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.