Full Text Archive logoFull Text Archive — Books, poems, drama…


Part 5 out of 5

Adobe PDF icon
Download this document as a .pdf
File size: 0.6 MB
What's this? light bulb idea Many people prefer to read off-line or to print out text and read from the real printed page. Others want to carry documents around with them on their mobile phones and read while they are on the move. We have created .pdf files of all out documents to accommodate all these groups of people. We recommend that you download .pdfs onto your mobile phone when it is connected to a WiFi connection for reading off-line.

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

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

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


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

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

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

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


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

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


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

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

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


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

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

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

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


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

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

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

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

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

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


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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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


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

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

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


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

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

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

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

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

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

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


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

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

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

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

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


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

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


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

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

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


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

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

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

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

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

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

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

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

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

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


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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



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

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

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

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

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


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

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

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

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

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

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

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

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

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

Slight dilatation being diagnosed, the treatment is as follows

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

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

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

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

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

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

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



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

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

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

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

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

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

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

2. Exertion and excitement. Every possible means should be
inaugurated to prevent muscular exertion and strain of the patient
while in bed. Proper help in lifting and turning the patient should
be employed, the bed-pan should be used, proper feeding methods
should be adopted, and friends should be excluded so that the
patient may not be excited by conversation.

3. Bad feeding. The diet should of course be sufficient, for the
patient and proper for the disease, but any diet which causes a
large amount of gas in the stomach, or tympanites, is harmful to the
patient's circulation, to say nothing of any other harm, such as
indigestion may do. All of the nutriments needed to keep the body in
perfect condition should be given to a patient who is ill; in some
manner he should receive the proper amounts of iron, salt, calcium,
starch, protein, sugar and water.

4. Intestinal sluggishness. This means not only that tympanites
should not be allowed, but also that necessary laxatives should be
given. It would be wrong to prostrate a patient with frequent saline
purgatives, but the bowels must move at least once every other day,
generally better daily; and if the case is one of typhoid fever,
they should be moved by some carefully selected laxative, and after
the bowels have sufficiently moved, the diarrhea should be stopped
by 1/10 grain of morphin, and the next day the bowels properly moved

5. Depressant drugs. In this age of cardiac failure, heart
depressants of all types, and especially the synthetic products,
should be given only with careful judgment, and, never frequently
repeated or long continued.

6. Pain. This is one of the most serious depressants a heart has to
combat; acute pain must not be allowed, and prolonged subacute pain
must be stopped. Even peripheral troublesome irritations must be
removed, as tending to wear out a heart which has all of the trouble
it can endure.

7. Insomnia. Nothing rests a heart or recuperates a heart more than
sleep. Insomnia and acute disease make a combination which will wear
a heart out more quickly than any other combination. Sleep, then,
must be produced in the best, easiest and safest manner possible.

8. A too speedy return to activity. The convalescence must be
prolonged until the heart is able to sustain the work required of

The treatment of gradual dilatation in acute disease has been
sufficiently discussed under the subject of acute myocarditis. The
treatment of acute dilatation is practically the same as the
treatment of shock plus whatever treatment must coincidently be
given to a patient for the disease with which he is suffering. The
treatment of shock will be discussed under a separate heading.


As pneumonia heads the list of the causes of death in this country,
and as the heart fails so quickly, sometimes almost in the beginning
in pneumonia, a special discussion of the management of the heart in
this disease is justifiable.

Acute lobar pneumonia may kill a patient in twenty-four or forty-
eight hours; lie may live for a week and die of heart failure or
toxemia, or he may live for several weeks and die of cardiac
weakness. If he has double pneumonia be may die almost of
suffocation. It is today just as frequent to see a slowly developing
and slowly resolving pneumonia as to see one of the sthenic type
that attacks one lobe with a rush, has a crisis in a seven, eight or
nine days, and then a rapid resolution. In fact the asthenic type,
in which different parts of the lung are involved but not
necessarily confined to or even equivalent to one lobe, is perhaps
the most frequent form of pneumonia.

The serious acute congestion of the lung in sthenic pneumonia in a
full-blooded, sturdy person with high tension pulse may be relieved
by cardiac sedatives, vasodilators, brisk purging, or by the
relaxing effect of antipyretics. Venesection is often the best

When the sputum almost from the first is tinged with venous blood,
or even when the sputum is very bloody, of the prune-juice variety,
the heart is in serious trouble, and the right ventricle has
generally become weak and possibly dilated. The heart may have been
diseased and therefore is unable to overcome the pressure in the
lungs during the congestion and consolidation.

There is a great difference in the belief of clinicians as to the
best treatment for this condition. It would seem to be a positive
indication for digitalis, and good-sized doses of digitalis given
correctly, provided always that the preparation of the drug used is
active, are good and, many times, efficient treatment. Small doses
of strychnin may be of advantage, and camphor may be of value. In
the condition described, however, reliance should be placed on
digitalis. Later in the disease when the heart begins to fail,
perhaps the cause is a myocarditis. In this condition digitalis
would not work so well and might do harm. It is quite possible that
the difference between digitalis success and digitalis nonsuccess or
harm may be as to whether or not a myocarditis is present.

If the expectoration is not of the prune-juice variety and is not
more than normally bloody, or in other words, typically pneumonic,
and the heart begins to fail, especially if there is no great amount
of consolidation, the left ventricle is in trouble as much as the
right, if not more. In this case all of the means described above
for the prevention of any dilatation of the heart will be means of
preventing dilatation from the pneumonia, if possible. The treatment
advisable for this gradually failing heart is camphor; strychnin in
not too large doses, at the most 1/10 grain hypodermically once in
six hours; often ergot intramuscularly once in six hours for two or
three doses and then once in twelve hours; plenty of fresh air, or
perhaps the inhalation of oxygen. Oxygen does not cure pneumonia,
but may relieve a dyspnea and aid a heart until other drugs have
time to act.

If there is insomnia, morphin in small doses will not only cause
sleep, but also not hurt the heart. In the morning hours of the day
the value of caffein as a cardiac stimulant and vasocontractor,
either in the form of caffein or as black coffee, should be
remembered. Strophanthin may be given intravenously.

One of the greatest cares in the treatment of heart failure in
pneumonia should be not to give too many drugs or to do too much.


The treatment of shock will probably always be unsatisfactory as the
cause is so varied, and, although circulatory prostration and
vasomotor paresis always constitute the acute condition, the
physiologic health of the heart and blood vessels is so varied. The
patient in shock has low temperature, low blood pressure, and a
pulse either rapid or slow, but excessively feeble; the face is
pale, the surface of the body cold, and there is more or less clammy
perspiration; there may be dyspnea and cardiac anxiety, or the
patient may hardly breathe.

An acute cause, as terrible pain or hemorrhage, must of course be
stopped immediately. There is more or less anemia of the brain, and
therefore the legs and perhaps the lower part of the body should be
elevated. It may even be wise to drive the blood from the legs by
Esmarch bandages into the rest of the circulation. As there is
always more or less paresis and dilatation of the large veins of the
splanchnic system, a tight bandage about the abdomen is of great
advantage in raising the blood pressure to the safety mark.

Strophanthin, given intravenously, is valuable as a quick
restorative of the heart. Digitalis is so slow that it is of little
value in an emergency. Camphor hypodermically, and hot liquids
(nothing is better than black coffee) given by the mouth, are
valuable remedies. The camphor may be repeated frequently.
Strychnin, the long-used stimulant, should generally be given, but
in not too large doses and not too frequently repeated; 1/30 grain
hypodermically is generally a large enough dose; this dose may be
repeated in three or four hours, but should ordinarily not be given
oftener than once in six hours. An aseptic preparation of ergot
given intramuscularly is most efficient in raising the blood
pressure and aiding the heart. One dose of brandy or whisky may do
no harm. Alcohol, however, should not be pushed.

A most important procedure in all kinds of shock is to surround the
patient with dry heat, hot-water bags, and hot flannels; gentle
friction of the arms and legs, unless the patient is too exhausted,
may be of benefit. A hot-water bag to the heart is always a
stimulant. Sometimes friction over the base of the heart in the
region of the auricles is of benefit.

If the collapse is not acute and there is gradual profound
prostration, or if the patient is improved but still in a serious
condition of shock, too energetic measures must not be used; neither
should too many drugs be administered, or drugs in too large doses.
Absolute quiet and the administration of liquid nourishment in but
small amounts at a time are essential.

The hypodermic administration of epinephrin solutions, 1:10,000, or
solutions of pituitary extract, 1:10,000, should be considered; they
are often valuable.

If the shock occurs in ether or chloroform anesthesia, the
vasopressor stimulating effect of inhalations of carbon dioxid gas
may be considered, as advised by Henderson."

If the shock is due to hemorrhage and the hemorrhage has ceased, a
transfusion of physiologic saline solution is generally indicated.
Transfusion of blood under the same conditions is still better.
Rarely is transfusion indicated in shock from other causes; it often
adds to the difficulty rather than improves it. Occasionally if
shock is decided to be due to a toxemia, the toxin may be diluted by
the withdrawal of a small amount of blood and the transfusion of an
equal amount of saline solution.


This condition is not well understood, nor is its frequence known,
but not a few instances of shock are due to dilatation of this
organ. The shock to the heart may be a reflex one through the
pneumogastric nerves.

It perhaps not infrequently occurs after abdominal operations and is
more or less serious, the symptoms being persistent vomiting, upper
abdominal distention and collapse. The vomiting is of bloody or
coffee-ground material.

Sometimes the ordinary treatment of the collapse and washing out the
stomach save the patient; at other times the patient with this
series of symptoms dies in spite of all treatment.

It has been shown that acute dilatation of the stomach may occur in
pneumonia, and may be one of the causes of cardiac collapse in

When the condition is diagnosed, the treatment would be that of
shock plus abdominal bandage and washing out the stomach with warm
solutions, if the patient is not too collapsed, or at any rate the
frequent administration of hot water in small quantities.

Sometimes when the stomach is dilated the pylorus becomes
insufficient, and bile regurgitates into the stomach, and is a cause
of the profound nausea and vomiting arid the subsequent collapse. In
these cases

114. Henderson: Am. Jour. Physiol., February and April, 1909. not
infrequently small doses of dilute hydrochloric acid seem to aid the
pylorus to maintain its normal contraction, the regurgitation of
bile does not take place, and the stomach may soon acquire a more
normal muscle tone. Not infrequently when a stomach is in this kind
of trouble and all the foods are rejected, and yet the patient
seriously needs nourishment, a warm, thin cereal, as oatmeal or
gruel or something similar, may be retained. Such patients, as has
been repeatedly stated, need starch as soon as possible, lest an
acidosis develop.

In these vomiting and collapse cases the hypodermic administration
of morphin and atropin will not only stop the vomiting, at least
temporarily, but will also give necessary rest. The dose of morphin
need not be large, and the atropin may prevent nausea from the drug.


While no physician likes to give an anesthetic to a patient who has
valvular disease of the heart, and no surgeon cares to operate on
such a patient unless operation is absolutely necessary, still in
valvular disease with good compensation the prognosis of either
ether or chloroform narcosis is good.

When there are evidences of chronic myocarditis or a history of
broken compensation and the borderline of compensation and
dilatation is very narrow, or when there is arteriosclerosis, the
danger from an anesthetic and an operation is much greater; it may
be serious, in fact, and the decision must be made whether or not
the operation is absolutely necessary. Under any circumstances it is
understood that the anesthetist must be an expert, as there can be
no carelessness and nothing but the best of judgment in causing
anesthesia when there is cardiac defect.

The anesthetic to select is a subject for careful decision, as one
cannot assert which anesthetic is the best.

While chloroform seems occasionally to cause a fatty degeneration of
the heart, or if given too rapidly at first may cause sudden death,
especially in cardiac weakness, ether has its disadvantages, owing
to the increased tension (especially if there is likely to be much
valvular or cerebral excitement), and the greater amount of ether
that must be given, with the attendant danger to the kidneys, which
may have been disturbed from the cardiac conditions. Generally,
however, the better method is perhaps to administer first chloroform
to the point of producing sleep and then to change to ether, the
first mild chloroform narcosis preventing the ether from causing
acute stimulation, and ether being better for the operation, as it
is more of a stimulant. Some anesthetists believe that it is better
to administer morphin, with perhaps atropin hypodermically before
the anesthesia, and then to use ether. Nitrous oxid gas would be
contraindicated as tending to increase arterial pressure, and
therefore endanger a damaged heart; it is a serious danger to
damaged blood vessels.

Book of the day: