Chapter IV: Preface: To the First Edition (4)

3. The Exudate.--When a fluid exudate into the pericardium has occurred from inflammation that is, when it is not an exudate from disturbed kidneys or circulation--it will continue to increase to some extent in spite of any treatment. Just how much this exudate may be prevented by the use of small blisters over or around the heart, and just how much watery stools and diuresis may prevent the advance of the exudate is difficult to determine. Small blisters, properly applied, have many times seemed to be the determining factor in stopping the increase in the fluid, or to have been the starting cause of the resorption of the exudate.

The amount of purging that should be caused by saline cathartics such as sodium sulphate (Glauber salt), potassium and sodium tartrate (Rochelle salt), or the official compound jalap powder cannot be declared dogmatically. Saline purging should be governed by the character of the circulation. If the heart is strong, the pulse not weak, and the blood pressure good, nothing is more valuable in this condition. Portal depletion is of great advantage, especially if the amount of liquid ingested is kept as low as possible, so that the blood vessels may become thirsty and thus tend to absorb an exudate wherever they find it. Much harm has been done, however, and death has been caused by saline purgatives in endeavoring to relieve edemas from a failing heart or to prevent a uremia from kidney inflammation. The depression following such purging is often serious. If the circulation is weak, dependence should be placed on purgation by some of the simple vegetable cathartics or a small dose of calomel. While it is advisable to give a saline in concentrated solution, it should not be so strong as to cause vomiting. With our better understanding of magnesium absorption and the depressant effect of magnesium on the nervous system, magnesium salts should not be used in serious conditions.

Diuretics often do not act well when most needed. The simplest diuretic is potassium citrate, given in wintergreen or peppermint water, in doses of 2 gm. (30 grains), three or four tunes in twenty- four hours. One or more of the vegetable, nonirritant diuretics may be tried if preferred. If the sickness preceding the pericarditis was not a long fever, and the heart muscle is considered in good condition, digitalis in small doses may be the best possible diuretic. Incidentally it will slow the heart, if there is not much elevation of temperature, and will give some cardiac rest.

Although the patient's diet should be limited in bulk, and especially in amount of liquids, good nutrition should soon be given. Systemic weakness certainly tends to increase the exudate; systemic strength aids in absorption of the exudate.

Iron is early indicated, and nothing is better than 5 drops of the tincture of chlorid of iron in a little lemonade or orangeade, administered once in eight hours.

If the exudate tends to decrease, it perhaps may be hastened by the local application of tincture of iodin over the cardiac region. Also the administration of small doses of an iodid, as 0.3 gm. (5 grains) of sodium iodid, given in plenty of water three times a day, is useful. An iodid circulating in the blood seems to aid absorption. It has long been believed that iodin in the blood tends to promote absorption of thickened, left-over material from exudates, and to prevent the formation of strong fibrous adhesions. Until our knowledge is more exact in this matter, it is advisable to use iodid as suggested. If the above-named dose is not tolerated, less should be given.

If in spite of all the therapeutic measures suggested, the fluid increases and the pericardium becomes more distended and the heart's action more labored, paracentesis must be done. The point at which the aspirating needle should be inserted into the pericardium depends somewhat on the conditions in each individual case. It is often best to insert an exploratory needle first. This will determine the fluidity and character of the exudate. If pus is found, a more radical surgical procedure than simple paracentesis must be done immediately. The point of puncture for aspiration most frequently chosen is in the fourth or fifth intercostal space, about an inch to the left of the sternal margin. Paracentesis is also often done in the region of the normal apex beat. The position of the patient is determined by his dyspnea; he should lie in the position most comfortable for him. The fluid should be withdrawn slowly and the pulse carefully watched. The withdrawal of a small amount of fluid may later seem to be the starting cause of resorption of the rest of the fluid. On the other hand, it may often be not of more value than the simple removal of the immediate pressure, the fluid may again accumulate, and more radical surgery must be performed.

4. To Strengthen the Heart.--Most of the methods of meeting this indication have already been stated, namely, absolute rest; absolute quiet; the use of the bed pan; any movement that must be made should be deliberate; the nurse and other attendants must be quiet; necessary conversation must be brief, and every method must be used to quiet and prevent the heart's action from becoming rapid. The food taken should be small in amount and nonstimulating; that is, no tea or coffee should be given, and nothing too hot or too cold. Movements of the bowels should be caused with the least possible general disturbance. If the patient does not sleep, he must be made to sleep. The whole body and the nervous system must have periods of rest. If the heart is very weak, small closes of morphin may be used. If the heart is not weak, bromids or chloral may be given. If the blood pressure is high, such hypnotics will lower it, or if the heart is strong and the condition does not contraindicate it, aconite may be used in small doses, for a day or two, unless the fever is high and it seems advisable to use one of the coal-tar antipyretics, which reduce the blood tension and the heart activity.

As stated above, pain must not be allowed. Sometimes, when the heart has not been injured by prolonged fever, digitalis in small doses may slow the heart and act for good.

Convalescence.--The convalescence should be prolonged as in any other cardiac inflammation. The patient should be given more and more nourishing food, and the iron tonic may be changed to a capsule containing 0.05 gm. of quinin and 0.05 gm. of reduced iron, three times a day.

It is a question as to when patients convalescent from pericarditis should be permitted exercise. It has been thought that gentle movements and possibly exercise, sooner than theoretically justified, might cause the heart to beat a little more actively and possibly prevent the formation of tight adhesions between the two layers of the pericardium. Whether such activity of the heart will prevent adhesions is something that has not been determined.

The small doses of sodium iodid, perhaps 0.2 gm. (3 grains) two or three times a day, should be continued for some time. Iodid in this dosage does no harm and may do a great deal of good.

ADHERENT PERICARDITIS

Following dry pericarditis or pericarditis with an exudate, especially when the exudate is fibrinous in character, the fibrous substance which is not absorbed or resorbed may develop into connective tissue, and the two pericardial surfaces become permanently grown together, causing the so-called adherent pericarditis. These adhesions between the two surfaces of the pericardium may be general throughout the entire pericardial sac, or they may be limited to some one or more parts of the pericardium. Perhaps one of the most frequent points of adhesion is the anterior part of the pericardium, while the apex is the part most likely to be free, even when other parts of the pericardium have grown together. This freedom of the apex is probably due to the constant and more extensive motion of the apical portion of the heart, and is the reason that it has been suggested, as referred to under acute pericarditis, that, other conditions not contraindicating, the patient may be allowed to move about a little during convalescence to cause the heart to beat more actively. Sometimes the surfaces of the pericardium are not closely adherent to each other, but bands of adhesion stretch from one surface to the other.

After adhesions have taken place between the two layers of the pericardium, the action of the heart is impaired, serious interference with the cardiac action may develop, and sudden death may occur. If the heart is given all the rest possible during the acute phase of the disease, there will be less likelihood of the surfaces becoming so irritated that adhesions readily form. Anything which permits complete absorption and resorption of tile exudate will tend to prevent these hampering adhesions. If the adhesions are such as to cause irregular heart, recurrent pain and the danger of sudden death, surgical help has been suggested. This surgical procedure is to remove a portion of the ribs, perhaps of the third, fourth and fifth, to allow the heart more freedom of action to compensate for the impairment of its activity from the adhesions. Such an operation was first suggested by Brauer of Heidelberg in 1902.

The question of the best method of producing anesthesia in this condition of the heart is a serious one. A patient might die during the anesthesia; but he might also die at any time from cardiac spasm. In certain instances, in adults, local anesthesia might be sufficient. Pain reflexes, however, would be serious. Such an operation would be indicated when the apex is fixed so that there is a constant sensation of hugging of the heart at the fourth and fifth ribs, with paroxysms of pain and cardiac weakness.

MYOCARDIAL DISTURBANCES

While the myocardium is the most important muscle structure of the body, it has but recently been studied carefully or well understood clinically or pathologically. A heart was "hypertrophied" or "dilated" or perhaps "fatty." It suffered from "pain," "angina pectoris," from some "serious weakness" or from "coronary disease," and that ended the pathology and the clinical diagnosis. This is the age of heart defects; no one can understand a patient's condition now, whatever ails him, without studying his heart. No one can treat a patient properly now without considering the management of the circulation. No one should administer a drug now without considering what it will do to the patient's heart.

Although we are scientifically interested in the administration of specific treatments, antitoxins and vaccines; although we have a better understanding of food values, and order diets with more careful consideration of the exact needs of the individual, and although we are using various physical methods to promote elimination of toxins, poisons and products of metabolism, we have until lately forgotten the physical fact that one thirteenth of the weight of a normal adult is blood. A man who weighs 170 pounds has 13 pounds of blood. This proportion is not true in the obese, and is not true in children. Whether the person is sick in bed, miserable though up and about, or beginning to feel the first sensations of slight incapacity for his life work, his ability properly to circulate this one thirteenth of his weight through the various arterial and venous channels and capillary tracts must, with the increasing tension and speed of our lives, be taken into consideration.

The more and more frequently repeated statements that the operation was successfully performed but that the patient died of shock, and that the typhoid fever and the pneumonia were being successfully combated, but that the patient died of heart failure, together with the increase in arteriosclerosis, cardiac disturbances and renal disease, emphatically present the necessity of more carefully studying the circulation. A better understanding and the constant study of the blood pressure shows nothing but the necessity of the age. The unwillingness of the patient to suffer pain, even for a few minutes, without some narcotic, generally a cardiac debilitating drug, means that, if he is a sufferer from chronic or recurrent pain, he has taken a great deal of medicine which has done his heart no good. Repeated high tension of life raises the blood pressure and puts more work on the heart. Therefore the heart is found weary, if not actually degenerated, when any serious accident, medical or surgical, happens to the patient.

The requirements of the age have, then, necessitated that the heart be more carefully studied, and therefore the heart strength and its disturbances are better understood. The mere determination as to where the apex beat is located, and as to what murmurs may be present is not sufficient; we must attempt to determine the probable condition of the myocardium. The following conditions are recognized: (1) acute myocarditis, (2) chronic myocarditis (fibrosis, cardiosclerosis), (3) fatty degeneration, and (4) fatty heart.

ACUTE MYOCARDITIS

Probably most acute infections cause more or less myocarditis, depending on their intensity and their prolongation. This disturbance of the heart is often unrecognized, and has been simply referred to as "the heart growing weaker from the fever process." The acute infections most likely to cause a myocarditis are rheumatism, influenza, sepsis, cerebrospinal meningitis, diphtheria, typhoid fever, scarlet fever, and mouth and throat infections. It is probably rare when acute endocarditis occurs that more or less myocarditis is not present. The acute myocarditis may develop some fatty degeneration, and with this softening and weakening of the heart muscle acute dilatation readily occurs, which may be a cause of sudden death, or, if less serious, may be the cause of prolonged disability, if the heart ever recovers its original size and strength.

The symptoms are often indefinite, and the diagnosis of the condition hardly possible. It may be taken for granted, however, that hardly any serious illness can long continue without cardiac muscle disturbance. If endocarditis is present, soft systolic murmurs soon appear. With the acute myocarditis developing, the apex beat is less positive, less accentuated, and later it becomes diffuse and even feeble. The closure of the aortic valve is less typically sharp, showing that the blood vessels are not so thoroughly filled. The peripheral circulation is not so active, the blood pressure falls, and the heart becomes more rapid, especially on the least exertion. All of these signs indicate myocardial weakness.

The treatment of this condition is largely preventive. It should be well recognized that prolonged high fever, prolonged insufficient or improper nutrition, prolonged acute pain, and especially prolonged septic processes will always cause myocardial degeneration. It should be recognized that after ether and chloroform anesthesia, especially after chloroform, the heart muscle may be disturbed and the tonicity be lost. Therefore after anesthesia, after operations, and after all illnesses which have lasted more than a few days, the convalescence of the patient must be more or less deliberate. Sudden rising, sudden erect posture, the exertion of walking too early, going up stairs too early or taking moderate, and later severe exercise too early, may cause dilatation of the heart muscle that has become weakened by acute myocarditis. If acute myocarditis is believed or known to be present, cardiac tonics such as digitalis should not be given; large doses of strychnin should not be given; vasocontractors such as ergot should not be given; large amounts of food or large bulks of liquid should not be taken into the stomach at one time; in fact, unless there is some special indication, the twenty-four hour amount of fluid should be diminished. The surface circulation and the muscle circulation should be improved by such cold or warm water applications as the disease or condition calls for. Massage should be early inaugurated to promote the return circulation. The heart should be treated as though it were the frailest of Venetian glass and would crack with the least rough handling, or even with a rapid change of temperature, great cold or too much heat. A prolonged, tedious convalescence, with the return to activity so graded as to give the heart no strain, and to keep its work always just below what it is able to do, will often mean return to perfect strength and health.

No cardiac debilitating drug should be administered when myocarditis has been surmised or diagnosed. The safest hypnotic, if one is needed, is morphin in small doses. If there are weakening perspirations, atropin should be given, especially as it is also a circulatory stimulant. Calcium in almost any form seems to be of value in the majority of heart conditions. It is a sedative to the nervous system, and is certainly indicated in acute myocarditis. Calcium lactate is perhaps the best salt to administer, in doses of 0.25 gm. (4 grains), three or four times in twenty-four hours. Calcium glycerophosphate may be used, in powder form or in capsule, in doses of 0.30 gm. (5 grains) three or four times in twenty-four hours; or lime-water may be given.

An exact prognosis of this inflammation is impossible. We do not know how far an acute myocarditis may progress and entire recovery take place; we do not know how slight a myocarditis may cause serious symptoms. Clinically we know that many patients after serious illness never again have perfect circulatory strength. Other patients almost die of heart failure and yet apparently absolutely recover their ability to do hard physical work.

CHRONIC MYOCARDITIS: FIBROUS

Chronic myocarditis may develop on an acute myocarditis, but is generally a slowly progressive chronic process from the beginning; it occurs mostly in persons past middle life, and as a rule is not primarily associated with rheumatism or valvular disease of the heart. Perhaps generally the term "chronic myocarditis" is incorrect, as a real inflammatory condition is not present and has not been present; it is really a degenerative process with the development of connective tissue, a fibrosis and more or less hardening of the arterioles, a cardiosclerosis. In many instances this fibrosis is associated with fat deposits or fatty degeneration. The disease is often caused by a narrowing or obstruction or calcareous degeneration of the coronary arteries, thus diminishing the blood supply to the heart muscle. This chronic myocardial degeneration is often a part of the general arteriosclerosis, and is an important factor in what is termed cardiovascular-renal disease. In simple chronic renal diseases the heart first normally hypertrophies to overcome the increased blood tension and increased resistance.

The principal causes of this degeneration are normal old age, or premature age caused by various conditions. In other words, anything which hastens arteriosclerosis will cause myocardial degeneration. The causes recognized as most frequently producing this condition are syphilis; gout; repeated attacks of rheumatism; excess in the use of alcohol (meaning repeated daily too large amounts, as well as actual dipsomania); the overuse of tobacco; excess in drinking tea or coffee; general overeating, and excessive eating of meat in particular, if the organs of elimination do not work perfectly and if such eating causes or allows putrefactive changes in the intestines; and progressive, prolonged wasting diseases, such as tuberculosis and cancer. It has also seemed in some cases that the only cause was excessive, hard physical labor, including excessive athletic work, and in other cases that prolonged anxiety and worry have been causes of cardiac degeneration and actual cardiac failure. Prolonged absorption of toxins from mouth and tonsil infections may be a not infrequent cause.

These myocardial changes are sometimes associated with chronic pericarditis and chronic endocarditis, and may accompany or follow valvular disease of the heart. Failure of compensation in valvular disease and dilatation of the heart are sequences which occur sooner or later.

SYMPTOMS AND SIGNS

The symptoms of chronic myocardial degeneration are progressive weakness, slight at first, noticeable on exertion (and what was not considered exertion becomes such), as evidenced by slight palpitation, slight shortness of breath, leg weariness and mental tire. The heart frequently becomes more rapid, not only with exertion and change of position to the erect, but even after eating. Slight cardiac stimulants, as coffee, affect the heart more than previously; there is some sleeplessness, more or less troublesome, and more or less indigestion. There may be mental irritability and some mental deterioration, as shown in various ways. There are likely to be slight edemas of the lower extremities toward night. The amount of urine may diminish. A previously high blood pressure becomes lower. The pulse may be occasionally intermittent, and later actually irregular.

The physical signs often show an enlargement of the heart, with increased activity at first, from irritability of the heart and a lack of perfect coordination; later the heart may show typical signs of weakness. Not infrequently a heart suffering from fibrosis acts perfectly until some sudden exertion, as lifting, running or serious illness causes it suddenly to become weak. Such a heart rarely regains its former strength. This occurs frequently to those who have supposed themselves to be in perfect physical health. Some sudden strain which they have previously been able to endure without injury, such as carrying a weight upstairs, cranking a refractory engine, pumping up a series of tires, or walking rapidly with a younger or more active companion, will suddenly give cardiac distress signals, serious exhaustion and more or less lengthy prostration, perhaps for an hour or so, or perhaps for several days. Permanent cardiac weakness may follow, or compensation may again occur, to be more easily broken later. Slight cardiac pains and sensations referred to the cardiac region become frequent. Disliking to lie on the left side, when previously the patient has been able to sleep on this side without discomfort, is an evidence of cardiac disturbance. There may be no real pains, but the patient becomes conscious of his heart, perhaps for the first time in his life. This alone is an indication of coming trouble.

If these signs and symptoms develop late in life, or at any age with other symptoms of sclerosis or senility, little can be done therapeutically except to afford temporary relief and to prevent the occurrence of acute attacks of cardiac distress or dyspnea. If the disturbance is really due to chronic cardiac degeneration, the sooner the patient learns that his ability is restricted, that his life is narrowed, the better for his future.

MANAGEMENT

The advice he should receive is well understood: to avoid physical efforts; to avoid mental tire; to avoid overeating or overdrinking of any foods or liquids; to reduce or abstain from alcohol, coffee, tea and tobacco, depending on what seems advisable in the individual case; to reduce the amount of meat eaten, especially if there is intestinal indigestion; to relieve intestinal indigestion; to cause free daily movements of the bowels; to abstain from any food which tends to cause gastric or intestinal flatulence; to abstain from such foods as contain nucleins, if the patient is gouty; to take frequent warm baths (not too hot) to promote the secretions and the circulation in the skin, and to take such daily exercise as seems advisable. If the patient cannot take exercise, simple calisthenics or massage should be instituted.

Whether nitroglycerin or other nitrite is advisable depends on the peripheral blood pressure. If the blood pressure is low, or not higher than is best for the patient, such treatment would be inadvisable. If, from the supposed cause, iodid seems to be indicated, it should be given in small doses and continued for some time. It is often wise, however, to give small doses, as 0.10 or 0.20 gm. (2 or 3 grains) once or twice in twenty-four hours, for a long period, to any patient who leas fibrosis or selerosis in any form. Iodid tends to prevent the progress of connective tissue formation. It is quite possible that some of its value is in activating a sluggish or imperfectly acting thyroid gland. If the patient is old, his thyroid is subinvoluting, and a little more of its activity will be of advantage. Many diseases which cause chronic myocarditis also cause, later, subactivity of the thyroid. Thyroid extract may be indicated if the patient is obese.

If, in spite of this management and treatment, the patient has cardiac asthma attacks, with or without pain, especially if there are pendent edemas, the question arises as to whether or not digitalis should be given. In such cases one cannot tell without trying whether digitalis will be of benefit or will cause more discomfort. 11 small dose of an active preparation should be given at first twice in twenty-four hours, and after a week once in twenty-four hours, its action being carefully watched and the decision as to whether the dose is too large or too small arrived at. It may do a great amount of good; it can cause increased cardiac pains. If used carefully and stopped when it appears not to be acting well, it will do no harm.

Chilling of the surface of the body should be avoided; sudden cold or sustained severe cold, which increases the contraction of the peripheral blood vessels and puts more strain on the heart muscle, is to be avoided if possible. More hours in bed at night and lying down after the heavier meals of the day will tend to give the heart the kind of rest it needs. Also complete rest for one day a week, or a rest of several days at a time, and a rest, both mental and physical, with such walking, golfing or riding as seems advisable, for at least one month every year, will prolong the lives of these patients, and may make an imperfect heart act well for months and years. If the patient is anemic he should, of course, receive some nonastringent iron; a. tablet of saccharated ferric oxid (Eisenzucker), in small doses, 0.20 gm. (3 grains), once or twice in twenty-four hours, is sufficient.

The prognosis of a case diagnosed as chronic myocarditis or chronic degeneration of the heart is doubtful, as one cannot tell until several weeks or months of observation whether this particular heart also has fatty degeneration or not. If there is fatty degeneration, the prognosis is bad. If there is no serious fatty degeneration, the patient, with the modified life outlined, may live for a long time. Acute dilatation from any serious strain on the heart may occur, and if there is fatty degeneration it is liable to occur at any time. Attacks of cardiac asthma are always serious, and always damage the heart a little more.

FATTY DEGENERATION

Fatty degeneration of the heart muscle may be caused by acute poisoning (as phosphorus, arsenic, etc.), by serious infections, or it may follow fibrosis of the heart or coronary artery disease. The symptoms are those of serious circulatory weaicnens, which does not seem to improve under any ordinary management. It is difficult, if the heart is enlarged, to determine whether there is more or less serious acute dilatation or whether the heart muscle has suffered fatty degenration.

The treatment of such a patient requires the best of judgment as to the amount of food and liquid that should be given, the regulation of the administration of laxatives, the sponging of the body, the means of producing sleep if there is insomnia, how much reading, conversation or amusements should be allowed, how much stimulation by stryclmin or other stimulating drug should be given, and whether or not very small doses of digitalis should he tried. These are all matters for individualizing, and for the best medical judgment which we are called on to give. How much repair can take place in a heart muscle when fatty degeneration has started we do not know. Such treatment will give the heart the only chance it has to recuperate, but the prognosis is bad.

FATTY HEART

The cause of deposits of fat around the heart or in between its chambers is the same as the cause of general obesity. These patients are likely to be obese, or at least to have large abdomens with large deposits of fat around the abdomen. This fat in itself will interfere somewhat with abdominal respiration. This tends to cause dyspnea, and the heart tends to be disturbed from these causes, if much fat is not really in the pericardium. The symptoms are those of imperfect heart action; the patient is dyspneic on exertion or in leaning over, the heart acts rapidly on such exertion, the patient puffs, perspires easily, and becomes leg weary, sedentary in his habits, and more or less incapacitated for work. He may not be a large eater; if he is, and his eating habit is corrected, the prognosis is better than if he is putting on weight in spite of eating sparingly.

The general treatment is that for obesity, and if the heart muscle is intact, various depletion methods may be inaugurated. More and more exercise, sweatings from Turkish baths, electric-light baths, body baking, vigorous massage and more or less purging are all valuable. Anything which reduces the general weight will help the heart. The prognosis is often good.

ENDOCARDITIS

It should be understood that especially in acute conditions a positive separation of endocarditis from myocarditis is incorrect. Acute endocarditis can probably not occur without some inyocarditis, and myocarditis probably does not occur without some endocardial disturbance and perhaps some pericardial irritation. This is especially true in endocarditis which occurs during any acute infection, even in rheumatism. The greater the amount of pericarditis, the more serious is the acute condition. The greater the amount of myocarditis, the more doubtful is the heart strength in the near future. The greater the amount of endocarditis, the greater the doubt of freedom from future permanent valvular lesions.

Endocarditis may be divided into: acute mild (simple) endocarditis, acute malignant (ulcerative, infective) endocarditis, chronic endocarditis and valvular disease.

ACUTE MILD ENDOCARDITIS

This inflammation of the endocardium is generally confined to the region of the valves, and the valves most frequently so inflamed are the mitral and aortic. There may be a slight inflammation or actual ulceration and loss of tissue. Vegetations more or less constantly occur on the inflamed surfaces, with more or less danger of particles becoming loosened and moving free in the blood stream, causing embolic obstruction in different parts of the body. There is also more or less probability of serious adhesions or contractions occurring from the healing of the ulcerated surfaces. The future health and welfare of the valves depend on the fact that the inflammation has healed without contractions or adhesions.

It is often difficult to decide when acute endocarditis has developed; but with the knowledge that the endocardium often becomes inflamed during almost any of the acute infections, the physician should repeatedly examine the heart for murmurs, for muffled closure of the valves, or for other evidences of endocarditis or myocarditis during the acute infective process.

It has been shown positively that acute endocarditis is due to micro-organisms, generally streptococci, staphylococci or pneumococci, and, more frequently than once believed, gonococci. The most frequent causes are acute rheumatic fever, diphtheria, pneumonia, cerebrospinal meningitis, scarlet fever, erysipelas, influenza, chorea, gonorrhea, sepsis and typhoid fever. It may also follow a follicular tonsillitis or some infection of the mouth or throat with or without arthritis. Tuberculosis may also occasionally cause an endocarditis. Organisms may be found in a terminal simple endocarditis due to a chronic disease, as tuberculosis or cancer; such inflammations may have been caused by circulating toxins.

It will be noticed by the foregoing classification that the terms "mild" and "malignant" endocarditis are used. The purpose is to convey the fact that there may be no etiologic distinction between the two forms, and it is impossible to decide clinically in the beginning of an endocardial inflammation which form is present. In the malignant form the infection is probably more serious or the infective germs are more active, the ulcerations deeper, and the likelihood of emboli and the seriousness of such embolic infarcts more serious and more dangerous. The differences in inflammation in the two cases is really one of degree, and the classification is made to coincide with this probable fact. it is, of course, clinically recognized that endocarditis following certain diseases, especially rheumatism, is of the simple or mild type, while that termed ulcerative endocarditis may occur apparently as a primary or general infection, and the causative bacteria, as a rule, are readily discovered in the blood. The Streptococcus viridans is one of the most dangerous of these bacteria.

A SECONDARY AFFECTION

Mild endocarditis is rarely a primary affection, and is almost invariably secondary to one of the diseases named above. Nearly 75 percent of secondary endocarditis occurs as a complication of acute articular rheumatism and chorea, or subsequently. On the other hand, about 40 percent of all patients with acute articular rheumatism develop endocarditis, sometimes perhaps so mild as to be hardly discoverable. This complication is most likely to occur during the second or third week of rheumatic fever. It is not sufficiently recognized that a subacute arthritis, recurring tonsillitis, open and concealed infections in the mouth, and even a condition of the system with acute, changeable and varying joint and muscle pains may all develop a mild endocarditis, even with subsequent valvular lesions. Therefore in all of these conditions the decision can be made only as to how much rest the patient must have or how serious the condition is to be considered by careful examination of the heart in every instance.

Children are more liable than adults to this complication, especially with rheumatism. Therefore, acute mild endocarditis with future valvular lesions occurs most frequently during childhood and adolescence, and if one attack has occurred, a subsequent infection, especially of rheumatism, is liable to cause another acute endocarditis.

PATHOLOGY

The part of the heart most affected is the part which has the most work to do--the left side of the heart--and of this side the left ventricle and therefore the mitral and aortic valves; the most frequent valve to be inflamed and to stiffer permanent disability is the a mitral valve, the valve which in its inflamed condition is subjected to the greatest amount of pressure and therefore irritation. Not infrequently soft systolic murmurs are heard at the pulmonary and tricuspid valves during acute endocarditis. It is rare, however, that these valves are so affected during childhood or adult life as to be permanently disabled.

Whether a diminished alkalinity of the blood in rheumatism has anything to do with the cause of the frequent complication of endocarditis has not been determined. Whether the administration of alkalies to the point of increasing the alkalinity of the blood is any protection against the complication of endocarditis has also not been positively demonstrated, although clinically such treatment is believed by a large number of practitioners to be wise.

A chronic endocarditis with permanent lesions of the valves may become an acute inflammation with an infectious provocation.

It has been shown that even in a few hours after endocarditis has started, little vegetations composed of fibrin, with white blood cells, red blood pigment and platelets, may develop. Practically in all instances such vegetations develop, and later become more or less organized into connective tissue. These little vegetations, generally minute, perhaps not exceeding 4 mm. in height, are irregular in contour like a wart. Some of these may have small pedicles, and as such, of course, are more likely to become loosened and fly off into the blood stream. It is of interest to note that these little vegetations are more likely to be on the left side of the heart than the right; on the valves than any other part, and on the mitral valve than on the aortic. The consequence is a more frequent permanent disability of the valves of the left side of the heart, and of these more frequently the mitral. Although these little vegetations and excrescences sooner or later become mostly connective tissue, still fibrin and white blood cells may form thin layers over them, more or less permanent. In this fibrin are frequently found bacteria, even when there has been no recent acute inflammation. The deeper layers of the endocardium during acute inflammation may become infiltrated with young cells, with resultant softening and destruction of the intercellular substance. This softening and some swelling of the lower layers of the endocardium allow the pushing up of these extravasated blood cells which, being covered with fibrin, makes the little vegetations above described; and as just stated, the fibrin may form a more or less permanent cap. If this cap is disintegrated or lost and the cells under it washed away in the blood stream, ulceration takes place, which may be more or less serious, even to the perforation of a valve or actual erosion of one of its cusps, and the parts of the valves most seriously affected are the parts which strike against each other on closure; as previously stated, the parts subjected to the greatest strain and the greatest amount of friction during the inflammation are the parts most seriously affected afterward.

If a perforation has occurred, it may make a permanent leak. If an erosion of the edge of the valve has occurred, it may make permanent insufficient closure. If the valve has become thickened and stiffened during the cicatricial healing, it may not only be incompetent, but may not open perfectly, and a narrowed orifice may be the consequence. During the healing of these granulating ulcers there may be thickening of the part or shrinking of the tissue, and the valve may become shortened by adhesion to the wall, or the cusps of the valve may adhere together so that the valve becomes permanently unable to open properly or to close properly, or to do either.

Not infrequently and probably more frequently than we recognize, recovery without any of the pathologic lesions just described follows mild endocarditis. The occurrence of simple endocarditis is undoubtedly frequent during acute disease, and is unrecognized because there are no lesions of the heart at the time or subsequently; but valvular lesions only too frequently follow the endocarditis which occurs with rheumatism. Occasionally the ulcerations become serious, and ulcerative endocarditis or malignant endocarditis develops on the mild inflammation. In this form the little vegetations are liable to become loosened, fly off into the blood stream, and cause emboli in different parts of the body.

Recently Fraenkel [Footnote: Fraenkel: Beitr. z. path. Anat. u. z. allg. Path., 1912, iii, 597.] concluded that the microscopic nodules which occur in endocarditis in the myocardium, and which consist of the several varieties of white blood corpuscles first referred to by Aschoff in 1904, are characteristic only of acute rheumatism. Fraenkel found these nodules in the myocardium in a case of chorea, showing the close relationship between it and rheumatism.

While repeated careful examination of the heart during acute infections will generally show signs of endocarditis if it is present, even if there are no subjective symptoms, the disease may be so insidious as not to be noted until a valvular lesion occurs. Often, however, during the course of the disease, especially in rheumatism, there is a slight increase in fever and there is a discomfort complained of in the region of the heart, frequently accompanied by slight dyspnea. Real pain is seldom present unless the pericardium is affected. If the myocardium is much inflamed at the same time, the heart becomes more rapid and the blood tension lowered, and the apex beat diminished in intensity and perhaps not palpable. If there is pain, with or without pericarditis, it is often referred to the epigastrium, especially in children. The patient is often nervous, restless and sleepless. In simple endocarditis emboli rarely occur. If they do, of course the signs will be in the part in which the infarct occurs. Besides the diminished intensity of the apex beat and its greater diffusion, the valve sounds may be muffled, and sooner or later there may be systolic murmurs over the different orifices. Of course systolic murmurs may be due to a disturbed condition of the blood, but if they occur with the above-mentioned symptoms and signs, endocarditis should be diagnosed. If the heart becomes seriously weak and the patient suffers much dyspnea, myocarditis should be known to be present with the endocarditis. If there is a diastolic murmur, there can be no question of serious endocarditis having occurred. Unexplainable palpation during acute illness liar been thought to be a distinct symptom of endocarditis.

TREATMENT OF ENDOCARDITIS

As mild endocarditis rarely occurs primarily but is almost always secondary to some acute disease, its immediate treatment is only a slight modification of that of the disease which is causing it. A complication which is so frequent should always be expected, and consequently warded off or prevented, if possible. Knowledge of the diseases which are most liable to cause endocarditis makes frequent heart examinations a necessity, to note when it arrives. While an extra heart tire, sleeplessness, and the circulation of unnecessary toxins from a bad condition of the bowels and from improperly selected food all make this complication more liable, its occurrence is, nevertheless, often unpreventable.

The most efficacious preventive pleasures are sleep, rest, the stopping of pain, prevention of exertion, proper food which does not cause flatulence or other indigestion, good, sufficient daily movements of the bowels, the prevention of intestinal distention, and maintenance of a clean, moist surface of the body, produced by such sponging and bathing as the temperature demands.

The disease having developed, the indications for treatment are really few; in fact, the treatment is mostly negative. There is generally but little local pain; the temperature from simple endocarditis alone is not high and the acute symptoms tend to abate.

Local Treatment.--Endocarditis having been diagnosed, especially if there is palpation or pain, an ice bag over the heart is often of considerable value, but not so efficient as in pericarditis. It often tends to quiet the heart, and may be of some value reflexly in slowing the inflammation. If it causes restlessness, however, and does not lessen the pain (which in some instances it may increase), it certainly should be stopped. Children, in whom this complication so frequently occurs, generally do not bear the ice bag well. Sometimes it may be advisable to substitute warm applications, and often a great deal of comfort is derived from them, the patient soon going to sleep. One of the greatest values of either cold or hot applications is diminution of the discomfort from the cardiac disturbance, and the stopping of any pain which may be present. If they do not do this, there is no object in using either cold or heat.

The discomfort from blisters over the heart during the acute stage of endocarditis is greater than any good which they can do. In adults a few small blisters may be used intermittently around the borders of the heart, after the acute symptoms are over, to act reflexly on the heart and possibly aid absorption of inflammatory products. Sometimes improvement seems to follow such treatment; it certainly can do no harm.

During convalescence, the skin over the heart may be painted with iodin, repeated often enough to cause stimulation without injuring the skin; it seems at times to be of value. Various iodin or iodid ointments have been used, but they probably have no more value than the administration of small doses of iodid.

Systemic Treatment.--As this complication most frequently occurs during acute rheumatism, the question arises as to the value or harmfulness of salicylates and alkaline drugs. With our recent better understanding of the action on the heart of pure salicylates (either natural or synthetic saliclic acid, which have been shown to act identically, if equally pure), we must believe that in any ordinary dosage they will injure the heart but rarely. While salicylic acid will not prevent endocarditis, it should he continued, if it is of benefit with regard to the arthritis. The indication for its use depends on its effect on the joints. As it acts at times almost as a specific in rheumatism, it would seem that it should be of value in the endocarditis caused by rheumatism. On the other hand, the endocarditis occurs during the second or third week of acute rheumatism, after the blood has been thoroughly saturated with salicylic acid. Therefore it certainly does not tend to prevent rheumatic endocarditis; hence for this complication alone salicylic acid is not indicated.

ALKALIES

Anything which tends to increase the acidity of the tissues and to diminish the alkalinity of the blood, whether from starvation or outer causes, seems to pro-duce endocardial and myocardial irritation, if not actual inflammation. Therefore in a disease like rheumatism, which seems to be made worse by anything which increases the acidity, alkalies are obviously indicated, and it is probable that an increased alkalinity of the blood tends to prevent endocardial irritation, and may soothe an inflammation already present. Until we have some positive knowledge to the contrary, alkalies should be freely administered during endocarditis, especially during rheumatic endocarditis. Potassium citrate in 2 gm. (30 grain) closes, in wintergreen water, should be given every three to six hours, depending on how readily the urine is made alkaline. This may be given with the salicylic acid treatment, and also when the salicylic acid has been stopped. It may be well, if sodium salicylate is being used, to give also sodium bicarbonate, the sodium bicarbonate often preventing irritation of the stomach from the sodium salicylate, the dose being equal parts of the sodium salicylate and the sodium bicarbonate administered in plenty of water. If some other form of salicylic acid is preferred, novaspirin, which is methylene-citryl-salicylic acid and contains 62 percent of salicylic acid, is perhaps the least irritant to the stomach of the salicylic preparations. This drug is decomposed in the intestine into its component parts, salicylic acid and methylene-citric acid. If this drug is combined with sodium bicarbonate, the disintegration into its component parts would be likely to occur in the stomach.

IRON

It is essential for the welfare of the patient, especially after a long illness before the complication of endocarditis could occur, and in rheumatic fever, in which all meat and meat extractives have been kept from the diet, that small doses of iron should be administered daily. Not only the fever process, but also the salicylic acid tends to prevent the healthy normal growth of red corpuscles. and such patients suffering from rheumatism are often seriously anemic after the aente inflammation has ceased. The iron administered may be 5 drops of the tincture of the chlorid, in lemonade or orangeade, twice in twenty-four hours (and it should be remembered that lemon and orange burn to alkalies in the system and do not act as acids); or 0.1 gm. (1 1/2 grains) of reduced iron in capsule twice in twenty-four hours, or a 3 grain tablet of saccharated ferric oxid (Eisenzucker) twice in twenty-four hours.

OPIUM

As so many times repeated, real pain must be stopped, and morphin, either by the mouth or hypodermically, should be used to the point of stopping such pain. If the patient is a young child, codein sulphate or the deodorized tincture of opium may be used in the dose found sufficient, and either one will act satisfactorily. The dose given should be small but repeated sufficiently often to stop the pain. The dose necessary for the given individual will soon be learned, and that dose may be repeated at such intervals as the condition may require. Sometimes the hypnotic selected, if one is needed, will be sufficient to quiet the cardiac aches or pains.

BROMIDS AND CHLORAL

If there is much restlessness and the circulation is good, that is, if myocarditis is probably not present, the bromids may be of great value, especially in children. The dose should be sufficient to quiet the nervous system. The drug may be discontinued after a few days, if the conditions improve. If the bromid, except in large doses, will not cause sleep, a sufficient dose of chloral should be given. Chloral is one of the most satisfactorily acting drugs which we have to produce sleep and to cause cardiac rest. While it should not be given if there is real cardiac weakness, the good which it does is so much greater than the possible bad effect on the heart, that it should not be forgotten for some newer hypnotic. The worst part of this drug is its taste, and the best way to administer it is to have it in solution in water and the dose given on cracked ice with a little lemon juice to be followed by a good drink of water and a piece of orange pulp for the patient to chew. Ordinarily a bad-tasting drug such as chloral is well administered in effervescing water, but effeverscing waters are generally inadvisable when there is any kind of inflammation of the heart, as they are liable to cause distention of the stomach and pressure on the heart. Some physicians prefer chloralamid as a less disagreeable drug and one which acts almost as efficiently as chloral. As the close of this must be larger than the dose of chloral, it is a question of doubt as to which is the better drug to use. Of the newer hypnotics, veronal=sodium (sodium-diethyl-barbiturate) is among the best. It acts quickly, is less depressant and is a safer salt than most of the other newer hypnotics. It is the readily soluble sodium salt of veronal (diethyl-barbituric acid). When combined with any active drug, sodium seems to make it less toxic and less depressant. The dose of this drug is from 0.2 to 0.3 gm. (3 to 5 grains).

PREVENTION

If the patient is weak, the circulation depressed, the blood pressure low, and the heart rapid, the drug advisable to produce rest and sleep is almost always morphin or some other form of opium. Morphin, with few exceptions, is a cardiac tonic and a cardiac stimulant, unless the dose is much too large. As long as the bowels are daily moved and the food is not given at the time of the full action of the morphin, when digestion might be delayed or interfered with, in most patients the action of this drug during serious illness is entirely for good. The greatest mistake in using morphin for the production of sleep, or for physical and mental rest and comfort when there is not severe pain, is in giving too large a dose. If pain is not severe, or due to inflammatory distention of some undilatable part, to pressure on some nerve, to distention of some tube by a calculus or to some serious injury to the nerves, large doses of morphin are not needed. Small doses will act much more efficiently. It is excessively rare that a hypodermic of one- fourth grain of morphin sulphate is needed, except for the conditions enumerated. It is often a fact that so small a dose as one-eighth grain of morphin or even one-sixth grain will cause sufficient stimulation of a nervous patient, because its primary stimulant effect on the spinal cord is greater than its depressant effect on the brain, to require another dose (one-fourth grain altogether) to give such a patient rest. On the other hand, this patient may many times be quieted by one-tenth grain of morphin sulphate on account of the size of the dose being not sufficient to stimulate the spinal cord. Many a time clinically when one-eighth grain has failed, a dose of one-fourth grain having been apparently necessary, a change to one-tenth grain has proved entirely and perfectly satisfactory.

DIET

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

LAXATIVES

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

CARDIAC DRUGS