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DISTURBANCES OF THE HEART

Discussion of the Treatment of the Heart in Its Various Disorders,
With a Chapter on Blood Pressure




OLIVER T. OSBORNE, A.M., M.D.
Professor of Therapeutics and formerly Professor of Clinical
Medicine in Yale Medical School NEW HAVEN, CONN.



THE JOURNAL of AMERICAN MEDICAL ASSOCIATION
Five Hundred Thirty-Five
North Dearborn Street, Chicago




PREFACE

The second edition of this book is offered with the hope that it
will be as favorably received as was the former edition, The text
has been carefully revised, in a few parts deleted, and extensively
elaborated to bring the book up to the present knowledge concerning
the scientific therapy of heart disturbances. A complete section has
been added on blood pressure.



PREFACE TO THE FIRST EDITION

That marvelous organ which, moment by moment and year by year, keeps
consistently sending the blood on its path through the arteriovenous
system is naturally one whose structure and function need to be
carefully studied if one is to guard it when threatened by disease.
This series of articles deals with heart therapy, not discussing the
heart structurally and anatomically, but taking up in detail the
various forms of the disturbances which may affect the heart. The
cordial reception given by the readers of The Journal to this series
of articles has warranted its issue in book form so that it may be
slipped into the pocket for review at appropriate times, or kept on
the desk for convenient reference.




CONTENTS

Preface
Preface to First Edition
Disturbances of the Heart in General
Classification of Cardiac Disturbances
Blood Pressure
Hypertension
Hypotension
Pericarditis
Myocardial Disturbances
Endocarditis
Chronic Diseases of the Valves
Acute Cardiac Symptoms: Acute Heart Attack
Diet and Baths in Heart Disease
Heart Disease in Children and During Pregnancy
Degenerations
Cardiovascular Renal Disease
Disturbances of the Heart Rate
Toxic Disturbances and Heart Rate
Miscellaneous Disturbances




DISTURBANCES OF THE HEART IN GENERAL


Of prime importance in the treatment of diseases of the heart is a
determination of the exact, or at least approximately exact,
condition of its structures and a determination of its ability to
work.

This is not the place to describe its anatomy or its nervous
mechanism or the newer instruments of precision in estimating the
heart function, but they may be briefly itemized. It has now been
known for some time that the primary stimulus of cardiac contraction
generally occurs at the upper part of the right auricle, near its
junction with the superior vena cava, and that this region may be
the "timer" of the heart.

This is called the sinus node, or the sino-auricular node, and
consists of a small bundle of fibers resembling muscle tissue. Lewis
[Footnote: Lewis: Lecture in the Harvey Society, New York Academy of
Medicine, Oct. 31, 1914.] describes this bundle as from 2 to 3 cm.
in length, its upper end being continuous with the muscle fibers of
the wall of the superior vena cava. Its lower end is continuous with
the muscle fibers of the right auricle. From this node "the
excitation wave is conducted radially along the muscular strands at
a uniform rate of about a thousand millimeters per second to all
portions of the auricular musculature."

Though a wonderfully tireless mechanism, this region may fall out of
adjustment, and the stimuli proceeding from it may not be normal or
act normally. It has been shown recently not only that there must be
perfection of muscle, nerve and heart circulation but also that the
various elements in solution in the blood must be in perfect amounts
and relationship to each other for the heart stimulation to be
normal. It has also been shown that if for any reason this region of
the right auricle is disturbed, a stimulus or impulse might come
from some other part of the auricle, or even from the ventricle, or
from some point between them. Such stimulations may constitute
auricular, ventricular or auriculoventricular extra contractions or
extrasystoles, as they are termed. In the last few years it has been
discovered that the auriculoventricular handle, or "bundle of His,"
has a necessary function of conductivity of auricular impulse to
ventricular contraction. A temporary disturbance of this
conductivity will cause a heart block, an intermittent disturbance
will cause intermittent heart block (Stokes-Adams disease), and a
prolonged disturbance, death. It has also been shown that
extrasystoles, meaning irregular heart action, may be caused by
impulses originating at the apex, at the base or at some point in
the right ventricle.

In the ventricles, Lewis states, the Purkinje fibers act as the
conducting agent, stimuli being conducted to all portions of the
endocardium simultaneously at a rate of from 2,000 to 1,000 mm. per
second. The ventricular muscle also aids in the conduction of the
stimuli, but at a slower rate, 300 mm. per minute. The rate of
conduction, Lewis believes, depends on the glycogen content of the
structures, the Purkinje fibers, where conduction is most rapid,
containing the largest amount of glycogen, the auricular musculature
containing the next largest amount of glycogen, and the ventricular
muscle fibers the least amount of glycogen.

Anatomists and histologists have more perfectly demonstrated the
muscle fibers of the heart and the structure at and around the
valves; the physiologic chemists have shown more clearly the action
of drugs, metals and organic solutions on the heart; and the
physiologists and clinicians with laboratory facilities have
demonstrated by various new apparatus the action of the heart and
the circulatory power under various conditions. It is not now
sufficient to state that the heart is acting irregularly, or that
the pulse is irregular; the endeavor should be to determine whit
causes the irregularity, and what kind of irregularity is present.


CLINICAL INTERPRETATION OF PULSE TRACINGS

A moment may be spent on clinical interpretation of pulse tracings.
It has recently been shown that the permanently irregular pulse is
due to fibrillary contraction, or really auricular fibrillation--in
other words, irregular stimuli proceeding from the auricle--and that
such an irregular pulse is not due to disturbance at the
auriculoventricular node, as believed a short time ago. These little
irregular stimuli proceeding from the auricle reach the
auriculoventricular node and are transmitted to the ventricle as
rapidly as the ventricle is able to react. Such rapid stimuli may
soon cause death; or, if for any reason, medicinal or otherwise, the
ventricle becomes indifferent to these stimuli, it may not take note
of more than a certain portion of the stimuli. It then acts slowly
enough to allow prolongation of life, and even considerable
activity. If such a heart becomes more rapid from such stimuli, 110
or more, for any length of time, the condition becomes very serious.
Digitalis in such a condition is, of course, of supreme value on
account of its ability to slow the heart. Such irregularity perhaps
most frequently occurs with valvular disease, especially mitral
stenosis and in the muscular degenerations of senility, as fibrosis.

Atropin has been used to differentiate functional heart block from
that produced by a lesion. Hart [Footnote: Hart: Am. Jour. Med. Sc.,
1915, cxlix, 62.] has used atropin in three different types of heart
block. In the first the heart block is induced by digitalis. This
was entirely removed by atropin. In the second type, where there was
normal auricular activity, but where the ventricular contractions
were decreased, atropin affected an increase in the number of
ventricular contractions, but did not completely remove the heart
block. He adopted atropin where the heart block was associated with
auricular fibrillation. The number of ventricular contractions was
increased, but not enough to indicate the complete removal of the
heart block.

Lewis [Footnote: Lewis: Brit. Med. Jour., 1909, ii, 1528.] believes
that 50 percent of cardiac arrhythmia originates in muscle
disturbance or incoordination in the auricle. These stimuli are
irregular in intensity, and the contractions caused are irregular in
degree. If the wave lengths of the pulse tracing show no regularity-
-if, in fact, hardly two adjacent wave lengths are alike--the
disturbance is auricular fibrillation. Injury to the auricle, or
pressure for any reason on the auricle, may so disturb the
transmission of stimuli and contractions that the contractions of
the ventricle are very much fewer than the stimuli proceeding from
the auricle. In other words, a form of heart block may occur.
Various stimuli coming through the pneumogastric nerves, either from
above or from the peripheral endings in the stomach or intestines,
may inhibit or slow the ventricular contractions. It seems to have
been again shown, as was earlier understood, that there are
inhibitory and accelerator ganglia in the heart itself, each subject
to various kinds of stimulation and various kinds of depression.

Both auricular fibrillation and auricular flutter are best shown by
the polygraph and the electrocardiograph. The former is more exact
as to details. Auricular flutter, which has also been called
auricular tachysystole, is more common that is supposed. It consists
of rapid coordinate auricular contractions, varying from 200 to 300
per minute. Fulton [Footnote: Fulton, F. T.: "Auricular Flutter,"
with a Report of Two Cases, Arch. Int. Med., October, 1913, p. 475.]
finds in this condition that the initial stimulus arises in some
part of the auricular musculature other than the sinus node. It is
different from paroxysmal tachycardia, in which the heart rate
rarely exceeds 180 per minute. In auricular flutter there is always
present a certain amount of heart block, not all the stimuli
reaching the ventricle. There may be a ratio of auricular
contractions to ventricular contractions, according to Fulton, of
2:1, 3:1, 4:1 and 5:1, the 2:1 ratio being most common.

Of course it is generally understood that children have a higher
pulse rate than adults; that women normally have a higher pulse rate
than men at the same age; that strenuous muscular exercise,
frequently repeated, without cardiac tire while causing the pulse to
be rapid at the time, slows the pulse during the interim of such
exercise and may gradually cause a more or less permanent slow
pulse. It should be remembered that athletes have slow pulse, and
the severity of their condition must not be interpreted by the rate
of the pulse. Even with high fever the pulse of an athlete may be
slow.

Not enough investigations have been made of the rate of the pulse
during sleep under various conditions. Klewitz [Footnote: Klewitz:
Deutsch. Arch. f. klin. Med. 1913, cxii, 38.] found that the average
pulse rate of normal individuals while awake and active was 74 per
minute, but while asleep the average fell to 59 per minute. He found
also that if a state of perfect rest could be obtained during the
waking period, the pulse rate was slowed. This is also true in cases
of compensated cardiac lesions, but it was not true in decompensated
hearts. He found that irregularities such as extrasystoles and
organic tachycardia did not disappear during sleep, whereas
functional tachycardia did.

It is well known that high blood pressure slows the pulse rate; that
low blood pressure generally increases the pulse rate, and that
arteriosclerosis, or the gradual aging of the arteries, slows the
pulse, except when the cardiac degeneration of old age makes the
heart again more irritable and more rapid. The rapid heart in
hyperthyroidism is also well understood. It is not so frequently
noted that hypersecretion of the thyroid may cause a rapid heart
without any other tangible or discoverable thyroid symptom or
symptoms of hyperthyroidism. Bile in the blood almost always slows
the pulse.


INTERPRETATION OF TRACINGS

The interpretation of the arterial tracing shows that the nearly
vertical tip-stroke is due to the sudden rise of blood pressure
caused by the contraction of the ventricles. The long and irregular
down-stroke means a gradual fall of the blood pressure. The first
upward rise in this gradual decline is due to the secondary
contraction and expansion of the artery; in other words, a tidal
wave. The second upward rise in the decline is called the recoil, or
the dicrotic wave, and is due to the sudden closure of the aortic
valves and the recoil of the blood wave. The interpretation of the
jugular tracing, or phlebogram as the vein tracing may be termed,
shows the apex of the rise to be due to the contraction of the
auricle. The short downward curve from the apex means relaxation of
the auricle. The second lesser rise, called the carotid wave, is
believed to be due to the impact of the sudden expansion of the
carotid artery. The drop of the wave tracing after this cartoid rise
is due to the auricular diastole. The immediate following second
rise not so high as that of the auricular contraction is known as
the ventricular wave, and corresponds to the dicrotic wave in the
radial. The next lesser decline shows ventricular diastole, or the
heart rest. A tracing of the jugular vein shows the activity of the
right side of the heart. The tracing of the carotid and radial shows
the activity of the left side of the heart. After normal tracings
have been carefully taken and studied by the clinician or a
laboratory assistant, abnormalities in these readings are readily
shown graphically. Especially characteristic are tracings of
auricular fibrillation and those of heart block.


TESTS OF HEART STRENGTH

If both systolic and diastolic blood pressure are taken, and the
heart strength is more or less accurately determined, mistakes in
the administration of cardiac drugs will be less frequent. Besides
mapping out the size of the heart by roentgenoscopy and studying the
contractions of the heart with the fluoroscope, and a detailed study
of sphygmographic and cardiographic tracings, which methods are not
available to the large majority of physicians, there are various
methods of approximately, at least, determining the strength of the
heart muscle.

Barringer [Footnote: Barringer, T. B., Jr.: The Circulatory Reaction
to Graduated Work as a Test of the Heart's Functional Capacity,
Arch. Int. Med., March, 1916, p. 363.] has experimented both with
normal persons and with patients who were suffering some cardiac
insufficiency. He used both the bicycle ergometer and dumb-bells,
and finds that there is a rise of systolic pressure after ordinary
work, but a delayed rise after very heavy work, in normal persons.
In patients with cardiac insufficiency he finds there is a delayed
rise in the systolic pressure after even slight exercise, and those
with marked cardiac insufficiency have even a lowering of blood
pressure from the ordinary level. They all have increase in pulse
rate. He quotes several authorities as showing that during muscle
work the carbon dioxid of the blood is increased in amount, which,
stimulating the nervous centers controlling the suprarenal glands,
increases the epinephrin content of the blood. The consequence is
contraction of the splanchnic blood vessels, with a rise in general
blood pressure. Also, the quickened action of the heart increases
the blood pressure. After a rest from the exercise, the extra amount
of carbon dioxid is eliminated from the blood, the suprarenal glands
decrease their activity, and the blood pressure falls.

Nicolai and Zuntz [Footnote: Nicolai anal Zuntz: Berl. klin.
Wehnschr., May 4, 1914, p. 821.] have shown that with the first
strain of heavy work the heart increases in size, but it soon
becomes normal, or even smaller, as it more strenuously contracts,
and the cavities of the heart will be completely emptied at each
systole. If the work is too heavy, and the systolic blood pressure
is rapidly increased, it may become so great as to prevent the left
ventricle from completely evacuating its content. The heart then
increases in size and may sooner or later become strained; if this
strain is severe, an acute dilatation may of course occur, even in
an otherwise well person. Such instances are not infrequent. A heart
which is already enlarged or slightly dilated and insufficient,
under the stress of muscular labor will more slowly increase its
forcefulness, and we have the delayed rise in systolic pressure.

Barringer concludes that:

The pulse rate and the blood pressure reaction to graduated work is
a valid test of the heart's functional capacity. If the systolic
pressure reaches its greatest height not immediately after work, but
from thirty to 120 seconds later, or if the pressure immediately
after work is lower than the original level, that work, whatever its
amount, has overtaxed the heart's functional capacity and may be
taken as an accurate measure of the heart's sufficiency.

In another article, Barringer [Footnote: Barringer, T. B., Jr.:
Studies of the Heart's Functional Capacity as Estimated by the
Circulatory Reaction to Graduated Work, Arch. Int. Med., May, 1916,
p. 670.] advises the use of a 5-pound dumb-bell extended upward from
the shoulder for 2 feet. Each such extension represents 10 foot-
pounds of work, although the exertion of holding the dumb-bell
during the nonextension period is not estimated. He believes that if
circulatory tire is shown with less than 100 foot-pounds per minute
exercise, other signs of cardiac insufficiency will be in evidence.
He also believes that these foot-pound tests can be made to
determine whether a patient should be up and about, and also that
such graded exercise will increase the heart strength in cardiac
insufficiency.

Schoonmaker, [Footnote: Schoonmaker: Am. Jour. Med. Sc., October,
1915, p. 582.] after studying the blood pressure of 127 patients,
concludes that myocardial efficiency will be shown by a comparison
of the systolic and diastolic blood pressure, with the patient lying
down and standing up, after walking a short distance. Such slight
exercise should not cause any subjective symptoms, either dyspnea,
palpitation or chest pain. If the heart muscle is in good condition,
the systolic pressure should remain the same after this slight
exertion and these changes in posture. When the heart is good, there
may be slight increased pressure when the patient is standing. If,
after this slight exercise in the erect posture, the systolic
pressure is diminished, the heart muscle is defective.

Martinet [Footnote: Martinet: Presse med., Jan. 20, 1916.] tests the
heart strength as follows: He counts the pulse until for two
successive minutes there is the same number of beats, first when the
patient is lying down, and then when he is standing. He also takes
the systolic and diastolic pressures at the same time. He then
causes the person to bend rapidly at the knees twenty times. The
pulse rate and the blood pressure are then taken each minute for
from three to five minutes. The person then reclines, and the pulse
and pressure are again recorded, Martinet says that an examination
of these records in the form of a chart gives a graphic
demonstration of the heart strength. If the heart is weak, there are
likely to be asystoles, and tachycardia may occur, or a lowered
blood pressure.

Rehfisch [Footnote: Rehfisch: Berl. klin. Wehnsehr., Nov. 29, 1915]
states that when a healthy person takes even slight exercise, the
aortic closure becomes louder than the second pulmonic sound,
showing an increased systolic pressure. If the left ventricle is
unable properly to empty itself against the increased resistance
ahead, the left auricle will contain too much blood, and with the
right ventricle sufficient, there will be an accentuation of the
second pulmonic sound and it may become louder than the second
aortic sound, showing a cardiac deficiency. If, on the other hand,
the right ventricle becomes insufficient, or is insufficient, the
second pulmonic sound is weaker than normal, and the prognosis is
bad.

Barach [Footnote: Barach: Am. Jour. Med. Sc., July, 1916, p. 84]
presents what he terms "the energy index of the circulatory system."
He has examined 742 normal persons, and found that the pressure
pulse was anywhere from 20 to 80 percent of the diastolic pressure
in 80 per cent of his cases, while the average of his figures gave a
ratio of 50 percent; but he does not believe that it holds true that
in a normal person the pressure pulse equals 50 percent of the
diastolic pressure. Barach does not believe we have, as yet, any
very accurate method of determining the cardiac strength or
circulatory capacity for work. He does not believe that the estimate
of the pressure pulse is indicative of cardiac strength. He believes
that the important factors in the estimation of the circulatory
strength are the systolic pressure, which shows the power of the
left ventricle, the diastolic pressure, which shows the
intravascular tension during diastole as well as the peripheral
resistance, and the pulse rate, which designates the number of times
the heart must contract during a minute to maintain the proper flow
of blood. He thinks that these three factors are constantly adapting
themselves to each other for the needs of the individual, and he
finds, for instance, that when the left ventricle is hypertrophied
and the output of blood is therefore greater, then the pulse will be
slowed. His method of estimation is as follows: For instance, with a
systolic pressure of 120 mm. and a diastolic pressure of 80 mm.,
each pulse beat will represent an energy equal to lifting 120 mm.
plus 80 mm., which equals 200 mm. of mercury, and with seventy-two
pulse beats the force would be 72 X 200, which equals 14,400 mm. of
mercury. He finds an average circulatory strength based on examining
250 normal individuals by the index, which he terms S, D, R
(systolic, diastolic rate), to be 20,000 mm. of mercury per minute.

Katzenstein [Footnote: Katzenstein: Deutsch. med. Wehnsehr., April
15, 1915.] finds, after ten years of experience, that the following
test of the heart strength is valuable: He records the blood
pressure and pulse, and then compresses the femoral artery at
Poupart's ligament on the two sides at once. He keeps this pressure
up for from two to two and one-half minutes, and then again takes
the blood pressure. With a sound heart the blood pressure will be
higher and the pulse slower than the previous record taken. If the
blood pressure and pulse beat are not changed, it shows that the
heart is not quite normal, but not actually incompetent. When the
blood pressure is lower and the pulse accelerated, he believes that
there is distinct functional disturbance of the heart and loss of
power, relatively to the change in pressure and the increase of the
pulse rate. He further believes that a heart showing this kind of
weakness should, if possible, not be subjected to general
anesthesia.

Stange [Footnote: Stange: Russk. Vrach, 1914, xiii. 72.] finds that
the cardiac power may be determined by a respiratory test as
follows: The patient should sit comfortably, and take a deep
inspiration; then he should be told to hold his breath, and the
physician compresses the patient's nostrils. As soon as the patient
indicates that he can hold his breath no longer, the number of
seconds is noted. A normal person should hold his breath from thirty
to forty seconds without much subsequent dyspnea, while a patient
with myocardial weakness can hold his breath only from ten to twenty
seconds, and then much temporary dyspnea will follow. Stange does
not find that pulmonary conditions, as tuberculosis, pleurisy or
bronchitis, interfere with this test.

Williamson [Footnote: Williamson: Ant. Jour. Med. Sc., April, 1915,
p. 492.] believes that we cannot determine the heart strength
accurately unless we have some method to note the exact position of
the diaphragm, and he has devised a method which he calls the
teleroentgen method. With this apparatus he finds that a normal
heart responds to exercise within its power by a diminution in size.
The same is true of a good compensating pathologic heart. He thinks
that a heart which does not so respond by reducing its size after
exercise has a damaged muscle, and compensation is more or less
impaired.

Practical conclusions to draw from the foregoing suggestions are:

1. An enlargement of the heart after exercise can be well shown only
by fluoroscopic examination, and then best by some accurate method
of measurement.

2. The blood pressure should be immediately increased by exercise,
and after such exercise should soon return to the normal before the
exercise. If it goes below the normal the heart is weak, or the
exercise was excessive.

3. The pulse rate should increase with exercise, but not
excessively, and should within a reasonable time return to normal.

4. The stethoscope will show whether or not the normal sounds of the
heart become relatively abnormal after exercise. If such was the
fact, though the abnormality was not permanent, heart insufficiency
is more or less in evidence.

5. The relation of pulse rate to blood pressure should always be
noted, and the working power of the heart may be estimated according
to Barach's suggestion.

6. The dumb-bell exercise tests suggested by Barringer (only, the
dumb-bells may be of lighter weight) are valuable to note the
gradual improvement in heart strength of patients under treatment.

7. The holding the breath test is very suggestive of heart
efficiency or weakness, but a series of tests must be made before
its limitations are proved.


THE EFFECT OF ATHLETICS ON THE HEART

We can no longer neglect the seriousness of the effects of
competitive athletics on the heart, especially in youth and young
adults. Not only universities and preparatory schools, but also high
schools and even grammar schools must consider the advisability of
continuing competitive sports without more control than is now the
case. In the first place, the individual is likely to be trained in
one particular branch or in one particular line, which develops one
particular set of muscles. In the second place, competition to
exhaustion, to vomiting, faintness, and even syncope is absolutely
inexcusable. Furthermore, contests which partake of brutality should
certainly be seriously censored.

A committee appointed some time ago by the Medical Society of the
State of California [Footnote: California State Med. Jour., June,
1916 p. 220.] has recently reported its endorsement of Foster's
"Indictment of Intercollegiate Athletics." After five years of
personal observation of no less than 100 universities and colleges,
in thirty-eight states, Foster concludes that intercollegiate
athletics have proved a failure, and that they are costly and
injurious on account of an excessive physical training of a few
students, and of such students as need training least, while
healthful and moderate exercise at a small expense for all students
is most needed.

Experts, [Footnote: Rubner and Kraus: Vrtljsehr. f. gerichtl. Med,
1914, xlviii, 304.] appointed by the Prussian government to
investigate athletics, reported that for physical exercise to be of
real value it must be quite different from the preparation of a
specially equipped individual trained for a game. Exercise should
benefit all children and youth, while athletic prowess necessitates
taxing the organism to the limit of endurance, and hence is
dangerous and should not be allowed in schools or universities.

McKenzie [Footnote: McKenzie: Am. Jour. Med. Sc., January, 1913, p.
69.] found that exhausting tests of endurance were not adapted to
the development of children and youth, because the high blood
pressure caused by such exertion soon continued, and he found
athletes to have a prolonged increased blood pressure. As is
recognized by all, boat racing is particularly bad, especially the
4-mile row. Such severe exertion of course increases the blood
pressure, even in these athletes, and the heart increases its speed.
There is then exhilaration, later discomfort, and soon, as McKenzie
points out, a sensation of constriction in the chest and head. This
is soon followed by breathlessness, and soon by a feeling of fulness
in the head, and then syncope. The heart, of course, becomes
dilated. Heart murmurs are often found after much less severe
exertion than boat racing. They may not last long, or they may
disappear under proper treatment. He reported that after exercise
there were heart murmurs in seventy-four of 266 young men who were
in normal health, and that nearly 28 per cent of all normal young
men will show a murmur after exercise. He thinks that it is rare to
find, after a week, a heart murmur in a previously healthy heart, if
the athlete has not passed the age of 30.

There can be no doubt that even one, to say nothing of more, such
heart strains is inexcusable and may leave a more or less lasting
injury. Such heart strains and exertions are not entirely seen in
athletes. A man otherwise well may cause such a heart strain by
cranking his automobile, by pumping up a tire, by strenuous lifting,
by carrying a load too far or too rapidly, or by running, and an
elderly man may even cause such a heart strain by walking, hill
climbing, or even golfing, if he does these things. More or less
acute dilatation occurring in such persons is likely to recur on the
least exertion, unless the patient takes a prolonged rest cure and
the heart is so well that it recuperates perfectly. Any chronic
myocarditis, however, may prevent such a heart from ever being as
perfect as it was before.

Torgersen, [Footnote: Torgersen: Norsk Mag. f. Laegevidensk., April,
1914.] after making 600 examinations of 200 athletes, and 1,200
examinations of members of the rowing crew, decides that it is
absolutely essential that there should be skilled daily examinations
of every man during training, and a record kept of the condition of
his heart, urine, and blood pressure, before and after exercise.
When he found albumin in the urine it was always accompanied by a
falling of the blood pressure and a rapid heart, with loss of weight
and a general feeling of debility.

Middleton [Footnote: Middleton: Am. Jour. Med. Sc., September, 1915,
p. 426.] examined students who were training for football, both
during the training and after the training period, and found that
after the rest succeeding a training period there was an increased
systolic and diastolic blood pressure over the records of before the
training period. This would tend to indicate some hypertrophy of the
heart.

Insurance statistics seem to show that athletes are likely to have
earlier cardiovascular-renal disease than other individuals of the
same class and occupations.


SUGGESTIONS FOR THE CONTROL OF ATHLETICS

1. Gymnasiums and athletic grounds in connection with all colleges,
preparatory schools, seminaries and high schools are essential, and
they should be added to grammar schools whenever possible.

2. Physical training and athletic games, and perhaps some type of
military training are valuable for the proper development of youth.

3. Some forms of competitive games and some competitive feats are
valuable in stimulating training and healthful sports.

4. All competitive sports and all hard training should be under the
advice and supervision of a medical council or a medical trainer.
Competitive sports which are generally recognized as harmful, mostly
on account of their duration as related to the age of the
competitors, should be prohibited.

5. Each boy should be carefully examined by a competent physician to
decide as to his general health, his limitations and the special
training necessary to perfect him or to overcome any defect. Such
examinations are even more essential in schools for girls.

6. In all group training, the weak individuals should be noted by
the medical trainer, and they should receive special and more
carefully graded exercise.

7. In all strenuous training or competitive athletic work, the
participators should all be examined more or less frequently and
more or less carefully for heart strain and albuminuria and also for
a too great increase of blood pressure.

8. All training and all athletic sports should be graded to the age
of the boy or girl and not necessarily to his or her size. Many an
overgrown boy is injured by athletic prowess beyond his heart
strength.


SIGNS OF HEART WEAKNESS

It should be remembered that a normal heart may slow to about 60
during sleep, and all nervous acceleration of the pulse may be
differentiated during sleep by the fact that if the heart does not
markedly slow, there is cardiac weakness or some general
disturbance. There is also cardiac weakness if there is a tendency
to yawn or to take long breaths after slight exertions or during
exertion, or if there is a feeling of suffocation and the person
suddenly wants the windows open, or cannot work, even for a few
minutes, in a closed room. If these disturbances are purely
functional, exercise not only may be endured, but will relieve some
nervous heart disturbances, while it will aggravate a real heart
disability. If the heart tends to increase in rapidity on lying
down, or the person cannot breathe well or feels suffocated with one
ordinary pillow, the heart shows more or less weakness.
Extrasystoles are due to abnormal irritability of the heart muscle,
and may or may not be noted by the patient. If they are noted, and
he complains of the condition, the prognosis is better than though
he does not note them.

It has long been known that asthma, emphysema, whooping cough, and
prolonged bronchitis with hard coughing will dilate the heart. It
has not been recognized until recently, as shown by Guthrie,
[Footnote: Guthrie, J. B.: Cough Dilatation Time a Measure of Heart
Function, The Journal. A. M. A., Jan. 3, 1914, p. 30.] that even one
attack of more or less hard coughing will temporarily enlarge the
heart. From these slight occurrences, however, the heart quickly
returns to its normal size; but if the coughing is frequently
repeated, the dilatation is more prolonged. This emphasizes the
necessity of supporting the heart in serious pulmonary conditions,
and also the necessity of modifying the intensity of the cough by
necessary drugs.

In deciding that a heart is enlarged by noting the apex beat,
percussion dulness, and by fluoroscopy, it should be remembered that
the apex beat may be several centimeters to the left from the actual
normal point, and yet the heart not be enlarged.

The necessity of protecting the heart in acute infections, and the
seriousness to the heart of infections are emphasized by the present
knowledge that tonsillitis, acute or chronic, and mouth and nose
infections of all kinds can injure the heart muscle. In probably
nearly every case of diphtheria, unless of the mildest type, there
is some myocardial involvement, even if not more than 25 percent of
such cases show clinical symptoms of such heart injury. Tuberculosis
of different parts of the body also, sooner or later, injures the
heart; and the effect of syphilis on the heart is now well
recognized.


SYMPTOMS AND SIGNS OF CARDIAC DISTURBANCE

It is now recognized that any infection can cause weakness and
degeneration of the heart muscle. The Streptococcus rheumaticus
found in rheumatic joints is probably the cause of such heart injury
in rheumatism. That prolonged fever from any cause injures heart
muscle has long been recognized, and cardiac dilatation after severe
illness is now more carefully prevented. It is not sufficiently
recognized that chronic, slow-going infection can injure the heart.
Such infections most frequently occur in the tonsils, in the gums,
and in the sinuses around the nose. Tonsillitis, acute or chronic,
has been shown to be a menace to the heart. Acute streptococcie
tonsillitis is a very frequent disease, and the patient generally,
under proper treatment, quickly recovers. Tonsillitis in a more or
less acute form, however, sometimes so mild as to be almost
unnoticed, probably precedes most attacks of acute inflammatory
rheumatism. Chronically diseased tonsils may not cause joint pains
or acute fever, but they are certainly often the source of blood
infection and later of cardiac inflammations. The probability of
chronic inflammation and weakening of the heart muscle from such
slow-going and continuous infection must be recognized, and the
source of such infection removed.

The determination of the presence of valvular lesions is only a
small part of the physical examination of the heart. Furthermore,
the heart is too readily eliminated from the cause of the general
disturbance because murmurs are not heard. A careful decision as to
the size of the heart will often show that it has become slightly
dilated and is a cause of the general symptoms of weakness, leg
weariness, slight dyspnea, epigastric distress or actual chest
pains. Many such cases are treated for gastric disturbance because
there are some gastric symptoms. There is no question that gastric
flatulence, or hyperacidity, or a large meal causing distention of
the stomach may increase the cardiac disturbance, and the cardiac
disturbance may be laid entirely to indigestion; but treatment
directed toward the stomach, while it may ameliorate some of the
symptoms, will not remove the cause of the symptoms.

If the patient complains of pains in any part of the chest or upper
abdomen, or of leg aches, or of being weary, or exhausted, or of
sleeplessness at night, or of pains in the back of his head, we
should investigate the cardiac ability, besides ruling out all of
the more frequently recognized causes of these disturbances.

If there is more dyspnea than normally should occur in the
individual patient after walking rapidly or climbing a hill or going
upstairs, or if after a period of a little excitement one finds that
he cannot breathe quite normally, or that something feels tight in
his chest, the heart needs resting. If, after one has been driving a
motor car or even sitting at rest in one which has been going at
speed or has come unpleasantly near to hitting something or to being
run into, it is noticed that the little period of cardiac
disturbance and chest tension is greater than it should be, the
heart needs resting.

If the least excitement or exertion increases the cardiac speed
abnormally, it means that for many minutes, if not actually hours
during the twenty-four, the heart is contracting too rapidly, and
this alone means muscle tire and muscle nutrition lost, even if
there is no actual defect in the cardiac muscle or in its own blood
supply. If we multiply these extra pulsations or contractions by the
number of minutes a day that this extra amount of work is done, it
will easily be demonstrable to the physician and the patient what an
amount of good a rest, however partial, each twenty-four hours will
do to this heart. Of course anything that tends to increase the
activity of the disturbance of the heart should be corrected.
Overeating, overdrinking (even water), and overuse or perhaps any
use of alcohol, tobacco, tea and coffee should all be prevented. In
fact, we come right to the discussion of the proper treatment and
management of beginning high blood pressure, of the incipiency of
arteriosclerosis, of the prevention of chronic interstitial
nephritis, and the prevention of cardiovascular-renal disease.

When an otherwise apparently well person begins to complain of
weariness, or perhaps drowsiness in the daytime and sleeplessness at
night, or his sleep is disturbed, or be has feelings of mental
depression, or he says that he "senses" his heart, perhaps for the
first time in his life, with or without edema of the feet and legs,
or pains referred to the heart or heart region, we should presuppose
that there is weakening of the heart muscle until, by perfect
examination, we have excluded the heart as being the cause of such
disturbance.

Although constantly repeated by all books on the heart and by many
articles on cardiac pain, it still is often forgotten that pain due
to cardiac disturbance may be referred to the shoulders, to the
upper part of the chest, to the axillae, to the arms, and even to
the wrists, to the neck, into the head, and into the upper abdomen.
It is perhaps generally auricular disturbance that causes pain to
ascend, but disturbances of the ventricles can cause pain in the
arms and in the region of the stomach. Not infrequently disturbances
of the aorta cause pain over the right side of the chest as well as
tip into the neck. Real heart pains frequently occur without any
valvular lesion, and also when necropsies have shown that there has
been no sclerosis of the coronary vessels.

While angina pectoris is a distinct, well recognized condition,
pains in the regions mentioned, especially if they occur after
exertion or after mental excitement or even after eating (provided a
real gastric excuse has been eliminated), are due to a disturbance
of the heart, generally to an overstrained heart muscle or to a
slight dilatation. Too much or too little blood in the cavity of the
heart may cause distress and pain; or an imperfect circulation
through the coronary arteries and the vessels of the heart,
impairing its nutrition or causing it to tire more readily, may be
the cause of these cardiac pains, distress or discomfort.

Palpating the radial artery is not absolutely reliable in all cases
of auricular fibrillation, or in another form of arrhythmia called
auricular flutter or tachysystole. James and Hart [Footnote: James
and Hart: Am. Jour. Med. Sc., 1914, cxlvii, 63.] have found that the
pulse is not a true criterion of the condition Of the circulation.
There is always a certain amount of heart block associated with
auricular fibrillation so that not all of the auricular stimuli pass
through the bundle of His. James and Hart determine the heart rate
both at the radial pulse and at the apex, the difference being
called the pulse deficit. They use this deficit as an aid in
deciding when to stop the administration of digitalis. When the
pulse deficit is zero, the digitalis is stopped. In this connection
they also find that, even though the pulse deficit may be zero,
there may be a difference in force and size of the waves at the
radial artery. This can be demonstrated by the use of a cuff around
the brachial artery and by varying the pressure. It will be found
that the greater the pressure, the fewer the number of beats coming
through.

Besides the instruments of precision referred to above, more careful
percussion, more careful auscultation, more careful measurements,
roentgenoscopy and fluoroscopic examination of the heart, and a
study of the circulation with the patient standing, sitting, lying
and after exercise make the determination of circulatory ability a
specialty, and the physician who becomes an expert a specialist. It
is a specialization needed today almost more than in any other line
of medical science.

So frequently is the cause of these pains, disturbances and weakness
overlooked and the stomach or the intestines treated, or treatment
aimed at neuralgias, rheumatisms or rheumatic conditions, that a
careful examination of the patient, and a consideration of the part
the heart is playing in the causation of these symptoms are always
necessary.

The treatment required for such a heart, unless there is some
complication, as a kidney complication or a too high blood pressure,
or arteriosclerosis (and none of these causes necessarily prohibits
energetic cardiac treatment), is digitalis. If there is doubt as to
the condition of the cardiac arteries, digitalis should be given in
small doses. If it causes distinct cardiac pain, it is not indicated
and should be stopped. If, on the other hand, improvement occurs, as
it generally does, the dose can be regulated by the results. The
minimum dose which improves the condition is the proper one. Enough
should be given; too much should not be given. Before deciding that
digitalis does not improve the condition (provided it does not cause
cardiac pain) the physician should know that a good and efficient
preparation of digitalis is being taken. Strychnin will sometimes
whip up a tired heart and tide it over periods of depression, but it
is a whip and not a cardiac tonic. While overeating, all
overexertion, and alcohol should be stopped, and the amount of
tobacco should be modified, there is no treatment so successful as
mental and physical rest and a change of climate and scene, with
good clean air.

Many persons with these symptoms of cardiac tire think that they are
house-tired, shop-tired, or office-tired, and take on a physical
exercise, such as walking, climbing, tennis playing or golf playing,
to their injury. Such tired hearts are not ready yet for added
physical exercise; they should be rested first.

The treatment of this cardiac tire is not complete until the
tonsils, gums, teeth and the nose and its accessory sinuses are in
good condition. Various other sources of chronic poisoning from
chronic infection should of course be eliminated, whether an uncured
gonorrhea, prostatitis, some chronic inflammation of the female
pelvic organs, or a chronic appendicitis.

Longcope [Footnote: Longcope, W. T.: The Effect of Repeated
Injections of Foreign Protein on the Heart Muscle, Arch. Int. Med.,
June, 1915, p. 1079.] has recently shown that repeated, and even at
times one protein poisoning can cause degeneration of the heart
muscle in rabbits. Hence it is quite possible that repeated
absorption of protein poisons from the intestines may injure the
heart muscle as well as the kidney structure; consequently, in heart
weakness, besides removing all evident sources of infection, we
should also give such food and cause such intestinal activity as to
preclude the absorption of protein poison from the bowels.




CLASSIFICATION OF CARDIAC DISTURBANCES


For the sake of discussing the therapy of cardiac disturbances in a
logical sequence, they may be classified as follows:

Pericarditis
     Acute
     Adherent

Myocarditis
     Acute
     Chronic
     Fatty

Endocarditis
     Acute, simple malignant
     Chronic
Valvular Lesions
     Broken compensation
     Cardiac drugs
     Diet
     Resort treatment
Cardiac disease in children
Cardiac disease in pregnancy
Coronary sclerosis
Angina pectoris
     Pseudo-angina
Stokes-Adams disease
Arterial hypertension
Cardiovascular-renal disease
Arrhythmia
Auricular fibrillation
Bradycardia
Paroxysmal tachycardia
Hyperthyroidism
Toxic disturbances
Physiologic hypertrophies
Simple dilatation
Shock
Stomach dilatation
Anesthesia in heart disease




BLOOD PRESSURE


The study of the blood pressure has become a subject of great
importance in the practice of medicine and surgery. No condition can
be properly treated, no operation should be performed, and no
prognosis is of value without a proper consideration of the
sufficiency of the circulation, and the condition of the circulation
cannot be properly estimated without an accurate estimate of the
systolic and diastolic blood pressure. However perfectly the heart
may act, it cannot properly circulate the blood without a normal
tone of the blood vessels, both arteries and veins. Abnormal
vasodilatation seriously interferes with the normal circulation, and
causes venous congestion, abnormal increase in venous blood
pressure, and the consequent danger of shock and death. Increased
arterial tone or tonicity necessitates greater cardiac effort, to
overcome the resistance, and hypertrophy of the heart must follow.
This hypertrophy always occurs if the peripheral resistance is not
suddenly too great or too rapidly acquired. In other words, if the
peripheral resistance gradually increases, the left ventricle
hypertrophies, and remains for a long time sufficient. If, from
disease or disturbance in the lungs, the resistance in the pulmonary
circulation is increased, the right ventricle hypertrophies to
overcome it, and the circulation is sufficient as long as this
ventricle is able to do the work. If either this pulmonary increased
pressure or the systemic increased pressure persists or becomes too
great, it is only a question of how many months, in the case of the
right ventricle, and how many years, in the case of the left
ventricle, the heart can stand the strain.

If the cause of the increased systemic tension is an arterial
fibrosis, sooner or later the heart will become involved in this
general condition, and a chronic myocarditis is likely to result.
If, on the other hand, there is a continuous low systemic arterial
blood pressure, the circulation is always more or less insufficient,
nutrition is always imperfect, and the physical ability of the
individual is below par. It is evident, therefore, that an
abnormally high blood pressure is of serious import, its cause must
be studied, and effort must be made to remove as far as possible the
cause. On the other hand, a persistently low blood pressure may be
of serious import, and always diminishes physical ability. If
possible, the cause should be determined, and the condition
improved.

No physician can now properly practice medicine without having a
reliable apparatus for determining the blood pressure both in his
office and at the bedside. It is not necessary to discuss here the
various kinds of apparatus or what is essential in an apparatus for
it to give a perfect reading. It may be stated that in determining
the systolic and diastolic pressure in the peripheral arteries, the
ordinary stethoscope is as efficient as any more elaborate
auscultatory apparatus.

It is now generally agreed by all scientific clinicians that it is
as essential--almost more essential--to determine the diastolic
pressure as the systolic pressure; therefore the auscultatory method
is the simplest, as well as one of the most accurate in determining
these pressures. Of course it should be recognized that the systolic
pressure thus obtained will generally be some millimeters above that
obtained with the finger, perhaps the average being equivalent to
about 5 mm. of mercury. The diastolic pressure will often range from
10 to 15 mm. below the reading obtained by other methods. Therefore,
wider range of pressure is obtained by the auscultatory method than
by other methods. This difference of 5 or more millimeters of
systolic pressure between the auscultatory and the palpatory
readings should be remembered when one is consulting books or
articles printed more than two years ago, as many of these pressures
were determined by the palpatory method.

Sometimes the compression of the arm by the armlet leads to a rise
in blood pressure. [Footnote: MacWilliams and Melvin: Brit. Med.
Jour., Nov. 7, 1914.] It has been suggested that the diastolic
pressure be taken at the point where the sound is first heard on
gradually raising the pressure in the armlet.

In some persons the auscultatory readings cannot be made, or are
very unsatisfactory, and it becomes necessary to use the palpation
method in taking the systolic pressure. In instances in which the
auscultatory method is unsatisfactory, the artery below the bend of
the elbow at which the reading is generally taken may be misplaced,
or there may be an unusual amount of fat and muscle between the
artery and the skin.

The various sounds heard with the stethoscope, when the pressure is
gradually lowered, have been divided into phases. The first phase
begins with the first audible sound, which is the proper point at
which to read the, systolic pressure. The first phase is generally,
not always, succeeded by a second phase in which there is a
murmurish sound. The third phase is that at which the maximum sharp,
ringing note begins, and throughout this phase the sound is sharp
and intense, gradually increasing, and then gradually diminishing to
the fourth phase, where the sound suddenly becomes a duller tone.
The fourth phase lasts until what is termed the fifth phase, or that
at which all sound has disappeared. As previously stated, the
diastolic pressure may be read at the beginning of the fourth phase,
or at the end of the fourth phase, that is, the beginning of the
fifth; but the difference is from 3 to 10 mm. of mercury, with an
average of perhaps 5 mm.; therefore the difference is not very
great. When the diastolic pressure is high, for relative subsequent
readings, it is much better to read the diastolic at the beginning
of the fifth phase.

It is urged by many observers that the proper reading of the
diastolic pressure is always at the beginning of the fourth phase.
However, for general use, unless one is particularly expert, it is
better to read the diastolic pressure at the beginning of the fifth
phase. There can rarely be a doubt in the mind of the person who is
auscultating as to the point at which all sound ceases. There is
frequently a good deal of doubt, even after large experience, as to
just the moment at which the fourth phase begins. With the
understanding that the difference is only a few millimeters, which
is of very little importance, when the diastolic pressure is below
95, it seems advisable to urge the reading of the diastolic pressure
at the beginning of the fifth phase.

The incident of the first phase, or when sound begins, is caused by
the sudden distention of the blood vessel below the point of
compression by the armlet. In other words, the armlet pressure has
at this point been overcome. Young [Footnote: Young: Indiana State
Med. Assn. Jour., March, 1914.] believes that the murmurs of the
second phase, which in all normal conditions are heard during the 20
mm. drop below the point at which the systolic pressure had been
read, is "due to whirlpool eddies produced at the point of
constriction of the blood vessel by the cuff of the instrument." The
third phase is when these murmurs cease and the sound resembles the
first, lasting he thinks for only 5 mm. The third phase often lasts
much longer. He thinks the fourth phase, when the sound becomes
dull, lasts for about 6 mm.


TECHNIC

It is essential that the patient on whom the examination is to be
made should be at rest, either comfortably seated, or lying down.
All clothing should be removed from the arm, and there should be no
constriction by sleeves, either of the upper arm or the axilla. When
the blood pressure is taken over the sleeve of a garment, the
instrument will register from 10 to 30 mm. higher than on the bare
arm. [Footnote: Rowan, J. J.: The Practical Application of Blood
Pressure Findings, The JOURNAL A. M. A., March 18, 1916, p. 873.]

While it may be better, for insurance examinations, to take the
blood pressure of the left arm in right handed persons as a truer
indicator of the general condition, the difference is generally not
great. The right arm of right handed persons usually registers a
full 5 mm. higher systolic pressure than the left arm.

The patient, being at rest and removed as far as possible from all
excitement, may be conversed with to take his mind away from the
fact that his blood pressure is being taken. He also should not
watch the dial, as any tensity on his part more or less raises the
systolic pressure, the diastolic not being much affected by such
nervous tension. The armlet having been carefully applied, it is
better to inflate gradually 10 mm. higher than the point at which
the pulsation ceases in the radial. The stethoscope is then firmly
applied, but with not too great pressure, to the forearm just below
the flexure of the elbow. The exact point at which the sound is
heard in the individual patient, and the exact amount of pressure
that must be applied, will be determined by the first reading, and
then thus applied to the second reading. One reading is never
sufficient for obtaining the correct blood pressure. The blood
pressure may be read by means of the stethoscope during the gradual
raising of pressure in the cuff, note being taken of the first sound
that is heard (the diastolic pressure), and the point at which all
sound disappears, as the pressure is increased (the systolic
pressure). The former method is the one most frequently used.

By taking the systolic and diastolic pressures, the difference
between the two being the pressure pulse, we learn to interpret the
pressure pulse reading. While the average pressure pulse has
frequently been stated as 30 mm., it is probable that 35 at least,
and often 40 mm. represents more nearly the normal pressure pulse,
and from 25 mm. on the one hand to 50 on the other may not be
abnormal.

Faught [Footnote: Faught: New York Med Jour., Feb. 27, 1915, p.
396.] states his belief that the relation of the pressure pulse to
the diastolic pressure and the systolic pressure are as 1, 2 and 3.
In other words, a normal young adult with a systolic pressure of 120
should have a diastolic pressure of 80, and therefore a pulse
pressure of 40. If these relationships become much abnormal, disease
is developing and imperfect circulation is in evidence, with the
danger of broken compensation occurring at some time in the future.

It should be remembered that the diastolic pressure represents the
pressure which the left ventricle must overcome before the blood
will begin to circulate, that is, before the aortic valve opens,
while the pressure pulse represents the power of the left ventricle
in excess of the diastolic pressure. Therefore it is easy to
understand that a high diastolic pressure is of serious import to
the heart; a diastolic pressure over 100 is significant of trouble,
and over 110 is a menace.


FACTORS INCREASING THE BLOOD PRESSURE

With normal heart and arteries, exertion and exercise should
increase the systolic pressure, and generally somewhat increase the
diastolic pressure. The pressure pulse should therefore be greater.
When there is circulatory defect or abnormal blood pressure,
exercise may not increase the systolic pressure, and the pressure
pulse may grow smaller. As a working rule it should be noted that
the diastolic pressure is not as much influenced by physiologic
factors or the varying conditions of normal life as is the systolic
pressure.

In an irregularly acting heart the systolic pressure may vary
greatly, from 10 to 20 mm. or more, and a ventricular contraction
may not be of sufficient power to open the semilunar valves. Such
beats will show an intermittency in the blood pressure reading as
well as in the radial pulse. The succeeding heart beats after
abortive beats or after a contraction of less power have increased
force, and consequently give the highest blood pressure. Kilgore
urges that these highest pressures should not be taken as the true
systolic blood pressure, but the average of a series of these
varying blood pressures. In irregularly acting hearts it is best to
compress the arm at a point above which the systolic pressure is
heard, then gradually reduce the pressure until the first systolic
pressure is recorded, and then keep the pressure of the cuff at this
point and record the number of beats of the heart which are heard
during the minute. Then reduce the pressure 5 mm. and read again for
a minute, and so on down the scale until the varying systolic
pressures are recorded. The average of these pressures should be
read as the true systolic blood pressure. During an intermittency of
the pulse from a weak or intermittently acting ventricle, the
diastolic pressure will reach its lowest point, and in auricular
fibrillation the pressure pulse from the highest systolic to the
lowest diastolic may be very great.

In arteriosclerosis the systolic may be high, and the diastolic low,
and hence a large pressure pulse. When the heart begins to fail in
this condition, the systolic pressure drops and the pressure pulse
shortens, and of course any improvement in this condition will be
shown by an increase in the systolic pressure. The same is true with
aortic regurgitation and a high systolic pressure.

If the systolic pressure is low and the diastolic very low, or when
the heart is rapid, circulation through the coronary vessels of the
heart is more or less imperfect. Any increase in arterial pressure
will therefore help the coronary circulation. The compression of a
tight bandage around the abdomen, or the infusion of blood or saline
solutions, especially when combined with minute amounts of
epinephrin, will raise the blood pressure and increase the coronary
circulation and therefore the nutrition of the heart.

MacKenzie [Footnote: MacKenzie: Med Rec., New York, Dec. 18, 1915.],
from a large number of insurance examinations in normal subjects,
finds that for each increase of 5 pulse beats the pressure rises 1
mm. He also finds that the effect of height on blood pressure in
adults seems to be negligible. On the other hand, it is now
generally proved that persons with overweight have a systolic
pressure greater than is normal for individuals of the same age. He
believes that diastolic pressure may range anywhere from 60 mm. of
mercury to 105, and the person still be normal. A figure much below
60 certainly shows dangerous loss of pressure, and one far below
this, except in profound heart weakness, is almost pathognomonic of
aortic regurgitation. While the systolic range from youth to over 60
years of age gradually increases, at the younger age anything below
105 mm. of mercury should be considered abnormally low, and although
150 mm. at anything over 40 has been considered a safe blood
pressure as long as the diastolic was below 105, such pressures are
certainly a subject for investigation, and if the systolic pressure
is persistently above 150, insurance companies dislike to take the
risk. However, it should be again urged in making insurance
examinations that psychic disturbance or mental tensity very readily
raises the systolic pressure. MacKenzie believes that a diastolic
pressure over 100 under the age of 40 is abnormal, and anything over
the 110 mark above that age is certainly abnormal.

It has been shown, notably by Barach and Marks, [Footnote: Barach,
J. H., and Marks, W. L.: Effect of Change of Posture--Without Active
Muscular Exertion--on the Arterial and Venous Pressures, Arch. Int.
Med., May, 1913, p 485.] that posture changes the blood pressure.
When a normal person reclines, with the muscular system relaxed,
there is an increase in the systolic pressure and a decrease in the
diastolic pressure, with an increase in the pressure pulse from the
figures found when the person is standing. When, after some minutes
of repose, he assumes the erect posture again, the systolic pressure
will diminish and the diastolic pressure increase, and the pressure
pulse shortens.

Excitement can raise the blood pressure from 20 to 30 mm., and if
such excitement occurs in high tension cases there is often a
systolic blow in the second intercostal space at the right of the
sternum. This may not be due to narrowing of the aortic orifice; it
may be due to a sclerosis of the aorta. On the other hand, it may be
due entirely to the hastened blood stream from the nervous
excitability. This is probably the case if this sound disappears
when the patient reclines. If it increases when the heart becomes
slower and the patient is lying down, the cause is probably organic.

This psychic influence on blood pressure is stated by Maloney and
Sorapure [Footnote: Maloney and Sorapure: New York Med. Jour., May
23, 1914, p. 1021.] "to be greater than that from posture, than that
arising from carbonic acid gas control of the blood, than that
arising from mechanical action of deep breathing upon the
circulation, and than that arising from removal of spasm from the
musculature."

Weysse and Lutz [Footnote: Weysse and Lutz: Am. Jour. Physiol., May,
1915.] find that the systolic pressure varies during the day in
normal persons, and is increased by the taking of food, on an
average of 8 mm. The diastolic pressure is not much affected by
food. This increased systolic pressure is the greatest about half an
hour after a meal, and then gradually declines until the next meal.

Any active, hustling man, or a man under strain, has a rise of blood
pressure during that strain, especially notable with surgeons during
operation, or with brokers or persons under high nervous tension.
Daland [Footnote: Daland: Pennsylvania Med Jour., July, 1913.]
states that a man driving an automobile through a crowded street may
have an increase of systolic pressure of 30 mm., and an increase of
15 mm. in his diastolic pressure, while the same man driving through
the country where there is little traffic will increase but 10 mm.
systolic and 5 mm. diastolic. Fear always increases the blood
pressure. This is probably largely due to the peripheral
contractions of the blood vessels and nervous chilling of the body.


VENOUS PRESSURE

The venous pressure, after a long neglect, is now again being
studied, and its determination is urged as of diagnostic and
prognostic significance.

Hooker [Footnote: Hooker: Am. Jour. Physiol., March, 1916.] says
there is a progressive rise of venous pressure from youth to old
age. He has described an apparatus [Footnote: Hooker: Am. Jour.
Physiol., 1914, xxxv, 73.] which allows of the reading of the blood
pressure in a vein of the hand when the arm is at absolute rest, and
best with the patient in bed and reclining at an angle of 45
degrees. He finds that just before death there is a rapid rise in
venous pressure, or a continuously high pressure above the 20 cm. of
water level, and he believes that a venous pressure continuously
above this 20 cm. of water limit which is not lowered by digitalis
or other means is serious; and that the heart cannot long stand such
a condition. These dangerous rises in venous pressure are generally
coincident with a fall of systolic arterial pressure, although there
may be no constant relation between the two. He also finds that with
an increase of venous pressure the urinary output decreases. This,
of course, shows venous stasis in the kidneys as well as a probable
lowering of arterial pressure.

Clark [Footnote: Clark, A. D.: A Study of the Diagnostic and
Prognostic Significance of Venous Pressure Observations in Cardiac
Disease, Arch. Int. Med., October, 1915, p. 587.] did not find that
venesection prevented a subsequent rapid rise in venous pressure in
dire cases. From his investigations he concludes that a venous
pressure of 20 cm. of water is a danger limit between compensation
and decompensation of the heart, and a rise above this point will
precede the clinical signs of decompensation.

Hooker also found that there are daily variations of venous pressure
from 10 to 20 cm. of water, with an average of 15 cm., while in
sleep it falls 7 or 8 cm.

It seems probable that there may be a special nervous mechanism of
the veins which may increase the blood pressure in them as
epinephrin solution may cause some constriction.

Wiggers [Footnote: Wiggers C. J.: The Supravascular Venous Pulse in
Man, THE JOURNAL. A.M.A., May 1, 1915, p. 1485.] describes a method
of taking and interpreting the supraclavicular venous pulse. He also
[Footnote: Wiggers C. J.: The Contour of the Normal Arterial Pulse,
THE JOURNAL. A.M.A., April 24, 1915, p. 1380.] carefully describes
the readings and the different phases of normal arterial pulse, and
urges that it should be remembered that "the pulse as palpated or
recorded from any artery is the variation in the arterial volume
produced by the intra-arterial pressure change at that point."

A quick method of estimating the venous pressure by lowering and
raising the arm has long been utilized. The dilatation of the veins
of the back of the hand when the hand is raised should disappear,
and they should practically collapse, in normal conditions, when the
hand is at the level of the apex of the heart. When the venous
pressure is increased, this collapse will not occur until the hand
is above the level of the heart. Oliver [Footnote: Oliver: Quart.
Med Jour., 1907, i, 59.] found that the venous pressure denoted by
the collapse of the veins may be shown approximately in millimeters
of mercury by multiplying by 2 each inch above the level of the
heart in which the veins collapse. When a normal person reclines
after standing there is a fall in venous pressure, and when he again
stands erect there is an increase in venous pressure.

Bailey [Footnote: Bailey: Am. Jour Med. Sc., May, 1911, p. 709.]
states that in interpreting pulsation in the peripheral veins, it
should not be forgotten that they may overlie pulsating arteries.
Pulsation in veins may be due also to an aneurysmal dilatation, or
to direct connection with an artery. As the etiology in many
instances of varicose veins is uncertain, he thinks that they may be
caused by incompetence of the right heart, more or less temporary
perhaps, from muscular exertion. This incompetence being frequently
repeated, peripheral veins may dilate. Moreover, the contraction of
the right heart may cause a wave in the veins of the extremities,
and he believes that incompetency of the tricuspid valve may be the
cause of varicosities in the veins of the extremities.


NORMAL BLOOD PRESSURE FOR ADULTS

Woley [Footnote: Woley, II. P.: The Normal Variation of the Systolic
Blood Pressure, THE JOURNAL A. M. A., July 9, 1910, p. 121.] after
studying, the blood pressure in a thousand persons, found that the
systolic average for males at all ages was 127.5 mm., while that for
females at all ages was 120 mm. He found the average in persons from
15 to 30 years to be 122 systolic; from 30 to 40, 127 mm., and from
the ages of 40 to 50, to be 130 mm.

Lee [Footnote: Lee: Boston Med. and Surg. Jour., Oct. 7, 1915.]
examined 662 young men at the average age of 18, and found that the
average systolic blood pressure was 120 mm., and the average
diastolic 80 mm. Eighty-five of these young men, however, had a
systolic pressure of over 140. It is not unusual to find that a
young man who is very athletic has an abnormally high systolic
pressure.

Barach and Marks [Footnote: Barach, J. H., and Marks, W. L.: Blood
Pressures: Their Relation to Each Other and to Physical Efficiency,
Arch. Int. Med., April, 1914, p 648.] in a series of 656 healthy
young men, found that the systolic pressure was above 150 in only 10
percent, and that in 338 cases the diastolic pressure, read at the
fifth phase, did not exceed 100 mm. in 96 percent

Nicholson [Footnote: Nicholson: Am. Jour. Med. Sc., April, 1914, p.
514.] believes that with a low systolic pressure and a large
pressure pulse there is probably a strong heart and dilated blood
vessels, while with a low systolic pressure and a small pressure
pulse the heart itself is weak, with also, perhaps, dilated blood
vessels. If there is a high systolic pressure and a correspondingly
high diastolic pressure, the balance between the vessels and the
heart is compensated as long as the heart muscle is sufficient. He
believes the velocity of the blood in the blood stream may be
roughly estimated as being equal to the pressure pulse multiplied by
the pulse rate.

Faber 44 [Footnote: Faber: Ugeskrifta f. Laeger, June 10, 1915.]
examined 211 obese patients, and in 182 of these there was no kidney
or vascular disturbance. In 52 percent of these 211 persons the
systolic pressure was under 140, while in the remaining 48 percent
it ranged from 145 to 200 mm.


BLOOD PRESSURE IN CHILDREN

May Michael, [Footnote: Michael, May: A Study of Blood Pressure in
Normal Children, Am. Jour. Dis. Child., April, 1911, p. 272.] after
a study of the blood pressure in 350 children, came to the
conclusion that the blood pressure in children increases with age
principally because of the increase in height and weight, as she
found that children of the same age but of different weights and
heights had different blood pressures. Sex in children makes no
difference in the blood pressure, it being determined by the height
and weight.

Judson and Nicholson [Footnote: Judson, C. F., and Nicholson,
Percival: Blood Pressure in Normal Children, Am. Jour. Dis. Child.,
October, 1914, p. 257.] made 2,300 observations in children of from
3 to 15 years of age, and found there was a gradual increase in the
systolic blood pressure from 3 to 10 years, and a more rapid rise
from 10 to 14, with a rapid elevation during the fourteenth year, or
the age of puberty. The systolic pressure varied from 91 mm. in the
fourth year to 105.5 in the fourteenth year, while the diastolic
pressure remained almost at a uniform level. The pressure pulse,
therefore, increased progressively with the increase of the systolic
pressure.


BLOOD PRESSURE AND INSURANCE

An epitome of the consensus of opinion of the risk of accepting
persons for insurance as modified by the blood pressure is presented
by Quackenbos. [Footnote: Quackenbos: New York Med. Jour., May 15,
1915, p. 999.] Some companies have ruled that at the age of 20 they
will take a person with a systolic pressure up to 137; at the age of
30 up to 140; at the age of 40 up to 144; at 50 up to 148, and at 60
up to 153, although some companies will not accept a person who
shows a persistent systolic pressure of 150. Quackenbos says that
when persons with higher blood pressures than the foregoing have
been kept under observation for some time, they sooner or later show
albumin and casts in the urine. In other words, this stage of higher
blood pressure is too frequently followed by cardiovascular-renal
disease for insurance companies to accept the risk.

On the other hand, too low a systolic pressure in an adult, 105 mm.
or below, should cause suspicion of some serious condition, the most
frequent being a latent or quiescent tuberculosis. Such low pressure
certainly shows decreased power of resistance to any acute disease.

Statistics prove that there are more deaths between the ages of 40
and 50 from cardiovascular-renal disease, that is from heart,
arterial and kidney degenerations, than formerly. Whether this is
due to the high tension at which we all live, or to the fact that
more children are saved and live to middle life, or whether the
prevention of many infectious diseases saves deficient individuals
for this middle life period, has not been determined. Probably all
are factors in bringing about these statistics.

While the continued use of alcohol may not cause arteriosclerosis
directly, it can cause such impaired digestion of foods in the
stomach and intestine, and such impaired activity of the glands,
especially the liver, that toxins from imperfect digestion and from
waste products are more readily produced and absorbed, and these are
believed by some directly or indirectly to cause cardiovascular-
renal disease. Hence alcohol is an important factor in causing the
death of persons from 40 to 50 years of age.

The question of whether or not a person smokes too much, and what
constitutes oversmoking, will soon be asked on all insurance blanks.
As tobacco almost invariably raises the blood pressure, and when the
blood pressure again falls there is again a craving in the man for
the narcotic, it must be a factor in producing, later in life,
cardiovascular-renal disease. Hence an increased systolic blood
pressure must be in part interpreted by the amount of tobacco that
the person uses. BLOOD PRESSURE AND PREGNANCY Evans [Footnote:
Evans: Month. Cyc. and Med. Bull., November, 1912, p. 649.] of
Montreal studied thirty-eight pregnant women who had eclampsia,
albuminuria and toxic vomiting, and found the systolic pressures to
vary from 200 to 140 mm. He did not find that the highest pressures
necessarily showed the greatest insufficiency of the kidneys, but
that the blood pressure must be considered in conjunction with other
toxic symptoms. In thirty-two cases he was compelled to induce labor
when the blood pressure was 150 mm. or under, while in four cases
with a blood pressure over 150 mm., the toxic symptoms were so
slight that the patients were allowed to go to term and had natural
deliveries.

A rising blood pressure in pregnancy, when associated with other
toxic symptoms, is indicative of danger, and Evans believes that a
systolic pressure of 160 mm, is ordinarily the danger limit.

Newell [Footnote: Newell, h. S.: The Blood Pressure During
Pregnancy, THE JOURNAL A. M. A., Jan. 30, 1915, p. 393.] has studied
the blood pressure during normal pregnancy, and finds that when the
systolic pressure is persistently below 100, the patient is far
below par, and that the condition should be improved in order for
her to withstand the strain of parturition. When the systolic
pressure is above 130, the patient should be carefully watched, and
he thinks that 150 is the danger line. Some pregnant women have an
increasing rise in blood pressure throughout the pregnancy, without
albuminuria. In other cases this rise is followed by the appearance
of albumin in the urine. Thirty-nine of the patients studied by
Newell had albumin in the urine without increase in blood pressure;
hence he believes that a slight amount of albumin may not be
accompanied by other symptoms. Five patients had a blood pressure of
140 or over throughout their pregnancy, and in only one of these
patients was albumin found. All passed through labor normally,
showing that a blood pressure below 150 may not necessarily be
indicative of a serious condition; but a patient who has a systolic
pressure over 135 must certainly be carefully watched. A fact
brought out by Newell's investigations is very important, namely,
that a continuously increased blood pressure is not as indicative of
trouble as when a blood pressure has been low and later suddenly
rises.

Hirst [Footnote: Hirst: Pennsylvania Med. Jour., May, 1915, p. 615.]
also urges that a high blood pressure in pregnancy does not
necessarily represent a toxemia, and also that a serious toxemia can
occur with a blood pressure of 130 or lower, although such instances
are rare. Hirst believes that when a toxemia is in evidence in
pregnancy while the blood pressure is low, the cause of the toxemia
is liver disturbance rather than kidney disturbance, and he thinks
this form of toxemia is more serious and has a higher mortality than
the nephritic type. Therefore in a patient with eclamptic symptoms
and a low blood pressure, the prognosis is more unfavorable than
when the blood pressure is high. He believes that if high blood
pressure occurs early in the months of pregnancy, there is
preexisting, although perhaps latent, nephritis. In these conditions
the diastolic pressure is also likely to be high.

With the patient eclamptic and stupid, whatever the date of the
pregnancy, Hirst would do venesection immediately in amount from 16
to 24 ounces, depending on what amount seems advisable. If
venesection is done before actual convulsions have occurred, the
blood pressure falls temporarily but rapidly rises again. He finds
that if a patient is past the eighth month, rupture of the membranes
will usually bring a rapid fall of from 50 to 90 points in systolic
pressure. Usually, of course, such rupture of the membranes will
induce labor. He finds that the fluidextract of veratrum viride is
valuable when eclampsia is in evidence or imminent. He gives it
hypodermically, 15 minims at the first dose and 5 minims
subsequently, until the systolic pressure is reduced to 140 or less.
He admits that this is rather strenuous treatment. He does not speak
of treatment by thyroid extracts, which has been regarded as
valuable by some other workers.

In these patients who show eclamptic symptoms, he maintains a milk
diet, and purging and sweating. It should be remembered that
venesection or profuse bleeding during induced parturition is more
valuable than sweating in all eclamptic cases and in all nephritic
convulsions. Profuse sweating does little more than take the water
out of the blood, and even concentrates the poisons in the blood.

Hirst causes purging by 2 ounces of castor oil and a few minims of
croton oil. He also advises large doses of magnesium sulphate. In
such serious disturbances as eclampsia, it is not necessary to give
a magnesium salt, which, it has been shown, can have unpleasant
action on the nervous system. Sodium sulphate is as valuable and is
not open to this danger.

Hirst urges that whatever the blood pressure, with albuminuria, as
soon as persistent headache occurs, and especially if there are
disturbances of vision, the pregnancy must be terminated at once. On
this there can be no other opinion. Temporizing with such a case is
inexcusable.

After labor has been induced there is an immediate fall of blood
pressure, which lasts some hours. The pressure will again rise, and
usually is the last sign of toxemia to disappear, and he finds that
this increased pressure may last from two to three weeks when there
is not much nephritis, and several months when there is nephritis.

Although he says he has found no bad action from ergot, either by
the mouth or hypodermically in these eclamptic cases, it would seem
inadvisable to use ergot, which may raise the blood pressure. He
finds that pituitary extract "can cause dangerous rise of blood
pressure."

Pelissier [Footnote: Pelissier: Archiv. mens., d'obst. et de gynec.,
Paris, 1915, iv, No. 5.] believes that when there is prolonged
vomiting in early pregnancy, with an increase in systolic blood
pressure, and with an increased viscosity of the blood, the outlook
is serious, and active treatment should be inaugurated.

Irving [Footnote: Irving, F. C.: The Systolic Blood Pressure in
Pregnancy, THE JOURNAL A. M. A., March 25, 1916, p. 935.] reports,
after a study of 5,000 pregnant women, that in 80 percent the
systolic blood pressure varied from 100 to 130; in 9 percent it was
below 100, at least at times, but a pressure below 90 does not mean
that the woman will suffer shock; in 11 percent the pressure was
above 130, and high pressure in young pregnant women more frequently
indicates toxemia than when it occurs in older women; high pressure
is more indicative of toxemia than is albuminuria; a progressively
increasing blood pressure is of bad omen, and most cases of
eclampsia occur with a pressure of 160 or more, but eclampsia may
occur with a moderate blood pressure. Irving believes that with
proper preliminary preventive treatment most eclampsia is
preventable.


ALTITUDE

It has long been known that altitude increases the heart rate and
tends to lower the systolic and diastolic blood pressures; that
these conditions, though actively present at first, gradually return
to normal, and that after a prolonged stay at the altitude may
become nearly normal for the individual. Burker [Footnote: Burker,
K.; Jooss, E.; Moll, E., and Neumann, E.: Ztschr. f. Biol., 1913,
lxi, 379. The Influence of Altitude on the Blood, editorial, THE
JOURNAL A. M. A., Nov. 1, 1913, p. 1634.] showed that altitude
increases the red blood cells from 4 to 11.5 percent, and the
hemoglobin from 7 to 10 percent The greatest increase in these
readings is in the first few days. It has also been shown that with
every 100 mm. of fall of atmospheric pressure there is an increased
hemoglobin percentage of 10 percent over that at the sea level.
[Footnote: Blood and Respiration at Moderate Altitudes, editorial,
THE JOURNAL A. M. A., Feb. 20, 1915, p. 670.]

Schneider and Havens [Footnote: Schneider and Havens: Am. Jour.
Physiol., March, 1915.] find that in low altitudes abdominal massage
increases the red corpuscles, and the percentage of hemoglobin in
the peripheral vessels. While there is thus apparently a reserve of
red corpuscles while the individual is in a low altitude, in a high
altitude they find such reserve to be absent; in other words,
abdominal massage did not cause this increase in red corpuscles in
the peripheral vessels. This absence of reserve is easily accounted
for by the fact that after one reaches the high altitude there is an
increase in red corpuscles and hemoblogin in the peripheral blood.

Schneider and Hedblom [Footnote: Schneider and Hedblom: Am. Jour.,
Physiol., November, 1908.] showed that the fall in systolic pressure
at altitudes is greater and more certain than the fall in diastolic,
some individuals even having a rise in diastolic pressure. This rise
in diastolic pressure is probably caused by dyspnea.

Schrumpf, [Footnote: Schrumpf: Deutsch. Arch. f. klin. Med., 1914,
cxiii, 466] on the other hand, finds that normal blood pressure is
not much affected by an ascent of about 6,500 feet, while patients
with arteriosclerosis and hypertension, without kidney disease, have
a fall in pressure. A patient with coronary disease should certainly
not go to any great altitude, while patients with compensated
valvular lesions, he found, were not injured by ordinary heights. He
found that altitude seemed to decrease high systolic and diastolic
pressures, while it even elevated those which were below normal, and
caused these patients to feel better.

Any person who has a circulatory disturbance, and who must or does
go to a higher altitude, should rest for a series of days, until his
blood pressure and blood have reached an equilibrium.

Smith [Footnote: Smith, F. C.: The Effect of Altitude on Blood
Pressure, THE JOURNAL A. M. A., May 29, 1915, p. 1812.] made a
series of observations on blood pressures at Fort Stanton which has
an altitude of 6,230 feet. He took the blood pressure readings in
fifty-four young adults, seventeen of whom were women, and found
that the average systolic reading in the men was 129 mm., and in the
women 121, while the average diastolic in the men was 84, and in the
women 82. Therefore he agrees with Schrumpf that the effect of
altitude on normal blood pressure has been overestimated. In
tuberculosis he found that the effect of altitude was not great. He
does not believe that this amount of altitude, namely, a little more
than 6,000 feet, makes much difference in an ordinary tuberculous
patient. He did not find that artificial pneumothorax made any
important change in the blood pressure. His findings do not quite
agree with Peters and Bullock, [Footnote: Peters, L. S.r and
Bullock, E. S.: Blood Pressure Studies in Tuberculosis at a High
Altitude, Arch. Int. Med., October, 1913, p. 456.] who studied 600
cases of tuberculosis at an altitude of 6,000 feet, and found the
blood pressure was increased, both in normal and in consumptive
individuals. They also found that the increase in blood pressure,
which kept gradually rising up to a certain limit, was indicative
that the tuberculous patient was not much toxic; therefore the
increase in blood pressure was of good prognosis.


CONDITIONS CAUSING CHANGE IN BLOOD PRESSURE

Woolley [Footnote: Woolley, P. G.: Factors Governing Vascular
Dilatation and Slowing of the Blood Stream in Inflammation, THE
JOURNAL A. M. A., Dec. 26, 1914, p. 2279.] quotes Starling as
finding that the blood vessels dilate from physical and chemical
changes in the musculature, and that this dilatation is caused by
deficient oxidation and accumulation of the products of metabolism,
including carbon dioxid. This dilatation ordinarily is transient and
not associated with exudation, but in inflammation the dilatation is
persistent and there is exudation. The carbon dioxid increase during
exercise stimulates a greater circulation of oxygen in the tissues
which later counteracts the normal increase in acid products. In
inflammatory processes, however, the acid accumulates too rapidly to
allow of saturation. In this case the circulation becomes slowed and
the cells become affected.

Besides these charges in the blood vessels of the muscles, the
general blood pressure becomes raised on exercise, the heart more
rapid and the temperature somewhat elevated, and the breathing is
increased. This increased heart rate does not stop immediately on
cessation of the exercise, but persists for a longer or shorter
time. The better trained the individual, the sooner the speed of the
heart becomes normal.

Benedict and Cathcart [Footnote: Benedict and Cathcart: Pub. 77,
Carnegie Institute of Washington.] have found that the increased
absorption of oxygen, showing increased metabolism, persists after
exercise as long as the heart action is increased.

Newburgh and Lawrence [Footnote: Newburgh, L. H., and Lawrence C.
H.: The Effect of Heat on Blood Pressure, Arch. Int. Med., February,
1914, p. 287.] have found that increased temperature in animals,
equal to that occurring in persons suffering with infection, reduces
the blood pressure, causing a hypotension. This shows that high
temperature alone in an individual sooner or later causes
hypotension.

Although prolonged pain may cause a fall of blood pressure from
shock, the first acute pain may cause a rise in blood pressure, and
Curschmann [Footnote: Curschmann: Munchen. med. Wehnschr., Oct. 15,
1907.] found that the blood pressure was high in the gastro-
intestinal crises of tabes and in colic, and that the application of
faradic electricity to the thigh could raise the blood pressure from
8 to 10 mm. in normal individuals.

The positive effect of decomposition products in the intestine, more
especially such as come from meat proteins, is well recognized; but
the importance, in high pressure cases, of the absorption of toxins
derived from imperfectly digested food remaining in the bowels over
night is not sufficiently recognized. Patients with high blood
pressure should not eat a heavy evening meal, and especially should
they not eat meat. Willson [Footnote: Willson, R. N.: The
Decomposition Food Products as Cardiovascular Products, THE JOURNAL
A. M. A., Sept. 25, 1915, p. 1077.] well describes the condition
caused by the absorption of these toxins. If the heart muscle is
intact, he finds such absorption in high pressure cases will show
diastolic as well as systolic increase:

 The vessels pulsate and throb; the skin is pale; the head aches;
the tongue is coated; the breath is foul; vertigo is often
distressing; and not infrequently the hands and feet feel distended
and swollen. A thorough house-cleaning of the gastro-intestinal
canal causes the expulsion of the offending substances and the
expulsion of gas, whereupon the blood pressure often resumes its
normal level and the symptoms disappear.

Wilson suggests that not only the meat proteins, but also the
oxyphenylethylamin in overripe cheese may often cause this
poisoning; and cheese is frequently eaten by these people at
bedtime. Of course if any particular fruit or article of food causes
intestinal upset in a given individual, they should be avoided.

When the heart is hypertrophied in disease, the cavities of the
ventricles are probably also generally enlarged, and therefore they
propel more blood at each contraction than in normal persons and
thus increase the blood pressure.

The blood pressure is raised not only by intestinal toxemia and
uremia, but also by lead poisoning and the conditions generally
present in gout.

It has been pointed out by Daland [Footnote: Daland: Pennsylvania
Med. Jour., July, 1913.] that nervous exhaustion may raise the blood
pressure in those who are neurotic, and he finds that this
hypertension may exist for months in some cases. On the other hand,
in neurasthenics the blood pressure is generally lowered. As he
points out, there is often a very great increase in the systolic
blood pressure at the menopause, while the diastolic pressure may
not be high. This makes a very large pressure pulse. This suggests
the possibility of disturbances of the glands of internal secretion.
This hypertension is generally improved under proper treatment.

Schwarzmann [Footnote: Schwarzmann: Zentralbl. f. inn. Med., Aug. 1,
1914.] studied the blood pressure in eighty cases of acute
infection, and found that a high diastolic blood pressure during
such illness indicates a tendency to paralysis of the abdominal
vessels, and hence a sluggish circulation in the vessels of the
abdomen. He found that in seriously ill patients this high diastolic
pressure is of bad prognosis. He also found that a lower systolic
pressure with a lower diastolic pressure is not a sign that the
heart is weakening, but only that the visceral tone is growing less.
On the other hand, when the diastolic pressure rises while the
systolic falls, this is a sign of failing heart.

Newburgh and Minot [Footnote: Newburgh, L. H. and Minot, G. II: The
Blood Pressure in Pneumonia, Arch. Int. Med., July, 1914, p. 48.]
find that the blood pressure course in pneumonia does not suggest
that there is a failure of the vasomotor center. They found that
"low systolic pressures are not invariably of evil omen." They also
found that the systolic pressure in fatal cases is often higher than
in those in which the patients recovered, and they found that the
rate of the pulse is more important in determining the treatment
than the blood pressure measurements.

The work which has been described under this section is of interest
as indicating the newer experimental work on the physiology of blood
pressure. Much of it is new, however, and it is difficult to draw
absolute therapeutic conclusions from the evidence offered.


THE EFFECT OF DRUGS ON BLOOD PRESSURE

Free catharsis is a well established and valuable method of
relieving the heart in many cases of broken compensation, and in
cases with high blood pressure even while compensation is still
good, salines administered once or twice a week assist in
elimination, and in the reduction of blood pressure.

However, profuse purging in heart disease may be followed by
unfavorable symptoms, especially when the systolic blood pressure is
low. When there is hypotension, or when the diastolic pressure is
high and the venous pressure is high, and when there is edema or
effusion, watery catharsis should be caused only after due
consideration, and always with a careful watching of the effect on
the heart and blood pressure. The blood pressure is lowered by such
catharsis, and the heart is often slowed. Neilson and Hyland
[Footnote: Neilson, C. H., and Hyland, R. F.: The Effect of Strong
Purging on Blood Pressure and the Heart, THE JOURNAL A. M. A., Feb.
8, 1913, p. 436.] studied the effect of purging on the heart and
blood pressure, and were inclined to the view that in serious heart
conditions brisk purging should not be done. They think that the
slowing of the heart after such purging may be, due to an increased
viscosity of the blood, or perhaps to a reflex irritation from the
purgative on the intestinal canal.

Pilcher and Sollmann [Footnote: Pilcher and Sollmann: Jour.
Pharmacol. and Exper. Therap., 1913, vi, 323.] have shown that the
fall of blood pressure after the administration of nitrites is
mostly due to the action of these drugs on the peripheral vessels.
Chloroform, of course, depressed the vasomotor center, but ether had
no effect on this center, or slightly stimulated it. Such
stimulation, however, Pilcher and Sollmann believe may be secondary
to asphyxia. Nicotin they found to cause intense stimulation of the
vasomotor center. Ergot and hydrastis and its alkaloids seem to have
no effect on the vasomotor center. Strophanthus acted on this center
only moderately, and digitalis very slightly, if at all. Camphor in
doses large enough to cause convulsions stimulated the vasomotor
center. In smaller doses it generally stimulated the center
moderately, but not always. Even when this center was stimulated,
however, the camphor did not necessarily increase the blood
pressure. The rise in blood pressure from epinephrin is due entirely
to its action on the peripheral blood vessels and the heart. It has
no action on the vasomotor center. They found that strychnin in
large doses may stimulate the vasomotor center moderately, but
usually it did not act on this center unless the patient was
asphyxiated; then it acted intensely. The conclusion to be drawn
from their experiments is that when there is asphyxia, increased
venous pressure, and also a rising blood pressure from the
stimulation of carbon dioxid, strychnin is contraindicated.

It should be recognized that digitalis very frequently not only does
not raise blood pressure, but also may lower it; especially in
aortic insufficiency and when there is cyanosis. Even with some
forms of angina pectoris, digitalis in small doses may reduce the
frequency of the pain. This decrease of pain following the use of
digitalis has in some cases been ascribed to the improvement of
coronary circulation and resulting better nutrition of heart muscle.
Of course under these conditions the action of digitalis must be
carefully watched, and it should not be given too long.

Although sodium nitrite and nitroglycerin have but a short period of
action, in laboratory experimentation, in lowering the blood
pressure, when given repeatedly four or five times a day the blood
pressure is lowered in very many instances by these drugs. Sometimes
when the blood pressure is not lowered, there is relief of tension
in the head from high pressure, and the patient feels better. There
is also relief of the heart when it is laboring to overcome a high
resistance. One drop of the official spirit of nitroglycerin on the
tongue will cause a lowering in the peripheral pressure pulse, the
radial pulse becoming larger and fuller. This effect begins in three
minutes or less, reaches its maximum in about five minutes, and the
effect passes off in fifteen minutes or more. [Footnote: Hewlett, A.
W., and Zwaluwenburg, J. G. Van: The Pulse Flow in the Brachial
Artery, Arch. Int. Med., July, 1913, p. 1.]

It has been stated that iodids are of no value except in syphilitic
arteriosclerosis, but iodids in small doses are stimulant to the
thyroid gland, and the thyroid secretes a vasodilating substance.
Therefore, the use of either iodids or thyroid would seem to be
justified in many instances of high blood pressure.

Fairlee [Footnote: Fairlee: Lancet, London, Feb. 28, 1914.] has
studied the effect of chloroform and ether on blood pressure, and
finds that there is a fall of pressure throughout the administration
of chloroform, and but little alteration of the blood pressure
during the administration of ether. It may cause a slight rise, or
it may cause a slight fall, but changes in pressure with ether are
not marked. When there is slight surgical shock present, as from
some injury, they found that chloroform would lower the pressure
considerably. Hence it would seem that chloroform should not be used
as an anesthetic after serious injuries.


THE EFFECT OF DRUGS ON VENOUS BLOOD PRESSURE

Capps and Matthews [Footnote: Capps, J. A., and Matthews, S. A.:
Venous Blood Pressure as influenced by the Drugs Employed in
Cardiovascular Therapy, THE JOURNAL A. M. A., Aug. 9, 1913, p. 388.]
have shown that even with first class preparations of digitalis,
there may be only a moderate gradual rise in arterial pressure, but
not much change in venous pressure. Venous pressure was not much
affected by small doses of epinephrin, but with large doses it rose
from 10 to 80 mm. Pituitary extract acts somewhat similarly to
epinephrin. Caffein, though raising the arterial pressure, did not
influence the venous pressure. Strychnin did not raise either
pressure until the dose was sufficient to cause muscular
contractions. They found that the nitrites caused a fall in venous
pressure as well as arterial pressure, although the heart might be
accelerated and more regular. They think that the nitrites act by
depressing the nerve endings in the veins as well as the arteries.
Morphin they found did not act on the venous pressure, although it
lowered arterial tension, in ordinary doses of 1/8 or 1/6 grain; but
with doses of from 1/4 to 1/2 grain, both arterial and venous
pressures were lowered. They found that alcohol in ordinary doses
did not influence the venous pressure, although it lowered the
arterial pressure; but very large doses lowered the arterial and
raised the venous pressure. They think that when the venous pressure
is increased only by large doses of epinephrin, pituitary extract
and alcohol, the effect is due to failure of the heart, although it
may be due to an increase of carbon dioxid in the blood, in other
words, to asphyxia.




HYPERTENSION


Arterial hypertension may be divided into stages. In the first stage
the arteries are healthy, but the tone, owing to contraction of the
muscular walls, is too great. This condition or stage has been
termed "chronic arterial hypertension." This condition may be due to
irritants circulating in the blood, to nervous tension, to incipient
chronic interstitial nephritis, or may be the first stage of
sclerosis of the arteries. If from any cause this hypertension
persists, the muscular coats of the arteries will become more or
less hypertrophied, and sooner or later degenerative changes begin
in the intima, and finally fibrosis occurs in the external coat of
the arteries; in other words, arteriosclerosis is in evidence. If
the patient lives with this arteriosclerosis, a later stage of the
arterial disease may occur which has been termed atheroma, with
thickening, and possibly calcareous deposits in some parts of the
walls of the vessels, while in other parts the coats become thinner
and insufficient. At this stage the heart, which has already shown
some trouble, becomes unable to force the blood properly against
this enormous resistance of inelastic vessels and the blood pressure
begins to fail as the left ventricle weakens.

Edema, failing heart, perhaps aneurysms, peripheral obstruction, or
hemorrhages are the final conditions in this chronic disease of
arteriosclerosis.

Riesman [Footnote: Riesman: Pennsylvania Med. Jour., December, 1911,
p. 193.] divides hypertension into four classes hypertension without
apparent nephritis or arterial disease; hypertension with
arteriosclerosis; hypertension with nephritis, and hypertension with
both arteriosclerosis and nephritis. These classes are given here in
the order of the seriousness of the prognosis.


ETIOLOGY

One of the most common causes of hypertension is clue to excess of
eating and drinking. The products caused by maldigestion of
proteins, and the toxins formed and absorbed especially from meat
proteins, particularly when the excretions are insufficient, are the
most frequent causes of hypertension. Whatever other element or
condition may have caused increased blood pressure, the first step
toward improving and lowering this pressure is to diminish the
amount of meat eaten or to remove it entirely from the diet. In
pregnancy where there is increased metabolic change, when the
proteins are not well or properly cared for in gout, and when there
is intestinal fermentation or putrefaction, hypertension is likely
to occur. The increased blood pressure in these cases is directly
due to irritation of the toxins on the blood vessel walls.

While alcohol does not tend to raise arterial blood pressure, in
large amounts it may raise the venous pressure. Also, by causing an
abundant appetite and thus increasing the amount of food taken, by
interfering with the activity of the liver, and by impairing the
intestinal digestion, it can indirectly disturb the metabolism and
cause enough toxin to be produced to raise the blood pressure.

Any drug or substance that raises the blood pressure by stimulating
the vasomotor center or the arterioles, when constantly repeated,
will be a cause of hypertension. This is particularly true of
caffein and nicotin. Also, anything that might stimulate, or that
does stimulate, the suprarenal glands will cause a continued high
blood pressure. It is quite probable that in many cases of gout the
suprarenals are hypersecreting and it has been shown by Cannon, Aub
and Binger [Footnote: Cannon, Aub and Binger: Jour. Pharmacol. and
Exper. Therap., March, 1912.] that nicotin in small closes increases
the suprarenal secretion. Therefore, nicotin becomes a decided cause
of hypertension and arteriosclerosis.

Thayer found that heavy work is the cause of about two thirds of all
cases of arteriosclerosis, and one of the functions of the
suprarenals is to destroy the waste products of muscular activity;
hence these glands, in these cases, are hypersecreting. Furthermore,
the reason that many infections are followed later by arterio-
sclerosis may be the fact that the suprarenals have been stimulated
to hypertrophy and hypersecrete.

Many persons in middle life, and especially women at the time of the
menopause, show hypertension without arterial or kidney reason. At
this time of life the thyroid is disturbed, and often, especially if
weight is added, it is not secreting sufficiently. Whether, with the
polyglandular disturbance of the menopause the suprarenals are
excited and hypersecreting, or whether they are simply relatively
secreting more vasopressor substance than is combated by the
vasodilator substance from the thyroid, cannot be determined. These
women are energetic, and look full of health and full of strength,
but their faces frequently flush, sometimes they are dizzy, and the
systolic blood pressure is too high. Reisman has pointed out that
these patients are likely to have very large breasts, and there is
reason to believe that we must begin to study more carefully the
effect of large breasts on the metabolism of girls and women. There
certainly is an internal secretion of some importance furnished by
these glands.

In hyperthyroidism at first the blood pressure may be lowered on
account of the increased physiologic secretion of the thyroid gland.
Later the blood pressure may be raised by stimulation of the
suprarenals, or it may become raised from the irritated and
stimulated heart becoming hypertrophied. If the heart is normal the
ventricles should hypertrophy with the increased work that they are
under; and the blood pressure could increase for this reason. Later
in exophthalmic goiter the heart muscle may become degenerated, a
chronic myocarditis, and the ventricles may slightly dilate. At this
time the blood pressure is lowered. When such a condition has
occurred, the heart bears thyroidectomy badly; hence an operation on
this gland should, if possible, be performed before the heart muscle
has become injured. If the heart shows signs of loss of power, minor
operations to cut off the blood supply of the thyroid should first
be done, and the patient's heart allowed to improve before a
thyroidectomy is performed.

Men with hypertension without kidney or arterial excuse are likely
to have been athletes, or to have done some severe competitive work,
or, as above stated, to have labored hard, or to have worked at high
tension, or in great excitement, or with mental worry, all of which
tend, as long as there is health, to increase the blood pressure.
These men may add weight from the age of 40 on, or they may be thin
and wiry. Besides the hypertension there is likely to be a too
sturdily acting heart, which is often hypertrophied, and there is an
accentuated closure of the aortic valve. There may be dizziness, or
no head symptoms at all. Nicotin is likely to be an etiologic factor
in this class.

These women and these men may all be improved by proper treatment,
and the condition may not develop into arteriosclerosis or
nephritis.

Neurotic conditions, and in some instances neurasthenic conditions,
may show a blood pressure higher than normal. Lead may be a cause of
increased blood pressure, and diabetics occasionally have a high
pressure, although more frequently there is a lowering of blood
pressure in diabetes.

Richman believes that syphilis is the most common cause of
hypertension and arteriosclerosis without renal disease. When
arteriosclerosis and renal disease are combined, of course the
highest systolic readings occur. He thinks that when high tension
occurs under 40 years of age, kidney disease is generally the cause.
Of course it may be the only cause later in life.

High blood pressure due to syphilitic conditions may be greatly
improved by the proper treatment, although some one or more blood
vessels are likely to have been seriously damaged. Although these
patients may live for many years, they are likely to have an
apoplexy, cerebral disease or an aneurysm.

While hypertension is not a disease, and while it often should not
be combated, still, as it is always the forerunner of more serious
trouble, there can be no excuse for not most seriously considering
it and generally attempting its reduction. At the moment high
tension is discovered, there may be no special symptoms; but
troublesome symptoms are always pending, and while the patient need
not be unduly alarmed, there is no excuse for not rearranging the
individual's life so as to prolong it. This is not to state that
every high tension must be lowered, but every hypertension must be
studied and a safer systolic pressure caused if it is possible
without interfering with the person's efficiency. A high diastolic
pressure, one above 105, certainly must receive immediate attention,
and a diastolic pressure of 110 must be lowered, if possible. On the
other hand, a high systolic pressure without a high diastolic
pressure should not be rapidly lowered, else depression will be
caused.


SYMPTOMS

In hypertension, as long as the heart, which is probably
hypertrophied, remains perfectly competent, there are few symptoms,
and the person does not seek advice until he notices one or more of
several possible conditions. He may be dizzy, his head may feel full
and tight, he may have headaches, or he may have some cardiac pain
or distress. Other persons do not seek advice until there is a
slight weakening of the heart, showing the strain under which it is
laboring. In most of these high tension cases, the patients have
rather a slow heart, provided the heart is sufficient. Eyster and
Hooker [Footnote: Eyster and Hooker: Am. Jour. Physiol., May, 1908.]
found that the slowing of the heart in high blood pressure is due to
action through the vagus nerves either from the inhibitory center in
the medulla or reflexly by stimulation of the peripheral nerves of
the vessels.

Another symptom for which the patient frequently seeks advice is
that he is unable to relax from his business cares, when off duty.
He also finds that he works at a higher tension, and that coffee and
tea, alcohol and tobacco stimulate him more than usual. He sleeps
restlessly, and dreams at night. He has an increased frequency of
urination in the morning, especially after taking coffee, and
sometimes gets up once or twice at night to urinate. He is irritable
at times; short breathed on exertion, and sometimes has indigestion.
He may have pains or aches in his heart. He may find that he
dislikes to lie on his left side.

However much it may upset the patient and render him more nervous to
inform him that his blood pressure is too high, it is necessary to
give him this information. People now suspect the condition, and
they frequently seek their physicians to determine if the blood
pressure is too high and, from reading health journals, more or less
realize some of the things, at least, that must be done to decrease
the pressure. Consequently, the very things that are advised or
ordered give the patient the diagnosis, whether he is told directly
or not. Hence, we must talk freely with the patient, much as we do
in heart defects, and get his cooperation, stating how frequent the
condition is, how often it is readily improved, and how little it
may interfere with long life.

Wiener and Wolfner [Footnote: Wiener, Meyer, and Wolfner, M. L.: A
Reaction of the Pupil, Strongly Suggestive of Arteriosclerosis with
Increased Blood Pressure, THE JOURNAL A. M. A., July 17, 1915, p.
214.] state that they have found with blood pressure that the pupils
of the eyes are larger than normal, and that they readily contract
to the stimulus of light, but immediately return to their previous
size.


PROGNOSIS

Janeway [Footnote: Janeway, T. C.: A Clinical Study of Hypertensive
Cardiovascular Disease, Arch. Int. Med., December, 1913, p. 755.]
presented statistics of 458 patients with high blood pressure, 67
percent of whom were men. Of these 458 patients 212 had died, and he
found that the women with high blood pressure lived longer than men
with high blood pressure. They did not seem as likely to have
apoplexy or cardiac failure. About 85 percent of high tension cases
occur between the ages of 40 and 70.

While he believes that a systolic pressure of over 160 mm. is
pathologic, he does not find that any definite prognostic
conclusions can be drawn from the height of the pressure. Of course
the most important concomitant symptoms of high pressure are
cardiac, renal, and cerebral, and the typical headache, as he terms
it, is a symptom of serious import. In considering headache in
persons over 40, we must eliminate the eye headaches produced by the
need of presbyopic glasses or by the need of stronger lenses, as
this need is a frequent cause of headache. Dizziness and vertigo may
occur without headache, and drowsiness, though not so frequent a
symptom as insomnia, often occurs.

Janeway finds that all kinds of apoplectic attacks may occur from
simple transient aphasia to complete hemiplegia, and thirteen of his
patients who had died and thirteen of those living at the time of
this report showed failure of eyesight as an initial symptom of
arterial disease.

Janeway deplores the too frequent diagnosis of neurasthenia in these
patients. This diagnosis probably accounts for the frequency with
which neurasthenics have been said to have high blood pressure.
Patients with high blood pressure may show all kinds of symptoms
simulating neurasthenia, but hypertension is a much better diagnosis
than neurasthenia for such patients, and will lead to more rational
treatment.

Ninety-seven of these patients had hemorrhages somewhere, most
frequently epistaxes, sometimes hemoptysis. Janeway did not find
that purpuric spots on the skin occurred early in the disease in any
of his patients.

Gastro-intestinal disturbances were not much in evidence unless the
kidneys were insufficient. Intermittent claudication in the legs
occasionally occurred. While angina pectoris and edema of the lungs
were not infrequent causes of death in men, it was a rare cause of
death in women. Dyspnea is a frequent symptom, and one for which
many patients seek medical advice.

A constant systolic blood pressure of over 200 shows a probability
that the patient will ultimately die either of uremia or of
apoplexy. Janeway found that those patients who are to die from
cardiac weakness show cardiac symptoms early in their disease. He
found that rapid continuous loss of weight pointed to an early fatal
termination.

Of the 212 patients who had died, seventy-one had shown cardiac
insufficiency at the time of the first examination; twenty-one
showed albumin or casts at that time. Of course it should be
repeatedly emphasized that chronic interstitial nephritis may be in
evidence with either albumin or casts alone, or without either being
present.

Janeway sums up his conclusions by stating that "from the time of
the development of symptoms indicative of cardiovascular or renal
disease, four years will witness the death of half the men and five
years of half the women. By the tenth year half the remainder will
have died, leaving one fourth both of the men and the women who have
lived beyond ten years." The causes of death he would place in the
following order: gradual cardiac failure; uremia; apoplexy; some
complicating acute infection; angina pectoris; accidental causes;
acute edema of the lungs and cachexia. An early occurrence of
myocardial weakness shows a 50 percent probability that death will
be caused by cardiac insufficiency. Heart pains comprise another
important indicator of future cardiac death, perhaps not an angina.
Nocturnal polyuria would indicate a uremic death in about 50 percent
of the patients, and typical headache or cerebral symptoms show the
probability of uremic death in more than 50 percent, and death from
apoplexy in a large number of the other 50 percent As just stated,
rapid loss of weight is a bad symptom.

Janeway [Footnote: Janeway, T. C.: A Study of the Causes of Death in
One Hundred Patients with High Blood Pressure, THE JOURNAL A. M. A.,
Dec. 14, 1912, p. 2106.] has previously reported seven patients with
hypertension who had diabetes. Diabetes generally, on the other
hand, causes a low blood pressure. Patients with this trouble and
with hypertension, and without nephritis, probably have an increased
secretion from the suprarenals.

We may sum up the prognosis in hypertension as follows: Hypertension
alone is not of unfavorable omen; if it is not readily reduced by
ordinary means, it is more serious. If associated with kidney, heart
or liver defect, it is most serious. If there are such serious
conditions as edema, ascites, lung congestion, cyanosis and great
dyspnea, the prognosis is dire.

Obesity being a cause of high blood pressure, it should be treated
more or less energetically, even if the individual does not continue
to add weight.

Stone [Footnote: Stone, W. J.: The Differentiation of Cerebral and
Cardiac Types of Hyperarterial Tension in Vascular Disease, Arch.
Int. Med., November, 1915, p. 775.] believes that the higher the
diastolic pressure the greater danger there is of cerebral death,
while a patient with a very high systolic, but a diastolic pressure
of 100 or lower, is in more danger of cardiac death. He urges a
greater consideration of the pressure pulse in determining the load
of the heart and the great danger from a sustained diastolic
pressure of over 105 as sooner or later bound to cause myocardial
symptoms. This load of the heart is also shown by an increased pulse
rate and increased respiratory efforts. In cardiac failure, as the
systolic pressure falls the diastolic is likely to be increased, and
the pressure pulse thus diminishing, allows insufficient blood to go
to the medullary centers, and death soon occurs. Therefore, in acute
illnesses a sustained pressure pulse gives a better prognosis than a
diminishing pressure pulse. The strenuous measures that should he
used to lower a high diastolic pressure are contraindicated when the
diastolic pressure is already low, even if the systolic pressure 1s
high. If a high systolic pressure begins to fall more or less
rapidly the heart shows fatigue, and should be stimulated by
digitalis or strophanthin.

Rowan [Footnote: Rowan, J. J.: The Practical Application of Blood
Pressure Findings, THE JOURNAL A. M. A., March 18, 1916, p. 873.]
finds that a diastolic reading of 100 mm. or more usually means that
there is a narrowing of the lumen of the vessels, owing to
stimulation of the vasoconstrictors, although it may mean the
existence of a true arterial fibrosis. While a real atheroma
generally causes a reduction in diastolic blood pressure, or at
least but slight increase, he has found in syphilitic cases with
arteriosclerosis a high diastolic pressure. If the blood pressure
cannot be reduced by ordinary measures, arteriosclerosis is probably
present. Several blood pressure examinations must be made, while the
patient is being treated, to establish the diagnosis.

Rowan finds the reading of the pulse pressure to be of great
importance, as this will indicate, sometimes before any other
symptom is present, that the patient is either improving or doing
badly, and it also aids in indicating the proper medicinal
treatment.

In arteriosclerosis the systolic pressure may be high while the
diastolic is low; hence there is a large pressure pulse. If the
heart becomes weak the systolic pressure will drop, and any
improvement caused, especially in aortic regurgitation, is by an
increase of the systolic pressure.

Rowan finds, as has long been recognized, that a conclusion as to
whether or not cerebral hemorrhage will occur cannot be made from
the condition of the radial arteries, as patients with soft radials
may suffer from cerebral hemorrhage, while those "with hard,
sclerosed, pipestem-like arteries may live to a great age and die of
anything rather than apoplexy."

Swan, [Footnote: Swan: Interstate Med. Jour., March, 1915, p. 186.]
has studied the blood pressure in fifty cases of disturbed thyroid,
and finds that functional myocardial tests show that the myocardium
is nearly always disturbed in these patients.

Before taking up the subject of treatment of high blood pressure, it
may be suggested that a high diastolic pressure with a falling
systolic pressure may require vasodilators on the one hand or
cardiac tonics on the other, and sometimes the decision can be made
only by proper tests. In other words, if the diastolic pressure is
lowered the heart will be relieved. On the other hand, if the
diastolic is being raised by an increased venous pressure from a
failing heart, digitalis, strychnin and caffein may be of benefit in
lowering the diastolic as well as raising the systolic. However, if
there is a high systolic and a low diastolic pressure, vasodilators
are often contraindicated.


TREATMENT

In this rapid high tension age the physician should be as energetic
in teaching prevention of arterial hypertension as he is in
preventing contagion. As infectious diseases are reduced in
frequency, more patients live to die of diseases later in life, and
(as previously stated) diseases with hypertension are on the
increase. It is therefore the duty of the physician to urge youths
and adults to abstain from all kinds of excesses so common in this
age. We live at such speed, even the children, that this caution is
almost daily needed. We must caution against severe athletic
competition, against personal "stunts," against recreation excesses,
even golfing, automobiling and dancing, against excess in the use of
tobacco, in eating, in late dinners, in coffee, tea and alcohol. We
must take better care of patients during their convalescence from
some serious illness lest they have circulatory debility by becoming
strenuous too soon after their recovery. The pregnant woman must be
more carefully watched, not only for her own sake, but also for the
sake of her child. Intestinal indigestion, while not the cause of
all disturbances that occur in man after 40, is still an important
element in his deterioration and degeneration, and it should be
prevented if possible.

The tendency for hypertension and arteriosclerosis to occur early in
life in patients who have suffered some serious acute infection,
whether blood poisoning, typhoid fever, or other, shows that in all
probability in these acute illnesses the internal secretions are so
disturbed that the suprarenal activity is greater than normal, while
the thyroid activity may be less than normal, and hypertension is
the consequence. Therefore, these infected patients who recover
should probably have a longer convalescence in order for the more
delicate structures of the body, such as the internal secreting
glands, to have a better chance to recover and become normal.

The enumeration of these causes and the causes that have been
mentioned before not only suggest, but also direct the treatment of
hypertension after it has occurred. The most important of all
treatment for hypertension is rest. That means for an individual,
well except for his hypertension, a vacation, that is, a rest from
physical and mental labor. For a patient who is in serious trouble
from hypertension, bed rest is the most important element in the
management. As has been previously shown, good sleep lowers the
blood pressure, and Brooks and Carroll [Footnote: Brooks, Harlow,
and Carroll, J. H.; A Clinical Study of the Effects of Sleep and
Rest on Blood Pressure, Arch. Int. Med., August, 1912, p. 97.]
showed that the greatest drop in blood pressure occurs in the first
part of the night's sleep. In other words, a patient who lies awake
long loses the best part of his night's rest as far as his
circulation is concerned. This is one more reason for abstinence
from tea and coffee in the evening by those patients who are at all
disturbed by the caffein. On the other hand, patients who are not
seriously ill should not remain for days in bed, as the blood
pressure does not tend to continue to fall, although the heart may
become weakened by such bed rest. This is especially true if the
patient is nervous and irritable and objects to such confinement.

A systolic pressure much over 200 probably never goes down to
normal, and if such a high systolic pressure goes down to below 170,
we should consider the treatment successful.

Every active treatment of hypertension should begin with a thorough
cleaning out of the intestinal canal by purgation, best with mercury
in some form. Then the diet should be modified to meet the
individual case and the person's activity. If the blood pressure is
dangerously high, he should receive but little nourishment, best in
the form of cereals and skimmed milk.

On the other hand, if he has edema or dropsy, or if the heart showed
signs of weakness, large amounts of liquids should certainly not be
given, and in such cases it is better that he receive small
quantities of milk if that agrees, rather than large quantities of
skimmed milk. The amount of water should also be fitted to the
circulatory ability and the condition of the kidneys.

When more or less active treatment does not soon lower the
hypertension, and especially a high diastolic pressure, the
prognosis is bad. In a patient who is in more or less immediate
danger from his hypertension, the food and liquid taken, the care of
the bowels, and the measures used to cause secretions from the skin
must all be governed by the condition of his other organs. There is
no excuse for excessive, strenuous measures when the heart is
failing or when the kidneys are becoming progressively insufficient.
Strenuosity in treatment is as objectionable in these cases as is
neglect of treatment in earlier stages of the trouble.

Bie [Footnote: Bie: Ugesk. f. Laeger, March 4, 1915.] believes there
is no direct connection between the blood pressure and the anatomic
condition in the kidneys, although abnormal conditions in the two
are almost invariably found parallel.

A patient with simple hypertension and otherwise well, which means
that his diastolic pressure is at least no higher than 110, should
have his diet, tobacco, coffee and tea regulated; should have
recreation periods one or more times a week, and vacations not too
infrequently; should take some brisk purgative once or twice a week,
and may receive one or other of the physical treatments for the
reduction of blood pressure, whether Turkish baths or electric light
baths. If he does not sleep well, there is no hypnotic drug so
valuable in his case as chloral. This should not be long given, but
it will produce the purest kind of sleep and lowers the blood
pressure.

If any other drug is needed, nitroglycerin is the best. If
arteriosclerosis is present, sodium iodid in small doses, 3 grains
two or three times a day, is valuable. Larger doses of sodium iodid
are not needed, unless it is advisable to give such doses for a
short period. The value of iodid in these cases is best obtained by
small doses long continued. If the patient is obese, shall doses of
thyroid extract long continued are of value, such as 2 or 3 grains
once a day. If the thyroid extract causes the heart to become more
rapid, it should be discontinued.

Whether the diet should be meat protein free, or whether meat may be
allowed once a day, depends entirely on the individual and on his
physical activities. It is frequently a mistake to take all meat out
of his diet.

When there is obesity, the bulk of the food should be greatly
diminished, and anything that tends to stimulate the patient's
appetite should be withheld. This means all condiments, and at times
even salt. Sugar should be greatly reduced, and starches greatly
reduced, but he must have some. In other words, he should not be cut
down to a diabetic diet. No more liquid should be taken with the
meals than is essential to swallow the food. Water should be taken
between meals. There is no question that almost every one today
should have a very light breakfast, except perhaps those who labor
hard physically and are exposed for hours, daily, to the
inclemencies of the weather. Such patients probably need more food.
It is also well, in hypertension cases, to have one day a week in
which a very minimum amount of food is taken, whether that be milk,
or skimmed milk, or a small amount of carbohydrate, without protein
food.

If the foregoing management does not reduce hypertension, the
kidneys are generally beginning to become involved in the sclerotic
degeneration, whether the urine shows such a condition or not. On
the other hand, there are exceptions to this rule.

As indican in the urine gives evidence of putrefactive changes in
the intestines and the probability of the absorption of toxins from
the intestines, although we have no real proof that these toxins are
the direct cause of hypertension, our patient is undoubtedly
physically better, and will have less arterial tension when this
intestinal condition is removed. Therefore, our treatment of the
individual is not a success as long as such fermentation and
putrefaction persist. If such putrefaction cannot be removed by diet
and laxatives and mental rest and the prevention of physical
strenuosity, radical changes in diet are advisable, although it may
not be necessary to continue such a diet more than a few days at a
time. A rigid milk diet for a few days may change the flora of the
intestine completely; then a vegetable diet may be given, with
return to a mixed diet; or the various lactic acid bacilli may be
given, or one of the various fermented milks may be the diet, the
object being to change the flora in the intestine and thus modify
the ferments. So-called bowel antiseptics, such as salol, for a
short time may be of advantage. Colon washings may be of great
advantage. Liquid petroleum may be advantageous.

Besides preventing the absorption of toxins from the intestine, we
must prevent such absorption from any latent infection. The most
frequent kind of such infection is pyorrhea alveolaris.

A simple method that sometimes is an efficient aid in lowering the
blood pressure is complete muscular and mental relaxation. The
patient lies down for a while in the middle of the day and relaxes
every muscle of his body. With this he may take slow breathing
exercises. He should be in a dark room, quiet if possible, and
alone, and should teach his brain to be for a short time mentally
inert.

The physical methods of lowering the blood pressure are
hydrotherapeutic, whether by warm baths or more strenuously by
Turkish baths, by hot air baths (body baking) which is occasionally
very efficient, or, perhaps more now in vogue, by electric light
baths. The duration of these baths, and the frequency, must be
determined by the results. If the heart is made rapid, and the heart
muscle shows signs of weakness, the duration of these baths must not
be long, and they may be contraindicated. These baths are most
efficient in lowering the blood pressure when the patient reclines
for several hours after the bath. The amount of sweating that is
advisable in these cases depends on the condition of the heart. If
the heart muscle is insufficient, profuse sweating is inadvisable.
Also if the kidneys are insufficient, profuse sweating is
inadvisable as tending to concentrate the toxins in the blood. On
the other hand, when the surface of the body tends to be cool, and
there are internal congestions, the value of these baths is very
great. Sometimes the electric light baths increase the tension
instead of diminishing it, and when properly used they may be of
benefit in some cases of hypotension. The frequency of the baths and
the question of how many weeks they should be intermittently
continued, depend on the individual case. After a course of such
treatment sometimes patients have a diminished systolic blood
pressure not only for weeks, but even for months, provided they do
not break the rules laid down for them.

The Nauheim baths, while stated not to raise the blood pressure, are
not much advocated in hypertension, and Brown [Footnote: Brown:
California State Jour. Med., November, 1907, p. 279.] who made more
than 500 observations of patients of all ages, found that the full
strength Nauheim bath would raise the blood pressure in all feverish
and circulatory conditions. He also found that a fifteen minute
sodium chlorid bath, 7 pounds to 40 gallons, at a temperature of
from 94 to 98 degrees F., lowered the pressure from 10 to 15 mm.
This is not different from the effect obtained from a fifteen minute
warm bath at from 94 to 98 degrees F., or a fifteen minute mustard
bath of the same temperature. In other words, the slight irritation
of mustard or of salt in a warm bath made no special difference in
the amount of lowering of the blood pressure. On the other hand, he
found that a fifteen minute calcium chlorid bath, 1 1/2 pounds to 40
gallons, at 94 degrees F., raised the blood pressure 15 mm.

The autocondensation treatment to lower the blood pressure is not so
satisfactory as it was hoped to be. The blood pressure can thus be
lowered, but it soon again rises, and probably generally more
rapidly than after the bath treatments, and in some persons it
causes considerable depression. Van Rennselaer [Footnote: Van
Rensselaer: Month. Cycl. and Med. Bull., November, 1912, p. 643.]
has reviewed this subject of high frequency treatment, and recalls
the fact that Nicola Tesla demonstrated, in 1891, the form of
electricity which we now term high frequency. High frequency means
more than 10,000 cycles per second, at which frequency muscles do
not contract and pain is not felt, whereas in medicine the frequency
of the currents used runs up into the hundreds of thousands, or even
into the millions. The French investigator, d'Arsonval, studied the
physiologic action of these high frequency currents and found that
the respiration and heart are made more rapid and the blood pressure
is reduced, while the intake of oxygen is increased and the carbon
dioxid excretion is increased. The temperature may rise. The
excretion of the urinary solids is mostly increased. Perspiration
may be caused, and he believes the glandular activities are
increased. In a word, metabolic changes in the body are made more
active and the blood pressure is lowered.

Besides the effect of altitude on blood pressure, as previously
declared, patients with dangerously high blood pressure should, if
possible, not be subjected to intense cold. In other words, a person
with hyper-tension, if financially able, should not remain in a cold
climate during the winter. On the other hand, even if he is stout
and feels sufficiently warm with light clothing during the winter,
his skin becoming chilled adds to his tension. Therefore he should
be clothed as warmly as he will tolerate.

After a period which may be termed the normal period of hypertension
in normal life, as age advances the systolic tension may lower,
provided there is no kidney lesion. This is due to the slowly
developing chronic myocarditis and a lessening of the tension and
therefore lessening of the resistance to the heart. This may be
nature's method of lengthening the life of the individual. In other
words, as the arteries grow older the force of the heart slightly
lessens, the blood pressure lowers, and the individual is safer.
This frequently occurs in otherwise perfectly normal individuals,
without treatment.

When the blood pressure is suddenly excessively high from any cause,
venesection may be life saving, and should perhaps be more
frequently done than it is. It may save a heart that is in agony
from tension, and may prevent an apoplexy. It is of little value
except temporarily in uremic conditions, but at other times it may,
at the time, save life and allow other methods of reducing the
dangerous tension to become effective. A chronic high tension
patient may be repeatedly bled, although such treatment will not
long save life, as the blood pressure in many such cases soon
returns to its previous height.

Some very high tension cases, especially in women at the menopause,
and where there is no kidney involvement, have the blood pressure
reduced successfully only by large doses of thyroid, sometimes well
combined with bromids, especially if the thyroid causes excitation.
Such treatment persisted in for a time may cause months of
improvement, and even years.


DRUGS IN HYPERTENSION

The drugs that are mostly used to lower blood pressure are nitrites
or drugs which are like nitrites, and these are nitroglycerin,
sodium nitrite, erythroltetra nitrate and amyl nitrite, and the
frequency of their use is in the order named. Other drugs used to
lower blood pressure are iodids, thyroid, alkalies, chloral, bromids
and aconite, the latter rarely.

Amyl nitrite is required only when a sudden immediate effect is
desired in angina pectoris or in some other serious spasmodic
condition. Sodium nitrite is more likely to upset the stomach than
is nitroglycerin. It acts, however, a little longer, but not enough
to warrant its frequent selection. The dose of sodium nitrite is
from 0.03 to 0.06 gm. (1/2 grain to a grain), best in tablet form
and given with plenty of water. The tablet should of course be
dissolved or crushed with the teeth. It should not be given on an
empty stomach, as it may cause considerable irritation and pain. It
more or less actively lowers the blood pressure for about an hour.

Erythrol tetranitrate is preferred by some clinicians who find that
its effect lasts somewhat longer. There is probably, however, no
better nitrite or nitrate than nitroglycerin. While it acts but a
short time, it acts effectively, and although no nitrite has
vasodilating effects for any length of time from one dose, when the
doses are given repeatedly and for days at a time, the blood
pressure will generally be more or less reduced. The dose is from
1/500 to 1/100 grain, three or four times a day, or every three
hours, as desired. The best form in which to use it is in a very
soluble tablet, and the tablet should not be dissolved unless
intense immediate action is desired. It acts when absorbed from the
tongue almost as rapidly as when given hypodermically; it acts in
two or three minutes, and the blood pressure may drop from 20 to 30
mm. In experimental tests the action does not last more than from
fifteen minutes to half an hour, but clinically the effect of
repeated doses is much more satisfactory. Spirit of glyceryl
trinitrate or spirit of Nitroglycerin, dose 1 minim, keeps well if
care is taken to guard against evaporation of alcohol; tablets if
well made and kept in bottles properly corked, will retain their
activity for months.

The closer a physician is to the laboratory, the less he believes in
the value of nitroglycerin in hypertension. The nearer he is to
clinical work the more he believes in it. It is a fact that in some
instances, even with a dose as small as 1/200 grain of
nitroglycerin, three or four times in twenty-four hours, the blood
pressure will be lower, whatever the diet is and whatever the other
treatments are, than if the patient does not take the nitroglycerin.
Also the value of these short relaxation periods from the standpoint
of a strained and tired heart should not be underestimated, the same
as the value of a night's rest, or the value of a recreation period
of an hour or two. If a patient has hypotension and a systolic
pressure of 110, and is given nitroglycerin, the very unpleasant
results from its administration will be immediately noticed. Hence
nitroglycerin is one of the most valuable drugs that we possess for
the treatment of hypertension, and some patients are even benefited
by as small a dose as l/500 grain. Lawrence [Footnote: Lawrence, C.
H.: The Effect of Pressure-Lowering Drugs and Therapeutic Measures
on Systolic and Diastolic Pressure in Man, Arch. Int. Med., April,
1912, p. 409.] found that the fall of diastolic pressure from
nitrites was about half of the fall of systolic pressure. When there
is no kidney lesion a very high systolic pressure falls more under
nitroglycerin than does a medium high systolic pressure.

Alkalies, whether potassium or sodium citrate or sodium bicarbonate,
are often of advantage in so changing and aiding metabolism, or
perhaps reducing the irritation from hyperacidity or a mild
condition of acidosis, that their administration causes a lowering
of blood pressure.

While iodids may not be direct vasodilators and do not render the
blood more aplastic or diminish its viscosity, as shown by Capps
[Footnote: Capps, J. A.: Effect of Iodids on the Circulation and
Blood Vessels in Arteriosclerosis, THE JOURNAL A. M. A., Oct. 12,
1912. p. 1350.] still, iodids in small doses, 0.1 to 0.2 gm. (1-1/2
to 3 grains) given from once to three times a day, after meals
(these small doses do not disturb the stomach), will stimulate the
thyroid gland to greater activity, and when this gland secretes
properly, the blood pressure is somewhat lowered. Of course, in
syphilitic sclerosis large doses of iodids are indicated and are
valuable.

In obese patients with hypertension, in the hypertension of women at
the menopause, and in hypertension with insufficient kidneys,
thyroid medication is often of great value. Sometimes a small dose
of from 0.1 to 0.2 gm. (1 1/12 to 3 grains) once a day is all that
is needed. At other times, especially when there is no marked
arteriosclerosis and no marked kidney or liver lesion, very high
blood pressures are reduced only by very large doses, even as much
as 10 grains a day. Such treatment is often of very great benefit.
Of course, if one of the persons under consideration has symptoms of
hyperthyroidism, or if small doses of thyroid cause palpitation, the
treatment is not indicated, on the one hand, and should be stopped,
on the other. Sometimes when the blood pressure cannot be reduced,
in these cases without apparent organic lesions, and thyroid
treatment is more or less successful, but at the same time causes
great excitation, it may be combined with bromid medication, and
then the benefit is sometimes very great.

A patient who cannot sleep and who has hypertension may receive
bromids if he is very irritable or if there are symptoms of thyroid
irritability; but the most successful sleep and lowering of blood
pressure is caused by chloral. A dose of 0.5 gm. (7 1/2 grains) at
night is generally sufficient and need not be long continued.
Chloral has been frequently given to reduce pressure in 0.2 to 0.25
gm. (3 or 4 grain) doses, three times a day, after meals.

Bromids, of course, will lower the blood pressure, but they depress
all metabolism, interfere with digestion, and are not advisable for
any length of time. However, in some cases they cause a marked
improvement in the patient's condition.

Patients under treatment with chloral, bromids, and thyroid
especially, should be carefully watched and the treatment modified
to meet the varying conditions. Patients under iodid need not be
seen so frequently; those under nitroglycerin or alkalies still less
frequently. But all patients under the active management of
hypertension should be seen at from one to three week intervals, and
the urine should be repeatedly examined and the blood pressure
carefully recorded.




HYPOTENSION


A low systolic pressure and a low diastolic pressure may not cause
any symptoms or give any cause for anxiety. It does show, especially
if the systolic pressure is below normal for the age of the person,
a lack of reserve power, and such patients will not well stand
serious illnesses, operations, injuries or serious physical and
mental strains. If there is a low systolic pressure and a high
diastolic pressure, this shows impairment of the heart, whether or
not any other organic lesion is present.

Generally speaking, a low systolic pressure shows a weak acting
heart muscle, and a very low diastolic pressure shows a dilated
condition of the arterioles. In aortic regurgitation this low
diastolic pressure is constantly in evidence, and, if the systolic
pressure is not below normal, does not signify that the circulation
is insufficient. If the systolic pressure is not very low but the
diastolic is high, vasodilator drugs, by lowering the diastolic and
increasing the pulse pressure, are often of benefit. If there is
increased venous congestion and increased venous pressure and a high
diastolic pressure with a low systolic pressure, digitalis not only
will often raise the systolic pressure, but also will lower
diastolic by improving the general circulation and removing venous
congestion.

While intestinal indigestion and absorption of toxins often tend to
raise the blood pressure, some toxins thus absorbed, especially of
the ptomain variety, lower blood pressure and cause shock, perhaps
by weakening the muscle of the heart or by acting on the vasodilator
vessels; or they may cause dilation of the vessels of the abdomen
and in this manner lower blood pressure.

Very low blood pressure after exertion, after severe physical
exercise, or after competitive athletic tests shows that the heart
cannot sustain such strains and should not be again subjected to
them. In severe mental and physical strains the suprarenals may be
inhibited in their activities, and a hypotension, more or less
prolonged, may result.

Sewall [Footnote: Sewall: Am. Jour. Med. Sc., April, 1916, p. 491]
believes that hypotension is frequently due to splanchnic stasis,
and that sluggish circulation in this region, especially when the
person is in the erect posture, is an important factor in general
physiologic disturbances or lack of general tone. When the
splanchnic vessels are dilated there is also a lack of proper tone
to the cerebral vessels, and this may be a cause of mental weariness
and neurasthenia. While ptosis of organs in the abdomen and a
flaccid condition of the musculature of the abdomen are frequent
causes of this splanchlnic stasis, and therefore hypotension,
especially in women, it is quite possible that suprarenal
insufficiency will allow this condition of the splanchnic vessels to
occur frequently.

Serious illness and infections will lower the blood pressure
sometimes to a dangerous point. Of course, hemorrhages lower the
blood pressure. Shock and collapse cause lowering of blood pressure,
frequently to a fatal point, and Cornwall [Footnote: Cornwall: New
York Med. Jour. March 7, 1914, p. 470.] finds that a patient may
live several hours with a systolic pressure below 60, and several
days when it is below 70; that he may walk around with a systolic
pressure of 90, provided the pressure pulse is sufficiently large,
that is, that the diastolic pressure is low enough to cause a
circulation of blood. Of course, if the difference between the
systolic and the diastolic pressure is diminished to the vanishing
point, the patient cannot stand it, and dies. It should be
remembered that just before death venous pressure is likely to rise,
and this may raise the diastolic pressure.

With the progressive toxemia of typhoid fever the blood pressure
will become lowered from the myocardial degeneration. Of course, the
blood pressure will drop suddenly from a hemorrhage, but Piersol
[Footnote: Piersol: Pennsylvania Med. Jour., May, 1914, p. 625]
finds that with perforation the peritoneal irritation may cause a
rise of blood pressure, and he thinks that this sign may precede for
several hours more positive signs of the accident.

As in other infections, the blood pressure will fall in scarlet
fever; but if it suddenly rises, a kidney complication is to be
looked for. The blood pressure always falls in diphtheria, and
always falls in acute rheumatism; consequently, strenuous sweating
measures in the treatment of rheumatism should not be used as soon
as the blood pressure has become low.

Failing circulation in pneumonia, if accompanied by low blood
pressure, requires different treatment from the failure of
circulation in these cases when the blood pressure is high. Hence
the relationship of the systolic to the diastolic pressure in
pneumonia is of very great importance in deciding on the proper
treatment. In one instance the blood pressure must be lowered; in
the other, the heart must be stimulated.

While tobacco, in ordinary conditions, raises the blood pressure,
after the heart has been seriously injured by the nicotin, the blood
pressure is likely to be found lower, and such patients are quickly
benefited by the withdrawal of the tobacco and the administration of
digitalis.

Anemia almost invariably causes low blood pressure. Also in a
patient who has hypotension without any distinct evidence of
disease, especially if there has been any possible exposure to
tuberculosis, that disease should be suspected and every test made
to eliminate such a cause.

Serious cachexia, such as that caused by carcinoma or other growths,
gives low blood pressure. Diabetes causes low blood pressure,
provided there are no nephritis and no marked suprarenal
stimulation.

Excessive use of alcohol, while tending to promote hypertension by
the disturbances that it causes, may give, by causing a weak heart
muscle, a permanent low blood pressure. A single large dose of
alcohol always lowers the blood pressure.

Arteriosclerosis frequently reaches a stage when the blood pressure
is low, and with atheroma of the arteries of the arms a true blood
pressure is difficult to obtain. Addison's disease, or any other
organic lesion of the suprarenals, will lower the pressure, while
stimulation of the suprarenals increases the pressure. Any great
drain on the system, whether from diabetes without nephritis, or
from profuse diarrhea of any type, will cause hypotension.
Occasionally a girl with chlorosis who is not menstruating may have
an increased blood pressure. Many of the hemorrhagic or purpuric
conditions will show a hypotension.

Meningitis in various forms may show a hypertension from cerebral
and nervous irritation. Neurasthenic patients quite generally have
hypotension, although occasionally with suprarenal disturbance they
may have an increased tension.

In the hypotension of surgical shock and in shock during anesthesia,
Henderson's findings [Footnote: Henderson: Am. Jour. Physiol., 1910,
xxvii, 158.] that hyperoxygenation and insufficient carbon dioxid
may be partially responsible for the condition should be remembered,
and it has long been known that carbon dioxid congestion, as caused
by laughing gas anesthesia, for instance, increases the blood
pressure.

A systolic pressure of 110 mm. or lower in an adult should be
considered hypotension, anything below 105 mm. calls for treatment,
and a systolic pressure of 100 or lower in an adult calls for rest
from all active duties.

These patients are weary, they have mental and physical tire, may
get short breathed, may have palpitation of the heart, and often
have headaches and dizziness from imperfect circulation in the head.
There may be edemas of the legs and ankles toward night. If such
patients have the systolic blood pressure raised even a small
amount, or if the diastolic pressure, which is very low, is raised
even a small amount, they immediately feel better.

If the kidneys are normal, they should have meat as part of their
diet. If they are not nervous and irritable, coffee and tea should
be allowed, except at the evening meal. While sleep may tend to
lower pressure somewhat, these patients' hearts require a long bed
rest; in other words, they should go to bed at an early hour. They
should rise early, however, in the morning, and, as recommended by
Goodman, [Footnote: Goodman: Am. Jour. Med. Sc., April, 1914, p.
503.] they should perform mild calisthenic exercises before
dressing.

The increased muscle tone thus caused raises the blood pressure
somewhat, and the great depression before breakfast is not
experienced. These patients rely oil their morning coffee for
bracing. If they have much indigestion at night which keeps them
awake so that they do not get good comfortable rest, their largest
meals should be the morning and noon meals, and the evening meal
should be very light.

Pendent abdomens or ptosed abdominal organs should be held up by
proper abdominal bandages or corsets.

If the bowels are constipated, only the vegetable laxatives should
be used, if it drug is needed at all. Salines should not be allowed,
or other cathartics which cause profuse watery discharges. If a
brisk purge is required, castor oil is the best.

Plenty of fresh air, and mild exercises in the open air all tend to
increase the pressure. Graded walking, climbing, or other more
interesting exercises are advisable, as all tending to raise the
pressure, provided that at no time are they carried to the point of
exhaustion.

Forced feeding may be useful. Cool sponging in the morning, if there
is proper reaction, is often of benefit. Iron may be indicated;
bitter tonics may be indicated. Digitalis and strychnin are often of
advantage. Caffein may be used as a drug as well as given in coffee
and tea. Atropin may be of value in some forms of hypotension.

At times with a low systolic pressure, but a relatively high
diastolic pressure, nitroglycerin is valuable.

More or less actite hypotension may occur in hot weather or with
overheating, often termed heat exhaustion. Such patients should, if
possible, go to a cooler region, whether to the seashore or to the
mountains is unimportant. The treatment of dangerous sudden low
blood pressure, as shock, will be discussed elsewhere.




PERICARDITIS

ACUTE PERICARDITIS


As this inflammation is generally secondary to some other condition,
its treatment cannot be positively outlined. Furthermore, it is
often a terminal condition, and in such instances the results of
treatment are of necessity nil. The most frequent terminal cause is
nephritis; other terminal causes are pulmonary tuberculosis,
adjacent abscesses, cancer or other growth.

The most frequent infectious cause is rheumatism; other infectious
causes are cerebrospinal fever, typhoid fever, acute miliary
tuberculosis, pneumonia and Sepsis. Accidental causes are traumatism
and an adjacent inflammation of the pleura.

The result of an inflammation of the pericardium may be a fibrous
exudate, or an exudate which is both serous and fibrous, or one in
which pus is present in considerable amount.

The onset of pericarditis may be more or less acute, or it may
commence insidiously. For this reason, during severe illness, and
especially in those diseases which are known to have pericarditis
often as a sequence, frequent examination of the heart should be
made as a routine procedure.


SYMPTOMS AND SIGNS

If there is pain or much aching in the cardiac region, it tends to
disappear with the exudate, if such is to occur, in the same way as
does the pain of pleurisy. If there is much exudate, the pressure on
the heart of course increases, the cardiac dulness enlarges, dyspnea
occurs and even perhaps later cyanosis. As the exudate accumulates,
the patient must lie higher and higher in order that the fluid may
gravitate to the lowest part of the sac and give the heart the
greatest ability to work. Reflex pain may occur from disturbances of
the pneumogastric nerve, or from the weight and pressure of the
enlarged and heavy pericardium. Reflex vomiting may be a troublesome
and distressing symptom.

Acute pericarditis occurring in rheumatism, in acute infections, and
from simple injuries tends to recovery. In dry pericarditis with
serious adhesions, or if adhesions occur as a sequence of acute
pericarditis, the future prognosis is bad, as myocarditis may
develop and sudden death or acute dilatation may occur. As stated
above, if pericarditis develops during the progress of chronic
disease, such as interstitial nephritis, or during sepsis, or from
abscesses or growths in the region of the pericardium, the prognosis
is bad.


TREATMENT OF ACUTE PERICARDITIS

In acute pericarditis, absolute mental as well as physical rest is
essential. Even if the patient does not appear to be seriously ill
and has not much fever, he should not be allowed to have visitors,
to discuss business matters, or to carry on any conversation,
however little exciting. Anything which increases the heart beat
increases the irritation of the inflamed surfaces of the
pericardium. He should not be allowed to sit up, either to eat or to
attend to the calls of Nature. These rules are imperative, and when
they are followed the pain is less, the heart beats less rapidly, is
less hampered by pressure from whatever exudate may be present, and
the adhesions which are liable to form will be less in amount and
less serious for the future work of the heart.

The treatment, of course, depends largely on the cause of the
pericarditis, as, if the cause is one of those just enumerated in
which the prognosis is dire, any treatment directed toward the
pericardial inflammation is almost useless. The periearditis under
these conditions will be more or less benefited, if at all affected,
by the treatment directed toward the cause.

The indications for treatment in all other instances are:

1. To attempt to abort the inflammation.

2. To stop the pain.

3. To limit, if possible, the amount of exudate, and to diminish the
exudate already present.

4. To diminish the rapidity of the heart and to strengthen it.

1. Abortive Treatment.--For many years bloodletting was considered
of the greatest importance in the early treatment of this disease;
but owing to the fact that, except from traumatism, pericarditis
rarely occurs except as a sequela of acute disease after the patient
has been sick along time, or as a terminal condition in a patient
who has long been chronically diseased and therefore has already
lost more or less strength, venesection has been nearly abandoned.
Leeches may be used over the region of the pericardium, and cups are
sometimes used. Dry cupping is more frequently used. These measures
sometimes seem to reduce the inflammation, and certainly often
relieve pain, but the most valuable local treatment is cold, which
may be applied either in the form of an ice bag or by a small coil
through which ice water is caused to flow by siphonage. Cold may be
applied more or less continuously, depending on the sensations of
the patient. The bag or ice cap must not be overfilled and must not
be heavy, as the patient often cannot stand pressure over the
pericardium. Sometimes the relief from pain and the diminution of
the number of the heart beats is marked, and for this reason alone
the cardiac inflammation may be inhibited. If cold applications are
not tolerated by the patient (and they often are not in children)
warm applications may be used, such as an electric pad or cloths
wrung out of hot water and covered with oiled silk, and the pain
will often be relieved thus. While hot applications would not tend
to abort the inflammation, they probably do not tend to promote it.

A diminished diet, of small amount at a time, and such purging as
the patient's strength will allow are essential in attempting to
hasten recovery.

Just what can be done locally or generally to combat the
inflammation actively must depend on the cause. When the
inflammation occurs as a complication of acute rheumatism, it has
been suggested that salicylates, which arc not inhibiting rheumatism
and may be depressant to the heart, should be stopped if they are
being administered; but if the salicylates are apparently improving
the inflammation in the joints, pericarditis would not
contraindicate their continued use. Except in large doses,
salicylates probably do not depress the heart. In pericarditis it is
perhaps well always to administer an alkali in some form unless
otherwise contraindicated, whether or not the cause is rheumatism. A
diminished alkalinity of the blood would always increase the
likelihood of an augmented amount of pericardial or endocardial
inflammation. The blood must be kept strongly alkaline. It is
possible that one of the reasons why pericarditis or endocarditis
occurs so frequently in serious prolonged fevers is that the patient
has not eaten enough cereals or other carbohydrates, and the system
has become more or less endangered by acidosis. Carbohydrate
starvation is inexcusable with our present understanding of the
danger from acideinia, and even from a diminished amount of alkalies
in the blood.

The cause of pericarditis being so varied, any anti-toxin treatment
or any vaccine treatment could be indicated only if the cause of the
inflammation rendered the serum or vaccine advisable.

2. Stopping the Pain.--Nowhere else in the body should pain be so
speedily combated as when it occurs in the region of the heart.
Morphin, with or without atropin, as deemed best, should be
administered hypodermically in the amount and with the frequency
necessary to stop the pain and quiet the restlessness. As stated
above, the frequent need for morphin may be prevented by use of the
ice bag. Morphin might even be considered an abortive treatment, as
nothing tends so much to inhibit this inflammation as the quietude
of the heart caused by the absence of pain, the production of sleep
and the prevention of restlessness, muscle twitching and muscle
movements. The more quiet the patient is, the more quiet is the
heart.

If for any reason morphin is contraindicated, and if pain is not a
symptom, the patient's nerves may be quieted and rest may be given
by sodium bromid, or by veronal-sodium, the dose of the former being
2 gm. (30 grains) two or three times in twenty-four hours, according
to its action and the necessity for it, and the dose of the latter
0.2 gm. (3 grains) once in six hours, if deemed necessary.

Especially if there are cerebral symptoms, as typically presented in
cerebrospinal meningitis, and especially if the arterial tension is
low, the subcutaneous administration of an aseptic ergot will quiet
the central nervous system, increase the blood pressure, quiet the
heart, and prolong the action of a single dose of morphin. It is the
best plan to administer ergot deep into the muscles, with the
deltoid as the place of choice. If the skin is properly cleansed,
the syringe clean and the preparation of the drug aseptic, no
inflammation or abscess will ever occur. If there is any painful
swelling, a wet alcohol dressing to the part will soon relieve it.
The frequence with which ergot should be so administered depends on
the results and the indications. Once in twelve hours for several
doses is generally the best method for its use.

3. The Exudate.--When a fluid exudate into the pericardium has
occurred from inflammation that is, when it is not an exudate from
disturbed kidneys or circulation--it will continue to increase to
some extent in spite of any treatment. Just how much this exudate
may be prevented by the use of small blisters over or around the
heart, and just how much watery stools and diuresis may prevent the
advance of the exudate is difficult to determine. Small blisters,
properly applied, have many times seemed to be the determining
factor in stopping the increase in the fluid, or to have been the
starting cause of the resorption of the exudate.

The amount of purging that should be caused by saline cathartics
such as sodium sulphate (Glauber salt), potassium and sodium
tartrate (Rochelle salt), or the official compound jalap powder
cannot be declared dogmatically. Saline purging should be governed
by the character of the circulation. If the heart is strong, the
pulse not weak, and the blood pressure good, nothing is more
valuable in this condition. Portal depletion is of great advantage,
especially if the amount of liquid ingested is kept as low as
possible, so that the blood vessels may become thirsty and thus tend
to absorb an exudate wherever they find it. Much harm has been done,
however, and death has been caused by saline purgatives in
endeavoring to relieve edemas from a failing heart or to prevent a
uremia from kidney inflammation. The depression following such
purging is often serious. If the circulation is weak, dependence
should be placed on purgation by some of the simple vegetable
cathartics or a small dose of calomel. While it is advisable to give
a saline in concentrated solution, it should not be so strong as to
cause vomiting. With our better understanding of magnesium
absorption and the depressant effect of magnesium on the nervous
system, magnesium salts should not be used in serious conditions.

Diuretics often do not act well when most needed. The simplest
diuretic is potassium citrate, given in wintergreen or peppermint
water, in doses of 2 gm. (30 grains), three or four tunes in twenty-
four hours. One or more of the vegetable, nonirritant diuretics may
be tried if preferred. If the sickness preceding the pericarditis
was not a long fever, and the heart muscle is considered in good
condition, digitalis in small doses may be the best possible
diuretic. Incidentally it will slow the heart, if there is not much
elevation of temperature, and will give some cardiac rest.

Although the patient's diet should be limited in bulk, and
especially in amount of liquids, good nutrition should soon be
given. Systemic weakness certainly tends to increase the exudate;
systemic strength aids in absorption of the exudate.

Iron is early indicated, and nothing is better than 5 drops of the
tincture of chlorid of iron in a little lemonade or orangeade,
administered once in eight hours.

If the exudate tends to decrease, it perhaps may be hastened by the
local application of tincture of iodin over the cardiac region. Also
the administration of small doses of an iodid, as 0.3 gm. (5 grains)
of sodium iodid, given in plenty of water three times a day, is
useful. An iodid circulating in the blood seems to aid absorption.
It has long been believed that iodin in the blood tends to promote
absorption of thickened, left-over material from exudates, and to
prevent the formation of strong fibrous adhesions. Until our
knowledge is more exact in this matter, it is advisable to use iodid
as suggested. If the above-named dose is not tolerated, less should
be given.

If in spite of all the therapeutic measures suggested, the fluid
increases and the pericardium becomes more distended and the heart's
action more labored, paracentesis must be done. The point at which
the aspirating needle should be inserted into the pericardium
depends somewhat on the conditions in each individual case. It is
often best to insert an exploratory needle first. This will
determine the fluidity and character of the exudate. If pus is
found, a more radical surgical procedure than simple paracentesis
must be done immediately. The point of puncture for aspiration most
frequently chosen is in the fourth or fifth intercostal space, about
an inch to the left of the sternal margin. Paracentesis is also
often done in the region of the normal apex beat. The position of
the patient is determined by his dyspnea; he should lie in the
position most comfortable for him. The fluid should be withdrawn
slowly and the pulse carefully watched. The withdrawal of a small
amount of fluid may later seem to be the starting cause of
resorption of the rest of the fluid. On the other hand, it may often
be not of more value than the simple removal of the immediate
pressure, the fluid may again accumulate, and more radical surgery
must be performed.

4. To Strengthen the Heart.--Most of the methods of meeting this
indication have already been stated, namely, absolute rest; absolute
quiet; the use of the bed pan; any movement that must be made should
be deliberate; the nurse and other attendants must be quiet;
necessary conversation must be brief, and every method must be used
to quiet and prevent the heart's action from becoming rapid. The
food taken should be small in amount and nonstimulating; that is, no
tea or coffee should be given, and nothing too hot or too cold.
Movements of the bowels should be caused with the least possible
general disturbance. If the patient does not sleep, he must be made
to sleep. The whole body and the nervous system must have periods of
rest. If the heart is very weak, small closes of morphin may be
used. If the heart is not weak, bromids or chloral may be given. If
the blood pressure is high, such hypnotics will lower it, or if the
heart is strong and the condition does not contraindicate it,
aconite may be used in small doses, for a day or two, unless the
fever is high and it seems advisable to use one of the coal-tar
antipyretics, which reduce the blood tension and the heart activity.

As stated above, pain must not be allowed. Sometimes, when the heart
has not been injured by prolonged fever, digitalis in small doses
may slow the heart and act for good.

Convalescence.--The convalescence should be prolonged as in any
other cardiac inflammation. The patient should be given more and
more nourishing food, and the iron tonic may be changed to a capsule
containing 0.05 gm. of quinin and 0.05 gm. of reduced iron, three
times a day.

It is a question as to when patients convalescent from pericarditis
should be permitted exercise. It has been thought that gentle
movements and possibly exercise, sooner than theoretically
justified, might cause the heart to beat a little more actively and
possibly prevent the formation of tight adhesions between the two
layers of the pericardium. Whether such activity of the heart will
prevent adhesions is something that has not been determined.

The small doses of sodium iodid, perhaps 0.2 gm. (3 grains) two or
three times a day, should be continued for some time. Iodid in this
dosage does no harm and may do a great deal of good.


ADHERENT PERICARDITIS

Following dry pericarditis or pericarditis with an exudate,
especially when the exudate is fibrinous in character, the fibrous
substance which is not absorbed or resorbed may develop into
connective tissue, and the two pericardial surfaces become
permanently grown together, causing the so-called adherent
pericarditis. These adhesions between the two surfaces of the
pericardium may be general throughout the entire pericardial sac, or
they may be limited to some one or more parts of the pericardium.
Perhaps one of the most frequent points of adhesion is the anterior
part of the pericardium, while the apex is the part most likely to
be free, even when other parts of the pericardium have grown
together. This freedom of the apex is probably due to the constant
and more extensive motion of the apical portion of the heart, and is
the reason that it has been suggested, as referred to under acute
pericarditis, that, other conditions not contraindicating, the
patient may be allowed to move about a little during convalescence
to cause the heart to beat more actively. Sometimes the surfaces of
the pericardium are not closely adherent to each other, but bands of
adhesion stretch from one surface to the other.

After adhesions have taken place between the two layers of the
pericardium, the action of the heart is impaired, serious
interference with the cardiac action may develop, and sudden death
may occur. If the heart is given all the rest possible during the
acute phase of the disease, there will be less likelihood of the
surfaces becoming so irritated that adhesions readily form. Anything
which permits complete absorption and resorption of tile exudate
will tend to prevent these hampering adhesions. If the adhesions are
such as to cause irregular heart, recurrent pain and the danger of
sudden death, surgical help has been suggested. This surgical
procedure is to remove a portion of the ribs, perhaps of the third,
fourth and fifth, to allow the heart more freedom of action to
compensate for the impairment of its activity from the adhesions.
Such an operation was first suggested by Brauer of Heidelberg in
1902.

The question of the best method of producing anesthesia in this
condition of the heart is a serious one. A patient might die during
the anesthesia; but he might also die at any time from cardiac
spasm. In certain instances, in adults, local anesthesia might be
sufficient. Pain reflexes, however, would be serious. Such an
operation would be indicated when the apex is fixed so that there is
a constant sensation of hugging of the heart at the fourth and fifth
ribs, with paroxysms of pain and cardiac weakness.




MYOCARDIAL DISTURBANCES


While the myocardium is the most important muscle structure of the
body, it has but recently been studied carefully or well understood
clinically or pathologically. A heart was "hypertrophied" or
"dilated" or perhaps "fatty." It suffered from "pain," "angina
pectoris," from some "serious weakness" or from "coronary disease,"
and that ended the pathology and the clinical diagnosis. This is the
age of heart defects; no one can understand a patient's condition
now, whatever ails him, without studying his heart. No one can treat
a patient properly now without considering the management of the
circulation. No one should administer a drug now without considering
what it will do to the patient's heart.

Although we are scientifically interested in the administration of
specific treatments, antitoxins and vaccines; although we have a
better understanding of food values, and order diets with more
careful consideration of the exact needs of the individual, and
although we are using various physical methods to promote
elimination of toxins, poisons and products of metabolism, we have
until lately forgotten the physical fact that one thirteenth of the
weight of a normal adult is blood. A man who weighs 170 pounds has
13 pounds of blood. This proportion is not true in the obese, and is
not true in children. Whether the person is sick in bed, miserable
though up and about, or beginning to feel the first sensations of
slight incapacity for his life work, his ability properly to
circulate this one thirteenth of his weight through the various
arterial and venous channels and capillary tracts must, with the
increasing tension and speed of our lives, be taken into
consideration.

The more and more frequently repeated statements that the operation
was successfully performed but that the patient died of shock, and
that the typhoid fever and the pneumonia were being successfully
combated, but that the patient died of heart failure, together with
the increase in arteriosclerosis, cardiac disturbances and renal
disease, emphatically present the necessity of more carefully
studying the circulation. A better understanding and the constant
study of the blood pressure shows nothing but the necessity of the
age. The unwillingness of the patient to suffer pain, even for a few
minutes, without some narcotic, generally a cardiac debilitating
drug, means that, if he is a sufferer from chronic or recurrent
pain, he has taken a great deal of medicine which has done his heart
no good. Repeated high tension of life raises the blood pressure and
puts more work on the heart. Therefore the heart is found weary, if
not actually degenerated, when any serious accident, medical or
surgical, happens to the patient.

The requirements of the age have, then, necessitated that the heart
be more carefully studied, and therefore the heart strength and its
disturbances are better understood. The mere determination as to
where the apex beat is located, and as to what murmurs may be
present is not sufficient; we must attempt to determine the probable
condition of the myocardium. The following conditions are
recognized: (1) acute myocarditis, (2) chronic myocarditis
(fibrosis, cardiosclerosis), (3) fatty degeneration, and (4) fatty
heart.


ACUTE MYOCARDITIS

Probably most acute infections cause more or less myocarditis,
depending on their intensity and their prolongation. This
disturbance of the heart is often unrecognized, and has been simply
referred to as "the heart growing weaker from the fever process."
The acute infections most likely to cause a myocarditis are
rheumatism, influenza, sepsis, cerebrospinal meningitis, diphtheria,
typhoid fever, scarlet fever, and mouth and throat infections. It is
probably rare when acute endocarditis occurs that more or less
myocarditis is not present. The acute myocarditis may develop some
fatty degeneration, and with this softening and weakening of the
heart muscle acute dilatation readily occurs, which may be a cause
of sudden death, or, if less serious, may be the cause of prolonged
disability, if the heart ever recovers its original size and
strength.

The symptoms are often indefinite, and the diagnosis of the
condition hardly possible. It may be taken for granted, however,
that hardly any serious illness can long continue without cardiac
muscle disturbance. If endocarditis is present, soft systolic
murmurs soon appear. With the acute myocarditis developing, the apex
beat is less positive, less accentuated, and later it becomes
diffuse and even feeble. The closure of the aortic valve is less
typically sharp, showing that the blood vessels are not so
thoroughly filled. The peripheral circulation is not so active, the
blood pressure falls, and the heart becomes more rapid, especially
on the least exertion. All of these signs indicate myocardial
weakness.

The treatment of this condition is largely preventive. It should be
well recognized that prolonged high fever, prolonged insufficient or
improper nutrition, prolonged acute pain, and especially prolonged
septic processes will always cause myocardial degeneration. It
should be recognized that after ether and chloroform anesthesia,
especially after chloroform, the heart muscle may be disturbed and
the tonicity be lost. Therefore after anesthesia, after operations,
and after all illnesses which have lasted more than a few days, the
convalescence of the patient must be more or less deliberate. Sudden
rising, sudden erect posture, the exertion of walking too early,
going up stairs too early or taking moderate, and later severe
exercise too early, may cause dilatation of the heart muscle that
has become weakened by acute myocarditis. If acute myocarditis is
believed or known to be present, cardiac tonics such as digitalis
should not be given; large doses of strychnin should not be given;
vasocontractors such as ergot should not be given; large amounts of
food or large bulks of liquid should not be taken into the stomach
at one time; in fact, unless there is some special indication, the
twenty-four hour amount of fluid should be diminished. The surface
circulation and the muscle circulation should be improved by such
cold or warm water applications as the disease or condition calls
for. Massage should be early inaugurated to promote the return
circulation. The heart should be treated as though it were the
frailest of Venetian glass and would crack with the least rough
handling, or even with a rapid change of temperature, great cold or
too much heat. A prolonged, tedious convalescence, with the return
to activity so graded as to give the heart no strain, and to keep
its work always just below what it is able to do, will often mean
return to perfect strength and health.

No cardiac debilitating drug should be administered when myocarditis
has been surmised or diagnosed. The safest hypnotic, if one is
needed, is morphin in small doses. If there are weakening
perspirations, atropin should be given, especially as it is also a
circulatory stimulant. Calcium in almost any form seems to be of
value in the majority of heart conditions. It is a sedative to the
nervous system, and is certainly indicated in acute myocarditis.
Calcium lactate is perhaps the best salt to administer, in doses of
0.25 gm. (4 grains), three or four times in twenty-four hours.
Calcium glycerophosphate may be used, in powder form or in capsule,
in doses of 0.30 gm. (5 grains) three or four times in twenty-four
hours; or lime-water may be given.

An exact prognosis of this inflammation is impossible. We do not
know how far an acute myocarditis may progress and entire recovery
take place; we do not know how slight a myocarditis may cause
serious symptoms. Clinically we know that many patients after
serious illness never again have perfect circulatory strength. Other
patients almost die of heart failure and yet apparently absolutely
recover their ability to do hard physical work.


CHRONIC MYOCARDITIS: FIBROUS

Chronic myocarditis may develop on an acute myocarditis, but is
generally a slowly progressive chronic process from the beginning;
it occurs mostly in persons past middle life, and as a rule is not
primarily associated with rheumatism or valvular disease of the
heart. Perhaps generally the term "chronic myocarditis" is
incorrect, as a real inflammatory condition is not present and has
not been present; it is really a degenerative process with the
development of connective tissue, a fibrosis and more or less
hardening of the arterioles, a cardiosclerosis. In many instances
this fibrosis is associated with fat deposits or fatty degeneration.
The disease is often caused by a narrowing or obstruction or
calcareous degeneration of the coronary arteries, thus diminishing
the blood supply to the heart muscle. This chronic myocardial
degeneration is often a part of the general arteriosclerosis, and is
an important factor in what is termed cardiovascular-renal disease.
In simple chronic renal diseases the heart first normally
hypertrophies to overcome the increased blood tension and increased
resistance.

The principal causes of this degeneration are normal old age, or
premature age caused by various conditions. In other words, anything
which hastens arteriosclerosis will cause myocardial degeneration.
The causes recognized as most frequently producing this condition
are syphilis; gout; repeated attacks of rheumatism; excess in the
use of alcohol (meaning repeated daily too large amounts, as well as
actual dipsomania); the overuse of tobacco; excess in drinking tea
or coffee; general overeating, and excessive eating of meat in
particular, if the organs of elimination do not work perfectly and
if such eating causes or allows putrefactive changes in the
intestines; and progressive, prolonged wasting diseases, such as
tuberculosis and cancer. It has also seemed in some cases that the
only cause was excessive, hard physical labor, including excessive
athletic work, and in other cases that prolonged anxiety and worry
have been causes of cardiac degeneration and actual cardiac failure.
Prolonged absorption of toxins from mouth and tonsil infections may
be a not infrequent cause.

These myocardial changes are sometimes associated with chronic
pericarditis and chronic endocarditis, and may accompany or follow
valvular disease of the heart. Failure of compensation in valvular
disease and dilatation of the heart are sequences which occur sooner
or later.


SYMPTOMS AND SIGNS

The symptoms of chronic myocardial degeneration are progressive
weakness, slight at first, noticeable on exertion (and what was not
considered exertion becomes such), as evidenced by slight
palpitation, slight shortness of breath, leg weariness and mental
tire. The heart frequently becomes more rapid, not only with
exertion and change of position to the erect, but even after eating.
Slight cardiac stimulants, as coffee, affect the heart more than
previously; there is some sleeplessness, more or less troublesome,
and more or less indigestion. There may be mental irritability and
some mental deterioration, as shown in various ways. There are
likely to be slight edemas of the lower extremities toward night.
The amount of urine may diminish. A previously high blood pressure
becomes lower. The pulse may be occasionally intermittent, and later
actually irregular.

The physical signs often show an enlargement of the heart, with
increased activity at first, from irritability of the heart and a
lack of perfect coordination; later the heart may show typical signs
of weakness. Not infrequently a heart suffering from fibrosis acts
perfectly until some sudden exertion, as lifting, running or serious
illness causes it suddenly to become weak. Such a heart rarely
regains its former strength. This occurs frequently to those who
have supposed themselves to be in perfect physical health. Some
sudden strain which they have previously been able to endure without
injury, such as carrying a weight upstairs, cranking a refractory
engine, pumping up a series of tires, or walking rapidly with a
younger or more active companion, will suddenly give cardiac
distress signals, serious exhaustion and more or less lengthy
prostration, perhaps for an hour or so, or perhaps for several days.
Permanent cardiac weakness may follow, or compensation may again
occur, to be more easily broken later. Slight cardiac pains and
sensations referred to the cardiac region become frequent. Disliking
to lie on the left side, when previously the patient has been able
to sleep on this side without discomfort, is an evidence of cardiac
disturbance. There may be no real pains, but the patient becomes
conscious of his heart, perhaps for the first time in his life. This
alone is an indication of coming trouble.

If these signs and symptoms develop late in life, or at any age with
other symptoms of sclerosis or senility, little can be done
therapeutically except to afford temporary relief and to prevent the
occurrence of acute attacks of cardiac distress or dyspnea. If the
disturbance is really due to chronic cardiac degeneration, the
sooner the patient learns that his ability is restricted, that his
life is narrowed, the better for his future.


MANAGEMENT

The advice he should receive is well understood: to avoid physical
efforts; to avoid mental tire; to avoid overeating or overdrinking
of any foods or liquids; to reduce or abstain from alcohol, coffee,
tea and tobacco, depending on what seems advisable in the individual
case; to reduce the amount of meat eaten, especially if there is
intestinal indigestion; to relieve intestinal indigestion; to cause
free daily movements of the bowels; to abstain from any food which
tends to cause gastric or intestinal flatulence; to abstain from
such foods as contain nucleins, if the patient is gouty; to take
frequent warm baths (not too hot) to promote the secretions and the
circulation in the skin, and to take such daily exercise as seems
advisable. If the patient cannot take exercise, simple calisthenics
or massage should be instituted.

Whether nitroglycerin or other nitrite is advisable depends on the
peripheral blood pressure. If the blood pressure is low, or not
higher than is best for the patient, such treatment would be
inadvisable. If, from the supposed cause, iodid seems to be
indicated, it should be given in small doses and continued for some
time. It is often wise, however, to give small doses, as 0.10 or
0.20 gm. (2 or 3 grains) once or twice in twenty-four hours, for a
long period, to any patient who leas fibrosis or selerosis in any
form. Iodid tends to prevent the progress of connective tissue
formation. It is quite possible that some of its value is in
activating a sluggish or imperfectly acting thyroid gland. If the
patient is old, his thyroid is subinvoluting, and a little more of
its activity will be of advantage. Many diseases which cause chronic
myocarditis also cause, later, subactivity of the thyroid. Thyroid
extract may be indicated if the patient is obese.

If, in spite of this management and treatment, the patient has
cardiac asthma attacks, with or without pain, especially if there
are pendent edemas, the question arises as to whether or not
digitalis should be given. In such cases one cannot tell without
trying whether digitalis will be of benefit or will cause more
discomfort. 11 small dose of an active preparation should be given
at first twice in twenty-four hours, and after a week once in
twenty-four hours, its action being carefully watched and the
decision as to whether the dose is too large or too small arrived
at. It may do a great amount of good; it can cause increased cardiac
pains. If used carefully and stopped when it appears not to be
acting well, it will do no harm.

Chilling of the surface of the body should be avoided; sudden cold
or sustained severe cold, which increases the contraction of the
peripheral blood vessels and puts more strain on the heart muscle,
is to be avoided if possible. More hours in bed at night and lying
down after the heavier meals of the day will tend to give the heart
the kind of rest it needs. Also complete rest for one day a week, or
a rest of several days at a time, and a rest, both mental and
physical, with such walking, golfing or riding as seems advisable,
for at least one month every year, will prolong the lives of these
patients, and may make an imperfect heart act well for months and
years. If the patient is anemic he should, of course, receive some
nonastringent iron; a. tablet of saccharated ferric oxid
(Eisenzucker), in small doses, 0.20 gm. (3 grains), once or twice in
twenty-four hours, is sufficient.

The prognosis of a case diagnosed as chronic myocarditis or chronic
degeneration of the heart is doubtful, as one cannot tell until
several weeks or months of observation whether this particular heart
also has fatty degeneration or not. If there is fatty degeneration,
the prognosis is bad. If there is no serious fatty degeneration, the
patient, with the modified life outlined, may live for a long time.
Acute dilatation from any serious strain on the heart may occur, and
if there is fatty degeneration it is liable to occur at any time.
Attacks of cardiac asthma are always serious, and always damage the
heart a little more.


FATTY DEGENERATION

Fatty degeneration of the heart muscle may be caused by acute
poisoning (as phosphorus, arsenic, etc.), by serious infections, or
it may follow fibrosis of the heart or coronary artery disease. The
symptoms are those of serious circulatory weaicnens, which does not
seem to improve under any ordinary management. It is difficult, if
the heart is enlarged, to determine whether there is more or less
serious acute dilatation or whether the heart muscle has suffered
fatty degenration.

The treatment of such a patient requires the best of judgment as to
the amount of food and liquid that should be given, the regulation
of the administration of laxatives, the sponging of the body, the
means of producing sleep if there is insomnia, how much reading,
conversation or amusements should be allowed, how much stimulation
by stryclmin or other stimulating drug should be given, and whether
or not very small doses of digitalis should he tried. These are all
matters for individualizing, and for the best medical judgment which
we are called on to give. How much repair can take place in a heart
muscle when fatty degeneration has started we do not know. Such
treatment will give the heart the only chance it has to recuperate,
but the prognosis is bad.


FATTY HEART

The cause of deposits of fat around the heart or in between its
chambers is the same as the cause of general obesity. These patients
are likely to be obese, or at least to have large abdomens with
large deposits of fat around the abdomen. This fat in itself will
interfere somewhat with abdominal respiration. This tends to cause
dyspnea, and the heart tends to be disturbed from these causes, if
much fat is not really in the pericardium. The symptoms are those of
imperfect heart action; the patient is dyspneic on exertion or in
leaning over, the heart acts rapidly on such exertion, the patient
puffs, perspires easily, and becomes leg weary, sedentary in his
habits, and more or less incapacitated for work. He may not be a
large eater; if he is, and his eating habit is corrected, the
prognosis is better than if he is putting on weight in spite of
eating sparingly.

The general treatment is that for obesity, and if the heart muscle
is intact, various depletion methods may be inaugurated. More and
more exercise, sweatings from Turkish baths, electric-light baths,
body baking, vigorous massage and more or less purging are all
valuable. Anything which reduces the general weight will help the
heart. The prognosis is often good.




ENDOCARDITIS


It should be understood that especially in acute conditions a
positive separation of endocarditis from myocarditis is incorrect.
Acute endocarditis can probably not occur without some inyocarditis,
and myocarditis probably does not occur without some endocardial
disturbance and perhaps some pericardial irritation. This is
especially true in endocarditis which occurs during any acute
infection, even in rheumatism. The greater the amount of
pericarditis, the more serious is the acute condition. The greater
the amount of myocarditis, the more doubtful is the heart strength
in the near future. The greater the amount of endocarditis, the
greater the doubt of freedom from future permanent valvular lesions.

Endocarditis may be divided into: acute mild (simple) endocarditis,
acute malignant (ulcerative, infective) endocarditis, chronic
endocarditis and valvular disease.


ACUTE MILD ENDOCARDITIS

This inflammation of the endocardium is generally confined to the
region of the valves, and the valves most frequently so inflamed are
the mitral and aortic. There may be a slight inflammation or actual
ulceration and loss of tissue. Vegetations more or less constantly
occur on the inflamed surfaces, with more or less danger of
particles becoming loosened and moving free in the blood stream,
causing embolic obstruction in different parts of the body. There is
also more or less probability of serious adhesions or contractions
occurring from the healing of the ulcerated surfaces. The future
health and welfare of the valves depend on the fact that the
inflammation has healed without contractions or adhesions.

It is often difficult to decide when acute endocarditis has
developed; but with the knowledge that the endocardium often becomes
inflamed during almost any of the acute infections, the physician
should repeatedly examine the heart for murmurs, for muffled closure
of the valves, or for other evidences of endocarditis or myocarditis
during the acute infective process.

It has been shown positively that acute endocarditis is due to
micro-organisms, generally streptococci, staphylococci or
pneumococci, and, more frequently than once believed, gonococci. The
most frequent causes are acute rheumatic fever, diphtheria,
pneumonia, cerebrospinal meningitis, scarlet fever, erysipelas,
influenza, chorea, gonorrhea, sepsis and typhoid fever. It may also
follow a follicular tonsillitis or some infection of the mouth or
throat with or without arthritis. Tuberculosis may also occasionally
cause an endocarditis. Organisms may be found in a terminal simple
endocarditis due to a chronic disease, as tuberculosis or cancer;
such inflammations may have been caused by circulating toxins.

It will be noticed by the foregoing classification that the terms
"mild" and "malignant" endocarditis are used. The purpose is to
convey the fact that there may be no etiologic distinction between
the two forms, and it is impossible to decide clinically in the
beginning of an endocardial inflammation which form is present. In
the malignant form the infection is probably more serious or the
infective germs are more active, the ulcerations deeper, and the
likelihood of emboli and the seriousness of such embolic infarcts
more serious and more dangerous. The differences in inflammation in
the two cases is really one of degree, and the classification is
made to coincide with this probable fact. it is, of course,
clinically recognized that endocarditis following certain diseases,
especially rheumatism, is of the simple or mild type, while that
termed ulcerative endocarditis may occur apparently as a primary or
general infection, and the causative bacteria, as a rule, are
readily discovered in the blood. The Streptococcus viridans is one
of the most dangerous of these bacteria.


A SECONDARY AFFECTION

Mild endocarditis is rarely a primary affection, and is almost
invariably secondary to one of the diseases named above. Nearly 75
percent of secondary endocarditis occurs as a complication of acute
articular rheumatism and chorea, or subsequently. On the other hand,
about 40 percent of all patients with acute articular rheumatism
develop endocarditis, sometimes perhaps so mild as to be hardly
discoverable. This complication is most likely to occur during the
second or third week of rheumatic fever. It is not sufficiently
recognized that a subacute arthritis, recurring tonsillitis, open
and concealed infections in the mouth, and even a condition of the
system with acute, changeable and varying joint and muscle pains may
all develop a mild endocarditis, even with subsequent valvular
lesions. Therefore in all of these conditions the decision can be
made only as to how much rest the patient must have or how serious
the condition is to be considered by careful examination of the
heart in every instance.

Children are more liable than adults to this complication,
especially with rheumatism. Therefore, acute mild endocarditis with
future valvular lesions occurs most frequently during childhood and
adolescence, and if one attack has occurred, a subsequent infection,
especially of rheumatism, is liable to cause another acute
endocarditis.


PATHOLOGY

The part of the heart most affected is the part which has the most
work to do--the left side of the heart--and of this side the left
ventricle and therefore the mitral and aortic valves; the most
frequent valve to be inflamed and to stiffer permanent disability is
the a mitral valve, the valve which in its inflamed condition is
subjected to the greatest amount of pressure and therefore
irritation. Not infrequently soft systolic murmurs are heard at the
pulmonary and tricuspid valves during acute endocarditis. It is
rare, however, that these valves are so affected during childhood or
adult life as to be permanently disabled.

Whether a diminished alkalinity of the blood in rheumatism has
anything to do with the cause of the frequent complication of
endocarditis has not been determined. Whether the administration of
alkalies to the point of increasing the alkalinity of the blood is
any protection against the complication of endocarditis has also not
been positively demonstrated, although clinically such treatment is
believed by a large number of practitioners to be wise.

A chronic endocarditis with permanent lesions of the valves may
become an acute inflammation with an infectious provocation.

It has been shown that even in a few hours after endocarditis has
started, little vegetations composed of fibrin, with white blood
cells, red blood pigment and platelets, may develop. Practically in
all instances such vegetations develop, and later become more or
less organized into connective tissue. These little vegetations,
generally minute, perhaps not exceeding 4 mm. in height, are
irregular in contour like a wart. Some of these may have small
pedicles, and as such, of course, are more likely to become loosened
and fly off into the blood stream. It is of interest to note that
these little vegetations are more likely to be on the left side of
the heart than the right; on the valves than any other part, and on
the mitral valve than on the aortic. The consequence is a more
frequent permanent disability of the valves of the left side of the
heart, and of these more frequently the mitral. Although these
little vegetations and excrescences sooner or later become mostly
connective tissue, still fibrin and white blood cells may form thin
layers over them, more or less permanent. In this fibrin are
frequently found bacteria, even when there has been no recent acute
inflammation. The deeper layers of the endocardium during acute
inflammation may become infiltrated with young cells, with resultant
softening and destruction of the intercellular substance. This
softening and some swelling of the lower layers of the endocardium
allow the pushing up of these extravasated blood cells which, being
covered with fibrin, makes the little vegetations above described;
and as just stated, the fibrin may form a more or less permanent
cap. If this cap is disintegrated or lost and the cells under it
washed away in the blood stream, ulceration takes place, which may
be more or less serious, even to the perforation of a valve or
actual erosion of one of its cusps, and the parts of the valves most
seriously affected are the parts which strike against each other on
closure; as previously stated, the parts subjected to the greatest
strain and the greatest amount of friction during the inflammation
are the parts most seriously affected afterward.

If a perforation has occurred, it may make a permanent leak. If an
erosion of the edge of the valve has occurred, it may make permanent
insufficient closure. If the valve has become thickened and
stiffened during the cicatricial healing, it may not only be
incompetent, but may not open perfectly, and a narrowed orifice may
be the consequence. During the healing of these granulating ulcers
there may be thickening of the part or shrinking of the tissue, and
the valve may become shortened by adhesion to the wall, or the cusps
of the valve may adhere together so that the valve becomes
permanently unable to open properly or to close properly, or to do
either.

Not infrequently and probably more frequently than we recognize,
recovery without any of the pathologic lesions just described
follows mild endocarditis. The occurrence of simple endocarditis is
undoubtedly frequent during acute disease, and is unrecognized
because there are no lesions of the heart at the time or
subsequently; but valvular lesions only too frequently follow the
endocarditis which occurs with rheumatism. Occasionally the
ulcerations become serious, and ulcerative endocarditis or malignant
endocarditis develops on the mild inflammation. In this form the
little vegetations are liable to become loosened, fly off into the
blood stream, and cause emboli in different parts of the body.

Recently Fraenkel [Footnote: Fraenkel: Beitr. z. path. Anat. u. z.
allg. Path., 1912, iii, 597.] concluded that the microscopic nodules
which occur in endocarditis in the myocardium, and which consist of
the several varieties of white blood corpuscles first referred to by
Aschoff in 1904, are characteristic only of acute rheumatism.
Fraenkel found these nodules in the myocardium in a case of chorea,
showing the close relationship between it and rheumatism.

While repeated careful examination of the heart during acute
infections will generally show signs of endocarditis if it is
present, even if there are no subjective symptoms, the disease may
be so insidious as not to be noted until a valvular lesion occurs.
Often, however, during the course of the disease, especially in
rheumatism, there is a slight increase in fever and there is a
discomfort complained of in the region of the heart, frequently
accompanied by slight dyspnea. Real pain is seldom present unless
the pericardium is affected. If the myocardium is much inflamed at
the same time, the heart becomes more rapid and the blood tension
lowered, and the apex beat diminished in intensity and perhaps not
palpable. If there is pain, with or without pericarditis, it is
often referred to the epigastrium, especially in children. The
patient is often nervous, restless and sleepless. In simple
endocarditis emboli rarely occur. If they do, of course the signs
will be in the part in which the infarct occurs. Besides the
diminished intensity of the apex beat and its greater diffusion, the
valve sounds may be muffled, and sooner or later there may be
systolic murmurs over the different orifices. Of course systolic
murmurs may be due to a disturbed condition of the blood, but if
they occur with the above-mentioned symptoms and signs, endocarditis
should be diagnosed. If the heart becomes seriously weak and the
patient suffers much dyspnea, myocarditis should be known to be
present with the endocarditis. If there is a diastolic murmur, there
can be no question of serious endocarditis having occurred.
Unexplainable palpation during acute illness liar been thought to be
a distinct symptom of endocarditis.


TREATMENT OF ENDOCARDITIS

As mild endocarditis rarely occurs primarily but is almost always
secondary to some acute disease, its immediate treatment is only a
slight modification of that of the disease which is causing it. A
complication which is so frequent should always be expected, and
consequently warded off or prevented, if possible. Knowledge of the
diseases which are most liable to cause endocarditis makes frequent
heart examinations a necessity, to note when it arrives. While an
extra heart tire, sleeplessness, and the circulation of unnecessary
toxins from a bad condition of the bowels and from improperly
selected food all make this complication more liable, its occurrence
is, nevertheless, often unpreventable.

The most efficacious preventive pleasures are sleep, rest, the
stopping of pain, prevention of exertion, proper food which does not
cause flatulence or other indigestion, good, sufficient daily
movements of the bowels, the prevention of intestinal distention,
and maintenance of a clean, moist surface of the body, produced by
such sponging and bathing as the temperature demands.

The disease having developed, the indications for treatment are
really few; in fact, the treatment is mostly negative. There is
generally but little local pain; the temperature from simple
endocarditis alone is not high and the acute symptoms tend to abate.

Local Treatment.--Endocarditis having been diagnosed, especially if
there is palpation or pain, an ice bag over the heart is often of
considerable value, but not so efficient as in pericarditis. It
often tends to quiet the heart, and may be of some value reflexly in
slowing the inflammation. If it causes restlessness, however, and
does not lessen the pain (which in some instances it may increase),
it certainly should be stopped. Children, in whom this complication
so frequently occurs, generally do not bear the ice bag well.
Sometimes it may be advisable to substitute warm applications, and
often a great deal of comfort is derived from them, the patient soon
going to sleep. One of the greatest values of either cold or hot
applications is diminution of the discomfort from the cardiac
disturbance, and the stopping of any pain which may be present. If
they do not do this, there is no object in using either cold or
heat.

The discomfort from blisters over the heart during the acute stage
of endocarditis is greater than any good which they can do. In
adults a few small blisters may be used intermittently around the
borders of the heart, after the acute symptoms are over, to act
reflexly on the heart and possibly aid absorption of inflammatory
products. Sometimes improvement seems to follow such treatment; it
certainly can do no harm.

During convalescence, the skin over the heart may be painted with
iodin, repeated often enough to cause stimulation without injuring
the skin; it seems at times to be of value. Various iodin or iodid
ointments have been used, but they probably have no more value than
the administration of small doses of iodid.

Systemic Treatment.--As this complication most frequently occurs
during acute rheumatism, the question arises as to the value or
harmfulness of salicylates and alkaline drugs. With our recent
better understanding of the action on the heart of pure salicylates
(either natural or synthetic saliclic acid, which have been shown to
act identically, if equally pure), we must believe that in any
ordinary dosage they will injure the heart but rarely. While
salicylic acid will not prevent endocarditis, it should he
continued, if it is of benefit with regard to the arthritis. The
indication for its use depends on its effect on the joints. As it
acts at times almost as a specific in rheumatism, it would seem that
it should be of value in the endocarditis caused by rheumatism. On
the other hand, the endocarditis occurs during the second or third
week of acute rheumatism, after the blood has been thoroughly
saturated with salicylic acid. Therefore it certainly does not tend
to prevent rheumatic endocarditis; hence for this complication alone
salicylic acid is not indicated.


ALKALIES

Anything which tends to increase the acidity of the tissues and to
diminish the alkalinity of the blood, whether from starvation or
outer causes, seems to pro-duce endocardial and myocardial
irritation, if not actual inflammation. Therefore in a disease like
rheumatism, which seems to be made worse by anything which increases
the acidity, alkalies are obviously indicated, and it is probable
that an increased alkalinity of the blood tends to prevent
endocardial irritation, and may soothe an inflammation already
present. Until we have some positive knowledge to the contrary,
alkalies should be freely administered during endocarditis,
especially during rheumatic endocarditis. Potassium citrate in 2 gm.
(30 grain) closes, in wintergreen water, should be given every three
to six hours, depending on how readily the urine is made alkaline.
This may be given with the salicylic acid treatment, and also when
the salicylic acid has been stopped. It may be well, if sodium
salicylate is being used, to give also sodium bicarbonate, the
sodium bicarbonate often preventing irritation of the stomach from
the sodium salicylate, the dose being equal parts of the sodium
salicylate and the sodium bicarbonate administered in plenty of
water. If some other form of salicylic acid is preferred,
novaspirin, which is methylene-citryl-salicylic acid and contains 62
percent of salicylic acid, is perhaps the least irritant to the
stomach of the salicylic preparations. This drug is decomposed in
the intestine into its component parts, salicylic acid and
methylene-citric acid. If this drug is combined with sodium
bicarbonate, the disintegration into its component parts would be
likely to occur in the stomach.


IRON

It is essential for the welfare of the patient, especially after a
long illness before the complication of endocarditis could occur,
and in rheumatic fever, in which all meat and meat extractives have
been kept from the diet, that small doses of iron should be
administered daily. Not only the fever process, but also the
salicylic acid tends to prevent the healthy normal growth of red
corpuscles. and such patients suffering from rheumatism are often
seriously anemic after the aente inflammation has ceased. The iron
administered may be 5 drops of the tincture of the chlorid, in
lemonade or orangeade, twice in twenty-four hours (and it should be
remembered that lemon and orange burn to alkalies in the system and
do not act as acids); or 0.1 gm. (1 1/2 grains) of reduced iron in
capsule twice in twenty-four hours, or a 3 grain tablet of
saccharated ferric oxid (Eisenzucker) twice in twenty-four hours.


OPIUM

As so many times repeated, real pain must be stopped, and morphin,
either by the mouth or hypodermically, should be used to the point
of stopping such pain. If the patient is a young child, codein
sulphate or the deodorized tincture of opium may be used in the dose
found sufficient, and either one will act satisfactorily. The dose
given should be small but repeated sufficiently often to stop the
pain. The dose necessary for the given individual will soon be
learned, and that dose may be repeated at such intervals as the
condition may require. Sometimes the hypnotic selected, if one is
needed, will be sufficient to quiet the cardiac aches or pains.


BROMIDS AND CHLORAL

If there is much restlessness and the circulation is good, that is,
if myocarditis is probably not present, the bromids may be of great
value, especially in children. The dose should be sufficient to
quiet the nervous system. The drug may be discontinued after a few
days, if the conditions improve. If the bromid, except in large
doses, will not cause sleep, a sufficient dose of chloral should be
given. Chloral is one of the most satisfactorily acting drugs which
we have to produce sleep and to cause cardiac rest. While it should
not be given if there is real cardiac weakness, the good which it
does is so much greater than the possible bad effect on the heart,
that it should not be forgotten for some newer hypnotic. The worst
part of this drug is its taste, and the best way to administer it is
to have it in solution in water and the dose given on cracked ice
with a little lemon juice to be followed by a good drink of water
and a piece of orange pulp for the patient to chew. Ordinarily a
bad-tasting drug such as chloral is well administered in
effervescing water, but effeverscing waters are generally
inadvisable when there is any kind of inflammation of the heart, as
they are liable to cause distention of the stomach and pressure on
the heart. Some physicians prefer chloralamid as a less disagreeable
drug and one which acts almost as efficiently as chloral. As the
close of this must be larger than the dose of chloral, it is a
question of doubt as to which is the better drug to use. Of the
newer hypnotics, veronal=sodium (sodium-diethyl-barbiturate) is
among the best. It acts quickly, is less depressant and is a safer
salt than most of the other newer hypnotics. It is the readily
soluble sodium salt of veronal (diethyl-barbituric acid). When
combined with any active drug, sodium seems to make it less toxic
and less depressant. The dose of this drug is from 0.2 to 0.3 gm. (3
to 5 grains).


PREVENTION

If the patient is weak, the circulation depressed, the blood
pressure low, and the heart rapid, the drug advisable to produce
rest and sleep is almost always morphin or some other form of opium.
Morphin, with few exceptions, is a cardiac tonic and a cardiac
stimulant, unless the dose is much too large. As long as the bowels
are daily moved and the food is not given at the time of the full
action of the morphin, when digestion might be delayed or interfered
with, in most patients the action of this drug during serious
illness is entirely for good. The greatest mistake in using morphin
for the production of sleep, or for physical and mental rest and
comfort when there is not severe pain, is in giving too large a
dose. If pain is not severe, or due to inflammatory distention of
some undilatable part, to pressure on some nerve, to distention of
some tube by a calculus or to some serious injury to the nerves,
large doses of morphin are not needed. Small doses will act much
more efficiently. It is excessively rare that a hypodermic of one-
fourth grain of morphin sulphate is needed, except for the
conditions enumerated. It is often a fact that so small a dose as
one-eighth grain of morphin or even one-sixth grain will cause
sufficient stimulation of a nervous patient, because its primary
stimulant effect on the spinal cord is greater than its depressant
effect on the brain, to require another dose (one-fourth grain
altogether) to give such a patient rest. On the other hand, this
patient may many times be quieted by one-tenth grain of morphin
sulphate on account of the size of the dose being not sufficient to
stimulate the spinal cord. Many a time clinically when one-eighth
grain has failed, a dose of one-fourth grain having been apparently
necessary, a change to one-tenth grain has proved entirely and
perfectly satisfactory.


DIET

As intimated in the preceding paragraph, the diet during
endocarditis must be carefully regulated. It must be sufficient, and
appropriate for the disease in which the complication occurs, but it
must be in such dosage and administered with such frequency as to
cause the least possible indigestion. Large amounts of milk are
rarely advisable. Too much milk is certainly given, even in
rheumatism. While pretty well tolerated by children, it is often
badly tolerated as far as digestive symptoms are concerned, by
adults. The amount of liquid given should be governed by the amount
of urine passed and by the amount of perspiration. The patient
should not be overloaded with liquid if he does not need it. Enough
carbohydrate must be given.


LAXATIVES

If the bowels are known to be in excellent condition and not loaded
with fecal matters, brisk catharsis is not needed simply because
endocarditis has developed. If the bowels have been neglected, a
small dose of calomel, aided by a compound aloin tablet, is
necessary and good treatment. Subsequent movements of the bowels
should be daily obtained by vegetable laxatives with occasional
enemas, as needed. With all inflammation of the heart and the
possibility of myocarditis developing or being actually present, it
is not advisable to use salines freely or often.


CARDIAC DRUGS

Whether any drug should be used which acts directly on the heart is
often a question for decision. As endocarditis is generally
secondary to some acute disease, the patient has become weakened
already, and the circulation is not sturdy; therefore such a drug as
aconite is probably never indicated. The necessary diminished diet,
catharsis, hypnotic, salicylic acid and alkalies all tend to quiet
the circulation and diminish any strenuosity of the heart that may
be present. Unfortunately, during fever processes, digitalis in
ordinary doses rarely slows the heart; and while it might slow the
heart if given in large doses, it would also cause too powerful
contractions of the ventricles. Digitalis is inadvisable if there is
much endocardial inflammation, and especially if there is supposed
or presumed to be acute myocardial inflammation. If a patient had
already valvular disease from a previous endocarditis, and during
this attack insufficiency of the heart was evidenced by pendent
edemas, digitalis Should be administered; but it probably should not
be given to other patients during the acute period of inflammation.


BATHS

During rheumatism the peripheral blood vessels are generally dilated
and the skin perspires profusely. This is caused not only by the
rheumatism, but also by the salicylates. The surface of the body
should be sponged with cold, lukewarm or hot water, depending on the
temperature, especially of the skin. The cold water will reduce the
temperature and tone the peripheral blood vessels; the hot water, if
the temperature is low and the skin moist and flabby, will cleanse
it and also tone the peripheral blood vessels. If the blood vessels
are dilated and the perspiration profuse, atropin is indicated, both
as a cardiac stimulant and contractor of the blood vessels and as a
preventer of too profuse sweating. The dose should be from 1/200 to
1/100 grain for an adult, given two or three times in twenty-four
hours, depending on its action and the indications. It should be
remembered that atropin is not a sleep-producer; it may stimulate
the cerebrum. Therefore at night it might well be combined with a
possible necessary hypodermic injection of morphin.


STRYCHNIN

The question of the advisability of strychnin is a constant subject
for discussion. Strychnin is overused in the cases of most patients
who are seriously ill. In a patient in whom we are trying to cause
nervous and muscular rest, strychnin is certainly contraindicated.
On the other hand, if the heart is acting sluggishly, the peripheral
circulation is imperfect, and atropin is not acting well, it is
advisable to give strychnin in a dose not too large and not too
frequently repeated. Strychnin should be avoided, if possible, in
the evening in order that the patient may sleep. Whether it should
be given by the mouth or hypodermically would depend entirely on the
seriousness of the condition. Once in six hours is generally often
enough for strychnin to be administered unless the dose is very
small.


ALCOHOL

It is rarely, if ever, advisable to use alcohol. In certain
instances, however, especially in older patients who are accustomed
to alcohol, a little whisky administered several times a day may act
only for good, both as a food and as a peripheral dilator. But it
must be remembered that alcohol is not a cardiac stimulant, and that
a large dose will be followed by more cardiac depression.
Nitroglycerin may act as well as whisky in the kind of cases
mentioned. Caffein stimulation in any form is generally inadvisable
during inflammation of the heart.


PROGNOSIS AND CONVALESCENCE

The duration of acute endocarditis varies greatly; it may be two or
three weeks, or the inflammation may become subacute and last for
several months. Although mild endocarditis rarely causes death of
itself, it may develop into an ulcerative endocarditis, and then be
serious per se. On the other hand, it may add its last quota of
disability to a patient already seriously ill, and death may occur
from the combination of disturbances. As soon as all acute symptoms
have ceased, rheumatic or otherwise, and the temperature is normal,
the amount of food should be increased; the strongly acting drugs
should be stopped; the alkalies, especially, should not be given too
long, and the salicylates should be given only intermittently, if at
all; iron should be continued, massage should be started, and iodid
should be administered, best in the form of the sodium iodid, from
0.1 to 0.2 gm. (1 1/2 to 3 grains), twice in twenty-four hours, with
the belief that it does some good toward promoting the resorption of
the endocardial inflammatory products and can never do any harm.
Prolonged bed rest must be continued, visitors must still be
proscribed, long conversations must not be allowed, and the return
to active mental and physical life must be most deliberate.

No clinician could state the extent to which the valvular
inflammation will improve or how much disability of the valves must
be permanent. It is even stated by some clinicians that a rest in
bed for three months is advisable. While this is of course
excessive, certainly, when the future health and ability of the
patient are under consideration, and especially when the patient is
a child or an adolescent, time is no object compared with the future
welfare of the person's heart. It is one of the greatest pleasures
of a the clinician to note such a previously inflamed heart
gradually diminish in size and the murmurs at the valves affected
gradually disappear. Although they may have disappeared while the
patient is in bed, he is not safe from the occurrence of a valvular
lesion for several months after he is up and about.

While the discussion of hygiene would naturally be confined to the
hygiene of the disease of which the endocarditis is a complication,
still the hygiene of its most frequent cause, rheumatism, should be
referred to. Fresh air and plenty of it, and dry air if possible, is
what is needed in rheumatism, and a shut-up, over-heated and
especially a damp room will continue rheumatism indefinitely. It is
almost as serious for rheumatism as it is for pneumonia. Sunlight
and the action of the sun's rays in a rheumatic patient's bedroom
are essential, if possibly obtainable.

As so many rheumatic germs are absorbed from diseased or inflamed
tonsils or from other parts of the mouth and throat, proper gargling
or swashing of the mouth and throat should be continued as much as
possible, even during an endocarditis. The prevention of mouth
infections will be the prevention of rheumatism and of endocarditis.


MALIGNANT ENDOCARDITIS: ULCERATIVE ENDOCARDITIS

Since we have learned that bacteria are probably at the bottom of
almost any endocarditis, the terms suggested under the
classification of endocarditis as "mild" and "malignant" really
represent a better understanding of this disease. They are not
separate entities, and a mild endocarditis may become an ulcerative
endocarditis with malignant symptoms. On the other hand, malignant
endocarditis may apparently develop de novo. Still, if the cause is
carefully sought there will generally be found a source of
infection, a septic process somewhere, possibly a gonorrhea, a
septic tonsil or even a pyorrhea alveolaris. Septic uterine
disturbances have long been known to be a source of this disease.
Meningitis, pneumonia, diphtheria, typhoid fever and rarely
rheumatism may all cause this severe form of endocarditis.

Ulcerative endocarditis was first described by Kirkes in 1851, was
later shown to be a distinctive type of endocarditis by Charcot and
Virchow, and finally was thoroughly described by Osler in 1885.

Ulcerative endocarditis was for a long time believed to be
inevitably fatal; it is now known that a small proportion of
patients with this disease recover. Children occasionally suffer
from it, but it is generally a disease of middle adult life. Chorea
may bear an apparent causal relation to it in rare instances.

Ulcerative endocarditis may develop on a mild endocarditis, with
disintegration of tissue and deep points of erosion, and there may
be little pockets of pus or little abscesses in the muscle tissue.
If such a process advances far, of course the prognosis is
absolutely dire. If the ulcerations, though formed, soon begin to
heal, especially in rheumatism, the prognosis may be good, as far as
the immediate future is concerned. If the process becomes septic, or
if there is a serious septic reason for the endocarditis, the
outlook is hopeless. This form of endocarditis is generally
accompanied by a bacteremia, and the causative germs may be
recovered from the blood. One of the most frequent is the
Streptococcus viridans.


DIAGNOSIS

If a more malignant form of endocarditis develops on a mild
endocarditis, the diagnosis is generally not difficult. If, without
a definite known septic process, malignant endocarditis develops,
localized symptoms of heart disturbance and cardiac signs may be
very indefinite.

If there is no previous disease with fever, the temperature from
this endocarditis is generally intermittent, accompanied by chills,
with high rises of temperature, even with a return to normal
temperature at times. There may be prostration and profuse sweats.
Even without emboli there may be meningeal symptoms: headache,
restlessness, delirium, dislike of light and noise, and stupor; even
convulsions may occur. The urine generally soon shows albumin; there
may be joint pains; the spleen is enlarged and the liver congested.
Some definite cardiac symptoms are soon in evidence, with more or
less progressive cardiac weakness. Occasionally there are no
symptoms other than the cardiac.

Characteristic of this inflammation is the development of ecchymotic
spots on the surface of the body, especially on the feet and lower
extremities. Sooner or later, in most instances of the severe form
of this disease, emboli from the ulcerations in the heart reach the
different organs of the body, and of course the symptoms will depend
on the place in which the emboli locate. If in the abdomen, there
are colicky pains with disturbances, depending on the organs
affected; if in the brain, there may be paralysis, more or less
complete. In all infaret occurs in one of the organs of the body
there must of necessity occur a necrosis of the part and an added
focus of infection. If a peripheral artery is plugged, gangrene of
the part will generally occur, if the patient lives long enough.


TREATMENT

If pneumonia or gonorrhea is supposed to be the cause of the
endocarditis, injections of stock vaccines should perhaps be used.
If the form of sepsis is not determinable, streptococcic or
staphylococcic vaccines might be administered. It is still a
question whether such "shotgun" medication with bacteria is
advisable. Patients recover at times from almost anything, and the
interpretation of the success of such injection treatment is
difficult. Exactly how much harm such injections of unnecessary
vaccines can produce in a patient is a question that has not been
definitely decided. Theoretically an autogenous vaccine is the only
vaccine which should be successful. The vaccine treatment of
ulcerative endocarditis was not shown to be very successful by Dr.
Frank Billings [Footnote: Billings, Frank: Chronic Infectious
Endocarditis, Arch. Int. Med., November, 1909, p. 409.] in his
investigation, and more recent treatment of this disease, when
caused by the Streptococcus viridons, by antogenous vaccines has
confirmed his opinion.

Other treatment of malignant endocarditis includes treatment of the
condition which caused it plus treatment of "mild" endocarditis, as
previously described, with meeting of all other indications as they
occur. As in all septic processes, the nutrition must be pushed to
the full extent to which it can be tolerated by the patient, namely,
small amounts of a nutritious, varied diet given at three-hour
intervals.

Whether milk or any other substance containing lime makes fibrin
deposits on the ulcerative surfaces more likely or more profuse, and
therefore emboli more liable to occur, is perhaps an undeterminable
question. In instances in which hemorrhages so frequently occur, as
they do in this form of endocarditis, calcium is theoretically of
benefit. Quinin has not been shown to be of value, and salicylic
acid is rarely of value unless the cause is rheumatism.

Alcohol has been used in large doses, as it has been so frequently
used in all septic processes. If the patient is unable to take
nourishment in any amount, small doses of alcohol may be of benefit.
It is probably of no other value. It is doubtful whether ammonium
carbonate tends to prevent fibrin deposits or clots in the heart, as
so long supposed. In fact, whenever the nutrition is low and the
patient is likely to have cerebral irritation from acidemia,
whenever the kidneys are affected, or whenever a disease may tend to
cause irritation of the brain and convulsions, it is doubtful if
ammonium carbonate or aromatic spirit of ammonia is ever indicated.
Ammonium compounds have been shown to be a cause of cerebral
irritation. Salvarsan has not been proved of value.

Intestinal antisepsis may be attained more or less successfully by
the administration of yeast or of lactic acid ferments together with
suitable diet. The nuclein of yeast may be of some value in
promoting a leukocytosis. It has not been shown, however, that the
polymorphonuclear leukocyte increase caused by nuclein has made
phagocytosis more active.

Malignant endocarditis may prove fatal in a few days, or may
continue in a slow subacute process for weeks or even months.


CHRONIC ENDOCARDITIS

It is not easy to decide just whew all acute endocarditis has
entirely subsided and a chronic, slow-going inflammation is
substituted. It would perhaps be better to consider a slow-going
inflammatory process subsequent to acute endocarditis as a subacute
endocarditis; and an infective process may persist in the
endocardium, especially in the region of the valves, for many weeks
or perhaps months, with some fever, occasional chills, gradually
increasing valvular lesions and more or less general debility and
systemic symptoms. Such a subacute endocarditis may develop
insidiously on a previously presumably healed endocardial lesion and
cause symptoms which would not be associated with the heart, if an
examination were not made. Sometimes such a slow-going inflammatory
process will be associated with irregular and intangible chest
pains, with some cough or with many symptoms referred to the
stomach, so that the stomach may be considered the organ which is at
fault. There may be dizziness, headache, feelings of faintness,
sleeplessness, progressive debility and a persistent cough, with
some bronchial irritation and with occasional expectoration of
streaks of blood, which may cause the diagnosis of incipient
tuberculosis to be made. The need of a careful general examination
must be emphasized again before a decision is made as to what ails
the patient, or before cough mixtures are given unnecessarily,
quinin is prescribed for supposed malarial chills, or various diets
and digestants are recommended for a supposed gastric disturbance.

The term "chronic endocarditis" should be reserved for a slowly
developing sclerosis of the vavles. This may occur in a previous
rheumatic heart and in a heart which has suffered endocarditis and
has valvular lesions, or it may occur from valvular strain or heart
strain from various causes; it is typically a part of the
arteriosclerotic process of age, and is then mostly manifested at
the aortic valve.


ETIOLOGY

Rheumatism is the cause of most instances of cardiac disease which
date back to childhood or youth, while arteriosclerosis and chronic
infection cause most cardiac diseases in the adult. In the former
case it is the mitral valve which is the most frequently affected,
while in the latter it is the aortic valve. Any cause which tends to
induce arteriosclerosis may be a cause of chronic endocarditis, such
as gout, syphilis, chronic nephritis, alcoholism, excessive use of
tobacco, excessive muscular labor and hard athletic work. Lead is
also another, now rather infrequent, cause. Severe infections may
tend to make not only an arteriosclerosis occur early in life, but
also a chronic endocarditis. Heart strain may also be a cause of
chronic endocarditis, especially at the aortic valve. Forced marches
of soldiers, competitive athletic feats, and occupations which call
for repeated hard physical strain may all cause aortic valve
disease. Tobacco, besides increasing the blood tension and thus
perhaps injuring the aortic valve, may weaken the heart muscle and
cause disturbance and irritation and perhaps inflammation of the
mitral valve.

There is no age which is exempt from valvular disease, but the age
determines the valve most liable to be affected. If endocarditis
occurs in the fetus, it is the right side of the heart that is
affected; in children and during adolescence it is most frequently
the mitral valve that is involved; while in the adult or in old age
it is the aortic valve that is most liable to become diseased.
Statistics have shown that the valves of the left side of the heart
are diseased nearly twenty times as frequently as those of the right
side of the heart. They also show that the mitral valve is diseased
more than one and one-half times as frequently as the aortic valve.
Early in life probably the two sexes are equally affected with
valvular disease, with perhaps a slight preponderance among females,
because of their greater tendency to chorea. Females also show a
greater frequency to mitral stenosis than do males. Aortic disease,
on the other hand, from the very fact of their strenuous life and
occupations, is nearly three times more frequent in men than in
women.


PATHOLOGY

If a chronic endocarditis has followed an acute condition, some
slight permanent papillomas or warty growths may he left from the
healed granulating or ulcerated surfaces. Sometimes these little
elevations on the valves become inflamed and then adhere together,
or adhere to the wall of the heart, and thus incapacitate a valve.
Sometimes these excrescences undergo partial fatty degeneration, or
may take on calcareous changes and thus stiffen a valve.

If the chronic inflammation is not superimposed on an acute
endocarditis there may be no cell infiltration and therefore no
softening, but there is a tendency to develop a fibrillated
structure, and a fibroid thickening of the endocardium occurs,
especially around the valves. This induration causes contraction and
narrowing of the orifices with shortening and thickening of the
chordae tendineae, and the valves imperfectly open, or no longer
close. Fatty degeneration may occur in the papillary growths with
necrotic changes, and this may lead to the formation of atheromatous
ulcers which may later become covered with lime deposits, and then a
hard calcareous ring may form. Fibrin readily deposits on this
calcareous substance and may form a permanent capping, or may slowly
disintegrate and allow fragments to fly off into the blood stream
and cause more or less serious embolic obstruction. If this chronic
endocarditis develops with a general arteriosclerosis, the wine
inflammation soon occurs in the aorta, and, following the
endarteritis in the aorta, atheromatous deposits may also occur
there. Chronic endocarditis of the walls of the heart, not in
immediate continuity with endocarditis of the valves, is perhaps not
liable to occur, except with myocarditis.


TREATMENT

A subacute or a chronic infective endocarditis should be treated on
the same plan as an acute endocarditis, which means rest in bed and
whatever medication seems advisable, depending on the supposed cause
of the condition.

A chronic endocarditis which is part of a general arteriosclerosis
requires no special treatment except that directed toward preventing
the advance of the general disease.




CHRONIC DISEASES OF THE VALVES

PATHOLOGIC PHYSIOLOGY


The development of permanent injury to one or more valves of the
heart may have been watched by the physician who cares for a patient
with acute endocarditis, or it may have been noted early during the
progress of arteriosclerosis or other conditions of hypertension. On
the other hand, many instances of valvular lesions may be found
during a life-insurance examination, or are discovered by the
physician making a general physical examination for an indefinable
general disturbance or for local symptoms. without the patient ever
having known that he had a damaged heart. The previous history of
such a patient will generally disclose the pathologic cause or the
physical excuse.

As soon as a valve has become injured the heart muscle hypertrophies
to force the blood through a narrowed orifice or to evacuate the
blood coming into a compartment of the heart from two directions
instead of one, as occurs in regurgitation or insufficiency of a
valve. The heart muscle becomes hypertrophied, like any other muscle
which is compelled to do extra work. Which part or parts of the
heart will become most enlarged depends on the particular valvular
lesion. In some instances this enlargement is enormous, increasing a
heart which normally weighs from 10 to 12 ounces to a weight of 20
or even 25 ounces, and extreme weights of from 40 to 50 ounces and
even more are recorded.

As long as the heart remains in this hypertrophied condition, which
may be called normal hypertrophy since it is needed for the work
which has to be done in overcoming the defect in the valve, there
are no symptoms, the pulmonary and systemic circulation is
sufficient, and the patient does not know that he is incapacitated.
Sooner or later, however, the nutrition of the heart, especially in
atheromatous conditions, becomes impaired, and the lack of a proper
blood supply to the heart muscle causes myocardial disturbance,
either a chronic myocarditis or fatty degeneration. If there is no
atheromatous condition of the coronary arteries, and arterial
disease is not a cause of the valvular lesion, compensation may be
broken by some sudden extra strain put on the heart, either muscular
or by some acute sickness or a necessary anesthetic and operation.
From any of these causes the muscle again becomes impaired, and the
heart, especially the part which is the weakest and has the most
work to do relatively to its strength, becomes dilated, compensation
is broken, and all of the various circulatory disturbances resulting
from an insufficient heart strength develop.


PRECAUTIONS TO BE OBSERVED

As long as compensation is complete, there are no medication and
physical treatment necessary for the damaged heart. The patient,
however, should be told of his disability, and restrictions in his
habits and life should be urged on him. The most important are that
all strenuous physical exercise should be interdicted; competitive
athletics should be absolutely prohibited; prolonged muscular effort
must never be attempted, whether running, rowing, wrestling, bicycle
riding, carrying a heavy weight upstairs or overlifting in any form.
The patient should be taught that he should never rush upstairs, and
that he should never run rapidly for a car or a train or for any
other reason; he should not pump up a tire, or repeatedly attempt to
crank a refractory engine; even the prolonged tension of steering a
car for a long distance is inadvisable. He should be told that after
a large meal he is less capacitated for exertion than a man who has
not a damaged heart. It is better if he drinks no tea or coffee; it
is much better if he absolutely refrains from tobacco and alcohol.
Prolonged mental worry, business frets and mental depression are all
injurious to his heart. Anything which seriously excites him,
whether anger or a stimulating drug, is harmful. Any disease which
he may acquire, especially lung disturbances, as pneumonia or even a
serious cough, requires that he take better care of himself and be
more carefully treated and take more rest in bed than a patient who
has not a damaged heart. Anything which raises the blood pressure is
of course more serious for his heart than for a perfect heart;
therefore drinking large amounts of liquid, even water, is
inadvisable. It simply means so much more work for the heart to do.
Such patients should rarely be given any drug that causes cardiac
debility, and should never take one without advice. This applies to
all the coal-tar drugs, acetylsalicylic acid (aspirin), etc.

One other fact should be impressed on the person with a valvular
lesion and compensation, and that is that he has but little, if any,
reserve circulatory power. While he is in apparently perfect health,
it takes little circulatory strain to push his heart to the point of
danger or insufficiency. As nothing keeps this reserve so good or
increases it more than rest, he should expect to have a restful day
at least once a week, and a good rest of at least two or three weeks
once or twice a year.

A patient with these restrictions may live for years with a serious
valvular defect and may die of some intercurrent disease which has
nothing to do with the circulatory system.

It is easily recognizable that as the majority of acute lesions of
the valves occur in children, it is impossible to prevent them from
taking more or less strenuous exercise, and this is probably the
reason that we have so many serious broken compensations during
youth or early adolescence.

As referred to under the subject of myocarditis, many symptoms for
which a patient consults his physician are indefinite and
intangible, though due to cardiac weakness. If a patient with a
damaged heart has a sudden dilatation, of course his symptoms are so
serious that the physician is immediately summoned. If, however, he
has a slowly developing insufficiency of the heart muscle, his first
symptoms are more or less indefinite cardiac pains, slight shortness
of breath, slight attacks of palpitation, a dry, tickling, short
cough occurring after the least exertion, some digestive
disturbances, often sluggishness of the bowels, gastric flatulence,
possibly nosebleeds, and sooner or later some edema of the lower
extremities at the end of the day.


DECOMPENSATION

To understand the physiology, pathology and the best treatment for
broken compensation, it is necessary to study the physics of the
circulation under the different conditions. With the mitral valve
insufficient, a greater or less amount of blood is regurgitated into
the left auricle, which soon becomes dilated. Distention of any
hollow muscular organ, if the distention is not to the point of
paralysis, means a greater inherent or reflex attempt of that organ
to evacuate itself; the muscular tissue begins to grow, and a
hypertrophy of the left auricle with the above-named lesion
develops. The muscular tissue of the auricle, however, is not
sufficient to allow any great hypertrophy. The blood flowing from
the pulmonary veins into the left auricle finds this cavity already
partly filled with blood regurgitated from the left ventricle. The
pulmonary blood, being impeded, tends to flow more slowly, and
therefore dams back into the lungs, causing a passive congestion of
the lungs. The pulmonary artery thus finds the pressure ahead
unusually great, and the right ventricle reflexly learns that it
requires a greater force to empty itself than before; in fact, it
may not succeed in completely accomplishing this until its
distention, by an incomplete evacuation of its contained blood plus
the blood coming from the right auricle, has caused the right
ventricle also to become hypertrophied. This increased muscular
action of the right ventricle relieves the pulmonary congestion, and
an increased amount of blood is forced into the left auricle. On
account of its hypertrophy, the left auricle is able to send an
increased amount of blood into the left ventricle, which in turn
becomes hypertrophied and sends enough blood into the aorta to
satisfy the requirements of the systemic circulation in spite of the
leakage through the mitral valve.

As long as this compensation continues, there are no symptoms. If
any dilatation occurs from disease, degeneration or from increased
work put on the heart (and it is readily seen how delicate this
equilibrium is), signs of broken compensation begin to occur. The
left ventricle with its enormous strain is perhaps the first part to
dilate, thus enlarging the opening of the defective mitral valve.
The left auricle is then unable to cope with the increased amount of
regurgitant blood, and there is in consequence congestion in the
lungs, and the right ventricle finds the pressure ahead in the lungs
greater than it can well overcome. The right ventricle, in its turn
being overworked, becomes dilated, and as a result of the inability
of the right ventricle to evacuate its contents perfectly, the right
auricle is unable to force its venous blood into the right
ventricle, and there is then a damming back and sluggish circulation
in the superior and inferior venae cavae. The results of these
circulatory deficiencies are, in the first place, congestion of the
lungs and dyspnea; in the second place, with the impaired force of
the left ventricle making the arterial circulation imperfect, and
with the impaired return of venous blood to the right auricle making
the venous circulation sluggish, passive congestions of various
organs occur and are evidenced in headache and venous congestion of
the eyes and throat, with perhaps cerebral irritability,
sleeplessness, and inability to do good mental work. The sluggish
return of the blood in the inferior vena cava causes primarily a
sluggish portal circulation with a passive congestion and
enlargement of the liver. This causes imperfect bile secretion and
an imperfect antidotal action to the various toxins of the body or
to any alkaloidal drugs or poisons ingested. This congestion of the
liver causes a damming back of the blood in the various veins of the
portal system, which causes congestion of the stomach and of the
mucous membrane of the bowels, and an imperfect secretion of the
digestive fluids of these structures. There is also congestion of
the spleen. The imperfect return of the blood through the inferior
vena cava also interferes with the return of the blood through the
renal veins, and more or less renal congestion occurs, with a
concentrated urine and perhaps an albuminuria as the result. The
same sluggish flow of the inferior vena cava blood, plus the
imperfect tone of the systemic arterial system, means that the
circulation at the distal portions of the body--the feet and the
legs--is imperfect when the patient is up and about, with the result
of causing pendant edemas, which disappear at night when the patient
is at rest and the heart more easily accomplishes its work.

The physical signs of such a heart, the increased valvular murmur or
murmurs, its irregular action, possibly intermittence or irregular
contractions of different parts of the heart, causing diocrotic or
intermittent pulse with a lowered blood pressure, are all signs
readily found. The quickened respiration is Nature's method of
aiding the return circulation in the veins by increasing the
negative pressure in the chest. The increased number of pillows the
patient requires at night is to aid Nature's need to have a better
venous return circulation in the vital centers at the base of the
brain.

The dry, troublesome, tickling cough is generally due to a
congestion of the blood vessels at the base of the tongue, in the
lingual tonsil region, or possibly in the larynx. Later the passive
congestion of the lungs may be sufficient to cause a bronchitis,
with cough and expectoration.

Sometimes, as indicative of primary cardiac distress, these patients
have sharp pains through the heart. Such pains are the exception
rather than the rule, and are more likely to occur in chronic
myocarditis or in coronary disease: in other words, in true angina
pectoris.

If there is considerable venous congestion there may be more or less
frequent recurrent venous hemorrhages. This frequently is an
epistaxis, or a bleeding from hemorrhoids, or in women profuse
menstruation or a metrorrhagia.

It is perfectly understandable from the physics of the condition of
broken compensation that anything which improves the tone of the
heart and makes it again compensatory removes all of these many
disabilities, congestions and subacute inflammations. If, however,
these passive congestions are long continued, some organs soon
become chronically degenerated. This is especially true of the liver
and kidneys.


PHYSICS OF MITRAL STENOSIS

Mitral stenosis, though less common than mitral regurgitation, is a
frequent form of disease of the valves, especially in women. Often
this condition is associated with regurgitation; but in a simple
mitral stenosis the greatest hypertrophy is of necessity in the
right ventricle. The left auricle finds it difficult to empty all of
its blood into the left ventricle during the ordinary diastole of
the heart. This auricle then somewhat hypertrophies, but is unable
to prevent more or less damming back of the blood into the lungs
through the pulmonary veins. This causes passive congestion of the
lungs, and the right ventricle finds that it must labor to overcome
the increased resistance in the pulmonary artery, and hypertrophies
to overcome this increased amount of work. When this condition has
become perfected, compensation is established and the circulation is
apparently normal. Nature causes these hearts, when they are
disturbed or excited, to pulsate slowly, causing the diastole to be
longer than in a heart with mitral regurgitation. This allows more
blood to enter the left ventricle, and the left ventricle, acting
perfectly on the blood which it receives, causes a good systolic
pressure in the aorta and the systemic arteries. The left ventricle
in this condition does not become hypertrophied. If the heart does
act rapidly and the left ventricle contracts on an insufficient
amount of blood, the peripheral pulse is necessarily small and the
arterial tension is diminished. Very constant in this condition, and
of course noticeable whenever there is pulmonary congestion, is the
sharp, accentuated closure of the pulmonary valve. The lungs on the
least exertion are always a little overfilled with blood. The
pulmonary circulation is always working at a little disadvantage.

The first symptoms of lack of compensation with the lesion of mitral
stenosis are lung symptoms--dyspnea, cough, bronchitis, slight
cyanosis, sometimes blood streaks in the expectorated mucus and
froth, and, if the congestion is considerable, some edema of the
posterior part of the lungs, if the patient is in bed. Sooner or
later during this failing compensation the right ventricle becomes
dilated, and the symptoms of cardiac insufficiency and venous
congestion occur, as described above with mitral insufficiency.

Again, as in mitral insufficiency, if compensation is restored in
mitral stenosis, these symptoms are improved. These patients,
however, are never quite free from dyspnea on exertion. Any
inflammation of the lungs, even a severe bronchitis, is more or less
serious for the patients and their hearts. The mucous membrane of
their bronchial tubes and air vesicles is always hyperemic, and it
takes little more congestion to all but close up some of the
passages. and dyspnea or asthma, or suffocating, difficult cough is
the consequence.


PHYSICS OF AORTIC LESIONS

Next in frequency to mitral insufficiency is aortic insufficiency,
which occurs most frequently in men. The cavity of the heart that is
most affected by this lesion is the left ventricle, which receives
blood both from the left auricle, and regurgitantly from the aorta.
This part of the heart, being the strongest muscular portion, is the
part most adapted to hypertrophy, and the hypertrophy with this
lesion is often enormous. For a long time this large muscular
section of the heart can overcome all difficulties of the aortic
insufficiency. The pulse, however, will always show the quickly lost
arterial pressure of every beat on account of the aorta losing its
pressure through the regurgitant flow of blood. Sooner or later,
from the impaired aortic tension causing a diminished or imperfect
flow of blood through the coronary arteries, impaired nutrition of
the heart muscle occurs. In other words, an intestinal or chronic
myocarditis or fibrosis develops, with perhaps later a fatty
degeneration. When this condition occurs, of course, the repair of
the heart is impossible.

This form of valvular lesion is the one that is most likely to cause
sudden death. In aortic regurgitation Nature causes the heart to
beat rapidly. Such a heart must never beat slowly, as the longer the
diastole prevails the more blood will regurgitate into the left
ventricle, and death may occur from sudden anemia of the base of the
brain. Such a heart may, of course, receive a sudden strain, or the
left ventricle may dilate, and yet serious myocarditis or fatty
degeneration may not have occurred.

The signs of lack of compensation are generally cardiac distress,
rapid heart, insufficiency of the systolic force of the left
ventricle, and therefore impaired peripheral circulation, a sluggish
return circulation, pendent edemas, and soon, with the left auricle
finding the left ventricle. insufficiently emptied, the damming back
of the blood is in broken compensation with the mitral lesions.


AORTIC STENOSIS

Aortic narrowing or stenosis is a frequent occurrence in the aged
and in arteriosclerosis when the aorta is involved. It is not a
frequent single lesion in the young. If it occurs in children or
young adults, it is likely to be combined with aortic regurgitation,
meaning that the valve hay been seriously injured by an
endocarditis.

The first effect of this narrowing is to cause hypertrophy of the
left ventricle, and as long as this ventricle is able to force the
blood through the narrowed opening at the aortic valve, the general
circulation is perfect. Nature again steps in to cause such a heart
to heat deliberately, allowing time for the contracting ventricle to
force the blood through the narrowed orifice. The blood pressure may
be sufficient, or even increased if arteriosclerosis is present,
although the rise of the sphygmograph tracing is not so high as
normal. If the pressure in the aorta is sufficient from the amount
of blood forced into it, the coronary arteries receive enough blood
to keep up the nutrition of the heart muscle. Sooner or later,
however, the left ventricle will become weakened, especially when
there is arteriosclerosis or other hypertension, and chronic
endocarditis and fatty degeneration result. If the left ventricle
becomes sufficiently weakened or dilated, the same damming back of
the blood through the lungs and right heart occurs, and more or less
serious signs of broken compensation develop. The main danger,
however, with a heart with this lesion, occurring coincidently with
arteriosclerosis, is a progressive chronic myocarditis.


OTHER LESIONS

Tricuspid insufficiency, except as rarely found in the fetus, is
generally due to a relative insufficiency rather than to an actual
disease of the tricuspid valve. In other words, if the right
ventricle dilates the valve may be insufficient. Tricuspid stenosis,
pulmonary stenosis and pulmonary insufficiency are rare, and are
probably nearly always congenital.

The diagnosis as to whether the murmurs heard in the heart are
hemic, functional, accidental, or indicative of valvular lesions
would be without the scope of this book. It is always presumed that
a correct diagnosis has been made, or at least a presumptively
correct diagnosis. Frequently more than one murmur and more than one
lesion in a heart are present. Often one murmur denotes a permanent
lesion, and another may be one that will become corrected when
compensation is improved.


SYMPTOMATOLOGY AND TREATMENT OF CHRONIC VALVULAR LESIONS

Before discussing the treatment of broken compensation in general,
it may be well to describe briefly the differences in the symptoms
and treatment of the various valvular lesions.


MITRAL STENOSIS: MITRAL NARROWING

This particular valvular defect occurs more frequently in women than
in men, and between the ages of 10 and 30, and is generally the
result of rheumatic endocarditis or chorea, perhaps 60 percent of
mitral stenosis having this origin. Other causes are various
infections or chronic disease, such as nephritis. Of course, like
any valvular lesion, it may be associated with other lesions, and
sooner or later in many instances, when the left ventricle becomes
dilated or weakened, mitral insufficiency also occurs.

It has sometimes seemed that high blood pressure has caused the left
ventricle to act with such force as to irritate this mitral valve,
and later develop from such irritation a sclerosis or narrowing, and
stenosis occurs. It has been suggested that, though lime may be of
advantage in heart weakness, as will be stated later, if the blood
is overfull of calcium ions the valvular irritations may more
readily have deposits of calcium, in other words, become calcareous,
and therefore cause more obstruction. It is quite likely, however,
that this sort of deposit is only a piece of the general
calcification of tissue in arteriosclerosis and old age, and could
not be caused by the administration of calcium to a younger patient,
and might then occur in older patients even if substances containing
much calcium were kept out of the dict. Calcium metabolisim in
arteriosclerosis and in softening of the bones is not well
understood.

Patients with this lesion are seriously handicapped when any
congestion of the lungs occurs, such as pneumonia, pleurisy, or even
bronchitis. Asthma is especially serious in these cases, and these
patients rarely live to old age.

The pulse is generally slow, unless broken compensation occurs;
dyspnea on exertion is a prominent symptom; the increased secretion
of mucus in the bronchial tubes and throat is often troublesome, and
there is liable to be considerable cough. If these patients have an
acute heart attack, a feeling of suffocation is their worst symptom
and the dyspnea may be great, although there may be no tachycardia,
these hearts often acting slowly even when there is serious
discomfort. When compensation fails, there is an occurrence of all
the usual symptoms, as previously described.

The distinctive diagnostic physical sign of this lesion is the
diastolic and perhaps presystolic murmur heard over the left
ventricle, accentuated at the apex and transmitted some distance to
the left of the heart. There is also an accentuated pulmonary
closure. To palpation this lesion often gives a characteristic
presystolic thrill at and around the apex.

The first symptoms of weakening of the compensation are irregularity
in the beat and venous congestion of the head and face, causing
bluing of the lips, often nosebleed, and sometimes hemoptysis and
insomnia. Later the usual series of disturbances from dilatation of
the right ventricle occurs. As previously stated, with the absence
of good coronary circulation and the consequent impaired nutrition,
the left ventricle may also dilate and the mitral valve may become
insufficient. Sudden death from heart failure may occur with this
lesion more frequently than with mitral insufficiency but less
frequently than with aortic insufficiency.

A particularly dangerous period for women with this lesion is when
the blood pressure rises after the menopause and the patients become
full-blooded and begin to put on weight. Also, these patients always
suffer more or less from cold extremities. In most cases they sleep
best and with least disturbance with the head higher than one
pillow.

Besides the usual treatment for broken compensation in patients with
this lesion, digitalis is of the greatest value, and the slowing of
the heart by it, allowing the left ventricle to be more completely
filled with the blood coming through the narrowed mitral opening
during the diastole, is the object desired. This drug acts similarly
on both the right and left ventricles, and though there is no real
occasion for stimulation of the left ventricle, and it is the right
ventricle that is in trouble, dilated and failing, still a greater
force of left ventricle contraction helps the peripheral
circulation. The action on the right ventricle contributes greatly
to the relief of the patient by sending the blood through the lungs
and into the left auricle more forcibly. and the left ventricle
receives an increased amount of blood, the congestion in the lungs
is relieved, and the dyspnea improves. Perhaps there is no class of
cardiac diseases in which more frequent striking relief can be
obtained than in these cases of mitral stenosis.

If the congestion of the lungs is very great, and death seems
imminent from cardiac paralysis, if cyanosis is serious, and bloody.
frothy mucus is being expectorated, venesection and an intramuscular
injection of aseptic ergot may be indicated. Digitalis should also
be given, hypodermically perhaps, but its action would be too late
if it was not aided by other more quickly acting drugs. The
physician may often save life by such radical measures.


MITRAL INSUFFICIENCY: MITRAL REGURGITATION

This is the most frequent form of valvular disease of the heart, and
is due to a shortening or thickening of the valves, or to some
adhesion which does not permit the valve, to close properly, and the
blood consequently regurgitates from the left ventricle into the
left auricle during the contraction of the ventricle. Such
regurgitation may occur without valvular disease if for any reason
the left ventricle becomes dilated sufficiently to cause the valve
to be insufficient. Such a dilatation can generally be cured by rest
and treatment. As with mitral stenosis, the most frequent causes are
rheumatism and chorea, with the occasional other causes as
previously enumerated.

The characteristic murmur of this lesion is a systolic blow,
accentuated at the apex, transmitted to the left of the thorax,
generally heard in the back, near the lower end of the scapula, and
transmitted upward over the precordia.

Of all cardiac lesions, this is the safest one to have. Sudden death
is unusual, the compensation of the heart seems to be most readily
maintained, and the patient is not so greatly dangered by
overexertion or by inflammations in the lungs. As in mitral
stenosis, any increase in blood pressure--whether the normal
increase after the age of 40, any continued earlier high tension, or
increase from occupation or exercise--is serious as causing the left
ventricle to act more strenuously, so that more blood is forced back
into the left auricle, the lungs become congested, and the right
ventricle, sooner or later, becomes incompetent.

When compensation fails with these patients, the first sign is
pendent edema of the feet, ankles and legs; subsequently, if there
is progressive failure of compensation, the usual symptoms occur.

The treatment is principally rest and digitalis, and the recovery of
compensation is often almost phenomenal. Patients with this lesion
are likely to be children and young adults, and the heart muscle
readily responds as a rule to the treatment inaugurated. Later, in
these patients, or if the lesion occurs in older patients, the
return to compensation does not occur so readily. If the condition
is developed from a myocarditis or from fatty degeneration of the
heart, it may be impossible to cause the left ventricle to improve
so much as to overcome this relative dilatation or relative
insufficiency of the valve. If the dilatation of the left ventricle
is due to some poisoning such as nicotin, with proper treatment--
stopping the use of tobacco, administration of digitalis, and rest--
the heart muscle will generally recover and the valve again properly
close.


AORTIC STENOSIS: AORTIC OBSTRUCTION

Valvular disease at the aortic orifice is much less common than at
the mitral orifice, and while stenosis or obstruction is less common
from rheumatism or acute inflammatory endocarditis than is
insufficiency of this valve, a narrowing or at least the clinical
sign of narrowing, denoted by a systolic blow at the base of the
heart over the aortic opening, is in arteriosclerosis and old age of
frequent occurrence. If such narrowing occurs without aortic
insufficiency at the age at which it usually occurs, it may not
seriously affect the heart. It may follow acute endocarditis, but it
most frequently follows chronic endocarditis or atheroma, in which
the aortic valves become thickened and more or less rigid; this
condition most frequently occurs in men.

Anything that tends to increase arterial tension, as tobacco, lead
or hard work, or anything that tends to cause arterial disease, as
alcohol or syphilis, is often the cause of this lesion.

At times the edges of the valves may grow together from ulcerative
inflammation, and the lumen thus be diminished in size; or
projecting vegetations may interfere with the opening of the valve
and with the flow of blood. With such narrowing the left ventricle
more or less rapidly hypertrophies to overcome its increased work.

The murmur caused by this lesion is a systolic one, either
accentuated in the second intercostal space at the right of the
sternum, or perhaps heard loudest just to the left of the sternum in
this region. The murmur is also transmitted up the arteries into the
neck, and may at times be heard in the subclavian arteries. It may
also be transmitted downward over the heart. The pulse is slow, the
apex of the rise of the sphymographic arterial tracing is more or
less sustained and rounded, and the rise is much less than normal.

If this lesion occurs in old age, there is general arterial disease
present, and the tension and compressibility of the arteries vary,
depending on how much they are hardened. The disturbed circulation
is evidenced by imperfect peripheral circulation and capillary
sluggishly, with at times pendent edema of the feet and ankles, but,
perhaps, little congestion of the lungs. The left ventricle being
sufficient, there is no damming back through the left auricle to the
lungs. The left ventricle may, however, become weakened, either by
some sudden strain or by a chronic myocarditis, and relative
insufficiency of the mitral valve may occur. The subsequent symptoms
are typically those of loss of compensation.

This lesion may allow a patient to live for years, provided no other
serious disturbance of the heart occurs, such as myocarditis or
coronary disease; but sooner or later, with the failing force of the
blood flow and the lessened aortic pressure, slight attacks of
anemia of the brain occur, causing syncope or fainting. Also, sooner
or later these patients have little cardiac pains. They begin to
"sense" their hearts. There may not be actual anginas, but a little
feeling of discomfort, with perhaps pains shooting up into the neck,
or a feeling of pressure under the sternum. Little excitements or
overexertions are likely to make the heart attempt to contract more
rapidly than it is able to drive the blood through the narrowed
orifice, and this alone causes cardiac discomfort and the feeling of
cardiac oppression.

It is essential, then, that these patients should not hasten and
should not become excited; and any drug or stimulant which would
cause cardiac excitement is bad for them. On the other hand, these
are the very patients in whom, sometimes, alcohol in small doses may
be advisable, especially if the patient is old; and a dose of
alcohol used medicinally when an attack of cardiac disturbance is
present is good treatment. The quick dilatation is valuable.
Nitroglycerin will also do good work in these cases, and with high
blood tension may be the only safe drug for the patient to have on
hand. As soon as his attack occurs, with or without real angina
pectoris, let him dissolve in his mouth a nitroglycerin tablet. If
he feels faint, he will feel better the moment he lies down, and in
this instance he may be improved by a cup of coffee, or a dose of
caffein or camphor.

If the left ventricle becomes still weaker and shows signs of
serious weakness, or if there is actual dilatation, the question of
whether or not digitalis should be used is a subject for careful
decision. The left ventricle should not be forced to act too
sturdily against this aortic resistance. Consequently the dose of
digitalis must be small. On the other hand, it frequently happens,
especially in old age, that myocarditis or fatty degeneration has
already occurred before this cardiac weakness develops in the
presence of aortic narrowing, and digitalis may not be indicated at
all. We cannot tell how far degeneration may have gone, however, and
small doses of digitalis used tentatively and carefully, perhaps 5
drops of an active tincture two or three times a day, and then the
drug carefully increased to a little larger dose to see whether
improvement takes place, is the only way to ascertain whether or not
digitalis can be used with advantage. If it increases the cardiac
pain and distress, it should not be used. Strychnin is then the drug
relied on, with such other general medication as is needed, combined
with the coincident administration of nitroglycerin, which may also
be given in conjunction with digitalis, if deemed advisable.
Generally, however, if a heart with aortic stenosis needs
stimulation, the blood pressure is generally none too high, although
there may be arteriosclerosis present. Therefore when nitroglycerin
is indicated to lower blood pressure, digitalis is not usually
indicated; when digitalis is indicated to aid the heart,
nitroglycerin is generally not indicated. These patients must have
high blood pressure to sustain perfect circulation at the base of
the brain.

Patients who have this lesion should not use tobacco in large
amounts, or sometimes even small amounts, as tobacco raises the
blood pressure and thus puts more work on the left ventricle; in the
second place, if the left ventricle is failing, much tobacco may
hasten its debility. On the other hand, with a failing left
ventricle and a long previous use of tobacco, it is no time to
prohibit its use absolutely. A failing heart and the sudden stoppage
of tobacco may prove a serious combination.


AORTIC INSUFFICIENCY: AORTIC REGURGITATION

This lesion, though not so common as the mitral lesion, is of not
infrequent occurrence in children and young adults as a sequence of
acute rheumatic endocarditis. If it occurs later in life it
generally is associated with aortic narrowing, and is a part of the
general endarteritis and perhaps atheroma of the aorta. Sometimes it
is caused by strenuous exertion apparently rupturing the valve.

This form of valvular disease frequently ends in sudden death. On
the other hand, it is astonishing how active a person may be with
this really terrible cardiac defect. This lesion, from the frequent
overdistention of the left ventricle, is one which often causes
pain. While the left ventricle enlarges enormously to overcome the
extra distention due to the blood entering the ventricle from both
directions, the muscle sooner or later becomes degenerated from poor
coronary circulation. Unless the left ventricle can do its work well
enough to maintain an adequate pressure of blood in the aorta, the
coronary circulation is insufficient, and chronic myocarditis is the
result. If the left ventricle has maintained this pressure for a
long time, edemas are not common unless the cardiac weakness is
serious and generally permanently serious: that is, slight weakness,
in this lesion, does not give edemas as does slight loss of
compensation in mitral disease, and unless the weakness of the
ventricle is serious, the lungs are not much affected.

The physical sign of this lesion is the diastolic murmur, which is
loudest of the base of the heart, is accentuated over the aortic
orifice, and is transmitted up into the neck and the subclavians,
and down over the heart and down the sternum with marked pulsation,
of the arteries (Corrigan pulse) and often of some of the peripheral
veins, notably of the arms and throat.

If the left ventricle becomes dilated the mitral valve may become
insufficient, when the usual lung symptoms occur, with hypertrophy
of the right ventricle; and if it fails, the usual venous symptoms
of loss of compensation follow. This lesion not infrequently causes
epistaxis, hemoptysis and hematemesis.

Digitalis is always of value in these cases, but it should not be
pushed. If a heart is slowed too much, the regurgitation into the
left ventricle is increased. Therefore such hearts should not be
slowed to less than eighty beats per minute, or sudden anemia of the
brain and sudden death may occur. These patients must not do hard
work.


TRICUSPID INSUFFICIENCY

This rarely, if ever, occurs alone; it is generally a sequence of
other valvular defects, and represents an overworked, dilated right
ventricle. It may, however, occur from lesions of the lungs which
impede the blood flow through them. Such are fibroid changes in the
lungs, emphysema, prolonged chronic bronchitis, the last stages of
pulmonary tuberculosis, old neglected pleurisies with cirrhosis or
fibrosis of the lung, and repeated attacks of asthma--anything,
whether valvular defect or pulmonary circulatory disturbance, which
increases the pressure ahead and the work of this ventricle.

The symptoms are those of loss of compensation as described under
other valvular lesions. There may be jugular pulsation, especially
evident in the external jugular on the left side. The liver enlarges
and may pulsate. There are edemas, dropsies, ascites and perhaps
hemorrhages. The heart is enlarged and there is a soft systolic blow
heard at the lower end of the sternum. The dyspnea is sometimes very
great, and cyanosis may be present, especially during paroxysms of
coughing.

This lesion of the heart is always benefited by digitalis, but the
continuance of the improvement and its amount depend, of course, on
the cause of the dilatation of the ventricle. Strychnin is often of
advantage. These patients should rarely receive vasodilators, and
hot baths, overheating, overloading the stomach and vigorous purging
should never be allowed. Sometimes improvement will not take place
until ascitic or pleuritic fluid, if present, has been removed.


TRICUSPID STENOSIS: TRICUSPID OBSTRUCTION

This is rare and probably always congenital, and is supposed to be
due to an inflammation of the endocardium during intra-uterine life.
In early childhood it is possible that it may be associated with
left-side endocarditis.

A special treatment of the heart, if any is needed, would probably
not be indicated unless there was associated tricuspid
insufficiency, when digitalis might be used.


PULMONARY INSUFFICIENCY: PULMONARY REGURGITATION

If this rare condition occurs, it is probably congenital. A
distinctive murmur of this insufficiency would be diastolic and
accentuated in the second intercostal space on the left of the
sternum. It should be remembered that aortic murmurs are often more
plainly heard at the left of the sternum. Sooner or later, if this
lesion is actually present, the right ventricle dilates and cyanosis
and dyspnea occur. Digitalis would therefore be indicated.


PULMONARY STENOSIS: PULMONARY OBSTRUCTION

If stenosis is actually present in this location, the lesion is
probably congenital. It might occur after a serious acute infectious
endocarditis, but then it would be associated with other lesions of
the heart. It has been found to be associated with such congenital
lesions of the heart as an open foramen ovale or foramen Botalli, or
with an imperfect ventricular septum, and perhaps with tricuspid
stenosis--in short, a cardiac congenital defect. The right ventricle
becomes hypertrophied, if the child lives to overcome the
obstruction.

The physical sign is a systolic blow at the second intercostal space
on the left; but as just stated, such a murmur must surely be
dissociated from an aortic murmur if found to develop after
babyhood, and it should also be diagnosed from the frequently
occurring hemic, basic and systolic murmurs; that is, if signs of
pulmonary lesions are not heard soon after birth or in early
babyhood, the diagnosis of pulmonary defects can be made only by
exclusion.

Unless the right ventricle is found later to be in trouble, there is
no treatment for this condition. If the right ventricle dilates,
digitalis may be of benefit.




ACUTE CARDIAC SYMPTOMS: ACUTE HEART ATTACK


It is not proposed here to describe the condition of sudden cardiac
failure, or acute dilatation during disease, or after a severe heart
strain, but to describe the terrible cardiac agony which occurs,
sometimes repeatedly, with many patients who have valvular lesions.
These patients may not have the symptoms of loss of compensation.
Probably some one or more chambers of the heart become overdistended
and act irregularly, or the blood is suddenly dammed up in the
lungs, with the oppression and dyspnea caused by such passive
congestion, or perhaps it is the right ventricle that is suddenly in
serious trouble.

A physician receives an emergency call, and knows, if it is not a
patient who has hysteria, that it is his duty to see the patient
immediately. The friends of the patient all anxiously await the
physician's arrival; front doors are often wide open, and the
servants and the whole household are in a great state of excitement
and anxiety. The position in which the patient will be found is that
which he has learned gives him the greatest comfort. If the
physician knows his patient, he will know how he will find him. He
may lie sitting up in bed; he may be standing, leaning over a chair;
he may be sitting in a chair leaning over a table or leaning over
the back of another chair; but he is using every auxiliary muscle he
possesses to respire. He is generally bathed in cold perspiration;
the extremities are often icy cold; he calls for air, and to stop
fanning all in one breath; he wishes the perspiration wiped off his
brow, and nearly goes frantic while it is being done; there is agony
depicted on his face; his eyes stare; his expirations are often
groaning. Sometimes there is even incontinence of urine and feces,
often hiccup or short coughs, perhaps vomiting, and possibly sharp
pangs of pain in the cardiac region. A patient with these symptoms
may die at any moment, and the wonder is that so many times one
lives through these paroxysms.

The patient can hardly be questioned, can certainly not be carefully
examined; and herein lies the advantage of the family physician who
knows the patient and his heart, and in whom the patient has
confidence.

In fact, this confidence which such a patient has in the physician
who has more or less frequently aided him in weathering these
terrible attacks is alone the greatest boon the patient can have.


MANAGEMENT

The immediate conditions to meet are the rapid fluttering heart, the
nervous excitation and cardiac anxiety, and perhaps the most
important of all, the vasomotor spasm that is often so pronounced.
Physically we have, then, a heart with leaking or constricted
valves; in either case more blood is entering the chambers of the
heart than can be expelled in one contraction, while the peripheral
resistance due to the spasm of the blood vessels, because of fear,
becomes greater every minute and tends still more to interfere with
the peripheral circulation and the complete emptying of the heart of
its surplus blood. Owing to the well known stimulus to distention of
hollow muscular organs, the heart contracts faster and faster.

Soon, by some disarrangement of the inhibitory apparatus, the
pneumogastric nerves, the heart loses its governor, and the beats
increase to even 150 a minute, with irregular contractions, the
blood being sent through the arteries with irregular force, as
evidenced by the varying volume of the pulse. At this time, with or
without cardiac pain, which upsets the rhythm of the heart, the
patient becomes frightened at the feeling of impending demise, and
the cerebral reflexes begin to add to the cardiac difficulty. The
breathing becomes nervously rapid, besides that which is due to the
rapid heart. The chill of fear is added to the already contracted
peripheral vessels, and the surface of the body becomes cold, the
extremities sometimes intensely so. Next it seems as if the strongly
contracted arterioles begin actually to prevent some of the
peripheral circulation, the blood is piled up in the large arteries,
and the venous circulation becomes more and more sluggish, while the
lips, finger nails and forehead become cyanotic. Respiration becomes
more rapid and deep; the inspiration being as strong as possible
with every auxiliary muscle taking part, thus making the negative
pressure in the chest aid in bringing the blood back through the
veins. Part of the extra respiratory stimulus comes from the
imperfectly aerated blood reaching the respiratory center.

Two factors may normally, without treatment, stop these paroxysms,
and the "bad heart turn" may be cured spontaneously. The first of
these is self-control. If the patient does not lose his head, by an
effort of the will he saves himself from becoming nervous or
frightened and therefore escapes the result of mental excitement;
the increased peripheral blood pressure from fear does not occur,
and in a shorter or longer time the heart quiets down. The physician
recognizes this power, and gives his patient immediate assurance
that he will soon be all right; the patient who knows his physician
immediately feels this assurance and is quickly improved.

The second factor in spontaneous cure of the heart attack is
relaxation. The exhaustion from the respiratory muscular efforts,
together with the drowsy condition caused by the cerebral hyperemia
and from the imperfectly aerated blood, causes finally a dulling of
the mental acuity, and the nervous excitement abates, which, with
the exhaustion, gives a relaxation of peripheral arterioles: the
resistance to the flow of the blood is removed, the surface of the
body becomes warm, the heart quiets down by the equalization of the
circulation, and the paroxysm is over.


DRUGS

The part the nervous system plays in this paroxysm is shown by the
good result obtained from injections of morphin, even when there is
no pain; hence the action of morphin is directly in line with the
natural resolution of the symptoms: it quiets the nervous system,
causes drowsiness, relaxes spasm, and thus causes increased
peripheral circulation; many times this is the only treatment
necessary.

During these heart attacks it is more than useless to administer any
drug by the stomach, as in this condition there will be no
absorption, even if there is no vomiting.

While morphin is generally indicated, as just suggested, a very
large dose should not be given, lest the activity of the respiratory
center be impaired (it is already in trouble), and undoubtedly death
may easily be caused by an overaction of morphin during these heart
attacks. The addition of atropin to the morphin will prevent
depression from the morphin. Also, atropin sometimes quiets cardiac
pain, but it will not steady the heart, may irritate it, and will
increase vasomotor tension, although peripheral nerve irritation may
be diminished. Hence a fair dose of morphin hypodermicaly with a
small dose of atropin, if respiratory depression is feared, is a
physiologic method of bettering the condition. In this kind of heart
attack a drug which often acts well is nitroglycerin. It may be
given hypodermically in a dose of from 1/200 to 1/100 grain, or a
tablet may be dissolved on the tongue, and the dose be repeated once
or twice at fifteen-minute intervals, until there is throbbing in
the forehead, which shows that a sufficient amount of the drug has
been administered. This headache will generally not last long. In
the meantime the peripheral blood vessels are relaxed, the surface
of the body becomes warm, the heart quiets, and the attack is over.
To hasten the action of nitroglycerin (that is, to equalize the
circulation) a hot foot-bath is often valuable. Amyl nitrite may be
inhaled with the same object in view, but the action is very
intense, the prostration often severe, and unless there is angina
pectoris, nitroglycerin is much better.

The symptoms of a heart attack may not be quite those described
above; they may be those of sudden dilatation or semiparalysis of
the heart, in which the prostration is intense and the patient is
unable to sit up, although he may be leaning against several
pillows. There is dyspnea, but the patient cannot aid respiration
with the auxiliary muscles by holding the arms and shoulders tense
or obtaining support from the aruls; in fact, the arms are almost
strengthless. The surface of the body may be warm, and the arms may
be warm except the hands; the feet, ankles and legs may be cold.
There is generally more or less cyanosis, although the face may be
pale. The finger nails often show venous stasis. In these cases the
blood pressure is subnormal, the pulse may be hardly perceptible,
and there is none of the tension of the body from fear. The patient
may be fearful, but lie is completely collapsed. Such an attack may
occur suddenly in a heart that is perfectly compensating, or it may
accompany general edemas and dropsies.

If the emergency is excessively urgent, the lungs filling up with
blood, moist rales beginning to occur, and frothy and blood-tinged
sputum being coughed up, venesection may be indicated; combined with
proper hypodermic medication it may save life, and does at times. In
fact, a patient who shows every sign of fatal cardiac collapse may
be saved. (one of the best drugs to administer to such patient is an
aseptic ergot, injected intramuscularly.) The drug of all drugs for
future action (as it will not act immediately) is digitalis, given
hypodermically.

Whether digitalis shall be given at all, or how large the dose shall
be depends on whether or not the patient has been taking digitalis
in large quantities.

He may already be overpowered with digitalis. In that case it would
be contraindicated.

Stroplianthin, especially when given intravenously, has been found
to be a quickly acting circulatory stimulant. The dose of
strophanthin, Merck, ranges from 1/500 to l/200 grain. The
intravenous dose of strophanthin, Thoms, is about 1/130 grain. It
should not be repeated within a day or two, if at all. Ampules of
strophanthin in solution for intravenous use are now available.

Atropin in a dose of 1/150 grain, and strychnin in a dose of 1/40 or
1/30 grain are valuable aids in stimulating the circulation under
these conditions. The atropin should not be repeated. The strychnin
may be repeated in three, four or five hours, depending on the size
of the previous close.

Of all quickly acting stimulants, none is better than camphor in
saturated solution in sterile oil as may be obtained in ampules.
Alcohol is absolutely contraindicated in the latter condition. In
the former kind of heart attack, vasodilation from a large close of
whisky or brandy may be of value. The dose should be large to cause
immediate increased peripheral circulation, dilation, and even a
little stupefaction of the central nervous system, and it may be
effectual in a way not dissimilar to the action of morphiti.


TREATMENT OF BROKEN COMPENSATION

The consideration of this subject will include the following topics:
A.  Hygiene.
B.  Diet.
C.  Elimination.
D.  Physical measures.
E.  Medication.
   1.  Cardiac Tonics: Digiralis, strophanthus, caffein, strychnin.
   2.  Cardiac Stimulants: Camphor, alcohol, ammonia.
   3.  Vasodilators: Nitrites, iodids, thyroid extract.
   4.  Cardiac Nutritives: Iron, calcium.
   5.  Cardiac Emergency Drugs: Ergot, suprarenal active principle,
       pituitary active principle, atropin, morphin, and also some
       of the drugs already mentioned.


A. HYGIENE

Of all treatment for broken compensation or dilated heart, nothing
equals rest in bed. Sometimes it is the only treatment that is
needed. The rigidness of this rest, the length of time that it
should endure, and the period at which relaxation of such rest
should be allowed depend entirely on the individual patient; no rule
can be established. Most of the symptoms must disappear before
exercise is allowed. Perhaps a not infrequent exception to the rule
is when cardiac weakness, generally a inyocarditis, develops in a
patient after 50. It is not always wise to keep such a patient in
bed; he may be rested and his exercise greatly restricted, but
sometimes it is difficult to get him out of bed if he is kept there
any length of time.

Fresh air, sunlight and anything else that makes the bedroom
attractive and cheerful are essential and will aid in the recovery.
The kind of nurse that is needed, trained, untrained, or a member of
the family, and the amount of company or entertainment allowed must
be decided for the individual patient. The patient must be
distinctly individualized and the proper measures taken to give
mental and physical rest, to prevent excitement, worry, melancholia
and depression, and to improve the general nutrition of the body as
well as the condition of the heart.

Each occurrence of broken compensation in valvular disease causes
another attack of cardiac weakness to occur with less excuse than
before, and several serious attacks of broken compensation mean
before long the loss of the heart muscle's ability to recover, so
that permanent dilatation occurs.

B. DIET

The food given should be just sufficient for the needs of the body;
the patient should not be overfed or underfed. Any large bulk of
food or liquid should not be given. Pressure on the heart causes
discomfort and is therefore inadvisable. Food that causes flatulence
should be avoided. Theoretically the patient should receive a little
meat, an egg or two, cereal or bread, a small amount of simple
vegetables, a little fruit, often milk, a sufficient amount of
noneffervescent water, perhaps a cup of chocolate or cocoa, a simple
dessert, sometimes ice cream; in other words, a varied, limited diet
containing all the elements that are necessary to good nutrition.
The diet should be varied from day to day to encourage the appetite.

It has for several years been recognized that a salt-free diet in
dropsies due to disease of the kidneys is a valuable aid in causing
absorption of such exudates and of preventing greater exudations.
For this reason a salt-free diet is often ordered in dropsies
occurring in valvular disease. Its value, however, is not so great
as in kidney lesions, and if it causes hardship to the patient it
should not be continued rigorously. On the other hand, large amounts
of salt should of course be interdicted.

A most valuable aid in dropsies due to heart deficiencies is the so-
called dry diet, which means that as little liquid as possible
should be taken in order that the patient's blood may resorb the
exudate in the tissues and not have the blood vessels filled or
overfilled with liquid from the gastro-intestinal tract. When dropsy
is present, or even when serious pendent edemas are present, the
patient should drink as little liquid as possible with his meals,
and between meals should sip water rather than drink a large
quantity of it. This is one of tile reasons that a large milk diet,
even with kidney disturbance due to cardiac lesions, is generally
inadvisable. With cardiac or general circulatory weakness, a laige
amount of liquid to flush out the kidneys and the whole system, so
long ordered for all kidney defects or mistakes in metabolism, is a
seribus mistake. The Karel diet is described in the section on
cardiovascular-renal disease.

Whether it is better to give three or four small meals a day or to
give a small amount of nourishment every three hours during the
daytime must again depend on the individual and his ability to
digest without fermentation and putrefaction or discomfort. As
previously urged, not too much fluid, even milk, though it digest
perfectly, should be given, as the greater the amount of fluid the
greater the amount of work thrown on the heart.

C. ELIMINATION

A patient who has developed decompensation has always imperfect
elimination. The skin, bowels and kidneys do not act sufficiently or
well. The circulation in the skin is sluggish. The bowels are
generally constipated, or there is diarrhea of the fermentative
type. The amount of urine excreted is generally insufficient and
likely to be concentrated and show various signs of imperfect kidney
elimination. Therefore hot sponge baths, with perhaps warm alcohol
rubs, are daily necessary. Gentle massage, generally in the
direction to aid the circulation, will benefit the skin. If the skin
is dry or in places scaly, oil rubs are of great benefit.

The bowels must be moved daily and sufficiently, but there should be
no watery purging allowed or caused. If it seems advisable in the
beginning of the treatment to give a calomel purge, it should be
done, but such purging should ordinarily not be repeated, although
occasionally a grain or two of calomel, combined with the vegetable
laxatives needed, may act perfectly and without causing depression.
Saline purgatives, or even laxatives, are generally not good
treatment when there is cardiac weakness. The bowels should be moved
by vegetable laxatives, as aloin, cascara sagrada, or some simple
combination of either or both of these drugs.

Diuretics are often not satisfactory in cardiac insufficiency. The
cardiac tonics which are given the patient, and the improvement of
the heart from the rest in bed generally start the kidneys to
secreting properly. A diuretic administered when the kidneys are
suffering passive congestion from cardiac insufficiency does not
generally act, and is therefore useless. If digitalis is
administered, it will act as a diuretic; if caffein is deemed
advisable, that will act as a diuretic. Squills may be administered,
if it seems best. If for any reason the kidneys secrete less urine
and become insufficient, the diet should quickly be reduced to a
small amount of milk, cereal and water, and hot baths and local heat
to the back should be inaugurated.

D. PHYSICAL MEASURES

Hydrotherapy is often of great value in restoring compensation by
improving the surface circulation. Sponging with hot, tepid or cold
water, as indicated, will increase the peripheral circulation and
the normal secretions of the skin.

When compensation is perfect, in valvular lesions, more or less
frequent warm baths are advisable, and often relieve the heart by
equalizing the circulation. Cold sponging in the morning may be
advisable, but may do harm when there is high tension; warm, not too
hot, baths are of value. Anything is of value that improves the
peripheral circulation and prevents the extremities from being cold.

The value of the Nauheim or other carbonated baths is perhaps often
a question. They have seemed in many instances to aid in improving
compensation in such patients as have been able to go abroad for the
treatment. On the other hand, so many other regimens are ordered and
inaugurated for these patients at these "cures" that it is hard to
decide how much benefit the baths have really done. At home the
artificial carbonated or carbonic acid baths do not seem to be of
great value. Baths and bathing can do harm, and the decision as to
which hydrotherapeutic measure shall be used can be made only after
careful observation of the patient by the physician.

Gentle massage while the patient is in bed is of undoubted value;
more vigorous massage is later often of value, provided there is no
arteriosclerosis. As the patient grows stronger and the circulation
improves, the muscles are kept in good condition during the enforced
rest by massage. When properly applied, it promotes not only the
venous return circulation, but also the lymphatic circulation; it
often removes muscle aches and muscle tire and restlessness.

While the patient is still in bed, various resistant exercises are
of value, and should be begun. These tend to prepare the patient for
his later greater activities; the surprise to the heart when the
patient begins to sit up and walk is not so great if he has
previously taken these exercises. Later, when the patient is
ambulatory, he should by gradual gradation walk a little more about
the house and take a few steps of the stairs at a time, until
gradually he is able to mount the whole flight. Later he should take
out-door exercise, and when his heart has become compensated for
ordinary work, he should be given gradually graded hill-climbing
with the idea of increasing his reserve cardiac power. If it is
found that these increased exertions cause him to have pain or a
more rapid heart than is excusable, even after persisting for a few
days, the attempt to increase this reserve power of the heart should
be abandoned. There is probably, at least at that particular time,
considerable myocarditis, although the heart may eventually
recuperate still more. Pushing it to overexertion, however, will not
accomplish improvement. Some of the simple "tests of heart strength"
described under that heading may be used with these patients.

Graded exercise was first used scientifically by Oertel and Schott,
and has been for years designated by their names. Modifications of
their rigid rules are generally advisable.

E. MEDICATION

1. CARDIAC TONICS.-Digitalis: There is no drug that can take the
place of digitalis in loss of compensation in chronic valvular
disease. It acts specifically for good, and it has its greatest
success in the valvular lesions that cause enlargement of the left
ventricle, on which it acts the most intensely. It also acts for
good on the right ventricle. It has but little action on the
auricles. This is simply a question of muscle; the part that has the
greatest amount of muscle will receive the greatest benefit from
digitalis, and the parts that have the least, the least benefit. The
heart muscle is somewhat similar to other muscles; when we attempt
athletic improvement in any muscle of the body, we "train" by
stimulating it moderately at first, and are careful not to overwork
it; the object, then, is to train the heart muscle. For this reason
large doses of digitalis should ordinarily not be given to
overstimulate suddenly an overworked and weak heart. While in some
instances it has been declared that digitalis should be rapidly
pushed to the full extent and then dropped for a time, careful
experience shows that this method is often not tolerated, sometimes
does positive harm, and has at times seemed to hasten death.

Another valuable activity of digitalis is in slowing the heart by
action on the pneumogastric nerves. A dilated heart has lost more or
less of its regulating mechanism; this is the cause of its
irregularity and its increased rapidity. The action of digitalis in
slowing the heart, giving it a longer rest, and preventing it from
acting irregularly is of great value. This prolonged rest or
diastole of the heart allows the circulation in the coronary
arteries to become normal, and the nutrition and muscle tone of the
heart improves. Digitalis also increases the blood pressure, not
only by improving the activity of the heart, but also by causing
some contraction of the arterioles. This feature of digitalis action
in arteriosclerosis renders its use sometimes a question of careful
decision. The dose of digitalis under such a condition should not be
large. It may be indicated, however, and may do a great deal of
good, and it does not always increase the blood pressure.

If the patient is sufficiently ill to require the best action of
digitalis, an active preparation should be obtained. It was long
supposed that the infusion presented activities which could not be
furnished by the tincture of digitalis. This seems not to be true.
The greater value of the infusion is generally because it is freshly
made and active; the tincture which had been used previously in a
given case was old and useless; furthermore, most physicians give a
larger dose of the infusion than they ever do of the tincture. Owing
to the uncertainty of the value of the digitalis leaves found in the
various drug shops, however, and to variations in the preparation of
the infusion, it is generally better to use a tincture of known
character. The beginning dose of such a tincture should generally
not be more than 5 drops, and it should not be repeated more
frequently than once in eight hours. It is generally advisable, in
two or three days, to increase this dose to 10 drops once in twelve
hours, later perhaps to 15 drops twice a day, and still later to 20
drops once a day. This amount may then be decreased gradually, if
the action is satisfactory. Enough should be given to procure
results, and then the dose should be brought down to what seems
sufficient and best, administered once a day. The frequence advised
in the administration of this drug is because it is eliminated
slowly. Its greatest action develops a number of hours after it has
been taken, and then the action lasts for many hours; the
administration of digitalis once in twenty-four hours is perfectly
satisfactory for many patients, and more satisfactory than any more
frequent administration. On the other hand, some patients do better
on a smaller dose once in twelve hours. This frequence is always
sufficient.

Digipuratum and digitol, a fat-free tincture, proprietary
preparations accepted by the Council on Pharmacy and Chemistry for
inclusion in N. N. R., may be employed. They are standardized
preparations and may thus be more satisfactory than some
pharmacopeial preparations of digitalis, although their claims to
lessened emetic action are not borne out by recent experiments of
Hatcher and Eggleston.

Digipuratum may be obtained in tubes of twelve tablets. The advice
has been given for patients with loss of compensation to receive
four tablets the first day, three the second, three the third, and
two the fourth day. This, however, is generally an overdosage. The
most that should generally be given is one of these tablets in
twelve hours. Digipuratum fluid is also a valuable preparation.

Digitol is a fat-free tincture of digitalis which is physiologically
standardized and which bears on each package the date of
manufacture. The close is from 0.3 to 1 c.c. (5 to 15 mimims).

Digitalinum, one of the active principles of digitalis, is not very
satisfactory. It may be given hypodermically, but often causes
irritation, and the proper dose and its value are apt to be
uncertain.

Digitoxin, another active principle of digitalis, has been declared
by some investigators to be harmful, also to be liable to cause
serious disturbance of a damaged heart. Other investigators have
stated that it acts for good. Digitoxin does not represent the whole
value of digitalis, and in broken compensation digitalis itself, or
some preparation embodying the majority of its activities, should be
given. Digitoxin, however, is often valuable in conditions of
cardiac debility or slight weakening in patients who do not have
dilated hearts or edemas. The most satisfactory dose of digalen is
from 5 to 10 drops once or twice in twenty-four hours.

Digitalis should not be used when there is fatty degeneration of the
heart; it should ordinarily not be used when there is
arteriosclerosis, and very rarely, if ever, when it is decided that
there is coronary disease. Whether digitalis should be used when
there is considered to be much myocardial degeneration is a question
for individualization. One can never be sure that the heart muscle
is so thoroughly degenerated that no part of it would be benefited
by digitalis when compensation is lost; therefore, many times,
especially if other drugs have failed, small doses of digitalis
should be tried, to see if the heart will respond. Large doses or
frequent doses would be contraindicated.

The signs of overaction of digitalis are nausea, vomiting, a
diminished amount of urine, a tight, band-like feeling around the
head, perhaps occipital headache and coldness of the hands and feet,
or frequently of one extremity only, combined with a feeling of
numbness. The pulse is generally reduced to sixty or less a minute.
Such symptoms require that digitalis be immediately stopped. They
are the primary signs of cumulative action.

While many patients with ordinary dosage of digitalis may take the
drug for months and years without ever showing cumulative action,
other patients show this effect quickly. They are apt to be those in
whom the kidneys are not perfect. The signs of such undesired action
may develop slowly, as suggested by the symptoms just enumerated, or
they may develop suddenly. The pulse becomes rapid and irregular,
the heart action weak, there is severe backache in the region of the
kidneys, a greatly diminished amount of urine, or even partial
suppression, severe headache, vomiting, cold extremities and
shiverings.

The treatment of such an undesired behavior of digitalis is, of
course, to stop the drug immediately, give saline laxatives, hot
sponging or hot baths, nitroglycerin and perhaps alcohol.

Strophanthus: Strophanthus cannot be compared with digitalis, except
when the glucosid, strophanthin, is administered subcutaneously or
intravenously. Strophanthus is given either in the form of the
tincture, or as strophanthin. It has been shown that in neither of
these forms, when the drug is administered by the stomach, is the
muscle of the heart or the blood vessels much acted on. Compensation
could not be restored by strophanthus. In emergencies of serious
cardiac failure, strophanthin intravenously has been shown
apparently to save life. It acts quickly, and its power of
stimulating the heart and contracting the blood vessels lasts for
many hours. It is rarely, however, that the dose should be repeated,
and then not for twenty-four hours, but during that twenty-four
hours the patient may be saved until other drugs which act more
slowly have been absorbed, or perhaps until the emergency has
passed. It probably should not be given if the patient has
previously had good dosage of digitalis.

There are many, however, who believe that they obtain considerable
value from the tincture of strophanthus, and there seems to be no
doubt that although strophanthus, given in the form of the tincture
and by the mouth, may not increase the muscle power of the heart, it
many times acts as a satisfactory cardiac sedative. Under its action
the patient becomes less nervous, the heart often acts more
regularly, and the low blood pressure may improve. We should not be
quite ready to discard the internal use of the tincture of
strophanthus.

The tincture of strophanthus readily deteriorates, and the
preparation ordered should be known to be a good one.

Caffein: This should not be given or allowed, even in the form of
tea or coffee, to patients who have valvular lesions with perfect
compensation, as it is a nervous and cardiac stimulant and may cause
a heart to become irritable. It raises the blood pressure slightly,
acts as a diuretic, and hence is often of great value when used
medicinally. It should be ranked as a stimulotonic to the heart. It
increases its activity, but gives it a little more strength. It will
rarely slow a rapid heart; it will often stimulate a sluggish, slow
heart; it may increase the irritability of an irritable heart. As it
is a cerebral stimulant, it should not be given late in the
afternoon or evening, as it may prevent sleep.

The most frequent form of caffein used is the citrated caffein. The
dose is 0.1 gm. (1 1/2 grains) two or three times in the early part
of the day, or 0.2 gm. (3 grains) once or twice during the morning.
A few much larger doses may be given if desired. A cup of coffee may
be given the patient medicinally: as a substitute for the drug, an
ordinary cup of strong coffee containing between 2 and 3 grains.
Other preparations of caffein may be selected if desired, or a
soluble preparation may be given hypodermically.

Caffein is indicated if digitalis is contraindicated or does not act
satisfactorily, and the patient is not nervously excited, but
perhaps is stupid or apathetic, and also when diuresis is desired.

Strychnin: This is a valuable stimulator and heart tonic when
properly used. It promotes muscular activity of the heart much as it
promotes all muscular activities. It awakens nervous stimuli and
nervous transmissions to normal in all sluggish nerve functions. If
for these reasons the heart acts more perfectly, and the nutrition
of the heart muscle improves, it acts as a cardiac tonic. Many
times, by improving the action of the heart, and also by the action
of the drug on the vasomotor center, the pressure in the peripheral
circulation may be increased. On the other hand, strychnin in the
low blood pressure of serious illness, such as pneumonia, by no
means always raises the blood pressure.

It should not be forgotten that strychnin is a general nervous
stimulant, especially of the spinal cord. If it makes a nervous
patient more nervous, or a quiet patient restless and irritable, it
is acting for harm and should be stopped, just as caffein under the
same conditions should be stopped. Strychnin may cause diminished
secretion of the skin. This is not frequent, but it does occur. It
may prevent the patient from sleeping. If such be the fact,
strychnin is not acting for good in a patient who has cardiac
weakness.


INDICATIONS FOR STRYCHNIN

Strychnin is a much overused drug. It is now given for almost
everything and during almost every disease. It is true that the
administration of strychnin is largely due to the evolution of the
age in which we are now living. We have ceased to purge and bleed
and sweat, and to give large doses of aconite or veratrum viride;
have ceased to starve the patient too long; we have ceased to load
him with alcohol to the point of circulatory prostration, and we
have recognized that he must be braced from start to finish;
strychnin is the drug which has been used for this purpose, and, as
stated above, overused. Strychnin given too frequently or in too
large doses for a laboring heart can prevent its proper rest; the
diastole is shortened and the relaxation of the heart is incomplete,
its nutrition suffers, or even irregular and fibrillary contractions
of a weak heart may apparently be caused. While a large dose of
strychnin, even to one-twentieth grain hypodermically, may be used
once in serious emergency when it is deemed the drug to use, a dose
larger than one-thirtieth grain hypodermically is rarely indicated,
the frequency of such a dose should seldom be more than once in six
hours, and a smaller close of strychnin may act more satisfactorily.

Strychnin is indicated when the heart is acting sluggishly and the
contractions seem incomplete, and when digitalis either is not
indicated or is not acting perfectly. Small doses of strychnin may
aid such a heart during the administration of digitalis. In many
instances in which digitalis is contraindicated, strychnin is of
marked value. This is typically true in fatty hearts, and may be
true in arteriosclerosis, in which it often does not increase the
blood pressure at all.

2. Cardiac Stimulants.--A cardiac stimulant is a drug which makes
the heart beat more strongly and the frequence more nearly normal.
The drugs named as cardiac stimulants, however, camphor, alcohol and
ammonia, do not leave a heart better than they found it--they are
not cardiac tonics.

Camphor: This is one of the best cardiac stimulants that we possess.
It is a quickly acting nervous and circulatory stimulant, acting
principally on the cerebrum and causing a dilation of the peripheral
blood vessels. No subsequent weakness follows after a dose of
camphor. Too much will make a patient wakeful, a little often quiets
nervous irritability. It should be used as a cardiac stimulant
during serious illness more frequently than it has been; and during
the endeavor to make a noncompensating heart again compensatory
camphor will often act for good. The dose is 2 teaspoonfuls of the
camphor-water every three or four hours, as deemed advisable. Each
teaspoonful represents a little more than one-fourth grain of
camphor. The spirits of camphor, of course, may be used, if
preferred.

For cardiac emergencies, ampules of sterile saturated solutions in
oil are now obtainable and are valuable. Such hypodermic stimulation
acts quickly, and may be repeated every half hour for several times,
if the patient does not respond. The solution should be injected
slowly, and as a rule intramuscularly.

Many times while other measures are being used to repair a broken
compensation, camphor makes a splendid circulatory and nervous
bracer. Camphor has long been used as a so-called antispasmodic in
hysteric or other nervously irritable persons. It really acts as a
stimulant to the highest centers of the brain, promoting more or
less nervous control. Perhaps its ability to increase the peripheral
circulation may be one of the reasons that it seems at times to be
almost a nervous sedative by relieving internal congestion. As just
stated, after the camphor action is over there is no depression.
This is not true of alcohol.

Alcohol: It is of course now generally understood that alcohol is
not a cardiac stimulant in the sense of its being more than
momentarily helpful to a weak heart. If alcohol is pushed when a
heart is in trouble, the secondary vasodilatation and more or less
nerve prostration and muscle debility will cause greater circulatory
weakness than before it was administered.

To obtain cardiac stimulation from alcohol it must be given in
strong solutions, generally in the form of whisky or brandy, for
local irritation of the mouth, esophagus and stomach; reflexly the
heart is stimulated and the blood pressure rises. As soon as
complete absorption has taken place, the blood pressure falls. For
continuous stimulation, another dose of alcohol must be given before
this depression occurs. This may be in from one to three hours. To
continue such stimulation, the dose of alcohol must be increased.
The future of such treatment means an alcoholic sleep with
depression, alcoholic excitement which is not desired, or profound
nausea and vomiting, with peripheral relaxation and cold
perspiration.

Obviously none of these conditions is desirable; but in
arteriosclerosis, or when the blood pressure is high and the heart
labors tinder the disadvantage of contracting against an abnormal
circulatory resistance, alcohol may act perfectly to relieve this
kind of circulatory disturbance. In this condition the alcohol
should not be given concentrated, and as soon as it is thoroughly
absorbed vasodilatation occurs, peripheral circulation and therefore
warmth are increased, and the heart is relieved of its extra load.
In such instances, in proper doses not too frequently repeated,
rarely more than 1 or 2 teaspoonfuls every three hours, alcohol is a
valuable drug. Such good action of alcohol is often seen when the
surface of the body is cold from chilling, or the extremities are
cold from vasomotor spasm. A good-sized dose of alcohol, best given
hot, equalizes the circulation and acts for good. On the contrary,
it is obvious that, if the patient is cold from collapse and there
is cold perspiration and very low blood pressure, alcohol is not the
drug indicated, although one dose may be of benefit while other more
slowly acting cardiac tonics or stimulants are being administered.

During serious prolonged illness and when the patient has not had
sufficient food and is not taking sufficient food, alcohol in the
form of whisky or brandy, not more than a teaspoonful every three
hours, acts as a necessary food, and will more or less prevent
acidosis from starvation.

It will be seen that alcohol, except possibly in a single dose
occasionally, or for some special reason, is rarely indicated in
decompensation.

When alcohol is administered regularly, whether during a fever
process or for any other reason, if it causes a dry tongue, cerebral
excitement, flushed face and a bounding pulse or if there is the
odor of alcohol on the breath, the dose is too large, and alcohol is
contraindicated.

Ammonia: In the form of ammonium carbonate or the aromatic spirits
of ammonia, this has long been used with clinical satisfaction as a
cardiac stimulant. Probably, however, it is seldom wise to use
ammonium carbonate. It is exceedingly irritant, and constantly
causes nausea, perhaps vomiting, and often heartburn or other
gastric disturbance. It has no value over the pleasanter aromatic
spirits of ammonia, which is essentially a solution of ammonium
carbonate. The dose of the aromatic spirits is anywhere from a few
drops to half a teaspoonful, given with plenty of water. It is
thought to be a quickly acting stimulant, with an effect much like
alcohol, followed by very little or no depression. It is more of a
cerebral irritant than alcohol, and probably has few, if any,
advantages over camphor.

When but little nutriment has been taken for some days, it may be a
chemical question, since ammonium compounds so readily form and
become cerebral irritants, whether any more ammonium radicals should
be given the patient. This is especially true with defective
kidneys. In these conditions camphor is better.

3. Vasodilators.--In various conditions of high blood pressure,
arteriosclerosis and even during the sthenic stage of a fever,
vasodilators may be indicated. The most important are nitrites,
iodids and thyroid extracts. Alcohol, as stated above, may act as a
vasodilator. Aconite and veratrum viride are now rarely indicated,
although possibly aconite should be used when there is high tension
and the heart is acting irritably and stormily.

If the nitrites, no preparation seems to act more satisfactorily
than nitroglycerin (trinitrin, glyceryl nitratis, glonoin). Its
action may not be so prolonged as other forms of nitrite, such as
sodium nitrite or erythrol tetranitrate, but it is not irritant, and
only a little less rapid than amyl nitrite, and although the marked
dilation lasts but a short time, often apparently only for minutes,
still, when frequently repeated or given a few times (from four to
six) in twenty-four hours, it frequently keeps the blood pressure
lower than it would be without the drug. In diseases of the heart
the sudden vasodilation caused by amyl nitrite inhalations is
indicated only in angina pectoris. "Then the surface of the body
tends to be cold, however, when the peripheral blood pressure is
increased and the heart is laboring, nitroglycerin in small doses is
valuable. The dose may be from 1/400 to 1/100 grain, dissolved on
the tongue or given hypodermically for quick action, or given by the
mouth for more prolonged action. In sudden cardiac dyspnea
nitroglycerin sometimes acts specifically, especially when there is
asthma. When a drop or two of the official spirits, which is a 1
percent solution, is given on the tongue, or a soluble tablet of
1/100 grain is dissolved on the tongue, the action is almost as
rapid as though the dose had been administered hypodermically. Many
times when such increased peripheral circulation is desired and
alcohol seems indicated, nitroglycerin in small doses will act as
well. It cannot be termed a cardiac stimulant, although many times a
heart acts better and the pulse is fuller and stronger after
nitroglycerin than before. It should not be used, except if
specially indicated, in broken compensation or in other myocardial
weakness.

Iodids: These have no immediate action. The vasorelaxation that
often occurs from iodid is quite likely due to the stimulation of
the thyroid gland by the iodin, and the thyroid gland secretes a
vasodilating substance. Small doses of iodid, however, when
indicated in various kinds of sclerosis, have seemed to lower blood
pressure. While large doses may have more of this actioli, they are
not now under consideration, and large doses are rarely indicated.
Too mach iodid has been given for many conditions. If the
indications for an iodid are present, such as sclerosis anywhere, or
unabsorbed inflammatory products, exudation in or around the heart,
or an apparent insufficiency of the thyroid, from 0.1 to 0.2 gm. (1
1/2 to 3 grains) once or twice in twenty-four hours, after meals, is
all that is required to give the action desired, and the circulation
is benefited. It is sometimes a question whether small doses of
iodid are not actually stimulant to the heart, possibly through the
action on the thyroid gland.

Thyroid Extract: In slow hearts and in sluggish circulation, often
in old age, quite frequently in arteriosclerosis and in every
condition of insufficient thyroid secretion (these instances are
frequent), small doses of thyroid extract will benefit the
circulation. Its satisfactory action is to increase the cardiac
activity, slightly lower the blood pressure, and increase the
peripheral circulation and the health of the skin. If it causes
tachycardia, nervous excitement, sleeplessness or loss of weight, it
is doing harm and the dose is too large, or it is not indicated. The
dose for the cardiac action desired is a tablet representing from
1/2 to 1 grain of the active substalice of the thyroid gland, given
once a day, continued for a long period.

When an improved peripheral circulation is desired, and especially
when a reduction of the pressure in the heart is desired and a
diminished amount of blood in overfilled arteries is indicated, the
value of the sitzbath, hot foot-baths, warm liquids (not hot) in the
stomach, and warm, moist applications to the abdomen should all be
remembered.

4. Cardiac Nutritives.--Iron: Nothing is of more value to a weakened
heart muscle, when the nutrition is low, the patient anemic, and the
iron of the food not properly metabolized, than tonic doses of some
iron salt. It has frequently been repeated, but should constantly be
reiterated, that there is no physiologic reason or therapeutic
excuse for the patient to pay a large amount of money for some
organic iron preparation.

Small doses of an inorganic salt act perfectly, and nothing will act
better. As previously suggested, a drop or two of the tincture of
iron, a grain or two of the reduced iron, or 2 or 3 grains of
saccharated ferric oxid, given once or twice in twenty-four hours,
is all the iron the body needs from the points of view of the blood
and the heart.

Calcium: It has lately been learned that calcium is an element which
a heart needs for perfect activity. Many patients who are ill lose
their calcium, and they may not receive a sufficient amount of it
unless milk is given them. Even if such patients are taking milk,
the heart and the whole general condition sometimes such; to improve
when calcium is added to the diet. It may be given either in the
form of lime water, calcium lactate or calcium glycerophosphate. If
a medium-sized dose is given three or four times in twenty-four
hours, it is sufficient and will often act for good.

Whether calcium can do harm in a chronic endocarditis or an
arteriosclerosis to offset the value that it seems to have in
quieting the nervous system and in being of value to a weak or
nervously irritable heart is a question which has not been decided.
Theoretically lime should not be given when there is a tendency to
calcification, or when a patient is past middle age. Lime seems to
be essential to youth, and to the welfare of nervous patients.


EMERGENCIES

5. Cardiac Emergency Drugs.--Besides some of the drugs already
mentioned (such as camphor hypodermically, nitroglycerin when
indicated, strophanthin hypodermically or intravenously, caffein and
strychnin), often ergot, suprarenal vasopressor principle, pituitary
vasopressor principle, atropin and morphin should be considered.

When there is low blood pressure, venous stasis, pulmonary
congestion, cyanosis and a laboring, failing heart, intramuscular
injections of ergot, with or without coincident venesection, may be
the most valuable method of combating the condition. Life has been
saved in this kind of sudden acute cardiac failure in valvular
disease. When venesection is not indicated in certain conditions of
low blood pressure and heart failure, ergot has saved life. It
causes contraction of the blood vessels and seems to tone the heart.
Incidentally it quiets the central nervous system. If the blood
pressure is much increased by it, the ergot should not be repeated,
as too much work should not be thrown on the heart muscle. Often,
however, it may be administered intramuscularly with advantage in
aseptic preparation as offered in ampules, at the rate of one ampule
every three hours for two or three times, and then once in six hours
for a few times, the future frequency depending on the indications.

Epinephrin and Pituitary Extract: The blood pressure-raising
substance of the suprarenals or of the pituitary gland (hypophysis
cerebri) has been much used in heart failure. These substances
certainly would not be indicated in high blood pressure; they are
indicated in low blood pressure. They have been given intravenously;
they are frequently given hypodermically. They often act rapidly
when a solution in proper dose is dropped on the tongue. The blood
pressure rise from epinephrin is quickly over; that from the
pituitary extract lasts longer. In large doses, or when it is too
frequently repeated, epinephrin depresses the respiration. Pituitary
extract acts as a diuretic. Sterilized solutions of both, put up in
ampules ready for hypodermic medication, are obtainable, the
strength offered generally being 1 part of the active principle to
10,000 of the solution. Hypodermic tablets of epinephrin may also be
obtained. Stronger solutions of 1 part to 1,000 may be dropped on
the tongue, or tablets may be dissolved on the tongue. The blood
pressure is temporarily raised and the heart stimulated by these
treatments, but epinephrin is not used so often for cardiac failure
as it was a short time ago.

The most satisfactory action, especially from the epinephrin, is
from small doses frequently repeated. Sometimes in serious
emergencies it has been found to be of value when given
intravenously in physiologic saline solution. The close, of course,
should be very small. In circulatory weakness in acute illness,
epinephrin has been given regularly, a few drops (perhaps the most
frequent dose is 5) of a 1: 1,000 solution, on the tongue, once in
six hours. Such a dosage may be of value, and certainly is better
than the administration of too much strychnin. Much larger or more
frequent doses are likely, as just stated, to depress the
respiration.

Besides the small amount of blood pressure-raising substance
secreted by the hypophysis cerebri. it has not been shown that any
other gland of the body furnishes vasopressor substance except the
suprarenals.

Atropin: When there is great cardiac weakness, atropin may be used
to advantage. The dose is from 1/200 to 1/150 grain hypodermically,
not repeated in many hours. It will whip up a flagging heart, more
or less increase the blood pressure, cause cerebral awakening, and
may often be of value. If there is any idiosyncrasy against atropin,
if the throat and mouth are made intensely dry, or if there is
serious flushing or cerebral excitement, the dose should not be
repeated.

Morphin: This would rarely be considered as an emergency drug in
cardiac weakness. A small dose of it, not more than one-eighth
grain, especially if combined with atropin, will often quiet and
brace a weak heart, especially when there is cardiac pain. Just
which drug or drugs should be used and just which are not indicated
can never be specifically outlined in a textbook, a lecture or a
paper. The decision can be made only at the bedside, and then
mistakes, many times unavoidable, are often made.

In all conditions of shock with cardiac failure, the blood vessels
of the abdomen and splauclinic system are dilated, and more or less
of the blood of the body is lost in these large veins, and the
peripheral and cerebral blood pressure fails. The advantage in such
a condition of firm abdominal bandages, and of raising the foot of
the bed or of raising the feet and legs, need only be mentioned to
be understood.

It is a pretty good working rule, in cardiac failure, not to do too
much. On the other hand, life is frequently saved by proper
treatment, and the physician repeatedly saves life as surely as does
the surgeon with his knife.


CONVALESCENCE

When compensation has been restored, the patient may be allowed
gradually to resume his usual habits and work, provided these habits
are sensible, and the work is not one requiring severe muscular
exertion. Careful rules and regulations must be laid down for him,
depending on his age and the condition of his arteries, kidneys and
heart muscle. It should be remembered that a patient over 40, who
has had broken compensation, is always in more dancer of a
recurrence of this weakness than one who is younger, as after 40 the
blood pressure normally increases in all persons, and this normal
increase may be just too much for a compensating heart which is
overcoming all of the handicap that it can withstand. Such patients,
then, should be more carefully restricted in their habits of life,
and also should have longer and more frequent periods of rest.

The avoidance of all sudden exertion in any instance in which
compensation has just been restored is too important not to be
frequently repeated. The child must be prevented from hard playing,
even running with other children, to say nothing of bicycle riding,
tennis playing, baseball, football, rowing, etc. The older boy and
girl may need to be restricted in their athletic pleasures, and
dancing should often be prohibited. Young adults may generally,
little by little, assume most of their ordinary habits of life; but
carrying heavy weights upstairs, going up more than one flight of
stairs rapidly, hastening or running on the street for any purpose,
and exertion, especially after eating a large meal, must all be
prohibited. Graded physical exercise or athletic work, however, is
essential for the patients' future health, and first walking and
later more energetic exercise may be advisable.

These patients must not become chilled, as they are liable to catch
cold, and a cold with them must not be neglected, as coughing or
lung congestions are always more serious in valvular disease. Their
feet and hands, which are often cold, should be properly clothed to
keep them warm. Chilling of the extremities drives the blood to the
interior of the body, increases congestion there, and by peripheral
contraction raises the general blood pressure. A weak heart
generally needs the blood pressure strengthened, but a compensating
heart rarely needs an increase in peripheral blood pressure, and any
great increase from any reason is a disadvantage to such a heart.
The patient should sleep in a well ventilated room, but should not
suffer the severe exposures that are advocated for pulmonary
tuberculosis, as severe chilling of the body must absolutely be
avoided.

The peripheral circulation is improved, the skin is kept healthy,
the general circulation is equalized, and the heart is relieved by a
proper frequency of warm baths. Cold baths are generally
inadvisable, whether the plunge, shower or sponging; very hot baths
are inadvisable on account of causing a great deal of faintness;
while warm baths are not stimulating and are sedative. The Turkish
and Russian bath should be prohibited. They are never advisable in
cardiac disease. With kidney insufficiency, body hot-air treatment
(body-baking), carefully supervised, may greatly benefit a patient
who has no dilatation of the heart and who has no serious broken
compensation. Surfbathing, and, generally, sea-bathing and lake-
bathing are not advisable. The artificial sea-salt baths and carbon
dioxid baths may do some good, but they do not lower the general
blood pressure so surely as has been advocated, and probably no
great advantage is apt to be derived from such baths. If a patient
cannot properly exercise, massage should be given him
intermittently.

Any systemic need should be supplied. If the patient is anemic, he
should receive iron. If he has no appetite, he should be encouraged
by bitter tonics. If sleep does not come naturally, it must be
induced by such means as do not injure the heart.

Perhaps there is no better place in this series on diseases of the
heart to discuss the diet in general and the resort treatment than
at this point, as the question is one of moment after convalescence
from a broken compensation, at which time every means must be
inaugurated to establish a reserve heart strength to overcome the
daily emergencies of life.




DIET AND BATHS IN HEART DISEASE


The diet in cardiac diseases has already incidentally been referred
to. The decision as to what a patient ought to eat or drink must
often be modified by just what the patient will do, and, as we all
know, it is absolutely necessary to make some concessions in order
for him to aid us in hastening his own recovery or in preventing him
from having relapses. Consequently, we cannot be dogmatic with most
patients with chronic heart disease. Parents should be prohibited
from allowing children or adolescents with heart disease to drink
tea, coffee or any alcoholic stimulant. The young boy and young man
must absolutely be prohibited from indulging in tobacco at all.
There is no excuse for allowing these stimulants or foods in such
cases. If the patient is older and has been accustomed to tea and
coffee, one cup of coffee in the morning may be allowed, provided a
decaffeinated coffee is not found satisfactory. Whether a small cup
of coffee or a cup of tea is allowed at noon is again a matter for
individualization; they should rarely be allowed after the noon
meal. In a patient who has been accustomed to alcohol regularly
(generally an older patient), careful judgment should be used in
deciding whether or not a small amount of alcohol daily should be
allowed. It should never be in large amounts, even of a dilute
alcohol like beer; it may be a weak wine; it may be a small amount
of diluted whisky, if seems best. Ordinarily the patient is better
without it. If he is used to smoking and a small amount does not
raise the blood pressure much, it may do him no harm to smoke a
small mild cigar once or twice a clay. On the other hand, if a hard
smoker suddenly has heart failure, whether from exertion, from
chronic disease or from acute illness, a small amount of smoking is
of advantage as it tends to remove cardiac irritability, to raise
the blood pressure, and actually to quiet and improve the
circulation. It is unwise during acute circulatory failure to take
tobacco away entirely from a chronic tobacco user.

The character of the food which each patient should receive depends
on his blood pressure and his age. The older person with a tendency
to high blood pressure should have the protein (especially meat)
reduced in amount, as any putrefaction in the intestine with
absorption of products of such maldigestion irritates the blood
vessels, raises the blood pressure, and injuries the kidneys. On the
other hand, a young patient should receive a sufficient meat diet
rather than be overloaded with vegetables and starches, to the easy
production of fermentation and gas. Flatulence from any cause must
be avoided. It dilates the stomach and intestines, causing them to
press on the diaphragm, so that the heart and respiration are
interfered with. Also, an increased abdominal pressure, especially
if there is any edema or dropsy, is bad for the circulation. A
distended, tense abdomen is serious in cardiac failure. On the other
hand, a flaccid, flabby, lax abdomen should be well bandaged in
cardiac failure with low blood pressure.

Children do well on a milk diet, but it should be remembered that
excessive amounts of any liquid, even milk and water, are
inadvisable, if the circulation is poor and there is a tendency to
dropsy. It has been recommended at times to limit a patient's diet
for a week or so to a small amount of milk, not more than a quart in
twenty-four hours. If such a patient is in bed and does not require
carbohydrates, sugars or stronger proteins or more fat, such a
restricted diet may aid in establishing circulatory equilibrium,
although he will lose in nutrition. The excretory organs are
relieved by the decreased amount of excretory product, the digestive
system is rested and the circulation is improved. Such a limited
diet should not be tried longer than a week, but it may be the
turning point of circulatory improvement.

The ordinary diet for a convalescing heart patient should be small
in bulk, of good nutritive value, and should represent all the
different elements for nutrition. This means a small amount of meat,
once a day to older patients, twice a day to those who work hard or
for young patients; such vegetables as do not cause indigestion with
the particular patient, and these must be individualized; such
fruits as are readily digested, especially cooked fruits; generally
plenty of butter, cream, olive oil if the nutrition is low, and
milk, depending on the age of the patient or the ease with which it
is digested. Soups, on account of their bulk and low nutritive
value, should be avoided. Anything that causes indigestion, such as
fried foods, hot bread, oatmeal or any other gummy, sticky,
gelatinous cereal should be avoided; also spices, sauces and strong
condiments. Anything that is recognized as especially loaded with
nuclein and xanthin bodies, such as liver, sweetbreads and kidneys,
should be prohibited, as tending to cause uric acid disturbance; and
the more tendency to gout or uric acid malmetabolism the more
irritated are the arteries and the more disturbed the blood
pressure. Sugars should be used moderately unless the patient is
thin and feels cold, in which case more may be given, provided there
are no signs of gout or disturbed sugar metabolism. Sugar is at
times a good stimulant food. Very cold and very hot drinks or food
should be avoided.

Many times these patients have a diminished hydrochloric acid
secretion, and such patients thrive on 5 drops of dilute
hydrochloric acid in water, three times a day, after meals. When
their nutrition has improved and the digestion becomes perfect,
hydrochloric acid will generally be sufficiently secreted and the
medication may be stopped.

If the patient is overweight, this obesity must be reduced, as
nothing more interferes with the welfare of the heart than
overweight and overfat. In these cases the diet should be that
required for the condition. If there are edemas, or a tendency to
edemas, the decision should be made whether salt (sodium chlorid)
should be removed from the diet. Unless there is kidney defect,
probably it need not be omitted, and a long salt-free diet is
certainly not advisable. This salt-free diet has been recommended
not only in nephritis and heart disease, but also in diabetes
insipidus and in epilepsy. It is of value if there is edema in
nephritis; it is of doubtful value in heart disease; it is rarely of
value in diabetes insipidus; and in epilepsy its value consists
probably in allowing the bromid that may be administered to have
better activity in smaller doses, the bromin salt being substituted
in the metabolism for the chlorin salt.


THE RESORT TREATMENT OF CHRONIC HEART DISEASE

In line with the continued growing popularity of special resorts and
special cures for different types of disease, resort or sanatorium
treatment for chronic heart disease has grown to considerable
popularity during the last twenty years or more. The most popular of
these resorts owe their success to the personality of the
physicians, who have made heart disease a life study.

Perhaps the most noted of these resorts for the cure of heart
disease is that at Bad Nauheim, Germany, which was inaugurated by
Dr. August Schott and Prof. Theodore Schott, and is now conducted by
the latter, Dr. August Schott having died about fifteen years ago.
Hundreds of patients and many physicians have testified to the value
and benefit of the treatment carried out at this institution.

The method of treatment largely employed at these heart resorts is
to withdraw all, or nearly all, of the active drugs that the patient
may be taking, and to substitute physical and physiologic methods of
therapy. These include bathing, regulation of the diet, and
exercise. This exercise consists of two varieties: exercise of the
muscles against the resistance of an attendant, and exercise by
walking on inclined planes or up hills. The treatment is aimed at
chronic heart disease, to develop a greater cardiac reserve
strength; the whole object of the treatment is to strengthen the
myocardium, either in conditions of its debility or in conditions of
diminished compensation in valvular disease. Any treatment that will
develop a reserve heart strength to be called on in emergencies,
more or less similar to the reserve strength of a normal heart,
tends to prolong the patient's life and health.

Patients with acute heart failure or acute loss of compensation,
with more or less serious edemas, should rarely take the risk of
traveling any distance to be treated at an institution. As a general
rule they are better treated for a few weeks or months at home.
After the broken compensation is repaired, a reserve strength of the
heart may well be developed by a visit to one of these institutions,
if the patient can afford it.

The Oertel treatment consists chiefly in diminishing the fluids
taken into the body, and in graduated mountain climbing. By
diminishing the fluids taken, the work of the heart is diminished,
as the blood vessels are not overfilled and may be even underfilled.
The diet is carefully regulated with the object of removing all
superfluous fat from the body. The third leg of the tripod of the
Oertel treatment is the gradually increasing hill and mountain
climbing to educate the heart by graded muscular training to become
strong, perfectly compensatory, and later to develop a reserve
strength. This particular cure is especially adapted to the obese,
who have weakened heart muscles.


NAUHEIM BATHS

At Nauheim, under the direction of Dr. Theodore Schott, baths form
an important part of the treatment. These baths are of two kinds,
the saline and the carbonic acid. The medicinal constituents of the
saline bath are sodium chlorid and calcium chlorid, the strength of
each varying from 2 to 3 percent The baths at first arc given at a
temperature of 95 F., and as the patient becomes used to them and
can take them without discomfort, the temperature is gradually
reduced. The patient remains in the bath from five to ten minutes.
After the bath he is dried with towels and rubbed until the
cutaneous circulation becomes active. He must then lie down for an
hour. These baths are repeated for two or three days, and are
omitted on the third and fourth days, to be resumed on the following
day. After a few baths have been taken, the carbon dioxid baths are
commenced, beginning with a small quantity of the gas which is later
gradually increased. This course of baths should be continued from
four to eight weeks. Unless there is some special reason for taking
them at some other period of the year, they are taken more
advantageously during the warm months.

Besides the baths, all important part of the treatment at Nauheim
consists in the exercises against resistance. These are usually
given an hour or more after a bath, and are taken with great
deliberation; their effect is carefully watched by an intelligent
attendant so that no harm may be done by the exercise.

During this treatment the food is, of course, carefully regulated
with the aim of giving a mixed, sufficient, easily digestible and
easily assimilated diet. All highly seasoned dishes, all
effervescent drinks and anything that tends to cause gas in the
stomach and intestines are prohibited. Coffee and tea are not
allowed, except coffee without caffein; and it may be noted that it
has recently been shown that caffein is one of the surest of drugs
to raise the blood pressure, and is therefore generally not
desirable when the heart muscle requires strengthening. Because of
its tendency to raise blood pressure and weaken cardiac muscle,
tobacco is entirely forbidden at Nauheim, except in a few individual
instances, and then the amount allowed is a minimum one. Large
amounts of liquid are not allowed because they distend the stomach,
raise the blood pressure and increase the pumping work of the heart.

One of the greatest advantages of the treatment at an institution
like Nauheim is the general hopeful spirit instilled into the
patients, who are so many times seriously depressed by the knowledge
of a heart weakness and the realization of their physical inability
to do what other persons are able to do. Also, it is of great value
to send a patient to a resort where the climate is good and the
scenery is lovely and soothing. No disease, perhaps, needs
cheerfulness and pleasantness and lack of anxiety, or frets more
than does cardiac weakness. A tuberculous patient may sit on a
mountain top with snow blowing about him, and recover; a heart
patient must have sunshine and comfort.

The results of such sanatorium treatment of heart disease are often
evident not only to the patient by an increase of general muscle
strength, the ability to do ordinary things and perhaps even sustain
muscular effort without dyspnea and cardiac discomfort, but also to
the physician by the physical signs. The contraction of the heart
becomes stronger and the normal sounds more decided; murmurs which
were entirely due to dilated ventricles and insufficiency disappear,
while the permanent murmurs may become louder from a more forceful,
normal action of the heart muscle. The pulse becomes slower, and the
blood pressure, from being too low, becomes normal for the age of
the individual. The heart will often also actually decrease in size,
and the apex beat become localized rather than diffuse, The liver
becomes reduced in size; the urine is less concentrated, and if
there were traces of albumin after exertion, these disappear.

It should perhaps be emphasized that not a little benefit from these
resort treatments may be due to the withdrawal of unnecessary drugs.
Many heart patients are overdrugged.

This sort of treatment is contraindicated in some kinds of heart
disease, as heart weakness due to arteriosclerosis with high blood
pressure, to aneurysm of the thoracic or abdominal aorta, and to
nephritis.

So many heart patients have been improved by the Nauheim treatment
that the question arises as to whether the treatment can be
conducted at home or in a sanatorium near home, when the patient is
unable to go to this resort; that is to say, Can we establish this
treatment for the majority of patients who have chronic heart
disease? Of course, even at home, the sodium chlorid and calcium
chlorid baths may be given, and one may obtain the salts all
prepared to make the carbon dioxid bath; the exercises may be given,
and walking on various ascending grades may be inaugurated. All
patients will be more or less benefited, provided they will carry
out the treatment. Unfortunately, the surroundings at a patient's
home are generally adverse to perpetuating these treatments long
enough to develop the muscular strength of the heart to the reserve
desired. If a patient appears pretty well, especially if he is
stimulated by his family to believe that he is well, he thinks the
continuation of the treatment entirely unnecessary, and unless he
goes to a resort where he sees other patients with similar
conditions able to do what he is not able to do, and therefore is
stimulated to acquire their ability by the treatment outlined, he
will not follow his physician's directions. There are several
sanatoriums in this country where the diet, hydrotherapy and
exercise necessary for developing heart strength are carried out,
and patients are sent to some of them with great advantage.

It has been found that these stimulant baths do not act well in
mitral stenosis, if the left ventricle is small. If the left
ventricle is unable to receive and therefore send out into the
systemic circulation sufficient blood to dilate the peripheral
capillaries under the irritation of the baths or the vasodilator
effects of the baths, the bath treatment does harm instead of good.
A patient who has mitral stenosis and also a small left ventricle
will be found to be poorly developed, badly nourished, and to have
poor peripheral circulation.

As elsewhere stated, the improvised carbon dioxid bath, to stimulate
the skin so as to reduce the blood pressure, is not satisfactory.
Other methods of reducing blood pressure, when it is too high, are
much more effective.




HEART DISEASE IN CHILDREN AND DURING PREGNANCY


A common characteristic in a large proportion of middle-aged or old
patients with heart disease is the presence of degenerative changes
in the myocardium, the valves, or the arteries of the heart. In
children, on the other hand, the most common disturbances of the
heart are acute inflammations affecting its different structures,
and due in most instances to acute infections. Myocarditis and
endocarditis occur frequently, and pericarditis occasionally. As in
adults, rheumatism is the most common cause of inflammation of the
structures of the heart, but rheumatism causes inflammation of the
heart much more frequently in children than in adults. Besides this
infection, the most frequent causes of inflammation of the heart in
children are diphtheria, scarlet fever, typhoid fever, measles and
influenza, with the frequency, perhaps, in the order named.
Diphtheria frequently gives rise to myocarditis, which results in
dilatation of the heart. This may occur in the second or third week
of the course of the disease, and even up to the eighth and tenth
week from the beginning of the disease. The myocarditis due to
diphtheria is not always the cause of sudden death occurring during
the disease, as such a fatal result may be due to paralysis of
nervous origin. In scarlet fever, inflammation of the heart may be
due directly to the poison of the disease, or it may be secondary to
a nephritis which is so frequent a complication of scarlet fever. It
is probable that the inflammation of the skin in scarlet fever,
preventing normal secretion, may be a cause of a sometimes increased
blood pressure and also of the nephritis, both of which conditions
may predispose to the cardiac complication. Erysipelas may cause
acute inflammation of the heart, perhaps for the same reason.

A certain proportion of cardiac diseases in children, especially
endocarditis, seems to be due to a general septic infection which
results in the so-called septic, infectious or malignant
endocarditis. There is sometimes a tendency in certain children, and
perhaps in certain families, for the heart to become readily
infected during an infectious disease, more than in other children
who suffer from the same disease. Sometimes the heart becomes
inflamed in rheumatic children without any joint affection
occurring; the inflammation in the heart may be the only
manifestation of the disease.

This etiology of cardiac affections of children indicates the
directions in which therapeutic efforts should be aimed. In children
who are under the more or less constant care of the family
physician, the possibility of the occurrence of some cardiac
affection should be borne in mind, especially in children in
families which are known to be affected with what may be called a
rheumatic diathesis--families in which several members have suffered
from rheumatism. It is reasonable to suppose that children who are
delicate and feeble, who do not have sufficient fresh air, who do
not take sufficient exercise, and who are not properly fed are more
liable to be affected with cardiac complications in the presence of
infectious diseases than children who have had plenty of fresh air,
an abundance of exercise and a sufficient amount of proper food.

At the present day it is hardly necessary to insist on the
importance of giving every child an adequate amount of fresh air. It
is possible, however, that this gospel has been overworked, and it
is not infrequently necessary to caution some parents that there is
danger of impairing their children's health by too much exposure.
The old ideas of the influence of exposure to cold and dampness in
the production of rheumatism have not yet been so far abandoned that
we can entirely neglect the possibility of rheumatism being
developed, at least, by the exposure to cold winds and dampness of
children who are otherwise predisposed to this disease. It is
possible that the enormously increasing number of children with
adenoids and enlarged tonsils, who need operative measures for their
removal, may have these conditions aggravated by too much exposure
to the inclemency of variable, harsh weather.

It is not necessary to state that proper exercise develops the
heart, as it does all the other muscles; but at the same time it is
necessary to caution parents against allowing their children to
indulge in too violent and too prolonged exercise. Young children
probably stop often enough in their play not to overwork their
hearts. Older boys and girls, especially boys, are inclined to take
too severe athletics, such as long-distance running, competitive
rowing, violent football and rapid cycling. It should be emphasized
to school-masters, gymnasium teachers and athletic trainers that a
boy who is larger than he should be at his age has not the
circulatory ability that the older boy of the same size has. The
overgrown boy has all he can do to carry his bulk around at the
speed of his age and youth. The addition of competitive labor
overreaches his reserve heart power, and he readily acquires a
strained, injured heart. On the other hand, moderate indulgence in
walking, baseball, swimming, rowing and golf should be commended. It
is not exactly the exercise that does him the harm, it is the
competitive element in it. Until a boy is well developed in his
internal reserve strength, he should not compete with other boys who
are better developed. His pride makes him do himself injury.

Dietetic fads are so prevalent today that there is danger that many
children will not receive an adequate amount of nutriment, that they
will be fed an excess of such foods as are likely to produce damage
to their constitutions, or that they will be given food which does
not contain all the different elements of nutrition to satisfy their
economy and their growth. While it is now generally acknowledged
that an excess of meat is not beneficial to any one, on the other
hand a moderate amount is necessary for individuals who are working
or are mentally active, especially for growing children. Also a too
great limitation of the child's diet to farinaceous foods, and
especially the allowance of too much sugar and sugar-producing food,
is liable to encourage the development of rheumatism. A mixed diet,
not excessive in amount, and prepared so that it will be digested
without difficulty, is most useful, and it should include in
suitable proportions meat, milk, eggs, vegetables, starches and
fruit. These should all be taken at regular intervals, thoroughly
chewed, and should not be taken in excess.

If a child has had an attack of heart inflammation, a myocarditis or
an endocarditis, greater care should be taken of him not only when
he is well but especially when he becomes ill of any other disease.
If the child has had a rheumatic inflammation of the heart, or has
had rheumatism without such a complication, it is considered by some
clinicians wise to give a week's treatment with salicylates at
intervals of three or four months, for two or three years, perhaps.
It is hard to determine how much value this prophylactic treatment
has. If the child's surroundings cannot be changed and lie is
subjected to the same conditions of possible reinfection, it may be
a wise precaution, much like the prophylactic administration of
quinin in malarial regions. If a child has developed a cardiac
inflammation during any disease, the treatment is that previously
outlined.

An important part of prophylaxis and treatment of a cardiac
affection during the course of any disease is the prevention of
serious anemia. During sickness the patient is liable to become more
or less anemic, but the administration of iron, in the manner
previously suggested, during the course of the disease, and
especially during rheumatism, will prevent the anemia becoming rapid
or severe.


CARDIAC DISEASE IN PREGNANCY

It is so serious a thing for a woman with valvular lesion or other
cardiac defect to become pregnant that no young woman with heart
disease should be allowed to marry. Perhaps every normal heart
during pregnancy hypertrophies somewhat to do the extra work thrown
on it, but it may easily become weakened and show serious
disturbance as its work grows harder and the distention of the
abdomen and the upward pressure on the diaphragm increase. This
pressure perhaps generally displaces the apex of the heart to the
left and causes the heart to lie a little more horizontal. If the
patient is normal, there may be a gradually increasing blood
pressure all through the months of pregnancy, and if the kidneys are
at all disturbed this pressure is increased, and there is, of
course, much increased resistance to the circulation during labor.
The better the heart acts, the less likely are edemas of the legs
during pregnancy. It is thus readily seen that pregnancy is a
serious thing for a damaged heart. The reserve strength of the heart
muscle, as has been previously stated, is much less in valvular
compensation than that of the normal heart, and this reserve force
is easily overcome by the pregnancy, and loss of compensation occurs
with all of its usual symptoms.

The most serious lesion a woman may have, as far as pregnancy is
concerned, is mitral stenosis. An increased abdnominal pressure
interferes with her lung capacity, and her lungs are already
overcongested. The left ventricle may be small with mitral stenosis,
and therefore her general systemic circulation poor. For those two
reasons mitral stenosis should absolutely prohibit pregnancy. While
many women with well compensated valvular disease go through
pregnancy without serious trouble, still, as stated above, they
should be advised never to marry. If they do marry, or if the lesion
develops after marriage, warning should be given of the seriousness
of pregnancies.

If a woman becomes pregnant while there are symptoms or signs of
broken compensation, there can be no question, medically or morally,
of the advisability of evacuating the uterus. The same ruling is
true if during pregnancy the heart fails, compensation is broken,
and the usual symptoms of such heart weakness develop, provided a
period of rest in bed, with proper treatment, has shown that the
heart will not again compensate. Under such a condition delay should
not be too long, as the heart may become permanently disabled. If,
during pregnancy in a patient with a damaged heart, albuminuria
develops and the blood pressure is increased, showing kidney
insufficiency, there can be no question of delay, from every point
of view, and labor must be precipitated; the uterus must be emptied
to save the mother's life.

If a pregnant woman is known to have a degenerative condition of the
myocardium, or arteriosclerosis, the danger from the pregnancy is
serious, and the pregnancy should rarely be allowed to continue.

Even if no serious symptoms occur during the term of the pregnancy,
and the heart continues to compensate sufficiently for its defect,
labor should never be allowed to be prolonged. The tension thrown on
the heart during labor is always severe, and has not infrequently
caused acute heart failure by causing acute dilatation, and in these
damaged hearts tediousness and severe, intense exertion should not
be allowed. Proper anesthetics and proper instrumentation should be
inaugurated early.

Patients who have successfully passed through the danger of
pregnancy with cardiac lesions, possibly relieved by radical
treatments, should be warned against ever again becoming pregnant.
If this warning does not prevent future pregnancies, the family
physician and his consultant must decide just what it is proper to
do. It is to be understood that no uterus should ever be emptied
until one or more consultants have approved of such treatment.

Sometimes serious heart weakness develops during the later weeks of
pregnancy, requiring the patient to remain in bed and receive every
advantage which rest, proper care and well judged medicinal
treatment will give the circulation.

If the heart is weak and there have been signs of myocardial
weakness or loss of compensation, the sudden loss of abdominal
pressure after delivery may allow the blood vessels of the abdomen
to become so overfilled as to cause serious cerebral anemia and
cardiac paralysis. Therefore in such cases a tight bandage must
immediately be applied, and it has even been suggested that a
weight, as a bag of sand weighing several pounds, be placed
temporarily on the abdomen. The greatest possible care should be
given these women during and after labor.

Acute dilatation is not an infrequent cause of death during ordinary
labor, and is more apt to occur in these cardiac patients. If signs
of acute dilatation of the heart occur, with associated pulmonary
edema, venesection (especially if there has not been much uterine
hemorrhage), with the coincident intramuscular injection of one or
two syringefuls of aseptic ergot, will often be found to be life-
saving treatment. Septic infections after parturition are prone to
cause endocarditis and myocarditis, and a malignant endocarditis may
develop from uterine infection or uterine putridity.




DEGENERATIONS

CORONARY SCLEROSIS


While disease of the coronary arteries may occur without general
arteriosclerosis, it is so frequently associated with it that it is
necessary to give a brief description of the general disease.
Arteriosclerosis or arteriocapillary fibrosis is really a
physiologic process naturally accompanying old age, of which it is a
part or the cause, and it should be considered a pathologic
condition only when it occurs prematurely. It may, however, occur at
almost any age after 30, and is beginning to be frequent between 40
and 50. In rare instances it may occur between 20 and 30, and even
in childhood and youth. It is much more frequent in men than in
women. Its most common cause is hypertension; in fact, hypertension
generally precedes it. The most frequent cause of hypertension today
is the strenuousness of life, the next most frequent cause being the
toxins circulating in the blood from overeating, overdrinking,
overuse of tobacco and the overuse of caffein in the form of coffee,
tea or caffein drinks. Another common cause of arteriosclerosis
occurring too early is the occurrence of some serious infection in a
person, typhoid fever and sepsis being most frequent. Syphilis is a
frequent cause, especially of that form of arteriosclerosis which
shows the greatest amount of disease in the aorta. Mercury used in
the treatment of syphilis is more liable, however, than syphilis to
be the cause of arteriosclerosis. Although this drug, even with the
arsenic injections now in vogue, is necessary for the cure of
syphilis, it probably tends to raise the blood pressure by
irritating the kidneys and by diminishing the thyroid secretion,
both of these occurrences predisposing to arteriosclerosis. From the
fact that lead poisoning causes an increased blood pressure, lead is
a probable cause of arteriosclerosis. With the greater knowledge of
the danger of poisoning possessed by those who work in lead, chronic
lead poisoning is becoming rare, as evidenced by the lessening
frequency of wrist drop and lead colic.

Chronic nephritis is often a coincident disease, but the causes of
the arteriosclerosis and the nephritis are generally the same.
Alcohol, except as a part of overeating and as a disturber of the
digestion, is perhaps not a direct cause of arteriosclerosis, as
alcohol is a vasodilator. Hard physical labor and severe athletic
work may cause arteriosclerosis to develop, and it is liable to
develop in the arteries of the parts most used.

Hypertension is generally a prelude to arteriosclerosis, and
everything which tends to increase tension promotes the disease;
everything which tends to diminish tension more or less inhibits the
disease. Therefore a subsecretion of the thyroid predisposes to
arteriosclerosis, and increased secretion of the suprarenals
predisposes to arteriosclerosis, the thyroid furnishing vasodilator
substance and the suprarenals vasopressor substance to the blood.
Furthermore. if these secretions are abnormal, protein metabolism is
more or less disturbed.

While arteriosclerosis often occurs coincidently with gout, and gout
apparently may be a cause of arteriosclerosis, still the two
diseases are widely dissociated, and the causes are not the same.

Although the arterial pressure has been high before arteriosclerosis
developed, and may remain high for some time in the arteries, unless
the heart fails, the distal peripheral pressure, as in the fingers
and toes, may be poor in spite of the high blood pressure. When the
left heart begins to fail, pendent edema readily occurs.


PATHOLOGY

The pathology of arteriosclerosis is a thickening and diminishing
elasticity of the arteries, beginning with the inner coat and
gradually spreading and involving all the coats, the larger arteries
often developing calcareous deposits or thickened cartilaginous
plates--an atheroma. If the thickening of the walls of the smaller
vessels advances, their caliber is diminished, and there may even be
complete obstruction (endarteritis obliterans). On the other hand,
some arteries, especially if the calcareous deposits are
considerable, may become weakened in spots and dilation may occur,
causing either smaller or larger aneurysms.

Histologically the disease is a connective tissue formation
beginning first as a round-cell infiltration in the subendothelial
layer of the intima. This process does not advance homogeneously;
one side of an artery may be more affected than the other, and the
lumen may be narrowed at one side and not at the other, allowing the
artery to expand irregularly from the force of the heart beat. As
the disease continues, the internal elastic layer is lost, the
muscular coat begins to atrophy, and then small calcareous granules
may begin to be deposited, which may form into plates. In the large
arteries, the advance of the process differs somewhat. There may be
more actual inflammatory signs, fatty degeneration may occur, and
even a necrosis may take place.

However generally distributed arteriosclerosis is, in some regions
the disease is more advanced than in others, and in those regions
the most serious symptoms will occur. The regions which can stand
the disease least well are the brain and coronary arteries, and next
perhaps the legs, at the distal parts at least, where the
circulation is always at a disadvantage if the patient is up and
about.


SYMPTOMS

The symptoms are increased tension, which means, sooner or later,
hypertrophy of the left ventricle and an accentuated closure of the
aortic valve. This alone means more and more tendency to aortic
irritation and aortic valve irritation, with inflammation, and later
deposits of calcareous material, perhaps with stiffening of the
aortic valve and narrowing, aortic stenosis being the result. If
such a patient with the disease advanced to this stage must
overwork, or sustains any severe muscle strain, an aneurysm of the
aorta may occur. In the meantime, with the advancing degeneration of
the cerebral arteries, some sudden cerebral congestion, caused by
leaning over, lifting, vomiting or hard coughing, may rupture a
cerebral vessel, and all the symptoms of apoplexy are present. If
small hemorrhages occur in the arterioles of the extremities, of
course the prognosis is not serious. Sometimes some of the smaller
vessels of the brain may become obstructed and cerebral degeneration
occur. If distal vessels become obstructed, as of the toes or feet,
gangrene takes place unless the obstruction occurs at a place where
the collateral circulation could save the part from such a death.
These are some of the ultimate results of serious and final
arteriosclerosis. The more frequent result, when the disease has not
advanced so far, is a failing heart, either from degenerative
myocarditis, coronary sclerosis or dilatation, with all the symptoms
of coronary sclerosis and angina pectoris, or with the symptoms of
failing circulation.

With high blood pressure to the point of beginning endarteritis, a
gradually increasing force of the apex beat occurs, the aortic
closure is accentuated as just described, the pulse is slow, the
tensity of the arteries depends on the stage of the disease, and
when the disease is actually present, the palpable arteries do not
collapse on pressure. They soon lose their elasticity, and if this
occurs in parts which are soft and flexible, the arteries become
more or less tortuous by the force of the blood current twisting and
bending them, owing to the irregularity of their hardening. The
extremities readily become numb, or the part "goes to sleep," as it
is termed. This occurs frequently at night. Sooner or later some
edema of the feet and legs occurs in the latter part of the day.
Sometimes abdominal colic attacks occur, caused by disturbed
circulation. Various disturbances of metabolism may occur, depending
on the circulation in the different organs or on coincident disease,
and the liver, pancreas and kidneys may be affected.

The blood pressure, if taken in the arms especially, may appear
excessively high, but really the actual pressure in the blood
vessels may be low. This is on account of the inability to compress
the hardened arteries. A heart may be weak and actually need
strengthening even while the blood pressure reading is high.

The treatment of this disease is successful only in its prevention,
and consists in treatment of hypertension before arteriosclerosis is
present. When the disease is actually present, there is nothing to
do except for the patient to stop active labor, never to overeat or
overdrink, to prevent, if possible, toxemias from the bowels, to
keep the colon as clean as possible, and for the physician to give
the heart such medicinal aids as seem needed, vasodilators if the
heart is acting too strongly, possibly small doses of cardiac tonics
if the heart is acting weakly; always with the knowledge that a
degenerative myocarditis may be present in considerable amount, or
that coronary sclerosis may be present.

As stated above, coronary sclerosis probably seldom occurs without
more general arteriosclerosis. Obstruction of the coronary arteries,
however, not infrequently occurs at their orifices in conjunction
with sclerosis of that region of the aorta and of the aortic valve.
The more these arteries are diseased and the more they are
obstructed, the more the myocardium of the heart becomes
degenerated, softened and weakened, when dilatation of the
ventricles, especially the left, is liable to occur. Sooner or later
such a condition will cause attacks of angina pectoris and more or
less pronounced symptoms of chronic myocarditis and fatty
degeneration, as previously described.


TREATMENT

The treatment of a suspected coronary sclerosis is the same as that
of general arteriosclerosis--primarily the elimination of anything
which tends to cause high tension or to produce chronic
endarteritis. When either general or local arteriosclerosis is
present, the treatment which should be inaugurated comprises
anything which would tend to inhibit the endarteritis and the
classification--necessary periods of rest, the interdiction of all
physical effort or physical strain, and the regulation of the diet,
digestion and elimination. Perhaps there is no greater preventive of
the advance of this disease than a diet considerably less than would
be suitable for the same person when in perfect health and at his
regular work. The amount of protein especially should be reduced,
and the meal hours should be regular. Ordinarily all tea, coffee and
tobacco should be forbidden, and alcohol should be allowed only to
the aged, if allowed at all.

It has long been considered that iodin would inhibit abnormal
connective tissue growth. Iodin most readily reaches the blood as
sodium or potassium iodid. Large amounts of iodin are not needed to
saturate the requirements of the system for iodin, from 0.1 to 0.2
gm. (1 1/2 to 3 grains) preferably of sodium iodid, twice a day,
after meals given with plenty of water, being sufficient; but it
should be continued in one or two doses a day not only for weeks,
but for months. Whether this iodid or iodin acts per se, or acts by
stimulating the thyroid gland to increased activity and therefore to
more normal activity, so that it is the thyroid secretion which is
of benefit, it is difficult to decide. In view of the fact that in
advanced years the thyroid is always subsecreting, and after the
very diseases which cause arteriosclerosis or during the diseases
which cause arterinsclernsis the thyroid is generally subsecreting,
it would appear that the value of iodin is in its effect in
stimulating the thyroid gland.

If a small amount of thyroid secretion is evidenced by other
symptoms, thyroid extract should be given. The dose need not be
large, and should be small, but should be given for a considerable
length of time. If the patient seems to be improving on small doses
of iodid, however, and the thyroid is supposed not to be very
deficient, it is better not to administer thyroid extract, unless
the patient is obese.

A serum treatment given intravenously, hypodermically, by the mouth,
and by the rectum was inaugurated some years ago (1901 and 1902).
and is known as the "Trunecek serum." This first consisted of sodium
sulphate, sodium chlorid, sodium phosphate, sodium bicarbonate and
potassium sulphate in water in such amounts as to stimulate the
blood plasma. Later small amounts of calcium and magnesium phosphate
were added to the solution to be injected. These injections seemed
to lower the blood pressure, but it is doubtful whether they have
any greater ability than a proper regulation of the diet to inhibit
arteriosclerosis. At any rate, these injections are but seldom used.

An important means of inhibiting disturbance from any
arteriosclerosis which should be employed when possible is the
climate treatment. Warm, equable climates, in which there are no
sudden radical changes, are advantageous when coronary sclerosis is
suspected, and warm climates are valuable in promoting the
peripheral circulation and lowering the blood pressure in
arteriosclerosis. These patients always require more heat than
normal persons, always feel the cold severely, and their hearts
always have much less disturbance, fewer irregularities and fewer
attacks of pain during warm weather than during cold weather.

Simple hydrotherapeutic measures are also necessary for these
patients, but baths should not be used to the point of causing
debility and prostration. Applications of cold water in any form are
generally inadvisable. Very hot baths are also inadvisable; but
pleasantly warm baths, taken at such frequency as found to be of
benefit to the individual, relax the peripheral circulation relieve
the tension of the internal vessels, lessen the work of the heart,
and promote healthy secretion of the skin, the skin of
arteriosclerotic patients often being dry. This dry skin is
especially frequent if there is any kidney insufficiency, which so
soon and so readily becomes a part of the arteriosclerotic process.

If the patient is old, small doses of alcohol may act
physiologically for good. In these arteriosclerotic patients the
activities of alcohol should be considered from the drug point of
view, not from that of all intoxicating beverage. Other drugs are
considered in the discussion of hypertension.

If the heart actually fails, the treatment becomes that of chronic
myocarditis and of dilatation.

Not infrequently in sclerosis of the arteries, especially of the
coronary arteries, the blood pressure is not high, but low, and the
heart is insufficient. In such patients cardiac tonics may be
considered, but they must be used with great care. Digitalis may be
needed, but it should be tried in small doses. It often makes a
heart with arteriosclerosis have severe anginal attacks. On the
other hand, if the heart pangs or heart aches and the sluggish
circulation are due to myocardial weakness without much actual
degeneration, digitalis may be of marked benefit. The value of
digitalis in doubtful instances will be evidenced by an improved
circulation in the extremities, a feeling of general warmth instead
of chilliness and cold, an increased output of urine, and less
breathlessness on slight exertion.


ANGINA PECTORIS

This is a name applied to pain in the region of the heart caused by
a disturbance in the heart itself. Heart pains and heart aches from
various kinds of insufficiency of the heart, or heart weakness, are
not exactly what is understood by angina pectoris. It is largely an
occurrence in patients beyond the age of 30, and most frequently
occurs after 50, although attacks between the ages of 40 and 50 are
becoming more frequent. It is a disturbance of the heart which most
frequently attacks men, probably more than three fourths of all
cases of this disease occurring in men; in a large majority of the
cases the coronary arteries are diseased.

Various pains which are not true angina pectoris occur in the left
side of the chest; these have been called pseudo-anginas. They will
be referred to later. True angina pectoris probably does not occur
without some serious organic disease of the heart, mostly coronary
sclerosis, fatty degeneration of the heart muscle, adherent
pericarditis and perhaps some nerve degenerations. Various
explanations of the heart pang have been suggested, such as a spasm
or cramp of the heart muscle, sudden interference with the heart's
action, as adherent pericarditis, a sudden dilatation of the heart,
an interference with the usual stimuli from auricle to ventricle and
therefore a very irregular contraction, a sudden obstruction to the
blood flow through a coronary artery, or a sudden spasm from
irritation associated with some of the intercostal or more external
chest muscles causing besides the pang a sense of constriction.
Perhaps any one of these conditions may be a cause of the heart
pang, and no one be the only cause.

In a true angina, death is frequently instantaneous. In other
instances, death occurs in a few minutes or a few hours; or the
patient's life may be prolonged for days, with more or less constant
chest pains and frequent anginal attacks. Here there is a gradual
failing of the heart muscle, with circulatory insufficiency, until
the final heart pang occurs.

Anginal attacks before the age of 40, presumed, from a possible
narrowing of the aortic valve, to be due to coronary sclerosis, are
frequently due to a long previous attack of syphilis. In these
cases, active treatment of the supposed cause should be inaugurated,
including perhaps an injection of the arsenic specific, and
certainly a course of mercury and iodid, with all the general
measures for managing and treating general arteriosclerosis, as
previously described.


SYMPTOMS

The pain of true angina pectoris generally starts in the region of
the heart, radiates up around the left chest, into the shoulders,
and often down the left arm. This is typical. It may not follow this
course, however, but may be referred to the right chest, up into the
neck, down toward the stomach, or toward the liver. The attack may
be coincident with acute abdominal pain, almost simulating a gastric
crisis of locomotor ataxia. There may also be coincident pains down
the legs. It has been shown, as mentioned in another part of this
book, that disturbances in different parts of the aorta may cause
pain and the pain be referred to different regions, depending on the
part affected.

Instances occasionally occur in which a patient had an anginal
attack, as denoted by facial anxiety, paleness, holding of the
breath, and a slow, weak pulse, without real pain. This has been
called angina sine dolore. The patient has an appearanece of anxious
expectation, as though he feared something terrible was about to
happen.

The position of the patient with true angina pectoris is
characteristic. He stops still wherever he is, stands perfectly
erect or bends his body backward, raises his chin, supports himself
with one hand, leans against anything that is near him, and places
his other hand over his heart, although he exercises very little
pressure with this hand. The position assumed is that which will
give the left chest the greatest unhampered expansion, as though he
would relieve all pressure on the heart.

Besides the feeling of constriction, even to some spasm, perhaps, of
the intercostal muscles, respiration is slowed or very shallow,
because of the reflex desire of the patient not to add to the pain
by breathing. The face is pale, the eyes show fear, and the whole
expression is almost typical of cardiac anxiety. The patient feels
that he is about to die. The pulse is generally slowed, may be
irregular, and may not be felt at the wrist. The blood pressure has
been found at times to be increased. It could of course be taken
only in those cases in which there were more or less continued
anginal pains; the true typical acute angina pectoris attack is
over, or the patient is dead, before any blood pressure
determination could be made. When there is more or less constant
ache or frequent slight attacks of pain, the blood pressure may be
raised by the causative disease, arteriosclerosis. During the acute
attack with inefficient cardiac action and a diminished force and
frequency of the beat, the peripheral blood pressure can only be
lowered.

The duration of an acute attack, that is, the acute pain, is
generally but a few seconds, sometimes a few minutes, and rarely has
lasted for several hours. In the latter cases some obstruction to an
artery has been found at necropsy, but not sufficient to stop the
circulation at a vital point. Repeated slight attacks, more or less
severe, may occur frequently throughout one or more days, or even
perhaps a series of days, caused by the least exertion, even that of
turning in bed.

While most cases of sudden death with cardiac pain are due to a
local disease in or around the heart, it is quite probable that some
disturbance in the medulla oblongata may cause acute inhibitory
stoppage of the heart through the pneumogastric (vagi) nerves. The
power of the pneumogastric reflex to inhibit the action of the heart
is, of course, easily demonstrated pharmacologically. Clinically
reflexes down these nerves interfering with the heart's action cause
faintness and serious prostration, if not actual shock, and perhaps,
at times, death. The most frequent cause of such a reflex is
abdominal pain, perhaps due to some serious condition in the
stomach, to gastralgia, to an intestinal twist, to intussusception
or other obstruction, or to hepatic or renal colic. A severe nerve
injury anywhere may cause such a heart reflex. Hence serious nerve
pain must always be stopped almost immediately, else cardiac and
vasomotor shock will occur. In serious pain morphin becomes a life
saver.


MANAGEMENT

While a number of causes of true cardiac pain may be eliminated by
improvement in any loss of compensation, by improvement of the heart
tone, by more or less recovery from myocardial or endocardial
inflammation, and by the withdrawal of nicotin, which may cause
cardiac pains, still, true angina pectoris once occurring is likely
to be caused by a progressive, incurable condition, and the attacks
will become more frequent until the final one. It is possible that a
true angina may be due to a coronary artery disease or obstruction,
and that a collateral circulation may become established and repair
the deficiency. While this probably can take place, it must be rare.

Occasionally when the intense pain has ceased, the patient may be
nauseated and actually vomit, or he may soon pass a large amount of
urine of low specific gravity, or have a copious movement of the
bowels.

The first attack, and subsequent ones more and more readily, are
precipitated by any exertion which increases the work of the heart,
as walking up hill, walking against the wind, going upstairs,
physical strains, as suddenly getting out of bed, leaning over to
put on the shoes, straining at stool, or even mental excitement.
Exertion directly after eating a large meal is especially liable to
precipitate an attack. Food which does not readily digest, or food
which causes gastric flatulence may precipitate attacks. Any
indiscretion in the use of coffee, tea, alcohol or tobacco may be
the cause of the attack.

For treatment of the immediate pain, if the physician arrives soon
enough, anything may be given which quickly relieves local or
general arterial spasm and spasm of the muscles. The moment that the
heart and its arterioles relax, the attack is often over. The most
quickly acting drug for this purpose is amyl nitrite, inhaled. If
amyl nitrite is not at hand, or has been found previously to cause
considerable disturbance of the head or a feeling of prolonged
faintness, nitroglycerin is the next most rapidly acting drug. It
may be given hypodermically, or a tablet may be dissolved on the
tongue. The amyl nitrite should be in the emergency case of the
physician in the form of ampules, or may be carried by the patient
after he has had one or more attacks. The ampules now come made of
very thin glass with an absorbent and silk covering ready for
crushing with the fingers, and are thus immediately ready for
inhalation. One of these is generally all that it is necessary to
use at any one time. Nitroglycerin, if given hypodermically, should
be in dose of 1/100 grain. If given by mouth the dose should be the
same, repeated in ten minutes if the pain has not stopped.

Almost coincidently with the administration of nitroglycerin or the
amyl nitrite, a hypodermic injection of 1/8 or 1/6 grain of morphin
sulphate should be given without atropin, as full relaxation is
desired without any stimulation of atropin.

Alcohol is also a valuable treatment of this pain, when the drugs
mentioned are not at hand. The dose should be large; whisky or
brandy is best, and should be administered in hot or at least warm
water. The physiologic action of alcohol, which dulls or benumbs the
nervous system and dilates the peripheral blood vessels, is exactly
in line with the clinical indications.

If a patient is home and at rest at the time of an attack, a hot-
water bag but slightly filled, or a pad electrically heated, may be
placed over the heart some times with marked advantage and relief
from pain. Occasionally even such gentle applications are not
tolerated.

After the attack is over, absolute rest for some hours, at least, is
positively necessary. If the attack was severe, the patient should
rest several days, as there seems to be a great tendency for such
attacks to come in groups, the cause being acutely present for at
least some time. But little food should be given; nothing very hot
or very cold, and no large amount of liquids; gentle catharsis may
be induced on the following day, if deemed advisable; no stimulating
drugs should be administered, and nothing which would raise the
blood pressure.

The question often arises as to whether or not the patient shall be
told of the seriousness of his condition. It is hardly wise to
withhold this knowledge from him, and generally is not necessary.
The ordinary alert patient knows how serious the condition is by his
own feelings, and will even reprove or joke with his physician for
minimizing the danger. It is best that the whole subject be
discussed carefully with him and his life regulated and ordered, and
emergency drugs prepared and given him with proper instructions, to
the family, so that he may possibly prevent other attacks and, if
they occur, may have the best immediate treatment.

The acute symptoms being over, a careful analysis of the probable
cause of the anginal attack should be made. If it is a general
sclerosis, the treatment should be directed to that condition. If it
is a myocarditis, a fatty degeneration of the heart or a fatty
heart, this should be properly treated as previously described. If
it is due to a toxemia from intestinal disturbance, that may readily
be remedied. If due to nicotin, it need not again occur from that
reason, and perhaps the damage caused by the nicotin may be removed.
Any organic kidney trouble must, of course, be managed according to
its seriousness, and if there is hypertension without any serious
lesion, the treatment should be directed toward its relief.

Not infrequently, whether a patient is suffering from real angina
pectoris or a pseudo-angina pectoris, the absorption of toxins irons
the intestines, due to indigestion and fermentation, adds to these
cardiac pains, and may even be a cause of them. Consequently,
eliminative treatment and a temporary rigid diet, and various
treatments to prevent intestinal indigestion, are of great value in
angina pectoris.

It may be even advisable for twenty-four hours or so to give nothing
but water, and then perhaps a skimmed milk diet for a few days. This
treatment, combined with almost absolute rest, and later graded
exercise, with other measures to lower the blood pressure, and with
the absence of tobacco, sometimes is very successful treatment.


PSEUDO-ANGINA

While this name is more or less unfortunate, it has long been in
vogue as a designation for pains and disturbances referred by a
patient to his heart. Therefore with the distinct understanding that
if the diagnosis is correct the name is a misnomer, it may be
allowable to discuss under this heading some of the attacks which
may simulate an angina and must be separated from a true angina.

To decide whether pain in the region of the heart or irregularity of
its action is due to organic disease, to functional disturbance, or
to referred causes is often extremely difficult. Some of the most
disturbing sensations in the region of the heart are not due to any
organic trouble, and yet the patient is fearful that such sensations
mean some kind of heart disease, and therefore becomes exceedingly
anxious and watches and mentally records every sensation in the left
chest. This is unfortunate, as the patient may learn to note, if he
does not actually count, his heart beats, while normally he should
sense nothing of his heart's activity. On the other hand, as just
stated, it may be almost impossible to decide that this disturbance
of the heart is not due to an organic cause, but is entirely
functional, or due to some extraneous reason.

It seems justifiable in every case of irregular heart action to
assure the patient that the condition can be improved, which in most
instances is the truth. There can be no question of such urgent
assurance, if it is decided that the cause is not in the heart
itself, or at least is not organic. Irregularities in the heart's
action will be discussed later. At this time discussion will be
limited to pain which is not true angina pectoris, but which is in
the region of the heart or is referred to it.

Intercostal neuralgia is more likely to occur on the left side of
the chest than on the right. This is particularly unfortunate, as
tending to cause these pains to be referred to the heart. The
localization of tender spots along the course of a nerve with
demonstration of these to the patient and the diagnosis stated is
all the assurance that he requires.

Careful questioning, and if necessary scientific examination of the
stomach, may show that the patient has hyperchlorhydria, ulcer of
the stomach or duodenum, dilatation of the stomach, or some growth
in the stomach as a cause for the pain referred to the region of the
heart. Gallstones in the gallbladder may also give such referred
pains. Other lesions in the abdomen may cause pain referred to the
cardiac region. Not only will the demonstration of these causes and
their treatment assure the patient that he has not neuralgia of his
heart, but also, if curable, the cause of the pain may be removed.

Dry pleurisy of the left chest is not an infrequent cause of these
pains, and of course serious disease of the lungs, as tuberculosis,
unresolved pneumonia, pleuritic adhesions, ennphysema and tumor
growths, may all be the cause of a referred cardiac pain, the heart
being disturbed secondarily.

A stomach cramp is a not infrequent cause of serious pain referred
to the heart, and the rare condition of cardiospasm must also be
remembered as a cause of pseudo-angina. In other words, the
interpretation of these pseudo-anginas means a careful diagnosis of
the condition, and, as previously stated, not only must the above-
named causes be excluded, but also the reverse must be remembered:
that many disturbances treated as other conditions really are due to
cardiac weakness. The diagnosis of a real angina pectoris from a
false angina may not be difficult. A real angina generally occurs
after exertion of some kind, be that exertion ever so slight. False
angina may occur at any minute with or without exertion. Pain
referred to the heart which awakens a patient at night is not likely
to be a true angina; nervous patients are prone to have such night
attacks of cardiac disturbance of various kinds. A true angina
causes the patient's face to look anxious and pale, with the
breathing repressed. A false angina shows no such paleness, allows
deep breathing, crying and lamenting, and allows the patient to move
about in bed, or about the room. The true angina makes the patient
absolutely still and quiet: he hardly dares to speak or tell what he
is feeling and fearing. True angina is of course much more frequent
in older persons, while false anginas occur in the young, and
especially in the neurotic. With all the other manifestations of
hysteria, palpitation and cardiac pain are often symptoms.

It should not be decided, however apparently self-evident that a
referred pain is not due to cardiac lesion until a careful
examination of the patient has been made. Real cardiac disturbance
can of course occur at any time in a neurotic or hysterical patient,
and there should be no mistakes of omission from carelessness or
neglect on the part of the physician.

Other frequent causes of more or less disturbance of the heart's
action, often accompanied by pain, are overexertion, worry and
mental anxiety, and intestinal toxemias due to too much protein or
disturbed protein digestion. Frequent causes are tobacco, and the
overuse of tea and coffee. Many a patient's pseudo-anginas are
corrected by stopping tea and coffee. The effects of caffein and
tobacco on the heart will be considered later when toxic
disturbances are under discussion.

The above-mentioned causes of pseudo-anginas have only to be named
to indicate the treatment which will prevent the pain attacks. At
times, the cause being intangible, it may be necessary to change the
whole life and metabolism of the patient, as so often necessary in
hysteria, neurasthenia, gout, intestinal fermentation and kidney
inefficiency. Besides a rearrangement of the diet and measures for
causing proper activity of the bowels, massage, exercise and
hydrotherapy should lie utilized toward the end of improving the
nutrition of every part.


TREATMENT OF PSEUDO-ANGINAS

The treatment of these pseudo-angibas depends, of course, on the
diagnosis of the cause, and the cause should be eliminated or
modified. If the heart shows real disturbance from this reflex
cause, the treatment aimed toward it depends on whether the heart
action is weak or strong and the circulation poor or good. If the
circulation is poor, digitalis in small doses may be needed, either
5 drops of an active tincture twice a day, or 8 or 10 drops once a
day. If digitalis is not indicated, strophanthus sometimes is
valuable. While strophanthus has been shown not to be a real cardiac
tonic like digitalis, still there seems to be a nervous sedative
action when it is given by the mouth, and it often does good in
these cases. The dose is 5 drops of the tincture, in water, three
times a day, after meals. Strychnin in small doses may be needed,
but in these patients, who are generally nervous, it is usually
better not to give it.

One of the best sedatives to a heart that is irregular in its action
and not acting strongly is lime; a good way to administer it is in
the form of calcium lactate, and the dose is 0.3 gm. (5 grains), in
powder or capsule, three times a day, after meals.

If the circulation is good and the heart is strong, and yet these
irregular pains and irregular contractions occur, the bromids act
favorably and successfully. This is probably on account of their
ability to quiet the central nervous system, to quiet and soothe the
irritability of the heart, and to relax the peripheral blood
vessels. The dose should be from 0.5 to 1 gm. (7 1/2 to 15 grains),
in water, three times a day, after meals. It is not necessary or
advisable to continue the bromid very long. Whatever general tonic
or eliminative treatment the patient, requires should be given. The
value of hydrotherapy, massage and graded exercise should not be
forgotten.


STOKES-ADAMS DISEASE: HEART BLOCK

Stokes-Adams disease, or the Stokes-Adams syndrome, is a name
applied to a combination of symptoms which was described by Stokes
in 1846, and had been observed by Adams in 1827. The disease is
characterized by bradycardia and cerebral attacks, either syncope or
pseudo-apoplectic or convulsive attacks.

To understand the phenomena of this disease, it will be well to
refer to the first chapter of this book. Until 1893, when His
described the bundle of muscle fibers which is now known by his
name, the transmission of the cardiac stimulus to contraction was
not understood. It has been found, by studying the pathology of
Stokes-Adams disease, as well as by clinically noting with
instruments the contractions of different parts of the heart, that
these slow heart beats are really due to interruptions of the
impulse passing from auricle to ventricle through the bundle of His,
and degeneration in this region is generally the cause of Stokes-
Adams disease. The auricles often beat many times more frequently
than the ventricles, even two or three times as frequently, and, of
course, these auricular contractions are not transmitted to the
arterial system, and the radial pulse notes only the contractions of
the ventricles. The phrase that is used to describe this
nontransmission of the auricular stimulus to the ventricles is
"heart block."

While this disease almost invariably has a pathology, cases have
occurred in which no lesion of the heart could be found, but it
generally occurs coincidently with arteriosclerosis, in which the
coronary arteries are more or less involved and the arterial system
of the brain may be diseased. It occurs more frequently in men than
in women, and in them mostly after middle, or in advanced, life. The
previous history of the patient has often disclosed syphilis. The
intermittence of the pulse may be regular or irregular, and may not
be constant in the early stages of the disease; but when the disease
is established, the rate of the pulse may be reduced to forty,
thirty, or even twenty beats a minute, and it has been known to be
even less. When these intermittences are regular, perhaps two beats
to one intermittence, or three beats to one intermittence are the
most frequent types. When the auricles also beat slowly, perhaps the
vagiare for some reason overstimulated and thus inhibit the heart's
activity.

The attacks of syncope are doubtless due to anemia of the medulla,
because of the infrequent ventricular contractions. This anemia of
the medulla and of the brain may also cause an epileptic seizure, or
a partial paralytic seizure without any apparent paralysis. It is
probable, however, that in these cases there may be coincident
arterial disease in the brain. These sudden syncopal attacks are
likely to occur when a patient suddenly rises from a reclining
posture, especially if he has been asleep. Many persons whose
circulation is none too strong may feel faint on suddenly rising,
but in a person whose pulse is slow and the circulation weak the
danger of causing anemia of the brain by the sudden erect posture is
much increased. Slight faint turns are of frequent occurrence with
these patients; or the faintness may be so rapid and so intense that
the patient may drop in his tracks. Venous pulsation in the neck is
generally marked, showing an impeded contraction of tile right
auricle.

If the auricles are heard or found by instrumental readings to
contract more frequently than the ventricles, the trouble is quite
likely to be a heart block from disease in the heart itself, in the
bundle of His. If the heart is slowed as a whole, the trouble might
be due to diseased arteries or pressure from a growth, a gumma,
perhaps, or other brain tumor in the region of the pons Varolii or
medulla oblongata; or a hemorrhage into the fourth ventricle,
causing pressure, could be the cause.


TREATMENT

The treatment of true Stokes-Adams disease is unsuccessful. If
general arteriosclerosis is present, that condition should be
treated. Digitalis would seem almost invariably contraindicated,
although it is of value in extrasystoles without heartblock, or in
conditions which are not Stokes-Adams disease; but if this disease
was considered present, digitalis would probably do harm. Sometimes
strychnin is of benefit.

Atropin has sometimes caused stimulation of the heart to more normal
rapidity. Its benefit is generally only temporary, as most patients
cannot take atropin regularly without having it cause a disagreeable
drying of the throat and skin, a stimulation of the brain, and an
undesired raising of the blood pressure, to say nothing of its
action on the eyes.

The only value of the nitrites is when the blood pressure is high
and the nitrite action is desired on that account.

Coffee or caffein often causes these hearts to become irritable; it
certainly raises the blood pressure, and therefore is not generally
advisable. Both tea and coffee should generally be prohibited.

During the acute faint attack, camphor is one of the best
stimulants. Alcohol may be of benefit. If syphilis is a cause of the
condition, iodids are always valuable. If syphilis is not a cause
and arteriosclerosis is present, small doses of iodid given for a
long period are beneficial, although it may not much reduce the
blood pressure or decrease the plasticity of the blood. Iodid is a
stimulant to the thyroid gland, and therefore it is on this account
valuable.

An excellent stimulant to the heart is thyroid secretion or thyroid
extract. Theoretically thyroid extracts should be the treatment for
a slow-acting heart. It sometimes seems of benefit to these
patients, but it often causes such nervous excitation and
irritability as to preclude its use. The dose of thyroid for this
purpose would be small, about one-fourth to one-half grain of the
active substance three times a day. To be of any value, the
preparation must be good.

Epinephrin has been shown by Hirtz [Footnote: Hirtz: Arch d. mal. du
coeur, February, 1916] to overcome experimental heart block. It is
not clear just how it acts, but it could well be tried in heart
block when the blood pressure is not too high. A few drops of an
epinephrin solution 1:1,000 may be placed on the tongue, and
repeated three times a day, or from 5 to 10 minims of a weaker
solution may be given hypodermically.

The usual precautions against overeating, overdrinking, severe
physical exercise, sudden movements, overuse of tobacco, etc.,
should all be urged on the patient. The disease is sooner or later
fatal, although the patient may live some years. Death is generally
sudden.

It is understood that this disease must he separated from the
condition of bradycardia inherent in a few persons who have a slow
pulse throughout their life, without any untoward symptoms.




CARDIOVASCULAR RENAL DISEASE


With the strennousness of this era, this disease or condition, which
may be regarded as one of the accompaniments of normal old age, has
become of grave importance, and nowadays frequently develops in
early middle life. If it is diagnosed in its incipiency, and the
patient follows the advice given him, the progress of the disease
will generally be inhibited, and a premature old age postponed.

In the beginning the symptoms and signs of this disease are
generally those of hypertension, and the treatment and management is
that advised in hypertension. If the kidneys show irritation, as
manifested by the presence of albumini and casts in the urine, or if
they show insufficiency in the twenty-four-hour excretion of one or
more salts or other excretory product, the diet and life must be
more carefully regulated than advised in hypertension, and the
treatment becomes practically that of chronic interstitial
nephritis.

Sooner or later, in most instances of this disease, whether
hypertension, chronic endarteritis or interstitial nephritis or any
combination of these conditions is most in evidence, the heart will
hypertrophy. As long as the circulation in the heart itself is good
and not impaired by coronary sclerosis, and as long as this slowly
developing chronic myocarditis has not advanced far, cardiac
symptoms will not be in evidence; but if these conditions occur, or
if the blood pressure is so greatly increased as to damage the
aortic valve or strain and dilate the left ventricle, symptoms
rapidly appear, and the heart must be carefully watched.
Subsequently, as the disease advances, if the patient does not die
of angina pectoris, apoplexy or uremia, the symptoms of cardiac
decompensation will develop. As the heart begins to fail, a
dilatation of the right ventricle causes passive congestion of the
kidneys, and the chronic interstitial nephritis may progress more
rapidly. It is often difficult to decide which is more in evidence,
heart insufficiency or kidney insufficiency. The more the heart
fails, the more albumin will generally appear in the urine, and the
lower the blood pressure, especially the diastolic. The more
insufficient the kidneys, the higher the blood pressure, especially
the diastolic. The location of the edema will aid in deciding which
condition is most in evidence. If the edema is pendent in feet, legs
and perhaps genitals when the patient is up, with its disappearance
at night, and more or less backache and pitting of the back in the
morning, it is the heart that is most rapidly failing. If there is
more general edema, the hands and face puffing, and there are
considerable nausea and vomiting, headache and drowsiness, and
perhaps muscular twitchings, with neuralgic pains, the most serious
trouble at that particular time lies in the kidney insufficiency.
Kisch [Footnote: Kisch: Med. Klin., Feb. 27, 1916.] sums up the
procedural symptoms and signs of cerebral hemorrhage. The heart is
generally enlarged and hypertrophied. The patient is likely to be
overweight or adding weight, and to suffer from intestinal
indigestions. Signs of sclerosis of the blood vessels of the brain
are evidenced by transient dizziness; headaches; impaired sleep;
loss of memory, especially for names and words; slight disturbances
of speech, momentary perhaps, and more or less temporary localized
numbness of the hands or feet, or arms or legs, with perhaps
flushing of some part of the body, or little localized spasms of
vessels of other parts of the body, causing chilliness.

There is also a marked hereditary tendency to apoplexy.

Cadwalader, [Footnote: Cadwalader, W. R.: A Comparison of the Onset
and Character of the Apoplexy Caused by Cerebral Hemorrhage and by
Vascular Occlusion, The Journal A. M. A., May 2, 1914, p. 1385.]
after considerable investigation, has come to the conclusion that
large hemorrhages into the brain are the rule in apoplexy, and that
small hemorrhages are rare, and he is inclined to think that even
small, as well as large hemorrhages, are more frequently fatal than
supposed. In other words, he thinks that many of the nonfatal
hemiplegias are caused by vascular obstruction and softening and not
by hemorrhage. He finds that sudden death, or death within a few
minutes, does not occur from hemorrhage, even if the hemorrhage is
large, though a rapidly developing and persistent coma usually
indicates a hemorrhage. If the coma is not profound and is slow in
its onset, with symptoms noticed by the patient, and cerebral
disturbance, he believes it to be caused generally by softening of
the cerebral center, due to some obstruction of the blood flow, and
not to hemorrhage. While occasionally a slowly increasing loss of
consciousness may be due to hemorrhage, he thinks it is doubtful if
real hemorrhage ever occurs without loss of consciousness, while
softening of some part of the cerebrum may occur without
unconsciousness. He thinks that the size of the hemorrhage is of
more importance than its situation in causing the profoundness of
the symptoms, but he repeats that nonfatal cases of hemiplegia are
generally caused by vascular occlusion and subsequent softening, and
not by hemorrhage.


TREATMENT

While it is urged, in preventing the actual development of this
disease, and in slowing its progress, that it is advisable to lower
a high blood pressure, we must remember that this blood pressure mad
be compensatory, and many times should not be much lowered without
due consideration of the symptoms and the patient's condition. It is
better not to use drugs of any kind in this incipient condition. The
hypertension should be regulated by the diet; the purin bases and
meat should be reduced to a minimum; tea, coffee and alcohol should
be prohibited, and tobacco should be either entirely stopped or
reduced to a minimum. Regulated exercise is always advisable, the
amount of such exercise depending on the condition of the
circulation. Ordinary walking and graduated walking or graduated
hill climbing and golfing are good exercise for these patients.
Mental and physical strenuosity must be stopped, if the disease is
to be slowed. Sleeplessness must be combated, and perhaps actually
treated medicinally, and for a time sufficient doses of chloral are
perhaps the best treatment. The administration of chloral must
always be carefully guarded to avoid the acquirement of dependence
on the drug. Mouth and other infections should be sought and
removed. Warm baths, Turkish baths, electric light baths or body
baking may be advisable, and certainly obesity must always be
combated by a regulation of the diet. In obesity, stimulants to the
appetite, such as spices, condiments, and even sometimes salt, must
be prohibited. Butter, cream, sugar and starches must be reduced to
a minimum. A small amount of bread and a small amount of potatoes
should be allowed. Liquids with meals should be reduced. Fruits
should be given freely. Intestinal indigestion should be corrected,
and free daily movements of the bowels should be caused. If the
patient is obese, and especially if the blood pressure is high, the
administration of thyroid extract is very beneficial. This is
particularly true in women suffering from this disease; but the
patient should be carefully observed during its administration. It
may be advisable to administer small doses of iodid instead of the
thyroid treatment, or coincidently with it. Nitrites had better be
postponed, if possible, for cardiac emergencies.

White, [Footnote: White: Boston Med. and Surg. Jour., Dec. 2, 1915.]
after studying 200 cases of heart disease, finds that men are more
subject to auricular fibrillation, auricular flutter, heart block
and alternation of the pulse than are women. The greater frequency
of syphilis in men than in women should be considered in this
difference in frequency.

White finds that hyperthyroidism of long standing is often attended
with auricular fibrillation. He does not find that alcohol, tea and
coffee play much part in causing these serious disturbances of the
heart. His conclusions on this subject are certainly a surprise, and
do not coincide with the experience of many others. It would seem
that one of the causes of the greater frequency of these
disturbances in men would be the amount of alcohol and tobacco used
by men.

When the heart begins to fail from a gradually progressing
myocarditis, the pulse rate generally increases, especially on the
least exertion, and on fast walking may be as high as 120 or 130 a
minute, or even higher. It may be found near 100 on the least
exertion, even after some minutes of rest. These patients must have
more or less absolute bed rest. When this condition occurs in old
age, however, prolonged bed rest is inadvisable, for if the heart
once loses its energy, in such cases, it is practically impossible
to cause a return of normal function. However, in all acute cardiac
insufficiency in this disease, due to some heart strain or exertion
that was unusual, a bed rest of from one to two weeks and then
gradually getting up and returning to normal activity is the proper
treatment, and will generally be successful in restoring more or
less compensation. These patients may well recline in bed with
several pillows or with a back rest. During any cardiac anxiety in
this kind of insufficiency the patient breathes better when he is
sitting up or reclining with the head and shoulders high. The reason
for this is probably because his heart has more space in this
position--the same reason that he breathes better when his stomach
is empty. Very indicative of the coming cardiac insufficiency is the
inability to lie at night on the left side. The pressure of the
body, especially if the person is stout, interferes with the heart
action and causes dyspnea and distress. Some short, fat patients
with cardiac distress caused by this disease must even stand up to
relieve the condition, the erect position giving still more space
for the action of the heart.

Before these patients get up, after a period of bed rest, slight
exercises should be done, perhaps resistant exercises, to see what
the effect is on the heart, and also gradually to cause increase in
cardiac strength, much as any other training exercise. Whatever
exercise increases the heart rate more than twenty-five beats is too
strenuous at that particular period. The exercise should then be
still more carefully graduated. If the systolic blood pressure is
altogether too low for the age of the person or for the previous
history, it should be allowed to become higher, if possible, before
much exercise is begun.

The diet should be nutritious, but, of course, modified by the
condition of the stomach, intestines and kidneys, and whether or not
the patient is obese. The bulk of the meal should be small, and
nutriment should be given at three or four hour intervals during the
daytime.

The Karell milk diet or so-called "cure" was first presented in 1865
by Phillippe Karell, physician to the Czar of Russia. This treatment
was more or less forgotten until lately, when it has been more
frequently used in kidney, liver and heart insufficiency. Its main
object in kidney and heart disease is to remove dropsies. In cardiac
dropsy it is advised to give 200 c.c. of milk for four doses at four
hour intervals, beginning at 8 o'clock in the morning. Whether the
milk is taken hot or cold depends on the desire of the patient. This
treatment is supposed to be kept up for six days, and during this
time no other fluid is given and no solid food allowed. During the
next two days an egg is added to this treatment, given about 10
o'clock in the morning, and a slice of dry toast, or zwieback, at 6
p. m. Then up to the twelfth day the food is gradually increased,
first to two eggs a day, then more bread, then a little chopped
meat, then rice or some cereal, and by the end of two weeks the
patient is about back to his ordinary diet. During this period the
bowels are moved by enema or by some vegetable cathartic, or even
castor oil. If thirst is excessive, the patient must have a little
water, and if the desire for solid food is excessive, even Karell
allowed a little white bread and at times a little salt. He
sometimes even prolonged the period of treatment to five or six
weeks.

Various modifications of this treatment have been suggested, such as
skimmed milk, and more in quantity, or a cereal is added more or
less from the beginning, and perhaps cream. The diuretic action of
this treatment is not always successful. Also, sometimes the
treatment is even dangerous, the heart and circulation becoming
weaker than before such treatment was begun. Certainly the treatment
should be used in cardiac insufficiency with a great deal of care,
although it is often very valuable treatment. It should be
emphasized that most patients with cardiac dropsy receiving the
Karell treatment or a modification of it should also receive
digitalis in full doses, and should have daily free movement of the
bowels. It should be urged, however, that too free catharsis in
cardiac weakness is to be avoided, and the prolonged use of salines,
and sometimes even one administration is contraindicated. Before
cardiac failure has occurred in this disease, once a week a dose of
calomel or a brisk saline purge is advisable, and is good treatment;
but when cardiac weakness has developed, free catharsis is rarely
indicated, although the bowels should be daily moved, and vegetable
laxatives are the best treatment. The upper intestine and the liver
and kidneys may be relieved by a more or less abrupt modification of
the diet, or even a starvation period, and the bowels will generally
become cleaned; but frequent profuse purging with salines or some
drastic cathartic puts the final touch on a cardiac failure.

Recently Goodman [Footnote: Goodman, E. H.: The Use of the "Karell
Cure" in the Treatment of Cardiac, Renal and Hepatic Dropsies, Arch.
Int. Med., June, 1916, p. 809.] presented a report of his studies of
the Karell treatment in cardiac, renal and hepatic dropsies. He
finds that patients with uremia ordinarily should not be subjected
to the Karell cure, such patients needing more fluid.

As long as the patient remains in bed, and as long as his ability to
exercise is at a minimum, gentle massage is advisable.

In these cases of cardiac weakness, with or without dropsy, unless
the diastolic pressure is very high, digitalis is valuable. If there
is no cardiac dropsy, but other symptoms of heart tire are manifest
and the blood pressure is high, the nitrites are valuable. The
amount should be sufficient to lower the blood pressure. Sometimes
the diastolic pressure is high and the systolic low and the pressure
pulse small because of heart insufficiency; such a condition is
often improved by digitalis. In other words, with a failing heart
digitalis may not make a blood pressure higher, and often does not;
it may even lower a diastolic pressure, and the moment that the
pressure pulse becomes sufficient, the patient improves. Under this
treatment of digitalis, rest and regulated diet, a dilated left
ventricle with a systolic mitral blow often becomes contracted and
this regurgitation disappears.

The amount of digitalis that is advisable has been frequently
discussed. It should be given in the best preparation obtainable,
and should be pushed gradually (not suddenly) to the point of full
physiologic activity. While it may be given at first three times a
day in smaller doses, it later should be given but twice a day, and
still later once a day, in a dose sufficient to cause the results.
As soon as the full activity has been reached it may be intermitted
for a short time; or it may be given a longer time in smaller
dosage. In renal insufficiency associated with cardiac
insufficiency, its action is subject to careful watching. If there
is marked advanced interstitial nephritis, digitalis may not work
satisfactorily and must be used with caution. If, on the other hand,
a large part of the kidney trouble is due to the passive congestion
caused by circulatory weakness, digitalis will be valuable.

In sudden cardiac insufficiency, provided digitalis has not been
given in large doses a short time before, strophanthin may be given
intravenously once or at most twice at twenty-four-hour intervals.

If, in this more or less serious condition of the heart weakness,
there is great sleeplessness, a hypnotic must sometimes be given,
and the safest hypnotic is perhaps 3 / 10 grain of morphin. One of
the synthetic hypnotics, where the dose required is small, may be
used a few times and even a small dose of chloral should not be
feared when sleep is a necessity and large doses of synthetics are
inadvisable on account of the condition of the kidneys.

The value of the Nauheim baths with sodium chlorid and carbonic acid
gas still depends on the individual and the way that they are
applied. If the blood pressure is low and the circulation at the
periphery is poor, they bring the blood to the surface, dilating the
peripheral vessels, and relieving the congestion of the inner organs
and abdominal vessels, and they often will slow the pulse and the
patient feels improved. If they are used warm, a high blood pressure
may not be raised; if the baths are cool, the blood pressure will
ordinarily be raised. Provided the patient is not greatly disturbed
or exhausted by getting into and out of the bath, even a patient
with cardiac dilatation may get some benefit f rom such a bath, as
there is no question, in such a condition, that anything which
brings the blood to the muscles and skin relieves the passive
internal congestion. Sometimes these baths increase the kidney
excretion. At other times these, or any tub baths, are
contraindicated by the exertion and exhaustion they cause the
patient; and cool Nauheim baths, or any other kind of baths, are
inadvisable with high blood pressure.




DISTURBANCES OF THE HEART RATE

ARRHYTHMIA


While this terns really signifies irregularity and intermittence of
the heart, it may also be broadly used to indicate a pulse which is
abnormally slow or one which is abnormally fast, a rhythm which is
trot correct for the age, condition and activity of the patient.
Irregularity in the pulse beat as to volume, force and pressure,
except such variation in the pulse wave as caused by respiration, is
always abnormal. While an intermittent pulse is of course abnormal,
it may be caused in certain persons by a condition which does not in
the least interfere with their health and well-being.

As to whether a slow or a more or less (but not excessively) rapid
pulse in any one is abnormal depends entirely on whether that speed
is normal or abnormal for that person. As a general rule the heart
is more rapid in women than in men. It is always more rapid in
children than in adults, and generally diminishes in frequence after
the age of 60, unless there is cardiac weakness or some cardiac
muscle degeneration. The average frequence of the pulse in an adult
who is at rest is 72 beats per minute, but a frequency of 80 is not
abnormal, and a frequency of 65 in men is common; 60 is infrequent
in men but normal, while up to 90 is not abnormal, especially in
women, at the time the pulse is being counted.' It should always be
considered that in the majority of patients the pulse is slightly
increased while the physician is noting its rapidity. Anything over
90 should always be considered rapid, unless the patient is very
nervous and this rapidity is considered accidental. Anything below
60 is abnormally slow. In children under 10 or 12 years of age,
anything below 80 is unusual, and up to 100 is perfectly normal, at
least at such time as the pulse is counted and the patient is awake.

Referring to the first chapter of this book, it will be noted that
many physiologic factors must enter into the production of the
normal regularity of the pulse. The stimulus must regularly begin in
the auricle, must be perfectly transmitted through the bundle of His
to the ventricles, the ventricles must normally contract with the
normal and regular force, the valves must close normally and at the
proper time, the blood pressure in the aorta must be normally
constant to insure the perfect transmission of the blood to the
peripheral arteries and to insure the normal circulation through the
coronary arteries, and the arterioles must be normally elastic. The
nervous inhibitory control through the vagi must also be normal, and
there must be no abnormal reflexes of any part of the body to
interfere with the normal vagus control of the heart.

While the heart beats from an inherent musculonervous mechanism,
nervous interference easily upsets its normal regularity. It may be
seriously slowed by nervous shock, fear or sudden peripheral
contractions, spasm of muscles, or convulsive contractions, or it
may be stimulated to greater rapidity by nervous excitement. It may
be slowed or made rapid by reflex irritations, and it may be
seriously interfered with by cerebral lesions; pressure on the vagus
centers in the medulla oblongata will make it very slow. Various
kinds of poisons circulating in the blood, both depressants and
excitants, may affect the rapidity or the regularity of the heart.
Therefore, if it is decided that a given heart is abnormally slow or
abnormally rapid or is decidedly irregular or intermittent, the
various causes for such interference with its normal activity must
be investigated and admitted or excluded as causative factors.

Many investigations of the rhythm of children's pulses have been
made, and some of the later investigations seem to show that not
more than 40 percent are regular, the remaining 60 percent varying
from mild irregularity to extreme irregularity.

Scientifically to determine the exact character of a pulse which is
discovered by the finger on the radial artery and the stethoscope on
the heart to be irregular, tracings of one or more arteries, veins
and the heart should be taken. Two synchronous tracings are more
accurate than one, and three of more value than two in interpreting
the exact activity and regularity of the heart.


ETIOLOGY

The cause of an irregularly acting heart in an adult may be organic,
as in the various forms of myocarditis, in broken compensation of
valvular disease, Stokes-Adams disease, coronary disease, auricular
fibrillation, auricular flutter, cerebral disease, and toxemias from
various kinds of serious organic disease. The cause may be more or
less functional and removable, such as tea, coffee, alcohol,
tobacco, gastric indigestion and intestinal toxemia; or it may be
due to functional disturbances of the heart, such as that due to
what has been termed extrasystole, or to irregular ventricular
contractions. A frequent cause of irregular heart action in women,
more especially of increased rapidity, is hyperthyroidism.

There may be an arrhythmia due to some nervous stimulation, probably
through the pneumogastric, so that the pulse varies abnormally
during respiration, being accelerated during inspiration and
retarded during expiration more than is normally found in adults.
This condition is frequent in children, and is noticed in neurotic
adults and sometimes during convalescence from a serious illness.
Nervous and physical rest, with plenty of sleep and fresh, clean air
so that the respiratory center is normally stiniulated, will
generally improve this condition in an adult.

Extrasystoles causing arrhythmia give a more or less regularly
intermittent pulse, while the examination of the heart discloses an
imperfect beat or the extrasystole which is not transmitted or acted
on by the ventricles, and hence the intermittency in the peripheral
arteries. This condition may be due to some toxemia, nervous
irritability, or some irritation in the heart muscle. Good general
elimination by catharsis, warm baths to increase the peripheral
circulation, a low diet for a few days, abstinence from any toxin
which could cause this cardiac irritation, extra physical and mental
rest, sometimes nervous sedatives such as bromids, and perhaps a
lowering of the blood pressure by nitroglycerin, if such is
indicated, or an increase of the cardiac tone by digitalis if that
is indicated, will generally remove the cardiac irritation and
prevent the extrasystoles, and the heart will again become regular.
It should be carefully decided whether there is beginning heart
block or beginning Stokes-Adams disease, in which case digitalis
should not be used. This disease is not frequent, while
extrasystoles of a functional character are very frequent. Sometimes
this functional disease persists without any apparent injury to the
individual as long as the ventricle does not take note of these
extra auricular systoles and does not also become extra rapid. If
the ventricle does contract with this increased rapidity, it soon
wears itself out, and the condition becomes serious.

In this kind of arrhythmia, if there are no contraindications to
digitalis, it is the logical drug to use from its physiologic
activities, slowing the heart by its action on the vagi and causing
a steadier contraction of the heart; clinically this treatment is
generally successful. If digitalis should, however, cause the heart
to become more irritable, it is acting for harm, and should be
stopped.


TREATMENT

One has but to refer to the enumerated causes of irregular heart
action to determine the treatment. In that caused by extrasystole,
the treatment has just been suggested. In irregular heart caused by
serious cardiac or other lesions the treatment has already been
described, or is that of the disease that has a badly acting heart
as a complication. If the irregularity is caused by toxins, the
treatment is to stop the ingestion of the toxin and to promote the
elimination of what is already in the system; how much of the
irregularity was due to the toxin and how much is inherent
disturbance in the heart can then be determined. If the cause of a
toxemia developed in the system, perhaps most frequently from
intestinal putrefaction, increased elimination and a regulation of
the diet will cure the condition.

The valvular lesions most apt to cause irregular action of the heart
are mitral insufficiency or mitral stenosis. The lesion which is
most apt to cause auricular fibrillation and more or less
permanently irregular heart is perhaps mitral stenosis. Another
frequent cause of more or less permanent irregularity is the
excessive use of alcohol.

While an irregular pulse and an irregular heart are always of more
or less serious import, still, as the extrasystoles of the auricle
are better understood and more frequently recognized, and the habits
and life of the patients (most frequently men) are regulated and
revised, frequently a pulse and heart which would be rejected by any
medical examiner for an insurance company becomes, in a few weeks or
a few months, a perfectly acting heart, and remains so sometimes for
years. It also is not quite determinaible whether a heart that is so
misbehaving has a recurrence of such misbehavior more readily than a
heart which has never been so affected. However this may be, the
cause having been determined or presumed by the physician, it should
be so impressed on the patient that he does not again repeat the
insult to his heart.


AURICULAR FIBRILLATION: AURICULAR FLUTTER

Auricular fibrillation is at times apparently a clinical entity much
as is angina pectoris, but it is often a symptom of some other
condition. At times auricular fibrillation is only a passing
symptom, and is rapidly cured by treatment. A real auricular
fibrillation shows a semiparalysis of the auricles, and during this
condition normal systolic contractions do not occur, although there
are small rapid twitchings of different muscle fibers in the
auricles. Although it was once thought that the auricle was
paralyzed in this condition, it probably simply loses its coordinate
activity. Auricular fibrillation and auricular flutter are probably
simply different degrees of the same condition, and any contractions
of the auricles over 200 per minute may be termed an auricular
flutter, and below that the term auricular fibrillation may be used.
When ventricular fibrillation occurs, the condition is serious and
the prognosis bad. Both auricular fibrillation and auricular flutter
may be temporary or permanent, and the exact number of fibrillations
or tremblings of the auricular muscle can be noted only by
electrical instruments.

Tallman, [Footnote: Tallman: Northwest Med., May, 1916] after
examination of fifty-eight cases, classifies different types of
auricular flutter: (1) such a condition in an apparently normal
heart; (2) the condition occurring during chronic heart disease, and
(3) an auricular flutter with partial or complete heart block.

The irregular pulse in auricular fibrillation is more or less
distinctive, being generally rapid, from 110 upward. Occasionally
the pulse rate may be much slower, if the heart is under the
influence of digitalis. The irregularity of the pulse in this
condition is excessive; the rate, strength and apparent
intermittency during a half minute may not at all represent the
condition in the next half minute, or in the next several minutes.
If digitalis does not cure the irregularity, the condition has been
termed the "absolutely irregular heart." Other terms applied to the
condition have been "ventricular rhythm," "nodal rhythm" and "rhythm
of auricular paralysis." The condition of the pulse has been
Latinized as pulsus irregularis perpetuus.

While the condition is best diagnosed by tracings taken
simultaneously of the apex beat, jugular and radial, still the
jugular tracing is almost conclusive in the absence of the auricular
systolic wave. The radial tracing is exceedingly suggestive, and if
there is also a careful auscultation of the heart, a presumptive
diagnosis may be made.


OCCURRENCE

This condition of auricular fibrillation occurs occasionally in
valvular disease, and perhaps most frequently in mitral stenosis;
but it can occur without valvular lesions, and with any valvular
lesion. If it occurs in younger patients, valvular disease is apt to
be a cause; if in older patients, sclerosis or myocardial
degeneration is generally present.

It may also follow infections such as diphtheria, or some infection
which has caused a myocarditis. Rarely this fibrillation may be
caused by some of the drugs used to stimulate the heart.

It is astonishing how few symptoms may be present with auricular
fibrillation and an absolutely irregular heart action. The patient
may be able to perform all of his duties, however strenuous, until
coincident, concomitant or causative ventricular weakening and
dilatation of the ventricles or broken compensation occurs, and then
the symptoms are those due to the cardiac failure. Often in the
first stage of this weakening and later fibrillation of the auricles
the patient may recognize the cardiac irregularity and disturbances.
Generally, however, he soon becomes accustomed to the sensations,
and, unless he has cardiac pains or dyspnea, he becomes oblivious to
the irregularity. At other times he may be conscious of irregular,
strong throbs or pulsations of the heart, as such hearts often give
an occasional extra sturdy ventricular contraction. These he notes.
Real attacks of tachycardia may be superimposed on the condition.
Sooner or later, however, if the condition is not stopped, cardiac
weakness and decompensation, with all the usual symptoms, occur. It
seems to be probable that more than half of all cases of heart
failure are due to auricular fibrillation, or at least are
aggravated by it.

As previously stated, ventricular fibrillation is a very serious
condition, and may be a cause of sudden death in angina pectoris,
and is probably then caused by disturbed circulation in one of the
coronary arteries causing an irregular blood supply to one or other
of the ventricles. Absorption of some toxins or poisons which could
act on the blood supply of the ventricles could also be a cause of
this condition. This irregular ventricular contraction sometimes
displaces the apex beat.


PATHOLOGY

Schoenberg [Footnote: Schoenberg: Frankfurt. Ztschr. f. Pathol.,
1909, ii, 4.] finds that in auricular fibrillation there are
definite signs in the node, such as round cell infiltration, showing
inflammation, a fibrosis of the tissue, and perhaps a sclerosis of
the blood vessels of that region. He also found that compression of
this nodal region of the auricle from some growth or other
disturbance in the mediastinal region could cause auricular
fibrillation.

Jarisch [Footnote: Jarisch: Deutsch. Arch. f. klin. Med., 1914, cxv,
376.] finds by personal investigations and by studying the
literature that the node showed pathologic disturbance in less than
half the cases. Consequently, although a pathologic condition of the
node is a frequent, and perhaps the most frequent, cause of
auricular fibrillation, other conditions, especially anything which
dilates the right auricle, may cause it.


DIAGNOSIS

If the pulse is intermittent and there is apparently a heart block.
Stokes-Adams disease should be considered as possibly present, and
digitalis would be contraindicated and would do harm.

A scientific indication as to whether a heart is disturbed through
the action of the vagi or whether the disturbance is due to muscle
degeneration may be obtained by the administration of atropin.
Talley [Footnote: Talley, James: Am. Jour. Med. Sc., October, 1912.]
of Philadelphia shows the diagnostic value of this drug. It is a
familiar physiologic fact that stimulation of the vagi slows the
heart or even stops it. Stimulation of these nerves by the electric
current, however, does not destroy the irritability of the heart;
indeed, the heart may act by local stimulation after it has been
stopped by pneumogastric stimulation. It is also a well known fact
that anything which inhibits or removes vagus control of the heart
allows the heart to become more rapid, since these nerves act as a
governor to the heart's contractions. Under the influence of atropin
the heart rate is increased by paralysis of the vagi. Talley states
that a hypodermic injection of from 1/50 to 1/25 grain of atropin
produces the same paralytic and rapid heart effect in man. He
advises the use of 1/25 grain of atropin in robust males, and 1/50
grain in females and in less robust males, and he has seen no
serious trouble occur from such injections. The throat is of course
dry, and the eyesight interfered with for a day or more, but Talley
has not seen even insomnia occur, to say nothing of nervous
excitation or delirium. Theoretically, however, before such atropin
dosage, an idiosyncrasy against belladonna should be determined.

The value of such an injection rests on the fact that atropin thus
injected will increase the normal heart from thirty to forty beats a
minute, and Talley believes that if the heart beat is increased only
twenty or less, if the patient has not been suffering from an
exhausting disease, it shows "a degenerative process in the cardiac
tissue which makes the outlook for improvement under treatment
unpromising." He also believes that when the heart in auricular
fibrillation is increased the normal amount or more than normal, the
prognosis is good. He still further advises in auricular
fibrillation an injection of atropin before digitalis has been
administered, and another after digitalis is thoroughly acting.
Comparison of the findings after these two injections will determine
which factor, vagal or cardiac tissue, is the greater in the
condition present. The patients with a large cardiac factor are the
ones who may be more improved by the digitalis treatment than those
in whom the fibrillation is caused by vagus disturbance.


PROGNOSIS

The prognosis depends on the condition of the myocardium of the
vagus. If this muscle is intact, and there is no pathologic
condition in the sinus node (which can be proved by the successful
results of treatment), the removal of all toxins that could increase
the activity of the heart, and the administration of digitalis,
which will slow the heart by stimulating the pneumogastric control
of the heart, will produce a cure, temporary, if not permanent.

Although a patient with auricular fibrillation may have been
incapacitated by this heart activity, he may not yet have dilated
ventricles, and the digitalis need perhaps not be long continued. If
on account of some heart strain or some unaccountable cause the
fibrillation recurs, he of course must again receive the digitalis.
If the auricular fibrillation is superimposed, or is followed by
dilated ventricles and decompensation, the prognosis is bad,
although the condition may be improved. In other words, auricular
fibrillation added to these conditions is serious, but still, many
times a patient may be greatly improved by rest, digitalis, careful
diet, proper care of the bowels, etc. If the fibrillation occurs
with or was apparently caused by the dilatation of the ventricles,
the prognosis of improvement may be good. If the dilatation of the
ventricles occurs following auricular fibrillation, the prognosis is
not good.

White [Footnote: White: Boston Med. and Surg. Jour., Dec. 2, 1915.]
after studying 200 heart cases, finds that auricular fibrillation
and alternating pulse, as well as heart block, are more frequent in
men than in women, and both auricular fibrillation and alternating
pulse are more apt to occur after 50 years of age than before.
Auricular fibrillation may occur in hearts which are suffering from
valvular lesions, especially mitral stenosis, and may occur in
syphilitic hearts, in various sclerotic conditions of the heart, and
in hyperthyroidism.

Though disputed, it seems probable that fibrillation may be caused
by the excessive use of tea, coffee and tobacco. Paroxysmal
tachycardias are certainly caused by these substances, and the
conditions of auricular fibrillation and auricular flutter may be
found frequently present if such hearts are carefully examined with
cardiographic instruments.


TREATMENT

The condition may be stopped by relieving the heart and circulation
of all possible toxins and irritants, and by the administration of
digitalis. One attack is frequently followed by others, perhaps of
longer duration. Occasionally, however, the patient may be observed
for many years without the condition again being present. If the
pulse, in spite of treatment, is permanently irregular, and
auricular insufficiency is permanent, the patient is of course in
danger of cardiac failure; but still he may live for years and die
of some other cause than heart failure. The prognosis is better when
the pulse is not rapid--below a hundred. This shows that the
ventricles are not much excited and do not tend to wear themselves
out.

Any treatment which lowers the heart rate is of advantage, such as
the stopping of tea and coffee, and the administration of digitalis,
together with rest and quiet.

While large doses of digitalis are advised, and large doses are
given as soon as a patient with auricular fibrillation comes under
treatment, such large dosage is dangerous practice. Many patients
may be cured or may survive fluidram doses of the official tincture,
but such large doses should never be used unless it is decided,
after consultation, that, though dangerous, it may be a life-saving
treatment.

If a patient has not been receiving digitalis, it is best to begin
with a small close and gradually increase the dosage, rather than to
give the heart a sudden shock from an enormous dose of digitalis.
The preparation selected must be the best obtainable, but the exact
dosage of any preparation can be determined only by its effect, as
all preparations of digitalis deteriorate sooner or later. It is
well to administer digitalis at first three times a day, then as
soon as its action is thoroughly established, reduce to twice a day,
and later to once a day, in such dosage as is needed to make a
profound impression on the heart. The first dose may be from 5 to 10
drops, and the dosage may be increased by 5 drops at each dose,
until improvement is obtained. If the patient is in a momentary
serious condition and liable to die of heart failure, it is doubtful
if digitalis pushed at that time will be of benefit. On the other
hand, if, after consultation, it is deemed advisable to give half a
fluidram or more of digitalis at once, it is justifiable. It should
be emphasized that the proper dose of digitalis is enough to do the
work. If within a few days there is no marked improvement, the
prognosis is not good. Also, if the digitalis causes cardiac pain
when such was not present, or increases cardiac pains already in
evidence, and causes a tight feeling in the chest, nausea or
vomiting, or a diminished amount of urine, and a tight, bandlike
feeling in the head, digitalis is not acting well, and should be
stopped, or the dose is too large. Also, if there is kidney
insufficiency, or if the digitalis diminishes the output of urine,
it generally should be stopped.

If the blood pressure is high, and perhaps almost always, even in
those who are accustomed to the use of it, tobacco should be
stopped. Tea and coffee should always be withheld from such
patients.

The food and drink should be small in amount, frequently given, and
should be such as especially to meet the needs of the individual,
depending entirely on his general condition and the condition of his
kidneys.


PULSUS ALTERNANS

By this term is meant that condition of pulse in which, though the
rhythm is normal, strong and weak pulsations alternate. White
[Footnote: White: Am. Jour. Med. Sc., July, 1915, p. 82.] has shown
that this condition is not infrequent, as demonstrated by
polygraphic tracings. He found such a condition present In seventy-
one out of 300 patients examined, and he believes that if every
decompensating heart with arrhythmia was graphically examined, this
condition would be frequently found. The alternation may be
constant, or it may occur in phases. It is due to a diminished
contractile power of the heart when the heart muscle has become
weakened and a more or less rapid heart action is present.

Gordinier [Footnote: Gordinier: Am. Jour. Med. Sc., February, 1915,
p. 174.] finds that most of these patients with alternating pulse
are suffering from general arteriosclerosis, hypertension, chronic
myocarditis, and chronic nephritis, in other words, with
cardiovascularrenal disease. He finds that it frequently occurs with
Cheyne-Stokes respiration, and continues until death. He also finds
that the condition is not uncommon in dilated hearts, especially in
mitral disease, and with other symptoms of decompensation.

White found that about half of his cases of pulsus alternans showed
an increased blood pressure of 160 mm. or more; 62 percent. were in
patients over 50 years of age, and 69 percent. were in men.
Necropsics on patients who died of this condition showed coronary
sclerosis and arteriosclerotic kidneys.

The onset of dyspnea, with a rapid pulse, should lead one to suspect
pulsus alternans when such a condition occurs in a person over 50
with cardiovascular-renal disease, arid with signs of
decompensation, and also when such a condition occurs with a patient
who has a history of angina pectoris.

While the forcefulness of the varying beats of an alternating pulse
may be measured by blood pressure instruments by the auscultatory
method, White and Lunt [Footnote: White, P. D. and Lunt, L. K.: The
Detection of Pulsus Alternans, THE JOURNAL A. M. A., April 29, 1916,
p. 1383.] find that in only about 30 percent. of the cases, the
graver types of the condition, is this a practical procedure.

Pulsus alternans, except when it is very temporary, Gordinier finds
to be of grave import, as it shows myocardial degeneration, and most
patients will die from cardiac insufficiency in less than three
years from the onset of the disturbance.

The treatment is rest in bed and digitalis, but White found that in
only four patients out of fifty-three so treated was the alternating
pulse either "diminished or banished." In a word, the only treatment
is that of decompensation and a dilated heart, and when such a
condition occurs and is not immediately improved, the prognosis is
bad, under any treatment.


BRADYCARDIA

The first decision to be made is what constitutes a slow pulse or
slow heart. A pulse below 58 or 60 beats per minute should be
considered slow, and anything below 50 should be considered
abnormally slow and a condition more or less suspicious. A pulse
from 45 to 50 per minute occasionally occurs when no pathologic
excuse can be found, but such a slow rate is unusual. Before
determining that the heart is slow, it must of course be carefully
examined to determine if there are beats which are not transmitted
to the wrist; also whether a slow radial rate is not due to
intermitence or a heart block. Auricular fibrillation, while
generally causing a rapid pulse (though by no means all beats are
transmitted to the peripheral arteries), tray cause a slow pulse
because some of the contractions of the heart are not transmitted.

While any pulse rate below 50 should be considered abnormal and more
or less pathologic, still a pulse rate no lower than 60 may, be very
abnormal for the individual. For athletes and those who work hard
physically, a slow pulse is normal. Such hearts are often not even
normally stimulated by high fever, so that the pulse is unusually
slow, considering the patient's temperature, unless inflammation of
the heart has occurred.

Some chronic diseases cause a slow pulse; this is especially true of
chronic interstitial nephritis. In fact, it may be stated that any
disease or condition which increases the blood pressure generally
slows the pulse, unless the heart itself is affected. This is true
of hypertension, of arteriosclerosis, of nicotin unless the heart
has become injured, and often of caffein, unless it acts in the
individual as a nervous stimulant. Chronic lead poisoning causes a
slow pulse on account of the increased blood pressure.

A slow pulse may occur during convalescence from acute infections,
such as typhoid fever and pneumonia, and sometimes after septic
processes. While it may not be serious in these conditions, it
should always be carefully watched, as it may show a serious
myocarditis.

While weakness generally and myocarditis, at least oil exertion or
nervous excitation or after eating, cause a heart to be rapid, still
such a heart may act sluggishly when the patient is at rest, so that
he feels faint and weak and disinclined to attempt even the
slightest exertion. In such a condition calcium, iron and strychnin,
not too frequently or in too large doses, and perhaps caffein, are
indicated. Camphor is always a valuable stimulant, more or less
frequently administered, during such a period of slow heart. This
slow heart sometimes occurs after rheumatic fever; it is quite
frequent after diphtheria, and may show a disturbance of the vagi.

Although the prognosis of such slow hearts after serious illness is
generally good, a heart that is too rapid after illness is often
more readily brought to normal by proper management than a heart
which is too slow. Either condition needs proper treatment and
proper management.

It is well recognized that serious, almost major hysteria may be
present and the heart not only not be increased, but it may even be
slowed. The heart in this condition of course requires no treatment.
In cerebral disturbances, especially when there is cerebral
pressure, and more particularly if there is pressure in the fourth
ventricle, the pulse may be much slowed. It is often slowed in
connection with Cheyne-Stokes respiration. It may be very slow after
apoplexy, and when there are brain tumors. It is often much slowed
in narcotic poisoning, especially in opium, chloral and bromid
poisoning. Serious toxemia from alcohol may cause a heart to be very
slow. It is more likely, however, to cause a heart to be rapid,
unless there is actual coma.

A frequent condition causing a slowing of the heart is the presence
of bile in the blood, typically true of catarrhal jaundice. Uremic
poisoning and acidemia and coma of diabetes tray cause a pulse to be
very slow.

Not infrequently after parturition the heart quiets down from its
exertion to a rate below normal. If the urine is known to be free
from albumin and casts, and there are no signs of impending
eclampsia, the slow pulse is indicative of no serious trouble; but
the urine should be carefully examined and a possible uremia or
other cause of eclampsia carefully considered. Sometimes with
serious edema and after serious hemorrhage the heart becomes very
slow, unless some exertion is made, when it will beat more rapidly
than normal. This probably represents a diminished cardiac
nutrition.

The cardiac lesions which cause a pulse to be slow are sclerosis or
thrombosis of the coronary arteries, fatty degeneration of the
myocardium, and Stokes-Adams disease.

It is seen, therefore, that when a pulse is slower than normal, even
below 65 beats per minute, the cause should be sought. If no
functional or pathologic excuse is discovered, it must be considered
normal, for the individual, and, as stated above, even 58 or 60
beats per minute are in many instances normal for men. This is
especially true with beginning hypertension, and may be true in
young men who are athletic or who are oversmoking but are not being
poisoned by the nicotin, as shown by the fact that their hearts are
not rapid, that they are not having cardiac pains, that they do not
perspire profusely, and that they do not have muscle cramps. A pulse
of from 50 to 55 is likely to be seriously considered by an
insurance company in deciding the advisability of the risk, and
below 50 must be considered as abnormal.


SYMPTOMS

If a person has been long accustomed to a slow-acting heart, there
are no symptoms. If the heart has become slowed from disease or from
any acute condition, the patient is likely to feel more or less
faint, perhaps have some dizzines, and often headache, which is
generally relieved by lying down. Sometimes convulsions may occur,
epileptiform in character, due possibly to anemia or irritation of
the brain. If the slow heart does not cause these more serious
symptoms, the patient may feel week and unable to attend to his
ordinary duties. As previously urged an abnormally slow heart after
serious illness should be as carefully cared for as a too rapid
heart under the same conditions. Probably often a myocarditis and
perhaps some fatty degeneration are at the base of such a slowed
heart after serious infections.

A heart which has not always been slow but has gradually become slow
with the progress of hypertension and arteriosclerosis will often
disclose on postmortem examination serious lesions of the coronary
arteries.

Deficiency in the thyroid secretion will always cause a heart to be
slower than normal. The more marked and serious the hypothyroidism,
the slower the heart is apt to be. When such a condition is
diagnosed, the treatment is thyroid extract; or if the insufficiency
is not great, small doses of an iodid should be given. In either
case it is sometimes astonishing how rapidly a slow, sluggishly
acting heart, improves and how much improvement there is in the
mental condition of the patient.

In acute slowing of the heart, as in syncope, the patient must
immediately lie down with the head low, possibly with the feet and
legs elevated, and all constricting clothing of the abdomen and
chest should be removed. Whiffs of smelling-salts may be given;
whisky, brandy or other quickly acting stimulant, not much diluted,
play also be given. Camphor, a hypodermic dose of strychnin or
atropin if deemed necessary, a hot-water bag over the heart, and
massaging of the arms and legs to aid the return circulation, are
all means which are generally successful in restoring the patient's
circulation to normal. Caffein is another valuable stimulant,
perhaps best administered as a cup of coffee. Digitalis is not
indicated: neither is nitroglycerin, unless the slow heart is due to
cardiac pain or to angina.

Some patients have syncopal attacks with the least injury or with
any mental shock. Such patients as soon as restored are as well as
ever. Other patients who faint or have attacks of syncope should
remain at rest on a couch or bed for some hours.

A tangible cause, being discovered for an unusually slow heart is
sufficiently indicative of the treatment not to require further
comment. While generally toxins from intestinal indigestion make a
heart irritable and more rapid, sometimes they slow a heart, and in
such cases the heart will be improved when catharsis has been caused
and a modification of the diet is ordered.


PAROXYSMAL TACHYCARDIA

This condition is generally termed by the patient a "palpitation,"
and palpitation of the heart is recognized by most physicians as
meaning a too rapidly acting heart, the term "tachycardia" being
reserved for an excessive rapidity of the heart. Many of the so-
called tachycardias are really instances of auricular fibrillation
or flutter. Some persons normally have a pulse and heart too rapid;
children more or less constantly have a heart beat of from 90 to
100. Women have more rapid heart action than men, and it becomes
more rapid with their varying functions, specifically increasing its
rapidity before, and perhaps during, menstruation. Many patients
have a rapid heart action with the slightest increase in temperature
and in any fever process. Some have a rapid heart action after the
least exertion without any cardiac lesion or assignable excuse for
such rapidity. Others have a rapid heart with mental activity and
excessive excitement. Therefore in deciding that a heart is
abnormally rapid one must individualize the patient.

During or after illness many patients are said to have palpitation
when the real cause is an unhealed myocarditis. Tuberculosis almost
invariably causes increased heart action, even when there is no
fever. All high fever increases the heart's action, but not so
markedly in typhoid fever as in other fevers; in fact, the heart in
typhoid fever, during the early stages, is apt to be slower than the
temperature would seem to call for. In anemia when the patient is
active the heart is generally rapid. The rapid heart from cardiac
disease has already been considered. For the palpitation or rapid
heart Just described there is little necessity for other treatment
than what the acute or chronic condition would call for. With proper
management the condition will improve unless the patient has an
idiosyncrasy for intermittent attacks of slightly rapid heart, as
from 100 to 120 beats per minute.

A permanently rapid heart, when the patient has no heart lesion and
is at rest, is generally due to hypersecretion of the thyroid, which
will be discussed later. Paroxysmal tachycardia is a name applied to
very rapid heart attacks in persons who are more or less subject to
their recurrence. They may occur without any tangible excuse, and
are liable to occur during serious illness, after a large meal,
after a cup of tea or coffee, or after taking alcohol. The heart may
beat as rapidly as from 150 to 200 times a minute, or even more,
with no other symptoms than a feeling of constriction or tightness
in the chest, an inability to respire properly and a feeling of "air
hunger." The patient almost invariably must sit up, or at least have
his head raised. Attacks of cardiac delirium (often auricular
fibrillation) may occur with serious lesions of the heart, as
valvular disease or sclerosis, but paroxysmal tachvcardia occurs in
certain persons without any tangible cardiac excuse. The auricles of
the heart may act more energetically than normal, and precede as
usual the ventricular contraction; or the auricles and ventricles
may contract almost together--a so-called "nodal" type of
contraction. Rarely does a patient die of paroxysmal tachycardia.
The length of time the attack may last varies from a few minutes to
an hour, or even for a day or more.


MANAGEMENT

There is no specific treatment for paroxysmal tachycardia. What is
of value in one patient may be of no value in another; in fact,
drugs are rarely successful in ameliorating or preventing the
condition. Patients who are accustomed to these attacks often learn
what particular position or management stops the attack.

Sometimes a patient rises and walks about. Sometimes an ice-bag over
the heart will stop the attack.

If there is no serious illness present, and no serious cardiac
disease causing the condition, and a patient is known to have an
overloaded stomach or bowels, an emetic or a briskly acting
cathartic is the best possible treatment. The attack often
terminates as suddenly as it begins, without leaving any knowledge
as to which particular treatment has been beneficial. A patient who
is well and has an attack of tachycardia should be allowed to assume
the position which he finds to give him the most comfort, and to use
the means of stopping his attack which lie has found the most
successful. In the absence of his success or of his knowledge of any
successful treatment, a hypodermic injection of 1/6 or even 1/4
grain of morphin sulphate is often curative. Atropin should not be
given, as it may increase the cardiac disturbance. If an attack
lasts more than an hour or so, one of the best treatments is the
bromids, which should be given either by potassium or sodium bromid
in a dose of 2 or 3 gm. (30 or 45 grains) at once. Sometimes one
good-sized dose of digitalis may be of benefit, but it is often
disappointing, and unless there is a valvular lesion with signs of
broken compensation, it is rarely indicated. It should also be
remembered that, if the patient is receiving digitalis in good
dosage for broken compensation, tachycardia may be caused by an
overaction of the digitalis. Such overaction would be indicated by
previous symptoms of nausea, vomiting, intestinal irritation, a
diminished amount of urine, headache and a tight, bandlike feeling
in the head, cold hands and feet, and a day or two of very slow
pulse. If none of these symptoms is present, though a patient has
received digitalis for broken compensation, a tachycardia occurring
might not contraindicate digitalis, as much of the digitalis on the
market is useless; and a patient may not actually have been
obtaining digitalis action.

If the tachycardia occurs in a patient with arteriosclerosis,
especially if there is much cardiac pain, nitroglycerin is of
advantage; also warm foot-baths. If there is prostration and a
flaccid, flabby abdomen, a tight abdominal bandage may be of
benefit.

Gastric flatulence, while perhaps not a cause of the tachycardia, is
liable to develop and be a troublesome symptom. Anything that causes
eructations of gases is of benefit, as spirit of peppermint,
aromatic spirit of ammonia or plain hot water. If there is
hyperacidity of the stomach, sodium bicarbonate or milk of magnesia
will be of benefit.

The ability of some patients to stand a rapid heart action without
noting it or being incapacitated by it is astonishing. It may
generally be stated that a rapid heart is noted, and a pulse above
120 generally prostrates, at least temporarily, a patient who is
otherwise well, provided the cause is anything but hyperthyroidism.
A patient who has hypersecretion of the thyroid will be perfectly
calm, collected, often perhaps not seriously nervous, and, with a
heart beating at the rate of 140, 150, 160 and even 200 per minute,
will state that she has no palpitation now, although she sometimes
has it. A heart thus fast, with a patient not noting it and not
prostrated by it, is almost diagnostic of a thyroid cause.

Some patients, both men and women, cannot take even a small cup of
tea or coffee without an attack of paroxysmal tachycardia. Such
patients, of course, quickly learn their limitations.


HYPERTHYROIDISM

The presence of a well marked case of exophthalmic goiter is not
necessary for the secretion of the thyroid to be increased
sufficiently to cause tachycardia; in fact, an increased heart
rapidity in women often has hyperthyroidism as its cause. The
thyroid gland hypersecretes in women before every menstrual period
and during each pregnancy, and with an active, emotional, nervous
life, social excitement, theaters, too much coffee, and,
unfortunately today among women, too much alcohol, it readily gives
the condition of increased secretion; and the organ that notes this
increased secretion the quickest is the heart.

The tachycardia of a developed exophthalmic goiter is difficult to
inhibit. Digitalis is of no avail, and no other single medicinal
treatment is of any great value. The tachycardia will improve as the
disease improves. On the other hand, nothing is snore serious for
this patient than her rapid heart, and if it cannot be soon slowed,
operative interference is absolutely necessary. If the rapid heart
continues until a myocarditis has developed and a weakening of the
muscle fibers occurs, or dilatation is imminent or has actually
occurred, operative interference is serious, and most patients under
these conditions die after a complete operation, that is, the
removal of from one half to two thirds of the thyroid. In such cases
the only excusable operative interference is the graded one, namely,
the tying of first one artery and then another of the thyroid to
inhibit the blood supply to the gland in order that it may not
furnish so much secretion. If the heart then improves, a more
radical operation may be done without much serious danger. Therefore
the working rule should be that, if a heart does not quickly improve
under medical management, operative interference should not be
delayed until the heart has become degenerated.

If tachycardia is the only serious symptom present in a patient who
is considered to have hyperthyroidism, it may generally be
successfully treated by insistence on quiet, cessation of all
physical and exciting mental activities, more or less complete rest,
the absolute interdiction of all tear coffee or other caffein-
bearing preparations, total abstinence from alcohol, the restriction
to a cereal and fruit diet (the withdrawal of all meat from the
diet), the administration of calcium, as the calcium glycerophospate
in dose of 0.3 gm. (5 grains) in powder three times a day, and for a
time, perhaps, the administration of bromids. If the depressing
action of bromids on the heart is counteracted by the coincident
administration of digitalis, they will act only for good by quieting
the nervous system and more or less inhibiting the secretion of the
thyroid gland.

If a patient has exophthalmic goiter fully developed, absolute rest
in bed, with the treatment outlined above, should soon cause
improvement. If it does not, the operative treatment as advised
above should be considered. If myocarditis has been diagnosed, the
minor operations should be done if the patient does not soon
improve. The prolongation of the treatment depends on the condition
and the amount of improvement.

If the physician is in doubt as to whether or not this particular
tachycardia is caused by hyperthyroidism, the administration of
sodium iodid in doses of 0.25 gm. (4 grains) three times a day will
make the diagnosis positive within a few days. If the trouble is due
to hyperthyroidism, all of the symptoms will be aggravated; there
will be more palpitation, more nervousness, more restlessness, more
sweating and more sleeplessness. In such cases the iodid should be
stopped immediately, of course, and the proper treatment begun.




TOXIC DISTURBANCES AND HEART RATE


Under this head it is not proposed to consider disturbances of the
heart due to infections, to cardiac disease, or to localized or
general acute or chronic disease, but to discuss disturbances due to
the absorption of irritants froth the intestines, and to alcohol,
tobacco and caffein.

It is hardly necessary to repeat that various toxins which may
seriously irritate the heart may be absorbed from the intestines
during fermentation or putrefactives processes in either the small
or the large intestines. The heart may be slowed by some, made rapid
by others, and it is often made irregular. The relation of the
absorption of intestinal toxins to increased blood pressure has
already been described, and the necessity of removing from the diet
anything which perpetuates or increases intestinal indigestion in
all cases of high blood pressure has already been referred to
several times. The indications that such a condition of the
intestines is present are irregular action of the bowels, a large
amount of intestinal gas, sometimes watery stools, often a coated
tongue, and the presence of indican in the urine.


INTESTINAL PUTREFACTION

The most successful procedure in the management of intestinal
putrefaction is to remove meat from the diet absolutely. Laxatives
in some form are generally indicated, and one of tile best is agar-
agar. Of course aloin and cascara are always good laxatives, with an
occasional dose of calomel or saline, if such seem indicated. Some
of the solid hydrogen peroxid-carrying preparations (magnesium
peroxid, calcium peroxide [Footnote: See N. N. R., 1916, p. 232])
have been advised as bowel antiseptics, but they are not more
successful than many of the salicylic acid preparations,' and
perhaps none is more efficient than salol (phenyl salicylate) in a
dose of 0.3 gm. (5 grains), three or four times a day. Washing out
the colon with high injections is often of great value, but should
not be continued too long lest the rectum become habituated to
distention, and bowel movements not take place without an enema.

Lactic acid bacilli, best the Bulgarian, arc often of value in
intestinal fermentation. A tablet may be eaten with a little lactose
or a small lump of sucrose after each meal. Or yeast may be taken in
the forth of brewer's yeast, a tablespoonful in a glass of water,
two or three times a day, or one sixth of an ordinary compressed
yeast cake dissolved is a glass of `eater and taken once or twice a
day. Or various forms of lactic acid fermented milk may be
successful.

Any particular food which causes fermentation in the intestine of
the patient should be eliminated from his diet; the patient must be
individualized as to fruits, cereals and vegetables, Nit, as stated
above, meat should ordinarily be withheld for a time at least.


ALCOHOL

Enough has already been said of the value and limitations of alcohol
as a therapeutic agent. As a beverage, when constantly used, it is
liable to cause obesity, gastric indigestion, arteriosclerosis,
myocardial degeneration, chronic nephritis and cirrhosis of the
liver. Its first action is undoubtedly as a food, if not too large
amounts are taken, and therefore it is a protector of other food,
especially of fat and starch. A habitue, then, especially if he has
reached the age at which he normally adds weight, increases his
tendency to obesity, and the first mistake in his nutrition is made.
If lie takes too much alcohol when he eats or afterward, his
digestion will be interfered with. Sooner or later, then, gastritis
and stomach indigestion develop, with consequent intestinal
indigestion. If lie takes strong alcohol, like whisky, oil an empty
stomach, he may sooner or later cause serious disease of the mucous
membrane of the stomach, first chronic gastritis, and later atrophy
of the glands of the stomach.

Alcohol with meals which contain meat tends to the production of an
increased amount of uric acid. Alcohol taken before meals on an
empty stomach causes sudden vasodilatation after absorption. It goes
quickly to the liver, irritates it, and little by little causes
congestions of the liver, so that sooner or later sclerosis of this
organ develops.

Alcohol probably causes arteriosclerosis not by its action per se,
but indirectly by causing gastro-intestinal indigestion and
insufficiency of the liver, as a result of which more toxins
circulate in the blood, tending to produce arteriosclerosis. Sooner
or later these irritants cause kidney irritation, and chronic
interstitial nephritis may develop. just which process becomes the
farthest advanced and finally kills the patient is an individual
proposition and cannot be foretold. The finale may be cirrhosis of
the liver, uremia, arteriosclerosis, apoplexy or myocarditis with
dilatation or coronary disease.

While small, more or less undiluted closes of alcohol, as whisky or
brandy, may cause quick stimulation of the heart by reflex
irritation of the esophagus and stomach, vasodilatation occurs as
soon as the alcohol is absorbed, and if large closes are absorbed,
vasomotor paresis may occur, temporarily at least.

During acute fever processes with an increased pulse rate, provided
shock or collapse is not present, small or medium-sized doses of
alcohol, by dilating the peripheral blood vessels and increasing the
peripheral circulation, may relieve the tension of the heart and
slow the pulse by the equalization of the circulation. Some of this
action may be due to the narcotic effect of alcohol on the cerebrum.
Alcohol may thus in many instances act for good. Overdoses, as shown
by cerebral excitation, flushing of the face and increased pulse
rate, will do harm; in fact, many a patient with a serious illness,
as typhoid fever or pneumonia, is made delirious by alcohol. Large
doses of alcohol in shock or collapse are contraindicated.

Chronic overuse of alcohol may cause chronic myocarditis and fatty
degeneration of the heart, with later weakening of the heart muscle
and dilatation.

In acute alcohol poisoning the pulse may become very rapid and weak,
and the patient may die of heart failure. This is often seen in
delirium tremens. The administration in this condition of enormous
doses of digitalis by the stomach is inexcusable, and the reason
that such patients survive such digitalis poisoning is that the
stomach does not absorb during this cardiac prostration.

A treatment as successful as any in this heart weakness in delirium
tremens is morphin sulphate, 1/2 grain, and atropin, 1/15 grain,
given hypodermically, with the administration of digitalis
hypodermically for its later action on the heart. If the heart is
contracting very rapidly, an ice-bag over the precordia will often
quiet it. If the pulse is very weak, the cerebral sedatives more
frequently used in delirium tremens, such as chloral, bromids,
paraldehyd, etc., are generally contraindicated. A hot foot-bath and
an ice-cap on the head sometimes aid in establishing a more general
equalization of the circulation. It may often be necessary to
administer strychnin, although if the patient is greatly excited it
should be withheld as long as possible. For the same reason camphor,
coffee and other cardiac stimulants which cause cerebral excitation
should be withheld.

If the patient is in alcoholic coma, the pulse is generally slow,
although it may be of low pressure unless the patient is otherwise
diseased. Caffein or coffee is here indicated, and the patient
should be kept warm lest he lose necessary heat. The stomach should
be emptied by an emetic, often best by apomorphin hypodermically,
unless the pulse is excessively weak. Strychnin may also be given,
and digitalis, hypodermically, if it seems indicated. Camphor is
another cardiac and cerebral stimulant that is valuable in these
cases.

The treatment of an actual degeneration of the heart from overuse of
alcohol is similar to the sane condition from other causes.


CAFFEIN

Caffein can irritate the heart and cause irregularity and
tachycardia, especially in certain persons. In fact, some can never
take a single cup of coffee without having an attack of palpitation,
and many times when coffee and tea have been unsuspected by the
patient as the cause of cardiac irritability, their removal from the
diet has stopped the symptoms, and the heart has at once acted
normally.

Caffein is a stimulant and tonic to the heart, increasing its
rapidity and the strength of the contractions. It is also a cerebral
stimulant, one of the most active that we possess among the drugs.
It increases the blood pressure, principally by stimulating the
vasomotor center and by increasing the heart strength. It acts as a
diuretic, not only by increasing the circulatory force and blood
pressure, but also by acting directly on the kidney. This action on
the kidney contraindicates the use of caffein in any form, except in
rare instances, when there is acute or chronic nephritis. The
increased blood pressure caused by caffein also contraindicates its
use when there is hypertension. Caffein first accelerates the heart
and later may slow it and strengthen it; but if the dose is large or
too frequently repeated, the apex of the heart ceases to relax
properly and there is an interference with the contraction of the
ventricles, the heart muscle becomes irritable, and a tachycardia
may develop.

Therefore when a heart has serious lesions, whether of the
myocardium or of the valves, with compensation only sufficient, the
action of caffein in any form is contraindicated. The fact that it
raises the blood pressure, thus increasing the force against which
the heart must act, and that it irritates the heart muscle to more
sturdy or irregular contraction, indicates that a patient with a
heart lesion or with a nervously irritable heart should never drink
tea and coffee or take caffein in any beverage.

Many patients cannot sleep for many hours after they have taken
coffee or tea, as the cerebral stimulation of caffein is projected
for hours after its ingestion. Caffein does not absorb so quickly
and therefore does not act so quickly when taken in the form of tea
and coffee as it does when taken as the drug or as a beverage which
contains the alkaloid. Persons who are nervously irritable, excited
and overstimulated cerebrally, with or without high blood pressure,
should not take this cerebral and nervous excitant. This is true in
early childhood and in youth, and continues true as age advances, in
most persons. It is a crime to present caffein as a soda fountain
beverage to children and young persons when the excitement of the
age is such as already to overstimulate all nervous systems and all
hearts.

A considerable majority of persons over 40 learn that they cannot
drink tea or coffee with their evening meal without finding it
difficult to sleep. Such patients, of course, should omit this
stimulant. Some patients have already recognized this fact and its
cause; others must be told. The majority of adults are probably no
worse and may be distinctly benefited by the morning cup of coffee
and the noon coffee or tea, provided the amount taken is not large.
It seems to be a fact that the drinking of coffee is on the
increase, especially as to frequency. Certainly the five o'clock
tea, with women, is on the increase, and we must deal with one more
cerebral and nervous excitant in our consideration of what we shall
do to slow this rapid age.


TOBACCO

In spite of the fact that a large number of men today do not smoke,
more and more frequently every clinician has a patient who smokes
too much. The accuracy with which he investigates these cases
depends somewhat on his personal use of tobacco, and therefore his
leniency toward a fellow user. Perhaps the percentage of young boys
who smoke excessively is larger than the percentage of men. Whether
or not the term "excessive" should be applied to any particular
amount of tobacco consumed depends entirely on the person. What may
be only a large amount for one person may be an excessive amount for
another, and even one cigar a day may be too much for a person is as
much for him as five or more cigars for another. If one is to judge
by the internal revenue report it will appear that, in spite of the
public school instruction as to the physiologic action of tobacco
and its harm, and in spite of the antitobacco leagues, the
consumption of tobacco is enormously on the increase.

Alexander Lambert [Footnote: Lambert, Alexander: Med. Rec., New
York, Feb. 13, 1915] in studying periodic drinkers and alcoholics,
finds that most patients are suffering from chronic tobacco
poisoning, and if they stop their smoking, their drinking sometimes
ceases automatically.

Howat [Footnote: Howat: Am. Jour. Physiol., February, 1916.] has
shown that nicotin causes serious disturbances of the reflexes of
the skin of frogs.

Edmunds and Smith [Footnote: Edmunds and Smith: Jour. Lab. and Clin.
Med., February, 1916.] of Ann Arbor find that the livers of dogs
have some power of destroying nicotin, but their studies did not
show how tolerance to large doses of nicotin is acquired.

Neuhof [Footnote: Neuhof, Selian: Sino-Auricular Block Due to
Tobacco Poisoning, Arch. Int. Med., May, 1916, p. 659.] describes a
case of sino-auricular heart block due to tobacco poisoning.
Intermittent claudication has been noted from the overuse of
tobacco, as well as cramps in the muscles and of the legs.

A long series of investigations of the action of tobacco on high
school boys and students of colleges seems to show that the age of
graduation of smokers is older than that of nonsmokers, and that
smokers require disciplinary measures more frequently than
nonsmokers.

Some years ago investigation was made by Torrence, of the Illinois
State Reformatory, in which there were 278 boys between the ages of
10 and 15 years. Ninety-two percent of these boys had the habit of
smoking cigaretes, and 85 percent were classed as cigarete fiends.

The most important action of nicotin is on the circulation. Except
during the stage when the person is becoming used to the tobacco
habit, in which stage the heart is weakened and the vasomotor
pressure lowered by his nausea and prostration, the blood pressure
is almost always raised during the period of smoking.

The heart is frequently made more rapid and the blood pressure is
certainly raised in an ordinary smoker, while even a novice may get
at first an increase, but soon he may become depressed and have a
lowering of the pressure. While a moderate smoker may have an
increase of 10 mm. in blood pressure, an excessive smoker may show
but little change. Perhaps this is because his heart muscle has
become weakened. If the person's blood pressure is high, the heart
may not increase in rapidity during smoking, and if he is nervous
beforehand and is calmed by his tobacco, the pulse will be slowed.
It has been shown that the blood pressure and pulse rate may be
affected in persons sitting in a smoke-filled room, even though they
themselves do not smoke. The length of time the increased pressure
continues depends on the person, and it is this diminishing pressure
that causes many to take another smoke. The heart is slowed by the
action of nicotin on the vagi, as these nerves are stimulated both
centrally and peripherally. An overdose of nicotin will paralyze the
vagi. The heart action then becomes rapid and perhaps irregular. The
heart muscle is first stimulated, and if too large a dose is taken,
or too much in twenty-four hours, the muscle becomes depressed and
perhaps debilitated. The consequence of such action on the heart
muscle, sooner or later, is a dilation of the left ventricle if the
overuse of the tobacco is continued.

There is, then, no possible opportunity for any discussion as to the
action of tobacco on the circulation. Its action is positive,
constantly occurs, and it is always to be considered. The only point
at this issue is as to whether or not such an activity is of
consequence to the individual. The active principle of tobacco is
nicotin, besides which it contains an aromatic camphor-like
substance, cellulose, resins, sugar, etc. Other products developed
during combustion are carbon monoxid gas, a minute amount of prussic
acid and in some varieties a considerable amount of furfurol, a
poison. From any one cigar or cigaret but little nicotin is
absorbed, else the user would be poisoned. It is generally
considered that the best tobacco comes from Cuba, and in the United
States from Virginia. While it has not been definitely shown that
any stronger narcotic drug occurs in cigarets sold in this country,
it still is of great interest to note that a user who becomes
habituated to one particular brand will generally have no other, and
the excessive cigaret-smoker will generally select the strongest
brand of cigarets. The same is almost equally true of cigar smokers.

Besides the effect on the circulation, no one who uses tobacco can
deny that it has a soothing, narcotic effect. If it did not have
this quieting effect on the nervous system, the increased blood
pressure would stimulate the cerebrum. Following a large meal,
especially if alcohol has been taken, the blood vessels of the
abdomen are more or less dilated by the digestion which is in
process. During this period of lassitude it is possible that
tobacco, through its contracting power, by raising the blood
pressure in the cerebrum to the height at which the patient is
accustomed, will stimulate him and cause him to be more able to do
active mental work. On the other hand, if a person is nervously
tired, irritable, or even muscularly weary, a cigar or several
cigarets will increase his blood pressure, take away his circulatory
tire, soothe his irritability, and stop temporarily his muscular
pains or aches and muscle weariness. If the user of the tobacco has
thorough control of his habit, is not working excessively,
physically or mentally, has his normal sleep at night and therefore
does not become weary from insomnia, he may use tobacco with sense
and in the amount and frequency that is more or less harmless as far
as he is concerned. If such a man, however, is sleepless, overworked
or worried, if he has irregular meals or goes without his food, and
has a series of "dinners," or drinks a good deal of alcohol, which
gives him vasomotor relaxation, he finds a constantly growing need
for a frequent smoke, and soon begins to use tobacco excessively. Or
the young boy, stimulated by his associates, smokes cigarets more
and more frequently until he uses them to excess.

Just what creates the intense desire for tobacco to the habitue has
not been quite decided, but probably it is a combination of the
irritation in the throat, especially in inhalers; of the desire for
the rhythmic puffing which is a general cerebral and circulatory
stimulant; for the increased vasomotor tension which many a patient
feels the need of; for the narcotic, sedative, quieting effect on
his brain or nerves; for the alluring comfort of watching the smoke
curl into the air or for the quiet, contented sociability of smoking
with associates. Probably all of these factors enter into the desire
to continue the tobacco habit in those who smoke, so to speak,
normally.

The abnormal smokers, or those who use tobacco excessively, have a
more and more intense nervous desire or physical need of the
narcotic or the circulatory stimulant effect of the tobacco, and,
consequently, smoke more and more constantly. They are largely
inhalers, and frequently cigaret fiends.

It is probable that tobacco smoked slowly and deliberately, when the
patient is at rest, and when he is leading a lazy, inactive,
nonhustling life, such as occurs in the warmer climates, is much
less harmful than in our colder climates, where life is more active.
Something at least seems to demonstrate that cigaret smoking is more
harmful in our climate than in the tropics.

It has been shown by athletic records and by physicians'
examinations of boys and young men in gymnasiums that perfect
circulation, perfect respiration and perfect normal growth of the
chest are not compatible with the use of tobacco during the growing
period. It is also known that tobacco, except possibly in minute
quantities, prevents the full athletic power, circulatorily and
muscularly, of men who compete in any branch of athletics that
requires prolonged effort.

The chronic inflammation of the pharynx and subacute or chronic
irritation of the lingual tonsil, causing the tickling, irritating,
dry cough of inhalers of tobacco, is too well known, to need
description.

Many patients who oversmoke lose their appetites, have disturbances
from inhibition of the gastric digestion, and may have an irregular
action of the bowels from overstimulation of the intestines, since
nicotin increases peristalsis. Such patients look sallow, grow thin
and lose weight. These are the kind of patients who smoke while they
are dressing in the morning, on the way to their meals, to and from
their business, and not only before going to bed, but also after
they are in bed. It might be a question as to whether such patients
do not need conservators. The use of tobacco in that way is
absolutely inexcusable, if the patient is not mentally warped.
Cancer of the mouth caused by smoking, blindness from the overuse of
tobacco, muscular trembling, tremors, muscle cramps and profuse
perspiration of the hands and feet are all recognized as being
caused by tobacco poisoning, but such symptoms need not be further
described here.

The reason for which physicians most frequently must stop their
patients from using tobacco, however, is that the heart itself has
become affected by the nicotin action. The heart muscle is never
strengthened by nicotin, but is always weakened by excessive
indulgence in nicotin, the nerves of the heart being probably
disturbed, if not actually injured. The positive symptoms of the
overuse of tobacco on the heart are attacks of palpitation on
exertion lasting perhaps but a short time, sharp, stinging pains in
the region of the heart, less firmness of the apex beat, perhaps
irregularity of the heart, and cold hands and feet. Clammy
perspiration frequently occurs, more especially on the hands. Before
the heart muscle actually weakens, the blood pressure has been
increased more or less constantly, perhaps permanently, until such
time as the left ventricle fails. The left ventricle from tobacco
alone, without any other assignable cause, may become dilated and
the mitral valve become insufficient. Before the heart has been
injured to this extent the patient learns that he cannot lie on his
left side at night without discomfort, that exertion causes
palpitation, and that he frequently has an irregularly acting heart
and an irregular pulse. He may have cramps in his legs, leg-aches
and cold hands and feet from an imperfect systemic circulation. In
this condition if tobacco is entirely stopped, and the patient put
on digitalis and given the usual careful advice as to eating,
drinking, exertion, exercise and rest, such a heart will generally
improve, acquire its normal tone, and the mitral valve become again
sufficient, and to all intents and purposes the patient becomes
well.

On the other hand, a heart under the overuse of tobacco may show no
signs of disability, but its reserve energy is impaired and when a
serious illness occurs, when an operation with the necessary
anesthesia must be endured or when any other sudden strain is put on
this heart, it goes to pieces and fails more readily than a heart
that has not been so damaged.

If a patient does not show such cardiac weakness but has high
tension, the danger of hypertension is increased by his use of
tobacco, and certainly in hypertension tobacco should be prohibited.
The nicotin is doing two things for him that are serious: first, it
is raising his blood pressure, and second, it will sooner or later
weaken his heart, which may be weakened by the high blood pressure
alone. Nevertheless a patient who is a habitual user of tobacco and
has circulatory failure noted more especially about or during
convalescence from a serious illness, particularly pneumonia, may
best be improved by being allowed to smoke at regular intervals and
in the amount that seems sufficient. Such patients sometimes rapidly
improve when their previous circulatory weakness has been a subject
of serious worry. Even such patients who were actually collapsed
have been saved by the use of tobacco.

Whether the tobacco in a given patient shall be withdrawn
absolutely, or only modified in amount, depends entirely on the
individual case. As stated above, no rule can be laid down as to
what is enough and what is too much. Theoretically, two or three
cigars a day is moderate, and anything more than five cigars a day
is excessive; even one cigar a day may be too much.




MISCELLANEOUS DISTURBANCES

SIMPLE HYPERTROPHY


Like any other muscular tissue, the heart hypertrophies when it has
more work to do, provided this work is gradually increased and the
heart is not strained by sudden exertion. To hypertrophy properly
the heart must go into training. This training is necessary in
valvular lesions after acute endocarditis or myocarditis, and is the
reason that the return to work must be so carefully graduated. When
the heart is hypertrophied sufficiently and compensation is perfect,
a reserve power must be developed by such exercise as represented by
the Nauheim, Oertel or Schott methods. Anything that increases the
peripheral resistance causes the left ventricle to hypertrophy.
Anything that increases the resistance in the lungs causes the right
ventricle to hypertrophy. The right ventricle hypertrophy caused by
mitral lesions has already been sufficiently discussed. The right
ventricle also hypertrophies in emphysema, after repeated or
prolonged asthma attacks, perhaps generally in neglected pleurisies
with effusion, in certain kinds of tuberculosis, and whenever there
is increased resistance in the lung tissue or in the chest cavity.

The term "simple hypertrophy" is generally restricted to hypertrophy
of the left ventricle without any cardiac excuse--the hypertrophy by
hypertension and hard physical labor. It is well recognized that it
hypertrophies with hypertension and with chronic interstitial
nephritis. It also becomes hypertrophied when the subject drinks
largely of liquid--water or beer--and overloads his blood vessels
and increases the work the heart must do. This kind of hypertrophy
develops slowly because the resistance in the circulation is gradual
or intermittent. In athletes and in soldiers who are required to
march long distances, hypertrophy generally occurs. This
hypertrophy, if slowly developed by gradual, careful training, is
normal and compensatory. In effort too long sustained, especially in
those untrained in that kind of effort, and even in the trained if
the effort is too long continued, the left ventricle will become
dilated and the usual symptoms of that condition occur. Such
dilatation is always more or less serious. It may be completely
recovered from, and it may not be. Therefore it proper understanding
of the physics of the circulation by the medical trainer of young
men to decide whether or not one should compete in a prolonged
effort, as a rowing race, for instance, is essential. It is wrong
for any young athlete to have an incurable condition occur from
competition.

Sometimes simple hypertrophy of the left ventricle occurs from
various kinds of conditions that increase the peripheral
circulation. It may occur from oversmoking, from the mertisc of
coffee aid tea, from certain kinds of physical labor, or from high
tension mental work. It is a part of the story of hypertension. Many
times such patients, as well as occasionally trained athletes, and
sometimes patients with arteriosclerosis or chronic interstitial
nephritis complain of unpleasant throbbing sensations of the heart
added to these sensations are a feeling of fulness in the head,
flushing of the face, and possibly dizziness--all symptoms not only
of hypertension but of too great cardiac activity. Various drugs
used to stimulate the heart may cause this condition; when digitalis
is given and is not indicated or is given in overdosage, these
symptoms occur.

The treatment is simply to lower the diet, cause catharsis, give hot
baths, stop the tobacco, tea and coffee, stop the drinking of large
amounts of liquid at any one time, and administer bromids and
perhaps nitroglycerin, when all the symptoms of simple hypertrophy
will, temporarily at least, disappear.

If the heart is enlarged from hypertrophy, if it is the right
ventricle that is the most hypertrophied, the apex is not only
pushed to the left, but the beat may be rather diffuse, as the
enlarged right ventricle will prevent the apex from acting close to
the surface of the chest. If the left ventricle is the most
hypertrophied, the apex is also to the left, but the impact is very
decided and the aortic closure is accentuated.


SIMPLE DILATATION

The term "simple dilatation" may be applied to the dilatation of one
or both ventricles when there is no valvular lesion and when the
condition may not be called broken compensation. The compensation
has been sufficiently discussed. Dilatation of the heart occurs when
there is increased resistance to the outflow of the blood front the
ventricle, or when the ventricle is overfilled with blood and the
muscular wall is unable to compete with the increased work thrown on
it. In other words, it may be weakened by myocarditis or fatty
degeneration; or it may be a normal heart that has sustained a
strain; or it may be a hypertrophied heart that has become weakened.
Heart strain is of frequent occurrence. It occurs in young men from
severe athletic effort; it occurs in older persons from some severe
muscle strain, and it may even occur from so simple an effort as
rapid walking by one who is otherwise diseased and whose heart is
unable to sustain even this extra work. All of the conditions which
have been enumerated as causing simple hypertrophy may have
dilatation as a sequence.

Degeneration and disturbance of the heart muscle and cardiac
dilatation are found more and more frequently at an earlier age than
such conditions should normally occur. Several factors are at work
in causing this condition. In the first place, infants and children
are now being saved though they may have inherited, or acquired, a
diminished withstanding power against disease and against the strain
and vicissitudes of adult life. Other very important factors in
causing the varied fortes of cardiac disturbances are the rapidity
and strenuousness of a business and social life, and competitive
athletics in school and college, to say nothing of the oversmoking
and excessive dancing of many.

The symptoms of heart strain, if the condition is acute, are those
of complete prostration, lowered blood pressure, and a sluggishly,
insufficiently acting heart. The heart is found enlarged, the apex
beat diffuse and there may be a systolic blow at the mitral or
tricuspid valve. Sometimes, although the patient recognizes that he
has hurt himself and strained his heart, he is not prostrated, and
the full symptoms do not occur for several hours or perhaps several
days, although the patient realizes that he is progressively growing
weaker and more breathless.

The treatment of this acute or gradual dilatation is absolute rest,
with small doses of digitalis gradually but slowly increased, and
when the proper dosage is decided on, administered at that dosage
but once a day. Cardiac stimulants should not be given, except when
faintness or syncope has occurred, and if strychnin is used, it
should be in small closes. The heart nay completely recover its
usual powers, but subsequently it is more readily strained again by
any thoughtless laborious effort. The patient must be warned as
carefully as though he had a valvular lesion and had recovered from
a broken compensation, and his life should be regulated accordingly,
at least for some months. If he is young, and the heart completely
and absolutely recovers, the force of the circulation may remain as
strong as ever.

Sometimes the heart strain is not so severe, and after a few hours
of rest and quiet the patient regains complete cardiac power and is
apparently as well as ever; but for some time subsequently his heart
more easily suffers strain.

Chronic dilatation of the heart, However, perhaps not sufficient to
cause edema, slowly and insidiously develops from persistent
strenuosity, or from the insidious irritations caused by absorbed
toxins due to intestinal indigestion. A fibrosis of the heart muscle
and of the arterioles gradually develops, and the heart muscle
sooner or later feels the strain.

It is now very frequent for the physician, in his office, to hear
the patient say, "Doctor, I am not sick, but just tired," or, "I get
tired on the least exertion." We do not carefully enough note the
condition of the heart in our patients who are just "weary," or even
when they show beginning cardiovascular-renal trouble.

The primary symptoms of this condition of myocardial weakening are
slight dyspnea on least exertion; slight heart pain; slight edema
above the ankles; often some increased heart rapidity, sometimes
without exertion; after exertion the heart does not immediately
return to its normal frequency; slight dyspnea on least exertion
after eating; flushing of the face or paleness around the mouth, and
more or less dilatation of the veins of the hands. All of these are
danger signals which may not be especially noted at first by the
individual; but, if he presents himself to his physician, such a
story should cause the latter not only to make a thorough physical
examination, but also to note particularly the size of the heart.

It a roentgenographic and fluoroscopic examination cannot be made,
careful percussion, noting the region of the apex beat, noting the
rapidity and action of the heart on sitting, standing and lying, and
noting the length of time it takes while resting, after exertion,
for the speed of the heart to slacken, will show the heart strength.

Slight dilatation being diagnosed, the treatment is as follows

1. Rest, absolute if needed, and the prohibition of all physical
exercise and of all business cares.

2. Reduction in the amount of food, which should be of the simplest.
Alcohol should be stopped, and the amount of tea, coffee and tobacco
reduced.

3. If medication is needed, strychnin sulphate, 1/40, or 1/30 grain
three times a day, acid the tincture of digitalis in from 5 to 10
drop doses twice a day will aid the heart to recover its tone.

Such treatment, when soon applied to a slowly dilating and weakening
heart, will establish at least a temporary cure and will greatly-
prolong life.

If these hearts are not diagnosed and properly treated, such
patients are liable to die suddenly of "heart failure," of acute
stomach dilatation, or of angina pectoris. Furthermore, unsuspected
dilated hearts are often the cause of sudden deaths during the first
forty-eight hours of pneumonia.

Small doses of digitalis are sufficient in these early cases. If
more heart pain is caused, the dose of digitalis is too large, or it
is contraindicated. Digitalis need not be long given in this
condition, especially as Cohen, Fraser and Jamison [Footnote: Cohen,
Fraser and Jamison: Jour. Exper. Med., June, 1915.] have shown by
the electrocardiograph that its effect on the heart may last twenty-
two days, and never lasts a shorter time than five days. They also
found that when digitalis is given by the mouth, the
electrocardiograph showed that its full activity was not reached
until from thirty-six to forty-eight hours after it had been taken.
From these scientific findings it will he seen that if it is
necessary to give a second course of treatment with digitalis,
within two weeks at least from the time the last close of digitalis
was given, the dose of this drug should be much smaller than when it
was first administered.

Owing to our strenuous life, if persons over 40 would present
themselves for a heart and other physical examination once or twice
a year there would not be so many sudden deaths of those thought to
be in good health. It may be a fact as asserted by many of our best
but depressing and pessimistic clinicians, that chronic myocarditis
and fatty degeneration of the heart cannot be diagnosed by any
special set of symptoms or signs. However, it is a fact that a
tolerably accurate estimate of the heart strength can be made by a
careful physician, and if danger signals are noted and signs of
probable heart weakness are present, life may be long saved by good
treatment or management rigorously carried out. The patient must
cooperate, and to get him to do this he must be tactfully warned of
his condition. Many, such patients, noting their impaired ability,
do not seek medical advice, but think all they need is more
exercise; hence they walk, golf, and dance to excess and to their
cardiac undoing.


HEART IN ACUTE DISEASE

ACUTE DILATATION OF THE HEART IN ACUTE DISEASE

It has for a long time been recognized that in all acute prolonged
illness the heart fails, sooner or later, often without its having
been attacked by the disease. The prolonged high temperature causes
the heart to beat more rapidly, while the toxins produced by the
fever process cause muscle degeneration of the heart or a
myocarditis, and at the same time the nutrition of the heart becomes
impaired either by improper feeding or by the imperfect metabolism
of the food given; hence the heart muscle becomes weakened, and
cardiac failure or cardiac relaxation or dilatation occurs.

The specific germ of the disease, or the toxin elaborated by this
germ, may be especially depressant to the heart, as in diphtheria,
or the germ may be particularly prone to locate in the heart, as in
rheumatism and pneumonia. But all feverish processes, sooner or
later, if sufficiently prolonged, cause serious cardiac weakness and
more or less dilatation.

Just exactly what changes take place in the muscle fibers of the
heart in some of these fevers has not been decided. Whether an
albuminous or parenchymatous degeneration of the muscle fibers or a
fatty degeneration occurs, whether there is a real myocarditis that
always precedes the dilatation, or whether the weakening and loss of
muscle fibers or a diminished power of the muscle fibers occurs
without inflammation, dilatation of the heart is always a factor to
be considered, and frequently occurs in acute disease.

While it is denied that acute dilatation can occur in a sound heart,
at the latter end of a serious illness the heart is never sound, and
acute dilatation can most readily occur, though fortunately it is
generally preventable. When the dilatation occurs suddenly, as
indicated by a fluttering heart, a low tension, rapid pulse, dyspnea
and perhaps cyanosis with venous stasis in the capillaries, death is
imminent, although such patients may be saved by proper aid. Even
when the dilatation is slower, as evidenced by a gradually
increasing rapidity of the heart and a gradually lowering blood
pressure, and with more evidences of exhaustion, death may occur
from such heart failure in spite of all treatment.

Unless a patient dies from accident, as from a hemorrhage, from
cerebral pressure or from some organic lesion in acute disease, the
physician frequently feels that if he can hold the power and force
of the circulation for several hours or days, the patient will
recover from the disease, for in most acute diseases the patient has
a good chance of recovery if his circulation will only hold out
until the crisis has occurred or until the disease is ready to end
by lysis. Therefore anything during the disease that tends to
sustain, nourish, quiet and guard the heart means so much more
chance of recovery, whatever else may or may not be done for the
disease itself.

The best treatment of dilatation of the heart in acute disease is
its prevention, and to prevent it means to recognize the condition
which can cause it. These are

1. Prolonged high temperature. A short-lived temperature, even if
high, is not serious. Prolonged temperature of even 103 F. or more
is serious, and even that of 101 is serious if too long continued.

2. Exertion and excitement. Every possible means should be
inaugurated to prevent muscular exertion and strain of the patient
while in bed. Proper help in lifting and turning the patient should
be employed, the bed-pan should be used, proper feeding methods
should be adopted, and friends should be excluded so that the
patient may not be excited by conversation.

3. Bad feeding. The diet should of course be sufficient, for the
patient and proper for the disease, but any diet which causes a
large amount of gas in the stomach, or tympanites, is harmful to the
patient's circulation, to say nothing of any other harm, such as
indigestion may do. All of the nutriments needed to keep the body in
perfect condition should be given to a patient who is ill; in some
manner he should receive the proper amounts of iron, salt, calcium,
starch, protein, sugar and water.

4. Intestinal sluggishness. This means not only that tympanites
should not be allowed, but also that necessary laxatives should be
given. It would be wrong to prostrate a patient with frequent saline
purgatives, but the bowels must move at least once every other day,
generally better daily; and if the case is one of typhoid fever,
they should be moved by some carefully selected laxative, and after
the bowels have sufficiently moved, the diarrhea should be stopped
by 1/10 grain of morphin, and the next day the bowels properly moved
again.

5. Depressant drugs. In this age of cardiac failure, heart
depressants of all types, and especially the synthetic products,
should be given only with careful judgment, and, never frequently
repeated or long continued.

6. Pain. This is one of the most serious depressants a heart has to
combat; acute pain must not be allowed, and prolonged subacute pain
must be stopped. Even peripheral troublesome irritations must be
removed, as tending to wear out a heart which has all of the trouble
it can endure.

7. Insomnia. Nothing rests a heart or recuperates a heart more than
sleep. Insomnia and acute disease make a combination which will wear
a heart out more quickly than any other combination. Sleep, then,
must be produced in the best, easiest and safest manner possible.

8. A too speedy return to activity. The convalescence must be
prolonged until the heart is able to sustain the work required of
it.

The treatment of gradual dilatation in acute disease has been
sufficiently discussed under the subject of acute myocarditis. The
treatment of acute dilatation is practically the same as the
treatment of shock plus whatever treatment must coincidently be
given to a patient for the disease with which he is suffering. The
treatment of shock will be discussed under a separate heading.


THE HEART IN PNEUMONIA

As pneumonia heads the list of the causes of death in this country,
and as the heart fails so quickly, sometimes almost in the beginning
in pneumonia, a special discussion of the management of the heart in
this disease is justifiable.

Acute lobar pneumonia may kill a patient in twenty-four or forty-
eight hours; lie may live for a week and die of heart failure or
toxemia, or he may live for several weeks and die of cardiac
weakness. If he has double pneumonia be may die almost of
suffocation. It is today just as frequent to see a slowly developing
and slowly resolving pneumonia as to see one of the sthenic type
that attacks one lobe with a rush, has a crisis in a seven, eight or
nine days, and then a rapid resolution. In fact the asthenic type,
in which different parts of the lung are involved but not
necessarily confined to or even equivalent to one lobe, is perhaps
the most frequent form of pneumonia.

The serious acute congestion of the lung in sthenic pneumonia in a
full-blooded, sturdy person with high tension pulse may be relieved
by cardiac sedatives, vasodilators, brisk purging, or by the
relaxing effect of antipyretics. Venesection is often the best
treatment.

When the sputum almost from the first is tinged with venous blood,
or even when the sputum is very bloody, of the prune-juice variety,
the heart is in serious trouble, and the right ventricle has
generally become weak and possibly dilated. The heart may have been
diseased and therefore is unable to overcome the pressure in the
lungs during the congestion and consolidation.

There is a great difference in the belief of clinicians as to the
best treatment for this condition. It would seem to be a positive
indication for digitalis, and good-sized doses of digitalis given
correctly, provided always that the preparation of the drug used is
active, are good and, many times, efficient treatment. Small doses
of strychnin may be of advantage, and camphor may be of value. In
the condition described, however, reliance should be placed on
digitalis. Later in the disease when the heart begins to fail,
perhaps the cause is a myocarditis. In this condition digitalis
would not work so well and might do harm. It is quite possible that
the difference between digitalis success and digitalis nonsuccess or
harm may be as to whether or not a myocarditis is present.

If the expectoration is not of the prune-juice variety and is not
more than normally bloody, or in other words, typically pneumonic,
and the heart begins to fail, especially if there is no great amount
of consolidation, the left ventricle is in trouble as much as the
right, if not more. In this case all of the means described above
for the prevention of any dilatation of the heart will be means of
preventing dilatation from the pneumonia, if possible. The treatment
advisable for this gradually failing heart is camphor; strychnin in
not too large doses, at the most 1/10 grain hypodermically once in
six hours; often ergot intramuscularly once in six hours for two or
three doses and then once in twelve hours; plenty of fresh air, or
perhaps the inhalation of oxygen. Oxygen does not cure pneumonia,
but may relieve a dyspnea and aid a heart until other drugs have
time to act.

If there is insomnia, morphin in small doses will not only cause
sleep, but also not hurt the heart. In the morning hours of the day
the value of caffein as a cardiac stimulant and vasocontractor,
either in the form of caffein or as black coffee, should be
remembered. Strophanthin may be given intravenously.

One of the greatest cares in the treatment of heart failure in
pneumonia should be not to give too many drugs or to do too much.


SHOCK

The treatment of shock will probably always be unsatisfactory as the
cause is so varied, and, although circulatory prostration and
vasomotor paresis always constitute the acute condition, the
physiologic health of the heart and blood vessels is so varied. The
patient in shock has low temperature, low blood pressure, and a
pulse either rapid or slow, but excessively feeble; the face is
pale, the surface of the body cold, and there is more or less clammy
perspiration; there may be dyspnea and cardiac anxiety, or the
patient may hardly breathe.

An acute cause, as terrible pain or hemorrhage, must of course be
stopped immediately. There is more or less anemia of the brain, and
therefore the legs and perhaps the lower part of the body should be
elevated. It may even be wise to drive the blood from the legs by
Esmarch bandages into the rest of the circulation. As there is
always more or less paresis and dilatation of the large veins of the
splanchnic system, a tight bandage about the abdomen is of great
advantage in raising the blood pressure to the safety mark.

Strophanthin, given intravenously, is valuable as a quick
restorative of the heart. Digitalis is so slow that it is of little
value in an emergency. Camphor hypodermically, and hot liquids
(nothing is better than black coffee) given by the mouth, are
valuable remedies. The camphor may be repeated frequently.
Strychnin, the long-used stimulant, should generally be given, but
in not too large doses and not too frequently repeated; 1/30 grain
hypodermically is generally a large enough dose; this dose may be
repeated in three or four hours, but should ordinarily not be given
oftener than once in six hours. An aseptic preparation of ergot
given intramuscularly is most efficient in raising the blood
pressure and aiding the heart. One dose of brandy or whisky may do
no harm. Alcohol, however, should not be pushed.

A most important procedure in all kinds of shock is to surround the
patient with dry heat, hot-water bags, and hot flannels; gentle
friction of the arms and legs, unless the patient is too exhausted,
may be of benefit. A hot-water bag to the heart is always a
stimulant. Sometimes friction over the base of the heart in the
region of the auricles is of benefit.

If the collapse is not acute and there is gradual profound
prostration, or if the patient is improved but still in a serious
condition of shock, too energetic measures must not be used; neither
should too many drugs be administered, or drugs in too large doses.
Absolute quiet and the administration of liquid nourishment in but
small amounts at a time are essential.

The hypodermic administration of epinephrin solutions, 1:10,000, or
solutions of pituitary extract, 1:10,000, should be considered; they
are often valuable.

If the shock occurs in ether or chloroform anesthesia, the
vasopressor stimulating effect of inhalations of carbon dioxid gas
may be considered, as advised by Henderson."

If the shock is due to hemorrhage and the hemorrhage has ceased, a
transfusion of physiologic saline solution is generally indicated.
Transfusion of blood under the same conditions is still better.
Rarely is transfusion indicated in shock from other causes; it often
adds to the difficulty rather than improves it. Occasionally if
shock is decided to be due to a toxemia, the toxin may be diluted by
the withdrawal of a small amount of blood and the transfusion of an
equal amount of saline solution.


ACUTE DILATATION OF THE STOMACH

This condition is not well understood, nor is its frequence known,
but not a few instances of shock are due to dilatation of this
organ. The shock to the heart may be a reflex one through the
pneumogastric nerves.

It perhaps not infrequently occurs after abdominal operations and is
more or less serious, the symptoms being persistent vomiting, upper
abdominal distention and collapse. The vomiting is of bloody or
coffee-ground material.

Sometimes the ordinary treatment of the collapse and washing out the
stomach save the patient; at other times the patient with this
series of symptoms dies in spite of all treatment.

It has been shown that acute dilatation of the stomach may occur in
pneumonia, and may be one of the causes of cardiac collapse in
pneumonia.

When the condition is diagnosed, the treatment would be that of
shock plus abdominal bandage and washing out the stomach with warm
solutions, if the patient is not too collapsed, or at any rate the
frequent administration of hot water in small quantities.

Sometimes when the stomach is dilated the pylorus becomes
insufficient, and bile regurgitates into the stomach, and is a cause
of the profound nausea and vomiting arid the subsequent collapse. In
these cases

114. Henderson: Am. Jour. Physiol., February and April, 1909. not
infrequently small doses of dilute hydrochloric acid seem to aid the
pylorus to maintain its normal contraction, the regurgitation of
bile does not take place, and the stomach may soon acquire a more
normal muscle tone. Not infrequently when a stomach is in this kind
of trouble and all the foods are rejected, and yet the patient
seriously needs nourishment, a warm, thin cereal, as oatmeal or
gruel or something similar, may be retained. Such patients, as has
been repeatedly stated, need starch as soon as possible, lest an
acidosis develop.

In these vomiting and collapse cases the hypodermic administration
of morphin and atropin will not only stop the vomiting, at least
temporarily, but will also give necessary rest. The dose of morphin
need not be large, and the atropin may prevent nausea from the drug.


ANESTHESIA IN HEART DISEASE

While no physician likes to give an anesthetic to a patient who has
valvular disease of the heart, and no surgeon cares to operate on
such a patient unless operation is absolutely necessary, still in
valvular disease with good compensation the prognosis of either
ether or chloroform narcosis is good.

When there are evidences of chronic myocarditis or a history of
broken compensation and the borderline of compensation and
dilatation is very narrow, or when there is arteriosclerosis, the
danger from an anesthetic and an operation is much greater; it may
be serious, in fact, and the decision must be made whether or not
the operation is absolutely necessary. Under any circumstances it is
understood that the anesthetist must be an expert, as there can be
no carelessness and nothing but the best of judgment in causing
anesthesia when there is cardiac defect.

The anesthetic to select is a subject for careful decision, as one
cannot assert which anesthetic is the best.

While chloroform seems occasionally to cause a fatty degeneration of
the heart, or if given too rapidly at first may cause sudden death,
especially in cardiac weakness, ether has its disadvantages, owing
to the increased tension (especially if there is likely to be much
valvular or cerebral excitement), and the greater amount of ether
that must be given, with the attendant danger to the kidneys, which
may have been disturbed from the cardiac conditions. Generally,
however, the better method is perhaps to administer first chloroform
to the point of producing sleep and then to change to ether, the
first mild chloroform narcosis preventing the ether from causing
acute stimulation, and ether being better for the operation, as it
is more of a stimulant. Some anesthetists believe that it is better
to administer morphin, with perhaps atropin hypodermically before
the anesthesia, and then to use ether. Nitrous oxid gas would be
contraindicated as tending to increase arterial pressure, and
therefore endanger a damaged heart; it is a serious danger to
damaged blood vessels.