PRESENT fclLf "iO THE ARft-'iY MEDICAL LIBRARY SURGEONS ivr BY THE ASS'H.OF MILITARY March, 1939] NOTES ON CLINICAL HEART DISEASE : KELLY 129 When we speak of left-sided failure, e.g., hyper- tensive heart failure or failure of the left ven- Original Articles tricle behind high systemic blood pressure, we / visualize adequate filling but inadequate empty- ing of the left side of the heart with correspond- SOME NOTES ON CLINICAL HEART ing increase in its size. Our conception of right- DISEASE* sided heart failure, e.g., failure of the right ventricle behind mitral stenosis or behind chronic By GERARD KELLY, f.r.c.p. (I.) bronchitis and emphysema is precisely similar. MAJOR, I.M.S. Just over a century ago an English physician, Professor of Clinical Medicine; Medical College James Hope, inspired by the work of Corvoisart, Hospitals, Calcutta evolved the ' of cardiac ' back-pressure theory' HAVE these few notes in order to failure. As an obstacle to the circulation', he in c]' compiled ' Jcate to the general practitioner something of said, operates on the heart in a retrograde substance of heart disease: there is direction, the cavity situated immediately hing in them for the specialist. behind is the first to suffer from its influence Otherwise back of the ^y choice and I have stated, congestion failing in c i a?ly partly by request chamber is the cardinal feature of uded a few remarks on the following :? congestive failure rather than inadequate of the The or output v problem of the cardio- C problems failing chamber. This rediscovery of Hope's $cular dysfunction case. Heart failure? Heart failure. Left-sided heart failure. Right-sided heart failure. Mixed failure. ? Symptomatology? Dyspnoea. Pain. Palpitation. ? asthenia. ? Neurocirculatory Auscultation. of blood pressure. 7 ? estimation Radiography of the heart and aorta. problem or problems of the cardio- vascular DYSFUNCTION CASE Diagram illustrating the back pressure theory of Patient (left-sided and right-sided) heart failure. v complaining of symptoms of cardio- congestive (left-sided right-sided) ^ ar dysfunction presents for your apprecia- tirf^ one or more of the following problems :? vital observation is a recent landmark in the ? Is he a neuropath or a cardiopath ? study of heart failure. ? If a is there evidence of failure cardiopath, Left-sided (congestive) heart failure or impending failure, and to what ex- tent is the heart incapacitated ? This is the commonest of all forms of heart ? If failure. Its causes are left ventricular defeat a patient is a it does not by cardiopath, and of the left follow that all the are due overstrain disease ventricle, symptoms disease to the heart. There may be a neurotic namely, hypertension, coronary (arterio- sclerotic or and valvular disease element. That is to say?a patient syphilitic) or stenosis and mitral may be both a cardiopath and a neuro- (aortic regurgitation disease with Pul- path : if so, what is the responsibility preponderant regurgitation). or a rise of in the of each factor in the case ? monary hypertension pressure pulmonary circuit behind the failing left ven- tends to become a neuro- tricle constitutes the first of left ventri- p cardiopath stage ^'?Mackenzie. Actually, many cardiopaths cular failure. This is manifested clinically bi ,Gra^G their disablement with great fortitude, by an accentuated pulmonic second sound, often those with but little dilatation of the vessels ca v ProPortion only, by pulmonary <:Celiac damage, suffer more from psycho- seen in the lung roots of the radiogram and ^an heark- A very occasional cardio- by mitralization of the heart radiologically, Path0^8 his to the of the conus add .ay proclaim psycho-neuropathy by owing enlargement pulmonary v^^sing his doctor as if the doctor had given of the right ventricle behind the pulmonary hs disease. hypertension. In the next stage there is trans- shall refer to the commoner udation from the vessels with the inn / very briefly engorged danisms, left-sided and right-sided failure. production of pulmonary cedema, often later Hence the classical * g . paroxysmal persistent. reac* at Calcutta Medical symptoms of left-sided failure are effort dyspnoea 1 paPpr College ^eUniorfJ aJOQ, and cardiac asthma both of which own the same 130 THE INDIAN MEDICAL GAZETTE [March, 1939 fundamental mechanism, i.e., pulmonary con- the heart-rate. A regular rhythm failure may gestion and cedema. The most ominous signs of occur with a normal or moderate ventricular left-sided failure are gallop rhythm and pulsus rate, or a high rate \ Failure with normal alternans which may be combined with cardiac rhythm may be more serious than when auri- asthma to form the gravest triology in the cular fibrillation consorts with failure. Gavey domain of heart disease. Negativity of T in and John Parkinson's recent investigation lead I of the electro-cardiogram is of correspond- regarding the clinical value of digitalis in heart ingly evil prognosis. A widened low voltage and failure with normal sinus rhythm reveals the ' usually a bifid or flat-topped P-wave have following pertinent facts : In heart failure with recently been described by Wood and Selzer as normal rhythm digitalis is helpful in rather more an early sign of left ventricular failure. than half the cases. In heart failure with auri- Left ventricular failure is usually a passing cular fibrillation, digitalis is more often helpful phase, for the increased resistance in the lungs than it is in normal rhythm, for it benefits more soon stresses the right ventricle which fails in than two-thirds. The real difference in the res- turn thereby relieving somewhat the symptoms ponse of heart failure to digitalis lies not between of left ventricular failure. While the phase of auricular fibrillation and normal rhythm, but left ventricular failure lasts there is no oedema rather between rheumatic auricular fibrillation nor venous congestion, although pulmonary and all other kinds of heart failure irrespective hypertension and even pulmonary cedema are of rhythm. The course of the disease after the present and periodic attacks, of nocturnal onset of failure in normal rhythm is short?18 dyspnoea occur. Even hydrothorax may occur of 29 patients died within a year Failure with at this stage before the right ventricle fails. normal rhythm is relatively more common in Much less commonly the ventricular imbalance India in that for one thing cardiac rheumatism of a forceful right ventricle and av failing left which accounts for about half the cases of auri- ventricle may be long maintained to the greater cular fibrillation in Great Britain and Ireland respiratory distress of the patient; this form of is correspondingly less prevalent in India. left ventricular failure is sometimes improperly ' failure called dry failure a term that more correctly Right-sided (congestive) heart describes a right-sided congestive failure dehy- This is most frequently a proclamation of drated by salyrgan. previous left-sided failure due to hypertension, Coronary thrombosis is a combination of left coronary disease or aortic valvular disease. But heart failure and of peripheral circulatory the causal example par excellence of right ven- failure. When the usual clinical sequence tricular strain and failure is the correspondingly obtains in a case hitherto free from congestive infrequent congenital condition, namely pul- failure, the first phase of coronary thrombosis is monary stenosis, which incidentally produces marked by pain or. dyspnoea and by shock, pulmonary ischsemia and a proclivity to pul- of whereas the second phase, denoted by the offset monary tuberculosis?the converse effects of shock, is characterized by the appearance of mitral stenosis. congestive failure. In any case, the greater the The middle share of responsibility for right- shock the less apparent is cardiac failure and sided heart failure is claimed, firstly, by the pul- vice versa. In shock the heart's income is monary hypertension that is most emphatically reduced to an extent which is unembarrassing produced by mitral stenosis, and, secondly, by even to the grossly infarcted heart. With the pulmonary disease, notably emphysema, both of passage of shock, however, the venous income which quite obviously obstruct the blood flow increases and the failure of the left heart to rise through the lesser circulation. The ultimate to the occasion is soon translated to the right determinant, however, of right-sided failure is heart in terms of congestive failure. coincident right ventricular disease, e.g., arterio- the In pure left ventricular failure the rhythm is sclerosis, which so conspicuously involves regular. The inquiry of Parkinson and Clark- left ventricle, and expectedly implicates the right- Kennedy in 1926 regarding failure with normal ventricle as well. 1 rhythm established that there is an important A most exceptional cause of right heart failure, relation between the pathological basis for a i.e., primary endarteritis of the pulmonary cardiac disease and failure and the absence of arteries, is nevertheless worthy of recall on this fibrillation. In general, auricular fibrillation occasion because Sir Leonard Rogers of this was the rule in rheumatic heart disease arid College described some cases in Bengal soon goitre, while failure with normal rhythm was the after its original description by Ayerza of rule in hypertension, coronary disease and Buenos Ayres. emphysema \ It is also the rule in cardiovas- The clinical picture of right-sided heart failure cular syphilis. In the latter setiological groups, is reflected in the venous reservoir formed by the ventricular strain and disease cause the ventricles systemic and portal venous systems behind the to give way before the auricles have reached failing^ right ventricle. Its main features are, the stage of fibrillation. and John cervical veins ' Gavey accordingly, engorged (Lancisi's Parkinson remind us that apart from the factor sign), engorgement of the liver, and systemic of rhythm and the factor of specific pathology cedema.