some patients a constant temperature is maintained for the greater part of
the time.

The patient remains in the bath at first from 4 to 6 minutes; gradually
this time is increased to 10 or 12 minutes, exceptionally to 15 or 20. Upon
changing the bath for a stronger, the initial duration should be lessened and
the maximum time depends upon the patient's condition and his reaction
to the measure. The guide to the proper length of a bath, after the first few
have been taken, is a change of pulse from a slower and fuller to a more rapid
and smaller one or when other signs of weakness are noticed. After the bath
the patient should be dried with a warm towel and during the process or shortly
afterward he should take a little simple solid or liquid food, he should then rest
for about a half hour, during which he may doze but shoiild not slumber deeply
for this latter causes a relaxation, during which much of the tonic effect of
the bath is lost.

The baths produce the most benefit when given on alternate days and should
never be given upon two successive days without an omission upon the third.
In rare instances two day rests may be necessary. The strength of the baths
may be gradually increased and their temperature slightly lowered, never,
however, below 82° F. (27° C.) and seldom to this point.

The number of baths necessary to complete a treatment varies; usually
we anticipate a good result from twenty to twenty-five; often it is well to stop the
baths when this number has been reached and if the desired effect has not been
attained to advise a change of air for a month, the bathing to be resumed
at the end of this period.

The physiological effect of the baths results in a slowing of the pulse rate
and an increase in its force and a lessening of the dyspnoea, after the first few



550 DISEASES OF THE HEART AND BLOOD-VESSELS.

moments; in some instances internal congestion is so much relieved that in
thin subjects the area of cardiac dulness is diminished showing that the heart has
contracted as a result of the greater ease with which it performs its function;
the size of the liver is said also to diminish and the amount of haemoglobin
and number of red blood cells to become increased.

Before beginning the exercises we should attain positive benefit from the
baths and the employment of massage is advisable before commencing the
exercises proper. This massage should consist of a stroking of the limbs
from the extremities upward; abdominal massage should be performed with
the greatest care since it may cause cardiac depression. These strokings
may be continued at first for 5 or 10 minutes, later for 20 minutes and should
be followed by a period of rest. Respiratory exercises, in the open air, if
possible, if not in a thoroughly ventilated apartment, are very useful. The
patient places a cane behind his shoulders and in front of his upper arms
and walks about taking regular and deep breaths. After the latter and the
massage have been continued for two or three weeks the exercises may be
instituted under the following rules: The patient should not hold the breath
but should breathe with regularity; exercises which cause an intermittent
heart action must be omitted; only moderate resistance should be employed
at first; no movements should be used which bring the hands above the level
of the shoulders, for raising the hands increases arterial tension and weakness,
and retards the heart action. The exercises include all ordinary movements
of the limbs and extremities; these are made by the patient against the moder-
ate resistance of the attendant. Lateral and rotatory movements of the body
are included. They should never be continued until the patient is tired.

In fatty heart, after a course of the above treatment which has benefited
the patient to a sufficient degree, hill and stair climbing in moderation may be
prescribed. The walk should at first be short and up only a moderate incline,
stopping every 10 or 15 yards to rest and to take several full breaths. If
the respiration becomes hurried under this exercise it should be omitted; if
no untoward symptoms are induced the walks may be gradually lengthened
to from 100 feet to five or ten times this distance. Stair climbing, resting
for a few breaths every four or five steps, may be substituted in unpleasant
weather.

With regard to diet we can lay down no fixed rules. Alcohol should be
interdicted except in old persons who have become accustomed to its use.
Beer should not be allowed even here, but we may permit a little whiskey
or wine with the noon and evening meals. Coffee is best omitted but if tea
and cocoa are unpalatable a little very weak coffee may be taken at breakfast.
Milk is by far the drink to be preferred, and in arteriosclerosis should comprise
the chief part of the diet. Starches should be avoided here but eggs may be
allowed. With a fattv heart fats should be forbidden and starches as well;



CARDIAC ATROPHY. 55 1

lean meat, fish and green vegetables may be allowed. Liquids with meals
are not permissible but may be taken in the intervals.

Contraindications to the Schott or Nauheim treatment are chronic nephritis,
advanced aneurysm and arteriosclerosis in its late stages. All patients who
are afflicted with this stage even in its incipiency must be most carefully
watched while undergoing this treatment for often albuminuria and casts
in the urine appear which seem to be caused by the baths; these in many
instances may yet be continued with benefit to the patient but, as stated above,
the greatest watchfulness upon the part of the physician is necessary.

CARDIAC ATROPHY.

This condition consists in a diminution in the muscular substance of the
cardiac walls and a consequent contraction in the size of the chambers of the
organ. It occurs with the chronic wasting diseases, especially tuberculosis
and cancer; it is also observed in senile marasmus and occasionally in chronic
endocarditis. The reduction in size of the organ is usually symmetrical.
Its color is dark brown and its walls are firm in consistence. Under the
microscope, granules of a brown pigment are seen about the nuclei of the
muscle cells and between the fibrillag.

The condition causes no special symptoms, only those of the causal disease
being present, the pulse is weak and the physical signs consist of a reduction
in the normal area of cardiac dulness, weakness of the apex impulse and of
the heart sounds. In pulmonary emphysema the lung may overlap the heart
so as to diminish its area of dulness, consequently this condition is to be
excluded in the diagnosis of cardiac atrophy.

Treatment consists in the employment of the approved measures calculated
to benefit the causal affection.

MYOCARDITIS.
Parenchymatous Myocarditis.

Synonym. Parenchymatous or Albuminoid Degeneration of the Heart.

This condition consists of a conversion of the normal muscular substance
of the cardiac wall into a granular albuminoid matter soluble in acetic acid
but not in aether. Microscopically the striae of the muscle fibres are indistinct
or invisible; on gross inspection the heart muscle is pale and in consistency
it is very soft. Parenchymatous degeneration is believed to be the result of
some toxic influence and is met in the acute infectious diseases such as small-
pox, enteric fever, scarlatina, etc. It is no longer considered to be due to
prolonged high temperature and is not a permanent change.



552 DISEASES OF THE HEART AND BLOOD-VESSELS.

Fatty Myocarditis.

Synonym. Fatty Degeneration of the Heart.

Definition. A degeneration of the heart muscle characterized by the
replacement of the normal tissue by fat.

.Etiology. Fatty myocarditis occurs as a result of prolonged acute infec-
tions, in the chronic wasting diseases, especially pernicious anaemia, as a
senile change, in phosphorus and arsenic poisoning, in pericarditis and
withj sclerosis of the coronary arteries. The hypertrophied and dilated heart
of chronic endocarditis may undergo fatty degeneration.

Pathology. The replacement of normal muscle by fat may be localized
in one part of the organ or generalized; most frequently it affects the left
ventricle. In the former instance there may be small foci of fat in the muscle
immediately underlying the pericardium; these may occur only in the layers
subjacent to the myocardium or, as a result of thrombosis or embolism of a
branch of the coronary artery, an isolated focus of fatty metamorphosis may
be found in the wall of the left ventricle or in the interventricular septum;
this at first is haemorrhagic or brownish and later becomes white and is known
as a white infarct or an area of anaemic necrosis. This may finally disintegrate
and be replaced by caseous matter or, weakening the cardiac wall, may result in
rupture. General fatty myocarditis is evidenced by a dilatation of the organ;
it is soft and flabby, light yellowish-brown in color and little force suflGices
to tear its walls; there may be deposits of fat in the papillary muscles. Under
the microscope, fat droplets are seen along the margins of the muscle fibres;
in marked instances the fat may almost entirely replace the muscular tissue.
With the fatty degeneration of the myocardium there may be a similar condi-
tion in the solid viscera and in the muscular fibres of the diaphragm.

S5miptoms. These may be nil so long as dilatation does not supervene,
and upon the incidence of this complication it is responsible rather than the
fatty change in the heart wall for the clinical manifestations which occur.
These are those of dilatation occurring from any cause — dyspnoea, palpita-
tion, irregular and feeble heart action, etc.

The prognosis of the condition is unfavorable, no therapeutic measures being
able to influence the pathological condition which is permanent.

Treatment. This is identical with that of cardiac dilatation — rest in bed
and stimulation for the acute attacks and later, or before these appear, if the
diagnosis is made so soon, the Nauheim or Schott method (see p. 548) is indi-
cated.

Fatty Infiltration of the Heart.

Synonyms. Fatty Over-growth; Cor Adiposum.

This condition consists in an increase of the normal subpericardial fat but



FIBROUS MYOCARDITIS. 553

finally the myocardium may be involved, the fat making its way between the
muscular fibres of the heart wall even as far as its endocardial lining. It
is usually associated with obesity and is a disease occurring in late middle
life and affecting males more than females. The fatty change ultimately
interferes with the nutrition of the organ and impairs its action. Here the
symptoms are those of true fatty myocarditis. In the earlier stages the
symptoms are those of cardiac insufficiency associated with obesity.
The treatment is that of obesity and fatty myocarditis.

Amyloid degeneration of the heart has been observed. The patholog-
ical change involves the walls of the blood-vessels and the inter-muscular
connective tissue.

Hyaline degeneration (Zenker) affects the muscle fibres, rendering them
swollen and transparent and partially or wholly obliterating their striae.

Calcareous degeneration occurs rarely, being characterized by an infil-
tration of the muscular tissue with calcium salts.

Fibrous Myocarditis.

Synonyms. Fibro-myocarditis; Interstitial Myocarditis; Fibroid Heart;
Coronary Arteriosclerosis.

Definition. A condition in which the normal muscular tissue of the heart
is to a greater or less extent replaced by fibrous tissue.

^Etiology and Pathology. Fibrous degeneration of the heart wall is the
result of sclerosis of the coronary arteries, consequently the causes of fibro-
myocarditis are those of coronary arteriosclerosis and these are those of endar-
teritis in general (see p. 593). Disease of the coronary arteries diminishes
the blood supply of the heart muscle which resiilts in a gradual degeneration
of the muscular fibres which are finally replaced by sclerotic tissue. This
change is most frequently observed in the wall of the left ventricle near the
apex or in the septum, but may take place in any part of the cardiac muscle.

Disease of the coronary arteries also leads to the occurrence of areas of
anaemic necrosis in the heart wall as a result of thrombosis or embolism.
These areas are yellowish in color, may be conical in shape and may project
beyond the surface of the organ. They at first soften and become degenerated,
later they undergo sclerotic or hyaline changes.

"With the fibrous degeneration of the heart muscle valvtdar lesions may
co-exist which may be a factor in the production of the fibrosis because of the
resulting venous congestion, or emboli from the valves may find their way into
the coronary arteries and cause anaemic infarcts. The lodgment of infective
emboli from any source, in the coronary arteries gives rise to septic infarctions



554 DISEASES OF THE HEART AND BLOOD-VESSELS.

which become abscesses of varying size. Small ones may give no symptoms
but larger ones may either perforate internally or outwardly into the peri-
cardium — the so-called acute cardiac ulcer.

Symptoms. In the mild degrees of fibrosis there may be no symptoms
and the disease may be of such degree as to cause sudden death in a subject
who has never considered his heart diseased. The association of endo-
carditis with myocarditis may obscure the symptoms of the latter. When
occurring independently fibro-myocarditis is evidenced by the ordinary symp-
toms 'of cardiac dilatation (see p. 547), dyspnoea, palpitation, rapid or con-
stantly slow pulse, arrhythmia and often Cheyne-Stokes respiration at night.
Late manifestations are those referable to general venous congestion such as
oedema, cyanosis, etc. Anginoid attacks may occur and marked mental
symptoms, due to circulatory changes in the brain, may be observed.

Physical Signs. The apex impulse is usually weak and may be found
with great difficulty, unless dilatation is present, when its area is diffuse; the
area of cardiac dulness is diminished in size. The quality of the first sound at
the apex is less clear than normal and in the later stages both first and second
sounds become diminished in intensity. A ventriculo-systolic murmur may
be present at the apex, this murmur is less constant than that of mitral insuffi-
ciency and is not accompanied by an accentuation of the pulmonic second sound,
which latier may be reduplicated.

The diagnosis is not easy; the frequent presence of associated valvular
lesions does not tend to simplify matters; when we find a manifestly diseased
heart, in which no murmurs are heard and general arteriosclerosis is present,
in a subject beyond middle life, we are usually safe in diagnosticating fibrous
myocardial degeneration.

The prognosis is unfavorable yet life may be sustained for long periods
and in comparative comfort; the accompanying disease of the coronary arteries,
however, renders sudden death, due to blocking of these, possible at any
time.

Treatment. An endeavor to promote the absorption, or at least to prevent
the further production of fibrous tissue in the walls of the coronary arteries
may be made by administering iodine. The syrup of hydriodic acid — 5i (4-o)
in a wine glass of water one-half an hour before meals — or potassium iodide,
the latter having a vaso-dilator action, may be employed. The patient's
mode of life should be regulated just as in the treatment of arteriosclerosis
(see p. 595), alcohol and tobacco should be forbidden and over-eating and
over- work avoided. The vessels may be kept open if tension is present,
and the tendency to heart weakness and venous congestion combated by the
same means as those mentioned under the treatment of cardiac dilatation.
Rest in bed is often a very necessary adjunct to treatment. Digitalis should
not be prescribed for patients who have a constantly slow pulse and an increased



ACUTE SUPPURATIVE MYOCARDITIS. 555

vasciilar tension. The treatment by means of Nauheim baths, massage and
resistance exercises (see p. 548) in properly selected cases will prove of great
benefit.

Acute Suppurative Myocarditis.

Synonym. Cardiac Abscess.

In pysemic states infective emboli may lodge in the branches of the coronary
arteries, as previously stated, and cause abscesses. These may be very tiny,
in which case they usually cause no symptoms, or of larger size; in the latter
instance they may rupture into one of the chambers of the heart or externally
into the pericardial sac. In the former case the blood cmrent takes up the
infectious matter and scatters it through the body to cause other embolic
abscesses; in the latter suppurative pericarditis and death result.

ANEURYSM OF THE HEART.

Cardiac Aneurysm occurs in two forms:

a. Valvular aneurysm which may take place in acute endocarditis as a
result of weakening of a localized area in one of the valvular segments through
ulceration. Rupture may take place through the weakened area or the pres-
sure of the blood may cause an aneurysmal dilatation upon the ventricular
surface of the flap. Rupture of such an aneurysm results in insufficiency
of the affected valve. The aortic is the valve most often affected.

b. Aneurysm of the cardiac wall may be caused by injury or occiir as a
result of weakening due to myocardial degeneration. Its most frequent
site is in the wall of the left ventricle near the apex. The weakened wall bulges
and the resulting dilatation varies in size from that of a good sized pea to that
of the heart itself. Sacculation and multiple aneurysms have been observed.
Rupture into the pericardium may take place.

The symptoms are not definite and the condition is not likely to be diag-
nosticated with any certainty during life.

RUPTURE OF THE HEART.

Rupture of the cardiac wall may take place as a result of almost any disease
of this structure but is most frequent in fatty myocarditis with white infarct.
It has also been observed in fibrous degeneration of the heart muscle, abscess,
malignant neoplasm and gumma. It is most common in the aged but has
been noted in infants; it is usually induced by over-exertion but may take
place spontaneously and without symptoms of warning. The favorite site
of the rupture is the anterior wall of the left ventricle near the septum.



556 DISEASES OF THE HEART AND BLOOD-VESSELS.

Death from rupture may take place immediately or, exceptionally, life may
be prolonged for a few hours. In this case the patient suffers from oppression,
dyspnoea, cardiac pain and collapse. Physical examination should reveal
the signs of a pericardium distended with fluid.

DISEASES OF THE ENDOCARDIUM.

ACUTE ENDOCARDITIS.

t

Definition. An acute inflammation of the membrane lining the heart,
usually confined to that portion which covers the valves, and characterized
by the development upon these structures of vegetations with loss of valvular
substance. It is often and properly termed valvulitis. In rare instances the
lining of the heart's chambers may be involved.

Acute endocarditis occurs in two main types, the mild or simple and the
malignant, infective or mycotic; there is, however, no distinct line of demar-
cation to be drawn between these two types from a pathological standpoint,
they differ merely in severity. Both are the result of infective processes and it
is difficult to state why in one instance the mild form is met and in another
the malignant.

.Etiology. Simple acute endocarditis is always a secondary affection,
most often to acute articular rheumatism; in many instances, also, it occurs
with chorea; less frequently it complicates the acute infectious diseases, especi-
ally scarlatina and pneumonia, while it is less commonly seen in tonsillitis,
erysipelas, smallpox, diphtheria and enteric fever; in measles and varicella
it is rare. It is also met in chronic nephritis and the chronic wasting diseases
such as tuberculosis, cancerous cachexia, diabetes and gout and in addition
it is often engrafted upon the sclerotic valves of chronic endocarditis, causing
acute exacerbations of the symptoms of the latter inflammation; the term
recurrent endocarditis has been applied to this form of the affection.

The bacteriology of simple acute endocarditis following the infectious
diseases is identical with that of the malignant type of the disease.

Cultures from the valves in acute endocarditis due to the chronic diseases
are usually sterile. It is possible that micro-organisms have been previously
present but have disappeared or that the pathological condition is the result
of toxic substances.

Malignant endocarditis is also of infectious nature and may occur primarily
in rare instances; much more often it is a secondary affection, being met most
frequently in infectious pneumonia, acute articular rheumatism, gonorrhoeal
infection, peliosis rheumatica, puerperal fever and other forms of septicaemia,
and is distinctly predisposed to by chronic valvular lesions and congenital
cardiac defects. It is rare in chorea, tuberculosis, scarlatina and the other



ACUTE ENDOCARDITIS. 557

acute infectious diseases. The bacteria most often found in the valvular
lesions are the pheumococcus, the gonococcus, the staphylococcus and the
streptococcus. Rarely typhoid, tubercle and colon bacilli have been noted.
Mixed infections may occur.

Pathology. The morbid changes affect the left side of the heart in the
great majority of instances. The mitral valve is most often involved, then
the aortic, next the tricuspid and last the pulmonary valve. The character-
istic lesion is the occurrence of warty vegetations upon the valves and more
rarely upon the membrane lining the cardiac cavities. Upon the mitral and
tricuspid valves they are observed upon the auricular surfaces near their
margins and upon the aortic and pulmonary valves upon the ventricular
aspects. They are yV to | of an inch (2 to 3 mm.) in height, of irregular
surface and may be pediculated. At their inception they consist of cells
proliferated from the adventitia and connective tissue of the outer layers of
the endocardium. These cells are infiltrated with red and white blood cells
and fibrin which finally organize and the vegetation becomes wholly composed
of connective tissue, bits of which may become detached and carried as
emboli by the blood current. Micro-organisms are usually found enmeshed
in the fibrin which often forms a film over the summit of the vegetation. The
latter may undergo subsequent contraction and organization and disappear,
not, however, leaving behind a normal valve, but one thickened, sclerosed and
contracted, or the inflammatory process may continue and go on to an endo-
carditis of malignant type.

In malignant endocarditis vegetations are almost constantly present. These
vary in size from that of a pin-head to that of a pea and frequently undergo
ulceration which may go on to the formation of a valvular aneurysm or to
perforation. The endocardial lining of the cardiac chambers also may be
affected, most frequently in the left ventricle at the upper part of the septum.
The vegetations in this type of endocarditis contain pathogenic bacteria in
greater number than in the simple form and these are closely intermingled
with masses of fibrin. The process when involving the endocardial lining
may go on to perforation of the heart wall. According to Osier's statistics
of 209 cases the mitral valve alone is most frequently affected, next the aortic,
next both the mitral and aortic, next the mural endocardium, next the tricuspid
and lastly the pulmonary valve. Extension of the inflammatory process
may take place along the pulmonary artery to the hilum of the lung or to the
aorta producing multiple aneurysmal dilatations. Further than this the
pathological changes consist of those due to the primary infection, pneu-
monia, rheumatism, sepsis, etc., and the lesions due to the lodgment of emboli
deposited in various parts of the body by the blood current. These result
in the formation of metastatic abscesses or red infarctions. Emboli may be
absent or be numbered by hundreds. They may be situated in the spleen,



558 DISEASES OF THE HEART AND BLOOD-VESSELS.

kidney, brain, skin or intestines, and, in endocarditis of the right heart, in
the lungs.

Symptoms. Those of acute simple endocarditis are in no way typical and
are frequently overlooked, the first intimation of cardiac involvement being
the presence of vegetations as revealed upon the autopsy table. The symp-
toms of the primary disease are present and in those affections in which endo-
carditis is prone to occur, daily examinations of the heart should be made.