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

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

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

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

CARDIAC DISEASE IN PREGNANCY

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

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

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

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

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

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

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

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

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



DEGENERATIONS

CORONARY SCLEROSIS

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

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

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

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

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

PATHOLOGY

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

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

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

SYMPTOMS

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

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

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

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

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

TREATMENT

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

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

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

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

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

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

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

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

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

ANGINA PECTORIS

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

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

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

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

SYMPTOMS

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

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

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

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

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

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

MANAGEMENT

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

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

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

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

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

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

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

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

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

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

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

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

PSEUDO-ANGINA

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

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

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

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

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

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

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

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

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

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

TREATMENT OF PSEUDO-ANGINAS

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

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

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

STOKES-ADAMS DISEASE: HEART BLOCK

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

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

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

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

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

TREATMENT

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

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

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

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

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

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

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

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

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



CARDIOVASCULAR RENAL DISEASE

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

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

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

There is also a marked hereditary tendency to apoplexy.

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

TREATMENT

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



DISTURBANCES OF THE HEART RATE

ARRHYTHMIA

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

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

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

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

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

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

ETIOLOGY

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

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

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

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

TREATMENT

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

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

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

AURICULAR FIBRILLATION: AURICULAR FLUTTER

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

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

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

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

OCCURRENCE

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

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

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

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

PATHOLOGY

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

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

DIAGNOSIS

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

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

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

PROGNOSIS

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

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

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

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

TREATMENT

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

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

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

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

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

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

PULSUS ALTERNANS

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

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

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

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

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

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

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

BRADYCARDIA

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

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