Chapter D: Physical Measures (3)

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

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

TREATMENT

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

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

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

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

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

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

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

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

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

CARDIOVASCULAR RENAL DISEASE

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

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

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

There is also a marked hereditary tendency to apoplexy.

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

TREATMENT

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DISTURBANCES OF THE HEART RATE

ARRHYTHMIA

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

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

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

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

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

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

ETIOLOGY

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

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

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

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

TREATMENT

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

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

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

AURICULAR FIBRILLATION: AURICULAR FLUTTER

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

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

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

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

OCCURRENCE

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

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

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

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

PATHOLOGY

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

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

DIAGNOSIS

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

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

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

PROGNOSIS

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

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

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

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

TREATMENT

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

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

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

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

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

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

PULSUS ALTERNANS

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

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

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

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

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

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

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

BRADYCARDIA

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

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

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

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

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

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

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

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

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

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

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

SYMPTOMS