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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. + + + + + +End of Project Gutenberg's Disturbances of the Heart, by Oliver T. 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