to digitalis, but is not cumulative and is useful, especially m uncompensated
mitral disease.
Other cardiac stimulants that may be mentioned are adonidin, convalleria
and cactus grandiflorus. The first of these possesses the same indications
as digitalis; it is, however, less serviceable but may prove a satisfactory sub-
stitute when the latter drug is contraindicated or fails. Its action is prompt
and it is often valuable in beginning the regulation of the cardiac movements
THE TREATMENT OF VALVULAR LESIONS. 583
before digitalis has had time to take effect. Its dose is ^ to ^ of a grain (o.oi
to 0.02); it is too irritating to be employed hypodermatically. Convalleria
is unreliable in its effect and its vaunted selective action upon the right heart
is probably fictitious. Its indications are the same as those for digitalis. The
dose of the fluidextract is 8 minims (0.5). Cactus is of great use in aortic
insufl&ciency but is absolutely contraindicated in mitral obstruction, thus
being of value only where digitalis is inadmissible. It increases both the
cardiac force and rapidity, being, perhaps, the only drug which possesses
this effect. It does not replace other cardiac stimulants but is useful in many
instances where these are dangerous. Cactus is active only when carefully
prepared from the green plant. A properly made fluidextract is of a peculiar
opalescent-green color; if brown it is inert. The dose is from 10 to 30 minims
(0.66 to 2.0).
In addition to the administration of drugs there are other measures by which
the impeded circulation may be relieved. Of these venesection is one of
the most effectual and is particularly indicated in mitral obstruction with
pulmonary congestion, marked dyspnoea and cyanosis and in dilatation with
arteriosclerosis. As many as 20 or 30 ounces (600.0 to 900.0) of blood may
be withdrawn. Depletion through the bowels is another useful method of
relieving venous congestion and may be well carried out by the method of
Matthew Hay which consists of the administration in the evening of 2 ounces
(60.0) of magnesium sulphate which have previously been dissolved in an
equal amount of boiling water. The patient should take nothing to drink
before the noon of the following day and usually before this time he will have
had several watery stools and will have noticed a marked increase in the
quantity of urine. The exhibition of so drastic a cathartic as the above is
not contraindicated even if the pulse is feeble and irregular.
The Schott method of treatment by means of carbonic acid gas baths and
resistance exercises is useful in all forms of loss of compensation. For a
description of these measures the reader is referred to p. 548.
The anaemia which is so frequent an accompaniment of cardiac disease neces-
sitates the routine administration of iron and other tonics, especially strychnine.
The Treatment of Special Symptoms: Dyspnoea. This symptom is due
to insufficient oxygenation of the blood in the lungs as a result of the conges-
tion of these organs ; the correction of the pulmonary engorgement by means
of the remedies suggested above will often relieve the shortness of breath;
if the congestion has resulted in the transfusion of serum into the pleural
cavities these should be aspirated and the fluid withdrawn. Reaccumula-
tions necessitate repetition of the operation. Dyspnoea when due to arterial
contraction may be lessened by the vasodilators as suggested above. In
the marked nocturnal dyspnoea of advanced cardiac disease often nothing
but ■morphine will afford relief although the compound spirit of aether — i
584 DISEASES OF THE HEART AXD BLOOD-VESSELS.
drachm (4.) — repeated if necessary, sulphonethylmethane (trionalj, — gr. x
(0.66) — sulphonmethane (sulphonal), — gr. xx (1.33) — diethylmalomylurea
(veronal) — gr. x (0.66), or chloralformamide (chloralamide) — gr. xxx (2.0),
may be tried. These failing, morphine may be given without fear, for it
has a distinctly cardiac stimulant effect, in dose of ^ of a grain (0.016) either
subcutaneously or by mouth. Inhalations of oxygen may give relief.
Palpitation and Precordial Distress. In addition to the heart stimulants
discussed above we may employ locally the ice coil, a belladonna plaster,
a closSly watched nitric acid issue or other blister. The combination of
potassium iodide or glyceryl nitrate and belladonna with digitalis is often
effectual and when the heart is markedly over-active, turbulent and irregular,
the tincture of aconite in doses of 5 or 10 minims (0.33 to 0.66) every hour
often produces excellent resiilts. This drug should be carefully watched and
discontinued as soon as the condition is relieved or untoward effects are noted.
Palpitation and oppression due to gastric and intestinal distention necessitate
the exhibition of laxatives and intestinal antiseptics.
(Edema. In addition to the measures already described for relief of the
general venous congestion, particularly the administration of digitalis, stroph-
anthus and caffeine which are diuretics, and glyceryl nitrate and er}^throl
tetranitrate which increase the blood supply of the kidney by dilating the renal
arter}^, together with depletion by means of hydrogogue cathartics, such as
elaterin and jalap, and Hay's method, we have other means at our disposal.
The increase in the action of the kidneys following the employment of copious
high rectal irrigations of hot normal saline solution at 116° to 120° F. (46.5°
to 49° C.) is often very marked and this simple procedure may be repeated
several times daily if necessar}-. The Guy's diuretic piU consisting of i grain
(0.065) each of powdered digitalis, squill and calomel, given every four or six
hours for two or three doses and theobromine sodio-salicylate, i to 2 drachms
(4.0 to 8.0) have been used with benefit. (Edema of the legs may be lessened
by the recumbent position or by bandaging. In extreme instances scarifica-
tion may become necessar}^; this shoiild be done under the strictest antiseptic
precautions as should abdominal paracentesis, which is indicated in marked
degrees of ascites. The management of hydrothorax has already been con-
sidered. The treatment of dropsical conditions by means of decloridation
will be discussed in the section upon renal diseases.
The insomnia which is frequently a source of great discomfort to the patient
may be relieved in milder instances by a drachm (4.0) of the compound spirit
of aether or a half drachm (2.0) of paraldehyde or of amylene hydrate taken
on retiring. The great disadvantage of all these is their unpleasant taste
and the fact that the two first produce disagreeable eructations. Sulphon-
methane (sulphonal), sulphonethylmethane (trional) and veronal may prove
useful and it may become necessary to place our dependence upon morphine.
THE NEUROSES OF THE HEART. 585
With regard to diet no very fixed rules can be laid down. During the
absence of compensation the regimen should be of the lightest and consist
chiefly of milk, the meat broths and extracts and soft eggs. Carbohydrate
foods should be given with caution on account of their proneness to cause
flatulence. Shoiild the stomach become disturbed and nausea and vomiting
supervene these may be relieved by a greater restriction of the diet. Milk
with lime water or vichy may be given; bits of cracked ice and small quan-
tities of iced champagne are frequently useful. The addition of 10 grains
(0.66) of cerium oxalate and 20 grains (1.33) of sodium bicarbonate to each
glass of milk will sometimes relieve nausea. Upon the re-establishment of
compensation a gradual return to a more generous diet, which may include
fish, scraped beef, the white meat of poultry and other like articles, should
be allowed.
The treatment of congenital heart disease differs in no essential from that of
acquired cardiac defects; the measures discussed above should, however,
be so regulated as to render them applicable to children.
THE NEUROSES OF THE HEART.
PALPITATION.
Definition. An abnormally rapid action of the heart, not associated with
evidence of organic lesion, but of which the patient is conscious and which
may be regular or irregiflar. Murmurs due to functional disorders may be
present especially if anaemia is co-existent.
.Etiology. The condition is more common in the female sex and is very
frequently observed at the incidence of puberty, at the menstrual epoch
and at the menopause. All the causes contributing to the neurasthenic or
the hysteric state may be named as setiological factors, such as mental over-
work and emotion, uterine and gastric disorders, anaemia and the physical
weakness induced by over -work or long illness.
A frequent cause is the abuse of alcohol, tea, coffee, or tobacco. The
so-caUed "irritable heart" described by Da Costa as occurring in the soldiers
engaged in the Civil War was associated with neurotic palpitation but to its
causation there were other contributory factors such as mental anxiety, physical
over-work and weakness due to iUness. With the palpitation in these cases
dilatation was probably often associated.
Symptoms. Of these the consciousness of the heart's action is the most
prominent. The discomfort may be merely an evanescent fluttering accom-
panied by merely slight discomfort, or the action of the organ may be greatly
accelerated, irregular and markedly increased in force. This manifestation
lasts varying periods of time, occurring often in paroxysms {paroxysmal tachy-
586 DISEASES OF THE HEART AND BLOOD-VESSELS.
cardia) and may be associated with a sense of weakness or with nausea, flushing
or paleness of the face and an increased urinary excretion. An attack may
be induced by exertion.
Physical examination of the heart reveals little except the increased rate
of its pulsations; the heart sounds may be sharp and distinct or impure; there
may be accentuation of the pulmonic or aortic sounds. Ventriculo-systolic
murmurs may be present, heard usually at the base but sometimes at the
apex. ^
The diagnosis is based upon the intermittency of the attacks, the co-exist-
ent neurotic element or anaemia and the fact that the condition is met in
young individuals as a rule.
The prognosis as to life is favorable although the condition itself may
present difficulties as to its removal.
TACHYCARDIA AND BRADYCARDIA.
Tachycardia or rapid heart may be a normal condition, individuals having
been observed in whom the pulse-rate in perfect health was 100 or over.
Paroxysmal tachycardia is a condition in which spasmodic increase in the
pulse-rate takes place at intervals and without assignable cause. The parox-
ysms last from only a few moments to several hours and may occur at varying
intervals. The cardiac pulsations may reach 200 to 220 per minute.
Bradycardia or slow heart also may be a normal condition, many persons
having in health a pulse much lower than the normal 72; a rate of from 50
to 60 is not unusual and instances of much lower pulse have been reported.
Care should be taken to make sure that the radial impulses correspond in
niimber to the apical impulses, since it is not infrequent in certain cardiac
conditions for the alternate systole to be too weak to send an impulse to the
periphery. Slo-umess of the pulse may be observed during pregnancy and is a
natural consequence of hunger and senility.
Bradycardia has been noted as a pathological entity in (a) convalescence
after the acute infectious diseases; (b) dyspepsia, jaundice, gastric ulcer and
cancer; (c) pulmonary diseases, rarely; (d) circulator}' diseases, particularh'
those afi'ecting the cardiac muscle and in connection with deficient supply
of blood in the coronan,' circulation; (e) nephritis; (f) toxsemia from uraemia,
lead, alcohol, cofi'ee and digitalis; (g) constitutional diseases such as gout, anae-
mia and diabetes; (h) nervous diseases, apoplexy, neoplasms, affections of the
medulla and cervical cord, epilepsy, general paralysis, etc.; (i) genito-urinary
and cutaneous diseases.
Bradycardia is the result of irritation of the center of origin of the vagus or
of its peripheral portion; it also may be caused by a condition of exhaustion
of the cardio-motor apparatus.
ARRHYTHMIA. 587
Tbe Adams-Stokes syndrome is a variety of bradycardia sometimes
transient but usually permanent and associated with attacks of dizziness
or even convulsions and unconsciousness. Dyspnoea and perhaps Cheyne-
Stokes respiration are frequently associated symptoms. It is met with in
old subjects with arteriosclerosis, in myocarditis of syphilitic origin and may
occur as a neinrosis. The pulse-rate may fall even to 20 or 10 per minute.
In the neurotic cases it is not a serious condition but in its other forms the
prognosis is less favorable although death may not supervene for years. It is
the result of affections of the pneumogastric nerves, of the medulla oblongata,
and of disease of the interventricular septum which causes a disordered action
of the auriculo-ventricular bundle of His, a group of muscle fibres which has
its origin in the interauricular septum below the foramen ovale and passes
downward and anteriorly to the junction of the auricles with the ventricles,
where it is in close approximation to the mesial cusp of the tricuspid valve,
and finally ends just below the origin of the aorta.
Under the term heart block a condition has been described which is char-
acterized by failure of the ventricle to follow each auricular contraction, in
other words the aiiricular systole takes place more often than does the ven-
tricular contraction. This peculiarity is believed to be due to an affection
(a) of the ventricular wall, (b) of the pneumogastric nerve, or (c) of the con-
nection between the auricle and ventricle.
ARRHYTHMIA.
Cardiac arrhythmia or irregular pulse may occur in various forms: (a)
Irregularity in time in which an occasional beat is omitted; this omission
may occur at irregvdar intervals or more rarely it may appear as a regular
irregularity in which every second, fourth, sixth, etc., beat is lost. In other
instances the so-called pulsus bigeminus or trigeminus may be observed in
which two or three beats closely succeed one another to be followed after
an interval b)^ a repetition of the phenomenon. These often occur with
mitral disease, (b) Irregularity in force; here the rate is regular but the
strength of the pulsations is unequal and consequently an alteration in volume
is frequently co-existent, (c) Irregularity of force and frequency may occur
in combination.
Rarer varieties of cardiac arrhythmia are the pulsus paradoxus described
by Kiissmaul which is characterized by an increase of rate and a decrease in
force diiring inspiration. It is observed in chronic pericardial adhesions,
pleuro-pericardial adhesions, compression of the aorta and in weak heart
action due to any cause; the gallop rhythm in which the sounds occur in threes
and resemble in time the sounds made by the foot fall of a horse at a canter;
this is met in the cardiac hypertrophy of arteriosclerosis and nephritis, in
588 DISEASES OF THE HEART AND BLOOD-VESSELS.
certain forms of myocardial degeneration and extreme anaemia; emhryocardta
in which the first sound closely resembles the second, as in the fcetal heart.
This occurs in extremes of dilatation and in the cardiac weakness of the later
stages of the severer infectious diseases. Delirium cordis is the most extreme
type of cardiac irregularity; both force and frequency are afi'ected and the
condition may be seen in extraordinary types of dilatation and of severe exoph-
thalmic goitre.
-Etiology. Arrhythmia occurs as a result of (a) cerebral influences, both
organic, as in haemorrhage or concussion, and functional; (b) 'reflex disorders
of the circulation caused by associated digestive, pulmonary and renal affec-
tions; (c) the influence of poisons such as tobacco, tea, coffee and various
drugs; (d) cardiac changes which may affect either the innervation of the
organ or its muscular structure.
Symptoms. Cardiac irregularity in many instances is accompanied by no
symptoms and may be detected by accident. In other cases the patient
may be conscious of the condition and annoyed by it even though it interferes
in no way with his routine of life. In subjects in whom it occurs as a result
of cardiac weakness or disease it is associated with the other manifestations
of these conditions.
The diagnosis can be readily made by the careful routine methods of phys-
ical examination of the heart and pulse. When the condition is not organic
this fact can be ascertained from the history and consideration of the symp-
toms and physical signs.
The prognosis is in many instances most favorable, functional irregularity
not being prejudicial to health; the outlook is much more dubious when disease
of the arteries or of the heart muscle is present.
The Treatment of Palpitation and Tachycardia.
The same means are applicable to both these conditions. Recognition
of the cause is, of course, necessary, and this should receive appropriate treat-
ment. \Â¥hen due to hysteria or neurasthenia the management of the cardiac
condition is primarily that of the nervous condition; anaemia, digestive dis-
orders, uterine affections, etc., shoidd be corrected. Sexual excitement, tea,
coffee and tobacco should be prohibited and a life free from worry and from
physical over-exertion should be enjoined. In certain instances a course of
treatment by means of carbonic acid gas baths and resistance exercises is
very beneficial and the Weir Mitchell cure is strongly indicated in neuras-
thenic and hysteric patients when practicable. The application of the gal-
vanic current to the vagus has been suggested; the positive pole should be
placed under the angle of the mandible and the negative lower in the neck or
THE TREATMENT OF BRADYCARDIA. 589
over the sternum. Only a weak current should be used and this but for a
few minutes only. Electricity, it should not be forgotten, is often dangerous
and a strong current may cause stoppage of the heart's action.
During the paroxysm the patient should be put completely at rest, prefer-
ably in bed, although, if dyspnoea is present, the shoulders may be elevated.
Quiet should be enjoined and all disturbing influences should be avoided.
The over-acting heart may be calmed by the application of the ice coil to the
precordium and in connection with this, frequent drinking of cold water or
holding of bits of ice in the mouth is recommended. At the beginning of an
attack, as an abortive measure, we may rub in an ointment made as follows:
I^ veratrinae, gr. iii (0.2); extracti opii, gr. xv (i.o); olei terebinthinae, nxi
(0.065); olei menthse piperitae, rr^xv (i.o); adipis benzoinati, q.s. ad §i (30.0).
Misce et signa external use. When the heart action is markedly rapid
aconite or veratrum viride may be employed and in neurotic subjects the
bromides and the antispasmodics are beneficial. The following formulae
may be found useful. I^ camphorae monobromatas, gr. ii (0.13); zinci valer-
atis, gr. i (0.065); extracti hyoscyami, gr. ss (0.033). ^i^^ pilula numero i.
Signa one pill every 4 hours. I^ tincturae veratri, §ss (15.0); aqus destilla-
tae, syrupi aurantii, aa q.s. ad §iv (120.0). Misce et signa one teaspoonful
three or four times a day When precordial distress is marked it may be relieved
by a mixture containing tincture of veratrum, §ss (15.0); Hoffmann's an-
odyne, Biss (45.0); codeine, gr. V (0.33); compound â– tincture of cardamom
to §iv (120.0). If anaemia is present we may employ iron and arsenic.
Digitalis should be given with discrimination and in obstinate instances of
palpitation with weak, frequent and irregular pulse. In very severe cases the
use of morphine in i grain (0.016) doses may become necessary.
The Treatment of Bradycardia.
In managing this condition the primary cardiac affection, if detected,
should receive appropriate treatment. Concurrent arteriosclerosis should
also be given attention. Digitalis should not be employed in fatty heart but
in obstinate instances of bradycardia, if the pulse rate is not below 50, small
doses may be given with benefit in some instances. The patient's general
condition should be attended to and proper diet and inode of life enjoined;
the bowels should be kept open and all disturbances of digestion avoided in
so far as possible. The attacks necessitate confinement to feed and the dif-
fusible cardiac stimulants, alcohol, ammonia, etc., should be prescribed.
Inhalations of amyl nitrite are suggested if there is tendency to arteriosclerosis
and arterial contraction. Glyceryl nitrate (nitroglycerine) and strychnine
are also useful and the administration of caffeine either by mouth or hypoder-
590 DISEASES OF THE HEART AND BLOOD-VESSELS.
matically is recommended where the condition is due to lack of blood supply
in the medulla. The following formula may be prescribed to advantage:
I^ caffeina? sodio -benzoatis, gr. xx (1.33); sparteinse sulphatis, gr. iii (0.2);
aquae destillatae, s}Tupi aurantii, aa q.s. ad 5iv (120.0). Misce et signa one
teaspoonful tliree times a day. In the bradycardia of uraemia pilocarpine hy-
drochloride combined with alcohol is useful. The former when carefully
watched, and its depressing effect counteracted by alcohol, may be given in
divided doses up to i or 2 grains (0.065-0.13) daily.
The iAdams-Stokes s}!! drome is very difficult of treatment. The patient's
general condition should be cared for and ihe digestion should receive partic-
ular attention. The diffusible stimulants may prove of benefit but are often
disappointing; the inhalation of oxygen for a time each day, the hypoder-
matic administration of morphine and the employment of digitalis have all
acted well in certain instances but as a rule produce but indifferent results.
The same is true of glyceryl nitrate. A patient reported by Stokes was able
to abort or to lessen the severity of an attack by placing himself on his hands
and knees and hanging his head as low as possible; supposedly relief was
brought about by increasing the cerebral blood supply.
The Treatment of Arrhythmia.
The treatment of the disordered rhythm of chronic endocarditis is com-
prised in the treatment of the causative aft'ection. The cerebral conditions
which cause irregular heart action are difficult to influence but the instances
due to renal, digestive and pulmonar}' abnormalities may be benefited by
the proper management of the primary condition. The general treatment
of cardiac arrhythmia consists in forbidding tobacco, tea, and coft'ee, regu-
lating the diet and mode of life and if the symptom is associated with palpi-
tation, tachycardia or bradycardia, the employment of the means suggested
above for the amelioration of these aff'ections.
ANGINA PECTORIS.
Synonym. Stenocardia.
Definition. A symptom of various lesions of the heart and blood-vessels
characterized by paroxysms of severe pain referred to the heart and to the
neck, shoiilders'and even down the arms. The attack is often accompanied
by dyspnoea and in very marked instances by a sense of impending death.
.Etiology. The condition is confined almost exclusively to adult males,
heredity seems to have a certain influence in its causation and gout, diabetes
and influenza may be mentioned as predisposing factors. Anginal attacks
ANGINA PECTORIS.
591
may occur in endocardial lesions, particularly those affecting the aortic valve,
in adhesive pericarditis, syphilitic disease of the aorta, and during the develop-
ment of aortic aneurysm.
As exciting causes of the paroxysm sudden mental or physical over-exertion,
sudden exposure to cold and distention of the stomach by food or gas may
be mentioned.
Various theories have been advanced to explain the occurrence of the attack
and of these the most generally accepted is that it is the result of a temporary
diminution of the blood supply of the cardiac muscle due to sudden contrac-
tion or to disease of the coronary arteries, or affections of the neighboring
structures which interfere with the free passage of blood through them. Other
explanations of the symptom are that it is due to a spasm of the vasomotor
nerves of the heart, to a spasm of the heart muscle, to neuralgia of the cardiac
nerves, and that it is a functional neurosis.
Pathology. The most constant change found post mortem is an athe-
romatous condition of the coronary arteries and of the first part of the aorta;
with these general arteriosclerosis and myocardial degeneration are frequently
associated. By no means all instances of coronar}^ arteriosclerosis are char-