease that is responsible Morpliinc and related drugs and digi tali are common causes, and quinidine too may be te sponsible I ha e found it adusable to use as little opate as posible in treating the pain of acute Coronary throm bosis since the somiting that an ensuc may be more dis- ·62 DLAGNOSIS AND TRFATNIT OF SALT DISFASE ruins than ulic pain itself and may at such a critical time actually jeoparluze liſe. Finally it should be observed that there may occur amultancowls a heart attack such a coronary thrombosis and an abdominal ducase in particu lar cholecystius with gall stonas, primanly responsible for the nausea and vomiting and for abdominal pain Al dominal pan is rarely caused by ardiovascular dur Cake The exceptions are I) an epigutnc location of the oppreule pan of coronary insufficiency or thrombosis with or without radiation upwards or to the arms") puin and tenderness over a lucr cngurged acutely lovy heart failure or peruuardul effusion 3) arterial cmbolism to an alidominal branch of the porta or to iu bifurcation 1 ith obstruction of blood floty and 4) dissection of the aorta Trall or pressure froin or ripture of an abdominal an curym Tiesc conditions are sometnes very difficult in dced cien uroposible to diagnose but the presiko of licant or aortic disease or of petuardius slould always ante a consideration of the posibility that ope of these complk. tions may eplum an abdominal emergency not radily accounted for otherna Gascous dutcutron of the abilomen is a very common acompiniment of heart ducase and u usually unrelated to I but it can be produced or aggravated when there is con Gelnic hert falure or during the fans day immediately follon ing an autc coronary thrombosis as the rault of the narcouc Ulictapy tlie alsolute rost and die abripi change in dict Imlabiliyoj the colon eren truth diarthes may be calised by digitalis or quinidine intorcation and in some cases thereof is more prominent than nausea Urinary stmptoms are occasionally found in canliac patients, wally coincidentally alien diere is printauc obstruction with retention or when there is urinary tract ·OTHIL SITO IS infection of nephrtis. Hoxever such troubles arc agyra Yated when there is congeuse heart failure or acute coronary thromboses, and it may be necotary to Insutute atheter drainage and antibiouc therapy for some days or weeks. Hematuru may follok renul infarcuon due to cmbolism from an intricardiac thrombus and is then usually relausely painless in contrast to the hematuria which accompanies renal coll aused by alculi It should be added that bleeding from the kidneys as well as from the gastrointestinal and rapiratory tracts may result from inadequate control of the prothrombin time when anti coagulants are freely used, as for coronary or otlıçr throm bogus or anbolism. One other uninary symptom of interest is an increased frequency or amount caused by the reflex ellect of paroyms of tachycardua in some patients with such arrhythma It should also be remembered that a copious diuresis induced by treatment in particular lry mertural diuretics, may be superimposed on an obstru ting prostate to cause much distress unless it us quidly noted and relieved. Swealing 11 a common symptom in lieart disease us it is in many otliet rondiuons. As a cold sweat it often ac companies the state of shoch in Krious caxes of acute coronary thrombosis or acute pulmonary edetna. It occurs also in most paucnu with d secting aortic aneuryans and in many with pulmonary embolita. Ilahout Hoch it olay accompany diserewing parokyaits of tachyardia and it is common in neurocirculatory wlienia thyrotonicones, and hypetieDJIVC Co. In unusual cases it may also accompany and can rely preage attacks of coronar insuficiency and myocardul failure for crample at night without on nous pulmonary adema in these last mentioned cases clie upright position affords symptomatic relief Finally unknes us a tytoptom often complained of by ·GA DIAGNOSIS ANT TATTICNT or MIT ART DISEASE pauents with heart dirixe but except in a few individuals with marked aonic stenosu limiting the cardiac output and so the blood supply to the body tigues it u not a ardiac symptom per se it w related otherwise to the air culatory system only in advanced cases exhausted by their disease Vuch more often it u but a symptom of nervous fatigue of neurocirculatory asthenia, of physical unfimers duc to an invalid life, or to some specific disease such as Anemia or an infection that may complicate heart disease Honger unduc fatigue in older patients can rault from faulty circulation caused in part at Icast by heart disease and myocardial insulkiency ·CHAPTER 8 SIGNS Less important on the whole than symptoms clues to cardiovascular dagnosis and treatment arc rigns idenufied by physical cumination. Although thu sutement is true in the aggregate there are many excepuons 2 ungle sign may on occunon be the one cluc to a correct diagnosu. Those agns requinag inhruments for their detation euch us the stethoscope for cardiovascular sounds and murmur and the sphygmomanometer for blood prewure determination will be discussed in the next (wo chapters, to be followed by the hill more special techna of roentgenology and electrocardiography In the search for signs that may be important dues one should, of course, carry out a systematic phynal examina tion such as is routinely adriable in all cases anyway One an quickly colet the body from head to toe and in this chapter I shall follow that sequence. It u of interest bustorically to note that Theophilus Bonetu in the two large voluma of hu Sepulchrctum (First Edition 1679) chals Iished this systematic plan of the teaching What signs of cardiovascular value can one pick up apoo cremindson of the head! It is sometima said that prema tute granes and premature baldness are common among the young patients nith coronary heart disease the former * Tidence of early aging and the latter w a slgn of mascu linity the male being many times more often affected in 65 ·66 DLAONOSLS AND TREATOLPNT OF IRART DD LASE youth by krious coronary atlicrosclerosis than the female. Although this may be trus, there are so many exception to this statement from both point of view that onc annot place much of any reliance on it Somerilat the same thung may possibly be said about relative lack of a beard as a ſemınınc trait and therefore i point against coronary atlicrosclerosus but that too has not as yet been adequately Hudicd. The color of the hair and syes has sometimes becn men uoned us more or less diaracteristic of certain type of heart disease, but I have not found thus to be of any value nor freckling of the shin nor pallor nor tic brunette nor the presence or absence of acne Observations pro and con all these findings are hovec ull in the reilm of conjecture Since so far u I know there have been no adequate extensive systematic studies thereof There are lrouver er fide abnormalities of the skm whuch can be helpful clues. The first of these is pallor which is often due to anemia and indiatas the need of studying the blood suce anemua itself not only is an important Call of hcant murmuri which may simulate those of heart ducare Imut also can result from sulacute bacterial endo cardicus or apyratate the effects of hart disease already present as in the case of coronary insufficiency in onc Jinic my correspondent has 1 Titten that the hematologist reports that more than 50 per cent of hus untreated cases of pernicious anemia haut fxect sent to lum by the division of ardiology foute pallor is a common sign of KEYETT coronary musiciency Cranons then present m most olniows as a nile in the mucous membrano of sic mouth but it may le apparent in the shin of the nose cars checks, fingers, and anos. The source is to lxlorhed for in licart or lungs but it can I. pſiysioingially promlucal in the skin by ciparire in com There may be some local circulator fault to a plain a local ·NOX 67 qanots us from staw due to a vascular defect, but the general causes are commoaly pulmonary ducate (emphy kema extenslie infection pulmonary areal xcluson. emulxlum or thrombosis and an arution ETVOUS fula) congenital defect mth right to left shunu of large alber and failure of enthe engide (the left using pulmonary 126cular en gorgement and thu annemis the night causing peripheral arculatory itasu) Polyxy tiethia Increases cyan , anemu decreases it. Suike in dark-skinned pervont, especially in the black and bronn races, the lips often are highly pigmeared it w important t amme the much membrane of their mouths if cyanosu u tuissected Thert w a thin coloration that may be confused with cyanog although the differentiation is actually asy Argyra resulting from the chromic therapeutk wc of aler salts for nasal solations or gastric Ils m3 gue a ghastly stec! Hlue or gray color to the skin of the music paru of the bandy It is readily distinguished by the clor itxelfs hics is not the purple blue of charxmus in the fat that it u more intense around the mouth and eyes by the our sous alunkce of heart and lung duck and by is m xdificaur lry CTCise ahich impor un tie patients 1 Xery much the gras then {xx minge mere pink and more I calthy in spparance while man is due to heart tung disease is uncil, inacased in CTCISE There are the more clues that may be dened from arefu) scrutiny of the skin. Se nd repetalls in the prexne of congule heart failure with cigorgement ! the set tungen die paul slits of the presence of a large hemorriagc infarct ( fire kung me I thieumatic pheu mmity while felt hul hp orrir Sattered OLET iler \xxly should make me look for subcute haietul erelor ardius if there is alreuils als ular bear disease or a con genital defert of the lan ngreal varels The ars sometimes sueld salual le clues. Frophthalmo ·68 DLACNOH AND TREATMENT OF HLAIT DISTALE may at once suggest thytotoxicodus thich can explain tachy cardia arthythmia and in advanced cases cardiac enlarge ment and failure. It may be interpolated here that musked hyperthyroidun relly means that wc are masked cien though there may be little or no exoplithal mos in the case under study Pupils that are unequal or fail to react to light suggch central nervous system syphilus that may be accompanied by aoruitus cortic regurgitation or ancunsau. Characteristic retinal changes is ith arterial comprausion of icins hemorrhage retinitis and even chocked ducs point to the prolability of a seriolus grade of hypertension which not infrequently has been more prom anent in the page than in the present and wluchan explain Icft ventriculas enlargement mth or without fauJure Calm Tacts and the arcus senilis uluch are often of course ac companiments and manifostations of the aging process alc of little value os clues to coronary atherosclerosis they may accompany heart disease but I have not found them help ful many of my patienus with serious coromry heart disease having acicher while many persons with atliet of botlı shox no clipical evidence of heart disease Disturbances of tuuston have already been discussed in Chapter 7 Yanthrlame which consists of small slightly elevated whitishi spots of cholesterol deposition present in the shin of the upper part of the nose and around the eyes i con sidered by come to be important confirmatory evidence of atherosclerous of the cornery type The presence of large scarred tonsils mas common with rheurdatic heart disease many years ago but now one rarely sea them in anyone act with a normal heart Lucause of their ruune and often fully justified renoual in early liſc. Defeciar leeth have little relationship to heart disease except that their removal may exhaust an older person with rery limited myocardial or coronary reverie (if too ·HGY 69 many teeth are taken out at one otting) or may expose a young or even older person with congenital or rheumatic han disease to subacute bacterial endocardit through the invasion of the blood trezm by the Sureptococcu viridans vu the nav gum rurſace unless enough penialın 1 given prophylactically Abnormalities of the Ars may sometime reveal a clue. For example, a recent deafnew or naging in one car or both may explain vertigo dae to Mendre a dusease which on rare occasions, may be so Selete that it can awe 2 profound prostration which can be mutal en for a hart attack (coronary thrombo$19) 1 clue in differential diagnosis us that the patient with 10tense Ménières ducase prefers to lie flat with huges closed Sometimo exth systola or the posterth systolic beats are felt in the ans when there is a fzulty local circulation and in some cases a loud heart mummor aspecially one originating at the aortic valve 23 in 10tuc sen0115 can be heard uncomforta bly in one of both ars. Recently I have encountered a rare case of a roaring marmur in one car (the left) due to anerlosclerouc Darrowing of the left caroud artery in a diabetic patient of middle age die murmur (trich thnil) Over the croud artery was of grade 5 intensity Tlic neck affords on octauon xeneral valuable clua. A goiler with general enlargement or localued adenoma is often of course inert, but at uma it can explain tachy Cardu artbythm and cardiac enlargement One thould look for any asymmetry of the thyroid gland in doublul cases. A vigorous arterial (atrond) pulse is common with hypertension, a rigid sclerotic sorta and aorta regurgita tion In cases of marked so-called free onic regurgita tion, whicther syphilitic or rheumatic in ongin the head may bob a little mth eadı pulation thu lias been alled de Murets sign Sometimo when the chest la short the innominate pulation can be seen on the night particularly ·0 DIAGVOSIS AND TEATLET OF FICAT DLSLASE when the sorta and its brancha arc elongated and hyper tenure an aneurysm may then be simulated as a matter of fact, a ral aortic aneurysm may extend to the neck also And thrills and mumurs may be tranımitted to the neck from heart and aorta. Jugular vein pulation is always to be looked for vith the subject sented it is often normally visible in the supine position when renow pulsation u vible in the neck in the upright posture it is an indication that something 15 wrong cucept in very rare instances of short chested, usually obere perions (generally women) in whom the superior vena caval or jugular pulke u ju barely visible above die right clavicle Otheti ise the commonet cause is congestic failure of the right ventricle with increased systemic venous pressure the greater the congesuon the higher the pressure and the higher the venous polsc is ken in the neck extending een up to the right mastold und styloid processes and into the cranium itself which the rhythm is normal and can wually cally identify three wala rith each heart beat the a due to atual contraction the c due to intricular contraction and the ż a stavis way during ventricular systole ending with tlic beginning of dostole and the opening of the tricuspid valic When the presure in the jugular veins is very high they may not show much pulsguion but are constantly drended as in the case of the localled superior mediastinal syndrome duc to marked compression or thrombosis of the superior vena cand as from 2 tonk aneuryyn or to a lugh degree of chronic constrictie pericarditis or to accusise nght ventricular failure Thic reverse finding of cicarly vible and are marked ventricular ay#olic pulsation in the och scins with little or no engorgement in diastole means free (TICsprd regurgitation 1 ith relatively little congestion when this type of pulse is ker month after month rul relatively little disability in a patient i Ith chronk their ·HOY 71 matic vilçular disease it generally means thu Incupid stenoses and regurgitation are present us a fixed structural lesion accompanying mitral stenosis although in sen nue as it may be due to IrTeVersible dilatation of the in cupid ning with little or no salvular deformity per se Generally there is some slight increase in renow pressure even in duastole when one sees thus chronic systolic jugular pulse and also the atria are usually fibrillating so that no a uzve u vuible only the cand v mavos being seen Finally two other comments should be added about the abnormal jugular pulse. The fint is that in case of chronic stolic pulation the deep us well as the superfical rains are involved in fact wually much more so raulung in a forceful ventricular systolic elevation of the Hemoledo mastoid muscle which may simulate caroud pulation light pravure over the jugular bulb at the upper border of the right claircle quidly obliterates it, however The second comment is that with much rise in Chrow pressure the cand v taia are not so distinaly separated as when the preure is less and this roults in one broad prolonged pulauon quite oln jously longer in duration than the arotıd pulse Mackenzie used to all this the ventricular type of jugular pulse but the congestile type would be 1 Letter designation since someumes the rhythm is normal and the a trala are also seen. lon we reach the thorat iuself 'There are three deformi ties that can be helpful clues. The first appearing in child hood u that of a bulging of the precordiuen with actual boring out of the ribs due to early enlargement of the hean congenitally of the right ventricle or of the whole licart in cases of secte nieumatic feet The second is the protrusion of an aortic aneurysm high under the Hemdum and conul artilages on either side this was much more tor dxrown of Town New Yt he ppend (page 171) ·72 DIAGNOSIS AND TREATURT OF JITAIT DALAST often seen a generauon ago than now following the impres 311€ conuol of syphilis itkell. The third is the kyphons with deepening of the thorax that one seas in pulmonary emphy sema which may be responsible for dyspnea or the typho scoliosis due to carly deformity which in itself leads not infrequently to the cor pulmonalc tbe kyphosis that occun as a manifestation of extreme old age does not have any important significance Bada deformpita of the chat there are pulsations that an be helpful diagnostic signs. The apical impule of a very large haart, for example i cor boudum an be seen and felt in the axilla in the sixth and seventh spaces, and between that extreme and the normal there are many de grees of colargement with outirard or downward displace ment of the apex beat. One must, of course, take into ac count ardiac displacement to either side by hydrothorax or pneumothorax. When the chat wall us tlun one an (eel and rarely even xe the impulse produced on either side of the upper stemum by the slapping alut of thc pulmonary valic on the left or of the aortic valve on the right when there is incrcased pressure in the pulmonary or in the 1) Stemic circulation with accentuation of the second kundi II hen the heart is very large the a hole chest may uurile kith the heart beat specially when the atna art so large that they crtend almost to the night client kall There can then be a seeuw prication the venmcular walls retracting from contact with the left chat wall during systole and thrusting the atria out to the right, espeaally when the tricuspid and mitral values are incompetent as they usually are in the case of such large bearts with dwstole there is a relound in the otlier direction this pro diucing back and forth major pulation of the left and right chest walls. Normally the right ichiurile in its contraction card the ·SCY 73 chot mall whule the apex of the left ventricle como up and forward to strike the chest wall Ilhen the right ventride is very large it makes up so much of the thickened anterior portion of the hart that the chat wall antenorly at the Icft of the actum is thrust forward, wlule over the apex it retracts in systole simulatng die Broadbent sign whiclı consists of a syuolic retruction of the left nbs and inter spicas due to pulling in of the wall by clironic periardial adhesions. Careful Hudy is needed to differentiate these conditions, but it is much more important to dagnose dironic constrkatnc perianlitus by other agru (engorge ment of noch veins 10d liver 2 paradoxial mcrial pulse and abnormal T waves in the clectrocardiogram with very limited pulution and sometimo aldfication of the xray licart shadow in the absence of any other evidence of heart disease pet se) Tlıc importance of palpable thnlls has been overempha sized One finds them 01er the precordlum or larger arter 1es in thorax or nech accompanying louder murmurs in particular the typical murmurs of aorta, pulmonary and mitral stenosis, and of a ventricular septal defect. Once in a while one may pick up a continuous Umll by palpa tion of vrous parts of the body (accompanying, of course a conunuous mumur) This may be felt over a patent duc tus arteriosus, in the neck wliet there is a loud renows lum (sce Chapter 9) Over the aortk area after rupture of the gorta into the pulinonary artery and anywhere in the body (licad neck trunk or extremities) ar an artetoi nous fistula or aneurysm congenital or acquired Disease is not a cause nderness over the thorar cven when there are symptoms of pain or dyspnea euro circulatory athenia is a common cause of pracordul ieder neth. Tender spots are someumo found ose pulmonary infarcts. And injuries and neuritis (apecially herpes Zoster) ·74 DLAGNOSTY AND TREATIENT OF IT ALT DUFAIT are important causes of ficte local tenderneu, Examination of the abdomen may yield some liclpful clues and would never be omitted, aspecially in cases of uncertain diagno44. Palpation of the Iroer may dusclose three abnormalius enlargement tendernes and pula tion. Ballottenent has been used helpfully in rapid de termination of Lier size and tenderness. It is important to dutinguish between a big inser and one luat u lon in position many erron lave been made in this respect when the edge of the Inter is telt a fer cenumeters below the costal margin. It is wise always by percussion or yray cuminauon to determine the position of the upper bordet of the liver when die lonet edge u well below at wwal normal position at the costal border or a bit loner down. If the liver u found dehnucly to be enlarged and intrinsic disease of the liver is unlikely one swuld try to decide it a heal enlarged hicart u responsible Failure of thic right ventricle and consrictive perkarditis, uute or diront, may show thiensselia fint or to a preponderant degree in the uver which acts like a sponge jugular vein engorgement and pulution usually quickly follow or in deed may coincide with the enlargement of the congested Iner ind finally the legs inel4 Kquel very late as a rule is the dei clopment of congestive waites in heart failure or constrative pericarditu. Lover tenderness is common when the liver first begins to enlarge due to arctclung of the capsule and right upper quadrant perin on effort is one of the carliot aidence of failure of the right seninde in mitral stenou for example After the liver enlargenient has become chronx, the user is as a rule no longer tender or painful Cirrhosis of the liver is rare in ardiac puents but chronk congenion that has lasted for a good many yan, us in the case of chronic con Strictlic pencarditis may induce some ardıç dahon ·SC 5 Pulation of the Inter of slighe degree is common but not asily detected only pronounced pulsaun becomes obni out on palpation or by graphic record. us in cases of tricus pid regurgitauos Kithout much chronic congestion The pulation, of course represents an in the neck icin, the inaia transmitted from the right aurum, but ru the in ferror instead of the superios seria casa Splenic enlarge rent is common in win ardiac patienus but when present in care ducese it should alt aus malcone thunk of and look for 150 conditions 1) suboxcute bacterial endocarditis and ) infarction from embolissu anuing from intracardia thromboss of other future 11th freak intarr uon the splees may be terudes but the chronkally hard spleen is nou. Onlysarels dues the cardiac spleens become very large It u interesting thau although at autopay a wax of congetne leart failure may shor slight splenic conger uon and colargement clinical andoke these f us urxom mon even though the conyeste ser may lx very large It a alnays uelli palpate ihe kidno for an are care furgraal kidney disease may aplain hypertemukan i hich may be reliesed by nephrer mms and course Larged infected Widney may aplain the reason for the poorer ware of health of wme cardum paucni os may also . datended bladder the result of prostaru obtinction. One other imp sunt clue on abdominal cumination which may explain obxiure pain is the discovery of an ancunsm of the abdominal aorta. Enlargement incased pulouson and ondernes may be quicondent and since at fas become possible surgically to replace in grafis almor tal ons of the zorua us in the 2x of an aneurino ccarctauon it is no longer of only *ademic interest to mahe a diagnosis of an aneurysm the abdominal aorta. The vom fics can alord vital clues to cardiovascular dugtun There may be kelios of am and leg on one ·76 DIACMON AND TRLATUNT OF IT AT DPST UT xide nith hyperactii reflexos confirming or pointing to an old cerebral sexcular accident Thic kuce jerks should alirays be tested their complete absence silggasts central neous system and perhaps aortic sypłulis their excessive reaction like the finding of fingernail biung in adulis indicata a hypersensitive nenous state often found 10 neurocirculatory asthenia Whitenes and numbnes on exposure of the hands to cold supports a diagnosis of Raynaud s disease Cyanosu of fingers and toes i found under the une circumstances as that of the fact and mucous membrana, in certain cos of congenital heart disear (most commonly with the tetralogy of Fallot) and in patients with KTIOUN pulmonary disease or heart disease with advanced failure of either ventricle or both Clubling of fingers and toes is found in the majority of cases of the cyanouc type of con genital haart disease (most commonly the tetralogy of Fallot) and in subacute bacterial endocarditis sithout Accompanying cyanosis it may lorrater be a fanus erant in the absence of disease of heart or lungs. Splinter hcdior thages under the nails may be found with pelechial hemor rhages usually clsets here too in subacute lacterial endo carditi. Kantkomiala in the tendons of young patients strongly support a suspected dugnosis of coronary hcart disease and should be carefully looled for in doubtful Cum Remanber that edeme of the legs is due to licant failure in the minonty of cases there are many other causes especially olresity varicose icing and phlebothrombosis, Finally ke come to the blood vessels themselves in arms and lcg. The venus (and the aneno too) are much mre lilely to be abnormal in the legs tluan in the amnis. 7 Tiere are two chef gious abnormalitica l) varlane veins while ause trouble locally only except then « much I lood ·SICS 1 serio in large plexuss that the person so affected czuły feels faint with ortostatic hypotension and %) acute thrombophlebitus in the ches threatening to lead to sen ous pulmonary crabolists in the latter case one call or both tend to be sollen and tender and are painful hen the foot s fexed (Hornan i ugn) The artenes are important for 1 o reasons theu con diuon and thesr pulsuon The pulse should always be felt for in the feet (in the portenzor abul and dorulis pedus artesies). If the pulse u pot felt there be is important in some cases to palpare the popliteal and lmmoral anene. Abrent or much diminished pulsa in the legs mar be due to loal blocking by Kleron, endarteritis, thrombosis, or tmbolum or to coarctation of the sons When there wa pronounced difference between the pulsuoni in urms and legs or between the arms blood pressura in all four on trenutics should be taken for more definite informations Varked differences betn een the rada pulses may be due to congenital vascular anomalies to pressure on the rubclauean or brachial arterio from tumor or aneurytm or to atheroscleroux changes in the excel themselges. The anera may be Klerose (hard) tortuous or beaded and can often be clearls oudised on an rap film I have found by observations of thousands of patienu over many years thut by and large persons with letosed peripheral arteries, particularly the radial have not much chioscal madence of coronary aherosclerosis in their early lives, while the grat majority of my young and middle aged uctus of coronary heart disease have soft radials there the seem actually to be a reversed ratio One of the tro tochnia that comprised the wal cam, manion in ancient days was palpauion of the pulse to more its charact shy churn and rare the other sedini way urmo Kcopy Undoubtedly our med c31 ancestors a Ick frundred ·78 DLIG YOSIS AND TREATUIT OF FAIT DISTASE years ago paid much more attenuon to the pulse than tre do today but, of course not much was known to explain the vanations then. The rhythm and the rate have already been descued in Chapter 6 (Palpitation) and will be referred to again in Chapter 19 (Electrocardiography) The pressure will be discussed in Chapter 10 (Blood Pres Fore) The shape of the pulse women will be the subject of some of the remaining centences of the chapter 4 small thready pulse u found in shock, in pionibund patients, and in some cases of eceone taciyaardu full and bounding pulse is found often after CTUK in vasodilatation Inmi ang calue og alcoliolic drinking in cases with much gen cralized interiosclerosis including rigid porta and large anteries, rith parency of the ductus arterianus of luck degree or with a large anterioi nous fistula and at its highest degree in free aortic regurgiliuon wlien it is then alled the neler henne or Comgan pulse The ire per dictonic pulse u found in some ferent and other use of marhed vasodilatation The opposite finding of a placan or anacronic pulse u most commonly caused 20 AOTUK stenosis. The paradoxical pulse which when of marked degree tends to disappear on full inspiration fainn a diagnosus of ardiac constriction acute or chronic, includ ing a tamponade The most important of z11 abnormalities of the puise is that alled allemans in such with normal rhythm there is a regular alternation of blood pressure levels and thus of fulness most casily determined by spluygmomanometry but also soundtimes polpable priser altcrans u indicative of lelt ventricular i talnes A high fever eg 101 For 10 C, and a high ſculocy tosis, eg 20 000 or more suggest as a rule some other diagnosis than cither acute myocanal infarction or theu matic ſever when such conditions as the use they must be regarded as unusually serious i rith proper program ·VIGNS 79 There may be appended here best in thu chapter other important clua denved from technical studia not alrady entered in the chapters on roentgenology and electrocar diography of referred to under other chapters us in the case of the signuficance of the pulmonary blood preure in Chapter 10 One of theke u that a normal (or indeed in creased) arculation time (or warm hands and legs ) with obvious congestion suggests one of the high output types of folurenemu thyrotoxicosis, of benberi Increased oxygen in the blood in the night atnum u determined by ardlac atheterination, indicates the probability of an atrlal septal defect, in the nght ventricle a ventricular sep tal defect, and in the pulmonary artery a patent ductus urteriosus, ·CHAPTER 9 HEART SOUNDS AND MURMURS This chapier is not intended to be a treatise on auxultation bar rather a presentation of the more 15 portant clues to cardiovascular diagnosis and treatment that an be derived from listening over the licant and blood vessels At the outct it is to be recognized that serious heart discare may be present, specially that of coronary nature with nothing to be foond wrong on phalal etamination including auxultation Also it is true that much experi ence is needed not only to hear and cime saruauons from the normal hcart sounds and to pick up certain murmurs, but also to interpret them correctly Some obsctiers sull recommend direct auscultation especially in cases with very faint diabolic murmurs due to aoruc regurgitation and finally thc hearing ability of different obsery cti yang greatly some people ars cannot licar for example very low pitched mitral diastolic mumun that are quite olmous to others. Let us ducuss the heart sounds first I much accentuated first sound at the apex especially in the presence of con gestive licart failure always suggests the posibility of mitral Hctiosis cien though no murmurs inay le heard at first and even though it can be aused in a good many cases by a hyperactise licart in a person with a thin chest wall It is nell In rich patients to listen to the heart with 80 ·HT AIT FOUNDS AND BUYU 81 the subject lying in the left lateral position after some exct ax at which time an apical middast lic inumur say be come audible dccentuation of the pulmonary second sound (P +) u comman normally in young people after eXcTCe but wbenat there is suspiciou evideixe otherwise of increased pulmonary arteral pressure at rest thus ugn can often be confirmatory such increased pulpianary urtery prowwe may occur mith minal venou left ventri ular failure and the cor pulmonalc In such cases the pulmonary second sound is not only accentuated but often doubled also in patient with long soapding hypertension and accentuation of the aortic second round an important clue to begioning left heart failort is to be derived from the increasing loud ness of the palmotury second sound hich may eventually become cyen mare auentuated than the coruc second sound (P + + greater than A +). Increase in intensity of the aortic second sound (A.+) is of course, a long Loon sign of dystemu arterial hyperten ulon but a change in character of the sound is also of im portance and u not infequently found in cases with less of elasticity of the 201tic mall due cithe to advanced clerosis or to syphiles There a the montc of a ulapping, afmost metallic quality to the sound reminding one with what of the sound of amtet hammet Decrease in mensity of the heart sounds in gens accompania five iodu mois unusual thicknen of the Jun wall as in the case of grow obesity pulmonary empty with comiderable lung tissue between reart and clients Large periardial e oss, feebleness of the lean » and vascular shock These can ually be cauty and ituated sometimes tiey are combined. A des intenuity of a single pould may also be truporains a diminished lrk sound at the app without 1 7 ·80 DIAGNOLS AND TEATUIKT OT HEAT DULAST heart sounds otherwise may denote myocardial rakners. A much decreued or even absent zortic second round us commonly found in cases of considerable aortic valve Honosu similarly pulmonary valve stenoses (congenital) often raults in a much diminuhed pulmonary second sound A third heart sound may be heard normally at the apex in an occasional active young person in good health and as a frequent finding in the presence of mitral stenosu, but in a person with licart duease and enlargement duc to any other ause a loud third sound at the apex indicatos as a rule dilatation of the left ventricle on the verge of failure or actually shoving congestion under such conditions, and when the leart rate is rather raped it giic rises to the familiar diastolic gallop rhythm one of the most important cluo to left ventricular weakna Simuarly a loud third sound at thic lower end of the hernum giving rise to a diastolic gallop there u Pety suggestive of right reincular weaknes and dilatauon which should be looked for by other tests, especially ray and clectrocardiographic. Left ventricular failure mitral stenosis and chronic constrictive periardinus are important causes of the much increased right sentricular third sound. In the case of mitral stenosis the diastolic third round us usually followed by the la alled middianolic ruinble which may or may not be prolonged into a proholic murmur 4 third sound may also be heard in skole in rare cases 1 ho sem to be in good health and u frequently referred to then us a midsystolic click its mechanism is obscure but It has no clinical importance except that it may be misinterpreted by the physician as a serious sigti rendering ic then a source of apprehension on the part of the patient When complete licant bloch is present carclul ausculta tron at the left sternal border mas real faint sounds due to zlıe regular contraction of the atria dunng the long ·ULART FOUND AND AL lepincular diastolic pauses. This finding is of little 11- portance except that it indicates that the atia we follow ing a normal sinus rhythm and not fibrillating Sounds over the arteries are of luule importance By the time for example that the well known pistol shot 13 heard, other signs of free woruc regurgitation or extreme 12sodilauation have established the diagnosis long before Alurmuts Systolic There are a few systolic murTOUTI that with rare exceptions are important clues and sugget in the first place or help to establish a cardiac diagnosis. Such a murnar u one that is maxamal at the apex trans mitted well to the left axilla and lung bases but not to well to the aoruc valveare and of grade of 5 or louder This incans millal regurgitation but neither the character nor the Intensity of the murmur teals the ause of the re gurgitation that is whether its due to a structural de formity of the valve or to relauve insulbaccy roulung from left vaincular dilatation tu true however what the most intense murmurs of this wort (that is, of grede 5) usually attended by palpable thrills, do almost alwayu indr cateruitrol valve dues Another suolíc murmus of greater diagnostic ignifi and a loud op af grade 4 or 5 mually with palpable systolic thall maximal at the aortic area and widely transmitted especully to the vessels of the neck to the shoul ders and pic and to the cardiac ape, but not well heard in the lung bases this murmur u diagnostic of conic HCHLOSIS usually valvular but rarely infundibular in al most 100 per cent of the cases, the cry infrequent excep cron being a pauent with an aneurysm of the arending 20na. It should be recognval liokeset that are a lot The moon lee blat orduaanly mind I muriat 17 Tuh teen die tu ck Smith lemarked od ru ) und ·DLAGNOSIS AND TREATIENT OF HEART DISEASE licart sounds otheriizse may deporc myocardial wealaa. A much decreased or even absent aorta second round is commonly found in cases of considerable aortic valve stenosis umilarly pulmonary valve stenosu (congenlaal) often raulu in a much diminushed pulmonary second sound A third heart sound may be hard normally at the apex in an occavonal active young person in good halth and us a frequent finding in the presence of mitral stenosis, but in e person with licart disease and enlargezocht due to any other cause a loud third sound at the apex indicatos as a rule dilatation of the left scntncle on the verge of failure or actually showing congation under such conditions and which the heart rate u radlier rapid it give rises to the familiar diastolic gollop rhythm one of the most important clues to left cauricular realness Similarly a loud third sound at the tourer and of the sternum, giving rise to a diastolic gallop there is very suggestue of nght ventricular licalness and dilatation which should be looked for by other ico especially tray and electrocardiograplıc left ventricular failure mitral stenosis, and chronic constncure pericarditis are important cws of the much increased right ventricular third sound. In the case of mitral stenosis the diastolic third sound is usually followed by the so alled middiastolic rumble whuh may or may not be pro longed into a pra Holic murmur I third sound may also be beard in systole in care coxy who seem to be in good health and is frequently referred 10 then 4 a midsystolic click its mechanism is obscure but it has no clinical importance except that it may be misin terpreted by the physician as a serious ugn rendering it then a source of appreimension on the part of the patient When complete licart block is present arcſul zuxulla tion at the left semnal border may soal (ant sounds duc to the regular contraction of the atria dunng the long ·111 ART UD ADVIVIR R5 right rentricular contractions are forceful and the night atrium not so full of blood to danıp the retrograde flon Systolic murmuts heard over the artenes without coon praston of the vessels, which in itselt can cuve mumurs, may now and then rescal cluo to local abnormaliues Thus such a murmur someuma with a thall may be felt et an aneurysm anywhere in the bods In rare cases arteriosclerotic nartowing of the lumen of an artery may produce a spolar murmur thus is commonet in the case of the log arteries but I have hard it rarely over a nenosed arouid or subclavan Duustolic murmurs are een more definiuie than solic murmurs in establuhing specific diagnoses. Thw the localized middlagolic munnur at the super with or without prezystolic accentuation usually low pitchied and rumbling (rarely blowing) in character and when of higher grade, J or more attended by a palpable unill represents in the great majority of adult nitiral stenosu of rheumatic origin There are however actosional youngHet with freth or recent acute rheumauc fever and adults with free aorti regurgitation or rarely other awe lor left ventricular en largement who show slight grada of the same mumur Gwed by relatie mitral stenosis that is, a normal mitral valve but a dilated left ventricular diamber when this mumur is found with free xoruc regurgitation as in some cases of nplillitic zortiris it has been called an fustin Floni זוהתאח Rarely tricuspid stenosis gilts rise to a middlagolx murmur localized at the lone end of the semium Alvo I have heard on two or three occasions a right sided i.c right veptricular Austin Flint murmur An early diastolic murmur heard at the aortic vahcarta but best long the left stetra) border and not infrequently at the apex, and of any ride of intensity dans sortic rahe regurgitation this is due in the great majoriit of ·86 DLAC VOTS AND TREATDIENT OF VILART DKLUI cases to aortic valve deformity rheumauc or syphilitr, bat in rare instances to maely a more or less temporary of variable stretching of the poruc valve ning caused by hyper tension or by 1 loss of clasticity of 10nta secondary to arteriosclerosus or syplıılıs 4 tat has been proposed for the diagnosis of relative aortk regurgitation a drop in blood pressure caused by the adminuaration of nitroglycetine may aboluh the slight diastolic munnur and rouore a clear cut aortic second sound When a similar diastolic mummur u heard best in the pulmonan vale area and just belou 11, following as a rulc an accentuated pulmonary second sound, it is caused by pulmonary regurgitation In contrast to aortic regurgita con pulmonary regurgitation is rare and us wually due to anne valvular insufficiency from pulmonary hyperten ston in a minority of cases it is due to pulmonary alic deformity serondary to a congenital defect or to rheumatic involvement. Pulmonary hypertension sufficient to cause pulmonary regurgitation is due us a rule to mitral stenosu or to left ventricular failure rarely is it a part of the cor pulmonale of the roult of an atrial sepłal defect when ik as found with mitral stenosis it las been labeled the Graham Sicell murmur I ascular diastolic murmurs are of no importance is Duroucz sign such a murmur may be heard on a major artery on slight compression alien there as free aortic regurgitation Continuous murmurs The quest clues of all on aus cultauon come from continuous murmur That over the pulmonary valve is caracteristic of congenital parency of the ductus arteriosus it may be of any intetbity from grade I to grade 5 and if quite loud us likely to be accompanial buy a palpable thrill 4 rare anception to the satement is chic munour of the rule type that desclops suddenly dure to rupture of an aortic aneurysm into the pulmonary ·SIT AIT LUYDS AVD VLTU & artery usually in a muddle aged man who does not long survive this acadetit li tha kind of murmur abruptly appears to the night of the ucrnur in the contic al c area. It meant rigture of an aortic aneutyou into the superior vena 12 wah the development of all the high venous promure signs of the superior mediastinal syndrome When continuous mummuns are heard on or other areas of the bodysmink evremities, neck or head they are due to arteriovenous iustulas (aneurysms) auch may be congenital Ot acquired inumalic ut not, except for that heard not un Comonly donn the thior ac spine due to congenital coarctation of the dorte Inasinuch us anenormous fistulas anywhere in 1) c body are en mportant cause of ordine urain and enlargement it behoora the doctor when deal ing with heart disease of apparently uninown cause to Kearch the body for an unsuspected antenancnous fostula. unce the surgical conter ton of mul a fost la can restore the heart to normal or at least selieve it of 113 ST1013 strain Thert u onc cry important polentul cure for citor in dugnovu in dealing will contin cows m mun and lat u the inisinterpretation of the venous hum) the neck which is a normal phyuologual phenomenon in many young chil dren and even in a rare alult It may be cty loud and Toning in character and attended by a thin!! It is best lucard or et the right sue of the neck maximally just onet che cla vic and may be attended by a thrill it ts due to the rush of blood down le jugular cin into the miperior vena cava and may even be heard met the latter zuot lo the 72gt! and soncumar m over the center and to the left of the upper siettium, which circumstance is a saison for its cozsianal TOTINI intervention u priety of the dutus arenosiu or aortic al ular discis. It can be castly and quickly obliterated by sliglut pressure on CT the jugular cin alone the point of the maximal mummur or by ha 197 the subject change from the aiming to the eupine position, ·CHAPTER 10 BLOOD PRESSURE La qusculation the determination » the blood prasure may yield valuable clues to diagnosis and to the explanation of various symptoms and signs Before discussing the clue I shall interpolate a len obsetiauons about blood pressure itself For completenes the blood pressure includas not only that in thc #emic artera represenung the pressure it the left ventricle and aorta but also vanou other pressures namely that in the sitemic anteriola and capillancs, that in the systemic Tills, the renac Carac and right ainum that in the pulmonary artery and its branches representing tic systolic pressure in the right ventrale that in the pul monary veins represenung the pressure in the left atrium and finally that in the portal system Also some would in clude the promure in the lymplut syatem and thoner duct Vthough it would be of interest and sometime of valuc to know all these presura for practical purposes and in the absence of simple technia for their derermina tlon we are for routine use limited to the measurement of brachial and sometimo of femoral arterial pressure to a rough atimauon of the schous pressire in thic jugular cins, and on Occasion to a study by carlisc catheter of the pressure in the great veins the night atrium the right Tantricle the pulmonary artery and the pulmorary arteri olas 89 ·BLOOD HEUTE 89 Brachial arterial pressure Fortunately the blood pro sure which is the most important cuially to measure u 2180 the auuest to determine The various phygmomanom eters in routine use today whether of spring type or met cury column, are simple to manipulate and accurate enough for clinical use although they should be calibrated once in a while perhaps once cvery year or tho or if they do not record casily An accuracy within 3 mm of mercury u mufficient since that much blood pressure range and even up to 5 or 6 mm. 1 of no real chmal importance It is always adviable at the time of the first examination to measure the blood pressure in both arms. Often there is a slight difference not actually berneen the arms, but duc to the time factor The fint arm examined whether right or left is likely to show slightly higher pressures by 5 or 10 MIL than dog the second arm whether this can be 2xribed to a pressor effect of the first compression of an am by the blood pressure cuff or to a nerous rellex from the patient : mind, or to something else, I do not know However no matter whicheiet am one examino it is very wise if there is any suggestion of hypertension to re peat the test Keteral tima, best of all at the end of the total mamination us well as early in order to find what the range 4. Morcover it gives one much more information to record all the actual reading rather than to arerage them u simply one systolic pressure and one diastolic pressure or to record only the lowest reading which may be the last onc Nobodys blood prewure is Hatic and the range of blood pressure between that which us alled basil obtained at absolute rest, and that which is marimal obtained under varyung propoT strains should be nown wheurer there is hypertension of not at one time I measured the blood pressure of healthy young men when they first a role in ·90 DLAGOD AND TREATIENT OF JEAIT DISEAU the moming but while still in bed and again later in the midst of a busy days acurities and I found not ifre quently a range of 25 or 10 mod of mercury in sholic levels Thu vanation is even more pronounced in soalled hyperreactors and in hypertensiles and may even exceed 50 mm one hypertctuiic patient that I remember came into the hospital ured and nerous one conuing rith a dystolu preasure of '(0 mm after a good night s sleep hus pressure was 160 mm Rarely is it pcccary to measure and record the blood pressure in the legs Usually it nulice to feel both feet to determine the presence or absence of die pulses therein (dormalus pedis and postcnor tibial) and their fulnes. Il ne pulse u felt in the foot the poplitcal and femoral pulses may be palpated and the fenioral inetual pressure meus ured for later comparison n lien dealing with certain condi ciom which may latct improve citlier as the result of the apy surgal or mallcal or spontaneously rud conditions include congenital coarctation of the aorta dissection of the aortic wall (the salle dissecting aneurysm) uanlar aneurysms of the abdominal aorta, ilus, or feinoral ar iena artertal embolum or thrombosis blocking the blood sopply to the lays and throunboangutus ohlucans or arteri osclerouc narrowing of dic main arterios to the legs aluch inore frequently than is die case of the arms the legs show a difference in pressure because of the much greater tend ency of all the conditions just cited to insolve the circula tion in the lays than that in thic armas. It should be noted that the femoral antenal pressure is normally greater than the brachial especially with the subject in the sitting or standing position Diastolic presure Although it is customary to discum the swolk blood pressure first I shall not do so because of the much greater importance clinically of the diastolic ·ILOO0 Munu 97 pressure. The reason for this greater importance is that the latter prature more nearly than the spitolic pressure repte menu the mean presure which u cresting a constant krain on heart and intend the three most importuit of theme varels are the coroana, the cerebral and the retual Every millimeter rise in diastolic pressure u equlualent to several millimeter nix in yolc picmare ko far w these strains are concerned, although it u also doubtless true that Ilery high pulse pressure nihouc much of any eles auon of duxolic provre but a considerał ſe increase of suolto pressure can have a harmful water hammcr cffect on the arteries without much strain on the heart. 1 duscolsc brachial pressure constantly afx ve 120 mm of mercury and frequently reaching leighis of 150 or IGO or more bodas sl lor hean, braio or kidney and demands Store than the simple touune creatment that may ruffice for the great bulk of hypertensne parents. The sykolc pressure in the cases sofren not corropondingly buigh it may even be less than 3 mm so that the pulse pressure is relatsely wall esco as little as 10 or 50 mm in my own practice about 10 per cent of patients with high blood pressure belong to thu group and are as a rule good candi dala for radical therapy Those of the sort under 50 or 55 years of age are mortis malos and if they have remnabis good renal function and are not IB a state of Krious con granc failure they have ur rule keen much helped by lumbodorsal (thoracolumbar) sympathectomy Other cake of this type or those who are too old or too ill for the opera tion or refuse 16 luase been berusia be a very low sodiuca dict (itsch as the the diet represent m maximal degree) or by some of the new lspensiic drugs. I would add tho other obseTi 21100 alxot the duarolk blood procurc. In my own caperience 1 Hare found that its measurement during the increasing compression of the ·92 DIAGNOSTI AND MEATLIENT OF HLAIT DUCLE arm by the cuff on the way up to the upstolic reading gros a lower level, as a rule by a few spillimeters, than u truc on the way down after measuring the systolic pressure unst, with artifacts excluded Perhaps it would be best to note both lovels, such us has been of late the custom in record ing the duscolic pressure in aros of marked aortic regurgi tation or extreme peripheral vasodilatation where there is a waterhammet or Corrigan pulse. My second observation concerns thus measurement of the diastolic pressure in those ind conditions. Then there is a very distinct rather abrupt diminution in the sound on auscultation over the artety below the cuff or in the movement of mert in column or spłrygmomanometer needle that level winch is prolably the diastols pressure should be noted as well as zero where the bound may be sull audible On occa3100 houcier no ruch abrupt diminution u noted and, there fore one should record only the zero. Systolic pressure A generauon ago this ivas the only pro gure lanel measured and u all that most Laynen Inox about today it is important in wling to patients about their blood pressure, especially to those who overempha uze the hazard of every additional millimeter of systolic level to explain the unimportance of coact ligural and the great variability of the pressure both normally and in par ucular abnormally An INTCK of 3 to imm on occasion has worried a good many petson quite needlasly and it is not very important to combat much of the blood prestire neurons that has become common due to the little knoi 1 edge that the public has acquired Thiere are several phenomena concerned with solic pressure that may occasion erroncois conclusions or afford helpful clues One of these is the auculldorysp This is finding dependent on one Dethod of spługgmorgan. omers that by sukultation and not present in the other ·BLOUD ULRI 93 methods which should be used in doubtful ca con trols Ons occasion particularly in hipertensne patienu, there may be a please of silence or near silence of 30 or 10 mum of mercury dunng the time of the recording of the frue pulse pressure than the interval between the systok and diastolic lendi. tct the measurement of the actual ystolic pressure the ausculucony wund lades or disap pears some 20 or 10 m lonet dorn and reappears aftet 2 drop of another 30 or 40 mm. only a moderate degree of pressure above the dusolu lend! Thus a hyperions! pauc may late a systolic pressure of 190 mm while the upper level of the gap may regiset 110 and the lower laci 150 mith diastolic pressure at 100 Loles the cuff pressure in such a cak 13 nuised above 170 or the oscillauon of the michury column or dial needle observed as in the sallo roctric method of sphygmomanometry or the sadual pulse ſelt as in the palpatory method, an error in the recording of the syuolic pressure u Essily made being noted as 230 for example. The auscultatory gap is commonest in cases of hypertension or of aostke sterk.. Remembering that an aurulut my gap u poouble and uthung the correcti ni just noved it should txe east in Asord an error of the soft There are various unproueda planation of the auscultatory gap which seems to have no cmical importance prouded si dxs not cause an crtur in blood pressure measurement. The best clua to tu discos ery are to raise the prouure in the cut to a high level war or about 400 mm and to watch the collaboms of the sphsgoxoturometer Rasprauon especially when deep, causes a change in blood pressure then if us thorack $51 ape and fu}} there stormally • sligha loxeting of guolx prekure dunng inspiration and a slight ise during expiraison. When a patients wise fades or indeed in rare cases diappears al ·91 DIAGNOSIS AND TRADIENT OF LIFAXT DISTAN together dunng inspiration we 11210 a maximal degree of tu change due to the marked drop in systolic pressure Thu has been alled the paradorical pulse and is a valu able clue on occasion to constriction of the leart ather acutely us in tamponade by blood or pericardial effwion or chronally us in the case of fibrous or calcific comin bise periarditis. In either instance it is a clue to the need of therapeutic relief of the baan by aacuation of the fluid cawing the tamponade or by resection of the clironically conatricung pericardium One other un portant clue in cardiovascular diagnosis obtained by sphygmomanometry although wien of an treme degree also discoictable by palpauon of the radial pulse is pulsus allemans Ceruin precautom in its identi fication are necessary la tlie finu place the heart rhythm should be regular or disturbed only occasionally by pre mature beats which real or increase the alternution in the first 6 or 8 postextrasystolk beats secondly the cllect of respiration should be ruled out, if neccuery by the patients holding hus breath and thurdly die alternau n must extend beyond the fint three beau following an extrasystole Tlie pulsus alternans may last for minutos at a time or con for days or I echs. It varies from 2 or 3 mm up to 10 or 12 or more. It is one of the most important clues whide se possess of wealnew of the left ventricle appeanng early at und aen in the absence of all congestion and set it has been surpringly neglected by the medical proſession despite the case of its discovery Every case of chronic rathet HTCTe hypertension, of aortk valve discare (either stenosis or regurgitation) of more than sliglut de gree or of myocardial infarction being followed should be Quained for pulsus alternan at dic ume of die period.c checkups lus discovery warrant the use of digitalis and reduction of strain these measuro may delay or pract ·9% BLOXO PE R the development of congesuie can ízlure A few final remarks may be made about the systolk blood pressure. It is much more variable than the deatox presture txcing elevated much more bi mere ment, or tor agent. Physologically it may be slightly to moderately increased when the pulse rate is 1ery slor that 15 under 40 per minute in completo a bloch or mhen there u {ree aortic regurgitation. Also it may be increased more than the diastolic preuare in cases of congenital coarctation of the aorta. If u consideral le increase paro ymmally or constantly us accompanied by a high pula ratc and a much increased ructabolic rate one should consider the posibility of a pheochromocytoma in urast to the ordinary essential hypertension Pulse pressure The pulse pressure which us the differ ence in millimeteri mercury beti een the syrlic and dı aholic pretura affords a number of helpful clue fi o of them which involve periodic variations largely dependent on the systolic prcoure lezcla lave already been discussed namely the pulous predorus and the pulsus alterna and the physiologial increase pulse pressure due to marked bradycardu luas been mentwned Among other clues are the following a marhed wually tetaporary pretur in pulse pressure mas excur in hypotetuion when both Holc and diastolicia el are raised thu is due to the fact that the systolic pressure at nuch ume of stress or touc effect is rued much more than the detolic For example blood pressure reading that are ordinarily in the neighbor lood of 0 mm Ascoli and 120 duasolu may lemporarily rise during the cold pressor test to O systolic and 150 d. mtolk, the pulse pressure increasing from 80 to 190. Or the increak in pulse pressure may be due more to a lower ing of the diastolic pressure than to a mor of the suolic 19 the ax of free portic regurgital om en krimoreRONS ·96 NAGYONIS AND THATYEYT OF TART DISEASE fistula « rigid aorta or extreme vasodilatation Thu there may be only a slight elevation of systolic pressure to 160 gim. but a low diastolk pressure of 30 giving a pulse pres sure of 130 Sometimo hypertension may complicate aortic regurgitauon giving a systolic reading of 180 to 200 with diastolic level of zero. One of the most important conditions leading to a chronically increued pulse prauure is that alled Interio sclerotic hypertension here the systolic pressure u lugh often 900 min or more and the diastolic pressure normal or only slightly elevated, uay 90 to 100 In this condition there is relatnely little strain on the heart and Lidneys and many pruents surzie with it for a good many years, although quite likely it is soinething of a laard when the cerebral arteria are brittle A decrease of pulse pressure u found in a number of con dition and requira other information to establish the differenual diagnosis. Thus, when both stolic and di astolic prawuro are low spectally the sholic we may find that ie are daling with chronic adrenal insufficiency as in Addison s deseuse or with scutc prostrauon or shock Blood pressure readings in such cases may be in the neigh borhood of 80 mm systolic and 55 diastolic with ſecble pulse and a pulse pressure of only 25 instead of the 11crage normal of about 50 In cases of high grade aortic stenous che pulse pressure is small with a relatively low systolic level thus the syHolic pressure may be 105 mm and the diastol. letel 80 but now and then there is an ausculta tory gap in the condition and the systolic pressure may be higher than thus with a correspondingly larger pulse pret sarc. An anacrotic character of the puise with a slow rise and a platcau summit help mudi in the diagnosis. Fie in marked miiral dictions the pulse pronure may be qulic forall due to a low syHolic level.

·BLOQU MEHUR Pulmonary percular pressure he already suced in the chapter on sukultation the intentaty of the pulmonars xrond sound go a useful clue to the degree of the pul monary arterial presure but to obtain cien approumate tual figure cardiac carhelenization vnocentry The normal range of the presuro in the pulmonary anery and right ventricle are as follosis is to 35 (antrage **) mar. for the pulmonary artery sholic pressure and about 10 ram for the diastolic and 15 to $5 mm for the night en trucular systolic pressure and zero milimeters for the di unolc An Increase in the pulmonary arterial pressure found with I) left ventricular failure mitral steriosa (or regurgitation) and 3) pulmy nan tascular o'rtruction as ty thrombosis, embolum endarietine o rione pui monary discs and destruction 1 decrease in the pul monary arterial pressure is found with any aus for col lapre or shock and specifically sn the case of congenital pul monary cake or infundibular sienosil In increase of nogle peninfular pressure occur under the ume conditions 21 those luted for rease in pulmonary arter provure and in addition when there is pulmonan valse og infundibular RICTIONS while a decrease m night suincular pre surr . found in thod and with right seniorkular (allure Icnout pressure It u rarely bercutan to measure the pressure in the con las ago there were crude desca wch as a glaw capsule realed one the ikin \owadays when accurate mesartements are required they are best and mone cally bcained by inerzienoun or trucardiac atheter plus a hrain gauge Sest mic venou pre we trough but wally adequace eumation of the systemic 1 chow popure an be made by umple inspxim of the jugular runs mith the subject sitting actically in the upright prichut This jugulas pret TUIC is an inder of the degree of congation of the sheer is ·96 DLAGYOS AD NEATULT OF ALATT DUSEAL fistula angid aorta or extreme tasodilatation Thus there may be only a slight elevation of systolic pressure to 160 mm. but a low dizholic pressure of 30 giving a pulse pror sure of 130 Sometimes hypertension may complicate aortic regurgitation giving a ststolk reading of 180 to 900 nith duastolic lacl of zero One of the inost important conditions leading to a chronically increased pulse pressure is that called arterio sclerouc hypertemon here the systolic pressure is high often 0 mo or more and the diastolic pressure normal or only slightly clevated, as 20 to 100 In this condition there is relatively little strain on the Licart and Lidneys and many patients sunlie mith it for a good many yean, although quite likely it is something of a haard then the Cerebral arterio arc brittle 4 decrease of pulse pressure u found in a number of condiuons and requiros other informauon to establish the differental diagnoss. Thus, when boui sitolic and di stolic pressures are ton especially the systolic me may find that we are dealing th chronic adrenal insufficiency as in Addison s dwease or iath acute prostration or short Blood pressure readings in such cases may be in the neighborhood of 80 rom systolic and 55 diastolic with feeble pulse and a pule pressure of only 25 instead of the aittage normal of about 50 In cases of high grade aortic stenou the pulse pressure is mall ith a relatively los sgol level thus, the systolic pressure may be 10. mn and the duastolic level 80 but now and then there is an auxculta tory gap in tho condition and the systolic presure may be higlier than this with a corresponding's larger pulse pres sure. In anacrouc character of the pulse uith a slow Tlk and a plateau summit help much in the diagnosis Eren in marled mina) stenosis the pulse pressure may be quite small due to a lon ystolk lael ·BLODO PROSU arius and 3) obstruction of either vena cava or both by medlatinal tumors or inflammation, or of the night xinum by tumor or clot, or loal obstruction or compression of KOTILC particular icin One of the due clues distinguishing arrhosis of the liver with or without axiles from chronx Corsctive pericarditis is the high temu ienoupret nure in the lattes a clearly detonatrated by the engorgrd noch reins In some cases with coouderable tricuspid re gurgitation thee us a full venous pulse with a considerable pulse pressure which say equally be meanred thu u found sa cases of tricuspid valve disease or marked right ventricular dilatation. It gives rise to the important cluc of chronic deep tynouc jugular pulation indicative in the Txajority of cases of tricuspid stentosus (and regurgitaun) complicating mural senov Decrease in blemic winou pressure has no clinical sig nificance although it doubules occurs in cases of warration uod oligemia from any cause Pulmonary venous pressure u not measurable except as the time of operations on the heart when pressure in the left atrium may be determined as indicative of that in the large pulmonary veins. Such pressure both left atrial and pulmonary venous is increased in cases of left seatricular farture mural valve disease and thrombolu ar tumor oly struction of the left atrium. Portal pressure Inzimuch this pressure cannot be measured chacally me aced only to recognize iu increase in cases of advanced portal anthou of the lives and spletu ein torosbous which conditions ghenik to esophageal Varices and to splenomegals Surgical alleiation is prouble in some cases by anyomotic opcrauons. The normal range of portal blood presure 11 w generally agreed, is 15 to cmi of matet fostung in acou of "Os considered to be daaicd.

·CHAPTER 11 THE X RAY SHADO 11 OF THE HEART AND GREAT VESSELS Она NCE in a while although actually in but 2 small minority of patients x tag #tudy of the licant great vesels, and lungs affords the clue to the diagnosis. Often it 23 simply confirmatory of thc diagnoss already made cling cally On occasion it is negative failing to confirma diagnosis which had been made with the hope of x ray up port, and as the result of which need of funher study may bxc indicated For those variow reasons I have found fuori copy essential in the rouune examination of my patients cien Hough it rarely allords the only clue to the correct diagnosis I have found it locipful to olsone the heart and aorta lung luluses and dupliragm in action and to make 1 simple orthodlugraphic measurement of the transverk diameter of the liart aliadox for future comporton under the same conditions so far as thic cumination itself us COD cerned. Of course such masurements are inaccurate up to about half a cerumeter bat it is helpful to have serial reconds of the transerte dumeier as well as general descriptions of the Quoroscopic picture Best of all of course is the combinstion of ieierartigenogram (7 font film) or orthodíagram and Mucroscopy made serially at 100 ·XAY QALOW OF THE HLAIT AD GU41 US 101 jarly or more frequent intervals, although one an get along wually kill the one technic or the other As to clues the delermination of the heart stue is the Olost important. Not infrequently it is difficult or impoo ble to find out how large the heart us on physkal cumin ton because of obesity or pulmonary etaphysemu or cardiac duplacement by one cause or another In such ar the inny tube s invaluable immall or normal heart aliadow helps very much to rule out heart disease as a ause of dyspna or edema acepe un rare cases of mitral Henosis with paroxysmal dyspnea and not much enlarged left atrium and of chronic conuinctive penardı with big liver and engorged acck seins. In such mare cases the clues found elsewhere, by electroxardiogram playsıcal cu aminacion Wien the heart diadow is enlarged it is les helpful as a cluc for then can disease may or may not be the cause of dispnea or edema that is other conditions such a pulmonary disease may complicate tlic heart disease and be enurely responsible for the dyspnea or leg icin dirombosis may be the complication to cause the edema Enlargement of a particulas part of the hear #adon may afford the duc Although it is not easy in many axes to distinguish between left ventricular and night ventricu lar enlargement or to determine the relauic responsibili ug of the tko senin les for an enlargement that u caurd bry both careful studs especially during the rotation of dic thorax tinder the fluoroxope an sometime allord ade quate information left antrailar enlargement increase the shadow posteriorly and downward as I ell to the left (Fig. 1) while rigtit ventricular enlargement increases the shador antorly to hug the anterior c est wall as it M CTC as well as honroncally in the left (igt 2 1 and D) The shape of the chat and the height of the diaphragm alirays hain lenim into conideration A brad huur ·109 DIG VOSS AVO TREATIVT OF JILATT DUSTASE FC I died left entrrcular clargement D oung woman th free tortic gurglua roa due to a cogenluany blxcoyid tortical further damaged by robacute bacterial codocardith The Highth enlarged left ariamh Mble through th heart shadow short chosted person with high diaphragm may seem have a large heart when it us simply of full size and horizon ral in position while a wall person with long chest and low diaphragm mas set to tie a formal wiedlicant because It is so crical when actually it may be somewhat enlarged.

·X LAY FLADON OF THE ALAIT AND CREAT VESSELS 103 Incidentally it is in general better to speak of ienincular enlargement than of hypertrophy or dilatation alone inas much us in the great majonty of cases with more than 1ery slight enlargement both hypertrophy and dilatation arc responsiblc. Enlargement of the left atrium particularly in patients with mitral stenosu u a very helpful finding on rayon aminacion not umply to confirm the diagnosis but espc cally to ascertain the size of the left atnum which it as im posuble to do by physical aminiuon alone largely be ause that heart chamber is at the back of the heart and percused only with difficulty (Fig SA and B) On rare occasions roentgenology may reveal the left atrul enlarge ment of a mitral stenosu which is mussed or indeed diag nosed only with the greatest difficulty on physical enamina tion. Enlargement of the right aimum of considerable degree is uncommon but it can be diagnosed by the ray It is found in patients with tricuspid regurgilation or Henos complicating mitral stenous and atrial abrillation and in cenith a large atnal sepła) defect The bugat hearts in volume are of thieumark type with Fig right ventrcle and very large left and right atria with out much cplargenent of the left ventricle (Fig 1). The shadow of auch a heart sometimes almost fills the chest the Lorders closely approaching both walls. The cor bounum (Fig 1) of aoruc regurgitation is not to large in rolume though twice as licasy lus Nuadon l ulges lar downward and out toward the leltavilla In t not far into the right side of the dial A localized bulge of the left renuricular shadow (cardiac aneurysm) is sometimo ken In ass with large anterior OT lateral myocardial infarcts (Fig 5) This may even include the apci wlien it is very large and so located Although the ·101 DIAGNOHS AD TRIATHENT OF ILLANT DISTAL رک Fro wt. Pronounced right tourlula enlargement to i old woman bo ha ah ular pulmonary itenosh nd patent (mar oak. 7b characterial poutienoil dilauton of the poonary rtery and dateared narubrity ( the long reprexot The later ! KW 'whom the right venalche bkch has enlarged anteriorly on prostog rinse the HAPUID. bulge leself is tusually diagnostic ius pulsation is a further clue when the role of the icntrcular licart shadon con tracts in systole tie scarred region of the builge dilties, thus ·YHLY SHADOW OF THE LAST AD REAL INILS 105 FKC L Lateral lex causing a perdorical pulsation which can often be ob kerved ſluoroscoplcally If the earth not to large us to cause an actual aneurysm it not infrequently seems to stand still in shole cluanging tlie contour of the so-called Lymogram whuch records the Moment of the heart bordet either on the film itself by the use of a gred or elecinally by tic use of a pliotoclectric cell it is dificult for any laut aperienced roentgenologists to detect a moderately sired or relatively ·106 DLAGNONS AND TREATUINT OF ALATT DILAL F. JA to enlarged kft atrium ren projecting just beyond the right bordet of the beart in the fronul kew od dlepladog the coophagu posteriorly in the lateral bw Enlargement of the pulmonary nery and of the fight scntide are also present The patient had "pare mitnl scosh bkh was relied by ritrat rufey Larun Nxen in the cophagu small scar of a myocardial infarct fluoroscopially la crror in Interpretation of the tres film of the Liorax witch used to be made frequently but which now is ratlict ·YRAY HADOW THE LAST A D GILAT Etis 10 Fra JB. Lateral leve uncommon is to include in tre heart stiador mesure ments a considerable deposit of fat along the left bordet and sometimo als along the nglit border *This finding is most common in the case of a personalo usally has a good deal of fat located clservhere are die body and stese licart is olteii trametkely or horitontally placal 01 et a liigh diaplinzym which position in itself often malo the ·108 DLAGYONDS AND TRIATLIT OF HEART DEALE Fr. 4 sted cardnar enlargement in pace t with mitnl meno nd regargitauon ericaspid regurgiation od congrui e labore The keft main bronxhi i eks sed by the enlarged let atrium. lieart sludow appear to be somewhat enlarged The largest deposit of fat is Bually at or naar uic apex where the han pluadow merges mith that of the diaphragm (Fig 0). A Iriangle of fet ses cral centimeters in transierse diameter may be seen at this penardial diaphragmatic angle and be WTong's memurod a1 a part of the liatt shadow roulting

·X-RAY WADONY of ID ILAIT AVD GLAT IESTIS
109
+
Fr. 4 ntricula
Druty projecting from the topor art
of tbe beurt od bort set in the right ICT hirque ten Cake fea
Hoa in the deceat moordium or in
mwal throtus proudu
The parkut bad punied three mocardial to 21 on
In an erron cous diagnosis of carduc enlargement. The
realidation of the possibility of this finding in an obese
person should put one on gard and a careful shutiny of
the sum where a trangle of shadow less deme than the
beart shadow may be seen in dexend to the diaphragmı

·110 DLACNOSIS AND TREATMENT OF ITALT DUILASL Fk. 6 i ogolu lat pad at the ardic per a un obex patient Thb and netroneou impression of cardiac colargement The pricd imur of the arduc pe I seen to Ile within the wipose be diagonally towards the axilla should be criough to asorl an etior in interpretation Best of all us to observe the licart and lat shadows Ruoroscopially where the difference in denuty more obvious and where the far whadow can ky displaced froon die lieart slador during deep inspiration ·IRAY SHADOW OT TUE JEALT AYD MEAT EELIS 11 Pericardial disease u disgposable by any esamination In a minority of cases but fortunately in the majority of patients who are seniowly affected by it Acute por carditis of Finis origin, for example, or sheumatic in type cauning pain and ferer or a friction rub annot usually be duag noved by fluoroscopy or film. If however a considerable clusion develops, that is of more than 250 cc serial re cords may reveal it. In the case of acute or subacute tuber culosis of the pericardium the heart shadow may slowly enlarge to enormous site with relatively little in the way of symptoms. Early evidence of tamponade occur in patients who have a more rapid accumulzuon of Auid. Although Large penardial effusons bave been credited with giving characteristic changes in shape of the heart shader ( water bottle for example) it is by no means casy to rely on such changes and the heart shadow may simply enlarge in general due to the superimpoved periardial Muid (Fig. 74 and B) As a matter of fact, not infrequently there as a combinauon of myocardul dilatation 3rd pericardial cu son, u in pothe cases of acute thieumatic feet and then the differentiation by ray become 1ery difficult if not im posible. In such case physical signs are more valuable pericardial frktion rub paradoxical puke lavet enlarge ment, and fulness of the neck reim A clue that is soin tima helpful fluoroscopically is a decrease of pulsation of the hart shadow in the case of tight pericardul cffu sions but on acasion z wcak dilated heart may also fall to show much of any pulation csen If there is no increase of pencardul ſlund Chronic adheste pericarditis as in a case with Theuma tic heart disease is usually not aident by yras etamina tion. Ilhen horaer symptom and signs are aused by chronic consinchre pericarditis then it may la possible to confirm the diagoouus by the xray By the time that rocni

·11o
Di VOLS AND TEATUTYT OF IEAIT DLSLATE
3
Fro 1L Large pericardal Hoo abonn before od ftet
pericardul up with introdection ( ir
genology allords the evidence of serionis pericardial disease
It should be possible to lave already made the diagnosis
clinically but once in a while the discomety of pencardial
calafication (Figs. 8A and B) docs lead one to look ir
tipor signs of consumtion of the fear that might have
been previously oictlooled It should looked be olx
sened that aldation of the penaardium muy le of

·YŁY SHADOTY OF TE HEART AND CREAT DES 1 TX 7B dence of an old wually healed tuberculous lesion that in a four casos neser reached a degree sufficient to cause con striction. Finally it is true that chronic constricuse pen arditis with or without aldification may mo bind the heart by 1 shoe-leather like envelope that little or no pulez tion of the han shadott is visible Nuoroscopically when a relatnicly small heart studor in contrast to a much ca Larged one is noted to pulsatc little or not at all in the ·114 DLACNOSIS AND TEATUDT OF AFAXT DISCAJE FX 81 Comutahe perkarditis ta 50 yar old man Broderat aardlac enlargement nd right pleural i won are present !! olien the casc aldicason of the perkardium to sport writingly the Lateral la Barl mis een in the end gus Xth1 presence of signs of systemic lenous congestion we are thereby afforded a very helpful cluc. Of course in a p uent with such congestion a small size of heart shadow is in itself at once snggerisc of chronic conunaive pericarditis whether it pulala or not in such casa abnormal T waves ·I LY SHADOW OF THE HEART AND GREAT VEDELI 115 FM SD to the clectrocardiogram afford further cuidence. Non us to the shadows of the great ressels. Lule the left avlom the coria a largely out of reach of routine physical mamination except when an aneurysm thercof proktus itxelf in the anterior chau mall Esen modt sortic mour gsm in the thorax are, hoher evident only by x ray ex amination. This is one of the reasons why I am no et con- ·118 DIAGNOSIS AND TU TXT OF LART DISEASE FIG. 10 likken ing of the pork and dexaudingua duel dimung neuryum I the work in petteov e patient Before direction. The kind in uten 10 month fter the fun 61m De whorty Moulog • cplxle I pain 11 k Hly consturnt th witre dheutton. I thout any coronary insufficiency (because of thic des clopment of an adequate collateral coronary circulation) and Inasaud as most purimmis sheh angias perte til Or LOTIOTY tlırombosis do not liaic enougli coronarjalcification in line

·LAY PELADOW OR THE HEART AND CUAT TYLE
119
FC 10B
luble by Iras thu ugn 8 not un important clue.
Dwechson of the kortit well (dissecting aneurysm) may
De cident in rare caxes roentgenologlally by comparison
of anal films, us noted abone (see Figs. 104 und D) and in
more or les unique casos a double bandied aora with al
ified inner tube can be found. In obscure mich should
be looked for

·120 DLAGNOON AND TRLATVENT OF EAIT DUIT AL H t Fr. 11 Wxlening and aldlicetto the wkendi & morua du pbbitke sortiti. Thb a best reco in the I ft ntartar oblique Thew There are two congenital aortic abnormalities that may be found by x ray examination The first is the nght sided aorta which may be entirely unimportant dinically On occanon, honever it may be associated with other congeni tal defects to produce trouble, as in the case of an aberrant riglit subdavizo utery arising from the descending sorta ·ILAY SHADOW OF THE LAST AD QLAT 17SELS 121 Fro, ILL Coarctation of the porti H Dipe yea old box ho ya whom I only thyhet Dorching of the ribe The left cnonch hade Lart Toe hof oortuta odit ted by the UTON #ooted gainst the bar Bled crophagor Below thn print there hasht post tenork dl tauon anul responsible for a cominkung arenal ning sround trocha and esophagus lunce surgical relief is prasible in such cases not only should a night aortic arch le moted as suspicious aidence but also the contour of a barlu ·129 DIAGNOSIS AND TREATMEYT OF NEART DETAIL Fra 120. The cood film allantacourtaton of the sort in oldet perron, showing well marked Dorching of the riba column in the esophagus ( barium millor ) should be studied for an area of constriction The other aortic anomaly u congenital coarclation which is a not uncommon cause of hypertension in chil dren and young adult. There may be evident fattening or natoning of the aortic inob or of the aortic Hiadow just below the knob 10 the x ray film (Fig 12A) and there may ·KAY BLADOW OF THE 10F ART AYD GREAT ESIL 123 be notching of the ribs in older children and adulu duc to Tosion by the collaterally enlarged 10tercostal anteria (Fig 12B) often both of these may be noted lcans ago the roentgenologut on occasion discovered coortation of the aortu upon the finding of rib potching and called the at tenaon of the intemist or pediatrician to tin dugnostic explanation of otherwise une plained hypercnon, but the ulert practitioner of today should go to the rays simply for confirmation of lu clinical dugnowu. Acrenthe les we clo leave useful clua in the ray picture (Figa 194 and B) Tie surgeon who is to corretta congenitally nar roured aorta a today natinlly interested in iu cuact loca rion and extent, and for this purpose on occasion & COD trast dye aortogram is daired but since the procedure leself is not without some luard it should probably be rested for the more obscure cases The pulmonary artery and its I ranches form an impor tant part of the great sense sharon alone the heart itself and although great enlargement of the pulmonary anery can because of its anterior position in the thorax, become evidenc by percussion at the left of the upper sternum rray study is necessary to ouabluh clar idea 103 are and shape There are four chiel auses of chronic and nell marked enlargement of the so called pulinanary ar hores includes the main pulmonar enery and the base of the lelt main branch the right branch being largely helden by the aorta khich onelies it Thore four wo are 1) pol morary hypericDSON secondary to mitral genosi ) pul monary hypertenISK secondary to pulmonary 1l rombosis or endarietits oblierans and cawng the enlargement of the right veninde characteristic of the chronx cor pul monale 31 a large left to night shunt of blood to oscyload the pulmonary circulation as in the case of a congenital urial speal defect (Fig 13) or a parent duktus anerosus ·124 DIAGNOWS AND TEDNT OF HITAIT DULU WA Fr. 19 Atrial sepul delect thowlog marked enlargement of the main pulmonary itery uod lu branches (Fig 14) and 4) pulmonary valve stenosu, congenital in origin with pulmonary atery dilatauon jut beyond the stenot even though the pulmonary blood pressure itself low Pulmonary hypertension secondary to left ventricu Iar failure can to be strc, ause an enlargement of the pulmonary act; alto but thu is usually peither icy

·Y LAY ALADOW OF TIL HLAIT AVD GLAT VESEL
125
1
10 yr
Fro. 14 Patcat duxton Herloan |
kohth onderat
enlargont of the mal pulmonary mery Ad Teard kularity
in the lus
marked not chronic because of the often ratliet rapidly
enuing failure of the right veninde The condition wl ich
produce the most marked enlargement of the pulmonary
Artery often with ancurysmal dilatation of its branches
and whidi results is very wide lung lulus shadow is a
Large congenital atrial sepul defect.
Enlarged lung hilus shadows are composed for the mou

·IPO DAC1045 AYTI TREATIENT OF HIS ART DISEAST 75 Fre 15 4 lange darmold go of the medianinun flustrating iu стоmtb a 12 year period (from A to 1). It xu finally cachoed. part of both dilated pulmonary arteria and dilatel pul monary reims when mitral stenosis and left ventricular failure are rapozuble In the other cases, the pulmonary artenas are the vowels involved through actually the pulmonary arterios are located higher that is copiialad. in the mediastinum, there is not much dutance beinccn the levels of arteria and veins it is not alıray cury to differ ·XAY SHADOW OF 7222 RFAIT AVD OLLAT 236 197 Fa 150 cottate them fluoroscopially Tiere one condition which an be diagnosed or confirmed by Nuoroscopy and not on an vray film and that a pulmonary szkie regurgita tion which when of fair degree ausa a considerable pul Ation of the pulmonary artery and of the hilu shadony this Igorous pulsation has been alled the hul dance Xhen present it is a cty lielpful clue but it saries a good

·129
PLACNOSU AXD TILATIENT OF HEAT DISEASE
Fxc 16 L. Senere pulmonary edema mth dilatation
I the
petkor
CO
and of the wyso ein 0 1 young woman with nimal
uenosis, who u nov asymptomatk following min)
Ire noget
la tbe vroud Gilm, uten ter clearing of the sute pulmonin
edema in enlarged left triom bible through the right portion
of the beurt thador
deal in cases where there may be only transient relauve
polmonary regurgitation that valre defect is responsible
for . Graham Stcell murmur which a similarly come
and go (see Chapter 9)

·ILAY JHADONY OF THE LAIT AD CREAT TE 129 FC 16B Mediastinal tumors may on Occasion le differentiated from ardiovascular disease only with great difficulty ly symptom slyn or an by x ray stuly The greatest dull culty is in deciding netliet a mas is a fumor (Fig. 15A and ) or an ancuran unce the former may transmit a contiguous pulation and an anelinmal ex may be throm bose lifth rare exceptions, homesc areful amlysis of ·190 DIAGNOSIS AND TREATMENT OF HEART DISEASE > Fra 17 A pulmonary arterio enota fistula occurring i woman with polycy themia and papout The most cuble the Icft costophrenk engle A due to it nature is glien by the dlated cixcle running foto the man from the bílum of the left hoe the patient from all polnts of view atablish the correct diagnosis one may need to use all posible clue. It is important also not to confuse spinal xoliosis with enlargement or duplacement of beart or aorta which in sometimo done when there u too basty inspection of the ·T LAY HIADON OF THE HT ART AND OVAT V 511 11 sladom in the thorax in the ap view either fluoroscopi cally or on the xray film A correction is easily made by careful study of this 176 and by rotaung ti e subject under the fluoroscope or by taking blms in the olla que position. Two final comments should be made abrut the pulmon ary cintulauon u obtened by x nay Pulmonniy edema when of considerable degree an show itself clarly as a diffuse mottling of the lung fields either generalls or locally and the x-ray pature may demonstrate thu curly (Fig. 16A) when physical examination of the lungs may real little Such x ray evidence of pulmonary edema like the edema iwelf can qulchly come and go. The other point CONCETTI the opposite picture namely that of unusually clear and bright lung fields due to a decrease of circulaung blood in the lungs this may be found in a lung or a part of a lung distal to a point of pulmonary thrombosis and it 19 also setti In some cases of pulmonary HODOSP where a Jou coplou broncual arterial supply to the lungs fargely replaces the pulmonary anenal circulation Finally the great systemic cerns may be cngorged in Quins of failure of the right ventricle or of constrictive peti ardius, acute or dironic. Tie infenor cna ca a is not ordinarily vouble unless it contains an injected radiopaque substance (diodnast) but the superior ena air and the anygos veins can sometimes be identified when they are Chigothed (Fig 16 I and B). In rare ease there is a con geltal perustetic of a left superior vena cava draining into the coronary unus and in doul tful as this can be diagnosed by angiocardiography consisting of the injection of diodrast int the left arm icin. In rare cases of pulmonary arcT10-senous fistula it is possible to see the man insolved in the fntula in the xray filin (Fig 17) Tot thic more complicated technics of moenigenolong ·15 DIAGTOOB AVD TREATHALNT OF LEAST DISEASE nhidi may add further clua to diagnosis in rare cases the rcader is referred to textbooks and work of reference in ardiology and roentgenology Such techoso include angro ardiography cardiac catheterizauon electrolyiography and tomography Examples of further does are the visible passage of the ardiac cathetet through an atnal sepul dcfect from nght atrium to left or into the aorta from the nght ventncle in a case of the tetralogy of Fallot, and the quch demonstration of a thrombosed or compressed ruperior vena cava by diodrast injected into an arm icin.

·CHAPTER 12 ELECTROCARDIO GRAPHIC CLUES Mucsi help in cardson oscular diagam comes from the electrocardrogram in the way that its lal.cn and interpreted today and yet when didical elecuo ardiography was introduced some 10 years ago it had relaclcly little value being used umply to explain daturh ance of aardaac thythm. To be sure it untinuo to be very helpful in this respect but it has gronn to be renfold more useful in other ways It i to present ciuin clues correeming all aspects of electrocardiograplıy let this chapter has been prepared for a deuiled dextipuron of clectrocardiographu ichnk, beste principles, and inter pretation the mader is referred to the sper al solum on the subject. In Chapters Bon Palpation and 13 on Therapy a dis- Calon mll be found concerning the imptoms and imat ment of various diorders of them all of which an be quickly and best identified by the deathcardiogram and which include premature bats (ainal and mmmcular) perouwwel tacksandras anal fibrillation and fimilet and hrer block Depute the Cact that it may seem quite endent chinually that an anlyelmia comuns simply of premature Laats it is often useful to obtain an electrocardiogram to rule out other abnormalities and thus to be able fully to ·191 DTAG YOU AND TREATSINT OF HAT DUCASE raspire the patient also to have at hand a record for future comparison and infrequently to uncover some other ab normality such as bundic branch block thic presence of whiclı although hamiles in itself should be known It is more important still to obtain an electrocardiogram during a parolyam of tachycardu if it is frequent, pro longed or very troublesome in order to identify the type and also for future comparison Paroxysmal tachycardia of ventricular ongin u generally much more renow than that of atrial ongin and may be a manifchauon of coron asy lieart disease or of digitalis intoucauon. Sometia a paron consists of atrial fibrillation or anal futter which although on occasion occuring ara relaunvely simple disorder of function in a person without heart disease is muth more likely to appear us a complication of heart di case than as a happening in the community at large Also the treatment of paroxyıms long or short of atrial fibrilla tion and of atrial flutter is usually different froni that of umple paroxysmal tachycardia and one can often follow the effect of treatment hou by stial electrocardiograms. One example of the diffaccc u that of the effect of Groud sinus precure witch should alt ay be cated in a Like uith a parorym of Atrial tachycardia since it u suc causful in stopping an attack at once in 5 to 10 per cent of patients while it us 1 holly ineffetuve in atrial fibrilla tion and may simply slows the senincular rate temporarily in atrial Mutter by increasing the grade of block from the usual 2 to 1 to 3 of 4 or more to 1 Another crample is the greater effectivengs of digitalis therapy in atral nutter than in paroxyml tachycardia Before leaving the subject of atrial flutter I would like to ate the cause of a patient whom I Lale recently seen with that arlıythmia. He exemplifies a number of feature of that disorder whichi, although possible of loterpretation by ·ELECTROCARDIOGLAN studying thc lieart rate on phroleul nation, are intil itely more easily and quickly analyze! Is electroca ! + raphy He sa man aged 75 years with all d grees ot I perteryion and arterioklerosu but subje i to par ysms of atryal tachiyaardu every few weeks over the patrieraj yan During the paroasems which fease fien lased few hour cach time he has been cry (NXK 5 f the fast hon rate which has been rcoorded at 900 per minute oia litele la With the futter rata he has tell a biltterat wfustacie. A fortnight ago he was found on for tire a amination to have a regular heart rate of 160 of #lich le himself was not aware. An electrocardiogram wu talon #hich showed atrul flutter for the first one with an atrial rate of $20 and 'to la v bloch giving a ichiriaular rate of 160 a common finding in futter Digialu was begun in moderate dosage slowly to digitalue in addition to the quinidinc rations which he had been taking three times a day for a year or more Tho day later his catricular rate wus regular at 140 due to the slowing of the atrial rate to *80 by guinidine, the < 10 I block conunuing leer another two days the heart rate llad txecome regularly irregular with earlier beau ceny third or fourth beat dinlally resembling premature beaus but at the unwually rapid rate for the occurrence of c\ttasystola of 108 to 110 An electrocardiogram quickly rolled the mystery mhd could with more dificulty and much more clinical experi ence be solved irithout the help of the electixardiograpki The atrial Autrer has still present but Irith auch morca block cycles of 4 to 1 block predominating but irith occa vonal more or les regularly rccustent' 10 11 loch (Fig 18) Quinidine wat non stopped but the digitalis mas continued and in another in days the senincular rate was perfectly regular at 75 and the patient ſelt well in elecimcardio gram showed an increase in tl e atrial rate to 300 (follor ·136 DLAC VOTS AND TREAT TYT OF FAIT DISEASE ing the oiniuion of the quinidine) but a rady 4 to I block due to the digitalis giving the apparently normal heart rate A continued use of digitalis should maintain a muit factory ventricular rate whether futter condnud or cluanges to fibrillation or of course there may be a return to normal rhythm Finally so far as arrhythmias are concerned bradycardu of high degree, that is under 40 per minute, should always be sudied electrocardiographically though rare causes Lead 2 Amaran naminnin Fro. 18 Electrocardiogram shoming trial Butter with trbal ric of 520 od ventricular trigeniaal rhythm at f 98 doe to alle nating 46 1 4 to 1 and 2 to I block. LF male ged 75. nate apecially lughly trained dutance runners may have nor mal onw raia of 35 to 40 a very slon pulac usually signi fics heart block, more often einouentacular than singa trial If the rate u shoi n to be quite steady in the thirties and the pauent feels well no specific therapy 49 needed but if there are faint attacks, mth or without syncope and convuluons more study and treatment are indicated. In kevere cases of the Adams Stolos syndrome (slow pule with attacks of syncope and convulsons) it u very m portant to obtain an electroardiogran dunng an attack If the finding us simply that of ventricular or total heart stand till epinephrine is the therapy of choice gliem u often su may be needed. But if ventricular fibrillation is the ansiet Ulicn epinephrine it to be ridided once it an Itxelf sometimo induce such 20 Arhythmu Now let u consider electroardiographic clues that may ·ILICTROCADDIO ALAPHIC CLUTS 197 be found without relationship to antbythmia that is which Octur with eitier normal or abnormal thythm First as to the effect of heart position Before the days of the routine ux precordial lads it we often difficult to tell from the original three limb leads whether night arus deviation of slight degree giving an angle way of +93 degrees, or a bit More meant a vetlical heart position whidi it frequently did or enlargement of the right venince Of cours a high degree of riglit axis deviation or the presence of very prominent Pravas accompanying nglit axis deviation was talen correctly is evidence of night ventricular enlarge ment due cither to congenital pulmonary stenosis or atrial septal defect, mutral senose, or the cor pulmonale A high degree of right axs deviation with normal rhythm favor the diagnosis of one of the congenital delects over that of mitral stenosis which with much right axu deviation prac Excally always shows atrial fibrillation also in congenital licart disease the presence of right bundle Brancli block Cavors the diagnosis of an anal septal defect. Nowadays ke luve in the chest leads very helpful clues as to ienir ular size and details of atrial action in the case of right vert incular enlargement of more than the slightest degree die R Hava over die right sentricle tluat in in Leads ! V. and 1 and also in the I leads 2 and 3 to the right of the stermum have more amplitude than normally when they are amall Figure 19 Hons (HU records of nght avis destation in the limb leads, the first due to a ictikal heart position and the second 10 sight ventricular enlargement. Of course other factors too may Influence the herglit of the comple, especially the distance of the electrode from the leart therefore an obese chest wall or pulmonan) eroply sema or pleural or pericardial effusiops reduce the ampll tade of the electrocardlographic complexes, while a lan chat wall enhance it.

·118 DJAGYON AND TREATHINT OF MART PLAST LUFT PRET (a) 1 23 AVR aVL aVF FACERELE TUTTI V V V V F. 19 () Electrocardiogram (13 leads 123 VR. LAF V. d! ) tho ing right w da Latton to the care of Dormal ertical hent. JP pale ged 17 5 feet, 11 Incbe 185 pounds (B) Electrocardiogum (13 lade ISRVR, VL. IVF IV V v'v ud towing right no des lation with right colcular by pertrophy in me of micral renost, bowls to be effect of dit ulus EP femic d 23, 8 feet 5 inches, 129 pounds. A(a)-Umb leads 4b)-cheut lends, loduding 1x B-limb lande Bb)-chert lart focoding V- ·NETILOCAROTOCLAPEC (1 LFS 179 Left arus deviation in the three classical limb lads te quires much the Amc discussion as does rigtit avis desit tion In former days before the precordial leads were in troduced we couldn t tell in many cases of left axu devu tion of slight to moderate degree that u up to -30 degrets whether we were daling with a lorizontal heart position OT with left ventricular colargement of indeed mith both **Cc they are frequently combined Thiete kete lowever two helpful clua One of these w74 and 1 lolal inversion of Lead 3 that is, with an inverted Pwave an inverted QRS wale and an inverted T wale (with correspondingly upright T wave in Led 1-the means a horizontal heart position The second chuc masinoersion of the T uwes in Lead I accompanying left axu deruation hub inually means leli ventncular enlargene it due to systemic hyper terrsion or aortic valve descan though it may also result from coromry insufficiency myocardial disease or other type or perkardith The forecordial leads help to distin guul between left aus der Lation due to a horirontal haart position and left ventricular enlargement inmul as in the latter the R was as are of lighet amplitude than normal over the left sentricle, that , in Leads 1 Im and while thi T 101q tend to be lok lat, or on in enad. The game qualifying statement aplica liote that mas made in the case of the precordial leads mer the right veninde the nearer the heart to the clectrode the larget the com plexa since chest wall fan, pulmonın emply setha and pleural pericardial fluid decrease u er ampi tude Figurc "ORS Hotecorris of left av deration the fru die to a Lurizontal heart position without heart disease and us Komd due to let y entricular enlargenent It ho both mindes or clorged their ellects on the lıml leads of the electrocardiogram may result in a rela In ly noteal menguranent of the electrical ayis uuat is

·140
DIAG VOAN AND TATHIYT OF JILAIT DILALL
BERBER
.
!!"
2
3
AVR
AVL
LVF
(b)
....
B
(b)
i
V V: VA V V
F 20 (1) Electrocardorim bom g left u deration the are
of parmal horizaal heart. Po oale ed 4 5 feet & Inches
214 pounds
(B) Left or deslation a ax of ket sentrkular bypatrophy
(Hypericum coronary hart betr, DP 210/170 udda digiulb
therapy) J.A female, ued 44, 5 feet, 180 pounds
) od hmb lady Afb) od Bf6)-cheat lead

·FLICTLOCARDOQRAPHIC CIL! they may neutralize aach other but happily here the precordial leads come to the renue and usually clearly show the largement of both ventniles In occasional cases an unutual position of the heart duc to rotation around it was will cause fattening of clen AVR VL AYT V V4 Vs Fre 21 Electrocardiograma i nemul erkal beart thu t 1 wires i Lezda 2 nd SSL female, sed 17 5 feet, 3 Incben, 120 pound. inscruon of the T wases, most commonly in Lead' but also cven in Lead 1 and in the precordul leads, resembling at firit glance the cllects of coronary atheroscleroi OT ardiac enlargement For example a vertical heart position with low diaphragm may be attended by inversion of the T wald in Leads 2 and 3 largely corrected (apecially in Load) by elevation of the diaphragm by deep mpiration (Fig "1) It should be added that the Tsaic of course is normally inserted in lad al'R and not infrequently also ·1412 DIAGNOSIS AND TEATUITNT OF TITART DUSTALE in aVL or aVF The clue to the cffect of position is to re peat the electrocardiogram in different positions of the body and of the dupliragin in doubtfiu casas UN 2 3 B FK 22 (1) Elect udoga shoning Podie mit enlargement i I mitt redosle II R., leule ca (B) Electrocardiograd showing high Pm a asclared with right trial nd encicular enlargement e congcoltal ban dixer FIP mule, aged 26 It #alo endent that the degree of right uh der udon ho moch freater the rul in the ax of coagensbal bart diru the In that of astral stenoch. Lemb lerda I 2, Ipd 3 Atrial enlargement is often indicated by increased size of the Pirava. Leads I and and higher precordial leads than those routinely used and placed at the level of the thurd intecostal sprce olcr and close to thic Hemum slow the abnorma) P vasos best In Lead I for example there are not infrequently broad not necesarily high P wie due to the left ariel enlargement of oltral Henoois vulc

·ELECTOCARDIOCLAMIC GUI
113
10
ha
119
ZVR
VL
VF
In
(b)
B
11
(b)
Va V
Fra Electrocardiogram of
f au or pulomnak dor 1
manhe pulmon ry embollino R.P mak aged 11
(1) during maximum effect Al limbed 1(b)-cheat exch
(D) fler
reos CTT
BU Hrob kod 16 chow leuk
the P Hala of nghit aniel enlargem el duc to cemua n con
genital defects tend to be lugha rather than med (Fig
In mportant cluc to the acute enlargement and anorua
of the right ventrcle due to mastic pulmonary embolica
and alled the acute cor pulmonale u to be found in the
clegiocardiogram Tie electrocardiogram may sliow thi
pattern only transientis often for but an lour or two
narly for days, and so it is important to cure a record

·IH DIAGA013 AV TREATMEKT OF FAIT DISEASE as near the time of the height of the trouble as possible and to repeat it se eral times if necessary for comparson of serial records. The typial pattern consists of the nete de velopnient or of the increase in amplitude and duration of an S ware in Lead 1 and of a l aave in Lad 3 of the 2 3 AVR AYL AVF V VA V. FC 24 Electrocardrogram of axe of chronic cor pulmonale lo digitalis effect DR, malc, aged 40 5 feet 5 inches, 155 pound flattering or imension of the Traves in Lad 2, of the inversion or increased inversion of the T tara in Load Sand of invernon of the T waves in the precordial leads Oct the nght ventricle I and I (Fig ºg). Chronic enlargement of the right ventricle in a case of chronic cor pul monale of high degree is clearly revealed in the electro ardiogram (Fig 24). Now we come to the most important reason of all to tale an electrocardiogram, namely to determine the presence or absence of clua denoting coronaty insufficiency or Ka ning of the heart by myocardial infarction The use of the electrocardiogram for thus purpose tranxends its use for the study of all other conditions added together for three ·ELECTROCAL OGRAPHT CLLES 115 may be reasotu 1) coronary heart disease in civilized communi ua has become the commonch lind it is always of great immediate importance because of its hazard and 3) it may Le discos cred only by clectrocardiogram or at least con Armed thereby in doubtful cue with oborure bisory It should however be recognized that coronary heart duezx procat with no evidence of it in tic electroardiogram, even after exercise like the boalled two sep lot of Mawer or during the hypoxia tot of Lev a una cure with old coronary occlunod little or no karting therefron and no current coronary insufficiency Coronary insufficiency of more than Iery slight degree transiently us in the case of angina pectoru aused by effort OT excitement or prolonged even for run as in this case of Acute coronary thrombosis whether or not myocardial in farction can almost invariably shows itself in the elec trocardiogram It tends to aire a conuderable displace ment of the S-T keginents or in the chest leads on ctlying the region of anterior myocardial anos La a considerable ST Kegtuent cleauon as in the case of acute anterior myoard Lal infarction illustrated by F gure 5 Acute posterior myocardial adovia on the other hand may cause a transient deprewon of the precordul ST segment the waual acute pouckor myocardial infarct thon: relat sely normal chest itack and cleated CT segmento in leads 3 and al Fun Figure 96. A slight depression of the ST segmenu and a lowering of the T waves is, however a normal phyuological traction uskociated with the tachycardia caused by the Unhappily on occasion this physiologial reaction has been wrongly interpreted in a healthy man as cidence of coron ary licart disease and a kete ardiac neurosis has resulted 1 ha e encouDicted a number of such caser Ilso of course the depression of the ST segments and incloueting in Sonrning the Twt dit to the ter

·146
DIAG.YOSIS AD TEATITT OF FART PDEASE
2
3
AVR
aVL
VF
V2
V
V
Fro 23 Electroc Jogram ola Cox th Rute anterior myocard
lafzret (Infarct 8/8 33, co calen 8/10/53.) N Comale, aged 14
AVR
AVL
AVF
hampion
V
VA Vs
fe 26. [lectrocardiogram of CK with an acute portator mucandal
| farction (Ioferct 11/6/51 cs taken 11/9/51 ) B male aged se

·LECTROCARDIOrzu T - of digitalu (Fige 21 and 7) Lusting inds cels rica while the drug is being calen must be carefully diuin gulahed from the clfect of Cmonan insufficiency 1 huh differentiation is usually easily dine seats & Jirteer there was a noted trial in cm lork City Hagt rup of 1 1 2 ay AVL AVF LT VA Fra 17 LTLX digt mynning out of 1 xement dow dhkah It aim Dotext and di arbed w ( Uden ulan dughter! 4!) Exer o presku nate gd wa OKLETIN purpino and were more eduxorn free thn uning ur ) 6 ur cells Cox nary brant dhex) ji nuk rod 57 0 sphraton nho hard illegally secured Large sums of diubility inwrance by wing digitalks to mimic coronan haar dis case ciet trocardiographically Tee t mary msu TIGENCY atiended by angina pectoris and de longer lying myocardial anova aused by acile coronary tirumLx ritlimut myocardul infarcti numally Sulx le lout Jeaung any nen residual abnorpulity w the lettrocardiogram but if a miocand alter ol any ap ·118 DIAGNOSIS AND TRŁATWENT OF HEART DALASE preciable size results there are changa left in the electrical record such are very helpful cl110s to past happenings of the port For example of the car insolva the antenor wall of the left ventricle close to or including the septum Which us a very common locauon Q kalo are likely to appear in 1 2 الميا VR LVL AVF ГТ Vi V VA V. Fr. 28 Electrocardiogram ahon ng aidence of large attToptal myoordili farct which had occurred three mo ths arlier AG mule, aged 62 Leads 1 and aVL and the R waves diappear in the chest leads V and often V which overlic the infarcted arca (Fig °8) If the kar u very extensie Q waras are found also in Leads I and I or the R wave may disappear in those leads the infarct extending far laterally A lateral infarct may show changes only in the mout left of the pre cordul leads V and V or V and V (and in lunb leads I and al L) Sometimes there remain only a few tell-tale mies over the site of the well healed Kar (Fig 99) The chat leads have become very important for locaung, in fact aloost pinpointing, the damaged heart muscle all six or indeed even hien or eight precordul lands should be taken the old Lad 4 and the two or three routine pre- ·ILICROCALDIOCHAPIC LLUE 149 cordlal leads taken later in electrocardiograpluc history are quite ſnadequate in many cases. If on the other hand the car insolva the posterior all of the left ventricle whidi is also a common (though slightly len common) sito al wave usually appears or HWH MAHILI 2 VR AVL aVF ما مردها Vs Pro 20 let ocardiogram thon till det of wel he led ICT Laural Doardial i funt *blh bad ocemedai yan erket from prominent Qmoto Lerck 1 2. VL V IV od with nonal Tcv) EJF mal pred 51 grows larger if already present in loods 2 and a VF (Fig. 30 and 31) and of the wor is large en gli si include the Lateral walla Q also appear in leadıl and! If it wete a con lortable thing to do to take in pliagaal record one would find therein absence of the R kavo one that The precordial leads are usually normal in a case with a postenor left ventricular infarct of average size except during the initial proces when thic S-T vymenu may be muli depressed in contrast to their elevation in a case with an acute anlaior inlarat) Sme inlarcus are to large that they insolir loth anterior and posterior walls of the left ventricle or there may be

·150
DIAL YOSIS AND TREATIIN
or JILAT DIHAST
mething
AVR
VL
AVF
VI
VA
r com 50 Electrocardxoxt in whom cuid nc 1 wbuit posterior
myocardul I ra (i i ra 1 ch. 1952 ay when June 19572 VL
male, od 4
AVR
121
V
VE
FR 31 Elcctxurdayam shoving oidence [ *el heeled porterior
moorilul talachih had occurred 2 years aller (note prominent
Qwain Lod 3,3 od 1. LII make ved 17

·FLICIROGALDICA (10} kepante infarcu in front and in lach (often at different data) In such cases the electrocardiogram may be equila al and not clearly dlagnostic unce there is a balancing ol thic effects with a neutralination of die typical changes caused by both lesions. In sukti cases the clinical picture is more diagnour than the electrocardiogram and is to be relied upon On the other hand some infarcus are so small cluat they may affect only one chest lead and that lead may not be one of those rouunely talen but higher on the clich or further out in the axilla. It is very important to Lrreny that in a case of acute coronary thrombou the electrocardiogram may not show characteristic changes for a good many houn or och Koeral day and tlietefore it is essential to take at least veral serial records. Even after the clinial diagnosis has xen confirmed and the location of the infarct sublinird Krial electrocardiograms mien perhaps once a neck foi a month or two are often very helpful in the fullon up in closing thu discusH n of the clatrocardiogram in an nary heart disease I would add 1 luat luas been mentioned carlier in relaterte to disorders of rhythm namely that 11 ree disturbances are annionly caused by coronary III fi rency or exclusion ultirough they are ncx duagnost they can result from other causa they are entra ulai paroxysmal tachycard 2 ai llxh and Lundle Trankli block 11 e my kurdium may be affaced by other diseases thani That aused in conan atheter I mis Such more dolls whatever its can prodire electr randkrapla changes that are usually nondiagnostic There may be 107) low voltage of all the conpleno P QMS and Imagin thie luml leads and sometimo am in the el est lead the nay be simply a motinal (chiefly iniented) To thee may le I can I lexh, el a atri kaitricular or intra merne 12 Calle ·152 DLAGNONS AND TRADIENT OF HEART DISEAE ular (buodle branch) block or both (Fig 32) or there may be senincular paroxyınal tachyardia or athal flutter or fibrillauon. If there is widespread discase of some sort clsewhere in the body such us lymphoma or amyloidosis an abnormal electrocardiogram may in the absence of evidence of an unrelated specific disease of the ог incmia 3 AVR VL aVF V V. Fra 2 Electroa diogram of cre of astemh myocardul diente of known rgio, confirmed by topsy (note both 2- and bundle bri ch block) RG male, qed 21 6 feet, 160 pounde heart, man ardiac involvement by the particular syktonic disease. Sometime there may be a localued laion such as an chinococcus cyst or a new grolyth which muy give localized evidence of its presence in the electrocardiogram resembling somewhat the effect of an infarct. Pericarditu both acute and chronic, an affect the elec trocardiogram in large part doubtles due to the subjacent myocardial involvement. There may be for a few days in

·ILCTLOCATORAMIC aiu
153
clevation of ST segraenu in the limb leads (Fig. 33) and
in the precordial leade too subsiding late to lave po
Inace, or with a large effusion dicte may be generalued
low voltage. Chronic adhesive pericardius of slight degree
may produce no changes but chronic constitue pen
ardıcs, which means involvement of Krious degree aliray
affects the electrical record mth extensive T waic changes
2
AVA
LVL
w
VF
Vz VA Vs V
Fr. 3 Elmiro rukun showing the rol 4 pet din
domos proved a pontorteomination noce the key ted ST
keb and tai Twing in Lande i 2, VL. VE V Dut MS
male ed u
but fairly Dormal QRS Ka (Fig 31) n such
** atrial
Abrillation is often prevent also and in a few there may be
crudenre of nght ienirt ular enlargement duc to pre
porleant constriction of the left ventrcle so ghung rise
to an electrocardiograplık patio closely simulating that
of munactus with atrial fibrillation)
An inicrating and metima very useful electrocardio
graphie clue u thai in miedema In an ad anced case the
* are cat with low voltage of the QRS sain also

·131 ITAGNCAD AYD NATHNT OF ART DISTAD (Fig $5) Tlju abnormality us different as a rule from the various patternu found in other conditions or decades, such as coronary heart disease and yet I have encountered ucv cral cron in diagnosis based on muinterpretation of the 3 aVR av VF . V Ve VO V. IL B4 Electricardopt o showing th offert I rok onurk perkard to on froxed by operation Note the d phase 1 all 12 leo la with relath ly normal QRS V male med 31 OT lectroxardiograin with inadequate general clinical ap prawal Finally various drugs and toxins may affect the election cardiograd. The influence of digiulis luas already been menuioned (see Fig 27) Adrenalin in large dosage an in vert the T waves in lead 2 Quinidine sulpluate an produce bundle branch block and depress the pacemaken. Towao can lower the T waves, perlaps through to гут paulitic pe action Carbon monoxide con ause av block. Electrolyte imbalance an cause change. 101 cal qum content in the serum prolonge suole High potas

·FLE ROCARDIOGRAPHIC (IUF
155
uum levels (Ingfuerpotassenue) cause high pointed T wala
delayed a v conducuon und widening of the QRS mava
culminating in atrial paralyzus, grows bundle brancı bloch,
and deformed ST segments and T was. Hypopolavemik
-
2
3
YR
VL
YF
Y
V
Y
Y
Y
V
IK. 33 Electrox dmgr m show ng Lat P
the QRS i typx fouerlemu ID ſemal
ton lugt
al 61 BAR =
also distort the record i th depresion of IT segments
and 7 ma a prolonged l T duration nd large l mala
Incidentally negati e U waves usually indicate the prer
Crict of heart disease

·CHAPTER 13 THERAPEUTIC CLUES The cher clue of course, to the proper treatment of a pauent with disease or disorder of the heart and great varsels us the correct diagnosis but there are details of diagnosu and emetimes muluple conditions of varying degrees of inportance that require considerable skill in their therapy in the preceding chapters certain of the many therapeutic clues have been mentioned but for convenience emphasis and more comprehensive consider auon they are gathered together in the last chapter and othen added There are several observations about treatment in gen cnal that are worthwhile presenting before taking up thic individual clua The first is that it is always wise to get along with u uttle treatment as possible in reaching the dered goal Certainly one of the crrors of the past much u Aill too often encountered u overtreatment Even though each thing done can be approved Individually in a given care, it may not be necesary to use all or even kev eral of the measures available one or two may soffice. IVise judgment from this angle an often sie a patient the sran of excelle mediation the too arly use of some therapy which may be needed more later and the addi tional drain on his pocketbook 156 ·THERAPEUTIC CULES - kecond point is that now and then a rat day of een several days with bo medicinc at all may be lety helpful especially if the patient is having to effects from drugs or bred out from dicit effect, either physically or DICTtally or in need of reevaluation as to their neauty On rare occasions I have found such therapeutic hol days life AVIDS A thurd point concerns the polypharmacy that happily has been on the made during the last generation but which sull exuu in certain regions of countries. The compluted sborgun prescripuons of former days are now infrequently encountered in medual centers but their place is comc timas taken by a mulutude of drugs including itamins which are given sperately to that a patient may have a shelf or a drawe full of bottles from which he uales pills. capsules, powders or drops at frequent intervals all through the day and night Here should be included an indiament of much of the parenteral (hypodero« intra muscular and intra cnow) therapy of vart mus parts of die world wlwch should be free from dependence upon such a method of administration of the medicine. 4 fourth point has to do with the trade names of many of the mose important drug Often anous drug com pinia luaic tlieir own pet names for de sme deti ame of a commonly used drug such us diguals or one of the new popular blood presure melicines, and thus may and somnctimo docs lead to confusion. It is important for the pryskian to Leep timself posted about these names or else berier will to use the standard nama for the preparation with if daired, the name of a pharmaceutical house or it trade name for the drug in parenthems after it. Thus digtown is the ancu D gialine and furodigin Finally it is generally helpful to explain to clic patient hinell dlar the sari na malidnes and othet Uuttapeutic ·158 DLAL YOU AND TREATHERT or HLALT DHEAS effects actually are and why they are being employed li u half the battle to kcure die understanding and coopera tion of the pauent, especially when it s likely that yar of treatment lic ahead. Now let us ke up tlic clues to therapy themselves under vanous licadings 11yocardial weakness and failure Probably more knoryl edge and skill and experience are needed in handling heart muscle weaknes and failure than almost any other complaint in the practice of medicine The very first aidence of myocardul failure demands attention whether it in solve the left ventricie fir, as it wually does because of the frequency of systemic hypertension, aortic valve discase and myocardial infarction or the right ventricle fint u may happen with mitral stenosis or certain congenital defects. The clues to the beginning of left centncular laul ure already mentioned arc l) too casily induced dyspnea. °) pulsu alians 3) apral gallop rhythm and 4) accent tuation of the pulmonary second sound while thc nght ventricular failure cluo are 1) beginning engorgement and pulation of the jugular veins in the sitting position 2) tendemos and slight cnlargement of the liver and 3) x duazolic gallop at the lower cod of the sternum. Tiro measure of therapy are most useful at the very Hart of the failure Often they soffice if well applied with out the need of resorung to other more radial treatment which is often 2 bother The first of these masuros u rest more or les complete for us long a necazury unul some myocardial reserve has been reguned to or three wochs may suffice Complete Led rast is usually not neces Hry and as a matter of fact is ofteni univise To be up and around uung in a chair much of the day and with bath room priuileges u the best program for most patients. Much converation with famlly or vuitors and more than ·THELAITUTIC CLUD 759 cmentul telephoning are to be as olded After this initial aturation with roh rations of te dault weehis monthly and yearly should be arrangedh The second measure of equal importance is the use of diplalis which is the most fielpful medicine for a weak heart-nothing better tas as yet been found. The dnig should be guen to full but not to pluration (digialia uon) slowls that is in the course of a fen days to a nech unlas an emergency arises, and its effect mamuained as a sule permanenuy that , Lor the rest of the patients life To digitaluc 100 rapidly that, in a ſet houn or een in one day us usually unnecesary and often unrise since it may upset the patient who should not be disturbed by this medxcinc which he may have to the for the rest of his life and an antagonom to which should be carefully avoided con iu osie might then become repugnant. There are many different good preparations of digitals and many diferent ways of giving them I harc forind in the great majority of patienu te follotring plan to work well digitalu leaf 0005 gram or 1 grain pill or tablet tid for a week and then once a day thereafter Or one of tre pun fed preparation may be given in mach the same way of Digitinin 0 15 mg ud for a week and unice dails Ulkere aftet len patients need a luile larger datly dose than this or a latie unaller for crample a tablet of Ol gm Of 144 grains of the leaf or 0-2 mg of digitoun Ot 0 0 gm. or grain of the leal or 0 1 mg of digitonla Afer patients requ reino three of con four times the metage dose clety day for monilt or scan to maintain an xequate efect on Treart rate or more or hatt There is onls ons miraindication lor the use of dig tala, namely to tre it hlien it is not nealed If there ino meura do not suffice and as a matter of fan late are relati el fex pitent where they tho mt ·ICO DING YOLLS AND TREATMNT OF HEART DISEAST except near the end of their lives) then we have other resource, in particular reduction of codom intake in the diet and the administration of mercurial diuretics and in very rare causes thic iuse of irradiated sodınc To be sure excesne alt intake us wisely curtailed carly in all cases of cardiac strain and failure but conuderable or extreme salt restriction is so unpleasant that it is well not to apply it unul really necesary Tlie sme statement holds truc for the mercurial diuretia whether given parenterally or by mouth they are invaluable when needed and then grien wechly or a cry feu days or cren daily for awhile they can saic and prolong luas but they can also on occasion Le not only very uncomfortable but actually dangerous by depleting the patient and favoring the occurrence of the loi salt syndrome (prostration and resistance to therapy) which in turn require the replacement of sodium Mer cunal diuretics should be used sparingly when the intake of ult u very low now and then one can use helpfully a preparation of rei fortified with potassium to avoid ccessive low thereof to present some of the sodium in a inore palatable diet from being absorbed in the gastroin tatinal tract. In edematous paucnu rosistant to diureju iminophyllin intimously an be effecule in helping to clear anay the congestion but it must be used with care to avoid electro- Tyte depletion. On the other hand it is important to remember that morphine is an antidiuretic agent. cry infrequently does one need to resort to more radi al therapy but a clue to the posible value of such is the cironic persistence of ſalure despite the appliation of the acarura cited above. Then the administration of intedialed todme may have a place to reduce the basal meta I hyperton paikas ta Invictable cuogosul of "hypocrny drug Day the day Guurt the addition ·TATTUTIC CON 101 bolic rate of the body and its demand for oxygen na casing the strun on the heart One must figure lowever on z delay of ex weeks to three months for adequate effect of thu sort from adequate douage up to 50 or a 75 mulle Curva in one or Keral doce may be needed 77c use of Southegs tubes to draw fluid from the edematow legs (or even the scrotum) l a desperate but at timnas helpful meat ure ako Both of these procedures have been very unful in patients of my own Another treatment wlud. I have not employed but which has been recommended in desperate cixos of intractable congatie liean (ailure o ligation of the inferior vena cava urgial operations are lionevet wisely avoided as a rule in such cases. Finally in this discussion of myocardul failure mention should be made of an important clue to some kind of a serious complication. That clue is the very olmtinacym intractability of the congenise Gilure itself Often it man that there a present, perhaps obscurely a previously unrecognized or nei compixation and as arti e inlet tion #neumple of which is reumatk fener unlim or infarction cluen here us in the lung or hean and thyro- IM KOS13 One should search for such conditions. It is im portant to remember that in pzructiu Hith my cardial Callure death urually results from a fast Araw Akh - pul monary embolism and not from the farlure itself Coronary insufinoy So zoon us it is adent viat in. suficieny of the monary circulation is present beraire 1 the stuiptom of angina pectoris n hether or not there is any abnormality of the clectrocardiogram one should take action. It should not be treated lichily or casually but neither should it be viewed Fith alarm or pessimism. It is ua rulc best in the tfie parimt wholly into ono i confr detud plaining what the conduion n that it mug lx treatal with respect anul that canety of at Icau consider ·16 DIAGNOSIS AND TREATHINT OF IT ALT DELASE able improvement is, if not certain at last likely provided certain reasures are carried out. When some particular acrtion or excitement causes the discomfort of angina pectorus that exertion or excitement should be avoided for as long a time as necessary It may tale cehs or months or cien a yar or thio for the angina to plate and normal full or at least increased activity to be raumed the inculcuon of patience is therefore an cuen 1al part of the treatment in the majority of cases In gen cral it is like to tell the patient and his family that he should avoid hurry unnecessary worry on crexertion over eating (at any one time or in total number of alone in any one day) and exposure to severe leather (intense cold, stors and strong winds in particular) Te amount of restriction will depend, of course on the degree of trouble If the attacks are very easily induced several umes a day the patient had best rest up at liome (or in a hospital) for a fem nechs atray from his business and exciting visitors or telephone con cruations. Usually he is better up and around quietly rather than in bed. The nitrites are the only mediana, except perhaps for mild sedatives, that are of general value in such patient Contrary to much of the air rent autom I do not find or recommend the rise of alcoholic drinks as parucularly helpful they are for inferior to the nitrites as medicine and although in small to moderate dosage often plesent and relaxing, they faror overweight and at uma even alcoholum Only in chronically severe casas of this sort lasting six months to a year or more is it Wise to recommend radial treatment I have found that the best radical therapy in much casos is the reduction of the laul metabolic rate by the administration of irradiated lodinc Ingma pecions al rest that is, decubitus u specially important and demands great ropect Actually in many such czas coronary thrombosis hu taken place even if ·THERAPEUTIC US 163 parints particularly is rot at home (or in the hospiul) for there has developed no myocardial infarction. In these some wecks highly to be recommended but not in bed unless the patient feels better theme or infarction des clops. Nitrite may be freely used. Anticoagulanu to try to pro vent further thrombosis are being ined in some cases but we haven t yet the final answer u to the value in thn Tapet In days gone by engim pectors and coronary thrombo ne kere nered with ruch dread and pesardwn that many pauents, feeling fatalinrally that their dar nete nom bered anyway ignored precaution and did often come to grief Nor ke have learned that recovery men complete u not at all uncommon am in partenu inith the most Hiere angina pectoras decubrus, provided they are care Etel to avoid strain during the wrecks or month of their disalality This advance in our hiromladige and the raul ing change in the attitude of mam parienu lrave const Luitel one of the mot encouraging developmenu in rut treatment of coronan heart discase during the last geneta (1on1 In pauente nith actual scule myocardial infarction (KCY ondary to the coronary thrombi) a indicated by the clues of lenet leukocytou, and characterium clectrocarria ographic chunger, much the ame treatment a1 mentioned abone is to be recommended plus more complete ret for the first iliree wechs, preferally in bed the inte of anet. aurulants for womal keeks in the majority of achet po tients under hospital are and trapy of any complica chons may arise, mich a myocardial failure gain ilk cry important at the start of the treatment to explain to the patient just what is going on that he will gladly touperate in the pr gram and not rebel atilie TITUCIO ponech. I'mostration n lth xual slick dunng the first few liecins of scute coronary thromboa is a lot prognostic ·161 PLAGOS AND TREATIENT OF LAIT PLEASE sign but a good many cases reedier from thu ather with routine treatment or with the added help of ncosynephron or mephentermine sulphate transfusion of whole blood or pached red cells has also been thought to help but its value u sull open to quation The duration of the total conia lescence from several weeks to saytral raonths should naru rally depend on the amount of the heart muscle damaged and on the presence or absence of complications. A com plete recoity with Intle or no cardiac enlargement and onls residual adence of the scar in the electrocardiogram is a clue in most cases for the resumption of a normal active life Disorders of cardiac rhythm Since by far the common et disorder of rhythm is the premature beat or eurneystole mince this is found iuually in healthy people without heart disease and once it causes no harm and in many persons u not even nouced by them no treatment at all is necaary in the great majority of indivduals who shon thu arrhyth mia of the lieart There are persons hontiet who are bothered by their prediature beau n hether they have heart disease or not tiey may feel uncomfortable either due to the carly contraction isself hidi msy be felt as a tirob in their nech or the parise when their heart seems to stand still or the forceful thump of the afterbeat Persons troubled by auch nations may have uncomfortable days or nights and 10 desene come treatment. The amplest moure of all which aloue is often effective, u full rangurance and a statement that most perrons become so accustomed to the arthytunia that eventually they dont feel it at all Soinetimes it is obvious that there is a particular exciting cause of the attitola, such as tobacco coffee ica alcohol indigestion or unusual excitement or fatigue control of that particular faqor my then prove to be sufficient to aboluli at reduce the palpitation Infrequlently dnigs are ·THTILATTUTK QUE 165 needed but they should never include Darcotia. Quindine fulphate in tablet for 0.2 gm of 3 grains cach, may or may not be effecuse hen taken sencralima a day often it u not necessary to take it cty day but only on occasion when the arrhythmia a more ducurbing low and tell * wedative, particularly ruel a phenobarbital in small dos age may work well or een bromide which was recom mended yan ago by Sir Jama Macleone who found hortit that the best traumont commuted of remsurance od cxcrcise in the open air PATOesmal ladlegoardia may be as unimportant es ciera synola and may be ucated in eactly the same way u out lined above On the other hand it can be much more disagreeable and in the presence of heart disease an harmful and in rare casas dangerous therefore in such aises more than nmple reaguance should be applied the beginning of an attack of anal tachycardu pressure on the caroud unu may be used it u cffccuse in perhaps 10 per cent of cases. If it is ineflcuttie I ha e lound Chat the adminwrauon of two tableus of quinidine sul phare repeared in one of tho hours of the attack 11 pm longerl las shortenat elle paroxysm in many of my cases Syrup of sperac may work too but it is itself disasterable Mechwoll and pronestl may be ined in mure olunale carros and in a few patients digilai tation and iu mainte nance have been found 1c) useful if the primjmmal wachycardu ir senincular type quinidine and protrestyl are the drugs of choice. The mou important clue i ure Lent treatment is the ducation the mechanism at fault in the clecttxandiosani duh can be helpfully re peared in the full imup of the theraps of any anythimu Hirul Auller and Almilanon also les cent fied u ela Kartlinam, are more advanced diwides of thitim and m te ollen found in cardiac patient than in mormal ·106 DIAVON AND TREATINT or HTAT DLLAC persons. Although reasurance u still in order in most ama ut often needs to le qualified aaording to the extent of the underlying hart dverk. For paroxysmal or newly des eloped anal fibrillatwn the ratoration of normal rlıythm by quinidine u often to be recommended and u frequently successful if floweet the paroxysis often recur or atrial fibnſlation has been present for years the treatment of choice u digitalization and its maintenance For atrial futter I have found digitalus preferable to quin idine from the very start the ventricular nate can be re duced thereby through increasing the grade of block from oto 1 to 4 to 1 or thereabouts or atrial fibrillation may evolve or normal rhythm retum It has also been stated that full doses of atropioc after digitalition may abolislı atrial fluttet is in the case of myocardial failure so in the case of atrial fibrillation or flutter a refractory resistance to treat ment with maintenance of 100 fast a heart rate dapite ample digitalu may be a clue to the presence of some im portant complication sudi a Infection (eg rheumatic fever) infarction (pulmonary or myocardial) or thyro- COK KOOKL. It is raporuns, horrever to recognise that with atral fibrillation, much increase of heart rate on CCTCISC means that the patient is inadequately digicalized even though the heart rate at rest seems to be well controlled in the case of the complications just inondoned the heart rate tends to be rapid cven atrast Next, ke come to heart block Bundle branch block is a clinically silent condition and needs no treatment Even most aua of av block and H block need no treatment themselia unleu symptoms of dizzincu ar faininos or actual syncope irith or without convulsions (Adams-Stokes syndrome) develop when the heart rate drops 10 % or les pet minute or standaill acun for 8 to 10 seconds.

·THERATTLTIC CLLTS 167 Then the drug of choice is spinephrine hydrorhloride 1 1000 solution 16 to luc parenterally us often as needed ficntricular trillation has been ruled out by electro ardlognan u. ause of the lad of ventricular pulauion. In maildar cuxo cphednoe may have a favorabile effect In conclusion of thu chapter a fer observations may be added curcaning a few othe emergencias due to discare ut the licart and great vaseh. Acute pulmonary edema is commonly due to hear disease although there are other que. Imporunt cluas as to its treatment and also to the prevention of future attacks depend on the identification or use ind of hart disease that underlist it and on the drcovery of the factor of facton that have precipilased in However no matter what the cause there is one more or less specific immediate therapy for the great distrem that pratically always accompanies wie pulmonary edema, and that the parenteral administration of a barcotic mot phone sulphate is the narcotic colomanly used and get crally it is very helpful It is also wise usually to administer oxygen if it is available But that is not enough in many case If one dealing with suddo failure of the Ill! venince due to hypertension conx vale dokcase or mgucardial 10latction it is important to administer digitais in full dosage within a relatively len nun if the drug to not already being taken in adequate amount. In au cakes digitalis in puriled fom in kolulion may wisely be 8 en intra enoly half the digilalang dose at once to be fol lowed at four hour insatsals in the third and fourth quarters of the total dosage respecti ely anying the pro fram marhat as circumstances demand. Thus dui tin may lie injertel in doses of 08 mg of mg and of me reyrecti ely or digitovin in doses of or 03 mg und o 3 me, respertacy Omc xuie pulnorany nlema luas incent sec w in such cases full drgicaliration thrould le main ·168 DIAGNOSIS AD TREATIFNT OF HEART DIAL. tained act after If the cdema doo not subside in a fer houn mercunal diureju may be added helpfully to the tament And of course rent 17th licad elevated and limitauon of sodium italc are also to be prescribed Rarely us it necessary to resort to sencsection or compres son of die limbs by blood pressure cuits in the treatment of acute pulmonary edema. If honi ever the but factor is mural stenosis twith a superimposed tachycardia there should be instituted along with the opiate injection treatment is specific as possible for the fast heart rate if the tachycardia e of anus type its crue whether infectious tour, or emotional should be combatted by anubiouc intitoun, or sedation raspecurely it the cachycardu o paroxyımal ATI! Os sentriculas of due to fibrillation of futter the treatment should be directed thereto with quinidine or digulis or other therapy is already dexribed arlier in the chapter Prevention of such tachycardia in the future by appropriate measures should be planned at once on the subsidence of the present attack and in many cakes of mutral stenosu nho prove to be suitable subjects mitral commissurotomy may be a valuable protection for ytan to come A cardiovascular emergency that frequently complicato haart ducase and that in itself may precipitatc acute pul monary edema u pulmonary embolum After the immedi atc treatment of the attack of cdema as described above has been given, an effort should be made to prevent further episodes of the port Actual pulmonary embolectomy once suggested and tried has proved to be neither feasible nor wie but it may be possible to ward off further trouble by two proxedure 1) ligation of the Icg veins if there is any suspicion of thrombosus tiercin and embolism from night ·TILAM UTC du 169 bean duamlxts kems unlikely and 2) the use of anni coagulants. Coninctive pericardite demands nl en acule due to tamponade, cacuation of effused fluid and khen chronic penardul resection Theke masura are often lifcaring and may recsublith complete halth and fuli longevity Subcute or acute bacterial endocarditus or a strong suspicion thereof demands antibrotic therapy whid today usually cunuc It is best to Hart with and to con tinue penallio in large doage but in vitro testing of the effect of the various antibiotics on the causatıc organism should be carried out at the very start for future guidance of the therapy which requires a minimum of at least a month Finally among the more important emergencies due to diseases of the licart and great ressels dissection of thic aortic wall (dusecting aortic anentysm) should be con sidered Though uixomon 11 is very serioul Vorphine and the treatment of a Hate of thach iſ present are all me have to offer but the correc dugnosis should be made Lxecause such us a vital due to the lad prognosis about wun per cent of the casos die of rupture within a few hours or day

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·APPENDIX Sixcz INCE Llic completion of thu bool I have noted a few important omsons and have received seieral more clues from vanow sources arbach ve north adding in an appendix, Heniopisu should have been mentioned specifically as 2 fairly important cluc in Chapter 7 cnuitled Other Symp toms on page 60 following the discimuon of cough and hoarsene. Brush hemorrhages from the lungs have some armes been called pulmonary apopleny and are occasionally seen in the case of patients i ith tglit nut HOISIS but also in cixa nith bleeding into the pulmonary lonels due to other cusa for example, rupture of ancurysms, TOSION of cuels by tumors or tuberculosis or other infcc tions. Some patieno nith mitral senosis and fragile vessels may bleed from the lungs after eaceune effort or from extreme heart rates in parovsmal exchycardu or abnlla tion. Vost pauents with mitral stenosis mho bleed, hon ever have simply blood srcals in the sputum or blood stained (mth raised at the time of acute pulmonary oderna This ame situation holds in a les patients who develop this phenomenon sondary to actise infarction of the lung or pulmonary edema rouilting from arhite Gailure of the left mircle due to the arm of acute myocardial infarction or hypertension at 2011 alic discase is a ciue therefore liemoptysis aithongh important in itsell mint le carefully analyzed since it my be the result cithet I ntracanllac disease disake of the great ressels disaks I the lungs, os intratora k disease of other sort Sailarly from an oictuplit cun inel on of the lungs * S degint is presented in (anter i entitled Sigth ·DIAG YOU AND TRIATMINT OF FAIT MULAIL The discussion of the thorax 11th unusual deformities thereof and pulations should have included a Hatement about auxultation percussion and roentgenography of die lungs and pleura Rales are more commonly due to pulmonary discare tuan to licart disease Very often they are of no importance at all and represent no disease Thu is particularly true of the salled atelectatic ralos at ure lung bases of many patients who have shallots rospirauon Deep inspiration opens up the lases of the lungs and may induce for a few breaths crackling roles or even some that seem to be mout Several deep breauis clear these ralos honcier they are not evidence of pulmonary disease of congestion of the Jung bases due to heart failure or mitral involvement On the other hand penisent moist ralos at the lung bases in pucnu who have cardiac enlargement and dropna and no evidence of pulmonary disease per se may indicate the presence of congestion associated with pulmonary hyper tension and failure However such rala are a late mani fertation of left ventricular (ulurc dyspna being far more important as an early indicaron There are also the localized rules oict pulmonary infarcts to be considered and those due to infection of one kind or anotber Duinos to percusion bronchul breathing and increased density of the Jungs on x ray cxamination are found over areas of die lung which are consolidated as from infarction or in fection or compressed by very large parts pericardul or pleural effuions and tumor Hydrothorax u of much importance but wt be care fully unalyzed If in the ax of a cardiac pacient the hydrotiorax u wholly night-sided or preponderantly right-sided ngbt or total hart failure is to be suspected. If the effusiou is limited to the left side some other cause than ardiac is to be looked for this may comid of acute pleunis or ·APPENDIX 175 pulmonary infarction Thickening ot the pleura may cause slight dulocs but not the marked dulners of cffusion Friction rubs may be either pleural or pericardial As a matter of fact, not alrequeatly they are both and are then alled pleuropenardial In such cases aute penardits 11 to be dugnosed Once in a while when there i grec pressure over the pulmonary artery due to buiging thereul transient fraction rub may be licard cien in the absenc of actual pericarditis Thus has been noted in cases of the toscow and of the acute cor pulmonale Apral heart murmurs that are well heard in Justering over the night anterior chat all suggeh an ancur moral left atnum jus us bulging and pulsuon of die anterior chest wall to the left of the serum indicate the probability of luypertrophy of the right sentrale Rolgance and sclerosis in de pulmonary circulat n complicating dironic mitral stenosis adds an clement ! urain such usne ind in (axos of the chronic cor pulmonale Therefore long standing cocos Ferenc mitral henon huic sonicthing of the chroni (or pulmonale as well as the direct effect of an inxreased routaniet the lon blood through U e left side of the heart Persistence of a raprd sedimentation rate er a good many reels folloring myocardial infantion suggeus thi practice of mural thrombi The alxence of reciprocal changes in leads 1 and 3 in the electrocardiogram fasons the diagnosis of acute peti carditu ouer that of acute myaardial infarction llcat as well as exercise may be used to test the signal cance of anosi. In caso of night in teſt shunt Lwali hat and CTCİX Intrase the yanasik Tlic lon ait ayndrome proklucing mealness and aura sionally non confusion S xometimes rongly alied urem la ·174 NAGYOSH AVD TRLATENT OF HEART DISEASE Dilatauon of the aorta and of the pulmonary artery as seen by a raf cumination is coolmonly found in cases of 2ortic and of pulmonary Henosis respectively The serioidea of rentncular premature beau in which clic R wales fall on the preceding Twins luas been pointed out as suggesting the imminence of intricular Lachycardia or fibrillation On occasion weakness follouing mercunal diurais can be presented by the administration of potassium sala by inouth (3 to 5 grams) following the day of and the day after the injection of thic mercairy Finally the lise of norepinephan (arterenol) lias been emphasued us a number of my correspondeou as being distinctly helpful in some cases of shock accompanying mastic aciue myocardial infarction ·INDEX Per 9 3 3 31 17 aibe juar phleto Tertiart of 162 165 decubatoh 31 1163 Abdomen, Curonalton 71 Angourdog ph Abdoainleseren » AROITS 65 Abetosinal pala inain nundu! 147 kt. preende! ID Coroa dulmi Acme cor polotok 143 173 clettroca dost o doring 143 lar bw * Tap 103 Acu Aycandal laut. Ha mocnego lapu Dent h 167 117 19 10-16 169 Scule pulmonary cuketor 21 % A Curry 3 3 50,003187 ) 171 horo Addion diwets, LIKE OU 70 113 Ymphor 16 Ar u de 10 amiga mos 116 IIT Akobolk bat e Ympus to dat o 162 161 oua ing of 1 b wory oltre 15 duu kyk Altto of pale dimento да е 10 и Anoph , 160 179 18 inen om te of IA recull napirt 2 Inkoek palve tuke city lori nun, 0,95 Dole forum ( ah , 1 . 1. 171 177 Indunal. 40 x w prl nr 41 Tonton, 69 R$) rdxx, 101 lotinnph * 153517 In px non n ture of 13 ou de me te pul arute In muller It wat, 107 173 kated 5 Irina na RO bo 40 Ipimp 14 brain. 10 ipa! Aca MAS 373 hretos odlo fpoliarile 175 ען • נון ס ·176 DIAGNOW AND NEATLIENT OF NEAIT DUSLASE Aolculation, 7 ulatory gop. 44 44 Fint n Kit comic 83 nght otrkols 4 blod comptete, 13 52, 100 pertal, 42. H 168 Ah darathon Lelt, 199 clectrocardiogram homin. 110 Highet, 157 158 clectrocardiogu thowtog 1:14 B phow Apoa Arachnodactyl 18, 117 A cant14, Ang ru 07 Anhythmia 113 tantment of 191 107 InteTaOL, 171 Artarul ne contacting ol 180 121 Arterien, m noun OCT 83 ounds on U Arter onderou Darya 76 Intothon both the L pulmonary 87 131 ny picture of 150 #VI 57 03 Lotta, 74 Asthmi broochta 22 23 cardiac, 21 Wickertas raha, 172 Iual olero left 10% lectrocardiogram bow 142 my puct re of 100, 107 Habe 103 lectrocardiogram show me 112 ny picture of 108 Atral Gonzatlan, 77 47 131 tratat of. 161 16 Airal A tit 14, 131 tratthit ol. 10+16 trul purorul ttchardu 27 17 , 13+ tratpent of 1 Atnel spul defect, 133 Tuy Pict re ol, 121 Itral wound 2 Atri onlard left, , 100 100 107 Atropine 15 htutude of parent fail (koda w docton 7 Bacterul rubeculc, cdocarcin, 100 ukou. Belbadoona 15 ben beni 79 Bloct bupdke brunch. 13 12 154 106 complete 11 13 52 hart, 52 100 partul AVLSI 1.13 FA52 55.168 Blood p1 protone, 8909 rterul II busel, 09 brachial #9 dastojic, 20-2 | tbe kept go pinarda portal, 29 nunk, II đox H 2 epo 97-99 Hreals in potoba 171 Rod, bulld.. Brxhlal blood patrore, 9 Brodyardla 13 Brentbus discultla, 22 ·NR 1 Brodbent on 73 Brunoldas in the 165 Broochlat home, B cachlat bathing 22 Brouchilth, chronla Balld, body 9 Dulging of menor chox nu 173 Duoda boch blod, 11 12 134 137 Boulon, rebadon ol, to bart de uc, 10 с nra of joguhr phlebaran 70 Calabaton a soru, 110, 117 Tuy picture of 118 110 Caldbabon or wrocury arteries. 117 Caldunon of pertardium J11 nay picture of , 114 115 Caldun, low 154 Calorie in diet, J4 15 Carbon monouck, dfect on kattro ardor, 154 Cardus Lauryn, 103 ny pecture of 109 thirt 21 atbeteriatron, 14 3 7 112 clabouts of a 71 logement 72 102 103, 137 139141 Dcuro,& Anchtal Cardopex, 61 Cuock poke of u ptthote 135 163 nodrone, 51 Councu 10 Cart OK Cathetetla baantuc. 14 I (real nub muhaken Cbox lade clectrocardiopupbx 197 Carte Scolo ropnuoc, Childbirth 16 (baked dux 19 Cholecyuu 62 Chromx brooch, ronic cor pulmonok, 144 173 Caruation time, 79 Carbogn ofboardac. 74 Club, Adolf Qobbing of Dogos and toa 76 CO, co 24 Cold. 23 Cortation of the port 18, 77 80 22 -tay putard of 121 122 Collec, 1101 Colon moble 62 Color of hair or ca. 66 ( Josed 059 Corolom IL 106 (agen ual deberto, 10, 18 Coogestr lurt 158-101 Coodncing uterul ing el 10 121 Comencen petard, Kote cbresc, 16 D 111 109 Cag 1001 58 (or bolon 103 m picture of 10 Cor planak mte, 23, 31 hrook, 141 173 Cordowy retul tret 19 tet, akikation of 117 therosketor, 19 ucacy T. 43. 141 14 trami of 161 1 ples hroaboer, I 0 Cotria peke 78 Crott, Cadets 1.76, 1 Chat po on 155 ·178 DLACNOSIS AND TREATIENT OT IEAIT DISEAST D C Dath 19 Added 5 de function 09 Derailty of Iomp. 102 Darba Duutobc blood preare 901 Dhu tuc gallop brythin, Duncolic A11, 83 Dkt Pg hugory 14 lov vodom, 180 nice 59 100 dlorden, so D glonlu 13 det of 59 dl 131 1 145-1 Ho traitmenith. 21 58 91 131 135 139 160, 107 Dirilbox J57 Dritorn, 157 D goun, 107 Duration of morta, 84 174 bheutron of pulmonary artery 12 Urlaummation of 69 Ecola of the porta sulle 117 Ecopie muricula rhythm 59 dan ler 23 pulmonary 21 27 51 131 167 tay puture of 12 Electrocardiograro cute cor puidora, 5 hronk cor panorak, 141 Condal bairt dlar 1 Corova Iord.ocny 118 lo coronary thromboe 115 110, 119, 150 fn mbul scood, 142 indal Arction, 10, 14, 11. 150 10 soardius 25% in ) adema 155 perkarditis toute 1500 crank, 151 redprocul chunger in, I 3 stoming trual Atter Ich 1 0 1 ind 20 Bloch 150 showing depaalla cort, 11, 147 uborak burre P of tro) largement, 112 uboring left the day latron, 10 bon ng richt als donatkon 188 Electrocardiogram dort of digital, qdodone and other drugs on the 25, 131 electrolyt durabancos on, 151 bypet od bypopoolel. 00 the, 1.95 Eledi raudognapby IL ID 135 Electrolynompby 103 IR Electrolyt disturbanca, 151 103 Embolector 1 1 Diphthals. 15 Dorder of rythm, IN traatineet ol, 104 107 Dracting incary w of conta de 40 38, 90 in plaard of 118, 110 D weaton o porti all, 105 80. 119 D A Doretka, 100 18 Decora! 160 174 Doctor titude 3 Dropped bat, 42 Enne trattrocot, 23. 231 Doctus urtetton pitol, 16 m) pktore of. ID Drodet do Dplagla 00, 120-121 Draper 21 للمطع Datutak, pulmonary 2139 14, 161 168 purotitou 51 ·ND 19 الاh { [pbou, 77 Endooyoordbal fibroclatous, 42 Endocrdicht, abacate bacterial, 109 Encephalopathy u Folar cont of lett cotriche. 13 The Qurlik 137 173 Ephedroc, 107 Epilepry 56 Eplaephrioc, 53 13, 107 Eroog of crct 171 Tophageal spaar 07 Luache to dati od on electro ardorum 145 Lophthalom 67 truh, 6. 113 trolment of 101 Litretut cumine on ol, T Lycytoanch, 19 Eaumaation of 67 trkoba 55 IS F brocistos, and oardul 12 Had a booka, 74 Find a day 19 173 Fluorokop to. 100 F1 nal, 18 134 Fred. 60 Iruction nb penudul 111 173 pleurad 173 с wall bhediet dome 02 (Allop it hu datok 14 6 palo, Com latipul noplom 6 (.cnctal Pparoc Cenaal curs, J (trique 18 Glattory 19 Co cT (tding of pupun, Critus Sueci mirnur M, 12 (n har onci ray thedom of 113 T Face, 06 Fulare hart, 2,49 150 100 ki aurkaula 0.158-160 107 nght circula 90,18100 FALUNE 13 Fantom 3,4 F Low Keralogy of .. Flal gluttony 10 Foulallyprichokhatolewa 19 Fm adlock 7 are lo CU, 17 kredit 18 batory 17 11 Labur, 16 il tucm lon, A 1Led munimation Hectacker, sa Ilakid porre 20 Hart be 37 Hox, 13 133 foturc, 3,43 144, 16T 172 horunlu, 1 LE21 100 137 1.111 DNE IS ON to 157 we dromuloa ol, 101 un, 101 111 mul I andr 107 rict ol, 110 taa ·180 DLAUNCHIS AND TEATUFNT OF HEALT DWTAJE 1 IND 4270 L 11-19 p*, IS-14 Indigestioo 00-02 Ind Arblumnom, 12 I u on Ierior myoandul ito, 11A, 119 posterior moardal 116, 119 150 obart 19 treatment of 103 101 of Wicy af lun. U 171 I lection durin, 19. 1 Lenormaa lupation, 181 infund bula Kao, 81 Inhance of dine 18 leoppu, 13 57 Josu BDCT OTUL 03. , 144 145 101 Heitor) adal 157 141 Ilat tat, 173 Icountany Hicomplcre, 54 [emoptius, 23 0 IT! Hanorite acral as petcchal 7 putnyorun 25 60, 171 suburchnold, 39 Flaredury 18 Herpa pouta 73 Houmctbonton 15 HiL dance, 127 Hutu thedom IB ID History ham 1721 per ll 16 of patiel, o a Hartone, O Hounslein, 25,77 Horudgul troert, 119 Flora obalapce 19 Hip Deth, moun, Hydrobon 20177 H percholotcrolerou, 19 HyperdToKC palme, 78 Hypopna 20 Hyperpotanicou, 153 Hyperered uy 19 Hyperemyon 19 91 M. fellul, 19 palmorary too 97 10 9HX, I4 89, DI 171 Onde Hyperthyroldan, 06 T9 Ilypen mbton 2.21 Ilypoodka Ilypoder fection 157 Hypochondrias e Hypopounak 15 Ilypolcro, porton le 17 Hiperba to, desto on tertio arda, 14.3 mycardul 2. 107 Imonetan nations, 11 I encoural neung, I Irunthul imperion, 137 Inmntborcm tu mon, Inern edou therapy 187 IoT) T2on of Lord S, toul 10 Inictton or o 139 141 Ioduc Laduced, of 100-161 Ipeck grup o 183 L Lता mul colarct 103 bederlatton, 199 110 bubuk brunch bock, 131 coincuba mlaIL 159 failure, 20,1 100 101 Luik wrote I ver a di cortoghol 74 enlarrenet T1 14 pabato 71 73 derde 71 H ·183 Loolad polsonary ederu. 13) Louretty Graubal to Long ma anceston, 20 Low dupurupte ettert ** 181 Lot wet natrpest, 100 Lowodotto male, 100, 108 uy hilu dot eleget FRKİSA #5 prenox AS HEX 5 na 13 Yra de ses Wyocardu sorua 117 U Goudal doors 12 Gailu or XTKY $3.14 ma rtton, 19 101 141 ccrocardium of Ip nut udon d{} {R maretto of 17 pactor 10 I loent od 161 161 kar 117 nr picture of 100 cloth * BAH HOCUS 13. 191 352 her moca dogtam a de $55 to 1 Inumardana IT 51 מותגין Хаідео: nded byper by Ted* Hechoty 103 Mennal on superior ! 7 9 Sedmal urpot 12 13 Fay pentre of 126, 187 Medicines, LS, 137 Wattal ke 3 te doen, 37 9 vepTM phase AYO 103 Ser ud me. 160 TGA 174 Soodorphic brusle. not deck H Haty asom. 17 Мkrst connатори u rozpalon, na wenout M37 018 4 ral So cu 7% Vorbe couleur d Horphine, une am berpr 31 160 167 16 Vml hals fit mondaal in tarsm 373 toon, 3 O D mu FLOLA DUA, MT 0-1 zradrag of a toner hart. 13 . at 67 Wow there it Wawa 16 in Ingo of 63 Teen bepa 161 > Tian lart 13 Talon prog om 13 carton 2 Teruk 73 Tony panory thera, 13 0 . I 13 11 61 Vartom a du 1149 es vol 1 161 Aman Tube 53 JI HN Tab Lxb ardu Vareprophna 14 formul bent 4 Toschieri, won me 121 1 laukana! Totsime, ·18 DIAGNO313 AND TILATIFNT OF HEAT PLST ASE O Obaly 22 70 70, OI 101 109 110 137 Ollgou, 99 Operations, enthal 11 Orthoduszaphy 100 Orthopacz. 21 27 Ort bostatic bypotepukoo, 77 Oretreatment. 157 Orupo blood, tienP) 17 r P al clectrogrdiogram 143 PUA 1045 bdarovul s dute bogu, ou breathin 37 raduatlon OL SI Painbow coronary Ducrency 3 Mallor 68 Malpebhe thrill, 73, Malpenon of Lirer 74 Malplattoo, 15 3 41 32 Pandoraal pale 73 78,91 111 Purullary real, 60 Portocal therapy 197 hrutyurmal P history of patient, I 10 Patept doctoration, IL IL, 75 78 79 m, n is to thoning. 125 Pitcare to trathcot 102 Patent, hrpory of JIB Peakou therapy 09 10 l'euron 172 duinc 17" 173 Pertardul alatutto das 111 dulom 27 28 02 1.81 111 157 177 may ibor brg 112 fruction rub 23, il 17. recethan 11 ICO ponude, 2 Tartardık, 3M, 1112 kut 10 Il 12 JO 173 brooke, IU II, 111 15. JC9 (Doncti 112, 133 Porodic biathong. Do Populty of phal 7 leechul bemorrhage 07 Perobatut 167 Phcocbromocytoom 3 Phlebitis 77 Phlebo hrob, 13 767 Physal una tloo 03 fida poor 12 Mitol hot our AS Platen puhe, 78 Pray 10 Ibraton 27 17 134 131 100 171 A tot R143 131 160 baxtyardua 11 17 51 93 131 168 boodle branch block, 15 dyspoa. 51 txiyardla 15, 147 BS, 31 65 ID 163, 10, 171 tricula ibration, tachyarda. 133 134 12 Plumul friction rob 23 173 Memy #2. 20 Pkultk, 40 174 Peuroparla di 4 41 Pxt abo 2 B TY Potothema 67 Polypharm 137 Portal dotto, Touton or hall 77 197 logckor och anode 145 Partbl haart black, ·LYDEX tony. 137 13 trobaboy 10 11 fosthom woordeel mla crn, 14.151 dectrocardiogno thoni 10 130 Pontopesu (ompllabonu Postural bypolet, 15 Paunu 169, 174 Mordby buigint 77 Precordul lands lectrocardio pak. 137 153 Psexy 14, US Pretre beldmert, contralopr, 15 16 17 153 161 quipalme! ALDO, MI 121 robus obvinom 97 tokia 60 PORT to PTUT 93 Puhalou InThor chek 2 ITS Tula ca. 74 # 73 Founty, 72 1 Ion, 77 pitwTE 91 TA Putus khi 5 pendorn put a Po odig 137 11 Q Q cecilor runt 14. Premare blood * Blood pret Premte, porol 99 Preto electrocardiogra 11 Pirou nyawatom, 18 Fronchyl, H I 10 Prowritton 165 Proeula al sortic aneury, 75 Ponchom, no Pulogan poplety 171 AT I Lan, 29 * . 131 Artery 123 173 blood prevrt. * confort ou 173 di cac TX 69 TG, ST cca 21 28, n. 4, 63 13! 167 161 171 Tu peal of 17 nabon IN IN to bolo, 243831.6 7 II. IGI 18+ Kutxartopam , couTL & JOJ 197 n porn 123, naran, S, IL lub 11 12SS Nick minta Kinyound, Q5 & ra 343 Quem PT Pik 7 Powodu swiphate do 17 31 46, 15L 165 14d. R م ابرلیا Raluca al pain, 31 12 Ruud di Reciprocal um Latincardio T. 673 Lolor solidentale 100 RELNOU Homem kan puhren Tun ·181 DIAL YOSLS AND TREATUENT OF HEAIT DISEAST ام ايمايل Rcbuatlon la tratat 157 kool akukan, colx, plocrom, 03 Roun, ne ol, 100 Rautiot to dhurch, 160 t tratan 10 Repirator din lume, 2 za nlectron, 23 Rat therapa 187 154, 10 in Renton, Rul thua 6 Rhannalle no 13 ID .I, 111 181 180 been discoe, 13 19 49 A 103 111 Rube, Dorchung on Righ rulmuar fouent, 103 Right b do utron, 137 Kectrocardiogram thoning, 18 Right bundle beach bhoch, 137 Right-wlod sorta, 112 Rugbt upper quand pam 71 Right chirxcala enlargement 101 137 113 Huurt 70, 70, 747 9, 131 1100 177 hypertropby 154 prattore 91 Ruchi bo le shoot 173 Ringtox an9 ROCRITHRA 100 1.12 17+ Rupare of ancory 9, , 171 ottic Coro, 1 109 baut, 31 oferi catricula pina, 50 School cunoatlans, il 173 Selle carda 117 Scola) chectoardlamby, I Serum charolytes, 14 Sy9 Stuallow topérations IT Suape of heart, 28 Shape of pobe thoch, 29, 36, 37 1. 96, 97 10. 17+ Shortda of brath, 17 18 Shotgun pretproos, 137 Shoulder er npdrorde 37 Shangu S, 70 hent hart dine 53 Slooglal bloch, 35 sous tichyardi, 413) Superior wredlaniral zodiak, Superior cru a .. 131 congued, 70 139 lurombord, Saulo 4 patbectour) 14 59 Byaptor, aahto Scope 33 H 5% 156, 168 ingloor, 119 Sy odrome carould wmu, 51 My nephen, 174 Sphale, cardion moula 117 Syrup of peox 103 stic dor, 131 prote, 07 tonart * de cand, D Sxodk blood presure 97% arou 0 black, 2.100 Sacrubor arcury 118 Sarlet for Jurular pulation 74,75 an, 3 ilk ·KDO 185 Unia au com, Unile etal hydrochon, 172 173 I mual bara tv 20 Llonu, 173 Unary frequency Unnary napon, & Y ma of the jugolar phlebo mm, 70 т 1 va in detroardbogno 139 141 145 161 155 T diundu peal, 50, 03 10 171 I, 169 Toponde 111 Ta, clect of 13 164 Tecth, 3 Tdarentgenography 100 Tetane all, 1 - 74 precordul $ 57 thonix, 73 Tetralogy of Tulloc, 70, 162 Then peotc duci 150-109 Thuid baut round R? Thoraccatat. 21 Thort annutton of 71 171 13 Thready puber 76 ThrU, 73 Trocabad mor! 173 I bog bophlebtu, 3 77 Thyrold, 15 Thyrotoko, as, O, IL 101 164, 173 Ihmural nonosk, 171 Toburto, coed of, 15 5 156 101 Tomak, Totuont y of moru 117 Turde ama ol dret 137 ramon 101 Indent bundle branch boch. 13 Trungle of L +) Akture of 110 '11 Tudta lon , TIRI 103 HODOWL 71 , 103 TheTrulott, 171 TW ett borck 174 lua Igal porn, 5.54 Vihul DCU ET PU Ilular regeritaboo, conoc, 0 SI 1244 1 nuor , 70 taxcalar dugo aurron, ning 61 whock, 81 Ian, 70 obstructoa, Icoxatlon, 168 lenohun the bed 17 pour pour, 80, 87 Tepous praktion 70 com bonbo23 ontncular LeT, 103 hbruliona, 1%167 174 paroxy tachyardu. 1.33 131 II 174 probatur baat 133, 174 rhy a topic pal delect of kan122, JLA Imam alkalowk, 13 Iatal lart, 23 157 141 Toth $7 Ital apuary 9 walm, 14, 157 Iwal dius tona, 19 Tool Im GIS py 07 U non cedirardiogna 11 K kaupet pok ·186 DIAGNOLIS AND TRSATUINT OF VIFAIT DISFAST 11 alders, 6 173-174 Il betong o 21 Whiteen of land, 78 Hort) 14.19 20 Ya thelum 68 Xantho-ront 78 cumination, 100 cor bo Dup, 108 Ju of modlod m 120, 147 mlared at U 100 101 let antriche 102 Mght aurice 101 103 nor ting of ribe in contato a morte, 1911 poteni dacter Tor, 115 perlandbal caldiation, 114 116 etuman, 122 15 p loomry betul2, 130 edna 17., 129 trapgl of fat tardi per 110 window of the breert and prett anck, 100 1.22 puture of Lortlc LDCU, 110 dilatation, relied. 11B, 119 120 trul ptal detect, 121 aantun beutym 100 chronk onuran pertandiin 114 IIB

·Thu Bao
CLUES I\ THE DIAG VOSIS ID
TREATVENT OF HEART DISEASE
By
PAUL D Wins MD
w trh prinied ud bound by The Collegi Pres
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Th orthurulers I grew Company of Henke
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