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necessary, a change to one-tenth grain has proved entirely and
perfectly satisfactory.


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


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


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


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


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


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


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

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

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

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


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

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

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

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


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

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

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


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

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

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

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

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

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


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

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


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

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


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

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


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

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



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

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

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


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

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

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

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

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


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

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

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

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

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

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

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


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

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

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


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

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

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


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

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


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

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


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


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

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

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

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

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

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

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

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

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


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

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

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

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

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


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

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

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

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

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

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

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

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

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


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

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

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

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

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


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

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

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


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

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


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


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

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

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


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

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

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

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


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

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

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

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


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

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

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

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

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

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

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

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

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

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


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


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

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

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


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

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

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

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


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

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

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


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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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